 You as a doctor give hope and health to many each day, there are many more to give hope and health to and with Fujifilm we are doing that together. So now what we are going to do is I will be giving you about 10 seconds there will be a particular format on which you will have to look at the radiograph and give me the answer right. So you don't have to type the answers please don't bother about it just be true to yourself and once just just keep in your mind what you think is the diagnosis and then I'll show you the diagnosis. This is a trial run so here you can see this is a AP and lateral radiograph of the knee and this is the particular format you're going to look at. So medial femurotheal compartment looks normal lateral you can see that there is some nauseous fragments so there is a fracture the fracture is extending up to the articulate surface there is some articulate surface depression okay paternal femur compartment looks normal central I don't see any avulsion fractures of the intercondylar eminence displaced yes this does look out of place so there is some my displacement of the fracture fragment effusion yes there is a small effusion that is present so this is the particular format when you look at every excerpt in this format you will not miss on any of the findings and this particular format is predominantly for now we are going to only report fractures and injuries arthritis will be discussing later so just concentrate on fractures and injuries if you see joint space narrowing for now just ignore it okay so this was a very obvious finding this was a lateral femoral confined fracture and also called as the hofars fracture okay so I give you 10 seconds just have a look at it make up a diagnosis in your mind okay medial compartment looks normal lateral yes you see a fracture you see that there is a line over here and this is a lateral tbl fracture now this lateral tbl fracture has a gap also it is reaching up to the articulate surface this is my articulate surface gap also if you see this is how your tbl fracture should have been so there is some articulate surface depression or step off as well you cannot see a paternal femoral compartment on the at view so that's not applicable central normal displays no but depressed yes so it is a depressed lateral tbl fracture with an articulate surface gap a fusion you cannot comment on the APB so again this was a obvious finding this was a lateral tbl fracture which is also called as a shatka fracture this is another example of a very obvious shatka fracture and which is in fact shatka type 5 where even there is a dissociation between the tbl metaphysis and the tbl diaphysis whereas here if you see this is a very subtle shatka fracture so if you are just you know if you look at this x-ray hurriedly I bet on it that you will miss the fracture but when you have a particular format of how to look at the x-ray you will pick up that this is the fracture it is not so well seen on the lateral radiograph but on the AP radiograph you can appreciate that there is a lateral tbl fracture not much of an articulate surface step of a gap next case you have 10 seconds okay so again grossly I don't see anything no big fractures no joints there's narrowing nothing medially this side generally nothing laterally you can see this small Oshius plate over here this could be a fracture or this can be a calcification in the left knee joint okay which is where the medial ligament goes and attaches so I told you this is one of the review areas again lateral normal particular normal displace no this fragment is not displaced effusion you cannot comment on an AP so this is your medial collateral ligament and here you will see that this fracture fragment is in place of the medial collateral ligament so this is not so obvious finding you'll have to actually look for it and this is a filaggrinous tiada lesion filaggrinous tiada lesion is nothing it can be a valgian fracture from the medial femoral condy or in chronic MCL injuries calcification can develop towards the femoral attachment and it can give this appearance next is again a AP and a lateral radiograph 10 seconds get the diagnosis in your mind follow the format medial looks okay lateral looks okay particular femoral I don't see anything now next is central and you can see that there is a fracture over there okay so you can see that now if you closely see because you've seen the fracture over here lateral if you would not have if you've not seen this lateral you may actually miss this fracture because of the overlap but you'll see this is your fracture fragment right and this fracture fragment has surely displaced superior so there is some mild displacement mild superior displacement of the fracture fragment a fusion yes you have a small a fusion over here so this if you see fracture fragment is along the at tbl attachment of anti-recruciate ligament so that is the femoral attachment this is your tbl attachment and this tbl attachment fibers as evals of a bone piece in this patient and so if you correlate with the MR that's your ACL and that is the evals bone piece similarly here is the evals bone piece and you can see that there is a lot of marrow it so this is not an obvious finding you have to actually look for it and this is a anterior tbl intercondylar eminence fracture which is nothing but a anterior tbl evalsion fracture again in this patient you cannot