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Mrsc1100 Notes.

Diagnostic Radiography Methods 1 (University of Newcastle (Australia))

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MRSC1100- Diagnostic Radiography Methods.

Introduction.
Plain radiography, fluoroscopy, angiography, CT and Mammography are all forms of imaging
modalities which utilize ionizing radiation. Whereas, Ultrasound and MRI use non-ionizing
radiation. For radiation protection it is essential to apply the ‘ALARA’ principle- As Low As
Reasonably Achievable. Also the time with exposure should be reduced, distance increased
and shielding increased to reduce the amount of exposure. A minimal number of projection
should be made to reduce exposure, however they need to be sufficient for diagnosis. The
appropriate exposure parameters, in regards to kVp and mas should be used to provide a
clear image. Accurate collimation should be ensured to determine the size of the field, only
exposing the required area. It is essential for patient immobilization. Before releasing a
female patient between 12-55 years to radiation exposure, it is essential to perform a
pregnancy check, with those in early stages of pregnancy at greater risk of complication than
those in late stages. Gonad shielding should also be performed, protecting the most radio-
sensitive organs of the body, including the eyes, thyroid, breasts, ovaries and testes.

CR imaging systems are those, which contain a cassette with an imaging plate (IP). Initially
there is an x-ray exposure. The plate stores information into a matrix, with the electrons
trapped in the phosphor layer. A laser reads the information, releasing light, which
generates an electrical signal. This produces a digital image, whereby a hard and soft copy
can be generated. DR imaging systems have no cassette or contain a cassette with a cord.
There initially is an x-ray exposure, with a flat panel direction capture detector array. An
electrical charge is created with the images instantly available on the computer, able to
generate a hard of soft copy.

Terminology.
Medial: Toward midline of body.
Lateral: away from the midline of the body.
Proximal: toward a reference point.
Distal: Away from a reference point.
Inferior: lower or below.
Superior: upper or above.
Cephalad or Cranial: Head.
Caudal or Caudad: tail, tail end.
Anterior: front.
Posterior: back.
Ventral: Anterior.
Dorsal: posterior.
Supine: laying on back.
Prone: laying on stomach.
PA: posterior to anterior.
AP: anterior to posterior.

The Hand.
Primary ossification centres are known as a diaphysis and are mostly developed before birth.
Secondary ossification centres are known as epiphysis, and develop after birth allowing for
growth. A bone age scan is common, to determine the skeletal age in comparison to
chronological age. It can also determine the date of appearance of particular bones and the
dates of fusion. When performing a bone age scan, an x-ray is taken of the left hand, a
uniform picture able to be compared with those in an atlas. The focus to film distance would

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be set at 76cm, with the distance measured from the x-


ray tube to the film. The greater the distance the
greater the exposure required to develop an image. The
scaphoid bone is commonly looked at, and forms
between the ages of 4 and 6.

The carpal bones of the wrist:

Indications that may be evident perform performing an x-ray include: trauma, pain, lumps,
foreign body, swelling, infection, cuts, bone age, congenital abnormalities, metabolic
diseases such as arthritis, bruising, loss of function, deformity, and reduced range of
movement (ROM). Before performing an image it is important to provide an explanation of
the process to the patient, also informing them of what they can do for you. It is important
to remove all jewelry as metal will show on the image as an artifact. If the removal is not
possible, make a note for the radiologist to ensure they understand the artifact. It is
essential to check for pregnancy if the patient is pregnant. Also provide the patient with a
lead apron across their stomach to ensure the protection from radiation against their
gonads.

PA Hand: A PA hand is performed on a 24 x 30cm cassette, which can be divided into half
with a lead strip if the hand is not too large for the halved cassette. The patient needs to sit
at the end of the table, parallel to ensure their legs are not under the table. The elbow is
required to be flexed at 90 degrees, with the hand and forearm resting on the table. Place
the palm of the hand on the cassette and slightly spread the fingers, ensuring that the long
axis of the third digit is inline with the forearm and parallel to the short edge of the cassette.
Central ray needs to be perpendicular to the cassette. The centre of the image should be
placed at the 3rd MCP joint, and should be collimated on four sides to the outer margins of
the hand.
FFD= 100cm
kVp= 52
mAs= 6
Ensure that the tops of the digits, distal radius and ulna and soft tissue are included in the
image, that phalanges and metacarpals are free of bony superimposition, there is no
rotation, no overlap of soft tissue, the radius and ulna are not superimposed the MCP and IP
joints are open and the density and contrast are optimal to visualize bone and soft tissue.

PA Oblique: A PA oblique hand is performed on a 24 x 30cm cassette, with half the cassette
divided by a lead strip. The patient is to sit at the end of the table, parallel so their legs are
not under the table. From PA position rotate the hand and wrist 45 degrees so the radial
aspect is elevated. The long axis of the third digit should be inline with the forearm and
parallel to the short side of the cassette. Centre the 3rd MCP joint, collimate on four sides to
the outer margins of the hand.
FFD=100cm
kVp= 52
mAs= 6
Ensure that the tops of the digits, the distal radius and ulna and the soft tissue are included.
Midshafts of the third, fourth and fifth metacarpals should not overlap, however some
overlap of distal heads. No overlap of distal second and third metacarpals, density and
contract optimal to visualize bone and soft tissue.

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Supplementary projections:
• PA both hands: displays metabolic diseases, arthritis evaluation, sometimes in
pediatric patients for comparisons.
• Lateral: evaluate the alignment of fracture to metacarpal in initial trauma and
progress exams, evaluate the position of orthopaedic device and foreign body
localization.
• Norgaard method: used to evaluate the presence and extend of Rheumatoid
Arthritis, opens up the surface area of metacarpal head to visualize joint space
narrowing and erosion of articular surface joint.
• AP hand
• AP oblique.

Lateral: Performed on a 18 x 24cm cassette, with the patient sitting at end of table parallel.
The elbow is flexed at 90 degrees with the hand and forearm resting on the table. Hand on
the side so radial aspect is elevated and radial and ulna styloid processes are superimposed.
Long axis of hand should be in line with forearm, and parallel to long edge of cassette.
Centre to 2nd MCP joint, collimate on four sides to outer margins of hand.
FFD= 100cm
kVp= 55
mAs= 8
Include tips of digits, distal radius and ulna and soft tissue. Distal radius and ulna are
superimposed, metacarpals and phalanges are superimposed, thumb free of motion, density
and contrast optimal to visualize bone and soft tissue.

Norgaard Method: performed on 24 x 30cm cassette, with the patient sitting at the end of
the table (legs under table). Hands and forearms resting on table, supinate hands so palms
are up and place medial aspect of hands together. Internally rotate hands 45 degrees so
radial aspect is elevated. Extend fingers and abduct the thumbs, long axis should be in line
with forearm and parallel with short edge of cassette. Centre between hands and level of
MCP joints, collimate four sides to outer margins of hands.
FFD= 100cm
kVp= 52
mAs= 6
Include tips of digits, distal radius and ulna and soft tissue. Midshafts of 2-5th MC’s and base
of phalanges should not be superimposed. MCP joints should be open, thumb free of
superimposition, density and contrast optimal to visualize bone and soft tissue.

PATHOLOGY ABCS:
A= alignment of bones
B= bone margins and densities.
C= cartilage and joints
S= soft tissues

Types of fractures:
Complete, incomplete, closed (in skin),
open or compound, displaced, un-
displaced (need re-alignment),
compression fracture (spine), depressed
(indentation in skull), stress fracture,
pathological (metastases in bone causes weakness and fracture).

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Trauma to the wrist can be seen through: fractures, dislocations, fracture/dislocation,


foreign bodies and soft tissue injuries. Phalanges are the most common site of fracture in
the skeleton. Metacarpal fractures account for 36% of hand/wrist trauma, being the 5th most
common form of fracture. A boxers fracture is a neck fracture in the 4th or 5th metacarpal,
with anterior angulation of the head, and shortening and
rotation of the distal fragment. A metacarpal shaft fracture is
most common in the 3rd or 4th metacarpal, and dorsal
angulation is evident.

Boxers fracture,
and shaft
fracture.

Dislocations within the hand can either be simple or complex.


They can either be easily reduced or need open reduction. The
most common occur in the thumb, index finger and little finger.
X-rays are used to determine if a fracture is present, often
scanning before and after the relocation of the bone to
determine the extent or time of the fracture.

X-rays are used in foreign body localization to


determine the type of object or material that
has entered the body. It is important to mark
the entrance and exit sites. Two projections are
the minimum at 90 degrees, and tangential
projections are used, these are at right angles
to the foreign body.

Arthritis is joint inflammation which is characterized by pain, swelling, heat, redness and
limitation of movement.
Rheumatoid Arthritis: this is a chronic inflammatory disease of connective tissue, with an
unknown etiology. Inflammation of synovial membrane occurs, and increased synovial
exudate leading to the thickening of the membranes and swelling of the joints, causing
erosion of the articular cartilage and underlying bony cortex. Disease progresses proximally
towards the trunk until practically all joints in the body are involved. It generally occurs
between the ages of 30-40 years. It is 3 times more common in women.

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Early signs include: soft tissue swelling, periarticular osteoporosis


(bone turns from white to black around the joint areas),
destruction at edges of the joint, and joint space narrowing, with
the cartilage disappearing causing smaller gaps in the joints.

Late signs include: osteoporosis (appearing as black


bones) and cartilage and subchondral bone
destruction.

Osteoarthritis: a disease of cartilage, resulting from a


non-inflammatory deterioration of the joint cartilage
that occurs with the normal wear and tear of ageing.
It is the most common form of arthritis, and is also
known as degenerative joint disease (DJD).
Asymptomatic usually until 50+ years, with loss of
joint cartilage and reactive new bone formation. Bone
on bone formation occurs, which deposits calcium
leading to denser bones, with the potential for spurs
to form which appear whiter and more dense in x-
rays. Predominantly effects weight bearing joints.

RA involves soft tissue swelling, osteoporosis, joint erosion, joint space narrowing and
decreased exposure. OA involves cartilage thinning, joint space narrowing, small bony spurs,
increasingly dense articular end and increase exposure.

The Fingers and Thumb.

The thumb includes the distal and proximal phalanx, sesamoid, metacarpal and trapezium,
whereas the phalanges 2-5 include distal, middle and proximal phalanx, and the metacarpal.
The joints include the distal interphalangeal joint, proximal interphalangeal joint,
metacarpophalangeal joint, thumb interphalangeal joint and thumb carpometacarpal joint.
Indications of a pathology within the fingers and thumb include: trauma, pain, lumps,
foreign body, swelling, infections, cuts, bruising, loss of function, deformity and reduced
range of movement.

For patient preparation it is essential to provide for an explanation, remove jewellery, check
for pregnancy if female and between 11years and 55years. Also provide the patient with a
lead apron to shield their gonads.

For the fingers 2-5 there are three projections which can be taken.

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PA: A PA projection is required to be taken on a 18 x 24cm


cassette, which can be divided into three with lead strips. The
patient is required to sit at the end of the table, parallel to the
end so legs are not under the table. The elbow should be flexed
at 90 degrees, with the hand and forearm resting on the table.
Place the palm of the hand down on the cassette and slightly
spread the fingers, with the long axis of the digit parallel to the
short edge of the cassette. Centre to the PIP joint, and collimate
on four sides to the outer margins of the digit. The FFD should
be 100cm, kVp around 50, mAs around 5. Ensure that the tip of
the digit to distal metacarpal including soft tissue is imaged. The
digit should be free of superimposition, no rotation should be evident, MCP and IP joints
should be open and density and contrast optimal to visualize the bone and soft tissue.

Also for 2nd and 3rd finger extension of arm may be required for a more comfortable position,
with rotation of cassette (ensure finger tips are imaged at one end). Some cases will require
an AP rather than a PA, placing the injured phalanx parallel to the cassette, with the beam
perpendicular to the phalanx and cassette.

PA Oblique: A PA oblique projection should be taken on a 18x24cm cassette.


Using the next third of the cassette ensure the patient is sitting at the end of
the table with their legs parallel to ensure their legs are not under the table.
Flex the elbow at 90 degrees resting the hand and forearm on the table.
From PA position, rotate the hand and wrist to 45 degrees so the radial
aspect is elevated, with the long axes of the digit parallel to the short edge
of the cassette. Centre to the PIP joint, collimating four sides to the outer
margin of the digit. FFD should be 100cm, kVp 50 and mAs 5. The symmetry
on the image is lost. Be sure to put the finger under investigation as close to
the cassette as possible, supporting with the sponge. Include the tip of the
digit to the distal metacarpal, including the soft tissue and make sure the
digit is free of superimposition. MCP and IP joints should be open, digit
should be at 45 degree angle, and density and contrast should be optimal.

Lateral: a lateral projection should be taken on a 18x24cm cassette, using the last third of
the cassette. The patient needs to sit parallel at the end of the table so their legs are not
under the table. The elbow should be flexed at 90 degrees, and hand and forearm resting on
the table. The hand is on the side, with the 2nd and 3rd fingers the radial aspect placed on the
cassette and 4th and 5th fingers the ulna aspect is placed on the
cassette. Fold the other digits into a fist, with the long axis of the digit
parallel to the short edge of the cassette, Central ray should be
perpendicular to the cassette, centering to the PIP joint. Collimate on
four sides to outer margins of the digit. FFD should be 100cm, kVp 50
and mAs 5. Tip of digit to distal metacarpal including soft tissue should
be imaged, MCP and IP joints open. A concave position of the anterior
shaft of the phalange should be evident, least possible overlap of
other digits, digit free of motion and density and contrast optimal. To
ensure finger remains straight, hold sponge in opposite hand and
push on finger under examination to ensure a true lateral position.

