Radiographic Positioning &

Special Procedure
 Leahjen Mae B. Parba, RRT

Radiographic Positioning
Rules of Oblique

 Cervical – Far
 Thoracic – Far
 Chest – Near
 Axillary ribs – Near
 Lumbar – Near
 Ilium – Near
 Sacroiliac joint – Far
 Colic flexure – Far

IVF/Pedicles ZJ

C O L

T L O

L L O

Chest

PA Chest

 CR: MSP at T7.

 Scapulae outside of the lung field.
 10 posterior ribs above diaphragm.
 Costophrenic angles and apices.

 CR: MCP at T7
 Superimposition of ribs.
 No rotation.
 Costophrenic angles and apices.

AP Chest (Supine)

 CR: 3" below jugular notch.

 Magnified heart & vessels.
 Shorter lung fields.
 Clavicles projected higher & more horizontal.

AP Axial Chest (Lordotic) AKA Lindblom

 CR: Mid sternum

 Coronal plane of thorax form 15-20 degree angle
with CR & IR.
 Clavicles superior to apices.
 Distorted ribs.

Decubitus Chest

 CR: Center of plate; IR: 1 ½ - 2" above shoulders.

 Free air.
 Fluid position.

Abdomen

KUB

 CR: MSP, Illiac crest (L4).

 Psoas muscles, lower border of liver, and kidneys.
 Pubic symphysis to diaphragm.
Upright Abdomen

 CR: 2" above illiac crest.

 Demonstrate air fluid level.
 Costophrenic angles to acetabulum.

Decubitis Abdomen

 CR: MSP at illiac crest.

 Demonstrates air fluid levels.
 Include side up.
 Diaphragm to pubic bone.

Upper Extremities

PA Finger

 CR: PIP joint of the affected finger.

 Open IP & MCP joints.
 Entire digit from fingertip to distal portion of
metacarpal.

Oblique Finger – 2nd digit (45 degree)

 CR: PIP joint

 Include MCP joint.
 Medial oblique done to decrease OID.
 No superimposition.
Mediolateral Finger (2nd digit)

 CR: PIP joint

 Include MCP joint.
 No rotation.
 Open IP spaces.
 Mediolateral done to decrease OID.

Oblique Finger – 3rd to 5th digit (45 degree)

 CR: PIP joint.

 Include MCP joint.
 Distal portion of finger to adjoining metacarpal.

Lateromedial Finger (3rd to 5th digit)

 CR: PIP joint

 Include MCP joint.
 Open IP spaces.
 No rotation.

Oblique (PA) Thumb

 CR: MCP joint

 Distal tip of the thumb to the trapezium.
 Open IP and MCP joint spaces.

AP Thumb

 CR: MCP joint

 Distal tip of the thumb to the trapezium.
 Open IP and MCP joint spaces.

Mediolateral Thumb (Hitchhiker)

 CR: MCP joint

 Anterior/Posterior displacement.
 Distal tip of the thumb to the trapezium.
 Open IP and MCP joint spaces.

PA Hand

 CR: 3rd MCP joint

 PA hand, oblique thumb.
 1" distal forearm.
 Open MCP and IP joints.
 No rotation.

45 Degree Oblique Hand

 CR: 3rd MCP joint

 Slight overlap of the metacarpal bases and heads.
 Separation of 2nd & 3rd metacarpals.

Lateral Hand

 CR: 2nd MCP joint

 Superimposed metacarpals.
 Superimposition of distal radius and ulna.
 All digits are fully extended or fanned out.
PA Wrist

 CR: Midcarpal area at the level of distal radius and

styloid process.
 Styloid process
 Open radioulnar joint.
 No rotation of carpals, metacarpals or radius.

External (Lateral) Oblique Wrist (45 degrees)

 CR: Midcarpal area.

 Trapezium is best demonstrated.
 Distal half of the scaphoid is visualized.
 Open trapeziotrapezoid and scaphotrapezial joint
space.

Internal (Medial) Oblique Wrist (45 degrees)

 CR: Midcarpal area.

 Visualization of the pisiform, lunate and triquetrium.

45 Degree Semi-Supination Oblique of Wrist

 CR: Midcarpal area.

 Pisiform best demonstrated.
 Triquetrium, hook of hamate and pisiform free of
superimposition and in profile.

Lateromedial Wrist

 CR: Level of the distal radial styloid (Midcarpal).

 Superimposed distal radius and ulna.
 Superimposed metacarpals.

Ulnar Deviation of Wrist

 CR: Scaphoid (20 degree angle towards patient).

 Scaphoid best shown without superimposition.
 No rotation.

Carpal Canal of Wrist (Gaynor-Hart Method)

 CR: 1" distal to base of the 3 rd MC (25-30 degree

angle).
 Demonstrates the carpal canal.
 Palmar aspect.
 Hook of hamate, pisiform, and trapezium fractures.

Carpal Bridge of Wrist

 CR: Enters ~1 ½" proximal to the wrist joint (45

degree angle).
 Demonstrates the carpal bridge.
 Demonstrates fractures of scaphoid and lunate.
 Chip fractures, calcifications and foreign bodies of
the dorsum.

AP Forearm

 CR: Mid-shaft
 Slight superimposition of radial head.
 Entire forearm from wrist joint to elbow joint.
 Open radioulnar space.
 No elongation or foreshortening.

