Bontrager 9 Edicao

PERPUSTAKAAN
PRIBADI
AN-NUR
Th is p o cke t h an d b o o k b e co m e s a p e rso n al
n o t e b o o k an d re co rd o f p o sit io n in g an d t e ch n iq ue
fact o rs. It is a ve ry valuab le an d p e rso n al d o cum e n t
t o t h e o w n e r. Ple ase re t urn t o :
Nam e
Ad d re ss
Ph o n e
In st it ut io n
Bontrager’s
HANDBOOK of
RADIOGRAPHIC
POSITIONING
and TECHNIQUES
NINTH EDITION
John P. Lampignano, MEd, RT(R)(CT)

Leslie E. Kendrick, MS, RT(R)(CT)(MR)
3251 Riverport Lane
St. Louis, Missouri 63043
BONTRAGER’S HANDBOOK OF RADIOGRAPHIC POSITIONING ISBN: 978-0-323-48525-8

AND TECHNIQUES, 9TH EDITION
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is book and the individual contributions contained in it are protected under copyright by the
Publisher (other than as may be noted herein).
Notices
Knowledge and best practice in this eld are constantly changing. As new research and experience
broaden our understanding, changes in research methods, professional practices, or medical
treatment may become necessary.
Practitioners and researchers must always rely on their own experience and knowledge in
evaluating and using any information, methods, compounds, or experiments described herein. In
using such information or methods they should be mindful of their own safety and the safety of
others, including parties for whom they have a professional responsibility.
With respect to any drug or pharmaceutical products identi ed, readers are advised to check the
most current information provided (i) on procedures featured or (ii) by the manufacturer of each
product to be administered, to verify the recommended dose or formula, the method and duration
of administration, and contraindications. It is the responsibility of practitioners, relying on their
own experience and knowledge of their patients, to make diagnoses, to determine dosages and the
best treatment for each individual patient, and to take all appropriate safety precautions.
To the fullest extent of the law, neither the Publisher nor the authors, contributors, or editors,
assume any liability for any injury and/or damage to persons or property as a matter of products
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instructions, or ideas contained in the material herein.
Previous edition copyrighted 2014 by Mosby, an imprint of Elsevier Inc.

Previous edition copyrighted 2010 by Mosby, Inc., an a liate of Elsevier Inc.
Previous editions copyrighted 2002, 1999, 1995, 1994 by Kenneth L. Bontrager
International Standard Book Number: 978-0-323-48525-8
Executive Content Strategist: Sonya Seigafuse

Content Development Manager: Lisa P. Newton
Senior Content Development Specialist: Tina Kaemmerer
Publishing Services Manager: Julie Eddy
Senior Project Manager: Mary G. Stueck
Design Direction: Renée Duenow
Printed in the United States of America
Last digit is the print number: 9 8 7 6 5 4 3 2 1

Pre face
T is pocket handbook was rst developed by Kenneth Bontrager in
1994 as a response to the need felt by students and technologists for
a more thorough but still practical pocket guide covering the applied
aspects of radiographic positioning and techniques (exposure factors).
oday, this compact and durable pocket-sized handbook includes a
review of all the common imaging procedures, yet it is small enough
to be easily carried in clinical situations. Su cient space is included
for writing personal notes and exposure factors that technologists nd
are optimal for speci c equipment or in certain rooms or departments.
Careful attention has been given to ensure the information on posi-
tioning in the Bontrager text is re ected accurately in the handbook.
Positioning descriptions and photographs are provided for each
projection/position, along with CR locations, degrees of obliquity,
speci c CR angles, AEC cell locations, patient shielding, and sug-
gested kV ranges for analog and digital systems. A quick review of this
information before beginning a procedure can ensure the examination
is being correctly performed, reducing the need for repeat exposures as
e
a result of poor positioning or improper exposure factors.
c
a
f
e
r
P
St an d ard Rad io g rap h ic Im ag e
an d Evaluat io n Crit e ria
T e ninth edition of this handbook includes a standard, well-

positioned radiograph with each position described. Also added is a
brief summary of quality factors to use an image evaluation matrix.
Viewing this radiograph and comparing it with the list of evaluation
criteria leads users through a critique of the image they are viewing
for comparison to this standard.
Also included is an optional competency sign-o checksheet that
can be signed by the clinical instructor for individual student com-
petency records.
iii
Ackn o wle d g m e n t s
We would like to thank Kelli Haynes, MSRS, RT(R), who edited the
9th edition of the handbook. Kelli did an outstanding job updating
the content in an extremely short time frame. T is handbook is made
possible through her expertise and attention to detail.
Sonya Seigafuse, ina Kaemmerer, and Mary Stueck from Elsevier
were instrumental in providing support, guidance, and the resources
in the redesign and publishing of the pocket handbook. We are most
indebted to our former students, fellow technologists, and those
many educators throughout the United States and in the international
imaging community who challenged and inspired us. We thank all of
you and hope this pocket handbook continues to be a valuable aid in
improving and maintaining that high level of radiographic imaging
for which we all strive.
John and Leslie

A
c
k
n
o
w
l
e
d
g
m
e
n
t
s
iv
Co n t e n t s
1 Ch e st : Adult Chest, Up per Airway, and Ped iatric Chest 1
2 Up p e r Lim b : Fingers, Thum b, Hand, Wrist, Forearm ,
Elbow, and Pediatric Upper Lim b 20
3 Hum e rus an d Sh o uld e r Gird le : Hum erus, Shoulder,
Clavicle, Scapula, and Acrom ioclavicular (AC) Joints 65
4 Lo w e r Lim b : Toes, Foot, Calcaneus, Ankle, Lower Leg
(Tibia-Fibula), Knee, Intercondylar Fossa, Patella, and
Pediatric Lower Lim b 101
5 Fe m ur an d Pe lvic Gird le : Fem ur, Proxim al Fem ora
(Hips), Lateral Hip (Nontraum a), Lateral Hip (Traum a),
Pelvis, Acetab ulum , and Pediatric Hips and Pelvis 149
6 Ve rt e b ral Co lum n : Cervical Spine, Thoracic Sp ine, Lum bar
Spine, Sacrum and Coccyx, and Sacroiliac (SI) Joint 173
7 Bo n y Th o rax: Sternum , Sternoclavicular Joints, Ribs
(Bilateral), and Axillary Ribs 212
s
t
n
8 Cran ium , Facial Bo n e s, an d Paran asal Sin use s:
e
t
Cranium (Skull Series), Traum a (Skull Series), Facial Bones,
n
o
Traum a (Facial Bone Series), Optic Foram ina, Zyg om atic
C
Arches, Nasal Bones, Mandible, Tem porom andibular Joints,
and Paranasal Sinuses 225
9 Ab d o m e n an d Co m m o n Co n t rast Me d ia
Pro ce d ure s: Abd om en (Adult), Abd om en (Pediatric),
Esophagogram , Upper GI (Stom ach), Sm all Bowel, Barium
Enem a, Intravenous Urography (IVU), Cystography 269
10 Mo b ile ( Po rt ab le s) an d Surg ical Pro ce d ure s:
Mobile, Surgical C-arm , Procedure Notes 311
Ap p e n d ix A Reducing Patient Dose 320
Ap p e n d ix B Tim e-m A (m As) Chart 322
Ap p en d ix C Exposure–Distance Conversion Chart 323
Ap p en d ix D Cast Conversion Rule 324
Ap p e n d ix E Grid Ratio Conversion Chart 325
Ap p e n d ix F Initials (Ab breviations), Technical Term s,

and Acronym s 326
v
Exp lan at io n s fo r Use
T is handbook is intended as a quick reference and review of radio-
graphic positioning and procedures. It is not intended to replace the
positioning techniques described in the Bontrager text. Rather, it is
an ancillary tool that provides the technologist a quick review of the
critical elements on positioning, CR location, kV ranges, and methods
for reducing patient dose. T ese critical elements include:
Radiation protection: Certain radiation protection practices and

shielding descriptions are included with each projection, and it is
the responsibility of the technologist to ensure that shielding of
radiosensitive tissues, collimation, and proper exposure factors are
applied for each examination. Recommendations for reducing patient
dose are described in Appendix A.
kV ranges: Suggested kV ranges for analog and digital systems are

E
x
stated for each projection. T ese are recommendations based on best
p
l
a
practices and validated by imaging experts. T ese kV ranges may not
n
a
apply to every department protocol or imaging systems employed.
t
i
o
T e technologist should consult with his or her radiation safety o cer
n
s
or supervisor to determine appropriate kV ranges for their clinical
f
o
r
setting.
U
s
e
Chapter title pages: T e list of projections with page numbers is at
the beginning of each chapter for ease in locating speci c projections
and also as a reference for marking the basic department routines for
each examination. A small check (√ ) can be placed in the box by each
projection that is part of the preferred departmental routine. Each
projection is also followed by either an (R) or a (S) for a suggested
departmental routine or special.
Standard Radiographic Image and Evaluation Criteria: Associated

with each positioning page is a radiograph of that projection. T ese
radiographs demonstrate the critical anatomy that must be visualized.
A list of evaluation criteria is provided for the technologists to critique
the images they have produced.
Also included is an optional competency sign-o area to be signed

by the clinical instructor for individual student competency records.
vi
Each positioning page has a
format similar to this sample
page. PA Ch e st
1 Suggested location of 1
patient ID information with
analog imaging. For chest L
2
examinations, this represents
the top right of the image
receptor (IR).
2 Recommended AEC
3
chamber(s) (darkened R and
L upper cells indicated on this
PA chest example). Note: Verify • 35 × 43 cm (14 × 17″) 4
AEC chamber selection with portrait or landscape Fig . 1.2 PA
department before employing. • Grid below verteb
3 Collimation eld size with CR female, 18 c
Po sit io n 5
location in center.
• Erect, chin raised, hands on hips with pa
e
4 IR size recommended for an
s
forward
U
average adult, placed portrait • Center CR to the center of the lung lds
r
o
(lengthwise) or landscape with accurate collimation on both top an
f
(crosswise) in reference to the
s
• Center thorax bilaterally to IR borders wi
n
anatomy of interest. Grid or
o
sides; ensure there is no rotation of thora
i
t
nongrid. Central Ray: CR to IR, centered to T7, o
a
n
5 Patient position description. vertebra prominens (is also near level of inf
a
6
l
p
SID: 72–120″ (183–307 cm) 7
x
6 CR location and CR angle.
E
Collimation: Upper border to vertebra prom
7 Suggested SID range. margins
8 Suggested kV ranges. Analog Respiration: Expose at end of second deep
and digital systems. (Pencil
in kV range for your imaging
systems.)
9 Exposure factors to be lled in kV Range: 8 Analog and Digital Syste
(in pencil) as determined best
for small (S), medium (M), or cm kV mA Time mAs
large (L) patients. 9
10 T is additional space is S
provided for exposure factors
for analog systems or for 10
M
speci c types of digital image
receptors that require technique
adjustments. L
11 Corresponding page number
in textbook for detailed 4 11 Bontrager Textbook, 9th ed
information on the projection.
vii
This pa ge inte ntiona lly le ft bla nk
Ch ap t e r 1
1
Ch e st
• Positioning considerations and radiation protection 2

• Digital imaging considerations 3
Ad ult Ch e st Up p e r Airw ay
t
PA (R) 4 AP and lateral (trachea
s
e
h
Lateral (R) 5 and larynx) (S) 13
C
Lateral (wheelchair or AP and lateral critique 14
stretcher) (R) 6
PA (AP) (R) 7 Pe d iat ric Ch e st
PA and lateral critique 7 AP (tabletop) (R) 15
Lateral decubitus (S) 8 Erect PA (with
AP lordotic (S) 9 Pigg-O-Stat) (R) 16
Lateral decubitus and AP Lateral (tabletop) (R) 17
lordotic critique 10 Erect lateral (with
Anterior oblique (RAO Pigg-O-Stat) (R) 18
and LAO) (S) 11 PA (AP) and lateral
Anterior oblique (RAO critique 19
and LAO) critique 12
(R) Routine, (S) Special
1
Po sit io n in g Co n sid e rat io n s
an d Rad iat io n Pro t e ct io n
Co llim at io n
1
Restricting the primary beam coverage is a very ef ective way to reduce
patient exposure in chest radiography T is requires accurate and
correct location o the central ray (CR)
Co rre ct CR Lo cat io n
Correct CR location to the midchest ( 7) allows or accurate collima-
tion and protection o the upper radiosensitive region o the neck
area It also prevents exposure to the dense abdominal area below the
C
diaphragm, which produces scatter and secondary radiation to the
h
e
radiosensitive reproductive organs
s
t
5
6
7
1
J ugula r notch 2 Fe ma le - 7″ (18 cm)
3–4″ (8–10 cm) 3
4 Ma le - 8″ (20 cm)
5
6
CR 7
8
9
10
11
12
Fig . 1.1 Correct CR location
7 or the PA chest can be located posteriorly in re erence to C7,

the vertebra prominens. Level o 7 is 18–20 cm (7–8 inches) below
the vertebra prominens
T e CR or the AP chest is 8–11 cm (3–4 inches) below the jugular
notch and angled 3°–5° caudad (CR perpendicular to midsternum)
2
Sh ie ld in g
1
Shielding o radiosensitive organs and tissues should be used or all
procedures unless it obscures key anatomy Shielding is not a substitute
or close collimation
Backscat t e r Pro t ect io n

Shields placed between the patient and the wall bucky and wall can also
be used to keep scatter and secondary radiation rom these structures
rom reaching the patient’s gonadal regions
t
s
e
h
C
Dig it al Im ag in g Co n sid e rat io n s
T e ollowing technical actors will reduce dose to the patient and

improve image quality:
Collimation: Close collimation reduces dose to the patient and scatter
radiation reaching the image receptor
Accurate Centering: Most digital systems recommend that the
anatomy be centered to the receptor
Exposure Factors: Digital systems are known or wide exposure
latitude, utilizing a broad range o exposure actors (kV and mAs)
However, the ALARA principle must be ollowed, there ore, the
highest kV and lowest mAs, consistent with optimal image quality,
should be used
Exposure Indicator (EI): Check the EI to veri y that the optimal
exposure actors were in the correct range to ensure optimal image
quality and the least amount o radiation to the patient Keep in mind
that EI ranges are established by the manu acturers o the system and
validated by your imaging department
Grids: With certain digital systems, the grid may or may not be able
to be removed rom the receptor In those cases, it is departmental
protocol that determines whether a grid is le in place or removed
Bontrager extbook, 9th ed, pp 38–70 3

PA: Ch e st
1
L
• 35 × 43 cm (14 × 17″)
portrait or landscape
C
Fig . 1.2 PA chest (CR ≈20 cm [8″] below
h
• Grid
e
vertebra prominens) (average emale, 18 cm
s
t
[7″])
Po sit io n
• Erect, chin raised, hands on hips with palms out, roll shoulders
orward
• Center CR to the center o the lung elds on all types o patients
with accurate collimation on both top and bottom
• Center thorax bilaterally to IR borders with equal margins on both
sides; ensure there is no rotation o thorax
Central Ray: CR to IR, centered to 7, or 7–8″ (18–20 cm) below
vertebra prominens (is also near level o in erior angle o scapula)
SID: 72″ (183 cm)
Collimation: Upper border to vertebra prominens; sides to outer skin
margins
Respiration: Expose at end o second deep inspiration
kV Range: Analog and Dig ital System s: 110–125 kV
cm kV mA Time mAs SID Exposure Indicator
4 Bontrager extbook, 9th ed, pp 92–93

Lat e ral: Ch e st
1
L
• 35 × 43 cm (14 × 17″)
portrait
t
Fig . 1.3 Le lateral chest
s
e
• Grid
h
C
Po sit io n
• Erect, le side against IR (unless right lateral is indicated)
• Arms raised, crossed above head, chin up
• True lateral, no rotation or tilt Midsagittal plane parallel to IR
(Don’t push hips in against the IR holder)
• T orax centered to CR, and to IR anteriorly and posteriorly
Central Ray: CR to IR, centered to midthorax at level o 7; gener-
ally IR and CR should be lowered ≈1″ (2 5 cm) rom PA on average
patient
SID: 72″ (183 cm)
Collimation: Upper border to level o vertebra prominens, sides to
anterior and posterior skin margins
Respiration: Expose at end o second full inspiration
Bontrager extbook, 9th ed, p 94 5

Lat e ral ( Wh e e lch air o r St re t ch e r) : Ch e st
1
L
• 35 × 43 cm (14 × 17″)
portrait
C
Fig . 1.4 Le lateral on stretcher
h
• Grid
e
s
t
Po sit io n
• Erect, on stretcher or in wheelchair
• Arms raised, crossed above head, or hold on to support bar
• Center thorax to CR, and to IR anteriorly and posteriorly
• No rotation or tilt, midsagittal plane parallel to IR, keep chin up
Central Ray: CR to IR, centered to midthorax at level o 7
SID: 72″ (183 cm)
Collimation: Upper border to level o vertebra prominens, sides to
anterior and posterior skin margins
Respiration: Expose at end o second full inspiration
6 Bontrager extbook, 9th ed, p 95

PA ( AP) : Ch e st
Evaluat io n Crit e ria
1
Anatomy Demonstrated
• Both lungs rom apices to
costophrenic angles, and both
lateral borders o ribs
• 10 ribs demonstrated above
the diaphragm
Position
• Chin su ciently elevated
t
s
• No rotation, SC joints and
e
h
C
lateral rib margins equal
distance rom midline o spine
Exposure Fig . 1.5 PA chest
Competency Check:
• No motion, sharp outlines o Technologist Date
diaphragm and lung markings
visible
• Exposure su cient to visualize aint outlines o midthoracic and
upper thoracic vertebrae through heart and mediastinal structures
Lat e ral: Ch e st

• From apices to costophrenic angles,
rom sternum to posterior ribs
Position
• Chin and arms elevated to prevent
superimposing apices
• No rotation, R and L posterior ribs
superimposed except side away
rom IR projected slightly (1 cm)
posteriorly because o divergent rays
Exposure Fig . 1.6 Lateral chest
• No motion, sharp outlines o Competency Check:
Technologist Date
diaphragm and lung markings
• Su cient exposure and contrast to visualize rib outlines and
lung markings through heart shadow 7
Lat e ral De cub it us: Ch e st
1
DECUB R
• 35 × 43 cm (14 ×
17″) portrait with
respect to patient
• Grid
C
h
e
Po sit io n Fig . 1.7 Le lateral decubitus chest (AP)
s
t
• Patient on side
(R or L, see Note) with pad under patient
• Ensure that stretcher does not move (lock wheels)
• Raise both arms above head, chin up
• rue AP, no rotation, patient centered to CR at level o 7
Central Ray: CR horizontal to 7, 3–4″ (8–10 cm) below jugular
notch
SID: 72″ (183 cm) with wall bucky; 40–44″ (102–113 cm) with erect
table and bucky
Collimation: Collimate on our sides to area o lung elds (top border
o light eld to level o vertebra prominens)
Respiration: End o second full inspiration
Note: For possible uid (pleural ef usion), suspected side down; pos-
sible air (pneumothorax), suspected side up

AP Lo rd o t ic: Ch e st
1
R
• 35 × 43 cm (14 × 17″)
portrait
t
• Grid Fig . 1.8 AP lordotic (best demonstrates
s
e
apices o lungs)
h
C
Po sit io n
• Patient stands ≈1 (30 cm)
away rom IR, leans back
against chest board
• Hands on hips, palms out,
shoulders rolled orward
• Center midsternum and IR
to CR, top o IR should be
7–8 cm (3″) above shoulders
Central Ray: CR to IR, cen-
tered to midsternum (3–4 inches
[9 cm] below jugular notch) Fig . 1.9 AP supine, CR 15–20″ cephalad
SID: 72″ (183 cm)
Collimation: Collimate on our sides to area o lung elds (top border o
light eld to level o vertebra prominens)
Note: I patient is too weak and unstable or is unable to assume the erect
lordotic position, per orm AP semiaxial projection with 15°–20° cephalad
angle
Bontrager extbook, 9th ed, pp 96 and 98 9

Lat e ral De cub it us: Ch e st

1
• Entire lung elds,
including apices and
costophrenic angles
Position
• No rotation, equal
distance rom lateral
C
rib borders to spine
h
e
s
Exposure
t
• No motion; diaphragm, Fig . 1.10 Le lateral decubitus
ribs, and lung markings Competency Check:
Technologist Date
appear sharp
• Faint visualization o vertebrae and ribs through heart shadow
AP Lo rd o t ic: Ch e st

• Entire lung elds; include
clavicles, which should
appear above apices
Position
• Clavicles appear nearly
horizontal, superior to
apices
• No rotation as evident by
equal distance between
medial ends o clavicles Fig . 1.11 AP lordotic chest
Competency Check:
and lateral borders o Technologist Date
ribs and midline o spine
Exposure
• No motion; diaphragm, heart, and rib borders appear sharp
• Optimal contrast and density (brightness and contrast or digital
images) to visualize vertebral outlines through mediastinal structures
10
An t e rio r Ob liq ue ( RAO an d LAO) : Ch e st
1
L
RAO or LAO
• 35 × 43 cm (14 × 17″)
portrait
t
Fig . 1.12 45° RAO
s
e
• Grid
h
C
Po sit io n
• Erect, rotated 45°, right anterior shoulder against IR or RAO and
rotated 45° with le anterior shoulder against IR or LAO (Certain
heart studies require LAO, 60° rotation rom PA)
• Alternative posterior oblique positions can be per ormed LPO
best demonstrated le thorax and RPO the right thorax
• Arm away rom IR up resting on head or on IR holder
• Arm nearest IR down on hip, keep chin raised
• Center thorax laterally to IR margins; vertically to CR at 7
Central Ray: CR to IR, centered to level o 7 (7–8 inches [8–10 cm]
below level o vertebra prominens)
SID: 72″ (183 cm)
Collimation: Collimate on our sides to area o lung elds (top border
o light eld to level o vertebra prominens)

An t e rio r Ob liq ue ( RAO an d LAO) : Ch e st

1
L
• Included both lung elds
rom apices to costophrenic
angles; RAO will elongate
le thorax, and LAO will
elongate right thorax
Position
C
• With 45° rotation, distance
h
e
rom outer rib margins to
s
t
vertebral column on side
arthest rom IR should
be approximately 2 times Fig . 1.13 45° RAO
distance o side closest to IR Competency Check:
Technologist Date
Exposure
• No motion; diaphragm and L
rib margins appear sharp
• Vascular markings
throughout lungs and rib
outlines visualized aintly
through heart
Notes
• Anterior oblique positions
best demonstrate the side
arthest rom IR Posterior
oblique positions best
demonstrate the side closest
to IR Fig . 1.14 45° LAO
• Less rotation (15°–20°) may Competency Check:
Technologist Date
help better visualize areas o
lungs or possible pulmonary disease
12
AP an d Lat e ral: Up p e r Airw ay
Trach e a an d Laryn x
1
R
• 24 × 30 cm (10 × 12″) portrait

• Grid
t
s
Fig . 1.15 AP
e
h
Po sit io n
C
• Erect, seated or standing,
center upper airway to CR
• Arms down, chin raised
slightly
• Lateral: depress shoulders,
and pull shoulders back
• Center o IR to level o CR
Central Ray: CR to IR,
centered to level o C6 or C7, Fig . 1.16 Lateral
midway between the laryngeal
prominence o the thyroid cartilage and the jugular notch
SID: 72″ (183 cm)
Collimation: Collimate to region o so tissue neck
Respiration: Expose during slow, deep inspiration
kV Range: Analog and Digital system s: 75–85 kV
Bontrager extbook, 9th ed, pp 102 and 103 13

AP an d Lat e ral: Up p e r Airw ay
Evaluat io n
1
Crit e ria
Anatomy
Demonstrated
AP and Lateral
• Larynx and
trachea well
visualized,
lled with air
C
A B
h
e
Position
s
Fig . 1.17 AP upper airway
t
AP Competency Check:
• No rotation, Technologist Date
symmetric
appearance o SC joints
• Mandible superimposes base o
skull
Lateral
• o visualize neck region, include
external auditory meatus at upper
border o image
• I distal larynx and trachea is o
primary interest, center lower to
include area rom C3 to 5 (Fig
1 18)
Exposure
AP
• Optimal exposure visualizes
air- lled trachea through C and
vertebrae Fig . 1.18 Lateral upper airway
Competency Check:
Lateral Technologist Date
• Optimal exposure includes air-
lled larynx, and upper trachea
not overexposed
• Cervical and thoracic vertebrae will appear underexposed
14
AP ( Tab le t o p ) : Pe d iat ric Ch e st
1
L
• 18 × 24 cm or 24 × 30 cm
(8 × 10″ or 10 × 12″)
landscape
• Nongrid; grid with digital Fig . 1.19 Immobilization device
systems when it cannot be
removed
t
s
e
h
C
Po sit io n
• Supine, arms and legs extended, tape and sandbags or other
immobilization o arms and legs
• No rotation o thorax, gonadal shield over pelvic area
• IR and thorax centered to CR, with shoulders 5 cm (2″) below top
o IR
Central Ray: CR to IR, centered to midlung elds, mammillary
(nipple) line
SID: Minimum 50–60″ (128–153 cm); x-ray tube raised as high as
possible
Collimation: Closely collimate on our sides to outer chest margins
Respiration: Second full inspiration; i crying, time the exposure at
ull inhalation
Note: I parental assistance is necessary, have parent hold child’s arms
overhead tilting head back with one hand and holding down legs with
other hand (provide lead apron and gloves)
kV Range: Analog and Digital System s: 75–85 kV

Ere ct PA ( Wit h Pig g -O-St at ) : Pe d iat ric Ch e st
1
L
• 18 × 24 cm or 24 × 30 cm
(8 × 10″ or 10 × 12″)
landscape
• Nongrid or grid with
systems when it cannot
be removed
C
h
e
Po sit io n
s
t
• Patient on seat, legs
through openings Ma rke rs
• Adjust height o seat to a nd s hie ld
place shoulders 2 5 cm
(≈1″) below upper
margin o IR Fig . 1.20 PA chest (Pigg-O-Stat, or
• Raise arms, and gently 5-year-old) (DR)
but rmly place side
body clamps to hold raised arms and head in place
• Set upper border o lead shield with R and L markers 2 5–5 cm
(1–2″) above level o iliac crest
Central Ray: CR to IR, centered to midlung elds, mammillary
(nipple) line
SID: Minimum o 72″ (183 cm)
Collimation: Collimate closely on our sides to outer chest margins
Respiration: Full inspiration; i crying, expose at ull inhalation

Lat e ral ( Tab le t o p ) : Pe d iat ric Ch e st
1
L
• 18 × 24 cm or 24 × 30 cm
(8 × 10″ or 10 × 12″) portrait
• Nongrid or grid with systems
when it cannot be removed
Fig . 1.21 Lateral chest (with tape
t
s
e
Po sit io n and sandbags)
h
C
• Lying on side (typically le
lateral), arms up with head between arms
• Support arms with tape and sandbags; ensure a true lateral
• Flex legs; secure with tape and sandbags or with retention band
across legs and hips; lead shield over pelvic region
Central Ray: CR to IR, centered to midlung elds, level o mam-
millary (nipple) line
SID: Minimum o 50–60″ (128–153 cm); x-ray tube raised as high
as possible
Respiration: Second full inspiration; i crying, time exposure at ull
inhalation
Note: I parental assistance is necessary, have parent hold child’s arms
overhead, tilting head back with one hand and holding down legs with
other hand (provide lead apron and gloves)

Ere ct Lat e ral ( Wit h Pig g -O-St at ) : Pe d iat ric Ch e st
1
L
• 18 × 24 cm or 24 × 30 cm
(8 × 10″ or 10 × 12″)
portrait
• Nongrid or grid with
systems when it cannot be
C
h
removed
e
s
t
Po sit io n
• With patient remaining
in same position as
or PA chest, change
IR and rotate entire
seat and body clamps
90° into a le lateral
position; lead shield
just above iliac crest
• Change lead marker to Fig . 1.22 Lateral chest (Pigg-O-Stat,
indicate le lateral or 5-year-old)
Central Ray: CR to IR,
centered to midlung elds, mammillary (nipple) line
SID: 72″ (183 cm)
Respiration: Full inspiration; i crying, time exposure at ull inhalation

PA ( AP) : Pe d iat ric Ch e st
1
R
• Entire lungs rom apices to
costophrenic angles
Position
• Chin elevated su ciently
• No rotation, equal distance
rom lateral rib margins to
spine
t
s
• Full inspiration, visualizes 9
e
h
(occasionally 10) posterior
C
ribs above diaphragm
Exposure
• No motion, sharp outlines
o rib margins and Fig . 1.23 AP (PA) pediatric chest
diaphragm (breathing and voluntary motion
• Faint outline o ribs and is evident, blurred diaphragm)
Competency Check:
vertebrae through heart Technologist Date
and mediastinal structures
Lat e ral: Pe d iat ric Ch e st
Evaluat io n Crit e ria L

• Entire lungs rom apices to costo-
phrenic angles and rom sternum
anteriorly to posterior ribs
Position
• Chin and arms elevated su ciently
• No rotation, bilateral posterior
ribs and costophrenic angles are
superimposed
Fig . 1.24 Lateral
Exposure pediatric chest (DR)
• No motion; sharp outline o Competency Check:
diaphragm, rib borders, and lung Technologist Date
markings
• Su cient exposure to aintly visualize ribs and lung markings
through heart shadow 19
Ch ap t e r 2
Up p e r Lim b
2
• Technical factors and radiation protection 22
Fin g e rs ball-catcher’s option)

PA (R) 23 (S) 38
PA oblique (R) 24 AP oblique bilateral
PA and PA oblique (Norgaard method)
critique 25 critique 39
U
Mediolateral and
p
p
lateromedial (R) 26 Wrist
e
r
PA (R) 40
L
i
m
Th um b PA oblique (R) 41
b
AP (R) 27 PA and PA oblique
Lateral nger and AP critique 42
thumb critique 28 Lateral (R) 43
PA oblique (R) 29 Lateral critique 44
Lateral (R) 30 PA and PA axial with
PA oblique and lateral ulnar deviation (10°–15°
critique 31 and modi ed Stecher
AP axial (modi ed method) (S) 45
Roberts method) (S) 32 PA and PA axial with
ulnar deviation (10°–15°
Han d and modi ed Stecher
PA (R) 33 method) critique 46
AP axial thumb (modi ed PA with radial deviation
Roberts method) and PA (S) 47
hand critique 34 PA with radial deviation
PA oblique (R) 35 critique 48
“Fan” lateral and lateral Tangential inferosuperior,
in extension (R) 36 carpal canal (Gaynor-Hart
PA oblique and “fan” method) (S) 49
lateral critique 37 Tangential inferosuperior,
AP oblique bilateral carpal canal (Gaynor-Hart
(Norgaard method and Method) critique 50
20
Fo re arm AP oblique (medial and
AP (R) 51 lateral) critique 58
Lateromedial (R) 52 Lateromedial (R) 59
2
AP and lateromedial Lateromedial critique 60
critique 53 Axial lateromedial and
mediolateral, trauma
Elb o w (Coyle method) (S) 61
AP, fully and partially Axial lateromedial and
extended (R) 54 mediolateral, trauma
AP, fully extended (Coyle method)
AP, partially exed
b
critique 56 Pe d iat ric Up p e r Lim b
m
i
L
AP oblique (medial and AP (S) 63
r
lateral) (R) 57
e
Lateral (S) 64
p
p
U
21
Te ch n ical Fact o rs
e following technical factors are important for all upper limb pro-
cedures to maximize image sharpness
• 40″ (102 cm) SID, minimum OID
2
• Small focal spot
• Nongrid or TT (tabletop), detail (analog) screens
• Digital imaging requires special attention to accurate CR and part
centering and close collimation.
• Short exposure time
• Immobilization (when needed)
• Multiple exposures per imaging plate: Multiple images can be
placed on the same IP When doing so, careful collimation and
lead masking must be used to prevent preexposure or fogging
U
of other images However, one exposure per imaging plate is
p
p
recommended
e
r
• Grid use with digital systems: Grids generally are not used with
L
i
m
analog ( lm-screen) imaging for body parts measuring 10 cm or
b
less However, with certain digital systems, the grid may or may
not be able to be removed from the receptor In those cases, it is
departmental protocol that determines whether a grid is le in
place or removed Important: If a grid is used, the anatomy must
be centered to avoid grid cuto
Rad iat io n Pro t e ct io n
Co llim at io n
Close collimation is the most e ective practice for preventing unneces-
sary radiation exposure to the patient
Pat ie n t Sh ie ld in g
Erect Patients: Patients seated at the end of the table should always
have a shield over radiosensitive organs to prevent exposure from
scatter radiation and from the divergent primary beam
Recumbent Patients: A good practice to follow for upper limb exami-
nations for patients on a stretcher or table is to always have shielding
in place, especially the gonadal region
22
PA: Fin g e rs
2
Alternative Routine: Include entire
hand on PA nger projection for
possible secondary trauma to other
parts of hand (see PA Hand)
• 18 × 24 cm (8 × 10″) portrait
• Nongrid
• Lead masking with multiple
exposures on same IR
b
m
i
L
Po sit io n
r
e
• Patient seated at end of table,
p
p
elbow exed 90° (lead shield
U
on patient’s lap) Fig . 2.1 PA—second digit
• Pronate hand, separate ngers
• Center and align long axis of
a ected nger(s) to portion of IR being exposed
Central Ray: CR , centered to PIP joint
SID: 40″ (102 cm)
Collimation: On four sides to area of interest and distal aspect of
metacarpal
kV Range: Analog: 55 ± 5 kV Digital System s: 60 ± 5 kV
Bontrager Textbook, 9th ed, p 142 23

PA Ob liq ue : Fin g e rs
R
2
• 18 × 24 cm (8 × 10″)
portrait
• Nongrid
• Lead masking with
multiple exposures on
same IR Fig . 2.2 PA oblique, second digit
(parallel to IR) Inset: Minimized OID
Po sit io n
U
p
• Patient seated, hand
p
e
on table, elbow exed 90° (lead shield on patient’s lap)
r
L
i
• Align ngers to long axis of portion of IR being exposed
m
b
• Rotate hand 45° medially or laterally (dependent of digit
examined), resting against 45° angle support block
• Separate ngers; ensure that a ected nger(s) is (are) parallel to IR
SID: 40″ (102 cm)
Collimation: On four sides to area of a ected nger(s) and distal
aspect of metacarpal
24 Bontrager Textbook, 9th ed, p 143

PA: Fin g e rs

• Distal phalanx to distal
2
metacarpal and associated joints
Position
• Long axis of digit parallel to IR
with joints open
• No rotation of digit with
symmetric appearance of sha s
Exposure
b
• Optimal density (brightness) and
m
i
L
contrast
r
• So tissue margins and
e
p
p
bony trabeculation clearly Fig . 2.3 PA nger
U
demonstrated; no motion Competency Check:
Technologist Date
PA Ob liq ue : Fin g e rs

Position
• Interphalangeal and MCP joints
open
• No superimposition of adjacent
digits
Exposure
contrast
• So tissue margins and Fig . 2.4 PA oblique nger
bony trabeculation clearly Competency Check:
demonstrated; no motion Technologist Date
25
Me d io lat e ral an d Lat e ro m e d ial: Fin g e rs
R
2
• 18 × 24 cm
(8 × 10″)
portrait
• Nongrid
• Lead masking
with multiple
exposures on
same IR
U
p
Fig . 2.5 Lateromedial Fig . 2.6 Mediolateral
p
e
Po sit io n fourth digit second digit (digit parallel
r
L
• Patient to IR)
i
m
seated, hand on table (lead shield on
b
patient’s lap)
• Hand in lateral position, thumb side up for third to h digits,
thumb side down for second digit
• Align nger to long axis of portion of IR being exposed
SID: 40″ (102 cm)
Collimation: On four sides to area of a ected nger and distal aspect
of metacarpal

AP: Th um b
2
• 18 × 24 cm (8 × 10″) portrait
• Nongrid
Po sit io n
• Patient standing or seated,
b
hand rotated internally
m
with palm out to bring the
i
L
r
posterior surface of thumb in
e
p
direct contact with IR
p
U
• Align thumb to long axis of
portion of IR being exposed Fig . 2.7 AP thumb—CR to
Central Ray: CR , centered to rst MP joint
rst MCP joint
SID: 40″ (102 cm)
Collimation: Collimate closely to area of thumb (include entire rst
metacarpal extending to carpals)

Lat e ral: Fin g e rs

2
Position
• True lateral: joints are open and
concave appearance of anterior
surfaces of sha of phalanges
Exposure
U
contrast
p
p
e
r
bony trabeculation clearly
L
i
m
demonstrated; no motion Fig . 2.8 Lateral nger
b
Competency Check:
Technologist Date
AP: Th um b
Evaluat io n Crit e ria R

• Distal phalanx to proximal
metacarpal and trapezium
Position
• Long axis of thumb parallel to IR
with joints open
• No rotation of thumb with
symmetric appearance of sha s
Exposure
contrast
demonstrated; no motion Fig . 2.9 AP thumb
Competency Check:
28 Technologist Date
PA Ob liq ue : Th um b
2
• 18 × 24 cm (8 × 10″) portrait
• Nongrid
Po sit io n
• Patient seated, hand on
b
table, elbow exed (shield on
m
patient’s R lap)
i
L
r
e
p
portion of IR being exposed
p
U
• With hand pronated, abduct
thumb slightly is position Fig . 2.10 PA oblique thumb,
tends to naturally rotate CR to rst MCP joint
thumb into 45° oblique
Central Ray: CR , centered to rst MCP joint
SID: 40″ (102 cm)

Lat e ral: Th um b
R
2
• 18 × 24 cm (8 × 10″) portrait
• Nongrid
Po sit io n
U
p
p
patient’s lap)
e
r
L
i
portion of IR being exposed
m
b
• With hand pronated and
slightly arched, rotate hand Fig . 2.11 Lateral thumb, CR
medially until thumb is in to rst MCP joint
true lateral position
Central Ray: CR , centered to rst MCP joint
SID: 40″ (102 cm)

PA Ob liq ue : Th um b

2
Position
• Long axis of thumb parallel to IR R
with joints open
Exposure
contrast
b
m
i
L
bony trabeculation clearly Fig . 2.12 PA oblique thumb
r
e
demonstrated; no motion Competency Check:
p
p
Technologist Date
U
Lat e ral: Th um b

