Each person more than once in his life took X-rays, which are so necessary to clarify the diagnosis. This procedure is for all age groups: both for babies of the first year of life, and for the elderly. Based on this, many people have a question, how often can an x-ray be taken. This article will answer this question in as much detail as possible.
Is radiography considered dangerous?
The body of all people is characterized by individual resistance to radiation. But despite this, there are generally accepted indicators that medical professionals adhere to. Answering the question of how many times a year an X-ray can be done, some doctors are of the opinion that the frequency of this procedure depends on how much the patient's condition requires.
Sometimes frequent monitoring is necessary for the timely detection of pathologies. This opinion is not always rational, since more chest diseases can be detected using the safest methods, which include:
- general blood analysis;
- ultrasound diagnostics;
- listening.
This judgment is rational in the presence of suspicions of lung cancer or pneumonia. X-rays load the human body. X-rays are especially dangerous when living in conditions of increased environmental pollution, which is acceptable to any large industrial city. Of course, it is best to avoid frequent examinations if possible, but it happens that there is an urgent need for radiography.
Important! If the patient suffers serious illness, for example, a complex stage of pneumonia, then the procedure is allowed to be carried out several times a month. In this case, the risk from the disease will be higher than the possible harm from x-ray exposure.
A modern diagnostic device is considered a rather expensive device.
In addition, answering the question of how harmful X-rays are, most doctors argue that serious radiation exposure is possible only when using an old device. Today there is a big difference between the x-ray equipment of the last century. A modern device significantly reduces the dosage of radiation that has a negative effect on the patient.
In addition, there is a non-destructive body X-ray, in which the study is carried out on the selected area. Radiation load, which is directed to a separate area, is subjected to patients undergoing CT, MRI.
How often can x-rays be taken?
The question often arises of how often it is allowed to take x-rays for an adult and a child. This is especially true when the availability of images is necessary for several doctors, for example, for a pulmonologist and a cardiologist. If the patient's condition is stable, then the picture is valid for 1 year.
There is no unequivocal answer to the question of how many times an x-ray can be done, since it depends on the individuality of the patient, his condition, age, stage of the disease, and the features of the x-ray machine. For different categories, there is an individually permitted frequency of the study.
X-rays of the extremities of children are allowed to be carried out no more than 5 times a year. Radiation exposure is harmful not only to babies, but also to adolescents. Examination of the brain, trunk is not recommended without the presence of viscous indications.
Although the most modern devices have a weak radiation background, which practically does not have a detrimental effect on the body of children.
An examination of an adult is carried out based on the following standards:
- X-rays of the lungs in adults should not be done more than 1 time per year. However, some professions require more frequent examinations, in which case the x-ray is replaced by fluorography, which has a more weakened radiation effect.
- X-ray of the teeth is carried out no more than once a year, when the rays are fed through the spine or brain. If the survey is carried out from the side and has a point effect on the teeth, then it is allowed to do an examination up to 5 times a year.
- The sinuses are allowed to be removed no more than once a year, since they are close to the brain.
- Examination of the spine is the most unfavorable procedure, with the frequency of which it is better not to overdo it. Usually it does not exceed once a year.
Dental x-ray photo - low dose procedure
Important! CT carries the highest radiation load, the number of micro-roentgens during this procedure reaches 1100 mR per hour.
Is it possible to do an x-ray of a nursing woman
There are situations when a nursing woman needs to take an x-ray. At the same time, many people have a natural question whether it is possible to feed a child after the procedure. And today, fluorography is carried out even within the walls of the maternity hospital. In this case, it is recommended to feed before the procedure. After the X-ray, the milk must be expressed and poured out.
The next feeding can be carried out as usual. If a woman is being examined for the intended purpose, especially with the use of a dye, then it is recommended to refrain from breastfeeding during the day. Important! When taking x-rays for a nursing woman, the chest area should be covered with a protective screen.
Is it possible to reduce the negative impact of x-rays with frequent
In order for radiography to bring as few negative effects as possible, it is recommended to adhere to the following simple recommendations:
- first of all, you can strengthen the body by taking antioxidants, for example, the Omega-3 complex;
- you can increase immunity with the help of vitamin preparations, consisting of vitamins of the P, B, A, E, C groups;
- should be consumed before the procedure and after it more fermented milk products;
- if you eat oatmeal, prunes, granular bread, then you can remove the harmful elements that have entered the body during the examination.
Radiography is sometimes necessary and far from useful procedure which allows early detection of many diseases. Its frequent use can cause irreparable consequences for the body.
Review
Of all the radiation diagnostic methods, only three: x-rays (including fluorography), scintigraphy and computed tomography, are potentially associated with dangerous radiation - ionizing radiation. X-rays are capable of splitting molecules into their component parts, therefore, under their action, the membranes of living cells can be destroyed, as well as damage to DNA and RNA nucleic acids. Thus, the harmful effects of hard X-ray radiation are associated with the destruction of cells and their death, as well as damage to the genetic code and mutations. In ordinary cells, mutations over time can cause cancerous degeneration, and in germ cells, they increase the likelihood of deformities in the future generation.
The harmful effect of such types of diagnostics as MRI and ultrasound has not been proven. Magnetic resonance imaging is based on the emission of electromagnetic waves, and ultrasound examinations- on the emission of mechanical vibrations. Neither is associated with ionizing radiation.
Ionizing radiation is especially dangerous for body tissues that are intensively renewed or growing. Therefore, first of all, the following suffer from radiation:
- bone marrow, where the formation of immune cells and blood occurs,
- skin and mucous membranes, including the gastrointestinal tract,
- fetal tissue in a pregnant woman.
Children of all ages are especially sensitive to radiation, since their metabolic rate and cell division rate are much higher than in adults. Children are constantly growing, which makes them vulnerable to radiation.
At the same time, X-ray diagnostic methods: fluorography, radiography, fluoroscopy, scintigraphy and computed tomography are widely used in medicine. Some of us expose ourselves to the rays of an X-ray machine on our own initiative: in order not to miss something important and to detect an invisible disease at a very early stage. But most often, a doctor sends for radiation diagnostics. For example, you come to the clinic to get a referral for a wellness massage or a certificate to the pool, and the therapist sends you for a fluorography. The question is, why this risk? Is it possible to somehow measure the "harmfulness" with an x-ray and compare it with the need for such a study?
