RADS 216 – Image Evaluation: RadiographsFinal Oral PresentationAP 15°- 20° Oblique Ankle Projection (Mortise View)

Presented by: Joy Walker

HIPAA COMPLIANCE This image is HIPAA

compliant.

All information pertaining to the patient and the imaging facility has been removed.

This image does not violate patient confidentiality.

MARKER AND PATIENT IDIs a correct anatomical side marker visible in the image?

Yes, the correct left side marker is visible in this image.

Is the side marker placed correctly in the image?

Yes, the left side marker is placed correctly on this image.

Are there any markers superimposed on pertinent anatomy?

There are no markers superimposed on pertinent anatomy.

MARKER AND PATIENT IDAre additional markers needed? Were they used?

Yes, the additional standing marker was needed and it was used in this image.

Is the image displayed correctly based on marker placement?

Yes, this image is displayed correctly based on marker placement.

RADIATION HYGIENEThree sides of beam restriction must be visible on an image and gonadal shielding must be provided if gonads are within 5 cm of the primary beam

This image does not appear to have adequate collimation because beam restriction is not visible on this image. The primary beam is > 5 cm from the ankle but gonadal shielding is recommended.

RADIATION HYGIENE

Does “evidence” exist to indicate appropriate use of shielding?

No, there is no evidence of appropriate use of shielding because beam restriction was not used. We do not know if gonadal shielding was used.

COMPLETENESS OF POSITION/PROJECTION

Routine Procedures for an Ankle include:

AP Ankle

AP Oblique Ankle(15-20 degree medial rotation)

Lateral Ankle(Mediolateral)

COMPLETENESS OF POSITIONING/PROJECTION

CROSS TABLE L

Does the image comply with routine positions/projections?

This image is a AP oblique projection of the ankle which does comply with routine procedures.

Are all anatomical parts visualized in this image? Yes, all anatomical parts are visualized.

ARTIFACT IDENTIFICATION

Are preventable physical artifacts visible in the image?

No,there are no preventable physical artifacts visible in the image.

Are body parts superimposed that should not be?

No body parts are superimposed that should not be.

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ARTIFACT IDENTIFICATIONIs hospital paraphernalia present and/or visible in the image?

No, hospital paraphernalia is not present in this image.

Are patient clothing/belongings visible in the image?

No, there is no evidence of patient clothing or belongings in this image.

ARTIFACT IDENTIFICATION

Are any indwelling artifacts/foreign bodies visible in the image?

Yes, the indwelling artifact is a fracture found on the distal fibula.

ASSESSMENT OF IMAGE INTEGRITYARTIFACT IDENTIFICATION

Is excess fog visible and/or degrading the overall image quality?

No, excess fog is not visible and does not degrade overall image quality.

Are any CR/DR artifacts visible in the image?

No, there are not CR/DR artifacts visible in this image.

IMAGE SHARPNESS

Is gross voluntary motion visible in the image?

No, gross voluntary motion is not visible in this image.

Is excessive quantum mottle or image noise visible in the image?

There is no quantum mottle or image noise visible in this image.

IMAGE SHARPNESSIs evidence of double (or previous/ghosted) exposure present?

No, there is no evidence of a double or ghosted exposure in this image.

Are grid lines, grid artifact and/or grid cutoff visible in the image?

There are no grid lines, grid cutoff visible in this image. Grids are not used for this projection.

IMAGE SHARPNESS

Does size distortion appear greater than expected?

No, size distortion does not appear greater than expected.

Is shape distortion being caused by poor CR/IR part alignment?

Minimal shape distortion is evident in this image due to the obliquity of the ankle.

ACCURATE PART POSITIONING

Is the part adequately aligned to the image media?

Yes, the part is adequately aligned to the image media.

Is the part accurately centered to the image media?

Yes, the part is accurately centered to the image media.

ACCURATE PART POSITIONING

Is the CR centered within 1 cm of the anatomical part?

No, the CR is centered more than 1 cm of the ankle.

Is the CR adequately aligned with the image media?

Yes, the CR is adequately aligned with the image media.

ACCURATE PART POSITIONING

Does the CR’s alignment conform to an accepted IR exposure field recognition template/field?

No, the CR’s alignment does not conform to an accepted IR exposure field recognition template because collimation was not used.

ACCURATE PART POSITIONINGAP (15-20 degree) Oblique Ankle Medial Rotation Projection

Center the patient’s ankle joint to the IR.

Grasp the distal femur area with one hand and the foot with the other. Assist the patient by internally rotating the entire leg and foot together 15 to 20 degrees until the intermalleolar plane is parallel with the IR.

The plantar surface of the foot should be placed at a right angle to the leg.

Central Ray is perpendicular entering the ankle joint midway between the malleoli.

Collimate 1inch on all sides of the ankle and 8 inches lengthwise to include the heel.

EVALUATION CRITERIAThe following should be clearly shown:

Evidence of proper collimation

Entire ankle mortise joint

No overlap of the anterior tubercle of the tibia and superlateral portion of the talus with the fibula.

Talofibular joint space in profile

Talus shown with proper density

EVALUATION CRITERIA

Based on the evaluation criteria there is evidence of collimation. Entire ankle mortise is visible. Talofibular joint space is in profile. I believe it does meet most of the evaluation criteria.

JUDICIOUS EXPOSURE TECHNIQUE

• Radiolucent structures are those that are penetrated by x-rays. The structure most radiolucent in this image is the joint space of the ankle.

• Radiopaque structures are those structures that are not penetrable by x-rays. The most radiopaque structures are the tarsal bones.

JUDICIOUS EXPOSURE TECHNIQUE

• What is your assessment of the image’s contrast (window width)? I think the image has adequate contrast because there are varying shades of gray.What is your assessment of the image’s brightness (window level) and/or exposure indicator (EI) value?

I believe there is adequate brightness and the EI value would be within the normal range.

ACCEPT/REJECT IMAGE

Accept! I would accept this image because I would not want to expose the patient to any more radiation than necessary. Although, the collimation is not as adequate as it could be I do not believe it is probable reasoning to repeat. There is a fracture and it is visible on the image so I would not want to expose the patient again.

SUMMARY

Corrections that I would make if repeated:Closer collimation only including the

anatomy of interest.

Make sure gonadal shielding is used.

Be sure that the ankle is properly oblique.

Properly center the CR to the ankle joint.

REFERENCES

Frank, Eugene D., Eugene D. Frank, and Vinita Merrill. "Chapter 6 Lower Limb." Merrill's Atlas of Radiographic Positioning & Procedures. 12th ed. Vol. 1. St. Louis, MO: Mosby Elsevier, 2011. 151-63. Print.

McQuillen-Martensen, Kathy. "Chapter 6 Lower Extremity." Radiographic Image Analysis. 4th ed. St. Louis, MO: Saunders/Elsevier, 2011.

208-25. Print.