CLINICAL UTILITY OF X-RAY
PRESENTED BY
DR. RASHMI SHUKLA
PG SCHOLAR, DEPARTMENT OF ROGNIDAN
Guide- Dr. Avadhesh Kumar Co- Guide- Dr. D. N. Singh
Associate Professor Assistant Professor
X-RAYS
• X rays are the electromagnetic radiations having wavelength between
gamma rays and UV rays (.1A to 1A).
• X-rays, like gamma rays, are penetrating and carry enough energy to
ionize atoms in their path.
• X-rays can go through many solid materials. For this reason, taking
photograms with X-rays is used as medical diagnostic tools in order to
see Bones, Soft tissues, and other things inside the body.
DISCOVERY OF X RAY
• X-Rays were discovered in 1895 by German physicist named Wilhelm
Conrad Roentgen, while studying cathode rays (stream of electrons) in
a gas discharge tube.
• He observed that another type of radiation was produced. This
radiation could penetrate opaque substances, produce fluorescence,
blacken a photographic plate.
• He named his discovery “x rays” because “x” stands for an unknown
rays.
The Famous First Medical X-Ray by
Rontgen:- his Wife left Hand with ring
PROPERTIES OF X-RAY
• X-rays are invisible.
• X-rays have no mass.
• X-rays travel at the speed of light in a vacuum.
• X-rays travel in straight lines.
• They have a very short wavelength. They are unaffected by electric
and magnetic fields.
• They cannot be refracted.
• They cause ionization (adding or removing electrons in atoms and
molecules)
• They are transmitted by (pass through) healthy body tissue.
• They affect photographic film in the same way as visible light.
(turning it black)
• They are absorbed (stopped) by metal and bone. they can cause
photoelectric emission.
• They are produced when a beam of high-energy electrons strike a
metal target.
These properties make X-rays very useful for
medical diagnosis and treatment.
X- Ray TUBE
X-RAY TUBE
X ray are produced in the x-ray tube. The three main component of the
x-ray tube are-
CATHODE-The cathode is composed of tungsten filament which is
centered in a focusing cup. Electron are produced by the filament and
are focused on the target of the anode where the x-rays are produced.
• ANODE- The anode in the X-ray tube is composed of a tungsten target
embedded in a copper stem. When electrons from the filament enter
the target and generate X-rays a lot of heat is produced. The copper
helps to take some of the heat away from the target so that it doesn’t
get too hot.
Why Tungsten choose over other Metals:-
I. Very High Atomic Number(74)
II. Very high Melting point(3400 C)
III. Very High Thermal conductivity
IV. Very Low Vapor Pressure
• 3-GLASS ENVELOPE AND HOUSING- The Anode and
the Cathode are in a borosilicate glass envelope
containing a perfect vacuum.
• The envelope is Cylindrical and has a ‘Window Size’(5
into 5 cm) where the glass is thinner permitting the
X-rays to leave through them.
• The X-Rays tube is housed in a metal housing which
lines with lead except at window and oil inside the
housing surrounds the tube.
Production of X-rays
X-rays are produced when rapidly moving electrons that have been
accelerated through a potential difference of order 1 kV to 1 MV strikes
a metal target.
• Electrons from a hot element are accelerated onto a target anode.
When the electrons are suddenly decelerated on impact, some of the
kinetic energy is converted into Electromagnatic energy, as X-rays.
• Less than 1 % of the energy supplied is converted into X- radiation
during this process. The rest is converted into the internal energy of
the target.
USES OF THE X_RAYS
X-ray Radiography-The most common form of X-ray used is X-ray
radiography, which can be used to help detect or diagnose:
• Bone fractures
• Infections (such as pneumonia etc)
• Calcifications (like kidney stones or vascular calcifications)
• Some tumors
• Arthritis in joints
• Bone loss (such as osteoporosis)
• Dental issues
• Heart problems (such as congestive heart failure)
• Blood vessel blockages
• Digestive problems
• Foreign objects (such as items swallowed by children)
• Mammography: A radiograph of the breast that is used for cancer
detection and diagnosis. Tumors tend to appear as regular or
irregular-shaped masses that are somewhat brighter than the
background on the radiograph. Mammograms can also detect tiny
bits of calcium, called microcalcifications.