see anything on the at view but when you see on the lateral view you can clearly appreciate that this is your fracture fracture and it is slightly shifted superior so this is another patient with an ACL evalsion fracture okay again the same format 10 seconds all right so same thing medial normal lateral normal paternal femoral normal what is important is central now again here you don't see anything but in this particular case you can see that there is a fracture over here it's a very subtle fracture it's not displaced so unless you actually look at this region you're going to miss the structure displaced no there is no displacement of the austere's fragment and yes there is an effusion over here so please make sure that you follow this format so that you don't miss any of the fractures now this particular austere's fragment is along the attachment of the posterior cruciate ligament fibres so this is your femoral attachment and this is how the PCL comes and attaches to the tbl posteriorly and this is where it has evalsed off a bone from the tbl fracture or the intercondylar evidence and this is the MRI image of the patient and you can see that the PCL is good but it has evalsed off a bone from the underlying tbl so this is a PCL tbl attachment evalsion fracture another thing just a lateral view again if I would just see this x-ray in a hurry without using my review areas I'm gonna miss the fracture but if I start looking at the review areas this is your fracture so it's at there is actually a lot of overlap from other bones so unless you look for it you're going to miss it the key important thing to mention in this report is that there is a superior displacement of the austere's fragment also on the MR you can see that this austere's fragment is displaced by almost 9 millimeters and why this is important be it a ACL or a PCL evalsion fracture if the displacement is more than 5 millimeters they usually go and fix back the bone piece and that needs to be done immediately or on a urgent basis you cannot do it after months later because if the bone piece is not fixed back immediately the bone will undergo austere remodelling and once it undergoes austere remodelling this bone will not fix back into the defect in the bone so this is like a jigsaw puzzle and it won't fix back in the jigsaw puzzle so therefore it is very important that you pick up these evalsion fractures and if they are superiorly displaced you need to mention that so that the orthopole knows what he needs to do next for the patient another case 10 seconds okay for all of you who has picked up this fracture pat yourself pat your back because you've really done a very good job because this is actually a very subtle finding so grossly I don't see anything medial compartment looks okay lateral compartment actually here there's nothing but if you close the observe there is a small oceus plate which is there in this stage okay so there is a small fracture from the antrolateral tbl plateau which I have already told you is a review area so this and in fact in a lateral view you will never see this fracture because of the overlap less everything is normal except that yes it is mildly displaced effusion you have an effusion over here so this is actually along the attachment of the anterolateral ligament and this is your anterolateral it's a very thin ligament so this is a normal mr image of the ligament you'll see this is your anterolateral ligament okay this this is where it goes and attaches to the tbl and this is its femoral attachment so it's a very thin slender ligament and often with ACL injuries anterolateral ligament can evals off a bone from the anterolateral tbl plateau and this is nothing but a segon's fracture here you can see that this ligament also doesn't look that healthy it's injured and you can see that is evals off a bone from here now why is this important segon's fracture is is one of those hundred percent science so if a segon fracture is present there are hundred percent chances that patient has a ACL tear so on a radiograph if you pick up a segon fracture then it's actually a eureka moment for you because now you can actually call your orthopod and say that boss there is a second fracture there are chances that he has a ACL injury underlying ACL injury and your orthopod will be completely impressed with you he will say yes my lackman test is also positive I'll send the patient for an MRI to confirm if there is any any other findings in the scan so this is how your report will start to make a difference and you will start to gain recognition another thing which is important is if you get a MRI to report often these fractures are so small okay that always remember whenever there is a ACL injury on an MRI look at the anterolateral tbl plateau to pick up a fracture but often again in a hurry you may forget to see this review area on the MRI and during that time the x-ray will be your savior so even if you miss the segon fracture on the MRI because it's very small if you look at the x-ray you will get your answer that yes he has a second fracture now why it is important ACL injury is there we know that from the MRI now so why do we need to know if that there is a second fracture because if there is a second fracture it needs to be prepared otherwise the graph of the ACL can fade so if the segon fracture is not addressed to the patient can land up into a ACL graft failure