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 |
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). |
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. |
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. |
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.
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) |
6. Mnemonic for Systematic Review
“G‑J‑S” – General info → Joints → Soft tissues
(And always finish with Cortex check!)