Mod 2

Question 1

How to describe an x-ray?

Answer 1

Confirm patients name and DOB and date of x-ray
Determine adequacy of image. Two orthogonal views, joints above and below
O - open or closed?
L - location (part of bone?)
D - degree (complete vs incomplete)
A - articulate extension (dislocation, fracture-dislocation, intraarticular salter-Harris)
C - comminution/pattern (transverse, oblique, spiral, comminuted, avulsion, impacted, fissure, greenstick)
I - intrinsic bone quality (normal, osteopenia, osteopetrosis)
D - displacement (LARA: length, alignment, rotation, apposition/translocation)
S - soft tissue

Question 2

Complications of fractures

Answer 2

Immediate - bleeding (hypovolaemic shock), nerve damage, organ damage (pneumothorax, organ puncture), pain, disability, soft tissue entrapment between bone fragments, joint damage

Early - infection, tetanus, compartment syndrome, rhabdomyolosis (lead to kidney failure), fat embolism, thromboembolism,

Late - non-union, malunion (deformities), DVT, pressure ulcers, avascular necrosis, secondary OA, growth retardation, osteomyelitis, loosening of fixation

Question 3

March fracture

Answer 3

Fatigue/stress fracture classically 2nd metatarsal of foot

Question 4

Salter Harris classification

Answer 4

1 - straight across
2 - metaphysics and physis
3 - physis and epiphysis 
4 - metaphysis, physis and epiphysis 
5 - crush injury

Question 5

Bankart lesion

Answer 5

Glenoid fracture affecting the labrum due to multiple shoulder dislocations

Question 6

Hill-Sachs lesion

Answer 6

Humeral head fracture typically secondary to anterior shoulder dislocation
Increases risk of future dislocations

Question 7

Galeazzi fracture

Answer 7

Distal radius fracture with dorsal/Volta displacement+ intact ulna + dislocation of distal ulna

Question 8

Monteggia

Answer 8

Ulna shaft fracture with distal radial dislocation

Question 9

Nightstick

Answer 9

Isolated transverse fracture of ulna resulting from direct blow

Question 10

Colles fracture

Answer 10

Fracture of distal radius
Dorsal angulation of distal fragment
Usually results from fall on extended wrist

Question 11

Smiths fracture

Answer 11

Distal radius fracture
Volar angulation of distal fragment
Usually results from fall on flexed hand

Question 12

Boxers fracture

Answer 12

Transverse fracture of 5th metacarpal

Question 13

Scaphoid fracture

Answer 13

Neck of scaphoid
Usually results from fall on outstretched hand
Hard to detect, requires many views
Risk of avascular necrosis
Risk bigger the more proximal the fracture is due to blood supply from distal to proximal end

Question 14

Types of hip fractures

Answer 14

Intracapsular (sub-capital, trans-cervical, basi-cervical)
Extracasdular (intertrochanteric)
Subtrochanteric

Question 15

Garden classification

Answer 15

Neck of femur fractures using trabecular pattern
1 - incomplete stable with impaction in valgus
2 - complete but undisplaced with two groups of trabecula in line
3 - complete fracture, incomplete displacement, impaction in varus
4 - completely fractured and displaced

Question 16

Weber classification of ankle fractures

Answer 16

A - below tibiofibular syndesmosis, lateral malleolus fracture (sometimes medial), intact ligaments
B - at level of tibiofibular syndesmosis, medial malleolus may be fractured
C - fibula fracture above ankle joint, disrupted tibiofibular syndesmosis

Question 17

Gustillo anderson fracture of open fractures

Answer 17

1 <1cm
2 1-10cm
3 >10 cm
A
B
C arterial injury limb salvage repair

Question 18

Plain radiograph signs of osteoporosis

Answer 18

More than 50% bone loss is required to detect decreased bone density (not sensitive)

Loss of cortical and trabecular bone 
Compression fractures (wedge) and vertebrae plana

Question 19

Plain film signs of pagets

Answer 19

Cottonwool appareance 
Losers sign (pseudofractures)
Large well defined lyric lesions
Picture frame vertebrae
Tam o’shanter sign
Bowing of long bones

Question 20

Plain film signs of Osteomalacia/rickets

Answer 20

Bowing of long bones, losers zone, enlargement of epiphysis (tickets)

Question 21

Plain film signs of multiple myeloma

Answer 21

Pepper pot/raindrop skull and endosteal scalloping

Question 22

Spinal stenosis due to posterior disc bulge

What type of imaging and signs?

