Radiographic positioning review (ALL)

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1
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Image Receptor Size: 10 x 12
SID: 40"
Patient position
1) Patient is supine
2) Center the image receptor 1/2" below to the apex of the patella
3) Femoral epicondyles are parallel to the image receptor
4) Shield gonads
Central Ray
• Directed to a point 1/2 inferior to the apex of the patella
• Perpendicular for a sthenic patient (19-24cm)
• 3-5 degrees cephalic for hypersthenic (greater than 24cm)
• 3-5 degrees caudad for hyposthenic (less than 19cm)
Structures Shown
• Open knee joint
• Patella superimposed on femur
• Soft tissue

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AP of the Knee

2
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Image Receptor Size: 10 x 12
SID: 40"
Patient position
1) Patient is prone
2 )Center the image receptor 1/2" below the apex of the patella
3) Femoral epicondyles are parallel to the image receptor
4) Shield gonads
Central Ray
• 5-7 degrees caudad to exit 1/2" below the patellar apex
Structures Shown
• Open knee joint
• Patella superimposed on femur
• Soft tissue

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PA of the Knee

3
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Image Receptor Size: 10 x 12
SID: 40"
Patient position
1) Patient turns onto affected side
2) Flex the knee about 20-30 degrees
3) Center the image receptor to the knee joint (approximately 1" distal to the medial femoral condyle)
4) Femoral epicondyles and patella are perpendicular to the image receptor
5. Shield gonads
Central Ray
• 5-7 degrees cephalic centered 1" distal to the medial epicondyle (opens joint space)
Structures Shown
• Femoral condyles superimposed
• Open knee joint
• Patella in a lateral profile with an open
• Soft tissue

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Lateral of the Knee, Mediolateral

4
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Image Receptor Size: 10 x 12
SID: 40"
Patient position
1) Patient supine
2) Center the image receptor 1/2" below the patellar apex
3) Rotate the knee laterally
4) Shield gonads
Central Ray
• Perpendicular (or same angulation as AP knee) to the knee joint 1/2" below apex
Structures Shown
• Patella projected slightly over the border of the lateral femoral condyle
• Open knee joint
• Tibial plateau
• Soft tissue

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AP Oblique of the knee, Lateral rotation

5
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Image Receptor Size: 10 x 12
SID: 40"
Patient position
1) Patient is supine
2) Center the image receptor 1/2" below the patellar apex
3. Rotate the knee medially 45 degrees
4) Shield gonads
Central Ray
• Perpendicular (or same angulation as AP knee) to the knee joint 1/2" below apex
Structures Shown
• Open proximal tibiofibular joint
• Tibial plateau
• Open joint space
• Patella projected slightly over the border of the medial femoral condyle
• Soft tissue

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AP Oblique of the knee, Medial rotation

6
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Image Receptor Size: 10 x 12
SID: 40" UPRIGHT
Patient position
1) Patient is standing with their back against the upright grid device
2) Center the knees to the image receptor with no rotation. Toes straight ahead
3) Center of the image receptor is at the knee joints - 1/2" below apex of the patella
4) Shield gonads
Central Ray
• Horizontal and perpendicular 1/2" below the apices of the patellas and midway between the knees
Structures Shown
• Both knees on one exposure
• *May reveal a narrowing of the joint spaces which may appear normal without weightbearing - especially on arthritic patients*

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AP of the knee, Weightbearing

7
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Image Receptor Size: 8 x 10
SID: 40"
Patient position
1) Patient may be:
a. standing with affected knee resting on a stool
b. standing with the knee in contact with the front
c. kneeling on the table
2) Center the image receptor to the apex of the patella
3) Knee is flexed 70 degrees from full extension
4) Shields gonads
Central Ray
• Perpendicular to the knee joint
Structures Shown
• Open intercondyloid fossa
• Intercondyloid emminences
• Knee joint
• Soft tissue

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PA axial of the intercondyloid fossa, Holmbland Method

8
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Image Receptor Size: 8 x 10
SID: 40"
Patient position
1) Patient is prone
2) Flex the knee 40-50 degrees and support the foot
3) Center the proximal half of the image receptor to the knee joint
4) No rotation of the knee
5) Shield gonads
Central Ray
• Perpendicular to the long axis of the leg (40-50 degrees caudad), centered to the knee joint
Structures Shown
• Open intercondylar fossa
• Intercondyloid emminences
• Knee joint with soft tissue

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PA Axial of the intercondyloid fossa, Camp-Coventry Method, Tunnel View

9
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Image Receptor Size: 8 x 10
SID: 40"
Patient position
1) Patient is supine - sitting if possible
2) Flex the knee so the femur forms a 60 degree angle to the tibia
3) Place the image receptor under the knee
4) Shield gonads
Central Ray
• Perpendicular to the long axis of the tibia entering the knee 1/2" below the apex of the patella
Structures Shown
• Open intercondylar fossa
• Intercondyloid emminences
• Knee joint
• Soft tissue

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AP Axial of the intercondyloid fossa, Beclere Method, Tunnel view

