Film Critique of the Lower Extremity - Part 3

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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: Radiographic Critique of the Ankle Diagnostic Criteria for Imaging the Foot Radiographic Film Critique of the Lower Extremity: Pelvis, Femur, Knee, Tibia/Fibula, Ankle, and Foot Written by Nicholas Joseph Jr. RT(R) 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) To the top To the bottom Radiographic Critique of the Ankle Three views of the ankle are commonly made to evaluate for fracture/dislocation, instability, or disease: AP ankle should demonstrate the talus, distal tibia and fibula. Mortise view (15-20 degree medial oblique) should demonstrate the ankle mortise and most distal tip of the fibula free of superimposition by bones of the foot. This may require flexion of the ankle. Medial and lateral oblique views should demonstrate the distal tibia/fibula and proximal talus and their articulations. Lateral view should demonstrate a superimposed tibia and fibula, the talus, calcaneus, sinus tarsi, and navicular bones. Soft tissue and bone detail should be adequately visualized to evaluate fracture, dislocation, or soft tissue injury. Radiograph #113 What is your critique of this radiograph? Does it meet the diagnostic criteria for the AP view? Critique of Radiograph #113 Yes this radiograph does meet the diagnostic criteria for the AP view. The positioning is great showing good bone detail of the tibia/fibula and talus. The entire talus is seen through the cast material. The radiographic technique is excellent for bone, metal, and soft tissues seen through the cast material. Radiograph #114 What is your critique of this radiograph? Critique of Radiograph #114 This is a good trauma radiograph that shows the ankle in a true lateral position. It is important to get a true lateral, especially when the injury is of this magnitude. The talus, navicular, and calcaneus are included according to the diagnostic criteria. Good radiographic technique. Good bone penetration is also noted. We have good bone trabecular visualization and soft tissue detail throughout the film is demonstrated. Radiograph #115 Does this radiograph meet the diagnostic criteria for the AP and oblique views of the ankle? Critique of Radiograph #115 These images could have been collimated better. There is no useful information below the white line. Both views look like attempted oblique views and are not distinguished as an AP and oblique view. Radiographic technique is adequate for bone and soft tissue. Collimating will add a bit of contrast to the overall radiograph. Radiograph #116 What is your critique of this radiograph? Critique of Radiograph #116 These are good radiographs of the ankle. The left picture shows the ankle in the AP projection. The alignment of the bones and joint can be easily seen. The mortise view also shows good joint space between the fibula and talus. Radiographic exposure technique is good for bone detail and soft tissue evaluation. Radiograph #117 What are your comments on this radiograph? What is good about this picture? Would you have done anything differently to improve the quality of this radiograph? Critique of Radiograph #117 This oblique image falls short of the diagnostic standard. Notice that the fibula is superimposed on the heel because the foot is not flexed. Often the technologist does not attempt to flex the foot because the patient’s injuries do not permit it. However, you should always attempt to do so. Pain alone is not a reason to not flex the foot. This is the resulting radiograph that does not fully appreciate the anatomy. This view should be repeated. Radiographic technique is good and would demonstrate the distal fibula. Radiograph #118 What is your critique of this radiograph? Does it meet the diagnostic criteria? Critique of Radiograph #118 These are excellent radiographs. Notice that the AP view demonstrates the relationship of the ankle mortise to the talus very well. The oblique view shows good spacing of the fibula and talus. The distal fibula is not superimposed on the heel or talus. This is how they should all look. Radiographic exposure technique is adequate for the internal fixation, bone and soft tissue. Radiograph #119 What is your critique of this radiograph? Critique of Radiograph #119 The AP view is fine, but the oblique view shows that the foot could have been flexed a bit more. The slight overlap does not require repeating the image; however, you should not routinely overlap the distal fibula with bones of the foot. The radiographic technique selected shows good balance between soft tissues and bone. The trabecular pattern of the bones can be seen. Radiograph #120 What is your critique of this radiograph? Critique of Radiograph #120 This is a well positioned view of the ankle following surgery. The internal fixation is properly oriented to see the plate edge. The ankle mortise is well demonstrated. The radiographic technique shows good bone detail through the plaster cast. The exposure technique is great for bone, metal, and soft tissue detail. Radiograph #121 What is your critique of this radiograph? Critique of Radiograph #121 This is a serious injury for which the orthopedic surgeon needed good radiographs. Unfortunately the image should be repeated because the bone detail through the distal ankle is not well penetrated. The extent of injury cannot be assessed. Radiographic technique does not show the talus or other bone detail