LOWER EXTREMETIES
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Questions and Answers

What does an angle less than 20 degrees suggest in relation to the foot?

  • A condition of pes cavus
  • An ankle sprain
  • A calcaneal fracture or posterior facet disruption (correct)
  • A normal foot structure

    • Which of the following describes pes planus?

  • A flat foot with no arch (correct)
  • A normal arch structure
  • An abnormal high arch
  • A condition involving multiple foot deformities

    • In the AP axial Projection Weight-bearing method, what is the recommended angulation of the CR?

  • No specific angulation required
  • 30° posteriorly
  • 20-25° toward the heel
  • 10-15° toward the heel (correct)

    • What is typically the most common foot deformity demonstrated in imaging?

    <p>Hallux valgus</p> Signup and view all the answers

    What is the primary focus of the lateromedial projection in assessing foot structures?

    <p>To demonstrate the structural status of the longitudinal arch</p> Signup and view all the answers

    What does a Lisfranc injury involve?

    <p>Dislocation of the tarsometatarsal joint</p> Signup and view all the answers

    During the composite method for AP axial projections, what should the affected foot do during the second exposure?

    <p>Step forward while weighting the talus and calcaneus</p> Signup and view all the answers

    Which statement is true regarding the intact healthy foot structure?

    <p>It consists of phalanges, metatarsals, cuneiforms, cuboid, talus, and calcaneus</p> Signup and view all the answers

    What is the positioning requirement for the lateral projection of the toes?

    <p>Lateral recumbent on the unaffected side</p> Signup and view all the answers

    Which technique is used for visualizing the tarsal sesamoid bone?

    <p>Tangential Projection: Causton Method</p> Signup and view all the answers

    What is the primary purpose of the AP oblique projection in foot imaging?

    <p>To better visualize the MTP joint spaces</p> Signup and view all the answers

    In the AP axial projection of the foot, what is the direction of the central ray (CR)?

    <p>15° toward the heel</p> Signup and view all the answers

    Which foot projection method can help localize foreign bodies?

    <p>AP Axial Projection</p> Signup and view all the answers

    Which technical adjustment is suggested to prevent superimposition during foot imaging?

    <p>Applying tape above the examined area</p> Signup and view all the answers

    What is the recommended degree of rotation for the AP oblique projection of the foot?

    <p>30° to 45°</p> Signup and view all the answers

    What aspect of foot anatomy does Bohler's angle evaluate?

    <p>Talus positioning in relation to the calcaneus</p> Signup and view all the answers

    What is the proper leg rotation when performing an AP oblique projection for the foot in medial rotation?

    <p>30°</p> Signup and view all the answers

    In a PA oblique projection, what is the position of the affected foot?

    <p>Elevated with the dorsal on the image receptor</p> Signup and view all the answers

    Which statement is true regarding the lateromedial projection technique?

    <p>The foot should be dorsiflexed at a 90° angle from the lower leg.</p> Signup and view all the answers

    What is Bohler's angle and its significance in foot imaging?

    <p>It is formed by the intersection of the lines A and B in a lateral ankle radiograph, with a normal range of 20 to 40 degrees.</p> Signup and view all the answers

    When performing a lateral projection of the foot, which orientation is preferred for the foot?

    <p>Lateral position with the lateral side close to the image receptor.</p> Signup and view all the answers

    What should be achieved to obtain a true lateral view of the foot?

    <p>All metatarsals should be visible in profile.</p> Signup and view all the answers

    During which angle should the heel be rotated in a PA oblique projection to visualize the interspace between the 1st and 2nd metatarsals?

    <p>30° medially</p> Signup and view all the answers

    What is commonly assessed using Bohler's angle in foot imaging?

    <p>Presence of fractures in the calcaneus</p> Signup and view all the answers

    What is the correct angle of medial rotation for the AP oblique projection of the foot?

    <p>30°</p> Signup and view all the answers

    In a PA oblique projection with lateral rotation, which interspaces are best visualized?

    <p>3rd &amp; 4th MT</p> Signup and view all the answers

    What is the positioning requirement for achieving a true lateral view of the foot?

    <p>1st - 3rd MT should be parallel to the IR</p> Signup and view all the answers

    Which aspect of the foot is shown in profile during an AP oblique projection?

    <p>Navicular</p> Signup and view all the answers

    What does Bohler's angle assess in foot imaging?

    <p>The angle between the talus and calcaneus</p> Signup and view all the answers

    When performing a lateral projection of the foot, how should the foot be positioned?

    <p>Lateral aspect in contact with the IR</p> Signup and view all the answers

    What is the normal range for Bohler's angle?

    <p>20 to 40 degrees</p> Signup and view all the answers

    In the AP oblique projection, what is the correct positioning of the knee?

    <p>Flexed at 30°</p> Signup and view all the answers

    What condition is characterized by the absence of an arch in the foot?

    <p>Pes planus</p> Signup and view all the answers

    What projection technique is used to examine structural status when both feet are evaluated in comparison?

    <p>Lateral Projection Weight-Bearing method</p> Signup and view all the answers

    Which of the following best describes a Lisfranc injury?

    <p>Dislocation of the tarsometatarsal joint</p> Signup and view all the answers

    In a standing AP axial projection, the feet should be positioned at what level?

    <p>At the level of the third metatarsal base</p> Signup and view all the answers

    What is the purpose of the 10-15° angulation in the AP axial projection weight-bearing method?

    <p>To align the foot's rays with the central ray</p> Signup and view all the answers

    During the first exposure of the AP axial projection weight-bearing composite method, what should the unaffected foot do?

    <p>Step backward to prevent superimposition</p> Signup and view all the answers

    What type of foot abnormality is hallux valgus classified as?

    <p>A deviation of the first metatarsal</p> Signup and view all the answers

    Which ligament is specifically mentioned in the mechanics of a Lisfranc injury?

    <p>Middle cuneiform ligament</p> Signup and view all the answers

    What is the purpose of the 15° angulation in an AP axial projection for the toes?

    <p>To reduce foreshortening of the phalanges</p> Signup and view all the answers

    In the Lewis method for tangential projection of the sesamoids, what is the positioning of the ankle?

    <p>Elevated with the great toe on the imaging receptor</p> Signup and view all the answers

    What is the correct foot rotation for the AP oblique projection to visualize the 1st through 3rd metatarsophalangeal joints?

    <p>30-45° medial rotation</p> Signup and view all the answers

    What does the Holly method for sesamoid projection require of the foot's position?

    <p>The medial border of the foot should be 1 inch from the imaging receptor</p> Signup and view all the answers

    Which positioning is necessary for a PA oblique projection of the toes?

    <p>Lateral recumbent with the affected side down</p> Signup and view all the answers

    What is the purpose of the occlusal film technique in foot projections?

    <p>To improve detail and resolution of the sesamoid bone</p> Signup and view all the answers

    In an AP axial projection of the foot, where is the central ray (CR) directed?

    <p>1 inch proximal to the base of the 3rd metatarsal</p> Signup and view all the answers

    Which projection method is recommended for obtaining a true lateral view of the toes?

    <p>Mediolateral positioning with the affected side down</p> Signup and view all the answers

    What structural condition is characterized by a lack of an arch in the foot?

    <p>Pes planus</p> Signup and view all the answers

    Which imaging technique is designed to assess the structural status of the longitudinal arch?

    <p>Lateral Projection Weight-Bearing method</p> Signup and view all the answers

    In relation to foot imaging, which condition is most commonly indicated by the appearance of a dislocated second metatarsal?

    <p>Lisfranc injury</p> Signup and view all the answers

    What is the angle of the central ray (CR) used in the first exposure of the AP axial projection weight-bearing method?

    <p>15°</p> Signup and view all the answers

    Which anatomical structures are primarily examined to identify hallux valgus?

    <p>Metatarsophalangeal joint</p> Signup and view all the answers

    What is the recommended positioning for the feet when using the AP axial projection weight-bearing method?

    <p>Feet placed 1 inch above the 3rd MT bone level</p> Signup and view all the answers

    During which phase of the AP axial Projection Weight-bearing Composite Method is the unaffected foot moved backward?

    <p>During the first exposure</p> Signup and view all the answers

    Which of the following foot conditions is described as having an abnormal arch?

    <p>Pes cavus</p> Signup and view all the answers

    What is the minimum degree of medial rotation required in the AP oblique projection to avoid overlapping of the lateral cuneiform with other cuneiforms?

    <p>30°</p> Signup and view all the answers

    What positioning is necessary for performing a PA oblique projection while visualizing interspaces between specific metatarsals?

