IRJ National Teaching Series - MSK Session 1



This on-demand teaching session focuses on understanding the complex structures of the pelvis and femur, vital for medical professionals in their daily practice. The speaker provides an in-depth tutorial, utilizing various illustrations, animations, and CT scans for better visualization. Topics covered include the anatomy of the sacrum, ilium, pubic bone, pubic symphysis, acetabulum, greater tranter, and the lesser tranter of the femur bone. Emphasizing the need for a systematic review process, the session also explores fracture interpretation on a pelvic X-ray, distinguishing between intra and extracapsular fractures, and understanding the impact of blood supply disruptions to the femoral head. The session promises to deepen participants' knowledge and is extremely beneficial for those dealing with trauma or orthopedic cases.
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Join us for another instalment in our Collaborative National Radiology Teaching Series - a joint-effort between IR juniors and Radiology Societies at Sheffield, UCL, Cambridge and Leicester. This session is being hosted by Dr Samuel Crompton (Radiology Registrar - Sheffield Teaching Hospital Trust) on behalf of Sheffield RadSoc The session will focus on MSK imaging and will focus on common MSK problems you may see as a junior doctor.

Learning objectives

1. Identify the main bones and joints which compose the pelvic region including the sacrum, sacroiliac joints, the right and left side of the pelvis, and pubic symphysis. 2. Explain the difference between the different terms used for parts of the pelvis, such as ilium and pubic bone, and their significance in adult anatomy. 3. Understand and define the different parts of the pelvic anatomy displayed in the lateral and medial views, as well as from 3D angles, including the iliac bone, pubic bone, ischial bone, and the anterior and posterior columns of the acetabulum. 4. Discuss and identify the different parts of the femur, including the femoral head, neck, and the greater and lesser trochanters. 5. Follow a systematic process to examine the bones of the pelvic region and femur to detect potential abnormalities or fractures, and understand how to interpret pelvic X-ray findings.
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Computer generated transcript

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

Side of the sacrum, you've got your sacroiliac joints. So keeping it really nice and simple sacrum, sacro ilex, join each side. And then you've got basically the right side of the pelvis and the left side of the pelvis which are joined at the front of the pubic symphysis. So you've got pelvic bones on each side, sacrum in the middle and a pubic symphysis at the front. So you've got three joints and really 33 main bones. Now, there's a bit more to it than that. And this is why the different terms such as ilium is and pubic bone come into it. So, in adults, these are all fused bones and essentially this is all one bone in an adult, they're all fused when you're born, that bone is split into three and that's what these different colors represent. So here, we're looking at one view from a lateral aster. So if you look at this top right corner, you've got highlighted in blue, the bone we're looking at here. So this is just the right side of the pelvis. This lateral view is looking at it from here on the lateral side and this medial view is looking at it from the inside here. So we take a look at the lateral view. This whole big top part is the and the green part represents the iliac bone and that's what articulates with the sacrum. Hence, sacroiliac joints that also forms the top part of the acetabulum, which is the cup which your head of femur sits in, you've then got these orange and pink parts. So at the this is posterior and this is posterior. So medial is uh anterior is in the middle. Sorry. So here you've got your iliac bone which forms the posterior column of your acetabulum. And then at the front, we've got your pubic bone which forms the anterior column of your acetabulum. So there's some animations, but let's just take a sort of 3d view of the pelvis and look at it from a few different angles to try and conceptualize things. So this is a straight on 3d reformer of a CT scan of a normal pelvis. So you can see the sacrum here in the middle of the sacral joints either side. And then you've got your pelvic bone all the way around here. This is formed of your ilium anterior. Here is your pubic bone which extends inferiorly there. So this is your inferior pubic ramus and this is your superior pubic ramus. And then as we go posteriorly, which this is posterior, which as you, as we move around, you'll see better. This is the uh is bone. OK. So if we take a look going around that, so if we turn to the side a couple of times, you can see how this is projecting posteriorly and inferiorly. So this is the ischial bone, this is the pubic bone in the front and the iliac bone is up here. And as we take a look going around, you can see how this ischial bone forms. The posterior wall of this acetabulum go around a bit further. You can, if we go around 11 less, actually, it's a bit hard to see, but this is just posterior aspect of your uh pelvic bone here. So if we go back to the first one, so let's just recap before we move on. So you've got your pubic bone which extends, which is anterior and extends across and forms the anterior wall of your acetabulum. Ok. And then if we go immediately to posterior, you've got your ischial bone here that extends round and forms the posterior wall of your acetabulum. Ok. So we've talked about the pelvic anatomy. Next thing to talk about is going