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I everyone? My name is kept hanging on with the doctors in South Yorkshire in the UK Thanks for joining us this evening on, but I'm sure we'll have seen some of you before. But if not, then welcome to the next Webinar in this minor bleeds Radiology Siris. So November, December and January we are aiming to cover pretty much all the imaging modalities that doctors and healthcare professionals come across in the hospital and helped to interpret them. So last week, Dr Double took us through hand and wrist X rays. So today will be continuing the M S K section of the series So Dr Joe Can will take us through a structure approach to knee, ankle and foot plain films, which are some of the films that Junie doctors, including myself, often find more difficult to interpret. He'll go through a logical approach to interpreting all these plain films on will discuss some cases with us, so we will just come home with it. So, Joe, I'll 100 to you. Let's give a higher on my name's Joe. I'm regularly restaurant here in Sheffield eso For those of you who are north in the UK, Sheffield this year it's in. It's in Ah, Yorkshire on. And it's known for two things really used to be very big in the steel industry and BS the industrial era in the UK and also is next to you the peak strength, which is a very nice countryside. Um, but anyway, what we're gonna talk about today is imaging of the lower limb. So from the knee down to the foot, basically and I'll go over a few key principles, uh, then we'll cover bit of the basic and asked me, but not too much. Uh, but I will talk about the standard X ray views. So when you when you ask the radiology department of former foot on the X rays, you know what's combination of X rays? Will they give you to look at um, and I'll try and go through the principle? Is that a structured approach and how you should be looking at these with cases and example? Still a straight. So we're trying to keep his interactions possible. I've got my own, the the chance of any questions. Just talk message and I'll try to keep my eye out for that. So starting out with some basic principles. So the most important thing that I want you to take for this talk is that you need to views to exclude the fracture. Uh, as you can see here is that Ah, slightly silly photo of, ah, line holding a cup. And on the left here, it looks like the Linus swallowed the head of it. But with a north organ, all so you rotate with you 90 degrees on you actually get a better idea what's going on. So this is the same or fractures. So from one angle, something could look normal. Um, but when you rotate it and look at it from another salad, it look entirely abnormal. And lots of fractures can only be seen on one of the X rays of a serious you're given. So you need to look at all of them to exclude the fracture. Ah, so once you're happy with the the views, uh, which is satisfactory? You just look at the alignment of the bones. So clearly this is this is abnormal. So this is a lateral and collect three. And this is the distal tibia. So long alignment is the streets by this line here So this is a clear dislocated. Um, So you've happy with these? Looked at the alignment of the bones. Ah, and then units move on and look at the cortex to the cortex is so the outline of the boat. You can see my laser points. So every bone has a slightly denser, so dense of meaning, What's a Ellen to it, which is the cortex? And when there's an acute fracture, the the cortex will be disrupted. So, as an example, um, if we if I point out this abnormality here, there's, ah of around it lesion here behind the talus. And there's another round of lesion here which also behind the Taylors. So, guys, this is number one. This number two. Which one do you think is a fracture and which one is normal? Your type. Type your answers into the into the box. All right. Good. Some some people have some What someone said to, uh, someone said both, uh, some people said one a swell. Okay, So most people have said to consume one offer an explanation as to why? It's why it's too right? Okay. Yeah, we got a few ounces in. This is very good. So, um, who he said. Someone said Number one is struggling. Very good. Yeah, This isn't a fracture. This is a normal variant. There's a It's kind of a developmental thing, but there's commonly a fragment of normal bone in that position that's called the the Always Trigger them. But this number two is an avulsion fracture. Um, I think someone else has said the reason that's the Voltaren fracture is because the reason you can tell is because there's disruption of the cortex here. Where do you see here? There's a nice without lying to the back of the talus here, there isn't. It looks kind of ill defined, and actual fragment itself looks quite well defined as well. Where is here in the normal variant? The outline of the fragment is very well, corticated, so that's unlikely to be a fracture. This does involve knowing so the common places for use accessory bones. Uh, I think that just comes with experience. But the all struggle in them, which is post serious. That's a listen, a very common location of the foot. So if you look at it if ankle X rays, you'll see lots of these. The other thing that goes to be a Sinus. The we'll talk about it later, but the soft tissue swelling as well. So if you see here, the soft tissue is of behind the ankle joint. Is quite, uh, dentist that whiter than here? Or is this a nice and dark? You see, the so the subcutaneous fat on vehicle extended quite world finds here, the tendon is quite defiant because there's lots of soft tissue swelling here, so that's kind of a second resigned that suggest that this is more likely to be an acute fracture? Uh, yes. Everything else has said. Yeah. You guys already know this stuff, right? So then, yeah, I think I said it would be 12 is Look at the soft tissues. So, what do you think of this film on the left here? What's the abnormality? Yep, Exactly. So not from earlier. This fracture, I'm this rash is very obvious. I tried to find a more subtle example, but I couldn't Couldn't find a good one. But the thing I wanted to draw your attention to for this example is if you compare I mean, if you if you look at your own ankle and you palpates the lateral medial malleolus. There's very little soft tissue there. It will