Radiographic Procedures II Pelvis, Hip, Proximal Femur 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!