Radiologic Positioning of Toes and Feet (PDF)

TOES AP/AP AXIAL Projection Because of the natural curve of the toes, the interphalangeal joint spaces are not best demonstrated on the AP projection. When demonstration of these joint spaces is not critical, an AP projection may be performed. An AP axial projection is recommended to open the joint...

TOES AP/AP AXIAL Projection Because of the natural curve of the toes, the interphalangeal joint spaces are not best demonstrated on the AP projection. When demonstration of these joint spaces is not critical, an AP projection may be performed. An AP axial projection is recommended to open the joint spaces and reduce foreshortening Image Receptor: 8x10 (18 X 24 cm) Crosswise for two images on IR Position of patient: Have the patient seated or placed supine on the radiographic table. Position of part :With the patient in the supine or seated position, flex the knees, separate the feet about 6 inches (15cm), and touch the knees together for immobilization. Center the toes directly over one half of the IR or place a 15 degree foam wedge well under the foot and rest the toe near the elevated base of the wedge. Central Ray: Perpendicular through the third metatarsophalangeal joint Structures shown: The image demonstrates the 14 phalanges of the toes; the distal portions of the metatarsals; and, on the axial projections, the interphalangeal joints. Evaluation Criteria: The following should be clearly demonstrated: No rotation of phalanges Open interphalangeal and metatarsophalangeal joint spaces on the axial projections Toes separated from each other Distal ends of the metatarsals Soft tissues and bony trabecular detail  Toes PA Projection Image receptor: 8 x 10 inch (18 x 24 cm) crosswise for two images on one IR Position Of Patient: Have patient lie prone on the radiographic table because this position naturally turns the foot over so that the dorsal aspect is in contact with the IR. Position of Part: Place the toes in the appropriate position by elevating them on one or two small sandbags and adjusting the support to place the toes horizontal. Central Ray: Perpendicular to the midpoint of the IR entering the third metatarsophalangeal joint Structures Shown: This projection will demonstrate the 14 phalanges of the toes, the interphalangeal joints, and the distal portions of the metatarsals. Evaluation Criteria: The following should be clearly demonstrated: No rotation of phalanges Open interphalangeal and metatarsophalangeal joint spaces Toes separated from each other Distal ends of the metatarsals Soft tissues and bony trabecular detail  TOES AP OBLIQUE PROJECTION Medial Rotation Image receptor: 8 x 10 inch (18 x 24 cm) crosswise for two images on one IR Position of patient: Have the patient seated or placed supine on the radiographic table. Position of part :Position the IR half under the toes. Medially rotate the lower leg and foot, and adjust the plantar surface of the foot to form a 30- to 45-degree angle from the plane of the IR. Central Ray: Perpendicular entering through the third metatarsophalangeal joint Structure shown: An AP oblique projection of the phalanges shows the toes and the distal portion of the metatarsals rotated medially Evaluation Criteria: The following should be clearly demonstrated: All phalanges Oblique toes Open interphalangeal and second through fifth metatarsophalangeal joint spaces First metatarsophalangeal joint (not always opened) Toes separated from each other Distal ends of the metatarsals Soft tissue and bony trabecular detail  TOES PA OBLIQUE PROJECTION Medial Rotation Image receptor: 8 x 10 inch (18 x 24 cm) crosswise for two images on one IR Position Of Patient: Have patient lie prone on the radiographic table because this position naturally turns the foot over so that the dorsal aspect is in contact with the IR. Position of Part:Adjust the affected limb in a partially extended position. Have the patient turn toward the prone position until the ball of the foot forms an angle of approximately 30 degrees to the horizontal, or have the patient rest the foot against a foam wedge or sandbag. Central Ray: Perpendicular entering through the third metatarsophalangeal joint. Structure shown: A PA oblique projection of the phalanges shows the toes and the distal portion of the metatarsals rotated laterally. Evaluation Criteria: The following should be clearly demonstrated: All phalanges Oblique toes Open interphalangeal and second through fifth metatarsophalangeal joint spaces First metatarsophalangeal joint (not always opened) Toes separated from each other Distal ends of the metatarsals Soft tissue and bony trabecular detail  Sesamoids: TANGENTIAL PROJECTION Lewis and holly Methods Image receptor: 8 x 10 inch (18 x 24 cm) crosswise for two images on one IR Position of patient: Place the patient in the prone position. Elevate the ankJe of the affected side on sandbags for stability, if needed. Position of part: Rest the great toe on the table in a position of dorsiflexion, and adjust it to place the ball of the foot perpendicular to the horizontal plane Central Ray: Perpendicular and tangential to the first metatarsophalangeal joint Structures shown: The resulting image shows a tangential projection of the metatarsal head in profile Lewis Method and