Radiographic Positioning PDF

RADIOGRAPHIC POSITIONING Motion and Control Radiographic Examination or Procedure Positioning sponges commonly used as immobilization devices. A radiographic examination involves five g...

RADIOGRAPHIC POSITIONING Motion and Control Radiographic Examination or Procedure Positioning sponges commonly used as immobilization devices. A radiographic examination involves five general functions: Ferlic lead holder and immobilization holder. - Positioning of body part and alignment with Handling of Ill or Injured Patients the IR (image receptor) and CR (central ray). - Application of radiation protection measures and devices. - Selection of exposure factors (radiographic technique) on the control panel. - Instructions to the patient related to respiration (breathing) and initiation of the x- ray exposure. - Processing of the IR [(film-based) (analog) and cassette-based (PSP) system]. Clinical History Patient’s Attire, Ornaments and Surgical Dressings Technologist is often responsible for obtaining a - Patient should be dressed in a gown that clinical history from the patient. allows exposure of limited body regions under examination. Care of the Radiographic Examining Room - Patient is never exposed unnecessarily; a sheet should be used when appropriate. Radiographic room should be clean and straightened - If a region of the body needs to be exposed to before any examination begins. complete the examination, only the area under Standard Precautions examination should be uncovered while the rest of the patient's body is completely covered Technologist should practice scrupulous cleanliness for warmth and privacy. which includes regular hand washing. - When the technologist is examining part that Radiographic tables and equipment should be cleaned must remain covered disposable paper gowns with a disinfectant according to department policy. or cotton cloth gowns without metal or plastic snaps are preferred All needles should be discarded in puncture-resistant - If washable gowns are used, they should not be containers. starched; starch is somewhat radiopaque, which means it cannot be penetrated easily by Technologists must carefully position mobile x-ray tube x-rays. during a surgical procedure. - Any folds in the cloth should be straightened to Technologist should never move radiographic prevent confusing densities on the radiograph. equipment over uncovered sterile instruments or - The length of exposure should also be uncovered surgical site. considered. - Material that does not cast a density on a heavy Many radiographic procedures require strict aseptic exposure, such as that used on an adult technique such as procedure involving passing a abdomen, may show clearly on a light exposure, catheter into the patient’s femoral artery. such as that used on a child's abdomen.  - Any radiopaque object should be removed Film Screen Cassette Systems from the region to be radiographed. o Zippers, necklaces, snaps, thick elastic, - Includes data such as name, date, case number, and button should be removed when and institution is provided on an index card and is photo flashed on the film in the space radiographs of the chest and abdomen are produced. provided by a lead block in the film cassette - When radiographing the skull, the technologist each cassette or film holder should have a must make sure that dentures, removable marker on the exterior indicating this area bridgework, earring, necklaces, and all hair where the patient ID, including the date, will be pins are removed. flashed. - When the abdomen, pelvis, or hips of an infant Digital systems are radiographed, the diaper should be removed. - With storage phosphor cassette–based systems, o Some diaper rash ointments are often a bar- code system imprints the patient somewhat radiopaque the area may information before or after exposure. need to be cleansed before the - Care must be taken so that this area does not procedure. obscure the essential anatomy that is being - Surgical dressings such as metallic salves and demonstrated. adhesive tape should be examined for - With flat panel detector with thin film transistor radiopaque substances (FPD-TFT) systems and charged couple device - If permission to remove the dressings has not (CCD) systems, patient identification is typically been obtained or the technologist does not entered before exposure. know the way to remove them and the Anatomic Side Marker radiology department physician is not present, the surgeon or nurse and should be asked to - A right or left marker must also appear on accompany the patient to the radiology every radiographic image. department to remove the dressings. - A (R & L) marker shall also appear on every - When dressings are removed, the technologist radiographic image correctly indicating the should always make sure that a cover of sterile patient’s right or left side (e.g. upper & lower gauze adequately protects open wounds. extremities). - This side marker preferably should be placed Identification of Radiographs/Image directly on the IR inside the lateral portion of All radiographs shall include the following: the collimated border of the side being identified, with the placement such that the Case Number: marker will not superimposed over essential Name of Hosp.: anatomy. - These radiopaque markers shall be placed just Date: within the collimation field so that they will be exposed by the beam & included on the image. Patient’s Name: - Generally, it is an UNACCEPTABLE practice to - Correct ID is paramount & shall always be write or annotate digitally this information on confirmed. the image after it is processed because of legal - ID is vital in comparison studied, on follow up & liability problems caused by potential exams, & in medico-legal & compensation mismarking. cases.  - Radiograph taken without these two (2) - Other radiographs are marked to indicate the markings may have to be repeated, which position of the patient (e.g. upright, decubitus) results in unnecessary radiation to the patient. or other markings specified by the institution. - In the case of digital images, annotating the image to indicate side markers in an Methods of Marking for ID: UNACCEPTABLE practice. - Radiographing it along with the part, “flashing” o Exposure should be repeated to ensure it onto the film in the processing room. correct anatomy was imaged. - Writing it on the film after it has been processed. Additional Markers or Identification - Perforating the information on the film or using - Other markers or identifiers also may be used, the specialty IR-marking systems designed for such as technologist initials, which generally accurate & efficient operation. are placed on the R or L marker to identify the specific technologist responsible for the examination. - Sometimes the examination room number is also included. - Time indicators are also commonly used; these note the minutes of elapsed time in a series, such as the 1-minute, 5-minute, 15-minute, and 20-minute series of radiographs taken in an intravenous urogram (IVU) procedure. Specific Marker Placement Rules - Another important marker on all decubitus 1. For AP & PA projections that include both the R positions is a decubitus marker or some type of & L sides of the body (head, spine, chest, indicator such as an arrow identifying which abdomen & pelvis), an R marker is typically side is up. used. - An “upright” or “erect” marker must also be 2. For lateral projections of the head & trunk used to identify erect chest or abdomen (head, spine, chest, abdomen, & pelvis), always positions compared with recumbent, in addition mark the side closest to the IR. For example, if to an arrow indicating which side is up. the left side is closest use an L marker, the - Inspiration (INSP) and Expiration (EXP) markers marker is typically placed anterior to the are used for special comparison PA projections anatomy. of the chest. 