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Three thumb projections:

AP/PA: AP and PA are both taken on 18x24cm cassettes which are


divided into three strips, requiring the patient to sit parallel with the
table to ensure their legs are not under. The elbow is to be flexed at
90 degrees and the hand and forearm resin on the table. For the AP
view, the hand should be rotated internally so the pal, of the hand is
facing away from the cassette, and for the PA view the hand should
be on the side so the radial aspect is elevated. The other fingers
should be moved away and the long axis of the thumb should be
parallel with the short edge of the cassette. Centre to the MCP joint,
and collimate four sides to outer margins of the thumb. FFD should be
100cm and kVp 50 and mAs 5. For the AP position rotation of the cassette
may be required and extension of arm for immobilization and comfort
ability. Ensure that collimation is relatively wide so that the carpal bones are
not cut out of the image. The tip of the thumb to the trapezium including
the soft tissue should be included, with the thumb free of superimposition.
Thumb is free of motion, MCP and IP joints are open and no rotation should
be evident. Density and contrast should be optimal to visualise the bone
and soft tissue.

PA Oblique: PA oblique should be taken on an 18x24cm cassette,


using the next third of the cassette, with the patient sitting parallel
with the table so the legs are not under the table. The elbow should
be flexed at 90 degrees, with the hand and forearm resting on the
table. Place the hand flat on the cassette palm surface down as in PA
position, turning the fingers to an ulnar perspective. The long axis of
the thumb should be parallel to short edge cassette, centring to the
MCP joint. Collimate on four sides to outer margins of thumb. FFD is
100cm, kVp 50 and mAs 5. The tip of the thumb to the trapezium
including soft tissue should be imaged, the thumb should be free of
superimposition, free of motion, MCP and IP joints open and the
thumb at 45 degree angle. Density and contrast should be optimal.

Lateral: performed on a 18x24cm cassette, using the last third of the


cassette with the patient in the same sitting position. Flex the elbow at 90
degrees and hand and forearm resting on the table. From the PA oblique
position, slightly raise the fingers rolling hand onto the radial side, with
the long axis of the thumb should be parallel to the short edge of the
cassette. Centre of the MCP joint, collimating four sides to the outer
margins of the thumb. FFD should be 100cm, kVp 50 and mAs5. Tip f the
thumb to trapezium should be included, MCP and IP joints open, true
lateral position including the concave appearance of anterior surface of
the proximal phalanx and MC, thumb free of motion and density and
contrast should be optimal.

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Pathology:

Avulsion fracture:

Thumb Fractures:

Bennett Fracture: involves the


articulation surface. Shaft is displaced
dorsally and radially.

Rolando Fracture: involves the


articulation surface. Comminuted
Bennett.

Winterstein Fracture: most common through the transverse plane, does not involve
articulation surface.

Wrist and Scaphoid.

The carpal bones include: scaphoid (4-6years), lunate


(2-4 years), triquetrum (2-3 years), pisiform (8-12
years), hamate(2-4 months), capitate(1-3 months),
trapezoid (4- 6 years) and trapezium (4-6 years). Other
bones within the area include the base of the 1st-5th
metacarpals, radius, ulna and radial and ulna styloid
processes. The joints within the area also include the
CMC, midcarpal, radiocarpal, radioulnar and intercarpal
joins. The radial styloid process is 1cm distal to the ulna
styloid, and the carpal bones form rows, as seen in the
image.

Fat pads are evident within the wrist area, which can be useful when
searching for a fracture or other pathology within the area. If a fracture is
present a deviation in the fat pad will be evident. On an x-ray they are
displayed as a black line next to the bone. A pronator quadratus fat line is
a thin straight fat line which always is visible in the distal forearm on the
lateral wrist/forearm views. If fractured, bleeding will displace the fat pad,
forcing it to bulge.

Indications of injury to the wrist/scaphoid area include: trauma (FOOSH),


pain, lumps, foreign body, swelling, infections, cuts, brusing, los of
function, deformity and reduced range of movement.

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When preparing the patient for examination provide an explanation of the examination,
remove jewellery, check for pregnancy if female and provide a lead apron to cover gonads.

There are three wrist projections:

PA: A PA wrist projection is taken on a 24x30cm cassette which is


divided into three sections with the patient sitting parallel to the table.
Flex the elbow at 90 degrees with the hand and forearm resting on the
table. Place the palm of the hand down on the cassette and curl fingers
into a fist. The long axis of the forearm should be parallel to the short
edge of the cassette. Centre midway between the radial and ulna styloid
processes, collimating four sides to outer margins of the wrist. The FFD
should be 100cm, kVp 55 and mAs 6. The mid metacarpals to the distal
third of the radius and ulna including soft tissue should be imaged. No
rotation should be evident, separation of distal radius and ulna should
be evident and density and contrast should be optimal to visualise the
bone and soft tissue. APPLY WES (wrist, elbow shoulder lined up).
An AP can also be performed, displaying pisiform well.

PA Oblique: PA oblique should use the 24x30cm cassette, with


the next third of the cassette being used with the patient in
the same position. The elbow should be flexed at 90 degrees,
with the hand and forearm resting on the table. From PA
position, rotate the hand and wrist 45 degrees so the radial
aspect is elevated. The long axis of the forearm should be
parallel to the short edge of the cassette. Centre midway
between the radial and ulna styloid processes and collimate
dour sides to the outer margins of the wrist. FFD should be
100cm, kVp 55 and mAs 6. Mid metacarpals to distal third of
radius and ulna including soft tissue should be imaged,
trapezium and scaphoid should be well visualized, wrist at 45
degree angle, with the ulnar head partially superimposed by
the distal radius, superimposition of bases 3rd-5th MC’s and
density and contrast should be optimal. APPLY WES.

Lateral: Lateral projection should be taken on a 24x30cm cassette on


the final third of the cassette, with the patient sitting in the same
position. Flex the elbow at 90 degrees with the hand and forearm
resting on the table. Hand should be placed on the side so the ulnar
aspect is in contact with the cassette. Superimpose the radial and ulna
styloid processes, extending the digits and placing the thumb in a PA
position. Long axis of the forearm should be parallel to the short edge
of the cassette. Centre the radial styloid process and collimate on four
sides to the outer margins of the wrist. FFD should be 100cm, kVp 55
and mAs 6. APPLY WES. (can extend arm and rotate cassette). Mid
metacarpals to the distal third of the radius and ulna including soft
tissue should be imaged, with the radius and ulna superimposed, metacarpals 2-5
superimposed, thumb free of motion and density and contrast optimal.

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There are 4 scaphoid projections. PA with ulnar deviation (refer to wrist PA) allowing for the
radial joints to be open for investigation. PA oblique with ulnar deviation, which is the same
as a normal PA with the hand tilted to a 45 degree angle. A lateral position the same as a
wrist lateral position. The final view is called a stecher view, this is where the patient is
positioned as for a PA with ulnar deviation, however the central ray is angle proximally to 20
degrees. It is centred over scaphoid and collimated to the carpal region. This allows for
adjacent carpal interspaces to be opened and elongates scaphoid. All of these views are
taken on an 18x24cm cassette, with the cassette divided into 4. Positioning is the same as
wrist projections, however it is centred over the scaphoid and collimated to the carpal
region.

Macroradiography: this is whereby the cassette is placed on the ground beneath the table,
inline with the x-ray collimation. The table is then slide across this projection and the patient
positioned correctly inline with the area to be imaged. The exposure may need to be
increased, however the image will have increased magnification. Has been replaced with CT
and MRI recently.

Pathologies within the wrist are common injuries, with


greenstick fractures common in infants. These are incomplete
fractures. To identify these fractures it is essential to look for
fat pad displacement.

Old fractures healing can be identified


through callus formation around the fracture, which appears to be
whitening around the fracture location. If the healing of the bone in
children appears to be distort the body will adjust in growing to
account for this difference, however in adults will result in a shorter
arm.

Majority of scaphoid fractures occur through the waist or middle, (70%). The distal third
(20%) and the proximal third (10%). However waist breaks can become concerning as
vascularization may be cut off, resulting in the death of the bone. Scaphoid fractures are
difficult to identify so the patient may be sent home in plaster for a week and reexamined or
a CT, MRI or nuclear medicine test may be performed.

Lunate fractures are the second most likely carpal fracture.


Keinbock’s disease (IMAGED) is also known as avascular necrosis
of lunate. It appears as dense, chalky white, sclerotic. It is cystic
degeneration, fragmentation, collapse, los of carpal height and
scaphoid rotation. Lunate dislocation may occur whereby
scaphoid no longer resides in the semi-circle depression of the
lunate.

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Carpal instability may be evident as a result of carpal


ligament injury. This can cause partial or complete
ligament rupture, with abnormal joint space widening.
Perform an AP wrist with fist clenched.

Carpal tunnel syndrome is a nerve entrapment including


the median and ulna nerves. MRI and ultrasound are
the predominant modalities to assess this condition.
However, x-rays may be used to rule out abnormal
calcification and bony changes in the carpal sulcus
which may impinge on the median nerve. Also this
perspective may be helpful in assessing fractures of
Hook of hamate, pisiform or trapezium.

Colle’s Fracture- often occur from falling on an outstretched hand,


resulting in dorsal displacement. Can result in radial and/or ulna
styloid fracture.

Smith’s Fracture: fall on the back of the hand or


direct blow, resulting in ventral displacement. Can result in the fracture of
distal radius and extension into radioulnar joint.

Barton’s fracture: intra-articular fracture, at the


dorsal margin of the distal radius. Fracture in the
coronal plane.

Hutchinson’s Fracture: intra-articular fracture, at the lateral


margins of the distal radius. Sagittal orientation.

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The Forearm and Elbow.


The forearm and elbow includes: radius, ulna, radial and ulna
styloid processes, head, body or shaft, ulnar notch, radial notch,
radial tuberosity, radial neck and the radioulnar joints both distal
and proximal.

The elbow consists of: trochlear, capitulum,


medial epicondyle, lateral epicondyle,
humeral shaft and olecranon fossa. The
radius articulates with the capitulum and
the ulna with the trochlea. The elbow also
includes the coronoid process and
olecranon process.

Within the elbow there are both anterior and


posterior fat pads, as well as a supinator fat stripe.
When these fat pads are winged (directed outwards)
this is evidence of a fracture or other pathology.

Within the elbow there are several secondary


ossification centres. The capitulum is one, appearing
between 4 month and one year, although fusing
between 13-16 years. The trochlea is another
appearing at around 10 years and fusing also between
13-16. The radial head appears between 4-6 years and
fuses between 13-16 years. The olecranon appears
between 8-10 years and is fused between 13-15
years. The medial epicondyle appears between 3-6
years and is fused between 13-16 years. The lateral
epicondyle appears between 9-12 years and is fused
also between 13-16 years.

Indications of a pathology within the elbow include: trauma/ fall (FOOSH), pain, lumps,
foreign bodies, swelling, infections, cuts, bruising, loss of function, deformity, and reduced
range of movement.

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When preparing the patient for x-ray examination it is essential to provide them with an
explanation of the process, remove the jewellery within the exposed area, check for
pregnancy if female and provide a lead apron to cover the gonads.
Elbow projections are performed diagonally across the cassette, allowing for the complete
anatomy to be included in the x-ray field. A 24x30cm cassette should be used not bigger, as
the smaller the cassette the better the detail.

AP Forearm: This projection should be


performed on a 24x30cm cassette, dividing
the cassette into two for children and using
one per view for adults. The patient should sit
parallel to the end of the table, extending
their elbow. The WES principle should apply
with the palm of the hand supinated. The long
axis of the forearm should be diagonal across
the cassette, centring to the middle of the
forearm. Collimate on four sides to the outer
margins of the forearm. The FFD should be
100cm, kVp 55, mAs 8 using fine focus and no grid. The proximal carpal row to distal
humerus and soft tissue should be included in the image, with both joints included in
the image. No rotation should be evident. Separation of the distal radius and ulna should be
evident and the humeral epicondyles should be seen in profile (bumping out). The radial
head, neck and tuberosity slightly superimposed by the ulna, and the density and contrast
should be optimal to visualize bone and soft tissue.

Lateral Forearm: This projection should be


performed on a 24x30cm cassette, using
the other half for children of using a new
cassette for an adult. Patient is to sit
parallel to the end of the table, and the
elbow flexed at 90 degrees. The WES
principle should apply, with the wrist,
elbow and shoulder all horizontally aligned.
The hand should be on the side so the ulna
is placed in contact with the cassette, with the long axis of the forearm diagonal
across the cassette. The central ray should be perpendicular to the cassette,
centering to the middle of the forearm. Collimate on four sides to the outer margins
of the forearm. FFD should be 100cm, kVp 55, mAs 8 and fine focus and no grid should be
applied. Proximal row of carpal bones to the distal humerus should be included in the image
as well as soft tissue. Distal radius and head of ulna are superimposed, wit the humeral
epicondyles also superimposed. Radial head should superimpose the coronoid process, and
the radial tuberosity should be seen in profile. Both joints should be included on the film,
with the density and contrast optimal to visualise bone and soft tissue.

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If the patient has pathology present and the previous two views are impossible, therefore
we can do a PA wrist with a lateral elbow and a lateral wrist with an AP elbow. This is known
as the modified forearm series. Still apply WES.
PA wrist
and lateral
elbow.

Lateral
wrist and
AP Elbow.

