The Skyline Patella Projection - wikiRadiography

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Applied Radiography - by Share this Report page
M.J.Fuller
Using Baker Cones in the
Neonatal Intensive Care Unit
The Skyline Patella Projection
The Fronsko Dripstand Base
Head Clamps for Skull
Radiography
The Paediatric Elbow
The Supine Pneumothorax
The Abdominal Plain Film-
Ileus
Ulcerative Colitis and Crohn's Introduction
Disease There is nothing quite like nailing a perfect skyline knee projection. This page looks at some issues and tips for achieving the goal of perfect skyline knee radiography.
Normal Bowel Patterns in
Sedentary Patients
Acute Abomen1 The Positioning Sponge
Knee Trauma1 In pursuit of the perfect skyline knee projection, I investigated the idea that the ideal tube angle might be more consistent if the knee flexion was always the same. It would also be desirable in a trauma situation if you could flex the knee slightly and rest it
Soft Tissue Signs- Thoracic onto a positioning sponge such that it was positioned perfectly for a horizontal ray lateral using a 24 x 30cm (12 x 10 inch) cassette. Moreover, it would be desirable to leave the sponge in situ for the skyline view.
Spine
Elbow Trauma 1 I had a large number of off-cut sponge pieces that I cut down to different heights until I achieved what appeared to be the perfect height. The final result is shown below.
Ankle Trauma 1
Soft Tissue Signs- Skull and
Facial Bones
Soft Tissue Signs- Cervical
Spine
Imaging Subpulmonic
Effusions
Imaging Severe Hand
Trauma Sponge can be cut with a hot wire or an electric carving knife. I made my own hot wire cutter. You can do a google search for
Chest Trauma 2 more information if you want to make your own cutter. If you're not familiar with electrical safety issues, don't do it!
Passe Radiography
Alternatively, you can take your foam to a foam cutter for a professional looking result
Lateral Toe Radiography
Neonatal Abdominal
Pathology
Neonatal Chest Radiography
Neonatal Chest Pathology
Soft Tissue Calcification
Posterior Malleolus Fractures
Fuch's View of the Odontoid
Process
Right Middle Lobe Collapse
Lung Anatomy
Monteggia and Galeazzi
Fracture-dislocations of the
Forearm
False Consolidation The "Research"
Slit Basal and Teacup Views I was attempting to find what the ideal X-ray tube angle was to produce a perfect skyline knee image when using this
of the Zygoma
positioning sponge. A sample image is shown left.
The Terry-Thomas Sign
Dislocations and I made these same measurements on about 50 patients and found that, in adults, the positioning sponge caused the knee to
Subluxations of the Carpus be flexed to about 30 degrees. Importantly, the patella was angled at about 10-15 degrees to the horizontal. Using this
Imaging Scaphoid Fractures information, you could produce reliable skyline positioning.
Imaging Capitate Fractures
Imaging Rib Fractures Note that the sponge positions the knee in the middle of the cassette
Shoulder Arthrography
Dacrocystography
Lumbar Myelography
Open Book Fracture
Imaging Hamate Fractures
Pisiform Fractures
Imaging Radial Head
Fractures
Thumb Fractures
Lumbar Spine Radiography
Lateral Ankle Radiography
Imaging Mandibular Fractures
Normal Paediatric Hand
Anatomy

