Summary X-rays Orthopedics

Aspect	Critical Points
X‑ray Request Form	Patient ID (name, DOB, sex, UR #); clinical question; relevant history (age, mechanism, DDx); required views (AP, Lat, Oblique, Special); location (ED, ward); previous films; allergies; referring doctor details
Systematic Reading Workflow	1️⃣ General information 2️⃣ Bone 3️⃣ Joint 4️⃣ Soft‑tissue – always follow same order, compare bilateral sides & prior films
General Information Checklist	Patient data; anatomical region visualised; listed views; image quality (exposure, contrast); presence of casts, splints, pins, implants
Bone Assessment	- Age/quality – epiphyseal plates (open vs closed) - Morphology – diaphysis, metaphysis, epiphysis, growth plate, apophysis, sesamoids - Fracture search – cortical continuity, peri‑osteal reaction, lesions (lucent/blastic) - Key descriptors – varus/valgus, displacement, rotation, tilt, shift, impaction
Joint Assessment	- Identify joint name - Alignment – varus/valgus, subluxation, dislocation - Joint space – narrowing, widening, sclerosis - Articular surfaces – congruity, sub‑chondral bone, osteophytes
Soft‑Tissue Assessment	Air (open fracture), fluid, calcifications, fat‑pad sign, muscle bulk/planes, tendons, ligaments, unexpected masses (e.g., lung apex)
Fracture Evaluation (2 Joints / 2 Views)	Site (bone + specific region: shaft, neck, metaphysis, intra/extra‑articular) Type (simple, comminuted, spiral, oblique, transverse, segmental, butterfly) Fracture line (orientation, pattern) Displacement – shift (medial‑lateral, anterior‑posterior), tilt, rotation, overlap/shortening, gaping/lengthening, impaction Special Issues – neuro‑vascular injury, peri‑osteal reaction, callus, AVN risk, pathological‑fracture (osteopenia, tumor, cyst), fixation devices (plate, screw, IM nail, cast, slab)
Bone Lesion Characterisation	1️⃣ Location – sub‑cortical, intra‑medullary, juxta‑articular, etc. 2️⃣ Number – solitary vs. multiple 3️⃣ Pattern – bone‑forming (osteoblastic) vs. bone‑eating (osteolytic) 4️⃣ Margins – well‑defined/sclerotic (benign) vs. ill‑defined/wide transition (malignant) 5️⃣ Matrix – chondroblastic (calcified) vs. osteoblastic (cloud‑like) 6️⃣ Periosteal reaction – solid/continuous vs. interrupted (sunburst, lamellated, Codman triangle) 7️⃣ Cortex – intact, eroded, destroyed 8️⃣ Soft‑tissue extension – absent (benign) vs. present (malignant)
Key Normal Variants	Fabella, bipartite patella, sesamoid bones – recognize to avoid false‑positive fractures
Common Imaging Modalities	- X‑ray – first line, quality check, “follow the cortex” - CT – cortical detail, complex anatomy, intra‑pelvic/spine - MRI – soft‑tissue, marrow oedema, lesion extent, joint effusion - Bone scan (Tc‑99) – metabolic activity, skip lesions, metastasis
Exam‑Ready Mnemonics	C‑R‑I‑S‑P – Clinical info, Requested views, Image quality, Systematic approach, Peri‑osteal reaction S‑T‑A‑R‑T – Site, Type, Alignment, Rotation, Translation for fractures

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1. General Checklist (apply to every study)

✅ Item	What to look for
Patient data	Name, age, sex, date, view(s) (AP, Lateral, Oblique)
Image quality	Proper exposure, correct positioning, presence of casts/splints/implants
Systematic read	Bone → Joint → Soft‑tissue. Always review both joints and both views.
Cortex rule	If the cortex is intact → no fracture. Follow the cortex on every bone.
Compare	Other view, opposite side, prior X‑ray (if available).

