17'2 AP Lower Leg

1
17.2 A-P Lower Leg

• Measure A-P at mid-lower leg
• Protection Apron draped over pelvis
• SID 40 Table top
• No Tube Angle
• Film 7x17 I.D. down or diagonal 14 x 17

2
A-P Lower Leg

• Patient lies on back on table.
• Leg internally rotated 15 until in true A-P
  position
• Film centered to include knee and ankle joints.
  The top of the film will be about 2 above knee.
• Horizontal CR is centered to film

3
A-P Lower Leg

• Vertical CR long axis of lower leg
• Collimation top to bottom From knee joint to
  ankle joint or slightly less than film size.
• Collimation side to side soft tissue of lower
  leg
• Instructions Remain still
• Make exposure and let patient relax.

4
A-P Lower Leg Film

• Must include both knee and ankle articulations
• No evidence of rotation
• As with this example, the 14 x 17 cassette can
  be turned diagonally to get both joint spaces on
  film.

5
17.3 Lower Leg Lateral

• Measure Lateral at mid lower leg
• Protection Apron draped over pelvis
• SID 40 Table Top
• No Tube Angle
• Film 7 x 17 I.D. down or diagonal 14x17
  Regular

6
Lower Leg Lateral

• Patient lies on affected side with lower leg in
  lateral position.
• Film centered under leg to get both knee joint
  and ankle joint on film. Top of film will be
  about 2 above knee joint.
• Horizontal CR centered to film

7
Lower Leg Lateral

• Vertical CR long axis of lower leg.
• Collimation top to bottom to include knee joint
  space and ankle joints
• Collimation Side to side soft tissues of lower
  leg.

8
Lower Leg Lateral

• Make sure that the knee and ankle are in lateral
  position. The condyles should be perpendicular to
  film and foot in lateral position.
• Collimation Top to Bottom include both knee
  joint space and ankle joints

9
Lower Leg Lateral

• Collimation Side to Side soft tissues of lower
  leg.
• Instructions Remain still
• Make exposure and let patient relax

10
Lower Leg Lateral Film

• Must include both knee and ankle joints.
• Both joints should be in true lateral positions.
• A 14 x 17 may be turned diagonally to get both
  joints on film.

11
Ankle Radiography

• Routine views at PCCW
• AP
• Mortise Oblique
• Medial Oblique
• Lateral
• We do both oblique views for Dr. Scuderi
• The mortise open the joints better
• The medial oblique demonstrates Jones Fractures.

12
A-P Ankle
13
17.4 Ankle A-P

• Measure A-P at malleoli
• Protection lead apron
• SID 40 Table Top
• No Tube Angle
• Film 1/2 of 12 x 10 extremity cassette I.D. up

14
Ankle A-P

• Patient is seated or lying on table. Leg is
  internally rotated until the leg is in a true
  A-P position position.
• The foot is dorsiflexed until the plantar surface
  is perpendicular to film.
• Horizontal CR at level of talo-tibial joint or
  malleoli.

15
Ankle A-P

• Half of film is centered to Horizontal CR.
• Vertical CR Long axis of lower leg.
• Collimation top to bottom distal lower leg to
  soft tissue below calcaneus. Slightly less than
  film size.

16
Ankle A-P

• Collimation side to side soft tissue of lower
  leg and ankle.
• Patient Instructions Remain still
• Make exposure and let patient relax.

17
Ankle A-P Film

• A-P on left.
• There should be no rotation as evidenced by the
  medial mortise joint being open.
• The talotibial joint should also be open.
• Soft tissue of plantar area of foot should be
  seen.

18
Ankle Oblique ViewsMortise Medial
19
Always take a medial obliqueMedial
Oblique Lateral Oblique
20
17.5 Ankle Medial Oblique

• Measure A-P at malleoli
• Protection lead apron
• SID 40 Table Top
• No Tube Angle
• Film 1/2 of 12 x 10 extremity cassette I.D. up

21
Ankle Medial Oblique

• Patient is seated or lying on table. Leg is
  internally rotated 45 from true A-P position
  position.
• The foot is dorsiflexed until the plantar surface
  is perpendicular to film.
• Horizontal CR at level of talo-tibial joint or
  malleoli.

22
Ankle Medial Oblique

• Half of film is centered to Horizontal CR.
• Vertical CR Long axis of lower leg.
• Collimation top to bottom distal lower leg to
  soft tissue below calcaneus. Slightly less than
  film size.

23
Ankle Medial Oblique

• Collimation side to side soft tissue of lower
  leg and ankle.
• Patient Instructions Remain still
• Make exposure and let patient relax.

