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LOWER LIMB RADIOGRAPHY

MODERATOR :
 PRESENTED BY:
 MR. Ram Singh(Lech)
 LALITA PANDAY
 Deptt. Of Radio-
B.Sc. MED. TECH.(X-RAY)
diagnosis And Imaging
2ND YEAR
 PGIMER, CHANDIGARH
1
INTRODUCTION
 The radiography of lower limb
includes the radiography of the :-
 Foot
 Ankle joint
 Leg
 Knee joint
 Femur
 Hip joint
EQUIPMENT
 The equipment should have the provision of
floating table, revolving stool, vertical cassette
holder.

 Low mA machine is used but in the case of


paediatric radiography high mA machine is used
for shorter exposure.

 Portable X ray machine can also be used.

 Grid should be used in some cases like for the hip


joint.
3
FOOT
 It is composed of total-
 26 bones:
7 tarsal bones( bones of
ankle),
5 metatarsal bones( bones of
instep), 14
phalanges( bones of toes).
Tarsal bones are
talus,calcaneus,
navicular,cuboid, 3
cuneiform.

4
INDICATIONS:
 Fracture
 Dislocation
 Pathology
 Foreign body
 Flat foot

 VIEWS:

 Dorsiplantar
 Dorsiplantar oblique
 Lateral .
 Lateral for flat foot
5
A. For fracture and dislocation of
metatarsal-DP & DP OBL.

B. For fracture and dislocation of tarsal


bones-DP & LAT.

C. For foreign body-DP & LAT.

D. For flat foot-LAT VIEW WITH


HORIZONTAL EXPOSURE IN STANDING
POSITION.

6
DORSIPLANTAR VIEW OF THE
FOOT

 The patient is in sitting or lying


down position with knee flexed and
the foot is placed with the plantar
aspect in close contact with the
cassette.

 The cassette is centered to the base


of 3rd metatarsal bone.
7
Contd…
 CR-at the base of 3rd
metatarsal with 10-15*
angulation towards the
heel.

 This angulation is given


to the metatarsal part
because it is thicker than
the phalanges. if no
angulation is given then
the thicker part will be
under exposed so angel is
given to achieve the
uniform density in the
film.

8
EVALUATION CRITERIA
 The foot should L
be free of
rotation. L

 Phalanges, tarsal
bones as well as
metatarsal bones
should be seen.
9
DORSIPLANTAR OBLIQUE(FOR
MT DISLOCATION)
Medial oblique
 From the DP position the leg
is rotated medially, until the
sole of the foot makes an
angle of 30* with film

 Cassette is centered to the


base of the 3rd metatarsal.

 CR- passes through the


navicular cuboid articulation.

 In this the interspaces'


between the tarsal and the 10

metatarsal is seen.
EVALUATION CRITERIA
 3rd & 5th metatarsal base L
should be free of L
superimposition.
 Most of the tarsals should be
demonstrated better than
dorsiplantar position.
 Tarso metatarsal and inter
tarsal joints should be
visualized.
 Sinus tarsi should be seen.
 Base of 1st & 2nd metatarsal
should be superimposed.

11
LATERAL OBLIQUE
 From the DP position the
leg is rotated laterally,
until the sole of the foot
makes an angle of 30*
with film.

 Cassette is centered to the


base of the 3rd metatarsal.

 CR- passes through the


navicular cuboid
articulation.

12
EVALUATION CRITERIA
 1st & 2nd
rt
metatarsal base
should not overlap
 medial &
intermediate
cunieform should
not superimpose
 navicular better
seen in medial obl
FOOT LATERAL VIEW
 It is done to see the dislocation & the foreign
body.

 The patient is made to lie down in the lateral


position with the sound limb is either brought
forward. The foot is adjusted so that the
plantar surface of the foot is prependicular to
the film.

 CR-passes through the navicular cuneiform


joint.
14
EVALUATION CRITERIA:

• Metatarsals should
superimposed.

• Tibia and fibula should be


overlap.

• Distal leg and ankle joint


should be superimposed.

15
RADIOGRAPHY OF FLAT FOOT

 This is the lat view in standing


position done to see the longitudinal
arch of the foot are radiographed on
a single film for comparison.

16
Contd…

 The patient is made to stand on a


low platform. Each foot is placed on
a piece of balsa wood, or
transradiant material, leaving a
small gap between each foot. The
film is placed against the medial
aspect of the foot to be examined.

