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Radiographic Evaluation
Radiographic Evaluation
1 Radiographic Evaluation
Ugne Julia Skripkus and Amilcare Gentili
CONTENTS
U. J. Skripkus, MD 1.2
Musculoskeletal Radiology Fellow, University of California, Radiographic Projections of the Pelvis
San Diego, 200 West Arbor Drive, San Diego, CA 92075, USA
A. Gentili, MD
Professor, Department of Radiology, University of Califor-
Standard projections for the evaluation of the pelvis
nia, San Diego, 9300 Campus Point Drive, La Jolla, CA 92037, include AP, AP axial (“frogleg”) and posterior
USA oblique (“Judet”).
4 U. J. Skripkus and A. Gentili
1.2.2
AP Axial Projection of the Pelvis
(Frogleg–Cleaves or Modified Cleaves Method)
b
Fig. 1.1. a Patient positioning for anteroposterior (AP) pelvic This position is contraindicated in patients sus-
radiograph. b AP pelvic radiograph pected of having a fracture, dislocation of the hip.
Radiographic Evaluation 5
1.2.2.1
Technique
1.2.2.1.1
Modified Cleaves Method: Supine
1.2.2.1.2
Original Cleaves Method
a b
Fig. 1.3. a Patient positioning for posterior oblique “Judet” view of pelvis. b “Judet” view of pelvis, taken in RPO position
Radiographic Evaluation 7
1.3.1 1.3.1.2
AP Axial “Outlet” Projection of the Anterior Radiographic Evaluation
Pelvic Bones (Taylor)
On this projection, the pubic and ischial bones will
1.3.1.1 be magnified and only minimally superimposed on
Technique: Supine the sacrum and coccyx. The hip joints should also
be included.
The patient is supine on the table with the midsag-
ittal plane of the patient’s body centered about the
midline of the table. The pelvis is in true AP posi- 1.3.2
tion. A pillow or other supporting structure should AP Axial “Inlet” Projection of the Anterior Pelvic
be placed behind the head and the knees for comfort. Bones (Lilienfeld)
For males, the central ray is directed approximately
20°–35° cephalad and centered at a point 2 in. (5 cm) 1.3.2.1
distal to the upper border of the symphysis pubis. Technique: Seated Erect
For females, the central ray is directed approxi-
mately 30°–45° cephalad and centered to a point The patient is seated erect on the table, with the
1–2 in. (2.5–5 cm) distal to the upper border of the knees flexed slightly and the feet resting on the table
symphysis pubis. Respiration is suspended. Gonadal top. A supporting structure should be placed behind
shielding should be carefully applied to avoid obscu- the knees. The midsagittal plane of the patient’s
ration of essential bony structures. body should be centered about the midline of the
table. There should be no rotation of the pelvis. The
arms should be extended behind the patient with the
hands placed on the table top, supporting the torso
in a position approximately 50° from vertical. A sup-
porting structure should be placed behind the lower
back and the back should be arched to place the
pubic arch in a near-vertical position. The central
ray is directed perpendicularly to the cassette and
centered to a point 1.5 in. (3.8 cm) superior to the
symphysis pubis. Respiration is suspended. Gonadal
shielding for men should be carefully applied to
avoid obscuration of essential bony structures.
a 1.3.2.2
Technique: Supine
a b
Fig. 1.5. a. Patient positioning for seated erect AP axial “inlet” projection of the anterior pelvic bones. b “Inlet” radiograph of
the anterior pelvic bones
1.3.2.3
Radiographic Evaluation
a
1.4
Radiographic Projections of the
Sacroiliac Joints
1.4.1
AP Oblique Projection of the Sacroiliac Joints
1.4.1.1
Technique: Supine
side is centered about the midline of the table. The or upper abdomen or at the patient’s sides. A pillow
anterior superior iliac spines should be in the same or other support structure should be placed under
transverse plane. The head as well as the elevated the head and the knees. In the prone position, the
shoulder, lower back and thigh should be supported elbows should be flexed and the arms should be in a
by pillow wedges or by other means. With the central comfortable, bilaterally symmetrical position.
