Computer generated transcript

Warning!
The following transcript was generated automatically from the content and has not been checked or corrected manually.

Uh uh There we go. Okay, great. I got my chat open as well. Perfect. OK. All right, welcome everybody. Um I can't quite see how many people there are, but it looks like there's a few people there. Um, uh My, my name is David Ileus, a musculoskeletal radiologist at King's College Hospital in London. Um And so I was just gonna talk for the next hour about muscular skeletal X ray interpretation. I'm going to try and make it uh sort of a bit interactive. So, um feel free. I don't know if you're able to amuse, amuse yourselves but, or feel free also to um uh to put uh put comments in the chat, there will be certain points at which I'll, um ask you guys for your opinion or any thoughts. Um uh So, uh please do chip in um what I'm gonna do. Um uh basically is just really talk to start talking about some general principles um of looking at fractures. Um And then depending on how the time goes, we'll start looking a bit more specifically at upper limb radiographs. Um If I've got time to do that, then I'll sort of push that back to, uh, to sort of the next lecture with you. Um, all right. So, um, so I'm assuming everyone can hear me okay. I'm going to just crack on. Um, there we go. All right. So, just to start off with, how do we, uh, well, actually perhaps before I do that can you sort of give me some, some sense of, kind of where you're at? You, uh, sort of where the group are at. Are you mostly, um, sort of, what year are you in a medical, what year you guys in a medical school? I can see you from. Uh, obviously, uh, well, I've got one person there who said that they're um, um and Mumbai. Um, but just what year sort of are you mostly at a medical school? Are you at the beginning of your medical training or towards the end? I have written that in 60 or finally. So, okay. Have written the check and someone else has written six year. Okay. All right. Um, so that's, that's helpful to know. Okay. All right. So we'll get, we'll get, let's get cracking. So, um, just trying to open up the, that's better. All right. Now, I can see you a bit more. Okay. That's good. Okay, good. Um So, um, let's start out just by talking about how to describe fractures. So here's a sort of a list of things you could, um, uh, think through when you're seeing a fracture first of all um uh going to be important to decide when you see a sort of break in the bone. Is this acute or is this chronic? Is this the acute cause of the patient's presentation or not? Um And we're going to talk about each of these individual things um in a little bit of detail and how to assess them. Um The next thing you're going to think about in terms of describing the fracture. Is it common muted? Um uh Sorry, it's not working. There we go. Right. So, in terms of sorry, in terms of deciding whether it's acute or chronic, we're going to look at the margins of the fracture. We're going to see. Um Are they sharply marginated or is it ill defined? Um it'll be sharply marginated in acute fracture, it's going to be more ill defined um as it becomes more chronic. Um is there callous new bone formation, which is going to be a telltale sign of a more chronic injury. Um in terms of the description of the fracture itself, um we want to decide if it's um common muted or not. So, accommodative fracture has more than two fracture fragments. It's gonna be important to assess whether it's a compound or an open fracture and you may be able to see that on a radiograph. Um You may be easier seeing that clinically. Um but certainly on radiographs, you can sometimes see if that's the case and then you're going to want to assess displacement in different sort of um uh in different ways. Um The first is displacement itself. So is it displaced immediately or laterally? Is it displaced anteriorly or posteriorly? And we always describe this um with reference to the distal fragment relative to the proximal fragment. Um And then in terms of angulations is angled anteriorly or posteriorly. So is the distal fragment angled anteriorly and posteriorly to the proximal fragment is angled various or in the various or valgus direction. So various meaning um toward the midline or valgus, meaning away from the midline. And then we're going to look for distraction or shortening of the fracture and then finally, rotation which is often quite difficult on radiographs. Um and it's often easier clinically. Um So I'm just gonna say so do you let me know if this is all sort of making sense? Please feel free to put comments in the chat. Let me know if you don't understand anything or you can amuse yourself and just just ask questions as we go. So here's a here is I'm just trying to not sure if you've got, yeah, you can see that perfect. You can see that screen. Okay. Can you is the there's something sort of blocking my text on my screen? Is that blocking yours as well or is that okay? So we can see you 17, them 17 year old needs the blood. Perfect. Okay. So yeah, so 17 year old male with a football tackle. Um, no big prizes for spotting the tibial fracture here. You can all see that, but just thinking about the descriptors we've just been talking about. Do you want to just let me know what, what sort of descriptors you're going to use, um, for this fracture. If you're, if you're describing it to you, to the orthopedic surgeon, maybe you're, you're in A and E, you're in, you're in the emergency department, receiving the patient and you're gonna let the orthopedic surgeon. No. Um uh down the end of the phone, what you've seen. So do you want to just, you can put some descriptors in a chat or some, feel free to uh mute yourself and speak if you want to and just tell me how you describe it. Chef function. Say again, chef fracture. Yeah. The tibial shaft fracture. Good. Yeah. So it's probably a sort of lower third tibial shaft fracture of the, in the left leg. Okay. Is it displaced spiral fracture? Um, okay. Yeah, it's, it's a, it's an oblique or a spiral fracture. That's true. Yeah, it is closed fracture. Is, it looks like it's going to be closed. We can't see an obvious skin wind, can we? So, yeah, looks like it's not going to be open? Yeah. And is it right? Like, do you think it's acute or chronic? First of all? Is it, is it cute or is it chronic? The cortical, er, just look sharp. So acute. Yeah. Good. Yeah. So it looks like an acute fracture. It's got very sharp margins were not seeing any sclerosis. We're not seeing any new bone formation. So it does look acute good. And do we think it's common? You did or not lateral view shows it is community did. I don't know whether there is a small fragment. Yeah, exactly. So there's a little, there's slight combination. There's definitely a little fragment there. And what about displacement and angulations? And those sorts of things? I wonder whether long born angulations possible but it is displaced. So. Okay. Yeah. So I think what I would say is that it's um there is a the slight displacement in that lateral and the posterior direction. Yeah, you always do refer to the displacement of the distal fragment relative to the proximal fragment. Yeah. And then in terms of angulations, um it's angulated in various which is, which is really quite important actually because that various angulations going to really alter the weight bearing through the ankle. So, can you see um so that's sorry, there's that little