Lateral Scapula Radiography

1
Lateral Scapula Radiography

The lateral scapula ("Y" view) of the shoulder is one of those "signature" views that radiographers
approach in a variety of ways. The techniques can be divided into AP and PA. The techniques can
be further divided according to the patient's arm position. The best approach is the one that works
for you and achieves the imaging objectives. Note that I have presented almost all of the images as
a right shoulder- this is to facilitate comparison only. This page considers the lateral scapula
radiographic techniques in a trauma setting- information on the objectives and techniques of the
outlet view of the shoulder are not specifically considered.
The Lateral Scapula Projection Needs a Clinical

Context
Radiography is best performed with a clinical context in mind- the lateral scapula projection is no
exception to this general principle. A trauma lateral scapula projection is completely different to a
Neers (outlet) projection both in its technique and objectives. If the anatomy and potential pathology
are understood, the radiography will be more meaningful.
Anatomy
The acromion and coracoid form a "Y" or "peace
sign" shape with the body of the scapula.
The head of the humerus should be normally

centred to the middle of the "Y" shape as shown.
The acromion and distal end of the clavicle form

a "roof" over the shoulder joint and prevent
superior displacement of the humeral head.
A group of muscles and their tendons known as

the rotator cuff surround the shoulder and
contribute to movement of the humerus
2
The PA Approach
These images all taken with the patient in the PA oblique position. They could be performed equally
well in the AP position
Hand on Hip Arm by Side "Napoleon" Technique
3
Sheila Bull. Skeletal Radiography: A

Concise Introduction to Projection
Radiography
Edition: 2, Published by Toolkit
Publications, 2005
The disadvantage of this position is This position superimposes the This is my preferred lateral scapula
that the patient's chest is in a very patient's humerus over the body of positioning. For the left scapula, I
lateral position. This position the scapula. This is not ideal for would ask the patient to place
requires a greater X-ray exposure trauma radiography where you are his/her left hand on the right
than the other two techniques. attempting to achieve an shoulder as shown (cross arm
unobstructed view of the scapula adduction). The left scapula tends
(OK for Neer's view) to roll into the lateral position with
very little rotation of the chest.
The photograph is taken from a

textbook titled "radiographic Image
Analysis". The position looks too
4
lateral. I would also question the

term "proper". Although this is my
preferred position, there are other
legitimate positioning techniques
depending on your objectives.
Caudal Angulation
When do you use caudal angulation and how much?
Patients tend to lean/stoop forward when positioned

for lateral scapula radiography. How much caudal
angle to use is a matter of practise and judgment. It is
prudent to err on the side of too much caudal angle
rather than too little
The Supine AP Approach

Trauma patients will often present in the supine position with little scope for movement of any kind.
To achieve a lateral scapula in a supine patient, the patient is rolled affected side up and a triangular
positioning sponge inserted. This approach can be very challenging for a variety of reasons:
o if the patient is unable to adopt the Napoleon position, considerable rotation of the
patient will be required to achieve a true lateral scapula position
o if a non-grid technique is employed, the image may be degraded by lack of contrast
o if a stationary grid is employed, grid cut-off is a common problem
o patient may be unable/unwilling to be rolled
The answer sometimes is to use an alternate view- IS or SI
In order to minimise the rotation of the patient required to achieve a true AP position, have the
patient adopt the "Napoleon" Position
Patient's Affected Arm in Neutral Position Patient's Affected Arm in the "Napoleon" Position
5
on
With the patient's arm in the neutral position, the With the patient's arm in the "Napoleon" position,
patient must be rotated considerably to achieve a true there is very little rotation of the chest required to
lateral scapula position. This has disadvantages in achieve a true lateral scapula position.
terms of difficulty of positioning, radiation dose and
contrast/scatter degradation of the image.
Good Projection when Achieved

6
One of the shortcomings of the lateral scapula When the malposition is corrected, the observer can
projection is that it is frequently accepted by be confident that there is no subluxation/dislocation
radiographers despite malposition. To assess gleno- of the gleno-humeral joint
humeral alignment, the psoition barely satisfies.
What Went Wrong?

Image 1 Image 2 Image 3
7
...what went wrong- not much This is a satisfactory position. The The humeral head is dislocated
patient is leaning slightly too far anteriorly. The malpositioning is
forward (assuming PA projection). resulting in an extremely
Note that the humeral head and foreshortened scapula. Note how
glenoid are projected a little much of the scapula is projected
inferiorly in relation to the "Y" above the glenoid. This position
(compare with image 1). There is tends to occur in the erect PA
also more scapula seen above the position when the patient leans
humeral head/glenoid than in forward to position their shoulder
image 1. on the erect bucky/IR. You can
generally anticipate this effect and
angle caudally to some degree as a
matter of routine.
8
Remarkably similar to image 3. Similar to image 5 but a little Extreme malpositioning.

worse.
Anterior dislocation of the humeral This is an extreme example of
head Fractured neck of humerus noted. foreshortening. If this was a PA
projection, the patient is leaning
Slightly under-rotated and severely forward too much
foreshortened. (understatement). Note that the
glenoid and humeral head appear at
the inferior aspect of the scapula.
Note also tendon screws.
Probably underexposed.
9
Lack of image contrast associated

with non-grid technique
A very good position spoiled only Not so fortunate with the bra -under-exposed
by bra hardware. Bra strap is also hardware positioning -foreshortened
visible. Fortunately, the bra -humerus overlying scapula
hardware is not overlying the bony
shoulder anatomy

10
Foreshortened and under-rotated. The This is a well positioned Good position

patient needs to be further rotated lateral scapula in a child
towards a lateral position taken upright in the
Napoleon position. Note
that there is a subtle clavicle
fracture. Further images
here
Scapular Pathology
11
There is a fracture of the scapula There is a fracture of the neck of There is a fracture involving the
immediately inferior to the glenoid. humerus (arrowed) glenoid (not arrowed)
There also appears to be a fracture
of the distal clavicle (not marked)
12
There is a grade 3 dislocation of the There are calcific densities Comminuted fracture of the
AC joint (not arrowed). There also demonstrated surrounding the head scapula.
appears to be a clavicle fracture of humerus (arrowed). These are
(top arrow) and a fracture fragment likely to be tendon calcifications of
inferior to the clavicle (bottom the rotator cuff.
arrow)
Note that the lateral scapular
projection is notorious for throwing
up false AC joint dislocations- not
a good view for assessing the AC
joint
13
There is a fracture of the neck of There is a healing fracture of the Good position.
humerus. The humeral head is body of the scapula.
inferiorly subluxed. This is known
as a pseudosubluxation and is
caused by distention of the shoulder
joint capsule by blood.
14
There is a fracture of the acromion (arrowed) Fractured coracoid process (arrowed).
Concomitant Pathology and Incidental Findings

Shoulder radiography can be fertile territory for concomitant pathology and incidental findings. The
following cases provide some typical and unusual examples.
15
This elderly demented patient was referred for The compromise AP shoulder image demonstrates no
radiography of his shoulder following a fall at the acute bony injury. There is a veiled opacity underlying
nursing home. The patient's combative behaviour the right lung associated with the right pleural effusion.
associated with his dementia necessitated an This is difficult to appreciate without the other lung for
adaptive approach to his shoulder radiography. The comparison.
patient's shoulder imaging was all performed
bedside with the patient in a supine position. AP and
lateral views of the shoulder where achieved with
opposite 45 degree tube angulations to produce two
compromise views at 90 degrees. This image is the
'lateral scapula' image which is imperfectly
positioned as expected. The radiographer noted the
large pleural effusion (black arrow) and asked the
referring doctor if a chest X-ray could be included in
the series. The chest image revealed a large pleural
effusion and significant right lower lobe collapse
and consolidation. An underlying malignancy was
considered to be a possible cause.
The radiographer's diligence in identifying the

pleural effusion facilitated timely chest radiography,
16
and obviated the need to call the patient back from

the nursing home the next day for further imaging.
Modified Technique for Trauma Patients
This patient presented in an erect sitting position with This technique can be employed with patients who
very limited movement. The radiographer used the have very limited movement. The basis of the
modified lateral scapula technique by sitting him technique is to angle the X-ray beam rather than the
forward and placing a 45 degree sponge and X-ray patient. I have seen this technique used successfully in
cassette behind him and directing the X-ray beam as a patient who was sitting on a
shown above. The image successfully demonstrates an trolley/bed/barouche/gurney.
anterior shoulder dislocation.
Can the Lateral Scapula Projection Reliably

Demonstrate Shoulder Dislocation?
17
My department has utilised the lateral scapula projection as the view of choice for the demonstration
of shoulder dislocations for the last 30 years. There are departments that strictly forbid the lateral
scapula view for assessment of shoulder dislocation. They can't both be correct ... or can they?
Image 1 Image 2
The exponents of the lateral scapula view would suggest The same people would argue that this patient has an
that this GH joint is normally aligned and I would tend anterior shoulder dislocation, despite the suboptimal
to agree with them positioning. You can't demonstrate two structures as
being separated unless they are separated.
The counter argument is that there are several conditions where the results can be equivocal.
Amongst these conditions are the pseudosubluxation and the posterior dislocation.
The Counter-Argument
18
These images lack quality- The lateral scapula view is The IS view demonstrates a
they were taken on night shift using underexposed. Despite this image humeral head subluxation. This is a
a bedside technique in ICU. The quality issue, the humeral head is radiographer initiated
referring doctor was specifically demonstrated to be neither clearly supplementary view intended to
looking for gleno-humeral joint dislocated nor enlocated. This case clarify the alignment of the
dislocation. demonstrates the argument against glenohumeral joint.
There is evidence of the lateral scapula view.
shoulder arthropathy.
The humeral head appears
inferiorly subluxed.
There is a defect in the
humeral head medially which may
represent a reverse Hills-Sachs
lesion.
Discussion
The limitations of the lateral scapula view can be overcome with radiographer training.
Radiographers learn to identify cases where the lateral scapula view should be supplemented with
views such as the IS/SI view.
In one study, it was found that " .... the axillary view and scapular "Y" view visualized associated
pathology equally well" (1)
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The Neer's (outlet) View

The Neer's view of the scapula is very similar to the lateral scapula in its positioning but not in its
intent. The aim of the Neer's view is to demonstrate the subacromial space. This view is often
performed on patients who have a shoulder disorder known as impingement. The positioning for
the Neer's view will be covered elsewhere in this wiki.
This is the Neer's position. Note that the intention and This may not be a textbook Neer's view, but it does
coning are to demonstrate the subacromial space demonstrate a subacromial spur (arrowed)
With normal humeral elevation, the subacromial

structures are compressed up against the acromion. If
there is a bony spur projecting into the acromial space
(as shown above), the subacromial structures can
become damaged/inflamed.
Summary
The lateral scapula view is one of those views that is a pleasure to perform once it is mastered.
There is a great deal of satisfaction in being able to produce a high quality lateral scapula image with
consistency.
20
Clavicle Radiography
Introduction
For those radiographers who are employed in facilities that provide trauma and acute care services,
clavicle fractures are commonplace. This page considers clavicle radiography techniques and
clavicle trauma image interpretation.
Mechanism of Injury
adapted from Joseph David Zuckerman, Kenneth J. Koval.

