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Now or do you want us to wait? Let's start now, I think. Yeah. Yeah. All right. No problem. Um So, hi, everyone. My name is Lakshmi and I am an registrar in the Northwest. Um I work in the Mercy Region and um my presentation today is on lower limb M SK radiology. Uh So we'll try to keep this as attractive as possible. If you do have any questions, please feel free to ask. I'm really happy to answer. Right. So lower limb mamas radiology is a really worse topic. But given that most of us here are um medical students or foundation year doctors sort of earlier on in their training, sort of try to keep it as comprehensive as possible. Try to reduce this into um, a 45 minute talk so that we've got enough time at the end to ask any questions and have some discussion. Ok. Um So I have divided the whole topic uh into five main categories, uh which is mainly trauma, which would be the larger chunk of what we are going to talk today because, um I feel as junior doctors, trauma is something that you need to look at and interpret scans sort of in a very acute manner. And that is what makes a difference. Of course, other conditions like degenerative or inflammatory arthropathy as well is important from a knowledge perspective. But when you need an acute report, when you can interpret it on your own, that's what really makes a difference. So we'll focus mainly on trauma. We will also discuss about other conditions of the lower limb, um such as degenerative arthropathies, inflammatory conditions, infections, and then um winded up with a little bit of um a joke on tumor. So no matter what your clinical um indication is, no matter what imaging modality you're doing. Uh the most important thing when it comes to interpreting an image is to have a very systematic checklist. So this is to ensure that no, not only that you look at what your main clinical question is, you do have a good look at the peripheries and you do not miss anything that's there on the image, which might be actually very much relevant to your patient management. So it is really important that you have a systematic review pattern, a systematic search pattern. Um And you look at all the areas of whatever imaging that you're looking at uh to start with, make sure that you're looking at the right patient and make sure that you've got the right image details as an image that you are looking is the the most relevant one. Also make sure if the patient has had any previous imaging, it is very, very helpful, especially um when you are in doubt whether um this is a normal finding for this patient, has this patient always had this. So previous imaging can be really helpful um from that aspect. Um And when you look at lower limb M SK especially the the main sort of search pattern that I go through is whenever I have an image, I look at all the cortices of the bones, I identify what, what sort of area that is trace, the cortical outline, feel free to zoom in or uh window. The images have a good look at all the outlines of the cortices of all the bones that's involved, make sure they're nice and smooth and they do not have any sort of steps or cracks within them. And that by that you rule out fractures have a good look at the bone texture as well. And this comes with looking a few X rays, a few CT scans and um just make sure that the bone texture is nice and homogeneous throughout um to make sure that you know, there are no missed fractures or any other underlying pathology. The next thing you look at is the joint spacing, make sure that uh whatever joint that you have visualized in that particular image is very nice and homogeneous and smooth and doesn't have any sort of, you know, things that you shouldn't be finding with within a joint, for example, a bone fragment or some fluid within a joint. So make sure that your joint is nice and homogeneous and smooth and then check for alignments. Now this this varies highly uh depending on what particular region that you're looking at. And when we address each of these regions, I will tell you how to look at the alignments. And finally also make sure that you look at the soft tissues because sometimes the pathology might actually be within the soft tissues. Like say, for example, an injury to a tendon or ligament or a hemarthrosis. So make sure that you finish it up with a good look at the soft tissues as well. So uh no matter uh what region you're looking at, make sure you look at the cortices, the bone texture, then move on to the joint, have a look at the alignment and then finish it off with the soft tissue, right. So going on to trauma. And as you all know, if it is a localized trauma or um um not, not, not very severe trauma, often a plain film is what you get as your first imaging modality and you're right to request a plain. However, if it is a more severe form of injury such as a road traffic accident or an an elderly person, um falling down, which is called a silver trauma or someone falling from more than 2 m height, which is sort of um serious mechanism of injury or other serious mechanisms of injuries, road traffic accidents. Then the patient goes on to get whole body CT scan, which is really, really good because not only can you look at the bones there be, you can also look at the internal organs which uh might suffer from injuries as well. Uh CT scans especially can be really good in terms of POSTOP preoperative planning. Um It gives the surgeons a very nice understanding of where to approach from and it makes sure that you do not have any surprises when, when, when you take them to theaters. So, ct scan is really good from that point of view. However, the limitation for act scan when it comes to trauma is that it is something that has inherently got very low soft tissue contrast. So things like ligaments, tendons or even soft tissue changes will not, will not be that appreciated on act