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Accounting for radiation doses
By law, each diagnostic examination related to X-ray exposure must be recorded on a radiation dose record sheet, which is filled out by a radiologist and pasted into your outpatient card. If you are examined in a hospital, then the doctor must transfer these numbers to the extract.
In practice, this law is rarely followed. IN best case you will be able to find the dose you were exposed to in the conclusion of the study. At worst, you will never know how much energy you received with invisible rays. However, your full right is to demand information from the radiologist about how much the “effective dose of radiation” was - this is the name of the indicator by which the harm from x-rays is assessed. Effective radiation dose is measured in millisieverts or microsieverts - abbreviated "mSv" or "µSv".
Previously, radiation doses were estimated according to special tables, where there were averaged figures. Now every modern X-ray machine or CT scanner has a built-in dosimeter, which immediately after the examination shows the number of Sieverts you received.
The dose of radiation depends on many factors: the area of the body that was irradiated, the hardness of the x-rays, the distance to the ray tube and, finally, specifications the apparatus on which the study was conducted. The effective dose received in the study of the same area of the body, for example, the chest, can vary by a factor of two or more, so after the fact it will be possible to calculate how much radiation you received only approximately. It is better to find out right away, without leaving the office.
What examination is the most dangerous?
To compare the "harmfulness" of various types of x-ray diagnostics, you can use the average effective doses shown in the table. This data is from guidelines No. 0100 / 1659-07-26, approved by Rospotrebnadzor in 2007. Every year the technique improves and the dose load during research can be gradually reduced. Perhaps in clinics equipped with the latest devices, you will receive a lower dose of radiation.
| Part of the body, organ | Dose mSv/procedure | |
|---|---|---|
| film | digital | |
| Fluorograms | ||
| Rib cage | 0,5 | 0,05 |
| limbs | 0,01 | 0,01 |
| cervical spine | 0,3 | 0,03 |
| Thoracic spine | 0,4 | 0,04 |
| 1,0 | 0,1 | |
| Pelvic organs, thigh | 2,5 | 0,3 |
| Ribs and sternum | 1,3 | 0,1 |
| radiographs | ||
| Rib cage | 0,3 | 0,03 |
| limbs | 0,01 | 0,01 |
| cervical spine | 0,2 | 0,03 |
| Thoracic spine | 0,5 | 0,06 |
| Lumbar spine | 0,7 | 0,08 |
| Pelvic organs, thigh | 0,9 | 0,1 |
| Ribs and sternum | 0,8 | 0,1 |
| Esophagus, stomach | 0,8 | 0,1 |
| Intestines | 1,6 | 0,2 |
| Head | 0,1 | 0,04 |
| Teeth, jaw | 0,04 | 0,02 |
| kidneys | 0,6 | 0,1 |
| Breast | 0,1 | 0,05 |
| Fluoroscopy | ||
| Rib cage | 3,3 | |
| gastrointestinal tract | 20 | |
| Esophagus, stomach | 3,5 | |
| Intestines | 12 | |
| Computed tomography (CT) | ||
| Rib cage | 11 | |
| limbs | 0,1 | |
| cervical spine | 5,0 | |
| Thoracic spine | 5,0 | |
| Lumbar spine | 5,4 | |
| Pelvic organs, thigh | 9,5 | |
| gastrointestinal tract | 14 | |
| Head | 2,0 | |
| Teeth, jaw | 0,05 | |
Obviously, the highest radiation exposure can be obtained when undergoing fluoroscopy and computed tomography. In the first case, this is due to the duration of the study. Fluoroscopy is usually performed within a few minutes, and an x-ray is taken in a fraction of a second. Therefore, during a dynamic study, you are irradiated more strongly. Computed tomography involves a series of images: the more slices, the higher the load, this is the price for the high quality of the resulting image. The dose of radiation during scintigraphy is even higher, since radioactive elements are introduced into the body. You can read more about the difference between fluorography, radiography and other radiation methods.
To reduce the potential harm from radiation studies, there are remedies. These are heavy lead aprons, collars and plates, which a doctor or laboratory assistant must provide you with before diagnosis. You can also reduce the risk from x-rays or computed tomography by spreading the studies as far as possible in time. The effect of radiation can accumulate and the body needs to be given time to recover. Trying to do a full body scan in one day is unreasonable.
How to remove radiation after x-ray?
Ordinary X-ray is the effect on the body of gamma radiation, that is, high-energy electromagnetic oscillations. As soon as the device is turned off, the effect stops, the irradiation itself does not accumulate and is not collected in the body, so nothing needs to be removed. But with scintigraphy, radioactive elements are introduced into the body, which are the emitters of waves. After the procedure, it is usually recommended to drink more fluids in order to get rid of the radiation sooner.
What is the acceptable radiation dose for medical research?
How many times can you do a fluorography, X-ray or CT scan so as not to harm your health? It is believed that all these studies are safe. On the other hand, they are not carried out in pregnant women and children. How to figure out what is true and what is myth?
It turns out that there is no acceptable dose of radiation for a person when conducting medical diagnostics, even in official documents Ministry of Health. The number of sieverts is subject to strict accounting only for employees of X-ray rooms, who are irradiated every day for the company with patients, despite all protective measures. For them, the average annual load should not exceed 20 mSv, in some years the radiation dose may be 50 mSv, as an exception. But even exceeding this threshold does not mean that the doctor will begin to glow in the dark or that he will grow horns due to mutations. No, 20–50 mSv is just the limit beyond which the risk increases harmful effects radiation per person. The dangers of average annual doses below this value could not be confirmed over many years of observation and research. At the same time, it is purely theoretically known that children and pregnant women are more vulnerable to x-rays. Therefore, they are advised to avoid exposure just in case, all studies related to X-ray radiation are carried out with them only for health reasons.
Dangerous dose of radiation
The dose beyond which radiation sickness begins - damage to the body under the action of radiation - for a person is from 3 Sv. It is more than 100 times higher than the allowable annual average for radiologists, and to get it ordinary person medical diagnosis is simply impossible.
There is an order of the Ministry of Health, which introduced restrictions on the radiation dose for healthy people during medical examinations - this is 1 mSv per year. This includes usually such types of diagnostics as fluorography and mammography. In addition, it is said that it is forbidden to resort to X-ray diagnostics for prophylaxis in pregnant women and children, and it is also impossible to use fluoroscopy and scintigraphy as a preventive study, as the most "severe" in terms of exposure.
