Radiography Protocols (CUH)

Lower limb

  1. Toes
    1. DP
    2. DP Oblique
  2. Hallux
    1. DP
    2. Lateral
  3. Foot
    1. DP
    2. DP Oblique
    3. Lateral - in cases of a suspected Lisfranc injury
  4. Ankle
    1. Mortice
    2. Lateral
    3. Requests for tib/fib & ankle must have separate ankle views centred over the joint space.
    4. Straight AP (to evaluate syndesmosis for a “high ankle sprain” and also talar dome)
    5. Foot & Ankle - should not be ordered routinely.
    6. Ottawa ankle rules are used in the ED.
  5. Calcaneum
    1. Axial
    2. Lateral
  6. Tibia & Fibula
    1. AP
    2. Lateral full length.
      1. Include both joints.*
      2. Requests for tib/fib & ankle must have separate ankle views centred over the joint space. 
      3. * Fractures of the ankle involving the joint space must have tib/fib full length views, to show knee & ankle joints together.
  7. Knee
    1. AP
    2. Horizontal Beam Lateral
    3. HBL knee is mandatory at any stage post injury, regardless of the date of the injury.
  8. Patella
    1. PA if possible, AP if not
    2. Horizontal Beam Lateral
      * Modified 20° skyline may be possible if patient is holding knee in a partially bent position.
      * Regular skyline views are rarely indicated. If requested do only after the referring doctor or a radiologist has seen the AP & Lat
  9. Femur
    1. AP - both joints on one film if possible
    2. Lateral from knee up
    3. Lateral NOF view only if clinically indicated
  10. Hips & Pelvis
    1. AP
      For those with #NOF include 15cms of femur below the lesser trochanter for surgical planning.
    2. HBL NOF
      Must be horizontal beam for ?#
  11. Prostheses
    1. Patients with prosthesis do not need a lateral NOF view. They may need a full length femur as #s below the tip of the prosthesis are likely after trauma.
  12. DHS
    1. Patients with hip pinnings do need a lateral NOF.
  13. Dislocated hip prosthesis
    1. AP Pelvis
    2. AP Acetabulum (JUDET) centred over the affected side, collimated to that side only. Raise the affected side only. No need for the other judet.

Upper limb

  1. Fingers
    1. PA, include the finger next to the injured one. 
    2. Lateral
  2. Hand
    1. PA
    2. PA oblique
    3. Lateral - only if requested by senior medical staff.
  3. Thumb
    1. AP
    2. Lateral
  4. Wrist
    1. PA
    2. Lateral
    3. Obliques if requested
  5. Scaphoid: (Full 5 view series on presentation and follow up).
    1. PA with ulnar deviation and clenched fist
    2. Ant oblique with ulnar deviation
    3. Lateral wrist
    4. Post oblique
    5. Elongated scaphoid 30° cranial
  6. Forearm
    1. AP include both joints
    2. Lateral *
      All requests for forearm & elbow must have separate elbow views.
  7. Elbow
    1. AP
    2. Lateral
  8. Radial Head: Full 360° rotation of the radial head is achieved by the following 4 positions
    1. AP elbow
    2. True lateral thumb up
    3. True lateral palm down
    4. True lateral thumb down
  9. Radial head views are almost never needed
  10. Humerus (include both joints)
    1. AP
    2. Lateral
  11. Shoulder ? dislocation
    1. AP - straight - no rotation of patient
    2. Axial (either full or ½ axial)
    3. Y view
  12. Shoulder post relocation
    1. AP
    2. ½ axial (15% of anterior dislocations have avulsion of the greater tuberosity not seen on AP only).
    3. ±Y-view
  13. Shoulder other injuries
    1. AP - hand supinated, no rotation of the patient (rotation can mimic posterior dislocation)
    2. Tailor the second projection to the injury. Choice of:
      1. Axial - if patient can assume the position, best overall second view 
      2. Y view - good overall second view 
      3. AP with internal rotation of humerus - to show greater tuberosity
  14. Clavicle
    1. PA or AP - include whole shoulder area (no rotation of the patient)
    2. For #s of the medial end of the clavicle, please request CT. It may not be possible to clear the medial end of the clavicle from the lungs but it is very important. If you have to x-ray it one of these views may achieve it:
      Again, in red to stress that x-ray is a last resort
      1. Apical view of lungs (patient PA and leaning back with apices distant from detector, horz beam)
      2. Kitty Clarke angled clavicle with CR cassette (patient supine on table, shoulders raised 15°, cassette behind shoulder at 45°, tube angled cranially at 30°)
      3. Serendipity view (patient supine, tube angled 40° cranial
  15. AC joints
    1. AP of shoulder generally suffices.
  16. Greater tuberosity
    1. AP – hand in AP position, palm out
    2. AP with internal rotation of the hand
    3. Lateral head of humerus, PA
  17. Scapula
    1. AP shoulder 
    2. Y - view /lateral scapula


