HOW TO READ A CHEST XRAY- A STEP BY STEP APPROACH

1. How to read a Chest X-ray -
A step by step approach

2. Trachea and major bronchi
• Contain air
• Lower density (blacker) than the surrounding soft tissues
• Branches into the left and right main bronchi at the carina
• Trachea should be central or slightly to the right
• If trachea is deviated  Patient rotation or due to
pathology
• If trachea is deviated due to pathology  Decide if it has
been pushed or pulled by a disease process
• Anything that increases pressure or volume in one
hemithorax will push the trachea and mediastinum away
from that side
• Any disease which causes volume loss in one hemithorax
will pull the trachea over towards that side

3. Normal chest X-ray
•The trachea and bronchi are visible - branching at the carina
•The trachea passes to the right of the aorta and so may be slightly off mid-line
to the right

5. Trachea pulled by a disease process
• Trachea is shifted
to left
• Fibrosis of left
upper zone due to
PTB

6. Trachea pulled by a disease process
• Trachea is
shifted to right
• Fibrosis of right
upper zone due
to PTB

7. Trachea pulled by a disease process
Right lower lobe collapse

8. Trachea pulled by a disease process

9. Trachea pulled by a disease process
Right upper lobe collapse

10. • Effusion and collapse
• This is a more difficult case. At first glance there is clearly "white out" of the left hemithorax,
with a meniscus sign. This indicates the presence of a pleural effusion. Why then is the
trachea (arrow) moved towards the side of the effusion?
• The clue lies in the appearance of the left main bronchus, which is abruptly cut off
(arrowhead), in this case due to a cancer
• There is both an effusion and lung collapse. The volume loss due to the collapse is greater
than the volume of the effusion. The collapse is therefore dominant and the trachea is
PULLED towards this side

11. Tracheal deviation in pneumonectomy
• Possible staples near
the hilum , crowding of
ribs, tracheal deviation
to left, raised dome
and heart shifted to
left with scoliotic
curvature of dorsal
spine consistent with
history of
pneumonectomy
status

12. Trachea pushed by a disease process
• Trachea is shifted to
right
• Left massive pleural
effusion

13. Trachea pushed by a disease process
• Trachea is shifted to
left
• Right sided
pneumothorax

14. Trachea pushed by a disease process
• Trachea is shifted
to right
• Chest radiograph
showing a left
superior
mediastinal mass

15. Trachea pushed by a disease process
• Trachea is shifted
to right
• Asterisks:
Mediastinal goiter
shadow
• Arrow: Tracheal
deviation

16. Trachea pushed by a disease process
Lung cancer - Mass
Lung cancer - Mass

17. • Hilar structures
• Each hilum contains major bronchi and pulmonary vessels
• Hilar lymph nodes are not visible unless abnormal
• Both hila should be of similar size and density
• Hilar point is the angle formed where the upper and lower
lobe pulmonary vessels meet
• They are useful points of reference to determine the position
of the hila
• The left hilum is commonly higher than the right
• Check the position,size and density of each hilum
• If a hilum is displaced - try to determine if it has been pushed
or pulled
• If either hilum is bigger and more dense (whiter) than normal,
this may indicate an abnormality

18. Hilar position

19. Bilateral hilar enlargement
• Both hila are larger and denser than normal

20. Bilateral hilar enlargement
• Clinical information
• Joint pain
• Erythema nodosum
• Diagnosis
• Sarcoidosis
• Differential
• Lymphoma, metastatic disease or infection may
occasionally look similar
• Pulmonary arterial hypertension may also cause
bilateral symmetrical hilar enlargement

21. Asymmetric hilar enlargement
•Both hila are larger and denser than normal
•The right hilum is bigger than the left
•Multiple small lung nodules
.Missing right breast shadow (mastectomy)
Clinical information
•Known breast cancer, Increasing shortness of breath
Diagnosis
•Metastatic disease
•Breast cancer