17
Contd…
 CR-passes horizontally through base
of 5th metatarsal.

EVALUATION CRITERIA:
 Plantar aspect of the metatarsal
bone should superimposed.
 Entire foot and distal leg included
 Fibula over laps posterior part of
tibia.
18
Contd…

19
RADIOGRAPHY OF SESAMOID 20

BONE
Sesamoid bone is present at 1st
metatarsopharyngial joint of foot.

It can be seen in
lat and axial projection of foot.
Axial projection:-
 2 ways to do axial
views are
 Patient sitting on x-ray
table & cassette held firmly
against the instep or under
the Ankle . Flexion at the
jt. is aided by a tightened
bandage passed around the
digit of great toe with leg
fully extended.
 C.R:- passing
perpendicular to 1st
metatarsopharyngeal jt.
Contd.

2. Patient lie in prone


position, foot is rested
on film is R
dorsiflexed by putting
toe on cassette in
dorsiflexion and
pressing the toe.

C.R:- Passes
perpendicular to 2nd
metatarsopharyngeal
jt. 22
EVALUATION CRITERIA
 Sesamoid should
be projected free
L
of 1st metatarsal.
 Metatarsal head
should be clearly
demonstrated
ANKLE JOINT
 This is the synovial
joint of the hinge
variety.

 This joint is formed


by the lower end of
the tibia including the
medial malleolus,
lateral malleolus of
the fibula, and the
articular surface on
the upper, medial &
lateral aspects of the
tibia.
24
Indications:

 Trauma
 Pathology
 Subluxation (torn lateral ligament)

25
RADIOGRAPHY OF ANKLE JOINT
VIEWS:
 AP
MEDIOLAT
 LAT
LATEROMEDIAL

MEDIAL
 OBLIQUE
LATERAL

STRESS VIEW

26
AP VIEW
 The patient is made to lie
down in the supine position.
A small sand bag is placed
under the knee joint for
support. flex the ankle and
the foot enough to place the
long axis of the foot in the
vertical position and
prependicular to the
cassette. Rotate the leg
medially to bring the malleoli
in the same plane i.e.
equidistant from the film.

CR-passes through the ankle


joint at a point midway
between the malleoli. 27
EVALUATION
CRITERIA:
1. tibiofibular joint
space should be
seen.
2. Both the malleoli
should be seen.
3. Distal tibia & fibula
should be seen.
4. Moderate
overlapping of tibio
fibular articulation.
28
LAT VIEW (basic)-
mediolateral:
The patient is made to
lie down in the lateral
position on the
affected side. A small
sand bag is placed
under the knee joint to
bring the malleoli in
the same plane until L
the medial & the
lateral malleoli should
superimpose vertically.
CR-should pass through
the medial malleolus.
29
EVALUATION CRITERIA
1. Tibiotalar joint should
be well visualize. L

2. Fibula should overlap


posterior half of tibia.
3. Distal
tibia,fibula,talus &
adjacent tarsals
should be included

30
 LAT. VIEW
(LATEROMEDIAL):-

The patient lies on the side


opposite to that being
examined, and the limb underImg_0196.jpg
the examination is brought
over in front of the sound
limb. A small sand bag is
placed under the knee joint to
support the limb in the
position.

CR-it should pass through the


lateral malleolus.
31
EVALUATION CRITERIA
1. Tibiotalar joint should
be well visualize. rt

2. Fibula should overlap


posterior half of tibia.

3. Distal tibia, fibula,


talus & adjacent
tarsals should be
included

32
ANKLE JOINT – OBLIQUE VIEWS
 MEDIAL
OBLIQUE(INTERNAL
OBLIQUE):

From the AP position the leg


is rotated medially through
45* and supported by non
opaque triangular block.
CR- passes through ankle
joint at a point midway
between the malleoli.
This view is done to see
tibiofibular or talofibular
joint.

33
EVALUATION CRITERIA
1. Distal tibia & fibula
may demonstrate
some overlap of L
talus.
2. Distal tibia, fibula &
talus should be
included.
3. Talus, distal tibia &
fibula should be
adequately
penetrated

34
LATERAL OBLIQUE
(EXTERNAL OBLIQUE)
From the AP
position the leg is
rotated laterally
through 45* and
supported by non
opaque triangular
block.
CR-passes midway
between the
malleoli.

35
EVALUATION CRITERIA
1. The talocalcaneal
joint should be
seen .
L
2. The calcaneal
sulcus( superior
portion of
calcaneus) is
demonstrated .

36
ANKLE JOINT (STRESS STUDY)

 Subluxation of the ankle joint may be due


to the rupture or stretching of the lateral
ligament .