3. For oblique projections that include both the R - Internal (INT) and External (EXT) markers may & L sides of the body (spine, chest, & be used for rotation projections, such as for the abdomen) the side down, or nearest the IR is proximal humerus and shoulder. typically marked. For example, for a right - Other patient ID markings include the patient’s posterior oblique (RPO), mark the R side. age or DOB, time of day, name (initial) of 4. For limb projections, use the appropriate R or L technologist or attending physician. marker. The marker must be placed within the - For certain examinations, the radiograph should edge of the collimated x-ray beam. include such markings as cumulative time after 5. For limb projections that are done with two (2) introduction of contrast medium (e.g. 5mins images on one IR, only one of the projections post injection & level of fulcrum (e.g. 9cm) in needs to be marked. tomography). 6. For limb projections where both the R & L sides are imaged side-by-side on one IR (e.g. R & L, AP  knees), both the R & L markers must be used to Advantages: clearly identify the two (2) sides. 7. For AP and PA, or Oblique Chest Projections, - Permanent identification. the marker is placed on the upper-outer corner - Economical in time. - Shows information neatly & uniformly. so that the thoracic anatomy is not obscured. 8. For decubitus positions of the chest & - Reduces the likelihood. abdomen, the R & L marker should always be Gonad Shielding placed on the side up (opposite the side laid on) & away from the anatomy of interest. - When practical, gonad shielding shall always be used for abdomen, pelvis, hip etc… NOTE: No matter which projection is performed, and no matter what positions the patient is in, if possible, if an Guidelines on the Use of Gonadal Shielding: R marker is used it must be placed on the “right” side of - If gonads lie w/in or close to the primary beam. the patient’s body. If an L marker is used it must be - If the clinical interest is not compromised. placed on the “left” side of the patient’s body. - If patient has a reasonable reproductive Basic Marker Conventions include the following: potential. - Marker shall never obscure anatomy. Compensating Filters - Marker should never be placed over that - Body structures with significantly varied tissue patient’s ID information. thickness & density. - Marker should always be placed on the edge of the collimator border. Spartech Wedge Collimator Clear Pb filter - Marker should always be placed outside of a lead shielding. - AP hips, knees & ankles Methods of Recording Information Trough, Collimator-Mounted Al filter with Double Wedge Actinic Marker - AP T-spine - Will photograph the details onto the film after exposure but prior to processing. Boomerang Contact Filter - Uses a small light source to photograph the - AP shoulder & facial bones patient details from a slip onto an exposed area of the film for the purpose. Ferlic Collimator-Mounted Filter Perforating Devices - AP & PAO (scapular Y) shoulder. - Perforated with letters or figures. Ferlic Collimator-Mounted Filter - Films are indelibly marked with perforations arranged as characters through the use of a - AP Axial Foot highly machined, die punch. Ferlic Collimator-Mounted Filter - Applicable when a large number of radiographs has to be marked with same information e.g. - Lat. CT (swimmers) and Axiolateral (Danelllius- hosp. name and date of exam. Miller) hip. Body Planes - Plane passes vertically through the body from front to back. Mid Sagittal Plane (MSP) - Specific SP that passes through the midline of the body and divide it into equal R & L halves. - Planes are used in radiographic positioning to center a body part to the image receptor (IR) or central ray to ensure that the body part is properly oriented and aligned with the IR - (E.g. the midsagittal plane may be centered and perpendicular to the IR with the long axis of the IR parallel to the same plane). - Planes can also be used to guide projections of the central ray. Coronal Plane o The central ray for an anteroposterior (AP) projection, for example, passes - Divides entire body or a body part into anterior through the body part parallel to the and posterior segments. sagittal plane and perpendicular to the o Plane passes through the body coronal plane. vertically from one side to the other. - Quality imaging requires attention to all relationships among body planes, the IR, and Mid Coronal Plane/Mid Axillary Plane (MCP/MAP) the central ray. - Specific coronal plane that passes through the - Body planes are used in computed tomography midline of the body dividing it into equal (CT), magnetic resonance imaging (MRI), and anterior & posterior halves. ultrasound (US) to identify the orientation of anatomic cuts or slices demonstrated in the Horizontal Plane procedure. - Imaging in several planes is often used to - Passes crosswise through the body or a body demonstrate a body part. part at right angles to the longitudinal axis. - Positioned at right angles to the SP & CP. Sagittal Plane (SP) - Plane that divides the body into superior & inferior portions. - Divides the body or body part into R or L - Often referred to as Transverse or Axial Plane. segments. Oblique (“odd” angles) - Can pass through a body part an angle between the three planes. Planes to localized specific area of the body: Interiliac Plane - Transects the pelvis at the top of the iliac crests (IC) at the level of the fourth lumbar spinous process. - Used in positioning the lumbar spine, sacrum, and coccyx. Body Habitus Occusal Plane Body habitus directly affects the location of the ff: - Occusal plane is formed by the biting surfaces - Heart of the upper and lower teeth with the jaws - Lungs closed. - Diaphragm - Used in positioning of the odontoid process and - Stomach some head projections. - Colon - Gallbladder Division of the Abdomen Surface Landmarks Anatomical Relationship Terminology Patient Aspect Anterior (Ventral) Aspect - Seen when viewing the patient from the front posterior (dorsal) aspect. - Seen when viewing the patient from the back. Lateral Aspect SIM’S POSITION - Any view of the patient from the side medial - Recumbent Oblique Position with the patient aspect. lying on the left anterior side, with the right - Side of the body part closest to the midline knee and thigh flexed and the left arm extended (e.g. inner side of a limb is the medial aspect of down behind the back or flexed in front of the the limb). patient. Terms for surfaces of the Hands and Feet FOOT LITHOTOMY Plantar – refers to the sole or posterior surface of the - Supine position with the