Author Adam de Gruchy Last review March 2013 Rules of 2s 2 views 2 joints image the joint above and below a long bone 2 sides compare the other side in difficult cases only eg children ID: 774610
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Slide1
Radiograph Interpretation of the Peripheral Skeleton
Author: Adam de Gruchy Last review March 2013
Slide2Rules of 2s
2 views
2 joints: image the joint above and below
a
long bone
2 sides: compare the other side (in difficult cases only
eg
children)
2 abnormalities
2 occasions: compare current films with old films if available (especially chest x-rays)
2 visits: repeat the film after a procedure or period of time
2 opinions: ask a colleague for an opinion
8. 2 records: write down clinical and radiographic findings
9. 2 specialists: also get a formal radiological report
2 examinations: don’t
foget
other tests such as US, CT, MRI, bone scan
Slide32 views – Standard Views
Finger = AP and lateral
Hand = AP and oblique
Wrist = AP and lateral +/-
scaphoid
views
Elbow = AP and lateral
Shoulder = AP and Y view
Pelvis = AP only
Hip = AP and oblique/lateral
Knee = AP and lateral
Ankle = AP and lateral +/- AP
mortice
view
Feet/toes = AP and oblique
Cervical = AP, lateral and peg
Thoracic = AP and lateral
Lumbar = AP and lateral
Slide410 Commandments
Treat the patient not the radiograph
Take a history and examine before requesting a radiograph
Request a radiograph only when necessary
Never look at the radiograph without seeing the patient and never see the patient without reviewing the radiograph
Look at the radiograph, the whole radiograph and the radiograph as a whole in appropriate settings
Re-examine the patient when incongruity exists between the radiograph and expected findings
Remember the rules of 2
Take radiographs before and after procedures
If a radiograph does not quite look right, ask and listen
Ensure you are protected by failsafe
mechanisma
Slide5ABC Systematic Assessment
Alignment
Bones – exclude a fracture by carefully following the bony contours and checking bone density and trabecular pattern
Cartilage and joints – joint space should be uniform in width
Soft tissues and foreign bodies
Slide6Hand
Slide7Hand
Standard view
AP
Oblique
Slide8Hand
Adequacy and Alignment
2 views are needed to rule out dislocation
Oblique or lateral view is needed to detect Bennett’s and triquetral fractures
Slide9Hand
Bone
Commonest sites of injury are:
Finger tip (crush fracture)
Base of distal phalanx (mallet finger)
Neck of 5
th
metacarpal (boxer’s fracture)
Cartilage and joints
Look for overlapped joint space indicating subluxed or dislocated joints
Slide10Hand
Small avulsion injuries at the base of the phalanx may require further attention, such as:
Avulsion at base of the proximal phalanx on the palmar surface may indicate a volar plate injury
Avulsion on the lateral or medial aspect would indicate collateral ligament instability
Avuslion at the dorsal aspect of the base of the distal phalanx indicates a mallet finger
Slide11Hand
Volar plate injury - avulsion
Slide12Hand
Thumb Injuries
Skier’s or Gamekeeper’s Thumb
Ulnar collateral ligament injury at the MCP joint. May have an associated avulsion injury.
May require US scan to confirm diagnosis
Bennett’s Fracture
Fracture to base of first MC. Unstable as technically intra-articular and fracture/dislocation
Note 3 part fracture to the base is called a Rolando fracture
Slide13Hand
Bennett’s Fracture
Rolando Fracture
Slide14Wrist
Slide15Wrist
Standard views
AP
Lateral
Additional views
Scaphoid
Clenched fist
Slide16Wrist
Age related injuries:
4-10 = Torus and greenstick fractures
11-16 = Salter-Harris injuries
17-40 = scaphoid and triquetral fractures
40 to >60 = Colles’/Smith’s fractures
Slide17Wrist
Alignment
AP views:
Gilula’s
arcs should be parallel and 1-2 mm apart in adults
Check
lunate
is square if triangular then ? dislocation, and check for widening between
scaphoid
and
lunate
Distal ulna should overlap the radius slightly or almost touch it. Distal radius should be distal to distal
ulnar
styloid
with a 5-10°
ulnar
deviation. Rule of 11s for radial inclinations.
