The ability to perform a proper positioning during the detection of any abnormalities within the musculoskeletal system is of great essence Positioning in Radiography amongst health care providers, particularly, radiographers. Within this context, positioning refers to how patient bodies or affected body parts are placed close to the IR for radiographic images to be captured for analysis. Accurate positioning is critical in radiology as it enhances the capturing of high-quality images for diagnostic purposes as well as cushioning the patient from the adverse effects of radiation.

This post explains steps that should be observed for the positions of the humerus, Positioning in Radiography elbow, and femur for an X-ray. It also discusses what is seen in each position upon the capturing of the images. Lastly, to demonstrate the importance of radiography in the provision of health care services, this post will elucidate the application of this technique in two pathologies; Nursemaids elbow and Monteggia fracture.

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Definition of Radiography

Radiography is a technique of imaging whereby X-rays, or radiation is used to view the musculoskeletal system by medical personnel to detect any abnormalities within the system (Myatt, 2017). However, one of the critical skills in radiography is accurate positioning. Song, et al. (2018) defines positioning as methods of placing patients’ bodies or affected body parts close to an Image Receptor (IR) for capturing of radiographic images for orthopedic diagnosis. Positioning in Radiography Excellent position skills are of great essence for health care providers. Therefore, this paper seeks to illustrate the positions of humerus, elbow, and femur for an X-ray. It will also demonstrate how this technique is applied by explaining the nursemaid's elbow and monteggia fracture pathologies.

  • a) Humerus Positions

i) How to position Humerus AP

There various steps that should be followed while positioning the humerus AP for an x-ray as explained by Hengg, et al. (2016). It starts by ensuring that the patient is standing or is in the supine position. A lead shield is placed around the patient’s abdomen for protection from the effects of radiation. IR should be adjusted to 14 by 17 inches by The 14 by 17 inches by placing the upper margin of IR 1.5 inches above the humerus’ head. Take away the arm away from the body and supinate the hand. Positioning in Radiography The epicondyle should be parallel with the IR. Enhance collimation by directing the central ray (CR) to be perpendicular to the mid-point of the humerus and center of the IR. Collimation improves radiographic contrast. While making this exposure, the patient should remain still and suspend respiration.

What should be observed include; AP projection of the humerus should demonstrate the elbow, the shoulder joint, with maximum visibility of the non-rotated epicondyle. The humeral head, Positioning in Radiography and greater tubercle should be seen in profile, and the outline of the lesser tubercle seen between the humeral head and the greater tubercle. Appropriate contrast and density will be a demonstration of both soft tissue and tubercular of the bone.

ii) How to position lateral

The first step is to ensure that the patient is standing or in a supine position. A lead shield should be placed around the abdomen to cushion the patient from the effects of radiation. Adjust the IR to 14 by 17 inches by placing the upper margin at 1.5 inches above the head of the humerus. Positioning in Radiography Internally rotate the arm, flex the elbow and place the patient’s hand on the hip. The epicondyle should be perpendicular to the IR. The CR is directed perpendicularly to the mid-point of the humerus and the center of the IR to achieve collimation. Collimation improves radiographic contrast.

Lastly, have the patient suspend respiration (Hengg, et al. 2016). This is what should be observed here; the lateral projection of the humerus should demonstrate the elbow, the shoulder joint, and superimposed epicondyles. The lesser tubercle in profile and the greater tubercle is superimposed over the humeral head. Both soft tissues and bone tubercular will be seen as well.

iii) How to Position Transthoracic Lateral   

Positioning steps include; the transthoracic lateral of the shoulder is performed with the patient in supine or standing position. A lead shield should be placed around the patient’s abdomen for radiation protection. Adjust the center of 10 by 12 image receptor to the surgical neck of the affected humerus. Raise the uninjured arm and rest the forearm on the head.

The CR is directed perpendicularly to the IR and through the affected neck to achieve collimation for better contrast. Have the patient suspend respiration (Hengg, et al. 2016). The observation should entail; a transthoracic lateral projection of the shoulder demonstrating the proximal humerus and the scapula upon the clavicle. Both soft tissue and tubercular of the bone will be observed as well due to appropriate contrast and density.

  • b) Elbow Positions

i) Oblique Medial (Internal)

Trevail, (2018) insists that the following steps should be followed for better results; the AP internal oblique projection of the elbow to be performed with the patient seated at the end of the table. A lead shield should be placed on the patient’s lap for radiation protection. The height of the table should be adjusted to ensure that the patient’s entire arm rest easily on the table. The patient’s hand should be supinated and the elbow extended on the mass side of an 8 by 10 IR.