knees and hip flexed, foot. highs abducted and flexed, thighs abducted and rotated and externally, support by ankle Dorsal – refers to the top or anterior surface of the foot supports. (dorsum pedis). HAND Dorsal – refers to the back or posterior aspect of the hand (dorsum manus) SPECIFIC BODY POSITIONS: Palmar – refers to the palm of the hand; in the LATERAL POSITION anatomic position, the same as the anterior or ventral - Refers to the side of, or side view. surface of the hand. - Specific Later Positions described by the part GENERAL BODY POSITIONS closest to IR or body part from which the CR exits. Supine – lying on the back, facing upward - True Lateral Position is always 90, or Prone – lying on abdomen, facing downward (head perpendicular, or at a right angle, to a true AP maybe turned to one side). or PA projection. Erect – upright position, to stand or sit erect. RECUMBENT - Lying down in any position (prone, supine, or on side) OBLIQUE POSITION o Dorsal Recumbent (supine) o Ventral Recumbent (prone) - Refers to an angles position in which neither the o Lateral Recumbent – lying on side (right sagittal nor the coronal body plane is or left lateral) perpendicular or at a right angle to the IR. - Part closest to IR. TRENDELENBURG POSITION - Recumbent position with the body tilted with the head lower than the feet. FOWLER’S POSITION - Body tilted with the head higher than the feet.  - The patient is lying on the dorsal (posterior) surface with the x-ray beam directed horizontally, exiting from the side closest to the For Oblique Positions of the Limbs, the terms Medial IR. Rotation and Lateral Rotation have been standardized to designate the direction in which the limbs have been turned from the anatomic position. VENTRAL DECUBITUS POSITION—RIGHT OR LEFT LATERAL - The patient is lying on the ventral (anterior) surface with the x-ray beam directed horizontally, exiting from the side closest to the DECUBITUS IR. - Literally means to “lie down,” or the position assumed in “lying down.” - This term describes a patient who is lying on one of the following body surfaces: back POSITIONING PROJECTION (dorsal), front (ventral), or side (right or left lateral). PROJECTION - Decubitus is always performed with the central ray horizontal. - Path of the central ray (CR) as it exist the x-ray - Essential for detecting air-fluid levels or free tube and goes through the patient to the IR. - Entrance & Exit points in the body. air in a body cavity such as the chest or abdomen, where the air rises to the uppermost - Describes the direction or path of the CR of the part of the body cavity. x-ray beam as it passes through the patient, projecting an image onto the IR considered to RIGHT OR LEFT LATERAL DECUBITUS POSITION—AP or be the most accurate term for describing how PA projection the procedure is performed. - The patient lies on the side, and the x-ray beam COMMON PROJECTION TERMS: is directed horizontally from anterior to posterior (AP) or from posterior to anterior POSTERIOR (PA) PROJECTION (PA). - Refers to a projection of the CR from posterior - AP or PA projection is important as a qualifying to anterior. term with decubitus positions to denote the - CR enters at the posterior surface and exits at direction of the CR. the anterior surface (PA projection). DORSAL DECUBITUS POSITION —LEFT or RIGHT LATERAL ANTEROPOSTERIOIR (AP) PROJECTION LATERAL OBLIQUE - Refers to a projection of CR from anterior to - Central ray enters one lateral aspect, passes posterior, the opposite of PA. along a transverse plane at an angle to the - CR, which enters at an anterior surface and exits coronal plane, and emerges from the opposite at a posterior surface (AP projection). lateral aspect. - Assumes a true AP without rotation unless a - Coronal plane at right-angles to the cassette, qualifier term also is used, indicating it to be an lateral oblique projections can also be obtained oblique projection. by angling the central ray to the coronal plane. OBLIQUE PROJECTION - During an oblique projection the CR enters the body or body part from a side angle following MEDIOLATERAIL AND LATEROMEDIAL PROJECTIONS an oblique plane. - Projections may enter from either side of the - A lateral projection is described by the path of body and from anterior or posterior surfaces the CR. - If the CR enters the anterior surface and exits - Two examples are the Mediolateral projection the opposite posterior surface ⭬AP oblique of the ankle and the Lateromedial projection of Projection (APO). the wrist. - If the CR enters the posterior surface and exits - The medial and lateral sides are determined anteriorly ⭬PA Oblique Projection (PAO). with the patient in the anatomic position. - Indicate the sides entered and exited by the central ray. OBLIQUE USING BEAM ANGULATION - When the median sagittal plane is at right- angles to the cassette, right and left anterior or posterior oblique projections may be obtained by angling the central ray to the median sagittal plane. (NB: this cannot be done if using a grid, unless the grid lines are parallel to the central ray.) AXIAL PROJECTION TANGENTIAL PROJECTION - Refers to the long axis of a structure or part - Means touching a curve or surface at only one (around which a rotating body turns or is point. arranged). - A projection that merely skims a body part to project that part into profile and away from Special application—AP or PA axial: other body structures. - In radiographic positioning, the term Axial has - Toward the outer margin of a curved body been used to describe any angle of the CR of surface to profile a body part just under the 10° or more along the long axis of the body or surface and project it free of superimposition. body part. - Called a tangential projection because of the - Axial projection would be directed along, or tangential relationship formed between the parallel to, the long axis of the body or part. central ray and the entire body or body part. - Semi-axial, or “partly” axial, more accurately describes any angle along the axis that is not truly along or parallel to the long axis. AP AXIAL PROJECTION—LORDOTIC POSITION - A specific AP chest projection for demonstrating the apices of the lungs. INFEROSUPERIOR and SUPEROINFERIOR AXIAL - Sometimes called the Apical Lordotic PROJECTIONS Projection. - Frequently performed for the shoulder and hip, - The long axis of the body rather than the CR is where the CR enters below or inferiorly and angled. exits above or superiorly. - Lordotic position is achieved by having the - Opposite of this is the superoinferior axial patient lean backward while in the upright projection, such as a special nasal bone body position so that only the shoulders are in projection. contact with the IR. - Angulation forms between the central ray and the long axis of the upper body, producing an AP Axial Projection. - This position is used for the visualization of pulmonary apices. TRANSTHORACIC LATERAL PROJECTION (RIGHT VIEW LATERAL POSITION) - Used to describe the body part as seen by the - A lateral projection through the thorax. IR. - Requires a qualifying positioning term (right or - View and projection are exact opposites. left lateral position) to indicate which shoulder - Shadows cast on an IR by the x-rays projected is closest to