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Everyone and welcome to our second talk on the Bombs in Midland Series. On today's talk is on orthopedic imaging, uh so quick learning outcomes. So today we're going to understand the basic concepts on how to interpret X rays. Uh CTS and MRI S based on their advantages, disadvantages um described as systemically how they impact orthopedic injuries. I understand and describe various fractures, classifications and describe imaging, the fracture healing process. Um So, Y orthopedics, it's a great surgical specialty, in my opinion, it's a rewarding and life changing career. Um It's involved in multiple sport injuries. Um and it's getting very, very technological and, and there's new advances such as nana scoping now, which means it's, it's an area that's currently very, very well evolving. So now onto some imaging. So in terms of imaging, to understand uh the planes in the body, there's obviously sagittal, which, which is important in determining left to right. And then you got corona which is front to back, and then you've got transverse, which is sort of the actual plane of the body. Uh And then you've also got other views such as anterior, posterior, posterior, anterior lateral views and then like you said, south, still corona on transverse. So the views are very important just because um it depends, there's many types of ways to look at a bone. Uh And the, the next slide depicts that. So if that's the lateral, that would kind of look very different to what uh the A P looks like. So it's always good to look at all the views just touching quickly on the electromagnetic spectrum. as we know that radio waves had the biggest, biggest wave length. And then obviously, x rays have a very, very short wavelength X rays. Um It's basically a high form of energy um is based from a X ray source through to a receive er and and these pass through the body based on their density, but some of the X rays are resolved but some are scattered and this is known as attenuation. And the image obviously depends on the density in the atomic and the atomic number of the density. So therefore, we based on the Hounsfield Unit with challenges touch one after. Uh so the higher the density um therefore more attenuation and therefore the light of the appearance such as bones, metals, et cetera. It's the pros and cons of x rays, you can zoom with x rays. Uh it's quite relatively quick, it's good, it's quick to identify a fracture sometimes uh you can measure distances and angles, but the downsides of it is is um obviously you get some radiation. Um it's a two D view. So a single plane are, you can't visualize all the areas and you can miss pathology even when there's fractures that are evident. And obviously, you can't actually tell any soft tissue imaging. Uh Obviously, that is the most used to form of imaging in orthopedics. And um there's various classifications based on imaging such as uh Schatzker classification for timber plateau fractures um and just touching on the house floor unit. So it distinguishes which what structure is being shown depending on its density. And as we can see here, um the more dense objects have a high, have a higher houseful unit compared to those I love her. Um And there are less dense such as fat and air which appear more dark and actually like when this image shows here. So the highlighted density, the higher the hands full unit. So moving on to C T S. So it involves a rotating gantry where the X ray tube is on one silent detectors are on the other. It's made of many, many X ray measurements from different angles and produces a cross sectional image as a result. And it uses the same process of attenuation again, is used in X ray of bones for fractures, but it's also used for other medical procedures, which is uh internal organs, blood flow restrictions, stroke, and cancer. But the key to remember is is the image uh and the view and the view that we see on the unpacks, for example, on by the wrong placement is the view in the transverse plane when you're looking from the feet up. So as a result, the left side of the image is the right side of the body. And here we can see a left sided um total hip placement um as we can see very high house with unit. Hence why the prosthesis appears white in comparison to the contralateral side. And CTS are very important in specific fractures of pelvic ring, pelvic ring fractures. Pelvic fractures happen as a result of high ended trauma by three main forces. So you've got anterior posture compression which are open book or sprung pelvis fractures. Uh you get lateral compression as a result, leads to wind a windswept pelvis and you get vertical shearing which leads to a bucket handle fractures. So public fractures can be quite fatal as a result of as a result. A lot of the neurovascular later that is around the pelvic region and it can lead to pelvic hemorrhage. So CT is used in the complex diagnosis of as tablet fractures and pelvic going fractures. An unstable pelvis requires immediate management such as pelvic binding and surgical fixation. So based on the image that we have, the management is obviously very, very, very dependent on the what the outcomes of the imaging is. Uh So just to move on to a little quick quiz, there are forming um forming arteries and vessels that are mainly affected in pelvic fractures. I just want to quickly um ask you if you know what they are part of the popping in the chat. So throughout this talk, there's gonna be a few questions. I think it's about seven. So it'll be, it'll be, it'll be, it'll be a good way to get a bit of revision in as well. So first one is your internal iliac artery. then you're a superior deal, you're up curator and your potential. So all these vessels lie very, very close to the pelvic. Um It's pelvic region itself and answer at risk