Quantity x-rays and tomograms should be limited by the principle of strict reasonableness. That is, the study is necessary only in cases where refusing it will cause more harm than the procedure itself. For example, if you have pneumonia, you may need to take a chest X-ray every 7 to 10 days until you are fully recovered to monitor the effect of antibiotics. If we are talking about a complex fracture, then the study can be repeated even more often to make sure that the bone fragments are correctly compared and the formation of callus, etc.
Is there any benefit from radiation?
It is known that in the nome a natural background radiation acts on a person. This is, first of all, the energy of the sun, as well as radiation from the bowels of the earth, architectural buildings and other objects. The complete exclusion of the action of ionizing radiation on living organisms leads to a slowdown in cell division and early aging. Conversely, small doses of radiation have a restorative and therapeutic effect. This is the basis for the effect of the well-known spa procedure - radon baths.
On average, a person receives about 2–3 mSv of natural radiation per year. In comparison, with digital fluorography, you will receive a dose equivalent to natural radiation for 7-8 days a year. And, for example, flying on an airplane gives an average of 0.002 mSv per hour, and even the operation of the scanner in the control zone is 0.001 mSv per pass, which is equivalent to a dose for 2 days ordinary life under the sun.
All materials on the site have been checked by doctors. However, even the most reliable article does not allow taking into account all the features of the disease in a particular person. Therefore, the information posted on our website cannot replace a visit to the doctor, but only complements it. Articles are prepared for informational purposes and are advisory in nature. If symptoms appear, please consult a doctor.
Fluorography has been included in the compulsory medical examination program for many years. The procedure is technically simple and is a low-cost preventive examination method. However, in last years Increasingly, doctors are abandoning fluorography in favor of x-rays. Why? What are the features of X-ray examination? Let's consider the issue in detail.
What is the difference between a chest x-ray and a chest x-ray?
A chest x-ray is an informative and detailed examination. It allows you to diagnose:
The principle of taking a picture using x-rays is based on the difference in the absorption of radioactive particles by body tissues. Thus, calcium-rich bones of the skeleton retain the maximum number of X-rays. As a result, in the resulting image, the bone tissues look the brightest. Fat, muscle, fluids and connective tissue absorb less x-ray radiation. Therefore, in the picture they are displayed in grayscale. Air transmits a maximum of X-rays through itself. Because of this, the cavities filled with it look the darkest.
But what is the difference between classic fluorography and x-ray ? It would seem that the principle of diagnostics is the same and there should be no differences, but they exist and are due to differences in imaging technologies. First of all, every person going to the X-ray room should know that:
- during a fluorographic examination, the small size of the pathology is visible only as subtle threads, therefore, when the slightest suspicion appears, an x-ray is prescribed. Thus, today fluorography is more likely to be a preventive research method;
- X-ray allows you to get an image with a resolution an order of magnitude higher, thanks to which they can be increased to huge sizes;
- the radiation dose obtained with x-rays is several times less.
Traditional fluorography is recognized as an outdated method and is no longer used in many countries. Whereas radiography is a more accurate method of diagnosing, allowing not only to identify pathological processes on early stages, but also promptly monitor their change. However, the price of an x-ray is several times higher than the classic fluorographic analysis.
Indications for x-ray and fluorography
X-rays may be triggered by a variety of symptoms. The main ones are pain in the lungs, dry cough, hemoptysis, general weakness and unreasonable weight loss.
Note!
There are no categorical contraindications for the passage of x-rays of the lungs. But sending a pregnant woman for examination, the doctor must carefully weigh all the pros and cons.
Mandatory fluorography is provided for preventive purposes for patients:
- who applied to a medical institution for the first time;
- living with newborns and pregnant women;
- who are conscripts or entering military service under a contract;
- diagnosed with HIV infection.
How often can an x-ray be done and is it harmful?
The increase in knowledge about the effect of X-ray radiation on the human body has launched the process of developing state and international standards, regulating the permissible amount of exposure.
Modern methods of X-ray diagnostics involve the use of negligible doses of radiation that are absolutely safe for the human body. However, in order not to endanger yourself, you should not exceed the average annual exposure. Russian official medicine considers a permissible dose of 1.4 mSv per year per person. For comparison: in the USA and France, the average effective annual dose corresponds to 0.4 mSv, in Japan - 0.8 mSv, the UK adheres to the standard of 0.3 mSv. If you undergo radiography in the best clinics in the country using digital equipment, then you will not receive more than 0.03 mSv for 1 procedure. Outdated film x-ray machines give a one-time exposure of 0.3 mSv, which is the annual norm for the UK.
It is worth saying that modern digital equipment used for X-ray diagnostics emits a dose comparable to that acquired in the natural environment in 10 days. Such an X-ray system minimizes the risk of possible adverse effects of rays on the human body.
The question of how often an x-ray of the lungs is acceptable is an individual one. The doctor decides it by evaluating general state health of the patient and the level of achievement of the average permissible dose of radiation.
If we talk about pregnant women and children, then they are much less likely to be prescribed an X-ray examination. However, even these patients undergo it if necessary. The availability of modern equipment with reduced radiation exposure, compliance with safety regulations and competent maintenance of the X-ray diagnostic system are the key to an effective and harmless examination. Unlike x-rays, fluorography is legally prohibited for children under 15 years of age.
Description of the lung x-ray procedure
An x-ray examination of the lungs does not require any preparation of the patient for analysis. As well as a departure from the usual way of life after its implementation.
A modern X-ray machine is a complex high-tech equipment that allows you to notice changes in the size of less than 1 mm. With the results of the examination, provided in a few minutes, you can contact any medical institution. The resulting image format meets Russian and international standards.
The X-ray examination procedure takes only a few minutes. Thanks to the introduction innovative technologies the process has become instantaneous, the information is immediately displayed on the screen.
To perform an X-ray analysis, undress to the waist and remove all metal jewelry. The presence of hairpins or buttons on clothing can degrade the quality of the picture. Modern equipment allows you to shoot in underwear, the main thing is that it does not contain synthetics and metal. It is possible to perform the procedure in a standing, lying or sitting position. The patient is asked to hold their breath while the x-rays are being taken. If a child is examined, the specialist himself chooses optimal time procedures.
It is also worth noting that at present there are two approaches to performing the study - survey and sighting radiography. A survey x-ray examination of the lungs means taking pictures in two projections: frontal and lateral. Aiming technique consists in focusing the device on a certain area.