commuted fragment just to point out and there's just showing that various angulations that's very important actually in a tibia. Um And it's slightly angulated anteriorly, that's not so important because the flexion of the ankle will compensate for that. But the various angulations is important and certainly needs to be reduced. And also it is actually slightly shortens. Can you see how, um it's a, it's actually slightly reduced in length, the fragments have come uh and sort of slid slightly across each other. Um So there is slight shortening, um rotation alignment, obviously couldn't really just tell on that film. Um But what they did was they put a tibial nail in and can you see how those um uh that the fracture has actually been reduced, it's been brought out to length. Um They've got rid of the various angulations there. Um Yeah. So, so that's a sort of good reduction that they've got with that tibial nail in there. And let's see what happens to it over the next weeks. So, um the panel on your left is the sort of day, day after nailing and you can still see um the fracture has sort of very sharp, really quite sharp margins. And of course, what happens sort of a few weeks down the line is it starts to heal. And at four weeks, you're beginning to see that the fracture margins start to look a little bit less well defined. Um It's beginning to get a little bit of contiguity across the cortex on that lateral side. And you're seeing development of this callous formation, but this is the torn periosteum which is forming new bone which is bridging the fracture. And by 10 weeks, you can see that that's really bridging quite nicely on both the medial um and the lateral sides. So that's what happens. Um And, and the, and the fracture line itself has become much, much less well defined, you can barely see it really on the lateral side at all. Um So that's the sort of progression. Now, um let's have a look at this. So this is a patient who obviously has a, a left total hip replacement. Um Hopefully, and this is a lateral view of the hip. That's why it looks like the uh sort of in a sort of slightly funny position. But what I want to just draw your attention to or just maybe have a look at the only thing that worries you about this film if you were to see it. So you were on the orthopedic team and you were sent down to review this patient's postop film of their total. It's not an immediate postop film this as it happens. But anyway, so it was a POSTOP film of the total hip replacement. Um Was there, is there anything that would worry you? So it may not be that easy to see on that? But so what I'm gonna do is I'm gonna zoom it up a bit and now tell me if there's anything that worries you, I just zoomed up the edge of that May, the quality of a screen is going to be important here for some of these images I'm afraid. So I hope you can see what I'm pointing at. Um anyone see anything is that it, diagonal replacement or diagonal. What? Sorry. Uh, the placement of the road, the placement of it. Yeah, I wouldn't worry about that. Well, yeah, I mean, yeah, it's actually, it's, the placement is actually okay. It's not, it's not quite central. That's true. But I wouldn't worry about that. So, what I want the, the feeling of the bone marrow itself. So, uh, what's happening to the bone distilled to the actual implant? Good. Okay. Yeah. Can ever one c So there is a lucent line through that cortex. There. Can everybody see that? You see that on your screens? Yes, sir. Yeah. So the question is, what is that? Maybe that's a fragment which is breaking out, seen before? Ok. So could it be, could it be a fracture? Okay. So the answer is, is not a fracture. Um There are a number of things that will mimic fractures. Um And this is one of them and it's a sort of very typical place to actually see this. Um because you can get peri prosthetic fractures, obviously around hip replacements, but you also get um nutrient vessels and bones sometime. Um And this is a very um a sort of typical finding that you'll see on a lateral view. After a total hip replacement, you'll see this nutrient vessel going through the cortex prominent. It always goes in that particular orientation. The way to spot nutrient vessels is um to kind of know where they are first of all. And this is a particular site of one, um that you just have to be aware of and know that it's not a fracture also. Um, just to look at the sort of the difference between what that looks like and what an acute fracture looks like. And it's not always easy. But again, you're looking for, you know, is it, is it very sharply marginated and well defined which this isn't so much, um uh uh sometimes around nutrient vessels, you don't in this case, but you'll see a little bit of sclerosis around its margins, which will tell you that it's not actually an acute fracture, but this is actually a nutrient vessel. And we do see that in this particular location, there's a few others around the body too. Um So what about this? This is a 43 year old female who twisted her ankle, anybody spot anything. So you've got a two views of the foot. Um A uh also plant a view of the foot and a lateral view of the foot. And I'll tell you that she saw, in fact, over the kind of lateral uh Medford region, anybody spot anything. And again, it might depend a bit on your screens here. So I'm going to just zoom up a little bit to help you set the lateral epicondyle. So, yeah, I think, I guess that's probably what you were talking about was this is, this is the line of actually this is a fracture of the base or this is a lucency rather through the base of the fifth metatarsal, right? And that is in fact a fracture. Okay. So this is an acute fracture of the base of the fifth metatarsal. It's not displaced, it's a very common site for a fracture. Um So that was the left panel is the case. I've just shown you of this uh this fracture. What about on the right panel? What's this, is that also a fracture? So you'll notice um that there's something rather different about this fit. The French, I just showed you was in a 43 year old female. Do you think say again? Mhm metatarsal, the first metatarsal, first metatarsal? Yeah, I think that's okay. So you'll notice um that this is a very different looking foot to the to the previous foot I showed you. Um you can, can you see how this is actually a child's foot? So you can see that there are growth plates here on all the phalanges and the metatarsal. So um this is a child's foot that the the growth plates have not fused as yet. Um And this actually is not a fracture. Um This is a growth plate um forming at the apotheosis of the base of the fifth metatarsal. So you may or may not remember from your anatomy that there is a tendon attachment at the base of the fifth metatarsal. Any anybody anybody can remember who that, what attaches there? I'll be very impressed if you can. So go on, he said one of the bruise. No, no, I can't hear you. But anyway, it's the, the Peroneus Brevis. Is that what you said? I think that might have been what you said. Attach. Uh Okay. So attach is at the base of the fifth metatarsal. Um So um this is a secondary ossification center which forms at the base of the fifth metatarsal and they often occur either in joints or attachments of tendons. And, and there's a growth plate that forms in between the apotheosis and the bone itself. And um sometimes that can persist into adulthood as well. So you can get a persistent line. But the difference is that with