of the distal tibia/fibula. Radiograph #122 What is your critique of this radiograph? Critique of Radiograph #122 This radiograph is well positioned. In spite of the severity of the patient’s injuries, the radiographer has made a great AP radiograph of the ankle. This film describes what it is to be a professional radiographer who gets the diagnostic information without injury to the patient. Radiographic exposure technique is adequate for bone and soft tissue visualization. Radiograph #123 What is your critique of this radiograph? Critique of Radiograph #123 This is a well positioned part, although it does not look like the typical AP ankle radiograph in terms of positioning. This is because there are several fractures and dislocation of the ankle joint. This is a true AP image even though the heel is projected over the lateral edge of the tibia. It is important here that you do not work this patient too much to achieve a better image. A CT and MRI scan can be made to provide further information as to the extent of injuries. Radiographic technique is adequate for bone, soft tissue, and trabecular detail. Radiograph #124 What is your critique of this radiograph? Critique of Radiograph #124 Clearly this radiograph does not meet the diagnostic criteria for tan AP view of the ankle. A portion of the medial malleolus is clipped as well as the soft tissue around the medial ankle. This is sufficient clipping to warrant repeat of the view. The radiographic exposure technique is sufficient for bone and soft tissue evaluation. Good bone trabeculae are demonstrated. Radiograph #125 What is your critique of this radiograph? Critique of Radiograph #125 These are good radiographs of the AP and oblique views of the ankle. Note that the oblique view is not exactly the same as the ankle mortise view. In this radiograph the distal fibula malleolus is not superimposed on bones of the foot. The radiographic technique is good demonstrating bone trabeculae, and soft tissue detail. Radiograph #126 What is your critique of this radiograph? Critique of Radiograph #126 These radiographs show a profound comminuted fracture of the ankle. These are not great radiographs because they must be repeated. The reason being that the fibula is also fractured and both fracture ends are not demonstrated on either view. When in this situation and you know that the part is fractured, break with tradition and use one film to include as much of the part as is possible. It is better to do this than to repeat a film on a patient who is already in great pain. The radiographic technique is adequate. Sharp bone detail to accurately account for each fragment must be determined by CT scan because of the extent of the injuries. Radiograph #127 What is your critique of this radiograph? Critique of Radiograph #127 This is a good lateral ankle radiograph. Note the following: The ankle joint is open and a space between the tibia and smooth curvature of the body of the talus is seen. This is the ankle joint and should be seen on all lateral views w/o rotation. The subtalar joint should be open and easily seen (white arrow) The talo-navicular joint (yellow arrow) and calcaneo-cuboid joint (blue arrow) should be seen. The radiographic technique should show good soft tissue both anteriorly and posteriorly to the ankle. Good bone trabeculae such as is seen in this distal tibia and calcaneus. Radiograph #128 What is your critique of this radiograph? Critique of Radiograph #128 The ankle appears to meet the diagnostic criteria. The ankle is in sufficient external rotation for this mediolateral projection. The ankle joint space is adequately seen as well as the subtalar joint. The small fracture fragment of the posterior malleolus can be seen through the cast material. Radiographic exposure technique is adequate. Radiograph #129 What is your critique of this radiograph? Critique of Radiograph #129 The positioning seen here is adequate but could use some improvement. The foot is rotated too far towards the tabletop. The fibula is projected too far posteriorly. The ankle joint relationship can be seen; however, the space is hot opened very well. The subtalar joint is badly rotated such as seen with when positioning for a lateral foot. Note how much of the base of the 5th metatarsal is demonstrated, and the entire cuboid is profiled. Radiographic exposure technique shows good bone and soft tissue detail. Radiograph #130 What is your critique of this radiograph of the lateral ankle projection? Critique of Radiograph #130 The positioning has achieved a true lateral view that truly meets the diagnostic criteria. The ankle joint space is demonstrated opened. The subtalar joint is opened all the way posteriorly. The other mentioned joints are also visualized Radiographic exposure technique adequately demonstrates bone detail and soft tissues. Radiograph #131 What is your critique of this lateral radiograph? Critique of Radiograph #131 This radiograph is diagnostic; however, the ankle is not in a true lateral. The ankle should have been rotated more towards the tabletop. This would open the ankle and subtalar joints. Note that the base of the 5th metatarsal is not projected out enough as it would with a correctly positioned lateral ankle. Radiographic exposure technique is adequate for the study. Radiograph #132 What is your critique of this ankle radiograph taken in the temporary splint? Critique of Radiograph #132 This radiograph is positioned well considering the splint. Note that the