This document analyzes an x-ray image of a patient's AC joints without weights. It assesses the image for HIPAA compliance, correct anatomical markers and positioning, radiation safety standards, and image quality criteria. Overall, the image shows slight rotation of the shoulders and risk of clipping the left AC joint. The technique could be adjusted to provide more bone detail and the wire should be moved out of the exposure field. The author would reject this image and request positioning and technique corrections.

1. AC Joints
Kristen Andresen// Rads 216-C // April 28, 2016

2. AC Joints w/o Weights (Neutral Position)
Image Source:
http://velonews.competito
r.com/2010/11/training-
center/shoulder-
separations-
explained_150447

3. HIPAA COMPLIANCE
● This image is HIPAA compliant. The
patient and imaging facility’s information
is absent from the image. No identifiable
information is present.

4. Is a correct anatomical side marker visible in the
image?
● Yes, Both sides have been marked with the
correct side markers and “Neutral” was post-
processed in, but explains the patient’s position
(w/o weights).
Is the side marker placed correctly in the image?
● Yes. The side markers are placed correctly on the
image.
Are any markers superimposed on pertinent anatomy?
● No anatomy is being superimposed by any of the
markers.
Marker & Patient ID

5. Are additional markers needed? Were they used?
● Arrow markers could have been used to mark the
site of the patient’s pain/ trauma, and a
“Neutral”(Without weights) marker could have
been used prior to exposure.
Is the image displayed correctly, based on marker
placement?
● These are done AP, and both sides of the patient
were marked correctly.
Marker & Patient ID

6. Radiation Hygiene
Assess the accuracy/presence of acceptable beam
restriction on the image. (state rule)
● The state rule says that three sides of collimation
should be visualized on the image.There is
visualization of beam restriction on all sides. No
required anatomy has been clipped due to
collimation.
Does “evidence” exist to indicate appropriate use of
shielding? (state rule)
● There appears to be at least three sides of
collimation and there is collimation seen on the
side closest to the gonads. Collimation is the
best form of shielding, so the patient’s gonads
were “shielded” from the primary beam.

7. List the positions/projections required as part
of the “routine procedure” for this body part.
● AP Bilateral WITH weights
● AP Bilateral WITHOUT weights
Special/ Alternate Positions/Projection:
● AP Axial (Alexander Method)- 15° cephalad
● Supine Position: Patient is recumbent on table
with long strips of gauze on PT’s extremities to
pull shoulders down. This should only be done is
necessary and by experienced personnel to
prevent further injury.
Completeness of Position/Projection

8. Completeness of Position/Projection
Does the image comply with routine
position(s)/projection(s)?
● Yes, this image is the bilateral AP projection
which is part of the required routine imaging.
Are all anatomical parts correctly visualized in the
image?
● Part of the left shoulder is clipped, but all the
necessary anatomy required on this image is
visualized.

9. Are preventable physical artifacts visible in the image?
● There is a wire included on the image out of the
anatomy of interest. This could have been moved
further out of the way. No other physical artifacts
are present.
Are body parts superimposed that should not be?
● There is no major body superimposition that
shouldn’t be present, but the clavicles should be
straighter, in an even plane, and there should be no
rotation of the clavicles like in this image.
Is hospital paraphernalia present &/or visible in the
image?
● There is a wire present on the image towards the left
side. This is pointed out with the green arrow above.
Artifact Identification

10. Artifact Identification Are patient clothing/belongings visible in the
image?
● No articles of clothing are visible in the
image.
Are any indwelling artifacts/foreign bodies
visible in the image?
● No indwelling/ foreign objects are
visualized.

11. Is excess fog visible &/or degrading overall image
quality?
● No gridlines or excessive fogging is visible.
Are any CR/DR artifacts visible in the image
● No CR/DR artifacts are present in the image.
Assessment of Image Integrity

12. Image Sharpness Is “gross” voluntary motion visible in the image?
● No, the image appears clear with minimal
patient motion.
Is excessive quantum mottle (or image noise)
visible in the image?
● There is some quantum mottle specifically in
the soft tissue/ neck area, but not in excess.
Is evidence of double (or previous/ghosted)
exposure present?
● There is no evidence of double exposure
present.

