Skull Procedures 1. PA Projection 2. AP Projection

SKULL
Procedures
1. PA Projection
2. AP Projection
1. PA Projection
A. Patient Position
➤ Patient is in supine position with the midsaggital plane of
the body is center to the grid...
B. Part Position
➤ OML is perpendicular to the IR.
➤ Petrous pyramids should fill the orbits.
C. Central Ray
➤ Perpendicular to the nasion.
D. Patient Instructions
➤ Suspended respiration.
E. Exam Rationale
➤ The orbits are considerable magnified because of the increased
object-to-image receptor distance.
➤ Similarly, because of magnification the distance from the
lateral margin of the orbit to the lateral margin of the temporal
bones measures less on the AP projection than the PA projection
because of magnification.
F. Structure Shown
➤ Entire skull.
➤ Symmetric petrous ridges.
➤ Petrous pyraminds will fill the entire orbits.
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2. AP Projection
A. Patient Position
➤ Patient is either in prone or seated position. Midsaggital
plane of the patient's body is center to the grid.
B. Part Position
➤ Rest the patient's forehead and nose against the Table or
Bucky surface.
➤ Flex the patient's neck so that the OML is perpedicular to the
plane of the IR.
➤ Top of the image receptor is approximately 11⁄2 inches (4cm)
above the vertex of the skull.
C. Central Ray
➤ Perpendicular to the image receptor exiting at the nasion.
E. Exam Rationale
➤ Petrous pyramids should fill the orbits. Anterior and lateral
walls of the cranium.
➤ Frontal bone, Cristal galli, ethmoid air cells.
➤ Skull fractures neoplastic processes and paget's disease.
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ORBITS
Procedures:
1. Parietoacantial Modified (Waters) Projection
2. PA Projection
3. Lateral Projection
1. Parietoacanthial Modified (Waters) Projection
A. Patient Position
➤ Patient is either prone or erect position facing the
table/tube.
B. Part Position
➤ Extend the neck until the chin and nose resting
against the table
➤ Mentomeatal (mme) is perpendicular to the plane of the image
receptor
➤ OML will form 55° angle with the table
➤ MSP is perpendicular to the midline of the table
C. Central Ray
➤ Perpendicular to the image receptor to exit at the acanthion
➤ Suspended respiration
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E. Exam Rationale
➤ This projection is especially good for demonstrating fractures
of the orbit and depressed fractures of the nasal wings.
➤ Demonstrate the blowout fractures in the orbital floor
F. Structures Shown
➤ Orbital floors
➤ Superior and inferior orbital floors
Petrous ridges blow the maxillary sinuses
➤ Zygomatic arches
2. PA Projection
A. Patient Position
➤ Patient is in prone position
B. Part Position
➤ Image receptor is central to the orbit
MSP is perpendicular to the midpoint of the image receptor
➤ OML is perpendicular to the image receptor
C. Central Ray
➤ Perpendicular to the image receptor
E. Exam Rationale
➤ This projection demonstrate the upper two-thirds of the orbit
F. Structures Shown
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➤ Petrous Ridges.
➤ Orbital Roof
➤ Orbital Floor Crista Galli
A. Patient Position
➤ Patient is in prone or erect position
B. Part Position
➤ Image receptor is centered to the orbit
➤ MSP is parallel
➤ Interpupillary line is perpendicular to the IR
C. Central Ray
➤ Perpendicular to the outer canthus
E. Exam Rationale
➤ This projection is used to demonstrate foreign bodies
F. Structures Shown
➤ Frontal Sinuses
Orbital Floor
➤ Maxillary Sinus
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A. OPTIC FORAMEN
1. Parietoorbital Oblique Projection (Rhese Method)
A. Patient Position
➤ Patient is in semiprone or seated-upright position
B. Part Position
➤ Center the affected orbit to the image receptor until the
zygoma, nose and the chin rest on the radiographic table.
➤ AML is perpendicular to the plane of the film
➤ MSP forms an angle of 53°
➤ This is also called "three-point landing"
C. Central Ray
➤ Perpendicular, entering approximately 1 inch (2.5 cm) superior
and posterior to the upside Top of Ear Attachment (TEA)
E. Exam Rationale
➤ This projection demonstrates the optic foramen / canal, "on
end" and the optic foramen lying in the inferior and lateral
quadrant of the projected orbit.
➤ Any lateral deviation or displacement indicates incorrect
rotation of the head
➤ Any longitudinal deviation or displacement indicates incorrect
angulation of the AML or baseline adjustment
➤ Narrowing could indicate abnormal bone growth
➤ Both sides are taken for comparison
➤ It also demonstrates the ethmoidal, sphenoidal and frontal
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sinuses
F. Structures Shown
➤ Optic canal
➤ Entire orbital rim
➤ Superior and lateral margins
2. Orbitoparietal Oblique Projection (Alexander Method)
A. Patient Position
B. Part Position
➤ Forehead and nose are centered to the center line of the
radiographic table
➤ MSP forms an angle of 450 to the plane of the film
➤ AML is perpendicular to the Image receptor
C. Central Ray
➤ Perpendicular, it enters at the inferior and lateral margin of
the upper most orbit
E. Exam Rationale
➤ This projection demonstrates the optic canal in cross section,
lying in the inferior and lateral quadrant of the orbital shadow.
➤ Both sides are taken for comparison
F. Structures shown
➤ Optic canal / foramen
➤ Entire orbital rim
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B. Superior Orbital Fissures
1. PA Axial Projection
A. Patient Position
➤ Patient is in prone position.
B. Part Position
➤ Forehead and nose are centered to the center line of the
radiogprahic table
➤ MSP is perpendicular to the image receptor
➤ OML is perpendicular to the imager receptor
C. Central Ray
➤ 20 to 25° caudally, exiting at the level of the inferior
margin of the orbit.
E. Exam Rationale
➤ This projection demonstrated the superior margin of the
petrous portions of the temporal bones should be projected at or
just below the inferior margin of the orbits.
F. Structures Shown
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➤ Superior orbital fissure
➤ Petrous ridges
C. Inferior Orbital Fissures
1. PA Axial Projection (Bertel Method)
A. Patient Projection
➤ Patient is seated-upright or prone position
B. Part Position
➤ Forehead and nose are centered to the image receptor
➤ IOML is perpendicular to the IR
C. Central Ray
➤ 20 to 25° cephalad, exiting the nasion and enters
approximately 3 inches (7.6cm) below the external occipital
protuberance.
E. Exam Rationale
➤ This projection demonsrates the orbital floor and inferior
orbital fissure between the shadows of the lateral pterygoid
lamina of the sphenoid bone and the condylar process of the
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mandible.
F. Structures Shown
➤ Inferior orbital fissures with in the orbits
D. Sphenoid Strut
1. Parieto-Orbital Oblique Projection (Hough Method)
➤ Patient is either seated-upright or prone position
B. Part Position
➤ Supercillary ridge (arch) is centered to the image receptor
➤ IOML is perpendicular to the image receptor
➤ Rotate the bed towards the affected side
➤ MSP is 20° angle
C. Central Ray
➤ 7° caudally exiting the affected orbit.
E. Exam Rationale
➤ This projection demonstrate an obstructed and undistorted
image of the sphenoid strut in the center of the orbital shadow,
where it separates the optic canal from the superior orbital
fissure.
F. Structures Shown
➤ Sphenoid strut
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FACIAL BONES
2. Parietoacantial Projection (Waters Method)
3. Acanthioparietal Projection (Reverse Waters Method)
4. PA Axial Projection (Caldwell Method)
➤ Patient is in a semiprone or obliquely seated position
B. Part Position
➤ Head is in true lateral position
➤ MSP is parallel to the image receptor
➤ IPL is perpendicular to the image receptor
➤IOML is parallel with the transverse axis of the image receptor
➤ Image receptor is centered to the zygoma
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C. Central Ray
➤ Perpendicular to the image receptor entering to the malar
surface of the zygomatic bone between the outer canthus.
E. Exam Rationale
➤ This position is used to demonstrate the facial bones of the
side closest to the image receptor with the opposite side
superimposed.
➤ It is useful to demonstrate depressed fractures of the frontal
sinus, the orbital roof, sella turcica and mandible.
F. Structures Shown
➤ Superimposed facial bones
➤ Greater wings of the sphenoid
➤ Orbital roods
➤ Sella turcica
➤ Zygoma and mandible
2. Parietoacanthial Projection (Waters Method)
➤ Patient is in prone or seated upright position
B. Part Position
➤ The neck is extended and the chin placed on the bucky
➤ The image receptor is centered to the acanthion MSP is
perpendicular to the midline of the image elstreceptor
➤ OML forms a 37° angle to the image receptor
➤ The average patient's nose will be about 3/4 inch away from
the image receptor
C. Central Ray
➤ Perpendicular exiting to the acanthione
E. Exam Rationale
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➤ This projection is especially good for demonstrating fractures
of the orbit and depressed fractures of the nasal wings.
➤ It also demonstrates orbits, maxillae and zygomatic arches.
F. Structures Shown
➤ Inferior orbital rim
➤ Maxillae
➤ Nasal septum
➤ Zygomatic bones and bones
➤ Anterior nasal spine
3. Acanthioparietal Projection (Reverse Waters Method)
➤ Patient is in supine position
B. Part Position
➤ Extend the neck so that the OML forms a 37° angle with the
image receptor
➤ MML is perpendicular to the image receptor
C. Central Ray
➤ Perpendicular to the acanthion
E. Exam Rationale
➤ This projection us used to demonstrate the facial bones when
the patient cannot be placed in the prone position
➤ It demonstrates the superior facial bones but the facial
structures are considerable magnified.
F. Structures Shown
➤ Orbit
➤ Zygomatic bone
➤ Maxillary sinuses Petrous ridges
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B. Part Position
➤ Forehead and nose are resting against the table top
➤ Ensure no rotation or tilt of the head
C. Central Ray
➤ 15° caudally exiting the nasion
➤ Petrous ridges are projected into the lower third of
the orbit
➤ 30° caudally exiting the nasion if for the
demonstration of the orbital rims in particular orbital floors
(sometimes referred to as Exaggerated
Caldwell)
➤ Petrous ridges are projected below the inferior margins of the
orbit
E. Exam Rationale
➤ This projection is performed to demonstrate fractures of the
facial bones and is especially helpful to determine alveolar
ridge fractures.
➤ To demonstrates the orbital rim, the nasal septum and the
mandibular condyles, zygomatic bones and anterior nasal spine.
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F. Structures Shown
➤ Orbital rim Maxillae
➤ Nasal septum Zygomatic bones Anterior nasal spine
NASAL BONES
2. Superoinferior Projection (Tangential)
3. Parietoacantial Projection (Waters)
➤ Patient is in semi prone position, adjust the rotation
of the body so that the midsagittal plane of the head
is placed horizontally.
B. Part Position
➤ IPL is perpendicular to the image receptor
➤ IOML is parallel to the transverse axis of the image receptor
C. Central Ray
➤ Perpendicular to the bridge of the nose at a point% inch
inferior and posterior to the nasion
E. Exam Rationale
➤ This position is used to demonstrate the nasal bone and soft
tissue structures of the nose
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➤ It is also used to demonstrate non displaced, linear fractures
of the nasal bones
➤ Both laterals are normally done for comparison
F. Structures Shown
➤ Nasal bones with soft tissue structures
➤ Front nasal suture
➤ Anterior nasal spine
2. Superoinferior Projection (Tangential)
➤ Patient is either prone or seated in a chair at the end of the
table
B. Part Position
➤ Patient holds the image receptor in a horizontal position
under the chin.
➤ Adjust the flexion of extension of the head to place the
glabelloalveolar line perpendicular to the plane of the image
receptor.
➤ MSP is perpendicular to the midline of the image
receptor
C. Central Ray
➤ Perpendicular to the image receptor along the glabelloalveolar
line
E. Exam Rationale
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➤ This projection demonstrates medial or lateral displacement of
the nasal bone fractures
F. Structures Shown
➤ Nasal bone and soft tissue
N.B.
➤ This position will not adequately demonstrate the nasal bones on
individuals with a prominent forehead or chin of protruding front teeth. If
intraoral film is available place it in the mouth and position the patient
and central ray as described above.
3. Parietoacanthial Projection (Waters)
➤ Patient is either prone or seated position
B. Part Position
➤ The neck is extended and the chin is placed on the bucky
➤ MSP is perpendicular to the midline of the image
receptor
➤ OML forms 37° angle to the image receptor
C. Central Ray
➤ Perpendicular to the image receptor exiting at the acanthion
E. Exam Rationale
➤ The projection is used to demonstrate displacement of the bony
nasal septum and depressed fractures of the nasal wings.
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F. Structures Shown
➤ Petrous ridges below the maxillary sinuses
➤ Bony nasal septum
ZYGOMATIC ARCHES
1. Submento Vertical Projection (SMV or Basal) Tangential
2. PA Axial (Superior)Modified Titterington Method
3. Tangential Projection (May method)
4. AP Axial Projection (Towne/ Grashey Method)
1. Submento Vertical Projection (SMV or Basal) Tangential
➤ Patient is either supine or seated upright position
➤ Flex the patient knees to relax the abdominal muscles
B. Part Position
➤ Extend the neck until the head is resting on the vertex
➤ MSP is perpendicular to the plane of the image receptor
➤ IOML is parallel to the image receptor
C. Central Ray
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➤ Perpendicular to IOML entering midway between the zygomatic
arches; 1 inch posterior to the outer canthus.
E. Exam Rationale
➤ This projection can be used to demonstrate the lateral margins
of the zygomatic arches free of superimposition. It is usually
performed to identify fractures.
F. Structures Shown
➤ Zygomatic Arches
N.B
Zygomatic arches are well demonstrated by decreasing the mAs by 50% to
demonstrate the base of the cranium with proper density.
2. PA Axial (Superior) Modified Titterington Method
➤ Patient is in prone or seated upright facing the vertical
cassette holder
B. Part Position
➤ Nose and chin are resting on the table top
C. Central Ray
➤ 23 to 38° caudally, entering the vertex midway between the
zygomatic arches
E. Exam Rationale
➤ This projection demonstrate well the zygomatic arches
F. Structures Shown
➤ Zygomatic bone
➤ Coronoid process
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3. Tangential Projection (May method)
➤ Patient is either prone or seated upright position facing the
vertical cassette holder
B. Part Position
➤ Extend the patient's neck and rest the chin on the image
receptor
IOML is parallel wit the plane of the image receptor Rotate the
head 15° away from the side being
examined
C. Central Ray
➤ Perpendicular to the IOML, through the zygomatic arch
approximately 1 1⁄2 inches posterior to the outer canthus.
E. Exam Rationale
➤ This projection is used to demonstrate the zygomatic arch free
of superimposition, particularly those patients who have
depressed fractures or flat cheekbones.
F. Structures Shown
➤ Zygomatic arch free of superimposition
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4. AP Axial Projection (Towne / Grashey Method)
➤ Patient is either supine or seated-upright position
B. Part Position
➤ MSP is perpendicular to the center of the image receptor
➤ OML is perpendicular to the plane of the image receptor
C. Central Ray
➤ 30° caudally to the OML enter the glabella
➤ 37° caudally to the IOML enter the glabella and exit at the
level of mandibular angles.
E. Exam Rationale
➤ This projection is used to demonstrate fractures and zygomatic
arches free of superimposition
F. Structures Shown
MANDIBLE
2. PA Projection
3. Axiolateral Oblique Projection
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4. Submentovertical (SMV) Projection
➤ Patient is either prone or upright position
B. Part Position
➤ Forehead and nose are touching the table top
C. Central Ray
➤ 25-30° cephalad to exit at the acanthion.
E. Exam Rationale
➤ This projection demonstrate the mandibular rami, mandibular
condyles, and the temporomandibular
fossae.
➤ Fractures and inflammatory processes of the mandible.
F. Structures Shown
➤ Condylar processes of mandible below mastoid processes.
➤ Symmetrical views of the mandibular rami.
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2. PA Projection
➤ Patient is either prone or upright position
B. Part Position
➤ Forehead and nose are touching the table top OML is
perpendicular to the image receptor MSP is perpendicular to the
image receptor
C. Central Ray
➤ Perpendicular to the image receptor exiting at the junction of
the lips.
E. Exam Rationale
➤ This projection is used to demonstrate the mandibular nad rami
and body.
F. Structures Shown
➤ Mandibular rami and body
➤ Entire mandible
N.B.
If it used to demonstrate mentum, place the nose and chin against the bucky
with the MSP is perpendicular to the midline of the image receptor.
3. Axiolateral Oblique Projection
➤ Patient is either semiprone, semisupine or seated position
B. Part Position
➤ Head in a lateral position with the side of interest closest
to the image receptor
➤ Extend the chin to prevent superimposition on the cervical

spine
➤ Adjust the rotation of the patient's head in to place the area
of interest parallel to the image receptor.
RAMUS
➤ head should be in a true lateral position.
BODY
➤ rotate the head approximately 30° the image receptor.
MENTUM/SYMPHESIS MENTI
➤ rotate the head approximately 45° towards the image receptor.
C. Central Ray
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➤ 25 to 35° cephalad to enter slightly posterior to the
mandibular angle on the side farthest from the film
E. Exam Rationale
➤ This position demonstrates the TMJ, condyle, coronoid process,
ramus, body and menturn of the side of the mandible closest to
the image receptor.
F. Structures Shown
➤ Body of the mandible from the angle to the region of the
canine.
4. Submentovertical (SMV) Projection
➤ Patient is in supine
➤ Elevate the trunk 7 or 8 miles on firm pillows to permit
complete extension of the neck and flex the patient's to relax
the abdominal muscles and thus relieve strain on the neck
muscles.
B. Part Position
➤ Rest the head on the vertex so that the midsagittal plane is
vertical.
➤ IOML is parallel as possible to the image receptor.
C. Central Ray
➤ Perpendicular to the IOML and centered midway between the
angles of the mandible.
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E. Exam Rationale
➤ This projection is used to demonstrate the
mandibular body and showing the coronoid and condyloid processes
of the rami.
F. Structures Shown
➤ Entire mandible
➤ Coronoid and condyloid processes
TEMPOROMANDIBULAR JOINTS
1. AP Axial Projection
2. Axiolateral/ Axial Transcranial Projection
3. Lateral Transfacial Position (Albers-Schonberg Method)
4. Oblique Transfacial Position (Zaneli Method)
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➤ Patient is in supine or seated erect position
B. Part Position
C. Central Ray
➤ 35° caudally entering at a point approximately 3 inches (7.6
cm) above the nasion, centered between the TMJ's.
E. Exam Rationale
➤ This projection is used to demonstrate the condyloid processes
of the mandible and of the mandibular fossae of the temporal
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bones.
F. Structures Shown
➤ Condyle
➤ Temporomandibular articulation
2. Axiolateral / Axial Transcranial Projection
➤ Patient is in semi-prone position
B. Part Position
➤ Head in a lateral position
➤ TMJ's is centered to the image receptor
➤ IPL is perpendicular to the IR
➤ Exposure shall be made with the patient's mouth closed and
open unless contraindicated.
C. Central Ray
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➤ 25-30° caudally center to the image receptor, enters in the
about 1/2 inch (1.3 cm) anterior and 2 inches (5cm) superior to
the upside EAM and passes through the lower TMJ.
➤ Suspend respiration
if closed mouth: keep mouth close - if mouth open: keep mouth
open
E. Exam Rationale
➤ This projection better demonstrates the TMJ closest to the
image receptor.
➤ Demonstrate also the configuration of the condyle and
mandibular fossa and the direction and amount of movement.
➤ Can illustrate dislocation or small fractures of the cortex of
the condyle
➤ Both sides are taken in open and close mouth for comparison
F. Structures Shown.
➤ Temporomandibular joints
➤ Mandibular condyle
- inferior to the articular tubercle
N.B
Degree of caudal angulation may vary due to shape of patient's head.
- for Brachycephalic, decrease caudal angulation approximately 15-20°
caudally
for Dolicocephalic, increase caudal angulation approximately 30-35° caudally
3. Lateral Transfacial Position (Albers-Schonberg Method)
➤ Patient is in semiprone or seated upright position
B. Part Position
➤ TMJ must center to the image receptor > Head in true lateral
position
➤ IOML is parallel to the transverse axis of the film
➤ Make first exposure with mouth closed and second exposure with
mouth wide open unless contraindicated
C. Central Ray
➤ 20° cephalad directly through the TMJ
➤Suspended respiration
E. Exam Rationale
➤ This projection is used to demonstrate the lateral images of
the TJM in both open and closed mouth position.
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F. Structures Shown
4. Oblique Transfacial Position (Zanelli Method)
➤ Patient is in lateral position, either recumbent or ot out
seated upright position.
B. Part Position
➤ MSP forms and angle of 30°
➤ Rotate the chin of the affected side slightly from the lateral
position to prevent superimposition of the spine over the TMJ.
C. Central Ray
➤ Perpendicular to the midpoint of the film, entering distal to
the uppermost mandibular angle.
➤ Make one exposure with the mouth wide open unless
contrainidicated
E. Exam Rationale
➤ This position demonstrates mandibular joints in the open and
closed mouth positions.
F. Structures Shown
➤ Temporomandibular joint
➤ Mandibular fossa
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PARANASAL SINUSES
Procedures:
2. Parietoacantial Projection (Waters)
4. Parietoacantial Projection (Open-mouth waters method)/ Axial transorsl or
(PIRIE) Projection
5. Submentovertical (SMV)Projection (Basal)
➤ Patient is in prone or seated erect position with the head in
a true lateral position and placed the body in the RAO or LAO
position.
B. Part Position
➤ Side of interest closest to the image receptor
C. Central Ray
➤ Perpendicular at a point approximately 1/2 to 1 inch
posterior to the outer canthus.
➤ Horizontal if erect position
E. Exam Rationale
➤ This is the best projection demonstrating all paranasal
sinuses
Best projection for detecting fractures in the midfacial region
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➤ Demonstrate the inner and the outer tables of the skull
➤ Sphenoidal sinus is of primary importance
F. Structures Shown
➤ All paranasal sinuses
➤ Orbital roofs
N.B:
Radoigraphs of the paranasal sinuses should always be mode in the upright
position. This position is best demonstrating the presence or absence of
fluid and differentiating between fluid and other pathologic conditions.
If patient is unable to be placed in the upright position, a lateral
projection can be obtained using a dorsal decubitus utilizing a horizontal
beam.
2. Parietoacanthial Projection (Waters)
B. Part Position
➤ Hyperextend the patient's neck until the chin resting the
image receptor.
➤ MSP is perpendicular to the midpoint of the image receptor.
➤ OML forms an angle of 37° to the plane of the image receptor.
➤ Mentomeatal line is perpendicular to the film.
➤ The nose should be 0.5 to 1.5 from the film depending on the
shape of the face.
C. Central Ray
➤ Perpendicular to the midpoint of the film, exiting the
acanthion.
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E. Exam Rationale
➤ This projection is used to demonstrate sinusitis of the
maxillary sinuses, retention cysts and nasal
deviation.
➤ Demonstrate the foramen rotundum and structures inferior to
the medial aspect of the orbital floor and superior to the roof
of the maxillary sinuses.
O If extended to little, the petrosae are projection over

