(9)Toes,foot,calcaneous,ankle.ppt

PLEASE TURN ALL CELL PHONES TO SILENT MODE

*By the end of this Lecture the student will be able to: List and identify the different bones and joints related to lower limbs List the basic and Optional projections for radiographing toes ,foot and ankle joint Discus the correct body position, part position, central ray, and center point for specific positions of toes ,foot and ankle jointCritique and evaluate radiographs of shoulder based on (position, collimation and central ray, exposure, and structure best shown) Learning Objectives

*Basic Text book of radiographic positioning and related anatomy; Kenneth L.Bontrager,5th, 6th editionOptional Merrills Atlas of Radiographic Positions and Radiologic Procedures, P.W. Ballinger, E.D. FrankPositioning in Radiography: By k.C.Clarke.

Websites

http://www.e-radiography.net/

References

* Lower Limbs ( Anatomy Review)

2Right Foot Lower Limbs ( Anatomy Review)

Right Tibia and fibulaPosterior view Anterior view Lower Limbs ( Anatomy Review)

*Right femurRight Patella Lower Limbs ( Anatomy Review)

Lower Limbs ( Anatomy Review)

Bone cysts : Benign neoplastic bone lesions filled with a clear fluid near the knee joint in pediatric patients. Chondromalacia patellae (Runners knee): Is the softening of cartilage under the patella at a later stage. Ewing sarcoma : A primary bone malignancy in children, mainly in diaphysis of long bones. Osgood Schlatter's disease : Is the inflammation of bone and cartilage in the anterior proximal tibia (tibial tuberosity) of children. Osteoclastoma: A benign lesion in the proximal tibia/distal femur, usually affecting epiphyseal closure.

Osteogenic sarcoma Is a malignant primary bone tumor in long bones, usually causing gross destruction of the bone. Pathological Indications (Lower limb)Reference: Text book of radiographic positioning and related anatomy; L.Bontrager, 6th editions

Positioning principles as for upper limb applies to lower limb. kV should be lower to medium (50 70) KVp.For all parts discussed, center and align the long axis of the part to central ray (CR) and to long axis of the film.No secondary radiation grid used, except for knee (> 10 cm) and for the femur.Radiation protection has to be well observed, using the special gonad shields over pelvic region, or the lead apron as necessary. Also, the LBD or cone has to be used.FFD is generally 40 inches (100 - 102 cm).Optimal contrast and density will allow visualization of bony cortical margins soft tissue structures. 2 Technical PointsReference: Text book of radiographic positioning and related anatomy; L.Bontrager, 6th editions

For fractures and dislocations, osteoarthritis (OA), and gout (especially in the 1st digit).

Patient supine or seated, knee flexed, planter surface of the foot (sole) on film.Film: HD 18x24 cm.

CP: MTPJ(s). CR: 10-15 toward the Calcaneus (the heel) (90 to the phalanges). NB/ If a 15 wedge is used, CR must be 90 to the film.

Reference: Text book of radiographic positioning and related anatomy; L.Bontrager, 6th editions

B Lateral Toes

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

CP: IPJ (for 1st), proximal IPJ (2nd to 5th). CR: 90 to film.

Reference: Text book of radiographic positioning and related anatomy; L.Bontrager, 6th editions

B AP (Dorsiplanter) foot

For #s and dislocations, tissue effusion, joint-space abnormalities, opaque foreign bodies (F.Bs.).

Patient in supine, the knee flexed, planter surface on film, sandbags used to immobilize the film, opposite knee flexed and rests against affected knee.Film: HD 24x30 cm.

CP: Base of 3rd metatarsalCR: 10 posteriorly (toward the heel.

NB/ Perpendicular (0) for a F.B. and for a flat foot (pes planes), 5 for a low arch foot, and 15 for a high arch foot.

7Reference: Text book of radiographic positioning and related anatomy; L.Bontrager, 6th editions

RADIOGRAPHIC ANATOMYReference : http://www.szote.u-szeged.hu/Radiology/Anatomy/skeleton.htm

A-E: Toes 1-5. (A:Great toe) I-V. Metatarsals1,3: Distal phalanx 4: Middle phalanx 2,5: Proximal phalanx6. Interphalangeal joints 7. Metatarsophalangeal joints 8. Sesamoid 9. Head of metatarsal 10. Shaft (body) of metatarsal 11. Base of metatarsal 12. Cuneiforms 13. Navicular 14. Cuboid 15. Talus 16. Calcaneus 17. Tibia 18. Fibula 19. Tarsometatarsal joints 20. Transverse midtarsal joint

B APO foot

For #s and dislocations, soft tissue effusion, joint space abnormalities, opaque F.Bs.

Patient supine or seated, knee flexed, planter surface on film, foot rotated medially so that the sole is 30 to 40 to film. A 45 wedge can be used to support the foot and prevent motion.Film: HD 24x30 cm.

CP: Base of 3rd metatarsal.

CR: 90 perpendicular.

