PoI 4 Distortion

Principles of
IMAGING
Danni John P. Braña, RRT
“God is our refuge and
strength, an ever-present
help in trouble.”
—Psalms 46:1
DISTORTION
01
ASSESSING
DISTORTION
Assessing Distortion
Distortion is the second of the two
geometric properties affecting
radiographic image quality. Unlike
the photographic properties of
density/image receptor (IR)
exposure and contrast, which
control the visibility of detail, the
geometric properties control
detail itself.
Distortion is a misrepresentation
of the size or shape of the
structures being examined. It
creates a misrepresentation of
the size and/or shape of the
anatomical part being imaged.
This misrepresentation can be
classified as either size or shape
distortion.
Distortion, like detail, exists even when it cannot
be seen due to poor visibility or, in other words,
when the density/IR exposure and/or contrast are
poor. The evaluation and adjustment of distortion
require a thorough familiarity with normal
radiographic anatomy. Unless the normal size and
shape of a structure are known, comparison of the
size and shape cannot be accomplished.
Distortion can be difficult to
determine even when normal sizes
and shapes are known. Because the
objective of radiography is to
provide accurate images of
structures, methods of
minimizing distortion are
important to diagnosis.
The factors that control distortion are shown in
Figure 29-1. Careful examination of these
factors will reveal that distortion is directly
related to positioning. Only careful attention to
the distances, direction, and angulation
between the anatomical part, central ray, and
image receptor can minimize distortion.
02
FACTORS
AFFECTING SIZE
DISTORTION
Factors Affecting Size Distortion
Magnification is the only possible size
distortion in radiography. During acquisition of
the image, minification is impossible, due to
the divergent property of x-ray photons.
Because it is not possible to reflect or refract x-
ray photons by ordinary methods, they can
only diverge from their point source.
Thus, only magnification is
possible and all size distortion
is controlled by the
radiographic distances, SID and
OID. In digital image receptor
systems postprocessing can
resize the image.
In all instances, reduced
magnification size distortion
increases the resolution of recorded
detail. Therefore, the objective in
most radiography is to minimize
magnification as much as possible.
Magnification radiography is an
exception to this
rule.
In this instance, the principles of
magnification geometry are used to
increase the size of structures that
are too small to be easily
visualized. Special conditions
must be created to achieve
diagnostically acceptable
magnification
images.
Magnification size distortion
is controlled by positioning
the body part and tube to
maximize SID while
minimizing OID. This can be
accomplished by various
procedures and by
positioning.
For example, an upright oblique
cervical vertebra projection can be
performed at 72” (180 cm),
whereas a supine projection is
performed at 40” (100 cm). An AP
chest may place the heart 6” (15
cm) from the image receptor,
whereas a PA projection would
place it 2” (5 cm)
away.
Source-to-Image Receptor Distance
The SID has a major effect on
magnification (Figure 29-2).
The greater the SID, the smaller
the magnification, because as
SID increases, the percentage
of the total distance that
makes up OID decreases. The
OID is the critical distance for
magnification and resolution.
Although 40” (100 cm) has developed as the
current routine SID, this was not always so. The
popular SID has been increasing since the
advent of radiography and will probably
continue to do so. The first x-ray techniques
book in the United States is generally
recognized to be the 1918
, in which 20”
(50 cm) is discussed as a reasonable SID.
When Ed Jerman developed the first positioning
and technique book, , in 1928, he
recommended distances varying from 25” (63 cm)
to 36” (90 cm). Of course, in those days shorter
distances were necessary because the x-ray tubes
were not capable of handling the load required to
provide sufficient density/IR exposure with the film
and screens of the time. As generator technology
advanced, the SID increased.
Glenn Files’s 1945 book,
Medical Radiographic
Technic, established the 40”
(100-cm) SID. For over 65
years this has remained the
standard distance, but there
are institutions that use 48”
(120 cm) as a routine
distance, and the movement
appears to be growing.
Although a change demands
new grids as well as careful
consideration of x-ray unit
design so that tube-to-tabletop
distances can be achieved, and
low table design so that
radiographers can reach the
tube, the increased resolution is
worth the expense and trouble.
For many, many years chest
radiography has routinely
been performed at 72” (180
cm) because the erect
positioning arrangement
permits a horizontal beam to
be used and the increased
SID effectively minimizes
the magnification of the
heart shadow.
Any examination that
Source-to-Image Receptor
Distance
permits a horizontal
beam to be used can
easily be established at
an SID greater than 40”
(100 cm), and in many
places the lateral cervical
vertebral examination is
performed at 72” (180 cm)
as well.
The source-to-object
distance (SOD) is seldom
discussed because it is
included in descriptions of SID
and OID, which are more
critical. The SID is the distance
that must be established by
the radiographer when
positioning.
The SID must be maximized to
Source-to-Image decrease magnification.
Receptor Distance
Examinations of body parts
with large inherent OID, such
as the lateral cervical vertebra
and the chest, use large SID
whenever possible. In
addition, the historical trend
to increase the routine SID
should be continued.
Object-to-Image Receptor Distance
The OID is also a critical distance in
both magnification and resolution. Figure 29-3
illustrates two major facets of OID. First, when
objects within a structure are at different levels
(Figure 29-3, objects A and B), they will be projected
onto the image as different sizes. This is similar to
the manner in which the eye processes information
for depth perception; smaller objects are perceived
as more distant and larger objects as closer.
The radiographer should
develop a stereoscopic
Object-to-Image perception of the radiographic
Receptor Distance image, which is difficult
because radiographic
perceptions are in reverse of
the normal information the eye
is accustomed to processing.
This is because objects that are
further from the image receptor
will be magnified.
For example, in a chest radiograph
the ribs are seen as wider as they
Object-to-Image become more posterior. This effect
Receptor should make them appear closer,
Distance which is the opposite of the truth
for the PA projection. Nevertheless,
the perception of three-
dimensionality can be developed
and then used to determine object-
to-image-receptor distance
visually.
When describing
objects, it is important
to remember that the
size and distance
relationship in a
radiographically
projected image is the
opposite of that
perceived visually.
A more important size relationship that is
controlled by OID is shown in Figure 29-3
between objects B and C, where object C appears
identical in size to object B. This is an illusion
because object C is much smaller but is
magnified more because of its location in the
part. This illustrates that a thorough knowledge
of normal radiographic anatomy is a prerequisite
to making judgments about size
relationships.
This is also one of the reasons
radiographic examinations must
include two projections, as close to 90°
from one another as possible. When
AP and lateral projections cannot be
performed because of superimposing
structures, as in an examination of the
kidneys, it is important to include two
oblique projections at 90° to one
another.
The two 90°
opposing images
can be used to
verify the
positional
relationship of
structures. This is
also a shape
distortion issue.
The OID is also important in
Object-to-Image dosimetry because it
Receptor Distance establishes the source-to-
entrance skin distance that is
the benchmark maximum
exposure to the patient.
Because OID varies with the
part size and position of the
patient, it accounts for the
increased exposure that is part
of many examinations.
For example, there is
a significant
difference in the OID
between an AP and a
lateral projection
(Figure 29-4). Note
that the SOD changes
dramatically in the
figure as well.
Obviously the entrance skin exposure would be
greater with the lateral, even if the same
exposure factors were used. Consequently, larger
patients receive a greater exposure simply
because their entrance skin surface is closer to
the source, making their SOD much less. The
increased mAs that is often used to provide
sufficient image receptor exposure then
increases the patient entrance skin exposure
even more.
The OID must be minimized to
decrease magnification.
Examinations of body parts
with large inherent OID, such as
the kidneys and chest, use
positioning techniques to
achieve as small an OID as
possible.
Calculating Size Distortion
Size distortion is present in any radiographic image
and can be measured very accurately by using
simple geometry. Magnification, or size distortion,
can be assessed by calculation of the magnification
factor. The magnification factor is the degree of
magnification and is calculated by:
𝑆𝐼𝐷
𝑀=
𝑆𝑂𝐷
where: M = magnification factor