the inferior portions of the maxillary sinuses and thus
underlying pathologic conditions.
obscure
O If extended to much, the maxillary sinuses are
foreshortened and the antral floors are not demonstrated.
F. Structures Shown
➤ Frontal sinuses
➤ Bony nasal septum
➤ Inferior orbital rim
➤ Maxillary sinuses
➤ Petrous ridge
➤ Sphenoid sinus
➤ Patient position is seated upright position
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B. Part Position
➤ Forehead and nose are touching the table top mit MSP is
perpendicular to the midpoint of the image
receptor
C. Central Ray
➤ 15° degrees caudally exiting the nasion
E. Exam Rationale
➤ This projection best demonstrate inflammatory changes in the
frontal sinuses and the anterior ethmoid sinuses.
F. Structures Shown
➤ Frontal sinuses above the frontonasal
➤ Petrous ridges in the lower third of the orbits
➤ Anterior ethmoid below the frontal sinuses lateral to the
nasal bones
4. Parietoacanthial Projection (Open-mouth waters method) / Axial transoral

or (PIRIE) Projection
➤ Patient is seated upright position
B. Part Position
➤ Place to the nose and chin on the image receptor
➤ Mouth is open and center to the image receptor
➤ OML forms 37° from the lane of the film
C. Central Ray
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➤ 30° caudally along the line extending from the sella turcica
to the center of the open mouth.
E. Exam Rationale
➤ This projection demonstrate the sphenoid sinuses projected
through the open mouth.
➤ It demonstrate also the maxillary sinuses and nasal fossae.
F. Structures Shown
➤ Sphenoid sinuses
➤ Frontal sinuses
➤ Maxillary sinuses
➤ Nasal Fossae
➤ Alveolar process Petrous ridges
5. Submentovertical (SMV) Projection (Basal)
➤ Patient is in supine or seated upright position
B. Part Position
➤ Hyperextend the neck and rest the head on its vertex
➤ MSP is perpendicular to the midpoint of the IR
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➤ IOML is parallel to the plane of the image receptor
C. Central Ray
➤ Perpendicular to the IOML, midway between the angles of the
mandible approximately 2 inches (5cm) inferior to the mandibular
symphesis.
E. Exam Rationale
➤ This projection best demonstrate the sphenoid sinuses, ethmoid
sinuses and the nasal passages. > Demonstrate the anterior
portion of the base of the skull.
F. Structures Shown
➤ Sphenoid sinuses
➤ Mandibular symphesis / condyle
➤ Anterior frontal bone
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TEMPORAL BONE
Petromastoid Portion
Procedures
1. Axiolateral Oblique Projection (Original Law Method) Double Tube Angulation
2. Axiolateral Oblique Projection (Modified Law Method) Single Tube Angulation
3. Axiolateral Oblique Projection (Stenver's method) Posterior Profile
4. Axiolateral Oblique Projection (Arcelin Method) Reverse Stenver's
5. Axiolateral Projection (Schuller Method)
6. Axiolateral Projection (Henschen Method)
7. Axiolateral Oblique Projection (Mayer Method)
8. PA Projection (Transorbital Method)
9. PA Axial Position (Valdini Method)
10. Submentovertical Projection (Sub basal) Basilar Projection
11. Parietotemporal Position (Low Beer Method)
12. Chausse III Method (Attic-Aditus-Antral areas)
1. Axiolateral Oblique Projection (Original Law Method) Double Tube

Angulation
36
➤ Patient in prone with the head in true lateral position
B. Part Position
➤ The auricle or pinna of the ear should be taped
forward to prevent superimposition of it over the mastoid air
cells.
➤ Place the head in lateral position and then rotate the face
toward the image receptor so that the MSP is 15° to the plane of
the image receptor.
➤ IPL is perpendicular to the plane of the film
➤ IOML is parallel to the IR
C. Central Ray
➤ 15° caudally and 15° anteriorly, entering 2 inches (5cm)
posterior to and 2 inches (5cm) above the EAM.
E. Exam Rationale
➤ This projection is used to demonstrate the mastoid air cells,
lateral portion of the petrous pyramid, the superimposed internal
acoustic meatus (IAM), EAM, Tegmen tympani and when present, the
mastoid emissary vessel.
F. Structures Shown
➤ Mastoid process
➤ Internal and external acoustic meatuses
➤ Auricle
➤ Mastoid air cells
➤ Temporamandibular joints
37
2. Axiolateral Oblique Projection (Modified Law Method) Single
Tube Angulation
➤ Patient in prone with the head in true lateral position
B. Part Position
➤ The auricle or pinna of the ear should be taped forward to
prevent superimposition of it over the mastoid air cells.
➤ Place the head in lateral position and then rotate the face
toward the image receptor so that the MSP is 15° to the plane of
the image receptor.
➤ IPL is perpendicular to the plane of the film IOML is parallel
to the IR
C. Central Ray
➤ 15° caudally enterin approximately 2 inches (5cm) posterior
and 2 inches (5cm) superior to the uppermost EAM.
E. Exam Rationale
➤ This position demonstrate the mastoid aircells and the
internal auditory canal of the side closest to the image
receptor.
F. Structures Shown
➤ Auricle/Pinna of the ear
3. Axiolateral Oblique Projection (Stenver's method) Posterior Profile
➤ Patient in prone or seated upright facing the image receptor
B. Part Position
38
➤ Forehead, nose and cheek or a (zygoma) touching the table top
➤ IOML is parallel to the transverse axis of the image
receptor
➤ MSP forms an angle of 450 to the image rreceptor
* If brachycephalic, the petrous ridges form an angle of 54° with
the MSP
* If dolicephalic, the petrous ridges form an angle 40° with the
MSP.
C. Central Ray
➤ 12° cephalad, entering approximately 2 inches (5cm) posterior
to the uppermost EAM.
E. Exam Rationale
➤ This position demonstrates the dependent petrous portion
parallel to the image receptor.
➤ It demonstrate the petrous ridge, the mastoid air cells, the
mastoid antrum, tymphanic cavity, the bony labyrinth, the
internal acoustic canal and the cellular structure of the petrous
apex.
F. Structures Shown
➤ Petous portion of temporal bone
➤ Internal auditory canal
Middle ear structures
➤ Labyrinth (Cochlea, vestibule, semicircular canlas)
➤ Mastoid antrum and process
N.B.
This method is useful in children and in adults who art cannot be placed in
the prone or seated upright position for the stenvers method this is the
reverse stenvers method.
39
4. Axiolateral Oblique Projection (Arcelin Method) Reverse Stenvers
B. Part Position
➤ Rotate the head away from side of interest
➤ MSP forms an angle of 45°
➤ IOML is perpendicular to the image receptor
C. Central Ray
➤ 10° caudally, entering the temporal bone approximately 1 inch
(2.5cm) anterior to the EAM and 3/4 inch (1.9cm) superior to
elevated EAM.
E. Exam Rationale
➤ This projection is used to demonstrate the petrous portion of
the temporal bone.
➤ To demonstrate the advanced pathology of the temporal bone
(advanced acoustic neuroma)
F. Structures Shown.
➤ Petromastoid portion
➤ Internal acoustic canal
➤ Mastoid antrum
N.B
This method is useful in children and in adults who cannot be placed in the
prone or seated upright position for the stenvers method this is the reverse
stenvers method.
40
➤ Patient is in semiprone or seated upright position.
B. Part Position
➤ Head is in lateral position with EAM is center to the bortem
midline of the table.
➤ Tape each auricle / pinna of the ears to prevent ve
superimposition over mastoid air cells.
➤ MSP is parallel to the image receptor.
➤ IOML is place parallel to the transverse axis to the IR
C. Central Ray
➤ 25° caudally, entering approximately 1 1⁄2 inches (4cm)
superior to the EAM and exiting at the mastoid.
* For Brachycephalic, less caudal angulation at 15- 20°
caudally
* For Dolicephalic, more caudal angulation at 30- 35°
caudally.
E. Exam Rationale
➤ This projection demonstrates the pneumatic structure of the
mastoid process, mastoid antrum, the IAM and EAM, Tegmen Tympani,
sinus and dural plates and when present the mastoid emissary
vessel.
➤ Best projection to show the degree of pneumatization of
mastoid air cells.
F. Structures Shown
➤ Mastoid antrum
➤ IAM and EAM
41
B. Part Position
➤ Head in true lateral position
➤ Tape the auricles/pinnas forward to prevent superimposition
MSP is parallel to the image receptor
➤ IOML is parallel with the transverse axis of the IR
C. Central Ray
➤ 15° caudally, entering 1 inch superior to the EAM
E. Exam Rationale
➤ This projection demonstrates the mastoid air cells, mastoid
antrum, internal & external auditory
meatuses, Tegmen Tympani.
➤ Used to demonstrate tumors of the acoustic nerve.
F. Structures Shown
➤ Mastoid antrum
➤ IAM and EAM
➤ Tegmen Tympani
7. Axiolateral Oblique Projection (Mayer Method)
42
➤ Patient is in supine position or seated upright position.
B. Part Position
➤ Rotate the head toward side of interest
➤ Tape the auricle / pinna forward
➤ MSP is an angle of 45° from the table top
➤ IOML is parallel to the transverse axis of the IR
C. Central Ray
➤ 45° caudally exiting the EAM of interest.
E. Exam Rationale
➤ This projection is used to demonstrate the external auditory
meatus, mastoid antrum, tympanic cavity and ossicles, the
epitympanic recess (attic), aditus and bony labyrinth.
F. Structures Shown
➤ Mastoid antrum
➤ External acaustic canal
➤ Labyrinth
8. PA Projection (Transorbital Method)
➤ Patient is either prone or seated upright position
B. Part Position
➤ Rest the forehead and nose on the table
➤ MSP is perpendicular to the IR
➤ OML is perpendicular to the IR
C. Central Ray
➤ Perpendicular to the nasion, few patients may require an
approximate 50 cephalic angulation due to variation in the shape
of the skull.
E. Exam Rationale
➤ This projection is used to demonstrates the internal acoustic
canals projected through the shadow of the orbits.
F. Structures Shown
➤ Internal acoustic canal
➤ Semicircular canal
43
➤ Vestibule and cochlea
9. PA Axial Position (Valdini Method)
B. Part Position
➤ Rest the patient's forehead on the table
➤ IOML is 50° angle to the image receptor
* to demonstrate the labyrinths and the internal acoustic
canals.
➤ OML is 50 angle to the IR
* to demonstrate the external acoustic canal, the tympanic
cavities and the bony part of the eustachian tube.
C. Central Ray
➤ Perpendicular through the foramen magnum
E. Exam Rationale
➤ This position is best demonstrate the image of the
vestibulochlear organ (organ of hearing), the labyrinth and the
external auditory canals.
F. Structures Shown
➤ Foramen magnum
➤ Mastoid aircells
➤ Internal acoustic canals
➤ Petrous ridge
➤ Labyrinth
10. Submenovertical Projection (Sub basal) Basilar Projection
B. Part Position
➤ Flexed the knees to relax the abdominal muscles Rest the head
on the vertex
➤ IOML is parallel with the plane of the IR
C. Central Ray
➤ Perpedicular to the IOML
44
➤ Suspension respiration
E. Exam Rationale
➤ This projection is used to demonstrates the mastoid processes
the labyrinth, the tympanic cavities, the external acoustic
meatuses and the acoustic ossicles.
F. Structures Shown
➤ Mastoid process
➤ Mandibular condyle Acoustic canal
➤ Semicircular canal
➤ Cochlea
➤ Mastoid antrum
11. Parietotemporal Position (Low Beer Method)
➤ Patient in a semiprone position
B. Part Position
➤ Rest the head in a lateral position
➤ IOML is parallel with the transverse axis of the film
➤ MSP is parallel with IR
➤ IPL is perpendicular with the IR
C. Central Ray
➤ 33° angle anteriorly and 10° cephalad
E. Exam Rationale
➤ This projection is used to demonstrates the petrous apex the
labyrinth and sinus area, the internal
acoustic canals and the mastoid cells.
F. Structures Shown
➤ Petrous ridge
➤ Mastoid antrum
➤ IAM and EAM
➤ Mastoid process
12. Chausse III Method (Attic-Aditus-Antral areas)
B. Part Position
➤ Rotate the head away from the side of interest
➤ MSP is 10-20°
➤ OML is parallel with the transverse axis of the IR
C. Central Ray
45
➤ 20° caudally, to a point midway between the lateral margin of
the orbit and the tragus.
E. Exam Rationale
➤ This projection is used to demonstrate the attic- aditus-
antral areas and the oblique image of the petrosa
F. Structures Shown
➤ Attic-aditus-antral areas
➤ Lateral orbital margin
➤ Mastoid process
STYLOID PROCESSES
1. PA Axial Projection (Cahoon Method)
2. AP Projection (Modified Fuchs Method)
46
1. PA Axial Projection (Cahoon Method)
➤ Patient is either prone or seated-upright position
B. Part Position
➤ Rest the forehead and nose on the table
➤ OML is perpendicular to the IR
C. Central Ray
➤ 25° cephalad, directed to the nasion.
E. Exam Rationale
➤ This projection demonstrates a symmetric image of the styloid
processes of the temporal bones projected within or above the
maxillary sinuses.
F. Structures Shown
➤ Temporal styloid processes
➤ Coronoid process
2. AP Projection (Modified Fuchs Method)
B. Part Position
➤ Acanthiomeatal line is perpendicular to the IR Instruct the
patient to open the mouth during exposure to prevent the shadows
of the coronoid processes of the mandible from being
superimposed.
C. Central Ray
➤ 13° caudally
E. Exam Rationale
➤ This projection is best demonstrate the symmetric image of the
styloid processes of the temporal bone projected with in the
shadows of the maxillary sinus.
F. Structures Shown
➤ Styloid processes
➤ Coronoid processes
➤ Occipital bone
47
JUGULAR FORAMINA
1. Submentovertical Axial Projection (Kemp Harper Method)
2. Ersso Modification
3. Transoral Axial Position (Chausse II Method)
48
1. Submentovertical Axial Projection (Kemp Harper Method)
➤ Patient is either supine or seated-upright position
➤ Elevate the patient's trunk to permit full extension of the
head
B. Part Position
➤ Rest the patient's head on the vertex
➤ OML is parallel to the IR
C. Central Ray
➤ 20° posterior angle directed to 1 inch (2.5cm) distal to the
mandibular symphesis.
E. Exam Rationale
➤ This projection is used to demonstrate to jugular foramina
projected at or near the level of the angles of the mandible.
➤ Demonstrate the tumors of the temporal bone
2. Eraso Modification
➤ Patient is either supine or seated upright position > Elevate
the patients trunk the permit full extension of the head
B. Part Position
➤ OML is 25° angle from the plane of the IR
C. Central Ray
➤ Perpendicular to the midpoint of the IR, entering
approximately 2 inches (5cm) distal to the mandibular symphesis.
49
➤ Suspended respiration Y
E. Exam Rationale
➤ This projection is used to demonstrate jugular foramina, if
prominent mandible ray maybe increased from 5 to 10° caudally.
F. Structures Shown
➤ Jugular foramina
➤ Mandibular angle
3. Transoral Axial Position (Chausse II Method)
B. Part Position
➤ Rotate the head the side of interest
➤ MSP is 10° angle
➤ AML is 10° angle from vertical
➤ Instruct the patient the open the mouth as possible
C. Central Ray
➤ 25° cephalad, directed through the open mouth
E. Exam Rationale
➤ This position demonstrate the shadow of the jugular foramen on
the side closest to the table is seen
through the shadow of the open mouth
F. Structures Shown
➤ Jugular foramen
➤ Upper and lower molars
➤ Mandibular ramus
50
HYPOGLOSSAL CANAL
1. Anterior Profile Position (Miller Method) Axiolateral Oblique
2. AP Projection (Colcher-Sussman Method)
4. Thomas Method
1. Anterior Profile Position (Miller Method) Axiolateral Oblique
A. Patient Instructions
51
B. Exam Rationale
➤ This projection is used to demonstrate the hypoglossal canal
and shadow of the mandibular condyle projected inferior and
anterior to that of the canal when the patient can open the mouth
wide enough.
C. Structures Shown
➤ Hypoglossal canal
➤ Petrous ridge
➤ Mastoid process
2. AP Projection (Colcher-Sussman Method)
B. Part Position
➤ Flex the knees to elevate the forepelvis and separate the
thighs enough to permit correct placement of the pelvimeter
scale.
➤ Place the ruler horizontally to the gluteal fold at the level
of the ischial tuberosities
C. Central Ray
➤ Perpendicular to the midpoint of the IR at 1 1⁄2 (3.8cm)
superiorto the public symphesis
➤ Suspend respiration
E. Exam Rationale
➤ This projection is used to demonstrate the entire pelvis,
fetal head and visualization of all pelvic landmarks and
intersecting diameters.
F. Structures Shown
➤ Entire pelvis
➤ Entire fetal head
Metal ruler
➤ Patient is in lateral position.
B. Part Position
➤ Midcoronal plane of the body is center to the midline ve of
the table.
➤ Partially extend the thighs so they will not obscure the pubic
bones.
52
➤ Place a sandbags under the knees and ankles to immobilize the
legs
➤ Turn the ruler lengthwise and adjust its height to coincide
with the MSP of the patient's body
➤ Pelvimetry scale is placed is the upper part of the noiteler
gluteal fold and against the midsacrum
C. Central Ray
➤ Perpendicular to the most prominent point of the greater
trochanter.
➤ Suspended respiration at the end of inhalation
E. Exam Rationale
➤ This projection is used to demonstrate the entire pelvis,
fetal head and visualization of all pelvic landmarks and
intersecting diameters.
F. Structures Shown
➤ Sacrum
➤ Fetal head
➤ Symphesis pubis
➤ Ischial tuberosities
➤ Metal ruler
4. THOMS Method
A. Inlet Position
➤ Patient is seated on the Pelvimeter platfrom position
➤ Adjust the backrest at an angle about 50° and slide the
anterior post well toward the foot over the flat form.
B. Part Position
➤ Pelvic inlet is parallel with the plane of the film
➤ Posterior end of the conjugate diameter may be a little higher
than the anterior end.
C. Central Ray
➤ Perpendicular to the MSP to a point 2 1⁄2 inches (6cm)
posterior to the symphesis pubis.
➤ Suspended respiration at the end of inhalation
E. Exam Rationale
➤ This position demonstrates the pelvic inlet, the ischial
spines and the pelvic outlet.
53
F. Structures Shown
➤ Fetal head
➤ Ischial spine
➤ Acetabulum
➤ Symphesis pubis
B. Lateral Position
➤ Patient is in standing position with the weight of the body
equally distributed on the feet and the forearms crossed over the
chest
B. Part Position
➤ Align the body in a true lateral position
➤ Adjust the position sot he midgluteal fold and the midlabial
fold are equidistant from the table.
C. Central Ray
➤ Perpendicular to the midpoint of the film.
E. Exam Rationale
➤ This position is used to demonstrates the sacrum, sacrosciatic
notch, the ischial spines, tuberosities, acetabula, anterior and
posterior borders of the symphesis pubis.
F. Structures Shown
➤ Sacrum
➤ Acetabulum
➤ Ischial spines
➤ Ischial tuberosity
ATLAS AND AXIS (C1 and C2)

