X-ray Exam Protocols

ORTHO PCSM
Exam Imaging Views Evolution Definium 5000 Discovery

Abdomen (KUB) Upright AP √ √ √

AC Joints AP Bil Upright without weights √ √ √

AP Bil Upright with weights √ √ √

Ankle, 3 views AP - Standing √ √ √

Oblique - Standing √ √ √
Lateral - Standing √ √ √

Ankle Stress Views- Doctor to perform stress view AP Stress √ √

Internal Oblique Stress √ √

C-Spine, Complete "4 view" AP √ √ √

Odontoid √ √ √
Lateral -- anterior facing left √ √ √
Lateral Flexion √ √ √
Lateral Extension √ √ √

C-Spine 2 View AP √ √ √
Lateral -- anterior facing left √ √ √
Lateral -- anterior facing left √ √ √

Chest, 2 views PA √ √ √
Left lateral √ √ √

Clavicle, 2 views AP √ √ √
AP with 15 to 25 degree cephalic angle √ √ √
Elbow, 4 views AP √ √ √
External oblique √ √ √
Lateral √ √ √

Facial Bones, 4 views Waters √ √ √

Caldwell √ √ √
Towne (light for arches) √ √ √
Lateral of Affected Side √ √ √

Femur, 2 views Upright AP- Upper √ √ √

AP- Lower √ √ √
Lateral- Upper √ √ √
Lateral- Lower √ √ √

Finger, 3 views PA √ √ √
Oblique √ √ √
Lateral √ √ √

Foot, Weight Bearing 3 views AP √ √ √

Oblique √ √ √
Lateral √ √ √

Trauma Foot, 3 views (ie: stretcher/wheelchair) AP √ √

cassette on floor if in wheelchair or Oblique √ √
cassette on stretcher Lateral (most likely Cross Table Lateral) √ √

Forearm, 2 views AP √ √ √
Lateral √ √ √

Forearm, 2 views Trauma (ie: stretcher/wheelchair) AP √ √

cassette on PTs lap or arm sprawled across table Lateral √ √
 Cross Table Lat - for wrist √ √

Hand, 3 views PA √ √ √
cassette on PTs lap or arm sprawled across table
Oblique √ √ √
Lateral √ √ √

Hand, 3 views Trauma (ie: stretcher/wheelchair) PA √ √

cassette on PTs lap or arm sprawled across table Oblique √ √
Lateral - most likely cross table √ √

AP Pelvis (w/ Marker Board for 1st appt or if it's been

Hip 2-3 Views Per Dr. Le over a yr) √ √
AP Hip of affected side √ √ √
Lat Frog Leg of affected side √ √ √
Cross Table Lat - for 1st Post Op hip replacement appt √ √

AP Pelvis (w/ Marker Board for 1st appt or if it's been

Hip 2-3 Views Per Dr. Kraekel over a yr) √ √
AP Hip of affected side √ √ √
Lat Frog Leg of affected side √ √ √
Cross Table Lat - for 1st Post Op hip replacement appt or
if previous replacement √ √
from a different Physician

Hip, 2 views - for all other Physicians AP Pelvis √ √ √

Note: If prosthesis is present, must include both ends on
both views. √ √ √
Lat Frog Leg of affected side.

Hip - Judet Views RPO - positioned with pelvis in true 45 degree posterior
oblique, entire pelvis to be demonstrated. √ √ √
LPO - positioned with pelvis in true 45 degree posterior
oblique, entire pelvis to be demonstrated. √ √ √
Hip - False Profile
Note: Specific to Orthopedic Surgeons
RPO - standing with pelvis in 25 degree posterior oblique √ √ √
LPO- standing with pelvis in 25 degree posterior oblique √ √ √

Humerus AP- humerus to be rotated such that palm is facing

forward (hand is supinated). √ √ √
Lateral √ √ √

AP- humerus to be rotated such that palm is facing

Humerus - Trauma forward (hand is supinated). √ √
Cassette Table Top behind Pt Lateral √ √
Cross Table Lateral elbow to include humerus √ √

Knee, 4 views Bil AP Standing √ √ √

Merchant View-
Bucky all the way to the floor Lateral √ √ √
with 15 degree cephalic angle Standing Tunnel (PA standing with 45 degree knee
Tube with 65 degree caudal angle- tube set to 35degrees Pt flexion & 10 degree caudal angle) √ √ √
seated at front edge of chair and leaning back
Merchant -or- Sunrise √ √

