Radiography, Bone

Radiography, Bone

Synonym/acronym: Arm x-rays, bone x-rays, leg x-rays, rib x-rays, spine x-rays.

Common use

To assist in evaluating bone pain, trauma, and abnormalities related to disorders or events such as dislocation, fracture, abuse, and degenerative disease.

Area of application

Skeleton.

Contrast

None.

Description

Skeletal x-rays are noninvasive studies used to evaluate extremity pain or discomfort due to trauma, bone and spine abnormalities, or fluid within a joint. Serial skeletal x-rays are used to evaluate growth pattern. Radiation emitted from the x-ray machine passes through the patient onto an image receptor. X-rays pass through air freely and are absorbed by the anatomical structures of the body in varying degrees based on density. Bones are very dense and therefore absorb or attenuate most of the x-rays passing into the body and appear white; organs and muscles are denser than air but not as dense as bone, so they appear in various shades of gray. Metals absorb x-rays and appear white and thus facilitate the search for foreign bodies in the patient.

This procedure is contraindicated for

  • high alertPatients who are pregnant or suspected of being pregnant, unless the potential benefits of a procedure using radiation far outweigh the risk of radiation exposure to the fetus and mother.

Indications

  • Assist in detecting bone fracture, dislocation, deformity, and degeneration
  • Evaluate for child or elder abuse
  • Evaluate growth pattern
  • Identify abnormalities of bones, joints, and surrounding tissues
  • Monitor fracture healing process

Potential diagnosis

Normal findings

  • Infants and children: Thin plate of cartilage, known as growth plate or epiphyseal plate, between the shaft and both ends
  • Adolescents and adults: By age 17, calcification of cartilage plate; no evidence of fracture, congenital abnormalities, tumors, or infection

Abnormal findings related to

  • Arthritis
  • Bone degeneration
  • Bone spurs
  • Foreign bodies
  • Fracture
  • Genetic disturbance (achondroplasia, dysplasia, dyostosis)
  • Hormonal disturbance
  • Infection, including osteomyelitis
  • Injury
  • Joint dislocation or effusion
  • Nutritional or metabolic disturbances
  • Osteoporosis or osteopenia
  • Soft tissue abnormalities
  • Tumor or neoplastic disease (osteogenic sarcoma, Paget’s disease, myeloma)

Critical findings

    N/A

Interfering factors

  • Factors that may impair clear imaging

    • Retained barium from a previous radiological procedure.
    • Metallic objects (e.g., jewelry, body rings) within the examination field, which may inhibit organ visualization and can produce unclear images.
    • Inability of the patient to cooperate or remain still during the procedure because of age, significant pain, or mental status.

  • Other considerations

    • Consultation with a health-care provider (HCP) should occur before the procedure for radiation safety concerns regarding younger patients or patients who are lactating. Pediatric & Geriatric Imaging Children and geriatric patients are at risk for receiving a higher radiation dose than necessary if settings are not adjusted for their small size. Pediatric Imaging Information on the Image Gently Campaign can be found at the Alliance for Radiation Safety in Pediatric Imaging (www.pedrad.org/associations/5364/ig/).
    • Risks associated with radiation overexposure can result from frequent x-ray procedures. Personnel in the room with the patient should wear a protective lead apron, stand behind a shield, or leave the area while the examination is being done. Personnel working in the examination area should wear badges to record their level of radiation exposure.

Nursing Implications and Procedure

Pretest

  • Positively identify the patient using at least two unique identifiers before providing care, treatment, or services.
  • Patient Teaching: Inform the patient this procedure can assist in examining bone structure.
  • Obtain a history of the patient’s complaints, including a list of known allergens, especially allergies or sensitivities to latex, anesthetics, or sedatives.
  • Obtain a history of the patient’s musculoskeletal system, symptoms, and results of previously performed laboratory tests and diagnostic and surgical procedures.
  • Record the date of the last menstrual period and determine the possibility of pregnancy in perimenopausal women.
  • Obtain a list of the patient’s current medications, including herbs, nutritional supplements, and nutraceuticals (see Effects of Natural Products on Laboratory Values online at DavisPlus).
  • Review the procedure with the patient. Explain that numerous x-rays may be taken depending on the bones or joint affected. Address concerns about pain and explain that some pain may be experienced during the test, or there may be moments of discomfort. Inform the patient that the procedure is performed in the radiology department by an HCP, with support staff, and takes approximately 10 to 30 min.

