UCSD Musculoskeletal Radiology

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Radiographic MSK Projections

 

Head to toe radiographic projections.  Click on the hyperlinks for technique.  Use the back arrow to return to the images.

Head -> Sternum.  Clavicle -> Fingers.  Chest -> Toes

Skull                                   

                                               Townes                    AP                   Lateral

Face                                    

                                                  Lat                       OF                       OM                  OM30

Orbits                                

                                                 OF                       OM                     Lat

Eyes FB                          

                                         Looking down        Looking Up

Nasal bones                   

                                            Lt lat                     Rt lat                    OF

Mandible                             

                                               OF               Reverse OF               Lt Lat                 Rt Lat

Cervical Spine                           

                                             Lateral                    AP                   Open Mouth           Swimmers    

Cx spine extras                       

                                       Lateral Extension    Lateral Flexion      Oblique LPO       Oblique RPO              Fuchs

Sternoclavicular Joint       

                                            PA                        Obl               AP Serendipity

Sternum                       

                                            Lat                     RAO                  LAO

Clavical                         

                                              AP             10 deg cephalad

Acromioclavicular joint     

                                        AP with weight   AP without weight

Scapula                         

                                        Scapula Lat       Scapula AP Ab

Shoulder                                   

                                     External rotation    Neutral rotation     Internal rotation        Grashey               Lateral                    Axial

Shoulder extra                   

                                        Stryker notch          Westpoint              Velpeau

Humerus                             

                                        Proximal Lat          Proximal AP          Distal Lat             Distal AP

Elbow                                     

                                              AP                     Lateral              Supinated Obl     Pronated Obl          Radial head         Cubital tunnel

 

Forearm                         

                                                AP                    Lat

Wrist                                   

                                            Lat                         Obl                       PA

Wrist   extras                      

                                        Clenched fist            Scaphoid            Carpal tunnel

Hand                                

                                              PA                  Ballcatchers           Norgard

Fingers                                 

                                             Lateral 3                 Obl                    Lateral 4                 PA

Thumb                              

                                             Lateral                     PA                   PA hand

Ribs                                     

                                                  PA                        Lat                       RAO            Coned bb

Thoracic Spine                     

                                               AP                    Lateral                     RPO                    LPO

Scolosis series                  

                                            AP                           Lat

Scolosis lateral bending    

                                              AP                       Rt flex                 Lt flex

Lumbar Spine                      

                                            Lat                      AP                        RPO                    LPO                     Flex                     Ext

Sacrum and Coccyx       

                                          Lateral                  Inlet                       AP

Sacroiliac joints            

                                            AP                    RPO                    LPO

Pelvis                                     

                                       Pelvis AP         Pelvis frog leg  Shoot through lateral

Pelvis extras             

        Inlet/Outlet                Inlet                  Outlet

Pelvis extras             

        Obliques            RPO oblique       LPO oblique

Pelvis extras                        

      Judet views            Lt iliac LPO    Rt obturator LPO  Lt obturator RPO     Rt iliac RPO

Hip chronic             

                                        AP                 Frog lateral

Hip chronic extras    

                                     Dunn 90            False profile

Hip trauma                          

                                      Pelvis AP      Shoot through lateral

Femur trauma                  

                                        AP upper            AP lower              Lat upper             Lat lower

Femur non trauma         

                                      AP upper            AP lower              Lat upper             Lat lower

Limb length                     

                                    With grid

                                        Iliac                      Hips

Limb alignment       

                                    AP standing

Knee                                 

                                         AP                     Lat                       Obl IR                   Obl ER          Shoot X Table           Merchant

Knee extras              

                                 Rosenberg                Sunrise

 

Tibia/Fibula                

                                            AP                     Lat

Ankle                               

                                        Lat                    Lat WB               Mortise                  AP WB            

Subtalar joint              

                                      Broden           Broden neutral  Broden Inversion stress

Heel                         

                                       Axial                    Lat

Foot                             

                                         PA                        Obl                    Lat                    Sessamoid

Toes                           

                                          Obl                      PA                       Lat

 

                                                                                       CRANIUM RADIOGRAPHY

 

