1 CMC JOINT – THUMB
UPPER EXTREMITY
st
ROBERT METHOD
AP PROJECTION
IR: 8 x 10 inch (18 x 24 cm)
lengthwise
Demonstrate arthritic
changes,fracture,displacement
of the first CMC joint, and the
Bennett's fracture
BURMAN METHOD
AP PROJECTION
Hyperextension of the wrist is
not contraindicated, Burman
stated that this projection
provides a clearer image of the
1st CMC joint than the standard
AP projection.
HAND
PA PROJECTION
IR: 8 x 10 inch (18
x 24 cm)
lengthwise or
crosswise for two
or more images on
one IR.
PATIENT AND PART
POSITION
RP/CENTRAL RAY
Shoulder, elbow, and wrist on
same plane to prevent closing of
the 1st CMC joint, limb extended
straight, arm rotated internally,
posterior aspect of thumb
against IR, hyperextend hand
Long and Rafert: patient may
hold the fingers back with other
hand
Hyperextend hand, have the
patient hold the position with a
bandage looped around the
digits, hand rotated internally,
thumb flat on IR
Robert: ┴ entering 1st
CMC joint
Long and Rafert:
15˚ proximally
entering 1st CMC joint
EVALUATION
CRITERIA
1st CMC joint free of
superimposition and
metacarpal with the
base in convex profile

Trapezium
STRUCTURE
SHOWN
This projection
demonstrate the
1st CMC joint free
of superimposition
,soft tissues and
the hand.
Lewis: 10˚-15˚
proximally entering
1st MCP joint
Through the 1st CMC
joint at a 45˚ angle
toward the elbow


Trapezium in
concave profile
Base of 1st
metacarpal in
convex profile
1st metacarpal
NOTE
CR Angulation
Purposes
(1) Help project soft
tissue of the hand away
from the 1st CMC joint.
(2) Help open the joint
space when the space is
not shown with a ┴ CR.
Magnified
concavoconvex
outline of 1st CMC
joint
SID: recommended is 18” to
produce magnified image that
creates greater field of view of
the concavoconvex of the joint
PATIENT AND PART POSITION
Forearm resting on the table, hand
pronated, spread the finger
slightly, align long axis of the hand
in // with the long axis of the IR
AP PROJECTION
 If the patient cannot extend the
hand enough to place palmar surface
in contact with IR
 Also used for the metacarpals
when hand cannot be extended due
to an injury, pathologic condition or
use of dressings.
RP/CENTR
AL RAY
┴ to the
3rd MCP
joint
EVALUATION
CRITERIA
Equal concavity of
metacarpal and
phalangeal shafts,
fingernails, open MCP
and AP joints
(indicating that the
hand is placed flat to
IR), 1” distal forearm
STRUCTURE SHOWN
Projections of carpals,
metacarpals, phalanges
(except thumb),
interarticulations, distal
radius and ulna, PA oblique
of 1st digit
NOTE
SPECIAL TECHNIQUE:
Clements and Nakayama
describe a special
exposure technique for
imaging early rheumatoid
arthritis
PA OBLIQUE
PROJECTION
(Lateral Rotation)



LATERAL
PROJECTION
(Mediolateral or
lateromedial
Extension)
Lewis:
recommended
rotating hand 5˚
posteriorly from
true lateral, to
better demonstrate
fxs of 5th
metacarpal
FAN LATERAL
Seated and adjust
the patient's height
to rest the forearm
on the table.
Hand pronated,
MCP joints 45˚ with
IR, rotated
externally and
elevate the index
finger.
Opens the joint
spaces and reduces
the foreshortening
of the phalanges
Forearm in contact with
table and hand in
lateral (ulnar aspect
down), extend digits and
the 1st digit at a right
angle to palm, palmar
surface ┴ to IR
Alternative: radial side
of the wrist against IR
(mediolateral) but is
more difficult to assume
Hand and forearm
resting on table, rotate
hand and wrist into
lateral position (thumb
side up), spread fingers
and thumb into a fanlike position,
radiolucent.
┴ to the
3rd MCP joint




┴ to 2nd MCP
joint
Lewis: CR is
angled to be
// with the
extended
thumb
entering the
midshaft of
5th
metacarpal
┴ to 2nd MCP
joint
Minimal overlap of 3rd 4th and 4th -5th
metacarpal shafts
Separation of 2nd and 3rd
metacarpals
Open IP and MCP joint
The resulting image
shows a PA oblique
projection of the
bones and soft
tissues of the hand.
This supplemental
position is used for
investigating
fractures
and pathologic
conditions.
Superimposed
phalanges ,metacarpals
including radius and ulna
Thumb free of motion
and superimposition
This image, which
shows a lateral
projection of the
hand in extension is
the customary
position for localizing
of foreign bodies and
metacarpal fracture
displacement. The
exposure technique
depends on the
foreign body
Superimposed metacarpals
including radius
and ulna.
The fan lateral
superimpose
the metacarpals but
demonstrates almost
all of the individual
phalanges. The most
proximal portions of
the proximal
phalanges remain
superimposed
NORGAARD METHOD
AP OBLIQUE
PROJECTION
(Medial Rotation)
IR: 24 x 30 cm (10 x 12
inch) crosswise
Sometimes referred to a
the ball-catcher's position,
assists in detecting early
radiologic changes needed
to diagnose rheumatoid
arthritis. He also stated
that extremely fine-grain
intensifying screens should
be used to demonstrate
high resolution. Low kilo
voltage peak (60 to 65) is
recommended to obtain
necessary contrast.
PATIENT AND PART
POSITION
Both hands in
lateral, rotate hands
to a half-supinate
position, dorsal
surface resting
against 45˚ sponge,
fingers extended,
thumbs are slightly
abducted to avoid
superimposition
RP/CENTRAL RAY
┴ to a point
midway between
both hands at the
level of the MCP
joints
EVALUATION
CRITERIA
Both hands from the
carpal area to the tips
of the digits Metacarpal
heads free of
superimposition
STRUCTURE SHOWN
The resulting image
shows an AP 45˚oblique
projection of both hands
NOTE
The original method of
positioning the hands is
often modified. The
patient is positioned
similar to the method
described except that
the fingers are not
extended. Instead the
fingers are cupped a if
the patient were going
to catch a ball.
WRIST
PA PROJECTION
IR: 8 x 10 inch (18 x
24 cm) lengthwise or
crosswise for two or
more images on one
IR
Axilla in contact with
table, drop shoulder,
palm against IR, arch
hand slightly/ flex the
wrist to place wrist and
carpal area in close
contact with IR
Alternative: AP should
be taken when ulna is
under examination
┴ to the
midcarpal
area
No excessive and rotation
flexion to overlap and
obscure metacarpals with
digits.
A PA projection of the
carpals, distal radius
and ulna, and proximal
metacarpals is shown.
Distal radius and ulna
Carpals Proximal half of
metacarpals
The projection gives
a slightly oblique
rotation to the ulna.
When the ulna is under
examination, an AP
projection should be
taken.
To better demonstrate the
scaphoid and capitate
Daffner, Emmerling, and
Buterbaugh:
recommended angling the
central ray when the patient is
positioned for a PA radiograph.
A central ray angle of 30degree
toward the elbow elongates the
scaphoid and capitate, whereas
an angle of 30 degree toward
the fingertips only elongates the
capitate.
LATERAL
PROJECTION
Rest arm and forearm on
table to ensure wrist in
true lateral position,
elbow flexed 90˚ to rotate
ulna to lateral position
┴ to wrist joint
Comparison: radial
surface against IR
SCAPHOID SERIES
RAFERT LONG
METHOD
PA AND PA AXIAL
ULNAR DEVIATION
Scaphoid fractures
account for 60% of all
carpal bone injuries.
TRAPEZIUM
CLEMENTS
NAKAYAMAN METHOD
PA AXIAL OBLIQUE
PROJECTION
Seat the patient and
wrist on the IR for a PA
projection.
Without moving the
forearm, turn the
hand outward until the
wrist is in extreme
ulnar deviation
PATIENT AND PART
POSITION
Hand and wrist in lateral
resting on the
ulnar surface, rest the
anterior of the wrist on a
45˚ foam wedge
Ulnar Deviation: long axis
of IR and forearm align
with CR
Distal radius and ulna,
carpals, and proximal
half of metacarpals.
Superimposed distal
radius and ulna
metacarpals.
This image shows a
lateral projection of
the proximal
metacarpals, carpals,
and distal radius and
ulna.
Radiographic density
similar to PA or AP and
oblique radiographs,
which requires increased
exposure factors to
compensate for greater
part thickness.
An image obtained with
the radial surface
against the IR is shown
for comparison. This
position can also be used
to demonstrate anterior
or posterior displacement
in fractures.
0˚/ ┴, 10˚, 20˚, 30˚
cephalad CR should
directly enter the
scaphoid bone.
Collimation should be
close to improve
image quality
CENTRAL RAY
45˚ distally to enter
the anatomic snuffbox
of the wrist and pass
through trapezium
Without Deviation:
align the straight
wrist to IR, rotate
elbow end of IR
and arm in 20˚ away
from CR.
Burman et al: suggested that
lateral position of scaphoid be
obtained with wrist in palmar
flexion to rotate the bone anteriorly
into a dorsovolar position, valuable
only when sufficient flexion is
permitted.
Fiolle: first to describe a small
bony growth occurring on the
dorsal surface of the 3rd CMC joint
termed carpe bossu (carpal boss)
and found that it is demonstrated
best in lateral position with wrist in
palmar flexion.
No rotation of
the wrist
Scaphoid with
adjacent
articular areas
open
Extreme ulnar
deviation
Scaphoid is
demonstrated with
minimal superimposition
Rafert and Long:
described this method of
diagnosing scaphoid
fractures using a fourimage, multiple-angle
central ray series. The
series is performed after
routine wrist radiographs
do not identify a fracture.
EVALUATION
CRITERIA
Trapezium projected
free of other carpal
bones with the
exception of the
articulation with
Scaphoid.
STRUCTURE SHOWN
NOTE
The image clearly
demonstrates the
trapezium and its
articulations with the
adjacent carpal bones
The articulation of the
trapezium and scaphoid
is not demonstrated on
this image.
Fracture of the trapezium
are rare; however, if
undiagnosed, these
fractures can lead to
functional difficulties. In
certain cases the articular
surfaces of the trapezium
should be evaluated to
treat the osteoarthritic
patient.



