Film Critique of the Lower Extremity - Part 2

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Please note: This unit contains numerous images and may download slowly. If all of the images don't load, click the re-load button on your browser to continue loading the remaining images. Depending on your connection speed, you may need to click the reload button more than once. Article Navigation: Diagnostic Criteria for the AP and Lateral Knee Radiographs Diagnostic Criteria for the Oblique Knee, Tunnel View, and Sunrise View Diagnostic Criteria for Imaging the Tibia/fibula-AP and Lateral Views Radiographic Film Critique of the Lower Extremity: Femur, Knee, and Tibia/Fibula Written by Nicholas Joseph Jr. RT(R)(CT) B.S. M.S Film Critique is a visual learning tool that allows the radiographer to understand the diagnostic criteria for each view in a radiographic series. Film critique is where professional imaging standards move beyond the classroom and into the real life practice of radiographic imaging. This is a reverse learning session. You will see poorly made radiographs and then learn what can be done to make better images in many difficult situations. Before beginning this lesson you should be familiar with the anatomy of the lower extremity, the effects of radiographic exposure techniques (mA, kVp), and patient positioning. The imaging professional must decide if a film is truly useful as a diagnostic tool before it reaches the watchful eye of the radiologist who will use it for interpretation. Knowing the diagnostic standard for each film is of paramount importance where the goal is the presentation of useful images. Lower Extremity Film Critique The purpose of this critique is to raise the technologist’s awareness of what radiologists and orthopedic physicians require when diagnosing and treating injury and disease involving the lower extremity. It is hoped that your examination of this treatise will result in your production of better radiographs. This lesson is organized so that images are presented and then critiqued so as to promote effective learning. Each subject matter should take about 10 minutes. Upon completion, you may take brief exam which presents questions on a sampling of images. Glossary of terms: Overexposure (too much mAs) Underexposure (too little mAs) Overpenetrated (too much kVp) Underpenetrated (too little kVp) Positioning error (patient position) Tube error (improper tube angle) Diagnostic Criteria for the AP and Lateral Views of the Femur When a request for a femur is made the entire femur including both the hip joint and knee joint must be included on the radiograph. If it cannot be included as a single film then two films with overlapping parts should be made. AP femur should have the condyles of the femur parallel to the image receptor. The lateral should place the condyles perpendicular to the image receptor. Lateral femur should demonstrate either a frog lateral of the hip, or a crosstable lateral of the hip. Generally the AP and lateral femur is made to include the knee on the 14 X17 films, and 10 X12 films of the AP and lateral hip views. Radiographic technique should include good knee and hip densities with bone trabecular patterns seen; soft tissue detail should also be seen. Radiograph #60 What is your critique of this radiograph? Consider that this is the lower half of a two picture equals one lateral view. Critique of Radiograph #60 This radiograph includes as much femur as can be expected on one film, the upper femur can be imaged separately with overlap. The positioning is a bit rotated. This is enough to make viewing of the two pins out of orientation. For this post surgical image the positioning is very important to document. Therefore, repeat this view the knee in a true lateral without rotation. Radiographic exposure technique is good but could have a bit lower contrast to bring out a good penetration of the shaft. Radiograph #61 What is your critique of this radiograph? Critique of Radiograph #61 This is a good view of the distal femur to include the knee and fracture site. The proximal femur can be imaged as a hip series to complete the criterion for this view. Positioning and radiographic technique is adequate for this view. The patient I.D marker obstructs the soft tissues of the femur. When making the AP proximal femur radiograph be sure to overlap the segment that the I.D. marker blocks. Radiograph #62 What is your critique of this radiograph? Critique of Radiograph #62 This radiograph contains part motion which obscures image detail. Like most femur radiographs this image includes the bone extremity closest to the injury or pain on the 14 X 17 film. A separate lateral of the hip must be included on a second film (10 X 12). Position the knee in a true lateral when this film is repeated. Flex the knee joint making a 120 degree angle between the tibia and femur. The radiographic technique seems good enough to differentiate cortical bone and the medullary cavity. This will help in the diagnosis of the opaque densities seen on this radiograph. Radiograph #63 What is your critique of this film? Critique of Radiograph #63 This is the classic do not do radiograph. When imaging any long bone you must include at least one joint if you are splitting the views. Making a radiograph of the femur demonstrating the shaft but no extremity is a cardinal “no, no.” This view must be repeated to include at least one joint either