clinics

1. CLINICS AND PATIENT EVALUATION
BASIC RADIOLOGY INTERPRETATION

3. An x-ray (radiograph) is a noninvasive medical
test that helps physicians diagnose and treat
medical conditions.
Imaging with x-rays involves exposing a part of
the body to a small dose of ionizing radiation to
produce pictures of the inside of the body.
X-rays are the oldest and most frequently used
form of medical imaging.

4.  A radiologist, a physician specifically trained
to supervise and interpret radiology
examinations, will analyze the images and
send a signed report to your primary care or
referring physician, who will discuss the
results with you.

5.  Although “X-ray” is a term frequently used to
refer to the image/film produced, radiograph
is the correct term.

6.  the radiograph, irrespective of the
projection/view, is a 2-dimensional
representation of a 3- dimensional structure.
The image produced is therefore made up of
multiple overlying structures.

7.  Accurate localisation of an abnormality
frequently requires two radiographs obtained
at right angles to one another e.g.
anteroposterior (AP) and lateral
projections.

8.  Structures of high density (e.g. bones and
metal foreign bodies) will absorb (attenuate)
the X-ray beam more than structures of low
density (e.g. soft tissues and air).
— bones will appear white
— soft tissues will appear grey
— air/gas will appear black

10.  Remember that fluoroscopy(X-ray
screening) gives a negative image on the TV-
monitor or screen. Therefore, the
appearances are reversed with bones black
and air/gas white.

11. FOREIGN BODIES
 foreign bodies may be introduced into the
body by trauma, ingestion or at the time of
surgery.

12. INTERPRETATION
 interpretation of the radiograph(s) requires
a careful approach. The individual
responsible for interpreting the radiograph
should first ensure the following;
 1.Check patient name and side marker (left
or right) on film(s) are correct.
 2. Check clinical details (age, sex, history
etc.)

13.  the interpretation of the radiograph(s) should
finish with the production of a report detailing
the clinically relevant observations both
positive and negative together with a
diagnosis, if possible.
 consideration of possible pathologies in a
particular case should take into account the
life style, country of origin and residence of
the patient.

14. ABCS APPROACH
 A
◦ Adequacy, Alignment
 B
◦ Bones
 C
◦ Cartilage
 S
◦ Soft Tissues
  ABCs approach applies to every x-ray
image!

15. ADEQUACY
  Adequate views:
• Min. 2 views—AP & lateral
 (except maybe children)
• 3 views even better (oblique view)
• Sometimes more (i.e. Brodin’s)- CT is better
  Sufficient exposure!- visibility, image
resolution, technical adequacy

16. ALIGNMENT
  Alignment: anatomic relation of bone
axes
  Normal images have normal axes
relations
  Fractures and dislocations can alter
normal axes relations

17. BONES
  Examine bones- look for fractures,
cracks
 Examine the whole bone- holistic
approach :)
  Fractures are sometimes barely visible!

18. CARTILAGE
  Cartilage is not visible on x-ray; Evaluate
joint spaces
  Abnormaly wide joint spaces may speak
for ligament injuriy or impression fracture
  Narrow joint spaces mean thin cartilage
due to degeneration- osteoarthrosis

19. SOFT TISSUE
  Evaluate soft tissue swelling
 May speak for an occult fracture

20. REPEAT ABCS APPROACH
 A
◦ evaluate adequacy: adequate views and image
quality ◦ evaluate alignment- long axes of bones
 B
◦ Examine bones (whole)- look for cracks and
deformities
 C
◦ Examinie cartilage- joint space- width, assymetry,...
 S
 ◦ Evaluate soft tissues: swelling, joint effusion (relate
image to clinical exam)

21. TERMINOLOGY
 sclerotic
 lytic
 cortex
 medulla
 articular
 demineralization
 Ankylosis
 osteo
 chondro-
 fibro-
 arthro-
 spondylo-
 dactyl-

22. TERMINOLOGY

23. TERMINOLOGY USED TO DESCRIBE THE
DIFFERENT PORTIONS OF A LONG BONE

24. TERMINOLOGY USED TO IDENTIFY THE LOCATION
OF A LESION IN A LING BONE

25.  AP
PA
lateral
 oblique
 decubitus
 supine
 Prone
 erect
 axial
 cephalic
 caudal

27. CLASSIFICATION OF FRACTURES AND
DISLOCATIONS
 a fracture is either a complete break in the
continuity of a bone or an incomplete break
or crack.

