Injured workers often require imaging for joint-related trauma or pain. After a history and examination, plain radiographs are often the next step in investigating a patient’s musculoskeletal complaints. Patients with possible surgical pathology, such as osteoarthritis, may be referred to an orthopaedic surgeon, who often repeats the initial films. While there may be other reasons for requesting new X-rays, such as time elapsed since first films, specific views, or accessibility, a very common reason is that the original films were not ordered weight-bearing.
So why weight-bearing X-rays? For the hip, there are some authors who feel supine radiographs are sufficient, but many consider a weight-bearing AP pelvis film to be standard.[2,3] Although osteophytes can be seen on both, the discussion is on the best evaluation of joint space narrowing (JSN). The Osteoarthritis (OA) Research Society International noted that while standing films have a theoretical advantage of evaluating JSN, they can be assessed accurately supine as well for normal hip morphology. Patients with any hip dysplasia have been shown to be more accurately assessed for OA with standing films.
Standing foot and ankle X-rays are the standard for assessing conditions such as flat foot, ankle arthritis, and hallux valgus as well as other conditions.[5-9] Non-weight-bearing images are often felt to be misleading, while standing films allow better standardization and reliability in assessment between studies and patients. Weight-bearing radiographs are also used to assess patients for subtle ligamentous disruptions, such as Lisfranc injuries not seen on initial films.
The standard radiographic for OA of the knee includes weight-bearing AP, lateral, skyline views. A weight-bearing tunnel (Rosenberg) view may increase detection. Weight-bearing views have been shown to more accurately assess JSN than supine films. They can also better demonstrate malalignment, such as varus or valgus. For patients > 40 years old with > 50% JSN on weight-bearing films referred with only an MRI, the latter is found not useful in the majority of cases.
All this highlights some of the importance of obtaining weight-bearing X-rays. But the issue is hardly limited to Canada. A 2012 British study found no patients with knee issues referred from a GP’s office to an orthopaedic clinic had had weight-bearing films. Another 2014 British study found 98% of nontraumatic knee radiographs requested by GPs were non-weight-bearing. The former recommended all requests to the Radiology Department for knee radiographs from GPs to be standardized as weight-bearing while the latter advised GPs to order them as weight-bearing.
In the end, requesting weight-bearing radiographs for elective assessment of the lower extremity is obvious. The only question that remains is, is it weightbearing, weight-bearing, or weight bearing? Maybe just write “WB” or “standing,” and avoid the conundrum.
—Derek Smith, MD, FRCSC
WorkSafeBC Orthopaedic Specialist Advisor
This article is the opinion of WorkSafeBC and has not been peer reviewed by the BCMJ Editorial Board.
Above is the information needed to cite this article in your paper or presentation. The International Committee
of Medical Journal Editors (ICMJE) recommends the following citation style, which is the now nearly universally
accepted citation style for scientific papers:
Halpern SD, Ubel PA, Caplan AL, Marion DW, Palmer AM, Schiding JK, et al. Solid-organ transplantation in HIV-infected patients. N Engl J Med. 2002;347:284-7.
About the ICMJE and citation styles
The ICMJE is small group of editors of general medical journals who first met informally in Vancouver, British Columbia, in 1978 to establish guidelines for the format of manuscripts submitted to their journals. The group became known as the Vancouver Group. Its requirements for manuscripts, including formats for bibliographic references developed by the U.S. National Library of Medicine (NLM), were first published in 1979. The Vancouver Group expanded and evolved into the International Committee of Medical Journal Editors (ICMJE), which meets annually. The ICMJE created the Recommendations for the Conduct, Reporting, Editing, and Publication of Scholarly Work in Medical Journals to help authors and editors create and distribute accurate, clear, easily accessible reports of biomedical studies.
An alternate version of ICMJE style is to additionally list the month an issue number, but since most journals use continuous pagination, the shorter form provides sufficient information to locate the reference. The NLM now lists all authors.
BCMJ standard citation style is a slight modification of the ICMJE/NLM style, as follows:
- Only the first three authors are listed, followed by "et al."
- There is no period after the journal name.
- Page numbers are not abbreviated.
For more information on the ICMJE Recommendations for the Conduct, Reporting, Editing, and Publication of Scholarly Work in Medical Journals, visit www.icmje.org