Chapter 6 lab written

Osteomalacia (Rickets)

- "Bone softening" - Caused by lack of bone mineralization secondary to a deficiency of calcium, phosphorus, vitamin D. - Results in decreased bone density & bowing of weight bearing limbs on radiographic appearance. - Decrease in exposure factor.

Chondromalacia Patella

- "Runners knee" - Softening of cartilage under the patella resulting in wearing away that causes pain & tenderness. - Possible misalignment of patella in radiographic appearance.

Sunrise Patella Radiograph View:

- "Sun over the mountains" - If there's space = Incorrect angle - The more the knee bends the more the patella moves down so the more angle you'll need.

Talus (Astragalus)

- 2nd largest tarsal bone. - Located between lower leg & calcaneus. - The weight of the body is transmitted by this bone thru the important ankle & talocalcaneal joints. - The talus articulates with 4 bones: superiorly the tibia/fibula, inferiorly the calcaneus, anteriorly the navicular.

Cuneiforms

- 3 Wedge shaped bones. - Located on the medial mid aspect of the foot between first 3 metatarsals distally & the navicular proximally. - The largest cuneiform, which articulates with the 1st metatarsal, is the: medial (1st) cuneiform. - The intermediate (2nd) cuneiform articulates with the 2nd metatarsal & is the smallest cuneiform. - The lateral (3rd) cuneiform articulates with the 3rd metatarsal distally & cuboid laterally. - All 3 cuneiforms articulate with the navicular proximally. - Medial Cuneiform articulates with 4 bones: navicular proximally, 1st/2nd metatarsals distally, intermediate cuneiform laterally. - Intermediate Cuneiform articulates with 4 bones: navicular proximally, 2nd metatarsal distally, medial/lateral cuneiforms on each side. - Lateral Cuneiform articulates with 6 bones: navicular proximally, 2nd/3rd/4th metatarsals distally, intermediate cuneiform medially, cuboid laterally.

Distal Femur & Patella Lateral View

- A partial flexion of almost 45° shows the patella being pulled downward but with 90° flexion the patella would move down further over the distal portion of the femur. - The posterior surface of the distal femur is proximal to the intercondylar fossa called: popliteal surface, over which popliteal blood & nerve pass.

Projections of the Foot

- AP projections is the same as dorsoplantar (DP) projection. - PA projection is the same as plantodorsal (PD) projection.

Reiter Syndrome

- Affects the sacroiliac joints & lower limbs of young men. - Caused by previous infection of GI tract from salmonella or STD. - Asymmetric erosion of joint spaces on radiographic appearance.

Marker placement

- Always to place it in the location that is least likely to superimpose anatomy of interest. - At least one R or L marker should be visible on the lateral margin of the collimation field on at least one projection on each IR.

Pediatric Applications

- Ask a parent to help if necessary - Immobilization tools: sandbags, sponges, tape - Decrease in exposure factor - Shortest exposure time - Highest mAs possible

Osteoid Osteomas

- Benign bone lesions that usually occur in teenagers or young adults. - Pain worsens at night - Tibia/Femur are most common locations - Small rounded density with lucent center on radiographic appearance.

Bone Cysts

- Benign, neoplastic bone lesions filled with clear fluid that most occur at the knee joint in kids & young adults. - Well circumscribed lucency on radiographic appearance.

Exostosis (Osteochondroma)

- Benign, neoplastic lesion that's caused by overproduction of bone at a joint, usually the knee. - Grows parallel to shaft & away from nearest joint on radiographic appearance.

Joints of Phalanges & Metatarsals

- Between the proximal & distal phalanges of the 1st digit is the: interphalangeal joint (IP). - Digits 2-5 between the middle & distal phalanges is the: distal interphalangeal (DIP) joint & between the proximal & middle phalanges is the: proximal interphalangeal (PIP) joint. - Each of the joints at the head of the metatarsals is a: metatarsophalangeal (MTP) joint & each of the joints at the base of the metatarsals is a: tarsometatarsal (TMT) joint. - The 3rd metatarsal or TMT joint is important because this is the centering for an AP & oblique foot projections.

Obese Patient Considerations

- Clothing, especially tight fitting, is important because it can cause artifacts to appear on images & make it difficult to visualize fat pads. - Increase kVp to improve penetration. - An increase in cephalic CR angle may be required to better visualize open joint space when a patient has greater thickness. - May use a grid if lower limb is greater then 10cm.

Ewing Sarcoma

- Common primary malignant bone tumor that arises from bone marrow in kids/young adults. - "Onion peel" radiographic appearance.

Osteoarthritis

- Degenerative joint disease. - Noninflammatory joint disease. - Narrowing of joint space on radiographic appearance. - Decrease in exposure factor.

Distal Femur & Patella Axial View

- Demonstrates the relationship between the patella to the patellar surface or the distal femur. - The intercondylar fossa or notch is shown to be very deep on the posterior aspect of the femur. The epicondyles are seen as rough prominences on the outermost tips of the large medial & lateral condyles. - The posterior surface of the distal femur just proximal to the intercondylar fossa is the: popliteal surface.

Surfaces of the Foot

- Dorsal Pedis: anterior surface of foot - Plantar Surface: sole of foot

Motions of the Foot & Ankle

- Dorsiflex: is the action of raising the foot upwards towards the shin (decreasing angle). - Plantarflex: pointing the foot or toe downward like you're tip toeing (increasing angle). - Inversion/Varus: inward turning or bending of ankle. - Eversion/Valgus: outward turning or bending of ankle.

Metatarsals (5)

- Each contain a head, body, base. - Base of the 5th metatarsal is expanded laterally into a prominent rough tuberosity which provides attachment for a tendon. This is a common trauma site for the proximal aspect of foot & is well visualized on a radiograph.