28.  fractures are subdivided according to their
cause:
 1. acute traumatic fractures
 2. stress fractures
3. pathological fractures

29. Acute traumatic fractures are classified as:
 complete
 incomplete
 Displaced
 undisplaced
 closed/simple
 open/compound

31.  an open/compound fracture is liable to be
contaminated and has a high risk of infection.

32.  Descriptive terms used to indicate the
shape or pattern of an acute fracture in
the adult are
 1. transverse fractures
2. oblique fractures
3. spiral fractures
4. comminuted fractures(2 or more
fragments)
 5. compression/crush fractures
 6. depressed (in skull)

34. DISLOCATIONS
 a joint is dislocated (luxated) when its
articular surfaces are wholly displaced one
from the other, so that apposition between
them is lost

37.  subluxation exists when the articular
surfaces are partly displaced but retain some
contact with each other.

38. FRACTURES IN CHILDREN
 fractures in children are classified as:
— complete
— greenstick fracture
— torus (buckle) fracture
— pipe fracture
— bowing injury
— infant’s (toddler’s) fracture
— epiphyseal/metaphyseal fractures
— avulsion injuries

40.  Greenstick fracture is an incomplete
fracture.The cortex is broken on one side
and buckled on the other with a bending
deformity concave to the buckled side

41. GREENSTICK FRACTURE

42.  A buckle fracture is a buckling of the cortex
produced by compression (impaction) forces.
Typically seen in the metaphysis of long
bones particularly the radius and ulna

44.  a pipe fracture is a combination of an
incomplete transverse fracture of one cortex
and a torus fracture of the opposite side

46.  a bowing injury results in the bending of a
long bone usually without a fracture, but with
an associated fracture of an adjacent bone.
Typically affects the radius, ulna and fibula.

47.  an infant’s (toddler’s) fracture is seen in
young children who present with a limp
without a clear history of trauma. They are
subsequently found to have an occult
(unsuspected) undisplaced fracture.
Originally described in the distal tibia, it may
also be seen in the distal femur and
calcaneus.

48.  A fragmet of bone may be avulsed(pulled-off)
at the insertion of aligament or tendon at any
age. In adolescents it is the accessory
growth centres (the apophyses) which are
particularly prone to avulsion injuries.
These are typically seen in the pelvis

50. SALTER-HARRIS CLASSIFICATION OF
EPIPHYSEAL INJURIES
 in adolescent children the growth plate
(physis) is a potentially weak point and is
therefore susceptible to trauma. The Salter-
Harris classification of epiphyseal injuries
is illustrated in figure 4.9. The commonest
injury (75%) is a Salter-Harris Type 2 with
separation of the growth plate and a fracture
extending proximally to involve part of the
metaphysis (fig 4.10). A complication of a
epiphyseal injuries is premature fusion of the
growth plate.

53. RADIOGRAPHIC DIAGNOSIS OF FRACTURES
 A fracture is identified by the loss of
continuity of the cortex and a dark line
traversing the adjacent bone. The fracture
line appears dark because the soft tissue
(usually haematoma) between the bone ends
is of less density than the bone itself.

54.  A fracture may appear as a dense/sclerotic
line if the fracture ends are overlapping. At
this site there is therefore twice as much
bone attenuating the X-ray beam.
 The classic example is the depressed skull
fracture but it can also be seen with
overlapping long bone fractures.

55.  It is important to obtain two views at right
angles for all suspected fractures and
dislocations. On occasion a fracture or
dislocation may only be visible on one
projection (fig 4.10). Two views are also
essential to adequately see the degree of
deformity at the fracture site.

