Clark's Positioning in Radiography 13th Edition PDF

CLARK’S POSITIONING IN RADIOGRAPHY thirteenth edition A Stewart Whitley, Gail Jefferson, Ken Holmes, Charles Sloane, Craig Anderson, and Graham Hoadley WITH VITALSOURCE® EBOOK  CLARK’S...

CLARK’S POSITIONING IN RADIOGRAPHY thirteenth edition A Stewart Whitley, Gail Jefferson, Ken Holmes, Charles Sloane, Craig Anderson, and Graham Hoadley WITH VITALSOURCE® EBOOK  CLARK’S POSITIONING IN RADIOGRAPHY www.ketabpezeshki.com 66485457-66963820 www.ketabpezeshki.com 66485457-66963820  CLARK’S POSITIONING IN RADIOGRAPHY 13TH EDITION A. STEWART WHITLEY GAIL JEFFERSON KEN HOLMES CHARLES SLOANE CRAIG ANDERSON GRAHAM HOADLEY www.ketabpezeshki.com 66485457-66963820  CRC Press Taylor & Francis Group 6000 Broken Sound Parkway NW, Suite 300 Boca Raton, FL 33487-2742 © 2016 by Taylor & Francis Group, LLC CRC Press is an imprint of Taylor & Francis Group, an Informa business No claim to original U.S. Government works Version Date: 20150626 International Standard Book Number-13: 978-1-4441-6505-0 (eBook - PDF) This book contains information obtained from authentic and highly regarded sources. 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Trademark Notice: Product or corporate names may be trademarks or registered trademarks, and are used only for identification and explanation without intent to infringe. Visit the Taylor & Francis Web site at http://www.taylorandfrancis.com and the CRC Press Web site at http://www.crcpress.com www.ketabpezeshki.com 66485457-66963820 Dedication This volume is dedicated to the many student radiographers We also wish to acknowledge the professional support and and radiographers in the field of Diagnostic Medical Imaging advice of a huge number of colleagues who have given their whose skills, knowledge and dedication play an important and own time to offer advice and help in the preparation of the pivotal role in modern medicine and ensuring that the patient’s 13th edition. This has truly been a team effort. journey delivers the best outcomes. v www.ketabpezeshki.com 66485457-66963820 www.ketabpezeshki.com 66485457-66963820 Contents Foreword ix Authors and contributors xi Preface xiii Acknowledgements to the 13th edition xv Acknowledgements to previous editions xvii Abbreviations xix 1 Basic principles of radiography and digital technology 1 2 Upper limb 51 3 Shoulder 95 4 Lower limb 123 5 Hips, pelvis and sacro-iliac joints 169 6 Vertebral column 193 7 Thorax and upper airway 227 8 Skull, facial bones and sinuses 265 9 Dental radiography 311 Vivian Rushton 10 Abdomen and pelvic cavity 365 11 Ward radiography 385 12 Theatre radiography 405 13 Paediatric radiography 421 J. Valmai Cook, Kaye Shaw and Alaa Witwit 14 Miscellaneous 495 References/further reading 547 Index 555 vii www.ketabpezeshki.com 66485457-66963820 www.ketabpezeshki.com 66485457-66963820 Foreword Radiography remains at the forefront of diagnosis in health- dental, theatre and paediatric contexts. In addition Chapter 14, care. Competent practitioners are required to justify and Miscellaneous, addresses an array of important current emerg- optimise exposures so that diagnostic yield is maximised and ing contexts including bariatrics, tomosynthesis and forensic examination hazards minimised. There are a number of chal- radiography. The section on trauma radiography is particularly lenges facing educators of such practitioners including rapid impressive. technology developments, changing legal and policy con- It should not be a surprise that this text demonstrates excel- texts, increased variety of student types and greater patient lence. Alfred Stewart Whitley FCR, HDCR, TDCR has been reservations around radiation exposures. This text provides the driving force behind the work as well as being responsible a wonderful core text that considers all these challenges, and for a number of the sections. His involvement and leadership will continue to be an excellent reference text for qualified in radiography over five decades are evident throughout this personnel. project and his achievements with, and contributions to, our The approach used by the authors is comprehensive, current profession are an inspiration for all of us. It is clear that the and easy to follow. The chapters for the specific body areas revision process has been lengthy with significant contributions are presented extremely logically, each kicking off with a sum- from a dedicated team based at the University of Cumbria, and mary of the basic projections, followed by anatomic considera- a range of other individuals including Dr. Graham Hoadley and tions, which in turn is followed by a detailed treatment of the paediatric and dental experts, who have contributed to specific relevant projections. The chapters are superbly complemented sections. Stewart has steered this team of contributors to this by clear and up-to-date line diagrams, photographs and X-ray highly successful conclusion. images, with an easy to follow series of bullet points. The radi- In summary, this 13th edition of Clark’s Positioning is an ologic considerations are very useful and references provided excellent text, which I would recommend to all my students are an effective reflective resource. and academic and clinical colleagues. It conveys to the reader The preparatory sections in the text are invaluable, covering an immense amount of easy to digest knowledge that is current, issues such as terminology, image quality, digital imaging and relevant and essential to modern day radiographic practice. But exposure factors. It was very reassuring to see the emphasis it does more. Increasingly as practitioners and academics we placed on radiation protection, which includes a mature and must reflect wisely on our long-established techniques and realistic appraisal of doses delivered, associated risk factors and question dogma that is presented historically or by technology the latest IRMER regulations. Increasingly patients are expect- producers. This book encourages such reflection and question- ing to be examined by practitioners who can convey in the clear- ing, and thrusts the radiographer at the centre of the justifica- est way the potential dangers of diagnostic X-ray exposures; this tion and optimisation processes. book prepares the students well for these types of encounters. The patient must surely benefit by this publication. The text has not shied away from the variety of clinical situations facing radiographers and chapters are dedicated to Professor Patrick C. Brennan DCR, HDCR, PhD ix www.ketabpezeshki.com 66485457-66963820 www.ketabpezeshki.com 66485457-66963820 Authors and contributors A. Stewart Whitley Alaa Witwit Radiology Advisor Consultant Radiologist UK Radiology Advisory Services Queen Mary’s Hospital for Sick Children, Epsom and Preston, Lancashire, UK St. Helier University NHS Trust Carshalton, UK Gail Jefferson Viv Rushton Senior Lecturer/Advanced Practitioner Lecturer in Dental & Maxillofacial Radiology Department of Medical and Sport Sciences, University of Cumbria University Dental Hospital of Manchester Carlisle, UK Manchester, UK Ken Holmes Andy Shaw Radiography Programme Leader Group Leader Medical Physicist Department of Medical and Sport Sciences, University of Cumbria North West Medical Physics, Christie Hospital Lancaster, UK Manchester, UK Charles Sloane Alistair Mackenzie Principal Lecturer Research Physicist Department of Medical and Sport Sciences, University of Cumbria NCCPM, Medical Physics Department, Royal Surrey Lancaster, UK County Hospital Guildford, UK Craig Anderson Alexander Peck Clinical Tutor and Reporting Radiographer Information Systems Manager X-ray Department, Furness General Hospital Royal Brompton & Harefield NHS Foundation Trust Cumbria, UK London, UK Graham Hoadley Keith Horner Consultant Radiologist Professor Blackpool, Fylde and Wyre Hospitals NHS Trust School of Dentistry, University of Manchester Blackpool, Lancashire, UK Manchester, UK J. Valmai Cook Paul Charnock Consultant Radiologist Radiation