PPV 2013 /

IMAGING SERVICES

LAST REVISION DATE:JUNE 2013

ABDOMEN

*Cervical collars, casts, braces, etc. shall not be removed unless specifically requested by the referring physician.

ABDOMEN (1 image)

  • KUB

ABDOMEN: R/O OBSTRUCTION(2 images)

  • AP Supine
  • Upright or Decubitus

ACUTE ABDOMEN SERIES (3 images)

  • PA Chest
  • AP Supine
  • Upright or Decubitus

ABDOMEN: R/O AORTIC ANEURYSM (2 images)*Do not do a shoot through lateral.

  • AP Supine
  • LPO

ABDOMEN: POST COLONOSCOPY

  • If requisition states: pt with pain or r/o perforation, an Upright KUB should be performed first

BACLOFEN PUMP EN FACE

  • AP of baclofen pump, to include the entire length of wires into the thoracic/lumbar cavity
  • Lateral of baclofen pump, to include the spine to follow the wires into the thoracic/lumbar cavity

IMAGING SERVICES

LAST REVISION DATE: JUNE 2013

CHEST/THORAX

*Cervical collars, casts, braces, etc. shall not be removed unless specifically requested by the referring physician.

CHEST (2 images)

  • PA Chest
  • Lateral

**note: when taking special views such as apical lordotic, decubitus, or obliques, consult the ordering physician if they would like a PA and Lateral chest as well IF the patient has not had them done previously. An additional order must be placed by the physician.**

RIBS UNILATERAL (4 images)

  • AP Upper Ribs
  • Posterior Oblique Upper Ribs
  • AP Lower Ribs
  • Posterior Oblique Lower Ribs

RIBS BILATERAL (6 images)

  • AP Upper Ribs
  • AP Lower Ribs
  • Posterior Oblique Upper & Lower Ribs

STERNUM (3 images)

  • RAO
  • LAO
  • Lateral

STERNOCLAVICULAR JOINTS (3 images)

  • PA Projection
  • RAO & LAO

STERNOCLAVICULAR JOINTS: R/O DISLOCATION (4 images)

  • AP
  • PA Projection
  • RAO & LAO

IMAGING SERVICES

LAST REVISION DATE:JUNE 2013

DR HERZBERG

SHOULDER:AP 30° caudal angle

Supra outlet

Supine Axillary

True AP External Rotation

AP Internal Rotation

KNEE:Standing AP

Standing Lateral

Merchant (Bilateral)

Salt Lake (Bilateral)

PELVIS/HIP:Standing Pelvis

Roll out Lateral

FOOT:Weight bearing images if possible

AP

Oblique

Lateral (if possible)

ANKLE:Weight bearing images if possible

AP

Mortise

Lateral (if possible)

IMAGING SERVICES

LAST REVISION DATE:JUNE 2013

DR HERZKA

SHOULDER:True AP (Grashey)

Zenca

Supra Outlet

Supine Axillary

KNEE:Standing AP

Salt Lake (Bilateral – Wants to see joint space open)

Lateral

Lauren (Bilateral – Pointy sunrise)

PELVIS:Standing AP (NGS)

HIP:Frog Leg Lateral

IMAGING SERVICES

LAST REVISION DATE:JUNE 2013

DR HUFF

KNEE:Weight bearing if possible

AP

Lateral

Merchant (Bilateral)

Salt Lake (Bilateral)

FOLLOW UP/POST-OP KNEE:

Weight bearing if possible

AP

Lateral

Sunrise (affected side only)

PELVIS/HIP:Standing Hip-Centered Pelvis

Supine AP Hip

Supine Lateral Frog Leg (if bilateral ordered – take hip images unilaterally)

IMAGING SERVICES

LAST REVISION DATE:JUNE 2013

DR MIRZA

CLAVICLE:

WITH HARDWARE:

AP (Supine)

35° Caudal angle (Supine)

*Images should look like surgery images

WITHOUT HARDWARE:

Standard Protocol

IMAGING SERVICES

LAST REVISION DATE:JUNE 2013

LOWER EXTREMITY

*Cervical collars, casts, braces, etc. shall not be removed unless specifically requested by the referring physician.

