MIV: Radiographic Procedures of the Proximal Lower Limb PDF

Radiologic Positioning Radiologic Positioning MIV: Radiographic Procedures of the Structures Shown: Proximal Lower Limb - PA of the knee structures and knee joint...

Radiologic Positioning Radiologic Positioning MIV: Radiographic Procedures of the Structures Shown: Proximal Lower Limb - PA of the knee structures and knee joint Knee AP Patient/Part Position: - Supine - Extend the knee - Center the IR below 1⁄2 inch of the patellar Lateral (Mediolateral) apex; flex the joint slightly and locate the patella Patient/Part Position: - Femoral epicondyles parallel with the IR - Turn to affected side, bring the affected knee Central Ray: forward - Angulation of central ray depends on the pelvic - Extend unaffected knee behind thickness/ASIS: - Hold the epicondyles to adjust perpendicularly → 25cm = cephalic, 3-5° → 10° flexion for suspected fragments - Directed to.5 inchs inferior to patellar apex → 20-30° flexion to relaxes the muscle and Structures Shown: shows maximum volume of the joint cavity - AP of the knee structures Central Ray: - Angulated at 5-7° cephalic - Directed to the knee joint 1 inch distal to the medial epicondyle Structures Shown: - Lateral of distal end of femur, patella, knee joint - Proximal ends of tibia and fibula - Adjacent soft tissues Over rotation = less superimposition Under rotation = more superimposition Vontranger - if patient is recumbent while imaging the lateral knee PA CR angulation: Patient/Part Position: → 5° angulation if patient is tall, narrow pelvis, - Prone male, - Center the 1⁄2 inch below of the apex on the → 7-10° angulation if patient has wide pelvis, center of the IR short - Position the femoral epicondyles parallel with the tabletop AP - Toes resting on radiographic table (dorsiflex) Weight-bearing: Standing Central Ray: Patient/Part Position: - Directed with angulation of 5-7° caudally to the - Standing- upright inferior.5 inchs of patellar apex - Position the feet and toes facing straight ahead - Perpendicular central ray with large thighs or - Knees fully extended and feet separated foot is dorsiflexed enough for good balance while facing straight - With thick thighs or dorsiflexion of the foot, ahead direct the CR perpendicular to knee  Central Ray: AP Oblique (APO) - Horizontal and perpendicular Lateral Rotation - Entering at a point.5 inch below the apices of Patient/Part Position: the patellae - Supine Structures Shown: - Position the 1⁄2 inch below of the apex of - Knee joint spaces patella on the center of IR Note: - Laterally rotate the limb 45° - This procedure is used in varus and valgus Structures Shown: deformities imaging - AP Oblique images of the laterally rotated femoral condyles, patella, tibial condyles and fibular head; LR - M Leach, Gregg, & Siber - recommended that a bilateral weight-bearing AP must be routinely Medial Rotation used for patients with arthritic knees Patient/Part Position: - This reveals narrowing of joint space - Supine - If patient in recumbent, joint space orientation - Medially rotate the limb at 45° changes and produces normal image - Elevate the hip of the affected side to rotate the - Leach, Gregg, & Siber aka Alhback procedure limb (in board exam) Structures Shown: - Knee weight bearing can reach VCH, ankle - AP Oblique images of the medially rotated weight bearing needs low-riser femoral condyles, patella, tibial condyles and - If a patient has wide hips, take bilateral but 1 fibular head; MR = L foot per shot. Take 1 side first, with patient shifting weight to side being imaged Valgus = knock-kneed; upward eversion (value) Varus = bow-legged; inversion (varid) - AP weight bearing shows valgus and varied Lateral and Medial Rotation deformities Central Ray: - Directed 1⁄2 inch inferior to the apex of the PA patella Rosenberg: Standing Flexion - Angulation of central ray varies on ASIS: Patient/Part Position: → 24cm = 3-5° cephalad center of the vertical grid - Directed to.5 inches inferior to patellar apex - Flex the knees at 45° while standing Note: Central Ray: - Angulation of central ray is also utilized as - Horizontal and perpendicular.5 inch level below same goes with AP projection