Technique 1 Lower limbs 3

Radiography Technique

1. Radiographic Technique 1 Lecture 3: Lower Limbs Part 3 Pelvic, Hip September, 2011 Prepared by: Behzad Ommani Bachelor of Radiology Master of Medical Engineering

2. Radiography Pelvis

3. Pelvis AP PROJECTION Image receptor : 35 x 43 cm crosswIse Position of patient : Place the patient on the table In the supine position. Position of part : Center the midsagittal plane of the body to the midline of the grid, and adjust it in a true supine position. Unless contraindicated because of trauma or pathologic factors, medially rotate the feet and lower limbs about 15 to 20 degrees to place the femoral necks parallel with the plane of the image receptor (IR). Medial rotation is easier for the patient to maintain if the knees are supported.

4. The heels should be placed about 8 to 10 inches ( 20 to 24 cm ) apart. Immobilize the legs with a sandbag across the ankles, if needed. Check the distance from the ASIS to the tabletop on each side to be sure that the pelvis is not rotated. Center the IR midway between the ASIS and the pubic symphysis . The center of the IR will be about 2 inches (5 cm) inferior to the ASIS and 2 inches (5 cm) superior to the pubic symphysis in average-sized patients. Pelvis

5. If the pelvis is deep, palpate for the iliac crest and adjust the position of the IR so that its upper border will project 1 to 1/2 inches (2.5 to 3.8 cm) above the Crest. Respiration: Suspend. Central ray : Perpendicular to the midpoint of the IR Pelvis

6. Pelvis

7. Congenital dislocation of the hip 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. The first projection is obtained with the central ray directed perpendicular to the pubic symphysis to detect any lateral or superior displacement of the femoral head. The second projection is obtained with the central ray directed to the pubic symphysis at a cephalic angulation of 45 degrees . Pelvis

8. This angulation casts the shadow of an anteriorly displaced femoral head above that of the acetabulum and the shadow of a posteriorly displaced head below that of the acetabulum . Pelvis

9. Pelvis LATERAL PROJECTION Right or left position Image receptor : 35 x 43 cm crosswise Position of patient : Place the patient in the lateral recumbent, dorsal decubitus , or upright position. Position of part : When the patient can be placed in the lateral position, center the midcoronal plane of the body to the midline of the grid. Extend the thighs enough to prevent the femora from obscuring the pubic arch.

10. 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. Adjust the pelvis in a true lateral position, with the ASIS lying in the same vertical plane. Place one knee directly over the other knee. A pillow or other support between the knees promotes stabilization and patient comfort. Pelvis

11. Berkebile, Fischer, and Albrecht' recommended a dorsal decubitus lateral projection of the pelvis for demonstration of the "gull-wing sign" in cases of fracture dislocation of the acetabular rim and posterior dislocation of the femoral head. Central ray: Perpendicular to a point centered at the level of the soft tissue depression just above the greater trochanter (approximately 2 inches (5 cm)) and to the mid. point of the image receptor Center the lR to the central ray Pelvis

12. Pelvis

13. AP OBLIQUE PROJECTION MODIFIED CLEAVES METHOD This projection is often called the bilateral "frog leg" position. Image receptor : 35 x 43 cm crosswise Position of patient : Place the patient in the supine position. Position of part : Center the mid sagittal 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 ASISs equidistant from the radiographic table. Femoral Necks

14. 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 hips and knees and draw the feet up as much as possible. 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 soles against each other for support. Femoral Necks

15. According to Cleaves. the angle may vary between 25 and 45 degrees, depending on how vertical the femora can be placed. Unilateral projection Adjust the body position to center the ASIS of the affected side to the midline of the grid. Have the patient flex the hip and knee of the affected side and draw the foot up to the opposite knee as much as possible. After adjusting the perpendicular central ray and positioning the IR tray, have the patient brace the sole of the foot against the opposite knee and abduct the thigh laterally approximately 45 degrees. Femoral Necks

16. Femoral Necks

17. The pelvis may rotate slightly. Respiration : Suspend. Central ray : Perpendicular to enter the patient's mid sagittal plane at the level 1 inch ( 2.5 cm ) superior to the pubic symphysis . For the unilateral position, direct the central ray to the femoral neck . Femoral Necks

