Bhaskar Medical College

Department of Anatomy
X-Rays
 STANDARD VIEWS OF A RADIOGRAPH
Skiagrams are taken in different positions of the subject in relation to the source
of X- Rays and the photographic film. Some of the common positions used are :

1. Antero-posterior view (A.P.)

It is taken with the X-Ray tube anterior to the subject and the film posteriorly
placed. Posterior structures are better visualised in this view.

2. Postero-anterior view (P.A.)

It is taken with the X-ray tube posterior to the subject and the film anterior,
the rays thus passing postero-anteriorly through the subject. Anteriorly
placed structures are more clearly visible in this view. The more commonly
taken X-ray of the chest is a P.A. View.

3. Lateral views
These are used to assess the depth of the structures and can be:-
(i) Right lateral view : When the film is in contact with the right side of the
subject.
(ii) Left lateral view : When the film is kept against the left side of the subject.
 STANDARD VIEWS OF A RADIOGRAPH
4. Oblique views

These are used for special study of a particular structure. In the case of chest
X-rays these could be
(i) Right anterior oblique view (R.A.O)
(ii) Left anterior oblique view (L.A.O)
The subject stands in front of upright film cassette holder and is then turned 45 0
oblique (left or right).
The orientation of a radiograph is marked by incorporating a lead letter into the
cassette before exposing a film e.g. the right side with an ‘R’, and left side with
an ‘L’
 TYPES OF RADIOGRAPHS
1. Plain radiographs
When X-rays are allowed to pass through the subject without the
use of any medium the translucent portions appear black on the
developed x-ray plate, whereas the dense areas absorb the x-
rays in varying degree resulting in different shades of white.

2. Contrast radiographs
When X-rays are taken after filling a cavity or space with a contrast
medium in order to visualise the lumen of the viscus or extent of
the cavity.

The contrast media are of two types:-

(a) Opaque e.g., barium sulphate for the gastro-intestinal tract, and
iodine compounds for the urinary tract.
(b) Translucent e.g. air or oxygen for ventricles of brain.
 X-RAY APPEARANCES OF NORMAL SKELETON
Structure of mature bone
Because of their high calcium content, the bones of the skeleton are
clearly defined and contrasted with the soft parts. The long bones
show a dense white homogenous outer layer, the cortex, which
encloses a less dense inner portion, the cancellous bone, which is
represented by a series of fine white lines that correspond to the thin
sheets of bone known as the trabeculae or lamellae. These lamellae
are arranged mainly in the direction of the predominant stress, but
are joined to each other by cross bracing lamellar. Lamellae placed
on the lines of pressure are seen particularly clearly, in the neck of
the femur (calcar-femorale) and in the calcaneum, because they are
subjected to great stress. In the long bones of the limbs generaly they
tend to run vertically, but the number of cross bracing obscures the
pattern. Study of the trabecular architecture and the distribution of
the cortical and cancellous layers in each bone is useful because
alterations occur in many pathological conditons.
In the shafts of the long bones the cancellous bone is absent and is
replaced by a space, the medullary (marrow) cavity, which can be
 X-RAY APPEARANCES OF NORMAL SKELETON

Structure of immature bone

At birth considerable portions of the skeleton are formed of
cartilage, the radiographic density of which is much the same ad
that of the overlying skin and muscles. These portions are
therefore not normally distinguished in a skiagram e.g. the
cartilaginous carpal elements in the wrist and the ends of certain
long bones of the extremities.
 Shoulder
5
Joint
6 4 8

3 9
 Shoulder Joint

1. Head of Humerus
2. Glenoid clavity
3. Coracoid process
4. Acromio clavicular Joint
5. Clavicle
6. Acromion process
7. Scapula
8. Ribs
9. Lungs
Shoulder-AP view
 Elbow joint and palmar aspect of wrist Joint

3 7
2
9
4 13
12
5
17

8 14 15 10 16 11
 Elbow joint and palmar aspect of wrist Joint

1. Head of Radius 10 to 17 Carpal bones

2. Olecranon process 10. Scaphoid
3. Medial epicondyle 11. Lunate
4. Lateral epicondyle 12. Triquitrel
5. Ulna 13. Pisiform
6. Radius 14. Trapizium
7. Ulna 15. Trapezoid
8. Styloid process of Radius 16. Capitate
9. Styloid process of ulna 17. Hamate
 4 Elbow Joint

