Glossary of Pathology Test 3

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2 highly specialized connective tissues
bone and cartilage
bone is an
organic matrix in which inorganic salts (calcium and phosphate) are deposited
Parts of bone are:
medullary cavity

shaftlike portion
ends of bone
hollow tube like structure within the diaphysis
medullary cavity
membranes of bone
covers the outer surfaces of teh bone except at a joint surfaces, contains network of blood vessels from which nutrient arteries
- inner membrane that lines the medullary cavity
types of bone are
compact and cancellous
dense and structureless; consists of comples structural units called haversion systems; found in shafts of long bones
weblike matrix of marrow filled spaces and trabaculae; irregular bones
Until linear growth of bone is complete, the epiphysis remains separated from the diaphysis by a cartilaginous plate called the
epiphyseal cartilage.

When the bone is finished growing, the epiphyseal plate ossifies, and the epiphysis and diaphysis fuse.
Where they meet results in a slight flaring called the

Epiphyseal cartilage grows then ossifies resulting in an increase in length of long bones.
Diameter increases by the action of
osteoblasts and osteoclasts.

Films of wrists and hands can be taken to evaluate physiologic age and growth potential, and for predicting adult stature.
Example order would say,”Bone age wrist.”
Findings are based on radiographic atlas of ____ from thousands of exams on Amer

Greulich and Pyle
bone formation =

Bone destruction =

Bones also develop within a connective tissue membrane =
intramembranous ossification

Flat bones grow in size by the addition of osseous tissue to their outer surfaces = _____ They cannot grow by expansion.

appositional growth.
Bones perform 4 basic functions:

1. They serve as the supporting framework of the body and protect the vital organs.

2. Serve as levers on which muscles can contract and shorten and thus produce movement at a joint.

3. Red bone marrow within certain bones is the major site of production of blood cells.

4.Serve as the major storehouse for calcium salts. The maintenance of a normal level of calcium, which is essential for survival, depends on a balance in the rates of calcium movement between the blood and bones.

one that has characteristics of vertebrae on both sides of a major division of the spine.
transitional vertebrae
transitional vertebrae

Most frequently occur at the ____ junction and contain expanded transverse processes, which may form actual unilateral or bilateral joints with the sacrum.

posterior defect of the spinal canal resulting from failure of the posterior elements to fuse properly.
Occurs in 5% of live births

spina bifida
Mild, insignificant form =_______ = splitting of the bony neural canal at the L5 or S1 level

spina bifida occulta
______-associated malformations include clubfeet, gait disturbances, and bladder incontinence.

______has associated neurologic deficits @ and below the site of protrusion. Chiari II malformation and hydrocephalus are frequent complications

“marble bones”

Failure of the resorptive mechanism of calcified cartilage interfering with the normal replacement by mature bone, prevents bone marrow from forming

Stress fractures occur often
Pt. may become anemic due to lack of blood-producing marrow.

Varies in severity and age of clinical presentation = can be fatal at birth or in utero involving entire skeleton to essentially asymptomatic that can be an incidental radiographic finding

Symmetric, generalized increase in bone density.
Most commonly seen in vertebrae, pelvis, and cranial base
Chalky white or opaque

what do you do to technical factors for osteopetrosis?
Inherited, generalized disorder of connective tissue characterized by multiple fractures and an unusual blue color of the normally white sclera of the eye.

osteogeneis imperfecta
Adult patients are normally wheel-chair bound because the skeletal structure does not support their body weight.

“brittle bone disease”

osteogenesis imperfecta
2 forms of osteogenesis imperfecta
congenital and then the regular
most serious, fractures present at birth, usually die within a few days, Wormian bones within the skull (ossification of the skull progresses slowly, leaving wide sutures and multiple juxtasutural accessory bones within a suture.
congenital (osteogenesis imperfecta)
– most common and least severe, often mistaken for Battered Child Syndrome

Osteogenesis imperfecta tarda
osteogenesis imperfecta
Repeated fractures

Severe osteoporosis

Thin, defective cortices

Exuberant callus formation that may simulate a malignant tumor

Bizarre deformaties

Lower exposure factors in advanced stages

Most common form of dwarfism

Results from diminished proliferation of cartilage in the growth plate (decreased