  1. Chest 
    1. PA alone in the majority of cases
    2. LATERAL needed where:
      1. No previous CXR for this patient visible on our PACS system (from this or any hospital in the CUH group). This is regardless of clinical presentation.
      2. PA shows
        1. New lung mass
        2. New lung collapse
    3. No laterals needed for second or subsequent CXR where the patient has
      1. Consolidation
      2. Pneumothorax
    4. Never do a lateral on pregnant patients
  2. Trauma Low kV (65-77kV) CXR only in certain circumstances.
  3. Moderate /Major trauma Low kV CXR for demonstration of pneumo/haemothorax, rib, clavicular and scapular fractures, mediastinal widening / shift, aorta, fluid, lung contusion.
  4. Obliques specifically for demonstration of ribs are not indicated.
  5. Pneumothorax
    1. Low to medium kV CXR inspiration only - no grid
  6. Cardiology patients & others with no history of trauma
    1. High kV (80-110kV) CXR
  7. Pre-op CXR Not done routinely. All CXR requests must have clinical data with medical justification for the examination. (SI 478/ CUH Anaesthetic department)
  8. Ribs low kV CXR if complications suspected
  9. Sternum
    1. Lateral with grid
    2. CXR for demonstration of possible spinal, aortic and thoracic injuries following trauma
  10. Inhaled Foreign Body
    1. PA or AP CXR
    2. Lateral include neck on paediatric CXR


  1. Trauma
    1. PFA supine (may be KUB)
  2. GI Tract
    The indications for PFA with GI presentations are:
    1. ? Obstruction
    2. ? toxic megacolon / ulcerative colitis
    3. Position of dangerous (sharp or toxic) FB
  3. AP Supine
        1. Erect CXR may also be requested
  4. Renal system
    1. CT is first investigation
    2. PFA only after CT confirmed stone (to follow position)
  5. Ingested Foreign body
    1. Small round foreign bodies e.g. coins do not need to be located by x-ray.
    2. Exception - anything toxic such as batteries, which could leak. (See Foreign bodies all areas )
    3. Remember to include neck in CXR if possible swallowed FB and child has dysphagia
  6. Erect PFA is never indicated

Multiple Trauma

  1. CXR - Low kV (65-77kV) To show free fluid, widened mediastinum, pneumo/haemothorax. Do not repeat a film which shows this, even if it is poor quality.
  2. Pelvis
    1. For assessing pelvic ring integrity. Must be good quality. Use a grid. Include the sacrum and transverse processes of L5 as well as pubic rami. Repeat if sacrum is not seen. Do not repeat (in resus) for hips. External fixator may be in place - x-ray through it.
  3. Lateral Cervical Spine
    1. Do last. C spine immobilisation must be maintained until the spine can be cleared.

Departmental Series Will change according to the injuries but for all high-energy trauma expect requests for some or all of these:

  1. Cervical /Thoracic /Lumbar spine;
  2. Shoulders / Extremities;
  3. Calcaneum (in falls greater than 4m) Prioritise demonstration of serious/life-threatening injuries in case patient becomes unstable and imaging is cancelled.
  4. * If no resus series was done start with
    1. CXR and Pelvis
      then do
    2. lateral c spine
    3. all other lateral spine views
    4. AP spine views
    5. all other views
      If resus series was done this is the order of imaging: 1. lateral spine views 2. AP spine views 3. all other views For spine and pelvis protocols see Section: Spine & Pelvis

Vacuum immobiliser mattress: gives serious artefact and ↑ the radiation dose. It must be softened for lateral c. spine views.

Sandbags: give serious artefact. They must be removed for lateral c.spine.


