RadiologyPositioningExam 1

Terms
● Angle of gait (normal = 30°)
● Base of gait – distance between medial malleoli while bearing weight (normal = 3 in or 7-8 cm)
● Central axis – longitudinal axis
● Central ray – technical term for where primary beam is located
● Dorsal – top of foot or back of body
● Distal – further away from central part of body
● Evert – raise lateral edge, leave medial column on ground
● Invert – raise medial column, leave lateral column on ground
● Inferior – beneath something else
● Infra – below/beneath
● Lateral – further from the midline
● Medial – closer to the midline
● Oblique – at an angle (not perpendicular)
● Plantar – bottom of foot
● Proximal – closer to main part of body relative to something else
● Retro – behind (Ex: retrocalcaneal bursa is behind the calcaneus, retroachilleal bursa is behind n bbbbb
o Weight-bearing – standard because this is how body functions, better for biomechanical analysis of
alignment/subtle displacement
o Partial weight-bearing – simulate weight-bearing, post-operative when pt. cannot bear weight
o Non-weight-bearing – trauma or post-surgery
● Projection – direction of projected beam
● View – opposite of projection

Foot Projections
A. Dorsal Plantar (DP) Weight-Bearing (WB)
● Shoot at 15° in order to be perpendicular to metatarsals (pitch is about 15°, not flat to the floor
o Center should be 2nd metatarsal base
● Shoot at 0° if foreign object in foot to avoid distortion of marked portal of entry
o Center should be near the marker
B. Lateral Foot WB
● Beam hits lateral side of foot then cassette
● Place lateral margin parallel to cassette (might need to move heel laterally)
● Shoot parallel to the ground (90°) near 3rd – 5th Metatarsal Bases
● Need felt under foot to lift foot enough to see inferior skin folds (don’t see felt density on film)
● Lateral is standard; differences between lateral & medial are subtle on film
o Easier to shoot line up lateral side to parallel surface
o Awkward to move contralateral leg out of the way to do medial projection
o Generally more pathology in the first ray…better to be further from beam because less magnification
● Medial Projections vs Lateral Projections
o Only way to tell difference is to measure the thickness of the 1st Ray
▪ As 1st Ray is farther from the cassette it will magnify slightly
C. Lateral Raised Hallux WB
● Focuses on forefoot, want unobstructed view of hallux
● Use 2” roll of gauze (won’t show up on film) shot at 90o
● Alternate method
o lift digits 2-5 instead if hallux rigidis/limitus doesn’t permit elevation of hallux
● Can also raise a single digit to isolate
● Can also use sling to assist elevation if toes won’t stay up (typically elderly)

D. Lateral Oblique Projection/Medial Oblique View WB

● Beam strikes lateral side of foot at 40o near 3rd – 5th Metatarsal Bases
● 3rd most common view
● Completes 3 views that most physicians utilize
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● Highlights lateral side of foot

o good visualization of lateral toes, metatarsals, Lisfranc’s joint, Tailor’s bunion, digital fractures, metatarsal
fractures, CN bar (coalition)
E. Medial Oblique Projection/Lateral Oblique view WB
● Tube angulation = 25°
● Aiming for Navicular and Base of 1st Metatarsal
● Position medial column parallel to edge of cassette
● Highlights medial side of foo
o Good visualization of 1st metatarsal, sesamoid apparatus, arthritis, tibial sesamoid, foreign bodies, 1st
metatarsal, hallux, fractures
● Alternative angulation = 40°
o Helps view tibial sesamoid and inferior aspect of the Metatarsal-Phalangeal Joint but can’t see the rest of
the foot very well
Projection vs. View
Lateral oblique projection = Medial oblique view Medial oblique projection = Lateral oblique view
Highlights Lateral Column Highlights Medial Column

F. Axial Sesamoid WB
● To get unobstructed view of sesamoids (lift heel & toes)
● Tube angulation = 90°
● Best for viewing sesamoid fractures & erosion of crista
● Can use a fabricated orthoposer to force heel lift & dorsiflexion of hallux
G. Axial Calcaneal WB
● Tube angulation = 25°
● For stress fracture of calcaneus (because trabecular patterns are superimposed in medial & lateral view)
H. Harris & Beath Method
● Tube angulation = 40°
o Sometimes needs to be altered by 5o – 10o
● Lead apron goes on back of body
● Patient must lean forward
● Goal is to see Middle and Posterior Facets of the STJ (unions of talus & calcaneus)

Ankle Projections
● For All Ankle Projections:
o Cassette is vertical
o Patient stands on a piece of felt
o Tube angulation = 90° (parallel to the floor)
o Only changing position of foot & ankle

