This medical teaching session is designed to equip medical professionals with the understanding of human factors to help them better scale up their medical practice. The session will look at how to spot normal and abnormal abnormalities on X rays, what to consider when looking for fractures and how to avoid common mistakes. There will be opportunities to interact, ask questions and get a better understanding of the radiography process.
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MSK and human factors behind why people can miss fractures

Brought to you by Dr Nick Lorch, Radiology ST2 at BTHFT.

As usual, would recommend coming IN=PERSON for a feast!

Learning objectives

Learning Objectives: 1. Identify basic bones and anatomy of the shoulder on an X-Ray. 2. Identify and explain a fractured bone on an X-Ray. 3. Identify common explanations for missed fractures on X-Rays. 4. Identify a pneumothorax on an X-Ray. 5. Demonstrate an understanding of the 'cortex' of a bone and the implications of this relating to age of fractures.
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The following transcript was generated automatically from the content and has not been checked or corrected manually.

You just want to ask him to try if they can get, hi, we're just starting now. Can people viewing through metal? Um, just type of the chart if you can hear me and see the slides? Uh, you can see a fancy metal the same time. Yeah. Yeah, if you want. Yeah. Um, see how it goes. Okay. Okay. So we've got, oh, quite a few people um, at home. So thanks for, thanks for attending. And can someone just put in the chat if you can um, here and see the sides? Yeah. Okay. Great. Okay. So we'll make start. My name is Nick Radiology trainee. Before that I thought I wanted to do orthopedics. Um, I did a f three year in Ortho, which was great. Um, the best time of day was the trauma meeting where you went through all the x rays and then after that going to operate, going to see the patient's um, slightly, that's fun. Um, the x rays tell you really all you need to know about the patient's. Um, but beyond that, beyond the radiology, there is a lot more clinical knowledge, biome mechanics and a lot of anatomy. Uh what I'm focusing on today is um not the basics. So medical teach you that it's more about the human factors. The MS is how to really scale up your practice. Um So if you don't know, uh and you get a bit of loss during this lecture, tell me I'll cover the basics. I point out the normal structures which I've tried to include along all the abnormals and the fractures. And um it might be helpful to just go back and look at some normal X rays after. Um but the first side which might be looking at some time um does contain an abnormality. Um I'm gonna ask for people to volunteer and interact a bit if that's okay. And so people watching at home on metal, you can type in the chat but does anyone want to slowly talk through what they can see on this X ray of the shoulder? There's one taken sort of front on and one angled a bit. Um So you can see the shoulder joint here, the point with the mouse. Uh I thought, yeah, so humiral head here, scapula humor heads lying over the scapula because actually is taken diagonally on to those two overlay. Um But does someone want to volunteer and interpretation normal abnormal fracture? Something else? I'm sorry, do this. Okay. Um Okay, good, good, good guess. Good start. So to look for dislocation, um You check if this bit of the human head is sort of lying in the cup of the glenoid fossa. Um And that's uh meant to be sort of a ball and socket joint. But the bone part of that is quite flat. And then a lot of the cup is made up of cartilage which you can't really see on an X ray. So the if, if it was dislocated, this would be sort of lying down here. But I think there is sort of a good amount of contact and there is this little crescent here of um uh slightly darker color, so more x rays getting through here and this is a rare, that's a normal finding a bit like when you crack your knuckles. Um So you've all been saying this X ray for a long time, it's a really tricky one. Um I thought people would time in and say, what about this line here? Um Could that be a fracture? Did, did anyone think that because that's the normal growth plate? So you've got a sheet of um cartilage basically because this is a child or probably a teenager and that's when new bone is formed, but it's so regular. Um And it's got this sort of white line here that's um not a break as we'll see later, which would be irregular and that's normal, the abnormality, uh which bet down here do you want to come up and point? Um Okay, I think that's just a growing structure of the bone. And if you think about how, if you think about, like, holding that bone and breaking it, it would be unlikely for it to break in that direction. It would break into, like, if you have a strand of spaghetti or something, um, uncooked, it wouldn't split in half, it would like that. But you're quite right. Sometimes you have these subtle fractures which are more dense where bone is crushed and, uh, compacted together. Um, but it's not that, uh mainly because I'd expect it to go sort across if that was the case. Um In fact, um we'll come back to that because there is an abnormality which unfairly, I've chosen the hardest case first. So the sore could be relevant for everyone. Um You don't have to be a radiologist, an orthopod to look after people fractures. Um Come to any, obviously, if you do medicine, you have a lot of impatience you fall, you need to assess them, probably interpret X rays. And in G P, you will have a lot of people who, you know, maybe take a bit of tumble a few weeks ago and have come to see with a bit of a limp. You need to know what to do. Why do people miss things on x rays? So you can see one fracture, but on another, you can be distracted by something else. You can terminations search, that's the same thing you stop looking and, and call it normal. Uh People don't tend to look at the whole X ray, they just look at the center. So if that's the shoulder, you look at the shoulder, but actually on the X ray, we had a bit of the neck, the rib cage further down the arm. No one, I bet, looked at that. Um And then you can also have sort of an opportunity to spot something completely unrelated to the presentation. Um And this, that and if you don't know what normal is meant to look like you'll see something abnormal and say, oh, I'm sure that's fine. Um So you need to look at all, um, as many normal radiographs as you can see and as well as I'll show you, um, it's not the textbook ones which matter. It's the ones where the X rays taken with the patient slightly turned or there, it's a chest X ray and they breathed out and the slumped over because that's the most common thing you'll see. But for whatever reason, um, only the perfect pristine ones get into the text books and into the online libraries, um, and into the teaching sessions. So that's very important. Um This is, this is an X ray where I just know I'm going to miss something that someone's dumped a whole lot of spaghetti on this patient. Um, no, but they're, they're in ICU, they've got lines and tubes, they've got UCG leads everywhere and, you know, maybe one of these lines is meant to be in, in one place and it's in the wrong place. But I have no idea. And when I look at this, my brain just um stops and um you know, it would be impossible to do well with this. Uh Even if you try and follow really systematic approach, uh the imaging request is important too. So uh if you, you know, have someone with shoulder pain, but actually they've broken their clavicle um and you don't X ray, it, you're not going to get very far um, incomplete poor quality X rays, which fool you into thinking there's a false positive, false negative. Um And if you do the wrong sort of X ray and sort of give up on your search, um you're not do very well. So even if the X ray looks normal, there'll be some cases where you can still miss things and that's when you should get a CT and MRI something else. Um And that's where my job is pretty tricky because I'll write a normal report. But I still expect you to know all about what that means. What that doesn't mean what I've ruled in what I've not ruled out. Um And yeah, if you stop the change of investigations too soon, you'll have that error. So I can see from the chat that Sandra has commented. Was there a pneumothorax on that left shoulder X ray? And there was so well done. Sandra, I'll just show you what that is here. So there's um this bit of lung is letting too many X rays through. So it's appearing as darker on the X ray as it should. Um And there's this line here just under the rib, so rib here and then an extra line and that's the edge of the lung. So the lung is mostly airfield and then there's another bucket which is all air and that's really hard to spot. Uh Even if you were saying, is there a pneumothorax? Um I thought no one would get that because you don't look at the shoulder. Uh But well done. Okay. Can everyone see that now, your attentions drawn to it? Yeah, it's tricky. So here's an easy one, obviously. Um It's easy to, to look at this and say yes, this is a fracture. I know it because it looks like a fracture. Um But what is it we're looking at? It's these sharp bits, obviously. Um There's parts where uh fragments of bone have been broken and then they've come to life. So they overlap and things are uh stopping more X X rays than we'd expect, which is whiter on the X ray and then the opposite where fragments have been broken um and come apart and letting more X rays through and that's gonna be darker on the X ray like here. Um And one phrase we like to use a lot is if something is well corticated or not. So, has anyone heard that before. Has anyone know what that means? So, do you know what the cortex is of the bone? It's outside and it's um you know, this bit, it's much harder, it's thick, it's um stopping more X ray. So it's whiter on, on here and then this uh edge here of this sharp bit where the break is that doesn't have a cortex, it doesn't have a thick wall like this. So this um so I can say this is an acute fracture. It's not had time to heal if you left it months. And this patient didn't have