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Lower Limbs

Lower Limbs. Dr Mohamed El Safwany, MD. 1. Intended Learning Outcome. The student should be able to recognize technological principles of radiographic lower limb imaging. Pathological Indications (Lower limb).

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Lower Limbs

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  1. Lower Limbs Dr Mohamed El Safwany, MD. 1

  2. Intended Learning Outcome The student should be able to recognize technological principles of radiographic lower limb imaging.

  3. Pathological Indications (Lower limb) • Same positioning principles for upper limb applies to lower limb. kV should be lower to medium (50 – 70) kVp. • For all parts discussed, center and align the long axis of the part to central ray (CR) and to long axis of the film. • No secondary radiation grid used, except for knee (> 10 cm) and for the femur. • Radiation protection has to be well observed, using the special gonad shields over pelvic region, or the lead apron as necessary. Also, the LBD or cone has to be used. • FFD is generally 40 inches (100 - 102 cm). • Optimal contrast and density will allow visualization of bony cortical margins and traberculae and soft tissue structures. 2

  4. TECHNICAL POINTS • Bone cysts Benign neoplastic bone lesions filled with a clear fluid near the knee joint in pediatric patients. • Chondromalacia patellae (Runner’s knee): Is the softening and/or wearing of cartilage under the patella at a later stage. • Ewing sarcoma A primary bone malignancy in children, mainly in diaphysis of long bones. • Osgood Schlatter's disease Is the inflammation of bone and cartilage in the anterior proximal tibia (tibial tuberosity) of children. • OsteoclastomaA(Giant cell tumor): A benign lesion in the proximal tibia/distal femur, usually affecting epiphyseal closure. • Osteogenic sarcoma Is a highly malignant primary bone tumor in long bones, usually causing gross destruction of the bone. 2

  5. B AP Toes • For fractures and dislocations, osteoarthritis (OA), and gout (especially in the 1st digit). • Patient supine or seated, knee flexed, planter surface of the foot (sole) on film. • Film: HD 18x24 cm. • CP: MTPJ(s). • CR: 10-15 toward the calcaneus (the heel) (90 to the phalanges). 3

  6. B AP Toes 4

  7. B Lateral Toes • For fractures and dislocations, osteoarthritis, and gout (especially in the 1st digit). • Patient supine or seated, knee flexed, planter surface on the film, affected leg and foot both rotated medially (lateromedial) for 1st, 2nd, and 3rd, and laterally (for 4th and 5th), a cotton tape to separate and flex sound toes to prevent superimposition. • Film: HD 18x24 cm. • CP: IPJ (for 1st), proximal IPJ (2nd to 5th). • CR: 90 to film. 5

  8. B Lateral Toes 6

  9. B AP (Dorsiplanter) foot • For #s and dislocations, tissue effusion, joint-space abnormalities, opaque foreign bodies (F.Bs.). • Patient in supine, the knee flexed, planter surface on film, sandbags used to immobilize the film, opposite knee flexed and rests against affected knee. • Film: HD 24x30 cm. • CP: Base of 3rd metatarsa.l • CR: 10 posteriorly (toward the heel. 7

  10. B AP (Dorsiplanter) foot 8

  11. B APO foot • For #s and dislocations, soft tissue effusion, joint space abnormalities, opaque F.Bs. • Patient supine or seated, knee flexed, planter surface on film, foot rotated medially so that the sole is 30 to 40 to film. A 45 wedge can be used to support the foot and prevent motion. • Film: HD 24x30 cm. • CP: Base of 3rd metatarsal. • CR: 90 perpendicular. 9

  12. B APO foot 10

  13. B Mediolateral foot • For #s and dislocations, tissue effusion, joint space abnormalities, opaque F.Bs. • Patient in lateral recumbent, pillow under head, 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. • Film: HD 18x24 cm. • CP: Medial cuneiform (level of the base of the 3rd metatarsal). • CR: 90 perpendicular to film. 11

