How do you evaluate an X-ray?

From the Guidelines

To evaluate an X-ray, a systematic approach should be used, starting with ensuring proper patient identification and checking the date and type of examination, then analyzing image quality and anatomy, and finally comparing with previous imaging when available, as recommended by the most recent guidelines 1. When evaluating an X-ray, it is crucial to begin by checking the patient's identification and the date of the examination to ensure that the correct image is being assessed for the right patient.

• The next step involves examining the image quality, noting whether the positioning is proper, the penetration is adequate, and if there are any artifacts that could interfere with the interpretation.
• A structured approach should then be applied to analyze the anatomy visible in the image. This includes comparing the left and right sides for symmetry when applicable, looking for abnormalities in bone density, alignment, soft tissue structures, and the presence of foreign bodies.
• Special attention should be paid to areas where pathology is commonly missed, such as the lung apices on chest X-rays or subtle fractures on extremity films, as highlighted in the context of nontraumatic chest wall pain evaluation 1.
• The evaluation should follow a systematic approach, such as the ABCDE method: Alignment of structures, Bone density and texture, Cartilage spaces, Distribution of soft tissues, and Everything else including foreign bodies.
• It is also important to compare the current X-ray with any previous imaging available to identify changes over time, which can be critical in managing patient care, especially in conditions like prostate cancer where plain radiography can be used to evaluate symptomatic regions in the skeleton 1.
• However, it's worth noting that conventional plain X-rays have limitations, such as not being able to detect a bone lesion until nearly 50% of the mineral content of the bone is lost or gained, as mentioned in the context of prostate cancer evaluation 1.
• Therefore, a thorough and systematic evaluation of an X-ray, considering the patient's clinical context and the limitations of the imaging modality, is essential for accurate diagnosis and effective patient management, as supported by the most recent and relevant guidelines 1.

From the Research

Evaluation of X-ray

To evaluate an X-ray, several factors need to be considered, including the type of fracture, the location of the fracture, and the presence of any complications.

• The study 2 found that evaluating malleolar fractures solely on X-ray may be insufficient to identify many pathologies that potentially contribute to ankle arthrosis.
• The evaluation of X-ray images should be done by independent observers with varied experience in diagnostic imaging, as the study 2 showed that about 40% of pathologies may be overlooked based on X-ray evaluation, regardless of evaluator experience.
• The most frequently overlooked injuries on X-ray evaluation are Tillaux fracture, Pillon fracture, loose bodies, and syndesmosis injury, as reported in the study 2.

When to Order Imaging

Imaging should be ordered when the clinical presentation and history raise suspicion of complications, such as organ damage, or if the patient has other risk factors or conditions for which precise information would help in management decisions, as discussed in the study 3.

• The study 3 emphasizes the importance of radiographic confirmation of rib fracture in certain cases, especially when complications are suspected.
• The study 4 highlights the challenges in assessing fracture healing due to the lack of consensus on imaging and clinical criteria, as well as the lack of a true gold standard.

Limitations of X-ray Evaluation

X-ray evaluation has limitations, particularly in identifying occult traumatic arthrotomies, as reported in the study 5.

• The study 5 found that the presence of air on computed tomography (CT) scans can accurately diagnose occult traumatic arthrotomies, but the sensitivity and specificity of air on CT for identifying a type 1 open fracture were too low to be used reliably in isolation.
• The use of CT scans can help improve the accuracy of diagnosis and reduce the risk of ankle osteoarthrosis, as suggested in the study 2.