Lower extremities

16. Interphalangeal (IP) joint

16. For the lateral projection of the great toe, the central ray should enter at the _______________ joint of the great toe.

16. False (The foot should be dorsiflexed to place the long axis of the foot perpendicular to the IR.)

16. True or false. The foot should be plantar flexed to place the long axis of the foot parallel with the IR.

16. d. Between the navicular and the metatarsals

16. Where in the foot are the cuneiforms located? a. Between the cuboid and the calcaneus b. Between the cuboid and the metatarsals c. Between the navicular and the calcaneus d. Between the navicular and the metatarsals

16. Navicular

16. Which tarsal bone is located between the talus and the cuneiforms?

17. Proximal interphalangeal

17. For lateral projections of the lesser toes, the central ray should enter at the _______________ joint.

17. A. Fibula B. Lateral malleolus C. Tibia D. Medial malleolus E. Mortise joint F. Talus

17. Identify each lettered structure shown in Fig. 6-19. A. _____________________________________________ B. _____________________________________________ C. _____________________________________________ D. _____________________________________________ E. _____________________________________________ F. _____________________________________________

17. Cuneiforms and cuboid

17. Name the tarsal bones that articulate with metatarsals.

17. d. Metatarsophalangeal

17. Which articulation is an ellipsoid-type joint? a. Intertarsal b. Interphalangeal c. Tarsometatarsal d. Metatarsophalangeal

18. True

18. True or false. For the lateral projection of the great toe, the patient should lie in the lateral recumbent position on the unaffected side.

18. b. Intertarsal

18. Which articulation of the foot is a gliding-type joint? a. Mortise b. Intertarsal c. Interphalangeal d. Tarsometatarsal

18. Talus

18. Which tarsal bone forms part of the ankle joint?

19. The patient may be instructed to pull on a strip of bandage that is looped around the foot.

19. How can the patient hold the foot in the stress posi- tion during AP stress studies?

19. False

19. True or false. For the lateral projection of the fifth toe, the patient should lie in the lateral recumbent position on the unaffected side.

19. b. Talus and calcaneus

19. Which two tarsal bones articulate with each other by way of three facets? a. Talus and cuboid b. Talus and calcaneus c. Navicular and cuboid d. Navicular and calcaneus

2. Phalanges, 14; metatarsals, 5; tarsals, 7

2. Identify by group name and quantity the bones found in the foot and ankle.

2.c. Short

2. Which bone classification are tarsals? a. Flat b. Long c. Short d. Irregular

2. Perpendicular

2. With reference to the plane of the IR, the plantar surface of the foot should be for the axial projection.

20. An increase in the joint space on the side of the injury indicates a torn ligament.

20. How do images indicate that a patient has a torn ligament affecting the ankle?

20. True

20. True or false. Interphalangeal and metatarsophalan- geal joint spaces should appear open.

20. c. Trochlea

20. Which part of the talus articulates with the distal tibia? a. Styloid b. Tubercle c. Trochlea d. Epicondyle

21. a. Hinge

21. Which type of joint is the ankle joint? a. Hinge b. Gliding c. Ellipsoid d. Ball-and-socket

3. 40 degrees cephalad

3. How many degrees and in which direction should the central ray be directed for the axial (plantodorsal) projection?

3. Nine

3. How many interphalangeal articulations does one foot have?

3. 10 degrees posteriorly (toward the heel)

3. How should the central ray be directed for best demonstration of tarsometatarsal joints with a dorso- plantar projection?

3. a. Perpendicular

3. How should the central ray be directed to demon- strate toes when the plantar surface of the affected foot is in contact with a foam wedge, which should be inclined 15 degrees so that the toes are elevated above a horizontally placed IR? a. Perpendicular b. 15 degrees posteriorly (toward the heel) c. 15 degrees anteriorly (away from the heel)

3. False (Some overlapping of the distal fibula with the talus and tibia is expected.)

3. True or false. The AP projection should demonstrate the distal third of the fibula without superimposition with the talus or tibia.

3.b. Head

3. What is the most distal part of a metatarsal? a. Base b. Head c. Tuberosity d. Styloid process

3. The foot was plantar flexed rather than dorsiflexed, as evidenced by the appearance of the tarsals and the bases of the metatarsals.

3. What positioning error most likely produced this image?

32. Tarsometatarsal

32. TMT:

33. Metatarsophalangeal

33. MTP

34. Interphalangeal

34. IP:

35. DIP and IP are also used to refer to joints in the hand.

35. Which of the above-listed abbreviations are also used to refer to joints in the hand?

4. The talofibular joint is not open, probably resulting from too much internal rotation of the lower leg.

4. Fig. 6-35 is an AP oblique projection image of inferior quality demonstrating the mortise joint. Examine the image and state why it does not meet the evaluation criteria for this projection. Fig. 6-35 AP oblique ankle, medial rotation, with improper positioning. Fig. 6-36 is a lateral projection image of the knee that does not meet all of the evaluation criteria. Examine the image and answer the questions that follow.

