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Anterior Column Fractures
Wedge Fracture, stable
• Hyperflexion force
• Axial force
• Osteoporosis
• Codfish spine
appearance: biconcave
appearance of vertebral
end plates
Middle Column Fracture
Burst fracture
• Axial force
Lower arrow points to
intrusion into the spinal
-more sci involvement
Posterior Column Fractures
All three columns have a
This particular fracture is
called a Chance fracture
Notice the almost horizontal
line through the spinous
process and the
compression fracture
Caused by a seat belt, Force
is hyperflexion, distraction
and impaction forces www.learningradiology.com/archives06/COW%2021...
Stable or unstable fracture?
Fracture: wedge
compression fracture of
the vertebral body.
MOI: flexion force or
lateral flexion
a. Posterior ligaments and posterior bone
elements are intact
b. Kyphotic angulation less than 10
c. Loss of anterior vertebral body height is
less than 40%
d. Relatively stable injury
Unstable Compression Fracture
• Angulation is greater than 20 dg
• Loss of 50% or more of anterior height
• Creates pull on posterior ligaments of
the spine – supraspinous,
interspinous,ligamentum flavum or facet
joint capsule
Stable Burst Fracture:
MOI: axial loading force
(compression force)
a. Anterior and middle columns are
disrupted, posterior column is
b. Kyphosis is limited to 15 degrees
c. Loss of vertebral body height is
less than 50%
d. Neurologically intact
Unstable Burst Fracture
MOI: axial force (compression force)
a. Anterior and middle columns
are disrupted
Retropulsion of posterior column
fragments into the vertebral canal occurs
b. Pedicle widening on x-ray
c. Neurological injury varies based on the
level of injury rather than the canal
compromised by bone fragments
d. Fractures above L2 have greater
neurological involvement
anything below L2, have very mobile nerve roots
so they can get out of the way or find away around
the fracture.
Flexion - Distraction injury
MOI: seat belt injuries, lap belt injuries
a. Failure of posterior elements in
tension while the anterior and middle
columns are compressed
b. Widening of the spinous processes
c. Vertebral body is wedged anteriorally
d. Variable neurological involvement
-Middle and Anterior Column.
Chance Fracture
MOI: hyperflexion injury over a
secured lap belt (usually in back
seat, flexion over the lap belt,
fractures right into gut)
Type of flexion distraction injury –
involves more structures
• Tension failure of all spinal bone
elements and/or ligaments –
anterior, middle and posterior
• Bowel injuries occurs in 65%
• No compromise of anterior
elements occurs only when the
injury is primarily ligamentous
• Surgical candidate
Compression Torsion/Translational
MOI: shear force or rotary
force with compression
a. Force will fracture or
dislocate facet
b. Neurological involvement
c. Surgical candidate
RX for different fractures
a. Stable fractures without
neurological deficit:
d. Unstable fractures with
incomplete neurological deficit:
• surgery is usually not needed
• May or may not stabilize with
internal fixation at first.
b. Unstable fractures without
neurological deficit:
• External immobilization for 1216 weeks
• Dependent upon improvement
noted with a log rolling frame
• Operate if neurological deficit
becomes apparent
e. Unstable fracture with
complete neurological deficit:
c. Unstable fractures with
progressive neurological damage:
• will operate within 48 hours for
• Reduction of fracture and
internal stabilization - with or
without a fusion
Indications for Immediate Surgery
. Advancing or progressive neurological deficits
-get weaker, or can not move “big toe”
-Reflexes check
b. Paraplegia in absence of bony injury
c. Severe nerve root pain
-Usually a boney fragment.
Rib Cage Fractures
1. Minor: simple rib
fracture, in 1 spot, do not
do much.
2. Major: fracture of 1 or
more vertebrae resulting in
a flail chest and/or a
hemothorax or
Copyright 2004 Nucleus Communications,
Inc. All rights reserved.
Rib Fracture
SX: pain on inspiration
Signs: palpable defect, tender to palpate,
-Ask to breath in deep “if pain” then suspect a
rib fracture. Or tap, vibrate to see if pain,
symptoms increase.
