How to Read X-rays
Tracy Evans Gilbert –Paediatrics/HIV/Tropical Medicine
Principles of reading X-rays
Be Systemic • Have a Systematic Approach
• Interpret your findings along with the
Interpret clinical information
• Compare with a previous x-ray if
Compare available
RELATIVE DENSITIES ON XRAY
The image seen results from differences in densities on the chest
radiograph. From least ( black) to greatest density ( white)
• GAS ( Air in the lungs)
• FAT ( soft tissue) BONE
• WATER( same as heart and vessels)
AIR
• BONE ( the most dense)
• METAL ( foreign bodies
WATER
Relevance of densities
The loss of clarity of a
The borders, outlines and structure, suggests that
edges depend on two there is adjacent soft tissue
adjacent areas of different shadowing even when the
density abnormality itself is not
clearly visualised
Indications for thoracic radiograph
• Infection: exclude pneumonia, positive Mantoux test
• Major trauma: exclude widened mediastinum, pneumothorax and
haemothorax
• Acute chest pain: exclude pneumothorax, perforated viscus, aortic
dissection
• Asthma/bronchiolitis: when diagnosis unclear and/or not responding to
usual therapy
• Acute dyspnoea: exclude heart failure, pleural effusion
• Chronic dyspnoea: exclude heart failure, effusion and interstitial lung
disease
• Haemoptysis
• Suspected mass, metastasis or lymphadenopathy
Before interpreting
the X-ray: IDENTIFY
• Name
• Date
Identify Patient • View
IMAGE QUALITY
Assess the image
quality
Posterior Anterior ( PA)
FOUR Anterior Posterior(AP)
MAJOR
VIEWS OF Lateral
THE CXR Lateral Decubitus
The standard chest X-Rays consists
of a PA and lateral chest X-Ray
POSTERIO ANTERIOR (PA )VIEW
Patient stands upright facing the front of the film in full inspiration
Anterior Posterior
• Used when patient is debilitated ,
mobilised or unable to cooperate (
e.g. child)
• Film is placed behind the patients
back ( supine/ sitting)
• Heart is a greater distance from
the film so it appears larger than
PA.
• Hence generally should not
comment on the cardiac silhouette
on an AP
Compared with the PA the Scapula are usually visible in the lung field of the AP
John Brown
John Brown
October
October
31,2020
31,2020
ERECT SUPINE
• The pulmonary vasculature is altered when patients are examined in the supine position.
• The size of the pulmonary vasculature is more homogeneous throughout the upper and the lower lobes.
• Mediastinal structures are widened because of gravity in the semi erect /supine position
Before interpreting
the X-ray: IDENTIFY
• Name
• Date
Identify Patient • View
IMAGE QUALITY
Assess the
image quality
Rotation
IMAGE QUALITY- Inspiration
RIPE Penetration
Exposure
John Brown
October 31,2020
ROTATION
• The clavicles should
appear symmetrical
and be seen as equal
length.
• Measure the distance
from the medial end
of each clavicle to the
spinous process of the
vertebra at the same
level
Inspiration
On good inspiration,
the diaphragm should
be seen at the level of
the 8th – 10th
posterior rib or 5th –
6th anterior rib.
Penetration
• Ideally, you should be able to see the heart,
the blood vessels, and the intervertebral
spaces.
• one should barely see the thoracic
vertebrae behind the heart
• Exposure should be adequate if you are
able to see approximately T4 vertebra and
spinal process.
John Brown
Penetration October
31,2020
Underexposed PA X-
Ray film. Thoracic
vertebrae not
appreciated.
Exposure
One needs to be
able to identify
lung apices at the
top and
costophrenic
angles at the
bottom
John Brown
October
31,2020
Review
• This is the PA Erect Chest Xray of
John Brown , taken on October
31 2020
• The film is not Rotated
• There is adequate inspiration
• There is adequate penetration
and adequate exposure
• Airway: trachea, carina, bronchi and hilar
structures.
