Professional Documents
Culture Documents
Lower Limb Radiography
Lower Limb Radiography
MODERATOR :
PRESENTED BY:
MR. Ram Singh(Lech)
LALITA PANDAY
Deptt. Of Radio-
B.Sc. MED. TECH.(X-RAY)
diagnosis And Imaging
2ND YEAR
PGIMER, CHANDIGARH
1
INTRODUCTION
The radiography of lower limb
includes the radiography of the :-
Foot
Ankle joint
Leg
Knee joint
Femur
Hip joint
EQUIPMENT
The equipment should have the provision of
floating table, revolving stool, vertical cassette
holder.
4
INDICATIONS:
Fracture
Dislocation
Pathology
Foreign body
Flat foot
VIEWS:
Dorsiplantar
Dorsiplantar oblique
Lateral .
Lateral for flat foot
5
A. For fracture and dislocation of
metatarsal-DP & DP OBL.
6
DORSIPLANTAR VIEW OF THE
FOOT
8
EVALUATION CRITERIA
The foot should L
be free of
rotation. L
Phalanges, tarsal
bones as well as
metatarsal bones
should be seen.
9
DORSIPLANTAR OBLIQUE(FOR
MT DISLOCATION)
Medial oblique
From the DP position the leg
is rotated medially, until the
sole of the foot makes an
angle of 30* with film
metatarsal is seen.
EVALUATION CRITERIA
3rd & 5th metatarsal base L
should be free of L
superimposition.
Most of the tarsals should be
demonstrated better than
dorsiplantar position.
Tarso metatarsal and inter
tarsal joints should be
visualized.
Sinus tarsi should be seen.
Base of 1st & 2nd metatarsal
should be superimposed.
11
LATERAL OBLIQUE
From the DP position the
leg is rotated laterally,
until the sole of the foot
makes an angle of 30*
with film.
12
EVALUATION CRITERIA
1st & 2nd
rt
metatarsal base
should not overlap
medial &
intermediate
cunieform should
not superimpose
navicular better
seen in medial obl
FOOT LATERAL VIEW
It is done to see the dislocation & the foreign
body.
• Metatarsals should
superimposed.
15
RADIOGRAPHY OF FLAT FOOT
16
Contd…
17
Contd…
CR-passes horizontally through base
of 5th metatarsal.
EVALUATION CRITERIA:
Plantar aspect of the metatarsal
bone should superimposed.
Entire foot and distal leg included
Fibula over laps posterior part of
tibia.
18
Contd…
19
RADIOGRAPHY OF SESAMOID 20
BONE
Sesamoid bone is present at 1st
metatarsopharyngial joint of foot.
It can be seen in
lat and axial projection of foot.
Axial projection:-
2 ways to do axial
views are
Patient sitting on x-ray
table & cassette held firmly
against the instep or under
the Ankle . Flexion at the
jt. is aided by a tightened
bandage passed around the
digit of great toe with leg
fully extended.
C.R:- passing
perpendicular to 1st
metatarsopharyngeal jt.
Contd.
C.R:- Passes
perpendicular to 2nd
metatarsopharyngeal
jt. 22
EVALUATION CRITERIA
Sesamoid should
be projected free
L
of 1st metatarsal.
Metatarsal head
should be clearly
demonstrated
ANKLE JOINT
This is the synovial
joint of the hinge
variety.
Trauma
Pathology
Subluxation (torn lateral ligament)
25
RADIOGRAPHY OF ANKLE JOINT
VIEWS:
AP
MEDIOLAT
LAT
LATEROMEDIAL
MEDIAL
OBLIQUE
LATERAL
STRESS VIEW
26
AP VIEW
The patient is made to lie
down in the supine position.
A small sand bag is placed
under the knee joint for
support. flex the ankle and
the foot enough to place the
long axis of the foot in the
vertical position and
prependicular to the
cassette. Rotate the leg
medially to bring the malleoli
in the same plane i.e.
equidistant from the film.
30
LAT. VIEW
(LATEROMEDIAL):-
32
ANKLE JOINT – OBLIQUE VIEWS
MEDIAL
OBLIQUE(INTERNAL
OBLIQUE):
33
EVALUATION CRITERIA
1. Distal tibia & fibula
may demonstrate
some overlap of L
talus.
2. Distal tibia, fibula &
talus should be
included.
3. Talus, distal tibia &
fibula should be
adequately
penetrated
34
LATERAL OBLIQUE
(EXTERNAL OBLIQUE)
From the AP
position the leg is
rotated laterally
through 45* and
supported by non
opaque triangular
block.
CR-passes midway
between the
malleoli.
