Radiographic Positioning Summary

Anatomy

Projection

Positioning

Centering

Angle

Proximal Femur

AP

1. Place patient supine, arms across their chest 2. Rotate affected leg internally 15o to place femoral neck in profile

Perpendicular

Mediolateral lateral

1. Patient supine first, ask patient to move to far side of table 2. Ask patient to roll slightly towards affected leg & place a sponge behind them 3. Unaffected leg straight, bend affect leg 1. Patient supine, affected leg furthest away from x-ray tube 2. Place cassette & grid in the crease above the iliac crest at 45o 3. Place the x-ray tube perpendicular to the cassette 4. Ask patient to flex the unaffected leg and elevate until 90o and support with chair 1. Patient supine, arms across their chest 2. Rotate affected leg slightly internally to place patella in true AP

Collimate to 35 x43cm, place ASIS at the top of cassette/ Center 2.5cm below pubic symphysis/greater trochanter Collimate to 35 x43cm, place ASIS at the top of cassette

Horizontal beam axiolateral

Distal Femur

AP

Mediolateral lateral

1. Patient supine first, ask patient to move to far side of table 2. Ask patient to roll slightly towards affected leg & place a sponge behind them 3. Unaffected leg straight, bend affect leg

Perpendicular

Exposure Factors Grid 70kVp, 25mAs

Grid 75kVp, 20mAs

Center at the Perpendicular crease of leg between inside top of leg and pelvis (inguinal crease)

Grid 80-120kVp, 64-80mAs

Place bottom of cassette 5cm below knee joint

Perpendicular

Place bottom of cassette 5cm below knee joint

Perpendicular

Grid: 66kVp, 20-25mAs Non-grid: 60kVp, 1620mAs Grid: 66kVp, 20-25mAs Non-grid: 60kVp, 1620mAs

Pelvis

Horizontal beam lateral

1. Patient supine, place affected leg closest Place bottom of to x-ray tube cassette 5cm 2. Place cassette against medial side of leg below knee joint

Perpendicular

AP

1. Patient supine, arms across chest, legs extended 2. Patient to separate heels 20cm and rotate legs internally until big toes touch

Perpendicular

Pelvic Inlet

1. Patient supine, legs extended, arms across chest 1. Patient supine, legs extended, arms across chest

Center midway between the ASIS and superior border of the symphysis pubis Collimate to 35 x43cm cassette and place the top of the iliac crest at the top of collimation Center at the ASIS Center 5cm below greater trochanter

Angle 30o cephalad for male Angle 40o cephalad for female Perpendicular

Pelvic Outlet

Hip

Unilateral AP

1. Patient supine, arms across chest, leg extended 2. Patient to internally rotate affected leg 15o

Lateral Oblique (same as mediolateral lateral of proximal femur)

1. Patient supine first, ask patient to move to far side of table 2. Ask patient to roll slightly towards affected leg & place a sponge behind them 3. Unaffected leg straight, bend affect leg

Find the ASIS and the pubic symphysis, find the point midway and center 2.5cm below this point Place ASIS at the top of cassette or center at the inguinal crease

Angle 40o caudal

Perpendicular

Grid: 66kVp, 20-25mAs Non-grid: 60kVp, 1620mAs Grid 66-70kVp, 25-32mAs

Grid: 70kVp, 16mAs Grid: 70kVp, 16mAs

Grid 66-70kVp, 25-32mAs

Grid 75kVp, 20mAs

Judet’s downside (anterior rim) Judet’s upside (posterior rim) Sacroiliac AP Axial SI Joints joints

1. Patient supine, patient to roll towards their affected side and place sponge behind patient’s back 2. Ask patient to roll back onto the sponge 1. Patient supine, patient to roll towards their unaffected side and place sponge behind patient’s back 2. Ask patient to roll back onto the sponge 1. Patient supine, legs extended, arms across chest

