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Hand |
DP Oblique
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Indications for imaging
Injury, ? rheumatoid arthritis, bone pain. |
Anatomy Demonstrated Hand Lt DP Anatomy Meschan, I. 1955 An Atlas of Normal Radiographic Anatomy Saunders, London |
Basic Patient Position
The patient sits alongside the end of the table elbow flexed palm downwards, or at the end of the table with he elbow flexed at 90 degrees, hand and wrist flat on the cassette the hand is then rotated laterally 35 to 45 degrees laterally and supported so that the fingers are parallel to the film.  Hand Rt DP Oblique Position (Support removed to show position) |
Radiation protection
Direct lead rubber gonad protection using a "half apron". Ensure the lower limbs and torso are not below the table top in the primary beam. |
Central Ray
The vertical central ray is directed to the head of the third metacarpal. |
Exposure Factors
|
Evaluation of the Image
ID and markers must be present and correct in the appropriate area of the film Evidence of collimation on four sides equally around the centering point. Limits of the examination, proximally the radio and ulna carpal joints, distally the tips of the distal phalanges, laterally the skin margins of first and fifth digits The center of the 1st to 5th metacarpal shafts should not overlap, the heads of the 1st and 2nd metacarpals should be separated. Exposure, adequate penetration to visualise all bone detail and low enough contrast to visualise the soft tissues. 
Hand Rt DP Oblique Radiograph
http://www.vh.org |
Related Projections
Hand DP "Ball catching for rheumatoid) Hand DP Oblique Fingers Lat. Thumb AP Thumb Lat. Wrist AP Wrist Lat Wrist Oblique Wrist AP Angled for Scaphoid |
|
Additional modalities
RNI may be useful. |
|
Hand |
Brewertons Projection
|
Indications for imaging
Rheumatoid arthritis, |
Anatomy Demonstrated 
Hand Rt Anatomy
Meschan, I. 1955 An Atlas of Normal Radiographic Anatomy Saunders, London |
Basic Patient Position
The patient stands alongside the end of the table elbow extended palm upwards, hand flexed 40 degrees at the metacarpo phalangeal joints posterior aspect of the fingers in contact with the cassette, and the wrist supported as required. 
Hand Rt Brewertons Patient
Position
From Special Techniques in Orthopaedic Radiography W J Stripp) |
Radiation protection
Direct lead rubber gonad protection using a "half apron". Ensure the lower limbs and torso are not below the table top in the primary beam. |
Central Ray
The vertical central ray is angled 20 degrees laterally across the table and directed to he head of the third metacarpal. |
Exposure Factors
|
Evaluation of the Image
ID and markers must be present and correct in the appropriate area of the film Evidence of collimation on four sides equally around the centering point. Limits of the examination, proximally the radio and ulna carpal joints, distally the tips of the distal phalanges, laterally the skin margins of first and fifth digits. metacarpo phalangeal joints should be open and the shafts of the second to fifth metacarpals should be symmetrical. Exposure, adequate penetration to visualise all bone detail and low enough contrast to visualise the soft tissues. 