to be the femur. So this is just a standard front on also known as ap anterior to posterior view of the femoral head and neck. So if we go to the next slide, we can talk about the anatomy in a few different parts. So this highlighted in blue is the femoral head. This line across here is the head neck junction, the green area here represents the the neck of femur. So when people talk about a neck of femur fracture, this is classically uh so called the neck of femur. You then got the greater tranter of the femur here and the less tranter here, the yellow bit is slightly masking that. So it's this bit here. And if we go back to our pelvic view, you can see that you've got your lesser tranter here, your femoral neck, you've got your femoral head here. And if we swing around a bit, you can see a great tranter which is actually sitting almost slightly posterior to the rest of the femoral neck. This ridge here is where the joint capsule inserts. So basically anything, this side of this ridge is an intraarticular. So within the joint piece of bones. So this is all surrounded by synovium and that makes a difference which we'll come on to in a second. So how do I like to go about it? So, the best way really is to keep it really simple. We want to be thinking, let's look at all the bones. And then after we've looked at the bones, we wanna be going on to look at everything else. So, bones, how do I go about that? I like to try and follow a nice systematic process. So first of all, because the femurs are almost imagine them are separate to the pelvis because they are their own bone. And then um so I like to talk about them first. So I look at the femur, I trace around the edge of each femur and round check for no steps in the cortex, any lucency um in the bone architecture. Um So that's the first step and then move on to look at the ace which it's articulating with and then move to the middle and look at the pubic rami and the pubic synthesis and then move up to look at the ilium and then we look at the sacrum to finish. So let's have a look at that in practice. So first of all, we're gonna start with the femur, this is our first area. So you want to be tracing around the edge of the cortex all the way around. This should be really nice and smooth. You shouldn't see any steps here at the femoral neck. And then you're also looking for the bone architecture in the middle checking for no recent lesions or any missing cortex, which we suggest an aggressive bone lesion. So next, we're going on to look at the acetabulum which can be quite difficult and we'll go into um in a in a further slide after I've looked at the acetabulum, I look at the superior and inferior pubic ray my along with the pubic synthesis, again, we're tracing the cortex throughout to check that everything looks nice and smooth. No big steps to suggest a fracture. After I've looked. So obviously we're doing this on both sides as we go along. After that, I go superiorly and look at the ilium ILIM fractures or issues are very, very rare. So it's, it's more just make sure we're not missing anything. You have to have really high trauma to get an iliac wing fracture. Um So we're looking at the iliac bone, you can see your sacroiliac joints here. You can actually see, although it's one joint, it's quite a deep joint. So you see two bits of it because we're looking again at a 3d structure uh in two D and then the sacrum here, which is actually quite obscured by balgus in this case. So how do, so we've traced the cortex? But what else is there? Now in pelvic X ray interpretation, there's a lot of lines that can help us in drawing these lines can help us see subtle abnormalities. And it should always just be part of your review process for looking at these as well as just generally tracing the cortex. So this line here, does anybody know what this line is called? See if anybody in the chat knows what this is called or what everyone's knowledge is like? Yeah, great. So that's a couple of people already. This is Shen's line and I really use this. So the um to look at the femur. So you're tracing around, looking for any step in this line and then it should run smoothly nicely into the superior pubic ramus and into the midline. So this should be nice and smooth any disruption to this. And you want to be considering whether it could be a fracture. There are a couple of other things that can cause a slight disruption. So it doesn't necessarily mean fracture um such as hip dysplasia and things like that, which are probably a bit slightly outside the scope of what we're gonna cover today. But if you see an abnormality, think is there a an abnormality in this thing, is there a fracture? So one thing I haven't covered is when we look at. So pelvic X ray in itself, it would just usually just do a standard AP view or anterior to posterior. When we're specifically looking for a hip fracture, a a femoral fracture and a femoral neck fracture. We do this ap view anterior to posterior, but one view is not enough cos these fractures can be very, very subtle. So we also go on to do a lateral view, which is what we've got here and again. So this here is the greatest cancer we're seeing it from side on. This is the femoral neck coming into the femoral head. This this is anterior and we know that because this bony protuberance out the back represents your issue. So remember pubic bone at the front bone at the back and ilium at the top. Ok. So while we're here, we'll just go on to talk a little bit about neck of femur fractures and fractures of the femoral head. Um So we talked when we were looking at the anatomy about the uh joint capsule and where it inserts on. And as I said, it comes across here. So all of this is what's known