Imperial Radiology Tutorial Series: Musculoskeletal Imaging



This on-demand teaching session is tailored towards medical professionals to gain a better understanding of musculoskeletal radiographs. Participants will learn the basic principles of x-ray imaging, terminology for describing fractures, anatomical descriptors, and a Salter harris classification. The Royal College of Radiologists' undergraduate curriculum will be a guide for the session and a secret tip on the resources will be included. Sign up now to gain knowledge on an important role of radiology!
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Imperial Radiology Society is proud to present an informative talk featuring Dr. Hannah Steiniz on the topic of musculoskeletal imaging.

Dr. Hannah Steinitz is a final year clinical radiology registrar at the Royal Free London subspecialising in musculoskeletal radiology and will be sharing her expertise on how these imaging techniques are used in clinical practice. Get an inside look into how these tools are revolutionizing the diagnosis and treatment of musculoskeletal disorders!

This is an essential event for anyone interested in the field of radiology and musculoskeletal medicine, and an opportunity to learn from an expert.

Learning objectives

Learning Objectives: 1. Understand the principles of density imaging and the importance of looking at multiple views when evaluating bones. 2. Identify medical terminology used to describe fractures and dislocations. 3. Explain the differences between adult and pediatric bones. 4.Review the Salter-Harris classification of fractures. 5. Distinguish between open and closed fractures and the clinical management implications of these differences.
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Computer generated transcript

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

Is expanded with this contrast material, and this allows us to look in more detail at more specific smaller structures in the joints, which you wouldn't see without an infusion. So this is basically an iatrogenic infusion, which is used for diagnostic purposes um And you can also use other modalities such as ct, to guide musculoskeletal intervention, So here you can see a thoracic vertebra in an actual slice um with a needle, which has been placed there under ct guidance into this lucent bone. Asian you know, this could be a metastasis, which could be painful, maybe refractory to analgesics, radiotherapy, and they've injected some cement there, um which might provide symptom relief and also reduces the likelihood of a fracture in the future, so vast use of different modalities across m. S. K. And radiology and also a huge variety of different patient's that we see, so you think classically of orthopedic, patient's of like a diagram of a hip replacement, but we also see a lot of rheumatology patient's we have a strong presence and accident, emergency radiology, and then there's a more esoteric fields such as you know bone infection, um soft tissue infection, soft tissue tumor, and bone tumor's as well um So with this in mind, in order to decide what to talk to you guys about today. I looked up the undergraduate curriculum, which is a very helpful document by the Royal College of Radiologists, which guides medical schools about what you guys have to know by the time that you graduate and start your foundation jobs and when it comes to skeletal radiographs not that helpful, it's base, it covers a lot of different types of pathologies such as fractures this location, the fusion, dislocation of the spine, um pediatric so, fractures involving joints and the physio, plates long bones spell this summer like pretty much everything and it can be tested at all of the steps of your medical school assessments, so um I'll start by saying then that I used um some material from this book, which I have no affiliation with the osteo's whatsoever, but it's just a very helpful book. If you are interested in expensive emergency and radiology orthopaedics, very good examples descriptions, images and I'll tell you a secret is that this book used to be given um as part of a course um which is held by the authors, which still exist, but now I think is online, but what this means is that most radiology departments will have several copies lying around which you can borrow um And it's it is a very good book if you're interested in in further reading, so let's start talking about some principles um that we need to understand before we start looking at um diagnostic x ray, So this is a picture of a chicken bone which has been um x rayed in a, in a beaker containing water, so it's it's labeled as soft tissue density. Most of your soft tissues are predominately composed of water that's what's form the density that we see on the x ray, fat, and air, so it's going from more dense to less dense and the reason we see anything on x ray is because there has to be a different and the density of tissues which are interfacing, so tissues, which are touching each other, um So when you look at the soft tissue versus bone, because the soft tissue is the denser um tissue that that we're looking at when we're looking at musculoskeletal radiographs, there's less of a difference whereas when there is air touching the bone, you can see this really sharp contrast and this is kind of the principle that guy's things like the silhouette sign or the interior fat, pat sign, and elbow radiographs, which we'll talk about later, and he was just applying this into practice, So this is a fractured bone, where there's been um distraction of the fragments and you can see then that the, the kind of like density that surrounds the bone is also seeing at the fracture gap. Then when there's overlap, you've got um also the like the composition of the of the two layers of of density of the bone on top of each other. Um There's just things that you have to think about when you're looking at fractures because there are two D image of the three D structure right and the other very important principle is out of two views. So if you look at this finger x ray, you would be forgiven for saying that this this might be normal. You know this joint looks a bit narrow and it looks a bit narrow here, but it looks grossly unremarkable. But when you look at the second view, you can see that it every single interphalangeal joints is displaced. It's just a projection that can make it look like it's not as abnormal as it is so in any kind of like exam situation, or when you are in a, any looking at the plain films of your patient's you always have to assess the second view, um Even though it might not be the view that you prefer to look at uh It's just a funny example of how it's important some more aspects of life. It's just a picture of prints would um looking like he's doing something very rude actually, he's just doing the number three and I'll let you in on another secret, which is that radiology is about the words. People think it's about the pictures and it's very easy to focus just on the picture, but it's beyond the picture, there is a patient behind that picture, There's a whole clinical situation scenario background, and there's all the next steps that you have to to use the image for it's not it, doesn't the buck, doesn't stop with the x ray um and what makes you a good osti candidates very good. If I want doctors knowing what these next steps are and how to communicate them, so it's about the words and as I said you can't forget to think like a doctor, so you see an x ray, so factory have to think what does this mean what are the following steps and what what are the clinical implications of these findings, so we'll start with the