MERRILL’S ATLAS OF

RADIOGRAPHIC
POSITIONING
& PROCEDURES
This page intentionally left blank
THIRTEENTH EDITION VOLUME TWO

MERRILL’S ATLAS OF

RADIOGRAPHIC
POSITIONING
& PROCEDURES
Bruce W. Long, MS, RT(R)(CV), FASRT, FAEIRS
Director and Associate Professor
Radiologic Imaging and Sciences Programs
Indiana University School of Medicine
Indianapolis, Indiana

Jeannean Hall Rollins, MRC, BSRT(R)(CV)

Associate Professor
Medical Imaging and Radiation Sciences Department
Arkansas State University
Jonesboro, Arkansas

Barbara J. Smith, MS, RT(R)(QM), FASRT, FAEIRS

Instructor, Radiologic Technology
Medical Imaging Department
Portland Community College
Portland, Oregon
3251 Riverport Lane
St. Louis, Missouri 63043

MERRILL’S ATLAS OF RADIOGRAPHIC POSITIONING ISBN: 978-0-323-26342-9 (vol 1)

& PROCEDURES, THIRTEENTH EDITION ISBN: 978-0-323-26343-6 (vol 2)
ISBN: 978-0-323-26344-3 (vol 3)
ISBN: 978-0-323-26341-2 (set)
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 PREVIOUS AUTHORS
Vinita Merrill
1905-1977
Vinita Merrill was born in Oklahoma in
1905 and died in New York City in 1977.
Vinita began compilation of Merrill’s in
1936, while she worked as Technical
Director and Chief Technologist in the
Department of Radiology, and Instructor
in the School of Radiography at the New
York Hospital. In 1949, while employed
as Director of the Educational Department
of Picker X-ray Corporation, she wrote
the first edition of the Atlas of Roentgeno-
graphic Positions. She completed three
more editions from 1959 to 1975. Sixty-
six years later, Vinita’s work lives on in
the thirteenth edition of Merrill’s Atlas of
Radiographic Positioning & Procedures.
Philip W. Ballinger, PhD, RT(R),
FASRT, FAEIRS, became the author of
Merrill’s Atlas in its fifth edition, which
published in 1982. He served as author
through the tenth edition, helping to launch
successful careers for thousands of stu-
dents who have learned radiographic po-
sitioning from Merrill’s. Phil currently
serves as Professor Emeritus in the Radio-
logic Sciences and Therapy, Division of
the School of Health and Rehabilitation
Sciences, at The Ohio State University. In
1995, he retired after a 25-year career as
Radiography Program Director and, after
ably guiding Merrill’s Atlas through six
editions, he retired as Merrill’s author.
Phil continues to be involved in profes-
sional activities, such as speaking engage-
ments at state, national, and international
meetings.
Eugene D. Frank, MA, RT(R), FASRT,
FAEIRS, began working with Phil
Ballinger on the eighth edition of Merrill’s
Atlas in 1995. He became the coauthor in
its ninth and 50th-anniversary edition,
published in 1999. He served as lead
author for the eleventh and twelfth edi-
tions and mentored three coauthors. Gene
retired from the Mayo Clinic/Foundation
in Rochester, Minnesota, in 2001, after 31
years of employment. He was Associate
Professor of Radiology in the College of
Medicine and Director of the Radiography
Program. He also served as Director of
the Radiography Program at Riverland
Community College, Austin, Minnesota,
for 6 years before fully retiring in 2007.
He is a Fellow of the ASRT and AEIRS.
In addition to Merrill’s, he is the coauthor
of two radiography textbooks, Quality
Control in Diagnostic Imaging and Radi-
ography Essentials for Limited Practice.
He now works in hospice through Chris-
tian Hospice Care and helps design and
equip x-ray departments in underdevel-
oped countries.
v
 THE MERRILL’S TEAM
Bruce W. Long, MS, RT(R)(CV), FASRT,
FAEIRS, is Director and Associate Profes-
sor of the Indiana University Radiologic
and Imaging Sciences Programs, where he
has taught for 29 years. A Life Member of
the Indiana Society of Radiologic Tech-
nologists, he frequently presents at state
and national professional meetings. His
publication activities include 28 articles in
national professional journals and two
books, Orthopaedic Radiography and Radiography Essentials
for Limited Practice, in addition to being coauthor of the Atlas.
The thirteenth edition is Bruce’s third on the Merrill’s team and
first as lead author.
Jeannean Hall Rollins, MRC, BSRT(R)
(CV), is an Associate Professor in the
Medical Imaging and Radiation Sciences
department at Arkansas State University,
where she has taught for 22 years. She is
involved in the imaging profession at local,
state, and national levels. Her publication
activities include articles, book reviews,
and chapter contributions. Jeannean’s first
contribution to Merrill’s Atlas was on the
tenth edition as coauthor of the trauma radiography chapter. The
thirteenth edition is Jeannean’s third on the Merrill’s team and
first as a coauthor. Her previous role was writing the workbook,
Mosby’s Radiography Online, and the Instructor Resources that
accompany Merrill’s Atlas.
vi
Barbara J. Smith, MS, RT(R)(QM),
FASRT, FAEIRS, is an instructor in the
Radiologic Technology program at Port-
land Community College, where she has
taught for 30 years. The Oregon Society of
Radiologic Technologists inducted her as a
Life Member in 2003. She presents at state,
regional, national, and international meet-
ings, is a trustee with the ARRT, and is
involved in professional activities at these
levels. Her publication activities include articles, book reviews,
and chapter contributions. As coauthor, her primary role on the
Merrill’s team is working with the contributing authors and
editing Volume 3. The thirteenth edition is Barb’s third on the
Merrill’s team.
Tammy Curtis, PhD, RT(R)(CT)(CHES),
is an associate professor at Northwestern
State University, where she has taught for
14 years. She presents on state, regional,
and national levels and is involved in pro-
fessional activities on state level. Her pub-
lication activities include articles, book
reviews, and book contributions. Previ-
ously, Tammy served on the advisory board
and contributed the updated photo for
Vinita Merrill, as well as other projects submitted to the Atlas.
Her primary role on the Merrill’s team is writing the workbook.
The thirteenth edition is Tammy’s first on the Merrill’s team.
 ADVISORY BOARD

This edition of Merrill’s Atlas benefits from the expertise of a special advisory board. The following board members have provided
professional input and advice and have helped the authors make decisions about Atlas content throughout the preparation of the
thirteenth edition:

Andrea J. Cornuelle, MS, RT(R) Joe A. Garza, MS, RT(R)

Professor, Radiologic Technology Associate Professor, Radiography Program
Director, Health Science Program Lone Star College—Montgomery
Northern Kentucky University Conroe, Texas
Highland Heights, Kentucky

Patricia J. (Finocchiaro) Duffy, MPS, Parsha Y. Hobson, MPA, RT(R)

RT(R)(CT) Associate Professor, Radiography
Clinical Education Coordinator/Assistant Passaic County Community College
Professor Paterson, New Jersey
Medical Imaging Sciences Department
College of Health Professions
SUNY Upstate Medical University
Syracuse, New York

Lynn M. Foss, RT(R), ACR, DipEd, BHS Robin J. Jones, MS, RT(R)
Instructor, Saint John School of Radiological Associate Professor and Clinical Coordinator
Technology Radiologic Sciences Program
Horizon Health Network Indiana University Northwest
Saint John, New Brunswick, Canada Gary, Indiana

vii
 CHAPTER CONTENT EXPERTS
Valerie F. Andolina, RT(R)(M)
Senior Technologist
Elizabeth Wende Breast Care, LLC
Rochester, New York
Dennis Bowman, AS, RT(R)
Clinical Instructor
Community Hospital of the Monterey
Peninsula
Monterey, California
Terri Bruckner, PhD, RT(R)(CV)
Instructor and Clinical Coordinator,
Retired
Radiologic Sciences and Therapy
Division
The Ohio State University
Columbus, Ohio
Leila A. Bussman-Yeakel, MEd,
RT(R)(T)
Director, Radiation Therapy Program
Mayo School of Health Sciences
Mayo Clinic College of Medicine
Rochester, Minnesota
Derek Carver, MEd, RT(R)(MR)
Clinical Instructor
Manager of Education and Training
Department of Radiology
Boston Children’s Hospital
Boston, Massachusetts
Kim Chandler, MEdL, CNMT, PET
Program Director
Nuclear Medicine Technology Program
Mayo School of Health Sciences
Rochester, Minnesota
Cheryl DuBose, EdD, RT(R)(MR)
(CT)(QM)
Assistant Professor
Program Director, MRI Program
Department of Medical Imaging and
Radiation Sciences
Arkansas State University
Jonesboro, Arkansas
viii
Angela M. Franceschi, MEd,
CCLS
Certified Child Life Specialist
Department of Radiology
Boston Children’s Hospital
Boston, Massachusetts
Joe A. Garza, MS, RT(R)
Professor, Radiologic Science
Lone Star College—Montgomery
Conroe, Texas
Nancy Johnson, MEd, RT(R)(CV)
(CT)(QM)
Faculty Diagnostic Medical Imaging
GateWay Community College
Phoenix, Arizona
Sara A. Kaderlik, RT(R)(VI), RCIS,
CEPS
Special Procedures Radiographer
St. Charles Medical Center
Bend, Oregon
Lois J. Layne, MSHA, RT(R)(CV)
Covenant Health
Centralized Privacy
Knoxville, Tennessee
Cheryl Morgan-Duncan, MAS,
RT(R)(M)
Radiographer Lab Coordinator/Adjunct
Instructor
Passaic County Community College
Paterson, New Jersey
Susanna L. Ovel, RT(R), RDMS, RVT
Sonographer, Clinical Instructor
Sutter Medical Foundation
Sacramento, California
Paula Pate-Schloder, MS, RT(R)
(CV)(CT)(VI)
Associate Professor, Medical Imaging
Department
Misericordia University
Dallas, Pennsylvania
Bartram J. Pierce, BS, RT(R)(MR),
FASRT
MRI Supervisor
Good Samaritan Regional Medical
Center
Corvallis, Oregon
Jessica L. Saunders, RT(R)(M)
Technologist
Elizabeth Wende Breast Care, LLC
Rochester, New York
Sandra Sellner-Wee, MS,
RT(R)(M)
Program Director, Radiography
Riverland Community College
Austin, Minnesota
Raymond Thies, BS, RT(R)
Department of Radiology
Boston Children’s Hospital
Boston, Massachusetts
Jerry G. Tyree, MS, RT(R)
Program Coordinator
Columbus State Community College
Columbus, Ohio
Sharon R. Wartenbee, RT(R)(BD),
CBDT, FASRT
Senior Diagnostic and Bone
Densitometry Technologist
Avera Medical Group McGreevy
Sioux Falls, South Dakota
Kari J. Wetterlin, MA, RT(R)
Lead Technologist, General and
Surgical Radiology
Mayo Clinic/Foundation
Rochester, Minnesota
Gayle K. Wright, BS, RT(R)(MR)(CT)
Instructor, Radiography Program
CT & MRI Program Coordinator
Medical Imaging Department
Portland Community College
Portland, Oregon

Welcome to the thirteenth edition of
Merrill’s Atlas of Radiographic Position-
ing & Procedures. This edition continues
the tradition of excellence begun in 1949,
when Vinita Merrill wrote the first edition
of what has become a classic text. Over
the past 66 years, Merrill’s Atlas has pro-
vided a strong foundation in anatomy and
positioning for thousands of students
around the world who have gone on to
successful careers as imaging technolo-
gists. Merrill’s Atlas is also a mainstay for
everyday reference in imaging depart-
ments all over the world. As the coauthors
of the thirteenth edition, we are honored
to follow in Vinita Merrill’s footsteps.
Learning and Perfecting
Positioning Skills
Merrill’s Atlas has an established tradition
of helping students learn and perfect their
positioning skills. After covering prelimi-
nary steps in radiography, radiation pro-
tection, and terminology in introductory
chapters, the first two volumes of Merrill’s
teach anatomy and positioning in separate
chapters for each bone group or organ
system. The student learns to position the
patient properly so that the resulting
radiograph provides the information the
physician needs to correctly diagnose
the patient’s problem. The atlas presents
this information for commonly requested
projections, as well as for those less
commonly requested, making it the only
reference of its kind in the world.
The third volume of the atlas provides
basic information about a variety of spe-
cial imaging modalities, such as mobile
and surgical imaging, pediatrics, geriat-
rics, computed tomography (CT), vascular
radiology, magnetic resonance imaging
(MRI), sonography, nuclear medicine
technology, bone densitometry, and radia-
tion therapy.
PREFACE
Merrill’s Atlas is not only a compre-
hensive resource to help students learn,
but also an indispensable reference as
they move into the clinical environment
and ultimately into practice as imaging
professionals.
New to This Edition
Since the first edition of Merrill’s Atlas in
1949, many changes have occurred. This
new edition incorporates many significant
changes designed not only to reflect the
technologic progress and advancements
in the profession, but also to meet the
needs of today’s radiography students. The
major changes in this edition are high-
lighted as follows.
NEW PATIENT PHOTOGRAPHY
All patient positioning photographs have
been replaced in Chapters 4 and 8. The
new photographs show positioning detail
to a greater extent and in some cases from
a more realistic perspective. In addition,
the equipment in these photos is the most
modern available, and computed radiogra-
phy plates are used. The use of electronic
central ray angles enables a better under-
standing of where the central ray should
enter the patient.
REVISED IMAGE EVALUATION
CRITERIA
All image evaluation criteria have been
revised and reorganized to improve the
student’s ability to learn what constitutes
a quality image. In addition, the criteria
are presented in a way that improves the
ability to correct positioning errors.
WORKING WITH THE OBESE
PATIENT
Many in the profession, especially stu-
dents, requested that we include material
on how to work with obese and morbidly
obese patients. Joe Garza, of our advisory
board, assisted in the creation of this new
section. For this edition, new information
and illustrations have been added related
to equipment, transportation, communica-
tion, and technical considerations specific
to this patient population. This was accom-
plished with input from a wide variety of
educators and practitioners with expertise
working with obese patients.
FULLY REVISED PEDIATRIC
CHAPTER
The pediatric chapter has been completely
reorganized, with new photos, images,
and illustrations. Time-tested techniques
and current technologies are covered.
New material has been added addressing
the needs of patients with autism spectrum
disorders.
UPDATED GERIATRIC CHAPTER
To meet the need of imaging professionals
to provide quality care for all elderly
patients, material has been added, address-
ing elder abuse and Alzheimer’s disease.
Imaging aspects, in addition to patient
care challenges, are included.
CONSOLIDATED CRANIAL
CHAPTERS
The chapters on the skull, facial bones,
and paranasal sinuses have been com-
bined. This facilitates learning by placing
the introductory and anatomy material
closer to the positioning details for the
facial bones and sinuses.
DIGITAL RADIOGRAPHY
COLLIMATION
With the expanding use of digital radiog-
raphy (DR) and the decline in the use of
cassettes in Bucky mechanisms, concern
was raised regarding the collimation sizes
for the various projections. Because col-
limation is considered one of the critical
aspects of obtaining an optimal image,
especially with computed radiography
ix
 (CR) and DR, this edition contains the
specific collimation sizes that students
and radiographers should use when using
manual collimation with DR in-room and
DR mobile systems. The correct collima-
tion size for projections is now included
as a separate heading.
ENGLISH/METRIC IR SIZES
English and metric sizes for image recep-
tors (IRs) continue to challenge radiogra-
phers and authors in the absence of a
standardized national system. With film/
screen technology, the trend was toward
the use of metric measurements for most
of the cassette sizes. However, with CR
and DR, the trend has moved back toward
English sizes. Most of the DR x-ray
systems use English for collimator set-
tings. Because of this trend, the IR sizes
and collimation settings for all projections
are stated in English, and the metric
equivalents are provided in parentheses.
INTEGRATION OF CT AND MRI
In the past three editions, both CT and MRI
images have been included in the anatomy
and projection pages. This edition continues
the practice of having students learn cross-
section anatomy with regular anatomy.
NEW ILLUSTRATIONS
Many who use Merrill’s in teaching and
learning have stated that the line art is one
of the most useful aspects in learning new
projections. New illustrations have been
added to this edition to enable the user to
comprehend bone position, central ray
(CR) direction, and body angulations.
DIGITAL RADIOGRAPHY UPDATED
Because of the rapid expansion and accep-
tance of CR and direct DR, either selected
positioning considerations and modifica-
tions or special instructions are indicated
where necessary. A special icon alerts the
reader to digital notes. The icon is shown
here:
COMPUTED RADIOGRAPHY
OBSOLETE PROJECTIONS DELETED
Projections identified as obsolete by the
authors and the advisory board continue
to be deleted. A summary is provided at
the beginning of any chapter containing
deleted projections so that the reader
may refer to previous editions for infor-
mation. Continued advances in CT,
x
MRI, and ultrasound have prompted these
deletions. The projections that have been
removed appear on the Evolve site at
evolve.elsevier.com.
NEW RADIOGRAPHS
Nearly every chapter contains updated,
optimum radiographs, including many that
demonstrate pathology. With the addition
of updated radiographic images, the thir-
teenth edition has the most comprehen­
sive collection of high-quality radiographs
available to students and practitioners.
Learning Aids for
the Student
POCKET GUIDE TO
RADIOGRAPHY
The new edition of Merrill’s Pocket Guide
to Radiography complements the revision
of Merrill’s Atlas. Instructions for posi-
tioning the patient and the body part for
all the essential projections are presented
in a complete yet concise manner. Tabs are
included to help the user locate the begin-
ning of each section. Space is provided for
the user to write in specifics of department
techniques.
RADIOGRAPHIC ANATOMY,
POSITIONING, AND PROCEDURES
WORKBOOK
The new edition of this workbook features
extensive review and self-assessment exer-
cises that cover the first 29 chapters in
Merrill’s Atlas in one convenient volume.
The features of the previous editions, in-
cluding anatomy labeling exercises, posi-
tioning exercises, and self-tests, are still
available. However, this edition features
more image evaluations to give students
additional opportunities to evaluate radio-
graphs for proper positioning and more
positioning questions to complement the
workbook’s strong anatomy review. The
comprehensive multiple-choice tests at
the end of each chapter help students assess
their comprehension of the whole chapter.
New exercises in this edition focus on im-
proved understanding of essential projec-
tions and the need for appropriate collimated
field sizes for digital imaging. Additionally,
review and assessment exercises in this
edition have been expanded for the chap-
ters on pediatrics, geriatrics, vascular and
interventional radiography, sectional anat-
omy, and computed tomography in Volume
3. Exercises in these chapters help students
learn the theory and concepts of these spe-
cial techniques with greater ease. Answers
to the workbook questions are found on the
Evolve website.
Teaching Aids for
the Instructor
EVOLVE INSTRUCTOR
ELECTRONIC RESOURCES
This comprehensive resource provides
valuable tools, such as lesson plans,
PowerPoint slides, and an electronic test
bank for teaching an anatomy and posi-
tioning class. The test bank includes more
than 1,500 questions, each coded by cat-
egory and level of difficulty. Four exams
are already compiled in the test bank to be
used “as is” at the instructor’s discretion.
The instructor also has the option of
building new tests as often as desired by
pulling questions from the ExamView
pool or using a combination of questions
from the test bank and questions that the
instructor adds.
Evolve may be used to publish the class
syllabus, outlines, and lecture notes; set
up “virtual office hours” and e-mail com-
munication; share important dates and
information through the online class Cal-
endar; and encourage student participation
through Chat Rooms and Discussion
Boards. Evolve allows instructors to post
exams and manage their grade books
online. For more information, visit www.
evolve.elsevier.com or contact an Elsevier
sales representative.
MOSBY’S RADIOGRAPHY ONLINE
Mosby’s Radiography Online: Merrill’s
Atlas of Radiographic Positioning & Pro-
cedures is a well-developed online course
companion for the textbook and work-
book. This online course includes anima-
tions with narrated interactive activities
and exercises, in addition to multiple-
choice assessments that can be tailored to
meet the learning objectives of your
program or course. The addition of this
online course to your teaching resources
offers greater learning opportunities while
accommodating diverse learning styles
and circumstances. This unique program
promotes problem-based learning with the
goal of developing critical thinking skills
that will be needed in the clinical setting.
EVOLVE—ONLINE COURSE
MANAGEMENT
Evolve is an interactive learning environ-
ment designed to work in coordination with
Merrill’s Atlas. Instructors may use Evolve
to provide an Internet-based course compo-
nent that reinforces and expands on the
concepts delivered in class.
We hope you will find this edition of
Merrill’s Atlas of Radiographic Position-
ing &Procedures the best ever. Input from
generations of readers has helped to keep still so appreciated and valued by the
the atlas strong through 10 editions, and imaging sciences community.
we welcome your comments and sugges-
tions. We are constantly striving to build Bruce W. Long
on Vinita Merrill’s work, and we trust that Jeannean Hall Rollins
she would be proud and pleased to know Barbara J. Smith
that the work she began 66 years ago is Tammy Curtis
xi
 ACKNOWLEDGMENTS
In preparing for the thirteenth edition, our
advisory board continually provided pro-
fessional expertise and aid in decision
making on the revision of this edition.
The advisory board members are listed
on p. vii. We are most grateful for their
input and contributions to this edition
of the Atlas.
Scott Slinkard, a radiography student
from the College of Nursing and Health
Sciences in Cape Girardeau, Missouri,
and a professional photographer, provided
many of the new photographs seen
throughout the Atlas.
Contributors
The group of radiography professionals
listed below contributed to this edition of
the Atlas and made many insightful sug-
gestions. We are most appreciative of their
willingness to lend their expertise.
Special recognition and appreciation to
the imaging staff of St. Vincent Hospital,
Carmel, Indiana, for sharing their exten-
sive experience and expertise in imaging
obese and morbidly obese patients, as a
Bariatric Center of Excellence. We espe-
cially thank Carolyn McCutcheon, RT(R),
director of Medical Imaging; Todd Judy,
BS, RT(R), team leader of Medical
Imaging; and Lindsay Black, BS, RT(R),
clinical instructor. Thanks also to Mark
xii
Adkins, MSEd, RT(R)(QM), Radiography
Program director, for his assistance.
Special recognition and appreciation to
the imaging professionals at NEA Baptist
Hospital and St. Bernard’s Medical
Center in Jonesboro, Arkansas. The time,
expertise, and efforts of Gena Morris,
RT(R), RDMS, PACS administrator, and
Loisey Wortham, RT(R), at NEA Baptist
Hospital, and also to Mitzi Pierce,
MSHS, RT(R)(M), radiology educator at
St. Bernard’s Medical Center, have been
essential to this revision.
Suzie Crago, AS, RT(R)
Senior Staff Technologist
Riley Hospital for Children
Indianapolis, Indiana
Dan Ferlic, RT(R)
Ferlic Filters
White Bear Lake, Minnesota
Susan Herron, AS, RT(R)
Ezkenazi Health
Indianapolis, Indiana
Joy Menser, MSM, RT(R)(T)
Radiography Program Director
Owensboro Community & Technical
College
Owensboro, Kentucky
Michael Mial
Student Radiographer
Indiana University Radiography Program
Indianapolis, Indiana
(Patient model for Chapter 8)
Kate Richmond, BS, RT(R)
Radiographer
Indianapolis, Indiana
(Patient model for Chapter 4)
Susan Robinson, MS, RT(R)
Associate Professor of Clinical
Radiologic and Imaging Sciences
Clinical Instructor at Riley Hospital
for Children
Indiana University School of Medicine
Indianapolis, Indiana
Andrew Woodward MA,
RT(R)(CT)(QM)
Assistant Professor and Clinical
Coordinator
University of North Carolina at
Chapel Hill
Chapel Hill, North Carolina

1 Preliminary Steps in
Radiography, 1
2 Compensating Filters, 53
3 General Anatomy and
Radiographic Positioning
Terminology, 65
11 Long Bone Measurement, 1
12 Contrast Arthrography, 7
13 Trauma Radiography, 17
Joe A. Garza
14 Mouth and Salivary
Glands, 57
15 Anterior Part of Neck, 69
22 Central Nervous System, 1
Paula Pate-Schloder
23 Vascular, Cardiac,
and Interventional
Radiography, 19
Sara A. Kaderlik and
Lois J. Layne
24 Pediatric Imaging, 99
Derek Carver,
Angela Franceschi, and
Raymond Thies
25 Geriatric Radiography, 161
Sandra J. Sellner-Wee and
Cheryl Morgan-Duncan
CONTENTS
VOLUME ONE
4 Upper Limb, 99 9 Bony Thorax, 445
5 Shoulder Girdle, 173 10 Thoracic Viscera, 477
6 Lower Limb, 225 Addendum A
7 Pelvis and Proximal Summary of Abbreviations, 521
Femora, 325
8 Vertebral Column, 363
VOLUME TWO
16 Abdomen, 81 21 Mammography, 369
17 Digestive System: Alimentary Valerie F. Andolina and
Canal, 95 Jessica L. Saunders
18 Urinary System and Addendum B
Venipuncture, 181 Summary of Abbreviations, 475
19 Reproductive System, 237
20 Skull, Facial Bones, and
Paranasal Sinuses, 255
VOLUME THREE
26 Mobile Radiography, 183 31 Diagnostic Ultrasound, 369
Kari J. Wetterlin Susanna L. Ovel
27 Surgical Radiography, 213 32 Nuclear Medicine, 399
Kari J. Wetterlin Kim Chandler
28 Sectional Anatomy for 33 Bone Densitometry, 441
Radiographers, 251 Sharon R. Wartenbee
Terri Bruckner 34 Radiation Oncology, 479
29 Computed Tomography, 301 Leila A. Bussman-Yeakel
Gayle K. Wright and
Nancy M. Johnson
30 Magnetic Resonance
Imaging, 341
Bartram J. Pierce and
Cheryl DuBose
xiii
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 11 
LONG BONE MEASUREMENT

OUTLINE
Imaging Methods, 2
Abbreviations, 2
Radiation Protection, 2
Position of Patient, 2
Position of Part, 2
Localization of Joints, 2
Computed Tomography
Technique, 6

1
 Imaging Methods
Long Bone Measurement
Long bone measurement to evaluate for
limb length discrepancy may be accom-
plished by radiography, microdose digital
radiography, ultrasonography (US), com-
puted tomography (CT), and magnetic
resonance imaging (MRI).1 Radiographic
methods are the orthoroentgenogram,
scanogram, and teleoroentgenogram. Both
the orthoroentgenogram and the scano-
gram require three precisely centered
exposures at the hip, knee, and ankle
joints and include the use of a radiopaque
ruler taped to the table between the limbs.
The image receptor (IR) size is the primary
difference, with the orthoroentgenogram
using a single IR that remains stationary
while the table and the x-ray tube move to
an unexposed section. The scanogram
technique uses three separate IRs. The
teleoroentgenogram is a single upright AP
exposure of both limbs on a special long
IR at an SID of at least 6 ft (180 cm).
Digital imaging usually employs a hybrid
of these traditional techniques by obtain-
ing the three exposures centered at the hip,
knee, and ankle joints with the patient
standing upright. Digital postprocessing
“stitches” the three images together for
equally accurate measurements of the
entire lower limbs with lower radiation
dose than is used in the film-screen
methods.1,2 Although studies are occasion-
ally made of the upper limbs, radiography
is most frequently applied to the lower
limbs. This chapter explains patient posi-
tioning for the three joint exposures, as
well as for CT scanograms.
ABBREVIATIONS USED IN
CHAPTER 11
AP Anteroposterior
CT Computed tomography
IR Image receptor
MRI Magnetic resonance imaging
US Ultrasonography
See Addendum B for a summary of all
abbreviations used in Volume 2.
1
Sabharwal S, Kumar A: Methods for assessing leg
length discrepancy, Clin Orthop Relat Res 466:12,
2008.
2 3
Khakharia S et al: Comparison of PACS and hard-
copy 51-inch radiographs for measuring leg length
and deformity, Clin Orthop Relat Res 469:244, 2011.
2
Radiation Protection
Differences in limb length are common in
children and may occur in association
with various disorders. Patients with
unequal limb growth may require yearly
imaging evaluations. More frequent
examinations may be necessary in patients
who have undergone surgical procedures
to equalize limb length. For these reasons,
radiation protection is a primary consider-
ation in imaging for long bone measure-
ment. Gonad shielding is necessary, as are
careful patient positioning, secure immo-
bilization, and accurate centering of a
closely collimated beam of radiation to
prevent unnecessary repeat exposures.
Microdose digital radiography yields the
lowest dose but requires specialized
equipment, which can be cost-prohibitive.
MRI and US have promise as means
to safely image for long bone measure-
ment, with recent research demonstrating
99% accuracy and reliability for MRI
measurements.1,3
Position of Patient
Three exposures of each limb are made,
with the accuracy of the examination
depending on the patient not moving the
limb or limbs even slightly. Small children
must be carefully immobilized to prevent
motion. If movement of the limb occurs
before the examination is completed, all
images may need to be repeated.
• Place the patient in the supine
position for orthoroentgenography and
scanography.
• Stand the patient upright backed up
closely to the vertical Bucky device for
a digital teleoroentgenogram.
• Both sides are examined for compari-
son either separately or simultaneously
for all techniques.
• When a soft tissue abnormality (swell-
ing or atrophy) is causing rotation of the
pelvis, elevate the low side on a radio-
lucent support to overcome the rotation,
if necessary.
Position of Part
The limb to be examined should be posi-
tioned as follows:
Doyle A, Winsor S: Magnetic resonance imaging
(MRI) lower limb length measurement, J Med
Imaging Radiat Oncol 55:191, 2011.
• Adjust and immobilize the limb for an
AP projection.
• If the two lower limbs are examined
simultaneously, separate the ankles 5 to
6 inches (13 to 15 cm) and place the
specialized ruler under the pelvis and
extended down between the legs.
• If the limbs are examined separately,
position the patient with a special ruler
beneath each limb.
• When the knee of the patient’s abnor-
mal side cannot be fully extended, flex
the normal knee to the same degree and
support each knee on one of a pair of
supports of identical size to ensure that
the joints are flexed to the same degree
and are equidistant from the image
receptor (IR).
Localization of Joints
For methods that require centering of the
central ray above the joints, the following
steps should be taken:
• Localize each joint accurately, and use
a skin-marking pencil to indicate the
central ray centering point.
• Because both sides are examined for
comparison and a discrepancy in bone
length usually exists, mark the joints of
each side after the patient is in the
required position.
• With the upper limb, place the marks as
follows: for the shoulder joint, over the
superior margin of the head of the
humerus; for the elbow joint, 1 2 to 3 4
inch (1.3 to 1.9 cm) below the plane of
the epicondyles of the humerus (depend-
ing on the size of the patient); and for
the wrist, midway between the styloid
processes of the radius and ulna.
• With the lower limb, locate the hip joint
by placing a mark 1 to 1 1 4 inches (2.5
to 3.2 cm) (depending on the size of the
patient) laterodistally and at a right
angle to the midpoint of an imaginary
line extending from the anterior supe-
rior iliac spine to the pubic symphysis.
• Locate the knee joint just below the
apex of the patella at the level of the
depression between the femoral and
tibial condyles.
• Locate the ankle joint directly below
the depression midway between the
malleoli.
In all images made by a single x-ray
exposure, the image is larger than the
actual body part because the x-ray photons
start at a small area on the target of the
x-ray tube and diverge as they travel in
straight lines through the body to the IR

Localization of Joints
(Fig. 11-1). This magnification can be
decreased by putting the body part as
close to the IR as possible and using the
maximum SID allowed by the equipment.
For orthoroentgenography, a metal mea-
surement ruler is placed between the
patient’s lower limbs, and three exposures
are made on the same x-ray IR. The fol-
lowing steps are taken:
• Using narrow collimation and careful
centering of limb parts to the upper,
middle, and lower thirds of the IR,
make three exposures on one IR.
• For all three exposures, place the
central ray perpendicular to and passing
directly through the specified joint
(hence the term orthoroentgenology,
from the Greek word orthos, meaning E
“straight”).
• Do not move the limb between expo- Fig. 11-1  Conventional radiographic images are magnified
sures. Because the IR is in the Bucky (elongated) images. Proximal elongation in this example is equal
tray for all exposures including expo- to the distance (E ). Similar elongation occurs distally.
sure of the ankle, exposure factors must
be modified accordingly.
• Position the x-ray tube directly over the
patient’s hip, and make the first expo-
sure (Fig. 11-2, A).
• Move the x-ray tube directly over the
patient’s knee joint, and make a second
exposure (Fig. 11-2, B).
• Move the x-ray tube directly over the
patient’s ankle joint, and make a third
exposure (Fig. 11-2, C).
If the child holds the leg perfectly still
while the three exposures are made, the
true distance from the proximal end of the
femur to the distal end of the tibia can
be directly measured on the image, as
follows:
A

B C
Fig. 11-2  Patient positioned for orthoroentgenographic measurement of lower limb.
A-C, Central ray is centered over hip joint (A), knee joint (B), and ankle joint (C). A metal
ruler was placed near lateral aspect of leg for photographic purposes. Ruler is normally
placed between limbs (see Fig. 11-4).

3
 • Place a special metal ruler (engraved
Long Bone Measurement

with radiopaque 1 2 -inch [1.3-cm] marks

that show when an image is made) under
the leg and on top of the table (see
Fig. 11-2).
• If the IR is placed in the Bucky tray and
then is moved between exposures, as
for a scanogram (see Fig. 11-2), calcu-
late the length of the femur and tibia by
subtracting the numeric values pro-
jected over the two joints obtained by
simultaneously exposing the patient
and the metal ruler.
Another method of measuring the
length of the femurs and tibias is to
Fig. 11-3  Bilateral leg length measurement, with metal ruler examine both limbs simultaneously (Figs.
placed beside leg for photographic purposes. (Proper placement
11-3 and 11-4):
of ruler is shown in Fig. 11-4.)
• Center the midsagittal plane of the
patient’s body to the midline of the grid.
• Adjust the patient’s lower limbs in the
anatomic position (i.e., slight medial
rotation).
• Tape the special metal ruler to the top
of the table so that part of it is included
in each of the exposure fields. This
records the position of each joint.
• Place an IR in the Bucky tray, and shift
it for centering at the three joint levels
without moving the patient.

Fig. 11-4  Orthoroentgenogram for measurement of leg length. Fig. 11-5  Leg measurement showing that right leg is shorter than
left leg.

4
• Center the IR and the tube successively
at the previously marked level of exists (Fig. 11-5), it is impossible to place
the hip joints, the knee joints, and the
ankle joints for simultaneous bilateral
projections.
• When a difference in level exists
between the contralateral joints, center
the tube midway between the two
levels.
• Digital imaging typically requires three
exposures on three separate 14 ×
17-inch (35 × 43-cm) IRs with a
minimum 6-ft (180-cm) SID. The com-
puter postprocesses the three images
into a single image of the entire limb
through a process termed “stitching.”
Limb length can then be quickly calcu-
lated by the computer.1,2
The bilateral orthoroentgenographic
method is reasonably accurate if the limbs
are of almost the same length. When more
Fig. 11-6  Unilateral leg measurement.
than a slight discrepancy in limb length
the center of the x-ray tube exactly over
both knee joints and make a single expo-
sure or exactly over both ankle joints and
make a single exposure. In such cases, the
tube is centered midway between the two
joints; however, this results in bilateral
distortion because of the diverging x-ray
beam. In Fig. 11-5, the measurement
obtained for the right femur is less than
the actual length of the bone, whereas the
measurement of the left femur is greater
than the true length. The following
measure can be taken to correct this
problem:
• Examine each limb separately (Fig.
11-6).
• Center the limb being examined on the
grid, and place the special ruler beneath
the limb.
Fig. 11-7  Measurement of upper limb.
• Make a closely collimated exposure
Localization of Joints
over each joint. This restriction of the
exposure field not only increases the
accuracy of the procedure but consider-
ably reduces radiation exposure (most
important, to the gonads).
• After making joint localization marks,
position the patient and apply local
gonad shielding.
• Adjust the collimator to limit the expo-
sure field as much as possible.
• With successive centering to the local-
ization marks, make exposures of the
hip, knee, and ankle.
• Repeat the procedure for the opposite
limb.
• Use the same approach to measure
lengths of the long bones in the upper
limbs (Fig. 11-7).
5
 Computed Tomography long bone measurements. Both sets of • Place cursors over the respective hip,
Long Bone Measurement

investigators concluded that the CT scano- knee, and ankle joints, as described
Technique gram is more consistently reproduced and earlier in this chapter. To study the
Helms and McCarthy4 reported a method that it causes less radiation exposure to the upper limb similarly, obtain scout
for using computed tomography (CT) patient than the conventional radiographic images of the humerus, radius, and
to measure discrepancies in leg length. approach. The CT approach is as follows: ulna.
Temme et al5 compared conventional • Take CT localizer or “scout” images of • Place CT cursors over the shoulder,
orthoroentgenograms with CT scans for the femurs and tibias. elbow, and wrist joints, and obtain the
measurements. These measurements
are displayed on the cathode ray tube
(Figs. 11-8 to 11-10).
The accuracy of the CT examination
depends on proper placement of the cursor.
Helms and McCarthy4 found that accuracy
improved when the cursors were placed
three times and the values obtained were
averaged. These authors also reported that
CT examinations used radiation doses
that were 50 to 200 times less than those
used with conventional radiography, while
Sabharwal and Kumar1 reported the CT
dose as 80% less than that of orthoroent-
genograms. CT examination requires
about the same amount of time as conven-
tional radiography, and the costs are
comparable.1

4
Helms CA, McCarthy S: CT scanograms for mea-
suring leg length discrepancy, Radiology 252:802,
1984.
5
Temme JB et al: CT scanograms compared with
Fig. 11-8  Measurement of arms using CT. Note arm labels and measurements in right conventional orthoroentgenograms in long bone
lower corner. measurement, Radiol Technol 59:65, 1987.

Fig. 11-9  CT measurements of femurs. Right femur is 1 cm shorter Fig. 11-10  CT measurement of legs in the same patient as in Figs.
than left femur in the same patient as in Fig. 11-8. 11-8 and 11-9.

6
 12 
CONTRAST ARTHROGRAPHY

OUTLINE
Overview, 8
Summary of Pathology, 9
Abbreviations, 9
Contrast Arthrography Procedures
Removed, 9
Shoulder Arthrography, 10
Contrast Arthrography of
the Knee, 12
Double-Contrast Arthrography of
the Knee, 13
Hip Arthrography, 14
Other Joints, 16

7
 Overview • Contraindications for administration of Arthrography (Greek arthron, meaning
Contrast computed tomography (CT), gadolinium or lack of expertise for US “joint”) is radiography of a joint or joints.
shoulder magnetic resonance imaging exams1 Pneumoarthrography, opaque arthrogra-
Contrast Arthrography

(MRI) with and without contrast, and ultra­
sound (US) have drastically reduced the
need for radiographic contrast arthrogra­
phy (Fig. 12-1). Radiography of joints is
still recommended as the initial imaging for
many of the joints once imaged using con­
trast arthrography, yet the most recent rec­
ommendations by the American College of
Radiology (ACR) rank radiographic con­
trast arthrography from very low or not at
all as an appropriate diagnostic tool. Excep­
tions include the following:
• Aspiration in suspected septic or inflam­
matory arthropathies of the shoulder1
• After knee arthroplasty as a routine
follow-up or for complications2
• To rule out the hip as the referred pain
source after other negative imaging3
1
ACR Appropriateness Criteria®: Acute shoulder
pain, 2010.
2
ACR Appropriateness Criteria®: Imaging after total
knee arthroplasty, 2011.
3
ACR Appropriateness Criteria®: Chronic hip pain,
2011.
phy, and double-contrast arthrography are
terms used to denote radiologic examina­
tions of the soft tissue structures of joints
(menisci, ligaments, articular cartilage,
bursae) after injection of one or two
contrast agents into the capsular space.
A gaseous medium is used in pneu­
moarthrography, a water-soluble iodinated
medium is used in opaque arthrography
(Fig. 12-2), and a combination of gaseous
and water-soluble iodinated media is used
in double-contrast arthrography. Although
contrast studies may be made on any

A F B
Fig. 12-1  A, Non–contrast-enhanced MRI of shoulder. B, Non–contrast-enhanced MRI of
knee, showing torn medial meniscus (arrow).

Fig. 12-2  Bilateral opaque arthrogram of bilateral congenital hip dislocations.

8
encapsulated joint, the shoulder is the injection is made under careful aseptic After aspirating any effusion, the radio­
most frequent site of investigation. The conditions, usually in a combination logist injects the contrast agent or agents
joints discussed in this chapter—shoulder, fluoroscopic-radiographic examining room and manipulates the joint to ensure proper

knee, and hip—are the ones most likely to
be imaged using radiographic contrast
arthrography. Other joints may be imaged
occasionally with arthrography. As noted
previously, MRI, CT, and US are the
modalities most likely to be used to dem­
onstrate pathologies of the joints and asso­
ciated soft tissues.
Arthrogram examinations are usually
performed with a local anesthetic. The
that has been carefully prepared in advance.
The sterile items required, particularly the
length and gauge of the needles, vary
according to the part being examined. The
sterile tray and the nonsterile items should
be set up on a conveniently placed instru­
ment cart or a small two-shelf table
(Fig. 12-3).
Overview
distribution of the contrast material. The
examination is usually performed by fluo­
roscopy and spot images. Conventional
radiographic images may be obtained
when special images, such as an axial pro­
jection of the shoulder or an intercondy­
loid fossa position of the knee, are
desired.
CONTRAST ARTHROGRAPHY
PROCEDURES REMOVED
Based on review of the most recent
ACR Appropriateness Criteria® avail-
able at the time of publication of this
edition, contrast arthrography of the
following joint has been removed
from this edition. This procedure may
be reviewed in the twelfth and all
previous editions.
• Temporomandibular joint
arthrography

Fig. 12-3  Sterile arthrogram tray.

SUMMARY OF PATHOLOGY ABBREVIATIONS USED IN

CHAPTER 12
Condition Definition
ACR American College of
Radiology
DDH Developmental dysplasia of
Developmental dysplasia of Denotes a wide spectrum of congenital hip
the hip abnormalities, ranging from acetabular the hip
dysplasia, joint laxity, and subluxation to MRI Magnetic resonance imaging
complete dislocation PA Posteroanterior

Dislocation Displacement of a bone from a joint See Addendum B for a summary of all
abbreviations used in Volume 2.
Joint capsule tear Rupture of the joint capsule

Ligament tear Rupture of the ligament

Meniscus tear Rupture of the meniscus

Rotator cuff tear Rupture of any muscle of the rotator cuff

9
 Shoulder Arthrography double-contrast technique (Fig. 12-5) may For a single-contrast arthrogram (Fig.
Arthrography of the shoulder is performed be used. 12-6), approximately 10 to 12 mL of posi­
primarily for the evaluation of partial or The usual injection site is approxi­ tive contrast medium is injected into the
Contrast Arthrography

complete tears in the rotator cuff or mately 1 2 inch (1.3 cm) inferior and shoulder. For double-contrast examina­
glenoid labrum, persistent pain or weak­ lateral to the coracoid process. Because tions, approximately 3 to 4 mL of positive
ness, and frozen shoulder. A single- the joint capsule is usually deep, use of a contrast medium and 10 to 12 mL of air
contrast technique (Fig. 12-4) or a spinal needle is recommended. are injected into the shoulder.

Fig. 12-4  Normal AP single-contrast shoulder arthrogram with Fig. 12-5  Normal AP double-contrast shoulder arthrogram.
contrast medium surrounding biceps tendon sleeve and lying in
intertubercular (bicipital) groove (arrows). Axillary recess is filled
but has normal medial filling defect (arrowheads), created by
glenoid labrum.

Fig. 12-6  Single-contrast arthrogram showing rotator cuff tear

(arrowheads).

10
 The projections most often used are After double-contrast shoulder arthrog­ CT has been found to be sensitive and
the AP (internal and external rotation), raphy is performed, computed tomogra­ reliable in diagnosis. Radiographs and CT
30-degree AP oblique, axillary (Figs. 12-7 phy (CT) may be used to examine some scans of the same patient are presented in

and 12-8), and tangential. (See Volume 1,
Chapter 5, for a description of patient and
part positioning.)
patients. CT images may be obtained at
approximately 5-mm intervals through the
shoulder joint. In shoulder arthrography,
Shoulder Arthrography
Figs. 12-5 and 12-9. Shoulder arthrogra­
phy is increasingly performed with MRI,
with injection of gadolinium contrast
media into the joint capsule (Fig. 12-9, B).

Clavicle

Coracoid
Humeral process
head
Humeral
Contrast
head
medium
in glenoid
cavity
Glenoid
cavity
A
Scapula

O
O

Fig. 12-7  Normal axillary single-contrast shoulder arthrogram. Fig. 12-8  Normal axillary double-contrast shoulder arthrogram
projection of patient in supine position. Opaque medium (O) and
air-created (A) density are seen anteriorly.

H
A A

A Rib
G

A B F

Fig. 12-9  A, CT shoulder arthrogram. Radiographic arthrogram in this patient was normal
(see Fig. 12-5). CT shoulder arthrogram shows small chip fracture (arrow) on anterior
surface of glenoid cavity. Head of humerus (H), air surrounding biceps tendon
(arrowhead), air contrast medium (A), opaque contrast medium (O), and glenoid
portion of scapula (G) are evident. B, MRI arthrogram of shoulder with injection of
gadolinium contrast medium.

11
 Contrast Arthrography
of the Knee
VERTICAL RAY METHOD
Contrast Arthrography
Contrast arthrography of the knee by the
vertical ray method requires the use of a
stress device. The following steps are
taken:
• Place the limb in the frame to widen or
“open up” the side of the joint space
under investigation. This widening, or
spreading, of the intrastructural spaces
Fig. 12-10  Patient lying on lead rubber for gonad
shielding and positioned in stress device on
fluoroscopic table.
12
permits better distribution of the con­
trast material around the meniscus.
• After the contrast material is injected,
place the limb into the stress device
(Fig. 12-10). To delineate the medial
side of the joint, place the stress device
just above the knee and then laterally
stress the lower leg.
• When contrast arthrograms are to be
made by conventional radiography, turn
the patient to the prone position, and
fluoroscopically localize the centering
Fig. 12-11  Vertical ray double-contrast knee arthrogram.
point for each side of the joint. The
mark ensures accurate centering for
closely collimated studies of each side
of the joint and permits multiple expo­
sures to be made on one IR. The images
obtained of each side of the joint usually
consist of an AP projection and a
20-degree right and left AP oblique
projection.
• Obtain the oblique position by leg
rotation or by central ray angulation
(Fig. 12-11).
• On completion of these studies, remove
the frame and perform lateral and inter­
condyloid fossa projections.
NOTE: Anderson and Maslin1 recommended that
tomography be used in knee arthrography. In
addition, the technique frequently can be used for
other contrast-filled joint capsules.
1
Anderson PW, Maslin P: Tomography applied to
knee arthrography, Radiology 110:271, 1974.
Femoral
condyle
Meniscus
Tibia
Double-Contrast
Arthrography
of the Knee
HORIZONTAL RAY METHOD
The horizontal central ray method of per­
forming double-contrast arthrography of
the knee was described first by Andrén and
Wehlin2 and later by Freiberger et al.3
These investigators found that using a
horizontal x-ray beam position and a com­
paratively small amount of each of the
two contrast agents (gaseous medium and
water-soluble iodinated medium) improved
double-contrast delineation of the knee
joint structures. With this technique, the
excess of the heavy iodinated solutions
drains into the dependent part of the joint,
leaving only the desired thin opaque
coating on the gas-enveloped uppermost
part—the part under investigation.
2
Andrén L, Wehlin L: Double-contrast arthrography
of knee with horizontal roentgen ray beam, Acta
Orthop Scand 29:307, 1960.
3
Freiberger RH et al: Arthrography of the knee by
double contrast method, AJR Am J Roentgenol
97:736, 1966.
Fig. 12-12  Image showing tear
(arrow) in medial meniscus.
Medial meniscus
• Adjust the patient in a semiprone posi­
tion that places the posterior aspect
of the medial meniscus uppermost
(Fig. 12-12).
• To widen the joint space, manually
stress the knee.
• Draw a line on the medial side of the
knee, and direct the central ray along
the line and centered to the meniscus.
• With rotation toward the supine posi­
tion, turn the leg 30 degrees for each of
the succeeding five exposures.
• Direct the central ray along the local­
ization line for each exposure, ensuring
that it is centered to the meniscus.
Fig. 12-13  Normal lateral meniscus (arrows).
Lateral meniscus
• Adjust the patient in a semiprone posi­
tion that places the posterior aspect
Double-Contrast Arthrography of the Knee
of the lateral meniscus uppermost
(Fig. 12-13).
• To widen the joint space, manually
stress the knee.
• As with the medial meniscus, make six
images on one IR.
• With movement toward the supine posi­
tion, rotate the leg 30 degrees for each
of the consecutive exposures, from the
initial prone oblique position to the
supine oblique position.
• Adjust the central ray angulation as
required to direct it along the localiza­
tion line and center it to the meniscus.
NOTE: To show the cruciate ligaments after
filming of the menisci is completed,1 the patient
sits with the knee flexed 90 degrees over the side
of the radiographic table. A firm cotton pillow is
placed under the knee and is adjusted so that some
forward pressure can be applied to the leg. With
the patient holding a grid IR in position, a closely
collimated and slightly overexposed lateral pro­
jection is made.
1
Mittler S et al: A method of improving cruciate liga­
ment visualization in double-contrast arthrography,
Radiology 102:441, 1972.
13
 Hip Arthrography cement used to fasten hip prosthesis graphic brightness, a subtraction techni­
Hip arthrography is most often performed components has barium sulfate added to que is recommended—either photographic
on children in a surgery suite by an ortho­ make the cement and the cement-bone subtraction, as shown in Figs. 12-17 and
Contrast Arthrography

pedic surgeon. Arthrography is used to
evaluate lateral femoral head displace­
ment and after closed reduction to ensure
that there is no folding or impingement of
soft tissues (see Fig. 12-2, pretreatment)
(Figs. 12-14 and 12-15, post-treatment).
In adults, the primary use of hip arthrog­
raphy is to detect a loose hip prosthesis or
to confirm the presence of infection. The
interface radiographically visible (Fig.
12-16). Although the addition of barium
sulfate to cement is helpful in confirming
proper seating of the prosthesis, it makes
evaluation of the same joint by arthrogra­
phy difficult.
Because cement and contrast material
produce the same approximate radio­
12-18, or digital subtraction, as shown in
Figs. 12-19 and 12-20 (see Chapter 23). A
common puncture site for hip arthrography
is 3 4 inch (1.9 cm) distal to the inguinal
crease and 3 4 inch (1.9 cm) lateral to the
palpated femoral pulse. A spinal needle is
useful for reaching the joint capsule.

Fig. 12-14  AP opaque arthrogram showing treated Fig. 12-15  Axiolateral “frog” right hip of patient
congenital right hip dislocation in the same treated for congenital dislocation of the hip.
patient as in Fig. 12-2.

14

Fig. 12-16  AP hip radiograph showing radiopaque
cement (arrows) used to secure hip prosthesis.
Hip Arthrography
Fig. 12-17  AP hip arthrogram showing hip prosthesis in proper
position. Cement with radiopaque additive is difficult to
distinguish from contrast medium used to perform arthrography
(arrows).

Fig. 12-18  Normal photographic
subtraction AP hip arthrogram in the same
patient as in Fig. 12-16. Contrast medium
(black image) is readily distinguished from
hip prosthesis by subtraction technique.
Contrast medium does not extend
inferiorly below level of injection needle
(arrow). (See Chapter 23 for a description
of subtraction technique.)
Fig. 12-19  AP hip radiograph after
injection of contrast medium.
Fig. 12-20  Digital subtraction hip
arthrogram in the same patient as in Fig.
12-19. Contrast medium around prosthesis
in proximal lateral femoral shaft (arrows)
indicates loose prosthesis. Lines on medial
and lateral aspect of femur (arrowheads)
are a subtraction registration artifact
caused by slight patient movement during
injection of contrast medium. (See
Chapter 23 for a description of subtraction
technique.)

15
 Other Joints
Essentially any joint can be evaluated
by arthrography. A wrist arthrogram is
Contrast Arthrography

included here as an example (Fig. 12-21).

Fig. 12-21  Opaque arthrogram of wrist,

showing rheumatoid arthritis.

16
 13 
TRAUMA RADIOGRAPHY
JOE A. GARZA

OUTLINE
Introduction, 18
Trauma Statistics, 18
Preliminary Considerations, 20
Radiographer’s Role as Part of
the Trauma Team, 25
Best Practices in Trauma
Radiography, 28
Radiographic Procedures in
Trauma, 29
Abbreviations, 30
RADIOGRAPHY, 31
Cervical Spine, 31
Cervicothoracic Region, 32
Cervical Spine, 33
Thoracic and Lumbar Spine, 35
Chest, 36
Abdomen, 38
Pelvis, 41
Cranium, 42
Facial Bones, 46
Upper Limb, 47
Lower Limb, 50
OTHER IMAGING PROCEDURES IN
TRAUMA, 53
Computed Tomography, 53
Diagnostic Medical Sonography, 55

17
 Introduction
Trauma is defined as severe injury or
damage to the body caused by an accident
or violence. Victims of trauma require
immediate and specialized care, which is
Trauma Radiography
commonly provided in larger hospitals
within a specialized unit, termed the emer-
gency department (ED). Physicians and
many nurses specialize in trauma care.
Imaging professionals are essential to the
diagnosis of injuries sustained during trau-
matic events, so extra study in this area of
imaging is necessary. Trauma radiography
can be an exciting and challenging envi-
ronment for a properly prepared imaging
professional. These procedures can be
intimidating and stressful for individuals
unprepared for the innumerable injuries
14,000
12,000
10,000
NUMBER OF CASES
8,000
6,000
4,000
2,000
0
<1 year
Fig. 13-1  NTDB annual report, 2012, table showing number of trauma incidents by age
and gender.
(Reprinted by permission of the American College of Surgeons.)
18
seen in the ED. The essential key to
quality imaging procedures for trauma
patients is proper study and preparation
for imaging professionals.
Preparation for the trauma environment
requires an understanding of the follow-
ing: the most common traumatic injuries,
the most commonly affected populations,
types of trauma care facilities, specialized
imaging equipment designed for imaging
of trauma patients, the role of the imaging
technologist as part of the ED team,
and imaging procedures commonly per-
formed on trauma patients. This chapter
provides the information necessary to
improve the skills and confidence of all
imaging professionals caring for trauma
patients.
Incidents by Age and Gender
6 12 18 24 30 36 42 48 54
AGE
FEMALE
Trauma Statistics
Trauma-related injuries affect persons in
all age ranges. Fig. 13-1 shows trauma
incidence by age and gender, as reported
by the American College of Surgeons’
National Trauma Database (NTDB) 2012
annual report. The database contains more
than 5 million records from more than 744
hospitals and has received information
from across the United States. These data
show that trauma patients most commonly
are male and range in age from teenagers
to early adults. Fig. 13-2 shows the distri-
bution of trauma injuries by cause; the
most common are falls, followed by motor
vehicle accidents (MVAs). Firearms rank
last as a cause of injury; however, the
2012 NTDB report also shows that
60 66 72 78 84
MALE
firearms have the highest fatality rate. The
data show the most common trauma
patients and mechanisms of injury, but the
imaging professional who chooses to
work in the ED must be prepared to care
for patients of every age exhibiting a vast
array of injuries.
Many types of facilities provide emer-
gency medical care, ranging from major
medical centers to small outpatient
clinics in rural areas. The term trauma
center denotes a specific level of emer-
gency medical care as defined by the
American College of Surgeons Commis-
sion on Trauma. Four levels of care are
defined. Level I is the most comprehen-
sive, and Level IV is the most basic. A
Level I trauma center is usually a
university-based center, research facility,
or large medical center. It provides the
45.00
40.00
35.00
30.00
PERCENT
25.00
20.00
15.00
10.00
5.00
0.00
Fall
Fig. 13-2  NTDB annual report, 2012, table showing number of patients injured by each
mechanism.
(Reprinted by permission of the American College of Surgeons.)
most comprehensive emergency medical
care available with complete imaging
capabilities and all types of specialty
physicians available on site 24 hours per
day. Imaging professionals are also avail-
able 24 hours per day. A Level II trauma
center probably has all of the same spe-
cialized care available but is not a
research or teaching hospital, and some
specialty physicians may not be available
on site. Level III trauma centers are
usually located in smaller communities
where Level I or Level II care is unavail-
able. Level III centers generally do not
have all specialists available but can
resuscitate, stabilize, assess, and prepare
a patient for transfer to a larger trauma
center. A Level IV trauma center may not
be a hospital at all, but rather a clinic or
other outpatient setting. These facilities
Incidents by Selected Mechanism of Injury
Motor Vehicle Struck by, Transport,
Traffic against other
MECHANISM OF INJURY
usually provide care for minor injuries
and offer stabilization and arrange for
transfer of patients with more serious
injuries to a larger trauma center.
Trauma injuries can occur by several
Trauma Statistics
types of forces, including blunt, penetrat-
ing, explosive, and heat. Examples of
blunt trauma are MVAs, which include
motorcycle accidents, collisions with
pedestrians, falls, and aggravated assaults.
Penetrating trauma events include gunshot
wounds (GSWs), stab wounds, impalement
injuries, and foreign body ingestion or aspi-
ration. Explosive trauma causes injury by
several mechanisms including pressure
shock waves, high-velocity projectiles, and
burns. Heat trauma includes burn injuries,
which may be caused by numerous agents
including fire, steam, hot water, chemicals,
electricity, and frostbite.
Cut/pierce Firearm
19
 Preliminary
Considerations
SPECIALIZED EQUIPMENT
Time is a crucial element in the care of a
Trauma Radiography
trauma patient. To minimize the time
needed to acquire diagnostic x-ray images,
many EDs have dedicated radiographic
equipment located in the department or
immediately adjacent to the department.
Trauma radiographs must be taken with
minimal patient movement, requiring
more maneuvering of the tube and image
receptor (IR). Specialized trauma radio-
graphic systems are available and are
designed to provide greater flexibility in
x-ray tube and IR maneuverability (Fig.
13-3). These specialized systems help to
minimize movement of the injured patient
while imaging procedures are performed.
Additionally, some EDs are equipped with
specialized beds or stretchers that have a
movable tray to hold the IR. This type of
stretcher allows the use of a mobile radio-
graphic unit and eliminates the require-
ment for and risk of transferring an injured
patient to the radiographic table.
Computed tomography (CT) is widely
used for imaging of trauma patients. In
many cases, CT is the first imaging modal-
ity used, now that image acquisition has
become almost instantaneous. (Refer to
Chapter 29 in Volume 3 for a detailed
Fig. 13-3  Dedicated C-arm–type trauma radiographic room with
patient on the table.
(Courtesy Siemens Healthcare.)
20
explanation and description of CT.) The
only major concern with CT imaging
compared with radiography is the radia-
tion dose. The debate centers on the
exclusive use of CT, when lower-
dose radiographs may be sufficient for a
diagnosis. Patients who are at high risk
and who are not good candidates for
quality radiographs based on their injuries
may be referred to CT first.
Mobile radiography is often a necessity
in the emergency department. Many
patients have injuries that prohibit transfer
to a radiographic table, or their condition
may be too critical to interrupt treatment.
Trauma radiographers must be competent
in performing mobile radiography on
almost any part of the body and must be
able to use accessory devices (e.g., grids,
air-gap technique) to produce quality
mobile images.
Mobile fluoroscopic units, usually
referred to as C-arms because of their
shape, are becoming more commonplace
in EDs. C-arms are used for fracture
reduction procedures, foreign body local-
ization in limbs, and reduction of joint
dislocations (Fig. 13-4).
An emerging imaging technology has
the potential to have a significant effect on
trauma radiography. The Statscan (Lodox
Systems [Pty.], Ltd., Johannesburg, South
Africa) is a relatively new imaging device
that produces full-body imaging scans in
approximately 13 seconds without the
need to move the patient (Figs. 13-5 to
13-7). At present approximately 17 of
these systems are available worldwide. At
a cost of approximately $450,000, this
technology is an expensive addition to a
trauma imaging department.
Positioning aids are essential for quality
imaging in trauma radiography. Sponges,
sandbags, and tape used creatively are
often the trauma radiographer’s most
useful tools. Most patients who are
injured cannot hold the required positions
because of pain or impaired conscious-
ness. Other patients cannot be moved into
the proper position because to do so would
exacerbate their injury. Proper use of posi-
tioning aids assists in quick adaptation of
procedures to accommodate the patient’s
condition.
Grids and IR holders are also an impor-
tant part of trauma radiography because
many projections require the use of a
horizontal central ray. Grids should be
inspected regularly because a damaged
grid often causes image artifacts. IR
holders enable the radiographer to
perform cross-table lateral projections
(dorsal decubitus position) on numerous
body parts with minimal distortion. To
prevent unnecessary exposure, ED per-
sonnel should not hold the IR.
 Preliminary Considerations
Fig. 13-4  Mobile fluoroscopic C-arm.

(Courtesy OEC Diasonics, Inc.)

A B
Fig. 13-5  A, Statscan system configured for AP projection. B, Statscan system configured
for lateral projection.

(Courtesy Lodox Systems [Pty.], Ltd.)

21
Trauma Radiography

B C

A D
Fig. 13-6  Statscan of patient with multiple GSWs. A, AP full-body scan—13 seconds
required for acquisition. Shrapnel and projectile pathways identified by zooming in on
areas of full-body scan. B, Skull. C, Diaphragm area. D, Pelvis.

(Courtesy Lodox Systems [Pty.], Ltd.)

A
Fig. 13-7  Statscan of MVA victim with blunt trauma. A, AP full-body scan. Tension
pneumothorax shown without additional processing. B, Zoomed lower pelvis showing
multiple fractures (arrows). C, Zoomed bony thorax showing rib fractures (arrows).

(Courtesy Lodox Systems [Pty.], Ltd.)

22
EXPOSURE FACTORS
Patient motion is always a consideration
in trauma radiography. The shortest pos-
sible exposure time that can be set should
be used in all procedures, except when a
for the exposure. Conscious patients are
often in extreme pain and unable to coop-
erate for the procedure.
Radiographic exposure factor compen-
sation may be required when exposures
trauma patients arrive at the hospital with
some type of immobilization device (Fig.
13-8). Pathologic changes should also be
considered when technical factors are set.
Internal bleeding in the abdominal cavity

Preliminary Considerations
breathing technique is desired. Uncon- are made through immobilization devices would absorb a greater amount of radia-
scious patients cannot suspend respiration such as a spine board or backboard. Most tion than a bowel obstruction.

A B

Fig. 13-8  A, Typical backboard and neck brace used for

trauma patients. B, Backboard, brace, and other restraints are
used on the patient throughout transport. C, All restraints
remain with and on the patient until all x-ray examinations are
completed.

23
 POSITIONING OF THE PATIENT
The primary challenge of the trauma
radiographer is to obtain a high-quality,
diagnostic image on the first attempt when
the patient is unable to move into the
Trauma Radiography
or upright table as the patient’s condition
allows (Fig. 13-9). This location enables
accurate positioning with minimal patient
movement for cross-table lateral images
(dorsal decubitus positions) on numerous
superiorly to inferiorly. All lateral projec-
tions of the requested examinations are
then performed while moving inferiorly to
superiorly. This method moves the x-ray
tube in the most expeditious manner.

desired position. Many methods are avail-
able to adapt a routine projection and
obtain the desired image of the anatomic
part. To minimize the risk of aggravating
the patient’s condition, the x-ray tube and
IR should be positioned, rather than the
patient or the part. The stretcher can be
positioned adjacent to the vertical Bucky
parts of the body. Additionally, the grid in
the table or vertical Bucky is usually
of a higher ratio than grids used for
mobile radiography, so image contrast is
improved. Another technique to increase
efficiency while minimizing patient move-
ment is to take all of the AP projections of
the requested examinations while moving
When radiographs are taken to localize
a penetrating foreign object, such as metal,
glass fragments, or bullets, entrance and
exit wounds should be marked with a radi-
opaque marker that is visible on all projec-
tions (Fig. 13-10). Two exposures at right
angles to each other will demonstrate the
depth and path of the projectile.

Fig. 13-9  Stretcher positioned adjacent to vertical Bucky to expedite positioning. Note
x-ray tube in position for lateral projections.

Fig. 13-10  Proper placement of radiopaque markers (inside red circles) on each side of
bullet entrance wound. Red circles are “stickies” that contain radiopaque marker.

24

Radiographer’s Role as
Part of the Trauma Team
The role of the radiographer within the ED
ultimately depends on the department
protocol and staffing and the extent of
emergency care provided at the facility.
Regardless of the size of the facility, the
primary responsibilities of a radiographer
in an emergency situation include the
following:
• Perform quality diagnostic imaging
procedures as requested
• Practice ethical radiation protection for
self, patient, and other personnel
• Provide competent patient care
Ranking these responsibilities is impos-
sible because they occur simultaneously,
and all are vital to quality care in the ED.
DIAGNOSTIC IMAGING
PROCEDURES
Producing a high-quality diagnostic image
is an obvious role of any radiographer; a
radiographer in the trauma environment
has the added responsibility to perform
that task efficiently. Efficiency and pro-
ductivity are common and practical goals
for the radiology department. In the ED,
efficiency is often crucial to saving the
patient’s life. Diagnostic imaging in the
ED is paramount to an accurate, timely,
and often lifesaving diagnosis.
RADIATION PROTECTION
One of the most important duties and
ethical responsibilities of the trauma
radiographer is radiation protection of the
patient, members of the trauma team, and
the radiographer himself or herself. In
critical care situations, members of the
trauma team cannot leave the patient
while imaging procedures are being per-
formed. The trauma radiographer must
ensure that the other team members are
protected from unnecessary radiation
exposure. Common practices should mini-
mally include the following:
• Close collimation to the anatomy of
interest to reduce scatter
• Gonadal shielding for patients of child-
Radiographer’s Role as Part of the Trauma Team
bearing age (when doing so does not
interfere with the anatomy of interest)
• Lead aprons for all personnel that remain
in the room during the procedure
• Exposure factors that minimize patient
dose and scattered radiation
• Announcement of impending exposure
to allow unnecessary personnel to exit
the room
Consideration must also be given to
patients on nearby stretchers. If these
patients are less than 6 feet away from the
x-ray tube, appropriate shielding should
be provided. Some of the greatest expo-
sures to patients and medical personnel
result from fluoroscopic procedures. If the
C-arm fluoroscopic unit is used in the ED,
special precautions should be in place to
ensure that fluoroscopic exposure time is
kept to a minimum and that all personnel
are wearing protective aprons.
25
 PATIENT CARE
As with all imaging procedures, trauma
procedures require a patient history. The
patient may provide this history, if he or
she is conscious, or the attending physi-
Trauma Radiography
cian may inform the radiographer of the
injury and the patient’s status. If the
patient is conscious, the radiographer
should explain what he or she is doing in
detail and in terms the patient can under-
stand. The radiographer should listen to
the patient’s rate and manner of speech,
which may provide insight into the
patient’s mental and emotional status. The
radiographer should make eye contact
with the patient to provide comfort and
reassurance. A trip to the ED is an emo-
tionally stressful event, regardless of the
severity of injury or illness.
Radiographers are often responsible for
the total care of the trauma patient while
performing diagnostic imaging proce-
26
dures. It is crucial that the radiographer
constantly assess the patient’s condition,
recognize any signs of deterioration or
distress, and report any change in the
status of the patient’s condition to the
attending physician. The trauma radiogra-
pher must be knowledgeable in taking
vital signs as well as knowing normal
ranges and must be competent in perform-
ing cardiopulmonary resuscitation (CPR),
administering oxygen, and dealing with
all types of medical emergencies. The
radiographer must be prepared to perform
these procedures when covered by a
standing physician’s order or as depart-
mental policy allows. The radiographer
should also be familiar with the location
and contents of the adult and pediatric
crash carts and should understand how to
use the suctioning devices.
The CAB (compressions, airway, and
breathing) of basic life support techniques
must be constantly assessed during radio-
graphic procedures. Visual inspection and
verbal questioning enable the radiogra-
pher to determine whether the status of the
patient changes during the procedure.
Table 13-1 provides a guide for the trauma
radiographer regarding changes in status
that should be reported immediately to the
attending physician. Table 13-1 includes
only the common injuries in which the
radiographer may be the sole health care
professional with the patient during the
imaging procedure. Patients with multiple
trauma injuries and patients in respiratory
or cardiac arrest usually are imaged with
a mobile radiographic unit while ED per-
sonnel are present in the room. In these
situations, the primary responsibility of
the trauma radiographer is to produce
quality images in an efficient manner
while practicing ethical radiation protec-
tion measures.
TABLE 13-1 
Guide for reporting patient status change
Noted symptom Possible cause When to report to physician immediately
Cool, clammy skin Shock* Other symptoms of shock present
Vasovagal reaction†

Radiographer’s Role as Part of the Trauma Team

Excessive sweating (diaphoresis)
Slurred speech
Agitation or confusion
Vomiting (without abdominal
complaints) (hyperemesis)
Increased drowsiness (lethargy)
Loss of consciousness
(unresponsive to voice or
touch)
Pale or bluish skin pallor
(cyanosis)
Bluish nail beds
Patient complains of thirst
Patient complains of tingling or
numbness (paresthesia) or
inability to move a limb
Seizures
Patient states that he or she
cannot feel your touch
(paralysis)
Extreme eversion of foot
Increasing abdominal distention
and firmness to palpation
Shock* Other symptoms of shock present
Head injury Accompanied by vomiting, especially if
Stroke (cerebrovascular accident‡) vomiting stops when patient is moved
Drug or ethanol influence§ to different position
Head injury Accompanied by vomiting, especially if
Drug or ethanol influence§ vomiting stops when patient is moved
to different position
Head injury Position of patient abruptly stimulates
Hyperglycemia‖ vomiting or abruptly stops vomiting
Drug or ethanol overdose
Shock* Other symptoms of shock present or
Head injury accompanied by vomiting
Hyperglycemia‖
Shock* Immediately
Head injury
Hyperglycemia‖
Airway compromise Immediately
Hypovolemic shock
Circulatory compromise Immediately
Shock* Other symptoms of shock present
Hyperglycemia‖
Hypoglycemia
Spinal cord injury Accompanied by any symptoms of
Peripheral nerve impairment shock or altered consciousness
Head injury Immediately
Spinal cord injury Accompanied by any symptoms of
Peripheral nerve impairment shock or altered consciousness
Fracture of proximal femur or hip Report only if x-ray request specifies
joint “frog leg” lateral projection of hip.
This movement would exacerbate
patient’s injury and cause intense
pain. Surgical lateral position should
be substituted. Watch for changes in
abdominal size and firmness
Internal bleeding from pelvic Immediately
fracture¶ or organ laceration

*Hypovolemic or hemorrhagic shock is a medical condition in which levels of blood plasma in the body are abnormally low, such that
the body cannot properly maintain blood pressure, cardiac output of blood, and normal amounts of fluid in the tissues. It is the most
common type of shock in trauma patients. Symptoms include diaphoresis, cool and clammy skin, decrease in venous pressure, decrease
in urine output, thirst, and altered state of consciousness.
†
Vasovagal reaction is also called a vasovagal attack, situational syncope, and vasovagal syncope. It is a reflex of the involuntary nervous
system or a normal physiologic response to emotional stress. Patients may complain of nausea, feeling flushed (warm), and feeling light-
headed. They may appear pale before they lose consciousness for several seconds.
‡
Cerebrovascular accident (CVA) is commonly called a stroke and may be caused by thrombosis, embolism, or hemorrhage in the
vessels of the brain.
§
Drugs or alcohol. Patients under the influence of drugs or alcohol or both commonly present in the ED. In this situation, the usual symp-
toms of shock and head injury are unreliable. Be on guard for aggressive physical behaviors and abusive language.
‖
Hyperglycemia is also known as diabetic ketoacidosis. The cause is increased blood glucose levels. The patient may exhibit any com-
bination of symptoms noted and has fruity-smelling breath.
¶
Pelvic fractures have a high mortality rate (mortality with open fractures may be 50%). Hemorrhage and shock are often associated
with this type of injury.

27
 Best Practices in Trauma
Radiography
Radiography of the trauma patient seldom
allows the use of “routine” positions
Trauma Radiography
and projections. Additionally, the trauma
patient requires special attention to patient
care techniques while difficult imaging
procedures are performed. The following
best practices provide some universal
guidelines for the trauma radiographer.
1. Speed: Trauma radiographers must
produce quality images in the shortest
amount of time. Speed in performing
a diagnostic examination is crucial
to saving the patient’s life. Many
practical methods that increase exam-
ination efficiency without sacrificing
image quality are introduced in this
chapter.
2. Accuracy: Trauma radiographers
must provide accurate images with a
minimal amount of distortion and
with the maximum amount of
recorded detail. Alignment of the
central ray, the part, and the IR is
imperative in trauma radiography.
Using the shortest exposure time min-
imizes the possibility of involuntary
and uncontrollable patient motion on
the image.
3. Quality: Quality does not have to be
sacrificed to produce an image
quickly. The patient’s condition
should not be used as an excuse for
careless positioning and accepting
less than high-quality images.
4. Positioning: Careful precautions
must be taken to ensure that perfor-
mance of the imaging procedure does
not worsen the patient’s injuries. The
“golden rule” of two projections at
right angles from one another still
applies. As often as possible, the
radiographer should position the tube
28
and the IR, rather than the patient, to
obtain the desired projections.
5. Practice standard precautions: Expo-
sure to blood and body fluids should
be expected in trauma radiography.
The radiographer should wear gloves,
mask, eye shields, and gown when
appropriate. IR and sponges should
be placed in nonporous plastic to
protect them from body fluids. Hand
hygiene should be performed fre-
quently, especially between patients.
All equipment and accessory devices
should be kept clean and ready for
use.
6. Immobilization: The radiographer
should never remove any immobiliza-
tion device without physician’s
orders. The radiographer should
provide proper immobilization and
support to increase patient comfort
and to minimize risk of motion.
7. Anticipation: Anticipating required
special projections or diagnostic pro-
cedures for certain injuries makes the
radiographer a vital part of the ED
team. Patients requiring surgery gen-
erally require an x-ray of the chest. In
facilities where CT is not readily
available for emergency patients,
fractures of the pelvis may require a
cystogram to determine the status of
the urinary bladder. The radiographer
should know which procedures are
often referred to CT first or for addi-
tional images. Being prepared for and
understanding the necessity of these
additional procedures and images
instills confidence in, and creates an
appreciation for, the role of the
radiographer in the emergency setting.
8. Attention to detail: The radiographer
should never leave a trauma patient
(or any patient) unattended during
imaging procedures. The patient’s
condition may change at any time,
and it is the radiographer’s responsi-
bility to note these changes and report
them immediately to the attending
physician. If the radiographer cannot
process images while maintaining eye
contact with the patient, he or she
should call for help. Someone must be
with the injured patient at all times.
9. Attention to department protocol and
scope of practice: The radiographer
should know department protocols
and practice only within his or her
own competence and abilities. The
scope of practice for radiographers
varies from state to state and from
country to country. The radiographer
should study and understand the
scope of his or her role in the
emergency setting. The radiographer
should not provide or offer a patient
anything by mouth. The radiographer
should always ask the attending phy-
sician before giving the patient any-
thing to eat or drink, no matter how
persistent the patient may be.
10. Professionalism: Ethical conduct and
professionalism in all situations and
with every person is a requirement of
all health care professionals, but the
conditions encountered in the ED
can be particularly complicated. The
radiographer should adhere to the
Code of Ethics for Radiologic Tech-
nologists (see Chapter 1) and the
Radiography Practice Standards. The
radiographer should be aware of
the people present or nearby at all
times when discussing a patient’s
care. The ED radiographer is exposed
to countless tragic conditions. Emo-
tional reactions are common and
expected but must be controlled until
emergency care of the patient is
complete.
Radiographic
Procedures in Trauma
The projections included in this chapter
result from a telephone survey of Level I
trauma centers. The results indicate that
common radiographic projections ordered
for initial trauma surveys are as follows1:
• Cervical spine, dorsal decubitus posi-
tion (cross-table lateral)
• Chest, AP (mobile)
• Abdomen, AP (kidneys, ureter, and
bladder [KUB] and acute abdominal
series)
• Pelvis, AP
• Cervical spine, AP and obliques
• Lumbar spine
• Lower limb
• Upper limb
Skull radiographs did not rank as one of
the most common imaging procedures per-
formed in the ED of Level I trauma centers.
Most Level I trauma centers have replaced
conventional trauma skull radiographs
(e.g., AP, lateral, Towne, reverse Waters)
with CT scan of the head (Fig. 13-11).
Research articles continue to delineate the
advantages of CT over radiography, and the
results indicate that certain types of head
trauma should be referred to CT first.
However, because smaller facilities may
not have CT readily available, trauma skull
positioning remains valuable knowledge
for the radiographer.
1
Thomas Wolfe, Methodist Medical Center,
Memphis, TN, conducted the survey as a part of
his graduate practicum for Midwestern State
University.
This section provides trauma position-
ing instructions for radiography projec-
tions of the following body areas:
• Cervical spine
Lateral (dorsal decubitus position)
Cervicothoracic (dorsal decubitus posi-
tion)
AP axial
AP axial oblique
• Thoracic and lumbar spine
Lateral (dorsal decubitus position)
• Chest
AP
• Abdomen
AP
AP (left lateral decubitus position)
• Pelvis
AP
• Skull
Lateral (dorsal decubitus position)
AP or PA
AP axial (Towne method)
• Facial bones
Acanthioparietal (reverse Waters method)
• Limbs
• Other imaging procedures
In addition to the dorsal decubitus posi-
tions, AP projections of the thoracic and
lumbar spine are usually required for
trauma radiographic surveys. AP projec-
tions of this anatomy vary minimally in
Fig. 13-11  CT scan of skull showing displaced fracture (white arrow). Intracranial air is
present (black open arrow).
(Courtesy Sunie Grossman, RT[R], St. Bernard’s Medical Center, Jonesboro, AR.)
the trauma setting and are not discussed in
detail. Critical study and clinical practice
of these procedures should adequately
prepare a radiographer for work in the ED.
Certain criteria that apply in all trauma
Radiographic Procedures in Trauma
imaging procedures are explained next
and are not included on each procedure in
detail.
PATIENT PREPARATION
Remembering that the patient has endured
an emotionally disturbing and distressing
event in addition to the physical injuries
he or she may have sustained is important.
If the patient is conscious, speak calmly
and look directly into the patient’s eyes
while explaining the procedures that have
been ordered. Do not assume that the
patient cannot hear you, even if he or she
cannot or will not respond. Check the
patient thoroughly for items that might
cause an artifact on the images. Explain
what you are removing from the patient
and why. Place all removed personal
effects, especially valuables, in the proper
container used by the facility (i.e., plastic
bag) or in the designated secure area. Each
facility has a procedure regarding proper
storage of a patient’s personal belongings.
Know the procedure and follow it
carefully.
29
 BREATHING INSTRUCTIONS
Most injured patients have difficulty
following the recommended breathing
instructions for routine projections. For
these patients, exposure factors should be
Trauma Radiography
IMAGE RECEPTOR SIZE AND
COLLIMATED FIELD
The IR sizes (film-screen and CR imaging
plates) used in trauma procedures are the
same as those specified for the routine
DOCUMENTATION
Deviation from routine projections is nec-
essary in many instances. Documenting
the alterations in routine projections for
the attending physician and radiologist is

set using the shortest possible exposure
time to minimize motion on the radio-
graph, necessitating use of the large focal
spot. The decrease in resolution from
using a large focal spot is minimal com-
pared with the significant loss of resolu-
tion due to patient motion. If a breathing
technique is desired, this can be explained
to a conscious trauma patient in the usual
manner. If the patient is unconscious or
unresponsive, careful attention should be
paid to the rate and degree of chest wall
movement. If inspiration is desired on the
image, the exposure should be timed to
correspond to the highest point of chest
expansion. Conversely, if the routine pro-
jection calls for exposure on expiration,
the exposure should be made when the
patient’s chest wall falls to its lowest
point.
IMMOBILIZATION DEVICES
A wide variety of immobilization devices
are used to stabilize injured patients. Stan-
dard protocol is to perform radiographic
images without removing immobilization
devices. After injuries have been diag-
nosed or ruled out, the attending physician
gives the order for immobilization devices
to be removed or changed, or to remain in
place.
Many procedures necessitate the use of
some sort of immobilization to prevent
involuntary and voluntary motion. Many
patient care textbooks discuss prudent use
of such immobilization devices. The key
issues in the use of immobilization in
trauma are to avoid exacerbating the
patient’s injury and to avoid increasing his
or her discomfort.
projection of the anatomy of interest. important, so that they can interpret the
Occasionally, the physician may request images properly. Additionally, the radiog-
that more of a part be included, and then rapher often has to determine whether the
a larger IR or field size is acceptable. anatomy of interest has been adequately
When using the large flat panel digital shown and perform additional projections
radiography (DR) detectors, use the rec- (within the scope of the ordered examina-
ommended IR size as a reference; it is tion) on an injured part to aid in proper
important to collimate to the anatomy of diagnosis. Notations concerning addi-
interest to provide optimal quality images tional projections are extremely helpful
and ethical radiation protection for the for the interpreting physicians.
patient and other personnel who may be
required to be in the room during the
imaging procedures. Exposure of unnec-
essary tissue generates excessive scatter, ABBREVIATIONS USED IN
which is a primary source of radiation CHAPTER 13
exposure for radiographers and other
health care professionals. CPR Cardiopulmonary
resuscitation
CENTRAL RAY, PART, AND IMAGE CR Central ray
RECEPTOR ALIGNMENT CVA Cerebrovascular accident
Unless otherwise indicated for the proce- EAM External acoustic meatus
dure, the central ray should be directed ED Emergency department
perpendicular to the midpoint of the grid GSW Gunshot wound
IOML Infraorbitomeatal line
or IR or both. Tips for minimizing distor-
IVU Intravenous urography
tion are detailed in the procedures in KUB Kidneys, ureters, and
which distortion is a potential threat to bladder
image quality. MML Mentomeatal line
MVA Motor vehicle accident
IMAGE EVALUATION OML Orbitomeatal line
Ideally, trauma images should be of SID Source–to–image receptor
optimal quality to ensure prompt and distance
accurate diagnosis of the patient’s inju-
ries. Evaluate images for proper position- See Addendum B for a summary of all
abbreviations used in Volume 2.
ing and technique as indicated in the
routine projections. Allowances can be
made when true right-angle projections
(AP, PA, and lateral) must be altered as a
result of the patient’s condition.

30
 RADIOGRAPHY
Cervical Spine

LATERAL PROJECTION1 Patient position considerations Structures shown

Dorsal decubitus position • The patient is generally immobilized on The entire cervical spine, from sella
Trauma positioning tips a backboard and in a cervical collar. turcica to the top of T1, must be shown in
• Always perform this projection first, • The patient should relax the shoulders profile with minimal rotation and distor-
before any other projections. Level I as much as possible. tion (Fig. 13-13). Evidence of proper col-

centers may refer patients with indica-
tions for cervical spine imaging to
CT first, depending on concomitant
injuries.
• The attending physician or radiologist
must review this image to rule out ver-
tebral fracture or dislocation before
other projections are performed.
• Use a 72-inch (183-cm) SID whenever
attainable.
• Move the patient’s head and neck as
little as possible.
• Shield gonads and other personnel in
the room.
1
See mobile lateral projection in Volume 3, p. 207.
Cervical Spine
• The patient should look straight ahead limation should be visible.
without any rotation of the head or NOTE: If all seven cervical vertebrae including
neck. the spinous process of C7 and the C7-T1
• Place IR in a holder at the top of the interspace are not clearly visible, a lateral projec-
shoulder (Fig. 13-12). For DR, the col- tion of the cervicothoracic region must be
limated field should include the sella performed.
turcica (located 2 inches [5 cm] anterior
and superior to the external acoustic
meatus [EAM]) to T1, located 2 inches
(5 cm) above the jugular notch. The
anteroposterior field margins should
extend about 1 inch (2.5 cm) beyond
the skin shadow.
• Check that the IR is perfectly vertical.
• Ensure that the central ray is horizontal
and is centered to the midpoint of
the IR.

Horizontal CR to C4
Fig. 13-12  Patient and IR positioned for trauma lateral projection of cervical spine using
dorsal decubitus position. The X marks the CR entrance point.

C6

A B
Fig. 13-13  Dorsal decubitus position lateral projection of cervical spine performed on a
trauma patient. A, Dislocation of C3 and C4 articular processes (arrow). C7 is not well
shown, so lateral projection of cervicothoracic vertebrae should also be performed.
B, Fracture of pedicles with dislocation of C5 and C6. Note superior portion of C7 shown
on this image.

31
 Cervicothoracic Region

LATERAL PROJECTION Patient position considerations Structures shown

Dorsal decubitus position
This projection is often called the swim-
mer’s technique. (See Chapter 8, Vol. 1,
p. 402-403, for a complete description.)
Trauma Radiography
• Position the patient supine, usually on The lower cervical and upper thoracic ver-
a backboard and in a cervical collar. tebral bodies and spinous processes should
• Have the patient depress the shoulder be seen in profile between the shoulders.
closest to the tube as much as possible. Contrast and density should show bony

Trauma positioning tips
• This projection should be performed if
the entire cervical spine including C7
and the interspace between C7 and T1
is not shown on the dorsal decubitus
lateral projection. The patient must be
able to move both arms. Do not move
the patient’s arms without permission
from the attending physician and review
of the lateral projection.
• Collimate the width of the x-ray beam
closely, to approximately 10 × 12 inches
(24 × 30 cm) or less, to reduce scatter
radiation.
• If required and the patient is in stable
condition, position the stretcher adja-
cent to a vertical Bucky to increase
efficiency and obtain optimal image
quality.
• Shield gonads and other personnel in
the room.
Do not push on the patient’s shoulder.
• Instruct the patient to raise the arm
opposite the tube over his or her head.
Assist the patient as needed, but do not
use force or move the limb too quickly
(Fig. 13-14).
• Ensure that the patient is looking
straight ahead without any rotation of
the head or neck.
• The central ray is horizontal and per-
pendicular to the IR entering the side of
the neck just above the clavicle, passing
through the C7-T1 interspace.
• Instruct the patient to breathe normally,
if he or she is conscious.
• If possible, use a long exposure time
technique to blur the rib shadows.
cortical margins and trabeculation (Fig.
13-15). Evidence of proper collimation
should be visible.
  COMPENSATING FILTER
The use of a compensating filter can
improve image quality owing to the
extreme difference in thickness between
the upper thorax and the lower cervical
spine.
NOTE: A grid is required to improve image con-
trast. If a breathing technique cannot be used,
make the exposure with respiration suspended.

Horizontal CR to C7-T1
Fig. 13-14  Patient and IR positioned for trauma lateral projection
of cervicothoracic vertebrae using dorsal decubitus position.
Fig. 13-15  Dorsal decubitus position lateral projection of
cervicothoracic region performed on a trauma patient. Negative
examination. Note excellent image of C7-T1 joint with use of
Ferlic swimmer’s filter (arrow).

32
 Cervical Spine

AP AXIAL PROJECTION1 Patient position considerations Structures shown

Trauma positioning tips • Position the patient supine, usually on C3 through T1 or T2 including interspaces
• Do not perform this projection until the a backboard and in a cervical collar. and surrounding soft tissues should be
attending physician has reviewed the • Have the patient relax the shoulders as shown with minimal rotation and distor-
lateral projection. much as possible. tion. Density and contrast should show

Cervical Spine
• This projection is usually performed • Ensure that the patient is looking cortical margins and soft tissue shadows
after the lateral projection. straight ahead without any rotation of (Fig. 13-17). Evidence of proper collima-
• If the patient is on a backboard, either the head or neck. tion should be visible.
on a stretcher or on an x-ray table, • Place the IR under the backboard, if NOTE: If the patient is not on a backboard or an
gently and slowly lift the backboard present, centered to approximately C4 x-ray table, preferably the attending physician
and place the IR in position under the (Fig. 13-16). should lift the patient’s head and neck while the
patient’s neck. • The central ray is directed 15 to 20 radiographer positions the IR under the patient.
• Move the patient’s head and neck as degrees cephalad to the center of the IR
little as possible. and entering at C4.
• Collimate the width of the x-ray beam
to 1 inch (2.5 cm) beyond the skin to
reduce scatter radiation. Use 12-inch
(30.5-cm) lengthwise collimation.
• Shield gonads and other personnel in
the room.
1
See standard projection, Volume 1, p. 387-388.

CR

15°-20°

Bucky
Fig. 13-16  Patient and IR positioned for trauma AP axial Fig. 13-17  AP axial projection of cervical vertebrae performed on
projection of cervical vertebrae. an 11-year-old trauma patient. Cervical spine is completely
dislocated between C2 and C3 (arrow). The patient died on the
x-ray table after x-ray examinations were performed.

33
 Cervical Spine
AP AXIAL OBLIQUE PROJECTION
Trauma positioning tips
• Do not perform this projection until the
attending physician has reviewed the
lateral projection.
Trauma Radiography
• If the patient is on a backboard, gently
and slowly lift the board and place the
IR in position.
• Move the patient’s head and neck as
little as possible.
• Do not use a grid IR because the com-
pound central ray angle results in grid
cutoff. Many radiography machines do
not allow the x-ray tube head to move
in a compound angle, however. On
these machines, only the 45-degree
angle is used, and a grid IR may be used
to improve contrast.
• Collimate the width of the x-ray beam
to 1 inch (2.5 cm) of the skin lines to
reduce scatter radiation. Use 12-inch
(30.5-cm) lengthwise collimation.
• Shield gonads and other personnel in
the room.
CR
45°
Fig. 13-18  Patient and IR positioned for trauma AP
axial oblique projection of cervical vertebrae. Central
ray (CR) is positioned 45 degrees mediolaterally and,
if possible, 15 to 20 degrees cephalad.
34
Patient position considerations Structures shown
• Position the patient supine, usually on Cervical and upper thoracic vertebral
a backboard and in a cervical collar. bodies, pedicles, open intervertebral disk
• Have the patient relax the shoulders as spaces, and open intervertebral foramina
much as possible. of the side that the central ray enters are
• Ensure that the patient is looking shown. This projection provides excellent
straight ahead without any rotation of detail of the facet joints, and it is impor-
the head or neck. tant in detecting subluxations and dis­
• Place the IR under the immobilization locations (Fig. 13-19). If the 15-degree
device, if present, centered at the level cephalic angle is not used, the interverte-
of C4 and the adjacent mastoid process bral foramina are foreshortened. Evidence
(about 3 inches [7.6 cm] lateral to mid- of proper collimation should be visible.
sagittal plane of neck) (Fig. 13-18). If a NOTE: If the patient is not on a backboard or an
grid IR is used with one central ray x-ray table, preferably the attending physician
angle, the grid lines should be perpen- should lift the patient’s head and neck while the
dicular to the long axis of the spine. radiographer positions the IR under the patient.
• The central ray is directed 45 degrees
lateromedially. When a double angle is
used, angle 15 to 20 degrees cephalad.
• The central ray enters slightly lateral
to the midsagittal plane at the level
of the thyroid cartilage and passing
through C4.
• The central ray exit point should coin-
cide with the center of the IR.
Fig. 13-19  AP axial oblique projection of cervical vertebrae performed
on a trauma patient using 45-degree angle. Radiograph was made
using non–grid exposure technique. Negative image. Note excellent
alignment of vertebral bodies and intervertebral foramen.
 Thoracic and Lumbar Spine

LATERAL PROJECTIONS Structures shown

• Lumbar spine: Center the IR at the level
Dorsal decubitus positions of the iliac crests (Fig. 13-20). DR field
Trauma positioning tips projected size extends from the xiphoid
• Always perform dorsal decubitus posi- to the midsacrum and 8 inches (20 cm)
tions before AP projections of the spine in anteroposterior width, centered at the
For the thoracic spine, the image should
include T3 or T4-L1. The lumbar spine
image should, at a minimum, include T12
to the sacrum. The vertebral bodies should

Thoracic and Lumbar Spine

because the attending physician should
review the dorsal decubitus lateral pro-
jections to rule out vertebral fracture or
dislocation before other projections are
performed.
• Move the patient as little as possible.
• Use of a grid is necessary to improve
image contrast. Use a vertical Bucky, if
not working with a C-arm configured
unit, to maximize positioning and for
optimal image quality.
• Shield gonads and other personnel in
the room.
level of the midcoronal plane.
• Ensure that the IR is perfectly vertical.
• The central ray is horizontal, perpen-
dicular to the longitudinal center of the
IR, and going through the spine.
• Collimate closely to the spine to reduce
scattered radiation and patient dose.
be seen in profile with minimal rotation
and distortion. Density and contrast should
be sufficient to show cortical margins and
bony trabeculation (Fig. 13-21). Evidence
of proper collimation should be visible.
NOTE: A lateral projection of the cervicothoracic
spine must be performed to allow visualization of
the upper thoracic spine in profile.

Patient position considerations

• The patient is generally immobilized
and on a backboard.
• Have the patient cross the arms over the
chest to remove them from the anatomy
of interest.
• Thoracic spine: Place the top of the IR
1 1 2 to 2 inches (3.8 to 5 cm) above the
patient’s relaxed shoulders. DR field
projected size is from the jugular notch
to the inferior costal margin and 7 Horizontal CR to top
inches (18 cm) in anteroposterior width, of iliac crest
centered at the level of the midcoronal Fig. 13-20  Patient and IR positioned for trauma lateral projection of lumbar spine using
plane. dorsal decubitus position and vertical Bucky device.

A B
Fig. 13-21  Dorsal decubitus position lateral projection of lumbar spine performed on a
trauma patient. A, Fracture and dislocation of L2 (black arrow). Note backboard (white
arrow). B, Compression fracture of body of L2 (arrow). This coned-down image provides
better detail of fracture area.

35
 Chest
AP PROJECTION1,2
Trauma positioning tips
• Most trauma patients must be imaged
in the supine position. If it is necessary
to see air-fluid levels, a cross-table
Trauma Radiography
lateral x-ray beam (dorsal decubitus
position) can be performed. (Note:
Patients with chest trauma with sus-
pected vascular injury may be referred
to CT first.)
• Obtain help in lifting the patient to posi-
tion the IR if the stretcher is not
equipped with an IR tray or a C-arm
configured trauma unit is not being
used.
• Check for signs of respiratory distress
or changes in level of consciousness
during radiographic examination, and
report any changes to the attending
physician immediately.
1
See standard projection, Volume 1.
2
See mobile projection, Volume 3.
36
• Assess the patient’s ability to follow
breathing instructions.
• Use the maximum SID possible to
minimize magnification of the heart
shadow.
• Use universal precautions if wounds or
bleeding or both are present, and protect
the IR with plastic covering.
• Mark entrance and exit wounds with
radiopaque indicators if evaluating a
penetrating injury.
• Use of a grid improves image
contrast.
• Shield gonads and other personnel in
the room.
Patient position considerations
• Position the top of the IR about 1 1 2 to
2 inches (3.8 to 5 cm) above the
patient’s shoulders. DR field size should
measure approximately 14 × 17 inches
(35 × 43 cm) oriented to accommodate
the patient’s body habitus.
• Move the patient’s arms away from the
thorax and out of the collimated field.
• Ensure that the patient is looking
straight ahead with the chin extended
out of the collimated field.
• Check for rotation by determining
whether the shoulders are equidistant to
the IR or stretcher. This position places
the midcoronal plane parallel to the IR,
minimizing image distortion.
• The central ray should be directed per-
pendicular to the center of the IR at a
point 3 inches (7.6 cm) below the
jugular notch (Fig. 13-22).
CR to center of IR
Fig. 13-22  Patient and IR positioned for
trauma AP projection of chest.
 Chest

Structures shown NOTE: Ribs are visible on an AP projection,

AP projection of the thorax is shown. The
lung fields should be included in their
entirety, with minimal rotation and distor-
tion present. Adequate aeration of the
necessitating the use of a grid IR to increase
image contrast. Use proper breathing instructions
and techniques to ensure adequate visualization
of ribs of interest.

Chest
lungs must be imaged to show the lung
parenchyma (Fig. 13-23). Evidence of
proper collimation should be visible.

A B
Fig. 13-23  AP upright projection of chest performed on a trauma patient. A, Multiple
buckshot in chest caused hemopneumothorax. Arrows show margin of collapsed lung
with free air laterally. Arrowhead shows fluid level at costophrenic angle, left lung.
B, Open safety pin lodged in esophagus of a 13-month-old infant.

37
 Abdomen
AP PROJECTION1,2
Trauma positioning tips
• Note: Sonography is often used to eval-
uate abdominal trauma.
• Use of a grid provides optimal image
Trauma Radiography
quality. If not working with a C-arm
configured unit, verify transfer to a
standard x-ray table with the attending
physician before moving the patient.
• Determine the possibility of fluid accu-
mulation within the abdominal cavity to
establish appropriate exposure factors.
• For patients with blunt force or projec-
tile injuries, check for signs of internal
bleeding during radiographic examina-
tion and report any changes to the
attending physician immediately.
1
See standard projection, Volume 2.
2
See mobile projection, Volume 3.
38
• Mark entrance and exit wounds with
radiopaque markers if evaluating pro-
jectile injuries.
• Assess the ability of the patient to
follow breathing instructions.
• Use standard precautions if wounds or
bleeding or both are present, and protect
the IR with plastic covering if it is to
come in contact with the patient.
• Shield gonads, if possible, and other
personnel in the room.
Patient position considerations
• Ask ED personnel to assist in transfer-
ring the patient to the radiographic
table, if possible.
• If not working with a C-arm configured
trauma unit and transfer is not advis-
able, obtain assistance to lift the patient
carefully to position the grid IR under
the patient, centered to the level of iliac
CR
Bucky
Fig. 13-24  Patient and IR positioned for trauma AP projection of
abdomen.
crest (Fig. 13-24). (On patients with a
long torso, a second AP projection of
the upper abdomen may be required to
show the diaphragm and lower ribs.)
• If the patient is on a stretcher, check
that the grid IR is parallel with the
patient’s midcoronal plane. Correct
tilting with sponges, sandbags, or rolled
towels. The grid IR must be perfectly
horizontal to prevent grid cutoff and
image distortion. If you are unable to
correct tilt on grid IR, angle the central
ray to maintain part–IR–central ray
alignment.
• The central ray is directed to the center
of the IR. The DR collimated field
should be approximately 17 inches
(43 cm) in length on adult sthenic
patients, and the width should be
approximately 1 inch (2.5 cm) beyond
the skin margin.
 Abdomen

Structures shown
AP projection of the abdomen is shown.
The entire abdomen including the pubic
symphysis and diaphragm should be
included without distortion or rotation.

Abdomen
Density and contrast should be adequate
to show tissue interfaces, such as the
lower margin of the liver, kidney shadows,
psoas muscles, and cortical margins of
bones (Fig. 13-25). Evidence of proper
collimation should be visible.

A B
Fig. 13-25  AP projection of abdomen performed on a trauma patient. A, Table knife
in stomach along with other small metallic foreign bodies swallowed by the patient.
B, Coin in stomach swallowed by the patient.

39
 Abdomen

AP PROJECTION1,2
• Use universal precautions if wounds or • The patient should be in the lateral posi-
Left lateral decubitus position bleeding or both are present, and protect tion at least 5 minutes before the expo-
Trauma positioning tips the IR with plastic covering. Mark all sure to allow any free air to rise and be
• If not using a C-arm configured unit, a entrance and exit wounds with radi- visualized.
vertical Bucky provides optimal image opaque markers when imaging for pen- • The central ray is directed horizontal
Trauma Radiography

quality. If the patient must be imaged
using a mobile radiographic unit, a grid
IR is required.
• Verify with the attending physician
that patient movement is possible and
whether the image is necessary to assess
fluid accumulation or free air in the
abdominal cavity.
• The left lateral decubitus position
shows free air in the abdominal cavity
because the density of the liver pro-
vides good contrast for visualization of
any free air.
• If fluid accumulation is of primary
interest, the side down, or dependent
side, must be elevated off the stretcher
or table to be completely shown.
• Check for signs of internal bleeding
during the radiographic examination,
and report any changes to the attending
physician immediately.
etrating injuries.
• Shield gonads, if possible, and person-
nel in the room.
Patient position considerations
• Carefully and slowly turn the patient
into the recumbent left lateral position.
Flex the knees to provide stability.
• If the image is being taken for visual-
ization of fluid, carefully place a block
under the length of the abdomen to
ensure that the entire right side is
visualized.
• Ensure that the midcoronal plane is ver-
tical to prevent image distortion.
• Center the IR 2 inches (5 cm) above the
iliac crests to include the diaphragm
(Fig. 13-26). DR field size should be
approximately 17 inches (43 cm) in
length, and the width should be 1 inch
(2.5 cm) beyond the skin margins.
and perpendicular to the center of the
IR.
Structures shown
Air and fluid levels within the abdominal
cavity are shown. This projection is espe-
cially helpful in assessing free air in the
abdomen when an upright position cannot
be used. Density and contrast should be
adequate to show tissue interfaces, such as
the lower margin of the liver, kidney
shadows, psoas muscles, and cortical
margins of bones (Fig. 13-27). Evidence
of proper collimation should be visible.
NOTE: A lateral projection using the dorsal decu-
bitus position may be substituted for this projec-
tion if the patient is too ill or injured to be
positioned properly in a left lateral position. (The
position is identical to the dorsal decubitus posi-
tion, lateral projection of the lumbar spine. See
Fig. 13-20.)

1
See standard projection, Volume 2.
2
See mobile projection, Volume 3.

Horizontal CR to center of IR
Fig. 13-26  Patient and IR positioned for trauma AP projection of
abdomen using left lateral decubitus position and using vertical
Bucky device.
Fig. 13-27  Left lateral decubitus position AP projection of
abdomen performed on a trauma patient. Free intraperitoneal
air is seen on upper right side of abdomen (arrow). Radiograph is
slightly underexposed to show free air more easily.

