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 a couple years with serial x-rays
9 Salter-Harris IV Salter-Harris: Type V • Epiphysis + Metaphysis • Crush Injury • Distal Tibia = • Rare “triplane • High rate of fracture” premature fusion • Usually evaluated with CT
Bowing Greenstick • Adult bones are brittle – Tend to break like a dry • Adult bones are stick brittle • Child bones are soft – Tend to break – Can break like a green stick • Child bones are soft – Only through one cortex – They can bend – Incomplete Fx • Bowing (“plastic”) deformation • Typically will remodel with time
Radiographically Occult Fx Torus “Buckle ” Fracture Not detected on Fractures too non-displaced to radiographs see • Common fracture • Places with many • Femoral neck, scaphoid overlapping – CT is not good for these • Metaphyseal region structures fractures secondary to a – Non-displaced on • Cervical Spine radiographs is non- compressive loading • CT is good for these displaced on CT • Cortex “buckles ” fractures – MR is good for these fractures resulting in a stable Fractures with no cortical fracture disruption • Immobilize about 4 • Stress fractures – MR is good for these weeks and follow up fractures
10 Stress Fractures Fatigue Fractures Stress Fractures – Tibia • Abnormal forces on normal bones • Athletes; People who increase activities Common site for Fatigue Fractures in (Military) athletes • Change in habits (Different shoes) • Radiographically may see: • Occur in lower extremities – Nothing • Femur, Tibia, 2nd Metatarsal, Navicular most usual finding Insufficiency Fractures – • Periosteal Reaction • Normal forces on abnormal bones • Trabecular Sclerosis • Osteoporosis; Osteomalacia • Cortical Lucency • OCCUR IN FEMORAL NECK – “Dreaded Black Line” • Occur in Spine; Sacrum
Stress Fracture – Dreaded black Fatigue fracture Mx line Diagnosis primarily by History/Exam • Patient tells of new or repetitive activities • Pain worse with activity; relieved with rest • Focally tender • Get Radiographs • May confirm diagnosis (periosteal reaction) • Make sure not already a complete fracture • May find something else (arthritis, foreign body,...) • Treat (even if radiographs are negative) • Stop/change activity; hard soled shoe • DON’T NEED TO ORDER MRI
Two Common Mechanisms of Injury Fall on outstretched hand • Fractures we see every day (FOOSH) Colles fracture – Understand injury mechanisms • Hyperextensive forces: Radius – Recognize fracture patterns • First described by Abraham Colles (1773-1843) in 1814 • Transverse fracture • Distal radial metaphysis Hyperextensive forces: Dorsal angulation and/or Dorsal
FOOSH – fall on displacement entire distal Twisted radial articular surface. Ankle outstretched hand
11 Fall on Outstretched hand Hand Bones Some Lover’s Perhaps THE most common injury Try Positions • Humans are a clumsy This That They species mechanism of Can’t Handle Walk upright injury is Top heavy perhaps Scaphoid When falling, instinctively UNIQUE to Lunate protect head humans... Triquetrum • Stick out our arm Pisiform Strike the ground with Trapezium our palm Trapezoid Capitate Hamate
Radiography: Proper Positioning Wrist Analysis PA view and Lateral View • Radiography: Proper positioning • Joint spaces: Look for parallelism • Carpal arches: Disruption indicates fx or ligament tear • Shape: Lunate and Scaphoid Extensor carpi ulnaris groove Only on a good positioned lateral (yellow arrow) seen radial to view one can see the volar edges the mid portion of the ulnar of respectively scaphoid, pisiform styloid. and capitate separately and lined up as shown.
Joint Spaces: Look for parallelism Carpal Arcs Three carpal arcs: smooth curves joining the surfaces of the carpal bones as shown on the left. The first arc is a smooth curve outlining the proximal convexities of the scaphoid, Study the carpal bones as pieces of a jigsaw puzzle lunate and triquetrum. LEFT: Schematic representation of the wrist with the outlines tracing the The second arc traces the distal outer margins of the bones concave surfaces of the same RIGHT: Schematic representation of the wrist with the lines tracing the carpal bones, and the third arc follows bones as pieces of a jigsaw puzzle the main proximal curvatures of the capitate and hamate.