the IR and is being examined. through a body part are viewed on the resulting image from the opposite direction. NOTE: This is a special adaptation of the projection - The image “looks back" into the body from the term, indicating that the CR passes through the thorax side that was closest to the IR. even though it does not include an entrance or exit site. In practice, this is a common lateral shoulder projection METHOD and is referred to as a right or left transthoracic lateral shoulder. - Some radiographic projections and procedures are named after individuals (e.g., Water or Towne, Burman, etc...) in recognition of their development of a method to demonstrate a specific anatomic part. PRIMARY X-RAY PROJECTIONS, BODY POSITION DORSOPLANTAR and PLANTODORSAL PROJECTIONS - Secondary terms for AP or PA projections of the foot. - Dorsoplantar (DP) describes the path of the CR from the dorsal (anterior) surface to the plantar (posterior) surface of the foot. - A special plantodorsal projection of the heel bone (calcaneus) is called an Axial Plantodorsal Projection (PD) because the angled CR enters the plantar surface of the foot and exits the dorsal surface. RELATIONSHIP TERMS NOTE: The term dorsum for the foot refers to the anterior surface, dorsum pedis. MEDIAL VERSUS LATERAL - Medial (me′-de-al) versus lateral refers to toward versus away from the center, or median plane. - In the anatomic position, the medial aspect of any body part is the “inside” part closest to the median plane, and the lateral part is away from the center, or away from the median plane or midline of the body.  IPSILATERAL VS CONTRALATERAL IPSILATERAL – on the same side of the body part. CONTRALATERAL – on the opposite side. FLEXION – decreases the angle of the joint. ENTENSION – increases the angle as the body part moves from a flexed to a straightened position. HYPEREXTENSION - Extending a joint beyond the straight or neutral PROXIMAL VERSUS DISTAL position. - Proximal is near the source or beginning and distal is away from. - In regard to the upper & lower limbs, proximal & distal would be that part closes to or away from the trunk, the source or beginning of that limb. - Distal refers to parts farthest from the point of attachment; o Point of reference, origin, or beginning; away from center of body. - Proximal refers to parts nearer the point of attachment; o Point of reference, origin, or beginning: toward the center of the body. CEPHALAD – toward the head end of the body. CEPHALAD ANGLE – angle toward the head end of the body. CAUDAD – away from the head end of the body. CAUDAD ANGLE – angle to the feet or away from the head end. ULNAR DEVIATION - To turn or bend the hand & wrist from natural position toward the ulnar side. RADIAL DEVIATION - Toward the radial side of the wrist. DORSIFLEXION OF FOOT ABDUCTION - To decrease the angle (flex) between the - Lateral movement of the arm or leg away from dorsum (top of foot) & the lower leg, moving the body. foot & toes upward. - Another application is the abduction of the fingers or toes. PLANTAR FLEXION OF FOOT EXTENDING THE ANKLE JOINT ADDUCTION - Moving foot & toes downward from the normal - Movement of arm or leg toward the the body, position. to draw toward a center or medial line. - Flexing or decreasing the angle toward the - Fingers or toes mean moving them together or plantar (posterior) surface of the foot. toward each other. EVERSION – outward stress movement of the foot as SUPINATION applied to the foot without rotation of the leg. - Rotational movement of the hand into the INVERSION – inward stress movement of the foot as anatomic position (palm up in supine position applied to the foot without rotation of the leg. or forward in erect in erect position). - This movement rotates the radius of the Plantar surface (sole) of the foot is turned or rotated forearm laterally along its long axis. away from the median plane of the body (sole faces in amore lateral direction) for eversion & toward the PRONATION median plane for inversion. - Rotation of the hand into the opposite of the Leg does not rotate, & stress is applied to the medial & anatomic position (palms down or back). lateral aspects of the ankle joint for evidence of possible widening of the join space (ankle mortise). VALGUS - Describes the bending of the part outward or away from the midline of the body. - Sometimes used to describe eversion stress of the ankle joint. PROTRACTION – movement forward from a normal position. VARUS RETRACTION – movement backward or the condition of - Meaning “knock head”, describes the bending being drawn back. of a part inward or toward the midline. - Sometimes used to describe inversion stress ELEVATION – lifting, raising or moving of a part applied at the ankle joint. superiorly. MEDIAL ROTATION – rotation or turning of a body part DEPRESSION – letting down, lowering, or moving a part with movement of the anterior aspect of a part toward inferiorly. inside, or median plane. LATERAL ROTATION – rotation of an anterior body part toward the outside, or away from the median plane.  CLINICAL INDICATIONS (CHEST FOR HEART & LUNGS) ASPIRATION/FOREIGN BODY - inspiration of a foreign material into the airway. ATELECTASIS - collapse of all or part of the lung. BRONCHIECTASIS - chronic dilation of the bronchi or broncioles associated with secondary infection. END OF PART 1 BRONCHITIS - inflammation of the bronchi. CHRONIC OBSTRUCTION PULMONARY DISEASE (COPD) - chronic condition of persistent OBSTRUCTION of bronchial airflow. PATHOLOGICAL CONDITIONS CYSTIC FIBROSIS - disorder associated with widespread dysfunction of the exocrine glands, abnormal secretion of sweat and saliva, and accumulation of thick mucus in the lungs. EPHYSEMA - destructive and obstructive airway changes leading to an increase volume of air in the lungs. FUNGAL DISEASE - inflammation of the lungs cause by a fungal organism. HISTOPLASMOSIS - infection caused by the yeastlike organism Histoplasma Capsutalum. GRANULOMATOUS DISEASE - condition of the lung marked by formation of granulomas. SARCOIDOSIS - condition of unknown origin often associated with pulmonary fibrosis. TUBERCULOSIS - chronic infection of the lung due to the tubercle bacillus. HYALINE MEMBRANE DISEASE / RESPIRATORY DISTRESS SYNDROME - underaeration of the lungs due to lack of surfactant. PLEURAL EFFUSION - collection of fluid in the pleural cavity. PNEUMONIA - acute infection in the lungs EVALUATION CRITERIA parenchyma.  Area from the mid-cervical to mid-thoracic  ASPIRATION - pneumonia caused by aspiration region. of foreign particles.  Air-filled trachea region.  INTERSTITIAL/PNEUMONITIS - pneumonia  No rotation. caused by a virus and involving the alveolar LATERAL PROJECTION walls and intertitial structures.  LOBAR/BACTERIAL - pneumonia involving of an SID - 72" (183cm) to minimize magnification entire lobe without involving the bronchi.  