Spine & Pelvis

  1. Cervical Spine
    1. Lateral must include occiput to T1, soft tissues anteriorly & whole spinous processes posteriorly.
    2. AP
    3. Open mouth
  2. C7/T1
    1. Coned True Lateral (CTL) - for those whose lateral had 6 or more vertebrae visible. Must include whole of spinous processes for identification of levels and repeat for these if necessary. Very low dose.
    2. Swimmers - where CTL is unsuitable or did not work.
    3. Flexion / extension views may be requested by orthopaedics and EM consultants when suspecting ligamentous injury.
    4. MRI is thye modality of choice for ligamentous injury.
  3. Thoracic Spine
    1. AP
    2. Horizontal beam lateral.
  4. Lumbar Spine
    1. AP
    2. Horizontal beam lateral.
      Patients from eye ED may need lumbar spine or SIJ radiography for ? ankylosing spondylitis in cases of uveitis

Hips & Pelvis

  1. Hips & Pelvis
    1. AP. - * For those with #NOF include 15cms of femur below the lesser trochanter for surgical planning.
    2. Lateral NOF - ? # - must be horizontal beam
  2. Prostheses
    1. Patients with prosthesis do not need a lateral NOF view. They may need a full length femur as #s below the tip of the prosthesis are likely after trauma.
  3. Dislocated prostehsis
    1. AP acetabulum of the affected side only (Judet)
  4. DHS
    1. Patients with hip pinnings do need a lateral NOF
  5. Inlet/Outlet views
    1. Only when requested by the orthopaedic team. Rarely indicated in the ED.
  6. Coccyx
    1. Not indicated. Normal appearances are often misleading and findings do not alter management.

Foreign Bodies - all areas

    1. AP/PA
    2. Lateral for localisation PLUS
    3. Tangential for FBs in face and head area
  1. Inhaled Foreign Body
    1. PA or AP CXR
    2. Paediatrics: Lateral CXR *Include neck on paediatric CXR
    3. Adult: Lateral CXR only to include neck
  2. Ingested Foreign body
    1. Small round foreign bodies e.g. coins do not need to be located by x-ray unless inhalation is suspected.
    2. Exception: anything toxic such as batteries, which could leak, or sharp objects which could cause perforation.
    3. If indicated do;
      1. Adults - 1. Lateral CXR only; include neck
      2. Children - 1. PA (or AP) CXR; include neck
    4. Sharp objects may have to be followed up by x-ray over a period of time.
    5. PFA may be indicated also in this case

Fish Bone Visible on x-ray

  1. Cod, Haddock, Colefish, Lemon sole, Gurnard

More difficult to see

  1. Grey mullet, Plaice, Monkfish, Red snapper

Not visible on x-ray

  1. Herring, Kipper, Salmon, Mackerel, Trout, Pike

Skull & Facial bones

  1. CT is the modality of choice in head injury
  2. Indications for SXR in adult
    1. Penetrating trauma
  3. Indications for SXR in child - ? NAI - all others requiring imaging need a CT scan.
    1. Penetrating trauma
    2. Head injury with suspected NAI
  4. Skull Views
    1. AP
    2. Lateral
    3. Townes if suspected occipital injury.
  5. Facial Bones - all queries (erect only & post c.spine clearance in multi-trauma patients)
    1. OM
    2. OM 30
  6. Sinuses
    1. Never x-rayed. CT is the modality of choice.
  7. Orbits ?# 
    1. Undertilted OM
    2. ?FB
      1. Under-tilted OM with Eyes UP but if FB seen also do: Eyes DOWN
  8. Mandible
    1. OPG and PA mandible if ?#
    2. If OPG machine is unavailable a full mandibular series is necessary.
      1. PA mandible
      2. Lateral mandible
      3. Oblique mandible – both side obliques
  9. TMJs Clinical diagnosis X-ray not necessary in ED. If imaging is required - MRI is the modality of choice.
  10. Nasal Bones: Not indicated in the ED. (Maxillofacial follow-up).


  1. Extremities - AP and lateral (or oblique) as for adult.
  2. Foreign bodies - See above
  3. Skull Under review by the Radiology and EM consultant staff.
    1. If indicated do: - AP & Lateral  Where occipital injury exists include Townes
    2. < 2yrs - indicated in ?NAI
    3. Over 2 yr - As above.
  4. Pelvis
    1. Under 5 yr - AP only
    2. Perthe's - AP and frog lateral 
    3. Trauma - AP and lateral of affected side
    4. Over 5 yr - AP & frog lateral.
    5. Slipped upper femoral epiphysis (SUFE) - AP and frog lateral
  5. Limping child or sudden non-wt bearing child (no hx trauma)
    1. AP & Lateral of the part of the leg indicated by clinical examination, or by the child, as the most likely injured area. Follow with the rest of the leg if no injury is seen. Do not routinely x-ray from hip to ankle.

Content Drafted by Anne O' Loughlin, Dr Liam Spence, Dr Íomhar O' Sullivan 06/05/2005. Reviewed 15/03/2007.Last review Ms Anne O' Loughlin, Dr. ÍOS 15/03/16 .