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124
CHAPTER 5
|
IMAGING PROCEDURES
Demonstrates
• Distal one-third of tibia and fibula with fibula superim-
posed over the posterior one-third to one-half of tibia
• Talus and calcaneus in profile
• Navicular, cuboid, and base of 5th metatarsal should
be included
• Tibiotalar joint will be open
Lateromedial Lateral
Positioning Criteria
• Patient should be in a recumbent lateral position
• Patient’s medial aspect of the affected leg should be
down
• Align ankle and distal leg shaft to long axis of IR
• Dorsiflex foot so the plantar surface is at a right angle
to the leg
• Central ray should be directed to the lateral malleolus
Evaluation Criteria
• Image should be free of motion
• Sharp bony margins should be present
• Lateral malleolus should be seen through distal tibia
and talus
• Soft tissue should be demonstrated on the IR
• Four-sided collimation
Demonstrates
• Distal one-third of tibia and fibula with fibula superim-
posed over the posterior one-third to one-half of tibia
• Talus and calcaneus in profile
• Navicular, cuboid, and base of 5th metatarsal should
be included
• Tibiotalar joint will be open
• Truer lateral achieved due to the medial malleolus
allowing closer contact with the IR
• This is a difficult position for some patients
Anteroposterior Stress Views
Positioning Criteria
• Ankle joint should be centered to the IR
• The foot should be dorsiflexed
• Plantar surface is turned medially for inversion and
laterally for eversion
• Patient must hold position with gauze or another
health-care provider may hold the foot in place
• Central ray should be directed midway between malleoli
Evaluation Criteria
• Distal tibia and fibula will be slightly superimposed
• Distal anterior view of tibia, fibula, lateral and medial
malleoli, and tibiotalar joint and anterior view of talus
should be visualized
Demonstrates
• Entire ankle mortise joint
• Open lateral and medial mortise joints with the
malleoli in profile
• Tibial plafond
• Minimal superimposition of distal tibiofibular joint
• Base of 5th metatarsal
FIGURE 5-31
Mediolateral Lateral Ankle
Positioning Criteria
• Patient should be in a recumbent lateral position
• Affected lateral side down
• Align ankle and distal leg shaft to long axis of IR
• Dorsiflex foot so the plantar surface is at a right angle
to the leg
• Central ray will be directed at medial malleolus
Evaluation Criteria
• Image should be free of motion
• Sharp bony margins should be present
• Lateral malleolus should be seen through distal tibia
and talus
• Soft tissue should be demonstrated on the IR
• Four-sided collimation
125
CHAPTER 5
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IMAGING PROCEDURES
Evaluation Criteria
• There should be no rotation of the calcaneus
• Calcaneus and subtalar joint should be visualized
• Optimal density and contrast should allow for the
visualization of talocalcaneal joint without overexpo-
sure to the tuberosity
Demonstrates
• Open talocalcaneal joint, sustentaculum tali, tuber-
osity, lateral process, and peroneal/trochlear process
Dorsoplantar Axial
Positioning Criteria
• Patient will be prone
• Place sponges or sandbags under the affected side to
allow patient to dorsiflex foot
• The long axis of the foot should be perpendicular
to the tabletop and the plantar portion of the foot
should be directly against the IR
• Angle 40 degrees caudally to the long axis of the foot
• Central ray should enter 2⬙ (5 cm) superior to the cal-
caneal tuberosity
• Long axis of distal leg should run parallel with the IR
• Collimation should be four sided, but open enough to
include the soft tissue of the ankle
Demonstrates
• Inversion demonstrates the lateral aspect of the joint
for lateral ligament tear or rupture
• Eversion demonstrates the medial aspect of the joint
for medial ligament tear or rupture
Calcaneus (Os Calcis)
Plantodorsal Axial
Positioning Criteria
• Have a long strip of gauze or a sheet ready
• Patient will be supine
• Angle the tube 40 degrees cephalic from vertical
• Place the patient’s 90-degree flexed foot so that the
central ray enters the base of the 3rd metatarsal;
angle more if the patient can’t flex 90 degrees