operation. Uh this, this free edge here would start to heal and the bone, it would have this cortex like that. And then you'd say this is an old fracture. It's been months, it's trying to heal on its own. And, and then another thing you can do is follow the edge, follow the edge, follow the edge. And then you see obviously there's this angle and turn here, which shouldn't be uh this is what a normal hip X ray looks like. If you've not seen one before, when you start out reading, always go to this website radio pedia, which has uh excellent library of, of normal stuff and just say here's normal, I'm looking at something else is that normal abnormal um that really helps us okay. So overlapping small bones can look sharp anyway, if you look here, um you, you kind of think what's this funny dense triangle here. And is there one here? And this is such a sharp angle overlapping there? Could that occur naturally or is that sort of a fragment of bone that's lying there? And this sector is normal? What we've got is a projection of um three D structure onto a two D X ray, the foot and arch and where um this arch of bones sort of meets um on the X ray, it looks like they overlap, but they're all lying next to each other. Uh Normally as they should and there's no extra fragments or bone that's been sort of pushed together and squashed here and that's just a zoomed in view. Um Those are the, these sort of would, would catch me out and um that would be a chance to have sort of a false positive where you over pull that okay. So here's some, some more obvious signs of a fracture, um soft tissue swelling, joint diffusion. Um That's, that's important, you know, maybe on some, some other modalities like CT or MRI um obviously a clinical examination as well. Um But you can see you can see soft tissue swelling on, on an X ray and that sort of uh focuses need to look at exactly one part of the bone where there might be really subtle fracture, um the healing of the cortex, as we said, and then periosteal reaction. Um I've got some pictures of that in a minute. But has anyone heard of that in terms anyone know what that is? No. Okay. So, um, you've got this membrane around all of your bones that's called the periosteum. It's quite firm. It's quite tough. If you eat, um, ribs, you might have come across that um, as sort of this uh not, not gristle, but it's, it's just this thick membrane. Um And when the bone breaks, that membrane can be torn or intact, but it starts to heal, it starts to make new bones. And you can see that as sort of this uh white line adjacent to the bone. So it's not just fractures. Um Other pathology can sort of trigger this healing response. Infection abscess within a bone, bone cancers. Um But even if the bone itself hasn't really broken, it's just been squashed a bit. Um like if you have a rolled up paper and you bend that, um it won't look to broken, there won't be sharp edges and corners like that. Last extra I showed. So if you have that and this is very common in children's bones, which a bit more flexible, you can still see the periosteal reaction and that's a great sign that there's a fracture. So, um I'm going to show you some, some tricky cases as I said, if you have exams, um you know, you, you get shown something, you've got, you know, one minute to look at it and choose from an MCQ, but real life isn't like that. You can phone a friend, you can look at a textbook or website, you can take a few weeks, uh, to make a diagnosis because you're not sure. So, this is, um, someone who let's say, went for a, went for a run, had some foot pain and see their GP, um, you know, they could walk. It wasn't terrible. Um, but the foot is quite meaty. So it's, it's hard to really say exactly which bit hurts when you, when you press on it. And um this first X ray, um you can look at that for a minute but it's completely normal and you're looking at all the bones, you're sort of tracing around them looking for any irregularity, any bit where the cortex is interrupted where there's a fragment or something. And so that's normal. So I can say, you know, I don't think there's a fracture, there's nothing too bad but come back in two weeks and we'll do another X ray. And why do you do that? Well, because uh this repeat is abnormal. There's this extra calcification here which um isn't present on any of the other bones, foot and this is the periosteal reaction. So there's a hairline fracture here and here that you can't see because you can only see that when the bone is sort of broken and flown apart into loads of pieces. But we can see is the healing and that takes a few weeks to show up. And this is um calcification in sort of a blood clot that's formed under that periosteum and that's become calcified, making new bone in time, this will disappear and this will go back to its normal shape. And, but this is sort of the first stage of bone healing. This is also important um because you can't exactly predict how old an injury is. But if someone uh they brought their child to A and E and said they were injured today, but they had um an appearance like this, that, that would not quite fit with their story. So you might uh start asking a few more questions, uh start thinking about neglect and child protection. And so that's quite important as well and you can always repeat your x rays if you're not sure you can bring them back in a week or so. Two weeks. Um There are some areas where it's more important to get a quicker diagnosis like the hip. So that wouldn't quite be what we do today. That would be more of an old fashioned thing. Um And coming back for more X ray views, but for the hip as we see, you, you probably want a ct for that. Okay. Any questions about this, for the people who join just now. So this is um uh bone healing as a sign of fracture that that doesn't show up right at the start. Um What about this? Would, would anyone like to hazard a guess how we can interpret these hip x rays. So, there's the ball and socket of the hip joint up here. This is the femur coming down the leg. I've got two different ones. Both of which are abnormal. Um, you don't have to tell me the exact pathology. But would someone like to try and describe what they think they can see? Yeah. Go ahead. Yeah. And you're looking sort of here? Yeah. Great. And what could cause that have a guess? Okay. Um Yeah, osteo process maybe. Um, does that tend to show up just in one spot or is that sort of everywhere? All the bones, um, all of a bone and all the bones, but we've, we've only got this X ray of one. Um, someone's commented online, bone cancer. Yeah, it's very good thoughts. Any other guesses. Could it be blood? Um So if you, if you had a break, um and then a lot of bloods outside the bone inside the bone. Um So, no, but in a way, yes. Yeah, idea. Yes. That's another really good suggestion. So, infection, uh bone cancer and a few rare inflammatory conditions which have sort of inflammatory cells forming abscesses inside bones that aren't infected but sort of present in the same way. Um And then some things that it is aggressive and called bone cysts which are full of blood. Um, but it's, it's where there should be bone and cartilage. There's just a bit of fluid instead and those, those can grow quite slowly. Um You can have a fracture through that as we have with this case just here. Um And uh you can treat them by sort of making a cut scooping out the soft tissue fluid and sometimes bone grafting or waiting for, for normal bones grow in. So it's impossible to tell what this actually is. You could all be right. Um But the, the point is there's a break here and you can't just treat it normally. Um You have to have a real think about what this is. Maybe do an MRI maybe ask the surgeons to take a sample of this um for uh to put it under the microscope and see is a cancer is infection. Um And then so really good suggestions everyone. Um But if you see this, you, you can't just treat it normally. You have to, the alarm bells are ringing, you have to do all your special tests. Yeah. Um Yes, good question. Um They, you have, you have a few days where they could be in a cast or be in bed rest. Um But if you, if this was cancer and you sort of ignore that or missed it and you put a plate here, um it wouldn't work because the cancer would continue to grow. So it's not, it's not an urgent thing to find out within hours. It's sort of days or weeks and it's, it's just, um, it's just to sort of flag that up. Uh Someone's commented aneurysmal bone cyst. Um, and that's, uh, that's another really good guess. Um, that does tend to look like this. The word aneurysmal in that name though, just like an aneurysm of a vessel means um widening and normally because those grow so much that the bone itself widens and would bulge out a bit. Um, so that's, that's a good suggestion. It could be that or sort of the closely related cousin unicameral bone cyst, uh which just means um uni single camera room or chamber. Um And that's, that's another really good suggestion. So with all these um focal lesion's probably the most important thing to look at is the edge it makes with normal bone. Um Is it something nice and smooth you can draw around? In this case, I think it is those tend to be uh benign pathologies like, like these bone cysts or if that edge is sort of blurred, that's something that's growing into bone eating into normal bone and that can be cancer or infection. And so that's, that's probably the one thing to look at on an X ray is that, is that border between abnormal and the normal bone. And, but you can't always say exactly what it is a lot of the time you need an MRI. So if you say that, yeah, so I'd say this is I'm well defined. We use terms like narrow zone of transition um for that, but there is a fracture need to fix it. Um probably an MRI for this, but that's, that's getting very advanced. I think if you're um not an M S K radiologist, not an orthopod, you just um see this patient in A and E uh you don't say, oh it's simply a fracture, you just say fracture and something else mysterious. Um That's uh probably the most important thing to take away. Um This one um over here, this is different and this is fibrous dysplasia. So this is uh sort of soft tissue which is growing where there should be cartilage and