1
3

6 8

9
7

5 10
 Elbow Joint

1. Lateral epicondyle
2. Olecranon fossa
3. Olecranon process
4. Medial epicondyle
5. Trochlea
6. Elbow joint space
7. Tuberosity of Radius
8. Epicondyles
9. Head of radius
10. Olecranon process
Elbow-Lateral view
 Dorsal aspect of Hand

Phalanges

Meta carpals

Trapezoid
Trapezium
Scaphoid

Lunate
Capitate Hemate
Triquitrel
Wrist & Hand-AP view
 Pelvis and Hip Joint

6 7 8
 Pelvis and Hip Joint

1. Ilium
2. Ilio sacral joint
3. Grater trochanter
4. Lesser trochanter
5. Head of femur
6. Ischium
7. Pubis
8. Pubic symphysis
9. Intestinal gas shadow
Hip-AP view
Knee Joint

5
 Knee Joint

1. Patella

2. Inter condylar notch femur

3. Articular ends of femur & tibia along with
knee joint space

4. Head and styloid process of fibula

5. Inter condlyar eminence of tibia

Knee-AP view
 Knee Joint

Patella

Medial femoral
condyle Knee joint
Lateral femoral space
condyle
Inter condlyar
eminence of tibia

Head of fibula
Knee-Lateral view
 Ankle Joint

5
6
7
2 8
1 9
4
3
 Ankle Joint

1. Lower end of fibula

2. Lower end of tibia
3. Talus
4. Calcaneum
5. Lower end of tibia
6. Lower end of fibula
7. Talus
8. Navicular
9. Lateral cuneiform
Ankle-AP view
 Foot

Calcaneum

Talus

Cuboid

Navicular

Medial,
intemediate &
lateral cuneiform
Foot-Dorsoplantar view
 Foot
1 3 2 4 5

6
7

9
 Foot

1. Sesamoid bone
2. Medial cuneiform
3. Intemidiate cuneiform
4. Navicular
5. Talus
6. Lateral cuneiform
7. Cuboid
8. Calcaneum
9. First metatarsal
Ankle and foot-lateral view
 THORAX
Chest
X-ray examination of the chest is Important in diseases of the lungs
and heart. The ordinary standard x-ray film of chest is a postero-
anterior view (P.A.) that is to say one taken with the film against
the front of the patient’s chest and the x-ray tube two metres
behind the patient. With the subject sitting or standing the hands
are placed on the waist and the elbows are pointed antero-
laterally. This moves the scapulae from the lung fields. The
skiagram is taken the breathing is momentarily stopped after
taking a deep inspiration.
 1 Chest
4 5
3 2
6

8 18

9 17

10 16

11 12

13

14
15
 Chest

1. First Rib 10. Right atrium

2. Clavicle 11. Inferior vena cava

3. Scapula 12. Left ventricle

4. Trachea 13. Cardio phrenic angle

5. C7 Vertebra 14. Casto phrenic angle

6. T1 Vertebra 15. Stomach fundus gas shadow

7. Humerus 16. Hilar shadow

8. Lung shadow 17. Left atrium

9. Inferior angle of scapula 18. Aortic knuckle

Chest-Postero-anterior view
Chest - Lateral view

Sternum

Retro sternal space

Pulmonary trunk
Descending aorta

Retro cardiac space

Cupolae of diaphragm
Chest -Lateral view
Chest -Right anterior oblique view
Chest

Concavity of left Atrium due

to enlargement of Oesophagus
Oesophageogram-Left anterior-oblique view
 Skull

Outer and
inner tables

Frontal sinus

Orbit

Maxillary sinus
Vestibule
Skull-Antero-Posterior view
 Skull cald well view

Frontal sinus

Orbit

Nasal septum Ethmoidal sinus

Vestibule
Maxillary sinus

Mastoid process
Skull-Caldwell view
 Skull

7 4

8
6
 Skull

1. Frontal sinus
2. Outer & inner tables
3. Sphenoidal sinus
4. Maxillary sinus
5. Hard palate
6. Lower jaw / mandible
7. Mastoid air cells
8. External Acoustic meatus
Skull-Lateral view
 Neck