Lumbar Spine, Bending AP Upright √ √ √

Lateral √ √ √
Lateral Flexion -- anterior facing left √ √ √
Lateral Extension -- anterior facing left √ √ √

Lumbar Spine 2 View AP √ √ √

Lateral √ √ √

Mandible, 4 views PA √ √ √
Towne √ √ √
Right Oblique √ √ √
Mandible, 4 views

Left Oblique √ √ √

Nasal bones, 3 views Waters √ √ √

Right Lateral √ √ √
Left Lateral √ √ √

Orbits, 4 views Waters √ √ √

Caldwell - exaggerated 30 degrees down √ √ √
Lateral √ √ √

Orbits for Fracture Waters √ √ √

Right Rheese √ √ √
Left Rheese √ √ √

Ribs, 3 views AP or PA Upper Ribs -- area of concern being closest to √ √ √

imaging
AP or PAplate
Lower Ribs if needed-- area of concern being √
Note: Upper Ribs on Inspiration & Lower Ribs on √ √
closest to imaging plate
Expiration √ √ √
RPO or LPO of affected side

Sacrum & Coccyx AP with 15 degree cephalic angulation √ √ √

AP with 10 degree caudal angulation √ √ √
Lat -- anterior facing left (include sacrum and entire
coccyx) √ √ √

Scapula, 2 views AP √ √ √
Lateral - Tangential √ √ √

Scoliosis AP √ √
Shoes off. True AP with back completely against the Lateral
detector. Must include top of ear to both acetabulum's √ √

Shoulder, 3 views AP External Rotation (Include clavicle) √ √ √

Outlet - "Y" view with 30 degree Caudal Angle √ √ √
Axillary √ √ √
Shoulder Specialty View Grashey √ √ √
Only when specifically asked for by the Doctor Valpeau - √ √

Shoulder, Trauma (ie: stretcher/wheelchair) AP Internal Rotation √ √

AP External Rotation √ √
AP Scapi Y (Outlet) - if possible √ √

SI Joints AP √ √ √
30 degree upshot √ √ √
Right Oblique √ √ √
Left Oblique √ √ √

Soft Tissue Neck AP √ √ √

Lateral -- anterior facing left √ √ √

Sternoclavicular Joints RAO √ √ √

LAO √ √ √
Lateral of Affected Side (15 degree caudal angle, arms in
Swimmer's position) √ √ √

Sternum, 2-4 views RAO - shallow breathing during exposure √ √ √

LAO if needed √ √ √
Lateral- inspiration √ √ √

Thoracic Spine 2 views AP Standing √ √ √

Lateral Standing √ √ √

Thoracolumbar Spine AP Standing - Must include ASIS but try to center at

effected level √ √ √
Lateral Standing - Must include ASIS but try to center at
effected level √ √ √
Thumb, 3 views AP (Robert's View if looking at the CMC ( AP using 10
degree Cephalic angle)) √ √ √
Oblique √ √ √
Lateral √ √ √

CMC Thumb Stress using 2 angle sponges placed together like a pyramid. √ √ √
lateral aspects of thumb tips touching & wrists apart
have pt put stress against thumbs during exposure

Tibia/Fibula - Weight Bearing if indicated AP √ √ √

Lateral √ √ √

Toe, 3 views AP √ √ √
Mostly done NWB Oblique √ √ √
Lateral √ √ √

Wrist, 3 views
PA w/ 10 degree Cephalic Angle (or use wedge sponge) √ √ √
Oblique √ √ √
Lateral w/ 20 degree Cephalic Angle (or use wedge
sponge) √ √ √
Scaphoid if requested (radial deviation w/ 20 degree tube ti√ √ √

Wrist, 3 views Trauma (ie: stretcher/wheelchair)

PA w/ 10 degree Cephalic Angle (or use wedge sponge) √ √
cassette on PTs lap or arm sprawled across table Oblique √ √
Lateral w/ 20 degree Cephalic Angle (or use wedge
sponge) √ √
 Proteus

√
√

√
√

√
√
√
√
√

√
√
√

√
√

√
√
√
√
√

√
√
√
√

√
√
√
√

√
√
√

√
√
√
√
√

√
√
√

√
√
√

√
√
√

√
√

√
√

√
√
√
√

√
√

√
√
√
√

√
√
√

√
√
√

√
√
√

√
√

√
√

√
√

√
√
√
√

√
√
√
√

√
√

√
√

√
√
√

√
√

√
√
√
√

√
√

√
√
√

√
√

√
√
PEDIATRIC (16 and under) PROTOCOL VARIATIONS
All Pediatric images need to be imaged individually. (one body part per image) The only exception is a
bone age.