fractures in this location that always transverse, whereas with the normal, with the growth plate, they always run in a longitudinal plane like this. Um So um that's a normal finding, that's a normal finding um at the base of the fifth metatarsal uh in the panel on your right. And this is a fracture on the panel on your left. Okay. Um So uh growth plates are also fracture mimics. So you can sometimes get full by these. So you can see all these growth plates at the second to fifth metatarsals distally, you can see them at the basis of all the phalanges. Um And if I sort of go back, I think you were maybe wondering if there was a fracture line across the base of that first metatarsal. Again, that's a growth plate that occurs there as well. Um So these are more fracture mimics. Okay. Um Here's another case, uh 70 year old male falls onto his arm. Um And uh what would you, what would you say about this dissipation? All the dislocations? Uh Okay. So, dislocation, that's also certainly, um, the alignment at the glenohumeral joint is not normal. We'll park that for a minute. Just come to that in a second. What about, what about fractures? Neck? Okay. Humerus fracture on the anatomical neckline. Yeah, good. So, there's a proximal humerus fracture. You might say that it's commuted. Yeah, there's clearly more than one fracture line going on here. What about alignment? Would you say that it's angulated? Can you see that it's in various alignment so that it's rotated? Actually, it's, it's angulated so that the shaft is pointing. Um or there's an angle between the head and the, and the shaft of the humerus, which shouldn't be. It's actually in various ambulation. It's also shortened a little bit. Um uh Just going back to what you were saying about the alignment. You're right. The glenohumeral alignment is not normal that it's not actually dislocated, but the humiral head is subluxed um uh inferior early, um a little way and that will happen. Really? You see that always with proximal humeral fractures. Um Not because it's dislocated, but rather what happens is two things happen. One is that you get a bigger fusion in the joint and that will push the humiral head down a little bit. And the other thing is that the thing that normally holds the humerus up in places, the deltoid muscle, which is this big muscle here. Um And when you've had a fracture in the proximal humerus, the deltoid muscle loses its tone, it becomes atonic. Uh and it just allows the humerus to kind of fall downwards here. So you get this sort of little inferior subluxation, we'll see examples of dislocations later on. So, but this is not actually that anyway, this is a proximal humeral fracture. OK. Commentated various angulations and shortening. Now, what about this? So the question is, is there a fracture in the humeral neck in the coracoid and the glenoid? None of the above or even all of the above any votes? You can put a vote in the chat if you like, how do we, somebody said, how do we identify infusion? Um uh That's a good question. Um While you're looking at this film, um So the answer is um you can't really directly see a sign of an infusion in a glenohumeral joint as such because uh but, but the indirect sign that you'll see is that sort of inferior subluxation when there's a tense of fusion. There, there are other joints in which um uh you can much more actually see an infusion. So, in a knee in particular. Uh, and it won't be in this lecture, but maybe in the next lecture I'll get on to kind of looking at knees and we'll have a look at infusions in knees and also in ankles, which can be more useful. But later on in this lecture, we'll talk about infusions in the elbow which you can certainly see more direct signs of. Um, so somebody said be in the coracoid. Uh Somebody's also said d none of the above. Okay. We're going to go with d actually, none of the above. So this is a child's shoulder and this is a bit of a mean one because actually all of the lines here and there are several, all actually growth plates. Um So this is clearly a growth plate. It's a very sort of obvious one at the proximal humerus. You can see that it's got sclerosis around it. It's kind of ill defined, it looks like what you'd expect a growth plate to be between the shaft of the humerus and the epiphany sis here of the humeral head. So you're probably not going to confuse that with a fracture. But what about that? Well, that's actually part of the same growth plate, um, that sort of undulates through the humerus and it looks very much like it could be a fracture, but it isn't. Um what about that? That is a, a growth plate which occurs just within the spine of the scapular just where the a chromium processes and sometimes these persist into adulthood. Although this is actually a child, that's another one which occurs at the coracoid process. And that's another one which occurs at the glenoid. So all of these, in fact, our growth plates, um and these can be quite difficult. Um, certainly pediatric x rays and growth plates are often a bit of a challenge, but it's a question of eventually getting used to learning where all those growth plates are and also, um, looking at their characteristics and seeing that they're not sharply marginated, um, there's no soft tissue swelling. Um uh And maybe there's sometimes there's some sclerosis around them which helps. So what about this? Anybody see anything that you're worried about on this film or you might be worried about on this film? So this is a door. So plant a view of the right foot. So I'm gonna zoom it up for you. It could be a tailor could be a what? Say again. Sorry, I just, I couldn't catch that. Okay. So, um, what we're looking at here is, um, who can tell me which bone it is we're looking at to begin with. So what is this pain? Remember from your anatomy? A tailor fracture? Okay. Okay. So what we're looking at here? So the Taylors is here. Um I think the Taylors is okay. Can you see my mouse when I do this, by the way? Maybe you can, I can draw around it. Uh Let's just see if it will, you know, it's not letting me have a mouse for some reason. Okay. The tailors is here, the bone we're looking at here is the navicular which has quite an elongated um sort of medial portion to it. And can you see how there's an extra fragment, which is an extra bit of bone, which seems to be sitting here with a lucency across there? All right. Um So you could be forgiven for wondering whether this is a fracture. But again, as we can say, sorry, would we consider that as an avulsion if it is as an avulsion? Yeah, you'd be worried that it might be an avulsion fracture. Exactly. Um As we've been saying though, um it, well look, just looking at the characteristics of this. It's quite ill defined. It's not a well defined sharply marginated fracture line like the fractures that we've seen. Um And it's also in a, in a location where it's well known. There is an accessory ossicle here. It's called an accessory austin aviculare. E and it actually occurs at the insertion of the tibialis posterior attendant. Um And these accessory articles can sometimes mimic fractures. These are extra bones that occur sometimes in tendons or ligaments and they'll occur insertions, either insertions of tendons or ligaments or they sometimes act as a pulley. If a tendon goes around the corner somewhere, you'll, you'll sometimes see these and this is just one example of them, this is called an accessory as navicularis in the distal insertion of the tibialis