PREPARED BY: MAAM KENNY’S NEONATES

College of Radiologic Technology

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“Skyline Pigeon Fly”
A 12-year-old boy was admitted to the emergency room after having felt a severe
pain in his left knee on hitting the ground while skateboarding earlier that day. Knee
swelling and tenderness were noted. Though pain is experienced by the patient,
active range of motion of the injured knee was 45-90° of flexion. AP projection of the
knee joint demonstrates vertical fracture of the patella.
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Guide Questions
1. Identify all the structures on the
radiograph. (Label and present
them on your ppt)
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2. What structure can you observe that have
problem (pathology/complication/fracture)?
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3. Is the radiograph enough to provide a radiographic diagnosis of the condition of the
patient?

Yes, but only to conditions such as bone fractures, certain tumors and other abnormal
masses, pneumonia, some types of injuries, calcifications, foreign objects, or dental
problems. Nevertheless, clinical history of the patient should be taken to further help
the physician in diagnosing the patient.
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Knee
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AP PROJECTION

Clinical Indication:
• Fractures, lesions, or bony changes related to
degenerative joint disease involving the distal
femur, proximal tibia and fibula, patella, and
knee joint
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Patient Position:

• Patient in supine position so that the pelvis is

not rotated

Part position:
• With the IR under the patient's knee, flex the
joint slightly, locate the apex of the patella, and
as the patient extends the knee, center the IR
about Y2 inch ( 1 .3 cm) below the patellar apex.
This will center the IR to the joint space.
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Part position:
• Femural epicondyles parallel with the IR for a
true AP projection
• If the knee cannot be fully extended, a curved IR
may be used.
• Shield gonads.
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Central Ray:
• Directed to a point Y2 inch (1.3 cm) in­ferior to
the patellar apex.
• Variable, depending on the measurement
between the anterior superior iliac spine (AS IS)
and the tabletop (Fig. 6- 1 36), as follows:
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SID: Minimum SID—40 inches (102 cm)
Structure Shown:
• The resulting image shows an AP projec­tion of
the knee structures
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LATERAL PROJECTION

Clinical Indication:

• Fractures, lesions, and joint space abnormalities.

Patient position:

• Ask the patient to turn onto the affected side. Ensure that the
pelvis is not rotated.

• For a standard lateral projection, have the patient bring the

knee forward and extend the other limb behind it (Fig. 6-140).
The other limb may also be placed in front of the affected knee
on a support block.
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Part position:
• A flexion of 20 to 30 degrees is usually is
preferred because this position relaxes the
muscles and shows the maximum volume of the
joint cavity
• To prevent fragment separation in new or
unhealed patellar fracture , the knee should not
be flexed more than 10 de­grees
• Place a support under the ankle
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Part position:
• Grasp the epicondyles and adjust them so that they are
perpendicular to the IR (condyles superimposed). The patella
will be perpendicular to the plane of the IR (Fig. 6-14).
• Shield gonads
Central Ray:
• Directed to the knee joint I inch (2.5 cm) distal to the medial
epicondyle at an an­ gie of 5 to 7 degrees cephalad. This slight
angulation of the central ray will prevent the joint space from
being obscured by the magnified image of the medial femoral
condyle. In addition, in the lat­eral recumbent position, the
medial condyle will be slightly inferior to the lateral condyle.
• Center the I R to the central ray.
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SID: Minimum SID—40 inches
(102 cm)

Structure Shown:
• The resulting radiograph
shows a lateral image of the
distal end of the femur,
patella, knee joint, proximal
ends of the tibia and fibula,
and adjacent soft tissue
(Figs. 6- 1 42).
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AP PROJECTION (Weight-bearing Method)

Clinical Indication:

• Femorotibial joint spaces of the knees demonstrated for

possible cartilage degeneration or other knee joint
pathologies
• Bilateral knees included on same exposure for
comparison

Patient position:

• Patient in upright position with back toward a vertical

grid device
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Part position:
• Adjust the patient's position to center the knees
to the IR.
• Place the toes straight ahead, with the feet
separated enough for good balance. Ask the
patient to stand straight with knees fully
extended and weight equally distributed on the
feet
• Center the lR 't; inch ( 1 .3 cm) below the apices
of the patellae (Fig. 6- 1 43).
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Central Ray:
• Horizontal and perpendicular to the center of
the IR, entering al a point (2 inch ( 1 .3 cm)
below the apice of the patellae
SID: Minimum SID—40 inches (102 cm)
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Structure Shown:

• The resulting image

shows the joint spaces
of the knees. Varus and
valgus deformities can
also be evaluated with
thi procedure (Fig. 6-
144).
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AP OBLIQUE PROJECTION (Medial Rotation)

Clinical Indication:

● Pathology involving the proximal tibiofibular and

femorotibial (knee) joint articulations
● Fractures, lesions, and bony changes related to
degenerative joint disease, especially on the anterior and
medial or posterior and lateral portions of knee

Patient position:

• Patient in supine position, support the ankle.