40
 Pelvis

AP PROJECTION1,2 Patient position considerations • The DR field size should be approxi-

Trauma positioning tips • The patient is supine, possibly on a mately 14 × 17 inches (35 × 43 cm).
• Note: Level I centers often refer patients backboard or in trauma pants. Check the collimated field to ensure
with pelvic trauma to CT first because • Carefully and slowly transfer the patient that the iliac crests and the hip joints are
research has shown that CT is superior to the radiographic table to allow the included.

in showing fracture extent and associ-
ated visceral and vascular damage.
• Up to 50% of pelvic fractures are fatal
as a result of vascular damage and
shock. The mortality risk increases with
the energy of the force and according to
the health of the victim.
• Pelvic fractures have a high incidence
of internal hemorrhage. Alert the
attending physician immediately if the
abdomen becomes distended and firm.
• Hemorrhagic shock is common with
pelvic and abdominal injuries. Reassess
the patient’s level of consciousness
repeatedly while performing radio-
graphic examinations.
• Do not attempt internal rotation of the
limbs for true AP projection of proxi-
mal femora on this projection.
• Collimate closely to reduce scatter
radiation.
• Shield gonads, if possible, and other
personnel in the room.
1
See standard projection, Volume 1.
2
See mobile projection, Volume 3.
Pelvis
use of a Bucky, if not working with a
C-arm configured unit. Structures shown
• If unable to transfer the patient, use a The pelvis and proximal femora should be
grid IR positioned under the immobili- shown in their entirety with minimal rota-
zation device or patient. Ensure that the tion and distortion. Femoral necks are
grid is horizontal and parallel to the foreshortened, and lesser trochanters are
patient’s midcoronal plane to minimize seen. Optimal density and contrast should
distortion and rotation. Carefully align show bony trabeculation and soft tissue
it to the central ray to minimize distor- shadows (Fig. 13-29). Evidence of proper
tion and rotation. collimation should be visible.
• Position the IR so that the center is 2
inches (5 cm) inferior to the anterior
superior iliac spine or 2 inches (5 cm)
superior to the pubic symphysis.
• The central ray is directed perpendicu-
lar to the center of the IR (Fig. 13-28).
CR

Bucky
Fig. 13-28  Patient and IR positioned for trauma AP projection of
pelvis.

A B
Fig. 13-29  AP projection of pelvis performed on a trauma patient. A, Entire right limb
torn off after being hit by a car. Pelvic bone was disarticulated at pubic symphysis and
sacroiliac joint. The patient survived. B, Separation of pubic bones (arrowheads)
anteriorly and associated fracture of left ilium (arrow).

41
 Cranium

LATERAL PROJECTION1 Patient position considerations

• Vomiting is a symptom of intracranial
Dorsal decubitus position injury. If a patient begins to vomit, • Have the patient relax the shoulders.
Trauma positioning tips logroll him or her to a lateral position • After cervical spine injury has been
• Note: Patients with head injuries are to prevent aspiration, and alert the ruled out, the patient’s head may be
often referred to CT imaging first attending physician immediately. positioned to align the interpupillary
Trauma Radiography

because of its superiority in showing
associated soft tissue and vascular
damage.
• Because the scalp and face are vascular,
these areas tend to bleed profusely.
Protect IRs with plastic covering and
practice universal precautions.
• A grid IR is used for this projection.
Elevate the patient’s head on a radiolu-
cent sponge only after cervical injury,
such as fracture or dislocation, has
been ruled out.
1
See standard projection, Volume 2.
• Alert the attending physician immedi-
ately if there is any change in the
patient’s level of consciousness or if the
pupils are unequal.
• Collimate closely to reduce scatter
radiation.
• Shield gonads and other personnel in
the room.
line perpendicular to the IR and the
midsagittal plane vertical.
• If the patient is wearing a cervical
collar, carefully minimize rotation and
tilt of the cranium.
• Ensure that the IR is vertical.
• Direct the central ray horizontal enter-
ing perpendicular to a point 2 inches
(5 cm) above the EAM (Fig. 13-30).
The DR field should be set to 12 inches
(30 cm) in the anteroposterior dimen-
sion and 10 inches (24 cm) in the
supero­inferior dimension.

1" block

Horizontal CR
2 inches above EAM
Fig. 13-30  Patient and IR positioned for trauma lateral projection of cranium using dorsal
decubitus position. Note sponge in place to raise head to show posterior cranium (after
checking lateral cervical spine radiograph).

42
 Cranium

Structures shown
A profile image of the superimposed
halves of the cranium is seen with detail
of the side closer to the IR shown (Fig.
13-31). With some injuries, air-fluid levels

Cranium
can be shown in the sphenoid sinuses.
Evidence of proper collimation should be
visible.
NOTE: The supine lateral position may be used on
a patient without a cervical spine injury. See
Volume 2, p. 294-295.

A B
Fig. 13-31  Dorsal decubitus position lateral projection of cranium performed on a
trauma patient. A, Two GSWs entering at level of C1 and traveling forward to face and
lodging in area of zygomas. Note bullet fragments in EAM area. B, Multiple frontal skull
fractures (arrows) caused by hitting windshield during MVA.

43
 Cranium

AP PROJECTION1
• Vomiting is a symptom of an intracra- • If the patient is not transferred to the
AP AXIAL PROJECTION—TOWNE nial injury. If a patient begins to vomit, radiographic table, the grid IR should
METHOD2 logroll him or her to a lateral position be placed under the immobilization
Trauma positioning tips to prevent aspiration and alert the device. If no such device is present, the
• Profuse bleeding should be anticipated attending physician immediately. attending physician should carefully lift
Trauma Radiography

with head and facial injuries. Use uni-
versal precautions and protect IRs and
sponges with plastic.
• Cervical spine injury should be ruled
out before attempting to position the
head.
• AP projection is used for injury to the
anterior cranium. The AP axial projec-
tion, Towne method, shows the poste-
rior cranium.
1
See standard projection, Volume 2.
2
See standard projection, Volume 2.
• Alert the attending physician if the
patient’s level of consciousness
decreases or if pupils are unequal.
• Collimate closely to 1 inch (2.5 cm)
beyond projected skin shadows on all
sides of the cranium to reduce scatter
radiation.
• A grid IR or Bucky should be used to
ensure proper image contrast.
• Shield gonads and other personnel in
the room.
Patient position considerations
• If not using a C-arm configured unit,
and if the patient’s condition allows,
carefully and slowly transfer the patient
to the x-ray table using the immobiliza-
tion device and proper transfer tech-
niques. Transfer allows the use of the
Bucky and minimizes risk of injury to
the patient when positioning the IR.
the patient’s head and neck while the
radiographer positions the grid IR under
the patient.
• After a cervical spine injury has been
ruled out, the patient’s head may be
positioned to place the orbitomeatal
line (OML) or infraorbitomeatal line
(IOML) and midsagittal plane perpen-
dicular to the IR.
• If the patient is wearing a cervical
collar, the OML or IOML cannot be
positioned perpendicularly. For the AP
axial projection, Towne method, the
central ray angle may have to be
increased 60 degrees caudad, while a
30-degree angle to the OML is
maintained.

CR

Bucky
Fig. 13-32  Patient and IR positioned for trauma AP Fig. 13-33  AP projection of cranium performed on a trauma
projection of cranium. patient. Fracture of occipital bone (arrow).

44
 Cranium

• For an AP projection, the central ray Structures shown

enters perpendicular to the nasion (Fig. AP projection shows the anterior cranium
13-32). An AP axial projection with the (Fig. 13-34). AP axial projection, Towne
central ray directed 15 degrees cepha- method, shows the posterior cranium and
lad is sometimes performed in place of, foramen magnum (Fig. 13-35). Evidence

Cranium
or to accompany, the AP projection. of proper collimation should be visible.
• For AP axial projection, Towne method,
position the top of the IR at the level of
the cranial vertex. The central ray is
directed 30 degrees caudad to the OML
or 37 degrees to the IOML (Fig. 13-33).
The central ray passes through the
EAM and exits the foramen magnum.
• The DR field should be set at 10 inches
(24 cm) wide and 12 inches (30 cm) in
the inferosuperior dimension, centered
the same as for an imaging plate, as
specified previously.

CR

30°

Bucky
Fig. 13-34  Patient and IR positioned for trauma AP
axial projection, Towne method, of cranium using
30-degree central ray (CR) angulation.
Fig. 13-35  AP axial projection, Towne method, performed on a trauma
patient with GSW to the head. Metal clip (upper arrow) indicates
entrance of bullet on anterior cranium. Flattened bullet and fragments
(lower arrow) are lodged in area of C2.

45
 Facial Bones

ACANTHIOPARIETAL Patient position considerations Structures shown

PROJECTION1
• If required and if the patient’s condition The superior facial bones are shown (Fig.
REVERSE WATERS METHOD allows, carefully and slowly transfer 13-37). The image should be similar to
Trauma positioning tips the patient to the x-ray table using the parietoacanthial projection or routine
• Anticipate profuse bleeding with facial the immobilization device and proper Waters method and should show symme-
Trauma Radiography

trauma. Protect IRs with plastic cover-
ing and practice universal precautions.
• Cervical spine injury should be ruled
out before positioning of the head is
attempted.
• Alert the attending physician if the pa-
tient’s level of consciousness decreases
or if pupils are unequal.
• A grid IR or Bucky is used to ensure
proper image contrast.
• Collimate closely to the facial bones to
reduce scatter radiation. The DR field
should be set at approximately 10 inches
(24 cm) wide and 12 inches (30 cm) in
the inferosuperior dimension.
• Shield gonads and other personnel in
the room.
1
See standard projection, Volume 2.
transfer techniques. Transfer allows use try of the face. Evidence of proper colli-
of the Bucky and minimizes risk of mation should be visible.
injury to the patient when the IR is
positioned.
• If mobile radiography must be used,
the grid IR should be placed under
the immobilization device. If no such
device is present, the attending physi-
cian should carefully lift the patient’s
head and neck while the radiographer
positions the grid IR under the patient.
CR
• Trauma patients are often unable to
hyperextend the neck far enough to
allow placement of the OML 37 degrees
to the IR and the MML perpendicular
to the plane of the IR. In these patients,
the acanthioparietal projection, or
the reverse Waters projection, can be
achieved by adjusting the central ray
so that it enters the acanthion while
remaining parallel with the MML.
• The midsagittal plane should be per-
pendicular to prevent rotation. Bucky
• The central ray is angled cephalad until Fig. 13-36  Central ray aligned parallel to
it is parallel with the MML. The central MML for trauma acanthioparietal
ray enters the acanthion (Fig. 13-36). projection, reverse Waters method, of
• Center the IR to the central ray. cranium.

A B
Fig. 13-37  Acanthioparietal projections, reverse Waters method, performed on trauma
patients to show facial bones. A, Fracture of right orbital floor (arrow) with blood-filled
maxillary sinus (note no air is in sinus). The patient hit face on steering wheel during MVA.
B, Blowout fracture of left orbital floor (arrow) with blood-filled maxillary sinus (note no air
is in sinus). Patient was hit with a fist.

46
 Upper Limb

Trauma positioning tips
• Use standard precautions, and cover
IRs and positioning aids in plastic if
wounds are present.
• When lifting an injured limb, support it
• Check the patient’s status during radio-
graphic examination. Shock can occur
from crushing injuries to extremities.
• Long bone radiographs must include
both joints on the image.
Patient position considerations
• If possible, demonstrate the desired
position for a conscious patient. Assist
the patient in attempting to assume the
position, rather than moving the injured

at both joints and lift slowly. Lift only
enough to place the IR under the part—
sometimes only 1 to 2 inches (2.5 to
5 cm). Always obtain help in lifting
injured limbs and positioning the IRs to
minimize patient discomfort.
• If the limb is severely injured, do not
attempt to position for true AP or lateral
projections. Expose the two projec-
tions, 90 degrees apart, while moving
the injured limb as little as possible.
• Separate examinations of the adjacent
joints may be required if injury indi-
cates. Do not attempt to “short cut” by
performing only one projection of the
long bone.
• Shield gonads and other personnel in
the room.
Upper Limb
limb.
• If the patient is unable to position the
limb close to that required, move the IR
and x-ray tube to obtain the desired pro-
jection (Figs. 13-38 to 13-41).

CR to center of IR 2-inch block Horizontal CR to center of IR

Fig. 13-38  Patient and IR positioned for trauma AP Fig. 13-39  Patient and IR positioned for trauma cross-table lateral
projection of forearm. projection of forearm.

47
 Upper Limb

• Shoulder injuries should be initially

imaged “as is” without rotating the
limb. The “reverse” PA oblique projec-
tion of the scapular Y (an AP oblique)
is useful in showing dislocation of
Trauma Radiography

the glenohumeral joint with minimal

patient movement. The patient is turned
up 45 degrees and is supported in posi-
tion (Figs. 13-42 and 13-43).
• If imaging while the patient is still on a
stretcher, check to ensure that the IR is
perfectly horizontal to minimize image
distortion.
• The central ray must be directed per-
pendicular to the IR to minimize
distortion.
• Immobilization techniques for the IR
and upper limb are useful in obtaining
an optimal image with minimal patient
discomfort.

Fig. 13-40  AP projection of forearm performed on a trauma patient. Fracture of

midportion of radius and ulna (arrows).

CR

45° wedge

Bucky
Fig. 13-41  Cross-table lateral projection of forearm performed on Fig. 13-42  Patient and IR positioned for trauma AP
a trauma patient. GSW to forearm with fracture of radius and oblique projection of shoulder to show scapular Y.
ulna and extensive soft tissue damage. (Reverse of PA oblique, scapular Y—see Chapter 5.)

48
 Upper Limb

Structures shown
Images of the anatomy of interest, 90
degrees from one another, should be
shown. Density and contrast should be
sufficient to visualize cortical margins,

Upper Limb
bony trabeculation, and surrounding soft
tissues. Both joints should be included in
projections of long bones. Projections of
adjacent joints must be centered to the
joint to show the articular ends properly
(Figs. 13-44 and 13-45). Evidence of
proper collimation should be visible.

CR to center of IR

Fig. 13-44  Patient and IR positioned for

trauma AP projection of humerus.

Fig. 13-43  AP oblique projection of shoulder (reverse of PA Fig. 13-45  AP projection of humerus
oblique, scapular Y) performed on a trauma patient. Several performed on a trauma patient. Fracture
fractures of scapula (arrows) with significant displacement. of midshaft of humerus.

49
 Lower Limb

Trauma positioning tips
• Use standard precautions, and cover
IRs and positioning aids in plastic if
open wounds are present.
• Immobilization devices are often
Trauma Radiography
• If the limb is severely injured, do not
attempt to position it for true AP and
lateral projections. Take two projec-
tions, 90 degrees apart, moving the
injured limb as little as possible.
Patient position considerations
• Demonstrate or describe the desired
position for the patient and allow him
or her to attempt to assume the position,
rather than moving the injured limb.

present with injuries to the lower limbs,
especially in cases with suspected
femoral fractures. Perform image pro-
cedures with immobilization in place,
unless directed to remove them by the
attending physician.
• When lifting an injured limb, support at
both joints and lift slowly. Lift only
enough to place the IR under the part—
sometimes only 1 to 2 inches (2.5
to 5 cm). Always obtain help in lifting
injured limbs and in positioning IRs
to minimize patient discomfort (Fig.
13-46).
• Long bone examinations must include
both joints. Separate images may be
required.
• Examinations of adjacent joints may be
required if the condition indicates. The
central ray and IR must be properly
centered to the joint of interest to show
the anatomy properly.
• Check on patient status during radio-
graphic examination. Shock can occur
with severe injuries to the lower
extremities.
• A grid IR should be used on thicker
anatomic parts, such as the femur.
• Shield gonads and other personnel in
the room.
Assist the patient as needed.
• If the patient is unable to position the
limb close to the required true position,
move the IR and x-ray tube to obtain
projection (Figs. 13-47 and 13-48).
• If imaging while the patient is still on a
stretcher, check to ensure that the IR is
perfectly horizontal to minimize image
distortion.
• The central ray must be directed per-
pendicular to the IR to minimize
distortion.
• Immobilization techniques for the IR
and lower limb are extremely useful in
obtaining optimal quality with minimal
patient discomfort.

Fig. 13-46  Proper method of lifting lower limb for placement of IR (for AP projection) or
placement of elevation blocks (for cross-table lateral). Lift only high enough to place IR
or blocks underneath. Note that two hands are used to lift this patient with a broken leg
gently.

50
Lower Limb

Lower Limb
2-inch block Horizontal CR to center of IR
Fig. 13-47  Patient and IR positioned for trauma cross-table lateral projection of lower leg. IR and central
ray (CR) may be moved superiorly or inferiorly to center for other portions of lower limb. Note positioning
blocks placed under limb to elevate it so that all anatomy of interest is seen.

A B
Fig. 13-48  Cross-table lateral projection of lower limb performed on a trauma patient.
A, Dislocation of tibia from talus (double arrows) and fracture of fibula (arrow).
B, Complete fracture and displacement of femur. Proximal femur is seen in AP
projection, and distal femur is rotated 90 degrees at fracture point, resulting in lateral
projection. Note artifacts caused by immobilization devices.

51
 Lower Limb

Structures shown
CR Images of the anatomy of interest, 90
degrees from each other, should be shown.
Density and contrast should be sufficient
Wedge to visualize cortical margins, bony tra-
Trauma Radiography

beculation, and surrounding soft tissues.

Both joints should be included in exami-
nations of long bones. Images of articula-
tions must be properly centered to show
anatomy properly (Figs. 13-49 and 13-
Fig. 13-49  Patient and IR positioned for trauma AP projection of foot or toes. IR is 50). Evidence of proper collimation
supported with sandbags for positioning against foot.
should be visible.

A B
Fig. 13-50  AP projection of foot performed on a trauma patient. A, Fracture and
dislocation of tarsal bones with exposure technique adjusted for optimal image of this
area. B, GSW to great toe.

52
 OTHER IMAGING PROCEDURES IN TRAUMA

Follow-up imaging procedures by other

modalities are often warranted when
radiography reveals a traumatic injury. In
many instances, however, radiography is
not the modality used first for detection of

Computed Tomography
injuries sustained in a trauma. Because of
this fact, most trauma centers have CT
readily available or a dedicated unit for
trauma cases (Figs. 13-51 to 13-54). The
role of sonography in trauma imaging has
increased significantly, and it provides the
advantage of yielding a great deal of diag-
nostic information without radiation expo-
sure. Magnetic resonance imaging (MRI)
has also increased in its utility in trauma
imaging, primarily owing to decreased
scan times provided by newer scan proto-
cols and techniques. Fig. 13-51  CT scan of C5 showing multiple fractures (arrows) resulting from a fall from a
tree. (Courtesy Sunie Grossman, RT[R], St. Bernard’s Medical Center, Jonesboro, AR.)

Computed Tomography
In many major trauma centers, CT is
readily available for emergency imaging.
This fact has influenced the decision-
making policies associated with diagnos-
tic imaging of trauma. CT is the first
imaging modality used for trauma to the
following parts of the body:
• Head and brain
• Cervical spine
• Thorax
• Pelvis
The Glasgow Coma Scale (GCS) is
often the diagnostic indicator for the
necessity of a head CT scan. The GCS is
used to provide an objective and consis-
tent neurologic evaluation. The highest
possible score is 15, and the lowest

Fig. 13-52  CT scan of pelvis showing fracture of left ilium (arrow) Fig. 13-53  Three-dimensional reconstruction of pelvis from the
with fragment displacement. Clothing and backboard artifacts patient in Fig. 13-52. Multiple pelvic fractures are well visualized
are evident. (arrows).

(Courtesy St. Bernard’s Medical Center, Jonesboro, AR.) (Courtesy St. Bernard’s Medical Center, Jonesboro, AR.)

53
Trauma Radiography

B
Fig. 13-54  A, AP and lateral CT scout images of cranium. Note knife placement in
cranium. Conventional cranium radiographs were not obtained on this trauma patient.
The patient was sent directly to CT scanner for these images and sectional images
before going to surgery. The patient recovered and returned home. B, Axial and coronal
CT sectional images of cranium at level of the eye. The patient was shot in the left eye
with a BB gun. Note BB (arrow). Adjacent black area is air. The patient now has
monocular vision.

(A, Courtesy Tony Hofmann, RT[R][CT], Shands Hospital School of Radiologic Technology, Jacksonville,
FL; B, courtesy Mark H. Layne, RT[R].)

54
possible score is 3. The GCS score and
other head injury signs and symptoms,
such as headache, loss of consciousness,
post-traumatic amnesia, and seizure, are
used to determine whether a head CT scan
is required. Patients with cervical spine
injuries are often referred to CT first,
especially patients with multiple injuries
and associated symptoms of cord injury.
CT of the thorax is often the first imaging
modality used in cases of suspected aortic
dissection. Chest radiography is still the
gold standard for many emergency cases
involving the thorax, but because of time
factors, patients with certain types of force
trauma are sent directly to the CT scanner.
CT of the pelvis is often performed in
place of radiography because CT shows
the extent of pelvic fractures better than
radiography and offers the advantage of
showing injuries to the pelvic organs and
vasculature simultaneously.
Diagnostic Medical
Sonography
The role of sonography in emergency
imaging is evolving and increasing
rapidly. Focused abdominal sonography
in trauma (FAST) has been recognized as
a valuable trauma diagnostic imaging
tool. Research continues to assess the role
of sonography in trauma imaging, and a
wide variety of procedures have been
studied so far, such as pediatric fracture
reduction; chest and thoracic trauma, spe-
cifically pneumothorax and hemorrhage in
Diagnostic Medical Sonography
the abdomen and pelvis; cranial trauma in
infants; and superficial musculoskeletal
sprains and tears. Advantages of sonogra-
phy in trauma include lack of radiation
exposure and improved efficiency of
image access. The disadvantage is that
sonography image quality is critically
operator-dependent, and the ED physician
may be uncomfortable with image inter-
pretation, requiring the presence of a
radiologist.
55
 Selected bibliography
American College of Emergency Physicians:
Policy statement: emergency ultrasound
guidelines, Ann Emerg Med 53:550, 2009.
American College of Surgeons: National
Trauma Radiography
Centers for Disease Control and Prevention:
Guidelines for field triage of injured
patients: recommendations of the national
expert panel on field triage, MMWR Morb
Mortal Wkly Rep, Available at: http://
Kool D, Blickman J: Advanced trauma life
support. ABCDE from a radiological point
of view, Emerg Radiol 14:135, 2007.
Shanmuganathan K, Matsumoto J: Imaging of
penetrating chest trauma, Radiol Clin North

trauma databank annual report, 2012, www.cdc.gov/mmwr/preview/mmwrhtml/ Am 44:225, 2006.

Available at: http://www.facs.org/trauma/
ntdb/docpub.html. Accessed August 29,
2013.
Bagley L: Imaging of spinal trauma, Radiol
Clin North Am 44:1, 2006.
rr5801a1.htm. Accessed August 4, 2009.
Jagoda A et al: Clinical policy: neuroimaging
and decision making in adult mild traumatic
brain injury in the acute setting, Ann Emerg
Med 52:714, 2008.

56
 14 
MOUTH AND SALIVARY GLANDS

OUTLINE
SUMMARY OF PROJECTIONS, 58
ANATOMY, 59
Mouth, 59
Salivary Glands, 60
Summary of Anatomy, 61
RADIOGRAPHY, 62
Summary of Pathology, 62
Sialography, 62
Parotid Gland, 64
Parotid and Submandibular
Glands, 66

57
 SUMMARY OF PROJECTIONS

PROJECTIONS, POSITIONS, AND METHODS

Page Essential Anatomy Projection Position Method
64 Parotid gland Tangential
66 Parotid and submandibular glands Lateral R or L

58
 ANATOMY
Mouth
The mouth, or oral cavity, is the first divi-
sion of the digestive system (Fig. 14-1). It
encloses the dental arches and receives the
saliva secreted by the salivary glands. The
cavity of the mouth is divided into (1) the
oral vestibule, the space between the teeth
and the cheeks, and (2) the oral cavity, or
mouth proper, the space within the dental
arches. The roof of the oral cavity is
formed by the hard and soft palates. The
floor is formed principally by the tongue,
and it communicates with the pharynx
posteriorly via the oropharynx.
The hard palate is the anteriormost
portion of the roof of the oral cavity. The
hard palate is formed by the horizontal
plates of the maxillae and palatine bones.
The anterior and lateral boundaries are
formed by the inner wall of the maxillary
alveolar processes, which extend superi-
orly and medially to blend with the hori-
zontal processes. The height of the hard
palate varies considerably, and it deter-
mines the angulation of the inner surface
of the alveolar process. The angle is less
when the palate is high and is greater
when the palate is low.
Hard palate
Posterior arch
Uvula
Anterior arch
Soft palate
Tonsil
Apex
Fig. 14-1  Anterior view of oral cavity.
The soft palate begins behind the last
molar and is suspended from the posterior
border of the hard palate. Highly sensitive
to touch, the soft palate is a movable mus-
culomembranous structure that functions
chiefly as a partial septum between the
mouth and the pharynx. At the center of
the inferior border, the soft palate is pro-
longed into a small, pendulous process
called the uvula. On each side of the
uvula, two arched folds extend laterally
and inferiorly. The anterior arches project
forward to the sides of the base of the
tongue. The posterior arches project pos-
teriorly to blend with the posterolateral
walls of the pharynx. The triangular space
between the anterior and posterior arches
is occupied by the palatine tonsil.
The tongue is situated in the floor of the
oral cavity, with its base directed posteri-
orly and its apex directed anteriorly (Fig.
14-2; see Fig. 14-1). The tongue is freely
movable. The tongue is composed of
numerous muscles and is covered with a
mucous membrane that varies in complex-
ity in the different regions of the organ.
The extrinsic muscles of the tongue form
the greater part of the oral floor. The
Sublingual
space
Orifice of
submandibular
duct
Fig. 14-2  Anterior view of undersurface of tongue and
floor of mouth.
mucous membrane covering the undersur-
face of the tongue is reflected laterally
over the remainder of the floor to the
gums. This part of the floor lies under the
free anterior and lateral portions of the
tongue and is called the sublingual space.
Posterior movement of the free anterior
Mouth
part of the tongue is restricted by a median
vertical band, or fold, of mucous mem-
brane called the frenulum of the tongue,
which extends between the undersurface
of the tongue and the sublingual space. On
each side of the frenulum, extending
around the outer limits of the sublingual
space and over the underlying salivary
glands, the mucous membrane is elevated
into a crestlike ridge called the sublingual
fold. In the relaxed state, the two folds are
quite prominent and are in contact with
the gums.
The teeth serve the function of mastica-
tion, the process of chewing and grinding
food into small pieces. During mastica-
tion, the teeth cut, grind, and tear food,
which is then mixed with saliva and swal-
lowed, and later digested. The saliva
softens the food, keeps the mouth moist,
and contributes digestive enzymes.
Tongue
Frenulum of
tongue
Sublingual fold
59
 Salivary Glands
The three pairs of salivary glands produce
approximately 1 L of saliva each day. The
glands are named the parotid, submandibu-
lar, and sublingual (Fig. 14-3). Each gland
is composed of numerous lobes, and each
lobe contains small lobules. The whole
Mouth and Salivary Glands
Each of the parotid glands, the largest
of the salivary glands, consists of a flat-
tened superficial portion and a wedge-
shaped deep portion (Fig. 14-4). The
superficial part lies immediately anterior
to the external ear and extends inferiorly
to the mandibular ramus and posteriorly
The submandibular glands are large,
irregularly shaped glands. On each side,
a submandibular gland extends posteri-
orly from a point below the first molar
almost to the angle of the mandible (Fig.
14-5). Although the upper part of the
gland rests against the inner surface of the

gland is held together by connective tissue
and a fine network of blood vessels and
ducts. The minute ducts of the lobules
merge into larger tributaries, which unite
and form the large efferent duct that conveys
the saliva from the gland to the mouth.
to the mastoid process. The deep, or ret-
romandibular, portion extends medially
toward the pharynx. The parotid duct runs
anteriorly and medially to open into the
oral vestibule opposite the second upper
molar.
mandibular body, its greater portion pro­
jects below the mandible. The subman-
dibular duct extends anteriorly and
superiorly to open into the mouth on a
small papilla at the side of the frenulum
of the tongue.

Parotid Parotid
duct gland
Sublingual
ducts

Submandibular
duct
Sublingual Submandibular
gland gland

Fig. 14-3  Salivary glands from left lateral aspect.

Anterior

Muscle tissue

Tongue

Ramus of Parotid
mandible gland
Dens
Parotid
gland Atlas

Spinal
cord

Right B
A
Fig. 14-4  A, Horizontal section of face, showing relationship of parotid gland to mandibular
ramus. Auricle is not shown. B, Axial MRI of parotid gland.

(B, Courtesy J. Louis Rankin, BS, RT[R][MR].)

60
 The sublingual glands, the smallest
pair, are narrow and elongated in form
(see Fig. 14-5). These glands are located
in the floor of the mouth beneath the sub-
lingual fold. Each is in contact with the
mandible laterally and extends posteriorly
from the side of the frenulum of the tongue
small sublingual ducts exist. Some of
these ducts open into the floor of the
mouth along the crest of the sublingual
fold, and others open into the subman-
dibular duct. The main sublingual duct
opens beside the orifice of the subman-
dibular duct.

Salivary Glands
to the submandibular gland. Numerous

Anterior

Sublingual
gland
Mandible Sublingual
Submandibular
gland
gland

Oropharynx Submandibular
gland

Cervical Tip of
vertebral parotid gland
body

Right B
A
Fig. 14-5  A, Horizontal section of face, showing relationship of submandibular and
sublingual glands to surrounding structures. Auricle is not shown. B, Axial MRI of
submandibular and sublingual glands.

(B, Courtesy J. Louis Rankin, BS, RT[R][MR].)

SUMMARY OF ANATOMY
Mouth Salivary glands
Oral vestibule Parotid glands
Oral cavity Parotid ducts
Oropharynx Submandibular glands
Hard palate Submandibular ducts
Soft palate Sublingual glands
Uvula Sublingual ducts
Anterior arches
Posterior arches
Tonsil
Tongue
Apex
Sublingual space
Frenulum of the tongue
Sublingual fold
Teeth

61
 RADIOGRAPHY

Sialography
SUMMARY OF PATHOLOGY Sialography is the term applied to radio-
logic examination of the salivary glands
and ducts with the use of a contrast
Condition Definition
material, usually one of the water-soluble
iodinated media. Because of improve-
Calculus Abnormal concretion of mineral salts, often called a stone ments in computed tomography (CT) and
Mouth and Salivary Glands

magnetic resonance imaging (MRI) tech-

Fistula Abnormal connection between two internal organs or niques, sialography is rarely performed.
between an organ and the body surface When the presence of a salivary stone or
lesion is suspected, CT or MRI is often the
Foreign body Foreign material in the airway
modality of choice. Sialography remains
Salivary duct Condition that prevents passage of saliva through the duct a viable tool, however, when a definitive
obstruction diagnosis is necessary for a problem
related to one of the salivary ducts.
Stenosis Narrowing or contraction of a passage Sialography is used to show such
conditions as inflammatory lesions and
Tumor New tissue growth where cell proliferation is uncontrolled
tumors; to determine the extent of salivary
fistulae; and to localize diverticula, stric-
tures, and calculi. Because the glands are
paired and the pairs are in such close prox-
imity, only one gland at a time can be
examined by the sialographic method
(Fig. 14-6).

Submandibular
duct

Submandibular
gland

Fig. 14-6  Sialogram showing opacified submandibular

gland.

62
 Sialography is performed as follows:
• Inject the radiopaque medium into the
main duct. From there, the contrast
material flows into the intraglandular
ductules, making it possible to show the
surrounding glandular parenchyma and
the duct system (Fig. 14-7).
• About 2 or 3 minutes before the sialo-
graphic procedure, give the patient a
secretory stimulant to open the duct for
ready identification of its orifice and for
easier passage of a cannula or catheter.
For this purpose, have the patient suck
on a wedge of fresh lemon. On comple-
Most physicians inject the contrast
medium by manual pressure (i.e., with a
syringe attached to the cannula or cathe-
ter). Other physicians advocate delivery
of the medium by hydrostatic pressure
only. The latter method requires the use of
a water-soluble iodinated medium, with

• Obtain preliminary images to detect tion of the examination, have the patient
any condition demonstrable without the suck on another lemon wedge to stimu-
use of a contrast medium and to estab- late rapid evacuation of the contrast
lish the optimal exposure technique. medium.
• Take an image about 10 minutes after
the procedure to verify clearance of the
contrast medium, if necessary.
Sialography
the contrast solution container (usually a
syringe barrel with the plunger removed)
attached to a drip stand and set at a dis-
tance of 28 inches (70 cm) above the level
of the patient’s mouth. Some physicians
perform the filling procedure under fluo-
roscopic guidance and obtain spot images.

Parotid duct

Parotid gland

Fig. 14-7  Sialogram showing parotid gland in a patient

without teeth.

63
 Parotid Gland

TANGENTIAL PROJECTION Position of patient Position of part

Image receptor: 8 × 10 inch (18 ×
24 cm) lengthwise
Mouth and Salivary Glands
• Place the patient in a recumbent or a
seated position.
• Because the parotid gland lies midway
between the anterior and posterior sur-
faces of the skull, obtain the tangential
projection of the glandular region from
Supine body position
• With the patient supine, rotate the head
slightly toward the side being examined
so that the parotid area is perpendicular
to the plane of the IR.
• Center the IR to the parotid area.

the posterior or the anterior direction. • With the patient’s head resting on the
occiput, adjust the head so that the man-
dibular ramus is parallel with the longi-
tudinal axis of the IR (Fig. 14-8).

Fig. 14-8  Tangential parotid gland, supine position. Fig. 14-9  Tangential parotid gland, prone position.

Orbit

Zygomatic arch

Mandibular ramus

Parotid gland area

Fig. 14-10  Tangential parotid gland. Examination of right cheek Fig. 14-11  Right cheek (arrow) distended with air in mouth (same
area to rule out tumor reveals soft tissue fullness and no patient as in Fig. 14-10). No abnormal finding in region of parotid
calcification. gland.

64
 Parotid Gland
Prone body position
• With the patient prone, rotate the head
so that the parotid area being examined
is perpendicular to the plane of the IR.
• Center the IR to the parotid region.
• With the patient’s head resting on the
chin, adjust the flexion of the head so
that the mandibular ramus is parallel
with the longitudinal axis of the IR
(Fig. 14-9).
• When the parotid (Stensen) duct does
not have to be shown, rest the patient’s
head on the forehead and nose.
• Shield gonads.
• Respiration: Improved radiographic
quality can be obtained, particularly to
show calculi, by having the patient fill
the mouth with air and then puff the
cheeks out as much as possible. When
this cannot be done, ask the patient to
suspend respiration for the exposure.
Mastoid process
Opacified parotid gland
Mandibular ramus
Fig. 14-13  Tangential parotid gland showing opacification.
Central ray
• Perpendicular to the plane of the IR,
directed along the lateral surface of the
mandibular ramus
Structures shown
A tangential projection shows the region
Parotid Gland
of the parotid gland and duct. These struc-
tures are clearly outlined when an opaque
medium is used (Figs. 14-10 to 14-14).
EVALUATION CRITERIA
The following should be clearly shown:
■ Exposure technique demonstrating soft
tissues
■ Most of the parotid gland lateral to and
clear of the mandibular ramus
■ Mastoid overlapping only the upper
portion of the parotid gland
Fig. 14-12  Tangential parotid gland, with
right cheek distended with air. Considerable
calcification is seen in region of parotid
gland (arrows).
Fig. 14-14  Tangential parotid gland showing opacification.
65
 Parotid and Submandibular Glands
LATERAL PROJECTION
R or L position
Image receptor: 8 × 10 inch (18 ×
24 cm) lengthwise
Position of patient
Mouth and Salivary Glands
• Place the patient in a semiprone or
seated and upright position.
66
Position of part
Parotid gland
• With the affected side closest to the IR,
extend the patient’s neck so that the
space between the cervical area of the
spine and the mandibular rami is
cleared.
• Center the IR to a point approximately
1 inch (2.5 cm) superior to the man-
dibular angle.
• Adjust the head so that the midsagittal
plane is rotated approximately 15
degrees toward the IR from a true
lateral position.
Submandibular gland
• Center the IR to the inferior margin of
the angle of the mandible.
• Adjust the patient’s head in a true lateral
position (Fig. 14-15).
• An axiolateral or axiolateral oblique
projection may also be performed. See
Chapter 20 for positioning details.
Fig. 14-15  Lateral submandibular gland.
• Iglauer1 suggested depressing the floor
of the mouth to displace the subman-
dibular gland below the mandible.
When the patient’s throat is not too sen-
sitive, accomplish this by having the
patient place an index finger on the
back of the tongue on the affected side.
• Shield gonads.
• Respiration: Suspend.
Central ray
• Perpendicular to the center of the IR
and directed (1) at a point 1 inch
(2.5 cm) superior to the mandibular
angle to show the parotid gland or
(2) at the inferior margin of the man-
dibular angle to show the submandibu-
lar gland
1
Iglauer S: A simple maneuver to increase the visibil-
ity of a salivary calculus in the roentgenogram, Radi-
ology 21:297, 1933.
 Parotid and Submandibular Glands

Structures shown
A lateral image shows the bony structures
and any calcific deposit or swelling in the
unobscured areas of the parotid (Figs.
14-16 and 14-17) and submandibular
glands (Fig. 14-18). The glands and their
ducts are well outlined when an opaque

Parotid and Submandibular Glands

medium is used.

EVALUATION CRITERIA
The following should be clearly shown:
■ Mandibular rami free of overlap from
the cervical vertebrae to show best the
parotid gland superimposed over the
ramus
■ Superimposed mandibular rami and
angles, if no tube angulation or head
rotation is used for the submandibular
gland
■ Oblique position for the parotid gland Fig. 14-16  Lateral parotid gland showing opacified gland and parotid duct (arrow).
■ Submandibular gland shown without
superimposition of contralateral man-
dibular ramus, on axiolateral projections

Fig. 14-17  Lateral parotid gland showing opacification and Fig. 14-18  Axiolateral submandibular gland showing opacification
partial blockage of parotid duct (arrows). of submandibular duct (arrow).

67
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 15 
ANTERIOR PART OF NECK

OUTLINE
SUMMARY OF PROJECTIONS, 70
ANATOMY, 71
Neck, 71
Thyroid Gland, 71
Parathyroid Glands, 71
Pharynx, 72
Larynx, 72
Summary of Anatomy, 73
RADIOGRAPHY, 74
Soft Palate, Pharynx, and Larynx:
Methods of Examination, 74
Pharynx and Larynx, 76
Soft Palate, Pharynx, and Larynx, 78

69
 SUMMARY OF PROJECTIONS

PROJECTIONS, POSITIONS, AND METHODS

Page Essential Anatomy Projection Position Method
76 Pharynx and larynx AP
78 Soft palate, pharynx, and larynx Lateral R or L

70
 ANATOMY

Neck
The neck occupies the region between the
skull and the thorax (Figs. 15-1 and 15-2).
For radiographic purposes, the neck is
divided into posterior and anterior por-
tions in accordance with tissue composi-
tion and function of the structures. The
procedures that are required to show the
osseous structures occupying the posterior
division of the neck are described in the
discussion of the cervical vertebrae in
Chapter 8. The portions of the central
nervous system and circulatory system
that pass through the neck are described
in Chapters 22 and 23.
The portion of the neck that lies in front
of the vertebrae is composed largely of
soft tissues. The upper parts of the respira-
tory and digestive systems are the princi-
pal structures. The thyroid and parathyroid
glands and the larger part of the subman-
dibular glands are also located in the ante-
rior portion of the neck.

Parathyroid Glands
Thyroid Gland
The thyroid gland consists of two lateral
lobes connected at their lower thirds by a
narrow median portion called the isthmus
Nasopharynx (Fig. 15-3). The lobes are approximately
2 inches (5 cm) long, 1 1 4 inches (3.2 cm)
Nasal septum wide, and 3 4 inch (1.9 cm) thick. The
Nasopharynx isthmus lies at the front of the upper part
Soft palate
Uvula Uvula
of the trachea, and the lobes lie at the
sides. The lobes reach from the lower
Epiglottis third of the thyroid cartilage to the level
Piriform recess Epiglottis
Vocal folds of the first thoracic vertebra. Although the
Rima
Larynx glottidis thyroid gland is normally suprasternal in
Laryngo- position, it occasionally extends into the
pharynx superior aperture of the thorax.
Larynx

Parathyroid Glands
The parathyroid glands are small ovoid
B bodies, two on each side, superior and
A
inferior. These glands are situated one
Fig. 15-1  A, Interior posterior view of neck. B, Coronal MRI of neck.
above the other on the posterior aspect of
(B, Courtesy J. Louis Rankin, BS, RT[R][MR].) the adjacent lobe of the thyroid gland.

Soft palate

Pharyngeal tonsil
Hard palate Nasopharynx
Nasopharynx

Uvula
C2
Oropharynx Uvula

Oropharynx
Epiglottis Epiglottis

C5 Hyoid bone
Vocal cords

Larynx Larynx

C7 Laryngeal pharynx
Trachea
Trachea
Thyroid cartilage
Esophagus B
A
Fig. 15-2  A, Sagittal section of face and neck. B, Sagittal MRI of neck.

(B, Courtesy J. Louis Rankin, BS, RT[R][MR].)

71
 Pharynx
The pharynx serves as a passage for air
and food and is common to the respiratory
and digestive systems (see Fig. 15-2). The
pharynx is a musculomembranous, tubular
structure situated in front of the vertebrae
and behind the nose, mouth, and larynx.
Approximately 5 inches (13 cm) in length,
the pharynx extends from the undersur-
Anterior Part of Neck
face of the body of the sphenoid bone and
the basilar part of the occipital bone infe-
riorly to the level of the disk between the
sixth and seventh cervical vertebrae,
where it becomes continuous with the
esophagus. The pharyngeal cavity is sub-
divided into nasal, oral, and laryngeal
portions.
The nasopharynx lies posteriorly above
the soft and hard palates. (The upper part
of the hard palate forms the floor of the
nasopharynx.) Anteriorly, the nasophar-
ynx communicates with the posterior
apertures of the nose. Hanging from the
posterior aspect of the soft palate is a
small conical process, the uvula. On the
roof and posterior wall of the nasophar-
ynx, between the orifices of the auditory
tubes, the mucosa contains a mass of lym-
Superior
parathyroid
gland
Thyroid
gland
Inferior
parathyroid
gland
Esophagus
Fig. 15-3  Lateral aspect of laryngeal area showing thyroid
gland and isthmus that connects its two lobes.
72
phoid tissue known as the pharyngeal
tonsil (or adenoids when enlarged).
Hypertrophy of this tissue interferes
with nasal breathing and is common in
children. This condition is well shown
in a lateral radiographic image of the
nasopharynx.
The oropharynx is the portion extend-
ing from the soft palate to the level of the
hyoid bone. The base, or root, of the
tongue forms the anterior wall of the oro-
pharynx. The laryngeal pharynx lies pos-
terior to the larynx, its anterior wall being
formed by the posterior surface of the
larynx. The laryngeal pharynx extends
inferiorly and is continuous with the
esophagus.
The air-containing nasal and oral pha-
rynges are well visualized in lateral images
except during the act of phonation, when
the soft palate contracts and tends to
obscure the nasal pharynx. An opaque
medium is required to show the lumen of
the laryngeal pharynx, although it can be
distended with air during the Valsalva
maneuver (an increase in intrathoracic
pressure produced by forcible expiration
effort against the closed glottis).
Thyroid
cartilage
Isthmus of
thyroid
Trachea
Larynx
The larynx is the organ of voice (Figs.
15-4 and 15-5; see Figs. 15-1 through
15-3). Serving as the air passage between
the pharynx and the trachea, the larynx is
also one of the divisions of the respiratory
system.
The larynx is a movable, tubular struc-
ture; is broader above than below; and is
approximately 1 1 2 inches (3.8 cm) in
length. Situated below the root of the
tongue and in front of the laryngeal
pharynx, the larynx is suspended from the
hyoid bone and extends from the level of
the superior margin of the fourth cervical
vertebra to its junction with the trachea at
the level of the inferior margin of the sixth
cervical vertebra. The thin, leaf-shaped
epiglottis is situated behind the root of the
tongue and the hyoid bone and above the
laryngeal entrance. It has been stated that
the epiglottis serves as a trap to prevent
leakage into the larynx between acts of
swallowing. The thyroid cartilage forms
the laryngeal prominence, or Adam’s
apple.
The inlet of the larynx is oblique, slant-
ing posteriorly as it descends. A pouchlike
fossa called the piriform recess is located
on each side of the larynx and external to
its orifice. The piriform recesses are well
shown as triangular areas on frontal pro-
jections when insufflated with air (Val-
salva maneuver) or when filled with an
opaque medium.
Hyoid bone
Thyroid cartilage
Trachea
Fig. 15-4  Anterior aspect of larynx.
 The entrance of the larynx is guarded
superiorly and anteriorly by the epiglottis
SUMMARY OF ANATOMY
and laterally and posteriorly by folds of Thyroid gland Pharynx Larynx
mucous membrane. These folds, which Isthmus Nasopharynx Epiglottis
extend around the margin of the laryngeal Soft palate Thyroid cartilage
inlet from their junction with the epiglot- Parathyroid glands Hard palate Piriform recess
tis, function as a sphincter during swal- Superior Uvula Laryngeal cavity
lowing. The laryngeal cavity is subdivided Inferior Pharyngeal tonsil Vestibular folds (false
into three compartments by two pairs of Oropharynx vocal cords)

Larynx
mucosal folds that extend anteroposteri- Hyoid bone Laryngeal vestibule
orly from its lateral walls. The superior Laryngeal pharynx Rima glottides
pairs of folds are the vestibular folds, or Vocal folds (true vocal
false vocal cords. The space above them cords)
is called the laryngeal vestibule. The Glottis
lower two folds are separated from each
other by a median fissure called the rima
glottidis. They are known as the vocal
folds, or true vocal folds (see Fig. 15-5).
The vocal cords are vocal ligaments that
are covered by the vocal folds. The liga-
ments and the rima glottidis constitute the
vocal apparatus of the larynx and are col-
lectively referred to as the glottis.

Base of tongue
Epiglottis

Vestibular fold Vocal fold

(false vocal cord) (true vocal cord)

Rima glottidis open Rima glottidis closed

Fig. 15-5  Superior aspect of larynx (open and closed true vocal folds).

73
 RADIOGRAPHY

Soft Palate, Pharynx,
and Larynx: Methods of
Examination
The throat structures may be examined
with or without an opaque contrast
medium. The technique employed depends
on the abnormality being investigated.
Computed tomography (CT) studies are
Anterior Part of Neck
3. Simultaneously with the posterior
thrust of the tongue, the larynx moves
anteriorly and superiorly under the
root of the tongue, the sphincteric
folds nearly closing the laryngeal inlet
(orifice).
4. The epiglottis divides the passing bolus
and drains the two portions laterally
into the piriform recesses as it lowers
The shortest exposure time possible
must be used for studies made during
deglutition. The steps are as follows:
• Ask the patient to hold the barium
sulfate bolus in the mouth until signaled
and then to swallow the bolus in one
movement.
• If a mucosal study is to be attempted,
ask the patient to refrain from swallow-

often performed to show radiographically over the laryngeal entrance. ing again.
areas of the palate, pharynx, and larynx The bolus is projected into the pharynx • Take the mucosal study during the
with little or no discomfort to the patient. at the height of the anterior movement of modified Valsalva maneuver for double-
Magnetic resonance imaging (MRI) is the larynx (Figs. 15-6 to 15-8). Synchro- contrast delineation.
also used to evaluate the larynx. The nizing a rapid exposure with the peak of
radiologic modality selected is often the act is necessary.
determined by the institution and the phy-
sician. The only radiologic examination
currently performed to evaluate structures
of the anterior neck is positive-contrast
pharyngography.

POSITIVE-CONTRAST
PHARYNGOGRAPHY
Opaque studies of the pharynx are made
with an ingestible contrast medium,
usually a thick, creamy mixture of water
and barium sulfate. This examination is
frequently done using fluoroscopy with
spot-film images only. These or conven-
tional projections are made during deglu-
tition (swallowing).

Deglutition Fig. 15-6  Lateral projection with exposure Fig. 15-7  AP projection of the same
The act of swallowing is performed by the made at peak of laryngeal elevation. patient as in Fig. 15-6. Epiglottis divides
rapid and highly coordinated action of Hyoid bone (white arrow) is almost at level bolus into two streams, filling the piriform
of mandible. Pharynx (between large recess below. Barium can also be seen
many muscles. The following points are
arrows) is completely distended with entering upper esophagus.
important in radiography of the pharynx barium.
and upper esophagus:
1. The middle area of the tongue becomes
depressed to collect the mass, or bolus,
of material to be swallowed.
2. The base of the tongue forms a central
groove to accommodate the bolus and
then moves superiorly and inferiorly
along the roof of the mouth to propel
the bolus into the pharynx.

A B C
Fig. 15-8  AP projection of pharynx and upper esophagus with barium. A, Head was
turned to right, with resultant asymmetric filling of pharynx. Bolus is passing through left
piriform recess, leaving right side unfilled (arrow). B, Lateral projection after patient
swallowed barium, showing diverticulum (arrow). C, Lateral projection made slightly
later, showing only filling of upper esophagus.

74
 Some fluoroscopic equipment can
expose 12 frames per second using the
100-mm or 105-mm cut or roll film. Many
institutions with such equipment use it to
spot-image patients in rapid sequence
during the act of swallowing. Another
technique is to record the fluoroscopic
image on videotape or cine film. The
recorded image may be studied to identify
Gunson method
Gunson1 offered a practical suggestion for
synchronizing the exposure with the
height of the swallowing act in deglutition
studies of the pharynx and superior esoph-
agus. Gunson’s method consists of tying
a dark-colored shoestring (metal tips
removed) snugly around the patient’s
throat above the thyroid cartilage (Fig.

Soft Palate, Pharynx, and Larynx: Methods of Examination

abnormalities during the active progress
of deglutition.
15-9). Anterior and superior movements
of the larynx are shown by elevation of
the shoestring as the thyroid cartilage
moves anteriorly and immediately there-
after by displacement of the shoestring as
the cartilage passes superiorly.
Having the exposure coincide with the
peak of the anterior movement of the
larynx—the instant at which the bolus of
contrast material is projected into the
pharynx—is desirable. As stated by
Templeton and Kredel,2 the action is so
rapid that satisfactory filling is usually
obtained if the exposure is made as soon
as anterior movement is noted.

1
Gunson EF: Radiography of the pharynx and upper
esophagus: shoestring method, Xray Tech 33:1,
1961.
2
Templeton FE, Kredel RA: The cricopharyngeal
sphincter, Laryngoscope 53:1, 1943.

A B C
Fig. 15-9  A, An ordinary dark shoelace has been tied snugly around the patient’s neck
above the Adam’s apple. B, Exposure was made at peak of superior and anterior
movement of larynx during swallowing. Pharynx is completely filled with barium at this
moment, which is the ideal instant for making an x-ray exposure. C, Double-exposure
photograph emphasizing movement of Adam’s apple during swallowing. Note extent of
anterior and superior excursion (arrows).

75
 Pharynx and Larynx
AP PROJECTION
Radiographic studies of the pharyngo-
laryngeal structures are made during
breathing, phonation, stress maneuvers,
and swallowing. To minimize the inci-
dence of motion, the shortest possible
exposure time must be used in the exami-
nations. For the purpose of obtaining
improved contrast on AP projections, use
Anterior Part of Neck
of a grid is recommended.
Fig. 15-10  AP pharynx and larynx with patient in supine position for tomography.
Fig. 15-11  AP pharynx and larynx during quiet breathing.
76
Image receptor: 8 × 10 inch (18 ×
24 cm) or 10 × 12 inch (24 × 30 cm)
lengthwise
Position of patient
• Except for tomographic studies, which
require a recumbent body position (Fig.
15-10), place the patient in the upright
position, seated or standing, whenever
possible.
Position of part
• Center the midsagittal plane of the body
to the midline of the vertical grid
device.
• Ask the patient to sit or stand straight.
If the standing position is used, have the
patient distribute the weight of the body
equally on the feet.
• Adjust the patient’s shoulders to lie in
the same horizontal plane to prevent
rotation of the head and neck and resul-
tant obliquity of the throat structures.
• Center the IR at the level of or just
below the laryngeal prominence.
• Extend the patient’s head only enough
to prevent the mandibular shadow from
obscuring the laryngeal area.
• Shield gonads.
• Respiration: Obtain preliminary images
(AP and lateral) during the inspiratory
phase of quiet nasal breathing to ensure
that the throat passages are filled with
air. To determine the optimal time for
the exposure, watch the breathing
movements of the chest. Make the
exposure just before the chest comes to
rest at the end of one of its inspiratory
expansions (Fig. 15-11).
 Pharynx and Larynx

Central ray 3. During the modified Valsalva maneu- EVALUATION CRITERIA

• Perpendicular to the laryngeal promi- ver, immediately after the barium
nence swallow for double-contrast delinea-
tion of the piriform recesses
Collimation 4. During phonation and with the larynx
• Level of EAM to jugular notch and 1 in the rest position after its opacifica-
inch (2.5 cm) beyond the skin edges on tion with an iodinated contrast medium
the sides Tomographic studies of the larynx are
made during phonation of a high-pitched
Additional studies
The following should be clearly shown:
■ Evidence of proper collimation
■ Area from superimposed mandible and
base of the skull to lung apices and
superior mediastinum
■ No overlap of laryngeal area by the
mandible
■ No rotation of neck

Pharynx and Larynx

e-e-e. After these studies, one or more ■ Throat filled with air in preliminary
Additional necessary studies of the sectional studies may be made at the studies
pharynx and larynx are usually deter- selected level or levels with the larynx at ■ Exposure permitting visualization of
mined fluoroscopically. These studies may rest (Fig. 15-13). the pharyngolaryngeal structures
be made at the following times:
1. During the Valsalva or modified
Valsalva stress maneuver or both*
(Fig. 15-12)
2. At the height of the act of swallowing
a bolus of 1 tablespoon of creamy
barium sulfate suspension. The patient
holds the barium sulfate bolus in the
mouth until signaled and then swal-
lows it in one movement. The patient
is asked to refrain from swallowing
again if a double-contrast study is to be
attempted.

*The Valsalva maneuver is performed by forcible

exhalation against a closed airway, usually by
closing the mouth and pinching the nose shut. The
modified Valsalva maneuver is performed by forc-
ible exhalation against a closed glottis.

Fig. 15-12  AP pharynx and larynx showing Valsalva maneuver.

Fig. 15-13  AP pharynx and larynx with tomogram showing polypoid

laryngeal mass (arrows).

77
 Soft Palate, Pharynx, and Larynx

LATERAL PROJECTION Central ray Collimation

R or L position • Perpendicular to the IR, center the IR
(1) 1 inch (2.5 cm) below the level of
Image receptor: 8 × 10 inch (18 × the EAMs to show the nasopharynx and
24 cm) lengthwise to perform cleft palate studies; (2) at the
level of the mandibular angles to show
Position of patient the oropharynx; or (3) at the level of
• Ask the patient to sit or stand laterally the laryngeal prominence to show the
before the vertical grid device. larynx, laryngeal pharynx, and upper
Anterior Part of Neck
• Level of EAM to jugular notch; include
all anterior oropharyngeal structures
Procedure
Preliminary studies of the pharyngolaryn-
geal structures are made during the
inhalation phase of quiet nasal breathing
to ensure filling of the passages with air

• Adjust the patient so that the coronal end of the esophagus (Fig. 15-14). (Fig. 15-15).
plane passing through or just anterior to
the temporomandibular joints is cen-
tered to the midline of the IR.

Position of part
• Ask the patient to sit or stand straight,
with the adjacent shoulder resting
firmly against the stand for support.
• Adjust the body so that the midsagittal
plane is parallel with the plane of the
IR.
• Depress the shoulders as much as pos-
sible, and adjust them to lie in the same
transverse plane. If necessary, have the
patient clasp the hands in back to rotate
the shoulders posteriorly.
• Extend the patient’s head slightly.
• Immobilize the head by having the
patient look at an object in line with the
visual axis. Fig. 15-14  Lateral pharynx and larynx.

Fig. 15-15  Lateral pharynx and larynx during normal breathing.

78
 Soft Palate, Pharynx, and Larynx

According to the site and nature of the
abnormality, further studies may be made.
Each of the selected maneuvers must be
explained to the patient and practiced just
before actual use. The studies are obtained
at one or more of the following:
1. During phonation of specified vowel
sounds to show the vocal cords and to
perform cleft palate studies (Fig. 15-16)
4. At the height of the act of swallowing
a bolus of 1 tablespoon of creamy
barium sulfate suspension to show the
pharyngeal structures
5. With the larynx at rest or during phona-
tion after opacification of the structure
with an iodinated medium
6. During the act of swallowing a tuft or
pledget of cotton (or food) saturated
EVALUATION CRITERIA
The following should be clearly shown:
■ Evidence of proper collimation
■ Exposure sufficient to demonstrate soft
tissue pharyngolaryngeal structures
■ Area from nasopharynx to the upper-
most part of the lungs in preliminary
studies
■ Specific area of interest centered in

Soft Palate, Pharynx, and Larynx

2. During Valsalva maneuver to distend with a barium sulfate suspension to detailed examinations
the subglottic larynx and trachea with show nonopaque foreign bodies located ■ No superimposition of the trachea by
air (Fig. 15-17) in the pharynx or upper esophagus the shoulders
3. During modified Valsalva maneuver to ■ Closely superimposed mandibular
distend the supraglottic larynx and the shadows
laryngeal pharynx with air ■ Throat filled with air in preliminary
studies

Air-filled pharynx

C2

Hyoid bone

Laryngeal
structures

C5

Trachea

Fig. 15-16  Lateral pharynx and larynx during phonation Fig. 15-17  Lateral pharynx and larynx during Valsalva maneuver.
of e-e-e.

79
This page intentionally left blank
 16 
ABDOMEN

OUTLINE
SUMMARY OF PROJECTIONS, 82
ANATOMY, 83
Abdominopelvic Cavity, 83
Summary of Anatomy, 84
Summary of Pathology, 84
Sample Exposure Technique Chart
Essential Projections, 85
R
Abbreviations, 85
RADIOGRAPHY, 86
Abdominal Radiographic
Procedures, 86
Abdomen, 87
Abdominal Sequencing, 87

R L

81
 SUMMARY OF PROJECTIONS

PROJECTIONS, POSITIONS, AND METHODS

Page Essential Anatomy Projection Position Method
89 Abdomen AP Supine; upright
91 Abdomen PA Upright
91 Abdomen AP L lateral decubitus
93 Abdomen Lateral R or L
94 Abdomen Lateral R or L dorsal decubitus

Icons in the Essential column indicate projections frequently performed in the United States and Canada. Students should be competent
in these projections.

82
 ANATOMY

Abdominopelvic Cavity
The abdominopelvic cavity consists of
two parts: (1) a large superior portion, the
abdominal cavity; and (2) a smaller infe-
rior part, the pelvic cavity. The abdominal
cavity extends from the diaphragm to the
superior aspect of the bony pelvis. The
abdominal cavity contains the stomach,
small and large intestines, liver, gallblad-
der, spleen, pancreas, and kidneys. The
pelvic cavity lies within the margins of the
called the peritoneum. The outer portion
of this sac, termed the parietal perito-
neum, is in close contact with the abdomi-
nal wall, the greater (false) pelvic wall,
and most of the undersurface of the dia-
phragm. The inner portion of the sac,
known as the visceral peritoneum, is
positioned over or around the contained
organs. The peritoneum forms folds called
the mesentery and omenta, which serve to
support the viscera in position. The space
between the two layers of the peritoneum
is called the peritoneal cavity and contains
serous fluid (Fig. 16-1). Because there are
no mesenteric attachments of the intes-
tines in the pelvic cavity, pelvic surgery
can be performed without entry into the
peritoneal cavity.
The retroperitoneum is the cavity
behind the peritoneum. Organs such as the
kidneys and pancreas lie in the retroperi-
toneum (Fig. 16-2).

Abdominopelvic Cavity
bony pelvis and contains the rectum and
sigmoid of the large intestine, the urinary
bladder, and the reproductive organs.
Stomach
Anatomists define the “true pelvis” as that
portion of the abdominopelvic cavity infe-
Liver
rior to a plane passing through the sacral
promontory posteriorly and the superior
surface of the pubic bones anteriorly.
The abdominopelvic cavity is enclosed
in a double-walled seromembranous sac

Parietal Visceral
peritoneum peritoneum

Spleen
Parietal Visceral R Pancreas Kidney (top) Retroperitoneum L
peritoneum peritoneum
Fig. 16-2  Axial CT image of abdomen showing organs of
upper abdomen. Retroperitoneum is posterior and medial to
dashed line.
Liver (From Kelley LL, Petersen CM: Sectional anatomy for imaging professionals,
ed 2, St Louis, 2007, Mosby.)
Stomach

Peritoneal
cavity Diaphragm Esophagus

Retroperitoneum Liver, left lobe Stomach

Transverse
colon Falciform ligament
Spleen
Mesentery
Liver, right lobe
Pancreas
Omentum Gallbladder

Jejunum Ascending Transverse

colon colon
Sigmoid Ileum Descending
colon
colon
Urinary Appendix
Small intestine
bladder

Urinary
bladder

A B
Fig. 16-1  A, Lateral aspect of abdomen showing peritoneal sac and its components.
B, Anterior aspect of abdominal viscera in relation to surrounding structures.

83
 SUMMARY OF ANATOMY
Abdomen
Abdominopelvic cavity
Abdominal cavity
Pelvic cavity
Peritoneum
Parietal peritoneum
Mesentery
Omenta
Peritoneal cavity
Abdomen

Retroperitoneum
Visceral peritoneum

SUMMARY OF PATHOLOGY
Condition Definition

Abdominal aortic aneurysm (AAA) Localized dilation of abdominal aorta

Ascites Fluid accumulation in the peritoneal cavity

Bowel obstruction Blockage of bowel lumen

Ileus Failure of bowel peristalsis

Metastasis Transfer of a cancerous lesion from one area to another

Pneumoperitoneum Presence of air in peritoneal cavity

Tumor New tissue growth where cell proliferation is uncontrolled

84
 SAMPLE EXPOSURE TECHNIQUE CHART ESSENTIAL PROJECTIONS
These techniques were accurate for the equipment used to produce each exposure. However, use caution when applying
them in your department; generator output characteristics and IR energy sensitivities vary widely.1
This chart was created in collaboration with Dennis Bowman, AS, RT(R), Clinical Instructor, Community Hospital of the
Monterey Peninsula, Monterey, CA. http://digitalradiographysolutions.com/.

ABDOMEN
CR‡ DR§

Dose Dose

Abdominopelvic Cavity
Part cm kVp* SID† Collimation mAs (mGy)‖ mAs (mGy)‖

AP¶ 21 85 40″ 14″ × 17″ 25** 3.700 10** 1.474

(35 × 43 cm)

PA¶ 21 85 40″ 14″ × 17″ 22** 3.250 9** 1.321

(35 × 43 cm)

AP/Lateral 24 85 40″ 17″ × 14″ 28** 4.480 11** 1.753

Decubitus¶ (43 × 35 cm)

Lateral¶ 30 90 40″ 14″ × 17″ 50** 10.48 20** 4.170

(35 × 43 cm)

Lateral/Dorsal 30 90 40″ 17″ × 14″ 65** 13.64 25** 5.230

Decubitus¶ (43 × 35 cm)

1
ACR-AAPM-SIMM Practice Guidelines for Digital Radiography, 2007.
*kVp values are for a high-frequency generator.
†
40 inch minimum; 44 to 48 inches recommended to improve spatial resolution (mAs increase needed, but no increase in patient dose will result).
‡
AGFA CR MD 4.0 General IP, CR 75.0 reader, 400 speed class, with 6:1 (178LPI) grid when needed.
§
GE Definium 8000, with 13:1 grid when needed.
‖
All doses are skin entrance for average adult (160 to 200 pound male, 150 to 190 pound female) at part thickness indicated.
¶
Bucky/Grid.
**Large focal spot.

ABBREVIATIONS USED IN
CHAPTER 16

AAA Abdominal aortic aneurysm

ERCP Endoscopic retrograde
cholangiopancreatography
NPO Nil per os (nothing by mouth)
PTC Percutaneous transhepatic
cholangiography
RUQ Right upper quadrant

See Addendum B for a summary of all

abbreviations used in Volume 2.

85
 RADIOGRAPHY
Abdominal
Radiographic
Procedures
EXPOSURE TECHNIQUE
In examinations without a contrast
medium, it is imperative to obtain maximal
soft tissue differentiation throughout the
different regions of the abdomen. Because
of the wide range in the thickness of the
abdomen and the delicate differences in
Abdomen
physical density between the contained
viscera, a proper balance of exposure
factors is critical to show both solid
organs, as well as adjacent structures,
while delivering the lowest possible radia-
tion dose. If the kilovolt peak (kVp) is
too high, the possibility of not showing
small or semiopaque gallstones increases
(Fig. 16-3, A) particularly on film-screen
radiographs.
A B
Fig. 16-3  A, AP abdomen showing proper positioning and collimation. B, AP abdomen
showing kidney shadows (dotted line), margin of liver (dashed line), and psoas muscles
(dot-dash lines).
86
The best criterion for assessing the
quality of an abdominal radiographic
image is the ability to visualize each of the
following (Fig. 16-3, B):
• Sharply defined outlines of the psoas
muscles
• Lower border of the liver
• Kidneys
• Ribs and transverse processes of the
lumbar vertebrae
IMMOBILIZATION
A prime requisite in abdominal examina-
tions is to prevent voluntary and involun-
tary movement. The following steps are
observed:
• To prevent muscle contraction caused
by tension, adjust the patient in a com-
fortable position so that he or she can
relax.
• Explain the breathing procedure, and
ensure that the patient understands
exactly what is expected.
• If necessary, apply a compression band
across the abdomen for immobilization
but not for compression.
• Do not start the exposure for 1 to 2
seconds after suspension of respiration
to allow the patient to come to rest and
involuntary movement of the viscera to
subside.
Voluntary motion produces a blurred
outline of the structures that do not have
involuntary movement, such as the liver,
psoas muscles, and spine. Patient breath-
ing during exposure results in blurring of
bowel gas outlines in the upper abdomen
as the diaphragm moves (Fig. 16-4).
Involuntary motion caused by peristalsis
may produce localized or generalized
haziness of the image. Involuntary con-
traction of the abdominal wall or the
muscles around the spine may cause
movement of the entire abdominal area
and may produce generalized image
haziness.
 Abdomen
RADIOGRAPHIC PROJECTIONS
Radiographic examination of the abdomen
may include one or more projections. The
most commonly performed is the supine
AP projection, often called a KUB because
it includes the kidneys, ureters, and
bladder. Projections used to complement
the supine AP include an upright AP
abdomen or an AP projection in the lateral
decubitus position (the left lateral decubi-
tus is most often preferred), or both. Both
images are useful in assessing the abdomen
in patients with free air (pneumoperito-
neum) and in determining the presence
and location of air-fluid levels. Other
abdominal projections include a lateral
projection or a lateral projection in the
supine (dorsal decubitus) body position.
Many institutions also obtain a PA chest
image to include the upper abdomen and
diaphragm. The PA chest is indicated
because any air escaping from the gastro-
intestinal tract into the peritoneal space
rises to the highest level, usually just
beneath the diaphragm.
POSITIONING PROTOCOLS
The required projections obtained to eval-
uate the patient’s abdomen vary consider-
ably depending on the institution and
the physician. Some physicians consider
Fig. 16-4  AP abdomen showing blurred bowel gas in
right upper quadrant (RUQ), caused by patient
breathing during exposure.
the preliminary evaluation image (often
termed a scout or survey) to consist of
only the AP (supine) projection. Others
obtain two projections: a supine and an
upright AP abdomen (often called a flat
and an upright). A three-way or acute
abdomen series may be requested to rule
out free air, bowel obstruction, and infec-
tion. The three projections usually include
(1) AP with the patient supine, (2) AP with
the patient upright, and (3) PA chest. If the
patient cannot stand for the upright AP
projection, the projection is performed
using the left lateral decubitus position.
The PA chest projection can be used to
demonstrate free air that may accumulate
under the diaphragm.
Positioning for radiographic exami­
nation of the abdomen is described in
the following pages. (For a description
of positioning for the PA chest, see
Chapter 10.)
Abdominal Sequencing
To show small amounts of intraperitoneal
gas in acute abdominal cases, Miller1,2
recommended that the patient be kept in
the left lateral position on a stretcher for
10 to 20 minutes before abdominal images
are obtained. This position allows gas to
Fig. 16-5  Enlarged portion of AP abdomen, left lateral decubitus
position in a patient injected with 1 mL of air into abdominal cavity.
rise into the area under the right hemidia-
phragm, where the potential pathology
would not be superimposed by the gastric
gas bubble. If larger amounts of free air
are present, many radiology departments
suggest that the patient lie on the side
for a minimum of 5 minutes before the
exposure is made.
Projections of the abdomen are taken as
follows:
• Perform an AP or PA projection of the
Abdominal Sequencing
chest and upper abdomen with the
patient in the left lateral decubitus
position.
• Use the chest exposure technique for
this image (Fig. 16-5).
• Maintain the patient in the left lateral
decubitus position while the patient is
being moved onto a horizontally placed
table. Tilt the table and the patient to the
upright position.
• Turn the patient to obtain AP or PA
projections of the chest and abdomen
(Figs. 16-6 and 16-7).
• Return the table back to the horizontal
position for a supine AP or PA projec-
tion of the abdomen (Fig. 16-8).
1
Miller RE, Nelson SW: The roentgenologic demon-
stration of tiny amounts of free intraperitoneal gas:
experimental and clinical studies, AJR Am J Roent-
genol 112:574, 1971.
2
Miller RE: The technical approach to the acute
abdomen, Semin Roentgenol 8:267, 1973.
R↑
87
 Abdomen
Abdomen

Fig. 16-6  Enlarged portion of upright AP chest showing free air in same patient as in
Fig. 16-5.

R
R

Fig. 16-7  AP abdomen, upright position, showing air-fluid levels Fig. 16-8  AP abdomen. Supine study showing intestinal
(arrows) in intestine (same patient as in Fig. 16-8). obstruction in same patient as in Fig. 16-7.

88
 Abdomen
  AP PROJECTION
Supine; upright
Image receptor: 14 × 17 inch (35 ×
43 cm) lengthwise
Position of patient
• For the AP abdomen, or KUB, projec-
tion, place the patient in either the
supine or the upright position. The
supine position is preferred for most
initial examinations of the abdomen.
Position of part
• Center the midsagittal plane of the body
to the midline of the grid device.
• If the patient is upright, distribute the
weight of the body equally on the feet.
Fig. 16-9  AP abdomen, supine.
Fig. 16-10  AP abdomen, upright.
• Place the patient’s arms where they do
not cast shadows on the image.
• With the patient supine, place a support
under the knees to relieve strain.
• For the supine position, center the IR/
collimated field at the level of the iliac
crests, and ensure that the pubic sym-
physis is included (Fig. 16-9).
• For the upright position, center the IR/
collimated field 2 inches (5 cm) above
the level of the iliac crests or high
enough to include the diaphragm
(Fig. 16-10).
• If the bladder is to be included on the
upright image, center the IR/collimated
field at the level of the iliac crests.
• If a patient is too tall to include the
entire pelvic area, obtain a second
image to include the bladder, if neces-
sary. The 10 × 12 inch (24 × 30 cm) IR
or collimated field is oriented crosswise
and is centered 2 to 3 inches (5 to
7.6 cm) above the upper border of the
pubic symphysis.
• If necessary, apply a compression band
across the abdomen with moderate
pressure for immobilization.
• Shield gonads: Use local gonad shield-
ing for examinations of male patients
Abdomen
(not shown for illustrative purposes).
• Respiration: Suspend at the end of
expiration so that the abdominal organs
are not compressed.
Central ray
• Perpendicular to the IR at the level of
the iliac crests for the supine position
• Horizontal and 2 inches (5 cm) above
the level of the iliac crests to include
the diaphragm for the upright position
Collimation
• Adjust to 14 × 17 inches (35 × 43 cm)
on the collimator. For smaller patients,
collimate to within 1 inch (2.5 cm) of
shadow of the abdomen.
89
 Abdomen
Structures shown
AP projection of the abdomen shows the
size and shape of the liver, the spleen, and
the kidneys and intra-abdominal calcifica-
tions or evidence of tumor masses (Fig.
16-11). Additional examples of supine and
upright abdomen projections are shown in
Figs. 16-7 and 16-8.
Abdomen
A B
Fig. 16-11  A, AP abdomen, supine position. B, AP abdomen, upright position.
90
EVALUATION CRITERIA
The following should be clearly shown:
■ Evidence of proper collimation
■ Area from the pubic symphysis to
the upper abdomen (two images may
be necessary if the patient is tall or
wide)
■ Proper patient alignment, as ensured by
the following:
□ Centered vertebral column
□ Ribs, pelvis, and hips equidistant to
the edge of the image or collimated
borders on both sides
■ No rotation of the patient, as demon-
strated by the following:
□ Spinous processes in the center of
the lumbar vertebrae
□ Ischial spines of the pelvis symmet-
ric, if visible
□ Alae or wings of the ilia symmetric
■ Soft tissue brightness and contrast
showing the following:
□ Lateral abdominal wall and properi-
toneal fat layer (flank stripe)
□ Psoas muscles, lower border of the
liver, and kidneys
□ Inferior ribs
□ Transverse processes of the lumbar
vertebrae
■ Right or left marker visible but not
lying over abdominal contents
■ Diaphragm without motion on upright
abdominal examinations (crosswise IR
placement/collimated field is appropri-
ate if the patient is large)
■ Brightness and contrast on upright
abdominal examination, similar to
supine examination
■ Upright abdomen identified with appro-
priate marker
 Abdomen
  PA PROJECTION
Upright
When the kidneys are not of primary inter-
est, the upright PA projection should be
considered. Compared with the AP projec-
tion, the PA projection of the abdomen
greatly reduces patient gonadal dose.
Image receptor: 14 × 17 inch (35 ×
43 cm) lengthwise
Position of patient
• With the patient in the upright position,
place the anterior abdominal surface in
contact with the vertical grid device.
• Center the abdominal midline to the
midline of the IR.
• Center the IR/collimated field 2 inches
(5 cm) above the level of the iliac crests
(Fig. 16-12), as previously described
for the upright AP projection. The
central ray, structures shown, and eval-
uation criteria are the same as for the
upright AP projection.
Fig. 16-12  PA abdomen, upright position. This projection is
suggested for survey examination of the abdomen when the
kidneys are not of primary interest.
  AP PROJECTION
L lateral decubitus position
Image receptor: 14 × 17 inch (35 ×
43 cm)
Position of patient
• If the patient is too ill to stand, place
him or her in a lateral recumbent posi-
tion lying on a radiolucent pad on a
transportation cart. Use a left lateral
decubitus position in most situations.
• The radiolucent pad is particularly
important to ensure inclusion of the
entire dependent side when fluid
demonstration is of primary concern.
• If possible, have the patient lie on the
side for several minutes before the
exposure to allow air to rise to its
highest level within the abdomen.
• Place the patient’s arms above the
level of the diaphragm so that they
are not projected over any abdominal
contents.
• Flex the patient’s knees slightly to
provide stabilization.
• Exercise care to ensure that the patient
does not fall off the cart; if a cart is
used, lock all wheels securely in
position.
Position of part
• Adjust the height of the vertical grid
device so that the long axis of the IR is
centered to the midsagittal plane.
Fig. 16-13  AP abdomen, left lateral decubitus position.
• If the abdomen is too wide to include
both flanks on one image, adjust patient
and IR height to include side down
when intraperitoneal fluid is suspected
and to include side up when pneumo-
peritoneum is suspected.
• Position the patient so that the level of
the iliac crests is centered to the IR. A
slightly higher centering point, 2 inches
(5 cm) above the iliac crests, may be
necessary to ensure that the diaphragms
Abdomen
are included in the image (Fig. 16-13).
• Adjust the patient to ensure that a true
lateral position is attained.
• Shield gonads.
• Respiration: Suspend at the end of
expiration.
  COMPENSATING FILTER
For patients with a large abdomen, a com-
pensating filter improves image quality by
preventing overexposure of the upper-side
abdominal area.
Central ray
• Directed horizontal and perpendicular
to the midpoint of the IR
Collimation
• Adjust to 14 × 17 inches (35 × 43 cm)
on the collimator. For smaller patients,
collimate to within 1 inch (2.5 cm) of
shadow of the abdomen.
NOTE: A right lateral decubitus position is often
requested or may be required when the patient
cannot lie on the left side.
91
 Abdomen

Structures shown EVALUATION CRITERIA ■ No rotation of patient, as demonstrated

In addition to showing the size and shape
of the liver, spleen, and kidneys, the AP
abdomen with the patient in the left decu-
bitus position is most valuable for showing
free air and air-fluid levels when an
upright abdomen projection cannot be
obtained (Fig. 16-14).
Abdomen
The following should be clearly shown:
■ Evidence of proper collimation
■ Diaphragm without motion
■ Both sides of the abdomen. If abdomen
is too wide:
□ Side down when fluid is suspected
(ensure entire dependent side is
included in the collimated field)
□ Side up when free air is suspected
■ Abdominal wall, flank structures, and
by the following:
□ Spinous processes in the center of
the lumbar vertebrae
□ Ischial spines of the pelvis symmet-
ric, if visible
□ Alae or wings of the ilia symmetric
■ Appropriate brightness and contrast to
demonstrate abdominal contents
■ Proper identification visible, including
patient side and marking to indicate

diaphragm which side is up

R↑

Free air

Diaphragm

Intestinal gas

Surgical clips

Crest of ilium

Patient support

R↑

Fig. 16-14  AP abdomen, left lateral decubitus position, showing free air collection along
right flank. Note correct marker placement.

92
Abdomen
Fig. 16-15  Right lateral abdomen.
Fig. 16-16  Right lateral abdomen showing AAA graft with
extensions into both common iliac arteries.
(Image courtesy of NEA Baptist Memorial Hospital, Jonesboro, AR.)
  LATERAL PROJECTION
R or L position
Image receptor: 14 × 17 inch (35 ×
43 cm) lengthwise
Position of patient
• Turn the patient to a lateral recumbent
position on the right or the left side.
Position of part
Abdomen
• Flex the patient’s knees to a comfort-
able position, and adjust the body so
that the midcoronal plane is centered to
the midline of the grid.
• Place supports between the knees and
the ankles.
• Flex the elbows, and place the hands
under the patient’s head (Fig. 16-15).
• Center the IR at the level of the iliac
crests or 2 inches (5 cm) above the
crests to include the diaphragm.
• Place a compression band across the
pelvis for stability if necessary.
• Shield gonads.
• Respiration: Suspend at the end of
expiration.
Central ray
• Perpendicular to the IR and entering the
midcoronal plane at the level of the iliac
crest or 2 inches (5 cm) above the iliac
crest if the diaphragm is included
Collimation
• Adjust to 14 × 17 inches (35 × 43 cm)
on the collimator. For smaller patients,
collimate to within 1 inch (2.5 cm) of
shadow of the abdomen.
Structures shown
A lateral projection of the abdomen shows
the prevertebral space occupied by the
abdominal aorta and any intra-abdominal
calcifications or tumor masses. The lateral
abdomen is also used to show proper
placement of AAA grafts and other vascu-
lar interventional devices (Fig. 16-16).
EVALUATION CRITERIA
The following should be clearly shown:
■ Evidence of proper collimation
■ Appropriate brightness and contrast to
demonstrate abdominal contents
■ No rotation of patient, demonstrated by
the following:
□ Superimposed ilia
□ Superimposed lumbar vertebrae ped-
icles and open intervertebral foramina
■ As much of the remaining abdomen as
possible when the diaphragm is included
93
 Abdomen

  LATERAL PROJECTION Position of part Collimation

R or L dorsal decubitus position
Image receptor: 14 × 17 inch (35 ×
43 cm)
Position of patient
• When the patient cannot stand or lie on
the side, place the patient in the supine
position on a transportation cart or
other suitable support with the right or
Abdomen
• Adjust the height of the vertical grid
device so that the long axis of the IR is
centered to the midcoronal plane.
• Position the patient so that a point
approximately 2 inches (5 cm) above
the level of the iliac crests is centered
to the IR (Fig. 16-17).
• Adjust the patient to ensure that no rota-
tion from the supine position occurs.
• Shield gonads.
• Adjust to 14 × 17 inches (35 × 43 cm)
on the collimator.
Structures shown
The lateral projection of the abdomen is
valuable in showing the prevertebral space
and is quite useful in determining air-fluid
levels in the abdomen (Fig. 16-18).
EVALUATION CRITERIA

left side in contact with the vertical grid
device.
• Place the patient’s arms across the
upper chest to ensure that they are not
projected over any abdominal contents,
or place them behind the patient’s head.
• Flex the patient’s knees slightly to
relieve strain on the back.
• Exercise care to ensure that the patient
does not fall from the cart or table; if a
cart is used, lock all wheels securely in
position.
• Respiration: Suspend at the end of
expiration.
Central ray
• Directed horizontal and perpendicular
to the center of the IR, entering the mid-
coronal plane 2 inches (5 cm) above the
level of the iliac crests
The following should be clearly shown:
■ Evidence of proper collimation
■ Diaphragm without motion
■ Appropriate brightness and contrast to
demonstrate abdominal contents
■ Patient elevated so that entire abdomen
is shown

Fig. 16-17  Lateral abdomen, left dorsal decubitus position.

L↑

Gas-filled colon

Gas level in colon

Diaphragm

Posterior ribs

Support elevating
patient
Fig. 16-18  Lateral abdomen, left dorsal decubitus position, showing calcified aorta
(arrows). Note correct marker placement.

94
 17 
DIGESTIVE SYSTEM
Alimentary Canal

OUTLINE
SUMMARY OF PROJECTIONS, 96
ANATOMY, 97
Digestive System, 97
Esophagus, 97
Stomach, 98
Small Intestine, 101
Large Intestine, 102
Liver and Biliary System, 104
Pancreas and Spleen, 106
Abbreviations, 107
Sample Exposure Technique Chart
Essential Projections, 108
Summary of Anatomy, 108
Summary of Pathology, 109
RADIOGRAPHY, 110
Technical Considerations, 110
Radiation Protection, 115
Esophagus, 115
Stomach: Gastrointestinal
Series, 120
Contrast Studies, 121
Stomach and Duodenum, 124
Superior Stomach and Distal
Esophagus, 136
Small Intestine, 138
Large Intestine, 144
Decubitus Positions, 164
Biliary Tract, 173
Biliary Tract and Gallbladder, 173
Percutaneous Transhepatic
Cholangiography, 174
Biliary Tract, 174
Postoperative (T-Tube)
Cholangiography, 176
Biliary Tract and Pancreatic
Duct, 178
Endoscopic Retrograde
Cholangiopancreatography, 178

R L

95
 SUMMARY OF PROJECTIONS

PROJECTIONS, POSITIONS, AND METHODS

Page Essential Anatomy Projection Position Method
118 Esophagus AP or PA
118 Esophagus AP or PA oblique RAO or LPO
118 Esophagus Lateral R or L
124 Stomach and duodenum PA
126 Stomach and duodenum PA axial
128 Stomach and duodenum PA oblique RAO
130 Stomach and duodenum AP oblique LPO
132 Stomach and duodenum Lateral R only
134 Stomach and duodenum AP
136 Superior stomach and distal PA oblique RAO WOLF
esophagus
136 Stomach and duodenum serial PA oblique RAO
and mucosal studies
139 Small intestine PA or AP
154 Large intestine PA
156 Large intestine PA axial
157 Large intestine PA oblique RAO
158 Large intestine PA oblique LAO
159 Large intestine Lateral R or L
160 Large intestine AP
161 Large intestine AP axial
162 Large intestine AP oblique LPO
163 Large intestine AP oblique RPO
165 Large intestine AP or PA R lateral decubitus
166 Large intestine PA or AP L lateral decubitus
167 Large intestine Lateral R or L ventral decubitus
168 Large intestine AP, PA, oblique, Upright
lateral
169 Large intestine Axial CHASSARD-
LAPINÉ
174 Percutaneous transhepatic AP/AP oblique Supine/RPO
cholangiography
176 Postoperative (T-tube) AP/AP oblique Supine/RPO
cholangiography
178 Endoscopic retrograde AP/AP oblique Supine/RPO
cholangiopancreatography

Icons in the Essential column indicate projections frequently performed in the United States and Canada. Students should be competent
in these projections.

96
 ANATOMY

Digestive System
The digestive system consists of two parts:
the accessory glands and the alimentary
canal. The accessory glands, which
include the salivary glands, liver, gall-
bladder, and pancreas, secrete digestive
enzymes into the alimentary canal. The
alimentary canal is a musculomembra-
nous tube that extends from the mouth to
the anus. The regions of the alimentary
canal vary in diameter according to func-
tional requirements. The greater part of
the canal, which is about 29 to 30 ft (8.6
tine, in which the digestive process is
completed; and the large intestine, which
is an organ of egestion and water absorp-
tion that terminates at the anus.
Esophagus
The esophagus is a long, muscular tube
that carries food and saliva from the laryn-
gopharynx to the stomach (see Fig. 17-1).
The adult esophagus is approximately 10
inches (24 cm) long and 3 4 inch (1.9 cm)
in diameter. Similar to the rest of the ali-
The esophagus lies in the midsagittal
plane. It originates at the level of the sixth
cervical vertebra, or the upper margin
of the thyroid cartilage. The esophagus
enters the thorax from the superior portion
of the neck. In the thorax, the esophagus
passes through the mediastinum, anterior
to the vertebral bodies and posterior to
the trachea and heart (Fig. 17-1, B). In
the lower thorax, the esophagus passes
through the diaphragm at T10. Inferior to
the diaphragm, the esophagus curves
sharply left, increases in diameter, and

to 8.9 m) long, lies in the abdominal
cavity. The component parts of the ali-
mentary canal (Fig. 17-1) are the mouth,
in which food is masticated and converted
into a bolus by insalivation; the pharynx
and esophagus, which are the organs of
swallowing; the stomach, in which the
digestive process begins; the small intes-
Esophagus
mentary canal, the esophagus has a wall joins the stomach at the esophagogastric
composed of four layers. Beginning with junction, which is at the level of the
the outermost layer and moving in, the xiphoid tip (T11). The expanded portion
layers are as follows: of the terminal esophagus, which lies in
• Fibrous layer the abdomen, is called the cardiac antrum.
• Muscular layer
• Submucosal layer
• Mucosal layer

Parotid gland
Tongue

Sublingual gland Pharynx

Submandibular gland C6
Esophagus
Esophagus

Stomach

Spleen
Gallbladder
Aorta
Biliary ducts Pancreas

Duodenum Large intestine

Heart
Small intestine

Vermiform Diaphragm
appendix
Rectum Fundus
T12
A B
Fig. 17-1  A, Alimentary canal and accessory organs, with liver lifted to show gallbladder.
B, Lateral view of thorax shows esophagus positioned anterior to vertebral bodies and
posterior to trachea and heart.

97
 Stomach phragm. When the patient is in the upright The stomach has anterior and posterior
The stomach is the dilated, saclike portion position, the fundus is usually filled with surfaces. The right border of the stomach
of the digestive tract extending between gas; in radiography, this is referred to as is marked by the lesser curvature. The
the esophagus and the small intestine (Fig. the gas bubble. Descending from the lesser curvature begins at the esophago-
17-2). Its wall is composed of the same fundus and beginning at the level of the gastric junction, is continuous with the
four layers as the esophagus. cardiac notch is the body of the stomach. right border of the esophagus, and is a
The stomach is divided into the follow- The inner mucosal layer of the body of the concave curve ending at the pylorus. The
ing four parts: stomach contains numerous longitudinal left and inferior borders of the stomach are
• Cardia folds called rugae. When the stomach is marked by the greater curvature. The
• Fundus full, the rugae are smooth. The body of the greater curvature begins at the sharp angle
• Body stomach ends at a vertical plane passing at the esophagogastric junction, the
• Pyloric portion through the angular notch. Distal to this cardiac notch, and follows the superior
The cardia of the stomach is the section plane is the pyloric portion of the stomach, curvature of the fundus and then the
Digestive System

immediately surrounding the esophageal which consists of the pyloric antrum, to convex curvature of the body down to
opening. The fundus is the superior portion the immediate right of the angular notch, the pylorus. The greater curvature is four
of the stomach that expands superiorly and the narrow pyloric canal, which com- to five times longer than the lesser
and fills the dome of the left hemidia- municates with the duodenal bulb. curvature.

Cardiac notch
Cardiac sphincter

Fundus
Cardiac antrum

Cardia
ture
curva

Body Pyloric
Angular sphincter
Pyloric notch
r
sse

Duodenal
sphincter bulb Rugae
Le

ture

Duodenum
va
r
cu
er
at

re
G
Pyloric
orifice
Pyloric antrum
A Pyloric canal B Duodenum

R L R L

C D
Fig. 17-2  A, Anterior surface of stomach. B, Interior view. C, Axial CT image of upper
abdomen showing position of stomach in relation to surrounding organs. Note contrast
media (white) and air (black) in stomach. D, Axial CT image showing stomach without
contrast media. Note air (upper arrow) and empty stomach (lower arrow).

(D, Modified from Kelley LL, Petersen CM: Sectional anatomy for imaging professionals, ed 2, St Louis,
2007, Mosby.)

98
 The entrance to and the exit from the
stomach are controlled by a muscle
sphincter. The esophagus joins the
stomach at the esophagogastric junction
through an opening termed the cardiac
orifice. The muscle controlling the cardiac
orifice is called the cardiac sphincter. The
opening between the stomach and the
small intestine is the pyloric orifice, and
the muscle controlling the pyloric orifice
is called the pyloric sphincter.
The size, shape, and position of the
stomach depend on body habitus and vary
with posture and the amount of stomach
contents (Fig. 17-3). In persons with a
Hypersthenic
5%
Fig. 17-3  Size, shape, and position of stomach and large intestine for the four different
types of body habitus. Note extreme difference between hypersthenic and asthenic
types.
hypersthenic habitus, the stomach is
almost horizontal and is high, with its
most dependent portion well above the
umbilicus. In persons with an asthenic
habitus, the stomach is vertical and occu-
pies a low position, with its most depen-
dent portion extending well below the
transpyloric, or interspinous, line. Between
these two extremes are the intermediate
types of bodily habitus with correspond-
ing variations in shape and position of the
stomach. The habitus of 85% of the popu-
lation is either sthenic or hyposthenic.
Radiographers should become familiar
with the various positions of the stomach
Sthenic Hyposthenic
50% 35%
in the different types of body habitus so
that accurate positioning of the stomach is
ensured.
The stomach has several functions in
the digestive process. The stomach serves
as a storage area for food until it can be
digested further. It is also where food is
broken down. Acids, enzymes, and other
chemicals are secreted to break food down
chemically. Food is also mechanically
broken down through churning and peri-
stalsis. Food that has been mechanically
and chemically altered in the stomach is
Stomach
transported to the duodenum as a material
called chyme.
Asthenic
10%
99
 Cystic duct pys pya
R L
Common hepatic duct

Common bile duct

Gallbladder
Pyloric portion

Stomach

Hepatopancreatic ampulla
Pancreatic duct
Major duodenal papilla
(orifice of biliary and Pancreas
pancreatic ducts)
Duodenum

A B duo
Digestive System

First (superior) region/Duodenal bulb

Pancreas

Second (descending)
region

Suspensory muscle
of the duodenum
Villi
(ligament of Treitz)

Duodenojejunal
flexure
Intestinal
wall

Third (horizontal) region

Villi Fourth (ascending)

region

Jejunum

R L

Small
bowel

Loops of
jejunum
and ileum
Ascending
colon

Cecum

E
D

Fig. 17-4  A, Duodenal loop in relation to biliary and pancreatic ducts. B, CT axial image
of pyloric antrum (pya), pyloric sphincter (pys), and duodenal bulb (duo). C, Anatomic
areas of duodenum. Inset: Cross section of duodenum, showing villi. D, Loops of small
intestine lying in central and lower abdominal cavity. E, CT axial image of small bowel
loops with contrast media.

(B and E, Modified from Kelley LL, Petersen CM: Sectional anatomy for imaging professionals, ed 2,
100 St Louis, 2007, Mosby.)
Small Intestine
The small intestine extends from the
pyloric sphincter of the stomach to the
ileocecal valve, where it joins the large
intestine at a right angle. Digestion and
absorption of food occur in this portion of
the alimentary canal. The length of the
adult small intestine averages about 22 ft
(6.5 m), and its diameter gradually dimin-
ishes from approximately 1 1 2 inches
(3.8 cm) in the proximal part to approxi-
mately 1 inch (2.5 cm) in the distal part.
The wall of the small intestine contains
the same four layers as the walls of the
esophagus and stomach. The mucosa of
the small intestine contains a series of
fingerlike projections called villi, which
assist the processes of digestion and
absorption.
The small intestine is divided into the
following three portions:
• Duodenum
• Jejunum
• Ileum
The duodenum is 8 to 10 inches (20 to
24 cm) long and is the widest portion of
the small intestine (Fig. 17-4). It is retro-
peritoneal and is relatively fixed in
position. Beginning at the pylorus, the
duodenum follows a C-shaped course. Its
four regions are described as the first
(superior), second (descending), third
(horizontal or inferior), and fourth
(ascending) portions. The segment of the
first portion is called the duodenal bulb
because of its radiographic appearance
when it is filled with an opaque contrast
medium. The second portion is about 3 or
4 inches (7.6 to 10 cm) long. This segment
passes inferiorly along the head of the
pancreas and in close relation to the
undersurface of the liver. The common
bile duct and the pancreatic duct usually
unite to form the hepatopancreatic
ampulla, which opens on the summit of
the greater duodenal papilla in the duode-
num. The third portion passes toward the
left at a slight superior inclination for a
distance of about 2 1 2 inches (6 cm) and
continues as the fourth portion on the left
side of the vertebrae. This portion joins
the jejunum at a sharp curve called the
duodenojejunal flexure and is supported
by the suspensory muscle of the duode-
num (ligament of Treitz). The duodenal
loop, which lies in the second portion, is
the most fixed part of the small intestine
and normally lies in the upper part of the
umbilical region of the abdomen; however,
its position varies with body habitus and
with the amount of gastric and intestinal
contents.
Small Intestine
The remainder of the small intestine is
arbitrarily divided into two portions, with
the upper two fifths referred to as the
jejunum and the lower three fifths referred
to as the ileum. The jejunum and the ileum
are gathered into freely movable loops, or
gyri, and are attached to the posterior wall
of the abdomen by the mesentery. The
loops lie in the central and lower part of
the abdominal cavity within the arch of
the large intestine.
101
 Large Intestine
The large intestine begins in the right iliac
region, where it joins the ileum of the
small intestine, forms an arch surrounding
the loops of the small intestine, and ends
at the anus (Fig. 17-5). The large intestine
has four main parts, as follows:
• Cecum
• Colon
• Rectum
• Anal canal
The large intestine is about 5 ft (1.5 m)
long and is greater in diameter than the
Digestive System
small intestine. The wall of the large intes-
tine contains the same four layers as the
walls of the esophagus, stomach, and
small intestine. The muscular portion of
the intestinal wall contains an external
band of longitudinal muscle that forms
into three thickened bands called taeniae
coli. One band is positioned anteriorly,
and two are positioned posteriorly. These
bands create a pulling muscle tone that
forms a series of pouches called the
haustra. The main functions of the large
intestine are reabsorption of fluids and
The cecum is the pouchlike portion of
the large intestine that is below the junc-
tion of the ileum and the colon. The cecum
is approximately 2 1 2 inches (6 cm) long
and 3 inches (7.6 cm) in diameter. The
vermiform appendix is attached to the pos-
teromedial side of the cecum. The appen-
dix is a narrow, wormlike tube that is
about 3 inches (7.6 cm) long. The ileoce-
cal valve is just below the junction of the
ascending colon and the cecum. The valve
projects into the lumen of the cecum and
guards the opening between the ileum and

elimination of waste products. the cecum.

Left colic
Right colic flexure
Transverse colon
flexure

Transverse colon
Descending
colon
Ascending
colon
Taenia coli
Ascending Descending
colon colon Ileum
Ileocecal Haustra
valve

Sigmoid Cecum
Cecum Sigmoid colon
colon Vermiform
appendix
Rectum
Rectum
Anal canal

A B Anus

TC

P
L
Fig. 17-5  A, Anterior aspect of large intestine positioned in CT
SV
PV
abdomen. B, Anterior aspect of large intestine. C, Axial CT P
image of upper abdomen showing actual image of
transverse colon positioned in anterior abdomen.

K SP

102
 The colon is subdivided into ascending,
transverse, descending, and sigmoid por-
tions. The ascending colon passes superi-
orly from its junction with the cecum to
the undersurface of the liver, where it
joins the transverse portion at an angle
called the right colic flexure (formerly
hepatic flexure). The transverse colon,
which is the longest and most movable
part of the colon, crosses the abdomen to
the undersurface of the spleen. The trans-
verse portion makes a sharp curve, called
the left colic flexure (formerly splenic
flexure), and ends in the descending
portion. The descending colon passes
inferiorly and medially to its junction with
the sigmoid portion at the superior aper-
Sacrum
Rectum
A Anus
Fig. 17-6  A, Sagittal section showing direction of anal canal and rectum. B, Axial CT
image of lower pelvis showing rectum and sigmoid colon (si) in relation to surrounding
organs.
(B, From Kelley LL, Petersen CM: Sectional anatomy for imaging professionals, ed 2, St Louis, 2007,
Mosby.)
ture of the lesser pelvis. The sigmoid
colon curves to form an S-shaped loop
and ends in the rectum at the level of the
third sacral segment.
The rectum extends from the sigmoid
colon to the anal canal. The anal canal
terminates at the anus, which is the exter-
nal aperture of the large intestine (Fig.
17-6). The rectum is approximately 6
inches (15 cm) long. The distal portion,
which is about 1 inch (2.5 cm) long, is
constricted to form the anal canal. Just
above the anal canal is a dilatation called
the rectal ampulla. Following the sacro-
coccygeal curve, the rectum passes inferi-
orly and posteriorly to the level of the
Rectal ampulla
Anal R L
canal
B si
pelvic floor and bends sharply anteriorly
and inferiorly into the anal canal, which
extends to the anus. The rectum and anal
canal have two AP curves; this fact must
be remembered when an enema tube is
inserted.
The size, shape, and position of the
large intestine vary greatly, depending on
body habitus (see Fig. 17-3). In hyper­
sthenic patients, the large intestine is
positioned around the periphery of the
abdomen and may require more images to
show its entire length. The large intestine
Large Intestine
of asthenic patients, which is bunched
together and positioned low in the
abdomen, is at the other extreme.
103
 Liver and Biliary System
The liver, the largest gland in the body, is
an irregularly wedge-shaped gland. It is
situated with its base on the right and its
apex directed anteriorly and to the left
(Fig. 17-7). The deepest point of the liver
is the inferior aspect just above the right
kidney. The diaphragmatic surface of the
liver is convex and conforms to the under-
surface of the diaphragm. The visceral
surface is concave and is molded over the
viscera on which it rests. Almost all of the
right hypochondrium and a large part of
Digestive System
At the falciform ligament, the liver is
divided into a large right lobe and a much
smaller left lobe. Two minor lobes are
located on the medial side of the right
lobe: the caudate lobe on the posterior
surface and the quadrate lobe on the infe-
rior surface (Fig. 17-8, A). The hilum of
the liver, called the porta hepatis, is situ-
ated transversely between the two minor
lobes.
The portal vein and the hepatic artery,
both of which convey blood to the liver,
enter the porta hepatis and branch out
and the gallbladder, and from the pancreas
and the spleen. The blood circulating
through these organs is rich in nutrients
and is carried to the liver for modification
before it is returned to the heart. The
hepatic veins convey the blood from
the liver sinusoids to the inferior vena
cava.
The liver has numerous physiologic
functions. The primary consideration from
the radiographic standpoint is the forma-
tion of bile. The gland secretes bile at the
rate of 1 to 3 pints ( 1 2 to 1 1 2 L) each day.

the epigastrium are occupied by the liver.
The right portion extends inferiorly into
the right lateral region as far as the fourth
lumbar vertebra, and the left extremity
extends across the left hypochondrium.
through the liver substance (Fig. 17-8, C).
The portal vein ends in the sinusoids, and
the hepatic artery ends in capillaries that
communicate with sinusoids. In addition
to the usual arterial blood supply, the liver
receives blood from the portal system.
The portal system, of which the portal
vein is the main trunk, consists of the
veins arising from the walls of the stomach,
from the greater part of the intestinal tract
Bile, the channel of elimination for the
waste products of red blood cell destruc-
tion, is an excretion and a secretion. As a
secretion, it is an important aid in the
emulsification and assimilation of fats.
The bile is collected from the liver cells
by the ducts and is carried to the gallblad-
der for temporary storage or is poured
directly into the duodenum through the
common bile duct.

Parotid gland
Tongue
Pharynx

Sublingual gland Esophagus

Submandibular gland

Stomach
Gallbladder

Biliary ducts Spleen

Visceral surface of liver

Pancreas

Large intestine

Small intestine
Appendix

Fig. 17-7  Alimentary tract and accessory organs. To show position of gallbladder in
relation to liver, the liver is shown with inferior portion pulled anteriorly and superiorly,
placing the liver in an atypical position.

104
 The biliary, or excretory, system of the
liver consists of the bile ducts and gall-
bladder (see Fig. 17-8). Beginning within
the lobules as bile capillaries, the ducts
unite to form larger and larger passages as
they converge, finally forming two main
ducts, one leading from each major lobe.
The two main hepatic ducts emerge at the
porta hepatis and join to form the common
hepatic duct, which unites with the cystic
duct to form the common bile duct. The
hepatic and cystic ducts are each about
1 1 2 inches (3.8 cm) long. The common
enters the duodenum. The hepatopancre- der for concentration and temporary
atic ampulla is controlled by a circular storage; during digestion, it relaxes to
muscle known as the sphincter of the permit the bile to flow from the liver and
hepatopancreatic ampulla, or sphincter of gallbladder into the duodenum. The hepa-
Oddi. During interdigestive periods, the topancreatic ampulla opens on an eleva-
sphincter remains in a contracted state, tion on the duodenal mucosa known as the
routing most of the bile into the gallblad- major duodenal papilla.
Liver
Falciform ligament

Liver and Biliary System

bile duct passes inferiorly for a distance
of approximately 3 inches (7.6 cm). The Quadrate lobe
common bile duct joins the pancreatic
duct, and they enter together or side by Gallbladder Left lobe
side into an enlarged chamber known as Left hepatic duct
the hepatopancreatic ampulla, or ampulla Caudate lobe
Right lobe
of Vater. The ampulla opens into the
Common hepatic duct
descending portion of the duodenum. The
Common bile duct
distal end of the common bile duct is con- Cystic duct
trolled by the choledochal sphincter as it
Pancreatic duct

Pancreas
Hepatopancreatic ampulla

Duodenum
A

Cut surface of liver

Common hepatic duct

Common bile duct

Spleen Hepatic vein Inferior vena cava

Gallbladder Left kidney
Liver Spleen

Cystic duct

Right kidney Pancreas

Splenic vein
B Duodenum

Portal vein
Inferior
mesenteric
Common bile duct Pancreatic vein
duct
Mucosa of Superior
duodenum mesenteric vein

Hepatopancreatic
ampulla
C Portal system

Sphincter of the
hepatopancreatic
ampulla
Fig. 17-8  A, Visceral surface (inferoposterior aspect) of liver and
Major duodenal gallbladder. B, Visceral (inferoposterior) surface of gallbladder and
papilla bile ducts. C, Portal system showing hepatic artery and vein and other
D surrounding vessels. D, Detail of drainage system into duodenum.

