Radiographic Positioning and Procedures

Reference:
th
Merill’s Atlas of Radiographic Positions and Radiologic Procedures (9 Edition) by Philip W. Ballinger and Eugene Frank

I. General Anatomy
II. Upper Extremity
III. Shoulder Girdle
IV. Lower Extremity
V. Pelvic and Upper Femora

Prepared by: Timothy John D. Matoy

1
I. General Anatomy

 Anatomy – Science of the structure of the body.

 Physiology – study of the function of the organs.
 Osteology – detailed study of the knowledge relating to the bones of the body.

Body Planes
 Sagittal plane
o Midsagittal plane o Horizontal Plane
o Coronal Plane o Transverse or Axial Plane
o Midaxillary Plane o Oblique Plane

Body cavities
 Thoracic Cavity
o Pleural Membranes o Esophagus
o Lungs o Pericardium
o Trachea o Heart and Great Vessels

 Abdominal Cavity
o Peritoneum o Intestines
o Liver o Kidneys
o Gallbladder o Ureters
o Pancreas o Major Blood Vessels
o Spleen o Pelvic Portion: rectum, UB, pars of
o Stomach reproductive system

Division of the abdomen

 Quadrants
o RUQ o LUQ
o RLQ o LLQ
 Regions
o Superior
 Right hypochondrium
 Epigastrium
 Left hypochondrium
o Middle
 Right Lateral
 Umbilical
 Left Lateral
o Inferior
 Right Inguinal
 Hypogastrium
 Left Inguinal

Surface Landmarks
C1 Mastoid tip
C2, C3 Gonion (angle of mandible)
C5 Thyroid cartilage
C7 Vertebra prominens
T1 Approximately 5 cm (2 in) above level of sternal notch
T2, T3 Level of manubrial (sternal) notch and superior margin of scapulae
T4, T5 Level of sternal angle
T7 Level of inferior angle of scapulae
T10 Level of xiphoid tip
L3 Costal margin
L3, L4 Level of umbilicus
L4 Level of most superior aspect of iliac crest
S1 Level of anterior superior iliac spine
Coccyx Level of pubic symphysis and greater trochanters

2
Body Habitus
 Determines the size, shape, and position, tonus, and motility of the organs of the thoracic and abdominal
cavities.

Osteology
 Bones
o Attachment for muscles
o Mechanical basis for movement
o Protection of internal organs
o A frame to support the body
o Storage for calcium, phosphorus, and other salts
o Production of red and white blood cells

Bone development
 Ossification
o Term given to the development and formation of bones
 Intermembranous ossification
 Skulls, clavicles, mandibles and sternum
 Endochondrial ossification
 Short, irregular and long bones.
o Primary ossification
 diaphysis
o Secondary ossification
 Epiphysis

Classification of bones
 Long
o Femur, humerus
o To provide support
 Short
o Tarsals, wrist
o Allow minimum flexibility and motion in a short distance.
 Flat
o Diploe
o Cranium, sternum, scapula
o Provides protection, and their board surfaces allow muscle attachment.
 Irregular
o Vertebrae, pelvis
o Attachment for muscles, tendons and ligaments, or they attach to other bones
to create joint.
 Sesamoid
o Patella
o Develop inside and beside tendon
o Very small and oval
o Protect the tendon from excessive wear

Arthrology
 Functional Classification  Structural Classification
 Synarthroses: immovable joints  Fibrous Joints
 Amphiarthroses: slightly movable  Cartilaginous Joints
 Diarthroses: Freely Movable  Synovial Joints

Structural Classification of joints

 Fibrous Joints
o Do not have a joint cavity
o Strongest joints in the body
1. Syndemosis – tibiofibular joint
2. Suture – skull
3. Gomphosis – roots of teeth

3
 Cartilaginous Joints
o They do not have a joint cavity.
o They are virtually immovable.
 Symphysis – pubic symphysis
 Synchondrosis - epiphyseal plate found between the epiphysis and diaphysis
 Synovial Joint –

 Synovial Joints
o Gliding (Plane) – intercarpal and intertarsal joints of the wrist and foot
o Hinge (ginglymus) – elbow, knee and ankle
o Pivot (Trochoid) – atlas and axis
o Ellipsoid (condyloid) –
o Saddle (sellar) – between trapezium and 1st metacarpal
o Ball and Socket – hip and shoulder

Bone Markings and Features

 Processes or Projections
o Condyle o Line
o Coracoid or coronoid o Malleolus
o Horn o Protuberance
o Crest o Spine
o Epicondyle o Styloid
o Facet o Trochanter
o Hamulus o Tubercle
o Head o tuberosity

 Depressions
o Fissure o Meatus
o Foramen o Notch
o Fossa o Sinus
o Groove o sulcus

Processes or projections
 Condyle – rounded process at an articular extremity
 Coracoid or coronoid – beaklike or crownlike process
 Horn – hornlike process on a bone
 Crest – ridgelike process
 Epicondyle – projection above condyle
 Facet – small, smooth-surfaced process for articulation
 Hamulus – hook-shaped process
 Head – expanded end of a long bone
 Line – less prominent ridge than a crest; linear elevation
 Malleolus – club-shaped process
 Protuberance – projecting part or prominence
 Spine – sharp process
 Styloid – long pointed process
 Trochanter – either of two large rounded, and elevated process (greater or major and lesser or minor)
 Tuberle – small, rounded and elevated process
 Tuberosity – large, rounded and elevated process

Depressions
 Fissure – cleft or deep groove
 Foramen – hole in a bone for transmission of blood vessels and nerves
 Fossa – pit, fovea or hollow space
 Groove – shallow linear channel
 Meatus – tubelike passageway running within a bone
 Notch – indentation into the border of a bone
 Sinus – recess, groove or cavity, or hollow space
 Sulcus – furrow, trench or fissurelike depression

4
Fractures
 Closed
o Does not break through skin
o Open
o Serious fracture in which the broken bone or bones project through the skin
o Nondisplaced
o Which the bone retains its normal alignment
o Displaced
o The bones are not in anatomic alignment

Anatomic Relationship terms

 Anterior (ventral) – refers to forward or front part of the body or forward part of an organ
 Posterior (dorsal) – refers to back part of an organ
 Caudad – refers to parts away from the head of the body
 Cephalad – refers to parts toward the head of the body
 Superior – refers to nearer the head or situated above
 Inferior – refers to nearer the feet or situated below
 Central – refers to midarea or main part of an organ
 Peripheral – refers to parts at or near the surface, edge, or outside of another body part
 Medial – refers to parts toward the median plane of the body or toward the middle part of another body
 Lateral – refers to parts away from the median plane of the body or away from the middle of another body part
to right or left
 Superficial – refers to parts near the skin or surface
 Deep – refers to parts far from the surface
 Distal – refers to parts farthest from the point of attachment, point of reference, origin, or beginning; away from
the center of the body
 Proximal – refers to parts nearer the point of attachment, point of reference, origin, or beginning; toward the
center of the body.
 External – refers to parts outside an organ or on the outside of the body
 Internal – refers to parts within or on the inside of an organ
 Parietal – refers to the wall or lining of a body cavity
 Visceral – refers to the covering of an organ
 Ipsilateral – refers to a part or parts on the same side of the body
 Contralateral – refers to a part or parts on the opposite side of the body
 Palmar – refers to the palm of the hand
 Plantar – refers to sole of the foot

Radiographic positioning terminology

 Projection
 The path of the central ray as it exits the x-ray tube and goes through the patient to the IR.
 AP Projection  Lateral Projection
 PA Projection  Oblique Projection
 Axial Projection  Complex Projections
 Tangential Projection  True Projection
 Position
 Overall posture of the patient of the general body positions.
 Upright
 Seated
 Recumbent
 Dorsal recumbent, ventral recumbent or lateral recumbent
 Supine
 Prone
 Trendelenburg’s position
 Fowler’s Position
 Refers to the specific placement of the body part in relation to the radiographic table or IR during
imaging.
 Lateral Position
 Oblique Position
 Decubitus Position
 Lordotic Position

5
  View
 Used to describe the body part as seen by the IR.
 Method
 Specifies the x-ray projection and body position, and it may include specific items such as IR and central
ray position.

Body movement terminology

 Abduct or abduction – movement of part away from the central axis of the body or body part.
 Adduct or adduction – movement of a part toward the central axis of the body or body part.
 Extension – straightening of a joint.
 Flexion – act of bending of a joint.
 Hyperextension – forced or excessive extension of a limb or joints.
 Hyperflexion – forced overflexion of a limb or joints.
 Rotate/rotation – turning or rotating of the body or a body part around its axis.
 Circumduction – circular movement of a limb.
 Tilt – tipping or slanting a body part slightly.
 Deviation – a turning away from the regular standard or course.

