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MSK X- Rays Dr Peony Kan (ST1 Clinical Radiology)Objectives ● Have general approach to presenting MSK x-rays ● Exposure to common OSCE cases ● Gain some phrases and terms to describe your findings ● Get a flavour of common questions that might come up in MSK Xray OSCE stationsTo start off… 1. Patient demographic 2. Date 3. View 4. Body part being imaged (+ laterality) 5. Quality of film ○ Joint above & below ○ Rotation ○ PenetrationInterpretation of findings (ABCS) A lignment: dislocation, subluxation B ones: trace the cortex, ? fractures C artilage: joint spaces, disruption of joint contours S oft tissues: swelling, foreign bodies, disruption, calcificationAlignment 1. Fracture/ subluxation/ dislocation? 2. How is it displaced? ○ Check other views ○ Displacement refers to the relation of the fragment distal to the fracture site ○ Angulation ○ TranslationBones- Trace the cortices! 1. Where (which bone, extra/ intra articular) 2. Complete/ Incomplete (which subtype) 3. Open/ Closed 4. Displacement (look at a different view) 5. Shortening 6. +/- comment on bone texture (trabecular pattern)Cartilage 1. Review joint spaces 2. Narrowing can be due to: ○ Cartilage loss ○ Osteophytes ○ CalcificationSoft Tissue 1. Localised swelling 2. Joint effusions 3. Fat pads 4. Foreign bodies 5. Anything else…To complete… 1. Check other views (if not already done) 2. History and examination of patientPaediatric incomplete fractures Buckle fracture Greenstick fracturePaediatric fractures- Salter Harris classification ● Growth plate/ physis ● Mnemonic: ○ Slipped/ straight ○ Above ○ Lower ○ Through ○ RuinedCases Putting it all together…Left knee AP XRLeft knee XR ● Patient demographics ● Asymmetrical reduction of femorotibial joint space ● Osteophytes (medial femur & lateral tibia) ● Subchondral sclerosis (tibial plateau) ● No fracture, no misalignment ● Soft tissue normal Diagnosis= Osteoarthritis of the left knee ● Review other views ● Complete with history and examOsteoarthritis vs Rheumatoid vs Psoriatic arthritis?Osteoarthritis vs Rheumatoid vs Psoriatic arthritis?Osteoarthritis vs Rheumatoid vs Psoriatic arthritis?GoutPseudogout / Calcium pyrophosphate dihydrate deposition disease (CPPD)Common pathologies in the joint ● Rheumatoid arthritis ● Psoriatic arthritis ● Gout ● Pseudogout / Calcium pyrophosphate dihydrate deposition disease (CPPD)Right shoulder APRight shoulder XR ● Patient demographics ● Lightbulb sign appearance of right humeral head (internal rotation of humerus) ● No dislocation of the AC joint ● No fractures Diagnosis= Posterior dislocation of right shoulder (glenohumeral) joint ● Review other views ● Complete with history and examAnterior shoulder dislocationCommon pathologies on shoulder XR ● Anterior glenohumeral joint dislocation ● Acromioclavicular joint dislocation ● Clavicle fracture ● Proximal humeral fractureLeft upper limb XR AP: Lateral:Left upper arm XR ● Patient demographics ● Complete, extra-articular, transverse fracture in the left distal radius ● Closed fracture ● Palmar/ volar angulation ● No significant joint swelling Diagnosis= Smith’s/ reverse Colles’ fracture ● Complete with history and examWhich of the following statement is false regarding Colles’ fracture? A. Distal radius fracture with palmar/volar angulation B. Associated with fall on a outstretched hand (FOOSH) C. Associated with a ‘dinner fork’ deformity D. It is common in the elderlyFracture-dislocation of the upper limb Monteggia fracture-dislocation Galeazzi fracture-dislocation ● Fracture of the proximal ULNAR shaft with ● Fracture of the distal RADIUS with dislocation of the RADIAL head (proximal) dislocation of the distal radioULNAR joint GRUesome MURder Scaphoid fracture Complication if left untreated?Common pathologies in the upper limb XR Upper limb: ● Distal radius fractures (Colles’, Smith’s) ● Fracture-dislocations (Monteggia, Galeazzi) Wrist/ carpal bones: ● Scaphoid ● Triquetral ● Distal radioulnar joint dislocation ● Perilunate dislocationRight hip XRRight hip XR ● Patient demographics ● Displaced, comminuted oblique intertrochanteric fracture of the right femur ● Extra-capsular ● No dislocation ● Hip joint space is preserved Diagnosis= Right intertrochanteric fracture ● Review other views ● Complete with history and examWhich of the following statement is false? A. Intracapsular hip fractures are at risk of avascular necrosis of the femoral head B. Garden classification is used to assess risk of osteonecrosis in subcapital hip fractures C. Disruption of the circumflex femoral arteries can lead to avascular necrosis D. Transcervical fracture is a subtype of extracapsular fracturePubic rami fracturePerthes vs SUFE?Perthes vs SUFE?Common pathologies in the pelvis and hips Pelvis: ● Pubic rami, open book, acetabular, avulsion fractures Hips: ● Neck of femur fractures ○ Hip prosthesis ○ Garden classification system ● Paediatric hip conditions ○ Perthes Disease ○ Slipped upper femoral epiphysisLeft ankle XR AP: Lateral:Left ankle XR ● Patient demographics ● Comminuted oblique fracture of the distal left fibula ● At level of the syndesmosis ● Mild dorsal displacement ● Mild soft tissue swelling Diagnosis= Left distal fibula fracture (Weber B) ● Complete with history and examWeber classificationWhich of the following is false regarding Weber’s classification? A. Widening of the tibiofibular joint can be seen in Weber’s B injury B. Weber C fractures are above the level of the syndesmosis C. Weber A fractures are above the level of the syndesmosis D. Weber’s classification is important in determining treatment of distal fibula/ lateral malleolus fracturesCommon pathologies in the ankle and foot Ankle: ● Distal tibia (medial malleolus) ● Distal fibula (lateral malleolus) Foot: ● Metatarsal ● CalcanealSummary and Exam Tips ● Structured approach is key ● Don’t forget to check patient demographics ● Utilise ABCS ● Find films of common pathologies and practice presenting ● Be aware of classification systemsResources ● Geeky medics ● Radiopaedia ● www.radiologymasterclass.co.uk ● Ortho bullets ● Radiology assistant ○ Ankle fracture ○ Arthritis Thank you Questions? Contact: cheukyingpeony.kan@nhs.net