Considering the Factors When Evaluating Images of the Appendicular Skeleton System.
Introduction
For the accurate diagnosis it is essential radiographs must be of good quality (Robert, 1998). Consequently it is indispensable that the image must be diagnostic and optimal. The drivers that control the quality of the radiographs like technique and exposure factors are homogenized. The construction of a reliable radiological diagnosis
To aid in arriving at a correct diagnosis of the patients' condition, it is common practice for the medical professionals to send the sick or traumatized patients to the medical imaging (MI) department for radiographic examinations. At the MI department, the Medical Radiation Technologists (MRTs) are responsible for interacting with these patients and producing relevant images of the patients' anatomical region that is being evaluated. The images that are produced are then interpreted by radiologists to enable the MDs to diagnose and treat the patient's condition more precisely.
A familiarity with the data of normal and pathological anatomy, histology and physiology as well as considerable personal experience in the ability to discriminate between normal variants and overlying artefact and real pathology. Berlin, 2007 states the radiograph becomes that the more extensive the knowledge of the radiologist in the field of pathology and pathophysiology, the more enlightening. Recent years have seen the advent of non radiologists reporting radiographs. If these limited, knowledge in pathology and the information to acknowledge different medical conditions, it consigns the reader to produce reports of limited value. Some very significant subtle pathological processes in the skeletal system produce completely normal images and different pathological processes in the skeleton may give the same X-ray changes in the bones. Tuberculosis, hip, can manifest itself in an extremely wide and a diverse range of X-ray changes and reporters need to be aware of the information that will guide them to the correct differential diagnosis. (Berlin, 2007)
Reporters of radiographs need to be aware all the factors that will influence the final diagnosis and realize that their report may change how that patient is managed.
Technical issues
In the differential diagnosis of fracture special importance sometimes plays the shadow detected on the images, simulating the line of fracture, crack, and even displacement of bone fragments. Source of diagnostic errors may be the band, linear shadows and spots that appear on radiographs due to defects in X-ray films and intensifying screens. Folds of clothing or skin, as well as the imposition of the lumbar muscles, and a gas bubble may provide shade, simulating a line of fracture of a bone (Berlin, 2007). Differential diagnosis is based on the fact that this line is beyond the bones, while in turn it ends up within the bone. Overlay of contours of bones against each other, so called tangential effect, various kinds of bandages, ointments and adhesive residues can provide shade, simulating a fracture and even fragments.
In some urgent cases, the radiologist is forced to produce specific answer and is not asked to give a full etiologic diagnosis (Gleadhill et al., 1987). If the reporter produces a list of... different diagnostic possibilities, the degree of validity or likelihood of each presumptive diagnosis should be given in order to direct the clinican to appropriate patient management (Schiff et al., 2009). These differentials would be greatly influenced by the clinical information provided. If this is accurate the radiologist facilitates the work of the clinician, whether to have further imaging or how to treat him, etc. The displacement of bone fragments, especially in the long bones occurs in more than one particular plane, (Herrera-Soto et al., 2006).
Clinical Data Collection
A variety of illnesses occur in exactly the same anatomical, physiologically, radiological way and the same disease of bone or joint produce different images in different stages of the process (Berlin, 2007). Thus, reporters will make errors if the report is based solely on the radiographic examination. The ultimate goal of the reporters is a diagnosis of the disease, and they should come as closer to this goal as possible. A radiologist should give this an objective statement of facts from the traumatology, but not limited to the formal narrative side of things - it must also state of their opinion, to draw conclusions arising from this description. Adherence to a conservative school setting is essentially a means to engage in propaganda out of the conclusion. After all, knowledge of the attending physician in the field of radiology, of course, quite limited. Refusal of expanded clinical interpretation of bone picture deprives the radiologist physician assistance which he is obliged to do. It is from such a wrong statement of the case will eventually suffer the interests of the patient as the supreme criteria of the doctor - is the interest of the patient.
