AP PROJECTION: FEMUR - MID AND DISTAL

Note: If site of interest is in area of proximal femur, a unilateral hip routine or a pelvis is
recomended, as is describe in this chapter.

Pathology Demonstrated:

 Mid- and distal femur is demonstrated including knee joint for detection and
avaluation of fractures and/or bone lessions.

Technical factors:

 IR size- 35 x 43 cm (14 x 17 inches). lengthwise

 Moving or stationary grid
 75 +- 5 kV range
 Because of anode heel effect, place hip or head end of patient at cathode end of x-ray
beam.
 mAs: 12

Shielding:

 Place lead shield over pelvic area to ensure correct gonadal shielding because of
proximity to primary beam.

Patient Position:

 Take radiograph with patient in the supine position, with femur centered to midline of
table; give pillow for head. (This projection also may be done on a stretcher with a
portable grid placed under the femur.)

Part Position:

 Align femur to CR and to midline of table or IR.

 Rotate leg internally about 5 degree for a true AP, as for an AP knee. ( for proximal
femur, 15 to 20 degree intenal leg rotation is required, as for an AP hip.)
 Ensure that knee joint is included on IR, considering the divergence of the x-ray
beam. (Lower cassette margin should be approximately 2 inches [5 cm] below knee
joint.)

Central Ray:

 CR is perpendicular to femur and IR.

 Direct CR to midpoint of IR.
 Minimum SID is 40 inches (100 cm)
Collimation:

 Collimate closely on both sides to femur with end collimation to film borders.
 Routine to include both joints: Common departmental routines include both joints on
all initial femur exams. For a large adult, a second smaller IR then should be used for
an AP of either the knee or the hip, ensuring that both hip and knee joints are
included. If the hip is included, the leg should be rotated 15 to 20 degree internally to
place the femoral neck in profile.

Radiographic Criteria:

Structure Shown:

 Distal two-thirds of distal femur, including knee joints, is shown.

 Knee joint space will not appear fully open because of divergent x-ray beam.

Position:

 No rotation is evidenced; femoral and tibial condyles should appear symmetric in size
and shape with the outline of patella slightly toward medial side of femur.
 The approximate medial half of fibula head should be superimposed by tibia.

Collimation and CR:

 Femur should be centered to collimation field and aligned with long axis of IR with
knee joint space a minimum of 1 inch (2.5 cm) from distal IR margins.
 Minimal collimation borders should be visible on proximal and distal margins of IR.

Exposure Criteria:

 Optimal exposure with correct use of anode heel effect will result in near uniform
density of entire femur.
 No motion should occur; fine trabecular markings should be clear and sharp
throughout length of femur.
LATERAL-MEDIOLATERAL OR LATEROMEDIAL
PROJECTION: FEMUR-MID AND DISTAL
Note: For possible trauma if site of interest is in area of proximal femur, a unilateral trauma hip
routine is recommended. For nontrauma lateral of mid-and proximal femur.

Pathology Demonstrated:

 Mid and distal femur is demonstrated, including knee joint for detection and evaluation of
fracture and/or bone lesions.

Technical Factors:

 IR size - 35 x 43 cm (14 x 17 inches), lengthwise

 Moving or stationary grid
 75 +- 5 kV range
 Because of anode heel effect, place the hip of the patient at cathode end of x-ray beam.
 mAs: 7

Shielding:

 Place lead shield over pelvic area to shield gonads.

Patient Position:

 Take radiograph with patient in the lateral recumbent position, or supine for trauma patient.

Part Position:
Lateral Recumbent:

Warning: Do not attemp this position if patient has severe trauma.

 Flex knee approximately 45 degree with patient on affected side, and align femur to midline
of table or IR.
 Place unaffected leg behind affected leg to prevent overrotation.
 Adjust IR to include knee joint (lower IR margin should be approximately 2 inches [5 cm]
below knee joint). A second IR to include the proximal femur and hip generally will be
required on an adult.

