lower extremity 1. intended learning outcomes the student should be able to recognize clinical...
TRANSCRIPT
Intended Learning Outcomes
• The student should be able to recognize clinical radiographic technical principles of the lower limb.
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A-P Lower Leg
• Measure: A-P at mid-lower leg
• Protection: Apron draped over pelvis
• SID: 40” Table top• No Tube Angle• Film: 7”x17 I.D.
down or diagonal 14” x 17
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A-P Lower Leg
• Patient lies on back on table.
• Leg internally rotated 15° until in true A-P position
• Film centered to include knee and ankle joints. The top of the film will be about 2” above knee.
• Horizontal CR is centered to film
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A-P Lower Leg
• Vertical CR: long axis of lower leg
• Collimation top to bottom: From knee joint to ankle joint or slightly less than film size.
• Collimation side to side: soft tissue of lower leg
• Instructions: Remain still• Make exposure and let
patient relax.
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A-P Lower Leg Film
• Must include both knee and ankle articulations
• No evidence of rotation• As with this example,
the 14” x 17” cassette can be turned diagonally to get both joint spaces on film.
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Lower Leg Lateral
• Measure: Lateral at mid lower leg
• Protection: Apron draped over pelvis
• SID: 40” Table Top• No Tube Angle• Film: 7” x 17” I.D.
down or diagonal 14”x17” Regular
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Lower Leg Lateral
• Patient lies on affected side with lower leg in lateral position.
• Film centered under leg to get both knee joint and ankle joint on film. Top of film will be about 2” above knee joint.
• Horizontal CR centered to film
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Lower Leg Lateral
• Vertical CR: long axis of lower leg.
• Collimation top to bottom: to include knee joint space and ankle joints
• Collimation Side to side: soft tissues of lower leg.
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Lower Leg Lateral
• Make sure that the knee and ankle are in lateral position. The condyles should be perpendicular to film and foot in lateral position.
• Collimation Top to Bottom: include both knee joint space and ankle joints
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Lower Leg Lateral
• Collimation Side to Side: soft tissues of lower leg.
• Instructions: Remain still• Make exposure and let
patient relax
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Lower Leg Lateral Film
• Must include both knee and ankle joints.
• Both joints should be in true lateral positions.
• A 14” x 17” may be turned diagonally to get both joints on film.
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Ankle Radiography
• Routine views at PCCW– AP– Mortise Oblique– Medial Oblique– Lateral
• We do both oblique views for Dr. Scuderi– The mortise open the joints better– The medial oblique demonstrates Jones Fractures.
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Ankle A-P
• Measure: A-P at malleoli
• Protection: lead apron
• SID: 40” Table Top• No Tube Angle• Film: 1/2 of 12” x 10
extremity cassette I.D. up
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Ankle A-P
• Patient is seated or lying on table. Leg is internally rotated until the leg is in a true A-P position position.
• The foot is dorsiflexed until the plantar surface is perpendicular to film.
• Horizontal CR: at level of talo-tibial joint or malleoli.
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Ankle A-P
• Half of film is centered to Horizontal CR.
• Vertical CR: Long axis of lower leg.
• Collimation top to bottom: distal lower leg to soft tissue below calcaneus. Slightly less than film size.
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Ankle A-P
• Collimation side to side: soft tissue of lower leg and ankle.
• Patient Instructions: Remain still
• Make exposure and let patient relax.
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Ankle A-P Film
• A-P on left.• There should be no
rotation as evidenced by the medial mortise joint being open.
• The talotibial joint should also be open.
• Soft tissue of plantar area of foot should be seen.
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Ankle Medial Oblique
• Measure: A-P at malleoli
• Protection: lead apron
• SID: 40” Table Top• No Tube Angle• Film: 1/2 of 12” x 10
extremity cassette I.D. up
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Ankle Medial Oblique
• Patient is seated or lying on table. Leg is internally rotated 45° from true A-P position position.
• The foot is dorsiflexed until the plantar surface is perpendicular to film.
• Horizontal CR: at level of talo-tibial joint or malleoli.
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Ankle Medial Oblique
• Half of film is centered to Horizontal CR.
• Vertical CR: Long axis of lower leg.
• Collimation top to bottom: distal lower leg to soft tissue below calcaneus. Slightly less than film size.