Protection Adviser Queen Mary’s Hospital for Sick Children, Epsom and Integrated Radiological Services (IRS) Ltd St. Helier University NHS Trust Carshalton, UK Liverpool, UK Kaye Shah Ben Thomas Superintendent Radiographer Technical Officer Queen Mary’s Hospital for Sick Children, Epsom and Integrated Radiological Services (IRS) Ltd St. Helier University NHS Trust Carshalton, UK Liverpool, UK xi www.ketabpezeshki.com 66485457-66963820 www.ketabpezeshki.com 66485457-66963820 Preface This new edition, with a newly expanded team, continues with Services (IRS) Ltd, Liverpool. These DRLs are meant to guide the success of the 12th edition in containing the majority of cur- the student and to encourage them to look at the specific DRLs rent plain radiographic imaging techniques in a single volume. set in their respective health institutions. This in a small way Mammography, however, is not included but is to be found in reflects the original ‘Kitty Clark’ publications where guidance the companion volume Clark’s Procedures in Diagnostic Imaging, on exposure factors was provided. We hope that this will pro- where it is included in a separate chapter devoted to all the mote the importance of ‘optimisation’ and encourage practi- imaging modalities associated with breast imaging. tioners and students alike to be aware of the appropriate dose This fully revised 13th edition builds on the changes made for a specific patient-related examination. in the 12th edition, reflecting the changing technology and The Miscellaneous chapter includes a new section on bari- demands on a modern diagnostic imaging department and the atric radiography reflecting the challenges in society and the need to provide optimal images consistent with the ALARP need for careful pre-exposure preparation and patient care. principle. Additionally, the tomography section is expanded to include New in Chapter 1 is the emphasis on the ‘patient journey’, tomosynthesis, in order to provide a wider understanding as to with a focus on the needs of the patient and a reflection on the capabilities of this digital technique. the important steps in the process of delivering images of high Overall the book describes radiographic techniques under- quality. taken using either computed radiography (CR) or direct digital Also introduced is the formal process of ‘image evaluation’, radiography (DDR) equipment, which continues to advance which radiographers are frequently engaged in, delivering their both in terms of capability and detector size and weight. comments on acquired images as part of an ‘initial report’ in However, there is recognition that screen/film and chemical an agreed structure. Additionally, the student is further guided processing still exists and this is reflected in some of the text. with the inclusion of a ‘10 Point Plan’ which will aid in ensur- With respect to the standard template for the general radio- ing excellent diagnostic images are presented for viewing and graphic technique, the familiar sub-heading ‘Direction and interpretation. centring of the X-ray beam’ has been replaced with ‘Direction The important role that ‘imaging informatics’ plays is added and location of the X-ray beam’. This slight change is meant to provide a general understanding as to how it is used best, to focus on the fact that the beam should be collimated to the both to maximise image quality and to provide the means to area of interest whilst still paying attention to the general guid- administer, store and communicate images where they are ance related to centring points. needed. The Paediatric chapter has been updated with a number For the first time recommended diagnostic reference levels of images included focusing on image evaluation and the (DRLs) are included within the description of a number of Dental chapter updated to include coned beam computed radiographic techniques. Those quoted are derived from the tomography. recommended references doses published in the UK in the This edition contains a number of helpful references com- HPA – CRCE – 034 report Doses to patients from radiographic pared to previous editions with a number of suggestions for and fluoroscopic X-ray imaging procedures in the UK 2010 Review. further reading. For those DRLs not included in the report DRLs are added, We hope that these changes will improve the usefulness of which are calculated on a regional basis by means of electronic the book and its relevance to current radiographic practice, and X-ray examination records courtesy of Integrated Radiological provide a lasting tribute to the originator, Miss K.C. Clark. xiii www.ketabpezeshki.com 66485457-66963820 www.ketabpezeshki.com 66485457-66963820 Acknowledgements to the 13th edition We are indebted for the help and advice given by a vast range Infirmary, Michael MacKenzie of the Pennine Acute Hospitals of colleagues throughout the radiological community with NHS Trust, Andrea Hulme of the Royal Manchester Childrens ­contributions enthusiastically given by radiographers, radiolo- Hospital and Bill Bailey, Radiology Management Solutions gists, physicists, lecturers from many learning institutions and Ltd, Radiology management solutions, Elite MRI Ltd. colleagues in the medical imaging industry and UK govern- We are particularly indebted for specific and detailed advice ment public bodies. Particular thanks go to Philips Healthcare and illustrations to the following colleagues: Alistair Mackenzie, and Agfa HealthCare for their financial support in sponsoring Research Physicist, NCCPM, Medical Physics Department, much of the artwork of the book. Royal Surrey County Hospital, Guildford; Andy Shaw, Group We would particularly like to thank all of our partners and Leader Medical Physicist, North West Medical Physics, Christie families who patiently endured the long process and the sup- Hospital, Manchester; Alexander Peck, Information Systems port and from many staff within the School of Medical Imaging Manager, PACS/RIS/Agfa Cardiology, Royal Brompton & Sciences, University of Cumbria and the X-ray Department at Harefield NHSFT, London; Paul Charnock, Radiation Protection Blackpool Victoria Hospital who assisted with many aspects of Advisor and Ben Thomas, Technical Officer, Integrated the book. Radiological Services (IRS) Ltd, Liverpool, UK; Anant Patel, Our thanks go to Joshua Holmes who ably undertook the Barts Health NHS Trust; Adham Nicola and Neil Barron, majority of new positioning photographs of the book. London North West Hospitals NHS Trust; and Keith Horner, Thanks are also given to the many models who patiently Professor, School of Dentistry, University of Manchester, UK. posed for the photographs. These were drawn mainly from Thanks also go to Sue Edyvean, Kathlyn Slack and Sarah radiography students based at the Carlisle, Blackburn and Peters from Public Health England for their DRL advice and Blackpool Hospital sites. The students include Louise Storr, providing equipment photographs and to Dr Frank Gaillard Clare McFadden, Riad Harrar, Nicole Graham and Laith (Melbourne), founder of Radiopaedia.org, for access to images. Hassan. Other models who we also thank include Kevin Ney, Lastly, thanks go to Professor Maryann Hardy for her encour- Malcolm Yeo, Amanda Spence, Simon Wilsdon and Mark agement and helpful advice in a number of aspects of radio- Jackson and others who acted as models in the 12th edition graphic technique. but were not mentioned specifically. We also acknowledge those contributors for the 12th e­ dition We also would like to acknowledge the support provided whose help and advice is still used in the 13th edition. These by Philips Healthcare, GE Healthcare, Med Imaging UK include: Dr Tom Kane, Mrs K. Hughes, Mrs Sue Field, Mrs (Liverpool) and Siemens Healthcare for their assistance in the R. Child, Mrs Sue Chandler, Miss Caroline Blower, Mr Nigel provision of a number of diagrams, photographs and images, Kidner, Mr Sampath, Dr Vellore Govindarajan Chandrasekar with thanks to Stephanie Holden, Steve Oliver, Catherine