bone. Um You can be born with this, you can have this show up in lots of different places. It's not cancer. The thing about this is it bleeds a lot when you drill into it when you're trying to do an operation. Um So you need to tell the surgeons to expect that. Um otherwise it's, it's a blood bath and you can, you can bleed to death if you, if you're not um expecting to come up against that. Um So again, this could be many things just from the X ray. Um It does sort of have um that sharp border between the abnormal here and normal bone down here. Um But saying exactly what it is from the X ray, that's, that's quite complicated. So don't get into that, but this is just more than just a fracture. And the other important thing to do is think about the next steps for the operation. So with this, with a fracture in the middle of a long bone, um between the hip and the knee, it would be sort of here. Um What, what operations could a surgeon due for that? Does anyone know? What sort of kit, what sort of metal work they might put in? No intra medullary now? Yes. Uh What else? That's, that's um that's a very good answer. Uh There's a few options uh the nail or putting a plate on the outside. Um But no matter what you choose, you're going to have a normal bit of bone, the fracture and then another normal bit of bone and you need the metal to sort of bridge from normal to normal if, if it doesn't and you get sort of this lever effect with the metal is pushing on an abnormal bit of bone and that will just break and, or flip out. So, um what you do in this case is take an X ray further down in the knee just to check. There's not another one of these things lower down. Um Well, this is another X ray, this is um someone else different patient and they've got this periosteal reaction here and that's not from a fracture, that's from something nasty growing, growing the bone, eating away at the bone. The bone is trying to heal out here. Um, so this is, this is a different patient. There's something else. But if you George George throughput that I am nail in bridge this and had the tip of the nail sitting here, it wouldn't work, it would break this bit instantly because that's so weak and it would flip out and your patient be worse off. So, um, that's what I'm talking about. That's the I AM nail if you've not seen it before you, but this screw through the femoral neck and head and then this goes all the way down, all the way down and there's some small locking screws here which don't provide much stability. But if this bit and at the end was sitting in this, at the knee, um that would immediately break it because all the force would go through this part. Um So that's, that's the biomechanical explanation of what the nail changes when you put it in. The important thing is, um, have a think about X raying the whole of a bone before you operate on it and not if there's a simple fracture. Um But if you're facing uh if you're suspecting metastatic cancer, um if someone has one bone metastases, it's quite likely they'll have another. Yeah. Mhm Yeah. Um Yeah. So that's, that's probably the most common operation they do. This would be sort of the crazy alternative for when you come up with a case like this or there's something sort of destroying or eating away the whole bone, uh, normally cancer. So they've basically chopped out everything and joined it into a total knee replacement. And, um, obviously your muscles won't really be attached to this and it won't work like a normal leg. But this is maybe what you do if you had lots and lots of these funny spots in the bone. Okay. So that's so you can miss things if you do an incomplete imaging. Um So that's not something about radiology, that's not how to work out exactly what this funny spot in the bone is. That's thinking, what are the surgeons going to do this patient next? What, what do we need to do to, to think ahead and plan ahead. So reading hip x rays, um one thing that can really help you is looking at these lines which should be smooth arcs on normal structures and if there's a break in them, they'll be breaking the bone. So this um this is called Centonze Line. This, this does come up in exams a bit uh g here. So I learned that and it should be smooth um between the sort of inside of the leg onto the femoral neck. And here this is the uh obturator farming. Um There's a few others, I won't go into detail for that. So another case, 70 year old female, she's fallen, she's got right hip pain. Um We know she's got a left hip replacement here. So this very dense, very uh white thing on the X ray is metal and that's the hip replacement. And then this stuff here again, more dense than bone that's cement around the metal, sort of gluing it in place. But forget the left side. Focus on the right over here. Um Is there a fracture? Is they're not, what do people think uh type in the chat on metal as well? Well, while you're all thinking, I'll say what my process is to look at it. So I'm just looking here, this is the neck. This is where the brakes occur. I'm looking at this line and seeing is it completely smooth? Well, there's this funny bump here. There's a funny bump here. Um, so it's, it's possible that there's been a sort of break where this neck has been rammed in and it's collapsed and telescoped and formed a little bulge. Um, but it doesn't really look like sharp corners. So I think these are just osteophytes here. Um, and what would make that more likely is the fact they've got osteoarthritis, um, here and they've had a hip replacement. So, yes, they probably do have osteoarthritis. Uh, so that's the hip done. And if you give up there and say, all right, no fracture. Go home, walk, home, run home from a any, you're fine. And that's, that's not very good because you've sort of not looked at 90% of the X ray. So, has anyone spotted anything else yes, inside the pelvic uh this bit. Yeah. So, um so we're looking at a two D representation of the three D structure. Do you know which bit of the bone that was if we had a skeleton here? Do you know which part that would be? No worries, if not. So, it's sort of the inside of the cup of the sort of cop and cup and ball, ball and socket, which is called the acetabulum, which means cop in Latin. And what's happened is the ball and socket is sort of punched into that, um, socket and it's broken like that. And yes, you're quite right. There's a sharp break here, um, which should be a smooth line and if you compare it to the other side, that's nice and smooth there. Yeah. Mhm. Yeah, that's a really good question. Um, that would be a break where the ring itself is broken. Um But this is, this is a socket within the ring. So if you have, what people normally say, what you've probably heard is a polo mint, very brittle ring that can't be broken in one place. And this is just if you've chipped a corner off it, but the bring itself isn't broken. A break in the ring would be something like here going from the inside all the way to the outside. But this is uh not really going from here all the way through to that if that makes sense, but that's a really good point. Um And again, it shows, you know, something about biomechanics about how structures break, how they grow and how the force sort of goes through objects. Um But again, you've done really well and we also um who also put that in the chat really good spots. Um And I think most people reading, reading things quickly in a and E might be distracted. So here are the lines that's nice and smooth on the left and then here it's broken just to draw jury I to it. Okay. Um, I put this X ray in, um, because, uh this guy has had his femoral head and neck chopped out. Um, it's a fresh operation. They've got some clips here, some gas and soft tissue. Why on earth would you do this? Don't you sort of need that? Um, this leg isn't going to work at all this, um, top of the femoral, uh greater counters just come sort of bump around. It's not a ball and socket anymore. Well, you might do this if someone had infection or tuberculosis in their hip. Um, or if there's a fracture and you really couldn't piece it together. It was sort of exploded into a million pieces. But why did I put this one in? I wanted to show you what the, um, sock it looks like without the head in so socket, but no ball and there's actually too low lines you should be able to see and which are very hard to see on a normal X ray. And those are the front and back if you've got a cup and it's sort of pointing you diagonally, you can see that one hand, one edge, second hand, second edge and they lie on top of each other um and sort of spread apart diagonally and should have a zoomed in image of that and you can see 12 lines and you should always check that those two lines are intact on a normal X ray as well. Yeah, I think they are here. Um So there's the green, um which is sort of the top of the socket and then um d infertile and f in yellow are actually different. They look, these look like they're very similar, but one is the front of that cup and one is the back. Um And if you look here, you can see this and then there's another line there separate from the purple. That's the yellow on the other side, tricky. Um uh Yes. Would you then gave up late? Um So we don't, we don't really do this very much anymore. Um You, you could, you could put a hip replacement in that sort, sort of uh we're all out of options, let's do something at least. And you probably, you might meet someone who's really old now who's had it like 20 years ago. Um It's, it's very tricky to walk on a, on a like like that as you'd expect. So, you're right. You would want to, your instinct would be, let's put a new hip replacement in. Um, but it used to be sort of for someone who might shuffle around with a walker, um, and do that, but now we have much better options, uh, as I'm sure we'll see a good question. So, um, okay, we've got another case. We've got a 90 year old female nursing home residents. She's got dementia. Um They're not quite sure what the story is. Maybe you hear something that the uh nursing home staff have told to your colleague who's now relating to you. It's all, it's all sort of thirdhand. Um The patient can't really tell you. Unfortunately, she's got dementia but she's unable to mobilize. She's unable to use her