57.  it is important that the radiographs always
show the joint above and below any
suspected long bone fracture, unless it is
clinically obvious that the injury is only in the
most distal part of the limb. But even then,
the nearest joint must always be included on
the film.

58. FRACTURE HEALING STAGES/PHASES
 Inflammatory phase : a haematoma (blood
clot) forms at the site of the fracture.
 Reparative phase : bone at the fracture
margins is deprived of its vascular supply
resulting in resorption at the bone ends. On
radiographs, fractures which are difficult to see
at first, become more easily seen. The cells
lining the cortex start to produce immature bone
(callus). This is seen as faint calcification around
the fracture.

59.  Remodelling phase : the immature callus is
replaced by compact (denser) bone in the
cortex and cancellous bone within the
medullary cavity.

60. APPROACH
 A
◦ evaluate adequacy: adequate views and image
quality ◦ evaluate alignment- long axes of bones
 B
◦ Examine bones (whole)- look for cracks and
deformities
 C
◦ Examinie cartilage- joint space- width, assymetry,...
 S
 ◦ Evaluate soft tissues: swelling, joint effusion (relate
image to clinical exam)

61. COMPLICATIONS OF FRACTURES
 Complications of fractures maybe classified
into intrinsic(related to the fracture itself)
and extrinsic (the result of associated
injury).

62.  intrinsic complications include;
— delayed union and non-union
— malunion and shortening
— avascular necrosis
— infection
— degenerative joint disease

63.  extrinsic complications include;
— injury to adjacent vessels, nerves and
tendons
— injury to viscera
— fat embolism (release of marrow fat to the
lungs)
— reflex sympathetic dystrophy (Sudeck’s
atrophy)

64. DELAYED UNION FRACTURES
 as a general rule union is considered
delayed if the fragments remain freely mobile
several months after injury but there is
nothing in the appearance of the bones to
indicate that union will never happen.

65. NON-UNION FRACTURES
 If a fracture remains ununited for many
months distinctive radiographic features
develop which indicate that the fracture will
fail to heal (i.e. non-union). The bone ends
become hypertrophic, sclerotic and the
fracture line dark and well-defined . A classic
site for non-union is the scaphoid fracture.

67. MALUNION
 Mal-union indicates that the fracture has
united in an incorrect position. This includes
angulation, rotation and overlap at the
fracture site

69. SHORTENING
 shortening of bone after a fracture may occur
due to
 1. Malunion with angulation or overlap
2. Crushing of bone or bone loss
3. Premature growth plate fusion in children

72. AVASCULAR NECROSIS (AVN)
 avascular necrosis (osteonecrosis) occurs
when the blood supply to a bone or part of
bone is interrupted.
 It most commonly occurs as a complication
of a fracture, particularly near the articular
end of a bone.
 AVN may also occur due to non-traumatic
causes (e.g. infection, steroid therapy and
sickle cell disease).

74.  classic sites for AVN after trauma are;
— femoral head
— proximal scaphoid
— body of talus

75.  radiographic appearances of AVN include
— relative increased density of avascular bone
— fragmentation & collapse
— late development of premature degenerative
joint disease

76. INFECTION
 infection at a fracture site is most commonly
seen in open (compound) fractures.
 Infection may be confined to the soft tissues
but frequently will involve both the
bone(osteomyelitis) and soft tissues
 when there is a dirty open (compound)
fracture the possibility of developing gas
gangrene due to Clostridia or other bowel
organisms should be considered.

79. PHYSICAL ASSESSMENT OF THE ORTHOPEDIC
PATIENT
 INSPECTION
The first part of any physical examination is a
visual inspection of the area of the patient's
complaint. This is so immediate and automatic
that it is often done almost unconsciously.