Analysis of X-ray images of the lungs
The results of X-ray examination are presented in one of three options:
- on paper (allowed if no pathologies are found);
- on a special film (printed on a special high-resolution printer);
- directly in digital form (occurs only in the case of radiography), and not only in a standard graphic format, but also in DICOM or RAW formats, with a specialized viewer program placed on disk.
The difference between "medical" files and "classic" files is fundamental: special graphic formats allow you to store incomparably more information in a file that becomes visible to the human eye after applying filters and limiters provided by viewer programs.
By examining an image created by divergent X-beams, radiologists analyze areas of clearing and darkening. Starting the protocol for describing the radiograph of the lungs, the radiologist, first of all, indicates in which projection the image was taken.
Then the absence of focal and infiltrative shadows is mentioned. The presence of focal blackouts indicates damage to the lungs by a tumor, tuberculosis, or an occupational disease (asbestosis, talcosis, silicosis). Infiltrative shadows, if present, signal pneumonia, edema, or helminthic invasion.
If there are no disturbances in the blood supply and circulation in the small and large circle, there are no abdominal and cystic formations, no congestion is observed, the description protocol contains a phrase that the pulmonary pattern is not deformed and has a clear shape.
The phrase about the structure of the roots of the lungs, the absence of their expansion indicates the absence of additional shadows that can affect the “move” pulmonary artery and increase lymph nodes mediastinum. Changes seen here may indicate sarcoidosis, swollen lymph nodes, pulmonary congestion, and mediastinal tumors.
The presence of a shadow of the mediastinum without features will indicate that the specialist did not find additional formations visible from behind the sternum. The absence of a mention of “plus shadows” on a picture taken in frontal projection cannot guarantee the absence of tumors. If the formation is small and not of a bone structure, then it can be hidden by both the sternum and the heart. Sometimes even a side shot is not able to clarify the situation.
The analysis of the x-ray image of the lungs ends healthy person a message about the unchanged diagram, the free state of the costophrenic sinuses and the absence of visible pathologies.
Image quality and diagnosis accuracy
The main reason for incorrect interpretation of the lung image is dynamic blur. In other words, the pulsation of large vessels and respiration affect the clarity of the visible contours of the formations. Proper shutter speed, powerful modern equipment, correct consideration of the distance between the object and the focus can prevent this distortion. To obtain an accurate picture, an x-ray of the lungs is performed in 2 projections. If the patient has a preliminary diagnosis that needs to be clarified, an aiming image is taken. This slightly increases the radiation dose, but the accuracy of the result is worth it.
The radiologist must also remember that synthetic fibers, metal objects and a thick tuft of hair (in women with long hair) can distort or reduce the transparency of the tops of the lung fields.
The main pathologies detected by X-ray of the lungs:
- large focal blackouts signal pneumonia or bronchial tumors;
- small focal blackouts are a sign of focal forms of pneumonia or tuberculosis;
- a large round shadow in the lungs indicates a tumor in the lung or a tuberculous process that is gaining momentum;
- a cavity in the lung is a clear sign of decomposition of lung tissues, characteristic of an abscess, decay of a tumor or focus of tuberculosis;
- fluid in the pleural cavity is a sign of pleurisy or neoplasm;
- flattening of the diaphragm indicates the presence of emphysema;
- frequent small lesions indicate tuberculosis or sarcoside.
It is also possible to find a large number of minor pathologies of the lungs and lung tissues, which, with a comprehensive analysis, can clarify the patient's diagnosis. The picture will become complete after assessing the volume of the lungs, the location of their roots, the degree of airiness of the bronchi and other physiological indicators. As you can see, digital radiography allows you to quickly and clearly conduct the most complex studies and make an accurate diagnosis in a few minutes.
Monday, 04/23/2018
Editorial opinion
Medical technologies do not stand still, and the passage of a digital x-ray is gradually becoming a common thing for Russian citizens. When choosing a clinic, it is worth evaluating not so much the quality of the equipment (it is difficult for an ordinary person to distinguish between an X-ray machine of the latest and the penultimate generation), but the professionalism of diagnosticians and the organization of the study. You must be recorded, the procedure carried out just in time, the results must be provided, which are accompanied by a comprehensive description, not only in printed form, but also in digital form.
Thank you
The site provides background information for informational purposes only. Diagnosis and treatment of diseases should be carried out under the supervision of a specialist. All drugs have contraindications. Expert advice is required!
X-ray diagnostic method. Types of x-ray examination of bones
X-ray of bones is one of the most common research conducted in modern medical practice. Most people are familiar with this procedure because the possibilities for applying this method are very extensive. List of indications for x-ray bones includes a large number of diseases. Only injuries and fractures of the limbs require repeated X-ray examination.X-ray of the bones is carried out using various equipment, there is also a variety of methods for this study. The use of the type of x-ray examination depends on the specific clinical situation, the age of the patient, the underlying disease and concomitant factors. Radiation diagnostic methods are indispensable in the diagnosis of diseases. skeletal system and play a major role in the diagnosis.
There are the following types of x-ray examination of bones:
- film radiography;
- digital radiography;
- x-ray densitometry;
- x-ray of bones using contrast agents and some other methods.
What is an x-ray?
X-ray is one of the types of electromagnetic radiation. This type of electromagnetic energy was discovered in 1895. Electromagnetic radiation is also sunlight, as well as light from any artificial lighting. X-rays are used not only in medicine, but are also found in ordinary nature. About 1% of the Sun's radiation reaches the Earth in the form of X-rays, which forms a natural radiation background.The artificial production of X-rays was made possible by Wilhelm Conrad Roentgen, after whom they are named. He was also the first to discover the possibility of their use in medicine for "translucence" internal organs, in primarily - bones. Subsequently, this technology developed, new ways of using X-ray radiation appeared, and the radiation dose decreased.
One of the negative properties of X-ray radiation is its ability to cause ionization in the substances through which it passes. Because of this, X-rays are called ionizing radiation. In high doses, X-rays can lead to radiation sickness. For the first decades after the discovery of X-rays, this feature was unknown, which led to diseases in both doctors and patients. However, today the dose of X-ray radiation is carefully controlled and it is safe to say that the harm from X-ray radiation can be neglected.
