right side. On examination you note reduced range of motion & tenderness especially on hyperextension and internal rotation.
- Widening of joint
- Subsidence of
femoral head
Source: https://radiopaedia.org/cases/right-femoral-neck-fracture?lang=us
Attend the BIMA Radiology Crash Course to learn more about diagnosis and interpretation of limb x-rays. Led by Dr Edward Lim FY2 and Mr Shukla Orthopaedic Surgeon, the session will include an overview of indications for limb x-rays, types of limb x-rays, a review of anatomy (bones, joints, soft tissue), accessibility to x-ray reports, an ABCS approach to image interpretation, common fracture classifications and types, and Small Basic Assessment (SBA) questions based on clinical cases. Access critical knowledge to accurately diagnose and interpret limb x-rays.
right side.
- On examination, she is tender to palpation in the Right groin
area, with reduced range of motion of the Right hip. - ...with slight
displacement loss
Source: https://openorthopaedics.org/content/osteoporotic-nof-neck-of-femur-fracture
Learning objectives:
Warning!
The following transcript was generated automatically from the content and has not been checked or corrected manually.
LIM’S LIMB X-RAY INTERPRETATION Dr Edward Lim FY2 / Mr Shukla Orthopaedic Surgeon 17th OCTOBER 2023 18:30 @ BRITISHINDIANMEDICASSOCIATION @BINDIANMEDICS @BIMA BIMA Radiology Crash CourseOverview - Introduction - Indications for limb x-rays - Types of limb x-rays - Anatomy review (bones, joints, soft tissue) - XR reports - Image interpretation (ABCS) - Common fractures classifications/types - Clinical cases - SBA Q’s BIMA Radiology Crash CourseIntroduction What, when and why limb x-rays? Indications - Trauma - falls, RTA, physical altercations - Infections - joint infections, osteomyelitis - Arthritis - Inflammatory vs non-inflammatory - foreign bodies BIMA Radiology Crash CourseTypes of limb x-rays - Upper limb - shoulder girdle, humerus, elbow, radius, ulnar, wrist, hands - Lower limb - pelvic girdle, head of femur, femur shaft, knee, tibia, fibula, ankle, foot - Different views - AP, lateral, oblique BIMA Radiology Crash CourseLimb x-ray anatomy - Bone - Densest, white - Bone density - Alignment - Lesions/fractures - Soft tissue - less dense, grey - Muscles - Tendons & ligaments - calcification - Joint - least dense, black/grey - Joint space Source: https://radiopaedia.org/cases/normal-knee-x-rays?lang=us - Alignment - effusions BIMA Radiology Crash CoursePlain film/X-ray reports - Patient info Example report: Name: Mickey Mouse, 18/11/28 - Date & time Modality: Left knee AP & lateral view Date & time: 17/10/23, 14:30 - Radiographic views Findings: “No fracture is seen. Normal alignment of bone and architecture. Joint spaces and articular margins intact. Soft tissues normal.” - Findings Conclusion: No significant abnormality seen. - Conclusion/Impression BIMA Radiology Crash CourseInterpreting limb plain films (ABCS) A - alignment and joint space - Smooth contours and lines - Loss of joint space - Osteophytes - Chondrocalcinosis Source: https://radiopaedia.org/Source: https://radiopaedia.org/cases/severe-osteoarthritis-of-the-knee?lang=us BIMA Radiology Crash CourseABCS Approach B - bone texture - Normal trabeculae - Good density BIMA Radiology Crash CourseABCS Approach C - cortices - Fracture - Bone tumour - osteophytes Source: https://radiopaedia.org/cases/osteosarcoma-8?lang=us BIMA Radiology Crash CourseABCS Approach S - soft tissues - Difficult to elicit on plain films - Swellings, effusions or foreign bodies - Sometimes require other imaging modalities (eg. MRI) Source: Source: https://radiopaedia.org/cases/https://radiopaedia.org/cases/soft-tissue-haemangioma-in tramuscular-1?lang=us BIMA Radiology Crash CourseFractures Complete Fractures - Transverse - Oblique - Spiral - Comminuted Incomplete Fractures - Greenstick - Buckle - Bowing BIMA Radiology Crash CourseDescribing fractures - Where is the fracture - What type of fracture - Open vs closed fracture - Displacement - Angulation - Rotation (difficult to appreciate on X-rays) Source: https://radiopaedia.org/cases/femoral-shaft-fracture-2 - Translation BIMA Radiology Crash CourseFOOSH fractures Colles vs Smith’s Fracture - Colles fracture: distal radial fracture when fallen onto outstretched hand in wrist EXTENSION - Smith’s fracture: distal radial fracture when fallen onto outstretched hand in wrist FLEXION BIMA Radiology Crash CourseFOOSH fractures Monteggia vs Galeazzi Fracture - Monteggia fracture (Manchester United): Ulnar fracture with associated proximal radial head dislocation - Galeazzi fracture (Glasgow Rangers): Radial fracture with associated distal radio-ulnar joint dislocation BIMA Radiology Crash CourseClassifications Type of Hip Fractures - NOF (Neck of Femur) fracture - Intertrochanteric fracture - Subtrochanteric fracture - Pathological fracture Source: https://comportho.com/anti-aging/dont-delay-hip-fracture-surgery-heres-why/ BIMA Radiology Crash CourseClassifications Weber’s Fracture Classification (ankle fractures) - A - below the syndesmosis - B - trans-syndesmosis - C - above syndesmosis/lateral malleolus BIMA Radiology Crash CourseClassifications Salter-Harris classification (growth plate fractures) - (S)lipped : type I - (A)bove : type II - (L)ower : type III - (T)hrough : type IV - (R)ammed : type V BIMA Radiology Crash CourseClinical Case 1 Clinical presentation Right knee XR finding: - Bob, 65M presents to the orthopaedic clinic with worsening - Osteoarthritis bilateral knee joint pain and stiffness. He reports these of the knees symptoms have been present and worsened over the last bilaterally few years, gradually reducing his ability to engage in his favourite activities like gardening and hiking. - LOSS - On examination, you noted a mild varus deformity of both knees, joint crepitus as well as a limited range of motion in both flexion and extension bilaterally. Source: https://radiopaedia.org/cases/osteoarthritis-of-the-knee?lang=us BIMA Radiology Crash CourseClinical Case 2 Clinical presentation XR finding: - Annie, 64F presents with sudden onset pain around her right knee and her walking is limited due to this. - Visible layer in joint space - On examination, her joint is warm, erythematous and tender - Knee joint to palpation. aspiration - Pseudogout Source: https://www.orthobullets.com/basic-science/7040/pseudogout-cppd BIMA Radiology Crash CourseClinical Case 3 Clinical presentation Left knee XR finding: - Andre, 36M who had 2 day history of left knee pain and pyrexia. He presents to your A+E as he has never had knee - Normal knee XR pain before, denies any recent trauma to the knee and is concerned that his mobility is affected. - ABCS approach - Septic arthritis, does - On examination, the right knee joint is red, hot and tender to not usually present touch. You also noted that his inflammatory markers are raised. You then decide to order an x-ray of his knee. significant findings on XR imaging. Source: https://radiopaedia.org/cases/normal-knee-5?lang=us BIMA Radiology Crash CourseClinical Case 4 Clinical presentation XR finding: - Metal is dense on - Derrick, 53M who works in a steel manufacturing factory was x-rays involved with an industrial accident. While operating machinery, a metal shard from a broken component was forcefully propelled into his left upper arm. His colleagues - Foreign body visible had removed the 2.5cm wide shard and bandaged the injury lateral to the midshaft of the as promptly as they could as part of first aid prior to sending humerus, likely in him to hospital. the wound - On examination, you see that the bandage is intact with no - Likely remnant of strikethrough. He is still in pain especially on mobilising his metal shard left arm. The extent of the damage is difficult to determine secondary to and you decide to order an x-ray of his left humerus accident https://radiopaedia.org/cases/foreign-body-in-arm?lang=us BIMA Radiology Crash CourseClinical Case 5 Clinical presentation Right hip XR finding: - Margaret, 76F with a known background of osteoporosis - Osteoporotic fracture presents with difficulty weightbearing and hip pain on the of the Neck of Femur right side following a fall as she tripped on the carpet while mobilising from her kitchen to her bathroom. - displaced, angulated medially - On examination, the right hip is tender to palpation and you notice that the right lower limb appears shorter and externally rotated than the other. - Requires surgical intervention. THR vs hemiarthroplasty Source: https://radiopaedia.org/cases/femoral-neck-fracture-1?lang=us BIMA Radiology Crash CourseClinical Case 6 Clinical presentation Right wrist XR finding: - FOOSH injury - Bryan, 55M presents to A+E with severe right wrist pain after a fall. He reports that he was waking his dog when he tripped - Distal radius over a loosi paving stone, and instinttively put out his right fracture with hand to break his fall. He felt an immediate sharp pain in his dorsal right wrist and noticed it looked deformed compared to the displacement left. - Single view may not be sufficient - On examination, you noted tenderness around right distal to diagnose radius. His right wrist is swollen and the dorsum of the wrist Frontal view Lateral view is notably displaced dorsally. Source: https://radiopaedia.org/cases/colles-fracture-bilateral?lang=us BIMA Radiology Crash CourseClinical Case 7 Clinical presentation XR finding: - Sarah, 27F arrives in A+E in significant distress. She reports - Humeral head intense left shoulder pain and an obvious deformity of the left overlapping upper arm. She was playing football and had fell awkwardly scapula/glenoid on her outstretched left arm after attempting to catch the fossa football. - Humeral head is dislocated - On examination, Sarah is unable to mobilise her left arm anteriorly and without significant pain. Her arm appears deformed, with a inferiorly “boxy” or “square” appearance. - Hill-Sach lesion Source: https://radiopaedia.org/cases/anterior-shoulder-dislocation-26?lang=us BIMA Radiology Crash CoursePitfalls and common errors - Neglecting soft tissues - Stress fractures/hairline fractures - Look