Position
• True lateral position
open
• Anterior surfaces of rst
metacarpal and proximal phalanx
equally concave shaped; posterior
surfaces are relatively straight
Exposure
contrast
Fig . 2.13 Lateral thumb
• So tissue margins and Competency Check:
bony trabeculation clearly Technologist Date
demonstrated; no motion
31
AP Axial: Th um b
Mo d if e d Ro b e rt s Me t h o d
2
R
Note: is is a special
projection to better dem-
onstrate the f rst carpo-
metacarpal joint region
• 18 × 24 cm (8 × 10″)
portrait Fig . 2.14 AP axial thumb for rst
U
• Nongrid CMC joint (CR 15° proximally)
p
p
e
r
multiple exposures on same IR
L
i
m
b
Po sit io n
• Patient seated or standing, hand rotated internally placing
posterior surface of thumb directly on IR
• Align thumb to long axis of portion of IR being exposed
• Extend
Central Ray: CR angled 15° proximally, centered to rst CMC joint
e Lewis modif cation places the CR to the rst MCP joint with a
10°–15° proximal angle
SID: 40″ (102 cm)
Collimation: Collimate closely to entire thumb, including the trape-
zium carpal bone

PA: Han d
2
• 24 × 30 cm (10 × 12″) portrait
• Nongrid
Po sit io n
b
m
patient’s lap)
i
L
r
• Align long axis of hand and
e
p
wrist parallel to edge of IR
p
U
• Hand fully pronated, digits
slightly separated Fig . 2.15 PA hand
Central Ray: CR , centered to
third MCP joint
SID: 40″ (102 cm)
Collimation: Collimate on four sides to outer margins of hand and
wrist Include proximal and distal row of carpals
kV Range: Analog: 60–70 kV Digital System s: 60 ± 5 kV

AP Axial: Th um b
Mo d if e d Ro b e rt s Me t h o d

2
• Base of rst metacarpal and
trapezium well demonstrated
Position
• Long axis of thumb parallel to IR
with joints open
• No rotation
U
Exposure
p
p
e
r
Fig . 2.16 AP axial thumb
L
contrast
i
m
Competency Check:
• So tissue margins and bony
b
Technologist Date
trabeculation clearly demonstrated; no motion
PA: Han d

• Hand/wrist and 2 5 cm
(1″) distal forearm
Position
• Interphalangeal and MCP
joints open
• No rotation of hand with
symmetric appearance of
sha s of metacarpals and
phalanges
• Digits slightly separated
Exposure
• Optimal density Fig . 2.17 PA hand
(brightness) and contrast Competency Check:
Technologist Date
bony trabeculation clearly demonstrated; no motion
34
PA Ob liq ue : Han d
2
• 24 × 30 cm (10 × 12″) portrait
• Nongrid
Po sit io n
b
m
patient’s lap)
i
L
r
• Rotate entire hand and wrist
e
p
laterally 45°, support with
p
U
wedge or step block; align hand
and wrist to IR Fig . 2.18 PA oblique hand
• Ensure that all digits are (digits parallel to IR)
slightly separated and parallel
to IR
Central Ray: CR , centered to third MCP joint
SID: 40″ (102 cm)
Collimation: Collimate on four sides to hand and wrist Include
proximal and distal row of carpals

“Fan ” Lat e ral an d Lat e ral in Ext e n sio n : Han d
R
2
• 18 × 24 cm (8 ×
10″) portrait
• Nongrid
• Accessory—foam
step support
multiple exposures Fig . 2.19 “Fan” Fig . 2.20
on same IR lateral hand Alternative: lateral
U
p
(digits not in extension
p
e
Po sit io n superimposed) (for possible
r
foreign body
L
• Patient seated,
i
m
and metacarpal
hand on table, elbow exed (shield on
b
injury)
patient’s lap)
• Hand in lateral position, thumb side up,
digits separated and spread into “fan” position and supported by
radiolucent step block or similar type support (Ensure true lateral
of metacarpals)
Central Ray: CR , centered to second MCP joint
SID: 40″ (102 cm)
Collimation: Collimate on four sides to hand and wrist Include
36 Bontrager Textbook, 9th ed, pp 152 and 153

PA Ob liq ue : Han d

• Hand/wrist and 2 5 cm (1″) distal
2
forearm
Position
• Long axis of digits/metacarpals
parallel to IR with joints open
• No overlap of midsha s of third
to h metacarpals
Exposure
b
contrast
m
i
L
Fig . 2.21 PA oblique
r
e
hand (digits parallel)
p
p
U
Competency Check:
Technologist Date
“Fan ” Lat e ral: Han d

• Hand/wrist and 2 5 cm (1″) distal
forearm
open
Position
• Digits in true lateral position
• Phalanges and metacarpal
surfaces symmetric
• Distal radius, ulna, and
metacarpals superimposed
Exposure
• Optimal density (brightness) and Fig . 2.22 “Fan” lateral
contrast hand
• So tissue margins and Competency Check:
Technologist Date
37
AP Ob liq ue Bilat e ral: Han d
No rg aard Me t h o d an d Ball-Cat ch e r’s Op t io n
2
R
Ba ll-ca tche r’s
pos ition
• 24 × 30 cm (10
× 12″) or 35 ×
43 cm (14 × 17″)
landscape
45 45
• Nongrid
• Accessories—two
U
45° foam sponges
p
for support Fig . 2.23 AP 45° bilateral oblique Inset:
p
e
Ball-catcher’s option
r
L
Po sit io n
i
m
• Patient seated at end of table, both arms and hands extended with
b
palms up and hands obliqued 45°, medial aspects touching
• Fingers fully extended supported by 45° support blocks
Ball-Catcher’s Option:
• Fingers partially exed, which visualizes metacarpals and MCP
joints well but distorts interphalangeal joints
Central Ray: CR , centered to midway between h MCP joints
SID: 40″ (102 cm)
Collimation: Collimate to outer margins of hands and wrists Include

AP Ob liq ue Bilat e ral: Han d
No rg aard Me t h o d
Evaluat io n
Crit e ria
2
Anatomy
Demonstrated
• Both hands from
carpals to distal
phalanges
• Both hands
positioned in 45°
oblique
b
m
Position
i
L
• Midsha s of
r
e
second to h
p
p
metacarpals not
U
Fig . 2.24 AP bilateral oblique hand
overlapped Competency Check:
• MCP joints open Technologist Date
Exposure
• Optimal density (brightness) and contrast
• So tissue margins and bony trabeculation with MCP joints
clearly demonstrated to distal phalanges
39
PA: Wrist
2
R
• 18 × 24 cm (8 × 10″) portrait
• Nongrid
Po sit io n
• Patient seated, arm on table
U
(shield on patient’s lap)
p
p
• Align hand and wrist parallel
e
r
to edge of IR
L
i
• Lower shoulder, rest arm on
m
b
table to ensure no rotation of
wrist Fig . 2.25 PA wrist
• Hand pronated, ngers exed,
and hand arched slightly to place wrist in direct contact with
surface of IR
Central Ray: CR , centered to midcarpals
SID: 40″ (102 cm)
Collimation: Collimate to wrist on four sides Include distal radius
and ulna and the midmetacarpal area

PA Ob liq ue : Wrist
2
R
• 18 × 24 cm (8 ×
10″) portrait
• Nongrid
multiple exposures
on same IR
Fig . 2.26 45° PA oblique wrist (with support)
Po sit io n
b
m
• Patient seated, arm on table, elbow exed (shield on patient’s lap)
i
L
• Align hand and wrist parallel to edge of IR
r
e
p
• Rotate hand and wrist laterally into 45° oblique position
p
U
• Flex ngers to support hand in this position, or use 45° support
sponge
SID: 40″ (102 cm)

PA: Wrist

• Midmetacarpals; carpals; distal
2
radius, ulna, and associated joints
Position
• True PA is evidenced by
symmetry of proximal
metacarpals
• Separation of the distal radius
and ulna Fig . 2.27 PA wrist
Competency Check:
U
Technologist Date
Exposure
p
p
e
r
• So tissue margins and bony trabeculation of carpals clearly
L
i
m
b
PA Ob liq ue : Wrist

• Midmetacarpals; carpals; distal
radius, ulna, and associated
joints
Position
• Long axis of hand to forearm
aligned to IR
• 45° oblique of wrist
Exposure
• Optimal density (brightness)
and contrast Fig . 2.28 PA oblique wrist
• So tissue margins and bony Competency Check:
trabeculation of carpals clearly Technologist Date
42
Lat e ral: Wrist
2
• 18 × 24 cm (8 × 10″) portrait
• Nongrid
Po sit io n
• Patient seated, arm on table,
b
elbow exed, shoulder
m
dropped to place humerus,
i
L
r
forearm, and wrist on same
e
p
horizontal plane (shield on
p
U
patient’s lap)
• Align hand and wrist parallel
to edge of IR Fig . 2.29 Lateral wrist
• Place hand and wrist into
a true lateral position, use support to maintain this position if
needed
SID: 40″ (102 cm)

Lat e ral: Wrist

• Midmetacarpals; carpals; distal L
2
radius, ulna, and associated joints
Position
• True lateral of wrist
• Ulnar head superimposed distal
radius
Exposure
U
contrast
p
p
e
r
trabeculation of carpals clearly
L
i
m
b
• Demonstrate visible fat pads and
stripes
Fig . 2.30 Lateral wrist

Competency Check:
Technologist Date
44
PA an d PA Axial Wit h Uln ar De viat io n : Scap h o id
10°–15° an d Mo d if ed St e ch e r Me t h o d
2
Warning: e ulnar deviation projection
should be attempted only with possible wrist Fig . 2.31 Ulnar deviation,
trauma a er a routine wrist series rules out CR 10°–15° angle toward
gross fractures to wrist or distal forearm PA
elbow CR perpendicular to
axial projection recommended for obscure
fractures If patient can’t ulnar deviate wrist, scaphoid
elevate hand on 20° angle sponge
b
m
Note: See Chapter 1 in the 9th ed textbook
i
L
for joint movement terminology
r
e
• 18 × 24 cm (8 × 10″) portrait
p
p
• Nongrid
U
• Lead masking with multiple exposures on
same IR
Fig . 2.32 Modi ed Stecher
Po sit io n method Elevate hand on 20°
• From PA wrist position, gently evert sponge, CR , to IR
wrist toward ulnar side as far as patient can tolerate
Central Ray: CR perpendicular to IR Optional CR 10°–15° proxi-
mally toward elbow, centered to scaphoid (thumb side of carpal area);
if hand placed on 20° sponge, CR to IR
Note: A four-projection series with CR at 0°, 10°, 20°, and 30° may be required
SID: 40″ (102 cm)
Collimation: Collimate on four sides to carpal region
Bontrager Textbook, 9th ed, pp 158 and 159 45

PA an d PA Axial Wit h Uln ar De viat io n : Scap h o id
10°–15° an d Mo d if ed St e ch e r Me t h o d

2
• Scaphoid demonstrated clearly
without foreshortening or
overlap
trabeculation of scaphoid
clearly demonstrated; no
motion
Position
U
p
• Ulnar deviation evident
p
e
• Multiple CR angles may best
r
L
visualize this area Fig . 2.33 Ulnar deviation
i
m
• No rotation of wrist with 10°–15° CR angle
b
Competency Check:
Technologist Date
Exposure
and contrast
trabeculation of scaphoid
motion
Fig . 2.34 Modi ed Stecher

Competency Check:
Technologist Date
46
PA Wit h Rad ial De viat io n : Wrist
2
Warning: is position should be
attempted for possible wrist trauma
only a er a routine wrist series rules
out gross fractures to wrist or distal
forearm
Note: See Chapter 1 in the 9th ed

textbook, for explanation on wrist
b
joint movement terminology
m
i
L
• 18 × 24 cm (8 × 10″) portrait
r
• Nongrid
e
p
p
U
Fig . 2.35 Radial deviation,
Po sit io n CR perpendicular
• From PA wrist position, gently (Demonstrates ulnar side
carpals )
invert wrist toward radial side
as far as patient can tolerate (shield across lap)
Central Ray: CR , to midcarpals
SID: 40″ (102 cm)
Collimation: Collimate closely to four sides of carpal region (≈7 5 cm
or 3″ square)

PA Wit h Rad ial De viat io n : Wrist

Anatomy
Demonstrated
2
• Ulnar side carpals
best visualized
Position
• Radial deviation
evident
• No rotation of wrist
Exposure
U
• So tissue
p
p
margins and bony
e
r
trabeculation of Fig . 2.36 PA wrist—radial deviation
L
i
m
ulnar aspect of Competency Check:
b
Technologist Date
carpal region clearly
demonstrated; no
motion
48
Tan g e n t ial In fe ro sup e rio r: Wrist ( Carp al Can al)
Gayn o r-Hart Me t h o d
2
Warning: is position is
sometimes called the “tunnel
view” and should be
attempted for possible wrist
trauma only a er a routine
wrist series rules out gross Fig . 2.37 Tangential (Gaynor-Hart
fractures to wrist or distal method) projection (CR 25°–30° to
b
forearm long axis of hand)
m
i
L
• 18 × 24 cm (8 × 10″) portrait
r
e
• Nongrid
p
p
• Lead masking with multiple exposures on same IR
U
Po sit io n
• Patient seated, hand on table (shield on patient’s lap)
• Hyperextend (dorsi ex) wrist as far as patient can tolerate with
patient using other hand to hold ngers back
• Rotate hand and wrist slightly internally—toward radius (≈10°)
• Work quickly as this may be painful for patient
Central Ray: CR 25°–30° to long axis of the palmar surface of hand,
centered to ≈1″ (2–3 cm) distal to base of third metacarpal
SID: 40″ (102 cm)
Collimation: Collimate to carpal region (≈7 5 cm or 3″ square)

Tan g e n t ial In fe ro sup e rio r: Wrist ( Carp al Can al)
Gayn o r-Hart Me t h o d
Evaluat io n
Crit e ria
2
Anatomy
Demonstrated
• Carpals
demonstrated
in arched
arrangement
Position
• Pisiform and the
U
p
hamular process
p
e
separated (if
r
L
not, wrist was
i
m
not rotated 10° Fig . 2.38 Tangential (Gaynor-Hart)
b
Competency Check:
toward radius) Technologist Date
• Scaphoid/
trapezium in
pro le
Exposure
• So tissue margins and bony trabeculation of carpal canal clearly
50
AP: Fo re arm
2
• 35 × 43 cm (14 × 17″)
portrait or 30 × 35 cm
(11 × 14″) portrait for
smaller patients
• Nongrid
• Lead masking with Fig . 2.39 AP forearm (to include both
multiple exposures on joints)
same IR
b
m
i
L
Po sit io n
r
e
• Patient seated at end of table with arm extended and hand
p
p
U
supinated (shield on patient’s lap)
• Ensure that both wrist and elbow joints are included (use as large
an IR as required to include both wrist and elbow joints)
• Have patient lean laterally as needed for a true AP of forearm
Central Ray: CR , centered to midpoint of forearm
SID: 40″ (102 cm)
Collimation: Collimate on four sides Include a minimum of 2 5 cm
(1″) beyond both wrist and elbow joints

Lat e ro m e d ial: Fo re arm
2
R
• 35 × 43 cm (14 × 17″)
(11 × 14″) portrait for Fig . 2.40 Lateral forearm (to include
smaller patients both joints)
• Nongrid
U
p
p
e
r
L
Po sit io n
i
m
• Patient seated at end of table (shield on patient’s lap)
b
• Elbow should be exed 90°
• Hand and wrist must be in a true lateral position (distal radius
and ulna should be directly superimposed)
• Ensure that both wrist and elbow joints are included unless
contraindicated
Central Ray: CR , centered to midpoint of forearm
SID: 40″ (102 cm)
Collimation: Collimate on four sides Include a minimum of 2 5 cm
(1″) beyond both wrist and elbow joints

AP: Fo re arm

• Entire radius and ulna
2
• Entire elbow and proximal carpals
Position
• Slight superimposition of proximal
radius/ulna
• Humeral epicondyles in pro le
Exposure
b
contrast
m
L
i
L
r
Fig . 2.41 AP forearm
e
trabeculation clearly demonstrated;
p
p
Competency Check:
no motion
U
Technologist Date
Lat e ro m e d ial: Fo re arm

• Entire radius and ulna
demonstrated
• Entire elbow and proximal carpals
demonstrated
Position
• True lateral position
• Humeral epicondyles superimposed
• Head of ulna and distal radius are
superimposed
Exposure
contrast
Fig . 2.42 Lateral forearm
• So tissue margins and bony Competency Check:
trabeculation of carpal canal clearly Technologist Date
53
AP: Elb o w
Fully an d Part ially Ext e n d e d
2
R
• 24 × 30 cm (10 × 12″)
portrait
• Nongrid Fig . 2.43 AP, fully extended
U
p
Po sit io n
p
e
• Elbow extended and hand supinated
r
L
i
(shield on patient’s lap)
m
b
• Lean laterally as needed for true AP
(palpate epicondyles) Fig . 2.44 CR, to humerus
• If elbow cannot be fully extended,
take two AP projections as shown
(Figs 2 44 and 2 45), with CR
perpendicular to distal humerus on
one and perpendicular to proximal
forearm on another
Central Ray: CR , centered to midel-
bow joint Fig . 2.45 CR to forearm
SID: 40″ (102 cm)
Collimation: Collimate on four sides to area of interest

AP: Elb o w
Fully Ext e n d e d

Anatomy Demonstrated R
2
• Distal humerus
• Proximal radius and ulna
Position
• Slight superimposition of
proximal radius/ulna
Exposure
b
m
i
L
contrast
r
e
p
p
trabeculation of elbow clearly
U
Fig . 2.46 AP elbow fully extended

Competency Check:
Technologist Date
55
AP: Elb o w
Part ially Fle xe d
2
U
p
p
e
r
L
i
m
b
R R
Fig . 2.47 Humerus parallel to IR Fig . 2.48 Forearm parallel to IR

Competency Check: Competency Check:
Technologist Date Technologist Date

• Distal 1 3 of humerus
• Proximal 1 3 of forearm
Position
• Slight superimposition of proximal radius/ulna
Exposure
• Optimal density and contrast (brightness and contrast for digital
images)
• So tissue and bony trabeculation clearly demonstrated; no
motion
56
AP Ob liq ue ( Me d ial an d Lat e ral) : Elb o w
2
Medial (internal) oblique
best visualizes coronoid
process Lateral (external)
oblique best visualizes Fig . 2.49 Medial (internal) oblique (45°)
radial head and neck (most
common oblique projection)
b
• 24 × 30 cm (10 × 12″) portrait
m
i
• Nongrid
L
r
e
p
Po sit io n : Me d ial Ob liq ue
p
U
• Elbow extended, hand
pronated
• Palpate epicondyles to check
for 45° internal rotation Fig . 2.50 Lateral (external)
Lateral Oblique: Similar posi- oblique (40°–45°)
tion except supinate hand and
rotate elbow 40°–45° externally More di cult for patient; lean entire
upper body laterally, as needed
Central Ray: CR , centered to midelbow joint
SID: 40″ (102 cm)
Bontrager Textbook, 9th ed, pp 169–171 57

AP Ob liq ue ( Me d ial) : Elb o w

2
• Medial epicondyle and trochlea
Position
• Coronoid process in pro le
• Radial head/neck superimposed
over ulna
Exposure R
U
contrast
p
Fig . 2.51 Medial
p
e
(internal) oblique elbow
r
L
Competency Check:
i
m
Technologist Date
demonstrated
b
AP Ob liq ue ( Lat e ral) : Elb o w

• Lateral epicondyle and capitulum
Position
• Radial head, neck, and tuberosity
free of superimposition
• Humeral epicondyles and
capitulum in pro le
Exposure
• Optimal density (brightness) and R
contrast Fig . 2.52 Lateral
• So tissue margins and bony (external) oblique elbow
trabeculation demonstrated; no Competency Check:
motion Technologist Date
58
Lat e ro m e d ial: Elb o w
2
• 24 × 30 cm (10 × 12″) portrait
• Nongrid
Po sit io n
• Elbow exed 90°, shoulder
b
m
dropped as needed to rest
i
L
forearm and humerus at on
r
e
p
table and IR (shield on patient’s
p
U
lap)
• Center elbow to center of IR or Fig . 2.53 Lateral—elbow
to portion of IR being exposed, exed 90°
with forearm aligned parallel to
edge of cassette
• Place hand and wrist in a true lateral position
Central Ray: CR , centered to midelbow joint
SID: 40″ (102 cm)
Collimation: Collimate on four sides Include a minimum of ≈5 cm
(2″) of forearm and humerus

Lat e ro m e d ial: Elb o w
Evaluat io n
Crit e ria
Anatomy
2
Demonstrated
• Proximal
radius/ulna
and distal
humerus
• Region of
joint fat pads
Position R
U
• Olecranon
p
Fig . 2.54 Lateromedial elbow
p
process/
e
r
Competency Check:
trochlear
L
Technologist Date
i
m
notch in pro le
b
• Radial head, neck, and tuberosity free of superimposition
• Humeral epicondyles superimposed
• Elbow exed at 90°
Exposure
• So tissue margins and bony trabeculation clearly demonstrated
60
Axial Lat e ro m e d ial an d Me d io lat e ral:
Elb o w ( Traum a)
Co yle Me t h o d
2
R
Special views to
demonstrate radial
head and coronoid
process
• 24 × 30 cm (10 ×
12″) portrait
• Nongrid
b
m
Fig . 2.55 For radial Fig . 2.56 For coronoid
i
L
Po sit io n an d head and neck, elbow process, elbow exed
r
e
Ce n t ral Ray exed 90° 80°
p
p
Radial Head:
U
• Elbow exed 90° if possible, hand pronated
• Angle CR 45° toward shoulder, centered to radial head (CR to
enter at midelbow joint)
Coronoid Process:
• Elbow exed only 80°, with hand pronated
• Angle CR 45° away from shoulder, centered to coronoid process
(CR to enter at midelbow joint)
SID: 40″ (102 cm)
kV Range: Analog: 65–75 kV* Digital System s: 70 ± 5 kV
*Increase exposure factors by 4–6 kV from lateral elbow because of angled CR

Axial Lat e ro m e d ial an d Me d io lat e ral:
Elb o w ( Traum a)
Co yle Me t h o d
2
U
p
Fig . 2.57 Trauma axial Fig . 2.58 Trauma axial
p
e
lateral elbow (for radial lateral elbow (for coronoid
r
head, neck, and capitulum)
L
process and trochlea)
i
m
b

Anatomy Demonstrated and Position—Radial Head (CR 45°
Toward Shoulder: Lateromedial Projection)
• Radial head, neck, and capitulum projected away from proximal
ulna; elbow exed 90°
Anatomy Demonstrated and Position—Coronoid Process (CR 45°

Away From Shoulder: Mediolateral Projection)
• Coronoid process and trochlea demonstrated
• Coronoid process in pro le, elbow exed 80° ( exion of more
than 80° will obscure coronoid process)
Exposure
• So tissue margins and bony trabeculation clearly demonstrated;
no motion
62
AP: Up p e r Lim b ( Pe d iat ric)
2
With possible trauma,
handle limb very gently
with minimal movement
Take a single exposure to
rule out gross fractures Fig . 2.59 AP—upper limb
before additional images
are taken
b
• IR size determined by patient age and size
m
• Nongrid
i
L
r
e
p
Po sit io n
p
U
• Supine position, arm abducted away from body, lead shield over
pelvic area
• Include entire limb unless a speci c joint or bone is indicated
• Immobilize with clear exible-type retention band and sandbags,
or with tape
• Use parental assistance only if necessary; provide lead gloves and
apron
Central Ray: CR , centered to midlimb
SID: 40″ (102 cm)
Collimation: On four sides to area of interest
kV Range: Analog: 55–65 kV Digital System s: 60–70 kV

Lat e ral: Up p e r Lim b ( Pe d iat ric)
R
2
• IR size determined by
patient age and size
• Nongrid
Po sit io n
• Supine position with
Fig . 2.60 Lateral—upper limb
arm abducted away
U
from body, lead shield over pelvic area
p
p
• Include entire limb unless a speci c joint or bone is indicated
e
r
• Immobilize with clear exible-type retention band and sandbags
L
i
m
or with tape
b
• Flex elbow and rotate entire arm into a lateral position
apron
Central Ray: CR , centered to midlimb
SID: 40″ (102 cm)
Collimation: On four sides to area of interest

Ch ap t e r 3
Hum e rus an d Sh o uld e r Gird le
Hum e rus AP oblique, glenoid
3
AP (R) 67 cavity (Grashey method)
Rotational lateral (R) 68 (S) 81
Lateral (mid-to-distal AP oblique (Grashey
humerus), trauma (S) 69 method) critique 82
AP and lateral critique 70 Tangential—
Transthoracic lateral, intertubercular
trauma (S) 71 (bicipital) sulcus (Fisk
Transthoracic lateral, modi cation) (S) 83
proximal critique 72 Tangential—
e
l
d
intertubercular (bicipital)
r
i
G
Sh o uld e r sulcus (Fisk modi cation)
r
AP (external and internal critique 84
e
d
l
rotation) (R) 73 PA oblique, trauma
u
o
AP (external and internal (scapular Y lateral and
h
S
rotation) critique 74 Neer method) (S) 85
d
n
Inferosuperior axial PA oblique, trauma
a
s
(Lawrence method) (scapular Y lateral and
u
r
e
(S) 75 Neer method) critique 86 m
Inferosuperior axial AP neutral rotation,
u
H
(Lawrence method) trauma (S) 87
critique 76 Transthoracic lateral,
PA transaxillary trauma (Lawrence
(Hobbs modi cation) method) (S) 88
(S) 77 Transthoracic lateral,
PA transaxillary (Hobbs trauma (Lawrence
modi cation) critique 78 method) critique 89
Inferosuperior axial AP apical oblique axial,
(Clements modi cation) trauma (Garth method)
(S) 79 (S) 90
Inferosuperior axial AP apical oblique axial,
(Clements modi cation) trauma (Garth method)
65
Apical AP axial (S) 92 AP and lateral
Apical AP axial critique 93 critique 98
Clavicle Acro m io clavicular (AC)

AP and AP axial (R) 94 Jo in t s
AP and AP axial AP bilateral (Pearson
3
critique 95 method, with and
without weights) (S) 99
Scap ula AP bilateral (Pearson
AP (R) 96 method, with and
Lateral (erect and without weights)
recumbent) (R) 97 critique 100
Important for humerus and shoulder projections: Do not attempt to

rotate upper limb if fracture or dislocation is suspected without special
H
u
orders by a physician
m
e
r
u
s
a
n
d
S
h
o
u
l
d
e
r
G
i
r
d
l
e
66
AP: Hum e rus
3
• 35 × 43 cm (14 × 17″)
portrait or 30 × 35 cm (11 Fig . 3.1 AP supine
× 14″) portrait for small
patients
• Grid >10 cm, IR only <10 cm
Po sit io n
• Erect or supine with humerus aligned
e
l
d
to long axis of IR (unless diagonal
r
i
G
placement is needed to include both
r
e
elbow and shoulder joints) Place
d
l
u
shield over gonads
o
h
• Abduct arm slightly, supinate hand for
S
true AP (epicondyles parallel to IR)
d
n
a
Central Ray: CR ┴, to midhumerus
s
u
SID: 40″ (102 cm) r
e
Collimation: Collimate on sides to so Fig . 3.2 AP erect
m
u
tissue borders of humerus and shoulder
H

Ro t at io n al Lat e ral: Hum e rus
R
3
Fig . 3.3 Erect lateral (PA)
Warning: Do not attempt to rotate arm if fracture
or dislocation is suspected (see following page)
• 35 × 43 cm (14 × 17″) or 30 × 35 cm portrait
Fig . 3.4 Erect lateral (AP)
• Grid >10 cm, IR only <10 cm
Po sit io n (May Be Take n Ere ct
AP o r PA, o r Sup in e )
• Erect (PA): Elbow exed 90°,
H
patient rotated 15°–20° from PA
u
m
or as needed to bring humerus
e
r
and shoulder in contact with IR
u
s
Fig . 3.5 Supine lateral
holder (epicondyles ┴ to IR for
a
n
true lateral)
d
• Erect or supine AP: Elbow slightly exed, arm and wrist rotated
S
h
o
for lateral position (palm back), epicondyles ┴ to IR
u
l
• IR centered to include both elbow and shoulder joints Shield
d
e
radiosensitive tissues outside region of interest
r
G
Central Ray: CR ┴, to midhumerus
i
r
d
SID: 40″ (102 cm)
l
e
Collimation: Collimate on sides to so tissue borders of humerus
and shoulder

Lat e ral: Hum e rus ( Traum a)
Mid -t o -Dist al Hum e rus
3
For proximal humerus, see
Transthoracic Lateral or
Scapular Y
• 30 × 35 cm (11 × 14″)
landscape or 24 × 30 cm Fig . 3.6 Horizontal beam lateral cross-
(10 × 12″) landscape table, midhumerus and distal humerus
• Nongrid
Po sit io n
e
l
• Gently li arm, and place support block under arm; rotate hand
d
r
i
G
into lateral position, if possible, for true lateral elbow projection
r
• Place IR vertically between arm and thorax with top of IR at axilla
e
d
l
(place shield between IR and patient)
u
o
Central Ray: CR horizontal and ┴ to IR, centered to distal 1 3 of
h
S
humerus
d
n
SID: 40″ (102 cm)
a
s
Collimation: Collimate on four sides Include distal and midhumerus,
u
r
elbow joint, and proximal forearm e
m
u
H

AP an d Lat e ral: Hum e rus
R
3
R
H
u
m
e
r
Fig . 3.7 AP humerus Fig . 3.8 Lateral erect humerus
u
s
a
n
d
S
h
o
u
l
d
• AP and lateral view of the entire humerus, including elbow and
e
r
glenohumeral joints
G
i
r
d
l
Position
e
AP
• No rotation, medial and lateral epicondyles seen in pro le, greater
tubercle in pro le laterally
• Humeral head and glenoid cavity demonstrated
Lateral (PA)
• True lateral, epicondyles are directly superimposed
Exposure
• Sharp cortical margins and bony trabeculation clearly
demonstrated, no motion
70
Tran st h o racic Lat e ral: Hum e rus ( Traum a)
3
• 35 × 43 cm (14 × 17″)
portrait
• Grid
Po sit io n
• Patient recumbent or
erect
Fig . 3.9 Transthoracic lateral
• A ected limb closest
to IR
e
l
• Raise opposite arm over head
d
r
i
Central Ray: CR ┴ to IR through midsha of a ected humerus
G
r
SID: 40″ (102 cm)
e
d
Collimation: To so tissue margins—entire humerus
l
u
o
Respiration: Orthostatic (breathing) technique is preferred
h
S
If Orthostatic (Breathing) Lateral Technique Performed: Minimum
d
n
of 3 seconds exposure time (between 4 and 5 seconds is desirable)
a
s
u
r
e
m
u
H

Tran st h o racic Lat e ral: Pro xim al Hum e rus
Evaluat io n
Crit e ria
Anatomy
Demonstrated
• Lateral view of
the proximal
3
half of
humerus
Position Fig . 3.10 Recumbent transthoracic lateral

Competency Check:
• Proximal half Technologist Date
of sha of
humerus should be clearly visualized
• Humeral head and glenoid cavity demonstrated
H
u
Exposure
m
e
r
u
• Overlying ribs and lung markings blurred (with breathing
s
a
technique)
n
d
S
h
o
u
l
d
e
r
G
i
r
d
l
e
72
AP: Sh o uld e r
Ext e rn al an d In t e rn al Ro t at io n
Warning: Do not
3
attempt if fracture
or dislocation is
suspected
• 24 × 30 cm (10 ×
12″) landscape (or
lengthwise to show
proximal aspect of
humerus) Fig . 3.11 External (AP Fig . 3.12 Internal
• Grid “proximal” humerus) (“Proximal” lateral
e
humerus)
l
Po sit io n
d
r
i
• Erect (seated or standing) or supine, arm slightly abducted
G
• Rotate thorax as needed to place posterior shoulder against IR
r
e
d
• Center of IR to scapulohumeral joint and CR
l
u
o
External Rotation: Rotate arm externally until hand is supinated and
h
S
epicondyles are parallel to IR
d
Internal Rotation: Rotate arm internally until hand is pronated and
n
a
epicondyles are perpendicular to IR
s
u
r
Central Ray: CR ┴, directed to 1″ (2 5 cm) inferior to coracoid process e
m
SID: 40″ (102 cm)
u
H
Collimation: Collimate closely on four sides
Respiration: Suspend during exposure

AP: Sh o uld e r
Ext e rn al an d In t e rn al Ro t at io n

Anatomy
Demonstrated
• Proximal humerus
and lateral 2 3 of
3
the clavicle (entire
clavicle for crosswise
IR) and upper
scapula
Position
External Rotation
• Greater tubercle
visualized in full
H
u
pro le laterally
m
• Lesser tubercle
e
Fig . 3.13 External rotation—AP
r
u
superimposed over
s
Competency Check:
a
humeral head Technologist Date
n
d
Internal Rotation
S
h
(Lateral)
o
u
• Lesser tubercle
l
d
e
visualized in full
r
G
pro le medially
i
r
• Greater tubercle
d
l
e
superimposed over
humeral head
Exposure
• Optimal density
(brightness) and
contrast
• So tissue detail
Fig . 3.14 Internal rotation—lateral
and sharp bony
Competency Check:
trabeculation clearly Technologist Date
demonstrated; no
motion
74
In fe ro sup e rio r Axial: Sh o uld e r
Lawre n ce Me t h o d
Warning: Do not attempt
3
if fracture or dislocation is
suspected
• 18 × 24 cm (8 × 10″)
landscape
• Grid; grid lines horizontal
and CR to center line of Fig . 3.15 Inferosuperior axial
grid (Lawrence method)
• O en performed nongrid for smaller shoulder
Po sit io n
e
• Patient supine, to front edge of table or stretcher, with support
l
d
under shoulder to center anatomy to IR, head turned away from IR
r
i
G
• Arm abducted 90° from body, if possible
r
e
• Rotate arm externally, with hand supinated
d
l
Note: An alternative position is exaggerated external rotation with
u
o
the thumb is pointed down and posteriorly approximately 45° Recom-
h
S
mended in ruling out a Hills-Sachs defect
d
n
Central Ray: CR horizontal, directed 25°–30° medially to axilla, less
a
s
angle if arm is not abducted 90° (place tube next to table or stretcher
u
r
at same level as axilla) e
m
SID: 40″ (102 cm)
u
H

Evaluat io n
Crit e ria
Anatomy
Demonstrated
• Lateral view
3
of proximal
humerus in
relationship
to the scapu-
lohumeral
cavity
Fig . 3.16 Inferosuperior axial (Lawrence method)
Position Competency Check:
• Spine of Technologist Date
H
u
scapula is
m
seen in pro le inferior to the scapulohumeral joint
e
r
u
• A ected arm abducted about 90°
s
a
n
d
Exposure
S
h
o
u
• So tissue detail and sharp bony trabeculation clearly
l
d
e
r
G
i
r
d
l
e
76
PA Tran saxillary: Sh o uld e r
Ho b b s Mo d if cat io n
3
• 18 × 24 cm (8 ×
10″) portrait
• Grid
Po sit io n
• Patient recumbent
or erect PA Fig . 3.17 PA transaxillary (Hobbs
• A ected arm modi cation)
raised superiorly
e
l
and fully extended
d
r
i
• Head is turned away
G
r
Central Ray: Perpendicular to the IR, centered to the glenohumeral
e
d
joint
l
u
o
SID: 40″ (102 cm)
h
S
d
n
a
s
u
r
e
m
u
H

PA Tran saxillary: Sh o uld e r

• Lateral view of proximal
humerus in relationship
to scapulohumeral
3
(glenohumeral) joint
Position
• Coracoid process of scapula
is seen on end
• A ected arm elevated
completely
Exposure
H
u
• Optimal density
m
e
(brightness) and contrast
r
u
• So tissue and sharp
s
Fig . 3.18 PA transaxillary
a
n
(Hobbs modi cation)
d
S
Competency Check:
h
Technologist Date
o
u
l
d
e
r
G
i
r
d
l
e
78
Cle m e n t s Mo d if cat io n
3
A
• 18 × 24 cm (8 × 10″) portrait
• Nongrid (can use grid if CR is
perpendicular to it)
Po sit io n
• Lateral recumbent position; lying on
B
una ected side
• A ected arm up Fig . 3.19 Inferosuperior
axial (Clements
e
• Abduct arm 90° from body, if
l
d
possible modi cation)
r
i
G
Central Ray: Direct horizontal CR perpendicular to the IR (Angle the
r
e
tube 5°–15° toward the axilla if the patient cannot abduct the arm 90°)
d
l
u
SID: 40″ (102 cm)
o
h
S
d
n
a
s
u
r
e
m
u
H

Cle m e n t s Mo d if cat io n
Evaluat io n
Crit e ria R
Anatomy
Demonstrated
• Lateral view
3
of proximal
humerus in
relationship to the
scapulohumeral
joint
Position
• Arm is abducted
90° from the body
H
u
m
e
Exposure
r
u
• Optimal density Fig . 3.20 Inferosuperior axial (Clements
s
modi cation) (From Frank ED, Long BW,
a
(brightness) and
n
Smith BJ: Merrill’s atlas of radiographic
d
contrast
S
positioning and procedures, ed 11, St Louis,
h
• So tissue and
o
2007, Mosby )
u
sharp bony
l
d
Competency Check:
e
trabeculation Technologist Date
r
G
clearly
i
r
d
demonstrated; no
l
e
motion
80
AP Ob liq ue —Gle n o id Cavit y: Sh o uld e r
Grash e y Me t h o d
35°-45°
R S ca pula
Hume rus
2 inche s
CR
3
A special projection
for visualizing glenoid
cavity in pro le with
open joint space
• 18 × 24 cm (8 ×
10″) landscape
• Grid
Fig . 3.21 AP oblique—Grashey method
Po sit io n
• Erect or supine (erect preferred)
e
l
d
• Oblique 35°–45° toward side of interest (body of scapula should be
r
i
G
parallel with IR), hand and arm in neutral rotation
r
• Center midscapulohumeral joint and IR to CR (5 cm [2″] inferior
e
d
l
and medial from the superolateral border of shoulder)
u
o
Central Ray: CR ┴, to scapulohumeral joint
h
S
SID: 40″ (102 cm)
d
n
Collimation: Collimate so upper and lateral borders of the eld are
a
s
to the so tissue margins
u
r
Respiration: Suspend during exposure e
m
u
H

