7 th presentation Radiographic technique of Ankle Toes

7 th presentation Radiographic technique of Ankle, Toes, foot and Calcaneus

projections BASIC SPECIAL AP Ankle Mortise Lateral Ankle APO Ankle 45 Toes : AP Lateral Toes : APO AP foot APO foot lateral foot Axial Calcaneus Mediolateral Calcaneus AP and Lat both feet (Weight-bearing technique )

AP Ankle. Film Size: HD 24 x 30 cm, (10 x 12 in )crosswise. SHIELDING: Place lead shield over patient’s lap. Patient Position: Patient supine place pillow under head. Part Position: legs fully extended, foot in the natural position, foot and ankle in true AP. Distance: 100 cm or 40 in. C P: Midway between malleoli. CR : perpendicular to the film. Collimation: collimate on four sides to area of interest. Basic

AP Ankle Structure shown: distal third of tibia-fibula, the lateral and medial 1. Fibula malleoi, and the talus and the proximal half of the 2. Tibia metatarsals should be demonstrated. 5. Lateral malleolus 6. Ankle join 3. Distal Tibiofibular joint 7. Medial malleolus 4. Malleolar fossa 8. Talus

AP Ankle Mortise (15º– 20º medial rotation) Film Size: HD 24 x 30 cm, (10 x 12 in ) crosswise. SHIELDING: Place lead shield over patient’s lap. Patient Position: Patient supine place pillow under head. Part Position: legs fully extended, foot in the natural position (in natural extended position), leg and foot then medially rotated 15 to 20 until the intermalleolar line is parallel to the film. Distance: 100 cm or 40 in. C P : A point midway between malleoli. CR : perpendicular to the film. Collimation: collimate on four sides to area of interest Basic

Structure shown: distal one third of tibia and fibula, the lateral and medial malleoi, the talus, and the proximal half of the metatarsals should be demonstrated. The entire ankle mortise should be open and well visualized.

Lateral Ankle (Mediolateral) Film Size: HD 24 x 30 cm, (10 x 12 in )crosswise. SHIELDING: Place lead shield over patient’s lap. Patient Position: Patient in lateral recumbent give pillow for head. Part Position: the affected side down, knee of affected limb flexed 45 , sound leg behind the affected leg, foot and leg in a true lateral, sole approximately 90 to film. Distance: 100 cm or 40 in. C P : Medial malleolus. CR : perpendicular to the film. Collimation: collimate on four sides to area of interest. Basic

Structure shown: The distal one third of tibia and fibula, with the distal fibula superimposed by the distal tibia, the talus and calcaneus will appear in lateral profile. The tuberosity of the fifth metatarsal, the navicular, and cuboid will also be visualized. fifth metatarsal

APO Ankle 45 (medial rotation) Basic Film Size: HD 24 x 30 cm, (10 x 12 in )crosswise. SHIELDING: Place lead shield over patient’s lap. Patient Position: Patient supine give pillow for head. Part Position: legs fully extended, foot dorsiflexed so that planter surface is (80 to 85 ) from the film, leg and foot rotated internally 45 (similar position to ankle mortise). Distance: 100 cm or 40 in. CR : perpendicular to the film. C P: A point midway between malleoli. Collimation: Collimate on four sides to area of interest.

Structure shown: distal one third of the lower leg, the malleoi, the talus, and the proximal half of the metatarsals should be seen.

Toes : AP. Film Size: HD 18 x 24 cm (8 x 10 in ) crosswise. SHIELDING: Place lead shield over patient’s lap. Patient Position: Patient supine or seated. Part Position: knee flexed, planter surface of the foot (sole) on film. Distance: 100 cm or 40 in. CP : metatarsophalangeal joints MTPJ(s) in question. C R: 10 -15 toward the Calcaneus (the heel) or(perpendicular to the phalanges). Collimation: collimate on four sides to area of interest. NB/ If a 15 wedge is used, CR must be perpendicular to the film. Basic

Structure shown: digits of interest and a minimum of the distal half of metarsals should be included.

Lateral Toes : Film Size: HD 18 x 24 cm (8 x 10 in ) crosswise. SHIELDING: Place lead shield over patient’s lap. Patient Position: Patient supine or seated. Part Position: knee flexed, affected leg and foot both rotated medially (Lateromedial) for 1 st, 2 nd, and 3 rd, and laterally (for 4 th and 5 th) a cotton tape to separate and flex other toes to prevent superimposition. Distance: 100 cm or 40 in. C R: Perpendicular to film. CP: Interphalangeal joint IPJ (for 1 st digit ), Proximal Interphalangeal joint (PIPJ) (2 nd to 5 th). Collimation: collimate on four sides to area of interest. Structure shown: phalanges of digits in question should be seen in lateral position free of superimposition by other digits. Basic

Toes : APO Film Size: HD 18 x 24 cm (8 x 10 in ) crosswise. SHIELDING: Place lead shield over patient’s lap. Patient Position: Patient supine or seated. Part Position: knee flexed, planter surface on the film, affected leg and foot both rotated 30 to 45 medially (Lateromedial) for 1 st, 2 nd, and 3 rd, and laterally (for 4 th and 5 th). Distance: 100 cm or 40 in. CR: Perpendicular to film C P: metatarsophalangeal joints. MPJ(s) in question are centered to CR. Collimation: collimate on four sides to area of interest. Basic

Structure shown: digits in question and distal half of metarsals should be included without overlap (superimposition).