CARPAL BRIDGE
TANGETIAL PROJECTION
Seated the patient or stand
up
Originators: hand lie palm
upward on the IR, hand at
right angle to forearm
Directed to a point about 1 ½
inches
(3.8 cm) proximal to the
wrist joint at a caudal angle
of 45 degrees
Modified: forearm elevated
on sandbags, wrist flexed in
right angle, vertical IR.
CARPAL CANAL
GAYNOR-HART
METHOD
TANGETIAL
(Inferosuperior)
Hyperextend the wrist, and
center the IR to the joint at
the level of the radial styloid
process and radiolucent stick
3/4 inch (1 .9 cm) thick
under the lower forearm.
To prevent superimposition
of the shadows of the hamate
and pisiform bones, rotate
the hand lightly toward the
radial side.
FOREARM
AP PROJECTION
Directed to the palm of
the hand at a point
approximately 1 inch
(2.5 cm) distal to the
base of the third
metacarpal and at an
angle of 25 to 30
degrees to the long axis
of the hand.







Dorsal aspect of the
wrist
Carpals
Dorsal surface of the
carpals free of
Superimposition by
the metacarpal bases
Carpals in an arch
arrangement
Pisiform in profile
and free of
superimposition
Hamulus of hamate
All carpals
The originators recommended
this procedure for demonstration
of fractures of the scaphoid,
lunate dislocations, calcifications
and foreign bodies in the dorsum
of the wrist, and chip fractures
of the dorsal aspect of the
carpal bones.
This image of the carpal
canal (carpal tunnel)
Shows the palmar
aspect of the trapezium,
the tubercle of the
trapezium, and the
caphoid, capitate, hook
of hamate, triquetrum,
and entire pisiform
This projection was
added as an essential
projection based on the
1997 survey performed
by Bontrager.
PATIENT AND PART POSITION
CENTRAL RAY
EVALUATION CRITERIA
STRUCTURE SHOWN
Seated the patient low enough.
Place entire limb in same plane, hand
supinated, extended elbow, joint of
interest is included, lean laterally until
forearm is in a true supinated position,
humeral epicondyles equidistant from
IR.
┴ to midpoint of
forearm
• Wrist and distal humerus.
• Slight superimposition of the radial head,
neck, tuberosity over the proximal ulna.
• No elongation or foreshortening of the
humeral epicondyles.
• Partially open elbow joint if the shoulder
was placed in the arne plane as the
forearm.
• Similar radiographic densities of the
proximal and distal forearm.
An AP projection of the
forearm demonstrates the
elbow joint, the radius and
ulna, and the proximal row
of slightly distorted carpal
bones
LATERAL
PROJECTION
(Lateromedial)
Seated the patient low enough.
Place entire limb in same plane, elbow
flexed 90˚, entire joint of interest is
included, adjust limb in true lateral
(thumb side up)
HUMERUS
AP PROJECTION
Upright
IR: Lengthwise 18 x 43 cm to
35 x 43 cm
Place the patient in a seatedupright or standing position
used for an AP projection of
the freely movable arm.
The body position, whether
oblique or facing toward or
away from the IR, is
unimportant as long as a true
frontal radiograph of the arm
is obtained
LATERAL PROJECTION
(Lateromedial Upright)
IR:18 x 43 cm; 35 x 43 cm
Patient seated upright.
The body position, whether
oblique or facing toward or
away from the IR, is not
critical as long as a true
projection of the lateral arm
is obtained.
┴ to midpoint of
forearm
Wrist and distal humerus
• Superimposition of the radius and ulna
at their distal end
• Superimposition by the radial head over
the coronoid process
• Radial tuberosity facing anteriorly
• Superimposed humeral epicondyle
• Elbow flexed 90 degrees
• Soft tissue and bony trabeculation along
the entire length of the radial and
ulnar shafts.
Adjust the height of the IR to
place its upper margin about I
Y2 inches (3.8 cm) above the
head of the humerus.
• Abduct the arm slightly, and
supinate the hand.
• A coronal plane passing
through the epicondyles should
be parallel with the IR plane for
the AP (or PA)projection.
┴ to the midportion of
the humerus and the
center of the IR.
Place the top margin of the IR
approximately 1.1/2 inches (3.8
cm) above the level of the head
of the humerus.
• Unless contraindicated by
possible fracture, internally
rotate the arm, flex the elbow
approximately 90 degrees, and
place the patient's anterior
hand on the hip. This will place
the humerusin lateral position.
A coronal plane passing
through the epicondyles should
be ┴ with the IR plane
┴ to the midportion of
the humerus and the
center of the IR.
Elbow and shoulder joint
• Maximal visibi lity of
epicondyles with out rotation
• Humeral head and greater
tubercle in profile
• Outline of the lesser tubercle,
located between the humeral
head and the greater tubercle
• Beam divergence possibly
partially closing the elbow joint
• No great variation in
radiographic densities of the
proximal and distal humerus.
The lateral projection
demonstrates the bones of
the forearm, the elbow
joint, and
the proximal row of carpal
bones.
Entire length of the
humerus. The accuracy of
the position is shown by the
epicondyles
Entire length of the
humerus. A true lateral
image is confirmed by
superimposed epicondyles
DISTAL HUMERUS
AP PROJECTION
(Acute Flexion)
PATIENT AND PART
POSITION
Elbow fully flexed, IR
centered to epicondylar
area of humerus
RADIAL HEAD
LATERAL PROJECTION
(Lateromedial)
Four position series
IR; 8 x 10 inch (18 x 24 cm)
single or 24 x 30 cm divided
For demonstration of the entire
circumference of the radial head
free of superimposition,four
projections with varying
positions of the hand are
performed.
CENTRAL RAY
EVALUATION CRITERIA
┴ to humerus
approximately
2inches (5cm)
superior to
olecranon process
Elbow flexed 90˚, place joint in
lateral
1 st exposure: hand supinated
2 nd exposure: hand in lateral
(thumb side up)
3 rd exposure: hand pronated
4 th exposure: hand in extreme
internal rotation, thumb resting
against table



Forearm and
humerus
superimposed
No rotation
Olecranon process
and distal humerus
┴ to elbow
joint
STRUCTURE SHOWN
NOTE
This position superimposes
the bones of the forearm
and arm. The olecranon
process should be clearly
demonstrated
Jones orthopedic
Technique: (complete
flexion), the lateral
position offers little
difficulty, but the
frontal projection must
be made through the
superimposed bone of
the AP arm and PA
forearm.
Radial tuberosity facing
anteriorly (1 st and 2nd
images), posteriorly (3rd
and 4th images).
Radial head partially
superimposing coronoid
process.
The radial head is
projected in
varying degrees of
rotation
Greenspan and
Norman:
radial head can be
projected more clearly
with reduced
superimposition by
directing the central ray
45 degree medially
(toward the shoulder)
when the structure is
positioned. Useful for
elbow trauma.
ELBOW
AP PROJECTION
Supinate the hand to
prevent rotation of the
bones of the forearm.
LATERAL
PROJECTION
(Lateromedial)
Griswold: gave two
reasons for the
importance of flexing
the elbow 90 degrees:
( l) the olecranon
process can be seen in
profile.
(2) the elbow fat pads
are the least
compressed
AP PROJECTION
(Partial Flexion)
Both exposures can
be made on one 8 x10
inch (18x24 cm) IR or
on one IR placed
crosswise by
alternately covering
one half of the IR with
a lead mask.
PATIENT AND PART
POSITION
Seated the patient low
enough.
Entire limb in same plane,
elbow extended, hand
supinated, lean laterally
until humeral epicondyles
and anterior surface of
elbow are // with plane of
IR
Seated the patient low
enough.
Humerus and elbow joint
in same plane, elbow
flexed 90˚, elevate the wrist
to place forearm // with IR
on patients with muscular
forearm,diagonal IR, hand
in lateral to ensure
humeral epicondyles are ┴
to plane of IR.
Seated the patient low
enough.
Entire humerus on same
plane, forearm elevated
with support, hand
supinated possible, IR
centered to condyloid area
of humerus
CENTRAL RAY
┴ to elbow joint
EVALUATION CRITERIA



┴ to elbow joint
regardless of its
location on IR







┴ to the humerus,
traversing elbow
joint, angle CR
distally into the joint
depending on degree
of flexion



Radial head, neck
tuberosity slightly
superimposed over the
proximal ulna
Elbow joint open and
centered to the central
ray
No rotation of humeral
epicondyles
Open elbow joint
Elbow flexed 90 degrees
Superimposed humeral
epicondyles
Radial tuberosity facing
anteriorly
Radial head partially
superimposing the
coronoid process
Olecranon process seen
in profile
Bony trabeculation and
any elevated fat pads in
the soft tissue at the
anterior and posterior
distal humerus and the
anterior proximal forearm
Closed elbow joint
Proximal radius
superimposed over ulna
Distal humerus with no
rotation or distortion
STRUCTURE
SHOWN
An AP projection of
the elbow joint,
distal arm, and
proximal forearm is
presented
NOTE
The lateral projection
demonstrates the
elbow joint, distal
arm, and proximal
forearm
.
When injury to the soft
tissue around the elbow
is suspected, the joint
should be flexed only 30
or 35 degrees. This
partial flexion does not
compress or stretch the
soft structures as does
the full 90-degree
lateral flexion.
This projection shows
the
distal humerus when
the
elbow cannot be fully
extended
When the patient
cannot completely
extend the elbow, the
lateral position is
easily performed;
however, two AP
projections must be
obtained to avoid
distortion. A separate
AP projection of the
distal humerus and
proximal forearm is
required.
SHOULDER
AP PROJECTION
Neutral Rotation
PATIENT AND PART
POSITION
Upright (more
comfortable) or
supine; patient
slightly rotated;
scapula // to IR
CENTRAL RAY
┴ to a point 1 inch
(2.5 cm) inferior to
the coracoid
process.
EVALUATION CRITERIA