Hand Rt Brewertons
From Special Techniques in Orthopaedic Radiography W J Stripp) |
Related Projections
Hand PD "Ball catching for rheumatoid) Hand DP Oblique Fingers Lat. Thumb AP Thumb Lat. Wrist AP Wrist Lat Wrist Oblique Wrist AP Angled for Scaphoid |
Additional modalities
|
inger |
Lateral
|
Indications for imaging
Trauma, rheumatology. |
Anatomy Demonstrated
The phalanges and interphalangeal joints in true lateral position demonstrating the interphalangeal joints. |
Basic Patient Position
The patient sits alongside the end of the table elbow flexed and the hand in true lateral position the fingers are then flexed and the finger in question extended parallel to the film, a radio lucent pointer may aid maintenance of the extension. For fingers other than the middle the hand is rotated to the lateral position bringing the finger in question nearest the film or in contact with it for the 2nd and 5th.  |
Radiation protection
Direct lead rubber gonad protection using a "half apron". Ensure the lower limbs and torso are not below the table top in the primary beam. |
Central Ray
The vertical central ray is directed to the proximal interphalangeal (PIP) joint. |
Exposure Factors
|
Evaluation of the Image
ID and markers must be present and correct in the appropriate area of the film Evidence of collimation on four sides equally around the centering point. Limits of the examination, distally the tip of the finger proximally the metacarpo phalangeal joint, laterally the soft tissue margins of the finger. The central ray should pass through the PIP involved, visualising the joint space, when true lateral the palmar aspects of the phalanges appear concave. Exposure, adequate penetration to visualise all bone detail and low enough contrast to visualise the soft tissues.  Rt Third finger Lateral Radiograph |
Related Projections
Hand DP, DP Oblique and lateral |
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Additional modalities---
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humb |
PA/AP
|
Indications for imaging
Trauma, congenital abnormalities, rheumatology. |
Anatomy Demonstrated
The first metacarpal and trapezium.  Rt Thumb PA Anatomy |
Basic Patient Position
The PA position is easiest for the patient however the AP projection produces less magnification and better detail as the thumb is in contact with the cassette. PA Position, The patient sits alongside the end of the table elbow flexed palm downwards, or at the end of the table with he elbow flexed at 90 degrees, the hand is rotated into the true later position projecting the thumb clear of superimposition with the fifth metacarpal. AP Position, The patient stand with their back to the table and the arm is extended and internally rotted to bring the palmar aspect of the thumb facing upwards, adjust the table height to a comfortable position, adjust the rotation of the arm to bring the thumb into true AP position.  Rt Thumb PA Patient Position |
Radiation protection
Direct lead rubber gonad protection using a "half apron". Ensure the lower limbs and torso are not below the table top in the primary beam. |
Central Ray
The vertical central ray is directed to the center of the1st metacarpophalangeal joint. |
Exposure Factors
|
Evaluation of the Image
ID and markers must be present and correct in the appropriate area of the film Evidence of collimation on four sides equally around the centering point. Limits of the examination, distally the tip of the distal phalanx, proximally the trapezium, the skin surface externally and the 2nd metacarpal medially. The thumb should be projected true AP with equal concavity on either side of the 1st metacarpal. The joint spaces should be open. Exposure, adequate penetration to visualise all bone detail and low enough contrast to visualise the soft tissues.  Rt Thumb PA Radiograph |
Related Projections
Thumb Lat. Wrist for carpal bones |
Additional modalities
|
Thumb |
Lat
|
Indications for imaging
Trauma, rheumatology, congenital, |
Anatomy Demonstrated
Distal and proximal phalanges, first metacarpal and associated joints.  Rt Thumb Lat Anatomy |
Basic Patient Position
The patient sits alongside the end of the table elbow flexed palm downwards, or at the end of the table with he elbow flexed at 90 degrees, hand and wrist flat on the cassette the elbow may need a small pad to promote contact of the hand with the cassette. The fingers can be spread slightly. the thumb is abducted and the hand internally rotated and supported in position such that the thumb is lateral and in contact with the cassette.  |
Radiation protection
Direct lead rubber gonad protection using a "half apron". Ensure the lower limbs and torso are not below the table top in the primary beam. |
Central Ray
The vertical central ray is centered to the center of the first metacarpophalangeal joint. |
Exposure Factors
|
Evaluation of the Image
ID and markers must be present and correct in the appropriate area of the film Evidence of collimation on four sides equally around the centering point. Limits of the examination, distally the tip of the distal phalanx, proximally the trapezium, the skin surface externally and the 2nd metacarpal medially. The thumb should be true lateral with the dorsal surface of the 1st metacarpal almost flat. The joint spaces should be open. Exposure, adequate penetration to visualise all bone detail and low enough contrast to visualise the soft tissues.  Rt Thumb Lat Radiograp |
Related Projections
Thumb AP. Wrist for Scaphoid and Trapezium |
Additional modalities
|
Femur |
AP Midshaft to Knee
|
Indications for imaging
Trauma, bone pain, joint replacements, soft tissue calcifications, osteosarcoma |