22. Unilateral hilar enlargement

23. Abnormal hilar position
• The left hilum is large,
dense and pulled laterally
and upwards to the left
• The trachea is deviated
(pulled) towards the left,
indicating loss of lung
volume in the left
hemithorax
• Clinical details
• History of left hilar
malignancy treated with
radiotherapy
• Diagnosis
• Radiation fibrosis

24. Mediastinal contours
• Heart : located in the middle mediastinum
• Aortic knuckle
• Descending aorta
• Aortopulmonary window
• Right paratracheal stripe

25. Normal aortic knuckle
• The aortic knuckle
represents the left lateral
edge of the aorta as it
arches backwards over the
left main bronchus
• The contour of the
descending thoracic aorta
can be seen in continuation
from the aortic knuckle
• Displacement or loss of
definition of these contours
can indicate diseases such
as aortic aneurysm or
adjacent lung consolidation

26. Aortic unfolding – 66year old
•With age the aorta lengthens and appears to buckle or ‘unfold’
•The descending aorta may appear tortuous rather than straight

27. Aortic unfolding – 99 year old
•Aortic unfolding is not considered pathological but is associated with
atherosclerosis
•Calcification of the aorta is seen in this patient

28. Normal aortopulmonary window
• The aortopulmonary
window is located
between the Aortic
Knuckle (AK) and the Left
Pulmonary Artery (LPA)
• It is a space where
abnormal enlargement of
mediastinal lymph nodes
can be seen on a chest
X-ray

29. Normal right paratracheal stripe
• From the level of the clavicles to
the azygos vein the right edge of
the trachea is seen as a thin white
line or 'stripe'
• This stripe is created by air of low
density (blacker) lying either side of
the comparatively dense (whiter)
tracheal wall
• Thickening of the paratracheal
stripe (normally less than 3 mm)
may represent pathology such as a
paratracheal mass or enlarged
lymph nodes
• The left side of the trachea is not so
well defined because of the position
of the aortic arch and great vessels

30. Mediastinum and Hilum

31. Mediastinal abnormalities
• A widened mediastinum is often due to technical factors
such as patient positioning or the projection used
• Rotation, incomplete inspiration, or an AP view, may all
exaggerate the width of the mediastinum, as well as
heart size
• Genuine widening is usually due to a vascular
abnormality or a mediastinal mass
• A lateral view may help determine the location of a mass

32. Anterior mediastinal mass
B-cell lymphoma
The PA radiograph shows a very large mass extending laterally from the left
side of the mediastinum (arrows)
Its location in the anterior mediastinum is confirmed on the lateral view which
shows that the mass (outlined in yellow) is displacing the trachea (blue lines)
posteriorly

33. The coronal (left) and sagittal (right) CT images correlate nicely with the
radiographs and delineate the full extent of the mass as well as showing its
relations to the heart and aorta

34. • Differential diagnosis of anterior
mediastinal masses
• Lymphoma
• Thyroid enlargement
• Teratoma
• Tumours of the thymus
• Thoracic aorta aneurysm

35. Aneurysmal descending aorta
•This image shows a grossly enlarged descending aorta due to a thoracic aortic
aneurysm

36. Pulmonary hypertension
Central pulmonary artery dilatation

37. Pneumomediastinum

38. Pneumomediastinum
•Pneumomediastinum (gas within soft tissues of the mediastinum) may
result from injury to the lungs or structures of the mediastinum such as the
airways or oesophagus
•The mediastinal pleura is separated from the mediastinum and becomes
visible as a thin white line

39. Hiatus hernia
There is a large hiatus hernia and air fluid level within the stomach
There is consolidation in the right base

40. Heart size and contours
• The heart size is assessed as the cardiothoracic ratio
(CTR)
• CTR = Cardiac Width : Thoracic Width
• Frequently expressed as a percentage
• If the CTR is <50% on either a Posterior - Anterior (PA)
or an Anterior - Posterior (AP) view, then the heart size is
within normal limits
• A CTR of >50% is abnormal - PA view only

