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Dr.Saleem
Dr.Saleem, Doctor
Category: Medical
Satisfied Customers: 2302
Experience:  MBBS
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Is there an orthopedist online who can look at an X-ray?

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Is there an orthopedist online who can look at an X-ray?

Hello and welcome to JA. Dr Saleem here. Will be answering you shortly

Please share the x ray

Customer: replied 2 months ago.
Hi. Your profile says you're a cardiologist. Looking for someone to review X-ray of shoulder...

Would you mind if i have a look?

Customer: replied 2 months ago.
II was hoping for an orthopedist to review - but okay. Photos attached.

Alright . These images do not depict anything wrong there. Can you give me bit of history on your symptoms?

Customer: replied 2 months ago.
History of shoulder pain, limited range of motion (now fairly constant). Herniated discs in cervical and lumbar spine (back and neck pain), osteoporosis, possible mild compression fracture in lumbar spine. History of breast cancer/lumpectomies in both breasts.

Sorry to hear that. Well xray only shows whether there are any bony issues like a fracture. Thats not seen there so there has to be some other cause most likely involving soft tissues such as muscles, tendons, bursa or nerves.

An MRI and Nerve conduction studies are much more helpful in this regard.

You will need regular physiotherapy and TENS sessions alongwith painrelief.

Pain relief can range from simple tylenol to more potent like opioids which ever helps.

Nerve medications like pregabalin and gabapentin would help.

You will need to give your shoulder good rest too.

Customer: replied 2 months ago.
No - there actually IS a boney anomaly - which I guess you're not seeing. Other MD's have identified it, but have differing opinions about what it is (arthritic of normal bone variant versus possible lytic lesion). Already scheduled for an MRI, but trying to minimize worry in the interim.

Alright . The management remains the same for now . I wish you all the best

If you allow so ,i can get help from my radiology colleague. Would it be ok ?

Customer: replied 2 months ago.
Sure.

As per the radiologist too, there is no lytic lesion there however in one image he asked me to rule out old healed clavicle fracture but when i sent the next image with a better view of clavicle he ruled that out too.

Customer: replied 2 months ago.
Does you radiologist see the 'unsharp' boney anomaly on the scapula tip? If so, what does he/she think it is?On an X-ray taken several months ago, I did apparently have a 'questionable' healing rib fracture (I think it was 12th rib/lateral). Could that be what he saw on the clavicle?

He thinks its due to poor quality of the image and not a lytic lesion. No clavicle and 12th rib are actually quite a bit away from each other so its definitely not that.

Customer: replied 2 months ago.
Well - your radiologist is looking at photos I took of X-rays, not the actual film. Does he think there could be a lytic lesion there that's not visible because he's not looking at the actual films - or would a lesion in that location still be apparent these images?

No actually both of us really unable to pick up any lytic lesion there to be honest irrespective of film or image quality

Customer: replied 2 months ago.
is the radiologist who originally read the X-rays/wrote the report just protecting himself by saying he can't exclude something no one else appears to see? I now have two MRI's ordered, based on this X-ray report.

No as its sometimes not clear enough on images and real films might be telling some other story so he might be right there.

Irrespective of the xray findings you need an MRI as your problem is not bony in my view and soft tissue ccindition is only picked by MRI

Customer: replied 2 months ago.
Are you saying that your radiologist thinks he could be missing lesion in a specific location that has already been pre-identified if the image quality isn't optimal?

He is unable to pick any LYTIC LESIONS in the images i shared with him. So according to him there isnt any visible abnormality seen in these images of the x ray you had. Its my own opinion that seeing the real films can be different so your doctor might be in a much better place to comment ,with greater conviction. We comment on what we see ,as radiology is an operator dependent field so findings vary with competence / skill level of each radiologist

Customer: replied 2 months ago.
Here are some images taken directly from the X-rays.

Let me discuss these

He maintains ,no lytic lesions.

Only decreased bone mineral density.

Joint space intact

Customer: replied 2 months ago.
Do you both think these images were clearer/better quality?

Image 730 was much better

Customer: replied 2 months ago.
Can you also ask your radiologist if he sees what the radiologist who read this is referring to?

I did mention it to him but he was unable to find out the said abnormality

Customer: replied 2 months ago.
Even if he doesn't see a lesion, is he not able to see any anomaly (even arthritic or normal bone variant) to explain why the radiologist is pointing to that area?

According to him there is decreased bone mineral density and thats the reason probably why the radiologist has a suspicion.

Customer: replied 2 months ago.
Shouldn't a radiologist be able to distinguish between bone mineral density and a lesion?

Well that needs DEXA scan to be definitive about it. The lytic lesions are usually very circumscribed or well demarcated so may be thats what he thinks

Customer: replied 2 months ago.
Sorry - not sure I understand.

Lytic lesions well demarcated or distinguished from rest of the bone so one can immediately pick those. Here it seems more generalized , decreased bone mineral density . Patch of low density might have lead to suspicion of lytic lesion

Customer: replied 2 months ago.
But you, your radiologist, and a few other experts have all said there's no lesion. Why would a radiologist mistake mineral density for a possible lesion, when no one else is? If they can look that similar, is your radiologist sure he can exclude a lesion, based on these images?

Yes he is. Asked him twice with both sets of images. Well as i said radiology is afield that depends on skills of the radiologist. So the findings vary with skill level of each specialist.

Dr.Saleem and other Medical Specialists are ready to help you
Customer: replied 2 months ago.
Okay. Well, thus far, the radiologist who wrote the report seems to be the only one who isn't excluding a lytic lesion, so hopefully he's just being overly cautious. I appreciate your (and your radiologist's) help. Thanks!

You are welcome.

I wish you best of luck.

Kind regards.

Dr Saleem

Customer: replied 2 months ago.
By the way - your profile shows you as highly rated, but when your picture pops up when you respond to a question, it shows you only have one review- and it's one star. You may want to contact JA to correct this.

Oh thanks for that . I sure will. Grateful

Customer: replied 2 months ago.
Could you (and possibly your radiologist buddy) take a look at a few MRI images of the scapula to see if you still see nothing abnormal? I've attached two that I believe show this area.