• Have the patient hold the dorsiflexed position with
the gauze or sheet
• Exit through the IR
• Collimate closely to the calcaneus
FIGURE 5-32
126
CHAPTER 5
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IMAGING PROCEDURES
Evaluation Criteria
• The entire tibia and fibula are included
• Fibula is partially superimposed by tibia at both
proximal and distal ends
• If completely superimposed or free from superimpo-
sition, extremity is rotated
• Both ankle and knee joints are visible
• The image is properly exposed
Demonstrates
• An AP view of the tibia and fibula
• Medial/lateral displacement
Evaluation Criteria
• There should be no rotation of the calcaneus
• Calcaneus and subtalar joint should be visualized
• Optimal density and contrast should allow for the
visualization of talocalcaneal joint without overexpo-
sure to the calcaneal tuberosity
Demonstrates
• Open talocalcaneal joint, sustentaculum tali, calca-
neal tuberosity, lateral process, and peroneal/troch-
lear process
• Same anatomy as plantodorsal, but exhibits increased
recorded detail
Lateral Calcaneus (Os Calcis)
Positioning Criteria
• Patient will be placed in a recumbent lateral
• Affected side closest to the IR
• Adjust the long axis of the plantar surface so that it is
parallel with the IR
• Foot should be dorsiflexed
• Central ray should enter at the subtalar joint, which
is 1⬙ (2.5 cm) distal to the medial malleolus
Evaluation Criteria
• The calcaneus should not exhibit rotation
• Distal portion of the tibia and fibula should be present
in order to demonstrate the tibiotalar joint
• Sinus tarsi open
• Optimal exposure to demonstrate the calcaneus and
soft tissue
• Four-sided collimation including all of the calcaneus
and the tibiotalar joint
Demonstrates
• Lateral view of the calcaneus, tibiotalar joint, talus,
sinus tarsi, subtalar joint, calcaneal tuberosity, sus-
tentaculum tali, navicular, cuboid, calcaneocuboid
joint, and base of 5th metatarsal
• Calcaneal fractures
Tibia and Fibula Projections
Anteroposterior Tibia and Fibula
Positioning Criteria
• Place the lower extremity in the AP position
• Femoral epicondyles parallel to the IR
• Central ray directed perpendicular to midshaft
• Collimate to include both the ankle and knee joints
FIGURE 5-33
Lateral Tibia and Fibula
Positioning Criteria
• Rotate the lower extremity laterally
• Patella perpendicular to IR
to maintain proper position
• Central ray directed perpendicular to midshaft
• Collimate to include both the ankle and knee joints
127
CHAPTER 5
|
IMAGING PROCEDURES
Demonstrates
Medial Rotation Demonstrates
• Proximal and distal tibiofibular articulations
• Interosseous space between tibia and fibula
Lateral Rotation Demonstrates
• Fibula superimposed by lateral portion of tibia
Knee Projections
A grid should be used for all knees measuring more than
4⬙ (10 cm). For knees measuring less than 4⬙ (10 cm), it
is acceptable to perform imaging without the use of a
grid on tabletop.
Anteroposterior Knee
Positioning Criteria
• Patient in AP position
• Lower extremity fully extended
• Femoral epicondyles parallel to the image plane
• Central ray ½⬙ (1 cm) inferior to apex of patella
• Central ray angled depending on body habitus to
open joint space
Evaluation Criteria
• The entire tibia and fibula are included
• Proximal head of fibula superimposed by tibia
• Distal fibula lying over posterior half of tibia
• Both ankle and knee joints are visible
• The image is properly exposed
Demonstrates
• Lateral view of the tibia and fibula
• Tibial tuberosity
• Anterior/posterior displacement
Oblique Tibia and Fibula
Positioning Criteria
• Patient supine with lower extremity extended and
rotated 45 degrees (medial or lateral)
• Central ray directed perpendicular to midshaft
Evaluation Criteria
• 45-degree oblique projection
• Entire tibia and fibula visualized
• Optimal exposure
FIGURE 5-34
128
CHAPTER 5
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IMAGING PROCEDURES
Anteroposterior Medial (Internal)
Oblique Knee
Positioning Criteria
• Patient in AP position with lower extremity fully
extended
• Internally rotated lower extremity 40 degrees to
45 degrees
• Central ray ½⬙ (1 cm) inferior to apex of patella
• Central ray angled depending on body habitus to
