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Radiology Clinical III~~~
Lower Extremity ~~~~~
Image Review
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The following information is only a personal suggested guideline to follow when
positioning Lower Extremity exams.
For additional information on positioning of these
exams, please reference your Radiographic
Positioning and Related Anatomy Textbook.
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AP Toe• SID 40” / TT • CR < 10° -15°
towards calcaneusor ┴ to the phalanges
• CP to effected digit at the MTP jt
• Collimate• Shield
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Oblique Toes(s)• SID 40” / TT • Rotate foot 30°-45°
either medially or laterally
• CR ┴ to IR• CP to effected digit
at the MTP jt• Collimate• Shield
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Lateral Toe• SID 40” / TT • Foot on medial surface for
1st 2nd & 3rd digits, and lateral surface for 4th & 5th digits. (Use tape, tongue blades & gauze)
• CR ⏊ to IR• CP to effected digit at the
MTP jt• Collimate• Shield
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AP Toes
Repeatable error:
Good Image
Positioningor CR Angle
*Toes need to be parallel to the IR, put toes on a sponge or angle CR
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Toes
Pathology
ArthritisOr
Osteomyelitis
Good Image
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AP Foot• SID 40” / TT • Planter surface of foot
on IR w/ toes extended• CR < 10° towards
calcaneusor ⏊ to the metatarsals
• CP to the base of the 3rd MTP jt
• Collimate• Shield
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High Arch
CR 10°<
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Flat ArchCR-5°<
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AP Foot
Repeatable error:
Good Image
Collimation/CR
*Or patient’s foot slid forward on the IR
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AP Foot
Repeatable error:
Good Image
Collimation/CR*Or patient moved their foot. *Also remember to place part with long axis of IR
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FootPathology
Arthritis, Osteomyelitis
or Gout1st MTP Jt.
Good Image
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Foot
Pathology
MVAdecapitation of foot from
tib-fib
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Foot
Pathology
TraumaWith
reconstruction
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Oblique Foot• SID 40” / TT
• Planter surface of foot on IR w/ toes extended
• Rotate foot medially 30°-40°
• CR ┴ to IR• CP to the base of the
3rd MTP jt• Collimate• Shield
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Foot
Pathology
Arthritis, Osteomyelitis
or Gout1st MTP Jt.
Good Image
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Foot
Pathology
Surgical fixation
Phalanges
*image was shot standing
with angled CR Good Image
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Lateral Foot
• SID 40” / TT • Place foot on lateral
surface• Dorsiflex foot and
ensure plantar surface of foot is ┴ to IR
• CR ┴ to IR• CP to medial
cuneiform• Collimate• Shield
Good Image
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LateralFoot
Repeatable error:
Positioning
Good Image
Good Image
*over rotated
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Foot
Pathology
*foot infection with gangrene
causing subcutaneous gas within the
tissues
Good Image
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Plantodorsal Axial Calcaneus• SID 40”/ TT
• Pt. supine on table, legs fully extended• Dorsiflex foot to put plantar surface of foot ⏊ to IR• CR < 40° cephalad (or ⏊ to long axis of calcaneus)• CP to the base of the 3rd
metatarsal• Collimate • Shield
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Axial HeelRepeatableerror:
Good Image
Positioningor CR Angle error
*not enough dorsiflex or not enough CR angle
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Axial HeelRepeatableerror:
Good Image
Positioningor CR Angle error
*too much dorsiflex or too muchCR angle
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Lateral Calcaneus• SID 40” / TT • Place foot on lateral
surface• Dorsiflex foot and ensure
plantar surface of foot is ⏊ to IR (true lateral)
• CR ⏊ to IR• CP 1” inferior to medial
malleolus• Collimate• Shield
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Lateral HeelRepeatableerror:
Good Image
Positioning
*RotationThe leg is under rotated. The knee should be closer to the IR, and the foot should be dorsiflexed.
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Heel
Pathology
Bone cyst within the calcaneus
followed by bone graft
implant
Good Image
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AP Ankle• SID 40”/ TT• Pt. supine on table,
legs fully extended• Adjust foot (slight
dorsiflexion) to acquire true AP projection
• CR ⏊ to IR• CP to a point midway
between malleoli• Collimate• Shield
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AnklePathology
Rheumatoid ArthritisAnd/or congenital abnormalities, with ankle replacement surgery
Good Image
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32Good Image
Ankle
Pathology
Trauma
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33Good Image
Ankle
Pathology
Trauma
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Ankle
Pathology
Trauma
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3 4
1 2
Chose the best positioning
APMortise
View
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3 4
1 2
Best positioning
APMortise
View
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AP Mortise Ankle• SID 40”/ TT• Pt. supine on table,
legs fully extended• Rotate entire leg
medially 15°-20°until intermalleolar line is ∥ to IR
• CR ⏊ to IR• CP midway
between malleoli• Collimate• Shield
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AP 15°-20° Oblique (Mortise) 45° Oblique
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AP MortiseAnkle
Repeatableerror:
Good Image
Positioning*do not let foot droop causing the fibula to be superimposed onto the calcaneus.