Collecting all the relevant clinical and radiological data, in most cases a radiologist can put a final etiological diagnosis achieve the ultimate objective of correct patient management? However, there are cases where this problem still remains unresolved or partially impossible Diagnosis would have been simple if certain nosologic groups radiological picture. An image considered optimal and free of error labeling may then be assessed with the patient's age being put into consideration as certain radiological /anatomical variants (normal variant) especially in pediatric images such as the epiphyseal growth plates and ossification centers may be confused with fractures.
At least two views of the image, taken at 90 degrees to each other, must be obtained (Pretorius and Solomon, 2006).It is also important to understand some of the anatomical terms used in the skeletal systems.
Factors such as home location, occupation and even ethnic sub type can occasionally be helpful in steering the differentials toward or away from certain disease entities. White and Asian people are more likely to develop osteoporosis than black people. Other examples include thalassemia and sickle cell disease which are commoner in the blacks. The occupation is also important, for example officers in the force may be prone to march fractures of the foot.
Age Factor
In newborns and infants with epiphysiolysis physicians often have to say in retrospective - in connection with the appearance on the site of fracture callus. When epiphysiolysis occurs, the fracture line passes at the border zone of pre-sprout calcification of cartilage and bone of the metaphysis in a way that breaks off at the same wedge-shaped piece of bone from the metaphysis. In its pure form epiphysiolysis is observed in the femoral neck and is often complicated by aseptic necrosis of the head.
An X-ray detection of epiphysiolysis is possible only with the age at which appear the nucleus of ossification, and if the fracture is accompanied by the displacement of the nucleus of ossification relative to the metaphysis (Inagaki & Inoue, 1997).
The most serious source of diagnostic errors is such anatomical structures as apophyseal and epiphyseal cartilage germ band, vascular channels, pseudoepiphysis, extra bone and Loozer's zones. The differentiation of germ cartilaginous zones is based primarily on knowledge of the timing of ossification of various bones, accounting anamnestic and clinical data and personal experience of the doctor who performed the study. Differential diagnostic sign of a fracture in the zone of germ cartilage is more or less visible shift of the fragments, in particular the nucleus of ossification of the damaged bone compared to the healthy (Guix et al., 2009).
Gender Factor
The gender dissimilarity is regarded to be a significant determinant of the more probable incidence of fractures and osteoporosis in women as it is a reality that bone mass is lower in women than in men (Gilsanz et al., 1997).
Women are probably to uphold forearm and wrist fractures than men for all mechanisms of injury in patients over 65years Tornetta et al (2004). it has been revealed the gender effect on the distribution of fractures Gilsanz et al (1997) and Tornetta et al (2004). Slipped femoral capital epiphysis takes place in pubescent children that is persistent and it is usually found in boys impending puberty, predominantly those who are sexually immature and overweight (Sutton, 2006).
Clinical history
To assess the images an adequate clinical history is very essential part because to correlate radiological and clinical findings it is required (Vyborny, 1997). Clinical information affirming swelling and pain would bind the assessment to examination for fractures while in the same patient if the clinical information containing fever as one of symptom among many symptoms, then radiological signs of disease has to be deemed. Additionally, the past of other disease states would help in ascertaining features on the images, as history of carcinoma of other part of the body can predispose the patient to pathological fractures. The majority of cases of secondary metastatic deposits to the bone from cancer easily fracture as a result of destruction of the bones. Any osseous tumour, especially metastases, can be the underlying cause of a pathologic fracture. However, the notable exception to this rule is primary or secondary bone-forming tumours, such as osteosarcoma and osteoblastic metastases, which rarely result in a pathologic fracture (Bohndorf et al, 2001).
Overriding of bone fragments one after another in the longitudinal displacement on radiographs in one projection may be accompanied by layering the shadows all the fragments, so called superposition of the shadows. In this case, the precise definition of fragment displacement is possible on the basis of image data in the second projection. At the turn of the flat bones (scapula, pelvis, etc.), in which for technical reasons, the production shot in the second projection is difficult, the composition of the fragments is often the only reliable sign of integrity violations.
Recognition of longitudinal displacement due to differences of the fragments usually does not present any difficulties. This kind of displacement is observed at the turn of the patella with rupture of ligaments, the olecranon, turning the hips and other images in the corresponding projections allows judging the degree of displacement (Wen et al., 2009). By this same type of bias should be attributed detachments bony protrusions, which are attached to strong muscle and twitches in traumatic injuries and leads to the discrepancy. Interposition of soft tissue between the fragments of bone X-ray examination is not recognized.
