Orthopaedics Articles Interpreting Orthopaedic Radiographs

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'.

Deformity (see image 2).Pattern (see image 1) . Proximal. There is no formal order. each part of the x-ray. Scaphoid. and is a suitable image. What projection (view) is the x-ray? (Anterior-Posterior/AP. Joints AND Soft Tissues need to be addressed. Fractures: . however. you may want to begin there. you should orientate yourself. Now you have established that the X-ray is of the right patient. Lateral. Bone Is the bone regular. Mortis etc) What is the x-ray of? (Right or Left? Which bones? Which joints? Is there a joint replacement?)  Next. Mid or distal third) . or is there a gross abnormality? If so describe it. Is the cortex intact? Follow the entire cortex and look for any discontinuity.Location (Epiphysis/ Metaphysis/ Diaphysis . All deformities are described as distal fragment relative to proximal fragment.which direction? Does a fracture involve the joint? Are there any features of joint damage or degeneration? . The principle here is to say what you see. thinner than surrounding bone -Radio-opaque = thicker than surrounding bone Joints Is the joint in the correct position? Is it dislocated. if you see an obvious abnormality. Bones. Skyline. Is there any change in bone density? -Radio-lucent.

Soft tissues Is there any evidence to suggest this is an open fracture? Can you see any localised swelling? Image 1 Image 2 .

Osteophyte formation  Rheumatoid Arthritis .Subchondral cysts .Reduced joint space .Oesteoarthritis vs Rheumatoid Arthritis  Osteoarthritis .Loss of joint space .Radiographic Comparison.Subchodral sclerosis .

.Soft tissue swelling .Articular erosions .Periarticular osteopenia .

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. On the left is an AP X-ray of the shaft of Left Femur. . They were taken on December 25th 2010. date of birth January 1st 1900. On the right. including part of the knee joint. a Lateral xray of the distal Left Femur including knee joint.

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

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