II. Upper Extremity

Division of the upper limb

 Hand  Arm
 Forearm  Shoulder Girdle

HAND
 27 BONES
o Phalanges - 14
o Metacarpals - 5
o Carpals – 8
 Bones of the digits (14)
o 1st Digit – Thumb
o 2nd Digit – Index finger
o 3rd Digit – Middle finger
o 4th Digit – Ring finger
o 5th Digit – Small finger
 Bones of the palm (5)

Carpals Carpal Sulcus

6
Forearm

Upper Limb Articulations

General Procedures
• Remove accessories that might obstruct the image.
• Make the position of the patient.
• Shield gonads.
• Use right or left markers and all other vital identification markers.
• Unless otherwise specified, CR is at right angle to the cassette.
• Perform proper collimation.
• For bilateral examination, radiograph each side separately.

Digits (Second Through fifth)

1. PA Projection
 CR – Perpendicular to the PIP Joint of the affected digit
 Note: Digits that cannot be extended can be examined in small sections with dental films. When injury is
suspected, an AP projection is used instead of PA.
2. Lateral Projection
 Lateromedial or Mediolateral
7
  CR: Perpendicular to the PIP Joint of the affected digit
 Fingernail in profile, if visualized and normal
 Concave, anterior surfaces of the phalanges
 No rotation of the phalanges
3. PA Oblique Projection
 CR: Perpendicular to the PIP Joint of the affected digit.
 45 degree external angulation of the hand
 Some radiographers rotate the second digit medially for improved recorded detail and increased ability
to see fractures.

First Digit (Thumb)

1. AP Projection
 For AP, hand is in extreme internal rotation.
 Lewis suggested CR directed 10 to 15 degrees along the long axis of the thumb towards the wrist to
demonstrate the metacarpal free of superimposition.
 CR: Perpendicular to MCP joint
2. PA Projection
 If PA of the first CMC joint, place the hand in lateral position and abduct the thumb
 Magnified image
 CR: Perpendicular to the MCP joint
3. Lateral Projection
 Hand in natural arch position with the palmar surface down.
 CR: Perpendicular to MCP joint.
4. PA Oblique Projection
 Hand in prone position
 CR: Perpendicular to MCP joint

First Carpometacarpal Joint

1. AP Projection – Robert Method
 Robert first describe the projection of the first CMC joint in 1936.
o CR: Perpendicular entering at first CMC joint.
 Lewis modified the CR in 1988.
o CR: 10 to 15 degrees proximally along the long axis of the thumb and entering the first MCP
joint.
 Long and Rafert further modified CR in 1995
o 5 degrees proximally along the long axis of the thumb and entering the first CMC joint.
 This projection commonly performed to demonstrate arthritic changes, fractures, displacement of the
first CMC joint, and the Bennett’s fracture.
 Arm internally rotated and hand hyperextended.
2. AP Projection – Burman Method
 If hyperextension of the wrist is not contraindicated.
 SID – 18 inches to produce a magnified image that creates a greater field of view of the concavoconvex
aspect of the first CMC joint.
 Radial shift of the carpal tunnel view.
 CR: Through the first CMC joint at a 45 degree angle toward the elbow.

Hand
1. PA Projection
 CR: Perpendicular to third MCP Joint
 AP is used instead of PA if the hand cannot extend enough to place palmar surface in contact with the
cassette because of injury or pathological condition.
2. PA Oblique Projection – (Lateral Rotation)
 45 degree angulation of the hand
 Hand rotated laterally to open the MCP
 CR: Perpendicular to third MCP
 Lane, Kennedy and Kuschner – reverse oblique projection to demonstrate severe metacarpal
deformities or fractures. Hand is rotated 45 degrees medially (internally).
 Kallen – tangential oblique projection to demonstrate metacarpal head fractures. MCP joints are flexed
75 to 80 degrees; hand is rotated 40 to 45 degrees towards the ulnar surface; CR is directed tangentially
to the MCP joint of interest.

8
 3. Lateral Projection
 (Mediolateral, Lateromedial and fan lateral)
 Fan lateral is used to prevent superimposition of proximal phalanges.
 CR: Perpendicular to second digit MCP joint.
 For foreign body localization and metacarpal fracture displacement.
 Lewis – for better demonstration of fifth metacarpal fractures, rotate hand 5 degrees posteriorly from
true lateral position to remove superimposition of the second through fourth metacarpals.
4. Lateral Projection (Lateromedial in flexion)
 Hand in natural arch position
 CR: Perpendicular to the MCP Joints, entering MCP joint of the second digit.
5. AP Oblique Projection – Norgaard Method
 Ball-catcher’s position
 For detecting early radiologic changes needed to diagnose rheumatoid arthritis.
 Extremely fine-grain intensifying screens is used to demonstrate high resolution with low kVp ( 60 to 65)
to obtain necessary contrast.
 Stapczynski – recommended this for fractures of the base of fifth metacarpal.
 Both hands half-supinated 45 degrees
 CR: Perpendicular point midway between both hands at the level of the MCP joint for either of the two
positions.

Wrist
1. PA Projection
 Slightly arch the hand at the MCP joints
 CR: Perpendicular to midcarpal area
 Ulna is slightly oblique. When ulna is under examination, AP projection should be taken.
 Daffner, Emmerling, Buterbaugh – to better demonstrate the scaphoid and capitate, hand should be in
PA with CR 30 degrees towards the elbow.
2. AP Projection
 Patient should lean laterally to prevent rotation of the wrist.
 CR: Perpendicular to the midcarpal area.
 Carpal interspaces should be demonstrated in AP than in PA.
3. Lateral Projection (Lateromedial)
 Flex elbow 90 degrees.
 CR: Perpendicular to the wrist joint.
 Can also demonstrate anterior or posterior displacement in fractures.
 Burman – lateral position of the scaphoid should be obtained with the wrist in palmar flexion
 Fiolle – first to describe a small bony growth occurring on the dorsal surface of the third CMC joint. He
termed the condition carpe bossu (carpal boss) and found that it is demonstrated best in lateral position
with the wrist in palmar flexion.
4. PA Oblique Projection (Lateral Position)
 Pronate hands, rotate the wrist laterally (externally) 45 degrees
 CR: Perpendicular to the midcarpal area. It enters just distal to the radius.
 Demonstrates the carpals on the lateral side of the wrist particularly trapezium and scaphoid.
 Scaphoid superimposed on itself in the direct PA projection.
5. AP Oblique Projection (Medial Rotation)
 Hands in supine position; Rotate wrist medially (internally) 45 degrees
 CR: Perpendicular to midcarpal area. It enters the anterior surface of the wrist midway between its
medial and lateral borders.
 Carpals on the medial side of the wrist particularly triquetrum, hamate (unciform), pisiform
 It separates the pisiform from the adjacent carpal bones.
6. PA Projection - Ulnar Deviation (flexion)
 Also called ulnar flexion in radiography
 CR: Perpendicular to the scaphoid
o Clear delineation sometimes requires a central ray of 10 to 15 degrees proximally or distally.
 Carpal interspaces adjacent to scaphoid should be open.
7. PA Projection – Radial Deviation (Flexion)
 Also termed as Radial Flexion in radiography textbooks.
 CR: Perpendicular to midcarpal area.
 Opens the interspaces between carpals on the medial side of the wrist.

9
 8. Scaphoid – PA Axial Projection – Stecher Method
 finger end of the cassette is elevated 20 degrees
 CR: Perpendicular to the table and directed to enter the scaphoid
 Variations
o Cassette and wrist horizontally and CR is directed 20 degrees towards the elbow.
o To demonstrate a fracture line that angles superoinferiorly, the wrist is angled inferiorly and CR
maybe angled towards the digits.
o Have the patient clench the first to elevate the distal end of the scaphoid so that it lies parallel
with the cassette and to widen the fracture line. No CR angulation.
9. Scaphoid Series
 PA and PA Axial Projections
 Rafert-Long Method (1991)
 Scaphoid fractures account for 60% of all carpal bone injuries
 Four-image multiple-angle central ray series
 CR directed to the scaphoid with 0, 10, 20, 30 degrees
10. Trapezium – PA Axial Oblique Projection – Clements-Nakayama Method
 Fractures of trapezium and evaluation to treat osteoarthritic patient
 Articulations of the trapezium with the carpal bones except for the scaphoid.
 CR: 45 degrees distally to enter the anatomic snuffbox of the wrist and pass through the trapezium.