AP Ob liq ue : Sh o uld e r
Grash e y Me t h o d

• View of head of humerus in
relationship to glenoid cavity
3
Position
• Open scapulohumeral joint space
• Anterior and posterior rims of
glenoid cavity are superimposed Fig . 3.22 AP oblique—Grashey
method
Exposure Competency Check:
Technologist Date
contrast
• So tissue margins and sharp bony trabeculation clearly
H
u
m
e
r
u
s
a
n
d
S
h
o
u
l
d
e
r
G
i
r
d
l
e
82
Tan g e n t ial—In t e rt ub e rcular ( Bicip it al)
Sulcus: Sh o uld e r
Fisk Mo d if cat io n
• 18 × 24 cm (8 × 10″) landscape
3
• Nongrid
Po sit io n
• Supine or erect Palpate
anterior humeral head to Fig . 3.23 Supine inferosuperior
locate groove tangential projection (CR 15°–20° from
Supine: Abduct arm slightly, horizontal)
supinate hand
• Center IR and groove to CR
• CR 10°–15° posterior from
e
horizontal position of x-ray
l
d
r
tube, centered to groove,
i
G
IR vertical against top of
r
e
shoulder, perpendicular to
d
l
u
CR
o
h
Alternative Erect: Patient
S
standing, leaning over the end
d
n
of the table to place humerus Fig . 3.24 Erect superoinferior
a
tangential (humerus 15°–20° from
s
10°–15° from vertical, CR
u
vertical, ┴ to IR vertical, CR, ┴ to IR) r
e
m
SID: 40″ (102 cm)
u
H
Collimation: Collimate closely on four sides to area of anterior
humeral head

Tan g e n t ial—In t e rt ub e rcular ( Bicip it al)
Sulcus: Sh o uld e r
Fisk Mo d if cat io n
R
3
Fig . 3.25 Erect tangential projection (intertubercular
H
groove)
u
m
Competency Check:
e
Technologist Date
r
u
s
a
n
d
S
h
• Humeral tubercles and intertubercular groove seen in pro le
o
u
l
d
e
Position
r
G
• Intertubercular groove and tubercles in pro le
i
r
d
• No superimposition of acromion process
l
e
Exposure
• Sharp borders and sharp bony trabeculation clearly demonstrating
intertubercular sulcus seen through so tissue; no motion
84
PA Ob liq ue : Sh o uld e r ( Traum a)
Scap ular Y Lat e ral an d Ne e r Met h o d
3
• 24 × 30 cm (10 × 12″) portrait
• Grid
Po sit io n
Fig . 3.26 PA oblique (scapular Y lateral)
• Erect or recumbent (erect
preferred) with CR ┴
• Patient PA then rotate
a ected shoulder into a
45°–60° posterior oblique as
for a lateral scapula (body of
scapula perpendicular to IR)
e
l
d
• Una ected arm up in front
r
i
G
of patient, a ected arm down
r
(don’t move with possible
e
d
fracture or dislocation)
l
u
• Center scapulohumeral joint Fig . 3.27 Tangential (Neer method) with
o
h
and CR
S
CR 10°–15° caudad
d
Central Ray: CR ┴ to scapulo-
n
humeral joint
a
s
Neer Method: Angle CR 10°–15° caudad to better demonstrate the
u
r
acromiohumeral space (supraspinatus outlet), CR to superior margin of e
m
humeral head
u
H
SID: 40″ (102 cm)


PA Ob liq ue : Sh o uld e r ( Traum a)
Scap ular Y Lat e ral an d Ne e r Met h o d
R R
3
H
u
m
e
r
u
s
Fig . 3.28 PA oblique (scapular Y Fig . 3.29 Tangential projection (Neer
a
n
lateral) with no dislocation method)
d
S
h
o
u
l
d
e
r
G
i
• Scapular Y: True lateral view of the scapula, proximal humerus
r
d
l
e
• Neer method: Supraspinatus outlet region is open
Position
• Scapular Y: in body of the scapula seen on end without rib
superimposition Upper limb is not elevated or moved with
possible fracture or dislocation
• Neer method: in body of the scapula seen on end; humeral
head below supraspinatus outlet (arrow)
Exposure
• Bony margins clearly demonstrated; no motion
86
AP—Ne ut ral Ro t at io n : Sh o uld e r ( Traum a)
• 24 × 30 cm (10 × 12″)
landscape (or portrait
3
to show more of
humerus if injury
includes proximal half
of humerus)
• Grid Fig . 3.30 AP—neutral rotation
Note: Evaluation of AP
shoulder-neutral position is similar to external/internal rotation, but
neither the greater tubercle nor the lesser tubercle is in pro le (if limb
can be moved)
e
l
d
r
Po sit io n
i
G
• Erect (seated or standing) or supine, arm slightly abducted
r
e
d
• Rotate thorax slightly as needed to place posterior shoulder
l
u
against IR
o
h
S
• Arm in neutral position (generally with palm inward—no acute
d
trauma present)
n
a
Central Ray: CR ┴, to 3 4 ″ (2 cm) inferior to coracoid process
s
u
SID: 40″ (102 cm) r
e
m
u
H

Tran st h o racic Lat e ral: Sh o uld e r ( Traum a)
• 24 × 30 cm (10 × 12″) portrait

3
• Grid
• Orthostatic (breathing) technique is
preferred if patient can cooperate
Po sit io n
• Erect or supine, a ected arm Fig . 3.31 Erect transthoracic
against IR, arm at side in neutral lateral
position
• Raise una ected arm above head
H
• Elevate una ected shoulder,
u
or angle CR 10°–15° cephalad
m
e
to prevent superimposition of
r
u
s
una ected shoulder
a
n
• True lateral, or slight anterior
d
rotation of una ected shoulder
S
h
• Center grid IR to CR
o
u
Central Ray: CR ┴, through thorax Fig . 3.32 Supine transthoracic
l
d
e
to surgical neck lateral
r
G
SID: 40″ (102 cm)
i
r
d
l
e
Respiration: Expose on full inspiration; orthostatic (breathing)
technique preferred

Tran st h o racic Lat e ral: Sh o uld e r ( Traum a)

Anatomy
Demonstrated
• Lateral view of
proximal humerus
3
and glenohumeral
joint
Position
• Sha of the proximal
humerus should be
clearly visualized
• Humeral head and
the glenoid cavity
e
l
d
visualized
r
i
G
r
e
Exposure Fig . 3.33 Erect transthoracic lateral
d
l
• Optimal density
u
Competency Check:
o
Technologist Date
(brightness) and
h
S
contrast
d
n
• Ribs and lungs should be blurred due to breathing technique,
a
s
but bony outlines of the humerus should be sharp indicating no
u
r
e
motion
m
u
H
89
AP Ap ical Ob liq ue Axial: Sh o uld e r ( Traum a)
Gart h Me t h o d
45°
CR
3
A good projection for acute
shoulder trauma, demonstrat-
ing shoulder dislocations,
glenoid fractures, and
Hill-Sachs lesions Fig . 3.34 Erect apical oblique (45°
• 24 × 30 cm (10 × 12″) posterior oblique, CR 45° caudad)
portrait
• Grid
H
Po sit io n
u
m
• Erect preferred (recumbent, if necessary)
e
r
u
• Rotate thorax 45° with a ected shoulder against IR
s
a
• Flex a ected elbow and place hand on opposite shoulder
n
d
• Center IR to exiting CR
S
Central Ray: CR 45° caudad, to medial aspect of scapulohumeral joint
h
o
SID: 40″ (102 cm)
u
l
d
e
r
G
i
r
d
l
e

AP Ap ical Ob liq ue Axial: Sh o uld e r ( Traum a)
Gart h Me t h o d

R
• Humeral head, glenoid cavity,
and neck and head of scapula
free of superimposition
3
Position
• Acromion and AC joint
projected superior to humeral
head
Exposure
and contrast
e
l
d
• So tissue detail and sharp
r
i
G
r
e
d
l
u
o
h
S
Fig . 3.35 AP apical oblique
d
Competency Check:
n
a
Technologist Date
s
u
r
e
m
u
H
91
Ap ical AP Axial: Sh o uld e r
Demonstrates narrowing of acromiohumeral space and possible spur-

ring of the anteroinferior aspect of acromion
CR 30°
3
c a uda l
• 18 × 24 cm
(8 × 10″) or
24 × 30 cm
(10 × 12″)
landscape
• Grid
Fig . 3.36 Erect apical AP axial (CR 30° caudad)
Po sit io n
H
• Erect preferred
u
m
• Position patient with no rotation
e
r
u
• A ected hand in neutral position
s
a
Central Ray: Angle CR 30° caudad entering 1 2 ″ (1 25 cm) above
n
d
coracoid process
S
SID: 40″ (102 cm)
h
o
Collimation: Collimate to so tissue margins of shoulder
u
l
d
Respiration: Expose upon suspended respiration
e
r
G
i
r
d
l
e

Ap ical AP Axial: Sh o uld e r
Evaluat io n
Crit e ria
Anatomy
Demonstrated
• e
anteroinferior
3
aspect of the
acromion
process and
acromiohumeral
joint space is
open
• Proximal
humerus is
Fig . 3.37 Apical AP axial
projected in
e
Competency Check:
l
neutral rotation
d
Technologist Date
r
i
G
position
r
e
d
l
Po sit io n :
u
o
• Acromiohumeral space is more open as compared to routine AP
h
S
shoulder projection
d
n
• Anteroinferior aspect of acromion is demonstrated
a
s
u
r
Exposure e
m
u
H
93
AP an d AP Axial: Clavicle
• 24 × 30 cm
3
(10 × 12″)
landscape Fig . 3.38 AP, 0° Fig . 3.39 AP axial, 15°
• Grid to 30° cephalad
Po sit io n
• Erect or recumbent
• Center clavicle and IR to CR (midway between jugular notch
medially and AC joint laterally)
Central Ray: CR to midclavicle
H
AP: CR ┴, to midclavicle
u
m
AP Axial: 15°–30° cephalad* (thin shoulders require 5°–15° more
e
r
angle than thick shoulders)
u
s
Note: Departmental routines may include AP 0°, or axial AP, or both
a
n
SID: 40″ (102 cm)
d
S
Collimation: Collimate to area of clavicle (Ensure that both AC and
h
o
sternoclavicular joints are included)
u
l
d
Respiration: Expose upon full inspiration
e
r
G
i
r
d
*AP lordotic position can be performed rather than angling CR for AP axial
l
e

AP an d AP Axial: Clavicle
3
e
l
d
r
i
G
r
e
d
l
u
o
h
S
d
Fig . 3.40 AP and AP axial (lower image)
n
a
Competency Check:
s
u
Technologist Date
r
e
m
u
H
• AP 0°: Entire clavicle including both AC and SC joints
• AP axial: e entire clavicle including both AC and SC joints
above the scapula and ribs
Position
• AP 0°: Entire clavicle from AC to SC joint
• AP axial: Only medial portion of clavicle will be superimposed by
rst and second ribs
Exposure
95
AP: Scap ula
R
3
• 24 × 30 cm (10 × 12″)
portrait
• Grid
Po sit io n Fig . 3.41 AP scapula erect

• Erect or supine (erect
preferred with pain in scapula area)
• Gently abduct arm 90°, if possible; supinate hand (abduction
results in less superimposition of scapula by ribs)
H
• Center IR and entire scapula to CR
u
m
Central Ray: CR ┴, to midscapula (2″ or ≈5 cm inferior to coracoid
e
r
process and 2″ [5 cm] medial from lateral border of patient)
u
s
SID: 40″ (102 cm)
a
n
Collimation: Collimate on four sides of scapula borders
d
S
Respiration: Breathing technique preferred can be employed or
h
o
suspend respiration during exposure
u
l
d
e
r
G
i
r
d
l
e

Lat e ral ( Ere ct an d Re cum b e n t ) : Scap ula
• 24 × 30 cm
3
(10 × 12″)
portrait Fig . 3.43 For body
of scapula
Po sit io n
• Erect or Fig . 3.42 Lateral
recumbent (palpate scapular
(erect borders)
preferred)
• Palpate borders of scapula and
e
l
d
rotate thorax until body of scapula
r
i
G
is perpendicular to IR (will vary
r
e
from 45°–60° rotation) Fig . 3.44 Superior scapula
d
l
• If area of interest is body of scapula, (acromion or coracoid
u
o
with patient’s arm up, have patient process), place arm down,
h
S
reach across and grasp opposite ex elbow, palm out
d
n
shoulder
a
s
Central Ray: CR ┴, to midvertebral
u
r
e
border of scapula
m
SID: 40″ (102 cm)
u
H
Collimation: To scapular region
Bontrager Textbook, 9th ed, pp pp 208–209 97

AP an d Lat e ral: Scap ula
L
3
H
u
m
Fig . 3.45 AP scapula Fig . 3.46 Lateral scapula
e
r
u
s
a
n
d
S
h
o
u
l
d
• AP: Entire scapula
e
r
• Lateral: Entire scapula in a lateral position
G
i
r
d
l
Position
e
• AP: Lateral border of scapula free of superimposition
• Lateral: Humerus not superimposing over region of interest; ribs
free of superimposition by body of scapula
Exposure
• Sharp bony borders and trabeculation clearly demonstrated; no
motion
98
AP ( Bilat e ral) : Acro m io clavicular ( AC) Jo in t s
Pe arso n Me t h o d , Wit h an d Wit h o ut We ig h t s
Warning: Rule out fracture

before taking “with weight” (broa d-
18 cm R L
s houlde re d
projection (8”)
pa tie nt)
• 35 × 43 cm (14 × 17″) or
(2) 18 × 24 cm (8 × 10″) for 24 cm (10”) 24 cm (10”)
broad shoulders, landscape
3
• Grid or nongrid (depending on size of
shoulder)
• Use markers “with weights” and “without
weights”
Po sit io n
• Erect, standing if possible, or may be
seated on chair
• Arms at sides, one exposure for
bilateral without weights, and a
second exposure with 8–10 lb
e
l
minimum (5–8 lb for smaller patient)
d
r
i
weights tied to wrists, shoulders and
G
arms relaxed, center IR to CR Fig . 3.47 Bilateral with
r
e
Central Ray: CR ┴, to midpoint weights
d
l
u
between AC joints, 1″ (2 5 cm) above jugular notch
o
h
SID: 40″ (102 cm); 72″ (183 cm) recommended for bilateral studies
S
with a single IR
d
n
Collimation: Long, narrow horizontal exposure eld
a
s
u
r
Alternative AP Axial Projection (Alexander Method): A 15° e
m
cephalic angle centered at the level of the a ected AC joint to rule out
u
H
subluxation or dislocation of AC joint
(70–75 kV with grid) (grid recom m ended for
larger shoulders)

AP ( Bilat e ral) : AC Jo in t
Pe arso n Me t h o d , Wit h an d Wit h o ut We ig h t s
3
Fig . 3.48 AP acromioclavicular joints without weights
Competency Check:
Technologist Date
H
u
m
e
r
u
s
a
n
d
S
h
o
u
l
d
Fig . 3.49 AP acromioclavicular joints with weights
e
r
Competency Check:
G
Technologist Date
i
r
d
l
e
• Both R and L AC joints and SC joints included
Position
• No rotation, symmetric SC joints
Exposure
• Optimal density (brightness) and contrast; no motion
• Bony margins and sharp bony trabeculation clearly demonstrated
100
Ch ap t e r 4
Lo we r Lim b
• Technical considerations and radiation protection 103
To e s An kle
AP (R) 104 AP (R) 120
4
AP oblique (S) 105 AP mortise 121
AP and AP oblique AP oblique—45° medial
critique 106 rotation (R) 122
Lateral (R) 107 AP, AP mortise, and
Tangential, toes— AP oblique—45° oblique
sesamoids (S) 108 medial rotation
Lateral, toes and critique 123
tangential, toes— Lateral—mediolateral
sesamoids critique 109 or lateromedial (R) 124
b
m
Mediolateral critique 125
i
L
Fo o t AP stress, inversion
r
e
w
Dorsoplantar AP (R) 110 and eversion positions
o
L
AP medial oblique (R) 111 (S) 126
AP and AP medial
oblique critique 112 Lo we r Le g (Tib ia-Fib ula)
Lateral (R) 113 AP (R) 127
Lateral critique 114 Mediolateral (R) 128
Weight-bearing AP and AP and lateral critique 129
lateral (S) 115
Weight-bearing AP and Kn e e
lateral critique 116 AP (R) 130
AP oblique—medial and
Calcan e us lateral rotation (R) 131
Plantodorsal (axial) AP and AP oblique—
(R) 117 medial and lateral
Lateral—mediolateral rotation critique 132
(R) 118 Lateral—mediolateral
Plantodorsal (axial) and (R) 133
lateral—mediolateral Lateral—mediolateral
101
AP or PA weight-bearing Tangential—axial (patella)
bilateral (S) 135 (Merchant bilateral
PA axial weight-bearing method) (S) 142
bilateral (Rosenberg Tangential—axial, prone
method) (S) 136 (patella) (Settegast, and
PA axial weight-bearing Hughston methods)
bilateral critique 137 (S) 143
Superoinferior sitting
In t e rco n d ylar Fo ssa tangential (patella)
4
an d Pat e lla (Hobbs modi cation)
PA and AP axial (“tunnel (S) 144
views”), intercondylar Superoinferior sitting
fossa (Camp Coventry tangential (bilateral)
and Holmblad methods) (patella) critique 145
(S) 138
PA, patella (R) 139 Pe d iat ric Lo we r Lim b
Lateral—mediolateral AP (S) 146
L
(R) 140 Lateral (S) 147
o
w
PA axial (intercondylar AP and mediolateral
e
r
fossa) and PA (foot) (congenital
L
i
and lateral (patella) clubfoot—Kite method)
m
b
critique 141 (S) 148
102
Te ch n ical Co n sid e rat io n s
e principal exposure factors for radiography of the lower limbs

include the following:
• Low-to-medium kV (50–75); 70–80 digital systems
• Short exposure time
• Small focal spot
• Adequate mAs for su cient density (brightness)
• Grids: for anatomy measuring >10 cm in thickness
Dig it al Im ag in g Co n sid e rat io n s
4
• Four-sided collimation: Collimate to the area of interest with a
minimum of two collimation parallel borders clearly demonstrated
on the image Four-sided collimation is always preferred
• Accurate centering: It is important that the body part and the
central ray be centered to the IR
• Grid use with cassette-less systems: Anatomy thickness and kV
range are deciding factors for whether a grid is to be used With
cassette-less systems it may be impractical and di cult to remove
the grid erefore the grid is commonly le in place even for
b
smaller body parts measuring 10 cm or less If the grid is le in
m
i
L
place, it is important to ensure that the CR is centered to the grid
r
e
for all projections
w
o
L
Co llim at io n an d Sh ie ld in g
A general rule for protective shielding states that it should be used
whenever radiation-sensitive areas lie within or near the primary beam
Red bone marrow and gonadal tissues are two of the key radiation-
sensitive regions However, a good practice to follow, in addition to
close collimation to the area of interest, is to use shielding on youth
and patients of childbearing age for all lower limb procedures All
radiosensitive tissues should be protected unless it involves area of
interest is provides assurance to the patient that he or she is being
protected from unnecessary exposure
Mult ip le Exp o sure s p e r Im ag in g Plat e

Placing multiple images on the same IP is not recommended However,
if doing so, careful collimation and lead masking must be used to
prevent pre-exposure of other images
103
AP: To e s
Alternative Routine: May

include entire foot on AP
toe projection for possible
secondary trauma to other
parts of foot (see AP foot)
• 18 × 24 cm (8 × 10″)
4
landscape
• Nongrid Fig . 4.1 AP second digit, CR 10°–15°
• Lead masking with toward calcaneus
same IR
Po sit io n
• Supine or seated on table with knee exed, plantar surface of foot
resting on IR
L
o
• Align long axis of a ected toe(s) to portion of IR being exposed
w
e
Central Ray:
r
L
• CR angled 10°–15° to calcaneus (┴ to long axis of digits)
i
m
• CR centered to MTP joint(s) of interest
b
SID: 40″ (102 cm)
Collimation: Collimate on four sides to area of interest to include
so tissue margins

AP Ob liq ue : To e s
• 18 × 24 cm (8 × 10″)
landscape
• Nongrid
4
Fig . 4.2 Medial oblique rotation ( rst digit)
Po sit io n
• Supine or seated on
table, foot resting on IR
• Align long axis of
a ected toe(s) to portion
of IR being exposed
• Oblique foot 30°–45°
medially for rst to third
b
m
digits, and laterally for
i
L
fourth and h digits
r
Place support under foot Fig . 4.3 Lateral oblique rotation (fourth
e
w
digit)
o
as shown
L
Central Ray: CR ┴, centered to MTP joint(s) of interest
SID: 40″ (102 cm)
Collimation: Collimate on four sides to area of interest to include
so tissues

AP an d AP Ob liq ue : To e s
4
L
o
Fig . 4.4 AP toe Fig . 4.5 Medial oblique toe
w
e
Competency Competency
r
Check: Check:
L
i
m
b
• AP and AP Oblique: Entire digit and minimum of 1
2 of a ected
metatarsal
Position
• AP: No overlap of surrounding digits and metatarsals; no
rotation, equal concavity on both sides of sha s of phalanges and
metatarsals
• AP Oblique: Increased concavity on one side of phalangeal sha
Exposure
• Sharp cortical margins and bony trabeculae clearly demonstrated
106
Lat e ral: To e s
Fig . 4.6 Lateromedial ( rst Fig . 4.7 Mediolateral (fourth

digit) digit)
4
• 18 × 24 cm (8 × 10”) landscape
• Nongrid
Po sit io n
• Seated or recumbent on tabletop
• Carefully use tape and/or radiolucent gauze to isolate una ected
digits as shown:
• First to third digits—lateromedial projection ( rst digit down)
b
• Fourth to h digits—mediolateral projection ( rst digit up)
m
i
L
Central Ray: CR ┴, to IP joint for rst digit, and to PIP joint for
r
second to h digits
e
w
SID: 40″ (102 cm)
o
L
Collimation: Collimate closely to digit of interest to include so
tissues

Tan g e n t ial: To e s—Se sam o id s
• 18 × 24 cm
(8 × 10″)
landscape
• Nongrid Fig . 4.8 Patient prone Fig . 4.9 Alternative supine
• Lead position
4
masking
with multiple exposures on same IR
Po sit io n
• Patient prone with foot and great toe carefully dorsi exed so that
the plantar surface forms a 15°–20° angle from vertical, if possible
(adjust CR angle, as needed)
Alternative Supine Position: May be a more tolerable position for
patient to maintain if in great pain Long strip of gauze is needed for
L
o
the patient to hold the toes as shown
w
e
Central Ray: CR ┴, or angled, as needed, depending on amount of
r
L
dorsi exion of foot, centered to head of rst metatarsal
i
m
SID: 40″ (102 cm)
b
Collimation: Collimate closely to area of interest; include distal rst,
second, and third metatarsals for possible sesamoids

Lat e ral: To e s

• Entire digit, including proximal
phalanx
Position
• No superimposition of adjoining
digits
• Proximal phalanx visualized
4
through superimposed
structures
Exposure
• Contrast and density
(brightness) su cient to
visualize so tissue and bony
portions; no motion
b
m
i
L
r
e
w
Fig . 4.10 Lateromedial second digit
o
Competency
L
Check:
Technologist Date
Tan g e n t ial: Se sam o id s

• Sesamoid bones in pro le
Position
• No superimposition of
sesamoids and rst to third
distal metatarsals in pro le
Exposure
• Optimal density (brightness) Fig . 4.11 Tangential sesamoids
and contrast; no motion Competency
Check:
• So tissue, trabeculae, and Technologist Date
sharp cortical margins clearly
demonstrated 109
Do rso p lan t ar AP: Fo o t
• 24 × 30 cm
(10 × 12″)
portrait
4
• Nongrid
• Lead masking
with multiple
Fig . 4.12 AP foot, CR 10° posteriorly
exposures on
same IR
Po sit io n
• Supine or seated with plantar surface at on IR, aligned lengthwise
to portion of IR being exposed
L
• Extend (plantar ex) foot by sliding foot and IR distally while
o
w
keeping plantar surface at on IR (Support with sandbags to keep
e
r
foot and IR from sliding farther)
L
i
m
Central Ray: CR ┴, to metatarsals, which is about 10° posteriorly
b
(toward heel), centered to base of third metatarsal
SID: 40″ (102 cm)
Collimation: Four sides to margins of foot

AP Me d ial Ob liq ue : Fo o t
• 24 × 30 cm (10 × 12″)
portrait
• Nongrid
4
same IR Fig . 4.13 30°–40° medial oblique
Po sit io n
• Supine or seated with foot centered lengthwise to portion of IR
being exposed
• Oblique foot 30°–40° medially, support with 45° radiolucent angle
block and sandbags to prevent slippage
b
• Note 1: A higher arch requires nearer 45° oblique and a low arch
m
i
L
“ at foot” nearer 30°
r
• Note 2: A 30° lateral oblique projection will demonstrate the space
e
w
between rst and second metatarsals and between rst and second
o
L
cuneiforms
Central Ray: CR ┴, centered to base of third metatarsal
SID: 40″ (102 cm)
Collimation: Four sides to skin margins of foot and distal ankle

AP an d AP Me d ial Ob liq ue : Fo o t
4
Fig . 4.14 AP foot Fig . 4.15 Medial oblique foot
L
o
Competency Competency
w
Check: Check:
e
r
L
i
m
b
• AP and AP medial oblique: Entire foot, including tarsals,
metatarsals, and phalanges
Position
AP
• No rotation with tarsals superimposed
AP Medial Oblique
• ird to h metatarsals free of superimposition
• Cuboid clearly demonstrated; base of h metatarsal seen in
pro le
Exposure
• So tissue and sharp bony trabeculation clearly demonstrated
112
Lat e ral: Fo o t
• 18 × 24 cm (8 × 10″)
portrait (to foot)
or
• 24 × 30 cm (10 × 12″)
portrait for large foot
4
• Nongrid
Fig . 4.16 Mediolateral foot
Po sit io n
(Me d io lat e ral)
• Recumbent, on a ected side, knee
exed with una ected leg behind to
prevent overrotation
• Place support under a ected knee and
leg, as needed, to place plantar surface
b
of foot perpendicular to IR for a true Fig . 4.17 Lateromedial foot
m
i
L
lateral
r
e
Lateromedial Projection: May be easier to achieve a true lateral if
w
o
patient’s condition allows this position
L
Central Ray: CR ┴, centered to area of base of third metatarsal
SID: 40″ (102 cm)
Collimation: Four sides to skin margins of foot and distal ankle

Lat e ral: Fo o t
4
Fig . 4.18 Mediolateral foot
Competency Check:
Technologist Date

• Entire foot with ≈1″ (2 5 cm) of distal tibia- bula
L
Position
o
w
• True lateral with tibiotalar joint open
e
r
• Distal metatarsals superimposed
L
i
m
b
Exposure
114
We ig h t -Be arin g AP an d Lat e ral: Fo o t
Lateral projection is most common for lon-

gitudinal arch ( at feet); AP demonstrates
alignment of metatarsals and phalanges
Bilateral projections of both feet are o en Fig . 4.19 AP—both feet CR
taken for comparison 15° posteriorly
• 24 × 30 cm (10 × 12″) landscape; 35 ×
4
43 cm (14 × 17″) landscape for bilateral
study
• Nongrid
Po sit io n
• AP: Erect, weight evenly distributed
on both feet, on one IR
• Lateral: Erect, full weight on both
feet, vertical IR between feet,
b
standing on blocks, high enough
m
i
L
from oor for horizontal CR (R and
r
e
L feet taken for comparison)
w
Central Ray:
o
L
• AP: CR 15° posteriorly, CR to level Fig . 4.20 Lateral—right foot
of base of third metatarsal, midway between feet
• Lateral: CR horizontal, to base of third metatarsal
SID: 40″ (102 cm)
Collimation: Collimate to outer skin margins of the feet

We ig h t -Be arin g AP an d Lat e ral: Fo o t

• AP: Bilateral feet with
so tissue detail
• Lateral: Entire foot with
1″ (2 5 cm) of distal
tibia- bula
Position:
4
• AP: Open tarsometatarsal
joints; with approximately
equal spacing of second
to fourth metatarsals
• Lateral: Dorsum
to plantar surface Fig . 4.21 AP weight-bearing
demonstrated; heads of bilateral feet
Competency Check:
metatarsals superimposed Technologist Date
L
o
w
Exposure:
e
r
L
i
• So tissue, cortical margins, and sharp bony trabeculation clearly
m
b
Fig . 4.22 Lateral weight-bearing foot

Competency Check:
Technologist Date
116
Plan t o d o rsal ( Axial) : Calcan e us
• 18 × 24 cm (8 × 10″)
portrait
• Nongrid (detail
screens)
4
multiple exposures
on same IR
Fig . 4.23 CR 40° to long axis of foot
Po sit io n
• Supine or seated, dorsi ex foot to as near vertical position as
possible If possible, have patient pull on gauze as shown ( is
may be painful for patient to maintain, so do not delay!)
• Center CR to part, with IR centered to projected CR
b
Central Ray: CR 40° to long axis of plantar surface (may require more
m
i
L
than 40° from vertical if foot is not dorsi exed a full 90°)
r
e
• CR centered to base of third metatarsal, to emerge just distal and
w
o
inferior to ankle joint
L
• Note: Important to place the calcaneus on the lower aspect of the
IR closest to the x-ray tube because of the severe CR angulation
SID: 40″ (102 cm)
Collimation: Collimate closely to region of calcaneus

Lat e ral—Me d io lat e ral: Calcan e us
• 18 × 24 cm (8 × 10″)
portrait
• Nongrid
4
Fig . 4.24 Lateral calcaneus
same IR
Po sit io n
• Recumbent, on a ected side, knee exed with una ected limb
behind, to prevent overrotation
• Place support under knee and leg, as needed, for a true lateral
• Dorsi ex foot so that the plantar surface is near 90° to leg, if
L
possible
o
w
Central Ray: CR ┴, to midcalcaneus, 1″ (2 5 cm) inferior to medial
e
r
malleolus
L
i
m
SID: 40″ (102 cm)
b
Collimation: Four sides to area of calcaneus; include ankle joint at
upper margin

Plan t o d o rsal ( Ax ial) an d
Lat e ral—Me d io lat e ral: Calcan e us

• Plantodorsal: Entire
calcaneus from tuberosity
to talocalcaneal joint
• Lateral: Calcaneus in
pro le with talus to distal
tibia- bula
4
Position
• Plantodorsal: No rotation
with sustentaculum tali in
pro le medially
• Lateral: Partial
superimposed talus and Fig . 4.25 Plantodorsal (axial) calcaneus
Competency Check:
open talocalcaneal joint Technologist Date
b
m
Exposure
i
L
• Density and
r
e
w
contrast
o
L
(brightness)
su cient to
faintly visualize
distal bula
through talus; no
motion
• Sharp bony
margins and
trabeculation
clearly
demonstrated Fig . 4.26 Mediolateral calcaneus
Competency Check:
Technologist Date
119
AP: An kle
• 24 × 30 cm
(10 × 12″)
portrait
4
• Nongrid
multiple exposures
on same IR Fig . 4.27 AP ankle
Po sit io n
• Supine or seated on table, leg extended, support under knee
• Align leg and ankle parallel to edge of IR
• True AP, ensure no rotation, long axis of foot is vertical, parallel to
L
CR
o
w
Central Ray: CR ┴, to midway between malleoli
e
r
SID: 40″ (102 cm)
L
i
m
Collimation: Collimate to lateral skin margins; include proximal 1 2
b
of metatarsals and distal tibia- bula

AP Mo rt ise : An kle
is is a frontal view of the entire ankle

mortise joint and should not be a substitute
for the routine AP or 45° oblique ankle
• 24 × 30 cm (10 × 12″) portrait
4
• Nongrid
• Lead masking with multiple exposures
on same IR
Po sit io n
• Supine or seated on table, leg
extended, support under knee Fig . 4.28 AP, to visualize entire
• Rotate leg and long axis of ankle mortise (15°–20° medial
foot internally 15°–20° so that rotation)
b
m
intermalleolar line is parallel to
i
L
tabletop
r
e
w
o
L
SID: 40″ (102 cm)
Collimation: Collimate to lateral skin margins; include distal tibia-
bula and proximal metatarsals in collimation eld
Note: e base of the h metatarsal is a common fracture site and
may be demonstrated in this projection

AP Ob liq ue —4 5 ° Me d ial Ro t at io n : An kle
• 24 × 30 cm (10 × 12″)
portrait
• Nongrid
4
multiple exposures on Fig . 4.29 45° AP medial oblique ankle
same IR
Po sit io n
• Supine or seated, leg extended, support under knee
• Rotate leg and foot 45° medially (long axis of foot is 45° to IR)
Central Ray: CR ┴, to midway between the malleoli
SID: 40″ (102 cm)
L
Collimation: Collimate to ankle region; include proximal metatarsals
o
w
and distal tibia- bula
e
r
Note: e base of h metatarsal is a common fracture site and may
L
i
m
be visualized on oblique ankle projections
b

AP, AP Mo rt ise , an d AP Ob liq ue —4 5 ° Me d ial
Ro t at io n : An kle
4
Fig . 4.30 AP ankle Fig . 4.31 AP mortise Fig . 4.32 45° AP
(Courtesy E Frank, ankle medial oblique
RT[R], FASRT ) Competency
Check:
Technologist Date
b
m
i
L
r
e
• AP: Distal 1 3 of tibia- bula, lateral and medial malleoli, talus, and
w
o
proximal metatarsals
L
• AP Mortise: Entire ankle mortise should be open with distal 1 3
tibia and bula, lateral and medial malleoli talus and proximal half
of metatarsals
• AP 45° Oblique: Distal 1 3 tibia and bula, malleoli, talus,
calcaneus, and proximal half os metatarsals
Position
• AP: No rotation with medial mortise joint open and lateral
mortise is closed
• AP Mortise: Open lateral and medial mortise joint surfaces;
malleoli in pro le
• AP 45° Oblique: Open distal tibio bular joint, talus, and medial
malleolus open with no or only minimal overlap
Exposure
• Density and contrast (brightness) su cient to faintly visualize
distal bula through talus; no motion
• So tissue structures, bony margins and sharp bony trabeculation
clearly demonstrated
123
Lat e ral—Me d io lat e ral o r Lat e ro m e d ial: An kle
• 24 × 30 cm (10 × 12″) portrait

• Nongrid (detail screens)
Fig . 4.33 Mediolateral ankle
4
Po sit io n
• Recumbent, a ected side
down, a ected knee partially
exed
• Dorsi ex foot 90° to leg if
patient can tolerate
• Place support under knee
L
o
as needed for true lateral of
w
Fig . 4.34 Lateromedial ankle
e
foot and ankle
r
L
Central Ray: CR ┴, to medial malleolus
i
m
Note: May also be taken as a lateromedial projection if patient condi-
b
tion allows, may be easier to achieve a true lateral
SID: 40″ (102 cm)
Collimation: Four sides to ankle region; include distal tibia and bula
and proximal metatarsals

Me d io lat e ral: An kle

• Distal 1 3 of tibia and bula
with lateral view of tarsals,
base of h metatarsal,
navicular and cuboid
Position
• True lateral with no rotation,
4
distal bula superimposed
over posterior half of tibia
• Tibiotalar joint open
Exposure
• Density and contrast
(brightness) su cient to
faintly visualize distal bula Fig . 4.35 Mediolateral ankle
Competency Check:
through talus; no motion
b
m
Technologist Date
• Sharp bony margins and
i
L
trabeculation clearly
r
e
w
demonstrated
o
L
125
AP St re ss: An kle
In ve rsio n an d Eve rsio n Po sit io n s
43
R R
35
4
Fig . 4.36 Inversion stress Fig . 4.37 Eversion stress
Warning: Stress must be applied very carefully, either by a long gauze held by
the patient or handheld by a quali ed person wearing lead gloves and an apron
(may require injection of local anesthetic by a physician)
• 24 × 30 cm (10 × 12″) portrait or 35 × 43 cm (14 × 17″) landscape
• Nongrid
Po sit io n
L
o
• Supine or seated on table, leg extended
w
e
• Without rotating leg or ankle (true AP), stress is applied to ankle
r
L
joint by rst turning plantar surface of foot inward (inversion
i
m
stress), then outward (eversion stress)
b
SID: 40″ (102 cm)
Collimation: Collimate to lateral skin margins, including proximal
metatarsals and distal tibia- bula

AP: Lo w e r Le g ( Tib ia-Fib ula)
• 35 × 43 cm (14
4
× 17″) portrait;
diagonal IR
alignment only if Fig . 4.38 AP lower leg
needed to include
both ankle and knee joints
• Nongrid
• Knee at cathode end to utilize anode heel e ect
Po sit io n
• Supine, leg extended, ensure no rotation of knee, lower leg, or
b
m
ankle
i
L
• Include ≈3 cm (1–1 5″) minimum beyond knee and ankle joints,
r
e
w
considering divergent rays
o
L
Central Ray: CR ┴, to midsha of lower leg (to mid-IR)
SID: Minimum SID of 40″ (102 cm); may increase to 44–48″
(112–123 cm)
Collimation: On four sides to skin margins to include knee and ankle
joints

Me d io lat e ral: Lo w e r Le g ( Tib ia-Fib ula)
• 35 × 43 cm (14 × 17”)
4
portrait; diagonal IR
alignment or two
separate IRs to include Fig . 4.39 Mediolateral lower leg
both joints
• Nongrid
• Knee at cathode end (to utilize anode heel e ect)
Po sit io n
• Recumbent, a ected side down
• Place una ected limb behind patient to prevent overrotation
L
o
• Place support under distal portion of a ected foot as needed to
w
e
ensure a true lateral position of foot, ankle, and knee
r
L
• Ensure that both ankle and knee joints are 1–2″ (3–5 cm) from
i
m
b
ends of IR
Central Ray: CR ┴, to midsha of lower leg (to mid-IR)
SID: Minimum SID of 40″ (102 cm); may increase to 44–48″
(112–123 cm)
Collimation: On four sides to skin margins to include knee and ankle
joints