• Bone and soft tissue
• Cardiac: heart size and borders.
SYSTEMATIC • Diaphragm
RADIOLOGICAL • Effusion
• Fields
CHECKLIST • Gastric bubble
• Hilum
A- Airway
• Ensure trachea is visible and in
midline
• Trachea gets pushed away from
abnormality, eg pleural effusion,
tension pneumothorax ,
mediastinal tumor or
lymphadenopathy
• Trachea gets pulled towards
abnormality, eg atelectasis,
collapse of a lung segment
• Check for widened mediastinum
Tracheal deviation
Diagram on the left shows
a pneumothorax pushing
the trachea to the right.
Note the density of air on
the right , lack of lung
markings and displacement
of the heart to the left
Diagram on the right shows
pleural effusion pushing
the trachea to the left
Clavicle
Scapula
Rib
Vertebra
• Check clavicle , ribs, humerus, thoracic spine
BONES AND • Check for fractures, dislocation, subluxation,
SOFT TISSUE osteoblastic or osteolytic lesions or
osteoarthritic changes
Subcutaneous Pneumo peritonium
emphysema
C-CARDIAC
CARDIAC DENSITY
Left basal
consolidation
and effusion
• Both diaphragms should form a sharp margin with the
Diaphragm lateral chest wall and heart
• Right hemidiaphragm should be higher than the left
Diaphragm
• If much higher, think of
effusion, lobar collapse,
diaphragmatic paralysis
• If you cannot see parts of
the diaphragm, consider
infiltrate or effusion
Effusions
• The pleural space is only visible when there is an abnormaility
• Look for blunting of the costophrenic angle
• Identify the major fissures, if you can see them more obvious than usual, then this could mean that fluid is tracking along the fissure
• Look for thickening, loculations, calcifications and pneumothorax
EFFUSION
FIELDS
• Check for infiltrates
• Identify the location of infiltrates by use of known radiological phenomena, eg loss of heart borders or of the contour of the diaphragm
• Remember that right middle lobe abuts the heart, but the right lower lobe does not
• The lingula abuts the left side of the heart
LUNGS
• Identify the pattern of infiltration
• Interstitial pattern (reticular) versus
alveolar (patchy or nodular) pattern
• Lobar collapse
Fields • Look for air bronchograms, tram
tracking, nodules, Kerley B lines
Pay attention to the apices
• Check for granulomas, tumour and
pneumothorax
AIR BRONCHOGRAM
• When the internal tubular outline is visible within a thoracic opacity – that is an air
bronchogram
• It is most commonly associated with a simple pneumonia
• Sometimes it occurs with pulmonary oedema
GASTRIC
BUBBLE
Check correct position
Look for free air
Look for bowel loops between
diaphragm and liver
Hilum and
Mediastinum
• Check the position and size
bilaterally
• Enlarged lymph nodes
• Calcified nodules
• Mass lesions
Hilum
Hilar node
• Airway: trachea, carina, bronchi and hilar
structures.
• Bone and soft tissue
• Cardiac: heart size and borders.
It’s not a lung • Diaphragm
Xray • Effusion
• Fields
It’s a chest Xray • Gastric bubble
• Hilum and mediastinum
• This is the PA Erect Chest Xray of John Brown ,
taken on October 31 2020
• The film is not Rotated
• There is adequate inspiration ,adequate
penetration and adequate exposure( evidence)
• No prior imaging is available for comparison.
Presenting a • The trachea is central
• There are no bony or soft tissue abnormalities
chest xray • The cardiac silhouette is normal
• The cardio phrenic and costophrenic angles are
normal
• The diaphragm is normal
• There are no effusions , lung fields are clear and
hilum appears normal
• In summary, this is a normal plain radiograph
of the chest
ABDOMINAL XRAYS
Indications for plain abdominal radiograph
• to evaluate and diagnose the source of acute pain in the abdominal region
and/or lower back
• unexplained nausea and vomiting.
