CHEST RADIOGRAPHS, WAYANG KULIT

A REVISIONOF THE FUNDAMENTALSDr Ng Kian SengMBBS (Singapore) MCGP (Malaysia)Master Of Medicine (Internal Medicine, Singapore)FAFP (Malaysia) Cert In Occupational MedicinePh D (Theology, USA)

Hippocrates of C

os, Fath

er of Medicine

ANATOMY IN THE CHEST RADIOGRAPH

A Normal Chest Radiograph

Some examiners like you to call x ray films radiographs; strictlyspeaking you can’t actually see the x rays themselves.

A Chest Radiograph,Not A Chest X-Ray

Anatomy in the Chest Radiograph

The right main bronchus is slightly larger than the left & comesoff at a less acute angle than the left (hence septic material &foreign substances are more likely to be inhaled into the right lung than into the left).

Trachea Apex Of Lung

Carina

Aortic arch

Left ventricle

Gastric Air Bubble

Right para-tracheal stripe

MainPulmonaryArtery

Left Atrialappendage

Descending thoracic aorta

Chest Radiograph, PA View, No 1

Right lower lobe pulmonary

artery

Right hilum

Right upper lobe pulmonary

vein

Right Cardiophrenic Angle

Right Costophrenic Angle

Right atrium

Horizontal fissure

Chest Radiograph, PA View, No 2

Chest Radiograph, PA View, No 3

Scapula

Breast Soft Tissue

Diaphragm

Anterior Rib

Posterior Rib

Spinous process

Clavicle

Left Bronchus

Right Bronchus

Lung TissueSuperimposedOn diaphragm

Retrocardiac vertebra

Chest Radiograph, PA View, No 4

Anatomy Of the Heart In The Chest Radiograph

THE MEDIASTINAL STRUCTURES IN THE C-XRAY

Aorto-pulmonary window. The aorto-pulmonary window lies between the arch of the aorta and the pulmonary arteries. It contains the ligamentum

arteriosum, the recurrent laryngeal nerve, lymph nodes, and fatty tissue. ...

AortoPulmonaryWindow

From the level of the clavicles to the azygous vein the right edge of the trachea is seen as a thin white stripe. This appearance is created by air of low density (blacker) lying either side of the comparatively dense (whiter) tracheal wall. If this stripe is thickened

(normally less than 5 mm) this may represent pathology such as a paratracheal mass or enlarged lymph node. The left side of the trachea is not so well defined because

of the position of the aortic arch and great vessels.

RIGHTPARA-

TRACHEALSTRIPE

Anatomy in the

LateralChestX-ray

1. Ascending thoracic Aorta2. Sternum3. Right ventricle4. Left ventricle5. Left atrium 6. Gastric air bubble7. Right Hemidiaphragm8. Left Hemidiaphragm9. Right upper lobe bronchus10. Left upper lobe bronchus11. Trachea.

NAME THE STRUCTURES IN THE LATERAL CHEST X-RAY

9

10

1.Trachea2. Aortopulmonary window 3. Sternum4. Right ventricle 5. Right Hemidiaphragm 6. Left Hemidiaphragm 7. Left atrium 8. Scapula 9. Right Upper Lobe Bronchus10. Left upper Lobe Bronchus

 The mediastinum is divided by a plane passing from the sternal angle to T4-T5 into: Superior mediastinum and The inferior mediastinum

The inferior mediastinum is further subdivided into three regions namely:Anterior mediastinum Middle mediastinumPosterior mediastinum

These divisions are for descriptive purposes, theymerge into each other imperceptibly. There are no distinct boundaries between them.

THE MEDIASTINUM

ZONES OF THE CHEST RADIOGRAPH

UPPERZONE

MIDDLEZONE

LOWERZONE

Apex to a line drawn throughThe lower borders of theAnterior ends of the 2nd costalCartilage.

From the 1st line to one drawnThrough the lower borders of the4th costal cartilage & includesThe Hila of the lungs

From the 2nd line to theBases of the lungs.

THE FISSURES OF THE LUNGS

Oblique Fissure From 4 th Dorsal spine sweeping downObliquely to the 6th rib in mid mammary line or the 6th costo Chondral junction, anteriorly.Horizontal Fissure. Runs from the 4th costo chondral junction To meet Oblique Fissure at the mid axillary line.