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Part position:

• Medially rotate the limb, and elevate the hip of

the affected side enough to rotate the limb 45
degrees.
• Place a support under the hip, if needed (Fig. 6-
149).
• Shield Gonads
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Central Ray:
• Directed 1/2 inch (1.3 cm) inferior to the
patellar apex; the angle is variable, de­pending on
the measurement between the ASIS and the
tabletop, as follows:

SID: Minimum SID—40 inches (102 cm)

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STRUCTURE SHOWN:

• The resulting image shows

an AP oblique projection of
the medially rotated femoral
condyles, patella, tibial
condyles, proxi­mal
tibiofibular joint, and head
of the fibula (Fig. 6- 1 50).
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AP OBLIQUE PROJECTION (Lateral Rotation)

Clinical Indication:

● Pathology involving the proximal tibiofibular and

femorotibial (knee) joint articulations
● Fractures, lesions, and bony changes related to
degenerative joint disease, especially on the anterior and
medial or posterior and lateral portions of knee

Patient position:

• Patient in supine position, support the ankle.

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Part position:

• If necessary, elevate the hip of the unaf­fected

side enough to rotate the affected limb.
• Support the elevated hip and knee of the
unaffected side (Fig. 6- 1 47).
• Center the IR 1/2 inch (1.3 cm) below the apex
of the patella.
• Externally rotate the limb 45 degrees.
• Shield gonads.
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Central Ray:
• Directed 1/2 inch (1.3 cm) inferior to the
patellar apex; the angle is variable, de­pending on
the measurement between the ASIS and the
tabletop, as follows:

SID: Minimum SID—40 inches (102 cm)

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STRUCTURE SHOWN:

• The resulting image shows

an AP oblique projection of
the medially rotated femoral
condyles, patella, tibial
condyles, and head of the
fibula (Fig. 6- 1 48).
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Intercondylar
Fossa
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PA AXIAL PROJECTION (HOLMBLAD METHOD)

Clinical Indication:

• Intercondylar fossa, femoral condyles, tibial plateaus, and

intercondylar eminence demonstrated
• Evidence of bony or cartilaginous pathology, osteochondral
defects, or narrowing of joint space

Patient position:

• After consideration of the patient's safety, place the patient in

one of three positions: (1) standing with the knee of interest
flexed and resting on a stool at the side of the radiographic
table (Fig.6- 1 55),
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Patient position:

2) standing at the side of the radiographic table with the

affected knee flexed and placed in contact with the front of the
fR (Fig. 6- 1 56), or (3)kneeling on the radiographic table as
originally described by HoLmblad, with the affected knee over
the IR (Fig. 6- 1 57). In all three approaches, the patient leans
on the radiographic table for support.

Central Ray:

Perpendicular to the lower leg, entering the midpoint of the IR for

all three positions

• Minimum SID—40 inches (102 cm)

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Structures Shown:

The resulting image shows the intercondylar

fossa of the femur and the medial and lateral
intercondylar tubercles of the intercondylar
eminence in profile (Fig.6- 1 59). Holmblad I
stated that the degree of flexion used in this
position widens the joint space between the
femur and tibia and gives an improved image of
the joint and the surfaces of the tibia and femur.
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PA AXIAL PROJECTION (CAMP-COVENTRY METHOD)

Clinical Indication:

• Intercondylar fossa, femoral condyles, tibial plateaus, and

intercondylar eminence demonstrated
• Evidence of bony or cartilaginous pathology, osteochondral
defects, or narrowing of joint space

Patient position:

• Place the patient in the prone position, and adjust the body so that it is not
rotated.
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Patient position:

Central Ray:

● Perpendicular to the long axis of the leg and centered

to the knee joint (i.e., over the popliteal depression)
● Angled 40 degrees when the knee is flexed 40 degrees
and 50 degree when the knee i flexed 50 degrees

• Minimum SID—40 inches (102 cm)

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Structures Shown:

This axial image demonstrates an unobstructed

projection of the intercondyloid fossa and the medial and
lateral intercondylar tubercles of the intercondylar
eminence (Figs. 6- 1 62 and 6- 1 63).
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AP AXIAL PROJECTION (BECLERE METHOD)

Clinical Indication:

• Intercondylar fossa, femoral condyles, tibial plateaus, and

intercondylar eminence demonstrated to look for evidence of
bony or cartilaginous pathology
• Osteochondral defects, or narrowing of the joint space

