LOWER EXTREMITIES

PATHOLOGY
1.) Congenital Clubfoot A.) TOES
• Talipes equinovarus
• Abnormal twisting of the foot usually inward AP/AP AXIAL PROJECTION
& downward PP: Supine/Seated; knee flexed; 15o foam wedge
2.) Pott’s Fx under foot
• Avulsion fx of the medial malleolus with loss RP: 3rd MTP joint
of the ankle mortise CR: ┴ or 15o posteriorly
3.) Jones Fx SS: Phalanges & distal portion of metatarsals
• Avulsion fx of the base of the fifth metatarsal AP Axial (15o): Open IP joints & reduces
4.) Gout foreshortening
• Hereditary form of arthritis in which uric acid
is deposited in joints PA PROJECTION
5.) Osgood-Schlatter Disease PP: Prone (IP joints // to CR); dorsal aspect against IR
• Incomplete separation or avulsion of the tibial RP: 3rd MTP joint
tuberosity CR: ┴
6.) Giant Cell Tumor SS: IP joint spaces are well visualized
• Osteoclastoma
AP OBLIQUE PROJECTION
• Lucent lesion in the metaphysic usually at the
Medial Rotation
distal femur
PP: Supine/seated; knee flexed; lower leg & foot
7.) Chondromalacia Patellae
rotated medially 30-45o;
• Runner’s knee
RP: 3rd MTP joint
• Softening of the cartilage under the patella
CR: ┴
8.) Joint Effusion
SS: 2nd-5th MTP joint spaces; 1st-3rd toes
• Accumulation of fluid in the joint cavity
Lateral Rotation
9.) Lisfranc Injury
PP: Supine/seated; knee flexed; lower leg & foot
• Abnormal separation in the base of 1st & 2nd rotated medially 30-45o;
metatarsal & cuneiform RP: 3rd MTP joint
10.) Reiter Syndrome CR: ┴
• Erosions of sacroiliac joints & lower limbs SS: 3rd-5th toes
11.) Hallux Valgus
• Congenital abnormality of hallux LATERAL PROJECTION
• Lateral deviation of great toe PP: Lateral recumbent; toe in true lateral
RP: IP joint (1st toe); proximal IP joint (2nd-4th toes)
ROUTINE CR: ┴
1.) Bony Injuries – AP, APO & Lateral SS: Phalanges in profile; open IP joints spaces
2.) Bony Pathology – AP & APO B.) SESAMOIDS
3.) Foreign Body Localization – AP & Lateral
LEWIS METHOD
TANGENTIAL PROJECTION
DIVISIONS OF FOOT PP: Prone; dorsiflex great toe; ankle elevated; ball of
1.) Hindfoot – calcaneus & talus foot ┴ IR
2.) Midfoot – cuboid, navicular & cuneiform RP: 1st MTP joint
3.) Forefoot – metatarsals & phalanges CR: Perpendicular
 LOWER EXTREMITIES
SS: MT head & sesamoids in profile • 3rd-5th MT bases
• 5th MT tuberosity
HOLLY METHOD Lateral Rotation
TANGENTIAL PROJECTION PP: Supine; knee flexed; leg rotated laterally; plantar
PP: Seated; plantar 75o to IR; toe flexed & hold w/ surface of foot 30o to IR
strip gauze bandage; foot medial border ┴ to IR RP: 3rd MTP base
RP: 1st MTP head CR: ┴
CR: ┴ SS:
SS: MT head & sesamoids in profile • Navicular
• Interspaces on medial side of foot
CAUSTON METHOD • Medial & intermediate cuneiform
TANGENTIAL PROJECTION • 1st-2nd MT bases
PP: Lateral recumbent; patient lie against unaffected
side; limb partially extended; foot in lateral position; LATERAL PROJECTION
1st MTP joint ┴ to IR Mediolateral
RP: Prominence of 1st MTP joint PP: Dorsiflex foot (┴ to lower leg); leg & foot in
CR: 40o toward the heel lateral position; lateral side of foot against IR (more
SS: Sesamoids with slight overlap comfortable)
RP: 3rd MT base
C.) FOOT CR: Perpendicular
SS: Entire foot in profile
AP/AP AXIAL PROJECTION ER:
PP: Supine; knee flexed; plantar surface against IR
• For localizing foreign body
RP: 3rd MTP base
• Degree of anterior & posterior displacement
CR: ┴ or 10o posteriorly
of fx
SS: MT & Tarsal (┴); TMT joint (10o)
Lateromedial
ER:
PP: LPO/RPO; medial surface against IR; plantar
• For localizing foreign bodies surface of foot ┴ to IR
• Location of fragments in fx of metatarsals & RP: 3rd MTP base
anterior tarsals CR: Perpendicular
• General surveys of the foot SS: True lateral projection of foot
o
10 Angulation: reduces foreshortening of
metatarsals GRASHEY METHOD
PA OBLIQUE PROJECTION
AP OBLIQUE PROJECTION Medial and Lateral Rotation
Medial Rotation PP: Prone; foot elevated; dorsal surface against IR;
PP: Supine; knee flexed; leg rotated medially; plantar heel rotated medially 30o (to demonstrate 1st and 2nd
surface of foot 30o to IR MT); heel rotated laterally 20o (to demonstrate
RP: 3rd MTP base interspaces b/n 2nd-3rd, 3rd-4th & 4th-5th MT)
CR: ┴ RP: 3rd MTP base
SS: CR: Perpendicular
• Cuboid SS: PA oblique projection of the bones of the foot &
• Interspaces on lateral side of foot interspaces at the proximal ends of metatarsal
• Sinus tarsi
• Lateral cuneiform WEIGHT-BEARING METHOD
 LOWER EXTREMITIES
LATERAL PROJECTION • Degree of forefoot adduction & calcaneus
PP: Upright; feet elevated (use blocks); IR b/n feet; inversion
weight equally distributed on each foot 15 Angulation: places CR ┴ to tarsals
o