proximally or distally. A second film to include the remote joint and overlapping the first film should also be made. The radiographic positioning is adequate for the shaft; however, we cannot say for the joints because they are not visualized. Summary: AP & Lateral Femur Views The entire femur should be included on both views with both the hip joint and knee joint seen on each radiograph. If both joints cannot be included as a single film then two films with overlapping parts should be made. AP femur should have the condyles of the femur parallel to the image receptor. The lateral should place the condyles perpendicular to the image receptor. Lateral femur should demonstrate either a frog lateral of the hip, or a crosstable lateral of the hip. Generally the AP and lateral femur is made to include the knee on the 14 X17 films, and 10 X12 films of the AP and lateral hip views. Radiographic technique should include good knee and hip densities with bone trabecular patterns seen; soft tissue detail should also be seen. Always ask, "Did I achieve the diagnostic standard for this view?" To the top To the bottom Diagnostic Criteria for the AP and Lateral Knee Radiographs For the AP view the condyles of the femur are parallel to the image receptor: CR should pass through the knee joint just below the patellar apex. Supine view is good for identifying fractures/dislocations. Standing view when arthritic conditions are being evaluated. For the lateral view the condyles are superimposed by placing the tibia on the same plane as the femur. With the condyles perpendicular to the image receptor: Knee is flexed 20-30 degrees unless a patella fracture is suspected. The patellofemoral joint and knee joint should be seen with a space between the articulations on the lateral view. Radiographic technique should allow for visualization of blood effusion and air within the joint or its capsule. If a prosthetic device is present the entire device must be seen on a single radiograph of each view. Joint spaces must be seen with a prosthetic device as with the normal bone anatomy. Radiograph #64 What is your critique of this AP view of the knee? Critique of Radiograph #64 This is a relatively good AP view of the knee. The joint space on the right is not opened very well. The knee and femur should be on the same plane by placing a towel under the heel, or angle the tube 5-7 degrees cephalic. Radiographic exposure is adequate for this view. This picture should not be repeated. Radiograph #65 What is your critique of this radiograph? Critique of Radiograph #65 This radiograph includes all of the prosthesis as required by the diagnostic criteria. The condyles are parallel to the film so the image is a true AP view. The knee joint is not opened well, which is chronic. Radiographic technique is good for bone penetration and soft tissue surrounding the bone. Soft tissue is important for this type of radiograph make sure there is no air in the tissues which would indicate a bone infection. Radiograph #66 What is your critique of this radiograph? Critique of Radiograph #66 The positioning seen here is excellent. The tube angle is slightly off, but that’s ok. The joint spaces are open and the medial and lateral intercondylar tubercles of the tibia are well visualized. Radiographic technique shows good bone trabecular pattern and soft tissues. Radiograph #67 What is your critique of this radiograph? Critique of Radiograph #67 The positioning for this radiograph maintains the joint space open while demonstrating the fracture of the distal femur. The positioning is good with the condyles parallel to the image receptor. Radiographic technique is adequate for bone and soft tissue. Radiograph #68 What is your critique of this radiograph? Critique of Radiograph #68 This is a good film in terms of positioning of the part and collimation. The radiographic technique is adequate for bone and soft tissue. The entire internal fixation should be seen on all radiographs. Even though the bone has nearly healed, indicating this is a follow up radiograph, the entire fixation must be seen. Sometimes the surgeon may wish to see where all pins and screws are before planning to remove them. As technologist, we cannot make a value judgment related to the diagnosis of a radiograph: therefore, we must follow a diagnostic criteria. Radiograph #69 What is your critique of this radiograph? Critique of Radiograph #69 This radiograph is to evaluate the hemiarthroplasty of the knee. Knowing the different types of surgeries that a surgical radiographer images will help in critiquing this film. Basically the joint space should be well demonstrated with the anterior and posterior cortical lips superimposed (arrows). This radiograph does not need to be repeated, but you should know what an A+ film is. The radiographic exposure technique excellently displays the prosthesis, bone, and soft tissues. Radiograph #70 What is your critique of this standing bilateral knee radiograph? Critique of Radiograph #70 This is a good radiograph of bilateral standing knees. Notice each knee is positioned correctly by internally rotating the leg. Even though both knees are being radiograph together you must position each one separately to achieve this quality in your imaging. Radiographic technique is adequate for both knees. The penetration of the parts, bone trabeculae, and soft tissues are all well demonstrated on this film. Radiograph #71 What is