80.  The examiner observes the out- ward
appearance of the body part, how it is carried
or aligned, how it is used in functional
activities such as walking, and the range
through which it is able to move, if applicable

81. DIRECTIONAL TERMS
 anterior means toward the front of the body,
posterior toward the rear of the body,
 medial toward the midline of the body, and
lateral away from the midline of the body.

82.  In the limbs,
 proximal means closer to the trunk, and
 distal means away from it. In the spine,
 proximal means toward the head, and
 distal means toward the sacrum.

83.  Some clinicians prefer to say
 cephalad or rostral when they mean toward
the head
 caudad when they mean toward the
sacrum. In the trunk or the limbs,
 superior is often used as a synonym for
proximal or cephalad
 inferior as a synonym for distal or caudad.

84. 1. ALIGNMENT
 In the limbs, the most common types of
malalignment are:
 axial
 rotational.

85.  Axial alignment refers to the longitudinal
relationships of the limb segments. Often,
axial alignment is described in terms of the
angle made by the segments in relationship
to a straight line.
 Rotational alignment refers to the twisting
of the limb around its longitudinal axis

86.  When such deviations are toward or away
from the mid- line, the terms valgus and
varus are usually employed to describe the
alignment. These two terms are commonly
used but often confused.

87.  In valgus alignment, the two limb segments
create an angle that points toward the
midline.
 In hallux valgus, for example, the two
segments that constitute the angle are the
first metatarsal and the great toe. Instead of
forming a straight line, these two seg- ments
are angulated with respect to each other and
the angle points toward the midline.

88.  Another way to define valgus is to say that
the distal segment forming the angle points
away from the midline. In the example just
given, the great toe deviates away from the
midline.

89.  In genu val- gum, the angle formed at the
knee between the femur and the tibia points
toward the midline, and the tibia angles away
from the midline

90.  Varus alignment is the opposite of valgus. In
varus alignment, the angle formed by the two
segments points away from the midline, and
the more distal of the two segments points
toward the midline.

91.  For example, in genu varum, the angle
formed by the femur and the tibia at the knee
points away from the midline, and the tibia
angles back toward the midline


92.  Angulation does not have to occur at a joint
for these terms to be used. For example, in
tibia vara, the angle occurs within the shaft
of the tibia. In this case, the proximal and
distal portions of the tibia are considered the
two segments that constitute the angle.

93.  A number of other terms are used to describe
rota- tional alignment in different areas of the
body. For exam- ple, when ideal alignment is
present ,an individual's patellas point forward
when the feel are pointing forward. When the
kneecaps angle inward, they may be said to
be in-fac- ing; when they angle outward, they
may be said to be out- facing.

94. Similary, the term in-toeing is generally used
when an individual stands or walks with the
medial border of the foot pointing inward; if the
foot points outward, the term out-toeing is
commonly used.
The colloquial equivalents of these two terms
are pigeon-toed for in-toeing and slew-
footed for out-toeing.

95. RANGE OF MOTION
 Traditionally, joint motion is assessed within
three planes of movement, each described
with a pair of terms:
 flexion/extension,
 abduction/adduction,
 external rotation/internal rotation.

96.  Each pair of terms describes movement that
takes place in one of the body's cardinal
planes when the body is in the anatomic
position

97.  Flexion and extension-for example,
describe motion that occurs in the sagittal
plane. These movements could also be
described as occurring around a transverse
axis.

98.  The exact meaning of the terms flexion and
extension varies depending on the nature of
the joints in question. In the elbows, knees,
and digits, flexion means move- ments that
tend to bend the joint, and extension means
movements that tend to straighten it.

99.  In the shoulder and hip, flexion refers to
movements that bring the involved limb
anterior to the coronal plane, whereas
extension refers to movements that bring the
limb posterior to the same plane
 in the ankle, they are modified to dorsiflexion
and plantar flexion.

100.  Abduction and adduction refer to motion
within the coronal plane of the body, which
may also be described as motion about an
anteroposterior axis

101.  Abduction describes movements that take
the limb away from the midline of the body,
whereas adduction describes movements
that bring the limb back toward the midline.
The spine is a midline structure; therefore,
similar movements in the spine are described
as right and left lateral bending.