AP an d Lat e ral: Lo w e r Le g ( Tib ia-Fib ula)

• AP: Entire tibia- bula with ankle
and knee joints
• Lateral: Entire tibia- bula with
ankle and knee joints
Position
AP
4
• No rotation, with femoral and
tibial condyles in pro le
• Slight overlap at both proximal
and distal tibio bular joints
Lateral
• Tibial tuberosity in pro le
• Distal bula overlaps posterior
portion of tibia
b
m
Exposure
i
L
• Near equal density (brightness) Fig . 4.40 AP lower leg
r
e
(Courtesy J Sanderson, RT )
w
and contrast; no motion
o
L
Competency Check:
• So tissue and sharp Technologist Date
bony trabeculation
clearly
demonstrated
Fig . 4.41 Mediolateral lower leg

Competency Check:
Technologist Date
129
AP: Kn e e
• 24 × 30 cm
(10 × 12″)
portrait
• Grid >10 cm
4
• IR <10 cm
Po sit io n Fig . 4.42 AP knee (CR ┴, to lm for

• Supine, or seated average patient)
on table, with leg extended and centered to CR and midline of
table or IR
• Rotate leg slightly inward, as needed, to place knee and lower leg
into a true AP
• Center IR to CR
L
o
Central Ray: CR centered to 1 2 ″ (1 25 cm) distal to apex of patella
w
e
CR Parallel to Articular Facets (Tibial Plateau): Measure distance
r
L
from ASIS to tabletop (TT) to determine CR angle
i
m
• in thighs and buttocks (<19 cm ASIS to TT), 3°–5° caudad
b
• Average thighs and buttocks (19–24 cm), 0°, ┴ IR
• ick thighs and buttocks (>24 cm), 3°–5° cephalad
SID: 40″ (102 cm)
Collimation: Sides to skin margins; ends to IR borders

AP Ob liq ue —Me d ial an d Lat e ral Ro t at io n : Kn e e
Fig . 4.43 AP 45° medial Fig . 4.44 AP 45° lateral

oblique oblique
AP Medial Oblique: Demonstrates bular head and neck unobscured
4
(Lateral oblique may also be taken )
AP Lateral Oblique: Demonstrates medial condyles of the femur and
tibia in pro le
• 24 × 30 cm (10 × 12″) portrait
• Grid >10 cm
• IR <10 cm
Po sit io n
• Semisupine, leg extended and centered to CR and midline of table
b
• Rotate entire leg, including knee, ankle, and foot, internally 45° for
m
i
L
medial oblique, and 45° externally for external oblique
r
e
• Center IR to CR
w
Central Ray:
o
L
• CR ┴, to IR on average patient (see AP Knee)
• CR to midjoint space ( 1 2 ″ or 1 25 cm inferior to patella)
SID: 40″ (102 cm)
Collimation: Sides to skin margins; ends to IR borders

AP an d AP Ob liq ue —Me d ial an d Lat e ral: Kn e e
4
Fig . 4.45 AP knee Fig . 4.46 AP medial Fig . 4.47 AP lateral
(Courtesy Joss Wertz, DO ) oblique oblique (Courtesy
Competency Competency Joss Wertz, DO )
Check: Check: Competency
Technologist Date Technologist Date Check:
Technologist Date
L
o
w
• AP: Open femorotibial joint space
e
r
• AP Medial Oblique: Open proximal tibio bular joint; lateral
L
i
femoral and tibial condyles in pro le
m
b
• AP Lateral Oblique: Medial femoral and tibial condyles in pro le
Position
• AP: No rotation is evident by symmetric appearance of femoral
and tibial condyles Medial half of bular head is superimposed by
tibia Intercondylar eminence is seen
• AP Medial Oblique: Proximal tibio bular joint is open; tibial
lateral condyles are demonstrated Head and neck of bula and
half of patella are seen without superimposition
• AP Lateral Oblique: Proximal bula is superimposed by
proximal tibia Medial condyles of femur and tibia are in
pro le; Approximately half of patella should be seen free of
superimposition by the femur
Exposure
• Optimal density (brightness) and contrast; outline of patella
through distal femur; no motion
132
Lat e ral—Me d io lat e ral: Kn e e
• 24 × 30 cm (10 × 12″)
portrait
• Grid >10 cm
• IR <10 cm
4
Po sit io n
• Patient on a ected Fig . 4.48 Mediolateral knee, CR 5° cephalad
side, knee exed
≈20°–30°, centered to CR and midline of table or IR
• Una ected leg and knee placed behind to prevent overrotation
• Place support under a ected ankle and foot, if needed, and adjust
body rotation as required for a true lateral of knee
• Center IR to CR
b
m
Central Ray:
i
L
• CR 5°–7° cephalad (if lower leg can be elevated to plane of femur,
r
e
a perpendicular CR can be used)
w
o
• CR centered to ≈1” (2 5 cm) distal to medial epicondyle
L
SID: 40″ (102 cm)
Collimation: Sides to skin margins; ends to borders of IR

Lat e ral—Me d io lat e ral: Kn e e

L
• Distal femur, proximal
tibia and bula, and
patella in lateral pro le
• Patellofemoral and knee
joints open
Position
4
• True lateral with no
rotation; femoral
condyles superimposed
• Patella in pro le and
patellofemoral joint open
Fig . 4.49 Mediolateral knee
Competency Check:
Exposure Technologist Date
• Optimal density
L
(brightness) and contrast; no motion
o
w
• So tissue (fat pads) and sharp bony trabeculation clearly
e
r
demonstrated
L
i
m
b
134
AP o r PA We ig h t -Be arin g Bilat e ral: Kn e e
• 35 × 43 cm (14 × 17″) landscape

• Grid
4
Po sit io n
AP
• Erect, standing on step stool or
footboard as needed (high enough Fig . 4.50 AP weight-
to lower x-ray tube for horizontal bearing—bilateral,
beam) CR ┴ to IR
• Feet straight ahead, knees straight, weight distributed evenly on
both feet Have patient hold onto table handles for support
Alternative PA: Patient facing the table or IR holder, with knees
b
m
against table or vertical IR holder, knees exed ≈20°
i
L
Central Ray: CR to midpoint between knee joints, at level of ≈ 1 2 ″
r
e
(1 25 cm) distal to apex of patellae
w
o
AP: CR horizontal, ┴ to IR on average patient (see AP Knee)
L
PA: CR 10° caudad (if knees are exed ≈20°)
SID: 40″ (102 cm)
Collimation: To bilateral knee joint region including distal femurs
and proximal tibia and bula

PA Axial We ig h t -Be arin g Bilat e ral: Kn e e
Ro se n b e rg Me t h o d
45° X-ray
• 35 × 43 cm (14 × 17″) landscape be a m
Ima ge 10°
• Grid re ce ptor
4
40”
Fig . 4.51 PA axial weight-
bearing—CR 10° caudad
Po sit io n
• Patient erect PA
• Weight evenly distributed
• Knees exed to 45°
L
o
Central Ray: 10° caudad to midknee joints—
w
e
1 ″ (1 25 cm) below apex of patella
r
2
L
SID: 40″ (102 cm)
i
m
Collimation: Bilateral knee joint region,
b
including distal femora and proximal tibia
Fig . 4.52 Rosenberg

method

PA Axial We ig h t -Be arin g Bilat e ral: Kn e e
Ro se n b e rg Me t h o d
4
Fig . 4.53 PA axial weight-bearing knees—
Rosenberg method
Competency Check:
Technologist Date
b
m
i
• Distal femur, proximal tibia and bula, femorotibial joint spaces,
L
r
and intercondylar fossa
e
w
o
L
Position
• No rotation of both knees evident by symmetric appearance
• Articular facets in pro le
Exposure
• Sharp bony trabeculation clearly demonstrated
137
PA an d AP Axial ( “Tun n e l Vie w s”) :
In t e rco n d ylar Fo ssa
Cam p Co ve n t ry an d Ho lm b lad Me t h o d s
• 18 × 24 cm (8 × 10″) portrait
• Grid
4
Po sit io n : Fig . 4.54 PA axial projection
• Camp Coventry method: (Camp Coventry)
Prone, knee exed 40°–50°,
large support under ankle
• Holmblad method:
Kneeling on x-ray table or
partially standing
• Knee centered to CR
L
o
• IR centered to projected CR
w
Central Ray:
e
r
• Camp Coventry method:
L
i
m
CR 40°–50° caudad (┴ to
b
Fig . 4.55 Alternative Holmblad method:
lower leg), centered to knee – Patient kneeling, leans forward 20°–30°
joint, to emerge at distal – CR ┴ to IR
margin of patella
• Holmblad method: CR ┴ to lower leg to midpopliteal crease
SID: 40″ (102 cm)
Collimation: Four sides to area of interest

PA: Pat e lla
• 18 × 24 cm (8 × 10″)
portrait
• Grid
4
Po sit io n
• Prone, knee
Fig . 4.56 PA patella
centered to CR
and midline of table or IR
• If patella area is painful, place pad under thigh and leg to prevent
direct pressure on patella
• Rotate anterior knee approximately 5° internally or as needed to
place an imaginary line between the epicondyles parallel to the
plane of the IR
b
m
• Center IR to CR
i
L
Central Ray: CR ┴, centered to central patella region (at midpopliteal
r
e
crease)
w
o
SID: 40″ (102 cm)
L
Collimation: To area of patella and knee joint
kV Range: Analog: 75 ± 5 kV (Increase Digital System s:

4–6 kV from PA Knee) 75 ± 5 kV

Lat e ral—Me d io lat e ral: Pat e lla
• 18 × 24 cm (8 × 10″)
portrait
• Nongrid (detail
screens—may use
4
grid on large patient)
Fig . 4.57 Mediolateral patella

Po sit io n
• Recumbent on a ected side, opposite knee, and leg behind to
prevent overrotation
• Flex knee only 5°–10° to prevent separation of fractured
fragments, if present
• Patellofemoral joint area centered to CR and midline of IR
L
o
Central Ray: CR ┴, centered to midpatellofemoral joint
w
SID: 40″ (102 cm)
e
r
Collimation: To area of knee joint, patella, and patellofemoral joint
L
i
m
b

PA Axial: In t e rco n d ylar Fo ssa
PA an d Lat e ral: Pat e lla

• PA Axial: Intercondylar fossa,
femoral condyles, tibial plateaus, and
intercondylar eminence
• PA: Knee joint and patella outline
through distal femur
• Lateral: Patella, patellofemoral joint,
4
and femorotibial joint demonstrated in
pro le
Position
• PA Axial: No rotation evidenced by
symmetric distal femoral condyles and
intercondylar eminence centered
• PA: No rotation, femoral condyles
appear symmetric; patella appears
b
centered to femur
m
i
• Lateral: Patella in pro le and
L
Fig . 4.58 PA axial—
r
patellofemoral joint open intercondylar fossa projection
e
w
Exposure Competency
o
L
Check:
• Optimal density (brightness) and Technologist Date
contrast; no motion
• So tissue and sharp bony
trabeculation clearly demonstrated
Fig . 4.59 PA patella Fig . 4.60 Lateral patella

(Courtesy Joss Wertz, DO ) Competency
Competency Check:
Check: Technologist Date
Technologist Date
141
Tan g e n t ial—Axial: Pat e lla
Me rch an t Bilat e ral Me t h o d
• 18 × 24 cm (8 × 10″)
landscape or 35 ×
43 cm (14 × 17″)
landscape for large
4
knees
• Nongrid
• Adjustable leg and
IR-holding device Fig . 4.61 Bilateral tangential
required
Po sit io n
• Supine with knees exed 40° on leg supports (important for
patient to be comfortable with legs totally relaxed to prevent
L
patellae from being drawn into intercondylar sulcus)
o
w
• Place IR on supports against legs about 12″ (30 cm) distal to
e
r
patellae, perpendicular to CR
L
i
m
Central Ray:
b
• CR 30° caudad from horizontal (30° from long axis of femora)
• CR to midpoint between patellae
SID: 48–72″ (123–183 cm) greater SID reduces magni cation
Collimation: To bilateral patellae

Tan g e n t ial—Axial ( Pro n e ) : Pat e lla
Se t t e g ast an d Hug h st o n Met h o d s
L R
Generally taken bilaterally for comparison

purposes
• 24 × 30 cm (10 × 12″) landscape Fig . 4.62 Settegast:
• Nongrid – Knee exed 90°
4
• Lead masking with multiple exposures – CR 15°–20° to lower leg
on same IR
Po sit io n
• Settegast: Prone, knee exed 90°
• Hughston: Prone, knee exed
between 50° and 60° from full
extension
• Use long gauze or tape for patient
Fig . 4.63 Hughston:
b
to hold leg in position; for
m
– Knee exed 50°–60°
i
Hughston method, may support
L
– CR 45° cephalad
r
foot on supporting device (not
e
Warning: Possible hot
w
collimator)
o
collimator, use pad
L
Central Ray: CR centered to mid-
patellofemoral joint
Settegast: CR 15°–20° cephalad to long axis of leg (knee exed 90°)
Hughston: CR 45° cephalad to long axis of leg (knee exed 50°–60°)
SID: 40–48″ (102–123 cm)
Collimate: Closely to patella region

Sup e ro in fe rio r Sit t in g Tan g e n t ial: Pat e lla
R L
Generally taken bilaterally

on one IR for comparison
4
purposes
• 35 × 43 cm (14 × 17″)
landscape or 18 × 24 cm Fig . 4.64 Tangential superoinferior
(8 × 10″), landscape (Hobbs modi cation)
(unilateral)
• Nongrid
Po sit io n
• Patient seated
• Knees exed with feet placed under chair
L
o
• IR placed on footstool
w
e
Central Ray: Perpendicular to IR (tangential to patellofemoral joint)
r
L
centered to midway between patellofemoral joints
i
m
b
SID: 48–50″ (123–128 cm)
Collimation: Bilateral knee joint region, distal femora, and patella

Sup e ro in fe rio r Sit t in g Tan g e n t ial ( Bilat e ral) :
Pat e lla
Fig . 4.65 Superoinferior tangential sitting method
4
Competency Check:
Technologist Date

• Tangential view of patella
• Patellofemoral joint space open
b
m
Position
i
L
• Separation of patella and intercondylar sulcus
r
e
• Patellofemoral joint open
w
o
L
Exposure
145
AP: Lo w e r Lim b ( Pe d iat ric)
• Size determined by patient

size
• Nongrid (detail screen)
Note: If foot is speci c area
4
of interest, AP and lateral
projections of foot only may be
required Fig . 4.66 AP lower limb
Po sit io n —Sh ie ld Rad io se n sit ive Tissue s

• Supine, include entire limb, shield over pelvic area
• A second IR of pelvis and/or proximal femur may be required (see
Chapter 16 in the Bontrager textbook)
• Immobilize arms and una ected leg with sandbags
L
o
w
e
apron
r
L
Central Ray: CR ┴, centered to midlimb (mid-IR)
i
m
SID: 40″ (102 cm)
b

Lat e ral: Lo w e r Lim b ( Pe d iat ric)
• Size determined by patient size

• Nongrid (detail screen)
Note: If foot is speci c area of interest,
AP and lateral projections of foot only
4
may also be required Fig . 4.67 Lateral lower
limb (see Note)
Po sit io n —Sh ie ld Rad io se n sit ive Tissue s

• Semisupine, include entire limb, shield over pelvic area
• Immobilize arms and una ected leg with sandbags, as needed
• Abduct (frog leg) a ected limb into lateral position, immobilize
with tape or compression band (Do not attempt in patients with
hip trauma or hip disease)
b
m
• If parental assistance is necessary, provide lead gloves and apron
i
L
Central Ray: CR ┴, centered to midlimb (mid-IR)
r
e
SID: 40″ (102 cm)
w
o
L

AP an d Me d io lat e ral: Fo o t ( Pe d iat ric)
Co n g e n it al Club o o t —Kit e Me t h o d
Fig . 4.68 AP foot Fig . 4.69 Mediolateral foot
• 18 × 24 cm (8 × 10″) portrait
4
• Nongrid (detail screens)
Note: With Kite method, no attempt is made to straighten foot when placing
on IR e foot is held or immobilized for a frontal and side view (AP and
lateral projections) 90° from each other Both feet are generally imaged for
comparison
Po sit io n
• AP: Elevate patient on support, ex knee, foot on IR
• Lateral: Patient and/or leg on side, a ected side down, use tape or
compression band
L
o
w
Central Ray
e
r
• AP: CR ┴, to IR, directed to midtarsals (Kite recommends no
L
i
m
angle)
b
• Lateral: CR ┴, centered to proximal metatarsal area
SID: 40″ (102 cm)
Collimation: Closely on four sides to area of foot

Ch ap t e r 5
Fe m ur an d Pe lvic Gird le
• Radiation protection 150

• Localization methods for femoral head and neck 151
Fe m ur Axiolateral inferosuperior
AP (R) 152 (Danelius-Miller method)
Lateral (R) 153 critique 163
5
AP and lateral mid- and
distal femur 154 Pe lvis
Horizontal beam AP (R) 164
lateral (trauma) 155 AP critique 165
AP axial (inlet and
Pro xim al Fe m o ra (Hip s) outlet) (S) 166
AP bilateral (R) 156 AP axial (inlet and
AP unilateral (R) 157 outlet) critique 167
AP unilateral critique 158
e
Ace t ab ulum
l
d
r
Lat e ral Hip (No n t raum a) Posterior oblique
i
G
Unilateral frog-leg (Judet method) (S) 168
c
i
v
(modi ed Cleaves Posterior oblique
l
e
P
method) (R) 159 critique 169
d
n
AP bilateral frog-leg PA axial oblique
a
(modi ed Cleaves (Teufel method) (S) 170
r
u
m
method) (R) 160 PA axial oblique (Teufel
e
F
AP bilateral frog-leg method) critique 171
critique 161
Pe d iat ric Hip s an d Pe lvis
Lat e ral Hip (Traum a) AP and lateral (S) 172
Axiolateral inferosuperior
(Danelius-Miller
method) (R) 162
149
Accurate gonadal shielding

for pelvis and hip examina-
tions is especially critical
because of the proximity
of radiation-sensitive tissues
(proximal femurs, gonads,
noninvolved portions of the
pelvis) to the primary x-ray
beam But shielding must not Fig . 5.1 Male gonadal shielding
interfere with clinical intent
of radiographic study
5
Male Shielding: Gonadal
shields should be used on
pelvis and hip procedures
for all males Contact
shields should be placed
over the testes, with the
upper edge of the shield
placed at the inferior Fig . 5.2 Female ovarian shielding
margin of the symphysis (superior borders at or slightly
above level of ASISs and lower
F
pubis
e
m
border just above pubis)
Female Shielding: For AP
u
r
and “frog-leg” laterals of
a
n
the hips, specially shaped ovarian shields can be carefully placed
d
P
over the area of the ovaries without obscuring essential anatomy,
e
l
v
as shown is should be done on all females ese ovarian
i
c
shields, however, may obscure essential anatomy on certain pelvic
G
i
examinations Departmental policy regarding shielding and kV
r
d
l
range to be used should be determined
e
kV Range: A higher kV range (80 to 90 kV) with lower mAs may
be used for examinations of the hips and pelvis of adults to reduce
the total radiation dose to the patient
Close collimation to the area of interest is important for all proce-
dures, including the hips and pelvis, even with gonadal shields (See
Appendix A for further explanation )
150
Lo calizat io n Me t h o d s fo r
Fe m o ral He ad an d Ne ck
First Method: Location of the femoral head and neck regions can be
accurately determined by rst drawing an imaginary line between
two landmarks, the ASIS and the symphysis pubis. e midpoint
of this line is determined, from which a perpendicular imaginary
line is drawn to locate the head and/or neck e femoral head (A)
is approximately 1 5″ (4 cm) down on this line e midfemoral
neck (B) is approximately 2 5″ (6–7 cm) down, as shown in the
photo below
Second Method: A second method for locating the femoral neck (B)
is ≈1–2″ (2 5–5 cm) medial to the ASIS at the level of the proximal
or upper margin of the symphysis pubis, which is 3–4″ (8–10 cm)
distal to the ASIS
5
Me thod one : Me thod two:
He a d–1.5” 1–2”
(4 cm) (3–5 cm)
X X
Ne ck–2.5”
(6–7 cm)
3–4”
e
(8–10 cm)
l
d
H
r
i
N
G
N
c
i
v
l
A
e
P
d
n
a
r
u
m
×
e
(3–5 cm)
F
1–2"
×
(8–10 cm)
H 3–4"
N N
B
Fig . 5.3 A, Femoral head B, Femoral neck
151
AP: Fe m ur
• 35 × 43 cm (14 × 17″)
portrait
• Grid
• Hip at cathode end Fig . 5.4 AP mid- and distal femur
5
(anode heel e ect)
Note: For adults, a second smaller IR of either the hip or the knee should be
taken on trauma patients to demonstrate both knee and hip joints to rule out
possible fractures
Po sit io n
• Supine, femur centered to midline of table or grid IR
• Rotate entire lower limb internally ≈5° for AP of midfemur and
distal femur, and 15° internally for true AP to include hip
F
• Lower border of IR ≈5 cm (2″) below knee to include knee joint
e
m
adequately (see AP Unilateral Hip for proximal femur, p 153)
u
r
• Shield radiosensitive tissues for both male and female
a
n
Central Ray: CR to femur, to mid-IR
d
P
SID: 40″ (102 cm)
e
l
v
Collimation: Long, narrow collimation to femur area
i
c
G
i
r
d
l
e

Lat e ral: Fe m ur
Warning: Take horizontal beam

lateral if fracture is suspected Fig . 5.5 Mediolateral mid- and distal
• 35 × 43 cm (14 × 17″) portrait femur
• Grid
• Hip at cathode end (anode heel
5
e ect)
Note: For adults, take a second,
smaller IR of lateral hip or lateral
knee if both joints are areas of
interest
Po sit io n
• Lateral recumbent, with
una ected leg placed behind
Fig . 5.6 Mediolateral mid- and
to prevent over-rotation
e
l
proximal femur
d
• Include su cient amount of
r
i
G
either knee or hip at one end of IR
c
• Flex a ected knee ≈45°, and align femur to midline of table i
v
l
• Shield radiosensitive tissues when possible
e
P
Central Ray: CR femur, to mid-IR
d
n
SID: 40″ (102 cm)
a
Collimation: Long, narrow collimation to femur area
r
u
m
e
F

AP an d Lat e ral: Mid - an d Dist al Fe m ur
5
L
L
Fig . 5.7 AP Fig . 5.8 Lateral

F
e
m
u
r
a
n
d
P
• AP and Lateral: Distal of femur, including knee joint
e
2
l
3
v
i
c
G
Position
i
r
d
• AP: No rotation, femoral and tibial condyles appear symmetric in
l
e
size and shape
• Lateral: True lateral, femoral condyles appear superimposed
Exposure
AP and Lateral
• Fine trabecular markings; no motion
154
Ho rizo n t al Be am Lat e ral:
Mid - an d Dist al Fe m ur ( Traum a)
• 35 × 43 cm (14 ×
17″) portrait (to long
axis of femur)
• Portable grid
Note: For proximal
5
femur injuries, perform Fig . 5.9 Horizontal beam trauma
axiolateral (Danelius- projection (mid- and distal femur)
Miller method) hip
Po sit io n
• Without moving trauma patient from the supine position, gently
li injured leg, and place support under knee and leg
• Place vertical IR between legs, as far superiorly as possible, but
include knee distally Use tape to hold grid IR in position
e
l
• Shield radiosensitive tissues for both male and female
d
r
i
G
Central Ray: CR horizontal beam, to femur to midpoint of IR
c
SID: 40″ (102 cm) i
v
l
Collimation: Closely to four sides to area of interest
e
P
d
n
a
r
u
m
e
F

AP Bilat e ral: Pro xim al Fe m o ra ( Hip s)

to rotate leg if fracture is
suspected Perform “as is”
bilateral hips for compari-
son purposes Fig . 5.10 AP bilateral hips
Note: For AP pelvis centering, see p 273 in Bontrager textbook
5
• 35 × 43 cm (14 × 17″) landscape
• Grid
Po sit io n
• Supine, aligned and centered to CR and IR, both legs extended
and equally rotated internally 15°–20° (see Warning above)
• Ensure no rotation of pelvis (bilateral ASISs the same distances
from tabletop) Support under knees for patient comfort
• Center IR to CR Shield radiosensitive tissues (males and females)
F
e
Central Ray: CR , to midpoint between femoral heads (which is
m
u
about 2 cm or 1″ superior to symphysis pubis)
r
a
SID: 40″ (102 cm)
n
d
Collimation: To pelvic and hip borders
P
e
l
v
i
c
G
i
r
d
l
e

AP Un ilat e ral: Pro xim al Fe m ur ( Hip )
Warning: For possible

fractured hip, perform AP
bilateral hips (preceding
page) for comparison
purposes
• 24 × 30 cm (10 × 12″)
portrait Fig . 5.11 AP hip—CR to femoral neck
5
• Grid
Po sit io n
• Supine, leg extended and rotated internally 15°–20° (nontrauma)
• Center femoral neck to CR; support may be placed under knees
for patient comfort
• Center IR to CR; shield radiosensitive tissues (males and females)
Central Ray: CR IR, directed to 1–2″ (2 5–5 cm) distal to mid-
femoral neck (to include all of orthopedic appliance of hip, if present)
e
l
SID: 40″ (102 cm)
d
r
i
G
c
Respiration: Suspend during exposure i
v
l
e
P
d
n
a
r
u
m
e
F

AP Un ilat e ral: Pro xim al Fe m ur ( Hip )

• Proximal 1 3 of femur and
adjacent parts of pelvic
girdle
• Orthopedic appliance in
entirety
Position
• Greater trochanter, femoral
head and neck in pro le
5
• Lesser trochanter not visible
or minimally only
Exposure
and contrast
• Sharp trabecular markings
motion
F
e
m
u
r
Fig . 5.12 AP hip (Copyright Getty
a
n
Images/DieterMeyrl )
d
P
Competency Check:
e
Technologist Date
l
v
i
c
G
i
r
d
l
e
158
Un ilat e ral Fro g -Le g : Lat e ral Hip ( No n t raum a)
Mo d if e d Cle ave s Me t h o d
Warning: Do not attempt with

possible fracture of hip area
• 24 × 30 cm (10 × 12″)
landscape
• Grid
Fig . 5.13 Right hip frog-leg lateral
Po sit io n (for femoral neck)
• Patient supine
5
• For femoral neck, ex a ected knee and
hip, and abduct femur 45° from vertical*
• For femoral head, acetabulum, and
proximal femoral sha , oblique patient
35°–45° toward a ected side and abduct
leg to tabletop, if possible Center hip and Fig . 5.14 For femoral
neck area to CR head and acetabulum and
• Center IR to CR Shield radiosensitive proximal femoral sha
tissues (male and female)
e
Central Ray: CR , to midfemoral neck (see localization methods
l
d
on p 151)
r
i
G
SID: 40″ (102 cm)
c
i
Collimation: To proximal femur and hip v
l
e
P
d
n
*Less abduction of femora of only 20°–30° from vertical provides for the least
a
r
foreshortening of femoral neck
u
m
e
F

AP Bilat e ral Fro g -Le g : Hip s ( No n t raum a)
Mo d if e d Cle ave s Me t h o d
Warning: Do not
attempt with possible
fracture of hip areas
• 35 × 43 cm (14 ×
17″) landscape
5
• Grid
Fig . 5.15 Bilateral frog-leg (for comparison)
Po sit io n
• Supine, centered to CR and IR, ex hips and knees and abduct
both femora equally 40°–45° from vertical,* if possible, with
plantar surfaces of feet together
• Ensure no rotation of pelvis (ASISs equal distance from table)
• Center IR to CR, shield radiosensitive tissues (male and female)
Central Ray: CR to IR, to level of femoral heads (≈7–8 cm or 3″
F
e
m
inferior to level of ASISs)
u
SID: 40″ (102 cm)
r
a
Collimation: On four sides to anatomy of interest
n
d
P
e
l
*Less abduction of femora of only 20°–30° from vertical provides for the least
v
i
c
foreshortening of femoral neck
G
i
r
d
l
e

AP Bilat e ral Fro g -Le g : Hip s ( No n t raum a)
Evaluat io n R
Crit e ria
Anatomy
Demonstrated
• Femoral heads
and necks,
acetabulum,
and
trochanteric
anatomy
Position Fig . 5.16 AP bilateral frog-leg
5
• No rotation Competency Check:
Technologist Date
evident by
symmetry of
pelvic bones
• Lesser trochanters equal in size
• Minimal distortion of femoral neck
• Greater trochanters superimposed over femoral necks
e
Exposure
l
d
r
i
G
• Sharp trabecular markings clearly demonstrated; no motion
c
i
v
l
e
P
d
n
a
r
u
m
e
F
161
Ax io lat e ral In fe ro sup e rio r: Lat e ral Hip ( Traum a)
Dan e lius-Mille r Me t h o d
Warning: Do not
attempt to rotate leg
internally on initial
trauma examination
• 24 × 30 cm
(10 × 12″) landscape
(lengthwise to long
5
axis of femur)
Fig . 5.17 Axiolateral trauma hip (pad
• Portable grid
under foot)
Po sit io n
• Supine, no rotation of pelvis
• Flex and elevate una ected knee and hip and provide support
• Rotate a ected leg internally 15° unless contraindicated by
possible hip fracture
• Place vertical grid IR against side just superior to iliac crest with
F
plane of IR perpendicular to CR
e
m
Central Ray: CR horizontal, perpendicular to femoral neck area
u
r
and IR (see “hip localization methods” in chapter introduction)
a
n
SID: 40″ (102 cm)
d
Collimation: On four sides to proximal femur area
P
e
l
v
i
c
G
i
r
d
l
e

Ax io lat e ral In fe ro sup e rio r: Lat e ral Hip ( Traum a)
Dan e lius-Mille r Me t h o d
Fig . 5.18 Axiolateral hip (Courtesy Ferlic Filters,

White Bear Lake, Minnesota )
Competency Check:
5
Technologist Date

• Entire femoral head and neck, trochanters, and acetabulum
• Orthopedic appliance in entirety
Position
• Femoral head, neck, and acetabulum demonstrated with little
e
l
d
superimposition of opposite hip
r
i
G
• No grid lines visible on radiograph
c
• Minimal distortion of femoral neck i
v
l
e
P
Exposure
d
n
a
r
• Sharp trabecular markings clearly seen; no motion
u
m
e
F
163
AP: Pe lvis
To include proximal
femora, pelvic girdle,
sacrum, and coccyx
to rotate legs if fractures Fig . 5.19 AP pelvis (entire pelvis
involving hips are suspected centered to IR)
5
Note: For bilateral hips
centering, see p 156
• 35 × 43 cm (14 × 17″) landscape
• Grid
Po sit io n
• Supine, pelvis centered to centerline, legs extended
• Both feet, knees, and legs equally rotated internally 15°–20°
(secure with tape, if necessary) Support under knees for comfort
• Ensure no rotation of pelvis (ASISs equal distance from TT)
F
• Center IR to CR (include entire pelvis) Shield radiosensitive
e
m
tissues (if it does not compromise study)
u
r
Central Ray: CR , midway between ASISs and symphysis pubis
a
n
(approximately 5 cm or 2″ distal to level of ASISs)
d
SID: 40″ (102 cm)
P
e
Collimation: On four sides to include entire pelvis
l
v
i
c
G
i
r
d
l
e

AP: Pe lvis
Evaluat io n R
Crit e ria
Anatomy
Demonstrated
• Pelvic girdle,
L5, sacrum,
coccyx, and
proximal
femora
• Orthopedic
appliance in
entirety (if
5
present)
Fig . 5.20 AP pelvis
Position Competency Check:
• Lesser Technologist Date
trochanters
generally not visible (nontrauma)
• No rotation evident by symmetry of ilia and obturator foramina
e
Exposure
l
d
r
• Optimal density (brightness) and contrast visualizing L5 and
i
G
sacrum and margins of femoral heads and acetabula
c
i
v
• So tissue and sharp trabecular markings clearly demonstrated; no l
e
P
motion
d
n
a
r
u
m
e
F
165
AP Axial ( In le t an d Out le t ) : Pe lvis
• 35 × 43 cm
(14 × 17″) CR “inle t” CR
landscape “outle t”
• Grid
Fig . 5.21 AP
Po sit io n axial pelvis
Fig . 5.22 CR Fig . 5.23 CR
• Supine, 40° caudal for cephalad 20°–35° for
patient
5
inlet. males and 30°–45°
centered to for females—outlet.
centerline
• No rotation of pelvis (ASISs the same distance from tabletop)
• Center IR to projected CR Gonadal shielding may not be possible
without obscuring essential anatomy
Central Ray:
• Inlet: CR 40° caudal to level of ASISs, male and female
• Outlet (Taylor method): CR: male, 20°–35° cephalad; female,
F
30°–45° cephalad centered 1–2″ (2 5–5 cm) inferior to symphysis
e
m
pubis or greater trochanters
u
r
SID: 40″ (102 cm)
a
n
d
P
e
l
v
i
c
G
i
r
d
l
e
166 Bontrager Textbook, 9th ed, pp 281–282

AP Axial ( In le t an d Out le t ) : Pe lvis

• Inlet: Pelvic ring or inlet
in its entirety
• Outlet: Superior/inferior
rami of pubis and ramus
of ischium
Position
• Inlet: Ischial spines are
demonstrated and equal
in size; pelvic ring; no
5
rotation Fig . 5.24 AP axial inlet projection
Competency Check:
• Outlet: Obturator Technologist Date
foramina
are equal in
size; anterior/
inferior pelvic
bones; no
rotation
e
l
d
r
Exposure
i
G
• Optimal
c
i
v
density l
e
R
P
(brightness) MM
d
and contrast; S UP INE
n
a
no motion Fig . 5.25 AP axial outlet projection (Image
r
u
• Body and courtesy Joss Wertz, DO )
m
e
superior Competency Check:
F
Technologist Date
rami of pubis
demonstrated
• Superimposed anterior and posterior portions of pelvic ring
• Bony margins and trabecular markings appear sharp
167
Po st e rio r Ob liq ue : Ace t ab ulum
Jud e t Me t h o d
Note: Both sides are

generally imaged for
comparison, either
both for upside or
both for downside
• 24 × 30 cm Fig . 5.26 Downside Fig . 5.27 Upside
(10 × 12″) acetabulum acetabulum
5
portrait or
35 × 43 cm (14 × 17″) landscape (if both
hips must be seen on each projection)
• Grid
Po sit io n
• Patient in 45° posterior oblique position, centered for either
upside or downside hip joint (dependent on anatomy of interest)
• Place 45° support under elevated side, position arms and legs as
shown to maintain this position
F
e
Central Ray:
m
u
• Downside: CR to 2″ (5 cm) distal and 2″ (5 cm) medial to
r
downside ASIS
a
n
d
• Upside: CR to 2″ (5 cm) distal to upside ASIS
P
SID: 40″ (102 cm)
e
l
v
i
c
G
i
r
d
l
e

Po st e rio r Ob liq ue : Ace t ab ulum
Jud e t Me t h o d

R
• Downside: Anterior rim
of acetabulum, posterior
ilioischial column and iliac
wing demonstrated
• Upside: Posterior rim
of acetabulum, anterior
iliopubic column and
obturator foramen
5
demonstrated
Position
• Downside: Iliac wing
elongated and obturator
foramen closed Fig . 5.28 RPO—downside visualized
Competency Check:
• Upside: Iliac wing Technologist Date
foreshortened and obturator
foramen open
e
l
d
R
r
i
Exposure
G
c
• Optimal density (brightness) i
v
l
and contrast
e
P
• Bony margins and trabecular
d
n
markings are sharp; no
a
r
motion
u
m
e
F
Fig . 5.29 LPO—upside visualized
Competency Check:
Technologist Date
169
PA Axial Ob liq ue : Ace t ab ulum
Te u e l Met h o d
12
L
Both sides are generally

imaged for comparison
• 24 × 30 cm (10 × 12″)
portrait
• Grid
5
Fig . 5.30 PA axial oblique
Po sit io n
• Patient semiprone; a ected side down
• Rotate body 35°–40° anterior oblique
Central Ray:
• CR 12° cephalad
• When anatomy of interest is downside, direct CR at 1″ (2 5 cm)
superior to level of greater trochanter; ≈2″ (5 cm) lateral to the
midsagittal plane
F
SID: 40″ (102 cm)
e
m
Collimation: Region of acetabulum and proximal femur
u
r
a
n
d
P
e
l
v
i
c
G
i
r
d
l
e

PA Axial Ob liq ue : Ace t ab ulum
Te u e l Met h o d

Anatomy
Demonstrated
• Superoposterior wall
of the acetabulum
Position
• Fovea capitis with
the femoral head in
pro le
5
• Obturator foramen
open
Exposure
• Optimal density
(brightness) and
contrast; no motion
• Bony margins and L
sharp trabecular
e
l
markings clearly Fig . 5.31 PA axial oblique
d
r
i
seen
G
Competency Check:
Technologist Date
c
i
v
l
e
P
d
n
a
r
u
m
e
F
171
AP an d Lat e ral: Hip s an d Pe lvis ( Pe d iat ric)

frog-leg lateral with pos-
sible hip pathology unless
so indicated by a physician
a er review of AP pelvis
radiograph
• Size determined
by patient size; IR
5
landscape
• Grid >10 cm Fig . 5.32 Frog-leg lateral hips
Po sit io n (AP an d Lat e ral)

• Supine, pelvis centered to CR and to IR; use gonadal shields on
both male and female (Use ovarian shield of appropriate size for
female, ensuring that it does not cover hip areas)
• Immobilize arms and upper body with sandbags, tape, or
compression band, as needed
F
AP: Extend legs, and internally rotate 15°
e
m
Frog-Leg Lateral: Flex knees and hips, place soles of feet together and
u
r
abduct both legs, and secure with tape and sandbags
a
n
Central Ray: CR , centered to level of hips
d
SID: 40″ (102 cm)
P
e
l
Collimation: To pelvic margins
v
i
c
Respiration: Full inspiration if crying
G
i
r
d
l
e

Ch ap t e r 6
Ve rt e b ral Co lum n
• Intervertebral foramina and zygapophyseal joints 175

