| Projectional radiography | |
| Icd10: | B?0 |
Projectional radiography, also known as conventional radiography,[1] is a form of radiography and medical imaging that produces two-dimensional images by X-ray radiation. The image acquisition is generally performed by radiographers, and the images are often examined by radiologists. Both the procedure and any resultant images are often simply called 'X-ray'. Plain radiography or roentgenography generally refers to projectional radiography (without the use of more advanced techniques such as computed tomography that can generate 3D-images). Plain radiography can also refer to radiography without a radiocontrast agent or radiography that generates single static images, as contrasted to fluoroscopy, which are technically also projectional.
See main article: X-ray generator. Projectional radiographs generally use X-rays created by X-ray generators, which generate X-rays from X-ray tubes.
An anti-scatter grid may be placed between the patient and the detector to reduce the quantity of scattered x-rays that reach the detector. This improves the contrast resolution of the image, but also increases radiation exposure for the patient.
See main article: X-ray detector. Detectors can be divided into two major categories: imaging detectors (such as photographic plates and X-ray film (photographic film), now mostly replaced by various digitizing devices like image plates or flat panel detectors) and dose measurement devices (such as ionization chambers, Geiger counters, and dosimeters used to measure the local radiation exposure, dose, and/or dose rate, for example, for verifying that radiation protection equipment and procedures are effective on an ongoing basis).
See also: Radiography. Lead is the main material used by radiography personnel for shielding against scattered X-rays.
Projectional radiography relies on the characteristics of X-ray radiation (quantity and quality of the beam) and knowledge of how it interacts with human tissue to create diagnostic images. X-rays are a form of ionizing radiation, meaning it has sufficient energy to potentially remove electrons from an atom, thus giving it a charge and making it an ion.
When an exposure is made, X-ray radiation exits the tube as what is known as the primary beam. When the primary beam passes through the body, some of the radiation is absorbed in a process known as attenuation. Anatomy that is denser has a higher rate of attenuation than anatomy that is less dense, so bone will absorb more X-rays than soft tissue. What remains of the primary beam after attenuation is known as the remnant beam. The remnant beam is responsible for exposing the image receptor. Areas on the image receptor that receive the most radiation (portions of the remnant beam experiencing the least attenuation) will be more heavily exposed, and therefore will be processed as being darker. Conversely, areas on the image receptor that receive the least radiation (portions of the remnant beam experience the most attenuation) will be less exposed and will be processed as being lighter. This is why bone, which is very dense, process as being 'white' on radio graphs, and the lungs, which contain mostly air and is the least dense, shows up as 'black'.
Radiographic density is the measure of overall darkening of the image. Density is a logarithmic unit that describes the ratio between light hitting the film and light being transmitted through the film. A higher radiographic density represents more opaque areas of the film, and lower density more transparent areas of the film.
With digital imaging, however, density may be referred to as brightness. The brightness of the radiograph in digital imaging is determined by computer software and the monitor on which the image is being viewed.
Contrast is defined as the difference in radiographic density between adjacent portions of the image. The range between black and white on the final radiograph. High contrast, or short-scale contrast, means there is little gray on the radiograph, and there are fewer gray shades between black and white. Low contrast, or long-scale contrast, means there is much gray on the radiograph, and there are many gray shades between black and white.
Closely related to radiographic contrast is the concept of exposure latitude. Exposure latitude is the range of exposures over which the recording medium (image receptor) will respond with a diagnostically useful density; in other words, this is the "flexibility" or "leeway" that a radiographer has when setting his/her exposure factors. Images having a short-scale of contrast will have narrow exposure latitude. Images having long-scale contrast will have a wide exposure latitude; that is, the radiographer will be able to utilize a broader range of technical factors to produce a diagnostic-quality image.
Contrast is determined by the kilovoltage (kV; energy/quality/penetrability) of the x-ray beam and the tissue composition of the body part being radiographed. Selection of look-up tables (LUT) in digital imaging also affects contrast.
Generally speaking, high contrast is necessary for body parts in which bony anatomy is of clinical interest (extremities, bony thorax, etc.). When soft tissue is of interest (ex. abdomen or chest), lower contrast is preferable in order to accurately demonstrate all of the soft tissue tones in these areas.
Geometric magnification results from the detector being farther away from the X-ray source than the object. In this regard, the source-detector distance or SDD[2] is a measurement of the distance between the generator and the detector. Alternative names are source[3] /focus to detector/image-receptor[3] /film (latter used when using X-ray film) distance (SID,[3] FID or FRD).
The estimated radiographic magnification factor (ERMF) is the ratio of the source-detector distance (SDD) over the source-object distance (SOD).[4] The size of the object is given as:
Sizeobject=
| Sizeprojection | |
| ERMF |
The source-detector distance (SDD) is roughly related to the source-object distance (SOD)[7] and the object-detector distance (ODD) by the equation SOD + ODD = SDD.
Geometric unsharpness is caused by the X-ray generator not creating X-rays from a single point but rather from an area, as can be measured as the focal spot size. Geometric unsharpness increases proportionally to the focal spot size, as well as the estimated radiographic magnification factor (ERMF).