of their hemorrhage. So the pros and cons of CCS um quick. Now the same advantages X rays. So you can measure angles, etcetera has a good spat spatial resolution. Uh You can scan most areas when it all the downside is is obviously radiation. It can be affected by artefacts. You can have some, sometimes it can require holding your breath, overuse is something I think in orthopedics that a lot of people do tend to over U C T S just to be 100% sure of the diagnosis. You can also get a quick few incidental findings. So just looking at these two images here, we can see that the top image is a right um funeral head fracture. And then the second one is a is a either a burst fracture of the lumbar spine. Now we'll move on to um our MRI MRI s are very, very, very technologically advanced without going to too much detail about how they work. It's basically a magnetic field. And uh and a lot of through the magnetic field, there's uh the body is inside the magnetic field and our body has a lot of hydrogen atoms, a radio frequency pulses apply to stimulate these protons and they spin amount of equilibrium in within the magnetic field. And when the radio frequency is turned off, the MRI sensors detect the energy release and those protons and realign back into the magnetic field. And that's what produces the three D image. So I don't think this will ever be needed to know detail for any form of medical school examinations. But it just provides a bit of context and the MS Connolly relies on the magnetic field. So it needs an arrogant tree. That's why people come in quite claustrophobic and um have Alaska. Okay. So, orthopedic uses of MRI. So they examined bones, joints, soft tissues such as cartilage muscles and tendons, injury wise. You can look for tears probably using the knee for such as ACL tears, uh structural abnormalities, tumours, osteomyelitis, inflammatory disease, such as rheumatoid arthritis, congenital abnormalities. A V N uh bone marrow disease. We can use contrast such as good uh Gavin liam. Uh This improves and enhances the quality of the MRI images. Um MRI waiting's so this is something that I think is quite common question in medical school exams. And it's based on T 10 T two. Waiting's um the different relaxations produce different weightings from the soft tissue. So T one and T two. So in T one, the way I remember it is water is black and T to the fat is black. So we'll go through an image to demonstrate that. So a white image is a high energy signal and a black part of the images alone just so based on the T wise water is black and T two is fat is black. What is this MRI showing? Give a few few seconds? Yeah. Okay. So as you can see, it's a complete ACL tear. Yeah. Um It's the pros and cons of MRI S. So on the left here, on the right side, we have a picture of a rupture on the triceps and we can see the rupture. So the pros and cons it has no radiation at all as it used in magnetic field and it has a good contrast resolution downside of it is it's quite expensive time consuming. Uh it's not everywhere. So as you can see, some hospitals tend to have these mobile MRI scanners like which has claustrophobic, having a large body habitus can be quite challenging. Uh And you have, do you need to lie still for some time in touch? They usually it's about 10 to 15 minutes. Sometimes I'm one of three contra indications for MRI S. So I'm going to leave this here because I feel like this is quite common in exam question. Yeah. So pregnancy is the one of the first contraindications having a pacemaker or and anything metallic such as an IUD any order clip, a brain aneurysm clip. So be mindful of one of the contraindications. So this image kind of that demonstrates the three modalities that we've spoken about. So on the left, you got X ray of the lumbar spine in the middle of your CT and on the end of an MRI. So you can see the spinal cord isn't really visible. Uh And you can see that it's a lot more visible in CT that you can't really depict much. And an MRI scan, you can the hair, you can depict of the disk, disk extrusion leading to perhaps lower limb symptoms. If this patient presents a symptomatic, this is more respiratory, but just to be aware of this magnification of X rays objects in the ap view, a pear uh further away from the film. So therefore, a pair bigger um in the pa view objects that are close to the film, a pair smaller such as the heart. So, hence wine chest, X rays, we tend to use a pa view. Um So the A B CS approach to uh orthopedic imaging is something that I read quite a while back. So it's based on alignment, bones cartilage and soft fish uh for to ship X rays such as an example, this is uh which I want to is the relationship that of the mess talks to the media can a form um assess the adequacy of extra, including various views and penetration. Like we spoke about earlier, uh fractures and dislocations will impact the alignment on an extra. So this is what it's example, I was trying to say. So in the foot, it's naturally anatomically aligned. And when you look for the fractures, which is we'll go on to the type of outfracture that we call it when this alignment is out of place. Um and the lack of alignment can happen to various things and ligament injury is obviously quite common cause. So the lateral border of the first metatarsal is aligned with the lateral board over the of the mid lateral border of the medial cuneiform as you can see. Yeah, and the medial border of the first of the third canary form of the lateral connect form should align with the media border of a third measure tassel. So the the area we're talking about is here. So I know it's a bit confusing with lateral medial. But the key we're trying to say is the medial cuneiform lateral border and electoral border of the first metatarsal should tend to line up any abnormality in that leads to