the apices of patella - It depends on the pelvic thickness Structures Shown: - In Vontranger, when doing oblique knee - Joint space narrowing and showing articular imaging, if one rotation is requested, cartilage disease (includes arthritis) automatically do the other rotation Note: - Flexing the knees places the femur at an angle PA Oblique (PAO) of 45° Lateral Rotation - 10° angulation caudally is sometimes used Patient/Part Position: (when pt cannot reach 45°flexion) - Prone - Elevate the hip of the affected side - Rotate the toes and knees laterally at 45°  Structures Shown: - 20° angulation in relationship with the central - PA Oblique of femoral condyles, patella, tibial ray; if the patient cannot flex the leg condyle and head of fibula that are laterally - 70° if the patient is standing; can flex the knee rotated; LR = M - Also 70° in relation with the table top or image Note: receptor - Holmblad suggested 10° flexion of the knees → With 70° degrees of flexion, the joint of the intercondylar fossa is open Note: - First described in 1937 in kneeling position and was formerly known as Tunnel position Medial Rotation - In 1983, it was modified to Standing position for Patient/Part Position: the patient’s safety and comfortability - Prone - The degree of flexion widens the joint and - Medially rotate the leg and foot surfaces of the tibia and femur - Elevate the unaffected hip, rotating the limb 45° - According to Turner and Burners, if the patient medially is allowed to stand up, asked the patient to Structures Shown: stand up - PA Oblique images of medially rotated femoral condyles, patella, tibial condyles, proximal tibiofibular joint and head of fibula; MR = L Lateral and Medial Rotation Central Ray: - Perpendicular through the knee joint - At.5 inch below level of the patellar apex Camp-Coventry Method Note: Patient/Part Position: - Patella displaced depending on rotation - Prone - Flex the knees up to 40-50° Intercondylar Fossa - Position the femoral portion of the knee on IR PA Axial/ Tunnel Projection - Place support for the foot Holmblad Method Central Ray: Patient/Part Position: - Perpendicular to the long axis of lower leg - Kneeling or standing → 40° angulation for 40° flexion Position in either of the following: → 50° angulation for 50° flexion 1. Place the flexed knee of interest on a stool - Entering the popliteal fossa beside the radiographic table while having the Note: other limb support the body by standing - Flexion of 40 or 50° of the knee requires 40 or 2. Placing the flexed knee in contact with IR in 50° angulation of the CR, respectively front - Used in detecting loose bodies or joint mice and 3. Kneeling the affected knee on the radiographic in evaluating split and displaced cartilage in table, over the IR osteochondritis dissecans (joint mice) For all positions: - Also visualizes flattening or underdevelopment - Place the IR against the anterior surface of the of lateral femoral condyle in congenital slipped knee patella - Flex the knee at 70° - Center the IR to the apex of the patella Central Ray: - Perpendicular to the lower leg - Entering the superior aspect of popliteal fossa for all three position  Holmblad and Camp-coventry Method Lateral (Mediolateral) Structures Shown: Patient/Part Position: - Intercondylar fossa - Lateral recumbent - Posteroinferior articular surfaces of the - Turn to the affected hip condyles of the femur - Flex the unaffected knee and hip, placing it in - Profiles of medial and lateral intercondylar front of the patellofemoral joint space tubercles of the intercondylar eminence and - Flex affected knee 5-10° (reduces tibial plateaus patellofemoral joint space) Central Ray: AP Axial - Patella perpendicular to IR Beclere Method - Enters the knee at midpatellofemoraljoint Patient/Part Position: Structures Shown: - Supine - Lateral of the patella and patellofemoral joint - Flex the affected knee at an angle of 60° space - Ensure that the knee is centered and coincides with the central ray and IR - Adjust the femoral condyles to be equidistant from the IR Central Ray: - Perpendicular - Entering the knee joint.5 inch below the apex PA Oblique (PAO) of the patella Medial Rotation