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The opinion of a radiologist is still popular these days. This is explained primarily by the availability of equipment for x-ray diagnostics, because it can be done in almost any district clinic. Secondly, the information content of this technique makes it possible to detect a number of diseases and take measures to treat them. A radiologist essentially does not treat anything himself; his responsibilities include searching for pathologies using an X-ray machine.
When do you need an X-ray report?
In our country, the most common reason for contacting this specialist is to obtain a radiologist’s opinion on the lungs. In another way, this is called ready-made fluorography. The spread of tuberculosis infection is quite widespread, so Russians are required to take x-rays of their lungs every year with a transcript of the results. Without this certificate, it is impossible to get an appointment with free specialists, undergo medical examination, or receive a referral for hospitalization. It is also necessary to buy a radiologist’s report in many situations. For example, if a fracture is suspected, they are also sent to him. If a number of pathological processes occur in the body that are hidden from the human eye, you will also need a ready-made X-ray result.
How to get an X-ray certificate
There may be several options. If you need an X-ray report chest, then it is done on a referral from a therapist in a clinic if the appropriate equipment is available. It can also be obtained from the regional fluorographic station. Every year on Tuberculosis Prevention Day you can undergo a fluorographic examination free of charge and without a referral. If you need an X-ray certificate from a TB doctor, you should contact the TB dispensary. The fourth option is to buy a lung x-ray report from private medical centers.
If a radiologist's report on an injury is needed, it is issued at the emergency room. Such a document can become an excuse for absences from work.
Buy an x-ray certificate
In all of the above cases, getting an x-ray from a doctor will cost you time and possibly money. Moreover, everywhere, except for a private clinic, the answer will be given only after a few days. This is not always convenient, and sometimes even critical. For example, if you need to provide a chest x-ray certificate to a child in kindergarten or for inpatient treatment. As a rule, the preparation of medical documents is postponed until the last minute, despite the fact that they are not done quickly. But fortunately, this problem is solvable. Our company provides the opportunity to purchase a radiologist’s certificate for any case. You don’t need to stand in lines, get directions, we’ll take care of all this red tape. Another reason to buy a radiologist’s opinion is the reluctance to expose yourself once again to the far from harmless effects of X-rays.
We are aware of the role diagnostics plays in the prevention and treatment of various diseases, and we only welcome it when people take care of their health. But we also understand that a huge number of medical certificates issued are purely formal in nature, having nothing to do with treatment and preventive measures. We know how bureaucracy flourishes in this area, and therefore we offer our modest assistance in overcoming it. You can buy an X-ray report from us quite inexpensively, saving your nerves and time. Just leave a request on our website, we will do the rest for you!
(Radiation News 1998 5: 8-9)
The research protocol must be written in normal and common language for all medical specialties. pathological anatomy and physiology and, if possible, without the use of highly professional designations, florid comparisons and unusual abbreviations of words.
The content of the research protocol depends primarily on whether pathological changes are detected in the lungs. If the picture is normal, brief descriptions are acceptable. For example: “An X-ray examination of the chest organs did not reveal any pathological changes” or “No focal or infiltrative formations were found in the lungs. The position of the diaphragm is normal, the pleural sinuses are free. The heart and large vessels are unchanged.”
If there are deviations from the norm, the protocol summarizes the main manifestations of the pathological condition. Firstly, they characterize morphological changes. These include the prevalence and topography of the lesion, the number of lesions, their shape, size, shadow intensity (density), structure, contours. The following terms can be recommended:
1. number of lesions: single, two, three, several, few, multiple;
2. hearth shape: round, round, oval, oblong, cone-shaped, star-shaped, polygonal, irregular;
3. sizes of lesions: small (0.5-2 mm), medium-sized (2-5 mm), large (more than 5 mm, including lobular lesions reaching 10-15 mm in diameter);
4. location of lesions: in groups, evenly or unevenly scattered;
5. cavity sizes: small (up to 1.5 cm), medium (1.5-3 cm), large (3-8 cm), giant (over 8 cm);
6. intensity of the shadow of foci (formations, areas of compaction): low intensity shadow (in intensity corresponds to the shadow of the longitudinal projection of the pulmonary vessel), medium intensity (corresponds to the intensity of the shadow of cross sections of vessels), high intensity (corresponds to the intensity of the cortical layer of the ribs), calcification shadow, metallic density shadow;
7. contours of foci (formations, infiltrates): sharp, blurred, smooth, uneven, convex, concave, arched, polycyclic (scalloped);
8. seal structure: homogeneous, non-uniform.
Accurate characterization of the pulmonary pattern facilitates the recognition of many lung diseases. In particular, it helps in distinguishing the predominant damage to alveolar tissue, fibrous tissue, blood vessels, and bronchi. There are the following main types of changes in the pulmonary pattern:
1. strengthening and enrichment (increasing the number of pattern elements per unit area of the pulmonary field, including the disappearance of normally existing low-vascular zones);
2. attenuation (poor visibility of vascular branches due to pulmonary dissemination or fibrous meshwork);
3. depletion (with underdevelopment of the vascular network or as a result of swelling of the lung or part of it, which is observed with compensatory hyperpneumatosis);
4. deformation (change in the course of the vessels, lack of reduction in their caliber towards the periphery, uneven width of the shadow of the pattern elements, unevenness of their outlines);
5. the appearance of unusual elements (narrow shadows of dilated lymphatic vessels, shadows of compacted interlobular septa - the so-called Kerley lines, tubular shadows of the bronchi, shadows of lamellar atelectasis, shadows of fibrous scars and cords, cellular structures in panacinar and bronchiolar emphysema, cystic bronchiectasis, shadows of abnormal vessels ).
In the characteristics functional state organs include symptoms such as displacement of an organ or pathological formation (with a change in body position, breathing, coughing, swallowing movements), changes in the lumen of the trachea or large bronchus during inhalation, exhalation, coughing, amplitude and direction of movement of the ribs, diaphragm, mediastinal organs during deep breathing and functional tests (“Hitzenberger’s sniff” test, Valsalva’s and Müller’s tests).
If data from previous studies is available, then a dynamic characteristic of the process (increase, stabilization or decrease in pathological changes) can be given.
Examples of protocols.
On plain radiographs of the lungs in the frontal and right lateral projections, infiltration of the lung tissue of the anterior and partially posterior segments of the right lung is determined. Against the background of the infiltrate, narrow lumens of the bronchi are visible. No focal formations were identified in other parts of the lungs. Small infiltration of fiber in the root of the right lung. The position of the diaphragm and mediastinal organs is normal. The heart and large vessels are unchanged.
Conclusion: Acute sublobar right-sided pneumonia.
Plain radiographs and fluoroscopy reveal widening of the intercostal spaces, low position, flattening of the diaphragm and weakening of its mobility. The lungs are swollen, the large arterial vessels in them are dilated, and the small vessels are narrowed. There are no focal or infiltrative changes in the lungs. The pulmonary pattern is enhanced, mainly in the hilar and lower sections due to peribronchial sclerosis. Fibrous deformation of the roots of the lungs. The size of the heart shadow is relatively small, but the volume of the right ventricle is increased, and its contractions are enhanced.
Conclusion: Chronic obstructive bronchitis. Diffuse pulmonary emphysema.
Plain radiographs of the chest cavity in the direct and left lateral projections reveal a significant decrease in the lower lobe of the left lung. It contains randomly intertwined strands of fibrous tissue, between which swollen lobules stand out. The lower lobe bronchus is dilated and surrounded by a band of peribronchial fibrosis. The root of the left lung is displaced inferiorly and posteriorly. The upper lobe of the left lung is enlarged, the pulmonary pattern in it is depleted. There are no pathological changes in the right lung. The heart is not enlarged, but is slightly pulled to the left. The left half of the diaphragm is deformed, there are pleurodiaphragmatic and pleuropericardial adhesions.
Conclusion: Postpneumonic limited pneumosclerosis with damage to the lower lobe of the left lung.
Plain radiographs of the chest organs in the direct and left lateral projections reveal significantly enlarged lymph nodes in the roots of the lungs. The outlines of the nodes are arched and sharp. In the hilar sections, mainly in the anterior segments, the pulmonary pattern has a fine-mesh appearance with small foci located in chains along the vessels. The diaphragm position is normal. The heart and large vessels are unchanged.
Conclusion: Pulmonary sarcoidosis.
On radiographs of the chest organs in the direct and right lateral projections, an area of lobular infiltration is identified in the subpleural region of the posterior segment of the right lung. A “path” of lymphangitis stretches from the infiltrate to the root of the lung. At the root of the right lung and to the right of the trachea, enlarged lymph nodes without a pronounced perifocal zone appear. No pathological changes were detected in other parts of the lungs. The diaphragm is positioned normally and is not deformed. The heart and large vessels are without features.
Conclusion: Primary tuberculosis complex in the right lung.
On a plain X-ray of the chest organs, the upper lobes of the lungs are wrinkled and penetrated by rough fibrous cords, between which alternate multiple foci of varying sizes and areas of bronchiolar emphysema. In the posterior segment of the right lung, a cavity with a diameter of 2.5 cm with dense walls and no contents is determined. The middle and both lower lobes are swollen, with signs of moderate fibrosis. In the lower lobe of the left lung at the level of 3-4 intercostal spaces, multiple lobular foci with blurred contours are detected. The roots of the lungs are deformed, pulled up, and compacted. The lungs are surrounded by pleural layers. Pleurodiaphragmatic adhesions on both sides. The trachea is slightly pulled to the right. The heart and large vessels are unchanged.
Conclusion: Fibrous-cavernous tuberculosis with cirrhosis of the upper lobes and foci of bronchogenic dissemination in the left lung.
Plain radiographs and a series of linear tomograms of the lungs reveal a slight decrease in the upper lobe of the left lung. The pulmonary pattern in it is enhanced due to venous congestion and lymphostasis. The shadow of the root of the left lung is poorly differentiated. The lumen of the left upper lobe bronchus is narrowed, its upper contour is uneven. The lower lobe of the left lung is moderately inflated compensatory. The right lung is without features. The heart and large vessels are unchanged.
Conclusion: Central cancer of the left lung, emanating from the upper lobe bronchus, complicated by hypoventilation of the upper lobe of the lung.
Plain radiographs and linear tomograms of the lungs reveal a cavity with a diameter of 4 cm in the anterior segment of the right lung. The walls of the cavity are of uneven thickness (0.4-0.6 cm), its inner surface is uneven, with a tuberous formation in the lower pole. Around the cavity there is a narrow zone of restructuring of the pulmonary pattern. No pathological formations were identified in other parts of the lungs. No enlarged lymph nodes were detected in the roots of the lungs or in the mediastinum. The diaphragm is positioned normally. The heart is slightly enlarged due to left ventricular hypertrophy. The aorta is elongated and moderately dilated.
Conclusion: Disintegrating peripheral cancer of the right lung (“cavitary form”).
* Medical Imaging 1997: 4.
