Trauma Radiographic Procedures

Common Initial Trauma Exams

• XTL C-Spine

• AP CXR

• AP ABD/Pelvis

• C-Spine Routine

• Lumbar Spine

• Skull

• Lower Extremities

• Upper Extremities

• Note: The exams listed are initial exams. More comprehensive exams, which include full routines, and additional exams of the body may be ordered by the physician if deemed necessary. You may have also noticed that the exam of the skull is not included. In larger trauma centers, examination of the cranium is usually completed by CT because of its availability. However, some trauma centers still obtain skull radiographs, and most facilities that do not have CT available will perform skull exams, therefore the radiographer must be knowledgeable regarding skull radiography

Lateral C-Spine

• Must be done first

• Attending physician must review and clear

• Move patient’s head and neck as little as possible

• Patient supine on backboard in cervical collar - Dorsal Decubitus Position

• Patient should relax shoulder as much as possible and look straight ahead

• Vertical IR in holder and centered at C4

• Central ray is horizontal and perpendicular to IR

• Central ray enters MCP at level of CR

• 72” SID

Cervical Thoracic

• If all seven vertebrae, and C7-T1 are not clearly visible on the lateral, a swimmers must be performed

• Do not move patient’s arms without permission from physician

• Patient supine on backboard in cervical collar - Dorsal Decubitus Position

• Ask patient to raise arm opposite the x-ray tube overhead

• Relax shoulder closer to x-ray rube - do not force

• Vertical IR centered just above jugular notch

• Horizontal CR centered to C7-T1 interspace and midcoronal plane

• If shoulder can’t separate a 3-5 degree caudal angle may be used

• 40” SID

X Table Lateral C-Spine

X Table Lateral Cervicothoracic

AP Axial C-Spine

• Patient is supine

• Usually immobilized with collar and spine board

• Place IR under spine board, if present, centered to C4

• Head and shoulder without rotation

• Ask patient to look straight ahead

• Do not rotate head

• CR directed 15-20 degrees cephalic to enter MSP and C4

• Image demonstrates C3-T2, including all soft tissues

• If backboard is present, unavoidable artifacts may be seen

AP Oblique C-Spine

• Patient supine on backboard in cervical collar - Dorsal Decubitus Position

• Head and shoulders without rotation. Ask patient to look straight ahead. Do not rotate head

• CR has double angle

• 45 lateralmedially and 15-20 cephalic

• CR enters slightly lateral to MSP at C4

AP Axial C-Spine

AP Oblique C-Spine

Open Mouth C-Spine

• If condition allows have patient open mouth as far as possible without moving head or neck

• CR may be angled if needed to parallel the line from lower margin of upper teeth to base of skull (mastoid tips)

C-Spine Fuchs

• Cervical spine remains neutral in collar

• Central ray is angled to match MML

• Angle CR cephalic 35-40 degrees as needed to align CR parallel to the MML

• CR enters just beneath mentum of mandible

• Demonstrates dens within foramen magnum when open mouth not possible

Thoracic and Lumbar

• Always perform dorsal decubitus positions before AP

• Vertical grid IR below level of tabletop

• Horizontal beam

• Top of IR 1.5-2” above shoulders for thoracic. Centered to T7. 3-4” inferior to jugular notch

• Centered to level of iliac crests for lumbar L4-L5

• Laterals centered MCP

• AP centered MSP

• Have patients cross arm on anterior chest or above head

Chest

• Supine position used if general survey image of chest desired

• Check for need to demonstrate air-fluid levels

  • If air-fluid level are suspected, use dorsal decubitus position

  • If patient’s condition permits, lateral decubitus position with patient lying on affected side will also show air-fluid levels

• Obtain help to lift patient for IR placement

• Mark entrance and exit wounds, if present

• Top of IR placed about 1.5-2” (3.8-5 cm) above shoulders

• CR MSP and a level 3” below jugular notch

• Angle 3-5 degrees caudal to match long axis of sternum

• Arms abducted

• MCP parallel to IR

• Use maximum SID to reduce heart magnification

• Exposure at the end of deep inhalation

AP Abdomen

• If transfer to x-ray table is not possible, obtain lift help for IR placement

• IR centered to MSP at level of iliac crests

• Check for possibility of fluid accumulation in abdominal cavity

• Affects exposure factors

• Requires close monitoring of patient for status change during procedures

• Mark entrance and exit wounds, if present

• Align shoulders and hips in same plane

• MCP parallel to table

• CR perpendicular to center of IR

• Image demonstrates entire abdomen with pubic symphysis visible at lower border

• Instruct patient to exhale and hold their breath

Decubitus Abdomen

• Verify that patient movement is possible

• Left lateral decubitus position shows free air

• If fluid accumulation is of interest, the side down must be elevated off stretcher

• Carefully and slowly turn patient

• MCP is vertical

• Center IR 2” above the crests to include diaphragm

• Instruct patient to exhale and hold their breath

Pelvis

• Pelvic fractures have a high risk of hemorrhage - pay close attention to patient for status change. Up to 50% of pelvic fractures result in death due to vascular damage and shock