Shoulder fractures: the practical guide to management,
2005
Most patients with clavicle fracture will give a history of a direct fall onto the shoulder or fall onto an
outstretched hand. Note that in both fracture mechanisms demonstrated above, the clavicle is subjected to an
axial compression force.
Clinical diagnosis is straightforward- typical injury mechanism with pain, tenderness and deformity.
Anatomy
21
This image
is taken
from a
book titled
Borderlan
ds of
Normal
and Early
Pathologi
cal
Findings
in
Skeletal
Radiogra
phy. This
is a
textbook
with some
unique
information
that is well
worth
investing
in.
Source: Koehler/Zimmer's Borderlands of Normal and Early Pathological Findings in Skeletal Radiography, Thieme, 2003, 5th Edition,
p306
Source: Koehler/Zimmer's Borderlands of Normal and

Early Pathological Findings in Skeletal Radiography,
Thieme, 2003, 5th Edition, p307
22
The
arrowed
sructure is
commonly
referred to
as a
clavicle
companion
shadow.
This line is
caused by
the skin
and
subcutaneo
us tissues
curving
around the
clavicle.
23
The arrowed
structure is
referred to
as a
coracoclavi
cular joint.
This is an
anomalous
articulation
between the
coracoid and
the clavicle.
Clinical Presentation
Patients with clavicle fracture will almost invariably be experiencing pain associated with the fracture.
Given that the clavicle is a superficial bony structure, a clinical diagnosis is often made with
confidence. Consideration of acromioclavicular joint injury and sternoclavicular joint injury should be
made, particularly in patients who have significant symptoms (pain) and do not demonstrate a
clavicle fracture radiographically.
The following images follow a clavicle fracture from initial presentaion to post-op imaging.
24
Source: Injuries of the Clavicle, Acromioclavicular Joint and Sternoclavicular Joint

Andrew H. Schmidt, M.D., T.J. McElroy, January 2007
U01 clavicle AC SC Joints 1.ppt
This patient has suffered considerable trauma resulting in left sided scapula fracture, multiple rib fractures
and clavicle fracture.
The arrows indicate the overlapping segments of the fractured clavicle
25

The AP shoulder image demonstrates a mid-clavicle fracture, fractured scapula, haemothorax and multiple rib
fractures (? flail segment)
26

The clavicle fracture exposed at surgery

27

The ORIF of the left clavicle fracture with screws and plate.
28

Post operative radiography
Radiography
A typical trauma radiography series of the clavicle will include an AP shoulder projection and an AP
clavicle projection with cephalic angulation. This series is most suitable for patients who present with
convincing clinical signs of an isolated clavicle fracture. The AP shoulder projection is useful in
diagnosing other (unsuspected) shoulder girdle bony injury. The cephalic angle clavicle projection
should be included to avoid missing subtle clavicle fractures. This view also has the potential to
provide an improved appreciation of the nature of the fracture and its degree of displacement. See
cases below which illustrate these points.
29
Clavicle
radiography
is
frequently
performed
with the
patient in
the AP
erect
position as
shown in
this
illustration.
There are
multiple
variations
on this
technique
including
PA imaging
and patient
angulation
rather than
adapted from tube
Charles A. Rockwood, Frederick A. Matsen, III, Michael A. Wirth, Steven B. Lippitt. angulation.
The Shoulder, 2009
This is an
AP
projection
clavicle
image with
no tube or
patient
angulation.
30
This is an
AP
projection
of the
clavicle
with 15
degrees of
cephalic
tube
angulation.
The tube
angulation
can
typically
range from
15 to 30
degrees.
The greater
the tube
angulation
applied, the
greater the
superior
projection
of the
clavicle.
Inclusion of
the SC joint
is
reasonable
in trauma
situations.
Note that
the AC
joint is
more
clearly
demonstrat
ed using
this
projection
compared
to the
straight
tube (non-
angled) AP
projection
of the
clavicle.
31
Pathology
Displacement of the clavicular
fracture is always as shown-
the sternomastoid muscle tends
to pull the proximal fragment
in a cranial direction and
gravity largely takes care of the
distal fragment. Sometimes
there is a comminuted fragment
almost turned at right angles
between the ends.
http://www.orthospot.com.au/papers.orthospot.com.au/fracupl_files/frame.htm
32
This patient
has a grade III
AC joint
separation. In
addition, the
coracoclavicul
ar ligament
has avulsed a
segment of
bone from the
inferior aspect
of the
clavicle.
(sometimes
referred to as
a conoid
process or
conoid
tubercle
avulsion
fracture)
Case Studies
Case 1
This patient presented to the Emergency Department following a fall. The patient underwent a clinical
assessment and was subsequently referred for shoulder radiography with a clinical diagnosis of clavicle
fracture.
33
It is apparent
that there is
no clavicle
fracture. The
clavicle
appears to
have smooth
bony
contours and
there is no
obvious soft
tissue
swelling- the
soft tissue
line
visualized
running
parallel to
the upper
border of the
clavicle is
known as a
companion
shadow and
appears
unremarkabl
e. At this
point it
would be
reasonable to
question the
value of any
further
imaging of
the patient’s
clavicle.
Further
imaging of
the clavicle
would
appear to be
contributing
to the
patient’s
radiation
dose without
adding any
diagnostic
value.
The
radiographer
continued
34
the
examination
by
performing a
dedicated
collimated
AP cephalic
angle
clavicle
projection as
shown
below-left.
There is
clearly a
midshaft
clavicle
fracture that
was not
demonstrate
d on the first
image This
fracture was
superimpose
d over the
patient’s
second rib
causing it to
be
completely
obscured. In
retrospect,
there may
have been
minimal
distortion of
the clavicle
companion
shadow on
the initial
image, but
this could
have easily
have been
overlooked.
Case 2
35
What is
the value
of the
dedicated
AP
cephalic
angle
clavicle
projection
when a
clavicle
fracture is
clearly
evident on
the AP
shoulder
image?
Once
again,
there can
be
additional
informatio
n gleaned
from the
dedicated
clavicle
view
image.
This
patient
clearly has
sustained
a clavicle
fracture.
36
This is the
AP
clavicle
view with
cephalic
tube
angulation
. The
degree of
displacem
ent of the
fracture is
greater
than that
suggested
on the AP
clavicle
view
image
above.
Case 3
37
This patient
has a clearly
demonstrated
clavicle
fracture with
displacement
of the fracture.
The AP
cephalic angle
view image
provides
improved
visualisation
of the fracture
and addition
appreciation of
the degree of
comminution.
Note also the

subacromial spur.
Case 4
38
This 85
year old
lady
presente
d to the
Emergen
cy
Departm
ent
followin
g a fall.
She was
examine
d and
referred
for a
variety
of
imaging
including
left
shoulder
radiogra
phy.
There is
no
displaced
fracture
demonstr
ated.
Degener
ative
disease
of the
AC joint
and GH
joint
noted.
Plastic
patient
gown
press-
stud
artifacts
noted.
39
The
radiogra
pher
conside
red the
patient
to have
a high
likeliho
od of
medial
clavicle
fracture
. The
cephalic
angle
AP
shoulde
r image
demons
trated
no
displace
d
fracture
.
The
radiogra
pher
conside
red that
(clinical
ly) the
patient
had
sustaine
da
medial
clavicle
fracture
and the
imaging
thus far
had
failed to
40
demons
trate the
fracture
.
The AP
clavicle
projectio
n was
repeated
with a
severe
cephalic
tube
angle
(angle
employe
d is
unknown
). The
medial
clavicle
fracture
was
demonstr
ated.
41
medial
clavicle
fracture
arrowed.
Comment
This case presents a good example of a clinical approach to radiography. The radiographic series
was supplemented with additional projections to demonstrate the fracture that the radiographer
considered to be clinically evident.
Summary
The temptation not to perform a dedicated cephalic angle clavicle projection can be overwhelming in cases
where you think that you have clearly demonstrated, or not demonstrated, a clavicle fracture on the AP
shoulder image. However, it comes with a diagnostic risk. Single view radiography of any bony structure is a
hazardous practice and should be avoided whenever possible. In the words of John Harris, "one view is no
view".
42
AP Thoracic Spine Breathing Technique

Introduction
The breathing technique would be familiar to most radiographers when utilised to blur lung markings
which would otherwise obscure bony detail when performing the lateral thoracic spine view. The
breathing technique can also be used to good effect on the AP thoracic spine projection for the same
reasons that it is applied to the lateral projection.
Technique
The breathing technique combines a long exposure with gentle patient breathing.
Images
43
This image was taken on a DR imaging system.

The AP thoracic breathing technique provides
excellent bony detail of the thoracic spine bony
anatomy including clear visualisation of the
pedicles.
44
Case Study 1
This 13 year old boy presented to the Emergency Department following a fall from his pushbike. He was found
to have a tender thoracic spine and was referred for thoracic spine radiography
Short Exposure Time Technique Breathing Technique
45
The short exposure time AP thoracic spine image does This image utilized the same kVp and mAS but with a
not clearly demonstrate the thoracic vertebral bodies. longer exposure time of 1.6 seconds.
This is due in part to underexposure and to overlying
46
soft tissue structures
The patient had sustained a minor crush fracture of the body of T8 which was not well demonstrated on the AP
image.
Case Study 2
This patient presented to the Emergency Department following a motor vehicle accident.
47
The AP thoracic spine image demonstrates

multiple posterior rib fractures on the right
(arrowed).
Discussion
48
The breathing technique can be applied to any bony anatomy where patient breathing can be used to advantage
to deliberately cause movement unsharpness of soft tissue anatomy.
Lateral Lumbar Spine Breathing Technique
Introduction
There has been a longstanding practice in radiography to perform lateral thoracic spine
radiography using a long exposure time to blur out lung and other soft tissue markings. It is
unclear why this technique was not seen as equally applicable to the AP projection.
Equally, there are patients who present for lumbar spine radiography who have so much
small bowel gas that the bony anatomy is almost completely obscured when utilising a
short exposure time technique. Why not employ breathing technique for these patients?
Breathing Technique Case Study 1

This patient has presented to the Emergency Department following a motor-vehicle
accident. The patient was referred for lumbar spine radiography.
First Presentation Post Operative Imaging

49
There is a crush fracture of the body of L2. The patient returned to the X-ray department following spinal
The patient was referred for a surgical surgery for post-operative imaging. The radiographer selected
assessment and received pedicle screws to the following manual exposure factors
stabilise the fracture.
 85 kVp
The radiographer set the kVp at 85 and the  40 mA
automatic exposure device determined the  2.0 sec
exposure mA and time. The exposure was
made on arrested respiration. Note that The long exposure time has resulted in blurring of the bowel
there are bowel gas and diaphragmatic gas, ribs and diaphragm. The spinal bony anatomy remains
shadows overlying the spine. sharp. The patient was asked to hold still but remain breathing
during the exposure. This technique should not result in an
increase in the mAS used- the mA is reduced to match the
increased exposure time.
50

This patient has presented to the Emergency Department with back pain following a fall.
The patient has a history of disseminated cancer and was considered to be at risk of a
pathological fracture. The patient was referred for lumbar spine radiography with special
emphasis on the L3- L5 vertebra.
The lateral spine radiograph was performed using the The repeat radiograph was performed using a
automatic exposure chamber at 85 kVp. An acceptable manual exposure technique as follows
exposure was achieved but the area of interest is partially
obscured by bowel gas. The mAS was determined by the 85kVp 50mA 1.0 sec
AEC device and was recorded as 50 mAS.
This is the same mAS as used previously but
The radiographer considered that the area of interest (L3 - with a set exposure time of 1.0 seconds. The
L5) was sufficiently obscured by bowel gas to warrant a area of interest is now demonstrated without the
repeat view. detracting overlying bowel gas. This repeat
image is more likely to demonstrate a
pathological fracture in the area of interest that
the original lateral.
There is no clearly demonstrated crush fracture

or other acute pathology. There is minor
osteophytic lipping and some minor wedging of
the T12 vertebral body.
It is noteworthy that the spinous processes have

been inadvertently collimated off.

