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x ray

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basics of x ray

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x ray

  1. 1. P A G E | 1 INTRODUCTION Wilhelm Conrad roentgen a German physicist discovered electromagnetic radiation on 8th November 1895 & this earned him the first NobelPrize in physics in, he is considered as the father of diagnostic radiology. His discovery was an incidental finding as he was investigating the external effects from various types of vaccum equipment’s with a small aluminium window kept on the tube. He noticed a fluorescent effect on the cardboard screen painted with barium platino cyanide kept near to the aluminium window & he understood that this effect is because of some invisible rays which can penetrate harder substances.So, he invented this magical invisible rays & he named it as x-rays, using the mathematical designation for something eventually bear his name as Rontgenrays. The greatness of Rontgen lies in the fact that he refused to take out patents related to his discovery, as he wanted mankind as a whole to benefit from practical application of the same & that he did not want the rays to be named after him A radiographic film before an image is transparent & therefore appears white on a view box. When a radiograph is taken X-rays reach the film & darken it. The more the 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 & consequently the image of the object will appear white on the radiograph. However, if an object has little density, its image will appear black on the radiograph becauseit allows most of the x-ray beam to reach the film.
  2. 2. P A G E | 2 RADIOGRAPHIC DENSITIES Only five basic radiographic densities exist. They are in order of increasing brightness; gas, fat, fluid, bone& metal densities .This is a key concept. Anatomic structures seen on the radiograph can be identified by their characteristic density. For e.g; the lungs are dark, or air density, because they are filled with air. Organs such as the heart are largely composed of water. Therefore, it is no surprise that they appear lighter than the lungs, because they are fluid density. Bones are brighter structures because they are composed of calcium PROPERTIESOF X-RAYS  Wavelength : 10 – 0.01nm  Frequency : 30 petahertz to 30 exahertz  Energy : 120 eV to 120 Kev  Shorter in wavelength than UV rays & larger than gamma rays  X-rays 0.12 to 12 Kev (10-0.10nm wavelength)are soft x-rays 12 to 120 Kev (0.10 – 0.010nm wavelength) are hard x-rays [Due to their penetrating abilities, hard x-rays penetrate solid objects, to take images of objects in diagnostic radiography & crystallography; soft x-rays can hardly be said to penetrate matter]
  3. 3. P A G E | 3 UNDER EXPOSED&OVER EXPOSED FILM A good quality film is necessary for a right diagnosis. The precision of a diagnosis depends upon the proper exposure of the film. A film should not be too dark (over exposed) or (under exposed). While reading the x-rays it is important that we should see the name, number, left or right of the film. Making a right diagnosis in a wrong patient will be very much embarrassing, so identification of the x-ray in terms of right, left, patientsname, age& gender is very important for properradiological diagnosis. PURPOSEOF X-RAY EXAMINATION& TYPES  To confirm a diagnosis (e.g; pneumonia)  To exclude injury or disease(e.g; fracture)  To establish the extent of disease(e.g; metastatic invasion)  To assess the progress of disease or its responseto treatment (e.g; osteomyelitis, fracture healing etc.) TYPES: In x-rays again simple x-ray, miniature x-ray, computed x-ray, xero radiography, contrast medium x-ray like barium meal, barium swallow, barium enema, bronchography, sialography, phlebogram, arteriogram, intra cardiac catheterization, cine radiography etc. are there
  4. 4. P A G E | 4 DIGITAL SUBTRACTION X-RAYis a newer modality of investigation. Here a positive film & a negative film are superimposed on each other & a picture is taken. After taking the first x-ray, contrast is injected & the second is taken. So thesuperimposed film will show only the portion containing the dye. This is useful for angiograms, barium studies & all other situations using contrast CONTRAST MEDIUM X-RAY:To visualise radiolucent structures like stomach, intestines, blood vessels, ducts etc., a radiopaque substance is passed or injected into them & x-ray film is taken. Barium meal, intra venous pyelography (IVP), myelogram, intra cardiac catheterization, etc., are called contrast medium x-rays. In these, indirect viewing, of the required part with the help of injecting a radio opaque substanceis possible. MAMMOGRAPHY:A mammogram is an x-ray examination of the breast. It is used to detect & diagnose breast disease in women who either have breast problems such as a lump, pain, or nipple discharge, as well as for women who have no breast complaints. A screening mammogram is an x-ray of the breast changes in women who have no signs of breast cancer. It usually involves two x- rays of each breast. Using a mammogram, it is possible to detect a tumour that cannot be felt. A diagnostic mammogram is an x-ray of the breast used to diagnose unusual breast changes, such as a lump, pain, nipple thickening or discharge, or a change in breast size or shape. A mammogram helps to identify the following conditions:  Calcification – tiny mineral deposits within the breast tissue. There are two categories of calcifications: i. Macro calcification- coarse calcium deposits that usually indicates degenerative changes in the breasts, such as aging of the breastarteries,old injuries, inflammations etc.
