Radiographic Positioning of the Hip

Section objectives: Hip Series
At the conclusion of this course the student doctor should;
1.	Be able to efficiently conduct all parts of a 1 view pelvis and a 3 view hip series including determining the cassette size and orientation, setting of technical factors, patient positioning, placement of filters/shields, and giving patient instructions.
2.	Be able to identify the significant anatomy demonstrated on each view of the series.

Standard Pelvis Series - 1 view series
	A-P Pelvis
Standard Hip Series - 3 view series
	A-P Pelvis
	A-P Spot Hip
	Lateral Hip (Frogleg)
A-P Pelvis

PREPARE THE ROOM
Cassette:	black; 14" x 17", CW (flash up)
Tube:	40" FFD, no tube tilt
Technique:	80 kVp, small focal spot
Measure:	through central ray
Filter/shield:	gonad for males (Pb vinyl), not possible for females

PREPARE THE PATIENT
Position:	R or L, patient is fully gowned.
Patient standing or supine (preferred) with midsagittal plane centered to
midline of the table.
Both legs are rotated 15 medially to provide true AP of femora.
The film is placed so that its top edge is 1" above the iliac crests.
Central ray:	Perpendicular to film directed at the middle of the cassette.
Collimation:	Open to full cassette vertically, side-to-side soft tissue.
Marker:	R or L.

EXPOSURE
Patient directions: "Take a deep breath in, blow it all the way out. Now hold still, don't move" - expose.

EVALUATION CRITERIA: A-P Pelvis
•	Proximal femora should be included in their entirety as well as bilateral pubis, ischium and at least the distal half of the ilium.
•	No rotation: the two obturator foramina and the bilateral ischial spines (if visible) should appear equal in size and shape.
•	Optimum exposure should demonstrate both bone and soft tissue density.
•	Patient identification should be clear and legible, R/L marker should be clearly visible on lateral border without superimposing anatomy.

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Radiographic Positioning of the Hip

A-P Spot Hip

PREPARE THE ROOM
Cassette:	black; 10" x 12", LW (flash lateral)
Tube:	40" FFD, no tube tilt
Technique:	74 kVp, small focal spot
Measure:	through central ray
Filter/shield:	gonad (Pb vinyl), females can shield contralateral side

PREPARE THE PATIENT
Position:	R or L, patient is fully gowned.
Patient standing or supine (preferred) with midfemoral neck of affected
side in center of table.
The entire leg is rotated 150 medially to provide true AP of femur.
Central ray:	Perpendicular to film, through the midfemoral neck. This is determined by aiming at the femoral pulse. Center the film to the central ray.
Collimation:	Open to full cassette vertically, side-to-side to soft tissue.
Marker:	R or L.

EXPOSURE
Patient directions: "Hold still, don't move" - expose.

EVALUATION CRITERIA: A-P Spot Hip
•	The proximal one third of the femur should be visualized along with the acetabulum and adjacent parts of the pubis, ischium and ilium. The hip joint space, including the lateral borders of the femoral head should be clearly visualized.
•	The lesser trochanter should not project beyond the medial border of the femur at all or only its very tip is seen with sufficient internal rotation of the leg, indicating the greater trochanter, femoral head and neck are seen in hill profile without foreshortening.
•	Optimum exposure should demonstrate both bone and soft tissue density.
•	Patient identification should be clear and legible, R/L marker should be clearly visible on lateral border without superimposing anatomy.

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Radiographic Positioning of the Hip

Lateral Hip (Frogleg)

PREPARE THE ROOM
Cassette:	black; 10" x 12", LW (flash up)
Tube:	40" FFD, no tube tilt
Technique:	74 kVp, small focal spot
Measure:	through central ray
Filter/shield:	gonad (Pb vinyl), females can shield contralateral side

PREPARE THE PATIENT
Position:	R or L, patient is fully gowned.
Patient standing or supine (preferred) with midfemoral neck of affected side in center of table.
The leg is externally rotated and the heel is placed in the contralateral popliteal fossa. This creates a "figure 4" appearance.
If the femur is not flat, place a positioning block under the contralateral side so that the patient can place their femur flat on the table
Central ray:	Perpendicular to film, through the midfemoral neck. This is determined by aiming at the femoral pulse. Center the film to the central ray.
Collimation:	Open to hill cassette vertically, side-to-side to soft tissue.
Marker:	R or L

EXPOSURE
Patient directions: "Hold still, don't move" - expose.

