The image is of an AP hip x-ray. It meets HIPAA compliance standards and shows the correct anatomy, but some improvements could be made. Specifically, the CR is not centered on the femoral neck. Additionally, gonadal shielding should have been used since the gonads were within 5cm of the primary beam. Minor internal rotation of the lower limb could also have reduced visibility of the lesser trochanter. Overall the image is acceptable but positioning and shielding could be improved upon if the image needed to be repeated.

1. Image Eval. Final
Presentation
BOB SUTLIFF

2. AP Hip

3. HIPAA Compliance
The image is HIPAA compliant and
does not violate patient
confidentiality

4. Marker & Patient ID
A L side marker appears on the image
No additional markers were needed for this
examination
Although the marker was placed on the
patient and not the IR, it does not appear
to be superimposing any pertinent
anatomy
The image is displayed correctly based on
marker placement

5. Radiation Hygiene
At least three sides of collimation should
appear in order to meet the standard rule
for beam restriction;
◦ In this case, four sides appear to be present
No evidence of gonadal shielding is present
in this image. Gonadal shielding must be
used if the gonads are within 5cm of the
primary beam.
◦ In this case, gonadal shielding should have
been employed.

6. Completeness of
Position/Projection
The Positions/Projections required
for a “routine procedure” for this
body part:
◦ AP Projection
◦ “Frogleg” Mediolateral
◦ (Lauenstein & Hickey methods)
Does this image comply with routine
positions/procedures?
◦ Yes
Yes, all anatomical parts are
visualized in the image.
◦ (see slide 15)
AP
“Frogleg” Lateral

7. Artifact Identification
Are preventable physical artifacts visible in this
image?
◦ No preventable artifacts appear to be present in the
image
There is no unnecessary body part
superimposition.
No hospital paraphernalia artifacts appear to be
present
Are there foreign body/indwelling artifacts
present?
◦ High brightness specks, possible calcifications,
appear in the soft tissue located medially to the L
proximal femur.

8. Artifact Identification
Is excess fog visible &/or degrading overall image
quality?
◦ Excessive fog does not appear to be present in this
image.
Are any CR/DR artifacts visible in the image?
◦ No CR/DR artifacts are present in the image

9. Image Sharpness
Is “gross” voluntary motion visible in the image?
◦ Gross voluntary motion does not appear to be present
in this image
Is excessive quantum mottle (or image noise) visible
in the image?
◦ Excessive quantum mottle does not appear to be
present in the image

10. Image Sharpness
Is evidence of double (or previous/ghosted)
exposure present?
◦ There appears to be no evidence of a double exposure
present
Are grid lines, grid artifact &/or grid cut-off
visible in the image?
◦ The possibility for grid artifacts exist, but they do not
appear visible in this image. A high frequency or
recirprocating grid must have been used.

11. Image Sharpness
Does size distortion appear greater than
expected?
◦ Due to the typical OID when using the table bucky,
minimal size distortion is expected. In this case, it does
not appear to be greater than expected.
Is shape distortion being caused by
poor CR/IR/part alignment?
◦ Shape distortion is being caused due to poor part/CR
alignment
Is the CR centered to within 1 cm of anatomical
part?
◦ No. The CR is off-centered transversely and slightly
longitudinally to the femoral neck.

12. Accurate Part Positioning
Is the part adequately aligned to the
image media?
◦ The part appears to be adequately aligned to the
image media
Is the part accurately centered to the
image media?
◦ Assuming the CR is accurately centered, the part
does not appear to be accurately centered to the
IR

13. Image Sharpness
Is the CR adequately aligned with the image
media?
◦ Yes the CR appears to be adequately
aligned with the IR.
Does the CR’s alignment conform to an
accepted IR exposure field recognition
template/field?
◦ Yes

14. Positioning Criteria
Patient lies supine with ASISs level and equidistant from
tabletop.
MSP is centered to midline of table bucky.
Extend lower limbs.
Medially rotate affected lower limb 15 to 20 degrees, if this is
not contraindicated.
CR is directed perpendicular to middle of IR and enters
patient about 2 inches (6.4 cm) distal on a line drawn
perpendicular to the midpoint of a line between the ASIS and
the pubic symphysis
Collimate as close to anatomy of interest as possible and no
larger than 10 x 12 inches (24 x 30 cm).
Provide gonadal shielding as long as the exam objective is not
compromised.
Instruct patient to hold position and suspend respiration for
the exposure.

15. Evaluation Criteria
Femoral head penetrated and seen through the
acetabulum
Regions of the ilium and pubic bones adjoining the
pubic symphysis
Any orthopedic appliance in its entirety
Hip joint
Greater trochanter in profile
Entire long axis of the femoral neck not
foreshortened
Proximal third of the femur
Lesser trochanter is usually not projected beyond
the medial border of the femur, or only a very small
amount of the trochanter is seen. (Sample)

16. Evaluation Criteria
Femoral head penetrated and seen through
the acetabulum
Regions of the ilium and pubic bones
adjoining the pubic symphysis
Any orthopedic appliance in its entirety
Hip joint
Greater trochanter in profile
Entire long axis of the femoral neck not
foreshortened
Proximal third of the femur
Lesser trochanter is usually not projected
beyond the medial border of the femur, or
only a very small amount of the trochanter
is seen. (Sample)

17. Judicious Exposure
Technique
What is the most radiolucent structure? Is it
visible in the image?
◦ The soft tissue along the medial and lateral
aspect of the patient’s body. Yes it is visible.
What is the most radiopaque structure? Is it
visible in the image?
◦ The bony cortex of the head of the femur visible
in the acetabulum. Yes it is visible

18. Judicious Exposure
Technique
What is your assessment of the image’s contrast
(window width)?
◦ The image displays with adequate contrast
(window width)
What is your assessment of the image’s
brightness (window level) &/or exposure
indicator (EI) value?
◦ The image displays adequate brightness (window
level) and would likely exhibit an EI value within
the acceptable limit range.

19. Accept/Reject
Does this image meet (or exceed) minimum
established standards for acceptance criteria?
Accept / Reject
◦ I would accept this image as it does not meet the
minimum established standards for acceptance
criteria.

20. Accept/Reject
Summarize any/all required corrections for this
radiographic image, should a repeat image need
to be performed.
For future reference:
◦ Although the evaluation criteria states that a small
portion of the lesser trochanter may sometimes be
visible, I think the lower limb could have been
slightly more rotated internally due to the amount
of lesser trochanter visible.
◦ I would place the side marker on the image
receptor instead of the patient’s body.
◦ With extra caution not to superimpose/obscure
pertinent anatomy, I would be should to employ
gonadal shielding.

21. References
Merrill’s Atlas of Radiographic Positioning and Procedures
Class Notes
AuntMinnie