18. AXIOLATERAL PROJECTION ORIGINAL CLEAVES METHOD NOTE: This examination is contraindicated for patients with suspected fracture or pathologic. Image receptor : 35 x 43 cm crosswise Position of patient : Place the patient in the supine position. Position of part : NOTE: This is the same part position as the modified Cleaves method previously described. The projection can be performed unilaterally or bilaterally. Femoral Necks

19. Central ray : 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. Femoral Necks

20. Femoral Necks Congenital dislocation of the hip

21. Radiography Hip

22. AP PROJECTION ORIGINAL CLEAVES METHOD NOTE: This examination is contraindicated for patients with suspected fracture or pathologic. Image receptor : 24 x 30 cm lengthwise Position of patient : Place the patient in the supine position. Position of part : Adjust the patient's pelvis so it is not rotated. This is accomplished by placing the ASISs equidistant from the table. Hip

23. Medially rotate the lower limb and foot approximately 15 to 20 degrees to place the femoral neck parallel with the plane of the IR, unless this maneuver is contraindicated or other instructions are given. Respiration: Suspend. Central ray : Perpendicular to the femoral neck. Place the central ray approximately 2 ½ inches (6.4 cm) distal on a line drawn perpendicular to the midpoint of a line between the ASIS an the pubic symphysis . Hip

24. Hip

25. LATERAL PROJECTION Mediolateral LAUENSTEIN AND HICKEY METHODS NOTE: This examination is contraindicated for patients with suspected fracture or pathologic. Image receptor : 24 x 30 cm crosswise Position of patient : From the supine position, rotate the patient slightly toward the affected side to an oblique position. The degree of obliquity will depend on how much the patient can abduct the leg. Position of part : Adjust the patient's body, and center the affected hip to the midline of the grid. Hip

26. Ask the patient to flex the affected knee and draw the thigh up to a position at nearly a right angle to the hip bone. Extend the opposite limb and support it at hip level and under the knee. Central ray : Perpendicular through the hip joint, which is located midway between the ASIS and the pubic symphysis for the Lauenstein method and at a cephalic angle of 20 to 25 degrees for the Hickey method. Center the IR to the central ray. Hip

27. Hip

28. AXIOLATERAL PROJECTION DANELIUS-MILLER METHOD Surgical Lateral Image receptor : 24 x 30 cm lengthwise Position of patient : Place the patient in the supine position. Position of part Flex the knee and hip of the unaffected side to elevate the thigh in a vertical position. Rest the unaffected leg on a suitable Support Unless contraindicated, grasp the heel and medially rotate the foot and lower limb of the affected side about 15 or 20 degrees. Hip

29. Hip Place the IR in the vertical position with its upper border in the crease above the iliac crest . Central ray : Perpendicular to the long axis of the femoral neck.

30. Hip

31. AXIOLATERAL PROJECTION CLEMENTS-NAKAYAMA MODIFICATIONl When the patient has bilateral hip fractures, bilateral hip arthroplasty (plastic surgery of the hip joints), or limitation of movement of the unaffected leg the Danelius -Miller method cannot be used. Image receptor : 24 x 30 cm lengthwise Position of patient : Place the patient in the supine position. Hip

32. Position of part : For this position, do not rotate the lower limb internally. Instead, the limb remains in a neutral or slightly externally rotated position . Support a grid IR on the Bucky tray so that its lower margin is below the patient. Adjust the grid parallel to the axis of the femoral neck and tilt its top back 15 degrees. Respiration : Suspend. Central ray : Directed 15 degrees posteriorly and aligned perpendicular to the femoral neck and grid IR. Hip

33. Hip

34. Radiography Acetabulum

35. PA AXIAL OBLIQUE PROJECTION TEUFEL METHOD RAO or LAO position Image receptor : 8 x 10 inch (18 x 24 cm) lengthwise Position of patient : Have the patient lie in a semi prone position on the affected side. Position of part : Align the body, and center the hip being examined to the midline of the grid. Elevate the unaffected side so that the anterior surface of the body forms a 38-degree angle from the table. Acetabulum

36. Have the patient support the body on the forearm and flexed knee of the elevated side. With the IR in the Bucky tray, adjust the position of the IR so that its midpoint coincides with the central ray. Respiration: Suspend. Central ray : Directed through the acetabulum at an angle of 12 degrees cephalad . The central ray enters the body at the inferior level of the coccyx and approximately 2 inches (5 cm) lateral to the midsagittal plane toward the side being examined. Acetabulum