102.  External rotation and internal rotation
describe movements that take place within
the transverse plane, that is, motion about a
longitudinal axis

103.  External rotation describes movements in
which the limb rotates away from the midline
when viewed from an anterior perspective,
whereas internal rotation describes move-
ments in which the limb rotates toward the
midline when viewed from an anterior
perspective. In the spine, similar movements
are described as right and left lateral rotation.

104.  In any given joint, ROM may be measured
both actively and passively. Active range of
motion refers to the range through which the
patient's own muscles can move the joint;
passive range of motion refers to the range
through which an outside force, such as the
examiner, can move the joint.

105.  In the interests of time and patient comfort, it
is not always necessary to measure both
active and passive motion in every given
situation. For example, if active flexion and
extension of the knees appear full and
symmetric, measuring passive ROM is
probably superfluous.

106.  In general, active ROM is evaluated first,
and passive ROM is assessed if the active
ROM appears to be deficient.

107. PALPATION
 Palpation is the process of examining a body
part by pressing on it, usually with the
fingertips

108. PURPOSES OF PALPATION
 First, it can be used for orientation.
Careful palpation can help the examiner
identify the location of specific anatomic
structures. This, in turn, can aid in the
interpretation of symptoms or facilitate the
performance of other portions of the physical
examination.

109.  By determining the location of specific easily
recognizable structures, or landmarks, the
examiner can estimate the location of other
structures that are not otherwise identifiable.

110.  The second purpose of palpation is to elicit
tenderness.
 Tenderness is a semi-objective finding. It
requires the patient to inform the examiner
verbally or physically that palpation of a
given structure is painful.

111.  Tenderness must therefore always be
interpreted with the knowledge that
conscious deception or unconscious
overreaction may be playing a role in the
patient's response.

112.  The third purpose of palpation is to verify the
conti- nuity of anatomic structures. Careful
palpation of an injured Achilles tendon, for
example, will often allow the examiner to
identify the discontinuity that confirms the
diagnosis of Achilles tendon rupture.

113.  In the same way, palpation can help assess
the severity of an injury. For example,
palpating an identifiable divot in a strained
quadriceps muscle documents the presence
of a severe muscle injury.

114.  During palpation, the temperature of the
area being examined can be assessed. In
this manner, the warmth associated with
infection or posttraumatic inflammation can
be detected.

115.  Conversely, the coldness caused by vas-
cular compromise or the transient
vasoconstriction of reflex sympathetic
dystrophy can be detected. Changes in
temperature can often be quite subtle, so the
examiner should always palpate the opposite
limb simultaneously when a temperature
change is suspected.

116. MUSCLE TESTING
 Traditionally, muscle strength has been
evaluated by assigning the muscle a grade from
0 to 5.
 Grade 0 indicates that no contraction of the
muscle is detectable.
 Grade 1 is assigned to a muscle in which a
contraction can be seen or palpated but
strength is insufficient to move the appropriate
joint at all, even with gravity eliminated.
 Grade 2 is assigned to a muscle that can move
the appropriate joint if the limb is oriented so
that the force of gravity is eliminated.

117.  Grade 3 is assigned to a muscle that is
strong enough to move a joint against the
force of gravity but is unable to resist any
additional applied force.
 Grade 4 is assigned to a muscle that is
capable of moving the appropriate joint
against the force of gravity and additional
applied resistance but is not felt to be
normal.

118.  Grade 5 means that the muscle strength is
considered normal; it is capable of moving
the appropriate joint against gravity and
against the normal amount of additional
resistance.

119.  Most muscles that the clinician encounters
have at least grade 3 strength. Therefore, the
technique described for each muscle group
requires movement of the joint against the
force of gravity, except in a few cases where
such testing is awkward.

120.  If the muscle being tested is not capable of
moving the appropriate joint against the force
of gravity, the examiner should turn the
patient so that the equivalent test can be
performed with the force of gravity
eliminated.