tangent
06-27-02, 21:08
Minimizing unnecessary
X-ray examinations
A national and professional approach
Leslie R Whittaker FRCR*
Formerly Professor. Department of Diagnostic Radiology
University of Nairobi, Kenya
TROPICAL DOCTOR, 1997, 17, 62-66
Inspired by the World Health Organization studies
on Efficiency and Efficacy in Diagnostic Radiology,
and encouraged by the late Dr W Selentag (then
Chief, Radiation Health, WHO, Geneva), the
Kenya Association of Radiologists arranged three
meetings in 1982-83, to which were invited rep-
resentatives of national medical and paramedical
groups and associated professionals including trade
and legal representatives'. It was agreed that the
policies suggested by WHO to minimize unnecess-
ary radiation should be considered in the local
context and that principles should be agreed for
local implementation as standard radiographic and
radiological practice.
The WHO studies' drew attention to the often
unnecessary patient radiation exposure. Much of
this was "routine" radiography, and the general
principle enunciated by the WHO advisers that no
X-ray should be undertaken without a clinical
indication was accepted.
A clinician may be criticized for omitting radio-
graphy required solely for medicolegal purposes,
but rarely (if ever) is the patient consulted by the
medicolegal authorities as to whether there is con-
sent for the clinically unnecessary radiation. The
group discounted the likelihood of excess individual
patient radiation dose, though it accepted the
advisability of implementing the ten-day rule";
but concern was expressed in regard to the total
population radiation dose resulting from individual
radiography and the associated genetic hazard.
The Kenya Association of Radiologists was aim-
ing to produce guidelines for national policy in the
----
-Present address: c/o Department of Surgery, Faculty of Med-
icine, Addis Ababa University, PO Box 1176, Addis Ababa,
Ethiopia
" The 1966 report of the International Commission on Radio-
logical Protection recommended that all radiological examina-
tions of the lower abdomen and pelvis of women of reproductive
capacity that are not of importance in connection with the
immediate illness of the patient be limited to the 10-day interval
following the onset of menstruation, when pregnancy is
improbable. - Editor
----
local environment and economy, which it considered
its responsibility, and such guidelines would not
necessarily be appropriate in other circumstances'.
The need for adequately maintained and safe
equipment, competent and conscientious staff work-
ing under reasonable conditions, and adequate sup-
plies of material were discussed. Failure to meet
these criteria must lead to inefficiency and
uneconomic use of facilities expensive in capital and
recurrent cost. An adequate X-ray records depart-
ment, and intercommunication of records prevent
unnecessary wastage by repeat examination, when
reference to previously taken radiographs would
have met the clinical requirement.
Unnecessary or unskilled radiography and radio-
logy contribute to patient radiation dose and also
to genetic dose and total population radiation, a
concept often inadequately appreciated. Diagnostic
radiology is the greatest contributor to patient
radiation dose and hence to the now accepted
cumulative individual dose and the genetic hazard.
Where radiography can be minimized or avoided
this should be done, and where alternative, non-
invasive methods of examination, such as ultra-
sound, are available these should be used-not as
a supplement to radiography but as a substitute for
it, particularly in obstetrics and in the location of
lost intrauterine contraceptive devices. The same
policy of substitution could be applied to the use of
endoscopy, where relevant. Examples were given of
unnecessary fetal irradiation, due to inadequate
history-taking by the requesting clinician or inap-
propriate timing of nonessential radiographs, and
most agreed that the ten-day rule should be imple-
mented. The discipline of such a policy and hence
the need to bear in mind constantly the genetic
hazard of radiography would result in elimination
of at least some unnecessary radiography or its
postponement to a more acceptable time. However,
it was agreed that where the clinical state indicated
the need for the full resources of radiography and
radiology locally available, these would be used.
PRE-RADIOGRAPHIC CLINICAL ASSESSMENT
In the field of basic radiography a prime require-
ment is accurate preradiographic clinical assess-
ment by the clinician ordering the X-ray
examination. This leads to initially correct radi-
ographs by the radiographer and avoids multiple
radiography to ensure "nothing is missed"-with
no regard to radiation dose, clinical need and econ-
omic cost. Examples of unnecessary requests sub-
stituting for inadequate clinical examination were
radiographs of the foot and ankle when clearly there
were local fractures, e.g. of the fifth metatarsal; or
requests for radiography of the skull, sinuses and
cervical spine for headache, with no clinical speci-
fication; usually there is no radiological finding,
though instances where the likely cause was an
impacted lower molar tooth were quoted.
