East Kent Hospitals University NHS

Foundation Trust

General Radiography Protocols

(Adults and Children)

Radiological Sciences

EKHUFT

Version: 1.0

Ratified by: Radiological Sciences Board

Date ratified: 17/04/2018

Name of originator/author: Lynne Dolke and Lee Gavin

Date issued: 18/04/2018

Review date: 18/04/2020

1
General notes / Quality Standards

• This document has been approved by the Radiological Sciences Board (RSB). By approving
the protocols the RSB is taking the responsibility as the Practitioner for any exposure
authorised.

• The following protocols in conjunction with the Royal College of Radiologists iREFER
database are used as justification criteria for the examinations listed only.

• The following protocols have been developed to allow Operators to authorise exposures.

• If justification information is not available or absent for certain procedures then please use the
Royal College of Radiologists iREFER. If it is unclear whether or not an exposure can be
authorised then contact a Consultant Radiologist who can act as a ‘Practitioner’ if required. If
a Consultant Radiologist justifies an exposure then this must be recorded on the radiology
information system. (RIS)

• These protocols should be used in conjunction with the IRMER employers procedures for
general radiography and the Guidelines for Paediatric General Radiography(available on
SharePoint)

• Anatomical side markers and, where necessary, legends must be used on all films.

• If unconventional views or poor quality images are obtained a note should made on the
Radiology Information System in the remarks box found on the ‘service recording’ page.

• All additional examinations must be entered onto the RIS system to ensure an accurate
patient history record is kept.

• Guideline exposure factors for ADULT radiography using the Philips DigitalDiagost and Kodak
CR systems are included for reference only. Exposure factors for other units including the
Fujifilm DR systems and Paediatrics will be held locally and on SharePoint

2
 ABDOMEN

Blunt/stab injury (+erect CXR)---only if not for CT

Clinical
Indications Renal/Ureteric colic-- only if not for CT

Renal Calculi follow up

Ingestion of sharp/potentially poisonous FB

Perforation (+erect CXR)

Obstruction and obstruction monitoring

Acute exacerbation in inflammatory bowel disease

Acute Pancreatitis
Colonic transit studies for constipation in children ( x-ray day 5 post tablet )
Lost intrauterine contraceptive device when not seen on US.
The radiograph should include diaphragm to symphysis pubis and lateral soft
Typical diagnostic
features and tissue borders.
clinical conditions
to be Bowel Obstruction
demonstrated by
the procedure Radio-opaque stones ([Link]/gall stones)

Large abdominal masses

Radio-opaque foreign bodies

Patient On arrival in the department they are asked to undress and change into a
preparation hospital gown.
Patient to be sat erect for 10 minutes if perforation is suspected and CXR
required.
Views and
kV Local
projections FFD mAs AEC AEC
Positioning (for DRL
(additional views (cm) (CR) mode chamber 2
AEC) ([Link] )
in italics)
AP Abdomen The patient lies
supine on the x-ray
table with the
median sagittal
plane perpendicular
and ASIS 110 250 CR
77 30 S400 Outer
equidistant to the 250 DR
table top. Centre in
the midline at the
level of the iliac
crests

Cross Kidney (or Supine as required

bladder) if not demonstrated
110
on AP abdomen. 77 30 S400 Outer n/a
The patient lies
supine on the x-ray
3
 table with the
median sagittal
plane perpendicular
and ASIS
equidistant to the
table top. Centre in
the midline midway
between the
xyphoid process
and the lower costal
margin.

Bladder view The patient lies 110 77 30 S400 Centre n/a

supine on the x-ray
table with the
median sagittal
plane perpendicular
and ASIS
equidistant to the
table top. Centre in
the midline midway
between the ASIS
and symphysis
pubis with a 15
degree caudal
angulation.

Left Lateral Patient lies on the

Decubitus view left side with
median sagittal
plane parallel to the
table top. Centre in
110
the midline at the 77 40 S400 Centre n/a
level of the iliac
crests using an
horizontal central
ray

Patient Protection:-
Follow the Pregnancy Enquiries Flow
Chart in IRMER for female patients aged
12-55 years

4
 ACROMIO-CLAVICULAR JOINTS

Clinical Indications Trauma – AP Shoulder If equivocal, an AP of contralateral joint can be useful

Pain – AP Shoulder
The radiograph should include the whole of the clavicle, the inferior angle of
Typical diagnostic
the scapula the sternoclavicular joint and lateral soft tissues.
features and
clinical conditions Normally inferior aspect of the acromion and clavicle should be in a straight
to be line.
demonstrated by
the procedure Both radiographs should be comparable

Normal size of joint space is less than 10 mm in adult

Possible subluxation – clavicle will lift and separate from the acromion due to
a tear in the acromio-clavicular joint capsule

Dislocation

Patient preparation On arrival in the department they are asked to undress and change into a
hospital gown. Remove all jewellery that is in the field of view.
Views and
kV Local
projections FFD AEC AEC mAs
Positioning (for DRL
(additional views in (cm) mode chamber (CR) 2
AEC) ([Link] )
italics)
AP Patient erect facing
the tube with arm
placed down by the
side. Patients trunk is
rotated 10 degrees to
the side under
110
examination with the 60 n/a n/a 5 n/a
posterior aspect in
contact with the
digital detector.
Centre to the
coracoid process.

Comments None additional

5
 ANKLE

Clinical Indications Trauma (following Ottawa rules) – AP ( Mortice view ) and lateral. Obliques as
a specialist request only.
Foreign Body - AP ( Mortice view ) and lateral. Tangential view may be used
as an additional view
Pain - AP ( Mortice view ) and lateral.
Orthopaedic -Stress views specialist views under direct clinical supervision
only
The radiograph should include the lower third of the tibia and proximal
Typical diagnostic
metatarsals on the AP view. A clear joint space between the tibia, fibila and
features and
talus should be demonstrated (Mortice View).
clinical conditions
to be The lateral should include the lower third of the tibia, calcaneum and fifth
demonstrated by metatarsal. Soft tissue borders should be visible. A lateral horizontal beam
the procedure should be used for acute trauma.

A cast will require more exposure.

Injury - look for widening of the joint space.

Fracture and follow up

Dislocation

Foreign body

Osteomyelitis

Necrosis of the talus

Bony cyst

RA/OA

Exostosis

Patient preparation Remove all jewellery and clothing that is in the field of view.

Views and
kV Local
projections FFD AEC AEC mAs
Positioning (for DRL
(additional views in (cm) mode chamber (CR) 2
AEC) ([Link] )
italics)
AP The patient lies
supine with the
affected limb
extended. The ankle
is dorsiflexed and 110
55 n/a n/a 2.5 n/a
rotated so that the
malleoli are
equidistant from the
detector. Centre
midway between

6
 the malleoli.

Lateral The patient is turned

onto the affected
side. The ankle is
dorsiflexed and the
rotated until the 110
55 n/a n/a 2.5 n/a
malleoli are
superimposed.
Centre to the medial
malleolus.

Oblique The patient lies

supine with the
affected limb
extended. The ankle
is dorsiflexed and
110
rotated 45 degrees 55 n/a n/a 2.5 n/a
medially and then
laterally. Centre
midway between the
malleoli.

Comments None additional

7
 BONE AGE

Clinical Indications Developmental anomaly – DP of left hand and wrist

The radiograph should include the whole of the hand and the whole of the
Typical diagnostic
wrist.
features and
clinical conditions The bone age of a child indicates the level of biological and structural
to be development better than the chronological age calculated from the date of
demonstrated by birth. The standards of boneage are derived by comparing the level of
the procedure maturation of the hand and wrist bones with normal age levels.

Patient preparation Remove all jewellery and clothing that is in the field of view.

Views and
kV Local
projections FFD AEC AEC mAs
Positioning (for DRL
(additional views in (cm) mode chamber (CR) 2
AEC) ([Link] )
italics)
DP The axis of the
middle finger must be
in direct line with the
axis of the forearm.
The forearm should
be in the same
horizontal plane.
The fingers are
slightly separated
and the thumb in a
comfortable neutral
position, usual angle
between thumb and
index finger is 30°. 110
50 n/a n/a 2 n/a
The palm is pressed
lightly downwards on
the film prior to
exposure. The tube
is centred over the
head of the 3rd
metacarpal and
collimated to include
all the soft tissues
and the distal
aspects of the radius
and ulna (including
the growth plates).

Comments None additional

8
 CALCANEUM ( CALCANEUS/OS CALCIS )

Clinical Indications Trauma - Lateral and Axial

Foreign Body - Lateral and Axial. If there is a single entry site, use opaque
arrow marker. Tangential view may be used as an additional view
Pain – Lateral only
Plantar Fasciitis/Calcaneal Spur – Although not specifically indicated, a lateral
view should be taken to exclude other bony causes of pain
The radiograph should include the distal tibia / fibula , the calcaneum, subtalar
Typical diagnostic
joints and soft tissue borders.
features and
clinical conditions Fracture and follow up
to be
demonstrated by Foreign Body
the procedure
Suspected calcaneal spur

Bony cyst

Patient preparation Remove all clothing that is in the field of view.

Views and
kV Local
projections FFD AEC AEC mAs
Positioning (for DRL
(additional views in (cm) mode chamber (CR) 2
AEC) ([Link] )
italics)
Axial Patient lies supine on
the table with both
limbs extended. The
affected leg is rotated
medically until both
malleoli are
equidistant from the
detector. The ankle is
dorsiflexed. A
bandage strapped 110
55 n/a n/a 3.2 n/a
around the forefoot
may be used to
maintain position.
Centre to the plantar
aspect of the heel at
the level of the base
of the fifth metatarsal
with a 40 degree
caudal angulation.

Lateral Patient lies supine on

the table with both
110
limbs extended. The 55 n/a n/a 5 n/a
affected leg is rotated
laterally until the

9
 malleoli are
superimposed.
Centre midway
between the medial
malleolus and the
plantar aspect of the
heel.

Comments None additional

10
 Cervical Spine

Pain/brachyalgia (no trauma) – Lateral only ( + AP if history of malignancy)

Clinical Indications
and routine views
Trauma – AP, Lateral and Odontoid peg (peg view only if >10 yrs old)

Possible - atlanto-axial subluxation (no trauma e.g. RA) – lateral only in

comfortable flexion

Cervical rib – AP only (check for any previous imaging e.g. CXR)

The AP should demonstrate C3 to T1. Angles of the mandible and the lateral
Typical diagnostic
features and portions of the floor of the posterior cranial fossa should be superimposed.
clinical conditions Soft tissues of the neck should be included.
to be demonstrated
by the procedure The lateral and flexion and extension views should demonstrate the EAM
down to and including the body of T1. The mandible or occipital bone should
not obscure any part of the upper vertebra. Soft tissues of the neck should be
included.

The odontoid peg view should demonstrate the odontoid process clear of the
occipital bone and show C1 to C3.

Oblique views should demonstrate the EAM down to and including the body
of T1. The intervertebral joint spaces should be consistent and the vertebral
bodies should be rectangular. The RPO view would demonstrate the L
intervertebral joint spaces.