External Rotation
Neutral Rotation:
palmar/anterior
aspect of hand placed
against the hip;
humeral epicondyles
45 degree to IR




Internal rotation
Internal Rotation:
dorsal/posterior
aspect of hand
against hip; humeral
epicondyles ┴ to IR




Humeral head in profile
Greater tubercle in profile
on the lateral aspect of the
humerus
Scapulohumeral joint
visualized with slight
overlap of humeral head
on glenoid cavity
Outline of lesser tubercle
between the humeral head
and greater tubercle
Lesser tubercle in profile
and pointing medially
Outline of the greater
tubercle supelimposing the
humeral head
Greater amount of
humeral overlap of the
glenoid cavity than in the
external and neutral
positions
Greater tubercle
partially
superimposing
humeral head




External Rotation:
hand supinated;
humeral epicondyles
// to IR; arm
abducted slightly
Greater tubercle partially
superimposing the
humeral head
Humeral head in partial
profile
Slight overlap of the
humeral head on
the glenoid cavity
STRUCTURE SHOWN






Posterior part of
supraspinatus
insertion
Oblique proximal
humerus
Greater tubercle
Site of insertion of
supraspinatus
tendon
AP proximal
humerus
Lesser tubercle
Site of the
insertion of the
subscapular
tendon
Proximal humerus
in true lateral
position
NOTE
Do not have the
patient rotate the arm if
fracture or dislocation is
suspected.
LAWRENCE
METHOD
(TRANSTHORACIC
LATERAL
PROJECTION)
R or L Position
SCAPULA
SCAPULAR Y
(PA OBLIQUE
PROJECTION)
PATIENT AND PART
POSITION
Upright (more
comfortable) or supine;
patient in lateral
position; uninjured arm
raised; forearm rested on
head; midcoronal plane
┴ to IR; full inspiration
(improves contrast &
reduces exposure) or
breathing technique
(slow, deep breathing)
Upright/recumbent;
RAO/LAO; MCP 45-60
degree to IR; scapular
flat surface ┴ to IR;
RPO/LPO (for severely
injured patient)
RP/CENTRAL RAY
RP:Level of surgical
neck horizontal or
10-15 degree cephalad
(cannot elevate
unaffected shoulder.
EVALUATION CRITERIA




RP: Scapulohumeral
joint
CR: ┴
Proximal humerus
Scapula, clavicle, and
humerus seen through
the lung field
Scapula superimposed
over the thoracic spine
Unaffected clavicle and
humerus projected
above the shoulder
closest to the IR.
Useful in evaluation of
suspected shoulder
dislocations
Anterior/subcoracoid
dislocation: humeral head
beneath the coracoid
process
Posterior/subacromial
dislocation: humeral head
beneath the acromion
process
LATERAL
PROJECTION
Upright /seated;
RAO/LAO (more
difficult to
perform); 45-60
degree from IR;
RPO/LPO
(magnified scapula;
for trauma patient)
Arm Placement:
Elbow flexed & arm on
posterior chest

For demonstration
of acromion and
coracoid process
Arm extended upward
and forearm rested on
head or across upper
chest

For demonstration
of scapular body
RP: Midmedial border of
protruding scapula
CR: ┴





Lateral and medial
border superimposed
No superimposition of
the scapular body on
the ribs
No superimposition of
the humeru on the
area of interest
Inclusion of the
acromion process and
inferior angle
Lateral thickness of
scapula with proper
density
STRUCTURE SHOWN
Proximal humerus
(projected through
thorax)
NOTE
Trauma exists and the
arm cannot be rotated
or abducted because of
an injury.
Demonstrate proximal
humerus in 90 degrees
from AP projection
Show its relationship to
the scapula and clavicle







Scapular body (form the
vertical component);
acromion & coracoid
processes (form the
upper limbs)
Superimposed humeral
head & glenoid cavity
Superimposed humeral
shaft & scapular body
Coracoid process
superimposed or
projected below the
clavicle
Lateral image of scapula
No superimposition of
scapular body on ribs
Superimposed lateral and
medial border
Mazujian
Suggestion: arm
across the upper
chest (grasping
opposite shoulder)
CLAVICLE
AP PROJECTION
AP AXIAL
PROJECTION
(LORDOTIC
POSITION)
PATIENT AND PART POSITION
Supine (reduces the possibility of
fragment displacement/additional
injury) or upright
arms along the sides;
clavicle center to IR
RP: Midshaft of
clavicle
CR: ┴
Upright: 1 foot in front; lean
backward (lordotic); neck &
shoulder against IR; neck in
extreme flexion
Supine: cannot assumed lordotic
position
RP: Midshaft of
clavicle
CR: 0-15 degree
cephalad (upright);
15-30 degree
cephalad (supine)
Thinner patients
(more angulation)
 To project
clavicle off the
scapula and ribs
Suspend at end of full inspiration
(to further elevate and angle the
clavicle).
CHEST
PA PROJECTION
IR: 14x17
SID: 72 inches
LATERAL
PROJECTION
RP/CENTRAL RAY
Upright position, body againts the
vertical grid, adjust the IR height
atleast 2inches above, extend the
chin upward; place the arms at side
or in the back below; depress the
shoulder forward againts the IR.
Respiration: Full inspiration. The
exposure is made after the second
full inspiration to ensure maximum
expansion of the lungs.
Upright position, place in true lateral
position with arms above the head,
adjust the IR height atleast 2inches
above
EVALUATION CRITERIA
STRUCTURE SHOWN
SS:Frontal image of clavicle
PA Projection: reduces OID &
improved image contrast
Well accepted by patient who can
stand
Most of the clavicle projected
above the
ribs and scapula
• Clavicle in a horizontal
placement
• Entire clavicle along with the
acromioclavicular and
sternoclavicular joints
┴ to the center of the IR.
The CR should enter at
the level of T7.


┴ to the center of the IR.
The CR should enter at
midcoronal plane at the
level of T7 or inferior
aspect of the scapula.
Entire lung fields
from the apices to
the costophrenic
angles
No




True/axial projection of clavicle
Clavicle projected above the ribs;
true/exact axial projection of
clavicle
Slightly distorted image (due to
angulation)
Medial end overlapping 1st & 2nd
ribs
A PA projection of the thoracic viscera
shows the air-filled trachea, the lungs,
the diaphragmatic dome , the heart
and aortic knob, and if enlarged
laterally, the thy
roid or thymu gland.
The preliminary left lateral chest
position is used to demonstrate the
heart, the aorta, and left-sided
pulmonary lesions.
SESAMOID
TANGENTIAL
PROJECTION
HOLLY METHODS
TANGENTIAL
PROJECTION
CAUSTON METHOD
Place the patient in the
lateral recumbent
position on the
unaffected side,
and flex the knees.
Partially extend the
limb being examined
and put sandbags
under the knee
and foot.
PATIENT AND PART
POSITION
RP/CENTRAL RAY
Patient seated on the table.
the foot is adjusted so that the
medial border is vertical and
the plantar surface is at an
angle of 75 degrees with the
plane of the lR. The patient
holds the toes in a flexed
position with a strip of gauze
bandage.
RP: 1st MTP head
CR: ┴
Adjust the height of a sandbag
under the knee to place the
foot in the lateral
position, with the 1st MTP joint
perpendicular to the
horizontal plane of the IR
Place the IR under the distal
metatarsal region, and adjust
it so that the midpoint will
coincide with the central ray.
RP:Prominence of 1st
MTP joint
CR: 40 degrees
toward the heel.
FOOT
AP OR AP AXIAL PROJECTION
Radiographs may be obtained by
directing the central ray ┴ to the
plane of the IR or by angling the
central ray to degrees posteriorly.
When a 10 degree posterior angle
is used, the central ray is ┴ to the
MT therefore reducing
foreshortening.
The TNT joint spaces of the
midfoot are also demonstrated
better.
EVALUATION CRITERIA


Sesamoids free of any
portion of the first
metatarsal
Metatarsal heads
For improved detail, a similar
projection may be performed
using an occlusal film.
STRUCTURE SHOWN
NOTE
The resulting image shows
a tangential
projection of the
metatarsal head in profile
and the sesamoids
Holly' described this
position because he
believed that this was more
comfortable for the patient.
The tangential image
shows the sesamoid
bones projected
axiolaterally with a slight
overlap
PATIENT AND PART POSITION
RP/CENTRAL RAY
EVALUATION CRITERIA
STRUCTURE SHOWN
Place the patient in the supine
position. Flex the knee
RP: 3rd MTP base
CR: ┴ or 10 degrees
posteriorly.
The following should be clearly
demonstrated
• No rotation of the foot
• Equal amount of space between
the adjacent midshafts of the 2nd
through 4th MT
• Overlap of the 2nd through 5th
MT bases
• Visualization of the phalanges
and tarsals distal to the talus, as
well as the Metatarsals.
S: Metatarsal & Tarsal (┴);
tarsometatarsal joint (10 degrees).
Position the IR under the patient's
foot, center it to the base of the
3rdMT.
Having the patient flex the
opposite knee and lean it against
the knee of the affected side.
In this foot position the entire
plantar surface rests on the IR.
The resulting image shows an AP
(dorsoplantar) projection of the
tarsal anterior to the talus,
metatarsals, and phalanges
This projection is used for
localizing foreign bodies,
determining the location of
fragments in fractures of the
metatarsals and anterior tarsals,
and performing general
surveys of the bones of the foot.
PATIENT AND PART POSITION
AP OBLIQUE
PROJECTION
Medial rotation
Supine; knee flexed; leg rotated medially;
Place the IR under the patient's foot,
parallel with its long axis, and center it to
the midline of the foot at the level of the
base of the third metatarsal.
RP/CENTRAL
RAY
RP: 3rd MTP base
CR: ┴
EVALUATION CRITERIA




Rotate the patient's leg medially until the
plantar surface of the foot forms an angle
of 30 degrees to the plane of the IR, If the
angle of the foot is increased more than
30 degrees, the lateral cuneiform tends to
be thrown over the other
cunei forms.