The clinician ordering the radiograph should give
an assessment of the clinical diagnosis-not just a
few facts relating to the history or symptoms. This
would tend to ensure improved preradiographic
clinical assessment and give a better indication to
the skilled radiographer of the appropriate radio-
graphs to be produced.
A project to assess the accuracy of the prescribing
clinicians showed that in limb radiography there
was agreement in clinicians' clinical assessments,
radiographers' clinical assessments and radiologists'
reports of the diagnosis in the leg in 27% of patients,
and in the arm in 45% of patients; and that clinicians
and radiographers suspected a lesion not confirmed
radiologically in the leg in 17% of patients, and in
the arm in 16% of patients. It was considered that
in such cases radiographs were justifiable. But there
was a large number of radiographs where clinicians'
diagnoses were not confirmed by radiographers in
a clinical assessment, nor by radiologists' reports on
the films: in the leg in 52% of patients, and in the
arm in 33% of patients. This latter group represents
unnecessary radiography, avoidable by better pre-
radiographic assessment. Where requests for X-ray
examination were accepted from staff other than
qualified medical practitioners, preradiographic
assessment was worse'. It was clear that many
clinicians had inadequate knowledge of radio-
graphic technique, but this inadequacy would be
overcome by the competent trained radiographer
jbeing given a reasonable preradiographic pro-
visional diagnosis. However, where there were not
such highly trained radiographers this was not so,
and the situation was made worse by relatively
unskilled radiographic technique.
SPECIALIZED RADIOGRAPHIC EXAMINATIONS
Certain of the more specialized radiographic exam-
inations were considered with particular reference
to their greater cost, consumption of skilled man-
power hours, and radiation hazard. In many hos-
pitals the commonest such request was for a barium
meal examination, with the initial diagnosis of a
duodenal ulcer. It was recommended that where
endoscopy is available this is the method of choice
for investigation, particularly where there had been
recent haematemasis and where it was possible at
the same examination to perform any necessary
biopsy(6) It has been shown that in as many as 12%
of patients with reputedly normal barium meal
examinations lesions could be found by endoscopy'.
Double-contrast barium meal studies showed no
significant difference in the detection rate of duo-
denal ulcers in comparison with single contrast
examinations, but they were superior in detecting
abnormalities of the duodenal bulb and were more
informative than single-contrast studies.
Ultrasound (of limited availability in Kenya at
that time) is a safe and simple method of localizing
a mass in the abdomen and determining its nature.
This is particularly significant in relation to the
liver in the semitropical environment. In the inves-
tigation of cholelithiasis by ultrasound, rather than
by cholecystography, there is no risk of drug reac-
tion or failure of drug absorption, and the exam-
ination can be undertaken when there is liver failure
or when a female patient is pregnant, with the
further advantage of visualization of associated and
adjacent structures.
In the absence of computerized axial tomo-
graphy internal carotid arteriography was con-
sidered. Plain film skull radiography is a necessary
precursor and very careful clinical choice of patients
for that examination is essential. Instances were
quoted where errors of preradiographic diagnosis
led to unnecessary examinations. -
In dental radiography the failure of accurate
filing of exposed radiographs leads to much
unnecessary repeat radiography. For dental caries,
clinical examination remains the most accurate and
informative method of detection. Competent
radiography is of value in intraproximal caries. The
value of orthopantography (used in dental radiology
to make orbiting panoramic radiographs), both as
a full record and also to diminish the radiation dose,
was emphasized. This is especially so in jaw swell-
ings, where the alternative of intraoral and occlusal
films may need supplementation with jaw radio-
graphy, whereas all can be seen on one
orthopantogram.
CHEST RADIOGRAPHY
Chest radiography is the commonest X-ray study
in many departments (45-60% of the workload),
and is the most likely examination to be performed
on asymptomatic patients. The yield of clinically
significant information not available from the his-
tory, physical examination, or previous diagnostic
testing of routine chest examination of patients on
hospital admission is very low indeed(9,10). Compul-
sory chest radiography for initial or continuing
employment is not sufficiently productive to justify
use in tuberculosis detection".
