RADIOGRAPHIC TECHNIQUE I –RAD 245 Prepared By: Ala’a Ali Tayem Abed.

Lower-Limbs Positioning

Lower-Limbs Positioning Toes, Foot, Calcaneus and Ankle Positioning AP, Lateral, and Oblique Toes Technical Factors: Cassette Size: 18 x 24 cm (8 x 10 inches). Cassette Orientation: Landscape (Crosswise), Divide in Thirds, Tabletop ( Without Bucky). Exposure: kVp: 50 to 55, mAs: 2.5 FFD: 100cm. Central Ray: • Angle CR 10 to 15 degree toward Calcaneus, (In AP Projection). • Perpendicular to IR, (In Lateral and Oblique Projections). Centering Point: MTP Jt of Affected Toe. Collimation: To include Distal Tip of Toe and Distal End of Metatarsal. Positioning: • Patient Supine or Seated on Table, with Knee Bent and Plantar Aspect of Foot Placed on Cassette, (In AP Projection). • Rotate the Leg and Foot 45 degree Medially for the First, Second, and Third Digits and Laterally for the Fourth and Fifth Digits, (In Oblique Projection). • Rotate Affected Leg and Foot Medially (Lateromedial) for First, Second, and Third Digits and Laterally (Mediolateral) for Fourth and Fifth Digits, (In Lateral Projection).

AP Toes

Oblique Toes

Lateral Toes

AP Toes Evaluation Criteria • Digit(s) of interest and a minimum of the distal half of metatarsals should be included. • Individual digits should be separated with no overlapping of soft tissue. • Optimal contrast and density will allow visualization of bony cortical margins and trabeculae and soft tissue structures.

Oblique Toes Evaluation Criteria • Digit(s) in question and distal half of metatarsals should be included without overlap (superimposition). • Correct obliquity should be evident by increased concavity on one side of shafts and by overlapping of soft tissue of digits. • Heads of metatarsals should appear directly side by side with no (or only minimal) overlapping. • Interphalangeal and MTP joints of interest appear open, indicating correct CR. • Optimal contrast and density will allow visualization of bony cortical margins and trabeculae and soft tissue structures. Oblique Toes

Lateral Toes Evaluation Criteria • Phalanges of digits in question should be seen in lateral position free of superimposition by other digits, if possible. • Interphalangeal joints should appear open and unobstructed. • The MTP joint should be visualized even if superimposed. • No motion as evidenced by sharply defined cortical margins of the bone and detailed bony trabeculae. • Optimal contrast and density will allow visualization of bony cortical margins and trabeculae and soft tissue structures. Lateral Toes

AP, Lateral, and Oblique Foot Technical Factors: Cassette Size: 24 x 30 cm (10 x 12 inches), may be more. Cassette Orientation: Portrait (Lengthwise). Exposure: kVp: 55 to 60, mAs: 3 to 4 FFD: Minimum SID is 40 inches (100 cm). Central Ray: • Angle CR 10 degree (Toward Heel), (In AP Projection). • Perpendicular to IR, (In Lateral and Oblique Projections). Centering Point: Base of Third Metatarsal. Collimation: Collimate to Outer Margins of Foot on Four Sides. Patient Position: Take radiograph with patient supine or sitting; give pillow to patient for head; flex knee and place plantar (sole) of affected foot flat on cassette (IR), (In AP Projection). Position Patient Supine or Seated on Table, Knees Flexed with Feet Separated, Rotate foot medially to place plantar surface 30 degree to 45 degree to plane of IR, (In Oblique Projection). Position Patient Lying on Affected Side, Adjust Leg and Foot in Lateral Position with Patella Perpendicular to Table, make the Lateral Aspect of Affected Foot contacts with Film, (In Lateral Projection).

AP Oblique Lateral

AP FOOT Evaluation Criteria Entire foot should be demonstrated, including all phalanges and metatarsals and the navicular, cuneiforms, and cuboids. No rotation as evidenced by nearly equal distance between second through fifth metatarsals. Bases of first and second metatarsals generally are separated, but bases of second to fifth metatarsals appear overlapped. Center of four-sided collimation field (CR) should be at the base of the third metatarsal with collimation borders, including the soft tissue surrounding the foot. The MTP joints generally should appear open. Optimal density and contrast with no motion should visualize sharp borders and trabecular markings of distal phalanges and tarsals distal to talus. Sesamoid bones (if present) should be seen through head of first metatarsal.

