X-ray Interpretation Skills

Dr. Hisham Alsanawi

Assistant Professor
Medical Decision Making is a Triad

History from patients/records

Physical Examination
Confirming Studies Imaging, Labs, etc.
 Imaging
X-ray
Ultrasound
CT Scan
MRI
Nuclear Medicine
 X-RAY
Radiation Source
Patient Exposed
Capture Image
Interpret Image
 X-RAY
Ionizing Radiation
Radiation damages cells
 X-RAY
Patient Blocks Transmission of Radiation
Soft tissues Less
Bones More
 X-RAY
Capture Image
Films
Digital
 X-RAY
Interpret Image
Radiologist
Orthopaedist
 X-RAY
Best for:
Hard tissue
Bones
Often combined with other imaging
 OBJECTIVES
Review a systematic approach to interpreting
orthopedic x-rays

Review the language of fracture description

 ABCs APPROACH
Pre ABC: identify pt, read provided info
A
Adequacy
Alignment
B
Bones
C
Cartilage
S
Soft Tissues
Apply ABCs approach to every orthopedic film you evaluate
 ADEQUACY
All x-rays should have an adequate number of
views.
Minimum of 2 viewsAP and lateral
3 views preferred
Joint above and joint below

All x-rays should have adequate penetration

 ALIGNMENT
Alignment: Anatomic relationship between
bones on x-ray
Bone alignment vs other side
Bone alignment relative to proximal and distal
bones

Normal x-rays should have normal alignment

Fractures and dislocations may affect the

alignment on the x-ray
 BONES
1. Identify bone
2. Examine the whole bone for
1. Discontinuity fractures
2. Change in bone shadow consistency change in
density
3. Describe bone abnormality
1. Location
2. Shape
 CARTILAGE
Cartilage
joint spaces on x-rays
you cannot actually see cartilage on x-rays

Widening of joint spaces signifies

ligamentous injury and/or fractures
Narrowing of joint spaces arthritis
 SOFT TISSUES
Soft tissues implies to look for soft tissue
swelling and joint effusions

These can be signs of

Trauma
occult fractures
Infection
Tumors
 REVIEW: ABCs
A
Assess adequacy of x-ray which includes proper number of views
and penetration
Assess alignment of x-rays
B
Examine bones throughout their entire length for fracture lines
and/or distortions
C
Examine cartilages (joint spaces) for widening
S
Assess soft tissues for swelling/effusions
EXAMPLE # 1
 EXAMPLE # 1
This x-ray demonstrates a lateral elbow x-ray.
There is swelling anteriorly which is displaced
known as a pathologic anterior fat pad sign
There is swelling posteriorly known as a posterior
fat pad sign
Both of these are signs of an occult fracture
although none are visualized on this x-ray
Remember, soft tissue swelling can be a sign of
occult fracture!
EXAMPLE # 2WHERE ARE THE
FRACTURES?
 EXAMPLE # 2
If you follow ABCs, you will notice there is are
problems with alignment on this x-ray (A)
(B)You will notice there are fracture lines
through the 2nd, 3rd, and 4th metacarpals
These are 2nd, 3rd, and 4th, midshaft metacarpal
fractures.
A teaching point: Notice the ring on this film.
Always remove rings of patients with fractured
extremities because swelling may preclude
removal later.
LANGUAGE OF FRACTURES
Important for use to describe x-rays in medical
terminology.

Improves communication with orthopedic

consultants
LANGUAGE OF FRACTURES
Things you must describe (clinical and x-ray):
Open vs Closed fracture
Anatomic location of fracture
Fracture line
Relationship of fracture fragments
Neurovascular status
 OPEN VS CLOSED
Must describe to a consultant if fracture is open or closed
Closed fracture
Simple fracture
No open wounds of skin near fracture
Open fracture
Compound fracture
Cutaneous (open wounds) of skin near fracture site. Bone may
protrude from skin
Open fractures are open complete displaced and/or comminuted
 OPEN FRACTURES
Orthopedic emergency
Requires emergency orthopedic consultation
Bleeding must be controlled
Management
IV antibiotics
Tetanus prophylaxis
Pain control
Surgery for washout and reduction
 ANATOMIC LOCATION
Describe the precise anatomic location of the
fracture
Include if it is left or right sided bone
Include name of bone
Include location:
ProximalMidDistal
To aid in this, divide bone into 1/3rds
FOR EXAMPLE....WHERE IS THIS
LOCATED?
 EXAMPLE
This is a closed L distal femur fracture.