Routine preoperative chest radiography in
patients under 30 years of age has a low diagnostic
yield and contributes to a high marrow dose". In
the Royal College of Radiologists study of nonacute
noncardiopulmonary surgery, preoperative chest
radiography did not influence the decision to operate
or the choice of anaesthetic, nor was it found that
the preoperative film was of real value as a baseline
to assess postoperative complications". In out-
patients presenting with acute chest complaints
under the age of 40 years, 96% with a normal
physical examination and no haemoptysis had a
normal chest radiograph i4. Routine prenatal chest
radiography is not warranted". In tuberculosis fal-
low up, regular short-term routine radiography
should be discouraged, but occasional radiography
to confirm bacteriological and clinical findings may
be justified. Repeated X-rays of tuberculous
patients who have completed treatment and are
asymptomatic are of insufficient clinical value to
justify their continued use(16-18).
Population screening programmes have now been
abandoned because of the large population irradi-
ated, the low yield of suspected cases and the
economic burden. Mandated chest screening of un-
selected populations not based on history or specific
diagnostic testing is to be discouraged".
Good quality radiography and accurate inter-
pretation, especially in children, are essential for
the best use of any chest X-ray taken.
Chest injuries: The diagnosis of a rib fracture can
often be better assessed without irradiation, by
careful clinical examination. Rather than specific
radiographs to identify bony rib injury, a chest
radiograph to assess pneumothorax, surgical
emphysema, lung, diaphragm or mediastinal dam-
age, or effusion, is the examination of choice. Clin-
ical examination is particularly significant when the
trauma is to a costal cartilage, often not demon-
stratable radiographically. Care may be needed to
ensure that all the lower ribs are visible, for chest
trauma may be associated with upper abdominal
injury 20-22.
In the majority of chest conditions adequate
diagnosis can be made from an appropriate antero-
posterior or posteroanterior film which should be
reviewed before any supplementary films, such as
a lateral view, are taken.
Tropical Doctor, April 1987
TRAUMA
As trauma is an indication for many radiographic
procedures, and is likely so to be for many years,
the role of radiography in trauma was considered
in some detail. The value of an accurate and freely
available medical records system to avoid unnecess-
ary repeat radiography was constantly emphasized,
as was the principle that no radiograph should be
taken without a clinical indication for it; regular
routine radiography merely to conform to a
"routine' or to coincide with every outpatient
attendance was not advised. The role of adequate
clinical assessment and accurate clinical diagnosis,
made known to the radiographer, and the proper
and full completion of the X-ray request form were
emphasized; and multiple X-ray examinations of
adjacent areas, as a substitute for adequate clinical
examination, were deplored. Equally, no justifica-
tion was found for radiography of the opposite limb
to assess the normal state, which should be known
or should be available from standard normal radio-
graphs or textbooks.
Not only were "routine" requests considered but
also "routine radiographic procedures" in relation
to requests. In many instances not all the views
accepted as routine for a particular examination
are necessary. Especially is this so where there is
close cooperation between radiographer and radiol-
ogist, and where both are informed adequately of
the clinical presentation. It was considered that
where initial appropriate views could be taken and
immediately checked (perhaps especially where
there is automatic processing), such initial and
minimal views would often demonstrate the con-
dition fully and adequately. There might be a small
number of patients where further views, chosen
specially, are still necessary. This practice avoids
unnecessary radiographs and saves time, money and
patient radiation dose.
Certain specific traumas were discussed, and
radiography for chest injury is dealt with above.
Particular attention was paid to radiography of
patients with acute ankle injuries, where it had been
shown that unless soft-tissue swelling is present over
one or both malleoli ankle X-rays are not
indicated".
As radiography of the lumbar spine is so common,
its rote was reviewed. The extent of radiography
varies in different centres; it may routinely include
many views and in some instances even computer-
ized axial tomography (not then available in
Kenya). In general, such routine extensive series
are neither needed nor advisable, and appropriate
Tropical Doctor, April 1987
views should be chosen for each individual patient.