RX: simple fracture: can just bind the ribs to
assist with pain management and coughing,
will become stable within 1-2 weeks and heals
by 6 weeks
Flail Chest
Definition: segment of the chest wall doesn't
have continuity with the rest of the thoracic rib
cage (two fractures of same rib-floating)
Signs: Paradoxical motion occurs: moves in on
inspiration and out on expiration splinting of
chest wall muscles, decrease ventilation, decrease
vital capacity, when breathing it will do the
opposite of what ribs are suppose to do.
Lab tests: x-ray and blood gases help to make a
positive diagnosis
Joint Dysfunctions
Rib Cage Dysfunctions
1) Costochondritis: anterior chest wall syndrome
• pain in the costochondral articulation without swelling,
• affects T3,T4,T5 costochondral junction
• Similar signs to MI so people may jump to conclusion
Risk factors: women more than men, over 40
years old
SX: pain and tenderness in the anterior chest
wall, may radiate to the shoulder or arm,
aggravated by sneezing, coughing, inspiration,
bending, lying down or exertion
Signs: pain with palpation over the costochondral
*also commonly a structural dysfunction,
as something is irritating the cartiatlage
Tietze's syndrome
Tietze's syndrome is similar to costochondritis.
SWELLING only Difference!!!
The difference between the two is that
there is swelling over the costal cartilage with
Tietze's syndrome and not with costochondritis
-some research says Tietze may be the
“acute” form.
Definitions: A lateral curve of the thoracic or
lumbar spine or a combination of thoracic and
lumbar curves
Primary Curve: first curve or earliest curve to
appear in the thoracic or lumbar spine
Secondary Curve: curve above or below a major
Major Curve: largest structural curve
Minor Curve: smallest curve, more
Apical Vertebrae: vertebrae which is
furthest from the vertical axis of the
End Vertebrae:
The vertebrae are at the ends of the curve and
are maximally inclined toward the concavity of
the curve.
a. cephal: most cephal vertebrae maximally
inclined toward the concavity
b. caudal: most caudal vertebrae maximally
inclined toward the concavity
Rib Hump:
Rotation of the thoracic
spine which is noted in a
flexed position.
As the patient flexes forward,
the ribs push posterior on
one side of a scoliotic
Rib Hump
Apparent Deviation:
Line from the sacrum (gluteal
cleft) to the SP of C7.
Deviation occurs when there
is a linear distance between
the vertebrae at C7 from the
linear distance at the
sacrum. Indicates curve
-how much compensation.
Idiopathic: unknown cause
1) infantile: onset less than 3 years of age. 80 90% will resolve
2) juvenile: 3-10 years of age brace if curve is greater than
30 dg and less than 45 dg surgery if curve is greater than
45 dg after bracing
-checked in school
3) adolescent: onset is puberty ~ 10 years of age
until skeletal maturity
Paralytic scoliosis: muscle
Have “cafe au lait” spots, in ped
Adult Scoliosis
Adult Scoliosis: spinal deformity may be
more rigid
Spinal stenosis, DDD, osteopenia are
associated pathological conditions which
may contribute to an increase in Cobb angle
SX: pain on the convex side of the curve
due to muscle fatigue
Prevalence, Risk factors, Surgical
a. 5 % of all scoliotic curves are greater than
10 dg, .04% exhibit curves greater than 20
b. greater the angulation and rotation of the
spinal curve, the higher the possibility of
curve progression.
c. younger the child when diagnosed, the higher the
possibility for curve progression
Likeiness of Curve Progression
d. Risser Score of skeletal maturity: score of 1 or less, higher possibility
for curve progression
-Gives skeletal “age” of a person by epiphyseal plates.
e. A shorter curve progresses more
f. the higher the curve in the spinal column, the more likely the curve
is to progress
-No stable base
g. the stiffer the curve in an immature individual and the more flexible
the curve in a mature individual, the more likely the curve is to
Radiographic Assessment
1. Cobb Method: preferred method of curve measurement. Very
consistent between examiners
a. caudal and cephal end vertebrae are identified.
b. parallel lines to the end plates are drawn into
the concavity of the curve
c. lines drawn at right angles to the parallel lines
will intersect at an angle.
d. angle is measured for the degree of
Cobb Method.
