Radiography Dx

Synonyms: X-ray, conventional radiography, roentgenograms.

Description: Radiography is an imaging method used in assessment of osseous and soft tissue structures. Conventional radiography is useful in the diagnosis and staging of articular and osseous disorders.

Method: Symptomatic structures should be imaged from several views to allow a circumferential view of articular structures. Both the imaging equipment and film used in conventional radiography vary, as do the clarity and resolution of films obtained. The quality of radiographs can be enhanced by using faster machines and single-emulsion film cassettes without an intensifying screen. Ensuring patient comfort during the imaging procedure results in more reliable images. Those in pain or with severe deformities that limit proper positioning may have difficulty complying with the imaging process.

Recommended Views: The use of proper technique, patient positioning, and selected views may eliminate the need for further diagnostic studies. The following is a list of commonly requested views during routine radiography. These may be modified in accord with the clinical picture or after consultation with an experienced musculoskeletal radiologist.
—Hand/wrist: Posteroanterior and oblique (“pincer” or “ball catchers”) views.
—Elbows: Anteroposterior (AP) and lateral views.
—Shoulders: AP (with internal and external rotation) views; consider axillary view.
—Cervical spine: AP, obliques, lateral (extension and flexion), and open-mouthed views.
—Lumbar spine: AP, obliques, lateral, and L5–S1 views.
—Hips: AP of the pelvis and “frog leg” (external rotation) views.
—Sacroiliac joints: AP pelvis and AP with 30-degree cephalad angle.
—Knees: Standing AP and lateral views; axial (“sunrise”) view is best for the patella.
—Ankles: AP and lateral views.
—Feet: AP, oblique, and lateral views.

Abnormal Findings: A limited number of abnormalities can be identified by standard radiography. Such reports often comment on soft tissue alterations (e.g., effusions, calcification), articular malalignment (e.g., swan-neck deformity), bone stock (e.g., osteopenia, osteoporosis), joint space (implying cartilage thickness), changes in cortical bone (e.g., fracture, erosions, osteophytes, periosteal reaction), or subcortical bone (e.g., cysts). A poor correlation exists between clinical symptoms and radiographic changes in many disorders, but this is especially true in osteoarthritis. Findings of osteopenia are nonspecific because it is seen in a variety of inflammatory and metabolic disorders.

Indications: Plain x-rays are most appropriate when there is a history of trauma, suspected chronic infection, progressive disability, or monarticular involvement; when therapeutic alterations are considered; or as a baseline assessment for what appears to be a chronic process. Diagnostic patterns of radiographic change may be seen in conditions such as gout, pseudogout, RA, psoriatic arthritis, spondyloarthropathy, reflex sympathetic dystrophy, osteonecrosis, osteoarthritis, and diffuse idiopathic skeletal hyperostosis. Generalized bone surveys are not routinely recommended, unless evidence of skele- tal metastases or Paget disease of bone is sought. In most inflammatory disorders, early radiographs rarely help to establish a diagnosis and may only reveal soft tissue swelling or juxtaarticular demineralization.

Alternatives: Bone scans, computed tomography, and MRI are other modalities often used in evaluation of rheumatic complaints. Such modalities are far more costly and also have limited indications.

Cost: $100–300 per site (depends on locale and extent).