Cervical Rib

Spondylosis

Fracture

Atlanto-axial subluxation

RA+

Patient preparation On arrival in the department they are asked to undress and change into a
hospital gown. .Remove glasses and all jewellery that is in the field of view,
including piercings/necklaces etc.
Views and Local
Positioning and FFD AEC AEC
projections kV mAs DRL
centering (cm) mode chamber 2
([Link] )
AP Patient is erect or supine
with the median sagittal
plane parallel to the
detector. The jaw is
110 15 CR
raised to superimpose 70 S200 Centre 6
13 DR
the mandible over the
occiput. Angle the tube
10 degrees cephalad.
Centre in the midline to

11
 the thyroid cartilage.

Lateral Patient in the erect

position with the affected
side to the detector.
Median sagittal plane
parallel to the detector.
The chin is raised so the
180 15 CR
mandible does not 70 S200 Centre 8
12 DR
obscure the spine.
Centre 2.5 cm behind
and 5 cm below the
angle of the mandible
with a horizontal beam.

Odontoid Peg The patient is erect or

supine with the median
sagittal plane parallel to
the detector. The upper
occlusal is perpendicular
to the detector. The 110
70 n/a n/a 12.5 n/a
patient is asked to open
the mouth as wide as
possible. Centre in the
midline to the centre of
the open mouth.

Flexion/Extension Only as far as patient

can manage
comfortably. Lateral
position with the head 180 15 CR
70 S200 Centre 8
extended and / or flexed. 13 DR
Centre to the middle of
the cervical spine.

Swimmers The patient is erect or

supine. The arm nearest
the detector is raised
and folded over the
head. The arm nearest
110
the tube is depressed as 70 S200 Centre n/a
far as possible towards
the feet. Centre just
above the humeral head
at the level of C7

Posterior Obliques The patient is erect with

the back towards the
110
detector. The patient is 70 S200 Centre 6 n/a
turned 45 degrees with
the head rotated so the
12
 median sagittal plane is
parallel to the detector.
Angle 15 degrees
cephalad. Centre to the
middle of the cervical
spine.

Comments An anti-scatter grid is not required for average

size patients routinely.

13
 CHEST

Clinical Indications PA chest for all clinical indications patient condition permitting. Alternative
projection AP. Lateral projection or apices view taken only under Radiologist
request.
Acute chest pain
Acute abdominal pain-?perforation/obstruction
Adenopathy
Acute Aortic syndrome / suspected aortic dissection
Acute exacerbation of COPD
Asthma with poor response to treatment
Cancer Diagnosis
Chronic stable angina (for heart size)
Chest pain
Clubbing
Congenital Heart Disease
CCF
CVP/PICC line insertions-- Include whole line
Dyspnoea
Employment (e.g. divers)
Emigration (category 2)
Suspected Heart failure/myocarditis
Sarcoidosis
Haemoptysis
ITU/HDU/SCBU line changes/change in symptoms
Lymphoma
Major trauma series
Myotonic Dystrophy
NG tube insertion— (Under Certain Criteria follow separate policy)
Post pacemaker insertion
Persistent Cough ( for more than 3 weeks )
RA
Sarcoidosis
Suspected Oesophageal perforation
Suspected PE
Suspected Pericarditis/ pericardial effusion
Suspected Valvular heart disease
Suspected heart failure and / or myocarditis
Pneumonia & follow up

14
 Suspected Pleural effusion
STEMI
TB
Tumour staging/ unknown primary
Trauma-for Pneumothorax
Weight loss

The image should include the superior aspect of the first rib demonstrating the
Typical diagnostic
apices the costophrenic angles and the soft tissue borders. The image should
features and
demonstrate full inspiration and the scapulae should be clear of the lung
clinical conditions
fields.
to be
demonstrated by
the procedure
Patient preparation On arrival in the department they are asked to undress and change into a
hospital gown. .Remove all jewellery that is in the field of view, including
piercings/necklaces etc.
Views and
kV Local
projections FFD AEC AEC mAs
Positioning (for DRL
(additional views in (cm) mode chamber (CR) 2
AEC) ([Link] )
italics)
PA The patient faces
the detector with
the chin raised. The
dorsal aspects of the
hands are placed
behind and below
the hips with the
elbows brought 180 8 CR
125 S800 Outer 2
forward and. The 7 DR
shoulders rotated
anteriorly and are
pressed downwards
in contact with the
detector. Centre to
the level of T6 in the
midline.
AP The patient sits with
their back to the CR
cassette. The upper
border of the
cassette should be
seen above the
180 15 CR
apices. The arms are 81 n/a n/a 6.4
15 DR
extended forwards
with hands internally
rotated if patient
condition permits.
Centre with a
horizontal beam at

15
 right angles to the
cassette to the
midline and to the
middle of the chest.

Lateral The patient is rotated

so the median
sagittal plane is
parallel to the
detector. The arms
180
are folded over the 125 S800 Centre 6.4 n/a
head. Centre to the
mid-axillary line at
the level of the sixth
thoracic vertebra.

Apices Patient is erect facing

with tube with their
back a short distance
from the detector.
The trunk is reclined 180
125 S800 Centre 1 n/a
30 – 40 degrees to
the detector. Centre
to the sternal angle
with a horizontal ray.

Comments None additional

16
 CLAVICLE

Clinical Indications Trauma – AP Infero-superior 30 degrees if not # seen on AP

Pain – AP

The radiograph should demonstrate the whole of the clavicle.

Typical diagnostic
features and Fracture and follow up
clinical conditions
to be Bony lump
demonstrated by
the procedure
Patient preparation On arrival in the department they are asked to undress and change into a
hospital gown. .Remove all jewellery that is in the field of view.
Views and
kV Local
projections FFD AEC AEC mAs
Positioning (for DRL
(additional views in (cm) mode chamber (CR) 2
AEC) ([Link] )
italics)
AP The patient can be
supine or erect. The
shoulder is rotated so
it is flat with the
detector. Arm is 110
60 n/a n/a 5 n/a
placed down by the
side and supinated.
Centre to the middle
of the clavicle.

Infero-superior 30 Patient can be

degrees supine or erect. The
shoulder is rotated so
it is flat with the
detector. Arm is
placed down by the 110
60 n/a n/a 5 n/a
side and supinated.
The central ray is
angled 30 degrees.
Centre to the middle
of the clavicle.

Comments None additional

17
 COLONIC TRANSIT STUDY (FOR TECHNICAL PARAMETERS PLEASE SEE ABDOMEN)

Clinical Indications-Specialist Request Only

Colonic transit studies must be approved by a consultant radiologist. Capsules are given by
radiology nurses.
An Abdomen x-ray should be taken 120 hours after ingestion (5 days)

ELBOW

Clinical Indications Trauma – AP and Lateral

Pain – AP and Lateral
Foreign Body – AP and Lateral. If there is a single entry site, use opaque
arrow marker. Tangential view may be used as an additional view.
Orthopaedic - Radial head-capitellar view. Comparison view by specialist
request only
The radiograph should include the distal third of the humerus and proximal
Typical diagnostic
third of the radius and ulna as well as the soft tissue borders.
features and
clinical conditions Injury – a visible fat pad is abnormal
to be
demonstrated by Fracture and follow up
the procedure
Dislocation

Pulled elbow

OA/RA

Bursitis

Bony spur

Patient preparation Remove all clothing that is in the field of view.

Views and
kV Local
projections FFD AEC AEC mAs
Positioning (for DRL
(additional views in (cm) mode chamber (CR) 2
AEC) ([Link] )
italics)
AP The patient is seated
with the affected side
to the detector. The
arm is supinated so
that the epicondyles 110
55 n/a n/a 2.5 n/a
are equidistant from
the detector with the
wrist, elbow and
shoulder at the same
18
 level. Centre 2.5 cm
distal to a line joining
the epicondyles.

Lateral The patient is seated

with the affected side
to the detector. The
arm is flexed 90
degrees. The hand is
rotated so that the
radial and ulnar
110
styloid processes are 55 n/a n/a 2.5 n/a
superimposed. The
wrist, elbow and
shoulder should be at
the same level.
Centre to the lateral
epicondyle.

Radial Head The patient is seated

with the affected side
to the detector. The
elbow is flexed and
the forearm placed
on the detector. 110
55 n/a n/a 2.5 n/a
Rotate the humerus
5 degrees laterally.
Centre to the middle
of the crease of the
elbow.

Comments None additional

19
 FACIAL BONES

Clinical Indications Trauma – OM (Waters view), OM30. Additional / Alternative view OF20 (for
Orbits), lateral.
Trauma – unconscious AP reverse OM and Lateral

The OM image should demonstrate the petrous ridges just below the apex of
Typical diagnostic
the maxillary sinuses.
features and
clinical conditions The OM 30 demonstrates the floors of the orbit and the lower orbital margin.
to be The petrous bone should be al the level of the body of the mandible.
demonstrated by
the procedure The OF 20 demonstrates the frontal and ethmoidal sinuses. The petrous ridge
should be seen below the lower orbital margin.

The distance from the lateral orbital wall to the outer skull margins should be
equidistant in the above projections.

The lateral projections should have the cranial fossa superimposed as should
be the heads and angles of the mandible

Fracture

Foreign body

Patient preparation Remove glasses and all jewellery that is in the field of view, including
piercings/necklaces etc.
Views and
kV Local
projections FFD AEC AEC mAs
Positioning (for DRL
(additional views in (cm) mode chamber (CR) 2
AEC) ([Link] )
italics)
OM The patient is seated
facing the detector.
The orbito-meatal
baseline is 45
degrees to the
detector and median 110
77 S400 centre 12.5 n/a
sagittal line at 90
degrees. Centre at
the level of the lower
orbital margin with a
horizontal beam.

OM 30 The patient is seated

facing the detector.
110
The orbito-meatal 77 n/a n/a 12.5 n/a
baseline is 45
degrees to the

20
 detector and median
sagittal line at 90
degree. The tube is
angled 30 degrees
caudally. Central ray
should pass through
the lower orbital
margin.

OF 20 The patient sits

facing the detector
with the forehead
and nose in contact
with it. The median
sagittal plane is 90
degrees to the
110
detector and 77 S400 12.5 n/a
Radiographic
baseline parallel to
the floor. Centre to
the nasion with a 20
degree caudal
angulation.

Lateral The patient turns into

the lateral position so
the median sagittal
plane is parallel to
the detector. Using a
horizontal beam 110
77 S400 Centre 10 n/a
centre 2cm behind
the outer canthus of
the eye along the
anthropological
baseline.

