Adaptive Radiography

Front 1

Positioning for toes and feet

Back 1

- with knee extended
-used when the patient is unable to flex knee for routine projections of the toes/ foor
• use positioning aids
• maintain CR
• use same centering points and CR as with routine positioning

Front 2

Clinical Indications of Fracture proximal Femur

Back 2

o Pain immobility of affected lef
o Inability to weight bear

Front 3

Hip
Axiolateral Shoot thru/crosstable hip)

Back 3

• Ideal when only one hip is affected
• Internally rotate leg 15-20 degrees if patient can do so
• IR must be parallel to femoral neck
• CR- perpendicular to long axis of femoral neck 6.4 cm elow the line from ASIS and pubic symphysis
• Demonstrates hip joint, and acetabulum, femoral neck free from superimposition

Front 4

Hip
Modified Axiolateral of Hip

Back 4

• Used when neither leg can be lifted up
• Legs are not internally rotated
• IR- as with the axiolateral place IR parallel with neck with its upper boarder in the crease above iliac crest
• Then tip IR back 15 degrees
• CR angled 15 degrees posteriorly and aligned perpendiculately to the femoral neck and IR
• Demonstrates hip joint and acetabulum , femoral neck free from SI from greater trochanter

Front 5

What should not be done if broken Pelvis is suspected?

Back 5

Internally rotate Legs

Front 6

AP pelvis Projection

Back 6

o Common request following trauma
o Use rigid spine board to life patient to place the IR
o Do not rotate injured limbs
o Place IR with its upper border 2.5-3.8 cm above iliac crest
o Demonstrate entire pelvis and proximal femora, lesser trochanters seen medial if not internally rotated

Front 7

What two positions are used to show Acetabulum?

Back 7

internal oblique affected side up or external oblique affected side down

modified by using a cross table projection for trauma

Front 8

Posterior Oblique Projection of Acetabulum (Judet View)
Internal And External Oblique

Back 8

Internal:
-Rotate patient 45 degrees from the table with affected hip up
-CR- perpendicular to the IR entering 5cm inferior to raised ASIS
-Demonstrates iliopubic column and posterior rim of acetabulum
POI

External:
• Rotate patient 45 degrees on affected hip
• CR perpendicular to the IR entering pubsymph
• Demonstrates the ilioischial column and the anterior rim of the acetabulum

ACE

Front 9

Inlet Projection Of Pelvis (superoinferior)

Back 9

• CR directed 40 degrees caudad entering midline at the level of ASIS
• Demonstrates superimposed superior and inferior pubic rami, medially. Superimposed lateral two thirds of pubic and ischial bones, symmetrical pubes and ischial spines, both hips and the pelvis ring in its entirety

Front 10

Outlet Projection Of Pelvis (AP axial)

Back 10

• CR directed cephalad 20-35 degrees for males and 30-45 degrees for females entering a point 5cm distal to suprapubic border
• Demonstrates magnified pubic and ischial bones superimposed over sacrum/coccyx symmetrical obturator formina both hips pubic and ischial ram centered to the image

Front 11

What are the main goals while doing chest x-ray?

Back 11

• Obtain images upright when possible
• Maintain spinal immobilization precautions
• Use a long SID
• Use clear and concise breathing instructions
• Cover the IR to prevent contamination

Front 12

AP Chest

Back 12

• Performed supine most commonly
• Upright when possible
• Use the rigid spine board to life patient to place the ir
• Place IR 3.8-5 cm above shoulder 1.5-2”
• CR directed perpendicular to the center of the IR entering 7.8 cm below jugular notch 3”
• Demonstreates and image similar to PA projection except heart and great vessels are magnified and engorged and the lung fields appear shorter
• Remember to indicate if the image was obtained as AP versus PA and if the patient was upright or supine

Front 13

What to watch for while doing abdomen X-ray?