walker. She normally would and she's sort of pointing at a right near bit but, but no one really knows. Um Here's an X ray. Uh Does anyone want to talk me through this? Is that just from the gums? Um Yeah. Yeah. For good. H Yeah, that's all correct. Mhm Way. And then I go into the skin margins to check on his own breaks, which as well. Uh then go on to analyze the internal soft tissue inspection. So, yeah, so this and this um so this is, these are the quads muscles and this is fat above it and that's normal and we've got um some tendons here, but not much muscle, sort of within the knee joint and again, a bit more fat behind the tendons which sort of all blows together. Um, do you know if something important on any X ray that can guide you to sort of a hidden fracture? Yeah. Excellent. Um, it's not on this obviously. Um, but that's, that's a classic one for exams, medical knowledge so well done. Um, it didn't put that in so normal. So, what are we doing this patient? Okay. Um Kind of, but uh if you were examining a patient, your in your Rosky, um and you'd say, you know, I've examined a normal knee joint and then you stop and you say to complete my examination, I would it's a mhm. What was that? Yeah, that's right. Or you do further imaging. So, um if you really thought there was a break in the knee, you could say maybe there's a hairline fracture. We just can't see and let's do a CT or something. But yes, examine the joint above and below and oh, this is the knee from the front, sorry, should put that up. This is normal as well. Um This is, this looks much too nice to be a 90 rods knee because I googled normal knee X ray. Um But this, this is, this is this patient actually, this is her hip and you know, pain can be a bit funny. You can have referred pain. You can have people with dementia who don't really point to the right bit and fool you but always examine the joint above and below and that goes for x rays as well. Okay. That was cruel because I was trying to catch you out. You did an excellent job with the X ray. But uh this happens, people um send patient's home when they shouldn't. And it's, um, it's just you're thinking getting narrowed in way too early and it's, it's easy with your clinical examination to work through that routine. Um, and sort of people options open, but with radiology, for whatever reason, people can't do this and they get stuck in, you know, knee X ray, I'm only looking at the knee, I'm only thinking about the knee and the other thing is when you look at something, um, it's very hard to sort of force your eyes to move to all parts of it. So when you're listening to someone's chest, you know, you put it on, you know, maybe this bit at the start and if you hear crackles, you don't stop, you do everything, you move this in the front, the back, you do your whole routine. Um, but if you're looking, it's really hard to force your eyes to look everywhere. You just see, oh, there's a fracture, we're done next and you'll miss something, you know, on the other side. So that in mind as well. Okay. So what if, what if we're sort of still investigating one body part, 11 joint and we think the x rays looks normal and you give up your search. Well, that's another chance to, to miss things. So you should get a CT or even better. You should get an MRI. So um this is a CT, I've made it look like an X ray because it's slices taken in this same plane. But if you think of an X rays including all slices of the body sort of stuck onto each other superimposed. This is just one of the slices in the middle and we can't see anything in front, anything behind. There is an obvious break here. Um which, you know, that's not too hard to spot. Um Right. Yeah, obvious. So, um what uh what this boring paper is all about is if you think your patient has a hip fracture and the actually looks normal, they probably could still have a hip fracture, maybe one in three, which is quite a high number. If you send three people home, you know, that that could be one or two evenings working in A and E you don't, you really don't want to miss um these fractures. So ask for a C T, you'll get one. No one will say no. Um The, the real important thing here is knowing your clinical exam. So what words, what would you expect on history or examination that would really make you strongly suspect hip fracture? Any thoughts nonweightbearing? Yeah, someone just whispering their shortened, extremely irritated and yes. So those will be the very easy x rays to, to spot the fracture on because the bone will sort of broken and move and twist apart. It's the hairline fractures without much, much breaking movement. That are the really tricky ones. Um, what else for examination? Yeah. Yeah, definitely. Um, hard to, hard to judge really when, like, people are just lying down and that sort of like, awkward on the, on the a and the trolley. But, yes, um, that's a good one. And then you're examining them, you're starting to do some maneuvers. Obviously it's all very painful. But anything in particular, if they can't, the rest that they have to move around, is that, is that what you mean? Um, kind of, I think with? Yeah. Yeah, definitely. I think that, um, I think with, with the fractures, people tend to want to keep it quite still. And so if they break their arm they sort of hold it very still like this. Probably the same with, with that, with the, like, you kinda have some muscle spasm which, which can make you sort of move around the pink. Come on and off. Um, what I'm getting at is with, uh, with the fracture. If you take the leg and actually load it, you push the knee up towards the hip that will be quite painful as you'd expect. Um, you wouldn't have much pain if you have a pubic ramus fracture. Um, and that's, that's sort of the main thing I used to separate the two. So pubic ramus fracture. Um, the patient's normally point and say it hurts right here. This one spot, they may be able to weight, bear a little, they won't have pain on actual loading, which is a bit like weight bearing. We push the knee towards the hip. Um The other thing you can do is sort of take the knee and roll it I/O like that and that will obviously be painful with the hip fracture. Probably it's the muscle spasm which is contributing to the pain. Um The other thing and please don't actually do this because you look crazy and you do it is you can take stethoscope and put it on the pubic synthesis and knock on each knee cap and the sound transmitted through will be sort of different on one side probably due to like, ahem Arthros iss. Um but please do not do this, do not say you heard it from me because if you do that any like people will look at you like you're crazy. But that, that is another sort of biomechanics thing. So if you think of bone is like a crystal or a bit of coral, even a hairline crack will disrupt that you get sort of a slightly different sound going through. Um So that's, that's something that random to think about and never do. Yes. Yeah. Yes. Yeah, it will. Um, it will, but maybe just for telling, um, hip fracture from someone who's got just a bit of a bump and a bruise, but no break or a pubic ramus fracture. Um, I find it to be really helpful there. Um, so, yeah, but obviously if you have a break somewhere else, it will still hurt and you'd be examining the joint above and blows. You said, um, should we take a bit of a break for pizza now? Okay. Thank you so much that people online know that they can go jake. Thank you, sister so much. I'll put this on mute now. It allows me to. What do I do? But, oh my God. Is it? Is it still shad? Oh, what have I done? Hi, everyone. We're just going to start again now. Um, thanks for your patience. I got a refreshing break so completely, gotten more condensed. Um, okay. Yeah, this is what MRI looks like. Um, it's not what you'd expect. Um, the only reason I put this on, um, isn't to teach you exactly how MRI works. It's to show you that here. We've got a fracture of the left hip. We've taken a few different MRI S. This is in the same plane is before that slice the corona sections. You're looking sort of front on at the hip. Um, this is one femur, this is one few more, this is the spine and then you have the pelvis sort of coming in front of the screen behind the screen and urine. Um And there's a break here, this dark line through the femoral neck, um a classic place for fracture. But what we can spot with MRI is all this uh brightness here and this is water. This is a Dema in the bone marrow. Um So this is like your soft tissue swelling on an X ray around the fracture, uh which you can see inside the bone. Um And so if we're not sure if this hairline fracture is invisible, we've still got another chance to pick it up with all this. Um And there's some clever physics I won't go into, we can also do um something similar with CT now. And the way we do this is take two CTS at once um at different energy levels and those energy levels are a bit like colors of light, different wavelengths of light. And if you get sort of the numbers just write uh some uh chemical atoms, some molecules will stop some of the x rays and not the others. And there's um this funny sort of threshold effect where uh each um element has a threshold above which it blocks a lot of x rays and below which it doesn't really. Um And that's not really what you'd expect with, you know, sort of glass or paper blocking light. It, it doesn't really matter what color that light is. It all sort of goes through about the same. Um But what we can do is take some pictures and say, what if we ignore, well, the calcium in this and just look at the water in the soft tissue. And um that's sort of the blue and green map here. And this green streak here is just what we saw on the MRI, a bit more water in this funny line. And if you saw this Zoomed in hip X ray again, sorry, zoomed in hip ct again, in that Corona plane that front on slides, you might really, if you went up very close to the screen, you might see there's a tiny little uh irregularity here. Is that a break? Is that just a funny bone spur? You're not sure you might not even have spotted that. But with this um fancy technique, you can see this um extra bit of a Deemer going all the way through. So there's definitely a fracture here and you can't really see