Comments None additional

21
 FEMUR ( THIGH )

Clinical Indications Trauma - AP and Lateral

Pain - AP and Lateral
Foreign Body - AP and Lateral. If there is single entry site, use opaque arrow
Tangential view may be used as an additional view.
Post IM nail - AP hip down and lateral knee up
The AP and lateral projections should demonstrate from the hip joint to the
Typical diagnostic
knee joint and soft tissue borders. Where possible include the whole femur on
features and
one film. For fractures a horizontal beam lateral should be considered.
clinical conditions
to be Fracture and follow up
demonstrated by
the procedure Bony cyst

Metastatic deposits

Pathological Fracture

Patient preparation On arrival in the department they are asked to undress and change into a
hospital gown.
Views and
kV Local
projections FFD AEC AEC mAs
Positioning (for DRL
(additional views in (cm) mode chamber (CR) 2
AEC) ([Link] )
italics)
AP The patient lays
supine on the table
with the affected leg
extended. The leg is
medially rotated to
110
centralise the patella 60 S400 Centre 4 n/a
between the femoral
condyles. Centre
midway between the
hip and knee joint.

Lateral The patient turns

onto the affected side
with the knee and hip
slightly flexed. The
pelvis is rotated away 110
60 S400 Centre 4 n/a
from the leg under
examination. Centre
midway between the
hip and knee joint.

Patient Protection:- None additional

Follow the Pregnancy Enquiries Flow Chart
22
in IRMER for female patients aged 12-55
years

FINGER

Clinical Indications Trauma - DP and Lateral. DP oblique-if injury around MCPJ. AP instead of
DP-if unable to straighten finger
Pain - DP and Lateral. DP oblique-if injury around [Link] instead of DP-if
unable to straighten finger
Foreign Body - DP and Lateral. If there is single entry site, use opaque arrow
marker. Tangential view may be used as an additional view.
Bony lump - DP and Lateral
Orthopaedic - Obliques (specialist request)
The DP radiograph should include the full length of the metacarpal, terminal
Typical diagnostic
phalanx and soft tissue borders. The lateral should include the proximal and
features and
distal phalanx and soft tissue borders.
clinical conditions
to be Fracture and follow up
demonstrated by
the procedure Avulsion

Mallet finger

Dislocation

Foreign body

Bony cyst

RA/OA

Patient preparation Remove all jewellery that is in the field of view.

Views and
kV Local
projections FFD AEC AEC mAs
Positioning (for DRL
(additional views in (cm) mode chamber (CR) 2
AEC) ([Link] )
italics)
DP The patient is seated
with the affected side
toward the detector.
The palmer aspect is
placed on the
110
detector and fingers 50 n/a n/a 1.25 n/a
extended and slightly
separated. Centre to
the head of the
metacarpal.

Lateral The patient is seated

with the affected side 110
50 n/a n/a 1.25 n/a
towards the detector.
The hand is rotated

23
 medially for index
and middle fingers.
The hand is rotated
laterally for little and
ring fingers. The
fingers are separated
and supported as
required. Centre to
the proximal
interphalangeal joint.

Oblique The patient is seated

with the affected side
towards the detector.
The hand is rotated
45 degrees laterally. 110
50 n/a n/a 1.25 n/a
The fingers flexed
and separated.
Centre to the head of
the metacarpal.

Comments None additional

24
 FOOT

Clinical Indications Trauma - DP and DP oblique. Additional / alternative projection - To

demonstrate tarsometatarsal joints, DP with tube angled towards ankle, so as
to make angle of 90 degrees with dorsum of foot
Pain - DP and DP oblique. Additional / alternative projection - To demonstrate
tarsometatarsal joints, DP with tube angled towards ankle, so as to make
angle of 90 degrees with dorsum of foot
Foreign Body - DP and Lateral. If there is single entry site, use opaque arrow
marker. Tangential view may be used as an additional view
Hallux Valgus - DP only
Plantar arch - Weight bearing lateral
Hallux sesamoid - axial
The radiograph should include the head of the talus, great toe and soft tissue
Typical diagnostic
borders with the lateral including the whole of the calcaneum.
features and
clinical conditions Fracture and follow up
to be
demonstrated by Dislocation
the procedure
Foreign body

RA/OA

Osteomyelitis

Stress fracture

Avascular necrosis

Charcot’s joint

Patient preparation Remove all jewellery and clothing that is in the field of view.

Views and
kV Local
projections FFD AEC AEC mAs
Positioning (for DRL
(additional views in (cm) mode chamber (CR) 2
AEC) ([Link] )
italics)
DP Patient lies supine on
the table with the
knee flexed and the
plantar aspect of the
110
foot in contact with 55 n/a n/a 2.5 n/a
the table. Centre to
the base of the third
metatarsal.

DP oblique Patient lies supine on

110
the table with the 55 n/a n/a 2.5 n/a
knee flexed and the
25
 plantar aspect of the
foot in contact with
the table. The leg
and foot are rotated
medially 30 degrees.
Centre to the base of
the third metatarsal.

Lateral The patient on the

affected side with the
hip and knee flexed.
The knee is
supported so that the
plantar aspect of the 110
55 n/a n/a 2.5 n/a
foot is at 90 degrees
to the detector.
Centre to the
navicular-cuneiform
joint.

Axial sessamoid The patient lies

bones supine with the
affected limb
extended. The ankle
and are dorsiflexed 110 55 n/a n/a 2.5 n/a
and ankle rotated so
that the malleoli are
equidistant from the
detector. Centre over
the head of the first
metatarsal

Comments None additional

26
 HAND

Clinical Indications Trauma - DP and DP oblique

Foreign Body - DP and Lateral. If there is single entry site, use opaque arrow
marker. Tangential view may be used as an additional view.
Pain - DP and DP oblique
Arthropathy ( rheumatology ) – DP. Additional / alternative projection -
Ballcatchers (if first presentation)
The radiograph should demonstrate the terminal phalanges, distal radius and
Typical diagnostic
ulna and soft tissue borders. The metacarpals should not be superimposed on
features and
the oblique view.
clinical conditions
to be Fracture and follow up
demonstrated by
the procedure Foreign body

RA/OA

Bony cyst

Patient preparation Remove all jewellery and clothing that is in the field of view.

Views and
kV Local
projections FFD AEC AEC mAs
Positioning (for DRL
(additional views in (cm) mode chamber (CR) 2
AEC) ([Link] )
italics)
DP The patient is seated
with the affected side
towards the detector.
The palmer aspect is
placed on the
detector and the 110
50 n/a n/a 1.25 n/a
fingers are extended
and slightly
separated. Centre to
the head of the third
metacarpal.

DP oblique The patient is seated

with the affected side
towards the detector.
From the DP position
rotate the hand 110
50 n/a n/a 1.25 n/a
laterally to form an
angle of 45 degrees
and support in
position. The fingers
should be slightly

27
 flexed and
separated. Centre to
the head of the third
metacarpal.

Lateral The patient is seated

with the affected side
towards the detector.
From the DP position
rotate the hand so
110
the palmer aspect is 50 n/a n/a 1.25 n/a
90 degrees to the
detector. Centre to
the head of the
second metacarpal.

Ball catchers The patient is seated

facing the detector.
Both forearms and
hands are supinated.
The dorsa of the
hands are in contact
with the detector and
fifth metacarpals next
to each other. The
110
hands are internally 50 n/a n/a 1.25 n/a
rotated 45 degrees
and supported in
position. Centre
midway between
both hands at the
level of the head of
the third
metacarpals.

Comments None additional

28
 HIP

Clinical Indications Trauma - AP Pelvis, Lateral (horizontal beam)

? Dislocated THR - AP Pelvis
Slipped Upper Femoral Epiphysis (SUFE) - AP Pelvis & frog leg lateral
Pain - AP Pelvis. Additional / alternative projection - turned lateral if other than
OA
Post op THR/Hemiarthroplasty - AP Pelvis-include whole prosthesis & cement
marker lateral
Post op DHS - Theatre images only unless new trauma
Slipped Upper Femoral Epiphysis (SUFE) / Perthes - AP Pelvis & frog leg
lateral (gonad protection on follow up images)
Dysplasia(DDH) - AP Pelvis (gonad protection on follow up images)
The AP pelvis and lateral frog view should demonstrate the whole of the iliac
Typical diagnostic
crests, the proximal femurs and soft tissue borders. The distance from the
features and
spinous process to the ASIS should be equidistant to demonstrate the patient
clinical conditions
is not rotated.
to be
demonstrated by The lateral should demonstrate the acetabulum, head of femur and upper third
the procedure of femur. The greater trochanter should be superimposed over the neck of the
femur in the turned lateral

Features may include increased density due to impacted fracture, undisplaced

fracture shown with disruption to the trabecular lines, avascular necrosis or
fracture.

Fracture and follow up

Bony cyst

OA

Foreign body

Avascular necrosis

Pathological fracture

Suspected Metastases

Fusion of SI joints

Dislocation

Hip prosthesis follow up or loosening

SUFE

DDH

FOR CEREBRAL PALSY HIPS PLEASE FOLLOW GUIDANCE ISSUED

29
 FROM EVELINA CHILDREN’S HOSPITAL (INCLUDED AS APPENDIX A)

EVELINA CPIP
Imaging [Link]

Patient preparation On arrival in the department they are asked to undress and change into a
hospital gown.
Views and
kV Local
projections FFD AEC AEC mAs
Positioning (for DRL
(additional views in (cm) mode chamber (CR) 2
AEC) ([Link] )
italics)
AP Pelvis The patient lies
supine on the table.
With the median
sagittal plane at 90
degrees to the table
and ASIS equidistant
from the table top.
With the legs
extended the heels
258 CR
are separated and 77 S400 Centre 16
110 175 DR
the limbs are
internally rotated until
the toes touch.
Centre in the midline,
midway between the
ASIS and superior
border of the
symphysis pubis

Lateral Hip The patient lies

supine on the table.
( turned ) The patient is rotated
45 degrees on to the
Centre
affected side. Centre 77 S400 12.5 n/a
to the greater
trochanter in the
midline of the frmue.

Lateral Hip The patient lies

supine with the
( horizontal ray ) affected leg
extended. The foot is
rotated into the
81 S400 Centre 40 n/a
vertical position if
possible. The
opposite limb is
raised and flexed at
the knee and rested
30
 on the leg support.
The bed is rotated so
the neck of femur
and detector are
parallel. Centre at the
level of the greater
trochanter with a
horizontal ray.

Frog leg lateral The patient lies

supine on the table.
With the median
sagittal plane at 90
degrees to the table
and ASIS equidistant
from the table top.
The hips and knees
are flexed. The
knees are separated
and rotated laterally 258 CR
77 S400 Centre 16
60 degrees and the 175 DR
plantar aspects of the
feet are placed in
contact with one
another. Patient is
supported with pads.

Centre in the midline

2.5 cm superior to
the symphysis pubis.

Patient Protection:- None additional

Follow the Pregnancy Enquiries Flow Chart
in IRMER for female patients aged 12-55
years

31
 HUMERUS

Clinical Indications Trauma - Anteroposterior (AP), lateral

Pain - Anteroposterior (AP), lateral
Foreign Body - AP, Lateral. If there is single entry site, use opaque arrow
marker. Tangential view may be used as an additional view.
The radiograph should demonstrate both the shoulder and elbow joint and the
Typical diagnostic
soft tissue margins. The head and greater tuberosity of the humerus should be
features and
seen in profile in the AP view and the elbow joint AP. In the lateral view the
clinical conditions
epicondyles should be superimposed.
to be
demonstrated by Fracture and follow up
the procedure
Bony cyst

Pathological fracture

Metastatic deposits

Patient preparation Remove all jewellery and clothing that is in the field of view.

