X-RAY Patient Blocks Transmission of Radiation Soft tissues Less Bones More
X-RAY Capture Image Films Digital X-RAY
Interpret Image Radiologist Orthopaedist X-RAY Best for:
Hard tissue Bones Often combined with other imaging OBJECTIVES Review a systematic approach to interpreting
orthopedic x-rays Review the language of fracture description ABCs APPROACH Pre ABC: identify pt, read provided info A
Adequacy Alignment B Bones
C Cartilage S Soft Tissues
Apply ABCs approach to every orthopedic film you evaluate ADEQUACY All x-rays should have an adequate number of views. Minimum of 2 viewsAP and lateral
3 views preferred Joint above and joint below All x-rays should have adequate penetration ALIGNMENT
Alignment: Anatomic relationship between bones on x-ray Bone alignment vs other side Bone alignment relative to proximal and distal bones
Normal x-rays should have normal alignment Fractures and dislocations may affect the alignment on the x-ray BONES 1. Identify bone
2. Examine the whole bone for 1. Discontinuity fractures 2. Change in bone shadow consistency change in density 3. Describe bone abnormality
1. Location 2. Shape CARTILAGE Cartilage joint spaces on x-rays
you cannot actually see cartilage on x-rays Widening of joint spaces signifies ligamentous injury and/or fractures Narrowing of joint spaces arthritis
SOFT TISSUES Soft tissues implies to look for soft tissue swelling and joint effusions These can be signs of Trauma occult fractures
Infection Tumors REVIEW: ABCs A Assess adequacy of x-ray which includes proper number of views
and penetration Assess alignment of x-rays B Examine bones throughout their entire length for fracture lines and/or distortions
C Examine cartilages (joint spaces) for widening S Assess soft tissues for swelling/effusions
EXAMPLE # 1 EXAMPLE # 1 This x-ray demonstrates a lateral elbow x-ray. There is swelling anteriorly which is displaced
known as a pathologic anterior fat pad sign There is swelling posteriorly known as a posterior fat pad sign Both of these are signs of an occult fracture although none are visualized on this x-ray Remember, soft tissue swelling can be a sign of
occult fracture! EXAMPLE # 2WHERE ARE THE FRACTURES? EXAMPLE # 2
If you follow ABCs, you will notice there is are problems with alignment on this x-ray (A) (B)You will notice there are fracture lines through the 2nd, 3rd, and 4th metacarpals These are 2nd, 3rd, and 4th, midshaft metacarpal fractures.
A teaching point: Notice the ring on this film. Always remove rings of patients with fractured extremities because swelling may preclude removal later. LANGUAGE OF FRACTURES
Important for use to describe x-rays in medical terminology. Improves communication with orthopedic consultants LANGUAGE OF FRACTURES
Things you must describe (clinical and x-ray): Open vs Closed fracture Anatomic location of fracture Fracture line Relationship of fracture fragments Neurovascular status
OPEN VS CLOSED Must describe to a consultant if fracture is open or closed Closed fracture Simple fracture No open wounds of skin near fracture
Open fracture Compound fracture Cutaneous (open wounds) of skin near fracture site. Bone may protrude from skin Open fractures are open complete displaced and/or comminuted
Orthopedic emergency Requires emergency orthopedic consultation Bleeding must be controlled Management IV antibiotics
Tetanus prophylaxis Pain control Surgery for washout and reduction ANATOMIC LOCATION Describe the precise anatomic location of the
fracture Include if it is left or right sided bone Include name of bone Include location: ProximalMidDistal To aid in this, divide bone into 1/3rds
FOR EXAMPLE....WHERE IS THIS LOCATED? EXAMPLE This is a closed L distal femur fracture.