AP OBLIQUE
PROJECTION
Lateral rotation
LATERAL
PROJECTION
Mediolateral
More comfortable
to patient
LATERAL
PROJECTION
Lateromedial
More difficult to
assume.
Supine; knee flexed; leg rotated laterally
Place the IR under the patient's foot,
parallel with its long axis, and center it to
the midline of the foot at the level of the
base of the third metatarsal.
Rotate the leg laterally until the plantar
surface of the foot forms an angle of 30
degree to the IR.
Support the elevated side of the foot on a
30-degree foam wedge to ensure
consistent results.
Dorsiflex foot (┴ to lower leg); leg and foot
in lateral position; lateral side of foot
against IR;
Patient lie on the radiographic
table and turn toward the affected side
until the leg and foot are lateral. Place
the opposite leg behind the patient.
Patella perpendicular to the
horizontal plane. Dorsiflex the foot to
form a 90-degree angle with the lower
leg.
Supine position.
Turn the patient onto the unaffected side
until the affected leg and foot are
laterally placed. The patient's body will
be in an LPO or RPO position.
IR to the middle area.
Adjust the foot so that the plantar
surface is perpendicular to the IR.
RP: 3rd MTP base
CR: ┴




RP: 3rd MT base
CR: ┴
RP: 3rd MT base
CR: ┴
Third through fifth metatarsal bases
free of
superimposition
Lateral tarsals with Iess
superimposition than
in the AP projection
Lateral TM and intertarsal joints
Sinus tarsi
Tuberosity of the 5th MT
Bases of the 1st and 2nd MT
Equal amount of space between the
shafts of
the 2nd through 5th MT
Sufficient density to demonstrate the
phalanges, metatarsals, and tarsals
Separate first and second metatarsal
bases
No superimposition of the medial and
intermediate cuneiform.
Navicular bone more clearly
demonstrated than in the medial
rotation.
Sufficient density to demonstrate the
phalanges, metatarsals, and tarsals.
For localizing foreign body
• Degree of anterior and posterior
displacement of fractures.
 Metatarsals nearly superimposed
 Distal leg
 Fibula overlapping the posterior
portion of the tibia
 Tibiotalar joint .
 Sufficient density to demonstrate the
superimposed tarsals and
metatarsals.






Metatarsals usually more
superimposed than in the
mediolateral image, depending on the
transverse arch of the foot
Distal leg
Fibula overlapping the posterior
portion of the tibia
Tibiotalar joint
Sufficient density to demonst. the
superimposed tarsals and
metatarsals
STRUCTURE
SHOWN






NOTE
Cuboid in profile
Sinus tarsi (well
demonstrated)
Interspaces b/n:
A similar projection using a 45degree medial rotation of the foot
and a PA oblique projection is
described.
cuboid & calcaneus;
cuboid & 4th & 5th
MT
Talus & navicular
bone
A greater rotation can be helpful
in demonstrating the joint spaces
of the foot.
The resulting image show
the interspaces
between the 1st and 2nd
metatarsals and between
the medial and
intermediate cunei
forms.
Entire foot in profile, the
ankle joint, and the distal
ends of the tibia and
fibula.
The lateral (mediolateral)
projection is routinely used in
most radiology departments
because it is a comfortable
position for the patient to
assume. The lateromedial
projection, however, is the
recommended alternative when
the patient's condition permits.
A true lateromedial
projection of the foot,
ankle joint, and distal
ends of the tibia and
fibula
Lateral projections of
the foot should be made with the
medial side in contact with the
IR. In the absence of an
unusually prominent medial
malleolus, hallux valgus, or other
deformity, the
foot assumes an exact or nearly
exact lateral position when
resting on its medial side.
PATIENT AND PART POSITION
AP AXIAL PROJECTION
WEIGHT-BEARING
METHOD
Standing position
24x30 cm crosswise for both
feet on one IR:
SID: 48 inches SID is used
to reduce magnification and
improve recorded detail in
the image
AP AXIAL
PROJECTION
WEIGHT-BEARING
COMPOSITE
METHOD
Standing position
Standing-upright position.
Place the IR on the floor, and have
the patient stand on the IR with the
feet
centered on each side.
Pull the patient' pants up to the
knee level, if necessary.
Ensure that the patient's weight is
distributed equally on each foot.
The patient may hold the x-ray tube
crane for stability.
Standing-upright position. The patient
should stand on low stool or on the
floor
Adjust the IR under the foot and
center its midline to the long axis of
the foot.
To prevent superimposition of the leg
shadow on that of the ankle joint, have
the patient place the opposite foot one
step backward for the exposure of the
forefoot
and one step forward for the exposure
of the hind foot or calcaneus.
WEIGHT-BEARING
COALITION METHOD
(DORSOPLANTAR AXIAL PROJECTION)
This method, described by Lilienfeld' (cit.
Holzknecht), has come into use for the
demonstration of calcaneotalar coalition.
For this reason it has been called the
"coalition position."
RP/CENTRAL RAY
Angled 10º toward the
heel is optimal.
A minimum of 15º is
usually necessary to have
enough room to position
the tube and allow the
patient to stand.
EVALUATION CRITERIA




Both feet centered on one image
Phalanges, metatarsal , and distal tar
also
Correct right and left marker placement
and a weight-bearing marker
Correct exposure technique to visualize
all the components
STRUCTURE SHOWN
Weight-bearing AP axial
projection of both
feet permitting an accurate
evaluation and
comparison of the tarsal and
metatarsal.
The central ray between
the feet and at the level of
the base of the 3rd
metatarsal.
Direct the central ray along the plane of alignment of the
foot in both exposures. With the tube in front of the patient
and adjusted for a posterior angulation of 15º, center the
central ray to the base of the third metatarsal for the first
exposure.
Maintain the position of the affected foot and place the
opposite foot one step forward in preparation for the second
exposure.
Move the tube behind the patient, adjust it for an anterior
angulation of 25º, and direct the central ray to the posterior
surface of the ankle. The central ray emerges on the plantar
surface at the level of the lateral malleolus. An increase in
technical factors is recommended for this exposure.
Place the patient in the standing-upright position.
Center the IR to the long axis of the calcaneus,
with the posterior surface of the heel at the edge of
the IR.
To prevent Superimposition of the leg shadow,
have the
patient place the opposite foot one step forward
Angled exactly 45
degrees anteriorly and
directed through the
posterior surface of the
flexed ankle to a point
on the plantar surface
at the level of the base
of the 5th metatarsal.


All tarsals
Shadow of leg not
overlapping
Image shows a
weight-bearing AP
axial projection of all
bones of the foot.
The full outline of the
foot is projected free
of the leg.
ANKLE
AP PROJECTION
PATIENT AND PART POSITION
Adjust the ankle joint in the
anatomic position to obtain a true
AP projection.
Flex the ankle and foot enough to
place the long axis of the foot in the
vertical position .
RP/CENTRAL
RAY
RP: Point midway
between malleoli
CR: ┴ to ankle
joint
Ball and Egbert: stated that the
appearance of the ankle mortise is
not appreciably altered by moderate
plantar flexion or dorsiflexion as
long as the leg is rotated neither
laterally nor medially.
LATERAL
PROJECTION
Mediolateral
Have the supine patient turn toward
the affected side until
the ankle is lateral
Place the long axis of the IR parallel
with the long axis of the patient's leg
and center it to the ankle joint. o
Ensure that the lateral surface of
the foot is in contact with the IR.
LATERAL
PROJECTION
Lateromedial
Dorsiflex the foot and adjust it in
the lateral position.
Dorsiflexion is required to prevent
lateral rotation of the
ankle.
Supine patient turn away from the
affected side until the extended leg
is placed laterally.
Have the patient turn anteriorly or
posteriorly as
required to place the patella
perpendicular to the
horizontal plane.
RP: Medial
malleolus
CR: ┴ to ankle
joint
RP: 0.5 in.
superior to lateral
malleolus
CR: ┴ to ankle
joint
EVALUATION CRITERIA
Tibiotalar joint space
• Ankle joint centered to
exposure area
• Normal overlapping of
the tibiofibular
articulation with the
anterior tubercle slightly
superimposed over the
fibula
• Talus slightly
overlapping the distal
fibula

• Ankle joint centered to
exposure area
• Tibiotalar joint well
visualized, with the
medial and lateral talar
domes superimposed
• Fibula over the
posterior half of the tibia
• Distal tibia and fibula,
talus, and adjacent
tarsals
• Density of the ankle
sufficient to see the
outline of distal portion
of the fibula
STRUCTURE
SHOWN
Shows a true AP
projection of the
ankle joint, the
distal ends of the
tibia and fibula,
and the proximal
portion of the talus
Shows a true
lateral projection of
the lower third of
the tibia and
fibula, the ankle
joint, and the
tarsals.
NOTE
MORTISE JOINT
(AP OBLIQUE
PROJECTION)
Medial rotation
LEG
AP PROJECTION
Supine position.
Center the patient's ankle
joint to the IR.
Assist the patient by
internally rotating the entire
leg and foot together 15 to 20
degrees until the
intermalleolar plane is
parallel with the IR.
The plantar surface of the foot
should be placed at a right
angle to the leg.
PATIENT AND PART POSITION
Supine position.
Adjust the patient's body so that the
pelvis is not rotated.
Adjust the leg so that the femoral
condyles are parallel
with the IR and the foot is vertical.
RP:Midway between
malleoli
CR: ┴ to ankle joint



RP/CENTRAL
RAY
RP: Midshaft
CR: ┴
Talus demonstrated with
proper density
Entire ankle mortise joint
No overlap of the anterior
tubercle of the tibia and
the superolateral portion
of the talus with the
fibula
The entire ankle mortise
joint should be
demonstrated in profile.
The three sides of the
mortise joint should be
visualized
EVALUATION CRITERIA




