LOWER EXTREMITIES

PATHOLOGY DIVISIONS OF FOOT

1.) Congenital Clubfoot 1.) Hindfoot – calcaneus & talus
 Talipes equinovarus 2.) Midfoot – cuboid, navicular & cuneiform
 Abnormal twisting of the foot usually 3.) Forefoot – metatarsals & phalanges
inward & downward
2.) Pott’s Fx A.) TOES
 Avulsion fx of the medial malleolus with
loss of the ankle mortise AP/AP AXIAL PROJECTION
3.) Jones Fx PP: Supine/Seated; knee flexed; 15o foam wedge
 Avulsion fx of the base of the fifth under foot
metatarsal RP: 3rd MTP joint
4.) Gout CR: ┴ or 15o posteriorly
 Hereditary form of arthritis in which uric SS: Phalanges & distal portion of metatarsals
acid is deposited in joints AP Axial (15o): Open IP joints & reduces
5.) Osgood-Schlatter Disease foreshortening
 Incomplete separation or avulsion of the
tibial tuberosity PA PROJECTION
6.) Giant Cell Tumor PP: Prone (IP joints // to CR); dorsal aspect against
IR
 Osteoclastoma
RP: 3rd MTP joint
 Lucent lesion in the metaphysic usually at
CR: ┴
the distal femur
SS: IP joint spaces are well visualized
7.) Chondromalacia Patellae
 Runner’s knee
AP OBLIQUE PROJECTION
 Softening of the cartilage under the patella
Medial Rotation
8.) Joint Effusion
PP: Supine/seated; knee flexed; lower leg & foot
 Accumulation of fluid in the joint cavity
rotated medially 30-45o;
9.) Lisfranc Injury
RP: 3rd MTP joint
 Abnormal separation in the base of 1st & 2nd CR: ┴
metatarsal & cuneiform SS: 2nd-5th MTP joint spaces; 1st-3rd toes
10.) Reiter Syndrome Lateral Rotation
 Erosions of sacroiliac joints & lower limbs PP: Supine/seated; knee flexed; lower leg & foot
11.) Hallux Valgus rotated medially 30-45o;
 Congenital abnormality of hallux RP: 3rd MTP joint
 Lateral deviation of great toe CR: ┴
SS: 3rd-5th toes
ROUTINE
1.) Bony Injuries – AP, APO & Lateral LATERAL PROJECTION
2.) Bony Pathology – AP & APO PP: Lateral recumbent; toe in true lateral
3.) Foreign Body Localization – AP & Lateral RP: IP joint (1st toe); proximal IP joint (2nd-4th toes)
CR: ┴
SS: Phalanges in profile; open IP joints spaces
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B.) SESAMOIDS AP OBLIQUE PROJECTION

Medial Rotation
LEWIS METHOD PP: Supine; knee flexed; leg rotated medially;
TANGENTIAL PROJECTION plantar surface of foot 30o to IR
PP: Prone; dorsiflex great toe; ankle elevated; ball RP: 3rd MTP base
of foot ┴ IR CR: ┴
RP: 1st MTP joint SS:
CR: Perpendicular  Cuboid
SS: MT head & sesamoids in profile  Interspaces on lateral side of foot
 Sinus tarsi
HOLLY METHOD  Lateral cuneiform
TANGENTIAL PROJECTION  3rd-5th MT bases
PP: Seated; plantar 75o to IR; toe flexed & hold w/  5th MT tuberosity
strip gauze bandage; foot medial border ┴ to IR Lateral Rotation
RP: 1st MTP head PP: Supine; knee flexed; leg rotated laterally;
CR: ┴ plantar surface of foot 30o to IR
SS: MT head & sesamoids in profile RP: 3rd MTP base
CR: ┴
CAUSTON METHOD SS:
TANGENTIAL PROJECTION  Navicular
PP: Lateral recumbent; patient lie against
 Interspaces on medial side of foot
unaffected side; limb partially extended; foot in
 Medial & intermediate cuneiform
lateral position; 1st MTP joint ┴ to IR
 1st-2nd MT bases
RP: Prominence of 1st MTP joint
CR: 40o toward the heel
LATERAL PROJECTION
SS: Sesamoids with slight overlap
Mediolateral
PP: Dorsiflex foot (┴ to lower leg); leg & foot in
C.) FOOT
lateral position; lateral side of foot against IR (more
comfortable)
AP/AP AXIAL PROJECTION
RP: 3rd MT base
PP: Supine; knee flexed; plantar surface against IR
CR: Perpendicular
RP: 3rd MTP base
SS: Entire foot in profile
CR: ┴ or 10o posteriorly
ER:
SS: MT & Tarsal (┴); TMT joint (10o)
 For localizing foreign body
ER:
 Degree of anterior & posterior displacement
 For localizing foreign bodies
of fx
 Location of fragments in fx of metatarsals &
Lateromedial
anterior tarsals
PP: LPO/RPO; medial surface against IR; plantar
 General surveys of the foot
o
surface of foot ┴ to IR
10 Angulation: reduces foreshortening of
RP: 3rd MTP base
metatarsals
CR: Perpendicular
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SS: True lateral projection of foot  Second Exposure: opposite foot step
backward (for hindfoot); tube behind
GRASHEY METHOD RP: 3 MTP base (1st exposure); level of lateral
rd