**In trauma cases, include both joints if possible; otherwise, include joint nearest to area of injury.

FEMUR (2 – 4 images)

  • AP
  • Lateral

KNEE: NON-TRAUMA (2 images)

  • AP
  • Lateral

KNEE: TRAUMA (2 - 3 images)

  • AP
  • Lateral
  • Sunrise

INTERCONDYLAR FOSSA

  • Camp Coventry Method

TIBIA-FIBULA (2 – images)

  • AP
  • Lateral

ANKLE: TRAUMA & NON-TRAUMA (3 views)

  • AP
  • Mortise
  • Lateral

FOOT: TRAUMA & NON-TRAUMA (3 views)

  • AP
  • Medial Oblique
  • Lateral

OS CALCIS (2 images)

  • Axial
  • Lateral

TOE (3 images)

  • AP (AP of the entire foot, with arrow pointing to the affected toe)
  • Oblique (of affected toe only)
  • Lateral (of affected toe only)

BONE LENGTH STUDY (1 image)

  • AP OF ENIRE HIP TO ANKLE (include femoral head to ankle joint)
  • Be sure to use aluminum filter to avoid burn out of the bottom of the legs
  • Ruler taped to board
  • Average technique 80@100

IMAGING SERVICES

LAST REVISION DATE:JUNE 2013

SPECIAL VIEWS – LOWER

AXILLA:

  • Patellar tilt, Patellar subluxation,

  • Sulcus angle:
    - for assessment of femoral dysplasia;
    - sulcus angle averages 137 to 141 deg;
    - in patients w/ subluxation, the mean sulcus angle is 147 deg, with a range of 137 to 172;
    - references:
    - Shape of the intercondylar groove normally and in recurrent dislocation of the patella: A clinical and x-ray anatomical investigation.
    - Technique Pearls:
    - for x-ray to be meaningful, both knees should be included at the same time for comparison;
    - knees should be flexed in range of 20 to 45 deg, since more flexion will generally reduce most patellofemoral abnormalities;
    - Merchant technique
    - used to evaluate subluxation;
    - Laurin technique:
    - lateral patellofemoral angle is index of tilt but not of subluxation;
    - patellar alignment assessed using lateral patellofemoral angle on axial views, made w/ knee in 20 deg of flexion;
    - angle formed by lateral patellar facet & line drawn across most prominent aspects of anteriorportion of femoral trochlea should be open laterally in normal patellofemoral joint;
    - Stress Axilla View:
    - in some cases, there will be impressive differences between static and dynamic axilla knee views;
    - made with the knee flexed 35 deg off the end of the x-ray table;
    - a constant lateral pressure is exerted on to the patella in an attempt to displace the patella laterally;
    - comparisons should be made between the symptomatic and asymptomatic knees;
    - Sunrise View:
    - used to image a tangential view of the patella;
    - the patient is prone with the knee flexed 115 deg;
    - central beam is directed toward the patella with 15 deg cephalic tilt

BRODENS:

  • Patient is supine with knee slightly flexed and supported by a sandbag
  • Supine with leg internally rotated 30° in neutral flexion
  • CR directed toward the lateral malleolus
  • Images obtaind at 10°, 20°, 30°, & 40° of cephalic tilt to see all aspects of posterior facet from front to back (40° showing anterior and 10° showing posterior)
  • Sub-types
  • Lateral oblique view
  • Patient is supine with inner border of foot placed on cassette and the sole inclined 45°
  • Central beam directed vertically centered 1 in. below and 1 in. anterior to the tip of the lateral malleolus
  • Lateral oblique axial
  • Foot is passively everted, dorsiflexed and externally rotated 60°
  • Central beam centered 1 inch below tip of medial malleolus with 10 deg cephalic tilt
  • Medial oblique axial
  • Patient is supine
  • Foot is passively dorsiflexed, inverted, and internally rotated 60°
  • Broden described a similar projection with limb internally rotated 45°
  • Broden recommended taking four exposures with the CR andgled 40°, 30°, 20°, and 10° cephalad to see all aspects of posterior facet from front to back.