The main thing I want you to take from this

example is the description of location
 ANATOMIC LOCATION
Besides location, it is helpful to describe if the
location of the fracture involves the joint space
intra-articular
INTRA-ARTICULAR FRACTURE OF
BASE 1ST METACARPAL
 FRACTURE LINES
Next, it is imperative to describe the type of
fracture line

There are several types of fracture lines

FRACTURE LINES
 FRACTURE LINES
A is a transverse fracture

B is an oblique fracture

C is a spiral fracture

D is a comminuted fracture

There is also an impacted fracture where fracture ends are

compressed together
WHAT TYPE OF FRACTURE LINE IS
THIS???
 ANS: TRANSVERSE FRACTURE
Transverse fractures occur perpendicular to the
long axis of the bone.

To fully describe the fracture, this is a closed

midshaft transverse humerus fracture.
ANOTHER EXAMPLE OF
FRACTURE LINE
 ANS: SPIRAL FRACTURE
Spiral fractures occur in a spiral fashion along
the long axis of the bone

They are usually caused by a rotational force

To fully describe the fracture, this is a closed

distal spiral fracture of the fibula
ONE MORE EXAMPLE
ANS: COMMINUTED FRACTURE
Comminuted fractures are those with 2 or
more bone fragments are present

Sometimes difficult to appreciate on x-ray but

will clearly show on CT scan

To fully describe the fracture, this is a closed R

comminuted intertrochanteric fracture
 FRACTURE FRAGMENTS
Terms to be familiar with when describing the
relationship of fracture fragments
Alignment
Angulation
Apposition
Displacement
Bayonette apposition
Distraction
Dislocation
ALIGNMENT/ANGULATION
Alignment is the relationship in the longitudinal
axis of one bone to another
Angulation is any deviation from normal
alignment
Angulation is described in degrees of angulation
of the distal fragment in relation to the proximal
fragmentto measure angle draw lines through
normal axis of bone and fracture fragment
20 DEGREES OF ANGULATION
 OTHER TERMS
Apposition: amount of end to end contact of the
fracture fragments
Displacement: use interchangeably with apposition
Bayonette apposition: overlap of fracture fragments
Distraction: displacement in the longitudinal axis of
the bones
Dislocation: disruption of normal relationship of
articular surfaces
DESCRIBE FRACTURE FRAGMENTS
 ANSWER
This is a closed midshaft tibial fracture.But how do
we describe the fragments?
This is an example of partial apposition; note part of
the fracture fragments are touching each other
Alternatively you can describe this as displaced 1/3 the
thickness of the bone
Remember aposition and displacement are
interchangeablewe tend to describe displacement
Final answer: Closed midshaft tibial fracture with
moderate (33%) displacement
ANOTHER ONE
 ANSWER
There are 2 fractures on this film
Closed distal radius fracture with complete displacement.
Also there is an ulnar styloid fracture which is also
displaced
The displacement is especially prominent on the lateral
view highlighting the importance of multiple views.
There may be intra-articular involvement as joint space
is close by
Remember, remove all jewelry from extremity fractures
BAYONETTE APPOSITION
DISLOCATION
 DISLOCATION
Note the dislocation on the previous slide; the
articular surfaces of the knee no longer
maintain their normal relationship
Dislocations are named by the positioin of the
distal segemnt
This is an Anterior knee dislocation
 NEUROVASCULAR STATUS
Finally when communicating a fracture, you
will want to describe if the patient has any
neurovascular deficits

This is determined clinically

 LANGUAUGE OF FRACTURES
To review, when seeing a patient with a fracture
and the x-ray, describe the following:
Open vs closed fracture
Anatomic location of fracture (distal, mid, proximal)
and if fracture is intra-articular
Fracture line (transverse, oblique, spiral, comminuted)
Relationship of fracture fragments (angulation,
displacement, dislocation, etc)
Neurovascular status
DESCRIBE THIS R MIDDLE
PHALANX FRACTURE
 ANSWER
Oblique fracture of midshaft of R 4 th middle
phalanx with minimal displacement and no
angulation

Remember to comment if open vs closed &

neurovascular status
DESCRIBE TO ORTHO
ATTENDING
 ANSWER
This one is a bit more challenging!
R midshaft tibia fracture displaced the
thickness of the bone without angulation; also
there is bayonette appositioning of the fracture
fragments
R midshaft fibular fracture with complete
displacement and
Also comment if the fracture is open vs closed &
neurovascular status