Trauma Lateromedial Projection:

 Place support under affected leg and knee and support foot and ankle in true AP position.
 Place cassette on edge against medial aspect of thigh to include knee, with horizontal x-ray
beam directed from lateral side.
Central Ray:

 CR perpendicular to femur and IR directed to midpoint of IR

 Minimum SID of 40 inches (100 cm)

Collimation:

 Collimate closely on both sides to femur with end collimation to IR borders.

Radiographic Criteria:

Structure Shown:

 Distal two-thirds of distal femur, including the knee joint, is shown.

 Knee joint will not appear open, and distal margins of the femoral condyles will not be
superimposed because of divergent x-ray beam.

Position:

 True lateral: Anterior and posterior margins of medial and lateral femoral condyles should
be superimposed and aligned with open femoropatellar joint space.

Collimation and CR:

 Femur should be centered to collimation field with knee joint space a minimum of 1 inches
(2.5 cm) from distal IR margins.
 Minimal collimation borders should be visible on proximal and distal margins of IR.

Exposure Criteria:

 Optimal exposure with correct use of anode heel effect will result in near uniform density of
entire femur.
 No motion is present; fine trabecular markings should be clear and sharp throughout lenght
of femur.
AP BILATERAL "FROG LEG" PROJECTION:
PELVIS
MODIFIED CLEAVES METHOD

Warning: Do not attemp this position on patient with destructive hip disease or with
potential hip fracture or dislocation.

Pathology Demonstrated:

 This projection is useful for demonstration of a nontrauma hip or developmental

dysplasia of hip (DDH), also known as congential hip dislocation (CHD).

Technical Factors:

 IR size - 35 x 43 cm (14 x 17 inches), crosswise

 Moving or stationary grid
 80 +- 5 kV range or 90 +- 5 kV range
 mAs: 12

Shielding:

 Shield gonads for both males and females without obscuring essential anatomy.

Patient Position:

 Align patient to midline of table and/or IR and to CR.

 Ensure pelvis is not rotated (equal distance of ASISs to tabletop).
 Center IR to CR, at level of femoral heads, with top of IR approximately at level of
illiac crest.
 Flex both knees approximately 90 degree, as demonstrated.
 Place the plantar surfaces of feet together and abduct both femora 40 to 45 degree
from vertical. Ensure that both femora are abducted the same amount and that pelvis
is not rotated.
 Place supports under each leg for stabilization if needed.

Central Ray:

 CR is perpendicular to IR, directed to a point 3 inches (7.5 cm) below level of ASIS (
1 inch [2.5 cm] above symphysis pubis).
 minimum SID is 40 inches (100 cm).

Collimation:

 Collimate to IR borders on four sides.

Respiration:

 Suspend respiration during exposure.

Note 1: This projection frequently is performed for periodic follow-up exams on younger
patients, thus correct placement of gonadal shielding is important for both male and female
patients, ensuring that hips joints are not covered.

Note 2: Less abduction of femora such as only 20 to 30 degree from vertical provides for the
foreshortening of femoral necks, but this placement foreshortens the entire proximal femora,
which may not be desirable.

Radiographic Criteria:

Structure Shown:

 Femoral heads and necks, accetabulum, and tronchanteric areas are visible on one
radiograph.

Position:

 No rotation is evidenced by symmetric appearance of the pelvic bones, especially the

ala of the ilium, two obturator foramina, and ischial spines, if visible.
 The femoral heads and necks and greater and lesser trochanters should appear
symmetric if both thighs were abducted equally.
 The lesser trochanters should appear equal in size, as projected beyond the lower or
medial margin of the femora.
 Most of the area of the greater tronchanter appears superimposed over the femoral
neck, which appear foreshortened.

Collimation and CR:

 The pelvic girdle should be centered to the collimation field from right to left, with
the midpoint being about 2.5 cm (1 inch) superior to the symphysis pubis.

Exposure Criteria:

 Optimal exposure visualizes the margins of the femoral head and the acetabulum
through overlying pelvic structures, without overexposing the proximal femora.
 Trabecular markings appear sharp, indicating no motion.
AP AXIAL "INLET" PROJECTION: PELVIS

Pathology Demonstrated:

 This axial projection to the pelvic ring allows assessment of pelvic trauma for
posterior displacement or inward or outward rotation of the anterior pelvis.

