Clinical VI~~~~~~~

FINALImage Review

1

The following information is only a personal suggested guideline to follow when positioning for all

radiographic exams.

For additional information on positioning of these exams, please

reference your Radiographic Positioning and Related Anatomy

Textbook. 2

Chest Radiography

3

4

Most common AP/PA Chest Exam Errors

1.Artifacts - accidental

2.Clipped anatomy

3.Chin in the way

4.Rotation

5.Marker misuse

6.Poor CR angle

Bra Bra

necklace &nipple piercingsPLUSpoor centering!

ASK… Do you have any metal on under your gown?

Repeatable error:

Artifacts? Internal

or ? External

5

Glasses in pocket

Double exposure- Make sure you keep track of which IR plates have already been exposed!

6

Repeatable error:

Repeatable error: Centering

Clipped anatomy7

Good Image

Repeatable error: Positioning

Chin is in the way of anatomy

8

Good Image

Repeatable error: Positioning

Rotation

9

Good Image

Repeatable error: Positioning

Rotation and too many wires in the way 10

Good Image

For AP Chest imaging, the correct CR angle will produce the visualization of 3 ribs above the clavicles. Anything more or less than that could be because of poor CR angle.

11

12

Incorrect patient contact with the IR, will cause pertinent anatomy to project off IR.

Incorrect CR to IR,Will cause apical lordoticimage and/or grid cut-off

Left side down Decubitus Repeatable error: Positioning

Arm is obscuring anatomy

13

Good Image

Protocols for Decubitus Chest X-rays

*Remember:

Air goes UP

And

Fluid goes DOWN

(Abdomen Decubitus are ALWAYS Left side down! WHY?)14

Good Decubitus Chest Image showing pathology :

Pleural Effusion15

16

Most common Decubitus Chest Errors

1. Rotation

2. Marker misuse-always mark correct side of patient!

3. Clipped anatomy-always use a bolster

17

Most common Lateral Chest Exam Errors

1.Rotation

2.Clipped anatomy

3.Marker misuse

Repeatable error: Positioning

Rotation18

Good Image

Repeatable error: Centering

Know where your IR is and be centered to it.19

Good Image

Repeatable error: Positioning

Anatomy is obscured by the wheelchair. Need to use a sponge behind the patient’s back. 20

Good Image

Repeatable error: Centering

Clipped anatomy21

Good Image

Repeatable error: Positioning

Clipped anatomy-don’t walk the patient forward, instead have them bend forward at the waist. 22

Good Image

Abdomen Radiography

23

Repeatable error: Artifacts

ASK- Do you have any metal on under your gown?? 24

25

Most common Supine & Uprt Abdomen Exam Errors

1.Artifacts accidental and intentional

2.CR not centered to IR

3.Rotation

4.Marker misuse

Repeatable error: Positioning

Poor annotation placement, markers should be at the bottom of the IR. Know where the patient’s hands are. 26

Good Image

Repeatable error: Positioning

Know where the patient’s hands are before you expose. 27

Good Image

Repeatable error: Centering

Know where the IR plate is. Make sure it is centered to your CR. 28

Good Image

Repeatable error: Positioning

Rotation29

Good Image

30

Most common LEFT Lateral Decubitus Abdomen Errors

1. Rotation

2. Marker misuse –mark the side down

3. Clipped anatomy

Repeatable error: Positioning

31

Rotation

Good Image

Upper Extremity Radiography

32

33

Most common Upper Extremity Exam Errors

1.Part not parallel to the IR

2.Rotation

3.Collimation

4.CR not centered to IR

Lateral Thumb

Repeatable error: Positioning

*Need to separate thumb from other

digits

34

Oblique Hand

Repeatable error:

Positioning

*Over rotatedand the digits are

not separated

Good Image

35

Lateral Hand

Repeatable error: Centering

*Or Poor Collimation or patient moved

36

Lateral Wrist

Repeatable error:

Positioning

*Under rotated.

37

LateralForearm

Repeatable error:Poor

Positioning

*Not a true lateral and not a 90° flexion.

Good Image

38

LateralForearm

Repeatable error:

Positioning & Centering

*Poor image due to poor centering

of the CR.

Good Image

39

AP Elbow

Repeatable error:

Positioning

*Not a true AP. Appears as though the

patient placed their palm prone.

40

Oblique Elbow

Repeatable error:

Positioning

*Over rotated Internal Oblique.