open joint space
• Measure tabletop to ASIS and angle as follows:
Less than 8⬙ (20 cm): angle 5 degrees caudal
Between 8⬙ and 10⬙ (20 and 25 cm): perpendicular
central ray
More than 10⬙ (25 cm): angle 5 degrees cephalic
• Collimate to include the distal femur, proximal tibia,
and fibula and medial/lateral to include soft tissue
• Minimum SID: 40⬙ (100 cm)
• Measure tabletop to ASIS and angle as follows:
Less than 8⬙ (20 cm): angle 5 degrees caudal
Between 8⬙ and 10⬙ (20 and 25 cm): perpendicular
central ray
More than 10⬙ (25 cm): angle 5 degrees cephalic
• Collimate to include the distal femur, proximal tibia, and
fibula and medial/lateral to include soft tissue
Evaluation Criteria
• Distal femur and proximal tibia and fibula shown
• Femorotibial joint space is open
• Joint is centered on image
• No rotation of knee
• Image is exposed correctly
Demonstrates
• Femorotibial joint space
• Head of fibula slightly superimposed by tibia
• Medial/lateral fracture displacement
FIGURE 5-35
129
CHAPTER 5
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IMAGING PROCEDURES
Evaluation Criteria
• Distal femur and proximal tibia and fibula shown
• Patella is in profile (indicates no rotation)
• Evidence of rotation is seen as follows: underrotated
when the abductor tubercle is seen; overrotated when
the head of the fibula is seen free of superimposition
• Femoral condyles superimposed
Demonstrates
• Femoropatellar joint space
Lateral Knee (Trauma)
Positioning Criteria
• Patient is supine
• Minimal flexion 5 degrees to 10 degrees
• If transverse fracture of patella is present, no flexion
• Support and elevate the knee
• Femoral epicondyles perpendicular to IR
• Utilize a horizontal central ray
• Central ray directed ½⬙ (1 cm) inferior to lateral tibial
condyle
• Four-sided collimation
• Minimum SID: 40⬙ (100 cm)
Evaluation Criteria
• Distal femur and proximal tibia and fibula shown
• Patella is in profile (indicates no rotation)
• Evidence of rotation is seen as follows: underro-
tated when the abductor tubercle is seen; over-
rotated when the head of the fibula is seen free of
superimposition
• Femoral condyles superimposed
Demonstrates
• Femoropatellar joint space
• Femorotibial joint space
• Anterior/posterior fracture displacement
• Presence of joint effusion, indicative of fracture
Anteroposterior Weight-Bearing Knees
Positioning Criteria
• Patient standing AP against upright Bucky
• Typically done bilaterally
• Femoral epicondyles parallel to the image plane
• Central ray perpendicular to joint space
• Central ray ½⬙ (1 cm) inferior to apex of patella
• 14⬙ ⫻ 17⬙ (35 ⫻ 42.5 cm) IR placed crosswise
Evaluation Criteria
• Distal femur and proximal tibia and fibula shown
• Proximal tibiofibular articulations seen free of super-
imposition
Demonstrates
• Head of fibula free of superimposition
• Lateral tibial condyle
• Lateral tibial plateau
• Lateral femoral condyle
Anteroposterior Lateral (External)
Oblique Knee
Positioning Criteria
• Patient in AP position
• Lower extremity fully extended
• Lower extremity externally rotated 40 degrees to
45 degrees
• Central ray ½⬙ (1 cm) inferior to apex of patella
• Central ray angled depending on body habitus to
open joint space
• Measure tabletop to ASIS and angle as follows:
Less than 8⬙ (20 cm): angle 5 degrees caudal
Between 8⬙ and 10⬙ (20 and 25 cm): perpendicular
central ray
More than 10⬙ (25 cm): angle 5 degrees cephalic
• Collimate to include the distal femur, proximal tibia,
and fibula and medial/lateral to include soft tissue
Evaluation Criteria
• Distal femur and proximal tibia and fibula shown
• Fibula superimposed over midtibia
Demonstrates
• Head of fibula free of superimposition
• Medial tibial condyle
• Medial tibial plateau
• Medial femoral condyle
Lateral Knee (Nontrauma)
Positioning Criteria
• Patient is rotated toward affected side
• Knee flexed 20 degrees to 30 degrees
• Femoral epicondyles perpendicular to IR
• Central ray angled 5 degrees cephalic ½⬙ (1 cm) infe-
rior to medial condyle
• Four-sided collimation
130
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IMAGING PROCEDURES
Evaluation Criteria
• Knee joints centered to collimated area
• No rotation of knees
• Joint spaces are open
