Beth Israel Deaconess

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Beth Israel Deaconess
Medical Center Routine Diagnostic
Positioning Manual Revised August 2001
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Table of Contents

• Page 1 A-C Joints
• Ankle
• Calcaneous/Os Calcis
• Cervical Spine Non-trauma
• Cervical Spine Trauma
• Page 2 Chest
• Chest for pneumothorax
• Clavicle
• Coccyx
• Elbow
• Elbow Radial Head views
• Page 3 Facial Bones
• Femur
• Foot
• Foot Standing views
• Forearm
• Hand
• Page 4 Hip
• Hip Post operative

Page 6 Nasal Bones Navicular
Series Orbits Orbits Pre-MRI Screening Page
7 Patella Pelvis Pelvis Inlet / Outletet
views Pelvis Judet views Pelvis
Acetabulum Ribs Page 8 Sacrum Scapula Scoli
osis Series Sella Turcica Page
9 Shoulder S-I Joints Sinuses Skeletal
Series Page 10 Skull Sterno-clavicular
Joints Sternum Supraspinatus Outlet View Page
11 Temporo-Mandibular Joints Thoracic
Spine Thoraco-Lumbar Spine Thumb Tib/Fib T
oes Page 12 Wrist Wrist Instability Zygoma
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All extremities Be sure to mark where it
hurts with a BB marker or arrow Markers
are to be placed on the LATERAL ASPECT to the
part being x-rayed
Always use the smallest film possibleA-C
Joints Bilateral AP Without weights on a 14x17
at 72 to include both joints Weights at
physicians request Ankle AP With
toes toward ceiling, ankle in neutral
position Oblique Mortise view With internal
rotation 30 degrees Lateral To include base
of 5th metatarsal. Lateral malleolus
posterior to medial malleolus

Lateral rotation shouldnt create
superimpostion of the malleoli.
(mortise)Calcaneous/Os Calcis) AP Axial Angle
40 degrees cephalic LateralCervical Spine
All spine films are to be done upright if
possible and collimated on 10x12 film.
Non-trauma AP 15 degree angle
cephalad Lateral 72 SID to include ALL 7
vertebrae base of skull
Cervical
Spine Trauma AP 15 degree cephalic angle
Lateral
72 to include all seven cervical vertebrae and
base of skull.
Odontoid Open mouth view 8x10 or 9x9
film Obliques Only when requested.
Obliques should be marked side down/closet
to film. Trauma Obliques Only when requested.
Supine on board. Angle tube 45 degrees to
left then to right side of patient.

Acute Trauma Flexion and
Extension only with approval and when
monitored by physician.

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Chest PA Left Lateral Right and Left
Decubitus ONLY WHEN ORDERED Right side
down can show right effusion or left
pneumothorax Left side down can show left
effusion or right pneumothorax

Apical Lordotic View ONLY WHEN ORDERED
Shows apical lesions free of superimposition of
the clavicles

PA with Nipple markers ONLY WHEN ORDERED
Place BBs on nipples, delineates nipple
shadows from lesions

 Chest for Pneumothorax PA or AP upright
Full inspiration    Clavicle AP AP Axial 25
degree cephalic angle     Coccyx Lateral
only. Check with radiologist first before doing
AP AP 10 degree caudal angle
All requests for
sacrum/coccyx under the age of 40 should be
approved by a Radiologist   Elbow AP External
Oblique Lateral Elbow -Radial Head Axial Lateral
Position The elbow should be in the lateral
position with the humerus parallel with the
film and tabletop. Wrist and forearm should also
be in the lateral position. The elbow flexed
90 degrees. CR- should be angled 45 degrees
toward the shoulder along the long axis of
the humerus and directed to enter at the
elbow joint.


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Facial Bones Lateral Waters Caldwell PA 23
degrees caudal tube angle    Femur AP Include
joint closest to pain/surgery Lateral Include
joint closest to pain/surgery     Finger PA
If focal pain only finger. No focal pain,
entire hand must be included. Oblique Lateral
    Foot AP 15 degrees cephalic Oblique
30 degrees medial rotation Lateral To
include ankle joint Sesamoids
Axial (Tangential to planter surface)     Foot
Standing AP Weight bearing with cassette on
floor Lateral Weight bearing with horizontal
beam. Oblique Standing , central ray angled
40 degrees medially - foot flat,
weight bearing and use tube angle. When
both feet are ordered, do all views
separately.    Forearm AP Lateral To
include both elbow and wrist joints.     Hand PA
PA Oblique Semi-prone Lateral Fingers
separated ? Foreign Body PA
Lateral Use soft tissue technique ? Bone
Age PA Left Hand Include wrist and ulnar
styloid process

