Beth Israel DeaconessBeth Israel Deaconess Medical CenterMedical Center

Routine Diagnostic Positioning Routine Diagnostic Positioning ManualManual

Revised August 2001

Table of ContentsTable of ContentsPage 1 A-C Joints

AnkleCalcaneous/Os CalcisCervical Spine : Non-traumaCervical Spine : Trauma

Page 2 ChestChest for pneumothoraxClavicleCoccyxElbowElbow : Radial Head views

Page 3 Facial BonesFemurFootFoot : Standing viewsForearmHand

Page 4 HipHip : Post operativeHumerusInternal Auditory CanalsKnee : Non-traumaKnee : Trauma

Page 5 Knee : Tunnel viewKnee : 3’StandingLeg LengthsLumbar SpineLumbar Spine : Dynamic

Page 6 MandibleMastoids

Page 6 Nasal BonesNavicular SeriesOrbitsOrbits : Pre-MRI Screening

Page 7 PatellaPelvisPelvis : Inlet / Outlet;et viewsPelvis : Judet viewsPelvis : AcetabulumRibs

Page 8 SacrumScapulaScoliosis SeriesSella Turcica

Page 9 ShoulderS-I JointsSinusesSkeletal Series

Page 10 SkullSterno-clavicular JointsSternumSupraspinatus Outlet View

Page 11 Temporo-Mandibular JointsThoracic SpineThoraco-Lumbar SpineThumbTib/FibToes

Page 12 WristWrist : InstabilityZygoma

All extremities : Be sure to mark where it hurts with a BB marker or arrow Markers are to be placed on the LATERAL ASPECT to the part being x-rayed

Always use the smallest film possible

A-C Joints Bilateral AP Without weights on a 14x17 at 72” to include both jointsWeights at physician’s request

Ankle AP With toes toward ceiling, ankle in neutral positionOblique Mortise view With internal rotation 30 degrees Lateral To include base of 5th metatarsal.

Lateral malleolus posterior to medial malleolus Lateral rotation shouldn’t create superimpostion of the malleoli. (mortise)

Calcaneous/Os Calcis) AP Axial Angle 40 degrees cephalicLateral

Cervical Spine *All spine films are to be done upright if possible and collimated on 10x12 film. Non-trauma

AP 15 degree angle cephaladLateral 72” SID to include ALL 7 vertebrae & base of skull

Cervical Spine Trauma AP 15 degree cephalic angle Lateral 72” to include all seven cervical vertebrae and base of skull. Odontoid Open mouth view 8x10 or 9x9 film

Obliques *Only when requested. *Obliques should be marked side down/closet to film.

Trauma Obliques *Only when requested. Supine on board. Angle tube 45 degrees to left then to right side of patient.

Acute Trauma Flexion and Extension *only with approval and when monitored by physician.

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Chest PALeft LateralRight and Left Decubitus *ONLY WHEN ORDERED

Right side down can show right effusion or left pneumothorax Left side down can show left effusion or right pneumothorax

Apical Lordotic View *ONLY WHEN ORDERED

Shows apical lesions free of superimposition of the clavicles

PA with Nipple markers *ONLY WHEN ORDERED Place “BB’s” on nipples, delineates nipple shadows from lesions

 Chest for Pneumothorax PA or AP upright Full inspiration  Clavicle AP

AP Axial 25 degree cephalic angle   Coccyx Lateral only. *Check with radiologist first before doing AP

AP 10 degree caudal angle * All requests for sacrum/coccyx under the age of 40 should be approved by a Radiologist Elbow AP

External ObliqueLateral

Elbow -Radial Head Axial Lateral Position The elbow should be in the lateral position with the humerus parallel with

the film and tabletop. Wrist and forearm should also be in the lateral position. The elbow flexed 90 degrees.

CR- should be angled 45 degrees toward the shoulder along the long axis of the humerus and directed to enter at the elbow joint.

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Facial Bones LateralWatersCaldwell PA 23 degrees caudal tube angle

  Femur AP Include joint closest to pain/surgery

Lateral Include joint closest to pain/surgery   Finger PA If focal pain only finger. No focal pain, entire hand must be included.

ObliqueLateral

   Foot AP 15 degrees cephalic

Oblique 30 degrees medial rotationLateral To include ankle joint

Sesamoids Axial (Tangential to planter surface)   

Foot Standing AP Weight bearing with cassette on floorLateral Weight bearing with horizontal beam.Oblique Standing , central ray angled 40 degrees medially - foot flat,

weight bearing and use tube angle.When both feet are ordered, do all views separately.

