Radiology I: views & positioning

Standard views are almost always taken

15 standard views of the foot and ankle

Many are taken *weight bearing

Radiographic Views
*The path that the central x-ray beam follows as it enters and exits the body

An anterior posterior (AP) projection goes through the foot from anterior (dorsal) to posterior (plantar)

Projection
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Refers to the radiographic image only

An AP view is obtained from an AP projection, for example.

View
The terms *Projection and View are often (and incorrectly) used interchangeably.

Often the term “view” is used to describe both position and projection.

Projection vs. View: The Reality
Angle of Gait
Angle of Gait
Base of Gait
Base of Gait
Weight Bearing vs. Non-Weight Bearing
Weight Bearing vs. Non-Weight Bearing
AP View
Also called DP

Area visualized: distal to the midtarsal joint

Can be difficult to see tarsal-metatarsal area secondary to bony overlap

AP View
AP View Positioning
Taken weight bearing in the angle and base of gait
Aim central ray at *base of second metatarsal
What’s wrong in the photo?

Aim central ray 15 degrees cephalid.

Exceptions
NWB exam
AP of a toe
Use the angular indicator on the X-Cel to keep the central ray at 15 degrees.

AP View Positioning
Aim central ray 15 degrees cephalid.

Exceptions
NWB exam
AP of a toe

AP View Positioning
Lateral View
Area visualized: medial and lateral structures of the entire foot.
Difficult to view intermediate, lateral cuneiform and toes.
Lateral View
Cassette is vertical

Medial side of foot is against the cassette
Exception: NWB*
Angle and base of gait

Central ray at 90* degrees to the film

Aim at midfoot*

Lateral View Positioning
NWB Lateral
Uses:
locate a retained foreign body
when the patient is unable to bear weight (post op, fracture, etc.)

Lateral side of foot against the cassette

NWB Lateral
Weight Bearing vs. Non-Weight Bearing
Weight Bearing vs. Non-Weight Bearing
Isolated Lateral View
Raised Hallux lateral
Area visualized: side view of any digit
Position like a lateral

Elevate the digit with a plastic or wood block

Isolated Lateral View
Raised Hallux lateral
Medial Oblique (MO) View
Area visualized: *lateral structures-
plantar calcaneus, cuboid
lateral cuneiform, metatarsals
lateral aspect of navicular,
digits
Medial Oblique (MO) View
*Medial side of foot against the cassette

Central ray is *perpendicular to cassette

Patient tilts (everts) foot 45 degrees
30 degrees (lat cune)
60 degrees (cuboid)
Partial weight bearing

Not in angle or base of gait

MO View Positioning
Lateral Oblique (LO) View
Area visualized:
*medial structures,
including 1st met, navicular, medial
Lateral side of foot against the cassette

Invert foot 45 degrees

Central ray is *perpendicular to cassette.

Not in angle or base of gait

Lateral Oblique (LO) View
LO vs. MO
LO vs. MO
Plantar Axial View
Area visualized:
sesamoids, sesamoid/1st met articulations
lesser met heads
Plantar Axial View
Plantar Axial View Positioning
Foot on positioning block

Film perpendicular to the floor

Central ray aimed posterior and inferior to the calcaneus

Central ray is also perpendicular to cassette

Plantar Axial View Positioning
Other Plantar Axial Techniques
Holly method
X-ray table, toes dorsiflexed with a strip of gauze
Central beam at 0 degrees

Lewis method
Toes dorsiflexed against cassette
Central beam at 0 degrees

Other Plantar Axial Techniques
Holly method
X-ray table, toes dorsiflexed with a strip of gauze
Central beam at 0 degrees

Lewis method
Toes dorsiflexed against cassette
Central beam at 0 degrees

Calcaneal Axial View
Area visualized:
body of calcaneus
posterior and middle facets of the STJ
sustentaculum tali

Technically, posterior tangential projection modification

Calcaneal Axial View
Calcaneal Axial View Positioning
Full weight bearing

Central beam at 45 degrees

Not in angle or base of gait

Calcaneal Axial View Positioning
AP Ankle View
Area visualized:
ankle mortise, except lateral gutter.
Talar body
distal tibia
fibula
AP Ankle View
AP Ankle View Positioning
Cassette Vertical

Heel against plate, foot straight ahead (angle of gait)

Central beam from anterior, *aimed between the malleoli

AP Ankle View Positioning
Ankle Mortise View
Area visualized: Similar to ankle AP, except entire mortise is seen
Ankle Mortise View
Ankle Mortise View Positioning
Cassette vertical

Internally rotate leg about 15 degrees so that the malleoli are parallel with the plate.

Central ray from anterior

Ankle Mortise View Positioning
Ankle AP vs. Ankle Mortise
Ankle AP vs. Ankle Mortise
Lateral Ankle View
Area visualized:
distal tibia
talus
Calcaneus
ankle joint
Navicular
cuboid
Lateral Ankle View
Lateral Ankle View Positioning
Cassette vertical

Medial side of foot against cassette

Aim central ray at the lateral malleolus

Lateral Ankle View Positioning
Stress Ankle Views:
Stress Lateral View
Used to check for an osseous equinus
Stress Ankle Views:
Stress Lateral View
Stress Ankle Views:
Stress Lateral Position
Ski Jump” view

Position patient as a routine lateral, but have them flex knee and dorsiflex the ankle

Stress Ankle Views:
Stress Lateral Position
stress angkle views:
Anterior Drawer Stress View
Used to check for rupture of the *anterior talofibular ligament
stress angkle views:
Anterior Drawer Stress View
stress ankle view: Anterior Drawer (Push-Pull) Stress Positioning
To help rule out lateral ankle ligament damage
Lateral malleolus on cassette, which is vertical
Wear lead gloves or use a Telos device
stress ankle view: Anterior Drawer (Push-Pull) Stress Positioning
Anterior Drawer Telos Positioning
Anterior Drawer Telos Positioning
Inversion Stress View
To help rule out rupture of the calcaneal fibular ligament
Inversion Stress View
Inversion Stress Position
Malleoli parallel to film (like ankle MO)
Lead gloves or Telos device
Maximally invert the STJ
Inversion Stress Position
Inversion Stress Telos Positioning
Inversion Stress Telos Positioning
Lesion Markers
Lesion Markers
true
t/f The only x-ray you will regret is the one you
don’t take
–Steven Palladino, D.P.M.
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