your critique of this film taken to evaluate the knee hemiarthroplasty? Critique of Radiograph #71 To evaluate this radiograph we must look at the joint space opposite the hemiarthroplasty. Notice that the joint is open and the anterior and posterior cortical margins of the tibia are perfectly superimposed. This is the standard for imaging the knee. This is a well positioned part. The radiographic technique adequately demonstrates the space between the prosthesis, bone detail, and soft tissue detail. Radiograph #72 What is your critique of this post op knee radiograph? Critique of Radiograph #72 The radiographic technique is adequate for bone and soft tissue. Positioning of the part is good as the joint space is opened. When a post operative knee is requested and you did not do the surgical case, you must ask what the procedure was in order to make proper post op films. Here the technologist should include the entire internal fixation. The upper femur is not of significance to this knee radiograph. This very nice radiograph must be repeated to include the fracture and entire internal fixation. Radiograph #73 What are your comments on this radiograph? Is the diagnostic criteria accomplished for this prosthetic implant in the knee? Critique of Radiograph #73 Yes, it meets the diagnostic criteria for the following reasons: The condyles of the femur are not rotated. Joint space throughout the knee joint is opened and the tibial prosthetic plate is presented level. Radiographic exposure technique is adequate for metal, bone, and soft tissue. Radiograph #74 What is your critique of this radiograph? Critique of Radiograph #74 The radiographer’s first duty is to provide quality patient care. The diagnostic criteria for the knee are met by this film; however, seeing these fractures should cause one of two responses by the technologist. Repeat the film to include below the fracture of the tibia, or Call the ER physician to look at the film, or order a complete tibia/fibula radiographic series. The latter is preferred since you don’t really want to go chasing the extent of injuries this patient may have suffered. Radiograph #75 What is your critique of this film? Does it meet the diagnostic criteria? Critique of Radiograph #75 Be careful with the I.D. marker. This is a type of comminuted fracture that may have long term complication. The original post op films are considered a very important medical legal document. This film must be made correctly or it must be repeated. There is no exception! The long term health issues this patient faces are great, as well as the potential medical legal issues this injury may generate. Always find out where on the patient the surgery was performed and move the marker to a remote location before making a radiograph. Otherwise the radiographic technique and positioning is excellent. Radiograph #76 What is your critique of this film? Does it meet the diagnostic criteria? Critique of Radiograph #76 This is a good portable horizontal beam lateral of the knee. Because this is a post surgery film to document the surgery you must position these film correctly or repeat them. This is the perfect presentation of the post knee replacement radiograph. Notice the knee joint is presented with a space between the femur and tibia. The space between the patella and femur is also demonstrated. There is a meniscus like artificial material in the joint space that is evaluated as well as the prosthesis. This is what the orthopedic surgeon wants to see from the radiographer. The radiographic technique is good for metal, bone, and soft tissues of the knee. Radiograph #77 What is your critique of this standing lateral knee view? Critique of Radiograph #77 It is difficult to align the patient for an upright lateral knee. Some practice is required; however, the same criteria apply to an upright film as to a lateral recumbent image. The condyles of the knee should be superimposed. The patellofemoral joint should be opened. Internally rotate the knee until the condyles are superimposed. These radiographs must also be correct because evaluation and surgery measurements may be taken by the orthopedic surgeon. The radiographic technique is adequate for the knee. Radiograph #78 Does this radiograph meet the diagnostic criteria? Critique of Radiograph #78 This is how the joint spaces should look on a lateral radiograph. Note that the patellofemoral space is seen. The condyles of the femur are superimposed. This is also a standing knee radiograph and the knee is not flexed. Radiographic technique is adequate for bone and soft tissues of the knee. Radiograph #79 Does this radiograph meet the diagnostic criteria? Critique of Radiograph #79 This radiograph is also a post operative film to document the prosthesis placement. Notice the knee joint is opened but the patellofemoral space is closed. It is important for this picture to be made correctly. It should be repeated with the knee rotated more externally pointing the patella upward. Radiographic technique is good for bone and soft tissue detail. Radiograph #80 Does this horizontal beam lateral projection meet the diagnostic standards? Critique of Radiograph #80 Yes this radiograph does meet the diagnostic standards for the lateral knee. The sponge shadow under the knee indicates it was projected as a crosstable lateral. There is minimal rotation of the part as the condyles of the femur are superimposed. Radiographic technique