4. a. The base of the third metatarsal

4. Toward what point of the foot should the central ray be directed for AP and AP axial projections? a. The base of the third metatarsal b. The head of the third metatarsal c. The base of the fifth metatarsal d. The head of the fifth metatarsal

4. True

4. True or false. The AP projection should demonstrate the lateral and medial malleoli.

4. Flexion and extension

4. What types of movement do the interphalangeal joints permit?

4. Two images should be performed to demonstrate the entire calcaneus completely.

4. When performing the axial (plantodorsal) projection, what should the radiographer do to demonstrate a complete calcaneus if the anterior portion of the calcaneus is not seen in the image with the same brightness as the posterior portion?

4.d. Proximal portion of the fifth metatarsal

4. Where in the foot is the tuberosity that is easily palpable? a. Distal portion of the first metatarsal b. Distal portion of the fifth metatarsal c. Proximal portion of the first metatarsal d. Proximal portion of the fifth metatarsal

4.a. AP projection of the toes with the central ray directed perpendicular

4. Which of the following projections for toes normally does not demonstrate open interphalangeal joints? a. AP projection of the toes with the central ray directed perpendicular b. AP axial projection of the toes with a central ray angulation of 15 degrees c. AP axial projection of the toes with a 15-degree foam wedge and the central ray directed perpendicular

42. d. 15 degrees cephalad (toward the heel)

42. How many degrees and in what direction should the central ray be directed for the AP axial projection of the toes? a. 10 degrees caudad (toward the toes) b. 10 degrees cephalad (toward the heel) c. 15 degrees caudad (toward the toes) d. 15 degrees cephalad (toward the heel)

43. c. 30 to 45 degrees medially

43. How many degrees and in what direction should the foot be rotated for the AP oblique projection to dem- onstrate the second toe? a. 15 to 25 degrees medially b. 15 to 25 degrees laterally c. 30 to 45 degrees medially d. 30 to 45 degrees laterally

54. d. AP oblique projection (medial rotation)

54. Which projection of the foot best demonstrates the sinus tarsi? a. AP projection b. Lateral projection c. AP oblique projection (lateral rotation) d. AP oblique projection (medial rotation)

55. d. AP oblique projection (medial rotation)

55. Which projection of the foot best demonstrates most of the tarsals with the least amount of superimposition? a. AP projection b. Lateral projection c. AP oblique projection (lateral rotation) d. AP oblique projection (medial rotation)

56. d. AP oblique projection (medial rotation)

56. Which projection of the foot best demonstrates the bases of the fourth and fifth metatarsals free from superimposition? a. AP projection b. Lateral projection c. AP oblique projection (lateral rotation) d. AP oblique projection (medial rotation)

57. b. Lateral projection

57. Which projection of the foot should demonstrate the metatarsals nearly superimposed on each other? a. AP projection b. Lateral projection c. AP oblique projection (lateral rotation) d. AP oblique projection (medial rotation)

58.c. Axial (plantodorsal) and lateral projections

58. Which two projections comprise the typical series that best demonstrates the calcaneus? a. AP (dorsoplantar) and lateral projections b. AP (dorsoplantar) and medial oblique projections c. Axial (plantodorsal) and lateral projections d. Axial (plantodorsal) and medial oblique projections

59. d. 40 degrees cephalad

59. How many degrees and in what direction should the central ray be directed for the axial (plantodorsal) projection of the calcaneus? a. 10 degrees caudad b. 10 degrees cephalad c. 40 degrees caudad d. 40 degrees cephalad

6. False (The central ray should enter the plantar surface.)

6. True or false. The central ray should enter the dor- sal surface of the foot for the axial (plantodorsal) projection.

6.d. Calcaneus

6. Which tarsal bone is the largest of the tarsal bones? a. Talus b. Cuboid c. Navicular d. Calcaneus

6. Proximal phalanges

6. With what do the heads of metatarsals articulate?

6. Fig. 6-10

6.Which image was most likely obtained with the central ray angled 15 degrees posteriorly (toward the toes)?

60. a. Elevate the leg on sandbags to achieve the correct position.

60. What procedural compensation is required for the plantodorsal axial projection of the calcaneus when the patient cannot dorsiflex the foot sufficiently to place the plantar surface vertical? a. Elevate the leg on sandbags to achieve the correct position. b. Refer the patient to CT. c. Decrease the angle of the central ray. d. Reverse the angle of the central ray.

