Mrsc1100 Notes
Mrsc1100 Notes
Mrsc1100 Notes
Mrsc1100 Notes.
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
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.
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).
Boxers fracture,
and shaft
fracture.
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.
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 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.
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.
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.
Pathology:
Avulsion fracture:
Thumb Fractures:
Winterstein Fracture: most common through the transverse plane, does not involve
articulation surface.
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.
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 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.
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.
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.
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.
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.
superimposition of the ulna, with the elbow joint open. Density and contrast should be
optimal to visualise bone and soft tissue.
Transcondylar Fracture.
Epicondylar Fracture.
Capitellar Fracture.
Radial Fracture.
Ulna Fracture.
Dislocation.
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.
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.
In severe cases of shoulder injuries a horizontal beam can be used to perform a lateral
projection.
Humerus Pathologies:
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.
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.
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.
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.
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.
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.
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.
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.
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.
Feet being at the same level at the bottom, need to elevate the bottom.
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.
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.
Metastases: third of
patients with cancer
develop pulmonary
metastases. On an x-ray
there will be multiple well
circumscribed opaque
nodules.
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:
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.
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:
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.
Central venous pressure catheter: tip just below joint of brachiocephalic veins to form the
SVC.
Pace maker:
Perforated bowel:
Dextrocardia:
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.
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.
Haemothorax:
Penumomediastinum:
Indications of injury or pathology within this area includes: infection (croup, epiglottitis,
enlarged adenoids), foreign body localization, goiter and trauma.
Tonsilitis:
Retropharyngeal abscess:
The hindfoot includes the calcaneus and talus, the midfoot includes the navicular, cuboid
and cuneiforms, and the forefoot includes the metatarsals and phalanges.
The longitudinal arch of the foot runs with the length of the foot, and the transverse runs
across the width of the foot.
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.
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.
Pathologies:
Pes Planus- flat feet: longitudinal arch is reduced on standing, causing muscle weakness and
paralysis. Bilateral AP and lateral weight bearing will display this.
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
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.
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.
Pin and plates are often common as well, using both AP and lateral
projections.
Urology:
Spine:
Exposures.
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
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.
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.
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.
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.
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.
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.
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.
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:
Pilon Fracture:
Tillaux Fracture:
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
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:
Complications of the lower leg: this can include delayed union, non-union, limb length
discrepancies and osteomyelitis.
External Fixation:
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.
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.
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.
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.
Pathologies:
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
- Patella dislocation
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.
Pathologies:
Fractures:
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.