RESULTS OF RADIATION DIAGNOSTICS
RESEARCH
(Message 3. Bones and joints of the extremities) DEPARTMENT OF HEALTH OF THE MOSCOW GOVERNMENT
SCIENTIFIC AND PRACTICAL CENTER FOR MEDICAL RADIOLOGY
Moscow 2008
In the radiation departments and offices of medical institutions /.Moscow, thousands of protocols are drawn up daily based on the results of X-ray, tomography, ultrasound and radionuclide diagnostic studies. The level of diagnostics, the culture of medical care for patients, and the mutual understanding of doctors of various specialties depend to a certain extent on the objectivity and accuracy of these protocols.
In order to improve the quality of recording of radiation studies, a series of advisory messages have been prepared at the Scientific and Practical Center for Medical Radiology. They should contribute to the correctness of medical reports and the necessary unification of terminology used when describing research results. The recommendations are intended for a text-based information network. At the same time, standardization of terminology is especially important during the period of gradual transition to the use of automated workstations and a computer system for obtaining, analyzing, transmitting and archiving radiation images.
This message is devoted to recording the results of X-ray examination of bones and joints of the extremities. Emphasis is placed on describing the methodology for analyzing standard radiographs of the extremities. Issues of terminology when assessing scintigrams, sonograms, computed tomography and magnetic resonance imaging of the musculoskeletal system will be discussed in subsequent letters of instruction.
Brief introduction
Drawing up a protocol is an important final stage of the clinical and radiological examination of the patient. The quality of the protocol depends on compliance general principles examination of the patient and study of materials obtained as a result of the study.
1st rule. An X-ray image must be studied according to a certain plan, in a certain sequence.
Scheme for studying radiographs of bones and joints of the limbs:
I. General examination of the radiograph:
determination of research methodology; determination of the shooting projection and type of image (survey, sighting, electroradiogram, radiograph with direct image magnification, etc.); image quality assessment; general x-ray anatomical orientation.
II. A detailed study of the bone under study: the position of the bone among neighboring tissues and its relationship with other bones in the area; bone size; bone shape; contours of the outer and inner surfaces of the cortical layer; bone structure.
III. Study of the joint and articular surfaces of bones: the size and shape of the articular ends of the bones, their ratio, the size and shape of the x-ray joint space; contours and thickness of the closing bone plates of the articular cavity and articular head; condition of the subchondral (subchondral) layer of bone tissue; bone structure of the epiphyses; growth zones and ossification nuclei (in young people).
VI. Study of the soft tissues surrounding the bone (joint):
position, volume and configuration of soft tissues; structure of soft tissues, condition of peri- and paraarticular tissues.
2nd rule. Any part of the limb must be examined in at least two mutually perpendicular projections. The X-ray examination protocol is drawn up only after comparing all the images taken.
When studying radiographs of bones and joints, the radiologist should always familiarize himself with the clinical picture of the disease and the available laboratory data. In most cases, a personal examination of the patient and a conversation with him are necessary.
The radiologist should not strive for a detailed description of the shadow signs, which would make the protocol unreasonably long and not always clear to the clinician: The study of the shadow (skialological) picture is carried out mentally, but only the results of this analysis are stated in the protocol. The radiologist must, if possible, avoid specific expressions such as “clearance”, “darkening”, “superposition of shadows” and unusual abbreviations of words (abbreviations).
3rd rule. The research protocol should be written in the language of normal and pathological anatomy and physiology common to all medical specialties and, if possible, without the use of narrow professional designations.
The X-ray examination protocol and in particular the diagnostic report reflect the knowledge and experience of the doctor, and in addition are legal document.
4th rule. The protocol must be completed with the personal signature of the doctor who performed the x-ray examination. It is advisable to additionally use a small seal with the doctor’s surname and initials.
Structure and content of the protocol for the study of bones and joints of the extremities
The standard protocol consists of three parts: a title (introductory part), a description of the radiation pattern and a conclusion. The title should indicate the method (methodology) of the radiation study, the organ (body part, part of the limb) that was the object of study, and the shooting projections. In addition, the title indicates the date of the study, and in emergency medical care, the exact time of the procedure (hours and minutes).
If there are deviations from the “norm,” the protocol describes the manifestations of the pathological condition, guided by the points of the above diagram. Strict consistency is important because age and individual characteristics of the size, shape and structure of bones are very diverse. When assessing bone structure, it is necessary to constantly comply with clinical data due to the dependence of the structure on a person’s lifestyle, the state of his endocrine and hematopoietic systems. Relatively small deviations from the usual position, size and shape of bones, not accompanied by dysfunction of the musculoskeletal system, should be considered as options that do not have significant clinical significance. Developmental anomalies include more pronounced deviations, but not leading to a noticeable dysfunction. Gross changes entailing a sharp violation or impossibility of fulfillment important function, is commonly called a malformation of the development of the osteoarticular apparatus.
When describing pathological conditions, it is recommended to use the terms listed below. Deviation in the location of the axes of bones connecting to each other is called deviation. An example is varus and valgus positions of the bones of the extremities, clubfoot, flat feet, etc. When characterizing changes in the size of bones, one should distinguish between its uniform and uneven (local) decrease or increase. A uniform decrease in bone is observed when it is underdeveloped or with atrophy, an uneven decrease is observed mainly during inflammatory and tumor lesion. Bone elongation is observed with partial gigantism. Bone thickening occurs with increased load (working hypertrophy) or as a result of excessive growth and ossification of the periosteum with its assimilation by the cortical layer (occurs in circulatory disorders, intoxications, inflammatory processes). Bone deformations are extremely diverse. It is convenient to distinguish bone deformation with an increase in its volume, without a change in volume, and with a decrease in volume.
It is necessary to clearly distinguish between protrusions on the surface of the bone associated with developmental disorders (exostoses) and protrusions formed as a result of the inflammatory process (osteophytes). When describing the contours of a bone, it is advisable to use generally understood terms: sharp, unsharp, even, uneven, convex, concave, polycyclic (scalloped). The same terms are used when assessing the contours of focal formations in bones and joints. Small, distinct depressions on the inner surface of the cortex are called lacunae;
The central point of the analysis of radiographs is in most cases the study of the bone structure, that is, the relationship of bone beams and trabeculae and medullary spaces, the ratio of compact and spongy bone matter, the size of the medullary canal, etc. In this letter; it is impossible to present information about the multifaceted changes in the bone structure due to injuries, inflammatory, dystrophic and tumor lesions, etc. We will have to limit ourselves to listing the basic terms recommended when recording the results of x-ray examination of bones and joints.
Four types of bone structure restructuring can be distinguished: osteoporosis, osteosclerosis, zone of restructuring and periostosis. Osteoporosis is local (local), regional, widespread (affects the bones of the entire limb) and systemic (generalized). In addition, uneven (spotty) osteoporosis and uniform (diffuse) osteoporosis are distinguished. A manifestation of osteoporosis is also spongiosation of the cortical layer, its dissection. Osteosclerosis can be local (limited), widespread or systemic (generalized). The result of developmental disorders are intraosseous focal formations consisting of a compact substance. Small lesions of regular shape are usually called compact islands, and larger and irregularly shaped ones are called enostoses.
Significant disorders of the bone structure are observed during inflammatory and tumor processes. To denote the resorption of bone beams and trabeculae, the term “os-teolysis” is used, and their destruction is “destruction”. Foci of destruction can be located in the central part of the bone or in the marginal part (then indicate superficial or marginal destruction). Small edge defects are called defects. A dead area of bone is usually called necrosis, and a fragment separated from the surrounding bone tissue is called sequester (in inflammatory processes!). If, as a result of destruction, part of the diaphysis in its entire thickness has separated, then they speak of total (cylindrical) sequestration. More frequent are the so-called “partial” sequestrations; They may consist of compact bone substance (cortical sequestrum) or spongy substance (spongiosal sequestrum). Sequestration can be superficial (subperiosteal) or penetrating.
A number of terms are used to describe the pattern of periosteal calcification. In the presence of a narrow strip of calcified periosteum, separated from the shadow of the cortical layer by a zone of clearing, we speak of detached periostitis. Depending on the structure of the shadow of the exfoliated periosteum, linear, layered and multilayer periostitis is distinguished. If the periosteal layers form bizarre outlines, then they write about fringed or lace periostitis. If tissue calcification occurs along the vessels passing through the Volkmann canals, then thin strips appear on radiographs perpendicular to the surface of the bone (for example, with Ewing's tumor). They are called spicules or, not entirely accurately, needle periostitis.
Changes in bone structure may be associated with the appearance of cavities and defects in the bone. By analyzing clinical and radiological data, the doctor in most cases can distinguish cysts, cyst-like formations, abscesses, cavities (in tuberculosis), and defects resulting from surgical interventions.
An important stage of the analysis is the study of the joint and the articular ends of the bones. Normal relationships between articular ends in developmental anomalies and many traumatic, inflammatory and tumor lesions. In a healthy person, the shapes of the articular head and socket correspond to each other, their contours are rounded, sharp, and even. The gap of any joint has a uniform height, an arcuate or ribbon-like shape. With subluxation, the joint space takes on a wedge-shaped shape. A uniform narrowing of the X-ray joint space is observed with dystrophic changes in the articular cartilage, and uneven narrowing is observed mainly during inflammatory processes. Changes in the end plates of the epiphyses must be noted in the protocol. Normally, the endplate of the articular head is narrower than that of the glenoid cavity. When joint function is impaired due to deforming arthrosis, the thickness of the end plates of the head and glenoid cavity is often equalized. On the contrary, atrophy of the end plates of bone indicates the development of fibrous ankylosis. It, of course, must be distinguished from bone ankylosis, in which the bone beams directly pass from the articular head into the glenoid cavity. Along the way, we note the need to strictly distinguish ankylosis, that is, the fusion of the epiphyses of two adjacent bones, from the physiological process of fusion of the epiphyses and metaphyses, apophyses and diaphyses, which is called “synostosis.” The congenital anomaly of non-distinction of bones is designated by the term “concrescence” (for example, congenital non-separation of the bodies of adjacent vertebrae or non-separation of adjacent ribs).
When describing the condition of the end plates, the following terms are used: thinning, thickening, sclerosis, uneven thickness. And when assessing the subchondral layer of bone, the terms are: sclerosis (sclerosis), rarefaction. This is not limited to changes in the structure of the epiphyses. For a healthy epiphysis, a fine-mesh bone structure is typical; with osteoporosis, it becomes large-loop; with osteosclerosis, it becomes so fine-loop that sometimes the bone pattern is indistinguishable; In places where the articular capsule and ligaments are attached to the bony part of the epiphysis, ulcers may occur. Such small marginal defects at the articular ends of bones are called either foci of destruction or erosions. When analyzing the condition of the joint in children and adolescents, they pay special attention to the symmetry of the appearance of ossification points, the time of their detection on radiographs, the size in millimeters, and the correspondence of the timing of synostosis to the age of the subject.
Scrupulousness is extremely important when describing the nature of a bone fracture. Clearly defined terms should be used. There are complete and incomplete fractures (fracture, crack). A repeated fracture is called refracture. The nature of the fracture can be compression, torsion, avulsion, splintered, perforated. An indication of the extra- or intra-articular type of fracture is required. The amount of longitudinal or lateral displacement of fragments is indicated in centimeters, and angular and peripheral displacement - in degrees. To indicate the nature of the callus between fragments, the terms “periosteal,” “endosteal,” “parosteal,” and “excess” are used.