 From the normal AP position the foot is


turned forcibly towards the opposite side
without rotating the leg.

 The studies are done to see the presence


of the ligament tear. This is demonstrated
by the widening of the joint space on the
side of injury. 37
Contd…
 In this the two movements
are to be considered:

 EVERSION: movt. of the


foot when the ankle is
turned outwards, movt. Is
only between the ankle
joint & foot leg is not
moved.

 INVERSION: movt. Of the


foot when the ankle is
turned inwards.

38
L lt

inversion
CALCANEUM(HEEL)
 It is the largest tarsal bone, is more
or less cuboid in shape. It projects
posteriorly & medially at distal
posterior part of the foot directed
inferiorly. The log axis of calcaneus
form an angle of approximately 30*,
open forwarded with the sole of foot.
INDICATIONS:

 FRACTURE.
 PATHOLOGY.
 TRAUMA.
 CALCANEUM SPUR (extra growth of
the calcaneum)

41
 VIEWS:

 LAT
 AXIAL
 OBLIQUE

For the calcaneum spur, lat view of both the heels


is done for the comparison.

If there is suspected injury or pathology/fracture


not seen in lateral then axial projection of
calcaneum is taken.

42
LATERAL VIEW

 Patient is in lying down supine position & is turned


towards the affected side until the leg become lat.
Adjust calcaneus to the centre of the film

 CR:- passes perpendicularly to the mid of calcaneus


Both the heels is done for the comparison on single
film.

Both calcaneum can be done simultaneously in


single exposure, if patient can achieve this position.

43
EVALUATION CRITERIA

 No rotation of
calcaneus rt
 sinus tarsi should
be visualized.
 Ankle & adjacent
tarsal should be
included

45
RADIOGRAPHY OF OSTRIGONUM

 Occasionally an additional centre of


ossification develop in place of posterior
tubercle of Talus forming a separate bone
called Os Trigonum.
 This Fragment may lead to confusion in
fracture cases , so for comparison lat.
view of both foot done on single film
separately or simultaneously.
AXIAL PLANTODORSAL VIEW
(BASIC)

The patient is made to lie down in the


sitting position, with the legs fully
extended. Cassette is centered midway
between the ankle joint. Foot is flexed and
kept in the dorsiflexed position by putting
a bandage around the foot and the patient
is asked to pull the bandage towards
himself.

CR- passes through the plantar aspect of the


footmidway between the heels with 45*
cephalic angulation. 47
48
EVALUATION CRITERIA
 Calcaneus should
be visualized to
include
talocalcaneal joint.
 Calcaneus should
not be rotated.
DORSOPLANTAR AXIAL VIEW

The patient is made to lie down in the prone


position with the legs fully extended. Ankle joint
are elevated on the sand bags the foot is in the
dorsiflexed position to place the long axis of the
foot prependicular to the film.

The cassette is placed against the plantar surface


of the foot.

CR-passes through the posterior aspect between


the heels with 55-60*angulation towards the
heels. 50
STANDING POSITION
 The patient is made to stand
on the cassette . Edges of
the heels are kept at the
border of the cassette . The
legs are fully extended .

 CR- passes between the


heels with 30* angulation
towards the heels.

 EVALUATION CRITERIA:

 Calcaneus should not be


rotated.
 It should include the
talocalcaneal joint.
52
SUB TALAR JOINT
 Talus rests on the
calcaneous. The
calcaneous supports the
talus above, articulating
with an irregularly shaped,
3 faceted joint known as
talocalcaneal or subtalar
joint.Each of three parts of
subtalar joint is formed by
reciprocally shaped facets
on the inferior surface
talus & superior surface of
calcaneus.
RADIOGRAPHY OF THE
SUBTALAR JOINT
 INDICATIONS:
 Trauma
 Pathology
MEDIAL OBLIQUE
 VIEW:
LATERAL OBLIQUE

 MEDIAL OBLIQUE:

The patient is made to lie down in the supine position. A sand


bag is placed under the knee. The leg and the foot are rotated
medially through 45* .

CR-passes 1” below ant to the lat malleolus with 10*cephalic


angle.
54
10* Angulation is given
to see posterior part of
posterior talo calcaneal
joint

EVALUATION rt
CRITERIA:-

Anterior & posterior talo


calcaneal joint should be
visualized.
55
LATERAL QBLIQUE VIEW
The patient is made to
lie down in the supine
position. A sand bag is
placed under the knee.
The leg and the foot
are rotated laterally
through 45*.
CR-passes 1” below and
ant. to the medial rt
malleolus with
10*cephalic angle.
EC:- posterior portion of
talocalcaneal joint
should be visualized.
56
LEG
 It is composed of the
tibia and the fibula .