In severe cases a horizontal beam can be used to perform the lateral projection. This is
required to include at least one joint on the cassette. Use an even surface under the arm of
sponges to elevate the arm being exposed, ensuring that the complete anatomy is included
in the image.

AP Elbow: This projection is to be taken on


a 24x30cm cassette, dividing the cassette
into two halves using lead strips. Patient is
to sit parallel to the end of the table, with
their elbow extended. WES should apply,
with the long axis of the forearm parallel to
the short edge of the cassette. The central
ray should be perpendicular to the cassette,
and centred midway between the medial and lateral epicondyles. Collimate on
four sides to the outer margins of the elbow. FFD should be 100cm, kVp 58, mAs
10 and fine focus and no grid applied. The distal third of the humerus to the
proximal third of the radius and ulna should be included in the image also soft
tissue. No rotation should be evident, and the humeral epicondyles should be
visualized in profile. The radial head, neck and tuberosity should slightly superimpose the
proximal ulna. The elbow joint should be open and the density and contrast optimal to
visualise bone and soft tissue.

AP External Oblique Elbow: This


projection should be taken on a
24x30cm cassette, using the next half of
the cassette. The patient should sit
parallel to the end of the table with
their elbow extended. The WES
principle should still apply, with the
long axis of the forearm parallel to the
short edge of the cassette. Rotate the
arm alterally 40-45 degrees, elevating the ulna side. The central ray should be
perpendicular to the cassette, with the centre midway between the medial and
lateral epicondyle. Collimate on four sides to the outer margins of the elbow.
FFD should be 100cm, kVp 58 and mAs 10, with fine focus and no grid applied.
The distal third of the humerus to the proximal third of the radius and ulna including soft
tissue should be imaged. The radial head, neck and tuberosity projected free of

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superimposition of the ulna, with the elbow joint open. Density and contrast should be
optimal to visualise bone and soft tissue.

Lateral Elbow: This projection should be


performed on an 18x24cm cassette, with the
patient sitting at the end of the table parallel,
flexing their elbow at 90 degrees. WES should
apply, with the long axis of the forear parallel
to the long edge of the cassette. Either have
the hand on the side so the ulna aspect is
placed in contact with the cassette, or have
the hand PA and slightly elevated off the
table. Central ray should be perpendicular to
the cassette, with the centre to the lateral
epicondyle. Collimate on four sides to the outer margins of the elbow. FFD
should be 100cm, kVp 58, mAs 10 and fine focus and no grid applied. The
distal third of the humerus to the proximal third of the radius and ulna
including soft tissue should be imaged. Humeral epicondyles superimposed, radial head
superimposing the coronoid process, radial tuberosity seen in profile (if hand is pronated),
elbow joint open and contrast and density optimal.

AP Partial Flexion Elbow: This position is the same


as for AP, however only the humerus is in contact
with the cassette. Support the elevated forearm
and centre over the middle of the elbow joint.
Used an 18x24cm cassette, providing a good view
for distal humerus.

Also you can position the same for


AP however only the radius and
ulna are in contact with the
cassette. The patient should be
standing or seated high, with the
centre of the field over the elbow
joint.

AP Internal Oblique Elbow: Position as for


AP elbow, however internally rotate or
pronated the hand. This will project the
coronoid process free of superimposition
from the radial head.

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Axial Elbow: This is the same position as for AP,


however the elbow is flexed and the humerus is in
contact with the cassette. Centre a little above
the epicondyles. Central ray perpendicular to the
cassette to demonstrate distal humerus and
olecranon process.

Also, to demonstrate the proximal radius and


ulna, as well as the elbow joint more open
than the previous projection, make the
central ray perpendicular to the forearm.

Radial Head Capitulum Elbow: Patient positioned as


for a lateral elbow, however angle the central ray 45
degrees towards the shoulder (medially). This
projection, projects the radial head free of
superimposition.

Pathologies of the Forearm and Elbow.

Dinner Falk Fracture.

Galeazzi Fracture- Fracture of the shaft of the radius


and posterior dislocation of the ulna at the wrist.

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Supracondylar Fracture- Frequently seen in children 3-12


years. Vascular complication usually also occurs, requiring
immediate surgery.

Transcondylar Fracture.

Epicondylar Fracture.

Capitellar Fracture.

Radial Fracture.

Ulna Fracture.

Dislocation.

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Triceps Avulsion Fracture.

Osteochondritis Dissecans- A joint disorder in which a


piece of cartilage and neighbouring bone tissue become
dethatched from an articular surface. Elbow and knee
are the most common site of the injury. Commonly
involved in throwing sports, with plain films often little
value in staging. In children comparisons are useful as it
may be a congenital growth disorder. MRI and CT are
useful.

The Humerus.

The anatomy within images displaying the humerus includes: humerus, radius, ulna, scapula,
clavicle, glenohumeral joint, humeroulna joint and humeroradial joint. On the humerus the
prominent anatomical features include: the head, greater tubercle, lesser tubercle,
trochlear, capitulum, medial epicondyle, lateral epicondyle, humeral shaft and olecranon
fossa. Also evident is the anatomical neck, surgical neck and intertubercular groove.

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Additional secondary ossification centres to those


evident within the elbow include: the humeral head
which appears between 1-6 months and fuses between
15-20 years, the greater tubercle which appears
between 6 months and one year and fuses between 15-
20 years, and the lesser tubercle which appears
between 3-5 years and fuses between 18-20 years.

When examining the humerus and including the elbow


and shoulder joints, the difference in thickness of the
proximal end of the humerus to the distal end should be considered. To compensate for this
we use a wedge filter which can be placed in the LBD. The thin side of aluminum should be
placed at the end of the shoulder and the thicker side at the elbow.

Indications of evident pathologies include: trauma/ fall (FOOSH), twisting, direct blow,
pathological, non-accidental injury (NAI), pain, lumps, foreign body, swelling, infections, cuts
bruising, loss of function, deformity and reduced range of movement.

When preparing the patient for examination provide them with an explanation of the
process of examination, remove all their jewellery, have the patient take everything off from
the waist up and place on a gown, place a lead gown across the gonads.

The bucky is a sliding metal tray that holds the film. In front of the tray is a grid which
absorbs most of the scatter radiation before it hits the cassette. Scatter radiation increases
with a higher kVp, and degrades the detail of the image.

AP Humerus: This projection should be performed on


a 35x43cm cassette, with one cassette per view. The
patient will be standing with their back to the bucky,
with their elbow extended and the hand supinated.
The affected shoulder, elbow and forearm should be
in contact with the bucky. The humerus needs to be
moved out from the body and the long axis of the
humerus should be diagonal across the cassette. In
this projection respiration may need to be suspended.
The central ray should be perpendicular to the
cassette and centred to the middle of the humerus.
Collimate on four sides to the outer margins of the
humerus. FFD should be 100cm, kVp 70, mAs 20.
Broad focus should be used and filter, and a grid.
However is cassette is placed outside bucky use no
grid and 60kVp and 18 mAs. The proximal radius and
ulna to the acromion including soft tissue should be
imaged. Both joints should be included on the radiograph, with no rotation
evident. The greater tuberosity should be seen in profile. Minimal superimposition
of the humeral head with the glenoid, humeral epicondyles visualized in profile, humerus
free of superimposition and density and contrast optimal to visualise bone and soft tissue.

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Lateral Humerus: This projection should be


performed on a 35x43cm cassette, using a
new cassette. The patient should be
standing facing the cassette, with their
elbow flexed at 90 degrees (hand on hip).
The affected shoulder, humerus and
forearm should be in contact with the
bucky. Oblique the body 45 degrees away
from the bucky and move the humerus out
away from the body. The long axis of the
humerus should be diagonal across the
cassette. May need to suspend respiration. The central ray is perpendicular to
the cassette, with the centre in the middle of the humerus. Collimate on four
sides to outer margins of humerus. FFD should be 100cm, kVp 70, mAs 20 using broad focus,
grid and filter. If no grid is used, 60kVp and 18mAs. Proximal radius and ulna to acromion
including soft tissue should be images. The elbow should be lateral, with the humeral
epicondyles superimposed, and the radial head superimposing the coronoid process. Lesser
tubercle in profile partially superimposing lower portion of glenoid, humerus free of
superimposition, both joints included and density and contrast optimal.

AP Shoulder: This projection should be performed on a


24x30cm cassette, using one cassette per view. Patient should
be standing with their back to the bucky, extending their elbow
and supinating their hand. Affected shoulder, elbow and
forearm should be in contact with the bucky. Move the
humerus away from the body, with the long axis of the humerus
parallel to the short edge of the cassette. Suspend respiration.
Central ray should be perpendicular to the cassette, centre to
the coracoid process. Collimate on four sides to outer margins
of the shoulder. FFD 100cm, 70 kVp, 20mAs, using broad focus
and grid. The proximal humerus, clavicle and scapula including
the soft tissue should be imaged. No rotation should be
evident, greater tuberosity seen in profile, minimal
superimposition of humeral head with glenoid, humerus free
of superimposition and density and contrast optimal.

External Rotation: good view for tubercles.

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Internal Rotation: displays bicipital groove.

Neutral: displays greater tubercle.

Lateral Shoulder: This projection


should be performed on a 24x30cm
cassette, using a new cassette. The
patient should be standing facing the
bucky, flexing their elbow and placing
their hand on their hip. Affected
shoulder and humerus should be in
contact with the bucky. Oblique body
until the body of scapula is at right
angles to the bucky, with the long axis
of the humerus parallel to the short
edge of the cassette. Suspend
respiration. Central ray is perpendicular to the cassette, with the centre 5cm below the top
of the shoulder to the lateral border of the scapula. Collimate on four sides to outer margins
of the shoulder. FFD is 100cm, 70kVp, 20mAs, applying broad focus and gird. The proximal
humerus, clavicle and scapula including the soft tissue should be imaged. The medial and
lateral border of the scapula superimposed, coracoid and acromion processes visible,
scapula separated from ribs, humerus should superimpose the base of the Y, the density and
contrast should be optimal to visualise bone and soft tissue.

In severe cases of shoulder injuries a horizontal beam can be used to perform a lateral
projection.

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Humerus Pathologies:

Bone cysts: fluid filled with a wall of fibrous tissue.


Most are asymptomatic, with the cause unknown,
however can lead to pathological fracture.

Osteogenic sarcoma (osteosarcoma): occurs at the end of a long bone,


with the tumour consisting of osteoblasts which produce calcified bones.
Age usually occurs around 10-25 years. Pain and swelling will be evident.
Pulmonary metastases develop early, presenting a sun ray beam pattern.
Appears to be radio-opaque (white or dense).

Multiple Myeloma: malignancy of


plasma cells, resulting in bone
destruction. Most common
between 40-70 years of age,
attacking the intramedullary canal.
Multiple punched out osteolytic
lesions scattered throughout the
skeletal system, skeletal surveys are
required to be performed.

Bone Metastases: most common


malignant bone tumours, spread through
the blood, lymphatic’s or directly. Primary
sites include: breast, lung, prostrate,
kidney and thyroid.

Osteoporosis: generalized or localized deficiency of bone


matrix. The mass of bone per unit volume is decreased in
amount but normal in composition. Bone is more lucent
(darker) sometimes will require a decrease in kVp.
This will present with cortical thinning, irregularity an
resorption of the inner surface, as the bone density increases
the cortex appears as a dense prominent thin line.

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Anatomical Neck fracture: Surgical Neck Fracture.

Greater and lesser tubercle fracture. Fracture +/- dislocation.

Humeral Shaft Fracture. Spiral Fracture.

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The Chest.

The anatomy of the chest include the 12 ribs, with number 11 and 12 known as floating ribs,
as well as their costal cartilages and intercostal spaces. The spine is also included within the
chest radiographic area, including 7 cervical vertebra, 12 thoracic and 5 lumbar. The sternum
is also evident, including all three sections: the manubrium, body and xiphoid process. A
chest radiograph will also include scapulae and clavicles. Within a chest radiograph there are
a number of joints evident including: the sternoclavicular joint, acromioclavicular,
costotransverse, costovertebral and sternocostal.

Some people obtain a cervical rib which will most


commonly occur from C7. It is an extra rib which can
either occur on both sides or just on one side.

When performing a chest x-ray it is important to rotate the shoulders forward, as this allows
for the scapula to be out of the lung field. Rolling of the shoulder reduces the
superimposition cased by the scapula.

Within the chest there are a number of passages evident. The nasopharynx passage is
evident from the nose to the carina whereby it joints the oropharynx which runs from the
mouth. Also evident is the laryngopharynx the trachea and the esophagus (more posterior
to the trachea). The passage from the external environment is as follows: the trachea leads
to the carina, which leads to the right and left main bronchus, into the bronchi, then the
bronchioles, then the alveoli and then into the lungs which has an apex, hilum and base, as
well as costophrenic (middle where heart lies) and cardiopherenic angles (diaphragm). The
right lung consist of 3 lobes and 2 fissures whereas the left lung consists of 2 lobes and 1
fissure. The parietal pleura is the pleura which surrounds the ribs and chest cavity, whereas
the visceral is the pleura which surrounds the lungs. Fluid is present in between these two
layers.

Half of a diaphragm is known as a


hemidiaphragm, with the right hemidiaphragm
4cm superior to the left. Within the abdomen
often evident on a radiograph is a left gastric
bubble and a right liver. Air will rise to the top of
the chest cavity to the apex of the lungs, and fluid
will depress to the fundus of the stomach. On a
lateral position, the left hemidiaphragm is lower
anteriorly and higher posteriorly. The
hemidiaphragms do not superimpose 100%
accurately.

During inspiration the lung increases with size,


therefore the darker portion of the image is
increased, and the diaphragm depresses.

