X Ray Reading for UGs

How to study an X ray film in viva examination?

1. Reading X-Ray for UGs Dr.C.S.N.Vittal

2. Chest X – Ray Reading tips Location-Part of the body and the view (….. Eg. sir it is a plain x ray of chest in PA view) Focused area - Phase of Inspiration Centering / Rotation Exposure for quality / Penetration Diagnostic Exam Subcutaneous tissues Clavicles & Rib Trachea Hila Lung fields Cardio phrenic angles Vascular markings Diaphragm Heart

3. Anatomical land marks 1 3 2 5 4 10 6 7 9 8 11 13 12 14 15

4. Anatomical land marks

5. Bony cage First step is Identification of T1

6. AP view or PA view AP view PA view Clavicle At or above apex of lung fields Within the lung fields ribs horizontal oblique scapula Within lung fields Away from the lung fields Vertebral column Distinctly seen Less distinct and less dense Clavicle in / scapula out -> is PA view

7. Clavicle at or above apex of lung fields Clavicle Within the lung fields Ribs - horizontal Ribs - oblique Scapula – within the lung fields Scapula - away from the lung fields Vertebral column - Less distinct and less dense Vertebral column - Distinctly seen

8. Focused area Expiration Inspiration

9. Full inspiratory effort Adequate inspiration: diaphragm at 9 th rib Ensure 9 posterior ribs and 7 anterior ribs in children aged 3-7 years old in upright PA radiograph ( 8 visible posterior ribs in children aged 0-3 years old) Cardiac shadow not merged with diaphragmatic shadow

10. Look for alignment of clavicles Alignment of thoracic spine to the center of medial ends of clavicle or center of sternum. Centering

11. Rotation He clavicles lie on the same horizontal plane and anterior ribs are of equal length. Equidistant from spinous processes ​Use anterior rib ends to measure The head of clavicles to lie at the level between T2 and T4 Medial ends of the ribs are equal distance to the center of the spine

12. Rotation Patient in b is rotated to the left. The heart is appreciably in the left hemithorax, and the left side of the chest is relatively elongated, as compared to the right. Note the opacity in the right lower chest field (arrow). The reverse is true in e

13. Exposure

14. Penetration

15. DIAGNOSIS

16. Normal PA

17. Subcutaneous tissues Surgical emphysema Calcified lymphnodes

18. Clavicle Fracture

19. Ribs Fractures Deformity

20. Tracheal position Normal Deviated to Rt. Due to Pneumothorax on Lt side

21. HILA Normal

22. HILA

23. Lung Fields

24. Costophrenic angle

25. Costophrenic angle Blunting – due to effusion Fibrosis (rare in children)

26. Vascular markings

27. Diaphragm Normal Flat Diaphragm

28. Diaphragmatic Hernia Bowel loops in side the chest & No clear diaphragm shadow

29. RML Consolidation AIR BRONCHOGRAM SIGN When the internal tubular outline of a bronchus is visible within a thoracic opacity…that is an air bronchogram.

30. SILHOUETTE SIGN the left lower lobe—because the left dome of the diaphragm is blurred; the lingular segments of the upper lobe—because the left heart border is blurred; the middle lobe—because the right heart border is blurred; the right lower lobe—because the right dome of the diaphragm is blurred.

31. The CXR appearance of a blurred or missing interface is referred to as the silhouette sign An intrathoracic lesion touching a border of the heart, aorta, or diaphragm will obliterate part of that border on the radiograph. An intrathoracic lesion which is not anatomically contiguous with a border will not obliterate that border.

32. RML Consolidation AIR BRONCHOGRAM SIGN When the internal tubular outline of a bronchus is visible within a thoracic opacity…that is an air bronchogram. Rt border of heart not clear – ( Silhoutte Sign)

33. Lung Abscess Thick walled cavity in Rt mid zone

34. LLL collapse Collapsed Lt lower lobe line Lt dome of diaphragm pulled up

35. LLL consolidation Opacity with air bronchogram seen Left diaphragm not clear ( Silhoutte sign)

36. Pneumothorax Darker lung fields

37. Tension Pneumothorax Darker lung fields with shift of mediastilnal strucures too

38. Pleural Effusion Blunting of Costophrenic angel : Effusion Shadow extending towards axilla

39. Hydro pneumothorax Fluid level Thick opacity with obliteration of Rt costophrenic angle No aribronchogram seen…

40. Hydro pneumothorax Blunting of Costophrenic angel : Effusion Flat line : Air/ fuid level

41. Ground glass appearance of lung fields in a newborn chest film Hyaline Membrane Disease

42. Pneumonia Rt

43. Miliary T.B.

44. Emphysema Lt Exposed in expiration Right hemidiaphragm moves cephalad as you would expect with expiration, but the left hemidiaphragm is relatively immobile. This confirms the diagnosis of obstructive emphysema. The culprit was a foreign body (peanut) in the left main stem bronchus.

45. Pneumoperitoneum Air shadow under the diaphragm line

46. Heart

47. Cardiothoracic Index & Cardiomegaly Two rules of thumb: CXR evidence of cardiac enlargement. On an infant’s AP radiograph the normal cardiothoracic ratio ( CTR ) should not exceed 60%1. On a child’s PA radiograph the normal CTR can be slightly above 50%, though by the second year it rarely exceeds 50%1

48. Situs inversus, dextrocardia Shorter More Horiz . Bronchus Liver Stomach

49. Mitral Stenosis Mitralisation of Right border (due to enlarged pulmonary artery)

50. Pericardial effusion

51. Tetrology of Fallot Boot shaped heart

52. Transposition of Great Arteries Egg on end appearance

53. Obstructed TAPVC figure of 8’ appearance of mediastinum Or Snowman appearance

54. Coarctation of the aorta Notching of ribs

55. Heart Failure

56. Some Common Films Kept in Viva Exams

57. Mediastinal widening ? TB Lymphadenitis Malignancy

58. Rickets Cupping, fraying, splaying of lower ends of radius and ulna Swollen lower ends of these bones Under mineralization of bones Diminished ossification of carpal pones Genu valgum deformity

59. Scurvy

60. Beaten Silver Appearance  Increased intracranial pressure (ICP)

61. Hair on end appearance - Thalassemia

62. Osteopetrosis No demarcation of cortex and medulla

63. The erect film shows multiple air fluid levels. The baby have small bowel obstruction Plain X ray abdomen - Erect

64. General Instructions First look at the film given Identify the body part ( Eg. Chest or Chest and abdomen, Abdomen, Limb, etc.) How it is taken ( Eg. abdomen – erect or not? Is it plain or contrast? Chest: - already points given in the beginning Start narration:

65. Example 1 Sir, this is a plain x ray of chest taken in full inspiration. There is a slight bending of individual to left. (more gap on left than on right) Exposure good. Centering good. There is an opacity in Left lower zone with elevation towards axilla. Costophrenic angle obliterated on Lt. side No air bronchogram in the shadowed area Probable diagnosis: Lt sided Pleural Efusion

66. Example contd … Probable diagnosis: Lt sided Pleural Efusion Expected viva questions: What are the different cause of pleural effusion? [TB, empyema, CHF, cirrhosis, etc ] What are the clinical features of Pl effusion [Diminished breath sounds, stony dullness on percussion, diminished VR and VF, etc ] How to differentiate between an exudate and transudate? [Cell count, Protein, Gram’s stain, C/s. etc ] What are the treatment modalities for pleural effusion ? [Steroids for TB, Needle aspirations, Thoracic tube drainage for empyema, etc ]