LOBULAR/BRONCHOPNEUMONIA - pneumonia IR SIZE - 24x30cm (10x20 inches) (lengthwise) involving the bronchi and scattered throughout the lungs. PPX - upright (if possible), seated or PNEUMOTHORAX - accumulation of air in the pleural cavity resulting in collapse of the lungs. POSITION OF PART (PP) PULMONARY EDEMA - replacement of air with fluid in - Center upper airway (larynx & trachea) to CR. the lungs interstitium and alveoli. - Rotate shoulder posteriorly with arms hanging down and hand clasped behind the back. TUMOR - new tissue growth where cell proliferation is - Raise chin slightly, adjust IR height at level of uncontrolled. external auditory meatus. TRACHEA CENTRAL RAY (CR) - perpendicular AP PROJECTION REFERENCE POINT (RP) - center of IR at level of C6 or C7, midway between the laryngeal prominence of the IR - 24x30cm or 30x35cm (lengthwise) thyroid cartilage and the jugular notch. PPX - supine or upright position INSTRUCTION - slow, deep inspiration. POSITION OF PART (PP) (To ensure filling trachea and upper airway with air) - MSP centered STRUCTURE SHOWN (SS) - epiglottis, larynx, trachea - extend neck slightly - center IR at the level of manubrium The shadows of the shoulders should be primarily - collimate closely to the neck posterior to and should not superimpose the area of the trachea. CENTRAL RAY (CR) - perpendicular AP PROJECTION LATERAL PROJECTION REFERENCE POINT (RP) - manubrium INSTRUCTION - inhale slowly (ensure that the trachea is filled with air) STRUCTURE SHOWN (SS) - trachea superimposed on the shadow of the C-vertebrae. TRACHEA AND SUPERIOR MEDIASTINUM Thoracic Mediastinum and Air-filled Trachea LATERAL PROJECTION IR - 24x30cm or 30x34cm (lengthwise) PPX - lateral position either seated or standing. POSITION OF PART (PP) - Patient to clasp the hands behind the body. - Rotate the shoulder posteriorly as far as TRACHEA AND PULMONARY APEX possible. (Keep the superimposed shadows of AXIO LATERAL PROJECTION / TRANSHOULDER the arms from obscuring the structures of the LATERAL POSITION / TWINING / FLYING ANGLE superior mediastinum.) METHOD (R or L Position) - Center the trachea to midline of IR. - Height of IR at the upper border or above the level of laryngeal prominence. - Extend neck slightly. CR - horizontal REFERENCE POINT (RP) – point midway between the jugular notch and the MCP and through a point 4-5" lower for demonstration of the superior mediastinum IR - 24x30cm (lengthwise) INSTRUCTIONS - slow inspiration. (To ensure that the trachea is filled with air) PPX - seated or standing before a VGCH, with affected side toward IR. STRUCTURE SHOWN (SS) POSITION OF PART (PP) - Air-filled trachea, regions of the thyroid and thymus glands. - Elevate arm adjacent to IR in extreme - Used extensively to demonstrate retrosternal abduction, flex elbow and place forearm across extension of the thyroid gland, thymic or behind the head. enlargement in infants. (Recumbent Position) - Center IR to region of trachea at the the level - Pacified pharynx and upper esophagus. of axilla. - Outline of the trachea and bronchi. - Depress opposite shoulder as much as - Used for foreign body localization. possible. - Body in true lateral position, MSP parallel with EVALUATION CRITERIA: plane of IR.  Area from mid-cervical to mid-thoracic CENTRAL RAY (CR) - 15° caudad included.  Trachea or superior mediastinum should not REFERENCE POINT (RP) - adjacent supraclavicular superimposed by shoulders. impression (fossa)  Trachea filled with air and well demonstrated.  Patient not rotated. INSTRUCTIONS: CENTRAL RAY (CR) - perpendicular TRACHEA - inhale slowly REFERENCE POINT (RP) - level of T7 (inferior angle of scapula) LUNG APEX - end of full inspiration INSTRUCTIONS: STRUCTURE SHOWN (SS) - Second full inhalation. (Ensure maximum - Air-filled trachea expansion of lungs.) (Lungs expand - Apex of lung closer to IR. transversely, anteroposterior and vertically with vertical being the greatest dimension.) EVALUATION CRITERIA: - Full inspiration and expiration. (Pneumonia and presence of foreign body) (Shield Gonads -  Shoulders well separated from each other. place lead shield between the x-ray tube and  Area from mid-cervical to mid-thoracic region patient' pelvis) included.  Trachea should be filled with air and well STRUCTURE SHOWN (SS) demonstrated.  No rotation. - Air-filled trachea lungs, diaphragmatic domes, CHEST (LUNGS & HEART) heart and aortic knob, thyroid and thymus gland. (If enlarged laterally) PA PROJECTION - esophagus (If filled with barium sulphate suspension) (contrast studies) IR - 34x43cm (adult) SID - standard 183cm (72") (140cms-200cms) (decrease magnification of the heart and increase recorded detail of thoracic structures) PPX - Upright, either standing or seated - Air or fluid levels are seen. - Avoid distention of pulmonary vessels. - Diaphragm is at lowest position. POSITION OF PART (PP) ESOPHAGUS WITH BARIUM SULFATE CONTRAST - Upper shoulder of IR about 1.5-2" above MEDIA shoulders. - MSP centered - Chin upward or top of VGCH - Flex arms and rest back of hands low on hips, below level costrophrenic angles (CPA)- rotate shoulder forward (to allow scapulae to move laterally) (clear lung fields) - Depress shoulders downward. (Move clavicles below the apices) FEMALE - If patient's breasts are large enough to superimposed over the part of the lung fields, ask the patient to pull breast upward and laterally. EVALUATION CRITERIA:  Evidence of collimation.  Sternal ends of clavicle equidistant from vertebral column. AP PROJECTION  Trachea seen in the midline.  Scapulae projected outside lung field. IR - 35x43cm (lengthwise) SID - 183cm or 150cm  2" of lung apex above clavicles.  Ten post. ribs seen above diaphragm. PPX - supine or upright (used when px is too ill to be  Distance from vertebral column to lateral turned to the prone position) border of ribs equidistant on each side.  Small amount of heart seen on right side of POSITION OF PART (PP) vertebral column.  Lateral aspect of lung fields including - Center MSP to IR constrophrenic angles. - Upper border of IR approx. 3.8-5cm above  Sharp outlines of the heart and diaphragm. relaxed shoulders.  Faint shadow of ribs and superior T-vertebrae - Flex px's elbows (if possible), pronate hands. seen through heart shadow. - Place hands on the hips to draw the scapulae laterally. FOUR IMPORTANT AREAS IN THE LUNG FIELDS 1. Lung Field CR & RP - perpendicular (level of T7) (3-4" below 2. Lung Periphery jugular notch) 3. Mediastinum STRUCTURE SHOWN (SS) 4. Cardiac Shadow - Heart and great vessels (magnifies & distended) - Lung fields (appear shorter abdominal compression moves the diaphragm to a higher level) - Clavicles are projected higher - Ribs assume a more horizontal appearance  REFERENCE POINT (RP) - midsternal region LATERAL PROJECTION (R or L POSITION) IR - 35x43cm (lengthwise) SID - 183cm POSITION OF PART (PP) - MSP parallel with IR - MCP perpendicular to IR EVALUATION CRITERIA: - Extend arms directly upward, flex elbows. - Forearms resting on elbows, hold arms in  Evidence of collimation. position.  Medial portion of clavicles equidistant. - For unsteady patients: place an IV stand in  Trachea visible in the midline. front, extend arms and grasp the stand as high  Clavicles horizontal and obscuring more of the as possible for support. apices than PA projection. - Upper border of IR about 3.8-5cm above shoulder.  