S1 - Lab Positioning Guide: Upper/Lower Extremity

AIDET

1. Acknowledge - "Hello (patient's name), will you please verify your name and date of birth? Is there any chance you are pregnant?"

2. Introduce - "My name is (your name) and I am a radiography student."

3. Duration - "This exam should take about _____ minutes."

4. Explanation - "I will be taking images of your (body part.)"

5. Thank

Set up reminders

SHIELDING, MARKER, SIX (TABLE ARROWS), CR CENTERED ON DD

• If changing collimation size, double check proper SID selected

• Don’t move XR tube too fast

• SID 40

• Use foot stool; make sure it’s facing the right way for pt

• Move tube before/after pt gets on table so it’s not in their way

• Adjust table height so rectangle is above arrow

• Don’t let patient straddle table. Move table to pt so legs comfortable

Marker Placement Basic Guidelines

*Tested

• R or L markers must be placed on all radiographs

• The marker should never obscure the anatomy of interest

• The marker should always be placed in the exposure field on the edge of the collimation border

• The marker should always be placed outside of any lead shielding

• R and L markers must be used with CR and DR digital imaging

Additional Marker Recommendations

• AP and PA bilateral projections:

• For lateral projections of the head and trunk:

• Oblique projections

• For extremity projections

• Projections with two images on one DD:

• Limb positions where both the R and L sides are imaged side by side on one DD:

• AP, PA, or oblique chest projections:

• Decubitus positions of the chest and abdomen:

• AP and PA bilateral projections: (head, spine, chest, abdomen, and pelvis) R marker is typically used

• For lateral projections of the head and trunk: always mark the side closest to the DD, the marker is typically placed anterior to the anatomy

• Oblique projections: (spine, chest, and abdomen) always mark the side closest to the DD

• For extremity projections: use appropriate R or L marker; the marker must be placed within the edge of the collimated x-ray beam

• Projections with two images on one DD: only one of the projections needs to be marked

• Limb positions where both the R and L sides are imaged side by side on one DD: (ex. R and L AP knees) both the R and L markers must be used to clearly identify the two sides

• AP, PA, or oblique chest projections: marker is placed on the upper outer corner so that the thoracic anatomy is not obscured

• Decubitus positions of the chest and abdomen: the R or L marker should always be placed on the side up (opposite the side laid on) and away from the anatomy of interest

More marker notes

• Put marker on LATERAL side of body part

  • exs:

    • Right PA hand → marker on thumb side

    • AP forward → thumb

    • oblique → thumb

• But for LATERAL PROJECTIONS, marker goes ANTERIOR

PA Hand

• Collimation (never tested)

• SID

• Patient Position

• CR (central ray)

• Collimation: 7×8

• SID: 40

• Patient Position

  • Pronate hand

  • Forearm on table

  • Spread digits

• CR: ⏊ 3rd MCP (knuckle)

• Notes

  • can set up equipment before pt or vice versa

  • line up collimation with DD lines

  • wrist and middle finger lined up longitudinal lines

  • palm flat

OBL Hand

• Collimation: 7×8

• SID: 40

• Patient Position

  • MCP joints 45° to DD

  • Forearm on table

  • Spread digits

• CR: ⏊ 3rd MCP (or 2nd MCP)

• Notes

  • “hand flat, rotate, thumb down”

  • thumb parallel to DD

  • longitudinal line down finger and forearm

LAT Hand (blade)

• Collimation: 6×8

• SID: 40

• Patient Position

  • MCP joints 90° to DD

  • Forearm on table

  • Superimpose digits

• CR: ⏊ 2nd MCP

• Notes

  • karate chop (stacked fingers), thumb down and parallel to DD

  • longitudinal line down finger and wrist

LAT Hand (Fan)

• Collimation: 6×8

• SID: 40

• Patient Position

  • MCP joints 90° to DD

  • Forearm on table

  • Fan digits

• CR: ⏊ 2nd MCP

• Notes

  • karate chop, OK sign, spread last 3 fingers apart, separate thumb and finger so not touching