The mnemonic device
shown can be used by
placing a fingertip over
the variable for which you
wish to solve and then
viewing the mathematical
relationship (see
discussion of Ohm’s law in
Chapter 3).
If the SID is 40” (100 cm) and the SOD is 30”

(75 cm), what is the magnification factor?
𝑆𝐼𝐷
𝑀=
𝑆𝑂𝐷
40" 100𝑐𝑚
𝑀= 𝑀=
30" 75𝑐𝑚
If the SID is 40” and the OID is 2”, what is the

magnification factor?
Because the SOD is not supplied, it

must be found by using the formula:
SID = SOD + OID
40” = SOD + 2”
SOD = 40” – 2”
SOD = 38”
If the SID is 40” and the OID is 2”, what is

the magnification factor?
𝑆𝐼𝐷
𝑀= 𝑆𝑂𝐷
40"
𝑀= 38"
The magnification factor permits calculation of
the actual size of an object that is projected as an
image by using the formula:
𝐼
𝑂=
𝑀
where, O = object size

I = image size
M = magnification factor
The following
mnemonic device
can be used.
If a projected image measures 5” and the

magnification factor is 1.02, what is the
size of the actual object?
𝐼
= 𝑀
5"
= 1.02
If object B in Figure 29-3 is 2” in diameter on the image and
is measured to be 3” from the image receptor (by using a
lateral projection), what is its actual size if the SID is 40”?
Because the SOD is not supplied, it must be found