35
EVALUATION CRITERIA
1. The talocalcaneal
joint should be
seen .
L
2. The calcaneal
sulcus( superior
portion of
calcaneus) is
demonstrated .
36
ANKLE JOINT (STRESS STUDY)
38
L lt
inversion
CALCANEUM(HEEL)
It is the largest tarsal bone, is more
or less cuboid in shape. It projects
posteriorly & medially at distal
posterior part of the foot directed
inferiorly. The log axis of calcaneus
form an angle of approximately 30*,
open forwarded with the sole of foot.
INDICATIONS:
FRACTURE.
PATHOLOGY.
TRAUMA.
CALCANEUM SPUR (extra growth of
the calcaneum)
41
VIEWS:
LAT
AXIAL
OBLIQUE
42
LATERAL VIEW
43
EVALUATION CRITERIA
No rotation of
calcaneus rt
sinus tarsi should
be visualized.
Ankle & adjacent
tarsal should be
included
45
RADIOGRAPHY OF OSTRIGONUM
EVALUATION CRITERIA:
MEDIAL OBLIQUE:
EVALUATION rt
CRITERIA:-
58
VIEWS:
AP
LAT
OBLIQUE –it is done to see the
1. The introssues space between the
tibia and the fibula.
2. Proximal & distal tibiofibular joint.
59
AP VIEW
The patient is made to lie
down in the supine
position with the leg fully
extended. The ankle is
dorsiflexed & the leg
rotated medially until
medial & lateral malleoli
are equidistant from the
film. A pad is placed
against the plantar aspect
of the foot to maintain the
position. we must include
the joint close to the
injury.
60
Evaluation criteria
1. Both ankle & knee joint
should be included in one
or more films .
2. Proximal & distal
articulation of tibia &
fibula should have
moderate overlapping.
3. Ankle & knee joint should
be in true AP position.
4. Density should visualize
trabecular detail & soft
tissue for entire leg.
61
LATERAL VIEW
From the AP position the
patient is turned to 90* to
the affected side .Support
the leg in the position with
sandbags. If the patient is
unable to turn to the
affected side, the film
should supported vertically
against the medial side of
the leg & the beam
directed horizontally.
62
Contd.
1. Both ankle & knee joint should
be included in one or more
films .
2. Slight overlap of tibia on the
proximal fibular head is
normal.
3. Distal fibula should lie over
posterior half of tibia.
4. Ankle & knee joint should not
be rotated.
5. Femoral condyles may not be
superimposed because of
divergence of beam.
6. Moderate separation of tibia &
fibular shaft should be seen.
63
OBLIQUE VIEW
MEDIAL OBL
From AP position, patient
is turned 45* to medial
side. Support the leg at
45* sponge wedge.
64
EVALUATION CRITERIA
lt
1. Proximal & distal tibio
fibular articulations
should be
demonstrated.
2. Maximum
interosseous space
should be seen b/w
the tibia & fibula.
3. Ankle & knee joint
should be included.
65
Lateral oblique
From AP position,
patient is turned
45* to lateral side.
Support the leg at
45* sponge
wedge.
C.R. :- passes
through middle of
film
66
EVALUATION CRITERIA
1. Fibula is
superimposed by
lateral portion of lt
tibia.
2. Ankle & knee joint
should be
included.
67
Knee joint
The knee is the largest and
the most complex joint of the
body. It is synovial hinge
type of joint.
Two menisci, one medial &
one lateral condyles are
interposed between the
articular surface of tibia & the
condyles of femur. The jt. is
enclosed in an articular
capsule & held
together by numerous
ligaments.
68
Indications for the knee joint
Trauma
Loose bodies
Pathology
For Subluxation-lat view with limb raised and
suspended, lat view in standing is done.
For Tibial tubercle –Both knee lat is done for
comparison on single film.
For Semilunar Cartilages – PA Obl.
For Intercondylar fossa – Axial view is done.
69
RADIOGRAPHY OF THE KNEE
JOINT
BASIC VIEWS:
AP
LAT
OBLIQUE
PA
70
AP VIEW
The cassette is
centered half inch L
below the apex of
the patella.
C.R.:- is passing
perpedicularly 1”
below the apex of L
patella.
72
EVALUATION CRITERIA
74
Contd..
EVALUATION CRITERIA
1. The femoral condyles
should be
superimposed.
2. Joint space between the
femoral condyles and
tibia should be open.
3. Patella should be in lat
profile.
4. Femoropatellar space
should be open.
L 5. Soft tissue should be
included.
75
OBLIQUE VIEWS
76
PA
MEDIAL OBLIQUE LATERAL OBLIQUE
PA MEDIAL OBLIQUE:
The patient is made to
lie down in the prone
position. Now rotate the
foot and the knee joint
internally so that it
makes an angle of 45*
with the film.