Fibula, Tibia, Medial malleolus,Lateral malleolus.
Ankle and knee joints on one or more AP projections
Ankle and knee joints without rotation
Proximal and distal articulations of the tibia and
fibula moderately overlapped
Flex the ankle until the foot is in the
vertical position.
If necessary, place a sandbag against
the plantar surface
of the foot to immobilize it in the
correct position
LATERAL
PROJECTION
mediolateral
PP: Supine; RPO/LPO; patella ┴ to IR;
femoral condyles ┴ to IR.
RP: Midshaft
CR: ┴






Ankle and knee joints on one or more images
Distal fibula lying over the posterior half of the tibia
Slight overlap of the tibia on the proximal fibular head
Ankle and knee joints not rotated
Possibly no superimposition of femoral condyles
because of divergence of the beam
Moderate separation of the tibial and fibular bodies,
or shafts except at their articular ends.
STRUCTURE SHOWN
Image shows the tibia,
fibula, and adjacent joints
KNEE
AP PROJECTION
PATIENT AND PART POSITION
RP/CENTRAL RAY
Supine position and adjust the body so that the
pelvis is not rotated.
Depending on the
measurement between anterior
superior iliac spine and table
top.
With the IR under the patient's knee, flex the
joint slightly,
locate the apex of the patella, and as the patient
extends the
knee, center the IR about 1/2 inch (1.3 cm)
below the
patellar apex.
Adjust leg: placing the femoral epicondyle //
with the IR. The patella will lie slightly off center
to the medial side. If the knee cannot be fully
extended, a curved IR may be used.
LATERAL
Turn into the affected side. Pelvis is not rotated.
PROJECTION
The knee forward and extend the other limb
mediolateral
behind it. A flexion of 20 to 30 degrees is
usually preferred because this position relaxes
the muscles and shows the maximum volume
of the joint cavity. To prevent fragment
separation in unhealed patellar fracture , the
knee should not be flexed more than 10
degrees.
AP PROJECTION
Upright position with back toward a vertical
WEIGHT BEARING
grid device.
METHOD
Standing
Adjust the patient's position to center the
knees to the IR. Place the
toes straight ahead, with the feet separated
enough for good
balance. Knees fully extended and
weight equally distributed on the feet
Center the IR 1/2 inch (1.3 cm) below the
apices of the patellae.
PA Projection
Standing position with the anterior
ROSENBERG METHOD
aspect of the knees centered to the vertical
Weight-bearinggrid device.
Standing flexion
Center the IR at a level 1/2 inch (1.3 cm)
below the apices of the patellae.
Have the patient grasp the edge of the grid
device and flex knees to place the femurs at
an angle of 45 degrees



3-5 degree caudad (less
than 19 cm; thin pelvis).
┴ (19-24 cm)
3-5 degree cephalad
( greater 24 cm; large
pelvis)
EVALUATION CRITERIA




STRUCTURE SHOWN
Open femorotibial joint space
Knee fully extended if patient'
condition permits
Interspaces of equal width on
both sides if the knee is normal
Patella completely superimposed
on the femur
RP: 1 in. distal to medial
epicondyle
CR: 5-7 degree cephalad
hows a lateral image of the
distal end of
the femur, patella, knee
joint, proximal ends of the
tibia and
fibula, and adjacent soft
tissue.
RP: 0.5 in. inferior to patellar
apex
CR: Horizontal
Both knees
Knee joint space centered to the
exposure area
Adequate IR size to demonstrate
the longitudinal axis of the femoral
and tibial bodies or shafts
Shows the joint spaces of
the knees. Varus and
valgus deformities can also
be evaluated with this
procedure.
RP: 0.5 in. inferior to patellar
apex
CR: Horizontal or 10 degree
caudad
Weight-bearing study of a single
knee, the patient puts full weight
on the affected side. The patient
may balance with slight pressure
on the toes of the unaffected
Side.
weight-bearing method is
useful for evaluating joint
space narrowing and
demonstrating articular
cartilage disease.
INTERCONDYLAR FOSSA
PATIENT AND PART POSITION
HOLMBLAD METHOD
PA AXIAL PROJECTION
TUNNEL VIEW
PA Axial Projection
CAMP-COVENTRY
METHOD
BECLERE METHOD
(AP AXIAL
PROJECTION)
PATELLA
PA PROJECTION
RP/CENTRAL RAY
Anterior surface of knee against IR;
knee 60-70 degree from IR (20o
difference from CR) 3 positions:
• Standing; knee flexed & rested on a
stool
• Standing at side of table; knee flexed
& rested over the IR.
• Kneeling on table; knee over the IR
(Holmblad Method.)
RP: Popletial
depression
CR: ┴
Prone position and adjust the body so
that it is not rotated.
RP: Popletial
depression
CR: 40 degree (knee
flexed 40 degree )
or 50 degree (knee
flexed 50 degree )
caudally
Flex the patient' knee to either a 40- or
50-degree angle and rest the
foot on a suitable support.
Center the upper half of the IR to the
knee joint;A protractor may be used
beside the leg to determine the correct
leg angle. Adjust the leg so that the
knee has no medial or lateral rotation.
Supine position, and adjust the body so
that it is not rotated
Position of part:
Flex the affected knee enough to place
the long axis of the femur
at an angle of 60 degrees to the long
axis of the tibia. Support the knee on
sandbags.
RP: 0.5 in. inferior to
patellar apex
CR: ┴ to long axis of
lower leg
PATIENT AND PART POSITION
Prone position. If the knee is painful, place one
and bag under the thigh and another under the
leg to relieve pressure on the patella.
Position of part:
Center the IR to the patella.
The leg to place the patella parallel with the
plane of the IR. This usually requires that the
heel be rotated 5 to 10 degrees lateral.
EVALUATION CRITERIA
STRUCTURE SHOWN
The resulting image shows the
intercondylar fossa of the femur and the
medial and lateral intercondylar tubercles of
the intercondylar eminence in profile.
Holmblad stated that the degree
of flexion used in this position
widens the joint space between
the femur and tibia and gives an improved
image of the joint and the surface of the
tibia and femur.
This axial image demonstrates an unobstructed
projection of the intercondyloid fossa and the
medial and lateral intercondylar tubercles of
the intercondylar eminence.




Open intercondylar fossa
Posteroinferior surface of
the femoral condyles
Intercondylar eminence
and knee joint space
No superimposition of the
fossa by the apex of the
patella.
RP/CENTRAL RAY
RP: Mid-popliteal
depression
CR: Perpendicular
In routine examinations of the knee joint, an
intercondylar for a projection is usually
included to detect loose bodies (''joint mice").
The projection is also used in evaluating split
and displaced cartilage in osteochondritis
disease can and flattening, or
underdevelopment, of the lateral femoral
condyle in congenital slipped patella.
Shows the intercondylar fossa, intercondylar
eminence, and knee joint
EVALUATION CRITERIA



Patella completely
superimposed by the femur
Adequate penetration for
visualization of the patella
clearly through the
superimposing femur
No rotation
STRUCTURE SHOWN
the patella provides sharper
recorded detail than in the AP
projection because of a closer
object-to mage receptor distance
(SID)
LATERAL PROJECTION
mediolateral
HUGHSTON METHOD
TANGENTIAL
PROJECTION
IR:8x10 inch (18x24cm) for
unilateral examination
24x30cm crosswise for
bilateral examination
MERCHANT METHOD
TANGENTIAL
PROJECTION
24 x 30 cm bilateral
examination
SID: A 6-foot (2-m) SID is
recommended to reduce
magnification.
(Merchant reported that
the degree of angulation
may be varied between 30
to 90º to demonstrate
various patellofemoral
disorders.)
SETTEGAST
METHOD
TANGENTIAL
PROJECTION
Patient in the lateral recumbent position.
Position of part:
Ask the patient to turn into the affected hip. A
sandbag under the ankle for support. Flex the
unaffected knee and hip and place the
unaffected foot in front of the affected limb for
stability.
Flex the affected knee approximately 5 to 10
degrees. The patella is perpendicular to the IR.
RP: Midpatellofemoral
joint
CR: ┴
Prone position with the foot resting, Body so that it is not rotated.
Position of part:
IR under the patient' knee, and slowly flex the affected knee so that
the tibia and fibula form a 50- to 60- degree angle from the table.
Rest the foot against the collimator, or support it in position.Ensure
that the collimator surface is not hot because this could burn the
patient.
Adjust the patient's leg so that it is not rotated medially or laterally
from
the vertical plane.
Supine with both knees, Support the knees and lower legs by an
adjust table IR-holding device. To increase comfort and relaxation of
the quadriceps femoris, place a foam wedge under the patient's head
and back.
Using the "axial viewer" device, elevate the patient's knees
approximately 2 inches to place the femoral parallel. Adjust the angle
of knee flexion to 40º
Strap both legs together at the calf level to control leg rotation and
allow patient relaxation; IR perpendicular to the central ray and
resting on the patient’ shins (a thin foam pad aids comfort)
approximately 1 foot distal to the patellae.




Knee flexed 5 to 10 degrees
Open patellofemoral joint
space
Patella in lateral profile
Close collimation
show a lateral projection of the
patella and patellofemoral joint
space
RP: Patellofemoral joint
CR: 45o cephalad
RP: 40-degree knee
flexion, angle the CR 30
degrees caudad from the
horizontal plane (60
degrees from vertical) to
achieve a 30-degree
central ray to-femur
angle.