  5. 5. P A G E | 5 ii. Micro calcification- tiny(less than 1/50 of an inch) specks of calcium. When many micro calcifications are seen in one area, they are referred to as a cluster.  Masses – may occur with or without associated calcifications, & may be due to different causes,includingcyst&benign breastconditions. Cyst is a non-cancerous collection of fluid in the breast. Cysts cannot be diagnosed by physical examination alone nor by mammography alone. Either breast ultrasound or aspiration with a needle is required. FLUOROSCOPY –fluoroscopy is a study of moving body structures – similar to an x-ray “movie”. A continuous x-ray beam is passed through the body part being examined, & is transmitted to a TV- like monitor so that the body part & its motion can be seen in detail. Fluoroscopy is used in many types of examinations & procedures, such as barium x-rays, cardiac catheterization, & placement of intravenous (IV) catheters (hollow tubes inserted into veins or arteries0. In barium x-rays, fluoroscopy allows the physician to see the movement of the intestines as the barium moves through them. In cardiac catheterization, fluoroscopy enables the physician to see the flow of blood through the coronary arteries in order to evaluate the presence of arterial blockages. For intravenous catheter insertion, fluoroscopy assists the physician in guiding the catheter into a specific location inside the body. INTRAVENOUS PYELOGRAM (IVP)– An IVP is a diagnostic x-ray of the kidneys, ureters, & bladder. When a contrast agent is injected intravenously, the urinary tract will show up very clearly, which is not seen on regular x-rays. An IVP may be done for many reasons including: to detect kidney tumours, to identify blockages or obstructions of the normal flow of urine, to detect kidney stones or bladder stones, to establish if the prostate gland is enlarged, to detect injuries to the urinary tract.
  6. 6. P A G E | 6 BARIUM X-RAY – pure barium is rarely used outside the laboratory. Barium compounds are found primarily in two ores; the first is barite & the second is witherite. Barite contains a sulphate compound while witherite contains barium carbonate. While barium & all of its soluble compounds are poisonous, barium sulphate is used in medical procedures because it does not dissolve in water or other body fluids. Like other meals, barium is a good conductor of heat & electricity. It is silver & white in colour & relatively flexible. Chemically it resembles calcium & strontium fellow members of the alkaline earth family of metals. Barium’s many compounds have a number of practical applications. Perhaps the most familiar is the one used in a medical procedure, the barium meal & enema. When doctors need to examine a patient’s digestive system, a mixture containing barium sulphate is used to coat the inner lining of the intestines. Similarly, to enhance examination of the stomach & oesophagus; the patient drinks a chalky barium sulphate liquid. When the patient is x-rayed, the barium coating inside the digestive tract absorbs a large proportion of the radiation. Barium sulphate is non-toxic insoluble salt. This highlights the black & white contrast of the x-ray photograph, so that doctors can better diagnose digestive problems. For some patients it is necessary to inject contrast agents directly into arteries or veins. In this case, iodine based molecules are suitable contrast agents. Iodine is chosen because it has a relatively high atomic mass & so markedly attenuates x- rays, but also, importantly, it is naturally excreted via the urinary system.