Good Image

41

Lateral Elbow•Epicondylar line must be perpendicular to IR

•Use sponge to elevate hand if needed

•Elbow must be flexed to 90-degrees

•Patient’s elbow must be in same plane as shoulder

42

Lateral Elbow

Repeatable error:

Positioning

*Not flexed to 90°and arm is

rotated. Epicondyles are

not ┴ to IR.43

Lateral Elbow

Repeatable error:

Positioning

*Shoulder is not in same plane as

elbow. Epicondyles are

not ┴ to IR.44

A B

DC

LateralElbow

Which LateralElbow

Image is correctly

positioned?

45

90 degree Lateral Elbow is important for Fat Pad SignFat is less dense than bone & muscle. And when an accumulation of fluid persists, it make the fat pads flare out.

46Normal Abnormal

The three concentric arcs1-yellow= trochlear sulcus (midline on the humerus)2-green= outer ridges of capitulum & trochlea3-pink= trochlear notch is on the ulna

47

The three concentric arcs1-yellow= trochlear sulcus (midline on the humerus)2-green= outer ridges of capitulum & trochlea3-pink= trochlear notch is on the ulna

48

Coyle Method ~ “For Radial Head”

Upper limb flexed 90° and CR 45°< toward shoulder49

Upper limb flexed 80° and CR 45°< from shoulder

Coyle Method ~ “For Coronoid”

50

AP Humerus

Repeatable error: Exposure Criteria

& Collimation

*Poor centering and collimation

51

AP Humerus

Repeatable error: Exposure Criteria

& Positioning

*Poor centering making image poor

quality.*Clipped anatomy

52

AP Humerus

Repeatable error: Exposure Criteria

& Positioning

*Poor centering making image poor quality

*Arm is over rotated causing epicondyles to not be parallel to IR. 53

Lateral Humerus

Repeatable

error: Positioning

*Arm isacross abdomen

causing epicondyles tonot be parallel

to IR.

Good Image

54

Good Image

Lateral Humerus

Repeatable

error: Positioning

*Clipped Anatomy

55

AP Shoulder

Repeatableerror:

Technical

*Know where your marker is.

56

Grashey Shoulder

Repeatableerror:

Positioning

Artifact*Know where the snaps are on the

gown!

57

“Grashey”Shoulder

Repeatableerror:

Positioning

*Patient was rotated away from affected side, not towards

affected side.

58

Grashey Shoulder

Repeatableerror:

Positioning & Centering

* Patient is over rotated.

*Remember to fill the light field box for digital

radiography of the shoulder.

59

Scapular-YShoulder

Repeatableerror:

Positioning

*under rotatedand watch out for

snaps

60

Scapular-YShoulder

Repeatableerror:

Positioning

*Over rotated. The humerus should

not be in the ribs.

61

AxialShoulder

Repeatableerror:

Positioning

*Poor centering with clipped

anatomy

62

Lower Extremity Radiography

63

64

Most common Lower Extremity Exam Errors

1.Part not parallel to the IR

2.Rotation

3.Collimation

4.CR not centered to IR

AP Toes

Repeatable error:

Positioning

*Toes need to be parallel to the IR,

put toes on a sponge or angle

CR65

Good Image

AP Foot

Repeatable error:

Centering

*Or Poor Collimation or patient moved

66

LateralFoot

Repeatable error:

Positioning

*over rotated

67

Good Image

LateralAnkle

Repeatableerror:

Positioning

*Rotation

68Good Image

MortiseAnkle

Repeatableerror:

Positioning

*do not let foot droop causing

calcaneus to be superimposed by

the fibula

69

Good Image

Axial Heel

Repeatableerror:

Positioningor CR Angle

error

*under dorsiflexed

or not enough CR angle

70

Good Image

Axial Heel

Repeatableerror:

Positioningor CR Angle

error

*Over dorsiflexed

or too muchCR angle

71

Good Image

Lateral Knee•Knee should be flexed 20-30 degrees

•Angle CR appropriately or put entire leg parallel with the IR-get eye level to the leg.

•Standing-check dimples

B

Knee is under rotated(The knee is too far away from the image receptor)

The fibula head is too far anterior.

Knee is over rotated(The knee is too far towards the image receptor)

The fibula head is too far posterior.

SunrisePatella

Repeatableerror:

Positioning

*Ensure shoe/foot is not inthe way

75Good Image

AP Hip

Repeatableerror:

Centering

*Know Landmarks

76

AP FrogHip

Repeatableerror:

Centering

*Know Landmarks

77

APPelvis

Repeatableerror:

Positioning

*ArtifactKnow

where your patient’s

hands are!

