Lec2 X-Rays and Fluoros

X-Rays and
Fluoroscopy
What Is an X-ray?
 X-rays are a form of electromagnetic energy formed

when high-speed electrons bombard a tungsten anode
target. Like light energy, these useful rays have
properties of waves and particles. However, X-rays have
a much shorter wavelength than visible light, allowing
them to penetrate matter.
How can X-rays produce images of
internal structures of the body?
 Differences in body tissue densities are what allow us to

"see" inside the body by creating a shadow gram. The
body is composed of tissues containing many different
elements, which vary by atomic number (the number of
protons in the nucleus). The higher the atomic number,
the denser the element and the more effectively the X-
ray is blocked. Therefore, specific shadows of internal
body structures become visible because they contain
varying types of elements.
What are the five basic radiographic
densities?
 Metal (Bright white)
 Mineral (White)
 Fluid/soft tissue (Gray)
 Fat (Dark gray)
 Air (Black)
 The higher the atomic number of the matter, the more the X-rays
will be blocked from reaching the film. (N = atomic number =
number of protons in the atom of an element.) Metal and mineral
density
 X-ray pass through are least absorbed and cause the most
blackening of the Radiograph, Calcium absorbs most, so bone and
other calcified structures appear virtually white
 Soft tissues with the exception of Fat have similar density and appears same
shade of grey. Fat absorbs slightly fewer xrays and appear blacker then the
other soft tissues. white coloration is called ‘opacity’ and black coloration is
‘lucency’.
 A bone or tumor, which is denser than soft tissue, allows few X-rays to pass
through and appears white on X-ray
 Projections are usually described by the path of X-ray beam. thus the term PA
(Postero Anterior) view designate that the X-ray beam is passed, is from back
to front(the standard projection of the chest.)
 AP(Antero posterior) view means that the beam is passing from front to
back .The image on an X-ray Film is two dimensional. All the structures along
the path of the beam are projected.
 On the same portion of the film overlapping each other, therefore it is often
necessary to take at least two views to gain information about the third
dimension.
Why PA view??
 The patient is positioned easily, its comfortable and

they keep still because they can lean on the detector
 It is easier to move the scapula out of the lung fields
 We get an image of the heart with reduced
magnification The heart is distorted by its position in the mediastinum but
you can assess the size of the heart on a PA you cannot on an AP
 There is reduced radiation dose to the anterior

radiosensitive organs
 Respiration is more effective when standing
 The anterior ribs are better defined to enable you to check the level of inspiration
 Fluid levels are defined more easily with the use of a

horizontal central beam
Why AP view??
 The patient is not well enough to get into the correct position
 They may be:
 unconscious on the Intensive Treatment Unit (ITU)
 Catheters and tubes for life support and monitoring
 Generally unwell or have learning or physical disabilities
 The patient is being barrier nursed eg COVID-19 patients
 The three elements of radiation safety:
 Time (Reduce to a minimum the time you spend around
an X-ray source)
 Distance (X-ray dose is inversely proportional to the
distance squared)
 Shielding (Aprons composed of metal that block X-rays)
What can happen when people are
exposed to radiation?
 X-rays can dislodge electrons from the shell of an atom.

This results in the production of an ion (free radical). A
free radical is an unstable molecule with an extra
electron.
 Free radicals become stable by donating their extra
electron to other molecules within cells of the body.
This process permanently damages protein, DNA and
other vital molecules. Among the ill effects reported
from radiation exposure are birth defects, cancer and
cataracts.
Basic concept: Analysis of any structure
or mass on a radiograph
 1. Size of the structure