• Obtain lift help for IR placement if transfer to x-ray table is not possible

• IR centered 2” (5 cm) above pubic symphysis or 2” (5 cm) below ASIS

• MCP parallel to IR

• Lower limbs usually not internally rotated in trauma cases

• Ensure arms are not in anatomy of interest

• CR perpendicular to center of IR

• Exposure made on suspended respiration

• Image demonstrates entire pelvis and proximal femora

• Femoral necks foreshortened

Axiolateral Hip Danelius - Miller Method

• Cross table lateral

• Do not attempt to internally rotate affected limb

• Patient supine

• Position grid IR parallel with femoral neck centered to most prominent portion of greater trochanter, level midline of hip

• Obtain appropriate assistance to elevate non injured hip

• CR is horizontal and perpendicular to the IR at level of femoral neck

Modified Axiolateral Hip Clement Nakayama Method

• Used for patient with suspected bilateral hip fractures

• Position a grid IR aligned parallel to the femoral neck at a height to place the center of the hip on the IR

• Top of the grid IR back 15 degrees

• Do not attempt internal rotation of limb

• CR 15 degrees posteriorly and aligned to femoral neck and grid IR

Lateral Skull

• Patients with head trauma are often referred to CT first

• When x-rays are ordered, a general survey requires AP and Lateral projections

• Lateral projection uses dorsal decubitus position

• Lateral cranium

  • Elevate head on radiolucent sponge

    • Only after ensuring C-spine injury has been ruled out

  • Place vertical IR centered to cranium

  • Make sure interpupillary line is perpendicular to IR and MSP is vertical

  • Horizontal CR enters center of IR and patient at 2” (5 cm) above EAM

AP and AP Axial Reverse Caldwell Skull

• Demonstrate frontal cranium

• OML and MSP perpendicular to IR

• CR perpendicular to nasion AP

• CR 15 degrees cephalic for AP Axial Reverse Caldwell

• Image Magnified

AP Axial Towne Method Skull

• Demonstrate posterior cranium

• Angled 30 degrees caudal to OML

• Angled 37 degrees caudal to IOML

• Central ray passes through EAM exits foramen magnum

OML Positioning with patient’s with C-Collar: AP 0 Degrees to OML

• Angle CR parallel to OML: With a patient in a c-collar, this often occurs approximately 10-15 degrees caudal, but each patient and situation will be different

• Center CR to glabella; then center IR to projected CR

OML Positioning with patient’s with C-Collar: AP 15 degree reverse Caldwell projection

• Angle CR 15 degree cephalic to OML: To accomplish this, first find the OML on the patient; this varies in patients in cervical collars with the neck extended. Then angle the CR 15 degrees cephalic to the patient’s OML, which will result in appearance of the CR close to a perpendicular beam relationship to the patient and the IR.

• Center CR to nasion; then center IR to projected CR

OML Positioning with patient’s with C-Collar: AP Axial Towne Projection

• Angle CR 30 degrees caudal to OML or 37 degrees caudal to IOML. Once again, note that a patient in a c-collar with the neck extended will have OMLs and IOMLs that vary from the conventional parallel and perpendicular relationships formed through routine positioning

• Center CR to pass midway between EAMs and exiting the foramen magnum. This centers CR to MSP 2 ½ “ (6 cm) above superciliary arch; then center IR to projected CR

Facial; Acanthioparietal - Reverse Waters

• This projection best visualizes facial bone structures and the maxillary region by projecting the maxilla and maxillary sinuses above the petrous ridges

• Angle CR cephalic as needed to align CR parallel to MML

• Center CR to acanthion and then center IR to projected CR

Facial; Optional Modified Acanthioparietal Reverse Waters

• This projection best demonstrates the floor of the orbits and provides a view of the entire orbital rims. Petrous ridges are visualized in midmaxillary sinus region

• Angle CR cephalic as needed to align CR parallel to the lipsmeatal line (LML)

• Center CR to acanthion; then center IR to prjected CR

Facial; Lateral

• Horizontal beam is essential for visualization of intracranial air fluid levels

• Center CR to the zygoma, midway between the outer canthus and EAM

• Place lengthwise IR closest to the side of interest and center to the CR

• Head placement on table because don’t need back of skull

Upper and Lower Limbs

• Only move the patient when absolutely necessary and get assistance to do so

• The patient should be moved only after it is determined by qualified medical personnel confirms that it is safe to do so

• When moving a trauma patient, all injured limbs should be supported to prevent further injury

• Two projections of each body part should be taken, They should be a 90 degree angles, or as near to that as possible

• A horizontal beam will be necessary in many cases

• If the patient is conscious, an explanation should be given before they are moved

  • This helps the patient prepare for the move and they may be able to assist to minimize the pain

• When long bones are being imaged, both joints must be included

• If it is necessary to use two projections, the joint and the point of injury should be on one image, and the second joint should be radiographed separately

• Images similar to routine radiographs can be obtained with little or no movement of the patient, it the normal central ray entrance and exit points are maintained through tube angulation