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All you need to know about ORTHOPAEDICS X-RAYS and MANAGEMENT BART ROSIŃSKI AKUL KAROSHI Reviewed by: Aishwarya Baskar Here’s whatwedo: ■ Weekly tutorialsopento all! 18:00 every Thursday ■ Focussed oncore presentationsand teaching diagnostictechniquefrom a If you’re new here… clinical perspective Welcome to ■ Raccuracyby doctorsto ensure Teaching ■ We’ll keepyouupdatedabout our Things! upcoming events viaemail and groupchats!X-Rays and the Hip Bart RosińskiX-Rays 1. Adequacy/alignment 1. Adequacy– is everything that needstobe visible? 2. Alignment– is everything in the right place(patient position)? 2. B1.esCortical outline 2. Bony texture 3. symmetry ABCE 3. Cartilage(andjoints) 1. Joint spaces 2. End plates 4. Soft tissueand everything else 1. Effusion 2. Calcification 3. ForeignbodiesX-Rays 1. Confirm details 1. Patient name,DOB, MRN 2. Date andtime 3. Anatomical site 4. Any previousx-rays? VRIPE 2. Views(in Hipx-rays) 1. Antero-posterior Acronymmore forCXR– 2. Lateral (frog leg) – paediatricpatients butstilluseful points 3. Rotation(trueAPor not?) 4. Inspiration 5. Penetration (distinctionbetweenbone andsoft tissue) 6. Exposure(joints aboveand below)Specifics in hip X-rays 1. Adequacy/alignment 1. Adequacy– above iliaccrests, 1/3 downshaft 2. Alignment– coccyxtipand pubicsymphysisin midline 2. Bones 1. Cortical outline –Shenton’sline 2. Bony texture – scleroticareas,lyticareas 3. symmetry 3. Cartilage(andjoints) 1. Joint spaces – osteoarthritis (LOSS) 2. End plates– sacroiliitis(sclerosis andirregularity) 4. S1.t Effusion– inflammatorydisease 2. Calcification 3. Foreignbodies – hip replacementsQuestion 1 A90year old womanpresentswithleft hippain andrefusal to bear weight after afall.Theradiographbelow was managing the patient?ost appropriate next stepin a) Dischargeasthereis no fracture b) Total hip replacement c) Broadspec IV abx d) MRIhip e) CT hipQuestion 1 A90year old womanpresentswithleft hippain andrefusal to bear weight after afall.Theradiographbelow was managing the patient?ost appropriate next stepin a) Dischargeasthereis no fracture b) Total hip replacement c) Broadspec IV abx d) MRIhip e) CT hipRisk Factors andsymptoms Difference between osteoporosisand Riskfactors osteopenia? ■ Increasingage -1 - -2.5= osteopenia ■ Falls <-2.5= osteoporosis ■ Low BMI ■ Femalesex ■ Osteoporosis/osteopenia Symptoms ■ Non-weight bearing ■ Shortened ■ Externally rotatedRisk Factors SBA A 46-year-old man is seen in clinic following treatment for a hip fracture after a fall from standing. He has rheumatoid arthritis and chronic gastrointestinal problems, including diarrhoea, bloating, and weight loss. He appears pale and thin, with a BMI of 18.0 kg/m². A dual-energy x-ray absorptiometry (DEXA)scan of the hip reveals a T-score of -3.0. Which option is the best next step? a) Calculate his FRAX score b) Calculate his Qfracture score c) Order lateralradiographs of lumbar and thoracic spine d) Perform bloods to exclude secondary causes e) Prescribe BisphosphonatesRisk Factors SBA A 46-year-old man is seen in clinic following treatment for a hip fracture after a fall from standing. He has rheumatoid arthritis and chronic gastrointestinal problems, including diarrhoea, bloating, and weight loss. He appears pale and thin, with a BMI of 18.0 kg/m². A dual-energy x-ray absorptiometry (DEXA)scan of the hip reveals a T-score of -3.0. Which option is the best next step? a) Calculate his FRAX score b) Calculate his Qfracture score c) Order lateralradiographs of lumbar and thoracic spine d) Perform bloods to exclude secondary causes e) Prescribe BisphosphonatesTypes of hip fractures ■ INTRAcapsular – Subcapital regionof femoral head to basocervicalregion of femoral