Evaluating the Chest Radiograph

Step 4:  Bones and soft tissues

Many algorithms have been promoted describing the 'correct' way to evaluate the information on the Chest Radiograph and other radiographs for that matter.   All of the methods that are used are correct, provided that the user consistently apply their method every time they evaluate a film.  

In the evaluation of the Bones and Soft Tissues, it is suggested that the observer start at the periphery and work towards the center of the film.   Using this approach, first observations should include the following: Is the soft tissue of a normal, increased (obesity) or decreased (chronic illness) thickness.  Are there any unusual soft tissue densities? calcifications? metallic objects? gas collections (sub-cutaneous emphysema or abscess)?  Are both breasts present in a female patient? 

Relatively thin soft tissues. Note the metal foreign body which in this case represents a pierced nipple.  Both breasts are clearly present.

Fairly thick soft tissues suggesting obesity

 

As the observer moves towards the center, the bony thorax can be evaluated.  There is some logic to starting by evaluating the visualized bones of the shoulder girdle.  Are there abnormalities of the visualized bones? (destruction, spurs, degenerative changes).  The ribs and spine are then evaluated.  Are all the ribs present?  Are there fractures?  Are there destructive bone changes?  Do the vertebrae appear intact.  Are there compression fractures? (note:  best seen on lateral in most cases)  What about the clavicles, are they intact?  Are the companion shadows present? (soft tissue line seen just above the clavicle in the normal patient.