scan. And that's when you request an Mr for trauma. Uh I Mr can give you really good um information about tendons, ligaments and soft tissues that is involved in a particular joint that's involved in trauma. And that is when you request an Mr scan. And something that you really need to keep in mind is it's a very highly specific and sensitive test if you are suspecting an occult or an undisplaced fracture, especially fractures such as femoral fractures, neck of femur fractures of pelvic fractures Mr can be really, really helpful. It's highly specific and sensitive. Um Right. So the way that I approach any trauma approach, studying uh a trauma radiology is I usually go from the top to bottom. So, because we're talking about the lower limb, now we'll start with the hip and slowly we'll work our way towards um the ankle and foot. Yeah. So, um we'll talk about the pelvic fractures first or how you look at a pelvic pain from radiograph. Um The thing with pelvic radiographs is uh we're bilaterally symmetrical. So if you spot an abnormality somewhere and you're a bit doubtful about it, you always have the other side to compare. Um If you think, I don't know, this is, this is normal or not, always compare it to the other side. If the other side looks similar, then you can call it pretty much normal. Now, just like any other imaging, like we talked earlier, trace the cortices have a look at the bony trabeculations, the uh joint spaces alignment and then go on to the soft tissue. Now, when it comes to hips, you've got some, a few lines in place which will help you a certain as, as in whether the alignment is right or whether there's a fracture, the most important of that is uh can you see my point? Um No, I don't think so. Oh All right. That's fine. I will um just try to tell you in terms of the colors then. Um So we've got the orange line over here, which is called as a sheen's line, which is very important because uh many times the most commonly missed fracture when it comes to a pelvic X ray is a neck or femur fracture. And shen's line is disrupted um for your inner neck of femur fracture. So make sure that you follow that shen's line nice and well, um the red colored and the blue colored the iliac and ili is lines will help you understand, if there is an acetabular fracture or if there is a superior, inferior pubic grammar fracture and finally make sure to trace the anterior, the posterior border of that. Um the acetabulum which is the green and the pink dotted lines there. So those are the extra things that you need to look at um for in a hip X ray, right? So moving over, we've got a pelvic X ray over here. Uh It's uh a frontal radiograph. If anybody wants to have a go, please feel free. Uh If you find something, please feel free to put that in the chat. Has anybody seen anything on that x-ray? No, that's all right. It, it, it is a sub one. But if you uh of course, if you go by a systematic approach, you can see that almost all the cortices look fine. They, they, they look nice and fine and clean. But like we said, if we slightly compare both the sides. Do, do you, do you see the top bit of the femur? Do you feel, do you see the left femoral neck? And if you trace that cortex of that left femoral head down, down into the neck, you can see that there's a sudden step. Do you guys appreciate it? Uh I can see it. Uh I haven't had any comments but yeah. Right. OK. No, that's fine. So that, that's where your fracture is and this is where comparing to the opposite side is really helpful. You can see how nice and round and smooth it is on the right side. Whereas on the left it's a very abrupt se step. It is a subtle finding but you ha you do have a fracture there and um missing a neck or femur fracture can have devastating consequences. So always compared to the other side, when you run out like moving on to the uh to the to the next image. Does anyone want to have a go at this one? It's a lot more obvious here if anybody wants to shout out, are we seeing anything at all? Right. So that's all right. Um Again, if you look to trace all the cortices and have a look at all the lines, do you see something now maybe on the right side? Yeah, on the right side, if you have a look, you can see that the shen's line there, which is supposed to be from the neck of the femur into that, into that, the moving over into that superior pubic grammars, it should be the the orange line that we saw here. Do you see that? Do you see how nice and smooth that orange line is? Whereas if you look at the right femur here, there's a big step and that sentence line is not continuous. Now, it might not actually involve the, the fracture might not involve the line, but it helps to reduce a bigger picture into a smaller picture so that you can focus around that. And now if you look at that greater trachaner on the right side, you can see that it's a lot more, less dense as compared to the other side, it's a lot more loosened. And you can see a small tiny fracture line that's extending from the greater tubercle down and that's a fracture of the right femur, right? OK. So uh moving on to the next one. So this this case sort of is a 30 year old lady who has come in with a right sided um right sided trauma to her hip and got a plain film done completely fine. No problem. That is a very pristine looking right femur. But the patient still continues to have features of um femoral neck fracture and she just can't bear any weight. She's just in so much pain. So they decide to get a CT. Uh So this was done outside the UK often if you expect a neck or femur fracture in the UK, get an Mr straight away. Um I think this was done outside the UK. So they went on to get act. But when you look at the CT as well on the right side, do you see that again? The neck of looks pristine so nice and so clean, nobody would suspect a fracture there again, even after the CT, the patients still unwell cannot