PA OBLIQUE PROJECTION malleolus (2nd exposure)

Medial and Lateral Rotation CR: 15o posteriorly (1st exposure); 25o anteriorly
PP: Prone; foot elevated; dorsal surface against IR; (2nd exposure)
heel rotated medially 30o (to demonstrate 1st and 2nd SS: Full outline of the foot
MT); heel rotated laterally 20o (to demonstrate
interspaces b/n 2nd-3rd, 3rd-4th & 4th-5th MT) D.) CONGENITAL CLUBFOOT
RP: 3rd MTP base
CR: Perpendicular KITE METHOD
SS: PA oblique projection of the bones of the foot AP PROJECTION
& interspaces at the proximal ends of metatarsal PP: Supine; hips & knees flexed; foot flat on IR;
ankles slightly extended; legs are vertical
WEIGHT-BEARING METHOD RP: Tarsals
LATERAL PROJECTION CR: 15o posteriorly
PP: Upright; feet elevated (use blocks); IR b/n feet; SS:
weight equally distributed on each foot  True relationship of bones & ossification
RP: Point above 3rd MTP base centers of tarsals
CR: Horizontal  Degree of forefoot adduction & calcaneus
SS: Status of longitudinal arch (pes planus); inversion
Bohler’s critical angle (b/n 20-40o); calcaneal 15 Angulation: places CR ┴ to tarsals
o

fracture (less than 20o)

Bohler’s Critical Angle: angle b/n superior apex of KITE METHOD
mid-calcaneus to anterior process of calcaneus LATERAL PROJECTION
Mediolateral
WEIGHT-BEARING METHOD PP: Lateral recumbent; uppermost limb flexed &
AP AXIAL PROJECTION draw forward
PP: Upright; both feet against IR; weight equally RP: Midtarsal area
distributed on each foot CR: Perpendicular
RP: b/n feet at 3rd MTP base level SS:
CR: 10o or 15o posteriorly  Anterior talar subluxation
SS: Accurate evaluation & comparison of MT &  Degree of plantar flexion (equinus)
tarsals
 Hallux valgus & lishfranc injury KANDEL METHOD
DORSOPLANTAR AXIAL PROJECTION
WEIGHT-BEARING COMPOSITE METHOD PP: Bending forward position; plantar surface
AP AXIAL PROJECTION against IR
PP: Upright; 2 exposures RP: Lower leg
 First Exposure: opposite foot step CR: 40o anteriorly
backward (for forefoot); tube in front SS: Calcaneus
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Freiberger-Hersh-Harrison: CR 35o, 45o & 55o SS: Calcaneal tuberosity

