Final Evaluation

1. AP Projection of the Lower
Leg
Deanna Torres

3. Technical Preparation

4. HIPAA Compliance
• All information that could
connect this image to the
patient, technologist, or facility
is removed
• This image is HIPAA
Compliant

5. Marker & Patient ID
• The left side marker is visible in the
image
• The side marker is placed correctly on
the patient’s lateral side
• The marker does not superimpose any
pertinent anatomy
• No additional markers were needed to
include on this image
• The technologist could have included
an arrow pointing to pain, wound, or
any area that the Radiologist might
want to focus on
• The image is displayed correctly based
on the marker, it is a left lower leg and
that is what the marker indicates

6. Radiation Hygiene
• Primary beam restriction is collimation
• Secondary beam restriction is gonadal
shielding
• There is 3 sides of beam restriction
present on the image
• Gonadal shielding is required if the
gonads are within 5cm of the primary
beam
• For this image the gonads are not
within 5cm of the primary beam
• There is however collimation closet
to the patient’s gonads, so this is
acceptable for gonadal shielding

7. Completeness of
Position/Projection
• Routine Procedure for this
body part would consist of:
• AP
• Lateral (90 degrees from AP
projection)
• This image does comply with
the routine projection of this
body part
• All pertinent anatomy is visible
on this image

8. Artifact Indentification
• None of the anatomy in this image
superimpose each other that should not
• Artifacts that do not show on this image
• Patient clothing/belongings
• Indwelling artifacts/ foreign bodies
• Preventable physical artifacts
• Artifacts shown in this image
• Hospital Paraphernalia
• Rod and screw placed through the
patient’s tibia from previous fracture

9. Assessment of Image
Integrity

10. Artifact Identification
• There is no an excessive
amount of fog visible in the
image, however, when looking
at the image closely it is not as
sharp as you would except a
lower leg to appear
• There are no CR/DR artifacts
visible in the image

11. Image Sharpness
• Things that could affect image sharpness, but do
not appear on this image:
• Gross voluntary motion
• This can be determined by looking closely at
the bony trabeculae, cortex of the bone
• Its likelihood to occur can be reduce by good
communication with the patient
• Excessive quantum mottle
• Automatic rescaling could have occur and took
the present of it off the image, but we would
know if quantum mottle would appear because
we do not have the EI value that would inform
us if the image was underexposed
• Double exposure or ghosted image
• Grid lines, grid artifact, or grid cut off
• Grids are not typically used for X-Rays of the
lower leg because the anatomy is most likely
<10cm in thickness

12. Image Sharpness
• Size Distortion created by OID
(greatest contributor), SID, and
SOD
• On this image size distortion
does not appear greater than
normal
• Shape Distortion is cause by
the misalignment of the
CR/IR/part greater than 1cm
• No angulation is needed for
this projection as long as it
was a routine patient

13. Radiography of the
Anatomical Part

14. Accurate Part Positioning
• The part is not accurately
aligned to the image media,
the technologist needed to turn
the image media to ensure that
both the Knee and Ankle joint
would be on
• The part is accurately centered
to the image media

15. Accurate Part Positioning
• The CR is centered within 1cm
of the accurate centering point
• The CR is not aligned with the
image media, with turning the
image media and ensuring
both joints would appear on
one image it is difficult to
center to the image media

16. Accurate Part Positioning
• There is an acceptable field
recognition, this is
demonstrated by the
collimation area where the blue
triangles are
• The processor recognized that
collimation was used and thats
why black border appears on
the image

17. Accurate Part Positioning
• Positioning of patient:
• Place the patient in a supine position
• Positioning of part:
• Adjust the patient’s body so that the pelvis is not
rotated
• Adjust the leg so that the femoral condyles are parallel
with the IR and the foot is vertical
• Flex the ankle until the foot is in the vertical position If
necessary, place a sandbag against the plantar
surface of the foot to immobilize the leg
• Shield gonads
• 40 inch SID, however, expanded the SID beyond 40
inches will help demonstrate all the anatomy, is better for
patient dose, and increase spatial resolution
• Center Ray:
• CR should be perpendicular to the center of the leg
• Collimation:
• Collimation should be 1 inch on the sides and 1.5
inches beyond the ankle and knee joints
*two images are provided to display the two ways the
IR can be placed underneath the anatomy to ensure
both joints are seen on one image

18. Accurate Part Positioning
• The image shows the tibia, fibula, and
adjacent joints
• Evaluation Criteria:
• Evidence of proper collimation
• Ankle and knee joints on one or more
images
• Entire leg without rotation
• Proximal and distal articulations of
the tibia and fibula moderately
overlapped
• Fibular midshaft free of tibial
superimposition
• Soft tissue and bony trabecular detail

19. Accurate Part Positioning
• Evaluation of image:
• Evidence of beam restriction
• Ankle and knee joint are visualize
on one image
• Some rotation medially is seen
through the gap between the tibia
and fibula, but nothing excessive
because the head of the fibula and
tibia lateral condyle still
superimpose each other
• Fibular shaft is seen without
superimposition
• Bony trabecular and soft tissue are
seen with detail in most areas

20. Judicious Exposure
Technique
• The most radiolucent structure
in the image is the soft tissue
• The most radiopaque structure
in the image is the metal rod
through the tibia

21. Judicious Exposure
Technique
• Brightness (window level) is the balance of light and
darks shades in an image
• Within the shaft there is a good amount of brightness
seen that visualizes the anatomy. However, at both
joints there is an excessive amount of brightness.
• Near the ankle joint there is a lot more penetration, the
soft tissue is burnt out of the image. A compensated
filter could have been placed on the collimator to make
the image more uniform
• Contrast (window width) is a ratio of radiation intensities
transmitted through areas of the component being
evaluated. Determines how many gray levels are
displayed
• There a lot of gray throughout the image, the image
should be predominately black and white. If a
compensated filter was added the image would
appear with less grays
• There is no EI value given therefore the appearance of
the radiograph cannot be discussed through that value.

22. Accept or Reject Image

23. Accept
• I would accept this image, there is
very little that needs to be
adjusted to make for an optimal
image
• This image is a diagnostic image,
some things could be adjusted to
make it more optimal
• A compensating filter should be
added
• Readjustment of the leg to make
sure there is no rotation
• Ensure the foot is vertical

24. • https://evolve.elsevier.com/Courses/154283_kburns12_1001
#/content/7367580487
• https://www.ceessentials.net/article27.html
• https://evolve.elsevier.com/Courses/154283_kburns12_1001
#/content/7367580487
• https://orthoarizona.org/kassmanorthopedics/nhl-stamkos-
orthopedic-injury/
• https://www.pinterest.com/ccox5716/o-you-need-a-x~ray/
• http://www.radtechonduty.com/2012/09/ap-projection-
leg.html