CANALE AND KELLY:

  • Modified radiographic technique used for assessing fractures of the talar neck
  • Technique performed with cassette placed under the foot
  • Ankle is placed in maximal equinus facilitated by flexion of the hip and knee
  • Foot is pronated approximately 15°, while the CR is directed cephalad at a 75° angle from the horizontal table top
  • View shows lateral profile of the talus without superimposed osseous structures and the fracture and its reduction

DR CRAWFORD KNEE SIZE AND ALIGNMENT (GKNAL3):

  • 1ST View:AP standing knee. Place magnification/sizing marker on lateral side of knee straddling the joint space
  • 2nd View:Lateral single standing knee with magnification/sizing marker centered and anterior to the joint
  • 3rd View:hip to ankle image (scoliosis cassettes)

** Most images done at CHH**

DUNNE:

  • SUPINE
  • Have patient bend knee up towards affected hip
  • Keep foot on table or supported with footstool
  • Flex knee until femur is approximately 75°-85° from tabletop
  • Keep hip and knee in AP position
  • Image as an AP Hip on 10X12 cassette
  • STANDING
  • Have patient lift knee/femur of affected side up
  • Support foot with footstool or other device
  • Lift knee/femur until 15°-25° from horizontal
  • Keep hip and knee in AP position

Image as an AP Hip on 10X12 cassette

FALSE PROFILE:

  • 1st View:Upright pelvis
  • 2nd View:Oblique patient 60° towards hip in question.
  • Hip in question is next to upright bucky and foot is parallel with the bucky. The other foot is pointed (90°) towards tube.
  • Use 14X17 cassette crosswise.
  • Top of film at crest.
  • Both hips on film.
  • Both femoral heads should be seen and be at least 3 finger spaces apart when looking at it on the monitor.

FERGUSON (LUMBAR):

  • PA View of the lumbar spine at L5-S1
  • 20° caudad angle to open up joint space
  • Cone down to L5-S1 area
  • Central ray should be 2” above crests

**If done AP - 20 cephalad angle**

FERGUSON (SI JOINTS):

  • AP view done at a 35° cephalad angle
  • CR centered 1” above symphysis pubis
  • Use 10X12 cassette lengthwise

FLAMINGO VIEW:

  • 2 Views
  • Both views are imaged as an AP pelvis
  • 1st View:patient in AP standing position, and transfers weight on to one leg
  • 2nd View:patient in AP standing position, and transfers weight on to opposite side

**The entire pelvis should be visualized**

GRAVITY STRESS VIEW:

  • Cross table AP view of the ankle

JUDET:

  • Internal (Obturator) Oblique View:
  • Shows iliopectineal line anterior column of pelvis & posterior wall
  • Patient is supine with involved side of pelvis rotated anteriorly 45 deg & beam directed vertically toward affected hip
  • External (Iliac) Oblique View:
  • Shows ilioischial line (posterior) column & anterior wall
  • Patient is supine with uninvolved side of pelvis rotated ant. 45 degrees
  • Central beam directed vertically toward the affected hip
  • Intra-operative flourscopy: it may be difficult to achieve optimal flouroscopy views if the C-arm is placed on the same side as the fracture
  • Rotating the injured side to a lower position may improve the view;

    - Diagrams:

INLET/OUTLET:

  • Inlet View of the Pelvis: (caudad projection)
  • Caudad projection, also called inlet view, best demonstratesring configuration of pelvis, & narrowing or wideningof diameter of ring is immediately apparent
  • Evaluates for posterior displacement of pelvic ring oropening of pubic symphysis
  • TECHNIUQE:
  • X-ray is parallel to plane of sacrum, & sacrum is seen onend w/ vertebral body anteriorly & sacral lamina posteriorly
  • Patient is positioned as in AP view of pelvis w/ beam tilted25 degree caudally
  • Taken by directing X-ray beam 60 deg from head to mid pelvis,is best radiographic view to demonstrate posterior displacement
  • Outlet View: (cephalad projection)
  • Cephalad projection, also called the outlet or tangential view,shows the anterior ring superimposed on the posterior ring
  • Evaluates for vertical shift of pelvis (migration of hemipelvis)
  • Proximal or distal displacements of anterior or posterior portion of ring are best appreciated on this view
  • Sacrum appears in its longest dimension, w/ neural foramina evident
  • TECHNIQUE:
  • X-ray beam is perpendicular to plane of sacrum
  • Patient is positioned as in AP view of pelvis with beam tilted 35 degcephalad