  • keep wrist lateral (no rotation)

  • All MCP’s superimposed and fingers parallel to DD

PA Wrist

• Collimation: 4×8

• SID: 40

• Patient Position

  • Hand in a fist

  • Forearm on table

• CR: ⏊ midcarpals

• Notes

  • Collimate knuckle to wrist

OBL Wrist

• Collimation: 4×8

• SID: 40

• Patient Position

  • MCP joints 45° to DD

  • Forearm on table

• CR: ⏊ midcarpals

• Notes

  • raise wrist 45° (rotate)

  • Collimate knuckle to wrist

LAT Wrist

• Collimation: 3×8

• SID: 40

• Patient Position

  • MCP joints 90° to DD

  • Forearm on table

• CR: ⏊ wrist joint

• Notes

  • like a “thumbs up” but thumb not actually up

  • digits don’t matter

Ulnar Deviation (Scaphoid)

• Collimation: 4×8

• SID: 40

• Patient Position

  • Pronate hand

  • Forearm on table

  • Deviate hand outward

• CR: 10-15° toward elbow, ⏊ scaphoid

• Notes

  • Start PA wrist

  • medial rotation

  • make sure thumb WITH hand

  • Angulation 10-15° toward elbow, CHANGE SID from 40 to 37

How do you maintain 40 SID with angulation?

For every 5 degree tube turn, lower tube 1 inch

• ex: 10 degree angulation = change 40SID to 38 SID

AP Forearm

• Collimation: 5×15

• SID: 40

• Patient Position

  • Supinate hand

  • Shoulder, elbow, and wrist in same plane

• CR: ⏊ midpoint of forearm

• Notes:

  • no rotation

  • wrist joint parallel with DD

  • collimation light past elbow and wrist joints

  • don’t let pt straddle table, move table to pt

LAT Forearm

• Collimation: 5×15

• SID: 40

• Patient Position

  • Elbow flexed 90°

  • Shoulder, elbow, and wrist in same plane

• CR: ⏊ midpoint of forearm

• Notes

  • slide DD horizontal

  • 90° elbow (pinky on DD, thumb facing up)

  • lower shoulder so same plane as elbow/wrist

AP/PA Digits
*double check pic

• Collimation: 2×6

• SID: 40

• Patient Position

  • Pronate hand

  • Forearm on table

  • Spread digits

• CR: ⏊ MCP

• Note

  • Collimate to include the entire phalange and metacarpal

  • AP Thumb - Rotate in so fingernail on DD, thumb line up with long axis

  • PA Digits 2-5 - like PA hand

OBL Digits

*double check pic

• Collimation: 2×6

• SID: 40

• Patient Position

  • MCP joints 45° to DD

  • Forearm on table

  • Spread digits

• CR: ⏊ MCP

• Note

  • Collimate to include the entire phalange and metacarpal

  • Thumb: no need 45°, just palm on table and rotate wrist so thumb align with forewarm

  • Digits 2-5: regular OBL hand

LAT Digits

*double check pic

• Collimation: 2×6

• SID: 40

• Patient Position

  • MCP joints 90° to DD

  • Forearm on table

  • Fan digits

• CR: ⏊ MCP

• Note

  • Collimate to include the entire phalange and metacarpal

  • Thumb: PA Hand, rotate outwards, roll in 2-5 digits until thumb lateral

    • marker inside thumb (anterior)

  • 2nd and 3rd digit: finger out, rotate inwards wrist

  • 4th: karate, finger bend in, no rotate

  • 5th: fist, pinky out, no rotate

AP Elbow

• Collimation: 5×9

• SID: 40

• Patient Position

  • Supinate hand

  • shoulder, elbow, wrist in same plane

• CR: ⏊ elbow joint

• Note:

  • raise table

OBL Elbow (Medial)

• Collimation: 5×9

• SID: 40

• Patient Position

  • Elbow rotated 45°

  • Shoulder, elbow, and wrist in same plane

• CR: ⏊ elbow joint

• Note:

  • raise table

  • AP elbow, then turn palm prone

OBL Elbow (lateral)

• Collimation: 5×9

• SID: 40

• Patient Position

  • Elbow rotated 45°

  • Shoulder, elbow, and wrist in same plane

• CR: ⏊ elbow joint

• Note:

  • raise table

  • AP Elbow, rotate arm out (pt bend awkwardly)

LAT elbow

• Collimation: 5×9

• SID: 40

• Patient Position

  • Elbow flexed 90°

  • Shoulder, elbow, and wrist in same plane

• CR: ⏊ elbow joint

• Note:

  • raise table

  • make sure hand karate position

  • marker anterior

Partial Flexion Proximal Forearm Elbow

• Collimation: 5×9

• SID: 40

• Patient Position

  • Forearm on table

• CR: ⏊ elbow joint

• Note:

  • AP elbow, forearm on table

  • prob have pt stand

Partial Flexion Distal Humerus Elbow

• Collimation: 5×9

• SID: 40

• Patient Position

  • humerus on table

• CR: ⏊ elbow joint

• Note:

  • AP elbow, humerus on table

AP elbow vs partial flexions?

If pt can fully extend elbow → AP elbow

If cannot → partial flexion proximal forearm + distal humerus

AP Foot

• Collimation:

• SID:

• Patient Position

  • 
    

• CR:

• Note:

  • 
    

OBL Foot

• Collimation:

• SID:

• Patient Position

  • 
    

• CR:

• Note:

  • 
    

LAT Foot

• Collimation:

• SID:

• Patient Position

  • 
    

• CR:

• Note:

  • 
    

AP Ankle

• Collimation:

• SID:

• Patient Position

  • 
    

• CR:

• Note:

  • 
    

OBL Ankle (45 degree)

• Collimation:

• SID:

• Patient Position

  • 
    

• CR:

• Note:

  • 
    

OBL Ankle (Mortise)

• Collimation:

• SID:

• Patient Position

  • 
    

• CR:

• Note:

  • 
    

LAT Ankle

• Collimation:

• SID:

• Patient Position

  • 
    

• CR:

• Note:

  • 
    

AP Tib/Fib

• Collimation:

• SID:

• Patient Position

  • 
    

• CR:

• Note:

  • 
    

LAT Tib/Fib

• Collimation:

• SID:

• Patient Position

  • 
    

• CR:

• Note:

  • 
    

Axial Calcaneus (Os Calcis)

• Collimation:

• SID:

• Patient Position

  • 
    

• CR:

• Note:

  • 
    

LAT Calcaneus (Os Calcis)

• Collimation:

• SID:

• Patient Position

  • 
    

• CR:

• Note:

  • 
    

AP Knee

• Collimation:

• SID:

• Patient Position

  • 
    

• CR:

• Note:

  • 
    

OBL Knee (lateral)

• Collimation:

• SID:

• Patient Position

  • 
    

• CR:

• Note:

  • 
    

OBL Knee (medial)

• Collimation:

• SID:

• Patient Position

  • 
    

• CR:

• Note:

  • 
    

LAT Knee

• Collimation:

• SID:

• Patient Position

  • 
    

• CR:

• Note:

  • 
    

PA Axial Knee (Camp Coventry, Tunnel, Notch)*

• Collimation:

• SID:

• Patient Position

  • 
    

• CR:

• Note:

  • 
    

Sunrise Patella (Tangential) (Settegast)

• Collimation:

• SID:

• Patient Position

  • 
    

• CR:

• Note:

  • 
    

Merchant Patella (Tangential)

• Collimation:

• SID:

• Patient Position

  • 
    

• CR:

• Note:

  •