  7. 7. P A G E | 7 DIFFERENT VIEWS IN X-RAY Skiagrams are taken in different positions of the subject in relation to the source of x-rays & the photographic film. Some of the common position used are: (1)ANTERO-POSTERIOR VIEW (AP VIEW) In this the x-ray tube anterior to the subject & film is placed posteriorly. So rays are passing antero- posteriorly. Posterior structures are better visualized in this view.Taken at a distance of 100 cm. usually taken in supine position (lying down). It is substituted for the PA VIEW in very sick patients, infants & in one who is unable to stand or sit. (2) POSTERO-ANTERIOR VIEW In this the x-ray tube is posterior to the subject & the film is anterior, the x-rays thus passing postero anteriorly through the subject. Anteriorly placed structures are more clearly visible in this view. Routine PA VIEW is taken with patient upright (standing or sitting) with the x-ray tube directed horizontally at a distance of 6 feet from the film. (3)OBLIQUE VIEW In taking oblique views, the subject stands in front of upright film cassette holder & is then turned 45 degree oblique (left or right). Oblique views are taken to visualize certain special structures. In the case of chest x-rays, oblique views could be
  8. 8. P A G E | 8 i. Right anterior oblique view (R.A.O) ii. Left anterior oblique view (L.A.O) (4)LATERAL VIEW These are used to assess the depth of the structures. The position in this view is at right angle to that in AP or PA VIEW. Lateral views are of two types; i. Right lateral view- when the film is kept against the right side of the subject ii. Left lateral view – when the film is kept against the left side of the subject The fundamental rule of the radiography is to get the lesion as close to the film as possible, hence if the lesion is on right side we should take right lateral view & if the lesion on the left side the view to be taken will be left lateral view. This reduces the magnification & enhances the sharpness. (5)WATERS’S VIEW (occipito mental view) This view is taken to see the paranasal sinuses. To take this view the head is extended with chin touching the palate & nose raised from the plate (tragocanthal line forming an angle of 37 degree with the film cassette). X-rays are passed from posterior side. (6)EXPIRATORY FILM This view is used to demonstrate a small pneumothorax, vascular lesions, azygos veins or the changing shape of pulmonary hydatid cyst. It should be remembered that normally a chest PA VIEW is taken in full inspiration. (7)TRENDELENBURG VIEW
  9. 9. P A G E | 9 This view is taken with the patient in the head –low position. This helps to demonstrate movement of the fungal ball in the cavity. Shift of fluid in the pleura or pericardium can also be noted, when the patient is put in trendelenburg view (8)APICOGRAM/LORDOTIC VIEW Compared to the PA VIEW, in the lordotic view the lung apices are seen clearly & the x-ray is devoid of the overlapping clavicular shadows. Often small nodules, calcifications, azygos lobe & even middle lobe collapse are clearly demonstrated in this view. (9)DECUBITUS VIEW In this view, patient is lying on one side & x-ray beam is perpendicular to the film. When the patient is lying on his right side & faces the tube, & the film is placed behind his back, it is called right lateral decubitus view, similarly when he is lying on the left side it will be a left lateral decubitus view. Best for demonstrating minimal pleural effusion & to confirm air fluid levels in the lung. For demonstrating small pneumothorax, affected side should be in non-dependent position. (10)AXIAL VIEW Best used to assess the talocalcaneal joint & plantar aspects of the calcaneus. The axial view has a diagnostic sensitivity of 87% for calcaneus fractures. Patient is supine or seated with the affected limb extended, the posterior aspect of the ankle is resting on the image receptor. Foot is dorsiflexed until the plantar surface is running perpendicular to the image receptor (11)SKYLINE VIEW
  10. 10. P A G E | 10 Looks between the kneecap & the thigh bone. It is taken with the knee bent (about 30 degrees) & is used to diagnose arthritis. It is much less common. Only about 30% of orthopaedic surgeons use this view during a routine examination. This view is similar to the angle we see when sitting with our leg out in front of us, slightly bent. Only two bones are visible in this skyline view x-ray; the patella & the femur. In a healthy knee, the groove in the femur should match the shape of the patella & there should be a nice gap between the two of a consistent width. (12) MORTISE VIEW Ankle AP mortise view is part of a three view series of the distal tibia, distal fibula, proximal talus & proximal metatarsals. This view helps to assess the mortis joint of the ankle. The patient may be supine or sitting upright with the legs straighten on the table. The leg must be rotated internally 15-20 degree allowing the intermalleolar line to be parallel to the detector. This usually results in the 5 th toe directly in line with the centre of the calcaneum. Internal rotation must be from the hip, rotation isolated at the ankle will cause a non-diagnostic image, and foot is to be in slight dorsiflexion. INDICATIONS&CONTRAINDICATIONS:X-RAY INDICATIONS  Fractures  Dislocation  Determination of age by knowledge of ossification of bones  For diagnosis of Deficiency disease (e.g; rickets, scurvy); Infections(e.g; osteomyelitis); Osteoarthritis; Tumours; Non-fusion of bones (congenital deformity)
  11. 11. P A G E | 11 EXAMINATION OF X-RAY When a radiograph is requested, in most cases the standard views comprising an antero-posterior (AP) & a lateral projection will be provided Someone experienced in looking at radiographs will recognise the main pathology at a glance without following any analytical procedure, just as a familiar face is identified without apparently paying conscious attention to the relevant position & size of its main features. Until such skills are developed, it may be helpful for the student to have some simple scheme follow. One such is to look at each radiograph as though in the cinematic sequence of long shot, medium shot & close up. In the long (wide angle) shot a scene is established & the overall relationship of the important features is made clear. Start by looking at the radiograph in a general, unfocusedway, as though you were standing well back from it. Looking a little more closely, note whether the bone texture appears normal or disturbed, such as in osteoporosis, Paget’sdisease, avascular necrosis,etc. note if there are any areas of new bone, such as exostoses, sub periosteal new bone formation etc. note whether there are any areas of bone destruction, such as may be found in the presence of many tumours. Examination of the bone in close up may be done in two ways; either trace methodically round the contours of the bone, noting any abnormality in route, or go through a checklist of your own making: checklists can have different bases & can be used in combination. A list may be based on pathology ,you might then look for evidence of congenital abnormality,infection,trauma,neoplasm,metabolic disturbances, degeneration ; a list have an anatomical base; you might then assess ligamentous attachments, jointmargins, the joint space& the cortical & cancellous bone elements.