Mandible

Larynx

Transverse process Spinous process

of vertebral

First rib

Trachea
Cervical spine-AP view
 Neck

Arch of atlas
Odontoid process

Thyroid cartilage Spinous process

Body of verterbra

Intervertebral disc
Cervical spine-Lateral view
 ABDOMEN AND PELVIS
PLAIN X-RAY ABDOMEN
A plain rediograph of the abdomen is extremely valuable in
(i) Excluding biliary and renal calculi,
(ii) In urgent surgery for diagnosing:
• acute intestinal obstruction.
• paralytic ileus and
• rupture of a hollow viscus.
It is taken after preparing the patient in the following manner to eliminate
excessive faecal, air and gas shadows from the intestine.
• Purgative should be given 36 or 24 hours before x-ray is taken. Half to one
ounce of castor oil is effective in clearing the colon with most patients, but it
tends to encourage gas distension after the initial irritation. Milder purgatives
such as Senna may also be used. Colon wash-outs may also be given.
• Patient should be up and about before examination to dispel gases when this is
possible.
• Pitressin (1.5 ml) can also be given subcutaneously to cause the colon to
empty, provided the patient is not pregnant or suffering from high blood
pressure. Afteer the injection, the patient is instructed to retire to the lavatory
and pass flatus. The radiographs are taken after wards.
 Abdomen

Kidney

Psoas shadow

Lumbar vertebra

Ilia crest

Gas shadow in colon

Sacro iliac joint

Coceyx

Symphysis pubis
Abdomen-Plain X-Ray (KUB)
 CONTRAST RADIOGRAPHY GASTROINTESTINAL TRACT

The alimentary tract is examined with the aid of a contrast medium. Their
common value depends on their outlining the internal shape of hollow
organs. The most commonly employed medium in present day
radiography of the gastrointestinal tract is barium sulphate in water
suspension. 125 gm of barium sulfate powder to 180 ml of water is
adequate in most patients. If the small intestines are to be examined and
additional 120 to 180 ml of the mixture should be given routinely.
 BARIUM MEAL
Barium meal is flavoured with vanilla and sweetend with white saccharin. It has
a creamy consistency. Before giving barium meal, the patient is prepared in the
following manner.
• He should have nothing to eat or drink for six hours prior to the barium meal
and should not smoke, chew gum or take medicines during this period.
• No purgative should be given the night before the examination as they tend to
cause misleading motor phenomena.
• Medicines containing elements of high atomic weight such as bismuth, calcium
or magnesium should be discontinued at least three days prior to the test as
they may adhere to colon wall in the region of splenic fiexure and cast a
confusiing shadow.
The meal is best given at about 9 a.m. The patient drinks 0.5 to 1 pint (10 to
15 ozs.) of barium emulsion so that stomach is filled up. The barium emulsion is
then smeared over the interior of the stomach by gentle pressure on the
abdominal wall. The patient is radio-graphed immediately after the meal and
then at ½ hr., 1 hr. and 1 ½ hours intervals. The stomach starts emptying its
contents within a few minutes of their reaching it. A half pint of barium
suspension will usually have left the stomach in two hours.
 BARIUM ENEMA
The large intestine can be examined either after a barium enema or a barium
meal. A barium enema is used in preference for most purposes. A necessary
preliminary is to cleanse the bowel thoroughly, and for this purpose the
following procedure is adopted.
• A suitable purgative (castor oil 1-2 oz or Dulcolax tablets) is given 48 hours
before the examination to remove gross faecal masses.
• A clear liquid diet is given for a perior of 24 hours prior to X-ray.
• A high colonic wash-out is given just prior to the examination. Three pints of
plain water or normal saline are run into the rectum from douche can, at a
pressure of about one foot of water. No soap should be used for colonic lavage.
After the patient has been thus prepared, the whole colon is easily outlined by
slowly running in two to three pints of a simple barium sulphate suspension
through the anus. 300 gms of barium sulfate powder are added to each 1000 ml
of tap-water. Various drugs are sometimes added e.g. Clysotrast to help colonic
peristalsis and precipitate mucus which might otherwise cling to the mucosa.
The result is an improved post evacuation study.
 Abdomen – Barium meal