Radiography yields extremely little that could not
be strongly suspected from clinical investigations
alone, and clinically unsuspected positive findings
are very rare. Only a radiological diagnosis of
neoplasm, infection or ankylosing spondylitis is
likely to alter treatment; in those instances the
diagnosis could be made from a limited number of
radiographs, provided that they are chosen with
care in the light of an accurate and detailed clinical
assessment. Routine anteroposterior and lateral
views should first be taken and reviewed, before
adding any further views, limited in number but
specific to the clinical state and the findings on the
original films of that particular patient.
Back pain is usually caused by muscle or ligament
strain. Radiological examination could safely be
deferred (except where there is a clinically obvious
fracture), and undertaken for those few patients
whose symptoms persist despite appropriate treat-
ment. The tendency for back pains to be mis-
diagnosed as renal disease, with the consequent
performance of unnecessary pyelography, was
deplored(24-25).
Assessment of skeletal maturity was considered,
and it was emphasized that between the chrono-
logical ages of 0 and 16 years a posteroanterior
view of the left hand and wrist alone is sufficient
for a reliable assessment. It is, however, no more
than an assessment, and in many areas the available
standards have not been confirmed locally. For age
of i8 years, radiography of the left shoulder, includ-
ing the clavicle, and the left hemipelvis can give a
valuable assessment.
In skull trauma it is necessary to relate the
radiography to the clinical presentation. While
views such as the anteroposterior or posteroanterior
and at least one lateral view would be needed, other
specific views may be required after the initial films
have been reviewed. Many clinicians failed to
appreciate that facial injuries are not well demon-
strated on routine skull views. Clinicians who order
skull views, when what are really needed are views
of the orbit, maxilla or mandible, are failing to
advise the radiographer correctly. This shows a lack
of appreciation of the role of radiography in skull
trauma, or inadequate pre-radiographic clinical
assessment. Many such "skull" X-rays were
ordered, not after full clinical assessment and in
view of the clinical diagnosis, but rather as a pre-
cautionary medicolegal exercise.
In nontraumatic skull radiography most, if not
all, of the relevant radiological findings can be seen
RADIOLOGY 1 65
on a sole true lateral view(26-29). Hence it was rec-
ommended that this view should be taken first and
the film examined. If a diagnosis can be made, or
excluded, no further film need be made. If, however,
there is indication for another view, then the view
appropriate to the condition of the patient and to
the lateral film findings can be taken before the
patient leaves the X-ray department.
CONCLUSIONS
The conclusions of the meetings became an author-
itative guide for professional radiographic and
radiological practice in Kenya. The principles laid
down were accepted by the Ministry of Health and
in certain instances became the basis of depart-
mental circulars; a few appropriate posters to
emphasize particular points were distributed. The
principles were also incorporated in the undergrad-
uate and postgraduate teachings of the Department
of Radiodiagnosis of the Faculty of Medicine of the
University of Nairobi.
It is believed that implementation of this policy
did considerably diminish unnecessary radiography
and hence the economic cost, individual patient
radiation dose, and total population radiation dose.
The meetings were of great value in leading to
a reasonable, locally applicable policy. The advan-
tage of local advice for the application of inter-
national proposals, widely participated in by the
appropriate personnel, was obvious in ensuring the
success of the meetings and the subsequent imple-
mentation of the policy.
ACKNOWLEDGMENT
The author is grateful to the Division of Radiation Health of the
World Health Organization for the inspiration of and the assist-
arm for these meetings; and to the Kenya Association of Radiol-
ogists for the skill, diligence and enthusiasm of its members.
REFERENCES
I Proceedings of meetings to discuss the avoidance of
unnecessary radiography. April 1982, October 1982 and
April 1983. Nairobi: Kenya Association of Radiologists
Efficiency and efficacy studies in diagnostic radiology.
Geneva: World Health Organization
Anonymous. Unnecessary examinations? Br Med J
1982;285:1522
Whittaker Lit. Medical records in developing countries.