RP: Point above 3rd MTP base

CR: Horizontal KITE METHOD
SS: Status of longitudinal arch (pes planus); Bohler’s LATERAL PROJECTION
critical angle (b/n 20-40o); calcaneal fracture (less Mediolateral
than 20o) PP: Lateral recumbent; uppermost limb flexed & draw
Bohler’s Critical Angle: angle b/n superior apex of forward
mid-calcaneus to anterior process of calcaneus RP: Midtarsal area
CR: Perpendicular
WEIGHT-BEARING METHOD SS:
AP AXIAL PROJECTION • Anterior talar subluxation
PP: Upright; both feet against IR; weight equally • Degree of plantar flexion (equinus)
distributed on each foot
RP: b/n feet at 3rd MTP base level KANDEL METHOD
CR: 10o or 15o posteriorly DORSOPLANTAR AXIAL PROJECTION
SS: Accurate evaluation & comparison of MT & PP: Bending forward position; plantar surface against
tarsals IR
• Hallux valgus & lishfranc injury RP: Lower leg
CR: 40o anteriorly
WEIGHT-BEARING COMPOSITE METHOD SS: Calcaneus
AP AXIAL PROJECTION Freiberger-Hersh-Harrison: CR 35o, 45o & 55o for
PP: Upright; 2 exposures demonstration of sustentaculum talar joint
• First Exposure: opposite foot step backward
(for forefoot); tube in front E.) CALCANEUS
• Second Exposure: opposite foot step
backward (for hindfoot); tube behind AXIAL PROJECTION
RP: 3 MTP base (1st exposure); level of lateral
rd
Plantodorsal
malleolus (2nd exposure) PP: Supine/Seated; leg fully extended; dorsiflex foot
CR: 15o posteriorly (1st exposure); 25o anteriorly (2nd w/ strip of gauze; foot ┴ to IR
exposure) RP: 3rd MT base
SS: Full outline of the foot CR: 40o cephalad
SS: Calcaneus & subtalar joint
D.) CONGENITAL CLUBFOOT Dorsoplantar
PP: Prone; ankle elevated; dorsiflex ankle; foot ┴ to
KITE METHOD IR; IR vertical
AP PROJECTION RP: Dorsal surface of ankle joint
PP: Supine; hips & knees flexed; foot flat on IR; CR: 40o caudad
ankles slightly extended; legs are vertical SS: Calcaneus, subtalar joint & sustentaculum tali
RP: Tarsals
CR: 15o posteriorly LILIENFELD METHOD
SS: WEIGHT-BEARING COALITION
• True relationship of bones & ossification DORSOPLANTAR AXIAL PROJECTION
centers of tarsals
 LOWER EXTREMITIES
PP: Upright; posterior surface of heel at edge of IR; Lateral Rotation Ankle
opposite foot one step forward PP: Supine/seated; leg, foot & ankle rotated 30o
RP: Level of 5th MT base laterally; dorsiflex foot
CR: 45o anteriorly RP: 1 in. distal medial malleolus
SS: Calcaneotalar coalition CR: 10o cephalad
SS: Posterior subtalar articulation
LATERAL PROJECTION
Mediolateral BRODEN METHOD
PP: Supine; patient turn toward affected side; plantar AP AXIAL OBLIQUE PROJECTION
surface // to IR Medial Rotation
RP: 1 in distal to medial malleolus PP: Supine; leg & foot rotated 45o medially; dorsiflex
CR: ┴ foot; foot rested against 45o foam wedge
SS: Calcaneus & ankle joint RP: 2-3 cm to lateral malleolus
CR: 10o, 20o, 30oor 40o cephalad
WEIGHT BEARING METHOD SS: Posterior articulation
LATEROMEDIAL OBLIQUE PROJECTION • Anterior portion (40o)
PP: Upright; leg perpendicular to IR; calcaneus center • Posterior portion (10o)
to IR • Talus & sustentaculum tali articulation (20-
RP: Lateral malleolus 30o)
CR: 45o caudad (medially) Lateral Rotation
SS: Calcaneal tuberosity PP: Supine; leg & foot rotated 45o laterally; dorsiflex
ER: Useful in diagnosing stress fractures of foot; foot rested against 45o foam wedge
calcaneus or tuberosity RP: 2 cm distal & 2 cm anterior to medial malleolus
CR: 15o cephalad
F.) SUBTALAR JOINT SS: Posterior articulation
ER: To determine the presence of joint involvement
ISHERWOOD METHOD in cases of comminuted fx
LATEROMEDIAL OBLIQUE PROJECTION
Medial Rotation Foot
PP: Semisupine; foot & leg rotated 45o medially; knee
flexed
RP: 1 in. distal & 1 in. anterior to lateral malleolus
CR: ┴
SS: Anterior subtalar articulation

