4. Marker & Patient ID
❖Correct side marker (R)
was placed in collimated
field, but on the
“posterior” side. Should
appear on “anterior” side
for Lateral
❖A “portable” marker
should also have been
placed in the primary
beam
❖ New marker position to
adhere to the rule
5. Marker & Patient ID
❖No additional markers are
needed if the Port marker
is placed in the primary
beam
❖There are no markers
superimposing over any
pertinent anatomy
❖The image is now marked
and displayed correctly
6. Radiation Hygiene
❖Acceptable amount of beam
restriction:
➢STATE RULE- Minimum of
three sides of beam
restriction
➢Secondary shielding
must be provided if
gonads are within 5 cm
of the primary beam
❖Black border is visible
on the three sides of the
image demonstrating
collimation
7. Radiation Hygiene
❖It is difficult to tell
if this side demonstrates
collimation
➢Modern imaging systems
have “masking” (black
border)and post
processing shuttering
❖The patient was shielded
in this procedure
❖Proper beam restriction
is needed to reduce the
amount of scatter that
could reach the patient’s
gonads
❖ Sides closest to patients
gonads does not demonstrate
good beam restriction b/c
collimation is not clearly
visualized
8. Completeness of position/ Projection
❖Required Positions-
➢AP Elbow
■ Hand in anatomical
position
➢AP oblique medial
rotation
■ 45 degrees from AP
➢AP oblique lateral
rotation
■ 45 degrees from AP
➢Lateral (lateromedial)
■ Flexed 90 degrees
■ Hand in lateral
position
❖CR perpendicular to elbow
❖ Special position, radial
head, 45 degree cephalad
entering radial head
9. Completeness of position/ Projection
❖ Image complies with routine
projections
❖Patient's hand was not
placed in a lateral
position
❖All anatomical parts are
visualized in the image
➢Knowing the Patient had
FX of distal humerus,
Technologist should
have included more of
the patient's humerus -
humerus should also be
ordered
10. Artifact identification
❖There are non-preventable
artifacts within the image
(in this scenario!)
➢Patient’s cast
extending from proximal
humerus extending down
to the fingertips
❖No body part
superimposition, hospital
gowns, or indwelling
artifacts present (other
than patient’s non-
removable cast)
❖hospital paraphernalia-
patients cast
11. Artifact identification
❖No patient belongings
and/or clothing are
present in the radiograph
❖No excessive image fog
present
➢Casting material
somewhat degrades image
quality
❖No CR/DR artifacts visible
12. Image sharpness
❖No evidence of “Gross”
motion
❖No evidence of quantum
mottle or image noise
❖No evidence of previous
(ghosted) exposure on
image
❖No evidence of grid lines,
grid artifact, or grid
cut-off (grid not
“routinely” used for
elbow)
❖Size distortion seems
normal, no magnification
❖Slight shape distortion,
CR >1cm off-centered
13. Accurate part position
❖The humerus is aligned to
the IR’s longitudinal axis
❖The part is not centered
to the IR
➢Collimated, but isn't
in center of IR
❖The humerus is not aligned
to center of the
collimated field
➢Collimator turned?
14. ❖The CR is adequately
aligned to the body
part, but not centered
to the lateral
epicondyle
❖Image should include
distal 1/4 of the
humerus and proximal
1/4 of radius & ulna
15. Accurate part position
❖The CR is not centered to
within 1 cm of the
anatomical part
❖The CR is not aligned to
the image media
❖The CR’s alignment does
not conform to the
accepted IR exposure
recognition field because
collimated edges are not
parallel to adjacent
edges of IR. This could
cause histogram analysis
& rescaling errors.
16. Accurate part position
❖Align the CR
longitudinally along the
long axis of the humerus
❖Align the CR horizontally
to the long axis of the
forearm
❖No need for tube
angulation
❖Flex elbow 90 degrees
17. Accurate positioning/Criteria
❖Position the part so the
humerus and forearm are
on same plane
❖Externally rotate the
patient's hand and wrist
so the inter-styloid
process line is
perpendicular to IR
❖Use of sponges and other
devices can help help
ensure correct
positioning and decrease
motion artifact
18. EVALUATION CRITERIA
❖There should be an open
elbow joint space
❖Should demonstrate the
anterior fat pad
❖The radial tuberosity
should be superimposed
over the radius
❖Radial head distal and
posterior to the coronoid
process
❖Capitulum anterior and
distal to the medial
trochlea
19. Accurate positioning
❖Based on the previous
information, the part was
not centered correctly
➢Hand was not in a true
lateral
➢CR is not centered to
within 1 cm of correct
centering point
➢But, this is an
acceptable lateral
elbow
20. Judicious exposure technique
❖The most radiolucent
structures in the image
are the surrounding
tissues and elbow joint
space
❖The most radiopaque
structure is the bony
cortex
21. Judicious exposure technique
Assessment of Image Contrast
(window width)
❖Extremities are normally
displayed with short
scale (b&w) contrast
❖The image appears
adequate
22. Judicious exposure technique
Assessment of the Image’s
brightness level (window level)
❖Image brightness is
adequate.
❖All pertinent bony anatomy
and soft tissues are easily
visualized
❖I would suspect the EI value
to be be within normal range
& that the exposure
technique was adjusted (+10
kVp) to accommodate for the
cast
23. accept/reject❖ This image meets acceptable
diagnostic standards
❖ Corrections!!
➢ CR alignment to both body part
and IR (angle of image)
➢ Add tech marker and portable
marker to anterior surface in
the primary beam
➢ Rotate the hand laterally (true
lateral)
■ Helps to open joint space
➢ Elbow flexed 90 degrees
➢ Use sponges to ensure forearm
is in true lat position
➢ Center for a lateral elbow at
the elbow joint ❖ Elbow flexed <90 degrees,
but can’t correct this due to
cast and fracture.
24. References
Fauber, T. L. (2013). Radiographic imaging and exposure
(4th ed.). St. Louis, MO: Elsevier.
Frank, E, Long, B, & Smith, B. Merrill’s atlas of
radiographic positioning and procedures. 12th ed. St. Louis,
MOMosby, 2012.
McQuillen-Martensen, K. (2015). Radiographic image analysis.
Vol 4. St. Louis, MO: Elsevier
My own image was used!
