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Interpretation of normal radiograph
- 1. INTERPRETATION OF NORMAL RADIOGRAPH DR. ACHIMALO IFUNANYA MARILYN MEDICAL OFFICER GUARDS BRIGADE MEDICAL CENTRE
- 2. Outline Introduction Terminologies Radiological densities Skull radiograph Chest radiograph Abdominal radiograph Pelvic radiograph Spine radiograph Conclusion
- 3. Introduction Radiography is a process by which images are obtained by projecting x ray beams through a subject and onto an image detector. Xray was discovered in 1895 by a professor of physics, Wilhelm Roentgen The radiographic image produced is a projectional map of the amount of radiation absorbed by the subject along the course of x ray beam. When a radiograph is taken, X-rays reach the film and darken it. The more X-rays reach an area of the film, the darker that area will be on the radiograph. Therefore, if an object is very dense, less X-rays will reach the film and consequently the image of the object will appear white on the radiograph e.g. bone.
- 4. Common Radiographic Terminology •Erect : standing •Decubitus : lying down •Lateral decubitus : lying on one side Right lateral – right side touches Prone -: lying face down Anteroposterior – central rays passes perpendicular to coronal plane from anterior to posterior Posteroanterior – central rays passes perpendicular to coronal plane from posterior to anterior Opacity – area on the x-ray that is brighter than normal Lucency – area on the X ray that is darker than normal
- 5. Radiological densities There are 5 principle densities recognised on plain X-rays: 1. Air/ Gas = black (e.g. lung, bowel, stomach) 2. Fat = Dark grey (e.g. subcutaneous tissue layer, retroperitoneal fat) 3. Soft tissues/ Water = light grey (e.g. solid organs, heart ,muscle, bladder) 4. Bone = off white 5. Contrast material / Metal = bright white
- 7. Before interpreting a radiograph Patient’s identification Date The part of the body Check the marker – Left or Right Check if the film was adequately taken- eg. Rule out rotation in chest radiograph Follow a patten while studying the film- Inspect From outside to inside
- 8. The skull Since the advent of computed tomography and magnetic resonance the need for plain X-rays of the skull has almost disappeared. Plain films are of limited value in suspected intracranial pathology, especially in the absence of neurological signs. STANDARD VIEWS ; Lateral AP or PA Townes view ( half axial view) - is an angled anteroposterior radiograph of the skull and visualizes the petrous part of the pyramids, the dorsum sellae and the posterior clinoid processes, which are visible in the shadow of the foramen magnum.
- 9. Indication for skull radiograph Evaluation of skeletal dysplasia Diagnostic survey in abuse Abnormal head shape Infections and tumours affecting the skull bone Metabolic bone disease, leukaemia and multiple myeloma
- 10. Skull x-ray views •Lateral view - best displays the ethmoid and sphenoid sinuses •AP / PA view – usually taken PA . For visualization of skull fractures with medial and lateral displacement. •Towne’s view- This is taken with a 30 degree caudal tilt of the tube to project the occipital and petrous bones free of the overlying facial bones. •Waters view - a PA radiograph of the skull with the patient’s head tilted back (like someone drinking water!). This view displays best the orbital rim, the floor of the orbit, the maxillary sinuses, the zygomatic bones, the nasal septum and nasal bones •Caldwell’s view- a frontal radiograph of the head taken with the patient's face against the film (PA). This view best displays the frontal sinuses, the orbital rim and the medial orbital wall
- 11. (a) Caldwells view (b) Waters view (c) Lateral view
- 12. Towne view
- 13. Caldwell view
- 14. Waters view
- 16. Chest
- 17. Before interpreting a radiograph Patient’s identification Date Xray view- AP , PA , lateral Breath – inspiratory or expiratory Penetration From outside to inside- -Soft tissue and bones -Diaphragms - These have a smooth outline and are convex upwards. The right dome lies 1-2cm higher than the left. Usually at or below the level of the 10th posterior rib or 6th anterior rib. The costophrenic angle should be acute & clear -Lungs – opacity/luscency -Mediastinum – trachea (position), heart (size, border)
