Principles and Pitfalls of Skeletal Radiology

David T. Schwartz, MD
NYU School of Medicine, Bellevue Hospital, Emergency Medicine

A fracture is a clinical, not radiographic diagnosis

Predict injury based on:
1) Mechanism of injury; 2) Findings on physical examination; 3) Age of the patient.
Radiography confirms the diagnosis and provides anatomical detail.
Fractures can be present without radiographic abnormality. If a fracture is clinically suspected but
not radiographically apparent, treat the patient as though a fracture were present with
adequate immobilization and follow-up (e.g., scaphoid fracture, femoral neck fracture).

A fracture is a soft tissue injury with bony involvement

Soft tissue injuries may be more significant that the skeletal injury (ligaments, articular cartilage,
neurovascular injuries).
Diagnosis by physical exam or imaging studies: MRI, angiography, arthroscopy, stress views.

Radiographic Diagnosis of a Fracture

Identify the fracture line. At least two perpendicular views are necessary. Occasionally
supplementary views are needed to demonstrate the fracture, i.e., oblique views or a third
perpendicular view (axillary view shoulder, sunrise view patella). Anatomical variants can
produce lines that mimic fractures (pseudo-fractures).
Soft tissue changes can provide a clue to a fracture. They may be more conspicuous that the
fracture itself. For example: elbow fat pads, cervical spine prevertebral soft tissue swelling,
maxillary sinus air/fluid levels and orbital emphysema (see table 3 below).
Changes in bone contour and alignment. Normal radiographic anatomy must be understood.
Measurements serve as a guide but are less reliable than familiarity with the normal appearance.

How to Read Skeletal Radiographs

Know the standard and supplementary views included in a radiographic series (Table 1), whether
the views have been properly performed, and the role of each view in injury detection.
Systematic Approach: ABC'S (Table 2) Adequacy (all views included and properly performed),
alignment, bones (fractures), cartilage (joint spaces), and soft tissue signs (Table 3).
Targeted Approach Scrutinize the radiographs for:
Common sites of injury
Easily missed injuries with subtle radiographic findings (Table 4)

Pseudo-fractures Radiographic variants that mimic fractures:

Anatomical variants (congenital anomalies) such as accessory ossicles, developmental findings in
children (growth plates and ossification centers), degenerative changes (elderly patients), old
trauma, nutrient artery foramina, Mach bands (caused by overlapping bones or soft tissues),
suboptimal or incorrect positioning

Indications for radiography. Clinically distinguish an isolated soft tissue injury that does not need
radiography (e.g., sprain or contusion) from a fracture. Use clinical judgment and, when available,
clinical decision rules (e.g. Ottawa Ankle Rules).

When to order supplementary views (oblique view, view in a third perpendicular plane):
1.
2.
3.

Suspected injury is not seen on standard views

Better elucidate a questionable abnormality
Better delineate an identified injury

Pitfalls of Orthopedic Radiology

Misinterpretation of radiographs
Failure to recognize subtle signs of injury (false-negative)
Misinterpreting radiographic variants as acute injuries (false-positive)
Missed second injury (satisfaction of search error)
Inadequate radiographs
Inadequate views (technically suboptimal)
Incomplete radiographic series (missing views)
Failure to order supplementary views or other studies (CT, MRI)
Over-reliance on radiography: Clinical examination inadequate
Radiography of the incorrect region (hand/wrist, foot/ankle)
Missed soft tissue injury (neurovascular, compartment syndrome, ligamentous)
Missed second injury
Failure to obtain radiographs
Inadequate treatment
Failure to consider and treat potential occult fractures (scaphoid, femoral neck)
Poor discharge and follow-up instructions
Breakdown in radiograph follow-up (re-call) systems
Fracture description: Name the involved bone; location of the fracture; characteristics of the fracture
(displacement, comminution, spiral, intra-articular, impacted).
Also, stress fractures (overuse), insufficiency fractures (weak bone), and pathologic fractures.
Eponyms convenient names for typical injuries are based on the person who originally described the
injury. However, eponyms are sometimes not clearly defined and are occasionally misapplied.

Table 3. Soft Tissue Signs of a Fracture

Radiographic View

Soft Tissue Sign

Common Fractures

Elbow lateral

Elbow Fat Pads:

Posterior fat pad
Anterior sail sign

Radial head (adult)

Supracondylar humerus, lateral
condyle (child)

Elbow lateral

Supinator fat stripe

Proximal radius or ulna

Wrist lateral

Pronator quadratus fat stripe

Distal radius

Wrist PA

Scaphoid fat stripe

Scaphoid

Knee cross-table lateral

Knee lipohemarthrosis

Tibial plateau, intercondylar eminence,

osteochondral fracture

Ankle lateral

Ankle effusion

Distal tibia or fibula articular surface,

talar dome fracture

Cervical spine lateral

Cervicocranial prevertebral soft

tissue swelling

Cervicocranial injuries

Face Waters view (upright)

(occipitomental view)

Maxillary sinus air/fluid level

Blow-out fracture (orbital floor or

medial orbital wall), tripod fracture,
LeFort fracture

Waters view

Orbital Emphysema

Fracture into maxillary sinus, ethmoid

sinus, or frontal sinus (uncommon)

Head CT

Scalp swelling

Skull fracture. Coup injury (subdural

hematoma, epidural hematoma,
intracerebral hematoma)

Head CT (bone windows)

