Interpreting X-Rays in Orthopedic Settings

Definition of Fracture

• Interruption in the continuity of bone
• May or may not be associated with adjacent soft tissue injury
  • Soft tissue injury may be closed or open to the environment

ABCs Approach to X-Ray Interpretation

Step 1: Adequacy

• Assess film and patient details before the radiological image
  • Ensure correct patient: name, age/DOB, hospital folder number
  • Film details: date, side of body, view (e.g., AP, lateral)
• Rule of Twos:
  • Two views (AP & lateral)
  • Two joints visible (above and below the fracture site)
  • Both limbs imaged (important in children)
  • Previous x-rays for comparison
  • Two opinions on the film
  • X-rays on two occasions (before and after treatment)
• Specific views may be needed depending on the site of injury

Step 2: Bones

• Assess bone density and presence of fractures
  • Bone Density:
    • Outside-in approach (cortex then inside)
    • Look for degeneration or growth
    • Describe lesions (sclerotic, lytic, mixed)
  • Fracture Description (Six Steps):
    1. Soft tissue involvement (open or closed)
    2. Fracture position (proximal/distal, epiphysis/metaphysis/shaft)
    3. Fracture classification (complete/incomplete)
    4. Exact bone involved (e.g., humerus, femur, tibia)
    5. Bone displacement (LARA: Length, Apposition, Rotation, Angulation)
    6. Growth plate or intra-articular involvement
  • Fracture Classification:
    • Complete: Simple (transverse, oblique, spiral), Segmental, Complex (comminuted)
    • Incomplete: Common in children (green stick, buccal)
  • Displacement (LARA):
    • Length (shortening or impaction)
    • Apposition (movement in horizontal plane)
    • Rotation (assessed clinically)
    • Angulation (degrees, direction: dorsal/palmar, varus/valgus, radial/ulnar)

Step 3: Cartilage and Joints

• Look for subluxation, dislocation, and joint space degeneration
  • Subluxation: Partial dislocation
  • Dislocation: Complete loss of articulation
  • Joint Degeneration:
    • Features: Narrowing of joint space, osteophytes, subchondral sclerosis, subchondral cysts

Step 4: Soft Tissues

• Look for abnormalities such as foreign bodies, skin discontinuity, gas, and swelling
  • Examples:
    • Foreign body behind C3 and C4 vertebrae
    • Subcutaneous emphysema
    • Soft tissue swelling in the foot

Case Examples

• Various case examples and their descriptions were discussed based on the outlined approach

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