MSK radiology interpretation and presentation osce Fractures radiology PDF

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Summary

Fractures radiology presentation and interpretation...

Description

Generic Approach Demographics   

Patient: name, DOB, hospital number, age, sex Previous films Other orientations (need AP and another view – usually lateral)

Radiograph detail    

Date Type (AP, lateral, other view) Area of body (including left/right) Adequacy o Exposure i.e. Area: ideally need joint above and below o Rotation o Penetration

Only one view is one view too few

Interpretation (ABCS) Briefly mention obvious abnormalities first

Alignment 

Joints and bones – look for dislocation or subluxation (partial dislocation)

Bones     

Cortex – trace around outline looking for fractures → SEE NOTES BELOW FOR HOW TO DESCRIBE FRACTURES o Thinned cortex with osteoporosis Medullary cavity Bone fragments Texture of bone between cortex - Well defined trabecular pattern visible - in some bones a fine matrix of fine white lines (trabeculae) is seen. Sesamoid bones

Cartilage   

Joint spaces – loss or large, any sign of osteoarthritis LOSS, any sign of joint effusion Disruption of joint contours Signs of OA/RA/psoriatic/gout/pseudogout (below)

Soft tissues    

Disruption Swelling e.g. Joint effusion containing fat and blood (lipohaemarthrosis) Foreign bodies or calcification Artefact

To complete  

“To complete my analysis, I would examine other films and determine the clinical history” Summarise

System for describing a fracture (SOD)  Site o Bone o Intra/extra-articular o Position (proximal/middle/distal third)  Obliquity o Completeness (complete, incomplete) o Direction (transverse, oblique, spiral) o Skin penetration (open, closed) o Fragments – simple or comminuted\/ © 2013 Dr Christopher Mansbridge at www.OSCEstop.com, a source of free OSCE exam notes for medical students’ finals OSCE revision

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o Condition of bone (comminuted, segmental, multiple, impacted) Displacement o Translation (% of bone diameter) – ant/pos or med/lat o Angulation (˚) – transverse, oblique, spiral ant/pos or med/lat o Rotation (˚) o Length distraction/shortening o Radiolucent - new fracture lines are sharp, clear and radiolucent (i.e. dark black line)

Dark black line – decreased density – more x-rays passing through – fracture White line/area – increased density – less x-rays passing through – impacted bone or overlap Fracture description mnemonic – OL’ DAC O – open or closed L – Location D – displacement – RALT (rotation, angulation, length distraction, translation_ A – articular involvement – intra or extra articular C – communited / type – complete, incomplete S – stable/unstable PLASTER OF PARIS: Plane Location Articular cartilage involvement Simple or comminuted Type (eg Colles') Extent Reason Open or closed Foreign bodies disPlacement Angulation Rotation Impaction Shortening https://slideplayer.com/slide/3898197/ e.g. “There is an extra-articular fracture of the distil third of the right tibia. It is a complete transverse fracture. The fracture is closed. It is likely to be a stable fracture. It is non-displaced.” Glossary Completeness  Complete (bone breaks along the whole of its width)  Incomplete (bone cracks but ends do not separate) Direction  Transverse (stright break at a right-angle to the long axis of the bone due to trauma)  Spiral (corkscrew type fracture due to rotation injury)  Oblique (straight break through a bone but at an angle i.e. not transverse; very rare) Surrounding structural damage  Simple (isolated bone damage i.e. no significant soft tissue damage)  Complex (significant soft tissue damage)  Closed (skin is intact)  Open / compound (broken bone protrudes through the skin) Condition of bone  Stable (likely to stay in a sound position during healing)  Unstable (likely to change orientation)  Comminued (more than two detached bone fragments)  Segmental (multiple complete fractures to bone creating detached bone fragment)  Multiple (several fracture lines)  Impacted (ends of the break are compressed toether)  Hairline/fissure (crack through the outer layer of the bone)  Greenstick (incomplete fracture of one side of the bone resulting in bending of the bone, usually in children) © 2013 Dr Christopher Mansbridge at www.OSCEstop.com, a source of free OSCE exam notes for medical students’ finals OSCE revision

Common Joint Pathology 

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Osteoarthritis o Loss of joint space o Osteophytes o Subchondral cysts o Subchondral sclerosis Rheumatoid arthritis o Loss of joint space o Peri-articular osteopenia o Juxta-articuar (marginal) erosions - CLASSIC o Soft tissue swelling Psoriatic arthritis o Central erosions (→ pencil in cup appearance) Gout o Punched out lesions in bone (peri-articular tophi) Pseudogout o Chondrocalcinosis

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Musculoskeletal Radiograph Interpretation – Specific Approach by Joint/Area The generic approach to musculoskeletal radiograph interpretation is covered separately. This is sufficient for most single bone radiographs. However, radiographs of many joints/areas require a specific approach to interpretation or have specific signs which need to be looked for within the ABCS approach – these are outlined here.

Facial bones 

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Identify zygoma (stool) and look for fractures of its 4 legs: 1. Zygomatic arch – if you imagine the zygoma as an elephant’s head, this leg looks like an its trunk on a radiograph 2. Frontal process of zygoma 3. Orbital floor 4. Lateral wall of maxillary antrum Soft tissue signs indicating a fracture (working downwards) o Black eyebrow sign – black eyebrow like shadow across top of orbit (air in orbit from sinus, usually due to orbital blow-out fracture) o Teardrop sign – dark shadow at the top of the maxillary antrum (soft tissue herniation of orbital contents from orbital blow-out fracture) o Fluid level – in maxillary antrum (blood from fracture)

2 MAXILLARY ANTRUM

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Common pathology  Nasal bone fracture: commonly due to punch injury; may not be seen on radiographs and X-rays are not performed to specifically look for it as it does not change management; look up the patient’s nose to exclude a septal haematoma!  Mandible fracture: commonly due to punch injury; use an OPG X-ray to look for it, not a facial bone X-ray  Zygomatic arch fracture  Orbital floor fracture  ‘Tripod’ fracture: fractures of all 4 ‘legs’ of the zygoma due to major trauma – should really be called a quadripod fracture

Cervical spine Lateral view (ABCS)… © 2013 Dr Christopher Mansbridge at www.OSCEstop.com, a source of free OSCE exam notes for medical students’ finals OSCE revision

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Adequacy: Need to see skull base and C7/T1 disc space (if not, get swimmer’s view)

Alignment 

Alignment arcs (look for smooth curves) 1. Anterior vertebral body line 2. Posterior vertebral body line 3. Spinolaminar line (anterior edges of spinous processes) 4. Posterior spinous line (posterior edges of spinous processes)

Bones 

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Peg of C2 sticking up o Should be smooth and flat o Atlanto-axial space should be...