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The mediastinum is the central portion of the chest x-ray which


contains the heart, great vessels (thoracic aorta, pulmonary
arteries and pulmonary veins), the trachea, esophagus, thymus,
lymphatic’s and nerves.

As displayed in the diagram he


mediastinum can be divided into three
different compartments: the anterior
compartment containing only a lung,
the middle compartment containing the
mediastinum and the posterior compartment containing the spine,
some lung and the thoracic aorta.

On the right side of a chest there are three structures which develop a heart shadow. There
are brachiocephalic vessels, SVC and the right atrium. On the left hand side there are five
structures which develop a heart shadow: brachiocephalic vessels, aortic arch, pulmonary
artery, left atrial appendage and left ventricle.

Cardiothoracic ratio: this is performed on a PA chest, and is a measure of the maximum


transverse diameter of the heart, divided by the maximum transverse diameter of the chest
(inside the ribs). In an adult greater than 50% is abnormal, and in a child greater than 66% is
abnormal.

Indications of injury within the chest area include: pain, cough/wheeze, swallowed/inhaled
foreign body, infections, heart disease, rib fractures, shortness of breath, smoker, pre op
and trauma. Before commencing the radiographic examination it is essential to provide the
patient with an explanation of the exam, remove the jewellery present, have the patient to
take everything from the waist up and place a gown with the split at the back on, check for
pregnancy if female, provide the patient with a lead gown around their waist and be careful
of long hair which will show as an artifact.

The bucky or stationary grid is a sliding metal tray which holds the film. In front of the tray
there is a grid, the grid absorbs most of the scatter radiation before it hits the cassette.
Stationary grid is able to be taken anywhere with you.

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Automatic exposure control: There are three ionizing chambers between the grid and the
cassette. During an exposure the air in the chamber is ionized permitting a current to flow.
The current changes a capacitor, when the capacitor reaches a pre determined level the
voltage is used to terminate the exposure. On the device you are required to set the kVp
however not the mAs. For a PA projection the two lateral chambers will be selected,
however for the a lateral projection the central chamber will be selected. On a normal
patient the density should be set at 0, and for a small or larger patient the density should be
set at -1 or +1 respectively.

PA Chest: A PA chest is performed on a 35x43cm


cassette, using one cassette per view. The patient
should be standing facing the bucky, with their
hands on their hips or around bucky to rotate their
shoulders forward, slightly raise the chin. Chest
should be in contact with the bucky. Align the
midsaggital plane to the bucky and expose on
inspiration. Align the x-ray tube to the bucky with
the cassette 3cm above the acromioclavicular
joints. Central ray should be perpendicular to the
cassette, and centre to T7. Collimate on four sides
to the outer margins of the chest. FFD should be
180cm, kVp 110 or 85, mAs 2-10 or AEC two lateral
chambers and use broad focus and grid. It is important for
this projection that the marker is flipped. On a PA
projection of the chest both lungs from the apices to
costophrenic angles and ribs including the soft tissue
should be included. No rotation should be evident with
the sternal ends of clavicles equidistant from the VC and
the trachea in the midline. The scapulae should be
projected outside the lung fields and the heart and
diaphragm displaying sharp outlines. 5cm of lung apex
above the clavicles and 10 posterior ribs seen above the
diaphragm. There should be a faint shadow of ribs and
vertebrae seen through heart shadow.

AP Supine: Ensure that the patient is lying completely flat on their back. Slide the cassette
under their back. There should be around 3cm of cassette above the shoulders and the
distance between the chest wall and edges of the cassette should be about the same on
either side. Check the distance of the x-ray tube from the cassette and compensate for any
shorter than usual FFD in your exposure. Angle the tube slightly, towards the patients feet-
the face of the collimator should be approximately parallel to the sternum. The angle should
be between 5-10 degrees.

AP Semi Erect: ensure that the patient is sitting bolt


upright, placing the cassette behind the patients
back. If necessary place a pillow behind the cassette
to keep the patient in contact with the cassette. The
top of the cassette should be approximately 3cm
above the shoulders and the sides of the cassette
should be approximately equidistant from the chest
wall on either side. Check that the patient is not

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rotates to either side. You will need to angle the central ray
downwards, parallel to the sternum. Check that the FFD is
correct and centre to the cassette, just below the sternal
angle. If you have a kyphotic patient and you are doing
them AP, do not angle down as much, as you need to use
the divergent properties of the x-ray beam to open up the
chest and minimize the lung/chin superimposition.

Lateral Chest: this projection should be taken on a 35cmx43cm


cassette, using a new cassette. The patient should be standing with
their left side of the body against the bucky. Hands should be placed
on their head and the shoulders in contact with the bucky. Bend the
patient forwards a little with their chin elevated. The midsaggital
plane should be parallel to the film, with the posterior ribs
superimposed. Expose on inspiration. Align the x-ray tube to the
bucky, with the cassette 3cm above the AC joints. Central ray should
be perpendicular to the cassette, centring to T7 in the midaxiallary
line. Collimate on four sides to outer margins of the chest. FFD

should be 180cm, kVp 102 and mAs 15-30


(depending on size of patient) or AEC
central chamber. Broad focus and grid
should be used. Within the
radiograph both lungs from the apices
to costophrenic angles and ribs
including soft tissue should be
imaged. Ribs should be posterior to
the VC should be superimposed and
no arm should be shadowed
superimposing the lung. The long axis
of the lung fields should be vertical
and the lateral sternum should be
evident. The thoracic spine and

intervertebral discs should be open and the diaphragm


showing a sharp outline.

Lateral Decubitus: this projection is used to demonstrate air-


fluid volumes. The patient needs to be lying on their left side,
with their right side raised. This position is essential to
determine air-fluid volumes and not be confused with
stomach and abdomen anatomy.

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AP Lordotic View: this is commonly used for TB screening and to demonstrate the apices.
The patient is required to lean back on the bucky, so that the clavicles are up above the
apices. Use a straight tube with no angle applied. Can collimate up, as the top half of the
chest is under investigation.

The level of kVp utilized for a radiograph is dependent on: scale of contrast, visualization of
pathology and using the low kVp results in decreased scatter but no grid is used, decreases
the radiographic contrast due to scatter, however the mediastinum is not penetrated as
well. Using a grid or not is dependent on size, scale of contrast and the kVp used. Lateral
projection is always performed with a grid.

AGE: Left hand side is a young


child, whereas the right hand side
is an adult.

SEX: The right hand side is a female


and the left hand side a male.

The artifacts evident on the radiograph


are breast implants or argumentations.

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Paediatric Chest x-rays: those children under the age of 2 will generally have chest x-rays
performed supine, whereas those older than 2 will have them taken as erect AP/PA
projections. Often AP projections are used so the young child is not facing the wall which
may be scary or uncomfortable for them. The lateral projection is not usually taken only if
indicated from the PA or AP projection. Tube angulation is to be less than that used on
adults, to reduce the lordosis.

Causes of lordosis with children include:

Feet being at the same level at the bottom, need to elevate the bottom.

Arms extended- they need to be flexed slightly.

Arching back- hold the head with the hands.

Slumping- use a Velcro strap.

Lifting bottom- use Velcro strap.

Protruding abdomen- lean slightly forward.

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Chest Pathologies:
When examining chest radiographs for pathologies it is essential to check previous films and
reports. Determine which side was affected, allowing you to determine which lateral to
perform, see what projections were last performed, see the length of the lungs to include on
cassette and for the film orientation and modify the exposure.

Cystic Fibrosis: this is a heredity disease, which is


the secretion of excessively viscous mucus. The
mucus in the trachea and bronchi blocks the air
passages, with the focal areas of lung collapsing.
This can lead to infections. It can be seen on
radiographs through irregular thickening of linear
markings and hyperinflation (skinny, long lungs).

Hyaline Membrane Disease: this causes


respiratory distress in newborns,
premature infants. It is caused through
lack of surfactant which is a substance
allowing for high surface tension. This
results in under aeration of the lungs, and
the alveoli do not remain inflated. It can
be identified as having a granular
appearance or air bronchogram-small
airways dilate.

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Pneumonia: this is
inflammation often caused by
bacteria or through viruses.
Alveolar pneumonia is where
inflammatory exudate replaces
air in the alveoli and the lung
appears to be radiopaque.
Bronchopneumonia originates
in the bronchi with small
patches of opacifications. Interstitial pneumonia involves the walls
and lining of the alveoli and their septa, with linear apacifications.
Aspiration pneumonia occurs when esophageal or gastric contents enter the chest cavity,
developing multiple alveolar densities and posterior segments of the upper and lower lobes.

Tuberculosis: this is caused by a bacteria, spread by droplets in the air. Inflammatory cells
collect around the TB forming a mass. Proliferation of fibrous tissue around the mass limits
the spread, produces a scar and calcification occurs. Milliary TB is where the disease is
spread through the bloodstream, with uniform distribution throughout both lungs.
Secondary TB is the reactivation of organisms from previously formant TB, heals slowly with
extensive fibrosis. TB usually appears as a dense, homogenous, well defined area.

Chronic Obstructive Pulmonary Disease (COPD): this is the obstruction of the airways leading
to an ineffective exchange of respiratory gases and makes breathing difficult. It can include
chronic bronchitis, emphysema and asthma. Chronic bronchitis is excessive tracheobronchial
mucus production, the obstruction of small airways, either no change on chest x-ray or
increase in bronchiovascular markings. Emphysema is
the distention of distal air spaces, destruction of
alveolar walls, obstruction of small airways, increase
in the volume of air in the lungs, and is usually
associated with heavy cigarette smoking. On x-ray we
see over inflation, flattening of domes of the
diaphragm, increase in the size and luncency of
retrosternal air space seen on lateral and a barrel
shaped chest.

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Asthma is the swelling of the mucus membranes of the


bronchi, excessive secretion of mucus, bronchioles go into
spasm, narrowing of airways, decreased air flow and
sometimes the obstruction of airways, expiration is difficult.
Chronic asthma will prominently display the interstitial
markings.

Asbestos: asbestose fibers produce fibrosis in the lungs, major


complications is mesothelioma. On x-ray a pleural thickening
should be evident, calcification of pleural plaques is also evident
and linear and nodular opacities in the lung.

Atelectasis: diminished air within the lung,


resulting in reduced lung volume.
Commonly results from bronchial
obstruction, as the air is trapped in the lung
it is absorbed into the bloodstream and the
lung collapses. On an x-ray a local increase
in density will be evident.

Solitary pulmonary nodule:

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Bronchial adenoma: low grade malignancy, 1% of


bronchial neoplasms, hemoptysis. Recurring
pneumonia most occur centrally and cause
obstruction.

Bronchogenic Carcinoma: arises from the mucosa of the


bronchial tree, most common primary malignant lung
neoplasm. Closely linked to smoking, squamous
carcinoma. On an x-ray may be a discrete mass, and
obstructive changes.

Metastases: third of
patients with cancer
develop pulmonary
metastases. On an x-ray
there will be multiple well
circumscribed opaque
nodules.

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Pleural Effusion: accumulation of fluid in the pleural space. On an


x-ray will have the blunting of the costophrenic angle and seen on
erect images.

Adult respiratory distress syndrome: severe, unexpected, life threatening acute respiratory
distress. No major underlying lung disease, the structure of the lung completely breaks
down. Leaking of cells and fluid into the interstitial and alveolar spaces. Severe hypoxemia
(low oxygen within the blood). On an x-ray patchy ill-defined areas of consolidation, both
lungs are affected.

Rib Fracture:

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Rib fracture with haemothroax:

Flail Chest:

Subcutaneous Emphysema:
post surgery, penetrating or
blunt trauma. Disruption of
lung and parietal pleura. Air is
forced into tissues of the
chest and neck wall. Tissues
fives a crackling sound.

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Pneumothorax: air in the pleural cavity, partial or complete collapse of the lung. Sudden and
severe chest pain and difficulty breathing. On an x-ray this is displayed as a hyper lucent area
with no lung markings, with expiration film.

SHOWN BETTER ON
EXPIRATION.

Tension Pneumothroax:

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Pneumomediastinum: air within


the mediastinal space, usually
due to trauma. Longer linear
opacity that is the pleura
separated from the heart by air.

Traumatic Aortic Aneurysm: widened mediastinum,


apical pleural cap, displacement of midline
structures.

Goitre:

Congestive heart disease (CHD): inability of the heart to propel blood at a rate and volume
sufficient to provide an adequate supply to the tissues.

Left sided heart failure:

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Right sided heart failure:

Pulmonary edema: abnormal accumulation of fluid in


the extravascular pulmonary tissues. Commonly caused
by an elevation of pulmonary venous pressure. On an x-
ray there is a loss of sharp definition of pulmonary
markings, accentuation of markings at the hilum and thin
horizontal lines of increased density inferiorly.

Aortic Heart Valve:

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Pulmonary embolism: potentially


fatal, emboli mostly arise from
thrombus in the deep venous
system of the lower legs or right
side of the heart. Occlude blood
flow to a part of the lung,
infarction. On x-ray it will be normal
prior to infection, area of
consolidation will occur.

Tubes and catheters:

Endotracheal tube: tip 5-7cm above carina:

Central venous pressure catheter: tip just below joint of brachiocephalic veins to form the
SVC.

Swann- Ganz catheter: tip in


right or left main pulmonary
artery:

Nasogastric tube: tube should run to stomach on right.

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Pace maker:

Hatus Hernia: bowel protruding up.

Perforated bowel:

Dextrocardia:

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Ribs, Sternum and Sternoclavicular Joints.