Back 13

• Monitor patient for signs of shock and internal hemorrhage
• Increase technical factors if internal bleeding is suspected
• Maintain spinal immobilization precautions
• Use clear and concise breathing instructions
• Cover the IR to prevent contamination

Front 14

AP Abdomen

Back 14

• Common request following trauma
• Always use a grid
• Use the rigid spine board to lift patient to place the IR
• CR at iliac crests
• Ensure Pubic symph is included
• Ensure IR is perpendicular to CR
• Demonstrates entire abdomen from pubic symph to diaphragm

Front 15

Abdomen Lateral projection (dorsal decubital)

Back 15

• Used to visualize air fluid levels or free air when the patient is unable to stand to turn for left lateral decubitis
• Often used for neonates
• Center IR to a point 5cm above the level of iliac crest -- 2”
• CR directed horizontal and perpendicular to the IR entering the midcoronal plane 5cm above iliac crest – 2”
• Demonstrates the diaphragms without motion, prevertebral space, air fluid levels of free air

Front 16

What is the first image of the C-Spine acquired?

Back 16

Cross table lateral- dorsal decubitus

Front 17

Are you allowed to maneuver the patient in C spine precautions?

Back 17

NO! only doctors can.

Front 18

Cross Table lateral, Dorsal decubitus C Spine

Back 18

o Use 180 cm SID when possible
o Remove objects that will over lap anatomy
o Ask patients to depress shoulders as much as possible
o CR directed horizontal, perpendicular to C4
o Often will require a swimmers as the patients shoulders are harder to depress with the patient supine
o Grid not necessary due to air gap technique
o Include sella turcica, soft tissue nterior to C spine nd as many vertebra as possible
o Swelling of the soft tissue anterior to C spine (prevertebral space or retropharyngeal tissue) indicates high suspicious of a fracture

Front 19

What will the radiologist and CO use the following lines to evaluate C spine

Back 19

• Anterior contour line- connects anterior margins of the vertebrae
• Posterior contour line connects posterior aspect of the vertebrae
• Spinolaminar contour line connects bases of spinous processes
o More thean 6 mm at C3 and more than 22 mm at C6 is indicative of a fracture

Front 20

Odontoid Peg Fracture

Back 20

• Acute flexion or extension resulting in a fracture thourgh the base of the dens, most common fracture of C2

Front 21

Hangmans Fracture

Back 21

• Hyperextension injury resulting in a fracture of pedicles of C2
• Results from sever whiplash or hanging injuries

Front 22

Compressions Fracture

Back 22

• Hyperflexion injury resulting in an anterior compression of vertebral body

Front 23

Disarticulation

Back 23

• Hyperflexion or rotation resulting in anterior displacement of the vertebrae

Front 24

Spinous process fracture

Back 24

• Avulsion by the superspinatous ligament off the spinous process, usually C6 or C7
• Caused by flexion as the body rotates relative to the head and neck

Front 25

Cross Table lateral Swimmers (C- Spine)

Back 25

• Necessary if C7/T1 not clearly visualized on lateral
• Use the upright bucky when available
• If patient is unable to separate shoulders angle the stretcher board to separate shoulders
• CR directed horizontal and perpendicular to C7/T1
• Use breathing technique if possible
• Collimate closely
• A compensating filter or a saline bad may be placed over the proximal cervical vertebrae to make visualization of those vertebrae easier

Front 26

AP open mouth C- Spine

Back 26

• Modifications needed as patient is wearing cervical collar and on spinal precautions
• Rather than manipulating the patients head to place the occlusal plane perpendicular to the IR andle the CR to be parallel with occlusal plane, can be caudad or cephalad
• Will result in correct visualization of C1/C2 of giving against spinal precautions
• BEWARE- mach effect artifacts overlying peg and mimick fracture

Front 27

Burst Fracture of C1/Jefferson

Back 27

• Comminuted fracture of C1 caused by axial compression
• Unilateral C1/C3 odontoid peg joint space widening
• Lateral masses of C1 overhang the lateral masses of C2