basics um terminology. In terms of describing a fracture, you can talk about the size of a fracture. You can either use the anatomical descriptors such as here. In this um diagram of the shoulder, you have a scapula and the bits of the scapula have different names, so the acromion articulates with the clavicle. The corroborated processes, and one that points forwards, there's a blade of the scapula or if it's a long bone. You describe it in terms of thirds, so here we have a fracture of the mid third of the humerus and here we have a fracture of the distal third of the humerus. You can describe them as closed or open. This is not always obvious or able to be determined on a simple radiograph, um but it's it's important because it it changes clinical management because they're going to be more prone to infection and they might need more urgent orthopedic intervention. You can describe it in terms of fragments such as a two point fracture, three point fracture. If there is a three minimum amount of fracture fragments described them as common use it as well um the direction of the um of the bone defect, so a transverse oblique and spiral fracture the most common in long bones. Whether or not it involves the articular surface. This is important because it might um change the operative management because the fracture that does involve the articular cartilage. As you know, it won't heal um is more likely to develop into early onset arthritis of that joint, so it does change the management and the prognosis of the long term use of that joint and the displacement of fracture fragments has to be described um With respect to the distal fragment as opposed to the proximal, So, in this case, you've got so this is the same fracture. Yeah It's got the two views and oh sorry it's uh fracture at the same level, but one is this is undisplaced, and this one is displaced laterally, so it's displaced away from the body, or you can describe it as a radio displacement. If you think about the anatomical position and here you have a lateral view, so you can see the lateral cervical spine and that's the posterior displacement, so you wouldn't say that this fragment is anterior displaced, So this is still anatomical because it's attached to the rest of the body, and the distal fragment is posteriorly displaced or laterally displaced in this case and similar way to describe angulations whether it's angulated laterally, immediately anteriorly, in this case, um dislocation versus subluxation is something that used to confuse me. Um You have to think about the articular surfaces, so in this example, the humiral head has its current tillage here and the glenoid also has um the current ledge which forms the shoulder joint. If there's no contact between the articular surfaces that should be communicating, this is a fully dislocated joint. If the joint isn't in perfect anatomical position, so if it's for some reason displaced in any direction, but the articular surfaces are still speaking to each other, that's a sub state of joint and then you can describe it as inferior lisa blick state and in this case um and this can can be a for a variety of causes trauma, joint effusion, a bleed into the joint um earthrise itis, and then you have to look at the other findings on the x ray to be able to evaluate that and here's an x ray example of an inferior lisa bleck stated glenohumeral joint, so you've got the humiral head where the articular surface is here, you have the oval of the glenoid, and even though the humiral head isn't sitting perfectly where it should be in the shoulder joint, you still have some contact and this is important when we look at children dislocations later on a few important factors to go over about children's bones. Um As you know, they have a specific terminology, so the epithets isS is the most peripheral aspect of the bone, this is followed by the growth plate or the fyssas. Um The metaphysis is the kind of like flaring outfit into the long shaft of the bone, which is the diagnosis. The three major differences between children and adults bones is that children still have their growth plates and this acts as a kind of like a shock absorber. He has like a rubbery texture um where all the bone forming cells are um which adults don't have, and this is an extra point of weakness in the bone. Of, for children, children's won't have a stronger periosteum, which sometimes can hold the bone together um despite a a strong dramatic force or an injury, and the mineral structure of children's bones is less brittle than adults, so it doesn't fracture in the same way as adults where a bone can just completely break off. It can still happen in children, but then you have specific fracture patterns and children, which don't happen in adults, which we'll go over in a moment um And we have to talk about the Salter harris classification, which can look like a lot initially, but it's actually fairly easy to understand aunts to remember because the name salter very helpfully, it lends itself to a pneumonic um so we have here a normal bone and then types 125, which forms the classification of the Salter um classification of fractures s, I remember as slipped. It says you're straight across, but it means that there is an injury at the growth plates and nowhere else um and we'll see an example of this later A stands for above, so there's an injury to the bone above the growth blades that the metaphyseal region and also involves the growth plates, of course, but there is no involvement of the epiphany sis, of the most distal aspect of the long bone, Type three is l for low or below, which is the opposite of type two, so it involves the growth plate and it involves the epiphysis, but it does not involve an epitaph assis. Tea is through involves everything and are um you can remember to scrushy, remember it was rammed, which is when there's an injury to the growth plates itself, and these can be very difficult and most of the time very difficult to appreciate. On x ray here, we have some examples of the Salter harris type fractures. This is the lateral of the radius and a child, and where you're supposed to see the epithets. Iss of the radio, of the of the radius, just sitting like aligned with the Math asus and the growth that's in between. It has slipped backwards and angulated backwards so this is as for slipped. It's the Salter harris type one. We don't see any fracture lines in the epiphysis or in the metaphysis of this child. Here, you have a lateral ankle radiograph and you can see a fracture line here in the Math asus, but when you look through the epithets issue, don't see any lines and you also assess um the second view of the radiograph of course as with anything um now a frontal x ray of an ankle and you look through the meth athesis and it looks fine and then you start tracing the bone around the medial malleolus and that looks fine and then here there's a break and it goes into the growth plates and there's kind of like fragment um which is partially obscured by the other bones, but it is definitely there, so sorry this is above and this one is below, so salter has three, s, a. L3, and here, it's more easily seen, you can see that there's a fracture line that goes through this um medial malleolus across the metaphysis, the growth plates, and the epiphysis. So that's the salter harris, for and stars and green stick fractures. I used to find them really difficult to understand as well basically what they are there longitudinal compression fractures across the bone, but it depends on the axis of force, so if you have a direct longitudinal um impac, on the bone because of what I said that children's bones are more