Radiography

1. Lower limb radiography.
● Presented by - shivansh kumar kanoje( BSC MTR 3 rd year).
● Moderated by Dr akhil sir ( pg- jr).

2. ● What is lower limb radiography
● Lower limb radiography involves taking x ray images of
bones in the lower extremities including the hips,
thighs,knees,lower legs,ankels and feet this imaging helps
in diagnosing fractures ,joint problems and other
conditions affecting the bones and joints of lower limb.

3. Ankle joint.
Antero-posterior (AP view).
Pathology indication.
● Fractures.
● Dislocations.
● Arthritis.
● Soft tissue injuries.
● Osteoarthritis.
● Infections.
● Tumors.
Positioning.
The patient is either supine or seated on the x ray table
with both legs extended a pad may be placed under the
knee for comfort,the affected ankle is supported by
dorsiflexion by a firm 90° pad placed against the palmar
aspect of foot.the limb is rotated medially. approximately
20° until the medial and lateral malleoli are equidistant
from the film.

4. Direction and centering.
Midway between the malleoli with the vertical central ray at 90° to the imaginary line
joining the malleoli.
Essential image characteristics.
Lower third of tibia and fibula should be included.
A clear joint space between the tibia ,fibula and talus should be demonstrated.
Lateral.
Pathology indication.
● Fractures.
● Dislocations.
● Ligamentous injury.
● Soft tissue injuries.
● Arthritis.
● Tendon abnormalities.
● Chronic ankle pain.

5. Positioning.
A 15° pad is placed under the lateral border of
forefoot and a pad is placed under the knee for
support.the lower edge of the cassete is
positioned just below the plantar aspect of the
heel.
Direction and centering.
Centre over the medial malleolus with the central
ray at right angles to the tibia.
Essential image characteristics.
● Lower third of tibia and fibula should be
included.
● The medial and lateral borders of the trochlear
articular surface of the talus should be
superimposed on the image.

6. Antero-posterior - stress.
Pathology indication.
● Sprains and ligamentous injuries.
● Fractures with stress components.
● Chronic ankle instability.
● Syndesmotic injuries.
● Assessment of joint stability.
Positioning.
The patient and cassette are positioned for the routine antero-posterior projection.
The doctor in charge forcibly inverts the foot without internally rotating leg.
Direction and centering.
Centre midway between the malleolus with the central ray at right angles to the
imaginary line joining the malleoli.
Lateral- stress.
Positioning.
Patient lies supine on the table with the limb extended.
The foot is elevated and supported on a firm pad.
The ankle is dorsiflexed and the limb rotated medially until the malleoli are equidistant from the film.
The film is supported vertically against the medial aspect of foot.
The doctor applies firm downward pressure on lower leg.

7. Direction and centering.
Centre to the lateral malleoli with a horizontal beam.
Calcaneum.
Lateral.
Positioning.
From the supine position, the patient rotates on the
affected side.
The leg is rotated until the medial and lateral malleoli
are superimposed vertically.
A 15° pad is placed under the anterior aspect of the
knee and the lateral border of forefoot for support.
Direction and centering.
Centre 2.5 cm distal to the medial malleolus, with
the vertical central ray perpendicular to the
cassette.
Essential image characteristics.
The adjacent tarsal bones should be included in
the lateral projection, together with the ankle
joint.

8. Axial.
Positioning.
Patient sits or lies supine on the x ray table
with both the limbs extended and affected leg
is rotated medially until both malleoli are
equidistant from the film. the ankle is
dorsiflexed the position is maintained by using
a bandage strapped around the forefront and
held in position by the patient.
Direction and centering.
Centre to the plantar at the level of tubercle of
the fifth metatarsal.
The central ray is directed cranially at an angle
of 40° to the plantar aspect of heel.
Essential image characteristics.
The subtalar joint should be visible on the
axial projection.