I.                   Use 40" SID and small focal spot whenever possible.

II.                All requests will need to be evaluated by the Neuroradiologist.    Study of choice is usually CT/MRI.

III.             For best images, always use the smallest receptor size.

 

 

 

CRANIUM

 

 

Exams/Views

 

 

Image receptor size and orientation

 

 

Patient position relative to image receptor

 

 

Central ray (CR) direction

 

SKULL SERIES

 

 

4.                  PA - zero (0) tube     angle

 

 

10x12 LW

 

 

OML perpendicular, MSP perpendicular

 

 

CR perpendicular to image receptor, exits at glabella

 

 

5.                  PA Caldwell- 23º tube angle

 

 

10x12 LW

 

 

OML perpendicular, MSP perpendicular

 

 

CR 23°caudad, exits at nasion

 

 

6.                  AP axial (Townes)

 

 

10x12 LW

 

 

OML perpendicular, MSP perpendicular

 

 

CR 30° caudad, exits inion

 

 

7.                  Submentovertex (SMV)

 

 

10x12 LW

 

 

IOML parallel, MSP perpendicular.  Project mandible beyond the nasal septum and ethmoid air cells.

 

 

CR perpendicular to IOML, enters midway between gonion

 

 

8.                  Lateral - affected side

 

 

10x12 CW

 

 

IOML perpendicular to front edge of image receptor, MSP parallel, IPL perpendicular

 

 

CR perpendicular to 2" (5cm) superior to EAM

 

FACIAL BONES SERIES

 

1.                  Parietoacanthial     projection (Waters)

 

10x12 LW

 

OML forms an angle of 37º to image receptor, MSP perpendicular

 

CR perpendicular, exits at the acanthion

 

2.                  PA Caldwell

 

10x12 LW

 

OML perpendicular, MSP perpendicular

 

CR 23° caudal, exits at nasion

 

3.                  Lateral

 

10x12 LW

 

IOML perpendicular to front edge of image receptor, MSP parallel, IPL perpendicular, affected side to image receptor

 

CR perpendicular to outer canthus

 

4.                  Submentovertex

(SMV)

 

10x12 LW

 

IOML parallel to image receptor (neck hyperextended),

MSP perpendicular

 

CR perpendicular to IOML, enter midway between gonion

 

MANDIBLE

 

 

1.                  PA mandible

 

 

8x10 CW

 

 

OML perpendicular, MSP perpendicular

 

 

CR perpendicular, enters at the level of the gonion to exit at lips

 

 

2.                  AP axial (Townes)  open mouth

 

 

8x10 LW

 

 

OML perpendicular, MSP perpendicular, patient to have mouth open, if possible

 

 

CR 35° caudad, enters 3" above nasion, passes through TMJ's.

 

 

3.                  Right lateral oblique

 

 

 

8x10 CW

 

 

MSP forms 15° angle to image receptor, chin extended anterior to cervical spine.  (Total angle of tube + patient = 35.)

 

 

CR 20° cephalic, enters midway between gonion

 

 

4.                  Left lateral oblique

 

 

 

8x10 CW

 

 

MSP forms 15° angle to image receptor, chin extended anterior to cervical spine.  (Total angle of tube + patient = 35.)

 

 

CR 20° cephalic, enters midway between gonion

 

NASAL BONES - Always image both laterals.

 

 

1.                  Parietoacanthial  projection  (Waters)

 

 

8x10 LW

 

 

OML forms an angle of 37°, MSP perpendicular.  Collimate to 5" by 5".

 

 

CR perpendicular, exits at acanthion

 

 

2.                  Right lateral

 

 

8x10LW

 

 

IOML perpendicular to front edge of image receptor, MSP parallel, IPL perpendicular

 

 

CR perpendicular, 1" (2cm) above nasion

 

 

3.                  Left lateral

 

 

8x10LW

 

 

IOML perpendicular to front edge of image receptor, MSP parallel, IPL perpendicular

 

 

CR perpendicular, 1" (2cm) above nasion

 

ORBITS (Study of choice is CT.  Refer all requests to Neuroradiologist for protocol.)

