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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_5557_Библиотеки_им_академика_М_И_Перельмана.pdf
104
CHAPTER 5
|
IMAGING PROCEDURES
• Collimate to four sides to include all pertinent anatomy
• Place appropriate side marker within light field on
lateral aspect of image
• Minimum SID: 40⬙ (100 cm)
Evaluation Criteria
• Lateral views of acetabulum and femoral head and
neck, trochanteric area, and proximal one-third of
femur are visible
• Proper abduction of femur indicated by visualization
of femoral neck profile and its superimposition by
greater trochanter
• Femoral neck in center of collimated field indicates
proper centering
• Optimal exposure
Demonstrates
• Lateral view of hip joint and proximal femur to
midfemur
Demonstrates
• Proximal femur, acetabulum, and adjacent parts of
the pelvis
• Condition and placement of any existing orthopedic
appliance
• Pathology including but not limited to: intertrochan-
teric fracture, femoral neck fracture, pathological
fractures due to stress or low bone mass
Unilateral Frog-Leg Projection
(Modified Cleaves Method)
Positioning Criteria
• Patient supine; position affected hip area to be centered
to the midline of table and/or IR; gonadal region shielded
• Place 10⬙ ⫻ 12⬙ (25 ⫻ 30 cm) IR in table Bucky lengthwise
• Flex knee and hip of affected side; rest sole of foot
against the inside of the opposite leg, near knee
• Abduct femur 45 degrees from vertical to demon-
strate the proximal femur region
• Center affected femoral neck to central ray, which is
3⬙ to 4⬙ (7.5 to 10 cm) distal to ASIS
FIGURE 5-22
105
CHAPTER 5
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IMAGING PROCEDURES
• With inversion, lesser trochanter should be seen
• Distal aspect of femoral neck superimposed by
greater trochanter
• No superimposition of soft tissue from raised unaf-
fected leg
• No grid lines visible indicate proper central ray–IR
alignment
• Optimal exposure
Demonstrates
• Lateral view of proximal femur to midfemur
• Anterior/posterior dislocation of proximal femur to
midfemur
• Detection of fractures when affected leg is not able
to be moved
Modified Axiolateral:
Clements-Nakayama Method
Used in cases of bilateral lower limb immobility.
Positioning Criteria
• Patient supine; position affected side near edge of
table with legs fully extended and arms across chest;
gonadal regions shielded as much as possible
• Rest 8⬙ ⫻ 10⬙ (20 ⫻ 25 cm) stationary grid IR on
extended Bucky tray, placing bottom edge of IR 2⬙
(5 cm) below the level of the tabletop
• Maintain neutral (anatomic) position of leg
Axiolateral Inferosuperior
(Danelius-Miller Method)
Positioning Criteria
• Patient is supine/dorsal decubitus on stretcher, bed-
side, or radiographic table; elevate pelvis 1⬙ to 2⬙
(2.5 to 5 cm)
• Flex and elevate unaffected leg (for assistance, place
foot on step stool or lower leg on leg lift positioning
device) so that thigh is near vertical position and out-
side collimation
• To ensure no rotation of pelvis, ASIS to tabletop dis-
tance should be equal on both sides
• Place top of 10⬙ ⫻ 12⬙ (25 ⫻ 30 cm) IR in stationary
grid in crease above iliac crest on affected side and
adjust so that IR is parallel to the femoral neck
• Direct central ray so that it is perpendicular to the IR
and exiting femoral neck
• If not contraindicated by possible fracture or other
pathologic process, internal rotation of the affected
leg by 15 degrees to 20 degrees is recommended
• Close collimation to four sides to femoral head and
neck region
• Place appropriate side marker within light field on
lateral aspect of image
• Minimum SID: 40⬙ (100 cm)
Evaluation Criteria
• Entire femoral head and neck, trochanter, and acetab-
ulum should be visible on image
FIGURE 5-23
106
CHAPTER 5
|
IMAGING PROCEDURES
• Lesser trochanter seen posterior to femoral shaft
• Greater trochanter is superimposed by femoral head
and neck
• No visible grid lines indicate proper central ray–IR
alignment
• Optimal exposure
Demonstrates
