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X-RAY PATIENT POSITIONING MANUAL: ARTICLES COMPILATION

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A R T I C L E S: -Proper positioning for the pelvis and proximal femur -The lowdown on lumbar spine positioning -Radiographic positioning techniques for the cervical spine -Boning up on humerus, clavicle, and AC joint positioning -Getting the most from shoulder positioning -The bends and flexures of forearm and elbow x-ray positioning -The twists and turns of hand and wrist x-ray positioning -Digit imaging requires diligent positioning -Patient positioning techniques for a lower gastrointestinal series -Patient positioning tips for a premium UGI series -Positioning techniques for quality esophagrams -Dorsal & lateral decubitus patient positioning for abdominal x-ray exams -AP abdominal projection x-ray positioning techniques -Tips and techniques for decubitus and oblique chest x-rays -Mastering AP and lateral positioning for chest x-ray -Good positioning is key to PA chest x-ray exams
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  • Added: March, 29th 2011
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AUNTMINNIE.COM
X-RAY PATIENT POSITIONING MANUAL
HTTP://XRAY.AUNTMINNIE.COM
A R T I C L E S
DIGIT
Proper positioning for the pelvis and proximal femur
The lowdown on lumbar spine positioning
Radiographic positioning techniques for the cervical spine
Boning up on humerus, clavicle, and AC joint positioning
Getting the most from shoulder positioning
The bends and flexures of forearm and elbow x-ray positioning
The twists and turns of hand and wrist x-ray positioning
Digit imaging requires diligent positioning
AL X-RA
Patient positioning techniques for a lower gastrointestinal series
Patient positioning tips for a premium UGI series
Positioning techniques for quality esophagrams
Dorsal & lateral decubitus patient positioning for abdominal x-ray exams
AP abdominal projection x-ray positioning techniques
Tips and techniques for decubitus and oblique chest x-rays
Mastering AP and lateral positioning for chest x-ray
Good positioning is key to PA chest x-ray exams
Y
Copyright © 2008 AuntMinnie.com

AUNTMINNIE.COM
X-RAY PATIENT POSITIONING MANUAL
HTTP://XRAY.AUNTMINNIE.COM
Introduction
Dear AuntMinnie Member,
I’m pleased to present this compendium of positioning techniques for the most
commonly performed radiographic exams, based on a series of articles I authored
for AuntMinnie.com between 2001 and 2003.
The articles feature a clear, easy-to-follow organization, with positioning and
projection information in an easy-to-read, bulleted format, and corresponding
positioning photos, radiographic images, and anatomical drawings.
We hope having these articles available in a single, easily downloadable PDF
format will enhance your understanding of anatomy and positioning.
Dr. Naveed Ahmad
Orlando, FL
March 2008
Copyright © 2008 AuntMinnie.com,
1350 N. Kolb Road, Suite 215, Tucson, AZ 85715
Copyright © 2008 AuntMinnie.com

AUNTMINNIE.COM
X-RAY PATIENT POSITIONING MANUAL
HTTP://XRAY.AUNTMINNIE.COM
Proper positioning for the pelvis and proximal femur
Proper positioning for the pelvis and proximal femur
By Dr. Naveed Ahmad
August 8, 2003
This article is the 16th in our series of white papers on radiologic patient positioning
techniques for x-ray examinations. If you’d like to comment on or contribute to this
series, please e-mail editorial@auntminnie.com.
The standard radiographic projections used to evaluate injury to the pelvic girdle and
proximal femur include the anteroposterior (AP) pelvis (bilateral hips) and AP unilateral
hip. AP oblique pelvis (the “frog leg”) projections are commonly performed on non-
trauma patients to evaluate congenital hip dislocation. The AP view is frequently not
sufficient to provide adequate evaluation of the entire sacral bone, the sacroiliac (SI)
joints, and the acetabulum. Special radiographic projections are performed to evaluate
the SI joints, sacral bones, and acetabulum.
AP pelvis (bilateral hips) projection
The standard radiographic view for the pelvis is obtained in an AP position with the
patient supine. Most traumatic conditions involving the sacral wings, the iliac bones,
ischium, the pubis, and the femoral head and neck can sufficiently be evaluated on
the AP projection of the pelvis and hip. This view also demonstrates an important
anatomical relationship in the longitudinal axes of the femoral neck and shaft.
Normally, the angle formed by these axes ranges from 125°-135°. Varus and valgus
configuration of a femoral neck fracture is said to occur if there is decrease or increase,
respectively, in this angle.
Technical factors
• Image receptor (IR): 14 x 17 inch (35 x 43 cm) crosswise
• 75- 85 kVp range
• mAs 12 (at 80 kVp)
• Moving or stationary grid
• Surface-to-image distance (SID) of 40 inches (100 cm)
Positioning for the AP pelvis (bilateral hips) projection
1. The patient is positioned supine on the radiographic table, with arms placed at the
side or across the upper chest. Placing a support under the head and knee helps to
relieve the strain on the patient while in the supine position.