  Forearm AP

Lateral To include both elbow and wrist joints.   Hand PA

PA Oblique Semi-proneLateral Fingers separated

? Foreign Body PA & Lateral Use soft tissue technique ? Bone Age PA Left Hand Include wrist and ulnar styloid process

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Hip AP Pelvis AP hip Collimated; invert foot 15 degrees

Frog Lateral If there is a low possibility of fx and the patient is able, otherwise do a X-table lateral.

  Hip POST-OP ** ALL POST SURGERY HIPS INCLUDE ENTIRE APPLIANCE ON

BOTH VIEWS AND X-TABLE LATERAL MUST BE TAKEN. Frog view can not be taken.

 Humerus Include both elbow and shoulder joints AP Corner to corner , ID blocker at bottom

Lateral Corner to corner, ID blocker at bottom

Internal Auditory Canals See Radiologist first - Rarely indicatedAPTowneStenvers PA Head 45 degrees obliqued

Tube 12 degrees cephalic (Bilateral)

 Knee Non-Trauma AP CR angled 5-7 degrees cephalic to 1/2” below patella apex.

Patella Sunrise Merchant’s view in Ortho for Dr Davis (see instructions in Ortho)

Lateral Knee slightly flexed 5-10 degrees, tube angled 5 degrees cephalic X-table lateral at physician request

Trauma AP CR angled 5-7 degrees cephalic to 1/2” below patella apex.

Patella Sunrise Merchant’s view in Ortho for Dr Davis (see instructions in Ortho)

Lateral Knee slightly blexed 5-10 degrees, tube angled 5 degrees cephalic.

X-table lateral at physician requestOblique Medial rotation

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Knee : TUNNEL PA Femur parallel to film plane, knee flexed with Tib/Fib elevated approximately 40 degrees. Tube angled caudal so that CR is perpendicular

to the tib/fib and centered through the knee joint.   

Knee STANDING AP CR perpendicular Centered to knee

 Leg Lengths NO GRID~ USE FILTER~ Use 3 or 4 foot cassette

AP Be sure that the top of the pelvis and the ankles are on the film. If female use the triangle filter putting the smallest edge at the top.

If the patient has a large belly, the filter should start at about mid femur

Lumbar Spine All spine films should be standing if possible

AP To include hipsLateral L5-S1 Spot *ONLY IF NOT VISIBLE ON LATERAL

AND PATIENT IS OVER 40 YRS UNLESS REQUESTED BY RADIOLOGIST.Obliques *ONLY WHEN REQUESTED.

  Dynamic Lumbar Spine Upright AP

Upright Lateral Neutral, Flexion, and ExtensionRecumbent Lateral Flexion and Extension

*T12 - S1 should be included on all films. 

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Mandible PABoth ObliquesTowne Centered for mandible (Condyle joints should be

visualized)Panorex whenever possible

Mastoids Rarely indicated - See Radiologist firstTowneBase ConedBilateral Laws Views The mid sagittal plane is rotated 15 degrees towards

cassette from the true lateral position. CR is angled15 degrees caudad and centered 2” posterior & 2”

superiorto the uppermost EAM.

  Nasal Bones Waters

Laterals Bilateral; use extremity cassette table top  Navicular Series PA With clenched fist(4 views total) PA With wrist in ulnar flexion

CR angled towards elbow at 30, 45 and 60 degrees    Orbits Lateral Waters

Caldwell PA 23 degrees caudal

MRI Screening R/O foreign body in the orbitsAP Collimated to the orbitsWaters View Collimated to the orbits

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Patella PA LateralSettegast(Sunrise) MERCHANTS VIEW at physician request

** Mark films either Sunrise or MerchantsLateral

   Pelvis AP Internally rotate feet 15 degrees

Pelvis: INLET/OUTLET AP 30 Degree Angle cephalic for outlet, center at pubic symphysis

AP 30 Degree Angle caudal for inlet, center at ASIS  Pelvis: JUDET 45 Degree Obliques of entire pelvis Pelvis: False Profile Position the patient standing in a lateral position with the hip to be ACETABULUM examined against the cassette. Ask the patient to turn the opposite foot 90 degrees away, so that it points toward the x-ray tube. The pelvis will turn slightly and the CR should be over the hip to be examined.  

Ribs All rib films should be done recumbent if possible.All rib films should include a “BB” marking the point of pain.

