Don’t Rush: A Systematic Approach To X-rays

One of my responsibilities in our emergency hospital is the training and mentoring of veterinarians new to the field of emergency and critical care. A common area that I have found where clinicians request more training is radiographic interpretation. When I review radiographs and I find pathology that was missed it is more often due to a lack of systematic approach to reviewing a radiograph rather than experience or knowledge of that clinician.

There is of course, no one set way you should go about interpreting a radiograph, whatever the method the entire radiograph should be assessed not just the area of interest.

1) Try not to struggle with your patient, if possible appropriately sedate your patient or even anaesthetise if safe to do so. This reduces stress for everyone involved and gives your a greater chance to get a good radiograph. For musculoskeletal radiographs, you often need to manipulate painful joints and limbs to get diagnostic images.

2) Take appropriate views: For example I aim to get 3 plane projections for thorax and abdominal radiographs, i.e. left and right laterals and VD (or DV). Three views are critical for the assessment of both lung fields and also to be able to interpret abdominal gas patterns more effectively.

3) Collimate, rotate, crop, label and adjust the image appropriately: Displaying radiographs in a standardized method is important for proper assessment. Reviewing anatomy in the same way every time helps develop an understanding of normal and makes identifying abnormalities easier.

4) This is my top rule: IGNORE the area you are interested in first. This means, if you are interested in looking at the GI tract in a vomiting dog, try to not focus on the stomach and intestines initially on your radiograph.

3) Start at the periphery. This means things like the spine, subcutaneous tissue etc. You would be surprised how often lesions are missed in these areas!

4) Then, take a look at the cavity space, i.e. the pleural and abdominal space. You should not be able to see the pleural space of course, and you should see no evidence of air or fluid in the abdominal space. When it comes to musculoskeletal radiographs, don’t forget to consider joint cavities and soft tissue structures such as ligaments and tendons.

5) Lastly, make sure you assess every organ (again leaving your organ of interest to the last). Things that can often be overlooked include the prostate, kidneys, and mediastinal region. At the end of this, I always ask myself, have I missed an organ?

6) Another thing I like to do is to sometimes take a step back, literally, and assess the radiograph again. I find this gives you a better global view of the projection, as opposed to staring at it up close.

When we focus on our area of interest, we start developing the habit of a tunnel vision approach towards radiograph interpretation, which introduces the potential for missing lesions.