The principle of obtaining an x-ray
Three components are needed to take an x-ray. The first one is an X-ray source. The source of X-rays is an X-ray tube. In it, under the influence of an electric current, certain substances interact and release energy, from which most of it is released in the form of heat, and a small part in the form of X-rays. X-ray tubes are part of all x-ray machines and require significant cooling.The second component for obtaining a snapshot is the object under study. Depending on its density, partial absorption of X-rays occurs. Due to the difference in the tissues of the human body, X-ray radiation of different power penetrates outside the body, which leaves various spots on the picture. Where the X-ray radiation was absorbed to a greater extent, shadows remain, and where it passed almost unchanged, enlightenments form.
The third component for taking an x-ray is the x-ray receiver. It can be film or digital ( X-ray sensitive sensor). The most commonly used receiver today is X-ray film. It is treated with a special emulsion containing silver, which changes when X-rays hit it. The areas of enlightenment in the picture have a dark tint, and the shadows have a white tint. healthy bones have a high density and leave a uniform shadow in the picture.
Digital and film x-ray of bones
The first methods of X-ray research implied the use of a photosensitive screen or film as a receiving element. Today, X-ray film is the most commonly used X-ray detector. However, in the coming decades, digital radiography will completely replace film radiography, as it has a number of undeniable advantages. IN digital x-ray The receiving element of an image is sensors that are sensitive to X-rays.Digital radiography has the following advantages over film radiography:
- the ability to reduce the radiation dose due to the higher sensitivity of digital sensors;
- increase the accuracy and resolution of the image;
- simplicity and speed of obtaining a picture, no need to process a photosensitive film;
- ease of storage and processing of information;
- the ability to quickly transfer information.
X-ray of bones with contrast agent
Radiography of the bones of the extremities can be performed using contrast agents. Unlike other body tissues, bones have a high natural contrast. Therefore, contrast agents are used to clarify the formations adjacent to the bones - soft tissues, joints, blood vessels. These x-ray techniques are not used so often, but in some clinical situations they are indispensable.There are the following radiopaque techniques for examining bones:
- Fistulography. This technique involves filling the fistulous passages with contrast agents ( iodolipol, barium sulfate). Fistulas form in the bones in inflammatory conditions such as osteomyelitis. After the study, the substance is removed from the fistula with a syringe.
- Pneumography. This study involves the introduction of gas ( air, oxygen, nitrous oxide) with a volume of about 300 cubic centimeters into soft tissues. Pneumography is performed, as a rule, with traumatic injuries combined with crushing of soft tissues, comminuted fractures.
- Arthrography. This method involves filling the joint cavity with a liquid radiopaque preparation. The amount of contrast agent depends on the volume of the joint cavity. Arthrography is most commonly performed on knee joint. This technique allows you to assess the state of the articular surfaces of the bones included in the joint.
- Bone angiography. This type of study involves the introduction of a contrast agent into the vascular bed. The study of bone vessels is used in tumor formations, to clarify the features of its growth and blood supply. In malignant tumors, the diameter and location of the vessels are uneven, the number of vessels is usually greater than in healthy tissues.
X-ray and computed tomography ( CT) bones
Computed tomography is an X-ray method that has increased accuracy and information content. To date, computed tomography is the best method for examining the skeletal system. With CT, you can get a three-dimensional image of any bone in the body or sections through any bone in all possible projections. The method is accurate, but at the same time creates a high radiation load.The advantages of CT over standard radiography are:
- high resolution and accuracy of the method;
- the possibility of obtaining any projection, while X-rays are usually carried out in no more than 2 - 3 projections;
- the possibility of three-dimensional reconstruction of the studied part of the body;
- lack of distortion, compliance with linear dimensions;
- the possibility of simultaneous examination of bones, soft tissues and blood vessels;
- Possibility of real-time survey.
X-ray of bones and magnetic resonance imaging ( MRI)
Magnetic resonance imaging ( MRI) is a relatively new diagnostic method. MRI allows you to get an accurate image of the internal structures of the body in all possible planes. With the help of computer simulation tools, MRI makes it possible to perform a three-dimensional reconstruction of human organs and tissues. The main advantage of MRI is the complete absence of radiation exposure.The principle of operation of a magnetic resonance tomograph is to impart a magnetic impulse to the atoms that make up the human body. After that, the energy released by the atoms when returning to their original state is read. One of the limitations of this method is the impossibility of using in the presence of metal implants, pacemakers in the body.
MRI usually measures the energy of hydrogen atoms. Hydrogen in the human body is found most often in the composition of water compounds. Bone contains much less water than other tissues in the body, so MRI is less accurate when examining bones than it is when examining other areas of the body. In this, MRI is inferior to CT, but still exceeds conventional radiography in accuracy.
MRI is best method diagnosis of bone tumors, as well as metastases of bone tumors in remote areas. One of the serious disadvantages of this method is the high cost and time spent on research ( 30 minutes or more). All this time, the patient must take a stationary position in the magnetic resonance tomograph. This device looks like a tunnel of a closed structure, which causes discomfort for some people.
X-ray and bone densitometry
The study of the structure of bone tissue is carried out in a number of diseases, as well as in the aging of the body. Most often, the study of bone structure is carried out with a disease such as osteoporosis. A decrease in the mineral content of the bones leads to their fragility, the risk of fractures, deformations and damage to neighboring structures.An X-ray image allows you to evaluate the structure of the bones only subjectively. To determine the quantitative parameters of bone density, the content of minerals in it, densitometry is used. The procedure is fast and painless. While the patient lies motionless on the couch, the doctor examines certain parts of the skeleton using a special sensor. The most important are head densitometry data femur and vertebrae.
There are the following types of bone densitometry:
- quantitative ultrasound densitometry;
- x-ray absorptiometry;
- quantitative magnetic resonance imaging;
- quantitative computed tomography.
Densitometry is indicated in the following cases:
- osteoporosis;
- mature age ( over 40 - 50 years old);
- menopause in women;
- frequent bone fractures;
- diseases of the spine osteochondrosis, scoliosis);
- any bone damage
- sedentary lifestyle ( hypodynamia).