 TIBIA: it is the medial


and the 2nd largest
bone of the leg. it is
homologous with the
radius of the upper
limb. Proximal end
present two
prominent processes
the medial & lateral
condyle.
57
Contd.
 Superior surface of condyle form smooth facet
for articulation with condyes of femur. The under
surface of tibia is smooth & shaped for
articulation wit talus.
 FIBULA: it is the lateral and the smallest bone of
the leg. it is homologous with the ulna of the
upper limb. Proximal end of fibula is expanded
into head which articulates with lateral condyle of
tibia

58
 VIEWS:

 AP
 LAT
 OBLIQUE –it is done to see the
1. The introssues space between the
tibia and the fibula.
2. Proximal & distal tibiofibular joint.
59
AP VIEW
 The patient is made to lie
down in the supine
position with the leg fully
extended. The ankle is
dorsiflexed & the leg
rotated medially until
medial & lateral malleoli
are equidistant from the
film. A pad is placed
against the plantar aspect
of the foot to maintain the
position. we must include
the joint close to the
injury.

CR- passes through the


middle of the film.

60
Evaluation criteria
1. Both ankle & knee joint
should be included in one
or more films .
2. Proximal & distal
articulation of tibia &
fibula should have
moderate overlapping.
3. Ankle & knee joint should
be in true AP position.
4. Density should visualize
trabecular detail & soft
tissue for entire leg.

61
LATERAL VIEW
 From the AP position the
patient is turned to 90* to
the affected side .Support
the leg in the position with
sandbags. If the patient is
unable to turn to the
affected side, the film
should supported vertically
against the medial side of
the leg & the beam
directed horizontally.

CR- passes through the


middle of the film.

62
Contd.
1. Both ankle & knee joint should
be included in one or more
films .
2. Slight overlap of tibia on the
proximal fibular head is
normal.
3. Distal fibula should lie over
posterior half of tibia.
4. Ankle & knee joint should not
be rotated.
5. Femoral condyles may not be
superimposed because of
divergence of beam.
6. Moderate separation of tibia &
fibular shaft should be seen.
63
OBLIQUE VIEW
MEDIAL OBL
From AP position, patient
is turned 45* to medial
side. Support the leg at
45* sponge wedge.

C.R. :- passes through


middle of film

64
EVALUATION CRITERIA
lt
1. Proximal & distal tibio
fibular articulations
should be
demonstrated.
2. Maximum
interosseous space
should be seen b/w
the tibia & fibula.
3. Ankle & knee joint
should be included.

65
Lateral oblique
From AP position,
patient is turned
45* to lateral side.
Support the leg at
45* sponge
wedge.

C.R. :- passes
through middle of
film
66
EVALUATION CRITERIA
1. Fibula is
superimposed by
lateral portion of lt
tibia.
2. Ankle & knee joint
should be
included.

67
Knee joint
 The knee is the largest and
the most complex joint of the
body. It is synovial hinge
type of joint.
 Two menisci, one medial &
one lateral condyles are
interposed between the
articular surface of tibia & the
condyles of femur. The jt. is
enclosed in an articular
capsule & held

together by numerous
ligaments.

68
Indications for the knee joint
 Trauma
 Loose bodies
 Pathology
 For Subluxation-lat view with limb raised and
suspended, lat view in standing is done.
 For Tibial tubercle –Both knee lat is done for
comparison on single film.
For Semilunar Cartilages – PA Obl.
For Intercondylar fossa – Axial view is done.

69
RADIOGRAPHY OF THE KNEE
JOINT

 BASIC VIEWS:
 AP
 LAT
 OBLIQUE

 PA

70
AP VIEW

The patient is either


in sitting or in the
supine position.
The thigh is fully
extended at the hip
and the knee
joint.the foot is
slightly medially
rotated to bring the
patella in the
centre of femur.
71
Contd..

 The cassette is
centered half inch L
below the apex of
the patella.
C.R.:- is passing
perpedicularly 1”
below the apex of L

patella.

72
EVALUATION CRITERIA

 Femorotibial joint space should be


open.
 There should be no rotation of
femur and tibia.
 Knee joint should be fully extended.
 soft tissue should be seen.
 Patella should be in the centre.
73
LAT VIEW
From the AP position the
patient is turned 90*towards
the affected side. the leg is
flexed at the knee ad hip
joint. Small sand bag is
placed under the ankle joint
to bring the transverse plane
of the patella perpendicular
to the film. The sound limb is
either brought forward
C-ray; is directed at the medial
condyle of the tibia.
Sometimes 50 angle is given
towards head.