 2. Shape or contour of a structure
 3. Position of the structure
 4. Density of the structure
 Note: In general, a mass or nodule is more likely to be
benign if it is small, smoothly marginated, and
calcified. A mass or nodule is more likely to be
malignant if it is large, irregular in contour, and dense
but not calcified.
How will I know if the X-ray is of
diagnostic quality?
 As physicians, we are responsible not only for the

pathology present on an X-ray, but also for ensuring
good-quality images through feedback to and
supervision of the technologists who perform the
studies. An overpenetrated (overexposed) radiograph is
too dark. X-rays can penetrate through subtle pathology
and obscure an important finding. A malignant
pulmonary nodule may be difficult or impossible to see
if the film is overpenetrated.
 An underpenetrated (underexposed) radiograph can
make normal structures such as bronchovascular
structures in the lungs look like pathology. The image is
too light or white-looking. Sometimes a patient
suspected to have congestive heart failure based on an
underpenetrated radiograph may be treated for CHF
unnecessarily.
 The patient should be orthogonal to the X-ray beam on
a PA or AP view. This means that the beam enters the
patient at 90 degrees and there is no patient rotation.
 On a well-positioned PA chest X-ray, the spinous process
at T1 should be equidistant from the medial ends of the
clavicles.
 Watch out for artifacts. Objects in clothing and hair and
on the skin create shadows that can mimic pathology. A
patient who was sent for a chest X-ray was chewing a
piece of gum, which he put on his upper back for safe
keeping. The resulting nodular- appearing opacity
caused quite a stir until the patient was examined and
the cause of the "lesion" was revealed.
How can I develop a
differential diagnosis?
 I like the mnemonic “VITAMINS D and C":
 V = Vascular
 I= Infection or Inflammation
 T= Trauma
 A = Autoimmune or Allergic
 = Metabolic
 I = Idiopathic or latrogenic
 N = Neoplastic
 S = Structural
 D = Developmental
 C = Cardiac
Indications Of X-Rays
SKULL
 CONGENITAL DISEASES
 PNS
 TRAUMA
MUSCULOSKELETAL
 TRAUMA
 INFECTION
 METABOLIC DISEASES
 INFLAMMATORY DISEASES
 DEGENERATIVE CHANGES
CHEST
 Pneumonia of different etiologies.

 Anomalies and malformations of the respiratory system.
 Traumatic lesions.
 Infectious-inflammatory diseases of the lung.
 Degenerative-dystrophic processes (acquired emphysema, and
others).
 Foreign bodies in bronchial tree.
 Destructive pathology (abscess, gangrene).
 Neoplasms benign and malignant in nature, the sites of metastasis.
 Pleurisy.
 Fungal lung tissue.
 TB.
What are the benefits
 Benefits
 Bone x-rays are the fastest and easiest way for a physician to view
and assess bone injuries, including fractures, and joint
abnormalities, such as arthritis.
 X-ray equipment is relatively inexpensive and widely available in
emergency rooms, physician offices, ambulatory care centers,
nursing homes and other locations, making it convenient for both
patients and physicians.
 Because x-ray imaging is fast and easy, it is particularly useful in
emergency diagnosis and treatment.
 No radiation remains in a patient's body after an x-ray examination.
 X-rays usually have no side effects in the typical diagnostic range
for this exam.
Contraindications to x-ray
Contraindications to x-ray may be the

following:
• Pregnancy, especially first trimester.
• The study is not carried out when a serious

condition of the patient.
• Bone loss eg. Osteoporosis
• Open pneumothorax and bleeding.

Advantages of X-Ray
Fluoroscopy
• Allows a physician to see a
live image of the body's
internal organs in order to
observe their size, shape and
movement.
• Provide dynamic and
functional information.
• Readily available.
Disadvantage of
X-Ray Fluoroscopy
• Although radiation is
minimal, there is the chance
of skin injury due to
radiation exposure, as well
as the usual risks associated
with radiation.
• May display overlapping
anatomy.

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X-Rays and

 X-rays are a form of electromagnetic energy formed

 Differences in body tissue densities are what allow us to

 The patient is positioned easily, its comfortable and

 There is reduced radiation dose to the anterior

 Fluid levels are defined more easily with the use of a

 X-rays can dislodge electrons from the shell of an atom.

 1. Size of the structure

 As physicians, we are responsible not only for the

 Pneumonia of different etiologies.

Contraindications to x-ray may be the

• Pregnancy, especially first trimester.

• The study is not carried out when a serious

• Bone loss eg. Osteoporosis

• Open pneumothorax and bleeding.

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