Patient position:

• Place the patient in the supine position, and adjust the body so
that it is not rotated.
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Central Ray:
•

● Adjust the leg so that the femoral condyles are equidistant from
the IR. Immobilize the foot with sandbag .
● Perpendicular to the long axis of the tibia, entering the knee
joint Y; inch(1.3 cm) below the patellar apex
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Structures Shown:

The resulting image shows the intercondylar fossa, intercondylar

eminence, and knee joint (Figs. 6- 1 65 and 6-1 66).
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Patella
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PA PROJECTION

Clinical Indication:

• Evaluation of patellar fractures before knee joint is

flexed for other projections

Patient position:

• Place the patient in the prone position.

• If the knee is painful, place one and bag under the
thigh and another under the leg to relieve pressure
on the patella.
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PA PROJECTION

Part position:

• Center the IR to the patella.

• Adjust the position of the leg to place the patella
parallel with the plane of the IR. This usually
requires that the heel be rotated 5 to 10 degrees
laterally (Fig. 6- 1 67).
• Shield gonads.

SID: Minimum SID—40 inches (102 cm)

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PA PROJECTION

Central Ray:

• Perpendicular to the midpopliteal area exiting the

patella.
• Collimate closely to the patellar area.

Structures Shown:

• The PA projection of the patella provides sharper

recorded detail than in the AP pro­jection because of a
closer object-to­ [image receptor distance (aID)
(Fig . 6- 1 68 and 6- 1 69).
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LATERAL PROJECTION (MEDIOLATERAL)

Clinical Indication:

• Evaluation of patellar fractures in conjunction with the

PA
• Abnormalities of femoropatellar and femorotibial
joints

Patient position:

• Place the patient in the lateral recum­bent position.

SID: Minimum SID—40 inches (102 cm)

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LATERAL PROJECTION (MEDIOLATERAL)

Part position:

• Ask the patient to turn onto the affected hip. A sandbag may be placed under the ankle for support.
• Have the patient flex the unaffected knee and hip, and place the unaffected foot in front of the
affected limb for stability.
• Flex the affected knee approximately 5 to 10 degrees. Increasing the flexion re­duces the
patellofemoral joint space.
• Adjust the knee in the lateral position so that the femoral epicondyles are su­perimposed and the
patella perpen­dicular to the IR (Fig. 6- 1 70).
• Shield gonads.
• Center the IR to the patella.
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LATERAL PROJECTION (MEDIOLATERAL)

Central Ray:

• Perpendicular to the IR, entering the knee at the mid

patellofemoral joint.
• Collimate closely to the patellar area.

Structures Shown:

• The resulting image show a lateral pro­jection of the

patella and patellofemoral joint space (Fig. 6- 171 ).
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PA AXIAL OBLIQUE PROJECTION:

KUCHENDORF METHOD (LATERAL ROTATION)

Patient position:

• Place the patient in the prone position.

• Elevate the hip of the affected side 2 or 3 inches .
• Place a sandbag under the ankle and foot, and
adjust it so that the knee is slightly flexed
(approximately 10 degrees) to relax the muscles.

SID: Minimum SID—40 inches (102 cm)

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Part position:

• Center the IR to the patella.

• Laterally rotate the knee approximately 35 to 40 degrees from the prone posi­tion
(this position is more comfortable for the patient than the direct prone, be­cause no
pressure is placed on the in­jured patella. The patient rarely objects to the slight
pressure required to dis­place the patella laterally).
• Place the index finger against the me­dial border of the patella, and press it laterally.
• Rest the knee on it anteromedial side to hold the patella in a position of lateral
displacement (Figs. 6- 1 76 and 6- 1 77).
• Shield gonads.
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Central Ray:

• Directed to the joint pace between the patella and the

femoral condyle at an angle of 25 to 30 degrees
caudad. It en­ters the posterior surface of the patella.

Structures Shown:

• The resulting image will how a lightly oblique PA

projection of the patella, with most of the patella free
of superimposed structures (Fig. 6- 1 78).
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Patellofemoral
Joint
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TANGENTIAL PROJECTION: HUGHSTON METHOD

Clinical Indication:

Patient position:

• Place the patient in a prone position with the

foot resting on the radio­graphic table.
• Adjust the body so that it is not rotated.