Posterior Oblique

1. Patient supine, arms across their chest 2. Elevate patient with affected side up 2530o with sponge

Sacrum

AP (Axial)

1. Patient supine, arms across their chest, legs extended 2. Patient to hold their breath

Coccyx

AP (Axial)

1. Patient supine, arms across their chest, legs extended 2. Patient to hold their breath

Sacrum & Coccyx

Lateral (Sacrum & Coccyx)

1. Patient to roll onto their left side 2. Place support between knees 3. Place a sponge at between patient’s waist and table to ensure that the spine is straight

Center 5cm medial Perpendicular and 5cm distal to the ASIS

Grid 75kVp, 20mAs

Center 5cm distal to the ASIS

Perpendicular

Grid 75kVp, 20mAs

Center between level of pubic symphysis and ASIS in the midline Center over the elevated (affected) side, 2.5cm medial to upside ASIS Center 5cm superior to pubic symphysis Or center midway between the ASIS and pubic symphysis Center 5cm above pubic symphysis/ 5cm below the ASIS Or center midway between the ASIS and pubic symphysis Collimate to 24x30cm cassette and have the top of the collimation at the iliac crest and center in line

Angle 15o cephalad

Grid 75kVp, 20mAs

Perpendicular

Grid 75kVp, 20mAs

Angle 15o cephalad

Grid 70kVp, 32mAs

Angle 10o caudal

Grid 65kVp, 20mAs

Perpendicular

Grid 75kVp, 40mAs

Lumbar Spine

AP supine

1. Patient supine with legs flexed, arms across the chest 2. Patient to breathe in, breathe out and hold

AP erect

1. Patient to stand with their back against the bucky in the middle with weight evenly distributed between their feet

Lateral

1. Patient lying in recumbent position, place sponge between the knees 2. Patient to breathe in, breathe out and hold

Lateral erect

1. Patient left side against the bucky in true lateral position 2. Ask patient to place arms on top of their head 3. Patient to breathe in, breathe out and hold

Lateral flexion

1. Patient left side against the bucky, ask patient to place arms on their head 2. Patient to lean forward as much as possible using their lower back 3. Patient to breathe in, breathe out and hold 1. Patient left side against the bucky, arms on their head 2. Patient to lean back as much as possible using their lower back

Lateral extension

with the high point of the iliac crest Center at the lower costal margin in the midline, collimate to include SI joints Collimate to 35x43cm cassette, place the bottom of the bucky 7.5cm below the iliac crest Center to level of lower costal margin- this is where L3 is (same for HBL lateral Lspine) Center at the level of the iliac crest, ensure the bucky is 5-7cm below the iliac crest, center in the midcoronal plane Center at the level of the iliac crest, ensure that bucky is 5-7cm below the iliac crest Center at the level of the iliac crest

Perpendicular

Grid 70kVp, 32mAs

Perpendicular

Grid 70kVp, 32mAs

Perpendicular OR if L-spine is not straight, angle 8o cephalad male, 12o cephalad female Perpendicular

Grid 80kVp, 4060mAs

Perpendicular

Perpendicular

3. Patient to breathe in, breathe out and hold 1. Patient semisupine 45o with sponge for support 2. Ask patient to place elevated arm over their opposite shoulder 1. Patient supine with arms across chest, knees flexed 2. Patient breathe in and stop

Center at the level of the lower costal margin in the mid auxiliary line Center at the level of ASIS

Lateral L5/S1

1. Patient lying in recumbent position, place sponge between the knees 2. Patient to breathe in, breathe out and hold

AP Supine

1. Patient supine with arms by their side 2. Patient to flex hips and knees to place thighs vertical (reduces kyphosis) 3. Raise patient’s chin slightly to avoid superimposition 4. Ask patient to hold their breath

AP erect

1. Patient standing with their back against the bucky in the middle 2. Ask patient to breathe in, breathe out and hold

Center at the perpendicular intersects of the point of the highest point of the iliac crest laterally & posterior superior iliac spine Find xiphoid sternum & sternal notch, center half way between these points Collimate to 35x43cm and place top of cassette above patient’s shoulder, center at T7 Place detector at the top of the shoulders Center at T7