• Optimal technique employed
Demonstrates
• More accurate than upright AP projection
• Tibial plateaus are superimposed
• Pathology including but not limited to: assessment
of degenerative joint disease, joint space narrow-
ing, varus/valgus deformities, assessment of condy-
lar fossa
Knee Axial Projections
Positioning Criteria (Three Methods)
Posteroanterior Axial: Camp-Coventry Method
• Patient prone
• Affected leg flexed 40 degrees and supported
• Central ray angled 40 degrees caudal
• Central ray directed to enter popliteal depression
Evaluation Criteria
• Knee joints centered to collimated area
• No rotation of knees
• Joint spaces are open
• Optimal technique employed
Demonstrates
• More accurate than supine AP image
• Pathology including but not limited to: assessment
of degenerative joint disease, joint space narrowing,
varus/valgus deformities
Posteroanterior Weight-Bearing Knees
(Rosenberg)
Positioning Criteria
• Performed bilaterally
• Patient upright in a PA position
• Flex knees to 45 degrees
• 14⬙ ⫻ 17⬙ (35 ⫻ 42.5 cm) IR placed crosswise aligned
with the central ray
• Central ray directed 10 degrees to 15 degrees caudal
• Four-sided collimation
FIGURE 5-36
131
CHAPTER 5
|
IMAGING PROCEDURES
Demonstrates
• Intercondylar fossa
• Intercondylar eminence well visualized
• Pathology including but not limited to: avulsion frac-
tures, osteochondritis desiccans, joint space narrowing
Patella Projections
Posteroanterior Patella
Positioning Criteria
• Patient in the prone position with lower extremity
extended
• Provide support for ankle and foot
• Femoral condyles should be parallel to IR
• Utilize an 8⬙ ⫻ 10⬙ (20 ⫻ 25 cm) IR aligned with the
central ray
• Central ray perpendicular to midpatellar area/popli-
teal crease
• Increased collimation to anatomy of interest
• Minimum SID: 40⬙ (100 cm)
Posteroanterior Axial Holmblad Method
• Support knee on a chair or other flat surface
• Place patient in kneeling position with lower leg
parallel to IR
• Instruct patient to lean forward until femur forms a
70-degree angle to IR
• Central ray perpendicular
• Central ray directed to enter popliteal depression
Anteroposterior Axial Beclere Method
• Utilize a curved IR
• Patient supine with lower extremity extended
• Knee flexed approximately 60 degrees
• Central ray directed ½⬙ (1 cm) inferior to apex of patella
• Central ray cephalic at an angle perpendicular to tibia
Evaluation Criteria
• Intercondylar fossa centered on image
• Open intercondylar fossa
• Four-sided collimation
• No rotation of knee
FIGURE 5-37
132
CHAPTER 5
|
IMAGING PROCEDURES
• Place 8⬙ ⫻ 10⬙ (20 ⫻ 25 cm) IR under knee on tabletop
• Central ray is directed 15 degrees to 20 degrees
cephalic parallel to patella entering apex of patella
• Increased collimation
• Minimum SID: 40⬙ (100 cm)
Hughston
• Patient positioned prone on the table
• Affected leg flexed 40 degrees
• Have patient hold on to gauze or tape to maintain
position
• Place 8⬙ ⫻ 10⬙ (20 ⫻ 25 cm) IR under knee on tabletop
• Can be performed bilaterally on one larger IR
• Central ray directed 15 degrees to 20 degrees cepha-
lic entering the apex
• Collimate to anatomy of interest
• Minimum SID: 40⬙ (100 cm)
Inferosuperior Method (Bilateral)
• Patient supine on table
• Knees flexed 40 degrees to 45 degrees and supported
• Place 10⬙ ⫻ 12⬙ (25 ⫻ 30 cm) IR on edge resting on
midthighs, tilted to be perpendicular to central ray
• Central ray directed 10 degrees to 15 degrees cephalic
• Central ray enters apex of patella
• Collimate to include bilateral anatomy
• Minimum SID: 40⬙ (100 cm)
Superoinferior Sitting Method
• Patient seated in chair
• Knees flexed slightly with feet placed under chair
• IR placed on foot stool to reduce OID
• Central ray directed perpendicular to enter base of
patella
• Minimum SID: 48⬙ to 50⬙ (120 to 125 cm)
Evaluation Criteria
• Intercondylar sulcus and patella visualized
• Patellofemoral joint space is open
• Optimal exposure
Demonstrates
• Patellofemoral joint space
• Pathology including but not limited to: patellar frac-
ture, patellofemoral subluxation syndrome
Femur Projections
For all femur projections, take into consideration the
anode heel effect and place the hip of the patient at
cathode end of the x-ray beam.
