ENGLISH FOR MEDICAL IMAGING - RADIOGRAPHS
Introduction
Radiographs, which are commonly called ‘X-rays’, are two-dimensional images of the body that are
displayed as white, black, or varying shades of gray. Radiographs are used in all specialties of clinical
medicine, and they are widely accessible and fairly inexpensive.
How Images Are Obtained
Radiographs are images that are obtained using ionizing radiation. An X-ray passes through a patient to
hit a specialized detector. Historically, images were created and printed on film. Currently, radiography has
become digitalized and the images are viewed on specialized computer workstations.
X-rays are discrete quantities of electromagnetic radiation that are produced outside the nucleus of an
atom. X-rays are produced in a generator by the interaction of an electron beam with a Tungsten target.
The X-rays are emitted from the generator as a beam and travel through a patient. Tissues absorb
(attenuate) some of the x-rays, while others pass through and hit the cassette. The attenuation properties
vary among different tissue types, resulting in a heterogeneous distribution of X-rays emerging from the
patient to hit the detector (historically called a cassette).
Screen-film radiography: The cassette contains film and intensifying screens. When the X-rays hit the
film, a photochemical interaction occurs, causing the metallic silver in the film to precipitate. This renders
the film black when it is developed chemically.
Digital (computed) radiography: The cassette contains a photo-stimulable phosphor detector
system. When the X-rays hit the cassette, a fraction of the absorbed energy is trapped in the detector. A
red laser light stimulates the emission of the trapped energy, and blue-green light is emitted, collected, and
converted into an electric signal. This is digitized and stored as a pixel value, with the gray scale dependent
upon the amount of energy absorbed and released.
Factors Affecting Appearance
The composition, thickness and shape of a structure all interact to influence what an object looks like on
a radiograph.
DENSITY
What causes a structure to appear black, white, or gray on a radiograph? It depends on how much of
the x-ray beam is absorbed by the structure and how much passes through to reach the detector. The
density of the object being imaged determines how much of the x-ray beam will be absorbed.
Dense structures absorb (attenuate) more of the x-ray
beam than less dense structures. Thus, less of the beam
passes through to hit the cassette and these structures
appear white (they are called radioopaque). The radiograph
shown is a pair of metal scissors, which are radioopaque.
Note the scissors are brighter white in areas where the metal
is thicker, like the handles. Other dense structures include
calcium, barium and iodine, all of which look white on
radiographs.
Structures which are not very dense, such as air, absorb very little of the x-ray beam. Most of the beam
passes through the air and strikes the detector. As a result, these structures appear black on x-rays (they
are called radiolucent). Note that on the radiograph shown before, air surrounding the scissors is black.
The variable densities of structures in
the body result in the four basic
radiographic densities:
a. Air black
b. Fat gray/black
c. Soft tissues and organs gray
d. Metal, calcium, and bone white
Fat is low density, but is slightly greater
than air and so looks less black on a
radiograph than air. Muscles, organs, and
soft tissues are shades of gray, ranging from
light to dark gray depending on the
structure’s density. These shades of gray are
referred to as “water density”.
What Anatomical Structures Are Demonstrated Well on Radiography
Radiodense structures are easy to evaluate on radiography. Examples of these include bone, calcium,
barium and metal. Radiolucent structures are also easy to evaluate. Examples of these include air and fat.
Structures of intermediate density, such as fluid and soft tissues like organs and muscles are harder to
evaluate and differentiate. They all appear a similar shade of gray. How distinctly they are seen on
radiographs depends on what structures they are next to.
If two structures of similar density are adjacent to one another, they cannot be differentiated since they
appear the same shade of gray. In contrast, adjacent structures of differing densities, like bone and fat, can
be distinguished quite easily.
Indications for Use
Radiographs are commonly obtained to work up a wide variety of problems and symptoms of the chest,
abdomen, pelvis, extremities and spine. Radiographs are relatively inexpensive, widely available, and easily
accessible.
BONES
As bones are easily visible on radiographs, X-rays are a great way to evaluate for bone pathology. The
outer edge of long bones, called the cortex, is more dense than the inner portion, the medulla. Disruptions
of the cortex, as occurs in fractures, are readily seen on x-ray.
The hand radiograph on the right reveals an acute fracture of
the 5th metacarpal (arrow). The smooth outer edge of the bone is
disrupted at the site of the break. This is known as a "boxers"
fracture, as the mechanism of injury is usually a punch, where the
force is transmitted to the 5th metacarpal bone.
This is a magnified view:
In addition to fractures, radiography is an excellent way to look for focal lesions like tumors or infections
that cause bone destruction. Other indications for use include evaluation of joint spaces for infection,
arthritis, and dislocations.