malleable, less brittle than adults, and they have a stronger periosteum. It holds the bone together. What you get is a buckling of the long bone usually in the metaphyseal region. As this, so this is still a fracture, whether you don't see a line through it, this is a fracture and a greenstick is pretty much the same thing except that the force has happened as an angle and what this means is that the forces are transmitted through the opposite side of the bone where there might be a cortical break, but the other side of the bone remains intact, but angulated. So this is again still a fracture. This is a greenstick fracture, okay so we'll get onto it and just do a quick um review of important um common clinical situations where you might um be asked to interpret a musculoskeletal radiograph either as an f. One or during your off skis um shoulder x rays. The two most common views we do or an a. P. And which means anterior posterior, so it's the frontal projection and the second view is usually a scapular Y view, or this like oblique view where you can get this kind of like appearance of the scapula with the humeral head sitting in front of the glenoid which is projected over it, so it can be a bit more difficult for you to kind of like get your head around it, but you're still looking for the congruity of the articular surfaces and you also can see a bit of chest here, um some ribs and lungs, and in both of these, you can see the acromioclavicular joint. Um The normal alignment of this joint is that they have to be at the same line, so if one is above the other um then this means that this joint is also being disrupted um and you you look at fractures in the same way they look at fractures anywhere else um And this example, we have a common you did humeral head fractures, so there's a fracture of the neck of the humerus and there's avulsion of the greater tubercle of the humerus. This is important because your rotator cuff muscles attached to it, so this might um have implications about the physiotherapy that the patient might require um one recovering from this injury and we have fractures of the um anatomical and surgical neck of the humerus. The surgical neck of the humorous fractures are way more common, um but this is the way that you can describe them if you see them and don't forget to look at the other bones as I said the acromioclavicular joint remains aligned on all of these cases, but it's very easy to focus a lot on the glenohumeral joint and not for example see a smaller like minimally displaced clavicular fracture, which because it's a long bone and describe in terms of thirds right, so, here's a fracture of the mid third of the clavicle and of the distal third of the clavicle. Um medial third of the clavicles are in their third are more uncommon and they are associated with mediastinal vascular injury as well, so they're more usually seen on more high impact trauma going on. Two dislocations, um remember what I said about the humiral head sitting in front of the glenoid. Here, you can see that where the articular surface of the humeral head is is nowhere near where the articular surface of the leonard is and it seems to be projected either in front or behind of it. Remember that this is a two D image of the three d structure, so you need your second view and here is kind of like a slightly angulated scapular wide view, but you can still see the glenoid and the spines of the scapula and the humeral head. Seems to be sitting between the glenoid and the chest, so this is an anterior dislocation and when you see an anterior dislocation, the next step is to think is there any secondary injury, um which is common. Um in these cases, and I use I use to find it really difficult to remember which one was the hill sachs and which one was the bankcard. The hill sachs injury is a depression of the posterior lateral aspect right at the top of the humeral head, and it happens because when the humeral head displaces interiorly, it can get um lodged just at the base of the glenoid, which causes this focal depression and the bankers or the bony bank art is at the anterior inferior aspect of the glenoid. Because as you can imagine when the, when the humerus moves forward, it can it can chip the glenoid as it does so and the way that I remembered them was that the hill sachs is at the top of the humerus like at the top of the hill and the bankers. I would just remember before below for the inferior aspect of the glenoid and usually you see these, you can see these on the, on the dislocation x rays, but after you reduce these um dislocations, you will re image and then look look further because there's so much overlap here that you might miss these fractures um. So yeah, so you also look at the post relocation images and posterior shoulder um dislocations are less common in exam lands. They're usually spoken about in the context of post seizures um and they are more common procedures, but they're far less common than anterior shoulder dislocations. People classically classically talk about the lightbulb sign. I never found that particularly useful because I think that in some views of the humerus, it can still look a bit like a light bulb, so I don't go looking for the light bulb, I look for the articular surfaces, so here you can see that the humerus is rotated um It's still at the same level as the glenoid, so it's a bit more difficult to be 100% sure that this is not a subluxation or just a rotation of the joint that the shoulder has been imaged in, but when you look at your Y view, you have the Y of the scapula and the glenoid is in the oval here and you can see that the humors is behind, so it's not between the scapula and the chest wall as we saw in the anterior dislocation, It's it's it's posterior to the glenoid moving on to the elbow and to focus on the lateral view, which is the most useful and start talking about the fat pads, So you have an injury on a post your fat bad. The post to your fat bad in a normal elbow will always be hidden by a groove at the back of the distal humerus, so you shouldn't be able to see the very black density of the fat bad and the posterior humerus and the normal elbow answer your fat pad it's in front of the humerus, so this little slither of of darkness is normal and sometimes it can get overcalled as an elevated fat, then because people worry but this is fine. Um you'll see some examples of some elevated fat pads in the next slide and the joint has um the joint lining on some synovial fluid which is usually a small volume of fluid just to lubricate the joint. The reason the fat pad gets elevated in certain types of injury, or if there's an infusion for whatever reason is because there is a large volume of fluid in the joint and as the joint fills up, you can imagine that this lifts the fat pads up, so if you see a posterior fat pad it's always abnormal and if you see a raised anterior fat pad um that also indicates that there is a joint effusion, and in the context of drama, this will usually be due to a fracture. We'll see some cases next, and these diagrams illustrate the alignment of the elbow joint. This is the radiocapitellar line, the capital um is this part of the distal humerus laterally, and um the radius is the The radius and ulna are kind of like opposite bone, so the owner is big at the elbow and smaller the wrist and the radius is big at the wrist and smaller the elbow, So it's it's the smaller bone at the, at the elbow and it's got the typical rounded surface of the radiohead. If the radial head. If there's a dislocation of this joint, um this radiocapitellar line will be disrupted. It won't cross, it has to cross both the radius and the capital