posterior attendant. And this is again, another fracture mimic, it's an accessory article. So just to be aware of fracture mimics, um things that aren't always fractures. Um uh and these can include growth plates, nutrient vessels and accessory articles and in terms of distinguishing between them. Um for, I mean, the most important thing is really having the experience of having seen lots of them, which obviously you won't have at your stage. But if you're trying to distinguish between them, um it's often helpful to recognize that acute fractures, you will usually have soft tissue swelling around them and they'll have very sharp margins and they won't have sclerosis. So they won't be um they won't have bright white bone on their margins. Whereas these fracture mimics will not usually have soft tissue swelling around them and they'll have much more rounded or ill defined margins. Um and they will often have some marginal sclerosis as well, which might just help you. All right. So, um any, maybe if we just pause at that moment, any sort of questions at that point before we sort of move on? Okay. Um That's fine. Is this just, just for a bit of feedback as we're going? Is this all making sense? Is this helpful? Yeah. Yeah. Good. All right. Okay, good. All right. So, um Otto Chan was an old uh teacher of mine. Um and he sort of came up with this rule of two, which is often quite helpful um when you're trying to look at uh x rays of fractures um that uh and, and we're going to go through these uh rules of 21 by one just to kind of get a bit of an idea that sometimes there's sometimes a helpful to think of. Um So the first rule of two um is two views. Um So let's have a look at this. So, so what anyone think of this uh lateral x ray of a left ankle that you can see there, this was a 34 year old male who tripped up on the pavement, um comes into a knee, uh sort of really quite very sore and swollen ankle and you see this lateral view of the ankle, anybody, any ideas and the thing you're not happy with. So it's really at least and then uh I'm just guessing, but I don't know, like perfect. Uh uh The sound is not amazing. Actually, I can't, so I can't quite hear your, I was going to say is that uh sure of the tendon rupture of the, I'm not sure. I'm not sure. That's a, well, it's great that you're looking at the soft tissues. Um And uh probably not helped by the sort of image on the screen as such. But um so the achilles is going to be coming in here and I agree, the back of that looks a bit funny and I suspect that what's probably happening here is if you look at this, um, uh, there is some kind of a sort of bandage around this which is constricting all of the soft tissues all around here. So, I think that's probably why that's looking so odd, but that's a really good thought and I'm glad you're definitely looking at the soft tissues. Uh One more view. So. Well, that's exactly the right question to ask. Um So I'm glad that you're all not quite sure if there's anything wrong with this. Um You might sort of, if you're looking really carefully, you might see that there's maybe something going funny with, with a fibula just here, but it's a bit hard to know, but you would never guess just on that view quite how bad this ankle is because look at, look at the other view as you asked for. All right. So that's the AP view. Um And you can see that this is a gross um fracture dislocation of the ankle. Um No prizes for spotting the abnormality there. Um So the principle, first principle here is that one view, a single view is one too few. You, you always need two views normally, orthogonal normal at right angles to each other. Sometimes you really need more than two views, but don't just be happy with a single view where you're looking for, for fractures Okay. Um, so moving on, what does everyone think about this is a 42 year old male who was climbing and, um, had a bit of a nasty injury, trapping his thumb while he was climbing. I said first MCP J dislocation. Good. Right hand. I agree. Absolutely. Right. Okay. Any, anybody have any other comments? Okay. So I agree. There's an MCP joint dislocation. Absolutely. Um, but I always think that there might be more than one injury. Um So the temptation always is to be very happy once you've seen one fracture or in this case, one dislocation have a look carefully. And can you see how um the not only is the MCP joints clearly dislocated but actually the CMC joint of the thumb down here, the bones are actually overlapping and this is the CMC joint is actually dislocated as well. So don't stop looking after you've seen the first fracture. Uh And you can see this is what it looked like um after it was reduced. So they reduced the MCP joint, but they also reduce the CMC joint. You can see they had to do that surgically. They put an anchor in uh in order to to stabilize that CMC joint. You can see now here very clearly that how that was that was abnormal. So don't stop looking after you seeing the first fracture. So second rule of two is two fractures, okay. Have a look at this. Um So there's lots you could start saying about this film. Um So I'm gonna give you that, you're going to have a look at it and you're gonna say, well, clearly there's been some major surgery here. Um, it looks like they've excised the lateral end of the clavicle. They've put a couple of screws in here probably to fix, um, the coracoclavicular ligament. Um, so it's all probably trying to stabilize that a si joint. So you're going to spend a lot of time looking at all those things. And I think that's very helpful. Does anyone spot anything else? And this may be quite a difficult one, certainly depending on how good your screen is, I suppose. And I'm going to be very impressed if anyone spots this. So here we go, any one spot, the pneumothorax. So there's the lung edge just there. Hopefully you can see that on your screens. Um So this was a frontal view of a shoulder that was done as a post operative film. Um But it's really important not to just be focused on, on all of that. Uh And once you've seen one abnormality or once you've described one thing, always look around at the rest of the film and pick up the things that uh you may not, you may not otherwise expect to see. All right. So two views, two fractures to opinions often, uh x rays can be difficult, can be challenging, particularly if you've not had a lot of experience and if you're not sure, just, it's really helpful to ask a friend. So, here's a 27 year old male. He twisted his ankle playing football. Can anyone see the fracture or if there is a fracture, anyone see any abnormality? So, um, if the silence means that this is a difficult one, I agree. There'll be a tailor shipped. Saillant, snowed, don't think so. I think that's okay because the line is not clear. Is it the daylight? So that will depend a bit on the angulations of the frontal view. Um It's not a mortise view. This is a direct frontal view. So, but there isn't really any significant widening here on either side. So I wouldn't, I wouldn't say there was tailor shift. Go ahead. Sorry, somebody else was going to say something. I was going to sit on the second slide. Uh the second. Next way you can see the tarses very clearly on the front and yeah, a little bit of that, it's significant that you can't see clearly. So I think again, that's a kind of question of seeing lots of these. Um This is kind of what they look like really? So when you look at the tarsus that all the bones are kind of