ankle joint is well visualized through the cast material. The fracture fragments can also be seen in the lateral projection. The radiographic technique is good for bone and soft tissue seen through the splint. Radiograph #133 What are your critiques of this radiograph of lateral and external oblique views of the ankle? Critique of Radiograph #133 This lateral view shows the ankle joint is not opened, nor is the subtalar joint seen opened on this projection. The cause is the foot is improperly flexed, and the ankle not externally rotated enough. The external oblique view is the opposite of the medial oblique view that shows the ankle mortise. Some institutions do a 4 view ankle including this view. It does not have a strict diagnostic criterion, but is used to "give another look at the ankle." The radiographic technique lacks good bone detail and detail of the trabeculae. When the lateral is repeated adjust the technique using the 50/15 rule towards higher contrast. Radiograph #134 What is your critique of these images seen on the radiograph? Critique of Radiograph #134 The lateral is a good film. It should be noted that the ankle joint is not completely opened because of inversion to the foot. This is acceptable since the subtalar joint is opened nicely. The medial oblique view shows the ankle rotated externally too much diminishing its value. The radiographic technique is good for bone penetration and trabecular bone detail. Radiograph #135 What is your critique of this radiograph? Could anything have been done to improve this view of the ankle? Critique of Radiograph #135 This lateral view should be repeated. Not that the ankle is rotated too much towards the external side. The fibula is projected too far posteriorly and the subtalar joint is not displayed correctly. The entire cuboid bone is profiled and too much of the base of the 5th metatarsal is shown. Rolling the ankle back slightly towards the medial side will improve the positioning. Radiographic technique is adequate for this picture. Radiograph #136 What is your critique of this radiograph? Critique of Radiograph #136 This is not a bad lateral view. The ankle joint is seen with space between the talus and tibia. The subtalar joint is not badly positioned though it is slightly rotated. This view does not need to be repeated. Enough of the calcaneus is seen to make the diagnostic criterion. Radiographic technique does show good cortical and trabecular bone. Radiograph #137 What is your critique of this radiograph? Critique of Radiograph #137 This external oblique view of the ankle shows a different look at the ankle which is beneficial for this comminuted fracture. The external oblique does not have a strict diagnostic criterion, but usually a 15-20 degree rotation is adequate. Radiographic technique is good for bone and soft tissue. Radiograph #138 What is your critique of this radiograph? Critique of Radiograph #138 Again the diagnostic criteria is important especially when there is trauma with injuries. Notice that the ankle is in the lateral projection but is not true lateral. Obviously this radiograph was not repeated; however, if you are to become a master radiographer you must be able to get a true lateral on these types of injuries. While the technologist may not take note of this a a not true lateral position, the orthopedic surgeon and radiologist will. Providing the true lateral in this situation would make you a greatly respected radiographer. Try doing this view as a horizontal beam lateral for best results. Radiographic technique is good. Bone detail is not overshadowed by the slight motion seen on the radiograph. Radiograph #139 What is your critique of this radiograph? Critique of Radiograph #139 Here we see a good lateral radiograph that shows the fracture of the ankle. The subtalar joint is well demonstrated as well as is the ankle joint. A slight bit more penetration of the talus would have been more appreciated. Overall the radiographic density and contrast are adequate for this film. Radiograph #140 What are your comments and critique of this radiograph? Critique of Radiograph #140 Our first comment is that you should not position views at opposite ends of the radiograph. The second comment is that these are good images of the ankle, but too much of the leg is included for a pediatric patient. Unless the ordering physician requested this open length collimation it should not be done. Radiographic exposure technique is adequate for the two views. Radiograph #141 What type of radiograph is this, and what is your critique of it? Critique of Radiograph #141 This is a radiograph of a stress view of the ankle. The stress is applied from the medial side as the arrow points. This should open the joint space on the side of the lateral malleolus. This radiograph does not appear to have any ligament damage. Radiographic technique demonstrates the bone trabeculae well. Penetration of the bony architecture is also adequate. Radiograph #142 What is your critique of this radiograph? Critique of Radiograph #142 This stress view of the ankle shows no ligament damage. No separation of the fibula from the tibia is noted. The stress is applied from the medial side using a mechanical device. Radiographic technique is adequate. Radiograph #143 What is your critique of this radiograph? Critique of Radiograph #143 The radiographic technique is adequate for this view. With stress applied to the ankle from the lateral side the ligaments hold the ankle mortise. The