EVALUATION CRITERIA: Lateral Hip (Frogleg)
•	The proximal one third of the femur should be visualized along with the hip joint and acetabulum.
•	The greater trochanter will superimpose most of the femoral neck area.
•	The lesser trochanter will be partially seen more distally than the greater trochanter projecting beyond the lower or medial margin of the femur.
•	Optimum exposure should demonstrate both bone and soft tissue density.
•	Patient identification should be clear and legible, RI marker should be clearly visible on lateral border without superimposing anatomy.

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Radiographic Positioning of the Sacrum and Coccyx

Section objectives: Sacrum and Coccyx Series
At the conclusion of this course the student doctor should;
1.	Be able to efficiently conduct all parts of a 2 view sacral and a 2 view coccyx series including determining the cassette size and orientation, setting of technical factors, patient positioning, placement of filters/shields, and giving patient instructions.
2.	Be able to identify the significant anatomy demonstrated on each view of the series.

Standard Sacral Series -2 view series
	A-P Sacrum
	Lateral Serum

Standard Coccyx Series -2 view series
	A-P Coccyx
	Lateral Coccyx
A-P Sacrum

PREPARE THE ROOM
Cassette:	black; 10" x 12", crosswise (wide, flash down)
Tube:	40" FFD, 150 cephalad tube tilt
Technique:	80 kVp, small focal spot
Measure:	through central ray at appropriate angle
Filter/shield:	gonad for males (Pb vinyl), not possible for females

PREPARE THE PATIENT
An enema is required and will significantly improve visualization in the pelvic bowl. It should be administered immediately before the radiographic examination.

Position:	R or L, patient is fully gowned.
Patient supine with midsagittal plane centered to midline of the table.
Central ray:	2" above the symphysis pubis. Center cassette to central ray.
Collimation:	11" x 9", to area of interest.
Marker:	R or L.

EXPOSURE
Patient directions: "Take a deep breath in, blow it all the way out. Now hold still, don't move" - expose.

EVALUATION CRITERIA: A-P Sacrum
•	Sacrum should be centered and seen in its entirety, free of foreshortening with the sacral curvature straightened.
•	Pubic bones should not be overlapping the sacrum.
•	Tight collimation evident to improve the radiographic contrast, short scale contrast seen.
•	Patient identification should be clear and legible, RIL marker should be clearly visible on lateral border without superimposing anatomy.

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Radiographic Positioning of the Sacrum and Coccyx

Lateral Sacrum

PREPARE THE ROOM
Cassette:	black; 10" x 12", lengthwise (tall, flash up)
Tube:	40" FFD, no tube tilt
Technique:	80 kVp, small focal spot
Measure:	through central ray
Filter/shield:	gonad, Pb vinyl
Place lead vinyl on table behind patient to reduce scatter on film.

PREPARE THE PATIENT
An enema will significantly improve visualization in the pelvic bowl. It should be administered immediately before the radiographic examination.

Position:	L, patient is fully gowned, with no jewelry, metal fasteners on underwear, etc. Patient is recumbent with midcoronal plane centered to bucky, and left side closest to the bucky. Arms folded on chest.
Have patient flex hips and knees to a comfortable position, radiolucent sponge/support under lumbar spine.
If needed place positioning sponges under knees/legs to reduce coronal rotation of sacrum/pelvis.
Central ray:	1" below PSIS, and 2" anterior to posterior sacral surface.
Center cassette to central ray.
Collimation:	9" x 11", to area of interest.
Marker:	L.

EXPOSURE
Patient directions: "Take a deep breath in, blow it all the way out. Now hold still,
don't move" - expose.