41. Cardiothoracic ratio (CTR)
• Cardiac size is measured
by drawing vertical
parallel lines down the
most lateral points of the
heart and measuring
between them
• Thoracic width is
measured by drawing
vertical parallel lines
down the inner aspect of
the widest points of the
rib cage, and measuring
between them
• CTR = Cardiac Width :
Thoracic Width

42. Cardiothoracic ratio (CTR)
• CTR: Ratio of maximal
horizontal cardiac diameter
to maximal horizontal
thoracic diameter
• D1 is the greatest
perpendicular diameter
from the midline to the right
heart border
• D2 is the greatest
perpendicular diameter
from the midline to the left
heart border

43. CARDIOMEGALY
• CTR>50%

44. Cardiomegaly and heart failure
• If the heart is enlarged – look for signs of heart
failure (upper zone vessel prominence, pulmonary
oedema and pleural effusions)
• Pulmonary oedema manifests in two forms –
interstitial oedema (septal lines), and alveolar
oedema (airspace shadowing/consolidation)
• When the heart is enlarged it is sometimes possible
to determine if a specific heart chamber is enlarged
• The heart contour may be abnormal due to cardiac
or pericardial disease
• The heart contour may be obscured by adjacent
lung disease

45. Signs of heart failure
•Cardiomegaly CTR = 18/30 (>50%)
•Upper zone vessel enlargement (1) – a sign of pulmonary venous hypertension
•Septal (Kerley B) lines (2) – a sign of interstitial oedema
•Airspace shadowing (3) – due to alveolar oedema – acutely in a peri-hilar (bat's
wing) distribution
•Blunt costophrenic angles (4) – due to pleural effusions

46. Septal lines (Kerley B lines)
• Horizontal lines reaching the lung edge
• Differential diagnosis
• Heart failure
• Conditions that cause lymphatic obstruction – such as sarcoidosis or
lymphangitis carcinomatosa

47. Alveolar oedema - airspace shadowing
•Dense airspace shadowing is due to alveolar oedema caused by fluid filling
the alveoli and small airways
•In the acute setting this airspace shadowing radiates from the hilar regions in
a 'bat's wing' distribution and then becomes more generalised

48. • Heart chamber enlargement
• If the heart is enlarged it is sometimes
possible to determine which chamber is
enlarged
• For example, signs of left atrial
enlargement include a double right heart
border, bulging of the left heart border, and
splaying of the carina to greater than 90
degrees

49. Left atrial enlargement
•The left and right heart borders are marked (arrows)
•Extra right heart border – formed by the edge of the enlarged left atrium
(highlighted area)
•Slight bulge in the left heart border (asterisk) due to enlargement of the left
atrial appendage
•Splaying of the carina to greater than 90 degrees – the carina lies directly
above the left atrium
•Metallic aortic and mitral heart valve replacements (arrowhead)

50. Normal cardiac contours
•The left heart contour (red line) consists of the left lateral border of the Left
Ventricle (LV)
•The right heart contour is the right lateral border of the Right Atrium (RA)

51. • Abnormal heart contours
• The heart contours may be abnormal due
to cardiac abnormalities, such as a left
ventricular aneurysm, or pericardial
abnormalities such as a pericardial
effusion

52. Pericardial effusion
• Enlarged globular heart
• CTR >50%

53. Left ventricular aneurysm
There is an unusual contour of the left heart border (white arrow) and an
abnormal protuberance in the region of the left ventricle (red arrow).

