Why is it important for us to know how to interpret radiographs?
"If you're incapable of interpreting x-rays, you're incapable of evaluating orthopedic functional impairment." T.R. Miller, MD
Dr. Davies put this on a slide
an x-ray. Use this term when talking to medical professionals, use x-ray when talking to patients
What is attenuation when referring to a radiograph?
The degree to which x-rays are absorbed/deflected by the body part.
plain film radiograph
- The most common diagnostic radiograph format
- no contrast material
What are the types of Radiology/Imaging?
- plain flim
- Bone Scan
Four Types of Radiographic Densities
- Gas (Air)
The greater the density of the anatomy, _______ the absorption of x-rays.
And Does the denser part of the anatomy look darker or lighter?
It looks lighter
List 6 types of material that show on an x-ray on a continuum from radiolucent to radiopaque.
- Gas (Air)
- Contrast Media
- Heavy Metal
What is the "fat pad sign?"
a sign of joint swelling causing increased opacity of adipose tissue
What are the factors that Affect Image Quality (5)?
- Thickness of tissue
What are two variations on plain films?
Any of several techniques for making detailed x-rays of a predetermined plane section of a solid object while blurring out the images of other planes.
A special radiographic diagnostic method in which a "live view" of the internal anatomy is possible.
what is the most common diagnostic radiograph format?
What to look for when viewing a radiograph? (4 basic categories)
- Correct patient
- Orient to correct side-patient position (looking at patient)
- Adequate film
- Systematic Scanning
What things do you consider when checking for adequate film when looking at a radiograph? (3)
- Are structures visualized?
- Were correct views taken?
- is the density of the structures normal?
What things do you consider when systematically scanning a radiograph? (8)
- General Appearance
- Periosteum and cortex
- normal, anatomic curves
- fracture lines
- Long bones: general appearance
- Long bones: Fracture extended into the joint space?
- Long Bones: Epiphyseal injuries (Salter-harris fracture classification)
What are the radiograph interpretation ABCS?
- Soft Tissues
ABCS: What 4 things should you assess for A?
A = Alignment
- Assess size of bone
- Assess/count number of bones
- Assess bones for normal contour and shape
- Assess the position of the bone in relation to the joint
ABCS: What 3 things should you assess for B?
B = Bone
- Assess Bone density
- Compare bone density at weight bearing surfaces
- Look at the texture of the one
ABCS: What 3 things should you assess for C?
C = Cartilage 1. Look at the joint space 2. Assess subchrondral bone 3. Look at the growth plates and epiphysis
What are the Hallmarks of OA (Fairbanks Changes)? (4)
1. Joint space narrowing 2. Bone spurs 3. Sclerotic borders 4. Subchrondral bone cysts
ABCS: What 3 things should you assess for S?
S = Soft Tissue 1. Look at gross size of surrounding muscle 2. Notice joint capsule outline (might see effusion) 3. Look at periosteum
What are 5 things to remember when interpreting radiographs?
1. Stability of affected area 2. Joints/area proximal & distal to the area of concern 3. Area of concern associated with pathology, such as 4. Chest films with neoplasms 5. Calcaneal fx associated with thoracolumbar Fx
Why is it important to get two radiograph views?
one view is no view because each one is in two dimensions, but the body is in three. Two views creates a 3D picture.
What are CPRS? and why are they useful?
Clinical Prediction Rules. They are a set criteria by which to determine when a radiograph is needed. They can help reduce needless recommendations for radiographs. An example he used was the Ottawa Ankle Rules (find out mech of injury; palpate, palpate, palpate)
Where should you check in addition to at the joint with the primary injury/complaint?
Proximal and distal to the area
Clusters of signs and symptoms (fractures) - know at least 6
MOI Localized pain Decreased function of involved part Feel the ends of the bones grating (crepitus) Swelling Deformity Abnormal Movement Ecchymosis Localized Tenderness on palpation Muscle Spasms
Radiographic Signs of Fracture (know at least 6)
Displacement of bone Change in shape of the bone Avulsion fragment Double Density Abnormal Fat pat Linear region of sclerosis Lucent Line Focal discontinuity in the structure of the bone (cortical disruption) Etc
Language of fracture (know 6)
Location within involved bone (epiphysis, metaphysis, intra-articular) Closed or open Complete or incomplete (crack/hairline/greenstick) Morphology of fractures (transverse, oblique, spiral, comminuted) Alignment or angulation Position Articular involvement Classification
Language of Fracture: 4 Locations with in involved bone
1. Epiphysis 2. Metaphysis 3. Diaphysis 4. Intra-articular
Language of fracture: Open vs. closed
Used in place of the outdated terms "simple" vs "compound" open: bone breaks through the skin closed: does not break through the skin
Language of fracture: complete vs. incomplete fracture
complete - broken all the way through incomplete - only part of the cortex is fractured (common in children or adults with soft bone) (Crack/Hairline/greenstick are all types of incomplete I think)
Language of Fractures: 4 Morphologies of fracture
1. Transverse - butterfly component 2. Oblique 3. Spiral - usually create big problems 4. Comminuted
A comminuted fracture resulting in two fragments of bone on either side of a main fragment; the result resembles a butterfly.
s complete & the break occurs at a right angle to the axis of the bone
bone break where bone shatters into many small fragments (at least three)
produced by twisting stress
* fracture occurring at an angle
angulation of fracture
angle between the distal and proximal fragments as a function of the degree to which the distal fragment is deviated from its normal position
force pulls bone in longitudinal way in one direction
Fracture classifications are usually based on what two things?