Autosomal dominant

Does not affect membranous bone formation

characteristics of achondroplasia
nearly normal trunk size; large head with frontal bulging, saddle nose, jutting jaw, and prominent butt that gives impression of lumbar lordosis
Progressive narrowing of the interpedicular distances from above downward, the opposite of normal

Posterior scalloping of lumbar vertebral bodies

Decreased enchondral bone formation giving appearance of shortened long bones that are thick with a wide metaphysis ______

(Erlenmeyer flask deformity)


Most common congenital hip disorder
More common in firstborn females (83%) and 10X more common in breech fetal presentations
Results from incomplete acetabulum formation

congenital hip dysplasia
Ortolani’s sign =
infant is place supine, hips flexed and then abducted while the femur is pressed, this will dislocate the hip resulting in a clicking sound = “hip click” =
Trendelenburg’s sign =
infant is placed on affected side and opposite knee is lifted, the pelvis drops on the normal side where is remains horizontal on the other side

Chronic systemic disease of idiopathic etiology

Appears primarily as noninfectious, inflammatory arthritis of hands and feet

Women are affected 3X more frequently than men

Average onset is 40

rhematoid arthritis
rheumatoid arthritis

Gradual and slowly progressive

Leads to crippling deformity of affected joints or spontaneous remissions of variable length

Usually ______

Often progresses______ toward trunk until almost every joint in the


rhematoid arthritis

Begins as an inflammation of the ______ that lines the joints

Excessive exudate causes proliferation of the synovium = causes ______

Erosion occurs because inflammatory cells produce lytic enzymes.

synovial membrane; erosion of the articular cartilage and underlying bony cortex, fibrous scarring, and even the development of ankylosis

Usually begins in the SI joints
Causes bilateral and symmetric involvement

anklosing spondylitis
Blurring of the articular margins and patchy sclerosis generally progress to narrowing of the joint space and may lead to complete fibrous and bony ankylosis

ankylosing spondylitis
Characterized by arthritis, urethritis, and conjunctivitis

Primarily affects young men and appears to be a postinfectious syndrome after certain types of venereal (Chlamydia) or gastrointestinal infections

Reiters syndrome
Reiters Syndrome

Most frequently involves the_____, ____,____ Tends to asymmetric and primarily involves the feet rather than the hands

SI joints, heel, and toes

Rheumatiod like destructive process involving the peripheral joints that develops in patients with typical skin changes of psoriasis

Psoriatic Arthritis
Psoriatic Arthritis

Involves ____of the hands and feet

distal interphalangeal joint


Little or no periarticular arthritis

Bony ankylosis of interphalangeal joints of hands and feet and resorption of the terminal tufts of the distal phalanges

psoriatic arthritis
psoriatic arthritis

Erosions and hypertrophic changes occurring in the ___________

origin and insertion of the tendons and ligaments

Degenerative joint disease

Loss of cartilage and reactive new bone formation

Part of the wear and tear aging process

what joints does osteoarthritis tend to affect
Tends to affect the wt-bearing joints (spine, hip, knee, ankle) and the interphalangeal joints of the fingers

Narrowing of the joint space, caused by thinning of the articular cartilage

Small bony, spurs (osteophytes) along the margins of the articular edges of the bones

Sometimes due to repeated trauma or subjection to abnormal stresses because of orthopedic deformities or the result of a septic or inflammatory arthritis that

Chronic, indolent infection that has an insidious onset and a slowly progressive course

Usually involves only one joint

tuberculous arthritis
tuberculous arthritis usually affects what?
spine, hips, and knees
Joint effusion leads to soft-tissue swelling

Cartilage and bone destruction occur relatively late in the course of TB arthritis, tends to involve the periphery of the joint, sparing the maximal wt-bearing surfaces that are destroyed in pyogenic art

tuberculous arthritis
treatment of arthritis

Should protect affected joints, maintain mobility, and strengthen muscles

Lifestyle changes, use of support devices, drugs, and surgery

Rest and exercise

Medications such as NSAIDs, antimetabolites (methotrexate = a cytoxic drug), prostaglandin inhibitors such as aspirin and ibuprofen

Surgery involves replacing joints with new artificial joints to increase mobility

what are bursae
fluid-filled sacs near the joint spaces that reduce friction during movement
bursitis is not what?
visulaized on plain radiographs
a rotatator cuff is a musculoteninous structure composed of the ___, ____, ____, and ______
musculotendinous structure composed of the teres minor, infraspinatous, supraspinatus, and subscapularis muscles.
Rupture of the rotator cuff produces
a communication between the shoulder joint and subacromial bursae that can be demonstrated by arthrography.