as intracapsular, which you can see here and then anything outside of that. So here and below is known as extracapsular. So we can break those down into capital, which is a fracture through the femoral head, subcapital, which is a fracture just under the femoral head around the head, neck junction and transoral, which means a fracture through the actual neck itself and then the extra cap fractures. So represent intratrochanteric fractures and then fractures which is basically any line, any in the line between the greater and lesser trochanter. And then you've got your subtrochanteric fractures. Now, it matters because of the blood supply to the femoral head and where it comes from. So basically any fracture that's passed the uh into the capsule can have disrupted blood supply to the proximal uh bit of bone. So, femoral head uh and gets uh that bone then becomes at risk of avascular necrosis. So this is something the orthopedic surgeons take into account when they decide how to manage these fractures and the various types of um fixation or rep uh joint replacement that they can do in patients with these fractures. So next, we're gonna move on. So we've done the femur, we've moved on from there next, we're gonna move on to the acetabulum and looking at the pubic bone. Now, this is one of the most complex bits of anatomy to look at and it can be really confusing. So we've got a few, few lines on here. I'm gonna highlight this line here. And can anybody tell me what that line represents? Ok. I'm gonna take the silence as um this one's not as common as Shen's line. So this is called the iliopectineal line. And it's a slightly confusing name cos the ilio bit makes sense in that it comes from the ilium up here. Um Unfortunately, it's not called the iliopubic line, which if we're calling this, the pubic bone makes sense, it's called the iliopectineal line. OK. And this basically represents the anterior aspect of the pelvis and coming around the. So it's really sort of medial aspect of the pelvis coming around the front and it's the pelvic inlet. So we want to see if that line is nice and smooth throughout any disruption in that could represent a iliac fracture. It could represent an acetabular fracture or it could represent a superior pubic ramus fracture. Now, there's another line coming down here which again originates from the is but um does anybody know the name for this? So this one comes down here, but then goes into here. No, fine. So this is, yeah, exactly. That is the E line. So we've got eine line which comes around the front and then the eye, I remember pubic bone at the front and then we've got the IOI line which goes down the back into the ISS. So this really is looking at the posterior column of the acetabulum. So any disruption of this line might suggest either a fracture, a sort of posterior column of acetabular fracture or an iliac fracture, we can then move on to look at the acetabulum now because there's some lines overlying this, it can be difficult to trace. But if you remember our 3D structure that we looked at you, we had a coverage at the front of the acetabulum. And that is what this line represents. This is the inferior aspect of that front of the acetabulum which extends into the superior pubic ramus. So this is the front of the acetabulum on our 3D view. You couldn't anything past here, you couldn't see because it was all covered by that bone at the front. This here, this line that represents that posterior wall of the acetabulum, which we looked at from the 3D view from behind and that extends into the ischial bone. OK. And this here represents the roof of our acetabulum, which we couldn't see on our 3D model because it was covered up by the bone in the femoral head within it. OK. So I'm just gonna overlap some on the 3D model here to try and help you visualize that better. So this line, so if I, if, if I've just told you what we were looking at on the previous, what does this line represent or what's the name of this line? OK. So this is the iliopectineal line. So it runs from the ilium down into the front, down and into the top of the pubic bone. So if we compare that to the last slide, that's this line here. So that's what it looks like on the X ray. This is which part of the bone it's covering on the CT or, or a 3D model of the pelvis. OK. And then, as I was trying to describe this line represents the front of the acetabulum coming around here, which you can see why because that is the front of the acetabulum. And as I said, we can't see that roof of the acetabulum on the 3D model. And then we can also look at the posterior lines. So this is the ilioischial line. We can't see it at this point because it's the bone at the back. And this is an ap this is a front on view of the, of the 3d pelvis and then it runs into the ischial bone at the back. We've then got the posterior wall of the acetabulum, which on the X ray is this obviously on the 3D model, it's round the back. So we can't see it. And then that runs into the issue as well. Ok. So you can think of it as the iliopectineal line and the anterior line of the acetabulum represent the anterior col column of the acetabulum. The ao ischial line and the posterior wall of the co er of the acetabulum are looking at the posterior column of the acetabulum. So that's just one thing to remember that this line is posterior, whereas the iliopectineal line is coming anterior. So another thing that we can use to help us and should be part of your review pattern at this point is that you can think of the pelvis as three rings. So you've got the main ring here, which is your pelvic inlet. And that is basically a line that is drawn all the way around here. So that's like the entrance to your