VAN ROSEN:

  • Used to evaluate femoral head reduction in child with suspected congenital hip dislocation/subluxation
  • Patient is supine with hips abducted 45° and maximally internally rotated
  • AP projection of pelvis
  • Must hold legs in position

Calibration Marker for hips/pelvis

Dr. Schabel and Dr. Huff both want their AP pelvis and AP hip to have a visible calibration marker on them.

For both doctors AP Standing, hip centered pelvis with calibration and AP Standing hip with calibration

Lateral for Schabel = Cross table/shoot through

Lateral for Huff = Frog leg or roll out

For the calibration marker to be accurate, it must be placed on the outside of the patient’s affected leg. Placing it in between the legs, in front of or behind the leg is inaccurate.

When placing the marker first find the greater trochanter. Place the marker ball on that spot. There is no wiggle room for the marker to be moved toward the front or back of the patient; however the marker may be moved upward toward the iliac crest or downward toward the knee as long as it is still in the same line front to back as the trochanter.

We are measuring magnification from the OID created by the patient’s rear end and soft tissue; therefore the OID from the marker ball to the bucky must be the same as the greater trochanter to the bucky.

For larger patients:

Having the patient reach the hand of the affected side down and push the marker ball into their soft tissue is one way to have it be visible on a larger patient. If that doesn’t work look for any spot that you can see a tiny bit of light behind the patient, move the ball upward or downward to that spot keeping in line front to back with the greater trochanter and have the patient push the ball inward.

Also you can off center the patient to give them a little more room on the affected side along with the above method.

If there is still no seeing the ball, then you may have to take 2 images to get the ball on 1 and a centered pelvis on the other. The patient can be off centered pretty far as long as both hip joints are still visible on the image with the marker ball. The centered image is for the radiologist to be able to accurately read the images.

IMAGING SERVICES

LAST REVISION DATE:JUNE 2013

METASTIC BONE SURVEY

** Send to PACS in this order:

LATERAL SKULL & C-SPINE

  • Do both on 1 - 14 x 17" cassette at upright bucky, with patient sitting.

LATERAL T-SPINE

  • Do not collimate tight

LATERAL L-SPINE

  • Do not collimate tight

AP UPPER RIBS & SHOULDERS

  • Do UPPER RIBS AND SHOULDERS on a transversely positioned 14X17 cassette

AP LOWER RIBS & L-SPINE

  • Open cone on AP L-SPINE to include LOWER RIBS

AP PELVIS

AP RIGHT & LEFT FEMUR

AP RIGHT & LEFT HUMERUS

IMAGING SERVICES

LAST REVISION DATE:JUNE 2013

PELVIS

*Cervical collars, casts, braces, etc. shall not be removed unless specifically requested by the referring physician.

**In trauma cases, include both joints if possible; otherwise, include joint nearest to area of injury.

PELVIS (1 image)

  • AP

INLET & OUTLET VIEWS (2 images)

  • Inlet (use 14"x17" cassette)
  • Outlet (use 14"x17" cassette)

HIP: NON-TRAUMA (2 images)

  • AP Hip-Centered Pelvis
  • Lateral Frogleg If unable to do a frogleg lateral, do a roll out lateral instead.

HIP: NON-TRAUMA FOR TOTAL HIP PROSTHESIS (2 images) *Include entire prosthesis on both views.

  • AP Pelvis
  • Lateral Rollout

HIP: TRAUMA (2 images)

  • AP Hip-Centered Pelvis
  • Axiolateral(shoot through lateral) When there are bilateral hip fractures, do the Clements-Nakayama modification.

JUDET VIEWS (2 images)

  • RPO & LPO (perform on a 14"x17" and include both hip joints on each image)

IMAGING SERVICES

LAST REVISION DATE:JUNE 2013

SKULL

*Cervical collars, casts, braces, etc. shall not be removed unless specifically requested by the referring physician.