54. Obscured heart contours
• The heart contours may be obscured due to
disease of the adjacent lung
• Right middle lobe consolidation can obscure the
right heart border (right atrial edge)
• Consolidation of the lingula (an anterior segment
of the left upper lobe) can obscure the left heart
border (left ventricular edge)

55. Obscured heart contours
• Right middle lobe
consolidation obscure
the right heart border
(right atrial edge)

56. Consolidation of the lingula
•Poorly defined left heart border due to consolidation in the adjacent lingula

57. Lung zones
• For the purpose of description the lungs are divided into
zones: upper, middle and lower
• Each of these zones occupies approximately one third of
the height of the lungs
• The lung zones do not equate to the lung lobes
• For example, the lower zone on the right comprises the
middle and lower lobes

58. Lung zones
•Note that the lower zones reach below the diaphragm (dotted white line) –
the lungs pass behind the dome of the diaphragm into the posterior sulcus of
each hemithorax (asterisks)

59. • Assessing the lung zones
• Each zone is compared with its opposite side
• If the lungs appear asymmetrical it should be determined
if this is due to asymmetry of normal structures, technical
factors, such as rotation, or lung pathology
• If there is genuine asymmetry, decide which side is
abnormal
• Often a dense (whiter) area is abnormal, such as
in pneumonia or lung cancer, but some diseases cause
reduced density (blacker), such as a pneumothorax
• If there is an area that is different from the surrounding
areas of the same lung, then this is likely to be the
abnormal area
• Some diseases result in bilateral lung abnormalities
making comparison of left with right difficult

60. Lung lobes and fissures
• The visceral pleura covers the lung surfaces and is
continuous with the visceral pleura that covers the
fissures
• Left lung is divided into two lobes, upper and lower, by
the oblique (major) fissure
• Right lung has two fissures, oblique fissure and
horizontal fissure, which separate the lung into three
lobes - upper, middle, and lower
• Each lobe has its own visceral pleural covering
• Only the horizontal fissure is commonly seen on a frontal
chest X-ray
• Oblique fissures (also known as the major fissures) may
be visible on lateral images

61. Lobes and fissures (right lung)
Three lobes of the right lung separated by the horizontal and oblique (or
major) fissures

62. Lobes and fissures (right lung)

63. Lobes and fissures (left lung)
•There are two lobes on the left
•There is usually no horizontal fissure on the left

64. Lobes and fissures (left lung)

65. Horizontal fissure
• The horizontal fissure
separates the right
upper lobe from the right
middle lobe
• It may be seen on a
normal chest X-ray as a
thin line running roughly
horizontally from the
edge of the lung towards
the right hilum

66. Oblique fissures
•Oblique (major) fissures overlie each other on a lateral view and are not always seen
in entirety
•If seen at all, the lower end is usually seen most clearly (dotted lines = predicted
positions)
•The horizontal fissure is not seen at all on this lateral image (white dotted line =
predicted position)

67. Accessory fissure
Azygos fissure

68. Accessory fissure

69. Lung abnormalities
• Compare the left and right upper, middle and lower lung
zones
• Decide which side is abnormal
• Compare an area of abnormality with the rest of the lung
on the same side
• The whiter side is not always the abnormal side
• Remember many lung diseases are bilateral and
symmetrical

70. • Consolidation
• If the alveoli and small airways fill with dense material, the
lung is said to be consolidatedi
• Air bronchogram
• If an area of lung is consolidated it becomes dense and white
• If the larger airways are spared, they are of relatively low
density (blacker)
• This phenomenon is known as air bronchogram and it is a
characteristic sign of consolidationsis
• Differential diagnosis of consolidation
• Pneumonia - airways full of pus
• Cancer - airways full of cells
• Pulmonary haemorrhage - airways full of blood
• Pulmonary oedema - airways full of fluid

71. Consolidation with air bronchogram

72. Metastases (from lung to lung)
•This image shows a large right middle zone lung mass (found to be a cancer on
biopsy) with several nodules (metastases) elsewhere in both lungs
(arrowheads)