A. Anterior Posterior Ankle WB

● Shooting at Talar Dome in the Mid Anterior (2nd ray parallel to central beam)
● Tibia & fibula are superimposed so may be hard to see lateral gutter
B. Mortise Ankle WB
● Goal is to see medial & lateral gutters of ankle mortise
● Lateral malleolus is more posterior than medial malleolus so internally rotate leg 15° to get ankle axis parallel to
cassette
C. Lateral Ankle WB
● Aim at the Lateral Malleolus
● Highlights RF but might be interested in FF too
● Long axis of cassette should be parallel to foot
D. Lateral Oblique Ankle WB
● Externally rotate foot with respect to cassette & shoot from lateral side
● Highlights the lateral gutter better

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E. Medial Oblique Ankle WB

● Externally rotate foot from line perpendicular to cassette & shoot from medial side
● Heel should not touch the cassette
● Highlights medial malleolus
● Lot of superimposition, highlights just a small anatomical area
F. Partial WB
● For trauma patients, might be concerned about stress fracture
● Majority of weight is on uninvolved extremity
G. Non-WB
● Patient position depends on equipment operation & patient’s condition
● Unable to do biomechanical evaluation on DP or lateral
● Wheelchair or chair
● May shoot at 0° or 15° for Non-WB DP
● Can use wedged orthoposer if not comfortable for patient to get foot flat to the ground
● Can do NWB Lateral by resting foot on lateral column (shoot at 0°)
● Can do NWB Lateral Variation; tube angle at 90°, use felt pad (significant angulation between leg & foot)
● Can do NWB Lateral Oblique by lifting lateral column or medial oblique by lifting medial column (shoot at 0°)
H. Basic AP/Mortise Ankle Hospital/Clinic [RELISTEN]
● Patient is sitting or lying, shoot from behind
● Foot in relaxed plantarflexed position (NWB)
● Tube angulation = 0°
● Can use positioning wedge under plantar surface of foot, then make sure to move tube perpendicular to cassette
(angulate tube & cassette)
● Can use positioning wedge under calf (change tube angulation to accommodate)
o This position allows you to rotate leg to get oblique views (internal rotation 🡪 lateral oblique projection,

external rotation 🡪 medial oblique projection)

o Rarely need to provide manual stability
● Can do NWB medial/lateral with tube at 90° but patient has to be on the ground

Special Ankle Studies

● Stress inversion (stresses lateral side)
o Forceful varus rotation of foot on leg
▪ Can be painful, local anesthetic often needed
▪ Useful for evaluating integrity of lateral ankle ligament
● Specific for Calcaneofibular Ligament (CFL) injury
o Should see big gap or significant angulation between plafond & superior surface of talus
o Some people naturally have tighter or looser ligaments (ligamentous laxity) so might do bilateral to compare
involved side to baseline
o Positive for ligamentous rupture if > 10° more than contralateral foot
● Stress eversion (stresses medial side)
● Anterior drawer
● Stress dorsiflexion
o Foot fixed on floor, patient leans forward to maximally dorsiflex ankle, take lateral x-ray
o Useful for evaluating available ROM of ankle joint
o Useful in patients with limited dorsiflexion (tight heel cord or equinus contracture) & ankle spurs
● Details
o Always use lead gloves but make sure it doesn’t superimposed areas of interest
o Not as commonly done because US & MRI more readily available & give more information

Projection Selection

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● Need knowledge of radiographic & podiatric anatomy to choose which will best demonstrate anatomy of interest
● 3 projection rule: 2 at 90°, 3rd at oblique
● For fractures, foreign body, infection, articular disorders, masses
● Correct order = Cassette, Tube, Set, Part, Expose (CTSPE)
o Cassette setup first [how many you need]
o Tube angulation and collimation assessment
o Set the control box for exposure times
o Now bring the patient in
o Part positioning
o Expose
● Helpful hints
o Long axis of film & long axis of anatomy should be parallel
o Cassette in slot for lateral foot, hallux, digit, & axial sesamoid
o Shoot all WB ankles at 90° with vertical cassette
Bilateral Films
● Used to compare variations in anatomy
● Use lead blocker so that scatter from 1st exposure won’t affect contralateral image
● Be careful to fit all parts of both feet onto film
● For large feet, use one cassette for each foot
● Can use split film to include lateral oblique & dorsoplantar on same cassette

Generally speaking, with most patients you can:

● Have both DP projections on ONE cassette
● Have both Laterals on ONE cassette
o Make sure soft tissue margins are seen
● May need separate cassettes for obliques depending of width of foot
● Whenever possible, combine like projections (bilateral of same projection) 🡪 makes comparison easier
● Always check your light shadow to see what will be found on final image

Sequencing
● Before the patient enters:
o Position cassette: flat or vertical
o Determine tube angulation
o Collimate area to be exposed (area within lighted field)
o Place R/L marker
o Determine technical parameters
o Determine patient positioning (direction & need for felt pad)
● Bring patient into the room:
o PLACING PATIENT = LAST STEP
o Check light shadow
o Capture exposure