neck – proximal to trochanters ■ EXTRAcapsular – INTERtrochanteric – betweentrochanters – SUBtrochanteric – betweenlesser trochanter and 5cm below In intracapsularfractures there is arisk ofAVN–due toa retrograde supply via thfemoral arterymflexGarden Classification Further classification for intracapsular NOF# Aids in deciding further managementGarden ClassificationManagement Intertrochanteric DHS Extracapsular Subtrochanteric IM Nail Undisplaced DHS/Cannulated (Garden I/II) screws Intracapsular Hemiarthroplasty Displaced Arthroplasty (Garden III/IV) Displaced? Replace Cannulated screws DHS IMnail Cannulate d screws Arthroplasty HemiarthroplastyManagement Case Thepatient,60-year-old male,presented withahistory of fall froma 3-metreheight. Helanded onhisleft pelvisand presented withnopainor deformity noted inother parts ofhis body,noback pain,no upper limb painor deformity,nopain related to another leg. What is our next step inmanagement?Management Case Cannulated Hip Screw – why?An 83-year-old patient is brought into the emergency department following a fall at home. She reports getting out of bed to use the bathroom and falling on her hip. She tells you she heard a cracking noise and was unable to get up until the carers found her the next morning. On examination,the patient appears agitated with an inability to perform active hip movements and pain when the joint is moved passively. An X-ray shows a subtrochanteric fracture of the left femur. The patient was previously independent and coping well alone. Given the diagnosis, how should this patient be managed? a) DHS b) Hemiarthroplasty c) IM nail d) Supportive management e) THRAn 83-year-old patient is brought into the emergency department following a fall at home. She reports getting out of bed to use the bathroom and falling on her hip. She tells you she heard a cracking noise and was unable to get up until the carers found her the next morning. On examination,the patient appears agitated with an inability to perform active hip movements and pain when the joint is moved passively. An X-ray shows a subtrochanteric fracture of the left femur. The patient was previously independent and coping well alone. Given the diagnosis, how should this patient be managed? a) DHS b) Hemiarthroplasty c) IM nail d) Supportive management e) THRComplications following operation ■ Malunion ■ Clots ■ Joint loosening ■ Differingleg lengths ■ Asepticjoint loosening ■ Infection – Staphylococcus aureus – <6w – Staphylococcus epidermidis - >6w (biofilm productiononprosthetic joint) MANYARETHESAMEFORALLOPERATIONSPost-operative mx SBA An 86-year-old lady suffersa mechanical fall and sustainsa pertrochanteric hip fracture.Thisis treated withadynamichip screw(DHS).Post-operatively, theward physiotherapist asksyou what her weight bearing statusis. What instructions wouldyou give? a) Full weight bearingafter 24hrs b) Bed rest for first 24hrs, unrestricted weight bearing afterwards c) Full weight bearingimmediatelypost op d) Bed rest until there isradiographicevidencethat thefracture isuniting e) Partial weight bearing for first 48hrsPost-operative mx SBA An 86-year-old lady suffersa mechanical fall and sustainsa pertrochanteric hip fracture.Thisis treated withadynamichip screw(DHS).Post-operatively, theward physiotherapist asksyou what her weight bearing statusis. What instructions wouldyou give? a) Full weight bearingafter 24hrs b) Bed rest for first 24hrs, unrestricted weight bearing afterwards c) Full weight bearingimmediatelypost op d) Bed rest until there isradiographicevidencethat thefracture isuniting e) Partial weight bearing for first 48hrsThe limping child ■ Perthe’s disease – Alimp,stiffnessand reduced ROM,widening of joint space, decreased femoral head size ■ DDH – Newborn,bracetofix, BarlowandOrtolani’stest +ve,unequal skinfolds/leg length ■ SUFE – 10-15 yo,obeseand boys, lossof internal rotationin leg during flexion ■ Tr– 2-10yo,painassociatedwithviral infection ■ JIA – Joint painand swelling,ANA+ve ■ Septic arthritisHip dislocation ■ Posterior – 90% – Affectedleg isshortened,adducted and internallyrotated ■ Anterior – Affectedleg abducted and externallyrotated, no legshortening ■ Management – A-E,analgesia – Reductionunder general anaestheticwithin 4hrsto reducerisk of AVN – Physiotherapy to strengthenmusclesA 25-year-old man attends the emergency department after being involved in a road traffic accident. He was in the driver's seat when a lorry in front lost control and became trapped when the dashboard and footwell were pushed forward on impact. He is currently stable but has significant pain in his right leg. His right leg is shortened, internally rotated,slightly flexed and adducted compared to the left. What is the diagnosis? a) SUFE b) Anterior hip dislocation c) Femoralshaft fracture d) Posterior hip dislocation e) Neckof femur fractureA 25-year-old man attends the emergency department after being involved in a road traffic accident. He was in the driver's seat when a lorry in front lost control and became trapped when the dashboard and footwell were pushed forward on impact. He is currently stable but has significant pain in his right leg. His right leg is shortened, internally rotated,slightly flexed and adducted compared to the left. What is the diagnosis? a) SUFE b) Anterior hip dislocation c) Femoralshaft fracture d) Posterior hip dislocation e) Neckof femur fracture Other important fractures Akul KaroshiAnkle fractures - Anklecomponents – medial malleolus, lateral malleolus, distal tibia, talus - Indicationsfor anankleXray: o Otoo1- Bony tenderness atlateral malleolar zone (at tipup to 6cm border of fibula o 2- Bony tenderness atmedial malleolar zone (up to 6cmup the tibia) o 3- Inability to weightbearfor4 steps o SkipX ray if neurovascularcompromise anddoclosed reduction first - Management o Nonsurgical – closedreductionandCAMboot (controlled anklemotion boot).Betterfornon-displaced fractures/not fit for surgery o Surgery– openreduction andinternal fixation – openfractures, displacedAnkle fractures SBA A30-year-old manpresentsto theEmergency Department after twisting his right anklewhileplaying football.Onexamination,hehasswelling and tendernessover thelateral malleolus.AnkleX-ray showsa fibular fractureat thelevel of the syndesmosis,withnowideningof themortise. Themedial structures appear intact. Which Weber classification best describesthis injury? A. Weber A B.Weber B C.Weber CAnkle fractures SBA A30-year-old manpresentsto theEmergency Department after twisting his right anklewhileplaying football.Onexamination,hehasswelling and tendernessover thelateral malleolus.AnkleX-ray showsa fibular fractureat thelevel of the syndesmosis,withnowideningof themortise. Themedial structures appear intact. Which Weber classification best describesthis injury? A.Weber A B.Weber B C.Weber CAnkle fractures: Weber's ■ Weber A– analgesiaand weight bear as tolerated withCAM book ■ Weber B– Xray.If syndesmosisunstablethen surgery, if stable ->CAM boot ■ Weber B– openreduction internal fixationSpot diagnosisForearm fractures - Galeazzi fracture o Radial shaft fracture o Causes ulnardisplacement at wrist (distal radioulnar join) o Occursafter fall withrotational force - Monteggia's fracture o Ulnar shaft fracture o Causes radial displacement at elbow (proximal radioulnar joint) o Occursafter FOOSHand forced pronation- A22-year-old malepresentstoA&E after a fall during arugby match.He complainsof severepain inhisright shoulder andisholdingthearm