1. BASICS OF ORTHOPEDIC
RADIOLOGY
Nilesh Patel, DO
November 2008
St. Josephâs Regional Medical Center
Paterson, NJ
2. OBJECTIVES
ïReview a systematic approach to
interpreting orthopedic x-rays
ïReview the language of fracture
description
3. ABCs APPROACH
ïAâŠ
Adequacy, Alignment
ïBâŠ
Bones
ïCâŠ
Cartilage
ïSâŠSoft Tissues
ïApply ABCs approach to every orthopedic
film you evaluate
4. ADEQUACY
ïAll x-rays should have an adequate
number of views.
⊠Minimum of 2 viewsâAP and lateral
⊠3 views preferred
⊠Some bones require 4 views
ïAll x-rays should have adequate
penetration
5. ALIGNMENT
ïAlignment: Anatomic relationship
between bones on x-ray
ïNormal x-rays should have normal
alignment
ïFractures and dislocations may affect the
alignment on the x-ray
6. BONES
ïExamine bones for fracture lines or
distortions
ïExamine the entire length of bone
ïFractures may be subtle!
7. CARTILAGE
ïCartilage implies to examine the joint
spaces on x-rays (you cannot actually see
cartilage on x-rays)
ïWidening of joint spaces signifies
ligamentous injury and/or fractures
8. SOFT TISSUES
ïSoft tissues implies to look for soft tissue
swelling and joint effusions
ïThese can be signs of occult fractures
9. REVIEW: ABCs
ïAâŠ
Assess adequacy of x-ray which includes proper
number of views and penetration
⊠Assess alignment of x-rays
ïBâŠ
Examine bones throughout their entire length for
fracture lines and/or distortions
ïCâŠExamine cartilages (joint spaces) for widening
ïSâŠ
Assess soft tissues for swelling/effusions
11. EXAMPLE # 1âŠ
ïThis x-ray demonstrates a lateral elbow x-ray.
ïThere is swelling anteriorly which is
displaced known as a pathologic anterior fat
pad sign
ïThere is swelling posteriorly known as a
posterior fat pad sign
ïBoth of these are signs of an occult fracture
although none are visualized on this x-ray
ïRemember, soft tissue swelling can be a sign
of occult fracture!
13. EXAMPLE # 2âŠ
ïIf you follow ABCs, you will notice there is
are problems with alignment on this x-ray
(A)
ï(B)âŠYou will notice there are fracture lines
through the 2nd, 3rd, and 4th metacarpals
ïThese are 2nd, 3rd, and 4th, midshaft metacarpal
fractures.
ïA teaching point: Notice the ring on this
film. Always remove rings of patients with
fractured extremities because swelling may
preclude removal later.
14. LANGUAGE OF FRACTURES
ïImportant for use to describe x-rays in
medical terminology.
ïImproves communication with orthopedic
consultants
15. LANGUAGE OF FRACTURES
ïThings you must describe (clinical and x-ray):
⊠Open vs Closed fracture
⊠Anatomic location of fracture
⊠Fracture line
⊠Relationship of fracture fragments
⊠Neurovascular status
16. OPEN VS CLOSED
ïMust describe to a consultant if fracture is
open or closed
ïClosed fracture
⊠Simple fracture
⊠No open wounds of skin near fracture
ïOpen fracture
⊠Compound fracture
⊠Cutaneous (open wounds) of skin near fracture
site. Bone may protrude from skin
⊠Open fractures are open complete displaced
and/or comminuted
17. OPEN FRACTURES
ïOrthopedic emergency
ïRequires emergency orthopedic
consultation
ïBleeding must be controlled
ïManagement
⊠IV antibiotics
⊠Tetanus prophylaxis
⊠Pain control
⊠Surgery for washout and reduction
18. ANATOMIC LOCATION
ïDescribe the precise anatomic location of
the fracture
ïInclude if it is left or right sided bone
ïInclude name of bone
ïInclude location:
⊠ProximalâŠMidâŠDistal
⊠To aid in this, divide bone into 1/3rds
25. FRACTURE LINES
ïA is a transverse fracture
ïB is an oblique fracture
ïC is a spiral fracture
ïD is a comminuted fracture
ïThere is also an impacted fracture where
fracture ends are compressed together
27. ANS: TRANSVERSE
FRACTURE
ïTransverse fractures occur perpendicular
to the long axis of the bone.