78

APPelvis

Repeatableerror:

Centering

*Know your

landmarks

79

SpineRadiography

80

81

Most common Cervical Spine Exam Errors

1.Base of head, jaw, and teeth in the way of C-Spine

2.AEC does not hit part

3.CR not centered to IR

Lateral C-SpineRepeatable error: Positioning *Artifact & C7 is not visualized. Good Image

82

Lateral C-SpineRepeatable error: CenteringPatient motion- Resulted in AEC chambers not hitting the appropriate anatomy. Option: Choose manual technique.

Good Image

83

2

3

4

5

6

7

AP C-SpineRepeatable error: PositioningRed line = chin, pink line = base of skull.Head is flexed downward, causing chin to superimpose on top of upper C-spine.

Good Image 84

4

5

6

7 CR

AP C-Spine ~ Repeatable error: Positioning Red line = chin, pink line = base of skull.

Head is flexed downward, causing chin to superimpose on top of upper C-spine.85

2

3

4

5

6

7

AP C-SpineRepeatable error: Positioning Red line = chin, pink line = base of skull.Head is extended to far back, causing base of skull to superimpose on top of upper C-spine.

Good Image

86

2

3

4

5

6

7

CR

AP C-SpineRepeatable error: Positioning Red line = chin, pink line = base of skull. Left Image shows the head over extended, causing the base of skull to superimpose on top of upper C-spine. Right image shows how this positioning error took place viewing the patient from the side.

87

CR

Left Image is an excellent AP Cervical Spine ~ Right Image is an example of how you should step to the side, and view the patient’s lateral side to ensure that the “lower mandible to base of skull” line is parallel with the CR. 88

Oblique C-SpineRepeatable error: Positioning Patient’s mandible is in the way of the c-spine.

Good Image

89

Oblique C-SpineRepeatable error: Positioning Patient’s mandible is in the way of the Upper c-spine.

Good Image90

Odontoid C-SpineRepeatable error: Positioning

*Head is over extended

(Tilted too far back) .

Base of skull

Teeth

Good Image

91

Odontoid C-SpineRepeatable error: Positioning

*Head is flexed too far forward.

Base of skull

Teeth

Good Image

92

Above: Both the base of skull & the bottom edge of the teeth are superimposed. Sometimes, even perfect positioning can lead to no visualization of the odontoid. In this case, you would do an additional Judd or Fuchs position.

Besides excellent positioning, the mouth is also opened appropriately, showing both lateral margins of the lateral masses. This shows any displacement of C1 & C2 laterally. Sometimes fillings or crowns of the back molars prohibit this visualization.

93

Odontoid C-Spine

94

Most common Thoracic Spine Exam Errors

1.Poor image quality due to using AEC instead of manual technique

2.Laterals=AEC does not hit part

3.Missing T1-T3 or clipped T12(possibly increase SID)

Repeatable error: Exposure Criteria Poor image, possibly due to using AEC. Patient is obviously barrel chested causing lower T-spines to be too light. Manually set, long exposure techniques help blur out mediastinal structures to better visualize costovertebral joints.

Good Image

95

ThoracicSpine

Repeatable error: Exposure CriteriaPoor image, possibly due to using AEC. Use manual/long exposure technique to help blur out lung markings to better visualize the spine. Good Image

96

ThoracicSpine

97

Most common Lumbar Spine Exam Errors

1.AP=rotation

2.Laterals=Pop-can effect from not using a bolster

3.Laterals=rotation

4.Laterals=AEC does not hit part

L5-S1 Spot L-SpineRepeatable error: Positioning Left Image shows white ovals of the “cake top/pop can” effect of the vertebral bodies when no radiolucent support is used under the waist.

Good Image

98

L5-S1 Spot L-SpineRepeatable error: Positioning Left Image shows that no radiolucent support was used under the wait and possibly no caudad angle of the CR was used, causing the L5-S1 space to not be open. The yellow dotted lines show how the iliac crests are not superimposed.

Good Image

99

Bony ThoraxRadiography

100

101

Most common Bony Thorax Exam Errors

1.Poor image quality due to using AEC instead of manual technique

2.Over magnified with ribs being clipped=try increase SID

Rib Techniques“Long” exposure is best for fine detail of ribs.(Low MA @ 2-3 sec)

• Pt holds their breath in for upper ribs and out for lower ribs

• Expose on suspended respiration

102

AP RibsRepeatable error: Exposure CriteriaImage on the left - Uses AEC and is not ideal for rib x-rays. Image on the right -Uses a manually set long exposure technique which best visualizes rib detail.