| Anatomy Demonstrated Distal and mid to upper shaft and associated soft tissue structures.  Rt Femur Anatomy
Meschan, I. 1955 An Atlas of
Normal Radiographic Anatomy Saunders, London
|
| Basic Patient Position The patient lies supine on the table with the femur under examination aligned to the midline of the table. The femur is aligned in slight internal rotation to bring the distal femoral condyles equidistant from the film, ensure the knee joint is projected onto the film 
Lt Femur Patient Position
Meschan, I. 1955 An Atlas of Normal Radiographic Anatomy Saunders, London |
Radiation protection
Direct lead rubber gonad protection. |
Central Ray
The vertical central ray is centered to the film midway between the medial and lateral skin surfaces to include the knee joint upwards on the film. |
Exposure Factors
|
Evaluation of the Image
ID and markers must be present and correct in the appropriate area of the film Evidence of collimation on four sides equally around the centering point. Limits of the examination, distally the proximal 2 cm of the tibia, proximally as much of the proximal femur as allowed by the film and patient size, laterally and medially the skin margins. The femoral condyles should be symmetrical. Optimal exposure should penetrate all the bone structures and contrast should be low enough to visualise fully the bone and soft tissue structures.  |
Related Projections
Femur lateral Pelvis AP Hip AP & Lat. Knee AP and Lateral |
Additional modalities
CT RNI MRI |
Femur |
Lateral Midshaft to Knee
|
Indications for imaging
Trauma, bone pain, joint replacements, soft tissue calcifications, osteosarcoma |
| Anatomy Demonstrated Distal and mid to upper shaft and associated soft tissue structures. 
Lt Femur Anatomy
Meschan, I. 1955 An Atlas of Normal Radiographic Anatomy Saunders, London |
Basic Patient Position
(Non Trauma) The patient lies on the affected side and the upper limb is flexed maximally and drawn up over and in front of the affected limb and supported suitably. the knee of the affected side is flexed 20 degrees to aid stability, and the long axis of the femur is aligned to the long axis of the table. (Trauma cases require a horizontal ray lateral) With the patient supine on the table and the affected limb aligned to the long axis of the table. A small support is placed under the knee to raise the knee off the table, the unaffected leg is flexed 90 degrees at the hip and knee and supported.  Rt Femur Patient Position Non Trauma 
Rt Femur Patient Position Trauma
Meschan, I. 1955 An Atlas of Normal Radiographic Anatomy Saunders, London |
Radiation protection
Direct lead rubber gonad protection. |
Central Ray
(Non Trauma) The vertical central ray is directed to the midshaft of the femur midway between the anterior and posterior skin surfaces to include the knee joint on the film. (Trauma cases require a horizontal ray lateral) The horizontal central ray is midway between the anterior and posterior skin surfaces to include the knee joint on the film. |
Exposure Factors
|
Related Projections
Femur AP Pelvis AP Hip AP & Lat. Knee AP and Lateral |
Additional modalities
CT RNI MR |
Knee |
AP
|
Indications for imaging
Trauma, bone pain, arthritis, joint replacements, soft tissue calcifications loose bodies, osteosarcoma, Bakers cyst (a collection of synovial fluid which has escaped from the knee joint or a bursa and formed a new synovial-lined sac in the popliteal space; seen in degenerative or other joint diseases.) |
Anatomy Demonstrated
Distal femur, proximal tibia and fibula, knee joint and patella.  Rt Knee Anatomy Meschan, I. 1955 An Atlas of Normal Radiographic Anatomy Saunders, London |
Basic Patient Position
The patient lies supine on the table legs extended and the affected limb aligned to the long axis of the table. The leg is rotated inwards until the femoral condyles are equidistant from the film or the patella is midway between the femoral condyles. The tibia should be parallel to the film.  Lt Knee Patient position Meschan, I. 1955 An Atlas of Normal Radiographic Anatomy Saunders, London |
Radiation protection
Direct lead rubber gonad protection using a "half apron". |
Central Ray
The vertical central ray should be at 90 degrees to the tibia and is centered to the joint space which is palpable laterally, this point is generally about 2cm below the apex of the patella and in line with the crease of the knee. |
Exposure Factors
|
Evaluation of the Image
ID and markers must be present and correct in the appropriate area of the film Evidence of collimation on four sides equally around the centering point. Limits of the examination, superiorly the distal femur, inferiorly the proximal tibia and fibula laterally and medially the skin surfaces. The joint space should be visualised with the proximal articular surface of the tibia at 90 degrees to the film, the apex of the patella should be in line with the tibial spines. Optimal exposure should penetrate all the bone structures and contrast should be low enough to visualise fully the bone and soft tissue structures.  Lt Knee Radiograph http://www.vh.org |
Related Projections
Knee Lateral Femur Lateral and AP Tibia and fibula AP & Lat. |
Additional modalities
CT MRI |
Knee |
Lateral
|
Indications for imaging
Trauma, bone pain, arthritis, joint replacements, soft tissue calcifications loose bodies, osteosarcoma, Bakers cyst (a collection of sensorial fluid which has escaped from the knee joint or a bursa and formed a new sensorial-lined sac in the popliteal space; seen in degenerative or other joint diseases.) |
Anatomy Demonstrated
Distal femur, proximal tibia and fibula, knee joint and patella. 