ABDOMEN 1 view
ANKLE 3 views
Bone age 1 view
CALCANEUS/HEEL 2 views
C-SPINE age 0-7 2 views
C-SPINE age 8-16 3 views
Atlantoaxial instability in Down syndrome - Lateral
(neutral), lateral (flexion), AP.
C-SPINE 3 views
CHEST 2 views
CLAVICLE 2 views
ELBOW 2 views
FEMUR 2 views
FINGER 3 views
FOOT 3 views
FOREARM 2 views
HAND 3 views
HIP--always do pelvis 2 views (AP
& Frog)

KNEE 2 views
LUMBAR 2 views
SCOLIOSIS 1 view
SHOULDER 2 views (int & ext)
SINUS age 0-14 1 view (water's)
SINUS age 15-up 3 views
T-SPINE 2 views
THUMB 3 views
TIBIA/FIBULA 2 views
TOE 3 views
WRIST 3 views
e only exception is a

own syndrome - Lateral

P.
Standard Protocol for Joint Injections: MR/CT Arthrography and Therapeutic
MR Arthrography Joint Injection

Following is the standard injectate for all MR arthrogram injections (20 ml syringe):

10 ml sterile saline
5 ml Isovue 300
5 ml 0.5% Marcaine
0.1 ml Gadavist

Volume of standard injectate may be adjusted depending on size of the joint to be injected (see below).

Standard volumes of contrast mix injected in specific joints:

Shoulder: ~10 ml
Elbow: ~7 ml
Wrist: 2-3 ml
Hip: ~10 ml
Knee: 30-40 ml
Ankle (tibiotalar joint): ~7 ml
MTP (plantar plate): 1 ml

Notes:
·         Gadolinium should be drawn up in a tuberculin syringe and injected into a measured volume of saline, Isovue, a
gadolinium into 10 ml vial of saline as it is not a reliably measured volume)
·         The injectate for knee MR arthrogram should be prepared in (2) 20 ml syringes with the standard injectate in the
saline and 0.1 ml Gadavist in the second syringe.
·         The injectate for the wrist and small joints should be prepared in a 10 ml syringe using half volume of each com
·         If intraarticular steroid is requested at time of arthrogram, a 1 ml injection of Depo Medrol (80 mg/ml) may be pe
mixture.

For hips: Abbreviated range of motion exam to reproduce patient pain (eg. FABER, hip flexion internal rotation for im
prior to procedure and 5 min post procedure. Record pre and post pain levels. Pain journal given to patient for referr
patient as to the length of expected anesthetic phase and encourage activities during anesthetic phase that would ty
limits) to assess for intraarticular pain generator.

CT Arthrography Joint Injection

Following is the standard injectate for all CT arthrogram injections (20 ml syringe):

10 ml sterile saline
10 ml Isovue 300
Volume of standard injectate same as for MRI (see above).

Note:
·         CT hip arthrogram injectate should include 5 ml saline, 5 ml 0.5% Marcaine, and 10 ml Isovue 300. Abbreviated
levels obtained, and pain journal given to patient as for above MRI hip arthrograms.
Therapeutic/anesthetic Joint Injection

Following is the standard injectate for large joint pain injections (hip, shoulder, knee):

When steroid requested:

1 ml Depo Medrol (80 mg/ml)
5 ml 0.5% Marcaine
(in separate 3 ml and 5 ml syringes respectively)

When steroid not requested (anesthetic only):

5 ml 0.5% Marcaine

Ropivicaine can be substituted for Marcaine per ordering physician request.