the sesamoids Evaluation Criteria: The following should be clearly demonstrated: Sesamoids free of any portion of the first metatarsal Metatarsal heads NOTE: Holly' described a position that he believed was more comfortable for the patient. With the patient seated on the table, the foot is adjusted so that the medial border is vertical and the plantar surface is at an angle of 75 degrees with the plane of the lR. The patient holds the toes in a flexed position with a strip of gauze bandage. The central ray is directed perpendicular to the head of the first metatarsal bone. Holly Method  Sesamoids TANGENTIAL PROJECTION CAUSTON METHOD Image receptor: 8 x 10 inch (18 x 24 cm) crosswise for two images on one IR Position of patient: Place the patient in the lateral recumbent position on the unaffected side, and flex the knees. Position of part: Partially extend the limb being examined and put sandbags under the knee and foot. Central Ray:Directed to the promjnence of the first metatar ophalangeal joint at an angle of 40 degrees toward the heel. Structures shown: The tangential image shows the sesamoid bones projected axiolaterally with a slight overlap Evaluation Criteria: The following should be clearly demonstrated: First metatarsophalangeal sesamoids with little overlap Occlusal film technjque For improved detail, a similar projection may be performed using an occlusal film.  FOOT AP OR AP AXIAL PROJCETION Radiographs may be obtained by directing the central ray perpendicular to the plane of the IR or by angl ing the central ray to degrees posteriorly. When a 10-degree posterior angle is used, the central ray is perpendicular to the metatarsals, therefore reducing foreshortening. Image receptor: 11 x 12 inch (24 x 30 cm) crosswise for two images on one IR Position of patient: Place the patient in the supine position. Flex the knee of the affected side enough to rest the sole of the foot firmly on the radiographic table. Position of patient: Position the IR under the patient's foot, center it to the base of the third metatarsal, and adjust it so that its long axis is parallel with the long axis of the foot. Central Ray: Directed one of two ways: (1) 10 degrees toward the heel to the base of the third metatarsal, or (2) perpendicular to the IR and toward the base of the third metatarsal Structure shown: The resulting image shows an AP (dorsoplantar) projection of the tarsal anterior to the talus, metatarsals, and phalanges Evaluation Criteria: The following should be clearly demonstrated: No rotation of the foot Equal amount of space between the adjacent midshafts of the second through fourth metatarsals Overlap of the second through fifth metatarsal bases Visual ization of the phalanges and tarsals distal to the talus, as well as the metatarsals  FOOT AP OBLIQUE PROJECTION Medial Rotation Image receptor: 11 x 12 inch (24 x 30 cm) crosswise for Evaluation Criteria: two images on one IR The following should be clearly demonstrated: Position of patient: Place the patient in the supine position. Third through fifth metatarsal bases Flex the knee of the affected side enough to rest the sole free of superimposition of the foot firmly on the radiographic table. Lateral tarsals with Ie s superimposition than in the AP projection Position of part: Place the IR under the patient's foot, Lateral tarsometatarsal and intertarsal joints parallel with its long axis, and center it to the midline of the Sinus tarsi foot at the level of the base of the third metatarsal. Tuberosity of the fifth metatarsal Rotate the patient's leg medjally until the plantar surface of Bases of the first and second metatarsal the foot forms an angle of 30 degrees to the plane of the Equal amount of space between the shafts IR. of the second through fifth metatarsals Central Ray: Perpendjcular to the base of the third Sufficient density to demonstrate the metatarsal phalanges, metatarsals, and tarsals NOTE: A greater rotation can be helpful in demonstrating the joint spaces of the foot. Structure shown: The resulting image shows the interspaces between the following: the cuboid and the calcaneus; the cuboid and the fourth and fifth metatarsals; the cuboid and the lateral cuneiform; and the talus and the navicular bone. The cuboid is shown in profile. The sinus tarsi is also well demonstrated  FOOT AP OBLIQUE PROJECTION Lateral Rotation Image receptor: 11 x 12 inch (24 x 30 cm) crosswise for two images on one IR Position of patient: Place the patient in the supine position. Flex the knee of the affected side enough to rest the sole of the foot firmly on the radiographic table. Position of part: Place the IR under the patient's foot, parallel with its long axis, and center it to the midline of the foot at the level of the base of the third metatarsal. Rotate the patient's leg laterally until the plantar surface of the foot forms an angle of 30 degrees to the plane of the IR. Central Ray: Perpendjcular to the base of the third metatarsal Structure shown: The resulting image show the interspaces between the first and second metatarsals and between the medial and intermediate cuneiforms Evaluation Criteria: The following should be clearly demonstrated: Separate first and second metatarsal bases No superimposition of the medial and intermediate cuneifonns Navicular bone