Oblique

L5/S1

Thoracic Spine

AP Axial

Perpendicular

Grid 75kVp, 40mAs

Angle 30o cephalad male, 35o cephalad female Perpendicular OR 0-3o caudal with spine nearsufficient support OR 5-8o caudal with less support

Grid 75kVp, 35mAs

Perpendicular

Grid 70kVp, 25mAs

Perpendicular

Grid 85kVp, 50100mAs

AP erect lateral bending scoliosis

Lateral

Lateral erect

Cervical Spine

1. Patient standing with their back against the bucky in the middle 2. Ask patient to lean to their side keeping their hips still 3. Patient to breathe in, breathe out and hold 1. Patient lying on their left side in true lateral position, place a sponge between patient’s knees 2. Place lead mat behind collimated area on table 3. Patient to breathe gently 1. Patient standing with their left side against the bucky 2. Ask patient to place their arms on top of their head

Center in the Perpendicular middle between xiphoid and sternal notch Turn the beam diaphgram Top of collimation Perpendicular (35x43cm cassette) at the shoulder level Center below T7

Grid 73kVp, 40mAs

Collimate to 35x43cm cassette Center at the midcoronal plane and below T7 1. Patient standing with back of head Centered in the against the bucky middle of the 2. Ask patient to open their mouth by mouth, collimate dropping their lower jaw as wide as they to the edge of the can, align the base of skull (occiput) with height the inferior border of the front incisors

Perpendicular

Perpendicular

Grid: 70kVp, 16mAs Non-grid: 65kVp, 6mAs

AP (Axial)

1. Patient standing with back of head against the bucky 2. Patient to slightly lift chin up 3. Patient to stop breathing and don’t swallow

Center at lower thyroid cartilage

Angle 15o-20o cephalad

Lateral

1. Patient standing or sitting with left side against the IR (no grid) 2. Patient to place hands behind their back and pull down onto their shoulders 3. Patient to breathe in, breathe out and relax their shoulders and don’t swallow

Center at lower thyroid cartilage and collimate to include top of ear to AC joint

Perpendicular SID: 180cm (air gap)

Grid: 6070kVp, 16mAs Non-grid: 65kVp, 6mAs No grid 66kVp, 16mAs

AP Odontoid

Lateral (Swimmers)

1. Patient standing with left side against the bucky 2. Ask patient to place their left arm up and rest their arm on their head and keep the right arm down and patient to lean against the bucky

Lateral Flexion

1. Patient standing or sitting with left side against the bucky 2. Ask patient to tuck their chin into their chest as much as they can

Lateral Extension

1. Patient standing or sitting with left side against the bucky 2. Ask patient to raise their chin as high as they can

Anterior Obliques

1. Patient to face the bucky, patient turned so shoulder touches the bucky at 45o 2. Ensure patient’s head is in lateral position 1. Patient head against the bucky, patient turned so shoulder touches the bucky at 45o 2. Ensure patient’s head is in lateral position 1. Patient supine with neck hyperextended, arms by their side

Posterior Obliques

AP AxialVertebral Arch Facial Bones

OM (Waters)

1. Position chair close to the board, ask patient to sit on the chair facing the board 2. Ask patient to rest their chin on the board and relax shoulders forward 3. Adjust the patient’s head so MML

Center just above the AC joint on the right side (T1)2.5cm above the jugular notch Collimate to include the area that was missed in the lateral Center at the level of the thyroid cartilage Collimate to include tip of ear Center at the level of thyroid cartilage Collimate to include the tip of the ear Center above the thyroid cartilage Collimate to top of ear Center below the thyroid cartilage Collimate to top of ear

Perpendicular SID: 100cm (reduced)

Center to lower margin of thyroid cartilage Adjust the bucky so the centering will be at the acanthion Collimate to patient’s face-