Organs will have different relative distances to the detector depending on which direction the X-rays come from. For example, chest radiographs are preferably taken with X-rays coming from behind (called a "posteroanterior" or "PA" radiograph). However, in case the patient cannot stand, the radiograph often needs to be taken with the patient lying in a supine position (called a "bedside" radiograph) with the X-rays coming from above ("anteroposterior" or "AP"), and geometric magnification will then cause for example the heart to appear larger than it actually is because it is further away from the detector.[8]
In addition to using an anti-scatter grid, increasing the ODD alone can improve image contrast by decreasing the amount of scattered radiation that reaches the receptor. However, this needs to be weighted against increased geometric unsharpness if the SDD is not also proportionally increased.[9]
Projection radiography uses X-rays in different amounts and strengths depending on what body part is being imaged:
NOTE: The simplified word 'view' is often used to describe a radiographic projection.
Plain radiography generally refers to projectional radiography (without the use of more advanced techniques such as computed tomography). Plain radiography can also refer to radiography without a radiocontrast agent or radiography that generates single static images, as contrasted to fluoroscopy.
See main article: Mammography. Projectional radiography of the breasts is called mammography. This has been used mostly on women to screen for breast cancer, but is also used to view male breasts, and used in conjunction with a radiologist or a surgeon to localise suspicious tissues before a biopsy or a lumpectomy. Breast implants designed to enlarge the breasts reduce the viewing ability of mammography, and require more time for imaging as more views need to be taken. This is because the material used in the implant is very dense compared to breast tissue, and looks white (clear) on the film. The radiation used for mammography tends to be softer (has a lower photon energy) than that used for the harder tissues. Often a tube with a molybdenum anode is used with about 30 000 volts (30 kV), giving a range of X-ray energies of about 15-30 keV. Many of these photons are "characteristic radiation" of a specific energy determined by the atomic structure of the target material (Mo-K radiation).
See main article: Chest radiography. Chest radiographs are used to diagnose many conditions involving the chest wall, including its bones, and also structures contained within the thoracic cavity including the lungs, heart, and great vessels. Conditions commonly identified by chest radiography include pneumonia, pneumothorax, interstitial lung disease, heart failure, bone fracture and hiatal hernia. Typically an erect postero-anterior (PA) projection is the preferred projection. Chest radiographs are also used to screen for job-related lung disease in industries such as mining where workers are exposed to dust.[11]
For some conditions of the chest, radiography is good for screening but poor for diagnosis. When a condition is suspected based on chest radiography, additional imaging of the chest can be obtained to definitively diagnose the condition or to provide evidence in favor of the diagnosis suggested by initial chest radiography. Unless a fractured rib is suspected of being displaced, and therefore likely to cause damage to the lungs and other tissue structures, an X-ray of the chest is not necessary as it will not alter patient management.
See main article: Abdominal X-ray. In children, abdominal radiography is indicated in the acute setting in suspected bowel obstruction, gastrointestinal perforation, foreign body in the alimentary tract, suspected abdominal mass and intussusception (latter as part of the differential diagnosis).[12] Yet, CT scan is the best alternative for diagnosing intra-abdominal injury in children.[12] For acute abdominal pain in adults, an abdominal X-ray has a low sensitivity and accuracy in general. Computed tomography provides an overall better surgical strategy planning, and possibly less unnecessary laparotomies. Abdominal X-ray is therefore not recommended for adults presenting in the emergency department with acute abdominal pain.[13]
The standard abdominal X-ray protocol is usually a single anteroposterior projection in supine position.[14] A Kidneys, Ureters, and Bladder projection (KUB) is an anteroposterior abdominal projection that covers the levels of the urinary system, but does not necessarily include the diaphragm.
In case of trauma, the standard UK protocol is to have a CT scan of the skull instead of projectional radiography.[14] A skeletal survey including the skull can be indicated in for example multiple myeloma.[14]
The standard projections in the UK AP and Lateral. Peg projection with trauma only. Obliques and Flexion and Extension on special request.[14] In the US, five or six projections are common; a Lateral, two 45 degree obliques, an AP axial (Cephalad), an AP "Open Mouth" for C1-C2, and Cervicothoracic Lateral (Swimmer's) to better visualize C7-T1 if necessary. Special projections include a Lateral with Flexion and Extension of the cervical spine, an Axial for C1-C2 (Fuchs or Judd method), and an AP Axial (Caudad) for articular pillars.
These include:
This projection has a low tolerance for errors and accordingly needs proper execution.[15] The Y-projection can be traced back to Wijnblath's 1933 published cavitas-en-face projection.[16]
In the UK, the standard projections of the shoulder are AP and Lateral Scapula or Axillary Projection.[14]
A projectional radiograph of an extremity confers an effective dose of approximately 0.001 mSv, comparable to a background radiation equivalent time of 3 hours.
The standard projection protocols in the UK are:[14]
AP and Lateral.[14]
Applications include X-ray of hip dysplasia.
Certain suspected conditions require specific projections. For example, skeletal signs of rickets are seen predominantly at sites of rapid growth, including the proximal humerus, distal radius, distal femur and both the proximal and the distal tibia. Therefore, a skeletal survey for rickets can be accomplished with anteroposterior radiographs of the knees, wrists, and ankles.[18]
Radiological disease mimics are visual artifacts, normal anatomic structures or harmless variants that may simulate diseases or abnormalities. In projectional radiography, general disease mimics include jewelry, clothes and skin folds. [19] In general medicine a disease mimic shows symptoms and/or signs like those of another.[20]