What radiographs are most valuable for a patient?

Initial Radiographic Evaluation for Any Patient

The most valuable initial radiographs depend entirely on the clinical presentation and anatomical region of concern, but plain radiographs of the affected area should always be the first imaging modality obtained before considering advanced imaging. 1

General Principles Across All Clinical Scenarios

• Plain radiographs serve as the essential first-line imaging modality because they are widely available, low-cost, provide immediate results, and effectively screen for fractures, dislocations, foreign bodies, hardware complications, and gross pathology 1

• Standard radiographic series should include at least two orthogonal views (typically anteroposterior and lateral) of the region of interest to avoid missing pathology obscured in a single plane 1, 2

• Radiographs guide subsequent imaging decisions by identifying findings that require advanced imaging (CT, MRI, or ultrasound) versus those that can be managed based on plain films alone 1

Trauma Patients

Hemodynamically Unstable Trauma

• Portable AP chest and pelvis radiographs are the only appropriate initial radiographs for unstable trauma patients, as they rapidly screen for life-threatening injuries (tension pneumothorax, mediastinal injury, unstable pelvic fractures) and confirm line placement 1

• Do not delay surgical intervention for additional imaging if FAST examination is positive and the patient remains unstable despite resuscitation 1

Stable Trauma Patients

• Trauma series radiographs (chest and pelvis) remain valuable even in stable patients who will proceed to CT, as they provide immediate information while CT is being arranged and help guide the extent of CT imaging needed 1

• Penetrating torso trauma requires chest radiographs to identify pneumothorax, hemothorax, foreign bodies/ballistic fragments, and trajectory, which directly impacts surgical planning 1

Musculoskeletal Presentations

Hip Pain in Elderly Patients

• AP pelvis radiograph plus additional views of the affected hip (such as frog-leg lateral or cross-table lateral) should be obtained first, as this combination allows comparison to the contralateral side and evaluates associated pelvic structures 2, 3

• Never assume negative radiographs exclude fracture in elderly patients with osteopenia and fall-related hip pain—up to 10% of hip fractures are radiographically occult initially and require urgent MRI within 24-48 hours 4

• Patients unable to ambulate after a fall must be assumed to have an occult fracture until proven otherwise, even with negative radiographs, and should remain non-weight-bearing until MRI is completed 4

Hip Osteoarthritis Evaluation

• AP pelvis view with 15 degrees of internal rotation plus a lateral view (frog-leg or false profile) of the symptomatic hip provides excellent screening for joint space narrowing, osteophytes, subchondral sclerosis, and cysts 2

• In patients over 40 with typical OA presentation, clinical diagnosis without imaging is acceptable, though radiographs remain first-line when imaging is pursued 2

Suspected Infection

Osteomyelitis, Septic Arthritis, or Soft Tissue Infection

• Initial radiographs of the affected region are mandatory as the first imaging step, even though they have limited sensitivity for early infection, because they establish baseline bone architecture and can identify chronic changes, gas in soft tissues, or foreign bodies 1

• Radiographs reveal hardware loosening, fracture, degree of bone healing, heterotopic ossification, bone sclerosis, and areas of destruction in chronic osteomyelitis, though they should not be the sole imaging modality 1

Puncture Wounds with Suspected Foreign Body

• Radiographs are indicated for initial imaging when foreign body composition is unknown, as they effectively detect radiodense materials (metal, graphite, stone, and often glass) 1

• If radiographs are negative but clinical suspicion remains high for radiolucent material (plastic, wood), proceed directly to ultrasound for precise localization 1

Intensive Care Unit Patients

• Portable chest radiographs have approximately 85% diagnostic efficacy in ICU patients and are valuable for monitoring disease progression, documenting tube/line placement (endotracheal, nasogastric, chest tubes, central venous catheters), and detecting complications 1

• Routine daily chest radiographs are not recommended—obtain radiographs only after specific procedures, for clinical deterioration, or to confirm line placement 1

• Chest radiographs have low sensitivity (49%) but good specificity (92%) for detecting pathology in critically ill patients with respiratory symptoms, meaning negative radiographs do not exclude significant disease 1

Abdominal and Pelvic Pain

Acute Abdomen

• Plain abdominal radiographs are limited but useful in severely ill patients to rapidly detect bowel perforation (free air), obstruction (dilated bowel loops, air-fluid levels), or toxic megacolon 1

• Do not rely on abdominal radiographs to exclude intra-abdominal pathology—proceed to CT with IV contrast for definitive evaluation in most acute presentations 1

Spine Pain with Radicular Symptoms

• AP and lateral radiographs of the lumbar spine should be obtained initially to evaluate for degenerative changes, disc space narrowing, spondylolisthesis, fractures, or alignment abnormalities, with diagnostic yield of 9-22% when combined with clinical examination 3

• Radiating leg pain is a red flag warranting diagnostic imaging, and if radiographs are negative with persistent radicular symptoms, proceed to MRI lumbar spine without IV contrast to detect disc herniations and nerve root compression 3

Common Pitfalls to Avoid

• Never order advanced imaging (CT, MRI) without obtaining plain radiographs first unless the patient is too unstable for any imaging or has a clear indication that bypasses radiographs (e.g., suspected stroke requiring immediate CT head) 1, 2

• Do not order radiographs "just to be complete" without clinical indication—every radiograph should answer a specific clinical question that will impact management 1

• Avoid ordering only a single view of a joint or long bone, as pathology can be missed without orthogonal projections 1, 2

• Do not delay urgent MRI in high-risk patients with negative radiographs (elderly with hip pain after fall, suspected occult fracture, suspected early osteomyelitis) as this can lead to worse outcomes 1, 4

• Never assume radiographs are sufficient to exclude soft tissue infections, abscesses, or early osteomyelitis—these conditions require advanced imaging (MRI, CT, or ultrasound) for definitive evaluation 1