Slide18Wrist
Slide19Wrist
Slide20Wrist
Slide21Wrist
If the lunotriquetrial ligament is broken then the scaphoid will tip the lunate in a volar direction (VISI).
If the scapholunate ligament is disrupted then the triquetrium will tip the lunate in a dorsal direction (DISI).
If there is a break in the scaphoid, lunate, triquetrial connection then a DISI or VISI malalignment can occur which depends on where the break occurs.
Slide22Wrist
Alignment
Lateral views:
The radius, lunate, capitate and base of third MC all should articulate with each other
The lunate should look like a moon with its concavity facing distally, filled by the capitate
Palmar angulation of the radiocarpal joint should be 10-15°
Slide23Wrist
Bone
AP views:
Check the overall contour and bony margins of each bone and then trabecular pattern = linear lucency, line of sclerosis or a cortical break
start proximal and work distal
Lateral views
Any flake of bone may be avulsion injury
Slide24Wrist
Cartilage and Joint
Check for narrowing or widening of joint space as can indicate dislocation
Slide25Wrist
Fractured radius and scapholunate dissociation
Slide26Wrist
Soft tissues
Displacement of pronator quadratus fat pad (MRI studies show not reliable in # diagnosis)
Fat stripe = radiolucency on the radial side of the scaphoid (not seen < 12 years old)
Slide27Wrist
Pronator teres fat pad sign
Slide28Elbow
Slide29Elbow
Standard views
AP
Lateral
Additional views
Radial head-capitellum view
Oblique/olecranon view
Slide30Elbow
Alignment
Lateral View
Radio-
capitellar
line shows the last 2-4cm of the radius dissecting the
capitellum
. If passing anterior or posterior then ? radial head dislocation.
Anterior humeral line normally shows a J-shape or hockey stick. A line drawn along the anterior humeral cortex should have a third or more of the hockey blade (
capitellum
) anterior to it. Loss of the hockey stick appearance or less than a third of the blade suggests
supracondylar
fracture.
Also look for hourglass or figure 8 in the distal
humerus
. Loss suggests fracture.
Slide31Elbow
Figure 8 or hour glass
Radiocapitellar line – pink
Anterior humeral line – yellow
Normal measures
Slide32Elbow
Alignment
AP
The radiocapitellar and coranoid-trochelar joint spaces should be parallel and equal.
A line through the centre of the proximal 2-4cm of the radius should intersect the capitellum.
About half of the radial head fractures are undisplaced so it is important to look for subtle changes
Slide33Elbow
Congruity
The trochlea is congruous with the ulna
The capitellum is congruous with or parallels the articular surface of the head of the radius
Slide34Elbow
Soft Tissues
Anterior fat pad is a thin elongated radiolucency laying parallel to the distal humerus. Haemarthrosis will cause displacement of this fat pad causing appearance of the ‘sail sign’, indicative of a fracture at the elbow.
The posterior fat pad may be displaced by a very large effusion and shows up as a thin black line posterior to the cortex of the distal humerus
Slide35Elbow
Displacement of the fat pads of the elbow, indication of a haemarthrosis usually due to a fracture
Black arrow indicating anterior and posterior indicated by the white arrow
Slide36Shoulder
Slide37Shoulder
Glenohumeral Joint
Standard views
AP
Y view
Axial (Armpit) view or apical view
Additional views
Stryker notch view
Supraspinatus outlet view
Slide38Shoulder
Acromioclavicular Joint
Standard views
AP of shoulder
Additional views
Weightbearing/distraction
Zanca view
Slide39Shoulder
Alignment
Glenohumeral Joint
Humeral head should lie in the glenoid fossa and the joint space should be equal top and bottom
Loss of the features of the greater tuberosity and bicipital groove across in internal rotation and is known as the ‘light bulb sign’ and may be indicative of a posterior dislocation.
