Radiography Protocols (CUH)

Lower limb

Toes

1. DP
2. DP Oblique

Hallux

1. DP
2. Lateral

Foot

1. DP
2. DP Oblique
   In cases of a suspected – or seen - Lisfranc injury
   Lateral
   In cases of suspected but not seen Lisfranc injury
   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.
   *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 1^st 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:

3. 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.