Country Health SA Medical Imaging - Radiologists … Created by Lauren Rayner & Darren Kimber Last...

Country Health

SA Medical Imaging

REMOTE OPERATORS POSITIONING

GUIDE

[CHSA - REMOTE OPERATORS POSITIONING GUIDE]

Page | 2 2014 Created by Lauren Rayner & Darren Kimber Last updated Apr 2016, Next review Jan 2018

Contents

Image Evaluation Page 4

Positioning Guides

Section 1 - THORAX

1.1 Chest Page 5

1.2 Bedside Chest Page 7

1.3 Ribs Page 8

Section 2 – UPPER EXTREMITY

2.1 Hand Page 10

2.2 Thumb Page 13

2.3 Wrist/Scaphoid Page 16

2.4 Forearm 0

2.5 Elbow Page 22

2.6 Humerus Page 25

2.7 Shoulder/Clavicle Page 27

Section 3 – LOWER EXTREMITY

3.1 Foot Page 30

3.2 Ankle Page 33

3.3 Tibia/Fibula Page 36

3.4 Knee Page 38

Section 4 – PELVIC GIRDLE

4.1 Pelvis/Hip Page 40



Section 5 – SPINAL COLUMN

5.1 Cervical Spine Page 42

5.2 Thoracic Spine Page 44

5.3 Lumbar Spine Page 46

Section 6 – ABDOMEN

6.1 Abdomen Page 48

THIS DOCUMENT IS TO BE USED AS A GUIDE ONLY FOR

RADIOGRAPHIC PROJECTIONS.

REMOTE OPERATORS MUST OPERATE WITHIN THEIR RADIATION

LICENCE CONDITIONS, AS SET BY THE EPA.

Copyright © 2014. All rights reserved.



Image Evaluation

For every image produced PACEMAN should be used to evaluate image quality.

Positioning – Is the part being imaged in the correct position?

– Is the image rotated?

Area Covered – Has the area in question been covered adequately?

– Has an area been exposed that is not required?

Collimation – Could the collimation be smaller?

– Are all collimation lines evident?

Exposure – Is the image underexposed or overexposed?

– Does the image show correct contrast and density?

– Is the exposure index adequate?

Markers – Have markers been correctly used?

– Should be placed on the lateral aspect of the patient for AP/PA images.

– Should be placed on the anterior aspect of the patient for Lateral images.

Aesthetics/ – Does the image look diagnostic?

Artifacts – Is the image displayed correctly?

– Are there any artifacts that may cover pathology?

Name – Is the patient’s name/DOB entered correctly?



Section 1 – THORAX

1.1 CHEST - PA

Detector/Cassette: 35x43cm

Orientation: Landscape for men, portrait for women

FFD: 180cm

Central Ray: Perpendicular to bucky

Collimation: Collimate to cassette size. Reduce collimation to only include area of interest

Centre Point: T6/T7

Patient Positioning:

1. Patient’s chest against bucky

2. Patient’s backs of hands on back of hips, ensuring scapula are rolled forward off the lung fields

Respiration: Inspiration +/- Expiration for pneumothorax

Image Evaluation:

1. Lung apices & bases included

2. No rotation – medial clavicle equidistant from sternum

3. Adequate inspiration




Orientation: Portrait

FFD: 180cm



Centre Point: Middle of lungs at level of T6/T7


1. Patient’s left side against bucky

2. Patient’s hands on head, elbows in front of face

3. Right shoulder slightly further forward than left shoulder

Respiration: Inspiration

Image Evaluation:


2. No rotation – lung bases superimposed


Section 1 - THORAX

1.1 CHEST – LATERAL




Orientation: Landscape

FFD: 180cm



Centre Point: Lower third of sternum


1. Back of bed moved to upright position

2. Cassette placed behind patient’s back

3. X-ray tube angled to match angle of patient’s chest

Respiration: Inspiration +/- Expiration for pneumothorax

Image Evaluation:


2. No rotation – medial clavicle equidistant from sternum


Section 1 - THORAX

1.2 BEDSIDE CHEST - AP





FFD: 100cm



Area Covered: Upper ribs - 1st rib down. Lower ribs - 12th rib up. Include spine & lateral aspect of rib cage


1. Patient’s back against bucky, rotated 30° towards affected side - affected side down

2. Arm on affected side placed on patient’s head

Respiration: Inspiration for upper ribs. Expiration for lower ribs

Image Evaluation:

1. Ribs appear elongated

2. Must include at least the 1st rib or 12th rib

3. Good contrast between ribs and lung

Section 1 - THORAX

1.3 RIBS





FFD: 100cm



Area Covered: Upper ribs - 1st rib down. Lower ribs - 12th rib up. Include spine & lateral aspect of rib cage


1. Patient’s back against bucky, rotated 30° away from affected side – affected side up

2. Arm on affected side placed on patient’s head

Respiration: Inspiration for upper ribs. Expiration for lower ribs

Image Evaluation:

1. Ribs appear shortened

2. Must include at least the 1st rib or 12th rib

3. Good contrast between ribs and lung

Section 1 - THORAX

1.3 RIBS





FFD: 100cm

Central Ray: Perpendicular to cassette

Collimation: To include entire hand and distal radius/ulna

Centre Point: 3rd metacarpal-phalangeal joint


1. Place hand with palm down against cassette

2. Fingers as straight as possible and slightly separated

Image Evaluation:

1. X-ray viewed with fingers at top of film, not anatomically

2. All fingers included

3. Distal radius/ulna included


2.1 HAND - PA





FFD: 100cm



Centre Point: 3rd metacarpal-phalangeal joint


1. Place hand with palm down against cassette

2. Fingers as straight as possible and slightly separated

3. Whole hand angled 30˚ with thumb raised

Image Evaluation:




4. Metacarpals slightly overlapping


2.1 HAND - OBLIQUE





FFD: 100cm



Centre Point: Metacarpal-phalangeal joints


1. Place hand ulna side down

2. Thumb and forefinger pinched together

3. All other fingers fanned out

Image Evaluation:




4. Wrist lateral


2.1 HAND – LATERAL




2.2 THUMB - PA



FFD: 100cm


Collimation: To include whole thumb and carpal bones

Centre Point: Proximal inter-phalangeal joint


1. Hand in lateral position ulna side down

2. Thumb flat in front of hand, parallel to cassette

3. Thumb will not be touching cassette

Image Evaluation:

1. X-ray viewed with distal thumb at top of film, not anatomically

2. Entire thumb visualised including adjacent carpal bones

3. No rotation – equal concavity on each side of both phalanges





FFD: 100cm


Collimation: To include whole thumb and adjoining carpal bones



1. Hand palmar surface flat against cassette

2. Thumb extended slightly from other fingers

Image Evaluation:



3. Anterior aspect of proximal phalanx and metacarpals should appear slightly more concave than

posterior aspect


2.2 THUMB - OBLIQUE




2.2 THUMB - LATERAL



FFD: 100cm


Collimation: To include whole thumb and adjoining carpal bones



1. Hand palmar surface initially flat against cassette

2. Thumb extended slightly from other fingers

3. Lift hand off cassette while keeping thumb against cassette, pivoting onto lateral portion of thumb

Image Evaluation:



3. Anterior aspect of proximal phalanx and metacarpals should appear concave

4. Posterior aspect of proximal phalanx and metacarpals should appear straight




2.3 WRIST - PA



FFD: 100cm


Collimation: To include all carpal bones and distal third of radius/ulna

Centre Point: Midway between styloid process of radius and ulna


1. Place anterior surface of wrist flat against cassette

Image Evaluation:


2. Distal radius and ulna are free of superimposition

3. Mid metacarpals and distal third of radius/ulna visualised




2.3 WRIST - OBLIQUE



FFD: 100cm



Centre Point: Midway between styloid process of radius and ulna


1. Place anterior surface of wrist flat on cassette

2. Raise thumb approx. 30˚ while keeping ulna aspect against cassette

Image Evaluation:


2. Distal radius and ulna are slightly superimposed

3. 3rd to 5th metacarpal bases are slightly superimposed





2.3 WRIST - LATERAL



FFD: 100cm



Centre Point: Distal end of radius


1. Place wrist with ulna aspect against cassette

2. Superimpose radial and ulna styloid processes (HINT: Hand slightly rotated posteriorly for true

lateral position)

3. Thumb against 2nd metacarpal-phalangeal joint

Image Evaluation:


2. Distal radius and ulna superimposed

3. Metacarpals superimposed





2.3 SCAPHOID



FFD: 100cm

Central Ray: 30˚ uptilt (angled up the forearm)

Collimation: To include all carpal bones and distal end of radius/ulna

Centre Point: Carpal bones


1. Place anterior surface of wrist flat against cassette

2. While keeping forearm still, ulnar deviate the hand as much as possible

Image Evaluation:


2. All carpal bones and distal radius/ulna included

3. Scaphoid will appear elongated

4. All other carpal bones will appear more superimposed




2.4 FOREARM - AP


Orientation: Portrait – forearm diagonally across cassette

FFD: 100cm


Collimation: To include elbow joint and wrist joint

Centre Point: Mid forearm


1. Place forearm with anterior surface facing up

2. Arm straight

Image Evaluation:

1. X-ray viewed with wrist at top of film, not anatomically

2. AP view of elbow and AP view of wrist

3. Entire radius/ulna visualised




2.4 FOREARM - LATERAL


Orientation: Landscape – forearm diagonally across cassette

FFD: 100cm


Collimation: To include elbow joint and wrist joint

Centre Point: Mid forearm


1. Elbow and wrist in lateral positions – elbow flexed 90˚with wrist straight

2. Ulna aspect of forearm against cassette

Image Evaluation:

1. X-ray viewed with wrist at top of film, not anatomically

2. Lateral view of elbow and lateral view of wrist

3. Entire radius/ulna is visualised




2.5 ELBOW - AP



FFD: 100cm


Collimation: To include elbow joint, distal third of humerus and proximal third of radius/ulna

Centre Point: Centre on elbow joint


1. Elbow as straight as possible

2. Posterior surface against cassette

Image Evaluation:

1. Entire elbow joint with distal third of humerus and proximal third of radius visualised

2. Bilateral epicondyles seen in profile

3. Radial head and ulna slightly superimposed




2.5 ELBOW - OBLIQUE



FFD: 100cm



Centre Point: Centre on elbow joint


1. Elbow as straight as possible

2. Posterior surface against cassette

3. Instruct patient to rotate entire arm laterally so anterior surface of elbow is approx. 45˚ to cassette

4. Patient will need to lean into affected shoulder

Image Evaluation:


2. Radial head and ulna will not be superimposed

3. Lateral epicondyle will appear more in profile and elongated




2.5 ELBOW - LATERAL



FFD: 100cm



Centre Point: Ensure centred over elbow joint


1. Elbow and wrist in lateral positions – elbow flexed 90˚with wrist straight

2. Ensure cassette is raised to a level in line with patient’s shoulder, brings the humerus parallel to

the cassette

3. To align epicondyles, wrist will need to be slightly elevated off cassette while maintaining elbow

contact with cassette – sponge support advised

Image Evaluation:


2. Both epicondyles superimposed

3. Olecranon process seen in profile




2.6 HUMERUS - AP



FFD: 100cm


Collimation: To include shoulder and elbow joints. Twist collimators to run along humerus

Centre Point: Mid humerus


1. Posterior aspect of humerus against bucky

2. Entire arm slightly abducted away from body

3. Palmar surface of hand facing forward

Image Evaluation:

1. Entire humerus included

2. Ensure both shoulder and elbow joints are visualised in AP projections

3. Greater tubercle seen in profile




2.6 HUMERUS - LATERAL



FFD: 100cm


Collimation: To include shoulder and elbow joints. Twist collimators to run along humerus

Centre Point: Mid humerus


1. Patient facing bucky

2. Instruct patient to flex elbow and place hand on lower abdomen

3. Arm slightly abducted away from body

4. Humerus touching bucky

Image Evaluation:

1. Entire humerus included

2. Ensure both shoulder and elbow joints are visualised in lateral projections

3. Epicondyles of elbow superimposed




2.7 SHOULDER - AP



FFD: 100cm


Collimation: To include proximal third of humerus and entire clavicle and scapula

Centre Point: 2.5cm inferior to coracoid process


1. Posterior aspect of shoulder against bucky

2. Clavicle should run parallel to bucky

3. Hand externally rotated

Respiration: Suspend respiration

Image Evaluation:

1. Proximal third of humerus, entire clavicle and scapula visualised

2. Adequate external rotation of hand is demonstrated by greater tubercle on lateral aspect of

humeral head viewed in full profile




2.7 SHOULDER - LATERAL



FFD: 100cm


Collimation: To include entire shoulder joint and scapula. Twist collimators to run along humerus

Centre Point: Mid scapula


1. Patient facing bucky

2. Instruct patient to flex elbow and place hand on lower abdomen

3. Arm slightly abducted away from body

4. Palpate medial border of scapula, rotate patient so scapula is perpendicular to bucky


Image Evaluation:

1. Entire scapula visualised in ‘Y’ position indicating true lateral

2. Humeral head superimposed on body of scapula

3. Proximal third of humerus




2.7 CLAVICLE – AP UPTILT



FFD: 100cm

Central Ray: 20-30˚ uptilt

Collimation: To include entire clavicle

Centre Point: Mid clavicle


1. Posterior aspect of shoulder against bucky

2. Clavicle should run parallel to bucky


Image Evaluation:

1. Entire clavicle visualised

2. Most of clavicle should be projected above scapula and ribs




3.1 FOOT - DP



FFD: 100cm

Central Ray: 15˚ uptilt

Collimation: To include all toes and metatarsals

Centre Point: Mid 3rd metatarsal


1. Patient supine with knee flexed

2. Plantar surface of foot against cassette

Image Evaluation:

1. X-ray viewed with toes at top of film, not anatomically

2. No rotation – equidistant between 2nd-5th metatarsals

3. All toes and tarsal bones visualised




3.1 FOOT - OBLIQUE



FFD: 100cm


Collimation: To include all toes and metatarsals

Centre Point: Mid 3rd metatarsal


1. Patient supine with knee flexed

2. Dorsal surface of foot against cassette

3. Entire leg internally rotated until plantar surface approx. 30-40˚ to cassette

Image Evaluation:


2. Correct obliquity demonstrated when 2nd-5th metatarsals are free of superimposition of each other

3. All toes, tarsal bones and calcaneum visualised




3.1 FOOT – LATERAL



FFD: 100cm


Collimation: To include toes to calcaneum and distal tibia/fibula

Centre Point: Base of metatarsals


1. Patient supine and rolled slightly onto affected side

2. Knee flexed with lateral aspect of foot against cassette

3. Ensure the plantar aspect is perpendicular to cassette

Image Evaluation:


2. Metatarsals superimposed on each other

3. Toes to calcaneum and distal tibia/fibula must be visualised




3.2 ANKLE - AP



FFD: 100cm


Collimation: To include distal tibia/fibula and proximal half of metatarsals

Centre Point: Midway between malleoli


1. Foot flexed with plantar surface perpendicular to cassette

2. Leg in true AP position

Image Evaluation:

1. Medial mortise joint should be open, and the lateral closed

2. Some superimposition of the distal tibia and fibula




3.2 ANKLE - OBLIQUE



FFD: 100cm


Collimation: To include distal tibia/fibula and proximal half of metatarsals

Centre Point: Midway between malleoli


1. Foot flexed with plantar surface perpendicular to cassette

2. Internally rotate entire leg until 5th toe lines up with middle of heel

Image Evaluation:

1. Both medial and lateral mortise joints will be open

2. Less superimposition of distal tibia and fibula than AP projection

3. Malleoli will be visualised in profile




3.2 ANKLE - LATERAL



FFD: 100cm


Collimation: To Include base of 5th metatarsal, calcaneum and distal tibia/fibula

Centre Point: Medial malleolus


1. Patient supine, rolled slightly onto affected side

2. Foot flexed to 90°

3. Plantar surface perpendicular to cassette

Image Evaluation:

1. Distal tibia/fibula superimposed

2. No rotation – tibiotalar joint will be uniformly open

3. Ensure base of 5th metatarsal is included



Section 3 - LOWER EXTREMITY

3.3 TIBIA / FIBULA - AP


Orientation: Portrait – tibia diagonally across cassette

FFD: 100cm


Collimation: To include knee and ankle joint. Twist collimators to run along tibia

Centre Point: Mid tibia/fibula


1. Patient supine with leg extended

2. Posterior aspect of calf against cassette

Image Evaluation:

1. Entire tibia/fibula visualised with knee and ankle joints in AP position




3.3 TIBIA / FIBULA - LATERAL


Orientation: Portrait – tibia diagonally across cassette

FFD: 100cm


Collimation: To include knee and ankle joint. Twist collimators to run along tibia

Centre Point: Mid tibia/fibula


1. Patient supine rolled slightly onto affected side

2. Knee flexed

3. Lateral aspect of leg against cassette

Image Evaluation:

1. Entire tibia/fibula visualised with knee and ankle joints in lateral position

2. Proximal and distal portion of tibia/fibula will be superimposed on each other




3.4 KNEE - AP



FFD: 100cm


Collimation: To include knee joint and patella, distal femur and proximal tibia/fibula

Centre Point: 1cm below patella


1. Patient supine with leg extended

2. Posterior aspect of leg against cassette

3. Ensure patella is centred to femur for true AP position

Image Evaluation:

1. Femoral condyles in profile

2. No rotation – intercondylar eminence central to femur

3. Head of fibula will be partially superimposed by tibia




3.4 KNEE - LATERAL



FFD: 100cm


Collimation: To include knee joint and patella, distal femur and proximal tibia/fibula

Centre Point: 1cm below patella, along midline axis of leg


1. Patient lying completely on affected side

2. Other leg brought up and over affected leg.

Patient ends up laying in a ‘recovery position’

Image Evaluation:

1. Patella in profile

2. Medial and lateral femoral condyles superimposed

3. Fibula head partially superimposed by tibia




4.1 PELVIS / HIP – AP



FFD: 100cm


Collimation: Collimate to cassette size. Do not increase collimation greater than cassette size.

Centre Point: Midway between ASIS and pubic symphysis, along patient midline


1. Patient supine

2. Heels hip width apart

3. Feet internally rotated so toes touch – ‘pigeon toed’ (if fracture suspected, don’t internally rotate)


Image Evaluation:

1. Must include iliac crests, greater trochanters and proximal third of femurs

2. No rotation – iliac wings and obturator foramen will appear same size

3. Correct internal rotation will hide lesser trochanters behind femurs and bring greater trochanters

into profile




4.2 HIP – LATERAL (PERFORM ONLY IF NO FRACTURE)

Detector/Cassette: 24x30cm, use 35x43cm if for THR follow-up


FFD: 100cm


Collimation: Collimate to cassette size. Twist collimators to run along femur

Centre Point: Level of pubic symphysis, along axis of femur of affected side


1. Patient supine, roll patient 30˚ onto affected hip with support under back

2. Flex hip and knee slightly

3. Keep knee slightly raised off bed to keep Neck Of Femur elongated


Image Evaluation:

1. Must include entire hip joint, acetabulum and proximal third of femur

2. Lesser trochanter visualised in profile

3. Obturator foramen adjacent to affected hip will be closed

4. If prosthesis, must include entire prosthesis




5.1 CERVICAL SPINE - AP



FFD: 100cm

Central Ray: 15-20˚ uptilt

Collimation: To include mastoid air cells of skull and sternal notch

Centre Point: Adam’s apple - to pass through C4


1. Patient’s back against bucky

2. Chin slightly raised

3. No rotation of the head

Image Evaluation:

1. Ensure C3-T1 are visualised in AP projection

2. No rotation – spinous process of each vertebra should appear in the middle of each vertebra,

Sterno-clavicular joints equal size

3. Mandible and skull base superimposed on each other and over C1 and C2




5.1 CERVICAL SPINE - LATERAL



FFD: 100cm


Collimation: Collimate to cassette size. Position with upper border of collimation just above top of ear

Centre Point: Level of C4


1. Patient in lateral position with left shoulder against bucky

2. Shoulders relaxed


Respiration: Expiration – this will relax patient’s shoulders

Image Evaluation:

1. Visualise C1 to upper border of T1

2. C1 and C2 free of superimposition from mandible

3. All spinous processes

4. Anterior soft tissue structures




5.2 THORACIC SPINE - AP



FFD: 100cm


Collimation: Collimate to cassette size. Reduce lateral borders to approximately 15cm wide

Centre Point: Level of T7, entering through lower third of sternum


1. Patient supine



Image Evaluation:

1. Ensure C7 to L1 visualised

2. No rotation – spinous process of each vertebra should appear in the middle of each vertebra,

Sterno-clavicular joints equal size




5.2 THORACIC SPINE - LATERAL



FFD: 100cm



Centre Point: T7, along axis of spine


1. Patient lies on left side in lateral position

2. Both hands resting on pillow in front of face

3. Ensure upper and lower back are in lateral position


Image Evaluation:

1. Ensure T3 to L1 is visualised (T1 and T2 usually aren’t seen)

2. All intervertebral disc spaces open

3. Spinous processes in profile

4. No rotation – posterior aspects of all vertebra should be superimposed




5.3 LUMBAR SPINE - AP



FFD: 100cm



Centre Point: 3cm above iliac crest, along axis of spine


1. Patient supine or prone if possible (prone will allow all intervertebral disc spaces to be seen)

Respiration: Expiration

Image Evaluation:

1. Ensure T12 to sacrum is visualised, including SI joints

2. No rotation – spinous process of each vertebra should appear in the middle of each vertebra




5.3 LUMBAR SPINE - LATERAL



FFD: 100cm



Centre Point: 3cm above iliac crest, along axis of spine (spine falls midway between ASIS and PSIS)


1. Patient lies on left side in lateral position

2. Ensure upper and lower back are in lateral position

3. Both legs resting on top of each other, knees slightly bent

Respiration: Expiration

Image Evaluation:

1. Ensure T12 to sacrum is visualised

2. All intervertebral disc spaces open

3. Spinous processes in profile

4. No rotation – posterior aspects of all vertebra should be superimposed



Section 6 - ABDOMEN

6.1 ABDOMEN – AP SUPINE



FFD: 100cm


Collimation: Collimate to film size. Do not increase collimation greater than film size.

Centre Point: Iliac crest, along midline


1. Patient supine

2. For erect AXR patient’s back against upright bucky


Image Evaluation:

1. Pubic symphysis at bottom of image

2. Soft tissue shadow of liver visualised at top of film

3. No rotation – iliac wings equal size

Country Health SA Medical Imaging - Radiologists … Created by Lauren Rayner & Darren Kimber Last...

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Transcript of Country Health SA Medical Imaging - Radiologists … Created by Lauren Rayner & Darren Kimber Last...