Patellae in profile
Femoral condyle and
intercondylar sulcus
Open patellofemoral
articulations
CR: midway between the
patellae at the level of
the patellofemoral joint.
Ensure that the patient is able to relax. Relaxation of the quadriceps
femoris is critical for an accurate diagnosis If these muscles are not
relaxed, a subluxed patella may be pulled back into the intercondylar
sulcus, showing a false normal appearance. Record the angle of knee
flexion for reproducibility during follow-up examination , because the
severity of patella subluxation commonly changes inversely with the
angle of knee flexion.
Supine or prone position. The latter is
preferable because the knee can usually be flexed to a greater degree and
immobilization is easier
If the patient is seated on the radiographic table, hold the IR.
Position of part:
Flex the patient' knee lowly as much as possible or until the patella is
perpendicular to the IR if the patient' condition permits. With slow, even flexion,
the patient will be able to tolerate the position, whereas quick, uneven flexion may
cause too much pain. If desired, loop a long strip of bandage around the patient's
ankle or foot. Have the patient grasp the ends over the shoulder to hold the leg in
position. Gently adjust the leg that its long axis is vertical.
Perpendicular to the joint
space between the patella
and the femoral condyles
when the joint is
perpendicular.
When the joint is not, the
degree of central ray
angulation depends on the
degree of flexion of the knee.
The angulation typically will
be 15 to 20º
Bilateral tangential image
demonstrate an axial projection
of the patellae and patellofemoral
joints.
Because of the right-angle
alignment of the IR and central
ray, the patellae are seen as non
distorted albeit slightly magnified
images
Patella in profile
Open patellofemoral
articulation
Surfaces of the femoral
condyle
Shows vertical fractures of
bone and the articulating
surfaces of the
patellofemoral articulation
SUNRISE METHOD
(TANGENTIAL
PROJECTION)
MOUNTAIN/SKYLINE VIEW
PP: Supine/Sitting; knee flexed 40-45 degree
FEMUR
AP PROJECTION
Supine position.
Pelvis is not rotated
Position of part:
Center the affected thigh to
the midline of the IR. When
the patient is too tall to
include the entire femur,
include the joint closest to
the area of interest on one
image.
LATERAL PROJECTION
Mediolateral
Ask the patient to turn
onto the affected side.
Adjust the body position
and center the affected
thigh to the midline of the
grid.
DANELIUS-MILLER
METHOD
AXIOLATERAL
PROJECTION
Cross-table/Surgicallateral Projection
With the knee included: For projection of the distal femur,
rotate the patient's limb internally to place it in true anatomic
position. The limb will naturally be turned externally when laying
on the table. Ensure that the epicondyle are parallel with the IR.
Place the bottom of the IR 2 inches (5 cm) below the knee joint
RP: Patellofemoral joint
CR: 30 degrees from
horizontal
ER: Joint space b/n
patella & femoral
condyles
Perpendicular to
the mid femur
and the center of
the IR
With the hip included:
The proximal femur, which must include the hip joint, place the
top of the IR at the level of the ASIS.
Rotate the limb internally 10 to 15 degrees
to place the femoral neck in profile.
Position of part:
With the knee included:
For projection of the distal femur, draw the patient's uppermost
limb forward and supp0l1 it at hip level on sandbags. Adjust the
pelvis in a true lateral position
Flex the affected knee about 45 degrees, place a sandbag under
the ankle, and adjust the body rotation to place the epicondyles
perpendicular to the tabletop. Adjust the position of the Bucky
tray so that the lR project approximately 2 inch. (5 cm) beyond
the knee to be included.
Perpendicular to
the mid-femur
and the center of
the IR.
With the hip included:
For projection of the proximal femur, place the top of the IR at
the level of the ASIS.
Draw the upper limb posteriorly and support it.
Adjust the pelvis so that it is rolled posteriorly just enough to
prevent superimposition; 10 to 15 degrees from the lateral
position is sufficient
Supine; pelvis elevated; knee & hip of
unaffected side flexed; leg of unaffected side rested
on support; foot & leg of affected side rotated 1520o; IR vertical; IR // to long axis of femoral neck
RP: Femoral
neck
CR: Horizontal
• Majority of the femur and
the joint nearest to the
pathologic condition or site
of injury (A 2nd radiograph of
the other end of the femur is
recommended.)
• Any orthopedic appliance
in its entirety
• Inferior surface of the
femoral condyles not
superimposed because of
divergent rays With the hip
included.
• Opposite thigh not over
area of interest
• Greater and lesser
trochanters not prominent
NOTE:
Because of the danger
of fragment
displacement, the
aforementioned position
is not recommended for
patients with fracture or
patients who may have
destructive disease.
SS: Hip joint;
acetabulum, femoral
head & neck;
trochanters
Pelvis
AP
PROJECTION
IR: 14 x 17
inches
PATIENT AND PART POSITION
RP/CENTRAL RAY
Supine position.
Pp: Center the midsagittal
plane of the body to the
midline of the grid, and adjust
it in a true supine position.
RP: 2 in. inferior to ASIS
or 2 in. superior to pubic
symphysis
CR: ┴
Trauma or pathologic
factor,medially rotate the feet
and lower limbs about 15 to 20
degrees to place the femoral
necks parallel with the plane of
the IR.
• Shield gonads.
• Respiration: Suspend.
EVALUATION CRITERIA
STRUCTURE SHOWN
NOTE
 Entire pelvis along with the
proximal femora
 Lesser trochanters, if seen,
demonstrated on the
medial border of the
femora
 Femoral necks
 Greater trochanters inprofile
 Lower vertebral column
centered to the middle of
the radiograph
The resulting image
shows an AP projection of
the pelvis and of the
head, neck,
trochanters, and proximal
one third or one fourth of
the shaft of the femora.
Martz and Taylor
recommended two AP
projections of the pelvis for
demonstration of the
relationship of the femoral
head to the acetabulum in
patients with congenital
dislocation of the hip.
• Entire pelvis and the
proximal femora.
• Sacrum and coccyx.
• Superimposed posterior
margins of the ischium and
ilium.
• Superimposed femora.
• Superimposed acetabular
shadow.
The resulting image
shows a lateral
radiograph of the
lumbosacral junction,
sacrum, coccyx, and
superimposed help bones
and upper femora
Berkebile, Ficher, and
Albrecht' recommended a
dorsal decubitus lateral
projection of the pelvis for
demonstration of the
"gull-wing sign" in case of
fracture dislocation of the
acetabularrim and posterior
dislocation of the femoral
head.
Medial rotation easier for the
patient to maintain if the knees
are supported. The heels
should be placed about 8 to10
inches (20 to 24 cm) apart .
LATERAL
PROJECTION
Right or left
position
IR: 14 x17
inches
80-90 factors
Place the patient in the lateral
recumbent, dorsal decubitus,
or upright position.
Recumbent position
Center the MSP; Extend the
thighs enough; Place a support
under the lumbar spine, and
adjust it to place the vertebral
column parallel with the
tabletop. If the vertebral
column is allowed to sag, it will
tilt the pelvis in the
longitudinal plane.
Lateral pelvis:
Adjust the pelvis in a true
lateral position, with the ASIS
is lying in the same vertical
plane. Place one knee directly
over the other knee. A pillow or
other support between the
knees promote stabilization
and patient comfort.
RP: 2 in. above greater
trochanter
CR: ┴
The Larger circle of the fossa
(farther from the IR) will be
equidistant from the
smaller circle of the fossa
nearer the IR throughout their
circumference.
• Pubic arch unobscured by
the femora.
Femoral Necks
AP OBLIQUE
PROJECTION
MODIFIED
CLEAVES
METHOD
Image receptor:
35 x 43 cm crosswise
PATIENT AND PART POSITION
RP/CENTRAL RAY
 Supine position.
Position of part
 Center the midsagittal plane of the body to the midline of the grid.
 Flex the patient's elbows, and rest the hands on the upper chest.
 Adjust the patient so that the pelvis is not rotated. This can be
achieved by placing the two ASIS equidistant from the
radiographic table.
 Place a compression band across the patient well above the hip
joints for stability, if needed.
Bilateral projection
Step 1
 Have the patient flex the hip and knees and draw the feet up as
much a possible (i.e., enough to place the femora in a nearly
vertical position if the affected side permits).
 Instruct the patient to hold this position, which is relatively
comfortable, while the x-ray tube and IR are adjusted.
Step 2
 Center the IR I inch (2.5 cm) superior to the pubic symphysis.
Step 3
 Abduct the thighs as much as possible, and have the patient turn
the feet inward to brace the ole again t each other for support.
According to Cleave , the angle may vary between 25 and 45º,
depending on how vertical the femora can be placed.
 Center the feet to the midline of the grid.
 If possible, abduct the thighs approximately 45º from the vertical
plane to place the long axe of the femoral neck parallel with the
plane of the IR.
 Check the position of the thighs, being careful to abduct them to
the same degree.
Unilateral projection
 Adjust the body position to center the ASIS of the affected side to
the midline of the grid.
 Patient flex the hip and knee of the affected side and draw the foot
up to the opposite knee a much a possible.
 After adjusting the perpendicular central ray and positioning the
IR tray, have the patient brace the ole of the foot against the
opposite knee and abduct the thigh laterally approximately 45º.
The pelvis may rotate lightly.
 Shield gonads.
 Respiration: Suspend.
Perpendicular to
enter the patient's
midsagittal plane
at the level 1inch
(2.5 cm) superior to
the pubic
symphysis.
For the unilateral
position, direct the
central ray to the
femoral neck
EVALUATION
CRITERIA
• No rotation of the
pelvis, as evidenced
by a symmetric
appearance.
• Acetabulum,
femoral head, and
femoral neck.
• Lesser trochanter
on the medial side
of the femur.
• Femoral neck
without
superimposition by
the greater
trochanter. Excess
abduction causes
the greater
trochanter to
obstruct the neck.
• Femoral axes
extended from the
hip bone at equal
angles.
STRUCTURE
SHOWN
The bilateral
resulting image
hows an AP
oblique projection
of the femoral
heads, necks, and
trochanteric areas
projected onto one
radiograph for
comparison
PATIENT AND PART POSITION
AXIOLATERAL
PROJECTION
ORIGINAL CLEAVES
METHOD
IR:
35 x 43 cm crosswise
Place the patient in the supine
position.
Position of part
NOTE: This is the same part position
as the modified Cleaves method
previously described.
RP/CENTRAL RAY
EVALUATION CRITERIA
STRUCTURE SHOWN
Parallel with the femoral
shafts. According to
Cleaves: the angle may vary
between 25 and 45 degrees,
depending on how vertical the
femora can be placed.
•Axiolateral projections of the femoral
neck
• Femoral necks without overlap from
the greater trochanter
•Small parts of the Iesser trochanters on
the posterior surfaces of the femur
• Small amount of the greater
trochanters on both the posterior and
anterior surfaces of the femurs
• Both sides equidistant from the edge
of the radiograph
• Greater amount of the proximal femur
on a unilateral examination
• Femoral neck angles approximately 15
to 20 degree superior to the femoral
bodies.
The resulting image shows an
axiolateral
projection of the femoral heads,
necks, and trochanteric areas.
The projection can be performed
unilaterally or bilaterally.
Before having the patient abduct the
thighs, direct the x-ray tube parallel to
the long axes of the femoral shaft.
• Adjust the IR so the midpoint
coincides with the central ray.
• Shield gonads.
• Respiration: Suspend.
Cranium
PATIENT AND PART POSITION
AP PROJECTION
LATERAL PROJECTION
R OR L POSITION
RP/CENTRAL RAY
Supine; MSP & OML perpendicular to IR
RP: Nasion
CR: Perpendicular
Seated-upright
or semiprone position.
┴, to enter 2 inches (5
cm) superior to the
EAM.
Place one hand under the mandibular region
and the opposite hand on the
upper parietal region of the patient's head to
help guide it into a true lateral position.
Center the IR to the
central ray.
Adjust the flexion of the patient's neck so that
the IOML is perpendicular to the front edge of
the IR. The IOML also should be //to the long
axis of the IR.
AP AXIAL PROJECTION
Check the head position so that the
interpupillary line is ┴ to the IR.
Supine; OML perpendicular to IR
RP: Nasion
CR: 15o cephalad
EVALUATION
CRITERIA
STRUCTURE SHOWN
The sella turcica,
anterior clinoid
processes, dorsum
sellae, and posterior
clinoid processes are
well demonstrated in
the lateral projection.
NOTE
PA PROJECTION
PP: Prone; forehead &
nose against IR; MSP &
OML perpendicular to IR
RP: Nasion
CR: Perpendicular
SS: Petrous pyramid
completely filled the orbits;
frontal bone
SS: Same as PA axial but orbits are magnified &
the distance b/n lateral margin of orbits & temporal
bones are less on AP than PA
PATIENT AND PART
POSITION
PA AXIAL PROJECTION
CALDWELL METHOD
Prone; forehead and
nose against IR; OML
perpendicular to IR;
MSP perpendicular to
IR
CR: Central ray to exit
the nasion at an angle
of 15º caudad.
PA AXIAL PROJECTION
TOWNE METHOD
Patient supine or
seated
MSP and OML
perpendicular to IR
RP/CENTRAL RAY
For demonstration of
the superior ororbital
fissures, direct the
central ray through the
midorbits at an angle
of 20 to 25º caudad.
For demonstration of

