17.2 A-P 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
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

12
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.

13
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.

14
Ankle A-P

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

15
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.

16
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

17
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.

18
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.

19
Ankle Medial Oblique

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

20
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.

21
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

22
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.

23
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.

24
Ankle Mortise Oblique

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

25
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.

26
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

27
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.

28
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

29
Ankle Lateral

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

30
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

31
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

32
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.

33
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

34
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.

35
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.

36
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

37
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.

38
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.

39
Calcaneus Lateral View

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

40
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.

41
Chapter 18 Foot Radiography

• Fractures are characterized by involvement of the
  subtalar joint (75) and not involving the
  subtalar joint.
• Stress fractures are common in runners but
  typically not seen on radiographs.
• Stress fractures , plantar fascitis or heel spurs
  are common repetitive use conditions.

42
Foot or Heel Radiography

• Views of the foot and calcaneus are totally
  different.
• If a heel injury is suspected, take heel views
  and not foot views.
• A 30 degree medial oblique view can be useful.
  The oblique and lateral will demonstrate the
  subtalar joint.

43
Foot Radiography

• Foot view must include the tarsal bones,
  metatarsals and phalanges.
• A tube angle is used to open the tarsal bone
  articulations on the A-P view.
• If the patient is flat footed, no tube angle
  would be needed.

44
Foot Radiography

• The medial oblique view is particularly useful.
  It provides
• A clear view of the tarsal bone including the
  calcaneus.
• The 4th 5th metatarsals
• Intertarsal joints
• Detail of the 5th metatarsal

45
Foot Radiography

• The basketball foot is a traumatic medial
  subtalar dislocation resulting from landing on an
  inverted foot.
• The Jones fracture is an avulsion fracture off
  the base of the 5th metatarsal.
• Stress fractures of the metatarsals are generally
  transverse resulting from marching or jumping.

46
Toe Radiography

• Toe radiography can be particularly challenging.
• The natural curve of the toes toward the plantar
  surface of the foot results in foreshortening and
  closure of the interphalangeal joint spaces.
• Besides the A-P, an angled axial view is used to
  open the joint spaces.

47
18.4 Foot A-P

• Measure A-P at base of third metatarsal
• Protection Apron
• SID 40 Table Top
• Tube Angle 10 cephalad
• Film 1/2 of 10 x 12 Extremity Cassette I.D. up

48
Foot A-P

• Patient seated or lying on table with the long
  axis of the affected foot centered to table.
• Place cassette on table.
• Have patient place foot flat on cassette.
• Horizontal CR base of third metatarsal

49
Foot A-P

• Vertical CR long axis of foot.
• Collimation Top to Bottom distal tibia to tips
  of toes.
• Collimation Side to Side soft tissue of foot
• Instructions Remain still
• Make exposure and let patient relax

50
Foot A-P Film

• Should demonstrate toes , metatarsals and most of
  the tarsal bones. The talus and calcaneus will
  not be seen.
• The tube angle will help open the tarsal joint
  spaces.

51
18.5Foot Oblique

• Measure A-P at base of third metatarsal
• Protection Apron
• SID 40 Table Top
• No Tube Angle
• Film 1/2 of 10 x 12 Extremity Cassette I.D. up

52
Foot Oblique

• Patient seated or lying on table with the long
  axis of the affected foot centered to table.
• Place cassette on table.
• Have patient place foot flat on cassette.
• The foot is medially rotated 30 to 40
• A sponge may be used under the plantar surface of
  the foot.

53
Foot Oblique

• Horizontal CR base of third metatarsal
• Vertical CR long axis of foot.
• Collimation Top to Bottom distal tibia to tips
  of toes.
• Collimation Side to Side soft tissue of foot
• Instructions Remain still
• Make exposure and let patient relax

54
Foot Oblique Film

• Should demonstrate toes , metatarsals and most of
  the tarsal bones. The talus and calcaneus will
  not be seen.
• The calcaneus will be well visualized
• Tarsal joint spaces should be open.

55
18.6 Foot Lateral

• Measure Lateral at base of first metatarsal
• Protection Lead Apron
• SID 40 Table Top
• No Tube Angle
• Film 8 x 10 or 10 x 12 Extremity depending
  on foot size.

56
Foot Lateral

• Patient lies on the affected side with lower leg
  in lateral position.
• The foot should be dorsiflexed until the plantar
  surface is perpendicular to ankle.
• The plantar surface of foot is perpendicular to
  film.