Equal distance from vertebral column to lateral border of ribs on each side. (LL - to show heart and left lung)  Faint image of ribs and T-vertebrae visible through heart shadow, entire lung fields from (RL - right lung) apices to costrophrenic angle, pleural markings CR - perpendicular visible from hilar regions to periphery of lungs. RP - level of T7 (inferior angle of scapula) INTRUCTIONS - second full inspiration MODIFICATIONS: STRUCTURE SHOWN (SS) RESNICK METHOD Left Lateral Chest: heart, aorta, left- sided pulmonary lesions - 30° AP Projection (To avoid superimposition of the basal portions Right Lateral Chest: right-sided pulmonary lesions of the lung fields by the anterior diaphragmatic, abdominal and cardiac structures)  Lateral are used extensively to demonstrate - Differentiates middle lobe and lingular interlobar fissures. processes from lower lobe disease.  Differentiate the lobes. PPX - upright or supine  Localize pulmonary lesions. CR - 30° caudad or more based on preliminary film. EVALUATION CRITERIA: STRUTURE SHOWN (SS) in LAO  Evidence of collimation. - Maximum area of the right lung field (side  Superimposition of posterior ribs to vertebral farther) along with the thoracic viscera. column. - Anterior portion of left lung superimposed by  Arm or soft tissues overlapping superior lung the spine. field. - Entire branch of bronchial tree.  Lung axis of lung fields in vertical position - Heart and descending Aorta. (Lying just in from without forward or backward leaning. of the spine) - Arch of Aorta STRUCTURE SHOWN (SS) in RAO - Right hang on hip with palm outward. - Left arm raised to shoulder level and grasp the top of VGCH. - Maximum area of the left lung field (side farther) along with the thoracic viscera. - Anterior portion of right lung superimposed by the spine. - Trachea and entire left branch of bronchial tree. PA OBLIQUE PROJECTION - Gives the best image of the Left Atrium. - Anterior portion of the Left Ventricle. IR - 35x43cm SID - 183cm - Right retrocardial space. PPX - standing or seated POSITION OF PART (PP) - Turn approx. 45° toward left side or right side. - Side of interest farther from IR. - Veretebral prominens 3.8-5cm from top of IR. LAO (Left Anterior Oblique) - Left hand on hip wiht palm outwards. EVALUATION CRITERIA: - Right arm raised to shoulder level and grasp the top of vertical gridded cassette holder  Evidence of proper collimation entirely of both (VGCH) for support. lungs. - Use 55-60° (MSP rotation) when cardiac series  Trachea filled with air. is performed.  Visible ID markers  Heart and mediastinal structure within the CR - perpendicular lung fields of the elevated side in oblique images of 45°. RP - T7 (inferior angle of scapula)  Max. area of left lung on LAO. INSTRUCTIONS - second full inspiration  Max. area of right lung on RAO. 45° LAO POSITION (PAO PROJECTION) EVALUATION CRITERIA:  Evidence of proper collimation.  Entire lungs.  Trachea filled with air.  Visible ID  Lung fields and mediastinal structures.  Max. area of left lung on LPO.  Max. area of right lung on RPO. 45° RAO POSITION (PAO PROJECTION) RECUMBENT RPO POSITION ANTEROPOSTERIOR OBLIQUE PROJECTION (APO) (RPO &LPO POSITIONS) IR - 35x43cm (lengthwise) SID - 183cm PPX - upright or recumbent POSITION OF PART (PP) - Vertebral prominens 3.7-5cm from top of IR, or top of IR 12.7cm above the jugular notch. - Side of interest is closest to IR - If patient is recumbent: support elevated hip and arm. - Flex elbows and place the hands on hips with palms facing outward or pronate hands beside hips. - Arm closer to IR may be raised as long as the shoulder is rotated anteriorly. CR - perpendicular RP - 7.6cm below jugular notch (CR exit at T7) PULMONARY APICES (APICOGRAM) STRUCTURE SHOWN (SS) AP AXIAL PROJECTION (LINDBLOM METHOD - LORDOTIC POSITION) - Comparable to PAO projection however, lung field of elevated side appear shorter because IR - 35x43cm (lengthwise) SID - 183cm of the magnification of the diaphragm. - Magnified heart and vessels. PPX OBLIQUE LORDOTIC POSITION (LPO or RPO) - Upright and standing approx. 1 foot (30cms) - Rotate body approx. 30° away from the away from IR and leaning back with shoulder, position used for AP position. neck, and back against IR/VGCH. - Affected side toward and centered to IR. - Hands on hips, palms out; shoulders rolled - With either of the above positions: flex elbows forward. and place hands and palms out on hips. - Lean backward in a position of extreme PP - center MSP to CR and to centerline of IR upper lordosis and rest the shoulders against VGCH. margin of IR about 7-8cm above the upper of the shoulders when patient is positioned in lordotic LORDOTIC POSITION position. CR - perpendicular to IR, centered to mid-sternum about 3-4 inches (9cm) below the jugular notch. RP - mid-sternum INSTRUCTION - second full inspiration. LPO LORDOTIC POSITION SS - lung apices and interlobar effusions. EVALUATION CRITERIA: LORDOTIC - Clavicles superior to apices. - Sternal ends of clavicles equidistant from vertebral colum. - Entire apices and lungs. - Clavicles lying horizontally with medial ends overlapping first or second ribs. - Ribs distorted with anterior and posterior superimposed. PA AXIAL PROJECTION OBLIQUE IR - 24x30cm or 30x35cm SID - 183cm - Entire dependent apex and lung of affected side. PPX - seated or standing LORDOTIC POSITION POSITION OF PART (PP) - Adjust patient for the AP Axial Projection. - IR centered at level of jugular notch. - MSP centered - MSP centered, rest chin against VGCH. - Flex elbows and place hands, palms out on hips.  - Depress shoulders, rotate them forward (to REFERENCE POINT (RP) - manubrium move scapulae from lung fields) INSTRUCTION - full inspiration CR/RP (CENTRAL RAY/REFERENCE POINT) STRUCTURE SHOWN (SS) - apices lying below clavicles. - Inspiration (10-15° cephalad through T3) - Expiration (optional) (perpendicular through T3) Note: AP Axial Projection is used in preference to the PA Axial Projection in hypersthenic patient and INTRUCTIONS: patients whose clavicles occupy a high position. - Full inspiration (clavicles are elevated) - Full exhalation (clavicles are depressed) SS - apices are projected above shadows of clavicles. EVALUATION CRITERIA:  Entire apices.  Superior lung region adjacent to apices.  Clavicles below apices. EVALUATION CRITERIA:  Medial portion of clavicles equidistant from vertebrral column.  Entire apices.  Superior lung region adjacent to apices. AP/PA AXIAL PROJECTION  Clavicle lying below apices.  Medial clavicles equidistant from vertebral IR - 24x30cm or 30x35cm (crosswise) SID - 183cm column. PPX- seated or erect AP AXIAL PROJECTION PA - CR 30° caudally IR - 24x30cm or 30x35cm (crosswise) SID - 183cm RP - C7 (coincides with sternal angle) PPX - upright or supine AP - 30° cephalad POSITION OF PART (PP) RP - sternal angle - MSP centered - IR centered at level of T2 AP - Flex elbows and place hands on hips with palms out, or pronate hands on hips. - Px in reclining position, CP 30° to IR. - Neck nape resting against upper border of CR - 15° or 20° cephalad cassette. CR - directed at right angles to IR toward sternal angle PA PROJECTION (this technique is adapted with patient reclining 15° and tube angles 15°) IR - 35x43cm (lengthwise) PPX - clasp the sides of the VGCH - Patient bends backwards at the waist. - Degree of dorsiflexion varies for each patient. - In general it is about 30-40. CR - horizontal at right angles to IR AP or PA PROJECTION (R or L LATERAL DECUBITUS POSITIONS) IR - 35x43cm (lengthwise) PPX - lateral decubitus, lying on either affected or unaffected side. (As indicated by existing condition) POSITION OF PART (PP) - Small amount of fluid in the pleural cavity. (Best shown with patient lying on affected side) (Mediastinal shadows and fluid will not overlap) - Small amount of free air in the pleural cavity. (Patient to remain in the position for 5mins before the exposure to allow the fluid to settle and air to rise.) - If lying on affected: elevate body 5-8cm on a suitable platform or a firm pad. - Extend arms well above head. - Thorax in true lateral position. - IR approx. 