Medical Record 1979; page 525
Whittaker LR. More active participation by radiographers
in the radiography of trauma. Radiography 1983;19:125-9
Cumberland DC. Fibreoptic endoscopy and radiology in the
investigation of the upper gastrointestinal tract. Clin Radial
1975;26:223-36
Lavelle MI, Venables CW. Douglas AP, Thompson MH,
Owen JP, Hacking PH, Comparative study of double
contrast and single contrast barium meals with endoscopic
(sorry clipped it -t)
X-ray examinations
A national and professional approach
Leslie R Whittaker FRCR*
Formerly Professor. Department of Diagnostic Radiology
University of Nairobi, Kenya
TROPICAL DOCTOR, 1997, 17, 62-66
Inspired by the World Health Organization studies
on Efficiency and Efficacy in Diagnostic Radiology,
and encouraged by the late Dr W Selentag (then
Chief, Radiation Health, WHO, Geneva), the
Kenya Association of Radiologists arranged three
meetings in 1982-83, to which were invited rep-
resentatives of national medical and paramedical
groups and associated professionals including trade
and legal representatives'. It was agreed that the
policies suggested by WHO to minimize unnecess-
ary radiation should be considered in the local
context and that principles should be agreed for
local implementation as standard radiographic and
radiological practice.
The WHO studies' drew attention to the often
unnecessary patient radiation exposure. Much of
this was "routine" radiography, and the general
principle enunciated by the WHO advisers that no
X-ray should be undertaken without a clinical
indication was accepted.
A clinician may be criticized for omitting radio-
graphy required solely for medicolegal purposes,
but rarely (if ever) is the patient consulted by the
medicolegal authorities as to whether there is con-
sent for the clinically unnecessary radiation. The
group discounted the likelihood of excess individual
patient radiation dose, though it accepted the
advisability of implementing the ten-day rule";
but concern was expressed in regard to the total
population radiation dose resulting from individual
radiography and the associated genetic hazard.
The Kenya Association of Radiologists was aim-
ing to produce guidelines for national policy in the
----
-Present address: c/o Department of Surgery, Faculty of Med-
icine, Addis Ababa University, PO Box 1176, Addis Ababa,
Ethiopia
" The 1966 report of the International Commission on Radio-
logical Protection recommended that all radiological examina-
tions of the lower abdomen and pelvis of women of reproductive
capacity that are not of importance in connection with the
immediate illness of the patient be limited to the 10-day interval
following the onset of menstruation, when pregnancy is
improbable. - Editor
----
local environment and economy, which it considered
its responsibility, and such guidelines would not
necessarily be appropriate in other circumstances'.
The need for adequately maintained and safe
equipment, competent and conscientious staff work-
ing under reasonable conditions, and adequate sup-
plies of material were discussed. Failure to meet
these criteria must lead to inefficiency and
uneconomic use of facilities expensive in capital and
recurrent cost. An adequate X-ray records depart-
ment, and intercommunication of records prevent
unnecessary wastage by repeat examination, when
reference to previously taken radiographs would
have met the clinical requirement.
Unnecessary or unskilled radiography and radio-
logy contribute to patient radiation dose and also
to genetic dose and total population radiation, a
concept often inadequately appreciated. Diagnostic
radiology is the greatest contributor to patient
radiation dose and hence to the now accepted
cumulative individual dose and the genetic hazard.
Where radiography can be minimized or avoided
this should be done, and where alternative, non-
invasive methods of examination, such as ultra-
sound, are available these should be used-not as
a supplement to radiography but as a substitute for
it, particularly in obstetrics and in the location of
lost intrauterine contraceptive devices. The same
policy of substitution could be applied to the use of
endoscopy, where relevant. Examples were given of
unnecessary fetal irradiation, due to inadequate
history-taking by the requesting clinician or inap-
propriate timing of nonessential radiographs, and
most agreed that the ten-day rule should be imple-
mented. The discipline of such a policy and hence
the need to bear in mind constantly the genetic
hazard of radiography would result in elimination
of at least some unnecessary radiography or its
postponement to a more acceptable time. However,
it was agreed that where the clinical state indicated
the need for the full resources of radiography and
radiology locally available, these would be used.
PRE-RADIOGRAPHIC CLINICAL ASSESSMENT
In the field of basic radiography a prime require-
ment is accurate preradiographic clinical assess-
ment by the clinician ordering the X-ray
examination. This leads to initially correct radi-
ographs by the radiographer and avoids multiple
radiography to ensure "nothing is missed"-with
no regard to radiation dose, clinical need and econ-
omic cost. Examples of unnecessary requests sub-
stituting for inadequate clinical examination were
radiographs of the foot and ankle when clearly there
were local fractures, e.g. of the fifth metatarsal; or
requests for radiography of the skull, sinuses and
cervical spine for headache, with no clinical speci-
fication; usually there is no radiological finding,
though instances where the likely cause was an
impacted lower molar tooth were quoted.