Structures Shown: Patient/Part Position: - Intercondylar fossa - Prone - Intercondylar eminence - Flex the knee approximately up to 5-10° - Knee joint - Rotate the knee 45-55° from prone to medial Note: Structures Shown: - Requires - PA Oblique image of medial portion of the rolled film patella which is free from superimposition of femur Patella PA Patient/Part Position: - Prone Lateral Rotation - Position the leg, placing the patella parallel with Patient/Part Position: the plane of IR - Prone - Rotate the heel laterally to 5-10° - Flex the knee up to 5-10° - Place sandbags to elevate the thigh and relive - Laterally rotate it 45-55° from prone pressure to the patella Structures Shown: Central Ray: - PA Oblique image of lateral portion of the - Perpendicular to the popliteal area patella which is free from superimposition of - Exits the patella femur Structures Shown: - Sharper recorded detail of the patellar area Note: - Shaper recorded detail because of short OID - Knee joint = 0.5 inches inferior to the apex of Medial and Lateral Rotation patella Central Ray: - Perpendicular through the lateral portion of the patella to the IR - Exits at the palpated patella  PA Axial Oblique Hughston, Laurin, Fodor et.al. Kuchendorf Method Central Ray: Patient/Part Position: - Angulation cephalically at 45° - Prone - Direct through the patellofemoral joint - Rotate externally the knee at approximately Structures Shown: 35-40° from prone - Sublaxation of the patella - Flex the knee approximately 10° (incomplete dislocation) - Place index finger on patella and push it and patellar fractures laterally - Femoral condyle - Laterally displaced the patella, rest the knee & place the weight on the anteromedial side Merchant Method Central Ray: Patient/Part Position: - Direct towards the joint space between the - Supine; bilateral image (non-distorted, patella and femoral condyle magnified) - Angulate at 25-30° caudally - Use of “axial viewer” device to elevate the knee - Enters the posterior surface of the patella approximately 2 inches Structures Shown: - Flex the knee at 40° - Slight oblique and PA image of the patella - Strap the calf together, controlling the rotation which is free from superimposing of the and relaxation of the leg structures and the outline is more clearer - Place IR on shins approx. 1ft distal to patella Note: Central Ray: - Placing the weight on the anteromedial side - Perpendicular to IR hold the patella in lateral displacement - Angulate the central ray at 30° caudally in reference with the horizontal plane → 60° from vertical plane → 40° for knee flexion - Enters midway the patellae at the level of patellofemoral joint Structures Shown: Patellofemoral Joint - Axial image of patellae and patellofemoral joint Tangential Note: Laurin - 6ft (2m) SID to reduce magnification Patient/Part Position: - Degree of angulation of the knee flexion varies - 20° flexion of the knee between 30-90° which demonstrates the Note: patellofemoral disorders - Patellar sublaxation is easier to visualize in this - Pillow or foam wedge on patient’s head to allow angle; used to be a struggle in imaging patella patient to relax - Former method but Hughston was widely used - Rectus femoris relaxes as a result which later increases quality of image Fodor, Malott, Weinberg, Merchant - Tense rectus femoris pulls patella up Patient/Part Position: - Non-distorted patella but magnified - 45° flexion of the knee Note: - Former method but Hughston was widely used later Hughston Method Patient/Part Position: Settegast Method - Prone Patient/Part Position: - 55° flexion of the knee - Supine or prone; bilateral imaging - Position the IR under the knee - Flex the knee as low as possible or the patella Note: is perpendicular to IR (>90° acute flexion) - Flexion of the knee for the tibia and fibula form - Center IR to the joint space between patella 50-60° angle and femoral condyles  Central Ray: - Femur needs to be parallel to IR to image the - Perpendicular to the joint space between the distal femur patella and femoral condyles - If whole lower limb is affected, 2 images (1 in - When the knee is flexed, angulation of the hip joint and 1 on hip joint) should be taken (if