Pelvis, Hip, Proximal Femur Radiographic Procedures PDF

Radiographic Procedures II Pelvis, Hip, Proximal Femur Jena Heflin, MBA, RT(R), CMOM Pelvis    Pelvis means: Basin Serves as the base of the trunk and forms the connection between the vertebral column and lower limbs Consists of 4 bones    2 Hip bones (Os Coxae or Innominate) 1 Sacrum 1 Coccyx...

Radiographic Procedures II Pelvis, Hip, Proximal Femur Jena Heflin, MBA, RT(R), CMOM Pelvis    Pelvis means: Basin Serves as the base of the trunk and forms the connection between the vertebral column and lower limbs Consists of 4 bones    2 Hip bones (Os Coxae or Innominate) 1 Sacrum 1 Coccyx Pelvis Pelvis Pelvic Girdle Consists of all 4 bones Consists of only the 2 hip bones Pelvis – Gender Differences Female Feature Shape Bony Structure Male Female Male Wide, shallow Narrow, deep Light Heavy Superior Aperture (Inlet) Oval Round Inferior Aperture (Outlet) Wide Narrow True vs. False Pelvis    Pelvic Brim – extends from the upper anterior margin of the sacrum to the upper margin of the pubic symphysis False or Greater Pelvis = above the pelvic brim True or Lesser Pelvis = below the pelvic brim    Superior aperture (inlet) Pelvic cavity Inferior aperture (outlet) True vs. False Pelvis Pelvis  The part of the pelvis referred to as the hip bone is composed of     Ilium Ischium Pubis Acetabulum    2/5 Ilium 2/5 Ischium 1/5 Pubis Ilium     Consists of a body and the ala Body forms 2/5 of the acetabulum Ala forms the prominence of the hip Important structures:       Anterior superior iliac spine (ASIS) Anterior inferior iliac spine (AIIS) Posterior superior iliac spine (PSIS) Posterior inferior iliac spine (PIIS) Iliac crest – most superior aspect of pelvis Greater sciatic notch Ischium     Consists of a body and the ischial ramus Located inferior and posterior to the acetabulum. Body forms 2/5 of the acetabulum Important structures:     Ischial tuberosity – most inferior structure on pelvis Obturator foramen – formed by the ischium and the pubis; largest foramen in the body Ischial spine Lesser sciatic notch Pubis    Located inferior and anterior to the acetabulum Consists of a body, superior ramus, and inferior ramus Body forms 1/5 of the acetabulum Hip Bone Post Ant Lateral View Hip Bone Med Lat Anterior View Landmarks Proximal Femur    The proximal femur and pelvis join to form the hip joint (articulates at the acetabulum) Femur is the longest, strongest, and heaviest bone in the body Proximal femur includes:      Head Neck Greater Trochanter Lesser Trochanter Body Proximal Femur Anterior Posterior Proximal Femur Medial Aspect Proximal Femur Anterior Posterior Articulations of the Pelvis  Hip Joint     Classified as a synovial ball and socket joint Movement: Freely moving in all directions (a.k.a. Diarthrodial) Articulation between the acetabulum and the head of the femur Very strong, stable joint surrounded by dense, strong bands of ligaments Articulations of the Pelvis  Pubic Symphysis     Classified as a cartilaginous symphysis joint Movement: Slightly moveable (a.k.a. Amphiarthrodial) Articulation between the superior rami of the left and right pubic bones Sacroiliac Joint    Classified as a synovial irregular gliding joint Movement: Slightly moveable (a.k.a. Amphiarthrodial) Articulation of the left and right ilia with the sacrum posteriorly Articulations of the Pelvis Location of the Hip Joint Location of the Hip Joint Image Analysis Presentation of radiographs, pertinent anatomy, and positioning criteria General Considerations    10 x 12 IRs for hip 14 x 17 IRs for femur and pelvis Shield breasts on all patients    Provide gonadal shielding when possible Taken on suspended respiration Use cushions to aid in positioning AP Pelvis   Pt. supine Internally rotate legs 15-20    Heels should be 810 inches apart CR  to MSP, entering 2-inches inferior to ASIS or 2-inches superior to pubic symphysis IR 1-1½ inches above iliac crest Shielding for the Pelvis AP Pelvis Structures Seen Greater trochanters in profile, lesser trochanter not visualized Symmetric obturator foramina   AP Oblique Projection Pelvis (Modified Cleaves Method)    a.k.a. Bilateral Frog Leg Position Pt. supine Have pt. flex both hips and knees and draw the feet up    Soles of feet should be touching Abduct the thighs 45 from vertical to