The protocol ends with a conclusion. This is the doctor's diagnostic conclusion. The conclusion is based on an analysis of the X-ray picture, taking into account the medical history and data from clinical and laboratory studies. The conclusion may contain recommendations for subsequent clarifying studies.
Examples of protocols
1) Radiographs of the left wrist joint reveal an intra-articular fracture of the epimetaphysis of the radius, avulsion of the styloid process of the ulna and rupture of the distal radioulnar joint. The position of the articular surface of the radius in relation to the longitudinal axis of this bone is significantly changed due to the dorsal displacement of the peripheral fragment and rotation of the hand to the radial side. In the lateral projection image, the articular surface is inclined to the rear at an angle of 111. In the direct projection image, the angle between the articular surface and the longitudinal axis of the radius is 54.
X-rays of the right ankle joint reveal an intra-articular fracture of the inner and outer malleoli and a fracture of the posterior edge of the epiphysis of the tibia with subluxation of the foot outward and backward. Distal tibiofibular joint rupture.
Radiographs of the right knee joint and the lower third of the right thigh in the metaphysis and adjacent part of the diaphysis of the femur reveal multiple destructive foci of varying sizes, round and oval (elongated) in shape. The outlines of the lesions are blurred and uneven. There are small sequestrations. Along the medial edge of the bone, 1-2 mm away from its surface, a narrow strip of calcified periosteum appears (detached periostitis).
Conclusion: Acute hematogenous osteomyelitis of the right femur.
4) X-rays of the left elbow joint reveal regional osteoporosis and uneven narrowing of the X-ray joint space. At the sites of attachment of the articular capsule and ligaments to the condyles humerus marginal defects (usures) of irregular shape are noted. In the trochlea and capitate eminence of the humerus, as well as in the olecranon process of the ulna, there are large destructive foci with uneven and blurred contours containing sequestra.
Conclusion: Tuberculosis of the elbow joint (the height of the disease).
5.) On radiographs of the left hip joint regional osteoporosis, narrowing of the x-ray joint space and deepening of the acetabulum due to bone marginal growths around its outer edge are determined. Small bone growths are also present at the inner edge of the acetabulum. Small racemose clearings appear there as well.
Conclusion: Deforming arthrosis (coxoarthrosis).
6) X-rays of the right knee joint reveal a significant narrowing of the X-ray joint space, mainly in the internal part of the joint. The end plate of the epiphyses is unevenly expanded, there is subchondral sclerosis and regional osteoporosis. There are large bony marginal growths around the inner condyle of the femur and tibia. Small bony marginal growths are also observed in the outer part of the joint.
Conclusion: Deforming arthrosis of the knee joint.
7) Radiographs of the left foot reveal deformation of the head of the second metatarsal bone and the base of the main phalanx of the second toe. The head and glenoid cavity are enlarged, especially in diameter, flattened, and there are bone growths along their edges. The joint space of the second metatarsophalangeal joint is not of uniform height, with uneven contours, the end plates of the epiphyses are thickened.
Conclusion: Deforming osteoarthritis of the metatarsophalangeal joint of the second finger due to previous aseptic necrosis (osteochondropathy) of the head of the second metatarsal bone.
8) Radiographs of the right leg reveal a large defect of bone tissue in the upper metadiaphysis of the tibia. The defect has an irregular shape, uneven and blurred contours. There are no sequestrations in the area of destruction, as well as detached periostitis. The cortical layer in the proximal part of the defect is destroyed, and a protrusion of calcified periosteum in the shape of a “visor” has formed above the upper edge of the lesion.
Conclusion: Osteogenic sarcoma of the tibia.
STUDY PLAN (DESCRIPTION SCHEME) OF RADIOGRAPHS OF BONES
1. Area of study.
2. Projection of the image (direct, lateral, axial, tangential, special, additional or non-standard in a seriously ill patient).
4. Condition of soft tissues (shape, volume, intensity and structure of the shadow, presence of foreign bodies or free gas after injuries, etc.).
5. Bone position (normal, displacement due to dislocation or subluxation).
6. The size and shape of the bone (normal, shortening or lengthening, thickening due to working hypertrophy or hyperostosis, thinning due to congenital hypoplasia or acquired atrophy, curvature, swelling).
7. External contours of the bone, taking into account anatomical features (smooth or uneven, clear or unclear).
8. Cortical layer (normal, thinned or thickened due to hyperostosis or enostosis, continuous or discontinuous due to destruction, osteolysis or fracture).
9. Bone structure (normal, osteoporosis, osteosclerosis, destruction, osteonecrosis, sequestration, osteolysis, cystic restructuring, loss of integrity).
10. Reaction of the periosteum (absent, present: linear or exfoliated, fringed, layered or “onion-shaped”, spicules or needle-shaped, periosteal visor, mixed).
11. Growth zones and ossification nuclei in young people (age-appropriate, position, shape and size).
12. Condition of the x-ray joint space (normal width, deformed, narrowed evenly or unevenly, expanded evenly or unevenly, darkened due to calcifications or the presence of effusion, contains additional formations: bone fragments, foreign bodies, bone or cartilaginous fragments - articular mice).
13. X-ray morphometry.
14. X-ray (clinical and radiological) conclusion.
15. Recommendations. 6. Growth zones and ossification nuclei in young people (correspondence to age, position, shape and size).
7. The size and shape of the articular ends (normal, thickening or atrophy, swelling, flattening, mushroom-shaped deformation, etc.).
8. Congruence (correspondence to each other) of the glenoid cavity and the articular head.
9. Position of the articular ends (normal, displacement due to dislocation or subluxation, indicating the direction).
10. Contours of the endplates of the epiphyses (continuous or intermittent, smooth or uneven, clear or unclear, thickened or thinned).
11. Structure of the subchondral layer (normal, osteoporosis, osteosclerosis, destruction, sequestration, cystic restructuring).
12. Bone structure of the epiphyses and metaphyses (normal, osteoporosis, osteosclerosis, destruction, osteonecrosis, sequestration, osteolysis, cystic restructuring, violation of integrity).
13. Reaction of the periosteum (absent, present: linear or exfoliated, fringed, layered or “onion-shaped”, spicules or needle-shaped, periosteal visor, mixed).
14. X-ray morphometry. 6. Condition of the vertebrae:
- bodies (position, shape, size, contours, structure, ossification nuclei in young people);
- arches (position, shape, size, contours, structure);
- processes (position, shape, size, contours, structure, ossification nuclei in young people).
7. Condition of the intervertebral joints (facet joints, uncovertebral joints; in the thoracic region - costovertebral and costotransverse).
8. Condition of intervertebral discs (X-ray intervertebral spaces) (shape, height, shadow structure).
9. Condition of the spinal canal (shape and width).
10. Condition of other visible parts of the skeleton.
11. X-ray morphometry (for functional studies, scoliosis, etc.).
12. X-ray (clinical and radiological) conclusion.
13. Recommendations.
STUDY PLAN (DESCRIPTION SCHEME) OF SURVEY RADIOGRAMS OF THE SKULL
1. Image projection (over 20 overview and special projections).
2. Assessment of the correctness of installation (according to the criteria for each projection).
3. Assessment of image quality (physical and technical characteristics: optical density, contrast, image sharpness; absence of artifacts and veils).
4. The shape and size of the skull as a whole.
5. Correlation of the brain and facial regions.
6. Condition of the soft tissues in the area of the brain skull (shape, volume, intensity and structure of the shadow).
7. Condition of the cranial vault (shape and size; thickness and structure of bones, condition of the outer and inner plates and spongy layer; position and condition of the sutures; condition of vascular grooves, venous outlets, pachyonic fossae; severity of “finger impressions”; pneumatization frontal sinuses).
8. Condition of the base of the skull (configuration and dimensions; boundaries and contours of the anterior, middle and posterior cranial fossae; dimensions of the angles of the base of the skull; condition of the sella turcica; pneumatization of bones; condition of natural openings in the area of the base of the skull and pyramids of the temporal bones).
9. The presence of calcifications in the skull area and analysis of their shadow (physiological or pathogenic).
10. General overview of the facial part of the skull (shape, size).
11. Condition of soft tissues in the area of the facial skull (shape, volume, intensity and structure of the shadow).
12. Condition of the eye sockets (shape, size, contours).
13. Nasal cavity and pyriform opening (position, shape, size, pneumatization, condition of the turbinates).
14. Condition of the cells of the ethmoidal labyrinth (position, shape, size, contours, pneumatization).
15. Condition of the maxillary sinuses (position, shape, size, contours, pneumatization).
16. Condition of the visible parts of the jaws and teeth.
17. X-ray morphometry.
18. X-ray (clinical and radiological) conclusion.
19. Recommendations.
6. Position of the kidneys.
7. Kidney shape.
8. Kidney sizes.
9. Contours of the kidneys.
10. Intensity and structure of the bud shadow.
11. The presence of additional shadows in the projection of the urinary tract and other organs of the retroperitoneal space and abdominal cavity, suspicious for stones, petrification, tumors, etc.
12. Comparative assessment of the release of contrast agent by the kidneys (timing and severity of the nephrographic phase, timing and nature of filling of the abdominal systems with contrast).
13. Position, shape and size of the cups and pelvis.
14. Position, shape, contours and width of the lumen of various parts of the ureters.
15. The degree and nature of filling of the ureters with a contrast agent.
16. Position, shape, size Bladder.
17. Contours and structure of the shadow of the bladder.
18. X-ray morphometry.
19. X-ray (clinical and radiological) conclusion.
20. Recommendations.
A radiologist is a medical specialist who diagnoses various diseases using x-rays, as well as introduces new treatment methods and studies the effects of x-rays on the human body.
History of the profession
In 1895, the scientist Wilhelm Roentgen discovered new radiation, under the influence of which the photographic plate began to darken and a picture of the bone structure and internal organs person.
Later, this radiation began to be called X-rays and was used in medicine to diagnose various diseases. In the 20th century, X-ray clinics and offices began to open in Europe, and the production of specialized equipment was launched.
Currently, X-ray units have been significantly improved and allow a radiologist to conduct diagnostic studies to identify internal damage, determine the condition of internal organs, as well as injuries and fractures of bone structures.
Specifics of medical activities of a radiologist
A radiologist works in public and private institutions, including hospitals, clinics, specialized clinics, diagnostic centers and scientific institutes.
A radiologist diagnoses diseases, takes an x-ray and describes it. In accordance with the radiologist's conclusion, the attending physician determines the patient's diagnosis.
Using an x-ray, the doctor can identify damage to the bone and brain, identify problems in the functioning of the circulatory and cardiovascular systems, and determine the disease digestive system and other systems of the human body.
Radiation diagnostics makes it much easier to make the correct diagnosis and prescribe appropriate treatment for patients.
A radiologist is a high-risk profession associated with radiation. Currently, special radiation protection has begun to be used in radiologist's offices, but, nevertheless, it is always necessary to monitor the background radiation and avoid direct contact with X-ray equipment.