Carpal Bridge
 Tangential Projection
• CR: Directed to a point about 1 ½ inches (3.8 cm) proximal to the wrist joint at a caudal angle of 45
degrees
• Demonstration of
• fractures of scaphoid
• lunate dislocations
• calcifications and foreign bodies in the dorsum of the wrist

Carpal Canal
 Tangential Projections – Gaynor-Hart Method
• Fractures of the hook of the hamate, pisiform and trapezium
• Inferorsuperior
• CR: Directed to the palm of the hand at a point approximately 1 inch (2.5 cm) distal to the base
of the third metacarpal and at an angle of 25 to 30 degrees to the long axis of the hand.
• Superoinferior
• CR:
• Tangential to the carpal canal at the level of the midpoint of the wrist.
• Angled toward the hand approximately 20 to 35 degrees from the long axis of the
forearm.

Forearm
1. AP Projection
 Hand is supinated
 Pronation of the hand crosses the radius over the ulna at its proximal third and rotates humerus
medially.
 CR perpendicular to the midpoint of the forearm
2. Lateral Projection (Lateromedial)
 Flex the elbow 90 degrees
 CR: Perpendicular to the midpoint of the forearm
 Superimposed humeral epicondyles
Elbow
1. AP Projection
 Hand supinated
 CR: Perpendicular to the elbow joint
2. Lateral Projection (Lateromedial)
 Griswold gave two reasons for the importance of flexing the elbow 90 degrees
o the olecranon process can be seen in profile
o the elbow fat pads are the least compressed
 CR: Perpendicular to the elbow joint, regardless of its location on the cassette
 If there is suspected injury, flex elbow 30 to 35 degrees only
10
 3. AP Oblique Projection (Medial Rotation)
 Medially (internally) rotate or pronate the hand 45 degrees
 CR: Perpendicular tot the elbow joint.
 Coronoid process free of superimposition
4. AP Oblique Projection (Lateral Rotation)
 Rotate the hand laterally (externally) 45 degrees
 CR: Perpendicular to the elbow joint
 Radial head, neck and tuberosity projected free of ulna
 Open elbow joint
5. Distal Humerus – AP projection – Partial Flexion
 CR: Perpendicular to the humerus, traversing the elbow joint.
o Depending on the degree of flexion, angle the central ray distally into the joint
 Closed elbow joint
6. Proximal Forearm – AP Projection – Partial Flexion
 CR: Perpendicular to the elbow joint and long axis of the forearm
 Partially open elbow joint
 Holly - described a method AP projection of the radial head. Elbow is extended and forearm is
supinated to place the wrist at 30 degrees to the horizontal.
7. Distal Humerus – AP Projection – Acute Flexion
 Jones Orthopedic Technique (Complete Flexion)
 CR: Perpendicular to the humerus approximately 2 inches (5 cm) superior to the olecranon process.
8. Proximal Forearm – PA Projection – Acute Flexion
 CR: Perpendicular to the flexed forearm, entering approximately 2 inches (5 cm) distal to the olecranon
process.

Radial Head
 Lateral Projection – Lateromedial (Four-Position Series)
• For the demonstration of the entire circumference of the radial head free of superimposition.
• Flex elbow 90 degrees
• 1st exposure – hand supinated
• 2nd exposure – hand in lateral position
• 3rd exposure – hand pronated
• 4th exposure – extreme internal rotation
• CR Perpendicular to the elbow joint
• Greenspan and Norman – CR: 45 degrees medially (toward the shoulder)

Distal Humerus
 PA Axial Projection
• Flex elbow; supinate hands
• Humerus forms an angle of approximately 75 degrees from the forearm
• CR: Perpendicular to the ulnar sulcus, entering at a point just medial to the olecranon process
• This projection is used in radiohumeral bursitis (tennis elbow) to detect otherwise obscured
calcifications located in the ulnar sulcus.

Olecranon Process
 PA Axial Projection
• Arm is 45 to 50 degrees from the vertical position
• CR: Perpendicular to the olecranon process to demonstrate the dorsum of the curved extremity and
articular margin of the olecranon process.

Humerus
1. AP Projection (Upright)
 Respiration: Suspended
 Upper margin about 1 ½ inches (3.8 cm) above head of humerus
 Epicondyles should be parallel to the cassette
 CR: Perpendicular to the midportion of the humerus and the center of the cassette.
2. Lateral Projection (Lateromedial, Upright)
 Upper margin about 1 ½ inches (3.8 cm) above head of humerus
 Respiration: Suspended
 Flex elbow approximately 90 degrees, place hands on the patient’s hip (unless contraindicated)
 Epicondyles should be perpendicular to the cassette
11
  CR: Perpendicular to the midportion of the humerus and the center of the cassette
3. AP Projection (Recumbent)
 Upper margin about 1 ½ inches (3.8 cm) above head of humerus.
 Supinate the hands, epicondyles parallel with the cassette
 Respiration: Suspended
 CR: Perpendicular to the midportion of the humerus and the center of the cassette.
4. Lateral Projection (Lateromedial, Recumbent)
 Upper margin about 1 ½ inches (3.8 cm) above head of humerus
 Rotate forearm medially; posterior aspect of the hand against the patient’s side
 Epicondyles perpendicular to the cassette
 CR: Perpendicular to the midpoint of the humerus and the center of the cassette.
5. Lateral Projection (Lateromedial, Lateral Recumbent)
 Place the cassette close to the axilla; flex elbow; hands face up (unless contraindicated)
 Respiration: Suspended
 CR: Directed to the center of the cassette, which exposes only the distal humerus
 Epicondyles superimposed
6. Transthoracic Lateral Projection – Lawrence Method (R or L position)
 Used when trauma has occurred and the arm cannot be abducted or rotated for the AP or lateral
projection.
 Can be performed upright or supine.
 Raise the uninjured arm and rest on the forehead.
 Cassette centered to surgical neck of the affected humerus.
 Respiration:
o Full inspiration
o Slow deep breathing
 CR: Perpendicular to the cassette at the level of the surgical neck
o If the patient cannot elevate unaffected shoulder, 10 to 15 degrees cephalad
 Lateral projection of the proximal half or two thirds of the humerus

III. Shoulder Girdle

Shoulder Girdle
 Formed by clavicle and scapula
 To connect the upper limb to the trunk

Clavicle Humerus

Scapula

12
Shoulder Girdle Articulations
 Scapulohumeral Articulation
 Acromioclavicular Articulation
 Sternoclavicular Articulation

Shoulder
1. AP Projection (External Rotation)
 Center the cassette 1 inch (2.5) inferior to the coracoid process.
 Scapula parallel to the plane of the cassette.
 Epicondyles parallel to the plane of the cassette.
 Abduct arms and supinate hands.
 CR: Perpendicular to a point 1 inch (2.5 cm) inferior to the coracoid process.
 Respiration: Suspend.
2. AP Projection (Internal Rotation)
 Center the cassette 1 inch (2.5) inferior to the coracoid process.
 Epicondyles perpendicular to the plane of the cassette.
 Flex elbow somewhat to place the back of the hand on the hip.
 Proximal humerus is in true lateral position.
 CR: Perpendicular to a point 1 inch (2.5 cm) inferior to the coracoid process.
 Respiration: Suspend.
3. Transthoracic Lateral Projection – Lawrence Method (R or L position)
 Used when trauma has occurred and the arm cannot be abducted or rotated for the AP or lateral
projection.
 Can be performed upright or supine.
 Raise the uninjured arm and rest on the forehead.
 Cassette centered to surgical neck of the affected humerus.
 Respiration:
o Full inspiration
o Slow deep breathing
 CR: Perpendicular to the cassette at the level of the surgical neck
o If the patient cannot elevate unaffected shoulder, 10 to 15 degrees cephalad
 Lateral projection of the proximal half or two thirds of the humerus.

Shoulder Joint
1. Inferosuperior Axial Projection – Lawrence Menthod
 Patient supine
 Humerus in external rotation.
 Turn head away from the affected side.
 Use vertical cassette.
 CR: Horizontally through the axilla to the region of the acromioclavicular articulation. The degree of
medial angulation depends on the degree of abduction of the arm 15 to 30 degrees). The greater the
abduction, the greater the angle.
 Respiration: suspend
2. Inferosuperior Axial Projection – Rafert Modification
 Patient supine.
 Turn head away from affected area.
 Hill-Sachs defect – wedge-shaped compression fracture of the articular surface of the head. Fracture will
be located on the posterolateral humeral head.
 Exaggerated external rotation – hand 45 degrees
 CR: Horizontal and angled approximately 15 degrees medially, entering the axilla and passing through
the acromioclavicular joint.
 Respiration: Suspend.
3. Inferosuperior Axial Projection – West Point Method
 Patient in prone position.
 Turn patient head away from affected area.
 Abduct the affected arm 90 degrees.
 CR: Directed at a dual angle of 25 degrees anteriorly from the horizontal and 25 degrees medially.
Central ray enters approximately 5 inch (13 cm) inferior and 1 ½ inch (3.8 cm) medial to the acromial
edge and exits the glenoid cavity.