61. c. Base of the third metatarsal

61. At which level on the plantar surface should the central ray enter the foot for the axial (plantodorsal) projection of the calcaneus? a. Midpoint of the calcaneus b. Tuberosity of the calcaneus c. Base of the third metatarsal d. Head of the third metatarsal

62. b. Toward the midpoint of the calcaneus

62. Where should the central ray be directed for the lateral projection of the calcaneus? a. Toward the midpoint of the foot b. Toward the midpoint of the calcaneus c. Toward the base of the third metatarsal d. Toward the head of the third metatarsal

63. b. At the medial malleolus

63. Where should the central ray enter for the lateral projection of the ankle? a. At the lateral malleolus b. At the medial malleolus c. At the midpoint of the calcaneus d. At the base of the third metatarsal

64. b. 15 to 20 degrees medially

64. How many degrees and in which direction should the foot and leg be rotated for the best demonstration of the mortise joint for the AP oblique projection of the ankle? a. 15 to 20 degrees laterally b. 15 to 20 degrees medially c. 40 to 45 degrees laterally d. 40 to 45 degrees medially

65. d. AP oblique projection (medial rotation)

65. Which projection of the ankle best demonstrates the talofibular joint space free from bony superimposition? a. AP projection b. Lateral projection c. AP oblique projection (lateral rotation) d. AP oblique projection (medial rotation)

66.b. Talofibular

66. Which articulation should be seen in profile with the AP oblique projection (medial rotation) of the ankle? a. Subtalar b. Talofibular c. Talocalcaneal d. Distal tibiofibular

67. a. Parallel

67. With reference to the plane of the IR, how should the malleoli be positioned for the AP oblique projection of the ankle for the best demonstration of the mortise joint spaces open? a. Parallel b. Perpendicular c. 45 degrees lateral rotation d. 45 degrees medial rotation

68. a. AP projection with inversion

68. Which projection of the ankle should be performed for the best demonstration of a ligamentous tear? a. AP projection with inversion b. AP projection with dorsiflexion c. AP oblique projection (lateral rotation) d. AP oblique projection (medial rotation)

69. c. 8 inches (20 cm)

69. How long should the collimated field be for the AP and AP oblique projections of the ankle? a. 1 inch (2.5 cm) above and below the malleoli b. 3 inches (7.6 cm) above and below the malleoli c. 8 inches (20 cm) d. 10 inches (25 cm)

7. The talus and tibiotalar joint are not included in the collimated field.

7. Fig. 6-37 is a lateral projection of the foot with an error. Examine this image and explain why it does not meet the evaluation criteria for this projection. Fig. 6-37 Lateral foot with error.

7. Numbered 1-5 from the medial side (great toe) to the lateral side (small toe)

7. How are metatarsals identified within the foot?

7. A. Sustentaculum tali B. Trochlear process C. Lateral process D. Tuberosity

7. Identify each lettered structure shown in Fig. 6-15. A. ___________________________________________ B. ___________________________________________ C. ___________________________________________ D. ___________________________________________ Fig. 6-15 Axial (plantodorsal) calcaneu

7. True

7. True or false. The lateral (mediolateral) projection should demonstrate the fibula over the posterior half of the tibia.

7. d. AP oblique projection (medial rotation)

7. What projection of the foot best demonstrates the lateral tarsals with the least superimposition of structures? a. AP projection b. AP axial projection c. AP oblique projection (lateral rotation) d. AP oblique projection (medial rotation)

7.b. Cuboid

7. Which tarsal bone is located on the lateral side of the foot between the calcaneus and the fourth and fifth metatarsals? a. Talus b. Cuboid c. Navicular d. Lateral cuneiform

7. Fig. 6-9

7.Which image was most likely obtained with the foot and IR placed parallel with the surface of the table and the central ray directed perpendicular to the foot?

8. Make sure the top border of the collimated field was 1 inch (2.5 cm) above the medial malleolus.

8. Before making the exposure for Fig. 6-37, what should the radiographer have done to prevent this error?

8. c. 30 degrees

8. For the AP oblique projection, the leg should be rotated medially until the plantar surface of the foot forms an angle of ________________ with the IR. a. 10 degrees b. 20 degrees c. 30 degrees d. 40 degrees

8. a. Metatarsals and phalanges b. Cuneiforms, cuboid, and navicular c. Talus and calcaneus

8. Identify by individual name or group the bones found in each section of the foot. a. Forefoot: __________________________________ b. Midfoot: ____________________________________ c. Hindfoot: ___________________________________

8. A. Phalanges B. Sesamoid C. Metatarsals D. Distal interphalangeal joint E. Distal phalanx F. Middle phalanx G. Proximal interphalangeal joint H. Proximal phalanx I. Metatarsophalangeal joint

8. Identify each lettered bone, group of bones, or joint shown in Fig. 6-11. A._____________________________________________ B. _______________________________________ C. _______________________________________ D. _______________________________________ E. _______________________________________ F. _______________________________________ G. _______________________________________ H. _______________________________________ I. _______________________________________

8. False (The distal fibula will appear superimposed with the talus.)

8. True or false. An image of the lateral (mediolateral) projection should demonstrate the lateral malleolus free from superimposition by the talus.