    <p>Leg fully extended and turned toward midline</p> Signup and view all the answers

    Which of the following correctly describes the positioning technique for obtaining a lateral projection of the foot?

    <p>Dorsiflex foot 90° from lower leg</p> Signup and view all the answers

    During a lateral projection, how should the foot be oriented to achieve a true lateral view?

    <p>Lateral side of the foot close to IR</p> Signup and view all the answers

    What is the common method for obtaining a PA oblique projection of the foot?

    <p>Lateral aspect closer to IR</p> Signup and view all the answers

    What is the correct angle of rotation for assessing the interspace between the 2nd and 3rd metatarsals in a PA oblique projection?

    <p>20° lateral rotation</p> Signup and view all the answers

    What is the normal range for Bohler's angle as seen in the lateral ankle radiograph?

    <p>20 to 40 degrees</p> Signup and view all the answers

    Which of the following interspaces can be best visualized in the AP oblique projection of the foot?

    <p>Between the 1st and 2nd MT</p> Signup and view all the answers

    What is the correct positioning for the AP axial projection of the foot?

    <p>Supine with the knee flexed and the sole on IR</p> Signup and view all the answers

    During the PA oblique projection, which positioning adjustment allows for optimal visualization of the MTP joints?

    <p>Base of the foot forms a 30° angle to the horizontal</p> Signup and view all the answers

    What angulation is required for the CR in the AP axial projection of the foot?

    <p>10° towards the heel</p> Signup and view all the answers

    What is the purpose of the Lewis method in the tangential projection?

    <p>To clearly visualize the sesamoid bones at the 1st MT head</p> Signup and view all the answers

    Which projection technique specifically requires the affected limb to be lateral recumbent during the examination?

    <p>Tangential projection using the Causton method</p> Signup and view all the answers

    Which projection is best suited for reducing foreshortening in foot imaging?

    <p>AP axial with a 10° angulation</p> Signup and view all the answers

    When performing a medial rotation in an AP oblique projection, how many degrees should the foot be rotated?

    <p>30-45°</p> Signup and view all the answers

    What positioning is required to obtain a true lateral view of the toes?

    <p>Lateromedial or mediolateral, depending on the toe</p> Signup and view all the answers

    What is the primary indication of an angle less than 20 degrees in foot imaging?

    <p>Suggests a calcaneal fracture</p> Signup and view all the answers

    Which condition is characterized by a lack of arch in the foot?

    <p>Pes planus</p> Signup and view all the answers

    In the AP axial projection weight-bearing method, how should the feet be positioned?

    <p>Aligned at the base level of the 3rd MT bone</p> Signup and view all the answers

    What is true of hallux valgus?

    <p>It affects the MTP joint</p> Signup and view all the answers

    Which method is primarily utilized to assess the structural status of the longitudinal arch?

    <p>Lateral Projection Weight-Bearing method</p> Signup and view all the answers

    What is the purpose of angulating the central ray (CR) at 15 degrees in the AP axial projection?

    <p>To accurately evaluate the forefoot and metatarsals</p> Signup and view all the answers

    What characterizes a Lisfranc injury?

    <p>It is a dislocation of the tarsometatarsal joint</p> Signup and view all the answers

    What is the effect of a 10° angulation toward the heel in an AP axial projection of the foot?

    <p>Properly visualizes the 1st and 3rd MTP joints</p> Signup and view all the answers

    During the lateral projection of the foot, how should the position be adjusted?

    <p>Position the foot parallel to the imaging plate</p> Signup and view all the answers

    In which projection method are the toes medially rotated between 30-45° from the IR?

    <p>AP Oblique Projection</p> Signup and view all the answers

    Which method requires the foot to be dorsiflexed with the ankle elevated to visualize the sesamoid bone?

    <p>Lewis Method</p> Signup and view all the answers

    What is the primary purpose of the lateral recumbent position in a PA oblique projection of the toes?

    <p>To properly visualize the IP joint spaces</p> Signup and view all the answers

    In a lateral projection of the toes, which toes are positioned in true lateral?

    <p>1st and 2nd toes</p> Signup and view all the answers

    What common issue should be addressed to prevent superimposition during a foot examination?

    <p>Using tape or gauze above the evaluated toes</p> Signup and view all the answers

    Which projection method provides the best visualization of the interphalangeal joint spaces of the toes?

    <p>AP Oblique Projection</p> Signup and view all the answers

    When performing a sesamoid projection using the Holly method, what should the plantar surface be positioned against?

    <p>An imaging receptor</p> Signup and view all the answers

    What is the purpose of the PA oblique projection medial rotation when positioned with the lateral aspect closer to the image receptor (IR)?

    <p>To visualize the interspace between the 1st and 2nd metatarsals</p> Signup and view all the answers

    In a true lateral projection of the foot, which metatarsal bones should be primarily visualized?

    <p>1st to 3rd metatarsals</p> Signup and view all the answers

    During which projection method is the foot positioned on a 45° foam wedge?

    <p>PA oblique projection medial rotation</p> Signup and view all the answers

    What is the correct angle of rotation for the heel when performing a PA oblique projection for visualizing the interspace between the 2nd and 3rd metatarsals?

    <p>20° laterally</p> Signup and view all the answers

    Which aspect of foot anatomy does Bohler's angle encompass?

    <p>The angle formed by the calcaneal alignment</p> Signup and view all the answers

    What type of projection is described as requiring the affected foot to be elevated while in a prone position?

    <p>PA oblique projection</p> Signup and view all the answers

    Which of the following is true for the angulation of the foot in an AP oblique projection?

    <p>The foot is angled 30° medially to IR</p> Signup and view all the answers

    In what scenario would the lateral projection of the foot be considered difficult to achieve?

    <p>When the patient is unable to dorsiflex their foot</p> Signup and view all the answers

    In a lateral projection of the leg, what is the positioning of the femoral condyles in relation to the imaging receptor (IR)?

    <p>Parallel to IR</p> Signup and view all the answers

    What rotation is required for an AP oblique projection when medial rotation is performed?

    <p>45°</p> Signup and view all the answers

    Which projection method is used when a patient cannot turn for imaging of the tibia and fibula?

    <p>CROSS-Table Projection</p> Signup and view all the answers

    What is the result of medial rotation at the midshaft of the tibia during imaging?

    <p>Maximum interosseous space between tibia and fibula</p> Signup and view all the answers

    When performing a long leg CT, what is the correct technique regarding the unexposed part?

    <p>Cover with lead</p> Signup and view all the answers

    What is the correct position of the foot in the AP projection of the leg?

    <p>Dorsiflexed with toes pointing vertically</p> Signup and view all the answers

    How is the patient positioned for the lateral projection of the tibia and fibula?

    <p>Supine with the lateral side placed on the IR</p> Signup and view all the answers

    What is the positioning technique used for the AP oblique projection of the leg?

    <p>Rotate the leg 45° towards the midline</p> Signup and view all the answers

    What is one key difference when using the cross-table method compared to traditional positioning?

    <p>The CR is horizontal and the IR is positioned between the legs</p> Signup and view all the answers

    Which rotation maximizes the interosseous space between the tibia and fibula at the midshaft?

    <p>Medial rotation</p> Signup and view all the answers

    What should the foot's position be in the AP projection of the leg?

    <p>Dorsiflexed</p> Signup and view all the answers

    Which approach should be used when it is not possible to turn the patient for imaging?

    <p>Cross-Table Method</p> Signup and view all the answers

    In the lateral projection, where should the patella be positioned in relation to the image receptor?

    <p>Perpendicular to IR</p> Signup and view all the answers

    What is the degree of leg rotation for the AP oblique projection in medial rotation?

    <p>45°</p> Signup and view all the answers

    What is the result of performing a medial rotation at midshaft for the tibia and fibula?

    <p>Maximum interosseous space between tibia and fibula</p> Signup and view all the answers

    What is the appropriate leg rotation for an AP oblique projection in lateral rotation?

    <p>45° lateral rotation</p> Signup and view all the answers

    Which positioning technique is used when the patient cannot turn for a tibia and fibula projection?

    <p>Cross-Table with horizontal CR</p> Signup and view all the answers

    During a lateral projection (mediolateral) of the tibia and fibula, which position should the patient be in?

    <p>Supine turned toward the affected side</p> Signup and view all the answers

    What is an important consideration when performing a medial rotation of the tibia and fibula at midshaft?

    <p>Maximizing the interosseous space between the tibia and fibula</p> Signup and view all the answers

    In an AP projection of the leg, how should the foot be positioned?