wait, bear. And finally, we decided to um do an Mr. So we've got the MRI over here. Uh It's a sequence called a Speedy Fat set. You do not have to worry about the different sequences in Mr. It's quite um it's quite uh an extensive topic. So you do not have to worry about that. But what I want you to appreciate in this, this image, do you see this sort of bright area in the neck of femur on the right side, on the left side? Do you see that bit of them that actually is a fracture? So the patient has had a plain film, the plain film is negative. The ct the neck of femur looks absolutely fine, but when they got an Mr, there is a fracture. So that, that shows how sensitive and specific Mr is in finding really small fractures, um very occult undisplaced fractures. So despite the fact that your patient might have a negative pla and negative CT, please feel free to request an Mr scan and I'm I'm pretty sure that if you have clinical signs, radiologist would be more than happy to do an Mr, right. So, apart from the proper neck or feur femoral fractures, there are also entity, there's also an entity which you really need to look at called as an open book fracture where you where the symphysis pubis essentially widens. We usually take the cut off limit at around 10 millimeter one centimeter. And if it is bigger than that, we suspect um uh a diastasis or widening abnormal widening of the pubic symphysis. Now, this often happens in high velocity of high impact injuries. And uh very often they go on then go on to get a CT scan. Because if that has opened up, there's a high chance that your internal organs, your internal pelvic organs also have suffered some kind of damage. And it's always good to get a CT scan to look how your internal scan, uh internal organs are doing. Now as in with any other part of the body. Whenever there is a ring, you, we all know that pelvis is a ring. Whenever there is one fracture or one dislocation in that ring, there is a high chance that there is a second fracture as well. So make sure that you completely look around the ring, especially if there is that diastasis, make sure you look at the sac yeah, joints as well on both sides. Uh and make sure that you do not have a fracture elsewhere, right? Do you, do you guys have any questions regarding pelvic x rays? Right? Uh Take that as a no. And uh we'll just go on to the next joint, which is the knee joint, knee joint is um very important, especially in terms of trauma. You, you, you might have to review a lot of knee x rays. Um And it's really important to know the important anatomic landmarks. Again, systematic approach, cortex, b trabeculation, joint, space and alignment and soft tissue. Yeah. Uh So we've got the femur here, we've got the tibia and fibula at the bottom. Uh make sure that you look at all these bones, make sure that the patella is in place on the AP uh AP view and have a good look at the tibial plateau, um the media and the lateral and finally, um always, always look at the tibial spines. There are important ligaments and tendons going through there. It it a fracture might mean um a soft tissue injury. So make sure that you look look all around the plateau. Um Again, lateral imaging when it comes to um knee joint is really, really important, mainly because a lot of people suffer injury to the knee, but many times it's actually a soft tissue injury and not a fracture. And it is very easy to um say fine, this this X ray is normal, there's no fracture, but in fact, there might be an underlying soft tissue injury. And the biggest biggest pointed to that is to look at your suprapatellar pouch. You you can see over there, the the there are um there are two stars and there's a narrow pointing towards the suprapatellar pouch. Uh So how it should ideally look is like how it is in the image on the right, you should have a really nice um gray band growing across a dark black space, which means that the the space got some fat and then there is a tendon going through the middle of it and it is nice and clean, it's normal as it should be. And there is no fluid. Whenever there is a soft tissue injury, fluid's going to start building up in your joint. And that area where where you can see the arrow and the stars is basically going to look very, very hazy, you're going to lose that really dark area and it's going to become very, very hazy. And that often is your very first sign that there is an underlying soft tissue injury or a very small fracture. Again, um something to look on your lateral view is also the patella. Um now, if there is a patellar displacement, you often order an extra view which is called as a skyline view. And it is very easy to understand a lateral or a medial displacement of the petar where the pillar is not in the groove, it's gone to the either side, it's a lateral or medial displacement. However, what is difficult when it comes to a lateral view is to see if the inferior patellar tendon is structured and the petal has actually gone up. Yeah, pulled by the corps tendon and whether it's gone up or not. So, a useful thing that I do when, when, when, when I'm doubtful about it is I start, I measure the pilar from the most superior aspect of the pillar to the most inferior. And I sort of measure the length, the height of the petar. And then I look at how, how long the patellar tendon is, you can see it on the, it's, it's very well labeled over there. You then measure the patellar tendon from the lowermost point from where it goes into the patellar and then inserts into the tibia. You measure that if it is more than two times the patellar height, then you suspect an inferior patellar tendon rupture. Yeah. Uh Now, of course, it is in the right clinical context, some people might have a high riding patella or a patellar alter. Um So in, in the right clinical context, it can mean an inferior patellar tendon rupture. Yeah. Um So that was our knee um a