UCSD Musculoskeletal Radiology

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Plain Film Protocols

CHEST (Bony Thorax)

 

1.   Write time of exam on all chest films.  Films taken in surgery, portables, trauma, E.D. often have multiple studies; times are needed to sort films. 

 

2.   If photo-timing chest films, indicate on the finished radiograph the density setting used for exposure.

 

3.   Acute injuries:    For acute injuries, follow trauma protocol or other methods as directed by Radiologist.

 

4.   Ribs:      a.) DO NOT use upright Bucky in Main Rm. 3 or OPC Rm. B for bone studies.  Indicate area of injury on IDXRad Form.

              b.)  Oblique film critique:  The distance between the spine and lateral rib margin of affected side should be twice the unaffected side.

 

 

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


 

 

BONY THORAX (continued)

Exams/Views to be done

Cassette size, type

 and orientation

     Patient position relative to film            

Central ray (CR) direction

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)

       


 

 

VERTEBRAL COLUMN - (continued)

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


 

 

VERTEBRAL COLUMN - (continued)

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 " (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