Procedures:
1. AP Projection (Open Mouth)
2. PA Projection (Judd Method)
54
3. AP Axial Oblique Projection (Kasabach Method) R or L head rotation
5. AP Projection (Fuchs Method)
1. AP Projection (Open Mouth)
A. Patient Position
➤ Patient is in supine position with the midsagittal plane of
the body must center to the center line of the table.
B. Part Position
➤ Extend the neck so that a line from the lower edge of the
upper incisors to the mastoid tips is perpendicular to the table.
➤ Have the patient open the mouth as wide as possible, and then
adjust the head so that a line from the lower edge of the mastoid
process perpendicular to the film.
C. Central Ray
➤ Perpendicular to the center of the open mouth
E. Exam Rationale
➤ This projection demonstrates the first two cervical vertebrae
free of superimposition.
➤ Make sure that when patient is instructed to open mouth that
only the lower jaw moves.
F. Structures Shown
➤ Dens(odontoid process)
➤ Vertebral body of C2
➤ Lateral masses of C1
➤ Zygapophyseal joints between C1 and C2.
N.B:
A 30 inch (76 cm) SID is often used for this projection to increase the field
of view of the odontoid area.
Trauma to head and or neck area with possible fracture or subluxation
requires a horizontal beam cervical lateral taken first without moving the
patient's head and neck. Cervical collar if present, should NOT be removed.
This radiograph should be viewed by physician before attempting to move the
patient's head or neck for other cervical and/or skull trauma projections.
55
2. PA Projection (Judd Method)
A. Patient Position
➤ Patient is in prone position with the midsagittal plane of the
body is center to the center line of the table.
B. Part Position
➤ Extend the neck and rest the chin on the radiographic table.
➤ Adjust the head so that the chin and mastoid tips are vertical
or the OML is 37° to the plane of the image receptor.
C. Central Ray
➤ Perpendicular, directed distal to the level of the mastoid
tips.
E. Exam Rationale
➤ Demonstrates the dens and atlas as seen through the foramen
magnum.
F. Structures Shown
➤ Entire dens within the foramen magnum
➤ Anterior and Posterior arches of atlas.
N.B.
The radiographer should not attempt this position with a patient who has an
unhealed fracture or who has a degenerative disease or suspected fracture of
the upper cervical region.
3. AP Axial Oblique Projection (Kasabach Method) R or L head rotations
A. Patient Position
➤ Patient is in supine position with the mid-sagittal plane of
the body is center to the center line of the table.
B. Part Position
56
➤ Rotate the head either right or left 40 to 45°. Adjust the
head so that the IOML is perpendicular to the plane of the table.
C. Central Ray
➤ 10 to 15° caudally, directed to a point midway
between the outer canthus and the EAM.
E. Exam Rationale
➤ AP axial oblique projection demonstrates the dens, the of a
patient who has a possible fracture or degenerative disease must
not be rotated
F. Structures Shown
➤ Dens
A. Patient Position
➤ Patient is in supine position.
➤ Place a sponge or pad under the head unless traumatic injury
has been sustained.
57
B. Part Position
➤ Extend the neck slightly so that the shadow of the mandibular
rami does not overlap that of the spine.
➤ Adjust the head so that the midsagittal plane is perpendicular
to the table.
C. Central Ray
➤ Perpendicular, to a point 1 inch distal to the adjacent
mastoid tip.
E. Exam Rationale
➤ This projection demonstrates the atlas and axis as well as the
atlanto-occipital articulations using a 72- inches (183 cm)
distance.
F. Structures Shown
➤ Atlas and Axis
➤ Upper cervical vertebrae
➤ Mandibular Rami
5. AP Projection (Fuchs Method)
A. Patient Position
B. Part Position
➤ Extend the chin until the tip of the chin and the tip of the
mastoid process are vertical.
➤ Adjust the head so that the midsagittal plane is perpendicular
to the plane of the grid.
C. Central Ray
➤ Perpendicular, directed distal to the tip of the chin.
E. Exam Rationale
➤ This projection is demonstration of the dens when its upper
half is not clearly shown in the open mouth and where the
odontoid process is projected within the foramen magnum.
➤ This position must not be attempted if fracture or
degenerative disease of the upper cervical region is suspected.
F. Structures Shown
➤ Odontoid process
N.B:
Smith and Abel, visualized the laminae and articular facets of the upper
58
cervical vertebrae, where the neck is slightly extended and the mouth is
widely open. The central ray is 35 degrees caudally directed to the C3 and
rotate the head towards the side being examined approximately 10 degrees,
thereby removing the mandible from the overlying areas of interest.
CERVICAL SPINE
Procedures:
2. Lateral Projection (Grandy Method)
3. Lateral Projection (Hyperflexion and Hyperextension)
4. AP Axial Oblique Projection (RPO and LPO Positions)
5. PA Axial Oblique Projection (RAO and LAO Positions)
59
6. AP Projection (Otonello Method)
7. Lateral Projection (Twinning Method or Swimmer's View or Pawlow Method)
A. Patient Position
B. Part Position
➤ Extend the neck so that the line from the lower edge of the
upper incisors to the mastoid tips (occlusal plane) is
perpendicular to the table top.
C. Central Ray
➤ 15 to 20° cephalad, directed to C4 or slightly inferior to the
most prominent point of the thyroid cartilage, to open up the
intervertebral disk spaces.
E. Exam Rationale
60
➤ Examination of the cervical spine may be indicated in the
investigation of the degenerative disease or in cases of trauma.
➤ This projection demonstrates the lower five cervical bodies,
upper two or three thoracic bodies, interpedicute spaces and
intervertebral disk spaces.
F. Structures Shown
➤ Vertebral bodies
➤ Intervertebral disk spaces
➤ Spinous process
➤ Mandibular angles
2. Lateral Projection (Grandy Method)
A. Patient Position
➤ Patient is in lateral position either seated or standing
position with the left side against the image receptor. The top
of the image receptor will be 1 inch above the EAM.
B. Part Position
➤ Center the midcoronal plane to the midline of the image
receptor.
Rajse the chin slightly to prevent overlap of the mandibular rami
on the upper vertebrae.
➤ Rotate the shoulders anteriorly if the patient shoulder is
round or posteriorly according to the natural kyphosis of the
back.
➤ Adjust patient's shoulders to same horizontal level and body
to true lateral position.
➤ Weights may be attached to wrists to help lower shoulders.
C. Central Ray
61
➤ Horizontal and Perpendicular to C4.
➤ The superior border of the image receptor should be placed
about 2 inches above the external auditory meatus (EAM).
➤ Suspended respiration on full expiration to obtain maximum
depression of the shoulders.
E. Exam Rationale
➤ This projection shows the vertebral bodies in a latera
position, the intervertebral joint spaces, the articula pillars,
the spinous process, and the articular facet of the lower five
vertebrae.
F. Structures Shown
➤ Cervical vertebral bodies
➤ Intervertebral joint spaces
➤ Articular pillars
➤ Spinous process
➤ Zygapophyseal joints
62
3. Lateral Projection (Hyperflexion and Hyperextension)
A. Patient Position
➤ Patient is either erect or seated position with left side
against the image receptor.
B. Part Position
➤ Center the midcoronal plane to the midline of the image
receptor.
➤ Adjust the body so that the MSP is parallel with the image
receptor. Depress the shoulders.
➤ Hyperflexion
o The patient's head is dropped forward as close to
the chest as possible as much as patient can
tolerate.
➤ Hyperextension
o The patient's head is leaned backward as much as
possible (Do not allow patient to move backward to
ensure that entire cervical is included on film).
C. Central Ray
➤ Perpendicular to film, directed horizontally to area of C4.
➤ Superior border of the image receptor should placed about 2
inches above the EAM.
➤ Suspended respiration at the end of full expiration.
E. Exam Rationale
➤ This procedure must not be attempted until cervical spine
pathology or fracture has been ruled out.
➤ This is a functional studies of the cervical vertebrae in the
lateral position to demonstrate normal anteroposterior movement
or an absence of movement resulting from trauma or disease or
range of motion of the cervical vertebrae.
63
F. Structures Shown
➤ Spinous process
➤ Body of Mandible
➤ Whiplash type injuries
4. AP Axial Oblique Projection (RPO and LPO Position)
A. Patient Position
➤ Patient is either seated or standing position with the body at
a 45° angle facing the vertical cassette holder.
B. Part Position
➤ Adjust the whole body forms an angle of 45 degrees eg with the
plane of the image receptor.
➤ Place side of interest farthest from cassette
➤ Have the patient slightly extend the chin while looking
forward. Turning the chin to the side causes slight rotation of
the superior vertebrae and should be avoided.
64
C. Central Ray
➤ 15 to 20° cephalad, directed to C4.
E. Exam Rationale
➤ This oblique projections demonstrate the cervical
intervertebral foramina and pedicles farthest from the image
receptor and other parts of the cervical vertebrae.
F. Structures Shown
➤ Intervertebral foramina
➤ C1 to C7
N.B:
AP oblique projection (Hyperflexion and Hyperextension) is a functional
studies of the cervical vertebrae in the oblique to demonstrate fractures of
the articular processes as well as obscure dislocations and subluxations.
When acute injury has been sustained, manipuation of the patient's head must
be performed by a physician.
65
5. PA Axial Oblique Projection (RAO and LAO Positions)
A. Patient Position
➤ Patient is either erect or seated position with the body at an
angle of 45° from the PA position.
B. Part Position
➤ Rotate the patient's entire body to a 45 degree angle to place
the foramina closest the image receptor.
➤ Adjust the position of the patient's head so that the
midsagittal plane is aligned with the plane of the spine.
C. Central Ray
➤ 15 to 20° caudally, directed to C4.
E. Exam Rationale
➤ This position demonstrates the open intervertebral foramina
and pedicles closest to image receptor and other parts of the
cervical vertebrae.
F. Structures Shown
➤ Cervical Vertebrae
6. AP Projection (Ottonello Method or Chewing or Wagging Jaw)
A. Patient Position
the center to the midline of the table.
B. Part Position
66
➤ Adjust the head so that a line drawn from the lower margin of
upper incisors to the base of the skull is perpendicular to the
table.
➤ Ensure that there is no rotation of the head or thorax.

➤ Mandible must be in continuous motion during exposure. Use an
exposure technique with a low MA and long exposure time.
C. Central Ray
➤ Perpendicular to the film, directed to the most prominent
point of the thyroid cartilage.
E. Exam Rationale
➤ This method the mandibular shadow is blurred or even
obliterated by having the patient perform an even chewing motion
of the mandible during the exposure
F. Structures Shown
➤ Cervical vertebrae
➤ Mandible
7. Lateral Projection (Twinning, Swimmer's and Pawlow Methods)
A. Patient Position
➤ Patient is in lateral position either seated or erect
position.
B. Part Position
➤ Center the midcoronal plane of the body to the
➤ Elevate the arm and flex the elbow and rest the forearm on the
patient's head.
➤ Position arm and shoulder away from film down and slightly
anterior to place humeral head anterior to vertebrae.
➤ Depress the patient's shoulder that is farthest from the image
receptor as possible.
C. Central Ray
➤ Perpendicular if the shoulder is well depressed.
➤ 5° if the shoulder cannot be well depressed, directed to the
C7 and T1.
➤ Suspended respiration at the end of full expiration or shallow
brathing to blur the lung anatomy.
E. Exam Rationale
➤ This projection demonstrates the lower cervical and upper
thoracic vertebrae between the two shoulders that superimpose the
67
vertebrae in the area of interest.
F. Structures Shown
➤ Cervical and Thoracic vertebral bodies
➤ Zygapophyseal joints of C4 and T3
THORACIC VERTEBRAE
Procedures:
1. AP Projection
3. AP Oblique Projection (RAO and LAO Positions)
1. AP Projection
A. Patient Position
➤ Patient is in supine position with the midsagittal plane of
the body is center to the midline of the table.
B. Part Position
➤ Flex the patient's hips and knees, to place thighs in vertical
position to reduce kyphosis.
➤ Superior border of the image receptor is 11⁄2 to 2 inches
above the shoulders.
C. Central Ray
68
➤ Perpendicular to T6, directed 3 to 4 inches below the sternal
notch appoximately halfway between the jugular notch and xyphoid
process.
➤ Suspended respiration at the end of full expiration, reduces
air volume in thorax for more uniform density of complete T
spine.
E. Exam Rationale
➤ The most common indications for thoracic spine examinations
are trauma and degenerative disease. It is used to demonstrate
the thoracic bodies, intervertebral disk spaces, transverse
process, costovertebral articulations and surrounding structures.
F. Structures Shown
➤ Thoracic Vertebrae
➤ Transverse Processes
➤ Pedicles and Intervertebral disk spaces
A. Patient Position
➤ Patient is in left lateral recumbent position to place the
heart closer to the image receptor which minimizes overlapping of
69
the vertebrae by the heart.
B. Part Position
➤ Place the long axis of the spine parallel to the table.
Midaxillary line should be centered to the table.
C. Central Ray
➤ Flex the patient's hops and knees for stability with support
between knees.
➤ Perpendicular to the film, directed to T7 enters the posterior
half of the thorax.
➤ The superior border of the image receptor should be 1⁄2 to 1
inch above the top of the shouder.
➤ Normal respiration to obliterate or diffuse the vascular

markings and ribs or suspend respiration at the end of full
expiration.
E. Exam Rationale
➤ The lateral projection of the thoracic spine demonstrates
vertebral bodies intervertebral disk spaces and intervertebral
foramina. The spinous 'processes are not well visualized due to
their superimposition on ribs. The upper three to four vertebrae
are not visualized due to superimposition of from shoulder
structures.
F. Structures Shown
70
A. Patient Position
➤ Patient is in semi-supine position.
B. Part Position
➤ Rotate the body 20° posterior so that the coronal plane forms
an angle of 70 degrees from the plane of the table.
➤ Place the outer hand on the hip
C. Central Ray
➤ Perpendicular to the film, directed to the level of T7.
E. Exam Rationale
➤ Oblique projections of the thoracic spine are usually
done to demonstrate the zygapophyseal joints. They are
occasionally done to demonstrate mediastenal structures or to
remove mediastinal shadows from obscuring thoracic spine anatomy.
Both right and left obliques are done.
➤ This projection gives an excellent demonstration of the
cervicothoracic spinous processes and is used for this purpose
when the patient cannot be satisfactorily positioned for a direct
lateral projection.
F. Structures Shown
71
LUMBAR VERTEBRAE
Procedures:
1. AP Projection
3. AP Oblique Projection (RPO and LPO Positions)
1. AP Projection
A. Patient Position
➤ Patient is in supine position with the midsagittal plane of
B. Part Position
➤ Flex the patient's knees and hips to place back in firm and
help reduce the lumbar curvature.
C. Central Ray
➤ Perpendicular, directed above the level of the iliac crest
(L3) for the lumbar examination. At the level of the iliac crest
(L4) for the lumbo-sacral examination.
72
E. Exam Rationale
➤ The most common indications for lumbar spine examinations are
trauma and degenerative disease. It is also used to demonstrate
the lumbar bodies, intervertebral disk spaces, interpediculate
spaces, laminae, spinous and transverse processes.
➤ Some department protocols require collimation be open to
enables visualization of the liver, kidney, spleen and psoas
muscle margins along with air or gas patterns.
F. Structures Shown
➤ Lumbar Vertebral Bodies
➤ Transverse Processes
➤ Pedicles and Intervertebral disk spaces
73
A. Patient Position
➤ Patient is in left lateral recumbent with the knees and hips
flexed for comfort.
B. Part Position
➤ Align the midcoronal plane of the body to the midline of the
table.
Place a radiolucent support under the lower thorax as needed to
place the long axis of the spine near parallel to the table.
C. Central Ray
➤ Perpendicular, directed to the level of the iliac crest. When
the spine cannot be adjusted to the horizontal central ray
angulation is required. In most intances an average of 5 degrees
caudally for men and 8 degrees for women.
E. Exam Rationale
➤ This projection demonstrates the lumbar bodies and their
interspaces, intervertebral foramina of L1-L4, the spinous
processes and the lumbo-sacral junction. L5 intervertebral
foramina left and right are not usually well visualized because
of their oblique direction
F. Structures Shown
➤ Vertebral Bodies
➤ Spinous Processes
➤ Intervertebral Foramina
74
3. AP Oblique Projection (RPO and LPO Positions)
A. Patient Position
➤ Patient is in semi-supine position with arms placed at the
patient's sides.
B. Part Position
➤ Rotate the body towards the affected side approximately 45
degrees to demonstrate the joints closest the image receptor.
C. Central Ray
➤ For Lumbar Region
o Perpendicular to the film directed 2 inches bmedial to the
elevated ASIS and 1 1⁄2 inches above the iliac crest.
➤ For the Zygapophyseal Joint:
o Perpendicular to the film, directed 2 inches medial to the
elevated ASIS.
E. Exam Rationale
➤ This oblique projection gives a different perspective from the
AP and demonstrate the articular processes of the side closest to
the image receptor. Both sides are examined for comparison
It demonstrates also the "scotty dogs" sign, pedicles, laminae,
pars interarticularis, vertebral bodies and disk spaces.
F. Structures Shown
75
L5-S1 LUMBOSACRAL JUNCTION
Procedures:
A. Patient Position
B. Part Position
➤ Flex the knees to place the posterior surface close in contact
with the table and help reduce rotation.
C. Central Ray
➤ 30 to 35° cephalad, directed to 1 1⁄2 inches superior to the
symphysis pubis.
E. Exam Rationale
➤ Because the sacrum curves
curves posteriorly, this necessary to necessary to open the
intervertebral disk space between L5 and S1.
76
projection is often
F. Structures Shown
➤ Lumbosacral junction
➤ Intervertebral space between L5 and S1
A. Patient Position
➤ Patient is in left lateral recumbent position with hips and
knees flexed for comfort.
B. Part Position
➤ Place the long axis of the spine parallel and the coronal
plane perpendicular to the table.
➤ Place a radiolucent support under the lower thorax and adjust
it so that the long axis of the spine is horizontal.
C. Central Ray
➤ 5 to 10° caudally, directed to the space between the
ASIS and the iliac crest.
E. Exam Rationale
➤ The fifth lumbar vertebra and the intervertebral disk between
L5 and the sacrum is a common site of pathology. The region is
often not well visualized on the lateral lumbar spine because it
is much denser than the rest of the lumbar spine and lies at the
end of the image, causing the disk space to be closed by the
diverging x-ray beam.
F. Structures Shown
77
➤ L5-S1 joint space
➤ Spondylolithesis
SACRUM
Procedures:
A. Patient Position
➤ Patient is in supine position with arms placed at the
patient's sides.
B. Part Position
➤ Midsagittal plane of the body is centered to themidline of the
table.
➤ The knees may flexed to place the posterior surface of the
body in contact with the table and help reduce rotation of the
pelvis.
C. Central Ray
➤ 15° cephalad, directed to a point 2 inches superior to the
pubic symphysis.
E. Exam Rationale
➤ The most common indication for sacrum examination is trauma.
It demonstrates the ala, promontory, anterior sacral foramina and
78
the L5-S1 joint space.
F. Structures Shown
➤ Sacrum
➤ Pubic bones
COCCYX
Procedures:
1. AP Projection
1. AP Projection
A. Patient Position
➤ Patient is in supine position with midsagittal plane of the
body is center to the midline of the table.
B. Part Position
➤ Ensure there is no rotation of the pelvis
C. Central Ray
➤ 10° caudally, directed 2 inches superior to the symphysis
pubis
➤ Suspended respiration at the end of full expiration
E. Exam Rationale
➤ Demonstrate the coccyx free of superimposition
79
➤ The rectal and bladder shadows overlie the coccyx, it is often
desirable to have the patient void and defecate before the
radiographic examination.
F. Structures Shown
➤ Coccyx
➤ Symphysis Pubis
2. Lateral Position
A. Patient Position
➤ Patient is in left lateral recumbent with hips and knees are
flexed for comfort.
B. Part Position
➤ Support under the body to place the long axis of spine
horizontally.
➤ Place pelvis and body in true lateral postion
C. Central Ray
➤ Perpendicular, directed 3 1⁄2 inches posterior to the ASIS and
2 inches inferior.
E. Exam Rationale
80
➤ The most common indication for the examination of
the coccyx is trauma.
F. Structures Shown
➤ Coccyxoi
➤ L5-S1
SCOLIOSIS SERIES
Procedures:
1. PA or AP Upright (Ferguson method)
2. PA or AP with Right and Left Bending
3. Lateral Upright (with or without bending)
4. Lateral Projection (R or L Pos.) Hyperflexion and Hyperextension
5. AP Projection (R and L Bending)
1. PA or AP Upright (Ferguson Method)
A. Patient Position
81
➤ Patient is in standing position facing the image receptor,
shoes should be removed.
B. Part Position
➤ Center the midsagittal plane of the patient's body to the
➤ Lower margin of cassette is placed 1 to 2 inches
below the iliac crest.
C. Central Ray
E. Exam Rationale
➤ PA projections of the thoracic and lumbar vertebrae, which are
used for comparison to distinguish the deforming or primary curve
from the compensatory curve in patients with scoliosis.
➤ It demonstrate the amount or degree of curvature that occurs
with the force of gravity acting on the body.
F. Structures Shown
N.B.
➤ Thoracic and Lumbar Spine
PA projection is recommended rather than AP because of the significantly
reduced dosage to radiation sensitive areas such as female breast and the
thyroid gland.
82
2. PA or AP Upright (R and L Bending)
A. Patient Position
➤ Patient is in erect position either AP or PA.
B. Part Position
➤ Align midsagittal plane to the midline of the table.
➤ Lower margin of the cassette is 1 to 2 inches below the iliac
crest.
C. Central Ray
E. Exam Rationale
➤ To determine the range of motion.
F. Structures Shown
3. Lateral Upright Projections
A. Patient Position
➤ Patient is in upright lateral position with arms folded above
the head.
➤ The side of the convexity of primary curve should be against
the film.
B. Part Position
➤ Align the midaxillary of the body to the mid-line of the
table.
➤ Lower margin of the cassette a minimum of 1 to 2 inches below
the iliac crests.
C. Central Ray
➤ Horizontally, directed to the midpoint to the film.
E. Exam Rationale
➤ This erect lateral position demonstrate the amount or degree
of curvature that occurs with the force of gravity acting on the
body.
➤ It demonstrate possible spondylolisthesis or degree kyphosis
or lordosis.
F. Structures Shown
➤ Thoracic and Lumbar spine
83
4. Lateral Projection (R or L Position) (Hyperflexion and Hyperextension)
A. Patient Position
➤ Patient is in lateral recumbent position
B. Part Position
➤ For Hyperflexion:
o Have the patient get into fetal position (bend forward) and
draw legs up as far as possible. > For Hyperextension:
o Have the patient lean the thorax backward and posteriorly
extend the thighs and limbs as far as posssible.
➤ Ensure that there is no rotation of thorax or pelvis.
C. Central Ray
➤ Perpendicular to the spinal fusion area or at the level of the
lower costal margin.
84
E. Exam Rationale
➤ This hyperflexion and hyperextension studies used to
demonstrate anterior mobility at the fusion site and to determine
whether motion is present in the area of a spinal fusion or to
localize a herniated disk as shown by limitation of motion at the
site of the lesion.
F. Structures Shown
5. AP Projection (R and L Bending)
A. Patient Position
➤ Patient is in supine position with the mid-sagittal noplane of
B. Part Position
➤ Cross the patient's leg on the opposite side to be flexed over
the other leg, to obtain equal bending force throughout the
spine.
➤ Move the shoulders directly lateral as far as possible without
rotating the pelvis.
C. Central Ray
➤ Perpendicular, directed 1 to 1 1⁄2 inches above the iliac
crest.
➤ Suspended respiration at the of full expiration
E. Exam Rationale
➤ To determine the presence of structural change when bending to
the right and left in patients with early scoliosis.
➤ To localize a herniated disk by limitation of motion at
the site of the lesion.
➤ To demonstrate whether there is motion in the area
of a spinal fusion.
F. Structures Shown
➤ Site of the Spinal Fusion
➤ Thoracic and Lumbar Spine air
85
STERNUM
Procedures:
1. AP Oblique Projection (RAO Position)
3. PA Oblique Projection (Moore Method)
1. PA Oblique Projection (RAO Position)
A. Patient Position
86
➤ Patient is either in erect or prone position.
B. Part Position
➤ The Right anterior aspect of the patient's chest da ed! tej
against the bucky. Rotate the patient 15 to 20°.
➤ Align the long axis of the sternum to the long axis of the
image receptor.
➤ Upper border of the image receptor is 1 1⁄2 inches
above the manubrial notch.
C. Central Ray
➤ Perpendicular to the image receptor at the level of the
seventh thoracic vertebrae and approximately 1 inch to the left
of the midsagittal plane.
➤ Slow or Shallow breathing for blurring of overlying lung
markings.
When short time of exposure is to be used, suspend respiration at
the end of expiration to obtain a more uniform density.
E. Exam Rationale
➤ The RAO position is routinely selected because it projects the
sternum through the heart shadow, which takes advantage of the
more homogeneous anatomic density of the heart muscle to allow
improved demonstration of the sternum relative to radiographic