and the patient will require a resurgence and when that happens remember that you are going to go down in the eyes of the orthopods second important thing is whether you have seen the x-ray or not 95% of the time so orthopod is going to see the x-ray and he is going to pick up this fracture so please don't miss this fracture be it on an x-ray and please don't miss this fracture even if you are on reporting an MRI so even if you're reporting an MRI make sure to look at the x-ray to find such subtle fractures so this is another patient where you can see that there is a second fracture this is another patient so this segon fracture is displaced whereas this is an essentially non-displaced segon fracture so again it's a subtle finding but if you report it on an x-ray it's an indirect indicator of ACL injury okay another x-ray 10 seconds go okay this is also a very subtle finding just like a segon fracture and on the lateral compartment the femoral tibial is okay but here you can see that there is a small luscious bone which has been chipped off from the fibular styloid or the fibular head okay and the rest everything is normal it's not it's it's essentially non-displaced and obviously you cannot comment on the equation on an APP so what is this fracture now here something called as the postural lateral coroner who goes in attaches to the fibular head which is concept just comprising of multiple structures the important ones being popliteal fibular ligament, arcoid ligament and your biceps femoris tendon and lateral prolapse ligament so whenever there is a ACL injury it is often associated with postural lateral coroner injury and so whenever you see this fracture again it is an indirect indicator of a cruciate ligament injury postural lateral coroner injury can happen with both ACL and PCL injuries so but if there is this fracture you know that patient has a some some cruciate ligament is injured either of the two and why it is important again when the patient has a ACL tear the patient goes for a ACL graft reconstruction if this thing is not identified okay on the x-ray and on the MRI now MRI if you see this is the MRI of the patient and the fracture is so small you will surely miss this fracture on an MRI I myself didn't pick up the fracture on the MRI but before dispatching the report I did see the x-ray I saw this fracture and I reported on an MRI so if you miss this fracture again if this situation is not addressed in the patient the patient will result into ACL graft failure and a second surgery will be needed so it is very important to pick up postural lateral coroner injuries just like it is important to pick up Saigon fractures so it's a accurate fracture or a postural lateral coroner fracture and again it is an indirect indicator of cruciate ligament injury next is I have given you a history that the patient has a history of twisting injury and this is a very subtle finding only those who are aware of such a finding will be able to guess this okay so I have given you two needs for comparison now immediately just remember on a lateral radiograph the bone that is posterior and inferior is the medial contact okay the bone which is superior is your natural contact so immediately there is nothing much but laterally I've already told you this particular area is your selfless terminalist okay and here you can see that there is a depression in the selfless terminalist okay so this depression is nothing but it is again a indirect indicator of anterior cruciate ligament injury rest everything is normal okay now why is the selfless terminalist or why does this happen in the first place so whenever there is a twisting injury the TBR and there is a resultant ACL tear the TBR will translate anteriorly the postural lateral TBR impacts against the antrilateral femur in the region of the selfless terminalist and that as a result of which you get this depression so here on the MRI also you can appreciate that there is a depression and there is a lot of marrow edema in this region so on the MRI it doesn't matter because you can see the ACL whether there is selfless terminalist depression or not it has no prognostic value but if you got an x-ray for reporting and you see this finding again you can put in the report that there is selfless terminalist depression and clinical correlation for anterior cruciate ligament insufficiency is requested so at least the orthoport knows that this patient could be having a anterior ligament laxity selfless terminalist depression can be in acute injury or it can be in a chronic injury so you don't know whether the ACL injury is acute or chronic if you have a clinical history that's great if you don't then you don't know whether it's an acute or chronic but you surely know that some point in time this patient did have a ACL injury so that's how you can correlate your x-ray findings to report soft tissue injuries which are not seen on the x-ray so again it's a subtle finding and it's an indirect indicator of ACL injury okay this is a very subtle finding sudden onset of medial pain no trauma a word of caution before we go ahead don't overreport these x-rays okay unless you have a classical history and the finding is really obvious then you put it on paper otherwise do not overreport this x-ray so medial femorrhageal compartment what this patient has is this line of sclerosis again I told you that this is your review