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MSK X-RAY INTERPRETATION By Ronan FitzgeraldAIMS · MSK X-ray interpretation: general format · Wrist X-raysMSK X-RAY INTERPRETATION FORMAT · Confirm patientdetails and when X-ray was taken. Wouldalso like to compareto previous films if available · Radiograph details: 1. Type of film (AP/Laterale.t.c) 2. Which body part: (body part + side of the body (left or right)) 3. Adequacy (RiPE): Rotation,Penetration,Exposure · Stateany obviousabnormalitiesand then go through X-ray systematically · Also state,if you have only been offered 1 type of fil (e.g. AP) you would like another X-ray with a different orientatedview to properly assesscertain elementslike the jointsand bones. · Interpretation(ABCS; OSCE stop goesthrough same format) a) Alignment b) Bone c) Cartilage d) Soft tissue ABCS; ALIGNMENT · Any change in alignment either suggests subluxation, dislocation or possible associated fracture · When describing displacement, the position of the distal fragment is described in context MEDIAL · In this image the 3 MTP joint shows complete dislocation with the distal fragment being displaced laterally. · Subluxation suggests there is still some joint-to-joint contactAs you can see this is still a dislocation as the joint surfaces shown by a red and white line do not show any signs of some contact with each other making this a dislocation rather than subluxationThis is a subluxation as alignment has been disrupted but there is still some joint to joint contact. However very important to have 2 X-ray films.ABCS; BONES · Trace around the cortex and look for any disruption to the cortex indicating a fracture. · Any disruption to the bones internal matrix (trabeculae): altered density may indicate pathologyDESCRIBING FRACTURES 3 W’S · Where is the fracture? · What type of fracture? · Where is the bone going?WHERE (IS THE FRACTURE) · Which bone? · Where abouts on the bone: proximal, middle or distal third? · Does it involve the joint as well (intra or extra articular)WHAT (TYPE OF FRACTURE IS IT) · Completeness (complete/incomplete) · Direction (transvere, oblique, spiral) · Are they any separated pieces of bone (comminuted, segmental e.t.c.)· Complete-Bone has cortical disruption on both sides of the bone and the fracture extends the whole width of the bone · Transverse: fracture occurs at horizontal plane to axis of bone (at a right angle) · Spiral: fracture caused by twisting injury · Oblique: fracture at an angle to the shaft · Comminuted: More than 2 detached bone fragments · Segmental: Multiple complete fractures creating an isolated bone fragment · Impacted: break ends are compressed together · Greenstick: Incomplete fracture of the bone resulting in bending of the bone (seen in children)GREENSTICK FRACTUREWHERE (IS THE BONE GOING) · Is the bone being displaced? When describing displacement of the bone comment on % of bony contact remaining · If yes then describe bone in the 3 different planes (translation, angulation, rotation): only can comment on certain elements if more then 1 field of view e.g. AP and lateral view.ABCS; CARTILAGE · Joint spaces: assess for loss of joint space or joint widening · Disruption of joint contours · Signs of Osteo/rheumatoid/psoriatic arthritis or gout/pseudogoutABCS: SOFT TISSUE · Soft tissue swellings · Joint effusion · Evidence of emphysema · Foreign bodies · Surgical or medical apparatus in situ· Arrows indicated effusion in the knee which can actually be seen displacing the patellar anteriorily.· Red arrow=lipohaemarthrosis · Blue arrow= tibial plateau fractureSURGICAL EMPHYSEMAWRIST X-RAYS: ANATOMYPA VIEWLATERAL VIEWOBLIQUE VIEWALIGNMENT-AP VIEW · Assess the distal radius articular surface’s position: should be cupping the carpal bones · Assess carpal arcs (also called gilulas lines): any disruption to an arc could suggest fracture or ligamentous injuriesLunate dislocation Way I used to remember what the capitate bone outline should look like is the ‘cap’itate bone looks like a ALIGNMENT-LATERAL VIEW toothpaste ‘cap’ Normal findings: • The long axis of the radius, lunate, capitate and the third metacarpal bone should align. • The palmar/volar cortex of the pisiform bone should lie between Lunate bone the scaphoid and capitate bones. looks like a • The radial surfaces should appear lunar eclipse smooth. moon • There should be a volar tilt of between 10°- 25° (to advanced to comment on- but say you could Scaphoid and check this) pisiform are found by their association to each otherCups of tea sign Spilled tea cupVOLAR TILT (ONLY FOR INTEREST) Volar tilt, or palmar tilt, is an important measurement in the evaluation of distal radius fractures and radial deformities. The volar tilt is assessed on the lateral radiograph of the wrist, it corresponds to the angle formed by a line drawn perpendicular to the axis of the radial shaft, and a line that passes through the tips of the dorsal and volar rims (i.e. along the radius articular surface) Normal is 7-15 degreesBONES · Radius: assess to ensure no distal or proximal fractures · Ulnar styloid · Carpal bones: pay careful attention to the proximal row and the scaphoid as these are most commonly injured · **Scaphoid is particularly at risk of avascular necrosis · MetacarpalsCARTILAGE · Spaces between carpal bones is normally 1-2mm: any increase/decrease in space is indicative of pathologySOFT TISSUES · Generally assess soft tissue structures of the wristSpot diagnosesCOLLES FRACTURE · FOOSH · Fracture at distal end of radius · Dinner fork deformity · ‘D’ for the ‘d’istal end of the radius is ‘d’orsally displaced · Smiths fracture is the opposite: palmar (volar displacement)Smiths fracture · Reverse of colles fracture · Fracture at distal end of radius · palmar (volar displacement) · FOOSH backwards fallingBARTONS FRACTURE: INTRAARTICULAR DISTAL RADIUS FRACTUREHutchinson fracture/chauffers fracture · Fracture of radial styloid process