Lateromedial Forearm

 CR: Mid-shaft
 Demonstrates the entire forearm from wrist joint to
elbow joint.
 Superimposition of distal radius and ulna.
 Superimposed humeral epicondyles.

AP Elbow

 CR: 1" below medial epicondyle.

 Radial head, neck and tuberosity superimposed over
the proximal ulna.
 Open elbow joint.
 True AP; no elongation or foreshortening.

45 Degree Internal Oblique Elbow

 CR: Elbow joint

 Coronoid process in profile and free of
superimposition.
 Demonstrates trochlea.
 Olecranon process within its fossa.

45 Degree External Oblique Elbow

 CR: Elbow joint

 Radial head, neck and tuberosity free of
superimposition.
 Demonstrates capitulum.
 Open elbow joint.

Lateromedial Elbow

 CR: Elbow joint

 Olecranon process in profile.
 Open elbow joint.
 Radial head partially superimposing coronoid
process.

Axial Lateromedial Projection (Coyle Method) for Radial

Head

 CR: 45 degrees towards shoulder at elbow joint.

 Joint space between radial head and capitulum
open.
 Radial head, neck and tuberosity should be in
profile, free of superimposition.

Axial Lateromedial Projection (Coyle Method) for

Coronoid Process

 CR: 45 degrees away from the shoulder at elbow

joint.
 The distal portion of the coronoid appears elongated
but in profile.
 Open joint space between coronoid and trochlea.
 Radial head and neck superimposed by ulna.
PA Proximal Forearm (Acute Flexion)

 CR: Angle tube perpendicular to forearm, entering 2"

distal to the olecranon process.
 Forearm and humerus superimposed.
 No rotation.

AP of distal humerus (Acute Flexion)

 CR: Entering 2" superior to the olecranon process.

 Distal humerus and olecranon process.
 Forearm and humerus superimposed.

AP of Proximal forearm

 CR: Perpendicular to the elbow joint & long axis of

the forearm.
 Proximal radius and ulna without rotation.
 Radial head, neck and tuberosity slightly
superimposed over the proximal ulna.
 Partially open elbow joint.

AP of Distal Humerus

 CR: Perpendicular to the condyloid area of the

humerus.
 Distal Humerus without rotation or distortion.
 Proximal radius superimposed over ulna.
 Closed elbow joint.

AP Humerus

 CR: Mid-shaft
 Epicondyles are seen in profile without rotation.
 Humeral head and greater tubercle are seen in
profile.
 Lesser tubercle superimposed between greater
tubercle and humeral head.

Lateral Humerus

 CR: Mid-shaft
 Epicondyles are superimposed.
 Lesser tubercle in profile medially.
 Greater tubercle superimposed over humeral head.

Transthoracic Lateral Humerus

 CR: Axillary border exiting the level of the mid-shaft

of the injured humerus.
 Glenohumeral articulation.
 Scapula, clavicle and humerus seen through the
lung field.
 Unaffected side should not superimpose affected
side.

AP Internal Shoulder
 CR: 1" below coracoid process.
 Lesser tubercle in profile.
 Greater tubercle superimposed over the humeral
head.
AP External Shoulder

 CR: 1" inferior to the coracoid process.

 Greater tubercle in profile.
 Lesser tubercle superimposed over humeral head.
 Humeral head in profile.

Y-View Shoulder

 CR: Glenohumeral joint humeral head superimposed

over the 'Y' of the scapula, placed between the
acromion and coracoid process.
 Acromion projected laterally and free of
superimposition.
 Acromion, coracoid, scapular body form the 'Y'.

Inferosuperior Axial Shoulder

 CR: Horizontal through the axilla to the region of the

AC joint. (The greater the abduction, the greater the
angle; 15-30 degrees).
 Scapulohumeral joint with slight overlap.
 Lesser tubercle in profile anteriorly.
 AC joint, acromion, and acromial end of clavicle
projected through the humeral head.

AP Oblique Shoulder (Grashey Method)

 CR: 2" medial & 2" inferior to superolateral border of
shoulder (Pt. rotated 45 degrees toward affected
side).
 Open joint space.
 Glenoid cavity in profile.

AP Clavicle

 CR: Mid-shaft of clavicle.

 Entire Clavicle.
 Medial aspect is superimposed over the thorax.
 Lateral aspect is projected above the scapula.

AP Axial Clavicle

 CR: Mid-shaft of clavicle (15-30 degree cephalic

angle).
 Most of the clavicle projected above the scapula.
 AC & SC joints.
 Demonstrates displacements and fractures.

AP Acromioclavicular (AC) Joints

 CR: Midline at the level of the AC joint; 1-1.5" above

the jugular notch.
 AC joints visualized without separation.
 Done bilaterally when possible.
 Demonstrates dislocation, separation and joint
function.
Lower Extremities

AP

 Supine/Sitting
 CR: ┴ 3rd MTP (15° wedge foam).

AP Axial

 Supine
 CR: 15° posteriorly to 3rd MTP.

PA

 CR: ┴ to 3rd MTP.

 BD: An open IP joint space between of the
divergence of the CR with the joint spaces.

AP Medial Oblique

 Medially rotate 30° – 45°.

 CR: ┴ to 3rd MTP.
 BD: 1st and 2nd digits.

AP Lateral Oblique

 Laterally rotate 30° – 45°.