Mild inferolateral subluxation may be due to haemarthrosis ? from a fracture
Slide40Shoulder
Alignment
AC Joint
Inferior margins of the lateral clavicle and the acromion should be aligned. Note though 20% of people may have some minor mal-alignment in which case bilateral AC joint x-rays (+/- weightbearing through AC joint) should be undertaken to exclude widening of the joint.
Slide41Shoulder
Alignment
Rockwood AC Joint Injury Classification
Type 1 – no joint separation
Type 2 - AC joint is disrupted with a slight vertical separation and there is a slight increase in the CC interspace of <25%
Type 3 - CC distance of 25-100% of other side
Type 4 - lateral end of the clavicle is displaced posterior through trapezius as seen on the axillary X-ray
Type 5 - CC distance > 100% of other side (usually associated with rupture of deltotrapezial fascia, resulting in subcutaneous distal clavicle)
Type 6 - rare injuries with the distal clavicle lying either in a subacromial or subcoracoid postition (infero-lateral under conjoinded tendon)
Slide42Shoulder
Alignment
Subacromial Space
Loss of acromiohumeral distance (<7mm) is usually from extensive loss of rotator cuff
Slide43Shoulder
Bone
Interpretation of the axial and Y-views are useful for assessing for dislocation and also reviewing for avulsion injuries from the glenoid rim and for impaction injuries on the humeral head
The trough line sign refers to a vertical or archlike sclerotic line of cortical bone projecting parallel and lateral to the articular cortical surface of the humeral head. This occurs due to the anterior aspect of the humeral head becomes impacted against the posterior glenoid rim
Slide44Shoulder
Light Bulb Sign
Trough Line
Posterior Glenohumeral Joint Dislocation
Slide45Shoulder
Soft Tissues
AC joint disruption is usually associated with adjacent soft tissue swelling
Intra-articular fractures of the humeral head can lead to a lipohaemarthrosis
Calcific tendonitis can be seen in the subacromial space or at the supraspinatus insertion to the humeral head.
Slide46Shoulder
Lipohaemarthrosis
Calcific Tendonitis
Slide47Shoulder
Soft tissue mass superior to clavicle and posterior to clavicle. Patient presented for review of radiculopathy, as symptoms were unremitting pain and paraesthesia into the right
armCT showed primary lung cancer and widespread metastatic disease
Slide48Shoulder
Neer’s Classification Of Proximal Humeral Fractures
1 Part = no significant displacement across fracture lines
2 Part = displacement across one fracture
3 Part = some displacement across 2 fractures
4 Part = serious displacement across 3 fractures, severe comminution
Note displacement is considered separation >1cm or angulation > 45 degrees
Slide49Neer’s Classifications
Slide50Shoulder
The AO classification divides proximal humeral fractures into three groups, A, B and C, each with subgroups, and places more emphasis on the blood supply to the articular surface.
The assumption is that if either the lesser or greater tuberosity remains attached to the articular segment, then blood supply is probably adequate to avoid AVN
Slide51Pelvis and Hip
Slide52Pelvis and Hip
Pelvis
Standard views
AP
Additional views
Judet (oblique)
Inlet
Outlet
Slide53Pelvis and Hip
Hip
Standard views
AP of both hips
Lateral
Additional views
Frogleg lateral
Slide54Pelvis and Hip
Alignment
3 circles of the pelvic rim = pelvic rim and the 2 obturator foramina.
Shenton’s line is formed by a line running from the the inferior border of the pubic ramus (ie top of obturator foramin) along the medial border of the neck of femur. If disrupted it is often from a #NOF rather than pelvic fracture.
For acetabular review use the iliopectineal line, ilioischial line (Kohler's line) and teardrop line.
