INTRODUCTION TO IMAGE CRITIQUE

Rini Indrati

JURUSAN TEKNIK RADIODIAGNOSTIK

DAN RADIOTERAPI
POLTEKKES KEMENKES SEMARANG
 Terminology
Positioning and anatomical placement terms.
Anterior (antero-) Frequently used combinations
Distal (disto-) – Anteroinferior
Inferior (infero-) – Anterolateral
Lateral (latero-) – Anteromedian
– Anteroposterior
Lateral position
– Anterosuperior
Medial (medio-) – Inferolateral
Oblique position – Inferosuperior
Posterior (postero-) – Lateromedial
Proximal (proximo-) – Mediolateral
Superior (supero-) – Posteroanterior
– Posteroinferior
– Posterolateral
– Posteromedian
– Posterosuperior
– Superoinferior
– superolateral
 Terms for body planes
Coronal
Midcoronal
Midsagittal (median)
Sagittal
Longitudinal
Transverse, horizontal, or crosswise.
 General terminology
Abduct Condyle
Adduct Convex
Align Cortical outline
Articulation Depress
Artefact Detail
Caudal Deviate
Cephalic Dorsiflex
Concave Elongate
elevate
 General terminology
Extension Profile
Flexion Pronate
Foreshorten Protract
Lateral (external) rotation Radiographic image
Magnification Radiolucent
Medial (internal) rotation Radiopaque
Object-image-distance OID. Retract
– This is OFD Source-image-distance
Palpate – This is FFD
Plantar flexion Superimpose
Supination
Symmetrical
Trabecular pattern
 Hanging radiographs
Before any critiquing is done the
radiograph should be correctly hung on the
viewing box.
Or displayed correctly on viewing monitor
in a CR department.
 Hanging radiographs
Torso, vertebral, cranial, shoulder and hip x-rays.
– As if patient is standing in upright position
Finger, wrist, and forearm x-rays.
– As if patient is hanging from fingertips
Elbow, humerus x-rays.
– As if hanging from shoulder
Toes, AP/Oblique foot x-rays.
– As if patient is hanging from toes
Lateral foot, ankle, lower leg and femur x-rays.
– As if hanging from hip
Decubitus chest and abdominal x-rays.
– As x-ray radiograph was acquired, i.e. if left side up then with left side
up.
Axiolateral positions of the shoulder and hip x-rays.
– Anterior surface up, and posterior surface down.
 Hanging radiographs
Anteroposterior(AP), Posteroanterior (PA) and oblique.
– AP/PA projections or oblique should be placed on viewing box
as if patient and radiographer are facing each other.
– Marker should appear in its correct orientation regardless of
projection
Lateral positions of the torso, vertebrae and cranium.
– Marker to be placed on the lateral aspect representing side
closest to film.
Extremities.
– Viewed in the same manner as the photons went through the
region
 Radiographic evaluation
The radiographic critique form
Once correctly viewed (hung/displayed). The
radiograph should be assessed for positioning
and technical accuracy
this should follow a consistent method, this will
ensure that all aspects of the radiograph are
evaluated
Identification.
– Facility identification (name of institution)
– Patient ID (Name, DOB)
– Exam ID (date of examination, and time of
examination)
– ID placement (not obscuring and anatomy of interest)
(Mcquillin-Martensen, Radiographic Critique. 1996.)
 Radiographic Critique form

Radiographic critique form

Examination…………………………………………………………………………….

ID requirements
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Correct use of markers
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Anatomy of interest on radiograph?
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Are the anatomical features in the correct alignment for this projection?
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Is collimation adequate? Keeping ALARA in mind.
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Radiation protection, present, obscuring anatomy?
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Bony cortical outline, bony trabecular pattern and or soft tissue structures sharply
defined?
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Radiograph demonstrated without distortion?
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Correct film size, correct alignment of anatomical region of interest?
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Correct image receptor utilised?
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Density and penetration adequate?
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adequate contrast?
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Preventable artefacts?
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The desired outcome (i.e. ordered x-ray demonstrates region of interest
diagnostically)?
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Radiograph is:…………………..Acceptable…………………….Unacceptable.

What could be done differently to overcome any inaccurate techniques?