feel like this side here. That's that's a normal matter. Soft tissues have for most people. Um, obviously some people have fat ankles and other people, but the way you can tell whether it's up a little bit, mister compared to other side, this soft tissue is clearly swollen. This isn't so. When you see when you look at the X ray, you follow the cortex. You don't immediacy a fracture necessarily. But you see very prominence off this. Your spelling, then that's going to make you go back on. Look at the bones again, because if there's loads of swelling, it's much more likely that this some kind of both. The injury underlying here is well, so you can see the thickness of the heart issue. But also, like I said, in the previous example, it just looks, looks a Demetrius denser. So two more more white on the X ray compared with normal fasting. The other side, uh, this this is perfectly prominent in the lower limit the ankle, because most people that have lots of fat over there over their mother your life, but also, I'm sure Henry sorts. But in his previous talk, if you look at the wrist, soft tissue swelling around the wrist is very obvious is well on X rays. So the so following on from that example, what do you guys think of be sexually? Yeah, So we've got a few few answers coming in. So the one person said effusion, which is spot on to this, which is, uh, someone was with a super patellar. Bursitis. So this is the knee. If you so normally you should see the patella tendon very clearly defined. And then basically, this shouldn't be a demonstration here. This should look like this defense. Don't see here. Um and I don't if I can convince you, but that's of around in the past here, which is displacing the patella tendon upwards. And this is because this fluid in the super patella ah, pouch. So this isn't so some. There's been a few ounces saying like a hemarthrosis. So, like a hemarthrosis is a type of joint effusion, but specifically referring to the fact that blood and fat in the joint So this isn't necessarily like a human versus I'll come on to that later. Um, what you can say about this this this quite big. The infusion. So when you see big effusion again, like the soft tissue swelling, it's kind of a reactive thing, and it suggests there's some kind of other underlying pathology, and that could be a fracture. So come on that later. But it could also be a ligamentous injury. So, such as the ACL PCL, which you wouldn't see on the plane radiograph like this. So if a patient has a big knee infusion, no obvious fractures, then they still might be referred to orthopedics. And we might do an MRI to look at the blueprints if there's a high suspicion that there's some kind of underlying injury, so Princeton affords, look at the soft tissues, soft tissue swelling guys, you towards the area where the pathology might be on. And if you see lots of effusion lost soft tissue swelling in the absence of other injuries, then you are these. Go back and look harder. And if the patient has persisting symptoms on this clinical suspicion or mechanism, injury is high. Then they might need further investigations such as them all right, Yeah, right so we'll talk about the knee X ray. Um, in our center, if you request in the x ray, you get three pictures. So this one on the left here is ah is an AP view. So that's that's friends back on someone's someone said, Is there, uh, a fracture of the tibia? Are you talking about this irregularity here? So I think that's just I think that's part of the insertion off the the patella tendon. You can get a bill like irregularity there from tendonitis and things. I'm no not sure if you fracture there. Could I think there might be a fracture in this to be a plateau, but I haven't got the HPV of this one, but I do have example of that. So I will come on to that. So normal frontal AP view of the knee. Uh, and then an important view, which I'll explain why we need to do Is thehuffingtonpost mean lateral? So it's a previous two HDL. So this is a true lateral film, which means the patient is lying on the table with their leg out flat, and we rotates the beam of the X ray to take a picture of the side. And the reason we do this is to look at the infusions. Uh, well, I've got a sample of a laser, and then the other view we do, it's the skyline for you here on the skyline. View is less important in trouble. It does that you have a good look at the patella for fractures. Um, but it's mainly used to evaluate the joint space to look for degenerative change. Or if there's a patellar dislocation, something you can always do a skylight of you like this because the patient has to bend. They're need to 90 degrees. So if they've injured, then the it might hurt you much delis. So if this trauma, you might just get the AP the lateral views, and it's important to get both uh right. What's this? There are several findings, so just just pass out who go a few a few ounces coming in. Okay. You guys are very good. You will see that. Yep. Okay. Ah. So I'll just for those of you who have been answered, the question or a point of the abnormalities. So after mounting them born Is this So this is why we do a horizontal being lateral view. This is something called the lipo hematemesis. Um, lipo means that's him. Oh, means blood and author assist means, uh, joint problems. So this means there's fat on blood in the joint space and that is suggestive off a fracture. That's intra articular. So a fracture within the joints bleeds and bleeds into the into the joint space because the leg is flat. You see a fat fluid level. Fat is less dense, the blood so it rises the top blood is dances, it sinks the bottom. And you get this very, very straight horizontal line the D markets the boundary between the two. If you see this on a on the next week, there has to be a fracture you might not, on diffraction has to be intra articular. So within the joint in this case, there is ah, very obvious intraarticular tibial plateau fracture. And there's also a fracture of the people ahead. I think I'm you don't always see this. Sometimes you just see the life of chemo first. But if you see this, there has to be a fracture. So so make sense. So if you see this, you look more carefully at the So you look at the AP view as well. You might see the French of there, and he still can't see the fracture. Then the patient needs