10
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Image Receptor Size: 8 x 10
SID: 40"
Patient position
1) Place the patient in the prone position.
2) If the knee is painful, place one sandbag under the thigh and another under the leg to relieve pressure on the patella.
3) Center the IR to the patella.
4) Adjust the position of 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 laterally
Central Ray
• Perpendicular to the midpopliteal area exiting the patella
• Collimate closely to the patellar area.
Structures Shown
• Patella completely superimposed by the femur
• Soft tissue and bony trabecular detail

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PA patella

11
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Image Receptor Size: 8 x 10
SID: 40"
Patient position
1) Place the patient in the lateral recumbent position.
2) Ask the patient to turn onto the affected hip. A sandbag may be placed under the ankle for support.
3) Have the patient flex the unaffected knee and hip, and place the unaffected foot in front of the affected limb for stability.
4) Flex the affected knee approximately 5 to 10 degrees. Increasing the flexion reduces the patellofemoral joint space.
5) Adjust the knee in the lateral position so that the femoral epicondyles are superimposed and the patella is perpendicular to the IR
6) Shield gonads.
7) Center the IR to the patella.
Central Ray
• Perpendicular to the IR, entering the knee at the midpatellofemoral joint
• Collimate closely to the patellar area.
Structures Shown
• Knee flexed 5 to 10 degrees
• Open patellofemoral joint space
• Soft tissue and bony trabecular detail

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Lateral patella

12
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Image Receptor Size: 8 x 10
SID: 40"
Patient position
1) Patient is prone
2) Flex the knee as much as possible or until patella is perpendicular to the image receptor
3) Place the image receptor under the knee centered to the femoropatellar joint space
4) Collimate
5) Shield gonads
Central Ray
• Perpendicular to the femoropatellar joint space. (The degree of angulation will depend upon the degree of flexion of the knee)
Structures Shown
• *Vertical fractures of the patella*
• Open patellofemoral articulation
• Patella in profile
NOTE:
This projection may be performed with the patient supine (seated
Knee is flexed and the image receptor is placed on the anterior surface of the femur
Central ray is angled upward, perpendicular to the femoropatellar joint space

Tangential patella, Sattegast Method, Sunrise View

13
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Image Receptor Size: 8 x 10
SID: 40"
Patient position
1) Patient is prone
2) No rotation of the knee
3) Flex the affected knee so the tibia/fibula forms a 50°-60° angle with the table
4) Support the leg
5) Shield patient
6) Collimate
Central Ray
• 45° cephalad through the patellofemoral joint
Structures Shown
• Subluxation
• Patellar fractures
• Patella in profile
• Open patellofemoral joint
NOTE:
Usually recommended both knees be examined for comparison

Tangential patella, Hughston Method

14
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Image receptor Size: 10 x 12
SID: 6 foot
Patient position
1) Using the Axial Viewer device, elevate the patient's knees approximately 2 inches to place the femora parallel with the tabletop
2) Adjust the angle of knee flexion to 40 degrees. (Merchant reported that the degree of angulation may be varied between 30 degrees and 90 degrees to show various patellofemoral disorders.)
3) Strap both legs together at the calf level to control leg rotation and allow patient relaxation.
4) Place the IR perpendicular to the central ray and resting on the patient's shins (a thin foam pad aids comfort) approximately 1 foot distal to the patellae.
5) Ensure that the patient is able to relax. Relaxation of the quadriceps femoris is crucial for an accurate diagnosis. If these muscles are not relaxed, a subluxated patella may be pulled back into the intercondylar sulcus, showing a false normal appearance.
6) Record the angle of knee flexion for reproducibility during follow-up examinations because the severity of patella subluxation commonly changes inversely with the angle of knee flexion.
7) Shield gonads.
Central Ray
• Perpendicular to the IR
• With 40-degree knee flexion, angle the central ray 30 degrees caudad from the horizontal plane (60 degrees from vertical) to achieve a 30-degree central ray-to-femur angle. The central ray enters midway between the patellae at the level of the patellofemoral joint (superior aspect of patella).
Structures Shown
• Patellae in profile
• Femoral condyles and intercondylar sulcus
• Open patellofemoral articulation
• Soft tissue and bony trabecular detail

Tangential patella, Merchant Method

15
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Image Receptor Size: 14 x 17
SID: 40" (bucky)
Patient position
1) Patient is supine
2) Center the affected thigh to the image receptor, making sure the joint closest to the area of interest is on the image receptor.
3) To include hip, place the top of the image receptor at the level of the ASIS and rotate the leg 10-15° internally (to place the neck in profile). To include knee, place the bottom of the image receptor 2" below the knee joint and make sure epicondyles are parallel to the image receptor
4) Shield gonads
5) Obtain a second radiograph to include the other joint
Central Ray
• Perpendicular to mid femur and centered to the image receptor
Structures Shown
• Majority of the femur and joint closest to the area of interest
• Femoral neck not foreshortening on proximal femur
• No rotation
• Any orthopedic appliance in its entirety

AP of the femur (distal)

