Remote Operators Radiographic Licensing

Radiographic Procedures Manual
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D EPART M E NT O F H EALTH

TABLE OF CONTENTS
Section 1 – Introduction
1.A 1.B 1.C General Introduction Legislation and Imaging Requirements Contacts

Section 2 - General Radiation Physics
2.A 2.B 2.C 2.D 2.E 2.F Introduction to Physics Production of X-rays The X-ray Tube Properties & Interactions of X-rays Biological Effects and Hazards Basic Radiation Protection

Section 3 - Radiographic Equipment
3.A 3.B 3.C 3.D 3.E Overall Description Basic Exposure Controls X-ray Installations in the Northern Territory Ancillary Equipment Film/Screen Radiography

Section 4 - Computed Radiography (CR)
4.A 4.B 4.C 4.D 4.E 4.F 4.G Introduction Cassettes Phosphor Plates Digitizer/ Scanner Post Processing Image storage & Transfer for Radiologist Review Image File Types

2011 Radiographic Procedures Manual.doc

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D EPART M E NT O F H EALTH

Section 5 - Working Procedures and Instructions
5.A 5.B 5.C Initial Preparation Positioning and Exposure Determination Patient Identification

Section 6 - Radiographic Critique & Positioning
6.A 6.B 6.C Radiographic Critique Chest Upper Extremity I. II. III. IV. V. VI. 6.D Hand & Fingers Thumb Wrist Forearm Elbow Shoulder

Lower Extremity I. II. III. IV. V. Foot & Toes Ankle Calcaneus Tibia/Fibula Knee & Patella

6.E

Exposure Chart

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doc Page 5 of 95 Version 2: 29-June-2011 Revision Date: June 2014 Department of Health is a Smoke Free Workplace .D EPART M E NT O F H EALTH Section 1 Introduction 2011 Radiographic Procedures Manual.

INTRODUCTION Section 1. however.http://remotehealthatlas.gov.D EPART M E NT O F H EALTH SECTION 1 .doc Page 6 of 95 Version 2: 29-June-2011 Revision Date: June 2014 Department of Health is a Smoke Free Workplace . The purpose of the program is to train GPs and Nurses from remote locations in basic radiographic position of Extremities and Chest imaging to decrease the need for patient transfer to larger regional centres for imaging and therefore treatment.pdf Commonwealth • Radiation Protection Regulations (RPR) o • The aforementioned provide a framework for the regulation of radiation related activities and include taking x-rays. With the recent change from conventional radiography to computed radiography and the increase of satellite health facilities with radiographic equipment it was thought that the entire program needed to be reviewed. The practical training of RO’s is undertaken at Royal Darwin Hospital and this document is aimed to be used to compliment that practical training and also as a reference for the RO in the future. Section 1.nt.A – General introduction The Remote Operators (RO’s) X-ray Program has been in operation within the Northern Territory since 1981. with recent legislative changes the Radiation Protection Section within Environmental Health now grants the licenses.B . Initially licences were granted by the Radiographers Board of the Northern Territory. Federal or Territory 2011 Radiographic Procedures Manual. And any relevant future legislation.Legislation and Imaging Requirements Currently Radiographers and RO’s performing radiography within the NT are bound by the following legislation and regulatory requirements: Northern Territory • • • • Radiation Protection Act Radiation Protection Regulations Health Practitioners Act NT Remote Health Atlas .au/xray_equipment.

D EPART M E NT O F H EALTH Further References • • • • Radiation Protection Series . in particularly the Radiation Protection Act. Royal Darwin Hospital have an internal document called a Radiation Safety and Protection Plan. Write and submit reports. It forms a generalised plan for radiation protection. This plan is formulated for the purpose of ensuring that all diagnostic radiography sites operate as safely as possible and in compliance with Northern Territory legislation.doc Page 7 of 95 Version 2: 29-June-2011 Revision Date: June 2014 Department of Health is a Smoke Free Workplace . National recommended dose limits for medical workers apply. It will also ensure that the number of people exposed to radiation and the likelihood of unexpected exposure to radiation are minimised. Monitor levels of radiation exposure and doses. This is the name for an application for a principal licence. Post appropriate signs and notices. Comply with certain directions in routine and emergency situations. • • • • A person dealing with radiation apparatus will have to: • • • • • • • • Apply for and maintain concurrency of all permit. Keep records. and Radiation Protection Regulations of the Northern Territory. It is an additional document to a RPP. who controls x-ray apparatus and all licence holders at a practice. 2011 Radiographic Procedures Manual. Pay prescribed fees (NTG employees are exempt from all fees under the Radiation Protection Act). license and/or registration certificates.published by the Australian Radiation Protection and Nuclear Safety Agency (ARPANSA) Radiation Protection in Diagnostic and Interventional Radiology – Safety Guide The Code of Practice for Radiation Protection in the Medical Applications of Ionizing Radiation establishes regulatory requirements for using x-ray apparatus in medicine. A copy of the plan must be easily accessible and is provided by the procession licensee of the premises. which is the principal licence holder. Compliance with this RPP (Radiation Protection Plan) will ensure that the radiation doses to users and patients are below the prescribed limits and are as low as reasonably achievable (ALARA Principle). The plan applies to all of the X-ray equipment and premises and is in the possession of the principal licensee. Disseminate information to employees and radiation workers. RADIATION PROTECTION PLAN (RPP) • All sites with Xray equipment require a Radiation Protection Plan.

Date of Birth 4.g.doc Page 8 of 95 Version 2: 29-June-2011 Revision Date: June 2014 Department of Health is a Smoke Free Workplace . ALARA should be considered when determining the initial need for the radiographic procedure and also the necessity for repeat exposures or any extra views. Date of Exposure 6. Sex of Patient 5. A remote area operator’s course may become available at Alice Springs Hospital at some stage in the future. You must complete: • • • • at least 40 hours experience working with a registered radiographer at Royal Darwin Hospital and successfully complete a 3 hour examination with a certain level of correct answers . Mandatory Image Identification All images must include the following details: 1. Tennant Creek and Gove Hospitals under the direct supervision of a radiographer. Some registered nurses may take x-rays at Katherine. which health facility) 8. which is available at Royal Darwin Hospital. this may not be required for remote locations) 7. Patient Identifier number 2. Patient Name 3. 2011 Radiographic Procedures Manual. diagnostic benefit. Exposure Number (if applicable. The process of image transfer and accompanying documentation will be discussed in more detail in Section 4 – Computed Radiography of this manual. when dealing with radiation. always weighing up exposure and radiation risks vs. Identifier of person taking the x-ray (either on image or legibly on request form) When images are transferred to the NT PACS for storage and/or to Royal Darwin Hospital for formal image reporting. a formal imaging request with the same above details as well as all relevant clinical information should be faxed to RDH as soon as possible to allow for the appropriate efficiency in reporting and storage. Location exposure was taken ( e. Appropriate side marking 9. Training • • Medical practitioners or registered nurses may conduct chest and extremity X-rays after passing a remote operator’s course.D EPART M E NT O F H EALTH ALARA Principle While undertaking any radiographic imaging it is important to adhere to the ALARA (As Low As Reasonably Achievable) Principle. Along with the request form a Medicare form signed by the patient should also be faxed to RDH.

Some non-ionising radiation apparatus are defined as radiation source in the RPR These legislation. store. dispose of or otherwise deal with x-ray apparatus and radioactive material. possess. use. sell.D EPART M E NT O F H EALTH Licensing • • • RPA includes the following radiation related activity: Licence to manufacture. Conditions of your license The licensee must operate in accordance with the Code of Practice for Radiation Protection in the Medical Applications of Ionizing Radiation (2008). acquire. This certificate means that it is safe to take x-rays. 2011 Radiographic Procedures Manual. Certificate of compliance is to ensure that a particular source is safe to use. regulatory requirements and references can be viewed electronically through any web search. this license expires at the same time.doc Page 9 of 95 Version 2: 29-June-2011 Revision Date: June 2014 Department of Health is a Smoke Free Workplace . Certificate of Compliance • • • • • One protection strategy is the certificate of compliance. This is issued by service providers who will be accredited to do this. Examinations are to be reported by a Radiologist unless advised otherwise. If the licensee’s professional registration is repealed by the licensee’s professional registration board. chest and extremity X-rays only. The licensee must operate according to the current radiation protection plan and must not use a radiation source unless a current certificate of compliance for a radiation place is on display in the radiation place. transport. Except in an emergency. A request for advice by email is sufficient. the licensee must limit taking radiographic views to those for which the licensee is trained. The radiation place must have a certificate of compliance and this must be prominently displayed. A record of each radiographic view and number of repeats must be maintained and made available when requested.

1.doc Page 10 of 95 Version 2: 29-June-2011 Revision Date: June 2014 Department of Health is a Smoke Free Workplace .gov. Section 3. Please be aware that there is a safety guide. with the same name.au. Section 3.D EPART M E NT O F H EALTH Code of Practice for Radiation Protection in the Medical Applications of Ionizing Radiation (2008) • • • You must comply with this code because it is a condition of your licence.3 (c) A licence condition limits you to chest and extremities and therefore you must ensure that the field of view is set so that embryos and unborn babies cannot receive a radiation dose in excess of 1 mSv. Of particular importance to Remote Operators are the following sections.3 (a) No x-ray image is to be taken unless it is justified and approved for each individual by you or a written guideline. 2011 Radiographic Procedures Manual. You can obtain this code and this guide from here: www. that helps you understand this code.arpansa.1...

The Department cannot indemnify a person who chooses to ignore the legislation.” 2011 Radiographic Procedures Manual. There are no special conditions provided by the Radiation Safety Act that say we can ignore the rules in emergencies. It highlights the severity and seriousness of following correct protocol and procedures when conducting radiographic examinations and highlights the fact that these issues are prosecuted in states and territories across Australia.au/health/radiationprotection The following statement was taken from the Queensland Government’s 2005 Licensed Operators Manual – For Chest and Extremities (Rural & Remote Extended). It is important never to increase mAs or kVp significantly because an acceptable image will be produced but the patient will receive a radiation dose that is significantly greater than that produced from using the stipulated radiographic factors. it is recommended that personal monitoring devices are used. • These are available to view the web page for the Radiation Protection Section www. There are other responsibilities that the clinic manager or the Director Remote Health must meet.D EPART M E NT O F H EALTH Section 3. or if you do have a “use” licence and you decide to use a radiation source in a way that is not covered by your licence.9 You must wear your personal monitoring device if you could exceed a radiation dose of 1 mSv in a year.1. If you do not have a “use” licence and you decide to use a radiation source. • If there is a change in the shielding design or this is a new practice.7 (a) You must use radiographic factors as described during your training. Section 3. you are responsible for that action.doc Page 11 of 95 Version 2: 29-June-2011 Revision Date: June 2014 Department of Health is a Smoke Free Workplace . This can be used to determine the radiation dose received by the patient.1.nt. You will be held liable for a breach of the legislation. Remember: The law is the law.gov.

doc Page 12 of 95 Version 2: 29-June-2011 Revision Date: June 2014 Department of Health is a Smoke Free Workplace .gov.weckert@nt.au Radiation Protection Officer – Royal Darwin Hospital: Mark Palmer ph: 08 8922 8784 Email: mark.loughman@nt.D EPART M E NT O F H EALTH Section 1.au Tutor Radiographer Royal Darwin Hospital: Andrew Loughman ph: 08 8922 8951 Email: andrew.buckley@nt.gov.gov.gov.au 2011 Radiographic Procedures Manual.palmer@nt.C – Contacts Radiographic: Clinical Director of Radiology Services – Royal Darwin Hospital Glenn Drogemuller ph: 08 8922 8080 Superintendant Radiographer – Royal Darwin Hospital Roger Weckert ph: 08 8922 8732 Email: roger.au Fax for Request Forms and Signed Medicare Forms: 08 8922 8908 PACS: PACS Administrator Royal Darwin Hospital: Grant Buckley ph: 08 8922 8951 Email: grant.

au Radiation Protection Section 2nd Floor. Most locations have Fuji CR systems and Shimadzu mobile X-ray units. Casuarina Plaza 258 Trower Road Casuarina NT PO Box 40596 Casuarina NT 0811 ph: (08) 8922 7152 Fax: (08) 8922 7334 Email : envirohealth@nt. Secondly refer to your service contracts and manuals for assistance with any equipment faults. 2011 Radiographic Procedures Manual. However some locations use AGFA CR Systems and will have different service contacts and help lines.D EPART M E NT O F H EALTH Licensing: Department of Environmental Health: Manager Radiation Protection ph: 08 8922 7489 Email: russell.gov.au Equipment Faults & Servicing: Contact your closest Base radiographic provider for advice first.doc Page 13 of 95 Version 2: 29-June-2011 Revision Date: June 2014 Department of Health is a Smoke Free Workplace .gov.robinson@nt.