• Lateral of proximal femur and hip for patients with
limited bilateral lower limb movement due to trauma
or arthroplasty
• Anterior/posterior dislocation of proximal femur
and hip
• Tilt IR 15 degrees from vertical and adjust alignment
of IR to ensure that the IR face is perpendicular to the
central ray to prevent grid cutoff
• Direct central ray mediolaterally and posteriorly
15 degrees to 20 degrees from horizontal so that
it is perpendicular and centered to femoral neck
and IR
• Minimum SID: 40⬙ (100 cm)
Evaluation Criteria
• Lateral oblique of acetabulum, femoral head and
neck, and trochanteric area visible
• Femoral head and neck seen in profile
107
CHAPTER 5
|
IMAGING PROCEDURES
• Collimate to four sides to include all pertinent
anatomy
• Place appropriate side marker within light field on
lateral aspect of the side down
• Minimum SID: 40⬙ (100 cm)
Evaluation Criteria
• No rotation or tilt of the cranium is evident
• Rotation evident by separation of EAMs, mandibular
rami, and greater wings of sphenoid
• Tilt evident by orbital roofs, EAMs, and lesser wings
of sphenoid
Demonstrates
• Superimposition of cranial halves
• Sella turcica and clivus in profile
• Sella turcica, anterior/posterior clinoids, and dorsum
sellae
Posteroanterior Caldwell Skull
Positioning Criteria
• Patient PA and shielded
• 10⬙ ⫻ 12⬙ (25 ⫻ 30 cm) IR lengthwise placed in Bucky
• OML perpendicular to IR
• Central ray angled 15 degrees caudal, directed to exit
the nasion
• Collimate to four sides to include all pertinent anatomy
• Place appropriate side marker within light field on
lateral aspect of image
• Minimum SID: 40⬙ (100 cm)
Evaluation Criteria
• No rotation evident by lateral orbit and lateral skull
symmetric on each side
Demonstrates
• Petrous pyramids in lower one-third of orbit
• Superior orbital ridge free of superimposition
• Greater/lesser sphenoid wing, frontal bone, superior
orbital fissures, frontal and anterior ethmoid sinuses,
superior orbital margins, and crista galli
• Skull fractures, neoplastic processes, and Paget disease
Posteroanterior (No Angle)
Positioning Criteria
• Patient PA and shielded
• 10⬙ ⫻ 12⬙ (25 ⫻ 30 cm) IR lengthwise placed in Bucky
• OML perpendicular to IR
• MSP perpendicular to table
• Central ray perpendicular and directed to exit glabella
HEAD
Skull
Anteroposterior Axial (Towne)
Positioning Criteria
• Patient AP; sitting, erect, or supine; and shielded
• 10⬙ ⫻ 12⬙ (25 ⫻ 30 cm) IR lengthwise
• Central ray angled 30 degrees caudal if orbitomeatal
line (OML) is perpendicular to the IR
• Central ray is angled 37 degrees caudal if the infraor-
bitomeatal line (IOML) is perpendicular
• Central ray is directed 2½⬙ (6 cm) superior to the
glabella and will exit ¾⬙ (2 cm) superior to the EAM,
through the foramen magnum
• Collimate to four sides to include all pertinent
anatomy
• Place appropriate side marker within light field on
lateral aspect of the image
• Minimum SID: 40⬙ (100 cm)
Evaluation Criteria
• No rotation is evident when distance from foramen
magnum to lateral aspect of skull is equal on both
sides of skull
• Petrous ridges should be symmetric
Demonstrates
• Occipital bone, petrous pyramids, and foramen magnum
• Dorsum sellae and posterior clinoids visualized through
the foramen magnum
• Underangulation projects the dorsum sella superior
to foramen magnum
• Overangulation will push the anterior arch of C1 into
the foramen magnum
• Petrous ridges superior to mastoid process
• Fractures, neoplastic processes, and Paget disease
Lateral Skull
Positioning Criteria
• Patient erect or prone, and shielded
• 10⬙ ⫻ 12⬙ (25 ⫻ 30 cm) IR crosswise in Bucky
• Place side of interest closest to IR
• Palpate occipital protuberance and nasion in order to
determine rotation
• MSP should be parallel to IR
• The interpupillary line should be perpendicular
• Adjust head so the IOML is perpendicular to the front
edge of the IR
• Central ray perpendicular to IR and directed 2⬙ (5 cm)
superior to the EAM
108
CHAPTER 5
|
IMAGING PROCEDURES
FIGURE 5-24
FIGURE 5-25
109
CHAPTER 5
|
IMAGING PROCEDURES
