Radiography Protocols (CUH)



Lower limb

Toes

  1. DP
  2. DP Oblique

Hallux

  1. DP
  2. Lateral

Foot

  1. DP
  2. DP Oblique

  3. In cases of a suspected – or seen - Lisfranc injury
  4. Lateral

  5. In cases of suspected but not seen Lisfranc injury
  6. DP of both feet weight bearing. Injured side only will suffice if this is too difficult but both is ideal.

Ankle

  1. Mortice
  2. Lateral
  3. Straight AP (to evaluate syndesmosis for a “high ankle sprain” and also talar dome)

Requests for tib/fib & ankle must have separate ankle views centred over the joint space.

Foot & Ankle

Should not be ordered routinely but may be necessary in a small number of cases.

Ottawa ankle rules are used in the ED.

Calcaneum

  1. Axial
  2. Lateral

Tibia & Fibula

  1. AP
  2. Lateral full length. Include both joints.

* Requests for tib/fib & ankle must have separate ankle views centred over the joint space.

* Fractures of the ankle involving the joint space must have tib/fib full length views, to show knee & ankle joints together, if the equipment permits (this is not always possible on the ED equipment due to restriction of ceiling height).

*A mid-shaft fracture of the shaft of any long bone needs a routine follow-on of a full length image with both joints on, if not done already.

Knee

  1. AP
  2. Horizontal Beam Lateral.

*HBL knee is mandatory at any stage post injury, regardless of the date of the injury. For all non-trauma presentations either turned lateral or HBL may be used.

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 & Lateral

Femur

  1. AP - both joints on one film if possible.
  2. Lateral from knee up. Lateral NOF view only if it is indicated by clinical data.
  3. *A mid-shaft fracture of the shaft of any long bone needs a routine follow-on of a full length image with both joints on, if not done already.

    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 ?#

    Prostheses

    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.

    DHS

    Patients with hip pinnings need a lateral NOF.

    Dislocated hip prosthesis

    • AP Pelvis
    • AP Acetabulum (JUDET) centred over the affected side, collimated to that side only. Raise the affected side only. No need for the other judet. This shows the exact position of the dislocated prosthesis in relation to the acetabular component of the prosthesis and also shows the position of the acetabular component.

Upper limb

Fingers

  1. PA, include the finger next to the injured one.
  2. Lateral

Hand

  1. PA
  2. PA oblique
  3. Lateral - only if requested by senior medical staff.

Thumb

  1. AP
  2. Lateral
    • If erect positioning is used, mark it as such
    • Include scaphoid on thumb views

Wrist

  1. PA
  2. Lateral
  3. Obliques - where the EM doctor requests them due to the results of clinical examination
  4. Where they are not requested, have a low tolerance for adding obliques, especially where the injury was caused by a big animal, cow, bull, horse etc. or some other major force such as a kick-back from a machine

Scaphoid

At 1st presentation and follow up

Full series:

  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 angulation

Include the whole wrist on every view. Never collimate tightly around the scaphoid.

Forearm

  1. AP include both joints
  2. Lateral*

A mid-shaft fracture of the shaft of any long bone needs a routine follow-on of a full length image with both joints on, if not done already.

All requests for forearm & elbow must have separate elbow views.

Elbow

  1. AP
  2. Lateral

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

Radial head views are almost never needed

Humerus

(include both joints)

  1. AP
  2. Lateral

A mid-shaft fracture of the shaft of any long bone needs a routine follow-on of a full length image with both joints on, if not done already.

Shoulder protocol

For patients who present with:

  • General shoulder trauma (no specific clinical Dx) or
  • Disocation - possible or derfinite

3 views

  1. AP - straight – no rotation of the patient
  2. Some form of AXIAL, either a FULL axial or a HALF axial
  3. Y-view

All 3 of these views have to be done even if the EM doctor is happy with just an AP.

If Relocated (full axial not possible):

  1. AP
  2. Half axial

If the EM doctor has doubts about the complete relocation or if the orthopaedics request it, then also do a:

  1. Y-view

As much as possible: Rotate patient to the affected side for gleno-humeral joint during HALF AXIAL view.