Identify caudel and
cephal end vertebrae
Draw parallel line
Draw perpendicular lines
Measure angle of curve
2. Risser Scale
Indicates the ossification of the iliac epiphysis which begins at the
ASIS and ends at the PSIS
*Ossifies Anterior to Posterior
a. Grades 0= 0% has closed,1= 25% or less has closed,2 are skeletally
immature: 50% or less has yet to ossify
b. Grade 3: progressing skeletal maturity: 75% or less has closed
c. Grade 4: end of spinal growth, epiphyseal plate has closed but not
fused =100% or less has closed
d. Grade 5: epiphyseal plate has fused
Greulich and Pyle Atlas
3. Bone age: radiograph of the left wrist
and hand and compared to standards set
forth by Greulich and Pyle Atlas
-compare to a series
4. Moire Thermography: heat pictures,
from the muscles
Other Testing:
1. Pulmonary function tests: curves
• greater than 70 dg have a decrease in
vital capacity
Management of Scoliosis
1. Goals of treatment:
a. prevent progression and maintain balance
b. maintain respiratory function
c. reduce pain and preserve neurological
d. Cosmesis- important for the kid
e. combo of bracing and physical therapy evidence
says is best
Non-operative treatment of
a. observation in curves less than 25 dg
in skeletally immature patients and
less than 50 dg in skeletally mature patients
b. exercise in combination with bracing
may be effective, without a brace has
been proven ineffective in stopping the
progression of a curve.
c. Bracing occurs with any curve greater than 25
dg in a skeletally immature patient
Milwaukee CTLSO Bracing
Milwaukee brace (MWB) or
cervical-thoracic-lumbarsacral orthosis (CTLSO)
- curve has an apex at T8 or
- provides pressure over the
point of maximum convexity,
traction between the occiput
and the pelvis
-Tries to stop curve at all parts, for T8 or
higher, provides distraction
Boston TLSO Bracing
Boston Bracing System or
orthosis (TLSO)
- pads are applied laterally
below the apex of the curve
- no head piece
- works best with apex of
curve lower than T8
Stop curve progression with either type of
The physician will look for a 50% reduction of the
curve with the brace on
Brace is worn 23 hours a day until a Risser 4 is
reached and, if female, two years after menarche
Patient will be weaned off brace for 1 year
Patient will be followed up with a physician visit
every 6 months and repeat x-rays every 12
progressive curve 40 - 50 dg
in growing children
failure to prevent
progression of the curve
with bracing or cannot get a
50% correction with the use
of a brace
progressive curves greater
than 50 dg in adults.
Goals: prevent progression
of curve
- spine and pelvic balance
are more important than
curve correction
- prevent respiratory
- prevent back pain
or decrease it
- cosmesis
Types of Surgery
posterior fusion
anterior fusion
combination of anterior
and posterior
- Harrington Rod techniques
- Drummond's technique using a combination
of Harrington Rod's and Luque rods/wires
- Luque rod with segmental sublaminar wires
- Multiple hook systems
Thoracic Spine Dysfunctions
Scheuermann's Disease: juvenile kyphosis,
vertebral epiphysitis
Etiology: may be secondary to repetitive trauma,
growth retardation or vascular disturbances are all
MOI: stress fracture of the anterior aspect of the
vertebral endplates.