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D EPART M E NT O F H EALTH Section 2 General Radiation Physics 2011 Radiographic Procedures Manual.doc Page 15 of 95 Version 2: 29-June-2011 Revision Date: June 2014 Department of Health is a Smoke Free Workplace .

doc Page 16 of 95 Version 2: 29-June-2011 Revision Date: June 2014 Department of Health is a Smoke Free Workplace . radio-waves etc. They have a wavelength of less than 1 x 10-10 metres. microwaves.Introduction Wilhelm Roentgen discovered X-rays in 1895 during his experiments on the passage of electricity through partially evacuated glass tubes. the emissions were given the name of X-rays. Wavelength in metres Wave type 10-14 10-12 10-10 10-8 10 -6 Cosmic rays Gamma rays X-rays Ultraviolet Visible light Non Ionising Ionising Figure 2. Roentgen realised he had found a previously unknown type of radiation and because very little was understood about its properties.D EPART M E NT O F H EALTH SECTION 2 – GENERAL RADIATION PHYSICS Section 2.1: Wavelength of Different Radiation 2011 Radiographic Procedures Manual.A . X-rays are electromagnetic radiation and form part of the electromagnetic spectrum along with visible light. Since those early days. much work has been done on X-ray radiation with the result that the properties of X-rays are now well understood.

When electrons are suddenly stopped by a metal object. One electrode is called the Cathode (negatively charged) while the other is called the Anode (positively charged). In fact. If we evacuate the air out of an X-ray tube.D EPART M E NT O F H EALTH Section 2. To cope with this large production of heat.000 volts [40kVp]) between the anode and the cathode. the electrons are accelerated faster and therefore have more energy when they reach the anode. When these fast moving electrons rapidly decelerate as they approach the anode (also called the target). X-rays are produced whenever very energetic electrons are rapidly decelerated. whilst only 1% is available for the production of X-radiation. This is an evacuated glass tube inside which is fitted two electrodes.doc Page 17 of 95 Version 2: 29-June-2011 Revision Date: June 2014 Department of Health is a Smoke Free Workplace . heat and X-ray photons are produced in all directions. the X-ray tube must be constructed so that the heat can be conducted away from the anode as rapidly as possible before it melts the anode. 2011 Radiographic Procedures Manual. Heat is produced when the fast moving electrons strike the target. Copper and tungsten are the most common materials used for the anode as both are very good heat conductors. This is referred to as Bremsstrahlung (braking) Radiation. If the number of electrons passing from the cathode to the anode is increased then the number of X-rays (photons) increases with a resultant increase in the intensity of the X-ray beam. An x-ray tube uses this principle to produce radiation. electrons will escape from the cathode and be accelerated towards the anode. heat the cathode filament with an electric current and apply a very high voltage (greater than 40. If the voltage between the anode and the cathode is increased. Tungsten has a melting point of 3380°C while copper has a melting point of 1070°C. The actual target area is usually tungsten while the backing and support material is copper. This results in the production of X-rays having a higher energy level. During X-ray exposures the target area may reach temperatures of approximately 2000°C. some of their Kinetic (motion) energy is converted into electromagnetic radiation. up to 99% of the kinetic (motion) energy of the electrons is converted into heat.B – Production of X-rays X-rays are produced within part of the X-ray unit called the tube.

doc Page 18 of 95 Version 2: 29-June-2011 Revision Date: June 2014 Department of Health is a Smoke Free Workplace . In the rotating anode tube.D EPART M E NT O F H EALTH Section 2. 2011 Radiographic Procedures Manual.1 for comparison of these two tube types. the target area is a section of tungsten embedded in a copper anode. Stationary anode tubes and rotating anode tubes. The rotating anode allows the electron beam to interact with a much larger target area. when the anode stops fast moving electrons. The result is that the heating of the anode track is not concentrated in such a small area as it is in that of a stationary anode tube. In the stationary anode tube.2: Comparison of Standard X-ray Tubes Focal spot Rotating Anode The target area of the anode from which the X-rays are emitted is called the focal spot. The tube is constructed so that only the useful beam of X-rays is able to escape from the tube through a specially designed window. The anode design also determines a preferred direction. Any radiation that does get through is termed ‘leakage radiation’. The anode is always tilted at an angle to the direction of the accelerated electrons. The glass tube and lead lined tube housing restricts X-rays from escaping from the tube in other directions. Stationary Anode Figure 2. (4) The approximate location of the focal spot is usually indicated on the tube housing by a dot or a cross. This radiation does not contribute anything useful to the image on the film. As stated earlier. X-rays are produced in all directions. See figure 2. the target is a rotating tungsten disc.C – The X-ray Tube Two types of X-ray tube are used in diagnostic medicine. instead it presents a hazard to the patient and the operator.

D – Properties & Interactions of X-rays Voltage (kVp) applied across the X-ray tube The Energy of the X-rays emitted from the X-ray tube depends upon the Energy of the electrons. 2011 Radiographic Procedures Manual. There is a linear relationship between mA and the amount of X-rays produced. Therefore the kVp determines the maximum energy of the X-rays produced. THE GREATER THE X-RAY TUBE CURRENT. For example: If 100 mA produces 500 X-ray photons in one second. For example: If 100 mA produces 500 photons in one second. The size of the current passing across the X-ray tube is in the milliampere range (50mA to 1200mA). it is possible and in fact easier. The number of X-rays produced depends on the number of electrons that strike the target of the X-ray tube. However. 200 mA will produce 1000 X-ray photons in one second (an X-ray photon is a bundle of X-ray energy). changing the X-ray tube current does not affect the penetrating power of the X-ray beam. the amount of X-rays produced is also doubled. Since the current flow across the tube is directly related to the heating current supplied to the cathode filament. THE GREATER THE VOLTAGE APPLIED ACROSS THE X-RAY TUBE. we can increase the time of the exposure and therefore the time that the filament is energised. X-ray tube current (mA) The unit of measurement for electric current is the Ampere (A).doc Page 19 of 95 Version 2: 29-June-2011 Revision Date: June 2014 Department of Health is a Smoke Free Workplace .D EPART M E NT O F H EALTH Section 2. THE GREATER THE INTENSITY OF THE XRAY BEAM. to set the controls to provide a given current across the tube. 100 mA will produce 1000 photons in 2 seconds. The greater the number of electrons. which bombard the target of the X-ray tube. If the mA is doubled. There is another way of increasing the number of electrons. Instead of increasing the tube current. One thousandth of an Ampere is a milliampere (mA). Exposure time (s) The number of X-ray photons produced depends on the number of electrons that strike the target of the X-ray tube. the greater is the current flow (mA) across the tube and the greater the number of X-rays produced. The peak kilovoltage (kVp) used across the X-ray tube between the cathode and the target determines the Energy of the electrons. The higher the Energy level. the more penetrating the X-ray beam. THE GREATER THE PENETRATING POWER OF THE X-RAY BEAM. The cathode filament produces electrons and the number of electrons depends directly on the heating current applied to the cathode filament.

most of the lower energy X-rays are absorbed in the first few centimetres of tissue. 2011 Radiographic Procedures Manual. scatter some of the radiation and also absorb some of the radiation. In fact it not only reduces the quality of the radiograph but it is a major source of unwanted absorbed radiation dose for both the patient and the operator. THE ONLY FUNCTION OF THIS FILTER IS TO REDUCE THE RADIATION DOSE TO THE PATIENT. bone and soft tissue).D EPART M E NT O F H EALTH Milliamp second (mAs) Tube current in milliamperes (mA) and exposure time in seconds(s) are often linked and become milliamp seconds (mAs). water and bone. The low energy X-rays can be removed from the beam by the use of an aluminium filter interposed between the X-ray tube and the patient. depend on the energy of the Xrays and the material that they encounter. Since the patient’s radiation dose depends on the number of X-rays absorbed. As the X-rays pass through a patient. the X-rays lose energy so that scattered radiation is always of lower average energy than the primary beam. and only the higher energy X-rays penetrate the patient to form the radiographic image. This figure is a product of the tube current and the exposure time. The production of a radiograph depends on the different absorption in different materials (e. which occur. Scatter When X-rays strike matter. some are absorbed. Scattered radiation is of no value in the production of a radiograph. Other materials such as soft tissue.doc Page 20 of 95 Version 2: 29-June-2011 Revision Date: June 2014 Department of Health is a Smoke Free Workplace . it can be seen that the low energy radiation adds to the radiation dose to the patient without contributing anything to the radiograph. In the process of scattering. The production of a radiograph depends on the different rates of absorption of X-rays by different tissues. three things happen: • • • some x-rays pass through with or without any interaction. (mA x seconds = mAs) Filtration The diagnostic X-ray beam is composed of X-rays that have a whole range of energies. X-rays may be scattered several times before finally being absorbed. Bone absorbs more radiation than soft tissue. Lead is a very efficient absorber of X-rays in the diagnostic energy range. The relative amounts of absorption and scattering. and some are scattered in a variety of directions.g. which absorbs more radiation than gas.

because the intensity of the radiation varies inversely as the square of the distance from the source. The relationship between distance and intensity of radiation is called the INVERSE SQUARE LAW.D EPART M E NT O F H EALTH Figure 2. 2011 Radiographic Procedures Manual. like light.4 in which the same radiation that covers a given area at a distance of 10cms disperses itself over four times as great an area at 20cms or twice the distance (4 is the square of 2).4: Inverse Square Law The Inverse square law The Inverse Square Law states: “THE INTENSITY OF THE X-RAY BEAM VARIES INVERSELY WITH THE SQUARE OF THE DISTANCE FROM THE SOURCE OF THE BEAM” X-rays.doc Page 21 of 95 Version 2: 29-June-2011 Revision Date: June 2014 Department of Health is a Smoke Free Workplace . diverge along straight paths and cover an increasingly larger area with diminishing intensity as they travel from their source. This effect is demonstrated in Fig 2. At 80 cm the intensity would be one sixty-fourth of the original. If the distance is increased to 40cms or four times the distance at 10cms then the intensity would be one sixteenth of the original (the square of 4 is 16).3: Scatter Radiation Figure 2. This means that the intensity of the radiation at a point in the area at 20cms is one fourth (or one quarter) of the intensity at 10cms.

A definite link has been established between irradiation of these organs and an increase in the natural mutation rate of offspring. therefore an exposure for use at a focal film distance of 100 cms will be unsuitable if the focal film distance is varied one way or the other. a pre-disposition to neoplasms or. They are a valuable therapeutic tool in the treatment of a great number of conditions. including the relief from symptoms of inoperable neoplasms 2011 Radiographic Procedures Manual. EXPOSURE FACTOR kV (kilovoltage) mA (milliamps) s (seconds) mAs FFD (Focus to Film Distance) RELATIONSHIP TO X-RAYS Controls Penetrating power of the x-rays Controls Quantity of the x-rays Controls Duration of the Exposure Product of mA multiplied by s Intensity of x-rays at the target.doc Page 22 of 95 Version 2: 29-June-2011 Revision Date: June 2014 Department of Health is a Smoke Free Workplace . See inverse square law Figure 2. They provide a valuable diagnostic aid for speedy and accurate assessment of a wide variety of conditions and may be used to check the efficacy of a particular treatment. Somatic effects include reddening of the skin. the GENETIC effects of radiation received by the gonads must be considered. In addition. be it the primary beam or scattered radiation. These effects are termed SOMATIC and may appear within a few days of exposure although some may not be apparent for many years. death of the individual. and the sensitivity of the organs irradiated.E – Biological Effects & Hazards of Radiation lonising radiations are dangerous The effects on the human body of exposure to ionising radiations are complex and depend upon the radiation dose received.D EPART M E NT O F H EALTH The inverse square law impacts on radiography in the following ways: Radiation safety: The further you are away from the source of radiation. Exposure: The intensity of the beam varies considerably as the distance from the source (X-ray tube) varies. the volume of tissue irradiated. The genetic effect represents a potential hazard to future generations Ionising radiations are beneficial to medicine when used under controlled conditions. with extreme doses.5: Relationship of exposure factors and X-rays Section 2. loss of hair. necrosis of tissues. the less radiation dose you will receive.

