Rad 112 Exam 4

Bones of the foot (in order)

Phalanges (distal phalanx, middle phalanx, proximal phalanx), Metatarsals (body, base, tuberosity), Tarsals

How many phalanges are there?

5

How many metatarsals are there?

5

How many tarsals are there?

(7)/26

Joints of the first digit (in order from distal to proximal)

Interphalangeal (IP joint), Metatarsophalangeal (MTP joint)

Joints of the 2-5 digits

Distal interphalangeal (DIP), Proximal interphalangeal (PIP), Tarsometatarsal (TMT)

Where is the central ray joint of the foot?

3rd TMT joint

Sesamoid Bones

• Embedded in tendons

• Present near joints

• Plantar surface of the foot

Tarsal bones (distal to proximal, left to right)

• 3 cuneiforms

• Cuboid

• Navicular

• Talus

• Calcaneus

Lateral ankle position

Distal fibula over posterior half of tibia on a true lateral

What is in view on a lateral ankle?

• Fibula

• Tibia

• Anterior tubercle

• Lateral malleolus

• Talus

Whats in view for a axial ankle joint?

• Tibial plafond

• Tibia

• Fibula

• Medial malleolus

• Lateral malleolus

What is the distance between the Coronal and Intermalleolar plane on an axial ankle?

15-20 degrees

What is the longest and strongest bone?

Femur

What is the angle of the distal medial and lateral condyle in a femur posterior view?

5-7 degrees

What must be imposed for a true lateral knee?

Condyles

Articular Capsule

Knee arthrogram

Joints of the lower limb (proximal to distal)

• patellofemoral

• knee

• proximal tibiofibular

• distal tibiofibular

• ankle

• intertarsal

• tarsometatarsal

• metatarsophalangeal

• interphalangeal

All joints except ____ are synovial/ diarthrodial (freely moveable)

Distal tibiofibular

Distal tibiofibular

Fibrous/ Amphiarthrodial (slightly moveable)

Interphalangeal (IP)

Ginglymus (hinge)

Metatarsophalangeal (MTP)

Condyloid (elliptical)

Intertarsal

Plane (gliding)

Ankle

Sellar

Femorotibial

Bicondylar

Patellofemoral

Plane (gliding)

Proximal tibiofibular

Plane (gliding)

Surfaces of the foot

• Dorsiflexion

• Plantar flexion

• Inversion (varus)

• Eversion (valgus)

Dorsiflexion of the foot

Upwards

Plantar flexion of foot

Downwards

Inversion of foot (varus)

Inwards

Eversion of foot (valgus)

Outwards

Chondromalacia patella

Abnormal alignment with osteoarthritis

Gout

• bone erosions

• urate crystals in tophus

• synovium

Lisfranc injury

Midfoot

Osgood- Schlatter Disease

Inflammation of the patellar ligament

Osteoarthritis

Degeneration of joint cartilage and the underlying bone (joint disease)

Osteomalacia-Soft bones Rickets (Children)

Soft and weak bones due to inadequate mineralization

Exostosis (osteochondroma)

• benign neoplastic bone lesion that causes overproduction of bone

• usually at joint spaces (knee)

Osteogenic Sarcoma

• Highly malignant bone tumors

• Usually seen in long bones

Paget’s Disease (osteitis deformans)

• Chronic bone disorder characterized by excessive breakdown and regrowth in the affected bone

• Cotton wool appearance

Reiter’s syndrome

Erosion at Achilles tendon insertion area

AP Toes (Digits)

• CR 10°-15° posterior to MTP joint

Routine

• AP

• Oblique

• Lateral

AP Second Digit

• 15° wedge, CR perpendicular to IR

AP Toes

• Digits and minimum of distal ½ of metatarsal demonstrated

• No overlap of soft tissues

• IP and MTP joints appear open

• Optimal exposure factors

AP Oblique

• CR perpendicular to MTP joint

• Medial rotation

• Lateral rotation

• 30-45 degrees of rotation

Oblique Toes

• Digits and minimum of distal ½ of metatarsal demonstrated

• IP and MTP joints appear open

• Increased concavity on one side of shaft

• Heads of metacarpals not overlapped

• Optimal exposure factors

Lateral First Digit

• Lateromedial

• CR to IP

• Routine

  • PA

  • Oblique

  • Lateral

Mediolateral Fourth Digit

• CR to PIP

Routine

• PA

• Oblique

• Lateral

Lateral toes

• Digits presented in true lateral position

• IP and MTP joints appear open

• Digit free of superimposition

• Optimal exposure factors

Tangential Sesamoids

• Sesamoids free of superimposition

• Minimum of three metatarsals seen

• Optimal exposure factors

Foot Routine

Routine

• AP

• Oblique

• Lateral

Special

• AP and lateral weight

bearing

AP Foot

• CR 10° angled posteriorly

• CR to base of 3rd MT

• Entire foot visualized

• No rotation of metatarsals

• MTP joints generally open

AP Oblique Foot

• 30°-40° medial rotation

• CR to base of third MT

Medial Oblique Foot

• Entire foot visualized

• Third through fifth metatarsals free of superimposition

• Tuberosity demonstrated at base of fifth metatarsal

Alternate Lateral Oblique

• 30° lateral rotation

• CR to base of third MT

• Demonstrates base of first MT and medial tarsals

Mediolateral Foot

• True lateral

• CR to midcuneiform (base of third MT)

Alternate Lateromedial Foo

• True lateral

• CR to midcuneiform (base of third MT)