pelvis. And um what your pelvic organs come through. Essentially, you've then got the obturator foramen on both sides, which are essentially a hole in uh in each side of the pelvis, of which uh vessels and nerves uh are transmitted. So that's there. And you, these rings again should be nice and smooth throughout all the way around. Now, I've not covered a specific line for the eyelid because you just need to trace round that. But once we've co so we've covered the femur, we've covered the acetabulum, we've covered the pubic bone, skip the island because you just trace around it. We then look at the sacrum. Now, there's a specific name for these lines and they're called the A lines. Now, what the aurate lines actually represent. If I go back to this is they represent the tops of the sacral foramen. So these are holes in the sacrum of which the sacral nerves pass through. So they come down from the spine and they pass through these holes at each level. And the acuate lines represent the um the tops of those foramen, it's difficult to appreciate on the X ray, but there is a hole left of the nerve to come out and that's what they are. So these lines across there. So the reason why we look at them is sacral fractures can be super, super subtle and any disruption to this line. I it should be a nice smooth line on the X ray, which if we look at here, I mean, they're quite difficult to see, but this line is smooth. Any disruption can make you think about a sacral fracture. And the other thing ii, these are lines that other people use. But I just, I like to look at the pubic synthesis when I'm looking at the pubic bones and I like to look at the sacroiliac joint. When I'm looking at the sacrum in trauma, you're mainly just checking that these are nice and close together and not wide to suggest a sort of pelvic trauma or er diastasis of the joint. So we've looked at the bones, we're happy with the bones, but it's important to not miss other things. So the sort of things that you might see on the soft tissues. So you might see hernias when we're looking for hernias, you're particularly looking in the sort of inguinal regions here for any bowel that could, could have herniated down. You actually get the bottom half of an abdominal X ray. So you need to check there's not any massive dilated bowel loops and things like that. I won't go into abdominal X ray interpretation today. And then the other thing we can see is various different calcifications ranging from Fliss, which are basically calcifications of little veins that we ignore to. Uh you might see calcified fibroids again, not particularly significant, but you can also see things like ureteric calculi. Um So it's just important to have a look and try and work out what you're looking at. OK. I'm just gonna recap um a few of these lines because um they can be very confusing. There's lots of different names. Um Yeah. So she's line. So if you all have a thing where you think she's line is um And then that is where it is. OK. So it's coming up the inside of the neck of femur running into the superior aspect of the acetabulum. So that is she's line me on to look at the acetabulum. So before I put the graphics over the top, have a look at this acetabulum and see if in your head, you can work out where the anterior wall of the acetabulum is. And the posterior wall of the acetabulum is because it can be really confusing to look at. If I can sell it to you, it's quite and I don't know how well this is projecting. But if I trace the, this front bit of the pubic bone up, it is continuous here and there's a change in density there. So that represents the anterior wall of the acetabulum back here is the posterior wall. You can see this line on the back. So this is all your cups at the head of the femur sits in. So as the green line, that is your anterior acetabulum, this is your posterior acetabulum and the pink line represents the roof of your acetabulum. So the iliopectineal line. So on this have a look at where you think it is. So it's there. So, so it runs down here and into the front. OK, the line, so again, have a thing where you think it is and it's there. So it's running down down the back. We don't see it too well at this region and then it runs into the issue of the back. So let's take through some cases, we'll go quite steadily with them and try and put this into practice and see if you and try and point out a few um few different things if you have any questions about a specific case or don't know what something is. Please put it in the chart as we go along and I'll try and uh clear up any queries as we go. Um And you know, clarify things that don't quite make sense. OK. So I want you all to have a look at this one, follow the system that we've talked about and can anybody tell me what's going on here? So, nothing so far. Um If I tell you all to look at the right femur and we follow the cortex round, this looks nice and smooth throughout. So this is the greatest tranter, it looks nice and smooth around here and she's line is nice and continuous around here. The femoral head and neck look nice and smooth. And now if we go on to the left, does that look the same? If you could all try and uh give your opinions? That would be great. Can anybody say does, does shen's line look intact if I run up around here? Yeah. Yeah, I agree. It's not very symmetrical at all, is it? So if I tell you how smooth this line looks that looks really smooth, doesn't it follow it around? If I follow this line round, it sort of comes to here and then you're not quite sure quite where to go or if we come up here, we see a big step there. So, yeah, that's great. So the, the neck of femur is really quite displaced and fractured here. So