Types of diagnostics
A radiologist uses various methods of radiation diagnostics in his work, including radiography, tomography and fluoroscopy.
There are several types of tomography - computed tomography and magnetic resonance imaging. This type of diagnosis represents the latest trend in radiology. Thanks to a tomograph, certain parts of the body are scanned, processed on a computer, and images are obtained on digital media.
The most effective is positron emission tomography, which allows you to diagnose diseases even at the earliest stages and identify foci of cancer. This type of tomography uses radioactive isotopes minimal harmfulness, produces color images that show all chemical processes in the body, as well as pathological disorders.
Responsibilities and professional qualities of a radiologist
A radiologist must have a high level of professionalism and responsibility. This specialist must be inclined to work, have a good memory and the ability to analyze the information received.
The radiologist's conclusion must be based on in-depth medical knowledge and the physics of x-rays. This specialist needs to constantly improve his skills and use the most effective methods of radiation diagnostics.
A laboratory assistant assists the doctor in the office, but the radiologist must independently be able to operate medical equipment and know the features of use x-ray radiation for the human body.
A radiologist carries out diagnostics and conducts studies of the lungs and spine, skeleton and teeth. This medical specialist must have skills in working with a mammograph and fluorograph.
The mandatory qualities of a radiologist are accuracy, ethics and responsiveness towards patients.
Formulation of the diagnostic conclusion. The radiologist's conclusion is the final stage of X-ray diagnostics. In exceptional cases, it can be communicated to the attending physician orally (in conditions of emergency X-ray diagnostics, X-ray diagnostics on the operating table during surgery, etc.), but, as a rule, the conclusion must be issued in writing as a protocol for an X-ray examination, which in an outpatient setting can be written on a special form, and in inpatient conditions entered directly into the medical history.
The protocol must be clear in form, understandable in content and consist of three parts.
The first part should reflect formal data: name and address of the institution, protocol number and date, last name, first name, patronymic and age of the patient, area (or areas) studied, etc.
The second part - descriptive - should contain in a laconic but comprehensive form a description of the pathological changes detected by the radiologist, expressed in generally understandable and generally accepted pathoanatomical and pathophysiological terminology in medicine. If, along with examining the area in which the attending physician suspects pathological changes (for example, the stomach), other areas were examined (for example, the intestines or chest organs), the protocol should reflect the pathological changes found in them or indicate the absence of them.
In the third - final - part, an x-ray diagnosis must be formulated if there are sufficient grounds for this arising from the second part of the protocol. In the absence of sufficient data to make an x-ray diagnosis, the radiologist can limit himself to the descriptive part, giving the clinician the opportunity to use that part of the x-ray data that may be useful for making or clarifying a general clinical diagnosis. If there are reasonable rational considerations about possible diagnostic options, the radiologist can present them in speculative form. If there is reason to believe that through certain additional studies it is possible to obtain significantly new data or for this purpose a repeat X-ray examination seems appropriate, the radiologist can finally offer his recommendations. Often, with repeated examination, the formulation of an x-ray diagnosis is possible.
The conclusion must be signed by the radiologist who performed the study, who bears full medical, moral and legal responsibility for it. Conclusions containing conclusions about the presence of life-threatening or incurable diseases should not be given to the patient, but sent to the attending physician through appropriate channels. See also Examination of the patient, X-ray examination, Semiotics.
The purpose of an x-ray examination is the sum of logical inferences and conclusions that makes up the diagnosis. Pictures are only a means, diagnosis is the goal. The image can be taken by a technician or a doctor, but the conclusion or diagnosis should only be given by a doctor. This right belongs only to the doctor, and he bears full responsibility for this conclusion.In order to make a diagnosis of a disease based on X-ray images, it is necessary to methodically and consistently: 1) become fully familiar with all the data of the clinical study; 2) detect and take into account the so-called radiological symptoms; 3) interpret these radiological symptoms from the point of view of pathological anatomy and pathological physiology; 4) conduct a general differential diagnosis based on X-ray and clinical examination data; 5) formulate conclusions orally or in writing, i.e. give a conclusion.
1. Recording of clinical trial data
The first step on the path to diagnosis is familiarization with the results of a general clinical examination. At present, there is probably not a single Soviet radiologist who does not believe that x-ray examination is only an integral part of the general clinical examination of the patient, that the x-ray examination method is only one of many methods of clinical examination. X-ray diagnostics is not something completely independent, much less self-sufficient; it does not compete with other methods, but only complements them. Diagnosis requires a synthesis of pathoanatomical and pathophysiological radiological and clinical data. A radiologist is an obligatory participant in a general clinical examination and study of the patient. This fundamental position - a view of X-ray diagnostics as a clinical discipline - has always served distinctive feature Soviet school of radiology. When we say “X-ray diagnostics”, we always mean “clinical X-ray diagnostics”.
Conversations that radiology leads to a decrease in the thoroughness of clinical examination, that it displaces old clinical skills and “corrupts” clinical thinking, are deeply conservative and, when properly formulated, are not based on anything. A radiologist who has undergone proper training will never speak out without knowing the clinical
Niki. If a patient is sent to the X-ray room with a medical history, which only contains its number, date and surname of the patient, then from such an “organization” of servicing patients with X-ray care, radiology suffers even more damage than the clinic.
A correct diagnosis is possible only if two indispensable conditions are present: firstly, knowledge of the disease in general and, secondly, knowledge of the medical history of each patient. The radiologist is obliged to know his patient in detail in all his individual, biological and social diversity. Consequently, taking into account all data from the anamnesis, the course of the process, previously applied treatment methods, research using conventional clinical methods, and, where necessary, blood tests, serological and bacteriological, are absolutely necessary for a modern radiologist.
The radiologist usually examines only one area of the skeleton that is of interest to the attending physician or patient. This circumstance in itself creates a real threat to the narrow organo-morphological understanding of bone disease, a threat to the localistic interpretation of the pathological process.
What is the way out of this dangerous situation, incompatible with Pavlovian medicine? To the credit of the advanced Soviet clinical radiology school, it should be stated that a way out of the situation has long been found. This is the use of valuable objective radiographic data within the broadest general clinical framework. This is a conscious rejection of the self-sufficient significance of radiology, the denial of narrow, naked technicalism in radiology, the interpretation of radiographic symptoms in the light of the entire clinic. Local X-ray data are used not in isolation from all other pathological processes in the bone skeleton and in other systems of the entire human body, but in the closest connection with them. In addition, as can be seen from the entire further presentation of the subject, the pathology of the skeletal system is not only considered as a disorder of the musculoskeletal system, but also the importance of the bone skeleton in all its diversity in the general metabolic system as the most important mineral depot is fully appreciated, and also fully appreciated. all possible influences on the skeleton of a wide variety of external and internal factors and above all the dominant influence of the central nervous system.
2. Radiological symptoms and shadow image analysis
To detect and take into account radiological symptoms means to understand the shadow picture of the bone, compare the image in this case with the normal picture, draw the line between normal and pathology and highlight in the picture those shadow images that are not found in normal conditions.
It goes without saying that the basic requirement obligatory for anyone who takes on the responsibility of reading a radiograph is, first of all, knowledge of the basics of general radiology and radiographic techniques. The doctor must be familiar with x-ray optics, with the physical laws of the passage of x-rays through various human tissues, with spatial geometric constructions - with general and particular skiology. He must be able to evaluate all the features of the image caused by the choice of hard or soft rays, irregularities in the exposure time, the path of rays at different angles.
provisions of the study and especially errors in photographic film processing. The main requirement is a complete and deep familiarity with the x-ray picture of the normal skeleton. It is not enough to know osteology, you need to know X-ray osteology, osteology in a specific shadow image. It is necessary to perfectly know all the variants of the structure of the skeleton, it is necessary to have accurate information about gender differences in the anatomy of the skeleton, and especially remember about age-related changes in normal photographs. It is also necessary to become familiar with social, professional, constitutional and endocrine features in each individual case. In other words, the reader of the x-ray is required to supplement his basic knowledge of normal anatomy with facts that previously were not at all of interest to the anatomist, pediatrician, surgeon, etc. and were outside the range of their ideas. Now everyone has realized the need to introduce radiology into modern anatomy, and the X-ray method is an integral part of morphology as the microscopic method. Unfortunately, in relation to physiology - normal and pathological - this process of mastering the x-ray method is carried out less effectively.
Each shadow must be characterized in terms of its following basic skialological properties; a shadow has: 1) number, 2) position, 3) shape, 4) dimensions, 5) intensity, 6) pattern, 7) contours, 8) mobility, displacement or immobility.
The number of shadow images may vary; the shadow can be single or multiple. To describe the position, it is necessary to use the usual anatomical terms (for example, distal, proximal, lateral, anterior) and the designations of the anatomical parts of the bone or joint (epiphysis, diaphysis, medullary canal, joint space). It is preferable to compare the shape with geometric figures (cylinder, cone, oval, linear, polygonal or round shadow). Dimensions are best given in centimeters and millimeters; in this case, it is necessary to make an adjustment due to the fact that the skeleton is often filmed at close range with a diverging beam of rays. It is better not to compare the size of a shadow with the size of well-known objects (coins, grains, fruits), since experience shows that these comparisons are usually extremely inaccurate. The intensity of the shadow is most accurately described when it is compared with the intensity, density, or depth of the shadow of normal bone. The shadow pattern can be uniform, homogeneous or uneven, irregular, inhomogeneous, spotty; in the latter case, it is necessary to analyze the relationship between light and dark areas. The contours can be even or uneven, smooth or pitted, sharply limited or blurred. The mobility of the shadow, of course, can only be determined by transillumination or in a series of photographs. IN general analysis The properties of shadow images on radiographs must be carried out very carefully, completely, consistently and pedantically, especially by beginners.
Radiological symptoms should be described in as simple, understandable terms as possible. Terms that are used differently by different authors should be retained. We must condemn those fanciful, newly invented expressions and buzzwords with which some like to clutter up and complicate the description of an x-ray. Only those expressions are suitable that are understandable without special training to an anatomically and physiologically thinking doctor who is not experienced in the intricacies of radiology.
3. Anatomical and physiological interpretation of radiological symptoms
When radiological symptoms are detected and described, the radiologist moves on to interpret these symptoms. A radiograph is an objective shadow image of the removed bone on photographic film and, of course, if in reality this shadow image is abnormal, then, having excluded all sources of physical and technical errors, we must be sure that the bone itself is pathologically changed. Here the radiologist faces a second task - to translate the radiological language into the language of pathological anatomy and pathophysiology, to find out what pathological changes underlie the radiological symptoms, what is the anatomical and physiological substrate of the changes detected in the image.