Evaluation Criteria
• Patella centered in collimated area
• No rotation
• Optimal exposure
Demonstrates
• Patella
• Transverse fracture of patella
Mediolateral Patella
Positioning Criteria
• Patient rotated toward affected side to bring knee
into a lateral position
• Flexion of knee should not exceed 5 degrees to
10 degrees
• Utilize an 8⬙ ⫻ 10⬙ (20 ⫻ 25 cm) IR aligned with the
central ray
• Central ray perpendicular to distal femoropatellar
joint
• Increase collimation to anatomy of interest
• Minimum SID: 40⬙ (100 cm)
Evaluation Criteria
• Patella centered on image
• Patella in true lateral position
• Optimal exposure
Demonstrates
• Lateral view of patella
• Patellofemoral articulation open
• Pathology including but not limited to: anterior/
posterior displacement of fractures
Patella Tangentials
Positioning Criteria (Five Methods)
Orthopedic Physicians Preferred Method
• Requires use of axial viewer
• Viewer aids in creation of 45 degrees of flexion
• Central ray directed 60 degrees caudal to enter base
of patella
• Collimate to anatomy of interest
• Minimum SID: 72⬙ (180 cm) to reduce magnification
Settegast
• Patient positioned prone on the table
• Affected leg slowly flexed approximately 120 degrees
until patella is perpendicular to IR
• Have patient hold on to gauze or tape to maintain
position
133
CHAPTER 5
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IMAGING PROCEDURES
• Place appropriate side marker within light field on
lateral aspect of image
• Minimum SID: 40⬙ (100 cm)
Evaluation Criteria
• Proximal femur to midshaft of femur demonstrated in
the AP position
• No rotation evident
Demonstrates
• An AP view of the proximal femur
• Medial/lateral displacement of the proximal femur
• Detection and evaluation of fractures and/or bone
lesions
Anteroposterior Femur: Midfemur to
Distal Femur
Positioning Criteria
• Patient supine and legs fully extended; gonadal region
shielded
• Place 10⬙ ⫻ 12⬙ (25 ⫻ 30 cm) or 14⬙ ⫻ 17⬙ (35 ⫻ 42.5 cm)
IR adjacent to the distal aspect of the IR from proximal
projection in table Bucky or tabletop depending on
part size (moving or stationary grid recommended)
Proximal Femur
Positioning Criteria
• Patient supine and legs fully extended; gonadal region
shielded
• Place 10⬙ ⫻ 12⬙ (25 ⫻ 30 cm) IR lengthwise in table
Bucky
• Rotate affected leg internally 15 degrees to 20 degrees
to provide a true AP projection of the proximal
femurs; places femoral heads and necks in profile
• Direct central ray perpendicular to IR, 1⬙ to 2⬙ (2.5 to
5 cm) medial and 3⬙ to 4⬙ (7.5 to 10 cm) distal to ASIS,
or 1⬙ to 2⬙ (2.5 to 5 cm) distal to the midfemoral neck
for orthopedic devices
• 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
• True AP projection of the proximal one-third of the
femur
• Greater trochanter and femoral head and neck in full
profile with no evidence of foreshortening
• Femoral neck in the center of IR indicates proper cen-
tering of part–IR–central ray
• Lesser trochanters not visible or slightly visible on
some patients
• No rotation evident by equidistant ASIS from tabletop
• Optimal exposure factors
Demonstrates
• Proximal one-third of femur; acetabulum and adja-
cent parts of the pubis, ischium, and ilium
• Medial/lateral displacement of the femoral head
• If patient has an orthopedic device, it should be visu-
alized in its entirety
Anteroposterior Femur: Proximal Femur to
Midfemur
Positioning Criteria
• Patient supine and legs fully extended; gonadal region
shielded
• Place top of 14⬙ ⫻ 17⬙ (35 ⫻ 42.5 cm) IR at ASIS in
table Bucky
• Rotate affected leg 5 degrees internally to bring femo-
ral condyles parallel to IR
• Direct central ray perpendicular and to the midpoint
of the IR
• Collimate to four sides to include all pertinent anatomy
FIGURE 5-38