LOWER LIMB  Normal respiration

TOES E. Exam Rationale

1. AP Projection (Dorsiplantar)  Demonstrate the interphalangeal joint

2. PA Projection spaces
3. AP Oblique Projection (Medial Rotation)
4. PA Oblique Projection (Medial Rotation)
5. Lateral Projection (Mediolateral or Lateromedial)
F. Structure Shown

 Phalanges of the toes

1. AP Projection
 Interphalangeal joints
A. Part Position  Distal portions of the metatarsals

 Patient 3. AP Oblique Projection (Medial Rotation)

is seated or supine
A. Patient Position
on the radiographic table
 Patient is in supine or
B. Part Position
seated on the
 Flex the knee until the foot flat on the radiographic table
image receptor
B. Part Position
 If there is no possibility of injury to the rest
of the foot or if it is a follow-up radiograph  Flex the knee with plantar surface of the
center on the toe concerned foot resting on the IR
 Rotate the lower leg and foot until the
C. Central Ray
plantar surface of the foot form 30 to 45
 Perpendicular to the metatarsophalangeal degree angle from the plane of the film
joint in question
C. Central Ray
 15 degrees posteriorly or toward the
calcaneus  Perpendicular to the metatarsophalangeal
joint concerned
D. Patient Instruction
D. Patient Instruction
 Normal Respiration
 Normal Respiration
E. Exam Rationale
E. Exam Rationale
 The most common indication of the toe(s) is
trauma  The oblique is a routine position of the toes
that gives a different perspective than that
F. Structure Shown
of an AP
 Phalanges
F. Structure Shown
 Interphalangeal joints
 Distal ends of metatarsals  Phalanges of the toes
 Interphalangeal joints
2. PA Projection
 Distal ends of metatarsals
A. Patient Position
4. PA Oblique Projection (Medial Rotation)
 Patient is in prone
A. Patient Position
position
 Patient in a lateral
B. Part position
recumbent position on
 Place the toes in the appropriate position in the affected side
the IR half under the toes with the midline
B. Part Position
of the side used parallel with the long axis
of the foot  Turn the patient toward the prone position
until the ball of the foot forms an angle of
C. Central Ray
30 degrees to the horizontal
 Perpendicular to the midpoint of the IR
C. Central Ray
entering the metatarsophalangeal joint
concerned  Perpendicular to the third
metatarsophalangeal joints
D. Patient Instruction
D. Patient Instruction  Dorsiflex the foot until the ball of the foot is
perpendicular to the IR
 Normal Respiration
 Ensure that the long axis of the foot is not
E. Exam Rationale rotated

 This projection shows the toes and the C. Central Ray

distal portions of the metatarsals rotated
 Perpendicular, posterior to the first
laterally without superimposition
metatarsophalangeal joint
F. Structure Shown
D. Patient Instruction
 Phalanges
 Normal Respiration
 Distal metatarsals and associated joints
E. Exam Rationale
5. Lateral Projections (Mediolateral or
Lateromedial)  Shows a tangential projection of the head of
metatarsals and sesamoids
A. Patient Position
F. Structure Shown
 Patient in lateral
recumbent position on  Metatarsal heads
the unaffected side  Sesamoids free of superimposition

B. Part Position 2. Tangential Projection (Causton Method)

 Rotate the affected leg and foot medially A. Patient Position

for lateromedial and laterally for
 Patient in lateral
mediolateral
recumbent position
C. Central Ray on the unaffected
side
 Perpendicular to the plane of the film,
entering the interphalangeal joint B. Part Position

D. Patient Instruction  Partially extend the limb being examined

 Place the IR under the distal metatarsal
 Normal Respiration
region
E. Exam Rationale
C. Central Ray
 Show a lateral projection of the phalanges
 45 degrees toward the heel, directed to the
of the toe and the interphalangeal
prominence of the first
articulations projected free of
metatarsophalangeal joint
superimposition
D. Patient Instruction
F. Structure Shown
 Normal Respiration
 Phalanges
 Interphalangeal joint spaces E. Exam Rationale

 Shows the sesamoid bones projected

axiolaterally with a slight overlap
SESAMOIDS
F. Structure Shown
1. Tangential Projection (Lewis and Holly Methods)
2. Tangential Projection (Causton Method)  Metatarsophalangeal joints
 Sesamoids with little overlap
1. Tangential Projection (Lewis and Holly Methods)

A. Patient Position

 Patient in prone
position

B. Part Position FOOT

 Elevate the ankle of 1. AP Projection (Dorsoplantar)

the affected side on 2. AP Oblique Projection (Medial Rotation)
sandbags for stability 3. Lateral Projection (Medilateral)
4. Lateral Projection (Weight-Bearing Method)
 E. Exam Rationale
1. AP Projection (Dorsoplantar)
 This projection shows the interspaces
A. Patient Position between the cuboid and the calcaneus,
cuboid and the fourth and fifth metatarsals,
 Patient is seated or
cuboid and the lateral cuneiform, talus and
supine position with
navicular bone
the knee flexed
F. Structure Shown
B. Part Position
 Phalanges
 Place the plantar surface of the foot flat on
 Metatarsals
the IR
 Sinus tarsi
 Ensure that no rotation of the foot occurs
 Lateral tarsometatarsal and intertarsal
C. Central Ray joints