Scheurmann’s Disease
Vertebral wedging of at
least 3 consecutive
End plate deformities
-box is shorter, angled
Scheurmann’s Disease: Diagnostic
Thoracic kyphosis > 45 deg (25 to 40 deg being
Wedging > 5 deg of three adjacent vertebrae
Thoracolumbar kyphosis > 30 deg
(thoracolumbar spine is normally straight);
Scheurmann’s Disease
DX: lateral radiograph shows decrease in disc
vertebral end plate irregularities such as
Schmorl's nodes may occur
Risk factors: adolescents, males and females
about equal, autosomal dominant
Scheurmann’s Disease
SX: back pain, worse with prolonged activity or
standing for long periods of time, relieved by rest
Signs: acute thoracic kyphosis and an increase in
lumbar lordosis, local tenderness to palpation,
limited extension & painful, sensory and motor
exam is normal
Conservative RX:
•At least two more years of skeletal growth
•Active exercises concentrating on
extension, can help prevent,
Surgical Candidates:
• Apical wedging severe deformity with disabling pain
• Neurologically compromised
• Continued progression despite conservative treatment
Type of surgery:
• Fusion if the curve is greater than 70 dg and rigid, severe
Diffuse Idiopathic Skeletal Hyperostasis, Ankylosis
Definition: common disorder, osteophytes develop
into bony spurs that may join to form bridges to each
Can occur in thoracic, lumbar or cervical spine
Type of Enthesopathy
Ossification of the
anterior longitudinal
ligament of the spine
-there is no anterior
At least four vertebral
Preserved disk space
*If not 4 then ankylosis
Risk factors: NIDDM (type II) diabetes, males 2:1
over females, middle aged or older
Onset: insidious
SX: back stiffness in the T or L spine, calcaneal
pain common, the groups of ossified vertebrae
will move as a group
Signs: early on the examination is normal, as
disease progresses, will see limitation is spinal
Lab tests: normal or slightly elevated ESR
Radiograph: calcification and ossification of the
ALL in 4 continuous vertebrae, preservation of
disc height, absence of facet ankylosis, SI
RX: symptomatic, treat similar to OA patients
with exercise to maintain mobility especially in
the peripheral joints
T4 Syndrome
Clinical pattern of pain and parasthesia in one or both
UE’s. Head pain can also occur due to embroyonic
May occur alone or in conjunction with other pathology in
the T spine
Area of Involvement: T2-T7, T4 almost always included
Incidence and Prevelence: females > males 79% to 21%.
Onset: variable
SX: dull aching pain in head, one or both hands, forearms
and shoulders can be affected
• Symptoms are intermittent, variable during time most felt, better
with movement
T4 Syndrome
•Positive palpation findings indicating some
restriction of T spine movement
•Deviation of SP from midline
•Uneven spacing of SP
Definition: fracture of the pars
interarticularis, unilateral or
-Most common in Lumbar, but
also can occur in thoracic and
MOI: stress fracture, non union
-like hiking with
backpack, or bending forward
with gardening so muscle
a. Posterior elements have a reduced ability to
stabilize the spinal unit
b. Soft tissue undergoes plastic deformation
Etiology: 5% in general population
•Related to activity
•Aching pain in back
•May radiate toward LE
•Relieved by rest or decreasing activity
•Stiffness noted
Signs: paravertebral muscle spasm, flattening of
the normal lumbar lordosis, tight hamstrings,
decrease in SLR motion
Radiograph: collar on the Scotty Dog
RX: modify activities, primary repair or fusion if
patient has unrelenting pain, stabilization
Scottie Dog
Scottie Dog
Body part of Dog
Anatomical Bone Segment
Superior articulating process,
Transverse process, ipsi
Front Paw
Inferior articulating process, ipsi
Pars Interarticularis
Rear Paw
Inferior articulating process, contra
Superior articulating process, contra
Definition: forward slippage of one vertebral
body on another, longstanding segmental
instability, spondylolysis associated with it
Five Types of Spondylolisthesis
Type I is called dysplastic
spondylolisthesis and is
secondary to a
congenital defect of
either the superior sacral
or inferior L5 facets or
both with gradual
slipping of the L5
Type II: Isthmic (Skinny Island)
Can be divided into three
• Bone defect
• Elongation of pars
• Repeated micro fracture
Stress spondylolisthesis
• most likely caused by recurrent
micro-fractures caused by
• It is also called a stress fracture of the
pars interarticularii
• much more common in males.
• Usually a sport related injury:
Five Types of Spondylolisthesis
Type III, is a degenerative spondylolisthesis
• Occurs as a result of the degeneration of the lumbar facet
• The alteration in these joints can allow forward or backward
vertebral displacement.
Five Types of Spondylolisthesis
Type IV, traumatic
spondylolisthesis, is
associated with acute
fracture of a posterior
element (pedicle, lamina
or facets) other than the
pars interarticularis.
