Lower Extremities PDF

LOWER PREPARED BY: ALDRIN LOPEZ, EXTREMETIES RRT, MSRT  PATHOLOGY 1.) Congenital Clubfoot Talipes equinovarus Abnormal twisting of the foot usually inward & downward Presentation Title  2.) Pott’s Fx A...

LOWER PREPARED BY: ALDRIN LOPEZ, EXTREMETIES RRT, MSRT  PATHOLOGY 1.) Congenital Clubfoot Talipes equinovarus Abnormal twisting of the foot usually inward & downward Presentation Title  2.) Pott’s Fx Avulsion fx of the medial malleolus with loss of the ankle mortise 3.) Jones Fx Avulsion fx of the base of the fifth metatarsal 9/3/20XX Presentation Title 3  4.) Gout Hereditary form of arthritis in which uric acid is deposited in joints 5.) Osgood-Schlatter Disease Incomplete separation or avulsion of the tibial tuberosity 6.) Giant Cell Tumor Osteoclastoma Lucent lesion in the metaphysic usually at the distal femur 9/3/20XX Presentation Title 4  7.) Chondromalacia Patellae Runner’s knee Softening of the cartilage under the patella 8.) Joint Effusion Accumulation of fluid in the joint cavity 9.) Lisfranc Injury Abnormal separation in the base of 1st & 2nd metatarsal & cuneiform 9/3/20XX Presentation Title 5  10.) Reiter Syndrome Erosions of sacroiliac joints & lower limbs 11.) Hallux Valgus Congenital abnormality of hallux Lateral deviation of great toe 9/3/20XX Presentation Title 6  ROUTINE 1.) Bony Injuries – AP, APO & Lateral 2.) Bony Pathology – AP & APO 3.) Foreign Body Localization – AP & Lateral DIVISIONS OF FOOT 1.) Hindfoot – calcaneus & talus 2.) Midfoot – cuboid, navicular & cuneiform 3.) Forefoot – metatarsals & phalanges 9/3/20XX Presentation Title 7  TOES 9/3/20XX Presentation Title 8  AP/AP AXIAL PROJECTION PP: Supine/Seated; knee flexed; 15o foam wedge under foot RP: 3rd MTP joint CR: ┴ or 15o posteriorly SS: Phalanges & distal portion of metatarsals AP Axial (15o): Open IP joints & reduces shortening 9/3/20XX Presentation Title 9 9/3/20XX Presentation Title 10 9/3/20XX Presentation Title 11  PA PROJECTION PP: Prone (IP joints // to CR); dorsal aspect against IR RP: 3rd MTP joint CR: ┴ SS: IP joint spaces are well visualized 9/3/20XX Presentation Title 12 9/3/20XX Presentation Title 13  AP OBLIQUE PROJECTION Medial Rotation PP: Supine/seated; knee flexed; lower leg & foot rotated medially 30-45o; RP: 3rd MTP joint CR: ┴ SS: 2nd-5th MTP joint spaces; 1st-3rd toes 9/3/20XX Presentation Title 14 9/3/20XX Presentation Title 15  Lateral Rotation PP: Supine/seated; knee flexed; lower leg & foot rotated medially 30-45o; RP: 3rd MTP joint CR: ┴ SS: 3rd-5th toes 9/3/20XX Presentation Title 16 9/3/20XX Presentation Title 17  LATERAL PROJECTION PP: Lateral recumbent; toe in true lateral RP: IP joint (1st toe); proximal IP joint (2nd-4th toes) CR: ┴ SS: Phalanges in profile; open IP joints spaces 9/3/20XX Presentation Title 18 9/3/20XX Presentation Title 19 9/3/20XX Presentation Title 20  SESAMOIDS 9/3/20XX Presentation Title 21  LEWIS METHOD TANGENTIAL PROJECTION PP: Prone; dorsiflex great toe; ankle elevated; ball of foot ┴ IR RP: 1st MTP joint CR: Perpendicular SS: MT head & sesamoids in profile 9/3/20XX Presentation Title 22 9/3/20XX Presentation Title 23  HOLLY METHOD TANGENTIAL PROJECTION PP: Seated; plantar 75o to IR; toe flexed & hold w/ strip gauze bandage; foot medial border ┴ to IR RP: 1st MTP head CR: ┴ SS: MT head & sesamoids in profile 