These projections possess the same anatomy as the chest x-rays, cervical ribs again may be
evident. In a projection of the ribs, the posterior ribs are prominently displayed, with them
being more superior then the anterior section of the rib and cartilage. The sides where the
curving occurs is known as the axillary section. During projections of the upper ribs,
inspiration should occur to get uniform lung behind the ribs, whereas for lower ribs,
expiration displays more dense abdomen structures. Indications of pathology within the
area include: pain, infections, rib fractures, shortness of breath, trauma, medico-legal (non-
accidental injury, assault, and compensation claim), metastasis, metabolic disease, arthritis
and osteomyelitis. Associated injuries within the area include: vertebral fractures,
pneumothorax, haemothorax, effusion, pulmonary contusion, atelectasis, heart contusion,
great vessel rupture, dissection or aneurysm, diaphragmatic rupture, and abdominal
rupture.

Before commencing the radiograph provide the patient with an explanation, remove their
jewelry, have the patient take everything off from the waist up and place on a gown, check
for pregnancy if female, provide a lead apron around the waist, be careful of long plated hair
which may become an artifact, and if for ribs place a marker on the skin over the patients
area of tenderness. Often the area of tenderness will be more anterior, therefore follow the
rib slightly posteriorly and place the marker.

The routine projections of the ribs include: PA chest, AP affected side and oblique affected
side (either RPO or LPO). The routine projections for the sternum include: RAO and lateral.
The routine projections for sternoclavicular joints include: PA, RAO and LAO, and lateral. For
these projection the bucky and grid are used, with the grid absorbing most of the scatter
radiation before it hits the cassette. The AEC can also be used.

AP Ribs of affected side: this projection is performed on a


35x43cm cassette, using one cassette per view. Patient
should stand with their back to the bucky, with the arms
away from the side and the chin slightly raised with the
back in contact with the bucky. Align the x-ray tube to the
bucky. For upper ribs expose on inspiration, and have the
cassette 3cm above the AC joints, whereas for lower ribs
expose on expiration and place the cassette 3cm below
the lower costal region (last rib we can feel, rib 10). The
central ray should be perpendicular to the cassette, centering to the
cassette and collimate on four sides to the outer margins of the rib
cage. The FFD should be 100cm, kVp 75, mAs 8 (upper ribs) and 20
(lower ribs), using broad focus and a grid. If using the AEC use the
central chamber. The breathing technique can be used if the patient
is breathing gently which will haze the lungs, providing good
contrast or the ribs, a manual exposure will have to be set reducing
the mA and increasing the time. Regional anatomy should be
included with either the first or twelfth rib included and from lateral
ribs to vertebral column, including the soft tissue. No rotation
should be evident and ribs should be demonstrated through the
heart and lung shadows. Density and contrast should be optimal to
visualise bone and soft tissue.

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Oblique Ribs (RPO or LPO): this projection should be performed


on a 35x43cm cassette, using a new cassette. The patient
should be standing with their back to the bucky, with their arm
away to the side and chin slightly raised. Rotate the patient 45
degrees so the back of the affected side is in contact with the
bucky. Align the SC joint to the centre of the cassette and align
the x-ray tube to the cassette. For the upper ribs expose on
inspiration and have the cassette 3cm above th AC joints, for
the lower ribs expose on expiration and have the cassette 3cm
below the lower costal margin. The central ray needs to be
perpendicular to the cassette, centered to the cassette,
collimate on for sides to the outer margins or the rib cage. FFD
should be 100cm, kVp 75 and mAs 8 for the upper and 20 for
the lower, using broad focus and grid. For a second view at 90
degrees you can rotate the affected side 45 degrees away from
the bucky and centre over the raised side. Either the first or
twelfth rib should be included from lateral ribs to the vertebral
column, including soft tissue. 45 degree rotation should be
evident to display the axillary region. Ribs are demonstrated
through the heart and lung shadows and contrast and density
should be optimal to visualise bone and soft tissue.

RAO Sternum: this projection should be


performed on a 24x30cm cassette, using
one view per cassette. Patient should be
standing facing the bucky with the body
rotated 15 degrees placing the right side
in contact with the bucky. Align the
sternum to the centre of the bucky with
the arms by the side and chin slightly
raised. Align the x-ray tube to the bucky with the cassette 4cm above the
jugular notch. Expose on expiration or use the breathing technique, with the
central ray perpendicular to the cassette. Centre to the cassette and collimate
on four sides to the outer margins of the sternum. FFD should be 100cm, kVp
80, mAs 30 or use the AEC central chamber, using broad focus and grid. The
entire sternum should be included, with the sternum superimposed on heart
shadow. The sternum should not be superimposed by the vertebral column,
with sharp bone margins evident, however if breathing technique is used
lungs will be blurred. Density and contrast should be optimal to visualize bone and soft
tissue.

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Lateral Sternum: this projection


should be taken on a 24x30cm
cassette, using a new cassette, with
the patient standing with their left
side of the body against the bucky.
Clasp the arms behind the back and
pull the shoulder back the chest
forward, holding the shoulder in
contact with the bucky, with the chin elevated. The midsaggital plane should
be parallel to the film, aligning the sternum to the centre of the bucky. Expose
on inspiration, aligning the x-ray tube to the bucky. The cassette should sit
4cm above the jugular notch, with the central ray perpendicular to the
cassette, centring to the cassette, considering the angle of the light beam
diaphragm to be equal to the sternum allowing for greater collimation.
Collimate on four sides to outer margins of the sternum. FFD should be
180cm, kV0 70, mAs 20, using broad focus and grid. The entire sternum
should be included, with the sternum free of superimposition. Sternum should
not be superimposed by the VC, with sharp bone margins demonstrating no motion.

PA SC Joints: this projection should be performed on an 18x24cm


cassette, using one cassette per view. The patient should be
standing facing the bucky, with the arms by their side or wrapped
around the bucky with the chin slightly raised. Chest should be in
contact with the bucky. Align the midsaggital plane to the centre
of the bucky, with the cassette 4cm above the jugular notch.
Expose on expiration, with the central ray perpendicular to the
cassette, centering to the cassette. Collimate on four sides
to the outer margins of the cassette. FFD should be 100cm,
kVp 80, mAs 30, suing broad focus and grid. The manubrium
and medial ends of clavicles should be included, with no
rotation evident with SC joints equidistant from the VC.
Density and contrast should be optimal to visualise bone
and soft tissue.

Oblique SC joints: this projection should be taken on an


18x24cm cassette, on a new cassette, with the patient
standing facingthe bucky with their arm by their side or
wrapped aroud the bucky with the chin slightly raised.
Rotate the patient 15 degrees so affected side is in contact
with the bucky, aligning the midsaggital plane to the centre
of the bucky, aligning the x-ray tube to the bucky. The
cassette should be 4cm above the jugular notch, exposing
on expiration. The central ray should be perpendicular to
the cassette, centring to the cassette. Collimate on four sides
to the outer margins of the cassette. FFD should be 100cm,
kVp 80, mAs 30, using broad focus and grid. The manubrium
and medial ends of clavicles should be included and the joint
of interest demonstrated without superimposition from the
VC. The joint space should be open and the density and
contrast optimal to visualise bone and soft tissue.

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Lateral SC joints: this projection should be taken on a 18x24cm


cassette, using a new cassette, with the patient standing with their
left side of the body against the bucky. Clasp the arms behind the
back and pull the shoulder back and chest forward, having the
shoulder in contact with the bucky holding the chin up. The
midsaggital plane should be parallel to the film aligning the
manubrium to the middle of the bucky. Expose on inspiration,
aligning the x-ray tube to the bucky. The cassette should be placed
4cm above the jugular notch, with the central ray perpendicular to
the cassette and centred to the cassette. Collimate on four sides to
the outer margins of the medial ends of the clavicles. FFD should be
180cm, kVp 70, mAs 20 using broad focus and grid. The manubrium
and medial ends of the clavicles should be included, with the
manubrium and SC joints free of superimposition. Sharp bone
margins demonstrating no movement should be evident.

Within this area there are multiple pathologies which may possibly be evident. These
include: congenital abnormalities, fractures, rib dislocation, neoplasia, metastasis, and
changes in trabeculation due to diseases and included in skeletal survey.

Rib fractures:

Flail Chest.

Pneumothorax: air in the pleural cavity and


collapsed lung:

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Haemothorax:

Penumomediastinum:

THE UPPER AIRWAYS:

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Indications of injury or pathology within this area includes: infection (croup, epiglottitis,
enlarged adenoids), foreign body localization, goiter and trauma.

AP Upper Airway: this projection should be


performed on a 24x30cm cassette, using one
cassette per view, with the patient standing
with their back to the bucky, with their arms
beside their side and their chin slightly raised.
The back should be in contact with the bucky
and the midsaggital plane should be aligned to
the centre of the bucky, aligning the x-ray tube
to the bucky. Expose on inspiration with puffed
out cheeks, with the central ray perpendicular
to the cassette and the centre of the cassette 2cm above the jugular notch.
Collimate on four sides to the outer margins of the neck. FFD should be
100cm, kVp 73, mAs 10 using broad focus and grid. Regional anatomy from the mandible to
T4 should be included including soft tissue, with the larynx and trachea filled with air and
seen through the spine. No rotation should be evident and the mandible should
superimpose the base of the skull.

Lateral Upper Airway: this projection should be


performed on a 24x30cm cassette, using a new
cassette with the patient standing with the left side
of the body against the bucky, with the arms
clasped behind the back pulling the shoulders back
and pushing the chest forward. The shoulder should
be in contact with the bucky with the chin up. The
midsaggital plane parallel to the film, aligning the
trachea to the middle of the bucky. Expose on
inspiration with puffed out cheeks, aligning the x-ray tube to the bucky. The
central ray should be perpendicular to the cassette, centring 2cm above the
jugular notch, collimating on four sides to the outer margins of the neck. FFD
should be 100cm, kVp 70 mAs 100 using broad focus and grid. The larynx and
trachea should be filled with air from the ear hole to the T3 included. Shoulders
should not superimpose the trachea, with sharp bone margins indicating no movement.

Pathologies of the upper airway:

Croup: this is a viral infection which occurs in young


children. It is an inflammatory obstructive swelling,
producing a harsh cough, narrowing the subglottic airway.

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Epiglottitis: this occurs in 3-10 year olds, with


drooling, fever, systemic toxicity, severe sore throat,
dysphagia, inspiratory stridor and respiratory distress
symptoms. It is a bacterial infection, producing a
dome like enlargement of the epiglottis, causing
airway narrowing and obstruction.

Tonsilitis:

Retropharyngeal abscess:

Goitre: enlargement of the


thyroid.

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Toes, foot and calcaneus.

The hindfoot includes the calcaneus and talus, the midfoot includes the navicular, cuboid
and cuneiforms, and the forefoot includes the metatarsals and phalanges.

The subtalar joint is between the inferior talus and


superior calcaneus. Inversion and eversion occur here.
There is an opening in the middle of the subtalar joint
known as the sinus tarsi, ligaments pass through here
providing stability.

The tarsal bones:

The longitudinal arch of the foot runs with the length of the foot, and the transverse runs
across the width of the foot.

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Ossification within the foot includes these following bones:

Accessory ossicles include:


• Os trigonum tarsi: present on 25% of children and often bilateral.
• Sesamoid bones: commonly paired and visualized on the plantar aspect of the head
of the 1st metatarsal, however can be present elsewhere.
• Separate navicular ossification site: seen in 5% of children.
• Calcaneal apophysis: fragmented, irregular and more dense than normal calcaneus.

Os trigonum tarsi. Calcaneal apophysis.

Indications of pathology include: trauma, pain, lumps, foreign body, swelling, infections,
cuts, bruising, loss of function, deformity, reduced range of movement, arthritis.

When preparing a patient for examination it is essential to provide them with an explanation
of the examination, remove jewellery, check for pregnancy if female, and provide them with
a lead apron.

AP Toe Projection: this projection should be performed on an


18x24cm cassette divided into two lead strips for toes 2-5 and
divided into 3 strips for the 1st digit. The patient should be lying
on the table, with the knee of the affected side flexed, and the
plantar aspect of the foot flat on the cassette, with the toes

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uncurled. The long axis of the foot should be parallel with the
short edge of the cassette. The central ray needs to be angle 15
degrees towards the ankle (posteriorly). For digits 2-5 centre to
the 3rd MTP joint and for the 1st digit centre to the first MTP
joint. Collimate on fours sides to the outer margins of the toes.
The FFD should be 100cm, kVp 48, mAs 5 using fine focus and
no grid. The tips of the digits to the distal metatarsals should be
included including soft tissue, with the digits free of
superimposition. No rotation should be evident, and MTP joints
and IP joints should be open.

AP Medial Oblique Toes: this projection should be


performed on an 18x24cm cassette, using the next
section of the cassette, with the patient sitting on
the table and the knee of the affected side flexed.
The plantar aspect of the foot should be flat on the
cassette, with the toes uncurled and the long axis of
the foot parallel with the short edge of the cassette.
From AP position rotate the foot and leg 45 degrees
medically, with the central ray perpendicular to the
cassette. Centre to the 3rd MTP joint for digit 2-5 and to the 1st MTP joint for
the first digit. Collimate on four sides to the outer margins of the toes. The
FFD should be 100cm, kVp 48, mAs 5 using fine focus and no grid. The tips of the digits and
to the distal metatarsals should be included including the soft tissue, and the digits should
be free of superimposition. MTP and IP joints should be open and the digits should be at a
45 degree angle.