 Perpendicular to the base of the third 3. Lateral Projection (Medial Rotation)

metatarsal
A. Patient Position
 10 to 25° towards the ankle, directed to the
navicular  Patient is in lateral
recumbent on the
D. Patient Instruction
affected side with
 Normal Respiration the unaffected leg
behind the affected leg
E. Exam Rationale
B. Part position
 This projection provides a general survey of
the bones of the foot, including  Dorsiflex the foot to form a 90° angle with
demonstrating of the phalanges, the lower leg
metatarsals, and the tarsals  Lateral surface of the foot rest on the IR
 Show the tarsometatarsal articulations until the plantar surface of the foot is
 Localizing foreign bodies perpendicular to the film
 Determining the locations of fragments in
C. Central Ray
fractures of the metatarsals and anterior
tarsals  Perpendicular to the base of the third
metatarsal (Medial cuneiform)
F. Structure Shown
D. Patient Instruction
 Metatarsophalangeal joints
 Phalanges  Normal Respiration
 Tarsals distal to the talus
E. Exam Rationale
2. AP Oblique Projection (Medial Rotation)
 The lateral taken at 90 degrees from the
A. Patient Position from the AP is used to demonstrate the
anterior/posterior displacement of the bony
 Patient is seated on
structure and to localize foreign bodies
the radiographic table
with the knee flexed F. Structure Shown
B. Part Position  Entire foot
 Tibiotalar joint space
 Rotate the patient’s leg medially until the
 Ankle joint
plantar surface of the foot forms an angle of
 Distal ends of the tibia and fibula
30°
 A greater rotation can be helpful in
demonstrating the joint spaces of the foot

C. Central Ray
4. Lateral Projection (Weight-Bearing Method)
 Perpendicular to the base of the third
metatarsal A. Patient Position

D. Patient Instruction  Patient in upright

position, weight is
 Normal Respiration evenly distributed on
both feet
B. Part Position 6. AP Axial Projection (Weight-Bearing Composite
Method)
 The feet should be flat in a natural position
with the weight equally distributed on the A. Patient Position
feet
 Patient is in
 Lower edge of the film is 2.5 cm below the
standing-upright
soles of the foot
position
C. Central Ray
B. Part position
 Horizontally, to the level of the base of third
 Place the plantar
metatarsals
surface of the foot
D. Patient Instruction flat
 To prevent the superimposition of the leg
 Normal Respiration
shadow on that of the ankle joint, place the
E. Exam Rationale opposite foot one step backward for the
exposure of the forefoot, and one step
 This projection shows the structural statues forward for the exposure of the hindfoot or
of the longitudinal arch of the foot and calcaneus
demonstrate pes planus
C. Central Ray
F. Structure Shown
 Exposure 1:
 Entire foot  15° posterior angulation to the base
 Distal tibia and fibula of the third metatarsals
 The superimposed tarsals and metatarsals  Exposure 2:
5. AP Axial Projection (Weight-Bearing Method)  25° anterior angulation to the
posterior ankle at the level of the
A. Patient Position lateral mallelus
 Patient in standing- D. Patient Instruction
upright position
 Normal Respiration
B. Part Position
E. Exam Rationale
 Ensure that the left and right markers and
upright marker are placed in the IR  Shows all bones of the foot and the full
 Ensure that full weight evenly distributed outline of the foot is projected free of the
on both feet leg

C. Central Ray F. Structure Shown

 10 to 15° posteriorly, midpoint between  Tarsals, Metatarsals, and the Toes

feet at the level of the base of the third
metatarsal
CONGENITAL CLUBFOOT
D. Patient Instruction
1. Kite Methods
 Normal Respiration A. AP Projection
E. Exam Rationale B. Lateral Projection

 This projection is used to demonstrate a 2. Kandel Method

weight-bearing axial projection of all A. Axial Projection (Dorsoplantar)
the bones of the foot, projected free Kite Method
from the distal lower leg 1. AP Projection
 Permitting an accurate evaluation and
comparison of the tarsals and A. Patient Position
metatarsals
 Infant patient in supine
 To demonstrate the hallux valgus
position
F. Structure Shown
B. Part Position
 Phalanges, Metatarsals, and Tarsals
 Flex the knee and the hip until the plantar
surface of the foot rest flat on the IR
C. Central Ray B. Part Position

 15° posterior angle, directed to the tarsals  The plantar surface of the foot should rest
 Perpendicular to the tarsals for bilateral on the IR
projection. To project the true relationship
C. Central Ray
of the bones and ossification centers
 40° anteriorly through the lower leg
D. Patient Instruction
D. Patient Instruction
 Normal respiration
 Normal Respiration
E. Exam Rationale
E. Exam Rationale
 To demonstrates the degree of adduction of
the forefoot and the degree of inversion of  The inclusion of the dorsoplantar axial
the calcaneus projection in the examination of the patient
with a clubfoot
F. Structure Shown
F. Structure Shown
 Talus
 Calcaneus  Calcaneus
 Tibia and Fibula  Sustentaculum talar joint
2. Lateral Projection (Mediolateral)

A. Patient Position CALCANEUS

 Place the infant 1. Axial Projection (Plantodorsal)
patient on his/her 2. Axial Projection (Dorsoplantar)
side as possible 3. Axial Projection (Weight-Bearing) (Coalition
Method)
B. Part Position 4. Lateral Projection (Mediolateral)
 Flex the uppermost limb, draw it forward
1. Axial Projection (Plantodorsal)
and hold it in place
 Hold the infant’s toes in position with tape A. Patient Position
C. Central Ray  Patient is seated or
supine position with
 Perpendicular, to the midtarsal area
the knee extended
D. Patient Instruction
B. Part Position
 Normal respiration
 Dorsiflex the foot until the plantar surface is
E. Exam Rationale perpendicular to the IR
 Loop gauze around the ball of the foot and
 To demonstrate the anterior talar
ask the patient to pull gently but firmly
subluxation and the degree of plantar
flexion C. Central Ray

F. Structure Shown  40° cephalad from the long axis of the foot,
directed to the base of the third metatarsal
 Talus, Calcaneus, and Metatarsals
 Distal tibia and fibula D. Patient Instruction

 Normal Respiration

Kandel Method E. Exam Rationale

1. Axial Projection (Dorsoplantar)  The most common indication for an

examination of the heel is trauma and to
A. Patient Position
show axial projection of the calcaneus
 The infant patient is held
F. Structure Shown
in a vertical or a bending
forward position  Calcaneus and talocalcaneal joint
  Anterior portion of the calcaneus  Calcaneus and subtalar
joint
2. Axial Projection (Dorsoplantar)
 Sustentaculum tali
A. Patient Position
4. Lateral Projection
 Patient is in prone position (Mediolateral)