density.
F. Structures Shown
➤ Entire sternum
N.B.
This position may be difficult to perform on trauma patients. Use an upright
position if necessary or possible. On trauma patients, obtain this projection
87
with the patient supine, and use the LPO position and an AP oblique
projection.
2. Lateral Projection (R or L Position)
A. Patient Position
➤ Patient is in lateral position either seated or standing
position against the vertical cassette holder.
B. Part Position
➤ Have patient clasp hands behind back to move shoulders
posteriorly and to project the sternum anteriorly.
➤ Midsagittal plane of the body is parallel to the image
receptor.
➤ The superior border of the image receptor is 1 1⁄2 inches

above the manubrial notch.
C. Central Ray
➤ Perpendicular to the lateral border of the sternum midway
between the manubrial notch and the xiphoid process.
➤ Suspended respiration at the end of deep inspiration, to
provide sharper contrast between the posterior surface of the
sternum and adjacent structures.
E. Exam Rationale
➤ This allows the sternum to be visualized in a lateral
orientation that complements the RAO and allows evaluation of
depression of the sternum following a fracture.
F. Structures Shown
➤ Entire sternum
Manubrium
88
3. PA Oblique Projection (Moore Method)
A. Patient Position
➤ Patient is in standing position at the side of the
radiographic table directly in front of the bucky tray.
➤ Ask the patient to bend at the waist, and place the sternum in
the center of the table directly over the prepositioned image
receptor.
B. Part Position
➤ Ensure that the patient is in true prone position and that the
midsternal area is at the center of the radiographic table.
➤ Place the patient's arms above the shoulders and the palms
down on the table.
C. Central Ray
➤ 25° centered to the image receptor, directed to the level of
T7 or 2 inches to the right of the spine. This angulation places
the sternum over the lung to maintain maximun contrast of the
sternum.
➤ Slow or Shallow Breathing or Suspended respiration at the end
of full expiration to obtain a more uniform density.
E. Exam Rationale
➤ This method shows a slight oblique of the sternum. The degree
of detail demonstrated depends largely on the technique used.
F. Structures Shown
➤ Entire sternum
➤ Blurred posterior ribs
89
STERNOCLAVICULAR ARTICULATIONS
Procedures:
1. PA Projection
2. PA Oblique Projection (Body Rotation Method) RAO or LAO Pos.
3. Axiolateral Projection (Kurzbauer Method)
90
1. PA Projection
A. Patient Position
➤ Patient is in prone position with the mid-sagittal plane of
B. Part Position
➤ For unilateral:
o Turn the head towards the affected side.
➤ For bilateral:
o Chin should be extended with midsagittal plane is
vertical to the table.
➤ Arms on the side of the body with palms up and shoulders on
the same plane.
➤ Turning the head rotates the spine slightly away from

the side being examined and thus provides better visualization of
the lateral portion of the manubrium.
C. Central Ray
➤ Perpendicular, directed to T3.
E. Exam Rationale
➤ Occasionally, radiographic visualization of the
sternoclavicular articulations may be desirable to demonstrate
possible traumatic or pathologic changes.
F. Structures Shown
➤ Sternoclavicular joints
Frontal view of the clavicles
91
2. PA Oblique Projection (Body Rotation Method) RAO or LAO Position
A. Patient Position
➤ Patient is in prone or upright position
B. Part Position
➤ Rotate the patient 15° to place the side of interest closest
to the bucky.
➤ Midsagittal plane forms 15° to the image receptor.
C. Crntral Ray
➤ Perpendicular to the sternoclavicular joints, directed at the
level of T2-T3 or distal to the vertebral prominence.
E. Exam Rationale
➤ The oblique projection complement the PA projection by
projecting the sternoclavicular articulations to one side of the
thoracic vertebrae, which reduces superimposition and "opens" the
joint space for better visualization. Both sides are examined for
comparison. The RAO best demonstrates the right joint and the LAO
the left joint.
F. Structures Shown
➤ Sternoclavicular joint
3. Axiolateral Projection (Kurzbauer Method)
A. Patient Position
➤ Patient is in lateral recumbent on the side.
B. Part Position
➤ Flex the patient's hips and knees in a comfortable position.
➤ Fully extend the arm of the affected side and grasp the end of
the table for support.
➤ The opposite arm along side of the body.
➤ Adjust the thorax to place the anterior surface of the A
manubrium perpendicular to the plane of the image receptor.
C. Central Ray
➤ 15° caudally, directed to the sterno-clavicular joint.
➤ Suspended respiration at the end of full inspiration.
E. Exam Rationale
➤ To show an unobstructed axiolateral projection of the
sternoclavicular articulation.
F. Structures Shown
92
➤ Sternoclavicular joints
RIBS
Procedures:
1. PA Projection (Anterior Ribs) erf
2. AP Projection (Posterior Ribs) (Above or Below Diaphragm)
3. PA Oblique Projection (RAO or LAO Projection)
93
1. PA Projection
A. Patient Position
➤ Patient is in PA projection either upright or recumbent
position.
B. Part Position
➤ Midsagittal plane of the body is center to midline of the
grid.
➤ Rest the patient's hands against the hips with the palms
turned outward to rotate the scapula away from the rib cage, if
the patient is in erect.
➤ If the patient is in prone position, rest the head on the chin
and adjust the midsagittal plane to be vertical.
C. Central Ray
➤ Perpendicular, directed to the level of T7.
➤ 10 to 15° caudally for demonstrating the 7th, 8th, and 9th
ribs to aid in projecting the diaphragm below that of the
affected ribs.
➤ Suspended respiration, at the end of full inspiration, to
depress the diaphragm as much as possible.
E. Exam Rationale
94
➤ Best demonstrates the anterior ribs above the diaphragm.
➤ For upright Position:
0 The diaphragm descends to its lowest level and also valuable
for demostrating fluid levels in the chest.
F. Structures Shown
➤ First to Ninth ribs
➤ First to Seventh anterior ribs
2. AP Projection (Above or Below Diaphragm)
A. Patient Position
➤ Patient is in erect position facing the x-ray tube.
95
B. Part Position
➤ Midsagittal plane of the patient's body to the midline
of the table.
➤ For ribs above the diaphragm:
o Place 1 1⁄2 inches above the uper border of
the relaxed shoulders.
➤ Rest the patient's hands, palms outward against the hips to
move the scapula off the ribs, or
➤ Extend the arms to the vertical position with the hands under
the head.
➤ For ribs below the diaphragm:
o Place the image receptor in crosswise with the lower edge at
the level of the iliac crest to ensure the inclusion of the lower
ribs.
C. Central Ray
➤ Perpendicular, directed to the level of the seventh
thoracic vertebrae.
➤ Suspended respiration at the end of full expiration to elevate
the diaphragm.
E. Exam Rationale
➤ This projection best demonstrates the posterior ribs above the
diaphragm if the patient is in erect and ribs ettevodis below the
diaphragm if the patient is in supine to permit gravity to assist
in moving the patient's
diaphragm.
F. Structures Shown
➤ First to tenth Posterior ribs
➤ Eight to Twelfth Posterior ribs
96
3. PA Oblique Projection (RAO or LAO Position)
A. Patient Position
➤ Patient is either supine or erect position.
B. Part Position
➤ Rotate the body 45° away from the affected side.
➤ For recumbent:
o Patient rest on the forearm and flexed the knee of the
elevated side, and image the ribs below the diaphragm.
➤ For erect:
o Image ribs above the diaphragm.
➤ Align a plane of the thorax midway between the spine and the
lateral margin of the thorax.
➤ The superior border of the cassette is 1 1⁄2 inches above the
upper border of the shoulder to image the ribs, or the lower edge
at the level of the
iliac crest.
97
C. Central Ray
➤ Perpendicular to the film holder
➤ Suspended respiration at the end of full expiration for the
ribs below the diaphragm and suspended respiration at the end of
full inspiration for the ribs above the diaphragm.
E. Exam Rationnale
➤ This projection demonstrate the axillary margin of the ribs on
the side of interest free of bony superimposition.
F. Structures Shown
➤ Axillary portion of the ribs
➤ First to tenth ribs
➤ Eight to twelfth ribs
98
ABDOMEN
Procedures:
1. AP Projection (KUB)
2. AP Upright Projection
3. Lateral Position
4. Lateral Decubitus
1. AP Projection (KUB)
A. Patient Position
the body is center to the midline of the table with the legs
extended.
B. Part Position
➤ Shoulders must be same transverse plane The pelvis is adjusted
so that it is not rotated. Center the cassette at the level of
the iliac crests. Apply gonadal shielding as appropriate. The
knees may be flexed for patient comfort.
C. Central Ray
➤ Perpendicular to midpoint of the image receptor, at the level
of the iliac crest.
E. Exam Rationale
➤ This projection often serves as a scout view for various,
radiologic exams. It is valuable for visualizing abdominal
masses, calcifications, foreign bodies, and intestinal
obstruction. The projection also provides a general survey of the
abdominal pattern, soft tissue shadows, organ configuration and
skeletal structures.
99
F. Structures Shown
➤ Liver
➤ Spleen
➤ Kidneys
➤ Abnormal masses
➤ Calcifications or accumulations of gas beoog
➤ Pelvis, Lumbar spine and Lower ribs
2. AP Upright Projection
A. Patient Position
➤ Patient is in erect position with the posterior surface of the
body is against the image receptor.
B. Part Position
➤ Center the midsagittal plane to the midline of the table or in
the upright grid device.
With the weight is equally distributed on both feet.
➤ Shoulders in same transverse plane
➤ Adjust the height of the cassette 2 to 3 inches above the
iliac crest to include the diaphragm for the average patient the
top of the cassetteis at the level of the axilla.
C. Central Ray
➤ Horizontal to the midpoint of the image receptor, 2 to 3
inches superior to iliac crest.
100
E. Exam Rationale
➤ This projection is most valuable for demonstrating free
intraperitoneal air and air/fluid levels. It is also good for
visualization of soft tissue structures, bowel gas patterns and
skeletal structures.
F. Structures Shown
➤ Liver, Spleen, Kidneys
➤ Abnormal Masses, Air-Fluid Levels
➤ Accumulations of gas or free intra-abdominal air.
A. Patient Position
➤ Patient is in left lateral position.
B. Part Position
➤ Knees may be flexed for support.
➤ Arms and elbows moved towards the head so that they are not in
the area of interest
➤ Shoulders and pelvis should be in true lateral position.
C. Central Ray
➤ Perpendicular to the image receptor at the level of sebim erit
the iliac crest.
E. Exam Rationale
➤ This position is useful for demonstrating of the calcification
of the aorta and blood vessels and aneurysms.
F. Structures Shown
➤ Pelvis and Lumbar vertebrae
Soft tissue structures of the abdomen Anterior portion of the
abdomen
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4. Lateral Decubitus
A. Patient Position
➤ Patient is in left lateral position.
B. Part Position
➤ Knees slightly flexed for support
➤ Arms above the level of the diaphragm
➤ Shoulders and pelvis should be in true lateral
position alays
C. Central Ray
➤ Horizontal to the midpoint of the film 2 to 3 inches above the
level of the iliac crests and aligned to midsagittal plane of the
patient
D. Patient Instruction
E. Exam Rationale
➤ This position is useful for demonstrating the air/fluid level
or free intraperitoneal air in cases of bowel obstruction or
perforated viscus. It also demonstrates abdominal masses and soft
tissue structures of the abdomen. This position also used when a
patient is unable to stand for an upright abdomen.
F. Structures Shown
➤ Pelvis and Abdomen
➤ Iliac alae and Spinous process
➤ Diaphragm
102
CHEST
Procedures:
1. PA Projection
3. Lateral Decubitus Position
4. AP Lordotic Position
5. Anterior Oblique Position (RAO and LAO)
6. Posterior Oblique Position (RPO and LPO)
1. PA Projection
A. Patient Position
➤ Patient is in erect position, facing the vertical cassette
holder, weight equally distributed on both feet.
arms
B. Part Position
➤ Midsagittal plane of the body must center to the midline of
the film holder.
103
➤ Top of the image receptor is 1 1⁄2 to 2 inches above the
shoulders.
Back of hands on hips with palms facing outward, depress the
shoulders and hold them in contact with the grid.
➤ Shoulders rotated forward against the film holder to allow the
scapulae to move laterally clear of the lung fields.
C. Central Ray
➤ Perpendicular to the MSP at the level of T7 with SID of 72
inches.
➤ Suspended respiration at the end of the 2nd full inspiration.
E. Exam Rationale
➤ The PA chest is performed to outline the anatomy of the lungs,
heart, great vessels and mediastinal wn structures to detect the
presence of chest lesions.
F. Structures Shown
➤ Lungs including both apices
➤ Air-filled trachea, Bronchi
➤ Heart and great vessels
➤ Diaphragm, Costophrenic angles and Bony Thorax.
104
A. Patient Position
➤ Patient is in erect position with the left side against the
cassette unless otherwise specified.
B. Part Position
➤ Midsagittal and sagittal plane are parallel to the cassette,
coronal plane is perpendicular.
➤ Arms rest over the head with each hand grasping opposite
elbow.
➤ To determine rotation, examine the posterior aspects of the

ribs. Radiographs without rotation show superimposed posterior
ribs.
C. Central Ray
➤ Perpendicular to the mid thorax at the level of T7.
E. Exam Rationale
➤ The lateral chest demonstrates the anatomy of the lungs,
heart, great vessels and mediastinal structures.
F. Structures Shown
➤ Lungs, Trachea, Heart and Great vessels
➤ Diaphragm, Posterior Costophrenic angles and bony Thorax
3. Lateral Decubitus Position
A. Patient Position
➤ Patient is in lateral recumbent position with both arms raised
over patient's head.
B. Part Position
➤ Ankles and knees on top of one another and the knees flexed
for support.
➤ Coronal plane is parallel to film with no body rotation.
➤ Superior border of the cassette is 2 inches above the
shoulders.
C. Central Ray
➤ Horizontally, directed to the level of T7 with 72 inches
SID.
105
E. Exam Rationale
➤ This position is used to demonstrate amounts of fluid in the
pleural cavity, which would be demonstrated with the patient
lying on the affected side, or amounts of air in the pleural
cavity, which would be demonstrated with the patient lying on the
unaffected side.
F. Structures Shown
➤ Pleural effusions
➤ Small amount of air or pneumothorax
4. AP Lordotic Position
A. Patient Position
➤ Patient is in erect position facing the tube, with 1 foot away
from the film holder and back with shoulders, neck, and back of
head against the film holder.
➤ Superior border of the cassette should be approximately 3

inches above the shoulders.
B. Part Position
➤ Adjust the patient with the midsagittal plane of the lesbody
center to the midline of the film
➤ Hands on hip and rotate the shoulders forward.
C. Central Ray
➤ Perpendicular to the cassette, directed to the mid sternum
with 72 inches SID.
➤ Suspended respiration at the end of the 2nd full inspiration..
E. Exam Rationale
➤ This position is used to demonstrate the apices free from
superimposition of the clavicles or to demonstrate a right middle
lobe pneumothorax.
F. Structures Shown
➤ Apices and Lungs
➤ Clavicles
➤ Interlobar effusions, calcification and masses beneath the
clavicles.
5. PA Oblique Projection (RAO and LAO Position)
A. Patient Position
➤ Patient is in erect position, adjust the coronal plane 45°
from plane of the cassette.
➤ Top of the cassette is 2 inches above the shoulders Side
106
farthest from the cassette is usually the side of primary of
interest.
➤ Weight of the patient's body must be equally distributed on
the feet to prevent unwanted rotation.
B. Part Position
➤ Rotate the patient's body 45° from the straight PA with either
the left (LAO) or right (RAO) shoulder and chest against the
image receptor.
➤ The arm farthest from the cassette placed on top of
the cassette holder.
C. Central Ray
➤ Perpendicular to the center of the cassette at the level of T7
with the SID of 72 inches.
➤ Suspended respiration at the end of the 2nd full inspiration,
to ensure maximum expansion of the lungs.
E. Exam Rationale
➤ This position is used to demonstrate the trachea, portions of
the right and left bronchial tree, heart, and aorta free from
superimposition of the vertebral column. Either a right or left

oblique position or both may be indicated. The side farthest from
the image receptor is demonstrated, so the LAO will best
demonstrate the right lung and the RAO will best demonstrate the
left lung.
F. Structures Shown
➤ LAO, right lung, trachea, bony thorax, heart and aorta, right
branch of the bronchial tree, descending aorta, and the arch of
the aorta.
➤ RAO, left lung, trachea, bony thorax, heart and aorta, left
atrium, anterior portion of the apex of the left ventricle and
right retro cardiac space.
6. AP Oblique Projection (RPO and LPO Position)
A. Patient Position
➤ Patient is either supine or erect position facing the x ray
tube. The upper border of the cassette is about 1 1/2 to 2 inches
above the vertebral prominens.
➤ Have the patient look straight ahead.
B. Part Position
➤ Rotate the patient toward the affected side approximately 45°.
➤ Flex the patient's elbows and place the hands on the hips with
the palms facing outward or pronate the hands beside the hips.
C. Central Ray
➤ Perpendicular, directed to the level of t7.
107
➤ Suspended respiration at the end of the 2nd full inspiration,
to ensure the maximum expansion of the lungs.
E. Exam Rationale
➤ RPO and LPO positions are used when the patient is too ill to
be turned to the prone position and sometimes as supplementary
positions in the investigation of the specific lesions. They also
used with the recumbent patient in contrast studies of the heart
and great vessels.
F. Structures Shown
➤ LPO left lung, trachea, bony thorax, heart and aorta in front
of vertebral column.
➤ RPO right lung, trachea, bony thorax, with heart and aorta in
front of vertebral column.
108
SHOULDER JOINTS
1. AP Projection Neutral
2. AP Projection Internal Rotation
3. AP Projection External Rotation
4. Transthoracic Lateral Projection (Lawrence Method)
5. Inferosuperior Axial Projection (Lawrence Method)
6. Inferosuperior Axial Projection (Rafert Modification)
7. Inferosuperior Axial Projection (West Point Method)
8. Inferosuperior Axial Projection (Clements Modification)
9. Superoinferior Axial Projection
10.AP Axial Projection
11.Tangential Projection (Fisk Method)
12.PA Oblique (RAO/LAO) (Scapular Y)
13.AP Apical Oblique (RPO&LPO) (Garth Method)
14.AP oblique Projection (RPO or LPO) (Grashey Method)
15.AP Oblique Projection (RPO/LPO) (Apple Method)
16.AP Axial Projection (Stryker "Notch" Method)
Routine
109
1. AP Projection Neutral
A. Patient Position
» Patient is supine or upright position with posterior
surface of the body against the IR
B. Part Position
» The palm of the hand placed against the hip
 Adjust the position of the IR so that its center is 1inch (2
Sem) inferior to the coracoid process
 Place the epicondyles of the distal humerus at an approximate
45 degree angle to the film.
C. Central Ray
» Perpendicular to the coracoid process 1inch inferior to the
coracoid process
» Suspended respi
E. Exam Rationale
» Shows the bony and soft structures of the shoulder and proximal
humerus in the anatomic position demons. the scapulohumeral joint
relationship and the region of the subacromial bursa
F. Structures Shown
» The frontal view of proximal humerus, lateral two thirds of the
clavicle and upper scapula including relationship of humeral head to
glenoid cavity.
2. AP Projection Internal Rotation

A. Patient Position
> Patient is supine or upright position with posterior surface of
the body against the IR.
B. Part Position
» Place the affected arm by the patient's side with the back of the
110
hand resting on the thigh to place in the intercondylar line
perpendicular to the IR.
C. Central Ray
> Perpendicular to the coracoid process 1inch inferior to the
coracoid process
> Suspended respiration
E. Exam Rationale
> To demonstrate fracture, dislocation, bursitis, tendon or
ligament damage, bony tumors and cysts and also possible calcium
deposits in muscles lesser tubercle is also demons. Pointing
medially.
F. Structures Shown
N.B.
Shows the lateral view of proximal humerus and lateral two-thirds of
clavicle and upper scapula, including relationship of humeral head to
glenoid
cavity.
The internal rotation should never be done if acute
trauma is evident or suspected.
3. AP Projection External Rotation
A. Patient Position
> Patient is supine or upright position with posterior surface of
the body against the IR.
B. Part Position
> Place the affected arm by the pxs side with the hand supinated to
place the intercondylar line parallel to the IR.
C. Central Ray
> Perpendicular to the coracoid process 1inch inferior
to the coracoid process
E. Exam Rationale
> Demonstrate Fracture, dislocation, bursitis, tendon or ligament
damage, bony tumors and cysts.
111
 Greater tubercle is now positioned laterally
 Lesser tubercle is now located anteriorly just medial to the
greater tubercle
F. Structures Shown
> Shows the frontal view of the proximal humerus and lateral two-
thirds of clavicle and upper scapula, including relationship of
humeral head to glenoid cavity.
N.B. External rotation should never be done if acute trauma is
evident or suspected.
ADDITIONAL ROUTINE
4. Transthoracic Lateral Projection (Lawrence Method)
A. Patient Position
> Patient in upright position with affected arm against IR
B. Part Position
> Affected arm is maintained in a neutral position
> Superior border of the IR should be placed 1 inch (2.5 cm) above
the affected shoulder
C. Central Ray
> To the midshaft of the humerus
> Normal respiration
112
E. Exam Rationale
> The transthoracic lateral is an alternate position taken primarily
in cases of acute trauma to the upper arm or shoulder or when the
patient is otherwise unable to rotate the arm
F. Structures Shown
> Head and shaft of the humerus in a lateral perspective
N.B.
A 15° cephalad angle can be used to prevent superimposition of the shoulders
if the patient is unable to raise the unaffected arm high over the head.
5. Inferosuperior Axial Projection (Lawrence Method)