and Sister Kathy Fraser, Blackpool Victoria Hospital; Dr J.R. Rock and Dawn Stewart. Drummond, Dental School, University of Dundee; the Thanks also go to the many departments who kindly pro- International Association of Forensic Radiographers; Keith vided images and photographs and in particular Lesley Stanney, Taylor, University of Cumbria, Lancaster; and Elizabeth M. Terry Gadallah, Elaine Scarles and Chris Lund of Blackpool Carver (née Unett) and Barry Carver, University of Wales, Victoria Hospital, Rosemary Wilson of the Royal Lancaster Bangor. xv www.ketabpezeshki.com 66485457-66963820 www.ketabpezeshki.com 66485457-66963820 Acknowledgements to previous editions Miss K.C. Clark was Principal of the ILFORD Department of enabled him to travel as lecturer to the Radiographic Societies Radiography and Medical Photography at Tavistock House, of Britain, Canada, America, South and West Africa. from 1935 to 1958. She had an intense interest in the teach- The 10th edition, also published in two volumes, was revised ing and development of radiographic positioning and proce- and edited by Louis Kreel MD, FRCP, FRCR, a radiologist of dure, which resulted in an invitation by Ilford Ltd to produce international repute and wide experience of new imaging tech- Positioning in Radiography. nologies. Her enthusiasm in all matters pertaining to this subject was The 11th edition, totally devoted to plain radiographic imag- infectious. Ably assisted by her colleagues, she was responsible ing, was edited by Alan Swallow FCR, TE and Eric Naylor FCR, for many innovations in radiography, playing a notable part in TE and assisted by Dr E J Roebuck MB, BS, DMRD, FRCR the development of mass miniature radiography. Her ability and Steward Whitley FCR, TDCR. Eric and Alan were both and ever active endeavor to cement teamwork between radi- principals of Schools of Radiography and well respected in the ologist and radiographer gained worldwide respect. radiography world and champions in developing and extending At the conclusion of her term of office as President of the radiography education to a wide radiographer and radiological Society of Radiographers in 1936 she was elected to Honorary community. Fellowship. In 1959 she was elected to Honorary Membership The 12th edition again totally devoted to plain radiographic of the Faculty of Radiologists and Honorary Fellowship of the imaging was edited by A. Stewart Whitley, FCR, TDCR, Australasian Institute of Radiography. Charles Sloane MSC DCR DRI Cert CI, Graham Hoadley BSc Miss Clark died in 1968 and the Kathleen Clark Memorial (Hons), MB BS, FRCR, Adrian D. Moore MA, FCR,TDCR Library was established by the Society of Radiographers. and Chrissie W. Alsop DCR. This successful team, represent- Today the library can be accessed by request at the Society and ing both clinical and academic environments, was responsible College of Radiographers. for updating the text during the transition to digital radiogra- The ninth edition was published in two volumes, edited phy and adding a number of new features to the book. and revised by James McInnes FSR, TE, FRPS, whose involve- We are indebted to these editors and the many radiogra- ment with Positioning in Radiography began in 1946 when he phers and radiologists who contributed to previous editions joined Miss Clark’s team at Tavistock House. He originated for providing us with the foundations of the current edition many techniques in radiography and in 1958 became Principal and we hope that we have not failed to maintain their high of Lecture and Technical Services at Tavistock House, which standards. xvii www.ketabpezeshki.com 66485457-66963820 www.ketabpezeshki.com 66485457-66963820 Abbreviations A&E accident and emergency IRMER Ionising Radiation (Medical Exposure) ACJ acromio-clavicular joint Regulations AEC automatic exposure control GCS Glasgow Coma Scale ALARP as low as reasonably practicable GIT gastrointestinal tract AP antero-posterior GP general practitioner ASIS anterior superior iliac spine HB horizontal beam ATLS Advanced Trauma and Life Support HDU High-dependency unit BSS Basic Safety Standards HIS hospital information system CBCT cone beam computed tomography HPA Health Protection Agency CCD charge-coupled device HSE Health and Safety Executive CCU Coronary care unit HTTP hypertext transfer protocol CDH congenital dislocation of the hip IAEA International Atomic Energy Agency CEC Commission of European Communities ICRP International Commission on Radiological CHD congenital hip dysplasia Protection CID charge-injection device IRMER Ionising Radiation (Medical Exposure) CMOS complementary metal oxide semiconductor Regulations CPD continued professional development ITU Intensive treatment unit CR computed radiography IV intravenous CSF cerebrospinal fluid IVU intravenous urogram/urography CSU Cardiac surgery unit KUB kidneys–ureters–bladder CT computed tomography LAO left anterior oblique CTU computed tomography urography LBD light beam diaphragm CTR cardio-thoracic ratio LDR local diagnostic reference level CXR chest X-ray LMP last menstrual period DAP dose–area product LPO left posterior oblique DCS dynamic condylar screw LUL left upper lobe DDH developmental dysplasia of the hip LUT look-up table DDR direct digital radiography MC metacarpal DHS dynamic hip screw MCPJ metacarpo-phalangeal joint DICOM digital imaging and communications in medicine MO mento-occipital DNA deoxyribonucleic acid MPE medical physics expert DP dorsi-palmar/dorsi-plantar MPR multiplanar reformatting/reconstruction DPO dorsi-plantar oblique MRCP magnetic resonance cholangiopancreatography DPT dental panoramic tomography MRI magnetic resonance imaging DQE detection quantum efficiency MRSA methicillin resistant Staphylococcus aureus DRL diagnostic reference level MSCT multislice computed tomography DTS digital tomosynthesis MT metatarsal ECG electrocardiogram MTF modulation transfer function EI exposure indicator MTPJ metatarso-phalangeal joint EAM external auditory meatus MUA manipulation under anaesthetic EPR electronic patient record NAI non-accidental injury ESD entrance skin/surface dose NGT naso-gastric tube ETT endotracheal tube NICE National Institute for Health and Care FB foreign body Excellence FFD focus-to-film distance NM nuclear medicine FO fronto-occipital NNU Neonatal unit FOD focus-to-object distance NRPB National Radiological Protection Board FoV field-of-view OA osteoarthritis FRD focus-to-receptor distance OF occipto-frontal FSD focus-to-skin distance OFD object-to-focus distance/object-to-film distance II image intensifier OM occipito-mental xix www.ketabpezeshki.com 66485457-66963820  OPG orthopantomography SCBU Special care baby unit ORD object-to-receptor distance SD standard deviation ORIF open reduction and internal fixation SIDS sudden infant death syndrome PA postero-anterior SMV submento-vertical PACS picture archiving and communication system SOD source-to-object distance PAS patient administration system SP storage phosphor PCNL percutaneous nephrolithotomy SPR storage phosphor radiography PET positron emission tomography SS solid state PNS post-nasal space SUFE slipped upper femoral epiphysis PPE personal protective equipment SXR skull X-ray PPR photostimulable phosphor radiography TB tuberculosis PSL photostimulable luminescence TFT thin-film transistor PSP photostimulable phosphor TLD thermoluminescent dosimeter QA quality assurance TMJ temporo-mandibular joint RBL radiographic baseline TOD table-to-object distance RIS Radiology information system UAC umbilical arterial catheter RML right middle lobe US ultrasound RPA Radiation Protection Advisor UVC umbilical venous catheter RPS Radiation Protection Supervisor VNA vendor neutral archive SCIWORA spinal cord injury without radiological WHO World Health Organization bony injury XDS-I cross enterprise document sharing for imaging xx www.ketabpezeshki.com 66485457-66963820  Section 1 Basic Principles of Radiography and Digital Technology CONTENTS TERMINOLOGY 2 EXPOSURE FACTORS 39 