place femoral necks parallel with the IR CR  to MSP, entering 1-inch superior to pubic symphysis AP Oblique Projection Pelvis (Modified Cleaves Method) Structures Seen    Acetabulum, femoral heads & necks Lesser trochanters seen on the medial aspect of the femora Femoral necks without superimposition by the greater trochanter AP Axial Outlet Projection Pelvis (Taylor Method)      a.k.a. Axial Anterior Pelvis Bones Pt. supine Men: Angle CR 20-35 cephalic Women: Angle CR 3045 cephalic CR enters 2-inches distal to the superior border of the pubic symphysis AP Axial Outlet Projection Pelvis (Taylor Method) Structures Seen     Superior and inferior pubic rami without foreshortening Pubic and ischial bones magnified Pubic bones superimposed over the sacrum/coccyx Symmetric obturator foramen AP Axial Inlet Projection Pelvis (Bridgeman Method)      a.k.a. Axial Anterior Pelvis Bones Pt. supine Ensure no rotation of the pelvis CR angled 40 caudal CR enters at midline at the level of the ASIS AP Axial Inlet Projection Pelvis (Bridgeman Method) Structures Seen     Entire pelvic ring (inlet) Medially superimposed superior and inferior pubic rami Nearly superimposed lateral 2/3 of the pubic and ischial bones Symmetric pubic and ischial spines AP Internal Oblique Pelvis (Judet Method)     Pt. in a 45 semi-supine position with affected hip up For Rt. Hip – place patient in LPO position For Lt. Hip – place patient in RPO position CR  and enters 2inches inferior to the ASIS of the affected (up) side AP Internal Oblique Pelvis (Judet Method) Structures Seen    Acetabulum centered to the IR Iliopubic colum and posterior rim of affected acetabulum Evaluates for fracture of the iliopubic column and the posterior rim of the acetabulum AP External Oblique Pelvis (Judet Method)     Pt. in a 45 semi-supine position with affected hip down For Rt. Hip – place patient in RPO position For Lt. Hip – place patient in LPO position CR  and enters at the pubic symphysis AP External Oblique Pelvis (Judet Method) Structures Seen    Acetabulum centered to the IR Ilioischial column and anterior rim of the affected acetabulum Evaluates for fracture of the ilioischial column and the anterior rim of the acetabulum Columns of the Pelvis Iliopubic column Ilioischial column Short segment of the ilium and pubis. Extends from anterior spine of ilium to the pubic symphysis and obturator foramen. Vertical portion of the ischium and the portion of the ilium immediately above the ischium. Extends from the obturator foramen through the posterior aspect of the acetabulum. (a.k.a. anterior column) (a.k.a. posterior column) AP Hip    Pt. supine Internally rotate legs 15-20 CR  to femoral neck Location of the Hip Joint Location of the Hip Joint AP Hip Structures Seen    Greater trochanter in profile, lesser trochanter not visualized Entire long axis of the femoral neck not foreshortened Include pubic symphysis and adjoining structures Lateral Hip (Modified Cleaves)       a.k.a. Unilateral Frog Leg Pt. supine Flex hip and knee of affected side and draw foot to the opposite knee Abduct thigh laterally 45 Try not to rotate pelvis too much CR is  to femoral neck Lateral Hip (Modified Cleaves) Structures Seen    Acetabulum, femoral head & neck Lesser trochanter seen on medial aspect of the femur Femoral neck without superimposition by the greater trochanter Cross-Table Lateral Hip     a.k.a. Axiolateral Projection Danelius-Miller Method Build up the patient’s hip using a firm pillow or folded sheets Flex the knee and hip of the unaffected leg and elevate it in a vertical position CR enters  to the long axis of femoral neck Cross-Table Lateral Hip Be sure to support the unaffected leg (i.e. use a sponge). Do NOT rest the patient’s foot on the x-ray tube. Cross-Table Lateral Hip CR  to long axis of the femoral neck Trauma Hip: Modified Axiolateral Projection      a.k.a. Clements-Nakayama Modification Pt. supine with affected side near edge of table and pelvis elevated using towels or sponges Limbs remain in neutral position Adjust the grid parallel to the axis of the femoral neck and tilt its top back 15 CR angled 15 posteriorly and aligned  to femoral neck and grid Trauma Hip: Modified Axiolateral Projection Trauma Hip: Modified Axiolateral Projection Structures Seen    Acetabulum and proximal femur in lateral