Violation of the integrity of the bone without displacement of bone fragments on radiographs, respectively, the plane of fracture (as in a sponge, and in the cortex of bone) is defined by a narrow strip of interruption of the bone structure. Most clearly it is seen in the cortex. A fracture line usually has rough edges, but the course and direction of it is different depending on the type of fracture (Maddison & Bacon, 1974). According to the shape and location of the fracture plane in the X-ray image, it distinguishes the following main types of fractures: transverse, oblique, longitudinal, T-shaped, U-shaped. If the violation of the integrity of a bone is accompanied by the presence of more than two fragments, then physicians can speak of comminuted fractures, which can be fragmented.
When the fracture line in the picture is not closed, i.e. does not reach the opposite edge of the bone, then this is an incomplete fracture or crack. Most often, cracks occur in the flat bones, and primarily in the bones of the skull and small bones of foot and hand, much less frequently they occur in traumatic injuries of long bones. Starting at one end of the bone, gradually narrowing, crack disappears in the structure of the unmodified bone substance. Radiological recognition of the fracture lines or cracks may state practically important question: if the crack is penetrating into the joint. So when the violation of the bone integrity extends to the articular end, i.e., the fracture line extends beyond the attachment points of the joint capsule, then it is the intra-articular fracture (Bahrs et al., 2010). All intra-articular fractures are accompanied by bleeding into the joint cavity and subsequently uncommon arthritis. In order to detect intra-articular fracture requires a careful analyze X-rays careful and to compare the data with the anatomical and topographical features of the attachment of the articular capsule of the bone.
Cracks and fractures without displacement of bone fragments are often so insensible that they are seen clearly on the radiograph only under very close examination with a magnifying glass. In these cases, the diagnosis is X-ray tomographic study of great importance with direct magnification. When a careful study of radiographs has not determined the signs of intact bone, and the clinical picture speaks in favor of it, the issue can be resolved by a control study 7-12 days. By this time due to restoration of necrotic bone trabeculae in the damaged area the fracture line becomes broader and more clearly visible on radiographs. Expansion and increase of the gap between the fragments, naturally, are observed in all kinds of violations of the integrity of bones, but distinctly and clearly they are seen just for minor-sized cracks and fractures.
Crucial X-ray method in pattern recognition research has impacted fracture, which occurs in conditions when the diameter of a fragment is smaller than the diameter of another, one fragment has a more compact, and the other has a sponge-like structure, compact substance fragment with a smaller diameter wedged into a spongy mass fragment with a wide diameter. These conditions exist in the femoral neck, proximal humerus, distal epiphysis of radius, etc., so that these parts of the skeleton are typical places for the occurrence of impacted fracture. Technically well-made X-rays allow these cases to detect not only the line of fracture, but a small deformation of the bones with shortening of the relevant department (hip, humerus, etc.). As a result, the displacement of the fragments by length and impact of distal fragment in the proximal fixation is enough of them. A characteristic feature of such fractures is the lasting of, albeit to a limited extent, motor function of limbs in clear violation of the integrity of the bone that can be determined by X-rays (Berlin, 2007). Very rarely the fixation of bone fragments can occur without impact of them, and in connection with the break of a fragment of an uneven surface and seizure of another.
Due to the nature of impacted fracture, to avoid separation of the fragments, the X-ray examination should be done with extreme caution. Such patient's radiographs are produced on a stretcher, on which they are supplied for research. Shifting the patient to a universal tripod or table is permissible only in the presence of a physician and with great caution.
Conclusion
Health professionals are required to critically evaluate data concerning patients referred for radiographic examinations of the appendicular skeletal system and be capable of relating diagnostic imaging reports to subsequent patient management. Age, Gender and clinical history are some crucial factors in assessment of images of the appendicular skeletal system. Factors such as home location, occupation and even ethnic sub type can occasionally be helpful in steering the differentials toward or away from certain disease entities.
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