EXAMINATION: ANKLE AP PROJECTION

IMAGE RECEPTOR: :
8 × 10 inch (18 × 24 cm) or 10 × 12 inch (24 × 30 cm) lengthwise, depending on availability;
crosswise for two images on one IR

POSITION OF PATIENT:
• Place the patient in the supine or seated position with the affected limb fully extended.

POSITION OF PART:
Adjust the ankle joint in the anatomic position (foot pointing straight up) to obtain a true AP
projection. Flex the ankle and foot enough to place the long axis of the foot in the vertical
position (Fig. 6-91).
• Ball and Egbert1 stated that the appearance of the ankle mortise is not appreciably altered
by moderate plantar flexion or dorsiflexion as long as the leg is rotated neither laterally nor
medially.
• Shield gonad

CENTRAL RAY:
• Perpendicular through the ankle joint at a point midway between the malleoli

COLLIMATION:
1 inch (2.5 cm) on the sides of the ankle and 8 inches (18 cm) lengthwise to include the heel
STRUCTURE SHOWN:
The image shows a true AP projection of the ankle joint, the distal ends of the tibia and
fibula, and
the proximal portion of the talus.

EVALUATION CRITERIA:
The following should be clearly shown:
■ Evidence of proper collimation
■ Ankle joint centered to exposure area
■ Medial and lateral malleoli
■ Talus with proper brightness
■ No rotation of the ankle □ Normal overlapping of the tibiofibular articulation with the
anterior tubercle slightly superimposed over the fibula □ Talus slightly overlapping the distal
fibula □ No overlapping of the medial talomalleolar articulation
■ Tibiotalar joint space
■ Soft tissue and bony trabecular detail
EXAMINATION: LATERAL PROJECTION

IMAGE RECEPTOR:
8 × 10 inch (18 × 24 cm) or 10 × 12 inch (24 × 30 cm) lengthwise, depending on availability

POSITION OF PATIENT:
Have the supine patient turn toward the affected side until the ankle is lateral (Fig. 6-93)

POSITION OF PART:
Place the long axis of the IR parallel with the long axis of the patient’s leg, and center it to the ankle
joint.
• Ensure that the lateral surface of the foot is in contact with the IR.
• Dorsiflex the foot, and adjust it in the lateral position. Dorsiflexion is required to prevent lateral
rotation of the ankle.
• Shield gonads.

CENTRAL RAY:
Perpendicular to the ankle joint, entering the medial malleolus

COLLIMATION:
1 inch (2.5 cm) on the sides of the ankle and 8 inches (18 cm) lengthwise. Include the heel and the
fifth metatarsal base.

STRUCTURE SHOWN:
The resulting image shows a true lateral projection of the lower third of the tibia and fibula; the
ankle joint; and the tarsals, including the base of the fifth metatarsal (Figs. 6-94 and 6-95).

EVALUATION CRITERIA:

The following should be clearly shown:

■ Evidence of proper collimation
■ Ankle joint centered to exposure area
■ Distal tibia and fibula, talus, calcaneus, and adjacent tarsals
■ Ankle in true lateral position □ Tibiotalar joint well visualized, with the medial and lateral talar
domes superimposed □ Fibula over the posterior half of the tibia
■ Fifth metatarsal base and tuberosity should be seen to check for Jones fracture
■ Brightness and contrast of the ankle sufficient to see the outline of distal portion of the fibula
■ Soft tissue and bony trabecular detail
EXAMINATION: LATERAL PROJECTION Lateromedial

IMAGE RECEPTOR:
8 × 10 inch (18 × 24 cm) or 10 × 12 inch (24 × 30 cm) lengthwise, depending on availability

POSITION OF PATIENT:
Have the supine patient turn away from the affected side until the extended leg is placed laterally
POSITION OF PART:
• Center the IR to the ankle joint, and adjust the IR so that its long axis is parallel with the long axis
of the leg.
• Adjust the foot in the lateral position
. • Have the patient turn anteriorly or posteriorly as required to place the patella perpendicular to
the horizontal plane (Fig. 6-96).
• If necessary, place a support under the patient’s knee.
• Shield gonads.

CENTRAL RAY:
• Perpendicular through the ankle joint, entering 1 2 inch (1.3 cm) superior to the lateral malleolus

STRUCTURE SHOWN:
The resulting image shows a lateral projection of the lower third of the tibia and fibula, the ankle
joint, and the tarsals (Fig. 6-97).

EVALUATION CRITERIA:
The following should be clearly shown:
■ Ankle joint centered to exposure area
■ Distal tibia and fibula, talus, and adjacent tarsals
■ Ankle in true lateral position □ Tibiotalar joint well visualized, with the medial and lateral talar
domes superimposed □ Fibula over the posterior half of the tibia
■ Brightness and contrast of the ankle sufficient to see the outline of the distal portion of the fibula
■ Soft tissue and bony trabecular detail
EXAMINATION: MEDIAL OBLIQUE POSITION

IMAGE RECEPTOR: 8 × 10 inch (18 × 24 cm) or 10 × 12 inch (24 × 30 cm) lengthwise, depending on
availability; crosswise for two images on one IR

POSITION OF PATIENT:
Place the patient in the supine or seated position with the affected limb fully extended.