12 Scaphoid shape Scaphoid Shape
LEFT: PA radiograph of the wrist in radial LEFT: Lateral radiograph of the deviation showing wrist in extension showing scaphoid elongation foreshortening of the scaphoid: signet ring sign RIGHT: PA radiograph of the RIGHT: Schematic wrist in ulnar deviation representation of the showing elongation of the wrist in flexion showing scaphoid tilting of the scaphoid towards the palm
Scaphoid Fracture Scaphoid • Most common fractured carpal • Rarely occurs in pediatric patients • Occurs during extreme dorsiflexion (FOOSH) or extreme ulnar deviation • If this fracture is missed, necrosis of the proximal pole may occur due to disruption of blood supply
Non-op Tx disadvantages Scaphoid pathoanatomy • Nonunion rate 5-55% • Blood supplied from distal pole • Delayed union • In children, 87% involve distal pole • Malunion • In adults, 80% involve “ ” waist • cast disease - joint stiffness • Treatment depends on Prolonged immobilization- sometimes >12 location of fracture • weeks • Loss of time from employment and avocations
13 Scaphoid fx referral Wrist
• Angulated or displaced (1mm) • Non-union or AVN • Proximal fractures • Late presentation • Early return to play desired
16 y.o. fx dislocation Wrist
Radial tilt - The normal volar tilt averages 11 degrees and has a range of 2-20 degrees
Forearm fracture
14 Nightstick – Isolated Ulnar Fracture Both Bone Forearm Fracture
Common Fracture – Children 75% are distal 1/3 Heal, remodel <10yo, <25 angulation OK – >10yo, >10 unlikely to correct • Adult – Most require ORIF
Adult Both Bone Forearm Monteggia Fracture Fracture • Fracture proximal 1⁄3 ulna + dislocation radial head relative to capitellum • Not uncommon • Important not to miss the radial head dislocation! • Example of why understanding injury mechanisms helps to detect fracture patterns
If you see isolated ulna fx... you need to look for the radial head dislocation!
Make sure radial head points Elbow needs AP, Lateral & to capitellum Radial Head Views
15 Fat Pads are NOT easy to see Radial Head Fractures
How do we detect a Radial Head fx if it is non- displaced? • 61%: Non-displaced Radial Head fractures • Key = Fat pads are your friends
Elevated Anterior Fat Pad • Sticks out like a spinnaker sail • “Sail Sign” • Not thin, flat, flush to the bone
Occult Radial Head Fracture Occult Radial Head Fracture
16 Radial head fracture Radial head fracture
Elbow Dislocation Fat Pads are your FRIEND
• In the setting of acute trauma, the blood came from an intra articular fracture • If the patient is an adult (skeletally mature), it’s telling you there’s a radial head fracture... even if you can’t see the fracture • REMEMBER - 61%: Radial Head fractures non-displaced • If the patient is a child (skeletally immature) DISTAL HUMERUS FRACTURE (81%)
Twisted Ankle Ottawa ankle rules • X-rays are only required if there is bony pain in the malleolar or midfoot area, and any one of the following: – Bone tenderness along the distal 6 cm of the posterior edge of the tibia or tip of the medial malleolus – Bone tenderness along the distal 6 cm of the posterior edge of the fibula or tip of the lateral malleolus – Bone tenderness at the base of the fifth metatarsal – Bone tenderness at the navicular bone – An inability to bear weight both immediately and in clinical follow-up for four steps • Certain groups are excluded, in particular children under 18, pregnant women, and those with diminished ability to understand
17 Ankle Anatomy
Ankle Weber A Distal Fibula Fracture
Greater than 3 mm displacement
18 Weber B Weber C
Weber C - unstable Weber C can be tricky - Maisonneuve
• Require internal fixation • Screws across the MM avulsion Weber C fx Don’t see a lateral • Plate across the fibula oblique fracture... fx Look higher up • Syndesmotic screw or tight rope
Weber C Okay for syndesmotic screw to break
19 Ankle - Summary Hand X-rays
Indications for Hand x- rays • Trauma – Falls (wrist) • Soft tissues • Bites… Infection – Humans (punches) • Ankle mortise width – Animals • Base of the 5 th metatarsal – Cats (Tooth chip) – Dogs • Cortices
Maisonneuve, If don’t see lateral fx look up
Boxer’s fracture
Not medial/lateral... Which finger is the 1 st radial/ulnar instead finger?
