Radiography - NOT Routine : Radiography - NOT Routine Connie Lyon, R.T.(R) (QM)
Objectives : Objectives To itemize & illustrate some alternatives in radiography of the non-routine patient and/or with limited equipment options
Contributors : Contributors Technologists from
Memorial Hospital, Aurora, NE
Nebraska Orthopedic & Sports
Lincoln Orthopedic & Spots
Lincoln Orthopedic Center
Southeast Community College
Selected slides made from
“Pocket Atlas - Handbook of Radiographic Positioning & Techniques” by Kenneth L. Bontrager
Slide 4 : Other Non-routine Situations, e.g. while driving
Slide 5 : More help?
Thorax - not ambulatory : Thorax - not ambulatory Seated at end of table or on adjustable stool
may be only option with limited equipment
Supine on the table
(erect or semi-erect is always better)
Thorax - not ambulatory : Thorax - not ambulatory AP Chest
maintain part-ray-film alignment
slight caudal angle will prevent clavicles from obscuring apices, I.e. “Lordotic appearance” Center about mid-point of sternum
Thorax : Thorax PA Chest - hypersthenic body type
Use landmarks
Mid-sagittal plane
T-7 bottom of scapula
Thorax : Thorax
Thorax : Thorax T7 1
2
3
4
5
6
Thorax - collimate to film size or smaller : Thorax - collimate to film size or smaller
Thorax - exaggerated kyphosis : Thorax - exaggerated kyphosis Kyphotic patient
Try doing an AP instead of PA
add a cephalic tube angle to “throw” chin up
take a second AP with no tube angle or slight caudal angle
Thorax - exaggerated kyphosis : Thorax - exaggerated kyphosis
Thorax - exaggerated kyphosis : Thorax - exaggerated kyphosis
Thorax : Thorax Requires a flexible tube
There are limits with limited equipment
Slide 16 : CR should be perpendicular to the plane of the cassette - show base of lungs Cephalic angle - like a clavicle to see apices Thorax - exaggerated kyphosis
Slide 17 : Thorax - exaggerated kyphosis Try smaller film size and ask patient to “hug” it for PA projection
Slide 18 : Tilt caudal to project apices downward & center higher Will require 2 films Beam perpendicular to cassette for base of lungs
Thorax : Thorax Lateral Chest
starts with feet being firmly planted, slightly separated and pelvis and shoulders in a true lateral position
minimize rotation with the “thumb trick” Courtesy of Kenneth Bontrager, “Pocket Atlas” 3rd edition
Technique - www.controlthedose.com : Technique - www.controlthedose.com Use medium kVp (80) for initial images of upper ribs
lower kVp = more contrast less information per film
lower kVp good after fracture has been identified to make it easier to see
mAs required is about the same as Bucky shoulder on same patient Ribs –
Ribs : Ribs lower ribs - AP/PA
similar technique as lumbar spine
need a good expiration to elevate the diaphragm
Ribs : Ribs LPO looks similar to RAO - demonstrates left ribs free of superimposed spine obliques - upper or lower
anterior - away
posterior - towards
Slide 23 : Another helpful principle - teamwork
Upper Extremity : Upper Extremity Consider reverses when patient unable to assume routine position
AP hand
AP wrist
Be sure to carefully mark image and note the change in routine for the physician
Upper Extremity : Upper Extremity
Upper Extremity : Upper Extremity high-frequency *100 speed imaging*40” SID 56-58 60 60 60 60
1.5-2.0 2.5-3.0 4.0 5.0-6.0 8.0 Technique - www.controlthedose.com
Upper Extremity : Upper Extremity Limited extension elbow Courtesy of Kenneth Bontrager, “Pocket Atlas” 3rd edition
Upper Extremity : Upper Extremity
Upper Extremity : Upper Extremity Creative “cross-table” projections with limited equipment Use a lead apron to shield the patient for this projection
Slide 30 :
Upper Extremity *creative positioning impacts exposure factors : Upper Extremity *creative positioning impacts exposure factors Don’t forget to change time or mAS if unable to get 40” SID
40” to 30” requires about 1/2
40” to 60” requires about 2X
Notice if the change adds or subtracts a grid
if adds, then 3-5 X original time or mAS
if subtracts, then 1/3 to 1/5 Technique - www.controlthedose.com
Upper Extremity : Upper Extremity Humerus - lateral Courtesy of Kenneth Bontrager, “Pocket Atlas” 3rd edition *TIP … Move humerus away from body
to minimized soft tissue superimposition
Slide 33 :
Upper Extremity - transthoracic humerus : Upper Extremity - transthoracic humerus VIP - begin with a true lateral thorax then depress affected humerus keeping it superimposed by the chest then raise unaffected arm over the head
Upper Extremity - transthoracic humerus : Upper Extremity - transthoracic humerus most similar technique is lateral thoracic spine
long exposure time (2 sec) while patient breathes
remember to include thickness of thorax and humerus
Upper Extremity - axial shoulder : Upper Extremity - axial shoulder patient supine - inferior to superior - requires flexible tube
tube below patient - inferior to superior - requires very flexible tube Courtesy of Kenneth Bontrager, “Pocket Atlas” 3rd edition
Upper Extremity - axial shoulder : Upper Extremity - axial shoulder leaning over the film - CR superior to inferior - most likely method with limited equipment
remember to maintain 40” SID Courtesy of Kenneth Bontrager, “Pocket Atlas” 3rd edition
Slide 38 : AP with arm adducted AP with arm abducted Lateral Scapula Scapular Y R
Scapular “Y” - : Scapular “Y” - starts with lateral scapula free of thorax Lateral for body of scapula - either med-lat or lat-med Laterals for superior structures - acromion, coracoid, “Y” Courtesy of Kenneth Bontrager, “Pocket Atlas” 3rd edition
Scapular “Y” - : Scapular “Y” - 20 degree caudal angle
CR exiting at head of humerus Bone spur on acromion
Upper Extremity - transthoracic humerus : Upper Extremity - transthoracic humerus Courtesy of Kenneth Bontrager, “Pocket Atlas” 3rd edition