105
 The gallbladder is a thin-walled, more
or less pear-shaped, musculomembranous
sac with a capacity of approximately 2 oz.
The gallbladder concentrates bile through
absorption of the water content; stores bile
during interdigestive periods; and, by con-
traction of its musculature, evacuates the
bile during digestion. The muscular con-
traction of the gallbladder is activated by
a hormone called cholecystokinin. This
hormone is secreted by the duodenal
mucosa and is released into the blood
when fatty or acid chyme passes into the
Digestive System
intestine. The gallbladder consists of a
narrow neck that is continuous with the
cystic duct; a body or main portion; and a
fundus, which is its broad lower portion.
The gallbladder is usually lodged in a
fossa on the visceral (inferior) surface of
the right lobe of the liver, where it lies in
an oblique plane inferiorly and anteriorly.
Measuring about 1 inch (2.5 cm) in width
at its widest part and 3 to 4 inches (7.5 to
10 cm) long, the gallbladder extends from
the lower right margin of the porta hepatis
to a variable distance below the anterior
border of the liver. The position of the
gallbladder varies with body habitus; it is
high and well away from the midline in
hypersthenic persons and low and near the
spine in asthenic persons (Fig. 17-9). The
gallbladder is sometimes embedded in
the liver and frequently hangs free below
the inferior margin of the liver.
Hypersthenic
Fig. 17-9  Gallbladder (green) position varies with body habitus. Note extreme difference
in position of gallbladder between hypersthenic and asthenic habitus.
106
Pancreas and Spleen
The pancreas is an elongated gland situ-
ated across the posterior abdominal wall.
Extending from the duodenum to the
spleen (Fig. 17-10; see Fig. 17-8), the pan-
creas is about 5 1 2 inches (14 cm) long
and consists of a head, neck, body, and
tail. The head, which is the broadest
portion of the organ, extends inferiorly
and is enclosed within the curve of the
duodenum at the level of the second or
third lumbar vertebra. The body and tail
of the pancreas pass transversely behind
the stomach and in front of the left kidney,
with the narrow tail terminating near the
spleen. The pancreas cannot be seen on
plain radiographic studies.
The pancreas is an exocrine and an
endocrine gland. The exocrine cells of the
pancreas are arranged in lobules with a
highly ramified duct system. This exo-
crine portion of the gland produces pan-
creatic juice, which acts on proteins, fats,
and carbohydrates. The endocrine portion
of the gland consists of clusters of islet
cells, or islets of Langerhans, which are
randomly distributed throughout the pan-
creas. Each islet comprises clusters of
cells surrounding small groups of capillar-
ies. These cells produce the hormones
insulin and glucagon, which are respon-
Sthenic Hyposthenic
sible for glucose metabolism. The islet
cells do not communicate directly with the
ducts but release their secretions directly
into the blood through a rich capillary
network.
The digestive juice secreted by the exo-
crine cells of the pancreas is conveyed
into the pancreatic duct and from there
into the duodenum. The pancreatic duct
often unites with the common bile duct to
form a single passage via the hepatopan-
creatic ampulla, which opens directly into
the descending duodenum.
The spleen is included in this section
only because of its location; it belongs to
the lymphatic system. The spleen is a
glandlike but ductless organ that produces
lymphocytes and stores and removes dead
or dying red blood cells. The spleen is
more or less bean-shaped and measures
about 5 inches (13 cm) long, 3 inches
(7.6 cm) wide, and 1 1 2 inches (3.8 cm)
thick. Situated obliquely in the left upper
quadrant, the spleen is just below the dia-
phragm and behind the stomach. It is in
contact with the abdominal wall laterally,
with the left suprarenal gland and left
kidney medially, and with the left colic
flexure of the colon inferiorly. The spleen
is visualized with and without contrast
media.
Asthenic
 R Stomach L

Duodenum
Stomach Liver

Liver

Right
side

Pancreas and Spleen

Inferior
vena Spleen
cava

Right kidney Spleen

Aorta Left kidney
A Pancreas B Pancreas Kidney (top) Retroperitoneum

Fig. 17-10  A, Sectional image of upper abdomen (viewed from the patient’s feet
upward), showing relationship of digestive system components. B, Axial CT image of
same area of abdomen as in A.

(B, From Kelley LL, Petersen CM: Sectional anatomy for imaging professionals, ed 2, St Louis, 2007,
Mosby.)

ABBREVIATIONS USED IN
CHAPTER 17

BE Barium enema
CTC CT colonography
MPR Multiplanar reconstruction
UGI Upper gastrointestinal
VC Virtual colonoscopy

See Addendum B for a summary of all

abbreviations used in Volume 2.

107
 SAMPLE EXPOSURE TECHNIQUE CHART ESSENTIAL PROJECTIONS
These techniques were accurate for the equipment used to produce each exposure. However, use caution when applying
them in your department because generator output characteristics and IR energy sensitivities vary widely.1
This chart was created in collaboration with Dennis Bowman, AS, RT(R), Clinical Instructor, Community Hospital of the
Monterey Peninsula, Monterey, CA.
http://digitalradiographysolutions.com/

DIGESTIVE SYSTEM, ALIMENTARY CANAL

CR‡ DR§

Dose Dose
Part cm kVp* SID† Collimation mAs (mGy)‖ mAs (mGy)‖

Esophagus
  AP and PA¶ 16 120 40″ 10″ × 17″ (24 × 43 cm) 8** 1.832 4** 0.904
  Obliques ¶
21 120 40″ 10″ × 17″ (24 × 43 cm) 12** 3.230 6** 1.621
  Lateral¶
30 120 40″ 10″ × 17″ (24 × 43 cm) 24** 8.230 12** 4.085
Stomach and duodenum
  PA and AP¶ 21 120 40″ 10″ × 12″ (24 × 30 cm) 10** 2.610 5** 1.291
Digestive System

  PA and AP oblique ¶
24 120 40″ 10″ × 12″ (24 × 30 cm) 15** 4.495 7.5** 2.245
  Lateral¶
27 120 40″ 10″ × 12″ (24 × 30 cm) 30** 9.770 15** 4.860
Small intestine
  PA and AP¶ 21 120 40″ 14″ × 17″ (35 × 43 cm) 16** 4.320 8** 2.160
Large intestine
  PA and AP¶ 21 120 40″ 14″ × 17″ (35 × 43 cm) 20** 5.420 10** 2.700
  PA and AP axial¶
24 120 40″ 14″ × 17″ (35 × 43 cm) 32** 9.365 16** 4.650
  PA and AP oblique ¶
24 120 40″ 14″ × 17″ (35 × 43 cm) 25** 7.310 12.5** 3.635
  Lower lateral (rectum) ¶
31 120 40″ 10″ × 12″ (24 × 30 cm) 60** 22.21 30** 10.89
  AP and PA decubitus 24 120 40″ 17″ × 14″ (43 × 35 cm) 25** 7.320 12.5** 3.640
(air contrast)¶

1
ACR-AAPM-SIMM Practice Guidelines for Digital Radiography, 2007.
*kVp values are for a high-frequency generator.
†
40 inch minimum; 44 to 48 inches recommended to improve spatial resolution (mAs increase needed, but no increase in patient dose will result).
‡
AGFA CR MD 4.0 General IP, CR 75.0 reader, 400 speed class, with 6 : 1 (178LPI) grid when needed.
§
GE Definium 8000, with 13 : 1 grid when needed.
‖
All doses are skin entrance for average adult (160 to 200 pound male, 150 to 190 pound female) at part thickness indicated.
¶
Bucky/Grid.
**Large focal spot.

SUMMARY OF ANATOMY
Digestive system Body Jejunum Porta hepatis
Alimentary canal Rugae Ileum Hepatic artery
Mouth Angular notch Portal vein
Pharynx Pyloric portion Large intestine Hepatic veins
Esophagus Pyloric antrum Taeniae coli Hepatic ducts
Stomach Pyloric canal Haustra Common hepatic duct
Small intestine Lesser curvature Cecum Cystic duct
Large intestine (colon) Cardiac notch Vermiform appendix Common bile duct
Anus Greater curvature Ileocecal valve Hepatopancreatic
Cardiac orifice Colon ampulla
Accessory glands Cardiac sphincter Ascending colon Sphincter of
Salivary glands Pyloric orifice Right colic flexure hepatopancreatic
Liver Pyloric sphincter Transverse colon ampulla
Gallbladder Chyme Left colic flexure Major duodenal papilla
Pancreas Descending colon Gallbladder
Small intestine Sigmoid colon
Esophagus Villi Rectum Pancreas and spleen
Fibrous layer Duodenum (four regions) Rectal ampulla Pancreas
Muscular layer First (superior)—duodenal Anal canal Head
Submucosal layer bulb Anus Body
Esophagogastric junction Second (descending)— Tail
Cardiac antrum major duodenal papilla Liver and biliary system Exocrine gland
Cardiac notch Third (horizontal) Falciform ligament Pancreatic juice
Fourth (ascending)— Right lobe Endocrine gland
Stomach duodenojejunal flexure; Left lobe Islet cells
Cardia suspensory muscle of Caudate lobe Pancreatic duct
108 Fundus duodenum Quadrate lobe Spleen
SUMMARY OF PATHOLOGY
Condition Definition

Achalasia Failure of smooth muscle of alimentary canal to relax

Appendicitis Inflammation of the appendix

Barrett esophagus Peptic ulcer of lower esophagus, often with stricture

Bezoar Mass in the stomach formed by material that does not pass into the intestine

Biliary stenosis Narrowing of bile ducts

Carcinoma Malignant new growth composed of epithelial cells

Celiac disease or sprue Malabsorption disease caused by mucosal defect in the jejunum

Cholecystitis Acute or chronic inflammation of gallbladder

Summary of Pathology
Choledocholithiasis Calculus in common bile duct

Cholelithiasis Presence of gallstones

Colitis Inflammation of the colon

Diverticulitis Inflammation of diverticula in the alimentary canal

Diverticulosis Diverticula in the colon without inflammation or symptoms

Diverticulum Pouch created by herniation of the mucous membrane through the muscular coat

Esophageal varices Enlarged tortuous veins of lower esophagus, resulting from portal hypertension

Gastritis Inflammation of lining of stomach

Gastroesophageal reflux Backward flow of stomach contents into the esophagus

Hiatal hernia Protrusion of the stomach through the esophageal hiatus of the diaphragm

Hirschsprung disease or congenital Absence of parasympathetic ganglia, usually in the distal colon, resulting in the
aganglionic megacolon absence of peristalsis

Ileus Failure of bowel peristalsis

Inguinal hernia Protrusion of the bowel into the groin

Intussusception Prolapse of a portion of the bowel into the lumen of an adjacent part

Malabsorption syndrome Disorder in which subnormal absorption of dietary constituents occurs

Meckel diverticulum Diverticulum of the distal ileum, similar to the appendix

Pancreatic pseudocyst Collection of debris, fluid, pancreatic enzymes, and blood as a complication of
acute pancreatitis

Pancreatitis Acute or chronic inflammation of the pancreas

Polyp Growth or mass protruding from a mucous membrane

Pyloric stenosis Narrowing of pyloric canal causing obstruction

Regional enteritis or Crohn disease Inflammatory bowel disease, most commonly involving the distal ileum

Ulcer Depressed lesion on the surface of the alimentary canal

Ulcerative colitis Recurrent disorder causing inflammatory ulceration in the colon

Volvulus Twisting of a bowel loop on itself

Zenker diverticulum Diverticulum located just above the cardiac portion of the stomach

109
 RADIOGRAPHY
Technical
Considerations
GASTROINTESTINAL TRANSIT
Peristalsis is the term applied to the con-
traction waves by which the digestive tube
propels its contents toward the rectum.
Normally three or four waves per minute
occur in the filled stomach. The waves
begin in the upper part of the organ and
travel toward the pylorus. The average
emptying time of a normal stomach is 2
to 3 hours.
Digestive System
Peristaltic action in the intestines is
greatest in the upper part of the canal and
gradually decreases toward the lower
portion. In addition to peristaltic waves,
localized contractions occur in the duode-
num and the jejunum. These contractions
usually occur at intervals of 3 to 4 seconds
during digestion. The first part of a
“barium meal” normally reaches the ileo-
cecal valve in 2 to 3 hours, and the last
portion reaches the ileocecal valve in 4 to
110
5 hours. The barium usually reaches the
rectum within 24 hours.
The specialized procedures commonly
used in radiologic examinations of the
esophagus, stomach, and intestines are
discussed in this section. The esophagus
extends between the pharynx and the
cardiac end of the stomach and occupies
a constant position in the posterior part of
the mediastinum; it is easy to show the
esophagus on radiographic images when a
contrast medium is used. The stomach and
intestines vary in size, shape, position, and
muscular tonus according to the body
habitus (see Fig. 17-3). In addition to
normal structural and functional differ-
ences, various gastrointestinal abnormali-
ties can cause further changes in location
and motility. These variations make the
gastrointestinal investigation of every
patient an individual study, and meticu-
lous attention must be given to each detail
of the examination procedure.
EXAMINATION PROCEDURE
The alimentary canal may be imaged using
only fluoroscopy or using a combination of
fluoroscopy and radiography. Fluoroscopy
makes it possible to observe the canal in
motion, perform special mucosal studies,
and determine the subsequent procedure
required for a complete examination.
Depending on the radiologist’s preference,
all images may be obtained during fluoros-
copy, thus the radiographer’s role is to
communicate with and assist the patient
before and after contrast administration
while assisting the fluoroscopist during
the procedure. Some facilities still obtain
radiographic images after the fluoroscopy
examination, and these images are the
responsibility of the radiographer. In both
types of examinations, the essential projec-
tions described in this chapter are obtained
to provide a permanent record of the find-
ings. Radiographers must be proficient in
recognizing the pertinent anatomy shown
in each position and projection to provide
proper patient assistance in fluoroscopy-
only procedures and to obtain accurate
radiographic images in the combination
examinations.
Contrast media
Because the thin-walled alimentary canal
does not have sufficient density to be
shown through the surrounding structures,
demonstration of it on radiographic
images requires the use of an artificial
contrast medium. Barium sulfate, which is
a water-insoluble salt of the metallic
element barium, is the contrast medium
universally used in examinations of the
alimentary canal (Fig. 17-11). The barium
sulfate used for this purpose is a specially Stomach
prepared, chemically pure product to

Technical Considerations
which various chemical substances have
Pyloric portion
been added. Barium sulfate is available as
Duodenum
a dry powder or as a liquid. The powdered
barium has different concentrations and is
mixed with plain water. The concentration
depends on the part to be examined and
the preference of the physician. Small bowel loops

Many special barium sulfate products

are also available. Products with finely
divided barium sulfate particles tend to
resist precipitation and remain in suspen-
sion longer than regular barium prepara- Fig. 17-11  Barium sulfate suspension in stomach, sthenic body habitus.
tions. Some barium preparations contain
gums or other suspending or dispersing
agents and are referred to as suspended or
flocculation-resistant preparations. The
speed with which the barium mixture
passes through the alimentary canal
depends on the suspending medium, the
temperature of the medium, the consis-
tency of the preparation, and the motile
function of the alimentary canal.
In addition to barium sulfate, water-
soluble, iodinated contrast media suitable
for opacification of the alimentary canal
are available (Fig. 17-12). These prepara-
tions are modifications of basic IV uro-
graphic media, such as diatrizoate sodium
and diatrizoate meglumine.

Fig. 17-12  Water-soluble, iodinated solution in stomach.

111
 Left colic Iodinated solutions move through the
flexure gastrointestinal tract quicker than barium
sulfate suspensions (Figs. 17-13 and 17-
14). An iodinated solution normally clears
the stomach in 1 to 2 hours, and the entire
Right colic iodinated contrast column reaches and
flexure outlines the colon in about 4 hours. An
orally administered iodinated medium
Transverse colon
differs from barium sulfate in the follow-
ing ways:
Descending colon 1. It outlines the esophagus, but it does
not adhere to the mucosa as well as a
Ascending colon
barium sulfate suspension does.
Digestive System

2. It affords an entirely satisfactory exam-

ination of the stomach and duodenum
including mucosal delineation.
3. It permits a rapid survey of the entire
Cecum small intestine but fails to provide
clear anatomic detail of this portion of
the alimentary canal. This failure
results from dilution of the contrast
Sigmoid colon
medium and the resultant decrease in
opacification.
4. Because of the normal rapid absorption
Rectum
of water through the colonic mucosa,
Fig. 17-13  Barium sulfate suspension administered by rectum, sthenic body habitus.
the medium again becomes densely
concentrated in the large intestine.
Consequently, the entire large intestine
is opacified with retrograde filling
using a barium sulfate suspension. As
a result of its increased concentration
and accelerated transit time, rapid
investigation of the large intestine can
be performed by the oral route when a
patient cannot cooperate for a satisfac-
tory enema study.
A great advantage of water-soluble
media is that they are easily removed by
aspiration before or during surgery. If a
water-soluble, iodinated medium escapes
into the peritoneum through a preexisting
perforation of the stomach or intestine, no
ill effects result. The medium is readily
absorbed from the peritoneal cavity and
excreted by the kidneys. This provides a
definite advantage when perforated ulcers
are being investigated.
A disadvantage of iodinated prepara-
tions is their strongly bitter taste, which
can be masked only to a limited extent.
Patients should be forewarned so that they
can more easily tolerate ingestion of these
agents. In addition, these iodinated con-
trast media are hyperosmolar, encourag-
ing movement of excess fluid into the
gastrointestinal tract lumen.

Fig. 17-14  Water-soluble, iodinated solution administered by mouth.

112
Radiologic apparatus
The fluoroscopic equipment used today
contains highly sophisticated image inten-
sification systems (Fig. 17-15). These
systems can be connected to accessory
units, such as cine film recorders, televi-
sion systems, spot-film cameras, digital-
image cameras, and video recorders.
Remote control fluoroscopic rooms are
also available and are used by the fluoros-
copist in an adjacent control area (Fig.
17-16). Although conventional IR-loaded
spot-image devices are still used with
Compression and palpation of the
abdomen are often performed during an
examination of the alimentary canal.
Many types of compression devices are
available. The fluoroscopic unit shown in
Fig. 17-15 shows a compression cone in
contact with the patient’s abdomen. This
device is often used during general fluo-
roscopic examinations.
Other types of commercial compression
devices include the pneumatic compres-
sion paddle shown in Fig. 17-17. This
device is often placed under the duodenal
bulb and inflated to place pressure on the
abdomen. The air is slowly released, and
the compression on the body part is
eliminated.

Technical Considerations
image intensification, digital fluoroscopic
units that permit the recording of multiple
fluoroscopic images are increasingly more
common.

Fig. 17-15  Image intensification system, with compression cone in contact with
abdomen.

Fig. 17-16  Remote control fluoroscopic room, showing Fig. 17-17  Compression paddle: inflated (above) and
patient fluoroscopic table (left) and fluoroscopist’s control noninflated (below).
console (right). The fluoroscopist views the patient through
the large window.

113
 Preparation of examining room
The examining room should be com-
pletely prepared before the patient enters.
In preparing the room, the radiographer
should do the following:
• Adjust equipment controls to the appro-
priate settings.
• Have the footboard and shoulder
support available.
• Check for proper operation of the
imaging and recording devices.
• Prepare the required type and amount
of contrast medium.
Digestive System
Before beginning the examination, the
radiographer must communicate with the
patient in the following ways:
• Explain the type and administration
route of the contrast media.
• Use lay terminology, such as “drink-
ing” for orally administered agents.
• Explain the taste and texture of the
contrast agent, such as “chalky and
thick” for barium and “bitter” for
iodinated agents.
• For an enema examination, show the
tube tip and explain insertion and the
potential abdominal sensations that
often accompany the flow of contrast
into the colon.
• Point out that the lights are dimmed in
the room during fluoroscopy, and
explain the need for a darkened room
during the procedure.
• The fluoroscopist will instruct the
patient to move into certain positions
A B
Fig. 17-18  A, AP spot image of barium-filled fundus of stomach. B, Spot image of
air-contrast colon, showing left colic flexure.
114
and will provide breathing instructions.
Assure the patient that you will assist,
as needed.
• If radiographic images are obtained
post fluoroscopy, inform the patient
of the approximate number of images
you will be obtaining when the fluo-
roscopist leaves the room.
• After you have verified that the patient
understands the overall procedure,
introduce the patient and the fluorosco-
pist to each other when the fluorosco-
pist enters the examining room.
Exposure time
One of the most important considerations
in gastrointestinal radiography is the elim-
ination of motion. The highest degree of
motor activity is normally found in the
stomach and proximal part of the small
intestine. Activity gradually decreases
along the intestinal tract until it becomes
fairly slow in the distal part of the large
bowel. Peristaltic speed also depends on
the individual patient’s body habitus and
is influenced by pathologic changes, use
of narcotic pain medication, body posi-
tion, and respiration. The amount of expo-
sure time for each region must be based
on these factors.
In esophageal examinations, the radiog-
rapher should observe the following
guidelines, if obtaining radiographic
images post fluoroscopy:
• Use an exposure time of 0.1 second or
less for upright images. The time may
be slightly longer for recumbent images
because the barium descends more
slowly when patients are in a recum-
bent position.
• Barium passes through the esophagus
fairly slowly if it is swallowed at the
end of full inspiration. The rate of
passage is increased if the barium is
swallowed at the end of moderate inspi-
ration. The barium is delayed in the
lower part for several seconds, however,
if it is swallowed at the end of full
expiration.
• Respiration is inhibited for several
seconds after the beginning of degluti-
tion, which allows sufficient time for
the exposure to be made without the
need to instruct the patient to hold his
or her breath after swallowing.
In examinations of the stomach and
small intestine, the radiographer should
observe the following guidelines:
• Use an exposure time no longer than
0.2 second for patients with normal
peristaltic activity and never longer
than 0.5 second; exposure time should
be 0.1 second or less for patients with
hypermotility.
• Make exposures of the stomach and
intestines at the end of expiration in the
routine procedure.
Radiation Protection
The patient receives radiation during fluo-
roscopy, while the procedure is recorded
and images obtained (Fig. 17-18). When
radiographic images are a required part
of a partial or complete gastrointestinal
examination, even more radiation is deliv-
ered to the patient. It is taken for granted
that properly added filtration is in place at
all times in each x-ray tube in the radiol-
ogy department. It is further assumed that
based on the capacity of the machines and
the best available accessory equipment,
exposure factors are adjusted to deliver
the least possible radiation to the patient.
Protection of the patient from unneces-
sary radiation is a professional responsi-
bility of the radiographer. (See Chapter 1
in Volume 1 of this atlas for specific
guidelines.) In this chapter, the Shield
gonads statement at the end of the Posi-
tion of part section indicates that the
patient is to be protected from unneces-
sary radiation by restricting the radiation
Fig. 17-19  Esophagogram images showing luminal indentations from adjacent anatomy.
Normally indented structures include aortic arch (A), left main stem bronchus (B), and
left atrium (C).
beam using proper collimation to include
only the primary anatomy of interest.
Placing lead shielding between the gonads
and the radiation source when the clinical
objectives of the examination are not
compromised is also appropriate.
Esophagus
CONTRAST MEDIA STUDIES
The esophagus may be examined by per-
forming a full-column, single-contrast
study in which only barium or water-
soluble, iodinated contrast agent is used to
fill the esophageal lumen. A double-
contrast procedure also may be used. For
this study, high-density barium and carbon
dioxide crystals (which liberate carbon
dioxide when exposed to water) are the
two contrast agents. No preliminary prep-
aration of the patient is necessary. These
contrast media procedures show intrinsic
lesions and extrinsic pathology impress-
ing on the esophagus. Anatomic structures
A
B
C C
normally indenting the esophagus must be
appreciated to identify pathology. Nor-
mally indenting structures include the
aortic arch, left main stem bronchus, and
left atrium (Fig. 17-19).
Barium sulfate mixture
A 30% to 50% weight/volume suspension1
is useful for the full-column, single-contrast
technique. A low-viscosity, high-density
barium developed for double-contrast
gastric examinations may be used for a
double-contrast examination. Whatever the
Esophagus
weight/volume concentration of the barium,
the most important criterion is that the
barium flows sufficiently to coat the walls
of the esophagus. The mixing instructions
of the barium manufacturer must be fol-
lowed closely to attain optimal perfor-
mance of the contrast medium.
1
Scukas J: Contrast media. In Margulis AR, Burhenne
HJ, editors: Alimentary tract radiology, vol 1, ed 4,
St Louis, 1989, Mosby.
A
115
 Examination procedures
For a single-contrast examination (Figs.
17-20 to 17-22), the following steps are
taken:
• Start the fluoroscopic and spot-image
examinations with the patient in the
upright position when possible.
Digestive System
• Use the horizontal and Trendelenburg
positions as indicated.
• After the fluoroscopic examination of
the heart and lungs and when the patient
is upright, instruct the patient to take
the cup containing the barium suspen-
sion into the left hand and to drink it on
request.
The radiologist asks the patient to
swallow several mouthfuls of the barium
so that the act of deglutition can be
observed to determine whether any abnor-
mality is present. The radiologist instructs
the patient to perform various breathing
maneuvers under fluoroscopic observa-
tion so that spot images of areas or lesions
not otherwise shown can be obtained.

Esophagus

Esophagus

Thoracic vertebra
Stomach

Fig. 17-20  AP esophagus, single-contrast study. Fig. 17-21  Lateral esophagus, single-contrast study.

116
 Performance of a double-contrast
esophageal examination (Fig. 17-23) is
similar to that of a single-contrast exami-
nation. For a double-contrast examination,
free-flowing, high-density barium must be
used. A gas-producing substance, usually
carbon dioxide crystals, can be added to
the barium mixture or given by mouth
immediately before the barium suspension
is ingested. Spot images are taken during
the examination, and delayed images may
be obtained on request.
OPAQUE FOREIGN BODIES
Opaque foreign bodies lodged in the
pharynx or in the upper part of the esopha-
gus can usually be shown without the use
of a contrast medium. A soft tissue neck
or lateral projection of the retrosternal
area may be taken for this purpose. A
lateral neck image should be obtained at
the height of swallowing for the delinea-
tion of opaque foreign bodies in the upper
end of the intrathoracic esophagus. Swal-
lowing elevates the intrathoracic eso­
phagus a distance of two cervical
segments, placing it above the level of the
clavicles.
Tufts or pledgets of cotton saturated
with a thin barium suspension are some-
times used to show an obstruction or to
detect nonopaque foreign bodies in the
pharynx and upper esophagus (Fig. 17-24).

Esophagus
Fig. 17-22  PA oblique esophagus, RAO Fig. 17-23  PA Fig. 17-24  Barium-soaked cotton ball showing
position, single-contrast study. oblique distal nonopaque foreign body in upper esophagus
esophagus, RAO (arrow).
position, double-
contrast spot
image.

117
 Esophagus
  AP, PA, OBLIQUE, AND
LATERAL PROJECTIONS
Image receptor: 14 × 17 inch (35 ×
43 cm) lengthwise and centered so
that the top of the IR is positioned at
the level of the mouth for inclusion of
the entire esophagus
Position of patient
• Position the patient as for chest images
(AP, PA, oblique, and lateral; see
Chapter 10, Volume 1). Because the
Digestive System
RAO position of 35 to 40 degrees (Fig.
17-25) makes it possible to obtain a
wider space for an unobstructed image
of the esophagus between the vertebrae
and the heart, it is usually used in pref-
erence to the LAO position. The LPO
position has also been recommended.1
• Unless the upright position is specified,
place the patient in the recumbent posi-
tion for esophageal studies. The recum-
bent position is used to obtain more
complete contrast filling of the esopha-
gus (especially filling of the proximal
part) by having the barium column flow
against gravity. The recumbent position
is routinely used to show variceal dis-
tentions of the esophageal veins because
varices are best filled by having the
blood flow against gravity. Variceal
filling is more complete during
increased venous pressure, which may
be applied by full expiration or by
the Valsalva maneuver (see Chapter 15,
p. 77).
1
Cockerill EM et al: Optimal visualization of esoph-
ageal varices, AJR Am J Roentgenol 126:512, 1976.
Fig. 17-25  PA oblique esophagus, RAO position.
118
  AP OR PA PROJECTION
The following steps are taken:
• Place the patient in the supine or prone
position with the arms above the head
in a comfortable position.
• Center the midsagittal plane to the grid.
• Turn the head slightly, if necessary, to
assist drinking of the barium mixture.
• Shield gonads.
  AP OR PA OBLIQUE
PROJECTION
RAO OR LPO POSITION
The steps are as follows:
• Position the patient in the RAO or LPO
position with the midsagittal plane
forming an angle of 35 to 40 degrees
from the grid device.
• For the RAO position, adjust the
patient’s side-down arm at the side
and the side-up arm on the pillow by
the head. For the LPO position, do the
same, with the side-down arm at the
side and the side-up arm on the pillow.
• Center the elevated side to the grid
through a plane approximately 2 inches
(5 cm) lateral to the midsagittal plane
(Fig. 17-26).
• Shield gonads.
  LATERAL PROJECTION
R OR L POSITION
The steps are as follows:
• Place the patient’s arms forward, with
the forearm on the pillow near the head.
• Center the midcoronal plane to the grid.
• Shield gonads.
Central ray
• Perpendicular to the midpoint of the IR
(the central ray is at the level of T5-6)
Collimation
• Adjust to 12 × 17 inches (30 × 43 cm)
on the collimator.
Structures shown
The contrast medium–filled esophagus
should be shown from the lower part of
the neck to the esophagogastric junction,
where the esophagus joins the stomach.
EVALUATION CRITERIA
The following should be clearly shown:
General
■ Evidence of proper collimation
■ Esophagus from the lower part of the
neck to its entrance into the stomach
■ Esophagus filled with barium
■ Penetration of the barium
AP or PA projection (see Fig. 17-20)
■ Brightness and contrast sufficient to
visualize the esophagus through the
superimposed thoracic vertebrae
■ No rotation of the patient
A B
Fig. 17-26  A, PA oblique esophagus,
RAO position. B, AP oblique esophagus,
LPO position.
 Esophagus
Oblique projection (see Fig. 17-26)
■ Esophagus between the vertebrae and
the heart
Lateral projection (see Fig. 17-21)
■ Patient’s arm not interfering with visu-
alization of the proximal esophagus
■ Ribs posterior to the vertebrae superim-
posed to show that the patient was not
rotated
NOTE: The general criteria apply to all projec-
tions: AP or PA, oblique, and lateral.
Barium administration and respiration
• Feed the barium sulfate suspension to
the patient by spoon, by cup, or through
a drinking straw, depending on its
consistency.
• Ask the patient to swallow several
mouthfuls of barium in rapid succes-
sion and then to hold a mouthful until
immediately before the exposure.
A B
Fig. 17-27  A, Spot-film studies showing esophageal varices. B, Barium bolus
clearly shows Schatzki ring (arrows).
(Courtesy Michael J. Kudlas, MEd, RT[R][QM].)
• To show esophageal varices, instruct
the patient (1) to exhale fully and then
swallow the barium bolus and avoid
inspiration until the exposure has been
made, or (2) to take a deep breath and,
while holding the breath, swallow the
bolus and then perform the Valsalva
maneuver (Fig. 17-27, A).
• For other conditions, instruct the patient
simply to swallow the barium bolus,
which is normally done during moder-
ate inspiration (Fig. 17-27, B). Because
respiration is inhibited for about 2
Esophagus
seconds after swallowing, the patient
does not have to hold his or her breath
for the exposure. If the contrast medium
is swallowed at the end of full inspira-
tion, make two or three exposures in
rapid succession before the contrast
medium passes into the stomach. To
show the entire esophagus, it is some-
times necessary to make the exposure
while the patient is drinking the barium
suspension through a straw in rapid and
continuous swallows.
• Ask the patient to swallow a barium
tablet to evaluate the degree of lumen
narrowing with esophageal stricture
(Fig. 17-28).
Fig. 17-28  AP projection showing barium pill
in distal esophagus, at the site of luminal
stricture.
119
 Stomach:
Gastrointestinal Series
Upper gastrointestinal (UGI) tract images
are used to evaluate the distal esophagus,
the stomach, and some or all of the small
intestine. A UGI examination (Fig. 17-29),
usually called a gastrointestinal or UGI
series, may include the following:
1. A preliminary image of the abdomen to
delineate the liver, spleen, kidneys,
psoas muscles, and bony structures and
to detect any abdominal or pelvic calci-
Digestive System
fications or tumor masses. Detection of
calcifications and tumor masses requires
that the survey image of the abdomen
be taken after preliminary cleansing of
the intestinal tract but before adminis-
tration of the contrast medium.
2. Fluoroscopic recorded images only or
a combination of fluoroscopic and
radiographic images after contrast
administration. Images will include the
esophagus, stomach, and duodenum
using an ingested opaque mixture,
usually barium sulfate.
3. When requested, a small intestine
study consisting of images obtained at
frequent intervals during passage of the
contrast column through the small
intestine, at which time the vermiform
appendix and the ileocecal region may
be examined.
Fig. 17-29  Barium-filled AP stomach and small bowel.
120
Nonambulatory outpatients or acutely
ill patients, such as patients with a bleed-
ing ulcer, are usually examined in the
supine position using a fluoroscopic and
spot-imaging procedure. Everything pos-
sible should be done to expedite the pro-
cedure. Any contrast preparation must be
ready, and the examination room must be
fully prepared before the patient is brought
into the radiology department.
PRELIMINARY PREPARATION
Preparation of patient
Because a gastrointestinal series is time-
consuming, the patient should be told the
approximate time required for the proce-
dure before being assigned an appoint-
ment for an examination. The patient also
needs to understand the reason for pre-
liminary preparation so that full coopera-
tion can be given.
The stomach must be empty for an
examination of the UGI tract (the stomach
and small intestine). It is also desirable to
have the colon free of gas and fecal mate-
rial. When the patient is constipated, a
non–gas-forming laxative may be admin-
istered 1 day before the examination.
An empty stomach is ensured by with-
holding food and water after midnight for
8 to 9 hours before the examination. When
a small intestine study is to be made, food
and fluid are withheld after the evening
meal.
Because some research suggests that
nicotine and chewing gum stimulate
gastric secretion and salivation, some
physicians tell patients not to smoke or
chew gum after midnight on the night
before the examination. This restriction is
intended to prevent excessive fluid from
accumulating in the stomach and diluting
the barium suspension enough to interfere
with its coating property. Radiographers
should verify patient compliance with the
preliminary preparation before obtaining
the scout abdominal image, and should
inform the fluoroscopist of the patient’s
answer when the scout image is provided
for preliminary inspection.
Barium sulfate suspension
The contrast medium generally used in
routine gastrointestinal examinations is
barium sulfate mixed with water. The
preparation must be thoroughly mixed
according to the manufacturer’s instruc-
tions. Specially formulated high-density
barium is also available. Advances in the
production of barium have all but elimi-
nated the use of a single barium formula
for most gastrointestinal examinations
performed in the radiology department.
Most physicians use one of the many
commercially prepared barium suspen-
sions. These products are available in
several flavors, and some are conveniently
packaged in individual cups containing
the dry ingredients. To these products, the
radiographer merely has to add water, recap
the cup, and shake it to obtain a smooth
suspension. Other barium suspensions are
completely mixed and ready to use.
Contrast Studies
Two general procedures are routinely used
to examine the stomach: the single-contrast
method and the double-contrast method.
A biphasic examination is a combination
of the single-contrast and double-contrast
methods during the same procedure. Hypo-
tonic duodenography is another, less com-
monly used examination.
SINGLE-CONTRAST EXAMINATION
In the single-contrast method (Fig. 17-30),
a barium sulfate suspension is adminis-
4. Detect any abnormal alteration in the
function or contour of the esophagus,
stomach, and duodenum.
5. Record spot images as indicated.
The contrast medium normally begins
to pass into the duodenum almost imme-
diately. Nervous tension of the patient
may delay transit of the contrast material,
however.
Fluoroscopy is performed with the
patient in the upright and recumbent posi-
tions while the body is rotated and the
table is angled, so that all aspects of the
Position of patient
The stomach and the duodenum may be
examined using PA, AP, oblique, and
lateral projections with the patient in the
upright and recumbent positions, as indi-
cated by the fluoroscopic findings.
One variation of the supine position is
the LPO position. In another variation, the
head end of the table is lowered 25 to 30
degrees to show a hiatal hernia. Finally, to
show esophageal regurgitation and hiatal
hernias, the head end of the table is
lowered 10 to 15 degrees and the patient

Contrast Studies
tered during the initial fluoroscopic exam- esophagus, stomach, and duodenum are is rotated slightly toward the right side to
ination. The barium suspension used for shown. Spot images are exposed as indi- place the esophagogastric (gastroesopha-
this study is usually in the 30% to 50% cated. If esophageal involvement is sus- geal) junction in profile to the right of the
weight/volume range.1 The procedure is pected, a study is usually made with a spine. The medical significance of diag-
as follows: thick barium suspension. In facilities in nosing hiatal hernia is a topic that has
• Whenever possible, begin the examina- which subsequent radiographic images of received much attention in recent years.
tion with the patient in the upright the stomach and duodenum are required, Some authors report little correlation
position. the required projections should be obtained between the presence of a hiatal hernia
• The radiologist may first examine the immediately after fluoroscopy before any and gastrointestinal symptoms. If little
heart and lungs fluoroscopically and considerable amount of the barium sus- correlation exists, radiographic evaluation
observe the abdomen to determine pension passes into the jejunum. is of little value in most hiatal hernias.
whether food or fluid is in the stomach.
• Give the patient a glass of barium and
instruct the patient to drink it as
requested by the radiologist. If the
patient is in the recumbent position,
administer the suspension through a
drinking straw.
• The radiologist asks the patient to
swallow two or three mouthfuls of
barium. During this time, the radiolo-
gist examines and exposes any indi-
cated spot images of the esophagus. By
manual manipulation of the stomach
through the abdominal wall, the radi-
ologist then coats the gastric mucosa.
• Images are obtained with the spot-
imaging device or another compression
device to show a mucosal lesion of the
stomach or duodenum.
• After studying the rugae and as the
patient drinks the remainder of the
barium suspension, the radiologist
observes filling of the stomach and
examines the duodenum further. Based
on this examination, the following can
be accomplished:
1. Determine the size, shape, and posi-
tion of the stomach.
2. Examine the changing contour of
the stomach during peristalsis.
3. Observe the filling and emptying of
the duodenal bulb.

1
Skucas J: Contrast media. In Margulis AR, Burhenne
HJ, editors: Alimentary tract radiology, vol 1, ed 4,
St Louis, 1989, Mosby. Fig. 17-30  Barium-filled PA stomach, single-contrast study.

121
 DOUBLE-CONTRAST
EXAMINATION
A second approach to examination of the
gastrointestinal tract is the double-contrast
technique (Fig. 17-31). The principal
advantages of this method over the single-
contrast method are that small lesions are
less easily obscured and the mucosal
lining of the stomach can be more clearly
visualized. For successful results, the
patient must be able to move with relative
ease throughout the examination.
For double-contrast studies, the proce-
Digestive System
• Just before the examination, the patient
may be given glucagon or other anti-
cholinergic medications intravenously
or intramuscularly to relax the gastro­
intestinal tract. These medications
improve visualization by inducing
greater distention of the stomach and
intestines. Before administering these
agents, the radiologist must consider
numerous factors, including side
effects, contraindications, availability,
and cost.
Radiographic imaging procedure
The conventional images obtained after the
fluoroscopic examination may be the same
as images obtained for the single-contrast
examination. Often the images with the
greatest amount of diagnostic information
are the spot images taken during fluoros-
copy. In most cases, the radiologist will
have already obtained most of the neces-
sary diagnostic images. Nonfluoroscopic
images may be unnecessary.

dure is as follows:
• To begin the examination, place the
patient on the fluoroscopic table in the
upright position.
• Give the patient a gas-producing sub-
stance in the form of a powder, crystals,
pills, or a carbonated beverage. (An
older technique involved placing pin-
holes in the sides of a drinking straw so Barium in fundus
that the patient ingested air while drink-
ing the barium suspension during the
examination.)
• Give the patient a small amount of
commercially available, high-density
barium suspension. For even coating of
the stomach walls, the barium must
flow freely and have low viscosity.
Air-filled, barium-coated stomach
Many high-density barium products are
available; these suspensions have
weight/volume ratios of up to 250%.
• Place the patient in the recumbent posi-
tion, and instruct him or her to turn
from side to side or to roll over a few
times. This movement serves to coat the
mucosal lining of the stomach as the
carbon dioxide continues to expand.
The patient may feel the need to belch
but should refrain from doing so until
the examination is finished to ensure
that an optimal amount of contrast
material (gas) remains for the duration
of the examination.

Fig. 17-31  Double-contrast stomach spot images.

122
BIPHASIC EXAMINATION
The biphasic gastrointestinal examination
incorporates the advantages of single-
contrast and double-contrast UGI examina-
tions, with both examinations performed
during the same procedure. The patient
first undergoes a double-contrast examina-
tion of the UGI tract. When this study is
completed, the patient is given an approxi-
mately 15% weight/volume barium sus-
pension, and a single-contrast examination
is performed. This biphasic approach
increases the accuracy of diagnosis without
HYPOTONIC DUODENOGRAPHY
The use of hypotonic duodenography as a
primary diagnostic tool has decreased in
recent years. When lesions beyond the
duodenum are suspected, the double-
contrast gastrointestinal examination
described can aid in the diagnosis. When
pancreatic disease is suspected, computed
tomography (CT) or needle biopsy can
also be used. Hypotonic duodenography is
less frequently necessary.
First described by Liotta,1 hypotonic
duodenography requires intubation (Figs.
17-32 and 17-33) and is used to evaluate
postbulbar duodenal lesions and to detect
pancreatic disease. A newer tubeless tech-
nique requires temporary drug-induced
duodenal paralysis so that a double-
contrast examination can be performed
without interference from peristaltic activ-
ity. During the atonic state, when the duo-
denum is distended with contrast medium
to two or three times its normal size, it
presses against and outlines any abnor-

Contrast Studies
significantly increasing the cost of the mality in the contour of the head of the
examination. pancreas.
1
Liotta D: Pour le diagnostic des tumeus du pan-
créas: la duodénographic hypotonique, Lyon Chir
50:445, 1955.

Fig. 17-32  Hypotonic duodenogram showing deformity of Fig. 17-33  Hypotonic duodenogram showing multiple defects
duodenal diverticulum by small carcinoma of head of pancreas (arrows) in duodenal bulb and proximal duodenum, caused by
(arrow). hypertrophy of Brunner glands.

123
 Stomach and Duodenum
  PA PROJECTION
Image receptor: 10 × 12 inch (24 ×
30 cm), 11 × 14 inch (30 × 35 cm), or
14 × 17 inch (35 × 43 cm) lengthwise,
depending on availability and radiol-
ogist preference
Position of patient
• For radiographic studies of the stomach
and duodenum, place the patient in the
recumbent position. The upright posi-
Digestive System
tion is sometimes used to show the rela-
tive position of the stomach.
• When adjusting thin patients in the
prone position, support the weight of
the body on pillows or other suitable
Fig. 17-34  PA stomach and duodenum.
Fig. 17-35  Single-contrast PA stomach and duodenum.
124
pads positioned under the thorax and
pelvis. This adjustment keeps the
stomach or duodenum from pressing
against the vertebrae, with resultant
pressure-filling defects.
Position of part
• Adjust the patient’s position recumbent
or upright so that the midline of the grid
coincides with a sagittal plane passing
halfway between the vertebral column
and the left lateral border of the
abdomen (Fig. 17-34).
• Center the IR about 1 to 2 inches (2.5
to 5 cm) above the lower rib margin at
the level of L1-2 when the patient is
prone (Figs. 17-35 and 17-36).
Fig. 17-36  Double-contrast PA stomach and duodenum.
• For upright images, center the IR 3 to
6 inches (7.6 to 15 cm) lower than
L1-2. The greatest visceral movement
between prone and upright positions
occurs in asthenic patients.
• Do not apply an immobilization band
for standard radiographic projections of
the stomach and intestines because the
pressure is likely to cause filling defects
and to interfere with emptying and
filling of the duodenal bulb—factors
that are important in serial studies.
• Shield gonads.
• Respiration: Suspend at the end of
expiration unless otherwise requested.
Central ray
• Perpendicular to the center of the IR
Collimation
• Adjust to 10 × 12 inches (24 × 30 cm)
on the collimator. If a 14 × 17-inch
(35 × 43 cm) IR is used for larger
patients, collimate to 11 × 14 inches
(28 × 35 cm).
Structures shown
A PA projection of the contour of the
barium-filled stomach and duodenal bulb
is shown. The upright projection shows
the size, shape, and relative position of the
filled stomach, but it does not adequately
show the unfilled fundic portion of the
organ. In the prone position, the stomach
moves superiorly 1 1 2 to 4 inches (3.8 to
10 cm) according to the patient’s body
habitus (Figs. 17-37 to 17-40). At the
same time, the stomach spreads horizon-
tally, with a comparable decrease in its
length. (Note that the fundus usually fills
in asthenic patients.)
 Stomach and Duodenum

The pyloric canal and the duodenal
bulb are well shown in patients with an
asthenic or hyposthenic habitus. These
structures are often partially obscured in
patients with a sthenic habitus and, except
in the PA axial projection, are completely
obscured by the prepyloric portion of the
stomach in patients with a hypersthenic
habitus.
EVALUATION CRITERIA
The following should be clearly shown:
■ Evidence of proper collimation
■ Entire stomach and duodenal loop
■ Stomach centered at the level of the
pylorus
■ No rotation of the patient
■ Exposure technique that shows the
anatomy
NOTE: A 14 × 17-inch (35 × 43-cm) IR is often
used when the distal esophagus or the small
bowel is to be visualized along with the stomach.

Stomach and Duodenum

T12

T12

Fig. 17-37  Hypersthenic patient. Fig. 17-38  Sthenic patient.

T12 T12

Fig. 17-39  Hyposthenic patient. Fig. 17-40  Asthenic patient.

125
 Stomach and Duodenum

PA AXIAL PROJECTION • For a sthenic patient, center the IR at Central ray

Image receptor: 14 × 17 inch (35 ×
43 cm) lengthwise
Position of patient
• Place the patient in the prone position.
Position of part
• Adjust the patient’s body so that the
midsagittal plane is centered to the grid.
Digestive System
the level of L2 (Fig. 17-41); center it
higher for a hypersthenic patient and
lower for an asthenic patient. L2 lies
about 1 to 2 inches (2.5 to 5 cm) above
the lower rib margin.
• Shield gonads.
• Respiration: Suspend respiration at the
end of expiration unless otherwise
requested.
• Directed to the midpoint of the IR at an
angle of 35 to 45 degrees cephalad.
Gugliantini1 recommended cephalic
angulation of 20 to 25 degrees to show
the stomach in infants.
Collimation
• Adjust to 14 × 17 inches (35 × 43 cm)
on the collimator.
1
Gugliantini P: Utilitá delle incidenze oblique cau-
docraniali nello studio radiologico della stenosi con-
genita ipertrofica del piloro, Ann Radiol [Diagn]

34:56, 1961. Abstract, AJR Am J Roentgenol 87:623,

1962.

35°-45°

Fig. 17-41  PA axial stomach.

126
 Stomach and Duodenum

Structures shown EVALUATION CRITERIA

Gordon1 developed the PA axial projec-
tion to “open up” the high, horizontal
(hypersthenic-type) stomach to show the
greater and lesser curvatures, the antral
portion of the stomach, the pyloric canal,
and the duodenal bulb. The resultant
image gives a hypersthenic stomach much
the same configuration as the average
sthenic type of stomach (Fig. 17-42).
The following should clearly be shown:
■ Evidence of proper collimation
■ Entire stomach and proximal duode-
num
■ Stomach centered at the level of the
pylorus
■ Exposure technique that shows the
anatomy

1
Gordon SS: The angled posteroanterior projection
of the stomach: an attempt at better visualization of

Stomach and Duodenum

the high transverse stomach, Radiology 69:393,
1957.

Fundus

Body

Lesser curvature

Greater curvature

Pyloric region

Duodenum

Fig. 17-42  PA axial stomach, sthenic habitus.

127
 Stomach and Duodenum
  PA OBLIQUE PROJECTION
RAO position
Image receptor: 10 × 12 inch (24 ×
30 cm), 11 × 14 inch (30 × 35 cm), or
14 × 17 inch (35 × 43 cm) lengthwise,
depending on availability
Position of patient
• Place the patient in the recumbent
position.
Digestive System
128
Position of part
• After the PA projection, instruct the
patient to rest the head on the right
cheek and to place the right arm along
the side of the body.
• Have the patient raise his or her left side
and support the body on the left forearm
and flexed left knee.
• Adjust the patient’s position so that a
sagittal plane passing midway between
the vertebrae and the lateral border of
the elevated side coincides with the
midline of the grid (Fig. 17-43).
• Center the IR about 1 to 2 inches (2.5
to 5 cm) above the lower rib margin, at
the level of L1-2, when the patient is
prone.
Fig. 17-43  PA oblique stomach and duodenum, RAO position.
• Make the final adjustment in body
rotation. The approximately 40 to 70
degrees of rotation required to give the
best image of the pyloric canal and duo-
denum depends on the size, shape, and
position of the stomach. Generally,
hypersthenic patients require a greater
degree of rotation than sthenic and
asthenic patients.
• The RAO position is used for serial
studies of the pyloric canal and the duo-
denal bulb because gastric peristalsis is
usually more active when the patient is
in this position.
• Shield gonads.
• Respiration: Suspend at the end of
expiration unless otherwise requested.
Central ray
• Perpendicular to the center of the IR
Collimation
• Adjust to 10 × 12 inches (24 × 30 cm)
on the collimator. If the 14 × 17-inch
(35 × 43-cm) IR is used for larger
patients, collimate to 11 × 14 inches
(28 × 35 cm).
 Stomach and Duodenum

Structures shown EVALUATION CRITERIA

A PA oblique projection of the stomach
and entire duodenal loop is presented.
This projection gives the best image of the
pyloric canal and the duodenal bulb in
patients whose habitus approximates the
sthenic type (Figs. 17-44 and 17-45).
Because gastric peristalsis is generally
more active with the patient in the RAO
position, a serial study of several expo-
sures is sometimes obtained at intervals of
30 to 40 seconds to delineate the pyloric
canal and duodenal bulb.
The following should be clearly shown:
■ Evidence of proper collimation
■ Entire stomach and duodenal loop
■ No superimposition of the pylorus and
duodenal bulb
■ Duodenal bulb and loop in profile
■ Stomach centered at the level of the
pylorus
■ Exposure technique that shows the
anatomy

Stomach and Duodenum

R

Fundus

Greater curvature

Duodenal bulb

Pylorus

Fig. 17-44  Single-contrast PA oblique stomach and duodenum, RAO Fig. 17-45  Double-contrast PA oblique stomach and
position. duodenum. Note esophagus entering stomach (arrow).

129
 Stomach and Duodenum
  AP OBLIQUE PROJECTION Position of part
LPO position • Have the patient abduct the left arm and
place the hand near the head, or place
Image receptor: 10 × 12 inch (24 × the extended arm alongside the body.
30 cm), 11 × 14 inch (30 × 35 cm), or • Place the right arm alongside the body
14 × 17 inch (35 × 43 cm) lengthwise, or across the upper chest, as preferred.
depending on availability • Have the patient turn toward the left,
resting on the left posterior body
Position of patient surface.
• Place the patient in the supine • Flex the patient’s right knee, and rotate
position. the knee toward the left for support.
• Place a positioning sponge against
the patient’s elevated back for
Digestive System
immobilization.
• Adjust the patient’s position so that a
sagittal plane passing approximately
midway between the vertebrae and the
left lateral margin of the abdomen is
centered to the IR.
Fig. 17-46  AP oblique stomach and duodenum, LPO position.
130
• Adjust the center of the IR at the level
of the body of the stomach. Centering
would be adjusted at a point midway
between the xiphoid process and the
lower margin of the ribs (Fig. 17-46).
• The degree of rotation required to
show the stomach best depends on the
patient’s body habitus. An average
angle of 45 degrees should be sufficient
for a sthenic patient, but the degree
of angulation can vary from 30 to
60 degrees.
• Shield gonads.
• Respiration: Suspend at the end of
expiration unless otherwise instructed.
 Stomach and Duodenum

Central ray EVALUATION CRITERIA

• Perpendicular to the center of the IR
Collimation
• Adjust to 10 × 12 inches (24 × 30 cm)
on the collimator. If the 14 × 17-inch
(35 × 43-cm) IR is used for larger
patients, collimate to 11 × 14 inches
(28 × 35 cm).
Structures shown
The AP oblique projection shows the
fundic portion of the stomach (Fig. 17-47).
The following should be clearly shown:
■ Evidence of proper collimation
■ Entire stomach and duodenal loop
■ Fundic portion of stomach
■ No superimposition of pylorus and
duodenal bulb
■ Body of the stomach centered to the
image
■ Exposure technique that shows the
anatomy
■ Body and pyloric antrum with double-
contrast visualization

Stomach and Duodenum

Because of the effect of gravity, the pyloric
canal and the duodenal bulb are not as
filled with barium as they are in the oppo-
site and complementary position (the
RAO position; see Figs. 17-43 to 17-45).

Esophagus

Fundus

Body

Pylorus

Duodenum

Fig. 17-47  Double-contrast AP oblique stomach and duodenum, LPO position.

131
 Stomach and Duodenum
  LATERAL PROJECTION
R position
Image receptor: 10 × 12 inch (24 ×
30 cm), 11 × 14 (30 × 35 cm), or 14
× 17 inch (35 × 43 cm) lengthwise,
depending on availability
Digestive System
132
Position of patient
• Place the patient in the upright left
lateral position to show the left retro-
gastric space and in the recumbent right
lateral position to show the right retro-
gastric space, duodenal loop, and duo-
denojejunal junction.
Fig. 17-48  Right lateral stomach and duodenum.
Position of part
• With the patient in the upright or recum-
bent position, adjust the body so that a
plane passing midway between the
midcoronal plane and the anterior
surface of the abdomen coincides with
the midline of the grid.
• Center the IR at the level of L1-2 for
the recumbent position (about 1 to 2
inches [2.5 to 5 cm] above the lower rib
margin) and at L3 for the upright
position.
• Adjust the body in a true lateral position
(Fig. 17-48).
• Shield gonads.
• Respiration: Suspend at the end of
expiration unless otherwise requested.
 Stomach and Duodenum

Central ray EVALUATION CRITERIA

• Perpendicular to the center of the IR
Collimation
• Adjust to 10 × 12 inches (24 × 30 cm)
on the collimator. If the 14 × 17-inch
(35 × 43-cm) IR is used for larger
patients, collimate to 11 × 14 inches
(28 × 35 cm).
Structures shown
A lateral projection shows the anterior and
posterior aspects of the stomach, the
The following should be clearly shown:
■ Evidence of proper collimation
■ Entire stomach and duodenal loop
■ No rotation of the patient, as shown by
the vertebrae
■ Stomach centered at the level of the
pylorus
■ Exposure technique that shows the
anatomy

Stomach and Duodenum

pyloric canal, and the duodenal bulb (Figs.
17-49 and 17-50). The right lateral projec-
tion commonly affords the best image of
the pyloric canal and the duodenal bulb in
patients with a hypersthenic habitus.

Fundus

Body

Duodenum

Duodenal bulb

Pyloric portion

Fig. 17-49  Single-contrast right lateral stomach and duodenum. Fig. 17-50  Double-contrast right lateral stomach and
duodenum.

133
 Stomach and Duodenum
  AP PROJECTION
Image receptor: 10 × 12 inch (24 ×
30 cm) lengthwise for small hiatal
hernias; 14 × 17 inch (35 × 43 cm)
lengthwise for large diaphragmatic
herniations or for the stomach and
small bowel
Position of patient
• Place the patient in the supine position.
The stomach moves superiorly and to
the left in this position, and, except in
Digestive System
thin patients, its pyloric end is elevated
so that the barium flows into and fills its
cardiac or fundic portions or both. Filling
of the fundus displaces the gas bubble
into the pyloric end of the stomach,
where it allows double-contrast delinea-
tion of posterior wall lesions when
a single-contrast examination is per-
formed. If the patient is thin, the intesti-
nal loops do not move superior enough
to tilt the stomach for fundic filling.
Rotating the patient’s body toward the
left or angling the head end of the table
downward is necessary.
• Tilt the table to full or partial Tren-
delenburg angulation to show diaphrag-
matic herniations (Fig. 17-51). In the
Trendelenburg position, the involved
organ or organs, which may appear to
be normally located in all other body
positions, shift upward and protrude
through the hernial orifice (most com-
monly through the esophageal hiatus).
NOTE: Valsalva maneuver may be used in
conjunction with or as an alternative to the
Trendelenburg position.
Fig. 17-51  AP stomach and duodenum with table in partial
Trendelenburg position.
134
Position of part
• Adjust the position of the patient so
that the midline of the grid coincides
(1) with the midline of the body when
a 14 × 17-inch (35 × 43-cm) IR is used
(see Fig. 17-51) or (2) with a sagittal
plane passing midway between the
midline and the left lateral margin of
the abdomen when a 10 × 12-inch (24
× 30-cm) IR is used (Fig. 17-52). Lon-
gitudinal centering of the large IR
depends on the extent of hernial protru-
sion into the thorax and is determined
during fluoroscopy.
• For the stomach and duodenum, center
the 10 × 12-inch (24 × 30-cm) IR at a
level midway between the xiphoid
process and the lower rib margin
(approximately L1-2). For the 14 ×
17-inch (35 × 43-cm) IR, center it at the
same level and adjust up or down
slightly, depending on whether the dia-
phragm or the small bowel needs to be
seen.
• Shield gonads.
• Respiration: Suspend at the end of
expiration unless otherwise requested.
Central ray
• Perpendicular to the center of the IR
Collimation
• Adjust to 10 × 12 inches (24 × 30 cm)
(for stomach) or 14 × 17 inches (35 ×
43 cm) (for stomach and small bowel)
on the collimator.
Fig. 17-52  AP stomach and duodenum.
Structures shown
Stomach.  An AP projection of the
stomach shows a well-filled fundic portion
and usually a double-contrast delineation
of the body, pyloric portion, and duode-
num (Fig. 17-53). Because of the eleva-
tion and superior displacement of the
stomach, this projection affords the best
AP projection of the retrogastric portion
of the duodenum and jejunum.
Diaphragm.  An AP projection of the
abdominothoracic region shows the organ
or organs involved in, and the location
and extent of, any gross hernial protrusion
through the diaphragm (Figs. 17-54
and 17-55).
EVALUATION CRITERIA
The following should be clearly shown:
■ Evidence of proper collimation
■ Entire stomach and duodenal loop
■ Double-contrast visualization of the
gastric body, pylorus, and duodenal
bulb
■ Retrogastric portion of the duodenum
and jejunum
■ Lower lung fields on 14 × 17-inch
(35 × 43-cm) images to show diaphrag-
matic hernias
■ Stomach centered at the level of the
pylorus on 10 × 12-inch (24 × 30-cm)
and 11 × 14- inch (28 × 35-cm) images
■ No rotation of the patient
■ Exposure technique that shows the
anatomy
 Stomach and Duodenum

Fundus

Body R

Stomach and Duodenum

Pyloric portion
Duodenal loop

Fig. 17-53  AP stomach and duodenum, sthenic habitus.

Esophagus

Fundus

Lung

Duodenum

Fig. 17-54  AP stomach and duodenum, showing hiatal hernia Fig. 17-55  Upright left lateral stomach showing hiatal hernia.
above level of diaphragm (arrow). (Comparison lateral images are shown in Figs. 17-49 and 17-50.)

135
 Superior Stomach and Distal Esophagus
PA OBLIQUE PROJECTION
WOLF METHOD (FOR HIATAL
HERNIA)
RAO position
Image receptor: 14 × 17 inch (35 ×
43 cm) lengthwise
The Wolf method1 is a modification of
the Trendelenburg position. The technique
was developed for the purpose of applying
greater intra-abdominal pressure than is
provided by body angulation alone and
Digestive System
ensuring more consistent results in the
radiographic demonstration of small,
sliding gastroesophageal herniations
through the esophageal hiatus.
The Wolf method requires the use of a
semicylindric radiolucent compression
device measuring 22 inches (55 cm) in
length, 10 inches (24 cm) in width, and 8
inches (20 cm) in height. (The compres-
sion sponge depicted in Fig. 17-56 is
slightly smaller than the one described
by Wolf.)
1
Wolf BS, Guglielmo J: Method for the roentgen
demonstration of minimal hiatal herniation, J Mt
Sinai Hosp NY 23:738, 741, 1956.
136
Wolf and Guglielmo1 stated that this
compression device not only provides
Trendelenburg angulation of the patient’s
trunk, it also increases intra-abdominal
pressure enough to permit adequate con-
trast filling and maximal distention of the
entire esophagus. A further advantage of
the device is that it does not require angu-
lation of the table; the patient can hold the
barium container and ingest the barium
suspension through a straw with compara-
tive ease.
NOTE: Valsalva maneuver also increases intra-
abdominal pressure and may be used instead of
the Wolf method.
1
Wolf BS, Guglielmo J: The roentgen demonstration
of minimal hiatus hernia, Med Radiogr Photogr
33:90, 1957.
Fig. 17-56  PA oblique stomach with compression sponge, RAO
position.
Position of patient
• Place the patient in the prone position
on the radiographic table.
Position of part
• Instruct the patient to assume a modi-
fied knee-chest position during place-
ment of the compression device.
• Place the compression device horizon-
tally under the abdomen and just below
the costal margin.
• Adjust the patient in a 40- to 45-degree
RAO position, with the thorax centered
to the midline of the grid.
• Instruct the patient to ingest the barium
suspension in rapid, continuous
swallows.
• To allow for complete filling of the
esophagus, make the exposure during
the third or fourth swallow (see
Fig. 17-56).
• Shield gonads.
• Respiration: Suspend at the end of
expiration.
 Superior Stomach and Distal Esophagus

Central ray EVALUATION CRITERIA

• Perpendicular to the long axis of the
patient’s back and centered at the level
of T6 or T7. This position usually
results in 10- to 20-degree caudad
angulation of the central ray.
Collimation
• Adjust to 14 × 17 inches (35 × 43 cm)
on the collimator.
The following should be clearly shown:
■ Evidence of proper collimation
■ Middle or distal aspects of the esopha-
gus and the upper aspect of the stomach
■ Esophagus visible between the verte-
bral column and the heart
■ Exposure technique that shows the
anatomy

Structures shown
The Wolf method shows the relationship

Superior Stomach and Distal Esophagus

of the stomach to the diaphragm and
is useful in diagnosing a hiatal hernia
(Fig. 17-57).

A B
Fig. 17-57  Comparison PA axial oblique images in one patient. A, Without abdominal
compression: no evidence of hernia. B, With abdominal compression: obvious large
sliding hernia (arrow).

137
 Small Intestine
Radiologic examinations of the small
intestine are performed by administering
a barium sulfate preparation (1) by mouth;
(2) by complete reflux filling with a large-
volume barium enema (BE); or (3) by
direct injection into the bowel through an
intestinal tube—a technique that is called
enteroclysis, or small intestine enema. The
latter two methods are used when the oral
method fails to provide conclusive infor-
mation.1 Enteroclysis is technically diffi-
cult, so its use is usually limited to larger
Digestive System
medical facilities.
PREPARATION FOR EXAMINATION
Preferably, the patient has a soft or low-
residue diet for 2 days before the small
intestine study. Because of economics,
however, it often is impossible to delay
the examination for 2 days. Food and fluid
are usually withheld after the evening
meal of the day before the examination,
and breakfast is withheld on the day of the
study. A cleansing enema may be admin-
istered to clear the colon; however, an
enema is not always recommended for
enteroclysis because enema fluid may be
retained in the small intestine. The barium
formula varies depending on the method
of examination. The patient’s bladder
should be empty before and during the
procedure to avoid displacing or com-
pressing the ileum.
1
Fitch D: The small-bowel see-through: an improved
method of radiographic small bowel visualization,
Can J Med Radiat Technol 26:167, 1995.
138
ORAL METHOD OF EXAMINATION
The radiographic examination of the small
intestine is usually termed a small bowel
series because several identical images
are done at timed intervals. The oral
examination, or ingestion of barium
through the mouth, is usually preceded by
a preliminary image of the abdomen. Each
image of the small intestine is identified
with a time marker indicating the interval
between its exposure and ingestion of
barium. Studies are made with the patient
in the supine or the prone position. The
supine position is used (1) to take advan-
tage of the superior and lateral shift of the
barium-filled stomach for visualization
of retrogastric portions of the duodenum
and jejunum and (2) to prevent possible
compression overlapping of loops of
the intestine. The prone position is used to
compress the abdominal contents; this
enhances radiographic image quality. For
the final images in thin patients, it may be
necessary to angle the table into the Tren-
delenburg position to “unfold” low-lying
and superimposed loops of the ileum.
The first exposure of the small intestine
is usually taken 15 minutes after the
patient drinks the barium. The interval to
the next exposure varies from 15 to 30
minutes depending on the average transit
time of the barium sulfate preparation
used. Regardless of the barium prepara-
tion used, the radiologist inspects the
images as they are processed and varies
the procedure according to requirements
for the individual patient. Fluoroscopic
and radiographic studies (spot or conven-
tional) may be made of any segment of the
bowel as the loops become opacified.
Some radiologists request that a glass
of ice water (or another routinely used
food stimulant) be given to a patient with
hypomotility after 3 or 4 hours of admin-
istrating barium sulfate to accelerate peri-
stalsis. Others give patients a water-soluble
gastrointestinal contrast medium, tea, or
coffee to stimulate peristalsis. Other radi-
ologists administer peristaltic stimulants
every 15 minutes through the transit time.
With these methods, transit of the medium
is shown fluoroscopically, spot and con-
ventional radiographic images are exposed
as indicated, and the examination is
usually completed in 30 to 60 minutes.
 Small Intestine

  PA OR AP PROJECTION Central ray EVALUATION CRITERIA

Image receptor: 14 × 17 inch (35 ×
43 cm) lengthwise
Position of patient
• Place the patient in the prone or supine
position.
Position of part
• Adjust the patient so that the midsagit-
tal plane is centered to the grid.
• For a sthenic patient, center the IR at
• Perpendicular to the midpoint of the IR
(L2) for early images or at the level of
the iliac crests for delayed sequence
exposures
Collimation
• Adjust to 14 × 17 inches (35 × 43 cm)
on the collimator.
Structures shown
The PA or AP projection shows the small
intestine progressively filling until barium
The following should be clearly shown:
■ Evidence of proper collimation
■ Entire small intestine on each image
■ Stomach on initial images
■ Time marker
■ Vertebral column centered on the image
■ No rotation of the patient
■ Exposure technique that shows the
anatomy
■ Complete examination when barium
reaches the cecum

the level of L2 for images taken within
30 minutes after the contrast medium is
administered (Fig. 17-58).
• For delayed images, center the IR at the
level of the iliac crests.
• Shield gonads.
• Respiration: Suspend at the end of
expiration unless otherwise requested.
Small Intestine
reaches the ileocecal valve (Figs. 17-59 to
17-62). When barium has reached the
ileocecal region, fluoroscopy may be per-
formed, and compression radiographic
images may be obtained (Fig. 17-63). The
examination is usually completed when
the barium is visualized in the cecum,
typically within about 2 hours for a patient
with normal intestinal motility.

Fig. 17-58  AP small intestine. Fig. 17-59  Immediate AP small intestine.

139
 Small Intestine

15 30

st

si
Digestive System

si
si

si

Fig. 17-60  AP small intestine at 15 minutes. Fig. 17-61  AP small intestine at 30 minutes, showing
stomach (st) and small intestine (si).

Ileocecal
valve
Cecum

Appendix

Ileum

Fig. 17-62  AP small intestine at 1 hour, showing Fig. 17-63  Ileocecal studies.
barium-filled cecum.

140
 Small Intestine
COMPLETE REFLUX EXAMINATION
For a complete reflux examination of the
small intestine,1,2 the patient’s colon and
small intestine are filled by a BE admin-
istered to show the colon and small bowel.
Before the examination, glucagon may be
administered to relax the intestine. Diaz-
epam (Valium) may also be given to
diminish patient discomfort during initial
filling of the bowel. A 15% ± 5% weight/
volume barium suspension is often used,
and a large amount of the suspension
(about 4500 mL) is required to fill the
colon and small intestine.
A retention enema tip is used, and the
patient is placed in the supine position for
the examination. The barium suspension
is allowed to flow until it is observed in
the duodenal bulb. The enema bag is
lowered to the floor to drain the colon
before images of the small intestine are
obtained (Fig. 17-64).
1
Miller RE: Complete reflux small bowel examina-
tion, Radiology 84:457, 1965.
2
Miller RE: Localization of the small bowel hemor-
rhage: complete reflux small bowel examination, Am
J Dig Dis 17:1019, 1972.
Fig. 17-65  Enteroclysis procedure with barium visualized in colon.
ENTEROCLYSIS PROCEDURE After fluoroscopic examination of the
Enteroclysis (the injection of nutrient or patient’s small intestine, images of the
medicinal liquid into the bowel) is a radio- small intestine may be requested. The pro-
graphic procedure in which contrast jections most often requested include
medium is injected into the duodenum AP, PA, oblique, and lateral. Recumbent
under fluoroscopic control for examina- and upright images may be requested.
tion of the small intestine. Contrast (Positioning descriptions involving the
medium is injected through a specially abdomen are presented in Chapter 16.)
designed enteroclysis catheter, histori-
cally a Bilbao or Sellink tube.
Before the procedure is begun, the
patient’s colon must be thoroughly
cleansed. Enemas are not recommended as
Small Intestine
preparation for enteroclysis because some
enema fluid may be retained in the small
intestine. Under fluoroscopic control, the
enteroclysis catheter with a stiff guidewire
is advanced to the end of the duodenum at
the duodenojejunal flexure, near the liga-
ment of Treitz. The retention balloon, if
present, is filled with sterile water or saline.
Barium is instilled through the tube at a rate
of approximately 100 mL/min (Fig. 17-65).
Spot images, with and without compres-
sion, are taken as required. In some patients,
air is injected after contrast fluid has
reached the distal small intestine (Fig.
17-66). When CT is to be performed, an
iodinated contrast medium (Figs. 17-67
and 17-68) or tap water (Figs. 17-69 and Fig. 17-64  Normal retrograde reflux
17-70) may be used. examination of small intestine.
Barium in colon
Enteroclysis
catheter
Small intestine
Terminal ileum
Barium air
in small
intestine
Fig. 17-66  Air-contrast enteroclysis.
141
 Small Intestine
Digestive System

Fig. 17-67  Enteroclysis with iodinated contrast medium. Filled Fig. 17-68  Axial CT enteroclysis of the patient in Fig. 17-67.
retention balloon is seen in duodenum (arrow). (Courtesy Michelle
Alting, AS, RT[R].)

Spleen

Colon Small intestine Kidney

Colon

Small intestine

Fig. 17-69  Axial CT enteroclysis with tap water and intravenous Fig. 17-70  Sagittal reconstruction of CT enteroclysis from Fig.
iodinated contrast medium. Intraluminal water (dark gray) is 17-69.
clearly delineated from bowel wall (light gray).

142
 Small Intestine
INTUBATION EXAMINATION
PROCEDURES
Gastrointestinal intubation is a procedure
in which a long, specially designed tube
is inserted through the nose and passed
into the stomach. From there, the tube is
carried inferiorly by peristaltic action.
Gastrointestinal intubation is used for
therapeutic and diagnostic purposes.
When gastrointestinal intubation is
used therapeutically, the tube is connected
to a suction system for continuous
siphoning of gas and fluid contents of the
gastrointestinal tract. The purpose of the
maneuver is to prevent or relieve postop-
erative distention or to deflate or decom-
press an obstructed small intestine.
Although used much less frequently
than in the past, a Miller-Abbott double-
lumen, single-balloon tube (or other
similar tubing) can be used to intubate the
small intestine. Just above the tip of the
Miller-Abbott tube is a small, thin rubber
balloon. Marks on the tube, beginning at
the distal end, indicate the extent of the
tube’s passage and are read from the edge
of the nostril. The marks are graduated in
centimeters up to 85 cm and are given in
feet thereafter. The lumen of the tube is
asymmetrically divided into (1) a small
balloon lumen that communicates with the
balloon only and is used for inflation and
deflation of the balloon and for injection
of mercury to weight the balloon and
(2) a large aspiration lumen that commu-
nicates with the gastrointestinal tract
through perforations near and at the distal
end of the tube. Gas and fluids are with-
drawn through the aspiration lumen, and
liquids are injected through it.
A B
Fig. 17-71  A, Miller-Abbott tube study with water-soluble medium. B, Small bowel
examination by Miller-Abbott tube with injection of barium sulfate.
The introduction of an intestinal tube is
an unpleasant experience for a patient,
especially one who is acutely ill. Depend-
ing on the condition of the patient, the
tube is more readily passed if the patient
can sit erect and lean slightly forward, or
if the patient can be elevated almost to a
sitting position.
With the intestinal tube in place, the
patient is turned to an RAO position, a
syringe is connected to the balloon lumen,
and mercury is poured into the syringe and
allowed to flow into the balloon. Air is
slowly withdrawn from the balloon. The
tube is secured with an adhesive strip
beside the nostril to prevent regurgitation
or advancement of the tube. The stomach
is aspirated by using a syringe or by
attaching the large position of the lumen
to the suction apparatus.
With the tip of the tube situated close
to the pyloric sphincter and the patient in
the RAO position (a position in which
gastric peristalsis is usually more active),
the tube should pass into the duodenum in
a reasonably short time. Without interven-
tion, this process sometimes takes many
hours. Having the patient drink ice water
to stimulate peristalsis is often successful.
When this measure fails, the examiner
guides the tube into the duodenum by
manual manipulation under fluoroscopic
observation. After the tube enters the duo-
denum, it is inflated again to provide a
bolus that peristaltic waves can more
readily move along the intestine.
When the tube is inserted for decom-
pression of an intestinal obstruction and
possible later radiologic investigation, the
adhesive strip is removed and replaced
with an adhesive loop attached to the fore-
head. The tube can slide through the loop
without tension as it advances toward the
obstructed site. The patient is then returned
to the hospital room. Radiographic images
of the abdomen may be taken to check the
progress of the tube and the effectiveness
of decompression. Simple obstructions
are sometimes relieved by suction; others
require surgical intervention.
If passage of the intestinal tube is
arrested, suction is discontinued, and the
patient is returned to the radiology depart-
Small Intestine
ment for a Miller-Abbott tube study. The
contrast medium used for studies of a
localized segment of the small intestine
may be a water-soluble, iodinated solution
(Fig. 17-71, A) or a thin barium sulfate
suspension. Under fluoroscopic observa-
tion, the contrast agent is injected through
the large lumen of the tube with a syringe.
Spot and conventional images are obtained
as indicated.
When the intestinal tube is introduced
for the purpose of performing a small
intestine enema, the tube is advanced into
the proximal loop of the jejunum and is
secured at this level with an adhesive strip
taped beside the nose. Medical opinion
varies regarding the quantity of barium
suspension required for this examination
(Fig. 17-71, B). The medium is injected
through the aspiration lumen of the tube
in a continuous, low-pressure flow. Spot
and conventional images are exposed
as indicated. Except for the presence of
the tube in the upper jejunum, resultant
images resemble those obtained by the
oral method.
143
 Large Intestine
CONTRAST MEDIA STUDIES
The two basic radiologic methods of
examining the large intestine by means of
contrast media enemas are (1) the single-
contrast method (Fig. 17-72), in which the
colon is examined with a barium sulfate
suspension or water-soluble iodide only,
and (2) the double-contrast method (Fig.
17-73), which may be performed as a two-
stage or single-stage procedure. In the
two-stage, double-contrast procedure, the
colon is examined with a barium sulfate
suspension and then, immediately after
Digestive System
evacuation of the barium suspension, with
an air enema or another gaseous enema.
In the single-stage, double-contrast
procedure, the fluoroscopist selectively
injects the barium suspension and the gas.
Positive contrast medium shows the
anatomy and tonus of the colon and most
of the abnormalities to which it is subject.
The gaseous medium serves to distend the
lumen of the bowel and to render visible,
through the transparency of its shadow, all
parts of the barium-coated mucosal lining
of the colon and any small intraluminal
lesions, such as polypoid tumors.
Fig. 17-72  Large intestine, single-contrast study.
144
A more recent development in radio-
graphic examination of the large intestine
is computed tomography colonography
(CTC), also called virtual colonoscopy
(VC)—a procedure used as a primary
screening tool for colorectal cancer or
after a failed conventional colonoscopy.
This software-driven technique combines
helical CT and virtual reality software to
create three-dimensional and multiplanar
images of the colonic mucosa. Examples
of currently available CTC techniques
include the perspective-filet or virtual dis-
section view, the three-dimensional topo-
graphic view, the multiplanar reformatted
(MPR) view, and the colonoscopic-like
endoluminal view (Figs. 17-74 to 17-76).
Contrast media
Commercially prepared barium sulfate
products are generally used for routine
retrograde examinations of the large intes-
tine. Some of these products are referred
to as colloidal preparations because they
have finely divided barium particles that
resist precipitation, whereas others are
Fig. 17-73  Large intestine, double-contrast study.
referred to as suspended or flocculation-
resistant preparations because they
contain some form of suspending or dis-
persing agent.
The newest barium products available
are referred to as high-density barium
sulfate. These products absorb a greater
percentage of radiation, similar to older
“thick” barium products. High-density
barium is particularly useful for double-
contrast studies of the alimentary canal in
which uniform coating of the lumen is
required.
Air is the gaseous medium usually used
in the double-contrast enema study. The
procedure is generally called an air-
contrast study. Carbon dioxide may also
be used because it is more rapidly absorbed
than the nitrogen in air when evacuation
of the gaseous medium is incomplete. Use
of air as a contrast medium for radio-
graphic evaluation of the colon is not
limited to the double-contrast enema pro-
cedure. Air or carbon dioxide insufflation
of the colon is used to perform CTC
or VC.
 Large Intestine

Water-soluble, iodinated contrast media

enemas are performed when colon perfo-
ration or leak is suspected. These iodin-
ated contrast agents are administered
orally to selected patients when retrograde
filling of the colon with barium is impos-
sible or is contraindicated. A disadvantage
of iodinated solutions is that evacuation
often is insufficient for satisfactory
double-contrast visualization of the
mucosal pattern. When a patient is unable
to cooperate for a successful enema study,
orally administered iodinated medium A

Large Intestine
allows satisfactory examination of the
colon. With these oral agents, transit time
from ingestion to colonic filling is fast,
averaging 3 to 4 hours. Iodinated solutions
are practically nonabsorbable from the
gastrointestinal mucosa. As a result, the
oral dose reaches and outlines the entire
large bowel. In contrast to an ingested B C D
barium sulfate suspension, this medium is
not subject to drying, flaking, and unequal Fig. 17-74  Examples of CTC or VC. A, Perspective-filet or virtual dissection view, showing
diverticulum (arrow). B, Three-dimensional topographic view: Purple line in the sigmoid
distribution in the colon. It frequently
shows length of filet in A. C, Axial MPR, showing same diverticulum as in A (arrow).
delineates the intestine almost as well as D, Endoluminal view showing opening (arrow) of diverticulum from A.
the BE does.
(D, Courtesy J. Louis Rankin, BS, RT[R][MR].)

Fig. 17-75  Endoluminal CTC image, showing two tubular Fig. 17-76  Axial MPR image of upper tubular
adenomas (arrows). adenoma (arrow) from Fig. 17-75.

145
 Large Intestine
Preparation of intestinal tract
Medical opinion about preparation mea-
sures varies. Members of the medical pro-
fession usually agree, however, that the
large intestine must be completely emptied
of its contents to render all portions of its
inner wall visible for inspection. When
coated with a barium sulfate suspension,
retained fecal masses are likely to simu-
late the appearance of polypoid or other
small tumor masses (Fig. 17-77); this
makes thorough cleansing of the entire
colon a matter of prime importance. Pre-
Digestive System
liminary preparation of the intestinal tract
of patients who have a condition such as
severe diarrhea, gross bleeding, or symp-
toms of obstruction is limited. Other
patients are prepared, with modification
as indicated, according to specifications
established by the examining physician.
The preliminary preparation usually
includes dietary restrictions (“clear”
liquids only) and a bowel cleansing
regimen. Methods of bowel cleansing
include the following:
• Complete intestinal tract cleansing kits
• Gastrointestinal lavage preparations
• Cleansing enema
Fig. 17-77  Single-contrast, barium-filled colon, showing fecal
material that simulates or masks pathologic condition (arrows).
146
Standard barium enema apparatus
Disposable soft plastic enema tips and
enema bags are commercially available in
different sizes. A soft rubber rectal cath-
eter of small caliber should be used in
patients who have inflamed hemorrhoids,
fissures, a stricture, or other abnormalities
of the anus.
Disposable rectal retention tips (Fig.
17-78) have replaced the older retention
catheters, such as the Bardex or Foley
catheter. The retention tip is a double-
lumen tube with a thin balloon at its distal
end. Because of the danger of intestinal
wall damage, the retention tip must be
inserted with extreme care. The enema
retention tip is used in a patient who has
a relaxed anal sphincter or another condi-
tion that makes it difficult or impossible
to retain an enema. Some radiologists rou-
tinely use retention enema tips and inflate
them if necessary.
The disposable rectal retention tip has
a balloon cuff that fits snugly against the
enema nozzle before inflation and after
deflation so that it can be inserted and
removed with little discomfort to the
patient. A reusable squeeze inflator is rec-
Fig. 17-78  Disposable retention enema tip. Uninflated balloon fits
snugly. Inset: Balloon cuff inflated with 90 mL of air (one complete
squeeze of inflator).
ommended to limit air capacity to approx-
imately 90 mL. One complete squeeze of
the inflator provides adequate distention
of the retention balloon without danger of
overinflation. Disposable retention tips
are available for double-contrast and
single-contrast enemas. For the safety of
the patient, any retention balloon must be
inflated with caution, using fluoroscopy,
just before the examination.
For performance of a double-contrast
BE examination, a special rectal tip is nec-
essary to instill air in the colon (Fig.
17-79). Alternatively, air can simply be
pumped into the colon using a sphygmo-
manometer bulb. Double-contrast reten-
tion tips are also available.
Most enema bags have a capacity of
3 qt (3000 mL) when completely filled
and have graduated quantity markings on
the side. A filter may be incorporated
within the bag to prevent passage of any
unmixed lumps of barium. The tubing is
approximately 6 ft (1.8 m) long. Smaller
enema bags (500 mL) with short, large-
diameter tubing have been developed for
double-contrast BE procedures.
 Large Intestine
Preparation of barium suspensions
The concentration of barium sulfate sus-
pensions used for single-contrast colonic
enemas varies considerably. The often
recommended range is 12% to 25%
for weight/volume. For double-contrast
examinations, a relatively high-density
barium product is used. A 75% to 95%
weight/volume ratio is common.
Commercial BE preparations are avail-
able as premixed liquids that can be
poured into the disposable enema kit bag.
Powdered barium is also available in
single-contrast disposable kit bags. Water
is added, and the solution is mixed by
shaking the bag. Instructions for mixing a
barium preparation vary according to the
manufacturer and the type of barium used.
The best recommendation is to follow the
manufacturer’s instructions precisely.
If warm BEs are administered, the
temperature should be below body
temperature—about 85° F to 90° F (29° C
to 30° C). In addition to being unpleasant
and debilitating, an enema that is too
warm is injurious to intestinal tissues and
produces so much irritation that it is dif-
ficult, if not impossible, for the patient to
retain the enema long enough to permit a
satisfactory examination.
Preparation and care of patient
In no radiologic examination is the full
cooperation of the patient more essential
to success than in the retrograde examina-
tion of the colon. Few patients who are
physically able to retain the enema fail to
Fig. 17-79  Air-contrast enema tip shown with air tube filled with
ink to show position.
do so when they understand the procedure
and realize that in large measure the
success of the examination depends on
them. The radiographer should observe
the following guidelines in preparing a
patient for retrograde examination of the
colon:
• Take time to explain the procedural dif-
ferences between an ordinary cleansing
enema and a diagnostic enema: (1) With
the diagnostic enema, the fluoroscopist
examines all portions of the bowel as it
is being filled with contrast medium
under fluoroscopic observation; (2) this
part of the examination involves palpa-
tion of the abdomen, rotation of the body
as required to visualize different seg-
ments of the colon, and taking of spot
images without and, when indicated,
with compression; (3) a series of large
radiographic images are taken before the
colon can be evacuated.
• Assure the patient that retention of the
diagnostic enema preparation is com-
paratively easy because its flow is con-
trolled under fluoroscopic observation.
• Instruct the patient to (1) keep the anal
sphincter tightly contracted against
the tubing to hold it in position and
prevent leakage; (2) relax the abdomi-
nal muscles to prevent intra-abdominal
pressure; and (3) concentrate on deep
oral breathing to reduce the incidence
of colonic spasm and resultant cramps.
• Assure the patient that the flow of the
enema would be stopped for the dura-
tion of any cramping.
A patient who has not had a previous
colonic examination is usually fearful of
being embarrassed by inadequate draping
and failure to retain the enema for the
required time. The radiographer can dispel
or greatly relieve the patient’s anxiety by
taking the following steps:
• Assure the patient that he or she will be
properly covered.
• Assure the patient that although there is
little chance of “mishap,” he or she will
be well protected, and there is no need
to feel embarrassed should one occur.
Large Intestine
• Keep a bedpan in the examining room
for a patient who cannot or may not be
able to make the trip to the toilet.
The preliminary preparation required
for a retrograde study of the colon is stren-
uous for the patient. The examination
itself further depletes the patient’s
strength. Feeble patients, particularly
elderly patients, are likely to become
weak and faint from the exertion of the
preparation, the examination, and the
effort made to expel the enema. The stren-
uous nature of these procedures presents
an increased risk for patients with a history
of heart disease. An emergency call button
should be available in the lavatory so that
the patient can summon help if necessary.
Although the patient’s privacy must be
respected, the radiographer or an aide
should frequently inquire to ensure that
the patient is all right.
147
 Large Intestine
Insertion of enema tip
In preparation for insertion of the enema
tip, the following steps are taken:
• Instruct the patient to turn onto the left
side, roll forward about 35 to 40 degrees,
and rest the flexed right knee on the
table, above and in front of the slightly
flexed left knee (Sims position). This
position relaxes the abdominal muscles,
which decreases intra-abdominal pres-
sure on the rectum and makes relaxation
of the anal sphincter less difficult.
• Adjust the IV pole so that the enema
Digestive System
contents are no higher than 24 inches
(61 cm) above the level of the anus.
• Adjust the overlapping back of the
gown or other draping to expose the
anal region only, but keep the patient
otherwise well covered. The anal orifice
is commonly partially obscured by
distended hemorrhoids or a fringe of
undistended hemorrhoids. Sometimes
there is a contraction or other abnor-
mality of the orifice. It is necessary for
the anus to be exposed and sufficiently
well lighted for the orifice to be clearly
visible, so that the enema tip can be
inserted without injury or discomfort.
148
• Run a little of the barium mixture into
a waste basin to free the tubing of air,
and then lubricate the rectal tube well
with a water-soluble lubricant.
• Advise the patient to relax and take
deep breaths so that no discomfort is
felt when the tube is inserted.
• Elevate the right buttock laterally to
open the gluteal fold.
• As the abdominal muscles and anal
sphincter are relaxed during the expira-
tion phase of a deep breath, insert the
rectal tube gently and slowly into
the anal orifice. Following the angle of
the anal canal, direct the tube anteriorly
1 to 1 1 2 inches (2.5 to 3.8 cm). Then,
while following the curve of the rectum,
direct the tube slightly superiorly.
• Insert the tube for a total distance of no
more than 4 inches (10 cm). Insertion
for a greater distance not only is unnec-
essary but also may injure the rectum.
• If the tube cannot be entered easily, ask
the patient to assist if he or she is
capable.
• Never forcibly insert a rectal tube
because the patient may have distended
internal hemorrhoids or another condi-
tion that makes forced insertion of the
tube dangerous.
Left colic
flexure
Right colic
flexure
Transverse colon
Descending colon
Ascending colon
Terminal ileum
Cecum
Sigmoid
Rectum
Air-filled retention tip
Fig. 17-80  Single-contrast BE image, sthenic habitus.
• After the enema tip is inserted, hold it
in position to prevent slipping while the
patient turns to the supine or prone
position for fluoroscopy, according
to the preference of the fluoroscopist.
The retention cuff may be inflated at
this time.
• Adjust the protective underpadding and
relieve any pressure on the tubing, so
that the enema mixture flows freely.
SINGLE-CONTRAST
BARIUM ENEMA
Administration of contrast medium
After preparing the patient for the exami-
nation, the radiographer observes the fol-
lowing steps:
• Notify the radiologist as soon as every-
thing is ready for the examination.
• If the patient has not been introduced to
the radiologist, make the introduction at
this time.
• At the radiologist’s request, release the
control clip and ensure the enema flow.
• When occlusion of the enema tip
occurs, displace soft fecal material by
withdrawing the rectal tube about 1
inch (2.5 cm). Before reinserting the
tip, temporarily elevate the enema bag
to increase fluid pressure.
 Large Intestine
The rectal ampulla fills slowly. Unless
the barium flow is stopped for a few
seconds after the rectal ampulla is full, the
suspension flows through the sigmoid and
descending portions of the colon at a fairly
rapid rate, frequently causing a severe
cramp and acute stimulation of the defeca-
tion impulse. The flow of the barium sus-
pension is usually stopped for several
seconds at frequent intervals during fluo-
roscopically controlled filling of the colon.
During the fluoroscopic procedure, the
radiologist rotates the patient to inspect all
segments of the bowel. The radiologist
Fig. 17-81  Postevacuation image showing mucosal pattern (arrows). Hyposthenic habitus.
takes spot images as indicated and deter-
mines the positions to be used for subse-
quent radiographic studies. On completion
of the fluoroscopic examination, the
enema tip is usually removed so the
patient can be maneuvered more easily,
and so the tip is not accidentally displaced
during the imaging procedure. A retention
tube is not removed until the patient is
placed on a bedpan or the toilet.
After the IRs have been exposed (Fig.
17-80), the patient is escorted to a toilet or
placed on a bedpan and is instructed to
expel as much of the barium suspension as
possible. A postevacuation image is then
taken (Fig. 17-81). If this image shows
evacuation to be inadequate for satisfactory
delineation of the mucosa, the patient may
be given a hot beverage (tea or coffee) to
stimulate further evacuation.
Positioning of opacified colon
The most commonly obtained projections
for single-contrast BE are PA or AP and
PA obliques, axial for the sigmoid, and
lateral to show the rectum.
Large Intestine
149
 Large Intestine
DOUBLE-CONTRAST BARIUM
ENEMA
Two approaches to administering double-
contrast BEs are currently in use. The first
technique is a two-stage procedure,
described by Welin,1 in which the entire
colon is filled with a barium suspension.
After administration of the enema, the
patient evacuates the barium and immedi-
ately returns to the fluoroscopic table,
where air or another gaseous medium is
injected into the colon. The second
approach is the single-stage, double-
Digestive System
contrast examination. The popularity of
this approach can be attributed primarily
to more recent advancements in the manu-
facture of high-density barium sulfate.
Single-stage procedure
In performing the single-stage, double-
contrast enema, certain requirements must
be met to ensure an adequate examination.
The most important requirement is that
the patient’s colon must be exceptionally
clean. Residual fecal material can obscure
1 1
Welin S: Modern trends in diagnostic roentgenology
of the colon, Br J Radiol 31:453, 1958.
Fig. 17-82  AP oblique colon, RPO position, double-
contrast study.
150
small polyps or tumor masses. A second
requirement is that a suitable barium sus-
pension must be used. A barium mixture
that clumps or flakes neither clearly shows
the lumen nor properly drains from the
colon.
Currently available, premixed liquid
barium products are generally more
uniform for radiographic use than most
barium suspensions mixed in the health
care institution. A barium product with a
density of 200% weight/volume may be
used for a single-stage, double-contrast
examination of the colon. The most impor-
tant criterion is that the barium flows suf-
ficiently to coat the walls of the colon.
With advances in the manufacture of
high-density barium, high-quality double-
contrast colon images can be consistently
obtained during one filling of the colon. In
the single-stage procedure, barium and air
are instilled in a single procedure. Miller1
described a 7-pump method for perform-
ing single-stage, double-contrast exami-
nations. This method reduces cost, saves
Miller RE: Barium pneumocolon: technologist-
performed “7-pump” method, AJR Am J Roentgenol
139:1230, 1982.
Fig. 17-83  AP colon, right lateral decubitus position.
time, and reduces radiation exposure to
the patient. (A more complete description
of the 7-pump method is provided in
the seventh edition or earlier editions of
this atlas.)
Fluoroscopy is performed to check the
location of the barium, and additional air
is instilled under fluoroscopic control. The
patient is slowly rotated 360 degrees and
is placed in the supine position. Spot
images and overhead radiographic images
are then taken (Figs. 17-82 and 17-83).
In addition to the 7-pump method, a
single-stage, double-contrast examination
can be performed using a technique that
does not employ a special air-contrast
enema tip. With this technique, barium
and air are instilled through the closed
enema bag system (Fig. 17-84).
Large Intestine

Filling colon with barium

Insertion of enema tip

creates closed system. Barium is instilled
in colon.

Flow rate controlled by:

Degree of elevation of bag

Large Intestine
Gentle manual pressure on bag
Pressure cuff (when thicker mixture is preferred)
Incorporated filter that prevents passage
of clumps into tubing.

Passive, controlled evacuation Amount of barium is adjusted.

is effected by lowering bag.

Amount of barium in colon

Patient does not adjusted by:
leave table. Siphoning of excess in retrograde
Enema tip is manner
not removed. Lowering bag, which enables bulk
of enema to be withdrawn with im-
mediate relief of distention and
cramps and prevention of spillage

Double-contrast study is started

immediately by simply inverting bag.

Filled colon is imaged.

Carbon dioxide or air is introduced

into colon by applying gentle pressure.
Amount and rate of flow are
controlled by fluoroscopic observation.

Reintroduction of material as indicated

by condition of patient

Examination is complete. Closed system has

not been broken. Entire examination has
been performed in single stage.
Fig. 17-84  Conduction of single-stage, closed-system, double-contrast examination.

(From Pochaczevsky R, Sherman RS: A new technique for roentgenologic examination of the colon,
AJR Am J Roentgenol 89:787, 1963.)

151
 Large Intestine
Welin method
Welin1,2 developed a technique for double-
contrast enema that reveals even the
smallest intraluminal lesions (Figs. 17-85
and 17-86). He stated that this method
of examination is extremely valuable in
the early diagnosis of conditions such as
ulcerative colitis, regional colitis, and
polyps.
Welin stressed the importance of pre-
paring the intestine for the examination,
stating that (1) the colon must be cleansed
as thoroughly as possible, and (2) the
Digestive System
colonic mucosa must be prepared in such
a way that an extremely thin, even coating
of barium can adhere to the colonic wall.
He recommended regulation of evacua-
tion so that the two stages of the examina-
tion can be carried out at short intervals to
avoid unnecessary waiting time, and the
patient does not have to be in the examin-
ing room for longer than 20 to 25 minutes.
1
Welin S: Modern trends in diagnostic roentgenology
of the colon, Br J Radiol 31:453, 1958.
2
Welin S: Results of the Malmo technique of colon
examination, JAMA 199:369, 1967.
Fig. 17-85  Upright oblique position of flexure after
implementation of Welin method.
152
Stage 1.  With the patient in the prone
position to prevent possible ileal leak, the
colon is filled to the left colic flexure, after
which a conventional radiographic image
is taken (i.e., a right lateral projection of
the barium-filled rectum). The patient is
sent to the lavatory to evacuate the barium.
Afterward, if the patient feels the need to
do so, he or she is allowed to lie down and
rest.
Stage 2.  When the patient returns to the
examining table, the enema tip is inserted,
and the patient is again turned to the prone
position. The prone position not only pre-
vents ileal leakage with resultant opacifi-
cation and overlap of the small intestine
on the rectosigmoid area, it also aids in
providing adequate drainage of excess
barium from the rectum.
Fig. 17-86  Upright PA colon after implementation of Welin
method.
The radiologist allows the barium
mixture to run up to the middle of the
sigmoid colon (slightly farther if the
sigmoid is long). The patient is turned
onto the right side, and air is instilled
through the enema tip. The air forces the
barium along, distributing it throughout
the colon, and the patient is turned as
required for even coating of the entire
colon. Spot images are made as indicated.
If barium flows back into the rectum, it is
drained out through the enema tip. More
air is then instilled. Welin stressed the
importance of instilling enough air (≈1800
to 2000 cc) to obtain proper distention of
the colon.
 Large Intestine
When sufficient distention of the colon
has been obtained, 14 × 17-inch (35 ×
43-cm) images are obtained (Fig. 17-87)
to include the rectum, using the following
sequence: PA projection, PA oblique
(LAO and RAO) projections, and right
lateral projection 10 × 12 inches (24 ×
30 cm). The patient is then turned to the
supine position for an AP projection and
two AP oblique (LPO and RPO) projec-
A B
tions, all to include the transverse colon
and its flexures. These studies are fol-
lowed by AP projections in the right and
left lateral decubitus positions to include
the rectum. Finally, the patient is placed
in the erect position for PA and PA oblique
(RAO and LAO) projections of the hori-
zontal colon and the left and right colic
flexures.
Large Intestine
Fig. 17-87  A, Pedunculated polyps (arrows) during stage
2 of Welin method. B, Small carcinoma with intubation
(arrow) during stage 2 of Welin method. C, Cobblestone
appearance of granulomatous colitis in image obtained
during stage 2 of Welin method.
153
 Large Intestine
OPACIFIED COLON
Radiographic studies of the adult colon
are made on 14 × 17-inch (35 × 43-cm)
IRs. Except for axial projections, these
IRs may be centered at the level of the
iliac crests on patients of sthenic build—
higher for hypersthenic patients and lower
for asthenic patients. AP and PA projec-
tions of the colon and abdomen may
require two exposures, with the IRs placed
crosswise: The first is centered high
enough to include the diaphragm, and the
second is centered low enough to include
Digestive System
the rectum. Localized studies of the
rectum and rectosigmoid junction are
often exposed on 10 × 12-inch (24 ×
30-cm) IRs centered at or slightly above
the level of the pubic symphysis. Preevac-
uation images of the colon include one or
more images to show otherwise obscured
flexed and curved areas of the large
intestine.
Depending on the preference of the radi-
ologist, the radiographic projections taken
after fluoroscopy vary considerably. Any
combination of the following images may
be taken to complete the examination.
154
  PA PROJECTION
Image receptor: 14 × 17 inch (35 ×
43 cm) lengthwise
Position of patient
• Place the patient in the prone position.
Position of part
• Center the midsagittal plane to the grid.
• Adjust the center of the IR at the level
of the iliac crests (Fig. 17-88).
• In addition to positioning for the PA
projection, place the fluoroscopic table
in a slight Trendelenburg position if
necessary. This table position helps
separate redundant and overlapping
loops of the bowel by “spilling” them
out of the pelvis.
• Shield gonads.
• Respiration: Suspend.
Fig. 17-88  PA large intestine.
Central ray
• Perpendicular to the IR to enter the
midline of the body at the level of the
iliac crests
Collimation
• Adjust to 14 × 17 inches (35 × 43 cm)
on the collimator.
Structures shown
The PA projection shows the entire
colon with the patient prone (Figs. 17-89
to 17-91).
EVALUATION CRITERIA
The following should be clearly shown:
■ Evidence of proper collimation
■ Entire colon including the flexures and
the rectum (two IRs may be necessary
for hypersthenic patients)
■ Vertebral column centered so that
ascending and descending portions of
the colon are included
■ Exposure technique that shows the
anatomy
 Large Intestine

Large Intestine
Fig. 17-89  Single-contrast PA large intestine.

Left colic
flexure

Descending colon

Transverse colon

Right colic
flexure

Ascending colon

Sigmoid

Rectum

Fig. 17-90  Double-contrast PA large intestine, hyposthenic body Fig. 17-91  Postevacuation PA large intestine.
habitus.

155
 Large Intestine

  PA AXIAL PROJECTION Collimation EVALUATION CRITERIA

Image receptor: 14 × 17 inch (35 ×
43 cm) or 10 × 12 inch (24 × 30 cm)
lengthwise
Position of patient
• Place the patient in the prone position.
Position of part
• Center the midsagittal plane to the grid.
• Adjust the center of the IR at the level
of the iliac crests (Fig. 17-92).
Digestive System
• Adjust to 14 × 17 inches (35 × 43 cm)
or 10 × 12 inches (24 × 30) on the
collimator.
Structures shown
The PA axial projection best shows the
rectosigmoid area of the colon (Figs.
17-93 and 17-94).
NOTE: This axial projection is sometimes per-
formed with the patient in the RAO position, to
further reduce superimposition in the rectosig-
moid area.
The following should be clearly shown:
■ Evidence of proper collimation
■ Rectosigmoid area centered to image
when a 10 × 12-inch (24 × 30-cm) IR
is used
■ Rectosigmoid area with less superim-
position than in PA projection because
of angulation of the central ray
■ Transverse colon and both flexures not
always included
■ Exposure technique that shows the
anatomy

• Shield gonads.
• Respiration: Suspend.

Central ray
• Directed 30 to 40 degrees caudad to
enter the midline of the body at the
level of the anterior superior iliac
30°-40°
spine (ASIS)

Fig. 17-92  PA axial large intestine.

R
Left colic
flexure

Transverse colon

Sigmoid

Rectum

Fig. 17-93  Single-contrast PA axial (30-degree angulation) large Fig. 17-94  Double-contrast PA axial (40-degree angulation) large
intestine. intestine.

156
 Large Intestine

  PA OBLIQUE PROJECTION Central ray EVALUATION CRITERIA

RAO position
Image receptor: 14 × 17 inch (35 ×
43 cm) lengthwise
Position of patient
• Place the patient in the prone position.
Position of part
• With the patient’s right arm by the side
of the body and the left hand by the
head, have the patient roll onto the right
• Perpendicular to the IR and entering
approximately 1 to 2 inches (2.5 to
5 cm) lateral to the midline of the body
on the elevated side at the level of the
iliac crest
Collimation
• Adjust to 14 × 17 inches (35 × 43 cm)
on the collimator.
Structures shown
The RAO position best shows the right
The following should be clearly shown:
■ Evidence of proper collimation
■ Entire colon
■ Right colic flexure less superimposed
or open compared with the PA
projection
■ Ascending colon, cecum, and sigmoid
colon
■ Exposure technique that shows the
anatomy

Large Intestine
hip to obtain a 35- to 45-degree rotation colic flexure, the ascending portion of the
from the radiographic table. colon, and the sigmoid portion of the
• Flex the patient’s left knee to provide colon (Figs. 17-96 and 17-97).
stability.
• Center the patient’s body to the midline
of the grid.
• Adjust the center of the IR at the level
of the iliac crests (Fig. 17-95).
• Shield gonads.
• Respiration: Suspend.

