General Radiology
Table of Contents
Page No.
Daily Room Check 5
History Taking 6
Pregnant
Patient Policy (Pregnancy) 7-8
ID Flash Cards
and Lead Markers 9
Gonadal Shielding 10
Checking of
Plain Films on Out-Patients 11
Headwork 12-14
Skull
Mandible
Temporomandibular (T.M.) Joints
Sinuses - Adult
Sinuses - Children under 2
Sinuses - Children over 2
Facial Bones
Mastoids
Optic Foramen
Orbits
Nasal Bones
Zygoma
Foreign Body of Eye
Spine 15-18
Cervical
Thoracic
Lumbar
Sacrum
Coccyx
Sacroiliac (S.I.) Joints
Pelvis
Pelvis: Radium Insertion
Hip - Trauma
Hip - Other Pathology
Infant Hip
Upper
Extremities 19-20
Finger
Hand
Wrist
Forearm
Elbow
Humerus
Shoulder
Lower Extremities 21-22
Toes
Foot
Calcaneus
Ankle
Tibia and Fibula
Knee
Knee Trauma
Femur
Congenital Foot Deformities
Thorax 23-24
Chest
Ribs
Acromio-Clavicular (A.C.) Joints Bilateral
Clavicles
Sterno-Clavicular Joints Bilateral
Sternum
Scapula
Abdomen 25
Survey Studies 26-31
Hyperparathyroidism
Renal Osteodystrophy
Skeletal Survey - Metastatic Bone Survey
Rheumatoid Arthritis Survey
Battered Child
Dwarfism Study
Lead Survey
Rickets Study
Long Bones for Syphilis
Bone Age - under 1 year of age
Bone Age - over 1 year of age
Neurofibromatosis
Shunt Series for Ventriculo-Peritoneal
Shunt Series for Jugular or Ventriculo-Atrial
Scanogram
CT Scanogram
Pre-ECT Survey
Scoliosis Series
Daily Room Check
Every radiographer
should do the following upon arrival at work, mid-shift and end of shift:
1. Clean the x-ray table and lead protectors
2. Check flash card clocks and correct errors
3. Check cabinet for x-ray apparatus and supplies
4. Check emergency drugs, oxygen and suction devices
5. Check x-ray equipment for malfunctions
6. Report all malfunctions to supervisors
History Taking
A. Before or during the examination, obtain and record history from patient regarding reason for examination.
B. Important questions to ask:
1. When did the injury/illness begin?
2. Where does it hurt?
3. Why did the doctor order this examination?
4. Women – is there any chance you are pregnant?
C. Additional information obtained should be handwritten onto requisition under "Reason for Study"
D. Mark films taken for trauma or foreign body as to location of symptoms.
Pregnant Patient Policy
A. Purpose
In order to comply with the
B. Procedure
1. Scheduling:
a. Requests from referring physicians’ offices for radiographic examinations of known pregnant females will be reviewed by a department radiologist prior to the performance of any studies.
b. The decision to perform an imaging study which utilizes ionizing radiation on a known pregnant female will occur only after the radiologist and referring physician confer with each other regarding the risk versus benefit of the exam.
2. At the time of procedure:
a. The radiologist, radiology resident or other physician will consult with the patient regarding their understanding of the potential risks of exposure of the fetus to ionizing radiation and the necessity of the radiological examination.
b. Appropriate shielding of the abdomen will be utilized in order to minimize direct or indirect exposure of the fetus.
C. Responsibilities
1. Physician/Physician’s Office:
a. It is the responsibility of the referring physician to discuss with his/her pregnant patient the risk versus benefit of any radiographic examination, which utilizes ionizing radiation and its possible effect on the unborn fetus.
b. It is the responsibility of the referring physician to confer with the radiology department and a department radiologist regarding the need for a study utilizing ionizing radiation in a known pregnant patient prior to ordering the exam.
2. Radiologist/Technologist:
a. It is the responsibility of the radiology department
personnel to question all females of childbearing age of the potential for
pregnancy prior to the utilization of ionizing radiation.
b. It is the responsibility of the radiologist to confer with the referring physician regarding the risk versus benefit of any study utilizing ionizing radiation in the pregnant patient.
c. The ultimate decision to perform an exam utilizing ionizing
radiation on a pregnant female will be decided through the consensus of the
radiologist and referring physician.
