Protection - Spinal cord.

Support - Weight of body - erect posture.

Point of Muscle attachment - muscles of the back

Provide cushioning.

Act as shock absorbers.

Allow movement to occur without damage.

26

7 cervical

12 thoracic

5 lumbar

Sacrum

Coccygeal

C7 - felt at back of neck

Inferior border of the scapula is at level of T5

Iliac crest is at L5

Occurs in the foetus.

One flexed smooth C shaped curve.

Maintained in thoracic and sacrococcygeal region.

Secondary Curves of the Spine

Occur after birth.

First curve is the cervical spine as the baby begins to lift his head.

Second is the lumbar spine as the toddler starts to stand.

Junctions between primary and secondary curves form weakness - fractures commonly found between C7/T1 and T12/L1.

Functions and shape of vertebra:

Cervical

Thoracic

Lumbar

Sacrum & Coccyx

Cervical - distinguished by transverse foramen - designed to support head and for movement.

Thoracic - heart shaped body - long transverse processes to articulate with ribs.

Lumbar - Large and broad body - strong oblong spinous process for muscle attachment - virtually no rotation but good flexion and extension.

Sacrum - fused - facets articulate with ilium to form sacroiliac joint.

AP

Superiorly - body of T12

Inferiorly - Sacroilliac Joints

Laterally Paoas Muscle and hila of kidneys - referred pain.

Spinous process in centre of body demonstraing no roation.

Lateral

Demonstrate disc spaces and vertebral body alignment.

Centreing point - Midline of lower closteral margains.

Hips and knees flexed.

Collimate to include T12 to S1, psoas muscle and hilia kidneys

Expose on expiration.

Apply 28 day rule.

Centring point: Level of lower costal margain 7.5 cm anterior to spinous processes.

Patient lies on their side with thair arms raised an knees flexed - brings spine parrallel to imaging plate.

Collimate to include vertebral bodies ans spinous process T12 - lumbar sacral region.

Lumbar Oblique view

Scotty dog

Used for assessing intervertebral foramen and pars inter-articularis - MRI prefarred.

Eye - pedicle

Nose - transverse process

Ear - superior articular process

Leg - Inferior articular process

Neck - pars interarticularis

Spine Variants

Sacralisation

Lumbarisation

Cervical Rib

Sacralisation - fusion of L5 - 4 lumbar vertebra

Lumbarisation - S1 seperated from rest of sacrum - 6 lumbar vertebra.

Cervical Rib - extra rib on C7 can cause nerve impingement leading to pain.

T1 to L1 visualised.

Medial end of clavicals equdistant - spinous process centre of bodies - no rotation

Include costo-vertebral joints

Vertebra in centre of image

Centering point: Mid way between sternal notch and xiphsternum.

Knees slightly flexed.

Collimate to include C7 to L1 and the transverse processes.

Centering point: Level of inferior angle of scapula 5 cm anterior to spinous proceses.

Medial Sagittal plane parallel to imaging plate.

Knees flexed and arms raised.

T3/4 to L1/2 visualised.

All anterior bodies and spinous processes demonstrated without rotation.

Intevertebral disc spaces demonstrated.

Force applied in a caudal direction.

May result in burst fracture

or may be do to pathology collapsed vertebra in osteoporosis.

Vertebra loses height anteriorly and posteriorly.

Fragments may be found in spinal canal.

Excessive flexion - diving in shallow water - car crash were body is thrown forward and pelvis stabilised by seatbelt.

Vertebra pulled apart - distraction.

Cause a chance fracture

Excessive extension.

Hitting dash board in RTA

Pars Fracture or hangmans's fracture - Scotty dog neck broken.

Transverse Process Fracture.

Extreme rotation or sideways (lateral) bending.

Stable fracture.

Unstable fracture involving bone and soft tissue.

Vertebra moved off adjacent vertebra.

Often cause spinal cord compression.

