Dorsi-plantar foot.

Dorsi-plantar oblique foot.

 Toes
Clinical Indication
• Fracture
• Dislocation
• Osteoarthritis
• Gout
• Osteomyelitis
• General toe pain

• Basic Projection
• DP
• DPO

• 18 × 24 cm Cassette
 AP DP-Toes
Position of patient and image receptor
• The patient is seated on the X-ray table, supported if necessary, with hips
and knees flexed.

• The plantar aspect of the affected foot is placed on the IR. A cassette may be
raised by 15°, using a pad.

Direction and location of the X-ray beam

• 3rd Metatarso-phalangeal joint.

• For single toes, the vertical ray is centred over the MTPJ of the individual
toe and collimated to include the toe of either side.
AP -TOES
AP TOES
 Dorsi-plantar oblique- Toes
Position of patient and image receptor
• From the basic DP position, the affected limb is allowed to lean medially to
bring the plantar surface of the foot approximately 45° to the IR.

• A 45° pad is placed under the side of the foot for support.

• Direction and location of the X-ray beam

• 3rd MTPJ if all the toes are to be imaged

• For single toes, the vertical ray is centred over the MTPJ of the individual
toe and collimated to include the toe of either side.
Dorsi-plantar oblique- Toes
 Dorsi-plantar oblique- Toes
DPO- 5th toe, showing # of the
proximal phalanx.
 Lateral- hallux
Position of patient and image receptor
• From the DP position the foot is rotated medially until the medial aspect of the
hallux is in contact with the receptor.

• A bandage is placed around the remaining toes (provided no injury is

suspected) and they are gently pulled forwards by the patient to clear the
hallux.

• Alternatively they may be pulled backwards. This shows the MTPJ more
clearly.

Direction and location of the X-ray beam

• 1st MTPJ
Lateral- hallux
 Lateral- hallux
Essential image characteristics
• Distal and proximal phalanges
• Distal 2/3 of the 1st metatarsal bone.

•The 1st MTPJ and interphalangeal joint

should be seen clearly.
 Phalangeal sesamoid bones
Position of patient and image receptor
• Patient lies Supine/Prone on the X-ray table

• Dorsiflex the foot so that the plantar surface of the foot forms about a 15° to 20°
angle from vertical.

• Dorsiflex the first digit and rest on IR to maintain position.

• Ensure that long axis of foot is not rotated; place sandbags or other support on both
sides of foot to prevent movement.

Centering Point
• Posterior aspect of the first MTP joint
Phalangeal sesamoid bones
Phalangeal sesamoid bones
 Foot
Clinical Indication
• Foot trauma
• Bony tenderness
• Inability to bear-weight more than four steps
• Non-traumatic foot pain
• Location of opaque foreign bodies

Basic Projection
• Dorsi-plantar
• Dorsi-plantar oblique

Additional Projection
• Lateral
 Dorsi-plantar foot.
Position of patient and image receptor
• The patient is seated on the X-ray table with the hip and knee flexed.

• The plantar aspect of the foot is placed on the IR and the lower leg is
supported in the vertical position by the other knee.

• The IR can be raised by 15° to aid positioning.

• This will improve the visualization of the tarsal and tarso-metatarsal joints.

• This angulation compensates for the inclination of the longitudinal arch and
reduces overshadowing of the tarsal bones.
 Dorsi-plantar foot.
Centering Point
• Base of third metatarsal.

• The X-ray tube is angled 15° cranially when the receptor is parallel to the
table.

• Alternatively, the X-ray beam is vertical if the receptor is raised by 15°.

• Radiation protection/dose
• Careful technique and close collimation will assist in reducing the patient dose.

• 18 × 24 cm Cassette.
Essential image characteristics
• The tarsal bones and tarso-metatarsal joints
should be demonstrated when the whole foot is
examined.