Indications and contraindications for X-ray of the bones of the skeleton
X-ray of the bones of the skeleton has an extensive list of indications. Various diseases may be characteristic of different ages, however, injuries or tumors of the bones can occur at any age. For the diagnosis of diseases of the skeletal system, X-ray is the most informative method. The X-ray method also has some contraindications, which, however, are relative. However, be aware that bone x-rays can be dangerous and harmful if used too frequently. Indications for bone x-ray
X-ray examination is an extremely common and informative study for the bones of the skeleton. Bones are not available for direct examination, but an x-ray can provide almost all the necessary information about the condition of the bones, their shape, size and structure. However, due to the release of ionizing radiation, an X-ray of the bones cannot be performed too often and for any reason. Indications for bone x-rays are determined quite accurately and are based on the complaints and symptoms of patients' diseases.X-ray of bones is indicated in the following cases:
- traumatic injuries of bones with severe pain syndrome, deformation of soft tissues and bones;
- dislocations and other damage to the joints;
- anomalies in the development of bones in children;
- growth lag in children;
- limited mobility in the joints;
- pain at rest or with movement of any part of the body;
- an increase in bone volume, if a tumor is suspected;
- preparation for surgical treatment;
- assessment of the quality of the treatment ( fractures, transplants, etc.).
X-ray of the bones in most cases allows differentiation between the listed diseases, due to the fact that each of them has reliable radiological signs. In difficult cases, especially before surgical operations, shows the use of computed tomography. Doctors prefer to use this study, as it is the most informative and has the least amount of distortion compared to the anatomical dimensions of the bones.
Contraindications for x-ray examination
Contraindications to X-ray examination are associated with the presence of an ionizing effect in X-rays. At the same time, all contraindications to the study are relative, since they can be neglected in emergency cases, such as fractures of the bones of the skeleton. However, if possible, the number of X-ray studies should be limited and not carried out unnecessarily.Relative contraindications for X-ray examination include:
- the presence of metal implants in the body;
- acute or chronic mental illness;
- severe condition of the patient massive blood loss, unconsciousness, pneumothorax);
- first trimester of pregnancy;
- childhood ( under 18).
- allergic reactions to components of contrast agents;
- endocrine disorders ( thyroid disease);
- severe liver and kidney disease;
Irradiation doses for various methods of X-ray examination
Modern radiation diagnostics adheres to strict safety standards. X-ray radiation is measured with the help of special dosimeters, and X-ray installations undergo special certification for compliance with radiological exposure standards. Irradiation doses are not the same for different research methods, as well as for different anatomical regions. The unit of radiation dose is milliSievert ( mSv).Irradiation doses for various bone x-ray methods
As can be seen from the data presented, computed tomography bears the greatest X-ray load. At the same time, computed tomography is the most informative method of examining bones today. It can also be concluded that digital radiography has a great advantage over film radiography, since the X-ray load is reduced by 5 to 10 times.
How often can an x-ray be taken?
X-ray radiation carries a certain danger to the human body. It is for this reason that all radiation that was received for medical purposes should be reflected in the patient's medical record. Such records should be maintained in order to comply with annual norms that limit the possible number of X-ray examinations. Thanks to the use of digital radiography, their number is sufficient to solve almost any medical problem.Annual ionizing radiation, which the human body receives from the environment ( natural background), ranges from 1 to 2 mSv. The maximum allowable dose of X-ray radiation is 5 mSv per year or 1 mSv for each of 5 years. In most cases, these values are not exceeded, since the radiation dose in a single study is several times less.
The number of X-ray examinations that can be performed during the year depends on the type of examination and the anatomical area. On average, 1 CT scan or 10 to 20 digital radiographs is allowed. However, there are no reliable data on the impact of radiation doses of 10-20 mSv annually. We can only say with certainty that to some extent they increase the risk of certain mutations and cellular disorders.
What organs and tissues suffer from ionizing radiation from x-ray machines?
The ability to cause ionization is one of the properties of X-rays. Ionizing radiation can lead to spontaneous decay of atoms, cellular mutations, failure in cell reproduction. That is why X-ray examination, which is a source of ionizing radiation, requires rationing and setting threshold values of radiation doses.Ionizing radiation has the greatest effect on the following organs and tissues:
- bone marrow, hematopoietic organs;
- lens of the eye;
- endocrine glands;
- genitals;
- skin and mucous membranes;
- the fetus of a pregnant woman;
- all organs of the child's body.
Is it possible to do bone x-rays for pregnant and lactating mothers?
Any x-ray examination is not recommended for pregnant women. According to the World Health Organization, a dose of 100 mSv almost inevitably causes fetal abnormalities or mutations leading to cancer. The first trimester of pregnancy is of the greatest importance, since during this period the most active development of fetal tissues and the formation of organs occurs. If necessary, all x-ray studies are transferred to the second and third trimester of pregnancy. Human studies have shown that x-rays taken after the 25th week of pregnancy do not lead to abnormalities in the baby.For nursing mothers, there are no restrictions in performing x-rays, since the ionizing effect does not affect the composition of breast milk. Full-fledged studies in this area have not been conducted, therefore, in any case, doctors recommend that nursing mothers express the first portion of milk while breastfeeding. This will help to play it safe and maintain confidence in the health of the child.
X-ray examination of bones for children
X-ray examination for children is considered undesirable, since it is in childhood the body is most susceptible to the negative effects of ionizing radiation. It should be noted that it is in childhood that the greatest number of injuries occur, which lead to the need to perform an X-ray examination. That is why X-rays are performed for children, but various protective devices are used to protect developing organs from radiation.An X-ray examination is also required for growth retardation in children. In this case, x-rays are taken as many times as required, since the treatment plan includes x-rays after a certain period of time ( usually 6 months). Rickets, congenital anomalies skeleton, tumors and tumor-like diseases - all these diseases require radiation diagnostics and cannot be replaced by other methods.
Preparing for a bone x-ray
Study preparation is at the heart of any successful study. Both the quality of diagnosis and the result of treatment depend on this. Preparing for an x-ray examination is a fairly simple event and usually does not create difficulties. Only in some cases, such as x-rays of the pelvis or spine, do x-rays require special preparation. There are some features of preparing children for x-rays. Parents should help doctors and properly psychologically prepare children for the study. It is difficult for children to remain motionless for a long time, they are also often afraid of doctors, people in white coats. Thanks to the cooperation between parents and doctors, it is possible to achieve good diagnosis and high-quality treatment of childhood diseases.
How to get a referral for a bone x-ray? Where is X-ray performed?
Bone X-rays can be performed today at almost any center that provides medical care. Despite the fact that today X-ray equipment is widely available, X-ray examinations are performed only with the direction of a doctor. This is due to the fact that x-rays to a certain extent harm human health and have some contraindications.X-ray of the bones is performed in the direction of doctors of different specialties. Most often, it is performed urgently when providing first aid in trauma departments, emergency hospitals. In this case, the referral is issued by the on-duty traumatologist, orthopedist or surgeon. X-rays of bones may also be performed at the direction of family physicians, dentists, endocrinologists, oncologists, and other physicians.