 

 

1.                  PA Caldwell

 

 

8x10 LW

 

 

OML perpendicular, MSP perpendicular

 

 

CR angled 23° caudad, exits at nasion

 

 

2.                  Lateral

 

 

8x10 LW

 

 

IOML perpendicular to front edge of image receptor, MSP parallel, IPL perpendicular

 

 

CR perpendicular to outer canthus

 

ORBITS - FOREIGN BODY (MRI screening)

 

 

1.                  Modified Parieto-

acanthial (Waters)

EYES LOOKING UP

 

 

8x10 LW

 

 

 

OML forms angle of 55°  with image receptor, MSP perpendicular

 

 

 

CR perpendicular, exits at acanthion

 

 

2.                  Modified Parieto-

acanthial (Waters)

EYES LOOKING DOWN

 

 

8x10 LW

 

 

 

OML forms angle of 55°  with image receptor, MSP perpendicular

 

 

 

CR perpendicular, exits at acanthion

 

 

MUSCULOSKELETAL

 

Write time of exam on all bone films.  Films taken in surgery, portables, trauma, E.D. often have multiple studies; times are needed to sort films.  For acute injuries, follow trauma protocol or other methods as directed by Radiologist.

 

If patient has internal fixators/prosthesis, always include the entire length of the fixator/prosthesis.

 

USE GONADAL SHIELDING WHENEVER PRIMARY BEAM IS WITHIN 5 CM OF GONADS.

 

 

UPPER EXTREMITIES

Exams/Views to be done

Cassette size, type

 and orientation

     Patient position relative to film

Central ray (CR) direction

FINGERS  (For acute injuries, film the PA hand and oblique/lateral of the affected digit.)  For thumb series, see next entry.

1.  PA Hand

½ of 10x12 LW, LFC, tabletop

Pronate hand onto extremity cassette, include all digits on radiograph. Flatten hand in cassette whenever possible.

CR perpendicular to base of third (3rd) metacarpal

2.  Oblique of digit

1/4 of 10x12 LW

Rotate hand laterally 45E, separate fingers

CR perpendicular to proximal PIP

3.  Lateral of digit

1/4 of 10x12 LW

Rotate hand into lateral position, separate affected finger and place closest to film

CR perpendicular to proximal PIP

THUMB

Follow protocol above.  PA hand position shows the thumb in oblique position.  Series will include:

1.  PA hand          2.  Lateral Thumb          3.  AP thumb

HAND   (Include the wrist on hand films.) 

1.  PA hand

½ of 10x12 CW

Pronate hand onto extremity cassette.  Flatten hand whenever possible and include wrist in collimation.

CR perpendicular to the base of third (3rd) metacarpal

2.  Oblique hand

½ of 10x12 CW

Rotate hand laterally 45E, separate fingers

CR perpendicular to third metacarpal

3.  Lateral hand

8x10 LW

Rotate hand 90E, thumb parallel to film, fingers "fanned" to avoid superimposition

CR perpendicular to second metacarpal

WRIST  (Non-trauma)

1.  PA

½ of 8x10 CW

Pronate hand, flex fingers to position wrist closer to film.

CR perpendicular to midcarpal

2.  Lateral

½ of 8x10 CW

Rotate hand and wrist 90E, elbow flexed 90E

CR perpendicular to midcarpal

WRIST - (Acute injuries)

1.  PA

½ of 8x10 CW

Same as described above for chronic conditions. 

Same as described above.

2.  Lateral

½ of 8x10 CW

Same as described above for chronic conditions. 

Same as described above.

3.  Ulnar oblique

½ of 8x10 CW

Rotate hand and wrist laterally 45E, elbow flexed 90E

CR perpendicular to midcarpal

WRIST - (Acute injuries)

4.  Radial oblique

½ of 8x10 CW

Pronate hand, have patient move hand laterally as much as possible without lifting or rotating forearm

CR angled 20E toward elbow, centered to scaphoid

5.  Navicular view

 

 

 

FOREARM

1.  AP  (Include BOTH

     joints on each film.)

½ of 11x14 LW

Supinate hand and forearm. 

CR perpendicular to mid-forearm

2.  Lateral - flex elbow 90E

½ of 11x14 LW

Flex elbow 90E,  rotate hand and wrist to lateral position; have hand, elbow and humerus in the same plane. 