uh superimposed on each other on that frontal view, aren't they? But I don't know if you can see there's a lot of soft tissue swelling there. Um And if you're finding this difficult, it's because I think it is difficult. But if you, I'm going to just assume this up a little bit. Um And there is actually a fracture just on the lateral view there, but that's a really hard one that's sort of going through the, the lateral malleolus. Um So basically, if you can't see something, if you're looking for a fracture, I mean, there's obviously gross soft tissue swelling here. Um Presumably it was probably a very tender ankle and you really expecting a fracture, get someone else to look at the film to you might have more experience, phone a friend if you can. Okay. Here's the next rule of two. So this is a 74 year old in a road traffic accident. So this was a major injury. Um They had radiographs of the right femur here. Uh And I don't think you can see any kind of fracture, but when you make sure that you um include the joint above and below, you'll sometimes pick up fractures that you were not expecting. So in major trauma, um it's always important to especially major long bone trauma, always make sure that the joint above and below are included. Uh So here you can see, see this patient obviously had a previous left sided femoral nail, but on the right side, uh they've got this common muted intertrochanteric fracture of the fema. So for long bone trauma include the joint above and below the injury site. So that's the next rule of two um visit reviews, I means refers to get old films. Um So if you've got the luxury of having previous X rays of the particular area you're looking at, look at them because often that comparison will be very helpful and you can see if things have changed to modalities is another uh principal. So here we've got a 64 year old woman who fell on the stairs and she's now unable to wait. Their, she's got right groin pain. Um Have a look at that. I mean, have a good look. I have to say, I don't think I can see anything on that. Um Anyone, anyone wants or anyone think they can see a see a fracture here. Um No, that I've said, I don't think I can see it. I think it will be too scared to say you think you can see one. But yeah, no, I don't believe there's any abnormality on that plane film, but she definitely had pain and the problem with hip fractures particularly um uh she's not very elderly, this person, but particularly elderly and osteoporotic patient's is that sometimes a non displaced hip fracture can be a cult can be very difficult to see on the plain film. So what should you do? Well, the best thing to do is to get a different imaging modality. So in this case, we went to MRI in this patient. Um and you can see that there's corona Lemm are images uh on the left panel is a fat sensitive T one weighted image. And on the right is a fluid sensitive stir image. And you can see I'll just assume those up for you. So on the stir image, you can see all that bright white signal within the intertrochanteric region in the right hip, which is all the marrow edema. And on the fat sensitive image, you can see that fracture line running through the intertrochanteric region of the right hip. So it's a non displaced intertrochanteric fracture with a completely normal plain film. Here's a different case. Um 35 year old male, he twisted his ankle um difficult here, you may just be able to see the fracture line um just at the uh the posterior tibia. But anyway, it wasn't picked up. Patient went for MRI and you can clearly see the fracture um in that posterior at the posterior so called posterior malleolus, the posterior part of the tibia on the on the MRI. So if you can't see it on a plain film, it doesn't mean it's not there. Think of two modalities and the modalities you might use might be CT ultrasound, MRI and nuclear medicine depending on the particular clinical situation, two occasions. So basically, if your patient goes home from E D uh and all seems fine. Uh and, and, and returns in uh sorry in the plain films, initial plain films are all fine, but returns with persistent pain and swelling, consider repeating the film because sometimes things will become much more obvious. Um, repeat or follow up imaging can be very useful. Rarely, we can radiograph two sides. The problem with this, obviously, you don't want to irradiate patient's unnecessarily. So certainly, um, you know, in Children were very wary of this. In adults, we're very aware of it too. Um, but on on odd occasions, it can be helpful to compare the normal side, but we don't tend to do that very often. So there's lots of rules of two there which can sometimes be helpful in interpreting muscular skeletal, plain films. Um And then, uh Otto had another rule, another rule which was S A B which I think can be helpful to kind of keep in mind. So that stands for soft tissues, A stands for adequacy on alignment and B stands for bones. So when you're looking at muscular skeletal films, try and think of all the, those four different things is a film adequate. What's the alignment like? Have we looked at the soft tissues carefully? Where's the soft tissue swelling? Uh And then also, of course, look at the bones and if you remember all that, you'll hopefully not go too far wrong. So we've got about another 15 minutes. So I'm gonna can start just any, any sort of questions up to that point. Um So if not, we can carry on just to look at some uh upper limb, um skeletal radiographs. So we'll start with the shoulder. Um And the sort of typical standard views of the shoulder are going to be um usually sort of these, these three views um will be an AP view which you can see here. You might have an axial view or an auxiliary view uh and a scapula y view and we're going to look at those, okay. No apologies for going back to basics with anatomy here. Um There you can see the scapula um and part of the scapula that you can see include the coracoid process which sticks out anteriorly. There's the scapula spine, there's the a chromium process, the clavicle and you can see the acromioclavicular joint in between them. There's the glenoid which articulates with the humiral head and there's the humeral neck. And if you look carefully at the humiral head, you can see a bump there um laterally and a little bump there more centrally. Um And these are the greater and lesser tuberosity ease and what runs between the two tuberosity. Xeni offers the long head of the Axion. Yeah, the long head of the biceps tendon which attaches up here on to the super Galena to Bickell and runs through the joint and runs in between the tuberosity ease. Okay. So that's some basic anatomy. So looking at this um plain film, there is a rule of sevens you can use on this actually, um which can be a bit helpful Um So the first thing is that the sub acromial space, so the distance between the under surface of the Ukrainian and the humeral head should be at least seven millimeters. Um So what, what's, what important structures run structure runs between those two bones dependent and best culture. Uh The Tennant. Yes. So specifically the rotator cuff. Yeah. So it's the supraspinatus tendon of the rotator cuff which runs between those. And if you, if the subacromial space is reduced to much less than seven millimeters, then that can suggest that there's been a massive rotator cuff tear. Okay. The second seven is um the width of the A C joint. So it should normally be um less than or equal to