Inflammation of the bone (osteitis) and bone marrow (myelitis) that is caused by a broad spectrum of infectious organisms that reach bone by hematogenous spread, by extension from an adjacent sit of infection, or by direct introduction of organisms (trauma or surgery)

Acute hematogenous osteomyleitis tends to
involve bones with rich red marrow


In infants and children, the metaphyses of long bones, especially the ____ and ____, are most often affected

femus and tibis
____and ____are the most common organisms when discussing osteomyleitis

staphylococci and streptococci
In adults, acute hematogenous osteomyelitis primarily occurs in the
vertebrae and rarely involves the long bones

Incidence and severity of osteomyelitis have decreased since the
advent of antibiotics

Begins as an abscess of the bone


Pus produced by acute inflammation spreads down the ______.

Once the infectious process has reached the outer margin of the bone, it raises the ______________.

medullary cavity and outward to the surface; periosteum from the bone and may spread along the surface for a considerable distance


Earliest evidence in a long bone is a localized, _________

deep soft-tissue swelling adjacent to the metaphysis


_____causes displacement or obliteration of the normal fat planes adjacent to and between the deep muscle bundles, unlike skin infections, in which the initial swelling is superficial


Initial bony change is subtle areas of _______

metaphyseal lucency reflecting resorption of necrotic bone


Bone destruction becomes more prominent, producing a ragged, _______

moth-eaten appearance bone,


Eventually, a large amount of new bone surrounds the cortex in a thick, irregular bony sleeve (______)

Disruption of cortical blood supply leads to _____

involucrum); bone necrosis


Segments of avascular dead bone (___) remain as dense as normal bone and are clearly differentiated from the _____

sequestra);demineralized infected granulation tissue and pus about them

loss of bone density
two groups of osteoporosis
primary/idiopathic and secondary


3 types:

Juvenile Osteoporosis
Afflicts younger people and the cause is idiopathic rather than metabolic

Lack of estrogen

Most common type

Juvenile Osteoporosis
afflicts yournger ppl and the cause is idiopathic rather than metabolic
postmenstrual osteoporosis
lack of estrogen
senile osteoporosis
most common
secondary osteoporosis
cause by other diseases
Radiographic Appearance of osteoporosis:

Cortical thinning
Most evident in the spine and pelvis

Insufficient mineralization of the adult skeleton

Lack of Vitamin D

Other causes
Chronic kidney failure
Certain renal diseases

Radiographic Appearance of osteomalacia:

Loss of bone density

Cortical borders are often indistinct

Bowing deformities

Deepening of the acetabular cavities

Childhood equivalent of osteomalacia

Rickets occurs before the unification of the diaphysis and epiphyses where osteomalacia occurs after epiphyseal closure

Rickets occurs before the
unification of the diaphysis and epiphyses where osteomalacia occurs after epiphyseal closure

Radiographic Appearance of rickets:

Radiograph knees, wrists & ankles

Bowing deformity with greenstick fractures

Decreased density between the ossified portion of the epiphysis and the end of the shaft.

Uric acid crystals are deposited in the joints, cartilage and kidney.


Clinical Symptoms of gout:

Painful arthritis
Initially attacks one joint (big toe)

Radiographic Appearance for gout


Joint effusion

Periarticular swelling

Punched-out erosions with thin sclerotic margins and overhanging edges (rat bite appearance)

Radiographic Appearance for gout


Large, lumpy, soft tissue swelling

pagets disease

______in the early stages

Radiographic findings found in 10% of all those over 60

Twice as common in ______

Asymptomatic;men than women

symptoms of pagets
Pain in

extreme cases of pagets
Extreme cases:
Difficult movement
Head size increases
Heart failure

etiology of pagets
Early viral infection (mumps) may be dormant and come up later

Increase in bone cell activity which causes an increase in vasculature / increased cardiac output

complications of pagets

Structural deformities:

Compression of spinal cord
Heart failure

Treatment for pagets
Drug Therapy
Surgery may be performed

Radiographic appearance for skull-- Pagets
Early: osteoporosis
Late: irregular islands of sclerosis / cotton wool appearance

Appearance for spine for Pagets
Enlargement of the vertebral body

Appearance for pelvis when a pt has Pagets disease
Most common and often the initial site
Coarsening of the iliac margins

A chronic and progressive condition that results from hyper-secretion of growth hormone from the pituitary gland.