Introduction 2 Introduction 39 Image evaluation – 10-point plan 8 Milliampere seconds 40 Anatomical terminology 13 Kilovoltage 40 Positioning terminology 13 Focus-to-receptor distance 41 Projection terminology 17 Intensifying screens 41 Digital imaging 41 THE RADIOGRAPHIC IMAGE 22 Secondary radiation grids 42 Image formation and density 22 Choice of exposure factors 42 Contrast 23 Magnification and distortion 25 SUMMARY OF FACTORS ­CONTRIBUTING Image sharpness 26 TO OPTIMUM RADIOGRAPHIC Image acquisition and display 28 IMAGE ­QUALITY 43 DIGITAL IMAGING 29 RADIATION PROTECTION 44 Image acquisition 29 Medical exposure 44 Factors affecting image quality 31 Occupational exposure 49 Imaging informatics 32 Image processing 36 1 www.ketabpezeshki.com 66485457-66963820 1 Undertaking the examination: Terminology Patient care. Radiographic procedure. Introduction Radiation protection. Post-examination and aftercare: The patient journey Image quality. Successful radiography is dependent on many factors but Patient aspects. uppermost is the patient’s experience during their short jour- Imaging informatics. ney and encounter with the Diagnostic Imaging Department (see Fig. 1.3). The radiographer has a duty of care to the Preparation for the examination patient and must treat them with respect and ensure their dignity is maintained. It is essential that the radiographer The request form establishes a rapport with the patient and carers. The radi- ographer must introduce themselves to the patient/carer and Ensure the examination requested is authorised and signed inform them of their role in the examination. They must with a suitable rationale. make sure the request form is for the patient being exam- Make sure the examination is justified using the IR(ME)R ined and that the clinical details and history are accurate. 2000 regulations1 and the request card has a justifiable clini- The radiographer must request consent from the patient and cal reason for the X-ray, e.g. history of injury and pain in the the patient must give consent for the examination before the metacarpal region ?fractured foot. radiographer starts the e­ xamination. Any examination using X-rays must affect the management The flow chart demonstrating a systematic way of undertak- of the patient. ing an X-ray examination is on page 7. The purpose of the flow Check the protocol for the examination. chart is to ensure that the patient journey is patient focussed and mistakes are eliminated. The key aspects are: Make sure you know which projections are required, e.g. DP and oblique foot. Effective communication with patients and carers. Preparation of the X-ray room The ability to follow a logical framework in order to be able to perform the X-ray examination proficiently and effectively. Make sure the X-ray room is clean, safe and tidy, ensure that the floor is clear and the X-ray tube is not in a position Efficient use of technology to produce diagnostic images at where the patient can walk into it. the first attempt. Evaluation of the radiographic image using the 10-point Set a preliminary exposure for the examination, i.e. X-ray plan. tube focus size, mAs and kV. Have any accessory equipment available, e.g. foam pads and Whilst there are several ‘main headings’ to the algorithm it lead-rubber. is essential to emphasise that the primary focus is the patient and their interaction within the process. Effective communi- Preparation of the patient cations encompasses a myriad of interactions, which include being ‘open and friendly’ to the patient, telling them who you Correctly note the details on the request form ready for checking with the patient: are, what you are intending to do, gaining consent and also inviting and answering any questions they may have about the Patient’s full name, date of birth and address. examination. Correct examination requested and reason for the X-ray. Is the patient fit and ambulant or have any physical needs? Stages of an X-ray examination Mode of transport. There are 3 stages to undertaking an X-ray examination, prep- If applicable ensure the patient is undressed and dress them aration, the radiographic procedure itself and follow up from in a radiolucent gown. the examination undertaken. Each of these stages can be fur- The patient is asked: ther subdivided as shown below: If they have carried out any required preparation for the examination. Preparation for the examination: If they understand the nature of the examination and if they The request form. have any questions prior to proceeding. The X-ray room. For verbal permission to proceed with the examination. The patient, including consent for the examination and For written consent if an examination incurs a higher risk, identity checks. e.g. angiography. 2 www.ketabpezeshki.com 66485457-66963820  1 To be able to give consent (adult or child) the patient should meet the following criteria. They should: Terminology Understand the risk versus benefit. Understand the nature of the examination and why it is Introduction (cont.) being performed. Understand the consequences of not having the examination. The procedure is explained to the patient in easy to under- Be able to make and communicate an informed decision. stand terms. If these conditions are not satisfied then other individuals Radiographic procedure may be able to give consent, e.g. parents, or in an emergency situation the examination may proceed if it is considered in the It is important that the department protocols are followed for best interest of the patient (see hospital policy). Page 7 has a the examination and that the equipment is used safely and pro- full page timeline. ficiently. The preliminary exposure should be set on control panel (make sure the exposure factors are optimised for the patient body type). Undertaking the examination As part of the procedure ensure: Patient care The patient is positioned accurately in relation to the exami- At the commencement of the examination introduce your- nation being undertaken. self to the patient and ask permission to take the X-ray. If the The X-ray tube is positioned and centred to the patient and patient has been prepared for the examination, check they image receptor. have followed the instructions, e.g. undressed appropriately The beam is collimated to the area of interest. and in a gown, nil by mouth or any other preparation. Make a positive identity check on the patient using the details on Appropriate radiation protection is carried out. the request form and ensure that the correct examination is An anatomical marker is correctly applied to the image indicated along with the rationale for the X-ray ­examination. receptor. Instructions are effectively communicated to the patient. Check the pregnancy status of the patient. Radiographers and other staff/carers stand behind the lead Check for the patient’s infection status, i.e. MRSA or other glass protective control screen and exposure undertaken transferable diseases, to prevent cross infection by appropri- after the exposure factors confirmed on control panel. ate methods. Image acquisition is correct first time. Visibly clean hands in front of the patient before you start the procedure. The patient waits whilst the image is checked. Patient identity. Once again the patients’ identity is estab- The image is assessed for diagnostic quality. lished using the departmental protocol, which normally You wash your hands or clean them with alcohol gel in sight asks the patient to state their full name, address and date of the patient. of birth. These are then cross referenced with the request You consider using pads and sandbags to immobilise the form. The examination must not proceed unless the radiog- patient when necessary. Distraction techniques may also be rapher is sure of the identity of the patient. of value with paediatric patients. 