Femur

• Clinical Indication
• Trauma
• Obvious deformities
• Suspected foreign body
• Inability to bear weight
• Osteomyelitis

• 35 × 43 cm cassette

• Radiation Protection

• A grid may be used so that the effects of scatter are reduced- Table top
 AP- Femur
Position of patient and image receptor
• The patient lies supine on the X-ray table, with both legs extended
and the affected limb positioned to the center line of the table.

• The affected limb is rotated to centralize the patella over the

femur.

• Sandbags are placed below the knee to help maintain the position.

• The IR/Bucky mechanism is located directly under the posterior

aspect of the thigh to include both the hip and the knee joints.
 AP- Femur

Direction and location of the X-

ray beam
• Mid-shaft of the femur, with the
central ray at 90° to an imaginary
line joining both femoral condyles.
 AP- Femur
• Essential image characteristics
• Ideally, the length of the femur should be visualized, including the hip and
knee joints.

• The patella should be centralized to indicate rotation has been minimized.

AP- Femur

Upper femoral shaft #

 Lateral- Femur
• Position of patient and image receptor
• From the AP position, the patient rotates on to the affected
side with the knee slightly flexed and the patient adjusted so
that the thigh is positioned to the center line of the
table/cassette.

• The pelvis is rotated backwards to separate the thighs.

• The position of the limb is then adjusted to superimpose the

femoral condyles vertically.
 Lateral- Femur

• Direction and location of the X-

ray beam
• Middle of the femoral shaft, with
the central ray parallel to the
imaginary line joining the femoral
condyles.
Lateral- Femur
Lateral- Femur
 Pelvis
• Clinical Indication
• Pubic ramus fracture
• Complex pelvic ring fracture
• Acetabular fracture
• Head of femur dislocation
• Sacral fracture
• Suspected foreign body
• Osteomyelitis

• 35 × 43cm cassette

• Radiation Protection

• A grid may be used so that the effects of scatter are reduced- Table top
Pelvic anatomy and image appearances
Pelvis
 Pelvis
Female pelvis Male pelvis.
Pelvis
 AP – Pelvis (Both Hips)
Position of patient and image receptor
• The patient lies supine and symmetrical on the X-ray table with the median sagittal
plane perpendicular to the tabletop.

• The midline of the patient must coincide with the centred primary beam and table
Bucky mechanism.

• To avoid pelvic rotation the ASIS must be equidistant from the tabletop.

• The limbs are slightly abducted and internally rotated to bring the femoral necks
parallel to the IR.

• Sandbags and pads are placed against the ankle region to help maintain this position.
 AP – Pelvis (Both Hips)
Centering Point
• Midline midway between the upper border of the symphysis
pubis and ASIS for the whole of the pelvis and proximal
femora.

• The upper edge of the IR should be 5 cm above the upper

border of the iliac crest to compensate for the divergent
beam and ensure the whole of the bony pelvis is included.

• The center of the IR is placed level with the upper border of

the symphysis pubis for the hips and proximal femora
 AP – Pelvis (Both Hips)
• Essential image characteristics
• For the basic view of both hips, both trochanters and the upper 1/3 of the femora must
be visible on the image.

• For the basic pelvis projection, both iliac crests and proximal femora, including the
lesser trochanters, should be visible on the image.

• To prove there is no rotation, the iliac bones should be of equal dimensions and the
obturator foramina of similar size and shape.

• Shenton’s line should be clearly identified, which forms a continuous curve between the
inferior aspect of the femoral neck and the inferior margin of the superior pubic rami.

• Any disruption in this curve indicates a femoral neck or superior pubic rami fracture.
AP – Pelvis (Both Hips)
AP – Pelvis (Both Hips) -Neck of Femur #
 AP – Pelvis (Both Hips)

Feet in neutral position. Both trochanters in profile

 AP – Pelvis (Both Hips)

Feet in internal rotation. Lesser trochanters not visible.

 AP – Pelvis (Both Hips)

Feet in an external rotation. Lesser trochanters clearly visible.

 PA- Sacro-iliac joints
Position of patient and image receptor
• The patient lies prone with the median sagittal perpendicular to the
tabletop.

• The posterior superior iliac spines should be equidistant from the tabletop
to avoid rotation.

• The midline of the patient should coincide with the centred primary beam
and table Bucky mechanism.

• The image receptor is positioned so that the CR passes though the center
of the IR.
 PA- Sacro-iliac joints

Direction and location of the X-ray

beam
• Midline at the level of the posterior
superior iliac spines.

• The central ray is angled 5–15º

caudally depending on the sex of the
patient due to the natural angulation
of the male/female pelvis and
lordosis of the lower lumbar spine.
AP- Sacro-iliac joints
Both Sacro-iliac joints for comparison
Bilateral sacroiliac joint dislocations
 Obstetrics – Pelvimetry
Indications
• Cephalopelvic disproportion
• Breech presentation
• Small stature
• Pelvic injury and non-engagement of the fetal head in primigravida.
Vertebral Column
Vertebral Column
 Vertebral Column
Useful landmarks
• The easily palpated tip of the mastoid process indicates the level of C1.