1.5-2 beyond the shoulders. CR - horizontal and perpendicular RP - 3" below jugular notch (AP) and T7 (PA) INSTRUCTION - second full inhalation (ensure max. expansion of lungs) SS - demonstrate change in fluid position and reveals any previously obscured pulmonary areas or in case of suspected pneumothorax, presence of any free air. EVALUATION CRITERIA: - extend arms well above head - affected side against VGCH  Evidence of collimation. - Top of IR extend or level of thyroid cartilage.  No rotation of patient from true frontal position, as evidenced by clavicles equidistant CR - horizontal from spine.  Entire affected side. REFERENCE POINT (RP)  Apices  Proper ID visible to indicate decubitus was - IR (enters level of MCP and 3-4" below jugular performed. notch for dorsal decubitus) - T7 for ventral decubitus.  Patient's arms not visible in field of interest. SS - change of position of fluids and reveals pulmonary areas that are obscured by the fluid in standard projection.EVALUATION CRITERIA: - Evidence of proper collimation. - Entire lung fields including entire anterior and posterior surfaces. - No rotation of thorax from true lateral position. - Upper lung not obscured by arms. - Proper ID marker visible to indicate decubitus is performed. - center of T7 LATERAL PROJECTION (R or L POSITION - VENTRAL or DORSAL DECUBITUS) IR - 35x43cm (lengthwise) PPX - prone or supine POSITION OF PART (PP) - Elevate thorax 2-3" on folded sheets or firm part. - Center thorax (allow patient to remain in position for mins before exposure to allow fluid to settle and air to rise) PART 3 – BONY THORAX (sternum, sternoclavicular joints, ribs) CLINICAL INDICATIONS STERNUM FRACTURE - disruption of the continuity of bone. PAO PROJECTION (RAO POSITION) METASTASES - transfer of cancerous lesion from one IR - 24x30cm (lengthwise) are to another. SID - 76cm (to blur the posterior ribs) OSTEOMYELITIS - inflammation of bone due to pyogenic infection. PPX - prone OSTEOPETROSIS - increased in density of atypical soft POSITION OF PART (PP) bone. - Adjust body into a RAO (average of 15-20°) OSTEOPOROSIS - loss of bone density. position. - Support body on forearm and flexed knee. PAGET'S DISEASE - thick, soft bone marked by bowing - Adjust elevation of left shoulder and hip so and fractures. that thorax is rotated just enough to prevent superimposition of vertebrae and sternum. TUMOR - new tissue growth where cells proliferation - Top of IR (3.8cm above jugular notch) is uncontrolled. CR - perpendicular CHONDROSARCOMA – it is the malignant tumor from cartilage cells. RP - elevated side of posterior thorax at level of T7 and approx. 2.5cm lateral to MSP. MULTIPLE MYELOMA - malignant neoplasm of plasma cells involving the bone marrow and causing INSTRUCTION - slow, shallow breathing or end of destructive of the bone. expiration. (To obtain more uniform density) The degree of obliquity required is dependent on the SS - slightly oblique view of sternum size of the thoracic cavity. EVALUATION CRITERIA: A patient with shallow or thin chest requires more rotation than a patient with deep chest to cast the - Evidence of proper collimation. sternum away from T-spine. - Entire sternum from jugular notch to tip of xiphoid process. Example: a patient with a large, barrel chested thorax - Reasonably good visibility of sternum through with a greater AP measurement requires less (»15°), thorax, including blurred pulmonary markings if whereas a thin-chested patient requires more rotation a breathing technique was used. (»20°). - Minimally rotated sternum and thorax. - Sternum projected free of superimposition from vertebral column. - Minimally oblique vertebrae to prevent excessive rotation of sternum. - Lateral portion of manubrium and SCJ free of superimposition by the vertebrae. - Sternum projected over heart.  (Large Patients, less angulation) (Thin Patients, more than the standard 25° angulation) RP - level of T7 and approx. 5cm to right of spine. SS - slightly oblique view of sternum EVALUATION CRITERIA: - Entire sternum from jogular notch to tip of xiphoid process. - Reasonably good visibility of the sternum through thorax. - Blurred pulmonary markings if breathing technique was used. - Blurred posterior ribs if a reduced SID was used. - Sternum projected free of superimposition from the vertebral column. PAO PROJECTION Moore Method - Modified Prone Position IR - 24x30cm (lengthwise) SID - 76cm (to blur posterior ribs) LATERAL PROJECTION PPX (R or L POSITION - UPRIGHT) - Before positioning patient, place IR crosswise in IR - 24x30cm (lengthwise) SID - 183cm (reduce cassette tray maginification and distortion) - Patient stand at side of table directly in front of cassette tray. PPX - lateral position, seated or standing before a VGCH. PP PP - Bend at waist and place sternum in the center of the table directly over the prepositioned IR. - Rotate shoulders posteriorly. - X-ray tube positioned over patient's right side. - Lock hands behind the back. - Arms above the shoulders and palms down on - Center sternum of midline of IR. table. (Acts as support for the side of head) - Broad surface of the sternum perpendicular to - Ensure that patient is in true prone position. plane of IR. - Upper border of IR is 3.8cm above jugular CR - 25° and centered to IR. notch. (Large breasts on female patients should be drawn to LATERAL PROJECTION sides and held in position with wide bandage so their shadows do not obscure the lower portion of the (R or L POSITION – RECUMBENT) sternum.) IR – 24x30cm (lengthwise) SID – 183cm (preferred) CR - perpendicular PPX – lateral recumbent RP - central of IR and entering the lateral border of mid PP – extend arms over head. (Prevent from overlapping sternum the sternum) - Rest patient’s head on arms or pillow. Instruction - suspended deep inhalation. (Provide - Center sternum contrast between posterior surface of sternum and - Upper border of IR is 3.8cm above jugular adjacent structure.) notch. STRUCTION SHOWN (SS) CR – perpendicular - Lateral view of the entire length of the RP – lateral border of midsternum. sternum. - Superimposed SCJs and medial ends of INTRUCTION – suspended deep inhalation. clavicles. SS – lateral aspect of entire length of sternum. - Medial ends of clavicles. Note: EVALUATION CRITERIA: - Use dorsal decubitus position for examination - Evidence of proper collimation. of patient with severe injury. - Entire sternum. - An SID of 183cm can be used for this position. - Manubrium free from superimposition by soft tissue of shoulders. EVALUATION CRITERIA: - Sternum free of superimposition by ribs. - Lower portion of sternum unobscured by - Evidence of proper collimation. breasts of female patient. - Entire lateral image of sternum. - Sternum free from superimposition by soft tissues of shoulders or arms and ribs. LATEROMDEIAL PROJECTION IR – 24x30cm (lengthwise) PPX – prone POSITION OF PART (PP) - MSP centered. - Manubrial notch 2” below upper border of IR. - Long axis of sternum centered to IR. STERNOCLAVICULAR ARTICULATIONS/JOINTS (SCA/J) - Body in true AP position. PA PROJECTION - Rest head on cheek or chin. - Measure depth of chest. IR – 18x24cm (crosswise) REFERENCE POINT (RP) PPX – prone or upright, standing or seated - Refer to thickness for degree of CR angulation POSITION OF PART (PP) required to project sternum from vertebral - MSP centered. column. - Center IR at level of spinous process of T3 - Preferably CR should be protected from left vertebra. (lies posteriorly to jugular notch) side of body. (Project heart shadow sternum) - Arms along sides of body with palms facing - Midpoint of film. upward. (prone) SS – slightly oblique PA projection of sternum 1.1 BILATERAL - Rest head on chin and adjust it so that MSP is vertical. 