    <p>Vertical with toes pointing upwards</p> Signup and view all the answers

    In an AP oblique projection, how should the leg be rotated?

    <p>45° medially or laterally</p> Signup and view all the answers

    What positioning adjustment is required for the lateral projection of the leg?

    <p>Turn the patient toward the affected side</p> Signup and view all the answers

    Which statement accurately describes the positioning of the femoral condyles in an AP projection?

    <p>They should be parallel to the image receptor</p> Signup and view all the answers

    What is the positioning requirement for a cross-table projection of the leg?

    <p>Place the IR between the legs with the CR directed vertically</p> Signup and view all the answers

    During lateral rotation, how does the tibia relate to the fibula?

    <p>The tibia superimposes the fibula</p> Signup and view all the answers

    In a lateral projection of the tibia and fibula, which positioning is required for the patella?

    <p>Patella perpendicular to the image receptor</p> Signup and view all the answers

    What is the best rotation technique for the AP oblique projection to maximize the interosseous space between the tibia and fibula?

    <p>Medial rotation of the leg</p> Signup and view all the answers

    When performing the cross-table projection, what is the orientation of the central ray?

    <p>Horizontal to the image receptor</p> Signup and view all the answers

    What specific positioning is required when using a 45° foam wedge for an AP oblique projection?

    <p>Ankle must rest on the wedge</p> Signup and view all the answers

    In lateral rotation of the leg during imaging, which anatomical relationship occurs between the tibia and fibula?

    <p>Fibula superimposes the tibia</p> Signup and view all the answers

    What is the recommended knee flexion angle for a lateral projection of the patella to ensure proper visualization?

    <p>5 to 10°</p> Signup and view all the answers

    In the Kuchendorf method for lateral oblique projection, what is the required angle of lateral rotation of the knee?

    <p>35-40°</p> Signup and view all the answers

    Which projection method allows for assessment of the femoral condyles as well as the patella?

    <p>Hughston method</p> Signup and view all the answers

    When using the Merchant method, at what angle should the knee be flexed?

    <p>40-45°</p> Signup and view all the answers

    What does a bipartite patella represent in radiological terms?

    <p>A normal variant</p> Signup and view all the answers

    What positioning is essential for ensuring the patella's medial portion is free of the femur in a PA oblique projection?

    <p>Knee flexed at 45-55°</p> Signup and view all the answers

    In the PA axial oblique projection with lateral rotation, what is the primary reason for placing the index finger against the patella?

    <p>To hold the patella in lateral displacement</p> Signup and view all the answers

    Which of the following describes the positioning needed for the Hughston method?

    <p>Recumbent with knees flexed 50-60°</p> Signup and view all the answers

    What position is required for the PA projection of the patella?

    <p>Prone with heel rotated laterally</p> Signup and view all the answers

    In a lateral projection of the patella, how much should the knee be flexed?

    <p>5-10 degrees</p> Signup and view all the answers

    Which projection technique allows for visualization of the medial portion of the patella free of femur?

    <p>PA Oblique Projection: Medial Rotation</p> Signup and view all the answers

    What angle is typically used for the knee in the KUCHENDORF method?

    <p>35-40 degrees laterally rotated</p> Signup and view all the answers

    What is the main purpose of the Merchant Method in patella imaging?

    <p>To demonstrate the sublaxation of the patella</p> Signup and view all the answers

    What is indicated if the knee flexion exceeds 10 degrees in a lateral projection of the patella?

    <p>Incomplete healing of patellar fracture</p> Signup and view all the answers

    What stage of patellar evaluation does the Laurin method primarily address?

    <p>Assessment of patellar sublaxation</p> Signup and view all the answers

    Which projection method requires the patient to be supine with both knees flexed between 40-45 degrees?

    <p>Merchant Method</p> Signup and view all the answers

    Study Notes

    Document Information

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    Text Analysis

    • The text appears to be asking questions about a document.
    • The questions are detailed, focusing on specific aspects of the document.
    • This suggests the document may be an official record or report containing key information.
    • The questions inquire about the document's contents and its purpose.
    • The information requested is likely to be important for understanding the document and its use.

    Foot Projections

    • Angles less than 20 degrees can suggest a calcaneal fracture or disruption of the posterior facet.

    • Lateral Projection Weight-Bearing

      • Upright position, distribute equal weight on each foot.
      • Feet elevated 1 inch above the third metatarsal bone.
      • IR positioned between the feet.
      • Weight equally distributed on each foot.

    • Lateromedial Projection Weight-Bearing

      • Patient stands with foot on IR.

    • Demonstrate:

      • The structural status of the Longitudinal arch.
      • (pes planus) Flat foot: A foot with a weak or no arch.
      • (pes cavus) Abnormal arch:
      • A foot with an abnormally high arch.

    Weight Bearing Foot

    • AP Axial Projection Weight-Bearing (Standing)

      • Patient stands with both feet against the IR, equal weight distribution.
      • 10 to 15 degrees of angulation towards the heel.
      • Feet level with the third metatarsal bone base.
      • Accurately evaluates the tarsals and metatarsals.

    • Hallux Valgus:

      • The most common foot deformity.
      • It affects the metatarsophalangeal (MTP) joint.

    • Lisfranc Injury:

      • This is a dislocation of the tarsometatarsal joint.

    • AP Axial Projection Weight-Bearing Composite Method (Standing)

      • Upright position.
      • Two exposures are taken in a specific sequence.
      • Affected foot steps on IR
      • First exposure:
        • CR directed for the forefoot.
        • Unaffected foot steps backward.
          • This prevents superimposition of the leg shadow over the metatarsals and phalanges
      • Second exposure:
        • CR directed for the hindfoot.
        • Unaffected foot:
          • CR is directed posteriorly 25 degrees
        • Affected foot:
          • Step forward to visualized the talus & calcaneus.
          • 15 Degrees posteriorly.
          • CR directed to the base of the third metatarsal bone.

    Mechanism of Lisfranc Injury

    • Medial View of the foot:
      • The second metatarsal is normally positioned distally.
      • Dislocation of the second metatarsal is a sign of Lisfranc injury.
    • Dorsal view of the foot with weight bearing:
      • The second metatarsal is normally positioned distally.
      • Under normal conditions, there is space between the bones due to ligaments.
      • Ligaments of the middle cuneiform, medial cuneiform, and navicular are important for maintaining foot stability.
    • Healthy foot:
      • The foot structure includes phalanges, metatarsals, cuneiforms, cuboid, talus, and calcaneus.
    • Lisfranc Foot:
      • The foot structure includes phalanges, metatarsals, cuneiforms, cuboid, talus, and calcaneus.
      • Lisfranc injury is a disruption of the ligaments and often results in bone displacement (fracture).
      • Fractures of the seventh metatarsal anterior often result in ligamentous instability.
      • Provides a general overview of the foot bones.

    Lateralside Seen

    • AP Oblique Projection (Medial Rotation)

      • Supine position with the knee flexed.
      • Plantar surface of the foot on IR, rotate leg medially 30 degrees.

    • Farthest Seen:

      • Less than 30 degrees of rotation may result in overlap of the lateral cuneiform over other cuneiforms in profile.
      • Increased angulation leads to open MTP spaces.

    • Interspaces b/n:

      • Visualize the interspaces between the calcaneus, cuboid, fifth, and fourth metatarsals.
      • Also, visualize the interspaces between the talus, navicular, lateral cuneiform, and sinus tarsi.

    • Medial part seen:

      • Interspaces between the 1st & 2nd MT, medial and intermediate cuneiforms are visible.
      • Navicular in profile.

    • AP Oblique bones of Foot:

      • Visualize the interspaces of the proximal end of the metatarsals.

    Nearest Seen

    • PA Oblique Projection
      • Prone position with the affected foot elevated.
      • The dorsal surface of the foot rests on the IR.
      • Grashey method is utilized.
      • Medial Rotation: Heel rotated medially 30 degrees for visualization of the interspace between the 1st & 2nd MT.
      • Lateral Rotation: Heel rotated laterally 20 degrees for visualization of the interspaces between the 2nd & 3rd MT, 3rd & 4th MT, and 4th & 5th MT.
    • PA Oblique Projection (Medial rotation)
      • Lateral recumbent position, affected side up.
      • Knees are flexed.
      • Leg is fully extended.
      • Patient rotates towards the midline prone.
      • Dorsum of the foot rests on a 45° foam wedge.
      • Similar to AP oblique projection of the foot medial rotation.
      • The lateral aspect of the foot is closer to the IR; more oblique than Grachey method.