CR perpendicular to mid-forearm

ELBOW  (Non-trauma, chronic injuries)

1.  AP

½ of 10x12 CW

Supinate forearm, fully extended

CR perpendicular to elbow joint

2.  Lateral

½ of 10x12 CW

Flex elbow 90E, have forearm and humerus in the same plane, wrist and elbow in true lateral 

CR perpendicular to elbow joint

ELBOW  (Trauma, acute injuries)

1.  AP

½ of 10x12 CW

Same as described above for chronic conditions. 

Same as described above.

2.  Lateral

½ of 10x12 CW

Same as described above for chronic conditions. 

Same as described above.

3.  Lateral oblique (radial)

½ of 10x12 CW

Forearm fully extended, supinate hand and laterally rotate arm to form an angle of 45E off film 

CR perpendicular to elbow joint

4.  Medial oblique (ulnar)

½ of 10x12 CW

Forearm fully extended, pronate hand

CR perpendicular to elbow joint

5.  Radial head view

8x10 LW

Elbow in true lateral, flexed 90E, humerus and wrist in same plane

CR angled 45E towards humerus, enters at radial head

HUMERUS

1.  AP - include BOTH  

     joints

14x17 LW

Patient supine or upright, supinate hand and arm, fully extended

CR perpendicular to mid-humerus

2.  Lateral - include

     BOTH joints

14x17LW

Patient supine or upright, abduct arm and flex elbow 90E, rotate humerus 90E from AP

CR perpendicular to mid-humerus

SHOULDER  (Non trauma, chronic pain)

1.  AP - internal rotation

10x12 CW

Patient supine or upright, rotate arm internally until epicondyles of humerus are perpendicular to film

CR perpendicular to glenoid fossa

2.  AP - external rotation

10x12 CW

Patient supine or upright, rotate arm externally to place epicondyles parallel to film

CR perpendicular to glenoid fossa

SHOULDER  (Trauma, acute injuries -  perform the following procedures)

 

1.  AP - neutral position

10x12 CW

Patient supine or upright, do not rotate arm.

CR perpendicular to glenoid fossa

2.  Lateral "Y" view -

    patient placed PA

10x12 LW

Patient PA , rotate patient's non-affected side away from film until scapula is perpendicular to film, the affected shoulder usually forms angle of 60E with film

CR perpendicular to mid vertebral border of scapula

SHOULDER - ADDITIONAL VIEWS   (As directed by radiologist.)

1.  Axillary view

8x10 CW

Abduct arm 90E away from body, supinate hand, rotate head away, place cassette firmly against shoulder and neck

CR perpendicular to glenoid fossa

3.  Supraspinatus view

     (Bigliani method)

8x10 LW

Follow positioning protocol for Lateral "Y" view

CR angled 15E caudad, enters at coracoid process

CLAVICLES

1.  AP - 0 tube angle

10x12 CW

Patient supine or upright with no rotation

CR perpendicular to mid-clavicle

2.  AP - axial view

10x12 CW

Patient supine or upright with no rotation

CR angled 20E cephalic

ACROMIOCLAVICULAR JOINTS (AC)

1.  AP - non-weight

             bearing

(Use 72" SID)

14x17 CW to include both joints or two 8x10 CW for each AC joint

Patient upright in AP position, equal weight on both feet, no rotation, arms relaxed at sides. patient to suspend respiration during exposure.  Always include both joints bilaterally.

CR perpendicular to AC joints

2.  AP - weight bearing

 

Follow non-weight bearing protocol, add 10 pound weights to each hand.   Always include both joints bilaterally.  Strap weights to wrist for optimum films.

CR perpendicular to AC joints

SCAPULA

1.  AP

10x12 LW

Patient supine or upright, rotate patients body until scapula rests on table, abduct affected arm 90E away from trunk, flex elbow for patient comfort

CR perpendicular to mid-scapula

2.  Lateral

10x12 LW

Patient PA, recumbent or erect, rotate patient's non-affected side away from Bucky until the scapula is lateral, angle of affected shoulder and film will be approximately 60E

CR perpendicular to mid-scapula

LOWER EXTREMITIES

TOES  (AP view of foot to be done with acute injuries, otherwise AP of affected toe only.)