collimation is close but acceptable. If you have not done stress ankle views you will need some orthopedic instructions in order to perform this series correctly. This is an otherwise good radiograph. Summary: Critique of Ankle Views Three view of the ankle are commonly made to evaluate for fracture/dislocation, instability, or disease: AP ankle should demonstrate the talus, distal tibia and fibula. Mortise view (15-20 degree medial oblique) should demonstrate the ankle mortise and most distal tip of the fibula free of superimposition by bones of the foot. This may require flexion of the ankle. Medial and lateral oblique views should demonstrate the distal tibia/fibula and proximal talus and their articulations. Lateral view should demonstrate a superimposed tibia and fibula, the talus, calcaneus, sinus tarsi, and navicular bones. Soft tissue and bone detail should be adequately visualized to evaluate fracture, dislocation, or soft tissue injury. Always ask, "Did I meet the diagnostic criteria for this view when making a radiographic image for a patient?" To the top To the bottom Diagnostic Criteria for Imaging the Foot Three standard views of the foot are the AP, medial oblique and lateral views. Each of these views has their diagnostic criteria: AP View-should demonstrate the entire foot including the phalanges, metatarsals, and tarsal bones. The entire talus is not required, only the talo-navicular joint. This view may be accomplished as a standing view or as a non weight bearing view. Medial oblique view-should demonstrate all of the foot from an oblique perspective. The articulations of the cuboid with the calcaneus and with the fourth and fifth metatarsals should been profiled. The talo-navicular joint and sinus tarsi should be well demonstrated. Lateral View-demonstrates superimposed tarsal, metatarsals, and phalanges. They should be easily distinguished. The distal tibia and fibula as well as the ankle joint should be seen. Radiographic exposure technique should demonstrate bone and soft tissue adequately. Radiograph #144 What is your critique of this radiograph? Critique of Radiograph #144 This radiograph shows the foot in the AP projection. All of the required anatomy is presented on the radiograph. Note that the talo-navicular articulation is well demonstrated (arrow). The distal phalanxes are not "burned out" and the talus is well penetrated. Radiographic exposure technique is excellently chosen. Radiograph #145 What is your critique of this radiograph? Critique of Radiograph #145 This radiograph demonstrates a correctly positioned lateral foot. Note that the ankle joint is included. The heel is in a true lateral demonstrating the sinus tarsi. The metatarsals and phalanges are superimposed and included on the radiograph. Radiographic exposure technique demonstrates the bone trabeculae and good bone penetration. Soft tissue detail is also seen. Radiograph #146 What is your critique of this radiograph? Critique of Radiograph #146 This is a good radiograph of the foot in the weight bearing position. Note that the mediolateral projection demonstrates the longitudinal arch very well while maintaining a good view of the cuboid and metatarsals. Radiographic technique used here is good, demonstrating bone and soft tissue detail. Radiograph #147 What is your critique of this medial oblique foot radiograph? Does it meet the diagnostic standard? Critique of Radiograph #147 This could have been a good radiograph except that the talus is clipped. Unfortunately this is unacceptable for a foot radiograph and requires repeating the view. Radiographic technique is adequate for bone and soft tissue detail. Radiograph #148 What is your critique of this radiograph? Critique of Radiograph #148 Here we see that the positioning of the part is correct. The required anatomy is demonstrated. However, the technologist wanted to penetrate the part sufficiently without burning out the toe and choose a low contrast technique. Using a sufficient kVp to penetrate the part and adjusting the mAs to bring out subject detail is the best approach. On this radiograph the kVp is too high and subject detail is compromised. This radiograph should be repeated to gain better control of subject detail. Notice the background density is inadequate, which is a primary indicator of too little mAs. Use the 50/15 rule to raise the contrast to an acceptable level of detail. Radiograph #149 What is your critique of this radiograph? Critique of Radiograph #149 This is a good well positioned radiograph. All of the required anatomy is included. Note that the entire talus is visualized. The joints of the foot are well seen. The cuboid’s relationships are profiled. The radiographic exposure technique demonstrates bone detail and soft tissue detail very well. This is a good radiograph. Radiograph #150 What is your critique of this weight bearing lateral foot radiograph? Critique of Radiograph #150 This radiograph shows good positioning of the foot for a weight bearing lateral view. All of the required anatomy is presented as well. There is no motion present that significantly reduces the subject detail. Radiographic exposure technique is adequate to visualize the anatomy. Radiograph #151 What is your critique of this radiograph? Critique of Radiograph #151 There are a lot of things going on with this patient. A good lateral radiograph is extremely important here. Our first clue that the positioning is not in a true lateral is the tibia/fibula is not superimposed. The