Background and Objective Content based medical image retrieval (CBMIR) systems enable fast diagnosis through quantitative assessment of the visual information and is an active research topic over the past few decades. Most of the state-of-the-art CBMIR systems suffer from various problems: computationally expensive due to the usage of high dimensional feature vectors and complex classifier/clustering schemes. Inability to properly handle the “semantic gap” and the high intra-class versus inter-class variability problem of the medical image database (like radiographic image database). This yields an exigent demand for developing highly effective and computationally efficient retrieval system. Methods We propose a novel interactive two-stage CBMIR system for diverse collection of medical radiographic images. Initially, Pulse Coupled Neural Network based shape features are used to find out the most probable (similar) image classes using a novel “similarity positional score” mechanism. This is followed by retrieval using Non-subsampled Contourlet Transform based texture features considering only the images of the pre-identified classes. Maximal information compression index is used for unsupervised feature selection to achieve better results. To reduce the semantic gap problem, the proposed system uses a novel fuzzy index based relevance feedback mechanism by incorporating subjectivity of human perception in an analytic manner. Results Extensive experiments were carried out to evaluate the effectiveness of the proposed CBMIR system on a subset of Image Retrieval in Medical Applications (IRMA)-2009 database consisting of 10,902 labeled radiographic images of 57 different modalities. We obtained overall average precision of around 98% after only 2–3 iterations of relevance feedback mechanism. We assessed the results by comparisons with some of the state-of-the-art CBMIR systems for radiographic images. Conclusions Unlike most of the existing CBMIR systems, in the proposed two-stage hierarchical framework, main importance is given on constructing efficient and compact feature vector representation, search-space reduction and handling the “semantic gap” problem effectively, without compromising the retrieval performance. Experimental results and comparisons show that the proposed system performs efficiently in the radiographic medical image retrieval field.