 CR: ┴ to 3rd MTP.
 BD: 3rd – 5th digits.
 Lateral Projections
 1st – 2nd digits lateral recumbent on the unaffected
side.
 3rd – 5th digits lateral recumbent on the affected side.

Lewis

 Prone, plantar surface forms an angle of 15° – 20°

from the vertical position.
 CR: ┴ to 1st MTP joint – tangential sesamoid bone.

Holly

 Supine, plantar forms an angle of 75° to IR.

 CR: ┴ to 1st MT.
 Tangential sesamoid bone.

Causton

 Lateral recumbent
 CR: 40° towards heel.
 Axiolateral projection of the sesamoid bone.

AP (Axial) Foot

 CR: Base of the 3rd metatarsal (10 degree toward

foot).
 Entire foot.
 Open tarsal articulations.
Medial Oblique (30 degree) Foot

 CR: Base of the 3rd metatarsal.

 Sinus tarsi.
 Cuboid seen best.
 Tuberosity of 5th metatarsal.
 3rd thru 5th bases free of superimposition.

Mediolateral Foot

 CR: Base of 3rd metatarsal.

 Lateral projection of foot and ankle.
 Distal tib/fib base of 5th metatarsal isolated.

Plantodorsal Heel

 CR: Centered to the 3rd metatarsal at the level of the

base of the 5th metatarsal.
 Distal calcaneus tuberosity.
 Sustentaculum tali and trochlea.
 Open talocalcaneal joint.

Mediolateral Heel

 CR: 1" distal to medial malleolus.

 Open sinus tarsi.
 Lateral malleolus superimposed over talus.

AP Tibia/Fibula
 CR: Midshaft
 Entire tib/fib including knee and ankle joint;
separation of diaphysis.

Mediolateral Tibia/Fibula

 CR: Midshaft
 Femoral condyles & malleoli superimposed.

AP Knee

 CR: ½" distal to the apex of the patella (5 degrees

cephalic).
 Open knee joint.
 Patella superimposed over femur.
 Slight superimposition of fibular head with tibia.

Medial (Internal) Oblique Knee (45 degree)

 CR: ½" distal to the apex of the patella (Optional 3-5

degree cephalic).
 Proximal tib/fib articulation.

Lateral (External) Oblique Knee (45 degree)

 CR: ½" distal to the apex of the patella (Optional 3-5

degree cephalic).
 Fibula superimposed over the lateral half of the tibia.
 Medial condyles of femur and tibia.
Mediolateral Knee

 CR: 1" distal to the medial epicondyle (5-7 degree

cephalic).
 Open patellofemoral joint space.
 Patella in profile.
 Fibular head slightly superimposed with tibia.

Axial Patella (Sunrise, Sunset, Settegast, & Skyline)

 CR: 15-20 degrees with the tib/fib passing through

patellofemoral joint space.
 Patella in profile w/bony detail.
 Open patellofemoral joint space.

AP Femur

 CR: Mid Femur (IR 2" below knee joint or at ASIS).

 No rotation of femur.
 Acetabulum, femoral head and neck in entirety.

Mediolateral Femur

 CR: Mid Femur (IR 2" below knee joint or at ASIS).

 Patella in profile.
 Superimposed femoral condyles.
 Trochanters not prominent.

AP Pelvis
 CR: 2" above greater trochanter (IR 1-1 ½" above
iliac crest) [Pigeon Toed 15-20 degrees].
 Greater trochanters in profile.
 Symmetric obturator foramina.
 Lesser trochanters not visualized

AP Hip

 CR: Femoral neck (Internally rotate legs 15-20

degrees).
 Greater trochanter in profile.
 Include pubic symphysis.

Lateral Hip (Modified Cleaves)

 CR: Femoral neck (Frog-leg).

 Greater trochanter is superimposed over femoral
neck.
 Lesser trochanter in profile medially.

X-Table Lateral Hip (Axiolateral Projection Danelius

Miller Method)

 CR: Long axis of the femoral neck.

 Hip joint with acetabulum.
 Femoral neck without overlaps of greater trochanter.

Vertebral Column
Left Lateral C-Spine

 CR: C4 posterior to EAM.

 Zygapophyseal joints and intervertebral disk spaces.
 Spinous processes seen in profile.

AP Axial C-spine

 CR: C4 (15-20 degrees cephalic).

 C3-T2
 Open intervertebral disk spaces.

45 Degree Axial Oblique C-Spine

 CR: C4 (15-20 degrees cephalic [AP] or caudal

[PA]).
 RPO/LPO: Intervertebral foramina demonstrated on
the up side.
 RAO/LAO: Intervertebral foramina demonstrated on
the down side.

AP Open Mouth Odontoid

 CR: MSP just below upper teeth.

 Dens free of superimposition by occipital bone.
 C1/C2 articulation.

Fuchs
 CR: Between mandibular angles distal to tip of chin
(30 degree cephalic).
 Dens projected through foramen magnum.

Trauma X-Table Lateral C-spine

 CR: C4
 Collar on.
 All cervical vertebrae.

Soft Tissue Neck (AP & Lat)

 CR: C4
 65 kVp.
 Demonstrates pharyngolaryngeal structures.

AP T-Spine

 CR: T7 halfway between jugular notch and xiphoid

process.
 All 12 thoracic vertebrae.
 Spinous processes at the midline of the vertebral
bodies.

Swimmers

 CR: C7-T1 (5 degrees caudal).

