Download MBBS (Bachelor of Medicine, Bachelor of Surgery) Important Topics Orthopaedics X Rays
R.G.Kar Medical College
Created by: Prithwiraj Maiti
Batch 2015
Email: prithwiraj2009@yahoo.in
Photos are taken from RGKMC
Reference: Class note
Additional reference: Apley
2-11-2014
Table of contents
Contents
Page no.
Introduction
2
Chronic osteomyelitis
2
Exostosis
4
Osteosarcoma
6
Fibrous dysplasia
9
Fracture shaft of humerus
9
Secondary osteoarthritis
11
Anterior dislocation hip
11
Posterior dislocation hip
12
GCT
13
Introduction
When analysing orthopaedics X-Rays, you should remember the rule of two:
2 views- AP and lateral
2 sides- Normal and affected
2 joints- Proximal and distal
2 occasions- Repeat X-Ray
More than 1 site- In case of polytrauma.
X-Ray 1
Chronic osteomyelitis
Description:
This is a plain X-Ray of left humerus
with shoulder joint, scapula and
clavicle showing:
1. Areas of bony destruction
2. An osteolytic cavity
containing a dead piece of
bone (sequestrum, a
radiodense area pointed by
the yellow arrow)
3. Irregularity and thickening of
the whole shaft.
- So, it seems to be a case of
chronic osteomyelitis.
What is sequestrum?
Sequestrum is a dead piece of bone
surrounded by infected granulation
tissue. It is seen in chronic
osteomyelitis.
Why sequestrum appears radio-dense in X-Rays?
1. Absence of resorption activity in that area due to loss of vascularity
2. Collapse of the affected segment
3. Sequestrum appears radiodense in the background of radiolucency.
Do you know the types of osteomyelitis?
Osteomyelitis is of 3 types: acute, subacute and chronic.
Give an example of subacute osteomyelitis?
Salmonella osteomyelitis.
What are the treatment options?
1. Sequestrectomy: Removal of sequestrum through a window cutting
through the involucrum.
2. Saucerization: The infected bone cavity is converted into a 'saucer' by
removing its wall. This allows free drainage of the infected material.
3. Curettage
4. Excision of an infected bone.
What are the pre-requisites for sequestrectomy?
1. Well separated sequestrum
2. Adequately formed involucrum.
What are the complications of chronic osteomyelitis?
Common complications:
1. Deformity
2. Pathological fracture
3. Shortening of limbs (especially in children).
Uncommon complications:
1. Sinus tract malignancy
2. Amyloidosis.
Why metaphysis is commonly affected in osteomyelitis?
1. Metaphysis is the growing end of bone, so it is ill matured
2. Hair pin arrangement of the blood vessels in metaphysis.
In which type of osteomyelitis, diaphysis is commonly affected?
In salmonella osteomyelitis, which is common in children with sickle cell anemia.
X-Ray 2
Exostosis/ Osteochondroma
Description:
This is a plain X-Ray of left knee joint
showing a pedunculated mass coming out
of the upper end of tibia arising from the
epiphysio-metaphyseal junction.
- So, it seems to be exostosis/
osteochondroma.
What is the commonest site?
Around the knee joint.
Why you are saying that the lesion is
benign?
Because of the well-defined outline.
What are the characteristic features of
exostosis?
1. Painless bony swelling around a joint
2. Progress very slowly
3. A long history
4. Stops growing after the age of skeletal maturity.
When does an exostosis become painful?
1. Bursitis of the overlying bursa
2. Stretching of nerve
3. Pathological fracture
4. In case of malignancy.
What is the chance of an exostosis becoming malignant?
Very less (around 1%).
In which type of exostosis, the chance of malignancy is higher?
Hereditary multiple exostosis (around 10% chance).
What are the changes in case of malignant transformation of an exostosis?
1. Rapid growth of the swelling
2. Pain
3. Skin changes:
Stretching
Loss of glistening
Vascular prominence.
What is the treatment of choice?
Excision of the lesion (including some normal bone around the lesion).
X-Ray 3
Osteosarcoma
Description:
This is a plain X-Ray of a part of femur,
knee joint, proximal tibia and fibula;
showing a bone mass arising from the
metaphysis of femur.
- It probably is an osteosarcoma.
Why are you saying that it is an
osteosarcoma?
1. Location: The most common
site of osteosarcoma is around
knee joint
2. Sunburst appearance (blue
arrow)
3. Codman's triangle (yellow
arrow).
Do you classify bone tumors?
The recent WHO classification of bone
tumors is based on the recognition of
the dominant tissue.
Example:
Predominant tissue
Example of benign tumor
Example of malignant tumor
Bone
Osteoblastoma
Osteosarcoma
Cartilage
Chondroma
Chondrosarcoma
Fibrous tissue
Fibroma
Fibrosarcoma
Giant cell tumor
Benign osteoclastoma
Malignant osteoclastoma
Vascular tissue
Hemangioma
Angiosarcoma
Mixed
Chondromyxoid fibroma
---
Other tumors
Neurofibroma
Adamantinoma
Can you describe the Enneking staging for benign bone tumors?