This patient presented to the Emergency Department with back pain following a 2.5metre fall.
The patient was complaining of hip and back pain. The patient was referred for hip and lumbar
spine radiography.
51
The radiographer considered the risk of rolling the

patient too high given the possibility of a lumbar spine
or pelvis fracture. The patient was slid onto the DR
table and an AP breathing lumbar spine technique
was employed (image left).
Although there was no evidence of a lumbar spine

fracture on the AP view, it was considered prudent not
to roll the patient for the lateral lumbar spine
projection. The patient was slid back onto the
barouche and a horizontal ray breathing lateral lumbar
spine technique was employed using the DR vertical
image receptor (image below). The lateral horizontal
ray image demonstrates that this technique does not
necessarily result in a sub-standard image.
Importantly, this technique frequently fails if the
patient is lying on a soft mattress. If you slide the
patient back onto the barouche using a slide board, it
is worth considering whether you can leave the slide
board under the patient until the horizontal ray image
has been checked.
52

These two images are follow-up lateral lumbar spine images on a patient who sustained a crush
fracture of T12
53
This is a CR image performed using the default This is the same patient imaged using a Philips DR
automatic exposure device on arrested respiration. system (reslease 2). The radiographer has selected a
manual breathing exposure technique using an
exposure time of 1.0 second and a fixed mA and kVp.
The combination of the DR technology and the
breathing exposure technique provides improved
demonstration of the patient's crush fracture.
(note that the CR image is probably underexposed

54
resulting in a low signal to noise ratio- i.e. operator

error rather than technology shortcoming)

55
This 31
year old
male
presented
to the
Emergency
Departmen
t after
falling off
a ladder. A
trauma
series was
requested
including
lumbar
spine.
The AP
projection
image
demonstrat
es the use
of
breathing
technique.
The
exposure
factors are
unknown.
The
transverse
processes
are
demonstrat
ed
particularl
y well.
56
This is a CR image performed using the default automatic exposure device on arrested
respiration.
Summary
A breathing exposure technique can be employed for all torso spine radiography. It comes with an increased
risk of unwanted movement unsharpness and should be used judiciously after assessing the patient's likelihood
of holding still during the exposure. The longer the exposure time, the greater the blurring of the soft tissue
structures and the greater the likelihood of movement unsharpness.
Large Bowel Obstruction
Introduction
Bowel obstructions are common abdominal pathologies. This page considers normal appearances of
the large bowel and patterns associated with large bowel obstruction. A few conditions that mimic
large bowel obstruction (LBO) are also covered. There are a number of pages on this wiki that cover
various aspects of abdominal plain film imaging listed here. It is worth reading the definition of terms
page before this page.
Definition of Terms
Obstruction
Bowel obstruction refers to a mechanical obstruction to the lumen of the bowel causing stasis of the bowel
contents above a focal lesion
•Complete or partial
•Cause- intrinsic, extrinsic, intra-luminal
Closed Loop Obstruction
Obstruction of the bowel at two separate points produces a closed loop. A gas-filled closed loop may double on
itself and assume a ‘U’ shape resembling a coffee bean- the Coffee bean sign.
Normal Radiological Appearance

Large bowel is characterized on plain film by its haustrations
and sacculations. These are most prominent in the ascending and
transverse colon but can be seen in the left colon.
With moderate distention of the large bowel, the plicae
appear to extend entirely across the lumen but this appearance may
disappear with further distension.
The plicae of the large bowel are more widely spaced than
the valvulae of the small bowel.
Large bowel will normally contain solid material- small
bowel almost always contains liquid and gas only. Solid faeces
always conclusively identifies the colon.
57
Large bowel tends to be peripherally located. (beware the

sigmoid)
Normally, the large bowel contains at least a small amount
of gas and, in the supine position, the least dependant (most anterior)
segment is the transverse colon followed by the sigmoid.
The identification of the transverse colon will usually assist
in identifying the position of the stomach which lies above it (the
gastrocolic ligament is variable in length)
Fluid levels in the abdomen are seen in normal patients
commonly in the stomach, often in the small bowel and never in the
colon distal to the hepatic flexure (Stephen Baker, The Abdominal
Plain Film)
Occasionally the features of large or small bowel are not
distinct and a loop of bowel is demonstrated that has features of both.
Causes of LBO
 Mechanical obstruction of the large intestine is most often due to primary carcinoma of the colon
(60%).
 Post-surgical adhesive bands rarely block the large bowel lumen.
The String of Pearls Sign

58
The string of pearls sign is a

distinct appearance associated
with small bowel obstruction.
There is however a similar
appearance that can occur in the
large bowel. The large bowel
"pearls" are bigger than those of
the small bowel and tend to have
flat bases
Radiological Appearances of LBO

59
Approximately 25% of
all intestinal obstructions occur
in the large bowel
Gas and faeces tend to

accumulate proximal to the point
of obstruction.
In a typical
configuration of mechanical
obstruction, all colonic segments
proximal to the point of luminal
narrowing are dilated.
In most cases of large

bowel obstruction, the bowel will
contain variable amounts of
solid, liquid and gaseous
constituents.
Fluid levels in the large

bowel tend to be less in number
but longer than those seen in the
small bowel.
Completely fluid-filled
large bowel may go undetected
on plain films (white arrows).
In long-standing LBO,
muscular exhaustion can ensue,
resulting in the effacement of
intra-luminal septa and haustra.
The colon is dilated

when it exceeds 6cm in diameter,
and the caecum is dilated when it
exceeds 9cm in diameter. (3,6,9
rule)
When the caecal

diameter exceed 10cm, the
probability of perforation is high.
The caecum always

dilates to the largest extent no
matter where the LBO is sited
(Laplace’s law ).
60
Laplace's Law
Case 1 Laplace’s Law
If there is free flow of gas and fluid
along a segment of bowel, intra-
luminal pressure must be constant
throughout. Laplace’s law states that
the pressure needed to distend a hollow
viscus varies inversely with its radius.
Thus, the caecum, usually the widest
part of the colon, expands to the
greatest extent as the large bowel
dilates.
Case 1
This case shows a distended transverse
colon (77mm) and a distended caecum
(113mm). Laplace's Law would
suggest that this is a genuine case of
colonic obstruction. This was proven
with subsequent enema which
demonstrated an obstruction of the
distal sigmoid.
Case 2 Case 2
This patient demonstrated a
grossly dilated transverse colon.
Note that the caecum appears to
be of normal calibre. The enema
image shows a smooth transition
from transverse colon to splenic
flexure suggesting that the cause
of the massively dilated
61
transverse colon is not

obstruction. This appearance is
typical of colonic pseudo-
obstruction.
Faecal Impaction and LBO

Faecal impaction is a common occurrence in :
the elderly (most common cause of colonic obstruction)
neurologically impaired
bed-ridden
younger patients who are chronic abusers of narcotic
medications.
The serious consequences of intractable constipation in the aged
or infirm is sometimes underestimated (blood flow/abrasive
effects).
The 3,6,9 Rule

62
The colon is dilated

when it exceeds 6cm in
diameter, and the caecum is
dilated when it exceeds 9cm
in diameter. (3,6,9 rule)
The caecum always

dilates to the largest extent no
matter where the LBO is sited.
(Laplace’s law )
When the caecal

diameter exceed 10cm, the
probability of perforation is
high
The Air in the Rectum Conspiracy

63
Obstruction of the bowel

does not mean immediate
disappearance of distal gas
A partial obstruction will
allow passage of air distally
In cases of complete
obstruction, the fermentation of
residual faecal matter in the large
bowel can produce gas distal to the
obstruction for some time after the
bowel becomes completely
obstructed
This patient has a tight stricture at

the level of the hepatic flexure.
Despite this stricture, there is clearly
gas in the rectum.
Establishing the Level of Obstruction

64
The exact point of a large bowel

obstruction is difficult to detect on abdominal
plain films. In most cases, the location of the
terminus of the colonic gas shadow does not
necessarily correspond with the site of the
bowel occlusion.
A typical pattern is continuous
dilation of the caecum, right colon, and
transverse colon up to the splenic flexure
caused by an obstructing tumour in the
sigmoid colon. The intervening descending
colon lacks gas, as it is distended by fluid and
solid faeces only.
This is a supine abdominal image on a patient

who presented to the Emergency Department
with acute abdominal pain. There is a dilated
air-filled caecum and ascending colon. The
transverse colon is not visualised. The level of
obstruction might be assumed to exist in the
transverse colon, however, close examination
shows the descending colon is also dilated
(white arrows) but is less obvious because it
is filled with fluid rather than air.
The patient proceeded to have a gastrografin

enema which demonstrated an applecore
lesion in the sigmoid colon (white arrow).
LBO Posing as an SBO

65
At a cursory glance this patient appears to

have a SBO. On closer examination, the
prominent air-filled loops of small bowel in
the LUQ (white arrow) have the features of
ileum rather than jejunum. Also, the caecum
appears unusually large and there appears to
be a sudden change in calibre in the large
bowel at the level of the hepatic
flexure(black arrow). This was reported as a
SBO. An alternative explanation is that the
large bowel is obstructed at the level of the
black arrow. This would account for the
dilation of the caecum. An LBO in patients
with incompetent ileocaecal valves can
mimic an SBO. The ileal loops may have
been displaced by the enlarged caecum or
they may be effaced jejunal loops..
Note that the patient has the reliably
unreliable sign of gas in the rectum!
This is a barium enema on the same patient.

Note the tight apple-core lesion at the level
of the hepatic flexure (white arrow)
Approximately a quarter of patients have an

incompetent ileocaecal valve.
Generalised Adynamic Ileus

66
The bowel could reasonably be said

to be a very sensitive organ. It has a
propensity to stop functioning with
little provocation. Amongst the
possible causes are
infection(anywhere), abdominal
inflammation ,
chemical/pharmacological causes and
trauma.
Abdominal surgery commonly results

in generalised adynamic ileus in
which the bowel is temporarily non-
functioning. This typically manifests
on around day 4 post-op. In response,
the patients are often referred for
abdominal plain film imaging to rule
out obstruction.
The appearance of generalised

adynamic ileus is quite characteristic.
The large and small bowel are
extensively airfilled but not dilated. I
have heard this described as the large
and small bowel "looking the same".
Caecal and Sigmoid Volvulus

Caecal Volvulus Sigmoid Volvulus
67
s
source unknown ource unknown
Caecal Volvulus Sigmoid Volvulus

Uncommon extends into the right upper abdomen to
caecum is characteristically relocated to T10 or higher
the mid-abdomen or left upper quadrant The colon proximal to the twist distends
68
accompanying SBO is rare The rectum usually empties

characteristically, the walls are smooth Gas distended sigmoid usually shows
and the haustra are preserved Coffee bean sign in common with other closed
Persistent dilated distal colon is rarely loop obstructions
seen At the point of the twist a barium
enema demonstrates a characteristic beak-like
termination
Colonic Pseudo-obstruction
69
Causes
Idiopathic/unk
nown (acute cases
sometimes referred to
as Ogilvie’s syndrome)
A severe form
of pseudo-obstruction
is sometimes found in
mentally disabled and
psychotic individuals
Features
No other
physical abnormalities
Rapidly
progressive dilation of
the colon
Uncontrolled
by rectal tube or
colonic decompression
Untreated-
-Grossly dilated transverse colon may lead to perforation
on supine plain film and death
-normal caecum Pattern Recognition

In most cases,
-smooth transition to normal the plain film
calibre splenic flexure on enema appearance is
sufficiently
-probably colonic pseudo- characteristic to
obstruction differentiate it from
large bowel
obstruction
Haustra are
smooth, regularly
spaced, and the septa
are smooth, thin and
sharply marginated
Lumen is gas
filled and the wall
contour is clearly
demarcated (as distinct
from obstruction in
which shaggy
interfaces are often
seen)
70
Can be
confirmed by
gastrografin enema but
this is usually
unnecessary
Post Washout and Post Endoscopy

