UCSD Musculoskeletal Radiology

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 _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