Oblique FOOT Evaluation Criteria Entire foot should be demonstrated from distal phalanges to posterior Calcaneus and proximal talus. Correct obliquity is demonstrated when third through fifth metatarsals are free of superimposition. First and second metatarsals also should be free of superimposition except for base area. Center of four-sided collimation (CR) should be to base of third metatarsal. Collimation field should include soft tissue surrounding the foot. Optimal density and contrast with no motion should visualized sharp borders and trabecular markings of phalanges, metatarsals, and tarsals.

LATERAL FOOT Evaluation Criteria Entire foot should be demonstrated with a minimum of 1 inch (2.5 cm) of distal tibiafibula. Metatarsals will be nearly superimposed. True lateral position is achieved when the tibiotalar joint is open. All soft tissue structure from phalanges to Calcaneus should be included in the center of the four-sided collimated field with the center (CR). No motion; cortical margins and trabecular markings of Calcaneus and nonsuperimposed portion of other tarsals should appear sharply defined. LATERAL FOOT

AP FOOT : WEIGHT-BEARING METHOD Pathology Demonstrated: These projection use usefull for demonstrating the bones of the feet to show the condition of the longitudinal arches under the full weight of the body. Also may demonstrate injury to structural ligaments of the foot such as a lisfranc joint injury. Note: Bilateral projections of both feet often are taken for comparison. Part Position: Take radiograph with patient standing erect, with full weight evenly distributed on both feet. Feet should be directed straight ahead, parallel to each other. Central Ray: Angle CR 15 degree toward heel to midpoint between feet at level of base of metatarsals.

LATERAL FOOT : WEIGHT-BEARING METHOD Have patient stand erect, with weight evenly distributed. support vertical cassette between feet, with long axis of foot aligned to long axis of IR. Changed cassettes and turn patient for lateral of other foot for comparison after first lateral has been taken. Central Ray: Direct CR horizontally to level of base of third metatarsals.

Lateral Calcaneus Technical Factors: Cassette Size: 18 x 24 cm (8 x 10 inches). Cassette Orientation: Landscape (Crosswise). Exposure: kVp: 60, mAs: 3 to 3.5 FFD: 40 inches (100cm). Central Ray: Perpendicular to IR. Centering Point: 1 inch (2.5 cm) inferior to medial malleolus. Collimation: Collimate to outer skin margins to include the ankle joint proximally and the entire Calcaneus. Patient Position: Position Patient Lying on Affected Side, Adjust Leg and Foot in Lateral Position with Patella Perpendicular to Table, make the Lateral Aspect of Affected Foot contacts with Film.

Lateral Calcaneus Evaluation Criteria Calcaneus is demonstrated in profile with the talus and distal tibia-fibula demonstrated superiorly, as well as the navicular and the open joint space of the Calcaneus and Cuboid distally. Four-sided collimation should include ankle joint proximally and talonavicular joint and base of fifth metatarsal anteriorly. Optimal exposure will visualize some soft tissue and more dense portions of Calcaneus and talus. The outline of the distal fibula should be faintly visible through the talus. Trabecular markings will appear clear and sharp, indicating no motion. Lateral Calcaneus

Calcaneus: PLANTODORSAL (AXIAL) Technical Factors: Cassette Size: 18 x 24 cm (8 x 10 inches). Cassette Orientation: Landscape (Crosswise). FFD: 40 inches (100cm). Central Ray: Angle CR 40degree Cephalic from long axis of foot Centering Point: Direct CR to base of third metatarsal Collimation: Collimate closely to area of Calcaneus. Patient Position: Take radiograph with patient supine or seated on table with leg fully extended. Dorsiflex foot so plantar surface is near perpendicular to IR. The affected leg is rotated medially until both malleoli are equidistant from the image receptor. Loop gauze or a tourniquet around foot, and ask patient to pull gently but firmly and hold the plantar surface of foot as near perpendicular to IR as possible. (Do not keep patient in this position any longer than is necessary because it may be very uncomfortable.)

