Radiology of Positioning and Applied Anatomy (For Students and Practitioners) GS Garkal
INDEX
ABDEFHIKLMNOPRSTUW
A
Abdomen 96
anteroposterior view 96
erect view 97
KUB—anteroposterior view 96
lateral view 98
prone oblique view 97
Abdomen 99
for pregnancy 99
anteroposterior view 99
prone oblique view 99
Acromioclavicular joint 127
AP scapular plane position 128
central ray 128
exposure settings 129
PA axial oblique position 127
central ray 128
exposure settings 128
Acromioclavicular joint 43
Ankle joint 54
ankle joint (lateral view) 56
anteroposterior view 54
right ankle—AP view 55
right ankle—lateral view 56
Arm (Humerus) 39
anteroposterior view 39
central ray 39
exposure settings 39
Atypical orthopedic radiographic techniques 119
B
Bronchography 160
contrast media 161
technique 162
preparation 162 route used 162
Calcaneum 53
axial view 53
central ray 54
exposure settings 54
lateral view 53 central ray 53
exposure settings 53
left calcaneum axial view 54
Chest 76
antero-oblique view 78
anterolateral portion of ribs 90
above diaphragm 90
anteroposterior 85
apicogram 80
chest lateral decubitus position 94
for ribs—anteroposterior view 81
lateral portion of ribs 90
through diaphragm 90
lateral view 76
lateroposterior portion of ribs 87
through diaphragm 87
posterior portion of ribs 83
above diaphragm 83
through diaphragm 83
posteroanterior view 76
ribs lateral-oblique view 82
Clavicle 45
anterioposterior 45
posterioanterior view 45
central ray 45
exposure settings 45
Common radiological investi- gations 137
techniques of 137
D
Double contrast barium enema 155
technique 155
cleansing the colon 155
instillation of barium 156
E
Elbow 131
axial lateral position 131
central ray 131
exposure settings 132
Elbow joint 37
anteroposterior view 37
central ray 37
exposure settings 37
lateral view 37
central ray 38
exposure settings 38
Esophagus 152
F
Fibula 132
oblique view 132
central ray 133
exposure settings 133
Fingers 30
posteroanterior view 30
central ray 31
exposure settings 32
Foot 49
anteroposterior (AP) 49
greater toe (lateral view) 52
left foot (oblique view) 50
right foot—anteroposterior view 50
toe (oblique view) 52
toes (anteroposterior view) 51
Forearm 35
anteroposterior view 35
central ray 36
exposure settings 36
lateral view 36
exposure factors 37
H
Hand 29
posteroanterior view 29
central ray 29
exposure settings 29
Hip 70
anteroposterior view 70
hip joint (lateral view) 72
hip joint—lateral view (frog posi- tion) 72
right hip—AP view 71
Hysterosalpingography 156
technique 157
roentgenographic findings 158 fallopian tubes 158
uterus 158
I
Intravenous pyelography 139
normal appearance 140
cystogram 141
nephrogram 140
pyelogram 140
ureters 141
rapid sequence pyelography 142
standardized technique 140
K
Knee joint 58
anteroposterior view 58
intercondyloid space 61
knee joint (oblique view) 61
lateral view 59
L
Laryngopharynx 151
radiography of 151
barium swallow 151
Left wrist 34
lateral view 35
wrist bending position 35
radial deviation 35
ulnar deviation 35
Leg 57
anteroposterior view 57
lateral view 57
Lower extremity 49
M
Mastoid 16
central ray 16
exposure settings 16
Metacarpals 120
AP and PA oblique positions 120
central ray 120
exposure settings 121
Micturating cystourethography 142
male urethrography 143
anatomy 143
N
Nasal bone 27
lateral view 27
central ray 27
exposure settings 28
O
Optic foramen 17
central ray 17
exposure settings 20
lateral oblique view 20
P
Patella 66
axial (skylene) view 68
axial view 67
posteroanterior view 66
central ray 66
exposure settings 67
Patella 133
flexion lateral position 134
tangential position 133
Pelvis 73
lateral view 74
Plain radiography abdomen 137
normal plain abdomen 137
extraurinary shadows 139
plain film 138
optimal bowel preparation 137
Posthepatic bile-collecting system 143
radiography of 143
anatomy 143
intravenous cholangio- graphy 145
oral cholesystography 145
radiographic considerations 144
R
Radiological examination 146
of the heart 146
correct position 146
S
Sacrum 113
anteroposterior view 113
lateral view 114
oblique view (anterior) 116
sacrum and coccyx—lateral view 115
Scaphoid 121
PA axial ulnar flexion position 121
central ray 122
exposure settings 122
Scapula 129
lateral scapular plane position 129
central ray 130
exposure settings 130
Scapula 43
antero-oblique (AO) view 43
central ray 44
exposure settings 44
lateral view 44
Shoulder joint 124
AP axial position 124
central ray 124
Shoulder joint 40
anteroposterior view 40
central ray 41
exposure settings 41
Sialography 158
contrast media 159
radiography 160
technique 159
Sinography 158
technique 158
Skull 1
view 1
base 10
Caldwell 3
lateral 8
posteroanterior 1
Towne 6
Waters’ 13
Small intestine 154
Spine 101
cervical 101
anteroposterior view 101
cervical spine—lateral view 103
atlas and axis—anteropos terior 104
dorsal 105
anteroposterior view 105
lateral view 107
lumbar 108
anteroposterior view 108
lateral view 108
lumbosacral 111
anteroposterior view 111
lateral view 111
Spine 116
coccyx 116
anteroposterior view 116
lateral view 118
Sternoclavicular articulation 46
unilateral posterioanterior position 46
central ray 46
exposure settings 47
Styloid process 26
anteroposterior view 26
central ray 26
exposure settings 27
T
Temporomandibular (TM) joint 21
anteroposterior view 24
lateral view 21
central ray 22
exposure settings 22
orbit view 22
Thigh 68
anteroposterior view 68
lateral view 69
central ray 70
exposure settings 70
Thumb 119
PA stress projection 119
central ray 120
Exposure settings 120
Thumb 32
anteroposterior view 32
central ray 32
exposure settings 32
U
Upper extremity 29
Upper GI Tract 153
barium meal 153
W
Wrist 122
lateral positions 122
central ray 123
exposure settings 123
Wrist joint 33
lateral view 33
central ray 34
exposure settings 34
posteroanterior view 33
central ray 33
exposure settings 33
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1Radiology of Positioning and Applied Anatomy: (For Students and Practitioners)2
3Radiology of Positioning and Applied Anatomy: (For Students and Practitioners)
(Third Edition)
Editors GS Garkal MBBS, DMRD, MD Consultant Radiologist Janta X-ray Clinical Lab 4, Raja Garden New Delhi
4Published by
Jitendar P Vij
Jaypee Brothers Medical Publishers (P) Ltd
B-3 EMCA House, 23/23B Ansari Road, Daryaganj
Post Box 7193, New Delhi 110 002, India
Phones: 3272143, 3272703, 3282021 Fax: 011–3276490
E-Mail: jpmedpub@del2.vsnl.net.in
Visit our web site: http://www.clinichem.com
Branches
Radiology of Positioning and Applied Anatomy
(For Students and Practitioners)
© 2000, GS Garkal
All rights reserved. No part of this publication should be reproduced, stored in a retrieval system, or transmitted in any form or by any means: electronic, mechanical, photocopying, recording, or otherwise, without the prior written permission of the editor and the publisher.
This book has been published in good faith that the material provided by the editor is original. Every effort is made to ensure accuracy of material, but the publisher, printer and editor will not be held responsible for any inadvertent error(s). In case of any dispute, all legal matters to be settled under Delhi jurisdiction only.
First Edition: 1983
Second Edition: 1986
Third Edition: 2000
Publishing Director: RK Yadav
9788171797707
Typeset at JPBMP typesetting unit
Printed at Lordson Publishers (P) Ltd, C-5/19, R P Bagh, Delhi 110 007
5Preface to the Third Edition
The purpose of writing present revised edition of the book is to add few atypical orthopedic radiographic techniques which are quite often needed by orthopedic surgeons for the diagnostic purpose. Diagrammatic analysis of six views of skull has also been included in detail, so that radiographers/practitioners could themselves decide which view of skull to be taken for a particular disease.
In my personal opinion with inclusion of atypical orthopedic radiographic technique and detail diagrammatic study of skull, this revised edition will provide further help to the people, who are running X-ray clinics or interested in radiography.
I once again thank Mr Jitendar P Vij, Managing Director of Jaypee Brothers Medical Publishers for completion of this book.
GS Garkal6
7Preface to the First Edition
In accordance with the wishes of private practitioners this book has been written chiefly for the students who cannot do the diploma course of radiography, but are interested to work as radiographer in private X-ray clinics. I feel even the doctors and unit incharges who possess X-ray units, but are not radiologists can also be benefitted significantly.
I must admit that in the preparation of this book I have freely consulted various books and periodicals, to the authors of which I acknowledge my grateful thanks.
I also express my sincere thanks to the doctors and radiology staff of Janta X-ray and Clinical Lab, Raja Garden New Delhi for every possible assistance to facilitate the completion of book.
Before concluding, I further desire to acknowledge my great indebtedness to Mr Jitendar P Vij, Managing Director of Jaypee Brothers for all out support proofs.
GS Garkal
11Introduction  
X-RAY
X-rays are part of the so-called electromagnetic spectrum. Because of their short wavelength X-rays can penetrate materials which do not transmit light. They were discovered in 1895 by Wilhelm Conrad Roentgen who was a German Physicist.
X-rays are produced by a process which converts energy from one form into another. Fast moving electrons possess energy of motion and this becomes changed into radiant energy when such electrons are suddenly slowed down.
This conversion of energy takes place inside the device known as an X-ray tube. The basic features of an X-ray tube in operation must include the following:
  1. A source of beam
  2. A mean to put them into rapid motion across a space where there is nothing to impede them so that the rapid motion may be maintained.
  3. A mean to slow the electrons suddenly.
    In the X-ray tube the following actions take place:
    1. The source of electron is a heated filament, which is called the cathod or negative electrode of the X-ray tube. When the filament is hot the agitation of its molecules causes electrons to leave the wire and form a cloud in front of it.
    2. The mean to put the electrons in motion, is a high voltage applied across the X-ray tube, and the lack of impediment to their passage is ensured by making the electrons travel across a vacuum.
    3. The mean to slow the electrons is provided as might be expected by putting something in the way. Basically this is a metal plate and it is called the anode or positive electrode of X-ray tube. The area on the anode which is bombarded by the electrons is called the focal spot. This focal spot becomes source of X-ray radiation usually emitted by the X-ray tube.
    4. Since a vacuum must have a wall around it, the two electrodes of X-ray tube are sealed into a glass envelope.
      12
 
Properties of X-rays
  1. Invisible.
  2. Travel in a straight line.
  3. Rays are not affected by electrical or magnetic fields.
  4. X-rays travel at the speed of 186,000 miles per second, the same as light.
  5. X-rays have short wavelength (1/6000 of yellow light). This allows rays to penetrate matter in which light cannot penetrate.
  6. X-rays affect photographic emulsion.
  7. Able to ionize matter.
  8. Produce visible fluorescence and phosphorescence in certain material.
  9. Differentially absorbed matter.
  10. X-rays can liberate photoelectrons.
  11. X-rays are partially scattered by matter.
 
MAIN FACTORS IN RADIOGRAPHY
The prime object of a radiographer is to produce a good diagnostic film. A good skiagram should possess the following:
 
Definition
Detail is described as the degree of sharpness of the contour lines of the object, as visible on the skiagram. Sharpness depends upon the following:
  1. Focal spot–should be as small as possible.
  2. Distance from focal spot to the object–should be as long as practicable.
  3. Direct radiography–without intensifying screen produce better detail.
  4. No movement–during exposure on the part of object, film or focal spot.
    13
 
Distortion
There should be smallest possible degree of distortion in the form of simple enlargement (magnification).
True distortion is an unequal magnification between different planes of the object. This is due to malalignment of focal spot, the film or object parallel to the film.
 
Density
The density should be sufficient to delineate the object properly. Following are the factors which make total latent density on the skiagram:
  1. Primary X-ray radiation.
  2. Secondary and characteristic radiation.
  3. All X-ray films possess a small amount of background density which is a normal characteristic.
The density is mainly produced by primary radiation. The density of primary beam is governed by the following factors:
Kilovoltage (kV) Intensity of radiation becomes higher as kilovoltage is increased. The higher the kilovoltage the shorter and therefore more penetrating radiation emerges from tube.
Milliampere (mA) Quantity of radiation varies directly with current.
Exposure time (S) Quantity of radiation varies directly from time.
Distance Intensity varies as the inverse square of the distance.
Filtration Intensity is affected by total amount of filtration.
 
Contrast
The contrast should be sufficient to differentiate between shadows of different structures and shadows within the structures on the same film. The contrast is increased by using intensifying screen.
Factors which influence the contrast are as follows:
Intensifying screen It increases the contrast.
Kilovoltage Higher the kilovoltage lesser the contrast.
Fog film (Due to bad safelight, poor storage) high contrast is impossible.14
Development of film Overexposed and underdeveloped film produces less contrast film. The contrast of the film is accentuated by a reasonable increase in development time.
Finally a radiograph will appear to be the best quality when displayed on a good illuminator. The light should be of proper intensity and equally distributed over the whole viewing screen.
  1. The radiographic factors which are described in the subsequent chapters are calculated on a young man of approximately 70 to 75 kg weight and with a fresh developer and fixer solution. Appropriate adjustments of factors can be made with age, thickness of body, strength of developer and fixer, etc.
  2. In skull radiography planes and sutures are mentioned.
 
Planes
Midsagittal It divides the skull into right and left halves.
Vertical It passes through between the external auditory meatuses and is perpendicular to the horizontal plane.
Horizontal It passes through the inferior margin of both orbits and the superior margin of both external auditory meatuses.
Occlusal It is an imaginary surface between the upper and lower teeth.
 
Sutures
Sagittal It is a joining of two parietal bones at top of skull.
Coronal It unites the frontal with the parietals and joins with the sagittal.
Lambdoid It unites the occipital and parietal bones.
Squamosal It is two in number and unites the temporal bones with the parietal bone.
 
CARE OF INTENSIFYING SCREENS
 
Screen Contact
In the earlier days of screen radiography proper contact between screen and film was a major problem. The importance of excellent 15contact remains today but the difficulty of obtaining this condition is considerably lessened by the improvement which has been made in the manufacture of cassettes. Contact is maintained in the conventional radiographic cassette by a smooth layer of felt mounted between the back screen and the cassette to which it is mounted. The front screen is held flat by mounting it directly on the flat non-wrapping material which is used to form the tube side of the cassette. The cassettes are closed and fastened under spring tension which maintains a constant pressure. Specialized cassettes have been devised which contain very thin pockets of air which are mounted behind the screens. Under pressure, the distribution of the air maintains the contact.
Intensifying screens are fragile and expensive. With reasonable care they will last for years or can be destroyed in a moment by careless handling. While loading and unloading films from a cassette, it is important to lift the film with the soft part of the fingers and not with the nails, because nail polish is particularly damaging. It goes without saying that screens should never be allowed to be spattered with processing solution because a single accident of this kind will produce a defect which cannot be removed. It is recommended that every week the cassettes be brushed out with a soft camel's hair brush. Since the cassettes are closed under pressure, it is possible over a length of time to push particles of foreign material deeply into the emulsion. If this occurs, a pit will remain even after the foreign material has been removed.
 
Cleaning of Screens
When it becomes necessary to utilize a solvent to remove spots from radiographic screens, the manufacturer should be consulted to determine the correct cleaner.
On some screens a pure white soap, cotton, and a small amount of water may be used, making sure to rinse and dry well with cotton, allowing the cassettes to remain open sufficiently long after the washing process to assure drying before films are replaced and the cassettes closed. Some manufacturers recommend the use of 95 percent pure ethyl alcohol as a solvent. Denatured alcohol is not satisfactory. Screens should be dusted and then wiped with a cotton pad saturated with the alcohol. Excess should be picked up with a dry cotton pad and the final drying must be done with lintless cloth. 16Although screens washed with alcohol will dry in shorter time than those washed with water, care must again be taken to wait long enough before reloading with film and closing the cassettes.
 
Mounting of Screens
Some manufacturers provide double-faced mounting material for fastening screens in cassettes. This material is applied to the back of the screen to form a border all the way around. After the protective covering of the tape has been removed, the screens are placed face to face in the manner in which they will enclose the film and then placed in the cassette. The cassette should be shut and the screens allowed to remain under pressure overnight before use.
 
Other Charts
One chart utilizes scales of various kV settings, and usually employs six scales with different body parts listed under each scale. The thickness of the part is meassured and the kV setting is computed by reading the correct scale. The following conditions are then established. An mAs factor is assigned according to the patient's age and/or condition, nonscreen, and screen, as well as Bucky and non-Bucky techniques as provided on the chart. Distance is constant; varying only with the body part which requires an increased distance, as in chest radiography where the distance is increased to 72 inches. This type of chart is difficult to use but is probably the most accurate from the standpoint of film quality.
Another type of technique chart is one which is employed for use with a dental type X-ray unit, using a fixed kV (usually about 65 kV) and a fixed mA (usually about 10–15 mA). The variable factors are the time and distance. Again screen and nonscreen techniques are provided, as well as provision for a grid technique when required.
 
Slide Rule Chart
Charts of this type are prepared and distributed by the various manufacturers of X-ray equipment and supplies. This type of chart combines the best features of the other charts. Body parts are selected and a kV factor is assigned. The thickness of the part is measured and this factor is used in determining the kV setting. An 17mAs factor is assigned to each body part or group of parts. Distance is assigned and the proper cone Bucky, etc is indicated. All of the above is conveniently arranged and laminated in a transparent cover.
 
RADIOGRAPHIC POINTERS AND PITFALLS
  1. As a guiding rule, remember that good results are looked for–not excuses. Explanations seldom, if ever, quite explain.
  2. Read the X-ray request carefully to determine what views are to be taken.
  3. Perplexing cases will often have to be dealt with. It is then advisable to consult the roentgenologist. Otherwise you may obtain unsatisfactory views which will necessitate retakes; consequently a loss of time, waste of material, and general inconvenience.
  4. Patients referred to radiography are often ill, apprehensive or irritable. They should invariably be treated with kindness, courtesy, and forebearance. Care should be especially taken for a painful patient. Rough handling is never permissible. Remember that radiographic tables are not comfortable. Use ingenuity to provide support to injured parts and get adequate help in moving seriously injured or helpless cases. Be careful not to add to injury by careless manipulation. Do not remove dressings, plaster casts, etc. of any kind without permission.
  5. In dealing with female patients do not forget such matters as sheet for draping and avoid any unnecessary exposure. Be sure to have a nurse or other women attendant present. Always instruct female patients to remove hair pins, girdles, corset, or any other radiopaque objects from the area being radiographed.
  6. In skull work, inquire as to dentures, removal may be necessary.
  7. Be precise in your movements and instructions. Work systematically and quietly. Such will instill confidence and aid in obtaining good cooperation from patient.
  8. Make all settings and adjustments of the unit; properly place the film and film marker before positioning the patient. Otherwise you may be guilty of leaving someone in awkward, uncomfortable and even painful position for an unduly long time. This is especially true when views are to be taken of ill patients in an upright position.
    18
  9. Never smoke in the radiographic room while working with patients, such action is intolerable.
  10. Never attempt to interpret films, nor to discuss such films with the patient.
  11. Remember that when you share in the professional knowledge pertaining to a case, such knowledge is not yours to broadcast. Loose tongues are not permissible and may cause considerable harm.
  12. Whenever possible, outpatients should remain in the department until their films have been inspected. Additional views or retakes may be required.
  13. In case of injured outpatients, determine if they are to be seen by a Medical Officer before they leave, and take appropriate action.
  14. To minimize exposure of patients to the softer rays, which experience has shown, are most dangerous to the skin, see that a 21/2 mm filter of aluminium is in place. Oil-immersed tubes nearly always have the equivalent of 1/2 mm aluminium filtration so that an addition of a 2 mm aluminium filter will be sufficient.
  15. Keep account of the amount of exposure in cases subjected to frequent radiation, bearing in mind safe tolerances.
  16. Minimize personal exposure.
  17. When dealing with extremities of children and young adolescents, it is often wise to take both extremities. The unaffected one provides a means of comparison.
  18. When young children are difficult to manage, it may sometimes be well to propose that a nurse or other attendant manages the child while the relatives wait elsewhere.
  19. In using any method it is not sufficient to follow charts blindly. The bulk of one subject may be largely bone and muscle; that of another may be soft fat. In the first instance there will be considerably more resistance to the passage of X-ray and more voltage or more milliampere-seconds will be required. Again a large abdomen may be due to gaseous distention and the routine exposure based on its size will be too great. The chests of infants will require more exposure to get adequate lung detail than does routine chest radiography. Children and aged persons otherwise take less exposure than that normally required.
    19
  20. When taking oblique views it is to be remembered that the thickness of tissue to be penetrated will often be different than the AP or lateral dimensions. Measure along the path of the central ray. Further, if the X-ray tube is tilted, rays are spread over a greater film area and some increase in exposure may be necessary.
  21. When small cones, diaphragms or extension cylinders are used, slightly mere exposure will be needed (the amount of increased exposure can be marked on the cone itself or embodied in the exposure chart).
  22. When using a variable kilovoltage scale, acute accuracy is essential because small variations cause disproportionately large effects on radiographic density.
  23. Screen speeds vary, and accordingly it is necessary to know what types of screens are being used. High-speed screens usually permit a drop of 20 to 25 percent in time, or 3–4 kVp in penetration.
  24. If special nonscreen films are used in the department, care must be taken to prevent it from becoming mixed with regular film.
  25. Films from various manufactures may vary in speed. If you change to a different brand, make tests to ascertain if your exposure factors need adjustment.
  26. It is necessary to keep in mind the type of detail desired and the pathology involved in certain cases. In some instances, visualization of the periarticular structure may be desired rather than bone detail. Less exposure will then be in order. At times, two views of different density will be desired. Again in cases of chronic bone infection there is often a great increase in bone density. Additional views with increased exposure are then advisable.
  27. Film is expensive; therefore, conservation must be exercised.
  28. Always use a cone. It limits the field of exposure to the patient and improves techniques.
  29. Identification of films is usually accomplished by lead numerals mounted in a suitable frame. The importance of correctness can hardly be overemphasized. Mistakes may lead to annoying confusion and loss of time, or to an erroneous diagnosis. The correct placing of the markers for right and left is also of great importance. This is often not realized by experienced workers 20and sometimes leads to unpleasant results. A film is often a legal record.
    With cystoscopic X-ray tables, since patients almost invariably are placed in the supine position, it is a good practice to mount an “R” or “L” under the table top so that it will show in the corner of every film made. To avoid blacking out the numbers when heavy exposures are made, the marker should be placed under a part of the body or provided with a thin strip of copper taped to the base of the marker.
  30. Make a habit of inspecting all your work with a critical eye–there is usually room for improvement.
  31. Keep in mind the capacity of your X-ray tubes. Tube rating charts should be posted in all control booths.
  32. Ascertain all works are properly authorized.
  33. Do not leave exposed films in the Bucky tray. Remove all films to the darkroom immediately upon completion of exposure.
  34. Use cassettes in regular rotation, otherwise film may remain in a cassette for a long period with resultant deterioration.
  35. Remember that very little stray or secondary radiation is required to fog a film; therefore, they must be kept in a place free of radiation.
  36. When taking several views on one film, avoid rotating the film; otherwise the radiologist will be required to turn the film to study each view.
  37. Allow no nonessential personnel in the radiographic room.
  38. Use sandbags and compression devices to obtain support and immobilization.
  39. Stationary grids should be kept flat and protected from moisture. Do not abuse by rough handling.