BasiC

ORTHOPEDIC RADIOLOGY
Masfuri
 OBJECTIVES
Review a systematic approach to interpreting
orthopedic x-rays
 ABCs APPROACH
A
Adequacy, Alignment
B
Bones
C
Cartilage
S
Soft Tissues
Apply ABCs approach to every orthopedic film
 ADEQUACY
All x-rays should have an adequate number of
views.
Minimum of 2 viewsAP and lateral
3 views preferred
Some bones require 4 views

All x-rays should have adequate penetration

 ALIGNMENT
Alignment: Anatomic relationship between
bones on x-ray

Normal x-rays should have normal alignment

Fractures and dislocations may affect the

alignment on the x-ray
 BONES
Examine bones for fracture lines or distortions

Examine the entire length of bone

Fractures may be subtle!

 CARTILAGE
Cartilage implies to examine the joint spaces
on x-rays (you cannot actually see cartilage on
x-rays)

Widening of joint spaces signifies ligamentous

injury and/or fractures
 SOFT TISSUES
Soft tissues implies to look for soft tissue
swelling and joint effusions

These can be signs of occult fractures

 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
 Bone anatomy
Key points:
Describing the location of a bone abnormality
within a growing bone: Diaphysis, metaphysis
or epiphysis
Similar to: - shaft - proximal/distal end -
cortical - medullary - articular surface
Bone anatomy
 Bone structure
Differentiation on X-rays - cortex being denser
and therefore whiter
 Joint anatomy
Most joints are synovial and comprise two
articulating bones lined with hyaline cartilage
and contained by a synovial lined capsule
 Descriptive terms
General terms can be used to describe the
location of an abnormality
 Systematic approach
Patient and image data
Bone and joint alignment
Joint spacing
Cortical outline
Bone texture
Soft tissues
Systematic approache
 Joint spacing
Joint spacing may be narrowed due to
cartilage loss or widened due to
dislocation/dissociation
X-Ray example: Osteoarthritis of the 1st
metatarsophalangeal joint
Look: oseophytes
 Cortical outline
Careful scrutiny of the bone cortex:
Check the cortical outline (white lines) of ALL
bones visible on every X-ray available
Check for any breach in this outline (red line ! )
Do not stop when you find one abnormality -
keep going until your eyes have covered all
bones
Boxer fracture
 Bone texture
Example: Proximal femur
Well defined trabecular pattern visible
forming the femoral neck architecture
Distortion of this trabecular pattern may make
an abnormality more conspicuous
Proximal femur
 Soft tissues
Scrutinising the soft tissues can often provide
helpful information.
Abnormality example: Joint effusion containing
fat and blood (lipohaemarthrosis) that has
'leaked' from bone following trauma
Visible fracture line - much less conspicuous than
the lipohaemarthrosis
Clinical information: Severe knee pain following
a fall
Diagnosis: Tibial plateau fracture
 Viewing principles
Confidence in assessing musculoskeletal system
X-rays comes from experience and a knowledge
of normal appearances. All patients are different,
so being sure of the distinction between normal
and abnormal is often difficult.

Key points:
2 views are better than 1
Check all available images
Compare with the other side (if imaged)
If available ALWAYS compare with old X-rays
2 views
 2 Views
Clinical information
Twisting injury to left ankle
Patient unable to bear weight
Lateral malleolus bone tenderness
Diagnosis
Oblique fracture of the distal fibula at the
level of the ankle joint
(Weber type B injury)
 Compare with other side
Images of the asymptomatic contralateral side to
a suspected abnormality are not routinely
acquired for assessment of all bones or joints.
Right v left example - Pelvis and hips
This image of the pelvis shows subtle irregularity
of the cortical outline of the right femoral neck
Comparison with the other side - which is
asymptomatic - increases confidence of a genuine
abnormality
There is also loss of the normal trabecular pattern
indicating a fracture (#)
 Compare 2 sides
Clinical information
Right groin pain after a fall
Shortened and externally rotated right leg
Diagnosis
Fractured neck of right femur
 Compare New and Old images
The 'old X-ray' is said to be the 'cheapest test
in radiology.'
The current X-ray shows an obvious displaced
fracture(#) of the femoral shaft
Diagnosis: Metastatic disease of bone with
pathological femoral shaft fracture (example:
lytic bone lesion)
 Keep your eye on the ball
When looking at an X-ray always keep the
current clinical features at the forefront of
your mind.
 Be focus on the Ball
Keep your eye on the ball:
Large calcified uterine fibroid
Loss of normal cortical contour of the femoral neck

Clinical information:
Elderly woman - mechanical fall
Right hip pain
Shortened and externally rotated right leg

Diagnosis:
Fractured neck of right femur (#)
Asymptomatic incidental uterine fibroid
 Look for the unexpected
Not all disease that presents with skeletal
symptoms is primarily related to bone or joints.
Very often pain is referred to the symptomatic
area and is explained by disease of another
system.
For example, shoulder pain is usually due to
shoulder pathology, but always keep in mind that
pain may be referred to the shoulder from the
cervical spine, brachial plexus or diaphragm.
 Look for the unexpected
Look for the unexpected :
Minor narrowing of the subacromial space (arrowheads) - suggesting
rotator cuff disease - very common cause of shoulder pain
It would be easy to consider this the only abnormality if not checking the
image systematically
Unexpected apical lung mass!
Clinical information:
Clinically suspected rotator cuff disease
Pain distal to the elbow - rarely if ever caused by shoulder pathology
Diagnosis:
Minor rotator cuff disease
'Pancoast' tumour - apical lung cancer (cause of distal pain - referred from
brachial plexus)
 Acromioclavicular joint
The acromioclavicular joint can be assessed with
standard shoulder X-rays.
Loss of alignment of the inferior surfaces of the
clavicle and acromion indicates disruption of the
acromioclavicular ligaments at the
acromioclavicular joint (ACJ).
Minor ligamentous disruption may not be
detectable on a plain radiograph as alignment is
not lost.
More severe injury can result in additional
disruption of the coracoclavicular ligaments.
 Acromioclavicular joint
Key points
Disruption of the acromioclavicular ligaments results in loss of
alignment of the clavicle and acromion inferior surfaces
Additional disruption of the coracoacromial ligament results in
separation of the entire scapula from the clavicle
Low grade ligament injury may not be visible on a plain X-ray
Acromioclavicular joint (ACJ) - Normal
The inferior margins of the acromion and clavicle are well aligned
(red lines) indicating integrity of the acromioclavicular ligaments
(not visible - position shown by blue lines)
The coracoid is not widely separated from the clavicle - this
indicates integrity of the coracoclavicular ligaments (not visible -
position shown by orange lines)
Others
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
 OPEN FRACTURES
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
spaceintra-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
Apposition
Displacement
Bayonette apposition
Distraction
Dislocation
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 4th 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
 Acknowledgement :
http://radiologymasterclass.co.uk/tutorials/
Nilesh Patel (2008). BASICS OF
ORTHOPEDIC RADIOLOGY