POSITION OF PART:
Center the IR to the ankle joint midway between the malleoli, and adjust the IR so that its long axis is
parallel with the long axis of the leg.
• Dorsiflex the foot enough to place the ankle at nearly right-angle flexion (Fig. 6-98). The ankle may
be immobilized with sandbags placed against the sole of the foot or by having the patient hold the
ends of a strip of bandage looped around the ball of the foot.
• Rotate the patient’s leg primarily and the foot for all oblique projections of the ankle. Because the
knee is a hinge joint, rotation of the leg can come only from the hip joint. Positioning the ankle for
the oblique projection requires that the leg and foot be medially rotated 45 degrees.
• Grasp the lower femur area with one hand and the foot with the other. Internally rotate the entire
leg and foot together until the 45-degree position is achieved
. • The foot can be placed against a foam wedge for support.
• Shield gonads.

CENTRAL RAY:
Perpendicular to the ankle joint, entering midway between the malleoli

COLLIMATION:
1 inch (2.5 cm) on the sides of the ankle and 8 inches (18 cm) lengthwise to include the heel.

STRUCTURE SHOWN:
The 45-degree medial oblique projection shows the distal ends of the tibia and fibula, parts of which
are often superimposed over the talus. The tibiofibular articulation also should be shown (Fig. 6-99).

EVALUATION CRITERIA:
The following should be clearly shown:
■ Evidence of proper collimation
■ Ankle joint centered to exposure area
■ Distal tibia, fibula, and talus
■ Proper 45-degree rotation of ankle □ Tibiofibular articulation open □ Distal tibia and fibula overlap
some of the talus
■ Soft tissue and bony trabecular detail
EXAMINATION: MORTISE JOINT LATERAL OBLIQUE POSITION

IMAGE RECEPTOR: 8 × 10 inch (18 × 24 cm) or 10 × 12 inch (24 × 30 cm) lengthwise, depending on
availability

POSITION OF PATIENT:
Seat the patient on the radiographic table with the affected leg extended.

POSITION OF PART:
Place the plantar surface of the patient’s foot in the vertical position, and laterally rotate the leg and
foot 45 degrees.
• Rest the foot against a foam wedge for support, and center the ankle joint to the IR (Fig. 6-104).
• Shield gonads.

CENTRAL RAY:
• Perpendicular, entering the ankle joint midway between the malleoli

COLLIMATION:

STRUCTURE SHOWN:
The lateral rotation oblique projection is useful in determining fractures and showing the superior
aspect of the calcaneus (Fig. 6-105).

EVALUATION CRITERIA:

The following should be clearly shown:

■ Evidence of proper collimation
■ Distal tibia, fibula, and talus
■ Tibiotalar joint
■ Calcaneal sulcus (superior portion of calcaneus)
■ Soft tissue and bony trabecular detail
EXAMINATION: AP PROJECTION STRESS METHOD

Stress studies of the ankle joint usually are obtained after an inversion or eversion injury to verify
the presence of a ligamentous tear. Rupture of a ligament is shown by widening of the joint space on
the side of the injury when, without moving or rotating the lower leg from the supine position, the
foot is forcibly turned toward the opposite side. When the injury is recent and the ankle is acutely
sensitive to movement, the orthopedic surgeon may inject a local anesthetic into the sinus tarsi
before performing the examination. The physician adjusts the foot when it must be turned into
extreme stress and holds or straps it in position for the exposure. The patient usually can hold the
foot in the stress position when the injury is not too painful or after he or she has received a local
anesthetic by asymmetrically pulling on a strip of bandage looped around the ball of the foot (Figs. 6-
106 to 6-108).
EXAMINATION: LEG AP PROJECTION

IMAGE RECEPTOR: : 14 × 17 inch (35 × 43 cm) lengthwise or diagonal

POSITION OF PATIENT:
Place the patient in the supine position.

POSITION OF PART:
Adjust the patient’s body so that the pelvis is not rotated.
• Adjust the leg so that the femoral condyles are parallel with the IR and the foot is vertical.
• Flex the ankle until the foot is in the vertical position.
• If necessary, place a sandbag against the plantar surface of the foot to immobilize it in the correct
position (Fig. 6-111).
• Shield gonads

CENTRAL RAY:
Perpendicular to the center of the leg

COLLIMATION:
• 1 inch (2.5 cm) on the sides and 11 2 inches (4 cm) beyond the ankle and knee joints

STRUCTURE SHOWN:
The resulting image shows the tibia, fibula, and adjacent joints (Fig. 6-112).