A. Patient Position
> Patient in supine position, elevate the head, shoulder and elbow
about 3 inches (7.6 cm)
B. Part Position
> Abduct the arm of the affected side at the right angles or 90° to
the long axis of the body.
 keep the arm/humerus in external rotation with the palm
 rotate the head toward the opposite side
C. Central Ray
> Suspended Respiration
113
E. Exam Rationale
> This is used primarily to obtain a lateral and its relationship to
the glenoid fossa
F. Structures Shown
> Hill-Sachs defect
> Lesser Tubercle
> Glenoid Humeral Joint
N.B.
If abduction of the arm is less than 90° the CR is decreased to 15-20. The
greater the abduction, the greater the angle.
6. Inferosuperior Axial Projection (Rafert Modification)
A. Patient Position
 Patient in supine position, elevate the head, shoulder and elbow
about 3 inches (7.6 cm).
B. Part Position
114
 Rotate externally the extended arm until the hand forms a 45°
oblique
 The thumb will be pointing downward
 Assist the patient in rotating the arm to avoid
overstressing the shoulder joint.
C. Central Ray
 Horizontally and 15° angled entering the axilla and passing
through the acromiaclavicular joint.
 Suspended respiration
E. Exam Rationale
 Demonstrate the fracture located on the posterolateral humeral
head. An exaggerated external rotation of the arm maybe required
to see the defect.
F. Structures Shown
 Hill-Sachs defect
 Lesser tubercle
 Coracoid process pointing Anteriorly
 Axially structures
7. Inferosuperior Axial Projection (West Point Method)
A. Patient Position
 Patient in prone position, elevate the shoulder 3 inches (7.6cm)
B. Part Position
 Abduct the arm of the affected side 90°
 IR against the superior aspects of the shoulder
C. Central Ray
 25º anteriorly from the horizontal and 25° medially. Enters the
inferior and medial to the acromial edge Jonne holes and exits
the glenoid cavity.
 Suspended Respiration
E. Exam Rationale
115
 Shows bony abnormalities of the anterior inferior rim of the
glenoid in patients with instability of the
shoulder.
F. Structures Shown
 Articulation between the head of the humerus and the glenoid
cavity
 Shoulder joint
8. Inferosuperior Axial Projection (Clements MModification)
A. Patient Position
 Patient is in lateral recumbent position on the unaffected
side
B. Part Position
 IR against the superior aspect of the patient's shoulder
 Abduct the affected arm 90° pointing toward the ceiling
C. Central Ray
 Horizontal to the midcoronal plane, passing through the
midaxillary region of the shoulder
E. Exam Rationale
 When the prone or supine position is not possible
F. Structures Shown

N.B.
> Humeral Head Shoulder joint
> Acromion
CR is 5-15° degrees medially when the patient cannot abduct the arm in
full 90
116
9.Superoinferior Axial Projection
A. Patient Position
> Patient is seated at the edge of the table on a stool or high
chair.
B. Part Position
> Flex the patient's elbow 90° and place the hand in pronation.
o Have the patient lean laterally over the IR
o Adjust any anterior or posterior leaning of the body to
place the humeral epicondyles in the vertical position.
C. Central Ray
> 5-15° toward the elbow
E. Exam Rationale
> Shows the joint relationship of the proximal end of the humerus
and the glenoid cavity
F. Structures Shown
> Acromioclavicular articulations
o Outer portion of the coracoid process
o Teres minor muscle
o Less tubercle
117
A. Patient Position
> Patient is either upright or supine position
B. Part Position
> Center the scapula humeral joint of the shoulder to the midline
of the grid.
C. Central Ray
> 35° cephalad
E. Exam Rationale
> Useful in cases of posterior dislocation of the shoulder
o shows the relationship of the head of the humerus to the
glenoid cavity.
F. Structures Shown
> Scapulohumeral joint
O Clavicle
O Proximal humerus
11.Tangential Projection (Fisk Method)
A. Patient Position
➤ Erect
o patient in supine with hand in supination
o IR against the superior aspect of the shoulder
o CR 10-150 posterior from horizontal mid anterior
B. Part Position
C. Central Ray
118
E. Exam Rationale
> Shows the intertubercular groove between the greater and lesser
tubercle
F. Structures Shown
> Anterior humeral head
o Humeral tubercle
o Intertubercle groove
12. PA Oblique (RAO/LAO) (Scapular Y)
A. Patient Position
➤ Patient is either supine or upright position depending patient
condition with posterior surface of the body against the IR
when severly injured.
B. Part Position
> Anterior surface of the shoulder against the IR.
O Rotate the patient body until the midcoronal plane forms
and angle of 45-60° to the IR.
O abduct arm slightly so as not to superimpose proximal
humerus over ribs
C. Central Ray
► Perpendicular to the scapulohumeral joint
E. Exam Rationale
> Useful in the evaluation of suspected shoulder dislocation
O This is an alternate view of the shoulder used primarily
with trauma patients for possible dislocations of the
head of the humerus.
F. Structures Shown
> Glenoid cavity
o Humeral head
119
o Subcoracoid
Anterior dislocation
> Humeral head beneath the coracoid process
Subacromial
> Posterior dislocation
> Humeral head beneath the acromion process
N.B.
The LPO is used for injuries to the right side and RPO for injuries to the left
side.
13.AP Apical Oblique (RPO&LPO) (Garth Method)

A. Patient Position
> Patient is either supine or upright position depending on
patient condition
B. Part Position
> Rotate the body 45 degree toward the affected side.
> Flex the elbow and place arm across chest or if trauma arm at
the side.
C. Central Ray
> 45° caudally to the scapulohumeral joint.
E. Exam Rationale
> A good Projection for possible scapulohumeral dislocations
especially posterior dislocations
120
> Glenoid fracture
> Hill-Sachs lesions and soft tissue calcifications
> Scapuhumeral instability
F. Structures Shown
Humeral head
> Glenoid cavity
> Scapular head and neck
14.AP oblique Projection (RPO or LPO) (Grashey Method)
A. Patient Position
> Patient in supine or upright position depending on px condition
B. PartPosition
>Rotate the body 35°-45° toward the affected side
>Abduct the arm slightly with arm in neutral rotation
>Place the affected arm by the patient side in a neutral
position or rest the forearm on the chest.
➤ If the patient is in supine position the body may need to be
rotated more than 45° to place the scapula parallel to the
IR.
C. Central Ray
> Perpendicular to the glenoid cavity, centered approximately 2
inches (5cm) inferior and medial to the superolateral border of
the shoulder
E. Exam Rationale
> This is taken primarily to demonstrate possible dislocations of
the head of the humerus and the glenoid cavity.
F. Structures Shown
> Acromial end of clavicle
121
> Coracoid process
> Glenoid cavity
> Head of Humerus
15.Tangential Projection (RAO/LAO) (Neer Method)
A. Patient Position
> Patient is seated or in standing position
B. Part Position
> Patient affected shoulder centered and in contact with the IR.
> Rotate the patient's unaffected side away from the IR 45-60
degrees from the plane of the film
> The degree of obliquity varies from patient to patient. Place
the patient's arm at the patient's side.
C. Central Ray
> 10-15 degrees caudally, entering the superior aspect of the
humeral head.
D. Patient Position
E. Exam Rationale
> This is useful to demonstrate tangentially the coracoacromial
arch or outlet to diagnose shoulder impingement.
demonstrate the posterior aspect of the humeral head.
122
F. Structures Shown
> Humeral head
> Acromioclavicular joint with bony detail
> Humerus and scapular body
16.AP Axial Projection (Stryker "Notch" Method)
A. Patient Position
> Patient in supine position
B. Part Position
> Flex the arm slightly beyond 90 degrees and place the palm of
the hand on top of the head with fingertips resting on the
head.
C. Central Ray
➤ 10 degrees cephalad, entering the coracoid process.
E. Exam Rationale
> Shows the posterosuperior and postero lateral areas of the
humeral head.
▸ Demonstrate the posterior defects involving the posterolateral
head of the Humerus "HILL-SACHS DEFECTS"
123
F. Structures Shown
> Overlapping of the coracoid process and the clavicle
> Long axis of the humerus.
A. Patient Position
> Patient is seating or in upright position
B. Part Position
> The posterior surface of the affected is closest to the IR.
> Rotate the body 35 to 45 degrees toward the affected side.
Scapula should be parallel to plane of the IR
> Abduct the arm 90 degrees from the midline of the body holding a 1
pound weight on the affected side.
C. Central Ray
> Perpendicular to the IR at the level of the coracoid process
E. Exam Rationale
> demonstrate a loss of articular cartilage in the scapulohumeral joint
uses weighted abduction.
124
F. Structures Shown
> Glenoid cavity
> Joint space between the humeral head and the glenoid cavity
> Soft tissue at the scapulo humeral joint.
CLAVICLE
1. AP Projection
2. PA Projection
3. AP Axial Projection (Tangential Projection)
5. Tangential (Tsrrsnt Method)
Routine
1. AP Projection
A. Patient Position
> Patient is either supine or upright position
B. Part Position
> Arms along the sides of the body and adjust the shoulders to
lie on the same horizontal plane.
125
C. Central Ray
> Perpendicular to the mid clavicle
> Suspended respiration at the end of exhalation
E. Exam Rationale
> Shows the posterosuperior and postero lateral areas of the
Humeral head
> Demonstrate the posterior defects involving the posterolateral
head of the humerus "HILL-SACHS DEFECTS"
F. Structures Shown
> Clavicle
> Acromio-clavicular and sterno-clavicular joints
2. PA Projection
A. Patient Position
> Patient is either in prone or upright position
B. Part Position
➤ Place the affected arm by the patient's side in neutral
position.
C. Central Ray
> Perpendicular to the midclavicle
> Suspended on inspiration
E. Exam Rationale
> This is most useful when improved recorded detail is desired.
> To make the clavicle closer to the IR thus reducing the OID
F. Structures Shown
> Entire clavicle
> Acromio-clavicular and sterno-clavicular joints.
126
3. AP Axial Projections
A. Patient Position
> Patient is either in supine or upright position with the
posterior surface of the body against the image receptor
B. Part Position
> Place the affected arm by the patient's side in a neutral
position.
> Lean backward in a position of extreme lordosi.
C. Central Ray
> For SUPINE position 15 to 30°
> For UPRIGHT position 0 to 15° directed to the midclavicle
> Suspend at the end of full inspiration
O To further elevate and angle the clavicle
E. Exam Rationale
> The most common indication for clavicle examination is trauma.
AP clavicle is performed when the patient cannot be placed into
a prone position. Although the AP clavicle demonstrates the
same structures as the PA, the AP results in more magnification
of the structures of interes
F. Structures Shown
> Entire Clavicle
> Acromioclavicular and sternoclavicular
➤ PA axial is similar to the AP axial projection of the
clavicle, structures shown and the exam.
> Rationale are the same.
> Central ray is 15 to 30 degrees caudally
127
5. Tangential Projection (Tarrant Method)
A. Patient Position
> Patient is in seating position
B. Part Position
> Ask the patient to lean forward and have the patient hold the
IR in position.
C. Central Ray
> 25 to 35° angle, perpendicular to the longitudinal axis
of the clavicle.
SCAPULA
1. AP Projection
2. Lateral Projection (RAO/LAO)
3. PA Oblique Projection (RAO/LAO)(Lorenz and Lilienfield Methods)
4. AP Oblique Projection (RPO/LPO)
ROUTINE
1. AP Projection
128
A. Patient Position
> Patient is either supine or upright position depending on
patient condition, with the posterior surface of the body
against the image receptor.
B. Part Position
> Flex the elbow and abduct the arm at 90 degrees from the body
to draw the scapula laterally.
> Do not rotate the body toward the affected side because the
resultant obliquity would offset the effect of drawing the
scapula laterally.
> The top of the image receptor is placed 1 to 2 inches above
the acromion process.
C. Central Ray
> Perpendicular to the midscapula, 2 inches inferior to the
coracoid process.
> Normal respiration/slow breathing to blur thorax shadows, which
frequently obscure bony detail.
E. Exam Rationale
> The most common indication for scapula examination is trauma,
to demonstrate the scapula.
F. Structures Shown
> Scapular body
> Acromion process
> Glenoid fossa and inferior angle Scapular spine
129
2. Lateral Projection (RAO/LAO)
A. Patient Position
> Patient is either in upright or seating position depending on
patient condition.
B. Part Position
> Rotate the body 45 to 60° with the affected scapula close in
contact with the film.
Place the arm in one of two positions according to the area of
the scapula to be demonstrated.
o For the demonstration of the body of scapula extend the
arm upward and rest the forearm on the head or across the
upper chest by grasping the opposite shoulder.
o For the demonstration of the acromion and coracoid
process, flex the elbow and place the back of the hand on
the posterior thorax with arm partially abducted
C. Central Ray
> Perpendicular to the mid vertebral border of the scapula.
E. Exam Rationale
> The lateral is one of the two routine positions of the scapula,
lateral scapula projected clear of the rib cage. Arm placement
should be determined by scapular area of interest to result in
the least superimposition of scapula by humerus.
F. Structures Shown
> Coracoid process projected anteriorly
> Acromion process and inferior angle
> Body of scapula
ADDITIONAL ROUTINE
130
3. PA Oblique Projection (RAO/LAO) (Lorenz and Lilienfeld methods)
A. Patient Position
> Patient is either upright or in lateral recumbent.
B. Part Position
Lorenz
 Flex the elbow and rest the hand against the patient's head.
 Rotate the body slightly forward and have the patient grasp the
side of the table.
Lilienfield
 Extend the arm of the affected side obliquely upward and have the
patient rest the hand on his/her head.
 Rotate the body slightly forward and have the patient grasp the
side of the table for support.
C. Central Ray
 Perpendicular to the image receptor between the chest wall and
the mid area of the protruding scapula.
E. Exam Rationale
> The degree of obliquity depends on the position of the arm.
The delineation of the different parts of the bone in the
two oblique projections are shown.
F. Structures Shown
> Scapula in oblique position
> Acromion process and inferior angle.
131
4. AP Oblique Projection (RPO/ LPO)
A. Patient Position
> Patient is either supine or upright position.
B. Part Position
> extend the arm superiorly, flex the elbow with the hand in
supination under the head or have the patient extend the
affected armacross the anterior chest. Rotate the shouder 15 to
25 degreess away from the affected side.
C. Central Ray
> Perpendicular to the mid scapular area.
E. Exam Rationale
> This projection shows oblique images of the scapula,
projected free or nearly free of rib superimposition.
F. Structures Shown
> Scapula in oblique position
> Acromion process and inferior angle.
SCAPULAR SPINE
1. Tangential Projection (Laquerrier-Pierquin Method)

2. Tangential Projection
Routine
1. Tangential Projection (Laquerriere-Pierquin Method)
A. Patient Position
➤ Patient in supine position
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B. Part Position
> Rotate the patient to place the body of the scapula in a
horizontal position.
> Turn the head away from the shoulder being examined to prevent
superimposition.
C. Central Ray
> 45 degrees caudally to the posterosuperior region of the
shoulder.
➤ 35 degrees for obese and round shouldered patients.
E. Exam Rationale
> The spine of the scapula is shown in profile and is free of
bony superimposition except for the lateral end of the
clavicle.
F. Structures Shown
> Scapular spine superior to the scapular body and soft
tissue around it.
2. Tangential Projection (Prone)
A. Patient Position
> Patient is in prone position
B. Part Position
> Arms along sides of the body with the hand in supination of
the affected side.
C. Central Ray
> 45 degrees cephalad to the scapular spine
E. Exam Rationale
> It shows the scapular spine in profile and free of
superimposition of the scapular body
F. Structures Shown
 Scapular spine above the scapular wing and soft tissue around
it.
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ACROMIOCLAVICULAR ARTICULATIONS
1.AP Projections (Bilateral)(Pearson Method)

2.AP Axial Projection (Alexander Method)
3.PA Axial Oblique Projection (RAO/LAO) Alexander Method
1.AP Projections (Bilateral)(Pearson Method)
A. Patient Position
> Patient is either seating or standing position
B. Part Position
 Ensure that the weight of the body is equally distributed on
the feet to avoid rotation.
 Make two exposures: one in which the patient is in standing
without weights attached and a second in which the patient has
equal weights (5 to 8 lbs).
C. Central Ray
> Perpendicular to the midline of the body at the level of the
acromioclavicular joints.
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E. Exam Rationale
 This projection is used to demonstrate dislocation, separation
and function of the joints.
> Avoid having the patient hold weights in each hand: this
tends to make the shoulder muscles contract, thus reducing the
possibility of demonstrating a small acromioclavicular
separation
F. Structures Shown
> Acromioclavicular joint space.
2. AP Axial Projection (Alexander Method)
A. Patient Position
> Patient in upright position
B. Part Position
> Place the back of the patient against the film
 midpoint of the film is at the level of the acromioclavicular
joint.
C. Central Ray
 15° cephalad, directed to the coracoid process.Patient
Instruction
E. Exam Rationale
 Axial oblique projections be used in cases of suspected
acromioclavicular subluxation or dislocation and each side is
examined separately.
 Acromioclavicular joint projected slightly superiorly compared
with an AP projection.
F. Structures Shown
 Acromioclavicular joint and clavicle.
3. PA Axial Oblique Projection (RAO/LAO) Alexander Method
A. Patient Position
 Patient is in standing position facing the IR.
B. Part Position
 Place the hand of the affected side under the opposite axilla.
 Rotate the body until the midcoronal plane forms an agle of 45
to 60°.
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 The scapula and acromioclavicular joint are thus placed in the
lateral position.
C. Central Ray
> 15° caudally, directed to the acromioclavicular joint.
E. Exam Rationale
> This projection demonstrates the acromio-clavicular joint and
the relationship of the bones of the shoulder.
F. Structures Shown
> Acromioclavicular joint with some soft tissue
FINGERS
Procedures:
1. PA
2. PA oblique
3. Lateral
1. PA
A. Patient Position
➤ Patient seated at the edge of the table
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B. Part Position
> Hand in pronation
> Fingers slightly spread
> Elbow flexed about 90°
C. Central Ray
. > Perpendicular to the film (PIP)
> Normal respiration
E. Exam Rationale
> Most common indication is trauma
> Visualized joint diseases
Such as:
- Arthritis or gout
Demonstrate all phalanges and all metacarpals of the affected fingers
F. Structures shown
➤ Distal, middle, proximal metacarpals and associated joints.
proximal phalanges,phalanges, distal
2.PA Oblique
A. Patient Position
➤ Patient seated at the edge of the table with elbow flexed at
90°
B. Part Position
➤ Hand in pronation and rotate the finger 45°
➤ Fingers slightly spread to avoid superimposition with other
fingers.
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C. Central Ray
➤ Perpendicular to the metacarpo-phalangeal joint to the PIP
➤ Normal respiratory
E. Exam Rationale
➤ Is a routine position of the finger that gives a different
perspective from the PA, that of a 45° oblique.
E. Structures Shown
➤ Phalanges Interphalangeal
➤ Metacarpophalangeal joints
3. Lateral
A. Patient Position
90° angle to IR.
B. Part Position
➤ Place the hand in lateral position with finger to be examined
fully extended.
➤ Ensure that the long axis of finger is parallel to film.
C. Central Ray
➤ Perpendicular to the proximal to the Interphalangeal joint.
➤ Normal respiration
E. Exam rationale
➤ To demonstrate anterior or posterior displacements of the bony
structures and to localize foreign bodies
F. Structures Shown
138
➤ Phalanges
➤IP
➤MCP Jt.
THUMB
Procedures:
1. AP
2. Oblique
3. Lateral
Routine
1. AP
A. Patient Position
B. Part Position
➤ Hand in pronation with internal rotation until the posterior
surface of the thumb is flat on the image receptor
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C. Central Ray
➤ Perpendicular to the first Metacarphalangeal joint.
➤ Most common indication is trauma
E. Exam rationale
➤ The thumb has several unique fractures that require
modification in positioning
F. Structures shown
➤ Distal and proximal phalanges
➤ First metacarpal and associated joints.
➤ Best of first metacarpal for ruling out a "BENNETT'S TYPE
FRACTURE"
2. PA Oblique
A. Patient Position
90°
B. Part Position
➤ Pronate the hand and place the hand and thumb flat on the IR.
C. Central Ray
➤ Perpendicular to the 1st MP joint
➤ Normal respiratory
E. Exam Rationale
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F. Structures Shown
➤ Metacarpal of first digit
➤ Associated joints of all in oblique position and sesamoid
bones if present.
3. Lateral
A. Patient Position
90°.
B. Part Position
➤ Begin with the hand pronated and rotate the thumb toward the
radial side until the digit is in a true lateral position.
C. Central Ray
➤ Perpendicular to the 1st MP Joint
E. Exam Rationale
F. Structures shown
141
➤ First metacarpal and associated joints.
➤ Best of first metacarpal for ruling out a "BENNETT'S TYPE
FRACTURE"
Additional routine
Modifications
1. Robert method (AP Projection)
A. Patient Position
➤ Shoulder, elbow and wrist on the same plane
➤ Entire limb must be on the same plane to prevent elevation of
the carpal bones and closing of the 1st CMC joint.
B. Part Position
➤ Limb extended
➤ Rotate the arm internally to place the posterior aspect of the
thumb on the IR with then thumb nail down.
C. Central Ray
➤ To the 1st CMC Joint - Robert
➤ Long and rafert 15° proximally to the long axis of the thumb.
➤ Lewis modification 10-15° proximately to project the soft
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tissue of the hand away from the 1st CMC joint.
➤ To open the joint space when the space is not shown with C.R.
E. Exam rationale
➤ Demonstrate the 1st CMC joint free of super imposition of the
soft
F. Structures Shown
➤ 1st metacarpal
➤ Trapezeum
➤ 1st CMC joint
2. Burman Method (AP Projection)
A. Patient Position
➤ Patient seated at the edge of the table with forearm parallel
with the long axis of the IR.
B. Part Position
➤ Hyperextend the hand and have the patient hold the position
with the opposite hand.
➤ Rotate the hand internally and abduct the thumb so that it is
flat on the IR.
C. Central Ray
➤ 45° angle toward the elbow through the 1st CMC joint.
E. Exam rationale
➤ Shows a magnified concavo-convex outline of the 1st CMC joint.
143
F. Structures Shown
➤ 1st metacarpal
➤ 1st CMC joint
➤ Trapezeum in concave profile
3. Folio method (PA projection) / "Skier's Thumb"
A. Patient Position
B. Part Position
➤ Hands resting on the cassette on their medial aspects
➤ Tightly wrap a rubber band around the distal portion of both
thumbs and place a roll of medical tape bet. the bodies of the
1st metacarpals
C. Central Ray
➤ Perpendicular to a point midway between both hands at the
level of the MCP joints.
E. Exam rationale
➤ Useful for the diagnosis of Ulnar Collateral Ligament (UCL)
rupture in the MCP joint of the thumb.
F. Structures Shown
➤ Metacarpophalangeal joints
➤Metacarpal phalangeal angles bilaterally.
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Hand
Procedures:
1. PA
2. PA Oblique
3. Lateral
4. Ball Catcher’s
Routine
1.PA
A. Patient Position
B. Part Position
➤ Pronate the hand and wrist to place them flat on the IR
➤ Fingers extended and slightly spread
C. Central Ray
➤ Perpendicular to the base of the third MCP Joint.
E. Exam rationale
➤ The most common indications are trauma and joint diseases
➤ Arthritis
➤ Gout
F. Structures Shown
➤ phalangeal
➤ Metacarpals
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➤ Carpals and all joints of the hand.
Note: AP projection may be substituted if the hand cannot be
flattened or the fingers extended. Better demonstrate the
bases of the metacarpals.
2. PA Oblique (Lateral Rotation)
A. Patient Position
B. Part Position
➤ Hand pronated and rotate the radial side of the wrist
laterally 45° from the IR
➤ Fingers parallel to the IR and slightly spread to prevent
excessive superimposition of bones on the image.
C. Central Ray
➤ Perpendicular to the third MCP joint.
E. Exam rationale
➤ It gives a different prospective from the PA, that of a45°
oblique
➤ Used for investigating functions and pathologic conditions.
F. Structures Shown
➤ All phalanges
➤ Metacarpals
➤ Carpals and joints of the hand and wrist
146
3. Lateral (Extension) alternates to FAN lateral (Latero Medial)
A. Patient Position
➤ Patient seated at the edge of the table with elbow at 90°.
B. Part Position
➤ Extend fingers and thumb.
➤ Ensure that all fingers are directly superimposed for a true
lateral position
➤ Ulnar aspect down
C. Central Ray
➤ Perpendicular to the 2nd MCP joint.
E. Exam rationale
➤ This is taken for localization of foreign bodies and
fractures of metacarpals
➤ Radiographic Positioning
F. Structures Shown
➤ Phalanges
➤ Metacarpals and carpals superimposed
147
4. Norgaard method (AP oblique) / Ball Catcher's medial rotation
A. Patient Position
➤ Patient seated at the edge of the table.
B. Part Position
➤ Place both hands together
➤ Rotate the patients hands to a half supinate until the dorsal
surface of each hand rests against the IR.
➤ Extend the patient fingers and abduct the thumbs slightly to
avoid superimposition over the fingers.
C. Central Ray
➤ Perpendicular to a point midway between both hands at the
level of the MCP joints.
E. Exam rationale
➤ Diagnose rheumatoid arthritis.
F. Structures Shown
➤ Both hands from the carpal area to the tips of the digits
148
WRIST
Procedures:
1. PA
2. Oblique
3. Lateral
Additional Routine
4. AP Oblique (Medial rotation)
5. PA (Ulnar Flexion) Scaphoid (Ulnar Deviation)
6. PA (Radial Flexion / Radial Deviation
7. Scaphoid PA Axial (Stretcher method)
8. Tangential Projection (Garnor Hart) – Carpal Canal/ Tunnel
9. Carpal Bridge (Tangential)
10. Scaphoid (PA Axial) / Ulnar Deviation – Rafert Long Method
1.PA
A Patient Position
B. Part Position
➤ Pronate the hand and wrist to place them flat on the image
Receptor.
➤ Arch hand slightly to place wrist and carpal area in close