more clearly demonstrated than in the medial rotation Sufficient density to demonstrate the phalanges, metatarsals, and tarsals  FOOT PA OBLIQUE PROJECTION Grashey Method Medial or Lateral Rotation Image receptor: 11 x 12 inch (24 x 30 cm) crosswise for Evaluation Criteria: two images on one IR Position of patient: Place the patient in the prone position. The following should be clearly demonstrated: Elevate the affected foot on sandbag.If desired, place a Heel medially rotated 30 degrees. folded towel under the knee. First and second metatar al bases free of uperimposition Medial cuneiform projected without superimposition Position Part: Adjust the elevation of the patient's Navicular bone seen in profile foot to place its dorsal surface in contact with the IR. Heel laterally rotated 20 degrees Position the lR under the foot, parallel with its long axis, Third through fifth metatarsal bases free of and center it to the base of the third metatarsal. uperimposition To demonstrate the interspace between the first and Tuberosity of the fifth metatarsal and second metatarsals, rotate the heel medially cuboid approximately 30 degrees To demonstrate the interspaces between the second and third, the third and fourth, and the fourth and fifth metatarsals, adjust the foot so that the heel is rotated laterally approximately 20 degrees Central ray: Perpendicular to the base of the third metatarsal Structure shown: The resulting image shows a PA oblique projection of the bones of the foot and the interspaces of the proximal ends of the metatar also  FOOT LATERAL PROJECTION Mediolateral Projection Image receptor: 11 x 12 inch (24 x 30 cm) crosswise for two images on one IR Position of the part: Have the patient lie on the radiographic table and turn toward the affected side until the leg and foot are lateral. Position ot part: Center the IR to the midarea of the foot, and adjust it so that its long axis is parallel with the long axis of the foot. Dorsi flex the foot to form a 90-degree angle with the lower leg. Central Ray: Perpendjcular to the base of the third metatarsal Structures shown: The resulting image shows the entire foot in profile, the ankle joint, and the distal ends of the tibia and fibula Evaluation Criteria: The following should be clearly demonstrated: Metatarsals nearly superimposed Distal leg Fibula overlapping the posterior portion of the tibia Tibiotalar joint Sufficient density to demonstrate the superimposed tarsals and metatarsals  FOOT AP PROJECTION Congenital Clubfoot Kite Methods The typical clubfoot, called taLipes equinovarus, hows three deviations from the normal alignment of the foot in relation to the weight-bearing axis of the leg. Position of patient: Place the infant in the supine poition, with the hip and knees flexed to permit the foot to rest flat on the IR. Elevate the body on firm pil lows to knee height to simplify both gonad shielding and leg adjustment. Position of Part: Rest the feet flat on the IR with the ankles extended slightly to prevent superimposition of the leg hadow. Hold the infant's knees together or in such a way that the legs are exactly vertical (i.e., so that they do not lean medially or laterally). Central ray: Perpendicular to the tarsal, midway between the tarsal areas for a bilateral projection. An approximately 15-degree posterior angle is generally required for the central ray to be perpendicular to the tarsals.  FOOT LATERAL PROJECTION Congenital Clubfoot Kite Methods The Kite method lateral radiograph demonstrates the NOTE: Freiberger, Hersh, and Harrison recommended that anterior talar subluxation and the degree of plantar flexion dorsiflexion of the infant foot could be obtained by (equinus). pressing a smal l plywood board against the sole of the foot. The older child or adult is placed in the upright Position of patient: Place the infant on his or her side in as position for a horizontal projection. With the upright near the lateral position as possible. position the patient leans the leg forward to Position of part: After adjusting the IR under the foot, dorsiflex the foot. place a support that has the same thickness as the IR under the infant's knee to prevent angulation of the foot NOTE: Conway and Cowell recommended tomography for and to ensure a lateral foot po ilion. the demonstration of coalition at the middle facet and particularly for the hidden coalition involving the anterior Central Ray: Perpendicular to mid tarsal facet. Evaluation Criteria: The following should be clearly demonstrated: No medial or lateral angulation of the leg Fibula in lateral projection overlapping the posterior half of the tibia The need for a repeat examination if sl ight variations in rotation are seen in either image when compared with previous radiographs Sufficient density of the talus, calcaneus, and metatarsals to allow assesment of alignment variations.  