3 www.ketabpezeshki.com 66485457-66963820 1 In the UK the underlying legislation is known as the Ionising Terminology Radiation (Medical Exposure) Regulations (IRMER) 2000.1 This legislation is designed to protect patients by keeping doses ‘as low as reasonably practicable’ (ALARP). The regulations Introduction (cont.) set out responsibilities: Radiation protection Those that refer patients for an examination (Referrers). Those that justify the exposure to take place (Practitioners). Patient protection Those that undertake the exposure (Operators). Radiation protection and patient dose matters are discussed in Radiographers frequently act as practitioners and operators depth at the end of this chapter. The following section sum- and as such must be aware of the legislation along with the marises some of the important aspects of the examination, risks and benefits of the examination to be able to justify it. which includes before and during the procedure both in terms of the patient, staff and carers with consideration to relevant Is there an alternative imaging modality? legislation. The use of an alternative imaging modality that may provide On reviewing a request for an X-ray examination, the radi- more relevant information or the information required at ographer needs to consider carefully if the request for the a lower dose should be considered. The use of non-ionising examination is appropriate and has sufficient information to imaging modalities, such as ultrasound and MRI should also be undertake it. In other words – is the examination justified? The considered where appropriate. radiographer should consider several questions when assessing Optimisation of radiographic exposure any request for imaging: The radiographer has a duty of care to ensure that the exposure Will the examination change the clinical management of the delivered to the patient conforms to the departmental optimi- patient? sation policy. This ensures that that the ALARP principle has been applied.2 While this can be a contentious area, the radiographer should Optimisation will involve consideration of a number of fac- consider if the requested examination will be of benefit to tors associated with image acquisition including: the patient and if the findings will affect the treatment or management of the patient. If the examination is not going Exposure factors applied. to change the management of the patient the radiographer Image detector system used. should seek further information from the referrer until they are satisfied the request is justified. Patient compliance. Collimation and field size. The Radiographer has a duty of care to have a further dis- cussion with the referrer. This must establish if the exami- Diagnostic reference levels nation is justified or not under the radiation regulations and Statutory dose limits do not apply to individual medical expo- protocols of the department. sures. However, IRMER requires employers to establish diag- nostic reference levels (DRLs) for their standard diagnostic Does the completed request comply with local protocols? and interventional procedures in order to assess whether these For example, is the request card completed in a legible man- exposures are optimised. These local DRLs are based on the ner? Are the requested projections in line with the departmen- typical doses received by average sized patients when they tal protocol? undergo common procedures. DRLs have been established as a What are the risks/ benefits of the examination? critical method in determining if a patient has been over irradi- Even low X-ray doses can cause changes to cell DNA, lead- ated. Contemporary practice will involve imaging departments ing to increased probability of cancer occurring in the years publishing a list of DRLs for all common X-ray examinations. following the exposure. While in many cases the probability Patient dose must be recorded for all examinations. This will of this occurring is low, this risk should always be balanced be given in different formats such as: against the benefits of the patient undergoing the examination. Dose (kerma) area product (DAP) – Gy cm2. This is often acutely emphasised when a seriously ill patient or a young patient undergoes frequent X-ray examinations and Entrance surface (skin) dose (ESD) – mGy. the need to consider carefully each request is very important. Exposure factors/examination room. Consultation with radiological colleagues is often required if Fluoroscopy times. there is any doubt over the legitimacy of any request. This will be explained fully in the radiation protection Does the request comply with government legislation? section at the end of this chapter, but it is important that Legislation varies between countries; however, the request the radiographer ensures that the local DRL has not been should comply with national legislation where applicable. exceeded. 4 www.ketabpezeshki.com 66485457-66963820  1 Pregnancy Avoiding exposure in pregnancy Terminology All imaging departments should have written procedures for managing the small but significant radiation risk to the ­foetus (Fig. 1.1). Radiographers should refer to their departmental Introduction (cont.) working procedures and apply them as part of their everyday Ask patient 'Are you or might you be pregnant?' working practice. The chart opposite has been constructed using joint guidance from the Health Protection Agency, the College of Radiographers and the Royal College of Radiologists (2009). Most departmental procedures will follow a similar procedure Answer: Yes Answer: Unsure† Answer: No, not pregnant although practices may vary between departments according to specific circumstances. The procedure for pregnancy is usu- ally applied to examinations that involve the primary beam For low-dose For high-dose Record LMP. procedures, e.g. procedures, e.g. Proceed with exposing the pelvic area. Examinations of other areas can be plain radiography CT of abdomen or examinationproviding undertaken as long as the radiographer ensures good beam col- of abdomen, spine pelvis, barium LMP was within limation and employs the use of lead protection for the pelvis. or extremities enema previous 28 days* Evaluating and minimising the radiation risks in pregnancy If a decision is made to irradiate a woman who is pregnant Patient has Patient has not Re-book it will be in conjunction with the referring clinician who will missed a missed a period, examination have decided that there are overriding clinical reasons for the period/their i.e. period less within first 10 examination to take place. In such cases the relatively small period overdue, than 28 days days of onset of i.e. more than ago* menstrual cycle radiation risk to the patient/foetus will be outweighed by the 28 days ago* benefit of the diagnosis and subsequent treatment of poten- tially life-threatening or serious conditions. These could pre- sent a much greater risk to both parties if left undiagnosed. Record LMP. Proceed with To minimise the risks when examining pregnant women the examination providing LMP radiographer should adopt the following strategies: was within previous 28 days* Use of the highest imaging speed system available, e.g. 800 speed or equivalent settings for CR/DDR. Review justification If overriding If patient subsequently Limit collimation to area of interest. for examination clinical reasons for is found to be pregnant Use of shielding (can the uterus be shielded without signifi- with referring clinician† examination exist, then proceed using then review justification for procedure with cant loss of diagnostic information?). dose reduction referring clinician Use of the minimum number of exposures to establish a diag- strategies nosis. A typical ‘pregnancy rule’ for women of child-bearing age. *Some women have menstrual cycles of more or less than 28 days or have Use of projections that give the lowest doses. irregular cycles. CT, computed tomography; LMP, last menstrual period. Use pregnancy tests if doubt exists. Fig. 1.1 Typical flow chart for ‘pregnancy rule’. Staff and other personnel protection Radiography is undertaken in conformance with relevant radi- ation legislation. This will be discussed in detail and the end of the section. The following section summarises some of the important protection aspects: Adherence to the local Radiation Rules. Monitoring of staff radiation doses. Staff doses conform with the ALARP principle. Adherence with the use of a controlled area both for static, mobile radi- ography and fluoroscopy. Collimation and limitation of X-ray beam. Use of personal protective equipment (PPE) when appro- priate. Safe use of X-ray equipment. 