Basic Principles of Radiology

As the majority of fractures are closed

fractures, the assessment needs to involve the Basic
Basic Principles
Principles of
of Radiology
Radiology
use of some form of imaging technology to be
able to visualise the fracture.

There are a number of different images a

doctor can get – Standard X-ray, CT scan,
Fluoroscopy or a MRI. The purpose of this
chapter is to understand the differences
between these images and why a surgeon might prefer one particular image over another
type.

X-rays
X-Rays
X-Rays
For the majority (if not all) patients entering an
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gamma irradiation. This is the part of the
electromagnetic spectrum where the
wavelengths are very short. As visible light is
also part of the same spectrum, the technology
behind X-ray machines is very similar to X-Rays
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Gamma irradiation is released from an

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unstable isotope and is absorbed by objects
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that lie in front of the source. The greater the

Negative
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image

density of the object, the more gamma

irradiation is absorbed. So, if a photographic
plate is placed behind the object an image is
created where the “picture” is created by the differences in densities of the various parts of
the object that is between the source and the photographic plate.

Due to the differences in density, it is possible for the surgeon to identify four basic types of
human tissue in the body – Bone, Organs, Fat and Air.
Air has virtually no density, therefore,
very little gamma irradiation is
absorbed. As a result, the image on an
X-ray corresponding to the presence of
air is black. This means that it is
possible to identify the lungs and
pockets of gas in the patient’s digestive
system.

Fat is denser than air and so absorbs

some of the gamma irradiation. As a result, fat appears as a dark grey material on an X-ray.
Obviously, the thickness of fat will have an impact on the amount of gamma ray absorption,
so this will affect the shade of grey that
is seen on the X-ray.

Organs contain blood and other

intracellular fluids. The water content is
denser than fat and so, organs will
absorb more of the gamma irradiation.
As a result, on X-ray organs will appear
as a lighter shade of grey than the fat.

Bone contains mineral salts which

make it very dense. Therefore, bones
absorb the most amount of gamma irradiation. This means that bones are the easiest to
identify on X-ray as they appear as a very light grey colour.

Finally, if a patient has had previous surgery, then the metal implants, which are even
denser than bone, will appear on X-ray as a white object.

Here is an example of an X-ray and from

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this it is possible to identify air, organs,

Heart
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When taking an X-Ray, the radiation AP
AP X-Ray
X-Ray
source is typically in front of the patient and
the photographic plate lies behind the part
of the anatomy that the doctor wants to
examine. This is called an AP (front to
back) X-ray.

As the bones are 3-D structures and an X-

Ray is only a 2-D picture, surgeons usually take two views, one is the AP view in the
coronal plane and the other is the lateral view in the sagittal plane

Standard
Standard X-ray
X-ray Views
Views Standard
Standard X-Ray
X-Ray Views
Views
AP
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This example of a finger clearly illustrates why the two views might be important. In
one view, the finger looks like the bones are correctly aligned, whereas in the second
view the dislocation of the bones can be seen more clearly.

Fluoroscopy

A fluoroscopy is an image that is taken by Fluoroscopy

Fluoroscopy
a “C-Arm” in the theatre. This is the same An
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the negative image of the X-ray. What this These

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images
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of
an
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means is that bones are dark in colour X-Ray.

instead of being white, as they appear on

an X-ray.
CT

Computerised Tomography (CT or

CAT) is also based on X-ray
technology. This is used by doctors
when they want an axial or 3D view of
the body. An X-Ray and detector are
rotated around the body and a
computer analyses the image to
create axial or 3 D slices of the body.
CTs are very good at looking at crush type injuries where the bone has broken into a
number of fragments as an axial slice makes it easier to see the amount of
fragmentation.

MRI

Magnetic Resonance Imaging (MRI) is

safer for the patient (but is much more
expensive) than an X-ray as it does not
involve ionising radiation. What happens is
that a very strong magnetic field forces the
hydrogen atoms in the body to align their
magnetic direction with the magnet. A burst
of radiowaves causes the hydrogen atoms
to return to their natural orientation and this
results in each atom releasing a tiny amount of energy. This energy is detected and
from the analysis it is possible to create
an image of the body.

Because the greatest source of

hydrogen atoms in the body is the
water content, MRI Scans are very
good at identifying changes in the soft
tissues or bleeding. This means that it
is used to identify difficult to see
fractures such as stress fractures, fractures due to tumours and conditions such as
Avascular Necrosis (AVN).

Summary

CT and Fluoroscopy are based on X-ray technology. This involves a radiation source
emitting gamma irradiation which is absorbed by the body. As the bone is very
dense, any changes to the bony structure are very clear on the resulting image.
However, the downside is that the patient is exposed to radiation.

MRI is not based on radiation and is very good at identifying changes to the parts of
the body that contain water or fluid. This technology can be very effective at
identifying whether fractures are normal or pathological and whether the body’s
natural response of bleeding is responding to the fracture.