1.2 UNILATERAL - Turn head to face the affected side and rest cheek on table. (Turning head rotate spine slightly away from side being examined and therefore provides better visualization of the lateral portion of manubrium.) CR – perpendicular RP – T3 (jugular notch) STRUCTURE SHOWN (SS) - SCJ - Medial Portion of Clavicles. EVALUATION CRITERIA: - Evidence of proper collimation. - Both SCJs and medial ends of clavicles. - SCJs through the superimposing vertebral and rib shadows. - No rotation present on a bilateral exam; slight rotation on unilateral exam. CR ANGULATION METHOD (NON-BUCKY) PAO PROJECTION IR – 18x24cm (lengthwise) (RAO or LAO POSITION) POSITION OF PART (PP) IR – 18x24cm (crosswise) - Center SCJ to IR. PPX – prone - Rest head on chin or rotate chin toward side of the joint that is being radiographed. BODY ROTATION METHOD CR – 15° toward MSP POSITION OF PART (PP) RP – Image Receptor (enters level of T2-T3 about 7.6cm - Affected side adjacent to IR. distal to vertebral prominens & 2.5 to 5cm lateral to - Position patient enough of an oblique angle MSP) (10-15°) to project the vertebrae well behind the SCJ close to IR. SS – slightly oblique view of SCJ - Center SCJ. (Joint is closer to IR and less distortion is obtained than CR – perpendicular when body rotation method is used) RP – SCJ close to IR. EVALUATION CRITERIA: CR enters level of T2-T3 (about 7.6cm distal to vertebral - SCJ should be in center of radiograph. prominens) and 2.5-5cm lateral (toward the joint) from - Manubrium and medial end clavicle included. MSP. - SCJ space should be open. - SCJ of interest should be directly in front of SS – slightly oblique view of SCJ vertebral column with minimal obliquity. - Visibility of SCJ through superimposing rib and lung fields should be reasonably good.  - POSITION OF PART (PP) - SCJ centered. - Flex hips and knees in comfortable position. - Extended fully arm of affected side and grasp the end of table for support. - Place other arm alongside of body. - Grasp dorsal surface of hip to hold shoulder in depressed position. (Extension of affected shoulder along with depression of uppermost shoulder) (Prevents superimposition of the 2 articulations) CR - 15° caudad RP – SCJ INSTRUCTION – end of full inhalation. SS – unobstructed axio-lateral view of SCJ closest to IR. AXIOLATERAL PROJECTION KURZBAUER METHOD IR – 18x24cm (lengthwise) PPX – lateral recumbent on affected side. EVALUATION CRITERIA: - SCJ demonstrated. - Shoulders should not superimpose SCAs. LATEROMEDIAL PROJECTION RIBS (UPPER ANTERIOR) ZIMMER METHOD (NON-BUCKY) PA PROJECTION IR – 18x24cm (crosswise) IR – 35x43 (lengthwise) POSITION OF PART (PP) PPX - MSP centered. - Upright or Recumbent - Place IR (or cassette tunnel) under chest and o Diaphragm descends to its lowest level. center to manubrial notch. - Valuable for demonstrating fluid levels in - Extend arms along sides of body with hands CHEST. facing upward. - Rest head on tip of chin with MSP vertical. POSITION OF PART (PP) - Locate spinous process of T3 vertebrae and - MSP Centered mark 6cm to each side of it to indicate - IR is 3.8cm above upper border of shoulders. centering points. - Rest hand against hips, with palms turned - Alternately mask ½ of IR with a piece of lead outwards. sheet. o Rotate scapulas away from rib cage. CR – 5 to 15° toward MSP - If in RECUMBENT o Rest head on chin and adjust MSP to (First from one side and then from opposite side) be vertical. (CR directed to marked localization points) CR – perpendicular or 10-15° (Caudad) (Long cylindrical cone may be used: short SID too) o To demonstrate the 7th, 8th and 9th ribs. RP – T7 INTRUCTION – suspended full inspiration SS – Anterior Ribs above Diaphragm SS – slightly oblique view of both SCJ (Vertebral shadow is absent) EVALUATION CRITERIA: - Entire 1st through 9th ribs, with posterior portion lying above diaphragm. - In a unilateral examination, ribs from the opposite side may not be entirely included. - Ribs visible through lungs with sufficient contrast. POSTERIOR RIBS EVALUATION CRITERIA: AP PROJECTION - Ribs above diaphragm, 1st through 10th posterior ribs. IR – 35x43cm or 30x35cm (lengthwise) - Ribs below diaphragm, 8th through 12th ribs. PPX - Ribs visible through lungs or abdomen. - UNILATERAL EXAM. - UPRIGHT o Ribs opposite side possibly not entirely o Ribs above Diaphragm. included. - SUPINE o Ribs below Diaphragm. AXILLIARY RIBS POSITION OF PART (PP) APO PROJECTION (RPO or LPO POSITION) - MSP Centered. IR – 35x43cm or 30x35cm (lengthwise) - RIBS ABOVE DIAPHRAGM PPX – Upright or Recumbent o IR is 3.8cm above upper border of the relaxed shoulders. POSITION OF PART (PP) o Hands, palms outward against hips or extend arms to vertical position with - Body 45° APO Projection using the RPO or LPO hands under the head. Position. o INSTRUCTION – full inspiration to o Affected side closest to IR. depress diaphragm. o Center affected side on Longitudinal - RIBS BELOW DIAPHRAGM. Plane drawn midway between the MSP o IR crosswise with lower edge at level of and Lateral Surface of body. iliac crests. o Support Elevated Hip o Arms in comfortable position.  If in Recumbent Position. o INSTRUCTION – full expiration to o Abduct arm of affected side and elevate it elevate the diaphragm.  To carry scapula away from rib CR – perpendicular cage. o Rest hand on Head. RP – Center of IR  Upright Position o Hand under or above the head  Recumbent Position o Abduct opposite limb with hand on hip. o Center IR with 3.8cm above upper border of shoulder or lower edge of IR at level of Iliac Crest. CR – perpendicular RP – center of IR INSTRUCTION - End deep EXHALATION. o Ribs below diaphragm.  - End deep INSPIRATION. PAO PROJECTION (RAO or LAO POSITION) o Ribs above diaphragm. IR – 35x43cm or 28x35cm (lengthwise) PPX - UPRIGHT o Image ribs above diaphragm. - RECUMBENT o Image ribs below diaphragm.  Unless contraindicated. POSITION OF PART (PP) - Body 45° RAO or LAO Position. - Affected side AWAY from IR. - RECUMBENT o Rest on forearm and flexed knee of elevated side. - Longitudinal Plane midway between the midline and Lateral surface of body centered. - Top of IR is 3.8cm above upper border of shoulder. SS – Axillary ribs projected free of superimposition. o Ribs above diaphragm. - Lower Edge of IR level of