profile Hip joint with the acetabulum Any orthopedic appliance in its entirety AP Femur   Requires 2 views to include the knee joint and hip joint Proximal femur: rotate lower leg, hip, & knee 1015 internally   Distal femur: place femoral epicondyles parallel with the IR    Top of IR at ASIS Bottom of IR 2-inches below knee joint Epicondyles are parallel to IR CR is  to midfemur  AP Distal Femur Include appropriate joint Structures Seen    Femoral neck not foreshortened on the proximal femur Lesser trochanter not seen or only a small portion seen on proximal femur No rotation of the knee distally; greater trochanter seen proximally Mediolateral Femur    Requires 2 views to include the knee joint and hip joint Roll patient towards affected side and flex knee 45 Proximal femur: adjust pelvis so that it is 10-15 from lateral to prevent superimposition   Distal femur: place femoral epicondyles  with the IR   Top of IR at ASIS Bottom of IR 2-inches below knee joint CR is  to midfemur  Include appropriate joint Structures Seen   Distal View - patella in profile, femoral condyles are superimposed Prox. View – greater and lesser trochanters not prominent Critical Thinking WHAT WOULD YOU DO? Situation A radiograph of an AP pelvis reveals that the right iliac wing is foreshortened as compared with the left side. Which specific positioning error has been made? Choice A Choice B The patient is rotated towards the left The patient is rotated towards the right Situation A radiograph of an AP hip reveals that the lesser trochanter is not visible. Should the technologist repeat the projection? Why or why not? Correct Answer: Situation The following image of an AP hip was taken on a post-op patient. Are any additional views necessary? Why or why not? Correct Answer: Assignment See course schedule for reading assignment Hip and Pelvis Worksheet – Section 1: Exercise 1 – 7 – Section 2: Exercise 1 and 3 Lower Limb Worksheet – Section 2: Exercise 9 Study Positioning Notes! Radiographic Procedures II Tib/Fib, Knee, & Distal Femur Jena Heflin, MBA, RT(R), CMOM The Lower Leg  Bones  Tibia  Fibula  Patella  Distal Femur  Joints  Ankle  Knee 1 Tibia  Weight-bearing bone of the lower leg  Can be felt through the shin (called the shin bone)  Consists of a body and two extremities  Proximal End  Distal End Tibia – Distal End  Smaller than the proximal end  Medial aspect ends in a short, pyramid-shaped process called the medial malleolus  Relates to medial aspect of the ankle  Lateral aspect contains the fibular notch  Flattened, triangular-shaped notch for articulation with the distal fibula  Anterior aspect contains the anterior tubercle  Overlays the fibula 2 Tibia – Proximal End  Contains two prominent processes:  Medial Condyle  Lateral Condyle  Intercondylar Eminence – located between the two condyles  Tibial Plateau  Smooth facets on the superior surface of the condyles  Articulates with the condyles of the femur  Slopes posteriorly 10°-20° Tibia – Proximal End  Anterior Crest  Sharp ridge of bone located along the anterior surface of the tibia  Extends from tibial tuberosity to the medial malleolus  Tibial Tuberosity  Rough-textured prominence  Located on the mid-anterior surface, distal to condyles  Osgood-Schlatter’s Disease  Separation of the tibial tuberosity from the body of the tibia  Occurs most commonly in boys ages 10 - 15 3 Osgood-Schlatter’s Disease Fibula  Located laterally & posteriorly to the tibia  Sometimes called the calf bone  Proximal End  Contains a neck, head, & apex  Head articulates with lateral condyle of tibia  Most proximal end of fibula is the apex  Neck is the tapered area below the head  Distal End  Lateral Malleolus – relates to lateral aspect of ankle joint  Lies 15°-20° more posterior than the medial malleolus 4 Tibia/Fibula Anatomy Patella  a.k.a. Knee Cap  Largest and most constant sesamoid bone  Flat, triangular-shaped bone  About 2 inches in diameter  Contains an apex and a base  Apex – inferior aspect; lies ½ inch above the knee joint  Base – superior aspect  Patella ONLY articulates with the femur (not the tib/fib) 5 Patella Anatomy Distal Femur  Femur is the longest, strongest bone in the entire human body  Contains two eminences:  Medial Condyle (larger)  Lateral Condyle (smaller)  Medial condyle extends 5°-7° lower than the lateral