ISHERWOOD METHOD
AP AXIAL OBLIQUE PROJECTION
Medial Rotation Ankle
PP: Seated or semi-lateral recumbent (more
comfortable); leg, foot & ankle rotated 30o medially;
dorsiflex foot
RP: 1 in. distal & 1 in. anterior to lateral malleolus
CR: 10o cephalad
SS: Middle subtalar articulation & “end on”
projection of sinus tarsi
 LOWER EXTREMITIES
G.) ANKLE
STRESS METHOD
AP PROJECTION AP PROJECTION
PP: Supine; leg & foot vertical & rotated 5o medially PP: Seated; foot forcibly turned toward the opposite
(places malleoli equidistant) side; inversion & eversion stress to joint
RP: Point midway between malleoli RP: Ankle joint
CR: ┴ to ankle joint CR: ┴
SS: Ankle joint & tibiotalar joint space ER: To evaluate the presence of ligamentous tear &
joint separation
LATERAL PROJECTION
Mediolateral WEIGHT-BEARING METHOD
PP: Semisupine; lateral surface of foot against IR; AP PROJECTION
dorsiflex foot PP: Upright; heels against the IR; IR vertical; toes
RP: Medial malleolus pointing toward the x-ray tube
CR: ┴ to ankle joint RP: Midway at level of ankle joint
SS: True lateral projection of lower third of tibia & CR: Horizontal
fibula, ankle joint & tarsals ER: Identify ankle joint space narrowing; side-to-side
• 5th metatarsal base (identify Jones fx) comparison of joint
Lateromedial
PP: Semisupine; medial surface of foot against IR; H.) LEG
dorsiflex foot
RP: 0.5 in. superior to lateral malleolus AP PROJECTION
CR: ┴ to ankle joint PP: Supine; femoral condyles // to IR; foot in vertical
SS: Lateral projection of lower third of tibia & fibula, position;
ankle joint & tarsals RP: Midshaft
CR: ┴
AP OBLIQUE PROJECTION SS: Tibia & fibula; ankle & knee joints
Medial Rotation
PP: Supine; LATERAL PROJECTION
• Leg & foot rotated 45o medially; dorsiflex MEDIOLATERAL
foot – to demonstrate bony structure PP: Supine; RPO/LPO; patella ┴ to IR; femoral
• Leg & foot rotated 15-20o medially; condyles ┴ to IR;
intermalleolar line // to IR – to demonstrate RP: Midshaft
mortise joint CR: ┴
RP: Point midway b/n malleoli SS: Tibia & fibula; ankle & knee joints
CR: ┴ to ankle joint
SS: Distal ends of tibia, fibula & talus; tibiofubular AP OBLIQUE PROJECTION
articulation; mortise joints PP: Supine; leg & foot rotated 45o medially or
Lateral Rotation laterally
PP: Supine; leg & foot rotated 45o laterally; dorsiflex RP: Midshaft
foot CR: ┴
RP: Point midway b/n malleoli SS: Tibia & fibula; ankle & knee joints
CR: ┴ to ankle joint
SS: Superior aspect of calcaneus I.) KNEE
ER: Useful in determining fxs
 LOWER EXTREMITIES
AP PROJECTION
PP: Supine; femoral epicondyles // to IR; leg 5o WEIGHT-BEARING METHOD
inward (places interepicondylar line // to IR) AP BILATERAL PROJECTION
RP: 0.5 in. inferior to patellar apex LEACH-GREGG-SIBER
CR: depending on the measurement b/n ASIS & table PP: Upright; knee fully extended; weight equally
top distributed on both feet; IR vertical
• 3-5ocaudad (<19 cm; thin pelvis) RP: 0.5 in. inferior to patellar apex
• ┴ (19-24 cm) CR: Horizontal
• 3-5ocephalad ( >24 cm; large pelvis) SS: Knee joint spaces
SS: Knee joint space ER:
• To reveal narrowing of knee joint space
PA PROJECTION • To evaluate varus & valgus deformities &
PP: Prone; femoral epicondyles // to IR; leg 5o inward degenerative joint disease
(places interepicondylar line // to IR)
RP: 0.5 in. inferior to patellar apex ROSENBERG METHOD
CR: 5-7ocaudad PA WEIGHT-BEARING
SS: Knee joint space STANDING FLEXION
PP: Upright; facing vertical IR; anterior surface of
LATERAL PROJECTION flexed knee against IR; femur 45o to IR
Mediolateral RP: 0.5 in. inferior to patellar apex