area and you can see this line of sclerosis over here it's very subtle if you are not confident it's okay you may not report it if you're confident about it you have a history that the patient has pain in the medial tibial condyne region you can raise a suspicion okay the rest everything is normal and what this is this is a proximal medial tibial stress fracture and this was the MRI of the patient where you can see that this was the hypo intense signal with a lot of marrow edema so if you're not confident you can actually not put it in the report you can just call up the orthopod and tell him that this is what I feel it may or may not be but an MRI would be a good option to confirm if the patient is having a stress fracture or not next case 10 seconds this is a very important case with two findings I've given you a hint there are two findings and arthritis is not one of the five okay so medially you can see that there is a irregularity right and there is a medial femoral cortical irregularity lateral looks normal particular femoral looks normal central looks normal so what is the second five so now the second fine thing is this you can see this small Oshius bone is Oshius chip so this could be a displaced Oshius fragment okay there is some amount of effusion so medial femoral cortical irregularity with a displaced Oshius fragment this is the case of osteocondritis desiccants with a displaced osteocondrial fragment in the suprapatellar region okay so this was what it was so please just remember that you can have very subtle slender Oshius fragments and don't miss them on the x-rays and this was the MR of the patient where you can see that there is a there was this irregularity there is small amount of osteocondrial fragment which is seen in this region but if you see this particular Oshius fragment is missing so there is a small fragment in C2 but the other fragment is missing and when you look at the MR here you can see this is your Oshius fragment which is correlating with this particular XA so this was the osteocondrial fragment which was displaced in the suprapatellar region which could have been easily picked up on the x-ray as well so these are some more examples of osteocondritis desiccants sometimes it can be where you can see the osteocondrial fragment which looks pretty much stable but again you cannot be 100% sure if it is stable or not that is more often MR I think here you can be 100% sure that this is an unstable fragment because you can see that there is a fracture and it is actually detached off from the parent bone again here you can see that there is a gap a bigger radionucent gap so this was also a unstable osteocondritis desiccants none of these to the extent that you can visualize have a displaced Oshius fragment next case very obvious finding sorry I don't have the AP view of this patient okay so medial normal there is a fracture this was a very obvious thing the important thing is the fracture is not displaced this is something that you really need to mention effusion yes there is effusion present so it's an obvious finding patella fracture you need to differentiate it from the normal variant bipartite patella so here also if you see there is a radionucent line this is a skyline view you can see radionucent line and it looks like a fracture then what is bipartite patella now bipartite patella usually happens at the superolateral corner so this is your fibula so that's the superolateral corner that's one thing second thing the radionucent line is very wide so if you go back and see this fracture line is very racket and the thin radionucent line okay whereas this is a smooth radionucent line and it is pretty wide so that is a second way of how to differentiate a bipartite patella from a patella fracture third thing is the Oshius fragment is very round so it will have smooth edges it will not have racket edges so that's how we differentiate between the normal variant and the actual patella fracture and this was the MR in the patient that you can see that this is a very round bone at the superolateral aspect of patella this was bipartite patella okay so next case ten seconds this is also not a very obvious finding okay first thing what you can see is that this is the immature skeleton right so you can see the Pisces and they are very well seen so let's take the compartment approach the medial is normal lateral is normal patella femoral you can see this slender fracture over here right so there is a small fracture at the inferior pole of patella rest everything is normal there is no displaced Oshius fragment this fragment is also not displaced okay and you don't see much of an effusion at least on this video that so it's a patella sleeve evulsion fracture now what is a patella sleeve evulsion fracture it is in first of all you need to understand that in a immature skeleton or in children who have a growing skeleton the bones are relatively weaker than the ligaments and the tendons okay so in then the ligaments and tendons are stronger the bones are still in the phase of ossification so they are not as strong as a result you get a bulging fractures more commonly in children as compared to the adults so all of these acl evulsion acl evulsion they can happen in adults but they are very much common in children similarly this periosteal sleeve evulsion usually happens in children where there's nothing but it is a avulsion of the