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Hip AP Pelvis
AP hip Collimated invert foot 15
degrees Frog Lateral If there is a low
possibility of fx and the patient is able,
otherwise do a X-table lateral.    Hip
POST-OP ALL POST SURGERY HIPS INCLUDE ENTIRE
APPLIANCE ON BOTH VIEWS AND X-TABLE LATERAL
MUST BE TAKEN. Frog view can not be
taken.   Humerus Include both elbow and
shoulder joints AP Corner
to corner , ID blocker at bottom Lateral
Corner to corner, ID blocker at bottom

Internal Auditory Canals See
Radiologist first - Rarely indicated AP Towne
Stenvers PA Head 45 degrees obliqued
Tube 12 degrees cephalic (Bilateral)  Knee
Non-Trauma AP CR angled 5-7 degrees
cephalic to 1/2 below patella apex. Patella
Sunrise
Merchants view in Ortho for Dr Davis (see
instructions in Ortho) Lateral Knee slightly
flexed 5-10 degrees, tube angled 5 degrees
cephalic X-table lateral at physician
request
Trauma AP CR
angled 5-7 degrees cephalic to 1/2 below patella
apex. Patella Sunrise Merchants view
in Ortho for Dr Davis (see instructions in
Ortho)
Lateral Knee slightly blexed 5-10 degrees, tube
angled 5 degrees cephalic. X-table lateral
at physician request Oblique Medial rotation
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Knee TUNNEL PA Femur parallel to film plane,
knee flexed with Tib/Fib elevated

approximately 40 degrees. Tube angled
caudal so that CR is perpendicular to the
tib/fib and centered through the knee
joint.     Knee STANDING AP CR perpendicular
Centered to knee

  Leg Lengths NO GRID USE FILTER Use 3
or 4 foot cassette AP Be sure that the top of
the pelvis and the ankles are on the film.

If female use the triangle
filter putting the smallest edge at the top.
If the patient has a large belly, the filter
should start at about mid femur

Lumbar Spine All spine films should be
standing if possible AP To include
hips Lateral L5-S1 Spot ONLY IF NOT
VISIBLE ON LATERAL AND PATIENT IS OVER 40
YRS UNLESS REQUESTED BY
RADIOLOGIST. Obliques ONLY WHEN REQUESTED.
    Dynamic Lumbar Spine Upright AP Upright
Lateral Neutral, Flexion, and
Extension Recumbent Lateral Flexion and
Extension T12 - S1 should be included on all
films.   Page 5
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Mandible PA Both Obliques Towne Centered for
mandible (Condyle joints should be
visualized) Panorex whenever possible Mastoi
ds Rarely indicated - See Radiologist
first Towne Base Coned Bilateral Laws
Views The mid sagittal plane is rotated 15
degrees towards cassette from the true lateral
position. CR is angled 15 degrees caudad and
centered 2 posterior 2 superior to the
uppermost EAM.    Nasal Bones Waters Laterals
Bilateral use extremity cassette table
top     Navicular Series PA With clenched
fist (4 views total)
PA With wrist in ulnar flexion CR
angled towards elbow at 30, 45 and 60 degrees
    Orbits Lateral Waters Caldwell PA 23
degrees caudal MRI Screening R/O foreign body in
the orbits AP Collimated to the orbits Waters
View Collimated to the orbits Page
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Patella PA Lateral Settegast(Sunrise) MERCHANT
S VIEW at physician request Mark films
either Sunrise or Merchants Lateral     Pelvis
AP Internally rotate feet 15 degrees Pelvis
INLET/OUTLET AP 30 Degree Angle cephalic for
outlet, center at pubic symphysis AP 30 Degree
Angle caudal for inlet, center at
ASIS    Pelvis JUDET 45 Degree Obliques of
entire pelvis   Pelvis False Profile
Position the patient standing in a lateral
position with the hip to be ACETABULUM
examined against the
cassette. Ask the patient to turn the opposite
foot 90 degrees away, so that it points
toward the x-ray tube. The pelvis will turn
slightly and the CR should be over the hip to
be examined.    Ribs All rib films should be
done recumbent if possible. All rib films
should include a BB marking the point of
pain. PA Chest For all trauma / ?FX
Posterior Ribs AP Oblique 45 degrees side
down. KV Upper Ribs 50-55 Lower Ribs
75-80 Anterior Ribs PA Oblique 45
degrees side away. KV Upper Ribs 50-55
Lower
Ribs 75-80   Page 7
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Sacrum Lateral only. Check with radiologist
first before doing AP AP Axial 15 degree
cephalic angle
All requests for sacrum/coccyx under the age
of 40 should be approved by a Radiologist    Scapu
la AP If the patient can tolerate , keep the
humerus abducted Lateral View AP - rotate the
patient 45 degrees affected side up.
PA - rotate patient 45 degrees
affected side down Scoliosis Series Use 3
foot film with graduated screens and GRID Be
sure the end marked top is at the top - faster