Fig. 17-95  PA oblique large intestine, RAO position.

R Left colic
flexure

Right colic
flexure

Descending colon

Ascending colon

Sigmoid

Fig. 17-96  Single-contrast PA oblique large intestine, RAO position. Fig. 17-97  Double-contrast PA oblique large intestine, RAO
position.

157
 Large Intestine

  PA OBLIQUE PROJECTION Collimation EVALUATION CRITERIA

LAO position
Image receptor: 14 × 17 inch (35 ×
43 cm) lengthwise
Position of patient
• Place the patient in the prone position.
Position of part
• With the patient’s left arm by the side
of the body and the right hand by the
head, have the patient roll onto the left
Digestive System
• Adjust to 14 × 17 inches (35 × 43 cm)
on the collimator.
Structures shown
The LAO position best shows the left
colic flexure and the descending portion
of the colon (Figs. 17-99 and 17-100).
The following should be clearly shown:
■ Evidence of proper collimation
■ Entire colon
■ Left colic flexure less superimposed or
open compared with the PA projection
■ Descending colon
■ Exposure technique that shows the
anatomy

hip to obtain a 35- to 45-degree rotation

from the radiographic table.
• Flex the patient’s right knee to provide
stability.
• Center the patient’s body to the midline
of the grid.
• Adjust the center of the IR at the level
of the iliac crest (Fig. 17-98).
• Shield gonads.
• Respiration: Suspend.

Central ray
• Perpendicular to the IR and entering
approximately 1 to 2 inches (2.5 to
5 cm) lateral to the midline of the body
on the elevated side at the level of the
iliac crest Fig. 17-98  PA oblique large intestine, LAO position.

L Left colic
flexure

Right colic
flexure

Transverse colon

Descending colon

Ascending colon

Vermiform
appendix
Sigmoid

Fig. 17-99  Single-contrast PA oblique large intestine, LAO position. Fig. 17-100  Double-contrast PA oblique large intestine, LAO
position.

158
 Large Intestine

  LATERAL PROJECTION Central ray EVALUATION CRITERIA

R or L position • Perpendicular to the IR to enter the
midcoronal plane at the level of the
Image receptor: 10 × 12 inch (24 × ASIS
30 cm) lengthwise
Collimation
Position of patient • Adjust to 10 × 12 inches (24 × 30 cm)
• Place the patient in the lateral recum- on the collimator.
bent position on the left or the right
side. Structures shown
The lateral projection best shows the
Position of part rectum and the distal sigmoid portion of
• Center the midcoronal plane to the the colon (Figs. 17-102 and 17-103).
The following should be clearly shown:
■ Evidence of proper collimation
■ Rectosigmoid area in the center of the
image
■ No rotation of the patient
■ Superimposed hips and femora
■ Superior portion of colon not included
when the rectosigmoid region is the
area of interest
■ Exposure technique that shows the
anatomy

Large Intestine
center of the grid.
• Flex the patient’s knees slightly for sta-
bility, and place a support between the
knees to keep the pelvis lateral.
• Adjust the patient’s shoulders and hips
to be perpendicular (Fig. 17-101).
• Adjust the center of the IR to the ASIS.
• Shield gonads.
• Respiration: Suspend.

Fig. 17-101  Left lateral rectum.

Sigmoid

Sacrum

Rectum

Pubic symphysis

Fig. 17-102  Single-contrast left lateral rectum. Fig. 17-103  Double-contrast left lateral rectum.

159
 Large Intestine

  AP PROJECTION Central ray EVALUATION CRITERIA

• Perpendicular to the IR to enter the The following should be clearly shown:
Image receptor: 14 × 17 inch (35 × midline of the body at the level of the ■ Evidence of proper collimation
43 cm) lengthwise iliac crests ■ Entire colon including the splenic
flexure and the rectum (two IRs may be
Position of patient Collimation necessary for hypersthenic patients)
• Place the patient in the supine • Adjust to 14 × 17 inches (35 × 43 cm) ■ Vertebral column centered so that the
position. on the collimator ascending colon and the descending
colon are completely included
Position of part Structures shown ■ Exposure technique that shows the
• Center the midsagittal plane to the grid. AP projection shows the entire colon with anatomy
• Adjust the center of the IR at the level the patient supine (Figs. 17-105 and
of the iliac crests (Fig. 17-104). 17-106).
Digestive System

• Shield gonads.
• Respiration: Suspend.

Fig. 17-104  AP large intestine.

R Left colic
flexure

Transverse colon

Right colic
flexure

Descending colon

Ascending colon

Sigmoid

Fig. 17-105  Single-contrast AP large intestine, sthenic habitus. Fig. 17-106  Double-contrast AP large intestine, asthenic habitus.

160
 Large Intestine

  AP AXIAL PROJECTION Structures shown EVALUATION CRITERIA

The AP axial projection best shows the The following should be clearly shown:
Image receptor: 14 × 17 inch (35 × rectosigmoid area of the colon (Figs. ■ Evidence of proper collimation
43 cm) or 10 × 12 inch (24 × 30 cm) 17-108 and 17-109). A similar image is ■ Rectosigmoid area centered when a
lengthwise obtained when the patient is prone (see 10 × 12-inch (24 × 30-cm) IR is used
Fig. 17-92). ■ Rectosigmoid area with less superim-
Position of patient position than in the AP projection
NOTE: This axial projection is sometimes per-
• Place the patient in the supine formed with the patient in the LPO position, to because of the angulation of the central
position. further reduce superimposition in the rectosig- ray
moid area. ■ Transverse colon and flexures not
Position of part included
• Center the midsagittal plane to the grid. ■ Exposure technique that shows the
• Adjust the center of the IR at a level anatomy

Large Intestine
approximately 2 inches (5 cm) above
the level of the iliac crests (Fig. 17-107).
• Shield gonads.
• Respiration: Suspend. 30°-40°

Central ray
• Directed 30 to 40 degrees cephalad to
enter the midline of the body approxi-
mately 2 inches (5 cm) below the level
of the ASIS
• Directed to enter the inferior margin of
the pubic symphysis when a collimated
image is desired to show the rectosig-
moid region

Collimation
• Adjust to 14 × 17 inches (35 × 43 cm)
or 10 × 12 inches (24 × 30 cm) on the
collimator

Fig. 17-107  AP axial large intestine.

Descending colon

Sigmoid

Rectum

Fig. 17-108  Single-contrast AP axial large intestine. Fig. 17-109  Double-contrast AP axial large intestine.

161
 Large Intestine

  AP OBLIQUE PROJECTION Central ray EVALUATION CRITERIA

LPO position • Perpendicular to the IR to enter approx- The following should be clearly shown:
imately 1 to 2 inches (2.5 to 5 cm) ■ Evidence of proper collimation
Image receptor: 14 × 17 inch (35 × lateral to the midline of the body on the ■ Entire colon
43 cm) lengthwise elevated side at the level of the iliac ■ Right colic flexure less superimposed
crest or open compared with the AP
Position of patient projection
• Place the patient in the supine Collimation ■ Ascending colon, cecum, and sigmoid
position. • Adjust to 14 × 17 inches (35 × 43 cm) colon
on the collimator ■ Exposure technique that shows the
Position of part anatomy
• With the patient’s left arm by the side Structures shown
of the body and the right arm across the The LPO position best shows the right
Digestive System

superior chest, have the patient roll onto colic flexure and the ascending and
the left hip to obtain a 35- to 45-degree sigmoid portions of the colon (Figs.
rotation from the table. 17-111 and 17-112).
• Use a positioning sponge and flex the
patient’s right knee for stability, if
necessary.
• Center the patient’s body to the midline
of the grid.
• Adjust the center of the IR at the level
of the iliac crests (Fig. 17-110).
• Shield gonads.
• Respiration: Suspend.

Fig. 17-110  AP oblique large intestine, LPO position.

Left colic
flexure

Right colic
flexure
L

Descending colon

Ascending colon

Sigmoid

Rectum

Fig. 17-111  Single-contrast AP oblique large intestine, LPO Fig. 17-112  Double-contrast AP oblique large intestine, LPO
position. position.

162
 Large Intestine

  AP OBLIQUE PROJECTION Central ray EVALUATION CRITERIA

RPO position • Perpendicular to the IR to enter approx- The following should be clearly shown:
imately 1 to 2 inches (2.5 to 5 cm) ■ Evidence of proper collimation
Image receptor: 14 × 17 inch (35 × lateral to the midline of the body on the ■ Entire colon
43 cm) lengthwise elevated side at the level of the iliac ■ Left colic flexure and descending colon
crest ■ Exposure technique that shows the
Position of patient anatomy
• Place the patient in the supine Collimation
position. • Adjust to 14 × 17 inches (35 × 43 cm)
on the collimator
Position of part
• With the patient’s right arm by the side Structures shown
of the body and the left arm across the RPO position best shows the left colic

Large Intestine
superior chest, have the patient roll onto flexure and the descending colon
the right hip to obtain a 35- to 45-degree (Figs. 17-114 and 17-115).
rotation from the radiographic table.
• Use a positioning sponge and flex the
patient’s right knee for stability, if
needed.
• Center the patient’s body to the midline
of the grid.
• Adjust the center of the IR at the level
of the iliac crests (Fig. 17-113).
• Shield gonads.
• Respiration: Suspend.

Fig. 17-113  AP oblique large intestine, RPO position.

Left colic
flexure

Transverse colon

Right colic
flexure

Descending colon

Ascending colon

Sigmoid

R Rectum

Fig. 17-114  Single-contrast AP oblique large intestine, RPO Fig. 17-115  Double-contrast AP oblique large intestine, RPO
position. position.

163
 Large Intestine
Decubitus Positions
When a patient is being prepared for an
examination in a decubitus position, the
following general guidelines are observed:
• Take all decubitus images (1) with the
patient lying on the fluoroscopic table
and a grid IR firmly supported behind
the patient’s body; (2) with the patient
lying on a patient cart with the body
against an upright table or chest device;
or (3) with the patient lying on a table
or cart and a specially designed vertical
grid device behind the patient.
Digestive System
164
• To ensure that the side on which the
patient is lying is shown, elevate the
patient on a suitable radiolucent support.
If this is not done, the image records
artifacts from the mattress or from the
table edge and superimposes these
images over the portion of the patient’s
colon on the “down” side.
• For all decubitus procedures, exercise
extreme caution to ensure that the
wheels of the cart are securely locked
so that the patient will not fall.
• For lateral decubitus images, have the
patient put the back or abdomen against
the vertical grid device. Most patients
find it more comfortable to have their
back against the vertical grid device
than to have their abdomen against the
same device.
• If both lateral decubitus images are
requested (which is often the case with
air-contrast examinations), take one
image with the patient’s anterior body
surface against the vertical grid device
and the second image with the posterior
body surface against the vertical grid
device.
 Large Intestine

  AP OR PA PROJECTION
Right lateral decubitus position

Image receptor: 14 × 17 inch (35 ×

43 cm) lengthwise

Position of patient
• Place the patient on the right side with
the back or abdomen in contact with the
vertical grid device.
• Exercise care to ensure that the patient
does not fall from the cart or table; if a
cart is used, lock all wheels securely.

Large Intestine
Position of part
• With the patient lying on an elevated
radiolucent support, center the midsag-
ittal plane to the grid. Fig. 17-116  AP large intestine, right lateral decubitus position.
• Adjust the center of the IR to the level
of the iliac crests (Fig. 17-116).
• Shield gonads.
• Respiration: Suspend. L↑

Central ray
• Horizontal and perpendicular to the IR
to enter the midline of the body at the
level of the iliac crests

Collimation
• Adjust to 14 × 17 inches (35 × 43 cm)
on the collimator.

Structures shown
The right lateral decubitus position shows
an AP or PA projection of the contrast-
filled colon. This position best shows the
“up” medial side of the ascending colon
and the lateral side of the descending
colon when the colon is inflated with air Fig. 17-117  Double-contrast AP large intestine, right lateral decubitus position.
(Figs. 17-117 and 17-118).

EVALUATION CRITERIA
L↑
The following should be clearly shown:
■ Evidence of proper collimation Left colic
■ Area from the left colic flexure to the flexure
rectum Sigmoid
■ No rotation of the patient, as demon-
strated by symmetry of the ribs and
pelvis
■ For single-contrast examinations, ade- Transverse colon
quate penetration of the barium; for
double-contrast examinations, the air-
inflated portion of the colon is of
primary importance and should not be
overpenetrated Right colic
flexure

  COMPENSATING FILTER
Image quality can be improved on larger
patients with the use of a special decubitus Fig. 17-118  Double-contrast AP large intestine, right lateral decubitus position.
filter.
165
 Large Intestine

  PA OR AP PROJECTION
Left lateral decubitus position

Image receptor: 14 × 17 inch (35 ×

43 cm) lengthwise

Position of patient
• Place the patient on the left side with
the abdomen or back in contact with the
vertical grid device.
• Exercise care to ensure that the patient
does not fall from the cart or table; if a
cart is used, lock all wheels securely in
Digestive System

position.

Position of part
Fig. 17-119  PA large intestine, left lateral decubitus position.
• With the patient lying on an elevated
radiolucent support, center the midsag-
ittal plane to the grid.
• Adjust the center of the IR at the level
of the iliac crests (Fig. 17-119). R↑
• Shield gonads.
• Respiration: Suspend. Right colic
flexure

Central ray Ascending colon

• Horizontal and perpendicular to the IR
to enter the midline of the body at the
level of the iliac crests Rectum

Collimation
• Adjust to 14 × 17 inches (35 × 43 cm) Sigmoid
on the collimator.

Structures shown
The left lateral decubitus position shows Descending colon
a PA or AP projection of the contrast-filled Left colic
colon. This position best shows the “up” flexure
lateral side of the ascending colon and the Fig. 17-120  Double-contrast PA large intestine, left lateral decubitus position.
medial side of the descending colon when
the colon is inflated with air (Figs. 17-120
and 17-121).

R↑
EVALUATION CRITERIA
The following should be clearly shown:
■ Evidence of proper collimation
■ Area from the left colic flexure to the
rectum
■ No rotation of the patient, as demon-
strated by symmetry of the ribs and
pelvis
■ For single-contrast examinations, ade-
quate penetration of the barium; for
double-contrast examinations, the air-
inflated portion of the colon is of
primary importance and should not be
overpenetrated

Fig. 17-121  Double-contrast PA large intestine, left lateral decubitus position.

166
 Large Intestine

LATERAL PROJECTION Central ray EVALUATION CRITERIA

R or L ventral decubitus position
Image receptor: 14 × 17 inch (35 ×
43 cm) lengthwise
Position of patient
• Place the patient in the prone position
with the right side or the left side against
the vertical grid device.
Position of part
• Elevate the patient on a radiolucent
• Horizontal and perpendicular to the IR
to enter the midcoronal plane of the
body at the level of the iliac crests
Collimation
• Adjust to 14 × 17 inches (35 × 43 cm)
on the collimator.
Structures shown
The ventral decubitus position shows a
lateral projection of the contrast-filled
colon. This position best shows the “up”
The following should be clearly shown:
■ Evidence of proper collimation
■ Area from the flexures to the rectum
■ No rotation of the patient
■ For single-contrast examinations, ade-
quate penetration of the barium; for
double-contrast examinations, the
air-inflated portion of the colon is of
primary importance and should not be
overpenetrated
■ Enema tip removed for an unobstructed
image of the rectum

Large Intestine
support, and center the midcoronal posterior portions of the colon and is most
plane to the grid. valuable in double-contrast examinations
• Adjust the center of the IR at the level (Fig. 17-122).
of the iliac crests.
• Shield gonads.
• Respiration: Suspend.

L↑

Left colic flexure

Rectum

Descending colon

Sigmoid
Right colic flexure
Transverse colon

Transverse colon
Ascending colon

B
Fig. 17-122  A, Patient in position for lateral projection, ventral decubitus position. B, Left
lateral large intestine, ventral decubitus position.

167
 Large Intestine

  AP, PA, OBLIQUE, AND

LATERAL PROJECTIONS
Upright position Left colic
flexure
Upright AP, PA, oblique, and lateral pro-
jections may be taken as requested. The
positioning and evaluation criteria for Right colic
upright images are identical to criteria flexure
required for the recumbent positions. The
IR is placed at a lower level, however, to
compensate for the drop of the bowel
caused by the effect of gravity (Figs. Transverse colon

17-123 to 17-125).
Digestive System

Descending colon

Cecum

Sigmoid

Rectum

Fig. 17-123  Upright double-contrast AP large intestine.

Fig. 17-124  Upright double-contrast PA large Fig. 17-125  Upright double-contrast AP oblique large intestine,
intestine. RPO position.

168
 Large Intestine

AXIAL PROJECTION
CHASSARD-LAPINÉ METHOD
The Chassard-Lapiné method is used to
show the rectum, rectosigmoid junction,
and sigmoid. This projection, which is
made at almost a right angle to the AP
projection, shows the anterior and poste-
rior surfaces of the lower portion of the
bowel and permits the coils of the sigmoid
to be projected free from overlapping.1-3
The projection may be exposed after evac-
uation of the large intestine, although a
preevacuation image can be exposed when
• Instruct the patient to abduct the thighs
as far as the edge of the table permits,
so that they do not interfere with flexion
of the body.
• Center the IR to the midline of the
pelvis, and ask the patient to lean
directly forward as far as possible
(Fig. 17-126).
• Have the patient grasp the ankles for
support.
• Respiration: Suspend.
The exposure required for this projec-
tion is approximately the same as that
Structures shown
The Chassard-Lapiné image shows the
rectum, rectosigmoid junction, and
sigmoid in the axial projection
(Fig. 17-127).
EVALUATION CRITERIA
The following should be clearly shown:
■ Evidence of proper collimation
■ Rectosigmoid area in the center of the
image
■ Rectosigmoid area not obscured by

Large Intestine
the patient has reasonable sphincteric required for a lateral projection of the superior area of colon
control.1 pelvis. ■ Minimal superimposition of rectosig-
moid area
Image receptor: 11 × 14 inch (30 × Central ray ■ Penetration of the lumbosacral region
35 cm) or 14 × 17 inch (35 × 43 cm) • Perpendicular through the lumbosacral and the barium
lengthwise, depending on availability region at the level of the greater
trochanters
Position of patient
• Seat the patient on the radiographic Collimation
table. • Adjust to 14 × 17 inches (35 × 43 cm)
on the collimator.
Position of part
• Instruct the patient to sit well back on
the side of the table so that the midcoro-
Femur
nal plane of the body is as close as
possible to the midline of the table.
• If necessary, shift the transversely
placed IR forward in the Bucky tray so
that its transverse axis coincides as
Greater
nearly as possible with the midcoronal trochanter
plane of the body.
Sigmoid
1
Raap G: A position of value in studying the pelvis
and its contents, South Med J 44:95, 1951.
2
Cimmino CV: Radiography of the sigmoid flexure Ischial
with the Chassard-Lapiné projection, Med Radiogr tuberosity
Photogr 30:44, 1954.
3
Ettinger A, Elkin M: Study of the sigmoid by special Rectum
roentgenographic views, AJR Am J Roentgenol
72:199, 1954.

CR

Fig. 17-126  Chassard-Lapiné method. Fig. 17-127  Axial rectosigmoid: Chassard-Lapiné method.

169
 Large Intestine

COLOSTOMY STUDIES
Enterostomy (Greek enteron, “intestine” +
stoma, “opening”) is the general term
applied to the surgical procedure of
forming an artificial opening to the intes-
tine, usually through the abdominal wall,
for fecal passage. The regional terms are
colostomy, cecostomy, ileostomy, and
jejunostomy.
The colon is the most common site of
disease in the large intestine, and surgical
procedures are often performed on this
structure. Loop colostomy is sometimes
Digestive System
A device must be used to prevent spill-
age of contrast enema material in a patient
with a colostomy. Otherwise, because of
the absence of sphincter control, the con-
trast enema may escape through the colos-
tomy almost as rapidly as it is injected. If
this happens, bowel filling is unsatisfac-
tory, and shadows cast by barium soilage
of the abdominal wall and the examining
table obscure areas of interest. Abdominal
stomas must be effectively occluded for
studies made by retrograde injection, and
leakage around the stomal catheter must
The radiographer observes the follow-
ing steps:
• Clothe the patient in a kimono type of
gown that opens in front or back,
depending on the location of the
colostomy.
• Place the patient on the examining table
in the supine position if he or she has
an abdominal colostomy and in the
prone position if he or she has a peri-
neal colostomy.
• Before taking the preliminary image
and while wearing disposable gloves,

performed to divert the fecal column, tem-
porarily or permanently, from areas of
diverticulitis or ulcerative colitis. Most
colostomies are performed because of
malignancies of the lower bowel and
rectum. When a tumor is present, the
lower carcinomatous part of the bowel is
resected, and the end of the remaining part
of the bowel is brought to the surface
through the abdominal wall. This passage,
or stoma, has no sphincter.
Preparation of intestinal tract
Postoperative contrast enema studies are
performed at suitable intervals to allow
the clinician to determine the efficacy of
treatment in a patient with diverticulitis or
ulcerative colitis and to detect new or
recurrent lesions in a patient who has had
a tumor. Adequate cleansing of the bowel,
which is as important in the presence of a
colostomy as otherwise, is crucial to show
polyps and other intraluminal lesions. In a
patient with a colostomy, the usual prepa-
ration is irrigation of the stoma the night
before the study and again on the morning
of the examination.
Colostomy enema equipment
Although equipment must be scrupulously
clean, and nondisposable items must be
sterilized after each use, sterile technique
is not required because the stoma is part
of the intestinal tract. Except for a suitable
device to prevent stomal leakage of con-
trast material, the equipment used in a
patient with a colostomy is the same as
that used in routine contrast enema studies.
The same barium sulfate formula is used,
and gas studies are made. Opaque and
double-contrast studies can be performed
in a single-stage examination with use of
a disposable enema kit.
be prevented for studies made by injection remove and discard any dressing.
into an abdominal or a perineal colostomy. • Cleanse the skin around the stoma
Numerous devices are available for this appropriately.
purpose. • Place a gauze dressing over the stoma
to absorb any seepage until the physi-
DIAGNOSTIC ENEMA cian is ready to start the examination.
Diagnostic enemas may be given through • Lubricate the stomal catheter or tube
a colostomy stoma with the use of tips and well (but not excessively) with a water-
adhesive disks designed for the patient’s soluble lubricant. The catheter should
use in irrigating the colostomy (Fig. be inserted by the physician or the
17-128). These tips are available in four patient. If a catheter is forced through a
sizes to accommodate the usual sizes of stoma, the colon may be perforated.
colostomy stomas. The tips usually have Spot images are taken during the exam-
a flange to prevent them from slipping ination. Postfluoroscopy images are taken
through the colostomy opening. An adhe- as needed. The projections requested
sive disk is placed over the flange to mini- depend on the location of the stoma and
mize reflux soilage. The enema tubing is the anatomy to be shown (Figs. 17-129
attached directly to the tip, which the to 17-132).
patient holds in position to prevent the
weight of the tubing from displacing
the tip to an angled position. In addition
to keeping a set of Laird tips on hand, it
is recommended that the patient be asked
to bring an irrigation device.
Retention catheters are also used in
colostomy studies. Some radiologists use
them alone, and others insert them through
a device to prevent slipping and to collect
leakage. Colostomy stomas are fragile and
are subject to perforation by any undue
pressure or trauma. Perforations have
occurred during insertion of an inflated
bulb into a blind pouch and as the result
of overdistention of the stoma.
Preparation of patient
If the patient uses a special dressing,
colostomy pouch, or stomal seal, he or she
should be advised to bring a change for
use after the examination. When fecal
emission is such that a pouch is required,
the patient should be given a suitable
dressing to place over the stoma after the
device has been removed.

Fig. 17-128  Laird colostomy irrigation

tips and Stomaseal disks.

170
 Large Intestine

Large Intestine
Fig. 17-129  Opaque colon via perineal colostomy. Fig. 17-130  Opaque colon via abdominal colostomy.

Left colic
flexure

Right colic
flexure

Transverse colon

Enema tubing

Stomaseal flange

Fig. 17-131  Double-contrast colon in patient with abdominal Fig. 17-132  Double-contrast AP oblique colon via
colostomy. abdominal colostomy.

171
 Large Intestine
DEFECOGRAPHY
Defecography, evacuation proctography,
or dynamic rectal examination is a radio-
logic procedure performed on patients
with defecation dysfunction. No prepara-
tion of the patient is necessary, and cleans-
ing enemas are not recommended because
water remaining in the rectum dilutes the
contrast medium.
Digestive System
B
A
Fig. 17-133  Defecography. Lateral anus and rectum spot image
showing long axis of anal canal (line A-B) and long axis of rectal
canal (line B-C) in a patient with anorectal angle of 114 degrees.
Anterior rectocele (arrow) also is shown.
172
Early investigators1 mixed a diluted
suspension of barium sulfate, heated it,
and added potato starch to form a smooth
barium paste that was semisolid and
malleable.2,3 Barium manufacturers now
package prepared barium products (100%
weight/volume barium sulfate paste) with
a special injector mechanism to instill
barium directly into the rectum. In addi-
tion, viscous barium may be introduced
into the vagina and the bladder filled with
aqueous iodinated contrast media.
1
Burhenne HJ: Intestinal evacuation study: a new
roentgenologic technique, Radiol Clin (Basel) 33:79,
1964.
2
Mahieu P et al: Defecography: I. Description of a
new procedure and results in normal patients, Gas-
trointest Radiol 9:247, 1984.
3
Mahieu P et al: Defecography: II. Contribution to
the diagnosis of defecation disorders, Gastrointest
Radiol 9:253, 1984.
Bladder
C
Vagina
Rectum
Anal canal
Fig. 17-134  Defecography. Lateral anal canal and rectum,
vagina, and urinary bladder shown during patient straining.
(Courtesy Michelle Alting, AS, RT[R].)
After the contrast medium is instilled,
the patient is usually seated in the lateral
position on a commercially available
radiolucent commode in front of a fluoro-
scopic unit. A special commode chair is
recommended so that the anorectal junc-
tion and the zone of interest on the image
are not overexposed. Lateral projections
are obtained during defecation by spot
imaging at the approximate rate of 1 to 2
frames per second. Video recording of the
defecation process may be used, but the
special equipment necessary to interpret
the images is not always available, and a
hard copy of the images is unavailable.1
The resulting images are then evaluated
(Fig. 17-133). This evaluation includes
measurements of the anorectal angle and
the angle between the long axes of the
anal canal and rectum. These measure-
ments are compared with normal values.
In addition, changes in proximity of the
rectum to the vagina and bladder during
defecation are assessed when these struc-
tures have been filled with contrast media
(Fig. 17-134).
1
Mahieu PHG: Defecography. In Margulis AR,
Burhenne H, editors: Alimentary tract radiology,
vol 1, ed 4, St Louis, 1989, Mosby.
 Biliary Tract

Biliary Tract and Advances in sonography, CT, MRI, and

Gallbladder
Several techniques can be used to examine
the gallbladder and the biliary ductal
system. In many institutions, sonography
is the modality of choice. This section of
the atlas discusses the radiographic tech-
niques currently available.
Table 17-1 lists some of the prefixes
associated with the biliary system. Cho-
legraphy is the general term for a radio-
graphic study of the biliary system. More
nuclear medicine have reduced the radio-
graphic examination of the biliary tract
primarily to direct injection procedures
including percutaneous transhepatic chol-
angiography (PTC), postoperative (T-tube)
cholangiography, and endoscopic retro-
grade cholangiopancreatography (ERCP).
The contrast agent selected for use in
direct-injection techniques may be any
one of the water-soluble iodinated
compounds employed for intravenous
urography.

Biliary Tract and Gallbladder

specific terms can be used to describe the
portion of the biliary system under inves-
tigation. Cholecystography is the radio-
graphic investigation of the gallbladder,
and cholangiography is the radiographic
study of the biliary ducts.

TABLE 17-1 
Biliary system combining forms
Root forms Meaning
Chole- Relationship with bile
Cysto- Bag or sac
Choledocho- Common bile duct
Cholangio- Bile ducts
Cholecyst- Gallbladder

173
 Biliary Tract

Percutaneous
Transhepatic
Cholangiography
PTC1 is another technique employed for
preoperative radiologic examination of
the biliary tract. This technique is used for
patients with jaundice when the ductal
system has been shown to be dilated by
CT or sonography but the cause of the
obstruction is unclear. Performance of
this examination has greatly increased
because of the availability of the Chiba
Digestive System

(“skinny”) needle. In addition, PTC is

often used to place a drainage catheter for
treatment of obstructive jaundice. When a
drainage catheter is used, diagnostic and
drainage techniques are performed at the
same time.
1
Evans JA et al: Percutaneous transhepatic cholangi-
ography, Radiology 78:362, 1962.

Fig. 17-135  PTC with Chiba needle (arrow) in position, showing dilated biliary ducts.

Fig. 17-136  PTC showing obstruction stone at ampulla Fig. 17-137  PTC showing stenosis (arrow) of common
(arrow). hepatic duct caused by trauma.

174
 Biliary Tract
PTC is performed by placing the patient
on the radiographic table in the supine
position. The patient’s right side is surgi-
cally prepared and appropriately draped.
After a local anesthetic is administered,
the Chiba needle is held parallel to the
floor and inserted through the right lateral
intercostal space and advanced toward the
liver hilum. The stylet of the needle is
withdrawn, and a syringe filled with con-
trast medium is attached to the needle.
Under fluoroscopic control, the needle is
slowly withdrawn until contrast medium
is seen to fill the biliary ducts. In most
instances, the biliary tree is readily located
because the ducts are generally dilated.
After the biliary ducts are filled, the needle
is completely withdrawn, and serial or
spot AP projections of the biliary area are
taken (Figs. 17-135 to 17-137).
Right hepatic duct
Catheter
Drainage catheter in
common bile duct
Contrast "spill"
into duodenum
Tip of catheter
Fig. 17-138  PTC with drainage catheter in place.
BILIARY DRAINAGE PROCEDURE
AND STONE EXTRACTION
If dilated biliary ducts are identified by
CT, PTC, or sonography, the radiologist,
after consultation with the referring physi-
cian, may elect to place a drainage cath-
eter in the biliary duct.1,2 A needle larger
than the Chiba needle used in the PTC
procedure is inserted through the lateral
abdominal wall and into the biliary duct.
A guidewire is passed through the lumen
of the needle, and the needle is removed.
After the catheter is passed over the guide-
wire, the wire is removed, leaving the
catheter in place.
Fig. 17-139  Post-PTC image showing wire basket
(arrow) around retained stone.
The catheter can be left in place for
prolonged drainage, or it can be used
for attempts to extract retained stones if
they are identified. Retained stones are
extracted using a wire basket and a small
balloon catheter under fluoroscopic
control. This extraction procedure is
usually attempted after the catheter has
been in place for some time (Figs. 17-138
and 17-139).
1
Molnar W, Stockum AE: Relief of obstructive jaun-
dice through percutaneous transhepatic catheter—a
Biliary Tract
new therapeutic method, AJR Am J Roentgenol
122:356, 1974.
2
Hardy CH et al: Percutaneous transhepatic biliary
drainage, Radiol Technol 56:8, 1984.
175
 Biliary Tract

Postoperative (T-Tube)
Cholangiography
Postoperative, delayed, and T-tube chol-
angiography are radiologic terms applied
to the biliary tract examination that is per-
formed via a T-shaped or pigtail-shaped
catheter left in the common hepatic and
common bile ducts for postoperative
drainage (Fig. 17-140). A pigtail catheter
is required for laparoscopic biliary proce-
dures because it can be placed percutane-
ously. The T-tube catheter can be placed
Digestive System
Postoperative cholangiography is per-
formed in the radiology department. Pre-
liminary preparation usually consists of
the following:
1. The drainage tube is clamped the day
before the examination to let the tube
fill with bile as a preventive measure
against air bubbles entering the ducts,
where they would simulate cholesterol
stones.
2. The preceding meal is withheld.
3. When indicated, a cleansing enema is
administered about 1 hour before the
The contrast agent used is one of the
water-soluble iodinated contrast media.
The density of the contrast medium used
in postoperative cholangiograms is rec-
ommended to be no greater than 25%
to 30% because small stones may be
obscured with a higher concentration.
After a preliminary image of the
abdomen has been obtained, the patient is
adjusted in the RPO position (AP oblique
projection) with the RUQ of the abdomen
centered to the midline of the grid
(Fig. 17-141).

only during an open surgical procedure. examination. Premedication is not

This examination is performed to show required.
the caliber and patency of the ducts, the
status of the sphincter of the hepatopan-
creatic ampulla, and the presence of resid-
ual or previously undetected stones or
other pathologic conditions.

Right hepatic duct

Hepatic duct

T-tube

Common bile duct

Pancreatic duct

Contrast medium in duodenum

A B
Fig. 17-140  A, Postoperative cholangiogram with T-tube catheter. B, Postoperative cholangiogram with
pigtail catheter.

176
 Biliary Tract

With universal precautions employed, tomic branching of the hepatic ducts in

the contrast medium is injected under this plane and to detect any abnormality
fluoroscopic control, and spot and con- not otherwise shown (Fig. 17-142). The
ventional images are made as indicated. clamp generally is not removed from the
Otherwise, 10 × 12-inch (24 × 30-cm) IRs T-tube before the examination is com-
are exposed serially after each of several pleted. The patient may be turned onto the
fractional injections of the medium and right side for this study.
then at specified intervals until most
of the contrast solution has entered the
duodenum.
Stern et al.1 stressed the importance of
obtaining a lateral projection to show ana-

Biliary Tract
1
Stern WZ et al: The significance of the lateral view
in T-tube cholangiography, AJR Am J Roentgenol
87:764, 1962.

• •
• •
• • •
• •
• • •
• •
•
• •

Fig. 17-141  AP oblique postoperative cholangiogram, RPO Fig. 17-142  Right lateral cholangiogram showing AP location of
position, showing multiple stones in common bile duct (arrows). T-tube (dots), common bile duct (arrow), and hepatopancreatic
ampulla (duct of Vater) (arrowhead).

177
 Biliary Tract and Pancreatic Duct

Endoscopic Retrograde
Cholangio­
pancreatography
ERCP is a procedure used to diagnose
biliary and pancreatic pathologic condi-
tions. ERCP is a useful diagnostic method
when the biliary ducts are not dilated and
when no obstruction exists at the ampulla.
ERCP is performed by passing a fiber-
optic endoscope through the mouth into
the duodenum under fluoroscopic control.
To ease passage of the endoscope, the
Digestive System
After the endoscopist locates the hepa-
topancreatic ampulla (ampulla of Vater), a
small cannula is passed through the endo-
scope and directed into the ampulla (Fig.
17-143). When the cannula is properly
placed, contrast medium is injected into
the common bile duct. The patient may
then be moved, fluoroscopy performed,
and spot images taken (Figs. 17-144 and
17-145). Oblique spot images may be
taken to prevent overlap of the common
bile duct and the pancreatic duct. Because
the injected contrast material should drain
are suspected, use of a more dilute con-
trast medium is suggested.1 A history of
patient sensitivity to an iodinated contrast
medium in another examination (e.g.,
intravenous urography) does not contrain-
dicate its use for ERCP. The patient must
be watched carefully, however, for a reac-
tion to the contrast medium during ERCP.
ERCP is often indicated when clinical
and radiographic findings indicate abnor-
malities in the biliary system or pancreas.
Sonography of the upper part of the
abdomen before endoscopy is often rec-

patient’s throat is sprayed with a local
anesthetic. Because this causes temporary
pharyngeal paresis, food and drink are
usually prohibited for at least 1 hour after
the examination. Food may be withheld
for 10 hours after the procedure to mini-
mize irritation to the stomach and small
bowel.
from normal ducts within approximately
5 minutes, images must be exposed
immediately.
The contrast medium that is used
depends on the preference of the radiolo-
gist or gastroenterologist. Dense contrast
agents opacify small ducts well, but they
may obscure small stones. If small stones
ommended to assure the physician that no
pancreatic pseudocysts are present. This
step is important because contrast medium
injected into pseudocysts may lead to
inflammation or rupture.
1
Cotton P, William C: Practical gastrointestinal
endoscopy, Oxford, England, 1980, Blackwell.

Fig. 17-143  Cannulation procedure. Procedure is begun with the patient in left lateral
position. This schematic diagram gives an overview of location of the examiner and
position of scope and its relationship to various internal organs. Inset: Magnified view of
tip of scope with cannula in papilla.

(From Stewart ET et al: Atlas of endoscopic retrograde cholangiopancreatography, St Louis, 1977,

Mosby.)

178
Biliary Tract and Pancreatic Duct

Common hepatic duct

Pancreatic duct

Cystic stump

Common bile duct

Endoscope

Biliary Tract and Pancreatic Duct

Fig. 17-144  ERCP spot image, PA projection.

Pancreatic duct

Cannula
Fig. 17-145  ERCP spot image, PA projection.

179
 Abdominal Fistulae
and Sinuses
To show radiographically the origin and
extent of fistulae (abnormal passages,
usually between two internal organs) and
sinuses (abnormal channels leading to
abscesses), the following steps are taken:
• Fill the tract with a radiopaque contrast
medium, usually under fluoroscopic
control.
Digestive System
Fig. 17-146  AP abdomen showing contrast
media–filled sinus tract with lead circular ring
on body surface.
Fig. 17-147  Lateral abdomen showing sinus tract with lead
circular ring on body surface.
180
• Obtain right-angle projections. Oblique
projections are occasionally required to
show the full extent of a sinus tract.
• To explore fistulae and sinuses in the
abdominal region, have the intestinal
tract as free of gas and fecal material as
possible.
• Unless the injection is made under fluo-
roscopic control, take a scout image of
the abdomen to check the condition of
the intestinal tract before beginning the
examination.
• When more than one sinus opening is
present, occlude each accessory opening
with sterile gauze packing to prevent
reflux of the contrast substance and to
identify every opening with a specific
lead marker placed over the dressing
(Figs. 17-146 to 17-148).
• Dress and identify the primary sinus
opening in a similar manner if the cath-
eter is removed after the injection.
• When reflux of contrast medium occurs,
cleanse the skin thoroughly before
making an exposure.
Fig. 17-148  Oblique abdomen, LPO position, showing fistula
(arrow).
• When fluoroscopy is not employed,
place the patient in position for the
first projection before the injection to
prevent drainage of the opaque sub-
stance by unnecessary movement. An
initial image is taken and evaluated
before the examination is started or the
patient’s position is changed.
To show a fistula involving the colon,
barium is instilled by enema. If a fistula
involving the small bowel is suspected,
the patient ingests a thin barium suspen-
sion, which is followed by fluoroscopy or
radiography until it reaches the suspected
region. The bladder is filled with iodinated
contrast media when involvement of this
structure is evaluated. Cutaneous fistulae
and sinus tracts are opacified by introduc-
tion of an iodinated contrast medium
through a small-diameter catheter. The
procedures are performed using fluoro-
scopic observation, with images taken as
indicated.
 18 
URINARY SYSTEM AND
VENIPUNCTURE
OUTLINE
SUMMARY OF PROJECTIONS, 182
URINARY SYSTEM ANATOMY, 183
Urinary System, 183
Suprarenal Glands, 183
Kidneys, 184
Ureters, 186
Urinary Bladder, 186
Urethra, 187
Prostate, 187
Summary of Anatomy, 187
Summary of Pathology, 188
Exposure Technique Chart, 189
Abbreviations, 189
URINARY SYSTEM
RADIOGRAPHY, 190
Overview, 190
Radiation Protection, 201
Intravenous Urography, 201
Urinary System, 204
Renal Parenchyma, 209
Nephrotomography, 209
Pelvicaliceal System and
Ureters, 212
Retrograde Urography, 212
Urinary Bladder, Lower Ureters,
Urethra, and Prostate, 214
R
Urinary Bladder, 216
Male Cystourethrography, 221
Female Cystourethrography, 222
VENIPUNCTURE AND IV CONTRAST
MEDIA ADMINISTRATION, 225
Professional and Legal
Considerations, 225
Medications, 225
Patient Education, 225
Patient Assessment, 228
Infection Control, 228
Venipuncture Supplies and
Equipment, 228
Procedure, 230
Reactions and Complications, 235
Documentation, 235

R L

181
 SUMMARY OF PROJECTIONS

PROJECTIONS, POSITIONS, AND METHODS

Page Essential Anatomy Projection Position Method
204 Urinary system AP
206 Urinary system AP oblique RPO and LPO
207 Urinary system Lateral R or L
208 Urinary system Lateral Dorsal decubitus
209 Renal parenchyma AP
212 Pelvicaliceal system and ureters: AP
retrograde urography
216 Urinary bladder AP axial or PA axial
218 Urinary bladder AP oblique RPO or LPO
220 Urinary bladder Lateral R or L
221 Male cystourethrography AP oblique RPO or LPO
222 Female cystourethrography AP INJECTION

Icons in the Essential column indicate projections frequently performed in the United States and Canada. Students should be competent
in these projections.

182
 URINARY SYSTEM ANATOMY
Urinary System
The urinary system includes two kidneys,
two ureters, one urinary bladder, and one
urethra (Figs. 18-1 and 18-2). The func-
tions of the kidneys include removing
waste products from the blood, maintain-
ing fluid and electrolyte balance, and
secreting substances that affect blood pres-
sure and other important body functions.
The kidneys normally excrete 1 to 2 L of
urine per day. Urine is expelled from the
body via the excretory system, as the
urinary system is often called. The excre-
tory system consists of the following:
Inferior vena cava Aorta
Right
suprarenal
gland
Right kidney
T12
L3
B C
Fig. 18-1  Anterior aspect of urinary system in relation to surrounding structures.
A, Abdominal structures. B, Bony structures. C, Three-dimensional CT image of
urinary system in relation to bony structures.
• A variable number of urine-draining
branches in the kidney called the
calyces and an expanded portion called
the renal pelvis, which together are
known as the pelvicaliceal system
• Two long tubes called ureters, with one
ureter extending from the pelvis of each
kidney
• A saclike portion, the urinary bladder,
which receives the distal portion of the
ureters and serves as a reservoir
• A third and smaller tubular portion, the
urethra, which conveys the urine to the
exterior of the body
Left kidney
Left ureter
Urinary bladder
Suprarenal Glands
Closely associated with the urinary system
are the two suprarenal, or adrenal, glands.
These ductless endocrine glands have no
functional relationship with the urinary
system but are included in this chapter
because of their anatomic relationship
with the kidneys. Each suprarenal gland
consists of a small, flattened body com-
posed of an internal medullary portion and
an outer cortical portion. Each gland is
enclosed in a fibrous sheath and is situated
in the retroperitoneal tissue in close contact
with the fatty capsule overlying the medial
and superior aspects of the upper pole of
Suprarenal Glands
the kidney. The suprarenal glands furnish
two important substances: (1) epinephrine,
which is secreted by the medulla; and
(2) cortical hormones, which are secreted
by the cortex. These glands are subject to
malfunction and numerous diseases. They
are not usually shown on preliminary
images but are delineated when computed
tomography (CT) is used. The suprarenal
circulation may be shown by selective
catheterization of a suprarenal artery or
vein in angiographic procedures.
183
 Kidneys
The kidneys are bean-shaped bodies. The
lateral border of each kidney is convex,
and the medial border is concave. They
have slightly convex anterior and poste-
rior surfaces, and they are arbitrarily
divided into upper and lower poles. The
kidneys are approximately 4 1 2 inches
(11.5 cm) long, 2 to 3 inches (5 to 7.6 cm)
wide, and about 1 1 4 inches (3 cm) thick.
The left kidney usually is slightly longer
and narrower than the right kidney.
The kidneys are situated behind the
peritoneum (retroperitoneal) and are in
contact with the posterior wall of the
Urinary System and Venipuncture
Right kidney abdominal cavity, one kidney lying on
each side of and in the same coronal plane
with L3. The superior aspect of the kidney
lies more posterior than the inferior aspect
(see Fig. 18-2). Each kidney lies in an
Right ureter oblique plane and is rotated about 30
degrees anteriorly toward the aorta, which
lies on top of the vertebral body (Fig.
Urinary bladder
18-3). This natural anatomic position is
the basis for the 30-degree rotation of the
AP oblique projections (RPO and LPO
Rectum positions). In AP oblique projections, the
Prostate elevated kidney is demonstrated without
distortion, as the 30-degree rotation
Anal canal
orients the upper kidney parallel to the IR
plane. The dependent kidney is positioned
almost perpendicular to the IR plane, so
Fig. 18-2  Lateral aspect of male urinary the lower kidney is oriented to demon-
system in relation to surrounding strate the anterior and posterior surfaces
structures. in the oblique positions.
R GB L R
A B
Fig. 18-3  A, Axial CT image through center of kidney. Note 30-degree anterior
angulation of kidneys (arrows). GB, gallbladder. B, Axial CT image of upper abdomen.
Note superior aspect of right kidney and midportion of left kidney showing lower placed
left kidney.
(From Kelley LL, Petersen CM: Sectional anatomy for imaging professionals, ed 2, St Louis, 2007, Mosby.)
184
The kidneys normally extend from the
level of the superior border of T12 to the
level of the transverse processes of L3 in
sthenic individuals; they are higher in indi-
viduals with a hypersthenic habitus and
lower in persons with an asthenic habitus.
Because of the large space occupied by the
liver, the right kidney is slightly lower
than, or caudal to, the left kidney.
The outer covering of the kidney is
called the renal capsule. The capsule is a
semitransparent membrane that is contin-
uous with the outer coat of the ureter. Each
kidney is embedded in a mass of fatty
tissue called the adipose capsule. The
capsule and kidney are enveloped in a
sheath of superficial fascia, the renal
fascia, which is attached to the diaphragm,
lumbar vertebrae, peritoneum, and other
adjacent structures. The kidneys are sup-
ported in a fairly fixed position, partially
through the fascial attachments and par-
tially by the surrounding organs. They
have respiratory movement of approxi-
mately 1 inch (2.5 cm) and normally drop
no more than 2 inches (5 cm) in the
change from supine to upright position.
The concave medial border of each
kidney has a longitudinal slit, or hilum, for
transmission of the blood and lymphatic
vessels, nerves, and ureter (Fig. 18-4). The
hilum expands into the body of the kidney
to form a central cavity called the renal
sinus. The renal sinus is a fat-filled space
surrounding the renal pelvis and vessels.
L
 Each kidney has an outer renal cortex
and an inner renal medulla. The renal
medulla, composed mainly of the collect-
ing tubules that give it a striated appear-
ance, consists of 8 to 15 cone-shaped
segments called the renal pyramids. The
apices of the segments converge toward
the renal sinus to drain into the pelvicali-
ceal system. The more compact renal
cortex lies between the periphery of the
organ and the bases of the medullary seg-
ments and extends medially between the
pyramids to the renal sinus. These exten-
sions of the cortex are called renal columns.
The essential microscopic components
and, as they ascend, unite to form a single
vessel leaving the capsule.
The vessel entering the capsule is called
the afferent arteriole, and the one leaving
the capsule is termed the efferent arteri-
ole. After exiting the glomerular capsules,
the efferent arterioles form the capillary
network surrounding the straight and con-
voluted tubules, and these capillaries
reunite and continue on to communicate
with the renal veins.
The thin inner wall of the capsule
closely adheres to the capillary coils and
is separated by a comparatively wide
space from the outer layer, which is con-
the cortical and medullary substances,
becoming the proximal convoluted tubule,
the nephron loop (loop of Henle), and the
distal convoluted tubule. The distal con-
voluted tubule opens into the collecting
ducts that begin in the cortex. The collect-
ing ducts converge toward the renal pelvis
and unite along their course, so that each
group within the pyramid forms a central
tubule that opens at a renal papilla and
drains its tributaries into the minor calyx.
The calyces are cup-shaped stems
arising at the sides of the papilla of each
renal pyramid. Each calyx encloses one or
more papillae, so that there are usually

of the parenchyma of the kidney are called
nephrons (Fig. 18-5). Each kidney con-
tains approximately 1 million of these
tubular structures. The individual nephron
is composed of a renal corpuscle and a
renal tubule. The renal corpuscle consists
of a double-walled membranous cup
called the glomerular capsule (Bowman
capsule) and a cluster of blood capillaries
called the glomerulus. The glomerulus is
formed by a minute branch of the renal
artery entering the capsule and dividing
into capillaries. The capillaries turn back
tinuous with the beginning of a renal
tubule. The glomerulus serves as a filter
for the blood, permitting water and finely
dissolved substances to pass through the
walls of the capillaries into the capsule.
The change from filtrate to urine is caused
in part by the water and the usable dis-
solved substances being absorbed through
the epithelial lining of the tubules into the
surrounding capillary network.
Each renal tubule continues from a glo-
merular capsule in the cortex of the kidney
and then travels a circuitous path through
Kidneys
fewer calyces than pyramids. The begin-
ning branches are called the minor calyces
(numbering from 4 to 13), and they unite
to form two or three larger tubes called the
major calyces. The major calyces unite to
form the expanded, funnel-shaped renal
pelvis. The wide upper portion of the
renal pelvis lies within the hilum, and its
tapering lower part passes through the
hilum to become continuous with the
ureter. This area, where the renal pelvis
transitions to the ureter, is called the ure-
teropelvic junction (UPJ).

Afferent arteriole

Efferent arteriole

Glomerulus

Distal
con-
voluted
tubule
Renal capsule
Cortex
Renal cortex
Glomerular
Renal sinus capsule

Proximal con-
Renal medulla
voluted tubule

Renal
papilla
Renal
pyramid
Hilum
Renal column Collecting duct
Descending
limb of Henle's
Renal Minor calyx loop
pelvis
Medulla
Ascending
Major calyx limb of Henle's
loop

Renal papilla

Fig. 18-4  Midcoronal section of kidney. Fig. 18-5  Diagram of nephron and collecting duct.

185
 Ureters
Each ureter is 10 to 12 inches (25 to
30 cm) long. The ureters descend behind
the peritoneum and in front of the psoas
muscle and the transverse processes of the
lumbar vertebrae, pass inferiorly and pos-
teriorly in front of the sacral wing, and
then curve anteriorly and medially to enter
the posterolateral surface of the urinary
bladder at approximately the level of the
ischial spine. The ureters convey the urine
Urinary System and Venipuncture
from the renal pelves to the bladder by
slow, rhythmic peristaltic contractions.
Urinary Bladder
The urinary bladder is a musculomembra-
nous sac that serves as a reservoir for
urine. The bladder is situated immediately
posterior and superior to the pubic sym-
physis and is directly anterior to the
rectum in the male and anterior to the
R L
vaginal canal in the female. The apex of
the bladder is at the anterosuperior aspect
and is adjacent to the superior aspect of
the pubic symphysis. The most fixed part
of the bladder is the neck, which rests on
the prostate in the male and on the pelvic
diaphragm in the female.
The bladder varies in size, shape, and
position according to its content. It is
freely movable and is held in position by
folds of the peritoneum. When empty, the
bladder is located in the pelvic cavity. As
the bladder fills, it gradually assumes an
oval shape while expanding superiorly
and anteriorly into the abdominal cavity.

The adult bladder can hold approximately

bl
500 mL of fluid when completely full.
Ureter The urge for micturition (urination) occurs
when about 250 mL of urine is in the
Urinary
bladder.
B ur
bladder The ureters enter the posterior wall of
the bladder at the lateral margins of the
Ureteral
openings superior part of its base and pass obliquely
through the wall to their respective inter-
Trigone nal orifices (Fig. 18-6). This portion of
each ureter, where it joins the bladder, is
Internal called the ureterovesical junction (UVJ).
urethral
orifice These two openings are about 1 inch
Urethra
bl
(2.5 cm) apart when the bladder is empty
and about 2 inches (5 cm) apart when the
bladder is distended. The openings are
External equidistant from the internal urethral
urethral orifice, which is situated at the neck
A orifice C pub ut (lowest part) of the bladder. The triangular
Fig. 18-6  A, Anterior view of urinary bladder. B, Axial CT image of pelvis showing contrast area between the three orifices is called
medium–filled bladder (bl) and ureters (ur). C, Sagittal MRI of female pelvis showing the trigone. The mucosa over the trigone
contrast medium–filled bladder (bl) and relationship to uterus (ut) and pubis (pub). is always smooth, whereas the remainder
(B and C, From Kelley LL, Petersen CM: Sectional anatomy for imaging professionals, ed 2, St Louis,
of the lining contains folds, called rugae,
2007, Mosby.) when the bladder is empty.

Ovary
Sacrum
Uterine tube

Bladder

Uterus Pubic symphysis

Prostatic
Rectum
Bladder urethra
Base of
apex
bladder Membranous
urethra
Pubic symphysis
Rectum
Spongy urethra Prostate
Urethra

A Vagina B
Fig. 18-7  A, Midsagittal section through female pelvis. B, Male pelvis.

186
Urethra
The urethra, which conveys the urine out
of the body, is a narrow, musculomembra-
nous tube with a sphincter type of muscle
at the neck of the bladder. The urethra
arises at the internal urethral orifice in the
urinary bladder and extends about 1 1 2
inches (3.8 cm) in the female and 7 to 8
inches (17.8 to 20 cm) in the male.
The female urethra passes along the
thick anterior wall of the vagina to the
external urethral orifice, which is located
in the vestibule about 1 inch (2.5 cm)
anterior to the vaginal opening (see Fig.
18-6). The male urethra extends from the
reaches from the bladder to the floor of the
pelvis, and is completely surrounded by
the prostate. The membranous portion of
the canal passes through the urogenital
diaphragm; it is slightly constricted and
about 1 2 inch (1.3 cm) long. The spongy
portion passes through the shaft of the
penis, extending from the floor of the
pelvis to the external urethral orifice.
The distal prostatic, membranous, and
spongy parts of the male urethra also serve
as the excretory canal of the reproductive
system.
Prostate
urethra, is situated just posterior to the
inferior portion of the pubic symphysis.
The prostate is considered part of the male
reproductive system, but because of its
close proximity to the bladder, it is com-
monly described with the urinary system.
The conical base of the prostate is attached
to the inferior surface of the urinary
bladder, and its apex is in contact with the
pelvic diaphragm. The prostate measures
about 1 1 2 inches (3.8 cm) transversely and
3 inch (1.9 cm) anteroposteriorly at its
4
base; vertically the prostate is approxi-
mately 1 inch (2.5 cm) long. The prostate
gland secretes a milky fluid that combines

bladder to the end of the penis and is
divided into prostatic, membranous, and
spongy portions (Fig. 18-7). The prostatic
portion is about 1 inch (2.5 cm) long,
Prostate
with semen from the seminal vesicles and
The prostate, a small glandular body sur- vas deferens. These secretions enter the
rounding the proximal part of the male urethra via ducts in the prostatic urethra.

SUMMARY OF ANATOMY
Urinary system Kidneys Urinary bladder
(excretory system) Adipose capsule Apex
Kidneys (R and L) Renal fascia Base
Ureters (R and L) Hilum Neck
Urinary bladder Renal capsule Trigone
Urethra Renal sinus Rugae
Renal cortex
Suprarenal glands Renal columns Urethra
(adrenal glands) Renal medulla Male urethra
Medullary portion Renal pyramids Prostatic
Cortical portion Nephrons Membranous
Renal corpuscle Spongy
Glomerular capsule
(Bowman Prostate
capsule)
Glomerulus
Afferent arteriole
Efferent arteriole
Renal tubule
Proximal convoluted
tubule
Nephron loop (loop
of Henle)
Distal convoluted
tubule
Collecting ducts
Renal papilla
Calyces
Minor calyces
Major calyces
Renal pelvis

187
 SUMMARY OF PATHOLOGY
Condition Definition

Benign prostatic hyperplasia (BPH) Enlargement of prostate

Calculus Abnormal concretion of mineral salts, often called a stone

Carcinoma Malignant new growth composed of epithelial cells

  Bladder Carcinoma located in the bladder

  Renal cell Carcinoma located in the kidney

Congenital anomaly Abnormality present at birth

Urinary System and Venipuncture

  Duplicate collecting system Two renal pelves or ureters from the same kidney

  Horseshoe kidney Fusion of the kidneys, usually at the lower poles

  Pelvic kidney Kidney that fails to ascend and remains in the pelvis

Cystitis Inflammation of the bladder

Fistula Abnormal connection between two internal organs or between an organ and the
body surface

Glomerulonephritis Inflammation of the capillary loops in the glomeruli of the kidney

Hydronephrosis Distention of renal pelvis and calyces with urine

Nephroptosis Excessive inferior displacement of the kidneys or kidney prolapse

Phleboliths Pelvic vein calcifications

Polycystic kidney Massive enlargement of the kidney with the formation of many cysts

Pyelonephritis Inflammation of the kidney and renal pelvis

Renal hypertension Increased blood pressure to the kidneys

Renal obstruction Condition preventing normal flow of urine through the urinary system

Stenosis Narrowing or contraction of a passage

Tumor New tissue growth where cell proliferation is uncontrolled

  Wilms Most common pediatric abdominal neoplasm affecting the kidney

Ureterocele Ballooning of the lower end of the ureter into the bladder

Vesicoureteral reflux Backward flow of urine from the bladder into the ureters

188
 SAMPLE EXPOSURE TECHNIQUE CHART ESSENTIAL PROJECTIONS
These techniques were accurate for the equipment used to produce each exposure. However, use caution when applying
them in your department because generator output characteristics and IR energy sensitivities vary widely.1
This chart was created in collaboration with Dennis Bowman, AS, RT(R), Clinical Instructor, Community Hospital of the
Monterey Peninsula, Monterey, CA. http://digitalradiographysolutions.com/

URINARY SYSTEM
CR‡ DR§

Part cm kVp* SID† Collimation mAs Dose (mGy)‖ mAs Dose (mGy)‖

Urinary system (urography)

  AP¶ 21 80 40″ 14″ × 17″ (35 × 43 cm) 40** 5.480 16** 2.188

Prostate
  AP oblique¶ 24 80 40″ 14″ × 17″ (35 × 43 cm) 56** 8.250 25** 3.660

  Lateral¶ 27 80 40″ 12″ × 17″ (30 × 43 cm) 100** 15.89 40** 6.320

Urinary bladder

  AP and PA axial¶ 18 80 40″ 9″ × 9″ (23 × 23 cm) 56** 6.790 22** 2.670

  AP oblique¶ 21 80 40″ 9″ × 9″ (23 × 23 cm) 65** 8.510 28** 3.660

  Lateral¶ 31 85 40″ 8″ × 9″ (20 × 23 cm) 110** 20.41 45** 8.300

1
ACR-AAPM-SIMM Practice Guidelines for Digital Radiography, 2007.
*kVp values are for a high-frequency generator.
†
40 inch minimum; 44 to 48 inches recommended to improve spatial resolution (mAs increase needed, but no increase in patient dose will result).
‡
AGFA CR MD 4.0 General IP, CR 75.0 reader, 400 speed class, with 6:1 (178LPI) grid when needed.
§
GE Definium 8000, with 13:1 grid when needed.
‖
All doses are skin entrance for an average adult (160 to 200 pound male, 150 to 190 pound female) at part thickness indicated.
¶
Bucky/Grid.
**Large focal spot.

ABBREVIATIONS USED IN
CHAPTER 18

ACR American College of

Radiology
ASRT American Society of
Radiologic Technologists
BPH Benign prostatic
hyperplasia
BUN Blood urea nitrogen
CDC U.S. Centers for Disease
Control and Prevention
GFR Glomerular filtration rate
IV Intravenous
IVP Intravenous pyelogram
UPJ Ureteropelvic junction
VCUG Voiding cystourethrogram

See Addendum B for a summary of all

abbreviations used in Volume 2.

189
 URINARY SYSTEM RADIOGRAPHY
Overview
Radiographic examination of the urinary
system involves the use of a water-soluble
iodinated contrast medium to allow visu-
alization of the pertinent anatomy and,
frequently, to evaluate physiologic func-
tion. The role of radiography in evaluation
of the urinary system has changed because
of the increased use of multiplanar imaging
modalities such as computed tomography
(CT), magnetic resonance imaging (MRI),
and ultrasonography (US). Multidetector
CT, with three-dimensional reconstruction
capabilities, has improved visualization
of small pathologies that were difficult
Urinary System and Venipuncture
R L
Fig. 18-8  CT of abdomen without contrast media showing parenchyma and renal pelvis
of both kidneys (arrows).
(Courtesy Karl Mockler, RT[R].)
R L
Fig. 18-9  CT “stone protocol” without contrast media showing renal calculus in left distal
ureter (arrow).
(Courtesy Karl Mockler, RT[R].)
190
or impossible to see on radiographic
images. Despite the decreased use of con-
trast urography, the American College of
Radiology (ACR) specifies that excretory
urography is particularly useful in demon-
strating the collecting system and ureters
and in evaluating ureteral obstruction,
compression, and displacement. Addition-
ally, contrast urography can be tailored to
provide diagnostic information at a lower
radiation dose than can be provided by
helical multidetector CT.1
1
ACR Practice Guideline for the Performance of
Excretory Urography, revised 2009.
The specialized radiography procedures
are preceded by a plain, or scout, image of
the abdominopelvic areas for detection of
abnormalities that can be shown on plain
radiography. The preliminary examination
may consist of only a KUB. Oblique
or lateral projections, or both, may be
obtained to localize calcifications, such as
urinary calculi or phleboliths, and tumor
masses. An upright position may be used
to show the mobility of the kidneys and to
demonstrate nephroptosis.
Preliminary radiography can usually
show the position and mobility of the
kidneys and usually their size and shape
because of the contrast furnished by the
radiolucent fatty capsule surrounding the
kidneys. In addition, properly selected CT
soft tissue windows can show the renal
parenchyma without contrast media (Fig.
18-8). Visualization of the thin-walled
drainage, or collecting, system (calyces
and pelves, ureters, urinary bladder, and
urethra) requires that the canals be filled
with a contrast medium. The urinary
bladder is outlined when it is filled with
urine, but it is not adequately shown. The
ureters and the urethra cannot be distin-
guished on preliminary images. A CT
“stone protocol” without contrast medium
can clearly show calcified renal stones
(Fig. 18-9).
CONTRAST STUDIES
To delineate and differentiate cysts and
tumor masses situated within the kidney,
the renal parenchyma is opacified by an
intravenously introduced organic, iodin-
ated contrast medium and then radio-
graphed by tomography (Fig. 18-10) or
CT (Fig. 18-11). The contrast solution
may be introduced into the vein by rapid
bolus injection or by infusion.
Angiographic procedures are used to
investigate the blood vessels of the kidneys
and the suprarenal glands (see Chapter 23,
Volume 3). An example of the direct injec-
tion of contrast medium into the renal
artery is shown in Fig. 18-12.
Radiologic investigations of the renal
drainage, or collecting, system are per-
formed by various procedures classified
under the general term urography. This
term embraces two regularly used tech-
niques for filling the urinary canals with a
contrast medium. Imaging of cutaneous
urinary diversions has been described by
Long.1
1
Long BW: Radiography of cutaneous urinary diver-
sions, Radiol Technol 60:109, 1988.
Antegrade filling
Antegrade filling techniques allow the
contrast medium to enter the kidney in the
normal direction of blood flow. In selec-
tive patients, this is done by introducing
the contrast material directly into the
kidney through a percutaneous puncture
of the renal pelvis—a technique called
percutaneous antegrade urography. Much
more commonly used is the physiologic
technique, in which the contrast agent
is generally administered intravenously.
This technique is called excretory or intra-
venous urography (EU or IVU) and is
shown in Fig. 18-13.
IVU is used in examinations of the
upper urinary tract in infants and children
and is generally considered to be the pre-
ferred technique in adults unless use of
the retrograde technique is definitely indi-
cated. Because the contrast medium is
administered intravenously and all parts
of the urinary system are normally shown,
the excretory technique is correctly
referred to as IVU. The term pyelography
refers to the radiographic demonstration
of the renal pelves and calyces. This
examination has been erroneously called
an intravenous pyelogram (IVP).
After the opaque contrast medium
enters the bloodstream, it is conveyed to
the renal glomeruli and is discharged into
the capsules with the glomerular filtrate,
which is excreted as urine. With the reab-
sorption of water, the contrast material
becomes sufficiently concentrated to
render the urinary canals radiopaque. The
urinary bladder is well outlined by this
technique, and satisfactory voiding ure-
thrograms may be obtained.

Overview
Kidney

Major calyx

R L

Renal pelvis

Ureter

Fig. 18-10  Nephrotomogram. Fig. 18-11  CT image of abdomen with contrast

media showing early filling of both kidneys
(arrows).

Fig. 18-12  Selective right renal arteriogram. Fig. 18-13  Excretory urogram.
191
 R
Urinary System and Venipuncture

Fig. 18-14  Retrograde urogram. Fig. 18-15  Voiding study after routine injection IVU. Dilation of
proximal urethra (arrows) is the result of urethral stricture.

Contrast-
filled
bladder

Catheter
in
urethra

Fig. 18-16  Voiding studies of same patient as in Fig. 18-15 after infusion Fig. 18-17  Cystogram.
nephrourography. Note increase in opacification of contrast medium–
filled cavities by this method and bladder diverticulum (arrows).

192
Retrograde filling
In some procedures involving the urinary
system, the contrast material is introduced
against the normal flow. This is called ret-
rograde urography (Fig. 18-14). The con-
trast medium is injected directly into the
canals via ureteral catheterization for con-
trast filling of the upper urinary tract and
via urethral catheterization for contrast
filling of the lower part of the urinary
tract. Cystoscopy is required to localize
the vesicoureteral orifices for the passage
of ureteral catheters.
Retrograde urographic examination of
the proximal urinary tract is primarily a
urologic procedure. Catheterization and
contrast filling of the urinary canals are
R R
Fig. 18-18  Cystoureterogram: AP bladder showing distal ureters.
performed by the attending urologist in
conjunction with a physical or endoscopic
examination. This technique enables the
urologist to obtain catheterized specimens
of urine directly from each renal pelvis.
Because the canals can be fully distended
by direct injection of the contrast agent,
the retrograde urographic examination
sometimes provides more information
about the anatomy of the different parts
of the collecting system than can be
obtained by the excretory technique. For
the retrograde procedure, an evaluation of
kidney function depends on an intrave-
nously administered dye substance to stain
the color of the urine that subsequently
trickles through the respective ureteral
Fig. 18-19  Injection cystourethrogram showing urethra in a male
patient.
catheters. The antegrade and retrograde
techniques of examination are occasion-
ally required for a complete urologic study.
Investigations of the lower urinary
tract—bladder, lower ureters, and urethra—
are usually done by the retrograde tech-
nique, which requires no instrumentation
beyond passage of a urethral catheter.
Investigations may also be done by the
physiologic technique (Figs. 18-15 and 18-
16). Bladder examinations are usually
denoted by the general term cystography
(Fig. 18-17). A procedure that includes
inspection of the lower ureters is cystoure-
terography (Fig. 18-18), and a procedure
Overview
that includes inspection of the urethra is
cystourethrography (Fig. 18-19).
193
 Contrast media
Retrograde urography (Figs. 18-20 and
18-21) was first performed in 1904 with
the introduction of air into the urinary
bladder. In 1906, retrograde urography
and cystography were performed with the
first opaque medium, a colloidal silver
preparation that is no longer used. Silver
iodide, which is a nontoxic inorganic
compound, was introduced in 1911.
Sodium iodide and sodium bromide, also
inorganic compounds, were first used for
retrograde urography in 1918. The bro-
mides and iodides are no longer widely
used for examinations of the renal pelves
Urinary System and Venipuncture
and ureters because they irritate the
mucosa and commonly cause consider-
able patient discomfort.
Because a large quantity of solution is
required to fill the urinary bladder, iodin-
ated salts in concentrations of 30% or less
are used in cystography. A large selection
of commercially available contrast media
may be used for all types of radiographic
examinations of the urinary system. It is
194
important to review the product insert
packaged with every contrast agent.
Excretory urography (Figs. 18-22 and
18-23) was first reported by Rowntree
et al. in 1923.1 These investigators used a
10% solution of chemically pure sodium
iodide as the contrast medium. This agent
was excreted too slowly, however, to
show the renal pelves and ureters satisfac-
torily, and it proved too toxic for func-
tional distribution. Early in 1929, Roseno
and Jepkins2 introduced a compound con-
taining sodium iodide and urea. The latter
constituent, which is one of the nitroge-
nous substances removed from the blood
and eliminated by the kidneys, served to
accelerate excretion and to fill the renal
pelves with opacified urine quickly.
Although satisfactory renal images were
obtained with this compound, patients
experienced considerable distress as a
result of its toxicity.
1
Rowntree LG et al: Roentgenography of the urinary
tract during excretion of sodium iodide, JAMA
8:368, 1923.
2
Roseno A, Jepkins H: Intravenous pyelography,
Fortschr Roentgenstr 39:859, 1929. Abstract: AJR
Am J Roentgenol 22:685, 1929.
In 1929, Swick developed the organic
compound Uroselectan, which had an
iodine content of 42%. Present-day ionic
contrast media for excretory urography
are the result of extensive research by
many investigators. These media are
available under various trade names in
concentrations ranging from approxi-
mately 50% to 70%. Sterile solutions of
the media are supplied in dose-size
ampules or vials.
In the early 1970s, research was initi-
ated to develop nonionic contrast media.
Development progressed, and several
nonionic contrast agents are currently
available for urographic, vascular, and
intrathecal injection. Although nonionic
contrast media are less likely to cause a
reaction in the patient, they are twice as
expensive as ionic agents.
Many institutions have developed crite-
ria to determine which patient receives
which contrast medium. The choice of
whether to use an ionic or nonionic con-
trast medium depends on patient risk and
economics.
 Overview
Fig. 18-20  Retrograde urogram with contrast medium–filled right Fig. 18-21  Retrograde urogram.
renal pelvis and catheter in left renal pelvis.

Fig. 18-22  Excretory urogram, 10 minutes after injection of Fig. 18-23  Excretory urogram on same patient as in Fig. 18-22, 25
contrast medium. minutes after contrast medium injection.

195
 Adverse reactions to
iodinated media
The iodinated organic preparations that
are compounded for urologic examina-
tions are of low toxicity. Consequently,
adverse reactions are usually mild and of
short duration. Common reactions include
a feeling of warmth and flushing. Occa-
sionally, nausea, vomiting, a few hives,
and edema of the respiratory mucous
membrane result. Severe and serious reac-
tions occur only rarely but are always a
possibility. The clinical history of each
patient must be carefully checked, and the
patient must be kept under careful obser-
Urinary System and Venipuncture
vation for any sign of systemic reactions.
According to the 2013 version of the
American College of Radiology (ACR)
Manual on Contrast Media, “nearly all
life-threatening contrast reactions occur
within the first 20 minutes after contrast
medium injection.” The patient should not
R
Fig. 18-24  Preliminary AP abdomen for urogram.
196
be left unattended during this time period.
Emergency equipment and medication
(diphenhydramine, epinephrine) to treat
adverse reactions must be readily avail-
able. The ACR additionally states that the
radiologist, or his or her qualified desig-
nee, who is on-site during the procedure
must be prepared and able to treat these
reactions.
Preparation of intestinal tract
Although unobstructed visualization of
the urinary tracts requires that the intesti-
nal tract be free of gas and solid fecal
material (Fig. 18-24), bowel preparation is
not attempted in infants and children. Use
of cleansing measures in adults depends
on the condition of the patient. Gas (par-
ticularly swallowed air, which is quickly
dispersed through the small bowel) rather
than fecal material usually interferes with
the examination.
Renal calyces
Renal pelvis
Abdominal ureter
Pelvic ureter
Urinary bladder
R
Fig. 18-25  Supine urogram at 15-minute interval with gas-filled
stomach.
Hope and Campoy1 recommended that
infants and children be given a carbonated
soft drink to distend the stomach with gas.
By this maneuver, the gas-containing
intestinal loops are usually pushed inferi-
orly, and the upper urinary tracts, particu-
larly on the left side of the body, are
clearly visualized through the outline of
the gas-filled stomach. Hope and Campoy
stated that the aerated drink should be
given in an amount adequate to inflate the
stomach fully: at least 2 oz. is required for
a newborn infant, and 12 oz. is required
for a 7-year-old child. In conjunction with
the carbonated drink, Hope and Campoy
recommended using a highly concentrated
contrast medium. A gas-distended stomach
is shown in Fig. 18-25.
1
Hope JW, Campoy F: The use of carbonated bever-
ages in pediatric excretory urography, Radiology
64:66, 1955.
 Berdon et al.2 stated that the prone posi-
tion resolves the problem of obscuring gas
in most patients (Figs. 18-26 and 18-27).
It is unnecessary to inflate the stomach
with air alone or with air as part of an
aerated drink. By exerting pressure on the
abdomen, the prone position moves the
gas laterally away from the pelvicaliceal
structures. Gas in the antral portion of the
stomach is displaced into its fundic
portion, gas in the transverse colon shifts
into the ascending and descending seg-
ments, and gas in the sigmoid colon shifts
into the descending colon and rectum.
These investigators noted, however, that
the prone position occasionally fails to
produce the desired result in small
infants when the small intestine is dilated.
Gastric inflation also fails in these patients
because the dilated small intestine merely
elevates the gas-filled stomach and does
not improve visualization. They recom-
mended examination of such infants after
the intestinal gas has passed.
2
Berdon WE et al: Prone radiography in intravenous
pyelography in infants and children, AJR Am J
Roentgenol 103:444, 1968.
R R
Fig. 18-26  Urogram: supine position. Intestinal gas obscuring left
kidney.
Preparation of patient
Medical opinion concerning patient prep-
aration varies widely. With modifications
as required, the following procedure
seems to be in general use:
• When time permits, have the patient
follow a low-residue diet for 1 to 2 days
to prevent gas formation caused by
excessive fermentation of the intestinal
contents.
• Have the patient eat a light evening
meal on the day before the
examination.
• When indicated by costive bowel
action, administer a non–gas-forming
laxative the evening before the
examination.
• Have the patient take nothing by mouth
after midnight on the day of the exami-
nation. The patient should not be dehy-
drated, however. Patients with multiple
myeloma, high uric acid levels, or dia-
betes must be well hydrated before IVU
is performed; these patients are at
increased risk for contrast medium–
induced renal failure if they are
dehydrated.
Fig. 18-27  Urogram: prone position, in the same patient as in Fig.
18-26. Visualization of left kidney and ureter is markedly improved.
• In preparation for retrograde urogra-
phy, have the patient drink a large
amount of water (4 or 5 cups) several
hours before the examination to ensure
excretion of urine in an amount suffi-
cient for bilateral catheterized speci-
mens and renal function tests.
• No patient preparation is usually neces-
sary for examination of the lower
urinary tract.
Outpatients should be given explicit
directions regarding any order from the
physician pertaining to diet, fluid intake,
and laxatives or other medication. The
patient should also be given a suitable
Overview
explanation for each preparative measure
to ensure cooperation.
197
 EQUIPMENT
Any standard radiographic table is suit-
able to perform preliminary excretory
urography and most retrograde studies of
the bladder and urethra. A combination
cystoscopic-radiographic unit facilitates
retrograde urographic procedures requir-
ing cystoscopy. The cystoscopic unit is
also used for IVU and retrograde bladder
and urethra studies; however, for the
patient’s comfort, the table should have an
extensible leg rest.
Infusion nephrourography requires a
table equipped with tomographic appara-
tus. Tomography should be performed
Urinary System and Venipuncture
when intestinal gas obscures some of the
underlying structures, or when hypersthe-
nic patients are being examined (Figs.
18-28 to 18-30).
For the patient’s comfort and to prevent
delays during the examination, all prepa-
rations for the examination should be
completed before the patient is placed on
R R
Fig. 18-28  Urogram: AP projection.
198
the table. In addition to an identification
and side marker, excretory urographic
studies require a time interval marker for
each postinjection study. Body position
markers (supine, prone, upright or semi-
upright, Trendelenburg, decubitus) should
also be used.
Some institutions perform excretory
urograms (proximal urinary tract studies)
using a 10 × 12-inch (24 × 30-cm) IR
placed crosswise, but these studies can
also be made on 14 × 17-inch (35 × 43-cm)
IRs placed lengthwise. The upright study
is made on a 14 × 17-inch (35 × 43-cm)
IR because it is taken to show the mobility
of the kidneys, to demonstrate nephropto-
sis, and to outline the lower ureters and
bladder. Studies of the bladder before and
after voiding are usually taken on 10 ×
12-inch (24 × 30-cm) IRs.
The following guidelines are observed
in preparing additional equipment for the
examination:
Fig. 18-29  Urogram: AP projection using tomography.
• Have an emergency cart fully equipped
and conveniently placed.
• Arrange the instruments for injection of
the contrast agent on a small, movable
table or on a tray.
• Have frequently used sterile items
readily available. Disposable syringes
and needles are available in standard
sizes and are widely used in this
procedure.
• Have required nonsterile items avail-
able: a tourniquet, a small waste basin,
an emesis basin, general disposable
wipes, one or two bottles of contrast
medium, and a small prepared dressing
for application to the puncture site.
• Have iodine or alcohol wipes
available.
• Provide a folded towel or a small pillow
that can be placed under the patient’s
elbow to relieve pressure during the
injection.
PROCEDURE
Image quality and exposure
technique
Urograms should have the same contrast,
density, and degree of soft tissue density
as abdominal images. The images must
show a sharply defined outline of the
kidneys, lower border of the liver, and
lateral margin of the psoas muscles. The
amount of bone detail visible in these
studies varies according to the thickness
of the abdomen (Fig. 18-31).

Motion control
An immobilization band usually is not

Overview
applied over the upper abdomen in uro-
graphic examinations because the resul-
tant pressure may interfere with the
passage of fluid through the ureters and
may cause distortion of the canals. The
L
elimination of motion in urographic
examinations depends on exposure time Fig. 18-30  Urogram: AP oblique projection, LPO position, using tomography. Note that
and on securing the full cooperation of the left kidney is perpendicular to IR.
patient.
The examination procedure should be
explained so that the adult patient is pre-
pared for any transitory distress caused by
injection of contrast solution or by the
cystoscopic procedure. The patient should
be assured that everything possible will be
done for the patient’s comfort. The success
of the examination depends in large part
on the ability of the radiographer to gain
the confidence of the patient.

• •
•
•
•
•
•
•
• • •• • •
•
• • •
•
•
• • • •
• • •
• • • •
•
•
• •
•
• • •

•
• •

Fig. 18-31  AP abdomen showing margins of kidney (dots), liver (dashes), and psoas
muscles (dot-dash lines).

199
 Ureteral compression
In excretory urography, compression is
sometimes applied over the distal ends of
the ureters. This compression is applied to
retard flow of the opacified urine into the
bladder and to ensure adequate filling of
the renal pelves and calyces. If compres-
sion is used, it must be placed so that the
pressure over the distal ends of the ureters
is centered at the level of the anterior
superior iliac spine (ASIS). As much pres-
sure as the patient can comfortably toler-
ate is applied with the immobilization
band (Figs. 18-32 and 18-33). This pres-
sure should be released slowly when the
Urinary System and Venipuncture

compression device is removed to reduce

Fig. 18-32  Ureteral compression device in place for urogram.
pain caused by rapid changes in intra-
abdominal pressure. Compression is gen-
erally contraindicated if a patient has
urinary stones, an abdominal mass or
aneurysm, a colostomy, a suprapubic cath-
eter, traumatic injury, or recent abdominal
surgery.
As a result of improvements in contrast
agents, ureteral compression is not rou-
tinely used in most health care facilities.
With the increased doses of contrast
medium now employed, most of the ure-
teral area is usually shown over a series of
images. In addition, a prone image is an
adequate substitute for ureteral compres-
sion for filling the pyelocalyceal system
and mid-ureters.

Respiration
For purposes of comparison, all exposures
are made at the end of the same phase of
breathing—at the end of expiration unless
otherwise requested. Because the normal
respiratory excursion of the kidneys varies
from 1 2 to 1 1 2 inches (1.3 to 3.8 cm), it is
occasionally possible to differentiate renal
shadows from other shadows by making
an exposure at a different phase of arrested
respiration. When an exposure is made at
Ureteral compression device
a respiratory phase different from what is
usually used, the image should be so
marked.

Fig. 18-33  Urogram showing ureteral compression device in

proper position over distal ureters.

200
PRELIMINARY EXAMINATION
A preliminary examination of the abdomen
is made before a specialized investigation
of the urinary tract is conducted. This
examination sometimes reveals extrarenal
lesions that are responsible for the symp-
toms attributed to the urinary tract and
renders the urographic procedure unnec-
essary. An upright AP projection may also
be required to show the mobility of the
kidneys. An oblique or lateral projection,
or both, in the dorsal decubitus position
may be required to localize a tumor mass
or to differentiate renal stones from gall-
stones or calcified mesenteric nodes.
The scout image—an AP projection
with the patient recumbent—shows the
contour of the kidneys; their location in
the supine position; and the presence of
renal calculi or calcifications outside the
renal collecting system, such as phlebo-
liths, which are small calcifications in the
wall of pelvic veins (see Fig. 18-31). This
image also serves to check the preparation
of the gastrointestinal tract and to enable
the radiographer to make any necessary
alterations to exposure factors.
Radiation Protection
It is the responsibility of the radiographer
to observe the following guidelines con-
cerning radiation protection:
• Apply a gonadal shield if it does not
overlap the area under investigation.
• Restrict radiation to the area of interest
by close collimation.
• Work carefully so that repeat exposures
are unnecessary.
• Shield males for all examinations
except examinations of the urethra by
using a shadow shield or by placing a
piece of lead just below the pubic
symphysis.
• When excretory urography IRs are cen-
tered to the kidneys, place lead over the
female pelvis for shielding. Unless the
procedure is considered an emergency,
perform radiography of the abdomen
and pelvis only if there is no chance of
patient pregnancy. For most projections
in this chapter, females generally cannot
be shielded without obscuring a portion
of the urinary system. (Gonad shielding
is not shown on the patient images in
this atlas for illustrative purposes.)
Carefully follow department guidelines
regarding gonad shielding.
Intravenous Urography
IVU shows the function and structure of
the urinary system. Function is shown by
the ability of the kidneys to filter contrast
medium from the blood and concentrate it
with the urine. Anatomic structures are
usually visualized as the contrast material
follows the excretion route of the urine.
The primary application of IVU is to eval-
uate the suspected or continued presence
of ureteral obstruction.
The ACR Practice Guideline for the
Performance of Excretory Urography
(2009) emphasizes that an evaluation of
the merits and availability of cross-
sectional imaging modalities should be
performed before IVU is performed. Indi-
cations for IVU include, but are not
limited to, the following:
• Evaluation of abdominal masses, renal
cysts, and renal tumors
• Urolithiasis—calculi or stones of the
kidneys or urinary tract
• Pyelonephritis—infection of the upper
urinary tract, which can be acute or
chronic
• Hydronephrosis—abnormal dilation of
the pelvicaliceal system (urography is
used to help determine the cause of the
dilation)
• Assessment of the effects of trauma and
therapeutic interventions
• Preoperative evaluation of the function,
location, size, and shape of the kidneys
Intravenous Urography
and ureters
• Renal hypertension (urography is com-
monly performed to evaluate functional
symmetry of the renal collecting
systems)
The most common contraindications
for IVU relate to (1) the ability of the
kidneys to filter contrast medium from the
blood and (2) the patient’s allergic history.
Some contraindications can be overcome
by the use of nonionic contrast agents.
Patients with conditions in which the
kidneys are unable to filter waste or
excrete urine (renal failure, anuria) should
have the kidneys evaluated by some tech-
nique other than excretory urography.
Older patients and patients with any of the
following risk factors are strong candi-
dates to receive a nonionic contrast
medium or should be examined using
another modality: asthma, previous con-
trast media reaction, circulatory or cardio-
vascular disease, elevated creatinine level,
sickle cell disease, diabetes mellitus, or
multiple myeloma.
201
 RADIOGRAPHIC PROCEDURE
Before the procedure begins, the patient
should be instructed to empty the bladder
and change into an appropriate radiolu-
cent gown. Emptying the bladder prevents
dilution of the contrast medium with
urine. The patient’s clinical history, aller-
gic history, and blood creatinine levels
should be reviewed. The normal creati-
nine level is 0.6 to 1.2 mg/100 mL. The
glomerular filtration rate (GFR), a calcu-
lation that uses the creatinine level (plus
age, race, gender, and body size), is the
best overall index of kidney function. The
National Kidney Foundation considers a
Urinary System and Venipuncture
normal GFR range to be 120 to 125 mL/
min and a value of 90 mL/min or less as
an indicator of renal dysfunction. A below-
normal GFR should be reviewed by the
radiologist or the physician before the
contrast media procedure is continued.
The radiographer then takes the following
steps:
• Place the patient on the table in the
supine position, and adjust the patient
to center the midsagittal plane of the
body to the midline of the grid.
• Place a support under the patient’s knees
to reduce the lordotic curvature of the
lumbar spine and to provide greater
comfort for the patient (Fig. 18-34).
Fig. 18-34  Patient in supine position for urogram, AP projection.
Note support under knees.
202
• Attach the footboard in preparation
for a possible upright or semi-upright
position.
• If the head of the table is to be lowered
farther to enhance pelvicaliceal filling,
attach the shoulder support and adjust
it to the patient’s height.
• When ureteric compression is to be
used, place the compression device so
that it is ready for immediate applica-
tion at the specified time.
• Obtain a preliminary, or scout, image of
the abdomen. Then prepare for the first
postinjection exposure before the con-
trast medium is injected.
• Place the IR in the Bucky tray; position
identification, side, and time interval
markers; and make any change in cen-
tering or exposure technique as indi-
cated by the scout image.
• Have ready a folded towel or other suit-
able support and the tourniquet for
placement under the selected elbow.
• Prepare the contrast medium for injec-
tion using aseptic technique.
• According to the preference of the
examining physician, administer 30 to
100 mL of the contrast medium to an
adult patient of average size. The dose
administered to infants and children is
regulated according to age and weight.
• Produce images at specified intervals
from the time of completion of the
injection of contrast medium. (This
may depend on the protocol of the
department.) These time intervals must
be included on each image. Depending
on the patient’s hydration status and the
speed of the injection, the contrast
agent normally begins to appear in the
pelvicaliceal system within 2 to 8
minutes.
Uptake of contrast medium is seen in
the nephrons of the kidney if an image is
exposed as the kidneys start to filter the
contrast medium from the blood. The
initial contrast “blush” of the kidney is
termed the nephrogram phase. Nephroto-
mography, if a component of the routine
IVU procedure, is usually performed
during the nephrogram phase. As the
kidneys continue to filter and concentrate
the contrast medium, it is directed to the
pelvicaliceal system. The greatest concen-
tration of contrast medium in the kidneys
normally occurs 15 to 20 minutes after
injection. Immediately after each IR is
exposed, it is processed and reviewed to
determine, according to the kidney func-
tion of the individual patient, the time
intervals at which the most intense kidney
image can be obtained.
Fig. 18-35  Urogram at 3 minutes.
 The most commonly recommended
radiographic images for IVU are AP pro-
jections at time intervals ranging from 3
to 20 minutes (Figs. 18-35 to 18-37).
Some physicians prefer bolus injection of
the contrast medium followed by a
30-second image to obtain a nephrogram.
AP oblique projections (30-degree) may
be taken at 5- to 10-minute intervals. In
some patients, supplemental images are
required to show better all parts of the
urinary system and to differentiate normal
anatomy from pathologic conditions.
These may include an AP projection with
the patient in the Trendelenburg or upright
position, oblique or lateral projections, or
a lateral projection with the patient in the
dorsal or ventral decubitus position.
Unless further study of the bladder is
indicated or voiding urethrograms are to
be made, the patient is sent to the lavatory
to void. A postvoid image of the bladder
(Figs. 18-38 and 18-39) may be taken to
detect, by the presence of residual urine,
conditions such as small tumor masses or
enlargement of the prostate gland in men.
When all necessary images have been
obtained, the patient is released from the
imaging department. Any contrast medium
remaining in the body is filtered from the
blood by the kidneys and eventually is
excreted in the urine. Some physicians
suggest having the patient drink extra
fluids for a few days to help flush out the
contrast medium.

Intravenous Urography
R R

Fig. 18-36  Urogram at 6 minutes. Fig. 18-37  Urogram at 9 minutes.

Fig. 18-38  Prevoiding filled bladder. Fig. 18-39  Postvoiding emptied bladder.

203
 Urinary System
  AP PROJECTION
Image receptor: 14 × 17 inch (35 ×
43 cm) lengthwise
Position of patient
• Place the patient supine on the radio-
graphic table for the AP projection of
the urinary system. Preliminary (scout)
and postinjection images are most com-
monly obtained with the patient supine
(Fig. 18-40).
• Place a support under the patient’s
knees to relieve strain on the back.
• Place the patient in an upright or a
Urinary System and Venipuncture
semi-upright position for an AP projec-
tion to show the opacified bladder and
the mobility of the kidneys (Fig. 18-41).
Fig. 18-40  Supine urogram: AP projection.
204
• To show the lower ends of the ureters,
it may be helpful to use the Trendelen-
burg position and an AP projection with
the head of the table lowered 15 to 20
degrees and the central ray directed per-
pendicular to the IR. In this angled
position, the weight of the contained
fluid stretches the bladder fundus supe-
riorly, providing an unobstructed image
of the lower ureters and the vesicoure-
teral orifice areas.
• If needed, apply ureteral compression
(see Fig. 18-32).
Position of part
• Center the midsagittal plane of the
patient’s body to the midline of the grid
device.
• Place the patient’s arms out of the col-
limated field.
• Center the IR at the level of the iliac
crests. If the patient is too tall to include
the entire urinary system, take a second
exposure on a 10 × 12-inch (24 ×
30-cm) IR centered to the bladder. The
10 × 12-inch (24 × 30-cm) IR is placed
crosswise and centered 2 to 3 inches (5
to 7.6 cm) above the upper border of
the pubic symphysis.
• Shield gonads.
• Respiration: Suspend at the end of
expiration.
Fig. 18-41  Upright urogram: AP projection.
Central ray
• Perpendicular to the IR at the level of
the iliac crests
Collimation
• Adjust to 14 × 17 inches (35 × 43 cm)
on the collimator.
Structures shown
AP projection of the urinary system
shows the kidneys, ureters, and bladder
filled with contrast medium (Figs. 18-42
to 18-44).
NOTE: The prone position may be recommended
to show the ureteropelvic region and to fill the
obstructed ureter in the presence of hydronephro-
sis. The ureters fill better in the prone position,
which reverses the curve of their inferior course.
The kidneys are situated obliquely, slanting ante-
riorly in the transverse plane, so the opacified
urine tends to collect in and distend the dependent
part of the pelvicaliceal system. The supine posi-
tion allows the more posteriorly placed upper
calyces to fill more readily, and the anterior and
inferior parts of the pelvicaliceal system fill more
easily in the prone position.
 Urinary System

EVALUATION CRITERIA
The following should be clearly shown:
■ Evidence of proper collimation

AP and PA Projections Renal pelvis

■ Entire renal outlines Left kidney
■ Bladder and pubic symphysis (a sepa-
rate image of the bladder area is needed
if the bladder was not included)
■ No motion
■ Exposure technique clearly showing R
contrast medium in the renal area,
ureters, and bladder
■ Compression devices, if used, centered
over the upper sacrum and resulting in

Urinary System
good renal filling
■ Vertebral column centered on the image
■ No artifacts from elastic in the patient’s
underclothing
■ Prostatic region inferior to the pubic
Bladder
symphysis on older male patients
■ Time marker
■ PA projection showing the lower Fig. 18-42  Semi-upright urogram: AP projection. Note
kidneys and entire ureters (bladder mobility of kidneys.
included if patient size permits)
■ Superimposing intestinal gas in the
AP projection moved for the PA
projection

AP Bladder
■ Bladder
■ No rotation of the pelvis
■ Prostate area in male patients
■ Postvoid images clearly labeled and
showing only residual contrast medium

R R

Fig. 18-43  Supine urogram: AP projection. Fig. 18-44  Trendelenburg position urogram: AP projection.

205
 Urinary System

  AP OBLIQUE PROJECTION Central ray EVALUATION CRITERIA

RPO and LPO positions
Image receptor: 14 × 17 inch (35 ×
43 cm) lengthwise
Position of patient
• Place the patient supine on the radio-
graphic table for oblique projections of
the urinary system. The kidneys are
situated obliquely, slanting anteriorly in
the transverse plane.
• When performing AP oblique projec-
tions, remember that the kidney closer
to the IR is perpendicular to the plane
Urinary System and Venipuncture
• Perpendicular to the center of the IR at
the level of the iliac crests, entering
approximately 2 inches (5 cm) lateral to
the midline on the elevated side
Collimation
• Adjust to 14 × 17 inches (35 × 43 cm)
on the collimator.
Structures shown
An AP oblique projection of the urinary
system shows the kidneys, ureters, and
bladder filled with contrast medium. The
elevated kidney is parallel with the IR,
The following should be clearly shown:
■ Evidence of proper collimation
■ Patient rotated approximately 30
degrees
■ No superimposition of the kidney
remote from the IR on the vertebrae
■ Entire down-side kidney
■ Bladder and lower ureters on 14 ×
17-inch (35 × 43-cm) IRs if patient size
permits
■ Exposure technique that shows the
anatomy
■ Time marker

of the IR and the kidney farther from and the down-side kidney is perpendicular
the IR is parallel with this plane. with the IR (Fig. 18-46).

Position of part
• Turn the patient so that the midcoronal
plane forms an angle of 30 degrees
from the IR plane.
• Adjust the patient’s shoulders and hips
so that they are in the same plane, and
place suitable supports under the ele-
vated side as needed.
• Place the arms so that they are not
superimposed on the urinary system.
• Center the spine to the grid (Fig. 18-45).
• Center the IR at the level of the iliac
crests.
• Shield gonads.
• Respiration: Suspend at the end of
expiration.
Fig. 18-45  Urogram: AP oblique projection, 30-degree RPO position.

Renal pelvis

Gas in colon
Ureter

Ureteral compression
devices

Fig. 18-46  Urogram at 10 minutes: AP oblique projection, RPO position.

206
 Urinary System

  LATERAL PROJECTION Central ray EVALUATION CRITERIA

R or L position
Image receptor: 14 × 17 inch (35 ×
43 cm) lengthwise
Position of patient
• Turn the patient to a lateral recumbent
position on the right or left side, as
indicated.
Position of part
• Flex the patient’s knees to a comfort-
able position, and adjust the body so
that the midcoronal plane is centered to
• Perpendicular to the IR, entering the
midcoronal plane at the level of the iliac
crest
Collimation
• Adjust to 14 × 17 inches (35 × 43 cm)
on the collimator.
Structures shown
A lateral projection of the abdomen shows
the kidneys, ureters, and bladder filled
with contrast material. Lateral projections
are used to show conditions such as rota-
tion or pressure displacement of a kidney
The following should be clearly shown:
■ Evidence of proper collimation
■ Entire urinary system
■ Bladder and pubic symphysis
■ Exposure technique clearly showing
contrast medium in the renal area,
ureters, and bladder
■ No rotation of the patient (check pelvis
and lumbar vertebrae)
■ Time marker

Urinary System
the midline of the grid. and to localize calcareous areas and tumor
• Place supports between the patient’s masses (Fig. 18-48).
knees and ankles.
• Flex the patient’s elbows, and place
the hands under the patient’s head
(Fig. 18-47).
• Center the IR at the level of the iliac
crests.
• Shield gonads.
• Respiration: Suspend at the end of
expiration.

Fig. 18-47  Urogram: lateral projection. Fig. 18-48  Urogram: lateral projection.

207
 Urinary System

  LATERAL PROJECTION Collimation EVALUATION CRITERIA

Dorsal decubitus position
Image receptor: 14 × 17 inch (35 ×
43 cm)
Position of patient
• Place the patient in the supine position
on a radiographic cart with the side in
question in contact with the vertical
grid device. Ensure that the wheels are
locked.
• Place the patient’s arms across the
upper chest to ensure that they are not
projected over any abdominal contents,
Urinary System and Venipuncture
• Adjust to 14 × 17 inches (35 × 43 cm)
on the collimator.
Structures shown
Rolleston and Reay1 recommended the
ventral decubitus position to show the
UPJ in the presence of hydronephrosis.
Cook et al.2 advocated this position to
determine whether an extrarenal mass in
the flank is intraperitoneal or extraperito-
neal, and they stated that the position
makes it easy to screen kidneys and
ureters for abnormal anterior displace-
ment (Fig. 18-50).
The following should be clearly shown:
■ Evidence of proper collimation
■ Entire urinary system
■ Bladder and pubic symphysis
■ Exposure technique clearly showing
contrast medium in the renal area,
ureters, and bladder
■ No rotation of the patient (check pelvis
and lumbar vertebrae)
■ Time marker
■ Patient elevated so that entire abdomen
is visible

or place them behind the head.

• Flex the patient’s knees slightly to 1
Rolleston GL, Reay ER: The pelvi-ureteric junction,
relieve strain on the back. Br J Radiol 30:617, 1957.
2
Cook IK et al: Determination of the normal position
of the upper urinary tract in the lateral abdominal
Position of part urogram, Radiology 99:499, 1971.
• Adjust the height of the vertical grid
device so that the long axis of the IR is
centered to the midcoronal plane of the
patient’s body.
• Position the patient so that a point
approximately at the level of the iliac
crests is centered to the IR (Fig. 18-49).
• Adjust the patient to ensure that no rota-
tion from the supine or prone position
is present.
• Shield gonads.
• Respiration: Suspend at the end of
expiration.

Central ray
• Horizontal and perpendicular to the
center of the IR, entering the midcoro-
nal plane at the level of the iliac crests

Fig. 18-49  Urogram: lateral projection, dorsal decubitus position.

L↑

Fig. 18-50  Urogram: lateral projection, dorsal decubitus position.

208
 Renal Parenchyma

Nephrotomography
AP PROJECTION
The renal parenchyma (nephrons and
collecting tubes) is best visualized by
performing tomography immediately after
the introduction of contrast medium.
Evans et al.,1,2 who introduced nephroto-
mography, found that by using tomogra-
phy rather than stationary projections,
they could eliminate superimpositions of
intestinal contents and more clearly define
small intrarenal lesions.
Examination procedure
After contrast medium has been injected
for IVU, the first AP projection of the
abdomen is performed during the arterial
phase of opacification (Fig. 18-51), and
multiple tomograms of the upper abdomen
are obtained during the nephrographic
phase after the renal parenchyma becomes
opacified—hence the term nephrotomog-
raphy (Fig. 18-52). The nephrotic phase
normally occurs within 5 minutes after
completion of injection or infusion.

Indications and contraindications

Renal Parenchyma
The use of nephrotomography has dra-
matically declined because of the avail-
ability of sectional imaging modalities
with greater specificity for renal disease.
The ACR states that “nephrotomography
may be useful to help distinguish renal
calculi from intestinal contents.”3 Contra-
indications are mainly related to renal
failure and contrast media sensitivity, as
noted for IVU.

1
Evans JA et al: Nephrotomography, AJR Am J
Roentgenol 71:213, 1954.
2
Evans JA: Nephrotomography in the investigation
of renal masses, Radiology 69:684, 1957.
3
ACR Appropriateness Criteria: Acute onset flank
pain—suspicious of stone disease. Retrieved on
December 20, 2013, from http://www.acr.org/~/
media/ACR/Documents/AppCriteria/Diagnostic/
AcuteOnsetFlankPainSuspicionStoneDisease.pdf.

Fig. 18-51  Nephrourogram: AP projection, arterial phase.

R R

•
• •
Renal margin
•
•
•
•
•
Renal pelvis
•

•
•
Minor calyx
•
•
•
•
A • •
B
Fig. 18-52  Nephrotomogram: A and B, AP projection at level of 9 cm (A) and 10 cm (B)
in the same patient as in Fig. 18-51.

209
 Renal Parenchyma

PERCUTANEOUS RENAL
L
PUNCTURE
Percutaneous renal puncture, as intro-
duced by Lindblom,1,2 is a radiologic pro-
cedure for the investigation of renal
masses. Specifically, it is used to differen-
tiate cysts and tumors of the renal paren-
chyma. This procedure is performed by
direct injection of a contrast medium into
the cyst under fluoroscopic control (Figs.
18-53 and 18-54). Ultrasonography of the
kidney has practically eliminated the need
for percutaneous renal puncture. Most
masses that are clearly diagnosed as cystic
by ultrasound examination are not surgi-
Urinary System and Venipuncture

cally managed.

1
Lindblom K: Percutaneous puncture of renal cysts
and tumors, Acta Radiol 27:66, 1946.
2
Lindblom K: Diagnostic kidney puncture in cysts
and tumors, AJR Am J Roentgenol 68:209, 1952.

Fig. 18-53  Upright AP left kidney: percutaneous injection of iodinated contrast material
and gas into renal cyst.

Fig. 18-54  AP projection left kidney, left lateral decubitus position, in the same patient as
in Fig. 18-53.

210
 Renal Parenchyma

In a similar procedure, the renal pelvis

is entered percutaneously for direct con-
trast filling of the pelvicaliceal system in
selected patients with hydronephrosis.1-3
This procedure, called percutaneous ante-
grade pyelography3 to distinguish it from
the retrograde technique of direct pel­
vicaliceal filling, is usually restricted to
the investigation of patients with marked
hydronephrosis and patients with sus-
pected hydronephrosis, for whom conclu-
sive information is not gained by excretory
or retrograde urography (Fig. 18-55). This
procedure may also be called a nephrosto-
gram because the contrast media injection

Renal Parenchyma
is frequently made through a percutane-
ous nephrostomy catheter. Normally, AP
abdominal images are obtained for this
procedure, although other projections may
be requested.

1
Wickbom I: Pyelography after direct puncture of the
renal pelvis, Acta Radiol 41:505, 1954.
2
Weens HS, Florence TJ: The diagnosis of hydrone-
phrosis by percutaneous renal puncture, J Urol
72:589, 1954.
3
Casey WC, Goodwin WE: Percutaneous antegrade
pyelography and hydronephrosis, J Urol 74:164,
1955.
Fig. 18-55  AP projection left kidney, left
lateral decubitus position, in the same
patient as in Fig. 18-53.