for demonstration of sustentaculum talar joint ER: Useful in diagnosing stress fractures of
calcaneus or tuberosity
E.) CALCANEUS
F.) SUBTALAR JOINT
AXIAL PROJECTION
Plantodorsal ISHERWOOD METHOD
PP: Supine/Seated; leg fully extended; dorsiflex LATEROMEDIAL OBLIQUE PROJECTION
foot w/ strip of gauze; foot ┴ to IR Medial Rotation Foot
RP: 3rd MT base PP: Semisupine; foot & leg rotated 45o medially;
CR: 40o cephalad knee flexed
SS: Calcaneus & subtalar joint RP: 1 in. distal & 1 in. anterior to lateral malleolus
Dorsoplantar CR: ┴
PP: Prone; ankle elevated; dorsiflex ankle; foot ┴ SS: Anterior subtalar articulation
to IR; IR vertical
RP: Dorsal surface of ankle joint ISHERWOOD METHOD
CR: 40o caudad AP AXIAL OBLIQUE PROJECTION
SS: Calcaneus, subtalar joint & sustentaculum tali Medial Rotation Ankle
PP: Seated or semi-lateral recumbent (more
LILIENFELD METHOD comfortable); leg, foot & ankle rotated 30o
WEIGHT-BEARING COALITION medially; dorsiflex foot
DORSOPLANTAR AXIAL PROJECTION RP: 1 in. distal & 1 in. anterior to lateral malleolus
PP: Upright; posterior surface of heel at edge of IR; CR: 10o cephalad
opposite foot one step forward SS: Middle subtalar articulation & “end on”
RP: Level of 5th MT base projection of sinus tarsi
CR: 45o anteriorly Lateral Rotation Ankle
SS: Calcaneotalar coalition PP: Supine/seated; leg, foot & ankle rotated 30o
laterally; dorsiflex foot
LATERAL PROJECTION RP: 1 in. distal medial malleolus
Mediolateral CR: 10o cephalad
PP: Supine; patient turn toward affected side; SS: Posterior subtalar articulation
plantar surface // to IR
RP: 1 in distal to medial malleolus BRODEN METHOD
CR: ┴ AP AXIAL OBLIQUE PROJECTION
SS: Calcaneus & ankle joint Medial Rotation
PP: Supine; leg & foot rotated 45o medially;
WEIGHT BEARING METHOD dorsiflex foot; foot rested against 45o foam wedge
LATEROMEDIAL OBLIQUE PROJECTION RP: 2-3 cm to lateral malleolus
PP: Upright; leg perpendicular to IR; calcaneus CR: 10o, 20o, 30oor 40o cephalad
center to IR SS: Posterior articulation
RP: Lateral malleolus  Anterior portion (40o)
CR: 45o caudad (medially)  Posterior portion (10o)
 LOWER EXTREMITIES

 Talus & sustentaculum tali articulation (20-

30o)
Lateral Rotation
PP: Supine; leg & foot rotated 45o laterally;
dorsiflex foot; foot rested against 45o foam wedge
RP: 2 cm distal & 2 cm anterior to medial malleolus
CR: 15o cephalad
SS: Posterior articulation
ER: To determine the presence of joint involvement
in cases of comminuted fx
 LOWER EXTREMITIES

G.) ANKLE CR: ┴ to ankle joint

SS: Superior aspect of calcaneus
AP PROJECTION ER: Useful in determining fxs
PP: Supine; leg & foot vertical & rotated 5o
medially (places malleoli equidistant) STRESS METHOD
RP: Point midway between malleoli AP PROJECTION
CR: ┴ to ankle joint PP: Seated; foot forcibly turned toward the opposite
SS: Ankle joint & tibiotalar joint space side; inversion & eversion stress to joint
RP: Ankle joint
LATERAL PROJECTION CR: ┴
Mediolateral ER: To evaluate the presence of ligamentous tear &
PP: Semisupine; lateral surface of foot against IR; joint separation
dorsiflex foot
RP: Medial malleolus WEIGHT-BEARING METHOD
CR: ┴ to ankle joint AP PROJECTION
SS: True lateral projection of lower third of tibia & PP: Upright; heels against the IR; IR vertical; toes
fibula, ankle joint & tarsals pointing toward the x-ray tube
 5th metatarsal base (identify Jones fx) RP: Midway at level of ankle joint
Lateromedial CR: Horizontal
PP: Semisupine; medial surface of foot against IR; ER: Identify ankle joint space narrowing; side-to-
dorsiflex foot side comparison of joint
RP: 0.5 in. superior to lateral malleolus
CR: ┴ to ankle joint H.) LEG
SS: Lateral projection of lower third of tibia &
fibula, ankle joint & tarsals AP PROJECTION
PP: Supine; femoral condyles // to IR; foot in
AP OBLIQUE PROJECTION vertical position;
Medial Rotation RP: Midshaft
PP: Supine; CR: ┴
 Leg & foot rotated 45o medially; dorsiflex SS: Tibia & fibula; ankle & knee joints
foot – to demonstrate bony structure
 Leg & foot rotated 15-20o medially; LATERAL PROJECTION
intermalleolar line // to IR – to demonstrate MEDIOLATERAL
mortise joint PP: Supine; RPO/LPO; patella ┴ to IR; femoral
RP: Point midway b/n malleoli condyles ┴ to IR;
CR: ┴ to ankle joint RP: Midshaft
SS: Distal ends of tibia, fibula & talus; tibiofubular CR: ┴
articulation; mortise joints SS: Tibia & fibula; ankle & knee joints
Lateral Rotation
PP: Supine; leg & foot rotated 45o laterally; AP OBLIQUE PROJECTION
dorsiflex foot PP: Supine; leg & foot rotated 45o medially or
RP: Point midway b/n malleoli laterally
 LOWER EXTREMITIES