  14. B Lateral foot 12

  15. B AP/Lat both feet (Weight-bearing technique) • To show condition of the longitudinal arches under full weight of body to exclude a flat foot abnormality (pes planes). • 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 in turn for lateral of the other foot for comparison. • Film: HD 24x30 cm, 18x24 (for laterals). • CP:(AP): CR 15 posteriorly to midpoint between the feet, at the level of the base of metatarsals. • (Lat): Horizontally to the level of base of the 3rd meta- tarsal. 13

  16. B AP/Lateral both feet (Weight-bearing technique) 14

  17. B Axial Calcaneus (Heel bone) • To show fractures, pathology, and lateral or medial displacement. • Patient supine or seated, legs fully extended, foot dorsiflexed (sole 90  to film), cotton ribbon looped around foot pulled by patient for support. • Film: HD 18x24 cm. • CP: Base of 3rd metatarsal. • CR: 40 cephalic from long axis of foot. 15

  18. B Axial Calcaneus 16

  19. B Mediolateral Calcaneus • For bony lesions of calcaneus, talocalcaneal joint, and talus. Also shows fractures. • Patient lateral recumbent, 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. • Film: HD 18x24 cm. • CP: 1 inch inferior to medial malleolus. • CR: 90 to film. 17

  20. B Mediolateral Calcaneus 18

  21. B AP Ankle • For bony lesions of ankle joint, distal tibia and fibula (NB/ Lateral aspect of ankle joint must not appear open in this projection). • Patient supine, legs fully extended, foot in the natural position, foot and ankle in true AP. • Film: HD 24x30 cm. • CP: Midway between malleoli. • CR: 90 to film. 19

  22. B AP Ankle 20

  23. B AP Ankle Mortise • For pathology involving entire ankle mortise and proximal 5th MT (a common fracture site). This view is not a substitute for AP or oblique ankle. It is basic in case of potential trauma or sprains of the ankle joint. • Patient supine, legs fully extended, foot in the natural position (in natural extended position), leg and foot then rotated 15 to 20 until the intermalleolar line is parallel to the film. • Film: HD 24x30 cm. • CP: A point midway between malleoli. • CR: 90 to film. 21

  24. B AP Ankle Mortise 22

  25. B APO Ankle 45 (medial rotation) • For pathology/fractures involving distal tibiofibular joint and distal fibula and base of 5th MT. • Patient supine, 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). • Film: HD 24x30 cm. • CP: A point midway between malleoli. • CR: 90 to film. 23

  26. B APO Ankle 45 (medial rotation) 24

  27. B Lateral Ankle(mediolateral/ lateromedial rotation) • For pathology and fractures, dislocations, joint effusions. (The mediolateral is more preferred). • Patient in lateral recumbent, 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. • Film: HD 24x30 cm. • CP: Medial malleolus. • CR: 90 to film. 25

  28. B Lateral Ankle(mediolateral/ lateromedial rotation) 26

  29. B AP Tibia and Fibula (leg) • For pathology, fractures, F.Bs, and other bone lesions. • Patient supine, leg fully extended, leg and knee in true AP, sandbag against the foot, foot dorsiflexed, both the knee and ankle joint must be included (film can be placed in a diagonal orientation), the heel effect must be well observed. • Film: HD 35x43 cm. • CP: Midshaft of leg. • CR: 90 to film. 27

  30. B AP Tibia and Fibula (leg) 28

  31. B Lat Tibia/ Fibula (leg) • For pathology, fractures, F.Bs, and other bone lesions. • Patient in the lateral recumbent, injured limb down, the opposite leg behind affected leg, sand bags for support, knee flexed 45, leg in true lateral (plane of patella 90 to the film), both joints must be included, the heel effect must be observed. • Film: HD 35x43 cm. • CP: Midshaft of leg. • CR: 90 to film. 29

  32. B Lat Tibia/ Fibula (leg) 30

  33. B AP Knee Joint • For pathology, dislocation, fractures, and bony changes secondary to degenerative disease. • Patient supine, leg fully extended, leg is rotated 3 - 5 for a true AP knee ((interepicondylar line must be parallel to film), sandbags over foot and ankle for support. • Film: HD 18x24 cm. • CP: 0.5 inch distal to apex of patella. • CR: 90 to film (Grid or Bucky for > 10 cm ) 31