20 Finger numbering = Finger Numbering = Confusion!! Confusion !!
Hands need 3 views Fan the fingers in lateral View
Oblique view shows Finger X-rays metacarpals
If interested in only one finger, should order radiographs of just that finger. • Cost less than hand • Bend other fingers out of the way • Center x-ray beam over that finger
21 Metacarpal fractures Metacarpal fractures
Up to 40 degrees of angulation is • Present with edema over the dorsum of th • acceptable for 5 metacarpal fractures the hand • Up to 15 degrees of angulation is • Point tender acceptable for 4 th metacarpal fractures • Ecchymosis • Accurate anatomical reduction is • The distal fragment usually displaces essential for 2 nd and 3 rd metacarpal volarly due to the interosseous muscles fractures • Radiographs: AP, lateral, oblique • Reduce, splint with orthopedic follow up
Metacarpal fx tx Metacarpal fx complications • degrees can be tolerated • Attempt reduction? • Malrotation • Different cast types • Common with spiral or oblique fractures • Greater than 10% malrotation leads to scissoring effect of the fingers • Metacarpal head – Loss of knuckle
Metacarpal fx referral Metacarpal Fractures Relatively common. 30-40% of hand fractures • Rotation Result from direct or indirect trauma. Direct trauma commonly results in transverse fracture, usually • Angulation > 70 degrees midshaft. • Preference Most fractures are easily reducible, stable and managed non- operatively. Don’t miss rotational deformity Indications of surgical intervention: ◦ Intra-articular fractures, ◦ Displaced and angulated fractures, ◦ Unstable fracture patterns, ◦ Combined or open injuries, ◦ Irreducible and unstable dislocations
22 Phalanges fractures Proximal and Middle Phalanx Distal Phalanx: • Extra-articular fractures are common, associated with significant soft tissue • Most common in athletes injury. – Fall or direct blunt trauma • Crush injuries from a perpendicular force (injuries from a car door or hammer) • Intra-articular fractures are associated with extensor tendon avulsion (Mallet’s • More difficult than metacarpal fractures finger), FDP tendon avulsion (Jersey finger). • Close relationship between fractured bone • Examination: – Inspection and pulley system – Neurovascular status should be examined. – Palpation is done for tenderness. • Closed treatment is recommended with splinting and if necessary closed reduction
Proximal Phalange referral Phalange finger treatment
• Early motion (3-5 days) • Inability to maintain proper • Splint and take out alignment • Can buddy tape • Rotation • Irreducible Injury • Any intra-articular fracture
Mallet finger presentation • Pain at dorsal DIP joint • Inability to actively extend the joint • Characteristic flexion deformity • On exam, very important to isolate the DIP joint to ensure extension from DIP and not the central slip • If can’t passively extend consider bony entrapment • All of these need x-rays
1 3 7
23 Mallet Finger Tx Mallet Finger Referral • Splint DIP in neutral or slight hyperextension for 6 weeks • Bony avulsion >30% of joint space • Cochrane review- all splints same • Inability to achieve passive extension results • Surgical wiring does not improve • Despite proper treatment permanent flexion of outcome the fingertip is possible • Office visit every 2 weeks • No fracture reduction in the splint • If not extension lag at 6 weeks, splint at night and for activity for 6 weeks. • Conservative treatment effective up to 3 months delayed presentation