RP: Midshaft  Perpendicular (19-24 cm)

CR: ┴  3-5ocephalad (>24 cm)
SS: Tibia & fibula; ankle & knee joints SS: Proximal tibiofibular joint; fibular head
Lateral Rotation
I.) KNEE PP: Supine; leg rotated 45o medially; hip of
unaffected side elevated
AP PROJECTION RP: 0.5 in inferior to patellar apex
PP: Supine; femoral epicondyles // to IR; leg 5o CR: 5o cephalad
inward (places interepicondylar line // to IR) SS: Tibial plateaus; medial femoral & tibial
RP: 0.5 in. inferior to patellar apex condyles
CR: depending on the measurement b/n ASIS &
table top WEIGHT-BEARING METHOD
 3-5ocaudad (<19 cm; thin pelvis) AP BILATERAL PROJECTION
 ┴ (19-24 cm) LEACH-GREGG-SIBER
 3-5ocephalad ( >24 cm; large pelvis) PP: Upright; knee fully extended; weight equally
SS: Knee joint space distributed on both feet; IR vertical
RP: 0.5 in. inferior to patellar apex
PA PROJECTION CR: Horizontal
PP: Prone; femoral epicondyles // to IR; leg 5o SS: Knee joint spaces
inward (places interepicondylar line // to IR) ER:
RP: 0.5 in. inferior to patellar apex  To reveal narrowing of knee joint space
CR: 5-7ocaudad  To evaluate varus & valgus deformities &
SS: Knee joint space degenerative joint disease

LATERAL PROJECTION ROSENBERG METHOD

Mediolateral
PP: Lateral recumbent; knee flexed 20-30o (relax
muscle & shows maximum volume of joint cavity)
or flexed <10o (for new or unhealed patellar fx);
femoral epicondyles ┴ to IR
RP: 1 in. distal to medial epicondyle
CR: 5-7o cephalad
SS: Knee joint space
PA WEIGHT-BEARING
STANDING FLEXION
PP: Upright; facing vertical IR; anterior surface of
flexed knee against IR; femur 45o to IR
RP: 0.5 in. inferior to patellar apex
CR: Horizontal or 10o caudad
ER: Useful for evaluating joint space narrowing &
demonstrating articular cartilage disease