24
Ankle Medial Oblique Film

• Oblique on right.
• The lateral malleolus should be clear of the
  talus.
• The medial mortise joint may be open
• The talotibial joint should also be open.
• The tarsal sinus will be open.

25
17.6 Ankle Mortise Oblique

• Measure A-P at malleoli
• Protection lead apron
• SID 40 Table Top
• No Tube Angle
• Film 1/2 of 12 x 10 extremity cassette I.D. up

26
Ankle Mortise Oblique

• Patient is seated or lying on table. Leg is
  internally rotated until the medial and lateral
  malleoli are parallel to the film , about 15 to
  20 .
• The foot is dorsiflexed until the plantar surface
  is perpendicular to film.
• Horizontal CR at level of talotibial joint or
  malleoli.

27
Ankle Mortise Oblique

• Half of film is centered to Horizontal CR.
• Vertical CR Long axis of lower leg.
• Collimation top to bottom distal lower leg to
  soft tissue below calcaneus. Slightly less than
  film size.

28
Ankle Mortise Oblique

• Collimation side to side soft tissue of lower
  leg and ankle.
• Patient Instructions Remain still
• Make exposure and let patient relax.

29
Ankle Mortise Oblique Film

• Oblique on right., Mortise on left
• The lateral malleolus should be clear of the
  talus.
• The medial mortise joint must be open
• The talotibial joint should also be open.

30
Lateral Ankle
31
17.7 Ankle Lateral

• Measure Lateral at malleoli
• Protection Lead Apron
• SID 40 Table Top
• No Tube Angle
• Film 8 x 10 I.D. up

32
Ankle Lateral

• Patient lies on the affected side with lower leg
  aligned with table center line.
• Foot dorsa-flexed to form a 90 angle with lower
  leg.
• Plantar surface of foot is perpendicular to film
  and malleoli are perpendicular to film.

33
Ankle Lateral

• Horizontal CR medial malleolus
• Vertical CR medial malleolus and long axis of
  lower leg.
• Collimation top to bottom distal tibia to soft
  tissue below calcaneus

34
Ankle Lateral

• Collimation side to side to include soft tissue
  around calcaneus and lower leg.
• Instructions Remain still
• Make exposure and let patient relax.

35
Ankle Lateral Film

• Must include distal tibia, talus and calcaneus.
• The talus domes must be superimposed.
• The fibula should overlie the distal tibia.
• The talotibial joint should be open.
• Note wrong I.D. location

36
18.2 Calcaneus Axial View

• Measure Lateral at calcaneus
• Protection Lead Apron
• SID 40 Table Top
• Tube Angle 40 cephalad
• Film 1/2 of 8x10 Extremity Cassette

37
Calcaneus Axial View

• Patient lies or sits on table with affected leg
  centered to table.
• Lower leg in true A-P position and foot
  dorsiflexed until the plantar surface is
  perpendicular to film.
• A strap or tape may be used for the patient to
  hold foot in dorsiflexion.

38
Calcaneus Axial View

• Horizontal CR 1.5 to 2 up the calcaneus
  tuberosity
• Film centered to Horizontal CR.
• Vertical CR long axis of foot.
• Collimation top to bottom to include all of
  calcaneus and adjacent soft tissues

39
Calcaneus Axial View

• Collimation Side to Side soft tissue of foot or
  slightly less than 1/2 of film.
• Instructions Remain still
• Make exposure and let patient relax.

40
Calcaneus Axial View Film

• The calcaneus tuberosity will be seen free of
  distortion.
• The Calcaneal-Talus joint space should be seen.
• If the foot is not properly dorsiflexed, the
  joint space will be closed and the tuberosity
  foreshortened.

41
18.3 Calcaneus Lateral View

• Measure Lateral at calcaneus
• Protection Lead Apron
• SID 40 Table Top
• No Tube Angle
• Film 1/2 of 8x10 Extremity Cassette

42
Calcaneus Lateral View

• Patient lies on table on affected side with
  affected leg centered to table.
• Lower leg in true lateral position and foot
  dorsiflexed.
• Horizontal CR 1.5 to 2 up the calcaneus
  tuberosity
• Film centered to Horizontal CR.

43
Calcaneus Lateral View

• Vertical CR through medial malleoli
• Collimation top to bottom to include all of
  calcaneus and adjacent soft tissues
• Collimation Side to Side soft tissue of foot or
  slightly less than 1/2 of film.

44
Calcaneus Lateral View

• Instructions Remain still
• Make exposure and let patient relax.