shows good bone detail, soft tissues, and bone trabeculae. Radiograph #81 What is your critique of this film? Does it meet the diagnostic criteria? Critique of Radiograph #81 This standing lateral knee shows the entire internal fixation as well as the knee joint. The patient is unable to completely extend the knee joint as can be seen on the radiograph. The positioning is excellent in that the condyles are superimposed. The patellofemoral space is not well opened, but this time it is ok. Radiographic exposure technique is adequate for bone and soft tissue detail. Radiograph #82 What is your critique of this post surgical radiograph? Critique of Radiograph #82 The positioning of the patient is adequate having the condyles superimposed. There is a space between the two prosthetic articulations which is required for this view. The patellofemoral space though small is acceptable. The exposure technique is superb having a good but delicate balance between bone penetration, trabecular pattern, and soft tissue visualizations. Radiograph #83 What is your critique of this radiograph taken of a patient with a history of knee replacement surgery who had a fall? Critique of Radiograph #83 This is a well positioned knee radiograph showing the prosthesis of a patient who fell. The physician wanted to r/o injury or displacement of the prosthesis resulting from the fall. The technologist elected to take the image as a horizontal beam lateral so comparisons could be made with films taken months earlier. The image shows no disruptions of the joint spaces, or dislocation. Being able to make radiographs of this quality using a horizontal beam is truly an art. The visualization of soft tissue and bone are balanced nicely on this radiograph. Notice there is no air in the joint, and the soft tissue detail shows the artificial meniscus in the joint, an A+ film. Radiograph #84 What is your critique of this radiograph? Critique of Radiograph #84 The positioning seen here is acceptable; however, the knee is rotated. To achieve a good lateral the recumbent knee should be flexed. The knee may have to be adjusted so that the radiation beam passes through the patellofemoral space to open it. Rotation of the knee and failure to open the patellar space are the two most common positioning errors of the knee. Radiographic exposure technique is good for bone and soft tissue detail. Summary: AP and Lateral knee Views For the AP view the condyles of the femur are parallel to the image receptor: CR should pass through the knee joint just below the patellar apex. Supine view is good for identifying fractures/dislocations. Standing view when arthritic conditions are being evaluated. For the lateral view the condyles are superimposed by placing the tibia on the same plane as the femur. With the condyles perpendicular to the image receptor: Knee is flexed 20-30 degrees unless a patella fracture is suspected. The patellofemoral joint and knee joint should be seen with a space between the articulations on the lateral view. Radiographic technique should allow for visualization of blood effusion and air within the joint or its capsule. If a prosthetic device is present the entire device must be seen on a single radiograph of each view. Joint spaces must be seen with a prosthetic device as with the normal bone anatomy. To the top To the bottom Diagnostic Criteria-Oblique Knee, Tunnel view, and Sunrise View There are three additional views of the knee that are commonly made. Medial and lateral oblique views, tunnel view, and the sunrise view. Medial and lateral oblique views are made with the knee either turned medially or laterally to demonstrate the joint space. The patella is also partially exposed since it is not seen well on the AP view. Tunnel view must demonstrate the intercondyloid fossa, tibial plateau and eminences. Tangential view (sunrise) demonstrates the patellofemoral articulation and space, and to evaluate for vertical fractures of the patella. These three views should be made with good bone detail. Radiograph #85 What is your critique of this radiograph? Critique of Radiograph #85 This is a well positioned medial oblique knee radiograph. Notice the patella is projected away from the femur providing a good look at its contour. The joint spaces of the knee are well demonstrated. The joint space between the head of the fibula and the inferior surface of the lateral condyle of the tibia is well demonstrated. Radiograph technique is good showing bone trabeculae and soft tissue details. Radiograph #86 What is your critique of this radiograph? Critique of Radiograph #86 Notice the positioning of this radiograph does profile the head of the fibula. However, the joint spaces of the knee articulation are not open very well. This is because the knee is partially flexed. If the knee cannot be extended then do not angle the tube. The CR must pass between the femur and tibia for the oblique views. Radiographic exposure technique is adequate for bone and soft tissues. Radiograph #87 What is your critique of this medial oblique knee radiograph? Critique of Radiograph #87 The problem areas to be demonstrated on the oblique views are the tibial plateaus, eminences, and joint spaces. This radiograph fails to demonstrate any of these structures very well. Sometimes placing a rolled towel under the ankle and using a perpendicular CR will help to open the spaces. Most technologists will use a slight cephalic tube angle