central ray depends with it patient is too tall) - Typically angulated at 15-20° - In profile = superimposing without any Structures Shown: obscurement of the structure - Vertical fractures of bone and articulations of - Rotation is enough if lesser trochanter not seen patellofemoral articulation or very small portion (proximal) Note: - Condyles should not be superimposing (distal) - Should not be attempted if transverse fracture of patella is present - Prerequisite is lateral projection - If done with fracture, patella fragments may be displaced Lateral (Mediolateral) Patient/Part Position: - With knee (distal femur): → Draw unaffected limb forward → Flex affected knee 45° → Epicondyles perpendicular to the table → Bottom of the IR 2in below the knee/patellla - Hip (proximal femur): → Draw unaffected limb backward Femur → Roll pelvis posteriorly to prevent AP superimposition—10-15° from lateral Patient/Part Position: → Top of the IR at the level of ASIS - Supine - Femoral neck in profile - Position the affected femur on the center of the - Not recommended for pts with fracture or midline of IR destructive disease. Pts with these conditions - When including the knee in imaging of the distal should be imaged in supine by placing the IR femur, rotate the limb medially vertically along the medial or lateral aspect of - When including the hip in imaging of the the thigh and knee and cr directed horizontally. proximal femur, position the IR at the level of - 10-15° rotation of the hip internally ASIS and rotating the limb medially 10-15°, - Central Ray: placing the femoral neck in profile - Perpendicular to midfemur → Knee with distal femur Structures Shown: → Hip joint with proximal femur - Lateral 3⁄4 of the femur and adjacent joint Central Ray: Note: - Perpendicular to midfemur - Epicondyles perp to IR, place pillow or sandbag Structures Shown: to allow patient to rotate ankle - AP of the femur - If patient in pain, alternative is patient is in - Knee or Hip joint supine, IR placed on side nearest patient, CR is → Majority of the femur and the jt nearest to the horizontal pathologic condition or site of injury. If the whole - If dorsal decubitus, IR is on affected side, CR lower leg is affected and the pt is tall take two on unaffected side images - AP and Lateral femur (Distal) bottom of the IR 2 inches below the knee Note: - AP and Lateral femur (Proximal) top of the IR at the level of the ASIS  - Distal femur, patella in profile, patellofemoral AP Projection space is open Patient/Part Position: - Divergence of beam shows condyles not - Supine superimposed - Medially rotate the feet and lower limbs about - Opposite thigh not superimposing affected thigh 15-20° → Unless contraindicated because of trauma or pathology. Femoral neck parallel with IR - The heels should be placed about 8-10” apart - Ensure pelvis is not rotated (make sure it is equidistant) - Center IR between ASIS and pubic symphysis. Pelvis - Upper border will be 1-1.5” above the crest - Female pelvis is wider and shallow in terms of Central Ray: the ileum - Perpendicular to the IR - Female sacrum is wider and curves more - Midway between the ASIS and the pubic sharply towards the posterior side symphysis - Males have sacrum that curves more anteriorly Structure Shown: - The sacral promontory is the highest point of - AP of pelvis/hip bones and the head,neck, the sacrum and in females it appears flat side trochanters, and proximal 1⁄3 or 1⁄4 of the - The female pelvis structure is different for the femoral shaft sake of child bearing and delivery Note: - Localizing body landmarks is done to center the - Martz and Taylor recommended two AP IR and CR. The thumb will be placed in the asis projections of the pelvis for demonstration of and the index finger in the pubic symphysis. the relationship of the femoral head to the Draw a line in between those two points; its acetabulum in patients with congenital midpoint directly located to the greater dislocation of the hip/congenital hip dysplasia or trochanter the malformation of the acetabulum. First - To locate the asis ask the patient to inhale projection is obtained with CR directed to pubic deeply and at the patient exhales