Approach to Orthopaedic X-rays

Question 1

Differentiate between open and closed fractures

Answer 1

CLOSED: No open wounds of skin near the fracture

OPEN: There is open wounds of skin near fracture. Bone might protrude from the skin. EG, Gunshot wounds.

Question 2

How do you manage an OPEN FRACTURE?

Answer 2

It is an orthopaedic emergency.

Bleeding must be controlled
Management:
1. IV antibiotics must be given ASAP
2. Tetanus( Tetanus is a potentially fatal bacterial infection that affects the nerves) prophylaxis
3. PAIN control
4. Wash out of open wound with sterile saline
5. Reduction of fracture or dislocation.
6. Immobilization of Fracture.

Question 3

Describe an overview of an approach you will use to describe EVERY orthopaedic X-ray you evaluate.

Answer 3

Use ABCS approach
A- Adequacy and Alignment
B-Bones
C-Cartilage
S-Soft tissue

APPLY THIS TO EVERY ORTHOPAEDIC X-RAY YOU EVALUATE.

To evaluate adequacy, check the patient’s name, hosp. number and date. Make sure you’re viewing correct side. Make sure the X-ray has adequate penetration.

Question 4

Describe the Rule of 2’s (viewing orthopedic X-rays)

Answer 4

• Two views –
  – Ussually AP and Lat
• Two joints
  – Visualise the joint below and joint above
  – Customise based on the x-ray – eg: distal radius focus on the wrist joint not the whole forearm
• Two occasions
  – Before and after intervention
  – Or a week after injury a fracture may be more clear –
  eg:scaphoid
• Two sides
  – To compare the injured and uninjured sides – especially in
  children to distinguish growth plates from fractures

Question 5

What is alignment, and how do we describe the fracture and its alignment?

Answer 5

Alignment: Is the relationship in the longitudinal axis of one bone to another.

We use LARA to describe alignment
L- Length- Is there shortening of the bone fragments.
A-Apposition-how displaced is the fracture? (100% apposition, 50%, 0%)
R-Rotation- Is there rotation of the limb? This is sometimes difficult to assess, so look at the view of the joint below and joint above.
A- Angulation- Is there angulation in the bone axis at the fracture?

Question 6

How do you describe a fracture in detail?

Answer 6

Well, start of by describing the position of the fracture
»Which bone

> > Where on the bone> Proximal, Middle, or distal third or INTRA-ARTICULAR

> > Fracture pattern> Transverse, oblique, spiral, butterfly fragment, segmental and comminuted.

Question 7

How do you describe a fracture site?

Answer 7

Describe the precise anatomic location of fracture

Include if it’s left or right sided bone

Include the name of the bone

Include location: Proximal, midshaft, distal (to aid this, divide the bone in 1/3)

Question 8

Describe the 4 types of fracture lines

Answer 8

1. Transverse- occur perpendicular to long axis of bone.
2. Oblique- occurs obliquely crossing the bone.
3. Spiral- occur in a spiral fashion along the long axis of bone.
4. Comminuted (Fragmented)- 2 or more bone fragment. Sometimes difficult to see on X-ray.

Question 9

How do you examine the bones on X-ray?

Answer 9

• Examine the bones for
  fracture lines or
  distortions – follow
  cortical lines
• Examine the entire length
  of the bone
• Fractures may be subtle!
• Check bone texture for
  abnormality e.g. in
  osteoporosis

Question 10

How do you examine the cartilage on X-ray?

Answer 10

• Cartilage implies to
  examine the joint spaces
  on X-rays ( you can not
  see the actual cartilage
  on X-rays
• Widening of joint spaces
  signifies ligamentous
  injury or dislocation or
  fractures
• Check for narrowing of
  joint space due to
  cartilage loss or widening
  due to dislocation

Question 11

How do you examine soft tissues on X-ray? What are you looking for?

Answer 11

• Look for soft tissue swelling and joint effusions
• These can be signs of occult fractures

Question 12

Describe a FAT PAD SIGN

Answer 12

swelling posteriorly – posterior fat pad sign

swelling anteriorly – know as pathologic anterior fat pad sign

Both of these are signs of occult fracture which is not seen on the X-ray

Question 13

Describe the clinical and X-ray analysis/ evaluation of fractures

Answer 13

• Clinical:
  – Open or closed fracture
  – Anatomical location of fracture
  – Neurovascular status
• X-rays:
  – Anatomical location of fracture
  – Fracture line
  – Relationship of fracture fragments