The large bowel in this image
looks unusual and it is not
immediately obvious why. The
unusual appearance could be
attributed to two features. The
first is that the colon is
extensively air-filled and the
small bowel is not. The second
feature is that the large bowel
contains no faeces. This is an
appearance that you will
occasionally see in patients
who have had bowel washouts.
Note that at 44mm diameter,
the colon is not enlarged.
Ischaemic Bowel
71
This patient has a very dilated

rectum caused by ischaemia.
Where there is an isolated
unexplained segment of grossly
dilated colon ischaemia should
be considered.
? early signs of mural gas
Case 1
72
This 88
year old
man
presented
to the
Emergency
Department
with
abdominal
pain and
distention.
The patient
was
examined
and refered
for an acute
abdominal
plain film
series. A
NGT had
been
inserted at
the time of
imaging.
All of the
large bowel
is air-filled
and
distended.
The
appearance
is more
typical of
large bowel
obstruction
in the
presence of
a
competent
ileo-caecal
valve than
it is of
pseudo-
obstruction.
73
The left
lateral
decubitus
image
demonstrat
es a
distended
gas-filled
caecum and
multiple
air-fluid
levels.
74
The patient
was
referred for
colonoscop
y and a
flatus tube
was
inserted
during the
procedure.
Follow up
abdominal
plain film
imaging
demonstrat
ed some
reduced
bowel
calibre
following
the flatus
tube
insertion.
Summary
Colonic obstruction has significant associated morbidity and mortality if untreated. Timely diagnosis
on plain abdominal film will potentially improve patient prognosis. The abdominal plain film may not
present a radiographic challenge for a seasoned radiographer but can present an interpretation
challenge for radiographer and radiologist alike. Radiographer skills in image interpretation will afford
additional meaning and professional satisfaction.
75
The Abdominal Plain Film- Gasless vs Featureless
Introduction
Gasless and featureless abdominal plain films have a 'look of the abnormal'. This page examines the
difference between gasless and featureless patterns and their significance.
Definition
A gasless abdominal plain film refers to an absence or minimum of gas in the gastrointestinal tract.
A featureless abdominal plain film is one in which there is little or no visualisation of the normal
abdominal viscera.
The Gasless Abdominal Plain Film

Gas in the gastrointestinal tract can commonly accumulate from two sources. Firstly, gas in the
stomach and small bowel can be ingested with food. Some patients habitually air swallow or may air-
swallow when in pain. Gas in the large bowel can be endogenous, resulting from fermentation
processes of faecal material.
An absence of gastrointestinal gas on abdominal plain film is not specifically abnormal (but is
suspect). However, consideration should be given to the possibility of a gasless obstruction. Equally,
a check of the patient history may reveal relevant information such as total colectomy.
Causes
•A gasless abdomen could indicate
•Patient is not an ‘air-swallower’
•Mesenteric ischaemia
•Obstruction of the stomach or oesophagus
•Persistent vomiting from conditions such as pancreatitis or gastroenteritis
Stephen R. Baker
The Abdominal Plain Film
1990, p161
Normal Gasless Small Bowel

76
This patient appears to have a

gasless small bowel. Fluid-filled
loops of small bowel are present
but are never as well visualised as
air-filled loops.
There is debate regarding what is

a normal amount of small bowel
gas. Gas enters the small bowel
during eating and drinking. Some
people habitually air-swallow
while others air-swallow at times
of stress or when they are in pain.
If the patient is air-swallowing at
a higher rate than the small bowel
can absorb the air, it will be
visualised in the bowel. Some
texts will claim that up to seven
fluid levels in the small bowel on
an erect abdominal film can be
normal. Most texts quote a more
conservative figure (2 is
common).
Don't confuse gasless with

featureless. A featureless
abdomen can be a result of
tumour or ascites. This patient has
a gasless rather than featureless
abdomen. Note that the renal,
liver, psoas muscles and urinary
bladder outlines are visualised
Note also that this abdominal film

is not guaranteed to be normal. It
could represent an early gasless
small bowel obstruction. Clinical
correlation is required.
Gasless Small Bowel Obstruction

77
You could be
forgiven for
thinking that this
patient has been
drinking dilute
gastrografin. This
appearance is a
gasless small bowel
obstruction and the
opaque looking
small bowel loops
(white arrow) are
filled with normal
succus entericus,
and/or ingested
fluid, rather than
gastrografin. If you
compare this image
with the gasless
small bowel image
above you can see
that this small
bowel is
significantly more
prominent.
There can be
difficulty in
distinguishing an
early gasless small
bowel obstruction
from a normal
appearance of the
small bowel in
someone who has
just eaten a large
meal.
Clinical correlation
and follow-up
imaging will
usually provide
confidence in the
diagnosis.
The large bowel is

not clearly
visualised
suggesting that it
may be collapsed.
78
Colectomy
This patient has
Crohn's disease and
has had a previous
colectomy. Note the
absence of the large
bowel. Note also a
faint suggestion of a
stoma in the left
iliac fossa.
The Featureless Abdominal Plain Film

Ascites
79
This patient has prominent loops of gas-filled small

and large bowel. The normal abdominal viscera are
not demonstrated. Apart from the prominent bowel,
the abdomen is featureless. The cause of this
appearance is a large quantity of ascites. Note that the
liver, spleen, kidneys, psoas and urinary bladder
outlines are not seen. The reason that the bowel is
somewhat centrally located is that it is floating in the
ascites.
If you are suspicious that the patient has air-filled
bowel floating in ascites, it can be useful to perform
an erect or decubitus view. This left lateral decubitus
view demonstrates that the air-filled bowel floats up to
the right flank which is the least dependant part of the
abdominal cavity in the left lateral decubitus position.
Note that this is not a "right decubitus"- The 'right'

annotation refers to the right side of the abdomen and
the "decubitus" annotation refers to the patient
position.
Tumour
80
•This is more likely to be

tumour than blood or ascites
•Bowel loops look more like
they are pushed down by
tumour(s) rather than
floating in fluid
Mass Effect
81
This patient has a rounded mass (arrowed) which

appears to be displacing bowel. Note that the psoas
shadows are preserved suggesting that the mass is
not adjacent to the psoas muscles.
The CT abdomen shows the mass (arrowed) sited

anterior to the psoas muscles.
Blood- AAA
82
This patient presented to the

Emergency Department with a
known history of Abdominal
Aortic Aneurysm (AAA).
The aneurysmal abdominal aorta

is visible (arrow) because of its
calcified wall. The abdominal
viscera are not well visualised.
The psoas, renal and kidney
outlines are not well
demonstrated. This raises the
question of whether the AAA is
leaking blood into the peritoneal
cavity.
Blood- Ruptured Viscus

83
This patient presented to the

Emergency Department after a
car accident. He looked pale.
He had a falling blood
pressure which stopped falling
spontaneously (sign of
retroperitoneal bleed with self-
tamponade).
The supine abdominal plain

film demonstrates a featureless
pattern. There are no clearly
defined psoas, kidneys or
spleen. A CT abdominal scan
revealed extensive laceration
of his left kidney and spleen.
Artifact is external to patient
Summary
Gasless and featureless plain abdominal films often strike the observer as having an unusual
appearance. It is useful to be able to distinguish between those images that are likely to be normal
from those that are not. As with all abdominal plain film imaging, the appearance of the abdomen on
plain film can have greater meaning when placed in the context of patient history, clinical
presentation and other test results.
84
Lateral Knee Radiography
Introduction
Lateral knee radiography commonly raises a number of questions:
is there a reliable technique for lateral knee radiography?
how do I correct a lateral knee malposition?
when is it malpositioned enough to warrant a repeat?
This page attempts to answer these and other lateral knee radiography questions
Indications for Knee Radiography
Ottawa rules
State that a knee X-ray is only required for patients with knee injuries with any of the following:
- Age 55 or over.
- Isolated tenderness of the patella (no bone tenderness of the knee other than the patella).
- Tenderness at the head of the fibula.
- Inability to flex to 90 degrees.
- Inability to weight bear both immediately and in the casualty department (ie, 4 steps – unable to
transfer weight twice onto each lower limb regardless of limping).
Image Interpretation Course

by Heidi Gable DCR(R) PgCert
http://www.imageinterpretation.co.uk/knee.html
Anatomy
Synovial Joint Synovium or capsule?
The terms synovium and capsule do

appear to get confused- they are not
interchangeable.
Synovial Cavity
synovial cavity is deepest layer of joint

capsule
although synovium membrane is

85
attached all around, above to articular

margins of femur and below to articular
margins of tibia, it is not
everywhere coextensive with the
capsule or ligament and tendons
because of folds of synovial membrane,

synovial cavity is not a simple,
short, cylindrical cavity
behind and above the patella, it is

single cavity that is usually
continuous above w/ suprapatellar
bursa between the tendon of
quads & femur;
cruciate ligaments, meniscii, &

infrapatellar fat pad are
outside the synovial cavity;
http://www.wheelessonline.com/ortho
/synovium_of_the_knee
Synovium is very variable but often has

two layers.
The outer layer, or subintima, can be of

almost any type: fibrous, fatty or
loosely "areolar".
The inner layer, or intima, consists of a

sheet of cells thinner than a piece of
paper.
Where the underlying subintima is

loose the intima sits on a pliable
membrane, giving rise to the term
synovial membrane. This membrane,
together with the cells of the intima,
provides something like an inner tube,
sealing the synovial fluid from the
surrounding tissue (effectively stopping
the joints being squeezed dry when
86
subject to impact, such as running).
The intimal cells are of two types,

fibroblasts and macrophages, both of
which are different in certain respects
from similar cells in other tissues.
* The fibroblasts manufacture a long

chain sugar polymer called hyaluronan
which makes the synovial fluid "ropy"
like egg-white, together with a
molecule called lubricin, which
lubricates the joint surfaces. The water
of synovial fluid is not secreted as such,
but is effectively trapped in the joint
space by the hyaluronan.
* The macrophages are responsible for

the removal of undesirable substances
from the synovial fluid.
http://en.wikipedia.org/wiki/Synovial_
membrane
The Articular Capsule of the Knee
The fibrous capsule is strong, especially

where local thickenings of it form
ligaments.
Superiorly, the fibrous capsule is

attached to the femur, just proximal to
the articular margins of the condyles
and to the intercondylar line
posteriorly.
It is deficient on the lateral condyle,

which allows the tendon of the
popliteus muscle to pass out of the
joint and insert into the tibia.
Inferiorly the fibrous capsule is

attached to the articular margin of the
tibia, except where the tendon of the
87
popliteus muscle crosses the bone.

Here the fibrous capsule is prolonged
inferolaterally over the popliteus to the
head of the fibula, forming the arcuate
popliteal ligament.
The fibrous capsule is supplemented

and strengthened by five intrinsic
ligaments; patellar ligament, fibular
collateral ligament, tibial collateral
ligament, oblique popliteal ligament,
and arcuate popliteal ligament. These
are often called the external ligaments
to differentiate them from the internal
ligaments (e.g., the cruciate ligaments,
which are internal to the fibrous
capsule).
http://download.videohelp.com/vituali
s/med/kneejnt.htm
88
When is a Knee Demonstrated in a True Lateral Position?