condyle  This is why we angle 5°-7° on AP & Lateral Knee x-rays—to open the joint space of the knee  Contains two surfaces:  Patellar Surface – anterior surface; separates the condyles anteriorly (a.k.a. Intercondylar Sulcus)  Popliteal Surface – posterior surface; superior to the intercondylar fossa 6 Distal Femur  Intercondylar Fossa – separates the condyles distally & posteriorly  Medial & Lateral Epicondyles  Located above the outermost portion of the medial and lateral condyles  Medial epicondyle is more prominent than lateral epicondyle  Adductor Tubercle  Located on the posterolateral aspect of the medial condyle  Receives the tendon of the adductor muscle  Assists in identifying over-rotation or under-rotation on lateral knee x-rays Distal Femur Anatomy Anterior Surface Posterior Surface 7 Joints of the Lower Leg  Ankle Mortise Joint  Synovial, hinge joint  Distal Tibiofibular Joint  Fibrous, syndesmosis joint (slight movement)  Proximal Tibiofibular Joint  Synovial, gliding joint Joints of the Lower Leg Knee Joint:  Patellofemoral Joint  Synovial, gliding joint  Femorotibial Joint  Synovial, hinge (modified) joint  Main joint of the knee 8 Knee Joint  Held together by 4 main ligaments  Posterior Cruciate Ligament (PCL)  Anterior Cruciate Ligament (ACL)  Tibial (Medial) Collateral Ligament (MCL)  Fibular (Lateral) Collateral Ligament (LCL)  Cruciate ligaments stabalize the knee & attach to the intercondylar eminence  Restricts anterior & posterior movements within the knee  Collateral ligaments attach at the sides of the knee joint  Restricts adduction & abduction movements Knee Joint  Largest joint space in the body  Enclosed in an articular capsule or bursa, filled with synovial fluid  Contains two fibrocartilage disks:  Medial Meniscus  Lateral Meniscus  Menisci act as shock absorbers  Located between the tibial plateau and the femoral condyles  MRI or Knee arthrogram used to visualize a torn meniscus 9 Knee Joint Anatomy Anterior Posterior Image Analysis Presentation of radiographs, pertinent anatomy, and positioning criteria. 10 General Considerations  14 x 17 IR for Tib/Fib  10 x 12 IR for Knee & Patella  SID is 40-inches for all views  Shield using full lead apron and thyroid shield  Ensure that apron does not cover the area of interest  No breathing instructions required AP Tib/Fib  Pt. supine or sitting on table  Ankle, knee, and hip on same     plane Femoral condyles parallel to the IR Dorsiflex foot & ankle CR  at midshaft Clip the knee if necessary  May increase SID to 48-inches to include knee joint  If increasing SID doesn’t work, take an additional AP Knee 11 AP Tib/Fib Structures Seen  No rotation  Fibular midshaft free of tibial superimposition  Prox. & distal tib/fib articulations moderately overlapped  Fracture of the distal tibia can indicate a fracture of the proximal fibula Mediolateral Tib/Fib  Roll pt. towards affected side     & flex knee slightly Femoral condyles superimposed Doriflex foot & ankle CR  at midshaft Clip the knee if necessary  May increase SID to 48-inches to include knee joint  If increasing SID doesn’t work, take an additional Lateral Knee 12 Mediolateral Tib/Fib Structures Seen  Moderate separation of the tibial and fibular shafts  Articular ends will overlap  Distal fibula lying over the posterior half of tibia  Slight overlap of the tibia on the proximal fibular head AP Oblique Tib/Fib Projections  From supine position, rotate patient’s entire lower leg 45 medially or laterally Medial rotation  A wedge may be used to assist with the medial rotation  CR  at midshaft  Clip the knee if necessary  May increase SID to 48-inches Lateral rotation to include knee joint  If increasing SID doesn’t work, take an additional Oblique Knee 13 AP Oblique Tib/Fib Projections Structures Seen  Medial Rotation:  Proximal & distal Medial rotation tibiofibular articulations  Maximum space between the tibia and fibula  Lateral Rotation:  Fibula superimposed by the lateral portion of the tibia Lateral rotation AP Knee  Pt. supine or seated  Femoral condyles are parallel to IR  CR enters ½ inch distal to apex of patella  To determine CR angle, measure the pelvis thickness through the ASIS:  < 19 cm: 3-5 caudal (thin pelvis)  19-24 cm: 0 degrees  > 24 cm: 3-5 cephalic (large pelvis) Some protocols may require a standard