211
 Pelvicaliceal System and Ureters

Retrograde Urography If elevation of the thighs does not

  AP PROJECTION
Retrograde urography requires that the
ureters be catheterized so that a contrast
agent can be injected directly into the pel-
vicaliceal system. This technique provides
improved opacification of the renal col-
lecting system but little physiologic infor-
mation about the urinary system.
reduce the lumbar curve, a pillow is
adjusted under the patient’s head and
shoulders so that the back is in contact
with the table. Most cystoscopic-
radiographic tables are equipped with an
adjustable leg rest to permit extension of
the patient’s legs for certain radiographic
studies.
The urologist performs catheterization
of the ureters through a ureterocystoscope,
which is a cystoscope with an arrange-
ment that aids insertion of the catheters
into the vesicoureteral orifices. After the
endoscopic examination, the urologist
passes a ureteral catheter well into one or
both ureters (Fig. 18-57) and, while
leaving the catheters in position, usually
withdraws the cystoscope.

Indications and contraindications

Retrograde urography is indicated for
evaluation of the collecting system in
patients who have renal insufficiency or
Urinary System and Venipuncture

who are allergic to iodinated contrast

media. Because the contrast medium is
not introduced into the circulatory system,
the incidence of reactions is reduced.

Examination procedure
Similar to all examinations requiring
instrumentation, retrograde urography is
classified as an operative procedure. This
combined urologic-radiologic examina-
tion is performed under careful aseptic
conditions by the attending urologist with
the assistance of a nurse and radiographer.
The procedure is performed in a specially
equipped cystoscopic-radiographic exam- Fig. 18-56  Patient positioned on table for retrograde urography, modified lithotomy
ining room, which, because of its collab- position.
orative nature, may be located in the
urology department or the radiology
department. A nurse is responsible for
preparation of the instruments and for care
and draping of the patient. A responsibility
of the radiographer is to ensure that over-
head parts of the radiographic equipment
are free of dust for protection of the opera-
tive field and the sterile layout.
The radiographer positions the patient
on the cystoscopic table with knees flexed
over the stirrups of the adjustable leg sup-
ports (Fig. 18-56). This is a modified
lithotomy position; the true lithotomy
position requires acute flexion of the hips
and knees.
If a general anesthetic is not used, the
radiographer explains the breathing proce-
dure to the patient and checks the patient’s
position on the table. The kidneys and the
full extent of the ureters in patients of
average height are included on a 14 ×
17-inch (35 × 43-cm) IR when the third
lumbar vertebra is centered to the grid.

Fig. 18-57  Retrograde urogram with catheters in proximal ureters: AP projection.

212
 Pelvicaliceal System and Ureters
After taking two catheterized speci-
mens of urine from each kidney for labo-
ratory tests—one specimen for culture and
one for microscopic examination—the
urologist tests kidney function. For this
test, a color dye is injected intravenously,
and the function of each kidney is deter-
mined by the specified time required for
the dye substance to appear in the urine
as it trickles through the respective
catheters.
Immediately after the kidney function
test, the radiographer rechecks the posi-
tion of the patient and exposes the pre­
liminary IR (if this has not been done
previously) so that the images are ready
for inspection by the time the kidney func-
tion test has been completed. After review-
ing the image, the urologist injects contrast
medium and proceeds with the urographic
examination. When a bilateral examina-
tion is to be performed, both sides are
filled simultaneously to avoid subjecting
the patient to unnecessary radiation expo-
sure. Additional studies in which only
one side is refilled may be performed as
indicated.
The most commonly used retrograde
urographic series usually consists of three
Fig. 18-58  Retrograde urogram with renal pelves filled: AP
projection.
AP projections: the preliminary image
showing the ureteral catheters in position
(see Fig. 18-57), the pyelogram, and the
ureterogram. Some urologists recommend
that the head of the table be lowered 10 to
15 degrees for the pyelogram to prevent
the contrast solution from escaping into
the ureters. Other urologists recommend
that pressure be maintained on the
syringe during the pyelographic exposure
to ensure complete filling of the pelvicali-
ceal system. The head of the table may be
elevated 35 to 40 degrees for the uretero-
gram to show any tortuosity of the ureters
and mobility of the kidneys.
Filling of the average normal renal
pelvis requires 3 to 5 mL of contrast solu-
tion; however, a larger quantity is required
when the structure is dilated. The best
index of complete filling, and the one
most commonly used, is an indication
from the patient as soon as a sense of full-
ness is felt in the back.
When both sides are to be filled, the
urologist injects the contrast solution
through the catheters in an amount suffi-
cient to fill the renal pelves and calyces.
When signaled by the physician, the
patient suspends respiration at the end of
Fig. 18-59  Retrograde urogram showing renal pelves and
contrast medium–filled ureters: AP projection.
expiration, and the exposure for the pyelo-
gram is made (Fig. 18-58).
After the pyelographic exposure, the IR
is quickly changed, and the head of the
table may be elevated in preparation for
the ureterogram. For this exposure, the
patient is instructed to inspire deeply and
then to suspend respiration at the end of
full expiration. Simultaneously with the
breathing procedure, the catheters are
slowly withdrawn to the lower ends of the
ureters as the contrast solution is injected
into the canals. At a signal from the urolo-
gist, the ureterographic exposure is made
(Fig. 18-59).
Pelvicaliceal System and Ureters
Additional projections are sometimes
required. RPO or LPO (AP oblique) pro-
jections are often necessary. Occasionally,
a lateral projection, with the patient turned
onto the affected side, is performed to
show anterior displacement of a kidney or
ureter and to delineate a perinephric
abscess. Lateral projections with the
patient in the ventral or dorsal decubitus
position (as required) are also useful,
showing the ureteropelvic region in
patients with hydronephrosis.
213
 Urinary Bladder, Lower
Ureters, Urethra, and
Prostate
With few exceptions, radiologic examina-
tions of the lower urinary tract are per-
formed with the retrograde technique of
introducing contrast material. These
examinations are identified, according to
the specific purpose of the investigation,
by the terms cystography, cystoureterog-
raphy, cystourethrography, and prostatog-
raphy. Most often, they are denoted by the
general term cystography. Cystoscopy is
not required before retrograde contrast
Urinary System and Venipuncture
filling of the lower urinary canals, but
when both examinations are indicated,
they are usually performed in a single-
stage procedure to spare the patient prepa-
ration and instrumentation for separate
examinations. When cystoscopy is not
indicated, these examinations are best
carried out on an all-purpose radiographic
table unless the combination table is
equipped with an extensible leg rest.
Indications and contraindications
Retrograde studies of the lower urinary
tract are indicated for vesicoureteral
reflux, recurrent lower urinary tract infec-
tion, neurogenic bladder, bladder trauma,
lower urinary tract fistulae, urethral stric-
ture, and posterior urethral valves. Contra-
indications to lower urinary tract studies
are related to catheterization of the urethra.
Contrast media
The contrast agents used for contrast
studies of the lower urinary tracts are ionic
solutions of sodium or meglumine diatri-
zoates or the newer nonionic contrast
media mentioned previously. These are
the same organic compounds used for
IVU, but their concentration is reduced,
usually to 30%, for retrograde urography.
Injection equipment
Examinations are performed under careful
aseptic conditions. Infants, children, and,
usually, adults may be catheterized before
they are brought to the radiology depart-
ment. When the patient is to be catheter-
ized in the radiology department, a sterile
catheterization tray must be set up to spec-
ifications. Because of the danger of con-
tamination in transferring a sterile liquid
from one container to another, the use of
commercially available premixed contrast
solutions is recommended.
214
Preliminary preparations
The following guidelines are observed in
preparing the patient for the examination:
• Protect the examination table from
urine soilage with radiolucent plastic
sheeting and disposable underpadding.
Correctly arranged disposable padding
does much to reduce soilage during
voiding studies and consequently elimi-
nates the need for extensive cleaning
between patients. A suitable disposal
receptacle should be available.
• A few minutes before the examination,
accompany the patient to a lavatory.
Give the patient supplies for perineal
care, and instruct the patient to empty
the bladder.
• When the patient is prepared, place the
patient on the examination table for the
catheterization procedure.
Patients are usually tense, primarily
because of embarrassment. It is important
that they be given as much privacy as
possible. Only required personnel should
be present during the examination, and
patients should be properly draped and
covered according to room temperature.
Contrast injection
For retrograde cystography (Figs. 18-60
and 18-61), cystourethrography, and
voiding cystourethrography, the contrast
material is introduced into the bladder by
injection or infusion through a catheter
passed into position via the urethral canal.
A small, disposable Foley catheter is used
to occlude the vesicourethral orifice in the
examination of infants and children, and
this catheter may be used in the examina-
tion of adults when interval studies are to
be made for the detection of delayed ure-
teral reflux.
Studies are made during voiding to
delineate the urethral canal and to detect
ureteral reflux, which may occur only
during urination (Fig. 18-62). When ure-
thral studies are to be made during injec-
tion of contrast material, a soft rubber
urethral-orifice acorn is fitted directly onto
a contrast-loaded syringe for female
patients and is usually fitted onto a can-
nula attached to a clamp device for male
patients.
RETROGRADE CYSTOGRAPHY
Contrast injection technique
In preparing for this examination, the fol-
lowing steps are taken:
• With the urethral catheter in place,
adjust the patient in the supine position
for a preliminary image and the first
cystogram.
• Usually, take cystograms of adult
patients on 10 × 12-inch (24 × 30-cm)
IRs placed lengthwise.
• Center the IR at the level of the soft
tissue depression just above the most
prominent point of the greater trochan-
ters. This centering coincides with the
middle area of a filled bladder of
average size. The 12-inch (30-cm) IR
includes the region of the distal end of
the ureters to show ureteral reflux and
the prostate and proximal part of the
male urethra.
• Have large IRs nearby for use when
ureteral reflux is shown. Some radiolo-
gists request studies during contrast
filling of the bladder and during voiding.
After the preliminary image is taken,
the physician removes the catheter clamp,
and the bladder is drained in preparation
for the introduction of contrast material.
After introducing the contrast agent, the
physician clamps the catheter and tapes it
to the thigh to keep it from being dis-
placed during position changes.
The initial cystographic images gener-
ally consist of four projections: one AP,
two AP oblique, and one lateral. Addi-
tional studies, including voiding cystoure-
thrograms, are obtained as indicated. The
Chassard-Lapiné method (see Chapter 17,
Volume 2), is sometimes used to obtain an
axial projection of the posterior surface of
the bladder and the lower end of the
ureters when they are opacified. These
projections of the bladder are also made
when it is opacified by the excretory tech-
nique of urography.
 Urinary Bladder, Lower Ureters, Urethra, and Prostate
Fig. 18-60  Retrograde cystogram after introduction of contrast medium: AP projection.

Fig. 18-61  Retrograde cystogram after introduction of air: AP Fig. 18-62  Serial (polygraphic) voiding cystourethrograms in an
projection. infant girl with bilateral ureteral reflux (arrowheads). Urethra is
normal. Vaginal reflux (arrows) is a normal finding.

215
 Urinary Bladder
AP AXIAL OR PA AXIAL
PROJECTION
Image receptor: 10 × 12 inch (24 ×
30 cm) lengthwise
Position of patient
• Place the patient supine on the radio-
graphic table for the AP projection of
the urinary bladder.
NOTE: Preliminary (scout) and postinjection
images are most commonly obtained with the
patient supine. The prone position is sometimes
used to image areas of the bladder not clearly seen
on the AP axial projection. An AP axial projection
Urinary System and Venipuncture
using the Trendelenburg position at 15 to 20
degrees and with the central ray directed verti-
cally is sometimes used to show the distal ends
of the ureters. In this angled position, the weight
of the contained fluid stretches the bladder fundus
superiorly, giving an unobstructed projection of
the lower ureters and the vesicoureteral orifice
areas.
216
Position of part
• Center the midsagittal plane of the
patient’s body to the midline of the grid
device.
• Adjust the patient’s shoulders and hips
so that they are equidistant from the IR.
• Place the patient’s arms where they do
not cast shadows on the IR.
• If the patient is positioned for a supine
image, have the patient’s legs extended
so that the lumbosacral area of the spine
is arched enough to tilt the anterior
pelvic bones inferiorly. In this position,
the pubic bones can more easily be pro-
jected below the bladder neck and prox-
imal urethra (Fig. 18-63).
• Center the IR 2 inches (5 cm) above the
upper border of the pubic symphysis (or
at the pubic symphysis for voiding
studies).
• Respiration: Suspend at the end of
expiration.
15°
Fig. 18-63  Retrograde cystogram. AP axial bladder with 15-degree caudal angulation of
central ray.
Central ray
AP
• Angled 10 to 15 degrees caudal to the
center of the IR. The central ray should
enter 2 inches (5 cm) above the upper
border of the pubic symphysis. When
the bladder neck and proximal urethra
are the main areas of interest, 5-degree
caudal angulation of the central ray is
usually sufficient to project the pubic
bones below them. More or less angula-
tion may be necessary, depending on
the amount of lordosis of the lumbar
spine. With greater lordosis, less angu-
lation may be needed (see Fig. 18-63).
PA
• When performing PA axial projections
of the bladder, direct the central ray
through the region of the bladder neck
at an angle 10 to 15 degrees cephalad,
entering about 1 inch (2.5 cm) distal to
the tip of the coccyx and exiting a little
above the superior border of the pubic
symphysis. If the prostate is the area
of interest, the central ray is directed
20 to 25 degrees cephalad to project it
above the pubic bones. For PA axial
projections, the IR is centered to the
central ray.
• Perpendicular to the pubic symphysis
for voiding studies
Collimation
• Adjust to 10 × 12 inches (24 × 30 cm)
on the collimator.
 Urinary Bladder

Structures shown EVALUATION CRITERIA

AP axial and PA axial projections show
the bladder filled with contrast medium
(Figs. 18-64 and 18-65). If reflux is
present, the distal ureters are also
visualized.
The following should be clearly shown:
■ Evidence of proper collimation
■ Regions of the distal end of the ureters,
bladder, and proximal portion of the
urethra
■ Pubic bones projected below the
bladder neck and proximal urethra
■ Exposure technique clearly showing
contrast medium in the bladder, distal
ureters, and proximal urethra

Urinary Bladder
R R

Fig. 18-64  Excretory cystogram: AP axial projection. Fig. 18-65  Retrograde cystogram: AP axial projection. Note
catheter in bladder.

217
 Urinary Bladder
  AP OBLIQUE PROJECTION
RPO or LPO position
Image receptor: 10 × 12 inch (24 ×
30 cm) lengthwise
Position of patient
• Place the patient in the supine position
on the radiographic table.
Position of part
• Rotate the patient 40 to 60 degrees RPO
or LPO, according to the preference of
the examining physician (Fig. 18-66).
Urinary System and Venipuncture
218
• Adjust the patient so that the pubic arch
closest to the table is aligned over the
midline of the grid.
• Extend and abduct the uppermost thigh
enough to prevent its superimposition
on the bladder area.
• Center the IR 2 inches (5 cm) above the
upper border of the pubic symphysis
and approximately 2 inches (5 cm)
medial to the upper ASIS (or at the
pubic symphysis for voiding studies).
• Respiration: Suspend at the end of
expiration.
Fig. 18-66  Retrograde cystogram: AP oblique bladder, RPO
position.
Central ray
• Perpendicular to the center of the IR.
The central ray falls 2 inches (5 cm)
above the upper border of the pubic
symphysis and 2 inches (5 cm) medial
to the upper ASIS. When the bladder
neck and proximal urethra are the main
areas of interest, 10-degree caudal
angulation of the central ray is usually
sufficient to project the pubic bones
below them.
• Perpendicular at the level of the pubic
symphysis for voiding studies
Collimation
• Adjust to 10 × 12 inches (24 × 30 cm)
on the collimator.
Structures shown
Oblique projections show the bladder
filled with contrast medium. If reflux is
present, the distal ureters are also visual-
ized (Figs. 18-67 and 18-68).
 Urinary Bladder

EVALUATION CRITERIA R
The following should be clearly shown:
■ Evidence of proper collimation
■ Regions of the distal ends of the ureters
and bladder, and the proximal portion
of the urethra
■ Pubic bones projected below the
bladder neck and the proximal urethra
■ Exposure technique clearly showing
contrast medium in the bladder, distal
ureters, and proximal urethra
■ No superimposition of the bladder by
the uppermost thigh

Voiding studies

Urinary Bladder
■ Entire urethra visible and filled with
contrast medium
■ Urethra overlapping the thigh on
oblique projections for improved Fig. 18-67  Excretory cystogram: AP oblique bladder, RPO position.
visibility
■ Urethra lying posterior to the superim-
posed pubic and ischial rami on the side
down in oblique projections

Fig. 18-68  Retrograde cystogram with catheter in bladder.

219
 Urinary Bladder
  LATERAL PROJECTION
R or L position
Image receptor: 10 × 12 inch (24 ×
30 cm) lengthwise
Position of patient
• Place the patient in the lateral recum-
bent position on the right or the left
side, as indicated.
Position of part
• Slightly flex the patient’s knees to a
comfortable position, and adjust the
body so that the midcoronal plane is
Urinary System and Venipuncture
centered to the midline of the grid.
• Flex the patient’s elbows, and place the
hands under the head (Fig. 18-69).
• Center the IR 2 inches (5 cm) above the
upper border of the pubic symphysis at
the midcoronal plane.
• Respiration: Suspend at the end of
expiration.
Fig. 18-69  Cystogram: lateral projection.
220
Central ray
• Perpendicular to the IR and 2 inches
(5 cm) above the upper border of the
pubic symphysis at the midcoronal
plane
Collimation
• Adjust to 10 × 12 inches (24 × 30 cm)
on the collimator.
Structures shown
A lateral image shows the bladder filled
with contrast medium. If reflux is present,
the distal ureters are also visualized.
Lateral projections show the anterior and
posterior bladder walls and the base of the
bladder (Fig. 18-70).
Fig. 18-70  Cystogram: lateral projection.
EVALUATION CRITERIA
The following should be clearly shown:
■ Evidence of proper collimation
■ Regions of the distal end of the ureters,
bladder, and proximal portion of the
urethra
■ Exposure technique clearly showing
contrast medium in the bladder, distal
ureters, and proximal urethra
■ Bladder and distal ureters visible
through the pelvis
■ Superimposed hips and femur
 Male Cystourethrography

  AP OBLIQUE PROJECTION
RPO or LPO position
Male cystourethrography may be pre-
ceded by an endoscopic examination,
after which the bladder is catheterized so
that it can be drained just before contrast
material is injected.
The following steps are taken:
• Use 10 × 12-inch (24 × 30-cm) IRs
placed lengthwise for cystourethro-
grams in men.
• The patient is adjusted on the combina-
tion table so that the IR can be centered
at the level of the superior border of the
pubic symphysis. This centering coin-
• The patient’s lower knee is flexed only
slightly to keep the soft tissues on the
medial side of the thigh as near to the
center of the IR as possible.
• The elevated thigh is extended and re-
tracted enough to prevent overlapping.
• With the patient in the correct position,
the physician inserts the contrast
medium–loaded urethral syringe or the
nozzle of a device such as the Brodney
clamp into the urethral orifice. The phy-
sician extends the penis along the soft
tissues of the medial side of the lower
thigh to obtain a uniform density of the
deep and cavernous portions of the ure-
• At a signal from the physician, instruct
the patient to hold still; make the expo-
sure while injection of contrast material
is continued to ensure filling of the
entire urethra (Fig. 18-72).
• The bladder may be filled with a con-
trast material so that a voiding study
can be performed (Fig. 18-73). This is
usually done without changing the
patient’s position. When a standing-
upright voiding study is required,
the patient is adjusted before a vertical
grid device and is supplied with a
urinal. (Further information on posi-
tioning is provided on pp. 216-220 of

Male Cystourethrography
cides with the root of the penis, and a thral canal. this volume.)
12-inch (30-cm) IR includes the bladder
and the external urethral orifice.
• After inspecting the preliminary image,
the physician drains the bladder and
withdraws the catheter.
• The supine patient is adjusted in an
oblique position so that the bladder
neck and the entire urethra are delin-
eated as free of bony superimposition
as possible. Rotate the patient’s body 35
to 40 degrees, and adjust it so that the
elevated pubis is centered to the midline
of the grid. The superimposed pubic
and ischial rami of the down-side and
the body of the elevated pubis usually
are projected anterior to the bladder
neck, proximal urethra, and prostate
(Fig. 18-71).

Fig. 18-71  Cystourethrogram: AP oblique projection, RPO position.

L
R

Bladder

Prostatic urethra

Membranous urethra

Spongy
(cavernous) urethra

Fig. 18-72  Injection cystourethrogram: AP oblique urethra, Fig. 18-73  Voiding cystourethrogram: AP
RPO position. oblique urethra, LPO position.

221
 Female Cystourethrography
AP PROJECTION
INJECTION METHOD
The female urethra averages 1 1 2 inches
(3.5 cm) in length. Its opening into the
bladder is situated at the level of the supe-
rior border of the pubic symphysis. From
this point, the vessel slants obliquely infe-
riorly and anteriorly to its termination in
the vestibule of the vulva, about 1 inch
(2.5 cm) anterior to the vaginal orifice.
The female urethra is subject to conditions
such as tumors, abscesses, diverticula,
dilation, and strictures. It is also subject to
urinary incontinence during the stress of
increased intra-abdominal pressure, as
Urinary System and Venipuncture
occurs during sneezing or coughing. In the
investigation of abnormalities other than
stress incontinence, contrast studies are
made during injection of contrast medium
or during voiding.
Cystourethrography is usually preceded
by an endoscopic examination. For this
reason, it may be performed by the attend-
ing urologist or gynecologist with the
assistance of a nurse and a radiographer.
The following steps are observed:
• After the physical examination, the cys-
toscope is removed, and a catheter is
inserted into the bladder so that the
bladder can be drained just before
injection of the contrast solution.
• The patient is adjusted in the supine
position on the table.
Fig. 18-74  Voiding cystourethrogram: AP
projection.
222
• An 8 × 10-inch (18 × 24-cm) or 10 ×
12-inch (24 × 30-cm) IR is placed
lengthwise and centered at the level of
the superior border of the pubic
symphysis.
• A 5-degree caudal angulation of the
central ray is usually sufficient to free
the bladder neck of superimposition.
• After inspecting the preliminary image,
the physician drains the bladder and
withdraws the catheter. The physician
uses a syringe fitted with a blunt-nosed,
soft rubber acorn, which is held firmly
against the urethral orifice to prevent
reflux as the contrast solution is injected
during exposure.
• Oblique projections may be required
in addition to the AP projection. For
oblique projections, the patient is
rotated 35 to 40 degrees so that the
urethra is posterior to the pubic
symphysis. The uppermost thigh is
extended and abducted enough to
prevent overlapping.
• Further information on positioning is
provided on p. 218 of this volume.
• The physician fills the bladder for each
voiding study to be made.
Contrast-filled
bladder
Urethra
Fig. 18-75  Serial voiding images showing four stages of bladder
emptying.
• For an AP projection (Figs. 18-74 and
18-75), the patient is maintained in the
supine position, or the head of the table
is elevated enough to place the patient
in a semi-seated position.
• A lateral voiding study of the female
vesicourethral canal is performed with
the patient recumbent or upright. In
either case, the IR is centered at the
level of the superior border of the pubic
symphysis.
Metallic bead chain
cystourethrography
The metallic bead chain technique of
investigating anatomic abnormalities
responsible for stress incontinence in
women was described by Stevens and
Smith1 in 1937 and by Barnes2 in 1940.
This technique is used to delineate ana-
tomic changes that occur in the shape
and position of the bladder floor, in the
1
Stevens WE, Smith SP: Roentgenological examina-
tion of the female urethra, J Urol 37:194, 1937.
2
Barnes AC: A method for evaluating the stress of
urinary incontinence, Am J Obstet Gynecol 40:381,
1940.
 Female Cystourethrography

posterior urethrovesical angle, in the posi- Comparison AP and lateral projections

tion of the proximal urethral orifice, and
in the angle of inclination of the urethral
axis under the stress of increased intra-
abdominal pressure as exerted by the Val-
salva maneuver.
are made with the patient standing at rest
(Figs. 18-76 and 18-77) and straining
(Figs. 18-78 and 18-79).

L
R

Female Cystourethrography
Bladder

Metallic
bead
chain

Fig. 18-76  Upright cystourethrogram: resting AP projection. Fig. 18-77  Upright cystourethrogram: resting lateral projection.

R L

Fig. 18-78  Upright cystourethrogram: stress AP projection in the Fig. 18-79  Upright cystourethrogram: stress lateral projection.
same patient as in Fig. 18-76.

223
 Female Cystourethrography
For this examination, the physician
extends a flexible metallic bead chain
through the urethral canal. The proximal
portion of the chain rests within the
bladder, and the distal end is taped to the
thigh. To show the length of the urethra, a
small metal marker is attached with a
piece of tape to the vaginal mucosa just
lateral to the urethral orifice. After instil-
lation of the metallic chain, a catheter is
passed into the bladder, the contents of the
bladder are drained, and an opaque con-
trast solution is injected. The catheter is
removed for the imaging procedure.
Urinary System and Venipuncture
224
Hodgkinson et al.1 recommended the
upright position, which uses gravity and
simulates normal body activity. Two sets
of images (AP and lateral projections) are
obtained, and the rest of the studies must
be exposed before the stress studies are
made because the bladder does not imme-
diately return to its normal resting posi-
tion after straining.
1 folded towel or disposable pad between
Hodgkinson CP et al: Urethrocystograms: metallic
bead chain technique, Clin Obstet Gynecol 1:668,
1958.
After the metallic chain and contrast
solution are instilled, the patient is usually
prepared for upright images. The examin-
ing room should be readied in advance so
that the patient, who will be uncomfort-
able, can be given immediate attention.
The patient must be given kind reassur-
ance and must be examined in privacy.
Klawon1 found that fear of involuntary
voiding can be relieved by placing a
the patient’s thighs before stress images
are taken. Thus protected, the patient will-
ingly applies full pressure during stress
studies.
The IR size and centering point are the
same as for other female cystourethro-
grams. (Further information on position-
ing of the lower urinary tract is provided
on p. 218 of this volume.)
1
Klawon MM: Urethrocystography and urinary
stress incontinence in women, Radiol Technol
39:353, 1968.
 VENIPUNCTURE AND IV CONTRAST MEDIA ADMINISTRATION
Radiologic technologists may perform
venipuncture and administer medications
by physician order for specific indications
in certain types of IV therapy related to
radiographic procedures. Most commonly,
this medication consists of some type of
radiographic contrast medium.1 For this
reason, this chapter provides additional
information on the professional and legal
considerations of IV access and medica-
tion administration, common medications
in the imaging department, patient educa-
tion and assessment, infection control,
venipuncture equipment and procedure,
contrast reactions, and documentation.
Professional and Legal
Considerations
Because of patient risk and legal liabili-
ties, the radiologic technologist must
follow professional recommendations,
state regulations, and institutional policies
for administration of medications. The
information presented in this section is
meant to be an introduction to IV therapy.
Competency in this area requires the
completion of a formal course of instruc-
tion with supervised clinical practice and
evaluation.
The American Society of Radiologic
Technologists (ASRT) includes venipunc-
ture and IV medication administration in
the curriculum guidelines for educational
opportunities offered to technologists.
Additional support for administration of
medications and venipuncture as part of
the technologist’s scope of practice is
found in the ACR’s 1987 Resolution
No. 27 and Manual on Contrast Media
1
Tortorici M: Administration of imaging pharmaceu-
ticals, Philadelphia, 1996, Saunders.
(2013).1,2 These documents support the
injection of contrast materials and diag-
nostic levels of radiopharmaceuticals
within specific established guidelines by
certified or licensed radiologic technolo-
gists. The ASRT Standards of Practice for
Radiography also support the administra-
tion of medication by technologists.
Technologists who perform venipunc-
ture and contrast media administration
must be knowledgeable about the specific
state regulations and facility policies that
govern these activities. Technologists also
are responsible for professional decisions
and actions in their practice. Competency
in the skills of venipuncture and contrast
media administration are based on cogni-
tive knowledge, proficiency in psychomo-
tor skills, positive affective values, and
validation in a clinical setting.
Medications
Medications for a specific procedure are
prescribed by a physician, who is also
responsible for obtaining informed
consent for the procedure. A technologist
may administer medications for radio-
graphic procedures, which can require
medications for sedation, pain manage-
ment, contrast media administration, and
emergencies.3 Technologists must have
extensive knowledge of all medications
used in the radiology department. IV med-
ications are administered into the body
via the vascular system; when adminis-
tered, they cannot be retrieved. Before
administering any medication, the tech-
nologist must know the medication’s
name, dosages, indications, contraindica-
tions, and possible adverse reactions
(Table 18-1).
1
Tortorici M: Administration of imaging pharmaceu-
ticals, Philadelphia, 1996, Saunders.
2
ACR Manual on Contrast Media, v.9, 2013, p. 13.
3
Kowalczyk N, Donnett K: Integrated patient care
for the imaging professional, St Louis, 1996, Mosby.
Patient Education
The manner in which the technologist
approaches the patient can have a direct
influence on the patient’s response to
the procedure. Although the technologist
may consider the procedure routine, the
patient may be totally unfamiliar with its
specifics. Apprehension experienced by
the patient can cause vasoconstriction,
making venipuncture more difficult and
more painful.1 Careful explanation and a
confident, sympathetic attitude can help
the patient relax.
The technologist must provide informa-
tion about the procedure in terms the
Patient Education
patient can understand. The patient’s
questions must be answered in “layman’s”
language. By explaining the details of the
procedure, the technologist can help alle-
viate fears and solicit cooperation from
the patient. It is important to explain the
steps in the procedure, its expected dura-
tion, and any limitations or restrictions
associated with its performance. The
patient may have heard an inaccurate
“horror” story about the procedure from a
neighbor or friend. The technologist may
need to correct misconceptions and
provide accurate information.
For simple procedures, the patient must
be reassured that the process is relatively
straightforward and causes only slight dis-
comfort. For more complex and longer
procedures, the technologist must gain the
patient’s cooperation by providing appro-
priate, factual information and offering
support. The patient should never be told
that insertion of the needle used in veni-
puncture does not hurt. After all, a foreign
object is going to be inserted through the
patient’s skin, which has myriad nerves
that may be aggravated by insertion of a
needle. The technologist must tell the
truth and explain that the amount of pain
experienced varies with each patient.2
1
Managing IV therapy: skillbuilders, Springhouse,
PA, 1991, Springhouse.
2
Hoeltke L: The complete textbook of phlebotomy,
ed 3, Albany, NY, 2006, Delmar.
225
 TABLE 18-1 
Medications commonly used in an imaging department

Generic name Brand name Indications Action Adverse reactions

Atropine sulfate Atropine Symptomatic Inhibits acetylcholine at Bradycardia, headache,
How supplied: bradycardia, parasympathetic dry mouth, nausea,
injection, bradyarrhythmia neuroeffector junction, vomiting
tablets enhancing and increasing
heart rate

Diphenhydramine Benadryl Allergic reactions, Competes with histamine for Seizures, sleepiness,
hydrochloride How supplied: sedation special receptors on insomnia,
tablets, effector cells; prevents but incoordination,
capsules, elixir, does not reverse restlessness, nausea,
syrup, injection histamine-mediated vomiting, diarrhea
Urinary System and Venipuncture

responses
Meperidine Demerol Mild to moderate pain; Binds with opiate receptors Seizures, cardiac arrest,
hydrochloride How supplied: adjunct to of CNS shock, respiratory
tablets, syrup, anesthesia depression
injection
Dopamine Dopamine Shock, increase Stimulates dopaminergic Tachycardia,
hydrochloride How supplied: cardiac output, and α and β receptors of hypotension, nausea,
injection correct hypotension sympathetic nervous vomiting, anaphylactic
system reactions
Adrenaline Epinephrine Restore cardiac rhythm Relaxes bronchial smooth Palpations, ventricular
How supplied: in cardiac arrest; muscle by stimulating β2 fibrillation, shock,
injection, bronchospasm; receptors and α and β nervousness
inhaler anaphylaxis receptors in sympathetic
nervous system
Glucagons Glucagon Hypoglycemia Increases blood glucose Bronchospasm,
How supplied: level by promoting hypotension, nausea,
injection catalytic depolymerization vomiting
of hepatic glycogen to
glucose
Morphine sulfate Morphine Severe pain Binds with opiate receptors Bradycardia, shock,
How supplied: of CNS cardiac arrest, apnea,
tablets, syrup, respiratory depression,
oral suspension, respiratory arrest
injection
Chloral hydrate Noctec Sedation Unknown, sedative effects Drowsiness, nightmares,
How supplied: may be caused by its hallucinations, nausea,
capsules, syrup, primary metabolite vomiting, diarrhea
suppositories
Promethazine Phenergan Nausea, sedation Competes with histamine for Dry mouth
hydrochloride How supplied: special receptors on
tablets, syrup, effector cells; prevents
injection, but does not reverse
suppositories histamine-mediated
responses
Diazepam Valium Anxiety Unknown; probably Cardiovascular collapse,
How supplied: depresses CNS at limbic bradycardia,
tablets, and subcortical levels respiratory depression,
capsules, oral acute withdrawal
solutions, syndrome
injections
Midazolam Versed Preoperative sedation Unknown; thought to Apnea, depressed
hydrochloride How supplied: (to induce sleepiness depress CNS at limbic and respiratory rate,
injection or drowsiness subcortical levels nausea, vomiting,
and relieve hiccups, pain at
apprehension) injection site
Hydroxyzine Vistaril Nausea and vomiting, Unknown; actions may be Dry mouth, dyspnea,
hydrochloride How supplied: anxiety, preoperative due to suppression of wheezing, chest
tablets, syrup, and postoperative activity in key regions of tightness
capsules, adjunctive therapy subcortical area of CNS
injection
226
Data from Nursing 2006 drug handbook, Ambler, PA, 2006, Lippincott Williams & Wilkins.
 Effects on diagnostic
Interactions imaging procedures Contraindications Patient care considerations
May increase None known Patients with obstructive Watch for tachycardia in cardiac patients;
anticholinergic drug disease of gastrointestinal may lead to ventricular fibrillation
effects; use tract, paralytic ileus, toxic
together cautiously megacolon, tachycardia,
myocardia or ischemia, or
asthma
Increased effects None known Hypersensitivity to drug during Use with extreme caution in patients with
when used with acute asthmatic attacks angle-closure glaucoma, asthma, COPD
other CNS and in newborns or
depressants premature neonates and
breastfeeding women

May be incompatible None known Patients with hypersensitivity
when mixed in to drug and patients who
same IV container have received MAO
inhibitors within past 14 days
α and β blockers may None known Patients with uncorrected
antagonize effects tachycardia,
pheochromocytoma, or
ventricular fibrillation
Avoid using with α None known Patients with shock, organic
blockers (may brain damage, cardiac
cause hypotension) dilation, arrhythmias,
coronary insufficiency, or
cerebral arteriosclerosis
Inhibits glucagon- None known Patients with hypersensitivity
induced insulin to drug or with
release pheochromocytoma
Patient Education
Give slowly by direct IV injection; oral dose
is less than half as effective as parenteral
dose; compatible with most IV solutions
During infusion, frequently monitor ECG,
blood pressure, cardiac output, central
venous pressure, pulse rate, urine output,
and color and temperature of limbs
Drug of choice in emergency treatment of
acute anaphylactic reactions; avoid IM
use of parenteral suspension into
buttocks
Arouse patient from coma as quickly as
possible and give additional
carbohydrates orally to prevent
secondary hypoglycemic reactions

In combination with None known Patients with hypersensitivity Use with extreme caution in patients with
other depressants to drug or conditions that head injuries or increased intracranial
and narcotics, use would preclude pressure and in elderly patients
with extreme administration of IV opioids
caution
Alkaline solutions None known Patients with hepatic or renal Note two strengths of oral liquid form;
incompatible with impairment, severe cardiac double-check dose, especially when
aqueous solutions of disease, or hypersensitivity administering to children
chloral hydrate to drug
Increased effects Discontinue drug Patients with hypersensitivity Do not administer subcutaneously
when used with 48 hr before to drug; intestinal
other CNS myelogram obstruction, prostatic
depressants because of high hyperplasias
risk of seizures

Other CNS May cause minor Patients with hypersensitivity Monitor respirations and have emergency
depressants changes in ECG to drug or soy protein, resuscitation equipment available before
patterns shock, coma, or acute administering
alcohol intoxication

CNS depressants may None known Patients with hypersensitivity
increase risk of to drug, acute angle-
apnea closure glaucoma, shock,
coma, or acute alcohol
intoxication
Can increase CNS None known Hypersensitivity to drug,
depression during pregnancy, and in
breastfeeding women
Use cautiously in patients with
uncompensated acute illness and in
elderly patients; have emergency
resuscitation equipment available before
administering
If used in conjunction with other CNS
medication, observe for oversedation

227
 Patient Assessment
The patient must be assessed before any
medication is administered. A thorough
patient history must be obtained, includ-
ing any allergies the individual may have.
It is essential to determine whether the
patient has any known allergies to foods,
medications, environmental agents, or
other substances. Before venipuncture is
performed, the technologist needs to be
aware of the potential for an allergic reac-
tion to the iodine tincture used in puncture
site preparation or an adverse reaction to
the medication being injected.
Other assessment criteria include the
Urinary System and Venipuncture
patient’s current medications. Knowledge
of some common medication actions can
help the radiologic technologist evaluate
changes in a patient’s condition during a
procedure. Certain diabetic medications
interact adversely with contrast media. The
interaction of medications must be assessed
before the procedure is performed.
During the physical evaluation, it is
important to determine whether the patient
has previously undergone surgical proce-
dures that might affect site selection for
venipuncture (e.g., a mastectomy with
resultant compromised lymph nodes and
vascular abnormalities, such as atrioven-
tricular shunts). To determine the appropri-
ate type and amount of medication to be
administered, the physician requires infor-
mation about the patient’s past and current
disease processes, such as hypertension
and renal disease. Evaluation of the glo-
merular filtration rate (GFR) (normal range
120-125 ml/min), blood urea nitrogen
(BUN) level (average range 10 to 20 mg/
dL), and the creatinine level (average range
0.05 to 1.2 mg/dL) should be included
among the assessment criteria.
Fig. 18-80  Plastic disposable syringes.
228
Infection Control
Each time the body system is entered, the
potential for contamination exists.1 Strict
aseptic techniques and universal precau-
tions must always be used when medica-
tions are administered with a needle.2 If
a medication is injected incorrectly, a
microorganism may enter the body and
cause an infection or other complications.
The U.S. Centers for Disease Control and
Prevention (CDC) has developed specific
guidelines to prevent the transmission of
infection during preparation and adminis-
tration of medications. These guidelines
are part of the standard precautions used
by every health care facility, and the
technologist must strictly adhere to the
guidelines when performing radiologic
procedures.
Studies using IV filters have shown a
significant reduction in infusion phlebitis.
Filters are devices located within the
tubing used for IV administration. Filters
prevent injection of particulate and micro-
bial matter into the circulatory system.
Use of a filter for a bolus injection reduces
the rate at which medication can be
injected. In addition, the viscosity of a
medication may determine whether a filter
is used and the rate of injection. Although
a filter helps in reducing the possibility of
bacteria being introduced into the blood,
its use creates additional factors of risks
versus benefits. The physician or health
care facility should have policies to
address these issues.
1
Smith S et al: Clinical nursing skills: basic to
advanced skills, ed 6, Stamford, CT, 2003, Appleton
& Lange.
2
Adler AM, Carlton RR: Introduction to radiography
and patient care, ed 4, Philadelphia, 2007,
Saunders.
Fig. 18-81  Types of needles: over-the-cannula needle, or
angiocatheter (bottom); hypodermic needle (center); and metal
butterfly needle (top).
Venipuncture Supplies
and Equipment
NEEDLES AND SYRINGES
The technologist assembles the proper
syringe and needle for the planned injec-
tion. The syringe may be glass or plastic.
Plastic syringes are disposed of after only
one use; glass syringes may be cleaned
and must be sterilized before they are used
again. The syringe has three parts: the tip,
where the needle attaches to the syringe;
the barrel, which includes the calibration
markings; and the plunger, which fits
snugly inside the barrel and allows the
user to instill the medication (Fig. 18-80).
The tip of the syringe for an IV injection
has a locking device to hold the needle
securely. The size of the syringe depends
on the volume of material to be injected.
The technologist should select a syringe
one size larger than the volume desired.
This larger syringe maximizes the accu-
racy of the dose by allowing the total
amount of medication to be drawn into
one syringe.
All needles used in venipuncture are
disposable and are used only once. During
preparation and administration of contrast
media, the technologist may use several
types of needles, including a hypodermic
needle, a butterfly set, and an over-the-
needle cannula (Fig. 18-81).
 Hypodermic needles vary in gauge and
length (see Fig. 18-81). Needle gauge
refers to the diameter of the needle bore,
with the gauge increasing as the diameter
of the bore decreases. An 18-gauge needle
is larger than a 22-gauge needle. As the
bore of the needle increases, a given
volume of fluid may be administered more
rapidly. If bore size is reduced and fluid
volume and rate of administration remain
constant, the pressure (force) of the injec-
tion increases. The length of a needle is
measured in inches and may range from
1
2 inch (1.3 cm) (used for intradermal
injections) to 4 1 2 inches (11.5 cm) (used
administered. During preparation and
again before administration, the medica-
tion in the container also must be
verified.
If medication is supplied in a bottle or
vial, the preparation procedure has several
variations. First, the solution must be
evaluated for contamination. Discolor-
ation and dissolution are the most common
signs of contamination. If either of those
is observed, the solution should not be
used. Then the protective cap is removed,
with care taken not to contaminate the
underlying surface. Containers have
rubber stoppers through which a hypoder-
For a closed system to be maintained
and to reduce the chance of possible infec-
tion, a volume of air equal to the amount
of desired fluid must be injected into the
bottle. The plunger of the syringe is pulled
back to the level of the desired amount of
medication. The shaft of the plunger must
not be contaminated at any time during
preparation of the medication. The needle
on the syringe is inserted into the rubber
stopper, all the way to the hub of the
needle. Then the vial is inverted by placing
the end of the needle above the fluid level
in the bottle (Fig. 18-82). Next, a small
amount of air is slowly injected into the

Venipuncture Supplies and Equipment

for intrathecal [spinal] injections). Gener- mic needle can be inserted. If a single- vial above the level of the fluid. This tech-
ally, needles 1 to 1 1 2 inches (2.5 to 3.8 cm) dose vial is being used, and no nique helps to decrease air bubbles in the
long are most commonly used for IV contamination has occurred, the rubber solution. After the air has been injected,
injections. The needle has three parts: the stopper requires no additional cleansing. the vial and syringe are held inverted and
hub, which is the part that attaches to the Multiple-dose vial stoppers must be perpendicular to a horizontal plane, and
syringe; the cannula or shaft, which is cleaned with an alcohol wipe. the tip of the needle is pulled below the
the length of the needle; and the bevel, fluid level. The desired amount of medica-
which is the slanted portion of the needle tion is aspirated into the syringe by pulling
tip. Needles should be visually examined down on the plunger of the syringe. This
before and after use to determine whether procedure may have to be repeated several
any structural defects, such as nonbeveled times to expel all of the medication. If air
points or bent shafts, are present.1 bubbles cling to the syringe casing, the
Butterfly sets or angiocatheters are syringe may be lightly tapped to release
preferable to a conventional hypodermic them. A one-handed method is used to
needle for most radiographic IV therapies. recap the syringe (Fig. 18-83).
The butterfly set consists of a stainless
steel needle with plastic appendages on
either side and approximately 6 inches of
plastic tubing that ends with a connector.
The plastic appendages, often called
wings, aid in inserting the needle and sta-
bilizing the needle after venous patency
has been confirmed.
The over-the-needle cannula is a device
in which, after the venipuncture is made, Fig. 18-82  Place tip of needle above level
of fluid before injection of air to decrease
the catheter is slipped off the needle into air bubbles in solution.
the vein and the steel needle is removed.
This type of needle is recommended for
long-term therapy or for rapid infusions,
such as infusions that use an automated
power injector. The choice of needle
should be based on assessment of the
patient, institutional policy, and technolo-
gist preference.

MEDICATION PREPARATION
Although IV drug administration offers
the most immediate results in terms of
effect, certain safety precautions must be
followed. The technologist must identify
the correct patient before medication is

1
Strasinger S, DiLorenzo M: Phlebotomy workbook
for the multiskilled healthcare professional, ed 2,
Philadelphia, 2003, FA Davis. Fig. 18-83  When recapping a syringe, use a one-handed method.

229
 Preparation of an infusion from a glass
bottle or plastic bag begins with identifi-
cation and verification of the solution and
its expiration date (Fig. 18-84). The solu-
tion should not contain any visible parti-
cles. The tubing used for the infusion is
determined by the method of injection and
the type of container. Electronic infusion
devices require different tubing than
gravity infusion devices. A glass container
necessitates vented tubing (Fig. 18-85),
whereas a plastic container requires non-
vented tubing (Fig. 18-86).
Urinary System and Venipuncture
Fig. 18-84  Identify the correct solution and
expiration date.
Fig. 18-86  Solutions in plastic bags require
nonvented tubing.
230
To prepare for drip infusion of a medi-
cation, the technologist removes the
tubing from the sterile package and closes
the clamp (Fig. 18-87). Failure to close the
clamp may result in loss of the vacuum in
the solution container. The protective cov-
erings are removed from the port of the
solution and the tubing spike. Then the fill
chamber of the tubing is squeezed, and the
spike is inserted into the solution. The
solution is then inverted, and the chamber
is released. The solution should fill the
chamber to the measurement line. The
tubing is primed by opening the clamp,
which allows the solution to travel the
length of the tubing, expelling any air. The
tube is filled with solution, the clamp is
closed, and the protective covering is
secured. The solution is then ready for
administration.
Fig. 18-85  Vented tubing is required for
glass bottle containers.
Fig. 18-87  Close tubing clamp before
inserting spike into container of solution.
Procedure
SITE SELECTION
Selection of an appropriate vein for veni-
puncture is crucial. Finding the vein is
sometimes difficult, and the most visible
veins are not always the best choice.1
Technologists administer IV medication
and contrast media via the venous system.
If a pulse is palpated during assessment
for a puncture site, that vessel must not be
used because it is an artery. The prime
factors to consider in selecting a vein are
(1) suitability of location, (2) condition of
the vein, (3) purpose of the infusion, and
(4) duration of therapy. The veins most
often used in establishing IV access are
the basilic or cephalic veins on the back
of the hand, the basilic vein on the medial,
anterior forearm and elbow and the
cephalic vein on the lateral, anterior
forearm and elbow. The anterior surface
of the elbow is also referred to as the ante-
cubital space2 (Fig. 18-88).
A general rule is to select the most
distal site that can accept the desired-size
needle and tolerate the injection rate and
solution. Although the veins located at the
antecubital space may be the most acces-
sible, the largest, and the easiest to punc-
ture, they may not be the best choice.
Because of their convenient location,
these sites may be overused and can
become scarred or sclerotic. Antecubital
accesses are located over an area of joint
flexion; any motion can dislodge the
cannula, causing infiltration or resulting in
mechanical phlebitis. A flexible IV cath-
eter is the needle of choice for placement
of a venous access in the antecubital
space. The patient’s arm should be immo-
bilized to inhibit the ability to flex the
elbow.
1
Steele J: Practical IV therapy, Springhouse, PA,
1988, Springhouse.
2
Jensen S, Peppers M: Pharmacology and drug
administration for imaging technologists, ed 2, St
Louis, 2006, Elsevier/Mosby.
 The condition of the vein must also be
considered in the selection of an appropri-
ate puncture site. The selected vein must
be able to tolerate the needed or desired
cannula size. The vein should have resil-
ience qualities and be anchored by sur- Superficial
rounding supportive tissues to prevent Dorsal dorsal veins

rolling. venous
Posterior
arch
Another consideration in vein selection Right Hand

is the rate of flow required for the proce- Basilic

dure and the viscosity and amount of vein
Cephalic
medication to be administered. Because vein
the purpose of the infusion determines the
rate of flow, the solution to be infused
should be evaluated during the site selec-

Procedure
tion process. Larger veins should be
selected for infusions of large quantities
or for rapid infusions. Large veins are also
used for the infusion of highly viscous
solutions or solutions that are irritating to
vessels.1
The expected duration of the therapy
and the patient’s comfort are other factors
Radial
that must be considered in selecting a vein
venipuncture site. If a prolonged course of
therapy is anticipated, areas over flexion
joints should be avoided, and the dorsal
surfaces of the upper limbs should be Anterior
carefully examined. Venous access in Right Forearm
these locations provides greater freedom
and comfort to the patient. Basilic
vein
1
Adler AM, Carlton RR: Introduction to radiologic Median vein
sciences and patient care, ed 5, St Louis, 2012, of forearm
Elsevier/Saunders.
Median
cubital
vein

Cephalic
Basilic vein
vein

Fig. 18-88  Veins easily accessible for venipuncture.

231
 SITE PREPARATION
The surface of the skin must be prepared
and cleaned. If the area selected for veni-
puncture is hairy, the hair should be
clipped to permit better cleansing of the
skin and visualization of the vein; this also
makes removal of the cannula less painful
when the infusion is terminated. Shaving
is not recommended. The skin is cleansed
with an antiseptic, which should remain in
contact with the skin for at least 30
seconds. The preferred solution is iodine
tincture 1% to 2%. Isopropyl alcohol 70%
is recommended if the patient is sensitive
to iodine. The skin should be cleaned in a
Urinary System and Venipuncture
circular motion from the center of the
injection site to approximately a 2-inch
circle. When the swab has been placed on
the skin, it should not be lifted from the
surface until the cleansing process is com-
plete (Fig. 18-89).
Many facilities have a policy that pro-
vides the patient an opportunity to request
a local anesthetic for IV infusion catheter
placement. This technique reduces the
pain felt by the patient during insertion of
an angiocatheter or needle. The local
anesthetic can be administered topically
or by injection.
Fig. 18-89  Prepare site for venipuncture.
232
A facility’s procedure for local anes-
thetic determines the specific criteria for
that institution. Commonly accepted
guidelines are as follows: First, 0.1 to
0.2 mL of 1% lidocaine without epineph-
rine or sterile saline is prepared in a tuber-
culin or insulin syringe with a 23- to
25-gauge needle. The site for injection is
selected and prepared. Then the anesthetic
is injected subcutaneously (beneath the
skin, into the soft tissue) or intradermally
(immediately under the skin in the dermal
layer) at the venipuncture site. Topical
anesthesia is achieved by applying 5 g of
eutectic mixture of local anesthetic cream
and covering the area with an occlusive
dressing. Maximal effects are achieved in
45 to 60 minutes.
The medication to be injected should
already be prepared, and any tubing
should be primed with the solution to
prevent injection of air into the vascular
system.
Fig. 18-90  Put on clean gloves.
VENIPUNCTURE
After the solution has been prepared, the
site has been selected, and the type of
syringe and the needle to be used have
been determined, the technologist is ready
to perform the venipuncture.
Techniques for venipuncture follow one
of two courses: (1) the direct, or one-step,
entry method or (2) the indirect method.
The direct, or one-step, method is per-
formed by thrusting the cannula through
the skin and into the vein in one quick
motion. The needle and cannula enter the
skin directly over the vein. This technique
is excellent as long as large veins are
available.1 The indirect method is a two-
step technique. First, the over-the-needle
cannula is inserted through the skin adja-
cent to or below the point where the vein
is visible. The cannula is advanced and
maneuvered to pierce the vein. For the
actual venipuncture procedure, the tech-
nologist washes the hands. The patient is
identified. Next, the technologist instructs
the patient about the procedure. The tech-
nologist performs the following steps:
1
Weinstein SM: Plumer’s principles and practice of
intravenous therapy, ed 8, Boston, 2006, Little,
Brown.
Fig. 18-91  Apply tourniquet 6 to 8 inches
above intended venipuncture site, with
free end directed superiorly.
 1. The technologist puts on gloves and
cleans the area in accordance with
facility protocol (Fig. 18-90).
2. A local anesthetic is administered
according to facility policy (optional).
3. A tourniquet is placed 6 to 8 inches
(15 to 20 cm) above the intended site
of puncture. The tourniquet should be
tight enough to distend the vessels but
not occlude them. The loose ends of
the tourniquet should be placed away
from the injection site to prevent
contamination of the aseptic area
(Fig. 18-91).
Fig. 18-92  Stabilize vein and enter skin with
needle at 45-degree angle.
Fig. 18-94  Anchor needle with tape to
secure placement.
4. The technologist holds the patient’s
limb with the nondominant hand,
using that thumb to stabilize and
anchor the selected vein. The best
method of accessing the vein—direct
or indirect technique—is determined.
5. Using the dominant hand, the tech-
nologist places the needle bevel up
at a 45-degree angle to the skin’s
surface. The bevel-up position pro-
duces less trauma to the skin and vein
(Fig. 18-92).
7. After the vein is punctured and blood
8. Release the tourniquet (Fig. 18-93).
9. If a backflow of blood does not occur,
Fig. 18-93  Release tourniquet after venous
access has been obtained. Do not permit
tourniquet to touch needle.
10. Anchor the needle with tape and a
Fig. 18-95  Administer medication.
6. The technologist uses a quick, sharp
darting motion to enter the skin with
the needle. On entering the skin, the
technologist decreases the angle of
the needle to 15 degrees from the long
axis of the vessel. Using an indirect
method, the technologist slowly pro-
ceeds with a downward motion on the
hub or wings of the needle; while
raising the point of the needle, the
technologist advances the needle par-
allel and then punctures the vein. The
needle may have to be maneuvered
slightly to facilitate actual venous
puncture. If the direct method of
Procedure
access is used, the needle is placed on
the skin directly over the vein, and
entry into the vein is accomplished in
one movement of the needle through
the skin and vein. When the vein is
entered, a backflow of blood may
occur—this indicates a successful
venipuncture.
return is noted, the cannula is
advanced cautiously up the lumen of
the vessel for approximately 3 4 inch
(1.9 cm).
verify venous access before injecting
the medication. Aspiration of blood
directly into the syringe of medication
verifies placement before injection.
Another method of placement verifi-
cation is to attach a syringe of normal
saline to the hub of the needle before
aspirating for blood. The advantage of
this method is that only saline, an iso-
tonic solution, is injected if the needle
is not in place and extravasation
occurs. A successful venipuncture
does not guarantee a successful injec-
tion. If a bolus injection is desired, the
tourniquet may not be released until
the injection has been completed. If
this technique is used, the protocol
must be included in the facility’s poli-
cies and procedures.
dressing, as required by policy (Fig.
18-94). Then administer the medica-
tion (Fig. 18-95).
233
 With experience, a technologist’s
fingers become sensitive to the sensation
of the needle entering the vein—the resis-
tance encountered as the needle penetrates
the wall of the vein and the “pop” felt at
the loss of resistance as the cannula enters
the lumen. If both walls of the vein are
punctured with a needle, the vessel devel-
ops a hematoma. The cannula should be
removed immediately, and direct pressure
should be applied to the puncture site. If
a venipuncture attempt is unsuccessful
with an over-the-needle cannula, and the
needle has been removed from the can­
nula, the needle should not be reinserted
Urinary System and Venipuncture
into the catheter. Reinserting the needle
into the cannula can shear a portion of the
catheter.
ADMINISTRATION
The technologist should administer the
medication or contrast medium at the
established rate. During the injection
process, the injection site should be
observed and palpated proximal to the
puncture for signs of infiltration. An infil-
tration, or extravasation, is a process
whereby fluid passes into the tissue instead
of the vein.
A patient may have a venous access
that was established before the radiologic
Fig. 18-96  Remove IV access.
234
procedure. Careful assessment of site and
medication compatibility must be per-
formed before the existing IV line can be
used. (Compatibility is the ability of one
medication to mix with another.) Special
precautions should be taken with a patient
who is currently receiving cardiac, blood
pressure, heparin, or diabetes medica-
tions. The physician, nurse, or pharmacist
should be consulted before medication is
administered to such a patient. Verifica-
tion must be obtained to ensure that the
medication being infused through the
established IV line is compatible with
the contrast medium to be administered.
Before the contrast medium is injected,
the infusion should be stopped, and the
line should be flushed with normal saline
through the port nearest the insertion site.
The contrast medium is then adminis-
tered, and the line is flushed again with
normal saline. The amount of normal
saline used depends on the facility’s poli-
cies and procedures. After the contrast
medium has been administered, the IV
infusion solution is restarted.
Heparin or saline locks allow intermit-
tent injections through a port. The port
is a small adapter with an access that
is attached to an IV catheter when more
than one injection is anticipated.1 As
Fig. 18-97  Discard needles in puncture-
resistant containers.
determined by procedure criteria, the
cannula is flushed with heparin and saline
to maintain patency during dormant
periods.
The patency (open, unobstructed flow)
of the intermittent device is verified by
aspirating blood and injecting normal
saline without infiltration. Then the medi-
cation is administered. Finally, the medi-
cation is flushed through the device with
saline. Depending on protocols, the device
may then be flushed with heparin or
normal saline.
After the medication has been adminis-
tered and the radiologic procedure has
been completed, the venous access may be
discontinued. The radiologic technologist
should carefully remove any tape or pro-
tective dressing covering the puncture
site. Using a 2 × 2-inch (6 × 6-cm) gauze
pad at the injection site, the technologist
removes the needle by pulling it straight
from the vein. Direct pressure on the site
is applied with the gauze only after the
needle has been removed (Fig. 18-96).
The technologist then puts the contami-
nated gloves, needles, and gauze in appro-
priate disposal containers (Fig. 18-97).
1
Ehrlich R, Coakes D: Patient care in radiography,
ed 8, St Louis, 2013, Elsevier/Mosby.
Reactions and
Complications
Any medication has the potential to be
harmful if it is not administered properly.1
Technologists must be aware of possible
untoward medication reactions and be able
to recognize and report signs and symp-
toms of side effects as they occur.2 The
technologist who prepares a medication
should also perform the administration.
Reactions can be mild, moderate, or
severe. Mild reactions can include a sen-
sation of warmth, a metallic taste, or
sneezing. Moderate reactions can mani-
fest as nausea, vomiting, or itching.
Finally, a severe, or anaphylactic, reaction
can cause a respiratory or cardiac crisis.
The treatment for each category of reac-
tion should be established in the proce-
dures of each facility or department. The
role of the radiologic technologist in the
case of a reaction should also be defined
in these documents. Competent profes-
sional standards of practice for the tech-
nologist include monitoring the patient’s
vital signs before, during, and after injec-
tion of a contrast medium or certain types
of medications. The specific monitoring
criteria should be established by institu-
tional policy. If an untoward event should
occur, responding personnel would have
access to important information about
the patient’s condition before the event
occurred.
Every health care provider should be
familiar with emergency procedures in the
work environment. Emergency crash carts
contain many medications and pieces of
equipment that require regular review.
Proficiency in operation of equipment and
administration of medications must be
maintained. The technologist must have
the knowledge, proficiency, and confi-
dence to manage crisis situations.
1
Kowalczyk N, Donnett K: Integrated patient care
for the imaging professional, St Louis, 1996, Mosby.
2
Adler AM, Carlton RR: Introduction to radiography
and patient care, ed 3, Philadelphia, 2003,
Saunders.
Infiltration, or extravasation, is another
complication associated with the adminis-
tration of contrast media or medications.
This complication occurs when the medi-
cation or contrast material enters the soft
tissue instead of the vein.1 Signs include
swelling, redness, burning, and pain. The
most common cause of extravasation is
needle displacement. If infiltration occurs,
the procedure should be stopped immedi-
ately, and venous access should be discon-
tinued. The physician must be notified,
and specific treatment instructions must
be requested. Although the ACR reports
no clear consensus on the most effective
treatment for extravasation, common ther-
apies are (1) cold compress to alleviate
pain at the injection site and (2) warm
compress to increase blood flow to the site
for more rapid absorption of the extrava-
sated contrast.1 The incident should be
charted in the manner specified by depart-
ment protocol.
Documentation
In the administration of any medication,
the radiologic technologist should always
observe five “rights of medication
administration”:
• The right patient
• The right medication
• The right route
• The right amount
• The right time
The right patient must receive the med-
ication. The identity of the patient must be
confirmed before the medication is admin-
istered. Methods of patient identification
include checking the patient’s wristband
and asking the patient to restate his or her
name. If the patient is unable to speak,
seek assistance in identifying the patient
from a family member or significant other.
Ensuring that the right medication is
administered requires that the name of the
medication be verified at least three times:
during the selection process, during prep-
aration, and immediately before adminis-
tration. The amount of medication is
determined by the physician or by depart-
mental protocols. The right route, right
amount, and right time are determined by
the physician, the type of medication, and
the procedure.
1
ACR Committee on Drugs and Contrast Media:
ACR manual on contrast media, version 9, 2013,
Reston, VA, 2013, American College of Radiology,
ACR Committee on Drugs and Contrast Media.
Documentation of the five rights of
medication administration should be
included in every patient’s permanent
medical record. In addition to these five
rights, the documentation should include
the size, type, and location of the needle;
the number of venipuncture attempts; and
the identity of the health care personnel
who performed the procedure. Informa-
tion about how the patient responded to
the procedure should also be documented.
The following is an example of correct
documentation technique for a technolo-
gist performing venipuncture and admin-
istering a medication:
Documentation
4-15-99 at 0900 a venous access on Mr.
John Q Public was performed using an
18-gauge angiocatheter. The access was
established in the dorsum of the left hand
after one attempt. Then 100 mL of [the spe-
cific name of the medication] was adminis-
tered by IV push via the access. The patient
tolerated the injection procedure and medi-
cation without complaints of pain or dis-
comfort and with no unexpected side effects.
(Sandy R. Ray, RT)
The objective of medication therapy
and administration is to provide maximal
benefit to the patient with minimal harm.
Medications are intended to help maintain
health, treat or prevent disease, relieve
symptoms, alter body processes, and diag-
nose disease. All medications are not ideal
in their effects on the human body. It is
important that health care providers
understand their role and responsibilities
in the administration of medications.
Because the medications used by the
radiologic technologist are imperfect,
caution for the patient’s well-being and
skill in the administration of medications
are priorities. Patients have the right to
expect that the personnel who administer
medications are informed about dosages,
actions, indications, adverse reactions,
interactions, contraindications, and spe-
cial considerations. Education, training,
licensing, and experience are crucial in
establishing competency in this area of
practice.
235
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 19 
REPRODUCTIVE SYSTEM

OUTLINE
SUMMARY OF PROJECTIONS, 238
ANATOMY, 239
Female Reproductive System, 239
Male Reproductive System, 242
Projections Removed, 243
Summary of Anatomy Terms, 244
Summary of Pathology, 245
Abbreviations, 245
RADIOGRAPHY, 246
Female Radiography, 246
Male Radiography, 253

bl

rec

237
 SUMMARY OF PROJECTIONS

PROJECTIONS, POSITIONS, AND METHODS

Page Essential Anatomy Projection Position Method
246 Hysterosalpingography AP, lateral, axial, oblique
253 Seminal ducts AP or AP oblique

238
 ANATOMY
Female Reproductive
System
The female reproductive system consists
of an internal and an external group of
organs, connected by the vaginal canal.
This chapter does not address the anatomy
of the external genitalia because those
structures do not require radiographic
demonstration. The internal genital organs
consist of the female gonads, or ovaries,
which are two glandular bodies homolo-
gous to the male testes, and a system of
canals composed of the uterine tubes,
uterus, and vagina.
OVARIES
The two ovaries are small, glandular
organs with an internal secretion that con-
trols the menstrual cycle and an external
secretion containing the ova, or female
reproductive cells (Fig. 19-1). Each ovary
is shaped approximately like an almond.
The ovaries lie one on each side, inferior
Primary ovarian follicles
Growing follicles
Fig. 19-1  Section of an ovary.
Cavity of uterus
Isthmus
Round ligament
Fig. 19-2  Section of left uterine tube.
and posterior to the uterine tube and near
the lateral wall of the pelvis. They are
attached to the posterior surface of the
broad ligament of the uterus by the
mesovarium.
The ovary has a core of vascular tissue,
the medulla, and an outer portion of glan-
dular tissue termed the cortex. The cortex
contains ovarian follicles in all stages of
development, and each follicle contains
one ovum. A fully developed ovarian fol-
licle is referred to as a graafian follicle.
As the minute ovum matures, the size of
the follicle and its fluid content increase
so that the wall of the follicle’s sac
approaches the surface of the ovary and
in time ruptures, liberating the ovum and
follicular fluid into the peritoneal cavity.
Extrusion of an ovum by the rupture of a
follicle is called ovulation and usually
occurs one time during the menstrual
cycle. When the ovum is in the pelvic
cavity, it is drawn toward the uterine
tube.
Graafian follicle
Ampulla
Infundibulum
Fimbriae
UTERINE TUBES
The two uterine tubes, or fallopian tubes,
arise from the lateral angle of the uterus,
pass laterally above the ovaries, and open
into the peritoneal cavity. These tubes
collect ova released by the ovaries and
convey the cells to the uterine cavity. Each
tube is 3 to 5 inches (7.6 to 13 cm) long
(Fig. 19-2) and has a small diameter at its
uterine end, which opens into the cavity
of the uterus by a minute orifice. The tube
itself is divided into three parts: the
isthmus, the ampulla, and the infundibu-
lum. The isthmus is a short segment near
the uterus. The ampulla comprises most of
the tube and is wider than the isthmus. The
terminal and lateral portion of the tube is
Female Reproductive System
the infundibulum and is flared in appear-
ance. The infundibulum ends in a series of
irregular prolonged processes called fim­
briae. One of the fimbriae is attached to
or near the ovary.
The mucosal lining of the uterine tube
contains hairlike projections called cilia.
The lining is arranged in folds that in-
crease in number and complexity as they
approach the fimbriated extremity of the
tube. The cilia draw the ovum into the
tube, which then conveys it to the uterine
cavity by peristaltic movements. Passage
of the ovum through the tube requires
several days. Fertilization of the cell
occurs in the outer part of the tube, and
the fertilized ovum migrates to the uterus
for implantation.
239
 UTERUS
The uterus is a pear-shaped, muscular
organ (Figs. 19-3 and 19-4). Its primary
functions are to receive and retain the fer-
tilized ovum until development of the
fetus is complete and, when the fetus is
mature, to expel it during birth.
The uterus consists of four parts: fundus,
body, isthmus, and cervix. The fundus is
the bluntly rounded, superiormost portion
of the uterus. The body narrows from the
fundus to the isthmus and is the point of
attachment for the ligaments that secure
the uterus within the pelvis. The isthmus
(superior part of the cervix), a constricted
area between the body and the cervix, is
approximately 1 2 inch (1.3 cm) long. The
Reproductive System
cervix, the cylindric vaginal end of the
uterus, is approximately 1 inch (2.5 cm)
long. The vagina is attached around the
circumference of the cervix.
Round ligament
Ovarian ligament
Uterine tube
Ovary
Fig. 19-3  Superoposterior view of uterus, ovaries, and uterine tubes.
Ovary
Uterine tube (cut)
Cervix
Uterine ostium
Rectum
Fig. 19-4  Sagittal section showing relation of internal genitalia to surrounding structures.
240
The nulliparous uterus (i.e., the uterus
of a woman who has not given birth) is
approximately 3 inches (7.6 cm) in length,
almost half of which represents the length
of the cervix. The cervix is approximately
3 inch (1.9 cm) in diameter. During
4
pregnancy, the body of the uterus gradu-
ally expands into the abdominal cavity,
reaching the epigastric region in the 8th
month. After parturition, the organ shrinks
to almost its original size but undergoes
characteristic changes in shape.
The uterus is situated in the central part
of the pelvic cavity, where it lies posterior
and superior to the urinary bladder and
anterior to the rectal ampulla. The long
axis, which is slightly concave anteriorly,
is directed inferiorly and posteriorly at a
near right angle to the axis of the vaginal
canal into which the lower end of the
cervix projects.
Fundus
Body
Isthmus
Cervix
Uterine tube
Uterus
Round ligament (cut)
Urinary bladder
Pubic
symphysis
Urethral
orifice
Vaginal
orifice
The cavity of the body of the uterus, or
the uterine cavity proper, is triangular in
shape when viewed in the frontal plane.
The canal of the cervix is dilated in the
center and constricted at each extremity.
The proximal end of the canal is continu-
ous with the canal of the isthmus. The
distal orifice is called the uterine ostium.
The mucosal lining of the uterine cavity
is called the endometrium. This lining
undergoes cyclic changes, called the men­
strual cycle, at about 4-week intervals
from puberty to menopause. During each
premenstrual period, the endometrium is
prepared for implantation and nutrition
of the fertilized ovum. If fertilization has
not occurred, the menstrual flow of blood
and necrosed particles of uterine mucosa
ensues.
VAGINA
The vagina is a muscular structure with
walls and a canal lying posterior to the
urinary bladder and urethra and anterior to
the rectum. Averaging about 3 inches
(7.6 cm) in length, the vagina extends
inferiorly and anteriorly from the uterus to
the exterior. The mucosa of the vagina is
continuous with that of the uterus. The
space between the labia minora, which is
known as the vaginal vestibule, contains
the vaginal orifice and the urethral orifice.
FETAL DEVELOPMENT Placenta
During the implantation process, the fer-
tilized ovum, called a zygote, is passed
from the uterine tube into the uterine
cavity, where it adheres to and becomes
embedded in the uterine lining. About
2 weeks after fertilization of the ovum,
the embryo begins to appear. The embryo
becomes a fetus 9 weeks after fertiliza-
tion and assumes a human appearance
(Fig. 19-5).
During the first 2 weeks of embryonic
development, the growing fertilized ovum Rectum
is primarily concerned with establishment
of its nutritive and protective covering, the Urinary bladder

chorion and the amnion. As the chorion

Pubic symphysis
develops, it forms (1) the outer layer of

Female Reproductive System

the protective membranes enclosing the
embryo and (2) the embryonic portion of Vagina
the placenta, by which the umbilical cord
is attached to the mother’s uterus, and
through which food is supplied to and
waste is removed from the fetus. The Fig. 19-5  Sagittal section showing fetus of about 7 months of age.
amnion, often referred to as the “bag of
water” by the laity, forms the inner layer
of the fetal membranes and contains amni-
otic fluid in which the fetus floats. After
birth, the uterine lining is expelled with
the fetal membranes and the placenta, Lateral Central Posterior
constituting the afterbirth. A new endome-
trium is then regenerated.
The fertilized ovum usually becomes
embedded near the fundus of the uterine
cavity, most frequently on the anterior or
posterior wall. Implantation occasionally
occurs so low, however, that the fully
developed placenta encroaches on or
obstructs the cervical canal. This condition
results in premature separation of the pla-
centa, termed placenta previa (Fig. 19-6).

Fig. 19-6  Schematic drawings of several placental sites in low implantation.

241

Male Reproductive
System
The male genital system consists of a pair
of male gonads, the testes, which produce
spermatozoa; two excretory channels, the
ductus deferens (vas deferens); the pros­
tate; the ejaculatory ducts; the seminal
vesicles; and a pair of bulbourethral
glands, which produce secretions that are
added to the secretions of the testes and
ductal mucosa to constitute the final
product of seminal fluid. The penis, the
scrotum, and the structures enclosed by
the scrotal sac (testes, epididymides, sper-
matic cords, and part of the ductus defer-
ens) are the external genital organs.
Reproductive System
SEMINAL VESICLES
The two seminal vesicles are sacculated
structures about 2 inches (5 cm) long (Fig.
19-9). They are situated obliquely on the
lateroposterior surface of the bladder,
where, from the level of the ureterocystic
junction, each slants inferiorly and medi-
ally to the base of the prostate. Each
ampulla of the ductus deferens lies along
the medial border of the seminal vesicle
to form the ejaculatory duct.
EJACULATORY DUCTS
The ejaculatory ducts are formed by the
union of the ductus deferens and the duct
of the seminal vesicle. The ejaculatory
ducts average about 1 2 inch (1.3 cm) in
length and originate behind the neck of the
bladder. The two ducts enter the base of
the prostate and, passing obliquely inferi-
orly through the substance of the gland,
open into the prostatic urethra at the lateral
margins of the prostatic utricle. These
ducts eject sperm into the urethra before
ejaculation.

TESTES
The testes are ovoid bodies averaging
Testicular artery
1 1 2 inches (3.8 cm) in length and about 1
inch (2.5 cm) in width and depth (Fig. Ductus
19-7). Each testis is divided into 200 to deferens
300 partial compartments that constitute
Head of epididymis
the glandular substance of the testis. Each
compartment houses one or more convo- Epididymis
Testis
luted, germ cell–producing tubules. These
tubules converge and unite to form 15 to
20 ductules that emerge from the testis to
Fig. 19-7  Frontal section of testes and ductus deferens.
enter the head of the epididymis.
The epididymis is an oblong structure
that is attached to the superior and latero-
posterior aspects of the testis. The duct-
ules leading out of the testis enter the head
of the epididymis to become continuous
with the coiled and convoluted ductules Sacrum
that make up this structure. As the duct-
ules pass inferiorly, they progressively
unite to form the main duct, which is con-
tinuous with the ductus deferens.
Bladder
DUCTUS DEFERENS
Pubis
The ductus deferens is 16 to 18 inches (40
Rectum
to 45 cm) long and extends from the tail
of the epididymis to the posteroinferior
surface of the urinary bladder. Only its Prostate
Urethra
first part is convoluted. From its begin-
ning, the ductus deferens ascends along
the medial side of the epididymis on the
posterior surface of the testis to join the
other constituents of the spermatic cord,
with which it emerges from the scrotal sac
and passes into the pelvic cavity through Fig. 19-8  Sagittal section showing male genital system.
the inguinal canal (Fig. 19-8). Near its
termination, the duct expands into an
ampulla for storage of seminal fluid and
then ends by uniting with the duct of the
seminal vesicle.

242
PROSTATE
The prostate, an accessory genital organ,
is a cone-shaped organ that averages
1 1 4 inches (3.2 cm) in length. The pros-
tate encircles the proximal portion of the
male urethra and, extending from the
bladder neck to the pelvic floor, lies in
front of the rectal ampulla approximately
1 inch (2.5 cm) posterior to the lower two
thirds of the pubic symphysis (see Fig.
19-9). The prostate comprises muscular
and glandular tissue. The ducts of the
prostate open into the prostatic portion of
the urethra.
Because of advances in diagnostic
ultrasound imaging, radiographic exami- PROCEDURES REMOVED
nations of the male reproductive system The following procedures have been
are performed less often than in the past. removed from this edition of the atlas.
The prostate can be ultrasonically imaged See previous editions of the atlas for
through the urine-filled bladder or by a description of these procedures.
using a special rectal transducer. The • Pelvimetry
seminal ducts can be imaged when the
rectum is filled with an ultrasound gel and
a special rectal transducer is used. Testicu-
lar ultrasonic scans are performed to eval-
uate a palpable mass or an enlarged testis
and to check for metastasis. Most testicu-
lar scans are performed because of a pal-
pable mass or an enlarged testis.

Male Reproductive System

Urinary bladder
Ductus
deferens

Ureter Ductus
deferens
Left ureter

Ampulla of ductus
deferens
Seminal
vesicle Seminal vesicle

Ampulla Seminal vesicle duct

Prostate gland
Prostate Ejaculatory duct

Penis

Epididymis

Testis
A B
Fig. 19-9  A, Sagittal section through male pelvis. B, Posterior view of male reproductive
organs.

243
 SUMMARY OF ANATOMY TERMS
Female reproductive Uterus Ductus deferens
system Fundus (vas deferens)
Ovaries Body Prostate
Uterine tubes Isthmus Ejaculatory ducts
Uterus Cervix Seminal vesicles
Vagina Uterine ostium Bulbourethral glands
Endometrium Penis
Ovaries Scrotum
Ova Vagina
Mesovarium Mucosa Testes
Medulla Vaginal vestibule Epididymis
Cortex Vaginal orifice
Ovarian follicles Urethral orifice Ductus deferens
Graafian follicle Ampulla
Ovulation Fetal development
Zygote
Reproductive System

Uterine tubes (fallopian Embryo

tubes) Fetus
Isthmus Placenta
Ampulla
Infundibulum Male reproductive
Fimbriae system
Cilia Testes

244
 SUMMARY OF PATHOLOGY
Condition Definition

Adhesion Union of two surfaces that are normally separate

Cryptorchidism Condition of undescended testis

Endometrial polyp Growth or mass protruding from endometrium

Epididymitis Inflammation of the epididymis

Uterine tube obstruction Condition preventing normal flow through uterine tube

Fistula Abnormal connection between two internal organs or between an organ and the body surface

Testicular torsion Twisting of the testis at its base, causing acute ischemia

Male Reproductive System

Tumor New tissue growth where cell proliferation is uncontrolled

Dermoid cyst Tumor of the ovary filled with sebaceous material and hair

Prostate cancer Second most common malignancy in men

Seminoma Most common type of testicular tumor

Uterine fibroid Smooth muscle tumor of the uterus

ABBREVIATIONS USED IN
CHAPTER 19

HSG Hysterosalpingography
IUD Intrauterine device

See Addendum B for a summary of all

abbreviations used in Volume 2.

245
 RADIOGRAPHY
Female Radiography
NONPREGNANT PATIENT
Radiologic investigations of the nonpreg-
nant uterus, accessory organs, and vagina
are denoted by the terms hysterosal­
pingography (HSG), pelvic pneumog­
raphy, and vaginography. Each procedure
requires the use of contrast medium and
should be performed under aseptic condi-
tions. HSG involves the introduction of a
radiopaque contrast medium through a
uterine cannula. The procedure is per-
formed to determine the size, shape, and
position of the uterus and uterine tubes; to
delineate lesions such as polyps, submu-
cous tumor masses, or fistulous tracts; and
Reproductive System
to investigate the patency of the uterine
tubes in patients who have been unable to
conceive (Fig. 19-10).
Pelvic pneumography, which requires
the introduction of a gaseous contrast
medium directly into the peritoneal cavity,
is now rarely performed because of the
development of ultrasound techniques
for evaluating the pelvic cavity. Vaginog­
raphy is performed to investigate congeni-
tal abnormalities, vaginal fistulae, and
other pathologic conditions involving the
vagina.
Contrast media
Various opaque media are used in exami-
nations of the female genital passages. The
water-soluble contrast media employed
for intravenous urography are widely used
for HSG and vaginography.
Preparation of intestinal tract
Preparation of the intestinal tract for any
of these examinations usually consists of
the following:
1. A non–gas-forming laxative is admin-
istered on the preceding evening if the
patient is constipated.
2. Before reporting for the examination,
the patient receives cleansing enemas
until the return flow is clear.
3. The meal preceding the examination is
withheld.
246
Appointment date and care
of patient
Gynecologic examinations should be
scheduled approximately 10 days after the
onset of menstruation. This is the interval
during which the endometrium is least
congested. More important, because this
time interval is a few days before ovula-
tion normally occurs, there is little danger
of irradiating a recently fertilized ovum.
The relatively minor instrumentation
required for the introduction of contrast
medium in these examinations normally
necessitates neither hospitalization nor
premedication. Some patients experience
unpleasant but transitory aftereffects.
The radiology department should have
facilities in which an outpatient can rest in
the recumbent position before returning
home.
The patient is requested to empty her
bladder completely immediately before
the examination; this prevents pressure
displacement and superimposition of the
bladder on the pelvic genitalia. In addi-
tion, the patient’s vagina is irrigated just
before the examination. At this time, the
patient should be given the necessary sup-
plies and instructed to cleanse the perineal
region.
Fig. 19-10  HSG reveals bilateral hydrosalpinx of uterine tubes (arrows). Contrast medium–
filled uterine cavity is normal (arrowheads).
Radiation protection
To deliver the least possible amount of
radiation to the gonads, the radiologist
restricts fluoroscopy and imaging to the
minimum required for a satisfactory
examination.
Hysterosalpingography
HSG is performed by a physician, with
spot images made while the patient is in
the supine position on a fluoroscopic
table. The examination may also be per-
formed by the physician with conven-
tional radiographic images obtained using
an overhead tube. When fluoroscopy is
used, spot images may be the only images
obtained. Preparation of the patient for the
examination includes the following steps:
• After irrigation of the vaginal canal,
complete emptying of the bladder, and
perineal cleansing, place the patient on
the examining table.
• Adjust the patient in the lithotomy posi-
tion, with the knees flexed over leg
rests.
• When a combination table is used,
adjust the patient’s position to permit
the IRs to be centered to a point 2
inches (5 cm) proximal to the pubic
symphysis; lengthwise 10 × 12-inch
(24 × 30-cm) IRs or collimated field
sizes are used for all studies.
 After inspection of the preliminary
image and with a vaginal speculum in
position, the physician inserts a uterine
cannula through the cervical canal; fits the
Uterine tube
attached rubber plug, or acorn, firmly
against the external cervical os; applies
counterpressure with a tenaculum to
Normal contrast “spill”
prevent reflux of the contrast medium; and into peritoneal cavity
withdraws the speculum unless it is radio-
lucent. An opaque or a gaseous contrast
medium may be injected via the cannula
into the uterine cavity. The contrast mate-
Body of uterus
rial flows through patent uterine tubes and
“spills” into the peritoneal cavity (Figs.
19-11 to 19-13). Patency of the uterine
tubes can be determined by transuterine Speculum

gas insufflation (Rubin test), but the

Fig. 19-11  Hysterosalpingogram, AP projection, showing normal uterus and uterine tubes.

Female Radiography
length, position, and course of the ducts
can be shown only by opacifying the
lumina.
Free-flowing, iodinated organic con-
trast agents are usually injected at room
temperature. These agents pass through
patent uterine tubes quickly, and the resul-
tant peritoneal spill is absorbed and elimi-
nated via the urinary system, usually
within 2 hours.
The contrast medium may be injected
with a pressometer or a syringe. Intrauter-
ine pressure is maintained for radiographic
studies by closing the cannular valve. In
the absence of fluoroscopy, the contrast
medium is introduced in two to four frac-
tional doses so that excessive peritoneal
spillage does not occur. Each fractional
dose is followed by a radiographic study
to determine whether the filling is ade-
quate as shown by the peritoneal spill. Fig. 19-12  Hysterosalpingogram, AP projection, showing submucous fibroid occupying
entire uterine cavity (arrowheads).
The images may consist of no more
than a single AP projection taken at the
end of each fractional injection. Other
projections (oblique, axial, and lateral) are
taken as indicated.

EVALUATION CRITERIA
The following should be clearly shown:
■ The pelvic region 2 inches (5 cm)
above the pubic symphysis centered on
the image
■ All contrast media visible, including
any “spill” areas
■ Brightness and contrast sufficient to
show soft tissues and contrast media

Fig. 19-13  Hysterosalpingogram, AP projection, revealing uterine cavity as bicornuate in

outline.

247
 Imaging of female contraceptive
devices
HSG is performed about three months
after insertion of the permanent type of
intrauterine device (IUD) (Fig. 19-14).
Additionally, HSG and other imaging
modalities, such as ultrasound, may also
be used to check for proper placement of
temporary IUDs and in cases of suspected
displacement. For these reasons, radio­
graphers should be acquainted with the
appearance of IUDs in images. IUDs have
Reproductive System
been used for contraception for many
decades. Currently, there are only two
forms of temporary IUDs and one for per-
manent contraception (Figs. 19-15 and
19-16). IUD insertion is usually performed
in an out-patient procedure in a physi-
cian’s office; however, conscious sedation
is required to insert the permanent IUD.1
1
Wittmer M et al: Hysterosalpingography for assess-
ing efficacy of Essure microinsert permanent birth
control device, AJR Am J Roentgenol 187:955, 2006.
While an HSG is required to insure that
the permanent IUD is properly function-
ing, insertion of this device is much less
invasive than the other permanent sterility
option, tubal ligation.
AP and lateral projections of the
abdomen are suggested for IUD localiza-
tion. Occasionally, oblique projections are
indicated. Most IUDs are radiopaque
because of their metallic composition.
Radiography alone is not a reliable method
of extrauterine localization of an IUD.

R R

Essure device
in right
uterine tube

Contrast-filled
uterus

A B
Fig. 19-14  Hysterosalpingogram three-months post Essure® insertion. (Essure confirmation
test). A, HSG spot image confirms occlusion of uterine tubes. B, HSG spot demonstrates
failure of left uterine tube occlusion (arrow points to contrast spill into peritoneum).

(Images courtesy of NEA Baptist Memorial Hospital, Jonesboro, AR.)

248
A B

Female Radiography
Fig. 19-15  Temporary intrauterine contraceptive device (IUD). A, ParaGard (intrauterine
copper contraceptive) manufactured by Teva Women’s Health, Inc. Actual size is 32 ×
36 mm. B, Mirena (levonorgestrel-releasing intrauterine system) manufactured by Bayer
Healthcare Pharmaceuticals.

Fig. 19-16  Permanent contraceptive IUD, Essure by Bayer Healthcare Pharmaceuticals.

249
 Pelvic pneumography
Pelvic pneumography, gynecography, and
pangynecography are the terms used to
Ovary denote radiologic examinations of the
female pelvic organs via intraperitoneal
gas insufflation (Fig. 19-17). These proce-
Uterine tube dures have essentially been replaced by
ultrasonography and other diagnostic
techniques. (Pelvic pneumography is
described in Volume 3 of the fourth edition
Round ligament
of this atlas.)

Vaginography
Vaginography is used in the investigation
of congenital malformations and patho-
Gaseous contrast medium
logic conditions such as vesicovaginal and
enterovaginal fistulae. The examination
Reproductive System

is performed by introducing a contrast

medium into the vaginal canal. Lambie
Urinary bladder et al.1 recommended using a thin barium
sulfate mixture to investigate fistulous
communications with the intestine. At the
Fig. 19-17  Normal pelvic pneumogram. (See Fig. 19-3 for correlation with image.) end of the examination, the patient is
instructed to expel as much of the barium
mixture as possible, and the canal is
cleansed by vaginal irrigation. For inves-
tigation of other conditions, Coe2 advo-
cated the use of an iodinated organic
compound.
A rectal retention tube is employed to
introduce the contrast medium so that the
moderately inflated balloon can be used to
prevent reflux. In one technique, the phy-
sician inserts only the tip of the tube into
the vaginal orifice. The patient is requested
to extend the thighs and to hold them in
close approximation to keep the inflated
balloon pressed firmly against the vaginal
ILEUM entrance. In another technique, the tube is
inserted far enough to place the deflated
balloon within the distal end of the vagina,
and the balloon is inflated under fluoro-
ILEUM scopic observation. The barium mixture is
introduced with the usual enema equip-
ment. The water-soluble medium is
injected with a syringe.
Vaginography is performed on a com-
FISTULAS
bination fluoroscopic-radiographic table.
Contrast medium is injected under fluoro-
scopic control, and spot images are
SIGMOID
VAGINA exposed as indicated during the filling
(Fig. 19-18).

1
Lambie RW et al: Demonstration of fistulae by
vaginography, AJR Am J Roentgenol 90:717, 1963.
Fig. 19-18  Vaginogram, spot image, PA oblique projection, LAO position. Sigmoid fistula 2
Coe FO: Vaginography, AJR Am J Roentgenol
and two ileum fistulae are shown. 90:721, 1963.

250
 The images in Figs. 19-19 to 19-21
were taken with the central ray directed
perpendicular to the midpoint of the IR.
For localized studies, the central ray is
centered at the level of the superior border
of the pubic symphysis.
In each examination, the radiographic
projections required are determined by the
radiologist according to fluoroscopic find-
ings. Low rectovaginal fistulae are best
shown in the lateral projection, and fistu-
lous communications with the sigmoid or
ileum or both are best shown in oblique
projections.

EVALUATION CRITERIA

Female Radiography
The following should be clearly shown:
■ Superior border of the pubic symphysis
centered on the image
■ Any fistulae in their entirety
■ Pelvis on oblique projections not super-
imposed by the proximal thigh
■ Superimposed hips and femora in the
Fig. 19-19  Vaginogram, AP projection, showing small fistulous tract (arrow) projecting
lateral image
laterally from apex of vagina and ending in abscess.
■ Exposure sufficient to demonstrate the
vagina and any fistula

FISTULAS
CECUM SIGMOID

ILEUM
VAGINA
RECTUM

VAGINA

Fig. 19-20  Vaginogram, AP oblique projection, RPO position. Fig. 19-21  Vaginogram, lateral projection, showing low
Fistulae to ileum and sigmoid are shown. rectovaginal fistula.

251
 PREGNANT PATIENT
Ultrasonography provides visualization of
the fetus and placenta with no apparent
risk to the patient or fetus. Diagnostic
sonography is the preferred diagnostic
tool for examination of a pregnant woman.
For informational purposes, the following
radiographic procedures are defined:
• Fetography—radiographic examina-
tion of the fetus in utero.
• This examination should be per-
formed after the 18th week of gesta-
tion because of the danger of
radiation-induced fetal malforma-
tions.
• Fetography is employed to detect
suspected abnormalities of develop-
Reproductive System
ment, to confirm suspected fetal
death, to determine the presentation
and position of the fetus, and to
Fig. 19-22  Fetography, PA projection. Twin pregnancy showing two fetal heads (arrows
and arrowheads).
252
determine whether the pregnancy is
single or multiple (Fig. 19-22).
• Pelvimetry—radiographic examination
to demonstrate the architecture of the
maternal pelvis to compare with the
size of the fetal head
• This examination was performed to
determine the necessity of a cesarean
section
• Placentography—radiographic exami-
nation to demonstrate the walls of the
uterus for localization of the placenta in
cases of suspected placenta previa.
For more detailed information on the
above procedures, refer to the 12th and
earlier editions of this atlas.
Radiation protection
Radiologic examinations of pregnant
patients are performed only when required
information can be obtained in no other
way. In addition to the danger of genetic
changes that may result from reproductive
cell irradiation is the danger of radiation-
induced malformations of the developing
fetus. When possible, radiation for any
purpose is avoided during pregnancy,
especially during the first trimester of ges-
tation. If examination of the abdominopel-
vic region is necessary, it is restricted to the
absolute minimum number of images. The
radiographer’s responsibility is to perform
the work carefully and thoughtfully so that
repeat exposures are unnecessary.
Male Radiography
SEMINAL DUCTS
Radiologic examinations of the seminal
ducts1-3 are performed to investigate
certain genitourinary abnormalities, such
as cysts, abscesses, tumors, inflammation,
and sterility. The regional terms applied to
these examinations are vesiculography,
1
Boreau J et al: Epididymography, Med Radiogr
Photogr 29:63, 1953.
2
Boreau J: L’étude radiologique des voies séminales
normales et pathologiques, Paris, 1953, Masson &
Cie.
3
Vasselle B: Etude radiologique des voies séminales
de l’homme, Thesis, Paris, 1953.
epididymography, and, when combined,
epididymovesiculography.
The water-soluble, iodinated com-
pounds used for intravenous urography
are also employed as contrast media for
these procedures. A gaseous contrast
medium can be injected into each scrotal
sac to improve contrast in the examination
of extrapelvic structures.
The seminal vesicles are sometimes
opacified directly by urethroscopic cath-
eterization of the ejaculatory ducts. More
frequently, the entire duct system is
inspected by introducing contrast solution
into the canals via the ductus deferens.
Small bilateral incisions in the upper part
of the scrotum are required for exposure
and identification of these ducts. The
needle that is used to inject the contrast
medium is inserted into the duct in the
direction of the portion of the tract under
investigation—distally for study of the
extrapelvic ducts, then proximally for
study of the intrapelvic ducts.
A nongrid exposure technique is used
to delineate extrapelvic structures (Figs.
19-23 to 19-25). The examining urologist
places the IR and adjusts the position of
the testes for desired projections of the
ducts. A grid technique is used to show the
intrapelvic ducts (Figs. 19-24 to 19-28).
AP and oblique projections are made
using 8 × 10-inch (18 × 24-cm) or 10 ×
12-inch (24 × 30-cm) lengthwise IRs or

Male Radiography
collimated field sizes and centered at the
level of the superior border of the pubic
symphysis.

EVALUATION CRITERIA
The following should be clearly shown:
Ductus deferens
■ Evidence of proper collimation

AP Projection
■ IR centered at the level of the superior
border of the pubic symphysis
■ No rotation of the patient
■ Exposure sufficient to demonstrate all
structures of interest
Proximal convoluted
ductus deferens
Oblique Projection
■ Region of interest in the center of the
collimated field
Epididymis
■ No superimposition of the seminal
ducts by the ilia
Needle ■ No overlap of the region of the
Fig. 19-23  Epididymogram showing normal epididymis and origin of ductus deferens. The prostate or urethra by the uppermost
needle is at the epididymovasal kink, which can be palpated. thigh

Fig. 19-24  Epididymogram showing tuberculosis (cold abscess) of Fig. 19-25  Epididymogram showing epididymal abscess (arrow)
epididymis (arrow). observed during acute orchitis (third relapse). Epididymovasal
kink is atrophic.

253
 PROSTATE
Prostatography is a term applied to inves-
tigation of the prostate by radiographic,
cystographic, or vesiculographic proce-
dures. It is seldom performed today
because of advances in diagnostic ultraso-
nography. Radiographic examination of Distal ductus deferens
the prostate gland was described in the 8th
and earlier editions of this atlas.
Seminal vesicle

Proximal ductus deferens

Reproductive System

Fig. 19-26  Normal vesiculogram.

Fig. 19-27  Vesiculogram of tuberculous seminal vesicle Fig. 19-28  Vesiculogram showing beginning (budding) metastasis of
associated with deferentitis, showing small abscesses, crista urethralis (arrow) discovered 2 years after prostatectomy for
ampullitis, and considerable vesiculitis on left (arrow). cancer of the prostate.

254
 20 
SKULL, FACIAL BONES, AND
PARANASAL SINUSES

OUTLINE
SUMMARY OF PROJECTIONS, 256
ANATOMY, 257
Skull, 257
Cranial Bones, 261
Ear, 271
Facial Bones, 272
Articulations of the Skull, 275
Sinuses, 276
Summary of Anatomy, 280
Summary of Pathology, 282
Sample Exposure Technique Chart
Essential Projections, 283
Abbreviations, 284
SKULL RADIOGRAPHY, 285
Skull Topography, 285
Skull Morphology, 286
Technical Considerations, 288
Radiation Protection, 288
Cranium, 291
Cranial Base, 310
Orbit, 312
Eye, 314
FACIAL BONES, 320
Nasal Bones, 331
Zygomatic Arches, 333
Mandibular Rami, 339
Mandibular Body, 341
Mandible, 343
Temporomandibular joints
(TMJs), 347
Temporomandibular
Articulations, 347
Panoramic Tomography of
the Mandible, 353
SINUS RADIOGRAPHY, 355
Technical Considerations, 355
R L
Paranasal Sinuses, 358
Frontal and Anterior Ethmoidal
Sinuses, 360
Maxillary Sinuses, 362
Maxillary and Sphenoidal
Sinuses, 364
Ethmoidal and Sphenoidal
Sinuses, 366
 SUMMARY OF PROJECTIONS

PROJECTIONS, POSITIONS, AND METHODS

Page Essential Anatomy Projection Position Method
291 Cranium Lateral R or L
294 Cranium Lateral R or L dorsal decubitus
294 Cranium Lateral R or L supine lateral
296 Cranium PA
296 Cranium PA axial CALDWELL
300 Cranium AP
300 Cranium AP axial
302 Cranium AP axial TOWNE
308 Cranium PA axial HAAS
310 Cranial base Submentovertical (SMV) SCHÜLLER
317 Eye Lateral R or L
318 Eye PA axial
319 Eye Parietoacanthial MODIFIED WATERS
320 Facial bones Lateral R or L
323 Facial bones Parietoacanthial WATERS
325 Facial bones Modified MODIFIED WATERS
parietoacanthial
327 Facial bones Acanthioparietal REVERSE WATERS
329 Facial bones PA axial CALDWELL
331 Nasal bones Lateral R and L
333 Zygomatic arches Submentovertical
335 Zygomatic arch Tangential
337 Zygomatic arches AP axial MODIFIED TOWNE
339 Mandibular rami PA
340 Mandibular rami PA axial
341 Mandibular body PA
342 Mandibular body PA axial
343 Mandible Axiolateral, axiolateral
oblique
346 Mandible Submentovertical
347 TMJs AP axial
349 TMJs Axiolateral R and L
351 TMJs Axiolateral oblique R and L
353 Mandible Panoramic TOMOGRAPHY
358 Paranasal sinuses Lateral R or L upright
360 Frontal and anterior PA axial Upright CALDWELL
ethmoidal sinuses
362 Maxillary sinuses Parietoacanthial Upright WATERS
364 Maxillary and Parietoacanthial Upright with open mouth WATERS
sphenoidal
sinuses
366 Ethmoidal and Submentovertical Upright
sphenoidal
sinuses

Icons in the Essential column indicate projections frequently performed in the United States and Canada. Students should be competent
in these projections.

256
 ANATOMY

Skull
The skull rests on the superior aspect of BOX 20-1 
the vertebral column. It is composed of 22 Skull bones
separate bones divided into two distinct
groups: 8 cranial bones and 14 facial Cranial bones (8) Facial bones (14)
bones. The cranial bones are divided Calvaria Nasal (right and left) 2
Frontal 1 Lacrimal (right and left) 2
further into the calvaria and the floor (Box
Occipital 1 Maxillary (right and left) 2
20-1). The cranial bones form a protective Right parietal 1 Zygomatic (right and left) 2
housing for the brain. The facial bones Left parietal 1 Palatine (right and left) 2
provide structure, shape, and support for Inferior nasal conchae (right and left) 2
the face. They also form a protective Floor Vomer 1
housing for the upper ends of the respira- Ethmoid 1 Mandible 1
tory and digestive tracts and, with several Sphenoid 1
of the cranial bones, form the orbital Right temporal 1
sockets for protection of the organs of Left temporal 1
sight. The hyoid bone is commonly dis-
cussed with this group of bones.
The bones of the skull are identified in
Figs. 20-1 to 20-3. The 22 primary bones

Skull
of the skull should be located and recog-
nized in the different views before they
are studied in greater detail.

Frontal bone

Parietal bone Supraorbital foramen

Glabella

Sphenoid bone Optic

foramen

Superior Sphenoid bone

orbital fissure

Temporal bone

Fig. 20-1  Anterior aspect of cranium.

257
 Bregma Coronal suture

Pterion

Frontal bone
Parietal bone

Glabella
Sq
ua
e m
n os
bo al
id su
e no tu
Sph Temporal bone re
Lambda

id Lambdoidal
to s
as es suture
M roc
Skull, Facial Bones, and Paranasal Sinuses

p
Occipital bone

External occipital
Asterion protuberance
(inion)

External acoustic meatus

A Styloid process

Crista galli

Cribriform plate

Orbital plate Cranial

fossae

Optic canal and foramen

Anterior

Tuberculum sellae
Lesser wing
Anterior clinoid process
Greater wing
Sella turcica
Optic groove

Foramen ovale Posterior clinoid

process
Middle
Foramen Foramen lacerum
spinosum
Temporal bone
Dorsum sellae
Diploe
Jugular foramen

Petrous portion
Posterior

Clivus
Hypoglossal canal
(dashed line)
B Occipital bone Foramen magnum

Fig. 20-2  A, Lateral aspect of cranium. B, Superior aspect of cranial base.

258
 The bones of the cranial vault are com-
posed of two plates of compact tissue
separated by an inner layer of spongy
tissue called diploë. The outer plate,
or table, is thicker than the inner table
over most of the vault, and the thick-
ness of the layer of spongy tissue varies
considerably.
Except for the mandible, the bones of
the cranium and face are joined by fibrous
joints called sutures. The sutures are
named coronal, sagittal, squamosal, and
Frontal bone
Frontal sinus
Crista galli
Nasal bone
Ethmoid bone
Vomer
Maxilla
Pterygoid hamulus
Palatine bone
A temporal bone
Bregma
lambdoidal (see Figs. 20-1 and 20-2). The
coronal suture is found between the
frontal and parietal bones. The sagittal
suture is located on the top of the head
between the two parietal bones and just
behind the coronal suture line (not visible
in Figs. 20-1 and 20-2). The junction of
the coronal and sagittal sutures is the
bregma. Between the temporal bones and
the parietal bones are the squamosal
sutures. Between the occipital bone and
the parietal bones is the lambdoidal suture.
Diploe
Clivus
Petrous portion of
Cerebrum
Bone (cross
section)
Pons
Cerebellum
Spinal cord
The lambda is the junction of the lamb-
doidal and sagittal sutures. On the lateral
aspect of the skull, the junction of the
parietal bone, squamosal suture, and
greater wing of the sphenoid is the pterion,
which overlies the middle meningeal
artery. At the junction of the occipital
bone, parietal bone, and mastoid portion
of the temporal bone is the asterion.
In a newborn infant, the bones of the
cranium are thin and not fully developed.
They contain a small amount of calcium,
Parietal bone
Skull
Sphenoidal sinus
Squamous portion of
temporal bone
Internal acoustic
meatus
Occipital bone
Fig. 20-3  A, Lateral aspect of interior of cranium.
B, Sagittal MRI of cranium showing contents and
position of brain. Note bony protective housing.
259
 are indistinctly marked, and present six
areas of incomplete ossification called
fontanels, often spelled fontenelles (Fig.
20-4). Two of the fontanels are situated in
the midsagittal plane at the superior and
posterior angles of the parietal bones. The
anterior fontanel is located at the junction
of the two parietal bones and the one
frontal bone at the bregma. Posteriorly
and in the midsagittal plane is the poste-
rior fontanel, located at the point labeled
lambda in Fig. 20-2. Two fontanels are
also on each side at the inferior angles of
the parietal bones. Each sphenoidal fonta-
nel is found at the site of the pterion; the
mastoid fontanels are found at the asteria.
The posterior and sphenoidal fontanels
normally close in the 1st and 3rd months
after birth, and the anterior and mastoid
Skull, Facial Bones, and Paranasal Sinuses
fontanels close during the 2nd year of life.
The cranium develops rapidly in size
and density during the first 5 or 6 years,
after which a gradual increase occurs until
adult size and density are achieved,
usually by the age of 12 years. The thick-
ness and degree of mineralization in
normal adult crania show comparatively
little difference in radiopacity from person
to person, and the atrophy of old age is
Anterior fontanel
Superior aspect
260
less marked than in other regions of the
body.
Internally, the cranial floor is divided
into three regions: anterior, middle, and
posterior cranial fossae (see Fig. 20-2, B).
The anterior cranial fossa extends from
the anterior frontal bone to the lesser
wings of the sphenoid. It is associated
mainly with the frontal lobes of the cere-
brum. The middle cranial fossa accom-
modates the temporal lobes and associated
neurovascular structures and extends from
the lesser wings of the sphenoid bone to
the apices of petrous portions of the tem-
poral bones. The deep depression poste-
rior to the petrous ridges is the posterior
cranial fossa, which protects the cerebel-
lum, pons, and medulla oblongata (see
Fig. 20-3, B).
The average or so-called normal
cranium is more or less oval in shape,
wider in back than in front. The average
cranium measures approximately 6 inches
(15 cm) at its widest point from side to
side, 7 inches (17.8 cm) at its longest
point from front to back, and 9 inches
(22 cm) at its deepest point from the
vertex to the submental region. Crania
vary in size and shape, with resultant vari-
Anterior fontanel
Posterior
fontanel
lambda
Mastoid
fontanel
Lateral aspect
Fig. 20-4  Fontanels of a newborn.
ation in the position and relationship of
internal parts.
Internal deviations from the norm are
usually indicated by external deviations
and can be estimated with a reasonable
degree of accuracy. The length and width
of the normally shaped head vary by
1 inch (2.5 cm). Any deviation from
this relationship indicates a comparable
change in the position and relationship of
the internal structures. If the deviation
involves more than a 5-degree change, it
must be compensated for by a change in
part rotation or central ray angulation.
This “rule” applies to all images except
direct lateral projections. A 1 2 -inch
(1.3 cm) change in the 1-inch (2.5-cm)
width-to-length measurement indicates an
approximately 5-degree change in the
direction of the internal parts with refer-
ence to the midsagittal plane.
It is important for the radiographer to
understand cranial anatomy from the
standpoint of the size, shape, position, and
relationship of component parts of the
cranium, so that estimations and compen-
sations can be made for deviations from
the norm.
Sphenoidal
fontanel
 Cranial Bones
FRONTAL BONE
The frontal bone has a vertical portion and
horizontal portions. The vertical portion,
called the frontal squama, forms the fore-
head and the anterior part of the vault. The
horizontal portions form the orbital plates
(roofs of the orbits), part of the roof of the
nasal cavity, and the greater part of the
anterior cranial fossa (Figs. 20-5 to 20-7).
The orbital plates of the horizontal
portion of the frontal bone are separated
by a notch called the ethmoidal notch.
This notch receives the cribriform plate of
the ethmoid bone. At the anterior edge of
the ethmoidal notch is a small inferior pro-
jection of bone, the nasal spine, which is
the superiormost component of the bony
nasal septum. The posterior margins of the
orbital plates articulate with the lesser
wings of the sphenoid bone.
Frontal eminence

On each side of the midsagittal plane of

the superior portion of the squama is a Frontal squama
rounded elevation called the frontal emi-
nence. Below the frontal eminences, just
above the supraorbital margins, are two
arched ridges that correspond in position
to the eyebrows. These ridges are called
Supraorbital foramen Superciliary arch
the superciliary arches. In the center of
the supraorbital margin is an opening for

Cranial Bones
nerves and blood vessels called the supra- Supraorbital margin Glabella Nasal spine
orbital foramen. The smooth elevation
Fig. 20-5  Anterior aspect of frontal bone.
between the superciliary arches is termed
the glabella.
Frontal
The frontal sinuses (Fig. 20-8) are situ- eminence
ated between the two tables of the squama Superciliary arch
on each side of the midsagittal plane.
Glabella Frontal squama
These irregularly shaped sinuses are sepa-
rated by a bony wall, which may be
incomplete and usually deviates from the
midline.
The squama articulates with the parietal
bones at the coronal suture, the greater
wing of the sphenoid bone at the fronto-
sphenoidal suture, and the nasal bones at Nasion
the frontonasal suture. The midpoint of
Supraorbital foramen
the frontonasal suture is termed the nasion.
The frontal bone articulates with the Fig. 20-6  Lateral aspect of frontal bone.
right and left parietals, the sphenoid, and
the ethmoid bones of the cranium.