9. Subtalar joint.
Oblique medial.
Positioning.
The patient lies supine on the x ray table with the affected limb extended the ankle
joint is dorsiflexed and the malleoli are equidistant from the film the leg is internally
rotated through 45° and a pad is placed under the knee for support.
Direction and centering.
Centre 2.5 cm distal to the lateral malleolus.
Pathology indication.
● Subtalar joint dislocations.
● Fractures of talus and calcenous.
● Arthritis.
● Soft tissue abnormalities.
● Chronic pain and instability.
● Post opreative assessment.

10. Oblique lateral.
Positioning.
The patient lies supine on the table, with the affected
limb extended the ankle joint is dorsiflexed and the
malleoli are equidistant from the cassette the leg is
externally rotated through 45°.
Direction and centering.
Centre 2.5cm distal to the medial malleolus, with the
central ray angled 15° cranially.
Pathology indication.
● Fractures.
● Arthritis.
● Subtalar joint dislocations.
● Tarsal coilation.
● Chronic pain and instability.
● Postoperative treatment.

11. Lateral oblique.
Positioning.
Patient lies on the affected side the opposite limb is flexed
and brought in front of the affected limb the affected foot
and leg are further rotated laterally until the plantar aspect
of foot is approximately 45° to the cassette.
Direction and centering.
Centre to the medial malleolus, with the central ray angled
20° caudally
Pathology indication.
● Subtalar joint dislocations.
● Fracture.
● Arthritis.
● Tarsal coilation.
● Soft tissue abnormalities.
● Chronic pain and instability.
● Post opreative assessment.

12. Leg.
Antero-posterior.
Positioning.
Patient lies supine with limbs extended ankle is dorsiflexed and limb rotated medially
until the medial and lateral malleoli are equidistant from the cassette
Centering.
Right angle to both the axis of tibia and Imaginary line joining malleoli midline at the
level of middle of cassette.
Essential image characteristics.
The entire tibia and fibula should be included with both the ankle and knee joint
demonstrated on one film correct use of anode heel effect will result in an image with
nearer equal density at both ends of the film no motion is present as is evidenced by
sharp cortical margins and trabecular patterns.
Pathology indication.
Pathologies involving fractures, foreign bodies,or lesions of bone are
demonstrated.

13. Lateral.
Positioning.
Patient turns on the side being examined ankle is
supported in dorsiflexion and the limb rotated until the
medial and lateral malleoli are superimposed vertically
the tibia should be parallel to the cassette.
Direction and centering.
Centre to the middle of the cassette, with the central ray
at right angles to the long axis of tibia and parallel to the
imaginary line joining the malleoli.
Essential image characteristics.
The knee and ankle joint must be included, since the
proximal end of fibula may also be fractured when there
is a fracture of distal fibula.
Pathology indication.
Localisation of lesions and foreign bodies and
determination of the extent and alignment of fractures
are demonstrated.

14. Lateral oblique.
Positioning.
Patient lies on the affected side with the knee slightly
flexed the other limb is brought forward in front of the one
being examined and supported by a sandbag the head of
the fibula and lateral tibial condyle of the affected side are
palpated and the limb rotated laterally to project the joint
clear of the tibial condyle.
Direction and centering.
The vertical central ray is directed to the head of fibula.
Antero-posterior oblique.
Positioning.
Patient is either supine or seated on the x ray table with
both legs extended palpate the head of fibula and lateral
condyle rotate the limb medially to project the tibial
condyle clear of the joint.
Direction and centering.
The vertical ray is directed to the head of fibula.

15. Knee joint.
Antero-posterior.
Positioning.
Patient lies supine or seated with
support and the limb under examination
extended rotate the limb to central
patella between femoral condyle.
Centering.
Directed to a point 1 cm distal to the
apex of patella.
Essential image characteristics.
The patella must be centralized over the
femur.
Pathology indication.
Any fractures lesions,or bony changes
related to degenerative joint disease
involving the distal femur, proximal tibia
and fibula, patella and knee joint may be
visualised in ap projection

16. Lateral.
Positioning.
Patient lies on the side under examination with the knee
flexed to approximately 30°the ankle on the side under
examination is raised on small sand bag to bring the axis of
tibia parallel to the film the anterior borders of femoral
condyles are palpated distal and posterior to patella and
limb rotated to superimpose them vertically.
Centering.
Midpoint of palpable superoir border of medial tibial condyle
with central ray at right angles to the axis of tibia.
Pathology indication.
Fractures, lesions and joint space abnormalities are
demonstrated.
Essential image characteristics.
● Patella should be projected clear of femur.
● The femoral condyles should be superimposed.
● The proximal tibio fibular joint is not clearly visible.

17. Antero-posterior axial projection.
Positioning.
Patient sits or lies with knee flexed to make an
angle of 60°and curved cassette is placed below
the knee joint knee joint is immobilzed by
placing sandbag.
Centering.
Centre immediately below the apex of patella,
with the following angulations.
110°- anterior aspect of notch
90° - posterior aspect of notch
Pathology indication.
The intercondylar fossa, femoral condyles,tibial
plateaus and intercondylar eminence are
examined for evidence of bony or cartilaginous
pathology, osteochondral defects or narrowing
of joint space.

18. Skyline projection.
Positioning.
Patient sits with knee flexed at an angle of about
135° and feet resting on sand bag cassette is
supported vertically about 6” proximal to femoral
condyle.
Condyle.
Inferior surface of patella with a tube angles about
10° towards head.
Essential image characteristics.
The intercondylar sulcus and patella of distal femur
should visualize in profile with the femoro patellar
joint space open optimal exposure should clearly
visualize soft tissue and joint space margins and
trabecular markings of patellae.
Pathology indication.
Abnormalities of patella and femoropatellar joint are
demonstrated.

19. Patella lateral.
( Medio- lateral projection).
Pathology indication.
Abnormalities of patella and femoropatellar
joint are demonstrated.
Positioning.
Patient lies in lateral recumbent position with
the affected side down, adjust the rotation of
body and leg until is in true lateral position
flex knee only 50°or100°.
Centering.
Direct CR to the mid femoropatellar joint.
Essential image characteristics.
Profile images of patella,the femoropatellar
joint and the femorotibial joint are
demonstrated.optimal exposure and density
will visualize soft tissue detail and the patella
well without exposure.

20. Femur.
Lateral.
Pathology indication.
Mid and distal femur is demonstrated including knee joint for detection and
evaluation of fractures and/ or bony lesions.
Positioning.
Patient is turned on the side under examination with hip and knee flexed slightly
pelvis is rolled backwards the anterior border of femoral condyle is rotated on the
side being examined and palpated distal and posterior end of patella and limbs
rotated vertically to superimpose them the film is positioned against lateral
aspect of thigh.
Centering.
Parallel to an imaginary line joining anterior borders of femoral condyles.
Essential image characteristics.
Distal two - third of distal femur, including knee joint is shown distal margins of
the femoral condyles will not be superimposed because of divergent x- ray
beam.optimal exposure with correct use of anode heel effect will result in near
uniform density of entire femur.no motion should occur.

21. Antero-posterior.
Pathology indication.
Mid and distal femur is demonstrated including knee joint for detection and
evaluation of fractures and/ or bony lesions.
Positioning.
Supine with the leg extended rotate limb to centralized patella if possible.
Centering.
Right angles to imaginary line joining anterior border of femoral condyles.
Essential image characteristics.
Distal two- third of distal femur is shown optimal exposure with correct
anode heel effect will result in near uniform density of entire femur no
motion should occur.

22. The following image show the positioning and radiographic images of
femur antero-posterior and lateral views.

24. Thank you
Refrence from Clark's positioning in radiography