Patella (kneecap)

- Flat triangular bone about 2 inches in diameter. - It appears upside down because it's pointed apex: is located along the inferior border & its base: is the superior border. The anterior surface: is convex & rough and the posterior surface: is smooth & oval shaped for articulation with the femur. - The patella protects the anterior aspect of the knee joint & acts as a pivot to increase leverage of the: large quadriceps femoris muscle. - The patella is loose & moveable but when the leg is flexed it becomes locked. - The patella only articulates with the femur, not the tibia or fibula.

Navicular (Scaphoid)

- Flattened, oval bone located on medial side of foot between talus & 3 cuneiforms. - The navicular articulates with 5 bones: posteriorly the talus, laterally the cuboid, anteriorly the 3 cuneiforms.

Gout

- Form of arthritis that may be hereditary in which uric acid appears in excessive quantities in the blood & may be deposited in the joints. - Common initial attack occurs in 1st MTP joint of the foot. - Commonly affects men. - Destruction of joint space on radiographic appearance.

Osteoclastomas

- Giant cell tumors - Benign lesions that occur in long bones of young adults. - Large "bubbles" separated by thin stripes of bone on radiographic appearance.

Osteogenic Sarcomas

- Highly malignant primary bone tumor. - Peak age is 20 - Classic appearance is sunburst pattern & destructive lesion with irregular periosteal reaction.

Osgood-Schlatter Disease

- Inflammation of the bone/cartilage of the anterior proximal tibia. - Most common in boys 10-15 years old. - Occurs when the large patellar tendon detaches part of the tibial tuberosity. -Fragmentation or detachment on radiographic appearance.

Lisfranc Ligament

- Is a large band that spans the articulation of the medial cuneiform and the 1st/2nd metatarsal base. - Abnormal separation or fracture of 1st/2nd metatarsal on radiographic appearance. - Slight increase in exposure factor. - Weight bearing AP & lateral and 30° medial oblique projections.

Synovial Membrane & Cavity

- Is the largest joint space of the human body. - The total knee joint is a synovial type enclosed in an: articular capsule or bursa. It's a complex, saclike structure filled with lubricating synovial fluid. It extends upward to the patella, identified as: suprapatellar bursa. Distal to the patella: infrapatellar bursa, is separated by a large infrapatellar fat pad which can be identified on radiographs.

Knee Joint

- Large complex joint that primarily involves the: femorotibial joint between the two condyles of the femur & tibia. - The patellofemoral joint: is the patella articulating with the anterior surface with the distal femur.

Calcaneus (Os Calcis)

- Largest & strongest bone in the foot. - The posterior portion is called: heel bone. - The most posterior-inferior part contains a process called: tuberosity, common site for bone spurs. - The largest tendon is the: achilles, attached to this rough/striated process which at its widest point includes two small rounded processes. The largest process is the: lateral & smaller is the: medial. - Another ridge of bone that varies in size/shape & is visualized laterally on axial projections is the: perineal trochlea or trochlear process. On the medial proximal aspect is a larger more prominent bony process called: sustentaculum tali, which means a support for the talus. - Calcaneus bone articulates with 2 bones: anteriorly the cuboid & posteriorly the talus. The superior articulation with the talus forms the: subtalar (talocalcaneal) joint. - 3 specific articular facets appear at the subtalar joint with the talus thru which weight of the body is transmitted to the ground in erect position: larger posterior articular facet, small anterior facet, middle articular facet. The middle articular facet provides medial support which is a important weight bearing joint. - The deep depression between the posterior & middle facet is called: calcanea sulcus. It forms an opening for certain ligaments to pass thru. This opening is called: sinus tarsi or tarsal sinus.

Cuboid

- Located on the lateral aspect of foot. - The cuboid articulates with 5 bones: calcaneus proximally, lateral cuneiform, navicular medially, 4th/5th metatarsals distally.

Geriatric Applications

- Look for telltale signs of hip fracture - Shorter exposure time - Higher mAs

Chondrosarcoma

- Malignant tumor of the cartilage that usually occurs in the pelvis & long bones of men older than 45+ years. - Bone destruction with calcifications in cartilaginous tumor in radiographic appearance.

Paget Disease (Osteitis Deformans)

- Most common disease of the skeleton. - Most common in middle and is twice as common in men. - A non-neoplastic bone disease that disrupts new bone growth resulting in overproduction of very dense yet soft bone. - Most common in skull, pelvis, femur, tibia, vertebrae, clavicles, rib. - Cotton wool & lucent areas on radiographic appearance. - Increase in exposure factor.

Multiple Myeloma

- Most common type of primary cancerous bone. - Ages 40-70 years old. - "Punched out" radiographic appearance.

Phalanges (14)

- Most distal bones. - These make up the toes or digits. - Big toe is 1st digit; only has proximal & distal phalanx. - 2nd-5th digits have a proximal, middle, distal. - Phalanges of foot are smaller & their movements are more limited than phalanges of the hand.

Joint Effusions

- Occur as accumulated fluid in the joint cavity. - These are signs of fracture, dislocation, soft tissue damage.

Tibia

- One of the larger bones of the body. - Is the weight bearing bone of the lower leg. - Can be felt easily thru the skin on the anteromedial part of the lower leg. - It has 3 parts: body & 2 extremities. - Proximal Extremity: medial & lateral condyles are the two large processes that make up the proximal tibia. The intercondylar eminence(tibial spine): includes two smaller prominences: medial & lateral intercondylar tubercles which are located on the superior surface of the tibial head between the 2 condyles. The upper articular surface of the condyles include two smooth concave articular facets: tibial plateau, that articulate with femur & these slope posteriorly from 10°-20°. The tibial tuberosity: on the proximal extremity of the tibia is a rough textured prominence located on the mid anterior surface of the tibia just distal to the condyles. If the tibial tuberosity separates the tibia it's a condition called: Osgood-Schlatter Disease. - Body: Is a long portion of the tibia between the 2 extremities. Along the anterior surface extending from the tibial tuberosity to the medial malleolus is a sharp ridge called: anterior crest also called the shin. - Distal Extremity: Is smaller than the proximal extremity & ends in a short pyramid shape process called: medial malleolus. The lateral aspect of the distal extremity of the tibia is a flattened, triangular shape process called: fibular notch.