to open the project the joint space open. Radiographic exposure technique is adequate for bone and soft tissue detail. Radiograph #88 What is your critique of this radiograph? Critique of Radiograph #88 This medial oblique is adequate; however, it does not demonstrate both joint spaces as it should. The head of the fibula is well profiled. The radiographic exposure is demonstrates bone trabeculae and soft tissues very well. Radiograph #89 What is your critique of this radiograph? Critique of Radiograph #89 Here we see the joint spaces are opened partially on the medial and lateral sides of the knee. The fibular head is shown in profile. However, the eminences are not well demonstrated because the knee is rotated too much medially. The positioning of this medial oblique approaches a lateromedial lateral projection. This has obstructed the view of the eminences in relationship to the condylar notch of the femur. Radiographic exposure technique is adequate for diagnosis of bone and soft tissues. Radiograph #90 What is your critique of this tunnel view? Critique of Radiograph #90 This radiograph shows the intercondylar fossa, tibial plateau, and eminences. The joint spaces and condyles of the femur are also noted. The patient positioning is very good. The radiographic technique is good for bone detail; however, the overall image shows high contrast and overexposure of the lateral margins of the distal femur and proximal tibia. This radiograph does not need repeating for the stated errors. Radiograph #91 What is your critique of this Tunnel view of the knee? Critique of Radiograph #91 The positioning of the patient for this radiograph is a bit off since the medial joint space is not opened and the femoral condyles are elongated. This is most likely caused by the tibia not being perpendicular to a vertical central ray. When doing this view the tibial plateaus should be demonstrated as well as the intercondylar notch and eminences. The radiographic technique is not so good. The radiograph is grainy having poor bone detail. The trabecular pattern is not defined, nor is the bone edges. Radiograph should be repeated to correct technique and positioning. Radiograph #92 What is your critique of this radiograph? Critique of Radiograph #92 This is a relatively good radiograph. It demonstrates the patellofemoral joint very well. This view is good for evaluating subluxation of the patella or a vertical patellar fracture. Radiographic technique is good, although the clothing has left some artifacts on the image. Radiograph #93 What are these views? What is your critique of them? Critique of Radiograph #93 This view is known as the tangential, sunrise, or the Hughston view. The two views presented are the 60 and 20 degree tube angle views. Notice that in both cases the patellofemoral joint is opened. These views are taken to r/o dislocation or vertical fracture of the patella. The 60 and 20 degree views are orthopedic specific and are taken prior to knee replacement surgery for some surgeons These are well positioned radiographs with good exposure technique. Radiograph #94 What is your critique of this radiograph taken for possible patella fracture, or ligament injury, or possible foreign body? Critique of Radiograph #94 This one is almost unbelievable that a technologist would collimate the image this close for a trauma survey. The pen (arrow) marks the site of pain. This does not make this an acceptable radiograph. The entire knee should be seen for a patella injury. Remember the patella is a sesamoid bone that is imbedded within the tendon of the quadriceps muscle. It inserts distally to the tibial tuberosity. The patellar ligament is that portion of the tendon that runs from the apex of the patella to the tibial tuberosity. This entire relationship must be seen on the lateral radiograph. Radiographic technique seems to have too high contrast to evaluate soft tissue detail as well as bone. Radiograph must be repeated. Radiograph #95 What is your critique of this radiograph? Critique of Radiograph #95 This is a well positioned 60 degree tangential view. The knee is flexed very well, the patellofemoral space is opened and the patella is profiled. However, there is motion on the radiograph. A gross fracture could be seen, but not subtle injury. The trabecular pattern is obliterated. Don’t pass this image. This radiograph must be repeated. Radiographic exposure technique is very good and should not be changed, except to increase the mA and reduce the exposure time. Radiograph #96 What is your critique of this radiograph? Critique of Radiograph #96 As apposed to the regular trauma sunrise view these 60 degree flexion of the knee tangential views are tricky. Notice the knee is bent properly evidenced by the tibia’s projection below the femur. The problem of the patellofemoral joint being closed is caused by improper tube angulation. In this case the angle should be decreased to open the joint space. But before we reach our final conclusion we must see the lateral view to make sure the patella is not dislocated superiorly. Radiographic technique is adequate for this view. Radiograph #97 What is your critique of this radiograph? Critique of Radiograph #97 Obviously this is an underpenetrated part. What is important here is that you repeat this quality radiograph. But before you repeat this image you should get as much information as you can about it so the repeat is a great radiograph. The