1. Lower extremity

2. Intended Learning Outcomes
The student should be able to recognize clinical radiographic technical principles of the lower limb.

3. A-P Lower Leg Measure: A-P at mid-lower leg
Protection: Apron draped over pelvis
SID: 40” Table top
No Tube Angle
Film: 7”x17 I.D. down or diagonal 14” x 17

4. A-P Lower Leg Patient lies on back on table.
Leg internally rotated 15° until in true A-P position
Film centered to include knee and ankle joints. The top of the film will be about 2” above knee.
Horizontal CR is centered to film

5. A-P Lower Leg Vertical CR: long axis of lower leg
Collimation top to bottom: From knee joint to ankle joint or slightly less than film size.
Collimation side to side: soft tissue of lower leg
Instructions: Remain still
Make exposure and let patient relax.

6. A-P Lower Leg Film Must include both knee and ankle articulations
No evidence of rotation
As with this example, the 14” x 17” cassette can be turned diagonally to get both joint spaces on film.

7. Lower Leg Lateral Measure: Lateral at mid lower leg
Protection: Apron draped over pelvis
SID: 40” Table Top
No Tube Angle
Film: 7” x 17” I.D. down or diagonal 14”x17” Regular

8. Lower Leg Lateral
Patient lies on affected side with lower leg in lateral position.
Film centered under leg to get both knee joint and ankle joint on film. Top of film will be about 2” above knee joint.
Horizontal CR centered to film

9. Lower Leg Lateral Vertical CR: long axis of lower leg.
Collimation top to bottom: to include knee joint space and ankle joints
Collimation Side to side: soft tissues of lower leg.

10. Lower Leg Lateral
Make sure that the knee and ankle are in lateral position. The condyles should be perpendicular to film and foot in lateral position.
Collimation Top to Bottom: include both knee joint space and ankle joints

11. Lower Leg Lateral Collimation Side to Side: soft tissues of lower leg.
Instructions: Remain still
Make exposure and let patient relax

12. Lower Leg Lateral Film Must include both knee and ankle joints.
Both joints should be in true lateral positions.
A 14” x 17” may be turned diagonally to get both joints on film.

13. Ankle Radiography Routine views at PCCW
Mortise Oblique
Medial Oblique
Lateral
We do both oblique views for Dr. Scuderi
The mortise open the joints better
The medial oblique demonstrates Jones Fractures.

14. A-P Ankle

15. Ankle A-P Measure: A-P at malleoli Protection: lead apron
SID: 40” Table Top
No Tube Angle
Film: 1/2 of 12” x 10 extremity cassette I.D. up

16. Ankle A-P
Patient is seated or lying on table. Leg is internally rotated until the leg is in a true A-P position position.
The foot is dorsiflexed until the plantar surface is perpendicular to film.
Horizontal CR: at level of talo-tibial joint or malleoli.

17. Ankle A-P Half of film is centered to Horizontal CR.
Vertical CR: Long axis of lower leg.
Collimation top to bottom: distal lower leg to soft tissue below calcaneus. Slightly less than film size.

18. Ankle A-P
Collimation side to side: soft tissue of lower leg and ankle.
Patient Instructions: Remain still
Make exposure and let patient relax.

19. Ankle A-P Film A-P on left.
There should be no rotation as evidenced by the medial mortise joint being open.
The talotibial joint should also be open.
Soft tissue of plantar area of foot should be seen.

20. Ankle Oblique Views Mortise Medial

21. Always take a medial oblique Medial Oblique Lateral Oblique

22. Ankle Medial Oblique Measure: A-P at malleoli Protection: lead apron
SID: 40” Table Top
No Tube Angle
Film: 1/2 of 12” x 10 extremity cassette I.D. up

23. Ankle Medial Oblique
Patient is seated or lying on table. Leg is internally rotated 45° from true A-P position position.
The foot is dorsiflexed until the plantar surface is perpendicular to film.
Horizontal CR: at level of talo-tibial joint or malleoli.

24. Ankle Medial Oblique Half of film is centered to Horizontal CR.
Vertical CR: Long axis of lower leg.
Collimation top to bottom: distal lower leg to soft tissue below calcaneus. Slightly less than film size.

25. Ankle Medial Oblique
Collimation side to side: soft tissue of lower leg and ankle.
Patient Instructions: Remain still
Make exposure and let patient relax.