slightly abductedand externally rotated.Thereisavisibledeformity,and he is unabletomovethearm.Onexamination, thereisreduced sensationover the lateral aspect of theshoulder. - What is thesinglemost likely diagnosis? - A. Posterior shoulder dislocation B.Anterior shoulder dislocation C.Acromioclavicular joint separation D. Claviclefracture E.Rotator cuff tear- A22-year-old malepresentstoA&E after a fall during arugby match.He complainsof severepain inhisright shoulder andisholdingthearm slightly abductedand externally rotated.Thereisavisibledeformity,and he is unabletomovethearm.Onexamination, thereisreduced sensationover the lateral aspect of theshoulder. - What is thesinglemost likely diagnosis? - A. Posterior shoulder dislocation B. Anterior shoulder dislocation C.Acromioclavicular joint separation D. Claviclefracture E.Rotator cuff tearShoulder dislocation - Head of humerus comes completely out of glenoid cavity - Subluxation = partial dislocation - >90% --> anterior dislocation of head o Presents as externally rotated,slightly abducted - Posterior dislocation tends to occur with the “three Es’ - Ethanoly (seizures) - Electrocution o X-ray: light bulb sign - Associateddamage o Tear in glenoid labrum o Bankart lesion o Hill-Sachs o Axillary nerve damageShoulder dislocation - Investigation - Apprehensiontesting - MRI– if suspected labrum tears, rotator cuff damage - Arthroscopy– if needed to visualise structures - Management - Analgesia,musclerelaxants and sedationasappropriate - Gas and air(e.g.,Entonox) maybe used - which containsa mixture of 50% nitrous oxide and 50% oxygen - Abroad arm sling canbeapplied to support thearm - Closed reduction oftheshoulder (after excluding fractures) - Dislocationsassociatedwitha fracturemay requiresurgery - Post-reduction x-rays - Immobilisation for aperiod after relocation oftheshoulderSpot diagnosesScapula and clavicle fracture - Scapular fracture o Highenergy trama o Mostlyassociatedwithother injuries likethorax ▪ Can be associated with pneumothorax andribfracture - Claviclefracture o 80% occurinthemidshaft o Occursfrom direct traumaor FOOSH o Canpresent asvisible bump, crack,grinding signwitharm movement, swelling,painandbruisingWrist and hand injuriesWrist and hand injuries - CollesFracture o FOOSHwithhand indorsiflexion o Most prevenlantin the elderly withosteoporosis o Dorsal displacement of distal radius o Dinner fork deformity - Smith'sfracture o Fall onback of hand o Volar displacementWrist and hand injuries - Scaphoid fracture o FOOSH o Bordersof theanatomical snuffbox o Mainvascular structure compromised – dorsal carpal branch ofthe radial artery– highrisk of avascular necrosis o Signs ▪ Painonpalpationof the anatomicalsnuffbox - Key signthat should promptyoutothink aboutscaphoid fractures ▪ Pain when telescopingthumb (pushingitback intowrist) ▪ X ray isoften normal ▪ If high suspicion, wristsplint in mean time andrepeatX ray in 10 daysQuickfirequestions ■ Diagnosis? 1. Patellar fracture 2. Tibial shaft fracture 3. Tibial plateau fracture 4. Fibular fractureQuickfirequestions ■ Diagnosis? 1. Patellar fracture 2. Tibial shaft fracture 3. Tibial plateau fracture 4. Fibular fractureQuickfirequestions ■ Diagnosis? 1. Greenstick fracture 2. Bucklefracture 3. Radial head fracture 4. Galeazzi fractureQuickfirequestions ■ Diagnosis? 1. Greenstick fracture 2. Bucklefracture 3. Radial head fracture 4. Galeazzi fractureQuickfirequestions ■ Diagnosis? 1. Scaphoid fracture 2. Hamatefracture 3. Boxer’sfracture 4. Barton’s fractureQuickfirequestions ■ Diagnosis? 1. Scaphoid fracture 2. Hamatefracture 3. Boxer’sfracture 4. Barton’s fracture THANKS FOR WATCHING! Tutor1: BartRosiński Tutor2: Akul Karoshi Pleasefill outthe feedback form on Medall and see you next week!