joint space is not appreciated on this film so the part or the CR angle should change slightly. Either decrease the tube angle or slightly extend the knee joint to open the space. Radiographic technique requires an increase in kVp to penetrate this knee. Radiograph #98 What is your critique of this radiograph? Critique of Radiograph #98 This appears to be a good radiograph, and it is, except for one small observation. The leg is not straight, that is, the leg and femur are not aligned on the same plane. The medial side of the joint is not opened as well as the lateral side of the joint. This can be corrected by keeping the femur and leg in the same plane. Most technologists who get a picture like this one are satisfied with it. But we should be correcting these small errors to reach a higher standard of image quality. This is the art of radiography to correct these small errors in positioning and technique. The radiographic technique is good showing bone detail and soft tissue. Radiograph #99 What is your critique of this sunrise view of the knee? Critique of Radiograph #99 This is a good attempt to get a sunrise view of this knee as part of a long term follow up to a knee injury. The technologist positioned the patient well; however, the patellofemoral space must be demonstrated. This film like any is for diagnostic purpose not photography. We must see the required anatomical presentation or the view is just a picture and worthless. Adjust the tube angle since the knee is properly bent and we do not see the tibia overlapping the joint or patella. Radiographic technique is good for bone and soft tissue. Radiograph #100 This one you do not have to critique, but is included to show the relationship of the popliteal artery to the knee. Dislocation of the knee and or crush fractures cause popliteal artery injury in approximately 40% of these patients. Usually the pulse below the site is weak and may return following reduction. This is a FYI radiograph of the blood flow through the femoral artery in the thigh and popliteal behind the knee! Summary of Critique: Oblique, Tunnel, and Sunrise Views. Medial and lateral oblique views are made with the knee either turned medially or laterally to demonstrate the joint space. The patella is also partially exposed since it is not seen well on the AP view. Tunnel view must demonstrate the intercondyloid fossa, tibial plateau and eminences. Tangential view (sunrise) demonstrates the patellofemoral articulation and space, and to evaluate for vertical fractures of the patella. These three views should be made with good bone detail. Always ask, "Did I meet the diagnostic criteria for this view?" To the top To the bottom Diagnostic Criteria for Imaging the Tibia/fibula-AP and Lateral Views A request for the leg is made the entire tibia/fibula including both the knee and ankle joints should be made. If it cannot be included as a single film then two films with overlapping parts should be made. Good soft tissue detail should be seen to evaluate whether there is an open fracture that is a surgical emergency. Good bone detail should be seen so that the trabecular pattern is noted throughout the tibia and fibula. Radiograph #101 What is your critique of this radiograph? Critique of Radiograph #101 This is a good radiograph of the leg in terms of positioning. The distal fibula is partially clipped; however, the view does not need repeating. What would have helped in the interpretation of this radiograph is for the technologist to indicate the location of the soft tissue injury. Radiographic technique is adequate for bone and soft tissue. Radiograph #102 What is your critique of this radiograph? Critique of Radiograph #102 This radiograph meets the diagnostic standards for imaging the leg. Positioning is accurate for both joints. Again the soft tissue injury is noted; however, the technologists did not mark the site of injury as is done artificially on the critique radiograph. Always mark the site of injury when a possible foreign body has penetrated the skin. Radiographic contrast is excellent for soft tissue and bone detail. Radiograph #103 What is your critique of this radiograph? Critique of Radiograph #103 This radiograph is underpenetrated. Usually the exposure when a cast has been placed on a patient should be increased. The cast material appears to be fiberglass so the technique should not change very much from a regular technique without a cast. Always check to see what type of material is used to splint an extremity so you can make the proper technique adjustment. The technologist simply needs to repeat this film with a good leg technique. Remember, a cast is just another opportunity to do a good job, and is not an obstacle to good work. As for positioning, you can omit portions of the leg above the splint, unless this is the initial radiograph. In such cases the radiology request should say x-ray of lower leg, or distal/proximal tibia, etc. Radiograph #104 What is your critique of this radiograph? Critique of Radiograph #104 Here is the repeat of the previous radiograph using sufficient kVp to penetrate the lower leg. Notice that the exposure is fairly even through the cast material. Remember that fiberglass is not an additive property for exposure, but plaster is. This is good positioning for the lateral view of the leg. Radiograph #105 What is your critique of this radiograph? Critique of Radiograph #105 The positioning of