Musculoskeletal X-ray - General principles
Systematic approach

Although the system for viewing X-rays of bones and joints varies depending on the anatomy being examined, there are some broad principles which can be applied in a number of situations.

A systematic approach involves checking alignment of bone structures, joint spacing, integrity of bone cortex, medullary bone texture, and for abnormalities of any visible surrounding soft tissue structures.

Patient and image details

Start by checking you are looking at the correct image. The patient's details should be checked and the date and time of the X-ray noted. The skeletal system is symmetrical, so it is particularly important to be sure you are looking at the correct side.

Bone and joint alignment

Loss of alignment may be due to a bone fracture or a joint dislocation. Both are associated with soft tissue injury that may not be directly visualised.

Joint spacing

Joint spacing may be narrowed due to cartilage loss or widened due to dislocation/dissociation.

Cortical outline

Careful scrutiny of the bone cortex is required because a check that is too brief will lead to incorrect or incomplete diagnosis.

In the context of trauma the clinical features of a significant injury may be masked by other injuries. Remember to be systematic, and if you spot one abnormality, do not stop until you are sure you have focussed on all areas of the anatomy shown.

Bone texture

In some bones a fine matrix of fine white lines (trabeculae) is seen. Occasionally bone injury or disease will result in abnormality of this texture.

Soft tissues

Scrutinising the soft tissues can often provide helpful information.

Not uncommonly an abnormality of soft tissues is more obvious than a bone injury, or may even imply a bone injury that is not visible at all.