EVALUATION CRITERIA: Lateral Sacrum
•	Use of tight collimation and a lead vinyl absorber to reduce primary beam leak and scatter. This will improve radiographic contrast.
•	Sacrum should be centered and seen in its entirety, short scale contrast evident.
•	Closely superimposed posterior margins of the ischia and ilia.
•	Patient identification should be clear and legible, L marker should be clearly visible on lateral border without superimposing anatomy.

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Radiographic Positioning of the Sacrum and Coccyx

A-P Coccyx

PREPARE THE ROOM
Cassette:	black; 8" x 10", lengthwise (tall, flash up)
Tube:	40" FFD, 100 caudal tube tilt
Technique:	70 kVp, small focal spot
Measure:	through central ray at appropriate angle
Filter/shield:	gonad for males (Pb vinyl), not possible for females

PREPARE THE PATIENT
An enema is required and will significantly improve visualization in the pelvic bowl.
It should be administered immediately before the radiographic examination.

Position:	R or L, patient is fully gowned.
Patient supine with midsagittal plane centered to midline of the table.
Central ray:	2" above the symphysis pubis. Center cassette to central ray.
Collimation:	~4”x4”, to area of interest.
Marker:	R or L

EXPOSURE
Patient directions: "Take a deep breath in, blow it all the way out. Now hold still,
don't move" - expose.

EVALUATION CRITERIA: A-P Coccyx
•	Coccyx should be centered and seen in its entirety.
•	Coccygeal segments should not be superimposed.
•	Tight collimation evident to improve radiographic visibility, short scale contrast seen.
•	Patient identification should be clear and legible, R/L marker should be clearly visible on lateral border without superimposing anatomy.

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Radiographic Positioning of the Sacrum and Coccyx

Lateral Coccyx

PREPARE THE ROOM
Cassette:	black; 8" x 10", lengthwise (tall, flash up)
Tube:	40" FFD, no tube tilt
Technique:	80 kVp, small focal spot
Measure:	through central ray
Filter/shield:	gonad, Pb vinyl
Place lead vinyl on table behind patient to reduce scatter on film.

PREPARE THE PATIENT
An enema will significantly improve visualization in the pelvic bowl. It should be
administered immediately before the radiographic examination.

Position:	L, patient is fully gowned, with no jewelry, metal fasteners on underwear, etc.
Patient is recumbent with midcoronal plane centered to bucky, and left side closest to the bucky. Arms folded on chest.
Have patient flex hips and knees to a comfortable position, radiolucent sponge/support under lumbar spine. If needed place positioning sponges under knees/legs to reduce coronal rotation of coccyx/pelvis.
Central ray:	Palpate coccyx and position central ray accordingly.
Center cassette to central ray.
Collimation:	5"x 5", to area of interest.
Marker:	L.
	
EXPOSURE
Patient directions: "Take a deep breath in, blow it all the way out. Now hold still,
don't move" - expose.

EVALUATION CRITERIA: Lateral Coccyx
•	Use of tight collimation and a lead vinyl absorber to reduce primary beam leak and scatter. This will improve radiographic contrast.
•	Coccyx should be centered and seen in its entirety, short scale contrast evident.
•	Patient identification should be clear and legible, L marker should be clearly visible on lateral border without superimposing anatomy.

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Radiographic Positioning of the Full Spine

Section Objectives: Full Spine
At the conclusion of this course the student doctor should;
1.	Be able to efficiently conduct a hill spine series including determining the cassette size and orientation, setting of technical factors, patient positioning, placement of filters/shields, and giving patient instructions.
2.	Be able to identify the significant anatomy demonstrated on each view of the series.
3.	Be conversant about the limitations of the hill spine study.

