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Today, I'll be talk to you um some M S K X rays um that might come up in your upcoming Oscars. I hope you guys will find it helpful. Um Okay, so um in terms of objectives, what I really want to you guys to get out of is to have a general approach to um presenting M S K X rays. I want you guys to have an exposure of some common cases in um M S K X rays in your rosky stations uh in some phrases and term descriptive terms that you can use to describe your findings. Get a flavor of uh some questions that might come up um related to these M S K X rays. Um And so these are the main things that we like to cover, so to start off like anything else and like presenting any E C G or chest X rays, um make sure you do your patient demographics. So your patient name, um date of birth, hospital numbers, those are easy marks. So just get them out of the way. Um when is this X ray taken? And then the view as well, especially in MSK A So any whether this film is an AP film or a lateral film, so kind of looking on the sideways. So and then next, you can talk about which part of the body is being imaged and which side is it? So is it the right or is it the left? So this is quite important. So make sure you always mention whether it's the right knee or the left knee or the right shoulder. Um And then lastly, you could also mention the quality of the film. So whether you can see the joint above or below, um is the patient rotated on this film or whether this film has enough penetration? So is it, can you see everything that you needed to see? Okay. And in terms of interpretative you're finding, so I find sticking to a structure very useful. So this is what I'll recommend for describing um M S K X rays. So A B C S so A is for alignment. So mainly you're looking at any dislocation or subluxation of the joint being imaged. So um subluxation, meaning a partial dislocation, um B is for bones. So you make sure to trace each and every single bone that you can see in the X ray and trace the cortex. Is is there any break in it, if it's a break or if there's a loose in line, think about any fractures there and then see it's for cartilage. So look at the joint spaces is there any narrowing? Does the cartilage space itself looks abnormal? You can comment on that and then as is for soft tissue. So any swelling of the soft tissue. So any swelling of that soft tissue should point to any kind of underlying bone injuries or underlying cartilage or uh soft tissue injury, uh tendon injury as well. Um Any foreign bodies that you can see any disruption of the soft tissue. So whether um the bone has breached the soft tissue, which then you will think whether this is open or close fracture, um or any calcifications that you can see within the soft tissue. And in terms of arranging this A B C N S I would normally go for the first most obvious finding. So if you can see a fracture, then I would first describe the bone findings first and then you can go through the rest of the um parts of the X ray using the eight S D N S for example. So just very briefly alignment that we've talked about this location and subluxation, you can also use the alignment to guide how to describe the fracture. So when you're talking about the fracture, you need to mention whether it's displaced and how it is displaced. And when we're talking about displacement, we're always referring to the fragment that is distal to the site of the fracture. So there's sometimes that can use. So whether this uh fracture is dorsally angulated. So if you think anatomically dorsal is to the back. So whether that fragment is pointing towards the back, so that will be Dorsey angulated or towards the front and that will be eventually or palmer angulations. Um translation is also mentioned in some of our ski resources, but I don't really use it in real life. So I think that is quite a minor point. Um bones, as I've mentioned, always very important to trace the quarters is don't miss any bones, especially in hand x rays. Um where you have multiple um challenge is that you have um just make sure you trace each and everyone. Um So basically, when you trace the bone, make sure you tell your examiner, where is this? Um whether it is within the joint or outside the joint, so, extra intra-articular um whether the breach in the cortex is complete. So that will be a complete fracture or incomplete, which will make it an incomplete fracture, which I will talk about a bit more later on. Um whether it's open or closed fracture and then you can confirm it with any breaching of the soft tissue displacement. We've just mentioned um shortening, which is whether um this fracture has caused a shortening of a limp. So if you could compare them, um that's great. You can mention that and you can also mentioned the bone texture. Um But to be honest, this is quite a minor point. And I think um if you can do any uh mention the other things you'll be fine for your skis, uh see what cartilage. So always look at the joints basis. So the main thing that will usually