Pneumocephalus

Open skull fracture (basilar, linear or

depressed fracture)
2

Table 1. Standard and Supplementary Views of the Extremities

Views that are standard vary from institution to institution.
Supplementary views are oblique views, axial views (third perpendicular plane), altered positioning (scaphoid view).
Obtain supplementary views when: 1) a fracture is suspected on physical examination but not seen on the
standard views; or 2) to better define a questionable abnormality seen on the standard views.
Standard Views
Shoulder
Clavicle
Elbow
Wrist

Hand

Finger

Pelvis
Hip

Knee

Ankle

Foot

Supplementary Views

AP views:
External rotation
Internal rotation
AP
Angled AP (15 cranial)
AP
Lateral
PA
Lateral
Pronation oblique
PA
Lateral
Pronation oblique
PA
Lateral
Pronation oblique

Y view (standard for trauma)

Axillary view (posterior dislocation)
Stress views of AC joint
Oblique views (2)
Olecranon view (axial)
Scaphoid view (PA in ulnar deviation)
Supination oblique
Carpal tunnel view (axial)
Supination oblique (Ball-catcher view)

AP

CT
Judet views (oblique of acetabulum)
Inlet and outlet views

AP (pelvis)
Frog-leg or oblique

Cross-table lateral

AP
Lateral

Oblique views (2)

Axial sunrise patellar view
Intercondylar notch view
(tunnel view AP knee flexed)

AP
Lateral
Mortise (15 internal oblique)
AP
Lateral
Internal oblique

Oblique views (2)

"Poor" lateral
Calcaneus axial view
External oblique

Table 2. ABCS Approach to Interpreting Skeletal Radiographs

Adequacy

All views are included

Correct positioning and penetration (exposure)

Alignment

Anatomical relationships between all bones are normal

Bones

Look for fracture lines, distortion of cortex or trabeculae

Supplementary views may be needed to detect nondisplaced
fractures
Pseudo-fractures can mimic a fracture:
Accessory ossicles, growth plates, nutrient artery foramina,
Mach bands

Cartilage

Joint spaces are uniform and have normal width

Fracture fragments may be seen within joint space

Soft Tissues

Soft tissue swelling, joint effusions and distortion of fat planes

can be easier to see than the fracture itself

Table 4. Easily Missed Fractures and Dislocations

Common injuries that present with subtle clinical and radiographic findings. The fractures are usually nondisplaced or
minimally displaced. Associated clinical signs must be sought when examining the patient. Additional radiographic
views are sometimes needed to visualize these injuries.
Shoulder

Elbow

Posterior dislocation light bulb on a stick (AP view: humerus fixed in internal rotation plus wide space
between humeral head and glenoid fossa), order axillary view to confirm. Beware of proximal
humerus fracture with sublet associated posterior dislocation.
Anterior dislocation with humeral neck fracture unstable for closed reduction
Distal clavicle fracture (elderly) or A-C separation (young adults) use bright-light for dark area of film
Fat-pad sign
Adult - Radial head fracture or other intra-articular fracture
Child - Supracondylar or lateral condylar fractures; medial epicondyle displaced into joint space

Forearm
Monteggia and Galeazzi fracture-dislocations examine the joint above and below the forearm fracture
Wrist
Distal radius fracture (non-displaced) on lateral view see displaced pronator fat stripe and disruption of cortex
Carpal fractures: scaphoid (snuff box tenderness), triquetrum, hamate, etc.
obtain scaphoid view, supination oblique or carpal tunnel view if diagnosis is uncertain
Dislocations/instability: perilunate, lunate, scapholunate dissociation (Terry-Thomas sign)
Metacarpal base fractures and intra-articular fractures (Bennett, Rolando)
Hand
Tendon and ligament injuries; phalangeal avulsion fractures
Pelvis
Acetabular fractures disrupted radiographic tear drop
Posterior pelvic ring fractures (sacral wing fractures) disrupted sacral neuroforaminal lines
Pubic ramus fractures, iliac wing fracture, avulsions (ischial tuberosity, anterior iliac spine)
Hip
Femoral neck fracture
(elderly, osteoporosis)
1. Discontinuity of the normal smooth contour of cortical bone
2. Discontinuity or disruption of the normal trabecular architecture
3. Transverse band of increased bone density (sclerosis) where the fracture fragments are impacted.
Diminished bone density where the fracture fragments are distracted
4. Foreshortening of the femoral neck (not due to poor positioning external rotation of hip)
5. Abnormal angle between the femoral neck and the femoral head
Intertrochanteric fracture may only be seen on frog-leg or lateral view
Pubic ramus fracture or other pelvis fracture obtain AP pelvis film rather than hip film
Knee
Tibial plateau fracture (lateral plateau) cortical irregularity, trabecular impaction, obtain oblique view
Patella fractures (vertical or oblique orientation) order sunrise patella view or oblique views
Osteochondral fractures or cruciate ligament avulsions bone fragment in joint space (tunnel view)
Ankle
Ligament tears and instability examine joint space on mortise view
Tibio-fibular syndesmosis tear - Maisonneuve fracture tender proximal fibula, obtain tib-fib films
Navicular and other midfoot fractures -- occur with ankle sprains
Fifth metatarsal tuberosity avulsion (pseudo-Jones fracture) (may see on lateral ankle view, obtain foot films)
Foot
Calcaneus and talus (hindfoot) fractures Boehlers angle on lateral view, axial calcaneus view
Tarso-metatarsal fracture-dislocation (Lisfranc)
see small fracture of 2nd metatarsal base, malalignment of metatarsal bases and cuneiforms
Fractures in children
Growth plate fractures (Salter-Harris)
Torus (buckle) fractures, greenstick fractures, and acute plastic bowing
Missed fractures in the multiple trauma victim (requires complete secondary survey)

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