• A wedge filter placed under the toes may be

used to give a uniform range of densities,
especially if the image is acquired using
screen/film technology.
 Dorsi-plantar oblique- Foot
• Position of patient and image receptor
• From the basic DP position, the affected limb is leaned
medially, bringing the plantar surface of the foot to
approximately 30–45° to the IR.

• A non-opaque angled pad is placed under the foot to maintain

the position, with the opposite limb acting as a support.

Centering Point
• Base of third metatarsal.
Dorsi-plantar oblique- Foot
 Dorsi-plantar oblique- Foot
• Essential image characteristics
• The image should adequately demonstrates the differences in subject
contrast and density between the toes and tarsus.
 Foot- Lateral
Position of patient and image receptor
• From the DP position, the leg is rotated outwards to bring the lateral aspect of
the foot in contact with the receptor.

• A pad is placed under the knee for support.

• The position of the foot is adjusted slightly to bring the plantar aspect
perpendicular to the receptor.

Centering Point
• Navicular–cuneiform joint
• Alternatively, if the area under question relates to a foreign body;
• FB Entry point.
Foot- Lateral
 Foot- Lateral
Essential image characteristics
•The whole of the foot, including the ankle
joint, calcaneum and toes should be seen.

•If FB is suspected, the contrast should be

optimized to show the FB against the soft-
tissue structures.
 Lateral – erect (weight-bearing)
• Both feet are examined for comparison.
• It is important that the full weight of the patient is placed on the feet, to allow an
accurate evaluation of the effect of normal weight on the longitudinal arch and bony
alignment.

Position of patient and image receptor

• The patient stands on a low platform with the receptor placed vertically between the feet.

• The feet are brought close together.

• The weight of the patient’s body is distributed equally.

• To help maintain the position, the patient should rest their forearms on a convenient
vertical support, e.g. the vertical Bucky.
 Lateral – erect (weight-bearing)

Centering Point
• Tubercle of the 5th metatarsal.
 Dorsi-plantar – erect (weight-bearing)
• Clinical Indication
• Alignment of the metatarsals and phalanges in cases of hallux valgus.

• Position of patient and image receptor

• Both feet are placed flat on the IR adjacent to one another to be imaged together;
however, often each foot is best imaged individually.

• The patient stands with their foot on the receptor.

• All the metatarsals and phalanges should be included on the image.

• To help maintain the position, the patient will require some support, for example by
placing their hands in a supporting position onto the raised X-ray table.
 Dorsi-plantar – erect (weight-bearing)
Centering Point
• Midway between the feet at the level of base of
1 metatarsals, or is centred over the specific
st

cuboid–navicular joint if a single foot is to be

examined.

• A 5° tube angulation towards the patient may be

required to allow the correct centering point to
be achieved.
Dorsi-plantar – erect (weight-bearing)
Lateral – erect (weight-bearing)- Demonstrating Hallux Valgus
 Ankle
Clinical indication
• Ankle trauma
• Bony tenderness of the medial and lateral malleoli
• Inability to bear weight
• Non-traumatic ankle pain

Basic Projection
• AP (mortise)
• Lateral
Ankle
 AP- Ankle (mortise)
Position of patient and image receptor
• The patient is either supine or seated on the X-ray table with both legs extended.

• A pad may be placed under the knee for comfort.

• The affected ankle is supported in dorsiflexion by a firm 90°pad placed against the plantar
aspect of the foot.

• The limb is rotated medially (approximately 20°) until the medial and lateral malleoli are
equidistant from the receptor.

• If the patient is unable to dorsiflex the foot sufficiently, then raising the heel on a 15° wedge or
using 5–10° of cranial tube angulation can correct this problem.

• The mid-tibia may be immobilized using a sandbag.

 AP- Ankle (mortise)

Direction and location of the X-ray

beam
• Midway between the malleoli with the
central ray at 90° to an imaginary line
joining the malleoli.
AP- Ankle (mortise)
 AP- Ankle (mortise)
Essential image characteristics
• The lower 1/3 of the tibia and fibula should be included.