key anatomic landmarks on our knee joint and things you need to look at the different views. And I've got an X ray over here. If anybody wants to have a shout what they see do they, do you see a fracture? Do you see any change in the joint space? Uh feel free to type in any sickness? Right. Um I think, I think the answer is fairly obvious over here. Uh So if you look at the lateral aspect of it, where the right above the fibula, you can see a sharp step in that cortex and then there's a fragment of the tibial plateau that's sort of pulled out towards the other side if you can see that. Uh So that's a tibial plateau fracture. And the, it's on the side of the fibula and the fibula is lateral. So there's a lateral tibial plateau fracture. Something that you really need to bear in mind about a um a knee X ray is that the amount the I it's, it's, it's a joint with a large amount of tendons and ligaments and something might look really, really small, it might look like it's a, it's a small break in the cortex, taking away a very small fragment of the bone. But when you do an MRI, it might be a fullblown ligament injury with bleeding into the joint. So make sure that you really look out for the plateau, right? Uh moving over to the next one again, we've got a new image, but it's a lateral one over here. Um And you take us for this, do we have any thoughts about this plain phone? So if you, if you, if you would remember what we discussed earlier, the supra pillar pouch and then the fat badge that we usually see behind the pillar, you can see that's clearly lost. You cannot see that um tendon at all, you cannot see a tendon going through that. What you can see is sort of levels like two fluid in there. So what you're seeing there is a layer of blood and fat about it, which is called a lipohemarthrosis again, which is, which can be an important sign of soft tissue injury. So there's active bleeding going into that joint as we speak, right? So we've got, we've got two images over here and does anybody think the images show fracture? And uh uh do we see any fractures here? Anybody thinks that? Right. I think we're all very shy today, right? Um So we've got this image on the right. Um Right. So, yeah, we've got an answer. So which one do you think is the fracture? Right. Yeah, agree. Agree. There's a fracture. Yeah, the battle is fractured, correct? Um And would you say both these pictures there is a fracture or one of these pictures got a fracture and if you were to pick one, which one would you pick, would, would it be the one on the left or the right? Right. So we think that the all, all, all three of them have fractures any more any more? Os, right. Right now. So, so you guys are right. We do have a petal of fracture. Yeah. So the one on the right. Correct. Yeah. The one on the right is a petal of fracture and the one on the left is actually not a fracture. It is a normal anatomical variant and this is one place that you might get really, really stuck and it, it is quite a common finding. A lot of people have a patella that looks like the one on the left side, right? And that is called a bipartite bela. And it is a normal anatomical variant. A lot of us might have have already been having it now. Uh And how do you differentiate a fracture from a bipartite bela? So if you look in the left side, do you see that the two bits of the pet are so nice and rounded, it looks like little maltese chocolate, whereas on the right side, it looks like a wafer that's been cracked. So on the right side, you can see really sharp borders and that is an actual factor. Whereas the one on the left is a bipartate petar. It's been there since a very long time. Yes. The one on the right is a fracture so well done to you guys uh moving over to tibia and fibula. Uh I think these fractures are often very, very obvious and the same system that you need to put into place. Look at the cortex. Um Over here there is a VV um evident fracture of the tibia and the fibula. If you remember from what we talked about the pelvis being a ring just like that, the tibia and the fibula as well is a ring. And if it fractures at one place, there's a high chance that there's a fracture elsewhere as well. So do not shy away from imaging a joint above or a joint below if you suspect that there's a fracture elsewhere. Ok. Uh Moving over to the ankle. Now, the ankle is a special joint because you have one more extra view, which is called as a motus view. You've got the AP view, the lateral view and a an ankle motor view. Um an ankle motor view sort of looks similar to an AP view. And how do you differentiate between the two? You asked me if you can see on, on, on the right side uh of the slide, there's an image and you can see two white lines sort of going parallel um to each other under the tibia between the tibia and the talus and the fibula and the talus. So um that is what differentiates an AP view from a motor view. And you'd ask me why complicate things with more views. It's only because the motor view gives a very clear uh picture of the ankle joint. Now, the ankle joint is not just formed by bones, there are ligaments as well. Um The the which is shown here as yellow lines, you've got the distal tibia frills and theis, you've got the lateral ligaments and the medial ligaments. Um you might have no fracture at all. You might have fractures as well. But in case these two, the space that is between the tibia and the talus, the fibula and the talus show some amount of widening. That means that these ligaments are ruptured. Yeah. So it's very important to keep an eye out on the motors view because it can give important information like ligament rupture. Uh Also make sure you look at your ap and your lateral view. Same approach, look for cortical break, look for trabeculation and joint space. Um Another commonly missed fracture uh which looks very, very normal. Um when there is an actual