How to interpret skeletal radiographs in adult trauma

Abstract

Musculoskeletal injuries, including fractures and dislocations, account for more than 60% of diagnoses in the emergency department in England.1 Interpreting a radiograph is a crucial part of diagnosis and management and a vital skill for junior doctors. It relies on good anatomical knowledge, an understanding of radiographic views, and a systematic approach. In this article we aim to enable you to develop these skills and boost your confidence. For the patient with a fracture or dislocation, a good outcome depends on sound radiographic interpretation. A missed or delayed diagnosis increases long term morbidity and is the commonest reason for litigation.2 The importance of accurate and early radiographic interpretation is well illustrated by the relatively common neck of femur fracture (fig 1).⇓ Non-displaced fractures are stable and usually fixed by cannulated screw pinning, whereas displaced fractures are unstable and require pinning in younger patients and hemiarthroplasty in older patients. A missed non-displaced fracture can progress to a displaced fracture that requires more complex surgical management and has much greater morbidity. Fig 1 The importance of correctly identifying fractures, exemplified by a case involving the femoral neck. An ambulatory 74 year old woman presented to the emergency department with left hip pain after a fall. Review the anteroposterior views of the left hip. The first radiograph (a) shows normal appearances of the left hip in a younger woman for comparison. Radiograph (b) shows a subcapital neck of femur fracture. Note the cortical discontinuity superolaterally. An irregular sclerotic band running diagonally across the neck represents impaction. This fracture is suitable for pinning, but was missed at initial presentation. The patient re-presented with the inability to bear weight and a shortened, externally rotated left leg. In (c) the follow-up radiograph shows how the fracture in (b) has progressed in displacement; it …