Lt Knee anatomy
Meschan, I. 1955 An Atlas of Normal Radiographic Anatomy Saunders, London |
Basic Patient Position
(Non Trauma) The patient lies on the affected side and the upper limb is flexed maximally and drawn up over and in front of the affected limb and supported suitably. The knee of the affected side is flexed 45 degrees. The femoral condyles should be in vertical alignment and the tibia parallel to the table. (Trauma cases require a horizontal ray lateral) With the patient supine on the table and the affected limb aligned to the long axis of the table. A small support is placed under the knee to raise the knee and support it in approximately 25 degrees of flexion.  Rt Knee Lateral Patient position (Non trauma) Meschan, I. 1955 An Atlas of Normal Radiographic Anatomy Saunders, London |
Radiation protection
Direct lead rubber gonad protection using a "half apron". |
Central Ray
(Non Trauma) The vertical central ray is centered to the palpable joint space immediately above the palpable tibial expansion. (Trauma cases require a horizontal ray lateral and usually a latero medial central ray)) The horizontal central ray is centered to the joint space approximately 2 cm below the femoral condyle, note this projection may be medio lateral or latero medial. |
Exposure Factors
|
Evaluation of the Image
ID and markers must be present and correct in the appropriate area of the film Evidence of collimation on four sides equally around the centering point. Limits of the examination, superiorly the distal femur, inferiorly the proximal tibia and fibula laterally and medially the skin surfaces. The femoral condyles should be superimposed, the lower border superimposition is affected by the angle between the femur and the central ray whilst alignment of the posterior borders is affected by the amount of rotation along the axis of the femur. optimum positioning will superimpose the anterior half of the fibula head on the tibia The tibia spines should be superimposed and the tibia plateau should be seen end on. The patella should be in profile and not superimposed on the femur. Optimal exposure should penetrate all the bone structures and contrast should be low enough to visualise fully the bone and soft tissue structures.  Rt Knee Lateral Radiograph http://www.vh.org |
Related Projections
Knee AP Femur Lateral and AP Tibia and fibula AP & Lat. |
Additional modalities
CT MRI |
Knee |
Intercondylar notch
|
Indications for imaging
? Loose bodies in the joint capsule in the intercondylar notch of femur, fractures of the tibial spines |
Anatomy Demonstrated
The femoral intercondylar notch, tibial spines, femoral condyle surfaces. 
Lt Knee Intercondylar notch
anatomy
Meschan, I. 1955 An Atlas of Normal Radiographic Anatomy Saunders, London
Basic Patient Position
Patient Prone, The patient lies prone on the table with the long axis of the leg aligned to the long axis of the table. The knee is flexed 45 degrees and the ankle supported. Patient supine, The patient sits on the table with the long axis of the leg aligned to the long axis of the table, the knee is flexed 45 degrees.   Knee notch views PA and AP Patient Positions
Meschan, I. 1955 An Atlas of
Normal Radiographic Anatomy Saunders, Londo
|
Radiation protection
Direct lead rubber gonad protection using a "half apron". |
Central Ray
Patient Prone, the central ray is angled 45 degrees caudally and centered midway between the skin surfaces at the skin crease of the knee, The angle between the central ray and the long axis of the tibia determines the part of the intercondylar notch shown best, at 90 degrees the anterior portion is best shown and at 100 degrees the posterior portion. |
Exposure Factors
|
Evaluation of the Image
ID and markers must be present and correct in the appropriate area of the film Evidence of collimation on four sides equally around the centering point. Limits of the examination, superiorly the femoral condyles, inferiorly the tibial plateau laterally the skin margins. Optimal exposure should penetrate all the bone structures and contrast should be low enough to visualise fully the bone and soft tissue structures. 