1mSv equivalent dose to the conceptus. Radiation Protection in Diagnostic and Interventional Radiology. economic and social factors taken into account (ALARA Principle). Pregnant staff should avoid work that may result in higher radiation doses (e. For X-Ray exposure: 1sievert (sv) = 1joule/kg of energy. 2011 Radiographic Procedures Manual. 500 mSv equivalent dose to hands and feet. after declaration of pregnancy for the remainder of the pregnancy All radiation exposure should be kept to as low as reasonably achievable values. Annex C. pregnant staff members involved in plain film/CR diagnostic radiography do not need to alter their duties. In light of the normal occupational levels of exposure evidenced by historical measurements made in diagnostic radiography practices. Pregnancy An employee who becomes pregnant and works in an area where they may be exposed to ionising radiation must advise the employer as soon as practicable. 500 mSv equivalent dose to the skin. The aim of radiation protection is to keep radiation doses as low as reasonably achievable. from exposure to normal natural background radiation. involvement in fluoroscopic procedures).doc Page 23 of 95 Version 2: 29-June-2011 Revision Date: June 2014 Department of Health is a Smoke Free Workplace . and less than 1mSv per annum. how their duties performed will be evaluated to ensure that the doses remain as low as reasonably achievable. or from other exposures received by the individual as a member of the public are not to be taken into account when working out their dose equivalent received while at work. The Australian Radiation Protection and Nuclear Safety Agency. Safety Guide. prescribes the following annual radiation dose limits: • • • • • • • 20mSv as effective dose for persons involved in carrying out a radiation practice (occupationally exposed) 1mSv as effective dose for other staff and members of the public 150 mSv equivalent dose to lens of the eye. Occupational Exposure Note: The doses received from any exposure to radiation as a patient.g.D EPART M E NT O F H EALTH The benefits to be had from the medical uses of ionising radiations greatly outweigh the dangers inherent in their use. However. so that appropriate measures may be taken to control her exposure and to provide adequate levels of protection.

Source exposure of % contribution to Average Annual Dose to the population Natural: cosmic Terrestrial gamma 2011 Radiographic Procedures Manual. the (UK) Health Protection Agency in its publication “Living with Radiation” gives the following breakdown for the average annual dose to the population of the U. There is also some contribution to a population’s radiation exposure from miscellaneous sources such as increased cosmic ray exposure from air travel and by-products from the nuclear fuel cycle. Radiation reaches us from outer space in the form of cosmic rays. People are exposed to radiation from artificial radiation sources in medical procedures. depending on where they live. The equivalent dose limit to the skin must not exceed 50 mSv annually. as fall out from nuclear weapons testing and sometimes as a result of occupational exposure in the course of their work e.g.0 Page 24 of 95 Version 2: 29-June-2011 Revision Date: June 2014 Department of Health is a Smoke Free Workplace . the emissions from radioactive elements in the earth’s crust irradiate us as the elements decay. • • Sources of radiation exposure Radiation is either of natural origin or it is artificially produced. the effective dose must not exceed 5 mSv in a year.doc 13.0 16. Everybody is exposed to natural radiation to some extent. o The annual equivalent dose limit to the skin applies to the average dose received by any 1 square cm of skin. The equivalent dose limit to the lens of the eye must not exceed 15 mSv annually. and there are natural radioactive elements in the air and in our diet. That is. and industrial radiographers.D EPART M E NT O F H EALTH Public Exposure The radiation dose limits applying to the public exposure of a person while the radiation practice is carried out are as follows: • The effective dose received by a member of the public must not exceed 1mSv in a year.K. regardless of the total area exposed. o For example a parent who assists a use licensee by holding their child’s arm in the correct position so that it maybe radiographed Under these circumstances. with the exception of a member of the public who assists a use licensee to carry out a diagnostic or therapeutic procedure involving the use of ionising radiation. For example. medical workers.

For example.7 0.D EPART M E NT O F H EALTH internal radiation 16. while a whole body dose of 5sv is likely to prove fatal within a few weeks. There are considerable variations about this value with some individuals receiving doses several times higher than the average. An instantaneous dose of 5 Sv to the skin only would probably cause it to redden in a few days. however.6: Radiation Source Vs % of Contribution to Annual Dose The overall effective dose equivalent from radiation of natural and artificial origin in the UK averages about 2.doc Page 25 of 95 Version 2: 29-June-2011 Revision Date: June 2014 Department of Health is a Smoke Free Workplace . 60 Sv delivered to a malignant tumour may kill it.0 Artificial: medical fallout Occupational Miscellaneous 20. Effects of radiation exposure The potential biological effects of ionising radiation can be divided into four groups: • • • • Acute – short term effects which appear in hours.5 Figure 2.0 sources Radon 33. 2011 Radiographic Procedures Manual.4 0. If.4mSv per year.4 0. days or a few weeks Delayed – later effects seen after months or years Genetic __ effects seen only in descendants Foetal – effects developing in irradiated embryos/foetuses Since 1895 the effects of high doses of X-rays have been catalogued. This does not mean that damage has not occurred since it may be that the damage will only become apparent in the individual later in their life or even in their offspring. there may be no obvious signs of injury in the short term. The effects of high radiation exposures are obvious. 5 Sv is delivered to a person over a long period of time.

D EPART M E NT O F H EALTH
Approximate whole body Acute clinical symptoms dose

100Sv and above

central nervous syndrome, death after several minutes(> 1000Sv) to 48 hours.

10 – 100Sv

gastro-intestinal syndrome predominant, death after 10 to 30 days

2 – 10Sv

bone marrow syndrome, death after 10 to 30 days

1 – 2Sv

mild symptoms

1Sv and below Figure 2.7: Acute Effects

few symptoms

Section 2.F – Basic Radiation Protection & Safety
A “Radiation Safety and Protection Plan”, is the comprehensive plan for the practice which the possession licensee must maintain and contains details of the radiation source which the possession licensee is allowed to possess under that licence. Radiation Safety and Protection Plans must state the following: particulars, and an assessment, of all the radiation hazards specific to the practice and source the licensee knows, or ought reasonably to know, exist or might arise; the radiation safety and protection measures to deal with the hazards; any other measures necessary to deal with the hazards; how the licensee proposes to monitor and review the implementation and effectiveness of the measures; An RSO is not specifically required but a holder of a Certificate of Accreditation to test only a radiation source is now called Radiation Protection Adviser; particulars of the training program for persons carrying out the practice.

• • • • • •

If a person, other than the patient being irradiated as part of a diagnostic, may receive from the carrying out of the practice, a radiation dose higher than the radiation dose limit prescribed under a regulation, the plan must provide for (a) the supply of a personal monitoring device to the person; and (b) the assessment of the device.
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The licensee’s radiation safety and protection plan for the practice must state the functions of the radiation safety officer appointed by the licensee for the practice. Please note a copy of RDH Radiation Safety Plan can be found on any NT Government computer at: F:\RadiationSafety\RadiationSafetyOfficer\RDH SafetyPlan

Operator protection
The diagnostic operator works with X-rays to exploit their benefits for medical diagnosis. Throughout his work, the operator must remember the dangerous nature of the X-rays he uses. Before any radiographic exposure, they must ensure that all persons present are being protected as fully as possible, from unnecessary radiation. The protective measures to be taken follow the recommendations of the Radiation Safety and Protection Plan formulated for each individual department. Persons to be considered for protection may be grouped under three headings the OPERATOR, the PATIENT and OTHER PERSONS. The more important considerations are given below: The OPERATOR • • • • • must never support patients during radiographic exposure; should make all exposures from behind a protective screen; must wear protective clothing when it is necessary to remain outside the protected area; should always be the maximum distance possible from the X-ray tube: must always wear a suitable monitoring device.

The PATIENT is best protected by • • • • • • a good radiograph first time; positive identification; careful use of limiting diaphragms and collimation; clear and concise instructions before exposure: the use of immobilisation aids; the correct use of gonad protectors:

OTHER PERSONS are best protected by • • • • • exclusion from the room if their presence is not essential: standing behind the protective screen during exposure; wearing protective apron and gloves when assisting; keeping outside the path of the main beam; not assisting too frequently;
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Personnel in the X-ray room: Only persons who are directly involved in the radiographic procedures should be in the X-ray room. Mobile X-ray equipment: When a mobile X-ray machine is used, the operator and other persons involved in the X-ray examination should stand away from the primary beam and at least 2 metres from the X-ray tube and patient when the exposures are made. If it is not possible for them to stand at this distance they must wear a protective apron of at least 0.25mm lead equivalent. If an operator protection screen is available, it should be used. When a fixed X-ray machine is used, the operator and other persons present should stand behind the protective screen which, under the legislation, must be provided. Primary Beam: The primary beam must not be directed towards any person other than the patient and must always be collimated to the anatomical area of interest. Holding a Patient: If it is absolutely necessary for a person to hold a patient, their hands should never be in the primary beam. If the hands are in close proximity to the primary radiation beam, protective gloves with a lead equivalent of 0.5mm should be worn. Doors: All doors to the X-ray room should be closed before making an exposure.

Patient protection
An X-ray examination should only be carried out if it is of benefit to the patient, particularly if pregnancy is an issue. Avoid retakes as they increase the radiation dose to the patient and the operator. Patient doses are reduced by: • • • • • • • • • correct patient positioning avoid irradiating a pregnant patient if possible reducing the irradiated area by primary beam collimation correct processing procedures using the correct exposure for the area under examination use of correct focus to film distance using non-grid techniques regular servicing of the X-ray equipment gonad protection should always be used for an X-ray examination unless direct irradiation of the organ is unavoidable for the purposes of the investigation. Lead rubber of at least 1mm lead equivalent should be used as gonad protection.

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D EPART M E NT O F H EALTH Section 3 Radiographic Equipment 2011 Radiographic Procedures Manual.doc Page 29 of 95 Version 2: 29-June-2011 Revision Date: June 2014 Department of Health is a Smoke Free Workplace .

Section 3.2 and the tube housing X-ray Tube Support or Stand Light Beam Diaphragm (LBD) An exposure switch incorporating a PREP and EXPOSE button. Figure 3. usually in the form of a dead-man switch. There are also many ancillary pieces of equipment that may be accessible to you in order to improve the quality of your image.doc Page 30 of 95 Version 2: 29-June-2011 Revision Date: June 2014 Department of Health is a Smoke Free Workplace . all units are made up of similar components: • • • • • Control Panel used to set kVp and mA and time (mAs).A – Overall Description The equipment you will be using will be either fixed or mobile. • • kVp can be manipulated independently mA and s are either manipulated individually or on one control setting as mAs.D EPART M E NT O F H EALTH SECTION 3 – RADIOGRAPHIC EQUIPMENT Section 3. An X-ray tube shown in figure 2. In any event. Exact specifics of this will be determined by the equipment at your facility however the fundamentals can be applied across any general radiographic equipment.1: Control Console at RDH Control Console of Shimadzu Mobile X-ray Unit 2011 Radiographic Procedures Manual.B – Basic Exposure Controls All x-ray units have a means to control your exposure settings.

which are also located in the following satellite locations: • • • • • • • Wadeye Health Clinic – Send paperwork to RDH Jabiru Health Centre – Send paperwork to RDH Maningrida Health Clinic – Send paperwork top GDH Alyangula Health Clinic . US & Fluoroscopy also provided. CT.C – X-Ray Installations in the NT Radiographic services are provided at many locations across the Northern Territory. US & Fluoroscopy provided Onsite Radiologists US provided US provided Alice Springs Hospital o o • • • • Gove District Hospital o Katherine District Hospital o Tennant Creek District Hospital Nguiu Health Clinic – Send paperwork to RDH These locations also have mobile x-ray units.doc Page 31 of 95 Version 2: 29-June-2011 Revision Date: June 2014 Department of Health is a Smoke Free Workplace . This system uses Film/Screen Radiography technology and is used for community screening in locations where there isn’t an available x-ray service 2011 Radiographic Procedures Manual.D EPART M E NT O F H EALTH Section 3. Remote Operators are trained primarily at Royal Darwin Hospital.Send paperwork top GDH Borroloola Health Centre – Send paperwork to KH Papunya Health Clinic – Send paperwork top ASH Yuendumu Health Clinic – Send paperwork top ASH The Centre for Disease Control (CDC) Darwin has a portable X-ray unit with a Bench-top Processor. The following is a list of fixed x-ray tubes across the NT: • Royal Darwin Hospital o o • MRI. Onsite Radiologists CT.

