Chapter 4: Principles of radiographic examination

In order to appropriately refer patients for radiographic examination and interpret the
resultant images, an understanding of the principles of image production, terminology and
how patient related factors (e.g. age; clothing; ability to co-operate) impact on the diagnostic
image quality are essential. This chapter provides a brief overview of conventional
radiographic imaging as it relates to musculoskeletal trauma. Later chapters consider the
review of radiographic images (Chapter 6) and the contribution of alternative imaging
modalities in trauma (Chapter 7).

X-ray Production
X-rays are one of the 7 types of radiation that make up the electromagnetic spectrum. They
are a high energy radiation with a short wavelength and are known to cause ionisation to
cells and tissue as they transfer through the body. As a result, X-rays, like Gamma radiation
and some ultraviolet light, are classified as ionising radiation and their use is governed in the
UK by the Ionising Radiations Regulations (IRR) (1999) [1] and the Ionising Radiation
(Medical Exposure) Regulations (IR(ME)R) (2000) [2] and by other bodies internationally.

Although X-rays occur naturally as a bi-product of radioactive decay or travel to Earth from
the sun, medical radiography produces X-rays in a controlled manner through the rapid
deceleration of fast moving electrons within the X-ray tube [3]. The strength and size of the
X-ray beam can be varied by changing the voltage and amperage applied to the X-ray tube.
As the X-rays pass through the patient’s body, some of the X-rays are completely absorbed.
This occurs mostly where the body tissues are dense (e.g. bone) and creates a white area
on the resultant image. Other X-rays pass through the patient’s body without loss of energy
and on reaching the image receptor create an area of blackness. This occurs most
commonly where the body tissues are least dense. Finally, some X-rays can be partially
absorbed within the patient’s body which means that the X-ray leaving the patients body has
less energy than the X-ray entering the body. These X-rays create the areas of different
‘greyness’ on the radiographic image, the lighter the shade of grey, the more energy having
been absorbed in the patients body.

Most radiographic imaging systems are now computerised rather than film based.
Consequently this and other contemporary texts will use the generic term of image receptor
rather than film or cassette. Image appearances can be altered by exposure factors and
post-processing algorithms as well as monitor resolution. Discussion of this aspect of
radiographic examination is beyond the scope of this book but there are several texts that
discuss digital imaging in detail available to interested readers. All clinicians should ensuer
they are confident in optimally using the computerised imaging equipment and Picture
Archiving and Capture Systems (PACS) in use locally.

Radiography of musculoskeletal structures

Radiographic images are a 2 dimensional display of 3 dimensional structures. Radiography
of musculoskeletal structures usually involves the production of at least 2 radiographic
images undertaken at 90o to each other (e.g. antero-posterior (AP) & lateral radiographs) to
improve the likelihood of trauma detection. This is particularly important where fracture
displacement is in a single plane and therefore visible on only 1 projection (figures 4.1a&b)

Fig 4.1a: AP radiograph (ankle) no fracture seen

Fig 4.1b: Lateral radiograph (ankle) – fracture fibula visualised

Sometimes, obtaining images at 90o to each other is not helpful for initial diagnosis. This is
particularly true where multiple bones are likely to be projected over each other on the
resultant image (e.g. hand; foot). Where this is the case, an oblique or other alternative
projection rather than a lateral radiograph is undertaken (figures 4.2a,b&c).

Fig 4.2a: DP hand radiograph

Fig 4.2b: Oblique hand radiograph
Fig 4.2c: Lateral hand radiograph

Supplementary, or non-AP, radiographic images can be difficult to diagnose, particularly if

the clinician is uncertain of the position of the patient at the time of imaging. For some
radiographic projections, the X-ray beam is not perpendicular to the anatomy being
examined and this can result in anatomical elongation or foreshortening and distort the
appearances of any pathology or trauma (see figure 4.3). Consequently, when referring for,
and interpreting, radiographic images, it is important that the clinician understands the
orientation of the anatomy as it is projected in the image in order to optimise the accuracy of
diagnostic interpretation.

Fig 4.3: Effect of X-ray tube angles on image appearances

The glossary of terms at the end of the book will assist in understanding radiographic
terminology and its implication for patient position at the time of radiography. However,
clinicians wanting to improve there knowledge in this area are recommended to spend some
time in the emergency care imaging department to observe radiographic practices.

Common problems experienced when imaging trauma patients

Patient condition and mobility
Patients referred for radiography from the emergency department (ED) may have limited
mobility as a consequence of their injuries. Sometimes, patient injuries prevent transfer to
the X-ray department for imaging and mobile radiographic examination is undertaken within
the ED. In this situation, the patient is usually positioned supine upon an ED trolley and a
variety of tubes, lines and wires may overlie the area of interest. Movement of the patient
may be contraindicated (due to injury or intervention) and radiography is undertaken with the
patient in a supine position. Depending on the radiographic equipment available, trolley type
and surrounding environmental space, the resultant radiographic images may appear
magnified and contain a number of artefacts related to patient clothing, trolley mattresses,
lines and wires. In addition, anatomical appearances (particularly visceral structures) will
vary from standard projections due to the supine orientation of the patient. All of these image
variations can distract the observer and radiographic pathology can easily be missed.