78
PA LAT OBLIQUE
Positioning is
same as that of the
pa medial oblique
but the foot is
rotated externally
so that it makes an
angle of 45* with
the film.
C-ray; passes through
the crease of the knee
joint
79
Evaluation criteria
1. Medial femoral & tibial
condyles should be well
demonstrated.
2. Knee jt. Should be seen and
open.
3. Fibula should be superimposed
over the lateral portion of tibia.
4. Patellar margin will project
slightly beyond the side of
femoral condyle.
5. Bony detail on distal femur &
proximal tibia should be
demonstrated.
80
AP
EXTERNAL(LATERAL) INTERNAL(MEDIAL)
EXTERNAL(LATERAL)
OBLIQUE:
From the AP position
rotate the leg laterally at
45*from the table.
Centre the cassette half
inch below the apex of
the patella.
C.R.:- is passing through
1” below the apex of
patella
81
AP MEDIAL OBLIQUE
From the AP
position the leg is
rotated medially so
that it makes an
angle of 45* with
the film.
C-ray; is passing
through 1” below
the apex of patella
82
NOTE:-
83
PATELLA
The patella is the largest
and most constant
sesamoid bone & situated
in the front of the lower
end of the femur about 1
cm above the knee joint.
84
RADIOGRAPHY OF PATELLA
VIEWS:
PA
LAT
PA –MEDIAL AND LATERAL OBLIQUE
AXIAL PROJECTIONS.
85
Lateral Horizontal View:
86
87
PA VIEW (for patella)
C.R.:- passes
through the crease
of the knee joint . R
91
SKYLINE VIEW
93
EVALUATION CRITERIA
AP AXIAL VIEW
97
Contd…
98
EVALUATION CRITERIA
Fossa should be open and well visualised.
Posteroinferior surface of the femoral condyles
should be demonstrated .
Intercondylar eminence and knee joint space
should be seen.
Soft tissue in the fossa and the interspace should
be seen.
Apex of the patella should not superimpose the
fossa.
Bony details on the intercondylar eminence,
distal femur and proximal tibia should be
demonstrated.
99
PA AXIAL (TUNNEL VIEW)
Patient is made to lie down in
prone position. Knee is flexed
to 40*& foot is kept on suitable
support. Place cassette under
knee & centre to apex of patella
more towards leg. Adjust knee
in true pa position with no
medial or lateral rotation.
C.R.- Passes through the crease of
knee jt. perpendicular to long
axis of leg. Means if leg is
flexed 40* than tube is angled
40* & if leg is flexed 50* than
tube is angled 50*
This view is also done to see
intercondylar fossa
100
This view can be done in 3 ways
1. Patient standing in
pa position with
knee flexed and
resting on stool at
the side of table.
101
Contd.
2. Patient standing at
the side of table
with affected knee
flexed & placed in
contact with front
of cassette.
102
Cond.
3. Kneeling on table
with knee over
cassette.
103
L
104
RADIOGRAPHY FOR SUBLUXATION
OF KNEE JOINT
There are two methods:-
1. Patient lie down in supine ,
105
contd.
2. Patient stand in lateral
position with cassette,
sound limb is placed
forward to affected limb &
affected limb take full
weight of body.
106
STRESS AP VIEW
This view is done in
case of the
subluxation of the
knee joint due to the
rupture of the
collateral ligaments.
The patient is
positioned as for the
basic AP projection of
the knee joint.
107
Contd.
The medical officer should
then forcibly abduct or
adduct the knee and must
wear the lead gloves and
apron.
C.R.:- midway between the
upper borders of the tibial
condyles with the central
ray directed at right angle
to the axis of the tibia.
Widening of the
femorotibial joint space
will be demonstrated on
the same side as a
ruptured ligament.
108
ANATOMY OF FEMUR
IT is the longest
bone of the body.
proximal end of the
femur consist of
head, neck & two
large processes
the greater& lesser
trochenter. The
head form hip jt.
Articulating with
acetabulam. 110
Contd.
In adult the neck project anteriorly from the
shaft at an angle of approximately 15*-20*&
superiorly at an angle of 120*-130* to long
axis of shaft.
111
RADIOGRAPHY OF FEMUR
BASIC VIEWS
AP
LAT
SPECIAL VIEWS
for neck of femur
shaft fracture
112
AP VIEW
Patient should lie down in
supine position . Centre the
affected femur with mid line
of table. Rotate the toes
approximately 15* internally
to overcome the anteversion
of the femoral necks.