Over production before the onset of puberty
Before epiphyseal closure

radiographic appearance of acromegaly
Ballooning of the sella turcica
Prominent tufts on the terminal phalanges with widening of the metacarpophalangeal joints

A well defined sclerotic edge is
almost always benign

An ill-defined sclerotic or lytic edge is
likely to be aggressive

adjacent cortex indicates:
Any destruction indicates malignancy

Bone expansion with an intact cortex indicates
a slow growing lesion

Active periosteal reaction in the absence of trauma indicates ____ Causes:

an aggressive lesion

Malignant bone tumor / Ewing’s Sarcoma

Patchy calcification of a popcorn type indicates_____

Diffuse ill-defined calcification suggests __________

a cartilage tumor

osteoid formation and indicates an osteosarcoma.

A soft tissue swelling suggests a _____The better defined the mass, ________

The more ill-defined, _________

tumor; the more likely it is to be a neoplasm

the more likely it is to be edema caused by an infection


Certain lesions occur at certain

Benign projection of bone with a cartilaginous cap that arises in childhood or the teens
Especially around the knee

Slow growing benign cartilaginous tumor arising in the medullary canal
Affects children and young adults
Small bones of the hands and feet

radiographic appearance of an endochondroma
Lesion is localized, radiolucent cystic defect

May be calcifications

Pathological fractures may develop

In children and young adults

Usually before 30

Occurs at the end of long bones, primarily the knee
Locally destructive but does not cause metastases or kill the patient

giant cell tumor
appearance of a giant cell tumor
Radiographic Appearance:
Large bubbles separated by thin strips of bone.

Most often occur in the outer table of the skull, sinuses and mandible

appearance of an osteoma
Well circumscribed, extremely dense round lesions

Develops in teenagers / young adults
There is local pain that is worse at night
Occurs in the femur or tibia

osteoid osteoma
appearance of an osteoid osteoma
Small, round or oval center surrounded by large, dense sclerotic zone of cortical thickening

True fluid filled cyst with a wall of fibrous tissue
Pathologic fractures can develop

simple bone cyst
appearance of a simple bone cyst
Expansive lucent lesion, demarcated from adjacent normal bone and may have a thin rim of sclerosis

Consists of numerous blood filled arteriovenous communications

aneurismal bone cyst

Expansible, eccentric cyst like lesions that causes marked ballooning of the thinned cortex

aneurismal bone cyst
Most common of the malignant tumors
Disease of the young
10 – 25
Rarely seen after age of 50
Usually occurs in males
Common Location
Ends of the long bones / knee

osteogenic sarcoma
appearance of osteogenic sarcoma
Periosteum is lifted from bone by the tumor and new bone is laid down – Sun Ray Effect

Codman’s Triangle
A thin periosteal elevation and subsequent new bone formation

Spread by the bloodstream and metastases often first appears in the lungs

osteogenic sarcoma
treatment of osteogenic sarcoma
Radiation Therapy

etiology of osteogenic sarcoma
symptoms of osteogenic sarcoma
bone pain-dull and localized

tumor masses that can be felt

Occurs at early age ( 5 – 15) rarely after 30
Usually affects males

Invades the bone more diffusely than osteogenic sarcoma

It does not begin at the ends of the bone rather it progresses to the flat bones like the scapula, sternum, vert

ewings sarcoma tumor
appearance of ewing sarcoma tumor
diffuse involment in the grater part of the shaft with bone destruction
treatment of ewing sarcoma tumor
Radiation Therapy
It is very responsive to radiation but tends to return

