residents review course common radiology procedures an incomplete positioning guide george david,...
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Residents Review Course
Common Radiology ProceduresCommon Radiology Procedures
An Incomplete Positioning Guide
George David, MS, FAAPMLou Ann Burnett, BSRTDepartment of RadiologyMedical College of GeorgiaAugusta, Georgia
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The Language of Diagnostic Radiology Bucky
LAO
All the KUB’s looked light
this morning?
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The Language of Diagnostic Radiology
Phototiming
He’s gotta be taller
than that!Did we use a 40” SID?
40”?
Grids
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The Language of Diagnostic Radiology
Barium EnemaDecub
Well, man, did you think
to checkfixer
retention?
Did they quit?
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Common Practice:40” SID for Table Bucky
• Used for– table bucky– table top
• compromise between– intensity fall-off with
square of SID– geometric unsharpness Tablet op
“Patient”
SID
X
Cassette in Bucky
SID = source-image (receptor) distance
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Common Practice:72” SID for Chest
• compromise between– intensity fall-off– geometric unsharpness– undesirable
magnification of heart
SID
X
Cassette in Chest Bucky
Patient
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More Common Practice: Phototiming
• Exposure time controlled by generator– based on sampled radiation
• Used only for bucky exposures– not tabletop
• Positioning critical
Fixed TechniquekVp kVp
mA mAs
time
PhototimedkVp
density
sensor cell location
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Bucky Imaging
• uses moving grid– reduces scatter– blurs grid lines– increases patient
exposure
• phototiming available
Tablet op
“Patient”
SID
X
Cassette in Bucky
GridPhototimerSensor
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Non-Bucky Imaging• small body parts /
extremities– minimal scatter
• situation precludes bucky use– portables– cross-table lateral
• phototiming not availableTablet op
SID
X
Cassette
Body Part
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Automatic Artifact
• Occurs whenever we image a 3D object in 2D
• Work-around– Multiple views
?? ??
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Distortion TypesDistortion Types
X-RayTube
Image
Shape Distortion
X-RayTube
Image
Relative Position Distortion
minimal distortion when object near central beam & close to film
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Common Projection Terminology
A = Anterior (front)P = Posterior (back)
AP
Oblique
PA
LAT
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Common Projection Terminology• RAO
• LAO
• RPO
• LPO
Tablet op
LPO
R = RightL = LeftA = Anterior (front)P = Posterior (back)O = Oblique
Left Posterior of Patient Closest to Film
Can you identify
this man?
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Decubitus Projection• Patient on side
• Causes changes in fluid levels
• Visualizes– plural effusion– air in abdomen
Cassette
Patient
Table
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iliac crest
symphysis
coracoid process
orbitomeatal line
manubrial notch
Common Positioning Landmarks
patella
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Chest Plain X-Ray
• High kVp– high latitude
required
• Phototimed• patient upright
– fluid levels / air
Technique
• PA
• LAT
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Chest Plain X-Ray
• Minimizes heart magnification– 72” SID– PA view– LAT with left side toward receptor
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Chest Plain X-Ray
•Shoulders rolled forward to remove scapulae shadows
•Include both lung apices and costophrenic angles
•Full inspiration
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Chest Plain X-Ray
•Shows lung apices below clavicles
•Patient AP, leaning back
or tube angled 15-200 cephalic
Lordotic view
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Chest Plain X-Ray
Pigg-O-Stat used for pediatric immobilization
Cassette
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Chest CT
• Axial images• Patient supine • Feet first, arms raised• Scan from above lung apices
to below diaphragm• Routinely- 3 mm cuts• Contrast
– may be IV– highlights blood vessels
Technique
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Chest CT
Scout image
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Abdomen Imaging
• Plain X-Ray• Fluoroscopy
– Upper GI
– Lower GI (Barium enema)
• Abdominal CT• Nuclear Medicine• Ultrasound
Studies
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Contrast Agents
• Water soluble (Hypaque)– better if leak
suspected
• Barium– highlights GI
tract
• Air
• Given orally
• Anatomy– esophagus– stomach– small
bowel
• Given by enema
• Anatomy– Colon
Upper GI Lower GI
Post fluoro views determined by radiologist
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Abdomen Plain X-Ray
• Mid-range kVp
• 40” SID
• Phototimed
Technique
• AP (KUB)
• Upright or decubitus for air/fluid levels
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KUB
• Patient supine • Center on iliac crest• Include diaphragm and symphysis
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Decubitus Abdomen
•Side of interest up
•Center on iliac crest
•Include diaphragm
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Abdominal CT• Routinely- 3mm cuts• Patient generally supine,
feet first• Scan from top of
diaphragm to iliac crest• IV Contrast highlights
– blood vessels– organs
• Dilute oral or rectal contrast highlights– GI tract– air not used
• streak artifact
Technique
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Abdominal CT
Scout Image
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Urinary Studies
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Urinary Tract Studies
• Intravenous Pyelogram (IVPIVP)
• Retrograde pyelogram / cystogram– contrast delivered
through catheter• Voiding Cystogram• CT
– kidneys• Nuclear Medicine• Ultrasound
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IVP• IV Contrast• Mid-Range
kVp– retain dye
contrast
• Images made at intervals post injection
• Post Void Image
Technique
• AP
• Obliques
• Center at iliac crest