113
EVALUATION CRITERIA
115
EVALUATION CRITERIA
1. Knee jt. should be
included.
2. There should be no
rotation of knee jt.
3. Trabecular detail
should be
demonstrated or
femoral shaft .
116
Lateral view of femur
117
EVALUATION CRITERIA
118
contd
119
For Shaft Fracture:
The patient remains on the
trolley or bed. If possible, the
leg may be slightly rotated to
centralize the patella b/w the
femoral condyles.
The cassette is supported
vertically against the lateral
aspect of the thigh, with the
lower border of the cassette at
the level of the upper border of
the tibial condyle.
The unaffected limb is raised
above the injured limb, with the
knee flexed & the lower leg
supported on a stool or
specialized support.
CR: - It is directed to the mid-
shaft of the femur.
120
L
NECK OF THE FEMUR
Lateral Horizontal Beam or
Axio-lateral view of
hip:-
This projection is used
in the suspected fracture
of the neck of the femur &
patient is unable to move.
Positioning:
The patient lies in supine
on the stretcher or a x-ray
table.
The legs are extended &
the pelvis adjusted to
make the median saggital
plane perpendicular to the
table top. This may not
always be possible if the
patient is great pain.
122
Contd.
If the patient is slender, it may be necessary to
place a non-radiopaque pad under the buttocks
so that the whole of the affected hip can be
included in the image.
123
Contd.
The cassette is supported in position by sand bags
or specific cassette holder.
125
ANATOMY OF HIP
Hip is the large irregular bone of the body. It
helps in the formation of pelvic girdle anteriorly
& laterally.it consist of three parts
Illium anteriorly, pubis anteroposteriorly, ishium
posteroinferiorly.
All the three parts enter into the formation of
acetabulam. pubis & ishium are separated by a
large opening called obturator foramen. The
pubis part of hip bone meet anteriorly to form
pubic symphysis.
126
HIP JOINT
128
INDICATIONS OF THE HIP JOINT
Dislocation
Fractured acetabulum
Prosthesis
129
RADIOGRAPHY OF HIP & FEMUR
For the radiograhic purposes the femur is
divided into two parts:
Upper 1/3rd with the hip joint:
Lower 2/3rd knee joint.
internally.
Contd…
CR-passes through
1” below the
midpoint of the line
joining the ASIS &
pubic symphysis of
the affected side .
L
131
Lateral –single hip
When pt. is able to move
,then the pt. is turned on
affected side, with flexion at
hip& knee jt , the pelvis is
tilted 45* backward & sound
limb raised & supported in
comfortable position. Centre
the affected hip jt. to centre
of bucky.
C.R.- Passes perpendicularly
through middle of upper 1/3rd
of femur or 1” below the line
joining the ASIS& pubic
symphysis.
132
EVALUATION CRITERIA
1. Hip joint should be
centred to radiograph.
2. Hip joint, acetabulam &
femoral head should be
well demonstrated.
3. Femoral neck will be
overlapped by the
greater trocanter in this
projection.
133
AP VIEW FOR BOTH THE HIP
JOINTS WITH UPPER FEMORA
The patient is made to lie
down in the supine position
with the midsagittal plane
of the body centered to the
centre of the bucky. The
legs are positioned in such
a way that toes of the feet
are touching each other
both the ASIS should be
equidistant from the film.
135
CONGENITAL DISLOCATION OF
THE HIP JOINT
Views:
AP
LAT
136
MODIFIED LATERAL VIEW
FROG LEG VIEW
It is done mainly for the
children. The patient is
made to lie down in the
supine position. The
midsagittal plane of the
body is centered to the
centre of the table. Legs
are flexed at the hip &
knee joint, soles of the
feet are touching each
other.
CR- passes through the p.s.
137
EVALUATION CRITERIA
Exposure should be such
that the femoral head is
penetrated & seen through
the acetabulum.
Adjacent region of the
illeum & pubic bone to L
symphysis pubis should be
included.
Greater trochanter should
be demonstrated in profile
Small amount of lesser
trochanter should be seen.
Hip joint acetabulum &
femoral head should be
well demonstrated.
138
VON & ROSEN METHOD
The patient is made to lie
down in the supine
position with each leg
abducted through
45*(producing a mutual
angle of 90*)and internally
rotated. so that the head
of the femur comes in the
lat position.
139
LOWER LIMB TRAUMA
While doing trauma radiography our aim is
to demonstrate the injured part in the
radiograph with minimal movement of the
patient or the injured part.
It may not always be possible to obtain
right projections as in the case when there
are large splints, back supports, traction
bars etc. in such cases we should obtain
the projection as near as right angle
possible.
RADIATION PROTECTION
142
PRECAUTIONS