13
 4. Inferosuperior Axial Projection – Clements Modification
 If prone or supine is not possible.
 Lateral recumbent position lying on the unaffected side.
 Flex the patient’s hips and knees.
 Abduct affected arm 90 degrees pointing to the ceiling.
 CR: Horizontal to the midcoronal plane passing through the midaxillary region of the shoulder.
o Angled 5 to 15 degrees medially when the patient cannot abduct the arm a full 90 degrees.
 Respiration: Suspend.
5. Superoinferior Axial Projection
 Flex the elbow 90 degrees and hand in prone position.
 Tilt head toward the unaffected side.
 May use curved cassette.
 CR: Angled 5 to 15 degrees through the shoulder joint toward the elbow.
6. Axial Projection – Cleaves Method with Rolled Film
 When patient cannot or should not abduct arms.
 Tube approximately 2 inches (5 cm) in diameter.
 CR: Perpendicular to the shoulder, entering 3/8 inch (1 cm) posterior to the acromioclavicular joint.
o Variations – Directed to the acromioclavicular articulation at a 5-degree medial angulation to
demonstrate the lesser tubercle and intertubercular (bicipital) groove and at a 5-degree lateral
angulation to demonstrate the coracoid process.
 Respiration: Suspend.
7. AP Axial Projection
 Patient is supine or upright.
 Center scapulohumeral joint
 CR: Directed through the scapulohumeral joint at a cephalic angle of 35 degrees.
 Respiration: Suspend.
8. Scapular Y – PA Oblique Projection (RAO or LAO position)
 Described by Rubin, Gray, and Green.
 The body of the scapula form the vertical component of Y, and the acromion and coracoid process form
the upper limbs.
 Useful in the evaluation of suspected shoulder dislocations.
 Respiration: Suspend.
 Patient’s midcoronal plane forms 45 to 60 degrees to the cassette.
 CR: Perpendicular to he scapulohumeral joint.
 In anterior dislocations (subcoracoid), the humeral head is beneath the coracoid process. In posterior
dislocations, it is projected beneath the acromion process.
9. Glenoid Cavity – AP Oblique Projection – Grashey Method (RPO or LPO)
 Rotate the body approximately 35 to 45 degrees toward the affected side.
 Scapula parallel to the plane of the cassette.
 Abduct the arm slightly in internal rotation, and place palm of the hand on the abdomen.
 Respiration: Suspend.
 CR: Perpendicular to the glenoid cavity at a point 2 inches (5 cm) medial and 2 inches (5 cm) inferior to
the superolateral border of the shoulder.
 Space between the humeral head and the glenoid cavity (scapulohumeral joint).
 Kornguth and Salazar – Apical oblique projection with caudal angulation of 45 degrees.
10. Supraspinatus “Outlet” – Tangential Projection – Neer Method (RAO or LAO)
 To demonstrate tangentially the coracoacromial arch or outlet to diagnose shoulder impingement.
 Body is 45 to 60 degrees from the plane of the film.
 Respiration: Suspend.
 CR: Angled 10 to 15 degrees caudad, entering the superior aspect of the humeral head.

Proximal Humerus
1. Proximal Humerus – AP Axial Projection – Stryker “Notch” Method
 Dislocation of the shoulder caused by posterior defects involving posterolateral head of the humerus.
 Described by Hall, Isaac, and Booth from the ideas expressed by W.S. Stryker.
 Patient is in supine.
 Coracoid process of the affected shoulder should be centered.
 Flex arm slightly beyond 90 degrees and place the palm of the hand on top of the head with fingertips
resting on the head.
 Respiration: Suspend.
14
  CR: Angled 10 degrees cephalad, entering the coracoid process.
2. Intertubercular Groove – Tangential Position – Fisk Modification
 Patient is supine, seated or standing.
 With patient supine, place the cassette against the superior surface of the shoulder.
 Respiration: Suspend.
 CR: Angled 10 to 15 degrees posterior (Downward from the horizontal) to the long axis of the humerus
for the supine position.
 Fisk Modification: Patient standing. Greater OID. Instruct the patient to flex the elbow. Have the patient
lean forward or backward as required to place the vertical humerus at an angle of 10 to 15 degrees.
 CR: Perpendicular to the cassette when the patient is leaning forward and the vertical humerus is 10 to
15 degrees.
3. Teres Minor Insertion – PA Projection – Blackett – Healy Method
 Patient in prone position, arms along the sides of the body and the head resting on the cheek of the
affected side.
 Turn the arm to a position of extreme internal rotation. If possible, flex the elbow and place the hand on
the patient’s back.
 Respiration: Suspend at the end of exhalation for a more uniform density.
 CR: Perpendicular to the head of the humerus.
4. Subscapular Insertion – AP Projection – Blackett-Healy Method
 Patient in supine position.
 Abduct the affected arm to the long axis of the body, flex the elbow, and rotate the arm internally by
pronating the hand.
 Respiration: Suspend
 CR: Perpendicular to the shoulder joint, entering the coracoid process.
5. Infraspinatus Insertion – AP Axial Projection
 Patient in supine position with the affected arm by the patient’s side.
 Turn the arm in external rotation to open the subacromial space.
 Rotate the arm to neutral position and then in complete internal rotation to allow full evaluation of the
humeral head.
 CR: Direct the central ray to enter the coracoid process at an angle of 25 degrees caudad.

Acromioclavicular Articulations
1. Bilateral AP Projection – Pearson Method
 SID – 72 inches (183 cm)
 Upright, seated or standing
 Weight of the body is equally distributed on the feet
 2 exposures – first without weights, second with weights tied to each wrist.
 Respiration: Suspend
 CR: Perpendicular to the midline of the body at the level of the acromioclavicular joints for a single
projection. If 2 exposures for broad-shouldered patient, center it to the acromioclavicular joint.
2. AP Axial Projection – Alexander Method
 Patient in upright position.
 Respiration: Suspend
 CR: Directed to the coracoid process at a cephalic angle of 15 degrees. (projects acromioclavicular joint
above the acromion)
 Alexander suggested that both AP and PA axial oblique projections be used in cases of suspected
acromioclavicular subluxation or dislocation.
3. PA Axial Oblique Projection – Alexander Method (RAO or LAO)
 Stand or sit. Affected hand should be placed under the opposite axilla.
 Midcoronal plane of the body is rotated 45 to 60 degrees to place the scapula perpendicular to the
cassette.
 CR: Directed through the acromioclavicular joint at an angle of 15 degrees caudad.

Clavicle
1. AP Projection
 Supine or upright position.
 Respiration: Suspend at the end of exhalation to obtain a more uniform density image.
 CR: perpendicular to the midshaft of the clavicle.
2. PA Projection
 Closer OID. Improved recorded detail.

15
  Patient is prone or standing upright (back to the x-ray tube).
 CR: Perpendicular central ray exits midshaft of the clavicle.
3. AP Axial Projection – Lordotic Position
 If patient cannot assume lordotic position, PA axial projection can be used for improved recorded detail.
 The patient seat or stand 1 foot in front of the vertical cassette device and have the patient lean
backward.
 Respiration: Suspend at the end of full inspiration to further elevate and angle the clavicle.
 CR: Directed to enter the midshaft of the clavicle.
o Thinner patients require more angulation to project the clavicle off the scapula ribs.
o For standing, 0 to 15 degrees is recommended.
o For supine, 15 to 30 degrees is recommended.
4. PA Axial Projection
 Similar to AP Axial projection
 Differences
o Patient is prone or standing, facing the vertical grid device.
o The central ray is angled 15 to 30 degrees caudad.
5. Tangential Projection
 Similar to AP axial projection, however increase angulation is required placing the CR nearly parallel to
the rib cage. The clavicle is projected free of the chest wall.
 Patient is supine.
 CR: 25 to 45 degrees from the horizontal passing between the clavicle and the chest wall.
o If medial third of the clavicle is in question, it is necessary to angle the central ray laterally, 15 to
25 degrees.
6. Tangential Projection – Tarrant Method
 For patients who have multiple injuries or who cannot assume the lordotic position.
 Ask the patient to lean forward and let him/her hold the cassette on his lap.
 Respiration: Suspend.
 CR: Directed anterior and inferior to the midshaft of the clavicle at a 25 to 35 degree angle. It should
pass perpendicular to the longitudinal axis of the clavicle.
 Increased SID is needed to reduce magnification.