Answer 22

MRI
Compression of nerves
Sagittarius and coronal view

Question 23

Plain film signs of spondylitis and spondyloslisthesis

Answer 23

Pars interaticularis defect (fracture) collar on Scottie dog on oblique view
Sagittarius view shows degree of slippage

Question 24

Plain film signs of Bone metastasis in lumbar spine

Answer 24

Winking owl sign (disappearance of Pedicles due to tumor or infection

Question 25

Plain film signs of ankylosing spondylitis

Answer 25

Sacroilitis - sclerotic lines, loss of joint space (fusion), subchodnral erosion Dagger sign - ossification of supraspinous and interspinal ligaments Bamboo spine - squaring of vertebrae due to erosions at entheses (enthesitis) - syndesmophytes : formation of “bridges” between vertebrae due to ossification of outer fibers of annulus fibrosus Fusion of lumbar spine

Question 26

Best imaging technique for Non-radio graphic axial spondyloarthritis

Answer 26

MRI may show erosions and bone marrow oedema

Question 27

Plain film signs of psoriatic arthritis

Answer 27

RA like - hand involvement, LESS spondylitis - spine involvement Arthritis mutilans - resorption of phalanges causing telescoping, severe erosions, sublux etc DIP involvement ``` Terminal phalanges resorption Mouse ears Pencil in cup deformities Dactylitis Ivory phalanx ```

Question 28

Plain film signs of RA

Answer 28

LESS -loss of joint space, erosions, soft bone (periarticular osteopenia), soft tissue swelling Commonly affects hands - MCP PIP, sublux, ulnar deviation, deformities Feet - MTP Cervical spine - atlantoaxial subluxation

Question 29

Additive arthritis ddx

Answer 29

RA

Question 30

Migratory arthritis ddx | Other signs of presentation

Answer 30

Rheumatic fever Autoimmune disease Following Streptococci infection. Heart, brain, skin and joint involvement

Question 31

Intermittent arthritis ddx

Answer 31

Gout

Question 32

Plain film shows signs of infection in two adjacent vertebrae and a disc between + Brodie’s abscess What is most likely organism?

Answer 32

Mycobacterial | Tuberculosis

Question 33

Plain film signs of OA

Answer 33

``` LOSS loss of joint space Osteophytes Subchondral cysts Sclerotic regions ``` Large weightbearing joints, asymmetric Lumbar and cervical spine PIP, DIP and base of thumb , (trapezium)

Question 34

Plain film signs of Gout

Answer 34

Diffuse opaque regions typically over first MTP joint indicates characteristic tophi formation Erosions Eat bite erosions ( well-defined “punches out erosions with sclerotic margins and overhanging edges)

Question 35

Plain film signs of Pseudogout

Answer 35

OA features with unusual joint distribution (symmetrical, non-weightbearing, intercarpal and MCP joints in hands) LOSS Chondrocalcinosis Wrist, knee

Question 36

Plain film signs of DDH

Answer 36

AP and frog lateral view Ossification of superior femora epiphysis should be symmetric Shenton line Draw line along inferior border of superior pubic ramus This line should continue laterally along inferomedial aspect of proximal femur Dislocations <6 weeks pavlik harness Older - closed reduction or open reduction, femoral osteotomy and fixation

Question 37

Plain film signs of SUFE

Answer 37

AP and frog leg lateral view SALTER HARRIS type 1 fracture Slip is posterior and slightly medial + inferior Klein’s line See straight line across lateral edge of femoral neck. Line fails to intersect the epiphysis Surgery;: open reduction and fixation with screws, prophylactically screwing opposite hip Femoral osteotomy Do not attempt closed reduction of severe slips (risk of AVN)

Question 38

Plain film signs of perthes disease

Answer 38

Signs of osteonecrosis Early: no signs Established: reduction in epiphysis size and lucency (herrings subtypes) Late: fragmentation and destruction proximal femoral neck widening (Coxa magna) Phases: initial (sclerotic), fragmentation, healing and remodeling Treatment: analgesia, physio, monitoring, non-surgical containment, group C may need surgical containment

Question 39

Plain film signs of osteomyelitis

Answer 39

X-ray changes after 10 days Lytic lesions with well defined border Periosteal reaction elevation (Codman triangle), onion skinning and sunray spicules New bone formation Sequestrum may be seen as sclerotic area Brodie’s abscess may be seen in distal femur

Question 40

What will show up as hot spots on bone isotope scan?

Answer 40

Pagets Malignant bone tumors Osteoid osteoma of the benign tumors