 Lateral projection C5-T4.
 Humeral heads minimally superimposed over spine.
Left Lateral T-Spine

 CR: T7 posterior to axillary border.

 T4-T12 well visualized.
 Ribs superimposed.
 Open intervertebral disk spaces.
 Foramina on the down side.

AP L-Spine

 CR: Level of iliac crest.

 Lumbar bodies, transverse processes and
intervetebral disks.
 T11 to distal sacrum open intervertebral joins.

45 Degree RPO/LPO L-Spine

 CR: Level of the bottom on the ribs & 2" medial to

ASIS.
 Zygapophyseal joints of L1-L4.
 "Scotty dogs"

Left Lat. L-Spine

 CR: Level of iliac crest.

 Intervertebral foramina L1-L4.
 Open intervertebral disk spaces.
 Spinous processes in profile.
 Entire sacrum.

L5-S1 Spot
 CR: Midway between iliac crest and level of ASIS (2"
posterior to ASIS and 1.5" inferior to iliac crest).
 Open lumbosacral intervertebral joint.

AP Sacrum

 CR: Midway between ASIS and pubic symphysis (2"

inferior to ASIS) 15 degrees cephalic.
 Entire sacrum and SI joints.
 Pubic bone not overlapping.
 Straightening of sacral curve.

AP Coccyx

 CR: Midway between ASIS and pubic symphysis (2"

inferior to ASIS) 10 degrees caudal.
 Coccygeal segments not superimposed.

Lateral Sacrum

 CR: Level of ASIS and 3 ½" posterior.

 Lateral aspect of the sacrum & coccyx if included.

Lateral Coccyx

 CR: 2" inferior and 3 ½" posterior to ASIS.

 Lateral aspect of coccyx.

Skull
AP Axial Skull (Caldwell)

 CR: Exits the nasion (15 degrees caudal, 23

degrees if using the GML) OML perpendicular.
 Entire cranium.
 Petrous Pyramids lie in the lower 1/3 of the orbit.
 Orbits magnified due to positioning.

PA Axial Skull (Caldwell)

 CR: Exits the nasion (15 degrees caudal, 23

degrees if using the GML) OML perpendicular.
 Entire cranium.
 Petrous Pyramids lie in the lower 1/3 of the orbit.

AP Towne Method

 CR: 2"-2 ½" above the glabella (30 degrees caudal,

37 degrees caudal when using the IOML).
 Symmetrical petrous pyramids.
 Posterior portion of foramen magnum.
 Dorsum sellae within foramen magnum.
 Occipital and posterior portion of parietal bones.

PA Haas Method

 CR: Enters 1 ½" below the inion to exit 1 ½" superior

to the nasion.
 Symmetrical petrous pyramids.
 Posterior portion of foramen magnum.
 Dorsum sellae within foramen magnum.
 Occipital and posterior portion of parietal bones.

Lateral Skull

 CR: Enters ~2" superior to the EAM.

 Side closest to cassette.
 Superimposition of the petrosae, mastoid processes,
TMJs, orbital roofs, greater wings of sphenoid.

Sinuses PA Caldwell

 CR: Exits the nasion (OML forms a 15 degree angle

with the CR)
 Frontal sinuses
 Maxillary sinuses
 Anterior ethmoid air cells.
 Horizontal CR improves detail of air fluid levels.

Sinuses Waters (Patrietoacanthial)

 CR: Exits the acanthion (OML is 37 degrees with

cassette, MML is perpendicular to bucky).
 Demonstrates the maxillary sinuses and rotundum
foramina.
 The petrous ridge is projected below the floor of the
maxillary sinus.
 Frontal and ethmoidal air cells are distorted.

Lateral Sinuses
 CR: ½" to 1" posterior to outer canthus of eye.
 All sinuses.
 No rotation of sella turcica.

Submentovertical Projection (SMV)

 CR: Perpendicular to IOML centered between

mandibular angles.
 Anterior frontal bone superimposed by mental
protuberance (Chin).
 Mandibular condyles anterior to petrous pyramids.
 Best view to demonstrate the sphenoid and ethmoid
sinuses.

PA Axial Orbits

 CR: Exits ¾" distal to nasion, at the center of the

orbits (30 degree caudal angle).
 Symmertrical superior orbital fissures.
 Petrous pyramids below inferior margins of the
orbits.

Parietoacanthial Orbits (Waters)

 CR: Mid Cassette exiting the orbits.

 Petrous pyramids lying well below the orbital
shadows.
 Symmetrical visualization of orbits.
 Demonstrates localization of foreign body.

Lateral Orbits
 CR: Outer canthus of eye.
 Superimposed orbital roofs.
 Demonstrates foreign body.
 Blowout fracture.
 Rules out blood in sinus cavity.

Optic Foramen (Rhese Method)

 CR: 1" superior and posterior to top of ear

attachment (3point landing: chin, cheek, and nose
touching the table) exits orbit on side closest to the
cassette.
 Optic canal and optic foramen visible at end of
sphenoid ridge.
 Entire orbital run.

PA Caldwell (Axial) Facial Bones

 CR: Exits nasion (15 degree caudal).

 Demonstates all facial bones.

Parietoacanthial Projection (Waters view) Facial Bones

 CR: Exits acantion.

 Petrous ridges below maxillae.
 Demonstrates the maxillae, orbits, and zygomatic
arches.