come up as narrowing of the joint spaces, especially in arthritis in different source of arthritis. So make sure to look at them and see what's causing the uh joint space narrowing. So it could be osteophytes in it and look inside the joints basis as well. Normally, it should be clear. But if you can see some calcification, then it might lead you to think to a certain diagnosis which will come onto as well later on and soft tissue. So as I've mentioned, localized soft swelling is a good sign too um for any underlying bone injury or ligamentous injury. So mentioned that and you joint effusions, fat pats um are basically parts of fat in the joint and sometimes when you have fractures, you have effusion. So these fat pats will become enlarged and raised. So uh this is one of the things that you can mention as well. Um foreign bodies, whether you can see anything embedded that shouldn't be there and anything else. So in terms of anything else, um it's mainly for things that you don't really expect to see in an M S K X ray. So for example, on a shoulder X ray, you might get a bit of a long apex um included into that shoulder X ray. So just make sure you have a quick glance and um that's nothing abnormal in that lung, okay. And to finish, just make sure you check other views available. So, uh already done. So, and you can always conclude your examination and presenting with um thing that you will follow up, follow it up with a history and examination of the patient. Okay. So enough, uh so now we'll talk about pediatric incomplete fractures. So these are just kind of extra stuff. So we've talked about complete and incomplete fractures and incomplete fracture is mainly concerned. Uh the pediatric patient's because the bones are softer and more malleable. So the configuration of fractures can look different. So on the left there, you can see a buckle fracture. So basically because of actual force, uh the bone is buckling on to yourself and you can see two bulges on either side of the bone. So that's a buckle fracture and you can't actually see a very loose in line that just goes straight through and on the right, you can see a Greenstick fracture, which is just a breach of the quarters, is on one side but not through the bone completely. So that is a greenstick fracture. And on the topic of pediatric fractures, just make sure that you're aware of the Salter Harris classification. So these are to describe fractures involving the growth plate or the Fyssas of pediatric patient's. Um there's a very useful Pneumonic code slipped. So, uh slipped above lower through a ruined. So just to describe the different kind of configuration of um these uh salty Harris um fracture. So I'm not gonna go into that, but that's something that you need to be aware of. So I've got some cases and some SBA questions and we can go through some cases and put everything together. So this is a left knee A P X ray. So I'll give everyone a few seconds to have a look and have a think of what you can see and what diagnosis do you think it is? Okay. So I know it's not a lot of time, but you can just go through this together now, okay. So first of all, you mention your patient demographics and then on the lateral side, you will know that it's lateral because you can see the fibula and the fibula is a smaller bone and it's always on the side laterally. So in that joint space, that uh to be a joint space, you can see some narrowing and yeah, I hope everyone can see it with that green circle. And also the with the red arrows is pointing to some osteophyte formation, mainly in the media of femur and the lateral tibia. And then there's also some subchondral sclerosis as well off the tibia. So can you see on the tibia? It's a bit more dense, it's more white. So that is subchondral sclerosis, there's no fracture that could see there's no misalignment of the joint and the soft tissue looks grossly normal. So these are actually very typical findings of osteoarthritis. So basically, this is an osteoarthritis of the left knee and to complete, I will also review other views of this knee and also complete this with a history and exam of the patient. Okay. And moving on, we're going to look at some hand x rays and these are some of the high yield things that like that will comment often in final exams. So is this osteoarthritis, rheumatoid or sorry attic? So just a few moments. So actually this is an osteoarthritis picture. So first of all, um you can look at the distribution of the joints affected. So if I can convince you the distal interval and your joints, so the most outwards finger joints, you can see some quite significant joint space narrowing there and osteophyte formation and also at the thumb base, you can also see the same findings there and the MCP joints are quite preserved, actually, they look quite normal. And so this is actually quite typical findings of osteoarthritis and we can look, we will look at some other different arthritis and you will be able to hopefully appreciate differences. Mhm So this is a different set of x rays. So, apologies. I