• Central ray angled 25 degrees to 30 degrees cephalic,
directed to enter 1½⬙ (4 cm) inferior to inion
• Collimate to four sides to include all pertinent anatomy
• Place appropriate side marker within light field on
lateral aspect of image
• Minimum SID: 40⬙ (100 cm)
Evaluation Criteria
• No rotation is evident when distance from foramen
magnum to lateral aspect of skull is equal on both
sides of skull
• Petrous ridges should be symmetric
Demonstrates
• Occipital bone, petrous pyramids, and foramen
magnum
• Dorsum sellae and posterior clinoids visualized through
the foramen magnum
• Petrous ridges superior to mastoid process
• Fractures, neoplastic processes, and Paget disease
Trauma Cross-Table Lateral Skull
Positioning Criteria
• Patient supine on stretcher or imaging table and
shielded
• 10⬙ ⫻ 12⬙ (25 ⫻ 30 cm) grid IR vertical lengthwise
• Carefully place radiolucent sponge under patient’s
head if possible; if patient’s head cannot be manip-
ulated, place grid IR at least 1⬙ below the inferior
aspect of the patient’s skull
• Bring patient as close to IR as possible
• MSP should be parallel to IR
• The interpupillary line should be perpendicular
• Adjust head so the IOML is perpendicular to the front
edge of the IR
• Horizontal beam is directed perpendicular to IR and
2⬙ (5 cm) superior to the EAM
• Collimate to four sides to include all pertinent
anatomy
• Place appropriate side marker within light field ac-
cording to side closest to IR
• Minimum SID: 40⬙ (100 cm)
Evaluation Criteria
• No rotation or tilt of the cranium is evident
• Rotation evident by separation of EAMs, mandibular
rami, and greater wings of sphenoid
• Tilt evident by orbital roofs, EAMs, and lesser wings
of sphenoid
• Collimate to four sides to include all pertinent anatomy
• Place appropriate side marker within light field on
lateral aspect of image
• Minimum SID: 40⬙ (100 cm)
Evaluation Criteria
• No rotation evident by lateral orbit and lateral skull
symmetric on each side
Demonstrates
• Petrous pyramids fill orbit
• Superior orbital ridge superimposed by petrous ridges
• Posterior/anterior clinoids superior to ethmoid
sinuses
• Greater/lesser sphenoid wing, frontal bone, frontal and
anterior ethmoid sinuses, superior orbital margins,
internal auditory canals, dorsum sellae, and crista galli
• Skull fractures, neoplastic processes, and Paget disease
Submentovertical (Full Basal)
Positioning Criteria
• Patient AP erect and shielded
• 10⬙ ⫻ 12⬙ (25 ⫻ 30 cm) IR lengthwise placed in Bucky
• Patient’s IOML is parallel to IR
• MSP is perpendicular to the IR
• Central ray perpendicular and directed 1⬙ (2.5 cm)
anterior to EAMs
• Collimate to four sides to include all pertinent anatomy
• Place appropriate side marker within light field on
lateral aspect of image
• Minimum SID: 40⬙ (100 cm)
Evaluation Criteria
• No rotation or tilt evident by equal distance bilaterally
from mandibular condyles to lateral border of skull
• Foramen magnum in center of image
Demonstrates
• Foramen ovale, spinosum, mandible, sphenoid, poste-
rior ethmoid sinus, mastoid processes, petrous ridges,
foramen magnum, and (of course) occipital
• Basal skull fractures
• Advanced bony pathology of inner temporal structures
Posteroanterior 25 Degrees to
30 Degrees (Haas)
Positioning Criteria
• Patient PA and shielded
• 10⬙ ⫻ 12⬙ (25 ⫻ 30 cm) IR lengthwise placed in Bucky
• OML and MSP perpendicular to IR
110
CHAPTER 5
|
IMAGING PROCEDURES
Anteroposterior Axial Trauma
Positioning Criteria
• Patient AP on stretcher or radiographic table and
shielded
• 10⬙ ⫻ 12⬙ (25 ⫻ 30 cm) IR lengthwise placed in
Bucky
• OML should be perpendicular to IR; however, if the
head cannot be manipulated because of trauma,
angle the central ray parallel to the patient’s OML
• Central ray angled 15 degrees cephalic to OML,
directed to exit the nasion
• Collimate to four sides to include all pertinent
anatomy
• Place appropriate side marker within light field on
lateral aspect of image
• Minimum SID: 40⬙ (100 cm)
Evaluation Criteria
• No rotation evident by lateral orbit and lateral skull