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Ankle Medial Oblique
• Collimation side to side: soft tissue of lower leg and ankle.
• Patient Instructions: Remain still
• Make exposure and let patient relax.
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Ankle Medial Oblique Film
• Oblique on right.• The lateral malleolus
should be clear of the talus.
• The medial mortise joint may be open
• The talotibial joint should also be open.
• The tarsal sinus will be open.
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Ankle Mortise Oblique
• Measure: A-P at malleoli
• Protection: lead apron
• SID: 40” Table Top• No Tube Angle• Film: 1/2 of 12” x 10
extremity cassette I.D. up
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Ankle Mortise Oblique
• Patient is seated or lying on table. Leg is internally rotated until the medial and lateral malleoli are parallel to the film , about 15 to 20 °.
• The foot is dorsiflexed until the plantar surface is perpendicular to film.
• Horizontal CR: at level of talotibial joint or malleoli.
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Ankle Mortise Oblique
• Half of film is centered to Horizontal CR.
• Vertical CR: Long axis of lower leg.
• Collimation top to bottom: distal lower leg to soft tissue below calcaneus. Slightly less than film size.
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Ankle Mortise Oblique
• Collimation side to side: soft tissue of lower leg and ankle.
• Patient Instructions: Remain still
• Make exposure and let patient relax.
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Ankle Mortise & Oblique Film
• Oblique on right., Mortise on left
• The lateral malleolus should be clear of the talus.
• The medial mortise joint must be open
• The talotibial joint should also be open.
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Ankle Lateral
• Measure: Lateral at malleoli
• Protection: Lead Apron
• SID: 40” Table Top• No Tube Angle• Film: 8” x 10” I.D. up
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Ankle Lateral
• Patient lies on the affected side with lower leg aligned with table center line.
• Foot dorsa-flexed to form a 90° angle with lower leg.
• Plantar surface of foot is perpendicular to film and malleoli are perpendicular to film.
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Ankle Lateral
• Horizontal CR: medial malleolus
• Vertical CR: medial malleolus and long axis of lower leg.
• Collimation top to bottom: distal tibia to soft tissue below calcaneus
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Ankle Lateral
• Collimation side to side: to include soft tissue around calcaneus and lower leg.
• Instructions: Remain still• Make exposure and let
patient relax.
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Ankle Lateral Film
• Must include distal tibia, talus and calcaneus.
• The talus domes must be superimposed.
• The fibula should overlie the distal tibia.
• The talotibial joint should be open.
• Note wrong I.D. location
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Calcaneus Axial View
• Measure: Lateral at calcaneus
• Protection: Lead Apron• SID: 40” Table Top• Tube Angle: 40°
cephalad• Film: 1/2 of 8”x10”
Extremity Cassette
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Calcaneus Axial View
• Patient lies or sits on table with affected leg centered to table.
• Lower leg in true A-P position and foot dorsiflexed until the plantar surface is perpendicular to film.
• A strap or tape may be used for the patient to hold foot in dorsiflexion.
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Calcaneus Axial View
• Horizontal CR: 1.5 to 2” up the calcaneus tuberosity
• Film centered to Horizontal CR.
• Vertical CR: long axis of foot.
• Collimation top to bottom: to include all of calcaneus and adjacent soft tissues
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Calcaneus Axial View
• Collimation Side to Side: soft tissue of foot or slightly less than 1/2 of film.
• Instructions: Remain still• Make exposure and let
patient relax.
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Calcaneus Axial View Film
• The calcaneus tuberosity will be seen free of distortion.
• The Calcaneal-Talus joint space should be seen.
• If the foot is not properly dorsiflexed, the joint space will be closed and the tuberosity foreshortened.
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Calcaneus Lateral View
• Measure: Lateral at calcaneus
• Protection: Lead Apron
• SID: 40” Table Top• No Tube Angle• Film: 1/2 of 8”x10”
Extremity Cassette
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Calcaneus Lateral View
• Patient lies on table on affected side with affected leg centered to table.
• Lower leg in true lateral position and foot dorsiflexed.
• Horizontal CR: 1.5 to 2” up the calcaneus tuberosity
• Film centered to Horizontal CR.
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Calcaneus Lateral View
• Vertical CR: through medial malleoli
• Collimation top to bottom: to include all of calcaneus and adjacent soft tissues
• Collimation Side to Side: soft tissue of foot or slightly less than 1/2 of film.