a list frank fracture. So moving on to bones, many types of fractures, you can get transverse linear oblique can be displaced or not spiral and greenstick, examine the bones for fracture lines and distortions. Examine the whole length of the bone. I know in an X ray it's quite common just to say, oh, there's a fracture but tend to look at, look align the whole congruence. See the bone and fractures can be settled which will come into. So we're just gonna have a bit of a quiz. Now pop into the chat, your answers as we go along. So uh this is the first, how would you describe it factor in very simple terms? And if there's not enough time to try on the chat full freeze, just think about it. So this is a transverse fracture of the mid shaft of the right tibia. How do you describe this one? This is a spiral fracture of the left femur and we can tell here there's quite a there must be as a different fracture as well, perhaps extending from that spiral fragment um presents a bit like uh might be the uh lesser drug and this one happens mostly in kids and I said greenstick fracture. So cartilage. So Carl is shown in the joint is showing any joint spaces on an on an X ray. You can't really see cartilage in an X ray. Um I've normal widening of joint space signifies ligamentous injury or fractures. So like you can see the lateral lateral gapping on these two knees uh left compared to right. And that obviously depicts that there's some injury there, there could be some arthritis, um or ligamentous damage, which is causing that gap to increase damage, which is damage on some, some of the cartilage. And that's this is indicative of the LCL too. Uh just, just quickly features of uh of our way on imaging. Uh Martin like loss, which is a loss of joint space for L osteo fight information. So you can see the joint spaces lost. We see some osteophytes growing at the end which is some, some chondral cysts and subchondral sclerosis, which is hardening of the bone just below the cartilage surface. So you can see that about, you can see that just do out here like you see the bones hardening underneath and this shows time test strip in a later arthritic joint and then this is the same in the hip. So a lot of joint space. Austin flight formation ing around the edges of the acetabulum and sclerosis and cysts as well. So we went mentioned soft tissue and soft tissue swelling is quite important in fractures as it's part of the fracture healing process. But some certain soft tissue damage can be quite a sign of an of an occult fracture, which is a hidden fracture. So this is the sale sign in the elbow and it suggests an acute fracture. His name derives from the as it's the same of a same of a sale like this like so and it's caused by the displacement of the fat pad around the elbow joint, both the anterior and posterior of fat pad signs exist and they both can be found on the X ray. So this probably depicts that there must be an occult fresh air and perhaps warrants a CT just to get a three D view. Yeah. So moving on to the next part of the talk, we're going to talk about the language of fractures. So obviously, when we get a fracture, you want to check the name date, the hospital number. This is something that we do in the Yassky Stations. I don't, I don't know how apparent this is in common practice. But when you describe uh huh, you want to use the terminology such as this is an open or closed fracture, then you know the exact location of the fracture, the relationship with the fracture fragments and the neurovascular status. So for a good example, um we can say, for example, this is a Fort all Iran oh present way uh intra articular fracture of the right elbow uh is neurovascularly intact. That's sometimes I can be a way of describing it when you are on the wards. Um So open windows, closed, closed fracture is a simple fracture, not there's no open moons due to the fracture itself. Far as an open is totally opposite. It's based on compound fractures, completely displaced or community bones made protrude from. Uh So you can see here that there is a closed okay and you fracture. Whereas here we can see that there's an open radio fracture. As you can see, the bone is protruding outside of the border of the skin, which is obviously at risk of getting infected and Osteomyelitis. So, antibiotics is quite important in patient's like these the anti mikel location. So when you describe a fracture, you want to say the exact point. So if someone was to just feel the body, they'll be able to guess it. So describe the exact location. Is it left or right? Named the bone uh location on the bone. Is it proximal admitted, the distal divide the bones into third such as this, the distal one third of the humerus. Is it, is it in tragically in the joint or is extra actively? Um That's quite important such as because it depends on how we treat such as in um in echo femur fractures, for example, and the relationship of fracture fragments. So this here is the description of the Weber classification. Um And what you want to talk about is the alignment which you spoke about earlier. The angulations is a NASA deviation from a normal alignment, the opposition and displacement. So that's the amount of end to end contact the fragments have. So how much contact they actually have um destruction. So displacement in the longitudinal axis of the bones and this location which is disruption of normal relationship with articular services. Finally, you want to just say about the new vascular stage, want to do a new vascular exam, look for any kind of neurological symptoms such as soft touch pain, proper section, check expiry a refill um to their pulse is um depending on where the fracture site is and always say that your rescuer status. Otherwise it because at the end of their new vascular status will prioritize who's fracture gets fixed