Postural Series
•	Full Spine A-P (FSAP)
•	Full Spine Lateral (FSL)

Scoliosis Series
FSAP
•	Recumbent A-P of curvature
•	Recumbent forced lateral bending, R and L
•	P-A left hand

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Radiographic Positioning of the Full Spine

Full Spine A-P (ESAP)
PREPARE THE ROOM
Cassette:	black, 14" x 36", LW
Tube:	72" FFD, no tube tilt
Technique:	70 kVp, large focal spot
Measure:	3 sites to measure;
	through neck
	through chest on sternum
	through hill thickness of abdomen
Use largest of the three for autotech or Super Tech calculation. 
Filter/shield:	Clear Pb system.
	Paraspinals; the bottom should be 1" above iliac crests and separated to see tips of the transverse processes.
	AP/PA; from top of cross upward.
	Thick build up; from lower edge of mandible down.
	Gonad; Pb shield for males, Cu heart for females.
Nolan system.
	Paraspinals; the bottom should be to bottom of breasts (be careful with scoliotic patients)
	Use chart to determine total points of filtration required but always use 5 pt wedge from bottom of mandible down.
Slightly stagger other filters to prevent harsh lines on radiograph.
	Gonad; Pb shield for males, Cu heart for females.
PREPARE THE PATIENT
Position:	Patient is fully gowned, shoes on, no jewelry (ask about belly button ring), watches, hairpins, glasses, bra, metal fasteners on underwear, etc.
Set the cassette so that the bottom of the cassette is below the ischial tuberosities.
Patient should bend forward at the waist and align the 2nd sacral tubercle to midline of film/cassette.
Have patient extend head slightly.
Collimation:	Open to below mandible but be certain ischial tuberosities are in beam. If not, adjust tube height accordingly. Side-to-side to edge of trochanters.
Marker:	R or L.

EXPOSURE
Patient directions: "Take a breath in and blow it out. Hold still, don't move" - expose.

EVALUATION CRITERIA: Full Spine A-P (FSAP)
•	Ischial tuberosities must be on the film (if dens is not seen, perform APOM).
•	Pubic symphysis and midline gluteal cleft should superimpose (means Pt. was not rotated) and be over midline lead reference line.
•	Base of dens should be fully visualized.
•	All vertebra should be demonstrated.
•	Patient identification and R/L marker should be clearly visible without blocking anatomy.

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Radiographic Positioning of the Full Spine

Full Spine Lateral (FSL)

PREPARE THE ROOM
Cassette:	black, 14" x 36", LW
Tube:	72" FFD, no tube tilt
Technique:	100 kVp, large focal spot
Measure:	3 sites to measure;
•	through neck
•	from axilla to axilla
•	through widest part of hips
Use largest of the three for autotech or Super Tech calculation. 
Filter/shield:	Clear Pb system.
•	Paraspinals; first one blocking the eyes and breasts in front of patient, second one behind pt acting as support for other shields.
•	Lateral cervical AND thick build-up from acromion up. Lateral thoracic from lowest part of axilla down.
•	Gonad; big Mickey (upside down) at approximately ASIS. 
Nolan system.
•	Lateral cervical to top of shoulder.
•	Lateral thoracic put in same slot as lateral cervical except up from the bottom to meet lateral cervical.
•	Lateral lumbar/lung even with lateral thoracic.
•	Gonad; lateral gonad even with ASIS (arc posterior)

PREPARE THE PATIENT
Position:	Patient is fully gowned, shoes on, no jewelry (ask about belly button ring), watches, hairpins, glasses, bra, metal fasteners on underwear, etc.
Usually L lateral but if pt has a major convexity, place it closest to film.
Set the cassette 2" above the top of the ear.
Midline of film/cassette should go through the greater trochanter.
Have forearms resting on support in front of the body. 
Central ray:	At about T6.
Collimation:	Open to hill cassette vertically, set cassette to top of ear, side-to-side to
posterior skin line.
Marker:	L (usually).

EXPOSURE
Patient directions: "Take a deep breath in and hold. Hold still, don't move" - expose.

EVALUATION CRITERIA: Full Spine Lateral (FSL)
•	Dens and sacral base must be on film.
•	ASIS should be parallel to midline lead reference line (this means Pt was not rotated).
•	All vertebra should be demonstrated.
•	Patient identification and L marker should be clearly visible without blocking anatomy.

Suggested further reading:
Taylor, 3. Full Spine Radiography: A Review. JMPT (1993) V16(7); 460-474.
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