fracture is a calcaneal fracture. Um and a very good method to use to make sure that you do not miss a calcaneal fracture. Classical history being um child, jumping off a swing or jumping from a tree or er things like that. It's usually is seen in more, more commonly in Children. Uh A good method to use is using something that was known as a bolus angle. Uh If you look at the calcaneum, you can see that there are two points there on the image, 12 and three, the two being the top most bit of the calcaneum. Uh one being the posterior bit and three being the anterior most bit. So if you draw a line connecting 1 to 2 and extend it 3 to 2 and extend it back. The angle that's formed by it should be between 2040. So if it is less than 20 or if it is more than 40 it means that there is um a calcaneal fracture. And it is important that you look at this angle in almost every calcaneal x-ray because calcaneum fractures can easily be missed. Sometimes you might see it in a foot X ray and you can request for additional Calcaneal views which sort of more zoomed in versions and sort of focused on that calcaneum more if you are suspecting a calcaneal fracture. And uh yeah, you can see on the right side here, there is extensive fracture, this the fracture of that fibula, this fracture of the tibia and also the medial malleus. But this is this is an actual motus view. That is the the picture in the middle is an actual motus view. And you asked me that the the you can actually see fragments of bone come into that joint, which means that there is also that joint disruption, this this ligamental injury associated with that as well. Um And that is an example of so the there is the lateral malleolus is fractured, the medial malleolus is fractured as well. And um yeah, so it is um and th this is posterior malleolus fracture as well and it's just a trimalleolar fracture. Uh do not worry about, um, a lot of bone anatomy. If you do not, uh, reco recollect, it, um, it's not essential that, you know, every single bone or every single anatomical landmark. But if you just keep, keep tracing the cortices know the trabeculations and joint spaces, you're good to go. You can always look up what bone it is, uh, moving over to the foot. Uh, you often get DP views, which is basically the, um the distal equivalent of AP views and you, you get oblique views. Um You need to make sure that the uh the, the f the first metatarsal, which is the long bone of your great toe, the longest bone of your great toe is in a is in alignment with the medial uniform. The second is in alignment with the intermediate and only then you move on to the oblique view and look whether the third and the fourth are in alignment uh with the uh lateral uniform and the cuboid, sorry, the navicular and look at the fifth metatarsal as well and make sure that uh the lateral borders of these bones are in alignment. And that's how you look at bony alignment in the foot. Uh The interphalangeal joints are very, very easy because you've got four other joints to compare it with on the same foot. So um compare it with the other joints nearby and see if the alignment is straight and nice and look for fractures, trace the bony cortices, right? So that's a foot. Um So that is the end of all the trauma imaging. Um Like you said, if, if the, if the imaging is inconclusive, plain radiographs are intra inclusive, they often move on to get CT scans or they, they move on to get MRI scans depending on the hospital that you're working in and again, soft tissue injuries, Mr is really helpful. So, uh does anybody have any questions to ask to there about trauma? Right. So I, I'm, I'm going to take that as a no and keep continuing. Um, so, so we, we're done with trauma, which is the major bit. Now, we're going to discuss a bit about degenerative changes and when it comes to lower limb M SK radiology, the most common, most common degenerative change that you're going to find is osteoarthritis. Now, not really. Most of the imaging that you get regarding osteoarthritis is going to be around, um, referrals from GPS to, to see if the patient has got osteoarthritis or if you, if they, they're known to have osteoarthritis, if that has progressed and painful LIMAs are often more than enough to sort of tell that this patient osteoarthritis and whether it has progressed or not. So we do see a little plain limbs to check for progression of osteoarthritis. Um, now when it comes to, uh, plain radiograph findings in osteoarthritis is, if you basically understand what is happening in that degenerative condition, it's sort of easy to correlate and draw connections and understand why something looks like it on plain film, right? So what happens in osteoarthritis is as we start to use, um, the joints a lot, we start to age a lot. We lose that bony cartilage that exists in between your bones, predominantly around your knees and your hips, you start to lose the bony cartilage. So when you lose the bony cartilage, that is that between two bones, what's gonna happen is that joint space is gonna reduce, you lose the cartilage and that joint space is slowly going to reduce. And that's going to show up on your x-ray as a joint space narrowing. Ok. And once you lose all the cartilage, now your bones sort of rubbing against each other, your body is fighting really hard uh to make that bone strong. Um It now recruiting more osteophytes to sort of make new bony, you know, new bony changes to make new irregular bone around that joints trying to sort of protect that joint and there's more dense, more dense bone there as well. So that results in osteophyte formation and subchondral sclerosis. It, it's just a fancy word for the bone under the cartilage is now getting hardened, that is subchondral sclerosis and you also get something called a subchondral cyst formation. No. Um uh again, osteoarthritis, it is very important to um compare between previ with previous