Sesamoid Bones

- Several small, detached bones. - These fractures are painful. - Usually found near joints & plantar surface at the head of the 1st metatarsal. - The largest one is the: patella(kneecap). - Sesamoid bones on the medial side of the lower limb are: tibial & lateral are: fibular.

Enchondroma

- Slow growing benign cartilaginous tumor that are found in small bones of hands/feet in young adults. - Radiolucent tumor with thin cortex on radiographic appearance.

Ankle Joint Structure

- The ankle joint is a: synovial joint of the saddle (seller) type with dorsi/plantar flexion & extension. - Requires strong collateral ligaments that extend from the medial/lateral malleoli to the calcaneus/talus. - Lateral stress results in: "sprained" ankle with stretch or torn collateral ligaments/muscle tendons which leads to an increases in parts of the mortise space. AP stress views of the ankle can be performed to evaluate stability of the most rise joint space.

Ankle joint frontal view

- The ankle joint is formed by 3 bones: tibia, fibula, talus. - The expanded distal end of the slender fibula, which extends alongside the talus, is called: lateral malleolus. - The medial elongated process of the tibia that extends down alongside the medial talus is called: medial malleolus. - The inferior portions of the tib/fib form a deep "socket" of 3 sided opening called a: mortise, into which the superior talus fits but it's never seen on a true AP projection because of overlapping of the distal tib/fib of the talus. A 15° internally rotated AP oblique called: mortise position, demonstrates the mortise joint which should have an even space over the entire taller surface. - The anterior tubercle: is an expanded process at the distal anterior & lateral tibia that has been shown to articulate with the superolateral talus while overlapping the fibula anteriorly. - The distal tibial joint surface forms the roof of the ankle mortise joint called the: tibial plafond (ceiling).

Mid & Distal Femur Anterior View

- The distal femur viewed anteriorly demonstrates the position of the patella: the largest sesamoid bone in the body. The most distal part of the patella is: superior or proximal to the actual knee joint by 1/2 inch with the lower leg fully extended. - The patellar surface: is the smooth shallow, triangular depression at the distal portion of the anterior femur that extends up under the lowest part of the patella. This depression is sometimes called: intercondylar sulcus or trochlear groove. - When the leg is flexed, the patella moves downward over the patellar surface.

Calcaneous Radiograph Views:

- The heel needs to be flat on the IR for a lateral view. - For axial make sure there's a 40° angle towards the heel. - Dorsiflex the foot. - Elongated = Too much angle. - Foreshorten = Not enough angle or the foot isn't dorsiflex.

Ankle joint lateral view

- The lateral view demonstrates that the distal fibula is located 1 cm posterior in relation to the distal tibia and the lateral malleolus is 1 cm more distal than the medial malleolus.

Menisci (Articular Disks)

- The medial & lateral menisci are crescent shaped fibrocartilage disks between the articular facets of the tibia and the femoral condyles. - They are thicker at their external margins, tapering to a very thin center portion. - They act as shock absorbers to reduce some of the direct impact & stress that occur at the knee. - The synovial membrane & menisci produce synovial fluid to lubricate the articulating ends of the femur & tibia that are covered with a tough slick hyaline membrane.

Mid & Distal Femur Posterior View

- The posterior view best demonstrates the two large rounded condyles that are separated distally & posteriorly by the deep: intercondylar fossa or notch. - The rounded distal portions of the medial & lateral condyles contains a smooth articular surfaces for articulation with the tibia. The medial condyle extends lower or more distally than the lateral when the femoral shaft is vertical. This explains why the CR must be angled 5°-7° cephalic for a lateral knee to cause the two condyles to be directly superimposed when the femur is parallel to the IR. The range is 5°-15° which is greater on women than men. - A distinguishing difference between the medial & lateral condyles is the presence of the: adductor tubercle, a slightly raised area that relieves the tendon of an adductor muscle. This tubercle is present on the: postolateral aspect the medial condyle.

Proximal Tibiofibular Joint & Major Knee Ligaments

- The proximal fibula is not part of the knee joint because it doesn't articulate with any aspect of the femur even tho the: fibular (lateral) collateral ligament (LCL) extends from the femur to the lateral proximal fibula. The head of the fibula articulates with the lateral condyle of the tibia to which is attached by this ligament. - The two collateral ligaments: are strong bands at the sides of the knee to prevent adduction & abduction movements at the knee. - The two cruciate ligaments: are strong rounded cords that cross each other as they attach to the anterior/posterior aspects of the intercondylar eminence of the tibia. They stabilize the knee joint by preventing anterior/posterior movement. - An anteriorly located patellar ligament & various minor ligaments help maintain the integrity of the knee joint. The patellar ligament: is part of the tendon of insertion of the large quadriceps femoris muscle that extends over the patella to the tibial tuberosity. The infrapatellar fat pad: is posterior to this ligament which aids in protecting the anterior aspect of the knee joint.

Fibula

- The smaller fibula is located laterally & posteriorly to the larger fibula. - Articulates with the tibia proximally & the tibia/talus distally. - The proximal extremity of the fibula is expanded into a: head, which articulates with the lateral aspect of the posteroinferior surface of the lateral condyle of the tibia. - The extreme proximal aspect of the head is pointed & is known as the: apex, of the head of the fibula. The tapered area just below the head is the: neck, of the fibula. - The body: is the long slender portion of the fibula between the two extremities. The enlarged distal end of the fibula can be felt as a distinct "bump" on the lateral aspect of the ankle joint called the: lateral malleolus.