• Topographic landmarks 175
Ce rvical Sp in e Th o racic Sp in e
AP “open mouth” AP (R) 188
C1-C2 (atlas and axis) Lateral (R) 189
(R) 176 AP and lateral
AP (PA) for dens critique 190
(Fuchs and Judd Oblique (S) 191
6
methods) (S) 177
AP “open mouth” and AP Lum b ar Sp in e
(PA) dens critique 178 AP (PA) (R) 192
AP axial (R) 179 AP (PA) critique 193
Oblique (R) 180 Lateral (R) 194
AP axial and oblique Lateral L5-S1 (R) 195
critique 181 Lateral and lateral
Lateral (erect) (R) 182 L5-S1 critique 196
Cervicothoracic Oblique (R) 197
n
(swimmer’s) Oblique critique 198 m
u
lateral (R) 183 PA: scoliosis series
l
o
C
Lateral (erect) and (Ferguson method)
l
a
cervicothoracic (swimmer’s) (S) 199
r
b
lateral critique 184 AP (right and le
e
t
r
Lateral (hyper exion bending) (S) 200
e
V
and hyperextension) Lateral (hyper exion
(S) 185 and hyperextension)
Lateral (hyper exion (S) 201
and hyperextension) Lateral (hyper exion
critique 186 and hyperextension)
Trauma series: critique 202
horizontal beam lateral,
AP, AP axial oblique, Sacrum an d Co ccyx
and cervicothoracic AP axial, sacrum (R) 203
lateral (S) 187 AP axial, coccyx (R) 204
173
AP axial, sacrum and Sacro iliac (SI) Jo in t
coccyx critique 205 AP axial (R) 209
Lateral, sacrum and Posterior oblique
coccyx (R) 206 (R) 210
Lateral, coccyx (R) 207 Posterior oblique
Lateral, sacrum and critique 211
coccyx critique 208

6
V
e
r
t
e
b
r
a
l
C
o
l
u
m
n
174
In t e rve rt e b ral Fo ram in a an d
Zyg ap o p h yse al Jo in t s
Certain lateral and oblique projections best demonstrate these impor-
tant foramina and joints of the spine as follows:
Zygapophyseal Joints Intervertebral Foramina
Cervical spine Lateral position 45° anterior oblique
(side closest to IR)
oracic spine 70° anterior oblique Lateral position
Lumbar spine 45° posterior oblique Lateral position
To p o g rap h ic Lan d m arks

Ve rte bra
promine ns
1.5″
T1 1
Jugula r
6
2
notch 3 A
1 EAM 4 Ma nubrium
2 S te rna l B
Ma s toid tip 3 4 5
a ngle 6 Body 2″
5
Ve rte bra 6 Gonion Mid thora x 7 C
7
(mid lung 8 3–4″
promine ns Thyroid Xiphoid proce s s
fie ld) 9
ca rtila ge 10 D
11
12
Fig . 6.1 Cervical spine Fig . 6.2 Sternum and thoracic spine
n
m
landmarks landmarks u
l
o
C
l
a
r
b
E. Xiphoid tip
e
(T9-T10)
t
r
e
V
1 1
2 D. Lowe r cos ta l
ma rgin (L2-L3) 2
3 3
4 C. Ilia c cre s t 4
5 (L4-L5) 5
B. AS IS
(S 1-S 2)
A. S ymphys is
pubis
Fig . 6.3 Lower spine landmarks

175
AP “Op e n Mo ut h ” C1 -C2 : Ce rvical Sp in e
At las an d Axis
CR
Warning: For trauma pa-

tients, do not remove cervi-
cal collar and do not move
their head or neck until au-
thorized by a physician who
has evaluated the horizontal
beam lateral image or CT
scan of the cervical spine Fig . 6.4 AP open mouth for C1-C2
• 18 × 24 cm (8 × 10″)
portrait
• Grid
6
• AEC not recommended because of small eld
Po sit io n
• Supine or erect, patient centered to CR and centerline
• Adjust patient’s head without opening his or her mouth—a line from
lower margin of upper incisors to the base of the skull (mastoid tips)
is perpendicular to table and/or IR, or angle the CR accordingly
• Center IR to CR
• As a last step before making exposure—have patient open mouth wide
without moving head (make nal check for head alignment)
V
Central Ray: CR to IR through midportion of open mouth (to C1-C2)
e
r
t
SID: 40″ (102 cm)
e
b
Collimation: Close collimation to C1-C2 region
r
a
l
C
o
l
u
m
n

AP ( PA) fo r De n s: Ce rvical Sp in e
AP (Fuch s Me t h o d ) an d PA (Jud d Me t h o d )
R
Warning: Do not attempt on

possible cervical trauma
• 18 × 24 cm (8 × 10″) landscape
• Grid
• AEC not recommended
Po sit io n
• Supine or erect, MSP Fig . 6.5 AP Fuchs for dens (within
aligned to centerline, no foramen magnum outline)
rotation
• Elevate chin until MML is
near to IR (may require
6
some cephalic CR angle
if chin cannot be elevated
su ciently)
Note: May also be taken PA
(Judd method) with chin
against tabletop, with same
CR alignment
• Center IR to exiting CR
Fig . 6.6 PA Judd method
Central Ray: CR parallel to
MML; 1″ (2 5 cm) inferoposterior to mastoid tips and angles of mandible
n
m
SID: 40″ (102 cm) u
Collimation: Close collimation to C1-C2 region
l
o
C
l
a
r
b
e
t
r
e
V

AP “Op e n Mo ut h ” an d AP ( PA) De n s

Anatomy
Demonstrated
• Open mouth: Dens
(odontoid process)
and vertebral body of
C2, lateral masses and
transverse processes
of C1, and C1-C2
atlantoaxial joints L
• AP Fuchs: Dens
Fig . 6.7 AP open mouth—dens
(odontoid process)
Competency Check:
within foramen Technologist Date
magnum
6
Position
• Open mouth:
Upper incisors and
base of the skull
superimposed
Entire dens
demonstrated
within foramen
V
e
magnum L
r
t
e
• AP Fuchs: Tip
b
Fig . 6.8 AP (AP Fuchs—dens)
r
of mandible not
a
l
Competency Check:
C
superimposed over Technologist Date
o
l
dens Symmetric
u
m
appearance of mandible
n
Exposure
• So tissue margins, bony margins and trabecular markings Sharp
outline of dens; no motion
178
AP Ax ial: Ce rvical Sp in e
• 18 × 24 cm (8 × 10″) or 24 × 30 cm
(10 × 12″) portrait
• Grid
Po sit io n
• Supine or erect, center midsagittal
plane to CR (and to centerline of IR)
Fig . 6.9 Erect AP (CR
• Raise patient’s chin slightly, as needed, 15°–20° cephalad)
so the CR angle superimposes the
mentum of the mandible over the base
6
of the skull (to prevent mandible from
superimposing more than C1-C2)
• Center IR to projected CR
Central Ray: CR 15°–20° cephalad, to
enter at C4 (inferior margin of thyroid 15° CR
cartilage)
SID: 40″ (102 cm)
Collimation: On four sides to anatomy
of interest Fig . 6.10 Supine AP
n
Respiration: Suspend during exposure (CR 15°–20° cephalad) m
u
l
o
C
l
a
r
b
e
t
r
e
V
Bontrager Textbook, 9th ed, p 311

179
Ob liq ue : Ce rvical Sp in e
Warning: Do not at-

tempt if there is pos-
sible cervical trauma
Right and le
obliques imaged for
comparison (as either
posterior or anterior
obliques); anterior
Fig . 6.11 LPO; Fig . 6.12 RAO;
obliques result in
less thyroid dose CR 15° cephalad CR 15° caudad
• 24 × 30 cm (10 × 12″) portrait
• Grid (optional for small patient or pediatrics)
6
Po sit io n
• Erect preferred (sitting or standing), entire torso and head turned
45° to IR, C spine aligned to CR (and centerline of IR)
• Have patient raise chin slightly, looking straight ahead (turn head
slightly toward IR to prevent superimposing C1 by ramus of
mandible)
Central Ray (Posterior Obliques): CR 15°–20° cephalad, to enter at
V
C4 15°–20° caudad angle required for anterior oblique
e
r
SID: 40–72″ (102–183 cm)—Longer SID recommended
t
e
b
Collimation: To C spine region
r
a
l
C
o
l
u
m
n

AP Axial an d Ob liq ue : Ce rvical Sp in e
6
Fig . 6.13 AP axial Fig . 6.14 RPO

Anatomy Demonstrated n
m
• AP axial: C3–T2 vertebral bodies and intervertebral joints
u
l
o
• Oblique: Intervertebral foramina open and pedicles
C
• LPO/RPO projections: Demonstrate upside (farthest from IR)
l
a
r
intervertebral foramina and pedicles
b
e
• LAO/RAO projections: Demonstrate downside (closest to IR)
t
r
e
V
intervertebral foramina and pedicles
Position
• AP axial: Intervertebral joints open and spinous processes
equidistant to midline
• Oblique: 45° (AP or PA): Intervertebral foramina uniformly open
and pedicles in pro le
Exposure
• So tissue and bony margins and trabecular markings sharp
181
Lat e ral ( Ere ct ) : Ce rvical Sp in e
Trauma patients: See

Trauma Series: Cervical
Spine
• 24 × 30 cm (10 × 12″)
portrait
• Grid (optional for small or Fig . 6.15 Erect lateral, 72″
pediatric patients) (183 cm) SID
Po sit io n
• Erect (sitting or standing) in lateral position, C spine aligned and
6
centered to CR (and centerline of IR)
• Top of IR ≈1–2″ (3–5 cm) above level of EAM
• Elevate patient’s chin slightly (to remove mandible angles from
spine)
• Relax and depress both shoulders evenly (weights in each hand
may be necessary to visualize C7)
Note: See following page for swimmer’s lateral if C7 is still not
visualized
Central Ray: CR IR to level of C4 (upper thyroid cartilage)
V
e
SID: 60–72″ (153–183 cm) (Longer SID provides for better visualiza-
r
t
e
tion of C7 because of less divergent rays)
b
r
Collimation: On four sides to C spine region
a
l
C
Respiration: Expose on complete expiration
o
l
u
m
n

Ce rvico t h o racic ( Sw im m e r’s) Lat e ral:
Ce rvical Sp in e
C5-T3 Re g io n
• 24 × 30 cm (10 × 12″)
portrait
• Grid
Po sit io n
Fig . 6.16 Cervicothoracic (swimmer’s)
• Erect (sitting or standing)
lateral
preferred; align C spine
to CR (and centerline of IR)
• Elevate arm and shoulder closest to IR, and rotate this shoulder
6
slightly anteriorly or posteriorly
• Opposite arm down, relax and depress shoulder, with slight
opposite rotation (from other shoulder) to separate humeral heads
from vertebra May also be taken in lateral recumbent position
with one arm and shoulder down and one up (trauma alternative)
Central Ray: CR centered to T1 (approximately 1″ [2 5 cm] above
level of jugular notch); optional 3°–5° caudad to separate the two
shoulders for patient with limited exibility
n
SID: 60–72″ (153–183 cm) m
u
Collimation: Collimate closely to area of interest
l
o
Respiration: Expose on full expiration or orthostatic (breathing)
C
l
technique
a
r
b
e
t
r
e
V

Lat e ral ( Ere ct ) an d Ce rvico t h o racic
( Sw im m e r’s) Lat e ral: Ce rvical Sp in e
6
Fig . 6.17 Erect lateral Fig . 6.18 Cervicothoracic
Competency Check: (swimmer’s) lateral
Technologist Date Competency Check:
Technologist Date
V
e
r
• Lateral: C1-C7 (minimum) intervertebral joint spaces and
t
e
b
vertebral bodies demonstrated
r
a
l
• Cervicothoracic: Vertebral bodies and intervertebral disk spaces
C
o
from C5-T3 (minimum) demonstrated
l
u
m
n
Position
• Lateral: Near superimposition of zygapophyseal joints; no
superimposition of mandible on C spine
• Cervicothoracic: Separation of humeral heads from C spine;
vertebral bodies in lateral perspective
Exposure
• Optimal density (brightness) and contrast of lower cervical and
upper thoracic spine; no motion
• So tissue margins and bony anatomy visible
184
Lat e ral ( Hyp e r e xio n an d Hyp e re xt e n sio n ) :
Ce rvical Sp in e
Warning: Functional study Do not

attempt on possible trauma patients
• 24 × 30 cm (10 × 12″) portrait
• Grid or nongrid Fig . 6.19 Hyper exion
Po sit io n
• Erect preferred (sitting or
standing) in true lateral
6
position, C spine aligned to CR
(and centerline of IR)
• Relax and depress shoulders as
much as possible
First IR: Depress chin to touch
Fig . 6.20 Hyperextension
chest, if possible
Second IR: Elevate chin as far as is comfortable (entire C spine is
included on both projections)
Central Ray: CR to C4 (level of upper margin of thyroid cartilage)
n
m
SID: 60–72″ (153–183 cm)
u
l
Collimation: To C spine area
o
C
Respiration: Expose on full expiration
l
a
r
b
e
t
r
e
V

Ce rvical Sp in e
6
Fig . 6.21 Hyper exion lateral Fig . 6.22 Hyperextension lateral
V
e
r
t
e
b
r
a
l
C
• C1-C7: Range of motion and ligament stability demonstrated
o
l
u
m
Position
n
• Hyperf exion: Spinous processes well separated
• Hyperextension: Spinous processes in close proximity
Exposure
• So tissue margins visible and trabecular markings sharp
186
Traum a Se rie s: Ce rvical Sp in e
Warning: Do not remove cervical

collar unless so indicated by the physi-
cian a er viewing horizontal beam
lateral
Ho rizo n t al Be am Lat e ral

• 24 × 30 cm (10 × 12″) portrait
• Grid or nongrid
• SID: 60–72″ (153–183 cm) Fig . 6.23 Horizontal beam
• CR to C4 (upper thyroid lateral
cartilage) (top of IR ≈3–5 cm or
1–2″ above EAM)
AP
• Depress shoulders
6
• 24 × 30 cm (10 × 12″) portrait
• Grid
• SID: 40–48″ (102–123 cm)
• CR: 15°–20° cephalad, to enter at
C4 Fig . 6.24 AP axial
• Expose upon full expiration
AP Axial Ob liq ue
• 24 × 30 cm (10 × 12″) portrait
• Grid n
m
• SID: 40–48″ (102–123 cm)
u
l
• CR: 45° medially (and 15° cephalad
o
C
if nongrid)
l
a
• CR to enter at level of C4
r
b
e
Fig . 6.25 Oblique (both R
t
r
Ce rvico t h o racic Lat e ral and L obliques)
e
V
(Optional projection if needed to
visualize C7)
• 24 × 30 cm (10 × 12″) portrait
• Grid
• Elevate shoulder and arm nearest
IR Depress opposite shoulder
• SID: 40–48″ (102–123 cm)
• CR: IR centered to T1
(approximately 1 5″ [2 5 cm] above
level of jugular notch) Fig . 6.26 Cervicothoracic lateral

AP: Th o racic Sp in e
• 35 × 43 cm (14 × 17″)
portrait Fig . 6.27 AP thoracic spine
• Grid
• Lower thoracolumbar spine at cathode end (anode heel e ect)
• Wedge compensation lter recommended to produce uniform density of
spine recommended
6
Po sit io n
• Supine, spine aligned and centered to midline of table and/or IR;
ex hips and knees to reduce lordotic curvature
• Ensure top of IR is at least 1½″ (3 cm) above shoulder
• Ensure no rotation of thorax or pelvis; shield radiosensitive tissues
Central Ray: CR to center of IR (at level of T7 [as for an AP chest],
3–4″ or 8–10 cm below jugular notch)
SID: 40″ (102 cm)
Collimation: Long narrow collimation eld to T spine region
V
e
Respiration: Expose on expiration for more uniform density
r
t
e
b
r
a
l
C
o
l
u
m
n

Lat e ral: Th o racic Sp in e
• 35 × 43 cm (14 × 17″) portrait

• Grid
• Lead mat placed on table Fig . 6.28 Lateral thoracic spine
posterior to patient to reduce scatter
• Do not use AEC if orthostatic breathing technique is used
Po sit io n
• Recumbent, support under head, lateral with knees exed, arms
6
raised, and elbows exed Shield radiosensitive tissues
• Align and center midaxillary plane to midline of table and/or IR
• Ensure top of IR is at least 1½″ (3 cm) above shoulders; no rotation
• Supports should be placed under lower back, as needed, to
straighten and align spine near parallel to tabletop (A slight
natural curvature corresponding to divergent rays is helpful)
Central Ray: CR to center of IR T7 (3–4″ [8–10 cm] below jugular
notch or 7–8″ [18–21 cm] below the vertebra prominens) A patient
with broad shoulders may require a 10°–15° cephalic CR angle if waist
is not supported n
m
SID: 40″ (102 cm)
u
l
Collimation: Long, narrow collimation eld to T spine region
o
C
Respiration: Orthostatic (breathing) technique recommended—
l
a
minimum of 2–3 seconds; or expose on full inspiration
r
b
e
t
r
e
V

AP an d Lat e ral: Th o racic Sp in e
6
Fig . 6.29 AP thoracic spine Fig . 6.30 Lateral thoracic spine
Competency Check: (suspended respiration)
Technologist Date

V
e
r
t
e
b
• AP and lateral: 12 thoracic bodies, intervertebral joint spaces, and
r
a
spinous and transverse processes
l
C
o
l
u
Position
m
n
• AP: SC joints equidistant from midline, no rotation
• Lateral: Intervertebral disk spaces open
Exposure
• Optimal density (brightness) and contrast; no motion on AP
projection Breathing technique for lateral projection is desirable
• So tissue margins visible and trabecular markings sharp
190
Ob liq ue : Th o racic Sp in e
Both oblique projections gener-

ally imaged for comparison May
also take as anterior oblique
(lower breast dose)
• 35 × 43 cm (14 × 17″) portrait
• Grid
Fig . 6.31 70° RPO (20° from
lateral)
6
Po sit io n
• Recumbent or erect, rotated posteriorly 20° from true lateral
• Align and center spine to midline of table and/or IR; place arm
away from IR behind back and arm closest to IR up in front of
head
• Ensure top of IR is at least 1 1 2 ″ (3 cm) above shoulders
Central Ray: CR to center of IR to T7 (3–4″ [8–10 cm] below
jugular notch or 2″ [5 cm] below sternal angle)
SID: 40″ (102 cm)
n
m
Collimation: Long, narrow collimation eld to T spine region
u
l
Respiration: Expose on expiration
o
C
l
a
r
b
e
t
r
e
V

AP ( PA) : Lum b ar Sp in e
Note: May be taken PA for

better opening of intervertebral
spaces by divergent rays
• 30 × 35 cm (11 × 14″)
• Grid Fig . 6.32 AP lumbar, hips and
knees exed
Po sit io n (AP)
6
• Supine, spine aligned to midline of
table and/or grid
• Flex hips and knees (to reduce
lordotic curvature)
• No rotation (ASISs same distance
from table)
• Center IR to CR Fig . 6.33 Alternate PA
Central Ray: CR to ≈1½″ (4 cm) above
iliac crest (L3); or center at crest for 35 × 43 cm IR
V
e
SID: 40″ (102 cm)
r
t
e
Collimation: Long, narrow collimation eld to L spine region (include
b
r
a
SI joints)
l
C
Respiration: Expose at end of expiration
o
l
u
m
n

AP ( PA) : Lum b ar Sp in e

• T12-S1 (minimum) demonstrated
• Lumbar vertebral bodies,
intervertebral joints, spinous and
transverse processes, SI joints and
sacrum
Position
• No rotation evident by symmetry
of transverse processes, SI joints,
and sacrum
• Spinous processes are midline
6
Exposure
contrast; no motion
• So tissue margins and sharp
trabecular markings clearly
demonstrated
Fig . 6.34 AP lumbar spine
Competency Check:
Technologist Date
n
m
u
l
o
C
l
a
r
b
e
t
r
e
V
193
Lat e ral: Lum b ar Sp in e
• 30 × 35 cm (11 × 14″)
(14 × 17″) portrait Fig . 6.35 Lateral L spine
• Grid
• Lower lumbar spine at cathode end
• Lead masking posterior to patient
Po sit io n
6
• Recumbent in true lateral position, ex hips and knees, align and
center midaxillary plane to centerline
• Place support under waist, as needed, to place entire spine parallel
to tabletop (see Note) Provide support between knees
• Center IR to CR
Central Ray: CR to level of ≈1½″ (4 cm) above iliac crest (L3), or
at iliac crest (L4) for 35 × 43 cm (14 × 17″) IR
SID: 40″ (102 cm)
Collimation: Long, narrow collimation eld to L spine region
V
e
r
t
e
Note: Patient with wide pelvis and narrow thorax may require a 3°–5° caudal
b
r
a
CR angle, even with support under waist If patient has natural lateral curvature
l
C
(scoliosis), place “sag” or convexity down
o
l
u
m
n

Lat e ral L5 -S1 : Lum b ar Sp in e
• 18 × 24 cm (8 × 10″)
portrait
• Grid
• Lead masking posterior to
patient
Fig . 6.36 Lateral L5-S1
Po sit io n
• Recumbent in true lateral position, ex hips and knees,
midaxillary plane aligned to midline of table and/or IR and CR
• Place support under waist, as needed, to place entire spine parallel
6
to tabletop Provide support between knees
• Center IR to CR
Central Ray:
• CR to IR if entire spine is parallel to table; or 5°–8° caudad if
entire spine is not parallel (most o en on females) Angle CR to
be parallel to the interiliac plane
• CR to 1 5″ (4 cm) inferior to iliac crest and 2″ (5 cm) posterior to
ASIS
n
m
SID: 40″ (102 cm)
u
l
Collimation: Collimate closely to area of interest
o
C
l
a
r
b
e
t
r
e
V

Lat e ral an d Lat e ral L5 -S1 : Lum b ar Sp in e
Fig . 6.37 Lateral lumbar Fig . 6.38 Lateral L5-S1

6
spine Competency Check:
Competency Check: Technologist Date
Technologist Date

• Lateral: L1-L4 vertebral bodies, intervertebral joints, and foramina
and spinous processes
• Lateral L5-S1: Open L5-S1 vertebral bodies, intervertebral joint
V
spaces, and intervertebral foramina
e
r
t
e
b
r
Position
a
l
• Lateral: Vertebral column parallel to IR; intervertebral joint spaces
C
o
and foramina open; no rotation
l
u
m
• Lateral L5-S1: Intervertebral joint spaces and intervertebral
n
foramina open; no rotation
Exposure
• So tissue margins visible and bony detail of vertebral bodies,
joint spaces, and spinous process
196
Ob liq ue : Lum b ar Sp in e
Both oblique projections

generally imaged for com-
parison (as either anterior
or posterior obliques)
• 30 × 35 cm (11 × 14″)
(10 × 12″) portrait Fig . 6.39 Posterior Fig . 6.40 Anterior
• Grid oblique (45° RPO) oblique (45° LAO)
6
Po sit io n
• Rotate body 45° and right and le posterior or anterior obliques
(use support angle blocks under pelvis and shoulders to maintain
position for posterior obliques)
• Align and center spine to CR and midline of table and/or IR
Central Ray: CR to body of L3 at level of lower costal margin (1–2″
[2 5–5 cm] above iliac crest) and 2″ (5 cm) medial to upside ASIS
SID: 40″ (102 cm)
Collimation: To area of interest
n
Respiration: Suspend during exposure m
u
Note: 50° oblique is best for L1-L2 zygapophyseal joints, and 30° for
l
o
C
L5-S1
l
a
r
b
e
t
r
e
V

Ob liq ue : Lum b ar Sp in e
R R
6
Fig . 6.41 Right posterior oblique Fig . 6.42 Right anterior oblique

V
• LPO/RPO: L1-L4 downside zygapophyseal joints Scottie dog
e
r
elements visible
t
e
b
• LAO/RAO: L1-L4 upside zygapophyseal joints Scottie dog
r
a
l
elements visible
C
o
l
u
Position
m
n
• Zygapophyseal joints and pedicle (“eye”) centered on the vertebral
body
Exposure
• So tissue margins visible and bony detail of vertebral bodies,
joint spaces, and elements of Scottie dog (arrows indicate
zygapophyseal joints)
198
PA: Sco lio sis Se rie s
Fe rg uso n Me t h o d
PA greatly reduces dose to radiation-

sensitive areas and is highly recom-
mended over AP projection
A scoliosis series frequently includes
two PA (or AP) images taken for
comparison, one erect and one
recumbent Fig . 6.43 PA Fig . 6.44 PA
• 35 × 43 cm (14 × 17″) portrait or without block with block under
35 × 90 cm (14 × 36″) portrait
foot on convex
6
• Grid
• Compensating lters to produce a more uniform density side of curve
of spine
Po sit io n
First IR:
• Erect, standing or seated, spine aligned and centered to midline of
table and/or IR, arms at side, no rotation of pelvis or thorax
• Lower margin of IR 1–2″ (2 5–5 cm) below iliac crest
Second IR: Place 3- to 4-inch (8- to 10-cm) block under foot (or buttock
if seated) on convex side of curvature (Identi es primary deforming curves
n
from compensatory curve) m
Shielding: Use gonad and breast shields
u
l
Central Ray: CR to center of IR
o
C
SID: 40–60″ (102–153 cm); longer SID is recommended
l
a
Collimation: Long and narrow to vertebral column region
r
b
Respiration: On full expiration
e
t
r
e
V

AP: Lum b ar Sp in e
Rig h t an d Le ft Be n d in g
Note: May be taken

erect PA to reduce dose
to radiation-sensitive
areas
• 35 × 43 cm (14 × 17″) Fig . 6.45 AP, Fig . 6.46 AP,
portrait or 35 × 90 cm right bending le bending
6
• Grid
• Compensating lters to produce a more uniform density of spine
Po sit io n
• Supine or erect, spine centered to CR and midline of table and/or IR
• Bend laterally as far as possible (right then le ) without tilting
pelvis (pelvis remains stationary and acts as a fulcrum)
• Ensure no rotation of pelvis and upper torso
Central Ray: CR to center of IR (higher centering if thoracic spine
V
is area of interest)
e
r
SID: 40–60″ (102–153 cm)
t
e
Collimation: Include vertebral column of interest
b
r
a
l
C
o
l
u
m
n

Lum b ar Sp in e
• 35 × 43 cm
(14 × 17″)
portrait
• Grid
• Lead masking
posterior to
Fig . 6.47 Hyper exion Fig . 6.48 Hyperextension
6
patient
lateral lateral
Po sit io n
• Recumbent or erect, spine centered to table
• Support under waist to align spine parallel to tabletop
• Hyper ex forward as far as possible, then hyperextend back as far
as possible for second IR; maintain true lateral position
Central Ray: CR to center of IR (or to site of fusion if known)
n
SID: 40″ (102 cm) m
u
Collimation: On four sides to near borders of IR
l
o
C
l
a
r
b
e
t
r
e
V

Lat e ral ( Hyp e r e xio n an d Hyp e re xt e n sio n )
Lum b ar Sp in e
L
6
Fig . 6.49 Hyper exion lateral Fig . 6.50 Hyperextension lateral

• Hyperf exion: oracic and lumbar vertebra including 1–2″
V
(≈3–5 cm) of the iliac crests Lateral view of lumbar vertebrae in
e
r
t
hyper exion
e
b
• Hyperextension: oracic and lumbar vertebra including 1–2″
r
a
l
(≈3–5 cm) of the iliac crests Lateral view of lumbar vertebrae in
C
o
hyperextension
l
u
m
n
Position
• Hyperf exion: True lateral with no rotation; spaces between
spinous processes open
• Hyperextension: True lateral with no rotation; spaces between
spinous processes closed
Exposure
• Bony detail of vertebral bodies, spinous processes, and
intervertebral joint spaces
202
AP Axial: Sacrum
• 24 × 30 cm (10 × 12″)
portrait
• Grid
Po sit io n Fig . 6.51 AP sacrum, CR 15° cephalad

• Supine, spine centered to
CR and midline of table and/or IR
• No rotation of pelvis (both ASIS same distance from table)
• Center IR to projected CR (Shield radiosensitive tissues Shield
6
gonads for males )
Central Ray: CR 15° cephalad, at 2″ (5 cm) superior to pubic
symphysis
SID: 40″ (102 cm)
Collimation: On four sides to area of sacrum
n
m
u
l
o
C
l
a
r
b
e
t
r
e
V

AP Axial: Co ccyx
Note: May be done PA with 10°

cephalic angle if patient cannot
sustain weight on the coccyx
area in a supine position
Urinary bladder should be
emptied before procedure is Fig . 6.52 AP axial coccyx, CR 10°
performed caudad
• 18 × 24 cm (8 × 10″) portrait
• Grid
• Cautious use of AEC
6
Po sit io n
• Supine, support under knees, shield radiosensitive tissue, gonad
shield for males
• Align and center midsagittal plane to midline of table and/or IR,
no rotation
• Center IR to level of projected CR
Central Ray: CR 10° caudad, centered to 2″ (5 cm) superior to
symphysis pubis
V
SID: 40″ (102 cm)
e
r
t
Collimation: Close collimation to area of coccyx
e
b
r
a
l
C
o
l
u
m
n

AP Axial: Sacrum an d Co ccyx
Evaluat io n
Crit e ria
Anatomy
Demonstrated
• AP sacrum:
Nonforeshortened
image of sacrum
• AP coccyx:
Nonforeshortened
image of coccyx
Position
• AP sacrum:
Sacrum free of Fig . 6.53 AP axial sacrum
6
superimposition Competency Check:
Technologist Date
and sacral
foramina visible
• AP coccyx: Coccyx free of
superimposition and not
rotated
Exposure
R
n
and contrast; no motion m
u
• So tissue visible and sharp
l
o
C
bony detail
l
a
r
b
e
t
r
e
V
Fig . 6.54 AP axial coccyx
Competency Check:
Technologist Date
205
Lat e ral: Sacrum an d Co ccyx
Note: Lateral sacrum and lateral coccyx

may be taken as one projection if both
sacrum and coccyx are being examined
(reduces patient exposure)
• 24 × 30 cm (10 × 12″) portrait
• Grid
• Use of boomerang-type
compensating lter is recommended
if coccyx is to be included
6
Po sit io n
• Lateral recumbent, hips and Fig . 6.55 Lateral sacrum and
knees exed, true lateral coccyx
position
• Center sacrum to CR and midline of table and/or IR (Align
patient and IR to correctly centered CR)
Central Ray (Sacrum): CR , directed to 3–4″ (8–10 cm) posterior
V
to upside ASIS
e
r
SID: 40″ (102 cm)
t
e
b
Collimation: On four sides to area of sacrum
r
a
l
C
o
l
u
m
n

Lat e ral: Co ccyx
Note: Lateral sacrum and lateral coccyx

are commonly taken as one projection if
both sacrum and coccyx are being exam-
ined (reduces patient exposure)
• 18 × 24 cm (8 × 10″) portrait
• Grid
• Cautious use of AEC
Po sit io n
• Lateral recumbent, with hips
6
and knees exed 90°, true lateral Fig . 6.56 Lateral coccyx
position
• Center coccyx to CR and midline of table and/or IR (remember
the coccyx is located super cially between buttocks slightly
superior to level of greater trochanter)
• Center IR to CR
Central Ray: CR to 2″ (5 cm) distal to level of ASIS and 3–4″
(8–10 cm) posterior
n
SID: 40″ (102 cm) m
u
Collimation: To area of distal sacrum and coccyx
l
o
C
l
a
r
b
e
t
r
e
V

Lat e ral: Sacrum an d Co ccyx

Anatomy Demonstrated L
• Lateral view of sacrum and
coccyx
• Lateral view of L5-S1
intervertebral joint
Position
• No rotation evident by greater
sciatic notches and femoral
heads superimposed
• Entire sacrum and coccyx
included
6
Exposure Fig . 6.57 Lateral sacrum
• Optimal density (brightness) and coccyx
and contrast; no motion Competency Check:
Technologist Date
• Trabecular markings clearly
demonstrated
V
e
r
t
e
b
r
a
l
C
o
l
u
m
n
208
AP Axial: Sacro iliac ( SI) Jo in t
• 24 × 30 cm (10 × 12″)
portrait
• Grid
Po sit io n Fig . 6.58 AP axial SI joints (CR

• Supine, center patient to 30°–35° cephalad)
midline of table and/or IR
• No rotation of pelvis (ASISs the same distance from tabletop)
• Center IR to projected CR Shield radiosensitive tissues as well as
6
gonads for males
Central Ray: CR 30° (males) and 35° (females) cephalad, 2″ (5 cm)
below level of ASIS
SID: 40″ (102 cm)
n
m
u
l
o
C
l
a
r
b
e
t
r
e
V

Po st e rio r Ob liq ue : Sacro iliac ( SI) Jo in t
• 24 × 30 cm (10 × 12″) portrait

• Grid
• Bilateral for comparison
Po sit io n
• Patient in 25°–30° posterior
oblique with side of interest
elevated (use support to
maintain this position)
6
• Align elevated SI joint to CR
and to midline of table and/
or IR (1″ [2 5 cm] medial to Fig . 6.59 25°–30° LPO for
upside ASIS) upside (right) SI joint
• Center IR to CR
• Shield radiosensitive tissue as well as gonads for males
Central Ray: CR to 1″ (2 5 cm) medial to elevated ASIS
SID: 40″ (102 cm)
V
e
r
t
Note: CR may be angled 15°–20° cephalad to best demonstrate the
e
b
distal part of joint
r
a
l
C
o
l
u
m
n

Po st e rio r Ob liq ue : Sacro iliac Jo in t

• Open upside (farthest
from IR) SI joint
Position
• LPO: Right SI joint open;
no overlap of iliac wing
and sacrum
• RPO: Le SI joint open;
no overlap of iliac wing
and sacrum
Exposure
6
• Optimal density
(brightness) and contrast;
no motion
• Bony margins and sharp Fig . 6.60 LPO projection of
trabecular markings (right) SI joint
Competency Check:
clearly demonstrated Technologist Date
n
m
u
l
o
C
l
a
r
b
e
t
r
e
V
211
Ch ap t e r 7
Bo n y Th o rax
• Positioning considerations 213
St e rn um AP (below diaphragm)
Right anterior oblique (R) 220
(RAO) (R) 214 AP (or PA) (above and
Lateral (R) 215 below diaphragm)
Oblique (RAO) and critique 221
lateral critique 216
B
o
Axillary Rib s
n
y
St e rn o clavicular Join t s Anterior oblique
T
h
PA and anterior (RAO) (R) 222
o
r
oblique (R) 217 Posterior oblique
a
x
PA and anterior (LPO) (R) 223
oblique critique 218 Anterior or posterior
oblique (above and
Rib s (Bilat e ral) below diaphragm)
AP (or PA) (above critique 224
diaphragm) (R) 219

7
212
Po sit io n in g Co n sid e rat io n s
St e rn um
T e routine for a sternum generally includes a lateral and an oblique
wherein the sternum is shi ed to the le of the spine and is superim-
posed over the homogeneous heart shadow A 15°–20° RAO achieves
this best An orthostatic-breathing technique generally is used to blur
out the lung markings and the ribs overlying the sternum If preferred,
exposure can also be made on suspended expiration A minimum SID
for sternum radiography is 40″ (102 cm) T e patient’s skin should be
at least 38 cm (15″) below the surface of the collimator to reduce skin
dose
Rib s
Each technologist should determine the preferred routine for his or
her department
x
a
r
o
Two -Im ag e Ro ut in e
h
T
One suggested two-image routine is an AP or PA with the area of
y
n
interest closest to the image receptor (IR) (above or below diaphragm)
o
B
and an oblique projection of the axillary ribs on the side of injury
T erefore the oblique for this routine on an injury to the le anterior
ribs would be an RAO, shi ing the spine away from the area of injury
and to increase visibility of the le axillary ribs T e oblique for an
injury to the right posterior ribs would be an RPO wherein the spine
again is rotated away from the area of injury
Th re e -Im ag e Ro ut in e
Another three-image routine required in some departments for all rib
7
trauma consists of AP above diaphragm or AP below diaphragm and
RPO and LPO of the site of injury
Ab o ve an d Be lo w Diap h rag m
T e location of the injury site in relationship to the diaphragm is
important for all routines T ose injuries above the diaphragm require
less exposure (nearer to a chest technique) when taken on inspiration
and those below the diaphragm require an exposure nearer to that of
an abdomen technique when taken on expiration
213
Rig h t An t e rio r Ob liq ue ( RAO) : St e rn um
• 24 × 30 cm (10 × 12″)
portrait
• Grid
• Orthostatic-breathing
technique (3–4
seconds) or
suspended expiration Fig . 7.1 Erect 15°–20° RAO sternum
• AEC not (inset: trauma option)
B
recommended
o
n
y
Po sit io n
T
h
• Erect (preferred) or semiprone, turned 15°–20° with right side
o
r
a
down (RAO) (A thin-chested patient requires slightly more
x
obliquity than a thick-chested patient)
• Center sternum to CR at midline of table or IR holder
Central Ray: CR to midsternum (1″ [2 5 cm] to le of midline and
midway between jugular notch and xiphoid process)
SID: 40″ (102 cm)
Collimation: Long, narrow collimation eld to region of sternum
7

Lat e ral: St e rn um
• 24 × 30 cm (10 × 12″)
or 35 × 35 cm
• Grid
• AEC not
recommended
• Place lead blocker Fig . 7.2 Lateral, erect sternum (insert:
anterior to sternum trauma option)
(for recumbent
x
a
position)
r
o
h
T
Po sit io n
y
n
• Erect (preferred) (seated or standing), or lateral recumbent lying
o
B
on side with vertical CR; or supine with cross-table CR for severe
trauma
• Arms up above head and shoulders back
• Align sternum to CR at midline of grid or table/upright bucky
• op of IR 1 5″ (4 cm) superior to level of jugular notch
Central Ray: CR to midsternum
SID: 60–72″ (152–183 cm) 40″ (102 cm) minimum
Collimation: Long, narrow collimation eld to region of sternum
Respiration: Expose upon full inspiration
7

Ob liq ue ( RAO) : St e rn um

L
• Entire sternum superimposed on
heart shadow
Position
• Correct patient rotation, sternum
visualized alongside vertebral
column
Exposure
• 3- to 4-second exposure using
breathing technique; lung
B
o
markings appear blurred
n
y
• Optimal contrast and density
T
h
(brightness) to visualize entire
o
Fig . 7.3 RAO sternum
r
sternum
a
x
Competency Check:
• Bony margins sharp Technologist Date
Lat e ral: St e rn um