Front 28

AP projection of the Dens (Fuchs)

Back 28

• Used when patient cant open mouth
• Or further investifate dens
• Eliminate the need to manipulate immobile patients by positioning the CR
• On a monile patient extend chin until the mentum and the mastoid processes are vertical and use a vertical CR
• On an immobile patient direct the CR parallel with a plane passing through the mentum and mastoid processes
• CR enters midsag plane at a point just distal to the mentum and passes through mentum and mastoid processes
• Demonstrates desn within the foramen magnum
• No rotation as indicated by symmetry

Front 29

Special Instructions while doing T and L spine?

Back 29

• Ensure spinal immobilization precautions are adhered to
• Closely adher to the trauma spine radiography protocols of your department
• Any manipulation to the patients position may be performed by the attending physician ONLY
• High risk of paralysis, spinal shock, and death
• A swimmers will be needed to visualize T1-T3

Front 30

Cross Table lateral T spine

Back 30

o CR- horizontal and perpendicular to IR at T7 enterinf posterior half of thorax
o Use breathing technique ot expose on full expiration
o Vertebrae seen clearly and in profile through ribs and lungs
o 12 thoracic vertebrae (T1-3) not well and L1
o posterior superimposition of ribs
o open disc spaces
o since the articulation between C7 and T1 is not clearly a swimmers must be performed

Front 31

Cross Table Lateral L spine

Back 31

o Raise both arms or cross over chest
o Remove objects that will overlap anatomy
o Align midcoronal plane with the IR at the level of the iliac crest
o CR horizontal and perpendicular to L4 at iliac crest
o Expose on full expiration
o Verterbarae clear and in profile
o Lower thoracic to sacrum cocyz
o Open disc spaces

Front 32

Spot projections, T or L

Back 32

• Ap projections/lateral “spot”
o Images acquired after centering over vertebrae of interest

Front 33

Most common adaptation for Skull?

Back 33

AP instead of PA

Front 34

What must you watch for while doing a Skull Trauma?

Back 34

patient for changes in LOC and for symmetry of the pupils

Front 35

Cross Table lateral Dorsal Decubitis Skull and Facial Bones

Back 35

• use a horizontal CR for lateral projections of the skull/facial bones as the presence of an air/fluid level within the sphenoid sinus is a sensitive sign for intracranial damage
• elevate the skull on a radiolucent pad to avoid clippin of occipital bone if cleared of spinal precautions
• Skull CR – horizontal and perpendicular to 5cm superior to EAM
• Facial bones CR – horizontal and perpendicular entering halfway between outer canthus and EAM

Front 36

AP projections for skull, facial bones and mandible

Back 36

• Reversals of standard PA projections
• Entry points become exit points , exit points become entry points
• Only position the CT and IR if the patient is on spinal precautions
• Anterior structures will appear magnified when compared to a PA
• Facial bones CR—directed to form a 15 degree angle with oml entering the nasion Cephalad
• Mandible CR—parallel with OML entering acanthion

Front 37

Acanthioparietal projection (reverse waters) of Skull

Back 37

• Entry point become exit point, exit point becomes entry point
• Position the CR and IR if the patient is on spinal precautions
• Anterior structures will appear magnified when compared to standard waters
• CR—directed parallel to MML entering acanthion

Front 38

Mandible Shoot thru Axial

Back 38

• Useful in obtaining mandible images on patients in spinal immobilizations
• A horizontal CR is directed cephalad to separate the halves on the mandible
• AK Pt. to depress shoulder to prevent SI
• CR – directed horizontal and 25 degrees cephalad through mandibular area of interest, usually the rami if unable to rotate head

Front 39

AP Projection of the Elbow in Partial Flexion

Back 39

Merrill's Vol. 1 pg 156-157 - Used when the patient is unable to fully extend elbow. The elbow must be extended past a 90o angle to use this method.