Amputation if there is no metastases

A neoplasm (tumor of bone marrow) of immature plasma cells that infiltrate bone to cause osteolytic lesions throughout the skeleton
Flat Bones
Vertebra, skull, pelvis, ribs
In late stages it infiltrates the body organs

multiple myeloma
Strikes mostly men between 50 – 70
More common in blacks than caucasians

multiple myeloma
Prognosis is poor because it is usually not diagnosed until it has infiltrated the bone

multiple myeloma
52% of the patients die within 3 months, 90% within two years of diagnosis

multiple myeloma
symptoms of multiple myeloma
Constant back pain
Joint swelling
Pathologic fractures
Even loss of height (up to 5”or more) due to compression of the vertebrae

appearance of multiple myeloma
Multiple punched out osteolytic lesions scattered throughout the skeletal system

treatment to multiple myeloma
Local Radiation Therapy
Renal Dialysis

Death follows complications such as renal failure, hyperuricemia and dehydration

multiple myeloma
most common skeletal abnormality seen in a general radiology practice
A fracture is
defined as a disruption of bone caused by mechanical forces applied either directly to the bone or transmitted along the shaft of a bone

Fractures are described and classified by:




number of fracture lines

integrity of the overlying skin

A fracture that results in discontinuity between two or more fragments

causes only partial discontinuity, with a portion of the cortex remaining intact

the overlying is intact; if the overlying skin is disrupted, the fracture is open, or compound.

Bone is separated into two or more and often numerous fragments
Seen in sever vehicular accidents an gunshot wounds

Runs at a right angle to the long axis of a bone

Most commonly the result of a direct blow or a fracture within pathologic bone.

Runs a course of approximately 45 to the long axis of the bone

Is the result of angulation or both angulation and compression forces

Encircles the shaft
Generally longer than an oblique fracture
Caused by torsional forces.

Generally small fragments torn off from bony prominences

They are usually the result of indirectly applied tension forces within attached ligaments and tendons rather than direct blows

Composed of more than two fragments

Results from a compression force that causes compaction of bone Trabeculae and results in decreased length or width of a portion of a bone

Compression fractures most commonly occur in the vertebral body as a result of flexion of the spine.

Is the response of bone to repeated stresses, no one of which is sufficient to cause a fracture

stress of fatigue
Occurs in bone at an area of weakness

Most Common Cause:
Metastatic cancer
Breast cancer in women
Lung cancer in men

An incomplete fracture with the opposite cortex intact

_____ are found almost exclusively in infants and children because of the softness of their cancellous bone.

A fracture is ____ when a plane of cleavage exists in the bone without angulation or separation

______ refers to separation of bone fragments; the direction of displacement is described by the relation of the distal fragment with respect to the proximal fragment and is usually measured in terms of the thickness of the shaft

Refers to displacement of a bone so that it is not in contact with its normal articulation

The overall goal of fracture treatment is
to restore function and stability with an acceptable cosmetic result and a minimum of residual deformity

In external, or closed, reduction the fracture is treated by
manipulation of the affected body part without surgical incision

____ is a surgical procedure in which there is direct or indirect manipulation of the fracture fragments and usually the application or insertion of some type of appliance or device to achieve and maintain the reduction

Open reduction
_____ is accomplished by the use of splints or casts

External fixation
______ uses metal plates and screws, wires, rods, or nails, either alone or in combination, to maintain the reduction

Internal fixation
The radiographic evidence of _______ is a continuous external bridge of callus (calcium deposition) that extends across the line of fracture and unites the fracture fragments.

fx healing
______ is the healing of fragments of a fracture in a faulty position. This leads to impairment of normal function or cosmetic appearance that may require surgical correction.

is an ill-defined term that is arbitrarily applied to any fracture that takes longer to heal than the average fracture at that anatomic location
delayed union
refers to a condition in which the fracture healing process has completely stopped and the fragments will remain ununited even with prolonged immobilization
Pathologic fx

The most common underlying process is _____

metastatic malignancy or multiple myeloma

In children, developmental diseases such as osteogenesis imperfecta, osteopetrosis, or nutritional deficiencies (rickets, scurvy) may result in
pathologic fractures

Refers to multiple, repeated physically induced injuries in young children caused by parents or guardians

battered child syndrome
appearance of battered child syndrome
Multiple fractures of varying age in various stages of healing

Fractures of the corners of metaphyses with or without associated epiphyseal displacement

Exuberant subperiosteal new bone formation along the shafts of long bones

Skull fractures or widening of the cranial sutures are commonly associated

Another highly suggestive finding is one or more fractures at otherwise unusual sites (fractured only by direct blows), such as the ribs, scapula, sternum, spine, or lateral

battered child syndrome
Transverse fracture through the distal radius with dorsal (posterior) angulation and often overriding of the distal fracture fragment