Left Lateral Facial Bones

 CR: Lateral surface of the zygomatic bone halfway
between the outer canthus and EAM.
 Facial bones closest to film.
 Orbital roofs superimposed.
 Almost perfectly superimposed rami.
 Sella turcica in profile.

Submentovertical Projection (SMV) Facial Bones

 CR: Perpendicular to IOML, enters MSP at level

approx. 1"posterior to outer canthus.
 Symmetrical bilateral zygomatic arches or "Jug
handles".
 If one side is not visualized, rotate MSP 15 degrees
towards affected side, then tilt the top of the head
away from the affected side and expose unilaterally.

Nasal Bones Parietoacanthial Projection (Waters View)

 CR: Exits the acanthion (OML is 37 degrees with

cassette).
 Nasal septum
 Petrous ridges below maxillae.
 Demonstrates the orbits and maxillary sinuses.

Lateral Nasal Bones

 CR: Perpendicular to bridge of nose ½ distal to

nasion.
 Demonstrates anterior nasal spine, frontonasal
suture and nasal bone.
PA Mandible

 CR: Exits acanthion (Nose and forehead rest on

table).
 Demonstrates the mandibular body and TMJ's.

Axiolateral Mandible

 CR: Centered between bodies of the mandible

(Degree cephalic angle).
 Patient in a RAO / LAO position with head in a
lateral position.
 Ramus closest to the cassette.

Axiolateral Mandible

 If imaging the Ramus: 0 degrees.

 If imaging the Body: 30 degrees.
 If imaging the Symphysis: 45 degrees.

Barium Enema

BE AP Projection

 CR: Level of iliac crest.

 All of colon.

AP Axial Projection (Recto-Sigmoid Angle View) BE

 CR: (30- 40 degrees cephalic) 2" below ASIS.

 Rectosigmoid area of the colon.
 Include the tip.
 Less superimposition than AP.

45 Degree Right Posterior Oblique (RPO) BE

 CR: 1-2" lateral to midline of body on elevated side

at top of the crest.
 Looking at the upside (Splenic or left colic flexure).
 Descending colon

45 Degree Left posterior oblique (LPO) BE

 CR: 1-2" lateral to midline of body on elevated side

at top of the crest.
 Looking at the upside (Hepatic or right colic flexure).
 Demonstrates ascending and sigmoid portions of the
colon.

Right Lateral Decubitus Position BE

 CR: At the level of the iliac crest.

 AP projection of the contrast-filled colon.
 "Up" medial side of the ascending colon and the
lateral side of the descending colon.

Left Lateral Decubitus Position BE

 CR: At the level of the iliac crest.

 PA projection of the contrast-filled colon.
 "Up" lateral side of the ascending colon and the
medial side of the descending colon.

Lateral Projection (Right Ventral Decubitus Position) BE

 CR: Midcoronal plane at level of iliac crest.

 Lateral projection of the contrast filled colon.
 "Up" posterior portion of the colon (Tip must be
removed before making exposure).

AP/PA Esophagram

 CR: Along the long axis of esophagus, 3" inferior to

jugular notch (Level of T5-T6).
 Esophagus through superimposed thoracic spine.
 Esophagus from lower part of neck to the EG
junction.

RAO/LPO Esophagram

 CR: 2" lateral to MSP on the up-side, 3" inferior to

jugular notch (Level of T5-T6).
 Esophagus free from superimposition of the
vertebral column.
 Esophagus seen between vertebral column and
heart.

Lateral Esophagram
 CR: MCP 3" inferior to jugular notch (Level of T5-
T6).
 Posterior ribs superimposed to demonstrate true
lateral position.

UGI AP

 CR: Midway between the xiphoid process and lower

rib margin (Level of L1-L2).
 Entire stomach and duodenal loop.
 Contrast in fundus of stomach.
 Rugae best seen with double contrast.

UGI Right Lateral

 CR: 1-2" above lower rib margin (Level of L1-L2).

 Fundus empty, pylorus and duodenal bulb filled with
contrast.
 Entire stomach and duodenal loop.

UGI RAO

 CR: 1" away from vertebral column towards elevated

side.
 Entire stomach and duodenal loop.
 Duodenal loop and bulb in profile.
 Pyloric canal and duodenal loop free of
superimposition.

UGI PA
 CR: 1-2" above lower rib margin (Level of L1-L2).
 Entire stomach and duodenal loop.
 Entire stomach contour and duodenal loop filled with
contrast.
 Lower lung field should be visualized for evaluation
of possible hiatal hernia.
Special Procedure

 OCG – By mouth
 IVC – By injection
 PTC
 IOC By direct
 T-TUBE injection CBD.
 ERCP

Biliary System

 Gallbladder – Temporary storage area of bile.

 Bile is manufactured by the liver.
o Liver is the largest organ.
 RUQ
 Bile is to aid in digestion of fats by breaking down fat
globules.
 Right and left hepatic duct = Common bile duct
 Duodenum bile by: Common bile duct → pancreatic
duct or duct of wirsung.
 Hypersthenic – Higher/Lateral
 Sthenic/Hyposthenic – Between xiphoid and lower
rib.
 Asthenic – Medial/Inferior
 Cholecystogram
o Gallbladder
 Cholangiogram
o Bile ducts
 Cholecystocholangiogram
o Gallbladder and bile ducts
 Stones
o Radiopague – Calcium containing.
o Radiolucent – Pure cholesterol.