  • Pediatric Considerations Preparation of children for a bone radiography depends on the age of the child. Encourage parents to be truthful about what the child may experience during the procedure and to use words that they know their child will understand. Toddlers and preschool-age children have very short attention spans, so the best time to talk about the test is right before the procedure. The child should be assured that he or she will be allowed to bring a favorite comfort item into the examination room, and if appropriate, that a parent will be with the child during the procedure. Provide older children with information about the test and allow them to participate in as many decisions as possible (e.g., choice of clothes to wear to the appointment) in order to reduce anxiety and encourage cooperation. If the child will be asked to maintain a certain position for the test, encourage the child to practice the required position, provide a CD that demonstrates the procedure, and teach strategies to remain calm, such as deep breathing, humming, or counting to himself or herself.

  • Sensitivity to social and cultural issues, as well as concern for modesty, is important in providing psychological support before, during, and after the procedure.
  • Instruct the patient to inhale deeply and hold his or her breath while the image is taken. Warn the patient that the extremity’s position during the procedure may be uncomfortable, but ask the patient to hold very still during the procedure because movement will produce unclear images.
  • Instruct the patient to remove jewelry and other metallic objects from the area to be examined prior to the procedure.
  • Note that there are no food, fluid, or medication restrictions unless by medical direction.

Intratest

  • Potential complications: N/A
  • Observe standard precautions, and follow the general guidelines in Patient Preparation and Specimen Collection. Positively identify the patient.
  • Ensure that the patient has removed all external metallic objects from the area to be examined prior to the procedure.
  • Avoid the use of equipment containing latex if the patient has a history of allergic reaction to latex.
  • Have emergency equipment readily available.
  • Instruct the patient to void prior to the procedure and to change into the gown, robe, and foot coverings provided.
  • Place patient in a standing, sitting, or recumbent position in front of the image receptor.
  • Ask the patient to inhale deeply and hold his or her breath while the x-ray images are taken.
  • Instruct the patient to cooperate fully and to follow directions. Ask the patient to remain still throughout the procedure because movement produces unreliable results.

Post-Test

  • Inform the patient that a report of the examination will be sent to the requesting HCP, who will discuss the results with the patient.
  • Recognize anxiety related to test results, and be supportive of impaired activity related to the perceived loss of daily function. Discuss the implications of abnormal test results on the patient’s lifestyle. Provide teaching and information regarding the clinical implications of the test results, as appropriate. Provide contact information, if desired, for the American College of Rheumatology (www.rheumatology.org) or for the Arthritis Foundation (www.arthritis.org).
  • Reinforce information given by the patient’s HCP regarding further testing, treatment, or referral to another HCP. Explain the importance of adhering to the therapy regimen. Answer any questions or address any concerns voiced by the patient or family.
  • Depending on the results of this procedure, additional testing may be performed to evaluate or monitor progression of the disease process and determine the need for a change in therapy. Evaluate test results in relation to the patient’s symptoms and other tests performed.

Related Monographs

  • Related tests include antibodies anti-cyclic citrullinated peptide, ANA, arthrogram, arthroscopy, biopsy bone, BMD, bone scan, calcium, CBC, CRP, collagen cross-linked telopeptides, CT spine, ESR, MRI musculoskeletal, osteocalcin, phosphorus, synovial fluid analysis, RF, vitamin D, and WBC scan.
  • Refer to the Musculoskeletal System table at the end of the book for related tests by body system.