D. Documentation
Documentation will be given in the first paragraph of the official radiology report of:
a. The discussion held between the referring physician and the radiologist regarding the risk vs. benefit of a specific ionizing radiology procedure requested on a given pregnant patient.
b. The discussion held by the referring physician and/or radiologist with the pregnant patient informing her of the risk vs. benefit of the requested imaging study.
ID Flash Cards and Lead Markers
A. ID Flash Cards
1. ID flash cards should contain:
¨ name of imaging site
¨ name of patient
¨ medical record number
¨ date of birth
¨ date of study
2. ID flash cards should not overlay pertinent parts of the image, whenever possible.
B. Lead Markers
1. Lead side markers (right, left) must be used on all plain films in order to designate the side of the body part being x-rayed, or which side of the body overlays a particular side of the film (e.g., right marker placed lateral to right side of chest).
2. Technologist lead marker initials should be clearly visible on each plain film.
Gonadal Shielding
A. Policy:
It is the policy of the Department of Radiology to minimize gonadal radiation dose to patients, while producing radiographs with maximum diagnostic value.
B. Male
gonadal shielding should not be used on:
1. Initial study of pelvis
2. Initial study of hip(s)
3. Urethrograms
4. Initial study of femur
5. Excretory urogram, VCUG
C. Male
gonadal shielding should be used on:
1. Follow-up study of pelvis
2. Follow-up study of hip(s)
3. Follow-up study of lumbar spine
4. Follow-up study of femur
5. All excretory urogram films except scout
6. Abdomen
7. Fluoro scout films, except VCUG
D. Female
gonadal shielding should not be used on:
1. Studies of pelvis
2. Initial study of hip(s)
3. Genitalia examinations
4. Lumbar spine films
5. Initial study of femur
6. Preliminary abdominal scout films
E. Female
gonadal shielding should be used on:
1. Follow-up studies of hip(s)
2. Follow-up study of femur
Note: The size of the
shield should be appropriate for the patient's size in order that all of the
soft tissues within the bony pelvis are protected.
Checking of Plain Films on Out-Patients
A. All
out-patient plain films done in the Main Department
should be checked by a radiologist for quality before the patient is permitted
to leave the Department:
1. The technologist should make it clear
to the radiologist that the films are being shown for “checking” only.
2. After the films are checked, the technologist should note on the request “Films checked by Dr. _______________.”
3. If the patient is taking the films out
of the Department, the technologist should tell the radiologist that the films
need to be reported. The patient’s master folder should be available at the
time of dictation.
4. Chest or abdominal films done after the
last pick-up of the day in the Klein building on patients with an acute history
should be checked by a radiologist before the patient leaves the Department.
5. Any out-patient study labeled “Stat” or “Please call with results,” regardless of the location the study is done, should be shown to a radiologist before the patient leaves the Department.
Headwork
A. Skull
1. PA
2. AP Towne
3. Lateral (right and left)
Note: Trauma room
only - AP and lateral
B. Mandible
1. PA with 15o cephalad tube angulation
2. AP Towne (central ray entering at TMJ)
3. Lateral oblique position of head (right and left); angle patient's mandible 15° away from film; central ray entering through ascending ramus of mandible closest to the film at an angle of 15° cephalad
4. Lateral of affected side
C. Temporomandibular
(T.M.) Joints
1. Towne view
2. Right and left lateral tomos with open and closed mouth
D. Sinuses
- Adult (erect)
1. PA
2. Waters
3. Lateral
E. Sinuses for Children under 2 years of age (erect if possible)
1. PA or AP
2. Water's (chin and nose touching film or in same plane)
3. Lateral neck to include sinuses
Note: see item #5 -
"Lateral Neck" – under "Cervical Spine”
F. Sinuses for Children over 2 years of age (erect whenever possible)
1. PA or AP
2. Water's (chin and nose touching film or in same plane)
3. True lateral
G. Facial
Bones
1. Waters (exaggerated)
2. Base (zygoma technique)
3. Lateral
4.
5. Towne for face: Orbitomeatal line perpendicular to film and 30o caudal angulation of tube with CR entering at nasion. Be careful to position the upper portion of the orbit at the top of the film.
