RADIOLOGY EXAMINATION IN ORTHOPAEDIC CASES

BAB II. DISCUSSION

2.1 DEFINITION
Specific views need to be requested depending on the suspected injured joint. An adequate x-ray
regarding demographic information of the patient, date, time, site, and view. For examples AP x-
ray of the right shoulder showing distal to the midshaft of the humerus and medial to past the
mid clavicle but not including the sternoclavicular joint. When requesting and evaluating
orthopedics x-ray, it is important to always apply the Rule of Twos, which are:
● 2 views: usually AP and lateral.
● 2 joints: include the joint above and below the bone with th pathology.
● 2 limbs: useful for comparison, particularly in children with growth plates provided the
other side is normal.
● 2 opinions
● 2 occasions: particularly in fractures before and after reduction or application of
splints/casts.
Bone was assess from outside (cortex) to inside (medullary cavity) and trace the outline of the
bone.
● Density: ‘darker’, less distinct bone projection with thin cortices is
described as osteopenic. Lesions are described compared to the
surrounding bone. Lytic, density is lover ; sclerotic, density is higher ; or
combination.
● Fracture: Kind of disruption or break in the cortex should be described
according to its locations (diaphysis, metaphysis, epiphysis, intra or extra
articular), pattern (simple or complex/comminuted) and displacement.
● Displacement: How the distal part of the bone has moved relative to the
proximal part of the bone. The displacement should be described at least 2
planes, the coronal plane as sen on an AP x-ray and the sagittal plane as
seen on a lateral x-ray. Displacement can be described as LARA (Length,
Apposition, Rotation, and Angulation)
 ● Example: the midshaft transverse tibia fracture is shifted is shifted 25%
medial and 25% posterior with 10 o of varus tilt and 30o of anterior tilt,
there is 5mm of impaction.

Fig. 2.1 Osteolytic lesion of an osteochondroma

Cartilage or joint assess for joint congruency, subluxation is when the joint is partially
enact and dislocation is when there is no contact between the articular surfaces. Assess for signs
of cartilage degeneration or osteoarthritis, joint space narrowing osteophytes, subchondral
sclerosis and subchondral cysts.
 Fig. 2.2 Osteoarthritis of the left hip

Soft tissue such as swelling or sign of joint effusion ott haemarthrosis, gas suggestions as
open wound or infection, foreign body for example glass, discontinuity of the soft tissue line or
dressings, indicating a wound.
When displayed with a understanding, the cause of whose side effect is obscure or
suspected on the premise of clinical information, the radiologist ought to avoid, as a point of
takeoff within the examination, the more innovatively progressed imaging modalities in favor of
making a conclusion, at whatever point conceivable, on the premise of simple routine
radiographs. This approach is fundamental not as it were to preserve cost-effectiveness but too to
diminish the sum of radiation to which a quiet is uncovered. Continuing to begin with with
ordinary method moreover encompasses a firm premise within the chemistry and physiology of
bone. The calcium apatite gem, one of the mineral constituents of bone, is an inborn differentiate
operator that gives skeletal radiology advantage over other radiologic subspecialties and makes
data on bone production and devastation promptly accessible through ordinary radiography.
Straightforward perception of changes within the shape or thickness of ordinary bone, for case
within the vertebrae, can be a choosing calculation in arriving at a particular conclusion.
2.2 UPPER LIMB
2.2.1 SHOULDER
The bear support comprises of osseous components—proximal humerus, scapula,
and clavicle, shaping the glenohumeral and acromioclavicular joints and different
muscles, tendons, and ligaments strengthening the joint capsule. The joint capsule
embeds along the anatomic neck of the humerus and along the neck of the glenoid. In
front, it is strengthened by three glenohumeral tendons (GHLs) (the predominant, center,
and second rate), which meet from the humerus to be connected by the long head of the
biceps ligament to the supraglenoid tubercle. The other vital tendons are the
acromioclavicular, coracoacromial, and the coracoclavicular (counting trapezoid and
conoid parcels).
The basic muscles are those that frame the rotator sleeve. The term rotator sleeve
is utilized to portray the gather of muscles that encompasses the glenohumeral joint,
holding the head of the humerus solidly within the glenoid fossa. They comprise of the
subscapularis anteriorly, the infraspinatus posterosuperiorly, the teres minor posteriorly,
and the supraspinatus superiorly (mental aide SITS). The subscapularis muscle embeds
on the lesser tuberosity anteriorly. The additions of the supraspinatus, infraspinatus, and
teres minor muscles are on the more noteworthy tuberosity, posteriorly. The
supraspinatus ligament covers the prevalent angle of the humeral head, embeddings on
the predominant aspect of the more noteworthy tuberosity. The infraspinatus ligament
covers the predominant and back perspectives of the humeral head and embeds on the
center feature, found distal and more back to the predominant feature. The teres minor is
lower in position and embeds on the posteroinferior feature of the more noteworthy
tuberosity. In expansion, the long head of the biceps with its ligament, which in its
intracapsular parcel runs through the joint, and the triceps muscle, embeddings on the
infraglenoid tubercle inferiorly, give extra back to the glenohumeral joint.

2.2.2 SHOULDER ASSESSMENT

The starting evaluation of the bear starts with a review of the bear support to as-
sess for any muscle decay. Both deltoid and infraspinatus decay are effectively
acknowledged. Separated infraspinatus decay can be auxiliary to a footing damage to the
suprascapular nerve or can result from compression neuropathy of the suprascapular
nerve. Compression neuropathy is more often than not auxiliary to a ganglion blister
within the spino- glenoid indent (Fig 1) or paralabral blisters, which are perpetually
related with posterosuperior labral tears. Neurogenic edema can be seen within the
muscle paunch within the more intense cases of neuropathy, such as footing wounds.
Whereas indeed inconspicuous infraspinatus decay can be identified with care- ful
clinical examination, supraspinatus decay is for the most part more troublesome to
appreciate since of the overlying trapezius muscle; in any case, it can be effortlessly
recognized at MR imaging. As a rule, a massive persistent rotator cuff tear or
compression of the suprascapular nerve by a injury within the supra- scapular score is
mindful for clinically apparent supraspinatus decay.
The beginning assessment of the bear begins with an audit of the bear back to as-
sess for any muscle rot. Both deltoid and infraspinatus rot are successfully recognized.
Isolated infraspinatus rot can be an assistant to a balance harm to the suprascapular nerve
or can result from compression neuropathy of the suprascapular nerve. Compression
neuropathy is more frequently than not assistant to a ganglion rankle inside the spino-
glenoid indent (Fig 1) or paralabral rankles, which are never-endingly related with
posterosuperior labral tears. Neurogenic edema can be seen inside the muscle paunch
inside the more serious cases of neuropathy, such as balance wounds. While in fact
unnoticeable infraspinatus rot can be recognized with careful clinical examination,
supraspinatus rot is for the foremost portion more troublesome to appreciate since of the
overlying trapezius muscle; in any case, it can be easily recognized at MR imaging. As a
run the show, a massive diligent rotator sleeve tear or compression of the suprascapular
nerve by a damage inside the supra- scapular score is careful for clinically clear
supraspinatus decay.
 Fig. 2.3 Anatomy of Shoulder

Fig. 2.4 Shoulder Bone

For anteroposterior (AP) view, it can be done in either supine or erect position
with the arm fully extended in neutral position. The central beam is directed toward the
humeral head. In this view, the humeral head will be seen overlapping the glenoid fossa.
 Fig. 2.5 Anteroposterior View of Shoulder

Grashey view is used to determine the glenoid and glenohumeral joint space in
true profile. The patient is in supine or erect position, rotated around 40 o toward the
affected side of the shoulder. The central beam is directed toward the glenohumeral joint.

Fig. 2.6 Grashey View of Shoulder

Axillary view demonstrates the relationship between humeral head and glenoid.
The patient is seated at the side of the radiographic table and the arm is abducted. The
axilla is positioned over the film. The radiographic tube is placed 5-10 o toward the elbow
while the central beam is directed through the shoulder joint.

Fig. 2.7 Axillary View of Shoulder

West point view is used to get better visualisation of anteroinferior glenoid rim.
The patient lies prone with a pillow placed under the shoulder to raise it around 8cm. The
radiographic tube is angled 25o to the patient’s midline toward the axilla and 25 o from the
table. The film is placed on the superior aspect of the shoulder.

Fig. 2.8 West Point View of Shoulder

 Transthoracic lateral view is used to see the true lateral view of proximal
humerus. The patient is erect with the infected arm against the table. The central beam is
directed below the axilla of the opposite side, slightly above the nipple. The opposite arm
is abducted.

Fig. 2.9 Transthoracic Lateral View of Shoulder

Bicipital groove view is performed in standing position and leaning forward. The
forearm is resting on the table with the hand in supination while holding the film above
the forearm. The central beam is directed vertically toward the bicipital groove.

Fig. 2.10 Bicipital Groove View of Shoulder

 Acromioclavicular view is used to evaluate acromioclavicular articulation. The
patient is erect and the arm is in neutral position. The central beam is directed 15 o
cephalad toward the clavicle. The radiographic needs to reduce the exposure around 33-
50% of those used in standard view to prevent overexposure on this site.

Fig. 2.11 Acromioclavicular View of Shoulder

Transcapular view can visualize a true lateral view of scapula and oblique view of
proximal humerus. The patient is erect and rotates around 20 o against the tablet. The arm
of the affected shoulder is slightly abducted, the elbow flexed with the hand resting on
the hip. The central beam is directed toward the medial border of the protruding scapula.
 Fig. 2.12 Transcapular View of Shoulder

X-ray can predict potential rotator cuff tears by considering radiographic indices
of the shoulder. The radiographic indices of shoulder are measured by:
- Acromial Slope (AS)
AS is measured by drawing a line that connects the midway point and the most
anterior point of acromion inferior edge, then another line that connects the
midway point and the most posterior of the acromion inferior edge on the outlet-
view X-ray. Larger AS tend to cause anterior tears, middle tears, or longitudinal
tears.
 Fig. 2.13 Acromial Slope of Shoulder

- Acromial Tilt (AT)

AT is measured by drawing a line that connects the most anterior point
and posterior point of acromion inferior edge, then another line that
connects the most posterior point of acromion inferior edge and the tip of
the coracoid process on the outlet-view X-ray.
 Fig. 2.14 Acromial Tilt of Shoulder

- Lateral Acromial Angle (LAA)

LAA is measured by drawing a line that connects the uppermost point and
lowermost point of lateral glenoid, then another line parallel to the acromion

inferior edge on anteroposterior-view X-ray. LAA with a value less than 80 ° is

associated with the presence of rotator cuff tears.

Fig. 2.15 Lateral Acromial Angle of Shoulder

- Acromion Index (AI)
AI is calculated as D1/D2. D1 is a line that measured the most lateral point of
acromion inferior edge and lateral glenoid line. D2 is a line that measured the
most lateral point of humeral head and lateral glenoid line. The lateral glenoid line
is drawn connecting the uppermost point and lowermost point of lateral glenoid.
AI that is greater than 0,74 is associated with rotator cuff tears.
 Fig. 2.16 Acromion Index of Shoulder

- Subacromial Distance (SAD)

SAD is the length of the line that is measured by drawing a line between midpoint
of acromion inferior edge and uppermost point of humeral head on
anteriorposterior view X-ray. SAD with value less than 8mm is associated with a
large rotator cuff tear.

Fig. 2.17 Subacromial Distance of Shoulder

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