contact with the IR.
C. Central Ray
➤ Perpendicular to the midcarpal area / midway between the Ulnar
and radial styloid process
149
E. Exam rationale
➤ The most common indication is trauma
➤ It gives a slightly oblique rotation to the ulna
F. Structures Shown
➤ Mid and proximal metacarpals
➤ Carpals
➤ Distal radius and ulna
➤ Pertinent soft tissues
- Fat pads
- Fat stripes of the wrist joint.
Note:
AP
➤ To better demonstrate intercarpal spaces and the distal radius
and ulna.
PA
➤ To better demonstrate The scaphoid and capitate C.R. is 30°
towards the elbow.
. ➤ To elongate's the capitate only C.R. is 30° towards the finger
tips.
2.PA Oblique
A. Patient Position
90°.
B. Part Position
➤ Hand pronated and rotate the radial side of the wrist laterally
45° from the IR fingers and the wrist are extended.
150
C. Central Ray
➤ Perpendicular to the midcarpal/ wrist joint / midway between
the radial and ulnar styloid process.
E. Exam rationale
➤ Is a routine position of the wrist, w/c gives a diff.
perspective from the PA, that of a 45° oblique.
➤ Demonstrate carpals on the lateral of the wrist, particularly
the trapezeum and the scaphoid.
F. Structures Shown
➤ Right carpals and portions of the proximal metacarpals and
distal radius/ ulna
3. Lateral (Lateromedial)
A. Patient Position
➤ Patient seated at the edge of the table with elbow
flexed at 90°.
➤ Shoulder, elbow and wrist be on same horizontal plane
B. Part Position
➤ Extend the fingers and place the hand and wrist at a 90° angle
to IR.
➤ Ulnar side down
C. Central Ray
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➤ Perpendicular to the radial styloid process
E. Exam rationale
➤ Demonstrate anterior and posterior displacement of the bony
structures
Demonstrate widening of the wrist joint due to fracture or
dislocation
F. Structures Shown
➤ Proximal- metacarpals
➤ Carpals
Rule out
* Barton's Fracture
- Distal portion of radius
* Colle's Fracture
- Post. Displacement of distal fragment
* Smith's Fracture
- Ant. Displacement of distal fragment
Additional Routine
4. AP Oblique (Medial rotation)
A. Patient Position
➤Patient seated at the edge of the table.
➤ Rest the forearm in supinate
B. Part Position
152
➤ Rotate the wrist medially approx. 45° degrees to the IR.
C. Central Ray
➤ To the midcarpal area
E. Exam rationale
➤ Demonstrate triquetrum and hammate.
➤ Separate the pisiform from the adjacent carpal bones
F. Structures Shown
➤ Carpals on medial side of the wrist
➤ Triquetrum, hammate and pisiform
5. PA (Ulnar Flexion) Scaphoid (Ulnar Deviation)
A. Patient Position
B. Part Position
➤ Turn the hand outward until the wrist extreme ulnar flexion
C.Central Ray
➤ 10-15° degrees proximally or distally
153
E. Exam rationale
➤ To obtain an elongated view of the scaphoid, free from
superimposition
➤ To connect fore shortening of the scaphoid
➤ It opens the spaces between the adjacent carpals
F. Structures Shown
➤ Scaphoid with adjacent articulation open
➤ Portions of the proximal metacarpals
6. PA (Radial Flexion / Radial Deviation)
A. Patient Position
B. Part Position
➤ Invert or flex internally
C. Central Ray
➤ Perpendicular to the midcarpal area
E. Exam rationale
154
➤ To open joint spaces between The carpals on the medial side of
the wrist, including the capitate, hammate triquetrum and
pisiform.
F. Structures Shown
➤ Carpals and their articulations on the medial side of the
wrist
7. Scaphoid PA Axial (Stetcher method)
A. Patient Positioning
B. Part Position
➤ Evert hand (toward the ulnar side)
C. Central Ray
➤ 20° angle toward elbow/ forearm and centered to the scaphoid
G. Exam rationale
➤ To obtain an elongated view of the scaphoid free from
superimposition
H. Structures Shown
➤ Scaphoid
➤ Other carpals, portions of the proximal metacarpals and distal
radius and ulna
155
8. Tangential Projection (Gaynor Hart) - Carpal Canal / Tunnel
A. Patient Position
➤ Patient seated.
B. Part Position
➤ Hand Pronated and flat on the IR
➤ Hyperextend the wrist as much as possible
➤ Rotate the hand slightly toward the radial side
C. Central Ray
➤ 25-30° degrees towards the long axis of the hand
F. rationale
➤ To identify abnormality of the bones or soft tissue of the
canal.
➤ Demonstrate Fracture of the hook or hammate, pisiform and
156
trapezium
F. Structures Shown
➤ Carpal canal/ tunnel
➤ Palmar aspect of trapezeum
➤ Tubercle of trapezeum
➤ Scaphoid, capitate
Hook of the hammate
Triquetrum and entire pisiform
9. Carpal Bridge (Tangential)
A. Patient Position
➤ Patient seated/ standing
B. Part Position
➤ Hand flat with palm upward on the IR
C. Central Ray
➤ 45° proximal to the wrist joint 25-30° from the long axis of
the forearm (Bondrager)
E. Exam Rationale
➤ Demonstrate Fracture Of the scaphoid
➤ Lunate dislocation
➤ Calcifications and FB in the dorsum of the wrist
➤ Chip fracture Of the dorsal aspect of the carpal bones
F. Structures Shown
157
➤ Carpal canal/ tunnel
➤ Tuberosity of the scaphoid
➤ Dorsal aspect of the wrist
➤ Carpals
➤ Hammulus process of the hammate, triquetrum and pisiform
vilisanonde
10. Scaphoid (PA Axial) / Ulnar deviation - Rafert Long Method
A. Patient Position
➤ Patient seated
B. Part Position
➤ Turn the hand outward until the wrist is in extreme ulnar
deviation
C. Central Ray
➤ 0, 10, 20 and 30 degrees cephalad
E. Exam Rationale
➤ Demonstrate Fracture Of the scaphoid with minimal
superimposition
F. Structures Shown
➤ Scaphoid
➤ Extreme ulnar deviation
158
FOREARM
Procedures:
1. AP
2. Lateral
ROUTINE
1. AP Projection
A. Patient Position
➤Patient seated at the edge of the table with the hand and arm
fully extended
B. Part Position
159
➤ Hand supinated, entire upper limb from the shoulder to the
hand should lie in the same horizontal plane
C. Central Ray
➤ Perpendicular to the mid- forearm
E. Exam Rationale
➤ The most common indication for forearm examinations is trauma
➤ Demons. the elbow joint, the radius ulna and proximal row of
slightly distorted carpal bones
F. Structures Shown
Note:
➤ Entire radius and ulna including portions of the wrist and elbow joints
PA projection is never performed because the radius and ulna cross over
each other.
2. Lateral Projection (Lateromedial)
A. Patient Position
B. Part Position
➤ Flex the elbow 90° and place the hand, wrist, and elbow in a
true lateral position resting on the ulnar
surface
C. Central Ray
➤ Perpendicular to the mid- forearm
160
E. Exam Rationale
➤The lateral is the second of two basic position s of the
forearm
F. Structures Shown
➤Entire radius and ulna, elbow joint and the proximal row of
carpal bones
ELBOW
Procedures:
1. AP
2. Lateral
3. AP Oblique (Medial Rotation)
4. AP Oblique (Lateral Rotation)
5. AP Partial Flexion (Trauma)
6. AP Partial Flexion (Proximal Forearm)
7. AP (Acute Flexion) Jones method
8. Lateral (Lateromedial) Radial head
9. Axial lateromedial (Trauma)
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1. AP
A. Patient Position
B. Part Position
➤ Extend the elbow, supinate the hand to prevent rotation of the
bones of the forearm and place the epicondylar line parallel to
the image receptor
C. Central Ray
➤ Perpendicular to the elbow joint, midway between The
epicondyles
E. Exam Rationale
➤ The most common indication for elbow examination is trauma
F. Structures Shown
➤Elbow joint space, proximal radius/ ulna, distal humerus
2. Lateral (Lateromedial) Projection
A. Patient Position
B. Part Position
➤ Flex the elbow 90° and place the humerus and forearm flat on
the IR
162
1. The olecranon can be seen in profile
2. The elbow fat pads are the least compressed
➤ Hand, wrist and elbow in a true lateral position with the
epicondylar line perpendicular to the IR
➤ On patient with muscular forearms. Elevate the wrist to place
the forearm parallel with the IR
C. Central Ray
➤ Perpendicular to the elbow joint, centered to the
lateral epicondyle
E. Exam Rationale
➤ This is the routine position of the elbow that demonstrate the
elbow joint space, proximal radius/ulna.
F. Structures Shown
➤ Best visualization of the elecranon process
➤ Visualization of the posterior fat pad
Note:
➤ When injury to the soft tissue around the elbow is suspected. The joint
should be flexed only 30-35° degrees.
ADDITIONAL ROUTINE
3. AP Oblique Projection (Medial Rotation)
A. Patient Position
163
➤ Patient seated at the edge of the table with the arm fully
extended
B. Part Position
➤ Shoulder and elbow on the same plane
➤ Pronate hand into a natural palm down position and rotate arm
medially ( internally) to place its anterior surface at an angle
of 45° degrees
➤ This degree of obliquity usually clears the coronoid process
of the radial head.
C. Central Ray
➤ To the 1 inch below of midpoint of the epicondyles
➤ Normal phonation
E. Exam rationale
➤ To demonstrate The coronoid process of ulna free from
supereimposition
F. Structures Shown
➤ Demons. The oblique view of distal humerus and proximal radius
and ulna
4. AP Oblique (Lateral Rotation) Projection
A. Patient Position
➤ Patient seated at the edge of the table with the arm extended
B. Part Position
164
➤ Supinate hand and rotate laterally (externally) to place the
posterior surface of the elbow joint at 45° degree angle
C. Central Ray
➤ To the joint
➤ Normal phonation
E. Exam rationale
➤ To show the radial head and neck free
superimposition
F. Structures Shown
➤ Demonstrate The oblique view of distal humerus and proximal
radius and ulna
5. AP Projection (Partial Flexion) Trauma
A. Patient Position
B. Part Position
First AP:
➤ Place the elbow so that the forearm is parallel to the IR
Second AP:
➤ Place the elbow so that the humerus is parallel to the IR
C. Central Ray
➤ To the elbow joint, midway bet. the epicondyle
E. Exam rationale
165
➤ These positions are use when injuries to the elbow do not
allow the patient to fully extended the elbow joint for the
routine AP.
F. Structures Shown
➤ Demonstrate elbow joint space proximal radius/ ulna and distal
humerus.
6. Acute Flexion Projection (AP Projection) Jones Method
A. Patient Position
B. Part Position
➤ Rest the posterior surface of the humerus on the IR so that
the humerus is parallel to it:
➤ Flex the elbow as much as possible
➤ The epicondyle line should be parallel to the IR.
166
C. Central Ray
A. Distal Humerus
➤ To the humerus approximately 2 inches (5 cm) superior to
the olecranon process
B. Proximal Forearm
➤ To the forearm approximately 2 inches (5 cm) superior to
the olecranon process.
E. Exam rationale
➤ This portion is use primarily to demons. injuries to the
olecranon process
F. Structures Shown
➤ Olecranon process
➤ Superimposed outlines of bones of forearm and arm
7. Lateral Projection (Lateromedial)
4 Position Series
A. Patient Position
B. Part Position
➤ Flex the elbow at 90°
1. Supinate hand (palm up), externally rotate as far as can be
tolerated
2. Place hand in true lateral position (thumb up)
167
3. Pronate hand
4. Rotate hand internally (thumb down)
C. Central Ray
➤ To the elbow joint, lateral epicondyle
E. Exam rationale
➤ The radial head is projected in varying degrees of rotation
F. Structures Shown
➤ Radial head and neck
➤ Radial tuberosity
N.B.
➤ Radial head can be projected more clearly with reduce superimposition by
directing the central ray 45° towards the shoulder.
8. Axial Lateromedial Proj. (Trauma Axial Laterals) COYLE METHOD
A. Patient Position
➤ Patient is either supine or erect seated at the edge of
the table RADIAL HEAD
B. Part Position
➤ Flex the elbow 90°, hand in pronation
C. Central Ray
168
➤ 45° toward the shoulder CORONOID PROCESS > Flex the elbow 80°,
hand in pronation
➤ 45° away from the shoulder
E. Exam rationale
➤ To demonstrate the joint space bet. radial head and capitulum.
➤ To demonstrate distal portion of the coronoid that will appear
elongated
➤ To demonstrate the joint space bet. coronoid process and
trochlea.
F. Structures Shown
➤ Radial head and neck, tuberosity and articular margin of
capitulum
➤ Coronoid process and articular margin of trochlea.
HUMERUS
A. RECUMBENT
Procedures:
1. AP
2. Lateral
169
1. AP Projection
A. Patient Position
➤ Patient in supine with the posterior surface of the body
against the IR
B. Part Position
➤ Fully extend the elbow and place the epicondylar line parallel
to the IR
➤ Abduct arm slightly and gently supinate the hand
➤ Place the upper margin of the IR 1 inch or 2.5 cm above the
humeral head
C. Central Ray
➤ To the midshaft of the humerus
E. Exam rationale
➤ The most common indication for humerus examinations is trauma.
Bony tumors and cyst are occasionally visualized on long bones
such as the humerus
F. Structures Shown
➤ Frontal view of the entire humerus and portion of the elbow
and shoulder joints
2. Lateral (Lateromedial)
A. Patient Positions
➤ Patient in supine with the posterior surface of the body
against the IR
B. Part Position
➤ Rotate the forearm medially to place the epicondylar line
perpendicular to the plane of the IR
➤ Rest of the posterior surface of the hand against the patient
side
➤ The patient maybe turned slightly to side to reduce the object
image receptor distance
luining ylemex
C. Central Ray
170
E. Exam Rationale
➤ The lateral is one of the two routine positions of the humerus
➤ Lesser tubercle should be demonstrated in profile on the
medial aspect of the humerus
F. Structures Shown
➤ Lateral view of the entire humerus and a portion of the elbow
and shoulder joints.
B. UPRIGHT
Procedures:
1. AP Projection
2. Lateromedial
1. AP Projection
3. Transthoracic Lateral Position (Lawrence Method)
1.AP Projection
171
A. Patient Position
➤ Patient in a seated- upright or standing position with
posterior surface of the body against the IR
B. Part Position
➤ Abduct the arm slightly and supinate the hand so that
epicondyles of elbow are parallel to the film.
C. Central Ray
E. Exam Rationale
➤ Shoulder and arm abnormalities, whether traumatic or
pathologic in origin, are extremely painful either standing or
seated should be used whenever possible.
F. Structures Shown
➤ Entire length of the humerus
➤ Greater tubercle seen laterally
➤ Humeral head seen medially
2. Lateromedial
A. Patient Position
➤ Patient in a seated-upright or standing position.
B. Part Position
➤ Flex the elbow partially
➤ Rotate the hand internally
➤ Place the patient's anterior hand on the hip to place the
humerus in lateral position
C. Central Ray
D. Exam Rationale
➤ Demonstrate the entire length of the humerus
➤ The image confirmed by superimposed epicondyles
E. Structures Shown
➤ Elbow and shoulder joints
➤ Lesser tubercle
172
➤ Greater tubercle superimposed over the humeral head
3. Transthoracic Lateral Position (Lawrence Method)
A. Patient Position
➤ Patient in upright position with affected arm against IR
B. Part Position
➤ Affected arm is maintained in a neutral position
➤ Superior border of the IR should
be placed 1
inch (2.5 cm) above the affected shoulder
C. Central Ray
E. Exam Rationale
➤ The transthoracic lateral is an alternate position taken
primarily in cases of acute trauma to the upper arm or shoulder
or when the patient is otherwise unable to rotate the arm
F. Structures Shown
➤ Head and shaft of the humerus in a lateral
perspective
N.B
A 15° cephalad angle can be used to prevent superimposition of the shoulders
if the patient is unable to raise the unaffected arm high over the head
TOES
1. AP Projection (Dorsi-plantar)
2. PA Projection
4. PA Oblique Projection (Medial Rotation)
5. Lateral Projection (Mediolateral or lateromedial)
173
1. AP Projection (Dorsi-Plantar)
A. Patient Position
➤ Patient is seated or supine on the radio-graphic table.
B. Part Position
➤ Flex the knee until the foot flat on the image receptor.
➤ If there is no possibility of injury to the rest of the foot

or if it is a follow-up radiograph center on toe concerned.
C. Central Ray
➤ Perpendicular to the metatarsophalangeal joint in question.
➤ 15 degrees posteriorly or toward the calcaneus
E. Exam Rationale
➤ The most common indication for examination of the toe(s) is
trauma.
F. Structures Shown
➤ Phalanges
➤ Interphalangeal joints
➤ Distal ends of the metatarsals
174
2. PA Projection
A. Patient Position
B. Part Position
➤ Place the toes in the appropriate position, in the IR half
under the toes with the midline of the side used
parallel with the long axis of the foot.
C. Central Ray
➤ Perpendicular to the midpoint of the IR entering the
metatarsophalangeal joint concerned.
E. Exam Rationale
➤ Demonstrate the interphalangeal joint spaces.
F. Structures Shown
➤ Phalanges of the toes
➤ Distal portions of the metatarsals
175
A. Patient Position
➤ Patient is in supine or seated on the radiographic table.
B. Part Position
➤ Flex the knee with plantar surface of the foot resting O the
IR
➤ Rotate the lower leg and foot until the planter surface of the
foot form 30 to 45 degree angle from the plane of the film
C. Central Ray
➤ Perpendicular to the metatarsophalangeal joint
concerned.
E. Exam Rationale
➤ The oblique is a routine position of the toes that gives a
different perpective than that of the AP.
F. Structures Shown
➤ Phalanges of the toes
➤ Distal ends of the metatarsals
4. PA Oblique Projection (Medial Rotation)
A. Patient Position
➤ Patient in a lateral recumbent position on the affected
side.
B. Part Position
➤ Turn the patient toward the prone position until the ball of
the foot forms an angle of 30 degrees to the horizontal.
C. Central Ray
176
➤ Perpendicular to the third metatarso-phalangeal joints.
E. Exam Rationale
➤ This projection shows the toes and the distal portion
metatarsals rotated laterally without
of the superimposition
F. Structures Shown
➤ Phalanges
➤ Distal metatarsals and associated joints
5. Lateral Projections (Mediolateral or Lateromedial)
A. Patient Position
➤ Patient in lateral recumbent position on the
unaffected side
B. Part Position
➤ Rotate the affected leg and foot medially for lateromedial)
and laterally for (mediolateral)
C. Central Ray
➤ Perpendicular to the plane of the film, entering the
interphalangeal joint.
D. Exam Rationale
➤ Show a lateral projection of the phalanges of the toe and the
interphalangeal articulations projected free of
superimposition.
E. Structures Shown
177
➤ Phalanges
➤ Interphalangeal joint spaces
SESAMOIDS
Procedures:
1. Tangential Projection (Lewis and Holly Methods)
2. Tangential Projection (Causton Method)
1. Tangential Projection (Lewis and Holly Methods) sits
A. Patient Position
➤ Patient in prone position
B. Part Position
➤ Elevate the ankle of the affected side on sandbags for
stability.
Dorsiflex the foot until the ball of the foot is perpendicular to
the image receptor.
➤ Ensure that the long axis of the foot is not rotated.
C. Central Ray
➤ Perpendicular, posterior to the first metatarsophalangeal
joint.
➤ Normal Respiration
E. Exam Rationale
➤ Shows a tangential projection of the head of the metatarsal
and sesamoids.
F. Structures Shown
➤ Metatarsal heads
➤ Sesamoids free of superimposition
178
2. Tangential Projection (Causton Method)
A. Patient Position
➤ Patient in a lateral recumbent position on the unaffected
side.
B. Part Position
➤ Partially extend the limb being examined
➤ Place the image receptor under the distal metatarsal ubo
region.
C. Central Ray
➤ 45° toward the heel, directed to the prominence of the first
metatarsophalangeal joint.
E. Exam Rationale
➤ Shows the sesamoid bones projected axiolaterally with a slight
overlap.
F. Structures Shown
➤ Metatarsophalangeal joints
➤ Sesamoids with little overlap
179
FOOT
Procedures:
1. AP Projection (Dorsoplantar)
3. Lateral Projection (Medilateral)
4. Lateral Projection (Weight-Bearing Method)
5. AP Axial Projection (Weight-Bearing Method)
6. AP Axial Projection (Weight-Bearing Composite Method)
*The foot varies in thickness, therefore in Radiographs of the whole foot the
toes are usually over exposed. On the dorsoplantar projection the bones
overlap and obscure the joint spaces between the
Tarsal bones, or the bases of the metatarsals.
1. AP Projection (Dorsoplantar)
A. Patient Position
➤ Patient is either seated or supine position on the
radiographic table, with the knee flexed.
B. Part Position
➤ Place the plantar surface of the foot flat on the image
receptor.
➤ Ensure that no rotation of the foot occurs.
C. Central Ray
➤ Perpendicular to the base of the third metatarsals. > 10 to
25° towards the ankle, directed to the navicular.
E. Exam Rationale
180
➤ This projection provides a general survey of the bones of the
foot, including demonstrating of the phalanges, metatarsals, and
the tarsals.
Show the tarso-metatarsal articulations. Localizing foreign
bodies.
➤ Determining the location of fragments in fractures of the