Knee imaging – 3 Bones Finger injury Pearls Radiographs (78%) • Treatment should restrict motion of the injured • Primary modality for knee pain structures while allowing uninjured joints to remain • Arthritis (joint narrowing, osteophytes) mobile • Fractures, loose bodies • Patients should be counseled that it is not unusual for MR (21%) an injured digit to remain swollen for some time and • Internal derangement that permanent deformity is possible even after • Ligament/meniscal tears, cartilage defects treatment Occult fractures CT (1%) • Surgical planning (of fxs seen on radiographs) Have Low threshold for consultation for hand and finger fx
Ottawa knee rules When to Refer knee to Ortho
• age 55 or over • IMMEDIATELY • isolated tenderness of the patella (no bone • Dislocated knee (tibiofemoral joint) tenderness of the knee other than the patella • Neurovascular injury • tenderness at the head of the fibula • Open injury • inability to flex to 90 degrees • Compartment syndrome • inability to weight bear both immediately and in the ED (4 steps - unable to transfer weight twice • Septic arthritis onto each lower limb regardless of limping). • Fractures involving the knee joint • Patella tendon rupture/Quadriceps tendon rupture
144
24 Knees Knee Osteoarthritis
•“Joint Space ” narrowing •Subchondral sclerosis •+/-Osteophytes •+/- Cysts IMPORTANT: Obtain X-rays with Weight-bearing Obtain “““Notch ””” AP X-Rays
A/P view Weight bearing P/A View (Rosenberg) • Knee arthritis • Knee arthritis • Tibial • Tibial Plateau Fx plateau fx • Distal Femur Fx • Distal femur fracture
147 148
Lateral view Suprapatella pouch • Knee arthritis • Tibial plateau fracture • The knee can hold a lot of fluid... • Distal femur fracture not between articular surfaces. • Patellar fracture • Joint effusions collect in the suprapatellar • Patellofemoral pouch. arthritis – Synovial lined space • Can show sizable joint – Normal extension of the joint capsule effusions... physical – Can easily hold > 40ml exam is more sensitive! Patella Alta
149
25 Suprapatella pouch Tunnel view (intercondylar notch view)
• Tibial eminence fx • Tibial spine fx • Distal femur fx
152
Sunrise View Merchant View
• Patellofemoral arthritis • Patellofemoral arthritis • Patellar fracture • Patella fracture • Patellofemoral pain • Patellofemoral Pain
153 154
Prepatellar Bursitis
Osteophytes of the Knee
26 Femoral Supra/Inter Condylar Patellar Fractures Fractures
Osteochondral Defect (OCD) Lipohemarthrosis
Tibial Plateau Fractures Working up Hip Pain
• Very Common Should order: • 80% MVA (the rest from falls, sports)* • 1) AP pelvis (both hips) • 60% involve lateral plateau** 2) Frog leg view of painful hip (or both hips) • CT used for surgical planning • Should not order: • Schatzker classification system* • AP view of just one hip without an AP pelvis Often helpful to compare with asymptomatic side
27 Working up Hip Pain Value of Frog leg view
88yoM hip pain • Width of both hip joints is normal. (Good ROM for 88) • Are there any other clues to the cause of his hip pain? – Severe DDD lower lumbar spine! – Lumbar nerve impingement • Consider getting lumbar radiographs to evaluate hip pain.
Osteoarthritis Hip Hip Osteophytes – best seen Frog Leg view
28 Femoral Neck Fracture Femoral Neck Fracture
Intratrochanteric Fractures AP View Shoulder • Stable get closed reduction with Dynamic Hip Screw (DHS) • Unstable get closed reduction with Gamma- Shows alignment Nail • of AC Joint • Shows lateral view of Surgical Neck • Does not profile GH Joint nor GT
Oblique: Humerus Ext. Rotated
• Shows alignment of AC Joint • Shows AP view of Surgical Neck • Does profile GH Joint and GT
29 West Point vs Axillary Axillary View
• Profiles the glenohumeral joint • Width Arthritis • Alignment Dislocations
Right shoulder pain after injury during football game
What is the injury?