metatarsals are not well spaced in their true lateral positions. This view should definitely be repeated with the foot more externally rotated. Radiographic exposure technique is inadequate for bone detail and should be sharpened as well by adjusting the technique towards higher subject contrast. Radiograph #152 What is your critique of these two images? Critique of Radiograph #152 This is the normal presentation of the foot for most technologists-a two on one film. Note that both views are correctly positioned. There is no overlap of the views which is required. The radiographic technique is close on both views making side-by-side evaluation easier. Radiographic exposure is even throughout the images. Good bone and soft tissue detail is seen. Radiograph #153 What is your critique of this weight bearing foot radiograph? Critique of Radiograph #153 The radiograph exposure technique is good demonstrating even the calcaneus. The toes are not too dark for this type of picture in adequate which bone penetration is required. Positioning of the part is adequate. It reflects the normal gait of this patient and not the positioning of the technologist. Radiograph #154 What is your critique of this oblique trauma foot radiograph? Critique of Radiograph #154 This is good positioning of the foot under trauma conditions. The relationships are well demonstrated. Looking at the cuboid relationships confirm this is a good oblique view. The fractures through several metatarsals and the dislocations seen in several bones of the foot are well demonstrated. Radiographic technique is excellent for bone and soft tissue. Radiograph #155 What is your critique of this radiograph? Critique of Radiograph #155 Here is an example of a radiograph that is clipped due to overlap when placing two images on the same film. Be careful when doing this because it is a primary cause of repeating images. Radiographic technique does not allow proper penetration of the bones of the foot. The talo-navicular relationship is seen but not well defined. Fractures cannot be completely ruled out with this technique. Repeat increasing the kVp for more penetration of the part. Radiograph #156 What is your critique of this radiograph? Critique of Radiograph #156 Whenever the toes are imaged, it should be clear which digits are the subject by the positioning style of the technologist. Here it is not clear because the oblique view is not very good. This takes away from our appreciation of the AP view. Both should be repeated because of the excessive motion. The oblique view adds nothing to the AP view and vice versa. The radiographic technique should be adjusted to offer better penetration through the metatarsals. This should increase the density throughout giving us better subject detail. Radiograph #157 What is your critique of this radiograph? Critique of Radiograph #157 Besides being underpenetrated the positioning of the radiograph is not good. The talus is clipped as well. This view definitely should be repeated. Radiographic exposure technique shows poor penetration of the part. Increasing the kVp is required to improve the penetration. Radiograph #158 What are your comments and critique of this radiograph? Critique of Radiograph #158 This is an example of a good radiograph with good bone and soft tissue detail. Note that the toes show the bone fragments within the soft tissue very well. The bone detail through the cuboid bone is well visualized. The radiographic exposure technique used here demonstrates good bone and tissue detail which is exactly what the physicians needed to see. Radiograph #159 What is your critique of this radiograph? Critique of Radiograph #159 This horizontal beam weight bearing lateral shows the longitudinal arch, ankle joint, and sinus tarsi very well. The bone trabecular pattern is seen throughout the survey. The clipping of the distal foot warrants repeating this radiograph. Radiographic technique is adequate for bone and soft tissue. Radiograph #160 What is your critique of this radiograph of the calcaneus? Critique of Radiograph #160 The radiographic exposure technique is very good. Note that it shows the entire heel without burn out of some of its parts. The bone trabecular pattern is also seen. The sustentaculum tali, trochlear process, and calcaneal tuberosity are well visualized on this radiograph. Summary of Critique of the Foot Views Three standard views of the foot are the AP, medial oblique and lateral views. Each of these views has their diagnostic criteria: AP View-should demonstrate the entire foot including the phalanges, metatarsals, and tarsal bones. The entire talus is not required, only the talo-navicular joint. This view may be accomplished as a standing view or as a non weight bearing view. Medial oblique view-should demonstrate all of the foot from an oblique perspective. The articulations of the cuboid with the calcaneus and with the fourth and fifth metatarsals should been profiled. The talo-navicular joint and sinus tarsi should be well demonstrated. Lateral View-demonstrates superimposed tarsal, metatarsals, and phalanges. They should be easily distinguished. The distal tibia and fibula as well as the ankle joint should be seen. All views may be made as weight bearing views or non weight bearing views. Radiographic exposure technique should demonstrate bone and soft tissue adequately. Always ask, "Did I achieve the diagnostic criteria for the view that I am taking?" Copyright 2006 Nicholas Joseph Jr. To the top