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Lateral Ankle
Choose the best
positioning.
1
3
2
4
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Lateral Ankle
Best positioning.
1
3
2
4
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Lateral Ankle
• SID 40” / TT • Place foot on lateral
surface• Dorsiflex foot so
plantar surface is at a right angle to the leg
• CR ⏊ to IR• CP to medial malleolus• Collimate• Shield
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LateralAnkleRepeatableerror: Positioning*Foot has too much droop. It needs to be dorsiflexed to put foot in true lateral position. Good Image
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LateralAnkleRepeatableerror:
Good Image
Positioning*RotationThe leg is under rotated. The knee should be closer to the table , and the foot should be dorsiflexed.
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LateralAnkleRepeatableerror:
Good Image
Positioning*RotationThe leg is over rotated. The knee is too close to the table, and the foot should be dorsiflexed.
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AnklePathology
Rheumatoid ArthritisAnd/or congenital abnormalities
Good Image
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Ankle
Pathology
Trauma
Good Image
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AP Tib-Fib• SID 40”/ TT• Pt. supine on table,
legs fully extended• Dorsiflex foot to
acquire true AP projection
• CR ⏊ to IR• CP to midpoint of leg• Collimate• Shield
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Lateral Tib-Fib• SID 40” / TT
• Flex knee 45° and place leg on lateral surface. Ensure both ankle & knee joints are on image
• Dorsiflex foot so plantar surface is at a right angle to the leg
• CR ⏊ to IR• CP to midleg• Collimate• Shield
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Tib-FibRepeatable Error:Exposure
*Make sure you keep track of which IR plates have already been exposed!
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Tib-Fib
Pathology
Osteogenesis Imperfecta
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Tib-Fib
Pathology
Osteosarcoma
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AP Knee• SID 40”/ TT• Pt. supine on table, legs
fully extended• Rotate leg 3°-5° for true AP• CR ║ with the tibial plateau
(3°-5° caudad for thin buttocks; 0° for average buttocks; 3°-5° cephalad for thick buttocks)
• CP to ½” distal to apex of patella
• Collimate• Shield
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CR guideline - AP Knee
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KneeRepeatable Error:
Good Image
Exposure
*ensure appropriate technique correlate's with grid.
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Good Image
Positioning
*the leg is rotated laterally. From True anatomical position, It should be rotated 3°-5° medially.
KneeRepeatable Error:
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Knee
Pathology
Surgical fixation of a fractured patella Good Image
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Good Image
Knee
Pathology
Arthritis
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Good Image
Knee
Pathology
Bone lesion
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Good Image
Knee
Pathology
Trauma
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Good Image
Knee
Pathology
Bone lesion
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Knee
Pathology
Bone Lesion Cancerous
With MRI & Nuc Med scans
Good Image
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Good Image
Knee
Pathology
Trauma
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Knee
Pathology
Impaction fracture
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Lateral Knee• SID 40” / TT • Flex knee 20°-30° and
place leg on lateral surface in true lateral position.
• CR 5°-7° cephalad (5° for narrow pelvis and 7°-10°for wide pelvis)
• CP 1” distal to medial epicondyle
• Collimate• Shield
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Lateral Knee•Knee should be flexed 20-30 degrees•Angle CR appropriately or put entire leg parallel with the IR-get eye level to the leg.•Standing-check dimples
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Positioning Error for mediolateral Lateral Knee:
Good Image
Too much of the proximal fibula is superimposed with the tibia. The knee is under rotated or too far away from the image receptor.
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The fibula head is too far posterior. The knee is over rotated or too far towards the image receptor
Good Image
Positioning Error for mediolateral Lateral Knee:
*This is opposite for Lateromedial Laterals (XTL)
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Knee
Pathology
Bone lesion
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Knee
Pathology
Bone growth abnormality
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2122
Anatomy
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Axial Intercondylar fossa (Tunnel view)Acronym:*Mr. Beclere & Rose went Hom(blad) to Camp Coventry
1. Beclere-AP2. Rosenberg-PA3. Homblad-PA4. Camp Coventry-PA
*For all views-the CR is ⏊ to Tib-Fib
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Rosenberg
Repeatableerror:
Positioning
*Ensure that the shield does not hang
down to interfere with the AEC.
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Tangential (Axial or Sunrise) PatellaAcronym *MISS HH
1. Merchant2. InferoSuperior3. Settegast4. Hughston5. Hobbs * For all views, the goal is to match the CR angle with the knee flexion angle.
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SunrisePatella
Repeatableerror:
Good Image
shoe
Positioning
*Ensure shoe/foot
is not in the way of
the CR
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SunrisePatella
Repeatableerror:
Good Image
Positioning
*Be sure to feel for the base
and the apex of the patella
when centering
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AP Femur• SID 40”/ Bucky• Pt. supine on table, leg fully
extended• Verbally ask patient to
internally rotate their leg 5° for distal femur & 15° for proximal femur, do not force!