8. At the midportion of the calcaneus (1 inch distal to the medial malleolus)

8. Where on the medial surface of the foot should the central ray enter the calcaneus for the lateral projection?

8.c. Navicular

8. Which tarsal bone is located on the medial side of the foot between the talus and the three cuneiforms? a. Talus b. Cuboid c. Navicular d. Calcaneus

9. True

9. True or false. The tuberosity and base of the fifth metatarsal should be demonstrated as a lateral pro- jection image of the ankle.

9. First and second

9. What two metatarsal bases appear overlapped in the image of the AP oblique projection, medial rotation?

9.d. Lateral cuneiform

9. Which bone articulates medially with the cuboid? a. First metatarsal b. Medial cuneiform c. Intermediate cuneiform d. Lateral cuneiform

9. The fifth metatarsal

9. Which metatarsal has a tuberosity that is prominent at its base?

9. b. Lateral

9. Which projection of the calcaneus best demonstrates the sinus tarsi? a. Plantodorsal axial b. Lateral

31. Distal interphalangeal

In items 31 to 34, write out the anatomic terms for the abbreviations of the lower limb. 31. DIP:

11. Lateral

Items 11-15 pertain to the lateral projection. 11. For patient comfort, which side of the foot (medial or lateral) should be placed in contact with the IR for the lateral projection?

15. Tape all toes above the affected toe into a flexed position.

Items 15-20 pertain to the lateral projection. 15. For lateral projections of the toes, what can be done to prevent the superimposition of toes?

2. c. Dorsoplantar

Items 2-5 pertain to AP and AP axial projections. 2. What other projection term refers to the AP projection? a. Axial b. Plantodorsal c. Dorsoplantar

2. True

Items 2-5 pertain to the AP projection. 2. True or false. The AP projection should demonstrate the joint space between the medial malleolus and the talus without any overlapping of structures.

2.b. 15 degrees posteriorly (toward the heel)

Items 2-8 pertain to the AP and AP axial projections. 2. What is the central ray orientation if the joint spaces of the toes are of primary interest? a. Perpendicular b. 15 degrees posteriorly (toward the heel) c. 15 degrees anteriorly (away from the heel)

6. Medially

Items 6-10 pertain to the AP oblique projection. 6. In which direction (medially or laterally) should the foot be rotated for the AP oblique projection for best demonstration of the cuboid and its related articulations?

9. Medially

Items 9-14 pertain to the AP oblique projection. 9. For the AP oblique projection demonstrating all of the toes, which way (medially or laterally) should the foot and lower leg be rotated?

1. 30

Section 1: Exercise 15 This exercise is a comprehensive review of the osteology and arthrology of the lower limb. Provide a short answer for each question. 1. How many bones are found in one lower limb?

1. The toes are not separated from each other.

Section 2: Exercise 10: Lower Limb Image Evaluation This exercise consists of images of the lower extremity to give you practice in evaluating extremity positioning. These images are not from Merrill's Atlas. Each image shows at least one positioning error. Examine each image and answer the questions that follow by providing a short answer or choosing the correct answer from a list. 1. Fig. 6-33 shows an AP oblique projection image of the toes. Examine the image and state why it does not meet the evaluation criteria for this projection. Fig. 6-33 AP oblique toes with improper positioning.

1.a. 14 phalanges, 5 metatarsals, and 7 tarsals

1. How many and what kind of bones comprise the foot and ankle? a. 14 phalanges, 5 metatarsals, and 7 tarsals b. 14 phalanges, 7 metatarsals, and 5 tarsals c. 7 phalanges, 5 metatarsals, and 14 tarsals d. 7 phalanges, 14 metatarsals, and 5 tarsals

1. AP n Collimate to 1 inch (2.5 cm) on all sides, including 1 inch (2.5 cm) beyond calcaneus and distal tips of toes n Seated or supine with knee exed and plantar sur- face of foot resting on IR; leg vertical, plantar surface of foot resting on IR n Plane of MTP joints parallel with plane of IR; long axis of foot aligned with long axis of IR n Perpendicular to base of third metatarsal AP axial n Collimate to 1 inch (2.5 cm) on all sides, including 1 inch (2.5 cm) beyond calcaneus and distal tips of toes n Seated or supine with knee exed and plantar sur- face of foot resting on IR; leg vertical, plantar surface of foot resting on IR n Plane of MTP joints parallel with plane of IR; long axis of foot aligned with long axis of IR n Angled 10 degrees; enters base of third metatarsal AP oblique n Collimate to 1 inch (2.5 cm) on all sides, including 1 inch (2.5 cm) beyond calcaneus and distal tips of toes n Seated or supine with knee exed and plantar sur- face of foot resting on IR; leg and plantar surface of foot medially rotated 30 degrees from IR n Plane of MTP joints rotated 30 degrees medially from plane of IR; long axis of foot aligned with long axis of IR n Perpendicular; enters base of third metatarsal Lateral n Collimate to 1 inch (2.5 cm) on all sides of foot shadow, including 1 inch (2.5 cm) above the medial malleolus n Seated or supine with knee exed and lateral sur- face of foot resting on IR; leg rotated laterally to place plantar surface of foot perpendicular to IR; foot dorsi exed to 90 degrees n Plane of MTP joints and plantar surface perpen- dicular to plane of IR; long axis of foot aligned with long axis of IR n Perpendicular; enters base of third metatarsal