• Entire sternum
7
Position
• No rotation, sternum visualized
with no superimposition on the
ribs
• Shoulders and arms drawn back
Exposure
• No motion, sharp bony margins
(brightness) to visualize entire
Fig . 7.4 Lateral sternum
sternum Competency Check:
Technologist Date
216
PA an d An t e rio r Ob liq ue :
St e rn o clavicular ( SC) Jo in t s
• 18 × 24 cm (8 ×
10″) landscape
• Grid
Fig . 7.5 Bilateral PA
Po sit io n
PA: Prone or erect, midsagittal plane to center-
line of CR
• urn head to side, no rotation of shoulders Fig . 7.6 RAO,
• Center IR to CR 10°–15° oblique, CR
Oblique: Rotate thorax 10°–15° to shi vertebrae (both obliques
x
away from sternum (best visualizes downside SC commonly taken for
a
r
o
joint) RAO will demonstrate the right SC joint comparison)
h
T
LAO will demonstrate the le SC joint
y
n
Less obliquity (5°–10°) will best visualize the upside SC joint next to
o
B
spine
Central Ray
• PA: Level of 2- 3 CR to MSP and ≈3″ (7 cm) distal to
vertebra prominens (3 cm or 1 5″ inferior to jugular notch)
• Oblique: Level of 2- 3 CR to 1–2″ (2 5–5 cm) lateral to MSP
(toward elevated side) and ≈3″ (7 cm) distal to vertebra prominens
SID: 40″ (102 cm)
Collimation: o region of sternoclavicular joints with four-sided
7
collimation
Respiration: Suspend respiration upon expiration

PA: SC Jo in t s

• Lateral aspect of
manubrium and medial
portion of clavicles
visualized lateral to
vertebral column
Position Fig . 7.7 PA bilateral SC joints

Competency Check:
• No rotation, equal Technologist Date
distance of SC joints
from vertebral column
B
o
Exposure
n
y
T
• SC joints visualized through ribs and lungs
h
o
r
• Optimal contrast and density (brightness) to visualize SC joints
a
x
An t e rio r Ob liq ue : SC Jo in t s

• Manubrium and medial
clavicles and downside
SC joints are visualized
7
Position
• Patient rotated 10°–15°,
correct rotation best
demonstrates downside Fig . 7.8 10°–15° RAO
Competency Check:
SC joint with no Technologist Date
superimposition of
vertebral column
Exposure
• Contrast and density (brightness) su cient to visualize SC joint
through ribs and lungs
218
AP ( o r PA) : Rib s ( Bilat e ral)
Ab o ve Diap h rag m
Generally taken as AP for

posterior ribs and PA for
anterior ribs
• 35 × 43 cm (14 × 17″)
landscape (or portrait for
unilateral study or narrow
x
chest dimensions)
a
r
• Grid Fig . 7.9 AP bilateral ribs (above
o
h
diaphragm)
T
y
Po sit io n
n
o
• Erect (preferred), or recumbent, midsagittal plane to midline of
B
table/upright bucky and CR
• op of IR ≈1 5″ (4 cm) above shoulders
• Roll shoulders forward, no rotation
• Ensure that thorax is centered to IR (bilateral study)
Central Ray: CR to center of IR and 3 or 4″ (8–10 cm) below
jugular notch (level of 7)
SID: 72″ (183 cm) erect; 40–48″ (102–123 cm) recumbent
Collimation: Collimate to region of interest
7
Respiration: Expose on inspiration (diaphragm down)

AP: Rib s ( Bilat e ral)
Be lo w Diap h rag m
• 35 × 43 cm (14 × 17″)
landscape (or portrait
for unilateral study
or narrow chest
dimensions) Fig . 7.10 AP bilateral ribs (below
• Grid diaphragm)
B
o
n
Po sit io n
y
T
• Erect (preferred), or recumbent, MSP to midline of table/upright
h
o
bucky and IR (and CR)
r
a
x
• Inferior margin of IR at iliac crest
• Ensure that both lateral margins of thorax are included (bilateral
study)
• Shield radiosensitive tissues
Note: Some routines include only unilateral ribs of a ected side
Central Ray: CR centered to IR at a level midway between the
xiphoid process and the lower rib margin
SID: 72″ (183 cm) erect; 40″ (102 cm) recumbent
7
Respiration: Expose on expiration (diaphragm at highest point)

AP ( o r PA) : Rib s ( Bilat e ral)

Anatomy Demonstrated R
Above Diaphragm
• Ribs 1–10 visualized
Below Diaphragm
• Ribs 10–12 visualized
Position
• No rotation, lateral rib
margins equal distance from
vertebral column
x
Fig . 7.11 PA bilateral ribs
Exposure
a
r
above diaphragm
o
• No motion, sharp bony
h
T
Competency Check:
margins Technologist Date
y
n
• Contrast and density
o
B
(brightness) appropriate
to visualize ribs 1–10
above diaphragm and
10–12 (minimum) below
diaphragm
7
R
Fig . 7.12 AP bilateral ribs
below diaphragm
Competency Check:
Technologist Date
221
An t e rio r Ob liq ue ( RAO) : Up p e r Axillary Rib s
• 35 × 43 cm (14 × 17″)
or 35 × 35 cm
(see Note)
• Grid Fig . 7.13 45° RAO above diaphragm—
bilateral, right anterior injury (to shi spine
away from injury)
B
Po sit io n
o
n
• Erect (preferred),
y
T
or recumbent if needed
h
o
• Oblique 45°, rotate spine away from area of interest
r
a
x
• Involved region of thorax is centered to IR
Note: Some routines indicate unilateral oblique only of a ected side
with smaller IR placed portrait
Central Ray: CR to center of IR to level 7–8″ (18 to 20 cm) below
vertebra prominens ( 7)
SID: 72″ (183 cm) erect, 40″ (102 cm) recumbent
Respiration: Above diaphragm—expose on inspiration
7

Po st e rio r Ob liq ue ( LPO) : Lo w e r Axillary Rib s
• 35 × 43 cm (14 × 17″) or 35 × 35 cm
• Grid
Po sit io n
• Erect or recumbent (recumbent
x
preferred)
a
r
o
• op of IR ≈1 5″ (4 cm) above
h
T
shoulders
y
n
• Rotate 45° from AP, arm closest
o
B
to IR up, resting on head; Fig . 7.14 45° LPO (below
diaphragm)
opposite hand on waist with
arm away from body
Central Ray: CR centered to IR to level midway between xiphoid
process and lower rib margin
SID: 72″ (183 cm) erect, 40″ (102 cm) recumbent
Respiration: Below diaphragm—expose upon expiration
7

An t e rio r o r Po st e rio r Ob liq ue : Axillary Rib s

Anatomy Demonstrated L
• LPO/RAO: Visualizes
(elongates) le axillary ribs
• RPO/LAO: Visualizes
(elongates) right axillary ribs
• Ribs 1–9 seen above
diaphragm
• Ribs 10–12 seen below
diaphragm (minimum)
• Axillary portion of
ribs projected without
B
superimposition
o
Fig . 7.15 LPO above diaphragm
n
y
Competency Check:
T
Position Technologist Date
h
o
• 45° oblique should visualize
r
a
x
axillary ribs in pro le with L
spine shi ed away from area
of interest
Exposure
• No motion, sharp bony
margins
(brightness) visualizes
7
ribs through lungs and
heart shadow for above
diaphragm, and through
dense abdominal organs for
below diaphragm
Fig . 7.16 LPO below diaphragm
Competency Check:
Technologist Date
224
Ch ap t e r 8
Cran ium , Facial Bo n e s,

an d Paran asal Sin use s
s
e
s
u
n
i
S
• Cranial positioning lines and landmarks 227
l
a
s
a
n
a
r
a
Cran ium (Skull Se rie s) Parietoacanthial and
P
AP axial (Towne modif ed parietoacanthial
d
n
a
method) (R) 228 (Waters and modif ed
,
AP axial (Towne Waters methods)
s
e
n
method) critique 229 critique 243
o
B
Lateral (R) 230 PA axial (15°) (Caldwell
l
a
Lateral critique 231 method) (R) 244
i
c
a
PA and PA axial (15°) PA axial (15°) (Caldwell
F
,
(Caldwell method) method) critique 245
m
u
(R) 232
i
n
a
PA and PA axial (15°) Traum a (Facial Bo n e
r
C
(Caldwell method) Se rie s)
critique 233 Lateral, acanthioparietal
Submentovertical (reverse Waters and
(SMV) (S) 234 reverse modif ed
SMV critique 235 Waters methods) (S) 246
Traum a (Skull Se rie s) Op t ic Fo ram in a

Lateral (S) 236 Parieto-orbital oblique
AP and AP axial (S) 237 (Rhese method) (S) 247
8
Lateral critique 238
AP and AP axial Zyg o m at ic Arch e s
critique 239 Bilateral SMV (R) 248
Oblique in erosuperior
Facial Bo n e s (tangential) (S) 249
Lateral (R) 240 SMV and oblique
Lateral critique 241 in erosuperior
Parietoacanthial (Waters (tangential) critique 250
and modif ed Waters AP axial (modif ed
methods) (R) 242 Towne method) (S) 251
225
Nasal Bo n e s Axiolateral (Schuller
Lateral (R) 252 method) (S) 261
Lateral critique 253 Axiolateral oblique
Superoin erior (Modif ed Law method)
C
r
tangential (axial) (S) 254 and axiolateral (Schuller
a
n
i
method) critique 262
u
m
Man d ib le
,
F
PA and PA axial (R) 255 Paran asal Sin use s
a
c
Axiolateral and axiolateral Lateral (R) 263
i
a
l
oblique (R) 256 PA (Modif ed PA—
B
o
Axiolateral oblique, Caldwell method) (R) 264
n
e
trauma (S) 257
s
Lateral and PA
,
a
PA and axiolateral (Modif ed Caldwell
n
d
oblique critique 258 method) critique 265
P
a
AP axial (mandible or Parietoacanthial
r
a
TMJ and condyloid (Waters method) (R) 266
n
a
s
processes) (R) 259 SMV (R) 267
a
l
Parietoacanthial
S
i
n
Te m p o ro m an d ib ular Jo in t s (Waters method) and
u
s
Axiolateral oblique
e
SMV critique 268
s
(modif ed Law method)
(S) 260

8
226
Cran ial Po sit io n in g Lin e s an d Lan d m arks
Gla be lloa lve ola r

(GAL)
Exte rna l
D E
a cous tic BC
s
F
e
A
me a tus
s
u
(EAM) or
n
i
S
a uricula r
l
point
a
s
a
n
a
r
a
P
Inion
d
Fig . 8.1 Positioning lines
n
a
,
s
e
A Glabellomeatal line (GML) D Acanthiomeatal line (AML)
n
o
B Orbitomeatal line (OML) E Lips-meatal line (LML) (used
B
l
C In raorbitomeatal line or modif ed Waters)
a
i
c
(IOML) (Reid’s base line, or F Mentomeatal line (MML)
a
F
“base line,” base o cranium) (used or Waters)
,
m
u
i
n
S upra orbita l
a
r
C
groove (S OG)
Gla be lla S upe rcilia ry
Na s ion ridge (a rch)
Inte rpupilla ry
line (IP L)
Aca nthion
Angle
Me nta l (gonion)
point
Mids a gitta l pla ne
(MS P )
8
Fig . 8.2 Cranial landmarks
• Common positioning errors: Rotation, tilt, exion, and extension

errors are the most common seen with cranial and acial bone
radiography See p 409 in text to review these positioning errors
and corrections
• Shielding: All radiosensitive tissues outside the region o interest
should be shielded during each imaging series
Remove all metal, plastic, or other removable objects rom the patient’s
head
227
AP Axial: Cran ium
To wn e Me t h o d
30
C
R
r
a
n
37
i
• 24 × 30 cm (10 × 12″) portrait
u
m
• Grid
,
F
a
Po sit io n
c
i
• Seated erect, or supine,
a
Fig . 8.3 AP axial (Towne)—CR
l
midsagittal plane aligned to
B
30° caudad to OML
o
CR and midline o the table
n
e
and/or IR, perpendicular to IR;
s
,
a
no rotation or tilt
n
d
• Depress chin to bring OML or
P
IOML perpendicular to IR
a
r
• Center IR to projecting CR
a
n
a
s
Central Ray:
a
l
• CR 30° caudal to OML; or 37°
S
i
Fig . 8.4 PA axial (Haas method),
n
caudal to IOML
u
OML CR 25° cephalad, through
s
• CR to ≈2 5″ (6 5 cm) above
e
level o EAMs
s
glabella (through 0 75″ [2 cm]
superior to level o EAMs)
SID: 40″ (102 cm)
Collimation: On our sides to skull margins
Note: PA Axial—Haas method (p 418 in text) is an alternative to AP
Towne Adjust head to bring OML to IR CR is angled 25° cephalad
and exits 1 1 2 ″ (4 cm) superior to nasion

8

AP Axial ( To w n e Me t h o d ) : Cran ium

• Occipital bone, petrous
pyramids, and oramen
s
e
s
magnum
u
n
i
S
Position
l
a
s
• Dorsum sellae within
a
n
a
oramen magnum
r
a
• No rotation evident by
P
d
symmetry o petrous
n
a
portion (pyramids) o
,
s
temporal bones
e
n
o
B
Exposure
l
a
R
i
c
• Optimal density
a
F
(brightness) and contrast Fig . 8.5 AP axial skull
,
m
to visualize occipital bone Competency Check:
u
i
Technologist Date
and structures within
n
a
r
oramen magnum
C
• Sharp bony margins; no motion
8
229
Lat e ral: Cran ium
R
C
r
a
• 24 × 30 cm (10 ×
n
i
12″) landscape
u
m
• Grid
,
F
a
c
Po sit io n
i
a
l
• Seated erect or
B
o
semiprone on
n
Fig . 8.6 Lateral skull
e
table
s
,
a
• Head in true lateral position, no rotation or tilt, midsagittal plane
n
d
parallel to IR, and IPL perpendicular to IR
P
• Adjust chin to place IOML parallel to upper and lower IR edges
a
r
a
• Center IR to CR
n
a
Central Ray: CR to IR, ≈2″ (5 cm) superior to EAM
s
a
l
SID: 40″ (102 cm)
S
i
n
u
s
e
s
8

Lat e ral: Cran ium

Anatomy
Demonstrated
• Entire cranium
s
e
s
visualized and
u
n
superimposed
i
S
cranial halves
l
a
s
• Entire sella turcica
a
n
a
and dorsum sellae
r
a
P
d
Position
n
a
• No tilt, evident by
,
s
superimposition o R
e
n
o
orbital plates (roo s) Fig . 8.7 Lateral skull
B
• No rotation,
l
Competency Check:
a
i
Technologist Date
c
evident by
a
F
superimposition
,
m
o greater wings
u
i
o sphenoid and
n
a
r
mandibular rami
C
Exposure
• Optimal density (brightness) and contrast to visualize sellar
structures
8
231
PA an d PA Axial ( 1 5 °) : Cran ium
Cald we ll Me t h o d
C
R
r
a
n
Note: Some departmental routines
i
u
include a PA to better demonstrate
m
,
the rontal bone in addition to the
F
a
15° PA axial (Caldwell)
c
i
Fig . 8.8 PA—0°
a
• 24 × 30 cm (10 × 12″) portrait
l
15
B
• Grid 30
o
n
Po sit io n
e
s
,
• Seated erect, or prone on
a
n
table, head aligned to CR and
d
midline o the table and/or IR
P
a
• With patient’s orehead and
r
a
n
nose resting on tabletop,
a
s
adjust head to place OML
a
l
perpendicular to IR
S
Fig . 8.9 PA axial—15° Caldwell
i
n
• No rotation or tilt,
u
s
midsagittal plane perpendicular to IR
e
s
Central Ray:
• PA: CR to IR, centered to exit at glabella
• PA axial (Caldwell): CR 15° caudad to OML, centered to exit at
nasion (25°–30° caudad best demonstrates orbital margins)
SID: 40″ (102 cm)
8

PA an d PA Axial ( 1 5 °) : Cran ium

• PA: Frontal bone and crista
s
e
galli demonstrated without
s
u
distortion
n
i
S
• PA axial 15°: Greater/lesser
l
a
s
wings o sphenoid, rontal
a
n
bone, and superior orbital
a
r
a
f ssures
P
d
n
Position
a
,
s
• PA: Petrous ridges at level
e
n
o superior orbital margin
o
R
B
No rotation; equal distance
l
a
i
between orbits and lateral Fig . 8.10 PA—0°
c
a
F
skull Competency Check:
,
Technologist Date
m
• PA axial 15°: Petrous ridges
u
projected in lower 1 3 o
i
n
a
orbits No rotation; equal
r
C
distance between orbits and
lateral skull
Exposure
and contrast to visualize
rontal bone and
surrounding structures
• Sharp bony margins; no
8
motion
R
Fig . 8.11 PA axial—15° Caldwell

Competency Check:
Technologist Date
233
Sub m e n t o ve rt ical ( SMV) : Cran ium
R
C
r
a
n
i
• 24 × 30 cm (10 ×
u
m
12″) portrait
,
• Grid
F
a
c
• AEC optional
i
a
l
B
o
Po sit io n
n
Fig . 8.12 SMV—CR to IOML
e
• Seated erect or
s
,
supine with head extended over end o table resting top o head
a
n
against grid IR (may tilt table up slightly) A positioning sponge/
d
P
pillow may be placed under shoulders
a
r
a
• Adjust IR and hyperextend neck to place IOML parallel to IR
n
a
• Ensure no rotation or tilt
s
a
l
• Center IR to CR
S
i
Central Ray: CR angled to be to IOML, centered to 0 75″ (2 cm)
n
u
anterior to level o EAMs (midpoint between angles o mandible)
s
e
s
Note: I patient cannot extend head this ar, adjust CR as needed to
remain perpendicular to IOML
SID: 40″ (102 cm)

8

SMV: Cran ium

• Foramen ovale and spinosum,
mandible, sphenoid and
s
e
s
posterior ethmoid sinuses,
u
n
mastoid processes, petrous
i
S
ridges, hard palate, oramen
l
a
s
magnum, and occipital bone
a
n
a
r
a
Position
P
d
• Mandibular condyles are
n
a
anterior to the petrous portion
,
s
o temporal bone
e
n
o
• No tilt; equal distance between
B
R
mandibular condyles and lateral
l
a
i
Fig . 8.13 SMV
c
skull
a
F
Competency Check:
• No rotation; MSP parallel to
,
Technologist Date
m
edge o radiograph
u
i
n
a
r
Exposure
C
• Optimal density (brightness) and contrast to visualize outline o
oramen magnum
8
235
Lat e ral: Cran ium ( Traum a)
L
C
r
a
Warning: Do NOT
n
i
u
elevate or move
m
patient’s head be ore
,
F
cervical spine injuries
a
c
have been ruled out
i
a
l
• 24 × 30 cm (10
B
o
× 12″) landscape
n
Fig . 8.14 Lateral, with possible spinal injury
e
(aligned to the
s
,
anterior-to-posterior dimension o the skull)
a
n
• Grid
d
P
a
Po sit io n
r
a
• Supine, without removing cervical collar, i present
n
a
s
• With possible spinal injury, move patient to back edge o table
a
l
and place IR about 1″ (2 5 cm) below tabletop and posterior skull
S
i
n
(move oating tabletop orward)
u
s
e
• Place head in true lateral position
s
• Center IR to horizontal beam CR (to include entire skull)
Central Ray: CR horizontal, to IR, centered to ≈2″ (5 cm) superior
to EAM
SID: 40″ (102 cm)
Respiration: Suspend respiration

8

AP an d AP Axial: Skull ( Traum a)
s
R
e
s
u
n
i
Warning: With possible spine or severe
S
l
head injuries, per orm all projections AP
a
s
without moving patient’s head or without
a
n
a
removing cervical collar unless requested
r
a
to do so by physician
P
• 24 × 30 cm (10 × 12″) portrait
d
n
• Grid (bucky)
a
Fig . 8.15 AP, CR—parallel to
,
s
OML—centered to glabella
e
n
Po sit io n
o
B
• Patient care ully moved onto
l
a
x-ray table in supine position
i
c
a
F
• All projections per ormed as is, without moving patient’s head
,
SID: 40″ (102 cm)
m
u
i
n
a
r
C
CR An g le an d Ce n t e rin g
• As indicated in Figs 8 15, 8 16 and 8 17
• IR centered to projected CR 8
Fig . 8.16 AP reverse Caldwell Fig . 8.17 AP axial (Towne)
CR—15° cephalad to OML— CR—30° caudad to OML—CR to
centered to nasion ≈2 5″ (5–6 cm) above glabella
Bontrager Textbook, 9th ed, pp 590–591 237

Lat e ral: Skull ( Traum a)
Evaluat io n
Crit e ria
Anatomy
Demonstrated
C
r
• Entire
a
n
i
cranium and
u
m
superimposed
,
F
cranial halves
a
c
• Entire sella
i
a
l
turcica and
B
o
dorsum sellae
n
e
s
,
a
Position
n
d
• No rotation or
P
a
tilt (see p 237 or
r
a
specif c criteria)
n
a
s
Fig . 8.18 Lateral trauma skull
a
l
Exposure Competency Check:
S
i
Technologist Date
n
• Optimal density
u
s
e
(brightness) and contrast to visualize sellar structures
s
8
238
AP an d AP Axial: Skull ( Traum a)
s
e
s
u
n
i
S
l
a
s
a
n
a
r
a
P
d
n
a
,
s
e
n
o
B
l
Fig . 8.19 AP to OML Fig . 8.20 AP axial (“reverse”
a
i
c
Competency Check: Caldwell) (15° cephalad)
a
F
,
m
Technologist Date
u
i
n
a
r
C
• AP 0°: Frontal bone and crista galli demonstrated (magnif ed
because o OID)
• AP axial 15°: Greater/lesser wings o sphenoid, rontal bone, and
superior orbital f ssures
Position
• AP 0°: Petrous ridges at level o superior orbital margin
No rotation; equal distance between orbits and lateral skull
• AP axial 15°: Petrous ridges projected in lower 1 3 o orbits
8
Exposure
• Optimal density (brightness) and contrast to visualize rontal bone
and surrounding structures
239
Lat e ral: Facial Bo n e s
R
C
r
a
n
• 18 × 24 cm (8 ×
i
u
10″) portrait
m
,
• Grid
F
a
c
i
a
Po sit io n
l
B
• Erect or
o
n
semiprone on
e
s
table
,
a
n
• Adjust head
d
to true lateral Fig . 8.21 Lateral acial bones
P
a
position with side
r
a
n
o interest closest to IR
a
s
a
• No rotation or tilt, midsagittal plane parallel to IR, IPL
l
S
perpendicular to IR
i
n
u
• Adjust chin to place IOML parallel to top and bottom edge o IR
s
e
• Center IR to CR
s
Central Ray: CR to IR, to zygoma (prominence o the cheek)
midway between EAM and outer canthus
SID: 40″ (102 cm)
Collimation: On our sides to area o acial bones

8

Lat e ral: Facial Bo n e s

• Superimposed acial
bones, greater wings
s
e
s
o sphenoid and sella
u
n
turcica
i
S
• Region rom orbital
l
a
s
roo s to mentum
a
n
a
demonstrated
r
a
P
d
Position
n
a
• No tilt; evident by
,
s
superimposition o
e
n
o
orbital plates (roo s)
B
• No rotation; evident
l
a
i
c
by superimposition R
a
F
o greater wings
,
m
Fig . 8.22 Lateral acial bones
o sphenoid and
u
i
Competency Check:
mandibular rami
n
Technologist Date
a
r
C
Exposure
• Optimal density (brightness) and contrast to visualize acial
structures
• Sharp bony margins; no motion 8
241
Parie t o acan t h ial: Facial Bo n e s
Wat e rs an d Mo d if e d Wat e rs Me t h o d s
R
C
r
a
• 18 × 24 cm (8 × 10″)
n
i
u
portrait or 24 × 30 cm Ere ct P os ition
m
(10 × 12″) portrait 37°
,
F
CR
• Grid
a
c
i
a
Po sit io n
l
B
Waters
o
Fig . 8.23 PA Waters, OML 37°—CR and MML
n
• Seated erect or
e
s
,
prone on table
a
n
(erect pre erred)
d
P
• Extend head resting on
a
r
chin; place MML to
a
n
a
IR, which places the
s
a
OML 37° to IR 55°
l
S
i
• Center IR to CR
n
u
s
Modif ed Waters
e
s
• OML is 55° to the plane Fig . 8.24 PA modif ed Waters, OML
o the IR, or line rom 55°—CR and LML
junction o lips to EAM
(LML) is to IR
Central Ray: CR to IR, to exit at acanthion (both projections)
SID: 40″ (102 cm)
Collimation: On our sides to area o acial bones
8

Parie t o acan t h ial an d Mo d if e d Parie t o acan t h ial
Wat e rs an d Mo d if e d Wat e rs Me t h o d s
s
e
s
u
n
i
S
l
a
s
a
n
a
r
a
P
d
n
a
,
s
e
Fig . 8.25 PA Waters Fig . 8.26 PA modif ed Waters
n
o
B
l
a
i
c
a
F
,
m
u
• Waters: General survey o acial bones; in erior orbital rims,
i
n
maxillae, and nasal septum
a
r
C
• Modif ed Waters: In erior orbital oors in prof le (undistorted)
Ideal projection to demonstrate possible “blow out” ractures o
orbital oor
Position
• Waters: Petrous ridges just in erior to oor o maxillary sinuses
• Modif ed Waters: Petrous ridges projected in lower 1 2 o
maxillary sinuses No rotation; equal distance between orbits and
8
lateral skull
Exposure
• Optimal density (brightness) and contrast to visualize maxillary
region and surrounding structures
243
PA Axial ( 1 5 °) : Facial Bo n e s
15°
R
C
r
a
n
• 18 × 24 cm (8 × 10″)
i
u
m
,
F
a
• Grid
c
i
a
l
Po sit io n
B
o
• Seated erect or
n
e
s
prone on table, MSP
,
a
aligned to CR and
n
d
to midline o the
P
a
table and/or IR
r
a
• With orehead and Fig . 8.27 PA axial—15° Caldwell (OML );
n
a
CR to exit at nasion
s
nose resting on
a
l
imaging device, adjust head to place OML perpendicular to IR;
S
i
n
ensure no rotation or tilt
u
s
e
• Center IR to projected CR (to nasion)
s
Central Ray: CR 15° caudal to OML, centered to exit at nasion
Note: A 30° CR angle is required to project petrous ridges below
lower orbital margins i this is an area o interest CR will exit at level
o midorbits
SID: 40″ (102 cm)
Collimation: On our sides to skull ( acial bones) margins

8

PA Axial ( 1 5 °) : Facial Bo n e s

• Orbital rims, maxillae,
s
e
nasal septum, and R
s
u
zygomatic arches
n
i
S
l
a
s
Position
a
n
• Petrous ridges projected
a
r
a
in lower 1 3 o orbits No
P
rotation; equal distance
d
n
between orbits and
a
,
s
lateral skull margins
e
n
o
B
Exposure
l
a
i
• Optimal density
c
a
F
(brightness) and
,
m
contrast to visualize Fig . 8.28 PA axial Caldwell—15°
u
maxillary region and
i
caudad
n
a
orbital oor
r
Competency Check:
C
• Sharp bony margins; no Technologist Date
motion
8
245
Lat e ral, Acan t h io p arie t al: Facial Bo n e s ( Traum a)
Re ve rse Wat e rs an d Re ve rse Mo d if e d Wat e rs Me t h o d s
Warning: With possible spine or

severe head injuries, per orm all pro-
jections with patient supine without
C
moving patient’s head or without
r
a
removing cervical collar, i present
n
i
u
m
,
Lat e ral (Ho rizo n t al Be am )
F
a
• 18 × 24 cm (8 × 10″) portrait
c
i
a
• Grid, placed on edge against Fig . 8.29 Horizontal beam
l
B
lateral cranium lateral—CR to midway
o
n
• Ensure no rotation or tilt, MSP between outer canthus and
e
s
EAM
,
parallel to IR
a
n
• CR horizontal, to midway
d
between outer canthus and
P
a
r
EAM
a
n
a
s
a
Re ve rse Wat e rs
l
S
• 18 × 24 cm (8 × 10″) portrait
i
n
u
• Grid (bucky), AEC—center
s
e
f eld
s
• MSP aligned to CR and Fig . 8.30 Trauma reverse
midline o table or IR Waters—CR parallel to
• Ensure no rotation or tilt MML, centered to acanthion
• CR parallel to MML
• CR centered to acanthion (CR
angled cephalad, as needed,
unless cervical injury has been
ruled out)
8
Re ve rse Mo d if e d Wat e rs
• Same as reverse Waters except:
• CR parallel to junction o Fig . 8.31 Trauma reverse
lips-meatal line (LML) modif ed Waters—CR
parallel to LML, centered to
• CR centered to acanthion
acanthion

Parie t o -Orb it al Ob liq ue : Op t ic Fo ram in a
Rh ese Me t h o d
CR
37°
L R 53°
s
e
s
u
n
• 18 × 24 cm (8 × 10″) landscape
i
S
• Grid
l
a
s
• Bilateral orbit study per ormed
a
n
or comparison A
a
r
a
P
d
Po sit io n
n
a
• Seated erect or prone on
,
s
e
table
n
o
• As a starting re erence,
B
l
adjust the head so the nose,
a
i
c
cheek, and chin are touching
a
F
the tabletop
,
m
• Adjust the head so the plane B
u
i
o AML is perpendicular to Fig . 8.32 A, Rhese oblique (right side)
n
a
r
the IR, and the midsagittal B, Rhese oblique
C
—AML and CR
plane is 53° to the IR (use
—53° rotation o head rom lateral
angle indicator)
• Center IR to CR (to downside orbit)
Central Ray: CR to IR, to midportion o downside orbit
SID: 40″ (102 cm)
Collimation: Closely collimate to 3–4″ (8–10 cm) square
8

Bilat e ral SMV: Zyg o m at ic Arch e s
R
C
r
a
• 24 × 30 cm
n
i
u
m
• Grid
,
• AEC not
F
a
c
recommended
i
a
l
B
o
Po sit io n
n
e
• Seated erect or Fig . 8.33 SMV, bilateral zygomatic arches,
s
,
supine with head erect—CR to IOML (nongrid may be
a
n
extended over end pre erred)
d
P
o table resting top
a
r
a
o head against grid IR (table may be tilted up slightly)
n
a
• Adjust IR and head to place IOML parallel to IR
s
a
l
S
i
• Center IR to CR
n
u
Central Ray: CR angled as needed to be to IOML, centered to
s
e
s
midway between zygomatic arches (≈1 5″ or 4 cm in erior to man-
dibular symphysis)
SID: 40″ (102 cm)
Collimation: To include area o zygomatic arches

8

Ob liq ue In e ro sup e rio r ( Tan g e n t ial) :
Zyg o m at ic Arch e s
s
L
e
s
u
n
i
S
Bilateral arches generally
l
a
taken or comparison
s
a
n
• 18 × 24 cm (8 × 10″)
a
r
portrait
a
P
• Grid
d
• AEC not
n
a
recommended
,
s
e
Fig . 8.34 Tangential o le zygomatic arch—
n
o
Po sit io n CR to IOML, head tilted 15°, rotated 15°
B
l
• Position as or an
a
i
c
SMV skull with the IOML parallel to the IR
a
F
• Rotate the head ≈15° toward side being examined
,
m
• Tilt the midsagittal plane ≈15° toward the side being examined
u
i
n
(more tilt may be needed to ree the zygomatic arch rom
a
r
superimposition by mandible or parietal bone)
C
• Center IR to CR
Central Ray: CR angled i needed to be to IOML, centered to
midzygomatic arch
SID: 40″ (102 cm)
Collimation: Collimate closely to area o interest

8

SMV an d Ob liq ue In e ro sup e rio r ( Tan g e n t ial) :
Zyg o m at ic Arch e s
C
r
a
n
i
u
m
,
F
a
c
i
a
l
B
o
n
e
s
R L
,
a
n
Fig . 8.35 SMV Fig . 8.36 Oblique tangential
d
P
a
r
a
n
a
s
a
l
S
i
n
• SMV: Bilateral zygomatic arches
u
s
e
• Tangential: Unilateral zygomatic arch
s
Position
• SMV: Unobstructed view o bilateral arches No rotation;
symmetry o arches
• Oblique in erosuperior (tangential): Unilateral view o
unobstructed arch No superimposition o arch with parietal bone
or mandible
8
Exposure
• Optimal density (brightness) and contrast to visualize the
zygomatic arches
• Sharp bony margins with so tissue detail; no motion
250
AP Axial: Zyg o m at ic Arch e s
Mo d if e d To wn e Me t h o d
s
e
s
u
• 18 × 24 cm (8 × 10″) landscape
n
i
S
• Grid
l
a
s
a
n
a
Po sit io n
r
A
a
P
• Seated erect or supine on
d
table, midsagittal plane
n
a
aligned to midline o table or
,
s
e
IR; ensure no rotation or tilt
n
o
• Depress chin to bring either
B
l
the OML or the IOML
a
i
c
perpendicular to IR
a
F
,
m
u
B
i
n
Central Ray:
a
r
• CR 30° caudad to OML; or Fig . 8.37 A, AP axial—CR 37° to
C
37° to IOML IOML B, AP axial
• CR 1″ (2 5 cm) superior to nasion to pass through level o
midarches
SID: 40″ (102 cm)
Collimation: On our sides to area o bilateral arches

8

Lat e ral: Nasal Bo n e s
L
C
r
a
Bilateral projections
n
i
generally taken or
u
m
comparison
,
• 18 × 24 cm (8 × 10″)
F
a
c
landscape
i
a
• Nongrid—detail
l
B
screens (analog)
o
n
e
Fig . 8.38 Le lateral—nasal bones
s
,
Po sit io n
a
n
• Seated erect or semiprone on table
d
• Center nasal bones to hal o IR and to CR
P
a
r
• Adjust head to bring IOML parallel to top and bottom edge o IR
a
n
• Ensure a true lateral, IPL perpendicular to IR, and midsagittal
a
s
a
plane parallel to IR
l
S
Central Ray: CR to IR, centered to ≈0 5″ (1 25 cm) in erior to
i
n
u
nasion
s
e
s
SID: 40″ (102 cm)
Collimation: Closely collimate to ≈4″ (10 cm) square

8

Lat e ral: Nasal Bo n e s
s
e
s
u
n
i
S
l
a
s
a
n
a
r
a
P
d
Fig . 8.39 Lateral nasal bones
n
a
Competency Check:
,
s
Technologist Date
e
n
o
B
l
a
i
c
a
F
• Nasal bones with so tissue structures
,
m
• Frontonasal suture to anterior nasal spine
u
i
n
a
r
C
Position
• No rotation; complete prof le o nasal bones
• Frontonasal suture to anterior nasal spine within collimation f eld
Exposure
• Optimal density (brightness) and contrast to visualize nasal bones
and surrounding so tissue structures
8
253
Sup e ro in e rio r Tan g e n t ial ( Axial) : Nasal Bo n e s
R
C
r
a
• 18 × 24 cm (8 × 10″)
n
i
u
landscape
m
• Nongrid—detail screens
,
F
(analog)
a
c
i
a
l
Po sit io n Fig . 8.40 Seated
B
o
• Seated erect at end o
n
e
table or prone on table
s
,
a
• I prone, place supports under chest
n
d
and under IR
P
a
• Rest extended chin on IR, which
r
a
should be perpendicular to GAL
n
a
s
(glabelloalveolar line) and to CR
a
l
Central Ray: CR directed parallel to
S
i
n
GAL, tangential to the glabella
u
s
SID: 40″ (102 cm)
e
s
Collimation: Closely collimate to ≈4″
(10 cm) square Fig . 8.41 Superoin erior

8

PA an d PA Axial: Man d ib le
s
e
s
u
n
• 18 × 24 cm (8 × 10″)
i
S
or 24 × 30 cm
l
a
s
a
n
• Grid
a
r
• AEC not
a
P
recommended
d
n
a
Fig . 8.42 PA mandible—CR and OML
,
Po sit io n
s
e
to IR )
n
• Seated erect or
o
B
prone on table,
l
a
head aligned to midline o the table and/or IR
i
c
a
• With orehead and nose resting on tabletop, adjust head to place
F
,
OML to IR
m
u
• No rotation or tilt, midsagittal plane to IR
i
n
• Center IR to CR (level o junction o lips)
a
r
C
Central Ray: CR to IR, to exit at level o lips
PA Axial (Optional): A CR angle o 20°–25° cephalad centered to
exit at the acanthion best demonstrates proximal rami and condyles
SID: 40″ (102 cm)
Collimation: Collimate to area o mandible (square area)

8

Axio lat e ral an d Axio lat e ral Ob liq ue : Man d ib le
R
C
r
a
n
i
u
m
,
F
a
c
i
a
Fig . 8.43 Semisupine Fig . 8.44 Erect axiolateral
l
B
R and L sides generally imaged or oblique
o
n
comparison unless contraindicated —CR 25° cephalad (maximum)
e
s
• 18 × 24 cm (8 × 10″) or 24 × 30 cm —10°–15° head rotation or gen-
,
a
(10 × 12″) landscape eral survey (as shown above)
n
• Grid or nongrid
d
—0° head rotation or ramus
P
—30° head rotation or body
a
r
a
Po sit io n —45° head rotation or mentum
n
a
• Seated erect, semiprone, or
s
a
semisupine, with support under shoulder and hip
l
S
• Extend chin, with side o interest against IR
i
n
u
• Adjust head so IPL is perpendicular to IR, no tilt
s
e
• Rotate head toward IR as determined by area o interest
s
• Head in true lateral demonstrates ramus (axiolateral)
• 10°–15° rotation best provides a general survey o the mandible
• 30° rotation toward IR best demonstrates body
• 45° rotation best demonstrates mentum
Central Ray: CR 25° cephalad to IPL, centered to downside midmandible
(≈2″ or 5 cm below upside angle)
SID: 40″ (102 cm)
Collimation: To area o mandible (square area)
8