9/3/20XX Presentation Title 24 9/3/20XX Presentation Title 25 9/3/20XX Presentation Title 26  CAUSTON METHOD TANGENTIAL PROJECTION PP: Lateral recumbent; patient lie against unaffected side; limb partially extended; foot in lateral position; 1st MTP joint ┴ to IR RP: Prominence of 1st MTP joint CR: 40o toward the heel SS: Sesamoids with slight overlap 9/3/20XX Presentation Title 27 9/3/20XX Presentation Title 28 9/3/20XX Presentation Title 29  FOOT 9/3/20XX Presentation Title 30  AP/AP AXIAL PROJECTION PP: Supine; knee flexed; plantar surface against IR RP: 3rd MTP base CR: ┴ or 10o posteriorly SS: MT & Tarsal (┴); TMT joint (10o) ER: For localizing foreign bodies Location of fragments in fx of metatarsals & anterior tarsals General surveys of the foot 10o Angulation: reduces foreshortening of metatarsals 9/3/20XX Presentation Title 31 9/3/20XX Presentation Title 32  AP OBLIQUE PROJECTION Medial Rotation PP: Supine; knee flexed; leg rotated medially; plantar surface of foot 30o to IR RP: 3rd MTP base CR: ┴ SS: Cuboid Interspaces on lateral side of foot Sinus tarsi Lateral cuneiform 3rd-5th MT bases 5th MT tuberosity 9/3/20XX Presentation Title 33 9/3/20XX Presentation Title 34 9/3/20XX Presentation Title 35  Lateral Rotation PP: Supine; knee flexed; leg rotated laterally; plantar surface of foot 30o to IR RP: 3rd MTP base CR: ┴ SS: Navicular Interspaces on medial side of foot Medial & intermediate cuneiform 1st-2nd MT bases 9/3/20XX Presentation Title 36 9/3/20XX Presentation Title 37 9/3/20XX Presentation Title 38  LATERAL PROJECTION Mediolateral PP: Dorsiflex foot (┴ to lower leg); leg & foot in lateral position; lateral side of foot against IR (more comfortable) RP: 3rd MT base CR: Perpendicular SS: Entire foot in profile ER: For localizing foreign body Degree of anterior & posterior displacement of fx 9/3/20XX Presentation Title 39 9/3/20XX Presentation Title 40 9/3/20XX Presentation Title 41  Lateromedial PP: LPO/RPO; medial surface against IR; plantar surface of foot ┴ to IR RP: 3rd MTP base CR: Perpendicular SS: True lateral projection of foot 9/3/20XX Presentation Title 42 9/3/20XX Presentation Title 43 9/3/20XX Presentation Title 44  WEIGHT-BEARING METHOD LONGITUDINAL ARCH LATERAL PROJECTION PP: Upright; feet elevated (use blocks); IR b/n feet; weight equally distributed on each foot RP: Point above 3rd MTP base CR: Horizontal SS: Status of LONGITUDINAL ARCH (pes planus); Bohler’s critical angle (20- 40o) Bohler’s Critical Angle: angle b/n superior apex of mid-calcaneus to anterior process of calcaneus 9/3/20XX Presentation Title 45 9/3/20XX Presentation Title 46 9/3/20XX Presentation Title 47  WEIGHT-BEARING METHOD AP AXIAL PROJECTION PP: Upright; both feet against IR; weight equally distributed on each foot RP: b/n feet at 3rd MTP base level CR: 10o or 15o posteriorly SS: Accurate evaluation & comparison of MT & tarsals Hallux valgus & lishfranc injury 9/3/20XX Presentation Title 48 9/3/20XX Presentation Title 49 9/3/20XX Presentation Title 50  WEIGHT-BEARING COMPOSITE METHOD AP AXIAL PROJECTION PP: Upright; 2 exposures First Exposure: opposite foot step backward (for forefoot); tube in front Second Exposure: opposite foot step backward (for hindfoot); tube behind RP: 3rd MTP base (1st exposure); level of lateral malleolus (2nd exposure) CR: 15o posteriorly (1st