referrals. Orthopedics? With these getting further imaging, we kind of do a CT of this or them all to look for a fracture. But if you see a like a hemarthrosis, there has to be a fracture. If you just see an effusion without this level in it, they might not necessarily be a fracture. Right? Everyone is any questions and just talk to him in a little I'll keep my eye out. Ah, right with you guys. Think about this one also. I'm aware that I said everything needs to views, but I found lots of one view example. Stay. Let's write this push away for a few more ounces. Uh, right. Okay, so go Fiance's in. Um, do someone said osteophytes. There are osteophytes, but that's not the primary finding. So the history is full knee pain? Yep. Tibial plateau fracture depressed. It'll far so good. Okay, so this is the abnormality. So this is a fracture of the natural to be a plastic. There's this is depressed fracture. So if we go back for are structured approach, so you want to look at follow the course Xeloda around. So this is we look at the medial aspect. We see this nice, sharp line of the cortex. There's all the way around, continuous all the way. Whereas if you try and follow this, you get to here and there's a step. So that's a fracture, and then you follow up to the top on the sixth grade. Indistinct. So this is a little the French or frequent this off the table batter. Sometimes it's more subtle than this. And the other thing that I like to look at so that this is quite obvious because there's a big step big discontinuity in the cortex. Sometimes it's more subtle. So can I convince you that if you look at the normal side here, Ah, work here, for example, there are lots of these little lines on, uh, darker bits in the bone here, So this is the normal trabecular pattern off the bone. So this side of normal, whereas if you look at the is that the underlying bone here, okay, it's not a regular trabecular pattern. All the way down. They're still do it. Dense obits, A normal business between. So this means this disruption to the specula bathroom, which implies there's a fracture. So again, this is a step here, so this is obviously a fracture. But sometimes you just see a slight change in trabecular pattern, which makes you think there is structure. Sorry, I don't know if my my internet sorry not require, but you can always compare it to a normal side. Or if they have a previous X ray, you can see how it looked before. Uh, we compared to the other leg, you're not sure wasn't osteophytes Yeah, these air. These are osteophytes of the tibial spine, which is just degenerative change on then. The other thing is that there was quite loss of tissue swelling around this knee as well. It's lots of edema here. Uh, yes. So this is a depressed tibial plateau fracture and also a fracture of the fibula head. The other thing I wanted to mention is that at least if you're working in the UK, if the radiographers see an abnormality on the next day, this is the right dose on it. So if you look at the X ray, and it says red dots in the corner and you don't see any abnormality. Go back and have another look. Okay? I don't I don't have to do this in other countries, but here they like to like to write this. If there's a no peace abnormality, right? How about this one? So again, it's ah, it's a similar history. Full knee pain, Uh, this question devotion to the lateral epicondyle. So I think this whole this is a low bone fragments. I'm not sure this is Oh, you Oh, you mean up here? Yeah. I think that there could be another associate injury here. I think this is This is quite bad. Twisting injury. So they've kind of, um this bit of bone has come down against this burn, so there's a twisting compression injury. That right? What do you guys think about this one? Yeah, exactly. I should have Should put this one in later on. So I've told you about it. Yes. And this is this is a more subtle example of a tibial plateau fracture. So, again, if we go back to our approach, you want to follow the cortex around everybody um, and you follow the the proximal tibia. Um, maybe if you hear there's a little step on this little Easton See on, Maybe if you look here, there's a step on the little Easton. See? But the finding that makes you more convinced that this is definitely a fracture. Is that this? This bit of bone extensive, the normal. And this disruption of the trabecular pattern here again, if you compare to the other side, that's very regular. Straight trabecular on down here is well, but they're disrupted here. So this now, this has to be a fracture. Even if you didn't see the defects were pointing to either side. This in itself is enough to call this a fracture. Uh, yeah, there probably is a little off the medial joint space. I think maybe lateral. I think some of this is This projection is not great of a pea view. The less you see the whole, the whole joint. Um, and they probably is a degenerative change is well, the osteophytes. Right. Okay, so we want to the next one. So what would you think about this one? Well, actually, first question how old you think this patient is? Yep. Good. Yeah. So this is so when we when we talk back strays, um, you can in for the so the rough age of a patient from this, But looking at the growth place, if the growth plates don't fuse that it has to be a child. And I think older, they kind of partially fused. And then for the fuse And Adel's So this is this is the child's me. Ah, right. So what? What do you think? The again? The history is always, as always, full d patients. Uh, right. Okay. Yeah. So the abnormalities in the proximal tibia. So this is the abnormality if you want is coming in. Yes. So this is, um this is an avulsion, an avulsion fracture of the tibial spine. So what? What structure attach is to this bit this broken off? Does anyone there? Yep. Exactly. So this is the ACL attach is this? People's fine and of ocean injuries more common in Children because the bones on Thurs on too strong. Well, well, mineralized. So this will be involved in injury caused by the ACL pulling off a bit of burning that's attached to you. And you could tell. It's Nick. You fracture because there's a decency through here and a cortical defect. Good. So we talked about we can the growth plates and a CEO of a little injuries. Right? The US? Very good. You already know this stuff. Okay. Ah, on D Would you think