um So in this example, it's anteriorly displaced, It's not crossing the capital and it's dislocated. You look at the other view and you dissence and, and have a look at the rest as well to see if there's any injury there, so here the examples of the fat beds completely normal. So the the density of the muscle here is the same density of the soft tissues. Your post series of the humerus, you don't see a posterior fat pad here and then you have this thin black line, which is the anterior fat bad, which is normal. Here, you see that there is a poster of fats bed. There's some soft tissue density in between the bone on the flat bed, which is the joint diffusion I was speaking about and then you have the triangular appearance of the anterior fats bad, which is no longer at the bottom of the humerus. It's just going all the way up and what you do when you see this is you look closely for the fracture and here you can see that there's some discontinuity in the cortical contour of the radius, whereas here you can you can follow the cortex nicely here there's a bit of a step so this is where the fracture is, but it's important to remember that these radiohead fractures can be completely are called. So sometimes you don't see them at all an x ray and here you have again very clear, raised interior fast, bad raised post your fats bad, you can kind of see the joints of fusion as well, um but you don't really see you can follow the court's bill Clinton well. I mean you scrutinize all the all the bits of the album, would look at the a. P. Radiograph, but a lot of the times, it's not uncommon that um the fractures are completely on this place, but they get managed as a fracture, so they get seen by the orthopedic. They go to fracture clinic. The elbow gets mobilized um in order to allow healing even of an undisplaced fracture moving on to the montage and gallian, see fractures, which can also be very difficult to remember. They're almost opposites of each other and that one is a factor of the ulna with dislocation of the proximal radioulnar joint, the other is a factor of the radius with dislocation of the distal radioulnar joint. You don't need to get bucked down with the names of the fractures. It is fine and uh Noski situation, or if you have to describe it to an orthopedic surgeon in any to say what you see you don't you don't need to give the name because if you're in an exam and you give the wrong name it, it will, it will look like it won't look as good as as or as professional slick as if you were just able to describe it using the anatomical descriptions and all the fracture descriptors that we've talked about um the way I remember them. If you think you can add this to all of your vast medical school knowledge is mantega, for you, for ulna and the gal, iatse, I just remember like radi us or the radi I, which is the plural of radius um and it helped me remember it's not beautiful um but if it helps you then um that's always good, so the reason that the uh these factors happen in this. In this kind of pattern is because the radius and ulna are connected by the two joints proximal in this, so as well as a strong interest, this membrane, so they serve as one functional unit, and it's kind of like the parliament principal where you can't break it just on one spot. So if if you have a disruption in in one side of the problem is like something else has to give on the other, so it's it's it's a similar principle you imagine as as if this they form a circle even though there are two different different bones, all of the soft tissues and ligamentous structures in between them hold them together. So if you if you have a break through the cortex of of the illness, something else in this circle has to dislocate and all of all that the names Montage eukaryotic fracture is, is there just descriptions of this particular pattern adventurous so you can get the fracture of the owner without having a dislocation of the proximal radioulnar joint. It's just that this is something that some sometimes people like to talk about and and describe and ask questions about moving on to the wrist. Um These are the basic wrist radiograph views uh frontal and lateral You've got your eight carpet bones. There's usually a lot of overlap. There's a lot of overlap with them at the carpal bones and particularly on the lateral views of the, of the risk. It can be quite difficult to interpret the way to start looking at these is to find the radius, which is the big one and the owners here behind it and it doesn't really contact the carpal bones in the same way as the radius does. Sitting directly on top of the radius is the moon shaped bone illuminate, which is this one here and then you can see that the illuminate and the lateral projection will overlap with the skate void, but the skateboard rises above it, So you kind of like find the one that overlaps with it, but that also continues forwards and this is the front bit of the scapegoat and then you can't really interpret there's too much overlap. Um the posterior aspect of the skateboard on the lateral view and on top of the lunate is the capitate, which is the big bone of the wrist. It's like the captain of the wrist and again you look for the alignment of the lunate capitate joint yeah for skateboard. We do extra views and all of this means is that we did two extra positions where the radiographer positions the patient's hand and slightly different angles and it allows us to have a better view of the cortex of this k void in these oblique views and this is very important because scapa fractures can be very difficult to see and they are very important as well explain to the next slide here you can see a hairline fracture through the waste of the skateboard. It's completely undisplaced and you can imagine how, depending on the slight projection angle, this could be completely not visible and x ray even though it is fractured here, we have just a small critical step and gap at the uh typical of the scale fight and here we have a slightly more obvious fracture of the scale fight, but if you're not used to looking at risk, it could just look like a another risk joint, um but it's it's a fracture of the lower pole of the skate fight and here's the explanation of why the skin food fractures are so critical to identify. Um The scale food is one of the bones in the body that has a retrograde blood supply, so it has a the blood supply to its middle and lower polls, comes off a dorsal branch of the radial artery which courses backwards and what this means is that If you get a fracture of the skate food from the waist downwards, there can be a disruption to this blood supply and remember that bone is living tissue, it needs the blood supply, and if this is disrupted, the bone cells that provide the callous formation that forms parts of the, of the fracture healing process, um will not unite as well, so you can get fractured nonunion, and if this part of the bone just loses its blood supply completely, it can undergo the process of avascular necrosis, which just means that the bone slowly dies, become sclerotic irregular um and this can compromise the entire structural integrity of the risk. Because you can imagine what this many bones. There's just more like governments holding them all together and this will predispose the patient too early and severe osteoarthritis of the wrist. So this is why the skated factors are so critical and if you suspect a fried injury if your patient has an anatomical snuffbox tenderness, you need to specifically ask for skate with meals and also we don't offer it won't do them and you might miss them um and just another slide. I know I went on about the montage and