- 18. Views •Posteroanterior view Chest X-rays (CXR) are normally taken erect and PA (posterior anterior). The anterior chest wall is against the film cassette and the X-ray tube behind the patient aimed towards the film. •Anteroposterior view- in patients unable to stand •Lateral view Further assessment & localisation of abnormalities seen or suspected on the PA film. Earlier detection of small pleural effusions if ultrasound is not available
- 21. A GOOD PA CHEST X-RAY? 1. The patient should not be rotated. Look at the anterior ends of the clavicles. They should be equidistant from the spinous processes. If the patient is rotated one side of the chest will look paler than the other & the mediastinum will appear abnormal 2. The film should be taken on full inspiration. To check for this count the number of ribs showing above the diaphragm. The top of the R diaphragm should lie below the anterior end of the 6th right rib. The left diaphragm is usually lower. 3. The ribs should be sloping and not horizontal. If they lie horizontally, it may be that the patient was leaning backwards and the diaphragms will obliterate the lung bases. 4. The anterior end of the first rib should lie just below the clavicle.
- 22. 5. The scapulae should not overlay the lung fields. 6. The spinous processes should be faintly visible through the heart shadow so that lesions behind or in front of the heart will not be missed. The bony detail should not be visible because the lungs will then appear too dark. 7. The whole of the lung fields should be fully included on the film. Make sure that part of the costo-phrenic angles & apices have not been missed.
- 25. Penetration
- 28. Cardiothoracic ratio is the simple method of estimating cardiac enlargement Estimation of cardiothoracic ration should always be done on a PA film The heart size should not measure greater than 14.5/15 cms in diameter in women, or 15.5/16cm in men. Normal: For adult – 50% For neonates - 60%
- 32. THINGS TO LOOK OUT FOR Patient’s name Date Position of film/view Any bowel preparation Preperitoneal fat line Size , position / location of visualised organs Any opacity or calcification Artefacts
- 33. Indication Bowel obstruction Perforation Renal pathology – renal stone Foreign body localization Control or preliminary film for contrast studies Aortic aneurysm Detection of calcifications or abnormal gas collection
- 34. Views Supine Erect –This is taken to look for fluid levels and free gas. bowel obstruction, KUB, pneumoperitoneum Lateral decubitus- This may be useful instead of an erect film if the patient is unfit to stand. A left lateral decubitus view is taken with the patient lying on the left side. This shows fluid levels and small amounts of free air will be seen between the liver and the diaphragm. Lateral abdomen- This is seldom necessary but may occasionally be useful for suspected aortic aneurysm (if ultrasound is not immediately available).
- 36. The large bowel lies peripherally. There may be longer fluid levels and the maximum diameter is variable. The large bowel often contains faeces & has a speckled appearance due to gas trapped in the faeces. The haustra can be recognised by the fact that they do not cross the full width of the bowel and they are not regular.
- 37. The small bowel lies centrally. There should be no more than 3 short fluid levels on an erect film. There should only be small amounts of gas in the small bowel. The jejunum is recognised by valvulae conniventes, folds which traverse the full width of the bowel.
- 38. Pneumoperitonium
- 39. Calcifications that may be seen that are not significant. - Phleboliths in the pelvis – these may mimic lower ureteric stones but are more rounded in appearance. Often multiple. - Prostate. Calcification is often seen in the prostate and is a normal finding. It should not be confused with a bladder calculus. It lies below the bladder, centrally. - Seminal Vesicles. These occasionally calcify. They are serpiginous in appearance, lying behind the bladder.