by using the formula:
SID = SOD + OID
40” = SOD + 3”
SOD = 40” – 3”
SOD = 37”
𝑆𝐼𝐷
𝑀= 𝑆𝑂𝐷
40"
𝑀= 37"
𝐼
𝑂= 𝑀
2
𝑂= 1.08
If the image size and the object size are known, the
percent of magnification can be determined using
the following formula:
1−0
× 100 = 𝑝𝑒𝑟𝑐𝑒𝑛𝑡 𝑜𝑓 𝑚𝑎𝑔𝑛𝑖𝑓𝑖𝑐𝑎𝑡𝑖𝑜𝑛 𝑜𝑓 𝑡ℎ𝑒 𝑜𝑏𝑗𝑒𝑐𝑡
0
If an object measures 5 cm and the image measures 6 cm,
what would be the percent magnification of the object?
1−0
0
6−5
5
1
5
0.2 x 100 = 20 percent of magnification of the object
The magnification formula assumes that the
focal spot is a point source. Because it is not, when
the object size approaches the effective focal spot
size or smaller, special problems develop from
penumbral overlap (Figure 29-5). Therefore,
objects smaller than the effective focal spot
cannot be demonstrated and the magnification
formula must be modified to consider the width of
the focal spot.
Calculating Size
Distortion
03
FACTORS
AFFECTING SHAPE
DISTORTION
Factors Affecting Shape
Distortion
Shape distortion is the
misrepresentation by
unequal magnification
of the actual shape of
the structure being
examined (Figure 29-6).
Factors Affecting Shape Distortion
Shape distortion displaces the projected
image of an object from its actual position
and can be described as either elongation or
foreshortening. projects the
object so it appears to be longer than it really
is, whereas projects it so it
appears shorter than it really is.
Elongation occurs when the tube or the image
receptor is improperly aligned. Foreshortening
occurs only when the part is improperly aligned.
Changes in the tube angle cause elongation,
never foreshortening. Shape distortion often
results because structures lie normally at
different levels within the body.
Shape distortion
also occurs because of
the divergence of the
x-ray beam. The
projected length varies,
depending on the angle
between the object and
the diverging beam
(Figure 29-7).
Factors Adjustment of shape distortion
Affecting requires careful consideration of the
Shape beam-part-image-receptor
Distortion geometry involved in the
projection. This information must
be combined with a knowledge of
the normal projection of the
structures to determine exactly how
improvements can be
achieved.
Alignment
Alignment
Shape distortion can be caused or
avoided by careful alignment of the
central ray with the anatomical part and
the image receptor. Proper positioning
is achieved when the central ray is at
right angles to the anatomical part
and to the image receptor. This
means the part and the image
receptor must be parallel.
Alignment
When the position of the body part or object within
the body does not permit this alignment, creative
positioning must be utilized. The half-axial 30°
angulation of the cranium to demonstrate the
occipital bone, the 25° cephalad angulation of
the pelvis to demonstrate the sigmoid colon,
and the 10° caudad angulation of the coccyx
are all examples of routine procedures that
were developed to minimize distortion.
Alignment
Alignment adjustments involve bringing the tube
central ray, the part, and the image receptor back
into their correct relationship—part and image
receptor parallel to one another with the central
ray perpendicular to both. Incorrect centering
may occur from off-centering the tube
(misalignment of the central ray), incorrectly
positioning the part, or off-centering the
image receptor (Figure 29-8).
Alignment
Alignment: Central Ray
The central ray is the theoretical photon that
exits from the exact center of the focal
spot. Ideally the central ray is intended to be
projected perpendicular to both the anatomical
part and the image receptor. Whenever the
central ray is not perpendicular, some degree of
shape distortion will result.
This occurs in every image because only the
central ray is truly perpendicular. Any structure
that is not positioned at the central ray will be
distorted because of the divergence of the beam —
the farther from the central ray, the greater the
distortion. This applies as distance from the central
ray increases transversely as well as longitudinally.
For example, an AP pelvis
Alignment: Central Ray will have more distortion of
an object near the right
greater trochanter than an
object near the symphysis
pubis. This is why it is so
important to position
according to standardized
central ray locations.
Long bone length studies are an example of a
procedure developed to ensure accurate central ray
centering. The procedure shown in Figure 29-9 uses
a radiopaque ruler, positioned from above the hip
joint to below the ankle joint, as a measurement
control. Spot exposures of the critical joints—hip,
knee, and ankle—are then made with the central ray
perpendicular to the joint space to ensure accurate
measurement.
Centering away from the specified central ray
entrance point is equivalent to angling the tube
away from perpendicular because the entire
perspective of the anatomical part is distorted.
Some projections take advantage of this type of
distortion. For example, a PA lumbar projection uses
the divergence of the beam to open the lordotically
curved intervertebral joints (Figure 29-10).
The central ray is normally positioned
perpendicular to the anatomical part
and to the image receptor. When the
part is superimposed over other
structures, central ray angulation can
be a useful tool to provide a projection
that would otherwise be impossible to
differentiate from overlying structures.
The use of the semiaxial AP projection of the skull