Views and
kV Local
projections FFD AEC AEC mAs
Positioning (for DRL
(additional views in (cm) mode chamber (CR) 2
AEC) ([Link] )
italics)
AP Patient is erect. Body
is rotated slightly
onto the affected side
so that the arm is in
contact with the
detector. The arm is
supinated and
110
slightly abducted 60 n/a n/a 3.2 n/a
form the body. The
epicondyles should
be equidistant from
the detector. Centre
to the middle of the
humerus.

Lateral Patient is erect facing

the detector. The
body is rotated onto
the affected side so
110
the lateral aspect of 60 n/a n/a 3.2 n/a
arm is in contact with
the detector. The
epicondyles should
be superimposed.

32
 The affected arm is
flexed and the
palmer aspect of the
hand is placed on the
upper abdomen. The
arm should be
abducted to so it is
clear of the rib cage.
Centre to the middle
of the humerus.

Comments None additional

33
 KNEE

Clinical Indications Trauma - AP (non-weight bearing) and Lateral (Horizontal beam). Additional /
Alternative projection - Obliques (specialist request) Also see ‘Patella’
Foreign Body - AP, Lateral. If there is single entry site, use opaque arrow
marker. Tangential view may be used as an additional view
Pain - AP standing (If safe to do so) and Lateral. Additional / Alternative
projection - Shuss, Obliques (specialist request)
Suspected loose body - AP standing, lateral and Intercondylar Notch (Tunnel
View)
The AP and lateral images should demonstrate the patella and distal femur,
Typical diagnostic
proximal tibia and fibula and show the soft tissue borders.
features and
clinical conditions On the AP view the patella should be centralised over the femur.
to be
demonstrated by The lateral view should show the femoral condyles superimposed, with a joint
the procedure space visible between the femur and patella. If the fibula is projected
posteriorly then the knee is over-rotated and under-rotated if the fibula head is
hidden behind the tibia. The image may show fluid levels and
lipohaemarthrosis in the horizontal beam view.

The intercondylar view should include the intercondylar fossa and will
demonstrate fractures of the tibial spine and loose bodies.

The skyline view should include the patella and femoropatellar joint space and
will demonstrate fractures not seen on routine projections.

The schuss view should include the distal femur, proximal tibia and fibula and
show the soft tissue borders and is used to demonstrate OA of the
tibiofemoral joint.

Fracture and follow up

OA

Loose bodies

Foreign body

Chondromalacia

Dislocation

Osteochonridits dissecans

Patient preparation On arrival in the department they are asked to undress and change into a
hospital gown if required.
Views and
kV Local
projections FFD AEC AEC mAs
Positioning (for DRL
(additional views in (cm) mode chamber (CR) 2
AEC) ([Link] )
italics)
AP The patient is either
erect or supine. The 60 n/a n/a 3.2 n/a
affected limb is 110

34
 extended and rotated
slightly medially to
centralise the patella
between the femoral
condyles. Centre with
2.5 cm below the
apex of the patella.

Lateral The patient lies on

the affected side with
the hip and knee
slightly flexed. The
unaffected limb is
extended. The limb is
rotated until the
patella is 90 degrees
to the cassette and
the knee flexed at 45
degrees. The foot is 110 60 n/a n/a 3.2 n/a
raised until the tibia
is parallel to the table
and supported on
pads or rested on the
unaffected limb.
Centre 2.5 cm below
and behind the apex
of the patella to the
medial tibial condyle.

Lateral horizontal The patient lies on

beam their back with the
leg extended as far
as possible and
supported with pads.
The CR cassette is
placed along the
medial aspect of the
knee. The knee is 110 60 n/a n/a 3.2 n/a
rotated if possible to
centralise the patella
over the femur. The
horizontal central ray
is directed to the
upper border of the
lateral tibial condyle
at 90 degrees to the
long axis of the tibia.

Skyline view The patient is seated

towards the end of
the x-ray table with

35
 the affected leg
flexed to form an
angle of 120 degrees 110 60 n/a n/a 3.2 n/a
and supported in
place. The knee is
medially rotated to
centralise the patella
between the femoral
condyles. A CR
cassette is placed on
the anterior aspect of
the thigh and is
angled 15 down from
the vertical. Centre to
the apex of the
patella with the
central ray 15
degrees to the
horizontal.

Oblique 110 60 n/a n/a 3.2 n/a

Intercondylar The patient lies

Notch supine on the x-ray
table. The knee is
positioned so that the
patella is in the
centre of the femur.
The leg under 110 60 n/a n/a 3.2 n/a
examination is flexed
to form an angle of
60 degrees and
supported in place.
The CR cassette is
placed underneath
the knee. Centre
immediately below
the apex of the
patella with the
central ray angle
perpendicular to the
axis of the tibia.

Shuss The patient stands 110 60 n/a n/a 3.2 n/a

facing the vertical
detector with the
knee positioned so
that the patella is
centred between the
femoral condyles.
The knee is flexed to

36
 30 degrees. The tips
of the toes should be
in line with front of
the detector. Centre
in the midline with
the tube angled 10
degrees caudally
from the horizontal.

Comments None additional

37
 LATERAL SOFT TISSUE NECK

Clinical Indications Foreign body in throat – Lateral

Acute stridor in children – Lateral
The lateral view should demonstrate the EAM down to and including the body
Typical diagnostic
of T1. The mandible or occipital bone should not obscure any part of the upper
features and
vertebra. Soft tissues of the neck should be included.
clinical conditions
to be
demonstrated by
the procedure Foreign body

Patient preparation On arrival in the department they are asked to undress and change into a
hospital gown. Remove glasses and all jewellery that is in the field of view,
including piercings/necklaces etc.
Views and
kV Local
projections FFD AEC AEC mAs
Positioning (for DRL
(additional views in (cm) mode chamber (CR) 2
AEC) ([Link] )
italics)
Lateral Patient in the erect 180 70 S200 Centre 8 15
position with the
affected side to the
detector. Median
sagittal plane
parallel to the
detector. The chin is
raised so the
mandible does not
obscure the spine.
Centre 2.5 cm
behind and 5 cm
below the angle of
the mandible with a
horizontal beam.
The exposure should
be performed on
Valsalva – forced
expiration against a
closed glottis to
show the airway.

38
Comments None additional

LUMBAR SPINE
AP and Lateral
Clinical Indications Trauma-with pain/neurological deficit - AP and Lateral. Additional /Alternative
projections - Coned lateral of # (specialist request) Lateral L5/S1.
Pain AP and Lateral. Additional /Alternative projections - Lateral
L5/[Link] AP & lateral at specialist request
Osteoporosis - Lateral

The AP should include T12 and the whole of the sacroiliac joints. Rotation
Typical diagnostic
should be assessed by ensuring the sacroiliac joints are equidistant from the
features and
spine.
clinical conditions
to be The lateral should include T12, L5 and sacral junction, the whole of the
demonstrated by vertebral bodies and spinous processes. The cortices at the posterior and
the procedure anterior margins should be superimposed and the intervertebral spaces
clearly demonstrated.

The Lumbosacral junction should include L5 down to sacral segment including

the spinous process.

Fracture and follow up

Osteoporotic fractures

Ankylosing Spondylitis

OA

Metastases

Discitis

Patient preparation On arrival in the department they are asked to undress and change into a
hospital gown. Remove all jewellery that is in the field of view, including
piercings etc.
Views and
kV Local
projections FFD AEC AEC mAs
Positioning (for DRL
(additional views in (cm) mode chamber (CR) 2
AEC) ([Link] )
italics)
AP The patient lies
supine on the table
with the median
saggital plane
perpendicular to the
table top and the
110 171CR
ASIS equidistant. 81 S400 central 32
143 DR
Hips and knees are
flexed and supported
in place. Centre in
the midline to the
level of the lower
costal margin. Image
39
 taken on expiration.

Lateral The patient lays on

their side with the
median sagittal plane
parallel to the table.
Arms are raised and
placed onto the
pillow. The knees
and hips are flexed. 110 186 CR
90 S400 central 50
Centre to the lower 186 DR
costal margin 7.5cm
anterior to the
spinous process of
the third lumbar
vertebra. Image
taken on expiration.

Lateral L5 / S1 The patient lays on

their side with the
median sagittal plane
parallel to the table.
Arms are raised and
placed onto the
pillow. The knees 110 90 S400 central 50 186 CR
and hips are flexed. 186 DR
Centre midway
between the ASIS
and PSIS with the
central ray passing
through both PSIS.

Patient Protection:- None additional

Follow the Pregnancy Enquiries Flow Chart
in IRMER for female patients aged 12-55
years

40
 MANDIBLE / JAW

Clinical Trauma - OPG and PA. Additional /Alternative projections - Obliques if OPG not
Indications possible
Pain - OPG
Dental Assessment- OPG. Additional /Alternative projections - Lat Ceph
(Specialist Request)
The PA mandible should demonstrate the whole of the mandible including the
Typical
symphysis menti and the temporo-mandibular joints. For the lateral oblique view
diagnostic
the ramus of each side of the mandible should not be superimposed.
features and
clinical conditions
to be
demonstrated by Fracture
the procedure
dislocation

Abscess

Patient Remove glasses and all jewellery that is in the field of view, including
preparation piercings/necklaces etc.
Views and
Local
projections FFD kV (for AEC AEC mAs
Positioning DRL
(additional views (cm) AEC) mode chamber (CR) 2
([Link] )
in italics)
OPG The patient stands
facing the unit. The
unit is adjusted to
the correct height.
the patient moves
forward so that the
chin is on the rest.
The Frankfurt line
should be parallel
to the floor. The Pre- As per
vertical laser lights set by pre- set for
on the unit should unit adult and
pass though the paediatrics
median saggital
plane and the
horizontal through
the Frankfurt line.
Adjust the head
supports to
maintain patient
position.

PA mandible The patient is

seated facing the 110
73 Y centre 12 n/a
vertical detector
with the nose and
41
 forehead against
the detector. The
median sagittal
plane is coincident
with the midline of
the detector. The
head is adjusted to
bring the orbito-
meatal baseline
perpendicular to
the detector. The
EAM’s should be
equidistant from
the detector.
Centre with a
horizontal beam to
the midline of the
patient at the level
of the angles of the
mandible

Oblique Mandible The patient lines

supine with a CR
cassette along the
affected side and
supported in
position with the
lower border of the
cassette 2cm
below the lower
border of the
mandible. The
shoulders are
lowered are far as
110
possible. The chin 60 n/a n/a 3.2 n/a
is raised to bring
the angle of the
mandible away
from the spine.
With a horizontal
beam the tube is
angled 30 degrees
cranially. Centre to
the angle of the
mandible nearest
the tube. Repeat
for the other side.