2. The midsagittal plane of the body should be centered to the midline of the grid
device. There should be no rotation of the pelvis. The distance from tabletop to each
anterior superior iliac spine (ASIS) should be equal.
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Continued
3. The feet are placed in approximately 15°-20° of internal (medial) rotation. This is
done to overcome the normal anteversion of the femoral necks and to place their
longitudinal axes parallel to the film. The heels should be 8-10 inches (20-24 cm)
apart.

4. For correct centering of the pelvis (bilateral hips), palpate for the iliac crest and
adjust the position of the cassette so that the upper border of the cassette is 1-1
½ inches (2.5-3.8 cm) above the iliac crest. The center of the cassette should be
midway between the ASIS and the pubic symphysis.
5. For a pelvis with bilateral hips projection, carefully palpate the superior portion of
the iliac crest and direct the central ray (CR) midway between the level of the ASIS
and the symphysis pubis.

6. Shield gonads on all male patients. Ovarian shielding on females, however, is
generally not possible without obscuring essential pelvic anatomy (unless interest is
in area of hips only).
7. Ask the patient to suspend their breathing on expiration.


Evaluation criteria for AP pelvis (bilateral hips)
• The entire pelvis along with proximal femoral neck including pelvic girdle, L5,
sacrum, and coccyx should be seen.
• The lesser trochanters usually are not visible at all, or if they are, should appear
equal in size and shape on the medial border of the femora. The greater
trichinae should be visible in profile.
• No rotation is evidenced by symmetric appearance of the two obturator
foramina, as well as a symmetric iliac alae and ischial spines. A closed or
narrowed obturator foramen indicates rotation in that direction.
• Correct collimation and centering is evidenced by demonstration of both ilia
equidistant to the edge of the radiograph, both greater trochanters equidistant
to the edge of the radiograph, and the lower vertebral column centered to the
middle of the radiograph.
• Optimal exposure should clearly demonstrate L5, sacral area, and margins of the
femoral heads and acetabula without overexposing the ischium and the pubic
bones.
• No motion is evidenced by sharp orbicular markings of the proximal femora and
the pelvic structures.
(see Fig. 1, next pg.)
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Continued
(Fig. 1)
Copyright © 2008 AuntMinnie.com

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Continued
AP unilateral hip projection
An AP unilateral hip study is usually a postoperative or a follow-up exam to
demonstrate the acetabulum, femoral head and neck, and the greater trichinae, as well
as the condition and placement of any existing orthopedic appliance. Technical factors
and patient positioning are the same as for an AP pelvis (bilateral hips) exam.
The CR is placed perpendicular to the femoral neck in question, approximately 2 ½
inches (6.4 cm) distal on a line drawn perpendicular to the mid point of a line between
the ASIS and the pubic symphysis. In other words, the CR is directed 1-2 inches (2.5-5
cm) distal to mid femoral neck.
The femoral neck can be located about 1-2 inches (3-5 cm) medial and 3-4 inches (8-10
cm) distal to the ASIS. The collimated field should demonstrate the femoral head and
neck, trochanters, the proximal third of the femur shaft, regions of the ilium, and the
pubic bones adjoining the pubic symphysis.
The greater trochanter and femoral head and neck should be in full profile without
foreshortening. The lesser trochanter should not project beyond the medial border of
the femur. Optimal exposure should ensure visualization of the femoral head through
the acetabulum.
AP oblique pelvis projection x-ray positioning techniques
This projection is also called the bilateral “frog leg” position. It is useful for
demonstration of a non-trauma hip or developmental dysphasia of the hip, also known
as congenital hip dislocation (CHD). It shows an AP oblique projection of the femoral
heads, necks, and the trochanteric areas projected onto one radiograph for comparative
purposes.
Technical factors
• IR: 14 x 17 inch (35 x 43 cm) crosswise
• 75-85 kVp range
• mAs of 12 (at 80 kVp)
• Moving or stationary grid

• SID of 40 inches (100 cm)