74
Contd..
EVALUATION CRITERIA
1. The femoral condyles
should be
superimposed.
2. Joint space between the
femoral condyles and
tibia should be open.
3. Patella should be in lat
profile.
4. Femoropatellar space
should be open.
L 5. Soft tissue should be
included.

75
OBLIQUE VIEWS

 These are taken to separate the


patella from the condyles thus it is
done to see the:
 Patella
 Tibiofibular space
 Condyles.

76
PA
MEDIAL OBLIQUE LATERAL OBLIQUE

 PA MEDIAL OBLIQUE:
The patient is made to
lie down in the prone
position. Now rotate the
foot and the knee joint
internally so that it
makes an angle of 45*
with the film.

C-ray; passes through the crease


77
of the knee joint
Evaluation criteria
1. Tibia and Fibula should be
separated at their proximal
articulation .
2. Post. Tibia should be
demonstrated.
3. Lat. Condyles of femur and
tibia should be seen.
4. Knee jt. Should be seen and
open.
5. Margin of patella will project
slightly beyond a side of the
femoral condyle.
6. Soft tissue around the knee jt.
Should be seen.

78
PA LAT OBLIQUE
 Positioning is
same as that of the
pa medial oblique
but the foot is
rotated externally
so that it makes an
angle of 45* with
the film.
C-ray; passes through
the crease of the knee
joint
79
Evaluation criteria
1. Medial femoral & tibial
condyles should be well
demonstrated.
2. Knee jt. Should be seen and
open.
3. Fibula should be superimposed
over the lateral portion of tibia.
4. Patellar margin will project
slightly beyond the side of
femoral condyle.
5. Bony detail on distal femur &
proximal tibia should be
demonstrated.

80
AP
EXTERNAL(LATERAL) INTERNAL(MEDIAL)

 EXTERNAL(LATERAL)
OBLIQUE:
From the AP position
rotate the leg laterally at
45*from the table.
Centre the cassette half
inch below the apex of
the patella.
C.R.:- is passing through
1” below the apex of
patella
81
AP MEDIAL OBLIQUE
 From the AP
position the leg is
rotated medially so
that it makes an
angle of 45* with
the film.
C-ray; is passing
through 1” below
the apex of patella

82
NOTE:-

 AP weight bearing study of the knee joint is done


in case of the OA (osteoarthritis) this view is
done to see the exact joint space. (as the joint
space get narrowed)

 In the patient’s who can’t extend the knee joint


curved cassettes are to be used.

 In the old patient’s the kv is reduced by 5 kv as


their bone density is less due to weak bones so
less penetration is required.

 Protection of the gonads and the pelvic area


should be concerned.

83
PATELLA
 The patella is the largest
and most constant
sesamoid bone & situated
in the front of the lower
end of the femur about 1
cm above the knee joint.

 The patella is flat and


triangular in shape with it’s
apex directed downwards,
lies slightly above the joint
space of knee & is
attached to the tuberosity
of the tibia by the patellar
ligament.

84
RADIOGRAPHY OF PATELLA

VIEWS:

 PA
 LAT
 PA –MEDIAL AND LATERAL OBLIQUE
 AXIAL PROJECTIONS.

85
Lateral Horizontal View:

This projection is used in the suspected transverse


fracture of the patella.
Positioning:
 the patient is remains on the trolley, with the limb
gently raised & supported on pads.
 If possible, the leg may be rotated slightly to
centralized the patella b/w the femur condyles.
 The film is supported vertically against the medial
aspect of the knee.
 The centre of the cassette is level with upper border of
the tibial condyle.
CR: - It is directed to the upper border of the lateral
tibial condyle at 90˚ to the long axis of the tibia.

86
87
PA VIEW (for patella)

The patient is lying


down in the prone
position. The leg is
extended at the hip
and the knee joint.
The knee joint is
slightly flexed and the
small sand bags are
kept under the thigh
and the ankle joint to
prevent the pressure
over the patella. 88
Contd..