locate the symphysis to detect any lateral or superior ASIS because the exhalation will cause the displacement of the femoral head. The second muscles to relax projection is an AP axial projection obtained - Greater trochanter is below the depression of with the CR directed 45° cephalad to pubic the lateral surface of the hip symphysis. This casts the shadow of an anteriorly displaced femoral head above that of the acetabulum and the shadow of a posteriorly displaced head below that of the acetabulum → Superior = anterior → Interior = posterior → Lateral = lateral; medial = medial Lateral Projection Patient/Part Position: - Lateral recumbent, dorsal decubitus, or - upright position - Patient in Recumbent position → Extend the thighs enough to prevent the Pelvis and Hip Joints femora from obscuring the pubic arch → Place one knee directly over the other knee - Patient in Upright position - Perpendicular through the lumbosacral region → Lateral position in front of VCH at the level of the greater trochanter → Equally distribute the body weight - When flexion of the body is restricted, direct the → With unequal length of limb, place a cr anteriorly, perpendicular to the coronal plane support of the pubic symphysis → Grasp sides of stand for support → Angulation of cr depends on the degree of - Berkebile, Fischer, and Albrecht recommended body flexion The body rotation and dorsal decubitus for demonstration of the CRangulation should produce 45° "gull-wing sign" in case of fracture dislocation of Structures Shown: the acetabular rim and posterior dislocation of - Axial of the pelvis, demonstrating the the femoral head relationship between the femoral heads Central Ray: - and the acetabula, the pelvic bones, and any - Perpendicular to the IR opacified structure within the pelvis - Point centered at the level of the tissue depression just above the greater trochanter (approximately 2”) Structure Shown: - Lateral of lumbosacral junction - Sacrum, coccyx, and superimposed hip bones Femoral Neck and upper femora Cleaves Projections - Often called the bilateral "frog leg" position–(modified and original) - Note: This examination is contraindicated for the patient suspected of having a fracture or other pathologic disease Pelvis and Hip Joint AP Oblique (APO) Modified Cleaves PA Axial Patient/Part Position: Charssed-Lapine - Supine - For the purpose of measuring the horizontal, or - Flex elbows and rest arms on the upper chest. diameter in pelvimetry of the pelvic outlet for - Pelvis should not be rotated. Place both ASIS childbirth. Some use this method to determine equidistant. the relationship of the femoral head to the - Compression band across the patient, above acetabulum, and others employ it to the hip joints for stability demonstrate the opacified rectosigmoid portion - Bilateral: of the colon → Flex both hips and knees (femur nearly - Considered axial due to the body leaning vertical) forward to 45 degree → Draw the feet up Patient/Part Position: → Center IR 1” superior to pubic symphysis - Seat at the end or side of the table (MSP is → Abduct thighs as much as possible centered on the long axis of the ir if pt is seated (45°) to place the long axis of the femoral neck on the side of the table. If the pt is seated on parallel to the IR the end of the table center the MSP to the → Turn feet inward midline of the grid) - Unilateral: → If needed place a stool or support under the → Center ASIS of the affected side feet → Flex the hip and knee of the affected - Abduct thighs as far as the end of the table → Draw the foot up to the opposite knee permits → Abduct the thigh laterally approximately 45° - Lean forward Central Ray: → Pubic symphysis in close contact with the - Perpendicular to a level 1” superior to the pubic table; vertical axis of pelvis tilted forward symphysis (Bilateral) approximately 45° - For the uni lateral,⊥ to the femoral neck - Grasp ankles to aid in maintaining the position Central Ray:  Structures Shown: radiographic table but are radiographed on the - The bilateral resulting image shows an APO of stretcher or bed. After the localization point, one the femoral heads, necks, and trochanteric assistant should beachside