Conflict of Interest Learner Outcome Objectives
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Conflict of Interest Five shades of gray (Part One); I hereby certify that, to the best of my Basic Radiographic knowledge, no aspect of my current personal or professional situation might interpretation and treatment reasonably be expected to affect for the APN significantly my views on the subject on which I am presenting. Christina M Kurkowski, Nurse Practitioner Learner Outcome Objectives • Describe the basic principles used in ordering As a result of this learning activity, the and interpreting musculoskeletal imaging participant will gain knowledge in the studies in acute musculoskeletal trauma. area of radiographic interpretation and • Describe the differences and similarities interventions and implement between pediatric and adult images. appropriate changes in practice • Identify common fractures and fracture patterns. Tips for requesting films www.acr.org • Consulting radiologist needs info to confirm: • American College of Radiology Appropriateness – Correct study was requested Criteria – Correct patient • Evidence–based guidelines to choose imaging – Meds, allergies, status caveats Relative Radiation Risk for each study – Cost/benefit ratio favors the patient: • • Risk, dose, pain, complication, sometimes $$ • Modality guidelines: CT, MRI, US, NM, PET…. • Will it alter management? If not – NO! • Practice Guidelines: When (in what order) to perform • DNR, religious beliefs, life expectancy….. • Old images available? 1 Suspected occult scaphoid Fx Radiation from Diagnostic Variant 6: Suspected occult scaphoid fracture. Initial radiographs and repeat radiographs after 10-14 days of cast are normal. Continued clinical suspicion Imaging scaphoid fracture. Next procedure. • Average background dose ≈2.4mSv/year • Chest Radiograph ≈0.06mSv – ≈1 week of background radiation • Chest CT ≈7.0mSv – ≈3 YEARS of background radiation How much radiation is too much? ………. Who the heck knows … http://www.xrayrisk.com Wow: practical considerations One view equals no One view equals no view view 2 Five Shades of Gray For Joints – need 3 views Air Fat Soft tissue Bone Metal least opaque to most opaque most lucent to least lucent Black to White Five shades of gray Interpretation – 3 basic steps From Black to White – Gas – black – few • First learn how each modality creates an molecules to stop image of internal body structures beam – Fat – dark gray • Next, be able to accurately label normal – Water – lighter anatomy (body structures) than fat but not as • Then, search for structures that don’t belong white as mineral and has uniform and for body structures that are abnormal in appearance size, shape, position and/or density – Mineral/Metal - white Reading musculoskeletal films Tips for reading radiographs A systematic approach involves checking • Turn off extraneous light • Use magnification – alignment of bone structures, • Adjust contrast – joint spacing, • Use rulers – (ie) the heart is ½ the size of chest – integrity of bone cortex, • Always check the names and dates on the film – medullary bone texture, and • Always compare old vs. new studies when – for abnormalities of any visible surrounding available. soft tissue structures. • Use a systematic approach to looking at films • 2 Views in trauma – at least 3 ABCs APPROACH Adequacy A……Adequacy (Alignment, Joint spacing) All x-rays should have an adequate number B……. Bones (integrity of bone cortex, of views. medullary bone texture) – Minimum of 2 views—AP and lateral C……Cartilage (Joint Anatomy) – 3 views preferred S……Soft Tissues (Fat pad sign on elbow, etc) – Some bones require 4 views Apply ABCs approach to every orthopedic film you evaluate • All x-rays should have adequate penetration Adequacy of Films/Artifacts Adequacy of Films Alignment “A”lignment - Cortical Outline • Alignment: Anatomic relationship between bones on x-ray • Normal x-rays should have normal alignment • Fractures and dislocations may affect the alignment on the x-ray 4 “B”one - Bone texture “B”one - Bone texture “C”artilage - Joint spacing “C”artilage – joint space • On plain films cartilage is not seen, just joint space “S”oft Tissue “S”oft Tissue What do you see in the soft tissue that would affect postoperative wound healing? A. Minimally displaced distal fibula fx B. Tilloux fracture C. Arthrosclerosis D. Foreign body You are correct: “Crispy Vessels” are present 5 “S”oft tissue - lipohemarthrosis “S”oft Tissue Fluid level - Worry “S”oft Tissues – Fat Pad Sign Language of fractures Bone Broke, Mongo • Important for us to Fix describe x-rays in medical terminology. • Improves communication with orthopedic consultants Example - Metatarsals Why are fractures hard? • There are 206 bones! They’re all different! 