  12. 12. P A G E | 12 Before asking for an x-ray, the following points should be kept in mind.  Both AP VIEW & LATERAL VIEWS should be requested in most cases.  X-ray requisition must specify the area of suspicion.  X-ray of the pelvis with both hips should be asked for in all cases of suspected pelvic injury. Major injuries of the thigh are often associated with.  Special views show fractures better in some cases (e.g; oblique view wrist-scaphoid fracture, judet view-acetabular fracture, merchant view-patello femoral joint, skyline view-calcaneous fracture) In some situations radiographs additional to the standard AP & lateral projections may be required. These may include:  COMPARISON FILMS – here films of the other limb may be taken so that the two sides may be compared; this may be indicated where there is some difficulty in interpreting the radiographs.(e.g;elbow region in the children, where the epiphyseal structures are continuously changing or where there is some unexplained shadowor congenital abnormality)  LOCALISED VIEWS –where there is marked local tenderness , but routine films are normal, coned down localised views may give sufficient gain in detail to reveal, for e.g; hairline fracture  STRESS FILMS – stress films can be of value in certain situations, especially when a substantial tear of a major ligament is suspected. For e.g; where the lateral ligament of the ankle is thought to be torn, x-ray of the joint taken with the foot in forced inversion may demonstrate instability of the talus in the ankle mortice.
  13. 13. P A G E | 13 READING AN X-RAY An x-ray view box should be used in all cases. If a fracture is obvious, one must make a note of the following points.  Which bone is affected?  Which partof the bone is affected? E.g;shaft etc.  At whatlevel is the fracture? i.e.;whetherthe fracture is in the upper,middle orlowerthird.  Whatis the pattern of the fracture? i.e.;whether the fracture is transverse,oblique etc.  Is the fracture displaced? If yes, in what direction i.e.;whether it is a shift (anteroposterior, sideways), atilt, or angulation in any direction, or a rotational displacement. Rotational displacementis sometimes notvisible on x-rays,& can only be diagnosed clinically.  Is the fracture line extending into the nearby joint?  Does the underlying bone appear pathological? E.g;a cyst, abnormal texture of the whole bone etc.  Is it fresh or an old fracture? An x-ray of a fresh fracture shows a soft tissue shadow resulting from haematoma, & the fracture ends are sharp. An old fracture shows callus formation & disuse osteoporosis &the fracture ends are smoothened. If the fracture is not obvious immediately, all the bones & joints seen on the x- ray must be examined systematically for a break in the cortex or loss of joint congruity. X-ray findings should be co –related with clinical findings, so as to avoid error because of some artefacts which may mimic a fracture. Also one must ensure that the part under question is visible on x-ray. An x- ray of a bone must include the joints proximal & distal to the bone. Do look for an associated injury to all the otherbones & joints visible on the x-ray. One must be aware of some normal x-ray findings, which are often misinterpreted as fracture. e.g; epiphyseal lines, vascular markings on bones, accessory bones etc. A comparison with the x-ray of the opposite limb helps in clearing any doubt. There are some injuries particularly liable to be missed by a novice. Before an x-ray is passed as normal, one mustcarefully look forthese injuries.