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 Markers
Lead markers
Brass markers
Barium sulphate.
Other metals and radiopaque material
Used to demonstrate right and left sides, elapsed
time, and variations in standard practice.
Is the marker within the collimated field?
Is the marker positioned over region of interest?
Is the marker positioned in the best possible location?
Is the marker correctly oriented?
 Marker placement
Top corner
Bottom corner
Lateral aspect of
region examined
 Required anatomy
Is this present on the
radiograph?
Is the anatomy of
interest demonstrated
in its entirety , and
correct for this
particular
projection/position?
 Correct relationship between
anatomical structures
Are they accurately
displayed for the selected
projection/position??
Free from undesired
superimposition?
That means correctly
positioned.
How should the patient’s
positioning be adjusted
before repeating the x-
ray?
 Collimation
Evidence of collimated border on all four sides of
the radiograph?
– Good collimation practices are essential in reduction of
radiation dose
– Good collimation practice is essential in detailed
radiography. Due to reduction of scattered radiation
reaching image receptor.
Collimation to skin edge on all extremities, chest
and abdominal radiographs
Have you collimated to the desired region of
interest?
Are all the anatomical structures of the region of
interest displayed on the collimated radiograph?
 Radiation protection
gonadal shielding
Correct gonadal shielding have proved to reduce
radiation exposure by about 50% in females, and
around 90-95% in males. (Mcquillin-Martensen, Radiographic Critique. 1996.)
Gonadal shielding is often not utilised due to fear
of misposition and covering up vital information.
Radiographers will argue that the radiograph
without shielding will require fewer repeat film.
This is a bad argument, as if lead protection is
positioned correctly the same outcome will be
achieved.
As professional technologists, you should always
strive to produce the best and safest diagnostic
images you are capable of.
 Radiographic appearance
What makes a diagnostic
Radiograph?
– Exposure
– Distance
– Positioning
– Scatter reduction
Bony cortical outline
– Hard dense line of bone
edge
Bony trabecular pattern
– Honeycomb appearance
inside bone edge
Soft tissue structures
– Adequate for region of
interest
 Distortion
Is the radiograph
displayed without
distortion?
Primary beam
angulation
Incorrect positioning
technique
Undesirable
positioning technique
 Distortion
Can be used to your
advantage
– Clavicle
– Scaphoid
Film size / alignment of anatomy
Size of film cassette relative to area of interest or
series of images.
– Smallest possible film size
Was the film positioned crosswise or lengthwise
to accommodate required anatomy / body
habitus?
Alignment of anatomy should be aesthetically
correct.
All multiple image radiographs must have
anatomy aligned in same direction
 Image receptor
Have you chosen the correct image
receptor system for the region of interest?
Correct combination of film and screen
speed, for desired area.
– Slow speed (fine detail)
– Medium speed (detail)
– Fast speed (general)
– Chest
 Is the penetration and density
adequate?
Does the x-ray demonstrate bony
trabeculae and soft tissue information
Is the image under exposed or over
exposed?
How much adjustment should be done to
correct these?
– Manual exposures
– Automatic exposures
 Contrast
Does the radiographic contrast
demonstrate the bony and soft tissue
adequately?
Minimal scattered radiation
 Preventable artifacts
Are there any on the radiograph
Can you identify the artifact
Can you remove the artifact

– Internal and external artifacts

Non preventable artifacts

Can you identify the artifact
Can you locate the artifact
 Desired outcome
Has the routine protocol been taken for the
region of interest as indicated by the
referring physician
Is the routine protocol sufficient in
demonstrating the required information, or
are additional views required?
 Have you filled out RCF
Is it complete
Repeat/reject analysis?
 PACEMAN
Position
Area
Collimation
Exposure
Markers
Aesthetics
Name
 PACEMAN
(P) - Position:
– Is the patient in the correct position?
– Is the patient rotated?
– Does the image correctly show any needed joint
spaces?
(A) - Area:
– Is enough of the area being filmed covered? eg: In an
abdominal film is pubic symphysis to diaphragms
covered?
– Have you exposed an area that is not required?
 PACEMAN
(C) - Collimation:
– Is the image properly collimated? eg is four way
collimation seen on an extremities film?
(E) - Exposure:
– Were the exposure factors set correctly?
– Does the image show the correct contrast and
density?
– Are there any factors that need to be changed to
produce a better image?
 PACEMAN
(M) - Markers:
– Have markers been placed on the image?
– Are they correctly identifying left and right?
(A) - Aesthetics:
– Is the image nice to look at?
– Is it centered on the film?
– Is there four way collimation?
(N) - Name:
– Does the image correctly identify the patient?
– Does it have any other relevant identification details?
eg episode number or department labels?