Clavicle

  1. PA or AP - include whole shoulder area (no rotation of the patient)
  2. AP with cranial angulation or PA with caudal angulation

For #s of the medial end of the clavicle, CT is the modality of choice. 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:

  • Apical view of lungs (patient PA and leaning back with apices distant from detector, horz beam)
  • Kitty Clarke angled clavicle with CR cassette (patient raised 15°, cassette behind shoulder at 45°, tube angled cranially at 30°)
  • Serendipity view (patient supine, tube angled 40° cranial
  • Greater tuberosity

    1. AP – hand in AP position, palm out
    2. AP with internal rotation of the hand
    3. Lateral head of humerus, PA

    AC joints

    1. AP of shoulder generally suffices.

    Scapula

    1. AP shoulder
    2. Lateral scapula Y - view

Thorax

CXR protocol re: PA & Lateral

Amended: August 2014

Adults

  1. PA only (in the majority of cases)

Lateral needed where:

  • 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.
  • PA shows:
    • New lung mass or
    • New lung collapse

No laterals needed for second or subsequent CXR where the patient has:

  • Consolidation
  • Pneumothorax
  • Never do a lateral on:

    • Pregnant patients or
    • Children < 16 years

    No laterals to be done on anyone under 16. If requested by EM doctors check first with Radiologists.

    Specific presentations

    Trauma CXR

    Low kV CXR: for demonstration of pneumo/haemothorax, rib, clavicular and scapular fractures, mediastinal widening/shift, aorta, fluid, lung contusion.

    Pneumothorax

    • Low kV CXR - No grid - Inspiration ONLY

    Cardiology patients and others with no history of trauma

    • High kV (80-110kV) CXR – PA as much as possible
      See new CXR protocol re: laterals (Aug 2014)

    Pre–op CXR

    • Not done routinely. All CXR requests must have clinical data with medical justification for the examination. (SI 478/2002 & CUH Anaesthetic dept.).

    Ribs

    • Specialised rib views not done.
    • Low kV CXR only, as specified above.

    Sternum

    • Lateral with grid.
    • CXR for demonstration of possible spinal, aortic and thoracic injuries following trauma.

    Suspect the need for lateral sternum in RTA patients where the CXR shows clavicle # and contra-lateral lower rib #s (seat belt injury).

    Inhaled Foreign Body

    1. PA or AP CXR
    2. Lateral - Include neck on paediatric CXR

    Patients referred from Eye ED

    • PA CXR for sarcoidosis

    The clinical data will indicate a finding of uveitis. These patients may also need radiography of the lumbar spine or SI joints for ankylosing spondylitis.

    Abdomen

    Trauma (blunt or penetrating)

    • PFA supine (may be KUB)

    GI Tract

    The indications for PFA with GI presentations are:

    • ? Obstruction
    • ? toxic megacolon / ulcerative colitis
    • Position of dangerous (sharp or toxic) FB

    AP Supine.

    Erect CXR may also be requested if perforation suspected

    Renal system

    CT is first investigation

    Occasionally: PFA supine and only after CT confirmed stone (to follow position)

    Ingested FB

    • Small round foreign bodies e.g. coins do not need to be located by x-ray.
    • Exception - anything toxic such as batteries, which could leak. (See Foreign bodies all areas )
    • Remember to include neck in CXR if possible swallowed FB and child has dysphagia

    Erect PFA is never indicated.


    Multiple Trauma

    Resusc. Series:

    1. CXR - Low kV (65-77kV)
      To show free fluid, widened mediastinum, pneumo/haemothorax & #ribs
      Do not use >75kV with the CR system
    2. Pelvis
      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
      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:

    • Cervical /Thoracic /Lumbar spine
    • Shoulders / Extremities
    • Calcaneum (in falls greater than 4m)

    Prioritise demonstration of serious/life-threatening injuries in case patient becomes unstable and imaging is cancelled.

    If no resus series was done start with:

    Start with the resusc. series in the x-ray room.

    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.

    The order of imaging in multi-trauma patients is important and must be followed despite equipment design.


    Spine & Pelvis

    Cervical Spine

    1. Lateral must include occiput to T1, soft tissues anteriorly & whole spinous processes posteriorly.
    2. AP
    3. Open mouth

    C7/T1

    1. Coned True Lateral (CTL)- with tube at 135cm and collimation of 15 x 15 - 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.
      Flexion and extension views are never done but may occasionally be requested by EM Consultant.
      MRI is the modality of choice for ligamentous injury.