D EPART M E NT O F H EALTH Section 3. The radiolucent interspace material allows almost all radiation to pass.2: Radiographic Grids Construction 2011 Radiographic Procedures Manual. all radiation that is not travelling in the same direction as the primary beam is then absorbed by the lead strip. Grids consist of alternating strips of lead interspaced with a radiolucent material. When using a grid your exposure factor needs to be doubled from the standard non-grid exposure. By having the Lead angled to the primary beam.g.doc Page 32 of 95 Version 2: 29-June-2011 Revision Date: June 2014 Department of Health is a Smoke Free Workplace . This is shown in figure 3. Parallel Grid Focused (angled Pb strips) Grid Figure 3. e. As a remote operator you will only need to use grids when imaging shoulders and adult chest.2 below. These strips of lead can either be parallel or angled.D – Ancillary Equipment Grids Grids are used to reduce the amount of scatter radiation that reaches the cassette this allows for a more detailed and sharper image with increased contrast. more scatter is produced when imaging a shoulder than with a wrist. Scatter radiation is produced when x-rays pass through and interact with human tissue. The amount of scatter radiation is increased as the thickness of the body part being imaged is increased. With a focused grid it is important that the recommended focal distance is observed. When the lead strips are angled the grid is called a focused grid. usually aluminium.

Figure 3. Internal Diagram Figure 3. The combination of knobs and shutters are known as collimators and the process of adjusting them is collimation. The tray ensures correct alignment between the cassette and the x-ray tube.3: Bucky Tray Light Beam Diaphragm (LBD) The LBD is attached directly to the underneath of the x-ray tube. It contain: • 2 sets of multi-planar internal lead shutters that are adjusted with external knobs. A light globe and mirror that reflects the light through the shutters in order to illuminate the collimated field.4: Light Beam Diaphragm External Picture 2011 Radiographic Procedures Manual.D EPART M E NT O F H EALTH Bucky A Bucky is a device that consists of an inbuilt grid along with a tray that is used to hold a cassette securely in position.doc Page 33 of 95 Version 2: 29-June-2011 Revision Date: June 2014 Department of Health is a Smoke Free Workplace . • The purpose of an LBD is to allow the radiographer to select the most appropriate field size for radiation to ensure that the smallest exposure field size is used for all imaging.

they require more radiation to produce a diagnostic image. The image capture devices (Cassettes) while superficially the same are internally different. Light sensitive emulsion The light sensitive emulsion is made up of innumerable tiny micro-crystals of photographic grains of silver halide suspended in gelatine. It is usually blue tinted. Film Screen is included in figure 4. The latent image. Silver halide is a compound of silver and bromine. Processing Procedures are vastly different The workflow comparison for CR vs.doc Page 34 of 95 Version 2: 29-June-2011 Revision Date: June 2014 Department of Health is a Smoke Free Workplace . which is important in processing. The patient positioning remains unchanged. exposure factors may vary slightly from CR if using film and the need for accurate exposure factors are more important as you have no ability to manipulate images after processing. chlorine or iodine. they require less radiation to produce a diagnostic film. In addition film emulsions are made with different sized micro-crystals and it is the size of these microcrystals that determine the speed and definition of the X-ray film.).1. X-ray film X-ray film consists of a base coated on both sides with a light sensitive emulsion and comes in various sizes.D EPART M E NT O F H EALTH Section 3. remains the same as used with computed radiography. bucky etc. has good dimensional stability.E – Film/Screen Radiography While it is unlikely that as Remote Operator in the Northern Territory you will experience film/screen radiography. It outlines the similarity and differences for the two. Some emulsions are sensitive to blue light whilst some are sensitive to green light. stiffness and flatness for handling. it was thought necessary to include a very brief overview. console. The light sensitive emulsion has a low sensitivity to X-rays and an increased sensitivity to light. and absorbs very little water. Silver bromide microcrystals containing small amounts of iodide are commonly used in emulsions of X-ray films. which are members of the halogen family of elements.e. (Gurney -Mott theory) 2011 Radiographic Procedures Manual. The sizes most commonly used by X-ray Operators are 24 x 30cm and 35 x 43cm.e. provides the right degree of strength. • • • • The exposure equipment (tube. Small micro-crystals give better definition but are less sensitive to light and therefore have slow speed i. The film base The film base or support is made from a transparent plastic that meets the fire retardant and other safety requirements of the American National Standards Institute. Image Capture is significantly different. Larger crystals do not give as good a definition as the smaller crystals but are more sensitive to light and have a faster speed i.

so the speed of the intensifying screen depends on the size of the phosphor crystals. absorption of moisture and staining. check the expiry date on each box as you add or remove from stock. This change – the formation of a latent or hidden image– cannot be detected by ordinary physical methods. 2011 Radiographic Procedures Manual. An intensifying screen consists of a layer of tiny phosphor crystals bonded together in a suitable binder and coated in a smooth uniform layer on a plastic or cardboard support. radiation sources.g. use oldest film first. a chemical reaction takes place. X-ray machines and room heaters. intensifying screens are placed either side of the Xray film so that the light produced by the interaction between the phosphor and the X-rays produces a latent image on the film. do not “draw” film across the screen as this can cause static discharge. A protective coating is applied over the external surface of these layers to guard against abrasion. never stack them “flat”. suspended in the gelatine. give finer definition but are less sensitive to X-rays. store film boxes upright. avoid using outdated film by making sure stock is rotated i. constitutes the visible image on the radiograph. a physical change takes place in them. when the exposed film is processed in a solution called a developer. In use. store films away from light. See fig 3. give slightly less definition but are more sensitive to X-rays.e. heat. check film boxes on delivery to ensure that they have not been damaged in transit. Observation of the following will reduce and possibly eliminate film artefacts: • • • • • • • • • ensure hands are clean and dry when handling films.D EPART M E NT O F H EALTH When the micro-crystals in the light sensitive emulsion absorb energy from light. Fluorescent intensifying screens X-rays have the ability to cause certain substances (phosphors) to fluoresce (that is to emit light). medium (regular) and fast.doc Page 35 of 95 Version 2: 29-June-2011 Revision Date: June 2014 Department of Health is a Smoke Free Workplace . Intensifying screens are attached to the back and front of the cassette. However. Use of hand cream can cause a problem. e. This black metallic silver. drink or smoke in the darkroom. Intensifying screens are classed according to their speed and are referred to as slow (detail or fine). Small crystals emit less light. storage and rotation X-ray film can be subject to damage and deterioration due to incorrect handling and storage.4 Just as the speed of the film is governed by the size of the micro-crystals. chemicals. which changes the exposed microcrystals of silver compound to tiny masses of black metallic silver and leaving the unexposed crystals unaffected. radioactive materials and sources. handle films only on edges and ideally at a corner. do not eat. Film handling. while larger crystals emit more light. The choice of which intensifying screens to use depends on the type of examination to be performed.

In order to achieve this. on completion of cleaning. wipe the surface dry using straight. Screen cleaning It is important that intensifying screens be inspected and cleaned regularly to keep them free from dust and foreign material.5: Cross section of a loaded cassette (not to scale) Fig 3. 2011 Radiographic Procedures Manual.4 shows the screen/film configuration most commonly used in medical radiography enclosed in a light proof container called a cassette. A double-coated film (one with emulsion on both sides of the support) is sandwiched between two intensifying screens and enclosed in a cassette which provides good screen/film contact and protection from light and damage.doc Page 36 of 95 Version 2: 29-June-2011 Revision Date: June 2014 Department of Health is a Smoke Free Workplace . turn cassette on end and leave open to dry for approximately 20 minutes. overlapping strokes with a soft. If a screen cleaning solution is not available use warm dilute soapy water: • • • • dampen a clean soft. screens should be cleaned with a compatible screen cleaning solution. after cleaning. dry. even.D EPART M E NT O F H EALTH Cassette front Front padding Support layer Phosphor layer Protective coating Double coated film Protective coating Phosphor layer Support layer Back padding Lead foil Cassette back Back Intensifying Screen Front Intensifying Screen Fig 3. repeat this procedure on the remaining screen. lint free cloth with the cleaning solution and using a circular motion clean one of the screens. The back of many cassettes is covered on the inside with a sheet of lead foil to prevent backscattered X-radiation from reaching the screen/film combination. lint free cloth.

cracks or blockages. Mix according to the manufacturer’s instructions. gloves. when handling chemistry always follow manufacturer’s instructions and precautions. adequate film storage – away from radiation. workbench – flat smooth surface for film and cassette handling. wear protective clothing as necessary. automatic film processor. adequate plumbing – hot and cold running water. with exhaust ducted to the external atmosphere. An adequate ventilation system providing at least 15 changes of air volume per hour is required to protect the operator and safeguard the equipment. chemicals – developer and fixer. adequate drainage. It should be shielded from all external light sources. faults and problems should be reported immediately so adequate remedial steps can be taken. etc. Store on edge. it is recommended that adequate ventilation be provided to ensure a minimum of 15 changes of air volume per hour. illuminated by red tinted safelights and have adequate film and chemical storage. do not eat. thermometer – alcohol or electronic. constant temperature and dry. respirator. so ensure the following: • • • • • • • • • • • processing solutions should not come into contact with skin. all materials contaminated by processing solutions either due to spillage or cleanup must be either thoroughly washed or disposed of in a sealed container. drink or smoke in the darkroom. splashes of processing solutions on skin should be washed off immediately.D EPART M E NT O F H EALTH Darkroom Darkroom safety precautions Exposure to processing chemicals and their fumes can be hazardous to one’s health. goggles. ensure processing chemicals are sealed and stored safely. Page 37 of 95 Version 2: 29-June-2011 Revision Date: June 2014 • • • • • • • 2011 Radiographic Procedures Manual. Basic design and equipment should include: • • • light tight darkroom – seals on all openings that exclude the entry of all white light. do not loiter next to the processor or use it as a source of heat. protective clothing – aprons. spillage should not remain to contaminate the environment. General darkroom design and basic equipment A properly designed darkroom will have the facility of automatic film processing. Check that globe is 25 watts for indirect light and 15 watts for direct light. check processing equipment plumbing for leaks.doc Department of Health is a Smoke Free Workplace . Red tinted safe lights – as recommended by the film manufacturer. Ensure light is at least 120cm above the bench.

agitation. replenishment. Page 38 of 95 Version 2: 29-June-2011 Revision Date: June 2014 2011 Radiographic Procedures Manual. fix. Under safelight conditions. wash and dry a radiograph in the short time available in an automatic processor requires several things: • • • • • specially formulated chemicals. If there is not a light proof door on the feed tray of the processor. See figure 3. chemicals and processor. Make sure that the processor has been switched on for sufficient time for the chemicals to reach their correct operating temperature. rigid control of solution temperatures. Reload the cassette carefully. make sure that all of the film has passed into the processor before opening the darkroom door.5 below. the cassette is opened and the film carefully removed. means of transporting the film at a controlled speed. Once a film has been exposed it is passed to the darkroom for processing.D EPART M E NT O F H EALTH Automatic processing With automatic processing of radiographic film. Principle of operation The essence of automated processing is the controlled interaction of film. Imprint the patient’s details onto the film by the use of the identification printer (I D Printer) then feed the film into the processor.6: A Modern Bench Top Processor (similar to the one owned by CDC) To develop. Figure 3. Handle the film by the corners and/or edges and take care not to allow the film to the flex and crease. Wait for the film to completely emerge from the drier. the results are accurate and reproducible. providing the chemicals are regularly changed and the temperature is consistent .doc Department of Health is a Smoke Free Workplace .

it must contain only developed silver masses suspended in the gelatine. In an automatic processor the squeegee action of the rollers removes most of the chemicals and the water dilutes and removes the rest. Developer A developer is a chemical solution that changes the latent image on a film to a visible image. the image may eventually discolour and fade. Fixer In a properly developed X-ray film. At the same time it has no appreciable effect on the unexposed grains in the emulsion. fixation.D EPART M E NT O F H EALTH • film with special characteristics that are compatible with processing conditions. The developer causes the gelatine of the film emulsion to swell so that the developing agents can penetrate to reach the silver halide crystals. Also the gelatine in the film emulsion must be hardened so that the film will resist abrasion and can be dried in warm air. Wash If a finished radiograph is to remain inert to light or chemical activity. This means that it must be properly washed to remove processing chemicals and any residual undeveloped silver crystals. DAILY MAINTENANCE • ensure adequate ventilation of the darkroom for the escape of fumes. The fixing agent is a chemical compound capable of clearing all undeveloped silver halide crystals and hardening the surface of the film. shortened processing times and the mechanical transport system. To complete the processing. the developed film must be cleared of all the undeveloped crystals before washing so that the film will not discolour or darken with age or exposure to light. The unexposed crystals are unaffected by the developer. closing down and maintenance procedures. Dryer In the dryer section of the automatic processor. Daily and weekly maintenance of automatic desktop processors with gravity feed replenishment systems All processors have service and operation manuals provided when installed and these should be followed for all starting up. washing and drying. If it is not washed long enough with proper agitation in an adequate volume of water.doc Department of Health is a Smoke Free Workplace . warm air is directed onto the film. Processing Operations Film processing consists of four operations: development. Page 39 of 95 Version 2: 29-June-2011 Revision Date: June 2014 2011 Radiographic Procedures Manual. those silver halide crystals that were exposed to light from the intensifying screens are converted to black metallic silver. This process is called fixation and it is important to the retention qualities of a radiograph. The developing agent is a chemical compound capable of converting exposed grains of silver halide into black metallic silver. In a properly functioning processor the film is dry by the time it exits from the processor.