1. List the essential projections of the foot, and describe the positioning steps used for each, as follows: Essential projection: __________________ CR orientation and entrance point: Size of collimated field: Key patient/part positioning points: Anatomic landmarks and relation to IR: Essential projection: __________________ Size of collimated field: Key patient/part positioning points: Anatomic landmarks and relation to IR: CR orientation and entrance point: Essential projection: __________________ Size of collimated field: Key patient/part positioning points: Anatomic landmarks and relation to IR: CR orientation and entrance point:

15. Cuboid

15. Which tarsal bone is lateral from the cuneiforms?

1. AP n Collimate to 1 inch (2.5 cm) on all sides, including 1 inch (2.5 cm) proximal to MTP joints n Seated or supine with knee exed and plantar sur- face of foot resting on IR; leg vertical; plantar surface of foot resting on IR; toes centered to col- limated eld n Plane of MTP joints parallel with plane of IR; long axis of foot aligned with long axis of IR n Perpendicular to third MTP joint AP axial n Collimate to 1 inch (2.5 cm) on all sides, including 1 inch (2.5 cm) proximal to MTP joints n Seated or supine with knee exed and plantar sur- face of foot on IR; leg vertical; plantar surface of foot resting on IR; toes centered n Plane of MTP joints parallel with plane of IR n Angled 15 degrees posteriorly; enters third MTP joint AP oblique n Collimate to 1 inch (2.5 cm) on all sides, including 1 inch (2.5 cm) proximal to MTP joints n Seated or supine with knee exed; foot resting on IR; foot and leg medially rotated to place plantar surface of foot at 30- to 45-degree angle from IR n Plane of MTP joints at 30- to 45-degree angle from plane of IR n Perpendicular to third MTP joint Lateral n Collimate to 1 inch (2.5 cm) on all sides, including 1 inch (2.5 cm) proximal to MTP joints n Seated or supine with knee exed and lateral side of foot on IR; leg and foot rotated laterally for toes 3-5 and medially for toes 1-2 to place in lateral position n Plane of MTP joints perpendicular to IR n Perpendicular to IP of great toe; PIP joint of toes 2-5

1.List the essential projections for the toes,and describe the positioning steps used for each, as follows: Essential projection: __________________ Size of collimated field: Key patient/part positioning points: Anatomic landmarks and relation to IR: CR orientation and entrance point: Essential projection: __________________ Size of collimated field: Key patient/part positioning points: Anatomic landmarks and relation to IR: CR orientation and entrance point: Essential projection: __________________ Size of collimated field: Key patient/part positioning points: Anatomic landmarks and relation to IR: CR orientation and entrance point: Essential projection: __________________ Size of collimated field: Key patient/part positioning points: Anatomic landmarks and relation to IR: CR orientation and entrance point:

10. The toes should have been elevated more to place the plantar surface parallel with the IR and superimpose the malleoli better.

10. Explain what positioning maneuver would correct the error.

10. 30 to 45 degrees

10. How many degrees of rotation are needed to rotate the foot properly for the AP oblique projection of toes?

10. A. Medial cuneiform B. Intermediate cuneiform C. Metatarsals D. Tuberosity (of the fifth metatarsal) E. Lateral cuneiform F. Cuboid G. Calcaneus H. Navicular I. Talus J. Sinus tarsi

10. Identify each lettered bone or joint shown in Fig. 6-13. A. _____________________________________________ B. _____________________________________________ C. _____________________________________________ D. _____________________________________________ E. _____________________________________________ F. _____________________________________________ G. _____________________________________________ H. _____________________________________________ I. _____________________________________________ J. _____________________________________________

10. A. Tibiotalar joint (mortise joint) B. Sinus tarsi C. Tuberosity D. Talus E. Navicular F. Sustentaculum tali

10. Identify each lettered structure or joint shown in Fig. 6-16. A. _____________________________________________ B. _____________________________________________ C. _____________________________________________ D. _____________________________________________ E. _____________________________________________ F. _____________________________________________