exposure); 25o anteriorly (2nd exposure) SS: Full outline of the foot 9/3/20XX Presentation Title 51 9/3/20XX Presentation Title 52 9/3/20XX Presentation Title 53  CONGENITAL CLUBFOOT 9/3/20XX Presentation Title 54  KITE METHOD AP PROJECTION PP: Supine; hips & knees flexed; foot flat on IR; ankles slightly extended; legs are vertical RP: Tarsals CR: 15o posteriorly SS: True relationship of bones & ossification centers of tarsals Degree of forefoot adduction & calcaneus inversion 15o Angulation: places CR ┴ to tarsals 9/3/20XX Presentation Title 55 9/3/20XX Presentation Title 56  Congenital Clubfoot LATERAL PROJECTION Mediolateral KITE METHOD PP: lateral position as possible; Hold the infant's toes in position with tape or a protected hand CR: perpendicular SS: calcaneus, and metatarsals Note: Freiberger, Hersh, and Harrison recommended dorsiflexion Note: Conway and Cowel recommended demonstration of coalition at the middle facet 9/3/20XX Presentation Title 57 9/3/20XX Presentation Title 58  KANDEL METHOD DORSOPLANTAR AXIAL PROJECTION PP: Bending forward position; plantar surface against IR RP: Lower leg CR: 40o anteriorly SS: Calcaneus Freiberger-Hersh-Harrison: CR 35o, 45o & 55o for demonstration of sustentaculum talar joint 9/3/20XX Presentation Title 59 9/3/20XX Presentation Title 60  CALCANEUS 9/3/20XX Presentation Title 61  AXIAL PROJECTION Plantodorsal PP: Supine/Seated; leg fully extended; dorsiflex foot w/ strip of gauze; foot ┴ to IR RP: 3rd MT base CR: 40o cephalad SS: Calcaneus & subtalar joint Presentation Title 9/3/20XX Presentation Title 63 9/3/20XX Presentation Title 64  Dorsoplantar PP: Prone; ankle elevated; dorsiflex ankle; foot ┴ to IR; IR vertical RP: Dorsal surface of ankle joint CR: 40o caudad SS: Calcaneus, subtalar joint & sustentaculum tali 9/3/20XX Presentation Title 65 9/3/20XX Presentation Title 66  LILIENFELD METHOD WEIGHT-BEARING COALITION DORSOPLANTAR AXIAL PROJECTION PP: Upright; posterior surface of heel at edge of IR; opposite foot one step forward RP: Level of 5th MT base CR: 45o anteriorly SS: Calcaneotalar coaliation 9/3/20XX Presentation Title 67 9/3/20XX Presentation Title 68 9/3/20XX Presentation Title 69  LATERAL PROJECTION Mediolateral PP: Supine; patient turn toward affected side; plantar surface // to IR RP: 1 in distal to medial malleolus CR: ┴ SS: Calcaneus & ankle joint 9/3/20XX Presentation Title 70 9/3/20XX Presentation Title 71  WEIGHT BEARING METHOD LATEROMEDIAL OBLIQUE PROJECTION PP: Upright; leg perpendicular to IR; calcaneus center to IR RP: Lateral malleolus CR: 45o caudad (medially) SS: Calcaneal tuberosity ER: Usefuk in diagnosing stress fractures of calcaneus or tuberosity 9/3/20XX Presentation Title 72 9/3/20XX Presentation Title 73  SUBTALAR JOINT 9/3/20XX Presentation Title 74  PA AXIAL OBLIQUE PROJECTION Lateral rotation PP: Flex the uppermost knee to a comfortable position ; Roll the Limb lightly forward from the lateral position. CR: double angIe of 5 degrees anterior and 23 degrees caudal. SS: e subtalar joint and give an "end-on" image of the sinu tarsi Presentation Title 9/3/20XX Presentation Title 76  ISHERWOOD METHOD LATEROMEDIAL OBLIQUE PROJECTION Medial Rotation Foot PP: Semisupine; foot & leg rotated 45o medially; knee flexed RP: 1 in. distal & 1 in. anterior to lateral malleolus CR: ┴ SS: Anterior subtalar