Good Image

103

Oblique RibsHow to remember which oblique to do in order to get the elongated view of the ribs:

• Turn the spine away from the effected side

• AP towards IR and

• PA “Away” from IR104

Oblique RibsRepeatable error: Exposure CriteriaImage on the left - Uses AEC and is not ideal for rib x-rays. Image on the right -Uses a manually set long exposure technique which blurs out heart and lungs to best visualize the rib detail.

Good Image

105

Sternum Techniques“Breathing” Technique is best for viewing the sternum in the RAO position. Low MA and 2-3 second exposure.

• Pt exhales slowly to blur out lung markings and ribs.

106

RAO SternumRepeatable error: Exposure CriteriaImage on the left - Uses AEC and is not ideal for oblique sternum. Image on the right - Uses a manually set long exposure technique which blurs out heart and lungs to best visualize the sternum detail.

Good Image

107

GastrointestinalContrast ExamRadiography

108

109

Most common Gastrointestinal Contrast Exam Errors

1.Poor centering, clipped anatomy

UGI

Repeatable Error:

Positioning

*Centering is too low.

Fundus and pyloric

sphincter are clipped.

110

UGI

Repeatable Error:

Positioning

*Centering point is too low. Fundus is clipped.

111

UGI

Repeatable Error:

Positioning

*Centering point is too

low. Fundus is clipped. And

there is motion.

112

UGI

Repeatable Error:

Positioning

*Centering is too close to the spine. The body of the stomach is clipped.

113

For all stomach images…

Ask yourself:

What is in the fundus?What is the spine doing?

114

In the fundus? Barium = APSpine doing? Straight = AP

115

In the fundus? Air = PAUpper spine doing? Straight = PA

Both images:What is in the fundus? AirWhat is the spine doing? Obliqued = RAO

116

Both Images:What is in the fundus? AirWhat is the spine doing? Lateral

117

Both Images:What is in the fundus? BariumWhat is the spine doing? Obliqued = LPO

118

SBFT

Repeatable Error:

Technical

*Transverse lock of CR tube is not on center

to the table bucky.

119

SBFT

Repeatable Error:

Centering

*Wrong centering for this timed

image. Pertinent

anatomy is clipped. 45 min

120

BE

Repeatable Error:Technical

Rectal sigmoid decompressed. Give more air and repeat image.

121

SkullRadiography

122

123

Most common Skull Exam Errors

1.Rotation

2.Positioning of petrous ridge

3.Tilt

4.CR angle with appropriate centering

AP/PA Skull

Repeatable Error:Positioning & Collimation

*Not enough head/chin tuck. OML must be

perpendicular to the IR which will put the

petrous ridge at the top of the orbits. Also should

have more collimation.

124

AP/PA Skull

Repeatable Error:

Centering

Excellent positioning*the petrous ridge is at top of the orbits.

However:Clipped anatomy at

top of skull.

125

Lateral Skull

Repeatable Error:

TerribleRotation

*ManibularRami; EAM’s; and Auricle of

the ears are not superimposed.

126

LateralSkull

No Errors:

ExcellentPositioningNo Rotation

127

Modified Caldwell

OrbitsRepeatable Error:

Positioning & Centering

*Rotation.Also, be aware of where the CR will be entering

and “exiting” the patient as it is projected onto

the IR. (*use finger/pen shadow check)

128

(Modified) 30°Caldwell Orbits

*Finger/pen shadow check

The red marker is at the level of the inferior orbital

margin.The grey pen is at

the level of the petrous ridge.

129

*Which proves that the petrous ridge will be below the level of the orbits

30° CR

(Modified) 30°Caldwell Orbits

Repeatable Error:Positioning

*Be aware of how much CR angle and how much

part positioning you have, because the

Petrous ridge must be below the lower orbital margin. Also, check for

rotation.130

(Modified) 30° Caldwell

Orbits*this view looks very

similar to the Modified Waters

Orbit view.

No Errors:

ExcellentImage 131

Lateral Sinuses

Repeatable Error:

Positioning

*Need better centering and collimation.

Also remember to remove metal (hearing aids)

132

WatersSinuses

Repeatable Error:

Positioning*Petrous

Ridge needsto be belowthe Maxillary

Bad Image Sinuses Good Image

Be aware of better positioning and knowing where the petrous ridge lies (at the TEA) and more

collimation should have been used on both images.133

~ The End ~

134