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Calcaneus Lateral Film
• The calcaneus, talus and ankle should be demonstrated in a true lateral position.
• The domes of the talus will be superimposed.
• Soft tissues adjacent to the calcaneus and ankle should be visualized.
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Foot Radiography
• Fractures are characterized by involvement of the subtalar joint (75%) and not involving the subtalar joint.
• Stress fractures are common in runners but typically not seen on radiographs.
• Stress fractures , plantar fascitis or heel spurs are common repetitive use conditions.
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Foot or Heel Radiography
• Views of the foot and calcaneus are totally different.
• If a heel injury is suspected, take heel views and not foot views.
• A 30 degree medial oblique view can be useful. The oblique and lateral will demonstrate the subtalar joint.
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Foot Radiography
• Foot view must include the tarsal bones, metatarsals and phalanges.
• A tube angle is used to open the tarsal bone articulations on the A-P view.
• If the patient is flat footed, no tube angle would be needed.
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Foot Radiography
• The medial oblique view is particularly useful. It provides:
• A clear view of the tarsal bone including the calcaneus.
• The 4th & 5th metatarsals
• Intertarsal joints
• Detail of the 5th metatarsal
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Foot Radiography
• The “basketball foot” is a traumatic medial subtalar dislocation resulting from landing on an inverted foot.
• The “Jones fracture is an avulsion fracture off the base of the 5th metatarsal.
• Stress fractures of the metatarsals are generally transverse resulting from marching or jumping.
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Toe Radiography
• Toe radiography can be particularly challenging.
• The natural curve of the toes toward the plantar surface of the foot results in foreshortening and closure of the interphalangeal joint spaces.
• Besides the A-P, an angled axial view is used to open the joint spaces.
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Foot A-P
• Measure: A-P at base of third metatarsal
• Protection: Apron• SID: 40” Table Top• Tube Angle: 10°
cephalad• Film: 1/2 of 10” x 12
Extremity Cassette I.D. up
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Foot A-P• Patient seated or lying on
table with the long axis of the affected foot centered to table.
• Place cassette on table.• Have patient place foot
flat on cassette.• Horizontal CR: base of
third metatarsal
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Foot A-P• Vertical CR: long axis of
foot.• Collimation Top to
Bottom: distal tibia to tips of toes.
• Collimation Side to Side: soft tissue of foot
• Instructions: Remain still• Make exposure and let
patient relax
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Foot A-P Film
• Should demonstrate toes , metatarsals and most of the tarsal bones. The talus and calcaneus will not be seen.
• The tube angle will help open the tarsal joint spaces.
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Foot Oblique
• Measure: A-P at base of third metatarsal
• Protection: Apron• SID: 40” Table Top• No Tube Angle• Film: 1/2 of 10” x 12
Extremity Cassette I.D. up
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Foot Oblique• Patient seated or lying
on table with the long axis of the affected foot centered to table.
• Place cassette on table.• Have patient place foot
flat on cassette.• The foot is medially
rotated 30 to 40°• A sponge may be used
under the plantar surface of the foot.
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Foot Oblique• Horizontal CR: base of
third metatarsal• Vertical CR: long axis
of foot.• Collimation Top to
Bottom: distal tibia to tips of toes.
• Collimation Side to Side: soft tissue of foot
• Instructions: Remain still
• Make exposure and let patient relax
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Foot Oblique Film
• Should demonstrate toes , metatarsals and most of the tarsal bones. The talus and calcaneus will not be seen.
• The calcaneus will be well visualized
• Tarsal joint spaces should be open.
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Foot Lateral
• Measure: Lateral at base of first metatarsal
• Protection: Lead Apron• SID: 40” Table Top• No Tube Angle• Film: 8” x 10” or 10” x 12”
Extremity depending on foot size.
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Foot Lateral
• Patient lies on the affected side with lower leg in lateral position.
• The foot should be dorsiflexed until the plantar surface is perpendicular to ankle.
• The plantar surface of foot is perpendicular to film.
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Foot Lateral
• The film may be turned diagonally or the foot placed diagonally on film to fit the entire foot on the film.
