Orthopaedics Articles Interpreting Orthopaedic Radiographs

Introduction
Plain radiographs (more commonly referred to as x-rays) are a routine investigation both for diagnosing and monitoring skeletal conditions. Common reasons to use skeletal x-rays are: - The identification of fractures - Osteomyelitis - Structural abnormalities (for example scoliosis) - Degenerative joint conditions - Follow up of joint replacements. This list is not exhaustive. When analysing (and ordering) x-rays you should remember the rule of two: 1. 2. 3. 4. Two views. At 90 degrees, usually anterior-posterior and lateral. Two joints. The joints above and below. Two occasions. Some fractures are not easily visible immediately after trauma. Two limbs. If required for comparison.

NB: In certain injuries, special views are required. These include Scaphoid views, Skyline views for the patello-femoral compartment of the knee and Mortis view at the ankle.

Description of an x-ray
X-Rays are only as reliable as the person interpreting them, therefore adopting a systematic approach will prevent you from missing anything.

Start with the basics

Patient Details- Name and Age / Date of Birth X Ray Details- Date, time and adequacy (Is the penetration of x-ray beam suitable? Does the image show the entire bone in question showing the joint and above?) NB make the point that it is 'a plain radiograph'.

Now you have established that the X-ray is of the right patient, and is a suitable image, you should orientate yourself.

What projection (view) is the x-ray? (Anterior-Posterior/AP, Lateral, Skyline, Scaphoid, Mortis etc) What is the x-ray of? (Right or Left? Which bones? Which joints? Is there a joint replacement?)

Next, each part of the x-ray, Bones, Joints AND Soft Tissues need to be addressed. There is no formal order, however, if you see an obvious abnormality, you may want to begin there. The principle here is to say what you see.

Bone Is the bone regular, or is there a gross abnormality? If so describe it. Is the cortex intact? Follow the entire cortex and look for any discontinuity. Fractures: - Location (Epiphysis/ Metaphysis/ Diaphysis ; Proximal, Mid or distal third) - Pattern (see image 1) - Deformity (see image 2). All deformities are described as distal fragment relative to proximal fragment. Is there any change in bone density? -Radio-lucent, thinner than surrounding bone -Radio-opaque = thicker than surrounding bone

Joints Is the joint in the correct position? Is it dislocated- which direction? Does a fracture involve the joint? Are there any features of joint damage or degeneration?

Soft tissues Is there any evidence to suggest this is an open fracture? Can you see any localised swelling?

Image 1

Image 2

Radiographic Comparison- Oesteoarthritis vs Rheumatoid Arthritis

Osteoarthritis

- Reduced joint space - Subchodral sclerosis - Subchondral cysts - Osteophyte formation

Rheumatoid Arthritis

- Loss of joint space

- Articular erosions - Periarticular osteopenia - Soft tissue swelling

Example Trauma Radiograph

An example of how you would present the x-rays of the fictional patient above would be:

"These radiographs belong to Mr John Smith, date of birth January 1st 1900. They were taken on December 25th 2010.

On the left is an AP X-ray of the shaft of Left Femur, including part of the knee joint. On the right, a Lateral xray of the distal Left Femur including knee joint.

The left femur has a completely displaced, oblique fracture of the midshaft. There is overlap of the distal fragment of approximately 10% length. The distal fragment is also angulated approximately 15 degrees varus. There appears to be a radio-lucent leision at the fracture site, visible on the Lateral film. There is no abnormality with the knee joint.

Soft tissues are swollen aroud the fracture site.