To build such a diagnosis on reliable morphological and physiological premises, it is necessary, first of all, to be thoroughly familiar with the data of pathological anatomy, histology and physiology, as well as a large personal experience in the ability to discern, without imagination, these objective changes in the bone itself or in the joint on the basis of their shadow image. Let us emphasize the words “without imagination” - this means that what is required is an interpretation of the x-ray picture that is completely consistent with the actual state of affairs, and not an imaginary one. “You need to read the photograph, and not guess from it,” T. P. Krasnobaev wisely warns. It is clear that the more extensive the radiologist's knowledge in the field of pathological anatomy and pathophysiology, the more the radiograph tells him. If the stock of anatomical, histological and pathophysiological concepts of the reader of the x-ray is very limited and the radiologist does not have solid theoretical anatomical and physiological training, then only a meager radiographic symptom complex falls into the scope of his attention. It is necessary to know what deviations from the norm in the bone structure appear on an x-ray and in what form; It must be remembered that some very significant pathological processes in the osteoarticular apparatus are compatible with a completely normal picture on the photographs. It is enough to point out as an example the X-ray negative picture of acute hematogenous osteomyelitis. Further, a number of completely different pathological processes in the skeleton can give the same radiological symptoms, and, conversely, the same changes in the bones can manifest themselves in a variety of shadow combinations. Isn’t it a fact that the most diverse pathological processes in the joints in their etiology and clinical significance can find their radiological expression in similar, even sometimes completely identical pictures, and the same process, for example, tuberculosis of the hip joint, can manifest itself in an extremely wide and diverse radiographic range? Finally, it is necessary to take into account the fact that for a number of radiological signs the anatomical and especially functional substrate has not yet been established with sufficient certainty; this applies mainly to those benign or rare diseases, or the earliest stages of the process, which exclude the possibility of surgical or sectional control, as well as experimental reproduction.
Due to its natural specific limitations, radiology most often reveals much fewer patterns than is available at autopsy and histological examination. Easier
speaking, many things are visible on radiographs incomparably worse than on a sectional or operating table. These are, for example, the same acute osteomyelitis, a number of tuberculous and other inflammatory bone destructive foci, fresh purulent arthritis, metastases of malignant tumors in the bone marrow in their certain phases and forms of development, etc. But much is visible on radiographs and is better than this given to the naked eye at autopsy or even under a microscope. As examples, we point out osteoporotic restructuring of bone substance, foci of aseptic necrosis, extremely profound changes in the bone structure in deforming osteodystrophy, some manifestations of myeloma, calcification and ossification of the bone marrow, etc.
Thus, it is scientifically unfounded and fundamentally incorrect to demand from a radiologist a 100% transfer of what pathological anatomy represents, since we are dealing with essentially different methods of cognition. In practical activities, a reasonable and restrained, very self-critical interpretation of the X-ray shadow picture in anatomical and physiological images and terms is necessary. It is necessary to accurately determine the boundaries and limits of the X-ray method of studying bones and joints, not to demand more than what it is essentially capable of providing, but at the same time not to go to the other extreme and not to detract from its actual capabilities. Natural discrepancies between the anatomical and physiological picture and its x-ray shadow image when drawing so-called parallels can give rise to some feeling of confusion among young doctors; Experienced specialists, over time, develop a calm and sober assessment of the inherent qualities of each method and knowledge of the limits of each method used.
Despite all these very real difficulties, we are still in the vast majority of cases able, guided by radiological symptoms, to describe the anatomical changes of the bone to approximately the same extent as if we were holding in our hands a macerated bone taken from a pathological museum. An experienced radiologist, trained in pathological anatomy and physiology, gets used to seeing in front of him in the picture not a flat shadow of a bone drawn in black, gray and white, but a raised living bone painted with natural colors.
In practical everyday work, taking into account radiological symptoms and pathological interpretation of them are very often combined together, and the radiologist immediately, without describing shadow images, reveals their essence. So, for example, in the case of a bone fracture with displacement of the fragments, the anatomical changes are so clear in themselves that it is easier and more natural for the doctor to immediately call the thing by its anatomical name than to give a description of the shadow picture. If such an acceleration of the work process is fully justified for an experienced person, then it is necessary to demand strictly strict methodology from novice radiologists.
4. General distinctive recognition
After reviewing all the data from the clinical and radiological examination, the radiologist can take the next step, that is, carry out a general differential diagnosis. All information is required for distinctive recognition. Clinical data alone is obviously not enough: if they were enough to determine the disease, the patient would not be sent for radiography.
Fiyu. Indeed, in most cases, it is customary to send for an X-ray examination when the clinical diagnostic arsenal is insufficient. At the same time, as we have seen, radiological data alone in most cases cannot provide recognition.
During a distinctive recognition analysis, it may turn out that the available information is not enough to substantiate the diagnosis; then the radiologist must either himself be such a generally educated doctor as to complement the study, or must decide on the issue of further consultation. It is clear that one should not unnecessarily complicate the diagnosis with the advisory help of other specialists; one should not refer patients without strict indications, for example, for a blood test for a serological reaction or to a neurologist, as is often practiced.
It is clear that in the daily activities of a radiologist, distinctive recognition should not be overly broad, far-fetched, artificially inflated, i.e., a large number should not be included in the differential diagnostic circle possible diseases, and even more so all generally conceivable pathological processes. This approach can still be justified to some extent from an academic, for example, scientific and literary, and especially from a pedagogical point of view. In other words, the scope of distinctive recognition in the daily practical work of a radiologist should be narrowed as much as possible by including only the most closely related diseases among the diseases being discussed, otherwise a violation of the important requirement is inevitable - to always remain in the position of clinical realism. Usually, it is not necessary to place more than two or three, maximum four or five nosological units on the differential diagnostic scales.
In practical work, it is often possible not to dwell at all on the clinical picture and distinctive recognition and immediately after interpreting the shadow picture to draw final conclusions. This applies to those cases where the radiograph itself is sufficient for an unmistakable and definite recognition of the disease, when radiological changes are pathognomonic and are of decisive importance. The X-ray picture of a number of diseases is so characteristic that it often gives the radiologist the right to make a diagnosis not only regardless of the clinical picture, but often even contrary to the data of a preliminary clinical study. In practical usage, it is often said and written that in a number of forms and phases of various diseases, X-ray examination provides so much that it becomes almost independent, self-sufficient, and for recognition it practically provides more than even an autopsy or histological examination.
However, we seriously caution against the desire to neglect the clinical picture of the disease. In the end, there are almost no truly pathognomonic pictures, that is, essentially not allowing for different interpretations, in bone x-ray diagnostics. Therefore, we fundamentally consider it necessary to carry out the third and fourth points of the study and never give conclusions without taking into account clinical symptoms and differentiation with other possibilities.
Having collected all the necessary clinical and radiological information, in most cases it is possible to make a final etiological diagnosis, that is, to achieve the final goal of the task. However, there are cases when this task still remains unresolved or partially impossible. All diagnostics would be a simple matter if certain
Nosological groups gave a certain radiological picture. But different diseases manifest themselves in exactly the same anatomical, physiological and radiological way, and the same bone or joint disease gives different pictures at different stages of the process and under the influence various conditions.
These considerations should guide the radiologist when he begins the last important step of his work - the formulation of the conclusion.
5. Formulation of the conclusion
What should be the conclusion of the radiologist, what information should his oral or written response to the attending physician referring the patient contain? Unfortunately, these issues have not yet been unanimously and definitively resolved, not only in the relationship between radiologists and clinicians, but even among radiologists themselves. On the issue of the boundaries of x-ray examination and the tasks of a radiologist in modern radiology, there are currently still two schools: the old, conservative one, and the young, progressive one. Representatives of the old school argue that the only objective thing that a radiograph gives is radiological symptoms; the conclusion should list only these changes in the shadow picture. Some representatives of the conservative point of view still allow a “cautious” pathological interpretation of the shadows to be given in the conclusion, but everyone categorically denies the possibility and necessity of making a diagnosis. The diagnosis of the disease should be made, in their opinion, not by a radiologist, but only by the attending physician, a clinician. Thus, the radiologist’s conclusion should contain only one statement of the objective shadow picture, i.e., a determination of what was found when examining the images, completely independent of the clinical examination data, knowledge of which is desirable for the radiologist, but not mandatory. The conservative school, therefore, narrows the scope of the radiologist's activities and limits him to the role of a technician who takes pictures, as well as an interpreter of shadows in special terms used only in radiology. Only as an exception, when possible, does the old school allow the use of pathological expressions. Conclusions should always be left entirely to the clinician.
The progressive school takes a different, to a certain extent opposite, point of view. A radiologist is now primarily a consultant doctor, rather than a narrow specialist technician. The radiologist must be a clinician in the field in which he undertakes research. His ultimate goal is the diagnosis of the disease, and he must get as close to this goal as possible. The radiologist must give this objective statement of facts from the field of skiology, but at the same time not limit himself only to the formally descriptive side of the matter - he must also state his judgment and draw conclusions arising from this description. Adhering to the principles of the conservative school essentially means promoting the rejection of confinement, as we understand it. After all, the attending physician’s knowledge in the field of radiology is naturally quite limited. By refusing a detailed clinical interpretation of the skialogical picture, the radiologist deprives the attending physician of the assistance that he is obliged to provide to him. It is from such an incorrect formulation of the case that the interests of the patient ultimately suffer, since the highest criteria in the work of a doctor are the interests of the patient.
Thus, the X-ray examination protocol must contain, in addition to the mandatory formal data, the name and address of the institution, the document number, the date of its preparation, full name, patronymic and surname of the patient, his age, etc., from two mandatory elements, namely the descriptive part and conclusions, judgments, i.e. the final, operative part.
Like every consultant, the radiologist must be informed by the referring physician of all the details of the clinical examination that preceded the radiography. Still commonly used today short notes with the proposal to “remove such and such an area” are insufficient and therefore unacceptable. A patient referred to a radiologist must have at least an answer to the following three questions: 1) how the disease progressed and what is determined by clinical objective examination, i.e. at least brief information about the anamnesis, course, treatment and data from a routine clinical study; 2) presumed diagnosis of the disease; 3) what is desirable to find out during an X-ray examination, i.e. what the referring physician wants from the radiologist.
No matter how elementary this requirement is, wide medical circles still sin against it and often send a patient to a radiologist without an accompanying document or a referral that should indicate the purpose of the consultation. On this basis, misunderstandings are inevitable if, from the very beginning, the radiologist does not put himself in his proper place and does not demand the necessary information from the attending physician in the interests of the case and the patients. A stencil request to take a photograph or so many photographs in such and such positions, which is usually written on accompanying notes, is just as inappropriate as a requirement for a histologist to fix or stain a specimen according to a certain method, or an instruction to a bacteriologist to culture on such and such a medium. The form should only indicate that an X-ray examination is necessary, and the implementation of all technical aspects, such as the size of films, the choice of certain photographic materials, etc., should be entirely left to the competence of the radiologist. Therefore, the participation of a radiologist in the process of radiographic examination of a patient with bone and joint diseases is necessary, and this work cannot be considered as narrowly technical, limited to the competence of nursing staff. Radiography is an essentially responsible process that requires a medical approach and cannot be reduced to a template. There is a fundamental difference between X-ray diagnostics and fluorography. Even in the most seemingly elementary case of suspicion of a typical fracture of the radius, only the radiologist, having obtained a normal picture on two standard radiographs, guided by clinical data, often on his own initiative takes another additional picture and reveals some pathology important for the victim carpal bone. The X-ray technician or X-ray technician will not do this himself. Only the personal participation of a radiologist in the process of producing radiographs is able to ensure the expansion of the scope of the study beyond the area indicated in the direction by the attending physician, as well as the inclusion of other systems of the human body in the X-ray study. These are, for example, X-ray examination of the lungs during osteoarticular tuberculosis, determination of syphilitic lesions of the aorta, solution to the issue
About the primary or metastatic nature of the tumor with the coexistence of bone and pulmonary pathologies, etc. Only with this approach is the most accurate, quick and economical resolution of the general diagnostic problem achieved. One should strictly condemn the vicious practice of the so-called recording of bone radiographs produced by a radiographer without a radiologist, when the latter withdraws himself from examining the patient, when he does not even see the patient and thereby emasculates the clinical essence and content of the x-ray method of examination.