about this one? Is there, uh, is there ahead of people of fracture nose? I think I think this is growth irregularity. I'm not sure that's an acute fracture. I think they're this partial fusion of these growth plates. Actually, I I think they're probably slightly older. Maybe a teenager. All right. Okay. Well, uh, do you think about this one? Okay. Very good. So you guys have spotted presumably this fragment here lateral aspect of the to be a sweet thing. Natural to be a condo. Good. Okay. You seen that? Is that a bad injury? Would you send the patient home with this? Oh, someone said yes, I presume. Yes, it's bad. What? What was it? A bad injury? Uh, people said we'll see what you guys have said, so check foot. Drop these rheuma paraneal nerve injury. Yeah. Good point. Uh, lateral collateral ligament. Yes. So? So there are two. There are two things I want to illustrate with it. So I agree there is an avulsion fracture of the lateral. That's what you and this is something called a PSA gone fracture. S e g o N d. And it's a very, very common X ray we see in radiology exams. Um, so this in itself isn't particularly bad, but it implies that the mechanism of injury involves some kind of high energy trauma. It's and involved suggest that other structures must be injured. So it's not just about the fracture that you see it's felt the other associated injuries. So you see, there's lots of soft tissue swelling on the lateral aspect of the knee here because this fracture is associate it with medial collateral ligament injury. And not only that, Ah, my second point is there's something called satisfaction of search. So you guys have all seen this lateral them this injury on the lateral aspect of the knee. But have you looked for any of the other injuries? So when coming back to our systematic review, follow the cortex around. We look at the trabecular pattern on, we look at the alignment, so just like you've seen one injury, you need to carry on looking at the rest of it to make sure you haven't missed anything else. Oh, yeah. So we'll see that. Yeah. So far. So, so similar to the previous one. There's injuries of the cereals. Finds the fracture here. This is this lucency. Here is another fracture. So the PSA gone fracture, which is this sign, implies there's injury commonly to the lateral collateral ligaments to the meniscus, which is in between the in the joint space on also to the anterior cruciate ligament. So to seeing this tiny bone fragments in itself is not basically remarkable, but implies that there are other injuries, other soft tissue injuries. So this patient, we'll need MRI of the need to assess the ACL. So this is whole day. A second fracture. S e g e o N d. Is there a white fracture line on tibia? Next? You two met this line here or this. That line here here, you mean? Oh, well, here. So I think I think this is just the outline of the fibula behind the tibia. I think that is the remnant of the growth plates. So I don't think there's. I mean, that's my first point. You want to look at the lateral view to make sure the fibula head is injured, But I think on this frontal view, that's just them So overlapping between the the tibia and fibula. Yes, I agree. If that you want to look at this on the lateral view to make sure there is no fracture, here goes. Is that old make sense? The PSA gone fracture? Is this here? But this implies that has to be injury. Or there is very like the injury to the collateral ligaments. The cruciate ligaments on the meniscus. Well, and it's commonly use off impact injuries, twisting injuries of the knee. Because this so if you're being tackled playing football or people skiing, visit anything where your foot starts moving. But your knee carries on moving it twists the knee. Uh, right. Okay, so think about couple more examples of these, So actually, there's a recap The the friends fall onto this right here is you see one abnormality. You don't stop looking. You finish your systematic review of the rest of the bones to make sure that myself a slightly more simple one What do you guys think about this? Yep. Good. So this is Ah, the patella fracture. She's losing lung here. Um, hoping Toso going to trick. You spent all this time talking about looking at the the court go outlines was hoping they will look at the patella, but Yep, You guys have seen it. Uh, and this is also why we do the skyline, because it's much, much more obvious on this for you here. Uh, yeah. So I I agree. Actually, on this AP view, you could This could conceivably be a bipartisan patella, which is a normal and some cough variant. Um, it's difficult to tell. You can't really look at the the cortex on this. Maybe the reason why I'm illustrates of this is because the patella is often hard to see on the HPV. Where is the very, very, obviously, the skyline If there's a fracture and you can see here that this is clearly a fracture, because it's new, there's no cause X. So I think if you we don't always do it, if you can. Yeah, I did. I I agree. This This would be very painful If the patients do. I think we probably wouldn't if there was an obvious fracture. This would be difficult. Get any into this position. But clearly they told racing. Then we matched. I get one. So I patella fracture. Tend not to be pretty unstable, I don't think because they there's lots of muscle supporting them. So I think bending the knee would be, well, medically bad. I say I'm not an orthopedic surgeon, so I'm not entirely sure about that. Uh, right. So moving down the leg. Ah, so this is pretty obvious. Well, you think about this. Yes, exactly. So they're Ah, yeah. Comey's French is, um, both so obvious examples coming first of the tibia fibular. Similarly here. Different patient oblique fractures, distal tibia on this little, um So the point I wanted to illustrate is single. The the polar is being referred to as a polo mint principal. So I think you guys have had a polar minutes before, but it's ah, it's a round meant with the wholeness. And the idea is that if you want to break the polo mint, it's very difficult to break the parliament in the ring just in one place. So if you break it always breaks in two places. And similarly, if you consider the tibia and the fibula as a A system, it's connected by the proximal tibia fibular joint of here on the distal to be a fibular joint down here and this kind