imaging and also between um the compared with the opposite side. Um So we've got a pelvic x-ray over here again. This was done in an old lady, uh, old man. Um, and uh with right sided hip pain, does anybody want to list the things that they see over here? I, I've, I've, I've just, just said all of them to be honest in the previous slide. So if you, if you wanna have a guest, please feel free to. Right. So if you actually compare the right side, so the patients symptoms on the right side, um and I think we all know the radiology, the radiological right is the left and the radiological left is the right. And if you, if you're confused, yeah, that is, that's, that's correct. That's brilliant. There's joint space narrowing on the right side. Um Anything else that you guys see? This is actually a really good example. If you compare it to the, yeah, subchondral sclerosis of the right, well done. That's correct. And if you compare it to the left side, you can see how much of joint is lost on the right side. Like there's literally no joint on the right side. To be honest, there's no joint space on the right side. And like we said, the subchondral sclerosis. And do you see that little tiny round lucency around that joint, that subchondral cysts? And um if you look at the acetabular roof on the right side, there's, there's a bit of overhanging bony growth right above that femoral head and those are osteophytes and these are all changes seen in osteoarthritis. Yeah, this is a very good example because your left side is right there for you to compare with a normal side. And then you've got the right side which is completely abnormal. It's actually a very advanced osteoarthritis, right. So, moving over again, we've got degenerative changes again within the knee joints. The hip, like I said, hip and knee joints are very commonly affected in osteoarthritis. Again, here, the sub this this literally loss of joint space. A lot of joint space is lost mainly around the medial bits of the medial compartments. The lateral compartments still have some amount of joint space left, which is sort of typical in case of osteoarthritis. Um There's subchondral sclerosis as well and osteophyte formation on both sides. And now the bones basically just bend and there's a deformity. And um you, you can sort of expect how this patient is going to be walking in real life. So it's a very, very advanced stage of osteoarthritis, right? So that is the uh the general idea of uh degenerative Arop withy. Um moving over to inflammatory arthropathy. There is a huge list of um inflammatory arthropathies that we could discuss about. But to keep it relevant to lower limb, I have predominantly thought of talking about gout and pseudo gout as well. There are, there are changes of psoriatic arthritis as well, but I, I'll only be talking about gout and pseudo gout because those are the most common inflammatory arthropathy that you see um sort of in clinical practice, the the more common, right? So we all know about gout gout is um uric crystals that are deposited and the classical involvement is a great tool many a times. Uh the clinical history and examination is more than enough to tell that this patient's got um gout, of course, your bloods help as well. Uh But imaging can come in when you want to exclude other things which would present in a similar way. For example, osteomyelitis can present in a similar way, pain tenderness, red hot, um joint. Um These can all be features osteomyelitis or even septic arthritis as well. And imaging can really help to distinguish those clinical entities from gout. No, whenever you do uh imaging in a gout, imaging in gout, uh it's, it's classic foot x-ray um ap and lateral views, you get it and often your ap or your DP views of your best, best friend here. The typical finding that you see like you can see from the image over here on, on the right foot. Let's just concentrate on the right foot for now. You can see that there are two big swellings at, on the great toe. Do you, do you agree with me? It's very hazy. It looks like a cloud over the joints. Do you see that? So those are the regions where there, there's an active ongoing gout. And if you look at the joints around it, if you look at the um sort of bones that form that joint, do you agree with me that looks like someone punched out regions of that bone? So that, that is a classic appearance of gout, which is basically punched out lytic bone lesions and the, the the margins will sort of be overhanging over there. You can see it in the most distal phx of the um great toe. So it's basically punched out and a bit of it is overhanging. And that's sort of very, very diagnostic of gout and will help exclude other things like, you know, arthritis, septic, arthritis or um osteomyelitis, right? So that's gout. And then we've got another entity pseudo gout of CPPD, um calcium pyrophosphate um crystals deposit. But unlike gout, they do not, um the they, they sort of tend to affect the cartilage. What happens in pseudo gout is there, there is calcification of the cartilage. So if you can see over them over there, o on the knee, you can see that something, something wrong with the cartilage, it looks very hazy, it looks very cloudy. So that is because there is calcium deposition with within the cartilage and that is sort of patho for pseudogout and that, that that entity is called as chondrocalcinosis and it's almost exclusively seen in pseudogout. So when you see that it is highly suspicious for pseudo gout. Yeah. So that sort of brings us to the end of, um, inflammatory arthropathies. Uh, does anybody have any questions so far? Right. So, we just move on to, um, osteomyelitis. Now, that is quite an important topic because again, it is something that you ha having a knowledge of how Osteomyelitis looks on plain food or what imaging you need to like, request further. It's, it's going to be really handy