Five Types of Spondylolisthesis
Type V
• pathologic spondylolisthesis
• occurs because of a structural
weakness of the bone
secondary to a disease
process such as a tumor or
other bone diseases.
Grading System
Based on the percent displacement of the
superior vertebral body on the inferior
vertebral body
Grade I: 0 - 25% length of vertebral body slide
of superior on inferior
Grade II: 25 - 50% may still not need surgery
Grade III: 50 - 75% surgery more than likely
Grade IV: 75-100% (surgery)
*Higher the Grade the more Neurological
Involvement, so Grade IV is the Worst!
SX: pain in the back, buttock or thigh. unilateral or
bilateral aching, pulling, weakness, heaviness, numbness,
Signs: pain with forward bending, muscle spasms or
erector spinae muscles, decrease pain with flexed
positions (such as supine with knees bent), increased with
*Flexion in supine will decrease s(x), but flexion in
standing will increase s(x).
*Extension will not make it feel better, but if
Spondylisis then extension will make it feel better
Radiographs: Collar on Scotty Dog - + pars
interarticularis fracture, lateral flexion
radiograph shows the slippage
RX: conservative for 6 months, PT for pain
management, lumbar stabilization, may
brace in grades II and III
Surgery: if it is a grade III or more and
conservative treatment has failed
Goals of surgery: prevent further slippage,
stabilize an unstable segment, prevention of
neurological deficits, pain relief, cosmetic,
posture and gait improvement
Ankylosing Spondylitis
Marie Strumpell disease,
rheumatoid spondylitis
Definition: chronic
inflammatory arthritis
which leads to deformity
and fusion of the spine
Ankylosing Spondylitis
Risk Factors:
•15-40 years of age,
•males 3:1 over females
•(fusion of entire spins in 20 years)
•complaints are related to spinal
movements or sacroilitis
Ankylosing Spondylitis
Medical Diagnosis:
• back pain greater than 3
• decrease in spinal
• decrease in chest
• sacroilitis
• peripheral joint
Lab Tests:
•95% have a +HLAB27 human leukocyte
Radiograph: Ankylosing
• bamboo spine in
advanced stages
• SI fusion in one or
both sides is earliest
Should be line, rather
solid mass
Clinical Manifestations: Ankylosing
spinal pain/stiffness
worse in am or after
improves with
• normal neurological
• SI tenderness
• + FABER's test
• decrease in lumbar
• rib expansion less
than 2 cm
Ankylosing Spondylitis
PT Interventions: pain relief, maintenance of
mobility, swimming
Surgical Interventions: peripheral joint disease
Fixed Flexion deformity
Review: Disc Herniation
Review Definitions
Review Signs and
Symptoms of a Disc
1) clinical symptoms
2) signs: Motor
T2 - T11: Specific to T and L spine
Thoracic discs are very
stable and herniations in
this region are quite rare.
Herniation of the
uppermost thoracic discs
can mimic cervical disc
herniations, while
herniation of the other
discs can mimic lumbar
Radiation of pain around
the rib cage (dermatome
pattern) can also occur
T12 - L3:
Reflexes: none
MMT: iliopsoas,
quadriceps, adductors
Dermatome pattern:
specific to each nerve
Lumbar Spine:
Most common areas
are L4-5 and L5-S1
Reflex: Quadriceps
MMT: tibialis anterior
Sensation: medial aspect
of foot to big toe
Reflex: Medial hamstring
Sensation: middle toes,
dorsum of foot, big toe
Reflex: Achilles
MMT: peroneus longus and
brevis, gastroc soleus,
gluteus maximus
Sensation: little toe, outside
of calf, lateral aspect and
plantar surface of foot
Spinal Surgeries
Decompression Back Surgery
•Small portion of the bone over the nerve
root and/or disc material from under the
nerve root is removed to give the nerve
root more space and provide a better
healing environment.
Best for treating
radiculopathies rather
than back pain
Open Decompression
Indications: spinal
stenosis, herniated disc
Remove lamina and
facet joints are trimmed
a bit to give nerve more
Success rate: 70-80%
improve function,
decrease back/leg pain
Spinal Fusion
Thoracic Spine: Radiographic Views
Standard Views
•AP View
•Lateral View
Special Views
•Swimmers View
•Oblique Views
•Utilized for viewing
the sternum
•Coned Views of
region or other
specialized areas
Thoracic spine radiology
Anteroposterior view:
*Know by the heart on the
left side visible.