• CT (computed tomography):- Combines traditional x-ray technology
with computer processing to generate a series of cross-sectional
images of the body that can later be combined to form a three-
dimensional x-ray images.
• Fluoroscopy: Uses x-rays and a fluorescent screen to obtain real-time
images of movement within the body or to view diagnostic processes,
such as following the path of an injected or swallowed contrast agent.
For example, fluoroscopy is used to view the movement of the beating
heart, and, with the aid of radiographic contrast agents, to view blood
flow to the heart muscle as well as through blood vessels and organs.
• Radiation therapy in cancer treatment: X-rays and other types of high-
energy radiation can be used to destroy cancerous tumors and cells by
damaging their DNA.
Chest X-ray
• A chest X-ray can reveal many things inside your Chest, including:
• The condition of your lungs. Chest X-rays can detect cancer, infection
or air collecting in the space around a lung, which can cause the lung
to collapse. They can also show chronic lung conditions, such as
emphysema or cystic fibrosis, as well as complications related to
these conditions.
• Heart-related lung problems. Chest X-rays can show changes or
problems in your lungs that stem from heart problems. For instance,
fluid in your lungs can be a result of congestive heart failure.
• The size and outline of your heart- Changes in the size and shape of your
heart may indicate heart failure, fluid around the heart or heart valve
problems.
• Blood vessels- The aorta and pulmonary arteries and veins — are visible on
X-rays, they may reveal aortic aneurysms or congenital heart disease.
• Calcium deposits- Chest X-rays can detect the presence of calcium in your
heart or blood vessels. Its presence may indicate fats and other substances
in your vessels, damage to your heart valves, coronary arteries, heart
muscle.
• Calcified nodules in your lungs are most often from an old, resolved
infection.
• Fractures- Rib or spine fractures or other problems with bone may be seen
on a chest X-ray.
BASIC KNOWLEDGE OF CHEST X-
RAYS FILM
• There are 3 types of chest films;
• AnteroPosterior (AP)
• PosteroAnterior (PA)
• Lateral
• The ideal timing can be defined as the end of inspiration,
and the patient should hold his breath at that time.
Meanwhile, the X-ray tube should be 180 cm away.
• Assessing The Image Quality
• The image quality is one of the most important things in
image interpretation.
• For this“RIPE” mnemonic is used.
• Rotation,
• Inspiration
• Position
• Exposure(Penetration).
Rotation:-
The clavicles should appear symmetrical and
be seen as equal length. The distance between
the thoracic spinal process and clavicular
heads should be equal .
If there is a rotation, mediastinum may look
abnormal.
The clavicular heads and spinous process
alignment.
The x-ray shows minimal rotation.
Compare X and Y.
Inspiration:
• On good inspiration, the diaphragm should be seen at the level of the
8th – 10th posterior rib or 5th – 6th anterior rib.
• This chest x-rays shows
adequate inspiration.
Position
• The standard chest X-Rays consists of a PA and lateral
chest X-Ray.
• The normal lateral chest x-ray view is obtained with
the left chest against the cassette. If the x-ray is a true
lateral, the right ribs are larger due to magnification
and usually projected posteriorly to the left ribs.
Normal Chest X-rays- (PA- VIEW)
The right ribs (red arrows)
left ribs (green arrows) on the lateral chest X-Ray.
• Exposure / Penetration: Ideally, you should be able to see the heart,
the blood vessels, and the intervertebral spaces. Exposure should be
adequate if you are able to see approximately T4 vertebra and spinal
process. If the film is underexposed, you will not be able to see them .
If the film is overexposed, details of bone structures will be lost.