If there is disruption in at one point in the circle be sure to check other areas as a second disruption is very common.
Slide55Pelvis and Hip
Slide56Pelvis and Hip
Standard views
Pelvis = AP
Hip = AP and lateral
Additional views
Pelvis = Judet views, inlet and outlet views
Hip = frog legged view
Slide57Pelvis and Hip
Injuries of interest
Avulsion injuries may occur in teenagers at the ASIS (rectus femoris), greater trochanter (gluteus medius) and lesser trochanter (iliopsoas). Less common are ligamentous avulsions and are generally found at the lateral border of the sacrum or ischial spines.
Metatastic disease and pathological fractures are generally found in the proximal femur, particularly subtrochanteric region.
Risk of avascular necrosis post intracapsular hip fractures or associated with longterm oral steroid use or deep sea diving.
Slide58Knee
Slide59Knee
Slide60Knee
Standard views
AP
Lateral
Additional views
Skyline
Tunnel or Notch
Internal and External Oblique
Slide61Knee
Alignment
AP
Lateral tibial line (lateral edge of tibia and lateral edge of the femoral condyle should be aligned) can assess for tibial plateau fractures
The tibial plateau is not flat but slopes at about 15° downwards from anterior to posterior.
Look for step deformity or sclerotic lines/loss of trabecular pattern to suggest tibial plateau fracture
Slide62Knee
Alignment
Lateral
The tibial plateau and femoral condyles should be aligned, anterior or posterior displacement would suggest loss of cruciate ligament integrity
Slide63Knee
Slide64Knee
Soft tissues
On the lateral view the presence of a lipohaemarthrosis would suggest the existence of a fracture
Fluid in the knee joint causes enlargement of the suprapatellar bursa which will separate the prefemoral and suprapatellar fat pads to be separated
Slide65Knee
Signs of ligamentous injuries of the knee
Segond fracture = Lateral capsular ligament avulses part of the lateral tibial plateau
Anterior tibial eminence or tibial spine avulsion = ACL avulsion
Pelligrini-Steida lesion = chronic recurrent injury to MCL
Avulsion of poles of patella or tibial tuberosity = quadriceps/patellar tendon avulsion
Avulsion of fibular styloid process = avulsion of LCL or biceps femoris
Slide66Knee
Segond Fracture
Slide67Knee
Pelligrini-Steida Lesion
Slide68Knee
Patella dislocation
Risk factors are:
Patella alta
High Q angle
Shallow patellofemoral groove
Genu valgum
Associated injuries include avulsion injuries to the patella or osteochondral defects to the patellafemoral joint surfaces
Slide69Knee
Fibula head fractures
May need to check for this injury with associated injury such as tibial plateau fracture or ankle fracture (eg Maisonneuve Fracture)
Slide70Ankle
Slide71Ankle
Slide72Ankle
Standard views
Lateral
AP or
Mortice view (AP at 20° internal rotation)
Additional views
Calcaneal view
Broden’s view
Stress views
Internal and External Oblique views
Slide73Ankle
Ottawa Ankle Rules
X-ray is indicated when on clinical examination the patient presents with either:
Tenderness at the tip or the posterior edge over the last 6cm of the distal fibula or tibia
Bony tenderness of the medial malleolus
Tenderness at the base of the fifth metatarsal
Unable to weightbear immediately after injury or in Emergency Department
Slide74Ankle
Slide75Ankle
Alignment
AP
The joint space should be uniformly spaced at < 4mm and clearspace <5mm
Normal talar tilt = -1.5 to +1.5° (ie close to parallel)
Talocrural angle = 83°+/- 4°
AP Mortise view
Tibiofibular overlap should be >10 mm
Tibiofibular clearspace (distance between lateral border of posterior tibia & medial border of fibula, 1cm above the joint line) should be <5 mm
Slide76Ankle
Clearspace
Overlap
Slide77Ankle
90
Talocrural
angle
Slide78Ankle
Alignment
Lateral
The long axis of the tibia and fibula should overlap and bisect the talar dome.