  14. 14. P A G E | 14 USES OF X-RAY X-rays are especially useful in the detection of the skeletal system, but are also useful for detecting some disease processes in soft tissue. Some notable examples are the very common chest x-ray, which can be used to identify lung diseases such as pneumonia, lung cancer or pulmonary oedema, & the abdominal x-ray, which can detect intestinal obstruction, free air(from visceral perforations)& free fluid(in ascites) X-rays may also be used to detect pathology such as gallstones (which are rarely radiopaque) or kidney stones which are often visible. Traditional plain x- rays are less useful in the imaging of soft tissues such as the brain or muscle. Imaging alternatives for soft tissues are CT scanning, MRI, and ultrasound. X-rays helps in determining the type & extent of a fracture, helps in detecting pathological changes in the lungs,& with use of radio-opaque contrast media(such as Barium),can visualise structures of the stomach & intestines. Helps in diagnosing ulcers or certain types of colon ulcer. A general practitioner should know about what type of x-ray or scanning is required in a particular condition or part of the body. Simple disorders like fractures, dislocations, bone tumours, congenital & nutritional deformities of bone, arthritis, vertebral disc prolapse, peptic ulcer through barium meal x-ray, pulmonary tuberculosis, enlargement of heart, aortic aneurysm, intestinal perforation, intestinal obstruction, foreign bodies in the GI tract, dental disorders etc. can easily be diagnosed by studying & observing a few films of x-ray. Dental x-ray plays a major role in identifying root infection, abnormal dentition, identification of the individual in medico-legal cases etc. Since 2005, x-rays are listed as a carcinogen by many governments. The use of x-rays as a treatment is known as Radiotherapy & is largely used for the management (including palliation) of cancer; it requires higher radiation energies than for imaging alone.
  15. 15. P A G E | 15 RISKS IN X-RAYS X-rays are relatively safe method of investigation & the radiation exposure is relatively low, depending upon the study. Experimental & epidemiological data, however, do not support the proposition that there is a threshold dose of radiation below which there is no increased risk of cancer. Diagnostic x-rays account for 14% of the total annual radiation exposure from man-made & natural sources worldwide. It is estimated that the additional radiation will increase a person’s cumulative risk of getting cancer by age 75 by 0.6-1.8%. The amount of absorbed radiation depends upon the type of x-ray test & the body part involved. CT & fluoroscopyentail higher doseof radiation than do plain x-rays. To place the increased risk in perspective, a plain chest x-ray or dental x-ray will expose a person to the same amount from background radiation that we are exposed to (depending upon location)everyday over 10 days. Each such x-ray would add less than 1 per 1,000,000 to the lifetime cancer risk. An abdominal or chest CT would be the equivalent to 2-3 years of background radiation, increasing the lifetime cancer risk between 1 per 10,000 & 1 per 1000. These numbers are very small compared to the roughly 40% chance of developing any cancer during over lifetime. Father’s exposed to diagnostic x-rays are more likely to have infants who contract leukaemia, especially if exposure is closer to conception or includes two or more x-rays of the lower gastro-intestinal (G.I) tract or lower abdomen. This side effect was misused by Hitler’s doctor in concentration camps to sterilize the Jew prisoners to eliminate the generations. These prisoners were made to fill a lengthy questionnaire at a special counter, taking few hours & for the same duration, a heavy x-ray radiation from a hidden source was focused on their pelvic areas. By the time they left the counter, irreversible damage had been done to the testicles, turning most of them sterile. (The risk of radiation is greater to unborn babies, so in pregnant patients, the benefits of the investigation (x-ray) should be balanced with the potential hazards to the unborn foetus.)
  16. 16. P A G E | 16 SAFETY WITH X-RAY APPARATUS Whenever a patient undergoes an x-ray or nuclear medicine investigation, a dose of radiation is given. As a general principle it is expected that the dose given is as low as reasonably possible for a diagnostic image to be obtained. Numerous laws govern the amount of radiation exposure that a patient can undergo for a variety of procedures, & these are monitored to prevent any excess or additional dosage. Whenever a radiograph is booked, the clinician ordering the procedures must appreciate its necessity & understand the dose given to the patient to ensure that the benefits significantly outweigh the risks. Investigations must be carried out judiciously, based on a sound clinical history & examination, for which an understanding of anatomy is vital. PRINCIPLES OF RADIATION SAFETY 1. MINIMISE EXPOSURE TIME Ensure all personnel minimise time spentclose to machine. 2. MAXIMISE DISTANCE FROM SOURCE Exposure falls at the square of distance from source. The longer the distance, the lowerthe dose. 3. USE CORRECTSHIELDING Most analytical x-ray machines have adequate shielding provided. It is important to periodically verify that shielding is functioning properly. Never tamper with or alter shielding. 4. FOLLOW MANUFACTURERS INSTRUCTIONS 5. FOLLOW THE “ALARA”PRINCIPLE Keep dose As Low as Reasonably Achievable.
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