EVALUATION CRITERIA:
The following should be clearly shown:
■ Evidence of proper collimation
■ Ankle and knee joints on one or more images
■ Entire leg without rotation □ Proximal and distal articulations of the tibia and fibula moderately
overlapped □ Fibular midshaft free of tibial superimposition
■ Soft tissue and bony trabecular detail
EXAMINATION: LEG LATERAL PROJECTION

IMAGE RECEPTOR: : 7 × 17 inch (18 × 43 cm) or 14 × 17 inch (35 × 43 cm) for two images on one IR

POSITION OF PATIENT:
Place the patient in the supine position

POSITION OF PART:
Turn the patient toward the affected side with the leg on the IR.
• Adjust the rotation of the body to place the patella perpendicular to the IR, and ensure that a line
drawn through the femoral condyles is also perpendicular
. • Place sandbag supports where needed for the patient’s comfort and to stabilize the body position
(Fig. 6-113, A). • The knee may be flexed if necessary to ensure a true lateral position.
• The projection may be done with IR diagonal to include the ankle and knee joints (Fig. 6-113, B).
Similar to the AP, if the leg is too long, it is imaged with the ankle joint, and a separate knee
projection is performed.

CENTRAL RAY:
• Perpendicular to the midpoint of the leg

COLLIMATION:
• 1 inch (2.5 cm) on the sides and 11 2 inches (4 cm) beyond the ankle and knee joints

STRUCTURE SHOWN:
The resulting image shows the tibia, fibula, and adjacent joints (Fig. 6-114).

EVALUATION CRITERIA:
The following should be clearly shown:
■ Evidence of proper collimation
■ Ankle and knee joints on one or more images
■ Entire leg in true lateral position
□ Distal fibula lying over the posterior half of the tibia
□ Slight overlap of the tibia on the proximal fibular head
□ Moderate separation of the tibial and fibular bodies or shafts (except at their articular ends)
■ Possibly no superimposition of femoral condyles because of divergence of the beam
■ Soft tissue and bony trabecular detail
EXAMINATION: LEG OBLIQUE PROJECTION

IMAGE RECEPTOR: : 7 × 17 inch (18 × 43 cm) or 14 × 17 inch (35 × 43 cm) for two exposures on one
IR

POSITION OF PATIENT:
• Place the patient in the supine position on the radiographic table.

POSITION OF PART:
• Perform oblique projections of the leg by alternately rotating the limb 45 degrees medially (Fig. 6-
115) or laterally (Fig. 6-116). For the medial rotation, ensure that the leg is turned inward, not just
the foot.
For the medial oblique projection, elevate the affected hip enough to rest the medial side of the foot
and ankle against a 45-degree foam wedge, and place a support under the greater trochanter.
• Shield gonads.

CENTRAL RAY:
Perpendicular to the midpoint of the IR

COLLIMATION:
STRUCTURE SHOWN:
The resulting image shows a 45-degree oblique projection of the bones and soft tissues of the leg
and one or both of the adjacent joints (Figs. 6-117 and 6-118).

EVALUATION CRITERIA:
The following should be clearly shown:
■ Evidence of proper collimation
■ Ankle and knee joints on one or more images
■ Soft tissue and bony trabecular detail Medial Rotation
■ Proper rotation of leg □ Proximal and distal tibiofibular articulations □ Maximum interosseous
space between the tibia and fibula Lateral Rotation
■ Proper rotation of leg □ Fibula superimposed by lateral portion of tibia
ANATOMY OF THE LEG

The leg has two bones: the tibia and the fibula. The tibia, the second largest bone in the body, is
situated on the medial side of the leg and is a weight-bearing bone. Slightly posterior to the tibia on
the lateral side of the leg is the fibula. The fibula does not bear any body weight.

TIBIA

The tibia (Fig. 6-4) is the larger of the two bones of the leg and consists of one body and two
expanded extremities. The proximal end of the tibia has two prominent processes—the medial and
lateral condyles. The superior surfaces of the condyles form smooth facets for articulation with the
condyles of the femur. These two flatlike superior surfaces are called the tibial plateaus, and they
slope posteriorly about 10 to 20 degrees. Between the two articular surfaces is a sharp projection,
the intercondylar eminence, which terminates in two peaklike processes called the medial and
lateral intercondylar tubercles. The lateral condyle has a facet at its distal posterior surface for
articulation with the head of the fibula. On the anterior surface of the tibia, just below the condyles,
is a prominent process called the tibial tuberosity, to which the ligamentum patellae attach.
Extending along the anterior surface of the tibial body, beginning at the tuberosity, is a sharp ridge
called the anterior crest.

The distal end of the tibia (Fig. 6-5) is broad, and its medial surface is prolonged into a large process
called the medial malleolus. Its anterolateral surface contains the anterior tubercle, which overlays
the fibula. The lateral surface is flattened and contains the triangular fibular notch for articulation
with the fibula. The surface under the distal tibia is smooth and shaped for articulation with the
talus.

FIBULA

The fibula is slender compared with its length and consists of one body and two articular extremities.
The proximal end of the fibula is expanded into a head, which articulates with the lateral condyle of
the tibia. At the lateroposterior aspect of the head is a conic projection called the apex.

The enlarged distal end of the fibula is the lateral malleolus. The lateral malleolus is pyramidal and is
marked by several depressions at its inferior and posterior surfaces. Viewed axially, the lateral
malleolus lies approximately 15 to 20 degrees more posterior than the medial malleolus.