Scapula
1. AP Projection
 Upright or supine position.
 Abduct the arm at right angle with the body to draw the scapula laterally. Flex the elbow, and support
the hand.
 Position the top of the cassette 2 inches (5 cm) above the top of the shoulder.
 Respiration: Make this exposure during slow breathing to obliterate lung detail.
 CR: Perpendicular to midscapular area at a point approximately 2 inches (5 cm inferior to the coracoid
process)
2. Lateral Projection – (RAO or LAO)
 Patient upright facing the vertical grid.
 Body rotation 45 to 60 degrees.
 For acromion and coracoid process – flex elbow and place the hand on the posterior thorax.
o Mazujian suggested that the patient place the arm across the upper chest by grasping the
opposite shoulder.
 For body of scapula – extend arm upward and rest the forearm on the head or across the upper chest by
grasping the opposite shoulder.
 Respiration: Suspend.
 CR: Perpendicular to the midmedial border of the protruding scapula.
3. PA Oblique Projection – Lorenz and Lilienfeld Methods – (RAO or LAO)
 Upright or lateral recumbent
 Lorenz – arm of the affected side at right angle to the body, flex elbow, and rest the hand against the
patient’s head. Rotate body slightly forward and have the patient grasp the side of the table.
 Lilienfeld – Extend the arm of the affected side obliquely upward, and have the patient rest the hand on
his or her head.
 Respiration: Suspend.
 CR: Perpendicular to the cassette, between the chest wall and the midarea of the protruding scapula.
4. AP Oblique Projection – (RPO or LPO)
 Supine or upright

16
  For moderate APO projection – flex elbow, place supinated hand under the head or have the patient
extend affected arm across anterior chest. Patient turn away from the affected side to rotate shoulder
15 to 25 degrees.
 For steeper oblique projection – rotate body 25 to 35 degrees.
 For direct lateral projection of the scapula – draw the arm across the chest and adjust the body rotation
to place the scapula perpendicular to the cassette.
 Respiration: Suspend.
 Central Ray: Perpendicular to the lateral border of the rib cage at the midscapular area.
5. Coracoid Process – AP Axial Projection
 Supine
 Abduct arm slight and supinate the hands.
 Respiration: Suspend at the end of exhalation for more uniform density.
 CR: Coracoid process at an angle of 15 to 45 degrees cephalad.
o Kwak, Espiniella and Kattan recommend 30 degrees. (Round-shouldered patients require more
angulation)

Scapular Spine
 Tangential Projection - Laquerriere-Pierquin Method
• Supine
• Respiration: Suspend
• CR: Directed through the posterosuperior region of the shoulder at an angle of 45 degrees. (35 degrees
for obese and round-shouldered patients)

IV. Lower Extremity

Divisions of the lower LIMB
 Foot  Thigh
 Leg  Hip

Foot
 Phalanges – 14
o Bones of the toes – (14)
 Metatarsals – 5
o Bones of the instep – (5)
 Tarsals – 7
o Bones of the ankle – (7)
 Calcaneus
 Talus
 Navicular bone
 Cuboid
 Medial Cuneiform
 Intermediate Cuneiform
 Lateral Cuneiform

Leg
 Tibia
 Fibula

17
 Ankle

Femur

Patella

Lower limb articulations

18
Toes
1. AP or AP Axial Projections
 Supine or seated
 Flex the knees, separate feet about 6 inches (15 cm)
 CR: Perpendicular through the 3rd Metatarsophalangeal joint.
o For joint spaces, direct 15 degrees posteriorly or use 15-foam wedge and CR is perpendicular.
2. PA Projection
 Patient in prone
 CR: Perpendicular to the midpoint of the cassette entering the 3rd metatarsophalangeal joint.
3. AP Oblique Projection – Medial Rotation
 Supine or seated.
 Flex knee of the affected side. Medially rotate the lower leg and foot to form 30 to 45-degree angle.
 Center the proximal phalanx of the 3rd toe to the cassette.
 CR: Perpendicular and entering the 3rd metatarsophalangeal joint.
4. PA Oblique Projection – Medial Rotation
 Patient in lateral recumbent on the affected side.
 Ball of the foot forms 30 degrees from the horizontal.
 CR: Perpendicular to the third metatarsophalangeal joint.
5. Lateral Projections – (Mediolateral or Lateromedial)
 Lateral recumbent position on the unaffected side.
 CR: Perpendicular to the plane of the cassette or film, entering the metatarsophalangeal joint of the
great toe or the proximal interphalangeal joint oft the lesser toes.

Sesamoids
1. Tangential Projection – Lewis and Holly Method
 Lewis
o Patient in prone.
o Elevate the ankle and perform dorsiflexion.
o CR: Perpendicular and tangential to the first metatarsophalangeal joint.
 Holly
o Patient is seated.
o Plantar surface is at 75 degrees with the plane of the cassette, let the patient hold a strip of
gauze bandage.
o CR is directed perpendicular to the head of the first metatarsal bone.
2. Tangential Projection - Causton Method
 Patient in lateral recumbent position on the unaffected side, and flex knees.
 CR: Directed to the prominence of the first metatarsophalangeal joint at an angle of 40 degrees toward
the heel.

Foot
1. AP or AP Axial Projection
 CR: Directed one of the two ways:
o 10 degrees toward the heel to the base of the third metatarsal.
o Perpendicular to the cassette and toward the base of third metatarsal.
 Used for localizing foreign bodies, determining the location of fragments in fractures of the metatarsals
and anterior tarsals, and performing general surveys of the bones of the foot.
2. AP Oblique Projection – Medial Rotation
 Patient in supine position.
 Rotate leg medially until foot forms 30 degrees from the plane of the cassette.
 CR: Perpendicular to the base of the third metatarsal.
 Sinus tarsi is seen on profile.
3. AP Oblique Projection – Lateral Rotation
 Patient in supine.
 Rotate leg laterally until plantar surface of the foot forms 30 degrees to the cassette.
 CR: Perpendicular to the base of the third metatarsal.
4. PA Oblique Projections – Grashey Methods – (Medial or Lateral Rotations)
 Patient in prone.
 Rotate heel 30 degrees medially - For interspace between 1st and 2nd metatarsal.
 Rotate heel 20 degrees laterally - For interspaces between 2nd and 3rd, 3rd and 4th, and 4th and 5th
 CR: Perpendicular to the base of the third metatarsal

19
 5. PA Oblique Projection – Medial Rotation
 Patient in lateral recumbent on the affected side.
 Turn the patient toward the prone position until the foot forms 45 degrees to the cassette.
 CR: Perpendicular to the midline of the foot at the level of the base of the 5th metatarsal.
6. Lateral Projection – Mediolateral
 Routinely used.
 Patient lie and turn toward the affected side until leg and foot are lateral.
 CR: Perpendicular to the base of the 3rd metatarsal.
7. Lateral Projection – Lateromedial
 Supine, turn the patient onto the unaffected side. The patient’s body will be in RPO or LPO.
 CR: Perpendicular to the base of the third metatarsal.
8. Longitudinal Arch – Lateral Projection (Lateromedial) – Weight-bearing Method (Standing)
 CR: Perpendicular to a point just above the base of 3rd metatarsal.
 Used to demonstrate the structural status of the longitudinal arch.
9. AP Axial Projection - Weight-Bearing Method (Standing)
 SID – 48 inches (122 cm)
 CR: Angled 10 degrees toward the heel, between feet at the level of the base of the 3rd metatarsal.
10. AP Axial Projection – Weight-Bearing Composite Method (Standing)
 CR: 1st exposure – 15 degrees posteriorly to the base of 3rd metatarsal
o 2nd exposure – 25 degrees anteriorly to the posterior surface of the ankle.

Congenital Clubfoot
 Talipes Equinovarus
• Plantar flexion and inversion of the calcaneus (equinus)
• Medial displacement of the forefoot (adduction)
• Elevation of the medial border of the foot (supination)
 Kite Method – AP and Lateral Projection
 Kandel Method – Axial Projection (Dorsoplantar)

1. AP Projection – Kite Method

 Demonstrates the degree of adduction of the forefoot and the degree of inversion of the calcaneus.
 CR: 15 degrees posteriorly through the tarsals
2. Lateral Projection (Mediolateral) – Kite Method
 Demonstrates the anterior talar subluxation and the degree of plantar flexion (equinus).
 CR: Perpendicular to the midtarsal area.
3. Axial Projection (Dorsoplantar) – Kandel Method
 Infant is held vertical or bending forward.
 CR: 40 degrees anterior through the lower leg.
Calcaneus
1. Axial Projection – Plantodorsal
 Patient is in supine or seated with legs fully extended.
 Long strip of gauze around the ball of the foot. Perform dorsiflexion.
 CR: cephalic angle of 40 degrees to the long axis of the foot and enters the base of the third metatarsal.
2. Axial Projection – Dorsoplantar
 Patient in prone.
 CR: 40 degrees caudally to the long axis of the foot, enters the dorsal surface of the ankle.
3. Weight-Bearing “Coalition Method”
 Described by Lilienfeld.
 Used for the demonstration of calcaneotalar coalition.
 CR: Angled exactly 45 degrees anteriorly through the posterior surface of the flexed ankle to a point on
the plantar surface at the level of the base of 5th metatarsal.
4. Lateral Projection – Mediolateral
 Supine and turn the patient toward the affected side.
 CR: Perpendicular to the midportion of the calcaneus, which is about 1 inch (2.5 cm) distal to the medial
malleolus.
 Sinus Tarsi.
5. Lateromedial Oblique Projection – Weight-Bearing Method
 Medially at a caudal angle of 45 degrees to enter the lateral malleolus.
 For diagnosing stress fractures of the calcaneus or tuberosity.
 Sinus tarsi, calcaneal tuberosity, cuboid

20
Subtalar Joint
 Calcaneus ha 3 articular surfaces: anterior, middle and posterior
• Located superior calcaneus and articulate with the inferior talus.