the rotundum
foramina, direct the
central ray to the
nasion at an angle of
25 to 30ºcaudad
RP: 2.5-3 in. above glabella
CR: 30º caudad (OML ┴);
37º caudad (IOML ┴)
EVALUATION
CRITERIA
Anterior ethmoidal air cells.

Petrous pyramids lying in lower third
of orbit with a caudal central ray
angulation of 15º and filling the orbits
with 0º central ray angulation
For patient with
pathologic condition,
trauma or deformity.
Symmetric image of the petrous
pyramids, the posterior portion of the
foramen magnum, the dorsum sellae
and posterior clinoid processes
projected within the foramen magnum,
the occipital bone, and the posterior
portion of the parietal bones.
Occipital bone
When patient cannot
flex neck, place IOML
perpendicular
PA AXIAL PROJECTION
HAAS METHOD
SUBMENTOVERTICAL
PROJECTION
SCHULLER METHOD
Prone; MSP and OML
┴to IR; forehead and
nose against the table;
IR center 1 in. to
nasion
RP: 1.5 in. below inion
(entrance); 1.5 in. superior
to nasion (exit)
CR: 25º cephalad to OML
ER: For obtaining
image of sellar
structures (DS &
PCP) within FM on
hypersthenic &
obese patient
Supine or Seatedupright (more
comfortable)
RP: ¾ in. anterior to EAM
(sella turcica)


CR: Perpendicular to IOML;
MSP of throat between
gonion (entrance)

IOML parallel to IR
MSP ┴to IR; head
rested on vertex; neck
hyperextended.
STRUCTURE SHOWN



Cranial base
Foramen ovale
and spinosum
Symmetric
petrosae
Mastoid
processes
Carotid canals
Sphenoidal &
ethmoidal
sinuses
Symmetric petrous pyramid
Dorsum sellae & posterior clinoid
processes within shadow of foramen
magnum







Mandible
Bony nasal septum
Dens of axis
Occipital bone
Maxillary sinus superimposed
over the mandible
Zygomatic arches (well
demonstrated if exposure factors
are decreased)
Axial tomography of orbits, optic
canals, ethmoid bone, maxillary
sinuses & mastoid processes
NOTE
Schuller, who first
described this
positioning for the skull,
recommended a caudal
angle of 25º.
Haas' devised this
projection for obtaining
an image of the sellar
structures projected
within the foramen
magnum on
hypersthenic, obese, or
other patients who
cannot be adjusted
correctly for the AP
axial (Towne) projection.
Patients placed in the
supine position
for the cranial base may
have increased
intracranial pressure.
As a result, they may be
dizzy or unstable for a
few minutes after having
been in this position.
Use of the upright
position may alleviate
some of this pressure.
SELLA TURCICA
PATIENT AND PART
POSITION
LATERAL
PROJECTION
R or L Position
Semiprone; MSP &
IOML parallel to IR;
IPL ┴ to IR
RP/CENTRAL RAY
EVALUATION
CRITERIA
RP: ¾ in. anterior & ¾
in. superior to EAM
CR: Perpendicular
STRUCTURE SHOWN
NOTE
Superimposed anterior and
posterior clinoid processes;
dorsum sellae
A closely collimated
projection of the sella
turcica is often
requested in addition
to the lateral projection
of the entire cranium.
OPTIC CANAL AND FORAMEN
PATIENT AND PART
POSITION
RP/CENTRAL RAY
PARIETO-ORBITAL
OBLIQUE
PROJECTION
RHESE METHOD
Prone; affected orbit
closest to IR; zygoma,
nose & chin against
IR (3-pt Lower
Landing); AML ┴ to
IR; MSP 53º angle to
IR.
RP: Affected orbit
closest to IR
CR: Perpendicular
RHESE METHOD
ORBITO-PARIETAL
OBLIQUE
PROJECTION
Supine; affected orbit
away from IR; AML ┴
to IR; MSP 53º angle
to IR
RP: Inferior and
lateral margin of
uppermost orbit
CR: Perpendicular
SUPERIOR ORBITAL FISSURES
PA AXIAL
Prone; forehead and
PROJECTION
nose against IR; OML
perpendicular to IR
EVALUATION
CRITERIA
STRUCTURE SHOWN
SS: Optic canal/foramen
(inferior & lateral quadrant
of orbital shadow)
PAZAM: Prone; Affected
orbit against IR; Zynoch; AML
┴; MSP 53ºto IR
RP: Nasion
CR: 20-25º caudad or
15º caudad
Magnified optic
canal/foramen
Increased radiation dose to
lens of eye


Superior orbital
fissures
Lying on the medial
side of orbits between
greater and lesser
wings of sphenoid.
NOTE
INFERIOR ORBITAL
FISSURES
PA AXIAL
PROJECTION
BERTEL METHOD
Prone; forehead and
RP: Nasion
nose against IR; IOML CR: 20-25º
┴ to IR
cephalad .
Inferior orbital
fissures
 Between shadows of
pterygoid process of
sphenoid bone and
mandibular ramus
 Anterior image of
each orbital floor

EYE- FOREIGN BODY LOCALIZATION
PATIENT AND PART
POSITION
RP/CENTRAL RAY
LATERAL PROJECTION
Semiprone; MSP parallel to
IR; IPL ┴ to IR; instruct
patient to look straight
ahead during exposure.
RP: Outer canthus
CR: Perpendicular
MODIFIED WATERS
METHOD
PARIETOACANTHIAL
PROJECTION
Prone; chin against IR;
MSP ┴ to IR; OML 50º to IR
(new); OML 25-37º to IR
(old); instruct patient to
close the eyes.
RP: Midorbits
CR: Perpendicular
FACIAL BONES
LATERAL PROJECTION
Semiprone; MSP and
IOML // to IR; IPL ┴ to IR
RP: Zygoma or malar
bone
CR: Perpendicular
EVALUATION
CRITERIA
STRUCTURE SHOWN
Density and contrast
permitting optimal
visibility of orbit and
eye for localization
of foreign bodies.