B. Part Position A. Patient Position

 Dorsiflex the ankle to place the long axis of  Patient is supine or in

the foot perpendicular to table top lateral recumbent, turn the patient toward
 IR should be place against the plantar the affected side until the leg is
surface of the foot approximately lateral

C. Central Ray B. Part Position

 40° caudally, to the long axis of the foot,  Dorsiflex the foot so that the plantar
enters the dorsal aspect of the ankle joint surface is at right angle to the leg
 Lateral surface of the foot rest on the IR

C. Central Ray
D. Patient Instruction
 Perpendicular to the 1 to 1 ½ inches distal
 Normal Respiration to the medial malleolus
E. Exam Rationale D. Patient Instruction
 Shows an axial view of the calcaneus, with  Normal Respiration
the sustentaculum tali and tuberosity
E. Exam Rationale
F. Structure Shown
 Shows the heel in profile and is used to
 Calcaneus and subtalar joint demonstrate the anterior/posterior
 Sustentaculum tali displacement of bony pieces
3. Axial Projection (Weight-Bearing) (Coalition F. Structure Shown
Method)
 Calcaneus
A. Patient Position  Sinus tarsi
 Patient is in standing-  Ankle joint and adjacent tarsals
upright position

B. Part Position SUBTALAR JOINT

 The long axis of the calcaneus, with the 1. Broden Method (Pate Nor
posterior surface of the heels is against the A. AP Axial Oblique Projection (Medial Rotation)
IR B. AP Axial Oblique Projection (Lateral Rotation)
 Place the opposite foot one step forward to
prevent superimposition of the leg shadow 2. Isherwood Method (Feist Monkin Method)
A. Lateromedial Oblique Projection (Medial
C. Central Ray Rotation Foot)
 45° anteriorly, directed to the posterior B. AP Axial Oblique Projection (Medial Rotation
surface of the ankle at the level of the base Ankle)
C. AP Axial Oblique Projection (Lateral Rotation
of the fifth metatarsal
Ankle)
D. Patient Instruction

 Normal Respiration

E. Exam Rationale

 To demonstrate the
calcaneotalar
coalition
Broden Method
F. Structure Shown
1. AP Axial Oblique Projection (Medial Rotation)

A. Patient Position
  Patient in supine position  Posterior portion of the subtalar joint

B. Part Position Isherwood Method

 Dorsiflex the foot to obtain a right angle 1. Lateromedial Oblique Projection (Medial Rotation
flexion at the ankle joint Foot)
 Rotate the leg and foot medially to form an
A. Patient Position
angle of 45°
 Patient in semiprone
C. Central Ray
or seated position
 40° caudally, directed 2 or 3 cm  Flex the knee to
caudoanteriorly to the lateral malleolus place the ankle joint in nearly right angle
 To demonstrate the anterior and flexion
posterior talocalcaneal articulation
B. Part Position
 20 to 30° caudally
 To demonstrate articulation  Medial border of the foot resting on the IR
between the talus and the
sustentaculum tali C. Central Ray
 10 caudally  Perpendicular, to a point 1 inch distal and
 To demonstrate the posterior part anterior to the lateral malleolus
of the posterior talocalcaneal
articulation D. Patient Instruction

D. Patient Instruction  Normal Respiration

 Normal Respiration E. Exam Rationale

E. Exam Rationale  Shows the anterior subtalar articular

surface and an oblique portion of the
 To demonstrate the articular facet of the tarsals
calcaneus and to determine the presence of
joint involvement in cases of comminuted F. Structure Shown
fracture  Anterior talar articular surface
 Shows the articulation between the talus
and sustentaculum tali (middle facet) 2. AP Axial Oblique Projection (Medial Rotation
Ankle)
F. Structure Shown
A. Patient Position
 Anterior and posterior portion of the
posterior subtalar joint  Patient in seated position

2. AP Axial Oblique Projection (Lateral Rotation) B. Part Position

A. Patient Position  Rotate the leg and

foot medially by 30°
 Patient in supine  Dorsiflex the foot,
position and invert it if
B. Part Position possible

 Rotate the leg and foot 45° laterally C. Central Ray

C. Central Ray  10° cephalad, directed to a point 1 inch

distal and anterior to the lateral malleolus
 15° cephalad (12-18°), directed 2 cm below
and in front of the medial malleolus D. Patient Instruction

D. Patient Instruction  Normal Respiration

 Normal Respiration

E. Exam Rationale E. Exam Rationale

 Shows the posterior facet of the calcaneus  Shows the middle articulation of the
and the articulation between the talus and subtalar joint and “end-on” projection of
sustentaculum tali the sinus tarsi

F. Structure Shown F. Structure Shown

  Middle Subtalar Articulation  Normal respiration
 Sinus Tarsi
E. Exam Rationale
3. AP Axial Oblique Projection (Lateral Rotation
 Radiographic examination of the knee is
Ankle)
commonly indicated in cases of trauma or
A. Patient Position degenerative joint disease

 Patient is either supine or seated position F. Structure Shown

B. Part Position  Distal femur

 Proximal tibia and fibula
 Rotate the leg and foot 30° laterally
 Patella and knee joint
 Dorsiflex the foot and evert it if possible
2. Lateral Projection
C. Central Ray
A. Patient Position
 10° cephalad, directed to a point 1 inch
distal to the medial malleolus  Patient is in lateral
recumbent on the
D. Patient Instruction
affected with the
 Normal Respiration unaffected leg may be placed in front of the
affected knee
E. Exam Rationale
B. Part Position
 Shows the posterior articulation of the
subtalar joint  Flex the knee 20 to 30° because this
position relaxes the muscle and shows the
F. Structure Shown maximum volume of the joint cavity
 Posterior subtalar articulation  Knee should not be flexed more than 10° to
prevent fragment separation in new or
unhealed patellar fractures
KNEE C. Central Ray
1. AP Projection  5 to 7° cephalad, directed 1 inch distal to
2. Lateral Projection the medial epicondyle. This angulation
3. AP Internal Oblique
prevent the joint space from being
4. AP Projection (Weight Bearing Method)
obscured by the magnified image of the
5. PA Projection (Rosenberg Method)
medial femoral condyle
6. AP Oblique Lateral Rotation
7. PA Axial Projection (Homblad Method) 8. PA Axial D. Patient Instruction
Projection (Camp-Coventry Method)
9. AP Axial Projection (Beclere Method)  Normal Respiration