Centering point: Midline just below thyroid cartilage. Through C5

Patient faces x-ray tube.

Posterior aspect of head and shoulders in contact with imaging plate.

Patient extends their neck clearing the jaw from upper vertebrae.

Tube anguled by 5-15 degrees so symphysis menti is superimpossed over the occipital.

Centering point: Prominance of thyroid cartilage

SID: 180cm

Shoulders against image receptor and feet apart to achieve stability.

Shoulders relaxed - expose on expiration patient hold weights.

Neck extended so manible doesnt over lie vertebra.

Atlano-occupital joint (C1) to body of T1.

Cervical spinous processes and soft tissue boarders of pharynx.

Vertebral bodies superimposed and clear joint spaces to show no rotation.

C2/3 to T1 demonstrated.

Transverse processes shown - Lateral soft tissue.

Lower boarder of mandible superimposed on occipital.

No rotation spinous processes equidistant from pedicles.

Open mouth/ Peg View

AP C1&2 Imaging Technique

Centering point: Midline of open mouth.

Neck extended so tip of mastoid process and inferior border of upper incisors are at right angles to receptor - superimposing occipital bone and upper incisors clearing area of interest.

Inferior border of upper incisors should be superimposed over the occipital bone.

The whole articulation between atlas (C1) and axis (C2) should be clearly shown.

Whole dens and lateral masses of C1 should be demonstrated and as much as C2 as possible

Performed if C7/T1 not visulaised clearly.

Usually performed on patients supine on a trolley.

Used to asses alignment of vertebrae.

Arm nearest receptor raised.

Centered to just above the shoulder.

Centering point: Midway between the anterior superior iliac spine.

Patinent supine - legs extended and internally rotated.

Collimate to include Iliac crest, proximal femurs and soft tissue boarders.

Iliac crest and greater and lesser trochanters demonstrated.

Centering point: Just below the crease of the groin in the midline of the thigh.

Lie patient on affected side in true lateral position.

Hip and knee flexed.

Rotate the patient backwards until the pelvis is at 45 degrees.

Collimate to include acetabulum to the proximal third of femur.

Sub-pubic angle - wider in females.

Pubic Inlet - Heart shaped in males - seen posteriorly.

Obturator Forame - oval in females and rounded in males.

Acetabulum - smaller in females.

Pelvis thin, light and less muscular in females.

Female sacrum is shorter and less curved.

Ring Structure

Disruption of joints, ligaments or bone likely to result in instability.

Greater the disruption greater instability.

Avulsion Fractures

Ischial and Pubic ramus fractures

Sacral Fractures

Complete break through ring structure.

High risk of haemorrhage.

Classified by mechanism of injury

Most common

Lateral force

Bilateral, superior and inferior pubic rami fractures.

Folding in of iliac wing.

Widening of sacroiliac joint.

Widening of symphysis pubis

Opening of iliac wings

(Open Book/sprung pelvis)

Rare but common result from falls from a height.

Vertical force.

Vertical fracture of pubic rami and distruption of sacroiliac joint.

Serve ligament damage

Majority females over 65.

Low energy trama in reduced bone density patients.

High energy/RTAs in younger patients.

Disruption in shentons line

Pain in groin

Inability to weight bear

Shortened affected leg

External rotation of affected leg

Should be one smooth continuous line

Follows superior boarder of obturator foramen and neck of femur.

Disruption of line = suspected fracure or dislocation of hip

1. Subcapital

2. Transcervical

3. Intertrochanteric

4. Subtrochanteric

Intracapsular hip fracture.

Likely to lead to AVN if displaced.

Impacted less likely to lead to AVN

Intracapsular

Fracture line runs across the neck of femur.

May lead to AVN

Extracapsular

Often comminuted fracture - lesser trochanter frequenty avulsed.

Less likely to lead to AVN

Extracapsular

Fracture line is across the proximal shaft of femur - inferior to trochanters.