5 www.ketabpezeshki.com 66485457-66963820 1 Terminology Imaging informatics It is important that the acquired images are viewed care- fully using optimised conditions, e.g. ambient light condi- Introduction (cont.) tions and the monitor is correctly adjusted. This may mean manipulating the image on the workstation monitor to dem- onstrate different areas of the image (Fig. 1.2). Post-examination and aftercare For extremity and axial radiography ensure an acquired Immediately following image acquisition the image will be image of a body part is displayed on a single monitor in reviewed to ensure it is of diagnostic quality; the patient will order to ensure optimum display (i.e. only one image per be managed and be given instructions as to what to do next monitor). and the examination will be completed in terms of the imaging information of the X-ray procedure. Department/manufacturers’ recommendations regarding any specific algorithms associated with a body part must be followed. Image quality Any further post processing must be carefully considered The image is reviewed using the ‘10-point plan’: before the images are sent to picture archiving and commu- 1. Patient identification. nication system (PACS). 2. Area of interest is included. Check the EI is of an optimum value to evaluate expo- sure to the patient and there is minimal /no noise on the 3. Markers and legends. image. 4. Correct projection. The images are sent to PACS so the referring clinician can 5. Correct exposure indicator (EI) – optimum EI and within view the image and the image can be reported by the report- acceptable range. Limited/no noise. ing radiographer or radiologist. 6. Optimum definition – can you see the detail of the relevant The examination is completed on the Radiology informa- anatomy/structures, i.e. is it sharp? tion system (RIS), making sure the image is in the correct 7. Collimation is restricted to the area of interest. patient folder and the documentation regarding exposure 8. Are there any artefacts and are they obscuring anatomy? details/dose reading and number of images taken is com- 9. Any need for repeat radiographs or further projections. pleted. 10. Anatomical variations and pathological appearances. The radiographer who is acting as the practitioner and oper- ator must be identified on the RIS system. Patient aspects At this important stage of the procedure the Radiographer has a duty of care to ensure the patient is given and under- stands instructions. They need to know what to expect next in regard to the report from the examination, who will receive the report and how long this process will take. There will be local protocols to ensure the process is robust and the patient is managed effectively, e.g.: Go back to clinic immediately. The report will be posted to your GP within a certain time- frame. Arrange transport via porters/ambulance or ensure the patient has transport home. It is important that the patient takes all their belongings and valuables home with them. The radiographer should answer any questions the patient or carers may have on the examination /process within their scope of practice. Fig. 1.2 Students and tutor at the monitor. 6 www.ketabpezeshki.com 66485457-66963820  Terminology 1 Examination timeline Requested Preparation X-ray room Patient procedure Review the request Room safe and tidy Communicate effectively Justification and authorisation of Equipment set up for the Introduce yourself examination using study and preliminary Identify the patient using local protocol appropriate legislation exposure set Check pregenancy status Check previous studies X-ray tube set for correct Explain procedure and gain consent Review departmental protocols procedure Are there any special needs for the and decide if any modfications Collect CR image receptors patient (Physical or psychological) are needed Accessory equipment Prepare patient if necessary Consider infection risk available e.g. appropriate clothing and Consider specific radiation Consider any remove any potential artifacts protection requirements contrandications and confounding factors Radiographic Radiation Examination Patient care procedure protection Visibly clean your hands Ensure the correct procedure is Follow local rules Communicate effectively carried out for the patient Correct protocol Be friendly and smile Use a precise technique Only essentials people in the room Give clear instructions Consider immobilisation or Optimum exposure for the Explain what you are doing distraction techniques examination Explain why you are doing it Follow deparment protocols Consider using an AEC Ensure patient is positioned Quick safe and efficient Correct collimation to the area of comfortably Get it right first time interest Invite and answer any questions Wash hands following the Lead protection where appropriate procedure Image Image Aftercare Patient quality informatics TEN POINT PLAN Identification parameters Wash hands following the Request card completed Area of interest included procedure Radiographer comment/initial Markers and legends Communicate effectively report Correct projection Explain what they need to Consider contacting referrer if Correct exposure do next major pathology or red flag Optimum definition Invite and answer any Check images are in the correct folder Collimation to area of interest questions within your role Images and data (e.g. dose) Artifacts obscuring image Arrange patient transfer if sent to PACS local archives Need for repeat radiographs or necessary IMMEDIATELY for reporting further projections (Are the images what you would expect for the examination undertaken) Anatomical variations and pathological appearances Fig. 1.3 Flow chart of the patient journey. 7 www.ketabpezeshki.com 66485457-66963820 1 It is important to consider the pathology in question Terminology and the clinical presentation of the patient. If debating whether a projection is acceptable always consider if the ‘diagnostic question’ has been answered. Image evaluation – 10-point plan 5. Correct exposure: the evaluation of the suitability of the exposure factors used for a radiograph will depend It is imperative that radiographic images are properly evalu- on the equipment and medium used to acquire and cap- ated to ensure that they are fit for purpose, i.e. they must ture the image. answer the diagnostic question posed by the clinician making Conventional screen/film-based imaging the request. In order to do this effectively the person undertak- ing the evaluation must be aware of the radiographic appear- Image density: the degree of image blackening should allow ances of potential pathologies and the relevant anatomy that relevant anatomy to be sufficiently demonstrated, thus needs to be demonstrated by a particular projection. Points allowing diagnosis. to consider when evaluating the suitability of radiographic Image contrast: the range of useful densities produced on images include: the radiographic image should correspond to the structures within the area of interest. Each anatomical area should be 1. Patient identification: do the details on the image match of sufficient contrast to allow relevant anatomical structures those on the request card and those of the patient who to be clearly visualised. was examined? Such details will include patient name and demographics, accession number, date of examination and Digital image acquisition systems the name of the hospital. Given the wide exposure latitude of digital systems, the ­primary task when evaluating the image is to assess for over- 2. Area of