ïTo fully describe the fracture, this is a
closed midshaft transverse humerus
fracture.
29. ANS: SPIRAL FRACTURE
ïSpiral fractures occur in a spiral fashion
along the long axis of the bone
ïThey are usually caused by a rotational
force
ïTo fully describe the fracture, this is a
closed distal spiral fracture of the fibula
31. ANS: COMMINUTED
FRACTURE
ïComminuted fractures are those with 2 or
more bone fragments are present
ïSometimes difficult to appreciate on x-ray
but will clearly show on CT scan
ïTo fully describe the fracture, this is a
closed R comminuted intertrochanteric
fracture
32. FRACTURE FRAGMENTS
ïTerms to be familiar with when
describing the relationship of fracture
fragments
⊠Alignment
⊠Angulation
⊠Apposition
⊠Displacement
⊠Bayonette apposition
⊠Distraction
⊠Dislocation
33. ALIGNMENT/ANGULATION
ïAlignment is the relationship in the
longitudinal axis of one bone to another
ïAngulation is any deviation from normal
alignment
ïAngulation is described in degrees of
angulation of the distal fragment in
relation to the proximal fragmentâto
measure angle draw lines through normal
axis of bone and fracture fragment
35. OOTTHHEERR TTEERRMMSS
ïApposition: amount of end to end contact
of the fracture fragments
ïDisplacement: use interchangeably with
apposition
ïBayonette apposition: overlap of fracture
fragments
ïDistraction: displacement in the
longitudinal axis of the bones
ïDislocation: disruption of normal
relationship of articular surfaces
37. ANSWER
ïThis is a closed midshaft tibial fractureâŠ.But
how do we describe the fragments?
ïThis is an example of partial apposition; note
part of the fracture fragments are touching each
other
ïAlternatively you can describe this as displaced
1/3 the thickness of the bone
ïRemember aposition and displacement are
interchangeableâwe tend to describe
displacement
ïFinal answer: Closed midshaft tibial fracture
with moderate (33%) displacement
39. AANNSSWWEERR
ïThere are 2 fractures on this film
ïClosed distal radius fracture with complete
displacement. Also there is an ulnar styloid
fracture which is also displaced
ïThe displacement is especially prominent on the
lateral view highlighting the importance of
multiple views.
ïThere may be intra-articular involvement as
joint space is close by
ïRemember, remove all jewelry from extremity
fractures
42. DISLOCATION
ïNote the dislocation on the previous slide;
the articular surfaces of the knee no
longer maintain their normal relationship
ïDislocations are named by the positioin of
the distal segemnt
ïThis is an Anterior knee dislocation
43. NEUROVASCULAR STATUS
ïFinally when communicating a fracture,
you will want to describe if the patient has
any neurovascular deficits
ïThis is determined clinically
44. LANGUAUGE OF
FRACTURES
ïTo review, when seeing a patient with a
fracture and the x-ray, describe the
following:
⊠Open vs closed fracture
⊠Anatomic location of fracture (distal, mid,
proximal) and if fracture is intra-articular
⊠Fracture line (transverse, oblique, spiral,
comminuted)
⊠Relationship of fracture fragments
(angulation, displacement, dislocation, etc)
⊠Neurovascular status
46. ANSWER
ïOblique fracture of midshaft of R 4th
middle phalanx with minimal
displacement and no angulation
ïRemember to comment if open vs closed
& neurovascular status
48. ANSWER
ïThis one is a bit more challenging!
ï R midshaft tibia fracture displaced Âœ the
thickness of the bone without angulation;
also there is bayonette appositioning of
the fracture fragments
ïR midshaft fibular fracture with complete
displacement and
ïAlso comment if the fracture is open vs
closed & neurovascular status