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SET T0017 -
Emergency Department

CASE 1

HISTORY	HISTORY 82 YO lady. Fell down the stairs. Injured her neck.
QUESTION	QUESTION Normal or abnormal?
RADIOGRAPHS	RADIOGRAPHS
ANSWER	ANSWER VIEW The degenerative changes in the mid and lower C-spine are consistent with the age of the patient. The important finding on this lateral view is the fracture through the base of the odontoid peg with a consequent posterior subluxation of the C2 vertebra on C1. If you are confused in relation to this patient's C1 / C2 articulation - start (a) by identifying the anterior arch of the C1 vertebra and then assess the position of the peg in relation to this anatomical constant; and (b) by tracing the posterior interlaminar line . . . *See : Accident & Emergency Radiology : A Survival Guide (3rd edition) : Pages 174-175*

CASE 2

HISTORY	HISTORY Injured in a Road Traffic Accident (RTA). Painful neck.
QUESTION	QUESTION Normal or abnormal?
RADIOGRAPHS	RADIOGRAPHS
ANSWER	ANSWER VIEW The body of the C7 vertebra is abnormal. It shows slight superior end plate compression and a fracture of its anterior cortex. The elsewhere appearances on this lateral radiograph are within normal limits. This includes the spinous process of the C3 veretebra. The normal C1 / C2 articulation allows comparison with the abnormal appearances in Case (1).

CASE 3

HISTORY	HISTORY Elderly patient. Complex fall in the kitchen. Painful neck
QUESTION	QUESTION An overexposed radiograph and much windowing of this image would be needed. Remember, radiography - following a neck injury - in an elderly patient in pain can be difficult. Is the upper C-spine normal or abnormal?
RADIOGRAPHS	RADIOGRAPHS
ANSWER	ANSWER VIEW Fracture of the base of the odontoid peg with forward subluxation of the C2 vertebra on the C1 vertebra. Agreed, it is difficult to evaluate this patient's C-spine inferior to the C4 vertebra on this image. Contrast the C1 / C2 articulation in this patient with that in Case (2) and also in Case (1).

CASE 4

HISTORY	HISTORY Another elderly patient. Assaulted and robbed. Found bleeding on the pavement. Painful neck.
QUESTION	QUESTION Is the upper cervical spine normal or abnormal?
RADIOGRAPHS	RADIOGRAPHS
ANSWER	ANSWER VIEW Considerable age related degenerative change below C2 vertebra. Probable old compression fracture of the body of C3 vertebra. The important finding: posterior subluxation of C2 on C1 vertebra. The odontoid peg appears to be intact. The explanation for the subluxation is that there has been a rupture of the transverse ligament (rather than being due to a peg fracture). Contrast the appearance of the anterior cortex of this odontoid peg and the body of C2 vertebra with that shown in Cases (1) and (3) in this Set. Artworks illustrating transverse ligament rupture vis a vis a peg fracture resulting in subluxation are available . . . *See : Accident & Emergency Radiology : A Survival Guide (3rd edition) : Pages 186-187*

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