symmetric on each side
• AP evident by magnified orbits due to OID
Demonstrates
• Petrous pyramids in lower one-third of orbit
• Superior orbital ridge free of superimposition
• Greater/lesser sphenoid wing, frontal bone, superior
orbital fissures, frontal and anterior ethmoid sinuses,
superior orbital margins, and crista galli
• Skull fractures, neoplastic processes, and Paget disease
Demonstrates
• Superimposition of cranial halves
• Sellae turcica and clivus in profile
• Sellae turcica, anterior/posterior clinoids, and dor-
sum sellae
• Intracranial trauma indicated by sphenoidal effusion
Trauma Anteroposterior (No Angle)
Positioning Criteria
• Patient AP and shielded
• 10⬙ ⫻ 12⬙ (25 ⫻ 30 cm) IR lengthwise placed in Bucky
• OML should be perpendicular to IR; however, if the
head cannot be manipulated because of trauma, angle
the central ray parallel to the patient’s OML
• MSP perpendicular to table
• Central ray directed to glabella
• Collimate to four sides to include all pertinent anatomy
• Place appropriate side marker within light field on
lateral aspect of image
• Minimum SID: 40⬙ (100 cm)
Evaluation Criteria
• No rotation evident by lateral orbit and lateral skull
symmetric on each side
Demonstrates
• Petrous pyramids fill orbit
• Superior orbital ridge superimposed by petrous ridges
• Posterior/anterior clinoids superior to ethmoid sinuses
• Greater/lesser sphenoid wing, frontal bone, frontal and
anterior ethmoid sinuses, superior orbital margins, in-
ternal auditory canals, dorsum sellae, and crista galli
• Skull fractures, neoplastic processes, and Paget disease
111
CHAPTER 5
|
IMAGING PROCEDURES
Evaluation Criteria
• No rotation evident by nasal septum to outer skull
margin
• Acanthion centered to image
Demonstrates
• Maxillae, inferior orbital rim, nasal septum, anterior
nasal spine, and zygomatic arches
• Petrous ridges inferior to maxillary sinus
• Entire skull demonstrated
• Best demonstrates blow-out and tripod fractures and
deviation of nasal septum
• Foreign body of orbit also demonstrated
Posteroanterior (Modified Waters):
Facial Bones
Positioning Criteria
• Patient PA erect or recumbent and shielded
• 10⬙ ⫻ 12⬙ (25 ⫻ 30 cm) IR lengthwise placed in
Bucky
• Canthus of lips and meatal line are perpendicular to
Bucky
• OML forms a 55-degree angle with the IR
• Central ray exits acanthion
• MSP perpendicular to midline of grid
• Collimate to four sides to include all pertinent
anatomy
• Place appropriate side marker within light field
• Minimum SID: 40⬙ (100 cm)
Evaluation Criteria
• No rotation evident by nasal septum to outer skull
margin
• Inferior orbital rims on center or image
Demonstrates
• Orbital floors and less distortion of orbital rims
• Petrous ridges in inferior half of maxillary sinus, inferior
orbital rim, nasal septum, anterior nasal spine, and zy-
gomatic arches
• Entire skull
• Foreign body of orbit
• Orbital fractures
FACIAL BONES
Lateral Facial Bones
Positioning Criteria
• Patient erect or prone
• 8⬙ ⫻ 10⬙ (20 ⫻ 25 cm) IR crosswise in Bucky
• Place side of interest closest to IR
• Palpate occipital protuberance and nasion in order to
determine rotation
• MSP should be parallel to IR
• The interpupillary line should be perpendicular
• Adjust head so the IOML is perpendicular to the front
edge of the IR
• Central ray perpendicular to IR and directed 1⬙ (2.5 cm)
inferior and 1⬙ (2.5 cm) posterior to outer canthus to
include mandible 2⬙ (5 cm) superior to the EAM
• Collimate to four sides to include all pertinent
anatomy
• Place appropriate side marker within light field on
lateral aspect of the side down
• Minimum SID: 40⬙ (100 cm)
Evaluation Criteria
• No rotation evident by superimposed mandibular rami
• No tilt evident by respective superimposition of
orbital roofs and greater wings of sphenoid
Demonstrates
• Superimposition of facial bones
• Greater wings of sphenoid, sellae turcica, sigma, and
mandible
• Fractures of facial bones
• Inflammation
Parietoacanthial (Waters): Facial Bones
Positioning Criteria
