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  • Print publication year: 2015
  • Online publication date: July 2015

45 - Chest x-ray

from Section 11 - Surgical radiology



‘This is a chest radiograph in AP/PA erect/supine view with no/some rotation. It is (is not) adequate.’


Examination sequence ABCDEF:

A Address

A Adequacy of film

A Airway

B Breathing

B Bones

B Breasts

C Circulation

D Diaphragm

D Danger areas

E Everything else

F Foreign objects



• Name and date of birth of patient



Rotation – symmetrical distances between spinous processes and clavicular heads

Inspiration – 5–6 anterior ribs cross the mid-clavicular line and diaphragm

Penetration – vertebral bodies seen behind heart

Orientation – PA usual, AP if patient is unwell


• Trachea:

• central or deviated

• carina: position and angle (widened by malignant carinal lymphadenopathy)

• endotracheal tube: tip should be 2 cm above carina

• Branches:

• inhaled foreign body: commonly right lower lobe, although may affect any lobe

Breathing (lung fields)

• Mediastinal shift: tension pneumothorax

• Lung parenchyma:

• increased lucency (black): pneumothorax (absent lung markings), bullae, COPD

• increased opacity (white): consolidation, pulmonary oedema, collapse, effusion, haemothorax, empyema

• Lobar involvement: ill-defined edges:

• right middle lobe: poor definition of right heart border

• right lower lobe: poor definition of right hemi-diaphragm

• left upper lobe/lingual lobe: poor definition of left heart border

• left lower lobe: poor definition of left hemi-diaphragm

• Hila: position (usually left higher than right), size, masses


• Fractures: ribs, sternum, clavicles, humerus, scapulae, vertebrae

• Dislocations: humerus, clavicles

Breast (in women)

• Present/absent (only relevant if at least one breast is seen)

• Breast implants


• Mediastinum: pericardial effusion, pneumopericardium, left lower lobe collapse, hiatal hernia

• Heart size > 50% of thoracic diameter on PA radiograph = cardiomegaly

• Aorta: widened (aneurysm, dissection, unfolded)


• Above diaphragm: loss of costophrenic angle (effusion, consolidation, lower lobe collapse)

• Below diaphragm:

• air below diaphragm: hollow viscus perforation, Chilaiditi's sign

• air below the diaphragm is physiological if on the left side and part of gastric bubble (air in fundus of stomach).