Wait until the processor and chemicals have reached correct operating temperature before processing films. Leave the door of the darkroom open to ensure adequate ventilation for escape of fumes when not in use. crossovers.doc Page 40 of 95 Version 2: 29-June-2011 Revision Date: June 2014 Department of Health is a Smoke Free Workplace . check and replace filters on incoming water supply if applicable.D EPART M E NT O F H EALTH • • • check correct operation of processor by the processing of a clearing film. turn the processor off if it is not to be used for a considerable period of time. etc. Always check temperature before use. Leave the lid of the machine ajar and allow drying. Thoroughly clean and rinse all tanks. • 2011 Radiographic Procedures Manual. wait until the tanks have filled up then re-start the machine. Process at least 2 cleaning films (old film) before developing any new work. Wait until the machine is required before mixing developer replenisher and filling water bottle. Report any faults to supervisor or service personnel if replenishing rate is unusually high or low. Put bottles onto machine. roller racks. • • WEEKLY MAINTENANCE • • drain all tanks. Freshly cleaned rollers may leave marks. lift the lid of the processor when not in use and leave ajar. splashguards. check the fixer and developer tank levels before start-up and replenisher reserves daily.

D EPART M E NT O F H EALTH Section 4 Computer Radiography (CR) 2011 Radiographic Procedures Manual.doc Page 41 of 95 Version 2: 29-June-2011 Revision Date: June 2014 Department of Health is a Smoke Free Workplace .

the imaging plate containing storage phosphor is inserted in a cassette similar to a film in a film/screen system.D EPART M E NT O F H EALTH SECTION 4 – Computed Radiography Section 4. In CR. N Pongnapang*. Post Process if required. and basic workflow is the same. PhD Faculty of Medical Technology.1 below). however there are some major functional differences between the two systems. portability.doc Page 42 of 95 Version 2: 29-June-2011 Revision Date: June 2014 Department of Health is a Smoke Free Workplace . Thailand). Repeat if necessary. digital format.1: Workflow Comparison: CR Vs Film/Screen View image on computer screen for review. The digital images can then be printed by laser printer. A photomultiplier tube then enhances the signal coming from the IP (Imaging Plate) and the final image is displayed on the computer screen. stored electronically or even printed to a paper printer. and post-processing capability. When exposed to x-rays the latent image is ‘trapped’ by the plate.A – Introduction Computed Radiography has been developed over the last 20 years and is becoming the most common system used in radiography. Mahidol University. Reading the image is done by the scanning of a laser beam within the digitizer. With CR the optical signals are processed based on a phenomenon called ‘photo-stimulated luminescence’ rather than ‘phosphorescence’ as in the case of film/screen radiography. Bangkok. The main difference between film/screen and CR is how the final image is generated. Place cassette in the Digitizer CR Position Patient and expose cassette Put Patient details on cassette Take cassette to processing area Film/Screen Process in Darkroom or place cassette in daylight processor View film on lightbox for review. Repeat if necessary 2011 Radiographic Procedures Manual. (Practical guidelines for radiographers to improve computed radiography image quality. Figure 4. Much of the equipment looks the same at first glance. The workflow remains predominantly the same with CR as with film/screen radiography (see figure 4. Some major advantages of CR are its large dynamic range of image processing.

During exposure the x-ray photons pass through the anatomy of interest. Each cassette contains backscatter protection and as a result it is important to place the cassette the correct way. The IP is then read by a digitizer where the latent image. In order to ensure the highest quality of imaging.doc Page 43 of 95 Version 2: 29-June-2011 Revision Date: June 2014 Department of Health is a Smoke Free Workplace . Care should be taken in situations where blood or body fluids may enter the cassette. The latent image has a half life and should be processed as soon as possible. they should be erased after a long period if un-used. Section 4.B – Cassettes CR cassettes are visually similar to film/screen cassettes and are available in all the same sizes. nor film. A more practical approach for RO’s could be to perform a secondary erase of each cassette prior to performing the examination.D EPART M E NT O F H EALTH Section 4. as this can be hard or impossible to clean and may result in the equipment needing replacing. However in the case of equipment failure it is possible to store the cassette in a radiation free environment for up to 24hrs before image quality is sufficiently compromised. They also have some form of method for linking the images to the study. At RDH we erase the plates that are not used over the weekend each Monday morning. Imaging plates can theoretically be re-used thousands of times if they are handled carefully. which consists of valence electrons stored in high energy traps. Imaging Plates are very sensitive to scatter and background radiation.2:Layers of a Phosphor Plate EBC = Electron Beam Coated Image from AGFA. the beam then strikes the phosphor layer within the IP and store the radiation level received at each point in local electron energies. water must NEVER be used please refer to the manufacturers guide Fig 4.com 2011 Radiographic Procedures Manual. A phosphor plate (often called the Imaging Plate or IP) is inserted and it is this that stores the latent image.C – Imaging Plates and Phosphor layer The IP (Imaging Plate) is the insert within the cassette that is responsible for capturing the latent image. is transformed into a format that is displayed on the screen. Cleaning of cassettes must be done with great care. It serves the same purpose as film does in film/screen radiography. wether it is via internal memory or a barcode system. CR cassettes do not contain intensifying screens.

When the plate is put through the scanner. Figure 4.3: Different Agfa Digitizers Benchtop Digitizer Portable Digitizer High Throughput 2011 Radiographic Procedures Manual. Digitizers should NEVER be opened. is some example that were found on the AGFA website. The electronic signal is then converted to discrete (digital) values and placed into the image processor pixel map and thus displayed on the computer screen. emitting blue light that is detected by an ultra-sensitive photo-multiplier tube.3. figure 4. Below. Due to the sensitivity of the photomultiplier.doc Page 44 of 95 Version 2: 29-June-2011 Revision Date: June 2014 Department of Health is a Smoke Free Workplace .e.D – Digitizer/Reader This device is used to convert the latent image on the phosphor plate into a format that can be displayed on a computer screen. Digitizers come in many different shapes and sizes. return to the valence band).D EPART M E NT O F H EALTH Section 4. the scanning laser beam causes the electrons to relax to lower energy levels (i. which is then converted to an electronic signal.

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Note: There are many different manufacturers that distribute CR related products. While most will be similar there will be differences. For maintenance protocols and procedures please refer to your manufacturer’s website, helpdesk or manuals.

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Section 4.E – Post Processing
Post processing is all image manipulation that occurs after the acquired image has been displayed on the computer screen and before the image is sent. It is here that you can add annotation and comments to your film (such as side of interest, weight bearing, erect, supine, prone etc). You can also crop, rotate and magnify your image through this software. Another feature of post processing is the ability to alter the window width and window levels (commonly referred to as “windowing”). This is the control of the displayed images contrast, density and brightness. You can use these features to change the appearance of the image to assist with diagnosis and interpretation.

Note: Post processing does not compensate for poor radiographic technique. While it may be possible to make a poor quality image look respectable through the use of post processing tools it, in actual fact does not, and poor radiographic technique can lead to misdiagnosis and misinterpretation.

As with digitizers, different vendors have different computer programs and tools and you should contact your vendor or refer to their website, helpdesk or manuals for specific assistance with post processing.

Section 4.F – Image Storage and Transfer for Radiologist Review
Most digitizers have a limited inbuilt memory which after a certain number of examinations will become full. This is one of the reasons why all images must be transferred onto a Picture Archival & Communications System (PACS). Under NT legislation all Xray examinations must be documented and stored for future reference. Transferring the images allows for Radiologist review and reporting in a timely manner. A Picture Archival & Communications System (PACS) is the preferred method of archiving images. While this is the optimal way to store images, it is expensive and not financially viable for most satellite locations. Alternative archive storing options include CDs/DVDs or transferring images to an off-site PACS. Sites with permanent digital imaging facilities will electronically transfer images into the Northern Territory Government PACS. Images saved onto CD/DVD can be imported to NTG PACS. When images are acquired at sites without digital equipment, images will be scanned into NTG PACS at Royal Darwin Hospital and Alice Springs Hospital.

Northern Territory Medical Imaging (NTMI) provides reporting services at Royal Darwin Hospital for the Top End. Jones and Partners provide reporting services at Alice Springs Hospital for Central Australia.

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Section 4.G – Image File Types
DICOM (Digital Imaging and Communications in Medicine) is a standard for handling, storing, printing, and transmitting information in medical imaging. It includes a file format definition and a network communications protocol. DICOM files can be exchanged between two entities that are capable of receiving image and patient data in DICOM format. DICOM is the preferred format for reporting and viewing purposes, as this file format allows manipulation of the image by the Radiologist/Clinicians. DICOM enables the integration of scanners, servers, workstations, printers, and network hardware from multiple manufacturers into a picture archiving and communication system (PACS). The different devices come with DICOM conformance statements which clearly state the DICOM classes they support.

This file format also provides the highest quality image. The file size is quite large and often takes considerable time to load and save. A DICOM image cannot be emailed.

BITMAP (map of bits) is the best format for displaying grayscale images besides DICOM. BITMAP is the preferred format for emailing images where a direct connection to NTG PACS is unavailable. JPEG (Joint Photographic Experts Group). This is the same file system that you would use to store your colour digital photos. The file size is much smaller than DICOM, however there is image degradation and leads to poorer quality images and as a result, Radiologists are reluctant to report this file type. In cases where images might need to be emailed, converting the Xray image from DICOM to Bitmap (.bmp) or JPEG (.jpg) are good options.

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D EPART M E NT O F H EALTH 2011 Radiographic Procedures Manual.doc Page 48 of 95 Version 2: 29-June-2011 Revision Date: June 2014 Department of Health is a Smoke Free Workplace .

D EPART M E NT O F H EALTH Section 5 Working Procedures & Instructions 2011 Radiographic Procedures Manual.doc Page 49 of 95 Version 2: 29-June-2011 Revision Date: June 2014 Department of Health is a Smoke Free Workplace .

Check previous examination o images and exposure factors used the tube-head is directed according to the first projection and the correct focal-film distance is set. will seriously impair the quality of the resulting radiograph. • • Take exposure Process image. Any ancillary equipment (grid. Identify patient and check pregnancy status where applicable. • • • Protective devices should also be applied if relevant.Initial Preparation A radiograph of top quality can only be obtained with the cooperation of the patient. compression bands. somewhat along the following lines: • • • • • Fill out or Authenticate patient’s request. if necessary. the first film is placed in position and the radiographic factors are set Room prepared in advance o o • Exposure selection o • • Patient preparation The patient is correctly positioned for the first exposure o Full use must be made of positioning aids for complete immobilisation e. and assurance given that what is required of the patient will be within his capabilities. respiratory movements are rehearsed. Page 50 of 95 Version 2: 29-June-2011 Revision Date: June 2014 2011 Radiographic Procedures Manual. sandbags.A .D EPART M E NT O F H EALTH Section 5 . The nature of the examination should be explained. Movement. • Complete documentation. size and type of cassettes are made available. sponge. lead rubber etc. The tube is accurately centred and the primary beam limited to the area in question. Ensure that patient side markers are affixed to cassette. Confirm required examination. All radiographic investigations should follow a planned sequence.doc Department of Health is a Smoke Free Workplace .Working Procedures and Instructions Section 5. radiolucent pads. o Apply any post-processing techniques that may be needed to make the image more aesthetically appealing and easier to report. The operator must bear in mind that a patient will frequently be in pain and may be very nervous. A calm and confident manner will put the patient at ease.g. Advise patient of respiratory state o the procedure is explained to the patient and. A patient who has held his breath must be instructed to recommence breathing.) is easily accessible the correct number. or failure to maintain the correct position.