Intravenous Cholangiography (IVC) – Biliary ducts of

cholecystomized patient

 30-40 minutes: Maximum opacification (Ducts

studies are ordinarily obtained at 10 minutes
interval).
 20 cc: Full dose

RPO Position

 BR: 15° – 40°

o 15° – 20° (Hypersthenic)
o 20° – 25° (Sthenic)
o 35° – 40° (Asthenic)

Demo: GB/Bile duct away from spine.

Percutaneous Transhepatic Cholangiography (PTC) –

Pre operative for biliary tracts.

Most invasive.
 Patient with jaundice.
Indications:

 Obstructive jaundice
 Stone
 Biliary
Contraindications:

 Liver hemorrhage
 Pneumothorax
 Escape of bile.

Chiba Needle (Skinny needle)

 Right lateral intercostal space towards liver hilum.

Immediate Operative Cholangiography (IOC)

 During cholecystomy.
o Patency of ducts.
o Final status of sphincter.
o Reveal presence of previously undetected
biliary tract calculi.
 6-8 ccc introduced into the CBD.
 RPO (15°–20°) – Projecting biliary ducts away from
the spine in hyposthenic patient.

T-tube Cholangiography – (Post Op)

 T-tube is left in the CBD (post-surgical).

 Patency of ducts.
 Detect new undetected stones.
 RPO (15°–20°)
 Lateral – Anatomic brunching of hepatic ducts.
Endoscopic Retrograde Cholangio Pancreotography
(ERCP) – Biliary & Pancreatic Duct

 Fluoroscopy
o Good if no dilation, no obstruction.
o Canulla is placed in CBD.
 Endoscope
o 5 minutes drainage only.

Food – Withhold for up to 10 hours to minimize

irritation to the stomach and small bowel.

Trendelenburg

 CM fills intrahepatic ducts.

Semi-Erect

 CM fills lower CBD.

Oral Cholecystogram – Gallbladder

Contraindicated if:

 Advanced hepatic disease.

 Active gastric disease.
 Hypersensitive to CM.
Preparation:
 No laxative before 24 hours.
 Fatty meal (lunch) – Drain GB of bile.
 Fat free evening meal – Prevent drainage of bile
from GB.
 2-3 hours after fat free evening meal CM is given.
 10-12 hours absorption time of CM.

Calcium – Heavier stone

Cholesterol – Lighter stone

PA Projection

 CR: ┴ L2
 Scout film.
o Location of opacified GB.
 BD: Milk calcium bile.

PA Erect

 Stratification or layering of GS.

 BD: Axial view of opacified GB.
 Mobility of stones; too small or not to cast.
 Differentiate Papilloma to GS.
 GB inferior and medial.

LAO – PA Oblique

 BR: 15° – 40°

o 15° – 20° (Hypersthenic)
o 20° – 25° (Sthenic)
o 35° – 40° (Asthenic)
 Demo: GB away from VS.
 BP: Differentiate gas in the bowel black stones in
GB.
 Oblique GB with less foreshortening.

Right Lateral Recumbent

 Demo: Opacified GB away from VS and bowel

loops.
 Use to:
o Gallstones vs renal stones or
o Calcified mesenteric lymph nodes.

Right Lateral Decubitus

By: Whelan

 Demo: Multiple stones that can’t be detected to

others.
 Stratification or layering of GS.
 Alternative PA upright.

Trendelenburg

 Supine
 15° – 20°
 Separate GB away from gas shadow in hepatic
flexure (contraction ability).

Fletchner Method
 BP: To separate GB shadow from hepatic flexure.
 Reverse Lindbloom.
FATTY MEAL (POST MOTOR MEAL)
o Egg + milk/eggnog
o RPO (best drain)
o Radiographs taken every 15 minutes.

Retrograde Urography – Kidneys & Ureters

AP Projection

 Supine
 Scout film.
o Catheter location.

AP Projection/Trendelenburg

 Pyelogram
 HR: 10° – 15° down.
 3-5 cc injected.

AP Projection Fowlers

 HR: 35° – 40° head elevated internal.

 Demo: Kidney and ureters.

RPO/LPO

 Ureter away from vertebral spine.

Lateral

 A and P
 Displacement of kidney & ureter.
 Delineate perinephric abscess.

Cross-Table

 Ureteropelvic region with hydronephrosis.

Retrograde Cystography – Urinary Bladder (Urethral

catheter)

 Trauma
 Calculi
 Tumor inflammation process of UB.
 UB = 150-500 cc CM
 Empty bladder
 Cystogram – Common to rule out trauma.

AP Projection

 CR: ┴ 2″ ↑ pubis.
 Contrast filled UB for possible reflux.

AP Axial

 Supine
 CR: 10° – 15° ↓
 Contrast filled UB for possible reflux.
 CR: 5° ↓
 BD: UB neck and proximal ureter.

PA Axial

 10° – 15° ↑ 1″ distal to tip of coccyx.

 Demo: UB neck
 CR: 20° – 25° ↑
 Demo: Shadow of prostate above pubic bone.

Trendelenburg

 Supine
 15° – 20° head ↓.
 // unobstructed view of distal ureter and
vesicoureteral orifice.

AP Oblique

 BR: 40° – 60°

 CR: ┴ 2″ above pubis, 2″ medial ASIS.
 BD: Posterior lateral.

RPO/LPO

 BR: 40° – 60°

 CR: 10° ↓
 UB neck and proximal uterus with pubic bone below.