metatarsals and anterior tarsals.
F. Structures Shown
➤ Metatarsophalangeal joints
➤ Phalanges
➤ Tarsals distal to the talus
A. Patient Position
➤ Patient is seated on the radiographic table with the knee
flexed.
B. Part Position
➤ Rotate the patient's leg medially until the plantar surface of
the foot forms an angle of 30 degrees. A greater rotation can be
helpful in demonstrating the joint spaces of the foot.
C. Central Ray
➤ Perpendicular to the base of the third metatarsals
E. Exam Rationale
➤ This projection shows the interspaces between the cuboid and
the calcaneus, cuboid and the fourth and fifth metatarsals,
181
cuboid and the lateral cunieform; talus and navicular bone.
F. Structures Shown
➤ Phalanges
➤ Metatarsals
➤ Sinus tarsi
➤ Lateral tarsometatarsal and intertarsal joints.
3. Lateral Projection (Mediolateral)
A. Patient Position
➤ Patient is in lateral recumbent on the affected side with the
unaffected leg behind the affected leg.
B. Part Position
➤ Dorsiflex the foot to form a 90 degree angle with the Its
lower leg.
➤ Lateral surface of the foot rest on the image receptor until
the plantar surface of the foot is perpendicular to the film.
C. Central Ray
➤ Perpendicular to the base of the third metatarsals." (Medial
Cunieform)
E. Exam Rationale
➤ The lateral taken at 90 degrees from the AP is used to
demonstrate the anterior/posterior displacements of bony
structure and to localize foreign bodies.
F. Structures Shown
➤ Entire foot
➤ Tibiotalar joint space
➤ Ankle joint
➤ Distal ends of the tibia and fibula
182
ADDITIONAL ROUTINE
4. Lateral Projection (Weight-Bearing Method)
A. Patient Position
➤ Patient in upright position, weight is evenly
distributed on both feet.
B. Part Position
➤ The feet should be flat in a natural position with the weight
equally distributed on the feet.
➤ Lower edge of the film is 2.5cm below the soles of the foot.
C. Central Ray
➤ Horizontally, to the level of the base of third metatarsal
E. Exam Rationale
➤ This projection shows the structural status of the
longitudinal arch of the foot and demonstrate pes planus.
➤ Right and left sides are examined for comparison.
F. Structures Shown
183
➤ Entire foot
➤ Distal tibia and fibula
➤ The superimposed tarsals and metatarsals.
5. AP Axial Projection (Weight-Bearing Method)
A. Patient Position
➤ Patient in standing-upright position.
B. Part Position
➤ Ensure that the right and left markers and upright marker are
placed on the image receptor.
➤ Ensure that full weight evenly distributed on both feet.
C. Central Ray
➤ 10 to 15° posteriorly, midpoint between feet at the level of
the base of the third metatarsal.
E. Exam Rationale
➤ This projection is used to demonstrate a weight- bearing,
axial projection of all the bones of the foot, projected free
from the distal lower leg.
184
➤ Permitting an accurate evaluation and comparison of the
tarsals and metatarsals.
➤ To demonstrate the hallux valgus.
F. Structures Shown
➤ Phalanges, Metatarsals and Tarsals
6. AP Axial Projection (Weight-Bearing Composite Method)
A. Patient Position
➤ Patient is in standing-upright position
B. Part Position
➤ Place the plantar surface of the foot flat
➤ To prevent superimposition of the leg shadow on that of the

ankle joint, place the opposite foot one step backward for the
exposure of the forefoot, and one step forward for the exposure
of the hindfoot or
calcaneus.
C. Central Ray
Exposure 1:
• 15° posterior angulation to the base of the third metatarsals.
Exposure 2:
• 25° anterior angulation to the posterior ankle at the level of
the lateral mallelus.
E. Exam Rationale
➤ Shows all bones of the foot and the full outline of the foot
is projected free of the leg.
F. Structures
➤ Tarsals, Metatarsals and Toes
185
CONGENITAL CLUBFOOT
Procedures
1. Kite Methods
A. AP Projection
B. Lateral Projection
2. Kandel Method
A. Axial Projection (Dorsoplantar)
Congenital Clubfoot
* The typical clubfoot is called "TALIPES EQUINOVARUS" which shows three
deviation from the normal alignment of the foot in relation to the weight-
bearing axis of the leg.
1. EQUINUS plantar flexion and inversion of the calcaneus.
2. ADDUCTION medial displacement of the forefoot.
3. SUPINATION elevation of the medial border of the foot.
186
1. AP Projection
A. Patient Position
➤ Infant patient in supine position.
B. Part Position
➤ Flex the knee and the hip until the plantar surface of the foot rest
flat on the image receptor.
C. Central Ray
➤ 15° posterior angle, directed to the tarsals.
➤ Perpendicular, to the tarsals for bilateral projection. To project
the true relationship of the bones and ossification centers.
E. Exam Rationale
➤ To demonstrates the degree of adduction of the forefoot and the
degree of inversion of the calcaneus.
F. Structures Shown
➤ Talus
➤ Calcaneus
➤ Tibia and Fibula
A. Patient Position
187
➤ Place the infant patient on his/her side as possible.
B. Part Position
➤ Flex the uppermost limb, draw it forward and hold it
in place.
➤ Hold the infant's toes in position with tape
C. Central Ray
➤ Perpendicular, to the midtarsal area.
E. Exam Rationale
➤ to demonstrates the anterior talar subluxation and the degree
of plantar flexion.
F. Structures Shown
➤ Talus, Calcaneus and Metatarsals
➤ Distal tibia and Fibula
2. Kandel Method
A. Axial Projection (Dorsoplantar)
A. Patient Position
➤ The infant patient is held in a vertical or a bending forward
position.
B. Part Position
188
➤ The plantar surface of the foot should rest on the image
receptor.
C. Central Ray
➤ 40° anteriorly through the lower leg.
E. Exam Rationale
➤ The inclusion of a dorsoplantar axial projection in the
examination of the patient with a clubfoot.
F. Structures Shown
➤ Calcaneus
➤ Sustentaculum talar joint
CALCANEUS
Procedures;
1. Axial Projection (Plantodorsal)
2. Axial Projection (Dorsoplantar)
3. Axial Projection (Weight-Bearing) (Coalition Method)
ROUTINE
189
1. Axial Projection (Plantodorsal)
A. Patient Position
➤ Patient is seated or supine position with the knee extended.
B. Part Position
➤ Dorsiflex the foot until the plantar surface is perpendicular
to the image receptor.
➤ Loop gauze around the ball of the foot and ask the patient to
pull gently but firmly.
C. Central Ray
➤ 40° cephalad from the long axis of the foot, directed to the
base of the third metatarsal.
E. Examination Rationale
➤ The most common indication for an examination of the heel is
trauma and to shows an axial projection of the calcaneus.
F. Structures Shown
➤ Calcaneus and talocalcaneal joints
➤ Anterior portion of the calcaneus
2. Axial Projection (Dorsoplantar)
A. Patient Position
190
B. Part Position
➤ Dorsiflex the ankle to place the long axis of the foot
perpendicular to table top.
➤ Image receptor should be place against the plantar surface of
the foot.
C. Central Ray
➤ 40° caudally, to the long axis of the foot, enters the dorsal
aspect of the ankle joint
E. Exam Rationale
➤ Shows an axial view of the calcaneus, with the sustentaculum
tali and tuberosity.
F. Structures Shown
➤ Calcaneus and subtalar joint
➤ Sustentaculum tali
3. Axial Projection (Weight-Bearing) (Coalition Method)
A. Patient Position
➤ Patient is in standing-upright position
B. Part Position
➤ The long axis of the calcaneus, with the posterior surface of
the heel is against the image receptor. ➤ Place the opposite
foot one step forward to prevent superimposition of the leg
shadow.
C. Central Ray
➤ 45° anteriorly, directed to the posterior surface of the ankle
at the level of the base of the fifth metatarsal.
E. Exam Rationale
➤ To demonstrate the calcaneotalar coalition
F. Structures Shown
➤ Calcaneus and subtalar joint Sustentaculum tali
191
A. Patient Position
➤ Patient is either supine or in lateral recumbent, turn Hop the
patient toward the affected side until the leg is approximately
lateral.
B. Part Position
➤ Dorsiflex the foot so that the plantar surface is at right
angle to the leg.
➤ Lateral surface of the foot rest on the IR
C. Central Ray
➤ Perpendicular to the 1 to 1 1⁄2 inches distal to the medial
malleolus.
E. Exam Rationale
➤ Shows the heel in profile and is used to demonstrate the
anterior/posterior displacements of bony pieces.
F. Structures Shown
➤ Calcaneus
➤ Sinus tarsi
➤ Ankle joint and adjacent tarsals
to SUBTALAR JOINTS (TALO CAL CANEAL)
SUBTALAR JOINTS
Procedures:
1. Broden Method
192
A. AP Axial Oblique Projection (Medial Rotation) B. AP Axial Oblique
Projection (Lateral Rotation)
2. Isherwood Method
A. Lateromedial Oblique Projection (Medial Rotation Foot)