    Lateral Projection

    • Lateromedial

      • The affected side is turned towards the IR.
      • Leg and foot are in lateral position.
      • Lateral side of the foot close to IR.
      • Dorsiflex the foot 90 degrees from the lower leg.
      • Most routinely used.

    • Lateromedial (difficult to assume)

      • Supine position.
      • Using an LPO/RPO position with affected side up.
      • Medial surface on IR.
      • Plantar surface of the foot on IR.
      • Foot in Lateral position.

    • TRUE Lateral FOOT

      • The 1st to 3rd metatarsal bones are visualized.
      • True Lateral of Foot is achieved when the lateral side of the foot is closest to the IR.

    • Lateromedial

      • Visualize the medial and lateral aspects.

    Bohler's Angle (a.k.a., "Tuber Angle")

    • Established by intersection of two lines in the lateral ankle radiograph.
    • Normal range is 20 to 40 degrees.

    Toes Projection

    • AP or AP Axial Projections:

      • Seated or supine position with knees flexed.
      • AP: 15 inch foam wedge is used.
      • AP Axial: 15 inches posteriorly.

    • PA Projection:

      • Prone position, dorsal aspect of the foot on IR.
      • IR parallel to 18 degrees.
      • CR Directed to: 3rd MTP Joint**

    • Partial CR: 15°

    • Well visualized Phalanges and Distal Metatarsals.

    • Axial CR:

      • More open interphalangeal joint (IP joint) spaces.
      • Reduced foreshortening of the structures.

    • AP Axial CR: 15°

    • Well visualized 1st to 3rd MTP joints spaces.

      • Well visualized Sesamoid bones of 1st Metatarsal.

    • Medial Rotation:

      • AP Oblique Projection
      • Supine or seated with knees flexed.
      • Rotate lower leg and foot medially.
      • 30 to 45 degrees from the IR.
      • Plantar surface of foot on IR. -Lateral Rotation:
      • 3rd to 5th lateral oblique toes.
      • MTP joints overlapped

    • PA Oblique Projection:

      • Lateral recumbent (affected side up).
      • Partially extended affected limb.
      • The base of the foot rests on a 30 degrees to horizontal (Patient toward prone).

    • Lateral:

      • Lateromedial/Mediolateral.
      • Great toe and second toe in true Lateral.
      • Lateral recumbent position, unaffected side up.
      • Superimposition can be avoided by:
        • Tape, gauze, or occlusal film.
        • One toe is examined at a time.

    • Mediolateral:

      • Visualize the 3rd, 4th, and 5th toes.
      • 3rd Toe Open (2nd to 5th MTPs closed).
      • Open MTP joint spaces with a slight degree of obliquity.
      • The 1st MTP joint might not be seen in the lateral projection.
      • The Apo and Proproy processes (medial and lateral aspects) might not be seen in this projection.
      • The 2nd to 5th MTP joint spaces are also open.

    • Other toes:

      • Visualize the proximal interphalangeal joint (PIP joint ).

    • Lateral

      • Lateromedial:
        • Visualize the 1st & 2nd toes.
      • Mediolateral:
        • Visualize the 3rd, 4th, and 5th toes.
        • Open IP Jts spaces.
      • True Lateral:
        • Lateral side of the foot closest to the IR.

    Sesamoids Projections

    Tangential Projection:

    • Lewis Method:
      • Prone position.
      • Great toe rests on the IR with dorsiflexion.
      • Ankle elevated.
      • Ball of foot 1 to IR.
      • Visualization of Sesamoid bone.
      • Visualization of the first MT head.
    • Holly Method:
      • Seated position (more comfortable).
      • Medial border of the foot 1 to the IR.
      • Plantar surface to IR.
      • The toes are flexed, held in place with gauze.
      • Visualization of the 1st MT head.
      • Visualization of the tarsal sesamoid bone.
    • ** Tangential Projection: Causton Method **
      • Lateral recumbent (unaffected side).
      • Knees are flexed.
      • Partially extended limb, foot in lateral position.
      • 1st MTP joint to IR with 40 degrees to the prominence of the 1st MIP.
      • Visualization of tarsal sesamoid bone.
      • Slight overlap axiolaterally.
    • Occlusal film technique: - To enhance the detail.

    Foot Projection

    • AP or AP Axial Projection:
      • Supine position;
      • Knee is flexed, sole on IR.
    • Visualize the 1st to 3rd MTP joints.
    • AP Axial: 10 degrees towards the heel.
      • CR directed 1 to MT bone.
    • RP: Base of 3rd MT bone
    • Elongated (10˚ angulation):
      • Reduces foreshortening of the structures.
      • Visualize the Talus, Metatarsals, Phalanges, TMT Joint.
      • Enhances visualization.
    • (10°) axial:
      • Used for localizing foreign bodies in the foot.

    Toes Projections

    • AP or APaxial Projections:
      • Seated or supine position with knees flexed
      • AP: 15" foam wedge
      • Aparial: 15" posteriorly
    • PA Projection:
      • Prone position with dorsal aspect of foot on IR
      • IR parallel to 18°
    • CR: 1 to 3rd MTP joint for all projections
    • Partial CR (15°): for phalanges and distal metatarsals
    • Apaxial CR (open): for interphalangeal joints (IP Jt), reduces foreshortening
    • Aarial CR (15°): for 1st - 3rd MTP Jt, helps visualize IP Jt spaces and sesamoid bone of 1st metatarsal.
    • Medial Rotation (AP oblique Projection):
      • Supine or seated with knee flexed
      • Lower leg/foot rotated medially 30-45° from IR
      • Plantar aspect of foot on IR
    • Lateral Rotation: for 3rd - 5th lateral oblique toes, MTP Jts overlapped
    • PA oblique Projection:
      • Lateral recumbent on affected side with partial extension of affected limb
      • Base of foot at 30° to horizontal, plantar toward prone
    • Lateral: Lateromedial/Mediolateral position
      • Great toe and 2nd toe in true lateral position
      • Lateral recumbent (unaffected side)
    • Mediolateral: for 3rd, 4th, 5th toes (affected side)
    • 3rd Open, 2nd to 5th MTP Jt: visualizes MTP Jt spaces and oblique toes
    • 1st MTP Jt: not always open
    • Apo Pros (medial not): open 2nd - 5th MTP joint space
    • Proproy (medial not): open 2nd - 5th MTP joint space
    • PIP joint: other toes

    Sesamoids Projections

    • Tangential Projection: visualizes the sesamoid bone and 1st MT head
      • Lewis Method:
        • Prone with great toe on IR and dorsiflexed
        • Ankle elevated with ball of foot 1 to IR
      • Holly Method:
        • Seated position with medial border of foot 1 to IR
        • Plantar surface on IR, toes flexed and held with a strip of gauze
      • Causton Method:
        • Lateral recumbent on unaffected side with knees flexed and limb partial extended
        • Foot in lateral position, MTP joint 1 to IR, 40° prominence toward 1st MIP
    • Occlusal film technique: used for improved detail

    Foot Projection

    • AP or AP axial Projection:
      • Supine position with knee flexed, sole on IR, 1st - 3rd MTP Jt
    • AP axial: 10° toward the heel
    • CR: directed 1 to MT bone
    • RP: base of 3rd MT bone
    • Elongated (10° angulation):
      • Reduces foreshortening
      • Visualizes talus, metatarsals, phalanges, TMT Jt
      • Provides better detail

    Lateralside Seen

    • AP oblique projection medial rotation:
      • Supine position with knee flexed, plantar aspect of foot on IR
      • Rotate leg medially; Plantar aspect of foot at 30° to IR
    • Interspace b/n:
      • Calcaneus and Cuboid
      • Cuboid and 5th MT
      • 4th MT
      • Talus and Navicular
      • Lateral cuneiform
      • Sinus Tarci
    • Medial part seen:
      • Interspace b/n:
        • 1st & 2nd MT
        • Medial and intermediate cuneiform
      • Navicular in profile
    • AP oblique bones of Foot: visualizes interspaces of the proximal end of the bones of foot.

    Nearest Seen

    • PA oblique Projection:
      • Prone position with affected foot elevated, dorsal of foot on IR
    • Grashey Methods:
      • Medial or lateral rotation of heel:
        • Heel Medially rotated 30°:
          • Visualizes interspace b/n 1st & 2nd MT
        • Heel Laterally rotated 20°:
          • Visualizes interspace b/n 2nd & 3rd MT
          • 3rd & 4th MT
          • 4th & 5th MT
    • PA oblique Projection Medial rotation:
      • Lateral recumbent (affected side) with knees flexed and leg fully extended
      • Turn towards midline prone
      • Dorsum on 45° foam wedge
      • More oblique than Grashey, lateral aspect of foot closer to IR.