In more than half the cases there is an associated avulsion fracture of the ulnar styloid process

colles fx
is usually caused by a fall on the outstretched hand and is the most common fracture about the wrist

Colles’ fracture
Identical to Colles’ fracture except that when the wrist is placed in the lateral position, the distal radius is displaced anterior or forward about 30 degrees

smiths fx
Most common fractures involving the carpal bones
They are usually transverse and occur through the central part (waist) of the bone

navicular fx
A transverse fracture of the neck of the fifth metacarpal with volar (palmar) angulation of the distal fragment
This injury typically is the result of a blow struck with the fist

boxers fx
Five distinct variations of epiphyseal plate in which there is trauma with hemorrhage into the growth plate

Results in retardation or cessation of growth

When occurring in the lower limb it may result in a shorter limb and a permanent limp

salter fx
The floor of the orbit is the most common portion of the orbit to sustain fracture

blow out fx
classic radiographic finding in blow-out fractures is the
presence of a polypoid mass (the tear-drop) protruding from the floor of the orbit into the maxillary antrum
The tear-drop represents _____in a blow out fx
the herniated orbital contents

In the detection of fractures about the elbow, a valuable clue is displacement
of the normal elbow fat pads (fat pad sign)

On lateral projections of the elbow, the anterior fat pad normally appears as a_____ closely applied to the anterior surface of the distal end of the humerus.

Most fractures of the forearm involve both the radius and ulna
If only one bone is fractured, it is essential to examine both the elbow and the wrist to exclude the possibility of proximal or distal joint dislocation

fxs of forearm
involves both malleoli (of tibia and fibula) with dislocation of the ankle joint

A bimalleolar fracture refers to one involving both the medial and the lateral malleoli

potts fx
Because of the mechanism of injury, the fracture on one side is transverse, whereas the opposite fracture is oblique or spiral

Trimalleolar fractures involve the posterior lip of the tibia in addition to the medial and lateral malleoli and usually

potts fx
The ____is by far the most commonly dislocated joint in the body

About 95% of_____dislocations are anterior and the result of external rotation and abduction of the arm

Fractures and dislocations of the spine may be the result of :

Direct trauma

Hyperextension-flexion injuries (whiplash)

Normal stresses in abnormal bone (osteoporosis, metastatic destruction)

The anterior column is composed of the
vertebral bodies, intervertebral disks, and anterior and posterior longitudinal ligament

The posterior column is formed by
facets, apophyseal joints, pedicles, laminae, spinous processes, and all the intervening ligaments

If one of the two columns remains intact, the injury is considered

If both columns are disrupted, the injury is considered

Two goals of Radiographer in eval of spine
Determine whether a fracture or dislocation is present

Whether the injury is stable or unstable

is comminuted fracture of the ring of the atlas that involves both the anterior and posterior arches and causes displacement of the fragments

Jefferson fracture
Fractures of the odontoid process are usually transverse and located at the base of the dens at its junction with the body

On an open mouth view, a lucency between the upper central incisor teeth often overlaps the dens; this must be differentiated

c spine
the result of acute hyperextension of the head on the neck
hangmans fx
It appears as a fracture of the arch of C2 anterior to the inferior facet and is usually associated with anterior subluxation of C2 on C3.

hangmans fx
transverse fracture of a lumbar vertebra that is often associated with significant visceral injuries
There is a horizontal fracture of the vertebral body that extends to involve some or all of the posterior elements

seat belt fx
a cleft in the pars interarticularis that is situated between the superior and inferior articular processes of a vertebra.

Occurs in about 5% of the population, these clefts are usually bilateral, most commonly involve the fifth lumbar vertebra, and predispose to the forward displacement of one vertebra on the other.

_____is the term for a defect in the pars interarticularis without displacement
If displacement occurs, the condition is called ______


May demonstrate the lucent cleft in the pars interarticularis even if no displacement has occurred

The diagnosis of spondylolysis without displacement may require an ______ of the lumbar spine, on which the appearance of the posterior elements has been likened to that of a Scotty dog.

oblique projection
The pedicle and transverse process form the
eye and nose

The superior and inferior articular processes form the
ear and leg

The pars interarticularis forms the ____-, which is “fractured” in a patient with spondylolysis


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