Lower extremity
1
Intended Learning Outcomes
• The student should be able to recognize
clinical radiographic technical principles of
the lower limb.
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
3
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
4
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.
5
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.
6
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
7
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
8
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.
9
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
10
Lower Leg Lateral
• Collimation Side to
Side: soft tissues of lower
leg.
• Instructions: Remain still
• Make exposure and let
patient relax
11
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.
12
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.
13
A-P Ankle
14
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
15
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.
16
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.
17
Ankle A-P
• Collimation side to
side: soft tissue of lower
leg and ankle.
• Patient Instructions:
Remain still
• Make exposure and let
patient relax.
18
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.
19
Ankle Oblique Views
Mortise
Medial
20
Always take a medial oblique
Medial Oblique
Lateral Oblique
21
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
22
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.
23
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.
24
Ankle Medial Oblique
• Collimation side to
side: soft tissue of lower
leg and ankle.
• Patient Instructions:
Remain still
• Make exposure and let
patient relax.
25
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.
26
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
27
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.
28
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.
29
Ankle Mortise Oblique
• Collimation side to
side: soft tissue of lower
leg and ankle.
• Patient Instructions:
Remain still
• Make exposure and let
patient relax.
30
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.
31
Lateral Ankle
32
Ankle Lateral
• Measure: Lateral at
malleoli
• Protection: Lead
Apron
• SID: 40” Table Top
• No Tube Angle
• Film: 8” x 10” I.D. up
33
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.
34
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
35
Ankle Lateral
• Collimation side to
side: to include soft
tissue around calcaneus
and lower leg.
• Instructions: Remain still
• Make exposure and let
patient relax.
36
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
37
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
38
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.
39
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
40
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.
41
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.
42
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
43
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.
44
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.
45
Calcaneus Lateral View
• Instructions: Remain still
• Make exposure and let
patient relax.
46
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.
47
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.
48
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.
49
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.
50
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
51
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.
52
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.
53
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
54
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
55
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
56
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.
57
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
58
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.
59
• 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
Foot Oblique
60
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.
61
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.
62
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.
63
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
64
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.
65
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.
66
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
67
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.
68
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.
69
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
70
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.
71
Toes Medial Oblique
• Measure: A-P at
metatarsalphalangeal joints
• Protection: Apron
• SID: 40” Table Top
• No tube angle
• Film: 1/4 of 10” x 12”
or 8” x 10” Extremity
Cassette
72
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.
73
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.
74
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.
75
Toes Medial Oblique
• The joint spaces should
be open.
• The distal metatarsal and
tips of the toes should be
visualized.
76
Toes Lateral
• Measure: Lateral across
the metatarsalphalangeal 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
77
• 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.
1st Toe Lateral
78
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
79
• 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.
3rd Toe Lateral
80
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.
81
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.
82
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.
83
ASSIGNMENT
One student will be selected for
assignment
Question
Mention routine radiographic
positioning of the ankle joint
Suggested Readings
Clark’s radiographic positioning and
techniques
End of Lecture
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87