2. +
IS THIS IMAGE HIPAA COMPLIANT?
Yes, this image is HIPAA
compliant as it does not display
any information that violates
HIPAA compliancy.
3. +
MARKER & PATIENT ID
The correct anatomical side marker is
placed on the lateral side making it
appear on the viewer’s left in relation
to the part
The marker was placed beside the
anatomical part prior to the exposure
The anatomical marker correctly marks
the side being imaged
The marker is not superimposing any
pertinent anatomy
There are no additional markers
needed/ used for this image
Could use “weight bearing” markers if
knee was ordered weight bearing
Based on the marker placement the
image is correctly displayed
4. +
RADIATION HYGIENE
Proper beam restriction requires the
presence of at least three sides of
collimation on the image
There are at least three sides of beam
restriction present
Black boarder
There is evidence to prove primary
shielding was used because there is
collimation on the side closest to the
gonads
I shielded the patient
Gonadal shielding must be provided if
gonads are within 5 cm of the
primary beam
5. +
ROUTINE RADIOGRAPHIC
PROJECTION PERFORMED:
AP
45 degree Oblique
Medial rotation
Lateral rotation
Lateral
mediolateral
Other Projections May Include:
• Cross Table Lateral “Shoot Thru”
• Tangential “Sunrise” Method
• Knees AP Weight – Bearing
• Knees PA Weight – Bearing, Rosenberg
• Intercondylar Fossa
• PA Axial Holmblad
• PA Axial Camp-Coventry
• AP Axial Beciere
** Projections differ based on
institutional / departmental protocls
6. +
This image complies with routine
position(s) / projections
ALL anatomical parts correctly
visualized
7. +
ARTIFACT IDENTIFICATION
There appears to be an artifact
on the medial side of the knee
along with a striped-pattern over
the distal femur
No body parts superimposed that
should not be
There appears to be hospital
paraphernalia ( crinkled bed
sheet)
There appears to be no
indwelling artifacts/ foreign
bodies visible
8. +
ARTIFACT IDENTIFICATION / IMAGE
SHARPNESS
There does not appear to be excess
fog that could degrade overall image
contrast/ visibility of recorded detail &
there are no visible CR/DR artifacts
The image contrast is quite grey making
it long scale contrast
There appears to be “gross” voluntary
motion due to the bony trabeculae
being well visualized throughout the
image
There is no excessive quantum mottle
visible
There is no evidence of double
exposure
There are no grid lines, grid artifact &/
or grid cut off due to the likelihood of
the use of a high frequency or
reciprocating grid
9. +
** Grids should be used w/ body
parts that measure more the 10cm
Avg knee measures 9-13 cm, where non-grid or gird technique
can be employed
Dependent upon patient knee size, radiographer/ physician
preference, department protocol
Bontrager:
Non-grid for smaller patients, with knees measuring 10cm or less
Grid for larger patients, with knees measuring 10cm or more
10. +
IMAGE SHARPNESS
Size distortion does not appear greater
than expected
The CR should enter 1cm (1/2 inch)
below the patellar apex
Off-centering is ≤1 cm –
shape distortion is
minimal
Correct centering, alignment, CR
location = important to avoid shape /
size distortion
Narrow joint spaces clearly demonstrated
CR angle improves visualization of joint
spaces
11. +
Visualization of Joint Space
To ensure CR is parallel to tibial plateau, & to visualize an open
joint space, measure distance between ASIS to table top to
determine CR angle …
Angle is varied depending on the measurement
<19 cm 3-5 degrees CAUDAD
Thin patient
19-24 cm 0 degrees
Average patient
> 25 cm 3-5 degrees CEPHALAD
Thicker patient
12. +
ACCUARATE PART POSITIONING
The part is adequately aligned to the
longitudinal axis of the imaging media
The part is not centered to the image
media
The CR is not centered within 1 cm of
the anatomical part
The CR is not adequately aligned with
the image media due to the irregular
amounts of beam restriction used
The CR’s alignment does conform to
an accepted IR exposure field
recognition template / field
13. +
POSITIONING
IR Size: 10 x 12 inch, lengthwise
40 in SID
Place patient in the supine
position, and adjust the body so
that the pelvis is not rotated
14. +
Positioning
With the IR under the patients knee, flex the joint slightly, locate
the apex of the patella and as the patient extends the knee,
center the IR about ½ inch below the patellar apex. This
centers the IR to the joint space
Adjust the patients leg by placing the femoral epicondyles
parallel with the IR for a true AP projection. The patella lies
slightly off center to the medial side
If the knee cannot be fully extended, a curved IR may be used
SHIELD GONADS
Collimate to 10 X 12 inch
15. +
EVALUATION CRITERIA
Knee fully extended if patient’s
condition permits
Entire knee without rotation
Femoral condyles symmetric and
tibia intercondylar eminence
centered
Slight superimposition of the
fibular head if the tibia is normal
Patella completely superimposed
on the femur
Open femorotibial joint space,
with interspaces of equal width
on both sides if the knee is
normal
Soft tissue and bony trabecular
detail
Evidence of proper collimation
16. + IMAGE EVALUATION
Knee fully extended ✔
Entire knee without rotation ✔
Femoral condyles symmetrical ✔
Tibia intercondylar eminence centered ✔
Slight superimposition of the fibular head ✔
Open femorotibial joint space, with
interspace of equal width on both sides ✔
Soft tissue & bony trabecular detail ✔
Evidence of collimation ✔
IS THE ANATOMICAL PART CORRECTLY POSITIONED?
YES
17. +
EXPOSURE TECHNIQUE
The most radiolucent structure is the soft
tissue margins and the joint space
The most radiopaque structure is the bony
cortex
The images contrast is more on the grey
side therefore it has long scale contrast
Since there is no EI value present it is
difficult to determine if the image is
adequately exposed
Since I took the image and it was
accepted by the techs, it is in normal
range of the hospital EI values, and is
adequately exposed !! But it should be
short scale contrast (black & white) and
the image looks more long scale (grey)
18. +
ACCEPT OR REJECT?
This image meets the standards
for acceptance criteria but the
striped pattern artifact over the
distal femur is concerning!
It is of diagnostic quality
I would / did accept this image
No repeat necessary, however I
would change ..
19. +
I would change the centering of the
position to the image media. I
centered the CR to the base rather
than the apex seen on the image.
And make sure there are no
crinkled sheets that could be seen
in the x-ray.
I would also identify what the
striped-pattern artifact over the
distal femur was caused by and try
and remove it!
20. +
REFRENCES
Frank, E. D., Long, B. W., Smith, B. J., & Merrill, V. (2012).
Merrill's atlas of radiographic positioning & procedures. St.
Louis, MO: Elsevier/Mosby.
McQuillen-Martensen, K. (2015). Radiographic image
analysis. St. Louis, MO: Elsevier Saunders.
Picture: BY ME @ Nazareth Hospital