C.R.:- passes
through the crease
of the knee joint . R

 The close contact


of the film gives
the sharply defined
image of the
patella.
 And the joint
space is also
visualised. 89
To see the patella in profile axial
projections are taken
Axial projections of the patella are to
be done by :
 INFEROSUPERIOR VIEW:
The patient is lying down in the prone
position. flex the knee till the leg
makes an angle of 90*with the film.
The leg is kept in the steady position
by putting a bandage around the
ankle joint .
90
Contd…
 The cassette is centered
to the knee joint .
C.R.:- Passes just behind the
patella with the tube
angled 15* towards the
knee.
This view confirms the
presence of minor fracture
of patella, without
displacement of fragment
(which is difficult to
demonstrate in usual ap &
lat view. )

91
SKYLINE VIEW

With the patient in the sitting position,


the knee is flexed. A cassette is placed
on the anterior aspect of the femur
and hold in the position by the patient
himself. The tube is lowered down to
the distance & angled upward towards
the knee joint.
CR-passes prependicular to the joint
space between the patella and the
femoral condyles.
92
Contd…

93
EVALUATION CRITERIA

 Patella should be seen in profile.


 Patella femoral articulation should be
open.
 Surface of the femoral condyles should
be visualised.
 Soft tissue of the patella femoral
articulation should be visualised.
 Bony details of the patella & femoral
condyles should be visualised.
94
KNEE JOINT AXIAL VIEW
(TUNNEL’S VIEW)
 This view is generally done to see the
intercondylar notch.

AP AXIAL VIEW

The patient is in the sitting position .The knee


joint is flexed over an angle block film is placed
under the knee more towards the femur and is
centered to the apex of patella .The knee is
adjusted in the AP position.

97
Contd…

C.R.:- is passing through just


below the lower level of
the patella making an
angle of 110* with the
long axis of the leg.

 At 110* to the axis of the


tibia to demonstrate the
anterior part of the notch.

 At 90* to the axis of the


tibia to demonstrate the
posterior part of the notch.

98
EVALUATION CRITERIA
 Fossa should be open and well visualised.
 Posteroinferior surface of the femoral condyles
should be demonstrated .
 Intercondylar eminence and knee joint space
should be seen.
 Soft tissue in the fossa and the interspace should
be seen.
 Apex of the patella should not superimpose the
fossa.
 Bony details on the intercondylar eminence,
distal femur and proximal tibia should be
demonstrated.
99
PA AXIAL (TUNNEL VIEW)
 Patient is made to lie down in
prone position. Knee is flexed
to 40*& foot is kept on suitable
support. Place cassette under
knee & centre to apex of patella
more towards leg. Adjust knee
in true pa position with no
medial or lateral rotation.
C.R.- Passes through the crease of
knee jt. perpendicular to long
axis of leg. Means if leg is
flexed 40* than tube is angled
40* & if leg is flexed 50* than
tube is angled 50*
This view is also done to see
intercondylar fossa
100
This view can be done in 3 ways

1. Patient standing in
pa position with
knee flexed and
resting on stool at
the side of table.

101
Contd.
2. Patient standing at
the side of table
with affected knee
flexed & placed in
contact with front
of cassette.

102
Cond.
3. Kneeling on table
with knee over
cassette.

103
L

104
RADIOGRAPHY FOR SUBLUXATION
OF KNEE JOINT
 There are two methods:-
1. Patient lie down in supine ,

affected limb is raised &


supported in relaxed
position, at the ankle joint,
the cassette is placed
vertically in contact with
medial aspect of knee .

C.R.:- passes horizontally to


lateral aspect of knee jt.

105
contd.
2. Patient stand in lateral
position with cassette,
sound limb is placed
forward to affected limb &
affected limb take full
weight of body.

C.R.:- passes horizontally


to medial aspect of knee
jt.

106
STRESS AP VIEW
 This view is done in
case of the
subluxation of the
knee joint due to the
rupture of the
collateral ligaments.
 The patient is
positioned as for the
basic AP projection of
the knee joint.

107
Contd.
 The medical officer should
then forcibly abduct or
adduct the knee and must
wear the lead gloves and
apron.
C.R.:- midway between the
upper borders of the tibial
condyles with the central
ray directed at right angle
to the axis of the tibia.
 Widening of the
femorotibial joint space
will be demonstrated on
the same side as a
ruptured ligament.

108
ANATOMY OF FEMUR

 IT is the longest
bone of the body.
proximal end of the
femur consist of
head, neck & two
large processes
the greater& lesser
trochenter. The
head form hip jt.
Articulating with
acetabulam. 110
Contd.
In adult the neck project anteriorly from the
shaft at an angle of approximately 15*-20*&
superiorly at an angle of 120*-130* to long
axis of shaft.