Axio lat e ral Ob liq ue : Man d ib le ( Traum a)
s
e
s
For trauma patients unable to
u
n
cooperate
i
S
• 18 × 24 cm (8 × 10″) or 24 ×
l
a
s
30 cm (10 × 12″) landscape
a
n
• Grid or nongrid
a
r
a
P
Po sit io n
d
• Supine, no rotation o head,
n
Fig . 8.45 Horizontal beam
a
MSP to tabletop
,
axiolateral—CR 25° cephalad
s
e
• IR on edge next to ace,
n
rom lateral, 5°–10° down
o
parallel to MSP with lower
B
l
edge o IR ≈1″ (2 5 cm) below lower border o mandible
a
i
c
• Depress shoulders and elevate or extend chin, i possible
a
F
Note: May rotate head toward IR slightly (10°–15°) to better visualize
,
m
body or mentum o mandible i this is area o interest
u
i
n
a
Central Ray:
r
C
• CR horizontal beam, 25° cephalad ( rom lateral or IPL); angled
down (posteriorly) 5°–10° to clear shoulder
• CR centered to ≈2″ (5 cm) distal to angle o mandible on side
away rom IR
SID: 40″ (102 cm)
Collimation: To area o mandible (square area)

8

PA an d Axio lat e ral Ob liq ue : Man d ib le
C
R
r
a
n
i
u
m
R
,
F
a
c
i
a
l
B
o
Fig . 8.47 Axiolateral
n
e
oblique mandible
s
,
a
Fig . 8.46 PA mandible Competency Check:
n
Technologist Date
d
Competency Check:
P
Technologist Date
a
r
a
n
a
s
a
l
S
i
n
• PA: Mandibular rami and lateral portion o body
u
s
e
• Axiolateral and Axiolateral Oblique: Mandibular rami, condylar
s
and coronoid processes, and body o near side
Position
• PA: No rotation evident by symmetry o rami
• Axiolateral and Axiolateral Oblique: Unobstructed view o
mandibular rami, body, and mentum No oreshortening o area o
interest
8
Exposure
• Optimal density (brightness) and contrast to visualize mandibular
area o interest
258
AP Axial: Man d ib le o r Te m p o ro m an d ib ular
Jo in t s an d Co n d ylo id Pro ce sse s
s
e
s
u
• 18 × 24 cm (8 × 10″) or
n
i
S
24 × 30 cm (10 × 12″)
l
portrait
a
s
a
• Grid
n
a
r
a
P
Po sit io n
d
• Seated erect or
n
Fig . 8.48 AP axial, CR 35° to OML (CR
a
supine on table, centered or mandible)
,
s
e
midsagittal plane
n
o
centered to midline o table; ensure no rotation or tilt
B
l
• Depress chin to bring OML perpendicular to IR, i possible (or
a
i
c
place IOML perpendicular and add 7° to CR angle)
a
F
,
m
u
i
n
Central Ray:
a
r
C
• CR 35° to OML (42° to IOML) caudad
• CR centered to glabella or mandible
Note: CR centered ≈1″ (2 5 cm) above glabella to pass through TMJs
i TMJs are o primary interest
SID: 40″ (102 cm)
Collimation: To include rom TMJs to body o mandible

8

Axio lat e ral Ob liq ue : Te m p o ro m an d ib ular Jo in t s
Mo d if e d Law Me t h o d
R
C
r
a
n
i
Bilateral sides imaged or
u
m
comparison in both open and closed
,
F
mouth positions
a
c
• 18 × 24 cm (8 × 10″) portrait Fig . 8.49 Closed mouth
i
a
l
(divided on same IR)
B
o
• Grid
n
e
s
,
Po sit io n
a
n
• Seated erect (pre erred) or
d
P
semiprone on table, a ected
a
r
side down
a
n
a
• Adjust chin to place IOML
s
a
perpendicular to ront edge o
l
Fig . 8.50 Open mouth
S
i
IR —15° oblique ( rom lateral)
n
u
• Rotate skull (midsagittal and 15° CR (caudad)
s
e
s
plane) 15° toward IR, no tilt, IPL remains perpendicular to IR
• Portion o IR being exposed centered to CR
• Second exposure in same position except with mouth ully open
Central Ray: CR 15° caudad, centered to enter 1 1 2 ″ (4 cm) superior
to upside EAM
SID: 40″ (102 cm)
Collimation: Collimate to 3–4″ (8–10 cm) square
8

Axio lat e ral: Te m p o ro m an d ib ular Jo in t s
Sch ulle r Me t h o d
s
e
s
u
n
Bilateral sides imaged or compari-
i
S
son in both open and closed mouth
l
a
s
positions
a
n
• 18 × 24 cm (8 × 10″) portrait
a
Fig . 8.51 Closed mouth
r
a
(divided on same IR)
P
• Grid
d
n
a
Po sit io n
,
s
e
• Seated erect or semiprone,
n
o
B
a ected side down
l
• Adjust chin to place IOML
a
i
c
perpendicular to ront
a
F
edge o IR, true lateral, no
,
m
rotation or tilt o head
u
i
Fig . 8.52 Open mouth
n
• Portion o IR being exposed
a
—25° caudad, 0° rotation
r
C
centered to projected CR
• Second exposure in same position except with mouth ully open
Central Ray: CR 25°–30° caudad, centered to enter 2″ (5 cm) superior
and 1 2 ″ (1–2 cm) anterior to upside EAM
SID: 40″ (102 cm)
Collimation: Collimate to 3–4″ (8–10 cm) square

8

Axio lat e ral Ob liq ue ( Mo d if e d Law Me t h o d )
an d Axio lat e ral ( Sch ulle r Me t h o d ) :
Te m p o ro m an d ib ular Jo in t s
C
r
a
n
i
u
m
,
F
a
c
i
a
l
B
o
n
e
s
,
a
n
d
P
Fig . 8.53 Axiolateral oblique— Fig . 8.54 Axiolateral projection—
a
r
a
closed mouth, downside TMJ shown open mouth; TMJ shown with
n
a
in ossa (modif ed Law) condyle moved to anterior margin
s
a
o ossa (Schuller)
l
Competency Check:
S
Technologist Date
i
Competency Check:
n
u
Technologist Date
s
e
s
Note: Positioning routine would require both open and closed mouth
o modif ed Law method, or both open and closed o Schuller method

• Modif ed Law: Bilateral, unctional study o TMJ and ossa
• Schuller: Bilateral, unctional study o TMJ and ossa
8
Position
• Modif ed Law: Unobstructed view o TMJ in both open and
closed mouth positions (only closed mouth is shown)
• Schuller: Unobstructed view o TMJ in both open and closed
mouth positions Greater elongation o the condyles (only open
mouth is shown)
Exposure
• Optimal density (brightness) and contrast to visualize the TMJ
and mandibular ossa
262
Lat e ral: Paran asal Sin use s
s
e
s
u
Requires an erect
n
i
S
position with
l
a
horizontal CR to
s
a
demonstrate air- uid
n
a
levels
r
a
P
• 18 × 24 cm (8 × 10″)
d
portrait
n
Fig . 8.55 Erect lateral
a
• Grid
,
s
e
n
o
B
Po sit io n
l
a
i
• Erect, seated acing IR, turn head into true lateral position
c
a
F
• Raise chin to bring IOML perpendicular to ront edge o IR
,
m
• No rotation, midsagittal plane parallel and IPL to IR
u
i
• Center IR to CR
n
a
Central Ray: CR horizontal to midway between EAM and outer
r
C
canthus
SID: 40″ (102 cm)
Collimation: Collimate on our sides to region o sinuses

8

PA: Paran asal Sin use s
Mo d if e d PA–Cald we ll Me t h o d
R
C
r
a
Requires
n
i
u
an erect
m
position with
,
F
horizontal CR
a
c
to demonstrate
i
a
l
air- uid levels
B
o
• 18 × 24 cm
n
e
(8 × 10″) Fig . 8.56 PA Caldwell Fig . 8.57 Modif ed PA
s
,
portrait (i IR holder can be Caldwell (i IR holder
a
n
• Grid tilted)
d
cannot be tilted)
• AEC not
P
a
recommended
r
a
n
a
Po sit io n
s
a
l
PA Caldwell:
S
i
• Patient seated erect, acing IR; tilt top o IR 15° toward patient
n
u
• Adjust head so that OML is to IR, no rotation
s
e
s
• IR centered to CR (nasion)
Modif ed PA Caldwell:
• Tilt head back to bring OML 15° rom horizontal
Central Ray: CR horizontal (parallel to oor) and exits at nasion
SID: 40″ (102 cm)
Collimation: To region o sinuses

8

Lat e ral an d PA ( Mo d if e d Cald w e ll
Me t h o d ) : Sin use s
s
e
s
u
n
i
S
l
a
s
a
n
a
r
a
P
d
n
a
,
s
e
n
o
B
L L
l
a
i
c
Fig . 8.58 Lateral sinuses Fig . 8.59 PA axial (Caldwell
a
F
Competency Check: method)—sinuses
,
m
u
Technologist Date
i
n
a
r
C
• Lateral: All paranasal sinuses demonstrated
• PA Caldwell: Frontal and anterior ethmoid sinuses
Position
• Lateral: No rotation or tilt; superimposition o greater wings/
sphenoid, orbital roo s, and sella turcica
• PA Caldwell: Petrous ridges in lower 1 3 o orbits No rotation;
8
equal distance between orbits and lateral skull
Exposure
paranasal sinuses
265
Parie t o acan t h ial: Paran asal Sin use s
Wat e rs Me t h od
R
C
r
a
Requires an erect
n
i
position with
u
m
horizontal CR to
,
F
demonstrate air- uid
a
37°
c
levels
i
a
CR
l
• 18 × 24 cm (8 × 10″)
B
o
or 24 × 30 cm
n
(10 × 12″) portrait Fig . 8.60 PA erect Waters, MML , and
e
s
,
• Grid CR horizontal
a
n
d
P
Po sit io n
a
r
a
• Seated erect, chin extended and touching imaging device
n
a
• Adjust height o IR to center at acanthion
s
a
l
• Adjust MML perpendicular to IR (OML is 37° to IR)
S
i
n
• No rotation, midsagittal plane perpendicular to IR
u
s
• Center IR to CR
e
s
Op t io n al Op e n -Mo ut h Po sit io n
• Patient opens mouth wide to better visualize sphenoid sinuses
through the open mouth
Central Ray: CR horizontal and to IR, to exit at acanthion
SID: 40″ (102 cm)
Collimation: Collimate on our sides to area o sinuses
8

SMV: Paran asal Sin use s
s
e
s
u
Requires an erect posi-
n
i
tion with horizontal
S
l
CR to demonstrate
a
s
a
air- uid levels
n
a
• 18 × 24 cm (8 × 10″)
r
a
or 24 × 30 cm
P
d
n
Fig . 8.61 SMV sinuses—CR to IOML
a
• Grid
and IR
,
s
• AEC not
e
n
recommended
o
B
l
a
Po sit io n
i
c
a
• Seated erect, leaning back in chair and extending head to rest top
F
,
o head against IR holder
m
u
• Adjust head to place IOML as near parallel to plane o IR as
i
n
a
possible; ensure no rotation or tilt
r
C
• Center IR to CR
Central Ray: CR horizontal and to IOML, centered to midpoint
between angles o mandible at level 1½–2″ (4–5 cm) in erior to man-
dibular symphysis
SID: 40″ (102 cm)
Collimation: On our sides to region o sinuses

8

Parie t o acan t h ial ( Wat e rs Me t h o d )
an d SMV: Sin use s
R
C
r
a
n
i
u
m
,
F
a
c
i
a
l
B
o
n
e
s
Fig . 8.63 SMV sinuses
,
a
Competency Check:
n
d
Technologist Date
Fig . 8.62 PA (Waters) sinuses
P
a
r
Competency Check:
a
n
Technologist Date
a
s
a
l
S
i
n
u
s
e
• Waters: Unobstructed view o maxillary sinuses
s
• SMV: Unobstructed view o sphenoid, maxillary, and ethmoid
sinuses
Position
• Waters: Petrous ridges just in erior to oor o maxillary sinuses
• SMV: Mandibular condyles projected anterior to petrous bone No
rotation or tilt; symmetry o petrous pyramids and equal distance
8
between mandibular border and lateral skull
Exposure
paranasal sinuses
268
Ch ap t e r 9
Ab d o m e n an d Co m m o n Co n t rast
Me d ia Pro ce d ure s
s
e
r
u
d
e
• Shielding and positioning landmarks 271
c
o
• Barium distribution and body positions 272
r
P
• Acute Abdomen Series 273
a
i
d
e
M
t
s
Ab d o m e n (Ad ult ) Up p e r GI (St o m ach )
a
r
t
AP supine (KUB) PA 287
n
o
(R) 274 RAO 288
C
AP erect (S) 275 PA and RAO critique 289
n
o
AP supine and AP Right lateral 290
m
m
erect critique 276 AP 291
o
C
Lateral decubitus Lateral and AP critique 292
d
(AP) (S) 277 LPO 293
n
a
Dorsal decubitus LPO critique 294
n
e
(lateral) (S) 278
m
Lateral and dorsal Sm all Bow e l
o
d
decubitus critique 279 PA 295
b
A
Ab d o m e n (Pe d iat ric) Barium En e m a
AP supine (KUB) PA (AP) 296
(R) 280 PA (AP) critique 297
AP erect (S) 281 RAO and LAO
AP supine and erect (RPO and LPO) 298
critique 282 Oblique critique 299
Lateral rectum (ventral
Eso p h ag o g ram decubitus) 300
9
RAO 283 Lateral decubitus
Lateral 284 (double contrast) 301
RAO and lateral AP (PA) axial 302
critique 285 Lateral decubitus and
AP (PA) 286 AP (PA) axial critique 303
269
In t rave n o us Cyst o g rap h y
Uro g rap h y (IVU) AP axial 308
AP (PA) (scout and Posterior oblique and
series) 304 optional lateral 309
A
b
RPO and LPO 305 AP and posterior
d
o
AP and posterior oblique critique 310
m
oblique critique 306
e
n
AP erect (postvoid) 307
a
n
d
C
o
m
m
o
n
C
o
n
t
r
a
s
t
M
e
d
i
a
P
r
o
c
e
d
u
r
e
s
9
270
Sh ie ld in g an d Po sit io n in g Lan d m arks
Sh ie ld in g
All radiosensitive tissues outside
the anatomy of interest should be
shielded
s
e
r
u
Go n ad al Sh ie ld in g
d
e
Males: Gonadal shields should
c
o
r
be used on all males of reproduc-
P
a
tive age, with upper edge of shield
i
d
placed at symphysis pubis unless
e
M
it obscures essential anatomy Fig . 9.1 Male gonadal shield
t
(top of shield at symphysis
s
Females: Ovarian gonadal
a
r
pubis)
t
shields may be used for abdomen
n
o
examinations on all females,
C
n
only if such shields do not obscure
o
m
essential anatomy for that examination
m
as determined by a radiologist/physician
o
C
(shielding is especially important for
d
children)
n
a
n
Pre g n an cy
e
m
Generally, no radiographic procedures
o
d
exposing the pelvic region should be
b
A
performed during pregnancy without
special instruction from a radiologist/
Fig . 9.2 Female ovarian
physician shield (top of shield at or
To p o g rap h ic Po sit io n in g slightly above the level of
Lan d m arks ASIS, lower border just above
symphysis pubis)
Certain positioning landmarks are
essential for positioning the general abdomen and speci c organs
within the abdomen because the borders of these organs and the upper
9
and lower margins of the general abdomen itself are not visible from
the exterior
Abdominal borders and organ locations, however, can be deter-
mined by certain landmarks, which can be located by gentle palpation
with the ngertips, being careful of painful or sensitive areas (T e
patient should be informed of the purpose for this before beginning
the palpation process )
271
Barium Dist rib ut io n an d Bo d y Po sit io n s
T e air-barium distribution within the stomach and large intestine

changes with various body positions By knowing these distribution
patterns, one can determine the body position a radiograph was taken
Air always rises to the highest levels, and the heavy barium settles to
A
the lowest levels (air is black, and barium is white)
b
d
o
m
St om ach
e
n
T e fundus is located more posteriorly; therefore in the supine posi-
a
n
tion, the fundus would be the lowest portion of the stomach and would
d
be lled with barium
C
o
In both prone and erect positions, the fundus would be lled with
m
m
air, as seen on the drawings below, with a straight air-barium line on
o
the erect
n
C
o
n
t
r
a
s
t
M
e
d
i
a
P
r
o
c
e
d
u
r
e
s
Fig . 9.3 Supine Fig . 9.4 Prone Fig . 9.5 Erect (straight-
(barium in fundus) (barium in body line barium-air level)
and pylorus) Barium = white
Air = black
9
272
Larg e In t e st in e
T e ascending and
descending portions
are located more
s
e
posteriorly, and thus
r
u
d
more of these parts
e
c
would be lled with
o
r
P
barium (white) in the
a
supine position and
i
d
e
with air (black) in the
M
prone position.
t
Fig . 9.6 Supine Fig . 9.7 Prone
s
a
Note: T is much sepa-
r
t
n
ration of barium and air
o
C
occurs generally only with double-contrast
n
barium-air studies
o
m
Air- uid levels would be seen in the
m
erect position, in which the air would
o
C
rise to the highest position in each of the
d
various sections of the large intestine, as
n
a
shown in the accompanying gure
n
e
Right and le decubitus projections
m
Fig . 9.8 Erect
o
(not shown on these drawings) also
d
b
would demonstrate air- uid levels, with air again rising to the highest
A
portions
Acut e Ab d o m e n Se rie s
T ree-way abdomen:
• AP supine (KUB)
• AP erect
• PA chest
9
wo-way abdomen:
• AP supine (KUB)
• Le lateral decubitus
273
AP Sup in e ( KUB) : Ab d o m e n ( Ad ult )
A
b
d
o
m
R
e
n
• 35 × 43 cm (14 ×
a
n
d
17″) portrait
C
• Grid
o
m
Fig . 9.9 KUB abdomen
m
Po sit io n
o
n
• Supine, legs extended, arms at sides
C
• Midsagittal plane aligned and centered to midline of table and/or
o
n
IR
t
r
a
• Ensure no rotation (ASISs equal distance from tabletop)
s
t
• Center of IR to level of iliac crests, ensuring that upper margin
M
e
of symphysis pubis is included on lower IR margin (A large
d
i
a
hypersthenic patient may require that the IR be placed landscape
P
r
with a second IR centered higher)
o
c
Central Ray: CR , to center of IR (level of iliac crests)
e
d
SID: 40″ (102 cm)
u
r
e
Collimation: Collimate to upper and lower abdomen so tissue
s
borders
kV Range: Analog: 70–80 kV Digital System s:* 80 ± 5 kV

*Recommended kV ranges are similar for analog and digital systems to
prevent overpenetration of small calculi in the abdomen

9
S

AP Ere ct : Ab d o m e n
T
C
E
R
E
s
e
r
u
d
e
R
c
o
r
P
a
• 35 × 43 cm (14 ×
i
d
17″) portrait
e
M
• Grid
t
s
• Erect marker
a
r
• Patient should be
t
n
o
on side a minimum
C
Fig . 9.10 Erect AP (include diaphragm)
of 5 minutes before
n
o
exposure; a period of 10–20 minutes is preferred
m
m
o
Po sit io n
C
• Erect, back against table, arms at sides
d
n
• Midsagittal plane aligned and centered to centerline
a
n
• Ensure no rotation
e
m
• Center of IR ≈2″ (5 cm) above iliac crest to include diaphragm
o
(For sthenic patient, top of IR is at level of axilla)
d
b
A
Central Ray: CR horizontal, to center of IR (2″ [5 cm] above iliac
crest)
SID: 40″ (102 cm)
Collimation: o so tissue margins of abdomen and diaphragm

9
S

AP Sup in e an d AP Ere ct : Ab d o m e n

• AP supine: Outline of
liver, spleen, psoas muscles,
A
b
and kidneys to include
d
o
symphysis pubis lower
m
abdomen
e
n
• AP erect: Hemidiaphragms
a
n
and signi cant portion of
d
C
lower abdomen
o
m
m
Position
o
n
• AP supine and erect: No
C
rotation; symmetry of iliac
o
n
wings and outer, lower rib
t
r
a
margins
s
t
Fig . 9.11 AP KUB
M
Competency Check:
e
Exposure
d
Technologist Date
i
a
• Optimal density
P
r
(brightness) and contrast to
o
c
visualize psoas muscles and
e
d
u
lumbar transverse processes
r
e
• Air- uid levels seen, if
s
present
• Liver margins and kidneys
visible on patients of
average size; no motion
9
Fig . 9.12 AP erect
Competency Check:
Technologist Date
276
Lat e ral De cub it us ( AP) : Ab d o m e n
R DECUB
s
e
r
u
d
e
c
• 35 × 43 cm (14 ×
o
r
17″) landscape
P
a
• Grid
i
d
• Decubitus marker
e
M
• Arrow marker to Fig . 9.13 Le lateral decubitus (AP)
t
s
include upside
a
r
• Patient should be on side a minimum of 5 minutes before exposure; a
t
n
o
period of 10–20 minutes is preferred
C
n
Po sit io n
o
m
• Lock wheels of stretcher
m
• Patient on side (on decubitus board or support to elevate
o
C
downside abdomen), knees partially exed, arms up near head
d
• Adjust patient and stretcher so that center of IR and table (and
n
a
CR) is approximately 2″ (5 cm) above level of iliac crest (to
n
e
include diaphragm)
m
o
• Adjust height of IR to ensure that upside of abdomen is included
d
b
for possible free air
A
Central Ray: CR horizontal, to center of IR
SID: 40″ (102 cm)
Collimation: o so tissue margins of abdomen and diaphragm

9
S

Do rsal De cub it us ( Lat e ral) : Ab d o m e n
R DECUB
A
b
d
o
m
• 35 × 43 cm (14 ×
e
n
17″) landscape
a
n
• Grid
d
• Include decubitus
C
o
marker
m
Fig . 9.14 Dorsal decubitus (R lateral)
m
o
Po sit io n
n
• Patient supine (on decubitus board or support to elevate posterior
C
o
abdomen), side against table, arms above head
n
t
r
• Secure stretcher (lock wheels)
a
s
t
• Center of IR and table (and CR) at level of iliac crest (2″ [5 cm]
M
above iliac crest to include diaphragm)
e
d
• Adjust height of IR to align midcoronal plane to centerline of IR
i
a
Central Ray: CR horizontal, to center of IR
P
r
o
SID: 40″ (102 cm)
c
e
Collimation: Collimate to upper and lower abdomen so tissue
d
u
r
borders
e
s

9
S

Lat e ral an d Do rsal De cub it us: Ab d o m e n

• Lateral decubitus:
Abdomen visualized
s
e
to include air- lled
r
u
d
stomach and bowel
e
c
and upside diaphragm
o
r
P
• Dorsal decubitus:
a
i
Abdomen visualized
d
e
to include
M
hemidiaphragms
t
s
a
r
Position Fig . 9.15 Lateral decubitus
t
n
o
• Lateral decubitus: No Competency Check:
C
Technologist Date
rotation; symmetry of
n
o
iliac wings and spine
m
m
straight
o
C
• Dorsal decubitus: R
d
No rotation;
n
a
symmetry of iliac
n
e
wings and diaphragm
m
Intervertebral joint
o
d
spaces and vertebral
b
A
bodies should be
visible
Exposure
Fig . 9.16 Dorsal decubitus
• Optimal density
Competency Check:
(brightness) and Technologist Date
contrast to visualize
so tissue structures and lumbar spine
• So tissue structures and any intraperitoneal air demonstrated on
9
patients of average size; no motion
279
AP Sup in e ( KUB) : Ab d o m e n ( Pe d iat ric)
R
A
b
d
o
m
• 18 × 24 cm (8 × 10″),
e
n
24 × 30 cm (10 × 12″), or
a
n
30 × 35 cm (11 × 14″) portrait
d
Fig . 9.17 Child AP abdomen (KUB)
(or determined by size of
C
o
patient)
m
• Screen <10 cm, grid >10 cm
m
o
n
Po sit io n (In fan t )
C
• Supine, immobilize arms above head (use stockinette, Ace
o
n
bandage, tape, or sandbags)
t
r
a
• Immobilize legs with Ace bandage or tape and sandbags
s
t
• Center IR to CR
M
e
• Shield gonads, if possible
d
i
a
Parental Assistance for Infant: Use only if necessary Supply with
P
r
lead apron and gloves, and have parent hold patient’s arms above head
o
c
with one hand and legs with other hand, preventing rotation
e
d
Central Ray: Newborns to 1 year old: CR to 1″ (2 5 cm) above umbi-
u
r
e
licus Older child: CR to level of iliac crest
s
SID: 40″ (102 cm)
Collimation: On four sides to abdominal borders
Respiration: Expose on expiration or when abdomen has least move-
ment If crying, time exposures at full expiration

9
S

AP Ere ct : Ab d o m e n ( Pe d iat ric)
T
C
E
R
E
R
s
e
r
u
Five -ye a r-old
d
e
c
• 18 × 24 cm (8 × 10″), 24 × 30 cm
o
r
(10 × 12″), or 30 × 35 cm (11 × 14″)
P
a
portrait (or determined by size of
i
d
patient)
e
M
• Screen <10 cm, grid >10 cm
t
s
a
r
Po sit io n
t
n
o
• Patient seated, legs through
C
openings
n
o
• Arms above head, side body
m
Fig . 9.18 Utilizing Pigg-O-Stat
m
clamps rmly in place
o
C
• Lead shield at level of symphysis pubis; center IR to CR
d
Parental Assistance: If necessary, have parent hold arms overhead
n
a
with one hand, and with other hand hold legs to prevent rotation of
n
e
pelvis or thorax (provide with lead apron and gloves)
m
Central Ray: Newborn–1 year old: CR to 1″ (2 5 cm) above umbilicus
o
d
Older child: CR ≈1–2″ (2 5–5 cm) (depending on the height of the
b
A
child) above the level of the iliac crest
SID: 40″ (102 cm)
Collimation: On four sides to abdominal borders
Respiration: Expose on expiration, or during least movement

9
S

AP Sup in e an d Ere ct : Ab d o m e n ( Pe d iat ric)
A
b
d
o
m
e
n
a
n
d
C
o
m
m
o
n
R
C
o
n
t
r
a
s
Fig . 9.19 AP supine abdomen Fig . 9.20 Erect AP abdomen
t
M
e
d
i
a
P
r
o
c
e
d
• AP supine and erect: So tissue and gas- lled structures; air- uid
u
r
e
levels on erect
s
Position
• AP supine and erect: Diaphragm to symphysis pubis included, if
possible
Exposure
• Optimal density (brightness) and contrast to visualize so tissue
structures and skeletal structures; no motion
9
282
RAO: Eso p h ag o g ram
s
e
r
u
d
e
c
o
r
P
• 35 × 43 cm (14 × 17″) portrait
a
i
• Grid
d
e
M
Po sit io n
t
s
• Recumbent or erect, recumbent
a
r
t
preferred for more complete lling
n
o
C
of esophagus
n
• Rotate 35°–40° from prone
o
m
position onto right side, right arm Fig . 9.21 35°–40° RAO for
m
down, le arm up; hold cup with esophagus (barium swallow)
o
C
le hand, straw in mouth
d
• Center thorax to centerline
n
a
• op of IR ≈2″ (5 cm) above level of shoulder
n
e
Central Ray: CR , to center of IR (≈2–3″ [5–8 cm] inferior to jugular
m
o
notch at 6 level)
d
b
SID: 40″ (102 cm)
A
Collimation: o area of interest (≈5–6″ [12–15 cm] wide)
Respiration: With thin barium, expose while swallowing (a er 3 or
4 swallows) With thick barium, expose immediately a er swallowing
T e patient generally does not breathe immediately a er a swallow

9
S

Lat e ral: Eso p h ag o g ram
R
A
b
d
o
m
e
n
• 35 × 43 cm (14 ×
a
n
17″) portrait
d
C
• Grid
o
m
m
Po sit io n
o
n
• Recumbent or Fig . 9.22 R lateral esophagogram (barium
C
erect; recumbent swallow)
o
n
preferred
t
r
a
• Right lateral position, right arm and shoulder up and forward
s
t
(holding cup)
M
e
• Center midcoronal plane to centerline
d
i
a
• op of IR ≈2″ (5 cm) above top of shoulder
P
Central Ray: CR , to center of IR (≈2–3″ [5–8 cm] inferior to jugular
r
o
c
notch at 6 level)
e
d
SID: 40″ (102 cm) or 72″ (183 cm) if performed erect
u
r
e
Collimation: o area of interest (5–6″ [12–15 cm] wide)
s
Respiration: With thin barium, expose while patient is swallowing
(a er 3 or 4 swallows) With thick barium, expose immediately a er
patient swallows T e patient generally does not breathe immediately
a er a swallow

9
S

RAO an d Lat e ral: Eso p h ag o g ram
s
e
r
u
d
e
c
o
r
P
a
i
d
e
M
t
s
a
r
t
n
o
C
n
o
m
m
o
C
Fig . 9.23 RAO esophagogram Fig . 9.24 Right lateral esophagogram
d
n
a
n
e
m
o
d
b
A
• RAO: Esophagus visible between vertebral column and heart
• Lateral: Entire esophagus visible between thoracic spine and heart
Position
• RAO: Entire esophagus lined with contrast media and not
superimposed over spine
• Lateral: No rotation; superimposition of posterior ribs, entire
esophagus lined with contrast media
9
Exposure
• Optimal density (brightness) and contrast to visualize borders of
contrast- lled esophagus
• Sharp structural margins; no motion
285
AP ( PA) : Eso p h ag o g ram
R
A
b
d
o
m
e
n
a
n
• 35 × 43 cm (14 ×
d
17″) portrait
C
o
• Grid
m
m
o
Po sit io n Fig . 9.25 AP esophagogram (barium swallow)
n
• Supine or erect;
C
o
supine preferred (may be performed PA if erect)
n
t
r
• Center patient to midline of table
a
s
t
• op of IR ≈2″ (5 cm) above top of shoulder
M
• Le arm at side, holding cup with right hand, straw in mouth
e
d
Central Ray: CR , to center of IR (≈3″ [8 cm] inferior to jugular
i
a
notch at 6)
P
r
o
SID: 40″ (102 cm) or 72″ (183 cm) if performed erect
c
e
Collimation: o area of interest (5–6″ [12–15 cm] wide)
d
u
r
Respiration: With thin barium, expose while patient is swallowing
e
s
(a er 3 or 4 swallows) With thick barium, expose immediately a er
patient swallows

9
S

PA: Up p e r GI ( St o m ach )
s
e
r
u
d
e
c
• 35 × 43 cm (14 × 17″), 30
o
r
× 35 cm (11 × 14″), or 24 ×
P
a
30 cm (10 × 12″) portrait
i
d
• Grid
e
M
Fig . 9.26 PA upper GI (stomach)
t
s
Po sit io n
a
r
t
• Prone, arms up beside head
n
o
• Align and center patient and IR to CR
C
Central Ray: CR , centered as follows:
n
o
m
Sthenic: Center ≈1–2″ (2 5–5 cm) above lower rib margin (level of L1)
m
and ≈1″ (2 5 cm) to le of vertebral column
o
C
Hypersthenic: Center 2″ (5 cm) above level of L1 nearer midline
d
Asthenic: Center ≈2″ (5 cm) below level of 1 and nearer midline
n
a
SID: 40″ (102 cm)
n
e
Collimation: o outer margins of IR or to area of interest
m
o
d
b
A
90–100 kV (Doub le-Contrast)
80–90 kV (Water-Soluble Contrast Media)

9
S

RAO: Up p e r GI ( St o m ach )
A
b
L
d
o
m
• 30 × 35 cm (11 ×
e
n
14″) or 24 × 30 cm
a
n
d
• Grid
C
Fig . 9.27 40°–70° RAO, upper GI (stomach)
o
m
Po sit io n
m
• Semiprone, rotate 40°–70° from prone with right anterior side
o
n
against table
C
• Right arm down, le arm up, partially ex le hip and knee
o
n
t
• Align and center patient to CR
r
a
s
Central Ray: CR to IR
t
M
Sthenic: Center ≈1–2″ (2 5–5 cm) above lower ribs and midway
e
d
between spine and upside le lateral abdominal border, 45°–55°
i
a
oblique from prone
P
r
Hypersthenic: Center 2″ (5 cm) above level of L1 and nearer midline,
o
c
e
≈70° oblique
d
u
Asthenic: Center ≈2″ (5 cm) below level of L1, ≈40° oblique
r
e
SID: 40″ (102 cm)
s

9
S

PA an d RAO: Up p e r GI ( St o m ach )

• PA: Entire stomach and
duodenum
s
e
• RAO: Entire stomach and
r
u
d
C-loop of duodenum
e
c
o
r
P
Position
a
i
• PA: Body and pylorus are
d
e
barium- lled; body and
M
pylorus are centered
t
s
a
• RAO: Pylorus and
r
t
n
duodenal bulb in pro le
o
C
and barium- lled
n
o
m
Exposure
m
Fig . 9.28 PA
o
• Optimal density
C
Competency Check:
(brightness) and Technologist Date
d
n
contrast to
a
n
visualize
e
L
m
gastric folds
o
without
d
b
A
overexposing
other
structures
• Sharp
structural
margins; no
motion
9
Fig . 9.29 RAO
Competency Check:
Technologist Date
289
Rig h t Lat e ral: Up p e r GI ( St o m ach )
A
b
R
d
o
m
• 30 × 35 cm (11 ×
e
n
14″) or 24 × 30 cm
a
n
d
• Grid
C
o
m
Po sit io n
m
Fig . 9.30 Right lateral upper GI (stomach)
o
• Patient on right
n
side, arms up, hips and knees partially exed
C
o
• Align and center patient and IR to CR
n
t
r
Central Ray: CR to the IR
a
s
t
Sthenic: Center to margin of ribs at level of L1, and 1–1 1 2 ″ (2 5–4 cm)
M
anterior to midcoronal plane (near midway between anterior border of
e
d
vertebrae and anterior abdomen)
i
a
P
Hypersthenic: Center ≈2″ (5 cm) above L1
r
o
Asthenic: Center ≈2″ (5 cm) below L1
c
e
d
SID: 40″ (102 cm)
u
r
e
s


9
S

AP: Up p e r GI ( St o m ach )
s
e
r
R
u
d
e
c
• 30 × 35 cm (11 × 14″) or 35 ×
o
r
P
a
• Grid
i
d
e
Fig . 9.31 AP supine rendelenburg,
M
Po sit io n upper GI (stomach) ( rendelenburg
t
s
• Supine, arms at side position best demonstrates hiatal hernia)
a
r
t
• Align and center patient
n
o
and IR to CR
C
n
Central Ray: CR to IR, centered to 2 5–5 cm (1–2″) to le of MSP
o
m
Sthenic: Center to level of L1 (midway between xiphoid process and
m
level of lower lateral ribs)
o
C
Hypersthenic: Center ≈5 cm (2″) above level of L1
d
Asthenic: Center ≈5 cm (2″) below level of L1 and nearer midline
n
a
SID: 40″ (102 cm)
n
e
Collimation: o outer IR margins or to area of interest
m
o
d
b
A

9
S

Lat e ral an d AP: Up p e r GI

• Right lateral: Entire
stomach and duodenum
A
b
and retrogastric space
d
o
demonstrated
m
• AP: Entire stomach and
e
n
C-loop of duodenum;
a
n
diaphragm included to r/o
d
C
hiatal hernia
o
m
m
Position
o
n
• Right lateral: Pylorus
C
and C-loop of duodenum
o
Fig . 9.32 Right lateral upper GI
n
demonstrated No
t
r
Competency Check:
a
rotation; evident by
s
Technologist Date
t
M
aligned
e
vertebral
d
i
a
bodies
P
r
• AP: Fundus
o
c
barium- lled
e
d
u
and centered
r
e
s
Exposure
• Optimal
density
(brightness)
and contrast to
visualize gastric
folds without
overexposing
9
other
structures
• Sharp
structural
margins; no
Fig . 9.33 AP upper GI
motion
Competency Check:
Technologist Date
292
LPO: Up p e r GI ( St o m ach )
s
e
r
u
d
e
c
• 30 × 35 cm (11 × 14″) or 24 ×
o
r
P
a
• Grid
i
d
e
M
Fig . 9.34 30°–60° LPO, upper
Po sit io n
t
GI (stomach)
s
• Semisupine, 30°–60°
a
r
t
oblique,* le side down, partially ex right knee
n
o
• Center patient and IR to CR
C
n
*Up to 60° for hypersthenic patients and 30° for asthenic patients
o
m
Central Ray: CR to IR, centered to le half of abdomen
m
Sthenic: Center to L1 (midway between xiphoid process and level of
o
C
lower lateral ribs), 45° oblique
d
Hypersthenic: Center 5 cm (2″) above L1, 60° oblique
n
a
Asthenic: ≈5 cm (2″) below L1 and nearer midline, 30° oblique
n
e
SID: 40″ (102 cm)
m
o
Collimation: o outer IR margins or to area of interest
d
b
A
90–100 kV (Double-Contrast)

9
S

LPO: Up p e r GI ( St o m ach )
Evaluat io n Crit e ria L

• Entire stomach
and duodenum;
A
b
unobstructed view of
d
o
duodenal bulb
m
e
n
Position
a
n
• Fundus is barium- lled;
d
C
gas- lled duodenal bulb
o
m
seen for double-contrast
m
study
o
n
• Duodenal bulb in
C
pro le
o
n
t
r
Fig . 9.35 LPO upper GI
a
Exposure
s
t
Competency Check:
M
• Optimal density Technologist Date
e
(brightness) and
d
i
a
contrast to visualize gastric folds without overexposing other
P
r
structures
o
c
• Sharp structural and gastric organ margins; no motion
e
d
u
r
e
s
9
294
PA: Sm all Bo w e l
s
e
r
u
d
e
L
c
o
r
P
a
A common routine
i
d
includes images at 15-
e
M
or 30-minute intervals
t
s
until barium reaches
a
Fig . 9.36 PA small bowel (15 or 30 minutes)
r
ileocecal valve
t
n
o
• 35 × 43 cm (14 × 17″) portrait
C
• Grid
n
o
• ime indicators visible on image
m
m
Po sit io n
o
• Prone preferred (may be taken AP supine, if necessary)
C
d
• MSP aligned to midline of table; no rotation
n
a
• Center patient and IR to iliac crest (center higher on early IRs)
n
Central Ray: CR to IR, to center of IR, ≈2″ (5 cm) above level of
e
m
iliac crest for early IRs (15 or 30 minutes), and at iliac crest for later
o
d
images
b
A
SID: 40″ (102 cm)
Respiration: Expose at end of full expiration
Note: Imaging series and technical factors are similar for enteroclysis
and intubation procedures