Ankle joint axial view

- This visualizes the "end-on" view of the ankle joint looking for the bottom up, demonstrating the concave inferior surface of the tibia plafond. - You can also see the lateral & medial malleoli of the tibia/fibula. - The smaller fibula is shown to be more posterior. - A horizontal plane is drawn thru the midportions of the 2 malleoli. This positioning line is termed: intermalleolar plane. The lower leg/ankle must be rotated 15°-20° to bring the intermalleolar plane parallel to the coronal place.

Tib/Fib Radiograph Views:

- We hang these up in anatomical position. 1. AP: Must include ankle/knee joints. If you cut one of the joints off, either take an AP knee or an AP ankle x-ray and make sure the foot is dorsiflex. 2. Lateral: Basically you want to position between a lateral ankle & a lateral knee. - Go corner to corner on the IR.

Knee Radiograph Views:

- We hang these up in the anatomical position. 1. AP: Patella is between the 2 condyles & proximal tib/fib joint is slightly superimposed. 2. Medial Oblique: 45°, opens up the proximal tib/fib joint. 3. External Oblique: 45°, the tib/fib is superimposed. 4. Mediolateral: 5°-7° cephalic angle because the medial condyle is slightly lower than the lateral condyle, if you don't angle there won't be space between the condyles, if you do angle the condyles are superimposed & the joint space will be open. If there's a rotation error, the adductor tubercle (which is a bump only on the medial condyle) will be behind the lateral condyle & the proximal tib/fib joint will be superimposed resulting in under rotation (too far away from IR). If there's rotation & tib/fib joint is open, it's over rotated. 5. Lateromedial: 5°-7° caudal angle, the knee will be too much rotated towards the IR, and everything is the opposite of the mediolateral. 6. Tunnel: Intecondylar fossa is open, if it's closing there's a rotation error, if there's a shadow behind it then the hamstring is in the way. You want the CR perpendicular. - Flabella: Calcifications near the knee only seen in a lateral view.

Ankle Radiograph Views:

- We hang these up in the anatomical position. 1. AP: Distal tib/fib is slightly superimposed. 2. AP Mortise: Tibial plafond/Mortise joint space is open with a 15°-20° medial oblique. 3. Oblique: 45°, distal tibiofibular joint is open. 4. Lateral: Tib/fib is superimposed or fibula is slightly posterior & if they're not superimposed at all there's over rotation. - Always dorsiflex the foot as much as possible.

Foot Radiograph Views:

- We hang these with the "toes up". 1. AP: Don't forget that 10° posterior angle towards the heel, 3rd,4th,5th bases of metatarsals & cuboid/3rd cuneiforms are slightly superimposed. 2. Oblique: 30°-40°, Sinus tarsi is open & there's no superimposition. 3. Lateral: Metatarsals are superimposed over each other with dorisflexed foot. The 5th MT might show & that's okay. - What view of the foot shows the cuboid, 3rd cuneiform & base of 5th metatarsal in profile? Medial oblique.

Where is the CR placed for a mediolateral projection of the calcaneus?

1 inch inferior to medial malleolus

Positioning Considerations

1. 40 SID bucky, 44 SID tabletop, SID high as possible for tib/fib. 2. Gonadal Sheilding. 3. Collimation borders should be visible on all four sides of the IR. 4. Use the smallest IR size possible. 5. Always place the long axis of the part that is being radiographed parallel to the long axis of the IR. All body parts should be oriented in the same direction. 6. Low to medium kVp (55-65 analog 70-85 digital). 7. Short exposure time. 8. Small focal spot. 9. Grids used only if body part is larger then 10cm.

Classification of Joints

1. Interphalangeal joints: ginglymus (hinge) 2. Metatarsophalangeal joints: ellipsoidal (condyloid) 3. Tarsometatarsal joints: plane (gliding) 4. Intertarsal joints: plane (gliding) 5. Ankle joint: saddle (sellar) 6. Femorotibial: bicondylar 7. Patellofemoral: saddle (sellar) 8. Proximal tibiofibular joint: plane (gliding) 9. Distal tibiofibular joint: syndesmosis (amphiarthrodial) - All lower limb joints are classified as synovial/diarthrodial except distal tibiofibular joint, it's fibrous joint.

Match the following foot/ankle movements to the correct definition: A. Inversion B. Plantar flexion C. Eversion D. Dorsiflexion

1. Inward turning or bending of ankle - A 2. Decreasing the angle between the dorsum pedis & anterior lower leg - D 3. Extending the ankle or posting the foot & toe downward - B 4. Outward turning or bending of ankle - C

Arches of the foot

1. Longitudinal Arch: Provides a strong, shock absorbing support for the weight of the body. The springy, longitudinal arch comprises a medial & lateral component with most of the arch located of the medial mid aspect of the foot. 2. Transverse Arch: Located along the plantar surface of the distal tarsals & TMT joints. Primarily made up of the wedge shaped cuneiforms & cuboid.

Match each of the following articulation to the correct joint classification or movement type: A. Synarthrodial B. Ginglymus (hinge) C. Saddle (sellar) D. Plane (gliding) E. Amphiarthrodial F. Bicondylar

1. ankle joint - C 2. patellaofemoral - C 3. proximal tibiofibular - D 4. tarsometatarsal - D 5. femorotibial - F 6. distal tibiofibular - E

Match the following characteristics to the correct tarsal bone: A. calcaneus B. talus C. cuboid D. navicular E. 3rd cuneiform F. 2nd cuneiform G. 1st cuneiform

1. forms an aspect of the ankle joint - B 2. the smaller of the cuneiforms - F 3. found on the medial side of the foot between the talus & 3 cuneiforms - D 4. the largest of the cuneiforms - G 5. articulates with the 2nd/3rd/4th metatarsal - E 6. the most superior tarsal bone - B 7. articulates with the first metatarsal - G 8. common site for bone spurs - A 9. a tarsal found anterior to the calcaneus & lateral to the 3rd cuneiform - C 10. the second largest tarsal bone - B

Match the following structures to the correct bone: A. tibia B. fibula C. distal femur D. patella

1. tibial plafond - A 2. medial malleolus - A 3. lateral epicondyle - C 4. patellar surface - C 5. articular facets - A 6. fibular notch - A 7. styloid process - B 8. base - D 9. intercondyloid eminence - A 10. neck - B

Where is the CR centered for an AP projection of the knee? 1/2 inch distal to apex of patella 1 inch proximal to apex of patella midpatella level to tibial tuberosity

1/2 inch distal to apex of patella

What CR is required for AP projection of the foot?

