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Radiology, X-ray Image Review
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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