even on, on the CT. Um And this will be another one that's, that's normal and we're looking at the amount of water here and it's sort of all the same all the way through and there's no green streak. Um Yeah, yeah. So it's a Dema it's like when you have um you know, uh an abscess or something and it's your redness warmth, swelling heat so that you can have that with infection. You can have that with processes that make more, more blood vessels, inflammation, tumor and fracture as well. It's just edema. So, um those, all those things will look the same. It's not just because there's a fracture, but in that sort of line pattern, it can be like that and not all CT scanners can do that. It's not usual to do that. It's just one of the fancy tricks we have. Um Here's our Einstein, he's about to explain these funny thresholds. Um So you see this lines of going down, it should be this nice smooth line as you change the energy or the color of the X ray from um one frequency to another. Um Here and here you get this funny threshold and that's the photoelectric effect. So he discovered or he knew about this and theorized that um instead of energy and X ray being like um water, which you can't really divide up or count, you can uh you can use it to fill up a bucket sort of quickly or slowly in a big stream or small stream. But it's the same, it gets full at the same rate, but it's not like that because if you have lots and lots of packets of the energy level down here, the absorption will be very different to the level up here. So the wavelength matters and that's how we discovered quantum mechanics because each photon is like a tiny packet, it's not like water, which can be a big drop, small drops. Um And this is what I think about the sort of two different colors of the two CTS with two energy levels, um, of the X rays, but that's all very complicated. Um You don't need to remember that. Just know we've got the special trick you can use that and a lot of other body systems, it's not just bones, um, it's not just taking away calcium to show the water. Um I think that'd be good things. So, you know, watch out for that in whatever subject of body system you're looking at. Okay. Another case something, a lot more simple. We've got a 17 year old male uh query left north neck of femur fracture. Um So yeah, down here have a look. Uh What do people think? This is another tricky one? Um chose that because it's something I might have missed when I was a student when I was a junior doctor. But now I know a bit better. I wanted to share that with you guys. What do people think? Yeah. Yes. You too. It seems cases as this another on the doctor, I'm just gonna move my mouth around randomly until you describe better where it is. Yeah. Yeah. Like that in the middle, in the middle of the uh uh uh but like, oh this, no, no, no, this Yeah. Yeah. Um No, that's, that is a good spot. Um That's, that would be a funny place to have a break. That would be sort of the strong, uh, top of it. What this is. Um, you've got a ligament which attaches the femoral heads to this, that's called ligamentum terrors. That sort of broad ligament and it carries some blood vessels into and it's just a tiny notch where that comes in. Um, so I don't know why it looks slightly bigger on one side than the other. Maybe it's angle. Um, that is very good that you spotted that, but that's not a fracture that had this bit flatter. Um, that's a very important thing to look out for in maybe pediatrics, um, and avascular necrosis of the femoral head or that's what happens if you miss a fracture and you don't treat it and those blood vessels get disrupted and it's not that, uh, shall I tell you that you've done a really good job at looking at the left hip, um, really good job and that's all normal. Um, but actually there's something else to spot somewhere else. Well, let's, let's go through, um, little by little. What about the right hip? Well, that all looks all right. There's, um, all these lines and everything. Um, you can see these, these are the issue of spines. Um, and they're, it's not a break there just pointing out a bit more, I think because the angle, the x rays taken out, he's sort of bringing his hips forward a bit more. Maybe he's bent at the knees. So it's just, it's just a funny angle, but that's a normal appearance. And up here these are the growth plates and these are the last to sort of close up and that's normal. Um And it, it looks sort of the same on both sides. And then you might want to look here at the sacrum, you could have a spinal fracture, you could have a fracture vertically through sacrum that this joint itself could break. And then as we said earlier, like a broken polar ring, you'd expect a break here and somewhere else may be here but here. Yes, well done. So that's, um, that's what's causing his pain. Um, someone else got that in the, in the chart as well, so well done. Um, this is, you know what it is excellent, really well done. So can you see how you spend a minute looking at the hip? You might because, you know, I told you to, I said queer left neck of femur fracture and that's not a mistake to do that. I told you to look there and then you need to stop and say, well, let me just check everywhere else and that's really hard to do. It's really hard to force yourself. Um One thing is though, if we have a bit more clinical information, um, we know that the sky, which I've now provide you with some pain after pain. Football, there was some tackles, he felt hip pain when he, when he walked halfway home and it would be unusual for a 17 year old to do that unusual for them to break their hip unless they were sort of hit by a car going really fast. Unusual to, to walk on it. Uh, that, that's sort of more the story that you get with someone very elderly with fragile bones. They might break the hip after just a fall from standing height. Um, and they, they might walk on it if it was one of those impacted fractures where, um, they're like, wouldn't be broken and sort of fractures that fragments that fly apart. It's sort of the bone is squashed down. Um, but that story that I've given you now doesn't really fit with, uh, complete break through the neck of femur. So it's a clue to look somewhere else. So, yes, this is an avulsion fracture. This guy has been using his quads a lot to kick the ball and his muscles are very strong. His bones are flexible, not, not weak but flexible and soft and, and that's pulled off a chunk of it. Um, this, this sort of injury doesn't need surgery. They don't really need to be mobilized. They can walk around, they probably shouldn't be playing football. Um, but they don't need an operation. So, uh, another really tricky case. Oh, I'll just put the lines in here. Mhm. Yeah. Yeah. And you can have this, um, uh, sort of anywhere in the body anyway. You've got a, a tendon that the joints to vote. Uh, so they just need painkillers and you say, you know, stop playing football for, um, you know, a month or something. Uh, but they don't, they don't, you don't need to put them in a cast or, or bed rest or anything. Um, you'd think the tendon would sort of fly off and shrivel shrivel up and sort of fall down, but it doesn't, it all sort of stays here and the bone will heal and join it back on and the power sort of gets back to normal pretty much um without any, any need to fix it or, um, you know, you think what if we try to staple this bone back in or put a screw in and fix it because it's a broken bone and, but you don't need to. So, yeah, you can, you can miss things if you, if you start looking at the X ray with sort of the wrong hypothesis. Um These are all the places where the muscles join in around the hip and you can have sort of fragments pulled off from anywhere. Okay. Um See a sponge and I'm going to do this one really quickly uh because it's, it doesn't really fit. We've mostly been talking about hips. Um or Yeah. Okay. So you've got a 27 year old, let's say you're working in A and E he's um falling off his bike cycling. Um, he's G C S, his Glasgow coma scale is 13, so he's not having a normal conversation. Um, he's sort of mumbling and slowing the odd word here and that, but he, even though he's got pain, his ankle pain in his neck and he's unfortunately one of these collars looking quite happy about it and that's stabilizing his neck. So if there is a break, um, it won't sort of let the spine move and stretch the spinal cord because if that happens, you're paralyzed and your spine irreversibly damaged. So, um anytime you suspect this, anytime someone's like knocked out and they've hit their heads, but they can't save my neck hurts because they're knocked out and you really want one of those collars. So here's this X ray we're looking from the side, you can see a bit of teeth and jaw here, you can see the spine, um that sort of overlies. Um the spinal canal here, which you can't see in the middle, you've got two sets of facet joints left and right, uh lying on top of each other on the X ray, got the spinous process on the back. And if you touch the back of your spine, it's these lumps you feel at the back here. Um So, uh this vertebras sort of a landmark for me, it's got this peg at the front, which is twice as high as it should be. And that's C two and C one c one is a, is a ring here which we're seeing sort of end on. But this, um this peg is what used to orient yourself because that's, that's got to be just, just the second vertebra. Um And then if you think 23456, we can't see, see seven, this guy's got his shoulders in the way. Um So we haven't definitely said um with his X ray that he hasn't broken a C spine. Um So this is sort of like taking an X ray of the hip, but you cut off one side, you got off the top of the hip. This just isn't good enough. Um How do you read the spine? X rays? Will you look at these columns here? These lines? Um There's three and they should all sort of be smooth. And if there was a step here, if this green line, the bone was sticking out much further before it would be probably a dislocation and this um stack of bones, one would have slipped out. Um Probably because of a fracture. But what's more important is the ligaments around, it would have been torn to permit that if that had happened and the spine would be unstable, there'd be