seven millimeters. Um If it's widened, then that suggests that there's an A C joint dislocation. And the third rule is the coracoclavicular distance. So the distance between the under surface of the clavicle and the tip of the coracoid and that should be less than twice seven, which is 14 millimeters. Um And let's just have a look at what that is referring to. So, here's a 23 year old male who fell off a horse. What what do we think about that? Any offers to be acromioclavicular dislocation? Good. So there's acromioclavicular joint dislocation. You can see that the acromioclavicular joint is markedly widens definitely more than seven millimeters. But also this coracoclavicular distance is certainly more than 14 millimeters. So the acromioclavicular joint here is actually stabilized by um two main sets of ligaments. One is the acromioclavicular ligament which runs across the joint. But actually, that's really not the most important stabilizer of the joint. There's a much stronger ligament which stabilizes this a si joint, which is the coracoclavicular ligament which runs here between the coracoid and the clavicle. And that's a much more important uh whoops and that's a much more important and much stronger stabilizer of the A C joint. So this leads to the classification of a si joint injuries. Um It's called the Rockwood classification. And where you have a type one injury, there's just a partial injury to the acromioclavicular ligament. So there's no widening of the joint. You probably will see nothing. You might see a little bit of soft tissue swelling over the joint but nothing else in a type two injury. The acromioclavicular ligament is completely torn um and there is widening of the joint, but the coracoclavicular distance is still preserved because that cora important coracoclavicular ligament remains intact. But in a type three, both the joint is widened and the coracoclavicular spaces widened because the coracoclavicular ligament is completely torn, okay. So that was the frontal view of the shoulder, the AP view. Um We remember that one view is one view too few. So the next favorite view is normally going to be um the axial view or the axilla review and this film is taken the arm in order for this film to be taken, the arm has to be abducted by 90 degrees. Um and they normally put sort of curved X ray cassette into the axilla and shoot the X rays down through the shoulder. So that produces this sort of appearance here. So what are we seeing on the axilla review of the Exile view? So you can see the humeral head, hopefully, pretty obviously and that's going to articulate with the glenoid there. So you can see that glenohumeral articulation, you can also see that there is a bone sort of sticking out on its own in the front, that's going to be the coracoid process. And then you can also see the acromion process leading into the spine of the scapula, the clavicle just there and then in between the acromioclavicular joint. So the way to look at these is really to first orientate yourself. If you find the bones sticking out on its own in the front, if you find a bone sticking out on its own, that's going to be the coracoid process. And once you found that, you know, which is anterior and which is posterior, and then you can work out where the clavicle and acromion art and the A C joint. So that's kind of how to look at these films. Um If you can't get an axial view or sometimes even if you can, you might do a scapula y view. Um The problem is that patient's who have injured their shoulders may not be able to abduct their um arm 90 degrees to put, in order to be able to put the X ray cassette into the axilla. And therefore the axial view may not be possible. So you might need to do a different sort of you. And often the scapula Y view is done um as a second option. So this is the Scapula Y view, sometimes called a Mercedes Benz view. It sort of makes an upside down Mercedes Benz sign. So what you're seeing here is the glenoid kind of on fast with the humiral head overlying it. You're seeing the coracoid process there in the front, the spine of the scapular at the back and the blade of the scapula below. So that's how it makes that sort of upside down Mercedes Benz sign. All right. So what do we think about this? This was a 24 year old male who had an injury in rugby and he was unable to move his arm. Any thoughts. There is a glenohumeral dislocation. Yeah, absolutely. Which, which, what kind of a glenohumeral dislocation be okay? It inferior. So it looks kind of inferior, doesn't it? Yes. Yeah. It's actually, it's an anterior dislocation. They kind of always go a bit inferior early as well. But let's let's just have a look at this. So, um and the anterior glenohumeral dislocations there. So the anterior ones basically account for 95% of glenohumeral dislocation. So most of them are going to be anterior. Um and they occur when um uh sort of patient's put their arm in a sort of forced labour position, which is stands for abducted externally rotated. So that sort of putting that arm uh kind of up and behind them. And then the, the humerus kind of leave us forward onto the front of the glenoid. Um And especially in young patient's are up to 40% of them can be, can be recurrent. Um They can be sub classified as being subcoracoid as this would have been sub sub glenoid. If they go sort of further in theory, Lee or they can be subclavicular or even very occasionally, I've never seen it in real life, but apparently they can be intrathoracic where they actually sort of it dislocates all the way in between the ribs into the chest. Um I've never, never actually seen that in real life. But anyway, um so these are the anterior dislocations. Um Now, if you can get an exile view. So as I'm saying, most patient's won't be able to tolerate this because you won't be able to abduct the arm. But if you can get an exile view, this is what it would look like. So I've put the normal axial view on the right panel just for you to compare with and this is the abnormal one on the left. And hopefully, you can see the glenoid is here and the humeral head is here. So it's dislocated anteriorly. This is the coracoid process. So we know this is anterior and that's posterior oops, sorry, we know that this is anterior and that's posterior and the humeral head is perched on to the anterior glenoid. And you can see there's a big defect in the bone of the anterior glenoid. And this is called a bony Bangkok, which is a defect of the anterior glenoid. Often there's a defect in that part of the humeral head as well where those two bones impact on each other. And this, it's called a Hill Sachs defect of the humeral head and a bony bank art of the anterior glenoid. So that's an anterior dislocation contrast that which which is a posterior dislocation. These are very difficult uh to see actually often on the, on the frontal views. But here's an exit, a review where you can see it and you can see the uh again, the anatomy on the zero review, there's the glenoid, there's your coracoid process. The humeral head is sitting posteriorly, it's dislocated posteriorly. You can see there's a bony defect here at the back of the glenoid and a bony defect at the front of the humeral head. These are reverse bony Bangkok and reverse hill Sachs defects due to the bones impacting upon each other. Posterior glenohumeral dislocations are much less common. There are any account for about 5% of glenohumeral dislocations and their diagnosis is often delayed in