CR angle of 5 cephalic 14 AP Knee Weight-Bearing  Patient upright  Back against bucky, center knee to IR, place toes straight ahead  Patient places full weight on affect side  Femoral condyles are parallel to IR  CR is  and enters ½ inch distal to apex of patella AP Knee Structures Seen  Open femorotibial joint space  Patella superimposed over femur  No rotation of femur and tibia  Symmetric femoral condyles and tibial intercondylar eminence is centered 15 Medial Oblique Knee  Rotate entire leg 45 medially  CR is ½ inch distal to apex of patella  Utilize same method as AP Knee to determine CR angle  Many protocols may not require an angle on the oblique views Medial Oblique Knee Structures Seen  Proximal tib/fib articulation  Lateral condyles of the femur and tibia  Both tibial plateaus  Patella is shown towards the tibia  Margin of patella projecting slightly beyond the medial side of the femoral condyle 16 Lateral Oblique Knee  Rotate entire leg 45 laterally  CR is ½ inch distal to apex of patella  Utilize same method as AP Knee to determine CR angle  Many protocols may not require an angle on the oblique views Lateral Oblique Knee Structures Seen  Medial condyles of femur and tibia  Tibial plateaus  Fibula superimposed over lateral half of tibia  Patella is shown towards the fibula  Margin of the patella projecting slightly beyond the lateral side of the femoral condyle 17 Mediolateral Knee  Roll pt. toward side of     interest Flex the knee 20-30 degrees Femoral condyles superimposed CR enters 1 inch distal to medial epicondyle Angle 5-7 cephalic Mediolateral Knee Weight-Bearing  Patient upright  Bend affected knee into a 20-30      flexion Patient places full weight on affect side Unaffected leg placed behind affected knee Femoral condyles are superimposed CR enters 1 inch distal to medial epicondyle Angle 5-7 cephalic 18 Mediolateral Knee Structures Seen  Open patellofemoral joint space  Open joint space between femoral condyles and tibia  Fibular head and tibia slightly superimposed  Patella is seen in profile PA Knee  Patient prone with toes resting on table  Femoral condyles parallel to the IR  Angle CR 5-7 caudal  May use  CR if the patient has large thighs when the foot is dorsiflexed  CR is ½ inch distal to apex of patella 19 PA Knee Structures Seen  Open femorotibial joint space  Knee fully extended if pt. condition permits  Slight superimposition of the fibular head with the tibia PA Axial Projection (Holmblad Method – Position 1)  a.k.a. Intercondylar fossa view or Tunnel view  Patient standing with knee flexed and resting on a stool  Flex the knee 70 from full extension  CR  and entering through the patellar apex 20 PA Axial Projection (Holmblad Method – Position 2)  Patient standing at the side of the table with the knee flexed and placed in contact with the front of a vertical IR  Flex the knee 70 from full extension  CR  and entering through the patellar apex PA Axial Projection (Holmblad Method – Position 3)  Patient kneeling on table with knee over IR  Flex the knee 70 from full extension  CR  and entering through the patellar apex 21 PA Axial Projection (Holmblad Method) Structures Seen  Open intercondylar     fossa Posteroinferior surface of femoral condyles Intercondylar eminence and knee joint space Apex of patella NOT superimposing the fossa Slight tib/fib overlap Axial Patella – Settegast Method (a.k.a. Sunrise, Sunset, & Skyline)  Patient has knees bent with feet on the edge of the table  Patient will be holding the IR to match tube angle  CR is 15-20 with the tib/fib, and passes through the patellofemoral joint space  Angle tube with the angle of the leg, then decrease angle (caudally) by 15-20  CR directed through patellofemoral joint space May be done prone 22 Axial Patella – Settegast Method (a.k.a. Sunrise, Sunset, & Skyline) Structures Seen  Patella in profile  Open patellofemoral joint space  Surfaces of femoral condyles  Provides good visualization of a vertical fracture Axial Patella – Merchant Method (a.k.a. Bilateral Tangential Patellae view)  Patient supine with both knees     at the edge of the table Support knees with an adjustable IR-holding device or merchant board Elevate knees 2-inches to place femoral parallel with the tabletop Flex knees 40 CR directed midway between patellae at the level of the