Technical Factors:

 IR size- 35 x 43 cm (14 x 17 inches)

 Moving or stationary grid
 80 +- 5 kV range
 mAs 12

Shielding:

 Gonadal shielding is possible for males if care is taken to not obscure essential pelvic
anatomy.

Patient Position:

 With patient supine, provide pillow for head. With patient's legs extended, place
support under knees for comfort.

Part Position:

 Align midsagittal plane to CR and to midline of table and/or cassette.

 Ensure no rotation of pelvis (ASIS-to-tabletop distance equal on both sides).
 Center cassette to projected CR.

Central Ray:

 Angle CR caudad 40 degrees (near perpendicular to plane of inlet).

 Direct CR to a midline point at level of ASISs.
 Minimum SID is 40 inches (100 cm).

Collimation: Collimate closely on four sides to area of interest.

Respiration: Suspend respiration during exposure.

Radiographic Criteria:

Structure Shown: This is an axial projection that demonstrates pelvic ring or inlet ( superior
aperture) in its entirely.

Position: No rotation: Ischial spines are fully demonstrated and equal in size and shape.
Collimation and CR:

 Proper centering and angulation are evidenced by demonstration of the superimposed

anterior and posterior portions of the pelvic ring.
 Center of pelvic inlet should be at center of collimated field.
 Lateral margins of collimation field should extend equally on both sides to just lateral
to the femoral heads and acetabula.
 Superior and inferior margins of field should include the ala and the symphysis pubis,
respectively.

Exposure Criteria:

 Optimal exposure demonstrates the superimposed anterior and posterior portions of

the pelvic ring. Lateral aspects of ala generally are overexposed.
 Bony margins and trabecular markings of pubic and ischial bones appear sharp,
indicating no motion.

AP AXIAL "OUTLET" PROJECTION* (FOR ANTERIOR/INFERIOR PELVIC

BONES) : PELVIS (TAYLOR METHOD)

Pathology Demonstrated:

 This projection presents an excellent view of the bilateral pubes and ischia to allow
assessment of pelvis trauma for fractures and displacement.

Technical Factors:

 IR size - 24 x 30 cm (10 x 12 inches), crosswise

 Moving or stationary grid
 80 +- 5 kv range
 10 mAs

Shielding:

 Gonadal shielding may be done if great care is taken not to obscure essential pelvic
anatomy.

Patient Position:

 With patient supine, provide pillow for head. With patient's legs extended, place
support under knees for comfort.

Part Position:

 Align midsagittal plane to CR and to midline to table and/or IR.

  Ensure no rotation of pelvis (ASIS-to-tabletop distance equal on both sides).
 Center IR to projected CR.

Central Ray:

 Angle CR cephalad 20 to 35 degrees for males and 30 to 45 degrees for females.

(These different angles are caused by differences in the shape of male and female
pelvis.)
 Direct CR to a midline point 1 to 2 inches ( 3 to 5 cm) distal to the superior border of
the symphysis pubis or greater trochanters.
 Minimum SID is 40 inches (100 cm)

Collimation:

 Collimate closely on four sides to area of interest.

Respiration:

 Suspend respiration during exposure.

Radiographic Criteria:

Structure Shown:

 Superior and inferior rami of pubes and body and ramus of ischium are demonstrated
well, with minimal foreshortening or superimposition.

Position:

 No rotation: Obturator foramina and bilateral ischia are equal in size and shape.

Collimation and CR:

 Correct CR angle evidenced by demonstration of the anterior/inferior pelvic bones,

with minimal foreshortening.
 Midpoint of symphysis joint should be at center of collimated field.
 Lateral margins of collimation field should extend equally on both sides to just lateral
to the femoral heads and acetabula.
 Superior and inferior margins of field should include the body and superior pubic
rami and the ischial tuberosities, respectively.

Exposure Criteria:

 Body and superior rami of pubes are well demonstrated without overexposure of
ischial rami.
 Body margins and trabecular markings of pubic and ischial bones appear sharp,
indicating no motion.