The clinician ordering the radiograph should give
an assessment of the clinical diagnosis-not just a
few facts relating to the history or symptoms. This
would tend to ensure improved preradiographic
clinical assessment and give a better indication to
the skilled radiographer of the appropriate radio-
graphs to be produced.
A project to assess the accuracy of the prescribing
clinicians showed that in limb radiography there
was agreement in clinicians' clinical assessments,
radiographers' clinical assessments and radiologists'
reports of the diagnosis in the leg in 27% of patients,
and in the arm in 45% of patients; and that clinicians
and radiographers suspected a lesion not confirmed
radiologically in the leg in 17% of patients, and in
the arm in 16% of patients. It was considered that
in such cases radiographs were justifiable. But there
was a large number of radiographs where clinicians'
diagnoses were not confirmed by radiographers in
a clinical assessment, nor by radiologists' reports on
the films: in the leg in 52% of patients, and in the
arm in 33% of patients. This latter group represents
unnecessary radiography, avoidable by better pre-
radiographic assessment. Where requests for X-ray
examination were accepted from staff other than
qualified medical practitioners, preradiographic
assessment was worse'. It was clear that many
clinicians had inadequate knowledge of radio-
graphic technique, but this inadequacy would be
overcome by the competent trained radiographer
jbeing given a reasonable preradiographic pro-
visional diagnosis. However, where there were not
such highly trained radiographers this was not so,
and the situation was made worse by relatively
unskilled radiographic technique.
SPECIALIZED RADIOGRAPHIC EXAMINATIONS
Certain of the more specialized radiographic exam-
inations were considered with particular reference
to their greater cost, consumption of skilled man-
power hours, and radiation hazard. In many hos-
pitals the commonest such request was for a barium
meal examination, with the initial diagnosis of a
duodenal ulcer. It was recommended that where
endoscopy is available this is the method of choice
for investigation, particularly where there had been
recent haematemasis and where it was possible at
the same examination to perform any necessary
biopsy(6) It has been shown that in as many as 12%
of patients with reputedly normal barium meal
examinations lesions could be found by endoscopy'.
Double-contrast barium meal studies showed no
significant difference in the detection rate of duo-
denal ulcers in comparison with single contrast
examinations, but they were superior in detecting
abnormalities of the duodenal bulb and were more
informative than single-contrast studies.
Ultrasound (of limited availability in Kenya at
that time) is a safe and simple method of localizing
a mass in the abdomen and determining its nature.
This is particularly significant in relation to the
liver in the semitropical environment. In the inves-
tigation of cholelithiasis by ultrasound, rather than
by cholecystography, there is no risk of drug reac-
tion or failure of drug absorption, and the exam-
ination can be undertaken when there is liver failure
or when a female patient is pregnant, with the
further advantage of visualization of associated and
adjacent structures.
In the absence of computerized axial tomo-
graphy internal carotid arteriography was con-
sidered. Plain film skull radiography is a necessary
precursor and very careful clinical choice of patients
for that examination is essential. Instances were
quoted where errors of preradiographic diagnosis
led to unnecessary examinations. -
In dental radiography the failure of accurate
filing of exposed radiographs leads to much
unnecessary repeat radiography. For dental caries,
clinical examination remains the most accurate and
informative method of detection. Competent
radiography is of value in intraproximal caries. The
value of orthopantography (used in dental radiology
to make orbiting panoramic radiographs), both as
a full record and also to diminish the radiation dose,
was emphasized. This is especially so in jaw swell-
ings, where the alternative of intraoral and occlusal
films may need supplementation with jaw radio-
graphy, whereas all can be seen on one
orthopantogram.
CHEST RADIOGRAPHY
Chest radiography is the commonest X-ray study
in many departments (45-60% of the workload),
and is the most likely examination to be performed
on asymptomatic patients. The yield of clinically
significant information not available from the his-
tory, physical examination, or previous diagnostic
testing of routine chest examination of patients on
hospital admission is very low indeed(9,10). Compul-
sory chest radiography for initial or continuing
employment is not sufficiently productive to justify
use in tuberculosis detection".