16
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Image Receptor Size: 14 x 17
SID: 40" (bucky)
Patient position
1) Patient turns onto affected side.
2) If the knee joint is to be included, place the uppermost extremity forward
3) Flex the knee about 45°
4) Femoral epicondyles are perpendicular to the image receptor
5) Include the knee joint (image receptor is about 2" below knee joint)
6) If the hip joint is to be included, place the top of the image receptor at the level of the ASIS.
7) Place the uppermost extremity posteriorly.
8) Rotate the pelvis back from the lateral position approximately 10-15 degrees.
9) Shield gonads
10) Obtain a second radiograph to include the other point
Central Ray
• Perpendicular to mid femur and center of the image receptor
Structures Shown
• Lateral projection of 3/4 of femur and the joint closest to the point of interest
• Any orthopedic appliance in its entirely

Lateral of the femur, Mediolateral (distal)

17
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Image Receptor Size: 14 x 17
SID: 40"
Patient position
1) Patient is supine
2) Unless unable, internally rotate the feet 15-20 degrees to place the femoral necks parallel with the image receptor
3) No rotation of the pelvis
4) Top of the image receptor should be 1-1½ " above the crests
5) Suspend respiration
Central Ray
• Perpendicular centered to the image receptor (approxiately 2" superior to the symphysis pubis or 2" inferior to the ASIS")
Structures Shown
• Entire pelvis
• Head, neck and trochanters in profile

AP of the Pelvis

18
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Image Receptor Size: 14 x 17
SID: 40"
Patient position
NOTE: THIS PROJECTION IS NOT PERFORMED ON PATIENTS SUSPECTED OF HAVING A FRACTURE!
BILATERAL
1) Patient is supine
2) Top of the image receptor is placed 1-1½ above the crests (1" superior to the symphysis pubis)
3) Flex knees, feel up as much as possible
4) Abduct the thighs (between 25-45 degrees) and place soles of feet together
5) Suspend respiration
UNILATERAL
1) Patient is supine
2) ASIS of affected side is centered to the image receptor
3) Flex the knee of the affected side, draw foot up
4) Abduct thigh approximately 45 degrees and place sole of foot on opposite leg
5) Suspend respiration
Central Ray
Bilateral
• Perpendicular, centered to the image receptor, approximately 1" superior to symphysis pubis
Unilateral
• Perpendicular to the femoral neck
Structures Shown
• Acetabulum, femoral head and neck
• Lesser trochanter
• No rotation of pelvis for Bilateral

AP Oblique of the Pelvis, Modified Cleaves Method, Frogleg (Bilateral)

19
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Image receptor Size: 10 x 12
SID: 40"
Patient position
1) Patient is supine
2) No rotation of the pelvis
3) Suspend respiration
Central Ray
Males
20°-35° cephalad centered 2" distal to the pubis symphysis
Females
30°-45° cephalad centered 2" distal to the pubis symphysis
Structures Shown
• Pubis & Ischial rami without foreshortening
• Symmetrical obturator foramen
• Hip joints

AP Axial of the Pelvis, Outlet, Taylor Method

20
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Image Receptor Size: 8 x 10
SID: 40"
1) Patient is supine
2) No rotation
3) Center the Image receptor to the level of the greater trochanters
4) Suspend respiration
Central Ray
• 40° caudad entering at the ASIS
Structures Shown
• Symmetrical pubic bones and ischial spines
• Hip joints
• Anterior pelvic bones

AP Axial of the pelvis, Inlet, Bridgeman Method

21
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Image Receptor Size: 10 x 12 Lengthwise
SID: 40"
Patient position
1) Patient is supine
2) Center the image receptor to the level of the greater trochanter (Top of the image receptor at the ASIS) and 2" medial to the ASIS
3) Unless contraindicated, internally rotate affected foot 15-20 degrees
4) Suspend respiration
Central Ray
• Perpendicular to the femoral neck
LOCALIZATION OF HIP JOINT:
Femoral head - 1½" distal to the midpoint of a line between ASIS and the superior margin of the symphysis pubis
Femoral neck - 2½" distal to the midpoint of a line drawn between ASIS and the superior margin of the symphysis pubis
Structures Shown
• Femoral head & acetabulum
• Greater trochanter in profile
• Entire femoral neck not foreshortened
• Any orthopedic appliance in its entirety

AP of the Hip

22
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Image Receptor Size: 10 x 12 Lengthwise or crosswise
SID: 40"
Patient position
1) Turn patient slightly toward affected side
2) Center affected hip to middle of image receptor
3) Flex knee, draw leg up and abduct the thigh
4) Suspend respiration
Central Ray
• Perpendicular through the hip joint - Lauenstein Method 20-25° cephalic - Hickey Method
Structures Shown
• Relationship of femoral head to acetabulum
• Hip joint
• Lateral hip

Lateral of the hip, Mediolateral, Lauenstein & Hickey Methods, Frogleg

23
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Image Receptor Size: 10 x 12 with grid Lengthwise
SID: 40"
Patient position
1) Patient is supine
2) If patient is extremely thin, elevate the affected hip slightly
3) Place the image receptor against the hip with upper border of the image receptor at the crest
4) If possible, internally rotate the affected leg 15°-20°
5) Flex the unaffected knee and lift unaffected leg in a vertical position (As high up as possible)
6) Have patient hold leg in position or place on a support
7) Suspend respiration
Central Ray
• Perpendicular to the long axis of the femoral neck, centered to the hip joint
Structures Shown
• Femoral head, neck & trochanters
• Acetabulum
• Ischial tuberosity below the femoral head
• Any orthopedic appliance