1st MT: 5th MT: – They have different functions. – Exposed to different mechanical forces. • Fractures Rare • Fractures Very – They each respond differently to stress/trauma. • Common OA Common • Even where fractures occur within a bone 2nd MT: • Base 5th MT affects the treatment, prognosis • Fractures • 1) Avulsion Fx Common 99% Heal Stress (Fatigue) • 2) Jones Fx “March” 50% non-union 6 Language of Fractures Open vs Closed Must describe to a consultant if fracture is open or closed • Things you must describe (clinical and x-ray): Closed fracture – Open vs Closed fracture ◦ Simple fracture – Anatomic location of fracture ◦ No open wounds of skin near fracture • Diaphysis: the shaft of the bone Open fracture • Metaphysis: the widening portion adjacent to the growth ◦ Compound fracture plate ◦ Cutaneous (open wounds) of skin near fracture site. Bone may protrude • Epiphysis: the end of the bone adjacent to the joint from skin – Fracture line ◦ Open fractures are open complete displaced and/or comminuted – Relationship of fracture fragments ◦ Remember – blood under nailbed of a fracture is an open fracture – Neurovascular status Open fracture Tenting Fractures • Orthopedic emergency • Requires emergency orthopedic consultation • Bleeding must be controlled • Management – IV antibiotics – Tetanus prophylaxis – Pain control – Surgery for washout and reduction Fracture lines Incomplete Fracture Lines A. Transverse B. Oblique • Incomplete: the whole C. Spiral cortex isn’t broken D. Comminuted – Bowing: the long bone has a E.There is also an been bent impacted – Buckle (torus): the fracture is fracture where of the concave surface fracture ends – Greenstick: the fracture is on are compressed the convex surface together • Salter-Harris: fracture that involve the growth plate 7 Is it displaced? Alignment/angulation • Angulation-distal fragment in relationship to proximal • Alignment is the relationship in the longitudinal axis fragment of one bone to another – Dorsal/palmar, varus/valgus, radial/ulnar • Angulation is any deviation from normal alignment • Translation-movement of fractured bones away from each other (ie) 25% of the width of the bone • Angulation is described in degrees of angulation of • Rotation – where there has been rotation of the distal fx the distal fragment in relation to the proximal fragment in relation to the proximal portion. Difficult to see fragment —to measure angle draw lines through on x-ray but can be seen on clinical exam. (ie) metacarpal normal axis of bone and fracture fragment fractures Colles Fracture Anatomic Location • Describe the precise anatomic location of the Angulation is the distal fragment in relation fracture to the proximal fragment —to measure • Include if it is left or right sided bone angle draw lines through normal axis of • Include name of bone bone and fracture fragment • Include location: – Proximal…Mid…Distal Transverse fracture of the distal radius 2.5 cm proximal to radiocarpal joint – To aid in this, divide bone into 1/3rd Dorsal displacement and volar angulation about 30 degrees Naming the parts of a long bone Distal Extra vs intra-articular • Intra-articular fractures – Involve articular cartilage – Extend into joints – Risk of developing secondary OA • Extra-articular fractures – Don’t involve joints – Reduction can be relatively anatomic Proximal • Bones will remodel – Particularly with weight bearing 8 Anatomic location Salter-Harris Fractures • All involve the physis Besides location, • If fx doesn’t involve the it is helpful to physis not Salter-Harris describe if the • If the patient is skeletally mature (physis fused) not location of the Salter-Harris fracture and if it • Physis fractures risk of involves the joint premature growth plate fusion space—intra- • Could lead to leg length articular discrepancy INTRA-ARTICULAR FRACTURE OF BASE 1 ST Types I-V As fracture gets worse number goes up METACARPAL Salter Harris (SALTR) Salter-Harris: Type 1 • Physis only • Salter I – Represents 6% of all physeal injuries • Can be quite subtle but is frequently missed and listed as an “ankle – Especially when non-displaced sprain ”! – Comparison with normal contralateral side helps – Often a clinical dx: immobilize for 1-2 weeks and • Salter II – Represents 75% of all physeal injuries recheck for tenderness (1-3% risk premature closure) – Can sometimes see healing on x-ray in 10-14 days • Salter III – Represents 8% (III, IV, and V present greatest risk to premature closure) • Salter IV – Represents 10% • Salter V – Represents 1 % Salter-Harris: Type II Salter-Harris III • Physis + Epiphysis • Physis + Metaphysis • Extends into joint • Doesn’t extend • Potentially more serious into the joint – >2mm articular step-off beds surgery • Most common – CT very helpful to assess alignment type • 1-3% chance of growth plate disturbance so follow for