11/13/24, 7\:33 PM Guide | MSK x-ray interpretation

MSK x-ray interpretation

Table of contents

Introduction

Musculoskeletal (MSK) X-ray interpretation can occasionally feature in OSCEs and therefore it's important to practice this skill
to develop a structured approach. This guide provides a brief overview of MSK X-ray interpretation, including a structured
approach you can apply to most X-rays and examples of relevant pathology.

Con

Always begin by checking the details discussed below.
Patient details
Con
Full name
Date of birth (DOB)
Unique identi
Film details
Con
Date and time the
The area of the body scanned
Adequacy of the
Views\: it is good practice have a minimum of 2 projections, this is because many fractures are not visible on a single view
(‘a single view is no view’)
Ideally the joint above and below should both be imaged
Rotation
Penetration
Previous imaging
Previous images provide a baseline for comparison.

X-ray interpretation (ABCS approach)

The ABCS approach of X-ray interpretation involves assessing the following\:
Alignment and joint space
Bone texture
Cortices
Soft tissues

General points

Don’t forget to review all views, compare both sides and re‐examine any previous imaging.
If you spot one abnormality, do not lose focus until you have reviewed all areas of the image, otherwise, you might miss
important pathology.

Alignment and joint space

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Changes in alignment suggest a fracture, subluxation (partial dislocation) or dislocation.
When describing the displacement, the position of the fragment distal to the fracture site is always described.
The radiograph below demonstrates why it is important to have more than one view.
Joint dislocation of the metacarpophalangeal joint of the 5th digit. [1]
Carefully look at the joint space to identify changes such as joint space narrowing due to cartilage loss, cartilage
calci
density) is often present along the joint lines in patients with osteoarthritis.
Osteoarthritis of the left knee. Note the osteophytes (right side of joint), narrowing of the joint space, and increased subchondral bone density (black
arrow). [2]
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Bone texture

Altered density or disruption in the usual internal matrix of
thick external covering (cortex) may indicate pathology.
Healthy cortex and trabeculae vs osteomyelitis. [4][5]

Cortices

Trace around the outline of each bone as any step in the cortex may indicate a fracture or other pathology.
Infection and tumours (primary and secondary) are the commonest causes of bony destruction.
A periosteal reaction is the formation of new bone in response to injury or other stimuli of the periosteum surrounding the bone.
It may be the only sign visible to denote a problem with the bone (stress or healing fracture, mild osteomyelitis or tumour).
Trace around the bone cortex carefully to identify fractures (arrow) [6]
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Soft tissues

Look for any swelling, foreign bodies or e
closer inspection for bony pathology.
X-ray of the knee of a 12-year-old male, showing knee e
extends into the suprapatellar bursa. [9]

Types of fractures

There are several di
Closed fracture
Open fracture
Transverse fracture
Spiral fracture
Comminuted fracture
Impacted fracture
Greenstick fracture
Oblique fracture
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Types of fractures [11]

Describing a fracture

Fracture descriptors depend on the class of bone and the direction of the fracture line.

Where is the fracture?

Describe which bone is involved and where the fracture is located (proximal/middle/distal).
State whether there is any involvement of the articular surface (as this may alter management).

What type of fracture?

Complete fracture
A complete fracture involves the fracture extending all the way through the bone.
Types of complete fractures include\:
Transverse\: fracture at right angles to the shaft
Oblique\: fracture at an angle to the shaft
Spiral\: caused by twisting injury
Comminuted\: 2 or more bone fragments
Impacted\: fractured bone forced together
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X-ray of Monteggia fracture of right forearm, showing transverse fracture of ulna and dislocation of radius [12]
Incomplete fracture
children.
Incomplete fractures do not involve the whole cortex (i.e. not all the way through the bone) and most commonly occur in
Types of incomplete fractures include\:
Torus/Buckle\: a bulge in the cortex
Bowing\: associated bend in the bone shaft
Greenstick\: bending of the shaft with a fracture on the convex surface
Salter-Harris\: involving the growth plate
Greenstick fracture of the ulna and radius [17]
Open or closed fracture
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If a fracture is associated with a puncture of the skin or open wound, this is classed as an open fracture.
If not, then it is termed closed.
This is important to state because of the risk of infection with open fractures.

Is there displacement?

Displacement is described in terms of the distal fragment to the body (e.g. anterior/posterior).
Displacement can also involve\:
Angulation\: changes in the axis of the bone, usually described as dorsal/palmar or varus/valgus or radial/ulnar.
Translation\: movement of the fractured bones away from each other. Described using the width of the bone as context (e.g.
translation of 25% of the width of the bone). If translation is further away than the width of the bone, it is said to be ‘o
.
Rotation\: usually di

Key points

By applying a structured approach to musculoskeletal X-ray interpretation you reduce the risk of missing pathology.
Always begin X-ray interpretation by carefully checking the details of the patient and radiograph.
The ABCS approach provides a generic framework to assess most types of X-rays (alignment and joint space, bone texture,
cortices and soft tissues).
There are several sub-types of fractures, each associated with di
When assessing a fracture, apply a structured approach paying particular attention to the location, type and displacement
of the fracture.

Reviewer

Dr Edward Twimasi
Consultant Radiologist

References

Source\: geekymedics.com
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