D EPART M E NT O F H EALTH o Operator to sign request form and ensure that it is faxed to Royal Darwin Hospital to be scanned onto PACS and to ensure the radiologist has sufficient clinical information available at time of reporting.B .2 mAs Tib/Fib: 58 kVp / 3. Optimal exposure of a radiograph revolves around penetrating power and duration of the primary x-ray beam. The Anatomy being imaged should be free from radio-opaque objects and clothing which may produce artefacts on the final image. Collimated field should be large enough to image anatomy but smaller than the cassette. Patient positioning will be explained in much greater depth in section 6 of this manual.doc Page 51 of 95 Version 2: 29-June-2011 Revision Date: June 2014 Department of Health is a Smoke Free Workplace .2 mAs Knee: 60 kVp / 5 mAs 2011 Radiographic Procedures Manual. Your facility should have an exposure chart that is suitable for your machine and the thicker the anatomy to be examined the higher exposure required. where relevant. Fax Number: RDH 08 8922 8908 o o • Evaluation of examination.8 mAs Ankle: 56 kVp / 3. Section 5. Penetration is controlled by the selection of the kVp and the duration of the exposure is determined by adjusting the mAs control. The golden rules for positioning of a patient are: 1. 7. 4. 5. Only the anatomy of interest should be exposed. You should ensure you are aware of which images you plan to take before the patient enters the room and have any ancillary equipment available before you start. 3. 6. Respiration should be explained to patient prior to exposure. For example: Lower Limb exposures at RDH for an average size adult with FFD = 100cm • • • • Foot: 55 kVp / 2. both the patient positioning and exposure factors must be considered.Positioning and Exposure Determination In order to take a diagnostic radiograph. Where possible the gonads should be shielded. Anatomy examined should be in centre of film 2. A Medicare form signed by the Patient must also accompany the Request Form. where practical and required. The body part should be immobilised.

Sex of Patient 5. Confirm required examination. Section 5.doc Page 52 of 95 Version 2: 29-June-2011 Revision Date: June 2014 Department of Health is a Smoke Free Workplace . Identifier of Operator (either on image or legibly on request form) 2011 Radiographic Procedures Manual.g. Date of Birth 4. this example gives you a trend to follow. GDH KH and TCH. Location exposure was taken ( e. Patient Identifier number (HRN. Patient Name 3. this is dependant on your operating system. not on the post processing software.) 2. Patient details are entered onto the CR system prior to image acquisition. Ensure that the side marker will not obscure any anatomy of interest.Patient Identification The first steps when imaging a patient are to: • • • • Fill out or Authenticate patient’s request. UR etc. This means pre-registration of patient details isn’t required at places like RDH. a. Date of Exposure 6. Exposure Number (if applicable.C . b. ASH. this may not be required for remote locations) 7. At the time of image acquisition. Markers are best placed anteriorly or laterally of the anatomy of interest c. which health facility) 8. Appropriate side marking. 9.D EPART M E NT O F H EALTH While the exposures at your facility may vary slightly from those above. Identify patient. All images must include the following details: 1. At the major centres the CR system is connected to the Hospital RIS (Radiology Information System) and patient identification is automatically transferred from the RIS. Check pregnancy status where appropriate.

doc Page 53 of 95 Version 2: 29-June-2011 Revision Date: June 2014 Department of Health is a Smoke Free Workplace .D EPART M E NT O F H EALTH Section 6 Radiographic Positioning 2011 Radiographic Procedures Manual.

(E) – Exposure Factors: Were the exposure factors set correctly? Does the image show the correct contrast and density? Are there any factors that need to be changed to produce a better image? (M) . is four way collimation seen on an extremities film? N.B: The collimated field should be the smallest possible. One way to ensure you cover all areas is to use an acronym such as: Positioning Anatomy of Interest Collimation Exposure Factors Markers Abnormality/Anomaly Name Below is a summary of the qualities that are needed for each letter of PACEMAN (P) .g.Collimation: Is the image properly collimated? E.A – Radiographic Critique When critiquing your radiograph it is useful to look at the aspects that make up a good image.Positioning: Is the patient in the correct position? Is the patient rotated? Does the image correctly show any needed joint spaces? (A) – Anatomy of Interest: Has the entire anatomy of interest been included within the collimated field? (C) . in order to adequately image the area of interest.doc Page 54 of 95 Version 2: 29-June-2011 Revision Date: June 2014 Department of Health is a Smoke Free Workplace .Markers: Have markers been placed on the image? (Markers are traditionally placed either laterally or anteriorly to the imaged anatomy) Are they correctly identifying left and right? 2011 Radiographic Procedures Manual.D EPART M E NT O F H EALTH Section 6 – Radiographic Positioning Section 6. and never larger than the cassette in order to help reduce scatter and patient dose.

This helps ensure correct diagnosis and therefore treatment of your patient. Sex of Patient 7. this may not be required for remote locations) 9. Does the image correctly identify the patient? 2. Exceptions to the standard viewing routine are:• • • Hands and wrists are viewed from the posterior aspect with fingers uppermost Toes and feet are viewed from the dorsal aspect with toes uppermost. or PA positioning was used to produce the radiograph. Date of Exposure 8. this is as though one were facing the patient who stands in the correct anatomical position. (if applicable.g.Name: 1. This viewing position is maintained whether AP.D EPART M E NT O F H EALTH (A) – Abnormality/Anomaly: Is there any abnormal pathology? Is there any anatomical anomalies? (N) . which health facility) By looking at each image with the aforementioned in mind you ensure that you take a radiograph that is the most diagnostic possible as well as aesthetically pleasing. Does it have any other relevant identification details? 3. Patient Identifier number 4. Lateral chest films are viewed from the film aspect. Location exposure was taken (e. Lateral projections are viewed from the aspect of the X-ray tube during exposure. Exposure Number. Viewing Radiographs All radiographs are viewed in a standard manner. Patient Name 5.doc Page 55 of 95 Version 2: 29-June-2011 Revision Date: June 2014 Department of Health is a Smoke Free Workplace . Date of Birth 6. With a few exceptions. 2011 Radiographic Procedures Manual.

lateral margins of chest and last rib (laterally) Positioning: • Pt should have there chest against the bucky and chin placed on the top of the bucky/cassette holder.D EPART M E NT O F H EALTH Section 6. • Pts arms should either be wrapped around the bucky for support or placed on the iliac crest with palms facing backwards. • Rotate the pt’s shoulders forward so that the scapulae rotate laterally and not superimposed over the lung field.B – CHEST PA CHEST PA CHEST – Preferred Projection Cassette Size: 35x43 cm Cassette Orientation: Landscape (unless pt is extremely tall then orientate cassette portrait) FFD: 180cm Central Ray: Perpendicular to Bucky Centring Point: Entering Pt at level of T6/T7 Collimation: To include apices and costophrenic angles. Respiration: Inspiration +/.doc Page 56 of 95 Version 2: 29-June-2011 Revision Date: June 2014 Department of Health is a Smoke Free Workplace .Expiration for Pneumothorax 2011 Radiographic Procedures Manual.

If pt is unsteady they can place their hands together on a drip stand at eye level.B – CHEST LATERAL CHEST LATERAL CHEST Should only be performed if something is seen on AP/PA that needs further investigation Cassette Size: 35x43 cm. • Pts hands on head with their elbows together.doc Page 57 of 95 Version 2: 29-June-2011 Revision Date: June 2014 Department of Health is a Smoke Free Workplace . • Rotate the pt slightly so that the costophrenic angles will be superimposed on the resultant image Respiration: Inspiration 2011 Radiographic Procedures Manual. Cassette Orientation: Portrait FFD: 180cm Central Ray: Perpendicular to Cassette Centring Point: Entering Pt in 5cm anterior the MCP at level of T6/T7 Collimation: To include apices and costophrenic angles. must use grid. Anterior and Posterior margins of lungs Positioning: • Left side of patient against the bucky.D EPART M E NT O F H EALTH Section 6.

doc Page 58 of 95 Version 2: 29-June-2011 Revision Date: June 2014 Department of Health is a Smoke Free Workplace . lateral margins of chest and last rib (laterally) Positioning: • Patient seated in wheelchair or upright in bed with back against cassette • Arms by side Respiration: Inspiration +/.D EPART M E NT O F H EALTH Section 6.B – CHEST AP CHEST AP CHEST Cassette Size: 35x43cm Cassette Orientation: Landscape (unless pt is extremely tall then orientate cassette portrait) FFD: 180cm Central Ray: Perpendicular to cassette Centring Point: Entering pt at the midpoint between xiphoid process and sternal notch Collimation: To include apices and costophrenic angles.Expiration for Pneumothorax 2011 Radiographic Procedures Manual.

Position of Patient: Seated at the end of table with legs parallel to the table end and affected limb on table.D EPART M E NT O F H EALTH Section 6.doc Page 59 of 95 Version 2: 29-June-2011 Revision Date: June 2014 Department of Health is a Smoke Free Workplace . For finger include distal tip of affected finger to proximal end of Metacarpal bone. gonads shielding is advisable.C – UPPER EXTREMITY I. HAND & FINGERS PA HAND Cassette Size: 24x30cm Cassette Orientation: Portrait FFD: 100cm Central Ray: Perpendicular to cassette Centring Point: Entering hand at 3rd MCP Jt Collimation: To include entire hand and carpal bones. Positioning: Place affected hand/finger palmar side down on cassette 2011 Radiographic Procedures Manual.

gonads shielding is advisable.doc Page 60 of 95 Version 2: 29-June-2011 Revision Date: June 2014 Department of Health is a Smoke Free Workplace . HAND & FINGERS OBLIQUE HAND Cassette Size: 24x30cm Cassette Orientation: Portrait FFD: 100cm Central Ray: Perpendicular to cassette Centring Point: Entering hand at 3rd MCP Jt Collimation: To include entire hand and carpal bones. Positioning: Place affected hand/finger palmar side down on a 450 sponge/angle thumb side raised.C – UPPER EXTREMITY I. Position of Patient: Seated at the end of table with legs parallel to the table end and affected limb on table. For finger include distal tip of affected finger to proximal end of Metacarpal bone.D EPART M E NT O F H EALTH Section 6. 2011 Radiographic Procedures Manual.

down on cassette. Position of Patient: Seated at the end of table with legs parallel to the table end and affected limb on table. To properly visualise the phalanges the fingers should be positioned in a fan like arrangement as per picture above.doc Page 61 of 95 Version 2: 29-June-2011 Revision Date: June 2014 Department of Health is a Smoke Free Workplace .D EPART M E NT O F H EALTH Section 6. This is not required if area of interest is the metacarpal bones. HAND & FINGERS LATERAL HAND Cassette Size: 24x30cm Cassette Orientation: Portrait FFD: 100cm Central Ray: Perpendicular to cassette Centring Point: To enter at the MCP Jt Collimation: To include entire hand and carpal bones For finger include distal tip of affected finger to proximal end of Metacarpal bone. gonads shielding is advisable. Positioning: Place affected hand with thumb raised.C – UPPER EXTREMITY I. 2011 Radiographic Procedures Manual.

doc Page 62 of 95 Version 2: 29-June-2011 Revision Date: June 2014 Department of Health is a Smoke Free Workplace . • PA Image should be to the medial side of the film FFD: 100cm Central Ray: Perpendicular to Cassette Centring Point: MCP Collimation: To include distal tip of thumb and distal carpal bones Position of Patient: Seated at the end of table with legs parallel to the table end and affected limb on table. • All three thumb images can fit on one film. Positioning: Place hand in lateral position with little finger on cassette. THUMB PA THUMB Cassette Size: 24x30cm Cassette Orientation: Landscape. A sponge can be used to steady the thumb if required 2011 Radiographic Procedures Manual.D EPART M E NT O F H EALTH Section 6. gonads shielding is advisable.C – UPPER EXTREMITY II. Lay thumb so that it is parallel with the cassette.

doc Page 63 of 95 Version 2: 29-June-2011 Revision Date: June 2014 Department of Health is a Smoke Free Workplace .D EPART M E NT O F H EALTH Section 6.C – UPPER EXTREMITY II. THUMB OBLIQUE THUMB Cassette Size: 24x30cm Cassette Orientation: Landscape. gonads shielding is advisable. • Oblique Image should be in the middle of the film FFD: 100cm Central Ray: Perpendicular to Cassette Centring Point: MCP Collimation: To include distal tip of thumb and distal carpal bones Position of Patient: Seated at the end of table with legs parallel to the table end and affected limb on table. Positioning: Place hand flat with the palmar surface down. This orientate the thumb to an oblique position 2011 Radiographic Procedures Manual. • All three thumb images can fit on one film.

doc Page 64 of 95 Version 2: 29-June-2011 Revision Date: June 2014 Department of Health is a Smoke Free Workplace . • Lateral Image should be to the lateral side of the film FFD: 100cm Central Ray: Perpendicular to Cassette Centring Point: MCP Jt Collimation: To include distal tip of thumb and distal carpal bones Position of Patient: Seated at the end of table with legs parallel to the table end and affected limb on table.C – UPPER EXTREMITY II.D EPART M E NT O F H EALTH Section 6. Positioning: Lateral aspect of thumb resting on the cassette with 2011 Radiographic Procedures Manual. • All three thumb images can fit on one film. gonads shielding is advisable. THUMB LATERAL THUMB Cassette Size: 24x30cm Cassette Orientation: Landscape.