Comments None additional

42
 NASAL BONES

Clinical Indications Specialist referral only – OM. Additional /Alternative projection - Lateral
The OM image should demonstrate the petrous ridges just below the apex of
Typical diagnostic
the maxillary sinuses.
features and
clinical conditions The distance from the lateral orbital wall to the outer skull margins should be
to be equidistant in the above projections.
demonstrated by
the procedure Fracture

Foreign body

Patient preparation Remove glasses and all jewellery that is in the field of view, including
piercings/necklaces etc.
Views and
kV Local
projections FFD AEC AEC mAs
Positioning (for DRL
(additional views in (cm) mode chamber (CR) 2
AEC) ([Link] )
italics)
OM The patient is seated 110 77 S400 centre 12.5 n/a
facing the detector.
The orbito-meatal
baseline is 45
degrees to the
detector and median
sagittal line at 90
degrees. Centre at
the level of the
lower orbital margin
with a horizontal
beam.

Lateral The patient turns into

the lateral position so
the median sagittal
plane is parallel to 110
60 n/a n/a 2 n/a
the detector. Using a
horizontal beam
centre to the nasion.

Comments None additional

43
 ORBITS

Clinical Indications Trauma – OM, OM30. Additional / Alternative view OF20 (for Orbits), lateral.
Trauma – unconscious AP reverse OM and Lateral
Intra-occular foreign body IOFB - Under-tilted (35 degrees) OM with eyes up.
Additional / Alternative view - Eyes down if FB seen
The OM image should demonstrate the petrous ridges just below the apex of
Typical diagnostic
the maxillary sinuses. On the under tilted view the petrous ridge should be
features and
seen through the middle of the maxillary sinus. The frontal sinus should be
clinical conditions
fully seen and the just below the inferior orbital margins.
to be
demonstrated by The OM 30 demonstrates the floors of the orbit and the lower orbital margin.
the procedure The petrous bone should be at the level of the body of the mandible.

The OF 20 demonstrates the frontal and ethmoidal sinuses. The petrous ridge
should be seen below the lower orbital margin.

The distance from outer canthus of the eye to the outer skull margins should
be equidistant in the above projections.

The lateral projections should have the orbital walls superimposed.

Fracture

Foreign body

Patient preparation Remove glasses and all jewellery that is in the field of view, including
piercings/necklaces etc.
Views and
kV Local
projections FFD AEC AEC mAs
Positioning (for DRL
(additional views in (cm) mode chamber (CR) 2
AEC) ([Link] )
italics)
OM The patient is seated 110 77 S400 centre 12.5 n/a
facing the detector.
The orbito-meatal
baseline is 45
degrees to the
detector and median
sagittal line at 90
degrees. Centre at
the level of the
lower orbital margin
with a horizontal
beam.

OM 30 The patient is seated 110 77 n/a n/a 12.5 n/a

facing the detector.
The orbito-meatal
baseline is 45
degrees to the

44
 detector and median
sagittal line at 90
degree. The tube is
angled 30 degrees
caudally. Central ray
should pass through
the lower orbital
margin.

Under tilted OM The patient is seated 110 77 S400 centre 12.5 n/a
facing the detector.
The orbito-meatal
baseline is 45
degrees to the
detector and median
sagittal line at 90
degrees. Centre at
the level of the
lower orbital margin
with a horizontal
beam. Eyes should
be looking upwards.

OF 20 The patient sits 110 77 S400 Centre 12.5 n/a

facing the detector
with the forehead
and nose in contact
with it. The median
sagittal plane is 90
degrees to the
detector and
Radiographic
baseline parallel to
the floor. Centre to
the naison with a 20
degree caudal
angulation.

Lateral The patient turns 110 77 S400 Centre 10 n/a

into the lateral
position so the
median sagittal
plane is parallel to
the detector. Using a

45
 horizontal beam
centre to the outer
canthus of the eye.

Comments None additional

46
 PATELLA

Clinical Indications Trauma-fracture - AP and Lateral Knee (Horizontal beam)

Trauma-?dislocation - AP, Lateral (Horizontal beam) and skyline
Pain - AP and [Link] Alternative projection -Skyline for
chondromalacia or specialist request

The AP and lateral images should demonstrate the patella and distal femur,
Typical diagnostic
proximal tibia and fibula and show the soft tissue borders.
features and
clinical conditions On the AP view the patella should be centralised over the femur.
to be
demonstrated by The lateral view should show the femoral condyles superimposed, with a joint
the procedure space visible between the femur and patella. If the fibula is projected
posteriorly then the knee is over-rotated and under-rotated if the fibula head is
hidden behind the tibia. The image may show fluid levels and
lipohaemarthrosis in the horizontal beam view.

The skyline view should include the patella and femoropatellar joint space and
will demonstrate fractures not seen on routine projections.

Fracture and follow up

OA

Loose bodies

Foreign body

Chondromalacia

Dislocation

Patient preparation On arrival in the department they are asked to undress and change into a
hospital gown if required.
Views and
kV Local
projections FFD AEC AEC mAs
Positioning (for DRL
(additional views in (cm) mode chamber (CR) 2
AEC) ([Link] )
italics)
AP The patient is either
erect or supine. The
affected limb is
extended and
rotated slightly
medially to
110
centralise the 60 n/a n/a 3.2 n/a
patella between the
femoral condyles.
Centre with 2.5 cm
below the apex of
the patella.

Lateral The patient lies on

the affected side

47
 with the hip and
knee slightly flexed.
The unaffected limb
is extended. The
limb is rotated until
the patella is 90
degrees to the
cassette and the
knee flexed at 45 110 60 n/a n/a 3.2 n/a
degrees. The foot is
raised until the tibia
is parallel to the
table and supported
on pads or rested
on the unaffected
limb. Centre 2.5 cm
below and behind
the apex of the
patella to the
medial tibial
condyle.

Skyline The patient is

seated towards the
end of the x-ray
table with the
affected leg flexed
to form an angle of
120 degrees and 110 60 n/a n/a 3.2 n/a
supported in place.
The knee is
medially rotated to
centralise the
patella between the
femoral condyles. A
CR cassette is
placed on the
anterior aspect of
the thigh and is
angled 15 down
from the vertical.
Centre to the apex
of the patella with
the central ray 15
degrees to the
horizontal.

Comments None additional

48
 POST NASAL SPACE

Clinical Indications Specialist request - Lateral (on nasal inspiration)

The image should demonstrate the nasal passages.
Typical diagnostic
features and
clinical conditions
to be Enlarged adenoids
demonstrated by
the procedure
Patient preparation Remove glasses and all jewellery that is in the field of view, including
piercings/necklaces etc.
Views and
kV Local
projections FFD AEC AEC mAs
Positioning (for DRL
(additional views in (cm) mode chamber (CR) 2
AEC) ([Link] )
italics)
Lateral The patient turns into
the lateral position so
the median sagittal
plane is parallel to
the detector. Using a 110 77 S400 Centre 10 n/a
horizontal beam
centre midway
between the nasion
and angle of the
mandible.

Comments None additional

49
 RADIUS & ULNA ( FOREARM )

Clinical Indications Trauma - Anteroposterior (AP), lateral

Pain - Anteroposterior (AP), lateral
Foreign Body - AP, Lateral. If there is single entry site, use opaque arrow
marker. Tangential view may be used as an additional view
For both views the elbow joint wrist joint and soft tissue borders should be
Typical diagnostic
demonstrated.
features and
clinical conditions
to be
demonstrated by Fracture and follow up
the procedure
Bony cyst

Patient preparation Remove all jewellery and clothing that is in the field of view.

Views and
kV Local
projections FFD AEC AEC mAs
Positioning (for DRL
(additional views in (cm) mode chamber (CR) 2
AEC) ([Link] )
italics)
AP The patient is seated
with the affected side
to the detector. The
forearm is supinated
with the wrist elbow
and shoulder at the
110
same level. The hand 52 n/a n/a 2.5 n/a
and elbow should be
in the true AP
position. Centre to
the middle of the
forearm.

Lateral The elbow is flexed

to 90 degrees. The
wrist elbow and
shoulder should be at
the same level. The
hand is rotated 110
52 n/a n/a 2.5 n/a
laterally so that the
styloid processes are
superimposed.
Centre to the middle
of the forearm.

Comments None additional

50
 SACRUM

Clinical Indications Trauma - AP (normally whole pelvis to ensure no fracture of pelvic ring) and
Lateral. Additional / Alternative projections - AP with 15 degree cephalic
angulation at specialist request
Specialist request for pain - Refer to radiologist. Additional / Alternative
Projections - AP with 15 degree cephalic angulation & lateral

The AP pelvis should demonstrate the whole of the iliac crests, the proximal
Typical diagnostic
femurs and soft tissue borders. The distance from the spinous process to the
features and
ASIS should be equidistant to demonstrate the patient is not rotated. The
clinical conditions
lateral should demonstrate the L5-S1 joint space and whole of the coccyx, as
to be
well as the sacral promontory and sacral spinous tubercles.
demonstrated by
the procedure Fracture

Patient preparation On arrival in the department they are asked to undress and change into a
hospital gown.
Views and
kV Local
projections FFD AEC AEC mAs
Positioning (for DRL
(additional views in (cm) mode chamber (CR) 2
AEC) ([Link] )
italics)
AP Pelvis The patient lies
supine on the table.
With the median
sagittal plane at 90
degrees to the table
and ASIS equidistant
from the table top.
With the legs
extended the heels
258 CR
are separated and 77 S400 Centre 16
110 175 DR
the limbs are
internally rotated until
the toes touch.
Centre in the midline,
midway between the
ASIS and superior
border of the
symphysis pubis

Lateral Sacrum The patient lays on

their side with the
median sagittal plane
parallel to the table.
Arms are raised and 110 186 CR
90 S400 central 50
placed onto the 186 DR
pillow. The knees
and hips are flexed.
Centre midway
between the PSIS

51
 and coccyx.

AP Sacrum The patient lies

supine on the table.
With the median
sagittal plane at 90
degrees to the table
and ASIS equidistant
from the table top. 258 CR
77 S400 Centre 16
Centre in the midline, 110 175 DR
with a 15 degree
cranial angulation 5
cm above the
superior border of the
symphysis pubis.

Patient Protection:- None additional

Follow the Pregnancy Enquiries Flow Chart
in IRMER for female patients aged 12-55
years

52
 SACROILIAC JOINTS ( SIJs )

Clinical Indications Pain - If requested with pelvis or lumbar spine- AP is [Link] requested
alone - PA with 15 degree caudal angulation. Additional / Alternative
projections - AP obliques-if unable to lay prone.
The AP/PA views should demonstrate whole of the sacroiliac joints and they
Typical diagnostic
should be equidistant from the spinous process. The oblique view joint should
features and
show the joint space.
clinical conditions
to be Sacroilitis
demonstrated by
the procedure Fusion

Patient preparation On arrival in the department they are asked to undress and change into a
hospital gown.
Views and
kV Local
projections FFD AEC AEC mAs
Positioning (for DRL
(additional views in (cm) mode chamber (CR) 2
AEC) ([Link] )
italics)
AP The patient lies
supine on the table.
With the median
sagittal plane at 90
degrees to the table
and ASIS equidistant
from the table top. 110 77 S400 centre 32 258 CR
Centre in the midline,
with a 15 degree 175 DR
cranial angulation 2.5
cm below the ASIS.