1.  AP foot

½ of 10x12 LW

Place sole of foot flatly on cassette in dorsal plantar position

CR angled 5E-10E to base of third (3rd) metatarsal

2.  Medial oblique of

     affected toe(s)

1/4 of 10x12 LW

From AP position, internally rotate foot 45E

CR perpendicular to proximal PIP joint

3.  Lateral of toe(s)

1/4 of 10x12 LW

Rotate foot towards affected side, until foot is in lateral position

CR perpendicular to proximal PIP joint

FOOT

1.  AP (Dorsoplantar)

½ of 10x12 LW

Plantar surface of foot against film, with no rotation

CR angled 5E-10E to base of third (3rd) metatarsal

2.  Medial Oblique

½ of 10x12 LW

Rotate foot medially 45E

CR perpendicular to base of third (3rd) metatarsal

3.  Medial-Lateral Lateral

½ of 10x12 LW

Rotate foot laterally until foot is in lateral position

CR perpendicular to base of third (3rd) metatarsal

FOOT (WEIGHT- BEARING)

1.  AP

½ of 10x12 LW

Patient upright, follow positioning protocol above

CR angled 5E-10E to base of third (3rd) metatarsal

2.  Lateral

½ of 10x12 LW

Patient upright, follow positioning protocol above

Horizontal CR perpendicular to base of third (3rd) metatarsal

3.  Oblique

½ of 10x12 LW

Patient upright, foot in Dorsoplantar position

CR angled 45E medially to base of third (3rd) metatarsal

OS CALCIS

1.  Lateral calcaneus

½ of 8x10 CW

Place foot in mediolateral position

CR perpendicular to mid-calcaneus

2.  Axial plantodorsal

½ of 8x10 CW

Place plantar surface perpendicular to film

CR angled 40E with long axis of the foot, to base of 3rd metatarsal

ANKLE

1.  AP

½ of 10x12 CW

Place foot so that plantar surface of foot is perpendicular to film

CR perpendicular to ankle joint

2.  Mortise

½ of 10x12 CW

From AP position, rotate leg medially 10E -15E until intermalleolar line is parallel to film

CR perpendicular to ankle joint

3.  Mediolateral lateral

8x10 LW

From AP position, rotate leg, foot and ankle towards affected side until foot is in lateral position

CR perpendicular to medial malleolus

TIBULA FIBULA

1.  AP

14x17 on diagonal

Patient supine, leg fully extended, no rotation on pelvis or leg

CR perpendicular to mid-tibia

2.  Mediolateral lateral

14x17 on diagonal

Patient to lie on affected side, ensure affected leg is in lateral position with the unaffected side anterior to part

CR perpendicular to mid-tibia

KNEE  - Non -trauma, chronic injury

 

 

 

 

1.  AP

10x12 LW

Patient supine, leg extended, femoral epicondyles parallel to table.  Perform erect if standing films ordered.

CR perpendicular to 1cm inferior to patellar apex

2.  Mediolateral lateral

10x12 LW

Patient to lie on affected side, unaffected leg anterior to part, knee flexed about 45E

CR angled 5E cephalic, to a point 1cm distal to epicondyle

KNEE - Trauma, acute injury

1.  AP

10x12 LW

Same as described above.

Same as described above.

2.  Mediolateral lateral

10x12 LW

Same as described above.

Same as described above.

3.  Lateromedial Cross

     table lateral

10x12 CW

Patient supine, part raised above tabletop, do not flex knee for cross-table lateral.

Horizontal CR perpendicular to knee joint

KNEE ADDITIONAL VIEWS - upon radiologist's approval

4.  Medial oblique

10x12 LW

From AP position, rotate knee medially 45E

CR perpendicular to 1 cm inferior to patellar apex

5.  Lateral oblique

10x12 LW

From AP position, rotate knee laterally 45E

CR perpendicular to 1 cm inferior to patellar apex

PATELLA

1.  PA

8x10 LW

Patient supine or upright, femoral epicondyles parallel to film, leg fully extended