FOOT AP AXIAL PROJECTION Congenital Clubfoot Kandel Method Kandel recommended the inclu ion of a dorsoplantar axial projection in the examination of the patient with a clubfoot For this method the infant is held in a vertical or a bending- forward position. The plantar surface of the foot should rest on the lR, although a moderate elevation of the heel is acceptable when the equinus deformity is well marked. The central ray is directed 40 degrees anteriorly through the lower leg, as for the usual dorsoplantar projection of the calcaneus  CALCANEUS AXIAL PROJECTION PLANTODORSAL Image receptor: 8 x 10 inch (18 x 24 cm) lengthwise Position of patient: Place the patient in the supine or seated position with the legs fully extended. Position of part: Place the IR under the patient's ankle, centered to the midl ine of the ankle Central ray: Directed to the midpoint of the IR at a cephal ic angle of 40 degrees to the long axis of the foot. The central ray enters the ba e of the third metatarsal. Structures shown: The resulting image shows an axial projection of the calcaneus Evaluaion Criteria: The fol lowing hould be clearly demonstrated: Calcaneus and subtalar joint. No rotation of the calcaneus-the first or fifth metatar als not projected to the sides of the foot. Anterior portion of the calcaneus without excessive density over the posterior portion. Otherwise two images may be needed for the two regions of thickness.  CALCANEUS AXIAL PROJECTION DORSOPLANTAR Image receptor: 8 x 10 inch (18 x 24 cm) lengthwise Position of patient: Place the patient in the prone position. Position of part: Elevate the patient's ankle on andbags. Place the IR against the plantar urface of the foot, and upport it in position with andbags or a portable IR holder Central ray: Directed to the midpoint of the IR at a caudal angle of 40 degrees to the long axis of the foot Structures shown: The resulting image shows an axial projection of the calcaneus and the subtalar joint Evaluation Criteria: The following should be clearly demonstrated: Calcaneus and the subtalar joint. Sustentaculum tali. Calcaneus not rotated-the first or fifth metatar als not projected to the sides of the foot. Anterior portion of the calcaneus without excessive density over posterior portion. Otherwise, two images may be needed for the two regions of thickness.  CALCANEUS LATERAL PROJECTION MEDIOLATERAL Image receptor: 8 x 10 inch (18 x 24 cm) lengthwise Position of Patient: Have the supine patient turn toward the affected side until the leg is approximately lateral. A support may be placed under the knee. Position of Part: Adjust the calcaneus to the center of the IR. Central ray: Perpendicular to the calcaneus. Center about I inch (2.5 cm) distal to the medial malleolus. This will place the CR at the subtalar joint. Structures shown: The resulting radiograph shows the ankle joint and the calcaneu in lateral profile Evaluation Criteria: The following should be clearly demonstrated: No rotation of the calcaneu Density of the sustentaculum tali, lateral tuberosity, and soft tissue Sinus tarsi Ankle joint and adjacent tarsals  SUBTALAR JOINT PA AXIAL OBLIQUE PROJECTION Lateral Rotation The calcaneus has three articular surfaces: anterior, middle, and posterior. These surfaces are located on the superior calcaneu and articulate with theinferior talus. The articulations form the subtalar (talocalcaneal) joint This projection best demonstrates the middle and posterior articulations. Position of patient: Have the patient lie on the affected side in the lateral position. Position of part: Ask the patient to extend the affected limb. Roll the Limb lightly forward from the lateral position. Center the IR 1 to 11; inches (2.5 to 3.8 cm) distal to the ankle joint and adjust it so that its midline is parallel with the long axis of the leg. Central ray: Directed to the ankle joint at a double angIe of 5 degrees anterior and 23 degrees caudal. Structure shown: The resulting image shows the middle and posterior articulation of the subtalar joint and give an "end-on" image of the sinustarsi and an unobstructed projection of the lateral malleolus Evaluation Criteria: The following should be clearly demonstrated: Open subtalar (talocalcaneal) joint articulations Sinus tarsi Lateral malleolus seen in profile  AP AXIAL OBLIQUE PROJECTION BRODEN METHOD Medial Rotation Broden recommended the lateromedial and mediolateral right-angle oblique projection for demonstration of the Evaluation Criteria: The following should be clearly posterior articular facet of the calcaneus to determine the demonstrated: presence of joint involvement in cases of comminuted Anterior and posterior portions of the posterior subtalar fracture. joint Image Receptor: 8 x 10 inch (18 X 24 cm) Position of patient: Place the patient in the supine position. Position of part: Place the IR under the patient's lower leg and heel with its midline parallel with and centered to the leg. Adjust the IR so that the lower edge is about 1 inch (2.5 cm) distal to the plantar surface of the heel. With patient's ankle joint maintained in right-angle flexion, rotate the leg and foot 45 degrees medially, and rest the foot against a 45-degree foam wedge. Central ray: Angled cephalad at 40, 30, 20, and 10 degrees, respectively. Four separate images are obtained. For each image, direct the central ray to a point 2 or 3 cm caudoanteriorly to the lateral malleolus, to the midpoint of an imaginary line extending between the most prominent point of the lateral malleolus and the base of the fifth metatarsal 40 Degrees 30 Degrees 20 Degrees 10 Degrees Structures shown: The anterior portion of the posterior facet is shown best in the 40-degree projection. The 10-degree projection shows the posterior portion. The articulation between the talus and sustentaculum tali (middle facet) is usually shown best in one of the intermediate projections.  