Orthopaedics X-Rays
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
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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.
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X-Ray 1
Chronic osteomyelitis
Description:
This is a plain X-Ray of left humerus with shoulder joint, scapula and clavicle showing:
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- Areas of bony destruction
- An osteolytic cavity containing a dead piece of bone (sequestrum, a radiodense area pointed by the yellow arrow)
- Irregularity and thickening of the whole shaft.
So, it seems to be a case of chronic osteomyelitis.
What is sequestrum?
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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?
- Absence of resorption activity in that area due to loss of vascularity
- Collapse of the affected segment
- Sequestrum appears radiodense in the background of radiolucency.
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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?
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- Sequestrectomy: Removal of sequestrum through a window cutting through the involucrum.
- Saucerization: The infected bone cavity is converted into a 'saucer' by removing its wall. This allows free drainage of the infected material.
- Curettage
- Excision of an infected bone.
What are the pre-requisites for sequestrectomy?
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- Well separated sequestrum
- Adequately formed involucrum.
What are the complications of chronic osteomyelitis?
Common complications:
- Deformity
- Pathological fracture
- Shortening of limbs (especially in children).
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Uncommon complications:
- Sinus tract malignancy
- Amyloidosis.
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Why metaphysis is commonly affected in osteomyelitis?
- Metaphysis is the growing end of bone, so it is ill matured
- 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.
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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.
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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?
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- Painless bony swelling around a joint
- Progress very slowly
- A long history
- Stops growing after the age of skeletal maturity.
When does an exostosis become painful?
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- Bursitis of the overlying bursa
- Stretching of nerve
- Pathological fracture
- In case of malignancy.
What is the chance of an exostosis becoming malignant?
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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?
- Rapid growth of the swelling
- Pain
- Skin changes:
- Stretching
- Loss of glistening
- Vascular prominence.
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What is the treatment of choice?
Excision of the lesion (including some normal bone around the lesion).
X-Ray 3
Osteosarcoma
Description:
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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?
- Location: The most common site of osteosarcoma is around knee joint
- Sunburst appearance (blue arrow)
- Codman's triangle (yellow arrow).
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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?
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Table 1
Enneking staging for benign musculoskeletal tumors based on radiographic characteristics of the tumor host margin
| Stage | Description |
|---|---|
| Latent | Well-demarcated borders |
| Active | Indistinct borders |
| Aggressive | Indistinct borders |
What is the most common bone tumor?
Secondary metastasis from other tumors.
What is the most common primary malignancy of bone?
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Multiple myeloma.
What is the 2nd most common primary malignancy of bone?
Osteosarcoma.
What is the age group commonly affected?
10-25 years.
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What are the clinical features?
- Pain
- Swelling
- Pathological fracture.
What are the mode(s) of treatment?
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Combined approach including:
- Surgical excision of affected area
- Radiotherapy
- Chemotherapy.
What are the types of chemotherapy?
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- Neo-adjuvant: Given before surgery
- Adjuvant: Given after surgery.
What are the advantages of neo-adjuvant chemotherapy?
- Downstaging of tumor
- Reduction in size of tumor, makes the tumor resectable
- Reduction in vascularity, less chances of bleeding
- Assessment of sensitivity to chemotherapy.
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What are the disadvantages of chemotherapy?
- Wound complications
- Delay of surgery due to side effects of chemotherapy.
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What is the advantage of adjuvant chemotherapy?
Destruction of residual malignant tissues after surgery.
What are the complications of osteosarcoma?
- Pathological fracture
- Metastasis
- Severe torrential hemorrhage
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What are the types of fracture according to the mechanism of fracture?
- Traumatic fracture: Caused by traumatic injury
- Stress fracture: Caused when a normal bone is exposed to repeated stress
- Pathological fracture: Fracture when a bone is already weakened by some underlying pathological process.
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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).
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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.
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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:
- Transverse
- Oblique
- Spiral.
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Right to left:
Transverse, oblique and spiral
What are the common clinical features of a fracture?
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- Pain
- Swelling
- Tenderness
- Movement restriction
- Loss of rotational movement.
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Can you classify fracture according to the integrity of skin?
It is of 2 types:
- Open
- Closed.
What are the complications of a fracture?
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- 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
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- Paralysis
- Pulselessness (occasionally occur).
X-Ray 6
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Secondary osteoarthritis
Description:
This is a plain X-Ray of pelvis and upper part of femur showing the following features in the left side:
- Irregular margin of femoral head and acetabulum
- Reduced joint space.
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So, it is a case of secondary osteoarthritis.
Name some common causes of secondary osteoarthritis.
- Avascular necrosis of femur
- TB hip.
X-Ray 7
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Anterior dislocation hip
Description:
It is a plain X-Ray of pelvis with portions of femur showing following features on the left side:
- Complete loss of contact between 2 articular surfaces (head of femur and acetabulum)
- Abduction and external rotation deformity
- Lesser trochanter more visible.
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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.
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X-Ray 8
Posterior dislocation hip
Description:
This is a plain X-Ray of pelvis along with upper portions of femur showing:
- Adduction and external rotation
- Lesser trochanter not visible.
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So, it seems to be posterior dislocation of hip.
Can you tell some complications of posterior dislocation of hip?
Immediate complications:
- Sciatic nerve injury
- Superior gluteal artery injury (causing hemorrhage).
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Remote complications:
- Avascular necrosis of femur
- Myositis ossificans.
X-Ray 9
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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?
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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?
- Curettage
- Bone grafting.
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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?
- Pathological fracture
- Deformity
- Recurrence after surgery
- Malignancy.
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