Axiolateral of the hip, Danelius-Miller, Cross-table

24
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Image Receptor Size: 10 x 12 (24 X 30)
SID: 40"
Patient position
1) Patient supine with the affected side near the edge of the table
2) Place the grid & image receptor at the crest of the affected hip
3) Adjust the grid parallel to the axis of the femoral neck & tilt it back 15°
4) Suspend respiration
Central Ray
• 15° posteriorly. Perpendicular to the femoral neck and image receptor
Structures Shown
• Hip joint with acetabulum
• Femoral head, neck & trochanters
• Any orthopedic appliance in its entirety

Modified Axiolateral of hip, Clements-Nakayama Modification

25
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Image Receptor Size: 10 x 12
SID: 40"
Patient position
INTERNAL OBLIQUE
1) Patient is supine
2) Top of the image receptor at the ASIS
3) Rotate the affected side up 45°
4) Suspend respiration
Central Ray
• Perpendicular to the image receptor, entering at the the pubic symphysis
EXTERNAL OBLIQUE
1) Patient supine
2) Top of image receptor at the ASIS
3) Rotate the affected side up 45°
4) Suspend respiration
Structures Shown
• Acetabulum
• Femoral head

AP Oblique of hip, Judet Method

26
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Image receptor Size: 10 x 12 Crosswise
SID: 40"
Patient position
1) Patient is upright or recumbent supine
2) Center the clavicle to the image
3) Shield patient
4) Suspend respiration
Central Ray
• Perpendicular to midshaft of clavicle
Structures Shown
• Entire clavicle

AP of the clavicle

27
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Image Receptor Size: 10 x 12 Crosswise
SID: 40" (Upright or supine)
Patient position
1) Patient is upright, supine
2) Have the patient lean backwards in a lordotic position
3) Center the clavicle to the image receptor
4) Shield patient
5) Suspend respiration after full inspiration
Central Ray
• Lordotic position = 0 - 15° cephalic, centered to midshaft of the clavicle.
NOTE: If the patient cannot assume a lordotic position, they can remain supine with a 15 - 30° cephalic angulation of the tube
Structures Shown
• Axial image of the entire clavicle projected above the ribs
• Clavicle in a horizontal placement
NOTE: For a PA axial, the image receptor size, SID, patient positioning and structures shown are all the same as the AP Axial except the patient is prone and the Central Ray is angled 15-30° caudad

AP axial of the clavicle

28
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Image Receptor Size: 10 x 12
SID: 40" (Upright or Supine)
Patient position
1) Patient is supine. (either recumbent or upright)
2) Center the image receptor 1" inferior to the coracoid process
3) The patient may have to be rotated slightly toward the affected shoulder
4) Supinate the hand and abduct the arm slightly
5) Humeral epicondyles are parallel to the image receptor
6) Shield patient
7) Suspend respiration
Central Ray
• Perpendicular to the patient, entering 1" inferior to be coracoid process
Structures Shown
• Humeral head and greater tubercle in profile
• Shoulder joint

AP of the shoulder, External rotation

29
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Image Receptor Size: 10 x 12 Crosswise or Lengthwise
SID: 40"
Patient position
1) Patient is supine. (either recumbent or upright)
2) Center the image receptor 1" inferior to the coracoid process
3) The patient may have to be rotated slightly toward the affected shoulder
4) Rest the palm of the hand against the thigh
5) Humeral epicondyles are at 45° oblique angle
Central Ray
• Perpendicular to the patient, entering 1" inferior to be coracoid process
Strictures Shown
• Greater tubercle partially superimposed on the humeral head

AP of the shoulder, Neutral rotation

30
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Image Receptor Size: 10 x 12
SID: 40"
Patient position
1) Patient is supine. (either recumbent or upright)
2) Center the image receptor 1" inferior to the coracoid process
3) The patient may have to be rotated slightly toward the affected shoulder
4) Flex the elbow slightly, internally rotate the arm so that the back of the hand rests on the hip
5) Humeral epicondyles are perpendicular to the image receptor
Central Ray
• Perpendicular to the patient, entering 1" inferior to be coracoid process
Structures Shown
• Lesser tubercle in profile
• Shoulder joint with humeral head overlapping glenoid cavity
• True lateral of proximal humerus

AP of the shoulder, Internal rotation

31
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Image Receptor Size: 10 x 12 Lengthwise
SID: 40" Upright or Supine
Patient position
1) Patient is upright with the affected side against the image receptor
2) Raise the uninjured arm over the head, or as much as possible
3) Surgical neck of affected arm is centered to the image receptor
4) Shield patient
5) Respiration is one of two choices
a) Hold on full inspiration
b) Use a breathing technique, with a 4-5 second exposure time (3 seconds remaining)
Central Ray
• Perpendicular to the surgical neck at the midcoronal plane
*NOTE: If the patient cannot raise the unaffected arm, a 10-15° cephalic tube angle can be utilized
Structures Shown
• Lateral shoulder through the thorax
• Proximal humerus