Centring Point: Midway between the radial and ulnar styloid processes Collimation: To include the distal 1/3 of the forearm and metacarpal bones Position of Patient: Seated at the end of table with legs parallel to the table end and affected limb on table. Positioning: Forearm resting with anterior aspect on the table. gonads shielding is advisable.C – UPPER EXTREMITY III. 2011 Radiographic Procedures Manual.D EPART M E NT O F H EALTH Section 6. • All three Wrist images can usually fit on one film. with cassette under wrist.doc Page 65 of 95 Version 2: 29-June-2011 Revision Date: June 2014 Department of Health is a Smoke Free Workplace . • PA Image should be to the medial side of the film FFD: 100cm Central Ray: Perpendicular to the cassette. WRIST PA WRIST Cassette Size: 24x30cm Cassette Orientation: Landscape.

Positioning: • Forearm resting with anterior aspect on the table. 2011 Radiographic Procedures Manual. with cassette under wrist. • Oblique Image should be in the middle of the film FFD: 100cm Central Ray: Perpendicular to the cassette. WRIST OBLIQUE WRIST Cassette Size: 24x30cm Cassette Orientation: Landscape. Centring Point: Radial Styloid Process Collimation: To include the distal 1/3 of the forearm and metacarpal bones Position of Patient: Seated at the end of table with legs parallel to the table end and affected limb on table. • All three Wrist images can usually fit on one film.D EPART M E NT O F H EALTH Section 6.doc Page 66 of 95 Version 2: 29-June-2011 Revision Date: June 2014 Department of Health is a Smoke Free Workplace . gonads shielding is advisable.C – UPPER EXTREMITY III. • Rotate wrist 450 with thumb side raised and rest on sponge if required.

• All three Wrist images can usually fit on one film. gonads shielding is advisable. with cassette under wrist.D EPART M E NT O F H EALTH Section 6. WRIST LATERAL WRIST Cassette Size: 24x30cm Cassette Orientation: Landscape.doc Page 67 of 95 Version 2: 29-June-2011 Revision Date: June 2014 Department of Health is a Smoke Free Workplace . Positioning: Forearm resting with ulnar side on the table.C – UPPER EXTREMITY III. 2011 Radiographic Procedures Manual. • Lateral Image should be in the lateral side of the film FFD: 100cm Central Ray: Perpendicular to the cassette Centring Point: At carpal bones Collimation: To include the distal 1/3 of the forearm and metacarpal bones Position of Patient: Seated at the end of table with legs parallel to the table end and affected limb on table.

gonads shielding is advisable.C – UPPER EXTREMITY III.D EPART M E NT O F H EALTH Section 6. WRIST – ADDITIONAL VIEW – SCAPHOID ULNAR DEVIATION SCAPHOID – ULNAR DEVIATION Cassette Size: 24x30cm Cassette Orientation: Portrait • Both Images will fit on one cassette • Use top half straight tube and bottom half for angled tube FFD: 100cm Central Ray: Perpendicular to cassette Centring Point: Anatomical Snuff Box Collimation: To include carpal bones Position of Patient: Seated at the end of table with legs parallel to the table end and affected limb on table. Positioning: As for PA wrist but with the wrist in ulnar deviation 2011 Radiographic Procedures Manual.doc Page 68 of 95 Version 2: 29-June-2011 Revision Date: June 2014 Department of Health is a Smoke Free Workplace .

D EPART M E NT O F H EALTH Section 6. Positioning: As for PA wrist but with the wrist in ulnar deviation 2011 Radiographic Procedures Manual. WRIST – ADDITIONAL VIEW – SCAPHIOD CRANIAL ANGLE SCAPHIOD – CRANIAL ANGLE Cassette Size: 24x30cm Cassette Orientation: Portrait • Both Images will fit on one cassette • Use top half straight tube and bottom half for angled tube FFD: 100cm Central Ray: 200 Cranial Angulation Centring Point: Anatomical Snuff Box Collimation: To include carpal bones Position of Patient: Seated at the end of table with legs parallel to the table end and affected limb on table.doc Page 69 of 95 Version 2: 29-June-2011 Revision Date: June 2014 Department of Health is a Smoke Free Workplace . gonads shielding is advisable.C – UPPER EXTREMITY III.

Positioning: Ideally you should have: • Posterior aspect of Forearm on cassette with both wrist and elbow in AP position. • Elbow straight.C – UPPER EXTREMITY IV. gonads shielding is advisable. FOREARM AP FOREARM Cassette Size: 35x43cm or 24x30cm depending on Patient size Cassette Orientation: Portrait or Diagonal if required FFD: 100cm Central Ray: Perpendicular to cassette Centring Point: Midshaft of forearm Collimation: To include both wrist and elbow within field Position of Patient: Seated at the end of table with legs parallel to the table end and affected limb on table. 2011 Radiographic Procedures Manual. When this isn’t possible due to trauma/injury try: • Elbow straight • Posterior aspect of elbow on cassette with wrist lateral and elbow AP.D EPART M E NT O F H EALTH Section 6.doc Page 70 of 95 Version 2: 29-June-2011 Revision Date: June 2014 Department of Health is a Smoke Free Workplace .

gonads shielding is advisable.C – UPPER EXTREMITY IV.D EPART M E NT O F H EALTH Section 6. When this isn’t possible due to trauma/injury try: • Elbow flexed at 900 • Anterior side of forearm on cassette with wrist PA and elbow lateral.doc Page 71 of 95 Version 2: 29-June-2011 Revision Date: June 2014 Department of Health is a Smoke Free Workplace . Positioning: Ideally you should have: • Medial side of Forearm on cassette with both wrist and elbow in lateral position. FOREARM LATERAL FOREARM Cassette Size: 35x43cm or 24x30cm depending on Patient size Cassette Orientation: Portrait or Diagonal if required FFD: 100cm Central Ray: Perpendicular to cassette Centring Point: Midshaft of forearm Collimation: To include both wrist and elbow within field Position of Patient: Seated at the end of table with legs parallel to the table end and affected limb on table. • Elbow flexed at 900. 2011 Radiographic Procedures Manual.

C – UPPER EXTREMITY V.D EPART M E NT O F H EALTH Section 6. Positioning: • Elbow as close to straight as the pt is able. • Humerus and forearm should both be in contact with the cassette in order to ensure a open joint space 2011 Radiographic Procedures Manual. ELBOW AP ELBOW Cassette Size: 24x30cm Cassette Orientation: Landscape FFD: 100cm Central Ray: Perpendicular to Cassette Centring Point: Elbow Joint Collimation: To include Distal third of humerus and proximal third of forearm Position of Patient: Seated at the end of table with legs parallel to the table end and affected limb on table. with posterior aspect on cassette. gonads shielding is advisable.doc Page 72 of 95 Version 2: 29-June-2011 Revision Date: June 2014 Department of Health is a Smoke Free Workplace .

• Humerus and forearm should both be in contact with the cassette in order to ensure an open joint space. 2011 Radiographic Procedures Manual. ELBOW OBLIQUE ELBOW Cassette Size: 24x30cm Cassette Orientation: Landscape FFD: 100cm Central Ray: Perpendicular to Cassette Centring Point: Elbow Joint Collimation: To include Distal third of humerus and proximal third of forearm Position of Patient: Seated at the end of table with legs parallel to the table end and affected limb on table. with posterior aspect on cassette • Rotate entire arm laterally as far as pt will tolerate • This should display the radial head clear of any superimposition from other bones.C – UPPER EXTREMITY V. Positioning: • Elbow as close to straight as the pt is able. gonads shielding is advisable.D EPART M E NT O F H EALTH Section 6.doc Page 73 of 95 Version 2: 29-June-2011 Revision Date: June 2014 Department of Health is a Smoke Free Workplace .

• Forearm. Humerus and cassette all parallel. • This ensures an open joint space as well as superimposition of the humeral epicondyles. with wrist in lateral orientation. You may need to raise the wrist slightly with a sponge in order for this to occur. ELBOW LATERAL ELBOW Cassette Size: 24x30cm Cassette Orientation: Landscape FFD: 100cm Central Ray: Perpendicular to Cassette Centring Point: Elbow Joint Collimation: To include Distal third of humerus and proximal third of forearm Position of Patient: Seated at the end of table with legs parallel to the table end and affected limb on table.doc Page 74 of 95 Version 2: 29-June-2011 Revision Date: June 2014 Department of Health is a Smoke Free Workplace . Positioning: • Elbow flexed at 900.D EPART M E NT O F H EALTH Section 6. gonads shielding is advisable. 2011 Radiographic Procedures Manual.C – UPPER EXTREMITY V.

Humerus and cassette all parallel. with wrist in lateral orientation. Positioning: • Elbow flexed at 900. ELBOW – ADDITIONAL VIEW – RADIAL HEAD ELBOW – RADIAL HEAD Cassette Size: 24x30cm Cassette Orientation: Landscape FFD: 100cm Central Ray: Angled at 200 Cranially (Towards Shoulder) Centring Point: Radial Head Collimation: To include Distal third of humerus and proximal third of forearm Position of Patient: Seated at the end of table with legs parallel to the table end and affected limb on table.doc Page 75 of 95 Version 2: 29-June-2011 Revision Date: June 2014 Department of Health is a Smoke Free Workplace . 2011 Radiographic Procedures Manual. You may need to raise the wrist slightly with a sponge in order for this to occur. • This ensures an open joint space as well as superimposition of the humeral epicondyles. gonads shielding is advisable.D EPART M E NT O F H EALTH Section 6. • Forearm.C – UPPER EXTREMITY V.

D EPART M E NT O F H EALTH Section 6.doc Page 76 of 95 Version 2: 29-June-2011 Revision Date: June 2014 Department of Health is a Smoke Free Workplace . SHOULDER AP SHOULDER Cassette Size: 24x30cm Cassette Orientation: Landscape FFD: 100cm Central Ray: Perpendicular to cassette/bucky Centring Point: Coracoid Fossa Collimation: To include the lateral skin edge and medial aspect of the clavicle Skin edge superiorly to inferior angle of scapula Positioning: • Patient standing • Arm hanging by side in neutral position • Back against the bucky 2011 Radiographic Procedures Manual.C – UPPER EXTREMITY VI.

2011 Radiographic Procedures Manual. • Hand should be resting on waist • Rotate the patient so the central ray will through the medial border of the scapula and the AC Jt.doc Page 77 of 95 Version 2: 29-June-2011 Revision Date: June 2014 Department of Health is a Smoke Free Workplace . SHOULDER LATERAL SHOULDER Cassette Size: 24x30cm Cassette Orientation: Portrait FFD: 100cm Central Ray: Perpendicular to cassette/bucky Centring Point: At level of scapulohumeral joint Collimation: To include the proximal third of the humerus and AC Jt Lateral skin edge and medial border of the scapula.D EPART M E NT O F H EALTH Section 6. Positioning: • Patient standing • Place pt with the point of their shoulder against the bucky.C – UPPER EXTREMITY VI.

C – UPPER EXTREMITY VI.D EPART M E NT O F H EALTH Section 6.CLAVICLE CLAVICLE Cassette Size: 24x30cm Cassette Orientation: Landscape FFD: 100cm Central Ray: Perpendicular to cassette/bucky Centring Point: Midshaft of the Clavicle Collimation: T o include the medial end of clavicle and the lateral skin edge Positioning: • Patient standing • Arm hanging by side in neutral position • Back against the bucky 2011 Radiographic Procedures Manual.doc Page 78 of 95 Version 2: 29-June-2011 Revision Date: June 2014 Department of Health is a Smoke Free Workplace . SHOULDER .

