welcome to this video in which we will describe an approach to interpreting x-rays in the orthopedic setting with a specific focus on the radiological assessment of fractures before introducing our approach to x-ray interpretation the term fracture should be defined a fracture is the interruption in the continuity of bone which may or may not be associated with adjacent soft tissue injury the soft tissue injury may be closed or open to the environment the abcs acronym is useful when interpreting an x-ray the adequacy bone cartilage or joint and soft tissue are all important aspects to assess with regards to this video the bones are the most important however they should never be considered in isolation step one of our abc's approach is adequacy here the film and patient details should be assessed before looking at the radiological image patient details are largely recalled for practical reasons to ensure that the viewed x-ray is in fact an image taken from the desired individual consequently it is important to report the patient's name age or date of birth 6 and possibly their hospital folder number for the dual purpose of identification and provision of brief clinical context the details of the film such as the date on which it was captured as well as the side of the body and view it depicts are equally important to consider before diving into the assessment of the various bones and displayed soft tissues a useful memory aids to utilize at this stage is the rule of twos the rule of twos dictates five criteria which should be fulfilled in order to adequately assess an affected site it calls for two views of the area usually ap and lateral and for two joints to be visible in the resulting film that is the joint above and below the potential fracture site additionally this principle states that best practice calls for x-ray of both limbs for the sake of comparison which is particularly important in children where growth plates may be affected it is also useful to note that when possible previously taken x-rays of the affected area should be considered for the same purpose of comparison from baseline as is always the case in the medical field it is often useful to get two opinions on the same radiological film to confirm the validity of the made assessment finally this approach calls for x-rays on two occasions particularly in the case of fractures before and after reduction or the application of therapeutic interventions as mentioned the view of the produced x-ray is an important thing to consider as part of your radiological approach and while ap and lateral images are by far the most widely employed specific views may need to be requested depending on the site of this suspected injury as outlined in the list provided in summary the adequacy of an x-ray can be deduced by reporting the details of the patient and the details of the film an example of how to present these findings has been included here please feel free to pause the video at this point to ensure that you have grasped this initial step of the approach to an orthopedic x-ray the b component of the abcs approach focuses on bones and here you can comment on the bone density and the presence of any fractures to assess the bone density it is best to adopt an outside in approach begin by looking at the outline of the bone or the cortex looking for any signs of bone degeneration or bone growth as seen in these examples after assessing the bone contour look for the presence of any lesions within the bone and if present describe these in relation to the surrounding bone lesions can be sclerotic meaning they appear hyper dense in comparison to the surrounding bone or they can be lytic appearing hypodense in relation to the surrounding bone as a result of disintegration or they can have features of sclerotic analytic lesions in which case they are a mix while assessing the bone you may come across fractures and these should be described in as much detail as possible with the help of these six steps outlined firstly begin by identifying any soft tissue involvement by indicating if the fracture is open or closed in other words does it communicate with the external environment or not and if it does and it's considered open provide the castillo anderson grade then describe the position of the fracture is it in the proximal or distal aspect of the bone is it in the epiphysis metaphysis or shaft in the case of a femur fracture on the pip or dip in the case of a hand fracture for example you should then classify the fracture indicating if it is complete or incomplete and describing its pattern this will be elaborated on in the next slide describe the exact bone that is involved is that the humerus the femur the tibia of the fibula and is it on the left or the right comment on any displacement of the bone with reference to lara which will also be elaborated on in a bit and finally look to see if there is any growth plate or intra-articular involvement after taking this all into account you will have described the fracture quite comprehensively but remember that x-rays supplement a history and examination thus you should also be able to comment on whether it is pathological or stress fracture based on the history provided and comment on the neurovascular status of the limb affected to classify a fracture first identify if it is complete or incomplete does it communicate with the cortex on either side of the bone or not complete fractures can then be simple segmental or complex simple fractures consist of a single fracture line and can be transverse running horizontally through the bone this is often the result of a direct blow oblique running at an angle through the bone often due to shearing forces or spiral where it appears to corkscrew around the bone and this often occurs due to rotational injury segmental fractures on the other hand occur when there are more than two fracture lines creating a tubular segment in the shaft and complex or comminuted fractures are those that consist of multiple fragments that usually occur due to high energy injuries and these are unstable fractures as they lack lateral and longitudinal stability in contrast fractures can also be incomplete and for the purpose of time i'll just focus on two that are common in the pediatric population there are green stick fractures which occur when the bone deforms without breaking completely and this is made possible by the elasticity of children's bones and buccal fractures which occur when the cortex of the bone buckles under a compression load but there is no loss of continuity or deformity of the bone the fifth consideration of the bone portion of our approach relates to displacement which describes how the distal part of the bone has moved relative to the proximal portion reported in each of the possible planes of movement lara will prove a useful mnemonic when considering all of the directions in which a bone can be displaced the l refers to the net change in the length also regarded as the degree of shortening of the injured bone compared to the uninjured side usually as a result of male union as depicted in leftmost image or impaction as seen in the rightmost image a denotes our position which is the movement of the edges of the fractured bones away from each other in the horizontal plane a movement which is quantified as a percentage of the total bone width as shown in the drawing alongside the r of lara refers to rotation that is displacement in the axial plane of the bone which is the one parameter that is assessed more appropriately by clinical rather than radiological means our final a relates to angulation which is the change in the axis of the pieces of the fracture bone in relation to one another this form of displacement like our position can be quantified yeah however degrees are used to describe the movement with the proviso of dorsal versus palmer varus versus velgus or radial versus ulna providing additional information related to the direction of the angulated shift the sea of the abcs approach refers to cartilage and joints and prompts you to look on for any subluxation or dislocation of the joints and any degeneration of the joint space so what's the difference between subluxation and dislocation well a dislocation refers to the complete loss of articulation of two opposing bones that comprise a joint while subluxation refers to an incomplete or partial dislocation where the two bones remain in contact though not completely in terms of a degeneration of the joint space it's important to look out for features of osteoarthritis such as narrowing of the joint space new bone formation with osteophytes evidenced on the bone edges subchondral sclerosis evidenced by hyper density of the bone and subchondral cysts which are seen as hypodensis near the articulating surfaces the last step of the abcs approach involves looking at the soft tissues abnormalities to look out for include the presence of foreign bodies discontinuity of the skin surface or the surface of dressings which could imply a wound gas which can be seen due to an open wound or due to infection and swelling a possible sign of infection hemothrosis or joint effusion here is an example of a foreign body pictured is a lateral x-ray of the c-spine showing a foreign body sitting behind the c3 and c4 vertebrae the x-ray on the left-hand side shows subcutaneous emphysema which has many possible causes the x-ray on the right shows an overt example of soft tissue swelling occurring medially at the distal portion of the right foot the last portion of this video involves some case examples of fractures and descriptions thereof based on the approach outlined in this video thank you very much for watching you