of, ah, the fibrous intereses membrane in between. But basically idea is, if you have a fracture through one side of it, one side of this ring, you have to have another fracture somewhere else of leads. It's very very, and that doesn't necessarily have to be fresh into the bone. It goes to the destruction of the joints. But if there's one injury to any part of this ring, you need to look for another one. Uh huh. So we'll come back to this. And when we talk about the ankle, so so these are so the standard views we do for ankle. So we do an A P front back. We do a natural inside. Some places will say, Oh, do you a dedicated mortis for you to look at this space here, but where I work, these are the sound of using you get a good view of the mortise on the AP that the radio is do you? And that's severe, that that's what you're going to get us for a ankle X ray. Um, so it's talking about some of the fractures. So a prison you guys will heard of something called the Weather Classification. So the weather classification something that you'll have to use to describe, um, fractures of the lateral malleolus on this is important because the weather classification effects the classifications off lot from others freshers effects, how they managed and certain types can. You managed conservatively that certain types are unstable and need surgery on Broadly speaking, it's all about the location of the fracture relative to the syndesmosis, which is this kind of fiber structure that connects that this stool tibia to the distal fibula and the constipation is a B and C confusingly, A is below rather above, but they is below the level of the Sinemet. It's in This versus be is at the level off the syndesmosis and see then anything above so a again. I'm not from a surgical background, but broadly speaking, A cough to be managed conservatively because they're stable, be sometimes require surgery and see is usually unstable and need something doing about it. That so, what do you think of this project for this century? Good says with a correctly here and back to my point about soft tissue swelling. There's lots of soft tissue swelling here. So even if this is more subtle, this will draw your attention to it. Uh, this one pregnant and finally No, no point to this either. Yep. Great. Uh, right. What we think about these two x rays? No. Yeah. Like, has someone said the views inadequate? Yeah, I agree. These these years, probably all are inadequate. But I borrowed this case from radio PDS. So it's not not my fault. Yes. So this this is something called amazing Live fracture. Uh, but this is about my points about the parliament, the idea that you have to have two fractures here. So if you there's a fracture of the proximal fibula here, um, which is so obvious. But you see this? So say you saw this at the bottom of the knee X ray. Then what you need is is also for the man called be imaged. Well, so you can look for the second injury on. Similarly see, when you look at the ankle, which this is admittedly a slightly inadequate view of the ankle you seen in recent, like formal your list and widening of the TV, a tailor, the widening of the ankle mortis. So this comes back to the prince flu, if you see one injury, um, one end of this, the parliament, you just look at the other side. Uh um, So you're here and see me, right? People's long term questions. Okay. Yes, His recap. This is Ah, amazing. Their fracture. So there's two injuries approximate fibula and medial malleolus and ankle. So the injury of the ankle doesn't have to be medial malleolus. It can be, uh, injury to the tube. You people joint sort of widening of this space here. It could be the injury, too. Ah, me a million. This or it could be an injury to both male. You live, but it is a combination off a fracture up here and some kind of widening of the space. That manifest is the second injury. Eso This is just another example. So again, slightly suboptimal view of a proximal fibula fracture. Ah, let's see if this new this No, this bone injury. But this space in the ankle. Mortise is abnormal to this. So normally, when you look at the mortise view this side to be the same as this side, it should be unequal joints with all the way around. But this is clearly widened here and narrowed here, and this space is also absolutely widen. This is a ligamentous injury. You don't have to have a fracture. With them is nerves. You have one fracture up here on the ligamentous entry down in the ankle. And again, this is so this is another example of an unstable ankle injury. So this is fractures through the both the medial and the lateral. Really? Um, and there's really, uh, widening of the ankle mortise lateral displacement of the talus. So you see this X ray? Well, Steve need to do. Yeah, well, good points, like someone said, Room relocates it yet. Well, there's as a radiologist. I wouldn't be wouldn't be touching that. You missed the knee up. Good. So the other thing is, I would I would look at the lateral view for this so that there's injuries have the lateral malleolus to the medium early of us, but the course to be more posterior injuries to the so the post here aspects of the tibia. So you have a try malleolus a try malleolus fracture, but basically it's called orthopedics and tell them about this and they probably asked to do a CT for operative planning. You have cold or exactly for the add See you need to do. Ah, East. You the x ray. And also look at the lateral to look at the post your aspects of the tibia. Right? So moving on TV. The foot. Um well, you think of this. Good. Sorry. I realize those music. So yeah, this is this is a communist cocaine. A fracture. I agree. Perlas angle is flattened. Sometimes they're more subtle than this. But this is very common. You tid fragmented. What's the more normally the mechanism for cocaine? It'll French is. How do people get them? Yes, it's full on DCruz early as I'm as a trillion send, You have fallen land on your feet. So what else would you be concerned about? If you saw, it's a If you saw this bilaterally in both calcaneal help both calcaneum. What are the injuries? Do you want to look for? Yes, exactly. So calcaneal fractures it themselves by the by. They're not particularly remarkable. But if you have them by actually, it implies high energy trauma. The force is transmitted upwards through the legs. The pelvis. That's