articulation 9/3/20XX Presentation Title 77 9/3/20XX Presentation Title 78 9/3/20XX Presentation Title 79  ISHERWOOD METHOD AP AXIAL OBLIQUE PROJECTION Medial Rotation Ankle PP: Seated or semi-lateral recumbent (more comfortable); leg, foot & ankle rotated 30o medially; dorsiflex foot RP: 1 in. distal & 1 in. anterior to lateral malleolus CR: 10o cephalad SS: Middle subtalar articulation & “end on” projection of sinus tarsi 9/3/20XX Presentation Title 80 9/3/20XX Presentation Title 81  Lateral Rotation Ankle PP: Supine/seated; leg, foot & ankle rotated 30o laterally; dorsiflex foot RP: 1 in. distal medial malleolus CR: 10o cephalad SS: Posterior subtalar articulation 9/3/20XX Presentation Title 82 9/3/20XX Presentation Title 83  BRODEN METHOD AP AXIAL OBLIQUE PROJECTION Medial Rotation PP: Supine; leg & foot rotated 45o medially; dorsiflex foot; foot rested against 45o foam wedge RP: 2-3 cm to lateral malleolus CR: 10o, 20o, 30oor 40o cephalad SS: Posterior articulation Anterior portion (40o) Posterior portion (10o) Talus & sustentaculum tali articulation (20-30o) 9/3/20XX Presentation Title 84 9/3/20XX Presentation Title 85  BRODEN METHOD Lateral Rotation PP: Supine; leg & foot rotated 45o laterally; dorsiflex foot; foot rested against 45o foam wedge RP: 2 cm distal & 2 cm anterior to medial malleolus CR: 15o cephalad SS: Posterior articulation ER: To determine the presence of joint involvement in cases of comminuted fx 9/3/20XX Presentation Title 86 9/3/20XX Presentation Title 87  ANKLE 9/3/20XX Presentation Title 88  AP PROJECTION PP: Supine; leg & foot vertical & rotated 5o medially (places malleoli equidistant) RP: Point midway between malleoli CR: ┴ to ankle joint SS: Ankle joint & tibiotalar joint space 9/3/20XX Presentation Title 89 9/3/20XX Presentation Title 90 9/3/20XX Presentation Title 91  LATERAL PROJECTION Mediolateral PP: Semisupine; lateral surface of foot against IR; dorsiflex foot RP: Medial malleolus CR: ┴ to ankle joint SS: True lateral projection of lower third of tibia & fibula, ankle joint & tarsals 5th metatarsal base (identify Jones fx) 9/3/20XX Presentation Title 92 9/3/20XX Presentation Title 93 9/3/20XX Presentation Title 94  Lateromedial PP: Semisupine; medial surface of foot against IR; dorsiflex foot RP: 0.5 in. superior to lateral malleolus CR: ┴ to ankle joint SS: Lateral projection of lower third of tibia & fibula, ankle joint & tarsals 9/3/20XX Presentation Title 95 9/3/20XX Presentation Title 96 9/3/20XX Presentation Title 97  AP OBLIQUE PROJECTION Medial Rotation PP: Supine; Leg & foot rotated 45o medially; dorsiflex foot – to demonstrate bony structure Leg & foot rotated 15-20o medially; intermalleolar line // to IR – to demonstrate mortise joint RP: Point midway b/n malleoli CR: ┴ to ankle joint SS: Distal ends of tibia, fibula & talus; tibiofubular articulation; mortise joints 9/3/20XX Presentation Title 98 9/3/20XX Presentation Title 99  Mortise Joint AP OBLIQUE Medial rotation PP: rotating the entire leg and foot together I5 to 20 degrees until the intermalleolar plane is parallel with the IR CR: Perpendjcular RP: entering the ankle joint SS: ankle mortis joints 9/3/20XX Presentation Title 100 9/3/20XX Presentation Title 101 9/3/20XX Presentation Title 102 9/3/20XX Presentation Title 103  Lateral Rotation PP: Supine; leg & foot rotated 