Transthoracic Lateral of the shoulder, Lawrence Method

32
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Image Receptor Size: 8 x 10
SID: 40"
Patient position
1) Patient is supine (recumbent)
2) If the patient is extremely thin, may need to elevate the affected shoulder (above 3")
3) Abduct the arm as much as possible (try to achieve a 90° angle with the body)
4) Keep the humerus in external rotation
5) Turn the head away from the affected side and place the image receptor against the top of the shoulder, close to the neck
6) Shield patient
7) Suspend respiration
Central Ray
• Horizontally and perpendicular to the image receptor, through the axilla
Structures Shown
• Proximal humerus & shoulder joint
• Coracoid process
• Soft tissue

Inferosuperior Axial of the shoulder, Lawrence Method, Axillary

33
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Image Receptor Size: 10 x 12
SID: 40" Crosswise or Lengthwise
Patient position
1) Patient is supine or upright
2) Center the image receptor to the shoulder joint. (2" medial & 2" inferior to the supralateral border)
3) Rotate the patient 35-45° toward the affected side
4) Abduct the arm slightly and place it on the abdomen in internal rotation
5) Shield patient
6) Suspend respiration
Central Ray
• Perpendicular to the glenoid cavity, 2" medial and 2" inferior to the superior/lateral border of the shoulder
Structures Shown
• Open shoulder joint
• Glenoid cavity in profile

AP Oblique of the shoulder, Grashey Method

34
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Image Receptor Size: 10 x 12
SID: 40"
Patient position
1) Patient is upright
2) Rotate the patient so the midcoronal plane forms an angle of 45-60°
3) Center the image receptor to the shoulder joint
4) Shield patient
5) Suspend respiration
Central Ray
• Perpendicular to the shoulder joint
Structures Shown
• Acromion projected laterally & free of superimposition
• Coracoid process
• Scapula in profile
**Useful in the elevation of shoulder dislocations
*NOTE: When the patient is severly injured, RPO/LPO projections may be obtained

PA Oblique of the shoulder, Scapular Y

35
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Image Receptor Size: 14 x 17 Crosswise
SID: 40" Upright or recumbent
Patient position
1) Patient is prone, either recumbent or upright
2) Adjust the top of the image receptor 1½" above the shoulders
3) Rest hands on the hips, palms turned outward
4) Rest the head on the chin
5) Shield patient
6) Suspend respiration after full inspiration
Central Ray
• Perpendicular, centered to the image receptor at the level of T7 and median sagittal plane
Structures Shown
• *PA best demonstrates ribs above the diaphragm*
• Rib pairs 1-9

PA of the ribs, Upper Anterior Ribs

36

Image Receptor Size: 14 x 17
SID: 40"
Patient position
1) Patient is prone, either recumbent or upright
2) Adjust the bottom of the image receptor to the level of the iliac crests
3) Shield patient
4) Suspend respiration after full inspiration
Central Ray
• Perpendicular, center to the image receptor and median sagittal plane
Structures Shown
• Lower rib pairs, 8-12

PA of the Ribs, Lower Anterior Ribs

37
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Image Receptor Size: 14 x 17
SID: 40" Upright or recumbent
Patient position
1) Patient is supine
2) Place the top of the image receptor 1½ above relaxed shoulders
3) Rest patient's hands against hips, palms outward
4) Shield patient
5) Suspend respiration after full inspiration
Central Ray
• Perpendicular, centered to the image receptor and the median sagittal plane
Structures Shown
• Rib pairs, 1-10

AP of the ribs, Upper Posterior Ribs

38
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Image Receptor Size: 14 x 17 Crosswise
SID: 40"
Patient position
1) Patient is supine
2) Place the bottom of the image receptor at the level of the iliac crests.
3) Place arms in a comfortable position
4) Shield patient
5) Suspend respiration at the end of the full exhalation
Central Ray
• Perpendicular, centered to the image receptor and median sagittal plane
Structures Shown
• Rib pairs, 8-12

AP of the Ribs, Lower Posterior Ribs

39
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Image Receptor Size: 14 x 17 Lengthwise
SID: 40" Upright or recumbent
Patient position
1) Patient is supine, either recumbent or upright
2) Rotate the body 45° into an RPO position
3) Abduct the arm of the affected side and elevate it; Abduct the opposite arm and place it on the hip
4) Center the image receptor to T7, with the top of the image receptor 1½" above relaxed shoulders for upper ribs.
5) Center the bottom of the image receptor at the level of the iliac crests, for lower ribs
6) Shield patients
7) Respiration is suspended after full inhalation for upper ribs. Full exhalation for lower ribs
Central Ray
• Perpendicular, centered to the image receptor and midway between the median sagittal plane and lateral border of the affected side
Structures Shown
• Axillary portion of the ribs are projected free of superimposition
• Ribs are either elongated or foreshortened, depending upon the oblique

AP Oblique of the Ribs, RPO

40
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Image Receptor Size: 14 x 17 Lengthwise
SID: 40" Upright or recumbent
Patient position
1) Patient is supine, either recumbent or upright
2) Rotate the body 45° into an LPO position
3) Abduct the arm of the affected side and elevate it; Abduct the opposite arm and place it on the hip
4) Center the image receptor to T7, with the top of the image receptor 1½" above relaxed shoulders for upper ribs.
5) Center the bottom of the image receptor at the level of the iliac crests, for lower ribs
6) Shield patients
7) Respiration is suspended after full inhalation for upper ribs. Full exhalation for lower ribs
Central Ray
• Perpendicular, centered to the image receptor and midway between the median sagittal plane and lateral border of the affected side
Structures Shown
• Axillary portion of the ribs are projected free of superimposition
• Ribs are either elongated or foreshortened, depending upon the oblique