Under-
exposed Film
Interpretation The interpretation of a chest X-Ray
should be approached systematically by ABCDEF
• The analysis is ABCDEF is-
• Airways
• Bones
• Cardiac
• Diaphragm
• Extra-thoracic tissues
• Fields
• A – AIRWAY
• The trachea, carina and both main bronchi are called the
upper airway and should all be visible on an AP view .
Look for if there is any deviation of the trachea away
from the midline. Introduction of air into one side of the
chest cavity will cause that side of the lung to collapse.
The collapsed lung will push the trachea to the opposite
side and resulting in a deviation that will show up on
chest X-Ray.
Airway structures on the chest X-Ray-(Red Arrows: trachea,
Green Arrow: carina, Pink Arrows: left and right main bronchus)
• B – BONES
• A chest X-Ray provides a good view to look for ribs
and clavicle fractures. Clavicular fractures are usually
at the middle 3rd of the clavicle, which is easy to see
in chest X-Rays. Rib fractures, however, can
sometimes be hard to see. Each rib should be
followed across its length to look for fracture lines or
step-offs that could indicate a fracture.
Bone structures on the PA chest X-Ray
red arrow: clavicle, yellow arrows: medial border of scapula, green
dashed line and arrows: 3rd rib, pink dashed line: vertebras
• C – CARDIAC:-
• This part involves the heart and surrounding
structures. The heart should be identified, and the
heart borders should be clear. As a general rule, the
heart base should not be wider than 1/2 the total
width of the diaphragm. If the heart base is 1/2 the
width of the diaphragm on the chest X-Ray, it refers to
cardiomegaly or pericardial effusion.
Heart borders on the AP chest X-Ray. (Pink dashed lines
and arrows: heart borders, Yellow dashed line and arrow:
Aortic Arch, Blue circle, and arrow: Aortopulmonary
Window)
• D – DIAPHRAGM
• The outline of the diaphragm should be clear and smooth. Right
hemidiaphragm should be higher than the left . It has 3 major
characteristics that can be found on chest X-Ray:-
• The gastric air bubble on the left.
• The diaphragmatic contour looks like a “dome” shape, and the right
side located little higher than the left.
• The costophrenic angle is the lateral point of attachment for the
diaphragm, and it should be a clear, sharp, and a triangle-shaped at
either end. If the angle is closer to 90 degrees, then the lungs could be
hyperexpanded (e.g., COPD) and be pushing the diaphragm down into
the abdomen. If the costophrenic angle is blunting, that usually is
indicative of pleural effusion.
• The view of the diaphragm on the AP chest X-Ray- (Yellow dashed
lines and arrows: diaphragm, red arrow: gastric air bubble, pink
dashed lines: costophrenic angles
• E – EXTRATHORACIC TISSUES-
• Mostly this means as the lung parenchyma. Lung fields can be divided into
zones: upper, middle, and lower zones-
• Upper zone: from the apex to 2nd costal cartilage.
• Middle zone: between 2nd and 4th costal cartilage.
• Lower zone: between 4th and 6th costal cartilage,
• F – FIELDS-
• You should check lung fields for
infiltrates. Identify the location of
infiltrates and identify the pattern of
infiltration (interstitial or alveolar
pattern). Look for air bronchograms,
nodules. You should also check for
masses, consolidation, pneumothorax
and vascular markings. Vessels should
be almost invisible at the lung
periphery.
Primary tuberculosis
Endobronchial TB Miliary Tuberculosis
Pleural thickening in COPD
mesothelioma
Right sided Pneumonia Lung Tumor
Right sided Pneumothorax Pneumoperitoneum
Pleural effusion with Trachial Deviation Covid- 19 Pneumonia(advance stage)
Cardiomegaly Congestive Heart Failure
Musculoskeletal x-rays
The musculoskeletal X-ray interpretation involves assessing
the following:-
• Alignment and joint space
• Bone texture
• Cortices
• Soft tissues
• Alignment and joint space-
• Changes in alignment suggest a fracture,
subluxation (partial dislocation) or dislocation.