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2. Upper Limb

Region	Key Radiological Findings	Typical Pitfalls / Tips
Shoulder	• Acromion, clavicle, humeral head, glenoid identified. • Dislocation: Light‑bulb sign (posterior) or widened glenohumeral space (anterior). • Fracture: Greater tuberosity (vertical line), surgical neck (transverse), clavicle (mid‑shaft transverse). • Soft‑tissue: Subacromial fat‑pad sign, calcific tendinitis.	Don’t miss a subtle clavicle fracture; check for subtle glenoid rim fractures.
Elbow	• Bony landmarks: Olecranon (short oblique intra‑articular), radial head, coronoid process. • Fracture: Olecranon (short oblique, displaced), distal humerus (supracondylar transverse), radial neck (transverse, lateral tilt). • Displacement: Posterior displacement of olecranon → “flipped” fragment.	Always view AP + lateral; the “posterior fat‑pad sign” suggests occult fracture.
Wrist / Hand	• Carpal row: scaphoid, lunate, triquetrum, pisiform. • Fracture: Scaphoid (waist, undisplaced), distal radius (Colles – dorsal tilt ~20°), distal ulna (styloid). • Joint space: Look for widening (intra‑articular fracture). • Soft‑tissue: Air → open fracture; periosteal reaction = healing.	Scaphoid fractures may be subtle – follow the cortex over the waist.
Forearm (Radius / Ulna)	• Diaphysis: Look for both‑bone forearm fractures – displaced radius & ulna, often with forearm rotation. • Growth plate: Salter‑Harris lesions (especially in children). • Special patterns: Green‑stick (partial bend) or torus (buckle) fractures in kids.	Check alignment of radius and ulna on both AP and lateral; “radius shift” suggests mal‑union.

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3. Lower Limb

Region	Key Radiological Findings	Typical Pitfalls / Tips
Hip / Pelvis	• Head‑neck‑shaft of femur; acetabular roof. • Fracture: Intracapsular neck (transverse, varus displacement → AVN risk), intertrochanteric (comminuted, valgus), greater trochanter (avulsion). • Dislocation: Posterior (femoral head displaced posteriorly). • Soft‑tissue: Joint effusion, calcified loose bodies.	Always assess for valgus/varus angulation; intra‑capsular → high AVN risk.
Femur (shaft)	• Diaphysis: Simple transverse, oblique, spiral, comminuted. • Special issues: Pathological fracture (lytic lesion, metastatic), callus formation (healing), implants (IM nail, plate). • Displacement: Medial shift, overlapping fragments.	Look for cortical thinning/lysis → underlying tumor.
Knee	• Joint: Distal femur, proximal tibia, patella. • Fracture: Distal femur (vertical split, intra‑articular), tibial plateau (lateral / medial, depressed or split). • Alignment: Varus/valgus angulation, joint space widening. • Patella: Bipartite patella (normal variant) vs. fracture line.	CT is often needed for depressed tibial plateau; check for fat‑pad sign in occult fractures.
Ankle / Foot	• Bones: Tibia, fibula, talus, calcaneus, navicular, cuboid, metatarsals. • Fracture: Lateral malleolus (spiral), medial malleolus (simple transverse), bimalleolar (fibular fracture above syndesmosis + medial). • Special: Syndesmotic injury (high fibular fracture), deltoid ligament rupture, talar dome fracture. • Foot: Metatarsal stress fracture (transverse line, periosteal reaction).	Don’t overlook a subtle fibular fracture above the syndesmosis – it dictates management.
Toe / Hand (small bones)	• Phalanges, metacarpals/metatarsals – look for torus (buckle) or green‑stick in children, and committed fractures in adults. • Avulsion: Small fragment at tendon insertion (e.g., sesamoid, fifth metatarsal tuberosity).	Check for displaced fat‑pad sign indicating intra‑articular injury.

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4. Spine (if covered in your exam)

Segment	Key Radiological Findings
Cervical	Alignment (lordosis), fracture (cervical spine, odontoid, Hangman), disc height loss, pre‑vertebral soft‑tissue swelling.
Thoracic	Compression fractures (wedge, burst), spondylolisthesis, rib fractures.
Lumbar	Burst & compression fractures, pars interarticularis defects, disc degeneration, osteophytes.

Use the “follow the cortex” rule for vertebral body integrity.

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5. Quick “Red‑Flag” List (must not miss)

Finding	Why it matters
Displaced intra‑capsular femoral neck fracture	High risk of AVN → urgent surgery
Open fracture (air in soft tissue)	Requires debridement & antibiotics
Syndesmotic injury + high fibular fracture	Needs ORIF & possible fixation of syndesmosis
Pathological fracture with lytic lesion	Look for underlying tumor or metastasis
Depressed tibial plateau or calcaneal fracture	Often needs CT & surgical elevation
Spinal burst fracture with canal compromise	Neurologic risk → urgent neurosurgery
Soft‑tissue mass + aggressive periosteal reaction	Suggests malignant bone tumor (e.g., osteosarcoma)

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6. Mnemonic for Systematic Review

“G‑J‑S” – General info → Joints → Soft tissues
(And always finish with Cortex check!)