E. Exam Rationale
1. AP Projection
 This radiograph shows a lateral image of the
A. Patient Position distal end of the femur, patella, knee joint,
proximal ends of the tibia and fibula, and
 Patient is seated
adjacent soft tissue.
or supine position
on the F. Structure Shown
radiographic table with the knee extended
 Distal femur, proximal tibia, fibula patella
B. Part Position and tibiofemoral joint and patellofemoral
joints
 Rotate the leg internally 3 to 5° until the
intercondylar line is parallel to the fil 3. AP Oblique Internal Rotation
 Center the knee joint ½ inch distal to the
A. Patient Position
patella apex.
 Patient is seated or
C. Central Ray
supine position on
 5° cephalad, to a point ½ inch below apex of the table with the
the patella knee extended

D. Patient Instruction B. Part Position

  Rotate the affected leg 45° internally, this  Place the patient in the standing position
may require elevation of the hip on the on with the anterior aspect of the knees
the affected side centered to the vertical grid device.

C. Central Ray B. Part Position

 5 cephalad, directed to ½ inch inferior to  For a direct PA projection, have the patient
the patellar apex stand upright with knees in contact with the
vertical grid device.
D. Patient Instruction
 Center the IR at a level 1/2 inch (1.3 cm)
 Normal Respiration below the apices of the patellae.
 Have the patient grasp the edge of the grid
E. Exam Rationale device and flex knees to place the femurs at
 The oblique is an alternative position of the an angle of 45 degrees
knee that is used to provide a different C. Central Ray
perspective from that of the AP and lateral.
 Perpendicular to the tibia and fibula.
F. Structure Shown  A 10-degree caudal angle is sometimes
 Lateral femoral and tibial condyles used.
 Lateral tibial plateau D. Patient Instruction
 Head of the fibula and
 The proximal tibiofibular articulation  Normal Respiration

4. AP Projection (Weight-Bearing Method) E. Exam Rationale

A. Patient Position  PA weight-bearing method is useful for

evaluating joint space narrowing and
 Patient is in erect or demonstrating articular cartilage disease
standing position
F. Structure Shown
B. Part Position
 Both knees
 Toes painting forward and the feet  Knee joint
separated sufficiently to achieve a good
balance with weight evenly distributed on 6. AP Oblique Lateral Rotation
both feet
A. Patient Position
C. Central Ray
 Patient is seated or
 Horizontally, directed ½ inch below the supine position on
apex of the patella the radiographic
table with the knee extended
D. Patient Instruction
B. Part Position
 Normal Respiration
 Rotate the affected leg 45° externally
E. Exam Rationale  Elevate the hip of the unaffected side to
 Weight bearing examination of the knee is rotate the affected limb
commonly indicated in cases of C. Central Ray
degenerative joint disease, spaces of the
knees, varus and valgus deformities.  5 cephalad, directed to ½ inch below the
 Reveals the narrowing of a joint space that apex of the patella
appears normal on the non weight bearing
D. Patient Instruction
study
 Normal Respiration
F. Structure Shown
E. Exam Rationale
 Knee joint
 Proximal tibia and fibula  The oblique is an alternative position of the
 Distal femur knee that is used to provide a different
perspective from that of the AP and Lateral
6. PA Projection (Rosenberg Method)
 It is used to demonstrate the medial
A. Patient Position femoral and tibial condyles and lateral tibial
plateau
F. Structure Shown  Normal Respiration

 Proximal tibia and fibula E. Exam Rationale

 Distal femur
 This axial image demonstrates an
 Knee joint
unobscured projection of the intercondylar
7. PA Axial Projection (Holmblad Method) fossa and the medial and lateral
intercondylar tubercles of the intercondylar
A. Patient Position
eminence.
 Patient is in
F. Structure Shown
kneeling position on
the radiographic  Intercondylar fossa
table, with the  Femoral and tibial condyles
affected knee over the IR  Intercondylar eminence
 Articular facets of tibia
B. Part Position
9. AP Axial Projection (Beclere Method)
 Flex the knee 70° and ask the patient to
lean forward A Patient Position

C. Central Ray  Patient is in

supine position.
 Perpendicular, directed to the mid popletial
crease. B. Part Position

D. Patient Instruction  Flex the knee 60°

to the long axis of the tibia.
 Normal Respiration
 If curved cassette is available, place under
E. Exam Rationale knee.

