Slide presentation on position/projection of the AP Oblique Ankle Mortise View

1. RADS 216 – Image Evaluation:
Radiographs
Final Oral Presentation
AP 15°- 20° Oblique Ankle
Projection (Mortise View)
Presented by: Joy Walker

2. HIPAA COMPLIANCE
 This image is HIPAA
compliant.
 All information pertaining to
the patient and the imaging
facility has been removed.
 This image does not violate
patient confidentiality.

3. MARKER AND PATIENT ID
Is a correct anatomical side marker visible in the
image?
Yes, the correct left side marker is visible in this
image.
Is the side marker placed correctly in the image?
Yes, the left side marker is placed correctly on this
image.
Are there any markers superimposed on pertinent
anatomy?
There are no markers superimposed on pertinent
anatomy.

4. MARKER AND PATIENT ID
Are additional markers needed? Were they used?
Yes, the additional standing marker was needed
and it was used in this image.
Is the image displayed correctly based on marker
placement?
Yes, this image is displayed correctly based on
marker placement.

5. RADIATION HYGIENE
Three sides of beam restriction
must be visible on an image and
gonadal shielding must be
provided if gonads are within 5 cm
of the primary beam
This image does not appear to
have adequate collimation because
beam restriction is not visible on
this image. The primary beam is >
5 cm from the ankle but gonadal
shielding is recommended.

6. RADIATION HYGIENE
Does “evidence” exist to indicate
appropriate use of shielding?
No, there is no evidence of
appropriate use of shielding because
beam restriction was not used. We
do not know if gonadal shielding
was used.

7. COMPLETENESS OF POSITION/PROJECTION
Routine Procedures for an Ankle include:
AP Ankle
AP Oblique Ankle
(15-20 degree medial rotation)
Lateral Ankle
(Mediolateral)

8. COMPLETENESS OF
POSITIONING/PROJECTION
CROSS TABLE LDoes the image comply with routine
positions/projections?
This image is a AP oblique
projection of the ankle which does
comply with routine procedures.
Are all anatomical parts visualized in
this image? Yes, all anatomical parts
are visualized.

9. ARTIFACT IDENTIFICATION
Are preventable physical artifacts
visible in the image?
No,there are no preventable
physical artifacts visible in the
image.
Are body parts superimposed
that should not be?
No body parts are
superimposed that should not
be.

10. ARTIFACT IDENTIFICATION
Is hospital paraphernalia present
and/or visible in the image?
No, hospital paraphernalia is not
present in this image.
Are patient clothing/belongings
visible in the image?
No, there is no evidence of
patient clothing or belongings in
this image.

11. ARTIFACT IDENTIFICATION
Are any indwelling artifacts/foreign
bodies visible in the image?
Yes, the indwelling artifact is a
fracture found on the distal fibula.

12. ASSESSMENT OF IMAGE INTEGRITY
ARTIFACT IDENTIFICATION
Is excess fog visible and/or
degrading the overall image
quality?
No, excess fog is not visible and
does not degrade overall image
quality.
Are any CR/DR artifacts visible in
the image?
No, there are not CR/DR
artifacts visible in this image.

13. IMAGE SHARPNESS
Is gross voluntary motion visible in
the image?
No, gross voluntary motion is
not visible in this image.
Is excessive quantum mottle or
image noise visible in the image?
There is no quantum mottle or
image noise visible in this image.

14. IMAGE SHARPNESS
Is evidence of double (or
previous/ghosted) exposure
present?
No, there is no evidence of a
double or ghosted exposure in this
image.
Are grid lines, grid artifact and/or
grid cutoff visible in the image?
There are no grid lines, grid
cutoff visible in this image. Grids
are not used for this projection.

15. IMAGE SHARPNESS
Does size distortion appear greater
than expected?
No, size distortion does not
appear greater than expected.
Is shape distortion being caused by
poor CR/IR part alignment?
Minimal shape distortion is
evident in this image due to the
obliquity of the ankle.

16. ACCURATE PART
POSITIONING
Is the part adequately aligned to
the image media?
Yes, the part is adequately
aligned to the image media.
Is the part accurately centered to
the image media?
Yes, the part is accurately
centered to the image media.

17. ACCURATE PART
POSITIONING
Is the CR centered within 1 cm of
the anatomical part?
No, the CR is centered more
than 1 cm of the ankle.
Is the CR adequately aligned with
the image media?
Yes, the CR is adequately
aligned with the image media.

18. ACCURATE PART
POSITIONING
Does the CR’s alignment conform
to an accepted IR exposure field
recognition template/field?
No, the CR’s alignment does
not conform to an accepted IR
exposure field recognition
template because collimation was
not used.

19. ACCURATE PART POSITIONING
AP (15-20 degree) Oblique Ankle Medial Rotation Projection
Center the patient’s ankle joint to the IR.
Grasp the distal femur area with one hand and the foot with the other. Assist the patient
by internally rotating the entire leg and foot together 15 to 20 degrees until the
intermalleolar plane is parallel with the IR.
The plantar surface of the foot should be placed at a right angle to the leg.
Central Ray is perpendicular entering the ankle joint midway between the malleoli.
Collimate 1inch on all sides of the ankle and 8 inches lengthwise to include the heel.

20. EVALUATION CRITERIA
The following should be clearly shown:
Evidence of proper collimation
Entire ankle mortise joint
No overlap of the anterior tubercle of
the tibia and superlateral portion of
the talus with the fibula.
Talofibular joint space in profile
Talus shown with proper density

21. EVALUATION CRITERIA
Based on the evaluation criteria there
is evidence of collimation. Entire
ankle mortise is visible. Talofibular
joint space is in profile. I believe it
does meet most of the evaluation
criteria.

22. JUDICIOUS EXPOSURE
TECHNIQUE
• Radiolucent structures are those
that are penetrated by x-rays. The
structure most radiolucent in this
image is the joint space of the
ankle.
• Radiopaque structures are those
structures that are not penetrable
by x-rays. The most radiopaque
structures are the tarsal bones.

23. JUDICIOUS EXPOSURE TECHNIQUE
• What is your assessment of the
image’s contrast (window width)?
I think the image has adequate
contrast because there are varying
shades of gray.
What is your assessment of the
image’s brightness (window level)
and/or exposure indicator (EI) value?
I believe there is adequate
brightness and the EI value would be
within the normal range.

24. ACCEPT/REJECT IMAGE
Accept! I would accept this image because
I would not want to expose the patient to
any more radiation than necessary.
Although, the collimation is not as
adequate as it could be I do not believe it
is probable reasoning to repeat. There is a
fracture and it is visible on the image so I
would not want to expose the patient
again.

25. SUMMARY
Corrections that I would make if repeated:
Closer collimation only including the anatomy of
interest.
Make sure gonadal shielding is used.
Be sure that the ankle is properly oblique.
Properly center the CR to the ankle joint.

26. REFERENCES
Frank, Eugene D., Eugene D. Frank, and Vinita Merrill.
"Chapter 6 Lower Limb." Merrill's Atlas of
Radiographic Positioning & Procedures. 12th ed.
Vol. 1. St. Louis, MO: Mosby Elsevier, 2011. 151-63.
Print.
McQuillen-Martensen, Kathy. "Chapter 6 Lower
Extremity." Radiographic Image Analysis. 4th ed.
St. Louis, MO: Saunders/Elsevier, 2011. 208-25.
Print.