- 40. Phlebolith
- 42. Indication Arthritis of the hip Pelvic fractures Hip dislocation Stiffness of spine or sacroiliac joint (ankylosing spondylitis)
- 43. Projections AP- standard projection INLET VIEW – demonstrates pelvic ring. Best for evaluating posterior displacement of pelvic ring and fracture of pubic symphysis OUTLET VIEW – assess for superior displacement of hemipelvis in fracture FLAMINGO VIEW- evaluation of suspected pubic symphysis instability JUDET (Oblique) VIEW- patient is place in 45 degree oblique position. Evaluation of superior, medial, lateral and posterior surfaces of acetabulum
- 44. Normal hip X-ray
- 45. FLAMINGO PROJECTION JUDET VIEW
- 47. Extremities
- 48. INDICATION Fracture Dislocation Congenital anomalies - achondroplasia Osteoarthritis Osteomyelitis Bone malignancy
- 49. Things to look out for Soft tissue abnormality Discontinuity of the bone Displacement/ dislocation of joint Density of the bone Narrowing of joint space
- 50. Elbow joint
- 51. Normal x-ray of the humerus
- 52. Knee joint
- 53. Xray of a fractured bone
- 54. Osteoarthritis of the knee Narrowed joint space Subarticular sclerosis
- 55. Spine
- 56. Indication for X-ray of the Spine Trauma Fracture Dislocation Pain Ankylosing spondylitis, Spondylosis Suspected neurofibromatosis TB spine Tumour
- 57. Cervical spine Lateral Antero-posterior(AP) AP odontoid view if there is a history of trauma. This is taken through the open mouth. Oblique views- are not routine but are sometimes needed in trauma. They are also indicated in suspected neurofibromatosis ( to show the intervertebral foramina) and are helpful in spondylosis if there are neurological signs. They show posterior osteophytes better than the lateral view.
- 58. Lateral view
- 59. Oblique view AP PA (PREFFERED)
- 60. Odontoid view
- 61. Following trauma it is important that the spine is not moved until fracture has been excluded. All the films should be taken with the patient supine. The lateral film should be inspected and obvious fracture excluded before moving the patient. All the vertebral bodies should be included on the film from C1 –T1.
- 62. Thoracic and Lumbar Spine The standard projections are Lateral and AP AP Usually the vertebrae are counted with reference to the 12th rib or the sacrum. The 3rd lumbar vertebra usually has the longest transverse process & this is sometimes a useful guide. The spinous processes lie in the centre of the bodies and should lie in a straight line. The pedicles are round oval structures on each side of the body and should be symmetrical. A pedicle is often destroyed in metastatic disease and the pedicles should always be checked. The vertebral bodies increase a little in size lower down the spine but the lateral vertebral lines should be un- interrupted. The outlines should be clear. The disc spaces should be equal in the thoracic region. In the lumbar spine they increase in size from L1 down to the L5/S1 disc space. The interpedicular distance increases slightly in the lumbar spine from L2 to L5.
- 63. LATERAL: The vertebral bodies in each region of the spine should be roughly the same size and shape. A lines drawn along the anterior and posterior bodies should be smooth and uninterrupted. The bodies should be roughly square shaped with well- defined outlines. The disc spaces increase in size from L1 to L5. The densities of the bodies should be equal and the trabeculae should be seen.
- 64. AP VIEW
- 65. LUMBAR SPINE (LATERAL VIEW)
- 67. Conclusion Radiographs play a role in the diagnosis of diseases and treatment follow–up. A good knowledge of the human anatomy is needed for proper interpretation of a radiograph
- 68. References Ouellette H. Tetreault P. Clinical Radiology made ridiculously simple. MedMaster, 2000 Tersoo’s Radiology. 2008. Revised edition. Bell D. Shetty A. Radiographic Positioning Terminology, http://radiopeadia.org/articles/radiographic-positioning-terminology/ accessed 25th May, 2021 Tarek M. Evaluation of plain skull X-ray Skull: A systemic approach Dr Arushi G. Abdominal Xray. https://www.slideshare.net/ArushiGupta119/abdominal-xray- imaging-and-interpretation-173049384. accessed 23rd May, 2021.
- 69. Thank you.