this patient following reduction and splint placement is adequate. Notice that both ends of the tibia/fibula have been clipped. This is not acceptable. With careful positioning almost any average length leg can be fitted on a 14 X 17 cassette. Be careful not to clip anatomy when turning the cassette crosswise. Radiographic technique is good for bone detail. The fracture of the distal leg and proximal fibula is well visualized. Radiograph #106 Does this radiograph meet the diagnostic criteria? Critique of Radiograph #106 Well, considering that the distal tibia is clipped the diagnostic criteria is not completely satisfied. But the question is should this radiograph be repeated? Probably not. It is a follow up study to check the healing process. Notice the deformity in the bone from a healed fracture. The bone has not yet completed its remodelling process, although it does have a bony callus and some lamellar bone. The soft tissues are easily seen using the presented radiographic technique. Radiograph #107 What is your critique of this film? Is this style of radiography an acceptable imaging technique? Critique of Radiograph #107 Now this is an old school style of radiography of the tibia and fibula. When the leg cannot fit on the cassette crosswise, or the technologist feels they can better orient the exam for diagnostic reading this method is used. You have to be careful not to overlap the images. Also you must choose a technique that does not produce excessive scatter. Radiographic exposure for this two images equals one view study is adequate for bone and tissue detail. Radiograph #108 What is your critique of this radiograph? Critique of Radiograph #108 This is another example of a two images equals one view technique. Notice the scatter edge of the film does not extend to the opposite image. This is important if you use the two view method for imaging the tibia/fibula. The positioning is good with good overlap. Sometimes with this method there is additional exposure to the patient in order to overlap these split views. Be sure to position the knee as if it were a separate study to assure there is no rotation of the knee as seen here. Radiographic technique is adequate for bone and soft tissue. Radiograph #109 What is your critique of this radiograph? Critique of Radiograph #109 This lateral tibia/fibula image taken for post op internal fixation is a good radiograph. The knee is positioned in a true lateral without rotation. This places the ankle in the lateral position so we can see the entire tibial rod and fibula fixation. The radiographic technique is good, demonstrating metal, bone, and soft tissue detail. Radiograph #110 What is your critique of this film? Critique of Radiograph #110 Positioning is excellent; the knee is not rotated and the patellofemoral joint space is demonstrated. Distally, the ankle joint is not fully appreciated on the film. This is not a post op film because there is no air in the soft tissues commonly seen immediately following surgery. The fracture of the distal fibula is not appreciated on this film because of poor subject detail and the presence of epiphyseal and metaphyseal lines. Subject detail is very much needed on this follow up film. Radiographic technique demonstrates a low contrast that favors soft tissue detail. We cannot say this is a bad technique because we do not know the exam history. I would assume the image was taken because of pain and they wanted to r/o infection. In such case we would be looking for gas produced by bacteria in the soft tissues. Otherwise it is not a good technique for bone detail. Be careful when making this type of radiograph that your technique reflects the history for diagnosis. Nevertheless, the fibula needs to be better demonstrated. Repeat just the lower leg including the ankle. Radiograph #111 What is your critique of this film? Is this positioning acceptable? Critique of Radiograph #111 The radiographic technique is great for bone detail, soft tissue detail, and metal. However, this radiograph will need to be repeated. Because it is a post op film the entire metal internal fixation and the proximal tibia must be demonstrated. We cannot get by with this one because it is almost there. There is a professional obligation to include the required anatomy. Besides, the orthopedic surgeon expects and trusts that you will include the entire fixation to document the surgery. Failure to do so is unacceptable. Radiograph #112 What is your critique of this radiograph? Critique of Radiograph #112 In terms of the radiographic exposure technique this is a great film. There is good bone penetration and bone detail. The trabeculae can be seen throughout the bone. Soft tissue detail is also presented on this radiograph. The distal tibia/fibula is clipped. This is a trauma image so the technologist should add an AP view of the distal tibia/fibula to complete the diagnostic criteria. Summary: Critique of Tibia/Fibula AP and Lateral Radiographic Views For radiography of the tibia/fibula the entire tibia/fibula including the knee and ankle joints should be made. If it cannot be included as a single film then two films with overlapping parts should be made. Good soft tissue detail should be seen to evaluate whether there is an open fracture that is a surgical emergency. Good bone detail should be seen so that the trabeculae is noted throughout the tibia and fibula. Copyright 2006 Nicholas Joseph Jr. To the top