Chassard Lapine

 Squat shot
 UB axial image and posterior surface of distal ureter.

Digestive System (+ & -)

 Most common forms of (-).

 Crystals: Calcium & Mg Citrate
 Double contrast
o Polyps
o Diverticula
 BaSO4
o Swallowed air
o Gas bubbles
 Water soluble

Esophagogram/Barium Swallow – Esophagus &

Pharynx

 Single Contrast
 Double Contrast
 Filling Phase
o Thin barium
o Distend lumen
o 1:1 & 3-4 swallow
 Mucosal Phase – Demo: Mucosal pattern/inner
coating.
o Thick barium
o Mucosal
o 4:1 BaSO4

Indicates:
 Achalasia/Cardiospasm – Less peristalsis of 2/3 of
eso/cardiospasm.
 Barrettes esophagus – Epithelium with columinar
lined lower end.
 Carcinoma/Adenocarcinoma – Most common cancer
of esophagus.
 Carcinocarcinoma – Large polyp.

Esophagogram/Endoscopy – Detection
CT scan – Staging

Entry of gastric to
Esophageal reflux
esophagus.
Esophageal varices
Dilation of veins in distal
 Best seen in
area; wormlike/cobble
recumbent.
stone.
 Cotton with barium.
Zenker’s diverticulum Large outpouching.
Technique:
 Breathing exercise
o Valsalva (most common)
o Mueller
 Water test (LPO)
o Positive water test.
 Compression paddle (Prone)
 Toe touch maneuver (Erect)
o Hiatal hernia
o Esophageal reflux

AP Projection

 Supine/Erect
 MSP ┴ MLT
 CR: ┴ 1″ inferior to sternal angle.
 Mucosal phase – 3:1 & 2-3 spoonful
 Filling phase – 1:1 & 3-4 cont. swallowing
 Esophagus superimposed in thoracic spine.

PA Oblique

 RAO position (ventral recumbent)

 BR: 35° – 40°
 CR: ┴ T5-T6
 BD: Entire esophagus free from S1 of heart and
vertebral.

Lateral

 Erect lateral/lateral recumbent

 MSP ┴ MLT
 CR: ┴ T5-T6
 BD: Esophagus between heart and thoracic spine.
 Also, anterior and posterior displacement of
esophagus

Swimmers Lateral

 BD: Upper esophagus without superimposition of the

shoulder.
Preferred: Recumbent to fill completely the
esophagus (gravity pull).
Voiding Cystourethrogram – Urinary Bladder & Urethra

 Trauma
 Incontinence
 After voiding shot is complete, voiding AP next.
 Evaluate the ability to urinate.
o Male: Supine/Erect, 30° – 40° RPO (ureter
compression)
o Female: Supine/Slight oblique (Urethra below
pubis)

Modifications for Barium Enema

Pathology:

 Polyps

Axial & Axial Oblique Projection

 Butterfly position.

AP Axial

 Supine
 CR: 30° – 40° ↑
 BD: Elongated view of rectosigmoid.

PA Axial

 Prone
 CR: 30° – 40° ↓
 BD: Elongated view of rectosigmoid.

AP Axial Oblique

 Supine
 LPO
 CR: 30° – 40° ↑
 BR: 30° – 40°
 BD: Elongated view of rectosigmoid.

PA Axial Oblique

 Prone
 RAO
 CR: 30° – 40° ↓
 BR: 30° – 40°
 BD: Elongated view of rectosigmoid.

Robin’s Modification

 Left lateral decubitus

 CR: ┴ 2″ posterior to MCP at level of ASIS.
 Most important modification of BaE.
 Demo: Direct lateral of rectosigmoid without
superimposition.

Chassard-Lapine Modification

 Sitting
 Lean forward
 CR: Lumbosacral
 Demo: Axial view of rectosigmoid.
 Right view angle of AP projection.
 A & P of lower part of large bowel.

Billing’s Modification

 Supine
 35° – 45° ↑ midway between ASIS.
 S/S: Rectosigmoid
Prevent overlapping loop of rectosigmoid.

Openheimer’s Modification

 Supine
 CR: 12″ ↓, 1″ upper border of pubis.
 S/S: Rectosigmoid

Fletcher’s Modification

 LAO
 CR: 30° – 35° ↑, 2″ medial to elevated ASIS.
 BR: 30° – 35°
 S/S: Rectosigmoid

Trendelenburg

 Supine/Oblique
 CR: ┴ midway between PNLS.
 S/S: Rectosigmoid
Post-Evac – AP Projection

 Supine, during crest.

 Determine how much barium retained.
 20% of barium must be retained.

Defecography – Anus & Rectum

 Lateral projection
 Anorectal between the long axis of canal and
rectum.

Small Intestinal Series (Barium Flow)

Administered by:

 Mouth
 Direct
 Complete reflux
Contraindicated:

 Perforated hallow viscus.

 Large bowel obstruction.
 Pre-surgical
 Use water-soluble iodinated CM.

Supine

 Retrogastric portion of duodenum, jenunum and c-

loop.
 Prevents compression of loops.

Prone

 High degree of visibility.

 Allows Compression to separate loops.

Trendelenburg

 Prevent overlapping or redundant loops.