26. Ankle Medial Oblique Film
Oblique on right.
The lateral malleolus should be clear of the talus.
The medial mortise joint may be open
The talotibial joint should also be open.
The tarsal sinus will be open.

27. Ankle Mortise Oblique Measure: A-P at malleoli Protection: lead apron
SID: 40” Table Top
No Tube Angle
Film: 1/2 of 12” x 10 extremity cassette I.D. up

28. Ankle Mortise Oblique
Patient is seated or lying on table. Leg is internally rotated until the medial and lateral malleoli are parallel to the film , about 15 to 20 °.
The foot is dorsiflexed until the plantar surface is perpendicular to film.
Horizontal CR: at level of talotibial joint or malleoli.

29. Ankle Mortise Oblique Half of film is centered to Horizontal CR.
Vertical CR: Long axis of lower leg.
Collimation top to bottom: distal lower leg to soft tissue below calcaneus. Slightly less than film size.

30. Ankle Mortise Oblique
Collimation side to side: soft tissue of lower leg and ankle.
Patient Instructions: Remain still
Make exposure and let patient relax.

31. Ankle Mortise & Oblique Film
Oblique on right., Mortise on left
The lateral malleolus should be clear of the talus.
The medial mortise joint must be open
The talotibial joint should also be open.

32. Lateral Ankle

33. Ankle Lateral Measure: Lateral at malleoli Protection: Lead Apron
SID: 40” Table Top
No Tube Angle
Film: 8” x 10” I.D. up

34. Ankle Lateral
Patient lies on the affected side with lower leg aligned with table center line.
Foot dorsa-flexed to form a 90° angle with lower leg.
Plantar surface of foot is perpendicular to film and malleoli are perpendicular to film.

35. Ankle Lateral Horizontal CR: medial malleolus
Vertical CR: medial malleolus and long axis of lower leg.
Collimation top to bottom: distal tibia to soft tissue below calcaneus

36. Ankle Lateral
Collimation side to side: to include soft tissue around calcaneus and lower leg.
Instructions: Remain still
Make exposure and let patient relax.

37. Ankle Lateral Film Must include distal tibia, talus and calcaneus.
The talus domes must be superimposed.
The fibula should overlie the distal tibia.
The talotibial joint should be open.
Note wrong I.D. location

38. Calcaneus Axial View Measure: Lateral at calcaneus
Protection: Lead Apron
SID: 40” Table Top
Tube Angle: 40° cephalad
Film: 1/2 of 8”x10” Extremity Cassette

39. Calcaneus Axial View
Patient lies or sits on table with affected leg centered to table.
Lower leg in true A-P position and foot dorsiflexed until the plantar surface is perpendicular to film.
A strap or tape may be used for the patient to hold foot in dorsiflexion.

40. Calcaneus Axial View
Horizontal CR: 1.5 to 2” up the calcaneus tuberosity
Film centered to Horizontal CR.
Vertical CR: long axis of foot.
Collimation top to bottom: to include all of calcaneus and adjacent soft tissues

41. Calcaneus Axial View
Collimation Side to Side: soft tissue of foot or slightly less than 1/2 of film.
Instructions: Remain still
Make exposure and let patient relax.

42. Calcaneus Axial View Film
The calcaneus tuberosity will be seen free of distortion.
The Calcaneal-Talus joint space should be seen.
If the foot is not properly dorsiflexed, the joint space will be closed and the tuberosity foreshortened.

43. Calcaneus Lateral View
Measure: Lateral at calcaneus
Protection: Lead Apron
SID: 40” Table Top
No Tube Angle
Film: 1/2 of 8”x10” Extremity Cassette

44. Calcaneus Lateral View
Patient lies on table on affected side with affected leg centered to table.
Lower leg in true lateral position and foot dorsiflexed.
Horizontal CR: 1.5 to 2” up the calcaneus tuberosity
Film centered to Horizontal CR.

45. Calcaneus Lateral View
Vertical CR: through medial malleoli
Collimation top to bottom: to include all of calcaneus and adjacent soft tissues
Collimation Side to Side: soft tissue of foot or slightly less than 1/2 of film.