FS
Glabella

Nasal spine

Supraorbital margin
Superciliary arch R L

Orbital plate

Ethmoidal air cells Ethmoidal notch

Fig. 20-7  Inferior aspect of frontal bone. Fig. 20-8  Coronal CT image of frontal sinuses (FS ).

(From Kelley LL, Petersen CM: Sectional anatomy for imaging

professionals, ed 2, St Louis, 2007, Mosby.)

261
 ETHMOID BONE
The ethmoid bone is a small, cube-shaped
bone that consists of a horizontal plate; a
vertical plate; and two light, spongy lateral
masses called labyrinths (Figs. 20-9 to
20-12). Situated between the orbits, the
ethmoid bone forms part of the anterior
cranial fossa, the nasal cavity and orbital
walls, and the bony nasal septum.
The horizontal portion of the ethmoid
bone, called the cribriform plate, is
received into the ethmoidal notch of the
frontal bone. The cribriform plate is per-
forated by many foramina for the trans-
mission of olfactory nerves. The plate also
has a thick, conical process, the crista
galli, which projects superiorly from its
anterior midline and serves as the anterior
attachment for the falx cerebri.
The vertical portion of the ethmoid
bone is called the perpendicular plate.
This plate is a thin, flat bone that projects
inferiorly from the inferior surface of the
cribriform plate and, with the nasal spine,
forms the superior portion of the bony
septum of the nose.
The labyrinths contain the ethmoidal
sinuses, or air cells. The cells of each side
are arbitrarily divided into three groups:
the anterior, middle, and posterior eth-
moidal air cells (see Fig. 20-12, A and B).
The walls of the labyrinths form part
of the medial walls of the orbits and part
of the lateral walls of the nasal cavity.
Projecting inferiorly from each medial
wall of the labyrinths are two thin, scroll-
shaped processes called the superior and
middle nasal conchae.
The ethmoid bone articulates with the
frontal and sphenoid bones of the cranium.

Crista galli

Superior nasal Ethmoidal sinus

Skull, Facial Bones, and Paranasal Sinuses

concha
Medial orbital wall

Middle nasal concha

Air cells in labyrinth
Perpendicular plate
Fig. 20-9  Anterior aspect of ethmoid bone.
Ets

Cribriform Crista galli

plate
R L

with
frontal
with sphenoid Articulates
with
nasal MS
A
Perpendicular plate

Articulates
Perpendicular plate
with vomer Articulates with cartilage
of nasal septum
Fig. 20-10  Lateral aspect of ethmoid bone with labyrinth
removed.

Ethmoid air cells

Perpendicular plate

Crista galli
Anterior air cells

Middle air cells

Cribriform plate
Posterior air cells
B
Fig. 20-12  A, Coronal CT image of ethmoidal sinuses (Ets).
B, Axial CT scan of ethmoidal sinus and perpendicular plate.
(A, From Kelley LL, Petersen CM: Sectional anatomy for imaging professionals,
Fig. 20-11  Superior aspect of ethmoid bone. ed 2, St Louis, 2007, Mosby.)

262
PARIETAL BONES
The two parietal bones are square and
have a convex external surface and a
concave internal surface (Figs. 20-13 and
20-14). The parietal bones form a large
portion of the sides of the cranium. They
also form the posterior portion of the
cranial roof by their articulation with each
other at the sagittal suture in the midsagit-
tal plane.
Each parietal bone presents a prominent
bulge, called the parietal eminence, near
the central portion of its external surface.
In radiography, the width of the head
should be measured at this point because
it is the widest point of the head.
Each parietal bone articulates with the
frontal, temporal, occipital, sphenoid, and
opposite parietal bones of the cranium.

Articulates
with opposite parietal bone

Parietal eminence

Cranial Bones
Articulates with
frontal bone
Articulates with
occipital bone

Articulates with temporal bone

Fig. 20-13  External surface of parietal bone.

Occipital angle Frontal

angle

Grooves for
middle
meningeal
vessels

Mastoid angle
Sphenoid
angle
Fig. 20-14  Internal surface of parietal bone.

263
 SPHENOID BONE
The sphenoid bone is an irregularly
wedge-shaped bone that resembles a bat
with its wings extended. It is situated in
the base of the cranium anterior to the
temporal bones and basilar part of the
occipital bone (Figs. 20-15 to 20-17). The
sphenoid bone consists of a body; two
lesser wings and two greater wings, which
project laterally from the sides of the
body; and two pterygoid processes, which
project inferiorly from each side of the
inferior surface of the body.
Skull, Facial Bones, and Paranasal Sinuses
The body of the sphenoid bone contains
the two sphenoidal sinuses, which are
incompletely separated by a median
septum (see Fig. 20-15, B, and 20-17). The
anterior surface of the body forms the pos-
terior bony wall of the nasal cavity. The
superior surface presents a deep depres-
sion called the sella turcica and contains a
gland called the pituitary gland. The sella
turcica lies in the midsagittal plane of the
cranium at a point 3 4 inch (1.9 cm) ante-
rior and 3 4 inch (1.9 cm) superior to the
level of the external acoustic meatus

Optic groove

Lesser wing Greater wing

Optic canal
Anterior clinoid process

Foramen rotundum
Foramen ovale
Tuberculum sellae
Foramen spinosum
Sella turcica Dorsum
A Posterior clinoid process sellae Carotid sulcus

Sphenoid
sinus

Greater
wing of
sphenoid
Foramen
ovale
Foramen
spinosum

Condyle
process

R L

Occipital
bone

B
Fig. 20-15  A, Superior aspect of sphenoid bone. B, Axial CT scan of sphenoid bone.

(B, From Kelley LL, Petersen CM: Sectional anatomy for imaging professionals, ed 2, St Louis, 2007,
Mosby.)

264
(EAM). The sella turcica is bounded ante-
riorly by the tuberculum sellae and poste-
riorly by the dorsum sellae, which bears
the posterior clinoid processes (see Fig.
20-16, B). The slanted area of bone poste-
rior and inferior to the dorsum sellae is
continuous with the basilar portion of the
occipital bone and is called the clivus. The
clivus supports the pons. On either side of
the sella turcica is a groove, the carotid
sulcus, in which the internal carotid artery
and the cavernous sinus lie.
The optic groove extends across the
anterior portion of the tuberculum sellae.
The groove ends on each side at the optic
canal. The optic canal is the opening into
the apex of the orbit for the transmission
of the optic nerve and ophthalmic artery.
The actual opening is called the optic
foramen.
Anterior clinoid
processes
Posterior clinoid
processes
Dorsum sellae
Clivus
Lateral pterygoid
Pterygoid lamina
process
Medial pterygoid
lamina
Pterygoid hamulus
A B
Fig. 20-16  A, Oblique aspect of upper and lateroposterior aspects of sphenoid bone
(right lateral pterygoid lamina removed). B, Sella turcica of sphenoid bone, lateral view.
Fig. 20-17  Sagittal CT scan of sella turcica and sphenoid sinus.
The lesser wings are triangular in shape
and nearly horizontal in position. They
arise, one on each side, from the antero-
superior portion of the body of the sphe-
noid bone and project laterally, ending in
sharp points. The lesser wings form the
posteromedial portion of the roofs of the
orbits, the posterior portion of the anterior
cranial fossa, the upper margin of the
superior orbital fissures, and the optic
canals. The medial ends of their posterior
borders form the anterior clinoid pro-
cesses. Each process arises from two
roots. The anterior (superior) root is thin
and flat, and the posterior (inferior) root,
referred to as the sphenoid strut, is thick
and rounded. The circular opening
between the two roots is the optic canal.
Optic canal and foramen Anterior
clinoid
processes
Lesser wing
Superior
orbital fissure
Greater wing
Sella turcica
Posterior clinoid
process
Sphenoid sinus
The greater wings arise from the sides
of the body of the sphenoid bone and
curve laterally, posteriorly, anteriorly, and
superiorly. The greater wings form part of
the middle cranial fossa, the posterolateral
walls of the orbits, the lower margin of the
superior orbital sulci, and the greater part
of the posterior margin of the inferior
orbital sulci. The foramina rotundum,
ovale, and spinosum are paired and are
situated in the greater wings. Because
these foramina transmit nerves and blood
vessels, they are subject to radiologic
investigation for the detection of erosive
lesions of neurogenic or vascular origin.
Cranial Bones
Sella turcica
Posterior
clinoid processes
Dorsum sellae
Clivus
265
 The pterygoid processes arise from the
lateral portions of the inferior surface of
the body of the sphenoid bone and the
medial portions of the inferior surfaces of
the greater wings. These processes project
inferiorly and curve laterally. Each ptery-
goid process consists of two plates of
bone, the medial and lateral pterygoid
laminae, which are fused at their supero-
anterior parts. The inferior extremity of
the medial lamina possesses an elon-
gated, hook-shaped process, the pterygoid
hamulus, which makes it longer and nar-
rower than the lateral lamina. The ptery-
goid processes articulate with the palatine
bones anteriorly and with the wings of the
vomer, where they enter into the forma-
tion of the nasal cavity.
Skull, Facial Bones, and Paranasal Sinuses
The sphenoid bone articulates with
each of the other seven bones of the
cranium.
OCCIPITAL BONE
The occipital bone is situated at the pos-
teroinferior part of the cranium. It forms
the posterior half of the base of the
cranium and the greater part of the poste-
rior cranial fossa (Figs. 20-18 to 20-20).
The occipital bone has four parts: the
squama, which is saucer-shaped, being
convex externally; two occipital condyles,
which extend anteriorly, one on each side
of the foramen magnum; and the basilar
portion. The occipital bone also has a
large aperture, the foramen magnum,
through which the inferior portion of the
medulla oblongata passes as it exits the
cranial cavity and joins the spinal cord.
The squama curves posteriorly and
superiorly from the foramen magnum and
is curved from side to side. It articulates
with the parietal bones at the lambdoidal
sutures and with the mastoid portions of
the temporal bones at the occipitomastoid
sutures. On the external surface of the
squama, midway between its summit and
the foramen magnum, is a prominent
process termed the external occipital pro-
tuberance, or inion, which corresponds
in position with the internal occipital
protuberance.

Squama External occipital

protuberance
(inion)

Occipital
condyle

Atlantooccipital
joint
Lateral mass C1
Foramen
magnum Odontoid
process C2
Condylar canal
Occipital condyle
B
A Basilar portion

Fig. 20-18  A, External surface of occipital bone. B, Coronal CT showing atlantooccipital

joint.
(B, Courtesy Siemens Medical Systems, Iselin, NJ.)

266
 The occipital condyles project anteri-
orly, one from each side of the squama,
for articulation with the atlas of the cervi-
cal spine. Part of each lateral portion
curves medially to fuse with the basilar
portion and complete the foramen
magnum, and part of it projects laterally
to form the jugular process. On the infe-
rior surface of the curved parts, extending
from the level of the middle of the foramen
magnum anteriorly to the level of its ante-
rior margin, reciprocally shaped condyles
articulate with superior facets of the atlas.
These articulations, known as the occipi-
toatlantal joints, are the only bony articu-
lations between the skull and the neck.
The hypoglossal canals are found at the
anterior ends of the condyles and transmit
the hypoglossal nerves. At the posterior
end of the condyles are the condylar
canals, through which the emissary veins
pass. The anterior portion of the occipital
bone contains a deep notch that forms a
part of the jugular foramen (see Fig. 20-2,
B). The jugular foramen is an important
large opening in the skull for two reasons:
It allows blood to drain from the brain via
the internal jugular vein, and it lets three
cranial nerves pass through it.
The basilar portion of the occipital
bone curves anteriorly and superiorly to
its junction with the body of the sphenoid.
In an adult, the basilar part of the occipital
bone fuses with the body of the sphenoid
bone, resulting in the formation of a con-
tinuous bone. The sloping surface of this
junction between the dorsum sellae of the
sphenoid bone and the basilar portion of
the occipital bone is called the clivus.
The occipital bone articulates with the
two parietals, the two temporal bones and
the sphenoid of the cranium, and the first
cervical vertebra.

Fossa for cerebrum

Cranial Bones
Internal
occipital
protuberance

Fossa for cerebellum

Hypoglossal canal

Foramen magnum
Basilar portion
Jugular process
Condyle for articulation
with atlas
Fig. 20-19  Internal surface of occipital bone.

Squama

External Hypoglossal canal

occipital Basilar portion
protuberance
(inion)

Condyles for
articulation
Foramen magnum with the atlas

Fig. 20-20  Lateroinferior aspect of occipital bone.

267
 TEMPORAL BONES
The temporal bones are irregular in shape
and are situated on each side of the base
of the cranium between the greater wings
of the sphenoid bone and the occipital
bone (Figs. 20-21 to 20-25). The temporal
bones form a large part of the middle fossa
of the cranium and a small part of the
posterior fossa. Each temporal bone con-
sists of a squamous portion, a tympanic
portion, a styloid process, a zygomatic
process, and a petromastoid portion (the
mastoid and petrous portions) that con-
tains the organs of hearing and balance.
The squamous portion is the thin upper
portion of the temporal bone. It forms a
part of the side wall of the cranium and
has a prominent arched process, the zygo-
matic process, which projects anteriorly to
Skull, Facial Bones, and Paranasal Sinuses
articulate with the zygomatic bone of the
face and complete the zygomatic arch. On
Squamous
portion
Mastoid portion
External acoustic
meatus
Mastoid process
Tympanic portion
Fig. 20-21  Lateral aspect of temporal bone.
Squamous
portion
Internal
acoustic
meatus
Styloid process
Fig. 20-22  Internal surface of temporal bone.
268
the inferior border of the zygomatic
process is a rounded eminence, the articu-
lar tubercle, which forms the anterior
boundary of the mandibular fossa. The
mandibular fossa receives the condyle of
the mandible to form the temporoman-
dibular joint (TMJ).
The tympanic portion is situated below
the squama and in front of the mastoid and
petrous portions of the temporal bone.
This portion forms the anterior wall, the
inferior wall, and part of the posterior
walls of the EAM. The EAM is approxi-
mately 1 2 inch (1.3 cm) in length and
projects medially, anteriorly, and slightly
superiorly.
The styloid process, a slender, pointed
bone of variable length, projects inferi-
orly, anteriorly, and slightly medially from
the inferior portion of the tympanic part
of the temporal bone.
Zygomatic
process
Articular tubercle
Mandibular fossa
Styloid process
Petrous
portion
Petromastoid portion
The petrous and mastoid portions together
are called the petromastoid portion. The
mastoid portion, which forms the inferior,
posterior part of the temporal bone, is pro-
longed into the conical mastoid process
(see Figs. 20-23 and 20-25).
The mastoid portion articulates with the
parietal bone at its superior border through
the parietomastoid suture and with the
occipital bone at its posterior border
through the occipitomastoid suture, which
is contiguous with the lambdoidal suture.
The mastoid process varies considerably
in size, depending on its pneumatization,
and is larger in males than in females.
The first of the mastoid air cells to
develop is situated at the upper anterior
part of the process and is termed the
mastoid antrum. This air cell is quite large
and communicates with the tympanic
cavity. Shortly before or after birth,
smaller air cells begin to develop around
the mastoid antrum and continue to
increase in number and size until around
puberty. The air cells vary considerably in
size and number. Occasionally, they are
absent altogether, in which case the
mastoid process is solid bone and is
usually small.
The petrous portion, often called the
petrous pyramid, is conical or pyramidal
and is the thickest, densest bone in the
cranium. This part of the temporal bone
contains the organs of hearing and balance.
From its base at the squamous and mastoid
portions, the petrous portion projects
medially and anteriorly between the
greater wing of the sphenoid bone and the
occipital bone to the body of the sphenoid
bone, with which its apex articulates. The
internal carotid artery in the carotid canal
enters the inferior aspect of the petrous
portion, passes superior to the cochlea,
then passes medially to exit the petrous
apex. Near the petrous apex is a ragged
foramen called the foramen lacerum. The
carotid canal opens into this foramen,
which contains the internal carotid artery
(see Fig. 20-2, B). At the center of the
posterior aspect of the petrous portion is
the internal acoustic meatus (IAM), which
transmits the vestibulocochlear and facial
nerves. The upper border of the petrous
portion is commonly referred to as the
petrous ridge. The top of the ridge lies
approximately at the level of an external
radiography landmark called the top of
ear attachment (TEA).
The temporal bone articulates with the
parietal, occipital, and sphenoid bones of
the cranium.
 Squamous portion

Petrous portion

Squamous Mastoid antrum

portion

Arcuate eminence
Semicircular canal
Petrous ridge
Mastoid
air cells Petrous apex

Carotid canal

Mastoid
Mastoid portion process
Promontory (formed
A Styloid process B by cochlear base)

Fig. 20-23  A, Anterior aspect of temporal bone in relation to surrounding structures.

B, Coronal section through mastoid and petrous portions of temporal bone.

Cranial Bones
Mastoid
air cells

Auditory
ossicles
Cochlea

External
auditory
meatus

Fig. 20-24  Coronal CT scan through temporal bones.

(Courtesy Karl Mockler, RT[R].)

Inner ear

External
Fig. 20-25  Axial CT scan of petrous portion at level of
auditory external auditory meatus.
meatus
(From Kelley LL, Petersen CM: Sectional anatomy for imaging
professionals, ed 2, St Louis, 2007, Mosby.)

Petrous portion, R L
temporal bone

Mastoidian
cells

269
 Top of ear
attachment

Tragus
External
acoustic
meatus Auditory
tube

Mastoid Semicircular
antrum Lateral
canals
Auditory Posterior
ossicles Anterior Stapes in oval window

Internal acoustic meatus

Skull, Facial Bones, and Paranasal Sinuses

Helix

Cochlear nerve

Cochlea
Auricle
Round window
Auditory
[eustachian] tube
Nasopharynx

Concha
Tympanic cavity
External
Cartilage acoustic meatus

B Tympanic membrane

Fig. 20-26  A, Frontal view of face showing internal structures of the ear (shaded area).
B, External, middle, and internal ear.

Mastoid
air cells

Semicircular
canals

Auditory
ossicles

Cochlea

Tympanic
cavity

Fig. 20-27  Coronal CT scan through petrous portion of temporal bone Fig. 20-28  Coronal CT scan of petromastoid portion of
showing middle and inner ear. temporal bone showing semicircular canals and
mastoid air cells.
(Courtesy Karl Mockler, RT[R].)
(Courtesy Karl Mockler, RT[R].)

270
Ear
The ear is the organ of hearing and balance
(Fig. 20-26). The essential parts of the ear
are housed in the petrous portion of the
temporal bone. The organs of hearing and
equilibrium consist of three main divi-
sions: external ear, middle ear, and inter-
nal ear.
EXTERNAL EAR
The external ear consists of two parts:
(1) the auricle, the oval-shaped, fibrocar-
tilaginous, sound-collecting organ situ-
ated on the side of the head, and (2) the
external acoustic meatus (EAM), a sound-
conducting canal. The superior attachment
of the auricle is the top of ear attachment
(TEA). The TEA is a reference point for
positioning the lateral cervical spine. The
auricle has a deep central depression, the
concha, the lower part of which leads into
the EAM. At its anterior margin, the
auricle has a prominent cartilaginous lip,
the tragus, which projects posteriorly over
the entrance of the meatus. The outer rim
of the ear is the helix. The EAM is about
1 inch (2.5 cm) long. The outer third of
the canal wall is cartilaginous, and the
inner two thirds is osseous. From the
meatal orifice, the canal forms a slight
curve as it passes medially and anteriorly
in line with the axis of the IAM. The EAM
ends at the tympanic membrane of the
middle ear.
MIDDLE EAR
The middle ear is situated between the
external ear and the internal ear. The
middle ear proper consists of (1) the tym-
panic membrane (or eardrum); (2) an
irregularly shaped, air-containing com-
partment called the tympanic cavity; and
(3) three small bones called the auditory
ossicles (see Figs. 20-25 and 20-26). The
middle ear communicates with the mastoid
antrum and auditory eustachian tube.
The tympanic membrane is a thin, con-
cavoconvex, membranous disk with an
elliptic shape. The disk, the convex surface
of which is directed medially, is situated
obliquely over the medial end of the EAM
and serves as a partition between the
external ear and the middle ear. The func-
tion of the tympanic membrane is the
transmission of sound vibrations.
The tympanic cavity is a narrow, irregu-
larly shaped chamber that lies just poste-
rior and medial to the mandibular fossa.
The cavity is separated from the external
ear by the tympanic membrane and from
the internal ear by the bony labyrinth. The
tympanic cavity communicates with the
nasopharynx through the auditory (eusta-
chian) tube, a passage by which air pres-
sure in the middle ear is equalized with
the pressure in the outside air passages.
The auditory tube is about 1 1 4 inches
(3 cm) long. From its entrance into the
tympanic cavity, the auditory tube passes
medially and inferiorly to its orifice on the
lateral wall of the nasopharynx.
The mastoid antrum is the large air cav-
ity situated in the temporal bone above the
mastoid air cells and immediately behind
the posterior wall of the middle ear.
The auditory ossicles, named for their
shape, are the malleus (hammer), incus
(anvil), and stapes (stirrup). These three
delicate bones are articulated to permit
vibratory motion. They bridge the middle
ear cavity for the transmission of sound
vibrations from the tympanic membrane
to the internal ear. The handle of the
malleus (the outermost ossicle) is attached
to the tympanic membrane, and its head
articulates with the incus (the central
ossicle). The head of the stapes (the inner-
most ossicle) articulates with the incus,
and its base is fitted into the oval window
of the inner ear.
INTERNAL EAR
The internal ear contains the essential
sensory apparatus of hearing and equilib-
rium and lies on the densest portion of the
petrous portion immediately below the
arcuate eminence. Composed of an irregu-
larly shaped bony chamber called the
bony labyrinth, the internal ear is housed
within the bony chamber and is an inter-
communicating system of ducts and sacs
known as the membranous labyrinth. The
bony labyrinth consists of three distinctly
Ear
shaped parts: (1) a spiral-coiled, tubular
part called the cochlea, which communi-
cates with the middle ear through the
membranous covering of the round
window (Fig. 20-27); (2) a small, ovoid
central compartment behind the cochlea,
known as the vestibule, which communi-
cates with the middle ear via the oval
window; and (3) three unequally sized
semicircular canals that form right angles
to one another and are called, according
to their positions, the anterior, posterior,
and lateral semicircular canals (Fig.
20-28). From its cranial orifice, the inter-
nal acoustic meatus (IAM) passes inferi-
orly and laterally for a distance of about
1 inch (1.3 cm). Through this canal, the
2
cochlear and vestibular nerves pass from
their fibers in the respective parts of the
membranous labyrinth to the brain. The
cochlea is used for hearing, and the vesti-
bule and semicircular canals are involved
with equilibrium.
271
 Facial Bones
NASAL BONES
The two small, thin nasal bones vary in
size and shape in different individuals
(Figs. 20-29 and 20-30). They form the
superior bony wall (called the bridge of
the nose) of the nasal cavity. The nasal
bones articulate in the midsagittal plane,
where at their posterosuperior surface
they also articulate with the perpendicular
plate of the ethmoid bone. They articulate
with the frontal bone above and with the
maxillae at the sides.
LACRIMAL BONES
The two lacrimal bones, which are the
smallest bones in the skull, are very thin
and are situated at the anterior part of the
medial wall of the orbits between the laby-
Skull, Facial Bones, and Paranasal Sinuses
rinth of the ethmoid bone and the maxilla
(see Figs. 20-29 and 20-30). Together with
Superior
orbital fissure
Zygoma
Inferior
orbital fissure
Vomer
Fig. 20-29  Anterior aspect of skull showing facial bones.
272
the maxillae, the lacrimal bones form the
lacrimal fossae, which accommodate the
lacrimal sacs. Each lacrimal bone contains
a lacrimal foramen through which a tear
duct passes. Each lacrimal bone articu-
lates with the frontal and ethmoid cranial
bones and the maxilla and inferior nasal
concha facial bones. The lacrimal bones
can be seen on PA and lateral projections
of the skull.
MAXILLARY BONES
The two maxillary bones are the largest of
the immovable bones of the face (see Figs.
20-29 and 20-30). Each articulates with all
other facial bones except the mandible.
Each also articulates with the frontal and
ethmoid bones of the cranium. The maxil-
lary bones form part of the lateral walls
and most of the floor of the nasal cavity,
part of the floor of the orbital cavities, and
bones
Nasal
Maxilla
Mandible
three fourths of the roof of the mouth.
Their zygomatic processes articulate with
the zygomatic bones and assist in the for-
mation of the prominence of the cheeks.
The body of each maxilla contains a large,
pyramidal cavity called the maxillary
sinus, which empties into the nasal cavity.
An infraorbital foramen is located under
each orbit and serves as a passage through
which the infraorbital nerve and artery
reach the nose.
At their inferior borders, the maxillae
possess a thick, spongy ridge called the
alveolar process, which supports the roots
of the teeth. In the anterior midsagittal
plane at their junction with each other, the
maxillary bones form a pointed, forward-
projecting process called the anterior
nasal spine. The midpoint of this promi-
nence is called the acanthion.
Optic
foramen
Lacrimal bone
Ethmoid bone
Infraorbital foramen
Inferior nasal concha
Anterior nasal spine
[acanthion]
Mental protuberance
ZYGOMATIC BONES
The zygomatic bones form the promi-
nence of the cheeks and a part of the side
wall and floor of the orbital cavities (see
Figs. 20-29 and 20-30). A posteriorly
extending temporal process unites with
the zygomatic process of the temporal
bone to form the zygomatic arch. The
zygomatic bones articulate with the frontal
bone superiorly, with the zygomatic
process of the temporal bone at the side,
with the maxilla anteriorly, and with the
sphenoid bone posteriorly.
PALATINE BONES
The two palatine bones are L-shaped
bones composed of vertical and horizon-
tal plates. The horizontal plates articulate
with the maxillae to complete the poste-
the mouth (see Fig. 20-3). The vertical
portions of the palatine bones extend
upward between the maxillae and the
pterygoid processes of the sphenoid bone
in the posterior nasal cavity. The superior
tips of the vertical portions of the palatine
bones assist in forming the posteromedial
bony orbit.
INFERIOR NASAL CONCHAE
The inferior nasal conchae extend diago-
nally and inferiorly from the lateral walls
of the nasal cavity at approximately its
lower third (see Fig. 20-29). They are
long, narrow, and extremely thin; they curl
laterally, which gives them a scroll-like
appearance.
The upper two nasal conchae are pro-
cesses of the ethmoid bone. The three
lateral portion of the respective sides of
the nasal cavity into superior, middle, and
inferior meatus. They are covered with a
mucous membrane to warm, moisten, and
cleanse inhaled air.
VOMER
The vomer is a thin plate of bone situated
in the midsagittal plane of the floor of the
nasal cavity, where it forms the inferior
part of the nasal septum (see Fig. 20-29).
The anterior border of the vomer slants
superiorly and posteriorly from the ante-
rior nasal spine to the body of the sphe-
noid bone, with which its superior border
articulates. The superior part of its ante-
rior border articulates with the perpen-
dicular plate of the ethmoid bone; its
posterior border is free.

Facial Bones
rior fourth of the bony palate, or roof of nasal conchae project into and divide the

Lacrimal bone

l
sa
Na ne
bo
Ethmoid bone

Anterior nasal Zygoma

spine
[acanthion]

Temporal Maxilla
process

Alveolar
process Mandible

External acoustic meatus

Mandibular condyle
Angle (gonion)
Mental foramen Mandibular notch
Coronoid process
Fig. 20-30  Lateral aspect of skull showing facial bones.

273
 MANDIBLE
The mandible, the largest and densest
bone of the face, consists of a curved hori-
zontal portion, called the body, and two
vertical portions, called the rami, which
unite with the body at the angle of the
mandible, or gonion (Fig. 20-31). At birth,
the mandible consists of bilateral pieces
held together by a fibrous symphysis that
ossifies during the first year of life. At the
site of ossification is a slight ridge that
ends below in a triangular prominence, the
mental protuberance. The symphysis is
the most anterior and central part of the
mandible. This is where the left and right
halves of the mandible have fused.
The superior border of the body of the
mandible consists of spongy bone, called
Skull, Facial Bones, and Paranasal Sinuses
the alveolar portion, which supports the
roots of the teeth. Below the second pre-
molar tooth, approximately halfway
between the superior and inferior borders
of the bone, is a small opening on each
side for the transmission of nerves and
blood vessels. These two openings are
called the mental foramina.
The rami project superiorly at an obtuse
angle to the body of the mandible, and
their broad surface forms an angle of
approximately 110 to 120 degrees. Each
ramus presents two processes at its
upper extremity—one coronoid and one
condylar—which are separated by a con­
cave area called the mandibular notch.
The anterior process, the coronoid process,
is thin and tapered and projects to a higher
level than the posterior process. The con-
dylar process consists of a constricted
area, the neck, above which is a broad,
thick, almost transversely placed condyle
that articulates with the mandibular fossa
of the temporal bone (Fig. 20-32). This
articulation, the TMJ, slants posteriorly
approximately 15 degrees and inferiorly
and medially approximately 15 degrees.
Radiographic projections, produced from
the opposite side, must reverse these
directions. In other words, the central ray
angulation must be superior and anterior
to coincide with the long axis of the joint.
The TMJ is situated immediately in front
of the EAM.

Condyle Alveolar portion

Condylar
process Neck Coronoid process
Symphysis

Ramus

Mandibular
fossa
Angle Mandibular
Body
condyle

A Mental foramen Mental protuberance

A
Coronoid process Neck

Condylar
process Mandibular
fossa
Alveolar portion Mandibular
Mandibular condyle
notch
Symphysis
Ramus

Angle (gonion)
Mental
protuberance
Body
B Mental foramen
B
Fig. 20-31  A, Anterior aspect of mandible. B, Lateral aspect of mandible. Fig. 20-32  CT scan of mandibular condyle
situated in mandibular fossa. A, Coronal.
B, Sagittal.

(Courtesy Karl Mockler, RT[R].)

274
HYOID BONE
The hyoid bone is a small, U-shaped struc-
ture situated at the base of the tongue,
where it is held in position in part by the
stylohyoid ligaments extending from the
styloid processes of the temporal bones
(Fig. 20-33). Although the hyoid bone is
an accessory bone of the axial skeleton, it
is described in this chapter because of its
connection with the temporal bones. The
hyoid is the only bone in the body that
does not articulate with any other bone.
The hyoid bone is divided into a body,
two greater cornua, and two lesser
cornua. The bone serves as an attachment
for certain muscles of the larynx and
tongue and is easily palpated just above
the larynx.
ORBITS
Each orbit is composed of seven different
bones (Fig. 20-34). Three of these are
cranial bones: frontal, sphenoid, and
ethmoid. The other four bones are the
facial bones: maxilla, zygoma, lacrimal,
and palatine. The circumference of the
orbit, or outer rim area, is composed of
three of the seven bones—frontal, zygoma,
and maxilla. The remaining four bones
compose most of the posterior aspect of
the orbit.
Articulations of the Skull
The sutures of the skull are connected by
toothlike projections of bone interlocked
with a thin layer of fibrous tissue. These
articulations allow no movement and are
classified as fibrous joints of the suture
type. The articulations of the facial bones,
including the joints between the roots of
the teeth and the jawbones, are fibrous
gomphoses. The exception is the point at
which the rounded condyle of the mandi-
ble articulates with the mandibular fossa
of the temporal bone to form the TMJ. The
TMJ articulation is a synovial joint of the
hinge and gliding type. The atlantooccipi-
tal joint is a synovial ellipsoidal joint that
joins the base of the skull (occipital bone)
with the atlas of the cervical spine. The
seven joints of the skull are summarized

Articulations of the Skull

in Table 20-1.

TABLE 20-1 
Joints of the skull
Structural classification
Joint Tissue Type Movement
Coronal suture Fibrous Suture Immovable
Sagittal suture Fibrous Suture Immovable
Lambdoidal suture Fibrous Suture Immovable
Squamosal suture Fibrous Suture Immovable
Temporomandibular Synovial Hinge and gliding Freely movable
Alveolar sockets Fibrous Gomphosis Immovable
Atlantooccipital Synovial Ellipsoidal Freely movable

Frontal

Sphenoid
Ethmoid (greater wing)

Palatine
Greater cornu
Medial Lateral

Lesser cornu

Lacrimal

Orbital surface Maxilla Zygoma

Body of maxilla
Fig. 20-33  Anterior aspect of hyoid. Fig. 20-34  Orbit. Seven bones of orbit are shown.

275
 Sinuses
The air-containing cavities situated in the
frontal, ethmoidal, and sphenoidal bones
of the cranium and the maxillary bones of
the face are called the paranasal sinuses
because of their formation from the nasal
mucosa and their continued communica-
tion with the nasal fossae (Fig. 20-35).
Although the functions of the sinuses are
not agreed on by all anatomists, these
cavities are believed to do the following:
• Serve as a resonating chamber for the
voice
• Decrease the weight of the skull by con-
taining air
• Help warm and moisten inhaled air
• Act as shock absorbers in trauma (as
airbags do in automobiles)
• Possibly control the immune system
Skull, Facial Bones, and Paranasal Sinuses
The sinuses begin to develop early in
fetal life, at first appearing as small sac-
culations of the mucosa of the nasal
meatus and recesses. As the pouches, or
sacs, grow, they gradually invade the
respective bones to form the air sinuses
and cells. The maxillary sinuses are
usually sufficiently well developed and
aerated at birth to be shown radiographi-
cally. The other groups of sinuses develop
more slowly; by age 6 or 7 years, the
frontal and sphenoidal sinuses are distin-
guishable from the ethmoidal air cells,
which they resemble in size and position.
The ethmoidal air cells develop during
puberty, and the sinuses are not com-
pletely developed until age 17 or 18 years.
When fully developed, each of the sinuses
communicates with the others and with
MAXILLARY SINUSES
The largest sinuses, the maxillary sinuses,
are paired and are located in the body of
each maxilla (see Figs. 20-35 and 20-36).
Although the maxillary sinuses appear
rectangular in the lateral image, they are
approximately pyramidal in shape and
have only three walls. The apices are
directed inferiorly and laterally. The two
maxillary sinuses vary considerably in
size and shape but are usually symmetric.
In adults, each maxillary sinus is approxi-
mately 1 1 2 inches (3.5 cm) high and 1 to
1 1 3 inches (2.5 to 3 cm) wide. The sinus is
often divided into subcompartments by
partial septa, and occasionally it is divided
into two sinuses by a complete septum.
The sinus floor presents several elevations
that correspond to the roots of the subja-

the nasal cavity. cent teeth. The maxillary sinuses commu-

An understanding of the actual size, nicate with the middle nasal meatus at the
shape, and position of the sinuses within superior aspect of the sinus.
the skull is made possible by studying the
sinuses on computed tomography (CT)
head images (Fig. 20-36).

Ethmoidal air cells

Posterior Middle Anterior

Frontal sinuses Frontal sinus
Intersinus Sphenoidal sinus
septum Ethmoidal sinuses

Sphenoidal sinuses
Maxillary sinus

Maxillary sinuses

A B
Fig. 20-35  A, Anterior aspect of paranasal sinuses, showing lateral relationship to each
other and to surrounding parts. B, Schematic drawing of paranasal sinuses, showing AP
relationship to each other and surrounding parts.

276
 FS

MS
R L R L

Sinuses
A B

SS

MS

R L R L

C D

Fig. 20-36  A, Coronal CT image of frontal sinuses (FS). SS

B, Coronal CT scan of maxillary sinuses (MS). C, Axial CT
image of MS. D, Axial CT image of sphenoid sinuses (SS).
E
E, Sagittal CT image of SS.
Continued

277
 EtS

EtS

R L R L
Skull, Facial Bones, and Paranasal Sinuses

MS
F G
Fig. 20-36, cont’d  F, Coronal CT image of ethmoidal sinuses (EtS). G, Axial CT image of EtS.

(From Kelley LL, Petersen CM: Sectional anatomy for imaging professionals, ed 2, St Louis, 2007, Mosby.)

278
FRONTAL SINUSES
The frontal sinuses, the second largest
sinuses, are paired and are normally
located between the tables of the vertical
plate of the frontal bone (see Figs. 20-35
and 30-36). The frontal sinuses vary
greatly in size and form. Occasionally
they are absent. One or both may be
approximately 3 4 to 1 inch (2 to 2.5 cm)
in the vertical or lateral dimension. The
sinuses often extend beyond the frontal
region of the bone, most frequently into
the orbital plates. The intersinus septum is
usually deviated from the midline; for this
reason, the frontal sinuses are rarely sym-
metric. Multiple septa are sometimes
present. Similar to maxillary sinuses, the
frontal sinuses drain into the middle nasal
meatus.
ETHMOIDAL SINUSES
The two ethmoidal sinuses are located
within the lateral masses of the labyrinths
of the ethmoid bone. They are composed
of a varying number of air cells that are
divided into three main groups: anterior,
middle, and posterior (see Figs. 20-35 and
20-36). The anterior and middle eth-
moidal cells range in number from two to
eight, and each group opens into the
middle nasal meatus. The posterior cells
range in number from two to six or more
and drain into the superior nasal meatus.
SPHENOIDAL SINUSES
The sphenoidal sinuses are normally
paired and occupy the body of the sphe-
noid bone (see Figs. 20-35 and 20-36).
Anatomists state that often only one sphe-
noidal sinus is present; however, more
than two sphenoidal sinuses are never
present. The sphenoidal sinuses vary con-
siderably in size and shape and are usually
asymmetric. They lie immediately below
the sella turcica and extend between the
dorsum sellae and the posterior ethmoidal
air cells. The sphenoidal sinuses open into
the sphenoethmoidal recess of the nasal
cavity.
Text continued on p. 285.
Sinuses
279
 SUMMARY OF ANATOMY
Skull Fossae Sphenoid bone Occipital bone
Cranial bones (8) Anterior cranial fossa Body Foramen magnum
Facial bones (14) Middle cranial fossa Sphenoidal sinuses Squama
Posterior cranial fossa Sella turcica External occipital
Cranial bones Tuberculum sellae protuberance (inion)
Calvaria Frontal bone Dorsum sellae Internal occipital
Frontal Frontal squama Posterior clinoid processes protuberance
Right parietal Frontal eminence Clivus Occipital condyles
Left parietal Supraorbital margins Carotid sulcus Hypoglossal canals
Occipital Superciliary arches Optic groove Condylar canals
Floor Supraorbital foramen Optic canals Jugular foramen
Right temporal Glabella Optic foramen Basilar portion
Left temporal Frontal sinuses Lesser wings Clivus
Sphenoid Nasion Superior orbital fissures
Ethmoid Orbital plates Anterior clinoid processes Temporal bones (R & L)
Diploë Ethmoidal notch Sphenoid strut Squamous portions
Nasal spine Greater wings Zygomatic process
Sutures Foramen rotundum Articular tubercle
Coronal suture Ethmoid bone Foramen ovale Mandibular fossa
Skull, Facial Bones, and Paranasal Sinuses

Sagittal suture Cribriform plate Foramen spinosum Tympanic portions

Squamosal sutures Crista galli Pterygoid processes External acoustic meatus
Lambdoidal suture Perpendicular plate Medial pterygoid lamina (EAM)
Bregma Labyrinths pterygoid hamulus Styloid process
Lambda Anterior air cells Lateral pterygoid lamina Petromastoid portions
Pterion Middle air cells Mastoid portions
Asterion Posterior air cells Mastoid process
Ethmoidal sinuses Mastoid antrum
Fontanels Superior nasal conchae Mastoid air cells
Anterior fontanel Middle nasal conchae Petrous portions (petrous
Posterior fontanel pyramids)
Sphenoidal fontanels (2) Parietal bones (R & L) Carotid canals
Mastoid fontanels (2) Parietal eminence Petrous apex
Foramen lacerum
Internal acoustic meatus
(IAM)
Petrous ridge
Top of ear attachment (TEA)

280
 SUMMARY OF ANATOMY—cont’d
Ear Facial bones (14) Inferior nasal conchae Articulations
External ear Nasal (R & L) (R & L) Coronal suture
Auricle Lacrimal (R & L) Sagittal suture
Concha Maxillary (R & L) Vomer (1) Lambdoidal sutures
Tragus Zygomatic (R & L) Nasal septum Squamosal sutures
Helix Palatine (R & L) Temporomandibular (TMJ)
EAM Inferior nasal conchae Mandible (1) Alveolar sockets
Middle ear (R & L) Body Atlantooccipital
Tympanic membrane Vomer (1) Alveolar portion
Tympanic cavity Mandible (1) Mental foramina Morphology
Auditory (eustachian) Hyoid bone Angle (gonion) Mesocephalic
tube Diploë Rami Brachycephalic
Auditory ossicles Coronoid process Dolichocephalic
Malleus Lacrimal bones (R & L) Condylar process
Incus Lacrimal foramen Condyle Orbit
Stapes Neck Base
Internal ear Maxillary bones (R & L) Temporomandibular joint Apex
Arcuate eminence Maxillary sinuses (TMJ) Optic foramen
Bony labyrinth Infraorbital foramen Mandibular notch Superior orbital fissures

Sinuses
Cochlea Alveolar process Mental protuberance Inferior orbital fissures
Round window Anterior nasal spine (mentum)
Vestibule Acanthion Symphysis Eye
Oval window Eyeball
Semicircular canals Zygomatic bones (R & L) Hyoid bone Conjunctiva
Anterior Temporal process Body Sclera
Posterior Zygomatic arch Greater cornua Cornea
Lateral Lesser cornua Retina
Membranous labyrinth Palatine bones (R & L) Rods
Vertical plates Paranasal sinuses Cones
Horizontal plates Maxillary sinuses
Frontal sinuses
Intersinus septum
Ethmoidal sinuses
Anterior ethmoidal cells
Middle ethmoidal cells
Posterior ethmoidal cells
Sphenoidal sinuses

281
 SUMMARY OF PATHOLOGY
Condition Definition

Fracture Disruption in continuity of bone

  Basal Fracture located at the base of the skull

  Blowout Fracture of the floor of the orbit

  Contre-coup Fracture to one side of a structure caused by trauma to the other side

  Depressed Fracture causing a portion of the skull to be pushed into the cranial cavity

  Le Fort Bilateral horizontal fractures of the maxillae

  Linear Irregular or jagged fracture of the skull

  Tripod Fracture of the zygomatic arch and orbital floor or rim and dislocation of the frontozygomatic suture
Skull, Facial Bones, and Paranasal Sinuses

Mastoiditis Inflammation of the mastoid antrum and air cells

Metastasis Transfer of cancerous lesion from one area to another

Osteomyelitis Inflammation of bone due to a pyogenic infection

Osteopetrosis Increased density of atypically soft bone

Osteoporosis Loss of bone density

Paget disease Thick, soft bone marked by bowing and fractures

Polyp Growth or mass protruding from a mucous membrane

Sinusitis Inflammation of one or more of the paranasal sinuses

TMJ syndrome Dysfunction of temporomandibular joint (TMJ)

Tumor New tissue growth where cell proliferation is uncontrolled

  Acoustic neuroma Benign tumor arising from Schwann cells of eighth cranial nerve (also termed “schwannoma”)

  Multiple myeloma Malignant neoplasm of plasma cells involving the bone marrow and causing destruction of the
bone

  Osteoma Tumor composed of bony tissue

  Pituitary adenoma Tumor arising from the pituitary gland, usually in the anterior lobe

282
SAMPLE EXPOSURE TECHNIQUE CHART ESSENTIAL PROJECTIONS
These techniques were accurate for the equipment used to produce each exposure. However, use caution when applying
them in your department because generator output characteristics and IR energy sensitivities vary widely.1
This chart was created in collaboration with Dennis Bowman, AS, RT(R), Clinical Instructor, Community Hospital of the
Monterey Peninsula, Monterey, CA.
http://digitalradiographysolutions.com/

SKULL, FACIAL BONES, AND PARANASAL SINUSES

CR‡ DR§
Dose Dose
Part cm kVp* SID† Collimation mAs (mGy)‖ mAs (mGy)‖

Cranium

  Lateral¶ 15 85 40″ 11″ × 9″ (28 × 23 cm) 6.3** 0.794 3.2** 0.399

  PA¶ 20 85 40″ 8″ × 10″ (20 × 25 cm) 12.5** 1.781 6.3** 0.891

Sample Exposure Technique Chart

  PA axial (Caldwell)¶ 20 85 40″ 8″ × 11″ (20 × 28 cm) 14** 2.008 7.1** 1.014

  AP¶ 20 85 40″ 8″ × 10″ (20 × 25 cm) 12** 1.781 6.3** 0.893

  AP axial¶ 20 85 40″ 8″ × 11″ (20 × 28 cm) 14** 2.005 7.1** 1.014

  AP axial (Towne)¶ 22 85 40″ 8.5″ × 12″ (21.3 × 30 cm) 20†† 3.030 10†† 1.507

  PA axial (Haas)¶ 21 85 40″ 8.5″ × 12″ (21.3 × 30 cm) 20†† 2.950 10†† 1.467

Cranial base

  SMV¶ 23 85 40″ 8″ × 11″ (20 × 28 cm) 28†† 4.330 14†† 2.169

Facial bones

  Lateral¶ 15 80 40″ 7″ × 7″ (18 × 18 cm) 6.3** 0.701 3.2** 0.354

  Parietoacanthial (Waters)¶ 24 85 40″ 7.5″ × 8″ (18.8 × 20 cm) 16** 2.470 8** 1.231

  Acanthioparietal (reverse Waters)¶ 24 85 40″ 7.5″ × 8″ (18.8 × 20 cm) 16** 2.470 8** 1,231

  PA axial (Caldwell)¶ 20 85 40″ 7.5″ × 8″ (18.8 × 20 cm) 14** 1.958 7.1** 0.988

Nasal bones

  Lateral‡‡ 6 70 40″ 3″ × 5″ (8 × 13 cm) 5.0** 0.282 2.5** 1.408

Zygomatic arches

  SMV¶ 23 80 40″ 8″ × 5″ (20 × 13 cm) 16†† 2.094 8†† 1.041

  Tangential¶ 20 80 40″ 3″ × 5″ (8 × 13 cm) 14†† 1.294 7.1†† 0.653

  AP axial¶ 17 80 40″ 8.5″ × 7″ (21.3 × 18 cm) 20†† 2.270 6.3†† 1.126

Mandibular rami

  PA¶ 17 80 40″ 8″ × 5″ (20 × 13 cm) 12.5** 1.367 6.3** 0.686

  PA axial¶ 17 80 40″ 8″ × 5″ (20 × 13 cm) 14** 1.532 7** 0.773

Mandible

  Axiolateral oblique¶ 13 80 40″ 8″ × 6″ (20 × 15 cm) 12.5** 1.266 6.3** 0.635

283
 SAMPLE EXPOSURE TECHNIQUE CHART ESSENTIAL PROJECTIONS—cont’d
SKULL, FACIAL BONES, AND PARANASAL SINUSES
CR‡ DR§
Dose Dose
Part cm kVp* SID† Collimation mAs (mGy)‖ mAs (mGy)‖

TMJ

  AP axial¶ 21 80 40″ 8.5″ × 7″ (21.3 × 18 cm) 20** 2.480 10** 1.233

  Axiolateral oblique¶ 15 80 40″ 4″ × 4″ (10 × 10 cm) 16†† 1.501 8†† 0.748

Paranasal sinuses

  Lateral¶ 15 85 40″ 6″ × 6″ (15 × 15 cm) 6.3** 0.721 3.2** 0.363

Frontal and anterior ethmoidal

sinuses
Skull, Facial Bones, and Paranasal Sinuses

  PA axial (Caldwell)¶ 20 85 40″ 6″ × 6″ (15 × 15 cm) 14** 1.807 7.1** 0.912

Maxillary sinuses

  Parietoacanthial (Waters)¶ 24 85 40″ 6″ × 6″ (15 × 15 cm) 16** 2.280 8** 1.133

Maxillary and sphenoidal sinuses

  Parietoacanthial (open-mouth 24 85 40″ 6″ × 6.5″ (15 × 16.3 cm) 14** 2.003 7.1** 1.011
Waters)¶

Ethmoidal and sphenoidal sinuses

  SMV¶ 23 85 40″ 6.5″ × 6.5″ (16.3 × 28†† 3.900 14†† 1.948

16.3 cm)

1
ACR-AAPM-SIMM Practice Guidelines for Digital Radiography, 2007.
*kVp values are for a high-frequency generator.
†
40 inch minimum; 44 to 48 inches recommended to improve spatial resolution (mAs increase needed, but no increase in patient dose will result).
‡
AGFA CR MD 4.0 General IP, CR 75.0 reader, 400 speed class, with 6:1 (178LPI) grid when needed.
§
GE Definium 8000, with 13:1 grid when needed.
‖
All doses are skin entrance for an average adult (160 to 200 pound male, 150 to 190 pound female) at part thickness indicated.
¶
Bucky/Grid.
**Small focal spot.
††
Large focal spot.
‡‡
Nongrid.

ABBREVIATIONS USED IN
CHAPTER 20

AML Acanthiomeatal line

EAM External acoustic meatus
GML Glabellomeatal line
IAM Internal acoustic meatus
IOML Infraorbitomeatal line
IPL Interpupillary line
MML Mentomeatal line
OID Object-to-IR distance
OML Orbitomeatal line
TEA Top of ear attachment
TMJ Temporomandibular joint

See Addendum B for a summary of all

abbreviations used in Volume 2.

284
 SKULL RADIOGRAPHY

Skull Topography
The basic localization points and planes of
the skull (all of which can be seen or pal-
pated) used in radiographic positioning
are illustrated in Figs. 20-37 and 20-38.
Accurate positioning of the skull
requires a full understanding of these
landmarks, which should be studied thor-
oughly before positioning of the skull is
learned. The planes, points, lines, and
abbreviations most frequently used in
skull positioning are as follows:
• Midsagittal plane
• Interpupillary line
• Acanthion
• Outer canthus
• Infraorbital margin
• EAM
• Orbitomeatal line (OML)
• Infraorbitomeatal line (IOML)
• Acanthiomeatal line (AML)
• Mentomeatal line (MML)
In an adult, an average 7-degree angle
difference exists between the OML and
the IOML, and an average 8-degree angle
difference exists between the OML and
the glabellomeatal line. The degree differ-
ence between the cranial positioning lines
must be recognized. Often the relationship
of the patient, IR, and central ray is the
same, but the angle that is described may
vary depending on the cranial line of
reference.

Skull Topography
Midsagittal plane
Top of ear
attachment

Glabella Glabelloalveolar line

Auricle

Glabella
Outer
Interpupillary line
canthus
l lin
e Nasion
Inner canthus ata atal line
Infraorbital me e
b elloOrbitom
margin Gla Infraorbitomeatal line
Acan
thiom
M eata
en l line
Nasion External
to
m Acanthion
ea
Angle of Acanthion acoustic meatus ta
l lin
mandible e
(gonion)
Mental point
Angle of mandible (gonion) Mental point

Fig. 20-37  Anterior landmarks. Fig. 20-38  Lateral landmarks.

285
 Skull Morphology
All radiographic images of the skull are
based on the normal size and shape of the
cranium. Rules have been established for
centering and adjustment of localization
points and planes and for the exact degree
of central ray angulation for each projec-
tion. Although the heads of many patients
fall within the limits of normality and can
be radiographed satisfactorily using estab-
lished positions, numerous skulls vary
enough in shape that the standard proce-
dure must be adjusted to obtain an undis-
torted image.
In the typically shaped head (see Fig.
20-36), the petrous pyramids project ante-
riorly and medially at an angle of 47
degrees from the midsagittal plane of the
skull. The superior borders of these struc-
Skull, Facial Bones, and Paranasal Sinuses
tures are situated in the base of the
cranium.
47°
Fig. 20-39  Mesocephalic skull.
286
Depending on its shape, the atypical
cranium requires more or less rotation of
the head or an increase or decrease in
angulation of the central ray compared
with the typical, or mesocephalic, skull
(Fig. 20-39). In the brachycephalic skull
(Fig. 20-40), which is short from front to
back, broad from side to side, and shallow
from vertex to base, the internal structures
are higher with reference to the IOML,
and their long axes are more frontal in
position (i.e., the petrous pyramids form a
wider angle with the midsagittal plane).
The petrous pyramids lie at an average
angle of 54 degrees. In the dolichoce-
phalic skull (Fig. 20-41), which is long
from front to back, narrow from side to
side, and deep from vertex to base, the
internal structures are lower with refer-
ence to the IOML, and their long axes are
less frontal in position (i.e., the petrous
54°
Fig. 20-40  Brachycephalic skull.
pyramids form a narrower angle with the
midsagittal plane). The petrous pyramids
form an average angle of 40 degrees in the
dolichocephalic skull.
Asymmetry must also be considered.
The orbits are not always symmetric in
size and shape, the lower jaw is often
asymmetric, and the nasal bones and car-
tilage are frequently deviated from the
midsagittal plane. Many deviations are
not as obvious as these, but if the radiog-
rapher adheres to the fundamental rules of
positioning, relatively little difficulty is
encountered. Varying the position of the
part or the degree of central ray angulation
to compensate for structural variations
becomes a simple procedure if care and
precision are used initially.
40°
Fig. 20-41  Dolichocephalic skull.
 If possible, the radiography student
should obtain a dry skull specimen and
image it in the standard positions. This is
the best technique for studying the
anatomy of different parts of the cranium
from actual and radiographic standpoints.
It is important to compare the actual struc-
ture (its position in the head, its relation-
ship to adjacent structures in each
radiographic position, and its relationship
to the IR and the central ray angulation)
with the resultant image. In this way,
the radiographer can develop the ability
to look at a head as though it were
transparent—to visualize the location and
direction of the internal parts according to
the shape of the cranium. By studying the
image cast by the part being examined
with reference to its relationship to the
images of adjacent structures, the radiog-
rapher learns to detect quickly and accu-
rately any error in the image and any
Fig. 20-42  Correct rotation clearly showing optic canal (arrow).
deviation from the normal cranium that
requires compensation.
It is also advisable to keep a complete
set of radiographic images of a normally
shaped skull. These images can be used
for comparison with atypical skulls in
determining the deviation and the correct
adjustment to make in the degree and
direction of part rotation or central ray
angulation. Radiographic examples of
correct and incorrect skull rotation are
shown in Figs. 20-42 and 20-43.
The radiographic positions depicted in
Chapter 20 show the patient seated at the
vertical grid device or lying on a radio-
graphic table. Whether the radiographer
elects to perform the examination with the
patient in the recumbent or upright posi-
tion depends on four variables: (1) the
equipment available, (2) the age and con-
dition of the patient, (3) the preference of
the radiographer and/or radiologist, and
Fig. 20-43  Incorrect rotation for optic canal (arrow).
(4) whether upright images would increase
diagnostic value, such as showing air-fluid
levels in paranasal sinuses.
With the exception of paranasal sinuses,
which should be radiographed upright,
the remaining radiographic positions
are shown with the patient either upright
or recumbent. Comparable images can
usually be obtained with the patient either
upright or recumbent. For example, a re-
cumbent skull image can also be obtained
with the patient upright as long as the
OML and central ray angulation remain
constant. Therefore unless specifically
noted in the text, the photographic illustra-
tion does not constitute a recommenda-
tion for performing the examination with
the patient in the upright or recumbent
position. Line drawings illustrating both
Skull Morphology
table and upright radiography are included
for most radiographic positions in this
chapter.
287
 Technical
Considerations
GENERAL BODY POSITION
The position of the body is important in
radiography of the skull. Uncomfortable
body position resulting in rotation or other
motion is responsible for most repeat
examinations. The radiographer, engrossed
in adjusting the patient’s head, may forget
that the head is attached to a body. If the
body is not correctly adjusted, this places
so great a strain on the muscles that they
cannot support the position. This is espe-
cially true when recumbent positions are
used for skull radiography. Some guide-
lines to alleviate strain and facilitate accu-
rate positioning are as follows:
• To prevent lateral rotation of the head,
Skull, Facial Bones, and Paranasal Sinuses
place the patient’s body so that its long
axis, depending on the image, either
coincides with or is parallel to the
midline of the radiographic table. To
prevent superior or inferior pull on the
head, resulting in longitudinal angula-
tion or tilt, place the patient’s body so
that the long axis of the cervical verte-
brae coincides with the level of the mid-
point of the foramen magnum.
• Support any elevated part, such as the
patient’s shoulder or hip, on a pillow or
sandbags to relieve strain.
• For examinations of hyposthenic or
asthenic patients, elevate the patient’s
chest on a small pillow to raise the cer-
vical vertebrae to the correct level for
the lateral, PA, and oblique projections
when the patient is recumbent.
• For examination of obese or hypersthe-
nic patients, elevate the patient’s head
on a radiolucent pad to obtain the
correct part-IR relationship if needed.
An advantage of a head unit is that it
simplifies handling of these patients.
288
• While adjusting the body, stand in a
position that facilitates estimation of
the approximate part position. For
example, stand so that the longitudinal
axis of the radiographic table is visible
as the midsagittal plane of the body is
being centered. This allows the anterior
surface of the forehead to be viewed
while the degree of body rotation for a
lateral projection of the skull is adjusted.
Therefore the body can be adjusted in
such a way that it does not interfere
with the final adjustment of the head,
and the final position is comfortable for
the patient.
When the body is correctly placed and
adjusted so that the long axis of the cervi-
cal vertebrae is supported at the level of
the foramen magnum, the final position
of the head requires only minor adjust-
ments. The average patient can maintain
this relatively comfortable position with­
out the aid of elaborate immobilization
devices, although the following tech-
niques may be helpful:
• If necessary, apply a head clamp with
equal pressure on the two sides of the
head.
• If such a clamp is not available, use a
strip of adhesive tape where it will not
be projected onto the image. The portion
of the tape touching the hair should
have the adhesive side covered with a
second piece of tape so that the hairs
are not pulled out when the tape is
removed. Do not place adhesive tape
directly on the patient’s skin.
• When the area to be exposed is small,
immobilize the head with sandbags
placed against the sides or vertex.
Correct basic body positions and
compensatory adjustments for recumbent
radiography are illustrated in Figs. 20-44
to 20-51.
CLEANLINESS
The hair and face are naturally oily and
leave a residue, even with the most
hygienic patients. If the patient is sick, the
residue is worse. During positioning of the
skull, the patient’s hair, mouth, nose, and
eyes come in direct contact with the
vertical grid device, tabletop, or IR. For
medical asepsis, a paper towel or a cloth
sheet may be placed between the imaging
surface and the patient. As part of standard
procedure, the contacted area should be
cleaned with a disinfectant before and
after positioning.
Radiation Protection
Protection of the patient from unnecessary
radiation is a professional responsibility
of the radiographer (see Chapter 1 for spe-
cific guidelines). In this chapter, radiation
shielding of the patient is not specified or
illustrated. The federal government has
reported that placing a lead shield over a
patient’s pelvis does not significantly
reduce gonadal exposure during imaging
of the skull, facial bones, or sinuses.1 Lead
shields should be used to reassure the
patient, however, and shielding the
abdomen of a pregnant woman is recom-
mended by the authors of this atlas.
Infants and children should receive
radiation shielding of the thyroid and
thymus glands and the gonads. The pro-
tective lead shielding used to cover the
thyroid and thymus glands can also assist
in immobilizing pediatric patients.
The most effective way to protect the
patient from unnecessary radiation is to
restrict the radiation beam by using proper
collimation. Taking care to ensure that the
patient is properly instructed and immobi-
lized also reduces the likelihood of having
to repeat the procedure, further limiting
the radiation exposure received by the
patient.
1
HEW 76-8013 Handbook of Selected Organ Doses.
 Technical Considerations
A B
Fig. 20-44  Horizontal sagittal plane (dashed lines). Fig. 20-45  Adjusting sagittal planes to horizontal position. A, Asthenic or hyposthenic
patient. B, Angulation corrected.

A B
Fig. 20-46  Horizontal sagittal plane. Fig. 20-47  Adjusting sagittal plane to horizontal position. A, Hypersthenic patient.
B, Angulation corrected.

289
 A B
Fig. 20-48  Perpendicular sagittal plane (dashed Fig. 20-49  Adjusting OML to vertical position. A, Hypersthenic or round-shouldered
lines). patient. B, Angulation corrected.
Skull, Facial Bones, and Paranasal Sinuses

A B
Fig. 20-50  Perpendicular sagittal plane (dashed Fig. 20-51  Adjusting OML to vertical position. A, Correction for hyposthenic patient.
lines). B, Correction for hypersthenic patient.

290
 Cranium
  LATERAL PROJECTION
R or L position
Image receptor: 10 × 12 inch (24 ×
30 cm) crosswise
Position of patient
• Place the patient in the anterior oblique
position, seated upright or recumbent.
• If recumbent anterior oblique position
is used, have the patient rest on the
forearm and flex the knee of the ele-
vated side.
Position of part
• With the side of interest closest to the
IR, place one hand under the mandibu-
lar region and the opposite hand on the
upper parietal region of the patient’s
head to help guide it into a true lateral
position.
• Adjust the patient’s head so that the
midsagittal plane is parallel to the plane
of the IR. If necessary, place a support
under the side of the mandible to
prevent it from sagging.
• Adjust the flexion of the patient’s neck
so that the IOML is perpendicular to the
front edge of the IR. The IOML also
should be parallel to the long axis of
the IR.
• Check the head position so that the
interpupillary line is perpendicular to
the IR (Figs. 20-52 and 20-53).
• Immobilize the head.
• Respiration: Suspend.
Central ray
• Perpendicular, entering 2 inches (5 cm)
superior to the EAM
• Center the IR to the central ray.
Collimation
• Adjust to 10 × 12 inches (24 × 30 cm)
on the collimator.
Structures shown
This lateral image of the superimposed
halves of the cranium shows the detail of
the side adjacent to the IR. The sella
turcica, anterior clinoid processes, dorsum
sellae, and posterior clinoid processes
are well shown in the lateral projection
(Fig. 20-54).
EVALUATION CRITERIA
The following should be clearly shown:
■ Evidence of proper collimation
■ Entire cranium without rotation or tilt,
demonstrated by:
□ Superimposed orbital roofs and
Cranium
greater wings of sphenoid
□ Superimposed mastoid regions and
EAM
□ Superimposed TMJs
□ Sella turcica in profile
■ Penetration of parietal region
■ No overlap of cervical spine by
mandible
291
 Cranium

CR
Skull, Facial Bones, and Paranasal Sinuses

A
B
Fig. 20-52  A, Lateral skull, recumbent position. B, Table radiography diagram: lateral
skull.

CR

A
B
Fig. 20-53  A, Lateral skull, upright position. B, Upright radiography diagram: lateral skull.

292
Cranium

Supraorbital margin

Sella turcica

External acoustic meatus

Temporomandibular joint

Petrous portion of

Cranium
temporal bone
A

B
Fig. 20-54  A, Right lateral skull. B, Left lateral skull.

(Courtesy of St. Bernard’s Medical Center, Jonesboro, AR.)

293
 Cranium

  LATERAL PROJECTION Supine lateral EVALUATION CRITERIA

Dorsal decubitus or supine
lateral position
R or L position
Dorsal decubitus
• With the patient supine, adjust the
shoulders to lie in the same horizontal
plane.
• After ruling out cervical injury, place
the side of interest closest to the verti-
cally placed grid IR. Elevate the
patient’s head enough to center it to the
IR, and then support it on a radiolucent
sponge.
• Adjust the patient’s head so that the
midsagittal plane is vertical and the
interpupillary line is perpendicular to
the IR (Fig. 20-55).
Skull, Facial Bones, and Paranasal Sinuses
• Place the patient in a supine or recum-
bent posterior oblique position, and
turn the head toward the side being
examined.
• Elevate and support the opposite shoul-
der and hip enough that the midsagittal
plane of the head is parallel and the
interpupillary line is perpendicular to
the IR.
• Support the patient’s head with a radio-
lucent sponge.
• Direct the central ray perpendicular to
enter 2 inches (5 cm) superior to the
EAM (Fig. 20-57).
• Center the IR to the central ray.
Structures shown
This lateral image of the superimposed
The following should be clearly shown:
■ Evidence of proper collimation
■ Entire cranium without rotation or tilt,
demonstrated by:
□ Superimposed orbital roofs and
greater wings of sphenoid
□ Superimposed mastoid regions and
EAM
□ Superimposed TMJs
□ Sella turcica in profile
■ Penetration of parietal region
■ No overlap of cervical spine by
mandible

• Direct the central ray perpendicular to halves of the cranium shows the detail of
the IR, and center it 2 inches (5 cm) the side adjacent to the IR. The sella
superior to the EAM. turcica, anterior clinoid processes, dorsum
• Robinson et al.1 recommended using sellae, and posterior clinoid processes
the dorsal decubitus lateral projection are well shown in the lateral projection
to show traumatic sphenoid sinus effu- (Fig. 20-58).
sion (Fig. 20-56). They stated that this
finding may be the only clue to the pres-
ence of a basal skull fracture.
1
Robinson AE et al: Traumatic sphenoid sinus effu-
sion, AJR Am J Roentgenol 101:795, 1967.

294
 Cranium

Fig. 20-55  Dorsal decubitus lateral skull. Fig. 20-57  Lateral skull with patient supine.

Cranium
R

Coronal suture

Orbital roof

Sella turcica

Sphenoidal sinus

Petrous portion of temporal bone

Temporomandibular joint

External acoustic meatus

Mandibular rami
Fig. 20-56  Dorsal decubitus lateral skull showing
sphenoid sinus effusion (arrows). A

B
Fig. 20-58  A, Lateral skull. B, Lateral skull showing surgical
removal of frontal bone.

295
 Cranium
  PA PROJECTION
  PA AXIAL PROJECTION
CALDWELL METHOD
Image receptor: 10 × 12 inch (24 ×
30 cm) lengthwise
Position of patient
• Place the patient in a prone or seated
position.
• Center the midsagittal plane of the
patient’s body to the midline of the grid.
• Rest the patient’s forehead and nose on
the table or against the upright Bucky.
• Flex the patient’s elbows, and place the
arms in a comfortable position.
Skull, Facial Bones, and Paranasal Sinuses
296
Position of part
• Adjust the flexion of the patient’s neck
so that the OML is perpendicular to the
plane of the IR.
• If the patient is recumbent, support the
chin on a radiolucent sponge if needed.
• If the patient is obese or hypersthenic,
a small radiolucent sponge may need to
be placed under (or in front of) the
forehead.
• Align the midsagittal plane perpendicu-
lar to the IR. This is accomplished by
adjusting the lateral margins of the
orbits or the EAM equidistant from the
tabletop.
• Immobilize the patient’s head, and
center the IR to the nasion (Figs. 20-59
to 20-62).
• Respiration: Suspend.
Central ray
• For the PA projection, when the frontal
bone is of primary interest, direct the
central ray perpendicular to exit the
nasion.
• For the Caldwell method, direct the
central ray to exit the nasion at an angle
of 15 degrees caudad.
• Center the IR to the central ray.
• To show the superior orbital fissures,
direct the central ray through the mid-
orbits at an angle of 20 to 25 degrees
caudad.
• To show the rotundum foramina, direct
the central ray to the nasion at an angle
of 25 to 30 degrees caudad. (The Waters
method, presented in the Sinus Radiog-
raphy section is also used to show the
rotundum foramina.)
Collimation
• Adjust to 10 × 12 inches (24 × 30 cm)
on the collimator.
 Cranium

15°

Fig. 20-59  PA skull: central ray angulation of 0 degrees for Fig. 20-60  PA axial skull: Caldwell method with central ray
frontal bone. angulation of 15 degrees.

Cranium
CR

15° CR
15º

Fig. 20-61  Table radiography diagram: Caldwell method. Fig. 20-62  Upright radiography diagram: Caldwell method.

297
 Cranium

R R

(R) Parietal bone

Frontal bone

Dorsum sella

Superior orbital margin

Petrous ridge

Crista galli

Ethmoid sinus
Skull, Facial Bones, and Paranasal Sinuses

Fig. 20-63  PA skull with perpendicular central ray. (Courtesy of St. Bernard’s Medical Center,
Jonesboro, AR.)

R R

Frontal sinus

Crista galli

Superior
orbital margin

Superior
orbital fissure
Ethmoidal sinus

Petrous ridge
Inferior orbital
margin

Fig. 20-64  PA axial skull: Caldwell method with 15-degree caudal central ray angulation.

298
 Cranium
Structures shown
For the PA projection with a perpendicular
central ray (Fig. 20-63), the orbits are
filled by the margins of the petrous pyra-
mids. Other structures shown include the
posterior ethmoidal air cells, crista galli,
frontal bone, and frontal sinuses. The
dorsum sellae is seen as a curved line
extending between the orbits, just above
the ethmoidal air cells.
When the central ray is angled 15
degrees caudad to the nasion for the PA
axial projection, Caldwell method, many
of the same structures that appear in the
PA projection are seen (Fig. 20-64);
however, the petrous ridges are projected
into the lower third of the orbits. The
Caldwell method also shows the anterior
ethmoidal air cells. Schüller,1 who first
described this positioning for the skull,
recommended a caudal angle of 25
degrees.
1
Schüller A: Die Schädelbasis im Rontgenbild,
Fortschr Roentgenstr 11:215, 1905.
Stretcher and bedside examinations
Lateral decubitus position
• When the patient cannot be turned to
the prone position for the PA or PA axial
Caldwell projection, and cervical spinal
injury has been ruled out, elevate one
side enough to place the patient’s head
in a true lateral position, and support
the shoulder and hip on pillows or sand-
bags if needed.
• Elevate the patient’s head on a suitable
support, and adjust its height to center
the midsagittal plane of the head to a
vertically positioned grid.
• Adjust the patient’s head so that the
OML is perpendicular to the plane of
the IR (Fig. 20-65).
• Direct the horizontal central ray per-
pendicular, or 15 degrees caudad, to
exit the nasion.
Fig. 20-65  PA skull with patient semi-supine.
EVALUATION CRITERIA
The following should be clearly shown:
■ Evidence of proper collimation
■ Entire cranium without rotation or tilt,
demonstrated by:
□ Equal distances from lateral borders
of skull to lateral borders of orbits on
both sides
□ Symmetric petrous ridges
□ MSP of cranium aligned with long
axis of collimated field
■ PA axial (Caldwell) demonstrates
petrous pyramids lying in lower third of
orbit
■ PA projection shows orbits filled by
petrous ridges
■ Entire cranial perimeter showing three
distinct tables of squamous bone
■ Penetration of frontal bone with appro-
Cranium
priate brightness at lateral borders of
skull
299
 Cranium
  AP PROJECTION
  AP AXIAL PROJECTION
Image receptor: 10 × 12 inch (24 ×
30 cm) lengthwise
When the patient cannot be positioned
for a PA or PA axial projection, a similar
but magnified image can be obtained with
an AP projection.
Position of patient and part
• Position the patient supine with the
midsagittal plane of the body centered
to the grid.
• Ensure that the midsagittal plane and
the OML are perpendicular to the IR.
Skull, Facial Bones, and Paranasal Sinuses
300
Central ray
• Perpendicular (Fig. 20-66) or directed
to the nasion at an angle 15 degrees
cephalad (Fig. 20-67)
• Center IR to the central ray
Collimation
• Adjust to 10 × 12 inches (24 × 30 cm)
on the collimator.
Structures shown
The structures shown on the AP projection
are the same as the structures shown on
the PA projection. On the AP projection
(Fig. 20-68), the orbits are considerably
magnified because of the increased object–
to–image receptor distance (OID). Simi-
larly, because of the magnification, the
distance from the lateral margin of the
orbit to the lateral margin of the temporal
bone measures less on the AP projection
than on the PA projection.
EVALUATION CRITERIA
The following should be clearly shown:
■ Evidence of proper collimation
■ Entire cranium without rotation or tilt,
demonstrated by:
□ Equal distances from lateral borders
of skull to lateral borders of orbits on
both sides
□ Symmetric petrous ridges
□ MSP of cranium aligned with long
axis of collimated field
■ Petrous pyramids lying in lower third
of orbit with a cephalad central ray
angulation of 15 degrees and filling
orbits with a 0-degree central ray
angulation
■ Entire cranial perimeter showing three
distinct areas of squamous bone
■ Penetration of frontal bone with appro-
priate brightness at lateral borders of
skull
Cranium

15°

Fig. 20-66  AP skull. Fig. 20-67  AP axial skull with 15-degree cephalad central ray.

Cranium
R

Fig. 20-68  AP skull with perpendicular central ray.

301
 Cranium
  AP AXIAL PROJECTION
TOWNE METHOD
Image receptor: 10 × 12 inch (24 ×
30 cm) lengthwise
NOTE: Although this technique is most com-
monly referred to as the Towne method,1 numer-
ous authors have described slightly different
variations. In 1912, Grashey2 published the first
description of the AP axial projection of the
cranium. In 1926, Altschul3 and Towne1 described
the position. Altschul recommended strong
depression of the chin and direction of the central
ray through the foramen magnum at a caudal
angle of 40 degrees. Towne (citing Chamberlain)
recommended that with the patient’s chin
depressed, the central ray should be directed
through the midsagittal plane from a point about
3 inches (7.6 cm) above the eyebrows to the
Skull, Facial Bones, and Paranasal Sinuses
foramen magnum. Towne gave no specific central
ray angulation, but the angulation would depend
on the flexion of the neck.
1
Towne EB: Erosion of the petrous bone by acoustic
nerve tumor, Arch Otolaryngol 4:515, 1926.
2
Grashey R: Atlas typischer Röntgenbilder vom nor-
malen Menschen. In Lehmann’s medizinische Atlan-
ten, ed 2, vol 5, Munich, 1912, JF Lehmann.
3
Altschul W: Beiträg zur Röntgenologie des Gehör-
organes, Z Hals Nas Ohr 14:335, 1926.
302
Position of patient
• With the patient supine or seated
upright, center the midsagittal plane of
the patient’s body to the midline of the
grid.
• Place the patient’s arms in a comfort-
able position, and adjust the shoulders
to lie in the same horizontal plane.
• To ensure the patient’s comfort without
increasing the IR distance, examine the
hypersthenic or obese patient in the
seated-upright position if possible.
• The skull can be brought closer to the
IR by having the patient lean back lor-
dotically and rest the shoulders against
the vertical grid device. When this
is impossible, the desired projection
of the occipitobasal region may be
obtained by using the PA axial projec-
tion described by Haas (pp. 308-309).
The Haas method is the reverse of the
AP axial projection and produces a
comparable result.
Position of part
• Adjust the patient’s head so that the
midsagittal plane is perpendicular to the
midline of the IR.
• Flex the patient’s neck enough to place
the OML perpendicular to the plane of
the IR.
• When the patient cannot flex the neck
to this extent, adjust the neck so that
the IOML is perpendicular and then
increase the central ray angulation by 7
degrees (Figs. 20-69 to 20-72).
• Position the IR so that its upper margin
is at the level of the highest point of
the cranial vertex. This places the center
at or near the level of the foramen
magnum.
• For a localized image of the dorsum
sellae and petrous pyramids, adjust the
IR so that its midpoint coincides with
the central ray. The IR is centered at or
slightly below the level of the occlusal
plane.
• Recheck the position and immobilize
the head.
• Respiration: Suspend.
Cranium

30°

30°

Fig. 20-69  AP axial skull: Towne method, upright position. Fig. 20-70  AP axial skull: Towne method, supine position.

Cranium
CR

CR 37°
30°

Fig. 20-71  Upright radiography diagram: AP axial skull: Towne method. Same
radiographic result with central ray directed 30 degrees to OML or 37 degrees to IOML.

CR
CR

30°
37°

Fig. 20-72  Table radiography diagram: AP axial skull: Towne method.

303
 Cranium
Central ray
• Directed through the foramen magnum
at a caudal angle of 30 degrees to the
OML or 37 degrees to the IOML. The
central ray enters approximately 2 1 2
inches (6.3 cm) above the glabella and
passes through the level of the EAM.
Collimation
• Adjust to 10 × 12 inches (24 × 30 cm)
on the collimator.
Skull, Facial Bones, and Paranasal Sinuses
304
Structures shown
The AP axial projection shows a symmet-
ric image of the petrous pyramids, the
posterior portion of the foramen magnum,
the dorsum sellae, and the posterior clinoid
processes projected within the foramen
magnum, the occipital bone, and the pos-
terior portion of the parietal bones (Fig.
20-73). This projection is also used for
tomographic studies of the ears, facial
canal, jugular foramina, and rotundum
foramina.
EVALUATION CRITERIA
The following should be clearly shown:
■ Evidence of proper collimation
■ Entire cranium, without rotation or tilt,
demonstrated by:
□ Equal distances from lateral borders
of skull to lateral margins of foramen
magnum on both sides
□ Symmetric petrous pyramids
□ MSP of cranium aligned with long
axis of collimated field
■ Dorsum sellae and posterior clinoid pro-
cesses visible within foramen magnum
■ Penetration of occipital bone with
appropriate brightness at lateral borders
of skull
Cranium

Parietal bone

Occipital bone

Foramen
magnum

Petrous ridge
Posterior
clinoid process

Cranium
Dorsum sellae

Fig. 20-73  AP axial skull: Towne method with 30-degree central ray angulation to OML.

305
 Cranium

Pathologic condition or trauma
To show the entire foramen magnum, the
caudal angulation of the central ray is
increased from 40 to 60 degrees to the
OML (Figs. 20-74 to 20-78).
Lateral decubitus position • Immobilize the IR and grid in a vertical
For pathologic conditions, trauma, or a position behind the patient’s occiput.
deformity such as a strongly accentuated • Direct the horizontal central ray
dorsal kyphosis when the patient cannot 30 degrees caudally to the OML
be examined in a direct supine or prone (Fig. 20-79).
position, the following steps should be
taken:
• Adjust and support the body in a semi-
recumbent position; this allows the
head to be placed in a true lateral
position.

45°
Skull, Facial Bones, and Paranasal Sinuses

Fig. 20-74  AP axial skull, Towne method, on a trauma patient. Fig. 20-75  AP axial skull: central ray angulation of 40 to 45
OML and IOML lines are not perpendicular, which would degrees.
require central ray angulation greater than 37 degrees.

Occipital bone

Foramen magnum

Petrous ridge

Posterior arch of C1

Mandibular condyle

Fig. 20-76  AP axial skull: central ray angulation of 45 degrees.

306
Cranium

55°

Fig. 20-77  AP axial foramen magnum, supine position.

Cranium
Posterior
arch of C1

Dens

Fig. 20-78  AP axial foramen magnum: 55-degree caudal central Fig. 20-79  AP axial skull, with the patient’s head in
ray. lateral decubitus position and with IR and grid
vertical.

307
 Cranium

  PA AXIAL PROJECTION
25°
HAAS METHOD
Haas1 devised this projection for obtaining
an image of the sellar structures projected
within the foramen magnum on hyper-
sthenic, obese, or other patients who
cannot be adjusted correctly for the AP
axial (Towne) projection.

Image receptor: 10 × 12 inch (24 ×

30 cm) lengthwise

Position of patient
• Adjust the patient in the prone or
seated-upright position, and center the
midsagittal plane of the body to the
midline of the grid.
Fig. 20-80  PA axial skull: Haas method. • Flex the patient’s elbows, place the
arms in a comfortable position, and
Skull, Facial Bones, and Paranasal Sinuses

adjust the shoulders to lie in the same

horizontal plane.

Position of part
• Rest the patient’s forehead and nose on
the table, with the midsagittal plane
perpendicular to the midline of the grid.
• Adjust the flexion of the neck so that
the OML is perpendicular to the IR (see
Figs. 20-80 to 20-82).
• Immobilize the head.
• For a localized image of the sellar
CR
region or the petrous pyramids, or both,
adjust the position of the IR so that the
midpoint coincides with the central ray;
shift the IR cephalad approximately 3
inches (7.6 cm) to include the vertex of
25° the skull. An 8 × 10-inch (18 × 24-cm)
IR is recommended.
• Respiration: Suspend.
11/2"

11/2"
11/2" Central ray
• Directed at a cephalad angle of 25
degrees to the OML to enter a point 1 1 2
inches (3.8 cm) below the external
25°
occipital protuberance (inion) and to
CR 11/2"
exit approximately 1 1 2 inches (3.8 cm)
Fig. 20-81  Upright radiography diagram: Fig. 20-82  Table radiography diagram: superior to the nasion. The central ray
PA axial skull: Haas method diagram. PA axial skull: Haas method diagram. can be varied to show other cranial
anatomy.

1
Haas L: Verfahren zur sagittalen Aufnahme der
Sellagegend, Fortschr Roentgenstr 36:1198, 1927.

308
 Cranium

Collimation
R
• Adjust to 10 × 12 inches (24 × 30 cm)
on the collimator.

Structures shown
PA axial projection shows the occipital
region of the cranium and shows a sym-
metric image of the petrous pyramids and
the dorsum sellae and posterior clinoid
processes within the foramen magnum
(Figs. 20-83 and 20-84). Occipital bone

EVALUATION CRITERIA
Foramen magnum
The following should be clearly shown:
■ Evidence of proper collimation
■ Entire cranium, without rotation or tilt,
Petrous ridge
demonstrated by:
□ Equal distances from lateral borders
Posterior clinoid process

Cranium
of skull to lateral margins of foramen
magnum on both sides
□ Symmetric petrous pyramids Dorsum sellae

□ MSP of cranium aligned with long Sphenoidal sinus

axis of collimated field Fig. 20-83  PA axial skull: Haas method, with 25-degree cephalad central ray.
■ Dorsum sellae and posterior clinoid
processes visible within foramen
magnum
■ Penetration of occipital bone with
appropriate brightness at lateral borders
of skull

Foramen
magnum

Petrous ridge
Mastoid air cells
Posterior clinoid
process

Dorsum sellae

Fig. 20-84  PA axial sella turcica: Haas method, using cylindric extension cone that
restricts collimation to small area. Beam restriction decreases scatter radiation and
increases visibility of detail of sellar structures.

309
 Cranial Base
  SUBMENTOVERTICAL
PROJECTION
SCHÜLLER METHOD
Image receptor: 10 × 12 inch (24 ×
30 cm) lengthwise
Position of patient
The success of the submentovertical
(SMV) projection of the cranial base
depends on placing the IOML as nearly
parallel with the plane of the IR as pos-
sible and directing the central ray perpen-
dicular to the IOML. The following steps
are taken:
• Place the patient in the supine or the
seated-upright position; the latter is
Skull, Facial Bones, and Paranasal Sinuses
Fig. 20-85  SMV cranial base, patient upright.
Fig. 20-87  SMV cranial base, patient supine.
310
more comfortable. If a chair that sup-
ports the back is used, the upright
position allows greater freedom in posi-
tioning the patient’s body to place the
IOML parallel with the IR. If the patient
is seated far enough away from the ver-
tical grid device, the head can usually
be adjusted without placing great pres-
sure on the neck.
• When the patient is placed in the supine
position, elevate the torso on firm
pillows or a suitable pad to allow the
head to rest on the vertex with the neck
in hyperextension.
• Flex the patient’s knees to relax the
abdominal muscles.
• Place the patient’s arms in a comfort-
able position, and adjust the shoulders
to lie in the same horizontal plane.
• Do not keep the patient in the final
adjustment longer than is absolutely
necessary because the supine position
places considerable strain on the neck.
Position of part
• With the midsagittal plane of the
patient’s body centered to the midline
of the grid, extend the patient’s neck to
the greatest extent as can be achieved,
placing the IOML as parallel as possi-
ble to the IR.
• Adjust the patient’s head so that the
midsagittal plane is perpendicular to the
IR (Figs. 20-85 to 20-88).
NOTE: Patients placed in the supine position for
the cranial base may have increased intracranial
pressure. As a result, they may be dizzy or unsta-
ble for a few minutes after having been in this
position. Use of the upright position may alleviate
some of this pressure.
CR
Fig. 20-86  Upright radiography diagram:
SMV skull.
CR
Fig. 20-88  Table radiography diagram:
SMV skull.
 Cranial Base
• Immobilize the patient’s head. In the
absence of a head clamp, place a suit-
ably backed strip of adhesive tape
across the tip of the chin and anchor it
to the sides of the radiographic unit if
needed. (The part of the tape touching
the skin should be covered.)
• Respiration: Suspend.
Central ray
• Directed through the sella turcica per-
pendicular to the IOML. The central ray
enters the midsagittal plane of the throat
between the angles of the mandible and
passes through a point 3 4 inch (1.9 cm)
anterior to the level of the EAM.
• Center the IR to the central ray. The IR
should be parallel to the IOML.
Collimation
• Adjust to 10 × 12 inches (24 × 30 cm)
on the collimator.
R R
Maxillary sinus
Ethmoidal air cells
Mandible
Sphenoidal sinus
Foramen spinosum
Mandibular condyle
Dens (odontoid
process)
Petrosa
Mastoid process
Occipital bone
Structures shown
SMV projection of the cranial base shows
symmetric images of the petrosae, the
mastoid processes, the foramina ovale and
spinosum (which are best shown in this
projection), the carotid canals, the sphe-
noidal and ethmoidal sinuses, the mandi-
ble, the bony nasal septum, the dens of the
axis, and the occipital bone. The maxillary
sinuses are superimposed over the man-
dible (Fig. 20-89).
SMV projection is also used for axial
tomography of the orbits, optic canals,
ethmoid bone, maxillary sinuses, and
mastoid processes. With a decrease in the
exposure factors, the zygomatic arches are
also well shown in this position (see sec-
tions on Facial Bone Radiography and
Sinus Radiography later in this chapter).
Fig. 20-89  SMV cranial base.
EVALUATION CRITERIA
The following should be clearly shown:
■ Evidence of proper collimation
■ Entire cranium, without tilt, demon-
strated by:
□ Equal distances from the lateral
borders of the skull to the mandibular
condyles on both sides
□ Symmetric petrosae
■ IOML is parallel to IR (full neck exten-
sion), demonstrated by:
□ Mental protuberance superimposed
over anterior frontal bone
□ Mandibular condyles anterior to
petrosae
■ Brightness and contrast sufficient to
demonstrate cranial base anatomy
NOTE: Schüller1 described and illustrated the
basal projections—SMV and verticosubmental
Cranial Base
(VSM)—but Pfeiffer2 gave specific directions for
the central ray angulation.
1
Schüller A: Die Schädelbasis im Rontgenbild,
Fortshr Reontgenstr 11:215, 1905.
2
Pfeiffer W: Beitrag zum Wert des axialen Schädel-
skiagrammes, Arch Laryngol Rhinol 30:1, 1916.
311
 Orbit
The orbits are cone-shaped, bony-walled
cavities situated on each side of the mid-
sagittal plane of the head (Fig. 20-90).
They are formed by the seven previously
described and illustrated bones of the
cranium (frontal, ethmoid, and sphenoid)
A F and the face (lacrimal, palatine, maxillary,
and zygomatic). Each orbit has a roof, a
medial wall, a lateral wall, and a floor. The
S easily palpable, quadrilateral-shaped ante-
rior circumference of the orbit is called its
E B Z
base. The apex of the orbit corresponds to
the optic foramen. The long axis of each
L orbit is directed obliquely, posteriorly, and
M
medially at an average angle of 37 degrees
C to the midsagittal plane of the head and
superiorly at an angle of about 30 degrees
Z
M
from the OML (Fig. 20-91).
Skull, Facial Bones, and Paranasal Sinuses

Fig. 20-90  Bones of left orbit of dry specimen. A, Optic canal and foramen. B, Superior
orbital fissure. C, Inferior orbital fissure. E, ethmoid; F, frontal; L, lacrimal; M, maxilla;
S, sphenoid; Z, zygomatic (palatine not shown).

30°

37°

A
Fig. 20-91  Cone-shaped orbit. A, Average angle of 37 degrees from midsagittal plane.
B, Average angle of 30 degrees superior to OML.

312
 The orbits serve primarily as bony R
sockets for the eyeballs and the structures
associated with them, but they also contain
blood vessels and nerves that pass through
openings in their walls to other regions.
The major and frequently radiographed
openings are the previously described
optic foramina and the superior and infe-
rior orbital sulci.
The superior orbital fissure is the cleft
between the greater and lesser wings of
the sphenoid bone. From the body of the
sphenoid at a point near the orbital apex,
this sulcus extends superiorly and laterally
between the roof and the lateral wall of
the orbit. The inferior orbital fissure is the
narrow cleft extending from the lower
anterolateral aspect of the sphenoid body
anteriorly and laterally between the floor

Orbit
and lateral wall of the orbit. The anterior
margin of the cleft is formed by the orbital
plate of the maxilla, and its posterior
margin is formed by the greater wing of
the sphenoid bone and the zygomatic Fig. 20-92  Parietoacanthial orbits using Waters method and
bone. showing blowout fracture of orbit (arrows).
Because the walls of the orbits are thin,
they are subject to fracture. When a person
is forcibly struck squarely on the eyeball
(e.g., by a fist, by a piece of sporting
equipment), the resulting pressure directed
to the eyeball forces the eyeball into the
cone-shaped orbit and “blows out” the
thin, delicate bony floor of the orbit (Figs.
20-92 and 20-93). The injury must be
diagnosed and treated accurately so that
the person’s vision is not jeopardized.
Blowout fractures may be shown using
any combination of images obtained with
the patient positioned for parietoacanthial
projections (Waters method), radiographic
tomography, or computed tomography
(CT).

Fig. 20-93  Tomogram: AP projection showing fracture (arrow) in the same patient as in
Fig. 20-92.

313
 Eye
The organ of vision, or eye (Latin, oculus;
Greek, ophthalmos), consists of the fol-
lowing: eyeball; optic nerve, which con-
nects the eyeball to the brain; blood
vessels; and accessory organs such as
extrinsic muscles, lacrimal apparatus, and
eyelids (Figs. 20-94 and 20-95).
Skull, Facial Bones, and Paranasal Sinuses
Crystalline lens
Retina
Zygoma
Fig. 20-94  Diagrammatic horizontal section of right orbital region: top-down view.
314
The eyeball is situated in the anterior
part of the orbital cavity. Its posterior
segment (about two thirds of the bulb) is
adjacent to the soft parts that occupy the
remainder of the orbital cavity (chiefly
muscles, fat, and connective tissue). The
anterior portion of the eyeball is exposed
and projects beyond the base of the orbit.
Bone-free radiographic images of the ante-
Conjunctiva
Cornea Pupil
Iris
Vitreous body
Brain
rior segment of the eye can be obtained.
The exposed part of the eyeball is covered
by a thin mucous membrane known as the
conjunctiva, portions of which line the
eyelids. The conjunctival membrane is
kept moist by tear secretions from the lac-
rimal gland. These secretions prevent
drying and friction irritation during move-
ments of the eyeball and eyelids.
Lacrimal sac
Orbital fat
Optic nerve
Optic foramen
Optic canal
 The outer, supporting coat of the eyeball
is a firm, fibrous membrane consisting of
a posterior segment called the sclera and
an anterior segment called the cornea. The
opaque, white sclera is commonly referred
to as the “white of the eye.” The cornea is
situated in front of the iris, with its center
point corresponding to the pupil. The
corneal part of the membrane is transpar-
ent, allowing the passage of light into the
eyeball, and it serves as one of the four
refractive media of the eye.
Optic nerve
Fig. 20-95  Diagrammatic sagittal section of right orbital region.
The inner coat of the eyeball is called
the retina. This delicate membrane is con-
tiguous with the optic nerve. The retina is
composed chiefly of nervous tissue and
several million minute receptor organs,
called rods and cones, which transmit
light impulses to the brain. The rods
and cones are important radiographically
because they play a role in the ability of
the radiologist or radiographer to see the
fluoroscopic image. Their function is
described in discussions of fluoroscopy
in radiography physics and imaging
textbooks.
Eye
Frontal sinus
Frontal bone
Eyeball
Lens
Conjunctiva
Cornea
Maxillary
sinus
Maxilla
315
 LOCALIZATION OF FOREIGN
BODIES WITHIN ORBIT OR EYE
Ultrasonography and CT (Fig. 20-96)
have been increasingly used to locate
foreign bodies in the eye. (Magnetic reso-
nance imaging [MRI] is not used for
foreign body localization because move-
ment of a metallic foreign object by the
magnetic field could lead to hemorrhage
or other serious complications.) Whether
an ultrasound or a radiographic approach
is used, accurate localization of foreign
particles lodged within the orbit or eye
requires the use of a precision localization
technique.
Localization methods removed
The Vogt method, Sweet method, Pfeiffer-
Comberg method, and parallax motion
Skull, Facial Bones, and Paranasal Sinuses
method are sometimes used to localize
foreign bodies in the eye. These methods
were described briefly in the eighth
edition of this atlas. Complete descrip-
tions appeared in the seventh and earlier
editions.
A B
Fig. 20-96  A, Lateral localizer CT image showing multiple buckshot in the face. B, Axial
CT image of same patient, showing shotgun pellets within the eye (arrows).
316
Image quality
Ultrafine recorded detail is essential for
detecting and localizing minute foreign
particles within the orbit or eyeball. The
following are required:
1. The geometric unsharpness must be
reduced as much as possible by the use
of a close OID and a small, undamaged
focal spot at a source–to–image recep-
tor distance (SID) that is as long as is
consistent with the exposure factors
required.
2. Secondary radiation must be mini-
mized by close collimation.
3. Motion must be eliminated by firmly
immobilizing the patient’s head and
by having the patient gaze steadily
at a fixed object, immobilizing the
eyeballs.
An artifact can cast an image that simu-
lates the appearance of a foreign body
located within the orbit or eye. IRs and
screens must be impeccably clean before
each examination. In institutions and
clinics that often perform these examina-
tions, an adequate number of IR holders
are kept in reserve for eye studies only.
This measure protects them from the wear
of routine use in less critical procedures.
PRELIMINARY EXAMINATION
Lateral projections, PA projections, and
bone-free studies are performed to deter-
mine whether a radiographically demon-
strable foreign body is present. For these
images, the patient may be placed in the
recumbent position or may be seated
upright before a vertical grid device.
These projections may be used for metal-
lic foreign body screening before MRI
procedures are performed.
 Eye

LATERAL PROJECTION
R or L position
A nongrid (very high-resolution) tech-
nique is recommended to reduce magnifi-
cation and eliminate possible artifacts in
or on the radiographic table and grid. The
following steps are taken:
• With the patient semi-prone or seated
upright, place the outer canthus of the
affected eye adjacent to and centered
over the midpoint of the IR.
• Adjust the patient’s head to place the
midsagittal plane parallel with the plane
of the IR and the interpupillary line per-
pendicular to the IR plane.
• Respiration: Suspend.

Central ray Fig. 20-97  Lateral projection for orbital foreign body localization.
• Perpendicular through the outer canthus

Eye
• Instruct the patient to look straight
ahead for the exposure (Figs. 20-97 and
20-98).

EVALUATION CRITERIA
The following should be clearly shown:
■ Entire orbit(s)
■ No rotation, demonstrated by:
□ Superimposed orbital roofs
■ Close beam restriction centered to
orbital region
■ Brightness and contrast permitting
optimal visibility of orbit and eye for R
localization of foreign bodies

Superior orbital margin

Nasal bone

Fig. 20-98  Lateral projection showing foreign body (white speck).

317
 Eye

PA AXIAL PROJECTION
A nongrid (very high-resolution) tech-
30° nique is recommended to reduce magnifi-
cation and eliminate possible artifacts in
or on the radiographic table and grid. The
following steps are taken:
• Rest the patient’s forehead and nose on
the IR holder, and center the holder 3 4
inch (1.9 cm) distal to the nasion.
• Adjust the patient’s head so that the
midsagittal plane and OML are perpen-
dicular to the plane of the IR.
• Respiration: Suspend.

Central ray
• Directed through the center of the orbits
at a caudal angulation of 30 degrees.
Fig. 20-99  PA axial projection for orbital foreign body localization. This angulation is used to project the
petrous portions of the temporal bones
Skull, Facial Bones, and Paranasal Sinuses

below the inferior margin of the orbits

(Figs. 20-99 and 20-100).
• Instruct the patient to close the eyes and
to concentrate on holding them still for
the exposure.

EVALUATION CRITERIA
The following should be clearly shown:
■ Entire orbit(s)
■ Petrous pyramids lying below orbital
shadows
■ No rotation of cranium, demonstrated
by:
□ Symmetric visualization of the orbits
■ Close beam restriction centered to
orbital region
■ Brightness and contrast permitting
optimal visibility of orbit and eye for
localization of foreign bodies

Fig. 20-100  PA axial projection showing foreign body (arrow) in

the right eye.

318
 Eye

PARIETOACANTHIAL PROJECTION
MODIFIED WATERS METHOD
Some physicians prefer to have the PA
projection performed with the patient’s
head adjusted in a modified Waters posi-
tion so that the petrous margins are dis-
placed by part adjustment rather than by
central ray angulation. The following
steps are taken:
• With the IR centered at the level of the
center of the orbits, rest the patient’s
chin on the IR holder.
• Adjust the patient’s head so that the
midsagittal plane is perpendicular to the
plane of the IR.
• Adjust the flexion of the patient’s neck
so that the OML forms an angle of 50
degrees with the plane of the IR. Fig. 20-101  Parietoacanthial projection, modified Waters method,
• Respiration: Suspend. for orbital foreign body localization.

Eye
Central ray
• Perpendicular through the mid-orbits
(Figs. 20-101 and 20-102)
• Instruct the patient to close the eyes and
to concentrate on holding them still for
the exposure.

EVALUATION CRITERIA
The following should be clearly shown:
■ Entire orbit(s)
■ Petrous pyramids lying well below
orbital shadows
■ No rotation, demonstrated by:
□ Symmetric visualization of orbits
■ Close beam restriction centered to the
orbital region
■ Brightness and contrast permitting
optimal visibility of orbit and eye for
localization of foreign bodies

Fig. 20-102  Parietoacanthial projection, modified Waters method,

showing foreign body (arrow).

319
 Facial Bones

  LATERAL PROJECTION
R or L position

Image receptor: 8 × 10 inch (18 ×

24 cm) lengthwise or 10 × 12 inch
(24 × 30 cm) lengthwise, depending
on availability

Position of patient
• Place the patient in a recumbent ante-
rior oblique or seated anterior oblique
position before a vertical grid device.
This is the same basic position that is
used for the lateral skull position.

Position of part
• Adjust the patient’s head so that the
midsagittal plane is parallel with the IR
and the interpupillary line is perpen-
Skull, Facial Bones, and Paranasal Sinuses

dicular to the IR.

• Adjust the flexion of the patient’s neck
so that the infraorbitomeatal line
(IOML) is perpendicular to the front Fig. 20-103  Lateral facial bones.
edge of the IR (Figs. 20-103 to 105).
• Immobilize the head.
• Respiration: Suspend.

CR CR

CR

CR

Fig. 20-104  Upright lateral facial bones diagram. Fig. 20-105  Table radiography diagram: lateral facial bones.

320
Facial Bones
Central ray
• Perpendicular and entering the lateral
surface of the zygomatic bone halfway
between the outer canthus and the
external acoustic meatus (EAM)
• Center IR to the central ray.
Collimation
• Adjust to 6 × 10 inches (15 × 24 cm)
on the collimator.
Structures shown
This projection shows a lateral image of
the bones of the face, with the right and
left sides superimposed (Fig. 20-106).
EVALUATION CRITERIA
The following should be clearly shown:
■ Evidence of proper collimation
■ All facial bones in their entirety, with
the zygomatic bone in the center
■ No rotation or tilt of the facial bones,
demonstrated by:
□ Almost perfectly superimposed man-
dibular rami
□ Superimposed orbital roofs
□ Sella turcica in profile
■ Brightness and contrast demonstrate
soft tissue and bony trabecular detail
Facial Bones
321
 Facial Bones

Frontal sinus

Nasal bone
Sella turcica

Maxillary sinus

External acoustic meatus

Maxilla
Skull, Facial Bones, and Paranasal Sinuses

Mandible

Fig. 20-106  Lateral facial bones.