Lateral Foot

• Entire foot visualized

• Tibiotalar joint demonstrated

• Metatarsals superimposed

AP and Lateral Weight Bearing

• Horizontal beam

• CR 15 posterior

• CR to base of MTs

AP

• Bilateral feet demonstated

• Phalanges and MTs not rotated

Lateral

• Entire foot demonstrated

• Plantar surfaces of MTs superimposed

Plantodorsal (Axial)

• CR 40° cephalad from long axis of foot (when

long axis is in a true vertical relationship to IR)

• CR to base of third MT to emerge posterior to

malleoli

Plantodorsal Calcaneus

• Entire calcaneus visualized

• No rotation

Calcaneus-Mediolateral

CR 1 inch (2.5 cm) inferior to medial malleolus

Lateral Calcaneus

• Calcaneus and talus visualized

• No rotation

Ankle Routines

Routine

• AP

• AP mortise

• 45° oblique

• Lateral

AP Ankle

• AP

• CR midway between malleoli

• Distal ⅓ of tibia and fibula demonstrated

• Proximal ½ of metatarsals included

• Medial and superior aspect of ankle joint open

AP Mortise

• Intermalleolar line parallel to IR

• CR midway between malleoli

• Entire ankle mortise open

• Distal ⅓ of tibia and fibula demonstrated

• Proximal ½ of metatarsals included

AP 45° Oblique

• 45° medial rotation

• CR midway between malleoli

• Distal tibiofibular joint open

• Distal ⅓ of tibia and fibula demonstrated

• Proximal ½ of metatarsals included

Lateral Ankle CR

Mediolateral, Alternate lateromedial (Centered to Medial Malleolus)

Lateral ankle

• Entire talus and calcaneus visualized (need navicular, cuboid, and base of 5th

metatarsal)

• Lateral malleolus superimposed over posterior half of tibia

AP Stress

• Inversion stress- Varus

• Eversion stress- Valgus

AP Stress Ankle

• Distal aspect of tibia and fibula demonstrated

• Ankle joint to center of collimation field

AP Lower Leg

• True AP position

• CR to midpoint of leg

AP leg

• Entire tibia and fibula demonstrated

• Knee and ankle joints demonstrated

• Partial superimposition of fibula and tibia at proximal and distal ends

Mediolateral Leg

CR to midpoint of leg

Routine

• AP

• Lateral

Lateral Leg

• Entire tibia and fibula demonstrated

• Knee and ankle joints demonstrated

• Proximal head of fibula superimposed by tibia

• Distal fibula superimposed over posterior half of tibia

Knee (routine)

• AP

• Oblique

• Lateral special

• AP weight bearing

• PA axial weight bearing (Rosenberg method)

AP Knee

• CR parallel to tibial plateaus

• CR ½ inch (1.25 cm) distal to apex of patella

• Femorotibial joint space open

• Knee joint centered to collimation field

• Articular facets profiled

AP Medial Oblique

• 45° medial rotation

• CR ½ inch (1.25 cm) distal apex of patella

AP Lateral Oblique

• 45 ° lateral rotation

• CR ½ inch (1.25 cm) distal to patella

Oblique Knee

• Proximal tibiofibular joint open

• Fibula superimposed over midtibia

• Medial oblique

• Lateral oblique

Mediolateral

• CR 5°-7° cephalad

• (to superimpose femoral condyles)

• CR 1 inch (2.5 cm) distal to medial epicondyle

• Flex knee 20°-30°

Lateral Knee

• Patella in profile (indicates no rotation)

• Patellofemoral joint space open

• Femoral condyles superimposed

AP Weight Bearing

• CR perpendicular

• Knee joints centered to collimation field

• No rotation of knees

• Joint spaces open

PA Axial Weight-Bearing Bilateral Knee Projection (Rosenberg Method)

Routine

• AP

• Oblique

• Lateral

• Special

• AP weight bearing

• PA axial weight bearing (Rosenberg method)

Intercondylar Fossa

Routine

• PA axial projections:

• Camp-Coventry method

• Holmblad method Special

• AP axial

PA Axial Projection

• Intercondylar fossa in profile

• No rotation

• Articular facets and intercondylar eminence well visualized

Holmblad Method

• Lean forward 20°-30°

• CR perpendicular to IR

• CR centered to popliteal crease

• Chair

• Wheelchair

AP Axial (Béclere Method)

• Knee flexed 40°-45°

• CR centered ½ inch(1.25 cm) distal to apex of patella

• CR perpendicular to lower leg

Patella and Patellofemoral Joint

Routine

• PA

• Lateral

• Tangential

• Merchant

• Inferosuperior

• Hughston

• Settegast

• Superoinferior sitting tangential method -Hobbs

PA Patella

• CR perpendicular to mid-patella area (popliteal crease)

• Rotate leg internally 5 degrees to align interepicondylar line parallel to IR

• Patella centered to collimation field

• No rotation

Mediolateral Patella

• CR perpendicular to mid-femoropatellar joint

• Flex only 5°-10°

Lateral Patella

• Patella and knee joint in center of collimation field

• Patella in true lateral

Merchant Bilateral Method

• Knee flexed 40°

• CR angled 30° from horizontal

Tangential Patella—Merchant Method

• Intercondylar sulcus and patella visualized

• Femoropatellar joint spaces open

Inferosuperior Projection

• 40°-45° flexion of the knees

• CR (tangential)10°-15° from lower legs

Hughston Method

• Knee flexed 55°

• CR (tangential) 45° cephalad

Settegast Method

• 90° flexion

• CR (tangential)15°-20° from lower leg

• Overflexion of knee draws patella into

  intercondylar sulcus