Front 40

AP/PA Projection of the Elbow in Acute Flexion

Back 40

Merrill's Vol. 1 pg 158-159 - Used when the patient is in acute flexion. The elbow must be flexed past a 90o angle to use this method. The greater the flexion, the better resultant image.

Front 41

Axiolateral Projection of the Radial Head (Coyle Method)

Back 41

Merrill's Vol. 1 pg 162-164 - Used when the patient is unable to extend the elbow for the medial/lateral oblique projections of the elbow or rotate the hand for the four-position radial head series.

Front 42

Transcapular Lateral Y of the Shoulder (AP Oblique Projection

Back 42

Merrill's Vol. 2 pg 50 (Modification of PA Oblique Projection Merrill's Vol. 1 pg 199-201) - Used when the patient is unable to be upright for a standard Transcapular Y, the CR may be reversed. The desired image is obtained with the patient in the semi-supine position. The resultant image will demonstrate increased magnification of the proximal humerus if compared to a standard PA Oblique Projection.

Front 43

The goal of every imaging modality?

Back 43

to record a visual representation of a patients anatomical structures with as much detail and accuracy as possible

Front 44

define adaptive radiography

Back 44

alteration of the routine radiographic procedures to accommodate the patients condition

Front 45

Define Trauma

Back 45

sudden unexpected, dramatic forcedul or violent leading
• 5th leading cause of death in north America
• leading cause of death in people under 45

Front 46

Causes of Trauma

Back 46

• blunt force- MVC, fall, assault
• Penetrating- GSW, stabbing
• Exploisve – pressure shock waves
• Burn-s fire chemicals frostbite

Front 47

5 level of trauma care

Back 47

• Level 1 trauma care centres
o Also called dedicated tertiary trauma centres
o Play a central role in the regional trauma system by handling the majority of trauma care
o Provide the complec and often unique trauma
• Level 2
o Decreased ability to treat the injured patient as their step increases
o Level 2 Centre comparable to MCH GNH QE2 NL

Front 48

What is MOI (mechanism of Injury)?

Back 48

• refers to how damage to the soft tissue or bones occur
• used to determine the severity
• Treatment protocals are often based on MOI

• Trauma patients that arrive to the emergency department with a high risk MOI are considered to have a potential spinal injury
• Despite a lack of indication by a patient regarding pain or discomfort clinical and diagnostic should

Front 49

For a sever motor vehicle collision what is the standard radiography protocol?

Back 49

AP chest AP pelvis and APS and laterals of the C/T.L spine

Front 50

What are distracting injuries?

Back 50

the patient may not be able to recognize or feel other injuries they have incurre

Front 51

Universal Guidelines to Trauma?

Back 51

• speed
• accuracy
• qualirt
• positioning
• practice standard precautions
• immobilization
• anticipation
• attention to detail

Front 52

Prioritizing Procedures?

Back 52

• begin with the most critical images being acquired first.
• Order should be such that it has less manipulation

Front 53

Different Types of communication?

Back 53

• conscious patient
o maintain eye contact
o use common and general terminology
o keep coive in calm and compassionate tone
o have patient assist where possible
o keep all instructions clear and concise
o demonstrate for the patient on yourself as you explain the exam
• Unconscious patient
o Never assume the patient cant here you
o Use name
• Communication
o Non Verbal Communication
o Do not react to the patients physical appearance or condition particularly if the patient has some form of disfigurement
o Do not react to them circumstances resulting in the patients presence in the hospital

Front 54

What factors affect patients mental state?

Back 54

• medications, substance use/ abuse, head injuries and shock can alter a patients ability to reason and cooperate appropriately

• may make patient uncooperative
• radiographer must be able to recognize signs of impairment and act accordingly
• common signs of impaired mental state, slurred speech

Front 55

The radiographer must know how to have theses basics:

Back 55

o Take and record vital signs
o Perform CPR
o Administer oxygen
o Deal with medical emergencies
o Utilize suction equipment
o Visually assessing position condition
o Document actives
o Determine the patients responsiveness

Front 56

Responsible radiation safety precautions:

Back 56

• use exposure factors that minimize dose and scatter
• collimate when possible to reduce scatter
• shield the patient when it will not interfere with area of interest
• provide shielding for all
• announce that exposure is about to occur
• ensure patients visitors and staff adjust
• treat unresponsive female as pregnant until proven otherwise

Front 57

What is mandatory in all Radiographic imaging regarding getting all the critical information to make a diagnosis?

