How to look at an X-ray

The X-ray image

After X-rays pass through an object under investigation, they are absorbed by a receiver on the other side of the object (this can be photographic plate, a fluoroscopic film or a digital plate). Dense material such as bone tends to prevent the x-rays from reaching the plate, and less dense material such as air allows them to pass. The image is developed in negative such that more x-rays hitting the receiver produce darker areas - bone appears pale, air in the lungs appears dark.

Hovering over the image will make the image negative - medics look at xrays in negative because it is easier to see something light against a dark background The resolution of X-rays can distinguish between 5 groups: Completely White White Light Dark Black Metal (foreign bodies or implants for example) Contrast media Bone Calcified soft tissue Water & fluids Normal soft tissue Fatty soft tissue Air

Lines on X-ray - The 'Silhouette' effect

Discrete lines on an x-ray (for example the borders of a bone) are produced when there is a difference in density between two adjacent groups, for example bone and soft tissue. This 'silhouette' is an invaluable property the loss of a normal line on x-ray implies that there is something of the same density adjacent to the structure which normally produces the line. New lines appearing can by the same token indicate abnormality.

In this image, there is air above fluid producing a fluid level seen in pleural collections like empyemas and pleural effusions.

On the above chest x-ray, the left border of the patients heart (on our right) is no longer visible, implying that there is something with a similar density immediately adjacent to it. A rather large something in fact as you can probably see...

Contrast media
In order to visualise soft tissues better, contrast media which falls into a known radio-density group can be introduced adjacent to body tissues to highlight their anatomical structure. On chest x-rays, air in the lungs is a

natural contrast media, but in the bowel for example, barium can be flushed in, producing an outline of the gut wall.

Hovering over the abdominal film above will inject contrast medium!

Commonly used contrast media: Medium Salts of heavy metals e.g. barium sulphate Organic Iodides Air or Carbon Dioxide Structure enhanced gut wall Urinary tract, blood vessels (lungs), used in conjunction with barium to produce "double-contrast" x-rays of the gut

Calcification
Calcification can be malignant or benign Phleboliths Faecoliths Stones Fibroids Tuberculosis Cancer small round opacities, frequently seen in the pelvis, they are calcified blood vessels seen end-on, and are harmless Round opacities seen in the colon sometimes in diverticular disease 1/3rd of gall stones can be seen on x-ray, but renal stones are seen more commonly Rarely, fibroids can calcify and be seen on x-ray TB can cause calcification anywhere in the body lungs, lymph nodes, even the mediastinum can be calcified by mycobacteria Cancers can calcify, particularly hepatomas

Calcification on x-ray - in this case a calcified lymph node (the patient has probably drunk unpasteurised milk in the past and this is bovine TB)

Using a 2D image to look at a 3D structure

A single x-ray gives information about internal structure in two dimensions only. Two x-rays taken from different angles provide a lot more information, and it is standard to have a PA and a lateral for chest xrays. On the standard PA film on the right, the heart appears central, but on the lateral we can see that it is anterior as well. Such information can be vital in defining whether a lung cancer is in a lower or middle lobe for example.

The same principle applies to fractures of bone in the x-rays below, on the AP (left) we can see that the distal fragment of the fibula is pointing medially, and on the lateral, we can see it is also anterior. This information is crucial to the management of fractures.

Presenting X-rays
While each class of x-ray has its own method of viewing which we will teach separately, they are all introduced in a similar format when discussed formally. Try this mini report generator below and create your own fancy report! This is an

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You can practise presenting reports at this tutorial page

The Chest X-Ray

Quickjump to teaching on: Pathology Pneumothorax Cardiomegaly Pleural Collection Pulmonary oedema Consolidation TB Consolidation Cancer Diffuse Lung Diseases Perforation The chest radiograph is the most commonly encountered of all radiological procedures, yet it is one of the most complex to interpret. Here we shall lead you through a step-by step guide at how to look at each system on the radiograph. If you haven't already done so, it would be a good idea to read the general introduction before this tutorial.

General 'how to look at them'

' These will all be discussed in detail below. There are many systems to looking at chest x-rays, but we prefer the 'start at the top and work your way down then back up again' approach: here is a quick summary of the process, which will be repeated later

Patient consider the gender and age of the patient - it will help put the x-ray in context and guide your differentials Technical - Assess technical details of the film - type of view, exposure, expansion, rotation Above the heart - trachea, aortic knuckle Heart - size, borders Diaphragm - borders, air underneath it? Hila and lungs - look at the blood vessels for enlargement, hila for lymph nodes, and the whole lot for masses Bones - check for fractures Soft Tissues - look for soft tissue masses outside the lungs - especially in the breasts Final Look - take the whole lot in , focus on areas you think are abnormal and decide what you think is going on.

Normal Chest X-ray