Sacral fracture By Zulhilmi Izzat Zuraili 2023/ 2024Radiographic anatomy & image analysis
Background Sacral fractures are one of the rare injuries that result from high-energy trauma which is usually caused by motor vehicle accidents (MVA) and due to their rarity, the injury is frequently underdiagnosed and mistreated. However, older people (geriatric ) have a high chance of breaking their sacrum in minor falls especially if they have osteoporosis. Sacral fractures can be difficult to diagnose due to poor visualization on standard radiographs and patients sometimes can cooperate during the examination. As a result, 30% of sacral fractures are identified late and in some cases may lead to mistreatment (Barber et al., 2022). Both non-operative and surgical methods can be used to treat sacral fractures. Rest, pain management techniques, and early mobilization are examples of non-operative care while the two main surgical techniques are Posterior pelvic fixation techniques and lumbopelvic fixation techniques. Figure 1 shows an example of a sacral fracture and it usually occurs at the S1 which is near to the lumbar spine. As sacral injuries can vary from a low energy insufficiency fracture to a U-type fracture with lumbopelvic dissociation, the associated injuries are largely dependent on the type of sacral fracture. The signs and symptoms of sacral fracture are pain in the hip or pelvis, pain in buttocks or groin, lower back tenderness, swelling at lower back and pain during exercise. Sacral fracture 1 Figure 1 (a)
Radiographic view Figure 1 (a) shows an AP axial X-ray of the sacral fracture. The sacral fracture appears to start from S1 until S5. The specific name for the fracture in Figure 1(a) is a vertical sacral fracture. The X-ray radiation exposure for this radiograph is adequate as we can clearly see the bony trabecular pattern and bony cortical outline of some structures like sacral itself, sacroiliac joint, and sacral foramen. Even the collimation is a bit tight, all the area of interest or important anatomical structures are visible and clearly demonstrated. There is no evidence of marker and patient identification. 2 Figure 1 (a) Figure 2 Figure 2 show the anatomical structures for sacral AP axial X-ray which are : - Sacral promontory, Sacroiliac joint, sacral foramen, Sacral cornua and coccyx. Source from Karadsheh (n.d.)
Radiographic view Figure 1 (b) shows a lateral X-ray of the sacral fracture. We can see that the fracture occurs at the S5. The best X-ray projection to diagnose a sacral fracture is a lateral X-ray of the sacral. This is because lateral projection can prevent from superimposing of the overlying bowel. The X-ray radiation exposure for this radiograph is adequate as we can see the bony trabecular pattern and bony cortical outline of some structures like the sacral itself, sacroiliac joint, and sacral foramen. Even if the collimation is a bit tight, all the areas of interest or important anatomical structures are visible and demonstrated. There is evidence of a marker but no evidence of patient identification. 3 Figure 1 (b) Figure 3 Figure 3 show the anatomical structures for sacral lateral X-ray which are : - Sacral promontory, 5th lumbar vertebra, crest of ilia, greater sciatic notches, ischial spine, coccyx, hip joint and sacrum. Source from Bell (2020)
aceman Figure 4 shows a patient positioning for the AP axial X-ray of the sacral. For an AP axial sacral X-ray, the patient is required to be in a supine position. Positioning is the first component of PACEMAN and it is used to determine the quality of a radiographic image. In positioning, In positioning, elements or indicators that can determine a good radiograph are the rotation and tilt of the radiograph structures. A rotation can be tell by looking at the horizontal structures while tilt can be tell by looking at the vertical structures. Figure 1(a) shows an AP axial Xray of a sacral fracture. In the radiograph image, we can tell that there is no rotation as both sacroiliac joints are equidistant to each other. Besides, there is also no tilt as all of the sacral foramen are open equally. Other than that, the patient is also in the correct position which is in the supine position. Thus, the radiograph image is a good quality one. 4 Positioning (AP Axial) P Figure 4 Figure 1(a)
aceman Figure 5 shows a patient positioning for a lateral Xray of a sacral. While Figure 1(b) shows a lateral Xray of a sacral fracture. The fracture of the sacral is at the S5. The fracture also is more clear to be seen on the lateral X-ray view rather than the AP axial view. This is because sacral fracture is quite difficult to diagnose due to an overlying bowel (Adkins & Beckmann, 2021). So, the best view for diagnosing the sacral fracture is the lateral X-ray of the sacral. In Figure 1(b), we can see that there is no rotation in the superimposition of the greater sciatic notches and femoral head (Murphy & McWilliam, 2016). The usage of sponge to be put under the patient during recumbent position is recommend to ensure the vertebrae spine straight and reduce the body tilt. 5 Positioning (Lateral) P Figure 5 Figure 1(b)