73. Pulmonary edema

74. Miliary tuberculosis
Miliary deposits appear as 1-3 mm diameter nodules, which are uniform in
size and uniformly distributed

75. Fluid in horizontal fissure

76. Right upper lobe consolidation
Right upper lobe
consolidation
Note the beautiful
air-bronchogram

77. Right middle lobe consolidation
•The right heart border (right atrial edge) is obscured
•Consolidation (asterisk) is limited above by a crisp line, formed by the
horizontal fissure
•The pathology must therefore involve the right middle lobe
•More extensive shadowing also involves the right and left peri-hilar regions

78. Right lower lobe consolidation
Consolidation
right lower lobe
Right dome of the
diaphragm is
blurred

79. Right upper lobe collapse
•The horizontal fissure (white line) has been displaced upwards from its
original position (red line)
•Dense opacification (asterisk) of the medial part of the right upper zone
•Enlarged right hilum

80. Left lower lobe cavity - frontal view
•Large, round, thick-walled lung cavity
•The cavity is in the left middle zone, close to the hilum
•Which lobe do you think it is in? See the lateral view below

81. Left lower lobe cavity – lateral view
view
must be in the lower lobe
The cavity is behind the oblique fissure (blue line) and so must be in the lower
lobe
Clinical information
•Long term smoker with a cough
Diagnosis
•Left lower lobe lung cavity – in this case due to a squamous cell lung carcinoma

82. Pleura and pleural spaces
• The pleura and pleural spaces are only clearly
visible when abnormal
• Some diseases, such as mesothelioma, cause
pleural thickening
• Other pleural diseases lead to fluid accumulation
(pleural effusion) or air gathering in the pleural
spaces (pneumothorax) thoracic wall

83. Normal pleura and pleural spaces
• Trace round the entire edge of the lung where pleural
abnormalities are more readily seen
• Start and end at the hila
• Is there pleural thickening?
• Is there a pneumothorax? The lung markings should be
visible to the chest wall
• Is there an effusion? The costophrenic angles and
hemidiaphragms should be well defined

84. Normal pleura and pleural spaces

85. Tension Pneumothorax
Signs of tension
•The left lung is completely compressed (arrowheads).
•The trachea is pushed to the right (arrow)
•The heart is shifted to the contralateral side - note right heart border is pushed
to the right (red line)
•The left hemidiaphragm is depressed (orange line)

86. Pleural effusion
•The left lower zone is uniformly white
•At the top of this white area there is a concave surface - meniscus sign
•The left heart border, costophrenic angle and hemidiaphragm are obscured
•Slight blunting of the right costophrenic angle indicates a small pleural effusion
on that side

87. Asbestos related pleural plaques
•Bilateral well defined irregular shadows that are as dense as the bones
•Peripheral pleural thickening

88. Unilateral pleural thickening
•Lobulated peripheral shadowing on the right
•Loss of right lung volume
Shadowing over the whole right lung due to circumferential pleural thickening
Clinical information
•Shortness of breath and right-sided chest pain,History of asbestos exposure
Diagnosis
•Biopsy results showed this to be a mesothelioma - a malignancy of the pleura
caused by exposure to asbestos

89. Costophrenic recesses and angles
• The costophrenic angles are formed by the
points at which the chest wall and diaphragm
meet
• The costophrenic recesses contain the lower
edges of the lungs which contact the diaphragm

90. Costophrenic recesses and angles
•The costophrenic recesses are seen on each side as the costophrenic angles
•The costophrenic angles are formed by the lateral chest wall and the dome of
each hemidiaphragm

91. Costophrenic recesses and angles -
lateral view
•On a lateral view the costophrenic recesses are seen in the region of the
anterior and posterior costophrenic angles formed by the chest wall and the
dome of each hemidiaphragm