CR perpendicular to mid-patella

2.  Mediolateral Lateral

8x10 LW

Patient to lie on affected side, with unaffected leg anterior, knee flexed 5E

CR perpendicular to mid-patella

3.  Merchants View -

     bilateral patellar view

11x14 CW

Patient supine with legs flexed over Merchant board

30E-45E, knees close together, film to lie on distal tibias

CR angled caudal parallel to patella, enters at joint space

4.  Axial projection

     (Sunrise method)

8x10 LW

Patient prone, knee flexed to maximum patient ability

CR angled cephalic so that there is a 45E with tibia

FEMUR - Include both joints on films if possible

1.  AP - to include knee

     and distal femur

14x17 LW

Patient supine, leg fully extended, femoral epicondyles parallel to film

CR perpendicular centered to include knee joint

2.  AP - to include hip

      and proximal femur

11x14 LW

Position patient and part exactly as above if performing two exposures.

CR perpendicular to include hip joint

3.  Mediolateral Lateral -

     to include knee

14x17 LW

Patient to lie on affected side, unaffected leg anterior to part, flex knee 45E

CR perpendicular to include knee joint

4.  Lateral frog-leg hip

11x14 LW

Patient supine, flex knee and fully abduct leg

CR perpendicular to femoral neck

HIPS - Non-trauma, chronic injury

1.  AP Pelvis

14x17 CW

Patient supine, legs fully extended and internally rotated 15E

CR perpendicular to MSP 2" inferior to ASIS

2.  Frog-leg lateral of

     affected hip

10x12 LW or

11x14 LW to include prothesis

Patient supine with knee flexed and knee fully abducted.  For older patients, you may oblique body slightly toward side of interest.

CR perpendicular to femoral neck

HIPS - Trauma, acute injury

1.  AP Pelvis

14x17 CW

Follow positioning protocol above for AP pelvis.

Same as above AP pelvis

2.  Translateral lateral of

     affected hip

10x12 CW or

11x14 CW

Flex and elevate unaffected leg, place cassette vertically on table lateral to affected hip.  Place cassette high enough to include femoral head.

Horizontal CR perpendicular to femoral neck

SACROILIAC JOINTS

1.  AP Pelvis

14x17 CW

Follow positioning protocol above for AP pelvis.

Same as above AP pelvis

2.  AP axial

10x12 LW

Patient in AP position.

CR angled 20E cephalic to mid sacrum

ACETABULUM (JUDET VIEWS) - include iliac crest to ischial tuberosities, collimate to affected side only

1.  AP Pelvis - if not taken

     previously for current

     injury

14x17 CW

Follow filming protocol for AP pelvis above

2.  Right Posterior Oblique

11x14 LW

Rotate body into 45E RPO, include iliac crest and ishial tuberosities on film

CR perpendicular to affected hip joint

3.  Left Posterior Oblique

     (LPO)

11x14 LW

Rotate body into 45E  LPO, include iliac crest and ishial tuberosities on film

CR perpendicular to affected hip joint

PELVIS - include Inlet/Outlet views only if requested

1.  AP Pelvis

14X17 LW

Follow AP pelvis protocol above

2.  AP axial outlet view

14x17 LW

Patient supine in AP pelvis position, include iliac crest and ischial tuberosities on film

Male: CR angled 20E-30E cephalic to 2 cm superior to symphysis pubis

Female: CR angled  30E to 45E  cephalic

3.  AP axial inlet view

14x17 LW

Patient supine in AP pelvis position, include iliac crest and ischial tuberosities on film

Male: CR angled 20E-30E caudal to ASIS

Female: CR angled  30E to 45E  caudal

MISCELLANEOUS BONE STUDIES

SCAN-O-GRAM:  Place and tape scanogram ruler under patient before positioning.  Must include ruler markings from iliac crest to ankle!  Use two (2) 14x17 cassettes.  DO NOT MOVE PATIENT ON THE RULER ONCE YOU HAVE BEGUN FILMING!  Show both right and left joint spaces.  In some cases, the joint spaces may not be in the same transverse plane.  In these cases, center between the two joints.