B. AP Axial Oblique Projection (Medial Rotation Ankle)
C. AP Axial Oblique Projection (Lateral Rotation Ankle)
1. Broden Method
A. AP Axial Oblique Projection (Medial Rotation)
A. Patient Position
➤ Patient in supine position
B. Part Position
➤ Dorsiflex the foot to obtain a right angleflexion at the ankle
joint.
➤ Rotate the leg and foot medially to form an angle of
45°.
C. Central Ray
➤ 40° caudally, directed 2 or 3 cm. caudoanteriorly to the
lateral malleolus.
o to demonstrate the anterior and posterior talocalcaneal
articulation.
➤ 30 and 20 degrees caudally.
O to demonstrate articulation between the talus and the
sustentaculum tali.
➤ 10° caudally.
O to demonstrate the posterior part of the of the posterior
talo-calcaneal articuation.
193
E. Exam Rationale
➤ To demonstrate the articular facet of the calcaneus and to
determine the presence of joint involvement in cases of
comminuted fracture.
Shows the articulation between the talus and sustentaculum tali
(middle facet)
F. Structures Shown
➤ Anterior and Posterior portions of the posterior subtalar
joint.
2. AP Axial Oblique Projection (Lateral Rotation)
A. Patient Position
B. Part Position
➤ Rotate the leg and foot 45° laterally
C. Central Ray
➤ 15° cephalad (12-18°), directed 2 cm below and in front of the
medial malleolus.
E. Exam Rationale
➤ Shows the posterior facet of the calcaneus and the
articulation between the talus and sustentaculum tali.
F. Structures Shown
➤ Posterior portion of the subtalar joint.
3. Isherwood Method
194
A. Latero Medial Oblique Projection (Medial Rotation Foot)
A. Patient Position
➤ Patient in a semiprone or seated position
➤ Flex the knee to place the ankle joint in nearly right angle
flexion.
B. Part Position
➤ Medial border of the foot resting on the image receptor.
C. Central Ray
➤ Perpendicular, to a point 1 inch distal and anterior to the
lateral malleolus.
E. Exam Rationale
➤ Shows the anterior subtalar articular surface and an oblique
projection of the tarsals.
F. Structures Shown
➤ Anterior talar articular surface
195
B. AP Axial Oblique Projection (Medial Rotation Ankle)
A Patient Position
➤ Patient in seated position
B. Part Position
➤ Rotate the leg and foot medially by 30"
➤ Dorsiflex the foot, then invert it if possible.
C. Central Ray
➤ 10" cephalad, directed to a point 1 inch distal and
anterior to the lateral malleolus.
E. Exam Rationale
➤ Shows the middle articulation of the subtalar joint and "end-
on" projection of the sinus tarsi.
F. Structures Shown
➤ Middle subtalar articulation
➤ Sinus tarsi
C. AP Axial Oblique Projection (Lateral Rotation Ankle)
196
A. Patient Position
➤ Patient is either supine or seated position
B. Part Position
➤ Rotate the leg and foot 30° laterally
➤ Dorsiflex the foot and evert it if possible.
C. Central Ray
➤ 10° cephalad, directed to a point 1 inch distal to the medial
malleolus.
E. Exam Rationale
➤ Shows the posterior articulation of the subtalar joint
F. Structures Shown
➤ Posterior subtalar articulation
LEG
Procedures:
1. AP Projection
1. AP Projection
A. Patient Position
➤ Patient is seated or supine position with the knee extended.
B. Part Position
➤ Center the leg to the image receptor.
➤ Adjust the leg so that the femoral condyles are parallel with
the IR.
➤ Dorsiflex the foot so it is perpendicular to the image
197
receptor.
C. Central Ray
➤ Perpendicular to the midshaft of the leg
E. Exam Rationale
➤ Trauma is the most common indication of the lower leg.
➤ Tibia and fibula should be slightly overlapped at both the
proximal and distal ends.
F. Structures Shown
➤ Tibia, fibula, knee and ankle joints.
A. Patient Position
➤ Patient in lateral recumbent on the affected side
down.
B. Part Position
➤ Flex the leg about 45° and ensure that the leg is in true
lateral position.
➤ Adjust the rotation of the leg so that the patella is
perpendicular to the image receptor.
198
➤ For most adults the leg must be placed diagonally.
C. Central Ray
➤ Perpendicular to the midshaft of the leg
E. Exam Rationale
➤ The lateral taken at 90° from the AP is used to demonstrate
anterior and posterior displacements of bony structures.
F. Structures Shown
➤ Tibia, fibula, knee and ankle joints.
NB
The oblique is an alternative position of the leg that is Occasionally
requested to demonstrate the tibiofibular articulations.
Procedures:
ANKLE
1. AP Projection
4. AP Oblique Projection (Mortise Joint)
5. AP Stressed / Forced Version
1. AP Projection
A. Patient Position
➤ Patient in the supine position with the affected lower
limb fully extended
B. Part Position
➤ Ankle joint anatomic position to obtain a true AP projection
199
➤ Flex the ankle and foot enough to place the long axis of the
foot in the vertical position. Do not force Dorsiflexion of the
foot but allow it to remain in the natural position.
C. Central Ray
➤ Perpendicular to the ankle joint, midway between the malleoli.
➤ No rotation, normal respiration
E. Exam Rationale
➤ Demonstrate the distal ends of the tibia and fibula, proximal
portion of the talus, the lateral and medial malleoli and the
proximal half of the metatarsals..
bells en down
F. Structures Shown
➤ Tibiotalar joint spaces
➤ Medial and lateral malleoli
➤ Proximal half of metatarsals
➤ Soft tissue.
A. Patient Position
➤ Patient in the supine position, turn toward the affected side
until ankle.
B. Part Position
➤ Place the long axis of the leg parallel with the long axis of
the Image Receptor
➤ Lateral surface of the foot in in the contact with the IR.
➤ Dorsiflex the foot so that the plantar surface is at right
angle leg.
➤ Dorsiflexion is required to prevent lateral rotation of the
ankle
200
C. Central Ray
➤ Perpendicular to the ankle joint, directed to the
medial malleolus.
D. Exam Rationale
➤ This projection is useful in the evaluation of fractures,
dislocations and joint effusions associated with other joint
pathologies.
E. Structures Shown
➤ Ankle joint
➤ Tibiotalar joint
➤ Distal one third of tibia and fibula
➤ Tuberosity of the fifth metatarsals, navicular and cuboid.
A. Patient Position
➤ Patient in the supine position with the affected limb normally
extended.
B. Part Position
➤ Dorsiflex the foot enough to place the ankle at nearly right-
angle flexion.
➤ Rotate the leg and foot medially by 45 degrees.
C. Central Ray
➤ Perpendicular to the image receptor and directed to midway
between the malleoli.
D. Exam Rationale
➤ This projection will demonstrate the distal tibiofibular joint
open, with no or only minimal overlap on the average person. The
201
lateral malleolus and talus joint should show no or slight
superimposition but medial malleolus and talus will be partially
superimposed.
E. Structures Shown
➤ Distal one third of the lower leg
➤ Tibiofibular articulation
➤ Distal tibia, fibular and talus
Proximal half of the metatarsals
ADDITIONAL ROUTINE
4. AP Oblique Projection (Mortise Joint)
A. Patient Position
➤ Patient in the supine position.
B. Part Position
➤ Do not Dorsiflex the foot. The plantar surface of the foot
should be placed at a right angle to the leg.
➤ Rotate the entire leg and foot 15-20 degrees internally, until
the intermalleolar line is parallel to the IR.
C. Central Ray
➤ Perpendicular entering the ankle joint midway between the
malleoli.
D. Exam Rationale
➤ Proper obliquity of the mortise joint will open the lateral
and medial mortise joints and only minimal superimposition should
exist at the distal tibiofibular
joint.
E. Structures Shown
202
➤ Entire ankle mortise joint
Talofibular joint
➤ Distal one third of the tibia and fibula
➤ Proximal fifth metatarsals
5. AP Stressed / Forced Inversion
A. Patient Position
➤ Patient in the supine position with the affecte lower limb is
fully extended.
B. Part Position
➤ Dorsiflex the fooas near as right angle to the leg as
possible.
➤ The entire plantar surface is turned medially for inversion
and laterally for eversion.
C. Central Ray
➤ Perpendicular to the IR and directed to a point miway
between the malleoli.
D. Exam Rationale
➤ Stress studies of the ankle joint usually obtained after an
inversion or eversion injury to verify the presence of a
ligamentous tear.
➤ Rupture of a ligament is demonstrated by widening of the joint
space on the side leg from the supine position. The foot is
forcibly turned toward the opposite side.
E. Structures Shown
➤ Anke joint
203
➤ Ligament tear or rupture
KNEE
Procedures:
1. AP Projection
3. AP Internal Oblique
4. AP Projection (Weight Bearing Method)
5. AP Oblique Lateral Rotation
6. PA Axial Projection (Homblad Method)
7. PA Axial Projection (Camp-Coventry Method)
8. AP Axial Projection (Beclere Method)
1. AP Projection
A. Patient Position
➤ Patient is seated or supine position on the radiographic table
with the knee extended
B. Part Position
➤ Rotate the leg internally 3 to 5° until the interepicondylar
line is parallel to the film.
➤ Center the knee joint 1⁄2 inch distal to the patellar apex.
C. Central Ray
204
➤ 5 cephalad, to a point 1⁄2 inch below apex of the patella.
E. Exam Rationale
➤ Radiographic examination of the knee is commonly indicated in
cases of trauma or degenerative joint disease.
F. Structures Shown
➤ Distal femur, proximal tibia and fibula, patella and knee
joint.
A. Patient Position
➤ Patient is in lateral recumbent on the affected with the
unaffected leg may be placed in front of the affected knee.
B. Part Position
➤ Flex the knee 20 to 30° because this position relaxes the
muscle and shows the maximum volume of the joint cavity.
➤ Knee should not be flexed more than 10° to prevent fragment
separation in new or unhealed patellar fractures.
C. Central Ray
➤ 5 to 7° cephalad, directed 1 inch distal to the medial
epicondyle. This angulation prevent the joint space from being
obscured by the magnified image of the medial femoral condyle.
205
E. Exam Rationale
➤ This radiograph shows a lateral image of the distal end of the
femur, patella, knee joint, proximal ends of the tibia and
fibula, and adjacent soft tissue.
F. Structures Shown
➤ Distal femur, proximal tibia, fibula, patella and tibiofemoral
joint and patellofemoral joints.
ADDITIONAL ROUTINE
3. AP Oblique Internal Rotation
A. Patient Position
➤ Patient is seated or supine position on the table with the
knee extended.
B. Part Position
➤ Rotate the affected leg 45° internally; this may require
elevation of the hip on the on the affected
side.
C. Central Ray
206
➤ 5° cephalad, directed to 1⁄2 inch inferior to the patellar
snapex.
E. Exam Rationale
➤The oblique is an alternative position of the knee that is used
to provide a different perspective from that of AP and lateral.
F. Structures Shown
➤ Lateral femoral and tibial condyles
➤ Lateral tibial plateaubelerigeo
Head of the fibula and
➤ The proximal tibiofibular articulation.
4. AP Projection (Weight-Bearing Method)
A. Patient Position
➤ Patient is in erect or sanding position
B. Part Position
➤ Toes pointing forward and the feet separated visufficiently to
achieve a good balance with weight evenly distributed on both
feet.
C. Central Ray
➤ Horizontally, directed 1⁄2 inch below the apex of the patella
D. Patients Instructions
207
E. Exam Rationale
➤ Weight bearing examination of the knee is commonly indicated
in cases of degenerative joint disease, spaces of the knees,
varus and valgus deformities.
➤ Reveals the narrowing of a joint space that appears normal on
the non weight bearing study.
F. Structures Shown
➤ Knee joint
➤ Proximal tibia and fibula
➤ Distal femur
5. AP Oblique External Rotation
A. Patient Position
➤ Patient is seated or supine position on the 3 radiographic
table with the knee extended
B. Part Position
➤ Rotate the affected leg 45° externally
Elevate the hip of the unaffected side to rotate the affected
limb.
C. Central Ray
208
➤ 5° cephalad, directed to 1⁄2 inch below the apex of the
patella.
E. Exam Rationale
➤ The oblique is an alternative position of the knee that is
used to provide a different perspective from that of
the AP and Lateral.
➤ It is used to demonstrate the medial femoral and tibial
condyles and lateral tibial plateau.
Woled
F. Structures Shown
➤ Distal femur
➤ Knee joint
6. PA Axial Projection (Homblad Method)
A. Patient Position
➤ Patient is in kneeling position on the radiographic table,
with the affected knee over the image receptor.
B. Part Position
➤ Flex the knee 70° and ask the patient to lean forward.
209
C. Central Ray
➤ Perpendicular, directed to the mid popletial crease.
E. Exam Rationale
➤ The degree of flexion in this position widens the joint space
between the femur and tibia and gives an improved image of the
joint and surfaces of the tibia and femur.
➤ It shows the intercondylar fossa of the femur and the medial
and lateral intercondylar tubercles of the intercondylar
eminence.
F. Structures Shown
➤ Intercondylar fossa
➤ Femoral and tibial condyles
Intercondylar eminence and
➤ Articular facets of tibia
7. PA Axial Projection (Camp-Coventry Method)
A. Patient Position
B. Part Position
➤ Flex the patient's knee 40 to 50°.
➤ Adjust the leg so that the knee has no medial or lateral
rotation.
210
C. Central Ray
➤ Perpendicular, directed to the mid popletial depression.
➤ 40° caudad when the knee is flexed 40° and 50° caudad when the
knee is flexed 50°.
E. Exam Rationale
➤ This axial image demonstrates an unobscured projection of the
intercodylar fossa and the medial and lateral intercondylar
intercondylar eminence.
F. Structures Shown
➤ Intercondyar fossa
➤ Intercondylar eminence and
➤ Articular facets of tibia
8. AP Axial Projection (Beclere Method)
A. Patient Position
211
B. Part Position
➤ Flex the knee 60° to the long axis of the tibia.
➤ If curved cassette is available, place under knee.
C. Central Ray
➤ Perpendicular to the long axis of the tibia, directed 1⁄2 inch
below the patellar apex.
D. Patients Instructions
E. Exam Rationale
➤ This is a reverse of the PA axial projection for those who cannot assume the
prone position.
F. Structures Shown
➤ Intercondylar fossa
➤ Intercondylar eminence and Articular facets of tibia
PATELLA
Procedures:
1. PA Projection
3. PA Axial Oblique Projection (Kuchendorf Method)
4. Tangential Projection (Hughston Method)
5. Tangential Projection (Merchant Method)
6. Tangential Projection (Settegast Method)
7. Tangential Projection (Sunrise / Skyline Method)
212
1. PA Projection
A. Patient Position
➤ Patient is in prone position with the leg extended. If the knee is
painful place a sandbag under the thigh and another under the leg. To
relieve the pressure on the patella.
B. Part Position
➤ Rotate the heel 5 to 10° laterally until the interepicondylar
line is parallel to the plane of the
film.
C. Central Ray
➤ Perpendicular to the mid popletial area.
E. Exam Rationale
➤ This examination is indicated in cases of trauma, and provides
a better detail than the routine AP projection of the knee.
F. Structures Show
➤ Distal femur
➤ Knee joint and Patella
A. Patient Position
➤ Patient in lateral recumbent position
B. Part Position
➤ Flex the unaffected knee and hip and place the unaffected foot
in front of the affected limb for stability.
213
➤ Flex the affected knee 5 to 10° until the interepicondylar
plane is perpendicular to the image receptor.
C. Central Ray
➤ Perpendicular, directed to the femoropatellar joint space.
E. Exam Rationale
➤ Shows a lateral projection of the patella and
patellofemoral joint space.
F. Structures Shown
➤ Distal femur
➤ Knee joint and Patella
ADDITIONAL ROUTINE
3. PA Axial Oblique Projection (Kuchendorf Method)
214
A. Patient Position
B. Part Position
➤ Elevate the hip of the affected side 2 or 3 inches.
➤ Rotate the knee laterally from PA 35 to 40° so that no
pressure is placed on the injured patella.
➤ Flex the knee slightly approximately 10 degrees to relax the
muscle.
C. Central Ray
➤ 25 to 30° caudally, directed to the joint space between the
patella and femoral condyles.
E. Exam Rationale
➤ To project more of the patella free of superimposition
of the femur.
F. Structures Shown
➤ Patella and its outline
4. Tangential Projection (Hughston Method)
A. Patient Position
215
➤ Patient is in prone position on the radiographic table with
the knee extended
B. Part Position
➤ Flex the knee 50 to 60°, rest the foot against the Bilo
collimator.
Ensure that the collimator surface is not hot.
➤ Place pad between foot and possible hot collimator
➤ Adjust the leg so that there is no medial or lateral deviation
of the leg from the vertical plane.
C. Central Ray
➤ 45° cephalad, directed to the patellofemoral joint.
E. Exam Rationale
➤ Tangential positions of the patella are used to demonstrate
patellar fracture or subluxation and allows radiologic assessment
of the femoral condyles, both knees shall be taken for
comparison.
F. Structures Shown
➤ Patella
➤ Patellofemoral articulations
Surfaces of the femoral condyles.
216
A. Patient Position
➤ Patient is in supine position in the radiographic table with
the knees flexed and the lower legs hanging off the end of the
radiographic table, a special image receptor-holding device is
required.
B. Part Position
➤ Place the femora parallel to the table top by elevating the
knees approximately 2 inches and flex the knees 40 to 45°
➤ Secure legs together below the knees to prevent rotation and
to allow patient to be totally relaxed.
C. Central Ray
➤ Perpendicular to the image receptor
➤ 30° caudally to the horizontal if the degree of knee flexion
is 40 degrees, directed between the patella at the level of the
patellofemoral joint.
E. Exam Rationale
patellar fracture or subluxation, and this method demonstrates
the patella and the patellofemoral joints.
F. Structures Shown
➤ Patella
Femoral condyles and intercondylar sulcus Patellofemoral
interspaces
217
6. Tangential Projection
A. Patient Position
➤ Patient is in prone position.
B. Part Position
➤ Slowly flex the knee until the patella is perpendicular to the
image receptor approximately 90 degrees.
➤ Gently adjust the leg so that its long axis is vertical.
C. Central Ray
➤ 15 to 20° cephalad, directed to the space between the patella
and the femoral condyles.
E. Exam Rationale
patellar fracture or subluxation, because of the danger of
separation of fractured segments of the patella, this position
should not be attempted until a lateral projection has been done
to rule out a sand to compeb transverse fracture. This position
is used to
demonstrate vertical fractures and to evaluate the articulating
surfaces of the patellofemoral articulation.
F. Structures Shown
➤Patella
➤ Patellofemoral articulation
➤ Femoral condyles
218
7. Tangential Projection (Sunrise / Skyline Method)
A. Patient Position
➤ Patient is either seated or supine position.
B. Part Position
➤ Flex the knees 40 to 45°
➤ The quadriceps femoris muscles must be relaxed to prevent
subluxation of the patella, wherein they are pulled into the
intercondylar sulcus or groove, which may result in false
readings.
C. Central Ray
➤ 30° from the horizontal, directed to the patellofemoral joint
spaces.
E. Exam Rationale
➤ This projection demonstrates fractures and subluxation of the
patella.
F. Structures Shown
➤ Axial view of the patella
Intercondylar sulcus Patellofemoral articulation
FEMUR
Procedures:
1. AP Projection
3. Translateral Projection
219
1. AP Projection
A. Patient Position
➤ Patient is in supine position with the knee extended.
B. Part Position
➤ Center the thigh to the midline of the table and position it
to include both joints when possible, the joint nearest the site
of injury or suspected pathology should be included.
➤ When the distal femur is included rotate the limb internally
to place it in true anatomic position.
➤ When the proximal femur is included, rotate the limb
internally 10 to 15 degrees to place the femoral neck in profile.
C. Central Ray
➤ Perpendicular, directed to the midshaft of the femur.
E. Exam Rationale
➤ The AP projection of the femur demonstrates the entire length
of the femur including knee and hip joint.
F. Structures Shown
➤ Mid and Distal femur, including knee joint.
220
A. Patient Position
➤ Patient is in lateral recumbent position on the affected side.
➤ If the proximal femur is the area of interest the
unaffected leg is placed behind the affected leg;
➤ If the distal femur is the area of interest, the unaffected
leg is flexed and in front of the affected leg.
B. Part Position
➤ Flex the affected knee 45°, and adjust the body rotation to
place the epicondyles perpendicular to the table top.
C. Central Ray
➤ Perpendicular, directed to the midshaft of the thigh.
E. Exam Rationale
➤ This position shows a lateral projection of about three
fourths of the femur and the adjacent joint.
F. Structures Shown
➤ Entire length of the femur
➤ Knee and hip joint.
3. Translateral Position
A. Patient Position
221
B. Part Position
➤ The knee of the affected leg should be extended. Elevate the
unaffected leg and place a high support under the foot and ankle
➤ Place the cassette on edge against the lateral thigh.
C. Central Ray
➤ Horizontally, directed from the medial side of the midshaft of
the femur.
E. Exam Rationale
➤ This translateral position of the femur is indicated when the
patient's condition contraindicates turning the patient for a
routine lateral.
➤ This position is recommended for patients with fracture or
patients who have destructive disease.
F. Structures Shown
➤ Entire length of the femur
➤ Knee joint
PELVIS
Procedures:
1. AP Projection
2. PA Projection
3. AP Axial Projection "Outlet" (Taylor Method)
4. Superoinferior Axial "Inlet" Projection (Lilienfeld Method)
5. PA Axal "Inlet" Projection (Staunig Method)
1. AP Projection
A. Patient Position
B. Part Position
222
➤ Rotate the feet and the lower limbs about 15 degrees to place
the femoral necks parallel with the plane of the image receptor.
➤ The heels should be placed about 8 to 10 inches
apart.
C. Central Ray
➤ Perpendicular between the ASIS and the pubic symphysis. 2
inches inferior to the ASIS and 2 inches superior to the pubic
symphysis.
E. Exam Rationale
➤ This projection provides a general survey of the bones of the
pelvis and the head, neck, and greater trochanter of each of the
femora.
➤ Proximal 1/3 of the shaft of the femora.
F. Structures Shown
➤ Entire pelvis
➤ Greater trochanters
➤ Femoral necks and Ischial spines
2. PA Projection
A. Patient Position
B. Part Position
➤ Center the IR at the level of the greater trochanters.
C. Central Ray
223
➤ Perpendicular enters the distal coccyx and exits the pubic
symphysis.
E. Exam Rationale
➤ This projection shows the pubic symphysis and ischia,
including the obturator foramina.
F. Structures Shown
➤ Pubic and Ischial bones
➤ Hip joints
➤ Obturator foramina
3. AP Axial "Outlet" Projection (Taylor Method)
A. Patient Position
➤ Patient is in supine position with the legs extended.
B. Part Position
➤ Midsagittal plane of the body should be centered to the
➤ The ASIS should be equidistant from the table.
C. Central Ray
➤ Males, 20 to 35° cephalad, directed to a point 2 inches distal
to the upper border of border of the symphysis pubis.
➤ Females, 30 to 45°cephalad, directed to a point 2 inches
distal to the upper border of the symphysis pubis.
224
E. Exam Rationale
➤ This axial projection demonstrates the pubic and ischial rami
elongated and magnified but free of superimposition.
➤ Assess for pelvic trauma or displacement of pubic or ischial
structures.
F. Structures Shown
➤ Hip joints and Obturator foramina
4. Superinferior Axial "Inlet" Projection (Lilienfeld Method)
A. Patient Position
➤ Patient is seated-upright position on the radiographic table.
B. Part Position
➤ Midsagittal plane of the patient's body is center to the
center line of the table.
➤ Flex the knees slightly and support them to relieve
strain.
➤ Lean backward 45 to 50°, and then arch the back, to place the
pubic arch in vertical position.
➤ Adjust the pelvis so that the ASIS is equidistant from
the table.
C. Central Ray
➤ Perpendicular, entering 1 1⁄2 inch superior to the pubic
symphysis.
E. Exam Rationale
➤ This projection shows the anterior pubic and ischial bones and
the pubic symphysis.
225
➤ The inlet can also be demonstrated with the patient in supine
position with 40 degrees caudal angulation.
F. Structures Shown
➤ Hip joint
➤ Anterior pelvic bones
5. PA Axial "Inlet" Projection (Staunig Method)
A. Patient Position
B. Part Position
➤ Midsagittal plane of the body is center to the midline of the
radiographic table.
➤ Adjust the body so that the pelvis will not be rotated.
C. Central Ray
➤ 35° cephalad, exiting the pubic symphysis at the level of the
greater trochanters.
E. Exam Rationale
➤ This PA axial projection of the pubic, ischial bones and pubic
symphysis will be nearly identical to the superoinferior axial
projection.
F. Structures Shown
➤ Hip joints
➤ Anterior pelvic bones
226
HIP
Procedures:
1. AP Projection
2. Lateral Projection (Lauenstien Methods)
3. Axiolateral Projection (Danelius-Miller or Lorenz Method)
4. Axiolateral Projection (Clements-Nakayama Modification)
5. Axiolateral Projection (Friedman Method)
6. PA Oblique Projection (Hsieh Method) RAO or LAO Position
7. Mediolateral Oblique Projection (Lilienfeld Method) RAO or LAO Position
1. AP Projection
A. Patient Position
227
B. Part Position
➤ Rotate the lower limb 15° medially to place the femoral neck
parallel with the plane of the image receptor.
➤ The sagittal plane 2 inches medial to the anterior superior
iliac spine of the affected side should be 10 centered to the
C. Central Ray
➤ Perpendicular, directed to the femoral neck, approximately 2
inches medial to the ASIS of the affected side at a level just
above the greater trochanter.
E. Exam Rationale
➤ This position is often done to demonstrate the entire pelvic
girdle and both upper femora and the greater
trochanters should be fully visualized.
F. Structures Shown
➤ Head, Neck, Trochanter and the proximal third of the femoral
shaft.
2. Lateral Projection (Lauenstien Method)
A. Patient Position
➤ Patient is in supine position, rotate the patient slightly
toward the affected side to posterior oblique body position.
B. Part Position
➤ Flex the affected knee and abduct the leg to place the femur
parallel to the image receptor.
228
➤ Extend the opposite limb.
C. Central Ray
➤ Perpendicular, to a point midway between ASIS and symphysis
pubis.
➤ For Hickey method, 20 to 25° cephalad
E. Exam Rationale
➤ This examination is contraindicated for patients with a
suspected fracture of pathologic condition.
➤ This method is used to demonstrate the hip joint and the
relationship of the femoral head to the
acetabulum.
F. Structures Shown
➤ Hip joint, acetabulum and femoral head.
3. Axiolateral Projection (Danelius-Miller or Lorenz Method)
A. Patient Position
229
➤ Patient is in supine position and elevate the pelvis 1 to 2
inches.
B. Part Position
➤ Flex the knee and hip of the unaffected side to elevate the
thigh in a vertical position.
➤ Rest the unaffected leg on a suitable support that will not
interfere with the central ray.
➤ Unless it is contraindicated, rotate the foot of the affected
leg medially 15°
➤ Place the IR in the vertical position with its upper border in
the crease above the iliac crest.
➤ The knee of the affected leg should be extended
C. Central Ray
➤ Horizontal, perpendicular to the long axis of the femoral
neck, about 2 1⁄2 inches below the point of intersection of the
localization lines.
E. Exam Rationale
➤ This projection of the hip is indicated when the patient
cannot be positioned for a routine lateral to show the
acetabulum, head, neck and trochanters of the femur.
F. Structures Shown
➤ Femoral neck, hip joint and ischial tuberosity below the
femoral head.
230
4. Axiolateral Projection (Clements-Nakayama Modification)
A. Patient Position
➤ Patient is in supine position on the radiographic table with
the affected side near the edge of the table.
B. Part Position
➤ Leg remains in neutral position.
The image receptor should be tilted 15° from the vertical, so it
is parallel to the central ray.
C. Central Ray
➤ 15° posterior angle aligned perpendicular to the
femoral neck.
E. Exam Rationale
➤ This projection is indicated when both a routine lateral and
axiolateral are contraindicated, and when the patient has
bilateral hip fractures, bilateral hip arthroplasty and due to
limited movement of both the affected and unaffected leg.
F. Structures Shown
➤ Hip joint
➤ Femoral head, neck, and trochanters
5. Axiolateral Projection (Friedman Method)
A. Patient Position
➤ Patient in lateral recumbent position on the affected side.
➤ Midcoronal plane of the body is center to the midline of the
table.
B. Part Position
➤ Extend the affected limb and adjust it in a lateral position.
➤ Roll Roll the
unaffected lower limb posteriorly,
approximately 10°.
C. Central Ray
➤ 35° cephalad, directed to the femoral neck.
E. Exam Rationale
➤ Shows the head, neck, trochanters and proximal shaft of the
femur.
F. Structures Shown
231
➤ Hip joint, Femoral head, neck and trochanters.
6. PA Oblique Projection (Hsieh Method) RAO or LAO Position
A. Patient Position
➤ Patient is in semiprone position with the affected hip close
in contact to the radiographic table.
B. Part Position
➤ Elevate the unaffected side approximately 40 to 45°, flex the
knee and forearm of the elevated side
C. Central Ray
➤ Perpendicular, midway between the posterior surface GE of the
iliac blade and the dislocated femoral head.
E. Exam Rationale
➤ This projection is used to demonstrates the posterior
dislocations of the femoral head in cases of other acute fracture
dislocations.
F. Structures Shown
➤ Hip joint, Ilium and Proximal femur
7. Mediolateral Oblique Projection (Lilienfeld Method) RAO or LAO Position
A. Patient Position
➤ Patient is in lateral recumbent position on the
affected side.
B. Part Position
➤ Fully extend the affected thigh
➤ Roll the upper limb forward approximately 15
C. Central Ray
➤ Perpendicular, to the midshaft of the image receptor.
E. Exam Rationale
➤ This examination is contraindicated for patients with a
suspected fracture or pathologic condition to demonstrates the
ilium, acetabulum and proximal
femur.
F. Structures Shown
232
➤ Hip joint, Femoral and Acetabulum
➤ To those patients who have an acute hip injury, COLONNA
recommends that the patient is placed on the UNAFFECTED SIDE and
adjusted to center the uppermost hip to the midline of the table.
He further recommends that the uppermost side, the affected side
be rotated 17 degrees anteriorly from the true lateral position.
He stated that this degree of rotation separates the shadows of
the hip joints and gives the optimum projection of the slope of
the acetabular roof and the depth of the socket.
8. AP Oblique Projection (Modified Cleaves or Frog-Leg Bilateral Projection)
A. Patient Position
B. Part Position
➤ Flex the hips and knees and draw the feet up as much as
possible.
➤ Abduct the thighs approximately 45° from the vertical plane to
place the long axis of the femoral necks parallel with the plane
of the IR.
C. Central Ray
➤ Perpendicular, to a point 1 inch superior to the symphysis
pubis.
E. Exam Rationale
➤ This examination is commonly indicated for investigation of
congenital hip disease, and it is contraindicated in patients
with suspected fractures or pathologic hip disease
F. Structures Shown
➤ Femoral heads and necks
➤ Pelvis, Ilium and Trochanters
ACETABULUM
Procedures:
1. PA Axial Oblique Projection (Teufel Method) RAO or LAO Position
2. AP Oblique Projection (Judet Method) RPO or LPO Position
1. PA Axial Projection (Teufel Method) RAO or LAO Position
A. Patient Position
➤ Patient is in semiprone position on the affected side.
B. Part Position
➤ Elevate the unaffected side so that the anterior surface of
the body forms 38° angle from the table
C. Central Ray
233
➤ Perpendicular, directed to the femoral neck,
approximately 2 inches medial to the ASIS of the
234

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Skull Procedures 1. PA Projection 2. AP Projection

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SKULL

1. Parietoacanthial Modified (Waters) Projection

1. Parietoorbital Oblique Projection (Rhese Method)

2. Orbitoparietal Oblique Projection (Alexander Method)

C. Inferior Orbital Fissures

1. PA Axial Projection (Bertel Method)

1. Parieto-Orbital Oblique Projection (Hough Method)

2. Parietoacanthial Projection (Waters Method)

3. Acanthioparietal Projection (Reverse Waters Method)

2. Superoinferior Projection (Tangential)

3. Parietoacanthial Projection (Waters)

1. Submento Vertical Projection (SMV or Basal) Tangential

2. PA Axial (Superior) Modified Titterington Method

3. Axiolateral Oblique Projection

➤ Extend the chin to prevent superimposition on the cervical

4. Submentovertical (SMV) Projection

2. Axiolateral / Axial Transcranial Projection

for Dolicocephalic, increase caudal angulation approximately 30-35° caudally

3. Lateral Transfacial Position (Albers-Schonberg Method)

4. Oblique Transfacial Position (Zanelli Method)

2. Parietoacanthial Projection (Waters)

O If extended to little, the petrosae are projection over

3. PA Axial Projection (Caldwell Method)

4. Parietoacanthial Projection (Open-mouth waters method) / Axial transoral

5. Submentovertical (SMV) Projection (Basal)

1. Axiolateral Oblique Projection (Original Law Method) Double Tube

3. Axiolateral Oblique Projection (Stenver's method) Posterior Profile

7. Axiolateral Oblique Projection (Mayer Method)

8. PA Projection (Transorbital Method)

9. PA Axial Position (Valdini Method)

10. Submenovertical Projection (Sub basal) Basilar Projection

11. Parietotemporal Position (Low Beer Method)

12. Chausse III Method (Attic-Aditus-Antral areas)

2. AP Projection (Modified Fuchs Method)

3. Transoral Axial Position (Chausse II Method)

1. Anterior Profile Position (Miller Method) Axiolateral Oblique

2. AP Projection (Colcher-Sussman Method)

ATLAS AND AXIS (C1 and C2)

1. AP Projection (Open Mouth)

3. AP Axial Oblique Projection (Kasabach Method) R or L head rotations

5. AP Projection (Fuchs Method)

2. Lateral Projection (Grandy Method)

4. AP Axial Oblique Projection (RPO and LPO Position)

6. AP Projection (Ottonello Method or Chewing or Wagging Jaw)

➤ Ensure that there is no rotation of the head or thorax.

7. Lateral Projection (Twinning, Swimmer's and Pawlow Methods)

➤ Normal respiration to obliterate or diffuse the vascular

1. PA or AP Upright (Ferguson Method)

3. Lateral Upright Projections

5. AP Projection (R and L Bending)

1. PA Oblique Projection (RAO Position)

improved demonstration of the sternum relative to radiographic

2. Lateral Projection (R or L Position)

➤ The superior border of the image receptor is 1 1⁄2 inches

➤ Turning the head rotates the spine slightly away from

3. Axiolateral Projection (Kurzbauer Method)

2. AP Projection (Above or Below Diaphragm)

➤ To determine rotation, examine the posterior aspects of the