AP OBLIQUE PROJECTION J.) INTERCONDYLAR FOSSA

Medial Rotation
PP: Supine; leg rotated 45o medially; hip of HOLMBLAD METHOD
affected side elevated PA AXIAL PROJECTION
RP: 0.5 in. inferior to patellar apex TUNNEL VIEW
CR: depending on the measurement b/n ASIS & PP: Anterior surface of knee against IR; knee 60-
table top 70o from IR (20o difference from CR)
 3-5ocaudad (<19 cm) 3 positions:
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 Standing; knee flexed & rested on a stool SS: Sharper image of patella (closer OID)
 Standing at side of table; knee flexed &
rested over the IR LATERAL PROJECTION
 Kneeling on table; knee over the IR PP: Lateral recumbent; unaffected knee & hip
(Holmblad Method) flexed; unaffected foot in front; affected knee flexed
RP: Popletial depression 5-10o or flexed not >10 (for new or unhealed
CR: ┴ patellar fx); femoral epicondyles & patella ┴ to IR;
SS: Intercondylar fossa RP: Midpatellofemoral joint
CR: ┴
CAMP-COVENTRY METHOD SS: Patella & patellofemoral joint space
PA AXIAL PROJECTION
PP: Prone; knee flexed 40-50o from IR; femur PA OBLIQUE PROJECTION
against IR; with support under foot Medial Rotation
RP: Popletial depression PP: Prone; knee flexed 5-10o; knee 45-55o medially
CR: 40o (knee flexed 40o) or 50o (knee flexed 50o) RP: Patella
caudally CR: ┴
SS: Intercondylar fossa SS: Medial portion of patella free of femur
ER: Lateral Rotation
 To detect loose bodies “joint mice PP: Prone; knee flexed 5-10o; knee 45-55o laterally
 To evaluate split & displaced cartilage in RP: Patella
osteochondritis CR: ┴
 To evaluate flattening or underdevelopment SS: Lateral portion of patella free of femur
of lateral femoral condyles in congenital
slipped patella KUCHENDORF METHOD
PA AXIAL OBLIQUE PROJECTION
BECLERE METHOD Lateral Rotation
AP AXIAL PROJECTION PP: Prone; hip elevated 2-3 in.; knee flexed 10o
PP: Supine; knee flexed; femur 60o to long axis of (relax the muscles); knee rotated 35-40o laterally
tibia; curved cassette is used RP: Joint space b/n patella & femoral condyles
RP: 0.5 in. inferior to patellar apex CR: 25-30ocaudad
CR: ┴ to long axis of lower leg SS: Oblique patella free superimposition of femur
SS: Intercondylar fossa, intercondylar eminence,
knee joint & tibial plateau HUGHSTON METHOD
TANGENTIAL PROJECTION
K.) PATELLA PP: Prone; anterior surface of knee against IR; knee
flexed 50-60o; foot rested against collimator/support
PA PROJECTION RP: Patellofemoral joint
PP: Prone; heel 5-10o laterally (places CR: 45o cephalad
patella // to IR) SS: Patella; patellofemoral joint
RP: Midpopliteal depression ER:
CR: Perpendicular  To demonstrate subluxation of patella &
patellar fx
 LOWER EXTREMITIES

 It allows assessment of femoral condyles L.) FEMUR

AP PROJECTION
MERCHANT METHOD
PP: Supine
TANGENTIAL PROJECTION
PP: Supine; both knee flexed 40o or b/n 30-90o (to  Distal femur (knee included): leg rotated
demonstrate various patellar disorders); IR resting 5o inward ( places limb in true anatomic
on patient’s shins; uses IR holding device & axial position)
viewer device  Proximal femur (hip included): leg
RP: Midway b/n patellae at level of patellofemoral rotated 10-15o inward (places femoral neck
joint in profile)
CR: 30o caudad from horizontal RP: Midfemur
SS: Femoral condyle; intercondylar sulcus & CR: ┴
magnified nondistorted patellae SS: Femoral neck & hip joint (10-15o); knee joint
(5o)
SETTEGAST METHOD
LATERAL PROJECTION
TANGENTIAL PROJECTION
Mediolateral
Disadvantage: Extreme flexion
PP: Lateral recumbent; affected side against IR
PP: Supine or prone (preferable); knee acutely
 Distal femur (knee included): unaffected
flexed until patella ┴ to IR; loop bandage around
limb draw forward; pelvis in true lateral
ankle or foot to hold the leg in position
position; affected knee flexed 45o; femoral
RP: Joint space b/n patella & femoral condyles
epicondyles ┴ to IR;
CR: Perpendicular (if joint is ┴); 15-20o cephalad
 Proximal femur (hip included):
(if joint isn’t ┴)
unaffected limb draw posteriorly; pelvis
 Angulation depends on knee flexion
rolled 10-15o posteriorly
SS: Patella; patellofemoral joint
RP: Midfemur
ER:
CR: ┴
 Useful for demonstrating vertical &
SS: ¾ of femur & adjacent joints
transverse fx of patella
 Useful for investigating articulating surfaces TRANSLATERAL PROJECTION
of patellofemoral articulation CROSSTABLE LATERAL
PP: Dorsal decubitus; IR placed vertically against
SUNRISE METHOD medial/lateral surface of femur;
TANGENTIAL PROJECTION RP: Medial side of midfemur
MOUNTAIN/SKYLINE VIEW CR: Horizontal
PP: Supine/Sitting; knee flexed 40-45o SS: Entire femur & knee joint
RP: Patellofemoral joint ER: For patient who can’t tolerate routine lateral
CR: 30o from horizontal position because of fractures or destructive disease
ER: Joint space b/n patella & femoral condyles
 THE END 
“BOARD EXAM is a matter of PREPARATION. If
you FAIL to prepare, you PREPARE to fail”
03/24/14