galbiati fractures and the temptation here is to say oh this is a communicated displaced in particular dorsal uh dorsally angulated distal radial fracture. This is the qualities fracture, but actually these are words that um names that were used in descriptions of um very old papers and you haven't really read the paper. You don't know if you can call an in particular fracture call these fracture, so I think in my opinion, it is safer to talk about distal radial fractures just using the anatomical and fracture descriptor terms, So in this example, this is a the still radial fracture appears commuted. I can't really say if there is any in particular extension, but it's definitely dorsally angulated and there's a bit of shortening of the limb because the fracture fragment has gone proximal. I would hesitate to call this a smith fracture because to be honest, it doesn't really change the management of the patient um and if you say it's in an exam it might be wrong or you might get an examiner, who is very pure negative about the terminology, so I would and in principle avoid using these names unless you are 100% sure that you can going on to the pelvis and lower limbs now, um the pelvis Forum is a rank, so the Parliament's principle applies. If you have disruption at any point of the ring, you have to look for the other points of disruption because you know it will be there and this might be at the stake. Really ac joints, it might be at the pubics emphasis, in which case it might be difficult to call on an x ray, but at least you have to look to make sure that you're not missing anything and we'll focus quite a bit on the, on, the proximal femoral as well because it's a very common injury that you'll definitely see a lot whether you do um orthopedics, amy, or geriatrics jobs. Here's an example of um an obturator ring fracture with superior pubic ramus and the inferior pubic ramus fracture and in this case, there is your pubic ramus fracture, which extends to the pubic body and the pubic synthesis, So this is the rink principal kind of like being a bit more difficult to understand and that you don't just see the parliament, um but here you can um you can see the fraction involves um the joint, so it's it is it is broken at two spots um It's just not not as easy a principle to to appreciate in a single image and moving on to the hip radiographs. So if you're suspecting a hip fracture, your patient will get an a. P. Pelvis, the frontal pelvis radiograph and if you can it's not always possible a lateral hip radiograph. They don't usually look as nice as this if you've seen any, there's usually a lot of overlap if the patient can't raise their other leg up, you'll see the other finger behind it, um but it's important that you use it to follow the cortical contour. As best as you can looking for any fracture or any steps particularly in the region of the femoral neck and most of you will be familiar with centonze line, which is this kind of like smooth arc that you can draw in a normal hip joint going from the inferior cortex of the security puke ramos along the medial cortex of the proximal femur and if there's any disruption to this line, you have to be suspicious about um involvement of the proximal femur or as a tabular displays or whatever cause. Um It doesn't necessarily have to mean that it's a broken bone, but for the principles of medical school, a, any um and your Oskin's that it most likely will be a fracture if it's abnormal and this is something that's highly testable so here you can see this x ray and this is a very typical a. N. E. X ray and that the patient is so osteoporotic. They have some random calcifications and pelvis don't know what they are. The soft tissues are all irregular. There's loads of vascular calcifications. This hip is severely degenerative. It's you know um There's no joint space of uroscopy information it looks a bit it already looks abnormal, but if you follow Shenzhen's line on this hip, you can see that it forms a smooth arc, whereas if you start following it on the right hip, it kind of you kind of lose it, so you can't you can't form that smooth art that we saw on the previous image and that we can see on on this hip. It it just it's discontinuous and if you look closely you can see that there is you know like overlap of bone density's here at the femoral neck. Um This cortex doesn't look completely continuous with this dense line. There is a fracture line here, it's just a bit angulated in the wrong way, so this is a an intertrochanteric femoral neck fracture with disruption of Santon's wine. So this needs your orthopedic review, you need to prepare the patient for surgery um and to plan what the prosthesis will be. Um Here's another example of what's on the ap, radiograph is quite a subtle hip fracture um where there's just a little cortical step at the superior aspect of the femoral neck, but then when you look on the lateral, if you follow the cortex here and the anterior aspect of the femur, you have your lateral trochanter and then the cortex kind of stops and goes nowhere and then you try following the femoral head in the acetabular socket. You can follow it, follow its follow it and then there's a bit of overlap here with the pelvis, but you can kind of still continue to see as it goes into the neck and then it stops here again and there's this kind of like gap in between. And then if you look at the whole thing, if it's you know take a few steps back, you can see that there's angulation of the femoral neck, so this is an intracapsular fracture of the femoral neck and what this means is that the you have to imagine that the the ligaments that keep the the hip together forming the joint capsule of the hip. They all attach around this intertrochanteric line, so you can describe fractures as intertrochanteric, which is when they fracture across this axis, um intracapsular, which is when it's involved the anatomical femoral neck of the femur or subject intact, which is when it involves the long bone parts of the femur and this is critically important again because it affects the management of the patient. Um The blood supply to the femoral head is is given off by circumflex branches of the profunda femoral artery which are also retrograde similarly to how the skateboard was, So If you break your intracapsular femoral neck, there is a high chance that there will be disruption to this retrograde blood supply and this bone will be at risk of avascular necrosis, whereas fractures that are intertrochanteric or subtrochanteric and configuration have a much lower risk of disruption to the blood supply of the femoral head and um and they're manage differently and this is an example of avascular necrosis of the thermal head. If you remember back a few slides where the scaphoid had some avascular necrosis, it looked it looked bright, so sclerotic little bit whiter than than the normal bones um irregular and this is a weight bearing joints. It's a bit flattened already and this bone is no good. It needs to come out. Um it will just get worse and it won't heal by itself and this might have happened For many reasons, there's a huge number of causes for avascular necrosis of the hip, one of which is is an intracapsular fracture, but um diabetes, steroids there are many other causes of avascular necrosis of the hip. Um So here we have examples of intertrochanteric fractures, so you can see the greater trochanter here, the lesser trochanter hit your fracture line goes through them, and the femoral neck appears preserved here. Is another one with the version of the lesser trochanter uh We can try and see centonze line here again and it stops there and then it jumps and