Calcaneus: PLANTODORSAL (AXIAL) Evaluation Criteria Entire Calcaneus should be visualized from the Tuberosity posteriorly to the talocalcaneal joint anteriorly. With the Foot in proper 90 degree flexion, correct alignment and Angulation of the CR are evidenced by an open talocalcaneal joint space, no distortion of the Calcaneus, and adequate elongation of the Calcaneus. Optimal density and contrast with no motion will demonstrate sharp bony margins and trabecular markings.. Calcaneus: PLANTODORSAL (AXIAL)

ANKLE PROJECTIONS AP, Lateral, and Oblique Ankle Technical Factors: Cassette Size: 24 x 30 Inches (10 x 12 cm). Cassette Orientation: Landscape (Crosswise), Divide in Thirds, Tabletop ( Without Bucky). Exposure: kVp: 60 to 65, mAs: 3 to 5 FFD: 100cm. Central Ray: Perpendicular to IR. Centering Point: Directed to a Point Midway Between Malleoli. (In AP and Oblique Projection). Directed to Medial Malleolus. (In Lateral Projection). Collimation: Collimate to lateral skin margins; include proximal one-half of metatarsals and distal tibia-fibula. Positioning: Take radiograph with patient in the supine position; place pillow under head; patient's leg should be fully extended. The affected leg is rotated medially until both malleoli are equidistant from the image receptor.(In AP Projection). Rotate the Leg and Foot 45 degree Medially, (In Oblique Projection).

Rotate Affected Leg and Foot Laterally (Mediolateral). Dorsiflex foot so plantar surface is at right angle to leg or as far as patient can tolerate; do not force. (This will help maintain a true lateral position), (In Lateral Projection). Alternate Lateromedial Projection: This lateral may be taken rather than the more commonly preferred mediolateral projection. (This position is more uncomfortable for the patient but may make it easier to achieve a true lateral position.)

Lateral AP Oblique

AP ANKLE Evaluation Criteria The distal one-third of the tibia-fibula, the lateral and medial malleoli, and the talus and proximal half of the metatarsals should be demonstrated. Optimal exposure with no motion will demonstrate clear bony margins and trabecular markings, All surrounding soft tissue also should be included. AP ANKLE

LATERAL ANKLE Evaluation Criteria The distal one-third of the tibia and fibula with the distal fibula superimposed by the distal tibia, the talus, and Calcaneus will appear in lateral profile. The tuberosity of the fifth metatarsals, the navicular, and Cuboid also will be visualized. No rotation is evidenced by the distal fibula being superimposed over the posterior half of the tibia. The tibiotalar joint will be open with uniform joint space. No motion, as evidenced by sharp bony margins and trabecular patterns. The lateral malleolus should be seen through the distal tibia and talus, and soft tissue must be demonstrated for evaluation of joint effusion. LATERAL ANKLE

OBLIQUE ANKLE Evaluation Criteria The distal one-third of the lower leg, the malleoli, the talus, and the proximal half of the metatarsals should be seen. A 45degree medial oblique will demonstrate the distal tibiofibular joint open, with no or minimal overlap on the average person. The lateral malleolus and talus joint should show no or only slight superimposition, but the medial malleolus and talus will be partially superimposed. The bony cortical margins and trabecular patient should be sharply defined on the image if no motion is present, and soft tissue structure also must be evident.

AP MORTISE PROJECTION, 15 TO 20 DEGREE MEDIAL ROTATION : ANKLE

AP Mortise 15-20 Degree Medial Rotation Evaluation Criteria The entire ankle mortise should be open and well visualized. Proper obliquity for the mortise joint is evidenced by demonstration of open lateral and medial mortise joints with the malleoli demonstrated in profile.

AP STRESS PROJECTION: ANKLE

AP stress (Inversion) Evaluation Criteria Ankle joint for evaluation of joint separation and ligament tear or rupture is shown. The appearance of the joint space may vary greatly depending on the severity of ligament damage.

Thank You Best Wishes For All