AP AXIAL OBLIQUE PROJECTION BRODEN METHOD Laterall Rotation Image Receptor: 8 x 10 inch (18 X 24 cm) Position of Patient: Place the patient in the supine position. Position of part: With the patient's ankle joint held in right-angle flexion, rotate the leg and foot 45 degrees laterally. The foot may rest against a 45-degree foam wedge. Central ray: Directed to a point 2 cm distal and 2 cm anterior to the medial malleolus, at a cephalic angle of 15 degrees for the first exposure. Two or three images may be made with a 3- or 4-degree difference in central ray angulation Structures shown: The posterior facet of the calcaneus is shown in profi le. The articulation between the talus and sustentaculum tali is usually shown. Evaluation Criteria: The following should be clearly demonstrated: Posterior portion of the subtalar joint  LATEROMEDIAl OBLIQUE PROJECTION ISHERWOOD METHOD Medial rotation foot Isherwood1 devised a method for each of the three separate articulations of the subtalar joint: (I) a medial rotation foot position for the demonstration of the anterior talar articular surface, (2) a medial rotation ankle position for the middle talar articular urface, and (3) a lateral rotation ankle position for the posterior talar articular surface. Feistl later described a similar position. Image Receptor: 8 x 10 inch (18 X 24 cm) Position of Patient: Place the patient in a semisupine or eated position, turned away from the side being examined Position of Part: With the medial border of the foot resting on the I R, place a 45-degree foam wedge under the elevated leg. Central Ray: Perpendicular to a point I inch (2.5 cm) distal and I inch (2.5 cm) anterior to the lateral malleolus Structures shown: The resulting image shows the anterior subtalar articular surface and an oblique projection of the tar als Evaluation Criteria: The following hould be clearly demonstrated: Anterior talar articular surface  AP AXIAL OBLIQUE PROJECTION ISHERWOOD METHOD Medial rotation foot Image Receptor: 8 x 10 inch (18 X 24 cm) Position of patient: Have the patient assume a seated position on the radiographic table and turn with body weight resting on the flexed hip and thigh of the unaffected side. Position of part: Ask the patient to rotate the leg and foot medially enough to rest the side of the foot and affected ankle on an optional 30-degree foam wedge Central ray: Directed to a point I inch (2.5 cm) di tal and I inch (2.5 cm) anterior to the lateral malleolus at an angle of 10 degrees cephalad. Structures shown: The resulting image shows the middle articulation of the subtalar joint and an "end-on" projection of the sinus tarsi Evaluation Criteria: The following should be clearly demostrated: Middle (subtalar) articulation Open sinus tarsi  AP AXIAL OBLIQUE ISHERWOOD METHOD Lateral rotation foot Image Receptor: 8 x 10 inch (18 X 24 cm) Position of patient: Place the patient in the supine or seated position. Position of part: Ask the patient to rotate the leg and foot laterally until the side of the foot and ankle rests against an optional 30-degree foam wedge. Central ray: Directed to a point I inch (2.5 cm) distal to the medial malleolus at an angle of 10 degrees cephalad Structures shown: The resulting image shows the posterior articulation of the ubtalar joint in profile Evaluation Criteria: The following should be clearly demonstrated: Posterior subtalar articulation  ANKLE AP PROJECTION Image Receptor: 8 x 10 inch (18 X 24 cm) Position of Patient: Place the patient in the supine position with the affected limb fully extended. Position of part: Adjust the ankle joint in the anatomic position to obtain a true AP projection. Flex the ankle and foot enough to place the long axis of the foot in the vertical position Central Ray: Perpendicular through the ankle joint at a point midway between the malleoli. Structures shown: The resulting image shows a true AP projection of the ankle joint, the distal ends of the tibia and fibula, and the proximal portion of the talus. Evaluation Criteria: The following should be clearly demonstrated: Tibiotalar joint space Ankle joint centered to exposure area Normal overlapping of the tibiofibular articulation with the anterior tubercle slightly superimposed over the fibula Talus slightly overlapping the distal fibula No overlapping of the medial talomalleolar articulation Medial and lateral malleoli Talus with proper density Soft tissue  ANKLE LATERAL PROJECTION MEDIOLATERAL Image Receptor: 8 x 10 inch (18 X 24 cm) Position of patient: Have the supine patient turn toward the affected side until the ankle is lateral Position of part: Place the long axis of the IR parallel with the long axis of the patient's leg and center it to the ankle joint. Ensure that the lateral surface of the foot is in contact with the I R. Central ray: Perpendicular to the ankle joint, entering the medial malleolus Structures shown: The resulting image shows a true lateral projection of the lower third of the tibia and fibula, the ankle joint, and the tarsals Evaluation Criteria: The following should be clearly demonstrated: Ankle joint centered to exposure area