SKULL (3 images)

  • AP/PA Skull
  • AP Towne
  • Lateral

FACIAL BONES (3 images)

*include mandible on all views*

  • PA Waters
  • Modified Waters
  • Lateral

MANDIBLE (5 images)

  • PA Projection
  • PA Axial Projection
  • Lateral
  • Bilateral AxiolateralObliques

ZYGOMATIC ARCHES (4 images)

  • PA Waters
  • AP Modified Towne
  • Bilateral Tangential Projections

NASAL BONES (3 images)

  • PA Waters
  • Bilateral Laterals

TEMPOROMANIDBULAR JOINTS (TMJs) (5 images)

  • Bilateral Axiolateral Oblique Projections, with open (when not contraindicated) and closed mouth
  • AP Modified Towne

PARANASAL SINUSES (4 images) *cone to sinuses, patient must be upright*

  • PA Caldwell
  • PA Waters
  • Lateral
  • SMV

ORBITS: TRAUMA & FOREIGN BODY (NOT PRE-MRI) (3 images)

  • PA Waters
  • PA Modified Waters
  • Lateral

ORBITS: PRE-MRI (2 images)

  • PA Waters*
  • Lateral

*a second PA waters will only be performed if instructed to by a Radiologist

OPTIC FORAMEN (2 images)

  • Bilateral Parietoorbital Oblique Projections (Rhese Method)

SELLA TURCICA (3 images)

  • Lateral
  • AP Towne
  • PA Caldwell

MASTOIDS (5 images)

  • Bilateral Stenvers
  • Bilateral Laws
  • AP Towne

IMAGING SERVICES

LAST REVISION DATE:JUNE 2013

SPINE

CERVICAL:

*Cervical collars, casts, braces, etc. shall not be removed unless specifically requested by the referring physician.

C-SPINE; ROUTINE (3 – 4 images)

  • AP
  • Lateral
  • Swimmers (Perform if unable to view C7 – T1)
  • Odontoid

C-SPINE OBLIQUES (2 images)

  • RAO & LAO

C-SPINE FLEXION & EXTENSION (2 images)

  • Flexion
  • Extension

TRAUMA C-SPINE

Trauma patients suspected of having severe injury to the cervical spine will receive a portable lateral view of the spine prior to the standard C-spine studies. It is of importance that the spine is cleared through C7 – T1. This may be accomplished by obtaining a lateral while the physician pulls on the patient's arms or by placing the patient in a swimmer's position (the technologist may need to over penetrate the mid section of the spine in order to visualize C7 – T1). The emergency room triage physician determines the neck trauma status prior to ordering images. Upon the completion of the lateral image, the triage physician will determine whether a consultation is necessary with the radiology staff. When it is determined that consultation is needed, the radiologist or resident will report to the emergency room for assistance and decide what further views are to be taken.

Policy for Clearing Cervical Spine:

When cervical spines need to be cleared, the AP, Lateral, and odontoid (and swimmer's view if necessary) should be shown to a radiology resident or staff. If the radiology resident or staff feels that it is safe to go ahead with flexion and extension views, this should be documented by that individual in the patient's chart.

  • If a cervical collar is present, it may then be removed and lateral flexion and extension views of the cervical spine are done with the patient flexing and extending unassisted.
  • If the C7 – T1 level is not demonstrated on the routine views, swimmer's lateral should be taken as well during the flexion and extension views.
  • In the uncooperative or incoherent patient who has normal AP, lateral, and odontoid views, it will be necessary for the referring attending staff or house staff to position the patient for the flexion and extension views.

Clearance under fluoroscopy is not to be done.

POST TRAUMA C-SPINE: FOR CLEARING C-SPINE (3 images)

  • AP
  • Cross-Table Lateral
  • Odontoid

*perform a swimmers view if unable to see C7 – T1.

SOFT TISSUE NECK:

  • LATERAL
  • To include tip of nose through the back of the C-spine.
  • Patient must inhale through their nose at time of exposure.
  • Use soft tissue technique.
  • If AP is requested, elevate chin to visualize trachea.

THORACIC: