Toes, Foot, Heel, & Ankle

What does patient prep entail for toe/foot/ankle/heel procedures?

removing any socks, toe rings, etc.

What are some ways you can get unwanted digits out of superimposition during toe images?

tape, sponges, tongue depressors

Where do you place your marker on all toe/foot/ankle/heel images?

lateral or anterior

What size IR is typically used for toe/foot/ankle/heel procedures?

10×12

What is the Aurora routine for toes?

AP, oblique, lateral

An AP image could also be called a ___ image

DP (dorsoplantar)

How should patient be positioned for an AP/DP toe?

• supine position

• knee flexed

• plantar surface flat on the IR

• unsuperimpose other digits if needed

How should the CR be for an AP/DP toe?

10^o to 15^o cephalic angle directed to MTP joint of interest (or wedge placed under foot or IR and perpendicular CR)

What does an AP/DP toe image demonstrate? (film eval)

• digit of interest and distal ½ of metatarsal

• open interphalangeal and MTP joints

• equal concavity

• L/R marker and digit # marker

How should patient be positioned for an AP/DP oblique toe?

• supine position

• knee flexed

• plantar surface on IR with foot and leg rotated 30-45 degrees

  • medial rotation for toes 1, 2, & 3

  • lateral rotation for toes 4 & 5

• unsuperimpose other digits

How should the CR be for an AP/DP oblique toe?

perpendicular to MTP joint of interest

What does an AP/DP oblique toe image demonstrate? (film eval)

• digit of interest and distal ½ of metatarsal

• open interphalangeal and MTP joints

• concavity (more on one side)

• L/R marker and digit # marker

How should patient be positioned for a lateral toe?

• lying recumbent

• place either lateral or medial surface of foot on IR

  • medial surface down for toes 1, 2, (3)

  • lateral surface down for toes (3), 4, 5

• unsuperimpose other digits

How should the CR be for a lateral toe?

1st toe: perpendicular to IP joint

2nd-5th toes: perpendicular to PIP joint

What does a lateral toe image demonstrate? (film eval)

• lateral view of phalanges and interphalangeal joints free of superimposition from other toes

• no rotation

• L/R marker and digit # marker

Explain patient positioning and CR for sesamoid bone images

• prone position

  • dorsiflex foot to form 15-20^o angle from vertical

• supine position

  • leg extended

  • dorsiflex foot

• CR

  • projection is tangential to first MTP joint

  • perpendicular to IR

What does a sesamoid image demonstrate? (film eval)

sesamoids in profile free of superimposition

What is an Aurora foot routine?

AP, oblique, lateral

How should patient be positioned for an AP/DP foot?

• supine

• flex knee

• plantar surface flat on IR

How should the CR be for an AP/DP foot?

• 10^o cephalic angle (15^o for high arch, 5^o for low arch)

• entering at the base of the 3rd metatarsal

Why is an AP/DP foot image taken with a 10^o angle?

reduces foreshortening of metatarsals and opens MTP joints

What does an AP/DP foot image demonstrate? (film eval)

• phalanges through talus

• no rotation

  • base of metatarsals superimposed

  • equal concavity

How should patient be positioned for an oblique foot?

• supine

• flex knee

• rotate leg medially 30-40^o

  • dorsal surface should be parallel to IR

How should the CR be for an oblique foot?

perpendicular to the base of the 3rd metatarsal

What does an oblique foot image demonstrate? (film eval)

• open joint all around cuboid

• visible sinus tarsi

• visible tuberosity of 5th MT

• 3rd-5th metatarsals free of superimposition

Which MT is the most commonly fractured?

5th

Which projection of the foot demonstrates the most metatarsals unsuperimposed?

medial oblique

Explain the lateral oblique foot image (not done at Aurora)

• rotate foot 30^o laterally

• demonstrates interspaces between 1st and 2nd MT

• demonstrates 1st and 2nd cuneiforms and navicular

How should patient be positioned for a lateral foot?

• supine

• flex knee

• drop leg to affected side

  • lateral surface against IR

  • plantar surface perpendicular to IR

  • mediolateral projection

• dorsiflex foot

How should the CR be for a lateral foot?

perpendicular to the level of the base of the 3rd MT/medial cuneiform

What does a lateral foot image demonstrate? (film eval)

• open tibiotalar joint

• 2” of distal tib/fib with fibula superimposed by posterior tibia

• foot dorsiflexed

• distal metatarsals superimposed

Explain the lateromedial foot projection

• considered a “true lateral”

• turn pt onto unaffected side

  • medial side of foot against IR

  • plantar surface perpendicular to IR

• dorsiflex foot

• uncomfortable for pt

• CR perpendicular to base of 3rd MT

What is an Aurora ankle routine?

AP, Mortise, lateral

How should patient be positioned for an AP ankle?

• leg extended

• no rotation of leg

• dorsiflex foot

  • ensures calcaneus will not obscure the joint space

How should the CR be for an AP ankle?

perpendicular midway between malleoli

What does an AP ankle image demonstrate? (film eval)

• ankle joint, 1/3 of distal lower leg, and upper portion of talus visible

• distal fibula overlapped on tibia and talus

• tibiotalar joint space

How should patient be positioned for a Mortise ankle?

• leg fully extended

• dorsiflex foot

• rotate leg and foot 15-20^o medially

  • intermalleolar plane is parallel to IR

How should patient be positioned for an oblique ankle? (not in Aurora routine)

• leg fully extended

• dorsiflex foot

• rotate leg and foot 45^o medially

What does a Mortise ankle image demonstrate? (film eval)

all 3 sides of Mortise joint should be visible

What does an oblique ankle image demonstrate? (film eval)

distal tibiofibular joint

How should patient be positioned for a lateral ankle?

• turn patient onto affected side

  • mediolateral projection

• dorsiflex foot

How should the CR be for an LAT ankle?

perpendicular at medial malleolus

What does a lateral ankle image demonstrate? (film eval)

• true lateral view of distal 1/3^rd tibia, fibula, tibiotalar joint, and tarsus

• fibula should be over posterior half of tibia

• open tibiotalar joint

• include entire heel and 5th tuberosity

Explain the routine for a trauma foot

AP: build up IR and angle CR to it

Oblique: put a 30-40^o tube angle toward midline

Lateral: do a shoot thru

Explain the routine for a trauma ankle

AP: do a shoot thru

Oblique: put a 15-20^o tube angle toward midline

Lateral: do a shoot thru

What is the Aurora routine for calcaneus?

tangential and lateral

How should patient be positioned for a tangential calcaneus?

• supine with leg fully extended

• dorsiflex foot

  • to place plantar surface perpendicular to IR

• may need device to hold foot

How should the CR be for a tangential calcaneus?

40^o cephalic angle entering plantar surface at level of base of 3rd MT

What does a tangential calcaneus image demonstrate? (film eval)

• axial projection of calcaneus

• open talocalcaneal joint

• shows potential medial/lateral displacement

Not dorsiflexing the foot enough in a tangential calcaneus procedure can cause ___

foreshortening (on the image)

Dorsiflexing the foot too much in a tangential calcaneus procedure can cause ___

elongation (on the image)

How should patient be positioned for a lateral calcaneus?

• lateral surface of foot against IR

• dorsiflex foot

How should the CR be for a lateral calcaneus?

perpendicular 1’’ distal to medial malleolus

What does a lateral calcaneus image demonstrate? (film eval)

• lateral projection of

  • heel

  • talocalcaneal joint

  • sinus tarsi

  • calcaneocuboid joint

• potential bone spurs

What is the Aurora weight bearing foot routine?

AP, oblique, lateral

Explain the AP weight bearing foot procedure

• pt standing on IR with affected foot forward

  • opposite foot step back

• CR angled 15^o cephalically

• annotate image with “weight bearing”

Explain the medial oblique weight bearing foot procedure

• pt standing with affected foot on IR

• 40^o - 45^o lateromedial CR angle

• annotate image with “weight bearing”

• tube angle causes distortion

• cuboid is the main focus

Explain the lateral weight bearing foot procedure

• patient standing on stairs with feet on opposite sides of IR

• CR perpendicular to base of 3rd MT

• demonstrates lateral view of bones in weight bearing position

• demonstrates structural status of longitudinal arch of foot

What is the Aurora weight bearing ankle routine?

AP, mortise, lateral

Explain the weight bearing ankle procedures

• pt standing upright

• same centering and angles as regular ankles

• lateral ankle is centered at 1” proximal to lateral malleolus

Explain the weight bearing tangential calcaneus view

• pt standing on IR with affected heel back behind them

• 45^o angle entering at talocrural joint

Explain the weight bearing lateral calcaneus view

• pt standing on stairs with feet on opposite sides of IR

• step unaffected leg forward to avoid leg shadow

• CR entering at lateral malleolus

Explain the ankle stress views

• leg fully extended

• dorsiflex foot

• plantar surface turned medially for inversion and laterally for eversion

  • doctor or rad will do the movement of the ankle

• CR perpendicular between malleoli

• demonstrates a tear/rupture of ligament by widening of joint space of affected side

What technique is used for toes?

60 kVp @ .8 - 1 mAs

What technique is used for AP and oblique foot?

60 kVp @ 1.2 - 1.6 mAs

What technique is used for lateral foot?

60 kVp @ 2 - 2.5 mAs

What technique is used for ankle?

60 kVp @ 2 - 2.5 mAs

What technique is used for lateral heel?

60 kVp @ 2.5 mAs

What technique is used for tangential heel?

60 kVp @ 4-5 mAs