fine. So you basically to image the rest of the skeleton? Yep. Very good. Right. Okay. Uh, well, this one? Yep. Good. So, again, you want to follow the cortex around a lot? These to the fibula. Looks okay to be a a meeting. My Lupus looks okay, but when you look at the Taylor dim, there's a irregularity here with a lucency difficult X. There's Ah, fracture of the Taylor doom. And again, this will be from trauma falling on landing on your feet. There's no huge what we'll say about this eso. So that was one of the points I want to make sure I forgot. So there's one thing that often catch people out. Is pathology of the edges of the film. So when you look at, you're the the obvious fractures will be in the middle of an X ray. The place is people tend not to look on the edges of the film. So once you've again coming back to my point about satisfaction of search. Once you've identified one pathology in the middle of film, you should go around the edges. Look at all the other structures. So sneaky fractures up here or commonly on the lateral ankle X ray. You can see the base of this. You know what this is? You seem very almost crops off on this picture. Yeah, exactly. So this is the base of the fifth metatarsal, and this is a common place for fractures. Do you know what structure inserts into this? So it's the paraneal brevis? Yep. So I mean, commonly people full in their ankle and inverts the more weaver them into an ankle x ray. But inversion injuries can also cause in the bulletin fracture of the base of the fifth metatarsal. You always need to look here, even if there isn't a foot X ray. You just look at it on the ankle X ray. Uh, I presume some of you guys at radiographers get someone said this is always needed on the lateral ankle. Yeah, I I was the standard view. That should be obvious, but I think sometimes there are several 12 use and they'll be right at the edge of the rice at the edge of the film. And this is where you miss stuff. There isn't a fracture here. Actually, I'm just illustrating the point. Uh, right. So moving on the foot. So, uh, we do three views of foot. There's ah, a p is an oblique and lateral. And again, the principles als the same. You want to use these to assess the so the cortical integrity of all of these. And you don't look at the alignment of the bones so crucially on the AP view, this needs to line up So the this bit if the great too mess tarsal on the, um medial, the lateral aspect of the medial in there for me flying up similarly on the oblique view. This it was one point that he's lined up and I'll come on. Why? That's important. And then we do a natural Well. Ah, right. Okay. What do you think? This I've given you some history here. Help! Oh, yeah. So So you guys have jumped in with the diagnosis so often? Myelitis. Ah, on and yes, and Jeremy is described the findings. Very good. Issue the Yes. So this is this is often my license, so I think the history kind of gives it away. But there's a lucency, which is abnormal in the great. So the stool and proximal phalanx and this cortical destruction. So yeah, it's hard with toes because they kind of overlap on these views. But I could probably convince you this like a nice shop cortex around these days. But here it's kind of very irregular and ill defined to this address, this bony destruction and also you can tell that there's soft if you lost, so they're sort of lots of soft tissue around these toes. But around here, there's this for where the ulcer is, it's very thin. So here on the medial aspect, problem is down to the bone and also at the tip. There's no soft tissue on the tip of that toe from the almost down to the bone, which is what is going infected. Yes, a lot of the instruction for amputation. Yeah, I mean, I suspect this toes it's pretty invested. Probably just need to come off again. I'm not I'm not Decision. Um, as an aside, if you're suspecting osteomyelitis, say there's someone with a big old PSA you're suspicious, but you don't see any changes on this X ray to look normal. What you do then? Yeah. Okay. Ah, So some people have said CT. Some people have said MRI. Um, so actually, in the first instance, I think if the it depends how high the clinical suspicion is, but normally least in our sensor, we recommend also doing doing a follow up film. So even if there is osteomyelitis, the bony changes on plain film don't necessarily manifest until slightly later on. So we often say, Repeat the film after a week or 10 days, and sometimes you'll see really changes. So you might not see really florid bone destruction like this, But you might see that of periods, still reaction or some early features In terms of CT, Mrs. MRI, CT is obviously very good at looking at bone. So you would see to this bone destruction you see very, very clearly on the CT. Um, but the most sensitive test is an MRI. The MRI will show early inflammatory change on a Dema within the bone marrow before CT show these cortical changes here. So, essentially, if you can see on the CT, you probably see features only obscene radiograph. But the early changes of osteomyelitis has seen on a memory predates this. So the whole foots really infected. They're also everywhere on you're not sure which gets infected. The Ortho, the orthopedic surgeons with us for an MRI in this case. And also, if they're planning to do an operation to say they're gonna amputate this too well once they're helpful infection is because it might be that this lows of time to change Onda Dema further, further back. So that's a resect more than they think. Based on this, because you don't want to take off the distal phalanx and find that the rest of the toe is not really viable. Yes. So, in summary, your followup film or if you want in the media and so we do that. All right. Right. Okay, so this is probably also quite easy. What's the abnormality Here? It bring it. Ah, about this one. If I don't, you guys with the answer is all of these. I would have made some of the harder right. It records. This is a fracture of the base of the fifth metatarsal, which is what's talking earlier. So inversion injuries of the ankle. The Peroneus Brevis tendon is attached to you. So as you stretch it, it kind of dulls the base of the with Ms Darcel. It's quite obvious on the for sexually person times You see it? Like I said on the lateral and collector is well, uh, and