Lower Limb 2

1
Lower Limb 2

• Calcaneum,Subtalar Joints,
• Tibia Fibula
• Knee
• Denise Ogilvie
• August 2007

2
Lateral Calcaneus (medio lateral)

• Position
• As for lateral ankle
• CP 2.5 cm distal to medial malleolus
• CR Perpendicular

3
Critique

• No rotation of calcaneus
• Appropriate density to view talus, tuberosity,
  sinus tarsi, soft tissue
• Demonstrate ankle joint and adjacent tarsals

4
Axial Calcaneus

• Position
• Supine or seated with legs extended
• Gauze bandage around foot
• Patient flexes ankle as much as possible
• CP midpoint of IR base of 3rd metatarsal
• CR 40 degrees cepahalic

5
Critique

• Demonstrate calcaneus subtalar joint
• No rotation
• Even exposure over posterior as well as anterior
  portion- use filter or 2 separate exposures

6
Oblique Sub-talar joint

• Position
• Patient on affected side in lateral position
• Flex uppermost knee
• Roll slightly forward from lateral so heel
  elevated approx 4cm
• CP to ankle joint
• CR 5 degrees anterior 23 degrees caudal

7
Evaluation

• Open sub talar joint
• Sinus tarsi
• Lateral malleolus in profile

8
Isherwoods view

• Positioning
• Semi supine or seated turn away from side
  examined
• Flex knee so ankle at right angle flexion
• Lean leg foot medially
• 45 degree foam under elevated leg
• CP 2.5 cm distal 2.5cm anterior to lateral
  malleolus
• CR Perpendicular

9
Critique

• Anterior talar articular surface demonstrated
• Oblique view of tarsals

10
Brodens view (sub-talar joint) medial rotation

• Position
• Patient supine with sandbag under each knee
• Dorsi flex ankle until foot vertical (bandage if
  required)
• Rotate 45 degrees medially
• CP 3cm medially to lateral malleolus
• CR 40, 30, 20, 10 degrees cephalad (4 views)

11
Critique

• Ant and post portions of sub talar joint

12
Brodens view (subtalar joint) Lateral rotation

• Positioning
• As for medial rotation
• Rotate leg and foot 45 degrees laterally
• CP 2cm anterior and 2 cm distal to medial
  malleolus
• CR 15 degrees cephalad

13
Critique

• Posterior sub talar joint

14
AP Tibia Fibula

• Positioning
• Patient supine
• No rotation of pelvis
• Foot vertical femoral condyles parallel with IR
• Flex ankle so foot vertical
• Include both joints
• CP Centre of tib and fib
• CR Perpendicular

15
Critique

• Both joints on film
• No rotation
• Proximal and distal articulations of tib fib
  moderately overlapped
• Midshaft free of overlap

16
Lateral Tibia Fibula

• Positioning
• Rotate patient towards affected side- laterally
• Patella perpendicular with IR
• Support with sandbags, sponges
• Flex knee to help with position

17
Critique

• Both joints demonstrated
• Distal fibula over post tibia
• Slight overlap of tibia on proximal fibular head

18
AP knee

• Position
• Supine-no rotation of pelvis
• IR directly under patients knee
• Adjsut leg so patella is central over femur
• CP Through knee joint 1.5cm distal to apex of
  patella
• CR Variable from 5 degrees caudal to 5 degrees
  cephalad

19
Thin pelvis
Average pelvis
Large pelvis
20
Critique

• Open femoro-tibial joint space
• Patella centrally superimposed on femur
• Slight imposition of fibular head over tibia
• Bony soft tissue detail

21
Lateral knee

• Position
• Patient on affected side
• Knee in front of or behind affected leg
• Flexion of 20-30 degrees
• Support under ankle
• Patella perpendicular to IR
• CP To knee joint 2.5 cm distal to medial
  epicondyle
• CR 5-7 degrees cephalad

22
Critique

• Femoral condyles superimposed
• Open joint space
• Patella lateral
• Fibular head and tibia slightly superimposed
• 20-30 flexion

23
Lateral knee rotation

• Identify adductor tubercle (medial condyle)
• Less superimposition of fibular head over tibia
  if over rotated

24
AP Knees Weight-bearing

• Patient standing back of knees against erect
  bucky or IR
• Toes forward or whatever to centre the patella
• Equal weight on both feet
• CR-1.3cm below apex of patella
• To show joint narrowing which may appear normal
  in supine view in arthritis

25
Intercondylar AP

• Knee flexed (femur at 60 deg to tibia)
• Support knee
• Place IR under knee
• CR perpendicular to long axis of tibia, 1.3cm
  below patella apex
• Shows intercondylar fossa, eminance and knee
  joint
• Patella not seen in fossa, no rotation

26
Intercondylar PA

• Patient prone, knee flexed 40-50 deg, rest foot
  on support
• CR perpendicular to the long axis of leg to the
  knee joint (popliteal depression)
• Looking for foreign bodies, and femoral condyles
  in osteochondritis dissecans

27
Axial Patella

• Patient seated near end of table, lower legs
  hanging half off table, knees supported by angled
  sponge. Quads relaxed but knees together
• Film placed vertically on femurs
• Tube angled depending on knee flexion about 15
  deg CR to patella apex
• Shows patella in profile, open patellofemoral
  joint

28
Oblique Knees p316 317 Merrills