PA The patient lies

prone on the table
with the median
sagittal plane at 90
degrees to the table
top. The PSIS should
be equidistant from 77 S400 centre 32 258 CR
110
the table. Centre in
the midline with a 15 175 DR
degree caudal
angulation at the
level of the PSIS

AP Obliques The patient lies

supine on the table.
With the median
sagittal plane at 90
degrees to the table 110 77 S400 centre 32 n/a
and ASIS equidistant
from the table top.
Elevate the side of

53
 interest 30 degrees
and centre 2.5 cm
medial to the ASIS.
Repeat for the other
side

Patient Protection:- None additional

Follow the Pregnancy Enquiries Flow Chart
in IRMER for female patients aged 12-55
years

54
 SCAPHOID

Clinical Indications Trauma - DP wrist, lateral wrist, anterior oblique, posterior oblique and DP 30o
(DP, anterior oblique and DP 30o to be taken in Ulnar Deviation )
Pain - DP Wrist, Lateral Wrist, anterior oblique and DP 30o
The images should include the carpal bones, radial and styloid processes and
Typical diagnostic
the lower third of the metacarpal bones. The scaphoid is accountable for 60-
features and
70 % of fractures of the carpal bones. Fracture of the waist of the scaphoid
clinical conditions
may not be visible on first presentation and a follow up x-ray may be required
to be
after 10 days.
demonstrated by
the procedure Fracture and follow up

Avascular necrosis

Patient preparation Remove all jewellery and clothing that is in the field of view.

Views and
kV Local
projections FFD AEC AEC mAs
Positioning (for DRL
(additional views in (cm) mode chamber (CR) 2
AEC) ([Link] )
italics)
DP Patient seated with
affected side towards
the table. Elbow is
flexed with wrist and
forearm on the digital
detector. Fingers are
flexed to keep the
wrist flat. Styloid
110
processes are 55 n/a n/a 2 n/a
equidistant to the
detector. The hand is
adducted and image
taken in ulna
deviation. Centre
midway between the
styloid processes

Lateral From the PA position

laterally rotate the
wrist until the palmer
aspect is 90 degrees
to the detector then
rotate a further 5 110
55 n/a n/a 2 n/a
degrees until the
styloid processes are
superimposed.
Centre to the radial
styloid process.

Anterior Oblique From the PA position 110

55 n/a n/a 2 n/a
rotate the wrist

55
 laterally until the
palmer aspect is 45
degrees to the
detector. The hand is
adducted and image
taken in ulna
deviation. Centre
midway between the
styloid processes

Posterior Oblique From the PA position 110 55 n/a n/a 2 n/a

straighten the arm
and rotate the wrist
laterally until the
dorsal aspect is 45
degrees to the
detector. Centre
midway between the
styloid processes

DP with ulna Patient seated with 110 55 n/a n/a 2 n/a

deviation and 30 affected side towards
degree cranial the table. Elbow is
angulation flexed with wrist and
forearm on the digital
detector. Fingers are
flexed to keep the
wrist flat. Styloid
processes are
equidistant to the
detector. The hand is
adducted and image
taken in ulna
deviation. Centre
midway between the
styloid processes
with a 30 degree
cranial angulation.

Comments None additional

56
 SCOLIOGRAM

Clinical Indications Scoliosis measurement - AP standing. Additional / Alternative projections -

lateral – specialist request.
PLEASE NOTE-SCOLIOGRAMS SHOULD ONLY BE UNDERTAKEN UPON
SPECIALIST REQUEST. GP REFERRALS FOR ? SCOLISOSIS OR PAIN ?
SCOLIOSIS DO NOT REQUIRE A SCOLIOGRAM AND CAN HAVE
STANDARD IMAGING. IF THERE IS BACK PAIN THEN LATERALS
SHOULD BE INCLUDED TO RULE OUT OTHER CAUSES.
Typical diagnostic
features and The AP and lateral should demonstrate from C3 to S2.
clinical conditions
to be
demonstrated by
the procedure Scoliosis, Kyphosis.

Patient preparation On arrival in the department they are asked to undress and change into a
hospital gown.
Views and
kV Local
projections FFD AEC AEC mAs
Positioning (for DRL
(additional views in (cm) mode chamber (CR) 2
AEC) ([Link] )
italics)
Less than 35 kg Use digital

35-65 Kg AP Use plates 2 and 3 only.

The patient stands erect
with back to scoliogram
unit, with the coronal plane
parallel and the median
sagittal and transverse
planes at 90 degrees to
the unit. Patient has arms
180
by side. Centre so that the 80 n/a n/a 40
superior collimation
includes C3 and the
inferior collimation
includes S2. Laterally
collimate to the skin
margins so the entire iliac
crests are visible

35-65 Kg Lat Use plates 2 and 3 only.

The patient stands erect
side on to the scoliogram
unit, with the apex of the
scoliosis closest to the
scoliogram unit. The
Median sagittal plan
parallel and the coronal 180
and transverse planes at 80 n/a n/a 50
90 degrees to the unit. The
patients hands should be
on the sides of their heads
with the elbows drawn
together. Superior
collimation should include
C3 with inferior collimation

57
 including S2. Laterally
collimate to the skin
margins.

65-85Kg AP Use plates 2 and 3 only.

The patient stands erect
with back to scoliogram
unit, with the coronal plane
parallel and the median
sagittal and transverse
planes at 90 degrees to
the unit. Patient has arms
180
by side. Centre so that the 80 n/a n/a 50
superior collimation
includes C3 and the
inferior collimation
includes S2. Laterally
collimate to the skin
margins so the entire iliac
crests are visible

65-85Kg Lat Use plates 2 and 3 only.

The patient stands erect
side on to thescoliogram
unit, with the apex of the
scoliosis closest to the
scoliogram unit. The
Median sagittal plan
parallel and the coronal
and transverse planes at
90 degrees to the unit. The 180
patients hands should be
80 n/a n/a 80
on the sides of their heads
with the elbows drawn
together. Superior
collimation should include
C3 with inferior collimation
including S2. Laterally
collimate to the skin
margins.

Patient Protection:- None additional

Follow the Pregnancy Enquiries Flow Chart
in IRMER for female patients aged 12-55
years

58
 SHOULDER

Clinical Indications Trauma - AP (15 degrees) and axial or lateral (Y-view).If possible and no
fracture is seen on AP, an axial/half-axial is preferable to Y-view
Post reduction - AP (15 degrees )
Pain - AP (15 degrees) Additional / Alternative projection - Glenohumeral Joint
View (30 degree rotation). Outlet (specialist request)
Recurrent dislocation - AP (15 degrees). Additional / Alternative projections -
Stryker’s view (specialist request)
Post-op replacement - AP (turned 45 degrees), lateral (Y-view)
The AP image should demonstrate the whole of the clavicle the inferior angle
Typical diagnostic
of the scapula and the sternoclavicular joint and the soft tissue borders.
features and
clinical conditions The lateral image should include the clavicle, scapula, and upper third of
to be humerus and area of rib cage.
demonstrated by
the procedure

Fracture and follow up

OA/RA

Dislocation

Patient preparation On arrival in the department they are asked to undress and change into a
hospital gown. Remove all jewellery that is in the field of view, including
piercings/necklaces etc.
Views and
kV Local
projections FFD AEC AEC mAs
Positioning (for DRL
(additional views in (cm) mode chamber (CR) 2
AEC) ([Link] )
italics)
AP 15 degree The patient stands
rotation erect with their back
to the detector. The
body is rotated 15
degrees to the
110
affected side. The 60 n/a n/a 3.2 n/a
arm is abducted from
the body and
supinated. Centre to
the coracoid process.

Lateral The patient faces the

detector. The
110
affected arm nearest 70 n/a n/a 15 n/a
the detector is
relaxed and the hand

59
 is placed on the hip.
The trunk is rotated
60 degrees and the
anterior surface of
the shoulder is
placed in contact with
the detector. Centre
to the midpoint of the
scapula.

Axial super inferior The patient sits with

the affected side
towards the detector
with the body inclined
towards it. The
affected arm is
abducted as much as
110
possible with the 60 n/a n/a 3.2 n/a
elbow resting on the
detector and the
palm of the arm
facing downwards.
Centre to the
acromion process.

AP 30 degree The patient stands

rotation erect with their back
to the detector. The
body is rotated 30
degrees to the
110
affected side. The 60 n/a n/a 3.2 n/a
arm is abducted from
the body and
supinated. Centre to
the coracoid process.

Outlet The patient faces the

detector. The
affected arm nearest
the detector is
relaxed and the hand
is placed on the hip.
The trunk is rotated
110
60 degrees and the 60 n/a n/a 3.2 n/a
anterior surface of
the shoulder is
placed in contact with
the detector. The
detector should be
perpendicular to the
scapula. Centre with

60
 a 20 degree caudal
angulation with the
central ray directed
along the
supraspinatous fossa
anterior to the
scapular spine.

Stryker view The patient lies

supine. The affected
arm is raised and
abducted above
shoulder With the
elbow flexed place 110
60 n/a n/a 3.2 n/a
the hand the top of
the head. Using a 10
degree cephalad
angulation centre to
the coracoid process.

Comments None additional

61
 SINUSES

Clinical Indications Pain, blocked - Refer to Radiologist

Typical diagnostic
features and
clinical conditions
to be
demonstrated by
the procedure
Patient preparation Remove glasses and all jewellery that is in the field of view, including
piercings/necklaces etc.
Views and
kV Local
projections FFD AEC AEC mAs
Positioning (for DRL
(additional views in (cm) mode chamber (CR) 2
AEC) ([Link] )
italics)

Comments None additional

62
 SKELETAL SURVEY ( MYELOMA )

Clinical Indications REFER TO RADIOLOGIST FOR AUTHORISATION AS A CT OR MRI SCAN

MAY BE MORE APPROPRIATE
MYELOMA
Plain films not indicated.
Whole body low-dose MDCT techniques are a realistic alternative to
conventional Skeletal Survey X-ray imaging (Downey et al, 2015), where
whole body MRI is not appropriate.

METASTATIC
Focal symptomatic areas/ correlation to Nuclear Medicine

METABOLIC-PARATHYROIDISM
Lateral SXR
Lateral T/L-Spine
AP pelvis
PA chest
DP both hands
Additional specialist views - DP feet-for paediatric

PAEDIATRIC DYSPLASIA
PA Chest
AP & Lateral T/L spine
AP pelvis
Lateral SXR
AP arms
AP legs

Non Accidental Injury-NAI

Refer to separate protocol

See individual examination sheets

Typical diagnostic
features and
clinical conditions
to be
demonstrated by
the procedure
Patient preparation On arrival in the department they are asked to undress and change into a
hospital gown. .Remove all jewellery that is in the field of view, including
piercings/necklaces etc.

63
Views and
kV Local
projections FFD AEC AEC mAs
Positioning (for DRL
(additional views in (cm) mode chamber (CR) 2
AEC) ([Link] )
italics)

Patient Protection:- None additional

Follow the Pregnancy Enquiries Flow Chart
in IRMER for female patients aged 12-55
years

64
 SKULL

Clinical Indications Foreign body - Tangential views with anatomical landmark present to identify
location.
Paediatric developmental abnormality - AP, lateral, Townes (FO30)
The images should demonstrate the whole of the cranial bones.
Typical diagnostic
features and The lateral should include the first cervical vertebra and the perfect
clinical conditions superimposition of the lateral floors of the anterior fossa and those of the
to be posterior cranial fossa. The lateral will demonstrate the coronal and
demonstrated by lambdoidal suture.
the procedure
The Townes should demonstrate the Clinoid process of the sella turcica
projected within the foramen magnum. The image should include all of the
occipital bone and posterior parts of the parietal bone and the lambdoidal
suture should be visualised clearly. The skull should not be rotated.

Craniosynostosis

Foreign body

Patient preparation Remove glasses and all jewellery that is in the field of view, including
piercings/necklaces etc.
Views and
kV Local
projections FFD AEC AEC mAs
Positioning (for DRL
(additional views in (cm) mode chamber (CR) 2
AEC) ([Link] )
italics)
AP The child lies supine
on the table with the
radiographic baseline
raised 20 degrees.
The outer canthuses
of the eye shoud be
110
equidistant to the 73 S400 Central 12.5 n/a
table top and medical
sagittal plane 90
degrees to the table.
Centre in the midline
to the naison.

Lateral The child lies on the

affected side with the
median sagittal plane
parallel to the table
top and supported in
110
place. Centre 73 S400 Central 12.5 n/a
midway between the
glabella and the
external occipital
protuberance to a
point approximately

65
 5cm superior to the
external auditory
meatus.

Townes The child lies supine

on the table with the
median sagittal plane
and radiographic
baseline at 90
degrees to the table. 110
73 S400 Central 12.5 n/a
Centre 6cm above
the glabella to the
hairline with a 30
degree caudal
angulation.

Comments None additional

66
 STERNO-CLAVICULAR JOINT

Clinical Indications Trauma - PA and Anterior Oblique of affected side .Show from to Radiologist.
CT preferable if available
Pain - PA and Anterior Oblique of affected side. Show form to Radiologist. CT
preferable if available
The views should include the medial third of each clavicle the junction with the
Typical diagnostic
sternum and part of the manubrium. The oblique view will demonstrate the
features and
joint closest to the detector.
clinical conditions
to be Swelling
demonstrated by
the procedure Subluxation

Patient preparation On arrival in the department they are asked to undress and change into a
hospital gown.
Views and
kV Local
projections FFD AEC AEC mAs
Positioning (for DRL
(additional views in (cm) mode chamber (CR) 2
AEC) ([Link] )
italics)
PA The patient stands
facing the detector
with the median
sagittal plane at right
angles to the 110
70 S400 Center 4 n/a
detector. Centre at
the in the midline
midway between the
ends of the sternum.

Oblique From the PA position

rotate the unaffected
side 30 degrees
away from the
detector. Centre 2.5
cm laterally from the
70 S400 Center 4 n/a
midline on the raised 110
side through the
sterno-clavicular
joint. Repeat for the
opposite side.

Comments None additional

67
 STERNUM

Clinical Indications Trauma - CXR(PA), lateral

Bone Pain - CXR(PA), lateral
The PA image should include the superior aspect of the first rib demonstrating
Typical diagnostic
the apices the costophrenic angles and the soft tissue borders. The image
features and
should demonstrate full inspiration and the scapulae should be clear of the
clinical conditions
lung fields.
to be
demonstrated by The lateral image should include the manubrium, body and xiphoid process.
the procedure
Fracture

Patient preparation On arrival in the department they are asked to undress and change into a
hospital gown.
Views and
kV Local
projections FFD AEC AEC mAs
Positioning (for DRL
(additional views in (cm) mode chamber (CR) 2
AEC) ([Link] )
italics)
PA chest The patient faces
the detector with
the chin raised. The
dorsal aspects of the
hands are placed
behind and below
the hips with the 180 8 CR
125 S800 Outer 2
elbows brought 7 DR
forward and. The
shoulders rotated
anteriorly and
pressed downward
in contact with the
detector.
Lateral sternum The patient sits or
stands with the
median sagittal plane
parallel to the
detector. The hands
are clasped behind
110
the back and 81 S400 Center 10 n/a
shoulders pulled well
back. Centre with a
horizontal central ray
2.5 cms behind the
sternal angle.

Comments None additional

68
 SUBMANDIBULAR GLAND

Clinical Indications Swelling - Refer to Radiologist

Typical diagnostic
features and
clinical conditions
to be
demonstrated by
the procedure
Patient preparation

Views and
kV Local
projections FFD AEC AEC mAs
Positioning (for DRL
(additional views in (cm) mode chamber (CR) 2
AEC) ([Link] )
italics)

Comments None additional

69
 TEMPORO-MANDIBULAR JOINTS ( TMJs )

Clinical Trauma - OPG, PA. Additional / Alternative projections - Lateral obliques if OPG
Indications not possible
Pain - Refer to Radiologist for MRI
Typical
diagnostic The image should demonstrate the whole of the TMJ down to the top of the
features and ramus.
clinical conditions
to be Fracture
demonstrated by
the procedure Subluxation

Dislocation

Patient Remove glasses and all jewellery that is in the field of view, including
preparation piercings/necklaces etc.
Views and
Local
projections FFD kV (for AEC AEC mAs
Positioning DRL
(additional views (cm) AEC) mode chamber (CR) 2
([Link] )
in italics)
OPG The patient stands
facing the unit. The
unit is adjusted to
the correct height.
the patient moves
forward so that the
chin is on the rest.
The Frankfurt line
should be parallel
to the floor. The Pre- Program
P1 for
vertical laser lights set by
adults and
on the unit should unit P10 for
pass though the paediatrics
median saggital
plane and the
horizontal through
the Frankfurt line.
Adjust the head
supports to
maintain patient
position.

PA mandible The patient is

seated facing the
vertical detector
with the nose and 110
73 Y centre 12 n/a
forehead against
the detector. The
median sagittal
plane is coincident

70
 with the midline of
the detector. The
head is adjusted to
bring the orbito-
meatal baseline
perpendicular to
the detector. The
EAM’s should be
equidistant from
the detector.
Centre with a
horizontal beam to
the midline of the
patient at the level
of the angles of the
mandible

Oblique Mandible The patient lines

supine with a CR
cassette along the
affected side and
supported in
position with the
lower border of the
cassette 2cm
below the lower
border of the
mandible. The
shoulders are
lowered are far as
110
possible. The chin 60 n/a n/a 3.2 n/a
is raised to bring
the angle of the
mandible away
from the spine.
With a horizontal
beam the tube is
angled 30 degrees
cranially. Centre to
the angle of the
mandible nearest
the tube. Repeat
for the other side.

Comments None additional

71
 THORACIC INLET

Clinical Indications Cervical rib - AP Cervical spine to include 1st Rib

All other CLINICAL INDICATIONS— Refer to Radiologist for CT/MRI

Typical diagnostic
features and The AP should demonstrate C4 to the bifurcation of the trachea at the level of
clinical conditions T4 and the whole of the spinous processes.
to be
demonstrated by Goitre
the procedure
Patient preparation On arrival in the department they are asked to undress and change into a
hospital gown. Remove all jewellery that is in the field of view, including
piercings/necklaces etc.
Views and
kV Local
projections FFD AEC AEC mAs
Positioning (for DRL
(additional views in (cm) mode chamber (CR) 2
AEC) ([Link] )
italics)
AP Patient is erect or
supine with the
median sagittal plane
parallel to the
detector. The jaw is
raised to 110 15 CR
70 S200 Centre 6
superimpose the 13 DR
mandible over the
occiput. Centre with
a in the midline to the
sternal notch.

Comments None additional

72
 THORACIC ( DORSAL ) SPINE

Clinical Indications Trauma-with pain/neurological deficit - AP and Lateral. Additional / alternative

projection - Coned lateral of # (specialist request)
Pain - AP and Lateral
(AP if ? scoliosis)
Osteoporosis - Lateral
The image should include the lower border of C7 to the upper border of L1
Typical diagnostic
and the whole of the vertebral bodies. On the lateral view the posterior ribs
features and
should be superimposed to demonstrate that the patient is not rotated.
clinical conditions
to be
demonstrated by
the procedure Fracture and follow up

Metastases

Osteoporotic fracture

Ankylosing Spondylitis

OA

Patient preparation On arrival in the department they are asked to undress and change into a
hospital gown. Remove all jewellery that is in the field of view, including
piercings/necklaces etc.
Views and
kV Local
projections FFD AEC AEC mAs
Positioning (for DRL
(additional views in (cm) mode chamber (CR) 2
AEC) ([Link] )
italics)
AP The patient lies
supine on the table
with the median
saggital plane
perpendicular to the
110 100 CR
table top. Centre in 77 S400 Center 20
86 DR
the midline 2.5 m
below the sternal
angle. Image taken
on expiration.

Lateral The patient lays on

their side with the
median sagittal plane
parallel to the table.
Arms are raised and
placed onto the 110 150 CR
77 n/a n/a 40
pillow. The knees 112 DR
and hips are flexed.
Centre 5cm anterior
to the long axis of the
thoracic vertebrae at
the level of T6. This
73
 view should be taken
on a breathing
exposure.

Comments None additional

74
 THUMB

Clinical Indications Trauma - AP and Lateral

Pain - AP and Lateral
Foreign Body/Lump – AP and Lateral. If there is single entry site, use opaque
arrow marker. Tangential view may be used as an additional view
The radiograph should include the terminal phalanx , carpo-metacarpal joint
Typical diagnostic
and the soft tissue borders. The metacarpals should not be superimposed
features and
over the base of the thumb.
clinical conditions
to be The PA projection increases unsharpness but may be used where the patient
demonstrated by finds the routine view too painful.
the procedure
Fracture and follow up

Avulsion

Dislocation

Skiers thumb

OA

Foreign body

Patient preparation Remove all jewellery that is in the field of view.

Views and
kV Local
projections FFD AEC AEC mAs
Positioning (for DRL
(additional views in (cm) mode chamber (CR) 2
AEC) ([Link] )
italics)
AP The patient is seated
with the affected side
to the detector. The
thumb elbow and
shoulder should be
level and the arm
rotated so the
110
posterior aspect of 50 n/a n/a 2 n/a
the thumb is in
contact with the
detector. Centre to
the
metacarpophalangeal
joint

Lateral The patient is seated

with the affected side
to the detector. With
the hand prone the 110
50 n/a n/a 2 n/a
hand is rotated
medially until the
thumb is lateral.
Centre to the
75
 metacarpophalangeal
joint.