Lateral 1st toe: this projection should be performed


on an 18x24cm cassette using the final section of
the cassette, with the patient lying on the table. Roll
them onto their side, with the medial aspect of the
1st toe in contact with the cassette. Move the other
toes out of the way suing a bandage so the long axis
of the foot is parallel to the short edge of the
cassette. The central ray should be perpendicular to the cassette, centring to the
1st IP joint. Collimate on four sides to the outer margins of the toe. The FFD should be
100cm, kVp 48, mAs 5 using fine focus and no grid. The tip of the digit and the distal
metatarsal should be included as well as the soft tissue. MTP and IP joints should be open
and the true lateral position performed, with the concave anterior surface of the shafts of
phalanges. Least possible overlap of other digits, with the digit free of motion.

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AP Foot: this projection should be


performed on a 24x30cm cassette, divided
into two with lead strips, with the patient
lying on the table and knee of the affected
side flexed. The plantar aspect of the foot
should be flat on the cassette, and the toes
uncurled. The long axis of the foot should
be parallel with the long edge of the
cassette, with the central ray 15 degrees
angle towards to ankle. Centre to the base of the third metatarsal (level of bmp on
foot but in middle) and collimate on four sides to the outer margins of the foot.
FFD should be 100cm, kVp 50, mAs 8 using fine focus and no grid. The tip of the
digits to the distal tibia and fibula should be included including soft tissue, with
the digits free of superimposition. No rotation should be evident, with some overlap of 2-5
metatarsal bases. MTP, IP and intertarsal joint spaces should be open.

AP Medial Oblique: this projection should be


taken on a 24x30cm cassette, with the other
half of the cassette used, with the patient
sitting on the table, with the knee of the
affected side flexed. The plantar aspect of the
foot should be flat on the cassette, and the toes
uncurled. The long axis of the foot should be
parallel to the long edge of the cassette, with
the foot in the same position as AP however the foot rotated medially 45 degrees.
The central ray should be perpendicular to the cassette, centring to the base of
the 3rd metatarsal. Collimate on four sides to the outer margins of the foot, with
the FFD 100cm, kVp 50, mAs 8 using fine focus and no grid. The tips of th digits to
the distal tibia and fibula including soft tissue should be imaged, with the digits
free of superimposition. 3-5 metatarsal bases free of superimposition, sinus tarsi
seen. The tuberosity of the 5th metatarsal is seen and the MTP, IP and intertarsal
joint spaces are open.

Lateral Foot: this projection should be taken on a 24x30cm


cassette, using a new cassette, with the patient lying on the
table on their affected side. The lateral aspect of the foot should
be in contact with the cassette, with the long axis of the foot
diagonal across the cassette, with the ankle flexed at 90
degrees. Elevate the knee slightly, with the central ray
perpendicular to the cassette and centre to the base of the
metatarsals. Collimate on four sides to the outer margins of the
foot. FFD should be 100cm, kVp 52, mAs 8 using fine focus and
no grid. The tips of the digits, distal tibia and fibula and the
calcaneus should be imaged including soft tissue. Metatarsals
nearly superimposed, with the tibiotalar joint open. Distal tibia
and fibula superimposed.

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Weight bearing functional projections:


• dorsiplantar (AP): bilateral usually for OA, post operative evaluation of osteotomy.
• Lateral: more commonly performed, bilateral for comparision, evaluation of flat
feet- ‘Pes Planus’.

Axial Calcaneus: this projection should be


performed on an 18x24cm cassette, divided
into two using lead strips. Patient should be
lying supine on the table with the knee
straight, and the ankle flexed at 90 degrees.
Heel and posterior aspect of the lower leg
in contact with the cassette, with the long
axis of the leg parallel to the short edge of
the cassette. Central ray should be 40
degrees towards the patients head, and the
centre at the base of the 3rd metatarsal. Collimate on four sides to the outer
margins of the calcaneus. FFD should be 100cm, kVp 55, mAs 16 using fine
focus and no grid. The entire calcaneus should be included and the talocalcaneal joint, with
the talocalacaneal joint open.

Lateral Calcaneus: this projection should be taken on a 18x24cm


cassette, with the other half of the cassette used. The patient
should be lying on the table, rolling them onto their affected
side, with the lateral aspect of the foot in contact with the
cassette. The long axis of the leg should be parallel to the short
edge of the cassette, with the ankle flexed at 90 degrees.
Elevate the knee slightly, with the central ray perpendicular to
the cassette,, with the centre in line with and 2cm inferior to
the medial malleolus. Collimate on four sides to the outer
margins of the calcaneus. FFD should be 100cm, kVp 52, mAs
8 using fine focus and no grid. The calcaneus, distal tibia and
fibula, and cuboid including soft tissue should be included and
the joint space between the calcaneus and cuboid open. The
talocalcaneal joint open, with the lateral malleolus
superimposed over the posterior half of the tibia and talus.
The tarsal sinus should be open.

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Pathologies:

Fractures: Talar body fractures:

Talar dislocation: total dislocation from


the ankle mortise and talocalcaneal and
talonavicular joints, uncommon and
leads to avascular necrosis, infection
and talectomy.

Subtalar dislocation: uncommon, ankle


inversion à

Calcaneal fracture classification:

Tarsometatarsal fracture dislocation,


lisfranc injuries:

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Fractured navicular and medial cuneiform:

Jones fracture: transverse fracture of the base of the 5th


metatarsal. Don’t get
confused with an
apophysis, which has a
vertical orientation.

Stress fractures: in the metatarsals are known as march fractures.


Can be displayed as fluffy periosteal new bone, subtle fracture line
of band of sclerosis.

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Rheumatoid arthritis: occurs at the MTP joints, IP of the


first toe and in the intertarsal joints. Joint space
narrowing, osteoporosis and bone deteriorates.

Osteoarthritis: also known as hallux valgus deformity.

Gout: increase blood levels of uric acid, resulting in deposits


of urea crystal within joint cartilage, synovium and
subchondral bone. Extrinsice perarticular bony erosions
with a distinctive lip of bone at the edge.

Plantar fasciitis calcaneal spur: insertion of plantar fascia, pain on


weight bearing under the heel. Causes bony spurs.

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Pes Planus- flat feet: longitudinal arch is reduced on standing, causing muscle weakness and
paralysis. Bilateral AP and lateral weight bearing will display this.

Hallux valgus deformity: lateral deviation


of 1st toe, bilateral AP weight bearing.
Buinion- inflammation of the bursa.

Kohlers Disease: avascular necrosis of tarsal navicular, pain and


flatfoot, the navicular appears irregular and fragmented.

Osteomyelitis: inflammation of the bone and


bone marrow. Infection caused by penetrating
wounds, fractures, surgery. Absorption of necrotic
bone.

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Mobiles and Theatre.


Patient may be unable to be transported to the radiography department. These may include
those in emergency departments, special wards including ICU, coronary cardiac unit,
neonatal intensive care unit, orthopedics in traction, spinal units, isolation, on suction,
required in surgery or recovery and required in a morgue. In using mobiles it is important to
adapt to the environment as there are limitation in space and maneuverability and barrier
nursed patients. We also need to adapt to the patients presentation and condition needs,
including checking for old films and check the condition of patient with
nursing staff. Alternate positioning techniques may need to be adapted
using a horizontal beam and using limited radiographic series. There may be
limitations of equipment.

A mobile x-ray unit looks like these images. They include a tube, collimator,
telescoping arm and vertical arm, control panel, drive/emergency stop,
exposure button and security.

They are known as constant potential mobiles as they are mains independent, with a self
contained battery which needs to be recharged. They have a high x-ray output, with two
controls- kVp and mAs. They also may have anatomical programming and automatic
exposure control which isn’t recommended to use on a mobile.

The radiographer and their equipment is not classified as sterile. We may cause cross
infection, therefore machines and cassettes must be washed down, hands must be washed,
gloves must be worn and pillow cases can be used to prevent contamination. There will be a
clean and dirty person system used at some stages, and it is recommended to stay away
from anything green or blue. A radiographer must wear: gloves, lead gown, thyroid
protector, eye wear, gown to cover clothes, wash hands, mask, cover any open cuts, stand at
least 2m away and warn staff by calling out x-ray.

In the emergency department the radiographer is a part of the trauma team. There is a team
approach and a trauma protocol which must be followed including a lateral cervical spine,
supine chest and an AP pelvis. In the emergency department it is essential to be preforming
at speed whilst producing accuracy. These patients may have respiratory distress, cardiac
arrests, and medically instable or potentially unstable patients. In this department there are
limited projections that are possible to be taken, artifacts are often evident, limited distance
can be achieved, and patient cooperation. Infection control, limiting radiation, oxygen
tubing, drains and catheters are all other issues which can be seen in the emergency
department.

Mobile chest x-rays can be performed in all postural states, including erect, semi erect and
supine. Only AP can be performed, and adjust exposures for duration which may include

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movement, also consider exposures for gird or non grid technique. For most mobiles, the
kVp is dropped to 80-85kVp not using the gird.

In the NICU department keep handling to a minimum and receive assistance from nursing.
To prevent infection, remove all jewellery, use hand wash, wear gloves and a gown, use
clean cassettes, and cover equipment. Maintain the warmth evident, only essential handling
and undressing, with the radiographic procedure within neonates own environment, whilst
keeping noise to a minimum. Artifacts should be removed as much as possible. Neonate
should be positioned supine, be immobilized and have radiation protection. A 5 degree
caudal angle should be evident to reduce lordosis. Watch respiration and expose on full
inspiration. Provide radiation protection for nearby staff. Perform only an AP projection,
using a digital film screen combination where possible. Use non gird with 50kVp and 2mAs.
Hyaline membrane diseases is most commonly
seen in neonates, with the deficiency of
pulmonary surfactant which prevents alveolar
distention.

The mobile x-ray machine produces great


movement:

Radiation protection includes distance, time, shielding, and c-arm orientation and exposure
field.

Infection control in theatre is a strict control that must be undertaken. All equipment must
be cleaned before entering and following the procedure. Maintain the sterile technique,
with a sterile field marked by green and blue and a non-sterile field generally where we are.
Set up prior to draping where possible. Staff are required to be protected with lead gowns
and sometimes mobile barriers are provided. It is essential to attend trauma in the
emergency department before attending theatre if required.

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An example of imaging in theatre is operative cholangirogram, which is


following the removal of the gallbladder to ensure that the tubes are free
flowing and no blockages are evident.

Pin and plates are often common as well, using both AP and lateral
projections.

Pin and plate repair for


fractures:

Urology:

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Spine:

Exposures.

The x-ray tube:

Kinetic energy through the moving electrons released from the cathode are produced into
electromagnetic energy and thermal energy. About 1% of the kinetic energy is transformed
into x-rays and 99% into heat. The cathode is the source of electrons, with the negative
electrode. It consists of 2 filaments of coiled tungsten wire one large and one small. The
anode is the positive side of the electrode, which stops or decelerates electrons. It is
rotating, and is made of tungsten. Mammography machines use molybdenum, this is the site
of heat and x-ray production. Electrons move between the cathode and the anode because
of the difference in charge between the two electrodes. Electrons striking the target cause
two interactions: bremsstrahlung interactions and characteristic interactions, characteristic
interaction only occur above 70kVp and compromise 15% of the beam. X-ray energy is
measured in kiloelectron-volt (keV). X-ray emission spectrum consists of a wide range of
energies, with the highest energies equal to the kVp set. The lowest energies are 15-20keV.

kVp gives quality of the x-ray beam and indicates its penetrating power. It determines the
speed at which the electrons in the tube current move, also determining the quality of
energy of the x-rays. Changing kVp results in changing the quality of the beam. Increased
kVp results in, increased beam energy, increased penetration, increased scattering,
increased image density and decreased image contrast.

mA is the flow of electrons from the cathode to the anode, also known as the tube current
and is measured in miliamperes (mA). mA gives quantity of the x-ray beam indicating the

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number of x-ray photons in the primary beam. mA is the number of electrons flowing per
unit of time between the cathode and anode. Time is measured in seconds, measuring the
length of time the x-ray tub produces x-rays. The longer the exposure time the greater the
quantity of electrons that will flow
from the cathode to the anode and
the greater the quantity of x-rays
produced. mAs is a result of mA x s.
As such the quantity of electrons
that flows from the cathode to the
anode is directly proportional to
mAs. mAs determines the quantity
of x-rays produced. When changing
the mAs it changes the quantity of
the beam.
Increasing the mA or time will increase the number of photons, increase the number of
interactions, increase image density and increase the patient dose.

Focal spot affects the size of the area on the anode that is exposed to electrons. Large focal
spot can withstand heat produced by large exposures. Small focal spots produce a better
image quality.

Through the use of filtration, low energy photons increase the patient dose, don’t contribute
to image formation, and use added filtration to absorb them. Added filtration is 1mm of
aluminum. Inherent filtration includes the glass envelope, oil surrounding tube and the
mirror inside the collimator. Total filtration is 2.5mm of aluminum or its equivalent.

Differential absorption is the absorption characteristics of the anatomical part which is


determined by composition such as thickness, atomic number, and compactness of cellular
structure. Some of the x-ray beam is absorbed and some passes through. Bone absorbs
more x-ray photons than air filled structures. The radiation that exists the patient will have
varying energies causing different shades of grey on the image.

Radiopaque are areas within the tissues which absorb the x-ray photons creating white
areas on the image. Material that inhibit the passage of x-rays are called radio dense. White
appearance of dense materials or substances on images is radiopaque.

Radiolucent is whereby the x-ray photons that are transmitted creating the black areas on
the image. Radiolucency indicates greater transparency to x-ray photons. Materials that
allow radiation to pass more freely are referred to as radiolucent. Darker appearance of less
dense materials is radiolucent.