funny. Well, you do you think about this? So there's, um the range of answers for this one. So lots of you said Lisfranc injury. Um, I could see what you say. That's I think this space looks It widens on, I think similarly here, it just looks like a what? Um, but that's I think if you compare, it's the other other joint spaces in the mid foot. It's not particularly worried that it's not not displaced. Not no, this place, that's all. They're not particularly, wouldn't the ah, But the rest of you said fourth metatarsal. Yeah, So the the ultimate here is a stress fracture. So this the finding is that this period still reaction around the shaft of the fourth methoxsalen here and there's ah, cortical isn't see broke out here on this film. What about here? So this is, um this is a stress fracture with surrounding period. Still reaction. So it's a healing fracture. Ah, pair. If the reaction employees that this of well, when it comes to franchise implies is healing and callous formation going on, there's quite common and people do. Lots of sports, particularly people have started doing a lot more sports than they used to look like you're running. I think it's stress fractures or they're common in the 3rd and 4th messed us a lot. But basically anyone with this kind of history, if you see any cortically regularity flatness of, ah, fluffy appearance here even without cortical decency, just the just period Still, reaction would make suspicious off. Um, the stress fracture or healing stress fracture. Right? Okay. Ah, about this one. Yeah. So? So, Firstly, there's Ah, there's a fracture of the media looking a form. So there's a lucency here and then looking at the alignment, the first metatarsal isn't aligned with the we look in there from. So so you call a It's called a fracture. Dislocation of the first empty. The first metatarsal. Oh, total joint. Um, but the economist name for this is a lisfranc injury. So the list Frank ligaments is in the mid foot, and any disruption of that commonly from trauma to the mid foot disrupt the alignment of the the 1st and 2nd Tarso metatarsal joints. It is a very complex consequences classifications system for this. That's I think when you're looking at these films, you just need to identify. Firstly, is there a fracture? And secondly, is the mid foot alignment normal as not, uh, how about this one? Yeah. So this is another another. Lisfranc and Rivers Divergent injury. This joint space here, it wouldn't. So between the medial and middle uniform bins Ah, and the normal alignment to expect here is that the the base of the second best Arsal to the line. I'll show you my next diagram. It should line with the medial aspect of the middle. Careful bone. So this little line up here? Yeah, this is a lisfranc injury. So this just the diagram that straits how it's all first line up on the TV use. Try next from Radio Pedia. So on the AP, you don't look at this line and on the oblique. You don't look at this red line here. I'm also this red line Him But the main thing is, you want to look it all of the joint spaces in the mid foot. And as a rule of thumb, all of these faces should look about the same. So in a young person without what's the authorities and degenerative disease full of these joints faces, it's the same. It's the same principle is the wrist. So all the midfoot joint spaces should be about the same width of anything is slightly widens. That would make you suspicious of an injury. And if anything is not probably lined up as it was rated here, that would make you suspicious of a ligamentous injury on their important. Because if you miss a Lisfranc injury, the unstable they could lead to art collapse and foot deformity. It's kind of a bad thing to miss, uh, so there's a lot of things to talk about. So in summary, Ah, when you guys were very good and you got most of the cases, so you always need that least you've used to exclude a fracture. Ah, you to look at the alignments and know what the normal alignment should be. Um, and then you follow the cortex of every bone all the way around looking for abnormal loose that sees and discontinuities in the cortex. And also looking for periosteal reaction. Yes. Or if it's mentioned that Yes. Do you mean my summary slide or the Lisfranc case? Sorry, I think I actually meted myself. So yes, there's Ah. So so this one. There's a fracture at the base of the the second best possible as well. But so so the Oh, sorry. Okay, I think I I'm eating myself it up it. So, yes, there's so this frank injuries. It's all about mid foot alignment. So on the AP view, you see the red lines basically illustrate the alignment. And so this is normal alignment on the oblique view. These two red lines, you want to make sure normal. And that's reassure you that the alignment of the mid foot and the torso metatarsal joints between these bones and these bones is normal because the list, frankly, gum it connects this part of the mid fit, provide stability there. So there's any instability or injury to us. Then these will be out of alignment on all three. All three of these red lines have to be correct as it were on then. The other sign is looking at the joint space, so the joint space between all of the tarsal bones should be about the same. And if you're not sure you compared to the other side or you compare other bits of the mid foot, it's a similar in principle to the bones of the wrist. You want to look at even joint spaces all of the way around. The only really exception to this is in older patients with degenerative disease. You can get a symmetric narrowing of certain joints. So, for example, the the Taylor individual joints and so the more proximal joints here, commonly effected by degenerative disease, you can see some narrowing here compared to you the rest of the mid foot. But broadly speaking, these faces will be regular. So for this frank injuries, you want to cut the alignment on both the AP and the oblique view, and you will look at the joint spacing between the tarsal bones. It's that Does that make sense? Okay, yes. So in summary, Um, as I said, everything needs a least two views to exclude the fracture. You want to look closely the alignment first, um, examples. But I think from looking at the use, you'll eventually learn what the normal alignment should be. Um, and then the next step in the systematic approach is to look the