patellofemoral joint 23 Axial Patella – Merchant Method (a.k.a. Bilateral Tangential Patellae view) Structures Seen  Bilateral patellae in profile  Femoral condyles and intercondylar sulcus  Open patellofemoral articulations Axial Patella – Hughston Method (a.k.a. Prone Flexion Tangential view)  Patient prone with foot resting     on table Place IR under the patient’s knee and flex the knee to form a 50-60 angle with the table Elevate knees 2-inches to place femoral parallel with the tabletop Angle CR 45 cephalic CR directed through the patellofemoral joint 24 Axial Patella – Hughston Method (a.k.a. Prone Flexion Tangential view) Structures Seen  Open patellofemoral articulation  Surface of the femoral condyles  Shows subluxation of the patella and patellar fractures PA Projection of Patella  Patient prone  Place patella parallel with the plane of the IR  Requires that the heel be rotated 5-10 laterally  CR  to the mid- popliteal area exiting the patella 25 PA Projection of Patella Structures Seen  Patella completely superimposed by the femur  Provides sharper detail than AP due to decreased OID Mediolateral Projection of Patella  Patient rolled onto affected knee  Place femoral condyles  to the IR  Flex knee 5-10  CR  entering at the mid-patellofemoral joint 26 Mediolateral Projection of Patella Structures Seen  Lateral projection of the patella  Open patellofemoral joint space  Patella in profile Critical Thinking What would you do? 27 Situation A knee radiograph is labeled as a medial oblique. The image reveals that the proximal tibia and fibula are superimposed. Is this a true medial oblique knee radiograph? Choice A Choice B Yes, on a medial oblique knee x-ray, the tibia and fibula should be superimposed No, on a medial oblique knee x-ray, the tibiofibular articulation should be visualized Situation A young male patient comes into the radiology department with a clinical history of OsgoodSchlatter’s disease. Which single projection of the basic knee series will best demonstrate this condition? Correct Answer: 28 Situation The technologist has forgotten to label this x-ray on PACS. Which view of the basic knee series is pictured? Correct Answer: Assignment  See course schedule for reading assignment  Study Positioning Notes!  Worksheet  Section 1: Exercise 4 – 13, 15, 17 (Q. 19- 35)  Section 2: Exercise 5, 6, 7, 8, 9 29 Toes, Foot, Heel, & Ankle Jena Heflin, MBA, RT(R), CMOM  Consists of 26 bones ◦ 14 phalanges (bones of the toes) ◦ 5 metatarsals (bones of the instep) ◦ 7 tarsals (bones of the ankle)  Three divisions of the foot ◦ Forefoot Metatarsals & Phalanges (Toes) ◦ Midfoot 5 Tarsals: 3 cuneiforms, navicular, & cuboid ◦ Hindfoot Talus & Calcaneus  Surfaces of the Foot ◦ Dorsum or Dorsal Surface ◦ Superior surface of the foot ◦ Plantar Surface ◦ Inferior surface of the foot  Arches of the Foot ◦ Longitudinal  Shock absorber  Weight bearing  Permits smooth walking  Medial more pronounced ◦ Transverse  Runs side-to-side  Supports the longitudinal arch  Cuneiforms & Cuboid  Dorsiflexion ◦ Flex ankle joint; pointing foot upward  Plantar Flexion ◦ Extend ankle joint; pointing foot downward  Inversion (Varus) ◦ Turning inward  Eversion (Valgus) ◦ Turning outward  14 Phalanges ◦ Two in the great toe distal & proximal ◦ Three each in 2nd - 5th toe distal, middle, & proximal  Each phalanx composed of a body, base, and head ◦ Base is proximal ◦ Head is distal  Compared to phalanges of the hand, phalanges of the foot are smaller and have limited movement Head Base       Numbered 1 – 5 starting from the medial side of the foot Consists of a body, base, and head ◦ Base is proximal ◦ Head is distal 5 heads form the “ball” of the foot 1st metatarsal is shortest and thickest 2nd metatarsal is longest 5th metatarsal contains a prominent tuberosity prone to fracture  Joints of the Phalanges ◦ Interphalangeal (IP) Joint: 1st digit only  Between proximal and distal phalanges ◦ Distal Interphalangeal (DIP) Joint: 2nd-5th digits  Between middle and distal phalanges ◦ Proximal Interphalangeal (PIP) Joint: 2nd-5th digits  Between proximal and middle phalanges  Joints of the Metatarsals ◦ Metatarsophalangeal (MTP) Joint  Located at heads of metatarsals ◦ Tarsometatarsal (TMT) Joint  Located at bases of metatarsals ***ALL of the joints of the foot are classified as Synovial