Xray Description in Written Exam Answers

This is snippet from our answer to VAQ5, but I thought it should be reproduced for those of you who missed it.  It’s one of my bug-bears while working on the floor, reading VAQ answers or listening to people doing SCE’s: junior docs (and some senior ones!) often don’t used the correct terminology when describing Xrays.  Some people say “pretend you’re describing it over the phone” but never say who you’re meant to be describing it to.  I say: “pretend you’re describing it to the head Orthopaedic Surgeon or Radiology Consultant over the phone at 4am”. Be accurate, concise, and use the correct terminology.

Still not sure what we mean? Then read some radiology reports on some of your recent patients. The good ones will have no extraneous words, no non-radiologic/non-orthopaedic words, and definitely no non-medical words. They will mention relevant negatives, with emphasis on relevant.

Have you ever seen phrases like:
“a really nasty fracture”, “badly bent”, “serious”, “quite”, “deformed” (this is NOT a radiologic term) …on a radiology report?

No. So what are the words that you use? Here’s an Xray and a description of the terms you should use to describe it:

VAQ5

When talking about fractures you need to mention the following:
Comminution:
Is there more than 2 fragments? Comminuted fracures are those that are broken into more than 2 pieces.
This fracture is non-comminuted
Direction of fracture through bone:
Transverse, spiral, longitudinal, oblique
This is transverse fracture
Displacement:
This means the amount by which the 2 bits of bone are displaced relative to each other.
If there is displacement, you need to state which direction it is: volar, dorsal, superior, inferior, lateral, medial, proximal, distal, and which bit is displced in which direction, and by how much (eg “the distal fragment is displaced dorsally by 5mm”)
NB: This fracture has complete separation of the radial fragments, with some dorsal and proximal displacement of the distal fragment
Shortening:
This means if the bone ends are driven into each other, or are overlapping each other (which can only happen if there’s displacement) resulting in the length of the bone being shorter than normal. Often seen in Colle’s fractures.
This fracture has some shortening related to the dorsal displacement of the distal radial fragment.
Angulation (& direction):
Self explanatory. What is the angle created by the 2 fragments of bone, measured down the middle of the long axis of the bone, and which direction is the distal fragment going.
This fracture is angulated – approx. 90 degrees dorsally
Which bones are broken:
Obvious really, but don’t forget to mention it!
In this case: Radius & ulna
Location of fracture in bone:
You can state this in centimeters from another bony landmark (eg the wrist joint), or you can sound even slicker by describing which part of the bone is broken: epiphysis, metaphysis, diaphesis/shaft.
This fracture: approx 6cm proximal to wrist joint, or it’s a diaphyseal/shaft fracture, or you could say junction of middle & distal 1/3 of forearm

Associated injuries (presence or absence)
Fractures/dislocations in structures that are often co-injured with the obviously injured part.
In this case you would look for Monteggia type dislocation of radial head
If unable to assess, state what you need to make the assessment (see below), ie further views/images
In this case, there is also no apparrent Galeazzi injury at the wrist
Complications:
As mentioned above
Need for other views:
Needs AP, and AP/Lat of whole forearm

So, in summary, for the exam, we would describe this fracture as:

LIMB THREATENING INJURY:
Transverse, grossly angulated (approx 90 degrees dorsally), non-comminuted, diaphyseal/shaft fracture of radius & ulna, approximately 6cm proximal to wrist joint.  Some dorsal and proximal displacement of distal radial fragment, resulting in some shortening.  No obvious Galeazzi injury.
Need AP view & AP/Lat elbow/whole forearm to exclude Monteggia dislocation/elbow injury

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One Response to Xray Description in Written Exam Answers

  1. doncuan January 13, 2012 at 7:32 am #

    I would disagree on the need for further imaging in this case – both radius and ulna are already thoroughly broken. The fracture line is complete. If only one is broken, then you need to seek another as it’s a functional ring, with a nightstick fracture being the common exception (though you could more easily justify the extra films there).

    Similarly for tib/fib – particular fracture patterns (med malleolus, talar shift without fibular fracture on ankle views) may well require further imaging to demonstrate that Maisonneuve injury.

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