10. A. Tibia B. Fibula C. Tibiotalar joint D. Talus E. Navicular F. Cuboid G. Calcaneus

10. Identify each lettered structure shown in Fig. 6-18. A. _____________________________________________ B. _____________________________________________ C. _____________________________________________ D. _____________________________________________ E. _____________________________________________ F. _____________________________________________ G. _____________________________________________

10. Medial cuneiform, intermediate cuneiform, lateral cuneiform, navicular, cuboid, talus, and calcaneus

10. List the names of the tarsal bones.

10. d. Navicular, cuboid, and cuneiforms

10. Which bones comprise the midfoot? a. Talus and cuboid b. Talus and calcaneus c. Metatarsals and toes d. Navicular, cuboid, and cuneiforms

11. 45 degrees medially

11. How many degrees and in what direction should the leg and foot be rotated?

11. b. Talus

11. Which bone articulates with the superior surface of the calcaneus? a. Tibia b. Talus c. Fibula d. Navicular

11. Fourth and fifth (and sometimes, third)

11. Which individual toes are best demonstrated using the AP oblique projection with the foot rotated laterally?

11. Calcaneus

11. Which tarsal bone comprises the heel of the foot?

12. Third metatarsophalangeal (MTP) joint

12. For AP oblique projections, the central ray should enter the foot at the _______________ joint.

12. a,d,e,f

12. From the following list, circle the structures and articulation that should be demonstrated in the image of the AP oblique ankle. a. Talus b. Cuboid c. Calcaneus d. Distal tibia e. Distal fibula f. Tibiofibular articulation g. Femorotibial articulation h. Metatarsophalangeal articulation i. Talofibular articulation Items

12.b. Cuneiforms

12. Which bones articulate distally with the tarsal navicular? a. Phalanges b. Cuneiforms c. Metatarsals d. Talus and calcaneus

12. Calcaneus

12. Which is the largest of the tarsal bones?

12. Dorsiflex the foot to form a 90-degree angle with the lower leg.

12. With reference to the lower leg, how should the foot be positioned for the lateral projection?

13. 15 to 20 degrees

13-17 pertain to the AP oblique projection (medial rotation) of the ankle for demonstrating the mortise joint. 13. From the supine position, how many degrees should the lower limb and foot be rotated to position the ankle for this projection?

13. False (The distal end [head] of metatarsals should be seen.)

13. True or false. The bases of metatarsals should be included within the image for AP oblique projections.

13. The distal fibula should overlap the posterior portion of the tibia.

13. Where should the distal fibula be seen in images of the lateral projection of the foot?

13. c. Metatarsals

13. Which bones articulate distally with the three cuneiforms? a. Navicular b. Phalanges c. Metatarsals d. Talus and calcaneus

13. Talus

13. Which tarsal bone articulates superiorly on the calcaneus?

14. True

14. True or false. All phalanges should be seen in the image.

14. True

14. True or false. The tibiotalar joint must be seen in the lateral projection of the foot.

14. c. Cuneiforms and cuboid

14. Which bones articulate with the metatarsals? a. Calcaneus and cuboid b. Calcaneus and navicular c. Cuneiforms and cuboid d. Cuneiforms and navicular

14. Cuboid

14. Which tarsal bone is located between the calcaneus and the fourth and fifth metatarsals?

14. The intermalleolar plane should be parallel with the IR.

14. With reference to the position of the patient's leg and foot during the procedure, how is it determined that the leg has been rotated the correct number of degrees?

15. A. Phalanges B. Metatarsals C. Fibula D. Tibia E. Tibiotalar joint (mortise joint) F. Navicular G. Talus H. Sinus tarsi I. Calcaneus J. Tarsals

15. Identify each lettered bone shown in Fig. 6-14. A. _____________________________________________ B. _____________________________________________ C. _____________________________________________ D. _____________________________________________ E. _____________________________________________ F. _____________________________________________ G. _____________________________________________ H. _____________________________________________ I. _____________________________________________ J. _____________________________________________

15. True

15. True or false. The talofibular joint space should be demonstrated in profile without any bony superimposition.

15. a. Medial

15. Which cuneiform is the largest cuneiform? a. Medial b. Intermediate c. Third d. Lateral

44.b. Perpendicular to the third metatarsophalangeal joint

44. How and toward what centering point should the central ray be directed for the AP oblique projection to demonstrate all five toes? a. Perpendicular to the proximal interphalangeal (PIP) joint of the third digit b. Perpendicular to the third metatarsophalangeal joint c. 15 degrees posterior (toward the heel) to the PIP of the third digit d. 15 degrees posterior (toward the heel) to the third metatarsophalangeal joint