13. ● No grid lines, grid artifact or grid cut-off is visible in the
image.
● Size distortion appears minimal in this image.
● The CR/IR appear to be properly aligned. No noticeable
shape distortion is caused.
Image Sharpness

14. Is the part adequately aligned to the image media?
● Yes. It’s not perfectly aligned, but it’s not off-center enough
to cause any major changes in the image.
Is the part accurately centered to the image media?
● It is slightly off-center, but not enough to cause any major
differences in the image.
Is the CR centered to within 1 cm of anatomical part?
● The CR is centered within 1 cm of the anatomical part.
Radiography of the Anatomical Part

15. ● Assuming the black border around the
image is the area of the IR, then the CR
appears to be properly aligned.
● The CR’s alignment conforms to an
acceptable IR exposure recognition field.
There is also good use of collimation.
Radiography of the Anatomical Part

16. Radiography of the Anatomical Part
Positioning Criteria: (Martensen, p. 268)
● Center the AC Joint to the upright IR in an AP
Projection
● Position the shoulder’s at equal distances from the
IR.
● Place shoulders on the same transverse plane
● Position the MCP vertically, aligning it parallel with
the IR
● Center a perpendicular CR to the AC joint of interest
● Center the IR to the CR
● Open the longitudinally and transversely collimated
field to include one half of the clavicle and the
coracoid process

17. Correct Patient Positioning

18. Evaluation Criteria: (Martensen, p.268)
● Lateral clavicle is horizontal
● About 0.125” (0.3 cm) of space is present
between the lateral clavicle and the acromial
apex
● Lateral clavicle demonstrates minimal acromion
process superimposition
● Clavicle & the superior scapula angle are
demonstrated at the same transverse level.
● AC Joint is at the center of the exposure field for
both the non-weight bearing and the weight
bearing exposures.
● Lateral clavicle, acromion process & superior
scapular angle are included within the exposure
field.
Radiography of the Anatomical Part

19. Radiography of the Anatomical Part
Is the anatomical part correctly positioned,
based on this criteria?
● The clavicles aren’t on the same
horizontal plane and the left shoulder is
higher than the right. The clavicles are
also rotated.
● The left AC joint is very close to the
collimated edges.
● Based on this criteria, the anatomical
parts aren’t positioned correctly.

20. ● The most radiolucent structure is the air
surrounding the patient and air in the PT’s
lungs. This area appears the most “black”.
● The Bony cortex and anatomy is definitely
the most radiopaque part of this image.This
area appears the most “white”.
Judicious Exposure Technique

21. Judicious Exposure Technique
What is your assessment of the image’s contrast
(window width)?
● The contrast for the upper extremities should be
relatively short-scale, with more black and white
as opposed to more greys. This image appears to
be on the longer side of short-scale contrast
which allows for better visualization of bony
anatomy.
What is your assessment of the image’s brightness
(window level) &/or exposure indicator (EI) value?
● There appears to be adequate brightness on the
image but I feel like the EI value would be on the
lower scale of an acceptable EI value.

22. Does this image meet (or exceed) minimum
established standards for acceptance criteria?
I would Reject this image. There is rotation of the
shoulders and the left AC joint was almost clipped.
The technique could also be adjusted to provide
more detail of the bony anatomy.
Accept/Reject Image(s)

23. ● I would make sure the clavicles are on the
same horizontal plane
● Make sure there’s no rotation of the patient
● Have both shoulders at equal lengths of each
other
● Have a “without weights” marker on the
image before exposure.
● Move the wire out of the exposure field
● Collimate more vertically
● Ensure both AC joints are fully in the
exposure field
Corrections

24. Bontrager, K. (2014). Textbook of Radiographic Positioning and Related Anatomy. (8th edition). St. Louis,
MO: Elsevier
Frank, E. (2012). Merrill’s Atlas of Radiographic Positioning and Procedures. (12th Edition). St.Louis, MO:
Elsevier
McQuillen-Martensen, K. (2015). Radiographic Image Analysis. (4th edition). St.Louis, MO: Elsevier
Sources List