at previous imaging - Tunnel vision - Lack of clinical correlation BIMA Radiology Crash CourseSingle Best Answer 1 You are an FY2 working in A+E. A 27M presented following a fall off his bike at 20mph. In an attempt to break his fall, he extended his right arm out as he landed onto the pavement. His right arm appears deformed and he tells you that he thinks he has broken it. What fracture does he have? a. Smith’s Fracture b. Colles Fracture c. Galeazzi Fracture d. Monteggia Fracture e. Barton’s Fracture BIMA Radiology Crash CourseSingle Best Answer 1 You are an FY2 working in A+E. A 27M presented following a fall off his bike at 20mph. In an attempt to break his fall, he extended his right arm out as he landed onto the pavement. His right arm appears deformed and he tells you that he thinks he has broken it. What fracture does he have? a. Smith’s Fracture b. Colles Fracture c. Galeazzi Fracture d. Monteggia Fracture e. Barton’s Fracture BIMA Radiology Crash CourseSingle Best Answer 2 You are a doctor working in orthopaedics. You have been asked by A+E to review a 36M who presents with a fracture of his ankle. How would you rate his fracture under the Weber’s classification? a. Weber’s B b. Weber’s E c. Weber’s A d. Weber’s C e. Weber’s D Source: ng=us://radiopaedia.org/cases/ankle-fracture-weber-c-9?la BIMA Radiology Crash CourseSingle Best Answer 2 You are a doctor working in orthopaedics. You have been asked by A+E to review a 36M who presents with a fracture of his ankle. How would you rate his fracture under the Weber’s classification? a. Weber’s B b. Weber’s E c. Weber’s A d. Weber’s C e. Weber’s D Source: ng=us://radiopaedia.org/cases/ankle-fracture-weber-c-9?la BIMA Radiology Crash CourseSingle Best Answer 3 You are working on the vascular ward. A 56M with known T2DM and previous amputation of the 2nd left toe. He now presents with an ulcer around the hallux, which you note pus coming from it. An x-ray of the foot is ordered. What is the likely diagnosis? a. Gout b. Osteomyelitis c. Osteoarthritis d. Septic arthritis e. Normal foot BIMA Radiology Crash CourseSingle Best Answer 3 You are working on the vascular ward. A 56M with known T2DM and previous amputation of the 2nd left toe. He now presents with an ulcer around the hallux, which you note pus coming from it. An x-ray of the foot is ordered. What is the likely diagnosis? a. Gout b. Osteomyelitis c. Osteoarthritis d. Septic arthritis e. Normal foot BIMA Radiology Crash CourseSingle Best Answer 4 10F with right sided hip pain and limp. Her parents tell you that she has been in good health until about a week ago when she had mild upper respiratory symptoms and a low grade fever. She noted the pain start a few days after a respiratory illness. She appears clinically well today. What is the most likely diagnosis? a. Slipped upper femoral epiphysis b. Perthes Disease c. Transient synovitis Source: https://www.orthobullets.com/pediatrics/4030/transient-synovitis-of-hip?section=bullets d. Septic arthritis e. Growing pains BIMA Radiology Crash CourseSingle Best Answer 4 10F with right sided hip pain and limp. Her parents tell you that she has been in good health until about a week ago when she had mild upper respiratory symptoms and a low grade fever. She noted the pain start a few days after a respiratory illness. She appears clinically well today. What is the most likely diagnosis? a. Slipped upper femoral epiphysis b. Perthes Disease c. Transient synovitis Source: https://www.orthobullets.com/pediatrics/4030/transient-synovitis-of-hip?section=bullets d. Septic arthritis e. Growing pains BIMA Radiology Crash CourseSingle Best Answer 5 46M construction worker fell off a ladder and landed with his left arm outstretched. He noted a sharp pain around his upper left arm and sees that it appears to be deformed. X-ray imaging shows a fracture, how would you describe this fracture? a. Incomplete, undisplaced spiral fracture of the humerus b. Incomplete, undisplaced transverse fracture of the humerus c. Complete, transverse, medially angulated displacement of the humerus d. Complete, spiral, laterally angulated displacement of the humerus e. Complete, comminuted, spiral, medially angulated displacement of the humerus https://www.wheelessonline.com/bones/humerus/transverse-humeral-shaft-fracture/ BIMA Radiology Crash CourseSingle Best Answer 5 46M construction worker fell off a ladder and landed with his left arm outstretched. He noted a sharp pain around his upper left arm and sees that it appears to be deformed. X-ray imaging shows a fracture, how would you describe this fracture? a. Incomplete, undisplaced spiral fracture of the humerus b. Incomplete, undisplaced transverse fracture of the humerus c. Complete, transverse, medially angulated displacement of the humerus d. Complete, spiral, laterally angulated displacement of the humerus e. Complete, comminuted, spiral, medially angulated displacement of the humerus https://www.wheelessonline.com/bones/humerus/transverse-humeral-shaft-fracture/ BIMA Radiology Crash CourseThank you QUESTIONS? BIMA Radiology Crash Course