Tibiotalar joint well visualized, with the medial and lateral talar domes superimposed Fibula over the posterior half of the tibia Distal tibia and fibula, talus, and adjacent tarsals Den ity of the ankle sufficient to see the outline of distal portion of the fibula  ANKLE AP OBLIQUE PROJECTION MORTISE JOINT MEDIAL ROTATION Image Receptor: 8 x 10 inch (18 X 24 cm) Position of patient: Place the patient in the supine position. Position of part: Center the patient's ankle joint to the IR. Grasp the distal femur area with one hand and the foot with the other. Assist the patient by internally rotating the entire leg and foot together 15 to 20 degrees until the intermalleolar plane is parallel with the IR Central ray: Perpendjcular, entering the ankle joint midway between the malleoli Structures shown: The entire ankle mortise joint should be demonstrated in profile. The three sides of the morti e joint should be visualized Evaluation Criteria: The following hould be clearly demonstrated: Entire ankle mortise joint Talus demonstrated with proper denity No overlap of the anterior tubercle of the tibia and the superolateral portion of the talus with the fibula Talofibular joint space in profile  LEG AP PROJECTION Image receptor: 18 x 43 cm or 35 X 43 cm for two images on one IR Position of patient :Place the patient in the supine position. Position of part: Adjust the patient's body so that the pelvis is not rotated. Adjust the leg so that the femoral condyles are parallel with the IR and the foot is vertical. Central ray: Perpendicular to the center of the leg Structures shown:The resulting image shows the tibia, fibula, and adjacent joints Evaluation Criteria: The following should be clearly demonstrated: Ankle and knee joints on one or more AP projections Ankle and knee joints without rotation Proximal and distal articulations of the tibia and fibula moderately overlapped Trabecular detail and soft tissue for the entire leg  LEG LATERAL PROJECTION Mediolateral Image receptor: 18 x 43 cm or 35 X 43 cm for two images on one IR Position of patient: Place the patient in the supine position. Position of part: Tum the patient toward the affected side with the leg on the IR. Adjust the rotation of the body to place the patella perpendicular to the IR, and ensure that a line drawn through the femoral condyles is also perpendicular. Central ray: Perpendicular to the mjdpoint of the leg Structures shown: The re ulting image shows the tibia, fibula, and adjacent joints EVALUATION CRITERIA The following should be clearly demontrated: Ankle and knee joints on one or more images Distal fibula lying over the posterior half of the tibia Sl ight overlap of the tibia on the proximal fibular head Ankle and knee joints not rotated Possibly no superimposition of femoral condyles because of divergence of the beam Moderate separation of the tibial and fibular bodies, or shafts except at their articular ends Trabecular detail and soft tissue  KNEE AP PROJECTION Radiograph of the knee may be taken with or without use Evaluation Criteria: of a grid. The size of the patient's knee and the preference The following should be clearly demonstrated: of the radiographer and physician are the factors Open femorotibial joint space considered in reaching a decision. Attention is again called Knee fully extended if patient' condition permjts to the need for gonad shielding in examinations of the Interspaces of equal width on both sides if the knee is lower limb. normal Patella completely superimposed on the femur Image receptor: 24 X 30 cm lengthwise No rotation of the femur and tibia Position of patient :Place the patient in the supine position, Slight superimposition of the fibular and adjust the body so that the pelvis is not rotated. head if the tibia is normal Soft tissue around the knee joint Bony detail surrounding the patella on the distal femur Position of part: With the IR under the patient's knee, flex the joint slightly, locate the apex of the patella, and as the patient extends the knee, center the IR about 1/2 inch (1.3 cm) below the patellar apex. This will center the IR to the joint space. Central ray: Directed to a point 1/2 inch (1.3 cm) inferior to the patellar apex. Variable, depending on the measurement between the anterior superior iliac spine (ASIS) and the tabletop. 24 cm 3 to 5 degrees cephalad (large pelvis) Structures shown: The resulting image shows an AP projection of the knee structures  KNEE LATERAL PROJECTION MEDIOLATERAL Image receptor: 24 X 30 cm lengthwise Patella in a lateral profile Open pateliofemoral joint space Position of patient: Ask the patient to turn onto the Fibular head and tibia slightly superimposed affected side. Ensure that the pelvis is not rotated. (Overrotation causes less superimposition, and For a standard lateral projection, have the patient bring the underrotation causes more superimposition.) knee forward and extend the other limb behind it. Knee flexed 20 to 30 degrees All soft tissue around the knee Position of part: A flexion of 20 to 30 degrees is usually Femoral condyles with proper density preferred because this position relaxes the muscles and shows the maximum volume of the joint cavity. To prevent fragment separation in new or unhealed patellar fracture, the knee should not be flexed more than 10 