when it comes to having to acutely read an image. Uh So it's really nice to have an understanding of what Osteomyelitis looks like. So, osteomyelitis is an infection of the bone and the most common appearance of an Osteomyelitis, a typical Osteomyelitis that is, would be, you see the bone, it looks like somebody has t punched out and taken a big lesion of the bone out. So that's how Osteomyelitis usually looks. It's, it's called a lytic lesion because a lot of bone is lost. It's, it's sort of there's a lot of abscess, this pus formation within it. And so the the normal bone is lost within. So it looks like someone's taken a bit out out of it. There's also something called a perio reaction. Um I'm sure you might have heard about this. Um It looks a bit different on X ray from what you would actually expect. It's when, whenever the there is an in there is sort of infection or a tumor going on, the inflammatory part gets activated and the periosteum, which is sort of the outermost layer of the bone, just sort of gets lifted up. And that gives us a clue into it sometimes. Oh, there is, there's a periosteal reaction going on. There's a bit of periostin that's lifted up. There might be something lying underneath. Um, osteomyelitis is very, very, very often associated with periosteal around. Uh and there, there, there would be loss of bony trabeculation, like I said, and some um the adjacent soft tissue, not always, uh but sometimes, especially if the osteomyelitis occurs, that can lead to an ulcer, very important in case of patients who have been, been in, you know, uh been in a bed for a while, been admitted to itu been sedated, um intubated and ventilated, been lying, uh been having pressure sores. Um They can go on to develop osteomyelitis. And in those patients, if you look at the X ray, you might be able to see loss of normal bone, uh sorry, loss of normal soft tissue like muscles or skin or subcutaneous tissue might be very hazy in that that situation. And sometimes you might even even see gas within the soft tissue. If they are gas forming organisms, you might be able to see gas within that soft. Now, Emma again, if, if your patient's got, uh you've got suspicion for Osteomyelitis, you've done a plain film, but you're not very convinced. Like is that Osteomyelitis many a times? Um Nearly, almost all times you do need an Mr to confirm that, that it is osteomyelitis. Um It is also really good, like I said before, to understand if there's soft tissue involvement, if there's a deep seated abscess and um if there are changes to cellulitis going on top of the Osteomyelitis as well, uh As much as Mr is helpful, it might not always be available because Mr slots take a long time, scans can go up to an hour, uh an hour and a half. But so slots may not be easily available. In that case, you might need to look for alternative imaging, which is more easily available like ultrasound. And you can request for an ultrasound to look for Osteomyelitis as well, especially if the, if the small Children. Um and if it is small joints uh and you're suspecting osteal or sorry septic arthritis, then ultrasound can be really, really helpful, right? So I've got a picture here put up here. It's very nice, well labeled with a black arrow. So um ii guess you guys can see that over there and like we were talking earlier, it looks like someone's taken out a piece of bone from there. That, that, that's, that's, that's classically how Osteomyelitis shows up. And if you like, of course, we, we've seen quite a few plain radiographs now and we, we tried tracing the cortex, cortices of all these bones. Well, if you look at these cortices uh of the tibia you can sort of see that there are 22 lines, can't you, the, the two lines on either side? It's not, it's not one line. Do you guys agree with me? So if, if I, if I go back and if you look at that there's just one line on the tibia on either side, well, as you come back here, do you see that there are two lines further down? II mean, so that's called a periosteal reaction. That gives you an idea if there's something, something going on underneath it and WW what is it? It, it is an Osteomyelitic change. Uh Well, of course, in the current clinical context, it is an Osteomyelitic change, but it can be other things as well such as tumors. But um given the clinical history, you need to correlate with it. Right. Right. So I will now talk about bone tumors. Um They're an extensive topic again. Um Usually if you have a radiology trainee, your bone tumor teaching is going to take at least two days. It's, it's very vast, but um I've got try to keep it as relevant as possible. And the main thing that you would need to do is to correctly identify a tumor versus a tumor mimic, which is most commonly osteomyelitis if you can differentiate osteomyelitis from tumor, of course, in clinical context, um it might look a bit similar. Both patients can come in with pain and tenderness or one part of their bone um of inability to move a particular joint and so on, might be features of both osteomyelitis and bone tumor, the primary bone, bone tumor. So it's important that you differentiate between the two. Uh and sometimes it might not be able to do it plain films. And that's when you request an Mr. And sometimes uh you might need to go down the road of a biopsy to find out what exactly that tumor is. Um the important thing that you need to know uh is whatever lesion you see on an X ray, just, just try to describe it using three main points. The first thing that I usually look for is a zone of transition. So if I see if, if, if you see sort of very irregular looking bone there, so some, there's something happening in that bone, it's very irregular looking, it's something that shouldn't be there. It's not the normal trabeculation. The first thing you need to do is to decide, can I draw around this lesion or not? So if I show you that the yellow