cortex of every bone. Follow it all the way around, so you want to look for any steps. Any discontinuities or any abnormal lucency is in the cortex, and you want to look slightly beyond the cortex to see if there's cortical, thickening or peri a fuel reaction. So that's the sort of fluffiness or so ill defined edge to the cortex. And even if you can't see a cortical step or a defect, Periosteal reaction implies that something else going on. And then once you looked at the cortex, you want to look at the trabecular pattern with the burn because there are more subtle fractures that disrupts just the trabecular pattern. But maintain the normal quarter outline you'll see on the plain film men you want. You could move outwards. Look at the soft tissue if there's any soft tissue swelling or there any joint effusions with general swelling around the joints. That makes you mawr vicious of an underlying bony injury and specific to the leg. The lower leg. Uh, we talked about the principle of the polar mint. So between the tibia and fibula, if you see a fracture in one, you need to image the whole of the the need to ankle joints to look for a second injury. Um, and I didn't realize that a lot you radiographers. But for those of you who aren't, if the radiographers say red dots on the film and you don't do what the abnormality is, you should look closer. Big says definitely. There's most likely an abnormality on the eso. That's everything I want to talk about. Um, most my pictures. Why the from where I work or from Radio Pedia? Um, another site was quite useful. Is radiology assistant dot n? Else there's a Do you recommend the sites for reading? Does anyone have any questions about anything I've talked about? Oh, sorry. What's red dots? So literally? All it is is if you when you look at the x ray, um, did you let me find your level? So to say, you're looking at this X ray, it'll say which side it is, and it will literally say the words red starts in the corner. So when the radiographers who are requiring the X ray, Um, but on the computer system and they look at it and they say, Well, obviously there's a to be a plastic a fracture there they'll ads red dots to it to draw your attention to it. So what I'm saying is, if you're if you're working in any on the ward or anywhere else and you see an X ray and it says red dots on it, that means there's probably a novice abnormality of you should be seeing on it. So sometimes I think it used to be a natural. Them a red sticker they put on the film X rays. But now there's like, um, use face, usually type red dots. Yeah, exactly. It means it means take a take a closer look at it. Yeah, it's the draw your attention to it, basically because they don't have any other any other questions. Thanks very much for that, Joe, you told a lot of evening and thanks to our views as well for being so interactive because it definitely makes these sessions more educational. Interesting. When you get involved in the chat on be sure that our participants will also agree that these cases will particularly helpful for their learning. So, um, just to reiterate with Joe's red dots, because I currently work in any of the moment. If you see a plain film that has a red dots in it and you can't see the abnormality, then it's worth having a chapter, a senior or maybe even a chapter. The radio prefer, because it probably is an abnormality on it, and you just haven't seen it. So, yeah, have a zar high threshold or low threshold. Sorry to seek senior help when you see that spot on the plain film, so you should get feedback links. They should have helped you already being emailed to you, but if not, then they should pop it in the next 10 minutes. I will also pay something in the chat now, so this has the top link is linked to the feedback for Joe's presentation. Andi Middle link is to next week's presentation that's going to be covering up a little escape that's going to cover the shoulder and elbow, and maybe if we have time the forearm as well. On the bottom link is just a sign up to the webinar. Any weapon arsinieries on mine? The bleep. So we also have medicines, surgery, um, pediatrics, finances, lows, a different Siris that you can sign up for. And that bottom link will take you to a page way you can sign up for whichever one you want. So I'll just leave another mineral. So just in case there any last minute questions. But, Joe, So someone's about how we access this lecture. So all these away, these webinars get but low determine it'll afterwards. So after this session finishes, this video will get saved and we'll get the plate back up onto medal. But because it's such a large file, because a 90 minute video is almost like a movie, then it should be the next couple days or so. But it should be accessible. Here is Well, if if you can't find it here, then I'll also go into the mind a bleep YouTube Channel two eso just to say again. So that's Wednesday evening at eight PM So this time next week Dr June, I'll be doing the upper limit. SKC. That's that shoulder and elbow and maybe four. Or if we have time on. Don't forget to sign. I don't get to felt those feedback forms as well, because that's how you get your certificate. And it's also how we know how to improve these theories on. There's an extra question on this week's feed about form. So it's it's exploring what we're going to do after this serious finishes. So I think there's about four or five of them left before we've wrapped up this webinar serious because we have covered pretty much all the imaging modalities. By that point on, it's just to gauge interest of how we can expand this further because this webinar serious actually got quite a lot of interest from you guys and just really good, because it shows that there's a need for radio radiology teaching, especially at both undergraduate post graduate level. So whether it be cases or going into specifics of what junior doctors might see, whether the NGO to placement or things are typically heart see on X rays. I don't know what you guys would want, which why it's really important for you to fill out that field so we can see how we can improve this in the future and see what you guys want. And so I can't see any other questions, Joe. So thanks so much for preventing that was really helpful on Deal. See you guys next week. No. Well, thanks for this thing goes all right.