AP Oblique of the Ribs, LPO

41
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Image Receptor Size: 8 x 10 Lengthwise
SID: 40" or 72"
Patient position
1) Patient is supine, either recumbent or upright
2) Extend the patient's chin slightly (this prevents superimposition of the mandible and midcervical vertebrae)
3) Center the image receptor to the level of C4 and median sagittal place
4) Shield patient
5) Suspend respiration
Central Ray
• 15 - 20° cephalic, entering at C4 (Adam's Apple)
Structures Shown
• Lower 5 cervical vertebrae
• Area from C3 - T2
• Open intervertebral disk spaces

AP Axial of the Cervical spine

42
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Image Receptor Size: 8 x 10 Lengthwise
SID: 40" or 72"
Patient position
1) Patient is supine, either recumbent or upright
2) Center the image receptor to the level of C2
3) Have the patient open their mouth as wide as possible and adjust the head so a line a drawn from the lower edge of the upper incisors to the tip of the mastoid process is perpendicular to the image receptor
4) Shield patient
5) Suspend respiration and phonate "ah" (This places the tongue on the floor of the mouth)
Central Ray
• Perpendicular to the midpoint of he open mouth (corners of the lips)
Structures Shown
• Dens, atlas and axis projected through the open mouth C1 - C2 articulation

AP of the Cervical Vertebrae, Open Mouth, For Atlas & Axis

43
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Image Receptor Size: 8 x 10 Lengthwise
SID: 72"
Patient position
1) Place patient in a true lateral position, upright
2) Rest the shoulder against the vertebral grid device and depress the shoulders as much as possible (hold sandbags if necessary)
3) The top of the image receptor should be about 1" above the EAM (external auditory meatus)
4) Elevate the chin slightly and protrude the mandible if possible (bite upper lip)
5) Ask the patient to look steadily at one point on the wall
5) Shield patient
6) Suspend respiration on full exhalation
Central Ray
• Horizontal and perpendicular to C4
Structures Shown
• All seven cervical vertebrae with spinous processes in profile
• Mandible is not superimposed over C1, C2
• Soft tissue

Lateral R or L, Grandy Method

44
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Image Receptor Size: 8 x 10 Lengthwise
SID: 72"
Patient position
1) Same positioning and central ray direction as a lateral
• HYPERFLEXION: Draw the chin as close to the chest as possible
• HYPEREXTENSION: Elevate the chin as much as possible and extend the head back
Structures Shown
• HYPERFLEXION - Spinous processes separated and elevated
• HYPEREXTENSION - Spinous processes depressed (close together)
• Demonstrates normal movement or an absence of movement if trauma or diseased

Lateral R or L, Hyperflexion/Hyperextension

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Image Receptor Size: 8 x 10
SID: 72" (preferred) or 40"
Patient position
1) Patient is supine, either recumbent or upright
2) Rotate the body 45° in either an RPO position
3) Center the image receptor to C3 (place the top of the image receptor at the level of the top of the ear)
4) Have the patient look straight ahead, elevate the chin and protrude the mandible
5) Shield patient
6) Suspend respiration
Central Ray
• 15 - 20° cephalic entering C4
Structures Shown
• Open intervertebral foramina farthest from the film
• Open intervertebral disk spaces
• All seven cervical vertebrae

AP Axial Oblique of Cervical vertebrae, RPO

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Image Receptor Size: 8 x 10
SID: 72" (preferred) or 40"
Patient position
1) Patient is supine, either recumbent or upright
2) Rotate the body 45° in either an LPO position
3) Center the image receptor to C3 (place the top of the image receptor at the level of the top of the ear)
4) Have the patient look straight ahead, elevate the chin and protrude the mandible
5) Shield patient
6) Suspend respiration
Central Ray
• 15 - 20° cephalic entering C4
Structures Shown
• Open intervertebral foramina farthest from the film
• Open intervertebral disk spaces
• All seven cervical vertebrae

AP Axial Oblique of Cervical vertebrae, LPO

47

Always perform a cross-table lateral cervical spine for severe injury FIRST. Do not move the patient or remove cervical collars.
Depress the shoulders as much as possible (Sometimes a physician will pull on the arms to depress the shoulders)

Trauma (of the cervical vertebrae)

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Image Receptor Size: 8 x 10
SID: 40"
Patient position
1) Patient is supine
2) Center the image receptor to the level of the tips of the mastoid processes
3) Extend the chin so the chin & the mastoid process are perpendicular
4) Shield patient
5) Collimate
Central Ray
• Perpendicular entering distal to the tip of the chin
Structures Shown
• Dens within the foramen magnum
• No rotation