PA Chest For all trauma / ?FX

Posterior Ribs: APOblique 45 degrees side down.

*KV Upper Ribs 50-55*Lower Ribs 75-80

Anterior Ribs: PA Oblique 45 degrees side away. *KV Upper Ribs 50-55 *Lower Ribs 75-80 

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Sacrum Lateral only. *Check with radiologist first before doing APAP Axial 15 degree cephalic angle

* All requests for sacrum/coccyx under the age of 40 should be approved by a Radiologist  Scapula AP If the patient can tolerate , keep the humerus abducted

Lateral View AP - rotate the patient 45 degrees affected side up. PA - rotate patient 45 degrees affected side down

Scoliosis Series Use 3 foot film with graduated screens and GRIDBe sure the end marked top is at the top - faster

screen speeds(400) will be at the bottom.  AP 3’ film at 72”. The top of the film should be just above the shoulder. Average technique: 70-77kv 200-250mas

Lateral 3’ film at 72”. The top of the film should be just above the shoulder. Average technique: 70-77kv 400-500mas

Follow-up Films: On female patients films are to be done PA to reduce dose to breasts.   Sella Turcica PA 10 degrees cephalic, coned

Lateral coned to sella

   

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Shoulder All films done upright when possible AP External-Grashey Supination of palm with patient 35-40 degrees oblique towards film

to visualize glenoid joint.AP Internal rotation In an AP positionAxillary Use curved cassette if possible.

If patient cannot tolerate axial, do Y view.“Y” view (PA) Patient PA; rotate 60 degrees affected side

to chest stand; CR directed to humeral neck S-I Joints AP Pelvis

Ferguson View AP with tube angled 35 degrees cephalic on a 10x12 film

Oblique *Only on request Sinuses All views should be done upright

Caldwell PA OML perpendicular to the film, 23 degree angle caudad

Waters CR exits acanthion, petrous ridges should be below the maxillary sinuses

Lateral

Skeletal Series Usually indicated for Multiple Myeloma Otherwise check indications with the radiologist.Lateral Skull

AP and Lateral Thoracic Spine-(coned)AP and Lateral Lumbar Spine (coned)AP PelvisAP Humerus - BilateralAP Femur - Bilateral

 Page 9  

Skull Caldwell PA 23 degrees tube angle caudal , CR exits the nasion Left Lateral Midsagittal plane parallel to film, interpupillary line perpendicular to

film,CR 2” above EAM

AP axial (Towne) 30 degree caudal angle. CR inters 1 1/2” to 2” above the glabella.Base *ONLY WHEN REQUESTED

IOML parallel to film , CR at goninon.  Sterno-Clavicular PA Head extended upward on chin.Joints Oblique Patient 15 - 20 degrees with head turned towards affected side

Bi-lateral obliques are always performed.   

Sternum RAO Breathing technique (2-4 seconds), 28” to 30” focal film distance. - collimate.

Lateral Collimated to sternum 

Supraspinatus PA Oblique 45 degreesOutlet View with affected side toward film and scapula

perpendicular to the film. CR angled 10-15 degrees caudal.

 

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TM Joints Panorex whenever possibleTowne coned for condylesLateral Bilateral open & closed mouth

tube angled 20 degrees caudal, coned

Thoracic Spine All spine films should be standing if possibleAP Include T1-T12 collimatedLateral Breathing technique to include T1-T12

  Thoraco-Lumbar All spine films should be standing if possibleSpine (Mid T – L5) *As requested. Follow up to mid back pain/trauma.

AP Center on T12Lateral Center on T12.

 Thumb AP

PA Oblique If trauma include entire hand Lateral

  Tib/Fib AP Include both joints. Angle film corner to corner.

Lateral Include both joints. Angle film corner to corner.**Place ID blocker at bottom of film so when the previous

films are compared the angle of the tib/fib will be the same.   

Toes AP Collimate.** However, if diabetic collimate for all toes.ObliqueLateral For trauma isolate symptomatic toe, tape others away

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Wrist PA Slightly clenched fist. - not stressed.Oblique PA semi proneLateral

Wrist Instability For chronic pain additional PA with clenched stressed fist with 10 degree pronation. Ulnar and radial deviation and dorsiflexion may be obtained as well as flexion and extension views laterally. Additional films per request.  

 Zygoma Base View Bilateral, (jug handle)

LateralWatersCaldwell PA , 23 degrees caudal

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