Comments None additional

76
 TIBIA & FIBULA ( LOWER LEG )

Clinical Indications Trauma - AP and Lateral

Pain - AP and Lateral
Foreign Body/Lump – AP and Lateral. If there is single entry site, use opaque
arrow marker. Tangential view may be used as an additional view
The radiograph should include the ankle and knee joint. Therefore a CR
Typical diagnostic
cassette is used to achieve this. The plantar aspect of the foot should be
features and
perpendicular to the cassette. Soft tissue borders should e visible.
clinical conditions
to be A lateral horizontal beam should be used for acute trauma.
demonstrated by
the procedure A cast will require more exposure.

Fracture and follow up

Dislocation

Foreign body

Osteomyelitis

Bony cyst

Patient preparation Remove all jewellery and clothing that is in the field of view.

Views and
kV Local
projections FFD AEC AEC mAs
Positioning (for DRL
(additional views in (cm) mode chamber (CR) 2
AEC) ([Link] )
italics)
AP The patient lies
supine with the
affected limb
extended. The ankle
is dorsiflexed and
rotated so that the
110
malleoli are 55 n/a n/a 2.5 n/a
equidistant from the
detector. Centre in
the midline midway
between the ankle
and knee joint.

Lateral The patient is turned

onto the affected
side. The hip and
knee joint are slightly
flexed. The ankle is 110
55 n/a n/a 2.5 n/a
dorsiflexed and the
rotated until the
malleoli are
superimposed.
Centre in the midline

77
 midway between the
ankle and knee joint.

Comments None additional

78
 TOE

Clinical Indications Trauma - DP and DP Oblique

Pain - DP and DP Oblique
Foreign Body/Lump – DP and Lateral. If there is single entry site, use opaque
arrow marker. Tangential view may be used as an additional view
The image should demonstrate the distal phalanges and proximal metatarsal
Typical diagnostic
region and soft tissue borders.
features and
clinical conditions Fracture
to be
demonstrated by Gout
the procedure
Osteomyelitis

Foreign body

Subluxation

Dislocation

Patient preparation Remove all jewellery and clothing that is in the field of view.

Views and
kV Local
projections FFD AEC AEC mAs
Positioning (for DRL
(additional views in (cm) mode chamber (CR) 2
AEC) ([Link] )
italics)
DP The patient lays
supine on the table
with the knee flexed
and plantar aspect of
the foot in contact
with the table. The
leg is supported in
the vertical position.
110
Centre with a vertical 55 n/a n/a 1.25 n/a
central ray over the
head of the third
metatarso-
phalangeal joint. (For
single toes centre as
above but over the
individual toe.)

DP Oblique The patient lays

supine on the table
with the knee flexed
and plantar aspect of
110
the foot in contact 55 n/a n/a 1.25 n/a
with the table.
Medially rotate the
foot to bring the
plantar surface of the
79
 foot is 30-40 degrees
to the image
receptor. Support the
toes in position.
Centre with a vertical
central ray over the
head of the third
metatarso-
phalangeal joint.

Comments None additional

80
 TRAUMA SERIES ( IF CT NOT REQUIRED OR AVAILABLE )

Clinical Indications Major Trauma - AP Chest, AP Pelvis, Lateral Cervical Spine

Typical diagnostic
features and To assess life-threatening pathology that requires immediate intervention.
clinical conditions
to be
demonstrated by
the procedure
Patient preparation Remove glasses and all jewellery that is in the field of view, including
piercings/necklaces etc. if possible patient condition permitting.
Views and
kV Local
projections FFD AEC AEC mAs
Positioning (for DRL
(additional views in (cm) mode chamber (CR) 2
AEC) ([Link] )
italics)
AP Chest The patient is supine
on the trolley. The
detector is placed on
the x-ray tray. The
upper border of the
cassette should be
placed above the 180 15 CR
81 n/a n/a 6.4
apices. Centre with a 15 DR
horizontal beam at
right angles to the
cassette to the
midline and to the
middle of the chest.

AP Pelvis The patient is supine

on the trolley. The
detector is placed on
the x-ray tray. The
upper border should
be just above the
n/a n/a 258 CR
iliac crests. Centre in 77 16
110 175 DR
the midline, midway
between the ASIS
and superior border
of the symphysis
pubis

Lateral C Spine The patient is supine

on the trolley. The
image receptor is
supported alongside
n/a n/a 15 CR
the cervical spine 70 8
180 12 DR
parallel to the median
sagittal plane. The
shoulders are
lowered as far as
81
 patient condition will
allow. Centre 2.5 cm
behind and 5 cm
below the angle of
the mandible with a
horizontal beam.

Patient Protection:- None additional

Follow the Pregnancy Enquiries Flow Chart
in IRMER for female patients aged 12-55
years or DR to complete rule to be ignored
section

82
 WRIST

Clinical Indications Trauma - PA and Lateral. Additional / Alternative projection - Anterior oblique
(to demonstrate #radial styloid)
Pain - PA and Lateral
Rheumatoid Arthritis - PA and Lateral
Foreign Body – PA and Lateral. If there is single entry site, use opaque arrow
marker. Tangential view may be used as an additional view
Carpal tunnel - Wrist in full dorsiflexion, axial projection of volar aspect
The radiograph should demonstrate the proximal two thirds of the
Typical diagnostic
metacarpals, the carpal bones and distal third of the radius and ulna.
features and
clinical conditions Fracture and follow up
to be
demonstrated by Dislocation
the procedure
OA/RA

Avascular necrosis ( lunate )

Patient preparation Remove all jewellery and clothing that is in the field of view.

Views and
kV Local
projections FFD AEC AEC mAs
Positioning (for DRL
(additional views in (cm) mode chamber (CR) 2
AEC) ([Link] )
italics)
PA Patient seated with
affected side towards
the table. Elbow is
flexed with wrist and
forearm on the digital
detector. Fingers are
flexed to keep the 110
55 n/a n/a 2 n/a
wrist flat. Styloid
processes are
equidistant to the
detector. Centre
midway between the
styloid processes

Lateral From the PA position

laterally rotate the
wrist until the palmer
aspect is 90 degrees
to the detector then 110
55 n/a n/a 2 n/a
rotate a further 5
degrees until the
styloid processes are
superimposed.
Centre to the radial

83
 styloid processes.

Oblique From the PA position

rotate the wrist
laterally until the
palmer aspect is 45
110
degrees to the 55 n/a n/a 2 n/a
detector. Centre
midway between the
styloid processes

Comments None additional

84
 EXAMPLE TEMPLATE

Clinical Indications

Typical diagnostic
features and
clinical conditions
to be
demonstrated by
the procedure
Patient preparation

Views and
kV Local
projections FFD AEC AEC mAs
Positioning (for DRL
(additional views in (cm) mode chamber (CR) 2
AEC) ([Link] )
italics)

Patient Protection None additional

85
APPENDIX A

86
Contents:

Background to CPIPSE Page 3

The Radiographers Role in CPIPSE Page 4

Radiographer Technique Page 5

X-ray Protocol Page 6 - 7

Audit Page 8 - 10

Contact Numbers Page 11

Useful Resources Page 12

Background:

87
The CPIPSE is the Cerebral Palsy Integrated Pathway for the South and South East.

Cerebral Palsy (CP) - a non-progressive neurological problem but a progressive orthopaedic problem.

The Cerebral Palsy Integrated Pathway (CPIP) is a follow up programme for children with CP or sus-
pected CP. It initially started in Sweden in 1994 and Scotland became part of this pathway it 2013.

The main purpose of the CPIP is to ensure that children with risk of developing contractures or hip
dislocation are detected early enabling a timely intervention.

Research has shown that x-rays taken of the hip at the correct time can help detect the problem earli-
er. In Sweden evidence has shown a significant decrease in the incidence of dislocations after the
introduction of the prevention programme.

88

NHS Scotland (n.d.)

The Radiographer’s Role in CPIPSE:

The Reimers’ hip migration percentage (MP) is commonly used to document the extent of hip dis-
placement in children CP.

(Scrutton, 1997)

The migration percentage determines the degree of dislocation however the accuracy of this meas-
urement is dependent on the radiographic positioning for the X-ray.

In order for accurate measurements to be taken the AP Pelvic X-ray MUST have:

- Hips equidistant from the table

- Legs parallel to each other with neutral abduction/adduction

- Patella’s should be facing upwards

- The lumbar spine should be completely flat on the bed, lower legs may be lifted to support
this.

89
Radiographic Technique for CP Patients:

90
X-ray Protocol:

It is important that across the South and South East that the Pelvic X-ray becomes standardised for
CP. This is to ensure the measurements are accurate and lead to the correct care pathway. In order
to achieve this the same protocol should be used in every imaging department across the country.
The CP Hip Surveillance protocol (page 7) has been complied by Paediatric Orthopaedic Surgeons
and a Radiographer from the Evelina London Children’s Hospital.

There is also a national code that can be used to identify these patients which is AP Pelvis for Hip
Surveillance: XPVHS

Normally children with CP have the first x-ray at 2 years of age and final x-ray at age 16. If the child is
mildly affected a further X-rays will be taken at 6 years old. Severely affected children will have annual
X-rays until aged 8 and then every other year preceding that. As shown by the tables below:

NHS Scotland (n.d.)

91
92
Audit:

In order to high quality imaging and ensure the correct positioning is being achieved a bi-annular au-
dits should be carried out in every radiology department. Below is an example of the audit used in the
Evelina London Children’s Hospital. Table one is a referrer audit and assesses the x-ray on PACS
and table two assesses the radiographer technique used.

93
 TABLE ONE: Referrer Audit

94
TABLE TWO: Radiographer Audit

95
Contact Numbers:

- At the Evelina London Children’s Hospital we image a number of

Cerebral Palsy patients using the previously mentioned protocol.

- The CPIPSE database launched on 1st November 2017.

- We need to ensure the standardised protocol is being used across

the South and South East.

- If this protocol is new for you and you have additional questions
please get in touch.

Email: [Link]@[Link]

Phone Number: 02071889215

96
Useful Resources:
Articles
Dobson, F., Boyd, R. N., Parrott, J., Nattrass, G.R. & Graham, H. K.
(2002) Hip Surveillance in Children with Cerebral Palsy: Impact on the
Surgical Management of Spastic Hip Disease. The Journal of Bone and
Joint Surgery.
Gangi, A. & Duncan, K. (2016) Re-audit of referrals to the cerebral palsy
hip surveillance programme.
Hagglund, G., Alriksson-Schmidt, A., Lauge-Pedersen, H., Rodby-
Bousquet, E., Wagner, P. & Westborn, L. (2014). Prevention of disloca-
tion of the hip in children with cerebral palsy. 20 year results of a popula-
tion-based prevention programme. The Bone and Joint Journal.

Websites
[Link]
[Link]
[Link]
013/CPIPS%20Presentation%20Susan%20Quinn%[Link]
[Link]
sm_final.pdf

References:
NHS Scotland. (n.d.) Cerebral Palsy Integrated Pathway Scotland
(CPIPS): Origins and Development, Core Dataset, Clinical Assessment.

Scrutton, D. & Baird, G. (1997). Surveillance measures of the hips of

children with bilateral cerebral palsy. Disease in Childhood. 76:4.

97
98