10° posterior

Bones of the foot:

14 Phalanges 5 Metatarsals 7 Tarsals = 26

How much should the foot & ankle be rotated for an AP mortise projection of the ankle?

15-20 degrees medially

How much flexion is recommended for a lateral projection of the knee to best demonstrate the patellofemoral joint space? None 20-30 degrees 30-35 degrees 45 degrees

20-30 degrees

Rotation can be determined on a radiograph of an AP foot projection by the near-equal distance between the _______ metatarsals.

2nd-5th

How many articular facets make up the subtalar joint?

3

What is the recommended CR angulation for an AP projection of the knee for a patient with thick thighs & buttocks? 3-5 degrees caudal 3-5 degree cephalic CR perpendicular

3-5 degrees cephalic

How much foot rotation is required for the AP oblique medial rotation projection of the foot?

30°-40°

How should the CR be angled from the long axis of the foot for the plantodorsal (axial) projection of the calcaneus?

40 degree cephalic

Which projection of the ankle best demonstrates a possible fracture of the lateral malleolus & the base of the 5th metatarsal?

45 degree AP oblique with medial rotation

What is the recommended CR placement for a lateral knee position on a tall, slender male patient with a narrow pelvis? 5-10 degrees caudal 5 degrees cephalic CR perpendicular to IR

5 degrees cephalic

How much flexion of the knee is recommended for the lateral projection of the patella? 5-10 10-15 5-7 none

5-10

List the 3 specific articular facets found in the joint described in the picture:

7. posterior facet 2. anterior facet 1. middle facet

What is the basic positioning routine for a study of the tibia & fibula?

AP & Lateral projections

Which type of study should be performed to best evaluate the status of the longitudinal arches of the foot?

AP & Lateral weight bearing projections

A patient with a possible Lisfranc joint injury comes in & wants to evaluate the arches on his feet, what projections would you do?

AP & Lateral weight bearing projections of the feet

Which projection of the knee will best demonstrate the neck of the fibula without superimposition of the tibia?

AP Medial Oblique

Which of the following projections of the ankle will best demonstrate the open joint space of the lateral aspect of the ankle joint?

AP Mortise Projection

A patient enters the emergency department (ED) with a possible transverse fracture of the patella. Which of the following routines would safely provide the best images of the patella?

AP and horizontal beam lateral, no flexion of knee

Why is it important to include the knee joint for an initial study of the tibia trauma even if the patients symptoms include the middle & distal aspect?

AP fracture may be present

A patient with trauma to the medial aspect of the foot comes to the ER. A heavy object was dropped on the foot near the base of the 1st metatarsal. A basic foot projection doesn't demonstrate this region. What other projection would you do?

AP lateral oblique projection with 30 degree external rotation will separate the base of the 1st/2nd metatarsals and cuneiforms.

Which basic projection of a knee best demonstrates the proximal fibula free of superimposition? true AP true lateral AP oblique 45 degree medial rotation AP olblique 45 degree lateral rotation

AP oblique 45 degree medial rotation

Which projection of the foot best demonstrates the navicular & the 1st/2nd cuneiforms with the minimal superposition?

AP oblique lateral rotation

What projection of the foot best demonstrates the cuboid?

AP oblique medial rotation

Which oblique projection of the foot best demonstrates the majority of the tarsal bones?

AP oblique medial rotation

A patient with a history of degenerative disease of the left knee comes in, what projections should be performed?

AP or PA weight bearing bilateral knee projection, this will best evaluate the joint spaces

Which special projection of the knee is best to evaluate the knee joint for cartilage degeneration or deformities?

AP or PA weight bearing knee projections

A patient enters radiology with a possible ligament tear to the lateral aspect of the ankle. Initial ankle radiographs are negative for fracture or dislocation. Because the clinic is in a rural setting, the patient cannot have an MRI performed to evaluate the ligaments of the ankle. Which of the following techniques may provide an assessment of the soft tissue structures of the ankle?

AP stress positions

Which projections of the ankle require forced inversion & eversion movement?

AP stress projections

A patient comes to the radiology department for a knee study with special interest in the region of the proximal tibiofibular joint and the lateral condyle of the tibia. Which of the following positioning routines should the technologist obtain?

AP, Lateral, Medial Oblique

A radiograph of a mediolateral knee projection demonstrates that the medial femoral condyle is projected inferior to the lateral condyle, what can you do to fix this error?

Angle CR 5-7 degrees, the medial femoral condyle will be superimposed with lateral condyle.

A radiograph of an AP knee projection demonstrates that the femorotibial joint space is not open at all, what positioning modification could you do?

Angle CR correctly to keep it parallel to articular facets (tibial plateau).

Where is the CR placed for a plantodorsal axial projection of the calcaneus?

Base of 3rd metatarsal

Where is the CR for an AP oblique of the foot?

Base of the 3rd metatarsal

Why must the CR be angled 5-7 degrees cephalic for a lateral knee position?

Because the medial condyle extends lower or more distally than the lateral condyle of the femur.

A projection is performed for the patellofemoral joint with the patient supine & the knee flexed 40 degrees. The CR is angled 30 degrees caudad from horizontal. The cassette is resting on the lower legs supported by a special cassette holding device. Which method is this?