Positioning for the AP oblique pelvis projection
1. The patient is positioned supine on the radiographic table, arms placed at the side
or across the upper chest. Placing a support under the head helps relieve the strain
on the patient while in the supine position.
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X-RAY PATIENT POSITIONING MANUAL
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Continued
2. The midsagittal plane of the body should be centered to the midline of the grid
device. There should be no rotation of the pelvis. The distance from tabletop to each
ASIS should be equal.
3. For a bilateral projection, both hips and knees are flexed approximately 90°.
Have the patient draw the feet up as much as possible. After correctly centering
the cassette 1 inch (2.5 cm) superior to the pubic symphysis, abduct both thighs
approximately 45° from the vertical plane to place the long axis of femoral necks
parallel with the plane of the cassette. Ensure that both thighs are abducted the
same amount and that pelvis is not rotated (equal distance of both ASIS to the
tabletop). Have the patient turn their feet to brace the soles against one another for
support.

4. For unilateral frog leg projection center the ASIS of the affected side to the midline
of the grid. Ask the patient to flex the hip and knee of the affected side, then
abduct the thigh laterally, approximately 45°. Have the patient draw the foot up to
the opposite knee as much as possible so that the sole of the foot is against the
opposite knee. The pelvis may rotate slightly in a unilateral projection.


5. Carefully palpate the superior portion of iliac crest and direct the CR to a point
3 inches (7.5 cm) below the level of the ASIS (1 inch or 2.5 cm above symphysis
pubis). For the unilateral position, direct the CR to the femoral neck.


6. Shield gonads on all male patients. Ovarian shielding on females, however, is
generally not possible without obscuring essential pelvis anatomy (unless interest is
in area of hips only).


(see Fig. 2, next pg.)
Evaluation criteria
Femoral heads and necks, acetabulum, and trochanteric areas should be visible on a
single radiograph.


No rotation is evidenced by symmetric appearance of the two obturator foramina
and pelvic bones. The lesser trochanters should appear equal in size as projected on
the medial margins of the femora. The greater trochanters are superimposed over the
femoral necks.


The femoral heads and necks and trochanters should appear symmetric if both thighs
are abducted equally.
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Continued
(Fig. 2)
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Continued
Special projections of pelvis and proximal femur
Other special radiographic projections to evaluate injury to the pelvic girdle include the
AP axial outlet projection, AP axial inlet projection, oblique projections for acetabulum,
groin projections (axiolateral), and posterior oblique projections for SI joints. These
are usually requested in trauma patients after a routine AP projection shows some
pathology, or in postsurgical patients who need follow-up evaluation.
AP axial pelvic outlet and AP axial pelvic inlet projections
The AP axial outlet projection shows an elongated projection of the pubic and ischial
rami. This projection provides an excellent view of the bilateral pubes and ischia to
assess pelvic bones for fractures and displacements. The AP axial inlet projection
provides assessment of the pelvic ring.
The technical factors and patient positioning for these projections are the same as for
an AP pelvis projection. The main difference lies in the CR angulations.
For an AP axial outlet projection, the CR is angulated cephalad 20°-35° for males and
30°-45° for females and is centered to a point 2 inches (5 cm) distal to the superior
border of the pubic symphysis. For an AP axial inlet projection, the CR is angulated
caudad 40° and is centered to a midline point at the level of both ASIS.
Oblique projections of the acetabulum
Oblique projections, known as Judet’s views, are necessary to evaluate the acetabulum.
The anterior (internal) oblique projection helps delineate the anterior column and the
posterior rim of the acetabulum. The posterior (external) oblique projection delineates
the posterior column and the anterior acetabular rim.
For a posteroanterior (PA) oblique projection the patient lies in a semi-prone position
on the affected side. The unaffected side is elevated so that the anterior surface of the
body forms a 38° angle from the table. The CR is directed 12° cephalic to the side being
examined, approximately 2 inches (5 cm) lateral to the midsagittal plane at the inferior
level of coccyx, permitting the CR to be directed through the acetabulum.
(see Fig. 3, next pg.)
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Continued
(Fig. 3)
Axiolateral projection of the hip and proximal femur (groin projection)
The groin projection is particularly useful in evaluating anterior and posterior
displacement of fracture fragments in proximal femoral fractures, as well as the degree
of rotation of the femoral head. This projection provides a true lateral image of the
proximal femur and also demonstrates an important anatomic feature, the angle of the
anteversion of the femoral neck, which normally ranges from 25°-30°.
It may be done on a stretcher or at bedside if the patient cannot be moved. The
unaffected leg is elevated and flexed so that the unaffected thigh is outside the
collimation field. The IR is placed in a crease above the iliac crest so that it is parallel to
the femoral neck and perpendicular to the CR. If the limb can be safely moved,
Copyright © 2008 AuntMinnie.com

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