AP of the cervical vertebrae, Fuchs Method

49
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Image Receptor Size: 10 x 12
SID: 40"
Patient position
1) Place the patient in a true lateral position, upright or recumbent
2) Elevate the arm closest to the image receptor and rest the forearm on the patient's head
3) Depress the opposite shoulder and rotate the arm slightly anterior
4) Center the image receptor at the level of C7 - T1
5) Shield patient
6) Suspend respiration or use breathing technique
Central Ray
• Perpendicular to C7 - T1 if shoulder is depressed
• 3 - 5° caudad if shoulder is not depressed
Structures Shown
• Lateral cervicothoracic vertebrae projected between the two shoulders

Lateral of the cervicothoracic region (R or L), Swimmers

50
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Image Receptor Size: 8 x 10 or 10 x 12 Lengthwise
SID: 40"
Patient position
1) Patient is supine
2) Depress the shoulders
3) Hyperextend the patient's head
4) Shield patient
5) Suspend respiration
Central Ray
• 20-30° caudad, directed to C7
Structures Shown
• Vertebral arch structures
• Articular processes
*NOTE: This procedure must not be attempted until cervical spine pathology or fracture has been ruled out

AP Axial of the cervicothoracic region, Vertebral Arch, Pillars

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Image Receptor Size: 14 x 17 or 7 x 17 Lengthwise
SID: 40"
Patient position
1) Patient is supine
2) Flex the knees and place the soles
3) Center the image receptor to T7 (approximately 3-4" distal to jugular notch) or 1½ - 2" above relaxed shoulders for the top of the image receptor
4) Center to the median sagittal plane
5) Shield patient
6) Suspend respiration after full exhalation
Central Ray
• Perpendicular approximately half way between the jugular notch and xiphoid process
Structures Shown
• AP of all twelve thoracic vertebrae

AP of thoracic spine

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Image Receptor Size: 14 x 17 or 7 x 17
SID: 40"
Patient position
1) Patient is placed in a true lateral position
2) Elevate the head to the long axis of the vertebral column
3) Flex the knees and hips into a comfortable position
4) Center the image receptor to T7 or place the top of the image receptor 1½ - 2" above relaxed shoulders
5) Adjust the arms at right angles of the body
6) Shield patient
7) Suspend respiration after full exhalation or use breathing technique (low mA, high second)
Central Ray
• Perpendicular to T7 and posterior half of thorax
Structures Shown
• Twelve thoracic vertebrae
• Intervertebral foramina
• Open intervertebral disk spaces
**NOTE: To improve image quality, a lead placed on the table behind the patient's back to attenuate the scatter radiation

Lateral of thoracic vertebrae (R or L)

53
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Image Receptor Size: 14 x 17 or 11 x 14 Lengthwise
SID: 40" (48" is suggested)
Patient position
1) Patient is supine
2) Flex the knees hips and place the soles of the feet on the table (This reduces the lordotic curvature of the lumbar region)
3) Center the image receptor at the level of the iliac crests for a 14 x 17 or 1½" above the crests for
C an 11 x 14
4) Center the image receptor to the median sagittal plane
5) Shield patient is possible
6) Suspend respiration at the end of expiration
Central Ray
• Perpendicular to the level of the iliac crests (L4) for a 14 x 17 or 1½" above the crests (L3) for an 11 x 14
Structures Shown
• All five lumbar vertebrae
• Open intervertebral disk spaces
*NOTE: PA projection significantly reduces the gonadal dose as compared to an AP projection
• Many radiologists request that limited collimation be utilized, so the liver, kidney, spleen and psoas muscle margins are visualized**

AP of the lumbar spine

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Image Receptor Size: 14 x 17 or 11 x 14
SID: 40"
Patient position
1) Place the patient in a true lateral position (usually left)
2) Flex the knees and hips to a comfortable position
3) Center the image receptor to the median coronal plane and level of the iliac crests for a 14 x 17, 1½" above the crest for an 11 x 14
4) If necessary, place a support under the lower thorax and waist
5) Shield patient
6) Suspend respiration after full exhalation
Central Ray
• Perpendicular to the level of the iliac crests (L4) for a 14 x 17 and median coronal plane
Structures Shown
• All five lumbar vertebrae
• Open intervertebral foramina
**NOTE: To improve image quality, a lead strip can be placed on the table behind the patient's back to attenuate scatter radiation**

Lateral of the lumbar spine (R or L)

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Image Receptor Size: 8 x 10 Lengthwise
SID: 40"
Patient position
1) Patient is placed in a true lateral position
2) Extend the knees and hips to a comfortable position
3) Center the image receptor to a point 2" posterior to the ASIS and 1½" inferior to the iliac crest, along the coronal plane
4) Shield patient if possible
5) Collimate
6) Suspend respiration
Central Ray
• Perpendicular if the patient's spine is horizontal - 2" posterior to the ASIS and 1½" inferior to the iliac crest, along the coronal plane
• 5° caudad for males, 8° caudad for females when the spine is not horizontal
Structures Shown
• Open lumbosacral joint

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(L5 - S1) Lumbosacral Junction, Lateral of the lumbar spine (R or L)