1.  AP - wing of pelvis

½ of 14x17 CW

Patient supine, legs fully extended in AP position

CR perpendicular to iliac crest

2.  AP - hip joint

½ of 14x17 CW

Same as above

CR perpendicular to hip joint

3.  AP - knee joints

½ of 14x17 CW

Same as above

CR perpendicular to knees

4.  AP - ankle joints

½ of 14x17 CW

Same as above

CR perpendicular to ankles

       

LEG ALIGNMENT - include joints from hip to ankle

  AP only (72" SID)

14x56 LW

Patient supine or upright, equal weight in each foot

CR perpendicular to include hip to ankle joints

 

ARTHRITIS JOINT SURVEY - Review each request with Bone radiologist for filming.  See previous sections for positioning criteria.

1.  AP/Lateral C-spine

2.  AP/Lateral

    T-spine

3.  AP/Lateral L-spine

4.  AP bilateral shoulders

5.  AP/Lateral bilateral knees

5.  AP/Lateral

   bilateral knees

6.  AP pelvis

6.  AP/Lateral bilateral ankles (include heel on     lateral views)

7. AP/Oblique/Lateral bilateral hands (to  include wrists)

8.  AP/Oblique bilateral feet

METASTATIC BONE SURVEY - Review each request with Bone radiologist for filming.

1.  Left lateral skull

3.  AP/Lateral

     C-spine

5.  AP/Lateral L-spine

7.  AP/Lateral bilateral

      humerus (to include

     shoulders)

9.  AP/Lateral bilateral

     forearms

2.  AP ribs, bilaterally

4.  AP/Lateral

    T-spine

6.  AP pelvis

8.  AP/Lateral bilateral

     femurs

10. AP/Lateral bilateral

      tibia/fibulas

CHONDROCALCINOSIS - Recurrent arthritis survey (pseudogout).  Review each request with Bone radiologist for filming.

1.  AP/Lateral bilateral

     hands to include wrists

2.  AP pelvis

3.  AP/Lateral bilateral

      knees

Knees are the most affected joints in pseudogout.

 

BONY THORAX

Exams/Views to be done

Cassette size, type

 and orientation

     Patient position relative to film            

Central ray (CR) direction

STERNUM

1.  Right anterior oblique

10x12 LW

Patient prone in 15E - 20E RAO to superimpose sternum on heart shadow, breathing technique

CR perpendicular to mid-sternum

2.  Lateral

10x12 LW

Patient upright in lateral position if possible, filmed on inspiration

CR perpendicular to mid-sternum

STERNO-CLAVICULAR JOINTS - Study of choice is CT.  Consult Radiology Bone  Fellow for protocol

RIBS: Trauma, acute injury (PA chest film usually done to evaluate for pneumothorax.  Review each request with chest radiologist.)

1.  AP or PA. 

Above diaphragm: 11x14LW or 14x17LW

Below diaphragm:

14x17 CW

Patient erect if possible, place patient to have affected side toward film (anterior vs posterior).  Above diaphragm, film taken on inspiration; below diaphragm, film taken on expiration

Above and below diaphragm: CR perpendicular to affected rib(s)

2.  Oblique

As stated above

From AP, rotate body 45E toward the site of injury.

From PA, rotate body 45E  away from site of injury

Same as above.  The distance between the spine and lateral rib margin on the affected side should be two times larger than the unaffected side.

RIBS - Non-trauma, chronic injury or to evaluate metastases  (Usually done after bone scan of affected area.)

1.  AP - above and below

    diaphragm

Same as above.

Follow positioning above.

Follow above protocol.

2.  Oblique - above and

     below diaphragm

Same as above.

Follow positioning above.

Follow above protocol.

CERVICAL SPINE - always include all views on new patients or following new injury.

1.  AP

10x12 LW

Patient supine or upright, neck slightly extended with no rotation.  Mastoid tip should be superimposed on the gonion.

CR angled 10E cephalic to

C-4

2.  Lateral  (Use 72" SID

     whenever possible)

10x12 LW

Patient supine or upright, film taken on expiration, shoulders relaxed to lower humeral heads

CR perpendicular to C4, include C1- T1 on film

3.  AP odontoid

     (open mouth)

8x10 LW

Patient supine or upright, open mouth, flex neck to have line from upper teeth to skull base perpendicular to table

CR parallel to the line from the teeth to skull base

4.  Swimmer's view - to

     visualize C7-T1

10x12 LW

Patient supine or upright, place left side against film, vertically raise left arm and relax right arm to side of the body.