first and between conservative and non conservative management. So for a few more questions, so we're going to describe a few fractures now. Um So this is using this um guy on the left if you could just describe his fracture in your own mind or write it down a chat fill fruit. Mhm So this is a ap view of a left closed distal femoral spiral fracture. So as you can see, it's uh an ap view, it's the left side. It would have been useful if the to be was visible to see what side it was on, it's definitely closed as it doesn't protrude out of the borders. It's on the distal one third of the femur and it's a spiral fracture just looking at the at the anterior surface of the bone. And that's the pasta reception time. What causes spiral fractures, a rotational force? Um So that can describe this fracture. So this is an ap view of a left closed intra-articular fracture of the base of the first metacarpal as we can see here. Another one. So opportunities a pediatric patient just look at the growth plates. So this is a closed, left trans versed midshaft fracture of humans. And why is it transverse as transverse fractures occur perpendicular to the long axis of the bone? So as you can see the bones that way and it's perpendicular is a fracture line. So this is an X ray and a ct of the same image try to describe this fracture. So this is a closed left intra-articular communicated fracture. Um And it's, it's an introduction, trochanteric nicotine a fracture and it's a fracture of the femoral heads. It's a very complex one. Uh and we'll break it down. So it's actually closed it within the body. Um It's in particular as it crosses the articular surfaces. Um It's community as more in more than a couple of fragment, more than two fragments. And it's in the er it goes through the instructor to recline and it has got a fracture of the femoral head. Why is it communicated as, as we said? So there's more than two bony fragments, but it's difficult to actually appreciate this on an X ray as um as the CT obviously different shapes between the two. So describe this fracture and comment on the displacement. So this is an ap view of an X ray of a closed left midshaft tibial fracture that's transverse and it has got model lateral displace. Uh And when we talk about the lateral and medial aspect. We talked about the proximal portion of the bone in the response to the distal portion. So as we can see here, 33% of the bone, it's kind of a rough estimate. So one of them moderately displaced away from the bed line of the boat. Sorry, I think what I meant was is actually the distal fragment is what's in question compared to the proximal in terms of displacement. Uh One more, it's quite a hard one and I think we probably work through this one, but I'll give you a minute or two to work it out. There's actually two fractures, I just wanna make it easier. So the first one is a closed distal radius fracture with complete displacement. And the second one is, is a moderately displaced into articular on the star lord fracture. Very hard fracture. Probably it's nothing like whatever doing exams, but it's food for thought that always be more than one fracture on the one image just touching on echo female fractures as I feel like it's one of those type of fractures I guess examined most. Um in 2018, the latest statistics that I could find there's 75,000 echo female fractures and the mortality rate is obviously quite high out of all of those commonly caused by afford affecting an older person with osteoporosis or osteopenia. And it tends to uh 9 2019. It cost the NHS about 2 billion lbs in total So the three R's and orthopedics in terms of management reduce whether this is an A and E or an outbreak there or you manipulate it in theater for attention. So that's conservative management such as casting Splinting or operative. Such a screwing when you can lock it or use cortical screws, plates and nails and rehab, physiotherapy. I think this runs in hand in hand with the MDT that postoperatively, um, physiotherapy are the guys and occupation therapy and all due respect other guys that get the patient's back onto their feet, back home, back doing what they enjoy doing after the orthopedic uh specialist have done their job just touching on fracture, healing is probably something from, from the first couple of years of medical school. Um So obviously, we have human term information after a fracture, we then get granulation tissue. So that's soft callus forms. That's what inflammation occurs. The phagocyte and osteoclasts remove the damaged tissue, new blood vessels infiltrate and bring in the fibroblasts. And that's known as granulation tissue, the fiber brass and laid down that collagen and some of the fiberglass differentiate endochondral glass which generate the highline cartilage and this is known as a soft callus. So then then that soft callus, then as a result of endochondral ossification replaces the cartilage with cancellous bone. So, cancers bones, a spongy type of bone that we see uh can also be called uh trabecular bone as well. And that's the hard callus and then it remodels um uh cancels bone is remodel based on the stress is applied to it. Um And this is where physiotherapy comes an important into compact bone. So these are two CT and MRI images that we could look at. We have touched on both of these today already. Um And we can always look at this in our own time. So these are the two links, these are based off radio Pedia. And I just wanted to thank you all for joining us today. The second, the third talk, sorry will be on pediatric uh injury and this will be held next week on medal. So do be sure to check out our Instagram age and for any new updates and follow the bombs uh initiative. It's great, great, great initiative for but students um to increase exposure to the orthopedic practice. Thank very much.