Distal end of femur consist of medial & lateral


condyles which help in formation of knee jt.
Articulating with two menisci of tibia

111
RADIOGRAPHY OF FEMUR

 BASIC VIEWS

AP
LAT

 SPECIAL VIEWS
for neck of femur
shaft fracture

112
AP VIEW
Patient should lie down in
supine position . Centre the
affected femur with mid line
of table. Rotate the toes
approximately 15* internally
to overcome the anteversion
of the femoral necks.

C.R.- Passes perpendicularly


to mid of the thigh.

113
EVALUATION CRITERIA

1. Majority of femur & jt.


Nearest to the pathology
or fracture should be
included.
2. Femoral neck should not
be foreshortened .
3. Small portion of lesser
trochenter may or may
not be seen.
4. Knee should not be
rotated.
5. Trabecular detail should L
be demonstrated or
femoral shaft
114
LOWER 2/3RD WITH THE KNEE
JOINT:- AP VIEW
 The patient is made to lie
down in the supine
position & the leg is fully
extended at the hip & the
knee joint .

The positioning is same as


that for the knee jt. AP
view but here the CR
passes through middle of
the lower 2/3rd of the
femur.

115
EVALUATION CRITERIA
1. Knee jt. should be
included.
2. There should be no
rotation of knee jt.
3. Trabecular detail
should be
demonstrated or
femoral shaft .

116
Lateral view of femur

 Normal condition: from the


AP position the patient is
turned through 90*.
Centre the affected side
hip to the centre of the
Bucky. The patient is
slightly turned 10-15*
backwards to prevent the
superimposition.

 CR- passes perpendicularly


through mid thigh.

117
EVALUATION CRITERIA

1. Majority of femur & jt. Nearest to


the pathology or fracture should
be included.
2. If knee included then –
-anterior surface of femoral
condyle should be superimposed.
-patella should be seen in profile.
-patellofemoral space should be
open.
3. If Hip included then –
-Opposite thigh should not
overlap.

118
contd

-greater and lesser trochanters should be very


prominent.

4. Trabecular detail should be demonstrated or


femoral shaft

119
For Shaft Fracture:
 The patient remains on the
trolley or bed. If possible, the
leg may be slightly rotated to
centralize the patella b/w the
femoral condyles.
 The cassette is supported
vertically against the lateral
aspect of the thigh, with the
lower border of the cassette at
the level of the upper border of
the tibial condyle.
 The unaffected limb is raised
above the injured limb, with the
knee flexed & the lower leg
supported on a stool or
specialized support.
CR: - It is directed to the mid-
shaft of the femur.
120
L
NECK OF THE FEMUR
Lateral Horizontal Beam or
Axio-lateral view of
hip:-
This projection is used
in the suspected fracture
of the neck of the femur &
patient is unable to move.
Positioning:
 The patient lies in supine
on the stretcher or a x-ray
table.
 The legs are extended &
the pelvis adjusted to
make the median saggital
plane perpendicular to the
table top. This may not
always be possible if the
patient is great pain.
122
Contd.
 If the patient is slender, it may be necessary to
place a non-radiopaque pad under the buttocks
so that the whole of the affected hip can be
included in the image.

 The grid cassette is positioned vertically against


the affected hip just above the iliac crest.

 The longitudinal axis of the cassette should be


parallel to neck of the femur. This can be
approximated by placing a 45˚ foam pad b/w the
front of the cassette & the lateral aspect of the
pelvis.

123
Contd.
 The cassette is supported in position by sand bags
or specific cassette holder.

 The unaffected limb is raised until the thigh is


vertical, with the knee flexed, this position is
maintained by supporting the lower leg on a stool

 The film-subject distance may be 6 inches or


more , but this is compensated for by increasing
the focus film distance. A fine focus tube will give
satisfactory results.
EVALUATION CRITERIA
1. As much of femoral neck
should be seen as possible
without overlap from the
greater trochenter.
2. Only a small amount of lesser
trochenter should be seen on
the posterior surface of femur.
3. Soft tissue of unaffected thigh
should not overlap .
4. Hip jt with acetabulam should
be included .
5. Identification marker should
not be in the area of interest .

125
ANATOMY OF HIP
 Hip is the large irregular bone of the body. It
helps in the formation of pelvic girdle anteriorly
& laterally.it consist of three parts
 Illium anteriorly, pubis anteroposteriorly, ishium
posteroinferiorly.
 All the three parts enter into the formation of
acetabulam. pubis & ishium are separated by a
large opening called obturator foramen. The
pubis part of hip bone meet anteriorly to form
pubic symphysis.

126
HIP JOINT

 It is the ball & socket


type of joint. It is
formed by the head of
the femur & acetabulam
of hip bone . This joint
permit flexion,
extension, adduction,
abduction, medial
rotation, lateral rotation
& circumduction.