Reference: Text book of radiographic positioning and related anatomy; L.Bontrager, 6th editions

A-E: Toes 1-5. (A:Great toe) 1,3: Distal phalanx 4: Middle phalanx 2,5: Proximal phalanx6. Interphalangeal joints 7. Metatarsophalangeal joints 8. Sesamoid 9. Head of metatarsal 10. Shaft (body) of metatarsal 11. Base of metatarsal 12. Cuneiforms 13. Navicular 14. Cuboid 15. Talus 16. Calcaneus 17. Tibia 18. Fibula 19. Tarsometatarsal joints 20. Transverse midtarsal jointRADIOGRAPHIC ANATOMYReference : http://www.szote.u-szeged.hu/Radiology/Anatomy/skeleton.htm

B lateral foot

For #s and dislocations, tissue effusion, joint space abnormalities, opaque F.Bs.

Patient in lateral recumbent, pillow under head, knee flexed 45, opposite leg behind injured leg, foot carefully dorsiflexed for a true lateral position, support under leg and knee, sole of foot 90 to film. Film: HD 18x24 cm.

CP: Medial cuneiform (level of the base of the 3rd metatarsal).

CR: 90 perpendicular to film.

11Reference: Text book of radiographic positioning and related anatomy; L.Bontrager, 6th editions

RADIOGRAPHIC ANATOMY Tibia. Calcaneus. Calcaneus tuberosity. Cuboid. 5th MT tuberosity. Superimposed cuneiforms. Navicular. Subtalar joint. Talus.

Lateral foot Reference : http://www.szote.u-szeged.hu/Radiology/Anatomy/skeleton.htm

B AP/Lat both feet (Weight-bearing technique) Flat Foot

Reference: Text book of radiographic positioning and related anatomy; L.Bontrager, 6th editions

B AP/Lat both feet (Weight-bearing technique)To show condition of the longitudinal arches under full weight of body to exclude a flat foot abnormality .AP: Patient standing erect, full weight evenly distributed on both feet (on the fluoroscopic foot-rest).Lat: Patient stand erect on wood blocks on the foot rest, film vertically between feet, cassettes changed in turn for lateral of the other foot for comparison.Film: HD 24x30 cm, 18x24 (for laterals).CP: (AP): CR 15 posteriorly to midpoint between the feet, at the level of the base of metatarsals. ( Perpendicular is preferred for flat foot) (Lat): Horizontally to the level of base of the metatarsals. Reference: Text book of radiographic positioning and related anatomy; L.Bontrager, 6th editions

B Mediolateral CalcaneusFor bony lesions of Calcaneum, talocalcaneal joint, and talus. Also shows fractures.Patient lateral recumbent, with affected knee flexed 45, opposite leg behind injured limb, support under knee and leg, sole 90 to the film, ankle and foot in the true lateral. Film: HD 18x24 cm.CP: 1 inch inferior to medial malleolus. CR: 90 to film.

Reference: Text book of radiographic positioning and related anatomy; L.Bontrager, 6th editions

Calcaneal (Heel) spurB Mediolateral CalcaneusReference: Text book of radiographic positioning and related anatomy; L.Bontrager, 6th editions

To show fractures, pathology, and lateral or medial displacement.Patient supine or seated, legs fully extended, foot dorsiflexed (sole 90 to film), cotton ribbon looped around foot pulled by patient for support.Film: HD 18x24 cm.

CP: Base of 3rd metatarsal.

CR: 40 cephalic from long axis of foot.

B Axial CalcaneusReference: Text book of radiographic positioning and related anatomy; L.Bontrager, 6th editions

B Axial CalcaneusReference: Text book of radiographic positioning and related anatomy; L.Bontrager, 6th editions

B AP AnkleFor bony lesions of ankle joint, distal tibia and fibula (NB/ Lateral aspect of ankle joint must not appear open in this projection).Patient supine, legs fully extended, foot in the natural position, foot and ankle in true AP.Film: HD 24x30 cm.CP: Midway between malleoli.CR: 90 to film. Reference: Text book of radiographic positioning and related anatomy; L.Bontrager, 6th editions

1. Fibula 2. Tibia 3. Distal Tibiofibular joint 4. Malleolar fossa 5. Lateral malleolus 6. Ankle joint 7. Medial malleolus 8. TalusAP AnkleRADIOGRAPHIC ANATOMYReference : http://www.szote.u-szeged.hu/Radiology/Anatomy/skeleton.htm

B Lateral Ankle (Mediolateral)

For pathology and fractures, dislocations, joint effusions.Patient in lateral recumbent, the affected side down, knee of affected limb flexed 45, sound leg behind the affected leg, foot and leg in a true lateral, sole 90 to film.Film: HD 24x30 cm.CP: Medial malleolus.CR: 90 to film. Reference: Text book of radiographic positioning and related anatomy; L.Bontrager, 6th editions

B APO Ankle 45 (medial rotation)For pathology/fractures of distal Tibiofibular joint and distal fibula and base of 5th MT.

Patient supine, legs fully extended, foot dorsiflexed so that planter surface is (80 to 85) from the film, leg and foot rotated internally 45 (similar position to ankle mortise). Film: HD 24x30 cm.

CP: A point midway between malleoli.

CR: 90 to film.

Reference: Text book of radiographic positioning and related anatomy; L.Bontrager, 6th editions

ANY QUESTIONS?

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