the stretcher to areas projected onto one radiograph for grasp the sheet and lift the pelvis just enough comparison for placement of the IR while a third person supports the injured limb. Any necessary Axiolateral Original Cleaves manipulation of the limb must be made by a Patient/Part Position: physician - Same position as the modified Central Ray: - CR is parallel with the femoral shafts - Angle may vary between 25-45° depending on how vertical the femora is placed Structures Shown: Lateral - Axiolateral projection of the femoral heads, Lauenstein Method necks, and trochanteric areas Central Ray: - Perpendicular through the hip joint Hickey Method Central Ray: - Angulated cephalad at 20-25° Lauenstein and Hickey Method Patient/Part Position: Andren and Von Rosen Method (Footnote) - Supine; from supine rotate toward the affected - Diagnosis of congenital dislocation of the side up to slightly oblique hip/hip dysplasia in newborns - Rotate toward the affected side up to slightly - Bilateral hip with both legs forcibly abducted to oblique at least 45° - Flex the knee of the affected side, positioning - Appreciable inward rotation of the femora the thigh at a right angle with the hip bone Knake and Kuhns device (Footnote) - Extend the opposite limb, supporting the hip - Construction of the device controlling the and knee degree of abduction and rotation of both limbs Structures Shown: - Essentially eliminates and simplifies the Lateral of the hip: positioning difficulties - The acetabulum - Reduces the number of repeat examinations - Proximal end of femur - Relationship of the head of the femur to the Hip acetabulum AP Note: Patient/Part Position: - Used to demonstrate the relationship of the hip - Supine joint and the femoral head with the acetabulum - Rotate the lower limb approximately 15-20° - Lauenstein and Hickey methods demonstrate medially the relationship of the hip joint and the femoral Central Ray: head with the acetabulum. This is similar to - Perpendicular to the femoral neck modified cleaves - 2 1⁄2 inches distally from a line which is drawn perpendicular from the midpoint of a line between ASIS and pubic symphysis Structures Shown: - Head, neck, trochanters, and proximal one third of the body of the femur → In cases of hip lesions, the pelvic girdle and proximal femur are included → Trauma patients who have sustained severe injury are not usually transferred to the  Axiolateral Structures Shown: Danelius-Miller Method - Lateral hip Patient/Part Position: - Acetabulum - Supine - Proximal Femur - Elevate the pelvis with supports - Lateral profiles of Head, neck and trochanters - Flex the knee and hip of the unaffected side, of femur elevating the thigh in vertical position Note: - Rotate the foot and lower limb medially by the - Instead of the toes being medially rotated, the heel and affected side at 15-20° central ray is angulated Central Ray: - Perpendicular to the long axis of the femoral neck Structures Shown: - Acetabulum - Head, neck and trochanters of the femur Friedman Method Note: Central Ray: - Rotating the limb is possible unless its condition - Cephalic at 35° contraindicates it Kisch - The central ray enters the midthigh and passes Central Ray: through the femoral neck 2 1⁄2 inches below its - 15-20° cephalic angulation point of intersection of the localization lines Friedman and Kisch Method Patient/Part Position: - Lateral recumbent - Positioned on the affected side - Extend and adjust it in lateral position - Roll the upper side of the limb posteriorly, approximately 10° Structures Shown: Leonard-George / Danellius-Miller - Axiolateral images of the head, neck, (Lateromedial) trochanters and proximal body of the femur - Used a curves cassette Patient/Part Position: - Unaffected side flexed - Thigh abducted - 15-20° internal rotation of foot - Uses curved cassette PA Oblique (PAO) Clements-Nakayama Method Hsieh Recommendation - If the patient has bilateral hip fractures, bilateral Patient/Part Position: hip arthroplasty (plastic surgery of hip joints), or - Semi prone limitation of movement of the unaffected leg, the - Elevate unaffected side approximately 40-45° Danelius-Miller method cannot be used. This - Support the body with flexed knee and forearm method will be used - Position the posterior surface of the affected Patient/Part Position: iliac bone over the midline of the grid - Supine Structures Shown: - Do not rotate the lower limb - PA Oblique of the ilium, hip joint and proximal - Keep the neutral or slightly rotation laterally of femur the limb Note: - Position the IR on the lower margin and parallel - Demonstrates the posterior dislocations of the to the axis of the femoral neck, tilting it 15° head of femur Central Ray: - Directed 15° posteriorly - Align perpendicular to the femoral neck and IR  AP Oblique (APO) Note: Urist Recommendation - Lilienfield method is not used to patients with Patient/Part Position: acute hip injury - Right or left posterior oblique position - The degree of rotation of the limb separates the Structures Shown: shadows of hip joints, allowing optimum - Posterior rim of the acetabulum rim of projections of the slope of the acetabular roof acetabulum in acute fracture dislocation injuries and depth of socket of the hip - Similar to Colonna is the False profile and Note: demonstrates the Acetabular roof - Urist recommended to position the patient in Lilenfeld and Colonna Semi supine for the PT's comfortability Central Ray: Hsieh and Urist Recommendation - Perpendicular to the IR Central Ray: - Traversing the hip joint - Perpendicular to midpoint of IR Structures Shown: - Passes through between the posterior surface - Mediolateral oblique images of the ilium, of the iliac blade and dislocated femoral head acetabulum and proximal femur Acetabulum Hsieh PA Axial Oblique Teufel Method Patient/Part Position: - Semi prone Mediolateral Oblique - Elevate the unaffected side forming 38° Lilienfeld Method angulation from the table Patient/Part Position: Central Ray: - Lateral recumbent - 12° cephalad angulation directed through the - Position on the affected side by fully extending acetabulum the thigh Structures Shown: - Gently roll forward the upper side approximately - Fovea Capitis 15° to separate the two pelvis Note: Reference point: - Inferior level of the body of the coccyx - Approximately 2 inches lateral to the MSP towards the side examined Colonna Recommendation (Lateromedial Oblique) - Is used when lilienfield is not used with pts who have an acute hip injury - Allows the ptt to be examined more comfortably, AP Oblique safely, and satisfactorily. Similar to the false Judet Method profile method which demonstrates the anterior Patient/Part Position: acetabular roof Internal Oblique: Patient/Part Position: - Semi supine - Same as Lilienfield method except: - Position the affected hip on uppermost side - Positioned only on the unaffected side - Elevate the affected side, positioning the - Rotate the affected side about 17° anterior from anterior surface of the body 45° from the table true lateral position External Oblique: → Degree of rotation separates the shadows of - Semi supine hip jts and give the optimum projection of the - Positioning the affected hip down slope of the acetabular roof and depth of the - Elevate the affected side at socket 45° from the table  - Centered 2 inches distal to the superior border Central Ray: of pubic symphysis Internal Oblique: Females: - Perpendicular to IR - 30-45° cephalic angulation - Enters 2 inches to ASIS of - Centered 2 inches distal to the upper border of affected side the pubic symphysis External Oblique: Structures Shown: - Perpendicular to IR - Rami without being foreshortened - Enters the pubic symphysis Note: Structures Shown: - Pelvic outlet - Acetabular rim PPIU - IlioPubic(anterior side) Posterior rim Internal oblique Up-affected side IDEA- Ilioischial (Posterior side) Down-affected side External oblique Anterior rim Note: - Two 45° posterior oblique positions useful in Superoinferior Axial (Inlet) diagnosing fractures of the acetabulum Lilienfeld Method - Internal Oblique: suspected fracture of iliopubic Patient/Part Position: column and posterior rim of acetabulum - Seated-upright - External Oblique: suspected ilioischial column - Flex the knees slightly fracture and anterior rim of acetabulum fracture - Lean backwards and extend arm for support - Lean