1. PA Axial Oblique Projection – Lateral Rotation

 Best demonstrates the anterior and posterior articulations.
 Lie on the affected side in the lateral position.
 Ball of the foot is 25 degrees.
 CR: Directed to the ankle joint at a double angle of 5 degrees anterior and 23 degrees caudal.
 “end-on” image of the sinus tarsi
2. AP Axial Oblique Projection – Broden Method – (Medial Rotation)
 Lateromedial and mediolateral right-angle oblique projections for the demonstration of the posterior
articular facet of the calcaneus to determine the presence of joint involvement in cases of comminuted
fracture.
 Patient in supine.
 CR: Angled cephalad 40, 30, 20, 10 degrees. Four separate images. 2 or 3 cm caudoanteriorly to the
lateral malleolus
3. AP Axial Oblique Projection – Broden Method – (Lateral Rotation)
 Patient in supine, rotate leg and foot 45 degrees laterally.
 CR: Directed to a point 2 cm and 2 cm anterior to the medial malleolus, at a cephalic angle of 15 degrees
for the first exposure.
o Two or three images may be made with 3 or 4 degree difference in CR.
 Posterior facet of the calcaneus. The articulation between the talus and sustentaculum tali.
4. Isherwood Method
 Medial rotation foot – position for the demonstration of the anterior talar articular surface.
 Medial rotation ankle – position for the middle talar articular surface.
 Lateral rotation ankle – for the posterior articular surface.
5. Lateromedial Oblique Projection – Isherwood Method – (Medial Rotation Foot)
 Semisupine or seated
 45-degree foam wedge under elevated leg.
 CR: Perpendicular to a point 1 inch (2.5 cm) distal and 1 inch (2.5 cm) anterior to the lateral malleolus
 Fiest-Mankin method produces a similar image representation
 Anterior talar articular surface
6. AP Axial Oblique Projection – Isherwood Method- (Medial Rotation Ankle)
 Seated and flex hip and thigh of the affected side.
 CR: Directed to a point 1 inch (2.5 cm) distal and 1 inch (2.5 cm) anterior to the lateral malleolus at an
angle of 10 degrees cephalad.
 Middle articulation of the subtalar joint and an “end-on” image of the sinus tarsi.
7. AP Axial Oblique Projection – Isherwood Method – (Lateral Rotation Ankle)
 Supine or seated
 CR: Directed to a point 1 inch (2.5 cm) distal to the malleolus at an angle of 10 degrees cephalad.
 Posterior subtalar articulation

Ankle
1. AP Projection
 CR: Perpendicular to the ankle joint at a point midway between the malleoli.
 The inferior tibiofibular articulation and the talofibular articulation will not be “open” nor shown in the
true AP projection.
2. Lateral Projection – (Mediolateral)
 Patella perpendicular to the horizontal.
 CR: Perpendicular to the ankle joint, entering the medial malleolus.
3. Lateral Projection – (Lateromedial)
 Medial side of the ankle should be in contact with the cassette (recommended)
 CR: Perpendicular through the ankle joint entering ½ inch (1.3 cm) superior to the lateral malleolus
4. AP Oblique Projection – (Medial Rotation)
 Supine
 Rotate leg and foot 45 degrees medially.
 CR: perpendicular to the ankle joint, entering midway between the malleoli.
5. Mortise Joint – AP Oblique (Medial Rotation)
 Supine

21
  Rotate leg and foot 15 to 20 degrees internally until the intermalleolar plane is parallel with the
cassette.
 CR: Perpendicular, entering the ankle joint midway between the malleoli.
 Mortise Joint.
6. AP Oblique Projection – (Lateral Rotation)
 Laterally rotate leg and foot 45 degrees.
 CR: Perpendicular, entering the ankle joint midway between the malleoli.
 Useful in determining fractures and demonstrating the superior aspect of the calcaneus.
7. AP Projection – Stress Method
 Obtained after inversion or eversion injury to verify presence of ligamentous tear.

Leg
1. AP Projection
 Patient in supine.
 Perpendicular to the center of the leg.
2. Lateral Projection – (Mediolateral)
 CR: Perpendicular to the midpoint of the leg.
3. AP Oblique Projecitons – (Medial and Lateral Rotations)
 Patient in supine.
 Rotate the leg 45 degrees medially for medial rotation; 45 degrees laterally for lateral rotation.
 CR: Perpendicular to the midpoint of the cassette.

Knee
1. AP Projection
 Patient in supine
 Center the cassette about ½ inch (1.3 cm) below the patellar apex.
 Femoral epicondyles parallel to the cassette.
 CR: Directed to a point ½ inch (1.3 cm) inferior to the patellar apex with angle of 5 to 7 degrees
cephalad.
2. PA projection
 Patient in prone position
 CR: Perpendicular to exit a point ½ inch (1.3 cm) inferior to the patellar apex.
3. Lateral Projection (Mediolateral)
 Patient supine and turn to the affected side.
 Flex knee 20 to 30 degrees is preferred because it relaxes the muscles and shows the maximum volume
of joint cavity.
 To prevent fragment separation in new or unhealed patellar fractures, the knee should not be flexed
more than 10 degrees.
 CR: Directed to the knee joint 1 inch (2.5 cm) to the medial epicondyle at an angle of 5 to 7 degrees
cephalad.
4. AP Projection – Weight-Bearing Method (Standing)
 Leach, Gregg, and Siber – recommended that a bilateral weight-bearing AP projection be routinely
included in the radiographic examination of the arthritic knees.
 CR: Horizontal and perpendicular to the center of the cassette, entering at a point ½ inch (1.3 cm) below
the apices of the patellae.
5. PA Projection – Weight-Bearing Method (Standing Flexion)
 Flex knees to place the femurs at an angle of 45 degrees.
 CR: Horizontal and angled 10 degrees caudad through the tibiofibular joint spaces located ½ inch (1.3
cm) below the patellar apices.
 For a weight-bearing study of single knee, the patient puts full weight on the affected side.
6. AP Oblique Projection – (Lateral Rotation)
 Externally rotate the limb 45 degrees.
 CR: Directed ½ inch (1.3 cm) inferior to the patellar apex.
7. AP Oblique Projection – (Medial Rotation)
 Medially rotate limb 45 degrees.
 CR: Directed ½ inch (1.3 cm) inferior to the patellar apex.
8. PA Oblique Projection – (Lateral Rotation)
 Patient in prone.
 Elevate hip of the affected side.
 Rotate toes and knees 45 degrees.

22
  Holmblad recommended that the knee be flexed about 10 degrees.
 CR: Perpendicular through the joint a level ½ inch (1.3 cm) below the patellar apex.
9. PA Oblique Projection – (Medial Rotation)
 Patient in prone.
 Elevate hip of the unaffected side.
 Medially rotate leg and foot 45 degrees medially.
 CR: Perpendicular through the knee joint at the level ½ inch (1.3 cm) below the apex of the patella.

Intercondylar Fossa
1. PA Axial Projection – Holmblad Method
 “tunnel” projection, described by Holmblad in 1937.
 Kneeling position.
 In 1983, was modified for standing position.
 3 variations
o Upright with knee on stool
o Standing using horizontal central ray
o Kneeling on radiographic table
 Flex the knee 70 degrees from full extension (20-degree difference from CR.)
 CR: Perpendicular to the lower leg, entering the midpoint of the cassette for all three positions.
2. PA Axial Projection – Camp-Coventry Method
 Patient in prone position.
 Flex the patients knee 40 or 50 degrees rest the foot on suitable support.
 CR: Perpendicular to the long axis of the leg and centered to the knee joint.
o Angled 40 degrees when the knee is flexed 40 degrees and 50 degrees when the knee is flexed
50 degrees.
 Used to detect loose bodies (joint mice).
 Used in evaluating split and displaced cartilage in osteochondritis dissecans and flattening, or
underdevelopment, of the lateral femoral condyle in congenital slipped patella.
3. AP Axial Projection – Beclere Method
 Curved cassette is preferred.
 Patient is supine.
 Long axis of the femur is 60 degrees to the long axis of the tibia.
 CR: Perpendicular to the long axis of the tibia, entering the knee joint ½ inch (1.3 cm) below the patellar
apex.