Slide79Ankle
Often on the AP view injuries, such as an oblique fracture through the distal fibula, can appear normal.
On the lateral view close attention should be paid to look for subtle abnormalities that can signify unstable ankle injuries.
Slide80Ankle
On the lateral view close attention should be paid to particular areas:
Lateral malleolus
Tibial plafond
Posterior malleolus
Superior surface of the talus and navicular
Calcaneus
Anterior process of the calcaneus
Base of the fifth metatarsal
Slide81Ankle
2
1
3
4
5
6
7
Slide82Foot
Slide83Foot
Standard views
AP
Oblique +/- Lateral (mediolateral)
Additional views
Canale view (Maximal PF and Inv 15°)= talar neck
Harris-Beath view = body of calcaneous, middle and posterior facets of the subtalar joint
Broden’s view = generally CT used instead
Slide84Foot
Slide85Foot
Alignment
Lateral view
The superior surface of the talus, navicular, medial cuneiform and first metatarsal lie in a straight line.
Bohler’s angle lies between the plane of the posterosuperior and anterosuperior surfaces of the calcaneus = 28-40° and <28 ° generally follows a calcaneal compression fracture
Slide86Foot
Slide87Foot
Alignment
The cyma line can be seen on lateral, AP and oblique images.
This represents an intact midtarsal joint. Note that disruption of the smooth curve is not always a traumatic injury and can occur in marked pes planus.
Slide88Foot
Cyma Line
Slide89Foot
Alignment
AP – the 2
nd
MT should align with the medial aspect of the middle cuneiform.
Oblique
the medial aspect of the 3
rd
MT should align with the medial aspect of the lateral cuneiform
The medial aspect of the 4
th
MT should align with the medial aspect of the cuboid
Loss of alignment could suggest injury such as Lisfranc injury
Slide90Foot
Slide91Foot
Slide92Foot
Calcaneal Fractures
60% of fractures in the foot
Often comminuted and often may require CT to show the full extent of the injury
25% of calcaneal fractures are extra articular = anterior process, posterior process (beak) and tuberosity
Slide93Foot
Talus Fractures
Avulsion fractures are the most common at 50%, while neck fractures are 30%
Neck fractures usually result from high velocity impaction injuries
Risk of AVN with this injury
May have associated subtalar disolcation which will show as loss of smooth cyma line
Slide94Foot
Navicular fracture
Avulsion superiorly or medially by posterior tibialis are the most common
Slide95Foot
Stress fractures can occur in the foot and generally occur at:
Sesamoids under hallux
First base of MT
Neck of 2-4
th
MTs
Base of 4
th
and 5
th
MTs
Cuneiforms, navicular and cuboid
Slide96Foot
Stress fractures may show up as periosteal reaction.
Often will not show up on initial onset and x-rays weeks later will start to show reaction if at all – may require MRI or bone scan
Slide97Fracture
Description
Open versus closed
Complete versus incomplete
Fracture plane (transverse, oblique, spiral, avulsion)
Displacement of distal fragment
Angulation (direction of fracture angle apex)
Comminution
Overriding fragments, limb shortening or distraction
Articular relation (intra or extra articular)
In pediatric population: involvement of physis
Associated subluxation/dislocation
Location ie body part, bony, region of the bone, anatomical region
Slide98Bone Lucency Lesions
Most important determinates in assessing bone lucencies are:
the morphology of the bone lesion on a plain radiograph
Well-defined vs ill defined osteolytic
Sclerotic
Age of patient
Other factors may include location on the bone
A good reference is:
http://www.radiologyassistant.nl/en/p494e15cbf0d8d
Slide99Bone Lucency Lesions
ABC = Aneurysmal bone cyst, CMF = Chondromyxoid fibroma, EG = Eosinophilic Granuloma, GCT = Giant cell tumour, FD = Fibrous dysplasia, NOF = Non Ossifying Fibroma HPT = Hyperparathyroidism with Brown tumour, SBC = Simple Bone Cyst
Image from
www.radiologyassistant.nl/en
Slide100Bone Lucency Lesions
Image from
www.radiologyassistant.nl/en
Slide101Bone Lucency Lesions
Image from
www.radiologyassistant.nl/en
Slide102Aggressive vs Benign Bone Processes
Edge of lesion/ Zone of transition
Benign:
sharply defined, may be sclerotic
Aggressive (infection, tumour):
poorly defined, almost blends into the surrounding bone, wide transition zone
Sometimes the abnormality is multifocal and the bone appears ‘moth eaten’.