degrees. Central ray: Directed to the knee joint I inch (2.5 cm) distal to the medial epicondyle at an angle of 5 to 7 degrees cephalad. Structures shown: The resulting radiograph shows a lateral image of the distal end of the femur, patella, knee joint, proximal ends of the tibia and fibula, and adjacent soft tissue Evaluation Criteria: The following should be clearly demonstrated: Femoral condyles superimposed (Locate the adductor tubercle on the posterior surface of the medial condyle to identify the medial condyle to determine whether the knee is overrotated or underrotated.) Open joint space between femoral condyles and tibia  INTERCONDYLAR FOSSA PA AXIAL PROJECTION HOLMBLAD METHOD The PA axial, or "tunnel," projection, first described by Evaluation Criteria: Holmblad in 1937, required that the patient assume a The following should be clearly demonstrated: kneeling position on the radiographic table. In 1983 the Open fossa Holmblad method was modified so that if the patient's Posteroinferior surface of the femoral condyles condition allowed, a standing position could be used. Intercondylar eminence and knee joint space Apex of the patella not superimposing Image receptor: 8 x 10 inch (18 X 24 cm) the fossa Position of patient: (1) Standing with the knee of No rotation, evident by sl ight tibiofibular overlap interest flexed and re ting on a stool at the side of the Soft tissue in the fos a and interspaces radiographic table. (2) standing at the side of the Bony detail on the intercondylar eminence, distal femur, radiographic table with the affected knee flexed and and proximal tibia placed in contact with the front of the IR. 3) kneeling on the radiographic table as originally described by Holmblad, with the affected knee over the IR. Position of part: For all positions, place the IR against the anterior surface of the patient's knee, and center the IR to the apex of the patella. Flex the knee 70 degrees from full exten ion (20-degree difference from the central ray. Central ray: Perpendicular to the lower leg, entering the midpoint of the IR for all three positions Structures shown: The resulting image shows the intercondylar fossa of the femur and the medial and lateral intercondylar tubercles of the intercondylar eminence in profile  INTERCONDYLAR FOSSA PA AXIAL PROJECTION CAMP COVENTRY Image receptor: 8 x 10 inch (18 x 24 cm) lengthwise Position of patient: Place the patient in the prone po ition, and adjust the body so that it is not rotated. Position of part: Flex the patient' knee to either a 40- or 50-degree angle, and rest the foot on a suitable support. Center the upper half of the lR to the knee joint; the central ray angulation projects the joint to the center of the IR Central ray: Perpendicular to the long axis of the leg and centered to the knee joint (i.e., over the popliteal depression) Angled 40 degrees when the knee is flexed 40 degrees and 50 degree when the knee i flexed 50 degrees. Structures shown: This axial image demonstrates an unobstructed projection of the intercondyloid fossa and the medial and lateral intercondylar tubercles of the intercondylar eminence Evaluation Criteria: The following should be clearly demonstrated: Open fossa Posteroinferior surface of the femoral condyles Intercondylar eminence and knee joint space Apex of the patella not superimpo ing the fo sa No rotation, evident by slight tibiofibular overlap Soft tissue in the fo sa and interspace Bony detail on the intercondylar eminence, distal femur, and proximal tibia  INTERCONDYLAR FOSSA AP AXIAL PROJECTION BECLERE METHOD Image receptor: 8 x 10 inch (18 x 24 cm) crosswise Position of patient: Place the patient in the supine position, and adjust the body so that it is not rotated. Position of part: Flex the affected knee enough to place the long axis of the femur at an angle of 60 degrees to the long axis of the tibia. Central ray: Perpendicular to the long axis of the tibia, entering the knee joint 1/2 inch (1.3 cm) below the patellar apex Structures shown: The resulting i mage shows the intercondylar fossa, intercondylar eminence, and knee joint Evaluation Criteria: The following should be clearly demonstrated: Open intercondylar fossa Posteroinferior surface of the femoral condyles Intercondylar eminence and knee joint space No superimposition of the fossa by the apex of the patella No rotation, evident by sl ight tibiofibu_x0002_lar overlap Soft tissue in the fossa and interspaces Bony detail on the intercondylar emi_x0002_nence, distal femur, and proximal tibia  PATELLA PA PROJECTION Image receptor: 8 x 10 inch (18 X 24 cm) lengthwise Position of patient: Place the patient in the prone position. Position of part: Center the IR to the patella. Central ray: Perpendicular to the midpopliteal area exiting the patella. Structures shown: The PA projection of the patella provides sharper recorded detail than in the AP projection because of a closer object-toImage receptor distance (OID) Evaluation Criteria: The following hould be clearly demonstrated: Patella completely superimposed by the femur Adequate penetration for vi ualization of the patella clearly through the superimposing femur No rotation  LATERAL PROJECTION Mediolateral Image receptor: 8 x 10 inch (18 x 24 cm) lengthwise Position of patient: Place the patient in