Routine preoperative chest radiography in
patients under 30 years of age has a low diagnostic
yield and contributes to a high marrow dose". In
the Royal College of Radiologists study of nonacute
noncardiopulmonary surgery, preoperative chest
radiography did not influence the decision to operate
or the choice of anaesthetic, nor was it found that
the preoperative film was of real value as a baseline
to assess postoperative complications". In out-
patients presenting with acute chest complaints
under the age of 40 years, 96% with a normal
physical examination and no haemoptysis had a
normal chest radiograph i4. Routine prenatal chest
radiography is not warranted". In tuberculosis fal-
low up, regular short-term routine radiography
should be discouraged, but occasional radiography
to confirm bacteriological and clinical findings may
be justified. Repeated X-rays of tuberculous
patients who have completed treatment and are
asymptomatic are of insufficient clinical value to
justify their continued use(16-18).
Population screening programmes have now been
abandoned because of the large population irradi-
ated, the low yield of suspected cases and the
economic burden. Mandated chest screening of un-
selected populations not based on history or specific
diagnostic testing is to be discouraged".
Good quality radiography and accurate inter-
pretation, especially in children, are essential for
the best use of any chest X-ray taken.
Chest injuries: The diagnosis of a rib fracture can
often be better assessed without irradiation, by
careful clinical examination. Rather than specific
radiographs to identify bony rib injury, a chest
radiograph to assess pneumothorax, surgical
emphysema, lung, diaphragm or mediastinal dam-
age, or effusion, is the examination of choice. Clin-
ical examination is particularly significant when the
trauma is to a costal cartilage, often not demon-
stratable radiographically. Care may be needed to
ensure that all the lower ribs are visible, for chest
trauma may be associated with upper abdominal
injury 20-22.
In the majority of chest conditions adequate
diagnosis can be made from an appropriate antero-
posterior or posteroanterior film which should be
reviewed before any supplementary films, such as
a lateral view, are taken.
Tropical Doctor, April 1987
TRAUMA
As trauma is an indication for many radiographic
procedures, and is likely so to be for many years,
the role of radiography in trauma was considered
in some detail. The value of an accurate and freely
available medical records system to avoid unnecess-
ary repeat radiography was constantly emphasized,
as was the principle that no radiograph should be
taken without a clinical indication for it; regular
routine radiography merely to conform to a
"routine' or to coincide with every outpatient
attendance was not advised. The role of adequate
clinical assessment and accurate clinical diagnosis,
made known to the radiographer, and the proper
and full completion of the X-ray request form were
emphasized; and multiple X-ray examinations of
adjacent areas, as a substitute for adequate clinical
examination, were deplored. Equally, no justifica-
tion was found for radiography of the opposite limb
to assess the normal state, which should be known
or should be available from standard normal radio-
graphs or textbooks.
Not only were "routine" requests considered but
also "routine radiographic procedures" in relation
to requests. In many instances not all the views
accepted as routine for a particular examination
are necessary. Especially is this so where there is
close cooperation between radiographer and radiol-
ogist, and where both are informed adequately of
the clinical presentation. It was considered that
where initial appropriate views could be taken and
immediately checked (perhaps especially where
there is automatic processing), such initial and
minimal views would often demonstrate the con-
dition fully and adequately. There might be a small
number of patients where further views, chosen
specially, are still necessary. This practice avoids
unnecessary radiographs and saves time, money and
patient radiation dose.
Certain specific traumas were discussed, and
radiography for chest injury is dealt with above.
Particular attention was paid to radiography of
patients with acute ankle injuries, where it had been
shown that unless soft-tissue swelling is present over
one or both malleoli ankle X-rays are not
indicated".
As radiography of the lumbar spine is so common,
its rote was reviewed. The extent of radiography
varies in different centres; it may routinely include
many views and in some instances even computer-
ized axial tomography (not then available in
Kenya). In general, such routine extensive series
are neither needed nor advisable, and appropriate
Tropical Doctor, April 1987
views should be chosen for each individual patient.