An x-ray of the bones is performed in various medical centers, clinics, and hospitals. To do this, they are equipped with special X-ray rooms, which have everything necessary for this kind of research. X-ray diagnostics are carried out by radiologists with special knowledge in this field.
What does an X-ray room look like? What is in it?
X-ray room - a place where x-rays are taken various parts human body. The X-ray room must meet high standards of radiation protection. In the decoration of walls, windows and doors, special materials are used that have a lead equivalent, which characterizes their ability to trap ionizing radiation. In addition, it has dosimeters-radiometers and personal radiation protection equipment, such as aprons, collars, gloves, skirts and other items.The X-ray room should have good lighting, primarily artificial, since the windows are small and natural light is not enough for high-quality work. The main equipment of the office is an X-ray unit. X-ray machines are various forms because they are designed for different purposes. All types of X-ray units are present in large medical centers, but the simultaneous operation of several of them is prohibited.
In a modern X-ray room there are the following types of X-ray units:
- stationary x-ray machine allows you to perform radiography, fluoroscopy, linear tomography);
- ward mobile x-ray unit;
- orthopantomograph ( X-ray machine for jaws and teeth);
- digital radiovisiograph.
Additional equipment for X-ray rooms includes:
- a computer for processing and storing digital images;
- film processing equipment;
- film drying cabinets;
- Consumables ( film, photoreagents);
- negatoscopes ( bright screens for viewing pictures);
- tables and chairs;
- filing cabinets;
- bactericidal lamps ( quartz) for disinfection of premises.
Preparing for a bone x-ray
The tissues of the human body, differing in different density and chemical composition, absorb x-rays differently and thus have a characteristic x-ray image. The bones have a high density and very good natural contrast, so that most bones can be x-rayed without much preparation.If a person is to have an x-ray examination of most of the bones, then it is enough to come to the x-ray room on time. At the same time, there are no restrictions on food intake, liquids, smoking before an X-ray examination. It is recommended that you do not bring any metal items with you, especially jewelry, as these will need to be removed prior to the examination. Any metallic objects interfere with x-ray.
The process of obtaining an X-ray image does not take much time. However, in order for the picture to turn out to be of high quality, it is very important for the patient to remain still during its execution. This is especially true for young children who are restless. X-rays for children are carried out in the presence of parents. For children less than 2 years old, X-rays are performed in the prone position, it is possible to use special fixation, which fixes the position of the child on the X-ray table.
One of the serious advantages of x-rays is the possibility of its use in emergency cases ( injuries, falls, traffic accidents) without any preparation. There is no loss in image quality. If the patient is not transportable or is in serious condition, then it is possible to perform an X-ray directly in the ward where the patient is located.
Preparation for X-ray of the pelvic bones, lumbar and sacral spine
An x-ray of the pelvic bones, lumbar and sacral spine is one of the few types of x-rays that requires special preparation. It is explained by anatomical proximity with the intestines. Intestinal gases reduce the sharpness and contrast of the x-ray, which is why special preparations are made to cleanse the intestines before this procedure.Preparation for x-ray of the pelvis and lumbar spine includes the following main elements:
- bowel cleansing with laxatives and enemas;
- following a diet that reduces the formation of gases in the intestines;
- conducting research on an empty stomach.
Bone X-Ray Techniques
X-ray examination is designed to examine all the bones of the skeleton. Naturally, for the study of most bones, there are special methods for obtaining x-rays. The principle of taking pictures in all cases remains the same. It involves placing the part of the body to be examined between the X-ray tube and the radiation receiver, so that the X-rays pass at right angles to the bone under examination and to the cassette with X-ray film or sensors. The positions occupied by the components of the x-ray machine relative to the human body are called stacking. Over the years of practice, a large number of x-ray stacks have been developed. The quality of x-rays depends on the accuracy of their observance. Sometimes, in order to comply with these prescriptions, the patient has to take a forced position, but the X-ray examination is performed very quickly.
Laying usually involves taking pictures in two mutually perpendicular projections - front and side. Sometimes the study is supplemented by an oblique projection, which helps to get rid of the overlap of some parts of the skeleton on each other. In the event of a severe injury, some styling becomes impossible. In this case, an X-ray is performed in the position that causes the least discomfort to the patient and which will not lead to displacement of the fragments and aggravation of the injury.
Method for examining the bones of the limbs ( hands and feet)
X-ray examination of the tubular bones of the skeleton is the most frequent X-ray examination. These bones make up the bulk of the bones, the skeleton of the arms and legs is completely made up of tubular bones. The technique of X-ray examination should be familiar to anyone who has received injuries to the arms or legs at least once in their life. The study takes no more than 10 minutes, it does not cause pain or discomfort.Tubular bones can be examined in two perpendicular projections. The main principle of any X-ray image is the location of the object under study between the emitter and the X-ray sensitive film. The only condition for a high-quality image is the immobility of the patient during the study.
Before the study, the limb section is exposed, all metal objects are removed from it, the study area is placed in the center of the cassette with x-ray film. The limb should “lie” freely on the film cassette. The X-ray beam is directed to the center of the cassette perpendicular to its plane. The picture is taken in such a way that adjacent joints are also included in the x-ray. Otherwise, it is difficult to distinguish between the upper and lower end of the tubular bone. In addition, the large coverage of the area helps to eliminate damage to the joints or adjacent bones.
Usually, each bone is examined in direct and lateral projection. Sometimes pictures are taken in conjunction with functional tests. They consist in flexion and extension of the joint or load on the limb. Sometimes, due to injury or the inability to change the position of the limb, it is necessary to use special projections. The main condition is to maintain the perpendicularity of the cassette and the X-ray emitter.
The technique of X-ray examination of the bones of the skull
X-ray examination of the skull is usually performed in two mutually perpendicular projections - lateral ( in profile) and direct ( full face). An x-ray of the skull bones is prescribed for head injuries, with endocrine disorders, for diagnosing deviations from indicators of age-related bone development in children.X-ray of the bones of the skull in direct anterior projection provides general information about the condition of the bones and the connections between them. It can be performed in a standing or lying position. Usually the patient lies on the X-ray table on the stomach, a roller is placed under the forehead. The patient remains motionless for several minutes while the X-ray tube is directed to the occipital region and the picture is taken.