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Chest Normal Anatomical

Variants
Colles' Fracture Radiography The Image
Pleural Effusions The skyline patellar image using positioning based on the measurements from the lateral knee is shown left.
Imaging Shoulder
Dislocations
Acromioclavicular Joint
Radiography
Judet Views
The Lateral Decubitus Skyline knee image with 10 degree cephalic angle based on measurements from the horizontal ray lateral knee shown
Abdominal Plain Film above.
Orthopaedic Internal Fixation
Failure
Orthopaedic Screws,Plates
and Prosthesis
Radiography of Pubic Rami
Fractures
Causes of Asymmetrical Lung
Density
Sternum Radiography
Foreign Body Radiography Discussion
Jones Fracture My understanding of the skyline patella position is that a minimum of knee flexion is more likely to reveal abnormal patellar tracking. The most frequent problem that I found with this technique was that there was too little knee flexion. Too little flexion of
Radiography of Hip the knee joint can cause the tibial tuberosity or other anatomical structures to be projected over the anatomy of interest.
Dislocations
Imaging Periprosthetic Hip These images were produced with a CR system which allows for the easy measurement of angles. It would be possible to measure the skyline angle from the lateral view for all patients and you are likely to achieve very consistent quality images. The
Fractures practicality of this approach is questionable.
Normal Elbow- Male 17
years, 8 months
Pneumothorax Cases
mobile chest x-ray
Tips
Abdominal Radiography of
The toes are in the way
the Morbidly Obese Patient
It is good practice to remove the patient's footwear.
Fifth Metatarsal Fractures
Lipohaemarthrosis You have a number of choices if the patient's foot anatomy is superimposed over the patella.
Tenneb Fracture plantar flex the ankle joint like a ballerina "on point"
Reverse Bennett Fracture increase knee joint flexion
Ulnar Bennett Fracture position the X-ray tube so that you are directing the X-ray beam along the medial or lateral side of the patient's foot
Metacarpal Fractures
Pneumothoraces Underexposure
Abdominal Calcifications The skyline projection requires considerably more radiation exposure than the AP/lateral. Also, the less flexion of the patient's knee, the more exposure you will need. Furthermore, for reasons of practicality, you could end up with a long FFD.
Normal Paediatric Shoulder-
13 year old male Comparison Views
Ingested/Aspirated Foreign As much as I dislike routine comparison views, there is justification for imaging both patellae in the one exposure. This is particularly useful when assessing subtle abnormal patellar tracking.
Body Radiography
Emphysematous Cystitis Supporting the cassette and patient
Geometric Concepts in
Sitting the patient up in a semi-sitting position is very uncomfortable. The DARRIN sponge is perfectly shaped to place behind the patient's back to provide support. One disadvantage of this approach is that the patient may receive a primary beam
Radiography radiation dose to the orbits and thyroid.
Osgood-Schlatter Disease
My preferred technique is to keep the patient supine and use the LEDDRA skyline cassette holder.
Scapular Fractures
Digital Double Dipping in
Chest Trauma Radiography
Intravenous pyelogram
Is the Screw in the Joint?
Radiographic Techniques
Imaging Talar Fractures There are a variety of radiographic techniques for achieving a tangential image of the patella. This table details some (but not
Coarctation of the Aorta
all) of the techniques.
The Lateral Elbow
Radial Head Dislocations
Imaging Olecranon Fractures
Elbow Dislocations
Imaging Supracondylar
Fractures of the Humerus
Chest Radiography for
Inhaled Foreign Body
Finger Radiography
Wrist Arthrography
Leg Venography
Scaphoid Radiography
Dupuytren's Fracture
Colle's Fracture of the Wrist
Wrist Measurements
Odontoid-lateral mass
Asymmetry
Lateral Chest Paravertebral
Gutter Positioning Technique
Lordotic Chest Technique
The Apical Lordotic
Radiography of Subtle Wrist
Fractures
Patterns of Collapse

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Conventions, Customs,
Cultures, Common Practices
and Quirks in Radiography
Conservative management of sports injuriesBy Thomas E. Hyde, Marianne S. Gengenbach, Jones & Bartlett Learning, 2007, p684
Patterns of Misdiagnosis in
Plain Film Radiography
What is the Value of the
Lateral Chest Projection?
Neonatal Abdominal
Is the Skyline Projection Necessary?
Radiography This 17 year old male presented to the Emergency Department following a fall from his bike. He was examined and the
Humour in Medicine requested radiography included his left knee.
Shoulder- SI vs Lateral
Scapula Is there any evidence of fracture or dislocation?
Lateral Scapula Radiography
Modified Trauma Lateral Hip
Radiography
Mach bands and other
Optical Illusions
The Swimmers Technique
The Abdominal Plain Film in
Clinical Context
The Abdominal Plain Film-
Appendicitis
Wrist Trauma 1E
The Skyline Patella Projection
Patellar Fractures and
Dislocations
The Erect Abdominal Plain
Film
Aluminium Filter Techniques
in Radiography
Modified Lateral Thoracic
Spine Technique
Pelvis Anatomy, Artifacts and
Variants
Supine Intercondylar Knee
Radiography
The Lateral Ankle Trap
Paediatric Wrist Trauma
Satisfaction Syndrome
The "Leaning Tower" view of
the Paranasal Sinuses
Lumbar Spine Breathing
Technique
Vacuum Phenomenon
Leddra Skyline Patella View
Cassette Holder
The AP Odontoid Peg
Projection
Preparing Images for the
Web with Photoshop
The lateral knee projection image demonstrates no fracture or dislocation.
The Trauma Lateral Cervical
Spine
Is further imaging required?
Bucky Markers
Artifacts and Artefacts
Simple Quality Control

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Testing
Lateral Soft Tissue Neck for
Foreign Body
Notes on Chest Radiography
Pneumoperitoneum
The Abdominal Plain Film-
Terminology
Small Bowel Obstruction
Neonatal Lines, Tubes and
Catheters
Trauma Obliques of the
Cervical Spine
Nutcracker Fracture of the
Cuboid
Top 20 Practical Tips for
Radiography in the
Operating Theatre
Soft Tissue Signs- The Wrist
Soft Tissue Signs- The Elbow
Soft Tissue Signs- The Ankle
Knee: non-trauma soft tissue
signs and artifacts
Soft Tissue Signs- Knee The skyline projection image demonstrates a possible fracture of the lateral aspect of the patella. Is this a fracture or a
Trauma secondary ossification centre? If you scroll up the page and review the AP image you will notice that there is a faint
The Smart Cone impression of a lucency over the supra-lateral aspect of the patella- this is the most common position to find a secondary
Stent Board ossification centre. If this was a fracture, would it have been missed without the skyline projection included in the routine
Soft Tissue Signs in radiographic series?
Orthopaedics
Radiography of the Bicipital
Groove
Arcuate Sign
Calcaneal Fractures
Imaging Abdominal Hernias
The Abdominal Plain Film-
Intramural Gas
The Fissures of the Lung
Left Lower Lobe What Went Wrong?
Consolidation
Case 1
Left Upper Lobe
Consolidation
Right Lower Lobe
Fault
Consolidation This is an example of incorrect centring. The central ray is directed too inferiorly. The central ray should be directed
Right Middle Lobe
to the patello-femoral joint. Apart from aesthetic considerations and failure to demonstrate the patello-femoral joint
Consolidation clearly, there has been unnecessary irradiation of the femur and lower leg.
Right Upper Lobe
Consolidation Correction
Lateral Lumbar Spine
Centre to the patello-femoral joint
Radiography
Oblique Lumbar Spine
Technique
Oblique Cervical Spine
Technique
Hyaline Membrane Disease
(syn RDS) and BPD
Imaging Nail Gun Injuries
Ankle Trauma 3
Ankle Trauma 2
Case 2
Ankle Trauma 1 (ST)
Knee Dislocations and
Subluxations
Cervical Myelography
T-tube Cholangiogram
Trigeminal Nerve Block Fault
Wrist Arthrogram One of the major objectives of the skyline view is to achieve an image of the patella which is unobscured by the
Thoracic Myelography patient's toes. This image demonstrates the importance of that objective!
Thumb Carpometacarpal
Joint Instability Correction
Plantarflex the patient's foot or direct the beam medially or laterally to the patient's foot
Normal Paediatric Elbow
Anatomy
Normal Paediatric Wrist
Anatomy
Hill-Sachs and Bankart
Lesions
Imaging Fractures of the
Acromion
Snow Globe Effect

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Common Abdominal
Pathologies and Normal
Anatomical Variants
Abdominal Artifacts and
Devices Case 3
Orthopaedic Clinic Wrist
Radiography
Lateral Condylar Elbow
Fractures
Radiography of Skull Devices
Elbow Medial Condyle Fault
Fractures
This image has a slightly vertically elongated look. This is likely to be attributable to a cassette that is not at right
Axial Elbow Radiography angles to the central ray. This can happen when the patient is holding the cassette above his/her knees and lets it
Salter-Harris Fractures tilt forwards/backwards.
Nightstick Fracture
Tarsal Bone Fractures Correction
Position the cassette/IR such that it is a right-angles to the central ray
Pelvic Trauma Radiography
Clavicle Radiography
Dextracardia in the Resus
Room
DISI and VISI Deformities
Functional Views of the Wrist
Elbow Supracondylar
Fracture- Cases
Triquetral Fractures
Carpal Bone Fractures
What Constitutes a True
Lateral Wrist Position? Case 4
Fracture Types and
Mechanisms of Injury
Subluxation of the distal Fault
radioulnar joint This image is suffering form movement unsharpness.
Neck of Femur Fractures-
Cases Correction
Neck of Femur Fractures This fault can be associated with technique. If you are using the "semi-sitting" patient position, it is best to put
The Binocular Cone something behind the patient's back so they are not left "rocking" while they are supporting the cassette. I found
Using the Lead Snake to that having the patient supine and using a cassette holder is a safer bet. See the page on the Leddra Skyline
Reduce Scatter Radiation Cassette Holder.
Soft Tissue Signs- Shoulder Shorter exposure time will also help reduce movement unsharpness
Lateral Lumbar Spine
Breathing Technique
Lateral Chest X-ray Digital
Double-Dipping
AP Thoracic Spine Breathing
Technique
Radiography in the Round
Pelvic Calcifications
Nasogastric Tube Position
Confirmation
Pellegrini-Stieda Disease
Lateral Sternum from Lateral
Chest- Digital Double
Case 5
Dipping
Imaging Vertebral Body
Wedge Fractures
Pneumoperitoneum-
Radiographic Techniques
Chest Trauma1 Fault
Left Lower Lobe Collapse The soft tissue density (arrowed) that is arcing through the middle of the image is likely to be the soft tissues of the
Left Upper Lobe Collapse
lower leg.
Right Lower Lobe Collapse
Correction
Right Upper Lobe Collapse Increase knee flexion

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Patterns of Consolidation
Knee Trauma 1E
Ankle Trauma 5
Ankle Trauma 4
The Abdominal Plain Film-
Gasless vs Featureless
Large Bowel Obstruction
The Abdominal Plain Film-
Differentiating Large and
Small Bowel
Imaging Tibial Plateau
Fractures
Lateral Knee Radiography Case 6
Transthoracic Lateral
Shoulder
Breathing Exposure
Techniques in Radiography
Interstitial vs Alveolar Lung
Patterns Fault
Toxic Megacolon If the aim of this view was to produce a skyline projection of the patient's patella, you would have to declare this
Gallstones imaging endeavour a failure
Lunate and Perilunate
Dislocations Correction
If the patient appears not appear to have a patella... ask the obvious question! Always check previous imaging
Facial Bone Radiography
when possible- you might discover that the patient has had a previous patellectomy.
Pneumothorax Self-test
Imaging Calcaneal Fractures
Multi-lobar Collapse
Pneumomediastinum
Cardiac Calcifications
CR vs DR Image Quality
Radiographic Terminology
Abdominal Plain Film
Anatomy
The Patella- Normal Case 7
Anatomical Variants
The SI Projection of the
Trauma Shoulder
Urethrography
Urthrography
General Radiography
Positioning Atlas
Glossary
CT
MRI
Ultrasound
Angiography
Associations & Unions
Mammography
PACS
Australian Universities and
A skyline knee projection taken in this position, with the central ray as shown above, will project the tibial tuberosity over Resultant skyline patella image. The tibial tuberosity (arrowed) is projected over the patello-femoral joint. To correct this
Research Institutes
the patello-femoral joint. error further flex the patient's knee.
Electronic Journals and
Databases
Note- patient has Osgood-Schlatter disease .
Evidence Based Medicine EBM
Links
Syndromes
Radiography as a Career Case 8
Pathology
Gross Anatomy
Medical Abbreviations
Mnemonics
Conferences / CPD / Seminars
Text Books
Wikiradiography Rules
Surviving Your PDY
Awards
Radiography of Sesamoid
Bones

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Paediatric Chest Immobilisation

Devices
Normal Pelvis - 7 yo male
Lateral Chest Case 6
Imaging Fractures of the
Coracoid Process
Radiography of VP Shunts
Bone Tumours
Missed Fractures- Peripheral
Pathology
"The patella initially ossifies at between three and five years, commencing as multiple foci that rapidly coalesce" (Ogden Resultant skyline patella image.
JA. Skeletal Radiol. 1984;11(4):246-57. Radiology of postnatal skeletal development. X. Patella and tibial tuberosity.)
Imaging During Olecranon The skyline projection will not demonstrate a patella that has not ossified.
Fracture Tension Band Wiring
Surgery
Westermark Sign
Operative Imaging for Distal Case 9
Radius Fracture Volar Plate
Surgery
Neck of Humerus Fractures
Salter Harris I Fracture
Proximal Humerus
Lunate Fractures
World Radiographers Day
Orthopaedic Clinic Radiography
Combination Shadows
Flexion and Extension Cervical
Spine Radiography
Ankle Anatomy
Proximal Tibiofibular Joint
Dislocation
Abdominal Aortic Aneurysm
Laparoscopic Cholangiography
Normal Paediatric Shoulder
Anatomy
Soft Tissues of the Chest
Diaphragmatic Hernias
Calcium Sign This 13 year old boy fell of his bike and was referred for right knee radiography. He was unwilling/unable to flex his knee Resultant skyline patella image. This has no diagnostic value and should not have been attempted.
Lead Snake Construction Notes
Quadriceps Tendon Rupture
Case of the Month Quiz 1
signs of increased intracranial
pressure on a skull plain x-ray Case Studies
pediatrics chest imaging
Case 1
CT FACIAL BONE CORONAL
This 23 year old male presented to the Emergency Department with a dislocated left patella. This is somewhat unusual in
facial series
that patients who experience a dislocated patella will often relocate the patella themselves prior to presentation to the
QA FOR CR Emergency Department.

The AP knee projection image demonstrates the patella to be dislocated laterally. There appears to be a lucent defect in
the inferomedial aspect of the patella. This may represent an avulsion fracture.

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The cross-table lateral knee image demonstrates the dislocated patella.

The patella was relocated in the ED. The post-relocation AP knee image demonstrates the relocated patella. The patella
is not centrally located due to external rotation positioning error.

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The post-relocation lateral knee projection demonstrates the relocated patella and a lipohaemarthrosis (arrowed). The
lipohaemarthrosis supports the possibility that the patient suffered an avulsion fracture of the patella with the donor site
demonstrated on the pre-reduction AP knee image.

The post-reduction skyline patellar image demonstrates the patella to be relocated. The possible site of the avulsion
fracture is shown (white arrow). A bony fragment (black arrow) demonstrated on the lateral aspect of the lateral femoral
condyle is of unknown significance.

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Case 2
This 13 year old boy presented to the Emergency Department with a sore left knee following a sports injury. He was
examined and found to be tender in the region of this left patellar tendon. He was referred for left knee radiography.

The AP knee image demonstrates no displaced fracture.

The tibial tuberosity is fragmented (white arrow). Whilst this is not diagnostic for Osgood Schlatter's disease (OSD), the
appearance is consistent with OSD.

Note the thickening of the patellar tendon with a possible fluid collection between the patellar tendon and the proximal
tibial epiphysis (black arrow). Hoffer's fatpad demonstrates mixed fat and fluid density consistent with an acute injury.

Patella alta noted

The position of the patella may be evaluated on the basis of the ratio of the greatest diagonal length of the patella to the
length of the patellar tendon on lateral radiographs (the Insall-Salvati ratio). This measurement is relatively independent

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of knee flexion, and a ratio of less than 0.80 indicates patella alta

quoted from The Journal of Bone and Joint Surgery

Image Quiz

The Insall-Salvati ratio in a normal knee (top) and in one with patella alta (bottom).

LP = length of the patella

LT = length of the patellar tendon.

adapted from The Journal of Bone and Joint Surgery

Image Quiz
The skyline knee projection demonstrates good patient positioning but the radiographer has had difficulty including all of
the anatomy on the IR because of the patella alta.

Case 3
This 34 year old male presented to the Emergency Department following a fall from his pushbike. On examination, he was
found to have a painful and swollen left knee. He was referred for knee radiography.

The AP projection image demonstrates patella alta. Patella alta refers to a condition in which the patella is located in an
abnormally proximal position.

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The cross-table lateral knee image also demonstrates patella alta.

Skyline knee radiography will be difficult given the high-riding position of the patella. It may be necessary to flex the
patient's knee more than would be normally required in order to project the tibial tuberosity clear of the patello-femoral
joint.

The skyline projection demonstrates tibial tuberosity overlying the patello-femoral joint space.

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Case 4
This 68 year old male presented to the Emergency Department following a fall onto a concrete floor. His
right knee was painful and deformed with a very prominent patella. He described a hyperflexion injury to
his right knee. He was referred for right knee radiography.

His right knee was seen to have a depression in the skin immediately superior to the upper pole of the
patella. This was not evident on the contralateral side.

The depression superior to the right patella(arrowed) was not evident on the contra-lateral side.

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The AP knee image is unremarkable.

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The lateral knee image demonstrates abnormal orientation of the patella. There is a some mixed density
within Hoffa's triangle. There is also loss of definition of soft tissue structures and mixed fat/fluid density in
the region of the suprapatellar pouch.

There is a well corticated bony density in the region of the suprapatellar pouch and a quadriceps tendon
enthesophyte.

The patella is pulled and tilted inferiorly by the action of patellar tendon in the absence of a countering
traction from the quadriceps muscle associated with a quadriceps tendon rupture.

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The skyline projection was destined for failure given the rupture of the quadriceps tendon

....back to the Applied Radiography home page here

Latest page update: made by M.J.Fuller

, Aug 4 2011, 4:24 AM EDT
(about this update
-
complete history)
Keyword tags: flexion
knee
patella
patella alta
positioning sponge
skyline
More Info:links to this page

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The Skyline Patella Projection - wikiRadiography

M.J.Fuller

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hertsstudent Revision 0 May 4 2010, 1:33 AM EDT by

hertsstudent

Thread started:May 4 2010, 1:33 AM EDT Watch

Really useful for my revision! Thanks

6
out of 6found this valuable.
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Keyword tags: flexion
knee
patella
positioning sponge
skyline

Post reply

xraygirl72 Lateral Knee 0 Jan 6 2010, 8:11 PM EST by

xraygirl72

Thread started:Jan 6 2010, 8:11 PM EST Watch

I found the information provided very helpful and easy to understand. Especially when you have a lateral view of the knee posted and with all the angles written out. I was wondering if you could do the same for the mediallateral knee as well.

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out of 1found this valuable.
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Keyword tags: flexion
knee
patella
positioning sponge
skyline

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