46. Calcaneus Lateral View
Instructions: Remain still
Make exposure and let patient relax.

47. Calcaneus Lateral Film
The calcaneus, talus and ankle should be demonstrated in a true lateral position.
The domes of the talus will be superimposed.
Soft tissues adjacent to the calcaneus and ankle should be visualized.

48. Foot Radiography
Fractures are characterized by involvement of the subtalar joint (75%) and not involving the subtalar joint.
Stress fractures are common in runners but typically not seen on radiographs.
Stress fractures , plantar fascitis or heel spurs are common repetitive use conditions.

49. Foot or Heel Radiography
Views of the foot and calcaneus are totally different.
If a heel injury is suspected, take heel views and not foot views.
A 30 degree medial oblique view can be useful. The oblique and lateral will demonstrate the subtalar joint.

50. Foot Radiography
Foot view must include the tarsal bones, metatarsals and phalanges.
A tube angle is used to open the tarsal bone articulations on the A-P view.
If the patient is flat footed, no tube angle would be needed.

51. Foot Radiography
The medial oblique view is particularly useful. It provides:
A clear view of the tarsal bone including the calcaneus.
The 4th & 5th metatarsals
Intertarsal joints
Detail of the 5th metatarsal

52. Foot Radiography
The “basketball foot” is a traumatic medial subtalar dislocation resulting from landing on an inverted foot.
The “Jones fracture is an avulsion fracture off the base of the 5th metatarsal.
Stress fractures of the metatarsals are generally transverse resulting from marching or jumping.

53. Toe Radiography Toe radiography can be particularly challenging.
The natural curve of the toes toward the plantar surface of the foot results in foreshortening and closure of the interphalangeal joint spaces.
Besides the A-P, an angled axial view is used to open the joint spaces.

54. Foot A-P Measure: A-P at base of third metatarsal Protection: Apron
SID: 40” Table Top
Tube Angle: 10° cephalad
Film: 1/2 of 10” x 12 Extremity Cassette I.D. up

55. Foot A-P
Patient seated or lying on table with the long axis of the affected foot centered to table.
Place cassette on table.
Have patient place foot flat on cassette.
Horizontal CR: base of third metatarsal

56. Foot A-P Vertical CR: long axis of foot.
Collimation Top to Bottom: distal tibia to tips of toes.
Collimation Side to Side: soft tissue of foot
Instructions: Remain still
Make exposure and let patient relax

57. Foot A-P Film
Should demonstrate toes , metatarsals and most of the tarsal bones. The talus and calcaneus will not be seen.
The tube angle will help open the tarsal joint spaces.

58. Foot Oblique Measure: A-P at base of third metatarsal
Protection: Apron
SID: 40” Table Top
No Tube Angle
Film: 1/2 of 10” x 12 Extremity Cassette I.D. up

59. Foot Oblique
Patient seated or lying on table with the long axis of the affected foot centered to table.
Place cassette on table.
Have patient place foot flat on cassette.
The foot is medially rotated 30 to 40°
A sponge may be used under the plantar surface of the foot.

60. Foot Oblique Horizontal CR: base of third metatarsal
Vertical CR: long axis of foot.
Collimation Top to Bottom: distal tibia to tips of toes.
Collimation Side to Side: soft tissue of foot
Instructions: Remain still
Make exposure and let patient relax

61. Foot Oblique Film
Should demonstrate toes , metatarsals and most of the tarsal bones. The talus and calcaneus will not be seen.
The calcaneus will be well visualized
Tarsal joint spaces should be open.

62. Foot Lateral Measure: Lateral at base of first metatarsal
Protection: Lead Apron
SID: 40” Table Top
No Tube Angle
Film: 8” x 10” or 10” x 12” Extremity depending on foot size.

63. Foot Lateral
Patient lies on the affected side with lower leg in lateral position.
The foot should be dorsiflexed until the plantar surface is perpendicular to ankle.
The plantar surface of foot is perpendicular to film.

64. Foot Lateral
The film may be turned diagonally or the foot placed diagonally on film to fit the entire foot on the film.
Horizontal CR: base of 1st metatarsal
Vertical CR: base of first metatarsal

65. Foot Lateral
Collimation Top to Bottom: to include ankle to plantar surface soft tissue
Collimation Side to Side: to include from heel to tips of toes.
Instructions: Remain still
Make exposure and let patient relax.