• Ensure both joints are included on image
• CR ┴ to IR • CP to mid femur• Collimate• Shield
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Lateral Femur• SID 40”/ Bucky
• Pt. supine on table, leg fully extended
• Flex knee 45° with lateral thigh on table
• Ensure both joints are included on image
• CR ┴ to IR • CP to mid femur• Collimate• Shield
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Femur
Pathology
Bone growth from previous fracture site
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Femur
Pathology
?
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Femur
Pathology
Trauma after total knee surgery. Also see previously fractured femur at mid shaft which is now healed.
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Femur
Pathology
Trauma*take note of how different bones look in two views at right angles to each other.
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Femur
Pathology
Trauma*Femur plate snapped in half. Question pathological fracture.
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AP Hip• SID 40”/ Bucky• Pt. supine on table, legs
fully extended• Verbally ask patient to
internally rotate their leg 15°-20°, do not force!
• CR ┴ to IR • CP 1”-2” distal to mid
femoral neck• Collimate• Shield“clinical trick” - the “crease” of the leg within the groin is where the femoral neck is located.
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AP Hip
Repeatableerror:
Centering
*Know your positioning
Landmarks. If you cannot feel them due
to body habitus, ask the patient to show you where their crest is.
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AP Hip
Repeatableerror:
Centering
*Feel for patient’s crest and/or ASISDo not assume the crease will work!
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AP Hip
Repeatableerror:
Positioning
*Artifact-hand.Pay attention to
where your patient’s hands are!
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Hip
Pathology
TraumaFractured femoral neck, most common after falls.
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Hip
Pathology
TraumaFemoral head dislocation
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Frog Hip - Modified Cleaves Method• SID 40”/ Bucky• Pt. supine on
table, legs fully extended
• Abduct femur 45° from vertical
• CR ┴ to IR • CP to mid femoral
neck• Collimate• Shield
What alternate view can you do if the patient cannot abduct their leg?
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Frog Hip
Repeatableerror:
Centering
*Know your positioning
Landmarks. If you cannot feel them due to body habitus, ask the patient to show
you where their crest is.
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Frog Hip
Repeatableerror:
Centering
*Know your positioning
landmarks.
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Axiolateral Inferosuperior HipDanelius-Miller Method
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XTL Hip
Repeatableerror:
Place marker along this area of the IR
Structures shown
& Markers
*Careful of your marker placement
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XTL Hip
Repeatableerror:
Structures shown &
Collimation/CR
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XTL Hip
Repeatableerror:
Technical/Positioning
*either the cassette was not below the table line,
or the Tech did not realize the anatomy would sink into the
stretcher or bed.
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Modified Axiolateral HipClements-Nakayama Method
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AP Pelvis• SID 40”/ Bucky• Pt. supine on table, legs
fully extended• Verbally ask patient
to internally rotate the long axes of the feet and lower legs 15°-20°, do not force!
• CR ┴ to IR • CP ½ way between the
ASIS & symphysis pubis.• Collimate“clinical trick” – Place the top of the IR just slightly above the crest, then center the CR to the IR.
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AP PelvisFemale shielding
Bilat HipsMale shielding
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APPelvis
Repeatableerror:
Positioning
*Artifact-Snaps on
gown
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APPelvis
Repeatableerror:
Positioning
*Artifact-handKnow
where your patient’s hands
are!
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APPelvis
Repeatableerror:
Positioning
*Artifact –hands. Often patient’s will
tuck their hands under their hips
because the table is so hard.
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APPelvis
Repeatableerror:
Positioning
*additional questions need to be asked of
patient… “Do you have any
buttons, snaps, trinkets or charms on your
underwear?”
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APPelvis
Repeatableerror:
Centering
*Centering is too low, know
your landmarks
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Hip
Pathology
Paget’s Diseaseto left superior pubic rami and ischium
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Hip
Pathology
Multiple Myeloma.Several lytic lesion throughout pelvis.
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AP Pelvis
Pathology
TraumaFemoral
head dislocation
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AP Pelvis
Pathology
TraumaFemoral
head dislocation
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APPelvis
Pathology
TraumaFemoral
neck fracture
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APPelvis
Repeatableerror:
Positioning
*Artifacts - before shooting the image through the trauma bed, you should try
remove all metal that is on the patient.
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Patient is pregnant - The fetal head is in the pelvis
AP Pelvis
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AP Axial “Inlet” Pelvis
This view shows superimposition of the pubic rami and ischium, which can best display anterior or posterior
displacement of those bones.
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Pelvis
Pathology
TraumaFracture of the left pubic rami and ischium.
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AP Axial “Outlet” Pelvis
This view shows a true AP view of the pubic rami and ischium, which can best display superior or inferior
displacement of those bones.
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Judet Views Pelvis
Oblique views of the hips/pelvis. Side up shows the rims of the acetabulum opened and side down shows it in
profile.
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Judet Pelvis
Pathology
TraumaFracture of the of the left acetabulum
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Leg Lengths
Exam done supine or standing to show leg length discrepancy.3 separate coned exposures were made onto one IR.
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~The End~