don't think I can see the chat and control my slice at the same time. So I'm just gonna give, give a few moments for everyone to have a think. So this is actually rheumatoid arthritis. And so what, what, what are we looking at basically? So on the left most image you can see the digits of the hand that they have owner deviation. So this is quite typical finding in the severe rheumatoid arthritis and in the middle picture. So the yellow arrows are pointing to fingers which have a Bhutanese deformity. So you're looking at hyper extension of the P I P J and, and these are, and that is different for um Swan neck deformity, which is the other way around so that there will be hyper extension. Um The red arrow is pointing to the hitchhiker's form also called Z thumb and you will see a hyperextension of the inter phalangeal joint there. So you look like someone is hitchhiking for, for a car and on the most right image, you can see some erosions of the bone on the side. Um And these are quite common in rheumatoid and also sorry attic arthritis. But in this case, with everything else going on, this is most likely to be a rheumatoid arthritis picture. Yeah. And then this one just a few moments for everyone to have a good look. So we've talked about osteoarthritis, rheumatoid arthritis. And so this is actually sorry, attic arthritis. And so what are some kind of common findings? So one of the common findings is called a finger and cup deformity. So on the left image and the fourth finger, you can see that um the metacarpal bone is being eroded and it's quite kind of narrow on the end and it's kind of abutting the next joint, which has looks a bit normal. So it looks like a finger in the cup. So hence it got its name. And on the other one, you can see the same kind of deformity, especially in the second digits on both hands. And you could also see that the subluxation. So it's basically um harshly dislocated fingers. And if I could also convince everyone that both second digits look a bit more swollen, there's more soft tissue swelling. And that is in keeping with dactylitis of the swelling of that whole digit, which you can often see in sorry attic arthritis and on the topic of inflammatory joint disorders. Um this is a picture of gout and just a few moments for everyone to have a look and then we can talk through the findings. So if I could um ask everyone to have a look at the first. And so the great toe and the little toe and look at the meta car metatarsal bone you can see on the head of the metatarsal bones are some erosions. Um These are called just articular erosions and they're quite common in gout. And what you can also see is there is some increased, increased density around that joint as well. And that is basically what Toaff I looks like on an X ray. So and these are quite typical um locations for tofu and gout to happen. However, you can't always base it on the location because gout could happen in other joints as well. But with everything else going on, this is most likely to be gout. And then this is a picture of pseudogout. So this is an X ray of the knee and just to draw your attention to the joint space. So look at where the cartilage should be and normally um you shouldn't be able to see some kind of fluffy white lines there. So actually, actually these are calcium deposits and um this is what you could see on pseudogout and make sure um you know, what are some um common systemic disorders that is associated with pseudo gout, for example, hemochromatosis. So we've covered some of the common pathologies that can involve the joint and just make sure, you know, um and familiarize yourself with these and then moving swiftly on looking at the right shoulder X ray. I'm not gonna spend too long on this because this is just one finding basically. Okay. So hopefully everyone had a look and this is the right shoulder X ray and the ap few and as usual patient demographics and what we're actually seeing here is a light bulb appearance of the right humeral head. Okay. So the the the humeral head is kind of facing you straight on and it looks like a light bulb. Um and this is indicated of a posterior dislocation of the right shoulder and looking at the other joints, especially the A si joints are the acromioclavicular joint just right above it. Um It looks intact, there's no dislocation of that joint and like following all the bone cortices, I could not see any fractures. So you can give the diagnosis of a posterior dislocation of the right shoulder, make sure especially um shoulder dislocation, look at different views to confirm. So a lateral view or wide view is very, very helpful and then finish it off over history and an examination of the patient. So just to kind of in contrast, look at interior shoulder dislocation. So it looks quite different to a posterior shoulder dislocation, isn't it? So in the interior shoulder dislocation, the humiral head is brought kind of inferior early both in the AP view in a, in a lateral view. So on the left, that's an AP view and on the right hand image, that's a