Bilateral Merchant

Which of the following knee projections requires the use of a special IR holding device: Bilateral Merchant Method, Camp-Coventry method, Béclere method ?

Bilateral Merchant Method

Fractures

Breaks in the structure of bone caused by a force (indirect/direct).

Saclike structures found in the knee joint that allow smooth articulation between ligaments and tendons are called?

Bursae

A radiograph of a PA axial projection for the intercondylar fossa (Camp-Coventry method) does not demonstrate the fossa well. It is foreshortened. The following positioning factors were used: patient prone, knee flexed 40° to 45°, CR angled to be perpendicular to the femur, 40-inch SID, and no rotation of the lower limb. Based on the factors used, what changes need to be made to produce a more diagnostic image?

CR must be perpendicular to lower leg

A radiograph of an AP projection of the foot shows that the metatarsalphalangeal joints are open & the metatarsals are somewhat foreshortened. There is equal spacing between the mid-metatarsals. What was the positioning error?

CR not angled correctly; adjust it to keep it perpendicular to metatarsals.

Which structure or bone contains the sustentaculum tali?

Calcaneus

A geriatric patient comes to the radiology department for a study of the knee. The patient is unsteady and unsure of himself. Which intercondylar fossa projection would provide the best results without risk of injury to the patient? Holmblad method Hughston method Camp-Coventry method Rosenberg method

Camp Coventry Method

What special projections can you do for a tunnel view?

Camp Coventry, Holmblad, Bèclere Methods

Tarsal Bones (7)

Come - Calcaneus (os calcis) To - Talus (astragalus) Colorado - Cuboid Next - Navicular (scaphoid) 3 Christmases - 1st, 2nd, 3rd Cuneiforms - These are larger & less mobile than the carpals. - Provide base of support when erect. - Sometimes referred to as "ankle bones". - Only the Talus is involved with the ankle joint.

Knee Trauma

Contact sports or activities can cause a tear of the tibial MCL or ACL or Medial Meniscus

Which two ligaments of the knee help stabilize the knee from the anterior & posterior perspective?

Cruciate

A radiograph of a lateral patella shows that the patella is drawn tightly against the intercondylar sulcus, what position modification should you do?

Decrease the amount of flexion of the knee to only 5-10 degrees.

Hobbs Modification (Superoinferior sitting tangetntial)

Do not do this projection until patella fracture is ruled out, IR is placed on a footstool to minimize the OID with patient sitting down, no angle, CR perpendicular to mid patellofemoral joint, SID 48-50 inches, disadvantage is acute flexion of knees.

Which term describes the top or anterior surface of the foot?

Dorsum

What is the major disadvantage of using 45° of flexion for the mediolateral projection of the knee?

Draws the patella into the intercondylar sulcus.

A radiograph of an AP mortise projection of the ankle shows that the lateral joint space isn't open with the lateral malleolus superimposed over the talus & the talus is distorted, what's the positioning error?

Excessive medial rotation

T/F: Grids are required for studies of the adult ankle.

False

T/F: The superoinferior, sitting tangential (Hobbs modification) projection for patellofemoral joint space requires a CR angle of 5° to 10° posterior.

False

T/F: When multiple exposures are placed on a single computed radiography image receptor (IR), lead masking should not be placed on the unexposed regions of the imaging plate.

False

T/F: The mortise of the ankle should be totally open & visible on a correctly positioned AP projection of the ankle.

False, it's never seen on a true AP.

The distal tibiofibular joint is classified as a ____ joint.

Fibrous

A bilateral patellofemoral joint space study is ordered. The patient is paraplegic & cannot stand. What special projection would you do?

Hobbs modification

Which of the following special projections of the knee best demonstrates the intercondylar fossa? Holmblad Merchant Settegast

Holmblad

Which positioning error is present if the distal borders of the femoral condyles are not superimposed on a radiograph of a lateral knee on an average sized knee?

Improper angle of CR or lack of support of the lower leg.

A radiography of the Camp-Coventry method was produced but the intercondylar fossa isn't open & is foreshortened. The following factors were used: prone position, lower leg flexed 45 degrees, CR angled 30 degrees caudal, centered to popliteal crease. What should be done for the repeat exposure?

Increase CR angle to 45 degrees caudal (angle should match knee flexion).

A radiograph of a plantodorsal axial projection of the calcaneus shows that it's foreshorten. The following factors were used: supine position, foot dorsiflexed perpendicular to IR, CR angled 30 degrees cephalic, centered at base of 3rd metatarsal. What should be done for the repeat exposure?

Increase CR to 40 degrees

A radiograph of a plantodorsal axial projection of the calcaneus shows considerable foreshortening of the calcaneus, what type of positioning modification needs to be fixed?

Increase cephalic angle of the CR to correctly elongate calcaneus.

Exposure Factors for Diseases

Increase: Lisfranc Joint Injury & Paget Disease Decrease: Osteoarthritis & Osteomalacia

What special projections can you do for a sunrise view?

Inferosuperior, Hughston, Settegast Methods

A radiograph of an AP mortise projection of the ankle reveals that the lateral malleolus is slightly superimposed over the talus and the lateral joint space is not open. What is most likely cause for this radiographic outcome?

Insufficient medial rotation of the foot and ankle

The purpose of the AP stress views of the ankle is to demonstrate?

Joint separation or ligament tears.

A young male comes in with a history of Osgood-Schlatter disease, what single projection of the knees will bestsellers demonstrate this condition?

Lateral knee projection will best demonstrate any separation of the tibial tuberosity from the shaft of the tibia.

A radiograph of an AP knee shows that the joint spaces are not equally open & the proximal fibula is superimposed over the tibia, what's the error?

Lateral rotation of the lower limb

Why is a PA projection of the patella preferred to an AP projection?

Less OID, magnification & distortion.

What are the 4 major ligaments of the knee?

MCL, LCL, ACL, PCL

The best method of evaluating injuries to the menisci and ligaments of the knee joint involves?

MRI

Which joint surfaces of the ankle joint are most commonly open with an AP projection of the ankle?

Medial & Superior

What is another term for intercondyloid eminence?

Medial & lateral intercondylar tubercles

Why is the CR angled 10-15 degrees toward the calcaneus for an AP projection of the toes?

Opens up the IP & MTP joint spaces

Why should the CR be perpendicular to the metatarsals for an AP projection of the foot?

Opens up the MTP & certain inter tarsal joints

A tangential inferosuperior projection of the patellofemoral joint space shows that the patella is seated in the intercondylar sulcus & the joint space is not demonstrated, what is the positioning error?

Over flexion of the knee because it draws the patella into the intercondylar sulcus; Flexion of the lower limb should not exceed 45 degrees. Another possible error is that the CR is not parallel to the joint space.

A radiograph of an AP oblique medial rotation of the foot shows that the proximal 3rd-5th metatarsals are superimposed, what's the position error?

Over rotation

The profile appearance of the adductor tubercle and excessive superimposition of the fibular head and neck on a lateromedial knee projection indicate?

Overrotation of the knee toward the IR.

Which tendon attaches directly to the tibial tuberosity?

Patellar

Rosenburg Method

Patient erect facing IR, 45 degree knee flexion, 10 degree caudal angle.

Holmblad Method

Patient on all fours putting all their weight on non-affected knee, 60-70 degree flexion of affected knee, can be performed using a wheelchair or lowered radiographic table.

Hughston Method

Patient prone with 50-60 degree knee flexion & 45 degree cephalic CR angle.

Camp Coventry Method

Patient prone with a 40-50 degree knee flexion & equal 40-50 degree caudal CR angle.

Settegast Method

Patient prone, requires 90 degree knee flexion, disadvantage is that knee flexion draws patella into intercondylar sulcus.

Merchant Method

Patient supine with 40 degree knee flexion & 30 degree caudal CR angle from horizontal; SID is 48-72 inches.

Inferosuperior for patellofemoral joint

Patient supine with cassette resting on midthighs, 40-45 degree knee flexion, CR perpendicular.

Bèclere Method

Patient supine, 40-45 degree knee flexion, CR 1/2 inch below apex of patella.

For the AP weight-bearing knee projection on an average patient, the CR should be?

Perpendicular to the image receptor.

A radiograph of an AP projection of the ankle shows that the lateral surface of the ankle joint is totally open, what else could have led to this joint space being open?

Possibly a spread of the ankle mortise caused by a ruptured ligament.

Which joint space should be open or almost open for a well positioned AP oblique knee projection with medial rotation?

Proximal tibiofibular

A radiograph of an AP & Lateral tibia/fibula shows that the ankle joint is not included on the AP projection, but both knee and ankle are included, what should you do?

Repeat AP projection to ensure ankle joint is demonstrated.

A radiograph of an AP knee reveals rotation with almost total superimposition of the fibular head and the proximal tibia. What must the technologist do to correct this positioning error on the repeat exposure?

Rotate the knee medially slightly.

A radiograph obtained by using the PA axial (Camp-Coventry method) reveals that the distal femoral condyles, articular facets, and intercondylar fossa are asymmetric. What possible positioning errors may have produced this distortion of the anatomy?

Rotation of the affected limb or incorrect CR angle to match the degree of flexion of the lower limb.

Increase Exposure With Cast

Small to medium: increase 5kVp-7kVp Large: increase 8kVP-10kVp Fiber Glass: increase 3kVp-4kVp

A DR orders a bilateral tangential projection of the patella & patellofemoral joint space. The patient is restricted to a wheelchair & cannot lie on the table. Which projection would you do?

Superoinferior sitting tangential method; While remaining in the wheelchair, the patient's knees can be flexed, and IR can be positioned on a foot stool, and the CR is placed vertically above the knees.

Which calcaneal structure should appear medially & profiled on a well positioned plantodorsal (axial) projection?

Sustentaculum Tali

What can weight bearing x-rays of the feet show?

Symptoms of arthritis

Which projection is best for demonstrating the sesamoid bone of the foot & how much is the foot dorsiflexed?

Tangential projection & 15-20 degrees

A mediolateral knee radiograph that is overrotated toward the image receptor can be recognized by?

The fibular head will appear less superimposed by the tibia than a true lateral.

A radiograph of an oblique projection of the second toe reveals that the interphalangeal joints are not open. What is the most likely cause for this radiographic outcome?

The toe wasn't parallel to the IR

A radiograph of an AP oblique with medial rotation of the knee to demonstrate the proximal fibula shows that there is total superimposition of the proximal tibia/fibula, what can be modified?

The wrong oblique position of the knee was obtained; This description is that of a laterally or externally oblique position of the knee.

Why should AP 45 degree Oblique & Lateral ankle radiographs include the proximal metatarsals?

To demonstrate a possible fracture of the 5th metatarsal tuberosity.

T/F: A correctly positioned AP 45° medial oblique ankle projection frequently may also demonstrate a fracture of the base of the fifth metatarsal if present.

True

T/F: A correctly positioned lateral ankle will demonstrate the lateral malleolus superimposed over the posterior half of the tibia.

True

T/F: The AP mortise projection of the ankle is commonly taken in surgery during open reductions.

True

T/F: The patella is drawn into the intercondylar sulcus when the knee is overextended.

True

T/F: With digital radiography, it is recommended the anatomy should be centered to the IR.

True

Which tuberosity of the foot is palpable & a common site of foot trauma?

Tuberosity of base of the 5th trauma

A patient with "joint mice" within the knee joint comes in. The AP & Lateral knee projections fail to show bony loose bodies. What additional projections would you do?

Tunnel views of either the Camp-Coventry, Holmblad, Rosenberg.