Patella
1. PA Projection
 Prone position.
 Rotate heel 5 to 10 degrees laterally.
 CR: Perpendicular to the midpopliteal area exiting the patella.
2. Lateral Projection – Mediolateral
 Patient in lateral recumbent position and turn onto the affected side.
 Flex affected knee approximately 5 to 10 degrees.
 CR: perpendicular to cassette, entering the knee at the midpatellofemoral joint.
3. PA Oblique Projection – (Medial Rotation)
 Patient in prone.
 Flex patient’s knee approximately 5 to 10 degrees.
 Medially rotate knee 45 to 55 degrees from the prone position.
 CR: Perpendicular to cassette, exiting the palpated patella.
4. PA Oblique Projection – (Lateral Rotation)
 Patient in prone.
 Flex knee 5 to 10 degrees, and externally (laterally) rotate knee 45 to 55 degrees.
 CR: Perpendicular to the cassette exiting the palpated patella.
5. PA Axial Oblique Projection – Kuchendorf Method – (Lateral Rotation)
 Prone and elevate the affected hip 2 or 3 inches.
 Rotate knee 35 to 40 degrees laterally.
 CR: Directed to the joint space between the patella and the femoral condyles at and angle of 25 to 30
degrees caudad.

23
Patella and Patellofemoral Joint
1. For Patellar Subluxation
 Laurin – knee flexed 20 degrees
 Fodor, Malott, and Weinberf amd Merchant – Knee flexion of 45 degrees.
 Hughston – Knee flexed 55 degrees, CR 45 degrees.
2. Tangential Projection – Hughston Method
 Prone
 Leg forms 50 to 60 degrees from the table and rest foot against collimator.
 CR: 45 degrees cephalad and directed through the patellofemoral joint.
3. Tangential Projection – Merchant Method
 SID – 6 ft (2 m) to reduce magnification.
 Knee flexion 40 degrees (may vary from 30 to 90)
 Used axial viewer device.
 CR: Perpendicular to the cassette
o With 40-degree knee flexion, angle the CR 30 degrees caudad from the horizontal plane.
4. Tangential Projection – Settegast Method
 This should not be attempted until a transverse fracture of patella has been ruled out with lateral image.
 Acute flexion.
 CR: Perpendicular to the joint space between the patella and the femoral condyles when the joint is
perpendicular.

Femur
1. AP Projection
 Patient in supine.
 Ensure that the pelvis is not rotated.
 Rotate limbs internally 10 to 15 degrees.
 CR: Perpendicular to the midfemur and the center of the cassette.
2. Lateral Projection – (Mediolateral)
 Turn into the affected side.
 Flex knees 45 degrees.
 CR: Perpendicular to the midfemur and the center cassette.
 For danger of fracture displacement, vertical cassettes may be used.

V. Pelvis and Upper Femora

Pelvis
 Serves as a base for the trunk and a girdle for the attachment of the lower limb.
 Pelvis is consist of 2 hip bones, the sacrum and the coccyx.
 Pelvic girdle is composed only of 2 hip bones.

Hip Bone
 Os coxae or innominate bone
 Consist of ilium, pubis and ischium

24
 Articulations of the pelvis

Male and Female Pelvis

Localizing Anatomic Structures

 Iliac Crest  Greater Trochanter of the femur
 ASIS  Ischial Tuberosity
 Pubic Symphysis  Tip of the coccyx

Pelvis and Upper Femora

 AP Projection
• Supine
• Flex elbow and rest hands on the upper chest
• Rotate feet 15 to 20 degrees medially to place the femoral necks parallel with the plane of the cassette.
• Center the cassette midway between the ASIS and pubic symphysis. 2 inches (5 cm) inferior to the ASIS,
and 2 inches (5 cm) superior to the pubic symphysis.
• Respiration: Suspend.
• CR: Perpendicular to a point approximately 2 inches superior to the pubic symphysis.
• Martz and Taylor – 2 AP projections: to demonstrate the relationship of the femoral head to the
acetabulum in patients with congenital hip dislocation.
• 1st – obtained with the CR perpendicular to pubic symphysis – to detect any lateral or superior
displacement if the femoral head.
• 2nd – 45 degrees cephalad to the pubic symphysis – to detect anterior and posterior
displacement.

Pelvis and Upper Femora

 Lateral Projection – (Right or Left)
• Lateral recumbent, dorsal decubitus, or upright position
• Berkebile, Fischer, and Albrecht – recommended dorsal decubitus lateral projection of the “gull-wing
sign” in cases of fracture dislocation of the acetabular rim and posterior dislocation of the femoral head.
• Respiration: Suspend.
• CR: Perpendicular to a point centered at the level of soft tissue depression just above the greater
trochanter (approximately 2 inches or 5cm)

25
Pelvis and Hip Joints
 Axial Projection – Chassard-Lapine Method
• 3 Purposes
• Measuring the horizontal, or biischial, diameter in pelvimetry.
• Determine the relationship of the femoral head to the acetabulum.
• Demonstrate the opacified rectosigmoid portion of colon.
• Contraindicated for patients with suspected fracture or pathologic condition.
• Posterior part of the knee is in contact with the edge of the table.
• Pelvis is tilted 45 degrees.
• CR: Perpendicular through the lumbosacral region at the level of the greater trochanters.

Femoral Necks
1. AP Oblique Projection – Modified Cleaves Method
 Bilateral “frog leg” position
 Contraindicated for patient suspected of having a fracture or other pathologic condition.
 Abduct thigh, approximately 45 degrees.
 Respiration: Suspend.
 CR: Perpendicular to enter the patient’s midsagittal plane at the level of 1 inch (2.5 cm) superior to the
pubic symphysis.
o For unilateral, direct CR to the femoral neck.
2. Axiolateral Projection – Original Cleaves Method
 Patient in supine position.
 Contraindicated for patient suspected of having a fracture or other pathologic condition.
 Respiration: Suspend.
 CR: Parallel with the femoral shafts. (may vary from 25 to 45 degrees)
3. Congenital Hip Dislocation
 Andren-von Rosen Approach – bilateral hip projection with both legs forcibly abducted to at least 45
degrees and inward rotation of femora.
 Knake and Kuhns – construction of a device that controlled the degree of abduction and rotation of both
limbs.

Hip
1. AP projection
 Patient is supine.
 Rotate lower limb and foot medially 15 to 20 degrees.
 Respiration: Suspend.
 CR: Perpendicular to the femoral neck.
2. Lateral Projection – (Mediolateral) – Lauenstein and Hickey Method
 Contraindicated for patient suspected of having a fracture or other pathologic condition.
 Demonstrate the hip joint and the relationship of the femoral head to the acetabulum.
 Supine then rotate patient toward the affected side.
 Respiration: Suspend.
 CR: Lauenstein: Perpendicular through the hip joint (midway between ASIS and pubic symphysis.
o Hickey: cephalic angle of 20 to 25 degrees.
3. Axiolateral Projection – Danelius-Miller Method
 Supine.
 Flex the knee and hip of the unaffected side to elevate the thigh in vertical position.
 Rotate foot medially 15 or 20 degrees.
 Place cassette in the vertical position with its upper border in the crease above the iliac crest.
 Respiration: Suspend.
 CR: Perpendicular to the long axis of the femoral neck. The CR enters midthigh and passes through the
femoral neck about 2 ½ inches (6.4 cm) below the point of intersection of the localization lines.
4. Axiolateral Projection – Clements-Nakayama Modification
 Patients with bilateral hip fractures, bilateral hip arthroplasty, or limitation of movement of the
unaffected leg.
 Limbs in neutral position.
 Respiration: Suspend.
 CR: Directed 15 degrees posteriorly and aligned perpendicular to the femoral neck and grid cassette.