lateral view and it doesn't really kind of just go straight into your face. It's not like a light bulb, you can kind of see a little bit more um um kind of sideways of the humeral head if I can convince everyone, but just make sure that in interior shoulder dislocation, the humor head is always inferior. So these are some of the common things that you could see on the shoulder X rays. And then we will look at some upper limb and wrist x rays. So again, a few moments for everyone to have a look. Okay. So hopefully everyone could spot a fracture and I'll go through how you described that. Okay. So this is a left upper arm X ray and you've got both a pa and lateral views, make sure you mention your patient demographics. And in this um to in this set of X ray, basically, you can see a complete extra articular transfer fracture of the left distal radius. So you can see that the fracture is going through completely through this radius. It is outside of the joint and a transfer. So it's a straight across fracture and this is the left radius and make sure you mention that and it's in distal for the distal radius. This is a close fracture because I couldn't see any breaching of the soft tissue. And if you can look at the lateral view of this X ray, um there is palmer angulations, meaning that the hand is actually pointing kind of inwards and there's no significant joy swelling. So putting this all together, that's his a fracture called a Smith fracture or reverse colleagues fracture, which I'm sure a lot of you will have heard about. Um and then we'll and basically finish off completely history and exam and you've looked at both views already. So that's good. And then we've got one question coming up. So again, a few moments for everyone to have a look. Okay. So let's go through the options. So the correct answer, as most of you said, it's a, so we've just gone through the reverse Colleagues Fracture, which is also called the Smith fracture, which you get a distal radial fracture with palmer angulations. But in Colleagues fracture is the opposite, it is dorsal angulated. Okay. So A is the right answer. Uh B for Colleagues fracture, we normally describe it as a uh fracture that is sustained over fall on an outstretched hair. So yeah, that is correct. See dinner for deformity. Exactly. So when your breast is kind of pointing backwards dorsally, then you look, it kind of looks like a fork sideways, isn't it? So C is correct and the it is also correct. So normally elderly people, when they fall on this outstretched hand, they can sustain a colleagues fracture. But Smith fracture is also likely. But um in the sense, in this case, it's correct. Okay. So I was moving on. Well, we'll look at some fracture dislocation um of the upper arm. So just make sure there's not too many fractures with names that you need to know. So the things that the ones that you need to know, I think will be colleagues. MS um as in reverse colleagues and these two and these two fractures are describing fracture dislocation patterns of the radius and the owner. So in Mantei JIA fracture dislocation, you've got a fracture of the proximal owner and at this location of the radio ahead. And in contrast, you've got the gal easy fracture dislocation, which the rate is, is fractured and the owner is being dislocated. Um You could use a simple phrase to help you remember these two. So it's called gruesome murder. So G for Galya Z and our is for a rage of fracture and you is for owner um dislocation. And see similarly for Mantega, you've got Mont Asia for em um owner um fracture for the U and Rs for Radiohead dislocation. So just make sure you kind of remember the look of this and use this phrase to help you remember which is which okay and another important fracture and the rest is a skate void fracture. So hopefully everyone can have, you can see with that white arrow pointing to the scaphoid bone. So one of the carpal bones in the joint and you can see a loosened line goes straight across um the skate Floyd in keeping with a skateboard fracture and just have a think of why this fracture is important and why we need to spot this. And what complication can we get if it's left untreated? This is so basically for scale for fracture if left untreated. Um One of the complications is a vascular necrosis and this is due to the blood supply um supplying to the skate void. So the blood supplies to the skateboard comes distantly. So comes from the finger, the end of your finger tips and kind of come and comes in words. So if there's a cut off the blood supply, usually the proximal end of the scale avoid will have less blood supply and then it will undergo a vascular necrosis of the scaphoid bone. So just make sure that you're aware of this complication. Okay. So we've gone through some um different upper limb kind of pathologies that could come up. And um these are some suggestions for you guys to make sure you get familiarized with. And then we'll have a look at this right hip X ray and again, a few moments for everyone to have a look. Okay. So let's look at