risk of stretching the spinal cord. Um And that would mean as soon as he took the collar off, his head would fall over and he'd be immediately paralyzed. Um Or maybe it's not quite that serious. But there'll be a risk of something really willful happening. So, do we do a lot of c spine, x rays for people who've had their neck? Have you seen that if you've had an A and E placement? Yeah. Yeah. How good are they spotting, uh, serious injuries do you think? Yeah. Yes. So, they're good at spotting really severe injuries in people who are young with normal spine with, um, without degenerative changes because as you get older, the space between these and the discs sort of shrinks and the edges of the bone become a lot. Um more indistinct, there's sort of bone formation and osteophytes and it all just looks like a mess and then they might be osteoporotic as well. So it's sort of a mess which makes a blurry X ray picture. It doesn't stop as many X rays. So you don't want um playing film for that. You want a CT. Okay. So do, do learn how to make. Uh so do, do learn how to read uh C spine, X rays. And this is just the front view with um all these sort of discs, bones and discs lying on top of each other. You want to check at each point. Um There's like a nice gap you're looking front on at a stack of discs and if one is dislocated, it comes off forward, you sort of see to overlying each other. Um But then as soon as you've learned all about c spine, X rays, forget immediately. Just get a CT. Okay. And there's one other very strange thing here. I want to show you. So this guy, we've asked him to open his mouth, we've taken an X ray through the open mouth and this is that peg I showed you the C two vertebra. We've got the ring of, see one which was seeing sort of front on. So the sides are very thick. They're stopping a lot of X rays, front and back, not so much. Um It's all sort of uh it looks very strange because it's an X ray taking three D structure making it look two D but this peg is very important and you're really looking for like a line that runs through here, which would be that peg flying off, it could pin back and hit the spinal cord. Um Yeah, take care. Uh but good to people think normal abnormal. Not sure. Uh huh Yeah. Yeah. Side to side. Yeah. Um So I think I can see a black line running through here. And what do you guys think? How does it show up on there? Maybe, maybe not. And this line doesn't exist, it's, it's not there on the screen, it's not there in the patient. It does unfortunately exist um on your retina and your so uh normal CT and why did this happen? So the um the problem is your retinas very good at detecting edges and um one group of uh photosensitive cells is inhibiting its neighbors. So you've got to slightly dense structures, white here and greyish white. But between them, your mind is your eyes making up this black line that isn't there. So this is the front of the ring and the back of the ring adding up here and then this will be just the front of the ring. Um So don't worry so much about the anatomy. Don't worry so much about the physiology of your retina. Just know that you can sometimes have these weird optical illusion lines and that show up on x rays and other places. Um It's called the mark effect M A C H. And um it's not one of these like optical illusions, you can fool yourself into seeing and then not seeing because it's happening in your eye and it also catches you out sort of in the chest. We've got the very dense heart and then next to it, um the lungs which are mostly translucent, mostly very dark and you often think you see this black line just next to it between the two. And you think, could that be a room of free air? Could that be pneumomediastinum? But it's not, it's something that your eyes tricking you into seeing. So really tough. Um And yeah, this, this line um always gets me and uh here I guess they've taken maybe they've got a coin and some like paperclip um legs, it overlaps and you can see this black line where the edge of the coin is, but it's not really there. It's just the difference between, um, you've got white here, you've got very bright white where these two overlap and then grayish. So, um whether it's just the, the single thing and there's a good video on youtube if you Google Mark effects because you won't really believe it until you, you see it and there's this um funny video where they sort of block out everything around it and you see there's no line but that's, that's a real um strange pitfall to, to fall down. So, what about his ankle? Um because you, you can't forget that. Uh What do people think for this one? So this is a front own view of the ankles. There's the big bone here, that's the tibia, smaller one, the fibula. This is the tailors. They should form not a ball and socket, but it's like a C shape. Um And a block like a C clamp, which is sometimes called a mortise. And your foot can move up and down like that, that's your ankle joint and only a tiny bit side to side. Um So we're going to do a trick of tracing around the court's sees that's normal, try or normal, um, or normal. So, does that break or not? So, um, you'd be surprised to know that even though there's no break, this ankle is really abnormal. So, the Taylors should say perfectly in the middle. Um So this sort of length here and this length here, the gap on either side around that funny c shape clamp that should be completely equal on both sides. But here it's very wide. So this is called Taylor shift. Um And each time I try and give a lecture, but I always say, oh, it's, it's, it's Taylor Swift. Um but it's not, the Taylors has shifted within that c clamp. So why has that happened? And the ligaments are disrupted? So the fibula tibula should sort of come together and there's a little notch here, which is why this bit of the bone is more dark, stopping less X rays because there's a notch there which the figure should sit in. So this part should be snug in there, but it's not, it's flown out. Um So the ankle ligaments have been all snapped. This clamp has flown apart and the top marks. Why has this happened? Yeah. Mhm. Yeah. Yeah. Well done. So it's, um, you wouldn't really get this if you jumped out of a window and landed on your foot. It's, it's sort of twisting and snapping that breaks the ligaments. You're right. And, but you remember what we said earlier about this, having a ring and you can't break it in just one place. And that's sort of true for the leg as well. You've got these two bones which are parallel a very long ring like this but very similar. And this is an X ray of the knee. So he has to have a fracture high up through the fibula and this is a side on X ray. So femoral condyles up here to be here just behind it, the fibula. So it's a break here through the ring here through the ring with the ligaments, um two breaks in a complete ring and this is called a mason of injury for whatever reason. Um Orthopods love to ask you this in theater. So even though that sounds like a completely random thing to happen of your ankle ligaments snapping in the X ray looking okay unless you know what you're looking out for and then they're being a fracture higher up that you need to be really smart to say we should do another X ray of this random bit where the patient has no pain. Um It happens a bit and they just love to ask you about that on M C Q s. So um it probably doesn't happen super often in real life, but it's a good one to, to know for sort of top marks. Um This is what a normal ankle, ankle X ray will look like. And if you sort of look at the distance between here and here, here and here on the inside of that c clamp that's abnormal. Uh Sorry, that's, that's normal because these are equal. And then if you look at this huge gap and compared to this side abnormal. So what, what would they do? Well, they need to fix this, there's not really a bone that's broken around here. So they um drill through the ankle from one side, they put um sort of this plastic or elastic uh so elastic rubber band through with metal buttons on either side and that would hold the ankle together, make that c shaped clamp normal. Again. Um This uh these screws here, forget those there for something else, but these are like rebuilding the ligaments. So if you look at x rays, you just think about the bones. But because you've done anatomy because you've, you know, been to surgery and you've, you looked at um people, their legs cut out than having surgery. You know, there's a lot more soft tissue and actually, that's much more important than if there was a break. If there's a tiny chip off here that, that wouldn't matter. It's the ligaments that cause the stability. Um You can do the same thing in the forearm. Most of the fractures will be of your distal radius and that can be just a single break in one bone, but that's sort of the edge of the ring. That's the corner being chipped off the parliament. But if you have a break here, you might expect um two breaks in the ring. That's not always true because your arm has a lot more flexibility because obviously you can turn your arm I/O. You can't really do that with your ankle. That's more of a closed ring. But you kind of have a similar thing. So this is a bad elbow fracture. I can tell you here, this is the radiohead, but instead of being nice and smooth, there's a break here. You can sort of see here that's all smashed to bits and down at the wrist, there's a big gap between the radius and owner. These two bones should be touching because they're a joint where one bone sort of spins around the other, but they've flown apart and that's just like what's happened in the ankle. Yeah. Um, another thing that always catches me out is positioning. Um If you take an X ray and then you move someone's arm, take an X ray again, it will look completely different. So there's this huge textbook that the radiographers will learn of always take your shoulder x rays with the arm. Exactly like this. Exactly in this position. Exactly in that position. Um We don't really tend to study that even in radiology. And yet we expect textbook x rays from people who hurt their shoulder there in a sleighing. Oh, they can't move their arm all around. Um I think if you know, this is my million dollar idea and I think if you have like