92. Assessing the costophrenic angles
• On a frontal chest X-ray the costophrenic angles
should form acute angles which are sharp to a point
• Costophrenic "blunting" is often due to the presence
of a pleural effusion, but it can also be related to
other pleural disease or lung disease
• Lung hyperexpansion can also lead to blunting of
the costophrenic angles
• This is because the domes of the diaphragm are
pushed downwards and so the angle becomes
rounded

93. • Costophrenic angle blunting
• Blunting of the costophrenic angles is usually
caused by a pleural effusion
• Other causes of costophrenic angle blunting
include lung disease in the region of the
costophrenic angle, and lung hyperexpansion

94. Right costophrenic angle blunting
•The left costophrenic angle is sharply defined (normal)
•The right costophrenic angle is blunt (abnormal)
•There is volume loss in the right hemithorax with corresponding shift of the
mediastinum and trachea to the right (arrows)
•Note: Pleural effusions do not cause volume loss

95. Lung hyperexpansion
•Both costophrenic angles are blunt due to lung hyper-expansion
•The hemidiaphragms are flattened indicating hyperexpansion
•The lung markings are distorted bilaterally

96. Diaphragm
• Diaphragm separates the lungs from the abdominal organs
• Abdominal organs are more dense (whiter) than the air-filled
lungs (blacker)
• Hemidiaphragms are domed structures
• Each hemidiaphragm should be well defined
• Right hemidiaphragm is slightly higher than the left
• Liver is located inferior to the right hemidiaphragm
• Stomach and spleen are located inferior to the left
hemidiaphragm
• The stomach is frequently visible as a gas-filled 'bubble' below
the left hemidiaphragm
• It is important to be aware that the lowest portion of the lungs –
which occupy the posterior costophrenic recesses – extend
below the level of the contours of the hemidiaphragms
• The stomach bubble forms a window through which this part of
the lung is visible on the left

97. Hemidiaphragms
•The right hemidiaphragm is slightly higher than the left
•The liver is located inferior to the right hemidiaphragm
•The stomach and spleen are located inferior to the left hemidiaphragm
•Lung markings are visible below the diaphragm on both sides – most clearly
through the stomach bubble
•The cardiophrenic angles (asterisks) are the points at which the hemidiaphragms
meet the heart
•On both sides the contour of the hemidiaphragm (dotted line) should be seen
passing medially as far as the spine

98. Hemidiaphragms - lateral view
• The right diaphragm should be visible all the way to the anterior
chest wall (red arrow)
• The left diaphragm can only be seen to a point where it borders the
heart (blue arrow)

99. • Assessing the diaphragm
• The contours of the hemidiaphragms do not demarcate
the bottom of the lungs
• Lung markings can be seen below the hemidiaphragms
• This area of the lungs should be checked whenever
assessing a chest X-ray
• Inferior displacement of the diaphragm is a sign of lung
hyperexpansion
• Raised position of a single hemidiaphragm may indicate
phrenic nerve palsy

100. Raised hemidiaphragm
Causes of a raised hemidiaphragm such as damage to the phrenic nerve,
lung disease causing volume loss, congenital causes such as a
diaphragmatic hernia, or trauma to the diaphragm

101. Inferior displacement of the diaphragm

102. Pneumoperitoneum on an erect
chest X-ray
•The lungs are normal
•The diaphragm is crisply defined on both sides (arrowheads)
•Air under the diaphragm (asterisks) is seen as crescents of relatively low
density (black)
•Black air can be seen on both sides of the bowel wall (blue line) – this is known
as the double-wall sign or Rigler's sign (usually only seen on abdominal X-rays)

103. Right lower lobe consolidation
Consolidation
right lower lobe
Right dome of the
diaphragm is
blurred

104. Soft tissues
• Check the soft tissues, especially around the neck, the
thoracic wall, and the breasts
• Thick soft tissue may obscure underlying structures
• Black within soft tissue may represent gas
• If a patient has very thick soft tissue due to obesity,
underlying structures such as the lung markings may be
obscured
• Large breasts may obscure the costophrenic angles
giving the impression of the presence of pleural effusions