how to describe this fracture. So, apologies should say right headaches around the top. So, patient demographic as usual and I'll say there's a displaced commuted oblique fracture involving in involving the intertrochanteric. So it's a intertrochanteric fracture of the right femur and it is an extracapsular fracture. There's no dislocation of the hip joint and the hip joint space is relatively well preserved. So this is a right into trochanter Terek fracture, okay. Um Make sure you look at both views lateral if you've got a lateral view and complete this with a history and examination and then when we can look at why this is an extra capsule of fracture and why this is important. Actually, we can. Oh yeah, I'll just give you more seconds. For everyone to have a look and then we can go through fine. Ok. So most people have answered d so, transcervical fracture is a subtype of extracapsular fracture, which is false. So everyone, most people got it correct. So let's go through the different options. So a inter capsule, it, hip fractures are at risk of a vascular necrosis of the femoral head. That is correct. And this is due to the blood supply to the different parts of the hip joint. So this links into option c actually, because the hip, the femoral head itself is supplied by a branch of the humerus profunda archery. And it's the circumflex arteries that that is supplying the femoral head. And um the head is basically relying on those circumflex arteries to, to get the nutrients and oxygen and everything else. So, if that is disrupted, then you'll get a vascular necrosis of the hip. So a is correct and see therefore, is also correct. Be the garden classification is used to assess risk of osteonecrosis in subcapital hip fracture. So, I'm afraid this is just one of the things that you might need to remember. So Garden classification is indeed used to assess this and a subcapital hip fracture is also uh intra uh particular uh intracapsular fracture, but that leaves a swifty a trans vehicle um fracture is a subtype of extra capital fracture. So, actually, transcervical means through the neck. Um So it is actually um yeah, so yeah, that is false. So this is just a hip x ray of annotations to remind everyone. So which bits of the hip we're talking about? So everyone can see that line, that solid line kind of just saying joint capsule and then at the at the bottom is basil cervical fracture. So everything above it including the line itself is intracapsular. So you need to be aware of the risk of a vascular necrosis if any fracture is above including this line, okay and anything that is below are classed as an extracapsular fracture. And why is important is because that will affect how we manage this hip fracture. And what kind of hip prosthesis that we use? And another fracture that is commonly seen in hip and pelvic x rays are these pubic remi fractures. So on the left hand image, hopefully everyone can see that um on the superior pubic remi ramos and also the inferior pubic ramus, this breach of the cortex and it's broken. And usually because the pubic Ramer is a ring, you will see to fracture points, but it's not one had always 100% of case, but normally they happen kind of simultaneously because of the ring structure. And another thing that too that you need to be aware about is that this these type of fractures um could um cause bladder injury because both fragments could easily puncture the bladder itself. So this is something to look out for. And then we've got some pediatric hips. So is this purpose or SUFI? So just a few moments for everyone to have a think. So this is actually a right SUFI. So slipped up ephemeral. Yep, if Asus. So looking at that right hip joint, hopefully everyone can see that uh the uh the upper femur Aleve femoral epiphysis is not in line with the rest of the hip bone. Uh Compared to compare that to the left hand side where everything is just move and just flows. And that is in keeping with a SUFI and make sure you guys know the kind of different demographics for SUFI and purpose because these are quite, quite common questions that can come up because they might look quite similar on X ray. And then just here, this is a picture of perf eyes of the right hip. As you can see the right from roll head is flattened. Um And this is due to this idiopathic uh vascular necrosis of the right hip joint. And so this is called perfect disease. So we've gone through some different um kind of pelvic and hip pathologies that you might see um in your skis. So I think, make sure you know how to describe your neck of femur fractures, make sure you know which when the fractures involved, which ones are extra or intracapsular, just to be aware of the garden classification and be able to differentiate Perthes and um SUFI. And then I think this is the last um X ray you've got. So this is a left ankle X ray and you've got a P and the lateral view. So a few moments for everyone to have a look, okay. So hopefully everyone should be able to spot the fracture. And man, let's look at how we would describe