Rt knee Intercondylar Notch
Radiograph
|
Related Projections
Hughston view: pt is prone with knee flexed 55o,
the x-ray beam is directed cephalad at 45o from vertical.Knee AP and Lateral Merchant view: The pt is supine with knee flexed 45o and the x-ray beam is directed caudally, 30o from vertical. Laurin view: The pt is sitting with the knee in 20o of flexion and the x-ray beam is directed cephalad at 160o from vertical. |
Additional modalities
CT MRI |
Knee |
PA Patella
|
Indications for imaging
? fractured patella, congenital abnormalities |
| Anatomy Demonstrated Similar to normal AP knee except the patella is better demonstrated as it nearer the film. Knee PA for Patella Rt Anatomy
Meschan, I. 1955 An Atlas of
Normal Radiographic Anatomy Saunders, London
|
Basic Patient Position
The patient lies prone on the table with the leg aligned to the long axis of the table, and supported so that the femoral condyles are equidistant from the film and the patella centered midway between the condyles. Note this position may note be possible on an injured patient.  Knee PA for Patella Lt Patient Position
Meschan, I. 1955 An Atlas of
Normal Radiographic Anatomy Saunders, London
|
Radiation protection
Direct lead rubber gonad protection using a "half apron". |
Central Ray
The vertical central ray is directed to emerge through the center of the patella at 90 degree to the film, midway between the skin surfaces at the crease on the skin surface. |
Exposure Factors
|
Evaluation of the Image
Evidence of collimation on four sides equally around the centering point. Limits of the examination, superiorly the distal femur, inferiorly the proximal tibia and fibula laterally and medially the skin surfaces. The joint space should be visualised with the proximal articular surface of the tibia at 90 degrees to the film, the apex of the patella should be in line with the tibial spines. Optimal exposure should penetrate all the bone structures and contrast should be low enough to visualise fully the bone and soft tissue structures.  Knee PA for Patella Rt, Radiograph |
| Related Projections Knee AP, Lateral and axial "skyline" oblique patella views |
Additional modalities
CT MR |
Knee |
Axial Patella "Skyline"
|
Indications for imaging
Trauma, Congenital abnormalities and Patella pathologies e.g., chondromalacea patella. |
| Anatomy Demonstrated The patella is projected at right angles to the lateral projection and demonstrates linear fractures and especially the posterior articular surface.  Patella Axial Rt "skyline" Anatomy
Meschan, I. 1955 An Atlas of
Normal Radiographic Anatomy Saunders, London
|
Basic Patient Position
The patient sits on the table with the long axis of the leg in line with the long axis of the table, the affected limb is flexed to bring the internal angle to 45 degrees, the tibia and fibula are in line with the femur.  Patella Axial Rt "skyline" Patient Position
Meschan, I. 1955 An Atlas of
Normal Radiographic Anatomy Saunders, London
There are several variations to this projection in position of the patient
for minimising radiation dose to the gonads by avoiding directing the central
ray in line with the rest of the body and comfort and ease of performing the
examination.