 The degree of flexion in this position C. Central Ray

widens the joint space between the femur
 Perpendicular to the long axis of the tibia,
and tibia and gives an improved image of
directed ½ inch below the patellar apex.
the joint and surfaces of the tibia
 It shows the intercondylar fossa of the D. Patient Instruction
femur and the medial and lateral
 Normal Respiration
intercondylar tubercles of the intercondylar
eminence E. Exam Rationale
F. Structure Shown  This is a reverse of the PA axial projection
for those who cannot assume prone
 Intercondylar fossa
position
 Femoral and tibial condyles
 Intercondylar eminence and F. Structure Shown
 Articular facets of tibia
 Intercondylar fossa
8. PA Axial Projection (Camp-Coventry Method)  Femoral and tibial condyles
 Intercondylar eminence
A Patient Position
 Articular facets of tibia
 Patient is in
supine position.
LEG
B. Part Position
1. AP PROJECTION
 Flex the patient's knee 40 to 50°
 Adjust the leg so that the knee has no A. Patient Position
medial or lateral rotation  Seated or supine
C. Central Ray  Knee extended
B. Part Position
 Perpendicular to the long axis of the tibia,
 Center the leg to the IR
directed to the mid popletial depression
 Adjust the leg so that the femoral condyles
 40° caudad when the knee is flexed 40° and
are parallel with the IR
50° caudad when the knee is flexed 50°
 Dorsiflex the foot so it is perpendicular to
D. Patient Instruction the image receptor
C. Central Ray  Demonstrate distal ends of the tibia and
 Perpendicular to the midshaft of the leg fibula, proximal portion of the talus, the
D. Patient Instruction lateral and medial malleoli and the proximal
 Normal Respiration half of the metatarsals
E. Exam Rationale F. Structure Shown
 Trauma is the most common indication of  Tibiofibular joint spaces
the lower leg  Medial and lateral malleoli
 Tibia and fibula should be slightly  Proximal half of metatarsals
overlapped at both the proximal and distal  Soft tissue
ends
F. Structure Shown 2. LATERAL PROJECTION
 Tibia, fibula, knee, ankle joints
A. Patient Position
2. LATERAL PROJECTION  Supine
 Turn toward the
A. Patient Position affected side until
 Lateral recumbent ankle is in lateral
on the affected side B. Part Position
down  Place the long axis of the leg parallel with
B. Part Position the long axis of the IR
 Flex leg about 45 degrees and ensure that  Lateral surface of the foot in the contact
the leg is in true lateral position with the IR
C. Central Ray  Dorsiflex the foot so that the plantar
 Perpendicular to the midshaft of the leg surface is at the right angle leg
D. Patient Instruction  Dorsiflexion is required to prevent lateral
 Normal Respiration rotation of the ankle.
E. Exam Rationale C. Central Ray
 The lateral taken at 90 degrees from the AP  Perpendicular to the ankle joint, directed to
is used to demonstrate anterior and the medial malleolus
posterior displacements of bony structures D. Exam Rationale
F. Structure Shown  This projection is useful in the evaluation of
 Tibia, Fibula, Knee, Ankle joints the fractures, dislocations and joint
ANKLE effusions associated with other joint
1. AP Projection
pathologies
2. Lateral Projection (Mediolateral)
E. Structure Shown
3. AP Oblique Projection (Medial Rotation)
 Ankle joint
4. AP Oblique Projection (Mortise Joint)
 Tibiotalar joint
5. AP Stressed/ Forced Version
 Distal and 1/3 of tibia and fibula
 Tuberosity of the 5th metatarsals, navicular,
1. AP PROJECTION and cuboid.

A. Patient Position 3. AP OBLIQUE PROJECTION (MEDIAL ROTATION)

 Supine with the
affected lower A. Patient Position
limb fully  Supine position
extended with the
B. Part Position affected limb
 Ankle joint anatomic position to obtain a normally
true AP projection extended
C. Central Ray B. Part Position
 Perpendicular to the ankle joint, midway  Dorsiflex the foot enough to place the ankle
b/w the malleoli at nearly right-ankle flexion
D. Patient Instruction  Rotate the leg and foot medially by 45
 No rotation degrees
 Normal respiration C. Central Ray
E. Exam Rationale
  Perpendicular to the IR and directed  Rupture of a ligament is demonstrated by
midway b/w the malleoli widening of the joint space on the side of
D. Exam Rationale the leg from the supine position
 Demonstrate the distal tibiofibular joint E. Structure Shown
open, with no or only minimal overlap on  Ankle joint
the average person  Ligament tear or rupture
E. Structure Shown
 Distal and 1/3 of the lower leg PATELLA
 Tibiofibular articulation 1. PA PROJECTION
 Distal tibia, fibula, talus
 Proximal half of the metatarsals A. Patient Position
 Prone with leg
4. AP OBLIQUE PROJECTION (MORTISE JOINT) extended
 If the knee is painful,
A. Patient Position place a sandbag under the thigh and
 Supine another under the leg. To relieve the
B. Part Position pressure on the patella
 Do not dorsiflex the B. Part Position
foot  Rotate the heel 5 to 10 degrees laterally
 Plantar surface of C. Central Ray
the foot should be placed at a right angle to  Perpendicular to mid popliteal area
the leg D. Patient Instruction
 Rotate the entire leg and foot 15-20  Normal respiration
degrees internally, until the intermalleolar E. Exam Rationale
line is parallel to the IR  Is indicated in cases of trauma, and
C. Central Ray provides a better detail than the routine AP
 Perpendicular entering the ankle joint projection of the knee
midway b/w the malleoli F. Structure Shown
D. Exam Rationale  Proximal tibia and fibula
 Proper obliquity of the mortise joint will  Distal femur
open the lateral and medial mortise joints  Knee joint and patella
and only minimal superimposition should
exist at the distal tibiofibular joint
2. LATERAL PROJECTION
E. Structure Shown
 Entire ankle and mortise joint
A. Patient Position
 Talofibular joint  Lateral recumbent
 Distal 1/3 of the tibia and fibula position
 Proximal 5th metatarsals B. Part Position
 Flex the unaffected knee and hip and place
5. AP STRESSED/ FORCED INVERSION the unaffected foot in front of the affected
limb for the stability
A. Patient Position
 Flex the affected knee 5 to 10 degrees until
 Supine with the
the interepicondylar plane is perpendicular
affected lower
to the image receptor
limb fully
C. Central Ray
extended
 Perpendicular directed to femoropatellar
joint space
B. Part Position
D. Patient Instruction
 Dorsiflex the foot as near as right angle to
 Normal respiration
the leg as possible
E. Exam Rationale
 The entire plantar is turned medially for the
 Shows a lateral projection of the patella and
inversion and laterally for eversion
patellofemoral joint space
C. Central Ray
F. Structure Shown
 Perpendicular to the IR and directed to a
 Distal femur
midpoint midway b/w the malleoli
 Proximal tibia and fibula
 Knee joint and patella
D. Exam Rationale
3. PA AXIAL OBLIQUE PROJECTION (KUCHENDORF  Uses axial viewer device
METHOD)
A. Patient Position
A. Patient Position  Supine
 Prone  Knees flexed and the lower legs hanging off
B. Part Position the end of the radiographic table, a special
 Elevate the hip of the affected side 2 or 3 image receptor-holding device is required
inches B. Part Position
 Rotate the knee laterally from PA 35 to 45  Place femora parallel to the table top by
degrees so that no pressure is placed on the elevating the knees approximately 2 inch
injured patella and flex the knees 40 to 45 degrees
 Flex the knee slightly approximately 10  Secure legs together below the knees to
degrees to relax the muscle. prevent rotation and to allow patient to be
C. Central Ray totally relaxed
 25 to 30 caudally directed to the joint space
b/w the patella and femoral condyles C. Central Ray
D. Patient Instruction  Perpendicular to IR
 Normal respiration  30degrees caudally to the horizontal if the
E. Exam Rationale degree of knee flexion is 40degrees,
 To protect more of the patella free of directed b/w the patella at the level of the
superimposition of the femur patellofemoral joint
F. Structure Shown D. Patient Instruction
 Patella and its outline  Normal respiration
E. Exam Rationale
4. TANGENTIAL PROJECTION (HUGHSTON
 Demonstrate the patella and the
METHOD/ SAROCHY METHOD)
patellofemoral joints
A. Patient Position F. Structure Shown
 Prone position  Patella
with the knee  Femoral condyles and intercondylar sulcus
extended  Patellofemoral interspaces