105. Soft tissue fat
•This close-up demonstrates a normal fat plane between layers of muscle
•Fat is less dense than muscle and so appears blacker
•Note that the edge of fat is smooth
•Irregular areas of black within the soft tissues may represent air tracking in
the subcutaneous layers (surgical emphysema)

106. S/P Left mastectomy Chest X ray
Patient with left
mastectomy for follow-
up, demonstrates
a hyperlucent left
lower hemithorax

107. Surgical emphysema
• Small residual right
apical pneumothorax
(arrows) following chest
drain insertion
• Extensive surgical
emphysema, with soft
tissue gas evident in the
right chest wall and
breast, and extending
through the right axilla
into the neck

108. Nipple shadows
Frequently, one may encounter two round symmetrical opacities at the bilateral
lower lung fields
These are often nipple shadows and can be confirmed by placing a radio-
opaque marker (e.g. metallic clips) over the nipples and repeating the CXR

109. Bones
• Densest structures
• Bones visible on a chest X-ray
• Clavicles
• Ribs
• Scapulae
• Spine
• Proximal humeri (upper arms)
• Useful markers of chest radiograph quality
• Used to assess patient rotation, adequacy of inspiration
and X-ray penetration

110. • Spinous processes of the vertebrae (posterior structures)
and the medial ends of the clavicles (anterior structures)
are landmarks to assess rotation
• Ribs should be checked on every chest X-ray
• Clavicle and ribs act as landmarks when assessing the
adequacy of inspiration taken by the patient
• Anterior end of approximately 5-7 ribs should be visible
above the point at which the mid-clavicular line intersects
the diaphragm
• Less than 5 ribs indicates incomplete inspiration
• More than 7 ribs suggests lung hyper-expansion
• A well penetrated chest X-ray is one where the vertebrae
are just visible behind the heart

111. Clavicles / Spinous processes / Ribs
•The spinous processes of the vertebrae (posterior structures) and the medial
ends of the clavicles (anterior structures) are landmarks to assess rotation
•The ribs should be checked on every chest X-ray
•The right 5th rib is highlighted (roll-over image)

112. Clavicle / Scapula / Humerus
•The clavicles, scapulae, and humeri are often clearly seen on a chest X-ray
•Occasionally you will see evidence of important disease such as metastases in
these bones
•1 - Clavicle 2 - Acromioclavicular joint 3 - Acromion process of scapula 4 - Body
of scapula 5 - Glenoid fossa of scapula 6 - Head of left humerus
•7 - Glenohumeral joint 8 - Coracoid process of scapula

113. Clavicle / Ribs
•The clavicle and ribs act as landmarks when assessing the adequacy
of inspiration taken by the patient
•The anterior end of approximately 5-7 ribs should be visible above the point at which
the mid-clavicular line intersects the diaphragm
•Less than 5 ribs indicates incomplete inspiration
•More than 7 ribs suggests lung hyper-expansion

114. Penetration

115. Bone abnormalities
• Malignant bone disease
• There may be evidence of metastatic bone disease
on a chest X-ray
• This may manifest as a single bone metastasis, or
as a diffuse abnormality representing widespread
metastases
• Bones may become denser (whiter) due to a
sclerotic process (often seen in prostate cancer), or
less dense (blacker) due to a lytic process (as is
often the case in renal cell cancer)
• Bone metastases may present with pathological
fractures which may appear as acute or old
fractures, depending on the stage of healing

116. Multiple bone metastases
•Pacemaker
•Dense/sclerotic ribs (arrowheads)
•Patchy dense/sclerotic clavicles and humeri (asterisk)
•Bilateral lower zone consolidation with a pleural effusion on the right
•No pathological fractures are seen

117. SCOLIOSIS

118. Right Cervical rib

119. Rib fractures

120. Notching of ribs in Coarctation of aorta