• Horizontal CR: base of 1st metatarsal
• Vertical CR: base of first metatarsal
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Foot Lateral
• Collimation Top to Bottom: to include ankle to plantar surface soft tissue
• Collimation Side to Side: to include from heel to tips of toes.
• Instructions: Remain still• Make exposure and let
patient relax.
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Foot Lateral Film
• The foot and ankle should be in a lateral position.
• The metatarsals and toes will be superimposed.
• The distal fibula should overlie the distal tibia.
• The talotibial joint space should be open.
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Toes A-P & Axial A-P
• Measure: A-P at 3rd metatarsal phalangeal joint or affected toe
• Protection: Lead Apron• SID: 40” Table Top• Tube Angle A-P: none• Tube Angle Axial A-P:
15° cephalad• Film: 1/4 of 10 x 12
Extremity
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Toes A-P & Axial A-P
• A-P : patient places foot flat on film.
• Horizontal & Vertical CR: 3rd M-P joint for all toes or M-P joint of the affected toe for individual toe series.
• A-P Axial tube angle: same as above but with 15° cephalad angle.
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Toes A-P & Axial A-P
• A-P Axial with Sponge: a 15° sponge is placed under toes instead of angling the tube. Or
• The Sponge is placed under the cassette
• Horizontal & Vertical CR: 3rd M-P joint for all toes or M-P joint of affected toe.
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Toes A-P & Axial A-P
• Collimation top to bottom: to include all M-P joints to tips of toes or M-P joint to tip of affected toe.
• Collimation Side to Side: soft tissue of foot or individual toe.
• Instructions: Remain Still
• Expose and let patient relax
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Toes A-P & Axial A-P Film
• A-P is upper right image.
• A-P Axial is upper left image. The phalangeal joints will be open on the axial view.
• Views must include all of the affected toe or toes.
• Note that collimation was too tight top to bottom.
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Toes Medial Oblique
• Measure: A-P at metatarsal-phalangeal joints
• Protection: Apron• SID: 40” Table Top• No tube angle• Film: 1/4 of 10” x 12”
or 8” x 10” Extremity Cassette
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Toes Medial Oblique
• Patient places distal foot on unexposed portion of cassette.
• Patient medially rotates lower leg until the plantar surface forms a 30 to 45° angle.
• Horizontal CR: 3rd MTP joint or the affected toe.
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Toes Medial Oblique
• Vertical CR: centered to long axis of foot or the affected toe
• Collimation top to bottom: Distal metatarsal to tips of toes or affected toe
• Collimation side to side: soft tissue of foot or affected toe.
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Toes Medial Oblique
• Patient instructions: Remain Still
• Make exposure and let patient relax.
• Note that a sponge may be placed under plantar surface of foot to control angle of view . It will also make it more comfortable for the patient.
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Toes Medial Oblique
• The joint spaces should be open.
• The distal metatarsal and tips of the toes should be visualized.
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Toes Lateral
• Measure: Lateral across the metatarsal-phalangeal joints For individual toe use A-P measurement.
• Protection: Apron• SID: 40” Table Top• No tube angle• Film: 1/4 of 10” x 12” or
8” x 10” Extremity Cassette
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1st Toe Lateral • Patient places distal foot
on unexposed portion of cassette.
• For 1st through 3rd toes
• Patient medially rotates lower leg until the plantar surface forms a 90° angle.
• For 4th and 5th toes
• Patient laterally rotates foot until the plantar surface is perpendicular to film.
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2nd Toe Lateral
• For individual toes, tape and tongue depressors are used to clear the other toes out of the view.
• Without the use of tape and tongue depressors, there will be too much superimposition
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3rd Toe Lateral• Horizontal CR: 3rd MTP joint or the affected toe.
• Vertical CR: centered to long axis of foot or the affected toe
• Collimation top to bottom: Distal metatarsal to tips of toes or affected toe
• Collimation side to side: soft tissue of foot or affected toe.
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4th Toe Lateral
• Patient instructions: Remain Still
• Make exposure and let patient relax.
• Note that the lateral surface of the foot is next to the film.
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5th Toe Lateral
• Note that the lateral surface of the foot is next to the film.
• The toe need to remain parallel to the film.
• The 5th toe is the most challenging lateral toe view.
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Toes Lateral Film
• The joint spaces should be open.
• The distal metatarsal and tips of the toes should be visualized.
• The affected toe should be free of superimposition.