• A clear joint space between the tibia, fibula and talus should be
demonstrated (commonly called the mortise view).
 Lateral- Ankle
Position of patient and image receptor
• A 15° pad is placed under the lateral border of the forefoot and a pad is placed
under the knee for support.

• From the supine position, the patient rotates on to the affected side.

• The leg is rotated until the medial and lateral malleoli are superimposed vertically.

• A 15° pad is placed under the anterior aspect of the knee and the lateral border of
the forefoot for support.

• The receptor is placed with the lower edge just below the plantar aspect of the
heel.
 Lateral- Ankle

Direction and location of

the X-ray beam
• Medial malleolus, with the
central ray at right-angle to
the axis of the tibia.
 Lateral- Ankle

Essential image characteristics

• The lower 1/3 of the tibia and fibula,
• Base of 5th metatarsal and calcaneum.

• The medial and lateral borders of the trochlear

articular surface of the talus should be
superimposed on the image.
Lateral- Ankle
 Tibia and Fibula
• Clinical Indication
• Trauma
• Suspected foreign body
• Inability to bear weight
• Osteomyelitis
• Osteoporosis

• Basic Projection
• AP
• Lateral

• 35 × 43 cm Cassette
 AP- Leg
Position of patient and image receptor
• The patient is either supine or seated on the X-ray table, with both legs
extended.

• The ankle is supported in dorsiflexion by a firm 90°pad placed against the

plantar aspect of the foot.

• The limb is rotated medially until the medial and lateral malleoli are
equidistant from the receptor.

• The lower edge of the receptor is positioned just below the plantar aspect of
the heel.
 AP- Leg

• Direction and location of the

X-ray beam
• Mid-shaft of the tibia
AP- Leg
AP- Leg
 Lateral- Leg
Position of patient and image receptor
• From the supine/seated position, the patient rotates onto the affected
side.

• The leg is rotated further until the malleoli are superimposed vertically.

• The tibia should be parallel to the image receptor.

• A pad is placed under the knee for support.

• The lower edge of the receptor is positioned just below the plantar
aspect of the heel.
 Lateral- Leg

Centering Point
• Mid-shaft of the tibia,
 Knee joint
Clinical Indication
• Knee bones #
• Joint dislocation
• Excess fluid accumulation
• Osteoarthritis
• Osteophytic growth
• Bone infections (Osteomyelitis).
• Bone thinning (osteopenia).
• Bone Cancer
Basic Projection
• AP (Weight Bearing)
• Lateral
• Alternate Projection
• AP Supine
• Additional Projection
• Lateral (Shoot through)
• 24 × 30 cm Cassette
Knee joint
 AP-Knee joint
Position of patient and image receptor
• The patient is either supine or seated on the X-ray table or trolley, with both
legs extended.

• The affected limb is rotated to centralize the patella between the femoral
condyles, and sandbags are placed against the ankle to help maintain this
position.

• The IR should be in close contact with the posterior aspect of the knee
joint.
 AP-Knee joint

Direction and location of the X-ray

beam
• 1 cm below the apex of the patella
through the joint space.
 AP-Knee joint
Essential image characteristics
•The patella must be centralized over the
femur.

•The image should include;

• Proximal 1/3 of the tibia and fibula
• Distal 1/3 of the femur.
AP Knee showing depressed tibial plateau #
 Lateral- Knee
Position of patient and image receptor
• The patient lies on the side to be examined, with the knee flexed at 45° or
90°.

• The other limb is brought forward in front of the one being examined and
supported on a sandbag.

• A pad is placed under the ankle of the affected side to bring the long axis of
the tibia parallel to the IR.

• The position of the limb is now adjusted to ensure that the femoral condyles
are superimposed vertically.
 Lateral- Knee

Centering Point
• 1 inch (2.5 cm) distal
to medial epicondyle,
with the CR at 90° to
the long axis of the
tibia.
 Lateral- Knee
• Ideal lateral knee with 90° flexion.
 Over-rotated Knee

If over-rotated;
• The medial femoral
condyle is projected in
front of the lateral
condyle

• The proximal tibio-

fibular joint will be well-
demonstrated
 Under-rotated- Knee
If under-rotated;
• The medial femoral
condyle is projected
behind the lateral condyle.