• When describing the displacement, the position of
the fragment distal to the fracture site is always described.
• The radiograph below demonstrates why it is important to
have more than one view.
Joint dislocation of the metacarpophalangeal joint of
the 5th digit
Osteoarthritis of the left knee. Note the osteophytes (right side Lateral X-ray of spondylosis of the lumbar spine, with
of joint), narrowing of the joint space, and increased osteophytes marked by arrows
subchondral bone density (black arrow).
• Bone texture
• Altered density or disruption in the usual internal
matrix of fine white lines (trabeculae) within the
substance of the bone and the thick external
covering (cortex) may indicate pathology
Healthy cortex and trabeculae vs
osteomyelitis.
• Cortices-
• Trace around the outline of each bone as any step in the cortex may
indicate a fracture or other pathology.
• Infection and tumours (primary and secondary) are the commonest
causes of bony destruction.
• A periosteal reaction is the formation of new bone in response to
injury or other stimuli of the periosteum surrounding the bone. It may
be the only sign visible to denote a problem with the bone (stress or
healing fracture, mild osteomyelitis or tumour)
Trace around the bone cortex carefully to identify Osteosarcoma affecting the tibia
fractures (arrow)
• Soft tissues-
• Look for any swelling, foreign bodies or effusions.
Sometimes soft tissue injuries are easier to visualize and
can prompt a closer inspection for bony pathology.
X-ray of the knee, showing knee effusion of medium severity, Lipohaemarthrosis (red arrow) due to a tibial plateau fracture
marked by black arrows. It displaces the patella anteriorly and (blue arrow)
extends into the suprapatellar bursa
• Types of fractures-
• There are several different types of fracture including:
• Closed fracture
• Open fracture
• Transverse fracture
• Spiral fracture
• Comminuted fracture
• Impacted fracture
• Greenstick fracture
• Oblique fracture
This is an x-ray image of a spiral fracture to the left
X-ray of Monteggia fracture of right forearm, showing humerus of a 27-year-old male. The injury was
transverse fracture of ulna and dislocation of radius sustained during a fall.
A comminuted pilon fracture of the lower tibia and fibula
X-ray of a Colles fracture of the left wrist accompanied by
ulnar styloid fracture.
Spine X-rays
A system for evaluating the spine includes:-
1-HEIGHTS OF THE VERTEBRAL BODIES AND
INTERSPACES
2-BONE DENSITY
3-FACETS (the Scotty dog)
4-NEUROFORAMINA
5-ALIGNMENTS
facets
margins
spinous and transverse processes
6-SOFT TISSUES
X-Ray- cervical Vertebrae
•
• cervical vertebrae – Normal Anatomy
Normal thoracic vertebrae anatomy
Lumber vertebrae-Normal Anatomy
Nornal Pelvis-Anatomy
SOME ABNORMAL MUSCULOSKELETAL
X-RAYS
Normal lordotic curve loss of lordosis
. There is
a hangman’s fracture of C-2 (red
arrow).
Lumber disc degeneration
Scoliosis
Oblique view of the cervical
White arrows point to normal
spine.
Black arrows point to
neuroforamina, as opposed to the
typical Schmorl’s nodes which indent
encroachment by enosteophytes as indicated
the normal vertebral margins on either
by the red arrow. This is a common finding
the inferior or superior surface.
in patients with osteoarthritis and may be
the cause of parathesias
Slip Disc- Sciatica
Spondylolisthesis
Osteophytes-Cervical spine Tuberculosis of spine- Pott’s Disease
Musculoskeletal Calcification
Knee joint -Osteoarthritis
Bony Cyst Ankylosing spondylitis Pelvic Calcification
Rheumatoid Arthritis-
Hand and Feet
Rheumatoid Arthritis Osteoarthritis
Gouty Arthritis Tophaceous Gout-Feet