45o laterally; dorsiflex foot RP: Point midway b/n malleoli CR: ┴ to ankle joint SS: Superior aspect of calcaneus ER: Useful in determining fxs 9/3/20XX Presentation Title 104 9/3/20XX Presentation Title 105 9/3/20XX Presentation Title 106  STRESS METHOD AP PROJECTION PP: Seated; foot forcibly turned toward the opposite side; inversion & eversion stress to joint RP: Ankle joint CR: ┴ ER: To evaluate the presence of ligamentous tear & joint separation 9/3/20XX Presentation Title 107 9/3/20XX Presentation Title 108 9/3/20XX Presentation Title 109  WEIGHT-BEARING METHOD AP PROJECTION PP: Upright; heels against the IR; IR vertical; toes pointing toward the x- ray tube RP: Midway at level of ankle joint CR: Horizontal ER: Identify ankle joint space narrowing; side-to-side comparison of joint 9/3/20XX Presentation Title 110 9/3/20XX Presentation Title 111  LEG 9/3/20XX Presentation Title 112  AP PROJECTION PP: Supine; femoral condyles // to IR; foot in vertical position; RP: Midshaft CR: ┴ SS: Tibia & fibula; ankle & knee joints 9/3/20XX Presentation Title 113 9/3/20XX Presentation Title 114 9/3/20XX Presentation Title 115  LATERAL PROJECTION MEDIOLATERAL PP: Supine; RPO/LPO; patella ┴ to IR; femoral condyles ┴ to IR; RP: Midshaft CR: ┴ SS: Tibia & fibula; ankle & knee joints 9/3/20XX Presentation Title 116 9/3/20XX Presentation Title 117 9/3/20XX Presentation Title 118  AP OBLIQUE PROJECTION PP: Supine; leg & foot rotated 45o medially or laterally RP: Midshaft CR: ┴ SS: Tibia & fibula; ankle & knee joints 9/3/20XX Presentation Title 119 9/3/20XX Presentation Title 120  KNEE 9/3/20XX Presentation Title 121  AP PROJECTION PP: Supine; femoral epicondyles // to IR; leg 5o inward (places interepicondylar line // to IR) RP: 0.5 in. inferior to patellar apex CR: depending on the measurement b/n ASIS & table top 3-5ocaudad (24 cm; large pelvis) SS: Knee joint space 9/3/20XX Presentation Title 122 9/3/20XX Presentation Title 123 9/3/20XX Presentation Title 124  PA PROJECTION PP: Prone; femoral epicondyles // to IR; leg 5o inward (places interepicondylar line // to IR) RP: 0.5 in. inferior to patellar apex CR: 5-7ocaudad SS: Knee joint space Presentation Title 9/3/20XX Presentation Title 126  LATERAL PROJECTION Mediolateral PP: Lateral recumbent; knee flexed 20-30o (relax muscle & shows maximum volume of joint cavity) or flexed 10 (for new or unhealed patellar fx); femoral epicondyles & patella ┴ to IR; RP: Midpatellofemoral joint CR: ┴ SS: Patella & patellofemoral joint space 9/3/20XX Presentation Title 151 9/3/20XX Presentation Title 152  PA OBLIQUE PROJECTION Medial Rotation PP: Prone; knee flexed 5-10o; knee 45-55o medially RP: Patella CR: ┴ SS: Medial portion of patella free of femur 9/3/20XX Presentation Title 153 9/3/20XX Presentation Title 154  Lateral Rotation PP: Prone; knee flexed 5-10o; knee 45-55o laterally RP: Patella CR: ┴ SS: Lateral portion of patella free of femur 9/3/20XX Presentation Title 155 9/3/20XX Presentation Title 156  KUCHENDORF METHOD PA AXIAL OBLIQUE PROJECTION Lateral Rotation PP: Prone; hip elevated 2-3 in.; knee flexed 10o (relax the muscles); knee rotated 35-40o laterally RP: Joint space b/n patella & femoral condyles CR: 25-30ocaudad SS: Oblique patella free superimposition of femur 9/3/20XX Presentation Title 157 9/3/20XX Presentation Title 158 9/3/20XX