For hips: If appropriate (many of these patients are severely degenerative and range of motion is not appropriate), a
reproduce patient pain (eg. FABER, hip flexion internal rotation for impingement, or extension) performed prior to pr
This can be reserved for younger patients with possible impingement. Record pre and post pain levels. Appropriate
steroid) to patient for referring physician follow up.
Colon Transit Study

REVIEW AVAILABLE PREVIOUS FILMS AND REPORTS

Determine that the ordered exam is for “Colon Transit” and not for “Gastric Emptying”

Hanging Protocol
Images should be presented in order taken.

All films must be clearly marked as “Scout”, “Day 4” or “Day 7”

Obtain a copy of the instruction page for this procedure and three (3) SITZMARKS capsules. Explain the
procedure to the patient, writing the appropriate dates and times on the procedure form on the lines prior to
each step. Copy this sheet and give one copy to the patient.

Explain and emphasize that the patient is not to use laxatives of any kind for the duration of the exam.

Tech must document patient compliance with instructions on the On Line Form (in the Comment Section)
including documentation of the dates the patient took the capsules.

IMAGING SEQUENCE :
Position: AP Supine Lower
Image Size: 14x17 lengthwise -- Include full symphisis
Technique: 80-85kvp

Position: AP Supine Upper

Image Size: 14x17 lengthwise -- Include the top of the right femur and the diaphragms

Technique: 80-85kvp
Special Notes
Link day 4 and day 7 images to Scout
Image.
Exam is complete at day 7 regardless of
the number of markers in the colon.

IMPORTANT:This is how the bowel is segmented for tallying the markers. The top of the right femur is
needed to adequately count the right colon. The symphysis to adequately tabulate the recto-sigmoid, and
the diaphragms to make sure the transverse colon and flexures are included.
 COLON TRANSIT STUDY INSTRUCTIONS

Explain the procedure to the patient

Patient should be instructed to ingest the Sitzmark capsules at the same time each day. The patient
should return to Inland Imaging for their films on days four and seven at the same time of day that they
ingested the capsules.
Explain and emphasize that the patient is NOT to use laxatives of any kind for the duration of the exam.
This includes stool softeners and suppositories.

Fill out this instruction sheet. Review the instructions on this sheet with the patient. Give this sheet along
with the capsules to the patient to take with them.

__________Day 0 Patient takes one SITZMARKS “O” capsule with a full glass of
water.

__________Day 1 Patient takes one SITZMARKS “O” capsule with a full glass of
water.

__________Day 2 Patient takes one SITZMARKS “Double D” capsule with a full

glass of water. This should be done at the same time of day
as the first capsule.

__________Day 3 Patient takes one STTZMARKS “Tri-Chamber” capsule with a

full glass of water. This should be done at the same time of
day as the other capsules.

__________Day 4 Patient returns to Inland Imaging for films. This should be

done at the same time of day that the capsules were ingested.

__________Day 7 Patient returns to Inland Imaging for another set of films. This
should be done at the same time of day that the capsules were
ingested.
 PEDIATRIC (Age 0-16)

COLON TRANSIT STUDY INSTRUCTIONS

Explain the procedure to the patient and parent/guardian.

Patient should be instructed to ingest the Sitzmark capsules at the same time each day. The patient
should return to Inland Imaging for their films on days four and seven at the same time of day that they
ingested the capsules. Let the patient know that they may be asked to return until the capsules have
cleared.

A preliminary KUB is not taken for this exam.

Fill out this instruction sheet. Review the instructions on this sheet with the patient and the patient’s
parent(s) or guardian. Give this sheet along with the capsules to the patient to take with them.

__________Day 1 Patient is given instructions. Patient takes one SITZMARKS

capsule with water or juice.

__________Day 2 Patient takes one SITZMARKS capsule with water or juice.

This should be done at the same time of day as the first
capsule.

__________Day 3 Patient takes one SITZMARKS capsule with water or juice.

This should be done at the same time of day as the other
capsules.

__________Day 4 Patient returns to the Imaging Center for a KUB. This should
be done at the same time of day that the capsules were
ingested.

__________Day 7 Patient returns to the Imaging Center for a KUB. This should
be done at the same time of day that the capsules were
ingested. ** If rings are still present anywhere besides the
descending colon, then follow up KUB will be needed every
two days.
Helpful Hints: If your child cannot swallow a pill, take the capsule apart and feed the markers placed in a
few spoonfuls of applesauce or pudding. Encourage the child to swallow without chewing.