1. Shoulder dislocation 2. Clavicle fracture 3. Rib fracture Shoulder 4. Humerus fracture Osteoarthritis Correct! The humeral head is displaced anteriorly and inferiorly. It is no longer articulating fully with the glenoid fossa of the scapula.
3- view shoulder series
Standard (trauma, pain) • 1) AP 2-views of: ACJ Proximal 2) Oblique Humerus 3) Axillary 2-views of: Scapular Y view Glenohumeral Joint Instability (3-views Glenohumeral Joint) (PA) • 1) Oblique 2) Axillary 3)West Point If need orthogonal views Scapula,ACJ • 4)Lateral (“Scapular Y”, “Arch”/“Outlet”)
30 Bilateral AC Joints with Weights (5 lb) Red Flag Diagnoses Fracture Tumor Progressive neurological deficit Infection
Red Flag Risk Factors Red Flag - Fracture
Malignancy - back pain in very young (<20yo)pts or older pts (>50yo), history of When to get an x-ray CA Mechanism of Injury Spinal infection- recent/ past infection, Bony tenderness immunosuppression, HIV, IVDA Ankle and Knee Ottawa Rules Fracture - age relative trauma (>65yo), osteoporosis, steroid use Pittsburgh Knee Rules
Red Flag Diagnoses- Cancers that go to the bone Tumor • History of cancer- “PT Barnum Loves Kids” 1:150-200 of pts presenting to PCP with LBP has undiagnosed cancer • P – Prostate • T – Thyroid Age >50 years • B – Breast Constitutional symptoms- recent • L – Liver/Lung unexplained weight loss, hair dropping • K - Kidney out Severe night pain or pain that worsens with lying down
31 Red Flag Dx-Radiculopathy Old Radiology Saying “The hardest fracture to find… is the second fracture” Progressive or severe neuromuscular • “Satisfaction of the Search” dysfunction (severe weakness, falling, • You feel good when you find one fracture…so you stop looking for cannot walk, dropping items or unable to other fractures carry items) secondary to nerve root • This is why it is important to understand pathology – Mechanisms of injury – Patterns of fractures • This is why it’s important to have a Radiologist formally interpret all studies!
DOI 7/31; surgery 8/8, more Dr. Cole’s Saying fx 8/14 “Trauma is not evenly distributed within the population” • Patients who come in with new fractures have had fractures in the past • People who drive recklessly… do so repeatedly • People who get into fights… do so repeatedly • Students who get drunk on Friday night and punch walls… do so repeatedly • It can be hard to tell old from new fractures 67 y.o. female fell down stairs. Consulted for ORIF R • This is why it’s important to have a Radiologist formally wrist in hospital. Radiologist missed left hand fractures and no-one x-rayed her left foot. Found at interpret all studies! 2 week po visit • Sometimes they suggest additional studies
Summary Points to take home • Plain radiographs provide information about bone, joint and soft tissue structures • Become familiar with terminology: epiphysis, • Be systematic metaphysis, diaphysis, cortex, medullary • Look at all views available cavity • If available compare with old images • Fracture description requires specific • Look for the unexpected vocabulary • Assess image quality and if clinically appropriate consider requesting a repeat X-ray • Don’t miss the second fracture
32 Best of luck – hope this was ????????????????????Questions???? helpful ?????????? [email protected] [email protected]
LIST OF POTENTIALLY HELPFUL WEBSITES CONTINUED RADIOLOGY WEBSITES http://www.med- http://learningradiology.com/index.htm ed.virginia.edu/courses/rad/ Seems to have some good stuff but difficult to Online tutorial series. navigate the site. http://radiopaedia.org/ http://www.swansea- A free educational radiology resource with radiology.co.uk/index.html one of the web's largest collections of http://bubbasoft.org/ radiology cases and reference articles. Strange name but the website is useful. Breaks http://www.radiologyassistant.nl/en/p42023 it into radiologic anatomy (identification of a885587e/welcome-to-the-radiology- structures) and clinical radiology (identification assistant.html of pathology).
33