• Patient PA erect or recumbent, shielded
• 10⬙ ⫻ 12⬙ (25 ⫻ 30 cm) IR lengthwise placed in Bucky
• MML perpendicular to IR
• OML 37 degrees to IR and MSP perpendicular to mid-
line of Bucky
• Central ray perpendicular and exits acanthion
• Collimate to four sides to include all pertinent
anatomy
• Place appropriate side marker within light field
• Minimum SID: 40⬙ (100 cm)
112
CHAPTER 5
|
IMAGING PROCEDURES
Evaluation Criteria
• No rotation evident by lateral orbit and lateral skull
symmetric on each side
Demonstrates
• Petrous pyramids in lower one-third of orbit
• Orbital rim, maxillae, nasal septum, zygomatic bones,
and anterior nasal
• Fractures, neoplastic processes, and inflammatory
conditions
Posteroanterior Caldwell: Facial Bones
Positioning Criteria
• Patient PA and shielded
• 10⬙ ⫻ 12⬙ (25 ⫻ 30 cm) IR lengthwise placed in Bucky
• OML perpendicular to IR
• Central ray angled 15 degrees caudal, directed to exit
the nasion
• Collimate to four sides to include all pertinent anatomy
• Place appropriate side marker within light field on
lateral aspect of image
• Minimum SID: 40⬙ (100 cm)
113
CHAPTER 5
|
IMAGING PROCEDURES
Posteroanterior Modified Waters: Mandible
Positioning Criteria
• Patient PA, erect or recumbent, and shielded
• 10⬙ ⫻ 12⬙ (25 ⫻ 30 cm) IR lengthwise placed in Bucky
• Canthus of lips and meatal line are perpendicular to
Bucky
• OML forms a 55-degree angle with the IR
• Central ray exits acanthion
• MSP perpendicular to midline of grid
• Collimate to four sides to include all pertinent
anatomy
• Place appropriate side marker within light field
• Minimum SID: 40⬙ (100 cm)
Evaluation Criteria
• No rotation evident by symmetrical mandibular rami
Demonstrates
• True PA of mandible
• 1⬙ (2.5 cm) superior to TMJ down to mentum of
mandible
Anteroposterior Axial Towne: Mandible
Positioning Criteria
• Patient AP and shielded
• 10⬙ ⫻ 12⬙ (25 ⫻ 30 cm) IR lengthwise
• Central ray angled 35 degrees to 40 degrees caudal if
OML is perpendicular to the IR
• Central ray is angled 7 degrees more caudal if the
IOML is perpendicular
• Central ray is directed to the glabella and midway
between EAMs and angles of mandible
• Collimate to four sides to include all pertinent
anatomy
• Place appropriate side marker within light field on
lateral aspect of the image
• Minimum SID: 40⬙ (100 cm)
Evaluation Criteria
• Distance from mandibular rami on each side should
be equal if there is no rotation
Demonstrates
• Condyles of mandible and temporomandibular (TM)
fossae
• Minimum superimposition of TM fossae and mastoid
process
• Includes condyloid processes and TM fossae
• Fractures, neoplastic processes, and Paget disease
MANDIBLE
Posteroanterior (No Angle)
Positioning Criteria
• Patient PA and shielded
• 10⬙ ⫻ 12⬙ (25 ⫻ 30 cm) IR lengthwise placed in
Bucky
• OML perpendicular to IR
• MSP perpendicular to table
• Central ray perpendicular and directed to lips
• Collimate to four sides to include all pertinent
anatomy
• Place appropriate side marker within light field on
lateral aspect of image
• Minimum SID: 40⬙ (100 cm)
Evaluation Criteria
• No rotation evident by symmetry of mandibular rami
• Mandibular rami in center of image
Demonstrates
• Mandibular rami and lateral portion of body
• Midbody and mentum slightly superimposed over
cervical spine
• Fractures and neoplastic pathology
Posteroanterior Axial Mandible
Positioning Criteria
• Patient PA and shielded
• 10⬙ ⫻ 12⬙ (25 ⫻ 30 cm) IR lengthwise placed in
Bucky
• OML perpendicular to IR
• MSP perpendicular to table
• Central ray angled 20 degrees to 25 degrees cephalic
and directed to exit acanthion
• Collimate to four sides to include all pertinent
anatomy
• Place appropriate side marker within light field on
lateral aspect of image
• Minimum SID: 40⬙ (100 cm)
Evaluation Criteria
• No rotation evident by symmetry of mandibular rami
• Mandibular rami in center of image
Demonstrates
• Temporomandibular joint (TMJ) and condyles are
evident through the mastoid process
• Condyloid processes are elongated
• Fractures and neoplastic pathology