arrow over there, do you agree with me that I will be able to draw a nice line around that, that, that lesion on plain film, the where, where, where the yellow arrow is pointing to, you can, you can pretty much draw very well defined lines in it. So that means it's called a narrow zone of transition. That is, you can understand what a normal bone is, whereas where the abnormal bone is big. So that's called as a narrow zone of transition. So if, if that exists, it means that it's a less aggressive pathology that's going on, right. The next thing I look for is a periosteal reaction. We've already discussed about periosteal reaction that you see in Osteomyelitis. You just saw that there were like two lines, wasn't there the, the cortex and then the, you see the periosteal reaction just like two lines next to each other. But there are other forms of periosteal reaction as well. The most commonly seen one with osteomyelitis is the one that we saw earlier, which is this. Whereas when it comes to tumors, there can be other sort of periosteal reactions as well. Uh The one on the left, the solid periosteal reaction is a benign entity. It's um it's usually associated with Osteomyelitis. It's usually associated with less aggressive forms of tumors like benign tumors or cysts. Whereas uh the more right you go, you can see that on the second picture, you can, you can sort of see less of periosteum being la laid over than skull is a classic onion skin. And um that is called as a Lamin periosteal reaction means that it is an aggressive process that is giving rise to that periosteal reaction. And then you have a speculated where you start to see sort of horizontal lines coming out from that cortex and the cortex starts to get destroyed at this point. And it's a more aggressive lesion that is causing that periosteal reaction. And if you go further down, you can see that was complete loss of cortex, the periosteum is basically just lifted up. So you've got the cortex, the periosteum that's lifted up and that's forming a Corman's triangle and that's very, very aggressive. That means that the tumor that you have in hand is a very aggressive process. Um So like, like you've, if you've seen this picture already, um And would you agree with me if I said that I can draw a line around it? So it's got a narrow zone of transition. Um It's, it's got, it's, it's not got much periosteal reaction to it. And um of course, the normal bony trabeculation is gone. So I would think that this is a more sort of benign or less or non aggressive process that's going on. So the patient had that on the plain film and then went on to get act, which is on the right side, it's the middle image. And um if you guys are interested, it's something called as an osteoid osteoma and it was confirmed on CT and it's a benign benign thing. So we're, we're right in calling it a benign benign tumor on painful. Whereas on the right side, if you look, you can see the red arrow pointing towards that layer of periosteum that's been lifted again, like we said, there, there's a very angry looking, um, lower femur, it's very, very irregular, very hazy. The periosteum is sort of making that triangle, which is a Corman's triangle and that is a very aggressive tube. And then later on when they followed up, it was an osteosarcoma, right? So the fro from this talk, what I would expect you guys to do is, uh you know, to at least have an idea how to differentiate a benign process from a more um aggressive process. And if you can differentiate Osteomyelitis from a tumor, that's, that's, that's very good. Uh Moving over um anybody who wants to have a go at this. Do you, do you see any dislocation? Do you see any fracture? Do you see any fragment which shouldn't be there? All right. So it is, it is, it, it is the right side. So it's the right femur and right under that femoral neck, you can see a small fragment. It's not too small, to be honest, it's a small fragment. II, I'm not entirely sure where that's come from. My best guess that it's sort of either from the acetabulum uh or it's from, it's most, most probably from that uh femoral head, it's chipped off and it's come outside where you saw this brain from you, you found out the fracture and you're very happy that you found out the fracture. But now that's the beauty of systematically approaching an X ray. So if you found something do not stop there. If you have a systematic approach, complete the systematic approach. The next thing if you, if you, you, you've now traced the cortex, you can see an extra bit of bone lying there. Do not stop that. You need to go further ahead. You have to have a look at the bone uribe. Now, when you look at that bone tribe, do you see something really weird? It's very irregular, it's very hazy. I would expect you to be a lot more uniform, right? Like this is very heterogeneous looking bone. So this in fact, is metastasis, bone metastasis, there's so much bone metastasis, it's very irregular and the bone is so weakened which has caused that fractured fragment. So do not stop looking. Uh it might be a fracture but it might also a simple fracture, but it might also be a pathological fracture. There might be two things going on and make sure that you do not miss it. Cause at the end of the day, you need to treat your patient, not the symptoms. So make sure that you get a complete picture, right? So that brings us to the end of the talk. Does anybody have any questions? Um Please feel free to ask um If you find yourself confused later, feel free to email me as well. No problem. Um Does anybody have any questions when I say that as a no, I have stunned silence, right? So yeah, no question. Thank you so much, Lakshmi for doing this all great. And if anyone's interested, the next one is on the seventh of June, so it'll be on upper limb. M sk Thank you. Thank you all for coming. Thank you guys. Bye. Have a nice evening. Bye bye.