periosteum and along with that it evils off the articular cartilage from the inferior pole of patella at the patella tendon attachment similar thing can also happen superiorly at the quadriceps tendon attachment so this is nothing but a patella sleeve evulsion fracture and what is important is sometimes it is only the cartilage that has been evulsed off the osceus fragment is not evulsed off and in such cases you will not be able to pick up this particular injury on a radiograph and that's when ultrasound will be really helpful to identify the condor fragment secondly like this usually these fractures are displaced and they require internal open reduction and internal fixation you need to fix this back okay but in fractures like this which is not displaced the patient can actually undergo a dynamic ultrasound where you can just see whether this fracture fragment is moving or not with flexion and extension so if the fracture fragment is moving the orthopod may consider a surgical intervention if the fracture fragment is not moving he may think to conserve the patient again it's not a hard and fast route but it just that it gives further information to the orthopod to take a decision next again this is a very subtle finding but with a very big diagnosis so brosley don't see anything medial is normal lateral is normal central is normal patella femoral what you see is that the bones are okay but there is another extra bone lying over here right so you can see this auspicious piece which is sitting over here rest everything okay obviously this is a displaced auspicious fragment you do not have any extra piece of bone lying in the opa's fat pad region so it's a displaced auspicious fragment and there is an effusion associated with it a young patient displaced auspicious fragment you can think of two things one is osteocondritis desiccants so when you see this fragment go back you see that the medial femur is actually looking very good the second thing could be a patella instability okay with this extra you cannot be 100% sure whether it is OCD or it's a patella instability but likely chances that it's patella instability because the medial femur looks very good okay so you can just follow up the orthopod and say that I am seeing a patella I'm seeing an auspicious fragment displaced in the joint do are you suspecting any patella instability in the patient and the orthopod will give you the answer that yes this patient had a recent patella dislocation or on clinical examination I think that there is a patella instability if you cannot reach out to the orthopod call up the patient ask for the history the patient may give you a history that I had a trauma and I just felt that my kneecap dislocated and came back so all of this will help you to come to a diagnosis okay so once you get this history of patella dislocation you have your answer that this was nothing but a patella dislocation with a displaced osteocondrial tract so this was the MRI picture where this was your osteocondrial fragment you can see this is your osteocondrial fragment the patient had a large Lito hemar process as well and on the axial image if you see from the patella the osteocondrial fragment is missing and this was your osteocondrial fragment lying in the joint recess so this is how you can just add up one plus one and come to a relevant diagnosis even on an x-ray you do not always need obviously the patient will require an MRF matching but you are directing the orthopod in the right direction by suggesting him that this could be the diagnosis okay next just 10 seconds and have a look at the x-ray it's a very it's obvious finding if you know the pathology so the finding is pretty obvious you can see that there is an irregularity of the tibial tuberosity and if you see that even the soft tissue of the main the soft tissue appearance of the patella so this looks thicker the patella tendon looks thicker right so we just follow the protocol and we find that the patella femoral compartment there is an abnormality there is no dysplastosis fragment there is not much of an effusion as well so this is nothing but a Osgoode-Schlatter disease if you know this you will not miss it okay this was the MRI appearance of the Osgoode-Schlatter disease where you can see that the patella also has signal within it there is a additional ossification or a calcification adjacent to the tibial tuberosity the tibial tuberosity is very much irregular and there is edema within it so all of this just adds together to Osgoode-Schlatter disease so we have discussed of all the different kinds of pathologies that you may get on a x-ray radiograph as far as fracture and internal derangement is concerned and we come back to the same x-ray okay and now I want all of you to please answer the question again now what do you think are the soft tissue structures which are injured okay so most of you are getting one thing right and that is the ACL so yes ACL everybody has picked up which is probably secondary to sulcus terminalis depression but the other thing was this this is your small segon fracture so even if I would not have given a lateral radiograph still with this particular finding you can say that the patient has a ACL injury or had a ACL injury in the past so this was the answer right so at least I hope you guys now have a format in your mind how to go through these injuries before and how to report them