9
S

PA ( AP) : Barium En e m a
L
A
b
d
o
m
e
n
• 35 × 43 cm
a
n
d
C
• Grid
o
m
m
Po sit io n Fig . 9.37 PA barium enema
o
n
• Patient prone (PA)
C
or supine (AP)
o
n
• Patient aligned and centered to centerline; no rotation
t
r
a
• Center IR to level of iliac crest (see Note)
s
t
Central Ray: CR to IR, to center of IR, at level of iliac crest
M
e
Note: For large or hypersthenic patients, the use of two IRs may be
d
i
a
necessary, placed landscape if the entire large intestine is to be included
P
r
(one centered for lower abdomen and one for upper abdomen)
o
c
SID: 40″ (102 cm)
e
d
Collimation: o outer IR borders or to area of interest
u
r
e
Respiration: Expose at full expiration
s
kV Range: Analog and Digital System s:
110–125 kV (Single Contrast)
90–100 kV (Double Contrast)

9
S

PA ( AP) : Barium En e m a

• Entire large intestine
demonstrated, including le
s
e
colic exure and rectum
r
u
d
e
c
Position
o
r
P
• ransverse colon primarily
a
i
lled with barium (PA) and
d
e
gas- lled with AP
M
• No rotation; evident by
t
s
a
symmetry of ala of ilium
r
t
n
and lumbar vertebra
o
C
n
Exposure
o
m
• Optimal density
m
o
(brightness) and contrast Fig . 9.38 PA single-contrast BE
C
to visualize mucosa Competency Check:
d
n
Technologist Date
without overexposing other
a
n
structures
e
m
• Sharp structural margins; no motion
o
d
b
A
9
297
RAO an d LAO ( RPO an d LPO) : Barium En e m a
A
b
d
o
L
m
Fig . 9.39 35°–45° RAO barium enema
e
n
Both right and le oblique projections are com-
a
n
monly performed
d
• 35 × 43 cm (14 × 17″) portrait
C
o
• Grid
m
m
Po sit io n
o
n
• Semiprone (PA) or semisupine (AP),
C
rotated 35°–45°
o
n
• Align and center abdomen to midline of
t
r
table
a
s
t
• IR centered to level of iliac crest (include Fig . 9.40 35°–45° LPO
M
rectal area)
e
d
Central Ray: CR to center of IR (at level 1–2″ [2 5–5 cm] above iliac
i
a
crest) ≈1″ (2 5 cm) to the le of the MSP
P
r
Note: Many patients require a second IR centered ≈2″ (5 cm) higher if
o
c
the le colic exure is to be included—most important on LAO or RPO
e
d
u
(determine departmental routine)
r
e
SID: 40″ (102 cm)
s
Respiration: Expose at expiration

9
S
298 Bontrager extbook, 9th ed, pp 516 and 517

RAO an d LAO ( RPO an d LPO) : Barium En e m a

• LPO/RAO: Right colic
exure and ascending and R. colic fle xure
s
e
sigmoid colon
r
u
d
• RPO/LAO: Le colic exure
e
c
and descending colon
o
r
P
a
i
Position
d
e
• LPO/RAO: Right colic
M
exure and ascending colon
t
s
a
in pro le
r
t
n
• RPO/LAO: Le colic exure
o
C
in pro le and descending
n
colon in pro le
o
m
m
o
Exposure
C
• Appropriate technique Fig . 9.41 RAO (centered high)
d
n
(brightness) to visualize Competency Check:
a
Technologist Date
n
mucosa without overexposing
e
m
other structures L. colic fle xure
o
• Sharp structural margins; no
d
b
A
motion
9
Fig . 9.42 RPO
Competency Check:
Technologist Date
299
Lat e ral Re ct um ( Ve n t ral De cub it us) :
Barium En e m a
L
A
b
d
o
Alternative ventral decubitus
m
projection is o en performed for
e
n
double-contrast studies
a
n
• 30 × 35 cm (11 × 14″) or 24 ×
d
Fig . 9.43 Le lateral for rectum
C
o
• Grid
m
• Compensating lter for ventral decubitus
m
o
lateral recommended
n
C
Po sit io n
o
n
• Recumbent in true lateral position
t
r
a
• Center midaxillary plane to midline
s
t
of table, with knees and hips
M
Fig . 9.44 Ventral decubitus
e
partially exed
d
lateral rectum (alternate
i
• Center patient and IR to CR
a
projection with double-contrast
P
Central Ray: CR to IR, to level of
r
o
examination)
c
ASIS, centered to midcoronal plane
e
d
(midway between ASIS and posterior sacrum) CR is horizontal for
u
r
e
ventral decubitus
s
SID: 40″ (102 cm)
110–125 kV (Single Contrast) 90–100 kV (Doub le Contrast)
9
S

Lat e ral De cub it us ( Do ub le Co n t rast ) :
Barium En e m a
DECUB
s
e
r
R
u
d
e
c
Both right and le lateral
o
r
P
decubitus are commonly
a
performed as part of a
i
d
double-contrast series
e
M
• 35 × 43 cm (14 × Fig . 9.45 Right lateral decubitus (AP)
t
s
17″) portrait to
a
r
patient
t
n
o
• Grid (portable grid or bucky)
C
• Compensating lter placed on upside of abdomen
n
o
m
Po sit io n
m
• Patient on side, arms up, knees partially exed, back against grid
o
C
cassette or table
d
• MSP aligned and centered to centerline of IR (and CR); no
n
a
rotation (lock wheels if stretcher is used)
n
e
• IR centered to level of iliac crest
m
o
Central Ray: CR horizontal to center of IR (to level of iliac crest at
d
b
midsagittal plane)
A
SID: 40″ (102 cm)

(Double-Contrast Study)

9
S

AP ( PA) Axial: Barium En e m a
A
b
R
d
o
m
e
Fig . 9.46 AP axial—CR Fig . 9.47 35° LPO axial—
n
• 30 × 35 cm 30°–45° cephalad CR 30°–40° cephalad
a
n
(11 × 14″)
d
portrait
C
o
• Grid
m
m
o
Po sit io n
n
C
Supine (AP) or Prone (PA): Patient aligned and centered to centerline
o
n
Alternate Oblique: LPO or RAO: Oblique patient 30°–40°
t
r
a
Central Ray: CR 30°–40° cephalad for AP; 30°–40° caudad for PA
s
t
AP axial: CR to 2″ (5 cm) inferior to ASIS
M
PA axial: CR to enter at level of ASIS
e
d
i
LPO axial: CR 2″ (5 cm) inferior and 2″ (5 cm) medial to right ASIS
a
P
SID: 40″ (102 cm)
r
o
Collimation: o area of interest
c
e
d
u
r
e
s

9
S

Lat e ral De cub it us an d AP ( PA) Axial:
Barium En e m a
Evaluat io n
Crit e ria
Anatomy
Demonstrated
s
e
• Lateral
r
u
d
decubitus:
e
c
Entire large
o
r
P
intestine
a
demonstrated
i
d
e
• AP/PA axial:
M
Elongated
t
s
a
views of
r
t
n
rectosigmoid
o
C
colon
n
Fig . 9.48 Le lateral decubitus
o
m
Competency Check:
Position
m
Technologist Date
• Lateral
o
C
decubitus: No
d
n
rotation evident by
a
symmetry of pelvis
n
e
m
and ribs
o
• AP/PA axial: Less
d
b
A
superimposition
between rectum and
sigmoid colon S igmoid
colon
Exposure
• Appropriate
Re ctum
technique (brightness) R
to visualize mucosa Fig . 9.49 AP axial
without overexposing Competency Check:
9
other structures Technologist Date
• Sharp structural
margins; no motion
303
AP ( PA) Sco ut an d Se rie s:
In t rave n o us Uro g ram ( IVU)
A
b
d
o
R
m
e
n
a
• 35 × 43 cm (14 ×
n
d
17″) portrait; 30 ×
C
35 cm (11 × 14″) for
o
m
nephrotomography,
Fig . 9.50 AP IVU
m
landscape
o
n
• Grid
C
• Include minute markers, where applicable
o
n
• Note that early images may include nephrotomography
t
r
• Shield gonads for males
a
s
t
M
Po sit io n
e
• Supine, midsagittal plane aligned and centered to midline of table;
d
i
a
support placed under knees; no rotation
P
r
Central Ray: CR , to center of IR, at level of iliac crest, or 1–2″
o
c
(2 5–5 cm) above crests on long-torso patients with second smaller IR
e
d
u
landscape for bladder area, to include symphysis pubis on lower border
r
e
of IR Nephrography: Center CR midway between xiphoid process and
s
iliac crest
SID: 40″ (102 cm)
Collimation: o outer margins of IR or area of interest

9
S

RPO an d LPO: IVU
s
e
r
u
R
d
e
c
o
r
P
Both R and L poste-
a
i
rior oblique projec-
d
e
tions should be part
M
of routine
t
s
a
• 35 × 43 cm (14 ×
r
t
17″) portrait Fig . 9.51 30°—RPO (Insert: LPO)
n
o
• Grid
C
• Include minute marker
n
o
• Shield gonads for males
m
m
o
Po sit io n
C
d
• Semisupine, 30° oblique to right (or le ), ex elevated knee and
n
a
elbow, as shown, for support (place angled support under back, if
n
needed)
e
m
• Align and center abdomen to centerline
o
d
• Center IR to level of iliac crest
b
A
Central Ray: CR , to center of IR, at level of iliac crest
SID: 40″ (102 cm)

9
S

AP an d RPO: IVU

• AP and oblique: Entire
urinary system visualized
A
b
from renal shadows to
d
o
symphysis pubis
m
e
n
Position
a
n
• AP: No rotation; evident
d
C
by symmetry of iliac
o
m
wings; symphysis pubis
m
and top of kidneys
o
n
included
C
• Oblique: Kidney on
o
n
elevated side in pro le;
t
r
a
downside ureter away
s
t
Fig . 9.52 AP—10 minutes (postinjection)
M
from spine
e
Competency Check:
d
Technologist Date
i
a
Exposure
P
r
• Appropriate technique
o
c
(brightness) and contrast
e
d
u
to visualize kidneys
r
e
and ureters without
s
overexposing other
structures; no motion
• Minute and side markers
visible R
9
Fig . 9.53 30°—RPO (From Frank ED,
Long BW, Smith BJ: Merrill’s atlas of
radiographic positioning and procedures,
ed 12, St Louis, 2012, Elsevier )
Competency Check:
Technologist Date
306
AP Ere ct ( Po st vo id ) : IVU
d
i
vo
t
s
s
o
e
p
r
u
R
d
e
c
o
r
P
a
• 35 × 43 cm (14 × 17″) portrait
i
d
• Grid
e
M
• Erect and postvoid markers
t
s
a
r
Po sit io n
t
n
o
• Erect, midsagittal plane aligned
C
and centered to midline of table,
n
o
no rotation
m
Fig . 9.54 AP erect postvoid
m
• Center IR to iliac crest—ensure
o
C
that bladder area, including the
d
symphysis pubis
n
a
Central Ray: CR , to center of IR (at level of iliac crests or ≈1″
n
e
[2 5 cm] lower than crest to include bladder area)
m
SID: 40″ (102 cm)
o
d
b
A

9
S

AP Axial: Cyst o g rap h y
R
A
b
d
o
m
• 30 × 35 cm (11 ×
e
14″) portrait for
n
a
adult
n
d
• Grid
C
o
m
Po sit io n Fig . 9.55 AP axial—CR 10°–15° caudad
m
• Supine,
o
n
midsagittal plane
C
aligned and centered to midline of table, legs fully extended
o
n
t
r
a
s
Central Ray: CR 10°–15° caudad, centered to ≈2″ (5 cm) superior to
t
M
symphysis pubis at MSP (projects pubis inferiorly to better visualize
e
bladder region)
d
i
a
SID: 40″ (102 cm)
P
r
Collimation: o outer margins of IR or area of interest
o
c
e
d
u
r
e
s

9
S

Po st e rio r Ob liq ue ( RPO, LPO) an d Op t io n al
Lat e ral: Cyst o g rap h y
s
R
e
r
u
d
Note: Cystogram routine may
e
c
not include a lateral because of
o
r
P
high gonadal dose
a
• 30 × 35 cm (11 × 14″)
i
d
portrait
e
Fig . 9.56 45° RPO
M
• Grid
t
s
a
Po sit io n
r
t
n
• Semisupine, 45°–60° oblique
o
C
(60° oblique best demonstrates
n
posterolateral bladder and UV
o
m
junction)
m
o
• Flex elevated arm and leg to
C
support this position
d
n
• Center patient and IR to CR Fig . 9.57 Optional lateral
a
n
Central Ray: CR to IR, to —CR , 2″ (5 cm) superior
e
and post to symphysis pubis
m
≈2″ (5 cm) superior to symphysis
o
pubis, and 2″ (5 cm) medial to elevated ASIS
d
b
A
SID: 40″ (102 cm)
Collimation: o margins of IR or area of interest
kV Range: AP Obliq ue—Analog: 70–75 kV

Digital System s: 80–85 kV
Lateral—Analog and Digital System s: 80 ± 5 kV

9
S

AP an d Po st e rio r Ob liq ue : Cyst o g rap h y
A
b
d
o
m
e
n
a
n
d
C
o
m
m
o
n
C
o
Fig . 9.58 AP axial 10°–15° caudad Fig . 9.59 45° posterior oblique
n
t
r
a
s
t
M
e
d
i
a
P
r
• AP axial and Oblique: Distal ureters, bladder, and proximal
o
c
urethra
e
d
u
r
e
Position
s
• AP axial: Urinary bladder not superimposed by pubic bones
• Oblique: Urinary bladder not superimposed by partially exed leg
Exposure
• Appropriate technique (brightness) to visualize urinary bladder
without overexposing other structures; no motion
9
310
Ch ap t e r 1 0
Mo b ile (Po rt ab le s) an d
Surg ical Pro ce d ure s
• Essential principles for trauma and mobile radiography 311
Mo b ile Modi ed axiolateral hip

AP chest (supine and and proximal femur
s
semierect) 312 (Clements-Nakayama
e
r
u
AP supine abdomen method) 317
d
e
(KUB) 313
c
o
Surg ical C-arm
r
Lateral decubitus
P
PA abdomen
l
(abdomen) 314
a
(cholangiogram) 318
c
i
AP pelvis or hip 315
g
Lateral hip 318
r
u
Axiolateral hip (Danelius-
S
Miller method) 316 Pro ce d ure No t e s
d
n
a
Esse n t ial Prin cip le s fo r Traum a an d Mo b ile Rad io g rap h y
)
s
e
T e following three principles must be observed for trauma and mobile
l
b
procedures:
a
t
r
• Two projections 90° to each other (minimum): rauma
o
P
(
radiography generally requires two projections taken at 90° (or right
e
l
angles to each other) while true CR-part-IR alignment is maintained
i
b
o
• Entire anatomic structure or trauma area on image receptor:
M
rauma radiography mandates that the entire structure being
examined should be included on the radiographic image to ensure
that no pathologic condition is missed Additional projections must
be performed if the entire structure is not seen on the initial image
• Maintain the safety of the patient, health care workers, and the
public: echnologists must maintain the safety and well-being of
patients, family/friends, and other health care workers during a
trauma or mobile radiographic procedure Safe handling of patients
and radiation protection of the patient and others in the immediate
0
1
vicinity of the exposure is the responsibility of the technologist
Sh ie ld in g
• Shield all radiosensitive tissues outside the region of interest, when
appropriate, during mobile imaging series
311
AP Ch e st ( Sup in e an d Se m ie re ct ) : Mo b ile
• 35 × 43 cm (14 × 17″) landscape or

portrait
• Nongrid or grid
Po sit io n
M
• Cover IR with plastic case, center to Fig . 10.1 Supine AP chest
o
patient with top of IR approximately
b
i
l
e
2″ (5 cm) above shoulders
(
P
• Supine, elevate head end of bed, if
o
r
possible, into seated or semierect
t
a
b
position
l
e
s
• Ensure no rotation of patient
)
a
• If patient condition allows, rotate
n
d
shoulders forward
S
u
r
Central Ray:
g
i
Fig . 10.2 Semierect AP chest
c
• CR 3°–5° caudal from
a
l
perpendicular to IR so as to be perpendicular to sternum
P
r
o
(prevents clavicles from obscuring apices of lungs)
c
e
• Center CR to 3–4″ (8–10 cm) below jugular notch at level of 7
d
u
SID: 48–72″ (123–183 cm); use greater SID, if possible
r
e
s
Respiration: Expose a er second full inspiration
kV Range: Analog and Digital System s: 90–125 kV*

*Lower kV for nongrid procedures
S
1
0
M

AP Sup in e Ab d o m e n ( KUB) : Mo b ile
• 35 × 43 cm (14 × 17″) portrait

• Grid
s
e
Po sit io n
r
u
• Cover IR with plastic case
d
Fig . 10.3 AP supine abdomen
e
c
• Center IR to patient at level of iliac
o
r
crest
P
l
• Place supports under IR, if needed, to ensure IR is level and
a
c
i
perpendicular to CR (prevents patient rotation and grid cuto )
g
r
u
Central Ray: CR perpendicular to IR, centered to IR at level of iliac
S
crest
d
n
a
SID: 40″ (102 cm)
)
s
e
l
b
a
t
r
o
P
(
e
l
i
b
o
M
kV Range: Analog 70–80 kV Digital System s 80 ± 5 kV
S
0
1
M

Lat e ral De cub it us ( Ab d o m e n ) : Mo b ile
R De cub
Le lateral best demon-

strates free air in right
upper abdomen Must
include diaphragm
• 35 × 43 cm
M
o
Fig . 10.4 AP le lateral decubitus abdomen
b
(to anatomy)
i
l
e
• Grid
(
P
• Decubitus marker
o
r
t
a
b
Po sit io n
l
e
s
• Patient on le (or right if indicated) side with support, as shown,
)
a
n
to prevent sinking into so bed
d
• Center of IR 2″ (5 cm) above level of iliac crest to include
S
u
diaphragm
r
g
i
• Ensure no rotation and that the IR plane is perpendicular to CR
c
a
l
Central Ray: Horizontal CR to center of IR 2″ (5 cm) above iliac crest
P
r
SID: 40″ (102 cm)
o
c
e
d
u
Note: Have patient on side 5 minutes (minimum) before exposure;
r
e
a period of 10–20 minutes is preferred. Ensure that diaphragm and
s
upside of abdomen are included
kV Range: Analog 70–80 kV Digital System s 80 ± 5 kV
S
1
0
M

AP Pe lvis o r Hip : Mo b ile
• Pelvis: 35 × 43 cm (14 × 17″) landscape

• Hip only: 24 × 30 cm (10 × 12″) portrait
• Grid
Po sit io n —Pe lvis
s
• Cover IR with plastic case, slide IR
e
r
under patient, centered landscape Fig . 10.5 AP pelvis (trauma
u
d
to patient hip without leg rotation)
e
c
o
• op of IR ≈1″ (2 5 cm) above iliac
r
P
crest
l
a
• Ensure no rotation of patient (equal
c
i
g
ASIS distances to IR)
r
u
• Internally rotate both legs 15° only if
S
hip fracture is not suspected
d
n
Central Ray: CR perpendicular midway
a
)
between ASIS and symphysis pubis
s
e
l
AP Hip: Center CR and IR to hip region
b
a
(2″ [5 cm] medial to ASIS at level of
t
r
o
greater trochanter)
P
(
SID: 40″ (102 cm) Fig . 10.6 AP hip (with leg e
l
i
Respiration: Suspend during exposure rotation)
b
o
M
kV Range: Analog Digital System s
Distal Fem ur 80 ± 5 kV 80 ± 5 kV
Proxim al 80 ± 5 kV 85 ± 5 kV
Fem ur/ Pelvis
S
0
1
M

Axio lat e ral Hip
( Dan e lius-Mille r Me t h o d ) : Mo b ile
• 24 × 30 cm (10 × 12″)
landscape (long axis of
IR aligned to long axis of
femur) Fig . 10.7 Axiolateral hip
M
• Grid
o
b
i
l
e
Po sit io n
(
P
• Place folded towels or support under a ected hip
o
r
• Place vertical grid against patient’s side with top of IR at the level
t
a
b
of the iliac crest with face of grid parallel to femoral neck and
l
e
s
perpendicular to CR
)
a
• Elevate opposite leg (DO NOT support leg/foot on collimator or
n
d
tube because of risk for burns or electrical shock)
S
u
• Internally rotate a ected leg only if unsecured hip fracture is not
r
g
suspected
i
c
a
Central Ray: Horizontal CR angled to be perpendicular to IR and
l
P
femoral neck
r
o
c
SID: 40″ (102 cm)
e
d
u
r
e
s
S
1
0
M

Mo d if e d Axio lat e ral Hip an d Pro xim al Fe m ur
( Cle m e n t s-Nakayam a Me t h o d ) : Mo b ile
Alternative
projection if Fig . 10.9 Lateral
both limbs Fig . 10.8 Modi ed proximal femur
have limited axiolateral projection (modi ed axiolateral
movement and the inferosuperior projection)
projection cannot be obtained
s
e
• 24 × 30 cm (10 × 12″) landscape
r
u
• Grid (aligned to CR angle to prevent grid cuto )
d
e
c
Po sit io n
o
r
P
• Patient supine, a ected side near edge of table with both legs fully
l
a
extended
c
i
g
• Provide pillow for head, and place arms across superior chest
r
u
S
• Maintain leg in neutral (anatomical) position
d
• Rest IR on extended bucky tray, which places the bottom edge of
n
a
the IR about 2″ (5 cm) below the level of the tabletop
)
s
e
• ilt IR approximately 15° from vertical and adjust alignment of IR
l
b
a
to ensure that face of IR is perpendicular to CR to prevent grid
t
r
o
cuto
P
(
• Center centerline of IR to projected CR e
l
i
Central Ray: Angle CR mediolaterally as needed so that it is per-
b
o
pendicular to and centered to femoral neck (≈15°–20° posteriorly
M
from horizontal)
SID: 40″ (102 cm)

S
0
1
M

PA Ab d o m e n ( Ch o lan g io g ram ) : Surg ical C-Arm
Po sit io n an d CR
• PA projection
(patient supine):
Image intensi er
on top, tube below
• Provide lead
aprons or portable
shields for all
personnel in room
• Maintain sterile
M
eld
o
Fig . 10.10 C-arm being positioned for PA hip or
b
• Automatic or
i
abdomen
l
e
manual exposure
(
P
o
control
r
t
• Foot pedal allows hands-free operation by physician of
a
b
l
uoroscopic image as displayed on monitor
e
s
)
a
n
d
Lat e ral Hip : Surg ical C-Arm
S
u
r
g
i
c
Po sit io n an d CR
a
l
• Superoinferior projection
P
r
o
• Horizontal CR, x-ray tube superior,
c
e
intensi er inferior
d
u
• Ensure sterile eld
r
e
s
• Provide lead aprons or shields
• Background exposure eld greatest at Fig . 10.11 C-arm for
tube end; operator should stand back lateral hip (Courtesy
away from tube region Philips Medical System )
Note: Recommended setup is a reversal of
this as an inferosuperior projection because
of increased radiation at tube end
1
0
318
Pro ce d ure No t e s
________________________________________________________
s
e
r
u
d
e
c
o
r
P
l
a
c
i
g
r
u
S
d
n
a
)
s
e
l
b
a
t
r
o
P
(
e
l
i
b
o
M
0
1
319
Ap p e n d ix A: Re d ucin g Pat ie n t Do se
T ere are seven common practices to reduce patient dose during

radiographic procedures. T ey include the following:
1. Minimize repeat radiographs: A primary cause of repeat
radiographs is poor communication between the technologist and
the patient. T e technologist must clearly explain the procedure to
the patient. Carelessness in positioning and selection of erroneous
technique factors are common causes of repeats and should be
avoided. Review technical and positioning errors with other
technologists and determine corrections before repeating the
exposures.
2. Correct ltration: Filtration of the primary x-ray beam
reduces exposure to the patient by preferentially absorbing
low-energy “unusable” x-rays, which mainly expose the patient’s
A
p
skin and super cial tissue without contributing to image
p
e
formation.
n
d
3. Accurate collimation: T e practice of close collimation to only
i
x
the area of interest reduces patient dose by reducing the volume
A
:
of tissue directly irradiated, and the amount of accompanying
R
e
scattered radiation is decreased. T e technologist must not rely
d
u
on positive beam limitation (PBL) collimators. T ey will collimate
c
i
n
to the size of the image receptor only. Additional collimation is
g
P
needed to further reduce exposure to surrounding tissues not
a
t
required for the study.
i
e
n
4. Shielding: All radiosensitive tissues outside the region of interest
t
D
should be shielded.
o
s
5. Speci c area shielding (gonadal and female breast shielding):
e
Speci c area shielding is essential when radiosensitive organs,
such as the thyroid gland, breasts, and gonads, are in or near the
useful beam and the use of such shielding do not interfere with
the objectives of the examination. T e most common and most
important area shielding is gonadal shielding, which signi cantly
lowers the dose to the reproductive organs. Gonadal shields,
if placed correctly, reduce the gonadal dose by 50%–90% if
the gonads are in the primary x-ray eld. Gonadal shielding is
necessary when the region of study is within or near (2 inches
[5 cm]) the primary beam.
6. Protection of the fetus: All women of childbearing age should
be screened for the possibility of pregnancy before an x-ray
examination.
320
7. Select projections and exposure factors appropriate for the
examination: Perform projections (pending department approval)
that minimize dose to radiosensitive tissues, such as the breast
and eye. A PA projection will greatly reduce dose to these tissues
compared with an AP projection. Select exposure factors that use
highest allowable kV and lowest mAs to further reduce patient
dose.
Ethical Practice in Digital Imaging: T e wide dynamic range of
digital imaging enables an acceptable image to be obtained with a
broad range of exposure factors. During the evaluation of the quality
of an image, the technologist must ensure that the exposure indicator is
within the recommended range. Any attempt to process an image with
a di erent algorithm to correct overexposure is not acceptable; it is
e
s
vital that patient dose be minimized at the outset and that the ALARA
o
D
(As Low As Reasonably Achievable) principle be upheld.
t
n
o maintain dose at a reasonable, consistent dose level, the following
e
i
t
practices are recommended:
a
P
• Use protocol-speci c kV ranges and mAs values for all procedures.
g
n
Use as high of a kV possible.
i
c
u
• Monitor dose by reviewing all images.
d
e
• If the exposure indicator for a given procedure is outside of
R
:
the acceptable range, review all factors, including kV, mAs,
A
positioning, collimation, and anatomy with a supervisor or
x
i
d
radiation safety o cer (RSO). n
e
p
p
A
321
t r a h C ) s
A m ( A m - e m
i T :
B x
i d n e p p
A
T
S
m
e i
A m
c
o e
n i
d
( n
s m A s i n B ox e s 50
)
322
Ap p e n d ix B: Tim e -m A ( m As) Ch art
W
C h
a r n
e i n g
c
: k t u b e r a t i n g c
N
O e
r w i
S I D gi n a l S I (
″
36
D 91 c m (
″
40
) 102 c m (
″
42
) 107 c m (
″
44
) 113 c m (
″
48
) 123
E
D
x e
a m
t p l e
e 1: r m i n e m A s w i t h
Ap p e n d ix C: Exp o sure -Dist an ce Co n ve rsio n Ch art
323
A
p p e n d i
x C : E
x p o s
u r e - D i
s t a n c e C o n v
e r s
i o n C h a r t
Ap p e n d ix D: Cast Co n ve rsio n Rule
A cast applied to upper or lower limbs (extremities) requires an

increase in exposure. One suggested method for determining exposure
compensation is to measure for the increased thickness of the part,
including the cast, and adjust the exposure factors accordingly.
T e above method can be used in general, but in addition to the
added thickness of the cast, the di erent densities of cast materials
also a ect the required exposure adjustments. T erefore the following
general cast conversion guide, which makes allowances for both the
size and type of cast material, is suggested.
In cre ase Exp o sure Wit h Cast

An upper or lower limb with a cast requires an increase in exposure.
A
p
T is increase depends on the thickness and type of cast, as outlined
p
e
in the following table:
n
d
i
x
Cast Conversion Chart
D
:
C
Cast Type Increase in Exposure*
a
s
t
Small-to-medium plaster 5–7 kV
C
o
Large plaster 8–10 kV
n
v
Fiberglass 3–4 kV
e
r
s
i
* o reduce patient dose, it is recommended to increase kV rather than mAs.
o
n
R
u
Example: An AP and lateral ankle were taken at 66 kV and 6 mAs
l
e
demonstrating a fracture. A medium-size plaster cast was applied,
and postreduction projections were ordered. What exposure factors
should be used?
Answer: 73 kV @ 6 mAs (+ 7 kV)
324
O
N on
r i g i n
g a l G r
r i d R a t
i
i o ( O r
d
i g i n a
l E x
p o s u r
5 e F a c t
o r s ) : 1 or
T
o
o i
s u
c
c on v
h
s
e r s
i o
e
n e c
h a
r t
c t
c a
n b e
k u
h s
e d f
or y
g
i
e n e
r a l g
r i
s
o
d c on v er s
i on c
u s b a s e
d on h
r e
r c
o m m e
n d e
d a m
a i
d - kV r a
n g e
r
s of
n e
a c h g
r i d t y
t
p e
. s , w d e
Ap p e n d ix E: Grid Rat io Co n ve rsio n Ch art
325
A p p e n d i
x E : G r i
d R a t i
o C o n v e r s i
o n C h a r t
Ap p e n d ix F: In it ials ( Ab b re viat io n s) ,
Te ch n ical Te rm s, an d Acro n ym s
e following are the more common initials (abbreviations) and acro-
nyms used in imaging departments today and as used in this pocket
handbook and in the 9th edition Bontrager Textbook.
Ge n e ral Po sit io n in g / An at o m y Te rm s
AC joints Acromioclavicular joints
AP, PA Anteroposterior, posteroanterior projections
A
p
ASIS Anterior superior iliac spine (pelvis landmark)
p
e
DP, PD Dorsoplantar and plantodorsal
n
d
LAO, RAO Le and right anterior oblique projections
i
x
LPO, RPO Le and right posterior oblique projections
F
:
MCP Midcoronal plane (plane dividing the body into
I
n
i
t
anterior and posterior halves)
i
a
l
MSP Midsagittal plane (plane dividing the body into right
s
(
A
and le halves)
b
b
SC joints Sternoclavicular joints
r
e
SI joints Sacroiliac joints
v
i
a
SMV, VSM Submentovertex or verticosubmental projections
t
i
o
n
s
)
Ab d o m in al Pro ce d ure Te rm s
,
T
BE Barium enema
e
c
CNS Central nervous system
h
n
CSF Cerebrospinal uid
i
c
a
CTC Computed tomography colonoscopy
l
T
e
ERCP Endoscopic retrograde cholangiopancreatography
r
m
GB Gallbladder
s
,
GI, UGI, LGI Gastrointestinal, upper and lower GI
a
n
IVP Intravenous pyelogram (older term)
d
A
IVU Intravenous urogram (accurate term)
c
r
KUB Kidneys, ureters, bladder (abdomen projection)
o
n
NPO Nil per os (nothing by mouth)
y
m
PTC Percutaneous transhepatic cholangiography
s
RLQ, LLQ Right and le lower quadrant
RUQ, LUQ Right and le upper quadrant
SBS Small bowel series
VC Virtual colonoscopy
326
Te ch n ical Te rm s
AEC Automatic exposure controls
Analog Film-screen imaging system
CR Central ray (for positioning centering)
CR Computed radiography—using image plates (IP)
CT Computed tomography
DF Digital uoroscopy
s
m
DR Digital radiography (cassetteless)
y
FS Focal spot (large or small)
n
o
r
HIS Hospital information system
c
A
IP Image plates (used with CR)
d
n
IR Image receptor ( lm/screen or digital)
a
Landscape Crosswise (IR orientation to patient)
,
s
m
MRI Magnetic resonance imaging
r
e
T
OID Object image receptor distance
l
a
PACS Picture archiving and communications system
c
i
n
PBL Positive beam limitation (collimation)
h
c
PET Positron emission tomography
e
T
PSP Photostimulable phosphor plate receptor (either
,
)
s
cassette or cassetteless)
n
o
Portrait Lengthwise (IR orientation to patient)
i
t
a
RIS Radiology information system
i
v
e
SID Source image-receptor distance
r
b
b
TT Tabletop (non-bucky) A
(
s
l
a
Te rm s Re lat e d t o Jo in t s o f Lim b s (Ext re m it ie s)
i
t
i
ACL, PCL Anterior and posterior cruciate ligaments (knee)
n
I
:
CMC Carpometacarpal (wrist)
F
x
DIP Distal interphalangeal (hand or foot)
i
d
IP Interphalangeal (hand or foot)
n
e
p
LCL, MCL Lateral and medial collateral ligaments (knee)
p
A
MCP Metacarpophalangeal (hand)
MTP Metatarsophalangeal (foot)
PIP Proximal interphalangeal (hand or foot)
TMT Tarsometatarsal (foot)
Te rm s Re lat e d t o Cran ium an d Facial Bo n e s

AML Acanthiomeatal line
EAM External acoustic meatus
327
GAL Glabelloalveolar line
GML Glabellomeatal line
IOML Infraorbital-meatal line
IPL Interpupillary line
LML Lips-meatal line (modi ed Waters projection)
MML Mentomeatal line (Waters projection)
OML Orbitomeatal line
A
SOG Supraorbital groove
p
p
TEA Top of ear attachment
e
n
d
TMJ Temporomandibular joints
i
x
F
:
I
n
i
t
i
a
l
s
(
A
b
b
r
e
v
i
a
t
i
o
n
s
)
,
T
e
c
h
n
i
c
a
l
T
e
r
m
s
,
a
n
d
A
c
r
o
n
y
m
s
328
Tab le o f Film Im ag e Re ce p t o rs
Metric Sizes British (inches) Sizes Usage

18 × 24 cm (7.1 × 9.5 inches) Mammography
(20.3 × 25.4 cm) *8 × 10 inches General
24 × 24 cm (9.5 × 9.5 inches) Fluoroscopy
(25.4 × 30.5 cm) *10 × 12 inches General
24 × 30 cm (9.5 × 11.8 inches) General
(7 × 17)
35 × 35 cm (13.8 × 13.8 inches) Fluoroscopy
(14 × 17)
Mammography
19 × 23 cm (7.5 × 9 inches) Mammography
Erect Spine and/or Lower Limb

(35.6 × 91.4 cm) *14 × 36 inches Scoliosis series
(35.6 × 129.5 cm) *14 × 51 inches Full lower limb study
Mandible and/or Dental

(12.7 × 30.5 cm) *5 × 12 inches Panoramic
(22.9 × 30.5 cm) *9 × 12 inches Panoramic
31 × 41 mm 1 1 4 × 15 8 inches #2 Adult Bitewing
22 × 55 mm ( 7 8 × 13 8 inches) #0 Child Bitewing
*T ese British (inches) lm sizes are generally still available due to the continued use of
these size cassettes and grid cassettes.

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PERPUSTAKAAN

John P. Lampignano, MEd, RT(R)(CT)

BONTRAGER’S HANDBOOK OF RADIOGRAPHIC POSITIONING ISBN: 978-0-323-48525-8

Copyright © 2018 by Elsevier, Inc. All rights reserved.

Previous edition copyrighted 2014 by Mosby, an imprint of Elsevier Inc.

International Standard Book Number: 978-0-323-48525-8

Executive Content Strategist: Sonya Seigafuse

Printed in the United States of America

Last digit is the print number: 9 8 7 6 5 4 3 2 1

T e ninth edition of this handbook includes a standard, well-

John and Leslie

Ap p e n d ix A Reducing Patient Dose 320

Ap p e n d ix B Tim e-m A (m As) Chart 322

Ap p en d ix C Exposure–Distance Conversion Chart 323

Ap p en d ix D Cast Conversion Rule 324

Ap p e n d ix E Grid Ratio Conversion Chart 325

Ap p e n d ix F Initials (Ab breviations), Technical Term s,

Radiation protection: Certain radiation protection practices and

kV ranges: Suggested kV ranges for analog and digital systems are

Standard Radiographic Image and Evaluation Criteria: Associated

Also included is an optional competency sign-o area to be signed

• Positioning considerations and radiation protection 2

(R) Routine, (S) Special

Fig . 1.1 Correct CR location

7 or the PA chest can be located posteriorly in re erence to C7,

Backscat t e r Pro t ect io n

T e ollowing technical actors will reduce dose to the patient and

Bontrager extbook, 9th ed, pp 38–70 3

kV Range: Analog and Dig ital System s: 110–125 kV

cm kV mA Time mAs SID Exposure Indicator

4 Bontrager extbook, 9th ed, pp 92–93

kV Range: Analog and Dig ital System s: 110–125 kV

cm kV mA Time mAs SID Exposure Indicator

Bontrager extbook, 9th ed, p 94 5

kV Range: Analog and Dig ital System s: 110–125 kV

cm kV mA Time mAs SID Exposure Indicator

6 Bontrager extbook, 9th ed, p 95

Evaluat io n Crit e ria

Evaluat io n Crit e ria

kV Range: Analog and Dig ital System s: 110–125 kV

cm kV mA Time mAs SID Exposure Indicator

8 Bontrager extbook, 9th ed, p 97

cm kV mA Time mAs SID Exposure Indicator

Bontrager extbook, 9th ed, pp 96 and 98 9

Evaluat io n Crit e ria

Evaluat io n Crit e ria

kV Range: Analog and Dig ital System s: 110–125 kV

cm kV mA Time mAs SID Exposure Indicator

Bontrager extbook, 9th ed, p 99 11

Evaluat io n Crit e ria

• 24 × 30 cm (10 × 12″) portrait

kV Range: Analog and Digital system s: 75–85 kV

cm kV mA Time mAs SID Exposure Indicator

Bontrager extbook, 9th ed, pp 102 and 103 13

kV Range: Analog and Digital System s: 75–85 kV

cm kV mA Time mAs SID Exposure Indicator

Bontrager extbook, 9th ed, p 627 15

cm kV mA Time mAs SID Exposure Indicator