89
The knee
is
generally
considere
d to be in
a true
lateral
position
when the
posterior
aspects of
the
femoral
condyles
are
superimp
osed. (it is
unclear
why this
criteria
was
chosen
when the
anterior
aspects,
and in
particular
the
patello-
femoral
joint, are
arguably
of greater
interest)
In
addition,
the
following
are
considere
90
d
desirable
demonstr
ation of
the
patello-
femoral
joint
demonstr
ation of
the joint
space
between
the
femoral
condyles
and the
tibia
knee
flexion no
greater
than 30
degrees
When does a lateral knee Image need to be repeated?
It is difficult to establish performance criteria in plain film radiography- at best, guidelines can be useful
but may do harm in that they suggest that judgement is not required. In most areas of plain film
radiography, the decision to repeat should be based on a balanced judgement taking into consideration
the likelihood of diagnostic yield vs the cost.
The diagnostic yield refers to the potential for additional useful diagnostic information.
The cost is in terms of:
patient care considerations (is the patient in pain, distressed, 'at the end of their tether' etc)
radiation dose
91
money (materials, wages)
opportunity cost (this cost is the forgone opportunity to provide a radiographic service to a patient who
actually needed it)
This is sometimes a difficult judgement and becomes easier with experience. One thing is clear, the
repeat view should be undertaken following consideration of the benefit to the patient not the
radiographer. That is to say, the radiographer's reputation is not a consideration. Another way of looking
at the dilemma is to "do what you can justify" on all occasions. This means that when you are taken to
task over a perceived failure to repeat a particular projection, you should have a reasoned explanation.
Despite my assertion that the individual circumstances of the case need to be taken into account, the
following is a consideration of when to repeat in cases of varying degrees of malposition
92
This is a
malposition
ed lateral
knee. The
knee is too
internally
rotated.
The degree
of
separation
of the
femoral
condyles is
so great as
to warrant
a repeat in
most cases.
Note fibula
head
position
(black
arrow) and
adductor
tubercle
(white
arrow)
93
This is a less
straightfor
ward case.
The knee is
malposition
ed. The
position of
the head of
fibula
suggests
that the
knee is
excessively
internally
rotated. It
could be
argued that
a
lipohaemat
hrosis has
been
demonstrat
ed and that
a repeat
will
probably
provide no
new
information
. My
concern
would be
that the
fracture is
not
demonstrat
ed and
there is a
chance that
the
malposition
94
is the
cause. In
addition,
this may be
a surgical
case, and
the surgeon
may require
a well
positioned
lateral knee
for surgical
planning.
On balance,
I would
probably
repeat this
projection.
95
This knee is
minimally
malposition
ed. The
knee is
excessively
externally
rotated
and, in
addition,
tube
angulation
adjustment
is required.
A
lipohaemar
throsis is
demonstrat
ed. I would
not
normally
repeat this
projection
on two
grounds
the
malpositon
is minimal
the repeat
position
requires
such small
adjustment
s in tube
angle and
knee
rotation
that it may
fail to
provide an
96
improved
outcome
a repeat is
unlikely to
provide
new useful
diagnostic
information
My focus at
this point
would not
be to
produce a
perfect set
of knee
images.
Rather, I
would
pursue the
cause of the
lipohaemat
hrosis and I
would have
a very low
threshold
for
performing
oblique
projections
of the knee
if the
fracture
was not
demonstrat
ed on the
routine
projections.
97
This is a
well
positioned
lateral knee
although
the knee
flexion is
greater
than the
recommend
ed 30
degrees..
Correcting a Malpositioned Lateral knee
1. Fibula head Position

98
This
patient
was
position
ed in a
'rolled
lateral
knee'
position.
The
knee is
clearly
not in a
true
lateral
position.
If this
lateral
knee
was
consider
ed
worthy
of
repeat,
how
would
you
correct
the
malposi
tion?
1. Fibula
head
Position
This is
the easy
one. The
fibula
head is
99
projecte
d
complet
ely clear
of the
tibial
metaphy
sis. This
suggests
that the
malposi
tion is
due to
excessiv
e
external
rotation
of the
knee.
patellar
fracture
noted
2. The lateral femoral notch

100
2. The lateral femoral

notch
The lateral condylopatellar

sulcus(arrowed) , also
known as the lateral
femoral notch,
distinguishes the lateral
femoral condyle from the
medial femoral condyle.
The lateral condylopatellar

sulcus, also known as the
lateral femoral notch,
normally forms a shallow
groove in the middle of the
lateral femoral condyle. It
represents the junction
zone on the lateral femoral
condyle where the
tibiofemoral and
patellofemoral radii of
curvature meet. ... This
appearance of the lateral
sulcus also facilitates
distinction between the
lateral femoral condyle
and the overlapping medial
femoral condyle on the
lateral projection.
Duke G. Pao, MD
The Lateral Femoral Notch
Sign
June 2001 Radiology, 219,
800-801.
http://radiology.rsna.org/c
ontent/219/3/800.full
101
The repeat lateral knee

image is shown left. The
radiographer has reduced
the degree of external
rotation of the leg resulting
in an improved lateral knee
position. The lateral
femoral notch is arrowed.
Note that the fibula head is
now largely superimposed
over the tibial metaphysis.
3. The Adductor Tubercle (medial condyle)

102
If you can
imagine
that you
are
looking at
the back
of your
patient's
left knee,
this is
what the
distal
femur
would look
like (may
not be
fractured
like this
though!).
The
smoothly
surfaced
adductor
tubercle is
on the
medial
side just
proximal
to the
posterior
aspect of
the medial
femoral
condyle.
This bony
prominenc
e can
sometimes
be utilised
adapted from http://www.nlm.nih.gov/visibleproofs/media/detailed/ii_a_116a.jpg to
differentia
103
te the
medial
femoral
condyle
from the
lateral
femoral
condyle
when
attempting
to assess a
malpositio
ned lateral
knee
image.
104
The most
reliable
method
for
identifying
the medial
condyle is
to locate
the
rounded
bony
tubercle
known as
the
adductor
tubercle.
Kathy
McQuillen-
Martensen
Radiograp
hic image
analysis
(2nd ed)
Kathy
McQuillen-
Martensen
Elsevier
Health
Sciences,
2006,
p319
This lateral
knee is
malpositio
ned. The
105
demonstra
tion of the
adductor
tubercle
(white
arrow)
allows
differentia
tion of the
medial
femoral
condyle
from the
lateral
femoral
condyle.
The fibula
head is
excessively
superimpo
sed over
the tibial
metaphysi
s. These
two
observatio
ns suggest
that the
knee is too
internally
rotated.
The
radiograph
er
repeated
the lateral
projection
with the
knee in a
more
106
externally
rotated
position
(see below
left).
The repeat
lateral
knee
shows
good
superimpo
sition of
the
posterior
aspects of
the
femoral
condylar
articular
surfaces.
Note
improved
demonstra
tion of the
suprapatel
lar pouch
extensive
degenerati
ve disease
of the
knee joint
and the
patello-
femoral
joint
fabella
107
How much Tube Angulation is Required?
Kathy McQuillen-Martensen
Radiographic image analysis (2nd ed)
Kathy McQuillen-Martensen
Elsevier Health Sciences, 2006, p319
adapted from
http://imaging.ubmmedica.com/shared/zone5/0806JMMAP
PF1.JPG
How much Knee Flexion is Required?
The knee
108
The Effect of Knee Flexion on the Patella and Suprapatellar Pouch should be
flexed no
more that 30
degrees when
performing
lateral knee
radiography.
Flexion of the
knee greater
than 30
degrees tends
to force the
patella down
into the
trochlear
groove of the
femur and can
distort/compr
ess the
suprapatellar
pouch and its
adjacent soft
tissue
structures.
109
adapted from http://upload.wikimedia.org/wikipedia/commons/f/f3/Knee-unfolding-