Even where patients are well enough to attend the X-ray department for radiographic
imaging following injury, patient presenting condition may still require radiographic technique
to be modified in order to achieve appropriate diagnostic images. In addition, the mode of
patient transport may also influence the radiographic technique adopted and because
patient movement is often contraindicated (due to injury or intervention), patients may be
imaged in the position, and on the transport on which they have arrived in the department,
using modified radiographic techniques. The resulting images will not be in standard
orientation and clinicians should be aware of the impact on resultant image appearances, as
abnormal appearances may be overlooked and normal anatomy mimic pathology.

Artefacts
Artefacts are commonly seen on trauma radiographic images as a consequence of the injury
mechanism (e.g. dirt or gravel in a wound), patient clothing or medical intervention. Artefacts
can easily distract from the anatomical information on a radiographic image and it is
important that the presence of artefacts is minimised through removal of clothing and
jewellery, use of radiolucent support pads and minimal use of dressings and bandages prior
to imaging (figures 4.4 & 4.5). Some artefacts cannot be controlled for or removed and
where this is the case, sub-optimal diagnostic images may result

Fig 4.4: Lateral cervical spine with head support artefact

Fig 4.5: AP knee with clothing artefact
Patient Co-operation
Successful radiographic examination often depends on patient co-operation. Where a patient
is unconscious, radiographic technique modification must take additional account of patient
immobilisation and safety. Similarly, where a person is exhibiting signs of depressed or
altered consciousness as a result of injury or drug/alcohol misuse, the radiographer must
make an assessment as to the ability of the patient to co-operate in order that a diagnostic
image can be achieved. A general rule of thumb is that if a patient is difficult to assess
clinically, then the patient is likely to be difficult to image successfully.

Patient Age
Patient age can significantly impact on radiographic techniques, particularly when imaging
young children and the elderly. Ability to communicate, consent to examination and follow
instruction all impact on the success of radiographic imaging. In many cases, a compromise
between image quality and patient radiation dose must be made, particularly in young
children. However, age and its associated issues should not be used as an excuse for poor
radiographic practice and clinicians must ensure that the images presented are appropriate
and of sufficient quality to answer the clinical question posed.

Age is also an important factor when reviewing radiographic images. Radiographic

appearances vary with patient age. Incomplete ossification in children or degenerative
changes in the elderly can create interpretive confusion. As a large proportion of patients
attending the ED are children or elderly, a general knowledge and understanding of these
appearances on radiographs is essential to accurate radiographic interpretation.

In children, knowledge of secondary ossification and fusion patterns are essential.

Secondary ossification centres occur at different, but predictable, ages depending on their
anatomical location. However, many can appear fragmented as a normal variant and this
can create confusion (figure 4.6). The delayed appearance of ossification centres or
inconsistent development may indicate pathology and should be noted (figure 4.7).

Fig 4.6: normal calcaneal apophysis

Fig 4.7: Perthes – abnormal epiphysis fragmentation

Fusion patterns are often less confusing although occasionally suspicion may be aroused by
secondary ossification fusion appearances, particularly around the elbow where a normal
epicondyle fusion pattern can suggest bony avulsion to the novice clinician (figure 4.8).

Fig 4.8: The lateral epicondyle is fused to the capitellum but not yet fused to the lateral condyle. This
can be mistaken for a fracture
In the elderly, arthritic changes are the main cause of interpretation problems in the trauma
situation. Joint space narrowing, osteophytic spurs, changes in bone density, development
of bone erosions and disruption to joint alignment may all be related to arthritic disease and
can mask injuries. In these cases careful scrutiny of the radiographic images is essential.
Where clinical suspicion is high, orthopaedic or rheumatology referral may be appropriate.

Summary
Emergency department radiographs do not, by the very nature of injury, represent textbook
anatomical ideals and technique modification often results in non-standard images being
undertaken to achieve a diagnostic image. ED clinicians need to have a basic understanding
of radiographic technique and positioning in order to accurately interpret trauma radiographic
images. However, where uncertain of patient orientation or anatomy displayed, radiography
staff will be able to explain the imaging appearances and assist with differentiating normal
from abnormal anatomical appearances.

References
1. British Government Statutory Instrument (1999) No 3232. Ionising Radiation
Regulations 1999. HMSO: London

2. Department of Health (2000) The Ionising Radiation (Medical Exposure) Regulations

2000. HMSO: London

3. Dixon AM (ed) (2008) Fundamentals of Diagnostic Imaging: An introduction for

nurses and allied health professionals. Reflect Pres Ltd: Exeter.