Plain radiographs

Plain radiographs, also known as x-rays or plain films, produce two-

dimensional images. X-rays are generated by the machine and
directed towards the subject (e.g. a wrist or chest). The detector on
the other side of the subject is a piece of film or (more commonly)
a digital plate. This records the magnitude of x-rays that have
managed to make it to the detector and we can thereby infer where
x-rays have been attenuated.

X-rays can be used in a wide variety of situations, such as

investigating fractures, pneumonia or confirming nasogastric tube
position.

They are quick and relatively simple to perform and compared to

other imaging modalities, relatively inexpensive. The image is
available almost immediately. However, they do make use of
ionising radiation and their use is limited to the situations where
there is a clinical need because of the risk of cancer induction.

The five basic densities

When x-rays meet the detector and create an image, there are five
main densities that can be visualized. They are a direct result of
how many x-rays have passed through the subject and arrived at
the detector.

If all of the x-rays continue through (e.g. air), that area of the image
has little density and is black. If the x-rays are blocked (e.g. bones),
that area of the image is very dense and is therefore white. There
are five basic densities you should be able to recognize - the
differences between them can be subtle and require experience!
Try to identify each of the five densities on the attached chest x-
ray:

• air: the blackest part of the radiograph. May include areas

outside the patient or air within the body (e.g. lungs).
• fat: lighter grey shade compared to air
• soft tissue or fluid: consists of denser organs and fluid within
the body. More white than fatty tissue
 • bones or calcium: bones are very dense and allow little x-rays
to get through them. Calcifications elsewhere (e.g. in arteries)
will also appear white.
• metal: extremely dense and white that will not allow any x-
rays to pass. Not normally present in the body and may be
placed on purpose (e.g. prosthetics, contrast media) or
accidentally (e.g. ingested foreign object).

Computed tomography (CT)

CT scans also use x-rays to create a picture. The patient lies down
on a table that passes into the CT scanner. A rotating x-ray source
and detector spin around the outside of the patient gathering data
similar to the plain radiograph above.

Once all the data has been gathered, a computer can build up the
data and present it as a series of images. These two-dimensional
cross-sectional images can be scrolled and viewed in the axial,
sagittal or coronal planes. This also means that overlapping
structures are not an issue, as they are in x-rays. Depending on the
type of imaging, 3D reconstructions can be created.

As technology and techniques improve, the dose required to

perform the scans is decreasing and the speed to acquire the
images has decreased also.

The benefits of CT scans are their speed, accuracy and quantity of

information. A CT can be taken within minutes of entering an
emergency department and can help direct future management of
the patient. Some disadvantages of CTs include their cost to
purchase and maintain, and the high dose of radiation. Due to the
potential effects on a fetus, a CT scan of the body is not usually
permitted on pregnant women.

CT densities
CT images are comprised of pixels or varying density. In the same
manner as conventional radiographs, the density of each pixel
corresponds to the type of tissue imaged. High density substances
absorb more x-rays and appear whiter. Low density substances
absorb few x-rays and appear darker.
The density of each pixel is measured in Hounsfield units (HU),
where air is assigned -1000 HU, water is 0 HU and bone is around
500 HU. The range of Hounsfield units included in a study is called
the window. Windowing is very important in diagnostic images at it
allows optimization of the CT to identify different types of
pathology - all without having to rescan the patient. A widely used
example of this is in chest CTs - where different windows can show
the bones, lung fields and mediastinum in detail. This may reveal
fractures, emphysema or heart disease respectively. By adjusting
the window you can highlight certain fields to maximize the
diagnostic power of the CT.

Ultrasonography (US)
Ultrasound probes produce high-frequency sound waves instead of
x-rays to create images. Sound waves travel inside the patient and
'bounce back' off of internal structures such as bone or organs. The
relative density of each substance varies and so does how much of
the sound is reflected. These reflected waves are read by the same
probe and are converted to produce a real-time image on the
machine. Tissues are described by their echogenicity, with bone
being hyperechoic and white, while fluid is hypoechoic and dark.

A Doppler ultrasound can interpret if an object is moving towards or

away from the probe. This is especially useful for imaging blood
flow and can determine the velocity and direction of blood in the
heart or blood vessels. US can also be applied to increase the
accuracy of biopsies (e.g. breast or thyroid mass) or can be used
internally in transvaginal or transesophageal studies.

US is widely available and has advantages of being safe,

inexpensive and portable. Since ionising radiation is not used, they
are harmless in children and during pregnancy. They are especially
good at differentiating between types of soft tissue, such as cystic
(fluid-filled) or solid lesions. The main disadvantages are related to
operator error and its inability to see past air and bone, as the
sound waves are all reflected back and deeper structures cannot
be visualized.

Magnetic resonance imaging (MRI)

MRI machines look similar to a CT scanner but utilize strong
magnetic fields instead of a rotating x-ray. The physics involved are
complicated but in a simplified manner, the magnetic fields cause
certain atoms to release radio waves which can be picked up by
the scanner. Hydrogen nuclei (comprised of one proton) have a
positive electrical charge which makes a very tiny magnetic field.
The MRI manipulates these protons to align with its own magnetic
field and release energy that can be collected and turned into an
image.

These machines are especially useful for visualizing soft tissue in

detail. MRI is applied to view diseases in muscles, ligaments,
brains, livers, masses and more. Another advantage is their
absence of ionising radiation. Disadvantages of MRI include their
cost and safety issues. Magnetic fields can manipulate
ferromagnetic objects within the patient (e.g. shrapnel) or turn
objects outside the patient in the room (e.g. scalpels) into high-
velocity projectiles. Many prosthetic devices such as surgical
staples or pacemakers are now made MRI compatible.