Radiography yields extremely little that could not
be strongly suspected from clinical investigations
alone, and clinically unsuspected positive findings
are very rare. Only a radiological diagnosis of
neoplasm, infection or ankylosing spondylitis is
likely to alter treatment; in those instances the
diagnosis could be made from a limited number of
radiographs, provided that they are chosen with
care in the light of an accurate and detailed clinical
assessment. Routine anteroposterior and lateral
views should first be taken and reviewed, before
adding any further views, limited in number but
specific to the clinical state and the findings on the
original films of that particular patient.
Back pain is usually caused by muscle or ligament
strain. Radiological examination could safely be
deferred (except where there is a clinically obvious
fracture), and undertaken for those few patients
whose symptoms persist despite appropriate treat-
ment. The tendency for back pains to be mis-
diagnosed as renal disease, with the consequent
performance of unnecessary pyelography, was
deplored(24-25).
Assessment of skeletal maturity was considered,
and it was emphasized that between the chrono-
logical ages of 0 and 16 years a posteroanterior
view of the left hand and wrist alone is sufficient
for a reliable assessment. It is, however, no more
than an assessment, and in many areas the available
standards have not been confirmed locally. For age
of i8 years, radiography of the left shoulder, includ-
ing the clavicle, and the left hemipelvis can give a
valuable assessment.
In skull trauma it is necessary to relate the
radiography to the clinical presentation. While
views such as the anteroposterior or posteroanterior
and at least one lateral view would be needed, other
specific views may be required after the initial films
have been reviewed. Many clinicians failed to
appreciate that facial injuries are not well demon-
strated on routine skull views. Clinicians who order
skull views, when what are really needed are views
of the orbit, maxilla or mandible, are failing to
advise the radiographer correctly. This shows a lack
of appreciation of the role of radiography in skull
trauma, or inadequate pre-radiographic clinical
assessment. Many such "skull" X-rays were
ordered, not after full clinical assessment and in
view of the clinical diagnosis, but rather as a pre-
cautionary medicolegal exercise.
In nontraumatic skull radiography most, if not
all, of the relevant radiological findings can be seen
RADIOLOGY 1 65
on a sole true lateral view(26-29). Hence it was rec-
ommended that this view should be taken first and
the film examined. If a diagnosis can be made, or
excluded, no further film need be made. If, however,
there is indication for another view, then the view
appropriate to the condition of the patient and to
the lateral film findings can be taken before the
patient leaves the X-ray department.
CONCLUSIONS
The conclusions of the meetings became an author-
itative guide for professional radiographic and
radiological practice in Kenya. The principles laid
down were accepted by the Ministry of Health and
in certain instances became the basis of depart-
mental circulars; a few appropriate posters to
emphasize particular points were distributed. The
principles were also incorporated in the undergrad-
uate and postgraduate teachings of the Department
of Radiodiagnosis of the Faculty of Medicine of the
University of Nairobi.
It is believed that implementation of this policy
did considerably diminish unnecessary radiography
and hence the economic cost, individual patient
radiation dose, and total population radiation dose.
The meetings were of great value in leading to
a reasonable, locally applicable policy. The advan-
tage of local advice for the application of inter-
national proposals, widely participated in by the
appropriate personnel, was obvious in ensuring the
success of the meetings and the subsequent imple-
mentation of the policy.
ACKNOWLEDGMENT
The author is grateful to the Division of Radiation Health of the
World Health Organization for the inspiration of and the assist-
arm for these meetings; and to the Kenya Association of Radiol-
ogists for the skill, diligence and enthusiasm of its members.
REFERENCES
I Proceedings of meetings to discuss the avoidance of
unnecessary radiography. April 1982, October 1982 and
April 1983. Nairobi: Kenya Association of Radiologists
Efficiency and efficacy studies in diagnostic radiology.
Geneva: World Health Organization
Anonymous. Unnecessary examinations? Br Med J
1982;285:1522
Whittaker Lit. Medical records in developing countries.
Medical Record 1979; page 525
Whittaker LR. More active participation by radiographers
in the radiography of trauma. Radiography 1983;19:125-9
Cumberland DC. Fibreoptic endoscopy and radiology in the
investigation of the upper gastrointestinal tract. Clin Radial
1975;26:223-36
Lavelle MI, Venables CW. Douglas AP, Thompson MH,
Owen JP, Hacking PH, Comparative study of double
contrast and single contrast barium meals with endoscopic
(sorry clipped it -t)