To help diagnose conditions such as:
• kidney and urinary bladder stones and gallstones
• intestinal blockages
• perforation of the stomach or intestine
• ingestion of foreign objects
To help properly place catheters and tubes used for feeding or to
decompress organs such as the gallbladder and kidneys.
Before interpreting the X-ray:
Identify Patient and Assess the image quality
IDENTIFY
• Name
• Date
• View
IMAGE QUALITY
• Anterior-posterior (AP) SUPINE
• Anterior-posterior (AP) ERECT
• If bowel perforation is being considered, an
erect chest X-ray is required
VIEW • this allows free gas under the diaphragm to
be identified
• the patient needs to have sat upright for at
least 15-20 minutes prior to the X-ray to
allow time for the air to rise.
• Assess the X-ray to ensure the whole
abdomen is visible from the level of the
diaphragm to the pelvis.
• Ensure the exposure is adequate to allow
Image radiological assessment of both the small
and large bowel.
• Abdominal X-rays do not provide a good
view of posterior abdominal structures
due to overlying bowel and gas.
• BOWEL and other organs: small bowel,
STRUCTURED large bowel, lungs, liver, gallbladder,
stomach, psoas muscles, kidneys, spleen
APPROACH TO and bladder.
INTERPRETATION. • BONES: ribs, lumbar vertebrae, sacrum,
coccyx, pelvis and proximal femurs.
The BBC Approach
• CALCIFICATION and artefact (e.g. renal
stones)
SMALL AND LARGE BOWEL-
How to tell the difference
• The small bowel usually lies more centrally,
with the large bowel framing it.
Small bowel
• The small bowel’s mucosal
folds are known as valvulae
conniventes and are visible
across the full width of the
bowel.
Large bowel
• The large bowel wall features pouches or
sacculations that protrude into the lumen,
known as haustra.
• In between the haustra ( black arrow) are
spaces known as plicae semilunaris ( white
arrow).
• The haustra are thicker than the valvulae
conniventes of the small bowel and typically do
not appear to completely traverse the bowel
but this is not a reliable feature
Solid organs
which may be
visible
Faeces
• Faeces have a mottled appearance and are
most often visible in the colon, due to
trapped gas within solid faeces.
Bones
• bones are useful landmarks which allow you to approximate the location of
soft tissue structures
• e.g. the ischial spines are the usual level of the vesicoureteric junction
Bony structures commonly visible on abdominal X-ray include:
• Ribs
• Lumbar vertebrae
• Sacrum
• Coccyx
• Pelvis
• Proximal femurs
Renal calculi
Calcification
Staghorn calculi
• This is a supine AP abdominal radiograph
of Michelle Dyer , date of birth 16th
January 1988.
• The film is of good quality with adequate
Presenting exposure.
• No prior imaging is available for
an comparison.
• Both the small and large bowel appear
abdominal within normal limits.
• Other abdominal viscera appear normal
xray within the limits of this projection.
• No obvious bony pathology is identified.
• No abnormal calcification is visible.
• In summary, this is a normal plain
radiograph of the abdomen
Small bowel
obstruction (note the
dilated loops of small
bowel creating a
Coiled spring “coiled-spring”
appearance
appearance).
air in the bowel wall
Pneumotosis intestinalis
↑
pneumoperitoneum
Faeces in the bowel
Note the air in the faeces
a) The air pattern is markedly abnormal,
showing multiple signs of
pneumoperitoneum.
b) Rigler’s sign -both sides of the bowel
wall are seen. c
c) The outline of the falciform ligament
b
is also seen. a
• All of these signs are the result of free
air (low density) being directly next to
another structure of higher density
Principles of reading X-rays
Be Systemic • Have a Systematic Approach
• Interpret your findings along with the
Interpret clinical information
• Compare with a previous x-ray if
Compare available