the lateral recum_x0002_bent position. Position of part: Ask the patient to turn onto the affected hip. Have the patient flex the unaffected knee and hip, and place the unaffected foot in front of the affected limb for stability. Central ray: Perpendicular to the IR, entering the knee at the midpatellofemoral joint. Structures shown: The reulting image show a lateral projection of the patella and patellofemoral joint space Evaluation Criteria: The following should be clearly demonstrated: Knee flexed 5 to 10 degrees Open patellofemoral joint space Patella in lateral profile Close collimation  PA AXIAL OBLIQUE PROJECTION KUCHENDORF METHOD lateral rotation Image receptor: 8 x 10 inch (18 X 24 cm) lengthwise Position of patient: Place the patient in the prone position. Elevate the hip of the affected side 2 or 3 inches Position of part: Center the IR to the patella. Laterally rotate the knee approximately 35 to 40 degrees from the prone position (this position is more comfortable for the patient than the direct prone, because no pressure is placed on the injured patella. The patient rarely objects to the slight pressure required to displace the patella laterally). Central ray: Directed to the joint pace between the patella and the femoral condyle at an angle of 25 to 30 degrees caudad. It enters the posterior surface of the patella. Structures shown: The resulting image will how a slightly oblique PA projection of the patella, with most of the patella free of uperimposed structures Evaluation Criteria: The following should be clearly demonstrated: Majority of the patella free of superimpoition by the femur Patella and its outline where it i superimposed by the femur  Patella and Patellofemoral Joint TANGENTIAL PROJECTION HUGHSTON METHOD Image receptor: 8 x 10 inch ( 1 8 X 24 cm) for unilateral examination ; 24 X 30 cm crosswise for bilateral examination Position of patient: Place the patient in a prone position with the foot re ting on the radiographic table. Position of part: Place the IR under the patient knee, and slowly flex the affected knee so that the tibia and fibula foml a 50- to 60-degree angle from the table. Central ray: Angled 45 degrees cephalad and directed through the patellofemoral joint Structures shown: The tangential image shows ubluxation of the patella and patellar fractures and allows radiologic a sessment of the femoral condyle. Hughston recommended that both knees be examined for comparison Evaluation Criteria: The following should be clearly demonstrated: Patella in profile Open patellofemoral articulation Surfaces of the femoral condyles Soft tissue of the femoropatellar articulation Bony recorded detail on the patella and femoral condyles  Patella and Patellofemoral Joint TANGENTIAL PROJECTION MERCHANT METHOD Image receptor: 24 x 30 cm cross_x0002_wise for bilateral examination SID: A 6-foot (2-m) SID is recommended to reduce magnification. Position of patient: Place the patient supine with both knees at the end of the radiographic table. Support the knees and lower legs by an adjustable IR- holding device Position of part: Using the "axial viewer" device, elevate the patient's knees approximately 2 inches to place the femora parallel with the tabletop Central ray: Perpendicular to the IR. With 40-degree knee flexion, angle the central ray 30 degrees caudad from the horizontal plane (60 degrees from vertical) to achjeve a 30- degree central ray to-femur angle. The central ray enters midway between the patellae at the level of the patellofemoral joint. Structures shown: The bilateral tangential image demonstrate an axial projection of the patellae and patellofemoral joints Evaluation Criteria: The following should be clearly demonstrated: Patellae in profile Femoral condyle and intercondylar sulcus Open patellofemoral articulations  Patella and Patellofemoral Joint TANGENTIAL PROJECTION SETTEGAST METHOD Image receptor: 8 x 10 inch (18 X 24 Col) Evaluation Criteria: The following should be clearly demonstrated: Position of patient: Place the patient in the supine or prone position. Patella in profile The latter is preferable because the knee can usually be flexed to a Open patel lofemoral articulation greater degree and immobil ization is easier Surfaces of the femoral condyle Position of part: Flex the patient' knee lowly as much Soft tissue of the patellofemoral articulation as possible or until the patella is perpendicular to the IR if Bony detail on the patella and femoral the patient' condition permits. With slow, even flexion, condyles the patient will be able to tolerate the position, whereas quick, uneven flexion may cause too much pain. Place the IR transversely under the knee, and center it to the joint space between the patella and the femoral condyles. By maintaining the same OID and SID relationships, this position can be obtained with the patient in a lateral or seated position Central ray: Perpendicular to the joint space between the patella and the femoral condyles when the joint is perpendicular. When the joint is not, the degree of central ray angulation depends on the degree of flexion of the knee. The angulation typically will be 15 to 20 degrees. Structures shown: The resulting image hows vertical fractures of bone and the articulating surfaces of the patel lofemoral articulation