66. Foot Lateral Film The foot and ankle should be in a lateral position.
The metatarsals and toes will be superimposed.
The distal fibula should overlie the distal tibia.
The talotibial joint space should be open.

67. Toes A-P & Axial A-P
Measure: A-P at 3rd metatarsal phalangeal joint or affected toe
Protection: Lead Apron
SID: 40” Table Top
Tube Angle A-P: none
Tube Angle Axial A-P: 15° cephalad
Film: 1/4 of 10 x 12 Extremity

68. Toes A-P & Axial A-P A-P : patient places foot flat on film.
Horizontal & Vertical CR: 3rd M-P joint for all toes or M-P joint of the affected toe for individual toe series.
A-P Axial tube angle: same as above but with 15° cephalad angle.

69. Toes A-P & Axial A-P
A-P Axial with Sponge: a 15° sponge is placed under toes instead of angling the tube. Or
The Sponge is placed under the cassette
Horizontal & Vertical CR: 3rd M-P joint for all toes or M-P joint of affected toe.

70. Toes A-P & Axial A-P
Collimation top to bottom: to include all M-P joints to tips of toes or M-P joint to tip of affected toe.
Collimation Side to Side: soft tissue of foot or individual toe.
Instructions: Remain Still
Expose and let patient relax

71. Toes A-P & Axial A-P Film
A-P is upper right image.
A-P Axial is upper left image. The phalangeal joints will be open on the axial view.
Views must include all of the affected toe or toes.
Note that collimation was too tight top to bottom.

72. Toes Medial Oblique Measure: A-P at metatarsal-phalangeal joints
Protection: Apron
SID: 40” Table Top
No tube angle
Film: 1/4 of 10” x 12” or 8” x 10” Extremity Cassette

73. Toes Medial Oblique
Patient places distal foot on unexposed portion of cassette.
Patient medially rotates lower leg until the plantar surface forms a 30 to 45° angle.
Horizontal CR: 3rd MTP joint or the affected toe.

74. Toes Medial Oblique
Vertical CR: centered to long axis of foot or the affected toe
Collimation top to bottom: Distal metatarsal to tips of toes or affected toe
Collimation side to side: soft tissue of foot or affected toe.

75. Toes Medial Oblique Patient instructions: Remain Still
Make exposure and let patient relax.
Note that a sponge may be placed under plantar surface of foot to control angle of view . It will also make it more comfortable for the patient.

76. Toes Medial Oblique The joint spaces should be open.
The distal metatarsal and tips of the toes should be visualized.

77. Toes Lateral
Measure: Lateral across the metatarsal-phalangeal joints For individual toe use A-P measurement.
Protection: Apron
SID: 40” Table Top
No tube angle
Film: 1/4 of 10” x 12” or 8” x 10” Extremity Cassette

78. 1st Toe Lateral
Patient places distal foot on unexposed portion of cassette.
For 1st through 3rd toes
Patient medially rotates lower leg until the plantar surface forms a 90° angle.
For 4th and 5th toes
Patient laterally rotates foot until the plantar surface is perpendicular to film.

79. 2nd Toe Lateral
For individual toes, tape and tongue depressors are used to clear the other toes out of the view.
Without the use of tape and tongue depressors, there will be too much superimposition

80. 3rd Toe Lateral Horizontal CR: 3rd MTP joint or the affected toe.
Vertical CR: centered to long axis of foot or the affected toe
Collimation top to bottom: Distal metatarsal to tips of toes or affected toe
Collimation side to side: soft tissue of foot or affected toe.

81. 4th Toe Lateral Patient instructions: Remain Still
Make exposure and let patient relax.
Note that the lateral surface of the foot is next to the film.

82. 5th Toe Lateral
Note that the lateral surface of the foot is next to the film.
The toe need to remain parallel to the film.
The 5th toe is the most challenging lateral toe view.

83. Toes Lateral Film The joint spaces should be open.
The distal metatarsal and tips of the toes should be visualized.
The affected toe should be free of superimposition.

84. ASSIGNMENT
One student will be selected for assignment

85. Question
Mention routine radiographic positioning of the ankle joint

86. Suggested Readings
Clark’s radiographic positioning and techniques

87. Return to Lecture Index Return to Radiologic Technology Two Home Page
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