Intraoperative Photos and Fluoro on the ABOS Part II: What to Include and Label

Most candidates obsess over their case summaries and operative notes — and they should. But there's another layer of documentation that quietly shapes how examiners evaluate you: the intraoperative fluoro shots and clinical photos you upload with each case.

The ABOS Part II is a two-examiner setup. Examiner 1 leads the questioning. Examiner 2 sits beside them and reviews your uploaded documentation silently while you present. Your intraop imaging is part of that silent review. If the images support your narrative, Examiner 2 stays quiet. If they don't — or if they tell a different story than your summary — that's when the pointed questions start.

Candidates only defend their own cases. Case selectors assign 12 cases from your submitted list, and every image attached to those cases is fair game. Here's how to think about what to include, how to label it, and how to narrate it when the examiner points at a specific shot and asks “what am I looking at?”

What Intraop Imaging Actually Does For You

Intraoperative fluoro and photos serve three purposes in your case defense:

They prove what you did. An op note describes the procedure in words. Fluoro images show the reduction, alignment, and implant position at specific moments. Together they're harder to challenge than either alone.

They show decision points. A sequence of fluoro shots tells a story — pre-reduction, post-reduction, provisional fixation, final construct. If you converted approach, deviated from your preop plan, or dealt with an unexpected finding, the imaging is where that decision lives.

They demonstrate technical skill. The technical skill rubric isn't evaluated by watching you operate — it's evaluated by looking at your outcomes, your documentation, and your imaging. A clean final construct shot on a difficult fracture speaks for itself.

What to Include

The Core Sequence

For most operative cases, aim to include imaging that covers these moments:

• Initial injury or pathology — the starting point before you touched anything
• Reduction or key intraop step — the moment the decision got made
• Provisional fixation — if applicable, shows your technique
• Final construct — at least two orthogonal views where anatomy allows

This isn't a rigid checklist. A simple elective case might have two images. A complex periarticular fracture might have eight. The goal is coverage of the moments that matter for defending your decisions.

Decision-Point Shots

If something about the case required judgment mid-operation, there should be an image of that moment. Examples:

• You planned percutaneous and converted to open — capture the reason (inadequate reduction, comminution you couldn't see on preop)
• You found unexpected pathology — joint chondral damage, a second fracture line, loose hardware from prior surgery
• You made an implant substitution — different plate, longer screw, alternate fixation strategy

Examiners are actively looking for judgment. When your imaging documents a mid-case decision and your narrative explains why you made it, you're showing exactly what they want to see.

Clinical Photos

Wound condition, limb alignment, soft tissue envelope, gross deformity — clinical photos carry weight when they're relevant to your reasoning. A pre-op photo of a compromised soft tissue envelope justifies staging. A post-op clinical photo showing restored alignment supports your outcome narrative. Don't include photos that don't serve the story.

How to Label

Labeling is where a lot of candidates lose small points silently. The second examiner is flipping through your images while you talk. Every second they spend trying to figure out what they're looking at is a second they're not listening to you.

Practical labeling standards:

• Time-stamped or sequenced — Pre-op, Intraop 1 (initial), Intraop 2 (post-reduction), Intraop 3 (final), Post-op week 2, Post-op 3 months. Order tells the story.
• View-identified — AP, lateral, oblique, axial, Judet, stress view. Don't make the examiner guess.
• Side-identified — left vs. right should match your op note and your narrative. An unlabeled mirror-image fluoro shot can create a nasty moment.
• Clean and readable — if your fluoro capture has a patient sticker or stray annotation from the C-arm tech, make sure it's legible and consistent.

Labels should match the language in your case summary. If your summary says “closed reduction achieved,” your image labeled “post-reduction AP” backs it up. Mismatches between summary language and image labels are the kind of thing Examiner 2 notices and Examiner 1 asks about.

How to Narrate When Asked

At some point, an examiner is going to point at one of your images and say some version of “tell me what I'm looking at.” This is a test. They're not confused. They want to hear you describe the image with precision.

Generic narration loses points.“That's the fracture, and that's the plate” tells them nothing they didn't already see.

Specific narration scores well. A strong response names the view, identifies the anatomy, describes the reduction or alignment, and comments on the hardware position. Something like:

“This is the post-reduction AP fluoro. You can see anatomic reduction of the articular surface, restoration of the joint line, and the provisional K-wire holding alignment while I assess before committing to the plate. Length, alignment, and rotation all look appropriate at this point.”

That answer does four things at once: it names the view, it identifies the key anatomy, it articulates what the image is actually showing, and it demonstrates that you were thinking deliberately at that moment in the case. Candidates who can narrate at that level come across as in control of their own operations.

Practice this out loud before the exam. Pull up your own cases, pick an image, and describe it the way you'd want to describe it to an examiner. Do it until it sounds natural and specific — not rehearsed, not generic.

Common Mistakes That Cost Points

A few patterns show up repeatedly in candidates whose imaging works against them instead of for them:

Too many images, no sequence. Twenty unlabeled fluoro shots in random order is worse than four well-chosen labeled ones. The second examiner will give up trying to piece together the sequence and just pick the messiest frame to ask about.

A final construct shot with bad hardware position. If a screw is clearly long, a plate is obviously not centered, or a reduction is imperfect — and there's no narrative explaining why you accepted it — you've handed the examiners a question you don't want to answer. Either address it proactively in your presentation or make sure your final shot shows your best work.

Mismatch between op note and imaging. Your op note says “anatomic reduction achieved” and the fluoro shows a 3mm step-off. That's the kind of inconsistency the silent examiner flags and the lead examiner then asks about. Review every case before you submit and make sure the words and the pictures agree.

Missing the intraop decision moment. If something interesting happened during the case — a conversion, a substitution, an unexpected finding — and there's no image documenting it, you're asking the examiner to take your word for it. An image makes the story real.

How to Prep Your Imaging Before Exam Day

Treat image prep as its own workstream, separate from writing your case summaries. Block time to go through every case on your list and audit the imaging the way an examiner would:

• Are all views present and labeled? Does the sequence tell a clear story from pre-op to final follow-up?
• Does the imaging match the language in your summary and your op note?
• For each image, can you narrate it in two specific sentences — naming the view, the anatomy, and what it's showing about your reduction or construct?
• Is there any image that raises a question you can't answer confidently? If yes, either prepare an answer or reconsider whether the image belongs in the packet.

Practice navigating your imaging the same way you'll do it on exam day. You'll be pulling images onto a large display while presenting, so get fluent with the interface and the click sequence. Fumbling with images mid-presentation breaks your rhythm and signals lack of preparation — and that's a composure problem, not a knowledge problem. Related: see our piece on the technical skill rubric for how examiners translate your imaging and outcomes into a score.

The Bottom Line

Your intraop imaging is talking to the second examiner the entire time you're presenting. Make sure it's saying the same thing your summary says — and make sure you can narrate any single frame with precision. That combination quietly moves you from average to credible in the room.