paceman X-ray tube and Image receptor (IR). X-ray tube and patient. Image receptor and patient. The alignment in general X-ray is one of the criteria that help radiographers to know if the only needed area is exposed to the X-ray radiation and helps to determine if the centering point is correct or not. There are three components for alignment: 1. 2. 3. Figure 1(a) shows an AP axial X-ray of a sacral. The centering point or cross point for the radiograph image is at the S1 and the patient’s S1 position is at the center of the image which indicates that the patient is at the center of the cassette. Thus, the alignment of the radiograph image for Figure 1(a) is correct. X-ray tube should have angle about 15° cephalic. Figure 1(b) shows a lateral X-ray of a sacral. The centering point or cross point for the radiograph image is also at the level of S1. The center of the of the Patient’s sacrum is at the center of the cassette. So, the alignment of the radiograph image for Figure 1(b) is correct. 6 Alignment a Figure 1(b) Figure 1(a)
Paceman Superior border - at least L5 or S1. Inferior border - coccyx. Lateral border - skin margin. Apart from exposure, collimation also plays an important role in ensuring that radiation to the patients is not high or harmful to them. The collimation helps to focus the X-ray beam only on the area of interest. Besides, collimation helps the radiographer to see only the area of interest. A radiograph will be considered as a low-quality radiograph if the collimation is not suitable for the type of examination. For AP axial sacral X-ray, anatomical structures that must be included in the radiograph are: 1. Superior border - at least L5 or sacral promontory. 2. Inferior border - pelvic brim or coccyx. 3. Lateral border - sacroiliac joint. Thus, the radiograph image of Figure 1(a) fulfill the collimation requirement for AP axial sacral Xray. For Lateral collimation, anatomical structures that must be included in the radiograph are: 1. 2. 3. Thus, the radiograph image of Figure 1(b) has fulfill the collimation requirement for lateral sacral X-ray. 7 collimation c Figure 1(b) Figure 1(a)
paceman Density Contrast Exposure for general X-rays is set or can be controlled by using the control panel. It is the responsibility of a radiographer to set or use adequate exposure to a patient to prevent from giving high radiation doses to the patient. Besides, Adequate or correct exposure also determines for quality of a radiograph as the thick and thin structures can be seen clearly. For example: -Bony trabecular pattern (BTP) of Sacral promontory (Thick structure). -Bony trabecular pattern (BTP) of the sacroiliac joint (Thin structure). -Bony cortical outline (BCO) of sacral promontory (Thick structure) -Bony cortical outline (BCO) of the sacroiliac joint (Thin structure). In Figure 1(a), both BCO and BTP of sacral promontory and sacroiliac joints are visible. In Figure 1(b), both BCO and BTP of sacral promontory and skin margin are visible. Thus, Both of the radiographs use adequate exposure. 8 Exposure e Figure 1(b) Figure 1(a)
paceman As a radiographer, we should know that a radiograph marker is an important criteria that must be in a radiograph. Besides, a radiograph without a marker must be reject and consider as low quality radiograph. A radiograph marker play an important role as an indicator to know the exact side of a patient’s injury. The injury may located on the right side or left side. Absence of a marker can leads to confusion about patient’s injury side and misdiagnose. That is one of the reasons a radiograph without a marker must be reject. Figure 1(a) show a radiograph of AP axial sacral without marker. So, the radiograph must be reject and the X-ray examination must be done again. The patient will get more radiation dose and it is something that we should prevent. Figure 1(b) shows a radiograph with marker. The marker also is located at the suitable place which is at away from area of interest. The usage of marker is also correct which is L that indicated for left side. 9 marker m Figure 1(b) Figure 1(a)
paceman Another important criteria that determine the quality of a radiograph image is aesthetic. A radiograph will be consider has high value or high quality if it follow a few elements such as correct positioning of marker, alignment of the X-ray tube to image receptor, X-ray tube to patient, and patient to image receptor. Besides, suitable film size and no artifact also indicate that a radiograph is high value and high quality. There are no marker and patient identification for a radiograph for figure 1(a). But, the collimation is acceptable as all anatomical structure and will be consider aesthetic for AP axial sacral X-ray. Figure 1(b) shows correct marker presence and the marker is located at suitable place which is away from area of interest. The correct centering point, suitable film size and acceptable collimation are also consider aesthetic for lateral sacral X-ray. 10 aesthetic a Figure 1(b) Figure 1(a)