• The spinous process of C7 produces a visible protuberance on the posterior

aspect of the inferior part of the neck.

• The inferior angle of the scapula indicates the level of T7 when the arms are
placed by the side.

• The sternal notch lies at the junction between T2 and T3.

• T4 is indicated by the sternal angle with T9 corresponding to the xiphi-sternal

joint, although the size of this structure is variable.
 Cervical vertebrae
• The lower costal margin indicates L3.

• A line joining the most superior parts of the iliac crests indicates the level
of L4.

• The anterior and posterior iliac spines lie at the level of the second sacral
spine.

• The coccyx can be palpated between the buttocks and lies at the level of
the symphysis pubis.
Vertebral Column
 Cervical vertebrae
Clinical Indication
• Trauma
• Infection
• Atypical pain
• Limb pain
• Osteoporosis
• Degenerative changes

• Basic Projection
• AP
• Lateral

• 18 × 24 cm /24 × 30 cm cassettes
 Lateral Cervical vertebrae- Erect
Position of patient and image receptor
• The patient stands or sits with either shoulder against the IR.

• The median sagittal plane should be adjusted such that it is parallel with the IR.

• The head should be flexed or extended such that the angle of the mandible is not
superimposed over the upper anterior cervical vertebra or the occipital bone does not
obscure the posterior arch of the atlas.

• To aid immobilization, the patient should stand with the feet slightly apart and with the
shoulder resting against the cassette stand.

• In order to demonstrate the lower cervical vertebra, the shoulders should be depressed.
 Lateral Cervical vertebrae- Erect

Direction and location of the X-ray

beam
• Below the mastoid process at the
level of the prominence of the
thyroid cartilage.
 Lateral Cervical vertebrae- Erect
Essential image characteristics
• The whole of the cervical spine should be included, from the atlanto-
occipital joints to the top of the first thoracic vertebra.

• The mandible or occipital bone does not obscure any part of the upper
vertebra.

• Soft tissues of the neck should be included.

• The contrast should produce densities sufficient to demonstrate soft tissue

and bony detail.
Lateral Cervical vertebrae- Erect
 AP – 1st and 2nd Cervical vertebrae (open mouth)
Position of patient and image receptor
• The patient stands with the posterior aspect of the head and shoulders against the vertical
Bucky detector system.

• The medial sagittal plane is adjusted to coincide with the midline of the IR, such that it is at
right-angles to the image receptor.

• The neck is extended, if possible, such that a line joining the tip of the mastoid process and
the inferior border of the upper incisors is at right-angles to the cassette.

• This will superimpose the upper incisors and the occipital bone, thus allowing clear
visualization of the area of interest.

• The receptor is centred at the level of the mastoid process.

 AP – 1st and 2nd Cervical vertebrae (open mouth)
Direction and location of the X-ray beam
• Midline to the center of the open mouth.

• If the patient is unable to attain the position described, then

the beam must be angled, typically 5–10° cranially or
caudally, to superimpose the upper incisors on the occipital
bone.

• The IR position will have to be altered slightly to allow the

image to be centred after beam angulation.
AP – 1st and 2nd Cervical vertebrae (open mouth)
 AP – 3rd to 7th cervical vertebrae
Position of patient and image receptor
• The patient stands with the posterior aspect of the head and shoulders
against the vertical Bucky detector system.

• The median sagittal plane is adjusted to be at right-angles to the image

receptor and to coincide with the midline of the table or Bucky.

• The neck is extended (if the patient’s condition will allow) so that the lower
part of the jaw is cleared from the upper cervical vertebra.

• The IR is positioned in the Bucky to coincide with the central ray.

 AP – 3rd to 7th cervical vertebrae

Direction and location of the X-ray beam

• Midline towards a point just below the prominence
of the thyroid cartilage through the C5 vertebra.

• The collimated beam is directed with a 5–15°

cranial angulation, such that the inferior border of
the symphysis menti is superimposed over the
occipital bone.
AP – 3rd to 7th Cervical vertebrae
 Thoracic vertebrae
Clinical Indication
• Trauma
• Infection
• Osteoporosis
• Degenerative changes
• Fall from a height of greater than 3 meters
• Ejection from a motor vehicle or motorcycle
• Neurological deficit
• Postoperative imaging
• Chronic conditions
• History of cancer and associated back pain

• Basic Projection
• AP
• Lateral

• 15x6” /35 ×43 cm cassettes

 AP- Thoracic vertebrae
Position of patient and image receptor
• The patient is lies supine on the X-ray table, with the median sagittal
plane perpendicular to the tabletop and coincident with the midline of the
Bucky.

• The upper edge of the IR should be at a level just below the prominence
of the thyroid cartilage to ensure that the upper thoracic vertebrae are
included.

• Exposure is made on arrested inspiration. This will cause the diaphragm

to move down over the upper lumbar vertebra, thus reducing the chance
of a large density difference appearing on the image from
superimposition of the lungs.
 AP- Thoracic vertebrae

Direction and location of the X-ray

beam
• 2.5 cm below the sternal angle.