57
Foot Lateral

• The film may be turned diagonally or the foot
  placed diagonally on film to fit the entire foot
  on the film.
• Horizontal CR base of 1st metatarsal
• Vertical CR base of first metatarsal

58
Foot Lateral

• Collimation Top to Bottom to include ankle to
  plantar surface soft tissue
• Collimation Side to Side to include from heel to
  tips of toes.
• Instructions Remain still
• Make exposure and let patient relax.

59
Foot Lateral Film

• The foot and ankle should be in a lateral
  position.
• The metatarsals and toes will be superimposed.
• The distal fibula should overlie the distal
  tibia.
• The talotibial joint space should be open.

60
18.7 Toes A-P Axial A-P

• Measure A-P at 3rd metatarsal phalangeal joint
  or affected toe
• Protection Lead Apron
• SID 40 Table Top
• Tube Angle A-P none
• Tube Angle Axial A-P 15 cephalad
• Film 1/4 of 10 x 12 Extremity

61
Toes A-P Axial A-P

• A-P patient places foot flat on film.
• Horizontal Vertical CR 3rd M-P joint for all
  toes or M-P joint of the affected toe for
  individual toe series.
• A-P Axial tube angle same as above but with 15
  cephalad angle.

62
Toes A-P Axial A-P

• A-P Axial with Sponge a 15 sponge is placed
  under toes instead of angling the tube. Or
• The Sponge is placed under the cassette
• Horizontal Vertical CR 3rd M-P joint for all
  toes or M-P joint of affected toe.

63
Toes A-P Axial A-P

• Collimation top to bottom to include all M-P
  joints to tips of toes or M-P joint to tip of
  affected toe.
• Collimation Side to Side soft tissue of foot or
  individual toe.
• Instructions Remain Still
• Expose and let patient relax

64
Toes A-P Axial A-P Film

• A-P is upper right image.
• A-P Axial is upper left image. The phalangeal
  joints will be open on the axial view.
• Views must include all of the affected toe or
  toes.
• Note that collimation was too tight top to bottom.

65
18.8 Toes Medial Oblique

• Measure A-P at metatarsal-phalangeal joints
• Protection Apron
• SID 40 Table Top
• No tube angle
• Film 1/4 of 10 x 12 or 8 x 10 Extremity
  Cassette

66
Toes Medial Oblique

• Patient places distal foot on unexposed portion
  of cassette.
• Patient medially rotates lower leg until the
  plantar surface forms a 30 to 45 angle.
• Horizontal CR 3rd MTP joint or the affected toe.

67
Toes Medial Oblique

• Vertical CR centered to long axis of foot or the
  affected toe
• Collimation top to bottom Distal metatarsal to
  tips of toes or affected toe
• Collimation side to side soft tissue of foot or
  affected toe.

68
Toes Medial Oblique

• Patient instructions Remain Still
• Make exposure and let patient relax.
• Note that a sponge may be placed under plantar
  surface of foot to control angle of view . It
  will also make it more comfortable for the
  patient.

69
Toes Medial Oblique

• The joint spaces should be open.
• The distal metatarsal and tips of the toes should
  be visualized.

70
18.8 Toes Lateral

• Measure Lateral across the metatarsal-phalangeal
  joints For individual toe use A-P measurement.
• Protection Apron
• SID 40 Table Top
• No tube angle
• Film 1/4 of 10 x 12 or 8 x 10 Extremity
  Cassette

71
1st Toe Lateral

• Patient places distal foot on unexposed portion
  of cassette.
• For 1st through 3rd toes
• Patient medially rotates lower leg until the
  plantar surface forms a 90 angle.
• For 4th and 5th toes
• Patient laterally rotates foot until the plantar
  surface is perpendicular to film.

72
2nd Toe Lateral

• For individual toes, tape and tongue depressors
  are used to clear the other toes out of the view.
• Without the use of tape and tongue depressors,
  there will be too much superimposition

73
3rd Toe Lateral

• Horizontal CR 3rd MTP joint or the affected
  toe.
• Vertical CR centered to long axis of foot or the
  affected toe
• Collimation top to bottom Distal metatarsal to
  tips of toes or affected toe
• Collimation side to side soft tissue of foot or
  affected toe.

74
4th Toe Lateral

• Patient instructions Remain Still
• Make exposure and let patient relax.
• Note that the lateral surface of the foot is next
  to the film.

75
5th Toe Lateral

• Note that the lateral surface of the foot is next
  to the film.
• The toe need to remain parallel to the film.
• The 5th toe is the most challenging lateral toe
  view.

76
Toes Lateral Film

• The joint spaces should be open.
• The distal metatarsal and tips of the toes should
  be visualized.
• The affected toe should be free of
  superimposition.
• Return to Lecture Index