What is the most common bone tumor?
Secondary metastasis from other tumors.
What is the most common primary malignancy of bone?
Multiple myeloma.
What is the 2nd most common primary malignancy of bone?
Osteosarcoma.
What is the age group commonly affected?
10-25 years.
What are the clinical features?
- Pain
- Swelling
- Pathological fracture.
What are the mode(s) of treatment?
Combined approach including:
1. Surgical excision of affected area
2. Radiotherapy
3. Chemotherapy.
What are the types of chemotherapy?
1. Neo-adjuvant: Given before surgery
2. Adjuvant: Given after surgery.
What are the advantages of neo-adjuvant chemotherapy?
1. Downstaging of tumor
2. Reduction in size of tumor, makes the tumor resectable
3. Reduction in vascularity, less chances of bleeding
4. Assessment of sensitivity to chemotherapy.
What are the disadvantages of chemotherapy?
1. Wound complications
2. Delay of surgery due to side effects of chemotherapy.
What is the advantage of adjuvant chemotherapy?
Destruction of residual malignant tissues after surgery.
What are the complications of osteosarcoma?
1. Pathological fracture
2. Metastasis
3. Severe torrential hemorrhage.
What are the types of fracture according to the mechanism of fracture?
1. Traumatic fracture: Caused by traumatic injury
2. Stress fracture: Caused when a normal bone is exposed to repeated stress
3. Pathological fracture: Fracture when a bone is already weakened by some
underlying pathological process.
X-Ray 4
Fibrous dysplasia
Description:
This is a plain X-Ray of left forearm with elbow
joint showing broadening and thickening of lower
ulna.
The bone is replaced by fibrous tissue (arrow).
- So, it seems to be fibrous dysplasia.
X-Ray 5
Fracture shaft of humerus
Description:
This is a plain X-Ray of shaft of humerus
with elbow joint, showing an oblique
fracture, which is displaced laterally.
What is the nature of this fracture?
Most likely traumatic fracture as the
bone is healthy.
Mention the types of fracture according
to geometry.
It is of 3 types:
1. Transverse
2. Oblique
3. Spiral.
Right to left:
Transverse, oblique and spiral
What are the common clinical features of a fracture?
- Pain
- Swelling
- Tenderness
- Movement restriction
- Loss of rotational movement.
Can you classify fracture according to the integrity of skin?
It is of 2 types:
1. Open
2. Closed.
What are the complications of a fracture?
Mal-union
Non-union
Compartment syndrome.
What are the features of microvascular compromise in a distal limb?
Pallor (earliest feature)
Pain (on passive stretching)
Paresthesia
Paralysis
Pulselessness (occasionally occur).
X-Ray 6
Secondary osteoarthritis
Description:
This is a plain X-Ray of pelvis and upper
part of femur showing the following
features in the left side:
1. Irregular margin of femoral head
and acetabulum
2. Reduced joint space.
- So, it is a case of secondary
osteoarthritis.
Name some common causes of
secondary osteoarthritis.
1. Avascular necrosis of femur
2. TB hip.
X-Ray 7
Anterior dislocation hip
Description:
It is a plain X-Ray of pelvis with portions of
femur showing following features on the
left side:
1. Complete loss of contact between 2
articular surfaces (head of femur and
acetabulum)
2. Abduction and external rotation
deformity
3. Lesser trochanter more visible.
- So, it seems to be anterior dislocation of hip.
Do you know the deformities you may find in dislocation of hip?
Posterior dislocation (commoner): FA(b)IR: Flexion Abduction Internal
rotation
Anterior dislocation: Opposite to posterior dislocation: Flexion Adduction
External rotation.
X-Ray 8
Posterior dislocation hip
Description:
This is a plain X-Ray of pelvis along
with upper portions of femur
showing:
1. Adduction and external
rotation
2. Lesser trochanter not visible.
- So, it seems to be posterior
dislocation of hip.
Can you tell some complications of
posterior dislocation of hip?
Immediate complications:
1. Sciatic nerve injury
2. Superior gluteal artery injury (causing hemorrhage).
Remote complications:
1. Avascular necrosis of femur
2. Myositis ossificans.
X-Ray 9
GCT
Description:
This is a plain X-Ray of right knee
joint showing irregular expansile
osteolytic lesion with multiple
septations (marked by arrow)
appearing like soap bubble.
- So, it seems to be a giant
cell tumor/ osteoclastoma.
What do you know about the
aggressiveness of this tumor?
It is a benign but locally aggressive
tumor.
What is the treatment of choice?
Radical excision with reconstruction of the area.
What are the methods of reconstruction?
1. Curettage
2. Bone grafting.
What is the advantage of using bone-cement in times of reconstruction?
Exothermic reaction of bone cement kills residual tumor cells effectively.
What are the complications of GCT?
1. Pathological fracture
2. Deformity
3. Recurrence after surgery
4. Malignancy.
This post was last modified on 01 September 2021