Slide103Aggressive vs Benign Bone Processes
Narrow Zone of Transition
Image from
www.radiologyassistant.nl/en
Slide104Aggressive vs Benign Bone Processes
Wide Zone of Transition
Image from
www.radiologyassistant.nl/en
Slide105Aggressive vs Benign Bone Processes
Periosteal Reaction.
Benign:
No or smooth periosteal reaction
Aggressive:
Periosteal reaction with a less organized appearance eg sunburst or lamellar reaction.
This is an acute periosteal reaction that has not had time to reorganise itself
Slide106Aggressive vs Benign Bone Processes
Osteosarcoma
Ewing Sarcoma
Lamellated Reaction
Infection Multilayered Reaction
Image from
www.radiologyassistant.nl/en
Slide107Aggressive vs Benign Bone Processes
Cortical Destruction.
Benign:
No cortical destruction, but may be expanile causing thinning of the cortex
Aggressive:
Malignant lesions may destroy the cortex.
Slide108Septic Arthritis
Very aggressive pathology
Patient will complain of systemic illness such as fevers, night sweats, malaise
Very painful and marked limitation to movement of the joint and palpation.
Slide109Paget’s Disease
Paget’s disease of bone is common, affecting up to 4% of Australians over the age of 55 years.
The cause of Paget’s disease is unknown, but there is a strong genetic influence.
It is a chronic condition that causes abnormal enlargement and weakening of bone.
Most common sites affected include the skull, spine, pelvis, thigh bone, shin and the bone of the upper arm.
Slide110Paget’s Disease
Slide111Osteoarthritis
Radiographic evidence of OA does not correspond well with patient symptom severity, but it is true to say the more extensive the changes on xray the more likely the patient is to have symptoms.
NWB films can underestimate the extent of OA in lower limb joints.
Most common grading is the Kellgren-Lawrence System
Slide112Osteoarthritis
Slide113Osteoarthritis
Kellgren Lawrence OA Grading
Grade 1: doubtful narrowing of joint space and possible osteophytic lipping
Grade 2: definite osteophytes, definite narrowing of joint space
Grade 3: moderate multiple osteophytes, definite narrowing of joints space, some sclerosis and possible deformity of bone contour
Grade 4: large osteophytes, marked narrowing of joint space, severe sclerosis and definite deformity of bone contour
Slide114Osteochondral Defects
Generally more prevalent in lower limb joints, such as the ankle on talar dome and knee on tibiofemoral or patellofemoral joint surfaces.
Also can occur post dislocation in any joint eg Hills-Sach lesion in shoulder dislocation is technically a OCD.
May not be evident on plain films and may require CT or MRI. MRI may show whether the lesion is ‘active’ or not, as OCD may be asymptomatic.
Slide115Osteochondral Defects
Extremely large OCD on medial aspect of the talus
Slide116Osteochondral Defects
Extremely large OCD in the elbow joint
Slide117Online Resources
Here are some websites to help get exposure to various pathologies and some good resources to extend knowledge:
www.auntminnie.com
www.auntminnieeurope.com
www.radiopaedia.org
www.radiologyassistant.nl/en/
www.rad.washington.edu/academics/academic-sections/msk/teaching-materials/online-musculoskeletal-radiology-book/
www.mypacs.net
Slide118