110
recess-diagram.svg
Radiographic Technique
Horizontal Ray
111
The
horizontal
ray is the
technique
of choice in
trauma
knee
radiography
. This
technique
has two
important
advantages
in the
patient with
an acute
injury
the
technique
requires
minimal
movement
of the
patient's
injured
knee
a
lipohaemar
throsis can
be
demonstrat
ed
Rolled Lateral
Rolled Lateral with Unaffected Leg Over (Rolled Rolled Lateral with Unaffected Leg Behind (Rolled
technique 1) technique 2)
112
Source: Jamie Beck and Gary Culpan Source: Jamie Beck and Gary Culpan
Synergy, July 2006, p21 Synergy, July 2006, p22
This technique requires a small positioning sponge This technique requires the foot of the affected leg
(or similar) to be placed under the foot on the to be raised and supported on the foot of the non-
affected side to bring the tibia parallel to the table affected leg.
top. My experience with this position is the the
patient's knee will not automatically fall into the
true lateral position. I unusually place my hand on
the patient's raised hip ad roll the patient's pelvis
until I am convinced that the patient's knee is in a
true lateral position. Note that it is the patient's
raised hip position that tends to determine the
degree of knee roll.
Which Rolled Lateral Knee Radiography Technique is Superior?
The superior technique is the one that works for you. Research published in Synergy in 2006 (Symes, E.
Lateral Knee Radiographs: Investigating the Techniques, Synergy, July 2006, p18) reported that 43% of
the radiographers preferred technique 1 and 57 % preferred technique 2 (to the authors and my
surprise!). The research also reported that radiographers did not always know why a lateral knee
position failed (and presumably therefore did not know how to correct the malposition).
Case 1
113
The
Indicators
The lateral
femoral
notch is
demonstrat
ed (white
arrow)
The
adductor
tubercle is
not
demonstrat
ed
The fibula
head
position is
unremarkab
le
For
Horizontal
Ray Lateral
Technique
To Correct
Rotation
Error:
Rotate leg
internally
(note
insignificant
error)
To Correct
Angulation
Error: More
caudal
angulation
114
For Rolled
Lateral
technique
To Correct
Rotation
Error:
Rotate leg
internally
To Correct
Angulation
Error: More
cephalic
Angulation
Note:
Horizontal
ray
technique
will always
require
opposite
angulation
correction
to rolled
technique
because
one
technique is
a medial-
lateral
beam and
the other is
lateral-
medial
115
beam
These
images are
presented
for the
purposes of
demonstrati
on and are
not
necessarily
worthy of
repeating.
The
decision to
repeat
should be
based on a
balanced
consideratio
n of the
costs vs the
likely
benefits to
the patient
Discussion
This lateral
knee would
not be
worthy of
repeating
under
normal
circumstanc
es
There is a
multilayere
d
lipohaemart
hrosis
116
indicating
articular
fracture
The
Indicators
The lateral
femoral
notch is
demonstrate
d (white
arrow)
The adductor
tubercle is
not
demonstrate
d
The fibula
head is
probably
excessively
superimpose
d over the
tibial
metaphysis
For
Horizontal
Ray Lateral
Technique
To Correct
Rotation
Error: Rotate
leg externally
To Correct
Angulation
Error: More
117
caudal
angulation
For Rolled
Lateral
technique
To Correct
Rotation
Error: Rotate
leg externally
To Correct
Angulation
Error: More
cephalic
Angulation
Note:
Horizontal
ray
technique
will always
require
opposite
angulation
correction to
rolled
technique
because one
technique is
a medial-
lateral beam
and the
other is
lateral-
medial beam
These images
118
are
presented
for the
purposes of
demonstrati
on and are
not
necessarily
worthy of
repeating.
The decision
to repeat
should be
based on a
balanced
consideratio
n of the costs
vs the likely
benefits to
the patient
Discusion
This degree
of rotation
may be
worthy of
repeat.
However,
the
lipohaemartr
osis has been
demonstrate
d and, if a
fracture had
not been
demonstrate
d, oblique
views of the
knee would
arguably
119
provide a
better
diagnostic
yield
Case 2
The
Indicators
The lateral
femoral
notch is
demonstrat
ed (white
arrow)
The
adductor
tubercle is
not well
demonstrat
ed
(although
probably
visible)
The fibula
head is not
superimpos
ed over the
tibial
metaphysis
suggesting
excessive
external
rotation of
the knee.
120
For
Horizontal
Ray Lateral
Technique
To Correct
Rotation
Error:
Rotate leg
internally
To Correct
Angulation
Error: More
cephalic
angulation
For Rolled
Lateral
technique
To Correct
Rotation
Error:
Rotate leg
internally
To Correct
Angulation
Error: More
caudal
Angulation
Note:
Horizontal
ray
technique
will always
require
121
opposite
angulation
correction
to rolled
technique
because
one
technique is
a medial-
lateral
beam and
the other is
lateral-
medial
beam
These
images are
presented
for the
purpose of
demonstrati
on and are
not
necessarily
worthy of
repeating.
The
decision to
repeat
should be
based on a
balanced
consideratio
n of the
costs vs the
likely
benefits to
the patient
122
Discussion
There is a
large knee
effusion
evident in
Hoffa's
fatpad and
the
suprapatella
r pouch
There is
probably a
lipohaemart
hrosis
123
The
Indicators
The lateral
femoral
notch is
demonstrate
d (white
arrow)
The adductor
tubercle is
not well
demonstrate
d (although
probably
visible)
The fibula
position
suggests too
much
external
rotation
For
Horizontal
Ray Lateral
Technique
To Correct
Rotation
Error: Rotate
leg internally
To Correct
Angulation
Error: More
cephalic
angulation
124
For Rolled
Lateral
technique
To Correct
Rotation
Error: Rotate
leg internally
To Correct
Angulation
Error: More
caudal
Angulation
Note
Horizontal
ray
technique
will always
require
opposite
angulation
correction to
rolled
technique
because one
technique is
a medial-
lateral beam
and the
other is
lateral-
medial beam
These images
are
presented
for the
purpose of
demonstrati
125
on and are
not
necessarily
worthy of
repeating.
The decision
to repeat
should be
based on a
balanced
consideratio
n of the costs
vs the likely
benefits to
the patient
Discussion
There is a
large knee
effusion
evident in
Hoffa's
fatpad and
the
suprapatellar
pouch
There is a
lipohaemart
hrosis
The lateral
condylar
sulcus is
largely
obscured by
the overlying
medial
condylar
articular
126
cortcal bone
Case 3
The
Indicators
The
lateral
femoral
notch is
demonstr
ated (top
white
arrow)
The
adductor
tubercle is
demonstr
ated
(bottom
white
arrow)
The fibula
head
appears
to be
excessivel
y
overlappi
ng the
proximal
tibial
metaphysi
s
For
127
Horizontal
Ray
Lateral
Technique
To Correct
Rotation
Error:
Rotate leg
externally
To Correct
Angulatio
n Error:
More
cephalic
angulatio
n
For Rolled
Lateral
technique
To Correct
Rotation
Error:
Rotate leg
externally
To Correct
Angulatio
n Error:
More
caudal
Angulatio
n
Note:
Horizontal
128
ray
technique
will
always
require
opposite
angulatio
n
correction
to rolled
technique
because
one
technique
is a
medial-
lateral
beam and
the other
is lateral-
medial
beam
These
images
are
presented
for the
purpose
of
demonstr
ation and
are not
necessaril
y worthy
of
repeating.
The
decision
to repeat
should be
based on
129
a
balanced
considera
tion of the
costs vs
the likely
benefits
to the
patient
The
Indicators
The lateral
femoral
notch is
not
demonstra
ted
The
adductor
tubercle is
not
demonstra
ted
The fibula
head is
largely
projected
free of the
proximal
tibial
metaphysis
suggesting
excessive
external
rotation of
the knee.
For
130
Horizontal
Ray Lateral
Technique
To Correct
Rotation
Error:
Rotate leg
internally
To Correct
Angulation
Error:
More
cephalic
angulation
For Rolled
Lateral
technique
To Correct
Rotation
Error:
Rotate leg
internally
To Correct
Angulation
Error:
More
caudal
Angulation
Note:
Horizontal
ray
technique
will always
require
131
opposite
angulation
correction
to rolled
technique
because
one
technique
is a medial-
lateral
beam and
the other is
lateral-
medial
beam
These
images are
presented
for the
purpose of
demonstra
tion and
are not
necessarily
worthy of
repeating.
The
decision to
repeat
should be
based on a
balanced
considerati
on of the
costs vs
the likely
benefits to
the patient
Discussion
This is a
132
repeat of
the lateral
knee
shown
above. The
radiograph
er has
over-
corrected
the
malpositio
n error
shown
above.
The
radiograph
er has
attempted
to correct
the
rotation
error only -
the tube
angle error
is
unchanged
.
Case 4
133
The
Indicators
The
lateral
femoral
notch is
demonstr
ated (top
white
arrow)
The
adductor
tubercle is
demonstr
ated
(bottom
white
arrow)
The head
of fibula is
too
superimp
osed over
the
proximal
tibial
metaphysi
s
suggestin
g the
need for
further
external
rotation
For
Horizontal
Ray
Lateral
134
Technique
To Correct
Rotation
Error:
Rotate leg
externally
To Correct
Angulatio
n Error:
More
cephalic
angulatio
n
For Rolled
Lateral
technique
To Correct
Rotation
Error:
Rotate leg
externally
To Correct
Angulatio
n Error:
More
caudal
Angulatio
n
Note:
Horizontal
ray
technique
will
135
always
require
opposite
angulatio
n
correction
to rolled
technique
because
one
technique
is a
medial-
lateral
beam and
the other
is lateral-
medial
beam
These
images
are
presented
for the
purpose
of
demonstr
ation and
are not
necessaril
y worthy
of
repeating.
The
decision
to repeat
should be
based on
a
balanced
considera
136
tion of the
costs vs
the likely
benefits
to the
patient
Discussion
This
lateral
knee
position
would
generally
be
considere
d within
acceptabl
e
positionin
g limits
Case 5
137
The
Indicators
The
lateral
femoral
notch is
demonstr
ated
(white
arrow)
The
adductor
tubercle is
not
demonstr
ated
The fibula
head
position is
normal
For
Horizontal
Ray
Lateral
Technique
To Correct
Rotation
Error: no
change
required
To Correct
Angulatio
n Error:
More
caudal
angulatio
138
For Rolled
Lateral
technique
To Correct
Rotation
Error: no
change
required
To Correct
Angulatio
n Error:
More
cephalic
Angulatio
n
Note:
Horizontal
ray
technique
will
always
require
opposite
angulatio
n
correction
to rolled
technique
because
one
technique
is a
medial-
139
lateral
beam and
the other
is lateral-
medial
beam
These
images
are
presented
for the
purpose
of
demonstr
ation and
are not
necessaril
y worthy
of
repeating.
The
decision
to repeat
should be
based on
a
balanced
considera
tion of the
costs vs
the likely
benefits
to the
patient
Case 6
140
The
Indicators
The
lateral
femoral
notch is
demonstr
ated
(white
arrow)
The
adductor
tubercle is
not
demonstr
ated
The fibula
head is
largely
unobscur
ed by the
proximal
tibial
metaphysi
s
suggestin
g
excessive
external
rotation
of the
knee
For
Horizontal
Ray
Lateral
Technique
141
To Correct
Rotation
Error:
Rotate leg
internally
To Correct
Angulatio
n Error:
no change
required
For Rolled
Lateral
technique
To Correct
Rotation
Error:
Rotate leg
internally
To Correct
Angulatio
n Error:
no change
required
Note:
Horizontal
ray
technique
will
always
require
opposite
angulatio
n
correction
142
to rolled
technique
because
one
technique
is a
medial-
lateral
beam and
the other
is lateral-
medial
beam
These
images
are
presented
for the
purpose
of
demonstr
ation and
are not
necessaril
y worthy
of
repeating.
The
decision
to repeat
should be
based on
a
balanced
considera
tion of the
costs vs
the likely
benefits
to the
143
patient
Discussion
this
lateral
knee
position is
acceptabl
e and
would not
need
repeating
under
normal
circumsta
nces.
144
The
Indicators
The lateral
femoral
notch is
demonstra
ted (white
arrow)
The
adductor
tubercle is
demonstra
ted (black
arrow)
The fibula
head is
largely
overlying
the
proximal
tibial
metaphysis
suggesting
excessive
internal
rotation
positioning
error.
For
Horizontal
Ray Lateral
Technique
To Correct
Rotation
Error:
Rotate leg
externally
145
To Correct
Angulation
Error:
More
caudal
angulation
For Rolled
Lateral
technique
To Correct
Rotation
Error:
Rotate leg
externally
To Correct
Angulation
Error:
More
cephalic
Angulation
Note:
Horizontal
ray
technique
will always
require
opposite
angulation
correction
to rolled
technique
because
one
technique
is a medial-
146
lateral
beam and
the other is
lateral-
medial
beam
These
images are
presented
for the
purpose of
demonstra
tion and
are not
necessarily
worthy of
repeating.
The
decision to
repeat
should be
based on a
balanced
considerati
on of the
costs vs
the likely
benefits to
the patient
patellar
fracture
noted
Case 7
147
The
Indicators
The lateral
femoral
notch is not
demonstrat
ed
The
adductor
tubercle is
not
demonstrat
ed
The fibula
head
position is
unremarkab
le
For
Horizontal
Ray Lateral
Technique
To Correct
Rotation
Error: no
change
required
To Correct
Angulation
Error: ?
For Rolled
Lateral
technique
148
To Correct
Rotation
Error: no
change
required
To Correct
Angulation
Error: ?
Note
Horizontal
ray
technique
will always
require
opposite
angulation
correction
to rolled
technique
because
one
technique is
a medial-
lateral
beam and
the other is
lateral-
medial
beam
These
images are
presented
for the
purpose of
demonstrati
on and are
not
149
necessarily
worthy of
repeating.
The
decision to
repeat
should be
based on a
balanced
consideratio
n of the
costs vs the
likely
benefits to
the patient
Comment
You will
sometimes
see a lateral
knee where
all of the
malposition
indicators
are absent
knee joint
effusion
noted
?
lipohaemart
hrosis
Case 8
150
The
Indicators
The
lateral
femoral
notch is
demonstr
ated
(white
arrow)
The
adductor
tubercle is
demonstr
ated
(black
arrow)
The fibula
head
position is
unremark
able
For
Horizontal
Ray
Lateral
Technique
To Correct
Rotation
Error:
there is
insignifica
nt error
To Correct
Angulatio
n Error:
151
More
cephalic
angulatio
n
For Rolled
Lateral
technique
To Correct
Rotation
Error:
there is
insignifica
nt error
To Correct
Angulatio
n Error:
More
caudal
angulatio
n
Note
Horizontal
ray
technique
will
always
require
opposite
angulatio
n
correction
to rolled
technique
because
152
one
technique
is a
medial-
lateral
beam and
the other
is lateral-
medial
beam
These
images
are
presented
for the
purpose
of
demonstr
ation and
are not
necessaril
y worthy
of
repeating.
The
decision
to repeat
should be
based on
a
balanced
considera
tion of the
costs vs
the likely
benefits
to the
patient
153
Case 9
The
Indicators
The
lateral
femoral
notch is
not well
demonstr
ated
(although
probably
visible)
The
adductor
tubercle is
not
demonstr
ated
The fibula
head
position is
normal
For
Horizontal
Ray
Lateral
Technique
To Correct
Rotation
Error:
none
To Correct
Angulatio
154
n Error:
none
For Rolled
Lateral
technique
To Correct
Rotation
Error:
none
To Correct
Angulatio
n Error:
none
Note
Horizontal
ray
technique
will
always
require
opposite
angulatio
n
correction
to rolled
technique
because
one
technique
is a
medial-
lateral
beam and
the other
155
is lateral-
medial
beam
These
images
are
presented
for the
purpose
of
demonstr
ation and
are not
necessary
worthy of
repeating.
The
decision
to repeat
should be
based on
a
balanced
considera
tion of the
costs vs
the likely
benefits
to the
patient
Case 10
156
The
Indicators
The
lateral
femoral
notch is
poorly
demonstr
ated (top
black
arrow)
The
adductor
tubercle is
also
poorly
demonstr
ated
(bottom
black
arrow)
For
Horizontal
Ray
Lateral
Technique
To Correct
Rotation
Error:
insignifica
nt error
To Correct
Angulatio
n Error:
increased
caudal
angulatio
157
For Rolled
Lateral
technique
To Correct
Rotation
Error:
insignifica
nt error
To Correct
Angulatio
n Error:
decreased
caudal
angulatio
n
Note
Horizontal
ray
technique
will
always
require
opposite
angulatio
n
correction
to rolled
technique
because
one
technique
is a
medial-
158
lateral
beam and
the other
is lateral-
medial
beam
These
images
are
presented
for the
purpose
of
demonstr
ation and
are not
necessaril
y worthy
of
repeating.
The
decision
to repeat
should be
based on
a
balanced
considera
tion of the
costs vs
the likely
benefits
to the
patient
Discussion
knee joint
effusion
noted
159
Case 11
The
Indicators
The
lateral
femoral
notch is
not
demonstr
ated
The
adductor
tubercle is
not well
demonstr
ated
The fibula
head
position is
unremark
able
For
Horizontal
Ray
Lateral
Technique
To Correct
Rotation
Error:
none
To Correct
Angulatio
n Error:
160
none
For Rolled
Lateral
technique
To Correct
Rotation
Error:
none
To Correct
Angulatio
n Error:
none
Note
Horizontal
ray
technique
will
always
require
opposite
angulatio
n
correction
to rolled
technique
because
one
technique
is a
medial-
lateral
beam and
the other
is lateral-
161
medial
beam
These
images
are
presented
for the
purpose
of
demonstr
ation and
are not
necessary
worthy of
repeating.
The
decision
to repeat
should be
based on
a
balanced
considera
tion of the
costs vs
the likely
benefits
to the
patient
Discussion
large knee
joint
effusion
noted
Case 12
162
The
Indicators
The
lateral
femoral
notch is
demonstr
ated
(white
arrow)
The
adductor
tubercle is
not
demonstr
ated
The fibula
head
position is
normal
For
Horizontal
Ray
Lateral
Technique
To Correct
Rotation
Error:
none
To Correct
Angulatio
n Error:
none
For Rolled
163
Lateral
technique
To Correct
Rotation
Error:
none
To Correct
Angulatio
n Error:
none
Note
Horizontal
ray
technique
will
always
require
opposite
angulatio
n
correction
to rolled
technique
because
one
technique
is a
medial-
lateral
beam and
the other
is lateral-
medial
beam
These
images
164
are
presented
for the
purpose
of
demonstr
ation and
are not
necessaril
y worthy
of
repeating.
The
decision
to repeat
should be
based on
a
balanced
considera
tion of the
costs vs
the likely
benefits
to the
patient
Discussion
knee joint
effusion
noted
Case 13
165
The
Indicators
The
lateral
femoral
notch is
poorly
demonstr
ated
(white
arrow)
The
adductor
tubercle is
also
somewha
t poorly
demonstr
ated
(black
arrow)
The fibula
head
position is
normal
For
Horizontal
Ray
Lateral
Technique
To Correct
Rotation
Error:
none
To Correct
Angulatio
166
n Error:
More
caudal
angulatio
n
For Rolled
Lateral
technique
To Correct
Rotation
Error:
none
To Correct
Angulatio
n Error:
More
cephalic
Angulatio
n
Note
Horizontal
ray
technique
will
always
require
opposite
angulatio
n
correction
to rolled
technique
because
one
167
technique
is a
medial-
lateral
beam and
the other
is lateral-
medial
beam
These
images
are
presented
for the
purpose
of
demonstr
ation and
are not
necessaril
y worthy
of
repeating.
The
decision
to repeat
should be
based on
a
balanced
considera
tion of the
costs vs
the likely
benefits
to the
patient
Discussion
168
Fractured
patella
noted
Case 14
This 73 year old lady presented