• The head of the fibula is

superimposed on the tibia
 AP Knee – weight-bearing
Position of patient and image receptor
• The patient stands with their back against the vertical Bucky

• The patient’s weight is distributed equally.

• The knee is rotated so that the patella lies equally between the femoral condyles.

• The center of the image receptor is level with the palpable upper borders of the
tibial condyles.

• This projection is useful to demonstrate alignment of the femur and tibia in the
investigation of valgus (bow-leg) or varus (knock-knee) deformity.
 AP Knee – weight-bearing
• Direction and location of the X-ray beam
• The collimated horizontal beam is centred 1 cm
below the apex of the patella through the joint space.

• Both knees;
• Midway between both knees at a level 1 cm below both
patellas.
Genu Valgus Vs Genu Varum
 AP Knee – weight-bearing
Essential image characteristics
•The patella must be centralized over the
femur.

•The image should include the proximal

1/3 of the tibia and fibula and distal 1/3
of the femur.
 Lateral Knee – horizontal beam (trauma)
• This projection replaces the conventional lateral in all cases of gross injury and
suspected # of the patella.

Position of patient and image receptor

• The patient remains on the trolley/bed, with the limb gently raised and supported on
pads.

• If possible, the leg may be rotated slightly to centralize the patella between the
femoral condyles.

• The imaging receptor is supported vertically against the medial aspect of the knee.

• The center of the receptor is level with the upper border of the tibial condyle.
Lateral Knee – horizontal beam (trauma)

• Direction and location of

the X-ray beam
• Upper Border of the lateral
tibial condyle, at 90° to the
long axis of the tibia.
 Lateral Knee – horizontal beam (trauma)

Essential image characteristics

• The image should demonstrate;
• Lower 1/3 of the femur

• Proximal 1/3 of the tibia.

• The femoral condyles should be superimposed.

• The soft tissues adequately demonstrated to visualize

any fluid levels within the supra-patella pouch.
 Lateral Knee – horizontal beam (trauma)
Caution
• No attempt must be made to either flex or extend the knee joint.

• Additional flexion may result in complicating patient condition.

• Any rotation of the limb must be from the hip, with support given to the
whole leg.

• By using a horizontal beam, fluid levels may be demonstrated, indicating

lipohaemarthrosis
Lateral Knee – horizontal beam (trauma)
Lateral Knee – horizontal beam (trauma)
 Skyline projections
Indication;
• Retro-patellar joint space degenerative diseases.
• Patella Subluxation.
• Chondromalacia patellae.
• Vertical patella fracture in acute trauma.

There are three methods of achieving the skyline projection:

• Supero-inferior – beam directed downwards.
• Conventional infero- superior.
• Infero-superior – patient prone.
 Skyline Knee- Supero-inferior
Position of patient and image receptor
• The patient sits on the X-ray table, with the affected knee flexed over the
side.

• The receptor is supported horizontally on a stool at the level of the inferior

tibial tuberosity border.
 Skyline Knee- Supero-inferior
Centering Point
• Posterior aspect of the proximal
border of the patella.

• The beam is collimated to the

patella and femoral condyles.

• This projection has the advantage

that the radiation beam is not
directed towards the gonads.
 Skyline Knee- Supero-inferior
Essential image characteristics
•The retro-patellar space should be
clearly seen without superimposition
of the femur or tibia within the
patella-femoral joint.
 Skyline Knee- Supero-inferior
Supero-inferior image showing advanced
Normal skyline radiograph of knee
degenerative changes
Centering Point
• The CR is angled 5–10°
cranially to pass through the
apex of the patella.
 Skyline – infero-superior (patient prone)

Centering Point
• Behind the patella, with the
vertical CR angled
approximately 15° cranially.