ray directed perpendicular to the plane of the film, For evaluation of the sacrum: In the supine posi-
it should enter 1 in. (2.5 cm) medial to the elevated tion, the central ray should be directed 15° cepha-
anterior superior iliac spine. With the central ray at lad and centered to the midpoint of the plane that
an angle of 25° cephalad, it should be centered 1 in. passes midway between the symphysis pubis and
(2.5 cm) medial and 1.5 in. (3.8 cm) distal to the ele- the anterior superior iliac spines. In the prone posi-
vated anterior superior iliac spine. Alternatively, with tion, the central ray should be directed 15° caudad
the central ray perpendicular, it should be directed and centered to the sacral curve. Respiration is sus-
1 in. (2.5 cm) medial to the elevated anterior superior pended. Gonadal shielding should be done carefully
iliac spine. Respiration is suspended. Gonadal shield- in males to not obscure significant bony structures.
ing should be done carefully to avoid obscuration of Respiration is suspended. Shielding in women is not
essential bony structures. Shielding for women may possible without significant image degradation. The
be difficult to achieve without significant obscura- urinary bladder should be empty. The lower colon
tion. Collimation should be close to the joint. should be free of gas for optimal image acquisition.
For evaluation of the coccyx: In the supine posi-
tion, the central ray should be directed 10° caudad
1.4.1.2 and centered to a point about 2 in. (5 cm) superior
Radiographic Evaluation to the symphysis pubis. In the prone position, the
central ray should be directed 10° cephalad and
On this projection, a profile view of the affected centered to the palpable coccyx. Respiration is sus-
sacroiliac joint is seen. The adjacent structures are pended. Gonadal shielding should be done carefully
seen in an oblique position. Both sides should be in males to not obscure significant bony structures.
evaluated for comparison. Respiration is suspended. Shielding in women is not
possible without significant image degradation. The
urinary bladder should be empty. The lower colon
should be free of gas for optimal image acquisition.
1.5
Radiographic Projections of the Sacrum
and Coccyx 1.5.1.2
Radiographic Evaluation
Standard projections for the evaluation of the
sacrum and coccyx include AP, PA, and lateral. On this projection, a true frontal projection of the
sacrum and coccyx, free of superimposition is dem-
onstrated. Evaluation of the sacrum should dem-
1.5.1 onstrate neither foreshortening nor rotation. Fecal
AP/PA Projection of the Sacrum and Coccyx material should not overlap the sacrum. The sacro-
iliac joints and L5–S1 junction should be included.
1.5.1.1 Evaluation of the coccyx should demonstrate no
Technique: Prone or Supine rotation and no segmental superimposition.
b d
Fig. 1.7. a Patient positioning for anteroposterior (AP) view of sacrum. b Patient positioning for anteroposterior (AP) view of
coccyx. c AP View of the sacrum. d AP view of the coccyx
comfortable position. For evaluation of the sacrum, position with the bony landmarks, such as the ante-
the coronal plane passing 3 inches posterior to the rior superior iliac spines, lying in the same vertical
midaxillary line is centered about the midline of the plane with respect to one another. Supports should
table. For evaluation of the coccyx, the coronal plane be placed under the head, ankles and knees. The film
passing through the coccyx should be placed about should be positioned so that its midpoint is either at
the center line of the table either by palpation tech- the level of the anterior superior iliac spines for the
nique or by appreciating that the coccyx lies approxi- sacrum or at the level of the center of the coccyx.
mately 5 in. (12.7 cm) posterior to the midaxillary For evaluation of the sacrum, the central ray should
line. The vertebral column should be parallel to the be directed perpendicular to a coronal plane 3 in.
tabletop. Therefore, a small support may be needed (7.6 cm) posterior to the midaxillary line at the level
under the lower thoracic/upper lumbar spine. The of the anterior superior iliac spine. For evaluation of
arms should be positioned at right angles to the body, the coccyx, the central ray should be directed per-
while allowing the patient to grasp onto the table pendicular to a coronal plane 3 in. (7.6 cm) posterior
for support. The pelvis should be in the true lateral to the midaxillary line at the level of the coccyx.