if you look at the angle of this neck of femur, it's nice and straight and smooth all the way around. If we go here, there's a step, it's not smooth, like the other side and it's angulated. So it's probably quite displaced as well, which is hard to appreciate on a, on at DX ray. But this is a fractured neck of femur here. So this is a sort of thing you're looking out for. If you trace around the top of the, of the top of the left, uh the right neck of femur, we can see it goes into the greater tranter and it's really nice there. If we follow it in here, it just sort of steps off there. So this is the, this is the fractured piece of bone, it's completely fractured off from the rest of the bone here. OK? And then after that, you can't just stop looking. So we have to go in and look at everything else. So see if there's anything to pick out here on this. Can anybody see that there's some calcification here? Does anybody know what that represents? Ok. So this is quite rounded and tubular, it's tubular calcification. So this is really common. Yeah, exactly. It's arterial calcification. So arterial calcification is really common. It's a sign of sort of atherosclerotic disease, but you'll, you'll see it really commonly. So it's just the things to, I want to know what you're looking at really um that you can see it on both sides. They've got arterial calcification. So well done. You guys that said that um I think is there anything else on that note? So, so again, we just go through the remainder of our review process. So I'm looking at the acetabulum. Now, the acetabular walls are quite hard to make out on this case. I think this probably represents the anterior wall of the acetabulum. This definitely represents the posterior wall going into the uh ischial bone and this represents the roof of the acetabulum. We can trace that ectal lines around here. We can do our ilio lines down there. We've looked at our chest tulum, we sort of see that the pubic synthesis is nice and close together. We go into our iliac bones, we trace these up and round. We go and look at our sacral iliac joints. We can see these lines here. So can anybody tell me we've just mentioned it previously? What's the name of these lines? No worries. If not, it's just why you wanna yeah, exactly accurate lines. So these are our accurate lines. And again, on this case, they look really nice and smooth. We can look at our three pelvic rings. So the pelvic ringing is nice and smooth, nice and smooth, nice and smooth. We then go on to look at the rest of the film. There's no significantly dilated bowel, there's no inguinal hernias down here and there's no real calcifications within the pelvis. OK. So we've talked about one, let's go on to the next one. So here we go. So again, we're gonna follow the same process. So anybody, first of all, can anybody tell me what they can see? So, while you're thinking, we'll just start getting through it. So there is exactly what about the left? So if we talk about the right side first, as you've said, so if we follow this up, we want to be going all the way up to the femoral neck and then we should be nice and smooth round, but we're way up here. So there's like the line essentially goes up here and then it like drops down to here. So if we follow that around, yeah, exactly. That's great guys. So we've got, we've got bilateral neck of femur fractures. So this is really displaced. So what's happened is this neck of femur should, should be art. So basically, if we draw a line up here, this line is all nice and smooth and then here it just disappears off, right. So this should actually be joined here. So it's really superiorly displaced and that's why she's line is disrupted. And then this here is the top of the femoral neck, which should be joining up with here. So again, that's a massive step in the cortex there. So this is displaced fracture of the femoral neck and it's just under the head. So that would be a subcapital neck of femur fracture. And again, if we go to the other side, so Shen's line, it would actually be up here and then it should start to go round. But obviously, we have to drop right down to here because this is so superiorly displaced and the heads completely come off that neck of femur. So that is bilateral meath fema fractures. So we've looked at that, we'll go on to look at everything else and we'll just quickly go over these on each case. So this here you can see a really faint line there. That is your anterior wall of your acetabulum. This is the posterior wall of your acetabulum and this here represents the roof of your acetabulum. We can look at the iliopectineal line coming around the front and the ileo line, you can actually see the ileo line slightly better on this one. It's projecting better. So this runs posteriorly into the bone. So these look nice and smooth on both sides for the obr foramen look, OK? The pelvic ring looks OK? The lines look OK. So we go on to look at everything else there. There is a small bit of calcification here. Now, that's the classic appearance of a flebilis, which is what I was talking about. A bit of calcification within a vein. So we don't need to worry about that. OK. So we'll move on to the next one. OK. This one is very tough if anybody gets this well done. Um But have a look at this and let's follow it systematically. So this is just another thing I wanted to flag up to you and how fractures can look in the neck of femur and how subtle they can be. So if you follow the right, everything is smooth up the greater counter up the neck. If we see how smooth that neck of femur is, that's what it should look like and compare it to this, see how it's completely disrupted, it should be nice and smooth all the way