as many as 50% of cases. Um really because they're hard to spot on the AP film. Um And they're, they're much, generally much rarer. Um They're often particularly seen in patients who have had an epileptic fit uh seizure. So you'll, you'll often see posterior dislocations in that, in that situation. All right. So any questions about shoulders before we move down to the elbow? Okay. So we're going to move down to the elbow. Um So the two standard views you're gonna have of a, of an elbow are going to be a lateral and an AP film. Um We're just going to go through the anatomy again. So you got the humerus, the owner and the radius very straightforward within the radius. You're gonna be able to see the head, the neck and then this bump here, which is the radial tuberosity, which forms the attachment of the biceps tendon in the proximal ulnar. Um You're going to see the electron on overlapping onto the back of the distal humerus and in the distal humerus, you've got the lateral epicondyle and the medial epicondyle which give rise to the extensor and flex attendant origins respectively. And then within the joint, you've got the articular surfaces of the capital in which articulates with the radial head and the trochlear which articulates with the proximal ulnar on the lateral view. Again, we're seeing the radius and the ulnar and the humerus and the trochlear and capital um are gonna be overlapping each other and you're gonna see the electron on uh their um within the proximal ulnar. So that's the sort of bony anatomy. The fat pads of the elbow, somebody asked about joint effusions. So the fat pads of the elbow are very important. Um There are two fat pads here which you need to know about one which lies anteriorly and one which lies posteriorly and they both kind of sit within the distal humerus. Uh Sorry. Oh yeah. Was that, that was a question or was that question or comment? Um Okay. So there are two um fat pads of the elbow, one which sits in the anterior humerus and one in the posterior. Um And these are sort of represented here on this diagram as these two fat pads. Now, normally they sit up against the bone and the anterior fat pad. Although it can be seen, it shouldn't be elevated. So you can see a very subtle little fat pad, just hear the posterior one shouldn't normally be seen at all because it sits in a divot at the back of the humerus, which is the electron fossa, if you have a fracture which extends into the joint, um then it will cause hemorrhage in the joint which pushes the fat pads out and this will elevate the anterior fat pad and it will make the posterior fat pad visible when it normally shouldn't be. So, here's a couple of examples. So you can see in the panel on your right, the elevated anterior fat pad and the visible posterior fat pad. Can anyone see where the fracture is on the, on the on the panel on the right? You're like um um holocrine. Yeah, good. So you can see that intraarticular fracture through the electron. Um What about the panel on the left? Well, actually, um it's quite hard to see, but there is a little approximal radial fracture. Yeah, but this was more to sort of show you the fat pads again. So there's the anterior fat pad elevated and there's the visible posterior fat pad. Um So posterior fat pads are uh are meant to be really quite specific. Posterior fat pad in particular are meant to be quite specific for a fracture following a excuse me following an injury. Uh It said that around 70 to 90% of Children or adolescents with a posterior fat pad will have a fracture and it's 97% specific for a fracture in an adult post injury. So even if you can't see the fracture, you should assume that there is one and treat it as such. Um you should be aware that really a fat pad sign is just a sign of a joint effusion. So if a patient's got arthritis and not a fracture, it will also be positive. And you should also be aware that in order to be positive, it requires capsular elevation and that's not going to happen if there was either capsular rupture or if the fracture was outside of the joint, um then you won't get hemorrhage into the joint and then, then it won't elevate the fat pad. So you can have a fracture with, without a fat pad in some cases. So here's a case. Um You can, hopefully, what, what does everybody does, everyone think about this. What can you see? Well, I can see the fact but that is anti, they posted their fat pad. Yeah, so very obvious, elevated anterior fat pad and posterior fat pad. But I don't think you can really see the fracture on that. I I can't anyway, those the fat pads. What about on this? Can you see any of the uh what about on the AP view? Can you see the fracture? Is it on the radio? Yeah, good. So it is, it's quite a subtle one, but you can just see a radial neck fracture. And if you can't see a fracture on uh certainly on an adults elbow, then it's probably going to be in the radial neck or head. And if you can't see it on the A P or lateral views, then one option is to do an oblique view, which is called a radial head view, which we did in this case. And you could see the fracture very clearly um on the radial head view here. So that, that can be, it's an oblique view, the radiographers will know what to do. So that can be quite useful. I'm conscious that we're sort of coming up to, um, time actually. Um, I am, I am I okay to sort of run over another 10 minutes or do you have another lecture after this? I don't know. No, we don't have any more lectures after this. So, am I okay to carry on for 10 minutes or? Yeah, that's fine. Okay. All right. So, um uh so now just to have a look at alignments in the elbow. Um So the first alignment is this, this is the anterior humeral line, which is a line running along the anterior cortex of the humeral shaft. And the rule with this line is that on a true lateral view and only on a true lateral view, it should pass through the middle third of the capital. Um This line is the radio, the pink line is the radiocapitellar line. Um And the rule for that is that a line through the proximal radius should pass through the capital. Um And that can be on any view. It doesn't have to be a true lateral. It can be on any ap or oblique view, it should always pass through the capital. Um So these are the two lines that you need to remember the anterior humeral line for a true lateral view and the radiocapitellar line for any view of the elbow. So, what do we think about this, this is obviously a child's elbow. Um You can see that the growth plates have not yet fused any thoughts about this case. Uh dislocation. Yeah, it's really good. Um So first thing is you can, I don't know if your screens show it well enough, but you can see fat pad signs here. So there's the elevated anterior fat pad, there's a posterior fat pad, but looking at the lines we were talking about um the anterior humeral lines, okay, that probably goes more or less through the middle third of the capital. Um But the radiocapitellar line isn't, it actually goes, um it doesn't go through the capital. Um So there's the capital. Um Yeah, and this is the radial head and that radiocapitellum line just doesn't work. Um And um in fact, unfortunately, this was missed. Um uh it's surprising how easy it is to kind of walk past these. Um But in fact, it was missed at the time. Unfortunately, there was the AP view which I don't think really showed very much else. Um And the child, it came back kind of week or two later. Um It looked even more dislocated now and