interest: does the radiograph include all the r­ elevant or underexposure. The imaging equipment will usually give a areas of anatomy? The anatomy that needs to be demon- numerical indication of the exposure used, the EI. The ­reading strated may vary depending on the clinical i­ndications for is compared with a range of exposure limits provided by the the examination. manufacturer to see if it is above or below recommended 3. Markers and legends: check that the correct ­anatomical ­values. Unfortunately, the method used is not standardised by side markers are clearly visible in the radiation field. the different manufacturers. Ensure the marker that has been used matches the body part on the radiograph and that this in turn matches Underexposure: images that are underexposed will show the initial request from the clinician. Ensure the cor- unacceptable levels of ‘noise’ or ‘mottle’ even though the ­ rect l­egends have been included if not stated in the computer screen brightness (image density) will be acceptable ­examination protocol, e.g. prone/supine. It is poor prac- (Fig. 1.4a). tice not to include a marker within the radiation field Overexposure: image quality will actually improve as exposure when making an exposure.3 increases due to lower levels of noise. However, once a ­certain 4. Correct projections: does the acquired image follow point is reached, further increases in exposure will result in ­standard radiographic technique as outlined throughout reduced contrast. Eventually a point is reached when the image the book, with the patient being correctly positioned contrast becomes unacceptable (Fig. 1.4b). together with the appropriate tube angulation? 8 www.ketabpezeshki.com 66485457-66963820  1 NB: There is considerable scope for exposing patients to unnecessarily high doses of radiation using digital imaging Terminology technologies. When evaluating images it is important always to use the lowest dose that gives an acceptable level of image noise. The EI must be in the appropriate range and must be Image evaluation – 10-point plan within the national and local DRLs. 6. Optimum definition: is the image sharp? Look at bone (cont.) ­cortices and trabeculae to ensure movement or other fac- 9. Need for repeat radiographs or further projections: a judge- tors have not caused an unacceptable degree of image ment is made from evaluations 1–8. If one or more factors unsharpness. have reduced the diagnostic quality to a point where a 7. Collimation: has any of the area of interest been over- diagnosis cannot be made the image should be repeated. looked due to over-zealous collimation? Check relevant Would any additional projections enhance the diagnostic soft tissues have been included. Also look for signs of col- potential of the examination? For example, radial head limation to evaluate the success of the collimation strategy projections for an elbow radiograph. If a repeat is required you used. This can then be used for future reference when it may be appropriate to image only the area where there performing similar examinations. Collimation outside the was uncertainty in the initial image. area of interest will increase both radiation dose and image 10. Anatomical variations and pathological appearances: note noise (due to increased scattered photons). anything unusual such as normal variants or pathology that 8. Artefacts: are there any artefacts on the image? These may may influence your future actions (see point 9) or aid diag- be from the patient, their clothing, the equipment or the nosis. For example, if an old injury is seen it may be worth imaging process. Only repeat if the artefact is interfering questioning the patient about their medical history. This with diagnosis. could then be recorded to aid diagnosis. Fig. 1.4a Underexposed digital radiograph. Fig. 1.4b Overexposed digital radiograph. 9 www.ketabpezeshki.com 66485457-66963820 1 Suggestions for an image assessment/evaluation process Terminology Gain an oral clinical history: obtaining a clinical history from the patient can be especially helpful for the radiographer to decide upon the correct projections required to demonstrate Image evaluation – 10-point plan the injury, and a greater understanding of the area to check (cont.) for injury. Use a logical system for checking the image and any pathol- Image evaluation – Radiographer ogy: many different approaches to evaluate radiographs are comments/initial report suggested in the radiology literature. The ‘ABCs’ system provides a simple and systematic approach and has been As part of the image evaluation process the radiographer may adapted to systems other than the musculoskeletal. The ABCs also be required to provide an initial report in respect of the stands for: radiological appearances of the acquired image in order to aid prompt diagnosis. This is particularly important in the accident A: Adequacy; alignment. Check that the image adequately and emergency environment (A&E) where the experienced radi- answers the clinical history/question. Are any additional ographer can make helpful comments to the referring ­clinician. projections required or repeat images needed? The methodology used is to apply an image assessment pro- B: Bones. Trace the cortical margins of all bones. Check for cess gained via formal learning and experience to enable the abnormal steps in the cortex and for any disruption in the radiographer to form an opinion as to whether the image is trabecular pattern. ‘normal’ or demonstrates a pathology/abnormality. The major- ity of current UK radiography degree courses include some ele- C: Cartilage. Alignment of all joints should be checked for ment of ‘red dot’ teaching with basic image interpretation for signs of dislocations or subluxations. Check each joint space undergraduate radiographers and there are also multiple study in an orderly fashion, looking specifically at the congruity days for CPD of this subject area. and separation of the margins of the joint space. The bones Radiographers due to their role have the greatest opportunity should not overlap and the joint spaces should be uniform of any health professional to see a large number of ‘normal’ in width. Check for small avulsion fractures. radiographs and thus have been shown to be able to identify S: Soft tissue and foreign bodies. For example, be able to ‘abnormal’ images or images with pathology with the appro- identify and recognise the significance of an elbow joint priate training for this role expansion.4 Some imaging depart- effusion or a lipohaemarthrosis (fat/blood interface within ments operate a ‘red dot’ policy whereby radiographers simply the knee or shoulder joint), all of which can be associated flag any abnormality on an image; others use a ‘Radiographer with an underlying fracture. commenting’ policy. Both act to enhance the radiographers’ role and assist the A&E referrers to determine the appropriate S: Satisfaction of search. If you spot one fracture, look for treatment pathway for the patient. another. It is a common mistake to identify a fracture but The Society and College of Radiographers recognises two miss a second by not checking the entire image. Be aware different levels of radiographer reporting: of principles such as the ‘bony ring rule’, which states that Clinical reporting: carried out by advanced practitioners who if a fracture or dislocation is seen within a bony ring (e.g. have acquired a postgraduate qualification that enables them pelvis), then a further injury should be sought as there are to produce a diagnostic report. frequently two fractures. Initial reporting: where a radiographer makes a judgement Utilise a system of pattern recognition: knowledge of normal based on their assessment of the image. It provides consid- anatomy and anatomical variants is essential. Radiographers ered comments to the referrer rather than a simple ‘red dot’. encounter a number of ‘normal’ examinations and as such It should be made clear that although this may be in written are well placed to