The effect of changing distance is referred to as the inverse square law whereby when he
distance is doubled decreasing the beam intensity by ¼. We have to increase FFD to
decrease beam intensity, decrease patient absorbed dose and increased image sharpness.

Radiographic density is the degree of blackening on an image, with the controlling factors of
mA and time. The quantity of radiation reaching the image receptor. Increased quantity
results in increased density. To make a slight visible change the mAs would need to be
adjusted by 30%, however in general the mAs should be adjusted by a factor of 2 to produce
a minimum change.

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Changing the kVp by 15% will have the same effect on radiographic density as changing the
mAs by 50%. So increasing the kVp by 15% increases the radiographic density unless the
mAs is increased. To maintain density:
• when increasing the kVp by 15% divide the original mAs by 2.
• When decreasing the kVp by 15% multiply the original mAs by 2.

Radiographic density is the difference in the degree of blackening at two different points on
a film that represent different tissue types or tissue thickness. kVp is the controlling factor.
High kVp increases the penetrating power of the x-ray beam and results in less absorption,
more transmission and fewer density differences in the anatomic tissues. High kVp results in
more densities with little different producing a low contrast image, and low kVp produces
fewer densities with greater differences producing a high contrast image.

The grid reduces the amount of scatter reaching the film by the post patient filtration. It
must be used for high kVp (>60) and for thick, dense body parts. It requires the use of a
higher mAs, increased patient radiation dose, and increased radiographic contrast.

When performing a radiograph always select the smallest cassette size possible, as the
smaller the cassette the more improved resolution as a result of the decreasing pixel size.

When performing radiographs with the presence of casts exposure factors may be required
to change. Fiberglass casts do not require an exposure change and wet plaster will require
an increase of mAs by three times and a dry plaster cast will require an in creased in mAs by
2 times.

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Through the use of digital imaging, the computer can adjust for exposure errors. Errors +/-
50% can be adjusted without sacrificing the image quality. Remember the optimal image vs
the patient dose, do not let the exposure creep up.

The Ankle.

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The ankle is a mortise joint. The joints within the ankle include: tibiotalar joint, talofibular
joint, distal tibiofibular joint and medial and lateral talarmalleolar joints. There are
numerous lgaments within the foot. The tibialis anterior inserts onto the 1st metatarsal,
peroneus brevis inserts onto the base of the 5th metatarsal, peroneus longus inserts
underneath the foot onto the 1st metatarsal, tibialis posterior inserts onto the navicular,
flexor hallcius longus inserts onto the 1st distal phalanx and flexor digitorum longus inserts
onto the 2-5 middle phalanges.

Various ossification centres are additionally


evident within the foot. The talus appears around
6months into the utero, distal tibia appears
between 4 months and one year, and is fused by
15-17 years. The distal fibula appears around
6months-1year and is fused by around 15-17
years. Within the foot there are two main fat pads
which are good indication to trauma in the area.
The pre-talar fat pad is a mass anterior to the
tibiotalar joint and the pre Achilles fat pad is a
triangular fat pad collection anterior to the
Achilles tendon.

Indication of injury to the ankle includes: trauma, pain, lumps, foreign body, swelling,
infections, cuts, bruising, loss of function, previous surgery, deformity, and reduced range of
movement. To prepare the patient for the imaging examination it is essential to provide
them with an explanation of the process, remove jewellery, check for pregnancy if female
and provide the patient with a lead apron.

For imaging the ankle there are three routine projections with 5 other projections which can
be used for additional perspectives.

AP Ankle: this projection should be


performed on a 24x30cm cassette,
divided into two with lead strips. The
patient should lie on the table with
the leg of the affected side
completely extended, with the heel in
contact with the cassette. Dorsiflex
the ankle, with the lateral malleolus
more posterior than the medial malleolus. The long axis of the leg should be
parallel to the long edge of the cassette. The central ray should be
perpendicular to the cassette, and centre to midway between the medial and
lateral malleoli at the level of the malleoli Collimate on four sides to the outer
margins of the ankle. FFD should be 100cm, kVp 55, mAs 10 using fine focus
and no grid. Regional anatomy including the talus, distal tibia and fibula and soft tissue
should be included on the image. The tibiotalar joint should remain open, and the medial
talarmalleolar joint free of overlap. Joint not open laterally and the density and contrast
optimal.

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AP Internal Oblique Ankle: this projection should be


performed on a 24x30cm cassette using the other half of
the cassette, divided with lead strips. The patient should
lie on the table with the leg of the affected side
completely extended. Heel should be in contact with the
cassette, and the ankle should be dorsiflexed. Rotate the
foot and leg medially 45 degrees, with the leg parallel to
the long edge of the cassette. The central ray should be
perpendicular to the cassette, with the centre between
the medial and lateral malleoli at the level of the malleoli.
Collimate on four sides to the outer margins of the akle.
FFD should be 100cm, kVp 55, mAs 10 using fine focus and no grid. The proximal
metatarsals, and distal tibia and fibula should be included including soft tissue. The
distal tibiofibular joint should be open and the lateral talarmalleoli joint fee of
overlap. The medial malleolus and talus should be partially superimposed.

Lateral Ankle: this projection should be


performed on an 18x24cm cassette,
with the patient lying on the table,
rolling them onto their affected side.
Dorsiflex the foot, superimposing the
lateral and medial malleolus. The long
axis of the foot should be 15 degrees to
the cassette, with the toes slightly
raised. The long axis of the leg should
be parallel to the long edge of the cassette. Central ray should be
perpendicular to the cassette, centring over the medial malleolus. Collimate
on four sides to the outer margins of the ankle. FFD should be 100cm, kVp
55, mAs 10 using fine focus and no grid. The proximal metatarsals and distal
tibia and fibula should be included with the fibular superimposing the
posterior half of the tibia. The calcaneus should be in profile and the tibiotalar joint open.
Lateral malleolus should superimpose the talus.

Mortise Ankle: this projection is done by


positioning the patient as for an AP ankle
projection, however internally rotating the foot
15 degrees so that the medial and lateral
malleolus are equidistant from the cassette. The
entire ankle mortise should be open and well
visualized.

Poor Lateral View: patient the patient as for a lateral projection however raise
the heel of the foot at 15 degrees to the cassette so the toes are in contact with
the cassette. This is useful in viewing the posterior lip of the tibia and posterior
process of the talus.

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Stress views: position the patient as for an AP projection. Stress should be applied by a
Doctor or Radiologist. 5-7 days after injury when the swelling has subsidized. Containdicated
in acute injury and fracture, assess instability which may be caused through ligamenent
damage.

Pathologies:

Fractures:

Unimalleolar:

Bimalleolar:

Trimalleolar:

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Pilon Fracture:

Tillaux Fracture:

Triplantar Fracture: fracture


of distal tibial epiphysis, in
transverse, oblique and
longitudinal planes.

Pott’s fracture: bimalleolar fracture with dislocation of ankle joint.

Calcification from Achilles tendonitis:

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The Lower Leg.

The anatomy of the lower leg includes: the femur, patella, the tibia and the fibula. On the
tibia major anatomical features include: tibial plateaus, intercondylar eminences or spines,
medial and lateral tibial condyles, tibial tuberosity and the medial malleolus.

Important anatomical features evident on the fibula include: the apex, the head, neck and
lateral malleolus. The lower leg anatomy also includes the talus.

The main joints within the lower leg include those of:
patellofemoral joint, proximal and distal tibiofibular joint,
medial and lateral femorotibial joints and talotibial joint.

Within the lower leg there are a variety of ossification centres. The distal femur appears
around 9 months in utero and is fused by 17-19 years. The proximal tibia appears around 9
months into utero and is fused between 16-18 years. The tibial tuberosity appears around
10-12 years and fuses between 12-14 years. The patella appears between 2-4 years and
fuses between 17-19 years. The talus appears around 6 months in utero. The distal tibia
appears between 4 months and one year and fuses between 15-17 years and the distal
fibula appears between 6 months and one year and fuses between 15-17 years.

Indications of pathology within the lower leg anatomical region include: trauma, pain,
lumps, foreign body, swelling, inflammation, infections, cuts, bruising, previous surgery and

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deformity. When preparing a patient for examination it is essential to provide them with an
explanation of the exam and the remove all clothing, placing on a gown with the opening to
the back. Check for pregnancy if the patient is female and provide the patient with a lead
gown to place over their lap.

AP Lower Leg: this projection is to be performed on a 35x43cm cassette, using one cassette
per view. The patient will lay on the table and the leg of the affected side on the table. Leg
of the affected side should be completely extended, with the heel and back of the leg and
knee in contact with the cassette. Dorsiflex the ankle and rotate the foot medially 5 degrees.
The long axis of the leg should be diagonal across the cassette. The central ray should be
perpendicular to the cassette and centre to the middle of the leg. Collimate on four sides to
the outer margins of the leg. FFD should be 100cm unless a greater area needs to be
examined, with the kVp around 55 and mAs 12, using fine focus and no grid. The distal
femur to the talus should be included on the image, with the femerotibial joint space open.
The tibiotalar joint space should also be open, and the femoral and tibial condyles should
appear symmetrical. The patella superimposed on the midline of the femur. Proximal and
distal fibula should be slightly superimposed on the tibia, and the intercondylar eminences
separated and in the centre of the intercondylar fossa.

Lateral lower leg: this projection should be performed on a 35x43cm cassette, using a new
cassette. The patient should lay on the table, rolling them onto their affected side. The other
leg should be placed behind the affected leg to avoid superimposition. Superimpose the
femoral condyles and the medial and lateral borders of the patella. Superimpose also the
medial and lateral malleoli. The knee should be flexed at 90 degrees and the long axis of the
leg should be diagonal across the cassette. The central ray should be perpendicular to the
cassette, centring to the middle of the leg. Collimate on four sides to the outer margins of
the leg. FFD should be 100cm unless increased for the AP leave as is, kVp 55 and mAs 12,
using fine focus and no grid. The distal femur to the talus should be included in the image.
The femorotibial joint space is open, and the femora and tibial condyles should appear
superimposed. The fibular head should only be slightly superimposed over the tibia. Fibular
distally should superimpose the posterior half of the tibia. The tibiotalar joint should be
open and the lateral malleolus superimposing the talus.

Pathologies:

Fracture:

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Complications of the lower leg: this can include delayed union, non-union, limb length
discrepancies and osteomyelitis.

Electrical stimulation of the bone:

Pins and plates:

External Fixation:

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Osteomyelitis: this is a bacterial infection which results in


the inflammation of the bone and bone marrow.
Infectious organisms reach the bone by haematogenous
spread, extension from an adjacent site of infection, and
after trauma or surgery by direct introduction. Fever may
also be evident, localized warmth, swelling and
tenderness, beginning as an abscess and spreading
through the medullary cavity and out the surface.
Metaphyseal lucency may be evident, with bone
destruction seen as ragged. Stimulation of new bone
deposits parallel to the shaft, and eventually a large
amount of new bone surrounds the cortex in a thick
irregular bony sleeve.

Paget’s disease: metabolic disease, resulting in bone destruction followed by bone repair.
The bone is weakened and deformed, then thickened making it more prone to fracture.
Affects the pelvis, skull, femurs, tibias, vertebrae, clavicles and ribs. On an x-ray during the
destruction phase it will appear radiolucent, beginning at one end and ending sharply in a V
shape, in the reparative phase the bone will be enlarged, having an irregularly widened
cortex, coarse thickened trabeculae and soft dense bones.

The Knee.

The anatomy of the knee includes: the medial and


lateral femoral condyles (the medial is larger than
the lateral), the medal and lateral femoral
epicondyles, the tibial plateaus, intercondylar
eminences or spines, medial and lateral tibial
condules, the femur, patella and fibula. Within the
knee there are a range of joints including: the
patellofemoral joint, proximal tibiofibular joint and
the medial and lateral femorotibial joints.

The menisci of the knee is not visible on plain film.


Muscles and tendons are obvious, look for
avulsions. Ligaments are also evident and laxity and
instability should be assessed. There are
approximately 13 bursae evident within the knee,
with the suprapatella bursa radiographically important to evaluate for joint effusion and
lipohaemarthrosis in injury and infective pathology.

There are a number of tendons


within the knee: the suprapatella
tendon is the tendon of quadriceps
femoris, with the muscle acting to
laterally rotate and adduct the
thigh. The infrapatellar tendon is
the patellar ligament, strengthening
the anterior surface of the joint.

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Within the knee there are also various ligaments. The lateral and medial collateral ligaments
act to strengthen the medial and lateral aspects of the joint. The anterior cruciate ligament
is located in the centre of the knee controlling rotaion and forward motion of the tibia. It
arises in the posterior lateral part of the femur and attaches in front of the intercondylar
eminences. The posterior cruciate ligament is also located in the centre of the knee,
controlling the backward movement of the tibia. It arises from the antero-lateral aspect of
the medial femoral condyle and attaches over the back of the tibial plateau.

Within the knee there are numerous ossification centres. The distal femur appears 9 months
in utero and is fused between 17-19 years of age. The proximal tibia appears 9 months in
utero and is fused between 16-18 years. The tibial tuberosity appears at 10-12 years and is
fused by 12-14 years. The patella appears 3-5 years and is fused at puberty. The proximal
fibula appears at 2-4 years and is fused between 17-19 years.

Indications of injury include: trauma, pain, lumps, foreign body, swelling, inflammation,
infections, cuts, bruising, clicking, mobile patella, loss of function, previous surgery,
deformity, and reduced range of movement. When preparing the patient for examination it
is important to provide them with an explanation, remove the clothing and place a gown on,
check for pregnancy if female and provide the patient with lead protection.