it's slightly lower and it continues, there doesn't form the smooth arc that you can see on the other side and these are managed with a dynamic hips group and the principle here is to preserve the articular cartilage of the hip joint, so yes you can just replace the whole joint, but joint replacements have a time span and you know you can last 10 15 years. If you have a young patient, it's much better to keep their own articular cartilage than to just put artificial mental or plastic or or prosthesis um in the joint, So this is the principle of why um these fractures where there's less risk of avascular necrosis of the femoral head. Um You try and preserve the patient's native bone um as much as possible hemiarthroplasty is what you would do if, if the, if the femoral head has to go, so you can see here, there's no femoral head bone left and they've taken it off throwing it away and put in the hemiarthroplasty, so one side of the joint is replaced and you can see here that the acid type of the rim it's just the patient's own bone and there is nothing sitting there. On the other side of the joint, they've only replaced one side of the joint and this is the most common treatment for an intracapsular um thermal neck fracture. You can treat um femoral neck fractures with a total hip replacement, So in this case, you can see that there's some material on the acetabular side of the joint and these can be done if the patient has an inter, displaced intracapsular fracture, who's who's young um These usually last a bit longer and they have a better functional outcome or um so it's on a case by case situation. So if it's it's a very old and frail patient um then there's probably no point doing a total hip replacement and they'll be they'll be better off and, and good enough and with what is a slightly safer surgery of the, of the hemiarthroplasty as opposed to the total hip replacement, which has slightly more complications just because it's slightly more involved it's involved both parts of the joint is, can be longer so it's it's a case by case situation, but the vast majority of intracapsular fractures will be replaced with hemiarthroplasty moving on to the knee. Um. I think people be very familiar with x rays of the knee uh the a. P. M. Lateral, these are taken not in a standing position but in a horizontal beam lateral. What this means that the patient is lying on the table and the x rays just placed at the size of the knees rather than having the patient standing um and the reason we do this is to look for the super patellar effusion or like oh hemarthrosis, so the super patellar bursa is a normal structure in the knee, which usually has a small volume of fluid and for many reasons, it can't fill up with fluid and then this would present a swelling of the knee and you can you can have the patellar fluctuation of the clinical finding and here you can see that there is compared to for example, here where all you see is a super patellar fat pad. Here, you have this fluid, soft tissue density and it's it looks swollen on the x ray, but it's just the uniform density and this could be due to injury. It could be due to inflammation. Um Many reasons as well are arthritis, whereas here we have a super patellar bursal infusion, but it's slightly special and that it's got to densities and it's got this fluid level. It's about layering. If you remember that um one of the first lines with the chicken bone and the three densities, you can see the fat lying above the fluid because it's less dense and where does this fat come from well. It has to come from somewhere because it's not normal for you to have fat inside the joint space and in the context of trauma, the libel hemarthrosis will be secondary to a cortical intra intra articular break um and it's the fatty bone marrow that leaks off into the joint and forms a libra hemarthrosis, So if you see a little hemarthrosis, you have to look for the fracture and usually these will be to build plateau fractures um which, which will be absolutely intra-articular and they can be very difficult to detect, but here you can see some depressed um tibial plateau fractures with some sclerosis and here you can see the light bottom arthros iss and the cortical break um in the same lateral image. If you don't see a fracture still needs to be investigated, we do we do ct, for when there's a liberal hemarthrosis and we don't see a fracture, then we'll be able to see very small undisplaced cortical breaks. Another important knee joint area fracture is the proximal fibula fibula neck fracture and the reason these are very important is that these patient's can present with foot drop, um so they'll be tripping over. They won't be able to walk normally and the reason that this can happen is because your common perennial uh nerve which is a terminal branch of the sciatic nerve. It loops around the neck of the fibula exactly where this fracture has happened and it gives off this deep fibular nerve, which has a cutaneous branch, which exclusively innervates the 1st and 2nd toe webspace. So if you see a patient with this kind of fracture and they have difficulty walking. You know it could be because of the pain of the fracture, but if they have a clinical foot draw um and you should the next thing you should do is test this the sensation in this area and then if the patient does have altered sensation there, you would say oh I'm very suspicious then for a common perennial nerve injury and you know this will require orthopedic inputs to fix the fracture and you know extensive video to your therapy to try and recover some of that movement. Um All right moving on to the ankle, the tibia and fibula, they form a bone units similar to the radius and ulna, so they are joined by the syndesmosis, is add to the proximal and distal um aspect of the lower leg, and what you look for mostly in these x rays is that this joint, the space at the distal tibia, no fibular simba's mus is's, preserved, and that's the space around the talus and the ankle joint is uniform all the way around. If you have widening in any of these areas. Um This suggests ankle and stability and um usually needs surgical fixation um and you also look at the lateral x ray, you follow the bone and contours and look at the tailor dome and the tibula friend fractures here are the examples of the Weber fractures, another thing that can be quite difficult to remember, so these are weber a. B, and c. I remember them as a being the lowest and going up as they go up in severity, so see is the most severe type of of Weber fracture, so it's the higher up one. This fracture just involves the distal fibula tip. This still to the Sindh osmosis, there's no disruption of the send osmosis and the tibial taylor um joint space appears preserved. This is a a bit of projection als um overlap, but if you can see here, this delete, the space is similar to the other side here, however, be fracture is defined by being at the level of the syndesmosis, so you can see the fracture line starts here, but it goes up so it involves the level of the syndesmosis and it curls up again um And there's also an associated fracture of the medial malleolus. The joint space here is roughly preserved as well. There's no big displacement, but this will be an unstable injury because it involves the structure that's holding together the distal tibia and fibula, and here you have a completely unstable joint where the fracture is completely above the level of this and is no sis, uh There is gross widening of of the distal tibiofibular syndesmosis and you have extensive lateral taylor shift as well, so you can imagine the whole foot has moved um to the lateral aspect and the