THE LOBES & FISSURES OF THE LUNGS

Base of the Lung: 6th costochondral junction, obliquely to the 10th rib in anterior Axillary line,

then horizontally to 12th thoracic vertebra

Oblique Fissure : From 4th Dorsal spine sweeping downObliquely to the 6th rib in mid mammary

line or the 6th Costochondral junction, anteriorly.Horizontal Fissure. Runs from the 4th costochondral

Junction to meet Oblique Fissure at the mid axillary line.

OBLIQUE FISSURE , HORIZONTAL FISSURE

From 4th Dorsal spine sweeping down Obliquely to the 6th rib

in midmammary line or the 6th

Costochondral junction, anteriorly.

THE RIGHT & LEFT OBLIQUE FISSURES

Horizontal Fissure. Runs from the 4th costochondral junction to meet Oblique Fissure at the Mid Axillary Line.

THE HORIZONTAL FISSURE

WHAT IS THE ABNORMALITY HERE?

ACESSORY FISSURE, THE AZYGOS FISSURE

.The azygos lobe appears starting in a teardrop shape at around the level of T5 to the right of the midline as a pale line curving outward and upward and then back in to meet the root of the neck, the line is the infolding of the pleura. Also described as a “curvilinear opacity,Inverted comma, tadpole.” (See Notes in “Companion”, J)

NORMAL VARIANTS IN THE CHEST RADIOGRAPH

Louis P

asteur

NIPPLE SHADOWS

NIPPLE SHADOWS

RIGHT NIPPLE

LEFT NIPPLE

Confirm these are indeed nippleShadows by using metal markers!

ASYMMETRY OF THE BREASTS

Breast asymmetry is very common, even to the extent that no breast tissue is visible on one side.

It should not be assumed that the patient has had a mastectomy, unless this is known from

the history.

BONE ISLAND IN THE RIB

DROMEDARY HUMP IN THE DIAPHRAGM

EXAMINE THE FIRST & SECOND RIBS ON BOTH SIDES

FUSION OF FIRST & SECOND RIB ON THE LEFT

PSEUDO-ARTHROSIS OF THE FIRST TWO RIBS ON THE LEFT

BIFURCATED RIB

Soft tissue fat This close-up demonstrates a normal fat plane between layers of muscle. Fat is less dense than muscle and so appears blacker. Note that the edge

of fat is smooth. Irregular areas of black within the soft tissues may represent air tracking in the subcutaneous layers. This is known as

surgical emphesyma

What is the bony abnormality in this patient?

Chest radiograph is showing well developed bilateral cervical ribs.

Cervical rib is an extra rib that arises from the 7th cervical vertebrae. How do you know these are cervical ribs? And

not the 1st thoracic ribs?

Look at the transverse processes that articulate with these ribs. Cervical transverse processes points down while thoracic transverse processes points up.

CervicalTransverseProcessesPoints Downwards=CD

ThoracicTransverseProcessesPoints Upwards =TU

THE BLACK & WHITERADIOLOGICALTERMS

Edw

ard Jenner

AIR

FAT

BLOOD

MUSCLE

BONE

BARIUM

RADIOLUCENT

RADIOPAQUE

INC

RE

AS

ING

RA

DIO

DE

NS

ITY

DE

CR

EA

SIN

G R

AD

IOD

EN

SIT

Y

RADIODENSITY SCALE

radioLucent = bLack radiopaquE = whitE

Radiodensity : Physical quality of an object that determines how muchradiation it absorbs from the X-Ray beam. Radiodensity is determined

by composition ( atomic weight) and thickness

“WHITE IMAGES” “BLACK IMAGES”

The greater the density, the lesserthe penetration of the X-Raysthrough the object.

The lesser the density, the greaterthe penetration of the X-Raysthrough the object

The film remains less exposed The film is more exposed

White Image Black Image

Term used : RadiodenseOr Radiopaque

Term Used : Radiolucent

RADIODENSITY SCALE

Term Density Appearance Example

Radiolucent Low Black Air, Fat

Radiodense(Opaque)

High White Bone, Barium

RADIODENSERADIOPAQUE

RADIOLUCENT

RADIODENSE VERSUS RADIOLUCENT

“What is the student but a lover courting a fickle mistress who ever eludes his grasp?”

Sir William Osler

Antonie

von Leeuw

enhoek

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