Radiographic Evaluation 11
1.5.2.2
Radiographic Evaluation
1.6
Radiographic Projections of the Hip
1.6.1
AP Projection of the Hip
1.6.1.1
Technique: Supine
c
Fig. 1.8. a Patient positioning for lateral sacral radiograph. b
Patient positioning for lateral coccyx radiograph. c Lateral
sacral radiograph
12 U. J. Skripkus and A. Gentili
a b
Fig. 1.9. a Patient positioning for anteroposterior (AP) hip radiograph. b AP hip radiograph
1.6.1.2
Radiographic Evaluation
1.6.2
Lateral Projection of the Hip
a
(Lauenstein and Hickey)
1.6.2.1
Technique: Supine
angle of 20° (for the Hickey method) through the hip greater trochanter. This will mark the axis of the
joint, located midway between the anterior superior femoral neck regardless of the position of the lower
iliac spine and the symphysis pubis. extremity. Unless contraindicated, the foot of the
affected side should be internally rotated approxi-
mately 15°–20° and fixed in position with sandbags
1.6.2.2 or other device. The elbows should be flexed and
Radiographic Evaluation the palms of the hands should rest gently on the
chest or upper abdomen. The cassette should be in
On this projection, the lateral position of the hip the vertical position exactly parallel to the long axis
is optimized. The acetabulum, proximal femur and of the femoral neck of the affected side. The central
the relationship of the acetabulum with the articu- ray should be directed perpendicularly to the long
lating femur are demonstrated. In the Lauenstein axis of the femoral neck and centered approximately
method, the femoral neck will be overlapped with 2.5 in. (6.4 cm) below the point of intersection of
the greater trochanter. the localization lines described above. Respiration is
suspended. Gonadal shielding is not possible with-
out obscuration of significant structures. Therefore,
1.6.3 close collimation is essential.
Axiolateral Inferosuperior Projection of the Hip
(Danelius–Miller)
1.6.3.2
1.6.3.1 Radiographic Evaluation
Technique: Supine
(Danelius–Miller Modification of Lorenz) The proximal femur, including the head, neck, is
well demonstrated in the lateral projection. The hip
The patient is in the supine position and the pelvis joint with the acetabulum should be well demon-
is elevated slightly while maintaining a true AP strated. Any orthopedic hardware should be fully
position without rotation. The unaffected limb is included.
elevated with the thigh placed in near vertical posi-
tion. The leg should be supported at hip level with
pillows or other supporting structures. The elevated
extremity should be positioned so as to be outside of 1.7
collimation field. To localize the long axis of the fem- Arthrographic Evaluation of the Hip
oral neck, the center point of a line drawn between
the anterior superior iliac spine and the superior 1.7.1
border of the symphysis pubis should be connected Technique: Supine
to a point drawn approximately 1 in. (2.5 cm) distal
to the most prominent lateral protrusion of the The patient is supine with the pelvis in true AP posi-
tion. Unless contraindicated, the feet are internally
rotated approximately 15° to get the long axis of the
femora parallel to the film. The feet may be gently
taped together or a sandbag may be placed across the
ankles to minimize movement during image acqui-
sition. In the case of trauma, or when femoral neck
fracture or dislocation is suspected, the feet should
not be internally rotated. The elbows should be
flexed and the palms of the hands should rest gently
on the chest or upper abdomen. Alternatively, the
arms may rest at the patient’s sides. The shoulders
should be in the same transverse plane as the pelvis.
A pillow or other supporting structure should be
placed behind the head and the knees. Palpate the
Fig. 1.11. Patient positioning for axiolateral inferosuperior femoral artery and draw the course of the artery on
radiograph of hip the skin with a permanent marker. Mark the mid
14 U. J. Skripkus and A. Gentili
a b
c d