AP foot (Dorsiplanter) Basic Film Size: HD 30 x 24 cm (10 x 12)in lengthwise. SHIELDING: Place lead shield over patient’s lap. Patient Position: Patient supine give pillow for head. Part Position : the knee flexed, planter surface on film, sandbags used to immobilize the film, opposite knee flexed and rests against affected knee for support. or extended. Distance: 100 cm or 40 in. CR: 10 toward the heel. C P: Base of 3 rd metatarsal. Collimation: Collimate on four sides to area of interest. NB/ Perpendicular (0 ) for a F. B. and for a flat foot or a low arch foot nearer 5 , and 15 for a high arch foot.

Structure shown: entire foot should be demonstrated including all phalanges and metarsals and the 1 - Navicular, 2 - Cuneiforms, and 3 - Cuboids.

APO foot : Film Size: HD 30 x 24 cm (10 x 12)in lengthwise. SHIELDING: Place lead shield over patient’s lap. Patient Position: Patient supine or seated. Part Position: knee flexed, planter surface on film, foot rotated medially so that the sole is 30 to 40 to film. A 45 radiolucent wedge can be used to support the foot and prevent motion , sandbags used to immobilize the film if necessary, turn body slightly away from side in question. Distance: 100 cm or 40 in. CR: perpendicular to the film. C P: Base of 3 rd metatarsal. Collimation: collimate on four sides to area of interest. Basic

Structure shown: Entire foot should be demonstrated from distal phalanges to posterior calcaneus. And proximal talus. A-E: Toes 1 -5. (A: Great toe) 1, 3: Distal phalanx 4: Middle phalanx 2, 5: Proximal phalanx 6. Interphalangeal joints 7. Metatarsophalangeal joints 8. Sesamoid 9. Head of metatarsal 10. Shaft (body) of metatarsal 11. Base of metatarsal 12. Cuneiforms 13. Navicular 14. Cuboid 15. Talus 16. Calcaneus 17. Tibia 18. Fibula 19. Tarsometatarsal joints 20. Transverse midtarsal joint

lateral foot: Basic Film Size: HD 24 x 30 cm (10 x 12 in ) lengthwise. large foot Film Size: HD 18 x 24 cm (8 x 10 in ) lengthwise. SHIELDING: Place lead shield over patient’s lap. Patient Position: Patient in lateral recumbent, pillow under head. Part Position: knee flexed 45 , opposite leg behind injured leg, foot carefully dorsiflexed for a true lateral position, support under leg and knee, sole of foot 90 to film. Distance: 100 cm or 40 in. CR: perpendicular to the film. C P: Medial cuneiform (level of the base of the 3 rd metatarsal). Collimation: collimate on four sides to area of interest. mediolateral Alternate lateromedial

RADIOGRAPHIC ANATOMY Lateral foot A. B. C. D. E. F. G. H. I. Tibia. Calcaneus tuberosity. Cuboid. 5 th MT tuberosity. Superimposed cuneiforms. Navicular. Subtalar joint. Talus. Structure shown: entire foot should be demonstrated and minimum of 1 in or 2. 5 cm of distal tibia-fibula. metarsals will be nearly (superimposition) with only the tuberosity of the fifth. metarsals seen in profile.

AP and Lat both feet (Weight-bearing technique ): Film Size HD 24 x 30 cm (10 x 12 in ) lengthwise (large foot for laterals). SHIELDING: Place lead shield over patient’s lap. • Patient Position : AP: Patient standing erect, full weight evenly distributed on both feet (on the fluoroscopic foot-rest). Lat : Patient stand erect on wood blocks on the foot rest, film vertically between feet, cassettes changed for lateral of the other foot for comparison. Distance: 100 cm or 40 in. Collimation: collimate on four sides to area of interest. CP: (AP): CR: 15 to midpoint between the both feet, at the level. of the base of metatarsals. (Perpendicular is preferred for flat foot). (Lat) : CR Horizontally to the level of base of the 3 rd metatarsals. Structure shown: for AP, projection shows bilateral feet from soft tissue surrounding phalangeas To distal portion of talus. For lateral entire foot should be demonstrated and a minimum of 1 in or 2 cm of distal tibia-fibula. . . CP CP S

Axial Calcaneus (Heel bone). Basic Film Size HD: 18 x 24 cm ( 8 x 10 in)crosswise. SHIELDING: Place lead shield over patient’s lap. Patient Position: Patient supine or seated. Part Position : legs fully extended, foot dorsiflexed (sole 90 to film), using a cotton ribbon or gauze looped around foot pulled by patient for support. Distance: 100 cm or 40 in. CR: 40 cephalic from long axis of foot. CP: Base of 3 rd metatarsal. Collimation: collimate on four sides to area of interest. Structure shown: entire Calcaneus should be visualized from the tuberosity posteriorly to the talocalcaneus joint anteriorly Axial Calcaneus (Heel bone) talocalcaneus joint

Mediolateral Calcaneus. Basic Film Size HD 18 x 24 cm ( 8 x 10 in)crosswise. SHIELDING: Place lead shield over patient’s lap. Patient Position: Patient lateral recumbent. Part Position : with affected knee flexed 45 , opposite leg behind injured limb, support under knee and leg, sole 90 to the film, ankle and foot in the true lateral. Distance: 100 cm or 40 in. CP: 1 inch inferior to medial malleolus. CR: perpendicular to the film. Collimation: collimate on four sides to area of interest. Structure shown: Calcaneus in profile with the talus and distal tibia-fibula demonstrated superiorly, and the navicular and the open joint space of the Calcaneus and Cuboid demonstrated Distally. Calcaneucuboid joint