Least likely to lead to AVN

Extracapsular fractures run a low risk of AVN so internal fixation often used - Dynamic Hip screws or cannulated screws.

Intracapsular fractures are subject to a greater risk of AVN so a total hip replacement or if acetabulum is helathy a hemiarthroplasty

Central Dislocation

Result of sideways blow to greater trochanter - femoral head forced through acetabulum

Anterior dislocation

Caused by violent abduction.

Present with external rotation

femoral head fracture in most cases

Most common

Typically from dashboard impact

Present with internal rotation

Associated acetabulum fractures

0-2

Common in females

Hip becomes dislocated easily due to shallow joint socket.

Shorter outward turned leg - uneven skin folds - less movement and flexibility on one side

Ability to say the appearences are normal - no abnomality present

Amount of people who dont have the disease that tested negative.

2D information

Quick to process and report

Cheap and highly avaliable

Ionising radiation

Operator dependant

Demonstrates bony anatomy and gross pathology well.

Radionuclide Imaging

RNI

Shows detailed physiological function rather than anatomy.

Uses radioactive material IV administered.

Time consuming - have to wait for isotope to accumilate in part of body under study.

Possible allergy to radio isotope.

Computerised Tomography 

CT

Good bony detail

Quick compared to MRI

3D reconstruction

Overview multiple of systems

Non-operator dependent

Uses ionising radiation

Contrast administration often required

Poor soft tissue differentiation

Lack of avaliability - Expensive

Good for soft tissue 

No ionising radiation

Demonstrates blood vessels, disc and spinal cord well.

Multiplaner imaging - 3D reconstruction

Non-operator dependant

Long scan time

expensive

Degenerative joint disease

Due to wear, tear and ageing.

Osteophyte formation - Nerve compression

Disc degeneration - water content lost - loss of disc heigh - lack of shock absorbance.

Lumbar and Cervical spine highly susceptible

Stress fracture around pars interarticularis.

Micro trauma

Common cause of lower back pain in males under 26.

Significant periods of rapid growth or sports such as gymnastics and weight lifting can put stress on spine.

Anterior displacement of a vertebra or vertebral column.

Fifth lumbar vertebra commonly affected.

Progression of spondylolysis.

Graded by the distance the vertebra has slipped.

Degenerative Inflammatory arthritis.

Eventually causes fusion of spine.

Affects ages 18 to 30

3:1 male to female ration

Decreased density in vertebrae from loss of trabecular structure.

Wedge fractures

Ballooning of intebertebral disc spaces

Picture framing - dense bony cortex - trabecular bone less dense

Curve that results in exaggerated round back.

Postural kyphosis - increase in the natural curve of spine - common in women.

Congenital kyphosis - born with wedged shaped vertebrae - can cause compression on spinal cord causing paralysis.

Scheuermann kyphosis - aparent in teen years - affects upper thoracic spine - vertebrae develop unevenly - wedge shaped.

Lateral curvature of spine.

Causes disfigurment - uneven hips, shoulders.

Vertebrae become twisted pulling ribs around with them.

Chest deformity can interfere with lung function - poor pulmonary efficiency - recurrent infections.

Observation - review regularly to ensure curve doesnt progress.

Bracing - Discourage further curvature.

Surgery - spinal fusion - bone harvested from elsewhere and grafted to vertbrae fusing them together - metal rods are also placed to correct correct the curve while it fuses making it straight and rigid.

Abnormal formation of bone tissue resulting in weakened deformed bones.

Osteoclasts (bone destroying) more active then osteoblasts (bone making) so more bone absorption than normal.

New bone is abnormally large, deformed and chaotically formed - random mosaic pattern.

Large dense but weak and brittle bones.

Prone to pathological fractures, bowing and deformity.

Affects white adults over 55

Male majority

Rare in Asians

No exact cause

Genetic Factor

May be triggered by virus infection

Hormonal dysfunction

Autoimmune States

Appear gradually.