D EPART M E NT O F H EALTH Section 6. SHOULDER .doc Page 79 of 95 Version 2: 29-June-2011 Revision Date: June 2014 Department of Health is a Smoke Free Workplace .C – UPPER EXTREMITY VI.CLAVICLE CRANIAL ANGLE CLAVICLE Should only be used for initial diagnosis Cassette Size: 24x30cm Cassette Orientation: Landscape FFD: 100cm Central Ray: 200 Cranial Angulation Centring Point: Midshaft of the Clavicle Collimation: To include the medial end of clavicle and the lateral skin edge Positioning: • Patient standing • Arm hanging by side in neutral position • Back against the bucky • Central Ray angulation clears the clavicle of superimposition with the ribs 2011 Radiographic Procedures Manual.

FOOT & TOES DP FOOT Cassette Size: 24x30cm Cassette Orientation: Portrait FFD: 100cm Central Ray: 50 Cranial Angulation Centring Point: Foot: Mid Foot Toes: MTP Jt of affected toe Collimation: Foot: To include entire foot Toes: To include distal tip of toe and distal end of metatarsal. with knee bent and plantar aspect of foot placed on cassette 2011 Radiographic Procedures Manual.D EPART M E NT O F H EALTH Section 6.D – LOWER EXTREMITY I. Positioning: Patient supine or seated on table.doc Page 80 of 95 Version 2: 29-June-2011 Revision Date: June 2014 Department of Health is a Smoke Free Workplace .

doc Page 81 of 95 Version 2: 29-June-2011 Revision Date: June 2014 Department of Health is a Smoke Free Workplace . with knee bent and plantar aspect of foot placed on cassette and rotated internally 450. FOOT & TOES OBLIQUE FOOT Cassette Size: 24x30cm Cassette Orientation: Portrait FFD: 100cm Central Ray: 50 Cranial Angulation Centring Point: Foot: Mid Foot Toes: MTP Jt of affected toe Collimation: Foot: To include entire foot Toes: To include distal tip of toe and distal end of metatarsal.D EPART M E NT O F H EALTH Section 6. 2011 Radiographic Procedures Manual. Positioning: Patient supine or seated on table.D – LOWER EXTREMITY I.

D EPART M E NT O F H EALTH Section 6. Separate toes using a tongue depressor or foam pad if required Positioning: • Patient supine or seated on table with leg externally rotated so that the lateral aspect of the foot is resting on the cassette.D – LOWER EXTREMITY I.doc Page 82 of 95 Version 2: 29-June-2011 Revision Date: June 2014 Department of Health is a Smoke Free Workplace . • Foot should be flexed at 900. 2011 Radiographic Procedures Manual. • Raise knee from bed until the plantar surface of the foot is perpendicular to the cassette. FOOT & TOES LATERAL FOOT Cassette Size: 24x30cm Cassette Orientation: Portrait FFD: 100cm Central Ray: Perpendicular to the cassette Centring Point: Foot: Mid Foot Toes: MTP Jt of affected toe Collimation: Foot: To include entire foot and tibiotalar Jt Toes: To include distal tip of toe and distal end of metatarsal.

• Foot Dorsi-flexed to 900.doc Page 83 of 95 Version 2: 29-June-2011 Revision Date: June 2014 Department of Health is a Smoke Free Workplace . • Toes pointing straight to roof. ANKLE AP ANKLE Cassette Size: 24X30cm Cassette Orientation: Portrait FFD: 100cm Central Ray: perpendicular to Cassette Centring Point: Midway between Malleolus Collimation: To include distal third of tib/fib and skin edge Positioning: • Patient supine or sitting on bed with leg straight.D EPART M E NT O F H EALTH Section 6. 2011 Radiographic Procedures Manual.D – LOWER EXTREMITY II.

2011 Radiographic Procedures Manual.doc Page 84 of 95 Version 2: 29-June-2011 Revision Date: June 2014 Department of Health is a Smoke Free Workplace .D EPART M E NT O F H EALTH Section 6. • Toes pointing straight to roof and leg internally rotated so that a line from the little toe to the middle of the Calcaneus is perpendicular to the cassette. • Foot Dorsi-flexed to 900. ANKLE MORTISE ANKLE Cassette Size: 24X30cm Cassette Orientation: Portrait FFD: 100cm Central Ray: perpendicular to Cassette Centring Point: Midway between Malleolus Collimation: To include distal third of tib/fib and skin edge Positioning: • Patient supine or sitting on bed with leg straight.D – LOWER EXTREMITY II. as per diagram above.

This tip can help when anatomy isn’t standard and you are having difficulty with positioning. • Raise knee from bed until the plantar surface of the foot is perpendicular to the cassette.doc Page 85 of 95 Version 2: 29-June-2011 Revision Date: June 2014 Department of Health is a Smoke Free Workplace .D EPART M E NT O F H EALTH Section 6. • Foot should be flexed at 900.D – LOWER EXTREMITY II. ANKLE LATERAL ANKLE Cassette Size: 24X30cm Cassette Orientation: Portrait FFD: 100cm Central Ray: perpendicular to Cassette Centring Point: Medial Malleolus Collimation: To include distal third of tib/fib. • A line from the little toe to the middle of the Calcaneus is parallel to the cassette. Posterior skin edge and head of 5th metatarsal Positioning: • Patient supine or seated on table with leg externally rotated so that the lateral aspect of the foot is resting on the cassette. as per diagram above. will ensure superimposition of the talar dome. 2011 Radiographic Procedures Manual.

• Cassette underneath leg. • Flex foot as far past 900 as pt will tolerate. depending on tolerated foot flexion.D – LOWER EXTREMITY III. Centring Point: At level of base of 5th Metatarsal in the midpoint of the foot Collimation: Lateral and Posterior skin edge and to include baser of 5th Metatarsal Positioning: • Patient Supine with leg straight and toes pointed to the roof. 2011 Radiographic Procedures Manual. CALCANEUS AXIAL CALCANEUS Cassette Size: 24x30xm Cassette Orientation: Landscape FFD: 100cm Central Ray: 300-500 Cranial Angulation.D EPART M E NT O F H EALTH Section 6.doc Page 86 of 95 Version 2: 29-June-2011 Revision Date: June 2014 Department of Health is a Smoke Free Workplace . You may need to use a belt or something similar in order to achieve this.

doc Page 87 of 95 Version 2: 29-June-2011 Revision Date: June 2014 Department of Health is a Smoke Free Workplace .D EPART M E NT O F H EALTH Section 6. • Foot should be flexed at 900. 2011 Radiographic Procedures Manual. • Raise knee from bed until the plantar surface of the foot is perpendicular to the cassette.D – LOWER EXTREMITY III. CALCANEUS LATERAL CALCANEUS Cassette Size: 24X30cm Cassette Orientation: Portrait FFD: 100cm Central Ray: Perpendicular to Cassette Centring Point: Mid Calcaneus Collimation: Posterior skin edge to base of 5th Metatarsal and Inferior skin edge to medial Malleolus Positioning: • Patient supine or seated on table with leg externally rotated so that the lateral aspect of the foot is resting on the cassette.

doc Page 88 of 95 Version 2: 29-June-2011 Revision Date: June 2014 Department of Health is a Smoke Free Workplace . • Foot flexed to 900.D – LOWER EXTREMITY IV. TIBIA/FIBULA AP TIB/FIB Cassette Size: 35x43cm or 24x30cm depending on Patient size Cassette Orientation: Portrait or Diagonal if required FFD: 100 – 150 cm depending on length of leg. • Cassette placed under leg. Central Ray: Perpendicular to cassette Centring Point: Midshaft of tibia Collimation: To include both knee and ankle within field Positioning: • Pt supine or seated with leg straight.D EPART M E NT O F H EALTH Section 6. Remember to adjust exposure according if you increase the FFD. 2011 Radiographic Procedures Manual.

Central Ray: Perpendicular to cassette Centring Point: Midshaft of tibia Collimation: To include both knee and ankle within field Positioning: • Patient to lay on side with lateral aspect of affected leg on cassette. TIBIA/FIBULA LATERAL TIB/FIB Cassette Size: 35x43cm or 24x30cm depending on Patient size Cassette Orientation: Portrait or Diagonal if required FFD: 100 – 150 cm depending on length of leg.doc Page 89 of 95 Version 2: 29-June-2011 Revision Date: June 2014 Department of Health is a Smoke Free Workplace . • Knee should be flexed at approx 450 • Foot should be flexed at 900 2011 Radiographic Procedures Manual.D EPART M E NT O F H EALTH Section 6.D – LOWER EXTREMITY IV. Remember to adjust exposure according if you increase the FFD.

doc Page 90 of 95 Version 2: 29-June-2011 Revision Date: June 2014 Department of Health is a Smoke Free Workplace .D – LOWER EXTREMITY V.D EPART M E NT O F H EALTH Section 6. KNEE & PATELLA AP KNEE Cassette Size: 24x30cm Cassette Orientation: Portrait FFD: 100cm Central Ray: 50-100 Cranial Angulation Centring Point: Apex of Patella Collimation: To include distal third of femur and proximal third of tibia and Lateral and medial skin edge Positioning: • Pt supine or seated with leg straight. 2011 Radiographic Procedures Manual. • Cassette placed under knee.

doc Page 91 of 95 Version 2: 29-June-2011 Revision Date: June 2014 Department of Health is a Smoke Free Workplace . • Knee flexed at 450. cassette under knee.D EPART M E NT O F H EALTH Section 6. • Sponge under foot to ensure that tibia is parallel with cassette and table. 2011 Radiographic Procedures Manual.D – LOWER EXTREMITY V. KNEE & PATELLA LATERAL KNEE Cassette Size: 24x30cm Cassette Orientation: Portrait FFD: 100cm Central Ray: 50-100 Cranial Angulation Centring Point: Medial Femoral Condyle Collimation: To include distal third of femur and proximal third of tibia and Anterior and Posterior skin edge Positioning: • Patient to lay on affected side.

2011 Radiographic Procedures Manual. • Pt to hold the cassette perpendicular to table resting on the anterior aspect of the femur. Collimation needs to be as tight as possible as primary beam is directed at the pts body.doc Page 92 of 95 Version 2: 29-June-2011 Revision Date: June 2014 Department of Health is a Smoke Free Workplace . Positioning: • Pt seated with knee flexed approx 450.D – LOWER EXTREMITY V. KNEE & PATELLA SKYLINE (AXIAL PATELLA) Cassette Size: 24x30cm Cassette Orientation: Landscape FFD: 100cm Central Ray: Angled so that it is perpendicular to the Patellofemoral Jt space Centring Point: Apex of Patella Collimation: To include medial. lateral and anterior skin edge and fibula head.D EPART M E NT O F H EALTH Section 6.

D EPART M E NT O F H EALTH 2011 Radiographic Procedures Manual.doc Page 93 of 95 Version 2: 29-June-2011 Revision Date: June 2014 Department of Health is a Smoke Free Workplace .

5 54/2.2 60/3.doc Page 94 of 95 Version 2: 29-June-2011 Revision Date: June 2014 Department of Health is a Smoke Free Workplace . such as FFD.2) 86/3.D EPART M E NT O F H EALTH Section 6. POP.E – Exposure Chart Please use the RDH Exposures for an average sized adult as a starting point and guide. Please alter your exposure factors to suit your situation and equipment. Area of Anatomy Projection PA Grid (No Grid) RDH Exposure kVp/mAs 105/4 (86/3.2 58/3.6 70/10 75/16 68/10 70/12 Remote Exposure Chest AP Lateral Grid Hand.2 110/8 52/2 54/2 56/3.2 58/3. body habitus and patient size. equipment etc. Fingers & Thumb PA Oblique Lateral PA Wrist Oblique Lateral AP Forearm Lateral AP Oblique Elbow Lateral Radial Head AP (Grid) Shoulder Lateral (Grid) AP (Grid) Clavicle Cranial Angle (Grid) 2011 Radiographic Procedures Manual.2 58/3.2 58/3.2 58/3.2 52/2. Different factors can affect the exposure required.5 56/3.

2 66/6 56/3.8 56/2.8 58/2.2 56/2.8 56/3.8 55/2.D EPART M E NT O F H EALTH AP Foot & Toes Oblique Lateral AP Ankle Mortise Lateral Axial Calcaneus Lateral AP Tib-Fib Lateral AP Knee Lateral Skyline 55/2.8 60/5 60/5 66/8 2011 Radiographic Procedures Manual.2 58/2.8 56/3.doc Page 95 of 95 Version 2: 29-June-2011 Revision Date: June 2014 Department of Health is a Smoke Free Workplace .

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