Thoracic vertebral bodies
The intervertebral disc
Alignment of the pedicles
Spinous processes
Transverse processes
Articular processes and the
Costovertebral joints
Posterior ribs.
Keys to viewing
• In this view, pay
attention to the
position of the pedicles,
they will indicate any
rotation of the thoracic
• Symmetry of the
vertebral bodies: any
change in symmetry or
curve of the spine
Bone Density:
• In this view, check each
vertebral body, does
one or two or many of
them appear to have a
different radiolucency
than the others?
Cartilage Space and Disc Height
•SC joints are easily
seen due to overlay
of vertebral spine
•Costovertebral joints
can be seen – better
in upper thoracic
than lower
Disc Height
•should appear
similar as you move
down the spine
Soft Tissue
Heart shadow should
be on the patient’s
left side
Lungs should appear
black due to the
amount of air
Diaphragm should be
overshadowing the
lower ribs and
vertebral spine
This view is often
used to detect the
presence of
pneumonia as lungs
won’t be as dark
Pedicle Position:
Rotation of the spine is determined by the
position of the pedicles in relation to
The closer to the midline a pedicle is, the
more rotation is occurring to that side.
Distance between the pedicles represents the
transverse diameter of the spinal canal
(Nash CL, Moe JH. A study of vertebral
rotation. J Bone Jt Surg Am 1969;51: 223-229.)
Nash-Moe Method
Grade Pedicle Displacement
0 = no rotation of the vertebral body
1 or + = minimal rotation of the vertebral body
2 or ++ = pedicles on the concave side of the
spinal curve rest on or near the margin of the
vertebral body
3 or +++ = only one pedicle is seen and it is
nearing the midline
4 or ++++ = the only visible pedicle is
beyond the midline of the vertebral column
2. Lateral view:
Demonstrates the thoracic
vertebral bodies,
intervetebral disc space
First 2-3 vertebrae are not
easily seen because of the
shoulder and scapula being
interposed between the body
and the film.
*Swimmers view gets the
arm up and out of the way
3 column
classification system
by McAfee
This picture includes
a little more of the
posterior structures
than the one in the
Swimmer's View
A lateral view with
arm closest to film
is raised to see
vertebrae C7-T1.
*Therefore wrong
view for Justin as
his pain is T7.
Computed Tomography
Picks up problems with
the posterior elements
Highly effective and
accurate in diagnosis of
Evaluates spinal canal
2-mm axial sections has
a confidence level of
98% that a fracture will
be seen (Nadalo,
Moody, 2007)
Axial CT’s may miss
small compression
Magnetic Resonance Imaging
Superior to CT scans in
detecting herniated
disk, ligamentous
edema and spinal cord
compression: see arrows
Does not pick up bone
fractures as well as CT
Minimally displaced
fractures are difficult to
Schmorl Nodes
Herniation of the disc
through the end plate of
the vertebral body
May or may not be
More schmorl nodes
MRI T2 sagittal image of large schmorl
Axial CT
Rib radiology
Standard Views:
•AP or PA
•Above Diaphragm or
below Diaphragm
•Anterior Oblique
•Posterior Oblique
Anteroposterior (AP) or
Posterioanterior (PA)
AP: posterior ribs are closest to the film cassette
PA: anterior ribs are closest to the film cassette
-used to look at lungs for pneumonia
Also, note views are taken as above the
diaphragm or below the diaphragm
•Thoracic vertebrae
Density: Uniformity
of bone appearance
Rib Fractures
AP view
Oblique View
These are the same patient, elderly female, minor fall
Axial CT of Rib Cage and Lungs
Black arrow – rib
White arrows –
Ultrasound and Rib Fractures
Lumbar Spine
Oblquies: Scooty Dogs
-will have a lateral view
-Also cone-in view for L5 and
-look for where heart is, and it
should be listed on the X-ray.