45
Calcaneus Lateral Film

• The calcaneus, talus and ankle should be
  demonstrated in a true lateral position.
• The domes of the talus will be superimposed.
• Soft tissues adjacent to the calcaneus and ankle
  should be visualized.

46
Formulating Technique Charts

• Accurate measurements and the used of technique
  charts will have the greatest impact on image
  quality and minimizing radiation exposure to the
  patient.
• Remember that over half of the repeated films are
  due to errors in the technical factors resulting
  in under or over exposed films.

47
Formulating Technique Charts

• Used equipment generally do not come with
  technique charts.
• If you buy someones practice, you may not get
  accurate charts.
• The complete x-ray chain must be in proper
  working order in order to establish accurate
  charts. Acceptance testing is a must!!!

48
Sources of Technique Charts

• If you have high frequency equipment, the Nolan
  Filter System and the screen speed matches those
  described in the text, baseline charts can be
  used based upon those in the text book.

49
Sources of Technique Charts

• Major x-ray equipment manufacturers may provide
  help with making technique charts for their
  equipment.
• Anatomically programmed generators have charts
  built into the unit. Make sure that they can be
  easily modified.
• Smaller dealer sold companies may not have the
  resources to provide much help.

50
Sources of Technique Charts

• Major film and screen manufacturers can be a
  source for help producing technique charts.
• The screens and film must match in order to get
  consistent results. The manufacturer can be a
  great help in this area.
• It is in the film manufacturers best interest
  that your films are of consistently high quality.

51
Types of Charts

• Fixed kVp charts are recommended because
• Optimum kVp for the body part is used
• Consistent contrast is maintained
• Reduced exposure for the patient
• Greater latitude of exposure.
• Fixed mAs charts lack these qualities.

52
Getting Started

• Make sure that the x-ray machine is properly
  calibrated across all mA stations.
• Make sure the processor is working properly and
  has fresh chemistry.
• The x-ray machine type (single phase, three phase
  or high frequency) will have a significant impact
  on the charts.

53
Getting Started

• The method for entering factors will affect the
  appearance of the chart.
• Do you enter mAs or mA and time?
• What focal spot and mA selections are available?
• Do you have power selection capabilities?
• Does the unit have line voltage adjustment?

54
Getting Started

• Do you have a non-Bucky film holder?
• What is the grid ratio of the Bucky?
• What is the Relative Speed Value of the cassettes
  and film used?
• What additional information do you want on the
  charts?
• SID, Tube Angles, Film Size or I.D. Location?

55
mAs Chart

• Units where the mA and time are set independently
  need a mAs Chart.
• You can change the mA stations and time to help
  control motion and get the same mAs.

56
Hand Written Charts

• This beats nothing.
• If may be all you get with a used unit.
• It is a good starting point.
• This is all we had at Palmer when I arrived and
  there were no extremity charts !

57
Complete Technique Charts

• Chart should be located in the control booth and
  easy to read.
• This will help avoid technique errors.
• They will work fine for 85 of the patients.

58
Adjustment of Factors

• Patient body habitus will greatly impact the
  technical factors.
• Fit muscular patient will require higher kVp and
  sometime increased mAs also.
• Fatty tissue will need an increase in mAs and no
  increase in kVp.
• Frail or elderly patients need a reduction in kVp.

59
Supertech Technique Calculator

• The Supertech Technique Calculator can be used
  to compute the technical factors.
• It consists of the slide rule, a penetrometer and
  calibration film.

60
Supertech Technique Calculator

• An exposure is made of the penetrometer for each
  mA station and cassette speed used.
• This can be used to check mA calibration and
  different factor established for each mA station.

61
Supertech Technique Calculator

• The correction factor is used to adjust the
  calculator for the equipment type, calibration
  and film speed.

62
Supertech Technique Calculator

• With the correction factors are set, just enter
  the patient measurements on one side.
• Turn it over and read the combinations of mAs and
  kVp that will produce a satisfactory image.

63
Supertech Technique Calculator

• Addition correction factors are provided for
  patient body habitus and changes in SID or film
  speed.
• The Supertech Technique Calculator works !!

64
Supertech Technique Program

• A computer program is also available.
• By entering the machine correction factor,
  technique charts can be printed.

65
Nolan Accu-rad Calipers

• Along with the filter system, Dr. Nolan designed
  the Accu-Rad Calipers.
• Once set up by setting film speed, grid ratio and
  machine type, the calipers will

66
Nolan Accu-rad Calipers

• Provide the technical factors
• CM thickness
• Points for additional filters needed for the
  view.
• The caliper system uses high kVp to reduce
  patient exposure.