45. c. 30 to 45 degrees medially

45. How many degrees and in what direction should the foot be rotated for the AP oblique projection for the best demonstration of the great toe? a. 10 to 15 degrees medially b. 10 to 15 degrees laterally c. 30 to 45 degrees medially d. 30 to 45 degrees laterally

46. b. Dorsoplantar

46. What other projection term refers to the AP projec- tion of the foot? a. Plantodorsal b. Dorsoplantar c. Inferosuperior d. Superoinferior

47. b. 10 degrees cephalad (toward the heel)

47. How many degrees and in what direction should the central ray be directed for the AP axial projection of the foot? a. 10 degrees caudad (toward the toes) b. 10 degrees cephalad (toward the heel) c. 15 degrees caudad (toward the toes) d. 15 degrees cephalad (toward the heel)

48. d. AP oblique (medial rotation)

48. Which projection of the foot best demonstrates the cuboid and its articulations? a. Lateral b. Dorsoplantar c. AP oblique (lateral rotation) d. AP oblique (medial rotation)

49. b. 30 degrees medially

49. How many degrees and in what direction should the foot be rotated for the AP oblique projection of the foot? a. 15 degrees laterally b. 30 degrees medially c. 45 degrees laterally d. 45 degrees medially

5. A. First metatarsophalangeal joint B. First tarsometatarsal joint C. Medial cuneiform D. Navicular E. Phalanges F. Metatarsals G. Tarsals H. Cuboid

5. Identify each lettered bone, joint, or group of bones shown in Fig. 6-12. A. ____________________________________________ B. ____________________________________________ C. ____________________________________________ D. ____________________________________________ E. ____________________________________________ F. ____________________________________________ G. ____________________________________________ H. ____________________________________________

5. A. Fibula B. Tibiotalar joint C. Lateral malleolus D. Tibia E. Medial malleolus F. Talus

5. Identify each lettered structure shown in Fig. 6-17. A. ___________________________________________ B. ___________________________________________ C. ___________________________________________ D. ___________________________________________ E. ___________________________________________ F. ___________________________________________

5. False (The heel should be in contact with the IR; the plantar surface should be perpendicular to the IR.)

5. True or false. The plantar surface of the foot should be in contact with the IR for the axial (plantodorsal) projection.

5. Hinge

5. What type of joint is an interphalangeal joint?

5.a. Talus

5. Which tarsal bone is the most superior tarsal bone? a. Talus b. Cuboid c. Navicular d. Calcaneus

50.b. 1 inch (2.5 cm) of all sides, including 1 inch (2.5 cm) beyond the calcaneus and distal tips of the toes

50. What is the appropriate collimated field size for the AP projection of the foot? a. 1 inch (2.5 cm) on all sides of the foot shadow, including 1 inch (2.5 cm) superior to the medial malleolus b. 1 inch (2.5 cm) of all sides, including 1 inch (2.5 cm) beyond the calcaneus and distal tips of the toes c. 1 inch (2.5 cm) past the posterior and inferior heel shadow, including the medial malleolus and fifth metatarsal d. 10 inches wide by 12 inches long (25 cm wide by 30 cm long)

51. a. To the base of the third metatarsal

51. Where should the central ray be directed for the AP oblique projection of the foot? a. To the base of the third metatarsal b. To the head of the third metatarsal c. To the metatarsophalangeal joint of the third digit d. To the proximal interphalangeal joint of the third digit

52. d. Ensure that the plantar surface is perpendicular to the IR.

52. Regardless of the condition of the patient, which positioning maneuver should be performed to position the foot for the lateral projection? a. Plantar flex the foot. b. Rotate the leg laterally until the knee is against the table. c. Ensure that the plantar surface is in contact with the IR. d. Ensure that the plantar surface is perpendicular to the IR.

53. b. 10 degrees posteriorly (toward the heel)

53. How should the central ray be directed for the best demonstration of the tarsometatarsal joint spaces of the midfoot for the AP projection of the foot? a. Perpendicularly b. 10 degrees posteriorly (toward the heel) c. 15 degrees posteriorly (toward the heel) d. 20 degrees posteriorly (toward the heel)

5. Fig. 6-10

Fig. 6-10 Image of the toes. 5.Which image best demonstrates interphalangeal joints?

6. To prevent lateral rotation of the ankle

Fig. 6-17 AP ankle. Items 6-10 pertain to the lateral projection. 6. Why is dorsiflexion of the foot required for the lateral (mediolateral) projection?

18. To verify the presence of a ligamentous tear

Fig. 6-19 AP oblique ankle, medial rotation. Items 18-20 pertain to AP projections (stress method). 18. State the purpose of performing AP stress studies of the ankle.

2. Moderate overlapping of the talus with the distal tibia has occurred, which obscures the tibiotalar joint, and some overlap of the medial talomalleolar articulation has occurred.