with right knee pain and a history
of gout. She was referred for
radiography of both knees. You can
be confident that you have
mastered lateral knee radiography
when you are producing good
quality images... you can be very
confident when you produce
bilateral knee images that look like
mirror images!
169
Comment
Lateral knee radiography is one of the more difficult radiographic positioning challenges (perhaps
surpassed only by the lateral elbow). Persistence and practice will yield results.
170
Nasogastric Tube Position Confirmation
Introduction
Chest radiography for nasogastric tube (NGT) position is commonplace in many hospitals. The aim is to
positively confirm that the exit hole(s) of the NGT is/are within the gastrointestinal tract (usually the stomach).
If the longer nasoenteric tube is used, the objective is to place the tip of the tube past the pylorus into the
jejunum. This tip position bypasses the regulatory function of the pylorus and delivers nutrition/therapeutic
agents directly into the jejunum. Even if a nasoenteric tube has its tip in the stomach, if there is enough tubing
in the stomach, normal peristalsis will tend to propel it distally (but not always).
The importance of establishing the position of the NGT cannot be understated. A patient who is fed or
administered drugs via a malpositioned NGT can have very poor outcomes including iatrogenic death. X-ray
confirmation of NGT position is not practised in some centres- the position of the tip of the NGT is assessed
by drawing back gastric contents and testing with ph paper.
Insertion Technique
There is no shortage of videos on Youtube covering the subject of NGT insertion. Here's a few of
them
(Note: Youtube videos are displayed at lower (Note: Youtube videos are displayed at lower
resolution when 'hot-linked'. Click on the bottom right resolution when 'hot-linked'. Click on the bottom right
corner of the video and it will open at full resolution.) corner of the video and it will open at full resolution.)
Select a tube size and type.
Explain the procedure to the patient and obtain consent from

the patient to proceed.
Sit patient upright for optimal neck/stomach alignment
Wash hands and don disposable gloves.
NGTs are generally inserted via the nostril (...by definition).

Alternatively, an orogastric tube can be used - this tube is
inserted via the patient’s mouth into the stomach. It is worth
asking the patient which nostril is more patent. A deviated
nasal septum, polyps or other pathology may suggest one
nostril will be more patent than the other. It can be helpful to
check nostrils for patency by asking patient to occlude one nostril and breathe normally through the
other. Select the nostril through which air passes most easily. Alternatively, ask the patient to blow
their nose into a tissue.
Close the access port on the NGT. It is amazing how often the contents of a patient's stomach are
deposited on their pillow because the access port was left open.
It is good practise to do a quick assessment of whether the NGT is long enough for the patient. Viasys
Healthcare recommend the following technique in their instructions for inserting an Enteral Feeding tube with
stylet.
"Place the exit port of the tube at the tip

171
of the nose. Extend tube to earlobe,

then to xiphoid process. ...Use the
printed centimeter marks on the tubes
to aid intubation and check for tube
migration.
If there are no centimetre marks on the tube, tape could be placed on the tube to mark the desired insertion
length. Lubricate the tip of tube (at least 1-2 inches) with water-soluble lubricant. Apply topical analgesic to
nostril and oropharynx or ask patient to hold ice chips in his or her mouth for several minutes.
Insert the tube into nostril while directing the tube downward and backward. Patient may gag when
the tube reaches the pharynx. Instruct the patient to touch his or her chin to chest. If the patient is
conscious and compliant, he/she is instructed to swallow during the insertion of the NGT. Swallowing
small sips of water may enhance the passage of the tube into the oesophagus. The swallowing
action and peristaltic waves assist the NGT to enter the oesophagus and also assist its passage to
the stomach. Advance the tube in a downward-and-backward direction when the patient swallows.
Stop when the patient breathes. If gagging and coughing persist, check placement of tube with a
tongue blade and flashlight. Keep advancing tube until tape marking is reached. Do not use force.
Rotate the tube if it meets resistance.
Apply tincture of benzoin to tip of nose and allow to dry. Secure

tube with tape to patient’s nose. Be careful not to pull the tube
too tightly against nose.
It is very helpful if the doctor/nurse leaves the NGT's luminal wire

(stylet) in place until the confirming radiograph has been
performed. Once that stylet is removed, it should not be
reinserted. I have heard it suggested that if the wire is removed
from the NGT, contrast medium could be injected down the NGT
to help identify its position. Air injected down the NGT has also
been suggested as a contrast agent to inflate the stomach. Both
techniques are not recommended unless it has been proven that
the NGT is not in the patient's pleural space or anywhere else
that it can cause harm.
NGT should be looped and taped to patient or secured at the patient's nose with suitable adhesive
tape.
You can estimate the amount of NGT inside the patient by examining the length of NGT outside the
patient. If you keep sample NGTs in you radiography suite, it might be worth checking whether the
tip of the NGT could even conceivably be located in the stomach. I have had patients referred for
chest radiography for NGT position despite the fact that almost the entire length of the NGT is
172
hanging out of the patient's nose!
Contraindications
 Patient non-consent to procedure
 Anticoagulation or coagulopathy
 Basilar skull fracture
 Nasal or other trauma that might affect insertion
 Sinus surgery
 Recent sphenoidal or transsphenoidal surgery
 Nasopharyngeal tumours
 Oesophageal varices
 Recent oesophageal surgery
 Oesophageal stricture

Complications
 Intracranial Insertion
 Pleural Space Insertion
 Lung insertion
 bleeding
 knot forms in NGT
Radiographic Technique
 The radiographic technique for NGT placement confirmation is most commonly erect or supine, AP or
PA chest radiography. The technique is modified to take into account that a successfully positioned NGT will
be visualised below the diaphragm. Radiographers will commonly place the cassette in the portrait position
rather than the landscape position to ensure that the subdiaphragmatic anatomy is included.
 There might seem like a prima facie case for abdominal radiography, or radiography centred on the
diaphragm, rather than chest radiography. However, the NGTs do not always end up in the desired position. In
some cases the NGT can become coiled up in the pharynx. If you don't include the pharynx, the result can be
puzzling- where did the NGT go?
173
 A penetrated exposure is often required to visualise the tip of the NGT below the diaphragm,
particularly when using non-digital equipment. Marking/annotating a radiograph as "penetrated" is prudent in
that the image might otherwise be interpreted as inadvertently overexposed (read bad radiography).
 Digital radiography is generally more effective in demonstrating the position of the NGT because of
its larger dynamic range.
 It has also been suggested that supine radiography is more effective in demonstrating the NGT
position than the AP sitting chest position. The reasoning is that in the AP sitting position, the abdominal
tissues are not as "stretched out" and will therefore tend to be underexposed.
 Patients can be referred for NGT insertion under fluoroscopic control. These are commonly patients
who have had multiple 'blind' attempts at NGT insertion in the ward. These NGT insertions are frequently
difficult insertions where fluoroscopic guided insertion provides much greater chance of success. A
fluoroscopic guided NGT insertion is also arguably safer for the patient and should result in a lower risk of
malposition and complication.
NGT Insertion Under Fluoroscopic Control

This is a fluoroscopic guided NGT insertion on an 81
year old lady who had suffered a recent stroke and
was unable to be fed orally. The procedure was
undertaken using a C-arm DSI fluoroscopic unit. The
C-arm machine has considerable advantage over a
non-C-arm unit in that the insertion of the NGT can
be followed closely with PA and lateral fluoroscopic
surveillance without the patient moving from the
supine position.
(Note: Youtube videos are displayed at lower

resolution when 'hot-linked'. Click on the bottom right
corner of the video and it will open at full resolution.)
The Marginal Position

The tip of the NGT can sometimes appear to be just within the fundus of the stomach. It
can be tempting to accept the position of the NGT, particularly when there have been
multiple attempts at insertion. This is very risky. Consider the NGT position shown
below
174
The tip of the NGT is within the fundus of the This is the tip of the NGT seen in the fluoro spot film
stomach. This tube has a sidehole only (no end hole). on the left. There is a large side-hole and no end-hole.
The sidehole is seen to be above the left
hemidiaphragm. This is an unacceptable position. The
position of the tip of the NGT can appear to be even
further into the gastric fundus on the AP view
depending on factors such as FFD and centring point
i.e. a NGT tip that appears to be just within the
fundus of the stomach may be a result of projection
rather than actual position.
Case 1
175
This NGT
is in a
normal
position in
the
stomach.
Case 2
176
normal naso-
enteric tube
position
177
Source: http://intensivecare.hsnet.nsw.gov.au/current/community/equipment/ngt
Case 3
178
These images demonstrate one of the most common problems with checking NGT positions radiographically-
the NGT is hard to see! If you look closely you can follow the path of the NGT.
With digital systems, post-processing your image can help. It is sometimes difficult to decide whether
to widen the window or narrow the window. It is probably wise to concentrate on the tip of the NGT.
Whatever post-processing settings show the tip should be used. It is also good practice to produce 2
images from the one exposure: One image can be post-processed to highlight the lungs/heart (a
normal CXR setting) while the other is just about the NGT position(black and contrasty).
This patient's NGT takes a tortuous course with the tip resting in an indeterminate position. On the
AP chest image, it does not appear that the NGT is within the patient's airway. It was considered
prudent to perform a lateral chest X-ray examination to provide additional confirmation as to the
course of the NGT. The lateral chest image demonstrates that the NGT is posterior to the airway and
is likely to be within the oesophagus. The lateral projection also provides additional information
about the tip position in relation to the fundus of the stomach.
Care must be taken to ensure that there is enough NGT in the stomach to be sure that the side
holes of the NGT are not in the oesophagus.
Inverting a digital image (black on white) can help to visualise a NGT.
Case 4
179
The NGT
appears to be
following the
trachea and
the left main
bronchus. It
is likely that
the tip of the
NGT has
entered the
left main
bronchus and
then deviated
down a
posterior
bronchus
into the left
lower lobe.
An
alternative
explanation
is that the
NGT is
within a
tortuous
oesophagus.
Regardless
of its course,
its final tip
position is
unacceptable
Case 5a
180
The NGT
can be seen
to deviate
down the
left main
bronchus. It
then appears
to reflect off
a bronchial
division and
then take a
course down
the right
main
bronchus,
possibly into
the right
middle lobe
(bronchus
intermedius)
.
Case 5b
181
This
makes a
matching
pair with
the NGT
position
shown
above.
The NGT
has
entered
the RMB
then
deflected
backward
s with the
tip
positione
d in the
LMB.
Case 6
182
This NGT has