up around the head and round, see how we go right above the left can before we go into Ent's line there. OK. So that all looks OK, we can look at the acetabulum on that side. This is the anterior wall, this is the posterior wall coming down here. This is the roof, the iliopectineal line looks OK? The ilioischial line looks OK, nice and smooth. Now we go to the left and I appreciate this is very difficult and it doesn't project that well. But if we follow Shen's line, that is nice and smooth and it is, if we follow the femur around here, we go into the neck. And if I if you can all sort of look in closely, the head is slightly impacted. And if you look how nice and long and smooth, the superior aspect of that femoral neck is there and compare it to this side, it's really short and sort of angulated. And that is because they've got an impacted neck of femur fracture. Um So that is one thing you have to be really careful of in this sort of line of increased density is because you've got two overlapping bones with this impacted fracture. Now, that is really difficult, but it's there some neck of feur fractures you actually just can't see on an X ray. So when you work on the wards and you'll, you'll find that in clinical practice. If you think somebody's got an echo feur fracture, the x-ray looks normal if they're having physio and they're still not mobilizing properly. They need further review by orthopedics and may need further imaging in Sheffield would, if they didn't have any metal work in their hips, we'd usually do an MRI to look for a fracture that we just can't see on the X ray and that does happen. So that is a really subtle impacted neck of femur fracture. Everything else looks ok on this again, we've got some calcifications in the pelvis which have the classic appearance of flebilis and then not anything you need to worry about. These are the accurate lines on this case and they're nice and smooth throughout. So we're not worried or there's not a sacral fracture that we can see on the X ray. Ok. Now, we've got just a lateral hip X ray here. Can anybody tell me what they think? Of this. I want you to pay particular attention to trying to follow the posterior femoral neck cortex. Does that person to move a slight leading question? Anybody say what they think they've seen? And just to remind you on a lateral hip, remember the bone is at the back. So this is the ischial bone and we're looking at the hip side on. So if we follow this up comes here would expect the head to come around here. But actually, there's a minor step there. If we come up the back, this should go in, this should go smoothly into a femoral head, but actually, it comes abruptly across here. And this is what a neck of femur fracture can look like on a side on lateral view. And sometimes you'll only see it on the lateral view and not on the AP or front on view. So it's just to look out for you're looking for any steps in the head. So this is the neck and then it's steps. It should be nice and smooth and round, but it's really acute angle there. OK. Now, right, have a look at this one. Tell me what you think again, follow the same process. I'll give you a few seconds or 20 seconds or something. If somebody could uh try and have a look and tell me what they think. OK. So if we start on the left and follow this up, this is a sign that is coming past the le count. But then the sort of cortex above the L you can is continuous, right? It's nice and smooth and it goes around into that. If I do that on the right, if I get to hear and then go past Janta, now, does that smoothly join up or does it, is there an angulation to the line there? Anybody know what this represents? OK. So this is another neck of femur fracture. So instead of this line coming smoothly round, could draw it nice and smooth around there. So yeah, we'll come on to the pubic ramus. Um What I want, there's so there's t there's a few things on this. So if I follow shen's line on this side, if I come up here, can you appreciate that this bit actually should be over here coming down there. So this femoral neck is fractured and the fracture line runs all the way up here. OK. You can see on this, in fact that they're slightly um their hips are slightly rotated actually, which makes it a slightly difficult, but this is disrupted here and there is a fracture coming across here that is an intratrochanteric neck, a feur fracture and then really well picked up. Um Lydia cos if we follow this shen's line round gates the middle, there's a slight step there. Can you appreciate that? This is nice and smooth whereas here it juts out and comes around. So that is a fracture of the superior pubic ramus. Here, there is also if we go on to look at our obturator foramen, although it looks nice and smooth, we've got to look at the cortex room for any luces. And there is another lucent line coming through here. So that is a inferior pubic ramus fracture, a superior pubic ramus fracture and a neck of femur fracture. So we can't stop when we look at one fracture. We've got to look for other fractures. So they've got a fracture there and a fracture there. We can highlight the other lines which look. OK. So we've got the iliopectineal line coming across here. We've got the ileo line coming down here. You can see the anterior wall of the acetabulum, the posterior wall of the acetabulum, the accurate lines in the sacrum. You can trace around everything else. Again, this is probably just a bit of vascular calcification just because of the position that it's in and how dense it is. Um So yeah, that is that one? No, have another look at this one and compare the right and left side. Do they look the same? Does everything look smooth? What do you think? So