Fig. 6-34 is an inferior-quality AP projection of the ankle. Examine the image and answer the questions that follow. Fig. 6-34 AP ankle with improper positioning. 2. Explain why the image does not meet the evaluation criteria for this projection.

9. The medial and lateral talar domes are not superim- posed. The fibula is too posterior to the tibia.

Fig. 6-38 is a lateral projection of the ankle with improper positioning. Examine this image and answer the questions that follow. 9. State why this image does not meet the evaluation criteria for this projection.

1. Plantodorsal axial n Collimate to 1 inch (2.5 cm) on three sides of the calcaneus shadow n Seated or supine with leg extended; posterior sur- face of foot resting on IR; foot dorsi exed so plantar surface is vertical and not rotated n Malleoli parallel with plane of IR; plantar surface vertical n Angled 40 degrees cephalic; enters base of third metatarsal Lateral n Collimate to 1 inch (2.5 cm) past posterior and inferior heel shadow; include medial malleolus and 5th metatarsal base n Seated or supine with knee exed and lateral sur- face of calcaneus centered to collimated eld; leg rotated laterally to place plantar surface of calca- neus perpendicular to IR n Long axis of calcaneus aligned with long axis of IR n Perpendicular; enters 1 inch (2.5 cm) distal to medial malleolus

Section 2: Exercise 3: Positioning for the Calcaneus This exercise pertains to the two essential projections of the calcaneus. Identify structures, fill in missing words, provide a short answer, or choose true or false (explain- ing any statement you believe to be false) for each item. 1. List the essential projections for the calcaneus, and describe the positioning steps used for each, as follows: Essential projection: __________________ Size of collimated field: Key patient/part positioning points: Anatomic landmarks and relation to IR: CR orientation and entrance point: Essential projection: __________________ Size of collimated field: Key patient/part positioning points: Anatomic landmarks and relation to IR: CR orientation and entrance point:

1. AP n Collimate to 1 inch (2.5 cm) on all sides of the ankle and 8 inches (18 cm) long to include the heel n Seated or supine with knee extended; dorsal sur- face of ankle centered to IR/collimated eld; ankle in anatomic position; foot dorsi exed to right angle n Malleoli in anatomic position; plantar surface of foot positioned vertical n Perpendicular; enters ankle joint midway between malleoli Lateral n Collimate to 1 inch (2.5 cm) on all sides of the ankle and 8 inches (18 cm) long to include heel and 5th metatarsal base n Turned on affected side until ankle is resting on lateral surface; ankle resting on lateral surface and centered to IR/collimated eld; foot dorsi exed and lateral n Malleoli superimposed and perpendicular to IR n Perpendicular; enters medial malleolus AP oblique—medial rotation n Collimate to 1 inch (2.5 cm) on all sides of the ankle and 8 inches (18 cm) long to include the heel n Seated or supine with knee extended; lower limb rotated medially 45 degrees; ankle centered to IR; foot dorsi exed n Coronal plane of lower limb and malleoli at 45- degree angle with IR n Perpendicular; enters ankle joint midway between the malleoli AP oblique—medial rotation for mortise joint n Collimate to 1 inch (2.5 cm) on all sides of the ankle and 8 inches (18 cm) long to include the heel n Seated or supine with knee extended; lower limb rotated medially 15 to 20 degrees; ankle centered to IR; foot dorsi exed n Coronal plane of lower limb at 15- to 20-degree angle with IR; intermalleolar plane parallel with IR n Perpendicular; enters ankle joint midway between the malleoli AP—stress n Collimate to 1 inch (2.5 cm) on all sides of the ankle and 8 inches (18 cm) long to include the heel n Seated or supine with knee extended; ankle in anatomic position while foot is forcibly held in inversion and eversion stress for two separate exposures n Malleoli in anatomic position; foot inverted and everted n Perpendicular; enters ankle joint midway between the malleoli

Section 2: Exercise 4: Positioning for the Ankle This exercise pertains to the essential projections of the ankle. Identify structures, fill in missing words, provide a short answer, or choose true or false (explaining any statement you believe to be false) for each item. 1. List the essential projections and positions for the ankle, and describe the positioning steps used for each, as follows: Essential projection: __________________ Size of collimated field: Key patient/part positioning points: Anatomic landmarks and relation to IR: CR orientation and entrance point: Essential projection: __________________ Size of collimated field: Key patient/part positioning points: Anatomic landmarks and relation to IR: CR orientation and entrance point: Essential projection: __________________ Key patient/part positioning points: Size of collimated field: Anatomic landmarks and relation to IR: CR orientation and entrance point: Essential projection: __________________ Size of collimated field: Key patient/part positioning points: Anatomic landmarks and relation to IR: CR orientation and entrance point: Essential projection: __________________ Size of collimated field: Key patient/part positioning points: Anatomic landmarks and relation to IR: CR orientation and entrance point: