How to Read X-rays Like an Ortho Surgeon

Format For Describing Fractures

1. Say the xrays views you are seeing and the laterality, if you are unsure of the view just say 1 or 2-view of a left or right “blank”.
   1. Example: “This is an AP, Mortise, and Lateral of right ankle in a skeletally mature individual showing a Weber B ankle fracture”
2. Look for open physes to say, “skeletally mature or immature individual”.
   1. Starting out this a good practice, when you are a resident it may not be necessary at your residency program
3. Describe the fracture in the most straightforward way possible
   1. Don’t get bogged down in the details (common mistake)
   2. Say the most accurate and elegant description of the fracture in the fewest amount of words as possible (Using more words is easier than an elegant and complete short description)
4. Say it with confidence (even if you are not).

If you’ve examined them, is it open or closed?

• You can’t always tell if a fracture is open or closed from the x-rays, always use orthogonal views because sometimes you can tell if the fractures are open based on the xrays.
• (Orthogonal views means that the xrays are 90 degrees from each other such as an AP and lateral).
• On your exam, keep an eye out for small “poke holes” in skin. Bleeding from bone is often constant slow venous type bleeding.
• Try to read the image below for practice.

AP xray of left tib/fib, in a skeletally immature individual with a likely open segmental midshaft tibia fracture and a segmental midshaft fibula fracture

• You technically can’t tell if this is open from the xray, but there looks like there are dressings over the fractures site. Keep an eye out for jagged and displaced edges.
• Here, the physes are still open, so they would be considered a skeletally immature patient.

Describing Fractures

• Here are the main types of fracture descriptions
  • Describing the displacement
  • Fracture morphology
  • Fracture location
  • Unique Scenarios
    • Periprosthetic fractures (hardware present)
    • Joint involvement, such as joint dislocation and subluxation

Describing the Fracture Displacement

• Displaced
  • If there has been movement of fracture pieces
• Nondisplaced
  • No movement between bone fragments
• Minimally displaced
  • When not much movement has occurred, this is a subjective description.
• The xray below shows a right hip AP in a skeletally mature individual showing a nondisplaced basicervical femoral neck fracture. (Types of femoral neck fractures to be discussed in future chapters)

Fracture Morphology

• Here are other important fracture morphology descriptions
  • Transverse
  • Short vs. Long Oblique
  • Spiral
  • Wedge (Butterfly Fragment)
  • Comminuted (many pieces)
  • Segmental
• Transverse

• Spiral (If it is hard to tell if it a spiral or oblique, you can say, “long oblique”)

• Oblique

• Wedge or “butterfly fragment”
  • The compression side of the fracture is on the butterfly fragment side. tension side of the fracture is on the opposite side. (The tibia below likely fracture from a blow coming from the lateral side bending the tibia in valgus, so the distal end of the tibia folded away from the midline.)

• Comminuted (many pieces)

• Segmental (the fractures create multiple sections)

• Angulation and translation
  • Important Rule: The proximal portion of the fracture is always anatomically correct
  • Translation is when the bone fragments are displaced in the coronal or sagittal plane in reference to one another. The degree of translation is rarely used as a descriptor in fracture conference (just using the word, “displaced” is more often used)
  • Angulation is often only used for for long bone shaft fractures or distal radius fractures
    • This distal tibia is 15% translated laterally (the proximal portion of the fragment is the anatomically correct fragment)
    • Valgus = the distal bone is angled away from midline of the body
    • Varus = the distal bone is angled towards midline of the body

Describing The Fracture Location

Bone Region followed by the bone name/bone location

• Proximal (most proximal portion, humeral head for example)
• Proximal third
• Midshaft (or middle third)
• Distal third
• Distal
• Certain bones have unique locations besides the bone regions listed above
  • For example: The Humerus
    • Proximal humerus, the humeral head
    • Greater and lesser tuberosity
    • Surgical neck
    • Humeral shaft
    • Supracondylar region
    • Condyles

Unique Scenarios

If there is joint involvement

• Joint dislocation
  • Describe the direction of the dislocation, the proximal fragment/bone in fractures and dislocations are always considered anatomically correct
    • Anterior, posterior, lateral, medial
    • If near the hand/wrist, volar and dorsal is the equivalent of anterior/posterior

AP of left ankle in skeletally mature individual showing a tri-mal (fractures of all three malleoli of the ankle) ankle fracture dislocation

• The posterior malleolus is easier to see on the lateral view
• If there are only two malleoli fractured, it is a “bi-mal” ankle fracture
• If the lateral mal is fractured, but there is no medial mal fracture it is a bi-mal equivalent (deltoid ligament is not intact, and it “acts” like a true bi-mal

• Subluxation (not quite dislocated, the joint is shifted out of position)

Periprosthetic fracture

• use the term “periprosthetic” any time there is a prosthesis and fracture in the same bone that you are describing even if there is a distal femur fracture with proximal hardware like a total hip.

Lateral and AP of a skeletally mature individual showing an oblique distal periprosthetic femur fracture