6. TANGENTIAL PROJECTION (SETTEGAST

METHOD)
B. Part Position
 Flex the knee 50 to 60, or 55 degrees rest A. Patient Position
the foot against the collimator  Prone
 Ensure that the collimator surface is not hot B. Part Position
 Place pad b/w foot and possible hot  Slowly flex the
collimator knee until the patella in perpendicular to
 Adjust the leg so that there is no medical or the IR approximately 90 degrees
lateral deviation of the leg from vertical  Gently adjust the leg so that its long axis is
plane vertical
C. Central Ray C. Central Ray
 45 degrees cephalad directed to the  15 to 20 degrees cephalad directed to the
patellofemoral joint space b/w patella and the femoral condyles
D. Patient Instruction D. Patient Instruction
 Normal respiration  Normal respiration
E. Exam Rationale E. Exam Rationale
 Demonstrate patellar fracture or  To protect more of the patella free of
subluxation superimposition of the femur
F. Structure Shown F. Structure Shown
 Patella  Patella and its outline
 Patellofemoral articulations
 Surfaces of the femoral condyles 7. TANGENTIAL PROJECTION (SUNRISE/SKYLINE
METHOD)
5. TANGENTIAL PROJECTION (MERCHANT
METHOD) A. Patient Position
 Mountain View
  Either seated or supine Lateral distal femur Proximal Femur
B. Part Position
 Flex the knees 40 to 45 degrees A. Patient Position
 The quadriceps femoris muscles must be  Lateral recumbent position on the affected
relaxed to prevent subluxation of the side
patella, wherein they are pulled into the  If the proximal femur is the area of interest,
intercondylar sulcus or groove, which may the unaffected leg is placed behind the
result in false readings affected leg
C. Central Ray  If the distal femur is the area on interest,
 30 degrees from the horizontal, directed to the unaffected leg is flexed and in front on
the patellofemoral joint spaces the affected leg
D. Patient Instruction B. Part Position
 Normal respiration  Flex the affected knee 45 degrees, and
E. Exam Rationale adjust the body rotation t o place the
 Demonstrates fractures and subluxation of epicondyles perpendicular to the table top
the patella C. Central Ray
F. Structure Shown  Perpendicular, directed to the midshaft of
 Axial view of the patella the thigh.
 Intercondylar sulcus D. Patient Instruction
 Patellofemoral articulation  Suspended respiration
E. Exam Rationale
FEMUR  Shows a lateral projection about ¾ of the
1. AP Projection femur and the adjacent joint.
2. Lateral Projection F. Structure Shown
3. Patellofemoral articulation  Entire length the femur
 Knee and hip joint
1. AP PROJECTION
3. TRANSLATERAL PROJECTION
A. Patient Position
 Supine A. Patient Position
 Supine
 Knee extended
B. Part Position
B. Part Position
 The knee of the affected leg should be
 Center the thigh to
extended
the midline of the table and position it to
 Elevate the unaffected leg and place a high
include both joints when possible
support under the foot and ankle
 When distal femur is included, rotate the
 Place the cassette on the edge against the
limb internally to place it in true anatomic
lateral thigh
position
C. Central Ray
 When the proximal femur is included,
 Horizontally, directed from the medial side
rotate the limb internally 15-20 degrees to
of the midshaft of the femur
place the femoral neck in the profile
D. Patient Instruction
C. Central Ray
 Suspended respiration
 Perpendicular and directed to the midshaft
E. Exam Rationale
of the femur
 This translateral position of the femur is
D. Patient Instruction
indicated when the patient’s condition
 Suspended respiration
contraindicates turning the patient for a
routine lateral
E. Exam Rationale  This position is recommended for patients
 The AP projection of the femur with fracture or patients who have
demonstrates the entire length of the destructive disease
femur including knee and hip joint F. Structure Shown
F. Structure Shown  Entire length the femur
 Mid and Distal femur, including knee joint.  Knee and hip joint