128
INDICATIONS OF THE HIP JOINT

 Fracture of the proximal end of the femur

 Dislocation

 Fractured acetabulum

 Congenital dislocated hip

 Prosthesis

129
RADIOGRAPHY OF HIP & FEMUR
 For the radiograhic purposes the femur is
divided into two parts:
 Upper 1/3rd with the hip joint:
 Lower 2/3rd knee joint.

RADIOGRAPHY OF UPPER 1/3RD WITH HIP


JOINT:- AP VIEW
The patient is made to lie down in the supine
position. The side to be examined is centered
to the bucky table. Rotate the foot 15* 130

internally.
Contd…

 CR-passes through
1” below the
midpoint of the line
joining the ASIS &
pubic symphysis of
the affected side .
L

131
Lateral –single hip
 When pt. is able to move
,then the pt. is turned on
affected side, with flexion at
hip& knee jt , the pelvis is
tilted 45* backward & sound
limb raised & supported in
comfortable position. Centre
the affected hip jt. to centre
of bucky.
C.R.- Passes perpendicularly
through middle of upper 1/3rd
of femur or 1” below the line
joining the ASIS& pubic
symphysis.
132
EVALUATION CRITERIA
1. Hip joint should be
centred to radiograph.
2. Hip joint, acetabulam &
femoral head should be
well demonstrated.
3. Femoral neck will be
overlapped by the
greater trocanter in this
projection.

133
AP VIEW FOR BOTH THE HIP
JOINTS WITH UPPER FEMORA
 The patient is made to lie
down in the supine position
with the midsagittal plane
of the body centered to the
centre of the bucky. The
legs are positioned in such
a way that toes of the feet
are touching each other
both the ASIS should be
equidistant from the film.

 CR- passes through 1 ½”


above the p.s. or 2” below
the mid point of the line
joining the ASIS.
134
EVALUATION CRITERIA
1. Both hip joint should be
included.
2. Lesser trochanters should be
demonstrated on medial
border of femurs.
3. Greater trochanters should
be fully demonstrated.
4. Femoral necks should be
demonstrated in their full
extent without anteversion.
5. Identification marker should
be clearly seen.
6. Lower vertibral column should
be centered to radiograph.

135
CONGENITAL DISLOCATION OF
THE HIP JOINT
 Views:
 AP
 LAT

AP: of both the hips is done for the comparison. The


positioning is same as that for the AP view of both the hip
joints but the CR passes through the p.s. here lat &
superior displacements is visible.

AP with the tube angulation: positioning is same but the CR


passes through p.s. 45* cephalic angulation here ant &
post displacement is visible.

In case of the ant. Displacement the head of the femur will


casts its shadow above the acetabulum & vice versa.

136
MODIFIED LATERAL VIEW
FROG LEG VIEW
 It is done mainly for the
children. The patient is
made to lie down in the
supine position. The
midsagittal plane of the
body is centered to the
centre of the table. Legs
are flexed at the hip &
knee joint, soles of the
feet are touching each
other.
CR- passes through the p.s.

137
EVALUATION CRITERIA
 Exposure should be such
that the femoral head is
penetrated & seen through
the acetabulum.
 Adjacent region of the
illeum & pubic bone to L
symphysis pubis should be
included.
 Greater trochanter should
be demonstrated in profile
 Small amount of lesser
trochanter should be seen.
 Hip joint acetabulum &
femoral head should be
well demonstrated.

138
VON & ROSEN METHOD
 The patient is made to lie
down in the supine
position with each leg
abducted through
45*(producing a mutual
angle of 90*)and internally
rotated. so that the head
of the femur comes in the
lat position.

CR-passes thru the p.s.

139
LOWER LIMB TRAUMA
 While doing trauma radiography our aim is
to demonstrate the injured part in the
radiograph with minimal movement of the
patient or the injured part.
 It may not always be possible to obtain
right projections as in the case when there
are large splints, back supports, traction
bars etc. in such cases we should obtain
the projection as near as right angle
possible.
RADIATION PROTECTION

 Follow the ALARA Principle.


 Technologist should stand behind the
lead screen while giving exposure.
 Gonadal shielding should be used
wherever necessary.

142
PRECAUTIONS

 Collimation should be accurate.


 Be assure that the correct person is
radiographed.
 Proximal joint should be included in
radiograph.
 Use correct lead marker for side
determination.
 Patient should be asked to remove any
metallic ornaments within the area of
interest.
143
144

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