• The beam is collimated tightly to

the spine.
 AP- Thoracic vertebrae
Essential image characteristics
• The image should include the vertebrae from C7 to L1.

• The image density should be sufficient to demonstrate bony detail for the
upper as well as the thoracic lower vertebrae.
AP- Thoracic vertebrae
 Lateral- Thoracic vertebrae
Position of patient and image receptor
• The examination is usually undertaken with the patient in the lateral
decubitus position on the X-ray table, although this projection can also be
performed erect.

• The median sagittal plane should be parallel to the IR and the midline of the
axilla coincident with the midline of the table or Bucky.

• The arms should be raised well above the head.

• The head can be supported with a pillow, and pads may be placed between
the knees for the patient’s comfort.
 Lateral- Thoracic vertebrae
Direction and location of the X-ray beam
• Centre just below the inferior angle of the
scapula (5 cm anterior to the spinous process of
T6/7).

• The collimated vertical beam should be at right-

angles to the long axis of the thoracic vertebrae.
This may require a caudal angulation.
Lateral- Thoracic vertebrae
 Lateral- Thoracic vertebrae
Essential image characteristics
• The upper 2 or 3 vertebrae may not be demonstrated due to the superimposition of the
shoulders.

• Look for the absence of a rib on L1 at the lower border of the image. This will ensure that T12
has been included within the field.

• The posterior ribs should be superimposed, thus indicating that the patient was not rotated too
far forwards or backwards.

• The trabeculae of the vertebrae should be clearly visible, demonstrating an absence of

movement un-sharpness.

• The image density should be adequate for diagnosis for both the upper and lower thoracic
vertebrae.
Lateral- Thoracic vertebrae
 L/S Vertebrae
Clinical Indication
• Trauma
• Infection
• Osteoporosis
• Degenerative changes
• Fall from a height of greater than 3 meters
• Ejection from a motor vehicle or motorcycle
• Neurological deficit
• Postoperative imaging
• Chronic conditions
• History of cancer and associated back pain

• Basic Projection
• AP
• Lateral

• 15x6” /35 ×43 cm cassettes

 AP L/S Vertebrae
Position of patient and image receptor
• The patient lies supine on the Bucky table, with the median sagittal plane coincident with, and at
right-angles to, the midline of the table and Bucky.

• The ASISs should be equidistant from the tabletop.

• The hips and knees are flexed and the feet are placed with their plantar aspect on the tabletop to
reduce the lumbar arch and bring the lumbar region of the vertebral column parallel with the IR.

• If using a CR cassette/DR system, the FOV should be large enough to include the lower thoracic
vertebrae and the sacro-iliac joints and is centred at the level of the lower costal margin.

• The exposure should be made on arrested expiration, as expiration will cause the diaphragm to
move superiorly. The air within the lungs would otherwise cause a large difference in density and
poor contrast between the upper and lower lumbar vertebrae.
 AP L/S Vertebrae
Direction and location of the X-
ray beam
• Midline at the level of the lower
costal margin (L3).
 AP L/S Vertebrae
Essential image characteristics
• The image should include from T12 down, to include all
of the sacro-iliac joints.

• Rotation can be assessed by ensuring that the sacro-iliac

joints are equidistant from the spine.

• The exposure used should produce a density such that

bony detail can be discerned throughout the region of
interest.
AP L/S Vertebrae
 Lateral L/S Vertebrae
Position of patient and image receptor
• The patient lies on either side on the Bucky table. If there is any degree of scoliosis, then the most
appropriate lateral position will be such that the concavity of the curve is towards the X-ray tube.

• The arms should be raised and resting on the pillow in front of the patient’s head. The knees and
hips are flexed for stability.

• The coronal plane running through the center of the spine should coincide with, and be
perpendicular to the midline of the Bucky.

• Non-opaque pads may be placed under the waist and knees, as necessary, to bring the vertebral
column parallel to the IR.

• The exposure should be made on arrested expiration.

• This projection can also be undertaken erect with the patient standing or sitting.
Lateral L/S Vertebrae
 Lateral L/S Vertebrae

Direction and location of the X-ray

beam
• Towards a point 7.5 cm anterior to
the 3rd lumbar spinous process at
the level of the lower costal margin.
Lateral L/S Vertebrae
Incorrect positioning – the vertebral column is not parallel with
the table.
 Lateral L/S Vertebrae
Essential image characteristics
• The image should include T12 downwards, to include the lumbar sacral
junction.

• Ideally, the projection will produce adequate demonstration through the center
of the intervertebral disc space, with individual vertebral endplates
superimposed.

• The cortices at the posterior and anterior margins of the vertebral body should
also be superimposed.

• The imaging factors selected must produce an image density sufficient for
diagnosis from T12 to L5/S1, including the spinous processes.
 Lateral L/S Vertebrae

Normal
Spondylolisthesis
 Lateral L/S Vertebrae

Spondylosis Spondylitis