paceman Name or patient identification is also one of the important criteria that must be put or must be on a radiograph. Missing or absence of patient identification will be considered a bad or failed radiograph and must be rejected as patient identification will help to differentiate a patient from another patient. In other words, patient identification holds information about the patient including the information about patient examination information. Things that must be in the patient identification on a radiograph are the patient’s name, ID number, date, name of the hospital, name of the examination, and patient ID. All of these elements will help to make the job or examination at the radiology department become smooth. The identification for both of the radiograph images (Figure 1(a) and Figure 1(b) ) must be at the left superior corner of the radiograph. But no sign of identification for both of the radiographs. 11 Name n Figure 1(b) Figure 1(a)
SACRUM Marker Exposure aesthetic and name Positioning Alingment Collimation Density Contrast Out from AOI(Above) Cassette is lenghtwise Correct patient's id AP sacrum Lateral sacrum superior of 5th lumbar or 1st sacrum of articulation Both sacroiliac joint Inferior of 5th sacrum 1. x-ray tube and patient.( MSP,mid of ASIS & symphysis pubis) 2. x-ray tube and IR. (center of IR) 3. patient and IR. (Center of IR & mid ofASIS & symphysis pubis) Ischial spines are equally demonstrated and are aligned with the pelvic brim. (no rotation) Median sacral crest and coccyx are aligned with the symphysis pubis Greater sciatic notches are superimposed. (no rotation) Femoral heads are aligned. Thick structure: - BTP of sacrum. Thin structure: - BTP of sacroiliac joint Thick structure: - BCO of sacrum. Thin structure: -BCO of sacral foramina Examination and date Mind map 12
13 Lets play a game!!!
Reflective essay My name is Muhd Zulhilmi Izzat Bin Mohd Zuraili and I am a student of University Zainal Abidin (UniSZA). This is my first time making a portfolio. In this section, I will share my journey regarding the making of the portfolio. Throughout this course, I have learned about how to know or differentiate the quality of a radiograph image, critique a radiograph image, and know more about our body structures. The in class activities and assignment helped me learn how to become a better radiographer in the future. After taking this course, I can see the differences from my knowledge about radiography in the past. I also identified and learned from my strengths and weakness throughout this semester. The reason I choose this pathology as my portfolio title is because I want to ensure all the people aware and know about the sacral fracture. As I have mention in the portfolio, sacral fracture usually happen to the old people (geriatrics) and the chance of misdiagnosed and mistreated the injury is high. The reason I made this portfolio is to help radiography student to know how to critique a sacral X-ray radiograph and what criteria must be follow to get a high quality of sacral X-ray radiograph. There are many problem that I have faced in order to complete this portfolio. One of the problem is to search any useful article about the sacral fracture and sacral Xray critique as the date for some research or article is too old. In other words, it is difficult to search any new article or research about sacral fracture and sacral X-ray radiograph image critique. Besides, there are also many different opinions from all the reseracher or people that made article as they tends to have many view according to their research. So, I must understand and take some research or article carefully so the information that I obtain is true and valid. Another problem that I faced during making the portfolio is problem regarding the large usage of internet quota. 14
Reflective essay So, the problem is overcome by using my university's wifi so I can save some of my internet quota. Last but not least, the problem that I encountered during making the portfolio is the confusion in choosing platform to make the portfolio. As we know, there are many potential platform that can be use to make a portfolio. As example, we got PowerPoint. However, I have choose Canva over PowerPoint because Canva can provide many benefits especially in term of portfolio template. In Canva, there are many free template that can be use. So, I can save some time and made the portfolio without need to spend any money. I hope that my portfolio can help people to understand more about the sacral fracture and know about sacral X-ray radiograph image critique. Thank you for spend some time and read my portfolio. I also hope that this portfolio will motivate the future radiographer. I also hope that I can learn more about the radiographic anatomy and image analysis as the subject give many important and best information to the radiographer and students. 14
References Adkins, J. M., & Beckmann, N. M. (2021). Imaging of pelvis and hip trauma. In Springer eBooks. https://doi.org/10.1007/978-3-030-44092-3_40-1 Barber, L. A., Katsuura, Y., & Qureshi, S. A. (2022). Sacral Fractures: a review. HSS Journal, 19(2), 234– 246. https://doi.org/10.1177/15563316221129607 Murphy, A., & McWilliam, R. (2016). Sacrum and coccyx (lateral view). Radiopaedia.org. https://doi.org/10.53347/rid-49815 Karadsheh, M., MD. (n.d.). Sacral fractures - trauma - orthobullets. https://www.orthobullets.com/trauma/1032/sacralfractures Bell, D. (2020). Sacral fracture. Radiopaedia.org. https://doi.org/10.53347/rid-85532 1. 2. 3. 4. 5. 15
2 Thank you