The main thing I want you to take from this example is the description of location ANATOMIC LOCATION Besides location, it is helpful to describe if the location of the fracture involves the joint space
intra-articular INTRA-ARTICULAR FRACTURE OF BASE 1ST METACARPAL FRACTURE LINES
Next, it is imperative to describe the type of fracture line There are several types of fracture lines FRACTURE LINES
FRACTURE LINES A is a transverse fracture B is an oblique fracture C is a spiral fracture D is a comminuted fracture There is also an impacted fracture where fracture ends are
compressed together WHAT TYPE OF FRACTURE LINE IS THIS??? ANS: TRANSVERSE FRACTURE
Transverse fractures occur perpendicular to the long axis of the bone. To fully describe the fracture, this is a closed midshaft transverse humerus fracture. ANOTHER EXAMPLE OF FRACTURE
LINE ANS: SPIRAL FRACTURE Spiral fractures occur in a spiral fashion along the long axis of the bone They are usually caused by a rotational force
To fully describe the fracture, this is a closed distal spiral fracture of the fibula ONE MORE EXAMPLE ANS: COMMINUTED FRACTURE
Comminuted fractures are those with 2 or more bone fragments are present Sometimes difficult to appreciate on x-ray but will clearly show on CT scan To fully describe the fracture, this is a closed R comminuted intertrochanteric fracture
FRACTURE FRAGMENTS Terms to be familiar with when describing the relationship of fracture fragments Alignment Angulation
ALIGNMENT/ANGULATION Alignment is the relationship in the longitudinal axis of one bone to another Angulation is any deviation from normal alignment Angulation is described in degrees of angulation
of the distal fragment in relation to the proximal fragmentto measure angle draw lines through normal axis of bone and fracture fragment 20 DEGREES OF ANGULATION
OTHER TERMS Apposition: amount of end to end contact of the fracture fragments Displacement: use interchangeably with apposition Bayonette apposition: overlap of fracture fragments Distraction: displacement in the longitudinal axis of
the bones Dislocation: disruption of normal relationship of articular surfaces DESCRIBE FRACTURE FRAGMENTS
ANSWER This is a closed midshaft tibial fracture.But how do we describe the fragments? This is an example of partial apposition; note part of the fracture fragments are touching each other Alternatively you can describe this as displaced 1/3 the
thickness of the bone Remember aposition and displacement are interchangeablewe tend to describe displacement Final answer: Closed midshaft tibial fracture with moderate (33%) displacement
ANOTHER ONE ANSWER There are 2 fractures on this film Closed distal radius fracture with complete displacement. Also there is an ulnar styloid fracture which is also
displaced The displacement is especially prominent on the lateral view highlighting the importance of multiple views. There may be intra-articular involvement as joint space is close by Remember, remove all jewelry from extremity fractures
BAYONETTE APPOSITION DISLOCATION DISLOCATION
Note the dislocation on the previous slide; the articular surfaces of the knee no longer maintain their normal relationship Dislocations are named by the positioin of the distal segemnt This is an Anterior knee dislocation
NEUROVASCULAR STATUS Finally when communicating a fracture, you will want to describe if the patient has any neurovascular deficits This is determined clinically
LANGUAUGE OF FRACTURES To review, when seeing a patient with a fracture and the x-ray, describe the following: Open vs closed fracture Anatomic location of fracture (distal, mid, proximal)
and if fracture is intra-articular Fracture line (transverse, oblique, spiral, comminuted) Relationship of fracture fragments (angulation, displacement, dislocation, etc) Neurovascular status
DESCRIBE THIS R MIDDLE PHALANX FRACTURE ANSWER Oblique fracture of midshaft of R 4 th middle phalanx with minimal displacement and no
angulation Remember to comment if open vs closed & neurovascular status DESCRIBE TO ORTHO ATTENDING
ANSWER This one is a bit more challenging! R midshaft tibia fracture displaced the thickness of the bone without angulation; also there is bayonette appositioning of the fracture
fragments R midshaft fibular fracture with complete displacement and Also comment if the fracture is open vs closed & neurovascular status
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