2. LATERAL PROJECTION PELVIS

1. AP Projection
2. PA Projection. 3. AP AXIAL “OUTLET” PROJECTION (TAYLOR
3. AP Axial Projection "Outlet" (Taylor Method) METHOD)
4. Superoinferior Axial "Inlet" Projection (Lilienfeld
Method) A. Patient Position
5. PA Axal "Inlet Projection (Staunig Method)  Patient is in supine
position with the
legs extended
1. AP PROJECTION B. Part Position
 Midsagittal plane of the body should be
A. Patient Position centered to the midline of the table
 Patient is in supine  The ASIS should be equidistant from the
position table
B. Part Position C. Central Ray
 Rotate the feet and the lower limbs about  Males, 20 to 35 cephalad. directed to a
15 degrees 20° to place the femoral necks point 2 inches distal to the upper border of
parallel with the plane of the image border of the symphysis pubis.
receptor  Females, 30 to 45°cephalad, directed to a
 The heels should be placed about 8 to 10 point 2 inches distal to the upper border of
inches apart. the symphysis pubis.
C. Central Ray D. Patient Instructions
 Perpendicular between the ASIS and the  Suspended respiration
pubic symphysis. 2 inches inferior to the E. Exam Rationale
ASIS and 2 inches superior to the pubic  This axial projection demonstrates the
symphysis. pubic and ischial rami elongated and
D. Patient Instructions magnified but free of displacement of pubic
 Suspended respiration or superimposition.
E. Exam Rationale  Assess for pelvic trauma or ischial
 This projection provides a general survey of
structures.
the bones of the pelvis and the head, neck,
F. Structures Shown
and greater trochanter of each of the  Pubic and Ischial bones
femora.  Hip joints and Obturator foramina
 Proximal 1/3 of the shaft of the femora.
F. Structures Shown 4. SUPEROINFERIOR AXIAL “INLET” PROJECTION
 Entire pelvis, Greater trochanters, Femoral (LILIENFIELD METHOD)
necks and Ischial spines
A. Patient Position
2. PA PROJECTION  Patient is seated-
upright position on
A. Patient Position the radiographic table
 Patient is in prone position
B. Part Position B. Part Position
 Center the IR at the level of  Midsagittal plane of the patient's body is
the greater trochanters. center to the center line of the table
C. Central Ray  Flex the knees slightly and support them to
 Perpendicular enters the distal coccyx and relieve strain
exits the pubic symphysis  Lean backward 45 to 50, and then arch the
D.Patient Instructions back, to place the pubic arch in vertical
 Suspended respiration
position.
E. Exam Rationale
 Adjust the pelvis so that the ASIS is
 This projection shows the pubic symphysis
equidistant from the table
and ischia, including the obturator
C. Central Ray
foramina.
 Perpendicular, entering 1 ½ inch superior to
F. Structures Shown
the pubic symphysis.
 Pubic and Ischial bones
D. Patient Instruction
 Hip joints.
 Suspended respiration
 Obturator foramina
E. Exam Rationale
  This projection shows the anterior pubic  Rotate the lower limb 15 medially to place
and ischial bones and the pubic symphysis. the 20 femoral neck parallel with the plane
 The inlet can also be demonstrated with the of the image receptor.
patient in supine position with 40 degrees  The sagittal plane 2 inches medial to the
caudal angulation anterior superior iliac spine of the affected
F. Structures Shown side should be centered to the midline of
 Pubic and Ischial bones the table.
 Hip joint C. Central Ray
 Anterior pelvic bones  Perpendicular, directed to the femoral neck,
approximately 2-inches medial to the ASIS
5. PA AXIAL "INLET” PROJECTION (STAUNIG of the affected side at a level just above the
METHOD) greater trochanter.
D. Patient Instructions
A. Patient Position  Suspended respiration
 Patient is in prone position E. Exam Rationale
B. Part Position  This position is often done to demonstrate
 Midsagittal plane of the body is center to the entire pelvic girdle and both upper
the midline of the radiographic table femora and the greater trochanters should
 Adjust the body so that the pelvis will not be fully visualized
be rotated. F. Structures Shown
C. Central Ray  Head, Neck, Trochanter and the proximal
 35 degrees cephalad, exiting the pubic third of the femoral shaft
symphysis at the level of the greater 2. LATERAL PROJECTION (LAUENSTIEN METHOD)
trochanters.
D. Patient Instructions A. Patient Position
 Suspended respiration  Patient is in supine
E. Exam Rationale position, rotate the
 This PA axial projection of the pubic, ischial patient slightly toward the
bones and pubic symphysis will be nearly affected side to
identical to the superoinferior axial posterior oblique body position
projection. B. Part Position
F. Structures Shown  Flex the affected knee and abduct the leg to
 Pubic and Ischial bones place the femur parallel to the image
 Hip joints receptor
 Anterior pelvic bones  Extend the opposite limb.
C. Central Ray
 Perpendicular, to a point midway between
HIP ASIS and symphysis pubis.
 For Hickey method, 20 to 25° cephalad
1. AP Projection
D. Patient Instructions
2. Lateral Projection (Lauenstien Methods)
 Suspended respiration
3. Axiolateral Projection (Danelius-Miller or Lorenz
Method) E. Exam Rationale
4. Axiolateral Projection (Clements-Nakayama  This examination is contraindicated for
Modification) patients with a suspected fracture of
5. Axiolateral Projection (Friedman Method) pathologic condition.
6. PA Oblique Projection (Hsieh Method) RAO or  This method is used to demonstrate the hip
LAO Position joint and the relationship of the femoral
7. Mediolateral Oblique Projection (Lilienfeld
head to the acetabulum.
Method) RAO or LAO Position
F. Structures Shown
1. AP PROJECTION  Hip joint, acetabulum and femoral head.