PP: Lateral recumbent; knee flexed 20-30o (relax CR: Horizontal or 10o caudad
muscle & shows maximum volume of joint cavity) or ER: Useful for evaluating joint space narrowing &
flexed <10o (for new or unhealed patellar fx); femoral demonstrating articular cartilage disease
epicondyles ┴ to IR
RP: 1 in. distal to medial epicondyle J.) INTERCONDYLAR FOSSA
CR: 5-7o cephalad
SS: Knee joint space HOLMBLAD METHOD
PA AXIAL PROJECTION
AP OBLIQUE PROJECTION TUNNEL VIEW
Medial Rotation PP: Anterior surface of knee against IR; knee 60-70o
PP: Supine; leg rotated 45o medially; hip of affected from IR (20o difference from CR)
side elevated 3 positions:
RP: 0.5 in. inferior to patellar apex • Standing; knee flexed & rested on a stool
CR: depending on the measurement b/n ASIS & table • Standing at side of table; knee flexed & rested
top over the IR
• 3-5ocaudad (<19 cm) • Kneeling on table; knee over the IR (Holmblad
• Perpendicular (19-24 cm) Method)
• 3-5ocephalad (>24 cm) RP: Popletial depression
SS: Proximal tibiofibular joint; fibular head CR: ┴
Lateral Rotation SS: Intercondylar fossa
PP: Supine; leg rotated 45o medially; hip of
unaffected side elevated CAMP-COVENTRY METHOD
RP: 0.5 in inferior to patellar apex PA AXIAL PROJECTION
CR: 5o cephalad PP: Prone; knee flexed 40-50o from IR; femur against
SS: Tibial plateaus; medial femoral & tibial condyles IR; with support under foot
 LOWER EXTREMITIES
RP: Popletial depression Lateral Rotation
CR: 40o (knee flexed 40o) or 50o (knee flexed 50o) PP: Prone; knee flexed 5-10o; knee 45-55o laterally
caudally RP: Patella
SS: Intercondylar fossa CR: ┴
ER: SS: Lateral portion of patella free of femur
• To detect loose bodies “joint mice
• To evaluate split & displaced cartilage in KUCHENDORF METHOD
osteochondritis PA AXIAL OBLIQUE PROJECTION
• To evaluate flattening or underdevelopment Lateral Rotation
of lateral femoral condyles in congenital PP: Prone; hip elevated 2-3 in.; knee flexed 10o (relax
slipped patella the muscles); knee rotated 35-40o laterally
RP: Joint space b/n patella & femoral condyles
BECLERE METHOD CR: 25-30ocaudad
AP AXIAL PROJECTION SS: Oblique patella free superimposition of femur
PP: Supine; knee flexed; femur 60o to long axis of
tibia; curved cassette is used HUGHSTON METHOD
RP: 0.5 in. inferior to patellar apex TANGENTIAL PROJECTION
CR: ┴ to long axis of lower leg PP: Prone; anterior surface of knee against IR; knee
SS: Intercondylar fossa, intercondylar eminence, knee flexed 50-60o; foot rested against collimator/support
joint & tibial plateau RP: Patellofemoral joint
CR: 45o cephalad
K.) PATELLA SS: Patella; patellofemoral joint
ER:
PA PROJECTION • To demonstrate subluxation of patella &
PP: Prone; heel 5-10o laterally (places patellar fx
patella // to IR) • It allows assessment of femoral condyles
RP: Midpopliteal depression
CR: Perpendicular MERCHANT METHOD
SS: Sharper image of patella (closer OID) TANGENTIAL PROJECTION
PP: Supine; both knee flexed 40o or b/n 30-90o (to
LATERAL PROJECTION demonstrate various patellar disorders); IR resting on
PP: Lateral recumbent; unaffected knee & hip flexed; patient’s shins; uses IR holding device & axial viewer
unaffected foot in front; affected knee flexed 5-10o or device
flexed not >10 (for new or unhealed patellar fx); RP: Midway b/n patellae at level of patellofemoral
femoral epicondyles & patella ┴ to IR; RP: joint
Midpatellofemoral joint CR: 30o caudad from horizontal
CR: ┴ SS: Femoral condyle; intercondylar sulcus &
SS: Patella & patellofemoral joint space magnified nondistorted patellae