322
 Facial Bones
  PARIETOACANTHIAL • Center the midsagittal plane of the
PROJECTION patient’s body to the midline of the grid
WATERS METHOD1 device.
Image receptor: 8 × 10 inch (18 × Position of part
24 cm) lengthwise or 10 × 12 inch • Rest the patient’s head on the tip of the
(24 × 30 cm) lengthwise, depending extended chin. Hyperextend the neck so
on availability that the orbitomeatal line (OML) forms
a 37-degree angle with the plane of the
Position of patient IR.
• Place the patient in the prone or seated- • The mentomeatal line (MML) is
upright position. approximately perpendicular to the
plane of the IR; the average patient’s
1
Waters CA: Modification of the occipito-frontal
nose is about 3 4 inch (1.9 cm) away
position in roentgenography of the accessory nasal from the grid device.
sinuses, Arch Radiol Electrother 20:15, 1915. • Adjust the head so that the midsagittal
plane is perpendicular to the plane of
the IR (Figs. 20-107 to 20-110).
• Center the IR at the level of the
acanthion.
• Immobilize the head.
• Respiration: Suspend.
Central ray
• Perpendicular to exit the acanthion
Fig. 20-107  Parietoacanthial facial bones: Waters method.
Collimation
• Adjust to 8 × 10 inches (18 × 24 cm)
on the collimator.
Structures shown
The parietoacanthial projection (Waters
method) shows the orbits, maxillae, and
zygomatic arches (see Fig. 20-110).
EVALUATION CRITERIA
The following should be clearly shown:
■ Evidence of proper collimation
■ Entire orbits and facial bones
■ No rotation or tilt, demonstrated by:
□ Distances between the lateral borders
of the skull and the orbits equal on
each side
□ MSP of head aligned with long axis
Facial Bones
of collimated field
■ Petrous ridges projected immediately
below maxillary sinuses
■ Brightness and contrast demonstrate
soft tissue and bony trabecular detail
323
 Facial Bones

CR

37°
53°

CR
Mentomeatal line

53°
37°
Mentomeatal line
Fig. 20-108  Upright radiography diagram: Fig. 20-109  Table radiography diagram:
parietoacanthial facial bones: Waters parietoacanthial facial bones: Waters
method. method.
Skull, Facial Bones, and Paranasal Sinuses

Orbit

Zygomatic
arch
Maxillary
sinus
Maxilla

Petrous ridge

Mandibular
angle

Fig. 20-110  Parietoacanthial facial bones: Waters method.

(Courtesy of St. Bernard’s Medical Center, Jonesboro, AR.)

324
Facial Bones

MODIFIED PARIETOACANTHIAL
PROJECTION
MODIFIED WATERS METHOD
Although the parietoacanthial projection
(Waters method) is widely used, many
institutions modify the projection by
radiographing the patient using less exten-
sion of the patient’s neck. This modi­
fication, although sometimes called a
“shallow” Waters, actually increases the
angulation of the OML by placing it more
perpendicular to the plane of the IR. The
patient’s head is positioned as described
using the Waters method, but the neck is
extended to a lesser degree. In the modi-
fication, the OML is adjusted to form an
approximately 55-degree angle with the
plane of the IR (Figs. 20-111 to 20-113).
The resulting radiographic image shows

Facial Bones
the facial bones with less axial angulation
than with the Waters method (see Fig.
20-110). With the modified Waters
method, the petrous ridges are projected
immediately below the inferior border of
the orbits at a level midway through the
Fig. 20-111  Modified parietoacanthial facial bones: Waters
maxillary sinuses (Fig. 20-114).
method.
The modified Waters method is a good
projection to show blowout fractures. This
method places the orbital floor perpen-
dicular to the IR and parallel to the central
ray, showing inferior displacement of the
orbital floor and the commonly associated
opacified maxillary sinus.

CR CR

35°

55°

Fig. 20-112  Table radiography diagram, modified

parietoacanthial facial bones: Waters method with OML adjusted
to 55 degrees.

325
 Facial Bones

55°

CR CR

35°

Fig. 20-113  Upright radiography diagram, modified parietoacanthial facial bones:

Waters method with OML adjusted to 55 degrees.
Skull, Facial Bones, and Paranasal Sinuses

Inferior
orbital margin
Maxillary sinus
Zygomatic
bone
Petrous ridge

Nasal septum
Mandible

Fig. 20-114  Modified parietoacanthial facial bones: Waters method.

326
 Facial Bones
  ACANTHIOPARIETAL
PROJECTION
REVERSE WATERS METHOD
Image receptor: 8 × 10 inch (18 ×
24 cm) lengthwise or 10 × 12 inch
(24 × 30 cm) lengthwise, depending
on availability
The reverse Waters method is used to
show the facial bones when the patient
cannot be placed in the prone position.
Position of patient
• With the patient in the supine position,
center the midsagittal plane of the body
to the midline of the grid.
Position of part
• Bringing the patient’s chin up, adjust
the extension of the neck so that the
OML forms a 37-degree angle with the
plane of the IR (Fig. 20-115). If neces-
sary, place a support under the patient’s
shoulders to help extend the neck.
CR
37°
Fig. 20-115  Table radiography. Acanthioparietal facial bones: reverse Waters method
with neck extended. MML is perpendicular to IR.
• The MML is approximately perpen-
dicular to the plane of the IR.
• Adjust the patient’s head so that the
midsagittal plane is perpendicular to the
plane of the IR.
• Immobilize the head.
• Respiration: Suspend.
Central ray
• Perpendicular to enter the acanthion
and centered to the IR
Collimation
• Adjust to 8 × 10 inches (18 × 24 cm)
on the collimator.
Structures shown
The reverse Waters method shows the
superior facial bones. The image is similar
to that obtained with the Waters method,
but the facial structures are considerably
magnified (Fig. 20-116).
Mentomeatal line
EVALUATION CRITERIA
The following should be clearly shown:
■ Evidence of proper collimation
■ Entire orbits and facial bones
■ No rotation or tilt, demonstrated by:
□ Distances between lateral borders of
the skull and orbits equal on each
side
□ MSP of head aligned with long axis
of collimated field
■ Petrous ridges projected below maxil-
lary sinuses
■ Brightness and contrast demonstrate
soft tissue and bony trabecular detail
Facial Bones
327
 Facial Bones

ACANTHIOPARIETAL PROJECTION
R
FOR TRAUMA
Trauma patients are often unable to hyper-
extend the neck far enough to place the
OML 37 degrees to the IR and the MML
perpendicular to the plane of the IR. In
these patients, the acanthioparietal projec-
tion, or the reverse Waters projection, can
be achieved by adjusting the central ray so
that it enters the acanthion while remain- Orbit
ing parallel with the MML (Fig. 20-117).

Zygomatic
bone

Maxillary
sinus
Skull, Facial Bones, and Paranasal Sinuses

Petrous
ridge

Fig. 20-116  Acanthioparietal facial bones: reverse Waters method.

CR

30°

Mentomeatal line

Fig. 20-117  Table radiography. Acanthioparietal facial bones: reverse Waters method
with central ray parallel to MML.

328
 Facial Bones
  PA AXIAL PROJECTION
CALDWELL METHOD
Image receptor: 8 × 10 inch (18 ×
24 cm) lengthwise or 10 × 12 inch
(24 × 30 cm) lengthwise, depending
on availability
Position of patient
• Place the patient in a prone or a seated
position.
• Center the midsagittal plane of the
patient’s body to the midline of the grid.
• Rest the patient’s forehead and nose on
the table or against the upright Bucky.
• Flex the patient’s elbows, and place the
arms in a comfortable position.
CR
15°
Fig. 20-118  Upright radiography, PA axial facial bones: Caldwell method.
Position of part
• Adjust the flexion of the patient’s neck
so that the OML is perpendicular to the
plane of the IR.
• If the patient is obese or hypersthenic,
a small radiolucent sponge may need to
be placed in front of the forehead.
• Align the midsagittal plane perpendicu-
lar to the IR by adjusting the lateral
margins of the orbits or the EAM equi-
distant from the tabletop.
• Immobilize the patient’s head, and
center the IR to the nasion (Fig. 20-118).
• Respiration: Suspend.
Central ray
• Direct the central ray to exit the nasion
at an angle of 15 degrees caudad.
• To show the orbital rims, in particular,
the orbital floors, use a 30-degree
caudal angle (sometimes referred to as
the exaggerated Caldwell).
• Center the IR to the central ray.
Collimation
• Adjust to 8 × 10 inches (18 × 24 cm)
on the collimator.
Structures shown
The PA axial projection, Caldwell method,
shows the orbital rims, maxillae, nasal
septum, zygomatic bones, and anterior
nasal spine. When the central ray is angled
15 degrees caudad to the nasion, the
Facial Bones
petrous ridges are projected into the lower
third of the orbits (Fig. 20-119). When the
central ray is angled 30 degrees caudad,
the petrous ridges are projected below the
inferior margins of the orbits.
15°
329
 Facial Bones

EVALUATION CRITERIA
The following should be clearly shown:
■ Evidence of proper collimation
■ Entire orbits and facial bones
■ No rotation or tilt, demonstrated by:
□ Equal distances from lateral borders
of skull to lateral borders of orbits on
both sides
□ MSP of head aligned with long axis
of collimated field
■ Symmetric petrous ridges lying in
lower third of orbit
■ Penetration of frontal bone with appro-
priate brightness at lateral borders of
skull, which shows the facial bones
Skull, Facial Bones, and Paranasal Sinuses

Frontal sinus

Crista galli

Petrous ridge

Ethmoid sinus

Infraorbital margin

Fig. 20-119  PA axial facial bones: Caldwell method.

(Courtesy of St. Bernard’s Medical Center, Jonesboro, AR.)

330
 Nasal Bones
  LATERAL PROJECTION
R and L positions
Image receptor: 8 × 10 inch (18 ×
24 cm) lengthwise or 10 × 12 inch
(24 × 30 cm), depending on availabil-
ity, crosswise for two exposures on
one IR
Position of patient
• With the patient in a recumbent or
upright anterior oblique position, adjust
the rotation of the body so that the mid-
sagittal plane of the head can be placed
horizontally.
Fig. 20-120  Lateral nasal bones.
CR
Fig. 20-121  Table radiography diagram: lateral nasal bones.
Position of part
• Adjust the head so that the midsagittal
plane is parallel with the tabletop and
the interpupillary line is perpendicular
to the tabletop.
• Adjust the flexion of the patient’s neck
so that the IOML is parallel with the
transverse axis of the IR (Figs. 20-120
and 20-121).
• Support the mandible to prevent
rotation.
• Respiration: Suspend.
Placement of IR
• When using an 8 × 10-inch (18 ×
24-cm) IR, slide the unmasked half of
the IR under the frontonasal region and
center it to the nasion (see Fig. 20-120).
This centering allows space for the
Nasal Bones
identification marker to be projected
across the upper part of the IR. Tape the
side marker (R or L) in position.
CR
331
 Nasal Bones
Central ray
• Perpendicular to the bridge of the nose
at a point 1 2 inch (1.3 cm) distal to the
nasion
Collimation
• Adjust to 3 × 3 inches (8 × 8 cm) on the
collimator, with the field extending
from the glabella to the acanthion and
1 inch (1.3 cm) beyond the tip of the
2
nose.
Skull, Facial Bones, and Paranasal Sinuses
A B
Fig. 20-122  Nasal bones. A, Right lateral. B, Left lateral.
332
Structures shown
The lateral images of the nasal bones
show the side nearer the film or IR and the
soft structures of the nose (Fig. 20-122).
Both sides are examined for comparison.
Nasofrontal suture
Nasal bone
Anterior nasal spine of maxilla
EVALUATION CRITERIA
The following should be clearly shown:
■ Evidence of proper collimation
■ Nasal bones, anterior nasal spine, and
frontonasal suture
■ No rotation of nasal bones and soft
tissue
■ Brightness and contrast demonstrate
soft tissue and bony trabecular detail
L
Zygomatic Arches

  SUBMENTOVERTICAL
PROJECTION
This projection is similar to the submen-
tovertical (SMV) projection described in
the Skull Radiography section.

Image receptor: 8 × 10 inch (18 ×

24 cm) or 10 × 12 inch (24 × 30 cm)
crosswise, depending on availability

Position of patient
• Place the patient in a seated upright or
supine position. A vertical head unit
greatly assists a patient who is unable
to hyperextend the neck.
• When the supine position is used,
elevate the patient’s trunk on several
Fig. 20-123  SMV zygomatic arches, patient upright. firm pillows or a suitable pad to allow
complete extension of the neck. Flex

Zygomatic Arches
the patient’s knees to relax the abdomi-
nal muscles.
• Center the midsagittal plane of the
patient’s body to the midline of the grid
device.

Position of part
• Hyperextend the patient’s neck com-
pletely so that the IOML is as parallel
with the plane of the IR as possible.
• Rest the patient’s head on its vertex,
and adjust the head so that the midsagit-
tal plane is perpendicular to the plane
of the IR (Figs. 20-123 to 20-125).
• Respiration: Suspend.
CR

Fig. 20-124  Upright radiography diagram: SMV zygomatic arches.

CR

Fig. 20-125  Table radiography diagram: SMV zygomatic arches.

333
 Zygomatic Arches

Central ray Structures shown EVALUATION CRITERIA

• Perpendicular to the IOML and entering
the midsagittal plane of the throat at a
level approximately 1 inch (2.5 cm)
posterior to the outer canthi
• Center the IR to the central ray.
Collimation
• Adjust to 8 × 10 inches (18 × 24 cm)
crosswise on the collimator.
Bilateral symmetric SMV images of the
zygomatic arches are shown, projected
free of superimposed structures (Fig.
20-126). Unless very flat or traumatically
depressed, the arches, being farther from
the IR, are projected beyond the promi-
nent parietal eminences by the divergent
x-ray beam.
The following should be clearly shown:
■ Evidence of proper collimation
■ Zygomatic arches free from overlying
structures
■ No rotation or tilt of head, demon-
strated by:
□ Zygomatic arches symmetric and
without foreshortening
■ Brightness and contrast demonstrate
soft tissue and bony trabecular detail
NOTE: The zygomatic arches are well shown with
a decrease in the exposure factors used for this
projection of the cranial base.

R
Skull, Facial Bones, and Paranasal Sinuses

Temporal process
of zygoma

Zygomatic
arch

B
Fig. 20-126  A, SMV projection showing normal zygomatic arch (right) and fracture
(arrow) of left zygomatic arch. B, SMV zygomatic arches.

(Courtesy of St. Bernard’s Medical Center, Jonesboro, AR.)

334
Zygomatic Arches

  TANGENTIAL PROJECTION

Image receptor: 8 × 10 inch (18 ×

24 cm) lengthwise or 10 × 12 inch
(24 × 30 cm) lengthwise, depending
on availability

Position of patient
• Seat the patient with the back against a
vertical grid device, or place the patient
in the supine position with the trunk
elevated on several firm pillows and the
knees flexed to permit complete exten-
sion of the neck.

Position of part
Seated position
Fig. 20-127  Tangential zygomatic arch, patient upright. • Hyperextend the patient’s neck, and
rest the head on its vertex.

Zygomatic Arches
• Adjust the position of the patient’s head
so that the IOML is as parallel as pos-
sible with the plane of the IR.
• Rotate the midsagittal plane of the head
approximately 15 degrees toward the
side being examined.
• Tilt the top of the head approximately
15° 15 degrees away from the side being
15° rotation examined. This rotation and tilt ensure
of head
that the central ray is tangent to the
CR
lateral surface of the skull. The central
CR ray skims across the lateral portion of
Fig. 20-128  Upright radiography diagram: tangential zygomatic arch. the mandibular angle and the parietal
bone to project the zygomatic arch onto
the IR.
• Center the zygomatic arch to the IR
(Figs. 20-127 to 20-129).
15° top of CR
CR head tilt

15°

Fig. 20-129  Table radiography diagram: tangential zygomatic

arch.

335
 Zygomatic Arches

Supine position Central ray EVALUATION CRITERIA

• Rest the patient’s head on its vertex.
• Elevate the upper end of the IR on sand-
bags, or place it on an angled sponge of
suitable size.
• Adjust the elevation of the IR and the
extension of the patient’s neck so that
the IOML is placed as nearly parallel
with the plane of the IR as possible.
• Rotate and tilt the midsagittal plane of
the head approximately 15 degrees
toward the side being examined (similar
to the upright position).
• If the IOML is parallel with the plane
of the IR, center the IR to the zygomatic
arch; if not, displace the IR so that the
midpoint of the IR coincides with the
central ray (see Fig. 20-129).
• Attach a strip of adhesive tape to the
Skull, Facial Bones, and Paranasal Sinuses
• Perpendicular to the IOML and cen- The following should be clearly shown:
tered to the zygomatic arch at a point ■ Evidence of proper collimation
approximately 1 inch (2.5 cm) posterior ■ Zygomatic arch free from overlying
to the outer canthus structures
• Centered to the IR ■ Brightness and contrast demonstrate
soft tissue and bony trabecular detail
Collimation
• Adjust to 6 × 10 inches (18 × 24 cm)
on the collimator.
Structures shown
A tangential image of one zygomatic arch
is seen free of superimposition (Fig.
20-130). This projection is particularly
useful in patients with depressed fractures
or flat cheekbones.

inferior surface of the chin; draw the

tape upward, and anchor it to the edge
of the table or IR stand. This usually
affords sufficient support. Do not put
the adhesive surface directly on the
patient’s skin.
• Respiration: Suspend.

R R
Temporal process of
zygomatic bone

Zygomatic arch

Temporal bone

Fig. 20-130  Tangential zygomatic arch.

(Courtesy of St. Bernard’s Medical Center, Jonesboro, AR.)

336
 Zygomatic Arches

  AP AXIAL PROJECTION Central ray EVALUATION CRITERIA

MODIFIED TOWNE METHOD
Image receptor: 8 × 10 inch (18 ×
24 cm) or 10 × 12 inch (24 × 30 cm)
crosswise, depending on availability
Position of patient
• Place the patient in the seated-upright
or supine position.
• Center the midsagittal plane of the body
to the midline of the grid.
Position of part
• Adjust the patient’s head so that the
midsagittal plane is perpendicular to the
midline of the grid.
• Adjust the flexion of the neck so that
the OML is perpendicular to the plane
• Directed to enter the glabella approxi-
mately 1 inch (2.5 cm) above the nasion
at an angle of 30 degrees caudad
• If the patient is unable to flex the neck
sufficiently, adjust the IOML perpen-
dicular with the IR and direct the central
ray 37 degrees caudad.
• Center the IR to the central ray.
Collimation
• Adjust to 8 × 10 inches (18 × 24 cm)
crosswise on the collimator.
Structures shown
A symmetric AP axial projection of both
zygomatic arches is shown. The arches
should be projected free of superimposi-
tion (Fig. 20-134).
The following should be clearly shown:
■ Evidence of proper collimation
■ No overlap of zygomatic arches by
mandible
■ No rotation or tilt, demonstrated by:
□ Symmetric arches
□ Zygomatic arches projected lateral to
mandibular rami
□ MSP of head aligned with long axis
of collimated field
■ Brightness and contrast demonstrate
soft tissue and bony trabecular detail

Zygomatic Arches
of the IR (Figs. 20-131 to 20-133).
• Respiration: Suspend.

CR
30°

30°

Fig. 20-132  Upright radiography

Fig. 20-131  AP axial zygomatic arches: modified Towne method. diagram: modified Towne method.

CR

30°

Fig. 20-133  Table radiography diagram:

modified Towne method.

337
 Zygomatic Arches

R
Skull, Facial Bones, and Paranasal Sinuses

(R) Zygomatic
arch

Mandibular
ramus
R

Fig. 20-134  AP axial zygomatic arches: modified Towne method.

338
 Mandibular Rami

  PA PROJECTION Structures shown EVALUATION CRITERIA

Image receptor: 8 × 10 inch
(18 × 24 cm) or 10 × 12 inch (24 ×
30 cm) lengthwise, depending on
availability
Position of patient
• Place the patient in the prone position,
or seat the patient before a vertical grid
device.
PA projection shows the mandibular body
and rami (Fig. 20-136). The central part of
the body is not well shown because of the
superimposed spine. This radiographic
approach is usually employed to show
medial or lateral displacement of frag-
ments in fractures of the rami.
The following should be clearly shown:
■ Evidence of proper collimation
■ Entire mandible
■ No rotation or tilt, demonstrated by:
□ Mandibular body and rami symmet-
ric on each side
□ MSP of head aligned with long axis
of collimated field
■ Brightness and contrast demonstrating
soft tissues and bony trabecular detail

Position of part
• Rest the patient’s forehead and nose on
the IR. Adjust the OML to be perpen-
dicular to the plane of the IR.
• Adjust the head so that its midsagittal
plane is perpendicular to the plane of
the IR (Fig. 20-135).

Mandibular Rami
• Immobilize the head.
• Respiration: Suspend.

Central ray
• Perpendicular to exit the acanthion
• Center the IR to the central ray.

Collimation
• Adjust to 8 × 10 inches (18 × 24 cm)
on the collimator.

Fig. 20-135  PA mandibular rami.

Mastoid air cells

Condyle

Ramus

Body
R R

Fig. 20-136  PA mandibular rami.

(Courtesy of St. Bernard’s Medical Center, Jonesboro, AR.)

339
 Mandibular Rami
  PA AXIAL PROJECTION
Image receptor: 8 × 10 inch
(18 × 24 cm) or 10 × 12 inch (24 ×
30 cm) lengthwise, depending on
availability
Position of patient
• Place the patient in the prone position,
or seat the patient before a vertical grid
device.
Skull, Facial Bones, and Paranasal Sinuses
Fig. 20-137  PA axial mandibular rami.
340
Position of part
• Rest the patient’s forehead and nose on
the IR holder.
• Adjust the OML to be perpendicular to
the plane of the IR.
• Adjust the patient’s head so that the
midsagittal plane is perpendicular to the
plane of the IR (Fig. 20-137).
• Immobilize the patient’s head.
• Respiration: Suspend.
Central ray
• Directed 20 or 25 degrees cephalad to
exit at the acanthion
• Center the IR to the central ray.
20°
R
Fig. 20-138  PA axial mandibular body and rami.
Collimation
• Adjust to 8 × 10 inches (18 × 24 cm)
on the collimator.
Structures shown
PA axial projection shows the mandibular
body and rami (Fig. 20-138). The central
part of the body is not well shown because
of the superimposed spine. This radio-
graphic approach is usually employed to
show medial or lateral displacement of
fragments in fractures of the rami.
EVALUATION CRITERIA
The following should be clearly shown:
■ Evidence of proper collimation
■ Entire mandible
■ No rotation or tilt, demonstrated by:
□ Mandibular body and rami symmet-
ric on each side
□ MSP of head aligned with long axis
of collimated field
■ Condylar processes
■ Brightness and contrast demonstrating
soft tissues and bony trabecular detail
 Mandibular Body

PA PROJECTION Central ray EVALUATION CRITERIA

Image receptor: 8 × 10 inch
(18 × 24 cm) or 10 × 12 inch (24 ×
30 cm) lengthwise, depending on
availability
Position of patient
• Place the patient in the prone position,
or seat the patient before a vertical grid
device.
• Perpendicular to the level of the lips
• Center the IR to the central ray.
Structures shown
This image shows the mandibular body
(Fig. 20-140).
The following should be clearly shown:
■ Evidence of proper collimation
■ Entire mandible
■ No rotation or tilt, demonstrated by:
□ Mandibular body symmetric on each
side
□ MSP of head aligned with long axis
of collimated field
■ Brightness and contrast demonstrating
soft tissues and bony trabecular detail

Position of part
• With the midsagittal plane of the
patient’s head centered to the midline of
the IR, rest the head on the nose and
chin so that the anterior surface of the
mandibular symphysis is parallel with
the plane of the IR. This position places

Mandibular Body
the acanthiomeatal line (AML) nearly
perpendicular to the IR plane.
• Adjust the patient’s head so that the
midsagittal plane is perpendicular to the
plane of the IR (Fig. 20-139).
• Respiration: Suspend

Fig. 20-139  PA mandibular body.

Ramus

Symphysis

Body
Angle

R R

Fig. 20-140  PA mandibular body.

341
 Mandibular Body

PA AXIAL PROJECTION Central ray EVALUATION CRITERIA

Image receptor: 8 × 10 inch
(18 × 24 cm) or 10 × 12 inch (24 ×
30 cm) lengthwise, depending on
availability
Position of patient
• Place the patient in the prone position,
or seat the patient before a vertical grid
device.
Position of part
• With the midsagittal plane of the
patient’s head centered to the midline of
the IR, rest the head on the nose and
chin so that the anterior surface of the
mandibular symphysis is parallel with
the plane of the IR. This position places
Skull, Facial Bones, and Paranasal Sinuses
• Directed midway between the temporo- The following should be clearly shown:
mandibular joints (TMJs) at an angle of ■ Evidence of proper collimation
30 degrees cephalad. Zanelli1 recom- ■ Entire mandible
mended that better contrast around the ■ TMJs just inferior to the mastoid
TMJs could be obtained if the patient process
was instructed to fill the mouth with air ■ No rotation or tilt, demonstrated by:
for this projection. □ Symmetric rami
• Center the IR to the central ray. □ MSP of head aligned with long axis
of collimated field
Structures shown
This image shows the mandibular body
and TMJs (Fig. 20-142).
1
Zanelli A: Le proiezioni radiografiche dell’
articolazione temporomandibolare, Radiol Med
16:495, 1929.

the AML nearly perpendicular to the

plane of the IR.
• Adjust the patient’s head so that the
midsagittal plane is perpendicular to the 30°
plane of the IR (Fig. 20-141).
• Respiration: Suspend.

Fig. 20-141  PA axial mandibular body.

Mastoid process

Condyle

Coronoid process

Ramus

Body

Symphysis

R R

Fig. 20-142  PA axial mandibular body.

342
 Mandible

  AXIOLATERAL AND
AXIOLATERAL OBLIQUE
PROJECTION
The goal of these projections is to place
the desired portion of the mandible paral-
lel with the IR.
Image receptor: 8 × 10 inch (18 ×
2 cm) or 10 × 12 inch (24 × 30 cm)
lengthwise, depending on availabil-
ity, placed according to region
Position of patient
• Place the patient in the seated, semi-
prone, or semi-supine position.
Position of part
• Place the patient’s head in a lateral posi-
tion with the interpupillary line perpen-
• Extend the patient’s neck enough that
the long axis of the mandibular body is
parallel with the transverse axis of the
IR to prevent superimposition of the
cervical spine.
• If the projection is to be performed on
the tabletop, position the IR so that the
complete body of the mandible is on the
IR.
• Adjust the rotation of the patient’s head
to place the area of interest parallel to
the IR, as follows.
Ramus
• Keep the patient’s head in a true lateral
position (Fig. 20-143).
Body
• Rotate the patient’s head 30 degrees
toward the IR (Fig. 20-144).
Symphysis
NOTE: When the patient is in the semi-supine
position, place the IR on a wedge device or wedge
sponge (Fig. 20-146). Ensure that combined CR
angle and midsagittal plane tilt equals 25 degrees.
Central ray
• Directed 25 degrees cephalad to pass
directly through the mandibular region
of interest (see Note on p. 345)
• Center the IR to the central ray for pro-
jections done on upright grid units.
Collimation
• Adjust to 8 × 10 inches (18 × 24 cm)
on the collimator.
Structures shown
Each axiolateral oblique projection shows
the region of the mandible that was paral-

Mandible
dicular to the IR. The mouth should be • Rotate the patient’s head 45 degrees lel with the IR (Figs. 20-147 to 20-149).
closed with the teeth together. toward the IR (Fig. 20-145).

25° 25°

Fig. 20-143  Axiolateral mandibular ramus. Fig. 20-144  Axiolateral oblique mandibular body.

25°

Fig. 20-145  Axiolateral oblique mandibular symphysis.

343
 Mandible

20°

Fig. 20-146  Semi-supine axiolateral oblique mandibular body and

symphysis.
Skull, Facial Bones, and Paranasal Sinuses

Coronoid process

Ramus

Body

Hyoid bone

Angle

Fig. 20-147  Axiolateral oblique mandibular body.

344
 Mandible

EVALUATION CRITERIA
The following should be clearly shown:
■ Evidence of proper collimation
Ramus and Body
■ No overlap of the ramus by the opposite
side of the mandible
■ No elongation or foreshortening of
ramus or body
■ No superimposition of the ramus by the NOTE: To reduce the possibility of projecting the
cervical spine shoulder over the mandible when radiographing
muscular or hypersthenic patients, adjust the mid-
Symphysis sagittal plane of the patient’s skull with an
■ No overlap of the mentum region by the approximately 15-degree angle, open inferiorly.
The cephalad angulation of 10 degrees of the
opposite side of the mandible
central ray maintains the optimal 25-degree
■ No foreshortening of the mentum central ray/part angle relationship.
region

R R

Mandible
Temporomandibular
joint

Condyle

Coronoid process

Ramus

Body

Angle

Fig. 20-148  Axiolateral oblique mandibular ramus.

Symphysis

Body

Fig. 20-149  Axiolateral oblique mandibular symphysis.

345
 Mandible
SUBMENTOVERTICAL PROJECTION
Image receptor: 8 × 10 inch
(18 × 24 cm) or 10 × 12 inch (24 ×
30 cm) lengthwise, depending on
availability
Position of patient
• Place the patient upright in front of a
vertical grid device or in the supine
position. When the patient is supine,
elevate the shoulders on firm pillows to
permit complete extension of the neck.
• Flex the patient’s knees to relax the
abdominal muscles and relieve strain
on the neck muscles.
• Center the midsagittal plane of the body
to the midline of the grid device.
Skull, Facial Bones, and Paranasal Sinuses
R R
Symphysis
Body
Coronoid
process
Ramus
Condyle
Petrous
ridge
346
Position of part
• With the neck fully extended, rest the
head on its vertex and adjust the head
so that the midsagittal plane is
vertical.
• Adjust the IOML as parallel as possible
with the plane of the IR (Fig. 20-150).
• When the neck cannot be extended
enough that the IOML is parallel with
the IR plane, angle the grid device and
place it parallel to the IOML.
• Immobilize the head.
• Respiration: Suspend.
Central ray
• Perpendicular to the IOML and cen-
tered midway between the angles of the
mandible
Fig. 20-150  SMV mandible.
Fig. 20-151  SMV mandible.
Structures shown
SMV projection of the mandibular body
shows the coronoid and condyloid pro-
cesses of the rami (Fig. 20-151).
EVALUATION CRITERIA
The following should be clearly shown:
■ Evidence of proper collimation
■ No rotation or tilt, demonstrated by:
□ Distance between the lateral border
of the skull and the mandible equal
on both sides
□ MSP of head aligned to long axis of
collimated field
■ Condyles of the mandible anterior to
the pars petrosa
■ Symphysis extending almost to the
anterior border of the face so that the
mandible is not foreshortened
Temporomandibular Articulations

Fig. 20-152  AP axial TMJs.
  AP AXIAL PROJECTION
For radiography of the TMJs in the closed-
mouth position, the posterior teeth, rather
than the incisors, must be in contact.
Occlusion of the incisors places the man-
dible in a position of protrusion, and the
condyles are carried out of the mandibular
fossae. In the open-mouth position, the
mouth should be opened as wide as pos-
sible but not with the mandible protruded
(jutted forward).
Because of the danger of fragment
displacement, the open-mouth position
should not be attempted in patients with
recent injury. Trauma patients are exam-
ined without any stress movement of
the mandible. Tomography is particularly
useful when a fracture or dislocation is
suspected.

Temporomandibular Articulations
Image receptor: 8 × 10 inch
(18 × 24 cm) or 10 × 12 inch (24 ×
CR 30 cm) lengthwise, depending on
35° availability

Position of patient
• Place the patient in a supine or seated-
upright position with the posterior skull
in contact with the upright Bucky.

Position of part
• Adjust the patient’s head so that the
midsagittal plane is perpendicular to the
plane of the IR.
• Flex the patient’s neck so that the OML
is perpendicular to the plane of the IR
(Figs. 20-152 to 20-154).
• Respiration: Suspend.
Fig. 20-153  Upright radiography
diagram: AP axial TMJs.

CR

35°

Fig. 20-154  Table radiography diagram: AP

axial TMJs.

347
 Temporomandibular Articulations

Central ray
R
• Directed 35 degrees caudad, centered
midway between the TMJs, and enter-
ing at a point approximately 3 inches
(7.6 cm) above the nasion
• Expose one image with the mouth
closed; when not contraindicated, ex-
pose one image with the mouth open. Condyle
• Center the IR to the central ray.

Collimation
• Adjust to 8 × 10 inches (18 × 24 cm) Ramus
on the collimator.

Structures shown
The AP axial projection shows the con-
dyles of the mandible and the mandibular Fig. 20-155  AP axial TMJs: mouth closed.
fossae of the temporal bones (Figs. 20-155
and 20-156).
Skull, Facial Bones, and Paranasal Sinuses

EVALUATION CRITERIA
The following should be clearly shown: R
■ Evidence of proper collimation
■ No rotation of head
■ Minimal superimposition of petrosa
on the condyle in the closed-mouth
examination
■ Condyle and temporomandibular artic-
ulation below pars petrosa in the open-
mouth position Condyle

Ramus

Fig. 20-156  AP axial TMJs: mouth open.

348
Temporomandibular Articulations

AXIOLATERAL PROJECTION
R and L positions
30° This projection is sometimes called the
Shüller method because it consists of
approximately the same positioning
details and CR orientation as the Shüller
method for the petromastoid portion of the
temporal bone, seen in the tenth edition of
Merrill’s Atlas.

Image receptor: 8 × 10 inch (18 ×

24 cm) or 10 × 12 inch (24 × 30 cm)
crosswise, depending on availability

Position of patient
• Put a mark on each cheek at a point 1 2
inch (1.3 cm) anterior to the EAM and
1 inch (2.5 cm) inferior to the EAM to
Fig. 20-157  Axiolateral TMJ: mouth closed. localize the TMJ if needed.

Temporomandibular Articulations
• Place the patient in a semi-prone posi-
tion, or seat the patient before a vertical
grid device.

Position of part
CR
• Center a point 1 2 inch (1.3 cm) anterior
30° to the EAM to the IR, and place the
patient’s head in the lateral position
with the affected side closest to the IR.
CR • Adjust the patient’s head so that the
midsagittal plane is parallel with the
plane of the IR and the interpupillary
line is perpendicular to the IR plane
(Figs. 20-157 to 20-159).
Fig. 20-158  Upright radiography diagram: axiolateral TMJ. • Immobilize the head.
• Respiration: Suspend.
• After making the exposure with the
patient’s mouth closed, change the
IR; then, unless contraindicated, have
the patient open the mouth widely
CR
(Fig. 20-160).
• Recheck the patient’s position, and
CR
make the second exposure.

30°

Fig. 20-159  Table radiography diagram: axiolateral TMJ.

349
 Temporomandibular Articulations

Central ray
• Directed to the midpoint of the IR at an 30°
angle of 25 or 30 degrees caudad. The
central ray enters about 1 2 inch (1.3 cm)
anterior and 2 inches (5 cm) superior to
the upside EAM.

Structures shown
These images show the TMJ when the
mouth is open and closed (Figs. 20-161
and 20-162). Examine both sides for
comparison.

EVALUATION CRITERIA
The following should be clearly shown:
■ Evidence of proper collimation
■ TMJ anterior to the EAM Fig. 20-160  Axiolateral TMJ with mouth open.
■ Condyle in mandibular fossa in the
Skull, Facial Bones, and Paranasal Sinuses

closed-mouth examination
■ Condyle inferior to the articular tuber-
cle in the open-mouth examination if
the patient is normal and able to open
the mouth widely

R R

External
acoustic
meatus

Fig. 20-161  Axiolateral TMJ, mouth closed. Mandibular condyle Fig. 20-162  Axiolateral TMJ, mouth open. Mandibular fossa
(small dots) and mandibular fossa (large dots) are shown. (arrow) and mandibular condyle (arrowheads) are shown.
Mandibular condyle of side away from film is also seen (arrow).

350
Temporomandibular Articulations

  AXIOLATERAL OBLIQUE
PROJECTION
15°
R and L positions
This projection is sometimes called the
modified Law method because it consists
of approximately the same positioning
details and CR orientation as the modified
Law method for the petromastoid portion
of the temporal bone, seen in the tenth
edition of Merrill’s Atlas.

Image receptor: 8 × 10 inch (18 ×

24 cm) or 10 × 12 inch (24 × 30 cm)
crosswise, depending on availability

Position of patient
• Place the patient in a semi-prone posi-
Fig. 20-163  Axiolateral oblique TMJ. tion, or seat the patient before a vertical
grid device.

Temporomandibular Articulations
• In TMJ examinations, make one expo-
sure with the mouth closed, and when
not contraindicated, make one exposure
with the mouth open.
• Use an IR-changing tunnel or Bucky
tray so that the patient’s head does not
15°
have to be adjusted between the two
CR exposures.
15°
• Examine both sides for comparison.

CR Position of part
• Center a point 1 2 inch (1.3 cm) anterior
to the EAM to the IR, and rest the
patient’s cheek on the grid device.
• Rotate the midsagittal plane of the
head approximately 15 degrees toward
Fig. 20-164  Upright radiography diagram: axiolateral oblique TMJ.
the IR.
• Adjust the interpupillary line perpen-
dicular to the plane of the IR.
• Adjust the flexion of the patient’s neck
so that the AML is parallel with the
transverse axis of the IR (Figs. 20-163
to 20-165).
CR
• Immobilize the head.
• Respiration: Suspend.
• After making the exposure with the
15° CR mouth closed, change the IR and
instruct the patient to open the mouth
widely.
15°
• Recheck the position of the AML, and
make the second exposure.

Central ray
• Directed 15 degrees caudad and exiting
through the TMJ closest to the IR. The
central ray enters about 1 1 2 inches
Fig. 20-165  Table radiography diagram: axiolateral oblique TMJ. (3.8 cm) superior to the upside EAM.

Collimation
• Adjust to 8 × 10 inches (18 × 24 cm)
on the collimator.

351
 Temporomandibular Articulations

Structures shown
R
The images in the open-mouth and closed-
mouth positions show the condyles and
necks of the mandible. The images also
show the relationship between the man-
Mandibular fossa
dibular fossa and the condyle. The open-
mouth position shows the mandibular
Articular tubercle
fossa and the inferior and anterior excur-
sion of the condyle. Both sides are exam- External acoustic meatus
ined for comparison (Fig. 20-166). The
closed-mouth position shows fractures of Condyle
the neck and condyle of the ramus.

EVALUATION CRITERIA
The following should be clearly shown:
■ Evidence of proper collimation
■ Temporomandibular articulation A
■ Condyle lying in the mandibular fossa
Skull, Facial Bones, and Paranasal Sinuses

in the closed-mouth examination L

■ Condyle lying inferior to the articular
tubercle in the open-mouth projection if
the patient is normal and is able to open
the mouth widely

B
Fig. 20-166  Axiolateral oblique TMJ. A, Mouth open,
right side. B, Mouth open, left side (same patient),
showing more movement on left side.

352
Panoramic Tomography
of the Mandible
Panoramic tomography, pantomography,
and rotational tomography are terms used
to designate the technique employed to
produce tomograms of curved surfaces.
This technique of body-section radiogra-
phy provides a panoramic image of the
entire mandible, including the TMJ, and
of both dental arches on one long, narrow
image. Digital panorex units are capable
of providing several images necessary for
orthodontic and dental treatments, includ-
ing three-dimensional images, cephalo-
Fig. 20-167  Digital panograph unit. (Courtesy Gendex.)
metric analysis, and surgical implant
treatment planning.
Two types of equipment are available
for pantomography. In the first type, the
patient and the IR are rotated before a
stationary x-ray tube. This type of machine
consists of (1) a specially designed chair
mounted on a turntable and (2) a second
turntable to support a 4 × 10 inch (10 ×
24 cm) IR. The seated and immobilized
patient and the film are electronically
rotated in opposite directions at coordi-
nated speeds. The x-ray tube remains sta-
tionary. In one machine, the exposure is
interrupted in the midline.
In the second type of unit, the x-ray
tube and the IR rotate in the same direc-
tion around the seated and immobilized
patient (Fig. 20-167). The x-ray tube and
IR drum are attached to an overhead car-
riage that is supported by the vertical
stand assembly. The chair of this unit is
fixed to the base but can be removed to
accommodate patients in wheelchairs.
The attached head holder and radiolucent
bite device center and immobilize the
patient’s head. A scale on the head
holder indicates the jaw size. The latest
digital technology offers 33 panoramic
options.
Panoramic Tomography of the Mandible
353
 In both types of equipment, the beam of
radiation is sharply collimated at the tube
aperture by a lead diaphragm with a
narrow vertical slit. A corresponding slit
diaphragm is fixed between the patient
and the IR so that the patient and the IR
(or the tube and the film) rotate. Each
narrow area of the part is recorded on the
film without overlap and without fogging
from scattered and secondary radiation.
The scan (exposure) time varies from
10 to 20 seconds in different makes of
Skull, Facial Bones, and Paranasal Sinuses
354
equipment. Because of the slit diaphragm,
however, radiation exposure to the patient
at each fraction of a second is restricted to
the skin surface that is passing before the
narrow vertical slit aperture.
Panoramic tomography provides a
distortion-free lateral image of the entire
mandible (Fig. 20-168). It also affords the
most comfortable way to position patients
who have sustained severe mandibular or
TMJ trauma, before and after splint wiring
of the teeth. It must be supplemented with
Fig. 20-168  Panoramic digital tomogram.
(Courtesy Gendex.)
an AP, PA, or verticosubmental projection
to establish fragment position.
This tomographic technique is useful
for general survey studies of various
dental and facial bone abnormalities. It is
also used to supplement rather than replace
conventional periapical images, although
digital units are capable of providing stan-
dard bitewing images as well as lateral
TMJ images.
 SINUS RADIOGRAPHY
Technical
Considerations
For digital imaging, the most important
technical consideration for demonstration
of potential pathology of the paranasal
sinuses is to image the patient in the
upright position whenever possible. The
upright position is best for demonstration
of air-fluid levels and to differentiate fluid
from other pathologic conditions, as
shown by the research by Cross1 and
Flecker.2 An appropriate balance of bright-
Fig. 20-169  Correctly exposed radiograph of sinuses.
Fig. 20-170  Overexposed radiograph of sinuses showing two
artifacts caused by dirt on screens (arrows).
ness and contrast is also necessary so that
air, fluid, soft tissue, and bony tissues are
all well visualized. An appropriate kVp
and mAs combination and a well-
collimated radiation field will ensure
optimum digital image quality at the
lowest possible patient dose.
In film-screen radiography, optimum
density is perhaps more critical in the
sinuses than in any other region of the
body. High kVp levels cause overpenetra-
tion, which can diminish if not completely
obliterate pathology, and low kVp under-
Fig. 20-171  Underexposed radiograph of sinuses.
penetrates this anatomy, which simulates
pathologic conditions that do not exist
(Figs. 20-169 to 20-171).
The paranasal sinuses vary not only in
size and form but also in position. The
cells of one group frequently encroach on
and resemble those of another group. This
characteristic of the sinuses, together with
their proximity to the vital intracranial
organs, makes accurate radiographic dem-
onstration of their anatomic structure of
prime importance. The patient’s head
must be carefully placed in a sufficient
number of positions so that the projections
of each group of cavities are as free of
superimposed bony structures as possible.
The images must be of such quality that it
is possible to distinguish the cells of
several groups of sinuses and their rela-
Technical Considerations
tionship to surrounding structures.
1
Cross KS: Radiography of the nasal accessory
sinuses, Med J Aust 14:569, 1927.
2
Flecker H: Roentgenograms of the antrum, AJR Am
J Roentgenol 20:56, 1928 (letter).
355
 Unless sinus images are almost perfect
technically, they are of little diagnostic
value. For this reason, a precise technical
procedure is necessary in radiography of
the paranasal sinuses. The first require-
ments are a small focal spot and IRs that
are free of artifacts. As mentioned previ-
ously, the image contrast must markedly
distinguish the sinuses from surrounding
structures. The head must be carefully
positioned and rigidly immobilized, and
respiration must be suspended for the
exposures.
The effect of body position and central
ray angulation is shown in radiographs of
a coconut held in position by head clamps.
Fig. 20-172 shows a sharply defined air-
fluid level. This coconut was placed in the
Fig. 20-172  Coconut, vertical position: horizontal central ray. vertical position, and the central ray was
Skull, Facial Bones, and Paranasal Sinuses

Air-fluid level is shown (arrow). directed horizontally. Fig. 20-173 was

also taken with the coconut in the vertical
position, but the central ray was directed
upward at an angle of 45 degrees to show
gradual fading of the fluid line when the
central ray is not horizontal. This effect is
much more pronounced in actual practice
because of structural irregularities. Fig.
20-174 was made with the coconut in the
horizontal position and the central ray
directed vertically. The resultant radio-
graph shows a homogeneous density
throughout the cavity of the coconut, with
no evidence of an air-fluid level.
Exudate contained in the sinuses is not
fluid in the usual sense of the word but is
commonly a heavy, semi-gelatinous mate-
rial. The exudate, rather than flowing
freely, clings to the walls of the cavity and
takes several minutes, depending on its
viscosity, to shift position. For this reason,
when the position of a patient is changed
or the patient’s neck is flexed or extended
to position the head for special projec-
Fig. 20-173  Coconut, vertical position: central ray angled 45 degrees upward. Air-fluid
level is not as sharp. tions, several minutes should be allowed
for the exudate to gravitate to the desired
location before the exposure is made.

356
 Although numerous sinus projections
are possible, with each serving a special
purpose, many are used only when
required to show a specific lesion. The
consensus is that five standard projections
adequately show all of the paranasal
sinuses in most patients. The following
steps are observed in preparing for these
projections:
• Use a suitable protractor to check and
adjust the position of the patient’s head
to ensure accurate positioning.
• Have the patient remove dentures, hair-
pins, and ornaments such as earrings
and necklaces before proceeding with
the examination.
• Because the patient’s face is in contact
with the IR holder or the IR itself for
Fig. 20-174  Coconut, horizontal position: vertical central ray. No
evidence of air-fluid level is seen.
many of the images, these items should
be cleaned before the patient is
positioned.
Even with the most hygienic patients,
the hair and face are naturally oily and
leave a residue. If a patient is sick, the
residue is worse. During positioning of the
patient’s head, the hair, mouth, nose, and
eyes come in direct contact with the verti-
cal grid device, tabletop, or IR. Medical
asepsis can be promoted by placing a
paper towel or sheet between the imaging
surface and the patient. As standard pro-
cedure, the contacted area should be
cleaned with a disinfectant before and
after positioning.
Technical Considerations
357
 Paranasal Sinuses
  LATERAL PROJECTION
R or L position
Image receptor: 8 × 10 inch (18 ×
24 cm) or 10 × 12 inch (24 × 30 cm),
depending on availability
Position of patient
• Seat the patient before a vertical grid
device with the body placed in the RAO
or LAO position so that the head can be
adjusted in a true lateral position. This
is the same basic position that is used
for the lateral skull and facial bone
positions.
Position of part
• Rest the side of the patient’s head on
the vertical grid device, and adjust the
Skull, Facial Bones, and Paranasal Sinuses
head in a true lateral position. The mid-
sagittal plane of the head is parallel
with the plane of the IR, and the inter-
pupillary line is perpendicular to the
plane of the IR.
• The infraorbitomeatal line (IOML) is
positioned horizontally to ensure proper
extension of the head. This position
places the IOML perpendicular to the
front edge of the vertical grid device
(Fig. 20-175).
• Respiration: Suspend.
358
Central ray
• Directed horizontal, enter the patient’s
head 1 2 to 1 inch (1.3 to 2.5 cm) poste-
rior to the outer canthus
• Center the IR to the central ray.
• Immobilize the head.
Collimation
• Adjust to 8 × 10 inches (18 × 24 cm)
on the collimator.
Structures shown
A lateral projection shows the AP and
superoinferior dimensions of the para­
nasal sinuses, their relationship to sur-
rounding structures, and the thickness of
the outer table of the frontal bone
(Fig. 20-176).
When the lateral projection is to be used
for preoperative measurements, it should
be made at a 72-inch (183-cm) source–to–
image receptor distance to minimize mag-
nification and distortion.
Fig. 20-175  Lateral sinuses.
EVALUATION CRITERIA
The following should be clearly shown:
■ Evidence of proper collimation; close
beam restriction to sinus area
■ All four sinus groups, but the sphenoi-
dal sinus is best demonstrated
■ No rotation or tilt of sinus anatomy, as
demonstrated by:
□ Sella turcica in profile
□ Superimposed orbital roofs
□ Superimposed mandibular rami
■ Brightness and contrast sufficient to
visualize air-fluid levels, if present
NOTE: If the patient is unable to assume the
upright body position, a lateral projection can be
obtained using the dorsal decubitus position. The
horizontal beam enables fluid levels to be seen.
Positioning of the part is the same except for the
IOML, which is vertical rather than horizontal.
Paranasal Sinuses

Frontal sinus

Sella turcica

Sphenoidal sinus

Ethmoidal sinuses

Maxillary sinus

Superimposed

Paranasal Sinuses
mandibular
rami

Fig. 20-176  Lateral sinuses.

359
 Frontal and Anterior Ethmoidal Sinuses

  PA AXIAL PROJECTION Position of part Vertical grid technique

CALDWELL METHOD
Because sinus images should always be
obtained with the patient in the upright
body position and with a horizontal direc-
tion of the central ray, the Caldwell
method is easily modified when a head
unit or other vertical grid device capable
of angular adjustment is used. For the
modification, all anatomic landmarks and
localization planes remain unchanged.
Image receptor: 8 × 10 inch
(18 × 24 cm) or 10 × 12 inch (24 ×
30 cm) lengthwise, depending on
availability
Position of patient
• Seat the patient facing a vertical grid
Skull, Facial Bones, and Paranasal Sinuses
Angled grid technique
• Before positioning the patient, tilt
the vertical grid device down so that
an angle of 15 degrees is obtained
(Fig. 20-177, A).
• Rest the patient’s nose and forehead on
the vertical grid device, and center the
nasion to the IR.
• Adjust the midsagittal plane and orbito-
meatal line (OML) of the patient’s head
perpendicular to the plane of the IR.
• This positioning places the OML per-
pendicular to the angled IR and 15
degrees from the horizontal central ray.
• Immobilize the head.
• Respiration: Suspend.
• When the vertical grid device cannot be
angled, extend the patient’s neck
slightly, rest the tip of the nose on the
grid device, and center the nasion to
the IR.
• Position the patient’s head so that the
OML forms an angle of 15 degrees with
the horizontal central ray. For support,
place a radiolucent sponge between the
forehead and the grid device (see Figs.
20-177, B, and 20-178).
• Adjust the midsagittal plane of the
patient’s head perpendicular to the
plane of the IR.
• Immobilize the head.
• Respiration: Suspend.

device.
• Center the midsagittal plane of the
patient’s body to the midline of the grid.

CR CR

A B
Fig. 20-177  Diagram of PA axial sinuses: Caldwell method. A, IR tilted 15 degrees.
B, Same projection with vertical IR.

Fig. 20-178  PA axial sinuses: Caldwell method.

360
 Frontal and Anterior Ethmoidal Sinuses
Central ray
• Directed horizontal to exit the nasion.
The 15-degree relationship between the
central ray and the OML remains the
same for both techniques.
• Center the IR to the central ray.
NOTE: The angled grid technique is preferred
because it brings the IR closer to the sinuses,
increasing resolution. Angulation of the grid
device provides a natural position for placement
of the patient’s nose and forehead.
Collimation
• Adjust to 8 × 10 inches (18 × 24 cm)
on the collimator.
R R
Frontal sinuses
Ethmoid sinuses
(anterior)
Sphenoid sinuses
Structures shown
The angled grid technique and the vertical
grid technique show the frontal sinuses
lying superior to the frontonasal suture,
the anterior ethmoidal air cells lying on
each side of the nasal fossae and immedi-
ately inferior to the frontal sinuses, and the
sphenoidal sinuses projected through the
nasal fossae just inferior to or between
the ethmoidal air cells (Fig. 20-179). The
dense petrous pyramids extend from the
inferior third of the orbit inferiorly to
obscure the superior third of the maxillary
sinus. This projection is used primarily to
show the frontal sinuses and anterior eth-
moidal air cells.
Fig. 20-179  PA axial sinuses.
EVALUATION CRITERIA
The following should be clearly shown:
■ Evidence of proper collimation with
close beam restriction to the sinus area
■ Frontal sinuses lying above the fronto-
nasal suture and the anterior ethmoidal
air cells lying above the petrous ridges
■ No rotation or tilt, demonstrated by:
□ Equal distance between the lateral
border of the skull and the lateral
border of the orbits
□ Petrous ridge symmetric on both
sides
□ MSP of head aligned with long axis
of collimated field
■ Petrous ridge lying in the lower third of
the orbit
■ Brightness and contrast sufficient to
visualize air-fluid levels, if present
Frontal and Anterior Ethmoidal Sinuses
361
 Maxillary Sinuses

  PARIETOACANTHIAL Position of patient • Rest the patient’s chin on the vertical

PROJECTION
WATERS METHOD
Image receptor: 8 × 10 inch
(18 × 24 cm) or 10 × 12 inch (24 ×
30 cm) lengthwise, depending on
availability
For the Waters method,1,2 the goal is to
hyperextend the patient’s neck just enough
to place the dense petrosae immediately
below the maxillary sinus floors (Fig.
20-180). When the neck is extended too
little, the petrosae are projected over the
inferior portions of the maxillary sinuses
and obscure underlying pathologic condi-
tions (Fig. 20-181). When the neck is
extended too much, the maxillary sinuses
Skull, Facial Bones, and Paranasal Sinuses
• Place the patient seated in an upright
position, facing the vertical grid device.
• Center the midsagittal plane of the
patient’s body to the midline of the grid
device.
Position of part
• Because this position is uncomfortable
for the patient to hold, have the IR and
equipment in position so that the exam-
ination can be performed quickly.
• Hyperextend the patient’s neck to
approximately the correct position, and
then center the IR to the acanthion.
grid device and adjust it so that the mid-
sagittal plane is perpendicular to the
plane of the IR.
• Using a protractor as a guide, adjust the
head so that the OML forms an angle of
37 degrees from the plane of the IR
(Fig. 20-182; see Fig. 20-180). As a
positioning check for the average-
shaped skull, the mentomeatal (MML)
line should be approximately perpen-
dicular to the IR plane.
• Immobilize the head.
• Respiration: Suspend.

are foreshortened, and the antral floors are

not shown.
1
Waters CA: A modification of the occipitofrontal
position in the roentgen examination of the acces-
sory nasal sinuses, Arch Radiol Ther 20:15, 1915.
2
Mahoney HO: Head and sinus positions, Xray Techn
1:89, 1930.
37°

CR
CR

Fig. 20-180  Proper positioning Fig. 20-181  Improper

diagram. Petrous ridges are positioning diagram. Petrous
projected below maxillary ridges are superimposed on
sinuses. maxillary sinuses.

Fig. 20-182  Parietoacanthial sinuses: Waters method.

362
 Maxillary Sinuses

Central ray
• Horizontal to the IR and exiting the
acanthion
Collimation
• Adjust to 8 × 10 inches (18 × 24 cm)
on the collimator.
Structures shown
The image shows a parietoacanthial pro-
jection of the maxillary sinuses, with the
petrous ridges lying inferior to the floor of
the sinuses (Fig. 20-183). The frontal and
ethmoidal air cells are distorted.
The Waters method is also used to show
the foramen rotundum. The images of
these structures are seen, one on each side,
just inferior to the medial aspect of the
orbital floor and superior to the roof of the
maxillary sinuses.
EVALUATION CRITERIA
The following should be clearly shown:
■ Evidence of proper collimation with
close beam restriction to the sinus area
■ Maxillary sinuses
■ OML in proper position (sufficient neck
extension), as demonstrated by:
□ Petrous pyramids lying immediately
inferior to the floor of the maxillary
sinuses
■ No rotation or tilt, demonstrated by:
□ Equal distance between the lateral
border of the skull and the lateral
border of the orbit on both sides
□ Orbits and maxillary sinuses sym-
metric on each side
□ MSP of head aligned with long axis
of collimated field
■ Brightness and contrast sufficient to

Maxillary Sinuses
visualize air-fluid levels, if present

R R
Frontal sinuses

Ethmoid sinuses

(R) Maxillary sinus

Petrous ridge

Mastoid air cells

A B
Fig. 20-183  A, Parietoacanthial sinuses: Waters method. B, Same projection.

363
 Maxillary and Sphenoidal Sinuses
  PARIETOACANTHIAL
PROJECTION
OPEN-MOUTH WATERS METHOD
Image receptor: 8 × 10 inch
(18 × 24 cm) or 10 × 12 inch (24 ×
30 cm) lengthwise, depending on
availability
This method provides an excellent
demonstration of the sphenoidal sinuses
projected through the open mouth. For
patients who cannot be placed in position
for the submentovertical (SMV) projec-
Skull, Facial Bones, and Paranasal Sinuses
364
tion, the open-mouth Waters method and
lateral projections may be the only tech-
niques to show the sphenoidal sinuses.
Because the open-mouth position is
uncomfortable for the patient to hold, the
radiographer must have the IR and equip-
ment in position to perform the examina-
tion quickly.
Position of part
• Hyperextend the patient’s neck to
approximately the correct position, and
then position the IR to the acanthion.
Fig. 20-184  Parietoacanthial sinuses: open-mouth Waters method.
• Rest the patient’s chin on the vertical
grid device, and adjust it so that the
midsagittal plane is perpendicular to the
plane of the IR.
• Using a protractor as a guide, adjust the
patient’s head so that the OML forms
an angle of 37 degrees from the plane
of the IR. The MML would not be per-
pendicular (Fig. 20-184).
• Have the patient slowly open the mouth
wide open while holding the position.
• Immobilize the head.
• Respiration: Suspend.
 Maxillary and Sphenoidal Sinuses

Central ray EVALUATION CRITERIA ■ No rotation or tilt, demonstrated by:

• Horizontal to the IR and exiting the
acanthion
Collimation
• Adjust to 8 × 10 inches (18 × 24 cm)
on the collimator.
Structures shown
The open-mouth Waters method shows
the sphenoidal sinuses projected through
the open mouth along with the maxillary
sinuses (Fig. 20-185).
The following should be clearly shown:
■ Evidence of proper collimation with
close beam restriction to sinus area
■ Sphenoidal sinuses projected through
the open mouth
■ Maxillary sinuses
■ OML in proper position (sufficient neck
extension), as demonstrated by:
□ Petrous pyramids lying immediately
inferior to the floor of the maxillary
sinuses
□ Equal distance between the lateral
border of the skull and the lateral
border of the orbit on both sides
□ Orbits and maxillary sinuses sym-
metric on each side
□ MSP of head aligned with long axis
of collimated field
■ Brightness and contrast sufficient to
visualize air-fluid levels, if present

Maxillary and Sphenoidal Sinuses

R

Maxillary sinus
Upper teeth

Sphenoidal sinuses

Lower teeth

Fig. 20-185  Open-mouth Waters modification shows sphenoidal sinuses projected

through open mouth along with maxillary sinuses.

365
 Ethmoidal and Sphenoidal Sinuses
Fig. 20-186  SMV sinuses.
Skull, Facial Bones, and Paranasal Sinuses
CR
Fig. 20-187  Upright radiography
diagram: SMV sinuses, preferred
position of skull.
366
  SUBMENTOVERTICAL
PROJECTION
Image receptor: 8 × 10 inch
(18 × 24 cm) or 10 × 12 inch (24 ×
30 cm) lengthwise, depending on
availability
Position of patient
The success of the SMV projection
depends on placing the IOML as nearly
parallel as possible with the plane of the
IR and directing the central ray perpen-
dicular to the IOML. The upright position
is recommended for all paranasal sinus
images and is more comfortable for the
patient. The following steps are observed:
• Use a chair that supports the patient’s
back to obtain greater freedom in posi-
tioning the patient’s body to place the
IOML parallel with the IR.
• Seat the patient far enough away from
the vertical grid device that the head
can be fully extended (Figs. 20-186
and 20-187).
• If necessary to examine short-necked or
hypersthenic patients, angle the vertical
grid device downward to achieve a par-
allel relationship between the grid and
the IOML (Fig. 20-188). The disadvan-
tage of angling the vertical grid device
is that the central ray is not horizontal,
CR
and air-fluid levels may not be shown
as easily as when the central ray is truly
Fig. 20-188  Upright radiography horizontal.
diagram: SMV sinuses.
Position of part
• Hyperextend the patient’s neck as far as
possible, and rest the head on its vertex.
If the patient’s mouth opens during
hyperextension, ask the patient to keep
the mouth closed to move the mandibu-
lar symphysis anteriorly.
• Adjust the patient’s head so that the
midsagittal plane is perpendicular to the
midline of the IR.
• Adjust the tube so that the central
ray is perpendicular to the IOML (see
Fig. 20-186).
• Immobilize the patient’s head. In the
absence of a head clamp, place a suit-
ably backed strip of adhesive tape
across the tip of the chin and anchor it
to the sides of the radiographic unit. Do
not put the adhesive surface directly on
the patient’s skin.
• Respiration: Suspend.
 Ethmoidal and Sphenoidal Sinuses

Central ray Structures shown ■ No tilt (MSP positioned perpendicular

• Horizontal and perpendicular to the
IOML through the sella turcica. The
central ray enters on the midsagittal
plane approximately 3 4 inch (1.9 cm)
anterior to the level of the external
acoustic meatus.
Collimation
• Adjust to 8 × 10 inches (18 × 24 cm)
on the collimator.
The SMV projection for the sinuses shows
a symmetric image of the anterior portion
of the base of the skull. The sphenoidal
sinus and ethmoidal air cells are shown
(Fig. 20-189).
EVALUATION CRITERIA
The following should be clearly shown:
■ Evidence of proper collimation with
close beam restriction to sinus area
■ Sphenoid and ethmoid sinuses
to IR), demonstrated by:
□ Equal distance from the lateral
border of the skull to the mandibular
condyles on both sides
■ IOML positioned parallel to IR (suffi-
cient neck extension), demonstrated by:
□ Superimposition of anterior frontal
bone by mental protuberance
□ Insufficient neck extension will
cause mandible to superimpose
ethmoid sinuses
■ Mandibular condyles anterior to petrous
pyramids
■ Brightness and contrast sufficient to
visualize air-fluid levels, if present

Ethmoidal and Sphenoidal Sinuses

R
Maxillary sinus

Ethmoidal
sinuses

Mandible

Vomer
Sphenoidal sinus

Pharynx

Petrosa

Fig. 20-189  SMV sinuses.

367
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 21 
MAMMOGRAPHY
VALERIE F. ANDOLINA
JESSICA L. SAUNDERS

OUTLINE
SUMMARY OF PROJECTIONS, 370
Principles of Mammography, 371
L
RM

Full-Field Digital Mammography

(FFDM), 375
Computer-Aided Detection, 376
ANATOMY, 380
Breast, 380
Tissue Variations, 382
FFDM Manual Technique Chart, 394
Summary of Anatomy, 394
Summary of Pathology, 394
RADIOGRAPHY, 396
Summary of Mammography
Projections, 411
Routine Projections of
the Breast, 411
Routine Projections of the
Augmented Breast, 417
Augmented Breast, 420
Male Mammography, 426
Routine Projections of the Male
Breast, 426
Image Enhancement Methods, 427
Supplemental Projections, 432
Ductography (Examination of Milk
Ducts), 459
Localization and Biopsy of
Suspicious Lesions, 461
Breast Specimen Radiography, 471
Breast Magnetic Resonance
Imaging, 472
Thermography and
Diaphanography, 473
Conclusion, 473

369
 SUMMARY OF PROJECTIONS

PROJECTIONS, POSITIONS, AND METHODS

Page Essential Anatomy Projection Method
413 Breast Craniocaudal (CC)
415 Breast Mediolateral oblique (MLO)
420 Breast Craniocaudal (CC) IMPLANT
422 Breast Craniocaudal (CC ID) IMPLANT DISPLACED
424 Breast Mediolateral oblique (MLO) IMPLANT
425 Breast Mediolateral oblique (MLO ID) IMPLANT DISPLACED
428 Breast Variable (M) MAGNIFICATION
429 Breast Variable SPOT COMPRESSION
433 Breast Mediolateral (ML)
435 Breast Lateromedial (LM)
437 Breast Exaggerated craniocaudal (XCCL)
439 Breast Craniocaudal (CV) CLEAVAGE
441 Breast Craniocaudal (RL) ROLL LATERAL
441 Breast Craniocaudal (RM) ROLL MEDIAL
443 Breast Tangential (TAN)
445 Breast Variable (CL) CAPTURED LESION
448 Breast Caudocranial (FB)
450 Breast Mediolateral oblique (AT) AXILLARY TAIL
454 Breast Lateromedial oblique (LMO)
456 Breast Superolateral to inferomedial oblique (SIO)

Icons in the Essential column indicate projections frequently performed in the United States and Canada. Students should be competent
in these projections.

370
Principles of
Mammography
INTRODUCTION AND HISTORICAL
DEVELOPMENT
The worldwide incidence of breast cancer
is increasing. In the United States, one in
eight women who live to age 95 years
develop breast cancer sometime during
their lifetime. Breast cancer is one of the
most common malignancies diagnosed in
women; only lung cancer has a greater
overall mortality in women. Research has
failed to reveal the precise etiology of
breast cancer, and only a few major
factors, such as family history, are known
to increase a woman’s risk of developing
the disease. Most women who develop
breast cancer have no family history of the
disease, however.
Despite its frequency, breast cancer is
one of the most treatable cancers. Because
this malignancy is most treatable when it
is detected early, efforts have been directed
toward developing breast cancer screen-
ing and early detection methods. Death
rates for breast cancer in the United States
have steadily decreased in women since
1989, with larger decreases in younger
women; from 2005 to 2009, rates
decreased 3.0% per year in women
younger than 50 and 2.0% per year in
women 50 and older. The decrease in
breast cancer death rates represents prog-
ress in earlier detection, improved treat-
ment, and possibly decreased incidence as
a result of declining use of menopausal
hormone therapy (MHT).a
a
American Cancer Society: Cancer Facts and Figures
2013, p9.
Before the radical mastectomy was Reflecting these principles, the theory
introduced by Halstead in 1898, breast
cancer was considered a fatal disease.
of removing all palpable breast masses in
hopes of finding earlier cancers was devel-
Less than 5% of patients survived 4 years oped, and it was recognized that careful
after diagnosis, and the local recurrence physical examination of the breast could
rate for surgically treated breast cancer lead to detection of some early breast
was greater than 80%. Radical mastec- cancers. Most patients with breast cancer
tomy increased the 4-year survival rate to still were not diagnosed until their disease
40% and reduced the rate of local recur- was advanced, however. This fact, coupled
rence to approximately 10%. No addi- with the dismal breast cancer survival sta-
tional improvement in breast cancer tistics, highlighted the need for a tool for
survival rates occurred over the next 60 the early detection of breast cancer. Mam-
years. Some of the principles of breast mography filled that need (Fig. 21-1).
cancer management were developed
during this time, however, and these
remain valid:
1. Patients in the early stage of the disease
respond well to treatment.
2. Patients with advanced disease do
poorly.
3. The earlier the diagnosis, the better the
Principles of Mammography
chance of survival.
RCC LCC
RMLO
LMLO
Fig. 21-1  Four-image, bilateral mammogram. Craniocaudal and mediolateral oblique
projections show normal, symmetric, heterogeneously dense breast parenchyma.
371
 In 1913, Albert Soloman, a German
physician, reported the radiographic
appearance of breast cancers. Using radio-
graphic studies of cancerous breasts
removed at surgery, he described the
mechanism of how breast cancer spread.
Stafford Warren of Rochester, New York,
noted in 1926 that he was able to see a
reasonable image of the female breast
during thoracic aortic fluoroscopy and
published a report of 119 women, 48 with
breast cancer.b The first published radio-
graph of a living person’s breast, made by
Otto Kleinschmidt, appeared in a 1927
German medical textbook on malignant
tumors. Although publications on mam-
mography appeared in South America,
the United States, and Europe during the
1930s, the use of mammography for the
diagnosis of breast cancer received little
clinical interest. A few pioneers, including
Mammography
LeBorgne in Uruguay, Gershon-Cohen in
the United States, and Gros in Germany,
published excellent comparisons of mam-
mographic and pathologic anatomy and
developed some of the clinical techniques
of mammography. At that time, the sig-
nificance of breast microcalcifications was
also well understood.
By the mid-1950s, mammography was
considered a reliable clinical tool because
of such refinements as low-kilovoltage
x-ray tubes with molybdenum targets and
high-detail, industrial-grade x-ray film.
During this time, Egan in the United States
and Gros in Germany popularized the use
of mammography by utilizing industrial
grade x-ray film for diagnosing and evalu-
ating breast cancer. Breast xerography was
introduced in the 1960s and was popular-
ized by Wolfe and Ruzicka. Xerography
substantially reduced the radiation dose
received by the patient compared with the
dose received using industrial grade x-ray
film (Fig. 21-2). Because many physicians
found xerographic images easier to under-
stand and evaluate, xeromammography
became widely used for evaluating breast
disease. The first attempts at widespread
population screening began at this time.
The combination of higher-resolution,
faster x-ray film and an intensifying screen
was first introduced by the duPont
Company. As a result, radiation exposure
to the patient was reduced even more.
Improved screen-film combinations were
developed by Kodak and duPont in 1975.
By this time, extremely high-quality
mammography images could be produced
with very low patient radiation exposures.
Since 1975, faster lower-dose films, the
magnification technique, and grids for
scatter reduction have been introduced.

b
Thomas AMK, Banerjee AK, Busch U: Classic
papers in modern diagnostic radiology, Berlin,
2005, Springer, p540.

A C
Fig. 21-2  A, Right lateral xeromammogram, circa 1981. B, Circled area is
photographically magnified, showing small area of microcalcifications. C, Film-screen
magnification study 10 years later shows same calcifications. This was proven to be
ductal carcinoma in situ on biopsy.

372
EVOLUTION OF MAMMOGRAPHY quality, and streamlined designs with may be the efficient waveform output that
SYSTEMS ergonomic patient positioning aids. produces a higher effective energy x-ray
Because the breast is composed of tissues The high-frequency generators offer beam per set kVp and mA. High-frequency
with very similar densities and effective more precise control of kilovolt (peak) generators are not as bulky, and they can
atomic numbers, little difference in atten- (kVp), milliamperes (mA), and exposure be installed within the single-standing
uation is noticed when conventional x-ray time. The linearity and reproducibility mammography unit operating on single-
equipment and techniques are used. of radiographic exposures using high- phase incoming line power, facilitating
Therefore, manufacturers have developed frequency generators are uniformly excel- installation and creating a less intimidating
imaging systems that optimally and con- lent. The greatest benefit of these generators appearance (Fig. 21-4).
sistently produce images with high con-
trast and resolution.
Diligent research and development
began in the 1960s, and the first dedicated
mammography unit was introduced in
1967 by CGR (France) (Fig. 21-3). In the
1970s, increased awareness of the ele-
vated radiation doses prevalent in mam-
mography served as the catalyst for the
rapid progression of imaging systems. In
the 1970s and the early 1980s, xeromam-
mography, named for the Xerox Corpora-

Principles of Mammography
tion that developed it, was widely used
(see Fig. 21-2). This method used much
less radiation than the direct-exposure,
silver-based films that were available.
Eventually, film manufacturers introduced
several generations of mammography
film-screen systems that used even
less exposure and improved tissue visual-
ization. Each subsequent new system
showed improvement in contrast and
resolution while minimizing patient
dose.
In the 1980s, the American College of Fig. 21-3  First dedicated mammography system: Senographe by CGR (France).
Radiology (ACR) accreditation program
established quality standards for breast
imaging to optimize mammographic
equipment, processors, and screen-film
systems to ensure the production of
high-quality images. This program was
expanded in the 1990s to include quality
control and personnel qualifications and
training. The voluntary ACR program has
become the model from which the Mam-
mography Quality Standards Act of 1992
(MQSA) operates, and the ACR has been
instrumental in designing clinical practice
guidelines for quality mammography in
the United States. The evolution of mam-
mography has resulted in the implementa-
tion of radiographic systems designed
specifically for breast imaging.

MAMMOGRAPHY EQUIPMENT
Over the years, equipment manufacturers
have produced dedicated mammography
units with high-frequency generators, A B
various tube and filter materials, focal spot Fig. 21-4  A, Senographe DMR film-screen mammography unit by General Electric
sizes that allow tissue magnification, spe- (Milwaukee, WI). B, Dimensions 3-D digital breast tomosynthesis unit by Hologic (Bedford,
cialized grids to help improve image MA).

373
 As manufacturers of dedicated mam-
mography equipment have sought to
improve image quality, they have tried
many different combinations of tube and
filter materials. The most widely accepted
combinations used at this time are
molybdenum target with molybdenum
filter (Mo/Mo), molybdenum target with
rhodium filter (Mo/Rh), and rhodium
target with rhodium filter (Rh/Rh). The
Mo/Rh and Rh/Rh combinations are used
for better penetration of denser breasts
with thick tissues.
Specialized grids were developed for
mammography during the 1980s to reduce
scatter radiation and increase image con-
trast in mammography. Many units employ
moving linear focused grids, but other
manufacturers have developed very spe-
cialized grids. The Hologic (Lorad)
High Transmission Cellular (HTC) Grid
Mammography
374
employs a honeycomb-pattern, multidi-
rectional design. All dedicated mammog-
raphy units today, with the exception of
slit-scan digital units, still employ grids.
Manufacturers also knew that technolo-
gists and physicians were interested in the
comfort of their patients. They worked to
make the examination more tolerable for
patients, more ergonomically acceptable,
and more efficient for the technologist
performing the examination, while devel-
oping positioning aids to increase visual-
ization of the tissue. Some of these
aids include rounded corners on Bucky
devices and compression paddles, auto-
matic release of compression after expo-
sure, and foot pedal controls.
The next logical step toward improved
breast imaging has been the adoption of
full-field digital mammography (FFDM)
and digital breast tomosynthesis (DBT),
also referred to as 3D breast imaging. To
bring mammography into the digital world
was no simple task. To achieve the
resolution and detail necessary for breast
imaging, entire systems, from acquisition
to diagnostic review workstations, were
developed by competing manufacturers.
Each of these included proprietary com-
ponents that made integration of the units
into a current picture archiving and com-
munication system (PACS) network dif-
ficult. Integrating the healthcare enterprise
has brought together manufacturers of the
many components necessary in a full-field
digital mammography (FFDM) system to
work out problems of compatibility and
language, allowing facilities the opportu-
nity to transition more seamlessly into
digital mammography.
Full-Field Digital
Mammography (FFDM)
Mammography has been the last area in
the field of radiography to take advantage
of digital technology. In addition to the
many technical issues associated with
FFDM, the prohibitive cost of the equip-
ment and its maintenance make digital
mammography not practical for all facili-
ties. Its many advantages in imaging dense
breast tissue have provided the motive,
however, for more than 89% of mammog-
raphy facilities in the United States to
transition to this technology over the past
8 years.
FFDM units allow radiologists to
manipulate digital images electronically,
potentially saving patients from undergo-
ing additional projections and additional
radiation. The ability to manipulate digital
images improves the sensitivity of mam-
mography, especially in women with
dense breast tissue. Results of the ACRIN
DMIST study, a multifacility, multiunit
study comparing film-screen mammogra-
phy with digital mammography, were
published in September 2005.1 The authors
of this study concluded that FFDM would
benefit some patients, specifically women
younger than age 50, premenopausal and
perimenopausal women, and women of
any age with dense breast tissue. If FFDM
is not available to women who fall within
these benefit guidelines, they should con-
tinue having film-screen mammography
studies because these have successfully
been used as a screening tool for breast
cancer for over 35 years.
Digital breast imaging requires much
finer resolution than other body imaging.
FFDM images are extremely large files
that require a great deal of archival space
in PACS. Because of regulations safe-
guarding the image quality of mammog-
raphy, the images cannot be interpreted on
a traditional PACS workstation; they can
be interpreted only on high-resolution
5-megapixel or better monitors.
1
Bassett L: Clinical image evaluation, Radiol Clin
North Am 33:1027, 1995.
Innovative solutions and approaches to
FFDM continue to be developed. Digital
breast tomosynthesis (DBT) is a three-
dimensional imaging technology that
acquires images of a stationary, com-
pressed breast at multiple angles during a
short scan. These images are reconstructed
into thin, high-resolution slices that can
be displayed individually or in a
dynamic cine mode. These units can
simultaneously acquire the traditional
two-dimensional mammogram and the
additional exposures necessary to recon-
struct a three-dimensional image. DBT
was approved for clinical use by the FDA
in 2011. It is believed that DBT will
reduce the number of patients recalled for
additional views, will reduce the number
of biopsies performed on benign lesions,
and will result in fewer short-interval
follow-up examinations.c
Full-Field Digital Mammography (FFDM)
c
Zuley M et al: Digital breast tomosynthesis versus
supplemental diagnostic mammographic views for
evaluation of noncalcified breast lesions, Radiology
266:89, 2013.
375
 Computer-Aided
Detection
When performing mammographic inter-
pretation, the radiologist must locate any
suspicious lesions (sensitivity) and then
determine the probability that the lesion is
malignant or benign (specificity). Even
with high-quality mammography, some
breast cancers are missed on initial inter-
pretation. Double-reading of screening
mammograms by a second radiologist can
improve detection rates by approximately
10%.1 Efforts have been made to develop
and apply a computer-aided detection
(CAD) system to achieve the same result
as double-reading. It has also been found
1 2
Kopans DB: Double-reading, Radiol Clin North Am
38:719, 2000.
Mammography
Fig. 21-5  LCC and MLO projections of extremely dense breast with CAD markers
indicating areas of suspicion that proved to be cancer.
376
that double-reading plus the use of CAD
can increase detection rates by an addi-
tional 8%.2
CAD is a method by which a radiologist
can use computer analysis of digitally
acquired images as a “second opinion”
before making a final interpretation. CAD
works similar to a spell-check on a com-
puter; an area is pointed out for the radiolo-
gist to check, but it is up to the radiologist
to decide whether the area is suspicious
enough to warrant additional procedures.
CAD requires that the mammographic
image exist in a digital format to facilitate
computer input. The use of images directly
acquired with full-field digital technology
is preferred; however, CAD can also be
Destounis SV et al: Can computer-aided detection
with double reading of screening mammograms help
decrease the false-negative rate? Initial experience,
Radiology 232:578, 2004.
LMLO
accomplished on film images with the use
of an optical scanner. The computer may
detect lesions that are missed by the radi-
ologist, minimizing the possibility of false-
negative readings (Fig. 21-5). When a
lesion is detected, the computer can be pro-
grammed with basic algorithms to estimate
the likelihood of malignancy, increasing
true-positive rates. Ultimately, the objec-
tive of this technology is to improve early
detection rates and minimize the number
of unnecessary breast biopsies. Another
advantage of CAD is that computers are
not subject to the bias, fatigue, or distrac-
tions to which a radiologist may be subject.
Because of the high rates of sensitivity and
specificity shown by CAD, it has become
a standard of care for many mammography
practices.
LCC
BREAST CANCER SCREENING
It is now known that high-quality mam-
mography, careful physical examination,
and monthly breast self-examination
(BSE) can result in the detection of breast
cancer at an early stage—when it is most
curable.
The 5-year relative survival rate for
female invasive breast cancer patients has
improved from 75% in the mid-1970s to
90% today. The 5-year relative survival
for women diagnosed with localized
breast cancer (cancer that has not spread
to lymph nodes or other locations outside
the breast) is 98%; if the cancer has spread
to nearby lymph nodes (regional stage) or
distant lymph nodes or organs (distant
stage), the survival rate falls to 84% or
24%, respectively.d
Mammography must be performed well
to be fully effective. The American College
fear of radiation exposure still causes
some women to refuse mammography,
and many women who undergo the exami-
nation are concerned about exposure
levels and the resultant risk of carcinogen-
esis. To assuage these fears, the radiogra-
pher must understand the relationship
between breast irradiation and breast
cancer and the relative risks of mammog-
raphy in light of the natural incidence of
breast cancer and the potential benefit of
the examination. No direct evidence exists
to suggest that the small doses of diagnos-
tic x-rays used in mammography can
induce breast cancer. It has been shown,
however, that large radiation doses can
increase the incidence of breast cancer,
and that the risk is dose-dependent. Evi-
dence to support increased risk of breast
cancer from breast irradiation comes from
studies of three groups of women in whom
mrad.1 If this level is used as a gauge,
the lifetime risk of mortality from
mammography-induced radiation is 5
deaths per 1 million patients. In other
terms, the risk received from an x-ray
mammogram that uses a screen-film com-
bination is equivalent to that associated
with smoking several cigarettes, driving
60 miles in an automobile, or being a
60-year-old man for 10 minutes.
Fig. 21-6 shows a chart displaying
average values for mean glandular dose
and estimates of image quality in mam-
mography for the period from the early
1970s to 2005. Doses in mammography
have consistently decreased with time, with
the most substantial reductions in dose
occurring from the early 1970s to the early
1980s. Image quality data are presented
from the mid-1980s to the present and
show consistent improvement with time.2

Computer-Aided Detection/Screening Principles

of Radiology (ACR) had been a proponent
of high standards in breast imaging since
1967 and implemented an optional Mam-
mography Accreditation Program in 1989.
In 1992, the Mammography Quality Stan-
dards Act (MQSA) was implemented to
mandate the maintenance of high-quality
breast cancer screening programs. In 1994,
mammography became the only radio-
graphic examination to be fully regulated
by the federal government. MQSA requires
formal training and continuing education
for all members of the breast imaging team.
In addition, imaging equipment must be
inspected regularly, and all quality assur-
ance activities must be documented. Facili-
ties are also required to provide protocols
documenting responsibility for communi-
cating mammogram results to the patient
and the referring physician, providing
follow-up, tracking patients, and monitor-
ing outcomes. The goal of MQSA is for
high-quality mammography to be per-
the incidence of breast cancer increased
after they were exposed to large doses of
radiation: (1) women exposed to the
atomic bombs at Hiroshima and Nagasaki,
(2) women with tuberculosis who received
multiple fluoroscopic examinations of the
chest, and (3) women who were treated
with radiation for postpartum mastitis.
The radiation dose received by these
women (600 to 700 rads) was many times
higher, however, than the dose received
from mammography.
Mean glandular dose provides the best
indicator of radiation risk to a patient. In
1997, the average mean glandular dose for
a two-projection screen-film-grid mam-
mogram for all facilities in the United
States inspected under MQSA was 320
16
14
12
An important observation in the previ-
ously mentioned population studies is that
the breast tissue of young women in their
teenage years to early 20s seems to be much
more sensitive to radiation than the breast
tissue of women older than 30 years.
Because breast irradiation is a concern,
radiologic examinations need to be per-
formed with only the radiation dose that is
necessary for providing accurate detection.
1
Haus AG: Screen-film and digital mammography
image quality and radiation dose considerations,
Radiol Clin North Am 38:871, 2000.
2
Spelic DC: FDA updated trends in mammography
dose and image quality—related article: dose and
image quality in mammography: trends during the
first decade of MQSA, Available at: www.FDA.gov.
Accessed August 18, 2009.
13
12
11
Phantom score

formed by individuals most qualified to do 10

Dose (mGy)

10
so and by individuals who are willing to
8 9
accept full responsibility for providing that
service with continuity of care. 6 8

4 7
RISK VERSUS BENEFIT
2 6
In the mid-1970s, the media-influenced
public perception was that radiation expo- 0 5
sure from diagnostic x-rays would induce 1970 1975 1980 1985 1990 1995 2000 2005

more breast cancers than would be Year

detected. Although radiation dosage
during a mammography examination has Mean Glandular Dose

decreased dramatically since the 1970s, Phantom score

(w/o artifact subtraction)

d
American Cancer Society: Cancer Facts & Figures Fig. 21-6  Average values for mean glandular dose and estimates of image quality in
2013, p11. mammography for the period from the early 1970s to 2005.

377
 Screening vs diagnostic
mammography
The frequency with which women
should undergo screening mammography
depends on their age and personal risk of
developing breast cancer. Current recom-
mendations from the American Cancer
Society and the ACR are that all women
older than 40 years should undergo annual
mammography and should continue yearly
mammography for as long as they are in
reasonably good health otherwise. A base-
line examination performed sometime
before the onset of menopause is useful
for comparison during subsequent evalu-
ations. High-risk patients should consider
beginning screening mammography at an
earlier age.
The term screening mammography is
applied to a procedure performed on an
asymptomatic patient or a patient who
Mammography
presents without any known breast prob-
lems. For a procedure to be used as a
screening method, it must meet the fol-
lowing criteria:
1. It must be simple.
2. It must be acceptable.
3. It must show high sensitivity.
4. It must show high specificity.
5. It must be reproducible.
6. It must be cost-effective.
7. It must have a low risk-to-benefit ratio.
Mammography is a relatively simple
procedure that takes only about 15 minutes
to complete. The acceptability of mam-
mography, which is the only radiographic
procedure used to screen cancer, has been
confirmed in numerous studies. Mammog-
raphy cannot detect all cancerous lesions,
however. An annual clinical breast exami-
nation is recommended by the American
Cancer Society. Many physicians also rec-
ommend that women perform monthly
BSEs. Even when mammography is per-
formed properly, approximately 10% of
cancers remain radiographically occult,
particularly in dense breasts and augmented
breasts. Even so, mammography has
greater sensitivity and specificity for detect-
ing breast tumors than any other currently
available noninvasive diagnostic tech-
nique. When compared with magnetic
resonance imaging (MRI), ultrasonogra-
phy, and digital techniques, mammography
is more cost-effective and more reproduc-
ible when quality control standards are
maintained. Mammography must be per-
formed properly to maintain these charac-
teristics, however. As with other imaging
modalities, high-quality mammography
378
requires an extremely dedicated staff with
the appropriate training and expertise.
Breast cancer screening studies have
shown that early detection is essential
for reducing mortality and that the most
effective approach is to combine clinical
breast examination with mammography
at directed intervals. Although massive
screening efforts initially may seem cost-
prohibitive, the actual cost of screening in
the long-term is much less than the
expenses involved in caring for patients
with advanced breast disease. To this end,
screening patients at high risk for breast
cancer with the addition of annual breast
MRI has been added to screening
recommendations.
The preceding paragraphs describe the
screening of patients who do not have sig-
nificant breast symptoms. All patients
with clinical evidence of significant or
potentially significant breast disease
should undergo a diagnostic mammogram
and subsequent work-up as necessary.
Diagnostic mammograms are problem-
solving examinations in which specific
projections are obtained to rule out cancer
or to show a suspicious area seen on
routine screening projections. They are
also indicated if a woman presents with a
palpable mass or other symptom. The area
of interest may be better shown using
image enhancement methods, such as spot
compression and the magnification tech-
nique. Further work-up may be necessary
if mammography does not show a correla-
tive mass. Alternative imaging modalities
such as ultrasonography are often used
to complete a successful work-up. The
radiologist and radiographer direct and
conduct the diagnostic mammogram to
facilitate an accurate interpretation.
Although most diagnostic mammo-
grams conclude with probable benign
findings, some women are asked to return
for subsequent mammograms in 3 or 6
months to assess for interval changes.
Other women must consult with a special-
ist or surgeon about possible options such
as fine-needle aspiration biopsy (FNAB),
core biopsy, or excisional biopsy.
Although it is an excellent tool for
detecting breast cancer, mammography
does not permit diagnosis of breast cancer.
Some lesions may appear consistent with
malignant disease but turn out to be com-
pletely benign conditions. Breast cancer
can be diagnosed only by a pathologist
through evaluation of tissue extracted
from the lesion. After interpreting the
diagnostic work-up, the radiologist must
carefully determine whether core biopsy
and/or surgical intervention is warranted.
RISK FACTORS
Assessing a woman’s risk for developing
breast cancer is complicated. An accurate
patient history must be elicited to identify
potential individual risk factors. The radi-
ologist considers these known risks after
interpreting the mammogram. Other than
gender, factors that are known to influence
the development of breast cancer include
age, hormonal history, and family history.
Besides being female, increasing age is
the most important risk factor for breast
cancer. Potentially modifiable risk factors
include weight gain after age 18, being
overweight or obese (for postmenopausal
breast cancer), use of menopausal hormone
therapy (combined estrogen and proges-
tin), physical inactivity, and alcohol con-
sumption. Medical findings that predict
higher risk include high breast tissue
density (a mammographic measure of the
amount of glandular tissue relative to fatty
tissue), high bone mineral density (women
with low density are at increased risk
for osteoporosis), and biopsy-confirmed
hyperplasia (overgrowth of cells), espe-
cially atypical hyperplasia (overgrowth of
abnormal cells). High-dose radiation to
the chest for cancer treatment also
increases risk. Reproductive factors that
increase risk include a long menstrual
history (menstrual periods that start early
and/or end later in life), recent use of oral
contraceptives, never having children, and
having one’s first child after age 30.
Risk is also increased by a family
history of breast cancer, particularly
having one or more first-degree relatives
with breast cancer (although most women
with breast cancer do not have a family
history of the disease). Inherited muta-
tions (alterations) in breast cancer suscep-
tibility genes account for approximately
5% to 10% of all female breast cancers
and an estimated 4% to 40% of all male
breast cancers but are very rare in the
general population (much less than 1%).
Most of these mutations are located in
BRCA1 and BRCA2 genes, although muta-
tions in other known genes have also been
identified. Individuals with a strong family
history of breast and certain other cancers,
such as ovarian and colon cancer, should
consider counseling to determine whether
genetic testing is appropriate. Prevention
measures may be possible for individuals
with breast cancer susceptibility muta-
tions. In BRCA1 and BRCA2 mutation car-
riers, studies suggest that prophylactic
removal of the ovaries and/or breasts
decreases the risk of breast cancer consid-
erably, although not all women who
choose this surgery would have developed
breast cancer. Women who consider pro-
phylactic surgery should undergo counsel-
ing before reaching a decision. The drugs
tamoxifen and raloxifene have been
approved to reduce breast cancer risk in
women at high risk. Raloxifene appears to
have a lower risk of certain side effects,
such as uterine cancer and blood clots;
however, it is approved only for use in
postmenopausal women.
Limited but accumulating evidence
suggests that long-term heavy smoking
increases the risk of breast cancer, particu-
larly among women who began smoking
at an early age. The International Agency
for Research on Cancer has concluded
that limited evidence indicates that shift
work, particularly at night, is also associ-
ated with an increased risk of breast
cancer.e
e
American Cancer Society: Cancer Facts and Figures
2013.
Screening Principles
379
 ANATOMY
Breast
The terms breast and mammary gland are
often used synonymously. Anatomy text-
books tend to use the term mammary
gland, whereas radiography textbooks
tend to use the term breast. The breasts
(mammary glands) are lobulated glandu-
lar structures located within the superfi-
cial fascia of the anterolateral surface of
the thorax of both males and females. The
mammary glands divide the superficial
fascia into anterior and posterior compo-
nents. The mammary tissue is completely
surrounded by fascia and is enveloped
between the anterior and posterior layers
of the superficial fascia. In females, the
breasts are secondary sex characteristics
and function as accessory glands to the
reproductive system by producing and
secreting milk during lactation. In males,
the breasts are rudimentary and without
Mammography
function. Male breasts are subject to
abnormalities such as neoplasms that
require radiologic evaluation; however
this occurs more rarely than in female
breasts.
Female breasts vary considerably in
size and shape, depending on the amount
of fat and glandular tissue and the condi-
tion of the suspensory ligaments. Each
breast is usually cone-shaped, with the
base or posterior surface of the breast
overlying the pectoralis major and ser-
ratus anterior muscles. These muscles
extend from the second or third rib inferi-
orly to the sixth or seventh rib, and from
Axillary tail
of breast
Serratus
anterior
Fig. 21-7  Relationship of breast to chest wall. Note extension of breast tissue posteriorly
into axilla.
380
near the lateral margin of the sternum lat-
erally toward the anterior axillary plane.
An additional portion of breast tissue, the
axillary prolongation or axillary tail (AT),
extends from the upper lateral base of the
breasts into the axillary fossa (Fig. 21-7).
The breast tapers anteriorly from the
base, ending in the nipple, which is sur-
rounded by a circular area of pigmented
skin called the areola. The breasts are sup-
ported by Cooper’s ligaments, suspensory
ligaments that extend from the posterior
layers of the superficial fascia through the
anterior fascia into the subcutaneous
tissue and skin. It is the condition of these
ligaments—not the relative fat content—
that gives the breasts their firmness or lack
of firmness.
The adult female breast consists of 15
to 20 lobes, which are distributed such
that more lobes are superior and lateral
than inferior and medial. Each lobe is
divided into many lobules, which are the
basic structural units of the breast. The
lobules contain the glandular elements, or
acini. Each lobule consists of several
acini, numerous draining ducts, and the
interlobular stroma or connective tissue.
These elements are part of the breast
parenchyma and participate in hormonal
changes. By the late teenage years to early
20s, each breast contains several hundred
lobules. These lobules tend to decrease in
size with increasing age, particularly after
pregnancy—a normal process called
involution.
Pectoralis minor
Cut
pectoralis major
The openings of each acinus join to
form lactiferous ductules that drain the
lobules, which join to form 15 to 20 lac-
tiferous ducts, one for each lobe. Several
lactiferous ducts may combine before
emptying directly into the nipple. As a
result, there are usually fewer duct open-
ings on the nipple than there are breast
ducts and lobes. The individual lobes are
incompletely separated from each other
by Cooper’s ligaments. The space between
the lobes contains fatty tissue and addi-
tional connective tissue. A layer of fatty
tissue surrounds the gland, except in the
area immediately under the areola and
nipple (Fig. 21-8).
The lymphatic vessels of the breast
drain laterally into the axillary lymph
nodes and medially into the chain of inter-
nal mammary lymph nodes (Fig. 21-9).
Approximately 75% of lymph drainage is
toward the axilla, and 25% is toward the
internal mammary chain. The number of
axillary nodes varies from 12 to 30 (some-
times more). The axilla is occasionally
radiographed during breast examinations
so the axillary nodes can be evaluated.
The internal mammary nodes are situated
behind the sternum and manubrium and,
if enlarged, are occasionally visible on a
lateral chest radiograph.
The radiographer must take into account
breast anatomy and patient body habitus
to successfully image as much breast
tissue as possible. Image receptor (IR)
size and compression paddles must be
appropriate for the breast being imaged.
Larger breasts would not be entirely
shown on small IRs. Conversely, smaller
breasts should not be imaged on larger IRs
because (1) other body structures may
interfere with the compression device,
resulting in an unacceptable image; and
(2) the pectoral muscle and the skin are
likely to become taut from upward stretch-
ing of the arm, preventing the breast tissue
from being completely pulled onto the
film.
The natural mobility of the breast is
another important consideration. The
lateral and inferior aspects of the breast
are mobile, whereas the medial and supe-
rior aspects are fixed. The breast is most
effectively positioned by moving the
mobile aspects toward the fixed tissues.
Likewise, the radiographer should avoid
moving the compression paddle against
fixed tissues because this would cause less
breast tissue to be imaged.
 Fat
Ducts
Alveoli

Nipple
Lobules

Cooper’s
Nipple (suspensory)
Pectoralis major ligament

Mammary
Retromammary fat
fat
Lactiferous
ducts
Lobe
Areola

Fat Ampulla

Subcutaneous fat Interlobular

Inframammary connective

Breast
A crease B tissue

Fig. 21-8  A, Sagittal section through female breast, illustrating structural anatomy.
B, Breast anterior view.

A B
Fig. 21-9  A, Schematic drawing of lymph node system surrounding the breast. B, MLO
views of the breast often include axillary lymph nodes; occasionally intramammary
lymph nodes may also be seen (arrow).

381
 Tissue Variations
The glandular and connective tissues of
the breasts are soft tissue–density struc-
tures. The ability to show radiographic
detail within the breast depends on the fat
within and between the breast lobules and
the fat surrounding the breasts. The post-
pubertal adolescent breast contains pri-
marily dense connective tissue and casts
a relatively homogeneous radiographic
Mammography
image with little tissue differentiation.
The development of glandular tissue
decreases radiographic contrast. During
pregnancy, significant hypertrophy of
glands and ducts occurs within the breasts.
This change causes the breasts to become
extremely dense and opaque (Fig. 21-10).
After the end of lactation, considerable
involution of glandular and parenchymal
tissues usually occurs, and these tissues
are replaced with increased amounts of
fatty tissue. Fat accumulation varies mark-
edly among individuals. This normal fat
accumulation significantly increases the
natural radiographic contrast within the
breasts. The breasts of patients with fibro-
cystic parenchymal conditions may not
undergo this involution.

Fig. 21-10  CC and MLO projections of a nursing mother. During lactation, the breasts
become very dense and opaque as the ducts and glands become hypertrophic and
engorged with milk. If mammography must be performed on a nursing mother, it is best
to have the patient nurse or pump her breasts immediately before imaging.

382
 The glandular and connective tissue
elements of the breast can regenerate as
needed for subsequent pregnancies. After
menopause, the glandular and stromal ele-
ments undergo gradual atrophy. External
factors such as surgical menopause and
hormone replacement therapy (HRT) may
inhibit this normal process. From puberty
through menopause, mammotrophic hor-
mones influence cyclic changes in the
breasts. The glandular and connective
tissues are in a state of constant change
(Fig. 21-11).
Breast tissue density is the ratio of fatty
to glandular tissue within the breast. The
more glandular tissue, the denser the Adolescent Prepregnancy Reproductive Menopausal Senescent
breast, meaning that it is more difficult for Fig. 21-11  Diagrammatic profile drawings of breast, illustrating most likely variation and
x-rays to penetrate the tissue. Breasts are distribution of radiographic density (shaded areas) related to the normal life cycle from
classified into four density ranges: fatty, adolescence to senescence. This normal sequence may be altered by external factors,
scattered, heterogeneously dense, and such as pregnancy, hormone medications, surgical menopause, and fibrocystic breast
condition.
extremely dense (Fig. 21-12). Breast

Tissue Variations
density has been brought to the forefront
recently, with several states mandating
that patients are told the composition of
their personal breast density and the clas-
sification that the radiologist has reported.

A B C D
Fig. 21-12  When reading the mammogram, the radiologist classifies the tissue density
into one of four categories based on the ratio of fatty to glandular tissue within the
breast: A, Fatty. B, Scattered. C, Heterogeneously dense. D, Extremely dense.

383
 PATHOLOGIC AND
MAMMOGRAPHIC FINDINGS
Numerous radiographic findings, benign
or malignant, can be evident within the
breast tissue on any mammogram. Distin-
guishing the characteristics of a finding is
the main function of the mammogram.
From these characteristics, the radiologist
can make a determination of the probabil-
ity of malignancy. This helps the radiolo-
gist determine whether biopsy of the
lesion is necessary, if the lesion is most
likely benign, or if the area should be fol-
lowed carefully for indications of change.
Characterization of a finding helps the
radiologist make these determinations, but
it must be kept in mind that cancer is a
very tricky disease, and sometimes even
the most benign-appearing lesion can be
found to be malignant. Therefore, some-
times biopsies are performed on probable
Mammography
benign lesions to ensure that they are
benign.
Each breast is a symmetric mirror
image of the other. Subtle variations may
normally occur from one breast to the
other, but an asymmetric variation that is
new or enlarging can be cause for concern
and can lead to a more thorough work-up.
These variations generally present as a
mass or density, calcifications within the
tissue, or distortion within the architecture
of the breast tissue. When these findings
384
are noted on a screening mammogram, the
radiologist will often request additional
diagnostic mammography views or spe-
cialized imaging such as ultrasonography
for a more clear view of the area of
concern.
Masses
A mass is generally categorized by its
shape, by the margins of the mass, and by
its radiographic density.
• The shape of a lesion is described as
round, oval, lobular, or irregular. A
round or oval mass is more likely to
indicate benign pathology such as a
cyst (a fluid-filled pocket within the
tissue) or a lymph node (depending on
its location). An irregularly shaped
mass can more likely indicate a malig-
nancy, or it can be an indication of
trauma to an area of breast tissue. This
illustrates the importance of taking a
thorough patient history.
• The margins, or borders, of the mass
are described as circumscribed (meaning
well defined or sharply defined), micro­
lobulated, obscured (meaning that parts
are hidden by superimposed tissue),
indistinct or ill defined, or spiculated
(showing fine spicules radiating from
the center of the mass). Margin charac-
teristics help the clinician to predict
whether a mass is malignant or benign.
A mass with a well-defined border is
more likely to be benign. Masses with
obscured, ill-defined, indistinct margins
are suspicious, and a spiculated mass
is more worrisome. Microlobulated
masses have a 50% chance of being
malignant. Post-biopsy scarring may
appear as a spiculated mass, and an
accurate patient history revealing previ-
ous breast biopsies can prevent an
unnecessary work-up (Fig. 21-13).
• Examples of benign stellate or spicu-
lated lesions include radial scar, fat
necrosis, breast abscess, and scleros-
ing adenosis. Examples of benign
circumscribed masses include fibro-
adenoma (Fig. 21-14), cyst, intra­
mammary lymph node, hematoma,
and galactocele.
• Density may be described as high
density, equal density or isodense, low
density, or radiolucent. Breast cancer
that forms a visible mass is more likely
to be higher in density than the fibro-
glandular tissue surrounding it, but it
can be of equal density. However, breast
cancers never contain fatty tissue.
Masses that are radiolucent contain fat
and are overwhelmingly benign appear-
ing. These include oil cysts, lipomas,
galactoceles, and mixed tissue lesions
such as hamartomas and fibrolipadeno-
mas (Fig. 21-15).
 RCC RMLO

Pathologic and Mammographic Findings

A B
Fig. 21-13  A, RCC projection of a patient who had previously undergone surgical biopsy for removal of a benign mass reveals an
area of architectural distortion with spiculated borders. B, MLO projection reveals that the area coincides with the surgical scar. Note
the radiopaque skin marker that the technologist placed over the site of the scar (thin arrows).

A B
Fig. 21-14  Circumscribed masses are often benign. A, TAN MAG projection of a fibroadenoma. B, Magnified view of a retroareolar
cyst. A mass is determined to be solid or cystic (fluid-filled) on ultrasound.

385
Mammography

A B

Fig. 21-15  Radiolucent masses include (A) oil cyst with a

calcified rim. Oil cysts are formed when trauma or
surgical intervention causes necrosis of fatty tissue. In
time, a calcific rim is formed by the body to isolate the
necrotic tissue. B, Lipoma—a lesion consisting of fatty
tissue. C, Hamartoma—a lesion consisting of a mixture of
fatty and fibrous tissue.