|
Radiation protection
Direct lead rubber gonad protection using a "half apron". |
Central Ray
The central ray is angled 45 degrees cranially and centered tot he palpable apex of the patella. |
Exposure Factors
|
Evaluation of the Image
ID and markers must be present and correct in the appropriate area of the film Evidence of collimation on four sides equally around the centering point. Limits of the examination, superiorly the skin surface superior to the patella, inferiorly the anterior femoral condyles, laterally and medially the skin margins. The intercondylar groove and the patella should be viewed in profile , the patella femoral joint space should be projected with no superimposition of the patella on the femur. Optimal exposure should penetrate all the bone structures and contrast should be low enough to visualise fully the bone and soft tissue structures.  Patella Axial Rt "skyline" Radiograph |
Related Projections
Knee AP, Lateral, oblique patella projections. |
Additional modalities
CT MRI |
Tibia & Fibula |
AP
|
Indications for imaging
Trauma, bone pain, ?rickets, non accidental injury, leg length assessment. |
| Anatomy Demonstrated Tibia and fibula including the knee and ankle joints.  Rt Tibia & Fibula AP Anatomy
Meschan, I. 1955 An Atlas of
Normal Radiographic Anatomy Saunders, London
|
Basic Patient Position
The patient lies supine on the table with the long axis of the tibia and fibula in line with the long axis of the table. If the leg is positioned in true anatomical normal position with neither the knee or ankle joint will be projected in the "normal " AP position, therefore it is probably best to position the joint nearest the suspected anomaly in correct AP position, i.e. when the knee is in true AP position the ankle will be internally rotated more than normal.  Lt Tibia & Fibula AP Patient Position
Meschan, I. 1955 An Atlas of
Normal Radiographic Anatomy Saunders, London
|
Radiation protection
Direct lead rubber gonad protection using a "half apron". |
Central Ray
The vertical central ray is directed midway between the lateral and medial skin surfaces in the midshaft position to include both joints. |
Exposure Factors
* The cassette may need to be positioned diagonally to include both ankle and knee joints. |
Evaluation of the Image
ID and markers must be present and correct in the appropriate area of the film Evidence of collimation on four sides equally around the centering point. Limits of the examination, superiorly the knee joint inferiorly the ankle joint laterally and medially the skin surfaces. The complete tibia and fibula should be demonstrated. Optimal exposure should penetrate all the bone structures and contrast should be low enough to visualise fully the bone and soft tissue structures.  Lt Tibia & Fibula AP, Radiograph http://www.vh.org/Providers/TeachingFiles/NormalRadAnatomy/Images/ |
Related Projections
Tibia and fibula lateral Knee and Ankle AP and Lateral |
| Additional modalities |
Tibia & Fibula |
Lateral
|
Indications for imaging
Trauma, bone pain, ?rickets, non accidental injury, leg length assessment. |
| Anatomy Demonstrated Tibia and fibula including the knee and ankle joints.  Lt Tibia & Fibula Lateral Anatomy
Meschan, I. 1955 An Atlas of
Normal Radiographic Anatomy Saunders, London
|
Basic Patient Position
The patient lies supine on the table with the long axis of the tibia and fibula in line with the long axis of the table and then rotates externally to the affected side. If the leg is positioned in true anatomical normal position with neither the knee or ankle joint will be projected in the "normal " lateral position, therefore it is probably best to position the joint nearest the suspected anomaly in correct lateral position, i.e. when the knee is in true lateral position the ankle will be externally rotated more than normal.  Rt Tibia & Fibula Lateral Patient Position
Meschan, I. 1955 An Atlas of
Normal Radiographic Anatomy Saunders, London
|
Radiation protection
Direct lead rubber gonad protection using a "half apron". |
Central Ray
The vertical central ray is directed midway between the anterior and posterior skin surfaces in the midshaft position to include both joints. |
Exposure Factors
* The cassette may need to be positioned diagonally to include both ankle and knee joints. |
Evaluation of the Image
ID and markers must be present and correct in the appropriate area of the film Evidence of collimation on four sides equally around the centering point. Limits of the examination, superiorly the knee joint inferiorly the ankle joint laterally and medially the skin surfaces. The complete tibia and fibula should be demonstrated, with either the knee or ankle correctly lateral. Optimal exposure should penetrate all the bone structures and contrast should be low enough to visualise fully the bone and soft tissue structures.  Lt Tibia & Fibula Lateral, Radiograph http://www.vh.org/Providers/TeachingFiles/NormalRadAnatomy/Images/ |
Related Projections
Tibia and fibula AP Knee and Ankle AP and Lateral |
| Additional modalities |
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