use this knowledge to identify any changes form it does not constitute the equivalent of a formal report.5 in the normal ‘pattern’ of bones and joints. Many useful ana- Radiographers in the UK are encouraged to work to com- tomical lines and measurements are used to check for abnor- menting/initial report level, but some radiographers are malities, for example ‘McGrigor’s three lines’ for evaluating allowed to opt out of the process. If a ‘red dot’ is applied to the facial bones. Whichever system is used try to apply it the image but no comments added, then this may cause some consistently and logically. This should reveal many subtle confusion upon review of the image by the referrer as well as injuries.6 when the image is viewed for a formal clinical report. The key points to include in the radiographers are comments Pay attention to ‘hot-spots’: pay attention to where frequent are: pathology, trauma or abnormalities occur, such as the neck of the 5th metacarpal, the base of the 5th metatarsal, the dorsal Abnormality Yes / No aspect of the distal radius or the supracondylar region of the Description ? fracture/dislocation/other abnormality humerus in children. Frequently, the way the patient presents or reacts to positioning gives strong clues as to the position of Region of abnormality e.g. distal radius the injury.7 10 www.ketabpezeshki.com 66485457-66963820  1 The following examples of how image evaluation is applied are illustrated throughout the book using a standard template that Terminology the reader is encouraged to apply, using the basics principles of evaluating an image and providing an initial report.8 In these first examples comments are listed that are helpful in Image evaluation – 10-point plan the checking process. In the other examples demonstrated not all correctly identified criteria are listed but only those main points to (cont.) consider that may require further attention, with the assumption that the absence of comments indicates a satisfactory situation. 6. Optimum definition. There is no blurring of the image and the structures appear to be well defined. Evaluation using the 10-point plan. In this example the 7. Collimation. The X-ray beam is collimated to the area of patient has been referred for a possible fracture of the interest. right hip. 8. Artefacts. There are no artefacts obscuring the anatomy. 9. Need for repeat radiographs or further projections. Additional 1. Patient identification. Patient identity has been removed images are required. It is not possible to evaluate any frac- from the image but should include the patient name and ture of the right hip without the hip being internally rotated. another form of identification. A lateral image is also required to determine the pathology. 2. Area of interest. The area of interest is included and 10. Anatomical variations and pathological appearances. No includes the top of the ilium superiorly, the lateral margins significant anatomical variations. Evaluation of a fracture of the pelvic ring and proximal femora. to the right hip needs to wait until a repeat hip X-ray and 3. Markers and legends. The Left marker is applied to the left lateral is undertaken. side of the patient. 4. Correct projection. The pelvis is not positioned correctly Radiographer Comments/Initial report as the hips are not at the same anatomical level; however, the pelvis is not rotated and the pelvic ring is symmetrical. AP pelvis (Fig. 1.5) The right hip is not internally rotated so the femoral neck is foreshortened. AP pelvis demonstrating foreshortening of right fem- 5. Image exposure. The EI is not indicated on the image; oral neck with a lateral projection required to exclude however, there is no noise in the image as the bony tra- NOF #. beculae can be clearly demonstrated. Fig. 1.5 Pelvic girdle. 11 www.ketabpezeshki.com 66485457-66963820 1 Terminology Image evaluation – 10-point plan Fig. 1.6a AP and lateral ankle. Fig. 1.6b DP foot. In this example a 20-year-old male was referred for ankle In this example a 34-year-old female runner was referred from X-ray following an injury playing football. The request was A&E with generalised forefoot pain, worse after exercise. The justified by the practitioner and the following images taken. request was justified by the practitioner and the following Patient identification was confirmed on the RIS/PACS system. image taken. Patient identification was confirmed on the RIS/ PACS system. IMAGE EVALUATION IMAGE EVALUATION AP & lateral ankle (Fig. 1.6a) DP foot (Fig. 1.6b) The main points to consider are: The main points to consider are: Images are of diagnostic quality with patient posi- Radio-opaque marker was applied post examina- tioned optimally. tion. There is an undisplaced fracture of the lateral Image is slightly over rotated. ­malleolus. Image is well penetrated through the tarsal area. There is some early callus formation around the neck of the 3rd metatarsal (MT). Radiographer Comments/Initial report Undisplaced fracture of the lateral malleolus. Radiographer Comments/Initial report ? Stress fracture neck of 3rd MT. 12 www.ketabpezeshki.com 66485457-66963820  Terminology 1 The human body is a complicated structure. Errors in radio- graphic positioning or diagnosis can easily occur unless practi- tioners have a common set of rules that are used to describe the body and its movements. This section describes terminology pertinent to radiogra- phy. It is vital that a good understanding of the terminology is attained to allow the reader to understand fully and practise the various techniques described in this text. All the basic terminology descriptions below refer to the patient in the standard reference position, known as the ana- tomical position (see opposite). Fig. 1.7a Anatomical position. Fig. 1.7b Anterior aspect of body. Anatomical terminology Patient aspect (Figs 1.7a–1.7e) Anterior aspect: that seen when viewing the patient from the front. Posterior (dorsal) aspect: that seen when viewing the patient from the back. Lateral aspect: refers to any view of the patient from the side. The side of the head would therefore be the lateral aspect of the cranium. Medial aspect: refers to the side of a body part closest to the midline, e.g. the inner side of a limb is the medial aspect of that limb. Fig. 1.7c Posterior aspect of body. Fig. 1.7d Lateral aspect of body. Positioning terminology Planes of the body (Fig. 1.7f) Three planes of the body are used extensively for descriptions of positioning both in conventional radiography and in cross- sectional imaging techniques. The planes described are mutu- ally at right-angles to each other. Median sagittal plane: divides the body into right and left Fig. 1.7e Medial aspect of arm. halves. Any plane that is parallel to this but divides the body into unequal right and left portions is known simply as a sagittal plane or parasagittal plane. Coronal plane: divides the body into an anterior part and a Sagittal posterior part. plane Coronal plane Transverse or axial plane: divides the body into an inferior and superior part. Axial or transverse plane Fig. 1.7f Body planes. 13 www.ketabpezeshki.com 66485457-66963820 1 Terminology Positioning terminology (cont.) (Figs 1.8a–1.8e) This section describes how the patient is positioned for the various radiographic projections described in the book. Erect: the projection is taken with the patient sitting or stand- ing. The patient may be standing or sitting when positioned erect with the: Posterior aspect against the image detector. Anterior aspect against the image detector. Right or left side against the image detector. Decubitus: the patient is lying down. In the decubitus position, the patient may be lying in any of the following positions: Supine (dorsal decubitus): lying on the back. Prone (ventral decubitus): lying face-down. Lateral decubitus: lying on the side. Right lateral decubi- tus – lying on the right side. Left lateral decubitus – lying on the left side. Semi-recumbent: reclining, part way between supine and sit-