The CR to be directed perpendicularly to the mid-point of the elbow joint to achieve collimation. When making the exposure, the patient should remain very still without suspending respiration. The obtained image should show an AP mid-oblique projection of the elbow demonstrating the coronoid process projected free of superimposition. Appropriate contrast and density will demonstrate both soft tissue and tubercular of the bone. In general, Internal, Coronoid Process, External, Radial head, (ICER) should be observed.

ii) Oblique Lateral (External)

Accurate positioning starts with the AP lateral or external oblique projection of the elbow being performed with the patient seated at the end of the table. A lead shield should be placed on the patient’s lap for radiation protection. The height of the table should be adjusted to ensure that the patient’s entire arm rests on the table with ease. The patient is supinated and the elbow is extended and rotated externally to place the posterior service of the elbow at a 45 degree angle on the on-mass side of an 8 by 10 IR. The patient’s first and second digits should touch the table.

The central ray to be directed perpendicularly to the mid-point of the elbow-joint to obtain collimation for a better image. When making the exposure, the patient should be still, but respiration suspension is not required (Trevail, 2018). Image evaluation should show the AP lateral oblique projection of the elbow demonstrating the radio head and neck projected free of superimposition of the ulna. Appropriate contrast and density would demonstrate both soft tissue and tubercular of the bone.  

iii) Lateral

In this position, the lateral projection of the elbow is performed with the patient seated at the end of the table. A lead shield should be placed on the patient’s lap for preventing exposure to radiation. The height of the table should be adjusted to ensure that the arm of the patient rests easily on the table and the elbow is flexed at 90 degrees. The thumb side of the hand should be up on the on mass side of an 8 by 10 image receptor and ensure that the humeral epicondyles are perpendicular to the IR.

The CR to be directed perpendicularly to the mid-point of the elbow to obtain collimation to enhance image clarity. When making the exposure the patient should remain very still, but suspended respiration is not a mandatory (Trevail, 2018). The following should be seen in the image; A lateral projection of the elbow demonstrating the elbow proximal radius and ulna and the distal humerus. Both soft tissue and tubercular of the bone will be observed as well.

iv) Axial Lateromedial (Coyle Method)

The patient should be seated on a chair placed at end of the table on which the IR has been placed. The lead shield should be placed over the gonadal area to shield the patient from the effects of radiation. If possible, the patient’s elbow should be flexed at 90 degrees for pronation. However, 90 degrees flexion is unnecessary. Direct the CR at an angle of 45 degrees towards the shoulder. Ensure that CR is centered to radial head or the mid-elbow joint. The source-image distance (SID) should be at minimum of 40 inches.

Flex the elbow at 80 degrees to avoid obscuring hand pronation and coronoid process. The areas of interest should be collimated at four sides. Due to the angle of the CR, exposure factor should be increased by 4 to 6 kV. This is to ensure that the projection is effective with or without a splint (Campeau, et al. 2016). What to see in the obtained image include; for the radial head; the neck and tuberosity should be in profile and superimposition free. Distal humerus and epicondyles may appear to be distorted due to the 45 degree-angle.

Also, joint space between capitulum and radial head should be clear and open. As for the coronoid process; distal anterior portion of the coronoid may be elongated but in profile. Joint space between trochlea and coronoid process should be clear and open. Radial head and neck are superimposed to the ulna. There should a clear visualization of the coronoid process in profile exposed by optimal exposure factors. Consequently, there should be a faint visualization of bony margins of superimposed radial head and neck.

v) Axial mediolateral (Coyle Method)

According to Campeau, et al. (2016) this positioning should be guided by the following steps; the patient should be seated at the end of the table on which IR has been placed. The lead shield should be placed over the gonadal area to shield the patient from the effects of radiation. Bring the arm slightly forward to ensure that the elbow surpasses the 90 degrees. Place the dorsal side of the fore arm against the IR. Direct the CR at 45 degrees for mediolateral projection. CR should be centered to the mid-elbow joint. The obtained image should show a clear coronoid process.

  • c) Femur Positions

i) AP distal and Proximal

According to Yang, et al. (2015) the following steps are critical; first ensure that the patient is on top of the table’s bucky top. The image receptor should be adjusted to 14 by 17 inches. The patient should be supinated. Consequently, ensure that the femur is centered on the film and the CR is directed to the mid-shaft. The obtained image should show the entire hip, the head, neck, trochanters and proximal is 1/3 or ¼ of the femur’s shaft.

ii) Lateral (Distal and Proximal)

In this position, the following steps should be followed; the patient should be positioned don side on the bucky or table top. The affected side should be close to the film. Adjust the film to 14 by 17 inches. Pull the opposite leg up and over the affected leg. The SID should be 40 inches with the CR pointed at the mid-shaft. The obtained image should show the hip joint, acetabulum, head of the femur and its relationship with the acetabulum (Yang, et al. 2015).

iii) Horizontal beam lateral (trauma)

Steps to be followed here include; the patient should be supine and both arms should be placed on the chest. Ensure that the affected area is close to the IR. Upright detector or portable detector IR in an upright stand can be used. Angle the IR between 20-45 degrees. The angle position should match the neck of femur’s angle. This is to ensure that foreshortening of anatomy or elongation is deterred. Place IR in a landscape orientation superior to the iliac crest to enhance adequate imaging of the femoral neck.