let's start basics. What does she's line look like? Is it smooth throughout? So I come here and come around. OK. Yeah, that looks OK. Right. Yeah, that's, that's brilliant. Yeah, that's both of you. That's really good. So we've got a few things here. So I'll start with the, well, in fact, let's go through our normal review pattern. So we follow line up, it should come into the superior pubic ramus here. If we come in, you can see that it's disrupted there, it's really angulated and it, and then it sort of so it does this weird thing where it comes up and then it comes straight down and then it's disrupted here as well. So we've got a fracture here. Um As you've correctly said, the le the left superior pubic ramus fracture is not looking good, er is not the less period human ramus is not looking good and it's cos there's a fracture. So if we follow, as we've said, the iliopectineal line is discontinuous. So if I follow this down, it then has a big step break goes down and it goes across here. So that's side is so nice and smooth, right, really nice and smooth. The ilio line is really nice and smooth, whereas this side we come across, go up, we go down, we go down here. They said it's fractured in two places. So there's a fracture here, then this bit of bone is sort of on its own and it's fractured again there. And then this is the pubic bone. So this is sort of in the middle of that and that bone is on its own. So that is a superior pubic ramus fracture. So well done. Uh well called um we can look at our aurate lines, look for any other fractures of which there isn't. So that again is just another appearance of the superior pubic ramus fracture if we go on to the next one. So this is the patient with a, this is the well, total hip replacements can have a lot of different appearances depending on the brand and what they've inserted. So we won't go into hip replacements today. Uh But this patient has had a hip replacement. Um Now, um can anybody tell? So if we ignore the left side because we've got a hip replacement here and I don't wanna confuse things if we look at the right side. What do we think? So, Shen's line if we follow it up here? Yeah, exactly. This is disrupted here. Look how smooth this is around here and then here. So, so fractured and well, the line is irregular and it's due to the superior pubic ramus fracture. So that's really good, well spotted. And as you can see these superior pubic ramus fractures disrupt the shen's line here. They also disrupt the iliopectineal line here because it comes in steps down and goes there. So that again is another example of C Peric Ramus fracture again, just to highlight the accurate lines because they can be difficult to see these things. And we'll see some examples of how we can use them to see abnormalities soon to look out for that. Um So we'll move on to the next case. Now, this is quite a difficult one. But if you put your lines into practice, you hopefully might spot an abnormality. So can anybody? So if we go through it systematically, Shen's line is nice and smooth, we can trace around the femur and everything is nice and smooth. We can do it on the left side as well. This is just a zip so we can ignore this. This is nice and smooth. The head is nice and smooth. Now, if we look at the left side and we follow the iliopectineal line, these are just your iliac spines which are projected slightly. They're, they're uh posterior projections which you don't need to worry too much about. So the iliopectineal line looks nice. The ilio ischial line again, nice and smooth. We can see the it's actually very difficult to tell where the anterior and posterior wall of the aceta on this one. So I won't get too bogged down on it. Yeah, great. I think Lydia, you said iliopectineal line on the right. So that's a really subtle fracture, but you've spotted that really well. So this is the ilio line and that is fine. But if we follow the iliopectineal line up from the top from the middle, there is then this disruption here. So that is an acetabular fracture and that is how subtle they can be on an X ray. So that's why using these lines um can really help you to notice these really subtle fractures. That's a really good spot, well done. Um, so we've got another one here. If we all have a look at this quite a lot going on here. Yeah, it is a little less subtle, but there's a few things that I want you to try and pick up. So, if we follow sentence line, it should come in. So, should we follow it on this? Well, I can't, we can't follow it on either side cos uh it's there. So there's about, there's a superior pubic ramus fracture there. So as we can see Shen's line is slightly disrupted, it should come round, but this is pushed superiorly. This is the iliopectineal line which is completely disrupted here. So this is a superior pubic ramus fracture on the left, on the right, the iliopectineal line comes down there and again, massive fracture there, displaced fracture there of the inferior pubic ramus. But we can't stop looking there because we need to look for other things. OK. So we go on to look at the rest. All right. Now, these arcuate lines here are nice and smooth whereas this one on the right, can I sell it to you that that is potentially slightly disrupted? But if you look how smooth these are, whereas this one is slightly irregular and that can be how subtle sacral fractures look on X ray. So you're looking, you wanna see these really smooth lines disruptions here. So there's a slight disruption, it goes there, then it goes there. That is how subtle sacral fractures are gonna be. So you really need to keep an eye out for them and not just stop because different thing, different fractures are managed very