Presentation Title 159  HUGHSTON METHOD TANGENTIAL PROJECTION PP: Prone; anterior surface of knee against IR; knee flexed 50-60o; foot rested against collimator/support RP: Patellofemoral joint CR: 45o cephalad SS: Patella; patellofemoral joint ER: To demonstrate subluxation of patella & patellar fx It allows assessment of femoral condyles Presentation Title 9/3/20XX Presentation Title 161  MERCHANT METHOD TANGENTIAL PROJECTION PP: Supine; both knee flexed 40o or b/n 30-90o (to demonstrate various patellar disorders); IR resting on patient’s shins; uses IR holding device & axial viewer device RP: Midway b/n patellae at level of patellofemoral joint CR: 30o caudad from horizontal SS: Femoral condyle; intercondylar sulcus & magnified nondistorted patellae 9/3/20XX Presentation Title 162 9/3/20XX Presentation Title 163 9/3/20XX Presentation Title 164  SETTEGAST METHOD TANGENTIAL PROJECTION Disadvantage: Extreme flexion PP: Supine or prone (preferable); knee acutely flexed until patella ┴ to IR; loop bandage around ankle or foot to hold the leg in position RP: Joint space b/n patella & femoral condyles CR: Perpendicular (if joint is ┴); 15-20o cephalad (if joint isn’t ┴) Angulation depends on knee flexion SS: Patella; patellofemoral joint ER: Useful for demonstrating vertical & transverse fx of patella Useful for investigating articulating surfaces of patellofemoral articulation 9/3/20XX Presentation Title 165 9/3/20XX Presentation Title 166 9/3/20XX Presentation Title 167  SUNRISE METHOD TANGENTIAL PROJECTION MOUNTAIN/SKYLINE VIEW PP: Supine/Sitting; knee flexed 40-45o RP: Patellofemoral joint CR: 30o from horizontal ER: Joint space b/n patella & femoral condyles 9/3/20XX Presentation Title 168 9/3/20XX Presentation Title 169  FEMUR Presentation Title  AP PROJECTION PP: Supine Distal femur (knee included): leg rotated 5o inward ( places limb in true anatomic position) Proximal femur (hip included): leg rotated 10-15o inward (places femoral neck in profile) RP: Midfemur CR: ┴ SS: Femoral neck & hip joint (10-15o); knee joint (5o) Presentation Title 9/3/20XX Presentation Title 172 9/3/20XX Presentation Title 173  LATERAL PROJECTION Mediolateral PP: Lateral recumbent; affected side against IR Distal femur (knee included): unaffected limb draw forward; pelvis in true lateral position; affected knee flexed 45o; femoral epicondyles ┴ to IR; Proximal femur (hip included): unaffected limb draw posteriorly; pelvis rolled 10-15o posteriorly RP: Midfemur CR: ┴ SS: ¾ of femur & adjacent joints 9/3/20XX Presentation Title 174 9/3/20XX Presentation Title 175 9/3/20XX Presentation Title 176  TRANSLATERAL PROJECTION CROSSTABLE LATERAL PP: Dorsal decubitus; IR placed vertically against medial/lateral surface of femur; RP: Medial side of midfemur CR: Horizontal SS: Entire femur & knee joint ER: For patient who can’t tolerate routine lateral position because of fractures or destructive disease 9/3/20XX Presentation Title 177  Hips, Knees, and Ankles AP PROJECTION WEIGHT-BEARING METHOD Standing PP: patient with the back against the upright grid unit CR: Perpendicular to the I R SS: entire right and left limbs from the hip joint to the ankle joint 9/3/20XX Presentation Title 178 9/3/20XX Presentation Title 179 9/3/20XX Presentation Title 180 9/3/20XX Presentation Title 181 9/3/20XX Presentation Title 182