Poorly mineralised bones - bowing of legs - scoliosis.

Bone pain - worse at night, numbness, weakness, tinitus - Compression of nerves.

Skull and pelvis enlargement - Overgrown bone.

Stiffness and fatigue

Based on x-ray appearance.

Elevated serum alkaline phosphatase.

Osteoarthritis - joints damaged

Pathological fracture - chalkstick - transverse fracture - delayed healing.

Deafness - tinitus - vision impairment - nerve compression.

Heart failure - blood vessesl in bone become damaged causing heart to work harder.

Osteosarcoma - bone cancer - rare complication - symptoms similar.

Relieve pain

Prevent progression and compliactions

Bisphosphates - reduce activity by binding to bone and stopping it being reabsorbing bone.

Calcitonin - inhibit osteoclast activity.

Pain relief - anti inflammatorys - paracetamol.

Vits and mins

Walking aids

Excersise

Surgery for fractures - osteoarthritis - nerve compression

Cortical thickening

Trabecular coarsening and distortion.

Cotton wool appearence of skull - sclerotic patches.

Sclertotic vertebra - Ivory Vertebra.

MRI and CT for nerve impingement

Cancerous bone tumour.

Common in tall people.

Common as child progresses into an adult.

Most common primary bone tumour.

Majority in long bones

Half found around the knee - distal femur - proximal tib.

Humerus.

Rapid bone growth

Ionising radiation

Complication of Pagets

The periostium provides a stong barrier.

Cance spread along path with least resistance.

Spreads locally along bone.

If gets into blood spreads to lung/liver.

Bone pain - worse at night

Swelling/tenderness - large tumour.

Pathological fracture - weakened bones.

Tiredness, fever, weight loss and anaemia.

Clinical examination of medical history

Conventianl radiography - initial signs.

CT - Evaluate bone lesions.

MRI - surgical margains and soft tissue involvement.

RNI - detect metastic lesions.

Codman's triangle - very aggressive

Periostium becomes elevated foming an angles with cortex.

Sunburst sign

Moderately aggressive.

Sharpey's fibres stretched and ossified.

Multi-disipline approach - surgeon and oncologist.

Remove tumour to prevent spread - surgery - replace with prosthesis.

Used to prevent progression of cancer

When massive skin ulceration.

Cancer spread to bone from another site - secondary cancer - lungs, breast, prostate or kidneys.

Lesions appear in medullary cavity - cancer cells travels in blood stream to red bone marrow.

Appear in axial skeleton due to increase in red bone marrow.

C - Capitellum - age 1

R - Radial head - age 4

I - Internal epicondyle - age 4-6

T - trochlea - age 9-10

O - Olecranon - Age 10

E - External epicondyle - Age 12

S - Slipped - Type 1

A - Above - Type 2

L - Lower - Type 3

T - Through - Type 4

(e)

R - Rammed - Type 5

Type 4 & 5 most likely to lead to complications.

Early closure of growth plate.

Shortened limb.

Uneven growth due to uneven closure - angular deformity.

Occurs along epipyseal plate - only epiphyseal plate affected.

Complications rare.

Difficult to diagnose unless displacement.

Most common salter harris

Involves epipyseal plate and METAPHYSIS

Corner sign displayed.

Compliacations rare

Involves epipyseal plate and epipysis.

Damage articular cartilage.

Growth disturbance rare.

Involves epiphyseal plate - metaphysis and epiphysis.

Growth distrubance can result.

Rare fracture.

Caused by compression or crushing of epiphyseal plate.

Difficult to diagnose until signs of growth disturbance.

Poor prognosis.

Requires Dose reduction techniques:

Non-grid techniques.

Good positioning to prevent repeats.

Accurate Collimation.

Lead Protection.

Approriate Focal spot size.

Increase tube filtration to use a kVp technique.

Use of AED not approriate due to patient size and chamber positions.

Invite parent or guardian.

Provide distractions.

Use sandbags.