for 45-50° arching the back if possible Anterior Pelvic Bones Central Ray: PA - Perpendicular to the midpoint of the IR Patient/Part Position: - Enters 1 1⁄2 inches superior to the pubic - Prone symphysis - Position the trochanters at the center of the IR Structures Shown: Central Ray: - Superoinferior axial images of the anterior - Perpendicular to midpoint of IR, specifically the pubic, pubic symphysis and ischial bone distal coccyx and exits of the pubic symphysis Note: Structures Shown: - Pelvic Inlet - PA of pubic symphysis and ischia which includes the obturator foramina Note: - Centering the trochanters on the IR also AP Axial centers the pubic symphysis Bridgman - Bridgman recommended that the inlet - can also be demonstrated with the pt in supine and the cr angled 40° caudad Patient/Part Position: - Patient in supine AP Axial (Outlet) Central Ray: Taylor Method - Angulate 40 degrees caudal to pubic symphysis Patient/Part Position: Note: - Supine - Pelvic inlet - Center the midsagittal plane to the midline of the grid PA Axial - Position the pelvis, avoiding its rotation Staunig Method Central Ray: Patient/Part Position: Male: - Prone - 20-35° cephalic angulation - Center the midsagittal plane on the radiographic table - Position the body that the pelvis is not rotated APO vs. PAO Central Ray: Note: - Direct 35° cephalic APO vs. PAO - Exits the pubic symphysis on the midsagittal - APO images broad surface of Iliac wing without plane rotation Structures Shown: - PAO images Ilium in-profile - PA Axial of pubic, Note (Ilium): pubic symphysis - Side in contact with IR is the side that will show and ischial bones up in image Note: - Known as AP near - Pelvic inlet - AP NEAR = side closest to the IR; APO - PA NEAR = side closest to IR; PAO Ilium - AP FAR = side farthest to IR; APO - In APO projections the side closest to the IR will - PA FAR = side farthest to IR; PAO be imaged. The ilium should be parallel to the - When ilium is parallel to IR, it is imaged in APO image receptor - When doing PAO, ilium is perpendicular to IR - In PAO the side farthest from the IR will be imaged. The ilium should be perpendicular to Added notes: the image receptor Projection Method/Modification AP Oblique (APO) Same definition Patient/Part Position: - Added note/explanation from recorded - Rotate the patient 40 degrees from supine discussion towards the affected side Central Ray: Intercondylar fossa - deep separation of the - Perpendicular to ASIS condyles distally and posteriorly Structures Shown: - On a PA, superimposed of the patella (the apex - Unobstructed projection of ala and sciatic of the patella) notches - The intercondylar fossa is not fully seen - Profile image of Acetabulum - Axial projections Cruciate ligaments - located posteriorly; stabilizes the knee joint by preventing excessive anterior or posterior flexion or flexion of the knee joint of the lower leg Collateral ligaments - located on the sides of the bone PA Oblique (PAO) - ACL anterior cruciate ligamentus fx Patient/Part Position: PA Axial is aka as Tunnel Projections - Rotate the patient 40 degrees from prone PA Axial camp coventry towards the affected side Joint mice - cut off of the bone cause by losing - Elevate the unaffected side approximately 40° bloodstream - Affected ilium ⊥ to the IR. - Images joint mice (loose bodies) - Support needed. Rest the forearm and flexed - May be caused by osteochondritis dissecans knee on the elevated side - If bones don't have blood supply, it can easily Central Ray: chip off and leave fragments (joint mice) - Perpendicular to ASIS Structures Shown: Intercondylar Fossa HBC - Ilium in profile - Hombland 70 deg – PA Axial - Femoral head within acetabulum - Beclere 60 deg – AP Axial - Camp coventry 50 to 40 deg – PA Axial  KMJS (increasing pneumonics) for Intercondylar Fossa Kuchendorf - only patella (oblique) - 10 deg flexion; CR 25-30 deg caudad Merchant - patella and patellofemoral joint - 40 deg flexion; CR 30 deg caudad Jarotsky (Hughston) - patella and patellofemoral joint - 50-60 deg flexion; CR 45 deg cephalad Settegast - patella and patellofemoral joint - 90 deg flexion - CR 90 deg perpendicular; if the px cannot do 90 deg → 15-20 deg