37. Acetabulum

38. AP OBLIQUE PROJECTION JUDET METHOD RPO or LPO position Image receptor : 24 x 30cm lengthwise Internal oblique: For a patient with a suspected fracture of the iliopubic column ( anterior ) and the posterior rim of the acetabulum . Position of patient : Place the patient in a semisupine position with the affected hip lip. Acetabulum

39. Position of part : Align the body, and center the hip being examined to the middle of the IR. Elevate the affected side so that the anterior surface of the body forms a 45 degree angle from the table . Respiration: Suspend. Central ray : Perpendicular to the IR and entering 2 inches inferior to the ASIS of the affected side. Acetabulum

40. Acetabulum

41. Acetabulum

42. External oblique: For a patient with a suspected fracture of the ilioischial column ' ( posterior ) and the anterior rim of the acetabulum . Position of patient : Place the patient in a semisupine position with the affected hip down. Position of part : Align the body, and center the hip being examined to the middle of the IR. Elevate the affected side so that the anterior surface of the body fonns a 45 degree angle from the table. Respiration: Suspend. Acetabulum

43. Central ray : Perpendicular to the IR and entering at the pubic symphysis . Acetabulum

44. Radiography Other Part

45. PA PROJECTION Image receptor : 8 x 10 inch (18 X 24 cm) crosswise Position of patient : Place the patient in the prone position, and center the midsagittal plane of the body to the midline of the grid. Position of part : With the IR in the Bucky tray, center the IR at the level of the greater trochanters.This positioning also centers the IR to the pubic symphysis . Respiration: Suspend. Anterior Pelvic Bones

46. Central ray : Perpendicular to the midpoint of the IR. The central ray enters the distal coccyx and exits the pubic symphysis . Anterior Pelvic Bones

47. AP AXIAL "OUTLET" PROJECTION TAYLOR METHOD Image receptor : 24 x 30 cm crosswise Position of patient : Place the patient in the supine position. Position of part : Center the midsagittal plane of the patient's body to the midline of the grid, and adjust the pelvis so that it is not rotated. The ASISs should be equidistant from the table With the IR in the Bucky tray, adjust the tray's position so the midpoint of the IR will coincide with the central ray. Respiration: Suspend Anterior Pelvic Bones

48. Central ray : Males Directed 20 to 35 degrees cephalad and centered to a point 2 inches (5 cm) distal to the superior border of the pubic symphysis . Females Directed 30 to 45 degrees cephalad and centered to a point 2 inches (5 cm) distal to the upper border of the pubic symphysis . Anterior Pelvic Bones

49. Anterior Pelvic Bones

50. SUPEROINFERIOR AXIAL "INLET“ PROJECTION LlLIENFELD METHOD Image receptor : 24 x 30 cm crosswise Position of patient : Place the patient on the radiographic table in a seated-upright position Position of part : Center the midsagittal plane of the patient's body to the midline of the grid. Flex the knees slightly and support them to relieve strain. Anterior Pelvic Bones

51. Have the patient extend the arms for support, lean backward 45 or 50 degrees, and then arch the back, if possible, to place the pubic arch in a vertical position. With the IR in the Bucky tray, center it at the level of the greater trochanters . Central ray : Perpendicular to the midpoint of the image receptor and entering ½ inches (3.8 cm) superior to the pubic symphysis . Anterior Pelvic Bones

52. Anterior Pelvic Bones

53. AP AND PA OBLIQUE PROJECTIONS RPO and LPO positions Image receptor : 24 x 30 cm lengthwise Position of patient : Place the patient in the supine position. Position of part : Center the sagittal plane passing through the hip joint of the affected side to the midline of the grid. Ilium

54. Elevate the unaffected side approximately 40 degrees to place the broad surface of the wing of the affected ilium parallel with the plane of the IR. Support the elevated shoulder, hip, and knee on sandbags. Adjust the position of the uppermost limb to place the ASISs in the same transverse plane. Center the IR at the level of the ASIS. Respiration: Suspend. Central ray : Perpendicular to the midpoint of the IR Ilium

55. Ilium