to project the occipital region free of facial bone
superimposition is an example. Failure to
maintain the correct relationship between the part
and the image receptor will produce a projected
image that may not be comparable to norms and
is therefore useless in the diagnostic process.
Alignment
Alignment: Anatomical Part
The long axis of the anatomical part, or object, is
intended to be positioned perpendicular to the
central ray and parallel to the image receptor.
When these positions are incorrect, distortion
may occur. Elongation occurs when there is poor
alignment of the tube and/or image receptor.
Foreshortening occurs only when there is poor
alignment of the part (Figure 29-11).
Figure 29-11A
shows the
intended
relationships of
central ray,
part, and image
receptor.
In Figure 29-11B the entire object
is foreshortened because of the
improper part-to-image-
receptor relationship. In addition
to the entire object being
foreshortened, one end is more
magnified due to increased OID,
which indicates that size
distortion is also occurring.
In Figure 29-11C the entire object
is again foreshortened, with one
end being more magnified due
to increased OID. However,
because of the differences in
the actual size of the two ends,
the increased size distortion of
the smaller end makes both
ends appear the same size.
Note especially the vast differences in the
projected images of these anatomical part
relationships. Figure 29-11A projects an accurate
image. Figure 29-11B projects distortion of both
size and shape so the entire object is
foreshortened and the large end appears larger
than it really is. Figure 29-11C also projects
distortion of both size and shape but has distorted
the relationship so both ends appear
the same size.
The anatomical part is normally positioned with its
long axis perpendicular to the central ray and
parallel to the image receptor. As with the central
ray, some routine projections are designed to vary
from this standard to avoid superimposition.
Failure to maintain the specified relationships
between the central ray and the image receptor
can result in an image that is not comparable to
norms and therefore of limited value in the
diagnostic process.
Alignment
Alignment: Image Receptor
The image receptor is intended to be positioned
perpendicular to the central ray and parallel to the
anatomical part. As long as the image receptor
plane is parallel to the object, the only result of off-
centering of the image receptor is the clipping of a
portion of the area of interest. Although this will
usually result in a repeated exposure, there is no
distortion of image size or shape.
However, when the image receptor plane is not
parallel to the object, or if the central ray is not
centered to the part, serious shape distortion
results exactly as if the object were not parallel.
Figures 29-11D and E illustrate for the image
receptor the same examples shown for the object in
Figures 29-11B and C.
The image receptor plane is normally positioned
perpendicular to the central ray and parallel to
the anatomical part. Even in routine projections
designed to vary from this standard, the
specified relationships must be maintained to
obtain a useful diagnostic image.
Angulation
Angulation
Angulation refers to the direction and degree the
tube is moved from its normal position
perpendicular to the image receptor. Numerous
radiographic projections utilize angulation
to avoid superimposition of parts. The
semiaxial AP projection of the
cranium, tangential calcaneus, and
axial clavicle are all examples.
Angulation
The angulation of the tube is designed to cause
a controlled or expected amount of shape distortion
to avoid superimposition. As long as the specified
angulation is applied, the image is comparable
to norms and is of diagnostic quality.
Angulation of the tube also changes the SID,
which, unless compensated for by a new
SID, will produce a decrease in image
receptor exposure.
Direction
Direction
The most common direction of tube angle is
longitudinal. Longitudinal angulations are usually
termed when the tube is angled toward the
head of the patient, and when it is angled
toward the patient’s feet.
Some radiographic
tubes can also be
angled transversely Direction
(sometimes referred to
as “roll”). Transverse
angulations are usually
identified as right and
left (in reference to the
patient).
Direction The direction of the tube
angle is specified according to
patient position and must be
maintained as specified. When
the patient position is reversed,
the direction of tube angle must
also be reversed to maintain the
relationship. For example, 25°
cephalad for an AP projection is
identical to 25° caudad for a PA
projection.
Angulation
Direction: Degree
Degree is simply a method of describing the
exact amount of angulation and is usually stated
as the angle between the central ray and the
image receptor plane from the standard
reference point of perpendicularity. Because the
standard reference point is 90° from the patient’s
head, radiographic angles must be added or
subtracted from that point.
Direction: Degree
For example, 5° cephalad is 5° from
perpendicular, as is 5° caudad. It is important to
maintain the correct degree of angle specified
for a given procedure. Tube angulations also
change SID, which will produce changes in
magnification. Table 29-1 provides conversions
for common tube angulations.
Direction: Degree
Tube Angulation Overhead Scale True SID