taken a path
down the right
main bronchus
then made its
own path
through lung
parenchyma
into the pleural
space.
This NGT was

removed from
the pleural
space and
replaced with
an underwater
sealed drain
(UWSD)
which was
inserted
percutaneously
.
Case 7
183
This patient has a hiatus hernia. The nasogastric tube has entered the hiatus hernia without passing
further into the non-herniated subdiaphragmatic stomach. The arrowed structure is likely to be the
stomach wall. The lateral projection assists in confirming the presence of the hiatus hernia and the
position of the NGT within the hiatus hernia. (note; the diaphragm demonstrated on the lateral view
is the right hemidiaphragm)
It is common for NGT insertions to fail in patients with a hiatus hernia. Rather than undertake
multiple attempts at insertion, it can be prudent to insert the NGT under fluoroscopic guidance. As a
radiographer it is in your interests, the interests of the patient, and the doctor’s interests to offer this
service when appropriate. The usual 'on balance' considerations of radiation dose, patient safety and
other relevant practical considerations apply.
Case 8
184
This patient
has a NGT
that has
passed down
the trachea
rather than the
oesophagus.
The NGT has
then deflected
into the left
main
bronchus
before being
pushed
through lung
parenchyma
and the
visceral
pleura into the
pleural space.
The mantra
for inserting
NGTs is
definitely not
"... just keep
pushing". The
result of this
insertion is a
left sided
pneumothorax
. This is
supported by
the deep
sulcus sign
that can be
seen at the
left lung base.
Case 9
185
Case
10a
186
This patient has a NGT that has either reflected and doubled back or has had its tip caught on the
way down. The NGT is not in the airway. The patient appears to have a large hiatus hernia and the
NGT may have reflected at the level of the gastro-oesophageal junction (GOJ). The GOJ is in the
thoracic cavity in this patient.
The tip of the NGT is marked with a white arrow
Case
10b
Same
Patient
A new NGT
has been
inserted.
187
Once again the NGT does not appear to be within the right main bronchus. The NGT is
likely to have entered the hiatus hernia.
Case
11
The NGT
is likely to
have
passed
down a
tortuous
188
oesophagus. The tip of the NGT is probably within the fundus of the stomach (white
arrow). The side hole (black arrow) may be within the oesophagus. This is an
unacceptable position. If the patient is fed via this NGT, the liquid may exit from the side
hole into the oesophagus. If there is sufficient fluid entering the oesophagus it can
overflow into the patient's lungs. If there is aspiration of the fluid the patient could die
Case 12
189
The tip of
the NGT
can be seen
to be sited
in the
distal
oesophagu
s. The side
hole may
be in the
fundus of
the
stomach
but it is
difficult to
be sure.
This NGT
is unlikely
to be
manipulate
d
successfull
y into the
correct
position
and should
therefore
be
removed.
Case 13a and 13b

These two NGT check images deserved to be presented as a pair.
190
The tip of the NGT is in the right lower lobe The tip of the NGT is in the left lower lobe
(can you see the button artifact?)
Case 14
191
The NGT is
coiled up in
the pharynx.
This position
can easily be
missed if the
patient's neck
is not
included on
the image.
Case 15
192
This NGT is
just plain
hard to see.
The
contributing
factors may
be
NGT
tube is not
sufficiently
radiopaque
erect
position
no air
in stomach
under-
exposure
Case 16
193
The tip of the

NGT
(arrowed) is
positioned in
the fundus of
the stomach.
This position
is marginal
and should be
adjusted for
two reasons
1. If the NGT
has side
holes, they
may be
within the
distal
oesophagus.
(the side hole
in this tube
appears to be
just within
the stomach)
2. If the side
hole is not in
the distal
oesophagus,
it wouldn't
take much for
it to end up
there
Case 17
194
This NGT has

cleverly
manipulated
itself into a knot
which is
positioned in the
nasopharynx.
The tube was
eventually
removed
through the oral
cavity by use of
a McGill
forceps.
source:
http://www.cmaj.ca/cgi/co
ntent-
nw/full/178/5/568/F118.
The knotting of
a NGT is not
common. It is
possible that
knots in NGTs
are a result of
having too much
NGT coiled in
the stomach.
Case 18
195
Same
issue
as
above.
NGT
was cut
near
the
patient'
s nose
and
pulled
out
throug
h the
patient'
s
mouth
Case 19
196
This patient was

referred for a NGT
position check
after the patient
pulled out his
original NGT.
The NGT tip is

probably within
the fundus of the
stomach. The side
hole of the NGT is
also likely to be
just within the
stomach. This
position is risky,
particularly in a
patient who has a
penchant for
giving his NGT a
tug.
The radiographer
advised the nurse
who accompanied
the patient that the
NGT should not
be used until
checked by the
referring doctor
given that the
position was at
best marginal.
This NGT has an

opaque tip which
is very helpful in
identifying the tip
position. The
stylet was
removed from the
NGT in the ward
prior to sending he
patient for
radiography.
197
The radiographic
technique used
was supine
bedside with no
grid. Deliberate
overexposure was
employed to
maximise the
chances of
demonstrating the
NGT tip below the
hemidiaphragm
The radiographers
noted that there
was a significant
length of NGT
hanging out of the
patient's nose-
approximately 18
inches.
198
The patient
represented
following
repositioning of
the NGT in the
ward. The tip of
the NGT is in a
similar position
with the tip
possibly caught at
the gastro-
oesophageal
junction.
The radiographers
noticed that there
was now only
about 6 inches of
NGT hanging out
of the patient's
nose. When the
nurse who
accompanied the
patient was asked
if a shorter NGT
had been used, she
said that the
existing NGT had
simply been
pushed in further.
The stylet had
correctly not been
reinserted while
the NGT was
insitu. This
presented several
problems to the
radiographer.
Firstly, the NGT
had been pushed
in without the
stylet insitu- this
was asking for
trouble because
this NGT had very
little strength
199
without the stylet

insitu. Secondly,
there was about 12
inches of NGT
that could not be
accounted for. The
radiographer asked
the patient to open
his mouth but no
NGT was visible.
It was decided to
do another NGT
check film centred
to include the
patient's neck. (see
below)
200
The NGT can be

seen to be coiled
within the patient's
pharynx
(arrowed).
This case
demonstrates that
a clinical approach
to radiography can
make a difference
even with a
humble NGT
insertion check.
The radiographer's
suspicion that the
NGT was coiled in
the patient's neck
was based on
observation and on
questioning the
nurse about the
insertion technique
used.
This case
demonstrates the
quandary between
including the
patient's neck and
upper abdomen on
the one image. I
would suggest that
it is prudent to
focus on including
the upper
abdomen. An
additional
exposure of the
patient's neck can
be undertaken if
the NGT is
suspected to be
coiled in the
pharynx.
201
Note the
difference in
image quality
when a bucky
technique is
employed. For
reasons of
radiation dose
reduction and
convenience a
non-grid technique
is more commonly
employed.
Case 20
202
This patient was

referred for a NGT
position check X-
ray.
The radiographer
performed an AP
sitting bedside
chest technique.
The radiographer
noted that the
NGT was visible
proximally
(arrowed) but was
very difficult to
follow distally. It
was thought that
an abdominal
technique should
clearly
demonstrate if the
NGT had passed
below the
diaphragm.
203
The patient was

transferred onto
the X-ray table
and a bucky
abdominal
technique was
employed. The
position of the
NGT is clearly
demonstrated. The
contrast between
the two techniques
is remarkable
(excuse pun).
Note image centre

point arguably too
low.
Case 21
204
This is the patient's first NGT check image. A follow-up examination shows the NGT is in
The NGT appears to be in a satisfactory an unusual position. On review of a recent CT
position (black arrow). abdomen, it was considered possible that this
image shows the NGT following the lesser
curve of the stomach posteriorly.
Note also that when an NGT appears to make a

sharp turn (arrowed) it is possible that the
appearance is due to the NGT being directed
anteriorly or posteriorly. The appearance is of a
sharp turn or of a kink in the NGT- the 3
dimensional reality might be quite different.
Discussion
205
One of the hidden dangers with NGT-check images is that they are commonplace and the dangers
are underestimated. The radiographer should report immediately when a NGT is suspected to be
positioned in the lung, or anywhere else that it shouldn't be.

Lateral Scapula Radiography

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Lateral Scapula Radiography

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1

Lateral Scapula Radiography

The Lateral Scapula Projection Needs a Clinical

The head of the humerus should be normally

The acromion and distal end of the clavicle form

A group of muscles and their tendons known as

Sheila Bull. Skeletal Radiography: A

The photograph is taken from a

lateral. I would also question the

Patients tend to lean/stoop forward when positioned

The Supine AP Approach

The answer sometimes is to use an alternate view- IS or SI

Good Projection when Achieved

What Went Wrong?

Image 4 Image 5 Image 6

Remarkably similar to image 3. Similar to image 5 but a little Extreme malpositioning.

Note also tendon screws.

Lack of image contrast associated

Image 7 Image 8 Image 9

Image 10 Image 11 Image 12

Foreshortened and under-rotated. The This is a well positioned Good position

There is a fracture of the acromion (arrowed) Fractured coracoid process (arrowed).

Concomitant Pathology and Incidental Findings

The radiographer's diligence in identifying the

and obviated the need to call the patient back from

Modified Technique for Trauma Patients

Can the Lateral Scapula Projection Reliably

The Neer's (outlet) View

With normal humeral elevation, the subacromial

adapted from Joseph David Zuckerman, Kenneth J. Koval.

Source: Koehler/Zimmer's Borderlands of Normal and

Source: Injuries of the Clavicle, Acromioclavicular Joint and Sternoclavicular Joint

Source: Injuries of the Clavicle, Acromioclavicular Joint and Sternoclavicular Joint

Source: Injuries of the Clavicle, Acromioclavicular Joint and Sternoclavicular Joint

The clavicle fracture exposed at surgery

Source: Injuries of the Clavicle, Acromioclavicular Joint and Sternoclavicular Joint

Source: Injuries of the Clavicle, Acromioclavicular Joint and Sternoclavicular Joint

Post operative radiography

Note also the

AP Thoracic Spine Breathing Technique

This image was taken on a DR imaging system.

soft tissue structures

The AP thoracic spine image demonstrates

Lateral Lumbar Spine Breathing Technique

Breathing Technique Case Study 1

First Presentation Post Operative Imaging

Breathing Technique Case Study 2

There is no clearly demonstrated crush fracture

It is noteworthy that the spinous processes have

Breathing Technique Case Study 3

The radiographer considered the risk of rolling the

Although there was no evidence of a lumbar spine

Breathing Technique Case Study 4

(note that the CR image is probably underexposed

resulting in a low signal to noise ratio- i.e. operator

Breathing Technique Case Study 5

Large Bowel Obstruction

Normal Radiological Appearance

Large bowel tends to be peripherally located. (beware the

The String of Pearls Sign

The string of pearls sign is a

Radiological Appearances of LBO

Gas and faeces tend to