The first and most important aspect of radiographer reporting is that before any report is issued by a radiographer, they should make sure that they are legally covered by their hospital management for any errors or mistakes that they may make. They should have the same indemnity as any radiologist. Do not proceed unless this legal cover is given.

The reporting radiographer will probably find, when they first start to dictate or type a report that they are lost for words. Say what you see. Try to keep it short and try not to use jargon. Some named fractures such as "greenstick" are O.K., but in the case of some of the less common fractures it may be better to describe the appearance of the fracture rather than just give it a name. If the person reading the report does not know what a Monteggia fracture is then the report is useless to them.

It has been said "never sit on the fence". To a certain extent this is correct. If the reporting radiographer is often not sure then perhaps they should not be reporting. In the vast majority of cases the decision should be made as to whether it is positive or negative, "There is a fracture of....." or "No bony injury is seen." or variations of for foreign bodies, dislocations etc.

Just occasionally however it is difficult to decide. It can be clear that the radiograph does not look quite normal but it is difficult to decide exactly what is wrong. Take a look at image 1, there is a tiny opacity lying superior to the talus. It is too small to see if it is definitely corticated, indeed it is too small to even be sure it is bone, although it is a similar density. It is lying a little too proximally to be characteristic of an avulsion fracture, although these can occur in this area. It is also too small to be characteristic of an accessory ossicle, although again, these do occur here.

There is nothing wrong with this, sometimes even radiologists can not make their minds up. In such cases all that is needed is to describe the appearances initially and follow with a phrase like "this is almost certainly normal however....." if the reporter is of the opinion that it is probably normal, or "appearances are highly suggestive of......." if it is thought that it could be traumatic in origin, and finish the report with something like "if symptoms persist, further radiographs may be helpful" or "further clinical assessment of this area is required". By doing this it is highlighting to the doctor that there may be something abnormal but it is not easily visualized, but if the doctor is clinically suspicious then he can recall the patient in a few days to see if there are any healing processes starting.

However the report is worded, the reporting radiographer needs to make sure that they have made their best efforts not to miss anything. Whenever they look at a radiograph they should establish their own system of how they look at it. By this it is meant that they should always look at radiographs the same way every time. For instance, look at image 2 to the left, when presented with a radiograph of the hand, the first thing the author will always look at (after the name and markers) are the carpal bones. He will look along each row of the carpals. Next he will look at all the metacarpals, from base to head, from first to fifth. Then he will move on to the phalanges, again proximal to distal, first to fifth, remembering at all times to check the cortex and trabeculae of each bone for any disruption. In this way he knows that he has checked all of the radiograph not just the area of interest suggested by the doctor. Make sure that which ever way the radiographs are viewed, do not fall into the trap of only looking at where the doctor thinks there may be an injury, as sooner or later something obvious will be missed. Image 3 is an example. This radiograph was taken for a wrist injury, but there is a subtle undisplaced longitudinal fracture of the distal shaft of the fifth metacarpal. This could easily be missed if the whole radiograph is not checked. The fracture was easily visible on the original radiograph but may be difficult on the web image, click on the image to be directed to the fracture lines, even then it is very subtle but take the author's word for it there was a fracture there which could be missed.

Remember also to check the soft tissue outlines, these will often direct you to bony trauma that might otherwise be missed. However, be very careful as the soft tissues will sometimes cause problems. Look at image 4 on the left. This looks quite straight forward, an oblique fracture of the proximal phalanx of the fourth toe. In fact this appearance is caused by air trapped in the skin fold under the toe, see how the lucency curves and extends outside the margins of bone to the right of the image. This is a soft tissue anomaly, not a fracture, and it can occur wherever there are skin folds.

Another thing to remember is never to be afraid of suggesting that the radiographs are sub standard. If the reporting radiographer is presented with sub standard radiographs, if they are "hot reporting", they should ask the radiographer to produce some more diagnostic films. If they are "cold reporting" and the patient has gone then they should state at the beginning of their report that the radiographs are "sub-optimal" and then make their best effort to report them. In this way they should not be entirely responsible for any misdiagnosis, part of the responsibility (the most part) must lie with the radiographer who produced the sub standard work.

Paediatrics offer very different problems. Scroll down to image 5 on the left. As it can be seen, the skeleton is not fully ossified and does not appear as the adult skeleton does. With radiographs appearing different at various ages it is difficult to apply the same rules to every one. There is no good substitute for experience in this area. It is suggested that the reader studies a good book about paediatric radiography and learns about the chronology of bone formation. Later pages in this web site will discuss some aspects of paediatrics and may offer some help.