Gas bubble in
fundus
Lesser curvature

Duodenal cap

Greater curvature
Pylori antrum

Jejunum Peristaltic wave

Coils of small
intestine
Stomach (J-shaped) immediately after barium
Stomach and duodenum-15 minutes after barium meal
 Urinary Tract
In a plain skiagram of abdomen (K.U.B. film) the kidney outlines can be
cleary seen. To outline the calyces, ureter and bladder, certain organic
compounds containing iodine in their molecule, have to be introduced
either intravenously or through a catheter to make the urinary tract
radio-opaque. Such an x-ray in which the urinary tract is visualised by a
radio-opaque medium is called a pyelogram. Plain radiographs of the
abdomen should be taken first, before pyelography, as these will show
whether the kidneys are normal in size, shape and position, and whether
there are any abnormal opacities in the renal tract, which may require
localisation by pyelography. Occasionally, they may reveal non-renal
conditions which make pyelography unnecessary.
 Urinary Tract
Descending Pyelogram
The preparation and technique is as follows:
Conray 420 (compound containing iodine) is the preparation of choice.
• A mild vegetable aperient on two consecutive evenings preceding examination.
• A light supper on the preceding evening.
• For twelve hours before the injection the intake of fluids is limited and diuretic
drugs are excluded.
• No food or fluid is given on the morning of the test.
• Urinary bladder should be empty when the injection is given.
• If possible the patient should be up and about to expel gases.
• Test for iodine sensitivity is done.
• Warm 20-40 ml of the solution to body temperature. Inject slowly taking care
that there is no leakage out of the vein.
 Urinary Tract
The first radiograph of the abdomen is taken five minutes after the
injection. A second radiograph ten minuts after the injection may
suffice but more may be taken if considered necessary.
Excretion urography or descending or intravenous pyelography
(I.V.P.) is not only performed to obtain an anatomic evaluation of
the urinary tracts, nut is also done to determine the functional
status of the kidneys and so constitutes one of the renal function
tests.
Ascending Pyelogram
If delineation of the calyces, pelvis or ureters is unsatisfactory on one or both sides
after intravenous pyelography, a retrograde pyelogram may be necessary. An
intravenous pyelogram is safe, but a retrograde pyelogram must be undertaken with
caution. The preparation and technique is as follous:
• Nothing by mouth after a light meal in the evening.
• Cleansing enema in the morning.
• A cystoscope is passed through the urethra into the bladder. A cystoscope is an
instrument of such a size that it can be passed up the urethra. The inner end carries
a small electric light and a mirror, the outer end a telescope, a system of lenses
focussed on the mirror. The light from the lamp luminates a part of the bladder wall.
Its image is reflected by the mirror along the tube into the eye piece. Special
channels are incorporated in the instrument through which fine flexible catheters
can be passed and guided into the orifices and then up the ureters.
• A ureteric catheter is manipulated through the
cystoscope into the bladder then under direct vision is
guided into the ureter.
• Hypaque (45 per cent) is injected by the catheter into
the ureter in a fully conscious patient.
• The injection of the opaque medium is continued until
the patient feels discomfort in the loin, or until 10 ml
have been introduced.
• The radiograph is taken.
• The fluid is aspirated from the renal pelvis and the
catheter is removed.
 Intravenous Pyelogram (IVP)

Minor calyx

Renal pelvis
Kidney

Double Ureter

Urinary bladder
Descending pyelogram
 FEMALE GENITAL TRACT
Hysterosalpingography
It is particularly useful in cases of sterility and to prove or disprove the
patency of the uterine tubes. It also outlines the uterine cavity, shows the
length, shape and position of the Fallopian tubes. The most common
contrast medium used is Lipiodol. A suitable cannula, which at the same
time obstructs the cervical canal, is inserted into the cervical canal of the
uterus. Approximately 6 ml of the opaque medium is injected and an
antero-posterior film is obtained. When iodized oil is used, another film is
obtained in twenty-four hours to detect the extent of the overflow into
the pelvis through the uterine tubes.
 Hystero Salpingo Gram (HSG)

1 4
6
3

5
Hystero Salpingo Gram (HSG)

1. Cornu of uterus
2. Fundus of uterus
3. Uterine tube
4. Peritoneal spill
5. Cannula in vagina
6. Uterine cavity
Uterus-Hystero Salpingogram
Twin X-rays