In the ortho world, most if not all decisions begin with an xray. If a patient has pain in a specific area such as a shoulder or ankle, any orthopod would recommend ordering an xray series of that area.
The orthopod will be sad if they are consulted without an xray ordered. Well, what about just soft tissue pain? Yes. What about knee swelling? Yes. What about a septic joint rule out? Yes…
Modern digital xrays can have some incredible detail that allows you to pick up on more soft tissue abnormalities than you might think.
Use the power of the xray for screening any type of pain. This is where the orthopods have an advantage over the radiologist for finding injuries. You have the physical exam, you know their story and where their pain is which can help put the xrays into a frame of reference.
Never trust the radiologist reads, always look at all the images yourself. Everyone makes mistakes, radiologists are excellent at what they do, but you have the power of actually seeing the patient, you will catch things the radiologist will miss.
Well what if they already have a CT scan? Order an xray anyways because the xray can show the whole image at once, the CT can only show one slice at a time. (No, scout CT films are not enough).
A perfect example of this is that in unstable pelvic ring injuries, the shape of the CT scanner can close down the pelvis, where as a flat plate pelvis xray can show severe pelvic symphysis widening which would warrant immediate binder placement.
Get xrays of a dislocation prior to any reduction attempt
This means you should order a repeat set of shoulder xrays if someone else has tried and failed a reduction attempt. You always want to make sure to identify any fracture that they might have produced before your attempt. (This goes for any joint dislocation).
Always use orthogonal views (1 view is not enough).
Never 100% trust that the xray or any imaging series is labeled 100% correctly 100% of the time. People can have the same names and birthdays where shoulder MRIs performed on the same day can get switched (this has happened and a surgery was carried out on the wrong person). An image can get labeled correctly based on the original order, but the image was of the wrong side. You get the picture, if the exam doesn’t fit with the xray always have some baseline trust issues…
Rules on Reading Xrays
Use a system, do it the same way every time so you don’t miss anything.
You’re responsible for anything found on the xray that you ordered. If there is a bone lesion there as an incidental finding and completely unrelated to why you ordered the image in the first place, you are still responsible for it.
Xray reading system for the Orthopod:
Verify the patient, date of birth, and date of xray
Know whether there are similar prior xrays to use as a comparison
Look at the whole image and identify the obvious findings right off the bat that stand out to you. Do this for each image in the series of what you ordered.
Describe this finding with saying what the image is, the laterality, bone maturity, and the most quick, accurate, clear, and complete description of the finding itself. (Here is the rundown on describing xrays: How to Read X-rays Like an Ortho Surgeon).
Now do the deep systematic comb through
Start proximally and work distally
Look at the cortices, joints, and canals of each bone as you go
Go back and look at the the surrounding soft tissue from proximally to distally
Use the rules and measurements listed for each anatomic area.