    Lateral Projection

    • Latero medial:
      • Turn towards affected side with leg and foot in lateral position
      • Lateral side of foot close to IR
      • Dorsiflex foot 90° from lower leg
    • Latero medial (difficult to assume):
      • Supine position
      • LPO/RPO with affected side up
      • Medial surface on IR
      • Plantar surface of foot on IR
      • Foot in lateral position
    • TRUE Lateral FOOT:
      • Visualizes 1st - 3rd MT bone
      • Achieved by latero medial and mediolateral positions

    Bohler's Angle

    • Bohler's angle (Tuber Angle): formed by lines A and B on a lateral ankle radiograph
    • Normal range: 20-40 degrees
    • Angles <20 degrees: suggestive of a calcaneal fracture or disruption of the posterior facet

    Longitudinal Arch

    • Lateral Projection Weight-Bearing method:
      • Upright with feet elevated 1 inch above the 3rd MT bone
      • IR b/n feet with weight equally distributed on each foot
      • Visualizes lateromedial of bones of foot, comparison of both feet
    • Lateromedial (Standing): per foot
    • Demonstrates the structural status of the longitudinal arch
    • Pes Planus (flat foot): no arch, weak
    • Pes Cavus (abnormal arch): abnormal arch

    FOOT weight bearing

    • AP axial Projection Weight-bearing method Standing:
      • Standing with both feet against IR and weight equally distributed
      • 10-15° toward the heel
      • Feet at 3rd MT base level
      • Accurate evaluation of ticals and metatarsals when comparing images
    • Demo of Hallux valgus: most common foot deformity, affects MTP joint
    • Lisfranc injury: dislocation of tarsometatarsal joint
    • AP axial Projection Weight-bearing Composite Method Standing:
      • Upright position
      • 2 exposures with affected foot stepping on IR
      • 1st exposure:
        • Forefoot tube, unaffected foot steps back (prevents MT and phalanges superimposition on leg shadow)
      • 2nd exposure:
        • Hindfoot tube, affected foot steps forward (visualizes talus and calcaneus)
      • 1st exposure: unaffected foot for posterior part
      • 2nd exposure: affected foot with 25° angulation CR of part for anterior part

    Mechanism of Lisfranc Injury

    • Medial view of the foot:
      • Normal position: 2nd metatarsal (distal first)
      • Dislocation: 2nd metatarsal
    • Dorsal view of the foot with weight bearing:
      • Normal position: 2nd metatarsal (distal first)
      • Space between bones under normal ligament
      • Ligament of the Middle cuneiform
      • Medial cuneiform
      • Ligament
    • HEALTHY FOOT:
      • Phalanges
      • Metatarsals
      • Cuneiforms
      • Cuboid
      • Talus
      • Calcaneus
    • LISFRANC FOOT:
      • Phalanges
      • Metatarsals
      • Cuneiforms
      • Cuboid
      • Talus
      • Calcaneus
      • Ligament
      • Ligament

    Toes Projections

    • AP Projection:
      • Patient is Seated or Supine
      • Knees are Flexed
      • 15" foam wedge is used
    • AP Axial Projection:
      • Patient is Seated or Supine
      • Knees are Flexed
      • 15" foam wedge is used Posteriorly
    • PA Projection:
      • Patient is Prone
      • Dorsal aspect of foot is placed on the IR
      • IR is parallel with 18°
    • CR for all Toes Projections:
      • 1 to the 3rd MTP joint

    Toes Projections (Specifics)

    • Partial CR (15°)
      • Visualizes Phalanges and Distal Metatarsals
    • Apaxial (Open CR)
      • Visualizes the Interphalangeal Joint (IP Joint)
      • Reduces foreshortening of the Phalanges
    • Axial CR (15°)
      • Visualizes the 1st to 3rd MTP Joints
      • Allows for visualization of the IP Joint spaces
      • Visualizes the sesamoid bone of the 1st Metatarsal
    • Medial Rotation (AP Oblique)
      • Patient is Seated or Supine
      • Knee is Flexed
      • Lower Leg/Foot is medially rotated
      • 30-45° angle from IR
      • Foot placed Plantar on the cassette
    • Lateral Rotation
      • Used for 3rd to 5th Lateral Oblique toes
    • PA Oblique Projection
      • Patient is in Lateral recumbent position (affected side down)
      • Affected Limb is partially extended
      • Base of the foot is positioned at a 30° angle to the horizontal (PT towards prone)
    • Lateral
      • Lateromedial or Mediolateral are used
      • Great Toe and 2nd Toe are visualized in True Lateral
      • Patient in Lateral recumbent (unaffected side down)
    • Preventing superimposition:
      • Tape or place gauze above the toe being examined
      • Occlusal film or stick may be used
    • Mediolateral
      • 3rd, 4th, 5th toes are visualized (affected side)
    • 3rd Open, 2nd to 5th MTP joint
      • Allows for visualization of the MTP Joint spaces
      • Used with Oblique Toes Projections
    • 1st MTP Joint
      • Not always open on 3rd Open position
    • Apo Pros (medial not)
      • Allows for visualization of the 2nd to 5th MTP joint spaces
    • Proproy (medial not)
      • Allows for visualization of the 2nd to 5th MTP joint spaces
    • Other Toes
      • PIP (Proximal Interphalangeal) Joints are visualized
    • Lateral
      • Lateromedial: 1st & 2nd Toes
      • Mediolateral: 3rd, 4th, 5th Toes
      • Allows for visualization of the IP Joint spaces
    • True Lateral
      • Used for all toes

    Sesamoid Projections

    Tangential Projection:

    • Lewis Method
      • Patient is Prone
      • Great Toe is placed on the IR, Dorsiflexed
      • Ankle is elevated
      • Ball of foot is 1 to the IR
      • Sesamoid bone and 1st MT head are visualized
    • Holly Method
      • Patient is Seated (more comfortable position)
      • Medial Border of the foot is 1 to the IR
      • Plantar surface of foot is placed on the IR
      • Toe is Flexed; PT holds toes with a strip of gauze
      • 1st MT head and tarsal sesamoid bone are visualized
    • Tangential Projection: Causton Method
      • Patient is in Lateral recumbent (unaffected side down)
      • Knee is Flexed
      • Limb is partially Extended
      • Foot is in lateral position
      • MTP Joint 1 is placed on the IR
      • 40° angulation is applied towards the prominence of the 1st MIP
      • Tarsal sesamoid bone is visualized
      • Axiolaterally with slight overlap

    Foot Projection

    • AP or AP Axial Projection:
      • Patient is Supine
      • Knee is Flexed
      • Sole of foot is placed on the IR
      • Visualizes the 1st to 3rd MTP Joints
    • AP Axial: 10° toward the Heel
    • CR is Directed 1 to MT bone
    • RP: Base of the 3rd MT Bone
    • Elongated (10° angulation):
      • Reduces foreshortening of Talus, Metatarsals, Phalanges, TMT Joint
      • Better visualization of the Foot bones

    Lateral Side Seen

    • AP Oblique Projection (Medial Rotation)
      • Patient is Supine
      • Knee is Flexed
      • Plantar surface of foot is placed on IR
      • Leg is Medially Rotated; Plantar surface is at 30° angle to the IR

    Farthest Seen

    • Less than 30°: The Lateral cuneiform bone is thrown over other cuneiform bones in profile

    • Greater angulation = Open MTP spaces

    • Interspace b/n:

      • Calcaneus and Cuboid
      • 5th and 4th MT
      • Talus and Navicular
      • Lateral cuneiform
      • Sinus Tarci

    • Medial Part Seen

      • Interspace b/n:
        • 1st and 2nd MT
        • Medial and Intermediate cuneiform
      • Navicular is visualized in profile

    • AP Oblique Bones of the Foot

      • Visualizes the interspaces of the Proximal ends of the foot bones

    Nearest Seen

    • PA Oblique Projection

      • Patient is Prone
      • Affected foot is elevated
      • Dorsal aspect of the foot is placed on IR

    • Grashey Method

      • Medial Rotation:
        • Heel is Medially Rotated 30°
        • Visualizes the interspace b/n 1st and 2nd MT
      • Lateral Rotation:
        • Heel is Laterally Rotated 20°
        • Visualizes interspace b/n 2nd and 3rd MT
        • Visualizes interspace b/n 3rd and 4th MT
        • Visualizes interspace b/n 4th and 5th MT