Back 57

2 images 90 degrees apart

Front 58

Should both joints always be included in extremity images?

Back 58

Yes

Front 59

Tube factors for adaptive rad?

Back 59

• SID- use 200 or 180 to standardize monitors
• CR- maintain a perpendicular relationship between the CR and IR/ part to reduce shape distortion
• Patient/Part mobility- the less mobile the part the more adaptation
• Foreign objects- assess whether image quality will be compromised by necklaces belts bras and earrings
• Part thickness and tissue density- if the density of the part increased, then increase technical setting would be needed
• Immobilization and Positioning Aids- use tape, sponges, sandbags
• OID- minimize OId to reduce magnification, Consider increasing the SID to compensate for a long OID
• IR cassette edge- elevate the part to perform cross table lateral images as the IR plate does not extend to the edge of the cassette
• Technical Considerations

Front 60

Documentation

Back 60

• exam verification
oit is the responsibility of tech to confirm the exam requested coincides with the patients injury must confirm request
• Document Modifications
oTech must document alterations from routine to ensure rads interpretation will be knowledgeable
• Documentation Of incidents
oDocument all incidents that occur duting the time the patient is in your care documentation should include as much detail of the incident as possible, the staff involved and be completed ASAP following the incident

Front 61

AP Projection with Partial Flexion of Distal Humerus (elbow)

Back 61

- entire humerus on same plane
- supinate hand if possible
- IR under elbow, centered to femoral condyles
-CR is perpendicular to humerus, traversing elbow joint
- depending on degree of flexion angle the CR distally into joint

Front 62

AP projection with Partial flexion of Proximal Forearm (elbow)

Back 62

-dorsal surface of forearm resting on table (or elevate limb on support, adjust limb to lateral, and shoot thru horizontally
- hand supinated
-CR perpendicular to elbow joint and long axis to forearm

Front 63

AP projection of Distal Humerus with acute flexion

Back 63

- elbow fully flexed unless contraindicated
-IR proximal to epicondyles area of humerus
-long axis of forearm and arm should be parallel with long axis of IR
-CR perpendicular to humerus approx 5 cm (2") superior to olecronon process

Front 64

AP Projection of proximal forearm with acute flexion

Back 64

- elbow fully flexed
- center flexed elbow inc centre of IR parallel with IT
-CR perpendicular to flexed fore arm entering 5 cm distal to olecranon process (change angulatiojn of tube to make perpendicular w/ forearm)

Front 65

Axiolateral Projection of radial head and coronoid process
Coyle Method

Back 65

- patient supine
- elevate elbow on sponge
-place Ir vertical position centred to elbow joint
- Epicondyles approximately perpendular to IR
- slowly flex elbow 90 degrees to show radial head or 80 degree for coronoid process
- turn hand so that the palmar aspect is facing medially
-CR for radial head- horizontal CR is directed cephalic at angle of 45 degrees to the radial head, entering the joint at mid elbow
- CR for Coronoid process- horizontal central tay is directed caudal at angle of 45 degrees to the coronoid process entering mid elbow

Front 66

Transcrapular Y of Shoulder

Back 66

Used when the patient is unable to be upright for a standard Transcapular Y, the CR may be reversed. The desired image is obtained with the patient in the semi-supine position. The resultant image will demonstrate increased magnification of the proximal humerus if compared to a standard PA Oblique Projection)

-CR perpendicular to scapulo humeral joint
-midcoronal plane 45-60 degrees to IR
-flat surface perpendicular to IR