The most natural and at the same time ideal organizational support for normal relationships between the attending physician and the radiologist, which is required by us and the corresponding instructions of the governing health authorities, is the participation of the attending physician in the discussion of radiological data, personal contact between the clinician and the radiologist, to whom both , so the other must strive. Undoubtedly, in the conditions of ordinary outpatient work such contact is difficult to achieve, but in clinical work it is obligatory and irreplaceable.
X-ray nomenclature should not be taken outside the walls of the X-ray room, because it is incomprehensible to the vast majority of attending physicians. It is unacceptable for each specialist to speak his own special language. For all medical specialties there is one common language - the language of pathological anatomy and physiology.
It is bad when radiographs fall into the hands of an inexperienced doctor. An X-ray image of a bone, in contrast to an image of the heart, stomach, lung, conveys basically the same picture as a macerated preparation, i.e., evoking in the viewer ideas for which he is already prepared, captivates with its apparent elementaryness and accessibility. Unfortunately, many doctors believe that reading an X-ray is a very simple matter, at least simpler than interpreting a microscopic picture, and, without sufficient experience, they make “X-ray diagnoses” 1.
Thus, we stand on the point of view that the radiologist himself must give conclusions based on radiographs and he himself must, whenever possible, make a diagnosis of the disease. Is this always possible? It goes without saying that the x-ray method, like every other research method, is limited and under some conditions is insufficient. In this respect, an x-ray image is also no different from a microscopic section. The most experienced histologists, as is known, often refuse a definite conclusion without knowing the clinical picture. For example, the morphological picture of the most diverse diseases of the lymph nodes can be completely the same, and the correct diagnosis can be made
1 Here is what one of the largest Russian surgeons and founders of domestic clinical osteo-articular X-ray diagnostics N.A. Velyaminov says about this (The doctrine of joint diseases from a clinical point of view, Giza, L., 1924, p. 71): “Roentgenology has created a new era in the study of diseases of bones and joints. There is no doubt that radiology provides an immeasurable amount for diagnosis and even studying the essence of the disease in bones, but only if two conditions are met: skillful use of the method and skillful reading of radiographs; both, especially the first, require special knowledge and skills; A bad radiograph can reveal relatively little; a good radiograph must be learned to read. I dare to think that in this last respect many practical surgeons sin; the result is the same as we often see with quantitative analysis urine, - the test results are in their hands, but they don’t know how to read them.”
flax only when the clinical picture, course of the disease, temperature, blood changes, etc. are fully taken into account. Various diseases such as cervical cancer and chronic gonorrhoidal changes can give microscopic pictures indistinguishable from each other. Finally, it is not so rare that there are cases when histological examination cannot completely solve the diagnostic mystery.
An experienced radiologist is primarily required to know the limits of x-ray examination and be able to assess in each individual case whether a diagnosis can be made based on the available data or whether the diagnosis remains unfounded and doubtful.
In difficult, intractable cases, the radiologist is forced to limit himself to only one radiological symptom complex and cannot give a complete etiological diagnosis. Then the x-ray report must contain an attempt to interpret x-ray shadows based on various assumptions. In these cases, the conclusion should indicate the various diagnostic possibilities and the degree of validity or likelihood of each proposed diagnosis. By this, the radiologist greatly facilitates the work of the clinician, brings a certain clarity, eliminating some clinical assumptions, and brings all possible significant assistance to the patient, while the clinician receives certain instructions for further examination of the patient, for his treatment, etc. Thus, our usual conclusion consists of a description of bone or joint changes in pathoanatomical and pathophysiological terms, a comparison of radiological findings with clinical findings, and a brief statement of the etiology of the process or differential diagnostic considerations. Sometimes proposals related to further medical tactics are quite appropriate and justified, for example, a recommendation to carry out such and such additional studies necessary for the final solution of the diagnostic problem.
The description of the shadow picture should not be overly detailed, cumbersome, or complicated by unnecessary details. It is advisable to begin the presentation with the main, fundamental, i.e., the most diagnostically important, and then in the background give secondary radiological symptoms. At the same time, one should not go to the opposite extreme and present the symptomatology too briefly and schematically. Gross changes on an x-ray will, of course, be detected by an attending physician or even an x-ray technician who has not undergone special training. The task of a radiologist is to draw the attention of the attending physician to subtle skiological symptoms. In all this, tact is needed, adherence to measures, rejection of the template. Protocols in case histories in inpatient clinical settings, especially in research institutes, are written in more detail than in outpatient settings.
This approach requires high qualifications from a modern radiologist. Therefore, the radiologist must be so competent that his conclusion is authoritative for the clinician. In the end, in fact, the diagnosis of a disease is made not by the one who, by his specialty, position or position, is obliged to do this, but by the one who knows how to do it. If another attending physician is better versed in images than a radiologist, then the role of the latter will sooner or later be reduced to only the technical side of his specialty.
The conclusion should in no way be impersonal. An entry in the medical history must always and invariably be signed by the radiologist who performed the study, because an X-ray study protocol that is not signed is irresponsible, while the radiologist’s responsibility for the conclusion is very high. It is enough to point out examples of the presence or absence of a bone fracture, tuberculosis or syphilis, or a malignant tumor. Far-reaching therapeutic measures depend on the radiologist’s conclusion. Therefore, it is necessary to constantly cultivate a sense of responsibility in yourself and in subordinate personnel. The issuance of a “silent” radiograph, an X-ray without a conclusion, is unworthy of a radiologist, since it reduces his role as a doctor and ultimately discredits him; it harms the patient and the entire cause of high-quality medical care for the working population. For the same reason, such an X-ray image in itself is devoid of judicial significance, since for the examination it is not so much the image that matters as the expert’s conclusion. A radiograph is never mistaken, because it is a dead product of technology, but a radiologist can make mistakes, and the fewer of these errors there will be, the greater the experience and knowledge of the radiologist and the more developed a sense of responsibility in him.
B. LIMITS OF THE X-RAY RESEARCH METHOD AND GENERAL ANALYSIS OF ERRORS IN X-RAY DIAGNOSIS OF DISEASES OF BONES AND JOINTS
An objective assessment of the role of x-ray diagnostics in recognizing diseases of bones and joints is possible only if the boundaries of the x-ray method become known to everyone who uses the services of this method, i.e. not only radiologists, but mainly non-radiologists. Therefore, it is appropriate here to make some general instructions and make a general critical analysis of those fundamental errors that are most often made during x-ray examination.
As already mentioned, the process of x-ray examination consists of five consecutive moments, and each of these purely medical moments of x-ray examination has its own sources of errors, which should be briefly discussed here.
Insufficient familiarity with the clinical picture is an inexhaustible source of radiological errors.
First of all, diagnostic errors are inevitable when the radiologist is simply not aware of this or that, more or less rare disease, when he is not aware of the nomenclature of nosological forms. For this reason, many cases of osteochondrodystrophy, fibrous bone dysplasia, bone lesions due to neurofibromatosis, eosinophilic granulomas, etc. too often remain unrecognized. Then, of course, everything “falls into a heap” of well-known, popular diseases such as osteomyelitis, tuberculosis, syphilis , and diagnostic errors are followed by even more annoying, unacceptable treatment errors. The issue is especially acute with a large group of so-called bone remodeling phenomena, since these diseases are very common and in practical radiological use they are generally underestimated. But even with good acquaintance With diseases, mistakes are most often made due to insufficient knowledge of the patient and his medical history. Note, k*
for example, after suffering from typhoid fever, sometimes the X-ray picture of the spine immediately brings clarity to the understanding; A history of syphilis in most cases resolves the question of the nature of periostitis. The pictures of bone myeloma and metastatic cancer lesions can be identical, and only the clinic makes it possible to make a final diagnosis. Without knowing the temperature curve, without information about the presence or absence of fistulas, it is impossible in some cases to distinguish bone osteomyelitis from a neoplasm. Without knowledge of the general clinical picture, it is impossible to recognize leukemic or xanthomatous bone lesions. Detailed clinical information is especially required for X-ray diagnosis of joint diseases; insufficient consideration of them can lead to gross errors.
The most important factor is the time factor - the duration of the disease, which should be known to the radiologist in each individual case. Information regarding the rate of growth, for example, of a tumor or cyst, the presence or absence of a history of trauma, etc., is also essential.
It must be remembered that some diseases give very diverse x-ray pictures in their various forms, phases, varieties, and types. Such are, for example, hyperparathyroid osteodystrophy, deforming osteodystrophy, myeloma. Therefore, in different patients suffering from the same disease, radiological manifestations may be so different from each other that it is difficult to imagine that they are essentially the same disease. Let us give just one illustrative example: the multifocal form of Rustitsky’s disease is unlike solitary myeloma, and the diffuse form may not change the X-ray picture of the bones at all or is only accompanied by general osteoporosis. Therefore, it is fundamentally important that negative X-ray data do not give the right to exclude the disease. In addition, cured diseases give completely different pictures than those forms that most radiologists are accustomed to seeing at the height of the acute clinical course of the process. So, for example, eliminated, in the clinical sense cured, tuberculosis of bones and joints often manifests itself radiographically in a fundamentally different way than at the beginning of the disease; If you don’t take the clinical picture into account, you can make a mistake here too. It is difficult, and sometimes impossible, to decipher a bone radiograph without information about the nature of the operation undergone, about complications in postoperative period, about treatment with iodoform or other emulsion, about the use of ointments with high-atomic components, etc.
In recent years, difficulties caused by the effect on the skeletal system of extremely effective therapeutic agents that have no analogues in clinical medicine past times. As an example, let us at least point to penicillin. This antibiotic, if promptly correct use radically changes the usual course of hematogenous osteomyelitis and brings to life completely new, previously unseen x-ray pictures. Further, after successfully performed x-ray therapy, the picture of severe bone destruction in eosinophilic granulomas, Ewing's tumor, bone reticulosarcoma, some forms of cancer metastases, etc. changes so much, the bone structure is restored to such an extent that without a series of sequential x-rays, the most serious doubts about the correctness of the initial recognition. It is also beneficial in medicinal terms
tion, in appropriate cases, is influenced by vitamins and hormonal drugs. In other words, medicine has an ever-growing arsenal of wonderful therapeutic agents that change the course of the pathological process in the desired direction and which also completely change the well-known natural unfavorable course of diseases. A modern radiologist is obliged to decipher all this from radiographs.