a camera on the X ray camera that just took a normal picture, so you could see at the same time, what position that arm was in? You just, you'd never have this problem. Um Some of the radiographers who report the X ray immediately after they take it, they won't be full by this. But we will because we, you know, we see the patient in A and E they go away to an X ray, they come back and you, you don't know what happens in the middle. Um So this is a normal shoulder X ray here. This one is very abnormal. I'll tell you that for free. Does anyone know why or what we call this? So there's no break. But the normal sort of shape of the shoulder has been twisted around and it's not lying quite where it should in the um glenoid fossa, which is the socket of the ball and socket. So the, this bit kind of behind that should be flush and overlapping here, but it's not. So does anyone knows it's ringing about nowhere because it's a really a really rare thing to see and tricky spot, but this shoulder's dislocated and it's actually a posterior dislocation, the shoulders sort of spun around. So it's not sort of stabilized normally. So it should be like this, it's come behind and then spun around and sometimes we call this the lightbulb sign. That's what it's meant to look like. But it's a bit more symmetrical than this, which has a greater tuberosity, lesser tuberosity. But if you get someone and they put their arm just like this, it's not dislocated. Um The X ray will look incredibly similar. It will look, well, look like this. Well, maybe it's halfway in between the two. But if you, if you see this, you'll say, oh, I'm not sure. Is the desiccators not, did it pop out of joint? And then I'm seeing them an hour later and it's popped back into joint, don't know. Um Just, there's no real way to get around this. Um Just be aware that positioning can really trip you up and maybe it's the same in the ankle as well. If you take an ankle, X ray and that um C shaped clamp in the tailor isn't completely facing the camera. It's turned a bit, there'll be a big gap on one side which can look a bit like um, that X ray we saw with Taylor shift. Um I'm coming up for seven o'clock, I'm gonna skip growth plates. Um This is just how your bones look like when you grow up. You've got at the start. Very little bone here. You think the femoral heads missing, it's fallen off, where could it be? Um It's still there. It's cartilage, it's not turned into bone, it's not got the calcium in it. It's not stopping the X rays. It is there. You've got the growth blades and that graduate closes up. Um There's a great website called bone X ray dot com which has all these x rays of all the different ages normal, definitely have a look at that. Um Don't memorize each one of them but just be aware that sort of things change to grow up. Okay. So five more minutes. Um this is a clinical case. This has very little to do with orthopedics and x rays fractures somehow, but it's probably the most important thing I'll say. And I know most of you aren't gonna be radiologists or orthopods or whatever. Um But this, this is uh the clinical pull at the end. So, imagine you're the general surgery. Shh. Cool. You're seeing Doreen, 75 years old. Um She's not very active, keeps out of hospital. Past medical history includes COPD and hypertension. Um She presents with central abdominal pain, vomiting, constipation. Um Why are we, why are we talking about this? What, what does this have to do with, with fractures? Um, pain started one month ago and she's been taking lots of codeine and actually the pain was sort of in her back earlier and she didn't, she wasn't vomiting then, but that's why she's turned up. Now. Um her inflammatory markers are normal as her liver enzymes and amylase. Um her stomach is a bit tender but not parity, knittig. And you do pr and um her rectum is loaded with hard stool. So, uh what, what would you do at this point? What other tests would you like? Um, why am I bringing up this completely unrelated case. What do people think, um, type in the chat if you're, if you're watching online as well? Mhm. Um, yeah, that's, that's a good first test. Um, that people like to do in the, it's, it's a bit old fashioned, I think. Um, some people would say that doesn't really show you anything and if you weren't too worried about having a proper look at the, uh, guts and insides, you know why you're doing a test to look at them if you don't really want a sensitive test. Um But if you do want a proper look, just do a CT. But yes, some people would get an abdominal X ray and it can be quite reassuring as well. Um So they did, you know, in this case, I've made up, they got a CT, maybe you don't need to, but let's read it together. Um Normal stomach and small bowel marked fecal distention of the large bowel and rectum. Is that what you guys were expecting? Was that a history that shouted constipation to you with? Um You can have a bit of vomiting when everything sort of backs up. Um Unremarkable hints of liver, pancreas, kidney spleen. It's great. Yeah. And then uh here's a bit of a surprise vertebral wedge fractures, um acute T 11 fracture, old L1 and L D fractures. So, okay. So we've got this patient's constipated. Um They don't have appendicitis. They don't have anything terribly wrong. With the tummy. But what, what do we do about this other thing? Um What, what would, what would you do? Mhm. Thank you. Okay. Um Yes, you do that when someone's spine is completely smashed to bits and you're worried has the spinal cord been torn or stretched or something? Um Yeah, that's a good, good thought. Um, with, with this patient. Uh, what I'll show you and what wedge fracture means is a little different. It's someone whose bones are very weak and crumbly and just the weight of standing up has caused them to gradually go from a block to a wedge. Um And with that pattern, it's rare to have the spinal cord uh damaged at all because it's not, it's not like they've fallen down a flight of stairs or something. But yes, that's a good point when you hear spinal fractures. So definitely important to bear in mind. Um Anyone else, the pressure is coming with some things, a terrific site and then, and also with you to see that. What is that? Yeah. Excellent. Ok. Well done. So. Um, yeah, for whatever reason, um, most people wouldn't have given that answer they think about, you know, is the spine broken. Do we need to refer to orthopedics to put some screws and plates in? Um, but if it's not that then it doesn't matter. Right? And, but it does matter. So, um, if we think about the history again, patient's got COPD, they might be taking a lot of steroids there, pain, um, started just taking the chance. Um Someone said vertebroplasty, we'll discuss that. That is definitely an option. Um The pain started one month ago and as I said, it was in the back, you know, a while ago that started her taking codeine, which might have been what made her constipated. Um, but it was the vertebral fractures which started now, that pain can be really hard for patient's to describe. I've had plenty of CTS where it's been pain radiating from the stomach to the back. Um Could this be pancreatitis? Could this be uh dissection? Um And we do the scan and it's, it's just just these vertebral fractures um had one case which was query pulmonary embolus, sharp pain in, in the chest with some inspiration, but it was this instead. Um So the, the good news is you don't need to know operation to fix these. Um Even better news is it's an important opportunity to protect and improve your patient's health. So, here's what I'm talking about. So this is a CT slice. It's um as if you're looking side on. So you've taken a slice through the middle of the body like this. Um The patient's uh Tommy will be in front here, the back will be back here. These are the vertebral bodies which look like blocks, but they've got sort of the um left and right sides in front of the screen behind the screen with the spinal canal in the middle here, this will be where the spinal cord is and you can't really say much about it on CT cause it's in the middle of bone and the x rays don't really get through so well, but it's the front of these, the vertebral bodies that we're interested in. And if you look at the heights, these are nice, nice, nice building blocks. This one squashed down and the bones gotten a bit more dense. It's got these funny gaps in it. This one as well a little. Um And these are the wedge fractures I was talking about. So if it was something that was going to damage the spinal cord, if this patient been hit by a truck, you'd see a huge uh fracture, huge crack like going all the way across. It's just the front of this which has started to crumble a bit. Um Yes, you can treat these with the tib rapacity and operation where you um stick uh cement in to sort of fix this fracture where you can blow it up first with a balloon to puff it back up to height and then put the cement in. Um that works a bit, not as well as it as it should or as we hope. Um it's really only the acute fractures which would benefit from this. Um So these are very painful, but the most important thing is what you do after this so that this patient can go home. You treat the constipation, they feel loads better. Um, maybe you cool the, with boards and they yell at you because, I mean, um, but they're just, they're just unhappy. They don't get to operate on this. So it's not personal. Um, but what do you need to do? Uh, you need to, um, protect the health, protect the bone health. Yes. What were you gonna say? And that's funny. Excellent. Yeah. To the laptop. No. Yeah. So that's um that's a really good question. Um My, my personal thought is no to the Dexa when someone has a fracture like this, you know, their bones are weak. Um If we look at these pictures to the um this, this just looks a lot fainter than it should. So I can already say um it's, it's osteoporosis. You're right about Dexa something. Um You do before this sort of thing happens. If your G P you've got this patient taking steroids all the time, you think I'll assess the risk? I'll do this nice um X ray test. Actually, it's the same as that funny. CT I showed you with the green blue line that's dual energy. CT Dexa is dual energy X ray. Um And it's sort of the