differently and they all need to be put into context by orthopedics. OK. So again, another um x-ray here, so we'll just go through it systematically. So Shan's line is nice and smooth, OK. On both sides, the femoral necks are nice and smooth. The heads are nice and smooth. The, this is the anterior wall of the acetabulum. This is the posterior wall, the iliopectineal lines, ilioischial lines on both sides look OK. What a what about the accurate lines? Yeah, exactly. This isn't a left sacral fracture. So you can see these on the right are really nice and smooth. We go around on the left. You've got big disruptions here. The steps in the line. So that is a left-sided sacral fracture. So well spotted. Um OK, have a look at this one. So I'm gonna go through it if anybody sees anything at any point. Let me know. So we're gonna start with our femurs. So we're gonna trace around them. We're gonna look at our, she's lining, superior pubic ramus. They are nice and smooth throughout. We're gonna do it on both sides. We're gonna look at uh anterior acetabulum, posterior acetabulum on both sides are anterior, posterior uh iliopectineal lines. Uh ilioischial lines, you can look at obturator foramen and the pelvic rings. Everything's looking great so far, uh, acuate lines, although quite difficult to see in this, they're nice and smooth. The sacroiliac joints are, um, not widened. The pubic synthesis looks ok. So we need to look at everything else. Um, the bowel looks ok. There's no calcifications, but if we look down here, can you appreciate that? There's this soft tissue density here. You can see some bowel gas within it. So it looks similar to this bowel gas up here. So that's an in what an inguinal hernia on a pelvic X ray with bowel and it can look like and these might be really obvious clinically and we might know about them. But if we don't, sometimes they might need sorting out or they might cause the patient problems in the future. And last one. so again, we can go through all our lines, we can trace them around shen's lines. Everything is nice and smooth, iliopectineal lines, ilioischial lines. So, has anybody seen anything that doesn't look quite right on this one? Ok. Ok. They are slightly overweight. Um, anything else? Yeah, these things. So they're calcified. They round. Does anybody know what they might be? Not an umbilical hernia if I told you it was a female patient within the uterus? Yeah, they're calcified fibroids. So that's what they can look like on X ray. Um, so, yeah, I think that is all the cases. Uh I've got, we, we were about right for time actually. Um So thanks everyone. Does anybody have any particular questions or things that you want clarifying? Um I appreciate if you've not looked at many pelvic x rays before it can be quite a lot to take in and very, very confusing and quite hard to look at. Um So if anybody has any specific questions, please let me know now. OK. Yeah, rotation is a good thing to talk about. So if we go, um I was trying to find the one I was talking about. So really um rotation wise you can have the pelvis can be rotated. I we've not got the X ray in the right position. So um what I would be thinking about this is really to, to know that you're straight on um the um pubic symphysis should be uh nice. And in line with the middle of the sacrum when I was talking about this one being slightly rotated. So this is for the pelvis, we're looking at the pelvis straight on. If you, if you imagine sort of with your hip, you can twist it, you can internally and externally rotate it and the degree of rotation on your hip will affect how it looks on an X ray. So if you can remember going way back to the uh if we go way back to the 3D uh view uh 3D model, the um the greater is actually posterior. So if you externally rotate your hip, I pull this further back, you see the femoral neck really nice. And uh sorry, if you accidentally rotate your hip, this sends this further on the back. And this is, that's when you get the appearance of, if I go back, I find a good example of the left tranter sort of overlying the femoral neck. That's because the hip is um externally rotated. So the um greatest tranter has swung around the back further if you internally rotate the hip and it, it makes this. So this person on the left is slightly externally rotated. So this is sitting quite posterior. If they internally rotated their hip, I turned their foot in, this would come further out the side and it would elongate the femoral neck and you would see it better. So that is how we go about looking at rotation. So femur and um pelvis are really separate because this can rotate on its own. Um So yeah, you just wanna make sure that the midline of the spine is lining up with the pubic symphysis. Any other questions at all? If uh anybody has any, any questions, if they upload them in the feedback, um I can have a look and I can pass any questions on. Um Thank you very much Sam for, for giving that. That was, that was really helpful. Yeah, no worries. I hope, I hope it was helpful to you all. Um appreciate, it can be quite hard to pick up new things and it's, it's really complicated and, I mean, it takes radiology registrars quite a while to pick these things up. So, um, really, it's just trying to take away these basics and things that can help you, um, to, you know, if, if you, if you're stuck in, you know, in F one and you're having to try and make a bit of a decision on your own with it. Just some basics to go back to that you can rely upon to help you try and work something out. So, yeah, good stuff. Thank you, everybody. Yeah. Thank you guys. Everyone. Have a, have a good evening and, and good night. Thank you very much, Sam. Yeah. Thanks everyone. Bye.