    • PA Oblique Projection (Medial Rotation)

      • Patient is in Lateral recumbent position (affected side down)
      • Knee is Flexed
      • Leg is fully extended
      • Patient turns towards the midline in prone position
      • Dorsum is placed on a 45° foam wedge
        • Same as AP Oblique of the Foot (Medial Rotated)
      • Lateral aspect of the foot is closer to the IR
        • More oblique than Grachey Method

    Lateral Projection

    • Lateromedial
      • Patient turns towards the affected side
      • Leg and foot are in lateral position
      • Lateral side of the foot is close to the IR
      • Foot is Dorsiflexed 90° from the lower leg
      • More routinely utilized
    • Lateromedial (difficult to assume)
      • Patient is Supine
      • LPO/RPO
      • Affected side is up
      • Medial surface of the foot is placed on IR
      • Plantar surface of the foot is placed on IR
      • Foot is in Lateral position
    • TRUE LATERAL FOOT
      • Visualizes the 1st to 3rd MT bone
      • Is achieved with Lateromedial
    • Medial
      • Lateral

    Bohler's Angle (a.k.a., "Tuber Angle")

    • Bohler's angle (aka "Tuber Angle") is visualized on the lateral ankle radiograph
    • Formed by the intersection of lines A and B
    • The normal range is 20 to 40 degrees.
    • Angles <20 degrees suggests a calcaneal fracture or disruption of the posterior facet

    Longitudinal Arch

    • Lateral Projection Weight-Bearing Method

      • Patient is Upright
      • Feet are elevated 1" above the 3rd MT bone
      • IR is placed b/n the feet
      • Weight is equally distributed on each foot
      • Lateromedial of the bones of the foot are visualized
      • Both feet are examined for comparison

    • Lateromedial (Standing)

      • Evaluates per foot

    • Demonstrate:

      • Structural status of the Longitudinal arch

    • (pes planus) Flat foot:

      • Absence of arch
      • Weak arch

    • (pes cavus) Abnormal arch:

      • Excessive arch

    Foot Weight-Bearing

    • AP Axial Projection Weight-bearing Method (Standing)

      • Patient Standing
      • Both feet are placed against the IR
      • Equal weight distribution on each foot
      • 10-15° angle toward the heel
      • Feet are at the 3rd MT base level
      • Evaluates the ticals and metatarsals

    • Demo of: Hallux valgus (most common foot deformity)

      • MTP Joint is affected

    • Lisfranc injury:

      • Dislocation of the Tarsometatarsal Joint

    • AP Axial Projection Weight-bearing, Composite Method (Standing)

      • Patient is Upright
      • 2 exposures are required
      • Affected foot steps on the IR
      • 1st exposure:
        • Forefoot Tube is used
        • Unaffected foot steps back
          • (Prevents the MT & Phalanges from superimposition on the leg shadow)
      • 1st Exposure:
        • Unaffected foot:
          • Hindfoot Tube is used with posterior exposure
          • 25° angulation is applied to the CR of the part
      • 2nd Exposure:
      • Affected foot:
        • Step forward (talus & calcaneus)
        • Posterior Part

    • 15° posteriorly

    • Base of 3rd MT bone

    Mechanism of Lisfranc Injury

    • Medial view of the foot:
      • Normal position of the 2nd Metatarsal (distal first)
      • Dislocation of the 2nd Metatarsal
    • Dorsal view of the foot (weight-bearing):
      • Normal position of the 2nd Metatarsal (distal first)
      • Space between bones under normal ligament
      • Ligament of the Middle Cuneiform
      • Medial Cuneiform
      • Medial Cuneiform
      • Ligament
    • HEALTHY FOOT:
      • Phalanges
      • Metatarsals
      • Cuneiforms
      • Cuboid
      • Talus
      • Calcaneus
    • LISFRANC FOOT:
      • Phalanges
      • Metatarsals
      • Cuneiforms
      • Cuboid
      • Talus
      • Calcaneus
      • Ligament
      • Ligament

    Toes Projections

    • AP or AP axial Projections:
      • Seated or supine position with knees flexed
      • AP: 15-inch foam wedge for foot elevation
      • AP axial: 15-inch posterior elevation
    • PA projection:
      • Prone position with dorsal aspect of foot on IR
      • IR parallel to 18°
    • Central Ray (CR): directed to the 3rd MTP joint
    • Partial CR at 15°:
      • For visualizing phalanges and distal metatarsal
    • Apaxial CR:
      • Open position for visualizing interphalangeal joint space
      • Reduces foreshortening of the toes
    • Aarial CR at 15°:
      • Visualizes the spaces of 1st-3rd MTP joints
      • Provides clear view of IP joints
      • Shows the sesamoid bone of the 1st metatarsal
    • Medial Rotation (AP Oblique):
      • Visualizes the lateral aspect of the toes
      • Supine or seated position with knee flexed
      • Rotate lower leg and foot medially by 30-45°
      • Plantar aspect of foot on IR
    • Lateral Rotation:
      • Visualizes the 3rd-5th toes
      • MTP joints are overlapped in this projection
    • PA Oblique Projection:
      • Lateral recumbent position with affected side down
      • Partially extend the affected limb
      • Base of foot forms 30° angle to horizontal
    • Lateral Projection:
      • Lateromedial or Mediolateral position
      • True lateral position for visualizing the great toe and second toe
      • Lateral recumbent position with unaffected side up
    • Mediolateral Projection:
      • Visualizes 3rd, 4th, and 5th toes on the affected side
      • Demonstrates the MTP joint spaces
    • 3rd Toe Open:
      • Visualizes the 2nd to 5th MTP joint spaces
      • Achieved through oblique toe projections
    • 1st MTP Joint:
      • Not always open in all projection
      • AP (medial) projection often does not visualize the 1st MTP space
      • PA projection (medial) often does not visualize the 1st MTP space
    • Proproy Projection:
      • Visualizes the 2nd-5th MTP joint spaces
    • Lateral Projection for other Toes:
      • Visualizes PIP joints
      • Lateromedial: for 1st and 2nd toes
      • Mediolateral: for 3rd, 4th and 5th toes; opens IP joint spaces

    Sesamoids Projections

    • Tangential Projection:
      • Visualizes sesamoid bones and 1st MT head
    • Lewis Method:
      • Prone position with great toe on IR and dorsiflexed
      • Ankle elevated
      • Ball of foot forms 1° angle to IR
    • Holly Method:
      • Seated position with medial border of foot 1° to IR
      • Plantar surface on IR
      • Flex the toes and place a strip of gauze over them
    • Tangential Projection: Causton Method:
      • Lateral recumbent position with unaffected side up
      • Flex knees with limb partially extended
      • Foot in lateral position
      • 1st MTP joint on IR
      • 40° prominence toward the 1st MP
    • Occlusal Film Technique:
      • Used to improve detail in sesamoid bone imaging

    Foot Projections

    • AP or AP axial Projection:
      • Supine position with knee flexed and sole on IR
      • Visualizes 1st-3rd MTP joints
    • AP axial with 10° toward heel:
      • Reduces foreshortening
      • Allows for better visualization of talus, metatarsals, phalanges, TMT joints
    • CR directed 1° to MT bone:
      • For accurate positioning
    • RP: Base of 3rd MT Bone:
      • Central point of reference
    • Elongated Projection:
      • Achieved with 10° angulation
      • Reduces foreshortening for better demonstration
    • (10') axial:
      • Alternative terminology for AP axial
      • Useful for localizing foreign bodies, fractures, and general survey of the foot bones

    Lateralside Seen

    • AP oblique Projection (Medial Rotation):
      • Supine position with knee flexed
      • Plantar aspect of foot on IR
      • Medially rotate leg medially by 30°
    • Interspaces:
      • Calcaneus and Cuboid, 5th and 4th MT
      • Talus and Navicular
      • Lateral cuneiform
      • Sinus Tarci
      • Medial cuneiform and intermediate cuneiform
      • 1st and 2nd MT
    • AP oblique bones of Foot:
      • Visualizes interspaces of proximal end of bones

    Nearest seen

    • PA oblique Projection:
      • Prone position with affected foot elevated
      • Dorsal aspect of foot on IR
    • Grashey Methods:
      • Medial or lateral rotations
      • Heel medially rotated 30° for visualizing 1st and 2nd MT interspace
      • Heel laterally rotated 20° for visualizing 2nd and 3rd, 3rd and 4th, and 4th and 5th MT interspaces.
    • PA oblique Projection (Medial Rotation):
      • Lateral recumbent position with affected side down
      • Knees flexed with leg fully extended
      • A turn toward the midline in the prone position
      • Dorsum of foot on 45° foam wedge
      • Similar to AP oblique medial rotation, but lateral aspect is closer to IR