opposite thing because on that CT we're looking at the water, we're taking away the bones, look at the water on the decks that you take away everything else. You just look at the calcium because you might have someone who's got a lot of muscle and fat and they're stopping a lot of x rays, but that's not due to the bones. It's just sort of everything you take away the everything else you say. Okay, just show me the calcium. Um, so that's Dexa, so, um, yeah, some people love to do that for everyone for some reason. But, um, in my opinion, probably not. But if you ask 10 people you might get, you might sort of split the room. Um, have you had a case like this? Where or what, what made you ask that? What, what made you ask that, I guess because I'm kind of reading that, uh, giving effect this gang that doesn't necessarily a lot of the time people find out they have possibly just have a fracture. So that's kind of, yeah, exactly. It's sort of telling you what you already know and you don't need a fancy test for that. Um, so, yeah, I hope that answers your question. But well done that you've heard about it and you thought about it because most, most people don't and they just, um, they see someone in a and E on the wards and they think you're going to drop dead. No. Well, then go home and they forget this sort of crucial, crucial staff so well done. Um, yes, you have a question. Yeah. What, before they get that? Yeah. Um, no. So, if someone comes in with fractures like this, you can start treatment when you can, you can offer it to them. Um There's lots of different things, bisphosphonates is probably the first thing to try. Then there's some other fancy things based on hormones that build your bones up. Um, the risk score ing and the Dexa scans, that's for sort of the before the fracture part. Um, so you, you, uh, there's a, there's a few things that it adds up age, um family history of fracture, diabetes, things like that. Um Oddly enough, there's another huge class, there's many other drugs which also increase your risk of fracture and your, make you osteoporotic for some reason, steroids gets all the blame. Um But basically, uh S S R I's and anything that gives you hyponatremia, um and a lot of anti epileptics uh can also do this, but they don't make it onto scoring systems. No one would sort of probably teach you about that before I'm guessing. But long term S S R I's um not great for your bones. Uh So to answer your question, um Do you do for Axiron Dexa in someone who's at risk but doesn't have a fracture yet? Yes, that's the perfect time to do it because that will tell you you might have a nice surprise. Oh, the bones are, are normal density um Or it might confirm what you suspect and give you the evidence to treat with this phosphinates. Um, it can be quite a hard sell to the patient. This, um, tablets not very nice. You take it once a week, which is hard to remember. It can give you a softener itis, it can really burn your, your esophagus and it can do some funny things to bone. It can make them incredibly strong but sort of brittle like a crystal in a way. You can have fractures when you wouldn't otherwise. Um The other thing is no one's really studied. The long term effect of viscosity is for years and years and years. So what people do, what they've guessed they should do is give it for about five years and then see if they can stop. And the best way to do that is if you have a before and after Dexa scan. So if you do one now and give this patient five years, then you can say, oh, we can stop because their numbers have gone from weak bones, too strong bones. Um But if you don't have the before, you're sort of guessing a bit about that, it's, it's a bit of a mysterious thing that's sort of a long term bisphosphonate treatment. And, but you've all done really well because you've heard of Frax Score ing and um you definitely, it seems like that would definitely enter into your clinical work, which is great. Um It's not just the tablets though. Um, you want to stop them falling exercise might be just as good as best phosphonates in preventing the morbidity and mortality from fractures. Um It will, you know, not just make the bone stronger but improve people's balance and muscles and recovery time if they, if they do break the hip, I need an operation. Um But then yeah, this phosphinates is the, is a central bit and um it's a bit like um how a transient ischemic attack T I A can proceed a stroke and be a scary sort of warning sign that something bad is about to happen and then you need to manage the risk. But like for hip fracture, uh and um 50% of people with hip fracture, uh elderly will be dead in six months, which is, um, you know, a lot worse than many, many cancers. The reason for that isn't sort of some crucial structure goes through your hip and that sort of keeps your, your heart and lungs going. And is that these patient's are frail to begin with and then the shock of surgery, if they have surgery, the effects on the body of bed rest, if they have six weeks of bed rest and that, that really takes its toll. So I think that's a lot worse than a stroke. Um And I think uh I think fragility fractures, writable fractures should be treated in the same way. Um It's, it's not just these wedge fractures. It's if you slip and fall, just walking and break your wrist and it's a low energy um impact that's a fragility fracture. That could be worth to think about bone health and vitamin D and bisphosphonates. Um And in some hospitals they've got a uh fracture liaison service. Um not, not an orthopod who fixes fractures, not um a and the radiology who, who sees it and spots it. Um Someone else who sort of phones these patient's um a few weeks later and says, oh, you know how they just put your arm in a cast and told you to sit around and let it heal. Well, actually, we need to do some proper medicine. Um And I don't think we have that yet in leeds. Um It's Sheffield who the people who invented the Frax score were most on it. Um But that is one of the things that's really gonna save lives and um keep people, you know, at the mobility and active and that's probably much more important than um doing nice operations and fixing fractures that's preventing them. That really matters. So that's why I put that point. Um Last of my talk, it seems like you already know quite a bit about this phosphinates uh and everything anyway. Um And, and that's it. Does anyone have any questions? I just the name of the protection that you mentioned. Um The okay. That's true. So that's, that's called mason of fracture. Um That every single possible fracture pattern you can think of has already been named and described. So you can't, you can't, can't learn the more. Um You also can't probably have one named after yourself because they've all been taken M A I S S O N E U V E. But it's, it's more the principle of having the strong ring that's broken in one place, must be broken in another. Actually, the liver and then step up from the polar going to them now. Um So the obviously, no, no structure is like a perfect ring. So you can have um broken wrist, very common, just the distal radius, probably the most common fracture in the elderly. And, and that's, that's obviously not within sort of the central part of the ring. Um So it's uh it's not, it's not all the time you'd expect that to happen. The, so part of that is the shape of the bones because that, that bit is like a one that points off the main part of the ring as it were. Um And then the extra flexibility in your wrist joint and at your elbow also sort of has a bit more give. Um but you can have a fracture through the mid radius and the dislocation of the owner of the elbow. And there's a few funny names for fracture patterns like that, but you might come across or read up a balance. Yeah, because uh mhm common uh negatively tasted. Um Yeah, it's a bit more rare. Expect it more with sort of high energy stuff. Um, someone jumping and falling several stories, um, someone who's driving their knees up on the dashboard and there's sort of a huge force that comes back. Um, the thing is going to tend to break in sort of simple ways first and there's some patterns that happen under so medium force and so much happened on the high force, um, pubic remi fractures tend to be low force and I sort of think of them as like crumple zones like in your car to absorb the uh the force. Um It's people say this, this can't be 100% true, but people say from sort of low or medium force injuries like a full from standing height, um It would be unlikely to have both pubic ramus and so from a fracture. So if you see the people grimace fracture, you might want to stop looking for the neck of femur fracture. You might not need that CT MRI. But can that be 100% true? 100% of the time? Probably not. But it is a good rule of thumb that you've got these sort of some, some parts will break first and protect the other parts. So if you think about it, like there's a level, people grab my first neck, a fema and then the ass to be in like on the top highest level of force, okay. Just see if there's anything in the chart. Okay. So um I just wanted to put some resources up for you guys to look at, um, if you want to look at loads of x rays, there's some websites um here, uh some apps Ortho bulletin Ortho flow which tell you more about the management of fractures. Um What to do if you're on call and, you know, you just put it in a cast. Can they go home? Um That's, you sort of have to learn it for each one. There's no like general principles, um physiology. It's all about the mechanics of the bones and joints. Um If you want to pay for an X ray course, I recommend red dot In London. The people who teach this also made this book, which is probably the best simplest radiology book of normal things that you'll see in A and E. Um And then I A junior is a group of doctors and med students who um do some education and um other events in person online. Um Kind of like this kind of a bit more interventional to, as the name suggests. Um Here's my email if you want to get in touch, if you have any more questions or you want to get more involved in the radiology department. At least I can point in the right way. All right. So, thanks everyone for attending. We'll close the event now.