Angle 20-30o caudal

Grid 80kVp, 80mAs

Perpendicular

Perpendicular

Angled 15o caudal

Grid 70kVp, 20mAs

Angled 15o cephalad

Grid 70kVp, 20mAs

Perpendicular If OMBL is not 37 degrees, angle tube accordingly so patient angle & tube angle is

Grid 63kVp, 40mAs

OM 30 MO - Trauma

1. Patient will be supine 2. Raise patient’s chin to bring OMBL (orbitomeatal baseline) 37O to IR, if patient cannot raise chin up, angle the CR cephalad to the amount equal to the difference between OMBL angle and the required 37O

Lateral

1. Patient erect, rotate the patient’s shoulder and ask them to stand up close to the bucky so the side of their face is touching the bucky in true lateral position 2. If the patient cannot move their neck, stand in true lateral position with their shoulders touching the bucky (this will increase OID so increase SID to compensate) 1. Patient seated erect facing the bucky or prone on the table 2. Ask patient to rest their forehead (and nose) on the bucky 3. Adjust patient’s head to place OML (orbitomeatal line) parallel to the ground 1. Patient in same position as Lateral facial bones 1. Patient sitting or lying supine against the bucky

PA Axial (Modified Caldwell) OF 15

Zygoma

(Mento-mandible line) parallel to the ground, OMBL is at 37 degrees 4. Ensure that there is no rotation of the patient’s head 5. Ask patient to suspend respiration 1. Same positioning as OM (waters)- above

Lateral Nasal Bones AP 30O (Slit Townes)

include the top of the frontal sinuses to the patient’s mandible

37O

Center to top of skull, beam should exit at acanthion

Angle 20-30o caudal

Center midway between EAM and canthus (outer canvas of the eye)

Angle CR cephalad to the amount equal to the difference between OMBL angle & 37O if patient cannot raise chin high enough Perpendicular

Center at the back of head so the exit point is at the nasion (below the glabella)

Angle 15O caudal

Center 1.25cm inferior to nasion Center 2.5cm superior to

Perpendicular Out of bucky Angle CR 35-40O caudal

Grid 63kVp, 40mAs

Grid: 65kVp, 16mAs Non-grid: 60kVp, 12mAs

No grid 66kVp,

Zygomatic arches

Mandible

2. Ask patient to look down to the ground and adjust patient’s head so the radiographic baseline (OML) is parallel to the ground 3. Suspend respiration PA Mandible 1. Patient sitting facing the bucky with forehead resting on the bucky 2. Patient can support their head by placing both hands on the side to stabilize 3. Adjust patient’s head so OML (EAM to outer canvas of eye) is parallel to the floor AP Axial 1. Have patient sitting or supine with back (Townes) of head against the bucky Mandible 2. Ask patient to look down to the ground and adjust patient’s head so the radiographic baseline (OML) is parallel to the ground 3. Suspend respiration Oblique 1. Patient sitting with their shoulders (Axiolateral) rotated and face on the bucky Mandible – 2. Ask patient to rest the side of their Lazy lateral forehead on the board (head tilted ~25o) (general survey 3. Ask patient to suspend respiration of mandible)

Protocols Facial Bones:  OM  OM 30  Lateral

glabella to pass midway between EAMs and angle of mandible

20mAs

Center at the junction of lips Collimate to 18x24cm & have top of collimate to top of ears

Perpendicular OR Angle 2—25O cephalad & have CR exit at acanthion

Center at galbella, pass midway between EAMs

Angle 35-40O caudal

Center mid body head tilt 15 Center so the exit beam is at the mandibular region of interest (mandible closest to IR)

Angle 10O cephalad (As patient cannot head tilt 25O)

Grid 75kVp, 20mAs Grid 70-80kVp, 12mAs

70-80kVp, 5mAs

Sinuses:  OM  Lateral  PA (Modified Caldwell view)