    Lateral Projection

    • Lateromedial:
      • Position with affected side up
      • Leg and foot in lateral position
      • Lateral side of foot close to IR
      • Dorsiflex foot 90° from lower leg
    • Lateromedial (Difficult to Assume):
      • Supine position with affected side up
      • LPO/RPO
      • Medial surface on IR
      • Plantar surface of foot on IR
      • Foot in lateral position
      • More routinely used
    • TRUE Lateral FOOT:
      • Visualizes 1st-3rd MT bones
      • Achieved through lateromedial positioning
      • Lateral positioning is achieved by turning the foot toward the affected side

    Bohler's Angle (a.k.a., "Tuber Angle")

    • Formed by intersection of lines A and B in the lateral ankle radiograph
    • Normal range: 20-40 degrees
    • Angles less than 20 degrees: suggestive of calcaneal fracture or posterior facet disruption

    Longitudinal Arch

    • Lateral Projection (Weight-Bearing Method):
      • Upright position with feet elevated 1 inch above the 3rd MT bone
      • IR between feet with equal weight distribution
      • Demonstrates the structural status of the longitudinal arch
      • Compares both feet for evaluation
    • Lateromedial (Standing):
      • For individual foot evaluation
    • Pes Planus (Flat Foot):
      • Weak arch
      • Demonstrated by the lateral projection
    • Pes Cavus (Abnormal Arch):
      • High arch
      • Demonstrated by the lateral projection

    FOOT weight bearing

    • AP axial Projection (Weight-bearing Method Standing):
      • Standing position with both feet against IR
      • Equal weight distribution and 10-15° angulation towards the heel
      • Feet at 3rd MT base level
      • Evaluates tibials and metatarsals
    • Hallux Valgus:
      • Most common foot deformity
      • Affects the MTP joint
      • Evaluated with AP axial weight-bearing method:
    • Lisfranc Injury:
      • Dislocation of tarsometatarsal joint
      • Evaluated with AP axial weight-bearing method
    • AP axial Projection (Weight-bearing Composite Method Standing):
      • Upright position with two exposures
      • Affected foot steps on IR
      • 1st exposure:
        • For forefoot tube
        • Unaffected foot steps backwards to prevent superimposition
      • 2nd exposure:
        • Affected foot steps forward
        • For hind foot tube
        • 25° angulation of CR
    • 15° posteriorly:
      • Angulation for composite method
    • Base of 3rd MT bone:
      • Central point of reference for composite method

    Mechanism of Lisfranc Injury

    • Medial view of the foot:
      • Demonstrates dislocation of the second metatarsal
    • Dorsal view of the foot with weight bearing:
      • Shows the ligament disruption and space between bones in Lisfranc injury
      • Demonstrates the ligament of the middle cuneiform, medial cuneiform and the affected ligaments
    • HEALTHY FOOT:
      • Visualizes the normal arrangement of bones: phalanges, metatarsals, cuneiforms, cuboid, talus, calcaneus
    • LISFRANC FOOT:
      • Demonstrates the disruption of the ligaments and the displacement of bones: phalanges, metatarsals, cuneiforms, cuboid, talus, calcaneus

    AP Projection

    • Patient lies supine.
    • Femoral condyles must be parallel to the image receptor.
    • The foot is vertical and dorsiflexed towards the image receptor.

    Lateral Projection Mediolateral

    • Patient lies supine, turned toward the affected side (RPO or LPO).
    • Patella is perpendicular to the image receptor.
    • Femoral condyles are perpendicular to the image receptor.
    • Lateral side of the leg is placed on the image receptor.

    Alternative Method

    • Patient lies supine with a cross-table horizontal central ray.
    • Image receptor is positioned between the legs on the affected side.

    AP Oblique Projection

    • Patient lies supine with the affected leg rotated 45 degrees medially or laterally for the desired oblique view.
    • Medial rotation requires turning the leg inwards.
    • Ankle and foot rest on a 45° foam wedge.

    Midshaft Medial Rotation

    • Proximal and distal tibiofibular joints show maximum interosseous space between the tibia and fibula.

    Midshaft Lateral Rotation

    • Tibia superimposes the fibula.
    • Ankle and knee joints are visible.

    Midshaft Lateral Projection

    • Demonstrates the tibia and fibula as adjacent structures.

    Long Legs - CT

    • Requires using two separate images.
    • The unexposed area of the leg is covered with lead shielding.

    Lateral Projection

    • Demonstrates the patella and femoral condyles.

    Fibula Position

    • The fibula is located about 1 cm posterior to the tibia.

    Leg Projection

    • AP Projection: Patient lies supine with femoral condyles parallel to the image receptor (IR). The foot is vertical and dorsiflexed to the IR.
    • Lateral Projection (Mediolateral): Patient lies supine and turns towards the affected side, achieving either right or left posterior oblique (RPO/LPO) position. The patella is perpendicular to the IR, and femoral condyles are parallel to the IR. The lateral side of the leg is placed on the IR.
    • Alternative Method (for patients unable to turn): Utilize a cross-table technique with a horizontal central ray (CR). Position the IR between the legs, with the right or left posterior side of the leg resting on the IR depending on the affected side.
    • AP Oblique Projection: Patient lies supine and rotates the leg 45° medially or laterally. For medial rotation, turn the leg inward. The foot and ankle should rest on a 45° foam wedge.

    Midshaft

    • Medial Rotation (Tibia and Fibula): Maximize the interosseous space between the tibia and fibula at the proximal and distal tibiofibular joints.
    • Lateral Rotation (Tibia and Fibula): The tibia superimposes the fibula. Identify adjacent joint spaces at the ankle and knee.
    • Lateral Projection Advantages (Tibia and Fibula): Visualize the tibia and fibula in close proximity to their adjacent joint spaces.

    Long Legs: Computed Tomography (CT)

    • Requires two separate images for complete visualization.
    • Shield the unexposed portion of the patient with lead.

    Anatomy and Positioning:

    • Lateral Projection: Features include the patella and femoral condyles.
    • Fibula Positioning: The fibula is positioned approximately 1 cm posterior to the tibia.
    • AP Oblique Projections: Specific projections are used to visualize fixation devices.

    Tibia and Fibula Projections

    • AP Projection: Patient supine with femoral condyles parallel to the image receptor (IR). Foot is vertical, dorsiflexed.
    • Lateral Projection Mediolateral: Patient supine, turned towards the affected side (RPO/LPO). Patella and femoral condyles are parallel to the IR. Lateral side of the leg is placed on the IR.
    • Alternative Lateral (if patient cannot turn): Cross-table, horizontal central ray (CR). IR placed between the legs, with the affected side lateral.
    • AP Oblique Projection: Patient supine, leg rotated 45° medially or laterally. For medial rotation, turn the leg inwards; for lateral rotation, turn the leg outwards. Rest the foot and ankle on a 45° foam wedge.

    Tibia and Fibula Midshaft

    • Medial Rotation: Proximal and distal tibiofibular joints are maximally separated.
    • Lateral Rotation: Tibia and fibula are superimposed.

    Long Legs: Computed Tomography (CT)

    • Use two separate images to capture the entire length.
    • Shield the unexposed portion with lead.

    Anatomy

    • Fibula: Located 1cm posterior to the tibia.
    • Lateral Projection (Fig. 6-129): Demonstrates the patella and femoral condyles.
    • AP Oblique (medial rotation): Shows fixation devices (Fig. 6-133).
    • AP Oblique (lateral rotation): Demonstrates fixation devices (Fig. 6-134).

    Leg Projection

    • AP Projection: Patient supine with femoral condyles parallel to the image receptor (IR). Foot is vertical and dorsiflexed to IR.
    • Lateral Projection Mediolateral: Patient supine, rotated towards affected side (RPO/LPO). Patella and femoral condyles are parallel to IR. Lateral side placed on IR.
    • Alternative Method (when patient can't turn): Cross-table horizontal central ray (CR), IR placed between legs with the affected side on the IR.
    • AP Oblique Projection: Patient supine, leg rotated 45° medially or laterally. Medial rotation: turn leg inward; lateral rotation: turn leg outward. Rest foot and ankle on a 45° foam wedge.