To ensure that both joints are included on an AP projection of the tibia and fibula on an adult, the technologist can?

Turn the image receptor diagonally to the lower leg.

A radiograph of a lateral recumbent knee shows that the posterior border of the medial femoral condyle is not superimposed but is slightly posterior to the lateral condyle. The fibular head is also completely superimposed by the tibia. What's the positioning error?

Under rotation of knee

A radiograph of an intended AP mortise projection shows that the lateral malleolus is superimposed over the talus & distal tibiofibular joint isn't demonstrated, what is the error?

Under rotation of the ankle; the described appearance is that of a true AP ankle with little or no obliquity.

CT

Used on lower limbs to evaluate soft tissue involvement of lesions, excellent to determine extent of fractures, evaluations bone mineralization.

Nuclear Medicine

Used radioisotopes injected into the bloodstream which are absorbed in great concentration in areas where pathologic conditions exist. Also good for showing osteomyelitis & metastatic bone lesions.

Bone Densitometry

Used to evaluate loss of bone in geriatric patients or in patients with a lytic (bone destroying) type of bone disease.

Arthrography

Used to image large diarthrodial joints such as the knee, requires a contrast medium injected into the joint capsule, disease or traumatic damage to menisci/ligaments/cartilage may be evaluated.

MRI

Used to image lower limbs when soft tissue injuries are suspected. The knee is the most evaluated. Detects ligament damage or meniscal tears of the joint capsule and lesions in the skeletal system.

A patient is referred to you for a possible Lisfranc injury, what positions would you perform?

Weight bearing foot study

Which large tendon attaches to the tuberosity of the calcaneus?

achilles tendon

What is the name of the small prominence located on the posterolateral aspect of the medial condyle of the femur that is an identifying landmark to determine possible rotation of a lateral knee?

adductor tubercle

The most proximal aspect of the fibula is the?

apex or styloid process

To include both joints for a lateral projection of the tibia & fibula for an adult, the technologist may place the IR ______ in relation to the part. parallel perpendicular diagonal transverse

diagonal

T/F: A 20 degree flexion of the knee forces the patella firmly against the patellar surface of the femur.

false

T/F: A kVp range between 50-55 should be used for analog knee radiography.

false

T/F: A kVp range for digital imaging is typically lower as compared with the analog kVp.

false

T/F: It is recommend that obese patients be allowed to wear pants for the lower limb radiography.

false

T/F: The posterior surface of the patella is normally soft.

false

A small, triangular depression located on the tibia that helps form the distal tibiofibular joint is called?

fibular notch

What is the name of the depression located on the posterior aspect of the distal femur?

intercondylar fossa

What are the two other names for the patellar of the femur?

intercondylar sulcus & trochlear groove

An imaginary line drawn across the distal aspect of the medial & lateral femoral condyles is called? And would be _____ degrees being at a right 90° to the long axis of the femur.

interepicondylar, 5-7

Which positioning line or plane is parallel to the IR for an AP mortise of the ankle?

intermalleolar line or plane

Which joint surface of the ankle is not typically visualized with a correctly positioned AP projection of the ankle? medial aspect of joint superior aspect of joint lateral aspect of joint all the above

lateral aspect of joint

The extreme distal end of the fibula forms the?

lateral malleolus

Which projection places the foot into a more neutral, true lateral position: mediolateral or lateromedial?

lateromedial (page 234 in the book)

What are the two arches of the foot?

longitudinal & transverse

What are the two palpable bony landmarks found on the distal femur?

medial & lateral epicondyle

For the AP oblique projection of the knee, the ______ rotation best visualizes the lateral condyle of the tibia & the head/neck of fibula.

medial internal

The 3 bones of the ankle form a deep socket into which the talus fits, this socket is called?

mortise

How much of the knee flexion is required of the horizontal beam lateral patella projection? 5-10 15-20 25-30 none

none

Which positioning error is present if the posterior portions of the femoral condyles are not superimposed on a mediolateral knee radiograph?

over rotation

What is the name of the largest sesamoid bone in the body?

patella

What's the joint between the distal femur & patella? What's the joint between the two condyles of the distal femur & tibia?

patellofemoral, femorotibial

The general region of the posterior knee is called?

popliteal region

With a true lateral projection of the ankle, the lateral malleolus is projected over the?

posterior aspect of the distal tibia

For which large muscle does the patella serve as a pivot to increase the leverage?

quadriceps femoris muscle

The small opening or space found in the middle of the subtalar joint is called?

sinus tarsi

What is the name of the joint found between the talus & calcaneus?

subtular joint

What are the two bursa found in the knee joint?

suprapatellar & infrapatellar bursa

What 3 bones make up the ankle joint?

talus, tibia, fibula

Which bone is the weight bearing bone of the lower leg?

tibia

The distal tibial joint surface forming the roof of the distal ankle joint is called ______? tibial plafond articular facet tibial plateau ankle mortise

tibial plafond

The articular facets of the proximal tibia are also referred to as? And how much degrees do they slope?

tibial plateau, 10-20

What is the name of the large prominence located on the mid anterior surface of the proximal tibia that serves as a distal attachment for the patellar tendon?

tibial tuberosity

T/F: A 5°-7° cephalic angle of the CR for a lateral projection of the knee helps superimpose the distal borders of the medial & lateral epicondyles of the femur when the lower leg has not been supported.

true

T/F: A foot with a high anterior arch may require an increase of CR 15 degrees posteriorly and a foot with a smaller arch may require a 5 degree increase.

true

T/F: Multiple images can be placed on the same IR when using analog imaging systems.

true

T/F: The AP stress projections of the ankle must have a physician or health care professional stress the ankle during exposures.

true

T/F: The patella acts as a pivot to increase the leverage of a large muscle found in the anterior thigh.

true

T/F: To place the interepicondylar line parallel to the IR for a PA projection of the patella, the lower limb must be rotated 5 degrees internally.

true