this. So as usual, your patient demographics and then I will describe this as a commuted oblique fracture of the distal left fibula, which is also known as your lateral malleolus. It is at the level of the Sindh osmosis. So that is a ligament is banned that connects your tibia and the femur um distantly. And there is mild dorsal displacement looking at that like from that lateral um X ray. And hopefully, you can also see at the ankle joint, there's some overlying soft tissue swelling. So this is a left distal fibula fracture and we'll classes as a Weber be fracture, which I will talk about in the next slide and we'll complete this with a history and examination of the patient. So, Webber classification is something that you need to know about when describing ankle fractures. And this is mainly concerning um where the fracture is located um in relation to the Sindh isthmus iss. So if it's uh I've got some questions coming up, so I'll have you guys answered the questions and then we can go through why it's important. So hopefully, everyone has had a read of these options and we'll go through the answers. So the correct answer is a so a uh sorry, the correct answer is see. So, apologies. So, waiver, see it labor, a fractures are above the level of the syndesmosis that is wrong and then let's go through the different options together. So widening of the tibia fibula joint can be seen in waivers, be injury. So that is correct because it's disrupting that syndesmosis from that previous picture you can see. So it will definitely widen um the space between the tibia and fibula and looking back at this picture be will be correct because Weber see fractures are seen above the level of the Sindh osmosis. Hopefully you can see from the diagram, it's above that Cindy asthma sis and then that will make options see wrong because Weber a ankle fractures are below the level of the Sindh osmosis. And then D is correct because that by definition, um waiver classification is used to look at um decide of the treatment of the distal fibula or the lateral malleolus fracture because depending on where the fracture is, it will make the joint unstable or stable. So it's always important for you to mention what level of this fracture is, is. And um whether you think it's a waiver A B or C because if it's an unstable joint, which is uh B or C, then they will need um some fixation. We were a typically as a stable fracture and could be usually managed conservatively. So we've looked at the lateral malleolus, which is the fibula fractures. They're still fibula fracture. Um Sorry, I think there's a mistake here. So distal fibula should be the lateral malleolus. So the brackets is wrong, but basically, we've looked at the fibula. So lateral malleolus fracture and the wave of classification. And then in terms of the foot yourself, um just make sure if you get presented a foot X ray, make sure you just trace every other bone like the hand X ray, so many to look at any metatarsal fractures and the calcaneal fracture. So the the base of your foot, so the biggest bone at the sole of your foot, so that as the calcaneus, just make sure um you know what it looks like. And in summary, my exam tips for you guys is just to use a structured approach. Um so that you cover everything because on an X ray, you've got so many findings and you just need to make sure you present everything and don't miss anything out. Um Don't forget to check your patient demographics, don't just say see your fracture and get so excited that you forget these very simple things that will score you marks. And in terms of keeping a structure, I would advise using A B C S and um presenting your most important findings. So for example, if you could find um a fracture, then you could describe the bone findings first and then go through the alignment of the joint and the cartilage as well. And so, um make sure before your exams look at different films of common pathologies that we've mentioned and make sure you know what a normal joint looks like. Um what these different can pathology will look like and try to practice presenting them with your friends. Um And just make sure you're able to pick up some of the key features, for example, in the three ITIS and be aware of some classification system. So we've talked about Weber just now, we've talked about, briefly, talked about um garden classification. Um I think these are the main to you that you need to know about uh some good resources for you guys to consult. Um uh these so geeky medics radio Pedia has quite good pictures and I've actually taken some of the pictures from Radio Pedia, Radio Masterclass also have some good pictures of normal joints and joints of those common pathologies. So make sure you have a look at both of them. And um there's a website also called Radiology Assistant and they do a pretty good page on ankle fractures and arthritis. So I highly recommend everyone having a look at those as well. So um um that's all of the things that I've got to share with you. So I will try to get to the questions and see and