26
 5. Axiolateral Projection – Leonard-George Method
 Supine.
 Flex the hip and knee of the unaffected side and abduct the thigh.
 Place the cassette in the vertical position, well up between the thighs and center to the femoral neck of
the affected side.
 Rotate foot internally 15 to 20 degrees. (to overcome anterversion of the femoral neck)
 Respiration: Suspend.
 CR: Lateromedially and perpendicular to the long axis of the femoral neck. CR enters the lateral surface
of the hip above the soft tissue depression just above the greater trochanter.
6. Axiolateral Projection – Friedman Method
 Contraindicated for patient suspected of having a fracture or other pathologic condition.
 Lateral recumbent position on the affected side.
 Respiration: Suspend.
 CR: Directed to the femoral neck at an angle of 35 degrees cephalad.
o Kisch – 15 or 20 degrees cephalad.
7. PA Oblique Projection – Hsieh Method (RAO or LAO)
 Demonstration of posterior dislocations of the femoral head in cases other than acute fracture
dislocations.
 Semiprone position on the affected side.
 Elevate unaffected side 40 to 45 degrees.
 Respiration: Suspend.
 CR: Perpendicular to the midpoint of the cassette passing between the posterior surface of the iliac
blade and the dislocated femoral head.
 Urist – Right or left posterior oblique (AP) position for the demonstration of the acetabulum in acute
fracture dislocation injuries of the hip.
8. Mediolateral Oblique Projection – Lilienfeld Method (RAO or LAO)
 Contraindicated for patient suspected of having a fracture or other pathologic condition.
 Lateral recumbent on the affected side.
 Roll the upper body slightly forward about 15 degrees.
 CR: Perpendicular to the midpoint of the cassette, traversing the affected hip joint.
 Respiration: Suspend.
 Colonna – affected side up, (body rotated 17 degrees anteriorly)
o Separates the shadows of the hip joints
o Gives the optimum projection of the slope of the acetabular roof and depth of socket.

Acetabulum
1. PA Axial Oblique Projection – Teufel Method (RAO or LAO)
 Semiprone on the affected side.
 Elevate the unaffected side so that the anterior surface of the body forms 38 degrees from the table.
 Respiration: Suspend.
 CR: Directed through the acetabulum at an angle of 12 degrees cephalad. CR enters at the inferior level
of the coccyx and approximately 2 inches (5 cm) lateral to the midsagittal plane toward the side being
examined.
2. AP Oblique Projection – Judet Method – (RPO or LPO)
 Judet and Letournel described two 45-degree posterior oblique positions useful in diagnosing fractures
of the acetabulum.
o Internal oblique (affected side up) position
o External oblique (affected side down) postion
 CR: Perpendicular through the acetabulum.
3. Axiolateral Projection – Dunlap, Swanson, and Penner Method
 2 exposures is made on the same image receptor. The patient should not move.
 Seated-upright
 Respiration: Suspend.
 CR: Directed to the crest of the ilium at a medial angle of 30 degrees (first from one side and then from
the other).

Anterior Pelvic Bones

1. PA Projection
 Patient in prone position.
 Respiration: Suspend.

27
  CR: Perpendicular to the midpoint of the cassette. CR enters the distal coccyx and exits the pubic
symphysis.
2. AP Axial Projection – Taylor Method
 Patient in supine position
 Respiration: Suspend.
 CR:
o males – 20 to 35 degrees cephalad and centered to a point 2 inches (5 cm) distal to the superior
border of the pubic symphysis.
o Females – 30 to 45 degrees cephalad and centered to a point 2 inches (5 cm) distal to the upper
border of the pubic symphysis.
3. Superoinferior Axial Projection – Lilienfeld Method
 Seated-upright position
 Flex knees, lean backward 45 or 50 degrees.
 Respiration: Suspend.
 CR: Perpendicular to the midpoint of the image receptor and entering 1 ½ inches (3.8 cm) superior to
the pubic symphysis.
4. PA Axial Projection – Staunig Method
 Prone position.
 Respiration: Suspend.
 CR: 35 degrees cephalad exiting the pubic symphysis on the midsagittal plane anteriorly at the level of
the greater trochanters.

Ilium
 AP and PA Oblique Projections.
• RPO and LPO
• Patient is supine
• Elevate the unaffected side approximately 40 degrees.
• Respiration: Suspend.
• RAO and LAO
• Patient is prone.
• Elevate the unaffected side approximately 40 degrees.
• Respiration: Suspend.
• CR: Perpendicular to the midpoint of the cassette.

Practice Question:

A. Identification: Identify the method used for each procedure described below.

1. PA Axial Projection of the anterior pelvic bones

2. Superoinferior axial projection of the anterior pelvic bones
3. AP axial Projection of the anterior pelvic bones
4. Axiolateral projection of the acetabulum
5. PA Axial Oblique Projection of the Acetabulum
6. AP Oblique Projection of the Acetabulum
7. Mediolateral Oblique Projection of the hip
8. PA Oblique Projection of the hip
9. Lateral Projection of the Hip
10. “Bilateral Frog Leg Position”
11. “Sunrise View”
12. PA Axial Oblique Projection of the Patella
13. AP Axial Projection of the Intercondyllar fossa
14. “Tunnel projection”
15. Weight-Bearing “Coalition Method”
16. Dorsoplantar Axial Projection of the congenital clubfoot
17. PA Oblique projections of the foot
18. Lateromedial tangential Projection of the sesamoids
19. Tangential Projection of the sesamoids
20. Axial Projection of the Pelvis and hip joints
21. Tennis elbow
22. Tangential projection of the Scapular Spine
28
 23. Tangential projection of the clavicle
24. AP axial Projection of the acriomioclavicular joint
25. AP projection of First Carpometacarpal Joint
26. AP Oblique Projection of the hands
27. PA axial projection of the scaphoid
28. Scaphoid series
29. PA Axial Oblique Projection of the wrist
30. Tangential Projection of the carpal canal
31. Transthoracic Lateral Projection
32. Rolled –Film Axial Projection of the shoulder joint
33. AP Oblique Projection of the glenoid cavity
34. Tangential Projection of the supraspinatus “Outlet”
35. Demonstration of Hill-Sachs Defects
36. Tangential Projection of the intertubercular groove
37. Subscapular Insertion
38. Bilateral AP projection of the Acromioclavicular joint
39. PA Oblique Projection of the shoulder joint
40. Infraspinatus Insertion

B. Enumeration:
1. Enumerate the six bony landmarks used in radiography of the pelvis and hips.
2. Name the seven tarsal bones.
3. Name at least 4 joints that can be found in your pelvis.
4. Name at least 4 joints in your lower limb.
5. Name the three division of your foot.
6. Name the different body planes.
7. Name at least four internal organs that can be found in the abdominal cavity.
8. Identify the different body habitus.
9. Name the nine region of the abdomen.
10. Give at least 3 functions of your bone.
11. Identify the different bone classifications.
12. Identify the classifications of the joints.

C. Supply the other term for each given anatomy:

1. scaphoid
2. Lunate
3. Triquetrum
4. trapezium
5. trapezoid
6. capitate
7. hamate
8. intertubercular groove

D. Answer the following questions:

1. Differentiate position and projection.
2. Differentiate the location of the internal organs of a hypersthenic and asthenic patient?
3. Why is it that we need to increase the SID for some radiographic procedures?
4. Why is it that we need to decrease the SID for some radiographic procedures?
5. How can you practice radiation protection? Give at least 3 examples.
6. Differentiate male and female pelvis.

E. Identify the correct terminology for each item.

1. Movement of part away from the central axis of the body or body part.
2. Inward turning of the foot at the ankle.
3. Rotation of the forearm so that the palm is up.
4. A term used to describe the body part as seen by the image receptor.
5. Refers to sole of the foot.
6. Refers to parts nearer the point of attachment, point of reference, origin, or beginning; toward the center of
the body.
29
 7. Refers to parts toward the head of the body.
8. Club-shaped process
9. Term given to the development and formation of bones
10. The position in which the central ray skims between body parts to profile a bony structure and project it free
of superimposition.

F. Multiple Choice: Encircle the letter of the BEST answer.

1. The esophagus is ___________ to the trachea.
A. anterior B. posterior C. medial D. lateral
2. The head is __________to the neck.
A. proximal B. distal C. superior D. inferior
3. The arm is ___________ to the forearm.
A. ventral B. dorsal C. proximal D. distal
4. The right ear is __________ to the nose.
A. medial B. lateral C. anterior D. posterior
5. The carpals are ______________ to the digits.
A. superior B. inferior C. proximal D. Distal

G. Define each following terms.

1. Central Ray:
2. Radiograph:
3. Collimation:
4. SID:
5. OID:

H. Fill in the blanks. Give the surface landmarks for each structure.

1. C1 8. T7
2. C2, C3 9. T10
3. C5 10. L3
4. C7 11. L3, L4
5. T1 12. L4
6. T2, T3 13. S1
7. T4, T5 14.Coccyx

Jeremiah 29:11
For I know the plans I have for you,” declares the Lord, “plans to prosper you and not to harm you, plans to give you hope
and a future.

30