Joints  Seven Tarsals ◦ Calcaneus (Os Calcis or Heel) ◦ Talus (Astragalus) ◦ Navicular (Scaphoid) ◦ Cuboid ◦ Medial Cuneiform (1st Cuneiform) ◦ Intermediate Cuneiform (2nd Cuneiform) ◦ Lateral Cuneiform (3rd Cuneiform)   Largest, strongest bone in the foot Contains 3 articular facets or surfaces that join with the talus    “Cuneiform” literally means “wedgeshaped” Medial cuneiform is the largest Intermediate is the smallest  Talus (Astragalus) ◦ 2nd largest tarsal and most superior tarsal ◦ Located between lower leg and calcaneus  Navicular (Scaphoid)  Cuboid ◦ Lies on medial side of foot between talus and the 3 cuneiforms ◦ Lies on lateral side of foot, distal to Calcaneus and proximal to the 4th and 5th Metatarsals      Located on the plantar surface by the head of the 1st metatarsal Usually there are 2 sesamoid bones Seen mostly in adults Detached from the foot and embedded within two tendons Common site of fracture      Formed by the tibia, fibula, & talus Synovial, hinge joint Lateral Malleolus: located on fibula Medial Malleolus: located on tibia a.k.a. Ankle Mortise ◦ Deep socket formed by the tibia and fibula into which the talus fits Presentation of radiographs, pertinent anatomy, and positioning criteria.    SID is at 40-inches table top 10 x 12 IRs used for all views Full lead apron and thyroid shield should be used ◦ If you can shield it, you SHOULD shield it!  No breathing instructions required      Patient supine or seated Bend pt.’s knee and place foot flat on IR 1st digit – CR  to IP joint 2nd-5th digits – CR  to PIP joint Optional method: Angle CR 15 cephalic ◦ Opens up the joint spaces  Collimate 1-inch on all sides including 1-inch proximal to MTP joint Some protocols may require an AP of the entire foot Structures Seen     No rotation of phalanges Open IP and MTP joint spaces Distal ends of metatarsals Soft tissue and bony trabeculation      Digits 1-2: Rotate foot medially 30 Digits 3-5: Rotate foot laterally 30 1st digit: CR  to IP joint 2nd – 5th digits: CR  to PIP joint Collimate 1-inch on all sides including 1inch proximal to MTP joint Shows medial rotation Structures Seen    Open IP and MTP joint spaces  1st MTP joint not always opened Distal ends of metatarsals Soft tissue and bony trabeculation       Lateromedial: digits 1-2 Mediolateral: digits 3-5 1st digit – CR  to IP joint 2nd – 5th digits – CR  to PIP joint Use tape to pull back unaffected toes Collimate 1-inch on all sides including 1-inch proximal to MTP joint Structures Seen     Phalanges in profile Open IP joint spaces MTP joints are overlapped and may be seen Soft tissue and bony trabeculation    Patient supine or seated Bend pt.’s knee and place foot flat on IR CR 0 or 10 cephalic ◦ Angling opens up tarsal articulations   CR enters at base of 3rd metatarsal Use of wedge filter will improve image quality      Patient standing Place IR on floor and have patient stand on IR Opposite foot should be placed back Angle CR 10-15 CR to base of 3rd metatarsal Structures Seen     No rotation of the foot Overlap of 2nd-5th metatarsal bases Open joint space between the medial and intermediate cuneiforms All tarsals distal to the talus, metatarsals, and phalanges   Rotate foot medially 30 CR  to base of 3rd metatarsal NOTE: A 30 lateral oblique may be used to demonstrate the 1st and 2nd metatarsal bases  Structures Seen 3rd-5th metatarsal bases free of superimposition  Sinus tarsi best seen   Best view to see the tuberosity of 5th metatarsal  5th metatarsal fx. Soft tissue and bony trabeculation   Roll pt. up onto hip of affected side Flex knee and place foot parallel to the IR ◦ Plantar surface  to IR   Dorsiflex the foot CR  to the level of the base of 3rd metatarsal      Patient standing Place IR in groove on platform Plantar surface  to IR Dosiflex foot 90 CR  to the level of the base of 3rd metatarsal Structures Seen     Metatarsals nearly superimposed Fibula overlapping posterior portion of tibia Tibiotalar joint Demonstrates anterior/posterior displacement of fx’s and foreign body   Pt. in prone position Rest the great toe on the table in a position of dorsiflexion ◦ Ball of foot should be  to the horizontal plane of the IR  CR:  and tangential to the 1st MTP joint   Pt. seated on table Adjust plantar surface of foot 75 with the plane of the IR ◦ Medial border of foot