AP Knee Projection: this


projection is performed on an
18x24cm cassette, using one
cassette per view. The patient is
to be lying on the table, with
the lg of the affected side
completely extended. Heel in
contact with the table and the
back of the knee in contact with
the cassette. Dorsiflex the ankle and rotate the leg medially 5 degrees. The long
axis of the leg should be parallel to the long edge of the cassette, and the central
ray perpendicular to the cassette. Centre to the apex of the patella, collimating on
four sides to the outer margins of the knee. FFD should be 100cm, kVp 60, mAs 10
using fine focus and no grid. The distal femur and proximal tibia and fibula should be
imaged, including the soft tissue. The femorotibial joint space should be open and the
femoral and tibial condyles should appear symmetrical. The patella is superimposed on the

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midline of the femur, and the medial half of the fibula head superimposed on the tibia.
Intercondylar eminences are separated and in the centre of the intercondylar fossa.

Rosenberg Weight bearing Knee


Projection: the maximum stress
placed on the knee occurs between
30-60 degrees of flexion. The
Rosenberg view is more sensitive
and specific for joint space
narrowing (cartilage loss) than the
conventional weight bearing AP
views and is useful for the
assessment of knees with early
degenerative change. For these projections place the cassette inside the bucky either erect
or table. FFD should be 100cm, kVp 65-70, mAs 10 using fine focus and grid.

Lateral Knee Projection: this


projection should be taken on an
18x24cm cassette, using a new
cassette, with the patient lying on the
table. Roll them onto their affected
side, with the leg either behind or in
front of the affected leg. Superimpose
the femoral condyles and medial and
lateral borders of patella. Have the knee slightly flexed and the long axis
of the left should be parallel to the long edge of the cassette. Angle the
central ray 5 degrees cephalad, centring 2cm distal to the medial
epicondyle. Collimate on four sides to the outer margins of the knee. The
FFD should be 100cm, kVp 60, mAs 10 using fine focus and no grid. The
distal femur and proximal tibia and the fibula should be imaged, with the
femorotibal joint space open. The femoral and tibial condyles should appear superimposed,
and the femoropatellar joint space open. The patella should be in profile, and the fibula
head only slightly superimposed over the tibia.
The lateral projection should be performed using the horizontal beam technique to detect
lipohaemarthrosis. The horizontal beam is tangential to the two layers of fat and blood,
therefore demonstrating a fluid level in the suprapatella pouch. Effusion shown as water
density enlargement of the suprapatellar joint space and displacement of the adjacent fat
strips in the area.

Intercondylar Knee Projection: this


projection should be taken on a
18x24cm cassette, using a new
cassette. The patient should be laying
on the table, with the knee of the
affected side flexed at 45 degrees.
The heel should be in contact with
the table, with the cassette built up as
close to the knee as possible. The
long axis of the leg should be parallel to the short edge of the cassette,
angling the central ray so that it is perpendicular to the long axis of the tibia. Centre to the
apex of the patella, and collimate on four sides to the outer margins of the knee. FFD should

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be 100cm, kVp 60, mAs 12 using fine focus and no grid. The distal femur and proximal tibia
and fibula should be imaged, with the intercondylar fossa open. The femorotibial joint space
should be open and the femoral and tibial condyles appearing symmetrical. The medial half
of the fibula head should be superimposed on the tibia and the intercondylar eminences
separated and in the centre of the intercondylar fossa.

Axial Patella Projection: this projection should be taken on


an 18x24cm cassette using a new cassette with the
patient lying at the end of the table with the knee of the
affected side at 45 degrees. Heel is in contact with the
table and the cassette resting on the mid thigh and tilted
so it is perpendicular to the central ray, with the patient
holding the cassette. The long axis of the leg should be
parallel to the short edge of the cassette, angling the ray
so it is parallel to the patella. Centre to the apex of the
patella and collimate on four sides of the knee. The FFD
should be 100cm, kVp 60, mAs 10 using fine focus and no
grid. Include the distal femur and patella, with the base
and apex of the patella superimposed. The femoropatellar
joint space should be open with the patella in profile.
Femoral condyles appear symmetrical.

Internal Oblique Knee Projection: Position patient as for AP and


medially rotate the leg 45 degrees.

External Oblique Knee Projection:


Position patient as for AP and
externally rotate the leg 45
degrees.

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Pathologies:

Lipohaemarthrosis: joint effusion with a fat or blood fluid


level. It occurs when fat and blood have escaped from a
fractured bone and leaked into the supra patella bursa. The
bursa appears expanded and has a darker upper half and a
light lower half. This is because the fat is less dense than
blood, and therefore floats on top of the blood and does
not absorb as much of the x-ray beam.

Joint Effusion: joint effusions may occur without a fracture


present, but fat will not be included in the effusion.

Complications within the knee include:


• Compromise of blood supply to the Popliteal Artery due to fractures near the
adductor canal and popliteal fossa.
• Damage to the common peroneal nerve due to a fracture of the head of the fibula
and compression of vessels caused by haematoma in the leg compartments.

Distal femoral fracture classification:

Proximal Tibial Fracture Classification:

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Classification of Patella Fractures:

Bipartite and Tripartite Patella: this is a


developmental variant of the accessory
ossification centre or centres of the
supralateral margin of the patella and should
not be mistaken for a fracture. This is
commonly seen bilaterally. The fragments
have smooth margins and well defined cortex
as compared to a fracture.

Dislocations: there can be a dislocation of the femorotibial joint which is not common and
patellofemoral joints which are more common. The patella is prone to dislocation,
subluxation and instability. To assess patella instability multiple Skyline or axial projections
are used in varying degrees of knee flexion. The objective is to: demonstrate joint line
without distortion, measure the patellofemoral relationship and to assess the configuration
of the patella and trochlea. Instability of the patella occurs close to full extension. The
patella first engages the femoral sulcus with 10-20 degrees of flexion then up to 90 degrees.

- patella dislocation

-Femorotibial - patella subluxation

- Patella dislocation

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Lose Bodies: presentation includes pain, catching and joint locking.


Often caused by trauma or degenerative disease. Seen as lose
osteophytes, osteochondral fracture or meniscal tag. Called a joint
mouse/mice, usually well demonstrated on intercondylar
projection.

Fabella: accessory ossicle in the gastrocnemius


muscle.

Osteoarthritis: commonly in knees as weight bearing joints. Present in a large majority of


people over the age of 55. Caused by repetitive and mechanical stresses over many decades
or long term sequel of previous fracture, meniscal or ligamentous damage. Presentation
includes pain, stiffness, and locking joints. Obvious visual deformity may include uneven gait
and varus or valgus deformity. Varus deformity is also
known as bow legged, with the angular deformity of
the lower legs outward and is caused by the medial
joint destruction. Valgus deformities are known as
knock knees, with the angular deformity of the lower
legs inwards, with lateral joint destruction. On a
radiograph they appear with decreased joint space,
subchondral bone sclerosis, joint margin osteophytes
and subchondral cysts.

Total Knee Replacement (TKR): replaces the articular


surfaces of the femur, tibia and patella. Complications
include: instability, bone fracture, infection, loosening
of prosthesis.

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Ruptured Medial Collateral Ligament: widened joint space


evident medially.

Osgood Schlatter Disease: an irritation of the patellar ligament a


the tibial tuberosity, occurring in active children ages 9-16
coinciding with periods of growth, also more prominent in boys
than girls. It is caused by stress placed on the tendon. Multiple
subacute avulsion fractures along with inflammation of the
tendon, leading to excess bone growth in the tuberosity and
producing a visible lump which can be very painful when hit.
RICE is the only treatment.

The Femur.

The femur is the longest and strongest bone within the entire
body. It is slightly bowed anteriorly, having three articulations. It
consists of a neck, head, greater and less trochanter, medial and
lateral epicondyles and medial and lateral condyles. The main
joints which include the femurs articulation include: the
patellofemoral joint, proximal tibiofibular joint, medial and lateral
femorotibial joints and the hip joint between the head of the
femur and the acetabulum. There are a number of ossification
centres evident: the femoral head appears 4-6 months and is
fused around 14-18 years, the greater trochanter appears 2-4
years and is fused 14-18 years, the lesser trochanter appears 10-
12 years and fuses 14-18 years, and the rest are mentioned within
the knee and lower leg.
Indication of pathology within the area include: trauma through
vehicle accidents and non-accidental, pain, lumps, foreign bodies,
swelling and inflammation, infetions, cuts, bruising, previous
surgery and deformity. When preparing the patient for
examination it is important to provide them with an explanation
fo te process, remove their clothing and place a gown on with
opening to the back, check for pregnancy if female and provide a
lead apron or lead cut outs for the patient.

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AP Hip Down Femur Projection: this


projection should be performed on a
35x43cm cassette, using one view per
cassette, with the patient lying supine on
the table. The leg of the affected side
should be extended, with the heel and back
of leg in contact with the cassette, having
the ankle dorsiflexed. Rotate the leg medially 5 degrees. The long axis of the leg
should be parallel to the long edge of the cassette, with the central ray
perpendicular to the cassette. Palpatate the greater trochanter and place the top
of the cassette 10cm above this. Centre to the cassette, collimating on four sides
to the outer margins of the leg. FFD should be 100cm, kVp 70, mAs 32 using broad
focus and grid. The entire hip and most of the femur should be included in the
image, with the femoral neck clearly seen. Both trochanter should be seen also.

AP Knee Up Femur Projection: this projection


should be taken on a 24x30cm cassette, using
one view per cassette, with the patient lying
supine on the tble. Leg of the affected side
should be extended with the heel and back of
knee in contact with the cassette, having the
ankle dorsiflexed. Rotate the leg medially 5
degrees. The long axis of the leg should be
parallel to the long edge of the cassette, with
the central ray perpendicular to the cassette, centering to the apex of the
patella. Collimate on four sides to the outer margins, however completely
lengthwise. Place the bottom of the cassette 3cm below the apex of the
patella. FFD should be 100cm, kVp 60, mAs 16 using broad focus and grid. The
proximal tibia, fibula and distal femur should be included on the image, with
the femorotibial joint space open. The femoral and tibial condyles should appear
symmetrical, with the patella superimposed on the midline of the femur. The medial half of
the fibula head should be superimposed on the tibia, and the intercondylar eminences
separated in the centre of the intercondylar fossa.

Lateral Hip Down Femur Projection: this


projection should be taken on a 35x43cm
cassette, using a new cassette, with the
patient lying supine on the table. Roll
them approximately 60-70 degrees onto
their affected side, with the other leg
behind the affected leg, with the knee
flexed. The long axis of the leg should be
parallel to the long edge of the cassette,
with the central ray perpendicular to the
cassette. Cassette in the same position as for AP, centring to the cassette and
collimating on four sides to the outer margins of the leg. FFD should be 100cm, kVp
70, mAs 32 using broad focus and grid. The entire hip and most of the femur should
be imaged, with the hip joint demonstrated. The greater and lesser trochanter
should superimpose the femur.

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Lateral Knee Up Femur Projection: this


projection should be taken on a
24x30cm cassette, using a new cassette,
with the patient lying supine on the
table, rolled onto their affected side.
The other leg should be in front or
behind. Superimpose the femoral
epicondyles and medial and lateral
borders of the patella, with the knee slightly flexed. The long axis of the leg
should be parallel to the long edge of the cassette, angling the beam 5
degrees upwards towards the head. Centre 2cm distal to the medial
epicondyle, and collimate on four sides to the outer margins of the knee,
hwoever completely lengthwise. Place the bottom of the cassette 3cm
below the apex of the patella. FFD should be 100cm, kVp 60, mAs 16 using
broad focus and grid. The proximal tibia and fibula, and distal femur should
be imaged, with the femorotibial joint space open. The femoral and tibial condyles should
appear superimposed, with the femoropatellar joint space open, with the patella in profile.
The fibula head should only slightly superimpose over the tibia. Consider use of horizontal
beam.

Pathologies:

Fractures:

Posterior Hip Dislocation:

Anterior Hip Dislocation:

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Fracture treatment usually occurs through traction, cast or internal fixation. Proximally they
generally use pin and plates, screws and THR. Mid shaft fractures usually
obtain an intramedullary K nail and distal use screws, plates.

Bone Islands: these are benign, solitary, sharply


demarcated area of dense compact bone.

Osteoid Osteoma: occurs in teenagers, with pain


being worse at night. It is a benign disease, which
originates from osteoblastic cells. Round oval
radiolucent centre nidus surrounded by a dense
sclerotic zone of cortical thickening.

Exostosis: benign, osteochondroma, bone projection with cartilganeous cap.


Teen years occurs, grows from epiphyseal plate parallel to the long bone.

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Osteogenic Sarcoma: this is a malignant disease


occurring at the end of a long bone in the metaphysis.
Consists of osteoblasts which produce osteoid and
spicules of calcified bone. Pulmonary metastases
develop early, with mixed lesion. Sunburst pattern,
soft tissue mass and elevation of periostium.

Ewings Sarcoma: this is a malignant disease, arising in the bone marrow


of long bones. Ill dfined area of bone destruction, within the central
portion of the shaft. Fusiform layered periosteal reaction.

Metastases: most common malignant bone tumours,


irregular poorly defined lucent lesions or poorly defined
increased densities. Weaken the bone.

Multiple Myeloma: this is a widespread malignancy of plasma


cells, attacking the intramedullary canal of the diaphysis.
Multiple punched out osteolytic lesions.

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