    Midshaft

    • Medial Rotation: Proximal and distal tibiofibular joints show maximum interosseous space between tibia and fibula.
    • Lateral Rotation: Tibia superimposes fibula; ankle and knee joints are seen.
    • Lateral Projection: Tibia and fibula are adjacent.

    Long Legs - Computed Tomography (CT)

    • Two separate images used.
    • Unexposed areas covered with lead.

    Lateral Projection Details

    • Includes visualization of patella and femoral condyles.

    Anatomical Considerations

    • Fibula is located 1 cm posterior to tibia.

    AP Projection

    • Patient Supine;
    • Femoral condyles parallel to Image Receptor (IR)
    • Foot is vertical (Dorsiflexed) and perpendicular to IR, and medial malleolus is closest to IR

    Lateral Projection Mediolateral

    • Patient supine and turned on affected side using Right Posterior Oblique (RPO) or Left Posterior Oblique (LPO) position
    • Patella is parallel to IR
    • Femoral condyles are parallel to IR
    • Lateral side of leg is closest to IR with Fibula closest to IR (Fibula should not be superimposed by Tibia)

    Alternative Method - Lateral Projection (For patient that cannot turn)

    • Patient supine, place IR between patient's legs, with leg closest to IR rotated laterally so that the lateral side is on the IR
    • Cross-table technique, horizontal CR

    AP Oblique Projection

    • Patient Supine, leg is rotated 45° medial or lateral
    • Patient rotates leg medially - turn leg inward (medial side)
    • Patient rotates leg laterally - turn leg outward (Lateral side)
    • Rest the foot and ankle on a 45° foam wedge

    Midshaft - Medial Rotation

    • Proximal and distal tibiofibular joints - maximum interosseous space between Tibia and Fibula

    Midshaft- Lateral Rotation

    • Tibia superimposed over Fibula, ankle, and knee joints
    • Advantages - Tibia and Fibula are adjacent joints to make identifying fracture easier

    Long Legs - Computed Tomography (CT)

    • Use 2 separate images to achieve a complete image of the entire leg
    • Cover the unexposed portion with lead

    Lateral Projection

    • Patella visualized
    • Femoral condyles visualized

    Fibula

    • Fibula is located 1cm posterior to the Tibia

    Tibia and Fibula Projections

    • AP Projection: Patient supine, femoral condyles parallel to IR, foot vertical and dorsiflexed.
    • Lateral Projection: Patient supine, rotated toward affected side (RPO/LPO), patella and femoral condyles parallel to IR, lateral side placed on IR.
    • Alternative Lateral Projection: Patient supine, cross-table, horizontal CR, IR placed between legs with affected side lateral.
    • AP Oblique Projection: Patient supine, leg rotated 45° medially or laterally. Medial rotation: Turn leg inward. Lateral Rotation: Turn leg outward. Rest foot and ankle on 45° foam wedge.

    Tibia and Fibula Positioning

    • Midshaft Medial Rotation: Maximum interosseous space between tibia and fibula.
    • Midshaft Lateral Rotation: Tibia superimposes fibula.
    • Lateral Projection of Midshaft: Tibia and fibula are adjacent.

    Imaging Considerations

    • Long Leg CT: Utilize two separate images, use lead to shield the unexposed portion.
    • Lateral Projection: Patella and femoral condyles should be visualized.
    • Fibula Location: The fibula is approximately 1 cm posterior to the tibia.

    PA Projection

    • Patient lies prone
    • Patella is parallel to imaging receptor
    • Heel rotated 5° to 10° laterally
    • The mid-popliteal depression is used for positioning
    • There is a void in the image
    • Patella is superimposed by the femur
    • Bipartite patella is visible as a radiolucent line
    • This is not a fracture

    Lateral Projection: Medio-Lateral

    • Patient lies on their side
    • Knee flexed 5° to 10°
    • Patella is perpendicular to the image receptor
    • Epicondyles are superimposed
    • A lateral projection shows the patellofemoral joint open

    PA Oblique Projection: Medial Rotation

    • Patient lies prone
    • Knee flexed 5° to 10°
    • Medial rotation of 45-55° to visualize the medial portion of the patella free of the femur

    PA Oblique Projection: Lateral Rotation

    • Patient lies prone
    • Knee flexed 5° to 10°
    • Knee laterally rotated 45° to 55°
    • Lateral portion of the patella is free of the femur.

    KUCHENDORF method: PA axial oblique Projection: Lateral Rotation

    • Patient lies prone
    • Hip is elevated 2-3 inches
    • Knee is flexed 10°
    • Knee laterally rotated 35-40°
    • 25° to 30° caudad angulation
    • Patellofemoral joint space between the two femoral condyles
    • Most of the patella is free of the femur except for the patellar outline
    • Thumb placed on patella for lateral displacement

    Hughston method: Tangential Projection (Jaroschy)

    • Patient lies prone
    • Knee on the image receptor
    • Knee flexed 50° to 60°
    • 45° cephalic angulation
    • Tangential image of the patellofemoral joint
    • Used for assessment of subluxation of the patella and patellar fractures

    Hughston (55°)

    • Both knees examined side-by-side for comparison

    Laurin method

    • Knee flexed 20°
    • Assesses patellar subluxation

    Fodor-Malott & Weinberg, Merchant et al

    • 45° knee flexion

    Merchant Method: Tangential Projection - Bilateral

    • Patient lies supine
    • Both knees flexed 40-45°
    • Knee elevated 2° (femora parallel to tabletop)
    • 30 ° caudad angulation from horizontal plane
    • Open patellofemoral joint
    • Patella non-distorted and slightly magnified

    Patella Projections

    • PA Projection:
      • Patient is prone with the knee extended and the patella parallel to the image receptor.
      • Heel is rotated laterally 5 to 10 degrees.
      • Center the beam on the midpopliteal depression to obtain sharper detail and avoid superimposition of the patella by the femur.
      • A radiolucent line on the x-ray or CT scan may indicate a bipartite patella, which is a normal variant and not a fracture.
    • Lateral Projection (Medio-lateral):
      • Patient is in a lateral recumbent position with the knee flexed at 5-10 degrees.
      • This angle minimizes the patellofemoral joint space, helpful for evaluating patellar injuries.
      • Flexing the knee greater than 10 degrees may be necessary for unhealed or new patellar fractures.
      • The patella should be internally rotated and the epicondyles superimposed.
      • This projection allows visualization of the patellofemoral joint space, with the patella and patellofemoral joint being open.
    • PA Oblique Projection (Medial Rotation):
      • Patient is prone with the knee flexed 5 to 10 degrees and medially rotated 45-55 degrees.
      • This projection allows the medial portion of the patella to be visualized free from the femur.
    • PA Oblique Projection (Lateral Rotation):
      • Patient is prone with the knee flexed 5 to 10 degrees and laterally rotated.
      • This projection allows the lateral portion of the patella to be visualized free from the femur.
    • KUCHENDORF Method (PA Axial Oblique Projection: Lateral Rotation):
      • Patient is prone with the hip elevated 2-3 inches and the knee flexed 10 degrees.
      • Knee is laterally rotated 35-40 degrees.
      • The beam is angled 25-30 degrees caudad.
      • This method allows for visualization of the joint space between the patella and the femoral condyles while keeping the majority of the patella free from the femur.
      • This position can be uncomfortable for the patient; a finger may be used to assist in laterally displacing the patella.

    Patella & Patellofemoral Joint Projections

    • Hughston Method (Tangential Projection, Jaroschy):
      • Patient is prone with the knee flexed 50-60 degrees and resting on the image receptor.
      • The foot is placed on the collimator.
      • The beam is angled 45 degrees.
      • This projection provides a tangential image of the patellofemoral joint, useful for assessing subluxation of the patella and patellar fractures, as well as the femoral condyles.
      • It also allows for visualization of bony detail of the patella and femoral condyles.
    • Hughston (55°):
      • This method is utilized to compare both knees for symmetry.
    • Laurin Method:
      • Patient's knee is flexed 20 degrees.
      • This projection is used to assess patellar subluxation.
    • Fodor-Malott & Weinberg wl Merchant et al.:
      • Patient's knee is flexed 45 degrees.
    • Merchant Method (Tangential Projection - Bilateral):
      • Patient is supine with both knees flexed 40-45 degrees.
      • The beam is angled 30 degrees caudad from the horizontal plane.
      • This method uses a skyline or "sunrise" projection to visualize the patellofemoral joint in an open position, minimizing distortion and slightly magnifying the patella.
      • It can be utilized for various patellofemoral disorders.

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