Barium Enema – Large Intestine + & -

 Single contrast – 12% – 25% weight/volume

 Double contrast – 75% – 95% weight/volume
 BaSO4 temperature: 29°C –30°C or 85°F – 90°F
 Cold barium: 41°F or 5°C
 Height of the barium: 18″ – 24″ or 45-60cm
 Tube total distance: 3.5″ to 4″
 During exhalation: 1″ – 1.5″ anteriorly.

Sims Position

 35° to 40° lean left side forward.

Relax abdominal pressure.

AP Projection

 Supine (SATS BAD)

 MSP ┴ MLT
 CR: ┴ iliac crest or L3/L4 umbilicus.
 Air (SATS)
 Barium (BAD)

PA Projection

 Prone (PARAD BTS)

 MSP ┴ MLT
 CR: ┴ iliac crest.
 Air (PARAD)
 Barium (BTS)

Trendelenburg

 Separates redundant and overlapping loops of

bowel.

AP Oblique

 RPO/LPO
 BR: 35° – 45° away from IR.
 CR: ┴ iliac crest.
 DB: Colic flexure farthest to IR.

PA Oblique

 RAO/LAO
 BR: 35° – 45° towards from IR.
 CR: ┴ iliac crest.
 DB: Colic flexure nearest to IR.
 RPO/LAO – Splenic flexure
LPO/RAO – Hepatic flexure

Ventral Decubitus

 Prone
 DB: Posterior portion of the colon/large intestine.

Right Lateral Decubitus

 Supine
 CR: ┴ iliac crest.
 BD: LW of D C and ML of AC.

Left Lateral Decubitus

 Prone
 CR: ┴ horizontally directed iliac crest.
 DB: LW of AC and MW of DC.
Air inflated portion of the large intestine for lateral.

Modification Of Ugis

Gordon – PA Axial
Hypersthenic patient
 Prone
 CR: 35° – 45° ↑
 4″ left to pylorus.
 Open high up and transverse stomach.
Gugliantini – PA Axial
Infants stomach
 Prone
 CR: 20° – 25° ↑
 Same as Gordon.

Hamptons – AP Oblique
Leaf-like pattern pylorus and duodenal bulb.
 Semi-supine
 LPO position
 BR: 45°

Poppels
Right angle view of stomach.
 Supine
 2 exposures:
o CR: ↕ direct level of pylorus.
o CR: ↔ direct level of pylorus.
 Retrogastric space, cancer and mass pancrea.

Wolf – PA Oblique
Hiatal hernia
Modified Trendelenburg
 RAO position
 Radiolucent compression
 o Intra-abdominal pressure
 No need right < of the table.
 BR: 40° – 45°
 CR: 10° – 20° ↓

Trendelenburg

 Partial fills barium of fundus for asthenic.

 Full hiatal hernia

Sommer-Foegelle

 34° angle board.

 Trendelenburg
 Patient flex trunk.
 CR: ┴ xiphoid process.
 S/S: Hiatal hernia

Hypotonic Doudenography – Doudenal Loop in Flaccid

State

 Uses intubation.
 Temporary drugs.
o Buscopan or Arobantin
 CM patient to swallow:
o 100mL – BaSO4
o 40 gas producing tablets.
 Right lateral recumbent
o Anticholingic drug
 AP, RAO, LPO, & Lateral
 o Taken after 15 mins.
5 hours NPO.

Urinary System

 Excretes: 1-2L of urine a day.

 Location kidney level: T12-L3
 Kidney lies oblique plane and rotate 30° towards
aorta.
 Ionic and nonionic CM is used:
o BUN and CREA
 Glucophage/metformin withhold 48hours
before and after procedure.
 Respiratory movement: 1″
 Expiratory movement: 2″ drop
 500mL urine – Adult UB
 250mL urine – Urination
 Urography
o IVU
o Catheter

Intravenous Urography – Urinary System Thru Injection

 True final test of urinary system.

Contraindicated:

 Anuria
 Hypersentivity
 Diabetes
 Renal disease
 Renal failure
Patient preparation:

 Bowel cleansing cathartics.

o 2 tabs Dulcolax
 Enema morning
 NPO
 Empty bladder
o Rapture (too full)
o Urine dilutes CM.

AP Scout Film

 ┴ iliac crest.

AP Supine

 ┴ midway between xiphoid tip and iliac crest.

 1 minute: Nephrogram
 5 minutes: Pyelogram

AP Oblique

 RPO/LPO (Near)
 BR: 30°
 CR: ┴ iliac crest (L3-L4)
 RPO – Left kidney // in profile.
 LPO – Right kidney // in profile.

AP Projection with Uteric Compression Device

 Supine
 CR: ┴ midway between xiphoid tip and iliac crest.
 Compression band: After 15 minutes.
 BD: Pelvocalyceal system and proximal ureter filled
CM.
 Pyelonephritis

PA Projection

 Alternative of ureteric device compression #2.

 Demo: Ureteric pelvic region.
 Hydronephrosis

Lateral – Recumbent

 BD: Pressure/rotation displacement.

 Localize tumors.

Trendelenburg

 Same with compression device without risk of

contraindications.

Post Void

 Prone
 Nephroptosis
 Enlargement prostate.

Lateral Decubitus
 Cook method
 Supine
 Dorsal decubitus
 Demo: Extrarenal mass
o Intraperitoneal
o Extraperitoneal
 Abnormal kidney displacement

Ventral Decubitus

 Rolleston-reay
 Prone
 Demo: Ureteropelvic region

Reverse Projection

 RPO/LAO
 LPO/RAO