should be vertical   Pt. holds toes in flexed position with a strip of gauze CR:  to head of the 1st metatarsal bone Lewis Method Holly Method Sesamoids free of any portion of the 1st metatarsal     Patient supine or seated with leg fully extended Use sheet, gauze, or tourniquet to assist pt. into extreme dorsiflexion Angle CR 40 cephalic CR enters at the base of the 3rd metatarsal Structures Seen    Calcaneus and subtalar joint No rotation of the calcaneus Anterior portion of the calcaneus without excessive density over the posterior portion     Patient prone with ankle elevated on sandbags Dorsiflex ankle to place long axis of foot  to the tabletop Angle CR 40 caudal CR enters dorsal surface of the ankle joint Structures Seen     Calcaneus and subtalar joint Sustentaculum tali No rotation of the calcaneus Anterior portion of the calcaneus without excessive density over the posterior portion     Roll pt up onto hip of affected side Plantar surface of foot parallel to the IR Dorsiflex the foot CR enters 1-inch distal to medial malleolus (at subtalar joint) Structures Seen    No rotation of calcaneus Sustentaculum tali, sinus tarsi, and lateral tuberosity seen Ankle joint and adjacent tarsals     Patient is supine or sitting Dorsiflex foot CR enters at ankle joint between malleoli Include distal tib/fib     Patient standing Place IR in groove on platform Heel pushed back against IR, toes pointing straight forward CR enters at ankle joint between malleoli Structures Seen    Tibiotalar joint space Talus slightly overlapping distal fibula Distal end of the tib/fib and proximal portion of talus      Internally rotate leg 15-20 Intermalleolar plane is parallel with the IR Dorsiflex foot CR enters midankle, between malleoli Include distal tib/fib      Patient standing Place IR in groove on platform Internally rotate leg 15-20 Dorsiflex foot CR  at anterior surface, mid-ankle, between malleoli Structures Seen    Three sides of mortise joint Talofibular joint space in profile No overlap of anterior tubercle of tibia with the fibula     Internally rotate leg 45 Dorsiflex foot CR enters midankle, between malleoli Include distal tib/fib Structures Seen   Tibiofibular joint Distal tib/fib overlapping some of the talus     Externally rotate leg 45 Dorsiflex foot CR enters midankle, between malleoli Include distal tib/fib      Patient standing Place IR in groove on platform Externally rotate leg 45 Dorsiflex foot CR  at anterior surface, mid-ankle, between malleoli Structures Seen    Calcaneal sulcus (superior portion of calcaneus) Subtalar joint Useful in locating fx’s     Roll pt up onto hip of affected side Flex knee and place foot parallel to the IR Dorsiflex the foot CR enters at the medial malleolus      Patient standing Place IR in groove on platform Lateral surface of foot in contact with IR Dorsiflex foot CR  to medial malleolus Structures Seen   Tibiotalar joint Fibula over the posterior half of the tibia      Roll pt away from affected side Medial surface of ankle in contact with the IR Dorsiflex the foot CR enters ½ inch superior to lateral malleolus This view allows the ankle to be viewed more easily in a true lateral position   Obtained after an inversion/eversion injury Done to verify the presence of a ligamentous tear ◦ Rupture of ligament would show a widening of the joint space on the side of the injury when the foot is forcibly turned toward the opposite side  Views include AP Neutral, AP Eversion Stress, & AP Inversion Stress AP Neutral AP Eversion AP Inversion Change in joint and rupture of lateral ligament (arrow) are seen What would you do? Choice A Choice B The foot has been overrotated medially The foot has been underrotated medially Choice A Choice B Re-center at the base of the 3rd proximal phalanx Angle the tube 10-15 degrees cephalic Situation A patient comes into the outpatient imaging center for a follow-up x-ray of her right foot. She has previously sustained an avulsion fracture of the tuberosity of the 5th metatarsal. Which routine view would best reveal her type of fracture? Correct Answer: Situation How many degrees has the patient’s ankle been obliqued in this image? See course schedule for reading assignment  Study Positioning Notes!!!  Worksheet  ◦ Section 1: Exercise 1, 2, 3, 16, 17 (Q.1-18) ◦ Section 2: Exercise 1, 2, 3, 4