    Thoracic Spine

    1. AP
    2. Horizontal beam lateral with a 1 second exposure on digital (get patient to whistle or blow out through pursed lips) or a longer exposure time (up to 6secs) with normal breathing on CR.
      This is important:
      The AEC must never be used for lateral thoracic spines. It fails to demonstrate fractures of the posterior elements and could be responsible for delayed diagnosis of serious posterior column fractures.

    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. AP.
      * For those with #NOF include 15cms of femur below the lesser trochanter for surgical planning.
    2. Lateral NOF
      ? #
      must be horizontal beam

    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.

    DHS

    Patients with hip pinnings do need a lateral NOF.

    Dislocated Prosthesis

    As well as an AP pelvis, patients with prosthetic dislocations need an AP acetabulum view of the affected side only, to show displacement in all four planes, superior, inferior, anterior and posterior. Raise the affected side 45°, centre over the affected hip and collimate around that hip only. No need for any other view.

    A raised leg lateral is not needed. The AP acetabulum can be done easily on the trolley and is comfortable for the patient as it takes the weight off the dislocated side.

    Inlet/Outlet views

    Only when requested by the orthopaedic team. Rarely indicated in the ED. If done, try 30 – 35 degrees cranial and 20 degrees caudal.

    Judet Views

    Only when requested by the orthopaedic team. CT is the investigation of choice for a complex pelvic fracture. Rarely indicated in the ED but may be requested by orthos prior to transfer to Tallaght.

    Sacro-Iliac Joints

    1. PA angled down 15 -25 degrees
      or
    2. AP angled up 15 -25 degrees

    Patients from eye ED may need lumbar spine or SIJ radiography for ? ankylosing spondylitis in cases of uveitis.

    Coccyx

    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

    Orbits ? BF

    1. Undertilted OM with Eyes UP
      but if FB seen also do:
    2. Undertilted OM with Eyes DOWN

    Inhaled Foreign Body

    1. PA or AP CXR
    2. Lateral CXR (Include neck on paediatric CXR)

    Ingested Foreign body

    Small round foreign bodies e.g. coins do not need to be located by x-ray unless inhalation is suspected. Size is important. Please see Paediatric FB ingestion for details.

    Toxic ingestion (e.g. batteries) or sharp objects which could cause perforation should be imaged.

    Adults

    1. Lateral CXR only; include neck
    2. PFA if indicated

    Children

    1. PA (or AP) CXR; include neck
    2. PFA if indicated

    Sharp objects may have to be followed up by x-ray over a period of time. PFA may be indicated also in this case.

    Fish Bone Visible on x-ray

    Visible on x-ray - Cod, Haddock, Colefish, Lemon sole, Gurnard.

    More difficult to see - Grey mullet, Plaice, Monkfish, Red snapper

    Not visible on x-ray - Herring, Kipper, Salmon, Mackerel, Trout, Pike


    Skull & Facial bones

    CT is the modality of choice in head injury.

    Indications for SXR in adult

    • Penetrating trauma

    Indications for SXR in child

    • Penetrating trauma
    • Head injury with suspected NAI

    Skull views

    • AP
    • Lateral
    • Townes if suspected occipital injury.

    Facial Bones

    Erect only & post c.spine clearance in multi-trauma patients.

    1. OM
    2. OM 30

    Sinuses

    • Never x-rayed
    • CT is the modality of choice.

    Orbits

    • ?#
    • Undertilted OM

    ? FB

    • Under-tilted OM with Eyes UP
      but if FB seen also do:
    • Eyes DOWN

    Mandible

    • OPG and PA mandible if ?#
    • If OPG machine is unavailable a full mandibular series is necessary:
      1. PA mandible
      2. Lateral mandible
      3. Oblique mandible – both side obliques

    TMJs

    • Clinical diagnosis X-ray not necessary in ED.
    • MRI is the modality of choice.
    • OPG and PA mandible for ? disloctaion only

    Nasal Bones

    • Not indicated in the ED. (Maxillofacial follow-up).


    Content Drafted by Anne O' Loughlin, Dr Íomhar O' Sullivan 06/05/2005. Reviewed 15/03/2007.Last review Ms Anne O' Loughlin, Dr ÍOS 20/10/18.