Description or MOI
Fracture Description Classifications (based on relation ship of fracture fragment to each, undisplaced or displaced). (6)
1. Translated (shifted sideways) 2. angulated 3. rotated 4. distracted 5. overriding 6. impacted
Radiographic signs of Open fractures (6)
1. Soft tissue defects 2. Bone fragments protruding beyond soft tissues 3. gas in soft tissues 4. intro-articular gas 5. presence of foreign body 6. missing bone fragments
Two reasons open fractures communicated with the external environment:
fracture fragment has penetrated skin from within or sharp object has penetrated the skin to fracture bone from without
What is a serious risk always associated with open fractures?
risk of complication from infection
a fracture as a result of compression. Often found in the vertebral bodies
Impacted fracture in which the periosteum is bulging; also known as a buckle fracture
Separation of a bone fragment from its cortex at an attachment of a ligament or tendon
involves the joint surface of a bone
Fracture involving the epiphyseal plate
9 Types of Fractures based on description
1. Transverse 2. Oblique 3. Spiral 4. Compression 5. torus 6. Comminuted 7. Avulsion 8. Intra-articular 9. Epiphyseal
6 types of fractures based on relationship of one bone to the other:
1. Translated 2. Angulated 3. Rotated 4. Distracted 5. Overriding 6. Impacted
Spiral fracture can also be called: (3 other names)
1. twisting 2. Tortional 3. rotational
Compression fracture can also be called: (2 other names)
1. Impacted 2. Crush
Torus fracture can also be called: (1 other names)
Draw and label Salter-Harris classification system:
Salter-Harris Classification system description
Type I: straight across through physis Type II: above (through metaphysis) Type III: lower (through epiphysis and into joint) IV: through all (metaphysis, physis, and epiphysis) V: erasure of growth plate (crush injury)
Salter Harris written description
Type 1: through physeal place Type II: Physeal fracture that extends through metaphysis Type III: Physeal frature that extends through epiphysis Type IV: physeal plate plus epiphysis and metaphysis Type V: compression fracture of growth plate
Classification of Salter Harris fractures (pneumonic)
"Prison Makes Every Boy Cry" - ALL of these somehow penetrate through to the articular space, i.e., there is joint involvement. III-V threat to growth I: Physis II: Metaphysis III: Epiphysis IV: Both V: Crush
Fracture descriptions based on deformity:
1. Angulation 2. Displacement or Dislocated (displaced/non-displaced) 3. Shortened 4. Rotation
Five things to remember
1. 1. naming of fractures is almost always a combination of terms 2. Many typical fractures are named for people 3. Radiographs don't lie! 4. one view is no view! 5. know when to seek assistance!
Radiographic findings in stress fractures (9)
1. Normal - early (
outer, hard, compact bone, cortical outline
1. In radiology, a region in an image caused by an absorber of lower x-ray attenuation than its surrounding tissues; in general, the opposite of opacity.
General principles of fracture management (6)
1. first, do no harm 2. base treatment on accurate diagnosis & prognosis 3. Select treatments with specific aims 4. Cooperate with the "laws of nature" 5. make treatments realistic and practical 6. select treatment for the individual patient
What are the specific aims in the general principles of fracture management? (3)
1. relieve pain 2. obtain and maintain satisfactory position of the fragments 3. allow, and if necessary, encourage bony union to restore optimum function
Specific treatments in fracture management: (8)
1. Protection alone (no reduction or immobilization) 2. Immobilization alone, external splint (w/o reduction) 3. Closed reduction by manipulation --> immobilization 4. Closed reduction by continuous traction --> immob. 5. Closed reduction --> functional bracing 6. Closed reduction by manip --> external skel. fixation 7. Closed reduction by manip --> internal skel. fixation 8. Open reduction --> internal skeletal fixation
reduction of a fracture
return of a fractured bone to a normal position; may be closed (not requiring surgery) or open (requiring surgery)
Healing process during fracture management: (6)
1. Fracture hematoma 2. Osteogenic cells form external callus 3. Endosteum forms internal callus 4. Fracture callus - clinical union - biological glue 5. Radiographic union 6. Wolff's law
What is a radiographic union?
when the cartilaginous callus is replaced by woven bone(hard callus) via endochondral ossification
A law of bone states that the architecture of bone is determined by mechanical stresses placed on it and the bone's adaptation to withstand those stresses.
Complications (general) in Fracture Management: (6)
1. skin injuries 2. neuro-vascular triad injuries 3. muscular injuries 4. other injuries from trauma 5. remote injuries 6. hemorrhagic shock
What is the "dreaded black line?"
* Stress fracture of the anterior tibia. * most be non-weight bearing to heal * DON'T ever miss it * Can lead to major fracture of Tibia
What is the gold standard radiograph type for a bony injury?