56
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Image Receptor Size: 8 x 10 or 10 x 12
SID: 40"
Patient position
1) Patient is supine
2) Rotate the patient 45° into an RPO or LPO position
3) Center the spine to the image receptor (2" medial to the elevated ASIS) approximately 1 - 1½" above the iliac crests at the level of L3
4) Shield patient
5) Suspend respiration after expiration
Central Ray
• Perpendicular, 1½" above the crest at the level of L3 and 2" medial to the elevated ASIS
Structures Shown
• Demonstrates the zygapophyseal joints closest to the image receptor ("Scottie Dogs")
• Both sides are done for comparison
**NOTE: In the PA Obliques (RAO/LAO), the zygapophyseal joints farthest from the image receptor are demonstrated**

AP Oblique of the lumbar spine, (RPO/LPO)

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Image Receptor Size: 14 x 17 Lengthwise
SID: 40"
Patient position
1) Patient is standing
2) Center the image receptor to the level of L3 (umbilicus)
3) Arms are outside the area of interest
4) Have patient bend forward as far as possible without rotation
5) Collimate
6) Suspend respiration
Central Ray
• Perpendicular to L3
Structures Shown
• Mobility of intervertebral joints
• Include lower thoracic to sacrum
**NOTE: AP right and left bending positions can be performed to demonstrate mobility of the intervertebral joints. These studies are also used in patients with early scoliosis to determine the presence of structural change when bending to the right or left**

Lateral of the lumbar vertebrae, Weightbearing Method, Flexion

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Image Receptor Size: 14 x 17 Lengthwise
SID: 40"
Patient position
1) Patient is standing
2) Center the image receptor to the level of L3 (umbilicus)
3) Arms are outside the area of interest
4) Have patient bend backwards as far as possible without rotation
5) Collimate
6) Suspend respiration
Central Ray
• Perpendicular to L3
Structures Shown
• Mobility of intervertebral joints
• Include lower thoracic to sacrum
**NOTE: AP right and left bending positions can be performed to demonstrate mobility of the intervertebral joints. These studies are also used in patients with early scoliosis to determine the presence of structural change when bending to the right or left**

Lateral of the lumbar vertebrae, Weightbearing Method, Extension

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Image Receptor Size: 14 x 36
SID: 60" minimum
Patient position
FIRST EXPOSURE
1) Patient is standing or seated PA
2) Arms hang relaxed at the sides
3) Midsagittal plane is centered to the image receptor is 1" below the iliac crest
5) Shield gonads
6) Suspend respiration
SECOND EXPOSURE
1) Elevate the patient's hip on the convex side 3-4" by having them step on a block
2) Midsagittal plane is centered to the image receptor
3) Bottom on the image receptor is 1" below the iliac crest
4) Shield gonads
5) Suspend respiration
Central Ray
• Perpendicular to the image receptor
Structures Shown
• Thoracic and lumbar verterbae

Scoliosis series, PA of the lumbar spine, Ferguson Method

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Image Receptor Size: 8 x 10 or 10 x 12
SID: 40"
Patient position
1) Patient is supine with their legs extended
2) Center the image receptor 1½" superior to the symphysis pubis
3) Suspend respiration
Central Ray
• 30° cephalic for males, 35° cephalic for females, entering the median sagittal plane, 1½" superior to the symphysis pubis
Structures Shown
• Lumbosacral joint
• Symmetrical image of sacroiliac joints free superimposition

AP Axial of the sacroiliac joints, Ferguson Method

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Image Receptor Size: 8 x 10 or 10 x 12
SID: 40"
Patient position
1) Patient is supine
2) Elevate the side being examined 25-30°
3) Center the image receptor to a point 1" medial to the elevated ASIS
4) Collimate
5) Suspend respiration
Central Ray
• Perpendicular entering 1" medial to the elevated ASIS
Structures Shown
• Open SI joint farthest from the film
• Both sides are examined for comparison
**NOTE: PA Obliques (RAO/LAO) will demonstrate the SI joints closest to the film**

AP Oblique of sacroiliac joints(RPO/LPO)

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Image Receptor Size: 10 x 12 (Sacrum)
SID: 40"
Patient position
1) Patient is supine with legs extended
2) Shield gonads for men
3) Suspend respiration
Central Ray
• 15° cephalic centered to a point 2" superior to the symphysis pubis
Structures Shown
• Sacrum free of foreshortening and rotation

AP Axial of the Sacrum

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Image Receptor Size: 10 x 12 (Sacrum) 8x 10 (Coccyx)
SID: 40"
Patient position
1) Patient is supine with legs extended
2) Shield gonads for men
3) Suspend respiration
Central Ray
• 10° caudad, centered to a point 2" superior to the symphysis pubis
Structures Shown
• Coccygeal segments not superimposed

AP Axial of the Coccyx

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Image Receptor Size: 10 x 12 (Sacrum) 8x 10 (Coccyx) Lengthwise
SID: 40"
Patient position
1) Place the patient in a true lateral position
2) Flex the knees and hips into a comfortable position
SACRUM
3) Place the top of the image receptor to the level of the iliac crests and passing 3½" posterior to the ASIS
4) Suspend respiration
Central Ray
SACRUM
• Perpendicular to the level of the ASIS and a plane 3½" posterior to the ASIS
COCCYX
• Perpendicular through the coccyx at a point 3½" posterior to the ASIS and 2" inferior
Structures Shown
• Lateral sacrum & coccyx

Lateral of Sacrum and Coccyx (R or L)