PA OBLIQUE PROJECTION SETTEGAST METHOD

Medial Rotation TANGENTIAL PROJECTION
PP: Prone; knee flexed 5-10o; knee 45-55o medially Disadvantage: Extreme flexion
RP: Patella PP: Supine or prone (preferable); knee acutely flexed
CR: ┴ until patella ┴ to IR; loop bandage around ankle or
SS: Medial portion of patella free of femur foot to hold the leg in position
 LOWER EXTREMITIES
RP: Joint space b/n patella & femoral condyles CR: ┴
CR: Perpendicular (if joint is ┴); 15-20o cephalad (if SS: ¾ of femur & adjacent joints
joint isn’t ┴)
• Angulation depends on knee flexion TRANSLATERAL PROJECTION
SS: Patella; patellofemoral joint CROSSTABLE LATERAL
ER: PP: Dorsal decubitus; IR placed vertically against
• Useful for demonstrating vertical & transverse medial/lateral surface of femur;
fx of patella RP: Medial side of midfemur
• Useful for investigating articulating surfaces CR: Horizontal
of patellofemoral articulation SS: Entire femur & knee joint
ER: For patient who can’t tolerate routine lateral
SUNRISE METHOD position because of fractures or destructive disease
TANGENTIAL PROJECTION
MOUNTAIN/SKYLINE VIEW
PP: Supine/Sitting; knee flexed 40-45o
RP: Patellofemoral joint
CR: 30o from horizontal
ER: Joint space b/n patella & femoral condyles

L.) FEMUR

AP PROJECTION
PP: Supine
• Distal femur (knee included): leg rotated 5o
inward ( places limb in true anatomic
position)
• Proximal femur (hip included): leg rotated
10-15o inward (places femoral neck in profile)
RP: Midfemur
CR: ┴
SS: Femoral neck & hip joint (10-15o); knee joint (5o)

LATERAL PROJECTION
Mediolateral
PP: Lateral recumbent; affected side against IR
• Distal femur (knee included): unaffected
limb draw forward; pelvis in true lateral
position; affected knee flexed 45o; femoral
epicondyles ┴ to IR;
• Proximal femur (hip included): unaffected
limb draw posteriorly; pelvis rolled 10-15o
posteriorly
RP: Midfemur