you can begin to see there's a little bit of Aasif occassion forming actually, which becomes denser. Uh It was, it was, it was missed again and it was, it became even denser at that point. So this was really quite a nasty injury by this time. Uh And by now, unfortunately, they really needed uh an operation to fix this. So this is one to kind of watch out for. So that was a radiocapitellar dislocation in a child. All right. So we'll move down to the forearm. Um Now, a principal to kind of be aware of um in looking at a number of bony areas in the body is the principal of a ring. So there's a number of bones that form rings. And one of those is the radius and the ulnar along with the proximal radio on the joint and the distal radio on the joints. So together they form a ring. And the important point about this is that actually it's quite difficult to break a ring like that in one place only. Um It's just like a polo mint. I don't know if they have polo mints in Ukraine, but it's a common mint in, in England. It's just a hard mint. Uh And it's um basically in order to break it, you've really got to break it in two places. Um So you can either break a ring in two places in 22 bones or you can break one bone and dislocate one of the joints that forms part of the ring. Um And this same is usually true of the forearm bones. Um It's also true of um the tibia and fibula along with the proximal tibia, fibula joint and the, and the ankle joint there. It's also true of the pelvis, the pelvis has a ring. So the pelvis in fact has three rings. So there's the main ring around the pelvis, there's also the rings around the obturator um regions on either side. And again, if you, if you break any one bone in any one of these rings, they'll usually be a break somewhere else as well. Um So um just, here's an example, here is very obvious fractures that you can see of the mid shaft of the radius and the ulnar. Um This is a different case. What do you think about this? Any thoughts on this one? Communicated fracture of radius goods? I agree. And uh it is close fracture. Uh Yes. Uh uh Is it um various angulated? Yeah, there's definitely some, definitely some angulations. I agree. Yeah. All know dislocation as well. That's the thing. Yeah. So that's what I want you to pick up on. Um So using the principle of rings, we've got a fracture here and I accept it certainly commuted, but you might expect something else to be going on in the ring. And the other thing that's happened in the ring here is that you've got a dislocation of the distal radioulnar, the joint, you see how wide that is and the ulnar, the illness kind of sitting that way and the radius is sitting that way. So this is a dislocation of the distal radioulnar joint along with the distal radial fracture that's known as a Gal iatse Fracture. It just has an eponymous name, get a fracture dislocation. Um Having given that rule, there are obviously always exceptions to rules. Um And this is called a nightstick fracture, which is where you've just got a single fracture of the mid owner. And that generally is happens where there's just been a day direct blow onto the mid forearm itself. So literally a a nightstick was an old policeman's truncheon. So they used to sort of uh if they, if they kind of struck somebody on the, on the arm like that on the forearm like that or the forearm got in the way when they were trying to strike someone, then they could just produce a single fracture of the ulnar without causing two fractures in the ring. Um Okay. So just moving down in the last five minutes, moving down to the wrist, um uh two views of the risk to standard views of the wrist. You've got an AP view and the lateral view. Um and just quickly moving through the bony anatomy radius and ulna, there's the ulnar styloid at the tip of the ulnar there. And then you've got the proximal carpal row which I'm sure you'll know your anatomy of. So the scaphoid lunate and triquetrum and the pisiform bone overlapping and then the distal carpal row which is formed of the trapezium, the trapezoid, the capitate and the hamate very common distal radial fracture. Um So, colleagues fractures which occur. Um uh very frequently you'll see these all the time in E D patient falls on the outstretched hand. Um usually in over 50 age group. Um these are distal radial, transverse metaphyseal fractures which have dorsal angulations or displacement, the same fracture. But with Vogler angulations, displacement is called a Smith's fracture. And the importance of these often is their association with osteoporosis. So they do tend to occur in osteoporotic patient's when they do occur in over fifties, you should look out for osteoporosis because they may be a harbinger of other fractures um to come. Um Here's another common fracture fall on the outstretched hand. Patient has tenderness on the radial side of the wrist. Um and often what's called the anatomical snuffbox as specific tenderness. And what do you see here? Yeah. So this is a typical skate avoid waste fracture. It looks undisplaced on this view. But what about this case? This was another patient who also fell on the outstretched hand. They've got clear tenderness in their anatomical snuffbox and they, they had a whole series of plain films. This is called a skateboard series, various oblique views. Um Hospitals often do a series of five different views to look at the skate void in different orientations to try and identify the fractures, but these were all felt to be normal and around 16% of patient's in this situation will actually have a fracture that you just cannot see. So this is a case of 22 modalities, ideally, um the ideal way to deal with this is to go on and do uh an M R if you've got the uh if you got the resource to do it. Um And this will, as I say, show fractures in the skateboarding, around 16% of patient's who have normal initial plain films following a sort of good history of a fall on the outstretched hand with tenderness in the anatomical snuffbox. So here you can see the fluid sensitive stir image which shows bone edema throughout the scaphoid and there's the fracture line along that proximal pole of the skateboard just there. Um Okay. So just to conclude, um we've talked about fracture descriptions, we've uh looked, we've said we've used lots of sort of terms to sort of talk about how we're going to describe fractures. Um When we see them, are they acute or chronic? Are they common? Muted? Are they compound or open? And what sort of displacements are there? Um We've talked about various rules of two which can help get you out of trouble um in looking at muscular skeletal, plain films. Uh And we've talked as well about SAB. So just remember when you're looking at these plain films, look at soft tissues, look at adequacy and alignment and look at bones. Um So that was all I had to say. I hope that's been of some help that I'm happy to uh stay on for questions if there's any questions or comments. Um, do you feel in the feedback? It's really helpful to know because obviously, I don't, don't know, you guys, uh, it's very helpful to know if this is sort of pitched reasonably appropriately, if it's helpful for you or not. Um, so do, do let us know. Great. Okay. All right. I'll take that silence as either of, uh, either I've put you all to sleep or you're, or you're all happy with everything. So, um, yeah, that's, uh, fine. All right. Hannah, thank you very much. I think. I guess that means we're, I guess that's, I guess we're done.