CT scan (Computed Tomography)
Injury on the opposite side of where there is an obvious injury. IMPORTANT
salter-Harris Fracture Classification system is for
Kids who have ophen physis
Salter-Harris, type I
Type I: transverse fracture through physis * Looks normal but there is swelling and pain * Palpate right over physis & it is extremely painful there * make assumption that they have type I * Will not show on radiograph
Salter-Harris, type II
Type II: Same as type I but also up into the metaphysis (the bone) * Will show on radiograph
Salter-Harris, type III
Type III: Intra physis goes into epiphysis, * Bad news * Effects chrondral surfaces * Chrondral surfaces do not heal and this is almost always the first step to OA * Can cause deformities when half of the physis grows and the other doesn't
What is almost always a first step to OA
Type III salter-harris fracture. intra physis fracture goes into epiphysis
Salter-Harris, type IV
Type IV: Metaphisis, physis, & metaphysis * Big issues
Salter-Harris, type V
Type V: Compaction * Compresses that area * Commonly leads to cessation of the growth plate on injured limb * Compression/crush injury
Local fracture complications: (5)
1. skin necrosis 2. compartment syndrome 3. joint infections 4. osteomyelitis 5. avascular necrosis
Remote fracture complications: (4)
1. Fat embolism 2. Pulmonary embolism 3. pneumonia 4. tetanus
bone marrow and other fatty intraosseous tissue enter the circulation as a result from severe fractures
Late AND local fracture complications: (9)
1. Joint stiffness 2. post-traumatic DJD 3. Abnormal fracture healing 4. Growth disturbances 5. Chronic osteomyelitis 6. Post-traumatic osteoporosis (related to Wolff's law) 7. Post-traumatic myositis ossificans 8. Tendon ruptures 9. RSD/CRPS (complex regional pain syndrome)
RSD or CRPS
Reflex Sympathetic Dystrophy, or Complex Regional Pain Syndrome sympathetic nervous system is in "overdrive", sustains neuropathic pain
Four Types of Fracture Complications:
1. Mal-union 2. Delayed union 3. Fibrous union (pseudoarthrosis) 4. Non-union
bone formation within muscle
- Direct bone infection - Often through blood, injury, or adjacent soft tissue infection - Staph, - Salmonella (increased risk with sickle cell disease), - Tuberculosis (in spine first) - Syphilis can cause (rarely)
Unsatisfactory position with residual bony deformity
Fracture delayed union
fracture may eventually heal but takes longer than normally expected time frame
fracture fibrous union
also called pseudoarthrosis soft tissue healing
fracture may fail to completely heal by bony union
Types of Imaging studies:
1. Radiographs 2. Fluroscopy 3. Video Fluroscopy 4. Bone Scans (scintigraphy) 5. Ultrasonography 6. Computed Tomography (CTs) 7. Magnetic Resonance Imaging (MRIs/MRAs)
* x-ray in real time
What is Floroscopy used for? (6)
1. Fracture fixation 2. arthrography 3. myelography 4. discography 5. biopsy 6. gastrointestial evaluation
-immobilization to maintain realignment of the fracture site... -traction, fixation (pinning/immobilizer), casts
study of the spinal column after injecting opaque contrast material
Special x-ray technique for examining a body part by immediate projection onto a fluorescent screen in real time. Can be called video fluroscopy
Bone scans are also called
Bone Scan (Radionuclide Scintigraphy)
* Nuclear imaging test that Helps to diagnose and track bone disease * Diagnose unexplained skeletal pain that's undetectable on an X-ray by showing increased blood flow. very useful in Dx of sublte fractures * MOSTLY REPLACED by MRI * Very sensitive, but NOT specific * can't figure out what is going on there. * called stress reaction
Rehabilitative US Imaging (RUSI)
- used in both PT research AND treatment - assesses muscle behavior and - treats pts (muscluloskeletal imaging --> biofeedback) Advantages: ease of access, portability, pt tolerance, real-time imaging Good validity & riliability Disadvantage : hard to interpret!!
Axial imaging with ability to reformat to any plane GOLD STANDARD for BONE IMAGING (do radiograph first, then gold standard CT if indicated)
inject dye into joint capsule and to CT to see if it leaks
* Gold Standard for Soft Tissue imaging * Expensive (MRAs most expensive) * Two Types * Type T1: Weighted (bright) image is fat, water dark * Type T2 Weighted image (bright) is water
Two types of MRI
* Type T1: Weighted (bright) image is fat, water dark * Best for anatomic structure Type T2 Weighted image (bright) is water * Best for contrasting normal and abnormal tissue.
magnetic resonance angiography (shows vessels) Increases sensitivity and specificity of the imagaing technique Use contrast dye
What things appear dark on T1 MRI and light on T2 MRI?
Water CSF Acute Hemorrhage (blood) soft tissue tumors (blood)
5 Disadvantages of MRI
1. Expensive 2. subject to artifact from metal 3. can cause shifting of metal/foreign objects in eyes/brain 4. can interfere with pacemakers 5. clausterphobia (10% pts can't tolerate)