A. Patient Position 3. AXIOLATERAL PROJECTIOON (DANELIUS-MILLER

 Patient is in supine or LORENZ METHOD)
position
B. Part Position A. Patient Position
  Patient is in supine position and elevate the arthroplasty and due to limited movement
pelvis 1 to 2 inches of both the affected and unaffected leg.
B. Part Position F. Structures Shown
 Flex the knee and hip of the unaffected side  Hip joint
to elevate the thigh in a vertical position  Femoral head, neck, and trochanters
 Rest the unaffected leg on a suitable 5. AXIOLATERAL PROJECTION (FRIEDMAN
support that will not interfere with the METHOD)
central ray.
 Unless it is contraindicated, rotate the foot A. Patient Position
of the affected leg medially 15 degrees  Patient in lateral
 Place the IR in the vertical position with its recumbent position on
upper border in the crease above the iliac the affected side.
crest.  Midcoronal plane of the
 The knee of the affected leg should be body is center to the midline of the table.
extended B. Part Position
C. Central Ray  Extend the affected limb and adjust it in a
 Horizontal perpendicular to the long axis of lateral position
the femoral neck, about 2 ½ inches below  Roll the unaffected lower limb posteriorly,
the point of intersection of the localization approximately 40
lines. C. Central Ray
D. Patient Instructions  35° cephalad. directed to the femoral neck.
 Suspended respiration D. Patient Instructions
E. Exam Rationale  Suspended respiration
 This projection of the hip is indicated when E. Exam Rationale
the patient cannot be positioned for a  Shows the head, neck, trochanters and
routine lateral to show the acetabulum, proximal shaft of the femur.
head, neck and trochanters of the femur. F. Structures Shown
 Hip joint, Femoral head, neck and
F. Structures Shown
 Femoral neck, hip joint and ischial trochanters.
tuberosity below the femoral head.
6. PA OBLIQUE PROJECTION (HSEIH METHOD) RAO
or LAO POSITION
4. AXIOLATERAL PROJECTION (CLEMENT’S
NAKAYAMA PROJECTION)
A. Patient Position
 Patient is in
A. Patient Position
 Patient is in supine semiprone
position on the position with the
radiographic table affected hip close in contact to the
with the affected side near the edge of the radiographic table.
table B. Part Position
 Elevate the unaffected side approximately
B. Part Position
 Leg remains in neutral position 40 to 45 degrees
 The image receptor should be tilted 15°  Flex the knee and forearm of the elevated
from the vertical, so it is parallel to the side
central ray. C. Central Ray
 Perpendicular, midway between the
C. Central Ray
 15 degrees posterior angle aligned posterior surface of the iliac blade and the
perpendicular to the femoral neck. dislocated femoral head.
D. Patient Instructions D. Patient Instructions
 Suspended respiration  Suspended respiration
E. Exam Rationale
E. Exam Rationale  This projection is used to demonstrates the
 This projection is indicated when both a posterior dislocations of the femoral head
routine lateral and axiolateral are contra- in cases of other acute fracture dislocations.
indicated, and when the patient has F. Structures Shown
bilateral hip fractures, bilateral hip  Hip joint, Ilium and Proximal femur
7. MEDIOLATERAL OBLIQUE PROJECTION ACETABULUM
(LILIENFIELD METHOD) RAO or LAO POSITION 1. PA Axial Oblique Projection (Teufel Method) RAO
or LAO Position
A. Patient Position 2. AP Oblique Projection (Judet Method) RPO or
 Patient is in lateral LPO Position
recumbent
position on the 1.PA AXIAL PROJECTION (TEUFEL METHOD) RAO or
affected side LAO POSITION
B. Part Position
 Center the midcoronal plane of the body to A. Patient Position
the midline of the table.  Patient is in
 Fully extend the affected thigh semiprone position
 Roll the upper limb forward approximately on the affected side
15 degrees B. Part Position
 Elevate the unaffected side so that the
C. Central Ray
 Perpendicular, to the midshaft of the image anterior surface of the body forms 38° angle
receptor from the table
D. Patient Instructions
 Suspended respiration
E. Exam Rationale
C. Central Ray
 This examination is contraindicated for
 Perpendicular, directed to the femoral neck,
patients with a suspected fracture or
approximately 2 inches medial to the ASIS
pathologic condition to demonstrates the
of the affected side at a level just above
ilium, acetabulum and proximal femur.
greater trochanter.
F. Structures Shown
D. Patient Instructions
 Hip joint, Femoral and Acetabulum
 Suspended respiration
E. Exam Rationale
8. AP OBLIQUE PROJECTION (MODIEFIED CLIEVES
 Demonstrates the fovea capitis and
or FROG-LEG BILATERAL PROJECTION)
particularly the superoposterior wall of the
A. Patient Position acetabulum.
 Patient is in supine F. Structures Shown
position  Superior and Posterior rim of acetabulum
B. Part Position  Hip joint and Femoral head
 Flex the hips and
knees and draw the feet up as much as 2 AP OBLIQUE PROJECTION (JUDET METHOD) RPO
possible. or LPO POSITION
 Abduct the thighs approximately 40-45
degrees from the vertical plane to pLace the
long axis of the femoral necks parallel with
the plane of the IR
C. Central Ray
 Perpendicular, to a point 1 inch superior to A. Patient Position
the Symphysis pubis  Patient is in semiprone position with the
D. Patient Instructions affected side up.
 Suspended respiration B. Part Position
E. Exam Rationale  Elevate the affected side approximately 45°
 This examination is commonly indicated for angle from the table.
investigation of congenital hip disease, and C. Central Ray
it is contraindicated in patients with  Perpendicular, directed 2 inches inferior to
suspected fractures or pathologic hip the ASIS of the affected side.
disease. D. Patient Instructions
F. Structures Shown  Suspended respiration
 Femoral heads and necks E. Exam Rationale
 Pelvis, Ilium and Trochanters  This position are useful in diagnosing
fractures of the acetabulum
  For internal oblique: the affected side up for
a patient with a suspected fracture of the
iliopubic column 'anterior' and the posterior
rim of the acetabuum.
 For external oblique: The affected side
down for a patient with a suspected
fracture of the ilioischial column 'posterior
and the anterior rim of the acetabulum
F. Structures Shown
 Acetabular rim
 Iliopubic and Ilioischial column