CR perpendicular to C4 (An angle of 5E  caudal may be needed to separate shoulders)

       

CERVICAL SPINE - Additional views - to be done on approval of bone radiologist

1. Right anterior oblique

10x12 LW

Place patient into 45E  RAO

CR angled 10E -15E  caudal to C-4

2.  Left anterior oblique

10x12 LW

Place patient into 45E  LAO

CR angled 10E -15E  caudal to C-4

3.  X-table Lateral.  Show    film to radiologist prior     to moving patient

10x12 CW

Follow positioning protocol above.

Horizontal CR perpendicular to C4.

THORACIC SPINE

1.  AP

14x17 LW

Patient supine or upright, film taken on inspiration

CR perpendicular to T7, 3"(7.5cm) below sternal angle

2.  Lateral

14x17 LW

Patient in left lateral, erect or recumbent, breathing technique preferred, otherwise on inspiration.

CR perpendicular to T7

THORACIC SPINE - additional views

1.  Swimmer's (If area of

     interest is T1-T4.)

10x12 LW

Follow positioning protocol for Swimmers described in cervical spine section

Follow protocol for cervical swimmers view EXCEPT central ray to C7..

2.  Right Posterior Oblique

14x17 LW

From AP position, rotate right side up from film 70E

CR perpendicular to T7

3.  Left Posterior Oblique

14x17 LW

From AP position, rotate left side up from film 70E

CR perpendicular to T7

LUMBAR SPINE - Include AP pelvis if patient has not had a pelvis within the last three months.  Schedule and bill patient for single view pelvis.

1.  AP pelvis

14x17 CW

Follow positioning protocol for AP pelvis previously described

Follow protocol previously described

2.  AP L-spine

11x14 LW

Patient supine with hips and knees flexed

CR perpendicular to L2, 3 cm superior to iliac crest

3.  Lateral L-spine

11x14 LW

Patient in left lateral position, knees flexed, use supports to place spine parallel to table

CR perpendicular to iliac crest

LUMBAR SPINE  - additional views

1.  Right Posterior Oblique

     L-spine

11x14 LW

From AP position, rotate body to the right 45E

CR perpendicular to iliac crest, 2" (5cm) medial to ASIS

2.  Left Posterior Oblique

     L-spine

11x14 LW

From AP position, rotate body to the left 45E

CR perpendicular to iliac crest, 2" (5cm) medial to ASIS

3.  Flexion Lateral L-spine

11x14 LW

Patient in lateral position, maximum patient flexion

CR perpendicular to iliac crest

4.  Extension Lateral

     L-spine

11x14 LW

Patient in lateral position, maximum patient extension

CR perpendicular to iliac crest

5.  L5-S1 Lateral

10x12 LW

Patient in lateral position

CR perpendicular to L5-S1 3cm inferior to iliac crest

SACRUM

1.  AP

10x12 LW

Patient supine, hips and knees flexed

CR angled 20E cephalic to MSP midway between ASIS and symphysis pubis

2.  Lateral

10x12 LW

Patient in left lateral position, knees flexed

CR perpendicular to ASIS and mid-sacrum

COCCYX

1.  AP

8x10 LW

Patient supine with hips and knees flexed

CR angled 10E caudal to 2" (5cm) superior to symphysis pubis

2.  Lateral

8x10 LW

Patient in left lateral position

CR perpendicular to ½" (1cm) superior to coccyx tip

SCOLIOSIS -   Use compensating filter and breast shields when possible, refer to patent's personal technique reference card.  Include C7-S1.

1.  PA (Use 72" SID)

14x36 LW

Patient erect or prone

CR perpendicular to include C7-S1 on film

2.  Lateral (Use 72" SID)

14x36 LW

Patient in left lateral position, elevate both arms to right angles to trunk

CR perpendicular to include C7-S1 on film

3.  AP best bend, right

14x36 LW

Patient supine or upright with maximum spine flexion laterally to the right

CR perpendicular to include C7-S1

4.  AP best bend, left

14x36 LW

Patient supine or upright with maximum spine flexion laterally to the left

CR perpendicular to include C7-S1