H. Mastoids
1. Suggest CT or MRI
I. Optic
Foramen
1. Rheese position(right and left)
3. Possible fluoroscopy after radiologist views films
J. Orbits
1. Waters (exaggerated)
2. Base
3. Lateral
4.
5. Rheese - opening cones to include both orbits: Position patient so that acanthiomeatal line is perpendicular to film. This will place patient's head in a 53o angle to table (usually outer corner of orbit, chin, cheek and nose will be resting against film or table)
K. Nasal
Bones
1. Waters
2. Nose pointing towards center of film (“kissing cousins”)
L. Zygoma
1. Waters (exaggerated)
2. Lateral
3. Underexposed basal view (zygoma technique)
Note: For children under 8 years of age, do Towne view
M. Foreign
Body of Eye
1.
2. Waters (looking up and down) - Parallex
Motion Method
(see p. 288 in Vol. 2 of Merrill's Atlas)
3. Lateral
Note: Waters only for
MRI if study is being done to see if MRI is safe
Note: Consult with
radiologist for CT or US
Spine
Important: A specific, single-view film cannot be ordered as a "study." It is acceptable to add a specific view to the routine study, but not to delete a view.
A. Cervical
Spine (8 x 10 LW)
1. Trauma
a. Lateral C-spine, clear with physician, remove collar and proceed with routine study **
b. AP
c. Odontoid
* * An adequate examination of the lateral cervical spine is defined as a film which demonstrates the superior endplate of T1. If the first attempt at obtaining this level is unsuccessful, then a second attempt will be made. If the second attempt is unsuccessful, then the patient will have a limited CT scan of the cervical spine to demonstrate C7, if clinically indicated.
2. Routine Study
a. AP (10o cephalad tube angulation, top of ear at top of film)
b. Obliques (right and left)
c. Lateral (72" distance)
Note: In pediatrics:
if child is unable to cooperate, do Towne view
3. Following bone scan:
a. AP
b. Lateral
4. Soft Tissue Neck
a. Lateral with deep inspiration
b. Use soft tissue technique
5. Lateral Neck (Pediatrics):
Erect whenever possible with neck hyperextended - use soft tissue technique. Avoid supine views in children suspected of epiglottitis or if they have a known mediastinal mass.
a. All films must be done on inspiration.
b. Children that are able to cooperate do breathing through the nose
Note: If patient must
be supine:
1. Supine horizontal beam lateral neck
2. Place sand bag or rolled up towel under back of child's neck to extend chin. Exact lateral position important.
B. Thoracic (14 x 17 LW)
1. AP
2. Lateral (use breathing technique if patient is able to cooperate)
Note: Cone to spine
unless requested otherwise
C. Lumbar
1. Routine
a. AP to include sacrum (14 x 17 LW)
b. Lateral to include sacrum - no rotation (14 x 17 LW)
c. Obliques - right and left (10 x 12 LW)
d. Lateral spot - L-5-S1 (8 x 10 LW)
2. Trauma:
a. AP (14 x 17)
b. Lateral (14 x 17)
3. To follow bone scan:
a. AP (14 x 17 LW)
b. Lateral (14 x 17 LW)
D. Sacrum (10 x 12 LW)
1. AP (15o cephalad tube angulation)
2. Lateral
E. Coccyx (8 x 10 LW)
1. AP (10o caudal tube angulation)
2. Lateral
F. Sacroiliac (S.I.) Joints
(10 x 12 LW)
1. PA view if possible. If not, AP with 15° cephalad angulation
2. Obliques (right and left, 15o oblique - film to include both SI joints
G. Pelvis (14 x 17 CW)
1. AP (show film to radiologist for additional films if necessary)
2. Both 20o obliques for trauma if requested by physician
3. AP - inlet and outlet 25o caudal, and 25o cephalad if requested by physician
4. Judet - 45o AP oblique if requested by physician
H. Pelvis: Radium Insertion
1. AP (14 x 17) center on symphysis
2. Transverse lateral in supine projections
Note: Patient must
never turn on side for lateral projection.
Do not move patient between projections.
I. Hip - Trauma
1. AP pelvis 14 x 17 CW to include proximal femora (separate request)
2. AP hip (10 x 12 LW)
3. Transverse lat - use grid
Note: If fracture is
visualized on pelvis, a 14 x 17 supine chest must be obtained
Note: Follow-up hip
for fracture requires:
i. AP - 10 x 12
ii. Transverse lat - 10 x 12 (use grid)
J. Hip - Other Pathology
1. AP hip (10 x 12 LW)
2. Frog lateral (10 x 12 LW)
K. Infant Hip (8 x 10 CW)
1. AP knees and ankles should be in anatomical position (tape knees and ankles if necessary and use sandbags for immobilization)
2. Frog Leg - abduct and externally rotate (use immobilization devices when necessary)
Note: Use gonadal
shields on all pelvic studies in males and premenopausal females with exception
of initial films
Upper Extremities
Important: A specific, single-view film cannot be ordered as a "study." It is acceptable to add a specific view to the routine study, but not to delete a view.
Use arrow or BB to
identify area of pain or suspected foreign body
A. Finger (10 x 12 CW) (All views on 1
film)
1. PA hand
2. Both obliques (use oblique finger wedge) - include metacarpal
3. Lateral (use lateral finger wedge)
Note: If thumb is
ordered - do AP thumb
B. Hand
1. PA
2. Oblique - use oblique finger wedge
3. Lateral - use lateral finger wedge
4. Hand for arthritis:
a. All 4 views (PA, lateral, both obliques)
b. PA (bilateral) use single emulsion film
C. Wrist (8 x 10 divided)
1. PA
2. PA Oblique
3. Lateral
4. Navicular (if indicated by physician)
D. Forearm (10 x 12)
1. AP (include AP of both wrist and elbow joints)
2. Lateral (90o angle of elbow to include lateral of both wrist and elbow joints)
E. Elbow
(2 - 8 x 10
divided)
1. AP
2. Lateral (90o angle of humerus and forearm and CR entering exactly at joint)
3 Pediatrics: age 15 and under, do opposite AP and lateral for comparison routinely when radiologist is not present
4. Radial head view (trauma) or external oblique (non-trauma)
F. Humerus
1. AP - include both elbow and shoulder joints (might have to abduct arm from body for diagonal placement on film)
2. Lateral - internal rotation of arm to include both joints
G. Shoulder
1. Shoulder Trauma (8 x 10 LW)
a. AP
b. Axial (45o posterior angulation)
c. Y view
d. Axillary view as requested by orthopedist
Note: Be careful on
fracture cases. Do not force patient to
move arm.
Note: A hanging cast
covering the forearm and distal humerus should be handled with extreme
care. Hanging casts should be done erect
(AP and lateral).
2. Shoulder (Bursitis)
a. AP - arm in neutral position
b. Internal and external position. Central ray angled 15o caudal.
c. When performed on Franklin Unit, use round cone.
Lower Extremities
Important: A specific, single-view film cannot be ordered as a "study." It is acceptable to add a specific view to the routine study, but not to delete a view.
Use arrow or BB to
identify area of pain or suspected foreign body
A. Toes (10
x 12 LW) (All
views on 1 film)
1. AP of entire foot
2. Oblique - internal oblique to include metatarsal
3. Lateral of affected toe
B. Foot (10
x 12 LW, divided) (8
x 10 lateral)
1. AP
2. Oblique (30o internal rotation)
3. Lateral
Note: Remember to
adjust technique for area of interest - i.e., lighter for metatarsals and
toes; darker for hindfoot
C. Calcaneus
(8 x 10 CW, divided)
1. Axial – exposed to show anterior calcaneus
2. Lateral
D. Ankle (8
x 10 CW, divided)
1. AP with long axis of foot in vertical position
2. Lateral with lateral side of ankle against film
3. Mortise view
E. Tibia and Fibula (14 x 17
LW)
1. AP to include knee and ankle joints
2. Lateral to include knee and ankle joints with patella perpendicular to film
F. Knee (8 x 10 LW)
1. AP
2. Lateral with slight flexion (~ 30°) of knee
3. Tunnel
Note: Do erect knees
if indicated (14
x 17 CW)
Note: Do patella
sunrise view if indicated by symptoms
G. Knee Trauma
1. AP
2. Lateral
3. Obliques
4. Cross-table lat knee (replaces #2 for trauma)
5. Patella view if indicated
H. Femur (14 x 17)
1. AP to include both knee and hip joints: Two films - one distal and one proximal - may be necessary, being careful to overlap)
2. Lateral (include both joints)
Note: Possible
fluoroscopy if requested by radiologist
I. Congenital Foot Deformities:
Clubfoot, flatfoot, rocker bottom (pes equinovarus, metatarsus varus, pes cavus, pes talipes equinovalgus, pes calcaneovalgus)
1. AP and lateral weight bearing views of foot.
2. If child cannot bear weight on his/her own, tape foot into weight bearing position and have accompanying person assist during upright filming.
3. Whenever possible, image both feet (side by side) on the
same film.
Thorax
A. Chest (14 x 17 LW)
1. For pre-employment or health services: PA and lateral
2. Portable: AP
3. Routine: PA and lateral
Note: Indicate if
x-ray is taken erect, semi-erect or supine.
4. For pectus excavatum:
a. AP or PA chest without barium
b. Left lateral with barium in depression of chest
5. For foreign body investigation:
a. PA or AP inspiration (marked with insp. markers)
b. PA or AP expiration (marked with exp. markers)
Note: If unable to
get insp. and exp. films, lateral decubs will be
necessary. Consider the age of the
patient, as children less then 5 years of age may not be able to cooperate.
6. To r/o pneumothorax:
a. PA or AP inspiration (marked with insp. markers)
c. Left lateral
b. PA or AP expiration (marked with exp. markers) if needed by radiologist
Note: Exam is done
only to diagnose pneumothorax: if diagnosis has already been
made, routine chest is sufficient
B. Ribs
1. PA chest
2. AP ribs
3. Oblique view of affected side; include an oblique view tangential to the marker
Note: Use lead B.B. for area of pain
Note: If injury is at
lower ribs, a film of upper abdomen will be necessary, using Abdomen technique!
C. Acromio-clavicular
(AC) Joints Bilateral
(14 x 17 CW)
1. AP with and without 5 lb sandbags
Note: Include both ACJ’s on one view if possible
D. Clavicles (10 x 12 CW)
1. AP
2. AP - 30o cephalic angulation
E. Sterno-Clavicular
Joints Bilateral (8
x 10 LW)
1. Consult with radiologist for possible CT
F. Sternum (10 x 12 LW)
1. Tomographic film with patient in 30o right anterior oblique (RAO) position, or single oblique film with breathing technique
2. Lateral - have patient pull arms behind chest and thrust chest forward
G. Scapula
1. AP
2. Scapular Y view
Abdomen
A. Abdomen (14 x 17 LW)
1. Abdomen:
a. AP to include pubic bone and diaphragm
Note: Two (2) films
may be needed
2. Obstruction Series - Adult:
a. PA chest (upright whenever possible)
b. Supine abdomen
c. Erect abdomen to include diaphragm, or, if patient cannot stand, left lateral decubitus. Make sure right abdomen is included on film.
d. Prone, or, if patient cannot turn into prone position, obtain lateral rectum
Note: For all
decubitus or erect films, the radiographic tube must remain parallel to
the floor of the room
Note: Follow-up examinations, consult radiologist
3. Obstruction Series - Pediatric (up to age 16 years):
a. Supine AP abdomen
b. Erect AP abdomen or left lateral decubitus AP abdomen
c. If necessary as per radiologist, prone cross table lateral of rectum
Note: For all
decubitus or erect films, the radiographic tube must remain parallel to
the floor of the room
4. Survey for Abdominal Aneurysm
a. Recommend ultrasound
5. Imperforate Anus
a. AP KUB
b. Upside down lateral view of rectum with BB on anal dimple
6. Abdominal Survey for Foreign Body
a. Abdomen AP
b. Chest AP
c. Lateral neck
Survey Studies
A. Hyperparathyroidism
1. PA hands - single emulsion films
2. AP both clavicles
3. AP pelvis
4. Lateral skull
B. Renal Osteodystrophy
1. PA both hands
2. AP both clavicles
3. AP knees
4. T-spine AP and lateral
5. L-spine AP and lateral
6. AP pelvis
C. Skeletal Survey -
Metastatic Bone Survey/Multiple Myeloma Survey
1. AP and lateral skull
2. AP and lateral cervical spine (don't cone down)
3. AP and lateral thoracic spine (don't cone down)
4. AP and lateral lumbosacral spine (don't cone down)
5. AP pelvis
6. AP both femora to knee
7. AP each humerus to include rib cage
8. AP tibiae and fibulae
Note: If preceded by
bone scan, some views may be eliminated as per Nuclear Medicine physician
D. Rheumatoid Arthritis
Survey
1. Cervical spine - lateral flex and extension
2. Pelvis - AP to include both hips
3. Hands and wrists - PA on single emulsion films
4. Hands and wrists - AP obliques on single emulsion films
5. Knees - bi-lateral AP on 14 x 17 CW
6. Knees - lateral on 8 x 10
E. Battered Child
1. Skull - 4 views (AP, Towne and both laterals)
2. AP or PA chest
3. Abdomen
4. Lateral spine - cervical, thoracic and lumbar (thoracic and lumbar can be combined on one film)
5. AP all extremities - legs in anatomical position, arms in anatomical position – separate films of each body part
6. Lateral all extremities
7. Hands (PA)
8. Feet (AP)
continued on next page
F. Dwarfism
Study
1. Skull - AP - lateral and base views
2. Chest - PA and lateral
3. Pelvis - AP
4. T spine - AP and lateral
5. L spine - AP and lateral
6. Hands - AP
7. Feet - PA (dorsal plantar)
8. Humeri - AP (anatomic position)
9. Forearms - AP (anatomic position)
10. Femori - AP (anatomic position)
11. Tibia and fibula - AP (anatomic position)
Note: If newborn,
obtain straight AP babygram on one 14x17 film
including extended arms and legs in anatomical position
G. Lead Survey
1. Knees (both) - AP
2. Abdomen - AP to include pelvis
H. Rickets Study
1. Hands and wrists (both) - PA
2. Knees (both) - AP
I. Long Bones for Syphilis
1. AP bilateral humerus and forearms (include hands in anatomical position)
2. AP femora and tibiae and fibulae (neutral position)
J. Bone Age
1. Under 3 months of age
a. Left hand/wrist AP
b. Left knee AP
2. Under 1 year of age
a. Left hand and wrist – fingers (PA) completely flat on cassette (use tape as necessary)
b. Left knee - AP
3. Over 1 year of age
a. Left hand and wrist PA - fingers completely flat on cassette (use tape as necessary)
Note: If unable to
obtain left hand, do right hand
L. Neurofibromatosis
1. C-spine - AP and lateral
2. Scoliosis series - AP and lateral
3. Skull - 4 views
4. Chest - PA and lateral
5. AP femora (neutral position)
6. AP tibiae and fibulae (neutral position)
7. AP humeri (anatomical position)
8. AP forearms (anatomical position)
M. Shunt
Series for Ventriculo-Peritoneal
1. Skull
a. AP
b. Lateral
c. If necessary, oblique tangential to view shunt away from cranium
2. Chest - PA and lateral
3. Abdomen - AP
4. C spine - AP if shunt is not overlapped on skull films
N. Shunt
Series for Jugular or Ventriculo-Atrial
1. Skull
a. AP
b. Lateral
c. Oblique tangential to view shunt away from cranium
2. Chest AP
O. Scanograms
1. Place body measurement ruler on center of table - tape to secure ruler
2. Patient should lay on table and ruler with higher number at crest
3. Divide 14 x 17 film into 3 sections
4. Center top third of film over hip joints; cone down and take exposure
5. Place second third of film under knee joint; cone down and expose
6. Place the last third of film under ankle joints; use medial and lateral malleoli to determine location; cone down and expose
P. CT Scanogram
1. Place patient supine on CT table – feet first
2. Patient to hold lower legs in anatomic position – tape feet together if necessary
3. Obtain scout AP of pelvis to feet
4. Obtain measurements off scout CT of right and left legs:
a. 1st measurement: top of femoral head to distal medial femoral condyle.
b. 2nd measurement: taken from medial femoral condyle to distal tibia epiphysis (mid plane at level of tibia talor surface)
c. Film taken with measurements and cursors.
Q. Pre-ECT
Survey
1. Chest - PA
2. C spine - lateral
3. T spine - lateral
4. L spine - lateral
R. Scoliosis Series
Note: Use 14 x 36 cassette with grid at AEMC/CORA
1. Initial Study:
a. AP - erect
b. Lateral erect
c. PA side-bending to right and left – include pelvis
2. Follow-up Study:
a. Erect PA only - include pelvis