• Include bladder and top of kidneys
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Retrograde Studies
• Mid-Range kVp
• 40” SID
• AP
• Obliques
• Center on iliac crest for pyelogram
• Cystogram/urethrogram-include bladder and entire urethra
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Kidney CT
• Patient positioned same as CT Abdomen
• Thin (1-2 mm) cuts• IV contrast used
if not post IVP
Technique
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Circulatory Studies
• Arteriogram– carotid / aortic
arch– runoff (leg)– renal
• Venogram– much less
common– extremity
• Heart Catheterization
Angiography
Patient supine, centered over area of interest
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Neuroradiology Studies• Skull Plain X-Rays• Spine Plain X-Rays• CT• MRI• Ultrasound• Myelogram
– Contrast injected into spinal canal– Mostly replaced by non-invasive MRI
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Skull
• Mid-Range kVp
• 40” SID
Technique • PA– facial bones close to receptor
• reduces magnification
• LAT
• Many specialized views– Waters– Towne’s– Basal
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Skull/SinusesPA
•Head rests on forehead and nose
•Orbitomeatal line (OML) perpendicular to receptor
•Angle tube 150 caudal
Towne’s
•Chin tucked, OML perpendicular to receptor
•Tube angled 400 caudal w/ patient AP
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Skull/Sinuses
Water’s
•Routinely PA, chin up
• OML angled 300 to receptor
and nose ~1 cm from receptor
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Skull/SinusesBasal •Routinely AP•If patient can tilt head back
–position tube / receptor lateral–OML parallel to image receptor
•If patient cannot tilt head back–tube / receptor tilted to achieve right angle to OML
•Shows zygomatic arches
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Head CT
• 2 mm cuts• Orbitomeatal line
perpendicular to floor• IV Contrast highlights
– blood vessels– lesions (metastases)– aneurysms– AVM’s
Technique
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MRI Brain Protocol
• 5 mm cuts, 1 mm spaces– minimizes crosstalk
• 1st study without contrast• If lesion suspected, study
repeated with contrast– Gadolinium injected IV– provides tumor edge
enhancement– aids in border determination
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Spine
• Mid-Range kVp
• Usually 40” SID
• Phototimed
Technique• AP
• LAT
• Oblique
• Coned spot
• C-spine– flexion
• chin toward chest
– extension• head back
– open mouth odontoid
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AP Cervical Spine•Occlusal plane and mastoid tips aligned-
to remove mandible shadow
•Angle tube 15-200 cephalic to open transverse foramina
•Center at thyroid cartilage
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Lateral C-spine Imaging
Swimmer’s view for C7/T1
•Routine- 72” SID to reduce magnification
•Consider weight to lower shoulders
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Odontoid Imaging
•Upper occlusal plane even with base of skull
•Mouth wide open
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Thoracic Spine•Patient AP
•Upright or supine
•Center ~3-4” below manubrial notch
•Breathing technique to blur rib/lung markings
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Lumbar SpineAP
•center on iliac crest Lateral •center on iliac crest• for spot, use 5-80 caudal tube angle to open L5/S1 space
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AP Scoliosis Imaging
•Patient AP, standing
•Include thoracic and lumbar
•Use long cassette or “pieced” method
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Myelograms•Fluoro with patient prone, knees and shoulders supported
•Cross-table lateral images at level of dye
•May CT while dye still present
Table
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Skeletal• Extremity
– usually plain film
• Spine– plain film– CT– MRI
• Skull– plain film– CT– MRI
• Other– ribs– pelvis / hip
• Pain
• Trauma
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Extremity
• Lower kVp• 40” SID• Not phototimed• No grid
Technique
• AP
• LAT
• Oblique
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Hand/WristPA
Lateral- fingers spread
Center to 3rd metacarpophalangeal joint
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ElbowAP
•Palm up to prevent forearm rotation
Lateral
•Elbow flexed 900
•Hand in lateral position
Center to joint
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Shoulder Projections Axillary projection
•Arm abducted at right angle to body
•Shows glenoid/humerus joint
AP
•upright or supine
•Palm out to rotate shoulder to true AP
Center on coracoid process
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Foot/Ankle
Weight-bearing lateral
•Demonstrate arch
•Center to base of 5th metatarsal
AP foot
•Sole flat on table
•Center to base of 3rd metatarsal
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Knee Projections
Can be done AP…
•Angle x-ray tube 15-200 cephalic
…or PA
•Angle x-ray tube 15-200 caudal
Tunnel view of the intercondyloid fossa
Center on
patella
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Knee Projections
Can be done PA…
•Angle 10-150 cephalic
Sunrise view of the patella
…or AP- standing, sitting
or lying
Center on
patella
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Pelvis/Hips AP
• Patient supine
•Toes turned inward to show femoral neck
•Pelvis- Include top of crest and bottom of ischium
•Hip- center to joint
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Pelvis/Hips
Frog Leg view
•Patient supine
•Knee(s) bent up and out
•Hip- center on joint
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Cross-table Lateral HipSeen from side Seen from overhead
•Can’t frog leg/fractures
•Tube and receptor parallel
•Angle into joint
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Mammography
•Compression to even out tissue densities
•Low range kVp
•Low dose film/screen combination
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MammographyCraniocaudad (CC)
•Shoulder back, arm supported
•Nipple in profile
•Skin folds smoothed
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MammographyMediolateral (ML)
Spot Compression•Unit angled•Arm supported•Nipple in profile•Skin folds smoothed
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