X Ray Positioning Guide – This chapter is designed as a quick guide to radiographic positioning and technique. Technical tips and additional feedback are provided to help you get the most out of your film using the right feedback. Common studies are highlighted in blue; this is the minimum number of observations that must be made to achieve a complete analysis of the area in question. For more information on the concepts covered in this chapter, a textbook on radiographic positioning should be consulted. A list of suggested further reading is included at the end of this section.
The basic components of a radiography unit are the radiation source (X-ray tube) and the receiver (X-ray film in the case of conventional plain film radiography or an intensifier plate in the case of computerized radiography). Figures 3-1 and 3-2 show the chair, table, shields, side markers, and other equipment used for radiographic setup.
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FIGURE 3-1 Typical radiographic system and associated equipment, including: A, network cabinet (Bucky); B, X-ray tube; C, collimator; D, movable table; Yes, sponging; and F, stool.
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FIGURE 3-2 Tools and equipment used for radiographic examinations, including A, calipers; B, lead apron; C, female gonadal shield; D, male gonadal shield; Yes, right and left markers (Mitchell); F, spies; G, cassettes; and H, for placing sponges.
The recommended method is at a fixed range of kilovolts (kV) per body part. For younger patients, a lower kV is used; for larger patients, higher kV ranges are used. In this system, milliampere-seconds (mAs) are variable, and exposure factor adjustments require only a change in mAs. To adjust exposure data for unexposed film, mAs must be adjusted by at least 30% to see a noticeable change, or 100% for a large change. The opposite is true for overexposed films. When using a fixed kV system, only one exposure factor, mAs, needs to be changed to correct errors. The methods in the table provide a starting point for appropriate exposure for the same radiographic system as specified. Corrections for individual variations in the machine are made by adjusting the mAs only because the graph is made using the fixed kV method.
There may be situations where a change in permeability, or kVp, is required. When the film is critiqued, if the bone detail is so light as to be invisible, increasing the kVp by 15% provides the necessary penetration. An increase in mAs is required if bony detail is present, but the general appearance of the film is too light.
Good patient education is important and must include a full explanation of the study being done and the patient’s role during the examination. Protective measures and breathing instructions should be considered. Patients should be properly dressed and all artifacts removed before the radiographic examination begins (Figure 3-3). Female patients of reproductive age should be evaluated for possible pregnancy. If there is a possibility of pregnancy, the test should be delayed, if possible, until it is established that the patient is not pregnant, either by the result of the human chorionic gonadotropin test or by the onset of menstruation. If possible, all radiographic examinations of the spine, abdomen and pelvis should be scheduled within the first 10 days after the onset of menstruation because this is the least sensitive period of pregnancy. Whenever possible, appropriate gonadal protection should be used in both male and female patients.
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FIGURE 3-3 Radiographic placement is best done by following a general sequence. The sequence begins with preparation of the patient, including A, dressing; followed by, B, selection of measurement method; C, selection and placement of cassettes; D, selection of movie viewing area; Yes, center beam placement; F, aligning the middle of the film with the middle rays. G, film size contact; H, lateral marking; and sometimes I use a filter.
The following tables show the most commonly performed radiographic measurements. Common studies are highlighted in blue. A standard survey is the minimum number of observations that must be made to obtain a complete survey of the area. Additional comments are included in many sections and can be added to the core lesson. Additional views have been added to better display the subject area or to assess motion or stability. For reference, radiographic examinations are referred to according to the part of the body being examined and whether the direction of the X-ray beam passes through the body (anteroposterior [AP]) or the part of the body part that touches the body oblique grid (right posterior oblique [RPO ]) (Figure 3-4).
FIGURE 3-4 Radiographic examinations. The radiographic term “projection” refers to the path of the central beam as it exits the x-ray tube and passes through the patient’s body. For example, A indicates an anteroposterior (AP) projection and B a posteroanterior (PA) projection. At the ends, the lateral projections are defined in the same way in the direction of the central rays; therefore, mediolateral and lateral projections are possible. However, when dealing with the head, neck or trunk, the lateral and oblique projections are further defined by the specific “position” of the patient. Position refers to the placement of the patient’s body, specifically the part of the patient’s body that relates to Bucky. For example, C shows a side view in the right lateral position, and D shows a side view in the left position. In E, the patient is in a left anterior oblique (LAO) position, and in F, the patient is in a right anterior oblique (RAO) position, both corresponding to PA oblique projections.
Each chart describes the position, center beam placement, tube deflection, appropriate film size, and film viewing area for each view. To preserve the X-ray film and facilitate viewing, the film is sometimes split so that multiple views of a body part can be seen on one film (Figure 3-5). For each placement in the tables, there is a diagram showing the position and center of the beam and another showing the anatomy displayed by the placement. The kV and mAs section lists the type of film screen combination used and whether the study was done online or on a bench. If internet access is specified, a fast rare earth movie screen is displayed. If detailed or off-grid data is specified, a low-speed film screen combination such as that found in extreme section cartridges or 100-speed cartridges is recommended. Recommended KV and mA are also given for the systems described in the previous section of the procedure. The “Additional Information” section describes additional displays that can be made to better display the desired format. Also included are technical tips to help you find the right lessons.
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FIGURE 3-5 A to D, For some small body parts (eg, leg and arm), the x-ray film can be split to accommodate several projections. From Ballinger PW, Frank ED: Merrill’s Atlas of Radiographic Conditions and Radiological Methods, ed 10, St. Lewis, 2003, Mosby.
Place the center of the caliper on the back of the skull. Slide the caliper arm until it rests slightly on the nasion.
The central beam uses a tail tube angle of 15 degrees and enters the back of the skull to exit the nasion.
Frontal, frontal and ethmoid bones, greater and lesser sphenoid wings, superior orbital fissure, foramen rotundum, orbital rims.
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The angle of the tail tube can be increased to 30 degrees to better define the lower edge of the orbit. Petroleum pyramids appear in the lower third of the circuit as was done in the previous display. They are presented below the lower orbital rim at an angle of 30 degrees.
Place the center of the caliper on the nape of the neck. Move the conveyor belt toward the patient’s head to touch the glabella.
Place the patient in the AP position with the back of the head touching the Bucky. Tilt the chin so that the orbitometal line is pointed at the film.
If the patient cannot tilt the chin sufficiently, turn the head so that the infraorbitomeatal line is directed at the film and increase the tube inclination to ≈37 degrees.
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Place the base of the caliper on the temporal bone on one side of the head and move the sliding tape toward the patient’s head so that it touches the temporal bone on the other side of the head.
Place the patient with the side of the head against Bucky. Tilt the patient’s body for comfort. The interpupillary line is perpendicular to the film. The external protrusion of the occipital and nasion should be equal to the film to prevent rotation.
Place the forceps on the back of the skull and move the sliding strip toward the patient’s face until it folds between the lower lip and the tip of the chin.
The central beam is directed around Bucky and is directed towards the center of the cassette.
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It should be done vertically to check the air-fluid level in the maxillary sinuses. In the lower part of the maxillary sinuses below the lower orbital rim petrous ridges should develop. Good view for evaluation of possible orbital fractures.
Place the center of the caliper against
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