50 39.8” 40”
100 39.4” 40”
150 38.6” 40”
200 37.6” 40”
250 36.2” 40”
300 34.6” 40”
350 32.8” 40”
Evaluating Shape Distortion
Evaluation Shape Distortion
Shape distortion is a more subjective
evaluation than size. It is much more difficult to
assess because there is no effect that can be
calculated, as in the magnification factor for
size distortion. Instead, the entire assessment
relies on the radiographer’s knowledge of
normal anatomy and the normal projected
images for each position.
03
EFFECT ON IMAGE
APPEARANCE
Effect on Image Appearance
Size
Size
Size distortion is generally a matter of
magnification (Figure 29-12). All
magnification involves a degree of loss of
resolution, even when special systems are
designed to minimize the loss.
Effect on Image Appearance
Shape
Shape
Shape distortion involves both elongation
and foreshortening and is a serious
alteration in the projected image (Figure
29-13). There are situations where shape
distortion can be used to advantage,
as in a tangential calcaneus
°
SUMMARY
Summary
Distortion is the second of the two geometric
properties affecting image quality. Unlike the
photographic properties of density/IR exposure
and contrast, which control the visibility of detail,
the geometric properties control detail itself.
Distortion is the difference between the
structures being examined and the
recorded image.
Summary
It creates a misrepresentation of the size and/or
shape of the anatomical part being imaged. This
misrepresentation can be classified as either size
or shape distortion. Distortion, like detail, exists
even when it cannot be seen due to poor
visibility or, in other words, when the
density/IR exposure and/or contrast
are poor.
Summary
The evaluation and adjustment of

distortion require a thorough familiarity
with normal radiographic anatomy. Unless
the normal size and shape of a structure are
known, comparisons of size and shape
cannot be accomplished.
Summary
When the factors that affect size and shape

distortion are altered, some change in distortion
will occur. No change will occur unless one of
these factors is altered. Table 29-2
illustrates the effect on distortion
when the various factors are
changed. ◾
Shape Distortion
+ Improper central ray alignment
Size Distortion Improper anatomical part
+
- Increasing SID alignment
+ Decreasing SID Improper image receptor
+
alignment
+ Increasing OID
Improper direction of central
- Decreasing OID +
ray angle
+ Increasing patient thickness Improper degree of central ray
+
- Decreasing patient thickness angle
THANKS
Does anyone have any questions?
dannijohnb.rrt@gmail.com
+63 926 038 7859
/dannijohnb
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Principles of

where: M = magnification factor

If the SID is 40” (100 cm) and the SOD is 30”

If the SID is 40” and the OID is 2”, what is the

Because the SOD is not supplied, it

If the SID is 40” and the OID is 2”, what is

where, O = object size

If a projected image measures 5” and the

Because the SOD is not supplied, it must be found

Tube Angulation Overhead Scale True SID

The evaluation and adjustment of

When the factors that affect size and shape

CREDITS: This presentation template was created by

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