SID: Minimum SID—40 inches (102 cm)

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TANGENTIAL PROJECTION: HUGHSTON METHOD

Part position:

• Place the IR under the patient' knee, and slowly flex the affected knee so that the
tibia and fibula form a 50- to 60- degree angle from the table.
• Rest the foot against the collimator, or support it in position (Fig. 6- 1 79).
• Ensure that the collimator surface is not hot because this could burn the patient.
• Adjust the patient's leg so that it is not rotated medially or laterally from the
vertical plane.
• Shield gonads.
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TANGENTIAL PROJECTION: HUGHSTON METHOD

Central Ray:

• Angled 45 degrees cephalad and directed through the

patellofemoral joint

Structures Shown:

• The tangential image shows subluxation of the patella

and patellar fractures and al­lows radiologic assessment
of the femoral condyle . Hughston recommended that
both knees be examined for comparison (Fig. 6- 1 80).
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TANGENTIAL PROJECTION: MERCHANT METHOD

Clinical Indication:

Patient position:

• Place the patient supine with both knees at the end of the radiographic table.
• Support the knees and lower legs by an adju table IR-holding device.
• To increase comfort and relaxation of the quadriceps femoris, place pillows or a
foam wedge under the patient's head and back.

SID: A 6-foot (2-m) SID is recom­mended to reduce magnification.

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TANGENTIAL PROJECTION: MERCHANT METHOD

Part position:

• Using the "axial viewer" device, elevate the patient's knees approximately 2 inches to place the
femora parallel with the tabletop (Figs. 6- 181 and 6- 1 82).

• Adjust the angle of knee flexion to 40 degree . (Merchant reported that the degree of angulation
may be varied be­tween 30 to 90 degrees to demonstrate various patellofemoral disorders.)

• Strap both legs together at the calf level to control leg rotation and allow patient relaxation.

• Place the IR perpendicular to the central ray and resting on the patient's hins (a thin foam pad
aids comfort) approxi­mately I foot distal to the patellae.
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TANGENTIAL PROJECTION: MERCHANT METHOD

Part position:

• Ensure that the patient is able to relax. Relaxation of the quadriceps femoris is critical for
an accurate diagnosis. If these muscles are not relaxed, a sub­luxed patella may be pulled
back into the intercondylar sulcus, showing a false normal appearance.

• Record the angle of knee flexion for re­producibility during follow-up exami­nation,
because the severity of patella subluxation commonly changes in­versely with the angle of
knee flexion.

• Shield gonads
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TANGENTIAL PROJECTION: MERCHANT METHOD

Central Ray:

• Perpendicular to the IR
• With 40-degree knee flexion, angle the central ray 30 degrees caudad from the horizontal plane
(60 degrees from verti­cal) to achieve a 30-degree central ray­ to-femur angle. The central ray
enters midway between the patellae at the level of the patellofemoral joint.

Structures Shown:

The bilateral tangential image demon­strate an axial projection of the patella and patellofemoral
joints (Fig. 6- 1 83). Because of the right-angle alignment of the IR and central ray, the patellae are
seen as non distorted albeit slightly magni­fied images.
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TANGENTIAL PROJECTION: SETTEGAST METHOD

Clinical Indication:

Patient position:

• Place the patient in the supine or prone position. The

latter is preferable be­cause the knee can usually be
flexed to a greater degree and immobilization is easier
(Figs. 6- 1 84 and 6- 1 85).
• If the patient is seated on the radio­graphic table, hold
the IR securely in place (Fig. 6- 1 86). Alternative
positions are shown in Figs. 6- 1 87 and 6- 1 88.
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TANGENTIAL PROJECTION: SETTEGAST METHOD

Part position:

• Flex the patient's knee slowly as much as possible or until the patella is per­
pendicular to the IR if the patient' con­dition permits. With slow, even flexion, the
patient will be able to tolerate the position, whereas quick, uneven flexion may
cause too much pain.

• If desired, loop a long strip of bandage around the patient's ankle or foot. Have the
patient grasp the ends over the shoulder to hold the leg in position. Gently adjust
the leg 0 that its long axis is vertical.
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TANGENTIAL PROJECTION: SETTEGAST METHOD

Part position:

• Place the IR transversely under the knee, and center it to the joint space
between the patella and the femoral condyles.

• Shield gonads.

• By maintaining the same OID and SID relationships, this position can be
obtained with the patient in a lateral or seated position (see Figs. 6- 1 87 and 6-
188).
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TANGENTIAL PROJECTION: SETTEGAST METHOD

Central Ray:

• Perpendicular to the joint space be­tween the patella and the femoral condyles when the joint is
perpendicu­lar. When the joint is not, the degree of central ray angulation depends on the degree
of flexion of the knee. The angu­lation typically will be 15 to 20 degrees.
• Close collimation is recommended.

Structures Shown:

The resulting image shows vertical frac­tures of bone and the articulating surfaces of the
patellofemoral articulation (Figs. 6- 1 89 and 6- 1 90).
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