All facial bones in
their entirety, with
the zygomatic
bone in the center
Almost perfectly
superimposed
mandibular rami


NOTE
Superimposed orbital
roofs
A nongrid (very high-resolution)
technique is recommended to reduce
magnification and eliminate possible
artifacts in or on the radiographic table
and grid.
Petrous pyramids
lying well below orbital
shadows
Some physicians prefer to have the PA
projection performed with the patient's
head adjusted in a modified Waters
position sp that the petrous margins
are displaced by part adjustment rather
than by central ray angulation.
Superimposed facial
bones
Superimposed
mandibular rami and
orbital roofs
WATERS METHOD
PARIETO-ACANTHIAL
PROJECTION
Prone; MSP and MML
perpendicular to IR;
OML 37º to IR; nose ¾ in.
(1.9cm) away from IR
RP: Acanthion (exit)
CR: Perpendicular




MODIFIED WATERS
ACANTHIOPARIETAL
PROJECTION
REVERSE WATERS
METHOD
The reverse Waters
method is used to
demonstrate the facial
bones when the patient
cannot be placed in the
prone position.
Prone; MSP and MML
perpendicular to IR;
OML 55º to IR
Supine position, center
the MSP of the body to
the midline of the grid.
Patient's chin up, adjust
the extension of the neck
so that the OML forms a
37-degree angle with the
plane of the IR.
MML is perpendicular to
the plane of the IR.
Adjust the patient's head
so that the midsagittal
plane is perpendicular to
the plane of the IR.
RP: Acanthion (exit)
CR: Perpendicular


Perpendicular to
enter the acanthion
and centered to the
IR.
Distance between
lateral border of
the skull and orbit
equal on each side
Petrous ridges
projected below
maxillary sinuses
Orbits, maxillae and
zygomatic arches
Best projection for facial
bones
Petrous ridges below the
maxillae
Blow out fractures.
Facial bones w/
less axial
angulation
Petrous ridges
below the inferior
border of orbits
Demonstrates
the superior facial
bones. The image is
similar to that obtained
with the Waters
method, but the facial
structures are
considerably magnifie.
Modified Waters method is a good
projection to demonstrate blow-out
fractures.
This places the orbital floor
perpendicular to the IR and parallel to
the CR demonstrating inferior
displacement of the orbital floor and
the commonly associated opacified
maxillary sinus.
ACANTHIOPARIETAl PROJECTION
FOR TRAUMA
Trauma patients are often unable to
hyperextend the neck far enough to
place the OML 37 degrees to the IR
and the MML perpendicular to the
plane of the IR. In these patients, the
acanthioparietal projection, or the
reverse Waters projection can
be achieved by adjusting the central
ray so that it enters the acanthion
while remaining parallel with the
MML.
NASAL BONES
PATIENT AND PART
POSITION
LATERAL
PROJECTION
RP/CENTRAL RAY
Semiprone with head turned
to lateral position
Head true lateral position
IPL perpendicular to IR
MSP parallel
EVALUATION CRITERIA
RP: ¾ in. (old) or ½
in. (new) distal to
nasion
CR: Perpendicular
STRUCTURE SHOWN
NOTE
Nasal bones and soft
tissue of the nose,
best position to
demonstrate non
displaced fractures of
the nasal bone.
ATLANTO-OCCIPITAL JOINTS
PATIENT AND PART
POSITION
AP OBLIQUE
PROJECTION
R & L head
rotations
DENS
FUCHS METHOD
AP PROJECTION
Supine;
Head rotated
45-60ºaway from side
of interest; IOML ┴ to
IR
Supine; chin extended;
chin tip and mastoid
tip ┴ to IR; MSP ┴ to IR
RP/CENTRAL RAY
RP: 1 in. anterior to
the EAM
CR: ┴
RP: Distal to
chin tip
CR: ┴
EVALUATION CRITERIA
Alternative projection
when a patient cannot be
adjusted in the openmouth position.
Recommended when
upper half of dens is
not clearly shown in
open-mouth position
STRUCTURE SHOWN


Atlanto-occipital joints
between orbit and
ramus of mandible
Dens is well
demonstrated
Dens within
foramen magnums
NOTE
Buetti' recommended a
position for the atlantooccipital articulations
wherein the head is turned
45 to 50º to one side and,
with the mouth wide open,
the chill is drawn down as
much as the open mouth
allows.
The central ray is then
directed vertically through
the open mouth to the
dependent mastoid tip.
Smith and Abel: Described a method for
demonstrating the laminae and articular
facets of the upper cervical vertebrae.
They slightly extend the patient's neck,
and the mouth is opened wide. The central
ray is directed 35º caudad and centered to
C3.
The exposure is made with the head
passively rotated 10º to the side, thereby
removing the mandible from the overlying
areas of interest.
KASABACH
METHOD
AP AXIAL
OBLIQUE
PROJECTION
R & L head
rotations
Supine; head rotated
40-45º ; IOML ┴
RP: Midway
between outer
canthus & EAM
CR: 10-15º
caudad
Recommended in
conjuction with AP
and lateral
projections
Herrmann and Stender' described a
position for demonstrating the
atlantooccipitaldens relationship: the head
is adjusted as for the Kasabach method,
and the central ray is then directed
vertically midway between the mastoid
processes at the level of the atlantooccipital
joints.
ATLAS AND AXIS
PATIENT AND PART
POSITION
ALBERS-SCHOBERG
AND GEORGE
METHOD
AP “OPEN-MOUTH"
PROJECTION
RP/CENTRAL RAY
EVALUATION CRITERIA
Supine; MSP ┴; open
mouth as wide as
possible
RP: Midpoint of open
mouth
CR: ┴
WATERS METHOD
PARIETOACANTHIAL
PROJECTION
Upright; neck
hyperextended
and rested against IR; OML
37º to IR; MML
perpendicular
to IR; mouth wide open
RP: Acanthion
CR: Horizontal
For the patients
who cannot be
placed in position
for SMV
PA PROJECTION
JUDD METHOD
Prone position; flex the
elbow; extended neck and
rest chin on the
table;mastoid tips are
vertical or OML is 37
degrees to the plane of IR.
RP: midpoint of thr
IR enetring on the
midsagittal plane just
distal to the level of
mastoid tips
CR: ┴

STRUCTURE SHOWN
NOTE
A 3D-inch (76 cm) SID
is often used for
this projection to
increase the field of view
of the odontoid area.


Entire dens wuthin
foramen magnum
Anterior and
psoterior arches of
atlas
No rotation of head
or neck.
 Sphenoidal sinuses
projected through open
mouth
 Petrous pyramids
inferior to
floor of maxillary
PA projction of dens
and atlas as seen
trough the foramen
magnum
CERVICAL VERTEBRAE
AP PROJECTION
LATERAL
PROJECTION
AP AXIAL
PROJECTION
LATERAL
PROJECTION
Hyperflexion &
Hyperextension
Supine/upright; chin extended;
occlusal plane ┴ to IR (prevents
superimposition of mandible and
midcervical vertebrae)
RP: C4
CR: 15-20º cephalad
Seated/upright; patient in true lateral
position; shoulder rotated posteriorly or
anteriorly (round shouldered); chin
slightly elevated (prevents
superimposition of mandibular rami &
spine); MSP // to IR
Supine/upright; chin extended;
occlusal plane ┴ to IR (prevents
superimposition of mandible and
midcervical vertebrae)
RP: C4
CR: Horizontal
Seated/upright; patient in true lateral
position; MSP // to IR
RP: C4
CR: Horizontal
For functional studies (motility) of
cervical vertebrae; To demonstrate
normal AP movement or
absence of movement
IV disks and
zygapophyseal joints
SS in Hyperflexion:
C1-C7


Elevated and widely
separated spinous
processes
SS in Hyperextension:

C1-C7

Depressed spinous
processes
RP: C4
CR: ┴
To blurred the mandibular shadow
to demonstrate all cervical
vertebrae
Entire cervical column
RP: C4
CR: 15-20º cephalad
Used to demonstrate the presence
or absence of cervical ribs


Used to demonstrate the presence
or absence of cervical ribs




Hyperflexion: head drop forward; draw
chin as close as possible to the chest
Hyperextension: chin elevated as
much as possible
OTTONELLO
METHOD
AP PROJECTION
Supine; MSP ┴ to IR; chin elevated;
upper incisors and mastoid tips ┴ to IR;
mandible in chewing motion during
exposure
C3-T2
Interpediculate
spaces

IV disk spaces
Superimposed transverse
and articular processes

C1-C7

Articular pillars

Zygapophyseal joints
(C3-C7)

Spinous processes
C3-T2
Interpediculate
spaces
IV disk spaces
Superimposed
transverse and
articular processes
TWINNING AND
PAWLOW METHOD
SWIMMER’S
TECHNIQUE
LATERAL
PROJECTION
Humeral head moved anteriorly or
posteriorly;
depress shoulder away from IR; MSP //
to IR;
breathing technique
RP: C7-T1 interspace
CR: ┴ (shoulder well depressed); 3-5º
caudad (can’t be depressed sufficiently)
Performed when shoulder
superimposition obscures C7 on a
lateral cervical spine projection
Cervicothoracic region (C7T1)
Monda Recommendation:
CR 5-15ºcephalad
To better demonstrate IV disk
spaces
Lateral recumbent (Pawlow): head
elevated on patient’s arm;
Upright (Twinning): arm closes to IR
extended; elbow flexed; forearm rested
on head
THORACIC VERTEBRAE
PATIENT AND PART POSITION
AP PROJECTION
Supine/upright; MSP ┴ to IR; hips and knees
flexed (to reduce kyphosis); place support under
knees
RP/CENTRAL RAY
RP: T7 (between
jugular notch and
xiphoid process)
CR: ┴
EVALUATION CRITERIA
STRUCTURE SHOWN


T1-T12
IV disk spaces

Transverse
processes
Costovertebral
articulation

LATERAL
PROJECTION
Lateral recumbent or upright (Oppenheimer); left
side against the table (places heart closer to IR)
MSP // to IR; hips and knees flexed; arms at
right angle to body (to elevate ribs enough); place
support under lower thoracic spine .
RP: T7
CR: ┴ (with support);
10-15º cephalad
(with or without
support); 10º(female)
or 15º (male)


T1-T12
IV disk spaces

Intervertebral
foramina
Lower spinous
processes

LUMBAR-LUMBOSACRAL VERTEBRAE
AP PROJECTION Supine/upright; elbow flexed; hands on
upper chest
Hips and knees flexed
 Reduces lumbar lordosis
 Places back in contact within table
 Reduces distortion of vertebral
bodies
 Better delineation of IV disk
LATERAL
PROJECTION
Lateral recumbent or upright; affected
side against IR; hips and knees flexed;
MCP ┴ to IR; place support under lower
thorax (places spine in true horizontal
position)
RP: L4 (for lumbosacral); L3 (for lumbar
spine only)
CR: ┴






RP: L4 (for lumbosacral); L3 (for lumbar
spine only)
CR: ┴ (with support); 5-8º caudad (w/o
support); 5º(male) or 8º (female)
Lumbar bodies
IV disk spaces
Interpediculate spaces
Laminae
Spinous & transverse
processes
Sacrum, coccyx & pelvic
bones (larger IR)
SS: Intervertebral foramina of
L1-L4 only; L5
intervertebral foramina
(Oblique Projection)