A finger should be placed on the anterior superior iliac spine of the affected area to confirm whether it is projected onto the superior third of IR. This usually promotes projection of the superior-inferior aspect. The bed or table should be elevated to position CR at the mid-thigh of the healthy leg. Flex and abduct the unaffected hip and place the leg on a dedicated stand for a short time (Yang, et al. 2015).

The following technical factors should be considered; projection of the axiolateral. Centering point should be ensured by angling the CR perpendicularly to the long axis of the femur’s neck and Positioning in Radiography adjust the IR to match CR’s angle, centering point should be 13 cm distal to the femur’s neck. For collimation, 9 cm for anteroposterior in each direction from the midline and 12 cm for the inferosuperior in each direction from the centering point. The orientation should be landscape. Detector size is 18 cm by 24 cm with an exposure of 80-100 KVp and 80-320 mAs (Yang, et al. 2015).

What to see in the image include; a uniform exposure evidenced by a fine bony detail. The lesser trochanter in profile. The greater trochanter superimposed by the proximal femoral shaft. Femoral neck being central to the image with no signs of elongation or radiographic foreshortening. Lastly, Visualization of the articular surface of the head of the proximal femur and the acetabulum should be clear (Yang, et al. 2015).

Pathology

Pathology refer to the study of the nature of diseases particularly the structural and functional changes caused by identified diseases. Healthcare providers seek to establish any Positioning in Radiography abnormalities in the structure and functions of body organs as well as any deviations from a normal state of the body (Zhang & Fenderson, 2015). Therefore, this section of the paper aims to explain two pathologies; nursemaids elbow and monteggia fracture.

a) Nursemaids elbow

The nursemaid’s elbow is an injury common among children aged between 1-4 years. In most instances, this injury occurs when a child is involved in an incident leading to the pulling of the extended arm. For instance, it may happen when a child trips and Positioning in Radiography the individual holding the child’s hand failure to let it go, or swinging the child while holding his/her hands. However, the injury normally caused by a fall (Cohen-Rosenblum & Bielski, 2016).

Nursemaid's elbow can be determined when the radiographic image shows the interposition of the annular ligament the radial joint of the humerus. Traction will be identified on the extended arm whereby the annular ligament will be found to have slid over the head of the radius into joint space and entrapped (Cohen-Rosenblum & Bielski, 2016).

However, there is no need for surgery as the forearm is pronated or supinated, while supporting the radial head, and flexed at the same time. A “click” will be heard as a confirmation of proper adjustment. Pronation is preferred to supination as it is less painful.

b) Monteggia Fracture

Monteggia fracture refers to the dislocation of the proximal radioulnar joint (PRUJ). It is normally associated with the fracture of the forearm, particularly, the ulna. However, monteggia fractures are not common as they only account for less than 5% of all fractures of the forearm. These fractures are manifested by pain in the elbow when the forearm is rotated or the elbow is flexed (Patel, 2018).

On an x-ray image, the lateral view of the elbow will indicate fractured ulna at the point of impact. The radial head will be found to have dislocated from its normal position. Also, on the anteroposterior projection, a fractured ulna is likely to be seen. However, the dislocation of the radial head might not be possible to see (Patel, 2018). Monteggia fractures happen when an individual falls on a hand that was outstretched with excessive pronation of the forearm. This is also referred to as hyper-pronation injury, which is characterized by ulna fractures in the proximal 1/3 of the shaft caused by extreme dislocation.

Consequently, it may be caused by a direct blow to the back of the upper forearm. However, this cause is not common. In the management of monteggia Positioning in Radiography fractures, surgery is required whereby the surgery aims to enable internal fixation for repairing the fractured bone, particularly for children. This is due to the risk of malunion perpetuated by displacement. Surgery or osteosynthesis of the shaft of the ulnar is also recommended for adults. This is done to avoid stiffness by promoting the stabilization of the dislocated radial head.

Conclusion

Radiography is of great importance in the treatment of bone fractures. However, the effectiveness of this technology is determined by the skills possessed by the medical personnel utilizing the equipment within a healthcare facility. One of these skills is positioning skills for high-quality images to be captured.

The medical personnel should be proficient in using this equipment by knowing how to ensure that patients are not affected by the radiation, how to adjust the IR, and positioning of CR.

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