When taking into account radiological symptoms and their interpretation, the vast majority of errors are made by inexperienced diagnosticians. This includes, first of all, the misinterpretation of shadows caused by various errors in the research technique. For example, if you select Too soft rays or insufficient exposure, you can view osteosclerosis, marbling of bones, a cavity in the bone surrounded by osteosclerotic walls, or a fracture line. On the contrary, the shadow of soft tissue under these conditions, for example, a skin fold, can be mistaken for a fracture line where there is none, or for periostitis. An image taken with too harsh rays or overexposed may give rise to an incorrect assessment of the overall picture of the bone structure, for example, to the definition of osteoporosis or osteosclerosis. As a rule, calcifications and ossifications in soft tissues adjacent to bone masses, for example, the greater trochanter, remain unnoticed and undetected.
Particular care is required in cases where the photograph was taken from an area that has unequal thickness in different parts of it. So, for example, on nice photo of the shoulder girdle, the structure of the laterally and medially located parts cannot give the same picture: if the quality and quantity of rays are correctly calculated for, say, the area of the coracoid process, then the area of the greater tuberosity of the humerus should be overexposed, too “broken,” and, vice versa, if calculated correct exposure for the greater tuberosity of the humerus, the scapula area will remain underexposed. Therefore, an inexperienced radiologist may see osteoporosis in the more transparent part of the shoulder where there is none. The same error can be made when comparing the structure, for example, of the lower cervical vertebrae with the upper thoracic vertebrae, or the structure of the metatarsal and tarsal bones, the greater trochanter with the femoral neck, etc.
If the position of the object is unsuccessful, i.e. if the projection is incorrect, a shadow of the fracture line or even a significant displacement of the fragments can be seen. The rule when X-ray diagnosing diseases of bones and joints is to take pictures in at least two projections, and not be limited to one picture, does not allow exceptions, of course, except for those cases where this is technically completely impossible, for example, with ankylosis at an acute angle. The vast majority of fractures or cracks observed occur as a result of unreasonable savings on films in cases where such savings are least appropriate. Due to the same inappropriate saving of films, multiple joint lesions remain overlooked, when only one joint is subjected to X-ray examination, which for some reason attracts the main attention at the time of examination. As prescribed by the attending physician, only the area of the hip or knee joint is examined for varus deformity, when the extension of radiography at the initiative of the radiologist to other areas of the skeleton would make it possible to diagnose the underlying disease - osteochondrodystrophy or, say, renal, or
intestinal osteodystrophy, so-called renal or intestinal rickets.
For the same reason, systemic and generalized bone lesions are viewed and incorrectly recognized, such as, for example, especially often osteochondrodystrophy, chondromatosis of bones, multiple cartilaginous exostoses, bone carcinosis, fibrous dysplasia of bones, Recklinghausen’s and Paget’s diseases, etc. This also includes those errors that arise due to savings in film sizes. So, for example, with a fracture of the medial malleolus of the tibia, clearly visible on 13X18 or 18X24 radiographs, a clinically particularly important, not expected, fracture is visible. upper third fibula. Further, if spondylitis is suspected, a radiograph taken on a small film may show a normal picture, while a pathological process could be detected higher or lower on a large film. Another example: with clinical indications of early tuberculosis, photographs of the knee joint show an unchanged picture, and the radiologist denies the possibility of tuberculosis; the further course of the process indicates damage to the hip joint, which could have been detected relatively early if this joint had been examined radiologically in a timely manner.
Even the most technically impeccable standard photographs of the wrist joint area do not provide the identification of very serious and severe traumatic violations of the integrity of one or another wrist bone; Additional radiographs in special projections are absolutely necessary, depending on the clinical indications. Conventional photographs of the lumbosacral spine in two mutually perpendicular projections often show only a normal picture, while additional special placements can reveal clinically important pathology in the intervertebral small joints. Is it necessary in this case, after what has been said, to repeat again that the great evil in the X-ray diagnosis of diseases of bones and joints lies in the widespread self-removal of the radiologist from the technical and methodological management of the study? Isn’t it clear that the examination of a patient in all successive stages is the work of the doctor, and not the x-ray technician? The radiologist often does not even see the patient; What kind of clinical x-ray diagnostics is this? This is one of the main sources of diagnostic errors and defects in work. The elimination of this vice depends entirely on us.
Some dangerous pitfalls are hidden in various artifacts on the photosensitive layer of the plate, which arise either during the factory production of some low-quality films, or, what is more common, during their photographic processing. All kinds of spotty shadows can be mistaken by an inexperienced radiologist for a variety of pathological formations, for example, round shadows projected into the joint space - for intra-articular free bodies or calcification of the joint capsule, the stripes can simulate a fracture line, etc. Spots on the intensifying screen can lead to this kind of error.
It is essential to refrain from reading radiographs unless they are technically perfect. It is better to refuse an X-ray examination and not give a conclusion at all, than to guess, having in front of you incomplete images or an insufficient number of radiographs, although technically perfect. In this regard
The radiologist must win for himself the same rights that have long been enjoyed by the histologist, who refuses a consultation if he is offered a poorly stained section.
The most experienced radiologist may miss some abnormal radiological sign, such as a fracture line. This usually occurs in cases of multiple or double fractures. This error is psychologically understandable: if a researcher has discovered one bone fracture, he pays less attention to the search for further changes. In this way, he can view the avulsion of the styloid process of the ulna with a typical fracture of the radius, a fracture of the transverse process of the vertebra with more significant damage to its body, a pathological fracture with a tumor, etc. Having noticed the intra-articular free body (mouse), the radiologist ignores the niche in the epiphyseal cavity end of the bone, which would immediately explain the essence of the disease, or secondary initial disfiguring changes in the joint, important for subsequent treatment.
Changes are often visible when reading radiographs while running, with attention diverted to the side, or in poor lighting conditions for the images, as is, for example, practiced during rounds in the wards. Just as a surgeon refuses to operate under inappropriate conditions, so a radiologist should fundamentally refuse to interpret radiographs when the necessary, even the most modest, special devices are not available for this.
As for the erroneous interpretation of normal shadows, when a normal radiological symptom is mistaken for a pathological one, such errors are completely unacceptable. This includes the most serious mistake of novice radiologists, who mistake the epiphyseal strip for a fracture line or the shadow of a fossa in the head of the femur, where the round ligament of the femoral head is attached, as the focus of destruction. An example of such an error can also be the confusion of the sesamoid bone in the lateral head of the gastrocnemius muscle with the intra-articular mouse of the knee joint or accessory bone of the foot, or the hand with a fragment. The channel of the feeding vessel of the bone can be mistaken for a crack. A common anatomical variant is poorly known - sulcus paraglenoidalis, at the edge of the ilium near the sacroiliac joint, often taken as an expression of a disfiguring process in synchondrosis. If you are not aware of the normal pattern of ridges and roughness on the surface of bones, especially in strong, muscular men, you may mistakenly consider them to be periosteal layers. The interosseous ridges of the forearm and lower leg often simulate periostitis. Especially often, a linear shadow parallel to the lateral surface of the upper third of the tibia or the origin of the posterior tibial muscle adjacent to it in the form of a flat ridge is mistaken for periostitis. Roughness of the deltoid muscle on the lateral surface of the shoulder, which after a bruise on the clinical side corresponds to particularly sharp pain, is relatively often classified as periosteal sarcoma. In such cases, control radiography of a known healthy paired limb is indispensable and, even better, a silent and at the same time most eloquent consultation with the skeleton, which the radiologist should always have at hand.
With insufficient experience, the shadow of a skin fold spreading over the upper surface of the clavicle in people with a deep supraclavicular fossa can also be mistaken for periostitis. A light shadow of a bronchus containing air, superimposed on the edge of one of the middle thoracic vertebrae, can be mistakenly interpreted as a focus of destruction
in the vertebral body. The reason for a similar error may be the accumulation of air or gases in the intestinal loop on an x-ray lumbar region spine and especially the ilium; only repeated research can resolve the doubt. The summation of the shadow of a linear pulmonary pattern with the shadow of a rib in some cases may be similar to the shadow of a carious lesion of the rib or to a fracture line, or to a periosteal process.
Too often mistakes are made when interpreting radiographs of the lumbosacral spine, when the radiologist does not critically evaluate the extreme abundance of various anatomical variants in the structure of the promontory region or overestimates various insignificant deviations from the norm in the symmetry of the picture of the transverse processes, intervertebral joints, arches, etc. Insufficiently it is also known that spina bifida Ls and especially Si should be considered as a common normal anatomical variant in an adult and as an absolutely normal anatomical and radiological sign in children under the age of 10-12 years.
Mistakes are inevitable when even a knowledgeable doctor goes too far with the interpretation of pathological contents in a joint or, for example, in a bone cavity. Blood, pus, serous effusion, granulation, dense fibrous tissue, cartilage and osteoid substance are equally permeable to X-rays, since they differ too little from each other in their specific gravity and other physical properties. Therefore, their interpretation in the image depends on a number of indirect, often shaky and unreliable radiological symptoms and requires extreme caution. Foci of destruction in the bone, as has already been repeatedly indicated, in a wide variety of diseases can be depicted on radiographs in the form of identical or slightly different shadow images. Therefore, one must beware of excesses in the interpretation of radiological pictures in too specific anatomical terms. Such morphological overdiagnosis is already above critically analyzed in detail and its inconsistency is clearly demonstrated.
It is also necessary to take into account the fact that normal anatomical and physiological relationships change under the influence of pathology, and sometimes are distorted to the extreme. Osteoarthropathy can serve as proof of this, when, however, in the most severe, cartoonish drawings, it is almost impossible to distinguish the elbow joint from the knee joint. A clear example of this is also the stretching of the joint capsule when the joint cavity is filled with some long-term and slowly accumulating pathological product, in particular, osteochondral bodies in chondromatosis. We have repeatedly witnessed how an erroneous diagnosis was made only because intra-articular loose bodies were projected in places that are really far beyond the usual limits of a normal bursa.
It is not always possible to draw correct conclusions about the size and distribution of true bone damage based on radiographs. For example, a surgeon plans a local limited operation, guided by the presence of a small tumor focus of destruction on radiographs, while in reality the tumor already occupies the entire medullary canal of the tubular bone. Too fine an X-ray assessment of the degree of osteoporosis is unreliable. It is necessary to skillfully and accurately draw anatomical and radiological parallels, critically compare anatomical data with radiological symptoms.
In the general differential diagnostic analysis of an x-ray, most errors arise from an incorrect assessment of individual research methods, mainly from insufficient familiarity with the boundaries of the x-ray method. A doctor who relies only on radiology to recognize fractures makes not only a radiological, but also a general medical error. Overestimation of negative X-ray data is especially dangerous. The fact is that with most diseases of bones and joints, with the exception of fractures and dislocations, the changes visible on an x-ray are somewhat delayed. It is well known that in most diseases there is a so-called latent period of X-ray diagnostics, i.e. the period that passes between the occurrence of pathological changes caused by a particular disease and the appearance of the first X-ray signs of this disease. The clinic is sometimes ahead of radiology, sometimes inferior to it.