X-ray of the bones of the skull in a lateral projection is used to study the bones of the base of the skull, the bones of the nose, but is less informative for other bones of the facial skeleton. To perform an x-ray in a lateral projection, the patient is placed on the x-ray table on his back, the film cassette is placed on the left or right side the patient's head parallel to the axis of the body. The X-ray tube is directed perpendicular to the cassette from the opposite side, 1 cm above the ear-pupillary line.
Sometimes doctors use an x-ray of the bones of the skull in the so-called axial projection. It corresponds to the vertical axis of the human body. This styling has a parietal and chin direction, depending on which side the X-ray tube is located on. It is informative for the study of the base of the skull, as well as some bones of the facial skeleton. Its advantage is that it avoids the many overlaps of bones that are characteristic of direct projection.
X-ray of the skull in axial projection consists of the following steps:
- the patient takes off metal objects, outerwear;
- the patient takes a horizontal position on the x-ray table, lying on his stomach;
- the head is positioned in such a way that the chin protrudes as much as possible forward, and only the chin and the front surface of the neck touch the table;
- under the chin is a cassette with x-ray film;
- the x-ray tube is directed perpendicular to the plane of the table, to the region of the crown, the distance between the cassette and the tube should be 100 cm;
- after that, a picture is taken with the chin direction of the x-ray tube in a standing position;
- the patient throws his head back so that the top of the head touches the support platform, ( raised x-ray table), and the chin was as high as possible;
- the x-ray tube is directed perpendicular to the anterior surface of the neck, the distance between the cassette and the x-ray tube is also 1 meter.
Methods of X-ray of the temporal bone according to Stanvers, according to Schüller, according to Mayer
The temporal bone is one of the main bones that form the skull. In the temporal bone there are a large number of formations to which muscles are attached, as well as holes and channels through which nerves pass. Due to the abundance of bone formations in the facial region, X-ray examination of the temporal bone is difficult. That is why a variety of styling has been proposed to obtain special X-ray images of the temporal bone.Currently, three projections of X-ray examination of the temporal bone are used:
- Mayer technique ( axial projection). It is used to study the state of the middle ear, the pyramid of the temporal bone and the mastoid process. Mayer X-ray is performed in the supine position. The head is turned at an angle of 45 degrees to the horizontal plane, a cassette with x-ray film is placed under the ear under study. The X-ray tube is directed through the frontal bone of the opposite side, it should be directed exactly to the center of the external auditory opening of the side under study.
- Method according to Schüller ( oblique projection). With this projection, the state of the temporomandibular joint, mastoid process, as well as the pyramid of the temporal bone is assessed. X-ray is performed lying on your side. The patient's head is turned to the side, and a cassette with X-ray film is placed between the ear of the examined side and the couch. The X-ray tube is located at a slight angle to the vertical and directed towards the foot end of the table. The X-ray tube is centered on the auricle of the examined side.
- Method according to Stanvers ( transverse projection). A picture in transverse projection allows you to assess the condition inner ear, as well as the pyramids of the temporal bone. The patient lies on his stomach, his head is turned at an angle of 45 degrees to the line of symmetry of the body. The cassette is placed in a transverse position, the X-ray tube is beveled at an angle to the head end of the table, the beam is directed to the center of the cassette. For all three techniques, an X-ray tube in a narrow tube is used.
X-ray laying of the zygomatic bones in a tangential projection
To examine the zygomatic bone, the so-called tangential projection is used. It is characterized by the fact that X-rays propagate tangentially ( tangentially) in relation to the edge of the zygomatic bone. This styling is used to identify fractures of the zygomatic bone, the outer edge of the orbit, the maxillary sinus.The X-ray technique of the zygomatic bone includes the following steps:
- the patient takes off his outer clothing, jewelry, metal prostheses;
- the patient takes a horizontal position on the stomach on the x-ray table;
- the patient's head is rotated at an angle of 60 degrees and placed on a cassette containing x-ray film measuring 13 x 18 cm;
- the side of the face being examined is on top, the x-ray tube is located strictly vertically, however, due to the tilt of the head, x-rays pass tangentially to the surface of the zygomatic bone;
- during the study, 2 - 3 shots are taken with slight turns of the head.
Method of X-ray examination of the pelvic bones. Projections in which an x-ray of the pelvic bones is performed
X-ray of the pelvis is the main study for injuries, tumors, and other diseases of the bones of this area. An x-ray of the pelvic bones takes no more than 10 minutes, but there is a wide variety of methods for this study. The most common x-ray of the pelvic bones is performed in the posterior projection.The sequence of performing a survey x-ray of the pelvic bones in the posterior projection includes the following steps:
- the patient enters the X-ray room, removes metal jewelry and clothing, except for underwear;
- the patient lies on the x-ray table on his back and maintains this position throughout the procedure;
- arms should be crossed on the chest, and a roller is placed under the knees;
- the legs should be slightly apart, the feet fixed in the established position with tape or sandbags;
- the cassette with a film measuring 35 x 43 cm is located transversely;
- the x-ray emitter is directed perpendicular to the cassette, between the upper anterior iliac crest and the pubic symphysis;
- the minimum distance between the emitter and the film is one meter.
To study the sacroiliac joint, a posterior oblique projection is used. It is performed when the examined side is raised by 25 - 30 degrees. In this case, the cassette must be located strictly horizontally. The x-ray beam is directed perpendicular to the cassette, the distance from the beam to the anterior iliac spine is about 3 centimeters. When the patient is positioned in this way, the X-ray image clearly shows the connection between the sacrum and the ilium.
Determining the age of the skeleton by X-ray of the hand in children
Bone age accurately indicates the biological maturity of the body. Indicators of bone age are the points of ossification and fusion of individual parts of the bones ( synostoses). On the basis of bone age, it is possible to accurately determine the final growth of children, to establish a lag or advance in development. Bone age is determined by radiographs. After the radiographs were made in this way, the results obtained are compared with the standards according to special tables.The most indicative in determining the age of the skeleton is the x-ray of the hand. The convenience of this anatomical region is explained by the fact that ossification points appear in the hand with a fairly high frequency, which allows regular examination and monitoring of growth rates. Bone age is mainly used to diagnose endocrine disorders such as growth hormone deficiency ( growth hormone).
Comparison of the age of the child and the appearance of ossification points on the x-ray of the hand
Ossification points |