screen speeds(400) will be at
the bottom.  
AP 3 film at 72. The top of the film
should be just above the shoulder.

Average technique 70-77kv
200-250mas Lateral 3 film at 72. The top of
the film should be just above the shoulder.

Average technique 70-77kv
400-500mas Follow-up Films On female
patients films are to be done PA to reduce dose
to breasts.

    Sella Turcica PA 10 degrees
cephalic, coned Lateral coned to
sella       Page 8 
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Shoulder All films done upright when possible
AP
External-Grashey Supination of palm with patient
35-40 degrees oblique towards film to
visualize glenoid joint. AP Internal rotation
In an AP position Axillary Use curved
cassette if possible. If patient cannot
tolerate axial, do Y view. Y view
(PA) Patient PA rotate 60 degrees affected side
to chest stand CR directed to humeral
neck   S-I Joints AP Pelvis Ferguson View
AP with tube angled 35 degrees cephalic on
a 10x12 film Oblique Only on
request   Sinuses All views should be done
upright Caldwell PA OML perpendicular to the
film, 23 degree angle caudad Waters CR exits
acanthion, petrous ridges should be below the
maxillary sinuses Lateral
Skeletal Series Usually indicated for
Multiple Myeloma Otherwise check indications
with the radiologist. Lateral Skull
AP and Lateral Thoracic
Spine-(coned) AP and Lateral Lumbar Spine
(coned) AP Pelvis AP Humerus - Bilateral AP
Femur - Bilateral   Page 9  
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Skull Caldwell PA 23 degrees tube angle caudal
, CR exits the nasion Left Lateral
Midsagittal plane parallel to film,
interpupillary line perpendicular to film, CR
2 above EAM AP axial (Towne) 30 degree caudal
angle. CR inters 1 1/2 to 2 above the
glabella. Base ONLY WHEN REQUESTED IOML
parallel to film , CR at goninon.    Sterno-Clavic
ular PA Head extended upward on
chin. Joints Oblique Patient 15 - 20 degrees
with head turned towards affected
side Bi-lateral obliques are always
performed.      Sternum RAO Breathing
technique (2-4 seconds), 28 to 30 focal film
distance. - collimate. Lateral Collimated to
sternum   Supraspinatus PA Oblique 45
degrees Outlet View with affected side toward
film and scapula perpendicular to the film.
CR angled 10-15 degrees caudal.  
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TM Joints Panorex whenever possible Towne
coned for condyles Lateral Bilateral open
closed mouth tube angled 20 degrees caudal,
coned Thoracic Spine All spine films should be
standing if possible AP Include T1-T12
collimated Lateral Breathing technique to
include T1-T12

    Thoraco-Lumbar All spine films should be
standing if possible Spine (Mid T L5) As
requested. Follow up to mid back pain/trauma. AP
Center on T12 Lateral Center on T12.

  Thumb AP PA Oblique If
trauma include entire hand Lateral     Tib/Fib
AP Include both joints. Angle film corner to
corner. Lateral Include both joints. Angle
film corner to corner. Place ID blocker at
bottom of film so when the previous
films are compared the angle of the tib/fib will
be the same.     Toes AP Collimate. However,
if diabetic collimate for all toes. Oblique Late
ral For trauma isolate symptomatic toe, tape
others away Page 11
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Wrist PA Slightly clenched
fist. - not stressed. Oblique PA
semi prone Lateral Wrist
Instability For chronic pain
additional PA with clenched stressed fist with

10 degree pronation. Ulnar and
radial deviation and dorsiflexion may

be obtained as well as flexion and
extension views laterally.

Additional films per request.       Zygom
a Base View Bilateral, (jug
handle) Lateral Waters
Caldwell PA , 23 degrees
caudal
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