medial malleolus has also come off. Here's a diagram for you to remember a. B and c. As it goes up, it gets progressively more severe and B and c will be unstable injuries, which require orthopedic fixation and we'll finish these um x rays with a fracture that can also be easily missed in the foot and this is the base of the fifth metatarsal fracture. If you're not used to seeing these quite similar to the skateboard fractures, it can just look like another little joint in the foot. Um This is the fracture line here and here on this um oblique projection of the foot, it almost follows completely the tarsometatarsal joints of the 1st 4th, But this is the fraction. This is what it's supposed to look like you're supposed to have this kind of like dull just end of the fifth metatarsal um without any learns going through it okay, so we'll go into cases and the focus of these cases is to kind of try and get into your heads how to approach an x ray. If you're ever shown one in an Oscar station, I had uh one of these in my final year, osk, e, a very complex um Weber see fracture and I had to talk about you know potential nerve injury, the displacement, a possible management what to do with the patient, how to prepare them for surgery, so it doesn't stop at the x ray. You have to think about what the next steps are and what's safe for your patient always remember that there's a patient behind the x ray, so um we'll start with this case of a 35 year old woman who fell off the bike pain on the shoulder, requiring analgesia, think like a doctor. The first thing you do after you've described the obvious x ray fine. As you say you know, there's lots of glenohumeral joint alignment. I would like to see the second projection to confirm that this is an interior joint dislocation, which is what I'm suspecting on this ap, view. I will look for any hill sachs or Bank Earth lesion um fractures on this radiograph, but I'm aware that there can be overlap, so I would also scrutinize these in any postreduction radiographs that we obtain, look at everything else remember other things can be injured. I'm looking for the alignment of the acromioclavicular joint. It appears preserved in this case. I'm not suspecting that there has been any kind of like disruption to this joint. I will follow the cortical contour of all the ribs. I can see this patient has fallen off a bike, so she may have fractured a rib and a fractured rib. Can give you any matara, so you'll say I look at the underlying lung to see if I can see any pleural line um that might indicate any mutharika's, which might need more urgent treatment than the fracture, So this is showing that you're thinking clinically, you're thinking about the patient's in front of you and how stable they are. The humiral head is now located in an auxiliary location and I'm concerned about the neuro vascular structures which live in the axilla, mostly the auxiliary vein and artery and the auxiliary nerve. Um So, I would like to test this by doing a neurovascular assessment of the upper limb, so you can mention things like testing for um pallor uh for whether it's clammy, pale, the capillary refill time, and you'll test the auxiliary nerve by testing the regimental badge patch area, and the lateral aspect of the deltoid, and then you'll say my initial management of this patient will consist of analgesia. I will involve the orthopedic team and I know that the first line treatment usually is to attempt a closed reduction of this joint with repeat radiographs following the attempt to check for any further injury and follow up, and the patient will usually have physiotherapy orthopedic follow up um to recover from this injury, So if you say all of these things examiner will be very impressed that you're not just looking at the x ray and thinking that's all you have to do because that's not what what you'll have to do as an f one, you'll have to manage the patient not the x ray. Um This is a case with some similarity to the previous one. It's a pediatric case of an eight year old boy fell at the trampoline with an obvious deformity, so you will get no prizes for seeing this fracture um since the transverse fracture of the distal humerus which is post eerily displaced. You can also describe this as a super Kanzler fracture, which is a specific um fracture pattern and children, which just means it's above the condyles of the of the humerus um here, but you have really important structures in your anti cubital fossa. You've got your brachial artery, you've got your brachial vein, you have your superficial veins and you have your median nerve and also your biceps tendon. So again, if you're looking at this x ray um and uh noski, you would have to say I will do in your vascular assessment of the distal limb and then you can specify we'll look for palate. I will look for um for clammy sensation whether it's cold or not the capillary refill time. I will look for any bruises in the, in the skin. You'll test the median nerve function and also test um whether that you can test the biceps or not. The patient might have too much pain for you to be able to test function of the biceps tendon and it is less important than the nerves and vessels, but it tells something to mention that it's a structure in this region that is at risk and of course you almost involve your the beauty um team when you see this, and if there is any vascular concern, you would also say that you'd like some joint input from vascular um team, so that they are aware if this patient is going to be um operated on in theater so that they can have a look and assess the vasculature at the same time. If there's any uh concern about the neuro vascular structures, another pediatric case um and this would be an opportunity for you to show your knowledge of the Salter harris classification um So you can see here a taurus pattern of injury where there's some buckling and there's also a cortical break here at the metaphyseal region of the distal radius and the radio epithets. Iss, which should be sitting flat on top of the radio, metaphysis above the growth plate has been displaced dorsally, So you would say there is disruption of the growth plate and there is a fracture line extending through the metaphysis. This is above um the line of the of the growth plate um so this would be consistent with a Salter harris type two classification and your next steps um after involved orthopedics, you'd say that this patient would need follow up of this fracture healing because it involves the growth blades. So if there's any kind of like disruption of the bone forming cells um at the growth blades, this fracture can heal with deformity and the radius might not grow as well as the owner, and this can result in a lifetime deformity of the, of the patient's wrist. So this is one of the reasons why it needs to have close follow to make sure that the fracture is healing appropriately moving on to hips, so this is a slightly different one. It's not a trauma case. It's a patient presenting with a one year history of hip pain which is getting worse and you should be aware of the findings of osteoarthritis in any joint. The hip is probably one of the easiest ones to find to to assess them and these are loss of joint space as you can imagine the cartilage gets destroyed and the bones get closer together, subchondral sclerosis, so where there's articular cartilage the bone just underneath it. The subchondral bone can become more dense and sclerotic because of the chronic wear and tear, subchondral cysts because of the altered pressure and the mechanics of the joint and osteophyte formation, which you can see here in fear really of the acetabular margins, so