With osteoporosis and bone atrophy, radiological signs are detected earlier than clinical ones. In osteochondropathy, in contrast, the first stage of avascular necrosis, which can already manifest itself very clearly clinically, still gives a normal x-ray image. Radiographs may be normal in cases of undoubted tuberculous spondylitis or arthritis, and the latent period can last several months. In acute osteomyelitis, radiographs at the onset of the disease do not show any deviations from the norm; If you are not familiar with this, time may be lost for one or another important therapeutic intervention. Life-threatening hyperparathyroid osteodystrophy may be compatible for the time being with a normal x-ray picture of the skeletal system. Significant changes in the intra-articular ligamentous apparatus, such as rupture of the cruciate ligaments, as well as damage to the menisci in knee joint, in most cases, do not give any radiological symptoms with the usual research technique; an incorrect understanding of the boundaries of x-ray examination misleads the clinician and prevents prompt surgical intervention and cure of the patient.
Thus, a serious mistake is made by the radiologist who categorically excludes pathological changes, based solely on X-ray data. It must be firmly remembered that the radiological norm in no way means the anatomical norm. In this regard, studies on corpses carried out by A. Khazin are especially convincing, as well as experimental studies on animals by N. M. Beschinskaya et al., which showed that artificially caused defects in the cortical and especially cancellous bone substance under some conditions are not outlined at all on radiographs. But overestimation of clinical data can also be the cause of a radiologist’s error. So, for example, with a positive Wasserman reaction, a disease that has nothing in common with syphilis, for example, Paget's deforming osteodystrophy or osteoblastic bone sarcoma, is mistakenly mistaken for a syphilitic bone lesion. An incorrect diagnosis may also be influenced by a discrepancy between the X-ray picture and age, for example, the typical picture of diaphyseal tuberculosis in an old man or the characteristic Pagetian pattern of bone remodeling in a young man. Hypnosis of clinical facts is especially effective in recognizing diseases of the lumbosacral spine, where under -
Under clinical pressure, completely normal pictures are too often mistaken for pathological.
The greatest danger is fraught with an excessive desire to achieve an etiological diagnosis in each individual case. After all, radiological symptoms immeasurably more often reveal morphogenetic patterns than etiological patterns. The X-ray picture of a destroyed vertebra can be almost the same in such different diseases as, for example, tuberculosis, syphilis, brucellosis, osteomyelitis, actinomycosis, leukemia, lymphogranulomatosis, xanthomatosis, Gaucher disease, compression fracture, so-called traumatic spondylitis, decompression disease, primary sarcoma, metastatic cancerous tumor or hypernephroma, syringomyelia, tabes dorsalis, compression or destruction by a tumor or aneurysm, etc. Periosteal deposits on the bones can be caused by all sorts of mechanical, chemical, infectious, chronic toxic and other factors; the periosteum responds to any irritation in the same way the same as ossifying periostitis, and the x-ray picture of periostitis of various origins can be almost identical.
Particularly fraught with bad consequences is the scientifically unfounded desire to make etiological diagnoses in arthrology, the desire to answer the question at all costs, based on the X-ray picture of the joint, in isolation from the clinic, whether there is tuberculosis or brucellosis, or purulent or infectious arthritis in a given case. etc. As is known, syphilis has long had a great attractive force in this regard, which is made responsible for everything unknown.
It should be remembered that it is often not possible to unravel the etiology of the disease histologically; the more narrow the scope of radiological etiological diagnosis should be. Therefore, in the most banal case, it is necessary to make etiological conclusions only in the case when the clinical and radiological picture is pathognomonic or when all the differential diagnostic possibilities that all modern research methods give us have been completely exhausted.
We must also not lose sight of the fact that when getting acquainted with x-ray diagnostics in manuals, atlases, and lectures, we are talking mainly about typical, characteristic for each separate disease symptom complexes. The concept of typical and atypical in clinical medicine has now been clarified. From the Marxist-Leninist point of view, one should consider typical pictures of the disease not to be those most frequently observed statistically, but to those pictures that express the essence of the pathological process in the most characteristic, qualitative features. Atypical manifestations of the disease, therefore, should be designated not only by pictures that are more rarely encountered in a quantitative sense, but by pictures that express the manifestations of the disease less fully and sharply in a qualitative sense. When dealing with truly rare diseases, the radiologist does not know what is characteristic of the disease in general and what is specific to this particular case of the disease. Impressions are seriously corrected when, based on collective experience, consolidated, final data is created, when statistical and digital materials appear, when subjective ideas about frequency and rarity are replaced by objective percentage calculations.
Each individual patient presents his own individual characteristics, and life is replete with atypical cases full of contradictions. There are also some forms of diseases that are diametrically opposed to the typical picture. For example, one of the main symptoms of tuberculosis is the absence of a periosteal reaction; however, the most magnificent periostitis occurs with tuberculous osteitis, namely with a relatively rare diaphyseal lesion of long tubular bones. Another example. Rare forms of tuberculosis may appear radiographically from the very beginning of the disease as a more or less typical picture of disfiguring osteoarthritis. Further, how “typical” is the picture of osteochondropathy of the femoral head, but the deeper and better we know this disease, the more we are forced to reckon with its numerous clinical and radiological variants. Just as “typical” are some forms of eosinophilic bone granuloma or cancer metastases or the most banal chronic osteomyelitis, just as “atypical” are these same nosological forms in other cases. This creates conditions for hesitation and doubt, and even for completely incorrect diagnostic conclusions. Therefore, dogmatic etiological x-ray diagnostics does not stand up to criticism, and errors in this regard are less common the more experienced the radiologist is.
It is necessary to take into account another source of errors in the clinical X-ray diagnosis of osteoarticular diseases, namely the underestimation of the simultaneous presence of several diseases, when each of them is quite important in itself. This is always not coexistence, but mutual influence. If there is a clinical suspicion of, say, a bone fracture, the radiologist will confirm this presumptive diagnosis. He, however, overlooks the pathological nature of this violation of integrity, for example, a metastatic destructive focus in the metaphysis, and thereby makes a serious mistake. Further, rickets or osteomalacia are accurately recognized, but clinically important restructuring phenomena remain unnoticed. Deforming osteodystrophy is clear, but vital radiological symptoms of early malignancy are overlooked. With the same frequent Paget's disease, osteomyelitis, cancer metastases, and myelomatosis may also be a second disease. A one-time shot, like any product special research, is essentially one-sided. We have already pointed out that the radiologist, due to the very essence of his static examination, faces a natural danger of a too narrow, organo-morphological, mechanistic understanding of the picture of the disease. The radiograph of tuberculous gonitis should not obscure the entire person suffering from tuberculosis; with osteogenic sarcoma, for example, of the left thigh, the disease is not limited to local anatomical and radiological data. Rickets or hyperparathyroid osteodystrophy is something much more complex than just changes in the bone apparatus, even if they are very richly reflected radiographically. Even an ordinary bone fracture cannot be considered a purely local pathological process. Of the two formally completely identical radiological pictures of tuberculous spondylitis, one may belong to a barely manifested, completely benign process, and the other may belong to a person dying from miliary tuberculosis. Therefore, you need to be extremely restrained with conclusions relating to the patient or the entire disease as a whole, you need to exercise maximum caution in assessing based on just one image
issues of the course of the disease, treatment and prediction. But the method of radiological observation and multiple serial examinations greatly contributes to the prevention of errors, and the radiologist must resort to repeated examinations much more often than he is accustomed to doing at the present time.
Errors associated with incorrect formulation of the conclusion are completely unacceptable. An incorrect diagnosis turns out to be just a misformulated or misunderstood diagnosis.
In order to avoid misunderstandings with the referring physician, it is fundamentally necessary to indicate in the report in precise anatomical terms what exactly was subjected to X-ray examination. So, for example, it is necessary to indicate that the image of the spine covers the area from such and such a thoracic to such and such a lumbar vertebra, especially when the x-ray picture is normal. The clinician could suspect a lesion that is actually located above or significantly below, and only repeated X-rays of another part of the spine can reveal the pathological process. It is also necessary to indicate in what position the study was carried out, if for some reason it was not complete, because a pathological process that was not detected in one position may be revealed in another projection, and silence about this can be a heavy burden on the reputation of the radiologist.
If a clinician sends a patient with a diagnosis of perichondritis or a suspected fracture of the costal cartilages for an X-ray examination, then a brief answer from the radiologist about the absence of pathological changes in the image would be a gross mistake. It is quite obvious that the referring doctor in this case is not aware of the possibilities and limits of x-ray diagnostics. Therefore, in such cases, the radiologist’s conclusion should also contain a pedagogical note, of course, a strictly tactful one. In conclusion, it should be clearly stated that, as is known, normal and pathological cartilage do not give a shadow on an x-ray, and therefore it is not possible to judge whether there is inflammation of the perichondrium or a fracture, or neither, on the basis of an x-ray examination possibilities. A reservation is also necessary in case of negative research data, for example, of a joint with suspected tuberculosis in the early stages of its development; it must be pointed out that a normal x-ray picture does not exclude the possibility of tuberculosis. Otherwise, an inexperienced clinician who is not experienced in X-ray diagnostics may misinterpret the radiologist’s instructions and conclude that the joint is normal.
The conclusion must be formulated in such a way that there are no ambiguities, omissions and unfortunate expressions that could be understood in different ways. Frank and truthful answers from a radiologist that do not hide doubts and difficulties always make a better impression and are more useful for the business than “diplomatic” expressions that can be interpreted this way or that. The radiologist must, in his conclusion, select words and expressions that objectively express the degree of reliability of the diagnostic conclusion in each individual case. He must remember that every case is potentially forensic. From this point of view, it should be strongly recommended to archive radiographs or copies thereof, both with pathological changes and normal ones. The conclusion is not
should give the patient a reason to incorrectly comment on the X-ray data of the study.
Radiologists usually have to listen to the reproach that the conclusions given on the same image or case by different people are contradictory. Indeed, it must be recognized that the formulations of two radiologists nowadays rarely agree in all details. These are often not serious differences in substance, but much more often there are only sharp editorial differences, which quite confuse those who read these documents. Unfortunately, uniform, standardized nomenclature in radiology remains a thing of the future. Fairness, however, requires that contradictions in conclusions occur not only in radiology, but also in all other medical disciplines. It is no coincidence that the call to common language began to be heard from the lips of representatives of all branches of medicine.
It cannot be argued that as the experience and knowledge of the radiologist increases, so does his diagnostic confidence. The more experienced the radiologist, the less dogmatic he is in his conclusions. The more a radiologist achieves, the deeper he strives to delve into the anatomical and functional essence of each individual disease, to unravel the causes of the disease even more closely, to extract even more clinically important details from radiographs, the greater, of course, are the difficulties of X-ray examination. Constantly checking the correctness of his conclusions is absolutely mandatory for the radiologist. The isolated work of a radiologist usually leads to the fact that over time he creates for himself his own world, his own limited circle of ideas, which is no longer subject to critical revision, he takes it on faith, but which is often not without errors and biases. Indeed, from this point of view, it is difficult to overestimate the great beneficial significance of communication with the clinic specifically for radiology.
Improvement is possible only when the radiologist ensures contact with pathologists, surgeons and clinicians, persistently self-critically checks his diagnoses and pays special attention not to successful diagnoses, but to mistakes.
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PART II