  34. B AP Knee Joint 32

  35. B APO Knee Joint (medial ‘internal’ rotation) 34

  36. B Mediolateral Knee Joint • For fractures, lesions, and joint space abnormalities. • Patient in lateral recumbent, affected side down, body and leg rotated until knee is in true lateral, knee flexed 20 to 30. • Film: HD 18x24 cm. • CP: 1 inch distal to medial epicondyle. • CR: 5 cephalic for tall male patient with narrow pelvis, 7 to 10 cephalic for a short male with a wide pelvis. (Grid or Bucky for > 10 cm ), 35

  37. B Bilateral Knee (weight-bearing) • For tibiofemoral joints to check for cartilage degenera- tion and other knee joint pathologies. Both knees are included on same film (one exposure) for comparison. • Patient erect standing on step stool, support handles for patient stability. • Film: HD 35x43 cm (cross-wise). • CP: Midpoint between the knees (0.5 inch below the apex of the patella). • CR: 90 for average patient, 5 - 10 caudal for thin patient. (Grid must be used – because of two joints!). 37

  38. B Bilateral Knee (weight-bearing) 38

  39. B PA Axial Tunnel View Knee (Intercondylar fossa) • (PRONE 40 to 50 FLEXION • For intercondylar fossa (notch), femoral condyles, tibial plateaus, intercondylar eminence, and for pathology. • Patient prone, knee 40 to 50. • Film: HD 18x24 cm. • CP: Knee Joint . • CR: 90 to lower leg. (grid must be used) 39

  40. B PA Axial Tunnel View Knee 40

  41. B PA Patella • For evaluating patellar fractures. • Patient prone, legs extended, support under ankle and leg, small support under femur to prevent the direct pressure on the patella, intercondylar line parallel to film (can be well achieved by 5 rotation of anterior knee). • Film: HD 18x24 cm. • CP: Midpatella area (midpopliteal crease). • CR: 90 to film center. (Grid for > 10 cm ). 41

  42. B PA Patella 42

  43. B Mediolateral Patella • For evaluating patellar fractures + abnormalities of the patellofemoral and tibiofemoral joints. • Patient in lateral recumbent, affected side down, sound limb behind affected limb, body rotated for a true lateral knee, knee flexed 5 to 10. • Film: HD 18x24 cm. • CP: Midpatellofemoral joint. • CR: 90 to film center. (65kV, 4 mAs) (Grid for > 10 cm ). 43

  44. B Mediolateral Patella 44

  45. B Tangential (Axial) Patella (Skyline View) • To show subluxation of patella, fractures, and other abnormalities of patella and patellofemoral joint. Both patellae are done for comparison. • Patient prone, film under the knees, knees flexed 45, 90 deg patient holds a cotton tape for support. • Film: HD 24x30 cm. • CP: Midpatellofemoral joint. • CR: 15 to 20 tangential to the joint. 45

  46. B Tangential (Axial) Patella (Skyline View) 46

  47. B AP distal femur • Fracture and bone lesions in mid and distal femur and knee joint. For proximal femur only, a unilateral hip or a pelvis is recommended with a lead shield over the pelvis. • For distal part, patient supine, leg rotated internally 5 for a true AP (10 to 15 for distal part), knee joint must be included, lower film margin 2 inches below the knee joint. • Film: HD 35x43 cm (lengthwise). • CP: Midshaft of femur. • CR: 90 to film center. (Grid used, hip under cathode end) ). 47

  48. B AP distal femur 48

  49. B Lat distal femur (mediolateral/lateromedial) • Fracture and bone lesions in mid and distal femur and knee joint. For proximal femur only, a unilateral hip or a pelvis are recommended with lead shield over pelvis. • Patient in a lateral recumbent (supine in case of a trauma patient): Lateral recumbent: Knee flexed 45, patient on affected side, sound leg behind affected leg, lower end of film 2 inches below knee joint. Trauma lateromedial: Support under affected leg and knee, foot/ ankle in true AP, film against the medial aspect of thigh (beam horizontally). • Film: HD 35x43 cm (lengthwise). • CP: Midshaft of femur. • CR: 90 to film center 49

  50. B Lat distal femur (mediolateral) 50

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