you think like a doctor, so this patient's presenting to you with the one you're history of pain. You will ask them if they've had analgesics, um if they help if they've had physiotherapy and how that helps and more importantly how is it affecting their activities of daily living. Because if, if the arthritis is so bad that it, it stops them from from doing any other activities that either um allows them to have you know an independent life or allows them to you know, exercise a cardiovascular health or or things like that, then it will it will only compound and add to the morbidity of this patient, so this might make this patient to candidates for potential hip replacement um and they might benefit from it if they're not controlling their pain otherwise, but you also have to thank is this a patient candidate for surgery, so can they have the analogies, is there anything that's stopping them from having a general anesthetic. Um You know can they have uh a general anesthetic. In terms of their you know all the other cardio, cardiopulmonary factors that might stop them from doing that, so you need to have this kind of like think holistically about the patient's when you're discussing um an x ray that's just at face value is bilateral hip osteoarthritis okay. So some pediatric hips as well, I've included these because I used to get confused about them as well. This is a classic sba type situation, 13 year old overweight boy with a traumatic hip pain and the lint, this hip is abnormal. The humiral head. If you compare it to the other side has slipped and it's kind of like facing inwards, whereas this one is facing upwards and the femoral neck has also slipped sideways, so this is a sufi, so it slipped upper femoral epiphysis. The upper femoral epiphysis is the is the femoral head, sorry, central before the femoral head and it's slipped. So I mean if you see an extra like this and think about the words, it is slightly easier to understand if you get shown this x ray in an osk E, your initial reaction would say I need to make this patient nonweightbearing until they are assessed by the orthopedic team. The orthopedic team will consider pinning of the reducing the um the sufi, and pinning it to prevent any further damage to the bone, and they might also consider prophylactic pinning of the contralateral hip, so a patient who has one sufi is more likely to develop sufi on the other hip, so often when they go in for surgery to fix the one that is abnormal. They will also pin the other one to make sure that it doesn't slip um again, and this prevents development of early onset um hip osteoarthritis in the future. A sufi is a salter harris type one fracture, so it's a it's a slip of the epiphany, this it's not involving the femoral head or the femoral neck. It's it's just slipped and this is the other classic um pediatric hip case and it's a six year old boy with a limp. The x ray is grossly abnormal, the femoral head, you can't really see the epiphysis well. It looks denser, um then the other femoral head, and there is remodeling an expansion of the bone. This is a perth, east I think a Perthes is less um interesting to talk about in an exam situation, uh but they can still ask you especially if you've done very well, this would be and the management is, is really varied and it's usually a step wise approach starts with conservative management, pain killers, they might have braces, physiotherapy, and then um surgical options are are left as a last resort and I think this is the last case um and it's a classic so again slightly dirty looking x ray, which you have to look with some attention. It's an 82 year old care home resident who's on warfarin and they reported a change in behavior. Shenton is line here is perfect. Shenton line, on the other side is just not there and you can see a fairly obvious displaced fracture of the um intracapsular femur, lots of vascular classifications and then you have to think about the patient, so you could you could just say oh this is an intra, counselor, factual call the orthopedic attainment it's their problem, but this patient some war for it, so you have to think does she have a large stuff, tissue bleed here, check her hemoglobin. Um Well, you need to do a blood transfusion check. Her i. N. R. Is. Is it high am I going to have to prescribe some prothrombin concentrate before she goes to theater for the joint replacement, So these are all things which, which foreign parts of the management, which will have to be responsible at some point um and which if you say if you if you presented this way in an exam, they will be, they will be, they will be impressed, um and finally they're gonna ask you do you think this patient will benefit from a dHS hemiarthroplasty or a total hip replacement and they will say well. I don't think the dhs would be appropriate in this case because um there's been displacement and in financial capsule fracture, so I'm very concerned about the arterial supply into the femoral head um and this patient would be at risk of avascular necrosis, hemiarthroplasty or a total hip replacement would be appropriate in this case because it would replace the femoral head, um but in terms of deciding between which of these, they'd have to take into account the multiple factors surrounding the patient's background mobility, health and they remember it was 82 years old. In these things that hemi is usually, have a lifespan of 15 years. Um So yeah because I don't want to have any questions, I feel like I've spoken a lot, if they're I hope you're still there. If there are no questions to take home points, I remember to look at the two views and ask for a second view. If you don't have one, it's all about the words you have to use the right words and the right orders, try and be as descriptive as possible, remember the patient behind the images and think like a doctor and practice practice. These with x rays when you go to the wards, um practice them with your friends last time I gave this talk. Someone asked if I had any book recommendations and this is the one I use at Medical School, it's a big book, and they have all these different chapters showing on one page, a large, quite good quality prints of an x ray and on the other page, it will have the x ray with kind of like colors and annotations over it um showing all the relevant relevant points it will have like a perfect Osk e answer and then the following pages will have some like questions and answers about um just all the um findings surrounding the um that particular pathology, it's it's it's it's quite good and it's good to practice on skis with um so yes if if you guys have any questions or or would like to you know to to stand to keep in touch with me, um can send me an email and they've helpfully um provided this qr code um for any feedback that you'd like to provide on this session, hung around for a few minutes. Thank you for a really interesting talk that that was really good um yep, so if anyone has any questions, please email um please even Doctor stein, she's by email right there and please fill in the feedback form, any input he gets very helpful to help improve these sessions and feedback for the speakers as well and if anyone has any questions, please put them in the chat. Currently no questions, but there's loads of thank use for you, doctor very welcome my pleasure, thanks for having me and for listening all of you any last questions anyone and please filling up your back forms as well, full functionary great good luck with your next sessions. Yeah Thank you so much thank you for for doing this, It was a really great talk, appreciate your time, No problem, that's all my pleasure, thank you.