C
386
 The malignant or benign nature of a
mass cannot be determined on the basis of
location. Most cancers are detected in
the UOQ of the breast; however, most
breast lesions—malignant and benign—
are found in that quadrant. Cancer can
occur in any region of the breast with a
certain degree of probability. It is impor-
tant to determine the location of a lesion
for additional diagnostic procedures such
as core biopsy or open surgical biopsy.
Interval change may increase the suspi-
cion of malignancy. The radiologist
carefully compares current images with
previous ones and notes whether the mass
is newly apparent, an interval enlargement
is present, the borders have become
nodular or ill defined, a mass has increased
in density, or calcifications have appeared
(Fig. 21-16).
Almost all (98%) of the axillary lymph
nodes are located in the UOQ. These
nodes are well circumscribed, may have a
central or peripheral area of fat, and can
be kidney bean–shaped (see Fig. 21-9). If
the lymph nodes appear normal, they are
rarely mentioned in the context of an iden-
tifiable mass on the radiology report.

Pathologic and Mammographic Findings

2013
2011

Fig. 21-16  Interval change. A change in tissue architecture and density was noted
during a screening mammogram on this 51-year-old woman. Core biopsy of this area
was positive for invasive ductal carcinoma.

387
 A density that is seen on only one projec-
tion is not confirmed three-dimensionally
and may represent superimposed struc-
tures. These may appear to have scalloped
edges or concave borders or both. The
radiologist may request spot compression
projections, rolled projections, or angled
Mammography
projections to confirm or rule out the pres-
ence of a real density. A suspicious density
seen on only one projection within the
breast is often a summation shadow of
superimposed breast parenchyma and dis-
appears when the breast tissue is spread
apart (Fig. 21-17).

A B
Fig. 21-17  An area of increased density was noted on this MLO projection of the right
breast (A). Spot compression of this area (B), also performed in the MLO position,
spreads the tissue out more uniformly. The density was no longer seen, indicating that
overlapped tissue was causing a summation shadow.

388
Calcifications
Calcifications are often normal metabolic
occurrences within the breast and are
usually benign. Approximately 15% to
25% of microcalcifications found in
asymptomatic women are associated with
cancer, however. These calcifications can
have definitive characteristics. Because of
size, some microcalcifications are more
difficult to interpret. The most valuable
tool for defining microcalcifications is a
properly performed image obtained using
the magnification technique. Using this
image, the radiologist can determine better
whether calcifications are suspicious and
warrant further work-up.
Calcifications are categorized by size,
shape, and distribution. Benign calcifica-
tions are generally larger, coarser, rounder,
and smoother. Typically, they are easily
seen on the mammogram, whereas malig-

Pathologic and Mammographic Findings

nant calcifications are usually very small,
often requiring magnification to be seen
(Fig. 21-18).

B
Fig. 21-18  Examples of benign calcifications seen on mammography: A, Coarse and
round calcification. B, Calcifications caused by dystrophic fat necrosis. Continued
389
Mammography

D E
Fig. 21-18, cont’d C, Popcorn calcification. D, Vascular calcification. E, Rodlike secretory calcifications.

390
 Benign calcifications may have one or
more of the following attributes: moderate
size, scattered location, round shape, and,
usually, bilateral occurrence. In addition,
they may be eggshell (lucent center),
arterial (parallel tracks), crescent, or
sedimented (“teacup” milk of calcium).
Calcifications may represent a fibroade-
noma (“popcorn”), postsurgical scarring
(sheets or large strands of calcium), skin
calcifications (which can mimic suspi-
cious microcalcifications within the breast
parenchyma), and vascular calcifications.
Vascular calcifications are often noted,
and studies have indicated that vascular
calcifications in women younger than 50
years of age may suggest potential risk for
coronary artery disease.
• The projection suggested for better
defined sedimented milk of calcium A
is the 90-degree lateral projection—

Pathologic and Mammographic Findings

lateromedial (LM) or mediolateral
(ML). If possible, the mammographer
should select the lateral projection that
places the suspected area closest to the
IR. The 90-degree lateral is also used as
a triangulation projection before needle
localization and to show air-fluid-fat
levels (Fig. 21-19).
Calcifications that are suspicious and
cause intermediate concern are catego-
rized as amorphous or indistinct, or coarse
heterogeneous calcifications. Amorphous
or indistinct calcifications appear small
and hazy. When diffusely scattered, they
can usually be dismissed as benign, but
when clustered, they may warrant biopsy.
Coarse heterogeneous calcifications are
conspicuous and irregularly shaped, are
generally larger than 0.5 mm, and can be
associated with malignancy, but they also B
may be present in areas of fibrosis, within
fibroadenomas, or in areas of trauma. Fig. 21-19  Milk of calcium occurs when residual milk remains in the alveoli following
lactation. Over time, the calcium within the milk solidifies into tiny particles that become
Fine pleomorphic calcifications and
sediment. On the CC projection, it appears as rounded low-density areas (A). On the
fine linear or branching calcifications indi- ML projection, the sediment appears crescent shaped as it settles, in a “teacup”
cate a higher probability of malignancy. appearance (B).
The fine linear type suggests filling of the
lumen of a duct involved in a breast
cancer. Fine pleomorphic forms vary in
shape but are generally smaller than
0.5 mm (Fig. 21-20).

391
 A
Mammography

Fig. 21-20  Examples of calcifications seen

on mammography that are suspicious or
have a high probability of indicating cancer.
A, These amorphous, diffuse calcifications
proved to be ductal carcinoma in situ (DCIS)
on biopsy. B, These linear, branching
calcifications proved to be invasive ductal
carcinoma on biopsy. C, Pleomorphic linear
calcifications proved to be DCIS.

C
392
 The distribution of the calcifications
describes the arrangement of calcifica-
tions in the breast. Diffuse or scattered
calcifications are usually benign and
usually bilateral. Regional distribution of
calcifications indicates that a large volume
of breast tissue contains calcifications. A
group or cluster of calcifications indicates
a minimum of five calcifications occupy-
ing a small volume of breast tissue. Linear
distribution calcifications are arranged in
a line, suggesting deposits within a duct.
Segmental distribution suggests deposits
in ducts and the possibility of extensive or
multifocal breast cancer. Although benign
causes of segmental calcifications are
known, segmental distribution of other-
wise benign-appearing calcifications ele-
vates suspicion of carcinoma.
Architectural Distortions
When the normal architecture of the breast
tissue is distorted but no definitive mass is
visible, this is called architectural distor-
tion (AD). AD is seen as a presentation of
thin lines or spiculations radiating from a
central point. Focal retraction or distortion
of the edge of the parenchyma may also
be present. Architectural distortion can be
associated with a mass or with asymmetry
or calcifications. A history of trauma or of
prior surgery may present as architectural
distortion, but in the absence of this
history, AD is suspicious for malignancy
or radial scar, and biopsy of the area is
appropriate (Fig. 21-21).

Pathologic and Mammographic Findings

A B
Fig. 21-21  Architectural distortion is seen on this CC projection (A). Spot compression
view (B) of this area confirms that this is a mass, not overlapped tissue. This proved to be
invasive ductal carcinoma on biopsy.

393
 FFDM MANUAL TECHNIQUE CHART
50%
Fatty fatty–50% Dense
Compressed breast dense breast
thickness Target filter kVp mAs Target filter kVp mAs Target filter kVp mAs
Amorphous selenium detector
  <3 cm Mo Mo 28 70 Mo Mo 28 80 Mo Mo 28 90
  3-5 cm Mo Mo 28 80 Mo Mo 28 80 Mo Mo 28 90
  5-7 cm Mo Rh 29 100 Rh Rh 29 100 Rh Rh 29 100
  >7 cm Rh Rh 30 120 Rh Rh 30 140 Rh Rh 30 160
CCD detector
  <3 cm Mo Mo 25 32 Mo Mo 26 28 Mo Mo 26 36
  3-4 cm Mo Mo 36 36 Mo Rh 26 45 Mo Rh 27 50
  4-5 cm Rh Rh 28 50 Rh Rh 29 56 Rh Rh 29 63
  5-6 cm Rh Rh 29 56 Rh Rh 29 63 Rh Rh 30 71
  6-7 cm Rh Rh 29 71 Rh Rh 29 80 Rh Rh 30 80
  7-8 cm Rh Rh 29 80 Rh Rh 30 90 Rh Rh 31 80
  >8 cm Rh Rh 30 90 Rh Rh 30 140 Rh Rh 31 140

Note: Manual techniques based on use of grid and taut compression.

SUMMARY OF ANATOMY
Mammography

Mammary gland Axillary fossa Axillary lymph nodes

(breast) Nipple Internal mammary lymph
Superficial fascia Areola nodes
Pectoralis major muscle Cooper’s ligaments Glandular tissue
Serratus anterior muscle Lobes Connective tissue
Axillary prolongation Acini Fatty tissue
(axillary tail) Lactiferous ductules

SUMMARY OF PATHOLOGY
Radiographic Findings Definition

Masses and Margins

• Circumscribed Smooth borders; mostly benign

• Indistinct Ill-defined borders

• Spiculated Mass with thin, elongated lines of tissue emerging from its center

Architectural Distortion The interruption of a regular pattern; when tissue opposes the natural breast pattern
flowing from ducts to nipple

Calcifications

Radiographic description

• Round or punctate Benign spherical calcium that can vary in size with well-defined margins

• Amorphous or indistinct Small or hazy calcium with no clearly defined shape or form

• Course heterogeneous Large calcium deposits of various sizes clustered together

• Fine heterogeneous Small calcium deposits of various sizes clustered together. Usually less than 0.5 mm in
diameter with a high probability of malignancy

394
SUMMARY OF PATHOLOGY—cont’d
Radiographic Findings Definition

Benign Calcifications

• Popcorn-type Large, thick, dense, popcorn shaped; often result from involuting fibroadenomas

• Rim calcifications Calcifications residing along the border of benign masses such as cysts, oil cysts, or
sebaceous cysts

• Milk of calcium (teacup) Found in microcysts, which contain radiopaque particles mixed with fluid

• Arterial calcifications Found within vessels resulting from arterial atherosclerosis

• Skin calcifications Found within the dermal layer of the breast, usually with smooth outlines and radiolucent
centers

Benign Pathologies

• Cyst Fluid-filled sac with distinct edges and round or oval in shape

• Galactocele Milk-filled cyst typically found in lactating women

• Fibroadenoma Solid benign tumor of glandular and connective tissue with clearly defined margins. Often
easy to move

• Lipoma Growth of fatty cells

• Hamartoma Typically well-circumscribed lesion comprised of fibrous, glandular, and fatty tissue

Summary of Pathology Table

• Papilloma Growth inside the ducts; may cause discharge

• Ductal ectasia Dilation of milk ducts with thickening of the walls; may cause discharge or fluid blockage

• Hematoma Collection of blood within the tissue, typically resulting from trauma

• Abscess and inflammation Accumulation of pus with swelling as a result of infection

• Fat necrosis Lucent area within the breast resulting from trauma, surgery, or radiation therapy

High-Risk Conditions

• Lobular carcinoma in situ Abnormal cell growth within the lobules or milk glands
(LCIS)

• Atypical ductal hyperplasia Increased production or growth within breast ducts causing architectural abnormalities
(ADH)

• Atypical lobular Increased cell growth within breast lobes

hyperplasia

• Radial scar Complex sclerosing lesion. Benign mass with spiculated borders not related to surgery.
Caused by abnormal cell growth

• Papilloma with atypia The presence of atypical hyperplasia within a papilloma

Malignant Pathologies

• Ductal carcinoma in situ Abnormal, cancerous cells within the milk ducts
(DCIS)

• Invasive/Infiltrating ductal Cancerous cells that started in the milk ducts and have spread to surrounding breast
carcinoma tissue. Most common type of breast cancer

• Invasive lobular carcinoma Cancerous cells that started within a lobule and have spread to other breast tissue

• Inflammatory carcinoma Aggressive carcinoma that blocks the lymph vessels in the skin of the breast, causing signs
of inflammation such as swelling, reddening of the skin, or an orange peel–like texture to
the skin (peau d’orange)

• Paget’s disease Carcinoma in the skin of the nipple causing a sore, reddened appearance of the nipple
and areola. Commonly associated with other types of carcinoma within the breast
tissue
• Sarcoma Cancerous cells that begin in the connective tissue supporting the lobules and ducts of
the breast
395
 RADIOGRAPHY

METHOD OF EXAMINATION
Both breasts are routinely radiographed
obtaining craniocaudal (CC) and medio-
lateral oblique (MLO) projections. Image
enhancement methods, such as spot com-
pression and the magnification technique,
are often useful as diagnostic tools. It is
sometimes necessary to enhance images
or vary projections to better characterize
lesions and calcifications. In symptomatic
patients, the examination should not be
limited to the symptomatic breast. Both
breasts should be examined for compari-
son purposes and because significant
radiographic findings may be shown in a
clinically normal breast.

Patient preparation
No specific patient preparations are
needed before a mammographic examina-
tion to enhance image quality. However,
Mammography

during the mammography procedure, the

breasts will be compressed, and this may
cause some discomfort to the patient. To
help alleviate the discomfort and solicit
patient cooperation, some practices rec-
ommend that the patient refrain from or
reduce caffeine intake for 2 weeks before
the examination, or take ibuprofen approx- A B
imately an hour before the examination.
Artifacts are common in mammogra-
phy because of the sensitivity of the
imaging techniques and the design of the
equipment used for mammography (Fig
21-22). To prevent artifacts caused by
objects protruding into the image, you
may need to ask the patient to remove
eyeglasses, earrings, and necklaces. Some
hairstyles may need to be pulled or clipped
Fig. 21-22  Frequently seen artifacts
back to prevent the hair from falling caused by positional, rather than
forward into the image. It is advisable to technical, errors include (A) earring
dress patients in open-front gowns because superimposed over the medial
the breast must be bared for the examina- portion of the breast on a CC
tion. The technologist needs to ensure projection; (B) hair superimposed
before each exposure that all of the above over the breast; and (C) the
patient’s chin superimposed over
items, as well as chins, fingers, and other the breast tissue as the result of
body parts, are outside of the field of patient motion or physical
radiation. limitations.
Some radiology practices require that
patients remove any deodorant and powder
from the axillary and inframammary
regions because these substances can
resemble calcifications on the resultant
image (Fig. 21-23). Before the breast is
radiographed, a complete history is taken,
and a careful physical assessment is
performed, noting all biopsy scars, pal-
pable masses, suspicious thickenings, C
skin abnormalities, and nipple alterations
(Fig. 21-24).

396
 Breast Radiography
A

B
Fig. 21-23  Artifacts are often the result of poor patient preparation. Figures A and
B show pseudocalcifications along the inframammary crease—the result of caked
powder. Figure C shows a band-aid applied by the patient on the posterior aspect of
the breast that was not noticed by the technologist until it was seen on the
mammogram.

397
 PLEASE BRING FORM AT TIME OF A PPOINTMENT—DO NOT MAIL. THANK YOU.
EWBC MEDICAL HISTORY FORM M.R.#
— please remember to sign the back of this form AN D only use ink to fi ll out this form—

1. Purpose of today’s visit?

2. Do you use: If discontinued
a. Hormones? Yes No Brand Dosage How long? when?
b. Oral Contraceptive? Yes No Brand
c. Anti-Estrogen/Breast Cancer Prevention? Yes No Brand ______________________________
3. Do you have breast implants? Yes No (type) Silicone Gel Saline Combination Unknown
4. Are you taking aspirin or blood thinners? Yes No
5. Are you allergic to any of the following?
a. Medicine(s)? Yes No (type) _____________________________________________
b. Adhesive Tape? Yes No
c. Lidocaine? Yes No
d. Iodine Contrast Material? Yes No
e. Latex? Yes No
f. Others? _______________________________________________________________________________________
6. Do you currently have any of the following? – please check only those that apply to you and explain below:
Fever/Chills Weakness Leg Swelling Seasonal Allergies
Eye Problems Depression Joint Aches Stomach Problems
Mammography

Kidney Problems Explanation _____________________________________

OFFICE All other systems
USE ONLY negative
7. Questions for female patients: (please circle your answers)
1. How many months since your physician examined your breasts? ________ months
2. Your age at birth of your 1st child. ____ No biological children
3. Your age at time of 1st menstrual cycle. ____
a. Are your periods regular? Yes No if no, date of your last period _________________
4. Age you entered menopause. ____ (If you are no longer having periods for at least one year).
5. Are you pregnant? Yes No
6. Are you breastfeeding? Yes No
7. Do you have your ovaries? Yes No (RIGHT) (LEFT)
8. Do you have your uterus? Yes No
9. Have you had breast surgery? Yes No

If yes, please mark the area of surgery with the year it was done.

10. Have you ever had radiation therapy to your breast/chest area? Yes No if yes, when? _____________________
11. Have you ever had chemotherapy? Yes No if yes, when? _____________ for what? _______________

8. Social History: Male Female

Marital Status: Single Married Divorced Partner Widowed
Occupation:
Do you drink alcohol? Yes No if yes, how often?
Do you smoke? check one: Daily Occasional Never Smoked Former Smoker Unknown
Race: American Indian Alaska Native Asian Black or African American
Native Hawaiian or Pacific Islander White
Ethnicity: Hispanic or Latino Not Hispanic or Latino
Preferred Language: English Other

Please list medications (include non-prescription medications and birth control pills, write “none” if no medications are used)
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________

Fig. 21-24  Sample mammography patient history questionnaire. Note that a good amount of emphasis is placed on patient and
family history to determine risk and inclusion for BRCA testing and breast MRI.
398 (Courtesy Elizabeth Wende Breast Care, LLC, Rochester, NY.)
 9. Medical/Family History: Directions-Check “None” if neither you nor anyone in your family has had this problem. Check “Self”
if this is true for you. Check “Family” if a member of your family has had this problem.
NONE SELF FA MILY
Breast Cysts
Breast Pain
Nipple Changes
Inversion: Left Right
Discharge: Left Right
Rash: Left Right
HIV
Heart Valve Replacement
High Blood Pressure
Pacemaker/Cardiac Stent
Heart Attack
Stroke
Hepatitis/Liver Problems type: _____________________________
Asthma
Diabetes
Arthritis type: _____________________________
Hives
Pancreatic Cancer

History Form
Melanoma
Lymphoma type: _____________________________
Leukemia type: _____________________________
Other Cancers type: _____________________________
(Please list breast and ovarian history below)

Have you ever been tested for BRCA1/BRCA2 Mutations?

NO YES If yes, were the results: Positive Negative Uncertain Variant
Are you of Ashkenazi Jewish Ancestry? NO YES
HISTORYOF BREAST CANCER:
NO YES Age if diagnosed
with a second NEW
Age at diagnosis Breast Cancer
Self
Mother
Sister
Daughter HISTORYOF OVARIAN CANCER:
Brother NO YES
Father Age at diagnosis
Son Self
Mother or
Niece Father’s side Mother
Nephew (PLEASE CIRCLE)
Sister
Grandmother M F Daughter Mother or
Grandfather M F Father’s side
Niece (PLEASE CIRCLE)
Aunt M F Grandmother M F
Uncle M F Cousin M F
Cousin M F Aunt M F
If we may contact you by email, please list your email address: ___________________________________________________________
Print Name: _________________________________________________ Date of birth: ____________ Date: ______________
Signature: ___________________________________________________________________________ Date: ______________
Patient Review: _______________________ Date: ______________ Patient Review: _____________ Date: ______________

OFFICE USE MD Review: _________________ MD Review: _________________ MD Review: _________________

ONLY Date: _________________ Date: _________________ Date: _________________
The above information is accurate and any unanswered questions are considered not applicable or negative. May 3.12

Fig. 21-24, cont’d

399
 EXAMINATION PROCEDURES
This section describes procedures for
conducting mammographic examinations.
Only dedicated breast imaging equipment
should be used to perform mammography.
The following steps should be taken:
• If possible, examine previous mammo-
graphic studies of patients who are
undergoing subsequent mammography
screening. These images should be
evaluated for positioning, compression,
and exposure factors to determine
whether any improvement in image
quality can be obtained with the current
study. Position the breast consistently
so that any lesion can be accurately
localized and a valid comparison with
prior studies can be made.
Mammography
400
• Determine the correct image receptor
(IR) and compression paddle size for
the patient, and use the smallest possi-
ble size to image all of the breast tissue
fully. Positioning the breast on a surface
and detector that is too large causes the
skin and muscles to overextend, reduc-
ing the amount of posterior tissue
imaged, and may compromise the tech-
nical image quality. Occasionally, a
patient may present with oversized
breasts that do not fit completely on the
largest IR. When this happens, overlap-
ping images are taken to visualize all of
the breast tissue. This is referred to as
“mosaic” imaging or tiling, as image
tiles are fitted together to form a com-
plete picture (Fig. 21-25).
• Explain the procedure simply and com-
pletely to the patient before beginning
the examination. It should never be
assumed that the patient is fully aware
of what the mammographer is about to
do, even if the patient has had prior
examinations.
• In many cases, routine projections do
not sufficiently show all of the breast
tissue, and additional projections may
be necessary. To allay patient concerns,
the mammographer should explain to
the patient, before beginning the proce-
dure, why additional projections are
sometimes needed and that they do not
indicate a potential problem.
 Examination Procedures
A

B
Fig. 21-25  When the breast is larger than the image receptor, several images of the breast should be taken to visualize all of the
tissue. A, Three mosaic images of the CC projection, taken to image anteromedial, anterolateral, and posterior tissue. B, Mosaic
images of the MLO view, imaging inferoposterior, anterior, and posteroaxillary tissue.

(Reprinted with permission from Andolina V, Lille S: Mammographic imaging, a practical guide, ed 3, Baltimore, 2011, Wolters Kluwer Health/Lippincott
Williams & Wilkins.) 401
 • Before positioning the patient’s breast
and applying compression, consider the
natural mobility of the breast, so that
patient discomfort can be minimized.
The inferior and lateral portions of the
breast are mobile, whereas the superior
and medial portions are fixed. When
possible, the mobile tissues should be
moved toward the fixed tissues.
• For each of the two basic breast projec-
tions, ensure that the breast is firmly
supported and adjusted, so that the
nipple is directed forward.
• Profile the nipple, if possible. Obtaining
an image of the posterior breast tissue
should be the primary consideration,
but positioning of the nipple in profile
is not always possible. An additional
projection can be obtained to profile the
nipple, if necessary. Alternatively, a
marker may be used to locate clearly
Mammography
the nipple that is not in profile, in which
case an additional image may not be
needed.
• Apply adequate compression to the
breast. Compression is an important
factor in achieving a high-quality mam-
mogram. The primary objective of
compression is to produce uniform
Fig. 21-26  Correct labeling of mammography image: MLO
projection.
402
breast thickness from the nipple to the
most posterior aspect of the breast.
Properly applied compression spreads
the breast so that the tissue thickness
is more evenly distributed over the
image and better separation of the glan-
dular elements is achieved. A rigid,
radiolucent mammography compres-
sion paddle facilitates breast compres-
sion. Generally, compression is applied
initially using a hands-free control and
is applied manually during the final
phase of compression. The compres-
sion should be taut but not painful. The
skin of a properly compressed breast
should feel tight when lightly tapped
with the fingertips. When evaluating
images, compare the degree of com-
pression with that of previous mam­
mograms, and note any variations. If
a patient is unable to tolerate an ade-
quate amount of compression, docu-
ment this information on the patient
history form for the radiologist. Use
only as much compression as the patient
can tolerate.
• Be sure that standard identification
information is included on the image.
For FFDM images, all of the pertinent
(B) (D)
L MLO 7
(F)
50
28 kVp
100 mA
0.5 s
22 lb
(C)
identification
Patient
(A)
(E) (G)
8 Jun 1999 III
information should be included in the
DICOM header. The information should
also be seen on the processed and
printed image. Often, this DICOM
overlay can be turned on or off as
needed by the radiologist to prevent
interference during interpretation of the
image. For film-screen images, the
American College of Radiology recom-
mends the following standard conven-
tions (Fig. 21-26):
A.  Before processing, photographi-
cally expose a permanent identifica-
tion label that includes on the image
the facility’s name and address; the
date of the examination; and the
patient’s name, age, date of birth,
and medical number. Include the
initials of the person performing the
examination on the identification
label (C).
B. On the IR near the patient’s axilla,
place a radiopaque marker indicat-
ing the side examined and the pro-
jection used (Table 21-1).
C. Label the mammography cassette
with an identification number (an
Arabic numeral is suggested by the
ACR).
 TABLE 21-1 
Labeling codes and uses for mammographic positioning
ACR Suggested Tissue best
View ID ID Projection C-arm angle Image receptor placement visualized Applications
Cranial-Caudal CC Sup-Inf 0 degrees Subareolar, Routine
central,
x-ray medial, and
beam posteromedial
tissue

Exaggerated XCCL Sup-Inf 0 degrees Posterolateral “Wrap-around” breast

Cranial-Caudal
x-ray
beam

Elevated Cranial- None ECC Sup-Inf 0 degrees Central and Superior lesion not seen
Caudal or medial, high on CC
Pushed-Up CC x-ray on chest wall
beam

Continued

403
Examination Procedures
 Mammography

404
TABLE 21-1 
Labeling codes and uses for mammographic positioning—cont’d
ACR Suggested Tissue best
View ID ID Projection C-arm angle Image receptor placement visualized Applications

Caudal-Cranial FB Inf-Sup 0 degrees Central and Non-conforming pt,

medial, high superior lesion not
on chest wall seen on CC

x-ray
beam

Mediolateral ML Med-Lat 90 degrees Lateral, central, True orthogonal to CC

Lateral superior, and for lesion localization,
inferior opens tissue for
structural overlap
x-ray
beam

Lateromedial LM Lat-Med 90 degrees Medial, central, True orthogonal to CC

Lateral superior, and for lesion localization,
inferior opens tissue for
structural overlap

x-ray
beam
 Medial-Lateral MLO SM-IL 30-60 degrees Posterior, upper Routine
Oblique outer
quadrant,
x-ray
beam axillary tail,
lower inner
quadrant

Superolateral- SIO SL-IM 1-90 degrees Posterior, medial, Additional view for
Inferomedial upper inner encapsulated
Oblique x-ray quadrant, implants, non-
beam lower outer conforming pt,
quadrant orthogonal to MLO
for localization

Inferolateral- LMO IL-SM 90-180 degrees Posterior, medial, Can replace MLO in
Superomedial upper outer pts with pacemakers,
Oblique quadrant, open heart surgical
lower inner scars
quadrant

x-ray
beam

Continued

405
Examination Procedures
 Mammography

406
TABLE 21-1 
Labeling codes and uses for mammographic positioning—cont’d
ACR Suggested Tissue best
View ID ID Projection C-arm angle Image receptor placement visualized Applications

Inferomedial- None ISO IM-SL 90-180 degrees Lateral, upper Stereotactic positioning
Superolateral inner
Oblique quadrant,
lower outer
quadrant

x-ray
beam

Axillary Tail AT SM-IL 60-80 degrees Posterior-lateral,

axillary tail

x-ray
beam

Axilla None AX SM-IL 70-90 degrees Axillary content Additional view for
cancer patients on
affected side,
x-ray suspected
beam inflammatory ca,
lymphadenopathy,
search for primary ca
 Cleavage View CV Sup-Inf 0 degrees Medial Extreme medial tissue,
slippery medial
x-ray lesions
beam

Rolled Lateral RL Sup-Inf 0 degrees Subareolar, Separation of

x-ray central, superimposed
beam medial, and glandular tissue
posteromedial
tissue

Rolled Medial RM Sup-Inf 0 degrees Subareolar, Separation of

x-ray central, superimposed
beam medial, and glandular tissue
posteromedial
tissue

Continued

407
Examination Procedures
 Mammography

408
TABLE 21-1 
Labeling codes and uses for mammographic positioning—cont’d
ACR Suggested Tissue best
View ID ID Projection C-arm angle Image receptor placement visualized Applications

Captured Lesion None CL All 0-90 degrees Posterior Palpable abnormality

(Coat-Hanger near chest wall or
View) implant, often
performed with
magnification

Tangential View TAN All 0-90 degrees All Palpable abnormality,

to visualize borders
with better detail;
often used in
x-ray
conjunction with
beam
magnification

TECHNIQUES
Magnification M Improved resolution;
better shows
calcifications and
borders of lesions
Implant ID Tissue anterior to Patients with implants
Displacement subpectoral
implants
Nipple In Profile NIP Subareolar
Spot Compression S Palpable abnormality,
to visualize borders
with better detail;
often used in
conjunction with
magnification

From Andolina V, Lille S: Mammographic imaging: a practical guide, ed 3, Baltimore, MD, 2011, Lippincott Williams & Wilkins.
• Mammography film labeling may also
include the following:
D. A separate date sticker or perfora-
tion
E. A label indicating the technical
factors used: kVp, milliampere-
seconds (mAs), target material,
degree of obliquity, density setting,
exposure time, and compression
thickness. This is often included on
the automatic identification labeling
system that most manufacturers
offer with their units.
F. Facilities with more than one unit
must identify the mammographic
unit used (Roman numerals are sug-
gested by the ACR).
G. For FFDM images, all of the afore-
mentioned pertinent information
should be included in the DICOM
header. This information should
also be seen on the processed image
or, if possible, used in a DICOM
overlay that can be turned on or off
as needed by the radiologist, to
prevent interference during inter-
pretation of the image.
• For patients with palpable masses, a
radiopaque (BB or X-spot) marker may
be used to identify the location of the
mass. A different type of radiopaque
marker may be used to identify skin
lesions, scars, or moles. This is deter-
mined by the policy of the facility, at the
discretion of the reading radiologists.
• When using automatic exposure control
(AEC), position the variable-position
detector at the chest wall, the mid-
breast, or the anterior breast, depending
on breast composition and size. The
appropriate location of the AEC detec-
tor must be determined for each indi-
vidual patient. If possible, the detector
should be placed under the most glan-
dular portion of the breast, usually just
posterior to the nipple. Most FFDM
units will automatically determine these
settings based on the technology used
by the manufacturer.
• When reviewing images, assess contrast
and density for optimal differentiation of
breast tissues. Anatomic markers should
be visible. The projections of one breast
should be compared with the same pro-
jections of the contralateral breast so that
symmetry and consistency of position-
ing can be evaluated. All images should
be absent of motion blur, artifacts, and
skin folds. Images must be evaluated
for potentially suspicious lesions and
calcifications that may require image
enhancement methods.
• To evaluate whether sufficient breast
tissue is shown, the radiographer should
measure the depth of the breast from the
nipple to the chest wall on the CC and
MLO projections. The posterior nipple
line (PNL) is an imaginary line that is
“drawn” obliquely from the nipple to
the pectoralis muscle or the edge of the
image, whichever comes first on the
MLO projection. On the CC projection,
the PNL is “drawn” from the nipple to
the chest wall or to the edge of the
image, whichever comes first. The PNL
on the CC should be within 1 3 inch
(1 cm) of depth of the PNL on the MLO
projection (Fig. 21-27).
• Between examinations, use a disinfec-
tant to clean the breast tray surface,
compression paddle, patient handle
grips, and face guard.
• If practical, a heating pad or a commer-
cially available mammography image
receptor cover may be used to warm the
image receptor tray surface and to
enhance patient comfort. Breast cush-
ions available through several manufac-
turers provide a warmer and more
comfortable examination for the patient
(Fig. 21-28). Check with the unit’s
manufacturer before implementing any
patient comfort modifications.
• Mammography is a team effort involv-
ing the patient and the mammographer.
Acknowledge the individual needs of
each patient to facilitate the cooperation
and trust necessary to complete the pro-
cedure successfully. The nature of the
interaction between the radiographer
and the patient is likely to determine
whether the patient chooses to have
subsequent mammograms.
Examination Procedures
Respiration
• To avoid patient motion and image
blurring, the patient may be asked to
suspend respiration during the expo-
sure. The preferred method is to ask the
patient to simply “stop breathing”
rather than “hold your breath.” Saying
“hold your breath” often implies to the
patient that she will need to take a deep
breath in, this may result in an uninten-
tional movement of the ribs and there-
fore the breast tissue, causing blurring
or a change in the position of the breast.
Alternatively, some mammographers
prefer to avoid suspending respiration
and simply ask the patient to remain
still throughout the exposure. Once the
breast is vigorously compressed, the
patient is not liable to take deep breaths,
especially if she is concentrating on not
moving.
409
 A B

L MLO L CC

Fig. 21-27  A, Schematic MLO projection with PNL

drawn. B, Schematic CC projection with PNL
drawn. PNL of CC projection should be within
PNL
PNL 1 cm of PNL of MLO projection, as noted on the
MLO (C) and CC (D) projections of this
mammogram.
Mammography

C D

Fig. 21-28  Breast cushions are sometimes used to provide a more

comfortable environment and examination for the patient.

410 (Image courtesy of Beekley Corp., Bristol, CT.)

Summary of Illustrative summary of mammography projections
Mammography Craniocaudal (CC)* Mediolateral oblique (MLO)*
Projections
Before beginning to learn mammography
projections, the student of radiography
should carefully study the illustrative
summary of mammography projections
shown in the box. Familiarity with the
different projection names and abbrevia-
tions would enhance the student’s under-
standing of the detailed discussions of the
projections presented in this chapter.

DESCRIPTIVE TERMINOLOGY FOR

LESION LOCATION
Descriptive terminology has been devel-
oped for the referring physician, the
technologist, and the radiologist to com-
municate efficiently regarding an area of
concern within a breast. When describing Mediolateral (ML)* Lateromedial (LM)

Routine Projections of the Breast

an area of concern, the laterality (right or
left) must accompany the description
(Fig. 21-29).
Each breast is divided into four quad-
rants: the upper outer quadrant (UOQ), the
lower outer quadrant (LOQ), the upper
inner quadrant (UIQ), and the lower inner
quadrant (LIQ). Clock time is also used to
describe the location of a specific area of
concern within the breast, but it changes
from the right to the left breast, that is,
2:00 in the right breast is in the UIQ,
whereas 2:00 in the left breast is in the
UOQ. This opposite labeling applies to all
clock times; therefore it is important to
identify the correct breast, clock time, and
quadrant. The distance of the abnormality
from the nipple, which is the only fixed
point of reference in the breast, is also
noted. The terms subareolar and periareo-
lar describe the area directly beneath the
nipple and near (or around) the nipple
area. Central describes a lesion located
directly behind the nipple in both radio- Routine Projections
graphic projections.
The location of a lesion seen on the of the Breast
mammogram is described using the clini- Mammography is routinely performed
cal orientation (described above) extrapo- using the CC and MLO projections. The
lated from the image location. The location combination of these two views best
of an imaged lesion is described by its allows visualization of the greatest amount
laterality, quadrant, clock location, and of breast tissue for screening purposes.
depth, thus providing a consistency check When diagnostic examinations are per-
for possible right-left confusion.f Depth of formed for specific areas of concern, addi-
a lesion on the mammogram is described tional views may be indicated as desired
as anterior (nipple), middle, or posterior. by the radiologist.
f
American College of Radiology (ACR): ACR BI-
RADS-mammography, 4th edition. In: ACR breast
imaging reporting and data system, breast imaging
atlas, Reston, VA, 2003, American College of
Radiology.
411
 Illustrative summary of mammography projections—cont’d
Exaggerated craniocaudal (XCCL)* Craniocaudal for cleavage (CV) Craniocaudal with roll lateral (RL)

Craniocaudal with roll medial (RM) Tangential (TAN) Caudocranial (FB)

Mammography

Mediolateral oblique for axillary tail (AT) Lateromedial oblique Superolateral to inferomedial oblique
(LMO) (SIO)

*Essential projection.

412
 Breast

  CRANIOCAUDAL (CC)
PROJECTION
Image receptor: 8 × 10 inch (18 ×
24 cm) or 10 × 12 inch (24 × 30 cm)
Position of patient
• Have the patient stand facing the image
receptor, or seat the patient on an
adjustable stool facing the unit.
Position of part
• While standing on the medial side of
the breast to be imaged, elevate the
inframammary fold to its maximal
height.
• Adjust the height of the C-arm to the
level of the inferior surface of the
patient’s breast.
• Have the patient lean slightly forward
from the waist. Use both hands to pull
the breast gently onto the image recep-
tor holder, while instructing the patient
to press the thorax against the image
receptor.
• Drape the opposite breast over the
corner of the image receptor. This
maneuver improves demonstration of
the medial tissue.
• Have the patient hold onto the grab bar
with the contralateral hand; this helps
steady the patient as you continue
positioning.
• Keep the breast perpendicular to the
chest wall. The technologist should use
his or her fingertips to pull the inferior
posterior tissue gently forward onto
the IR.
• Center the breast over the AEC detec-
tor, with the nipple in profile if
possible.
• Immobilize the breast with one hand,
while taking care not to remove this
hand until compression begins.
• While placing your arm against the
patient’s back with your hand on the
shoulder of the affected side, make
certain the patient’s shoulder is relaxed
and in external rotation.
• Rotate the patient’s head away from the
affected side, and rest the patient’s head
against the face guard.
• Make certain that no other objects such
as jewelry or hair obstruct the path of
the beam.
• With your hand on the patient’s shoul-
der, gently slide the skin up over the
clavicle.
• Using the hand that is anchoring the
patient’s breast, pull the lateral tissue
onto the image receptor without sacri-
ficing medial tissue.

Routine Projections of the Breast

• Inform the patient that compression of
the breast will begin. Using foot pedal
compression controls, bring the com-
pression paddle into contact with the
breast while sliding the hand toward the
nipple.
• Slowly apply compression manually
until the breast feels taut.
12 12 • Check the medial and lateral aspects of
12 the breast for adequate compression.
UOQ UIQ UIQ UOQ • Instruct the patient to indicate whether
9 3 9 3
LOQ LIQ LIQ LOQ
9 3
the compression becomes uncomfort-
able.
6 6 • After full compression is achieved and
6
checked, instruct the patient to stop
A B breathing (Fig. 21-30).
Fig. 21-29  A, Each breast is viewed as a clock and is divided into four quadrants to • Make the exposure.
describe the location of a lesion: upper outer quadrant (UOQ), upper inner quadrant • Release breast compression immedi-
(UIQ), lower outer quadrant (LOQ), and lower inner quadrant (LIQ). B, An abnormality ately.
should always be described in a consistent manner. For example, the location of the
abnormality denoted by the x would be described as “right breast UOQ at
approximately 10:30 position.”

A B
Fig. 21-30  A, Lift breast to adjust level of C-arm to elevated inframammary fold. B, CC
projection.

413
 Breast

Central ray EVALUATION CRITERIA ■ Nipple in profile (if possible) and at

• Perpendicular to the base of the breast
Structures shown
The CC projection shows the central, sub-
areolar, and medial fibroglandular breast
tissue. The pectoral muscle is shown in
approximately 30% of all CC images.1
1
Bassett L, Heinlein R: Good positioning key to
imaging of breast, Diagn Imaging 9:69, 1993.
Mammography
The following should be clearly shown:
■ The PNL extending posteriorly to the
edge of the image and measuring within
1 inch (1 cm) of the depth of the PNL
3
on MLO projection (Fig. 21-31)
■ All medial tissue, as shown by visual-
ization of medial retroglandular fat and
the absence of fibroglandular tissue
extending to the posteromedial edge of
the image
midline, indicating no exaggeration of
positioning
■ For emphasis of medial tissue, some
lateral tissue may be excluded
■ Pectoral muscle seen posterior to
medial retroglandular fat in about 30%
of properly positioned CC images
■ Slight medial skin reflection at the
cleavage, ensuring adequate inclusion
of posterior medial tissue
■ Uniform tissue exposure if compres-
sion is adequate

RCC LCC

Fig. 21-31  Bilateral CC projections show proper positioning and compression. The CC
projection should include maximal medial breast tissue (arrows) with the nipple
centered and in profile. As much lateral and inferior tissue as possible should be
pulled onto the image receptor without compromising visualization of medial tissue.
Note that pectoral muscle is seen posteriorly on these images, but this may not be
possible to achieve on most CC projections.

414
 Breast
  MEDIOLATERAL OBLIQUE
(MLO) PROJECTION
Image receptor: 8 × 10 inch (18 ×
24 cm) or 10 × 12 inch (24 × 30 cm)
Position of patient
• Have the patient stand facing the image
receptor with her feet pointed forward,
or seat the patient on an adjustable stool
facing the unit.
Position of part
• Determine the degree of obliquity of
the C-arm. The degree of obliquity
should be approximately 45 degrees but
will vary from 30 to 60 degrees, depend-
ing on the patient’s body habitus. Draw
an imaginary line from the patient’s
shoulder to midsternum, and angle the
C-arm to parallel this line.
• Adjust the height of the C-arm so that
the superior border of the IR is level
with the axilla.
• Instruct the patient to lean slightly
forward from the waist.
• Elevate the arm of the affected side
over the corner of the image receptor,
and rest the hand on the adjacent hand-
grip. The patient’s elbow should be
flexed and resting posterior to the image
receptor.
• Place the upper corner of the image
receptor as high as possible into the
patient’s axilla between the pectoral
and latissimus dorsi muscles, so that the
image receptor is behind the pectoral
fold.
• Ensure that the patient’s affected shoul-
der is relaxed and leaning slightly ante-
rior. While placing the flat surface of
the hand along the lateral aspect of the
breast, gently pull the patient’s breast
and pectoral muscle anteriorly and
medially.
• Holding the breast between the thumb
and fingers, gently lift it up, out, and
away from the chest wall.
• Center the breast on the IR with the
nipple in profile, if possible, and hold
the breast in position.
• Hold the breast up and out from the
body by rotating the hand so that the
base of the thumb and the heel of
the hand support the breast.
• Inform the patient that compression
of the breast will begin. Continue to
hold the breast up and out while
sliding the hand toward the nipple as
the compression paddle is brought
into contact with the breast. Loosen
the skin at the clavicle with the oppo-
site hand to ensure that posterior
tissue is imaged while preventing
injury to the shoulder. Roll the con-
tralateral shoulder toward the unit
to ensure that medial tissue is
visualized.
Fig. 21-32  MLO projection.
• Slowly apply compression until the
breast feels taut. The corner of the com-
pression paddle should be inferior to
the clavicle.
• Check the superior and inferior aspects
of the breast for adequate compression.
• Instruct the patient to indicate whether
the compression becomes uncomfort-
able.
• Gently pull down on the patient’s
abdominal tissue to open the inframam-
mary fold.
• Instruct the patient to hold the opposite
breast away from the path of the beam
if necessary.
• After full compression is achieved,
instruct the patient to stop breathing
(Fig. 21-32).
• Make the exposure.
• Release breast compression immedi-
ately.
Routine Projections of the Breast
415
 Breast
Central ray
• Perpendicular to the base of the breast
• The C-arm apparatus is positioned at an
angle determined by the slope of the
patient’s pectoral muscle (30 to 60
degrees). The actual angle is deter-
mined by the patient’s body habitus:
Tall, thin patients require steep angula-
tion, whereas short, stout patients
require shallow angulation.
Structures shown
The MLO projection usually shows most
of the breast tissue, with emphasis on the
lateral aspect and axillary tail.
Mammography
416
EVALUATION CRITERIA
The following should be clearly shown:
■ PNL measuring within 1 3 inch (1 cm)
of the depth of the PNL on CC
projection1
□ While drawing the imaginary PNL
obliquely following the orientation
of breast tissue toward the pectoral
muscle, use the fingers to measure its
depth from nipple to pectoral muscle
or to the edge of the image, which-
ever comes first (Fig. 21-33).
■ Inferior aspect of the pectoral muscle
extending to the PNL or below it if
possible
1
Bassett L: Clinical image evaluation, Radiol Clin
North Am 33:1027, 1995.
RMLO
Fig. 21-33  Bilateral MLO projections show proper positioning. Images should include
pectoral muscle to level of nipple (white line), posterior breast tissue; and junction of
inframammary fold and abdominal skin (arrow).
■ Pectoral muscle showing anterior con-
vexity to ensure relaxed shoulder and
axilla
■ Nipple in profile if possible
■ Open inframammary fold
■ Deep and superficial breast tissues well
separated when breast is adequately
maneuvered up and out from the chest
wall
■ Retroglandular fat well visualized to
ensure inclusion of deep fibroglandular
breast tissue
■ Uniform tissue exposure if compres-
sion is adequate
LMLO
Routine Projections of
the Augmented Breast
Mammography has an 80% to 90% true-
positive rate for detecting cancer in breasts
that do not contain implants. For the
millions of women in the United States
who have undergone augmentation mam-
moplasty for cosmetic or reconstructive
purposes, the true-positive (pathologic-
mammographic) breast cancer detection
rate decreases to approximately 60%
because implants can obscure 85% of the
breast’s structures, potentially hiding a
small cancer that could normally be
detected with mammography at an early
and curable stage.
Successful radiography of an aug-
mented breast requires a highly skilled
mammographer. During the examination,
precautions must be taken to avoid rupture
of the augmentation device.
Mammography of the augmented breast
presents a challenge that cannot be met
with the standard two-view examination
of each breast. An eight-radiograph exam-
ination (four views of each breast) is pre-
ferred when possible. The tissue within
the posterior and superior aspects of the
augmented breast can be satisfactorily
evaluated using the standard CC and MLO
projections. However, these four images
do not adequately show the surrounding
breast parenchyma. The addition of a
second set of images utilizing the implant
displacement technique (ID), also known
as the Eklund method or maneuver,
improves compression of the breast tissue
and visualization of breast structures. For
the Eklund method, the implant is pushed
posteriorly against the chest wall so that it
is excluded from the image, and the breast
tissue surrounding the implant is pulled
anteriorly and compressed. This technique
is most effective when used on patients
with implants that have been placed pos-
terior to the pectoral muscle. It can be
used when the implant is placed anterior
to the pectoral muscle, but notably less
tissue will be able to be pulled onto the IR
(Fig. 21-34).
Augmented Breast
417
 Complications frequently associated
with breast augmentation include fibrosis,
increased fibrous tissue surrounding the
implant, shrinking, hardening, leakage,
and pain. Breast augmentation does not
increase the risk of developing a cancer in
the breast; however the presence of the
implant may make detection of a cancer
on a screening mammogram more
Mammography
difficult.g Because mammography alone
cannot fully show all complications, ultra-
sonography and MRI are also used for
breast examinations in symptomatic
patients. Whether ultrasonography or
MRI is used as the adjunct imaging after
g
McIntosh SA, Horgan K: Augmentation mammo-
plasty: effect on diagnosis of breast cancer, J Plastic
Reconstr Aesthet Surg 61:124, 2008.
mammography for patients with suspected
implant rupture varies from practice to
practice.
Ultrasonography of the breast has
proved useful in identifying implant
leakage when implant rupture is suggested
by mammographic findings and clinical
examination, and occasionally when
leakage is not suspected. It has also

B
Fig. 21-34  A, Eight-view mammogram of a patient with implants placed anterior to the
pectoralis muscle (arrow). B, Eight-view mammogram of a patient with implants placed
posterior to the pectoralis muscle (arrow). Note that more pectoral muscle and breast
tissue are seen when the implant is placed posterior to the muscle.

418
successfully identified leakage that has
migrated to the axillary lymph nodes.
Although ultrasonography is not yet rec-
ommended as a screening modality for
implant leakage, it does enhance the mam-
mographic examination.
MRI is also commonly used for diag-
nostic evaluation of augmented breasts,
but there is disagreement over the appro-
priateness of guidelines for its use.h
h
Stoblen F et al: Imaging in patients with breast
implants: results of the First International Breast
(implant) Conference 2009, Insights Imaging 1:93,
2010.
Although MRI offers several diagnostic
advantages, the cost and time-consuming
nature of the procedure inhibit its use as
a screening modality for patients who
have undergone augmentation. It may be
used as a screening tool for women who
have undergone reconstruction after breast
cancer surgery. MRI has proved useful as
a preoperative tool in locating the position
of an implant, identifying the contour of
the deformity, and confirming rupture and
leakage migration patterns.1
1
Orel SG: MR imaging of the breast, Radiol Clin
North Am 38:899, 2000.
Augmented Breast
419
 Augmented Breast

  CRANIOCAUDAL (CC)
PROJECTION WITH FULL
IMPLANT
Image receptor: 8 × 10 inch (18 ×
24 cm) or 10 × 12 inch (24 × 30 cm)
Position of patient
• Have the patient stand facing the image
receptor, or seat the patient on an adjust-
able stool facing the unit.
Mammography
Position of part
• Turn the AEC off, and preselect a
manual technique. For FFDM units, be
sure that Implant View processing set-
tings are chosen if applicable.
• Follow the same positioning sequence
as for the standard CC projection.
• Inform the patient that minimal com-
pression of the breast will be used.
Bring the compression paddle into
contact with the breast, and slowly
apply only enough compression to
immobilize the breast. Compression
should be minimal. The anterior breast
tissue should still feel soft.
• Select the appropriate exposure factors,
and instruct the patient to stop
breathing.
• Make the exposure.
• Release compression immediately.

420
 Augmented Breast

Central ray EVALUATION CRITERIA ■ Nipple in profile, if possible, and at

• Perpendicular to the base of the breast
Structures shown
The image should show the entire implant
and surrounding posterior breast tissue
with suboptimal compression of the
anterior fibroglandular breast tissue
(Fig. 21-35).
The following should be clearly shown:
■ Implant projected over fibroglandular
tissue, extending to posterior edge of
image
■ Posterior breast tissue on medial and
lateral aspects extending to chest wall
midline, indicating no exaggeration of
positioning
■ Nonuniform compression of anterior
breast tissue

RCC LCC

Augmented Breast
RMLO LMLO

Fig. 21-35  Bilateral, four-image CC and MLO examination of

augmented breasts. Implants have been surgically placed
behind the pectoral muscle. Additional radiographs should be
obtained using the Eklund (ID) technique to complete the
eight-radiograph study (see Fig. 21-37).

421
 Augmented Breast

CRANIOCAUDAL PROJECTION
WITH IMPLANT DISPLACED
(CC ID)
Image receptor: 8 × 10 inch (18 ×
24 cm) or 10 × 12 inch (24 × 30 cm)
Position of patient
• Have the patient stand facing the image
receptor, or seat the patient on an adjust-
able stool facing the unit. Select an
AEC technique. For FFDM units, be
sure that Implant View processing set-
tings are chosen if applicable.
Mammography
Position of part
• While standing on the medial side of
the breast to be imaged, elevate the
inframammary fold to its maximal
height.
• Adjust the height of the C-arm to the
level of the inferior surface of the
breast.
• Standing behind the patient, place both
arms around the patient and locate the
anterior border of the implant by
walking the fingers back from the
nipple toward the chest wall, or
• Stand beside the patient lateral to the
breast being imaged. Have the patient
hold the grip with the opposite hand
to retain her balance. Locate the ante-
rior border of the implant by walking
the fingers back from the nipple
toward the chest wall.
• When the anterior border of the implant
has been located, gently pull the ante-
rior breast tissue forward onto the
image receptor (Fig. 21-36). Use the
hands and the edge of the image recep-
tor to keep the implant displaced
posteriorly.
• Center the breast over the AEC detector
with the nipple in profile if possible.
• Hold the implant back against the chest
wall. Slowly apply compression to the
anterior skin surface, being careful not
to allow the implant to slip under the
compression paddle. As compression
continues, the implant should be seen
bulging behind the compression paddle.
• Apply compression until the anterior
breast tissue is taut. Compared with the
full-implant projection, an additional
3
4 to 2 inches (2 to 5 cm) of compres-
sion should be achieved with the

implant displaced.
• Instruct the patient to indicate if the
A B compression becomes too uncomfort-
able or intolerable.
Compression paddle Compression paddle • When full compression is achieved,
move the AEC detector to the appropri-
ate position and instruct the patient to
stop breathing.
• Make the exposure.
7 cm Implant
• Release breast compression immedi-
ately.
Implant

Film holder Film holder

C
Implant
D
Compression paddle

Compression paddle

Implant 3.5 cm

Film holder Film holder

Fig. 21-36  A, Breast with implant and normal positioning techniques. B-D, Eklund
technique of pushing implant posteriorly against chest wall, pulling breast anteriorly, and
compressing tissue.

(From Eklund GW et al: Improved imaging of the augmented breast, AJR Am J Roentgenol 151:469,
1988.)

422
 Augmented Breast

Central ray EVALUATION CRITERIA ■ Implant along posterior edge of image,

• Perpendicular to the base of the breast
Structures shown
This projection shows the anterior and
central breast tissue projected free of
superimposition with uniform compres-
sion and improved tissue differentiation.
The implant is displaced posteriorly and
should not be visualized on the image
(Fig. 21-37).
The following should be clearly shown:
■ Breast tissue superior and inferior to
the implant pulled forward with the
anterior breast tissue projected free of
the implant
■ PNL extending posteriorly to edge of
implant, measuring within 1 3 inch
(1 cm) of depth of PNL on MLO pro-
jection with implant displaced
flattened against chest wall, should not
be visualized on the image, but often
remnants of the implant may be seen.
■ Image sharpness is enhanced by
increased compression of the breast
tissue and reduced scatter due to
removal of the implant from the path of
the beam.

Augmented Breast
RCCID LCCID

RMLOID LMLOID

Fig. 21-37  Bilateral, four-image CC and MLO projections with

implant displacement (ID) of the same patient as in Fig. 21-35,
using Eklund (ID) technique. Implants are pushed back for better
visualization of surrounding breast tissue.

423
 Augmented Breast
MEDIOLATERAL OBLIQUE (MLO)
PROJECTION WITH
FULL IMPLANT
Image receptor: 8 × 10 inch (18 ×
24 cm) or 10 × 12 inch (24 × 30 cm)
Position of patient
• Have the patient stand facing the image
receptor, or seat the patient on an adjust-
able stool facing the unit.
Position of part
• Turn the AEC off, and preselect a
manual technique. For FFDM units, be
sure that Implant View processing set-
tings are chosen if applicable.
• Follow the same positioning sequence
as for the standard MLO projection.
• Inform the patient that minimal com-
pression of the breast will be used. Con-
Mammography
tinue to hold the breast up and out while
sliding the hand toward the nipple as
the compression paddle is brought into
contact with the breast.
424
• Slowly apply only enough compression
to immobilize the breast. Compression
should be minimal, and the anterior
breast tissue should still feel soft.
• Pull down on the patient’s abdominal
tissue to open the inframammary fold.
• Select the appropriate exposure factors,
and instruct the patient to stop
breathing.
• Make the exposure.
• Release breast compression immedi-
ately.
Central ray
• Perpendicular to the image receptor
• The C-arm apparatus is positioned at an
angle determined by the slope of the
patient’s pectoral muscle (30 to 60
degrees). The actual angle is deter-
mined by the patient’s body habitus:
Tall, thin patients require steep angula-
tion, whereas short, stout patients
require shallow angulation.
Structures shown
The image shows the entire implant and
surrounding posterior breast tissue as well
as axillary tissue and pectoral muscle,
with suboptimal compression of the
anterior fibroglandular breast tissue (see
Fig. 21-35).
EVALUATION CRITERIA
The following should be clearly shown:
■ Implant projected over fibroglandular
tissue, extending to posterior edge of
image
■ Posterior breast tissue on the inferior
aspect, extending to chest wall
■ Nipple in profile if possible
■ Open inframammary fold
■ Breast adequately maneuvered up and
out from chest wall
■ Nonuniform compression of anterior
breast tissue
 Augmented Breast
MEDIOLATERAL OBLIQUE
PROJECTION WITH IMPLANT
DISPLACED (MLO ID)
Image receptor: 8 × 10 inch (18 ×
24 cm) or 10 × 12 inch (24 × 30 cm)
Position of patient
• Have the patient stand facing the image
receptor, or seat the patient on an adjust-
able stool facing the unit.
• Select an AEC technique. For FFDM
units, be sure that Implant View pro-
cessing settings are chosen if
applicable.
Position of part
• Determine the degree of obliquity of
the C-arm apparatus by rotating the
tube until the long edge of the image
receptor is parallel to the upper third of
the pectoral muscle of the affected side.
The degree of obliquity should be
between 30 degrees and 60 degrees,
depending on the patient’s body habitus.
• Adjust the height of the C-arm so that
the superior border is level with the
axilla.
• Instruct the patient to elevate the arm of
the affected side over the corner of the
image receptor and to rest the hand on
the adjacent handgrip. The patient’s
elbow should be flexed.
• Standing in front of the patient, locate
the anterior border of the implant by
walking the fingers back from the
patient’s nipple toward the chest wall.
• After locating the anterior border of the
implant, gently pull the anterior breast
tissue forward onto the image receptor.
Use the edge of the image receptor and
the hands to keep the implant displaced
posteriorly.
• Center the breast tissue over the AEC
detector with the nipple in profile if
possible.
• Hold the anterior breast tissue up and
out so that the base of the thumb and
the heel of the hand support the breast.
• Hold the implant back against the chest
wall while using fingers to bring the
anterior breast tissue forward onto
the IR. Slowly apply compression to the
anterior skin surface, taking care not
to allow the implant to slip under the
compression paddle. As compression
continues, the implant should be seen
bulging behind the compression paddle.
• Apply compression until the anterior
breast tissue is taut. Compared with the
full-implant projection, an additional
3
4 to 2 inches (2 to 5 cm) of tissue
should be adequately visualized with
the implant displaced.
• Instruct the patient to indicate if the
compression becomes uncomfortable
or intolerable.
• Pull down on the patient’s abdominal
tissue to open the inframammary fold.
• Instruct the patient to hold the opposite
breast away from the path of the beam,
as necessary.
• When full compression is achieved,
move the AEC detector to the appropri-
ate position if necessary and instruct the
patient to stop breathing.
• Make the exposure.
• Release breast compression immedi-
ately.
Central ray
• Perpendicular to the image receptor
• The C-arm apparatus is positioned at an
angle determined by the slope of the
patient’s pectoral muscle (30 to 60
degrees). The actual angle is deter-
mined by the patient’s body habitus:
Tall, thin patients require steep angula-
tion, whereas short, stout patients
require shallow angulation.
Structures shown
This image shows the anterior and central
breast tissue projected free of super­
imposition of the implant, with uniform
compression and improved tissue differ-
entiation (see Fig. 21-37).
EVALUATION CRITERIA
The following should be clearly shown:
■ Breast tissue superomedial and infero-
lateral to the implant with anterior
breast tissue projected free of the
implant
■ Pectoral muscle showing anterior con-
vexity to ensure relaxed shoulder and
axilla
■ PNL extending obliquely to edge of
implant, measuring within 1 3 inch
(1 cm) of depth of PNL on CC projec-
tion with implant displaced
Augmented Breast
■ Implant should not be visualized on the
image, but often some remnants of the
implant may be seen posteriorly.
■ Posterior breast tissue on inferior aspect
of breast, extending to chest wall
■ Nipple in profile if possible
■ Open inframammary fold
■ Breast adequately maneuvered up and
out from chest wall
■ Image sharpness is enhanced by
increased compression of the breast
tissue and reduced scatter due to
removal of the implant from the path of
the beam.
425
 Male Mammography
EPIDEMIOLOGY OF MALE
BREAST DISEASE
In the United States, more than 2200 men
develop invasive breast cancer every year,
and nearly 20% of these men die of the
disease.i Although most men who develop
breast cancer are 60 years of age and
older, juvenile cases have been reported.
Nearly all male breast cancers are primary
tumors. An estimated 4% to 40% of male
breast cancers are due to inherited muta-
tions. Men typically have significantly
less breast tissue; therefore smaller breast
lesions are palpable and diagnosed at
early stages. Other symptoms of breast
cancer in men include nipple retraction,
crusting, discharge, and ulceration.
Gynecomastia, a benign excessive
development of the male mammary gland,
can make malignant breast lesions more
Mammography
female breast cancer, the prognosis for
male breast cancer is directly related to the
stage of the disease at diagnosis. An early
diagnosis indicates a better chance of sur-
vival. Survival rates among male patients
with localized breast carcinomas are posi-
tive: 97% survive for 5 years.
Routine Projections
of the Male Breast
Male breast anatomy varies significantly
from female breast anatomy. The pectoral
muscle is more highly developed in men,
and most of the glandular breast tissue is
located directly posterior to the nipple.
The radiographer must take this variance
into consideration. The standard CC and
MLO projections may be applied with
success in most male patients (Figs. 21-38
to 21-40). For men (or women) with large
pectoral muscles, the radiographer may
perform the caudocranial (FB) projection
instead of the standard CC because it may
be easier to compress the inferior portion
of the breast. In addition, the lateromedial
oblique (LMO) projection may replace the
standard MLO.

elusive to palpation. Gynecomastia occurs

in 40% of male breast cancer patients;
however a histologic relationship between
gynecomastia and male breast cancer has
not been definitively established. Because
gynecomastia is caused by a hormonal
imbalance, it is believed that abnormal
hormonal function may increase the risk
of male breast cancer.j Other associated
risk factors for male breast cancer include
increasing age, positive family history,
BRCA1 and BRCA2 gene mutations, and
Klinefelter syndrome.1,2
Breast cancer treatment options are
limited among male patients. Because men
have less breast tissue, lumpectomy is not
considered practical. Most of the male Fig. 21-38  Positioning for CC projection of male breast.
glandular tissue is located directly posterior
to the nipple. Therefore, a modified radical
mastectomy including dissection of the
nipple is usually the preferred surgical
procedure.k,l Radiation and systemic
therapy are considered when the tumor is
located near the chest wall or when indi-
cated by lymph node analysis. Similar to

i
American Cancer Society: Cancer Facts and Figures
2013, Atlanta, GA, 2013, Corporate Center: Ameri-
can Cancer Society Inc., p9.
j
Weiss JR et al: Epidemiology of male breast cancer,
Cancer Epidemiol Biomarkers Prev 14:20, 2005.
Published online January 24, 2005.
1
Appelbaum A et al: Mammographic appearance of
male breast disease, RadioGraphics 19:559, 2001.
2
National Cancer Institute Factsheet. Available at:
www.cancer.gov. Accessed August 14, 2009.
k
Camus C et al: Ductal carcinoma in situ of the male
breast, Cancer 74:1289, 1994.
l
Hill T et al: Comparison of male and female breast
cancer incidence trend, tumor characteristics, and
survival, Ann Epidemiol 15:773, 2005. Fig. 21-39  Positioning for MLO projections of male breast.

426
 Keep in mind that these unconventional
views are rarely necessary but are viable
alternatives in extreme cases. These pro-
jections may allow the radiographer to
accommodate more successfully a patient
with prominent pectoral muscles. Some
facilities also use narrower quadrant com-
pression paddles (3 inches [8 cm] wide) to
compress the male breast or the extremely
small female breast.1 The smaller paddle
permits the radiographer to hold the breast
in position while applying final compres-
sion. A wooden spoon or a plastic spatula
can be used to hold the breast in place,
then can be slowly removed as the com-
pression paddle replaces it.
Because most men who undergo mam-
mography present with outward symp-
toms, mammography of the male breast is
usually considered a diagnostic examina-
tion. It can be considered a screening
examination for men who know they carry
the BRCA1 or BRCA2 gene, or who have
a history of breast cancer. The radiogra-
pher should work closely with the radiolo-
gist to achieve a thorough demonstration
of the potential abnormality. In the male
breast, most tumors are located in the sub-
areolar region. Careful attention should be
given to positioning the nipple in profile
and to providing adequate compression of
this area to allow the best visualization of
this tissue.
Calcifications are rare in male breast
cancer cases. When present, they are
usually larger, rounder, and more scattered
than the calcifications associated with
female breast cancer. Spot compression
and the magnification technique are
common image enhancement methods for
Fine-needle aspiration biopsy (FNAB)
and excisional biopsy of palpable lesions
are standard methods of diagnosis. Histo-
logically, most breast cancers in men are
ductal, and most are infiltrating ductal car-
cinomas. Very few in situ cancers are
found in male patients.
Because breast cancer is traditionally
considered a “woman’s disease,” the
radiographer should remain sensitive to
the feelings of the male patient by offering
not only physical comfort but also psy-
chological and emotional support during
the procedure.
Image Enhancement
Methods
The spot compression technique and the
magnification technique are designed to
enhance the image of the area under

Male Mammography
1
Eklund GW, Cardenosa G: The art of mammo-
showing the morphology of calcifications. investigation.
graphic positioning, Radiol Clin North Am 30:21, Procedures other than mammography
1992. are used to diagnose male breast cancer.

LCC

RCC LCC

A B
Fig. 21-40  A, Four-view mammogram of a 55-year-old man with a new palpable lump
(arrow). This proved to be cancer on biopsy. B, Left CC view of a 49-year-old male with
a new lump. This proved to be gynecomastia, a benign process, on biopsy.

427
 Breast
MAGNIFICATION TECHNIQUE
(M USED AS PREFIX)
Image receptor: 8 × 10 inch (18 ×
24 cm)
Position of patient
• Have the patient stand facing the image
receptor, or seat the patient on an adjust-
able stool facing the unit.
• Use only equipment designed to be
used for magnification mammography
to perform this maneuver, and use the
equipment according to the manufac-
turer’s directions.
Position of part
• Attach the firm, radiolucent magnifica-
tion platform to the unit. The patient’s
breast is positioned on the platform
between the compression device and a
Mammography
nongrid IR.
• Select the smallest focal spot target size
(≤0.1 mm is preferred). Most units
allow magnification images to be
exposed only when the correct focal
spot size is used.
Fig. 21-41  Radiolucent platform placed between breast and film
holder causes breast image to be enlarged.
(Courtesy Lorad Corp.)
428
• Select the appropriate compression
paddle (regular, quadrant, or spot com-
pression). Collimate according to the
size of the compression paddle.
• Position the patient’s breast to obtain
the projection that best shows the area
of interest. The angle of the C-arm can
be adjusted to accommodate any pro-
jection normally performed using a tra-
ditional grid technique.
• When full compression is achieved,
move the AEC detector to the chest wall
position (if necessary) and instruct the
patient to stop breathing (Fig. 21-41).
• Make the exposure.
• Release breast compression immedi-
ately.
Fig. 21-42  MLO projection using the magnification technique and
a quad paddle to better visualize microcalcifications.
Central ray
• Perpendicular to the area of interest
Structures shown
This technique magnifies the compressed
area of interest with improved detail,
facilitating determination of the character-
istics of microcalcificationsm (Fig. 21-42)
and the margins (or lack of definitive
margins) of suspected lesions (Fig. 21-43).
m
Kim HH et al: Comparison of calcification specific-
ity in digital mammography using soft-copy display
versus screen-film mammography, AJR Am J Roent-
genol 187:47, 2006.
 Breast
EVALUATION CRITERIA
The following should be clearly shown:
■ Area of interest within collimated and
compressed margins
■ Improved delineation of number,
distribution, and morphology of
microcalcifications
■ Enhanced architectural characteristics
of focal density or mass
■ Uniform tissue exposure if compres-
sion is adequate
Fig. 21-43  Right MLO projection using the magnification technique and a spot paddle
to perform a tangential view of a palpable mass. This proved that the mass was
smoothly outlined with uniform edges and was shown to be a cyst on ultrasound.
SPOT COMPRESSION TECHNIQUE
Image receptor: 8 × 10 inch (18 ×
24 cm)
Position of patient
• Have the patient stand facing the image
receptor, or seat the patient on an adjust-
able stool facing the unit.
• This technique is often performed in
conjunction with the magnification
technique, especially for determination
of number, distribution, and morphol-
ogy of microcalcifications.
Position of part
In conjunction with magnification technique
• Place a firm, radiolucent magnification
platform, designed for use with the
dedicated mammography equipment on
the unit, between the patient’s breast
and a nongrid image receptor.
• Select the smallest focal spot target size
(≤0.1 mm is preferred).
For palpable masses
A TAN projection combined with spot
compression and the magnification tech-
nique is most often used to image a
palpable mass; however the spot compres-
sion technique in a previously imaged
projection is also requested by many
radiologists.
• Select the appropriate spot compression
device.
• Mark the location of the palpable mass
with a felt-tip pen or with a radiopaque
beebee marker placed on the lump,
according to the policy of the facility.
• Center the area of interest under the
compression device in the position indi-
cated by the radiologist.
• Inform the patient that compression of
the breast will be used and may be
uncomfortable. Bring the compression
paddle into contact with the breast, and
Image Enhancement Methods
slowly apply compression until the
breast feels taut.
429
 Breast

• Instruct the patient to indicate if the

compression becomes too uncomfort-
able.
• When full compression is achieved,
move the AEC detector to the chest wall
position if necessary, and instruct the
patient to stop breathing (Fig. 21-44).
• Make the exposure.
• Release breast compression immedi-
ately.
For nonpalpable masses
• While viewing the routine mammo-
gram, measure the location of the area
of interest from a reference point (the
nipple), using a tape measure or the fin-
gertips (Fig. 21-45).
• Select the appropriate spot compression
device.
• Reposition the patient’s breast to obtain
the projection from which the measure-
ments were taken. Fig. 21-44  Spot compression used with CC projection.
Mammography

• Using the same reference point, transfer

onto the patient the measurements taken
from the mammogram.
• Mark the area of interest with a felt-tip
pen, or mentally note the location on LCC
the breast.
• Center the area of interest under the
compression device in the requested
view, which may be different from the LMCC
original projection.
• Inform the patient that compression of
the breast will be used. Bring the com-
pression paddle into contact with the
breast, and slowly apply compression
until the breast feels taut. Adequate
compression is especially important for
spot views of nonpalpable masses, as
the objective is to use targeted compres- 63.0 mm (6
sion to separate tissue islands that may
be overlapped, causing an area of suspi-
cious density.
• Instruct the patient to indicate if the
compression becomes too uncomfort-
able. 63.2 mm (1
• When full compression is achieved,
move the AEC detector to the appropri-
ate position if necessary, and instruct
the patient to stop breathing. Fig. 21-45  To find the area of interest in the breast for a spot view, measure how far
• Make the exposure. posterior the area is by using the nipple as a reference point. This image illustrates how
• Release breast compression immedi- measurement of the lesion from the nipple on the CC view approximates measurement
ately. of the lesion from the nipple on the magnified spot view.

430
 Breast

Central ray EVALUATION CRITERIA

• Perpendicular to the area of interest
Structures shown
The spot compression technique resolves
superimposed structures seen on only
one projection, better visualizes small
lesions located in the extreme posterior
breast, separates superimposed ductal
structures in the subareolar region, and
improves visualization in areas of dense
tissue through localized compression
(Fig. 21-46).
The following should be clearly shown:
■ Area of interest clearly seen within
compressed margins
■ Close collimation to the area of interest
unless contraindicated by radiologist
■ Improved recorded detail through the
use of close collimation and the magni-
fication technique employing a spot
compression device
■ Uniform tissue exposure if compres-
sion is adequate
NOTE: Densities caused by the superimposition
of normal breast parenchyma disappear on spot
compression images.

Image Enhancement Methods

LSMLO

LMLO

A B
Fig. 21-46  A, This 45-year-old woman with extremely dense tissue was recalled for a
questionable mass (arrow) in the left breast on screening mammography. B, A spot view
was performed to spread the tissue and more clearly delineate the borders of the mass.
This proved to be a fibroadenoma on biopsy.

431
 Breast

Supplemental
Projections
The routine projections are not always
adequate in completely showing a patient’s
breast tissue, or a specific area may require
clearer delineation. Supplemental projec-
tions complement the routine projections
and have distinct applications (Table
21-2). The mammographer should fully
understand the value of each projection
and its potential to show significant find-
ings in the breast. This section provides a
brief overview of significant mammo-
graphic findings in their most common
radiographic presentation and provides
suggested correlative supplemental pro-
jections. The language related to mam-
mographic findings must be appreciated
for the mammographer and the radiologist
to work collaboratively toward a success-
Mammography
It is identified on two projections of the
affected breast. A mass has a convex shape
or an outward contour to its margins. If a
suspected mass is identified on only one
projection, the mammographer must strive
to position the breast so that the area in
question is shown on at least two projec-
tions. If the suspected mass is seen only on
the MLO projection in the deep medial
aspect of the breast, a CC projection for
cleavage may complement the standard CC
projection. Conversely, if the mass is seen
in the extreme lateral aspect, an exagger-
ated craniocaudal (XCCL) projection later-
ally would be the projection of choice. In a
sense, the radiographer is collecting evi-
dence to prove whether the mass is real or
is merely a summation shadow of superim-
posed breast parenchyma.
Other supplemental projections are
intended to offer alternative methods for
cian. Often the need for additional projec-
tions is determined only after careful
examination of the standard projections.
Throughout mammographic procedures,
the radiographer should consistently eval-
uate the images, keeping foremost in mind
the optimal demonstration of possible
findings. For example, when performing
lateral projections, the mammographer
should place the area of interest closest to
the image receptor. The mammographer
may develop the expertise to predict and
perform supplemental projections that
confirm or rule out suspected breast
abnormalities. As with all radiographic
procedures, image evaluation is a crucial
component of high-quality imaging. In
evaluating images, the mammographer
becomes an integral member of the breast
imaging team, actively participating in the
work-up of an asymptomatic patient.

ful diagnostic examination. tailoring the mammographic procedure to

The mass is the most common presenta- the specific abilities of the patient and the
tion of a potential abnormality in the breast. requirements of the interpreting physi-

TABLE 21-2 
Supplemental projections or methods and their suggested applications
Projection or method Application
Spot compression Defines lesion or area through focal compression; separates overlying parenchyma
Magnification (M) Combines with spot compression to show margins of lesion; delineates
microcalcifications
Mediolateral (ML) Localization; shows air-fluid-fat levels; defines lesion located in lateral aspect of
breast; complements mediolateral oblique (MLO) projection
Lateromedial (LM) Localization; shows air-fluid-fat levels; defines lesion located in medial aspect of
breast
Exaggerated craniocaudal (XCCL) Visualizes lesions in deep outer aspect of breast that are not seen on standard CC
CC for cleavage (CV) Visualizes deep medial breast tissue; shows medial lesion in true transverse or axial
plane
CC with roll (RL, RM) Triangulates lesion seen only on CC projection; defines location of lesion as in
superior or inferior aspect of breast
Tangential (TAN) Confirms dermal vs. breast calcifications; shows obscure palpable lump over
subcutaneous fat
Captured lesion Shows palpable lump in posterior tissue that is difficult to immobilize with
conventional techniques
Caudocranial (FB) Visualizes superior breast tissue; defines lesion located in superior aspect of breast;
replaces standard CC for patients with kyphosis or prominent pectoral muscles
MLO for axillary tail (AT) Focal compression projection of AT
Lateromedial oblique (LMO) Shows medial breast tissue; replaces standard MLO for patients with pectus
excavatum, prominent pacemakers, prominent pectoral muscles, Hickman
catheters, and postoperative open heart surgery
Superolateral to inferomedial Visualizes upper-inner quadrant and lower-outer quadrant, which normally are
oblique (SIO) superimposed on MLO and LMO projections

432
 Breast

  90-DEGREE MEDIOLATERAL
(ML) PROJECTION
Image receptor: 8 × 10 inch (18 ×
24 cm) or 10 × 12 inch (24 × 30 cm)
Position of patient
• Have the patient stand facing the image
receptor, or seat the patient on an adjust-
able stool facing the unit.
Position of part
• Rotate the C-arm assembly 90 degrees,
with the x-ray tube placed on the medial
side of the patient’s breast.
• Have the patient bend slightly forward
from the waist. Position the superior
corner of the image receptor high into
the axilla, with the patient’s elbow
flexed and the affected arm resting
behind the image receptor.
• Ask the patient to relax the affected
shoulder.
• Pull the breast tissue and the pectoral
muscle superiorly and anteriorly, ensur-
ing that the lateral rib margin is pressed
firmly against the edge of the image
receptor.
• Rotate the patient slightly laterally to
help bring the medial tissue forward.
• Gently pull the medial breast tissue
forward from the sternum, and position
the nipple in profile.
• Hold the patient’s breast up and out by
rotating the hand so that the base of the
thumb and the heel of the hand support
the breast.
• Inform the patient that compression of
the breast will be used. Continue to
hold the patient’s breast up and out
while sliding the hand toward the nipple
as the compression paddle is brought

A B
Fig. 21-47  A, Lateral profile of breast showing
inadequate compression and drooping breast.
B, Lateral profile of properly compressed breast.
Note how compression has overcome the effect
of gravity and how the breast is spread out over a
greater area.
Supplemental Projections
into contact with the breast. Do not
allow the breast to droop (Fig. 21-47).
• Slowly apply compression until the
breast feels taut.
• Instruct the patient to indicate if com-
pression becomes too uncomfortable.
• Ask the patient to hold the opposite
breast away from the path of the beam.
• When full compression is achieved,
move the AEC detector to the appropri-
ate position if necessary, and instruct the
patient to stop breathing (Fig. 21-48).
• Make the exposure.
• Release breast compression immedi-
ately.

Fig. 21-48  ML projection.

433
 Breast
Central ray
• Perpendicular to the base of the breast
Structures shown
This projection shows lesions on the
lateral aspect of the breast in the superior
and inferior aspects. It resolves superim-
posed structures seen on the MLO projec-
tion, localizes a lesion seen on one (or
both) of the initial projections, and shows
air-fluid and fat-fluid levels in breast
structures (e.g., milk of calcium, galacto-
celes) and in pneumocystography (a rarely
performed procedure involving injection
of air into an aspirated cyst to image the
cyst lining for intracystic lesions). The
ML view is an orthogonal view to the CC
and is often used to localize the depth of
breast lesions.
Mammography
434
EVALUATION CRITERIA
The following should be clearly shown:
■ Nipple in profile
■ Open inframammary fold
■ Deep and superficial breast tissues well
separated when breast is adequately
maneuvered up and out from chest wall
(Fig. 21-49)
■ Retroglandular fat well visualized to
ensure inclusion of deep fibroglandular
breast tissue
■ Uniform tissue exposure if compres-
sion is adequate
RML
Fig. 21-49  ML projection
 Breast
90-DEGREE LATEROMEDIAL (LM)
PROJECTION
Image receptor: 8 × 10 inch (18 ×
24 cm) or 10 × 12 inch (24 × 30 cm)
Position of patient
• Have the patient stand facing the image
receptor, or seat the patient on an adjust-
able stool facing the unit.
Position of part
• Rotate the C-arm assembly 90 degrees,
with the x-ray tube placed on the lateral
side of the patient’s breast.
• Position the superior corner of the
image receptor at the level of the jugular
notch.
• Have the patient flex the neck slightly
forward.
• Have the patient relax the affected
shoulder, raise her arm on the affected
side and flex the elbow, then rest the
affected arm over the top of the image
receptor.
• Pull the breast tissue and pectoral
muscle superiorly and anteriorly, ensur-
ing that the patient’s sternum is pressed
firmly against the edge of the image
receptor.
• Rotate the patient slightly medially to
help bring the lateral tissue forward.
Fig. 21-50  LM projection.
• Have the patient rest the chin on the top
edge of the image receptor to help
loosen the skin in the medial aspect of
the breast.
• Position the nipple in profile.
• Hold the patient’s breast up and out. Do
not let it droop.
• Inform the patient that compression of
the breast will be used. Bring the com-
pression paddle past the latissimus
dorsi muscle and into contact with the
breast. Slowly apply compression while
sliding the hand out toward the nipple
until the patient’s breast feels taut.
• Instruct the patient to indicate whether
the compression becomes uncomfort-
able.
• When full compression is achieved,
move the AEC detector to the appro­
priate position if necessary, and
instruct the patient to stop breathing
Supplemental Projections
(Fig. 21-50).
• Make the exposure.
• Release breast compression immedi-
ately.
435
 Breast

Central ray EVALUATION CRITERIA

• Perpendicular to the base of the breast The following should be clearly shown:
■ Nipple in profile
Structures shown ■ Open inframammary fold
This projection shows lesions on the ■ Deep and superficial breast tissues well
medial aspect of the breast in the superior separated when breast is adequately
or inferior aspects (Fig. 21-51). It resolves maneuvered up and out from chest wall
superimposed structures seen on the MLO ■ Retroglandular fat well visualized to
projection, localizes a lesion seen on one ensure inclusion of deep fibroglandular
(or both) of the initial projections, and breast tissue
shows air-fluid and fat-fluid levels in ■ Uniform tissue exposure if compres-
breast structures (e.g., milk of calcium, sion is adequate
galactoceles) and in pneumocystography
(a rarely performed procedure involving
injection of air into an aspirated cyst to
image the cyst lining for intracystic
lesions). The LM view is an orthogonal
view to the CC and is often used to local-
ize the depth of breast lesions.
Mammography

Fig. 21-51  LM projection.

436
 Breast
  EXAGGERATED
CRANIOCAUDAL (XCCL)
PROJECTION
Image receptor: 8 × 10 inch (18 ×
24 cm) or 10 × 12 inch (24 × 30 cm)
Position of patient
• Have the patient stand facing the image
receptor, or seat the patient on an adjust-
able stool facing the unit.
Fig. 21-52  XCCL projection.
Fig. 21-53  Superior profile illustrates how placement of flat edge of image receptor
against curved chest wall excludes a portion of breast tissue (shaded area). Dashed line
indicates placement of image receptor for exaggerated position.
Position of part
• Elevate the inframammary fold to its
maximal height.
• Adjust the height of the C-arm
accordingly.
• Use one hand to scoop the inferior and
posterior breast tissue up from the
inframammary fold and place the breast
onto the image receptor.
• This should be done with the tech-
nologist’s right hand when the left
breast is positioned, and with the
left hand when the right breast is
positioned.
• Use both hands to pull the breast gently
onto the image receptor while instruct-
ing the patient to press the thorax
against the breast tray.
• Slightly rotate the patient medially to
place the lateral aspect of the breast on
the image receptor.
• Place an arm against the patient’s back
with the hand on the shoulder of the
affected side, ensuring that the shoulder
is relaxed in external rotation.
• Slightly rotate the patient’s head away
from the affected side.
• Have the patient lean toward the
machine and rest the head against the
face guard.
• Rotate the C-arm assembly mediolater-
ally approximately 5 degrees if neces-
sary to eliminate overlapping of the
humeral head.
• Inform the patient that compression of
Supplemental Projections
the breast will be used. Smooth and
flatten the breast tissue toward the
nipple while bringing the compression
paddle into contact with the breast.
• Slowly apply compression until the
breast feels taut.
• Instruct the patient to indicate if the
compression becomes uncomfortable.
• When full compression is achieved,
move the AEC detector to the appropri-
ate position if necessary, and instruct
the patient to stop breathing (Figs.
21-52 and 21-53).
• Make the exposure.
• Release breast compression immedi-
ately.
437
 Breast

Central ray EVALUATION CRITERIA

• Angled 5 degrees mediolaterally to the
base of the breast, if necessary
Structures shown
This projection shows a superoinferior
projection of the lateral fibroglandular
breast tissue and posterior aspect of the
pectoral muscle. It also shows a sagittal
orientation of a lateral lesion located in the
axillary tail of the breast.
Mammography
The following should be clearly shown:
■ Retroglandular fat well visualized to
ensure inclusion of deep fibroglandular
breast tissue on lateral aspect of breast
and lower axillary region
■ Pectoral muscle visualized over lateral
chest wall (Fig. 21-54)
■ Humeral head projected clear of image
with use of a 5-degree ML angle
■ Uniform tissue exposure if compres-
sion is adequate

RCC RXCC

A B
Fig. 21-54  A, CC projection of right breast. B, XCCL projection of right breast. This projection is
exaggerated laterally to show AT (arrow). Note also some visualization of pectoral muscle.

438
 Breast
CRANIOCAUDAL PROJECTION
FOR CLEAVAGE (CV)
Image receptor: 8 × 10 inch (18 ×
24 cm) or 10 × 12 inch (24 × 30 cm)
Position of patient
• Have the patient stand facing the image
receptor, or seat the patient on an adjust-
able stool facing the unit
A • Instruct the patient to indicate if the
B
Fig. 21-55  A, Craniocaudal projection for cleavage. Cleavage is slightly off-center, so
that AEC is under breast tissue. B, Craniocaudal projection for cleavage using a
smaller-quadrant paddle for maximum posterior visualization.
Position of part
• Turn the AEC off, and preselect a
manual technique. The radiographer
may use AEC only if enough breast
tissue is positioned over the AEC detec-
tor. The cleavage may be intentionally
offset for this purpose.
• Determine the proper height of the
breast tray by elevating the inframam-
mary fold to its maximal height.
• Adjust the height of the C-arm
accordingly.
• Lift and pull both breasts gently forward
onto the image receptor while instruct-
ing the patient to press the thorax
against the image receptor.
• Pull as much medial breast tissue as
possible onto the image receptor.
• Slightly rotate the patient’s head away
from the affected side.
• Have the patient lean toward the
machine and rest the head against the
face guard.
• Ask the patient to hold the grip bars
with both hands to keep in position on
the image receptor.
• Raise the height of the image recep-
tor slightly to loosen the superior
tissue.
• Place one hand at the level of the
patient’s jugular notch, and then slide
the hand down the patient’s chest while
pulling forward as much deep medial
Supplemental Projections
tissue as possible.
• Inform the patient that compression of
the breast will be used. Bring the com-
pression paddle into contact with the
breasts, and slowly apply compression
until the medial tissue feels taut. Using
a quadrant compression paddle allows
better compression of the cleavage area
and allows more of the area of interest
to be pulled into the imaging area. If a
quadrant paddle is used, collimate to
the area of compression to better visual-
ize the detail of the tissue.
compression becomes uncomfortable.
• When full compression is achieved,
move the AEC detector to the appro­
priate position if AEC is used, and
instruct the patient to stop breathing
(Fig. 21-55).
• Make the exposure.
• Release breast compression immedi-
ately.
439
 Breast

Central ray EVALUATION CRITERIA ■ All medial tissue included, as shown by

• Perpendicular to the area of interest or The following should be clearly shown:
the centered cleavage ■ Area of interest over the central portion
of the image receptor (over the AEC
Structures shown detector if possible) with cleavage
This projection shows lesions located in slightly off-centered or with cleavage
the deep posteromedial aspect of the centered to the image receptor and
breast. manual technique selected (Fig. 21-56)
■ Deep medial tissue of affected breast
Mammography
visualization of medial retroglandular
fat and the absence of any fibroglandu-
lar tissue extending to the posterome-
dial edge of imaged breasts
■ Uniform tissue exposure. It is not nec-
essary to image all of the breast tissue
on this projection.

LCV

Fig. 21-56  This Cleavage View was off-center to the left (LCV) but was performed to
view the medial aspect of the right breast. A mass was seen on the RMLO but was not
visualized on the standard RCC view. This extremely medial mass (arrow) proved to be
invasive carcinoma on biopsy.

440
 Breast

CRANIOCAUDAL PROJECTION
WITH ROLL LATERAL OR
ROLL MEDIAL (RL OR RM USED
AS SUFFIX)
Image receptor: 8 × 10 inch (18 ×
24 cm) or 10 × 12 inch (24 × 30 cm)
Position of patient
• Have the patient stand facing the image
receptor, or seat the patient on an adjust-
able stool facing the unit.
Source
L CC
Position of part
• Reposition the patient’s breast in the
CC projection.
• Place the hands on opposite surfaces of
the patient’s breast (superior/inferior),
and roll the surfaces in opposite direc-
tions. The direction of the roll is not
important as long as the mammogra-
pher rolls the superior surface in one
direction and the inferior surface in the
other direction. In a sense, the mam-
mographer is very gently rotating the
breast approximately 10 to 15 degrees
(Fig. 21-57).
L CC RM
• Place the patient’s breast onto the image
receptor surface with the lower hand
while holding the rolled position with
the upper hand.
• Note the direction of the superior
surface roll (lateral or medial), and
label the image accordingly. If the supe-
rior aspect of the breast is rolled medi-
ally, the image should be labeled RM.
• Inform the patient that compression of
the breast will be used. Bring the com-
pression paddle into contact with the
breast, and slide the hand out while
rolling the breast tissue.
• Slowly apply compression until the
breast feels taut.
• Instruct the patient to indicate if the
compression becomes uncomfortable.
• When full compression is achieved,
move the AEC detector to the appropri-
ate position if necessary and instruct the

Supplemental Projections
patient to stop breathing (Fig. 21-58).
• Make the exposure.
• Release breast compression immedi-
ately.
A B C
Fig. 21-57  A, CC projection showing lesion that may represent superimposition of two
structures. If spot compression fails to resolve these structures, CC projection with the roll
position may be performed. B, Anterior view of CC projection, with arrows indicating
rolling of superior and inferior breast surfaces in opposite directions to separate
superimposed structures. C, CC projection with RM, showing resolution of two lesions.
Arrow indicates direction of roll of superior surface of breast.

Fig. 21-58  CC projection with lateral and medial roll.

441
 Breast

Central ray EVALUATION CRITERIA ■ Nipple in profile and at midline, indi-

• Perpendicular to the base of the breast The following should be clearly shown: cating no exaggeration of positioning.
■ Suspected superimposition adequately The nipple is used as a point of refer-
Structures shown resolved ence to distinguish the location of the
This position shows separation of super- ■ Suspected lesion in superior or inferior suspected lesion, if it exists.
imposed breast tissues (also known as aspect of breast ■ Some lateral tissue possibly excluded
summation shadow), particularly those ■ All medial tissue included, as shown by to emphasize medial tissue visualized
seen only on the CC projection. The posi- visualization of medial retroglandular ■ Slight medial skin reflection at cleav-
tion also helps determine whether a lesion fat and the absence of fibroglandular age, ensuring that posterior medial
is located in the superior or inferior aspect tissue extending to posteromedial edge tissue is adequately included
of the breast (Fig. 21-59). Alternatively, of image ■ Uniform tissue exposure if compres-
the standard CC projection may be per- sion is adequate
formed using the spot compression tech-
nique, or with the C-arm assembly rotated
10 to 15 degrees mediolaterally or latero-
medially to eliminate superimposition of
breast tissue. These methods are often pre-
ferred because they allow for easier dupli-
cation of the projection during subsequent
examinations.
Mammography

Fig. 21-59  CC projection with RL.

442
 Breast

TANGENTIAL (TAN) PROJECTION
Image receptor: 8 × 10 inch (18 ×
24 cm)
Position of patient
• Have the patient stand facing the image
receptor, or seat the patient on an adjust-
able stool facing the unit.
Position of part
For a palpable mass
The TAN projection is most often per-
formed with use of the magnification
technique.
• Select a standard, quadrant, or spot
compression paddle, as appropriate.
• Place the AEC detector at the chest
wall.
• Locate the area of interest by palpating
the patient’s breast.
ence (Fig. 21-60), rotate the C-arm
apparatus parallel to this line. The
central ray is directed tangential to the
breast at the point identified by the BB
marker.
• Place the breast on the image receptor
or magnification stand with the area of
interest marked by the BB on the edge
of the skin.
• The “shadow” of the BB will be pro-
jected onto the image receptor
surface.
• Using the appropriate compression
paddle, compress the breast while
ensuring that enough breast tissue
covers the AEC detector area.
• Slowly apply compression until the
breast feels taut.
• Instruct the patient to indicate if the
compression becomes uncomfortable.
• When full compression is achieved,
Central ray
• Perpendicular to the area of interest
Structures shown
This projection shows superficial lesions
close to the skin surface with minimal
parenchymal overlapping. It also shows
skin calcifications or palpable lesions pro-
jected over subcutaneous fat (Fig. 21-63).
EVALUATION CRITERIA
The following should be clearly shown:
■ Palpable lesion visualized over subcu-
taneous fat
■ Tangential radiopaque marker or BB
marker accurately correlated with pal-
pable lesion
■ Minimal overlapping of adjacent paren-
chyma
■ Calcification in parenchyma or skin

• Place a radiopaque marker or BB on the
mass, or have the patient place the BB
on the area of concern.
• Using the imaginary line between the
nipple and the BB as the angle refer-
Supplemental Projections
instruct the patient to stop breathing ■ Uniform tissue exposure if compres-
(Figs. 21-61 and 21-62). sion is adequate
• Make the exposure.
• Release breast compression immedi-
ately.

12 12
70º 90º 70º 70º 90º 70º
UOQ 45º 45º UIQ UIQ 45º 45º UOQ
30º 30º 30º 30º
9 0º 0º 3 9 0º 0º 3
30º 30º 30º 30º
45º 45º 45º 45º
LOQ 70º 90º 70º LIQ LIQ 70º 90º 70º LOQ
6 6
Fig. 21-60  Degree of angle for TAN projection. Correlation of location of abnormality Fig. 21-61  TAN projection.
with degree of rotation of C-arm; an angle of the C-arm shows upper quadrant and
lower quadrant abnormality tangentially.

443
 Breast
Mammography

A Tangential B C
Fig. 21-62  TAN projection of palpable mass in LOQ. A, IR is angled parallel to nipple-to-
mass line. B, The mass, marked by BB, is positioned on edge of skin line. C, Radiograph
of mass imaged in tangent using the magnification technique. Spiculated borders
indicate cancer.

Fig. 21-63  Left magnified tangential view of a palpable mass

with a BB placed on it shows the area of interest in the
subdermal fatty tissue. The magnified view showed an area of
architectural distortion with scattered clusters of coarse
calcifications. This proved to be a cancer on biopsy.

444
 Breast
CAPTURED LESION OR COAT-
HANGER PROJECTION (CL)
This specialized positioning is seldom
used but is very useful when a palpable
lesion located in the extreme posterior or
lateral breast tissue is imaged. Sometimes
lesions in these areas tether themselves to
the chest wall and resist being pulled
forward to be visualized on a routine pro-
jection. This procedure is a variation of
the TAN projection and should be labeled
as such. It is generally performed using
magnification and tight collimation. The
captured lesion or coat-hanger projection
captures and isolates the palpable lump
for imaging (Figs. 21-64 and 21-65).
Image receptor: 8 × 10 inch (18 ×
24 cm)
Position of patient
• Have the patient stand facing the image
receptor, or seat the patient on an adjust-
able stool facing the unit.
Position of part
• Place the magnification platform
designed for use with the dedicated
mammography unit on the equipment.
• Place a lead BB over the palpable mass.
• Using your hands, determine the pro-
jection most likely to image the lump
with no superimposition of other tissue.
Place the area of clinical concern at the
edge of the breast in a tangent plane to
the film.
• The palpable area of clinical concern is
captured with a corner of a wire coat-
hanger or an inverted spot compression
device. No additional compression is
needed.
• It may be necessary to use a manual
technique if the amount of tissue cap-
tured within the coat-hanger or inverted
compression device does not cover the
AEC detector.
Central ray
• Perpendicular to the film
Structures shown
The area of clinical concern is positively
identified and visualized with the advan-
tages of magnification mammography.
EVALUATION CRITERIA
The following should be clearly shown:
■ Area of interest within collimated and
self-compressed margins
Supplemental Projections
445
 Breast

B
Mammography

C D
Fig. 21-64  Coat-hanger projection. A and B, A slippery lesion is captured for imaging by
the angle of a wire coat-hanger. C, Inverted spot compression device can sometimes
achieve the same results. D, Radiograph of lesion imaged using coat-hanger projection.
This lesion could not be viewed on routine projections because of its position within the
breast and the elastic nature of the lesion, which was determined to be a cancer on
biopsy.

446
Breast

Supplemental Projections
A B

C D
Fig. 21-65  This 40-year-old patient presented with a palpable lump on the left breast
extremely posterior at 1:00. A BB was placed on the lump before imaging. The area was
not visualized on the standard MLO view (A). Subsequent tangential imaging was
unsuccessful because of the proximity of the pectoral muscle (B and C). A CL view was
performed (D) to stabilize the lump within the imaged area. This proved to be a lipoma.

447
 Breast
CAUDOCRANIAL (FB)
PROJECTION
Image receptor: 8 × 10 inch (18 ×
24 cm) or 10 × 12 inch (24 × 30 cm)
Position of patient
• Have the patient stand facing the image
receptor.
Position of part
• Rotate the C-arm apparatus 180 degrees
from the rotation used for a routine CC
projection. The tube head will be near
the floor and the image receptor will be
above the patient’s breast.
• Standing on the medial side of the
breast to be imaged, elevate the infra-
mammary fold to its maximal height.
Mammography
448
• Adjust the height of the C-arm so that
the image receptor is in contact with the
superior breast tissue.
• Lean the patient slightly forward while
gently pulling the elevated breast out
and perpendicular to the chest wall.
Hold the breast in position.
• Have the patient rest the affected arm
over the top of the image receptor.
• Inform the patient that compression of
the breast will be used. Bring the com-
pression paddle from below into contact
with the patient’s breast while sliding
the hand toward the nipple.
• Slowly apply compression until the
breast feels taut.
Fig. 21-66  FB projection.
• Instruct the patient to indicate if the
compression becomes uncomfortable.
• To ensure that the patient’s abdomen is
not superimposed over the path of the
beam, have the patient pull in the
abdomen or move the hips back slightly.
• When full compression is achieved,
move the AEC detector to the appropri-
ate position, and instruct the patient to
stop breathing (Fig. 21-66).
• Make the exposure.
• Release breast compression immedi-
ately.
 Breast

Central ray EVALUATION CRITERIA ■ All medial tissue included as shown by

• Perpendicular to the base of the breast
Structures shown
This projection shows an inferosuperior
projection of the breast for improved visu-
alization of lesions located in the superior
aspect as a result of reduced object–to–
image receptor distance. The FB projec-
tion may facilitate a shorter route for
needle-wire insertion to localize an infe-
rior lesion (Fig. 21-67) or during prone
stereotactic core biopsy. The projection
may also be used as a replacement for the
standard CC projection in patients with
prominent pectoral muscles or kyphosis.
The following should be clearly shown:
■ Superior breast tissue and lesions
clearly visualized
■ For needle localization images, inferior
lesion visualized within specialized
fenestrated compression plate
■ Patient’s abdomen projected clear of
image
■ Inclusion of fixed posterior tissue of
superior aspect of breast
■ PNL extending posteriorly to edge
of image, measuring within 1 3 inch
(1 cm) of depth of PNL on MLO
projection
visualization of medial retroglandular
fat and absence of fibroglandular tissue
extending to posteromedial edge of
image
■ Nipple in profile, if possible, and at
midline, indicating no exaggeration of
positioning
■ Some lateral tissue possibly excluded
to emphasize medial tissue
■ Slight medial skin reflection at cleav-
age, ensuring that posterior medial
tissue is adequately included
■ Uniform tissue exposure if compres-
sion is adequate

Supplemental Projections
L
RM
B
RF

A B
Fig. 21-67  A, FB projection performed in a 57-year-old woman to access the
shortest route for localizing lesions identified in the inferior aspect of the breast (arrow).
B, Orthogonal 90-degree ML projection of the same patient, showing successful
placement of needle-wire system within lesion (arrow). The lesion was found to be a
9-mm infiltrating ductal carcinoma.

449
 Breast
MEDIOLATERAL OBLIQUE
PROJECTION FOR AXILLARY
TAIL (AT)
Image receptor: 8 × 10 inch (18 ×
24 cm) or 10 × 12 inch (24 × 30 cm)
Position of patient
• Have the patient stand facing the image
receptor, or seat the patient on an adjust-
able stool facing the unit.
Position of part
• Determine the degree of obliquity of
the C-arm apparatus by rotating the
tube until the long edge of the image
receptor is parallel with the AT of the
affected side. The degree of obliquity
varies between 10 degrees and 35
degrees.
• Adjust the height of the C-arm so that
Mammography
the superior border of the image recep-
tor is just under the axilla.
450
• Instruct the patient to elevate the arm of
the affected side over the corner of the
image receptor and to rest the hand on
the adjacent handgrip. The patient’s
elbow should be flexed.
• Have the patient relax the affected
shoulder and lean it slightly anterior.
Using the flat surface of the hand,
gently pull the tail of the breast anteri-
orly and medially onto the image recep-
tor, keeping the skin and tissue smooth
and free of wrinkles.
• Ask the patient to turn the head away
from the side being examined and to
rest the head against the face guard.
• Inform the patient that compression of
the breast will be used. Continue to
hold the breast in position while sliding
the hand toward the nipple as the com-
pression paddle is brought into contact
with the AT (Fig. 21-68).
Fig. 21-68  MLO projection for AT.
• Slowly apply compression until the
breast feels taut. The corner of the com-
pression paddle should be inferior to
the clavicle. To avoid patient discom-
fort caused by the corner of the paddle
and to facilitate even compression,
remind the patient to keep the shoulder
relaxed.
• Instruct the patient to indicate if the
compression becomes uncomfortable.
• When full compression is achieved,
move the AEC detector to the appropri-
ate position, and instruct the patient to
stop breathing. It may be necessary to
increase exposure factors if compres-
sion is not as taut as in the routine
projections.
• Make the exposure.
• Release breast compression immedi-
ately.
 Breast
Central ray
• Perpendicular to the image receptor
• The angle of the C-arm apparatus is
determined by the slope of the patient’s
AT.
Structures shown
This projection shows the AT of the breast,
with emphasis on its lateral aspect.
RAT
Fig. 21-69  Right AT projection.
EVALUATION CRITERIA
The following should be clearly shown:
■ AT with inclusion of axillary lymph
nodes under focal compression
(Fig. 21-69)
■ Uniform tissue exposure if compres-
sion is adequate
■ Slight skin reflection of affected arm on
superior border of image
Supplemental Projections
451
 Breast
AXILLA PROJECTION FOR
AXILLARY TAIL (AT)
Image receptor: 8 × 10 inch (18 ×
24 cm)
Position of patient
• Have the patient stand facing the image
receptor, or seat the patient on an adjust-
able stool facing the unit.
Position of part
• Rotate the c-arm to approximately 70
degrees.
• Adjust the height of the C-arm so that
the superior edge of the image receptor
is even with the top of the patient’s
shoulder.
• Select the appropriate compression
device. A quadrant paddle will capture
more deep axillary tissue; a standard
18 × 24-cm compression paddle will
Mammography
capture additional lateral tissue and
axillary tail.
452
• Instruct the patient to elevate the arm of
the affected side so that it is perpen-
dicular to the body.
• Place the arm against the image recep-
tor so that the posterior aspect of the
shoulder is resting against the IR. The
patient’s arm is draped across the IR
with the forearm resting on the grip bar.
• Have the patient relax the affected
shoulder and lean slightly anterior.
Using the flat surface of the hand placed
under the axillary region, gently pull
the tail of the breast anteriorly and
medially onto the image receptor,
keeping the skin and tissue smooth and
free of wrinkles.
• Inform the patient that compression of
the breast will be used. Slowly bring
compression down along the patient’s
ribs, with the top edge of the compres-
sion paddle skimming the lower edge of
the patient’s upper arm.
Fig. 21-70  Axilla projection for axillary tail (AT).
• Slowly apply compression until the
axillary tissue feels taut. The corner of
the compression paddle should be infe-
rior to the clavicle. To avoid patient
discomfort caused by the corner of the
paddle and to facilitate even compres-
sion, remind the patient to keep the
shoulder relaxed.
• Instruct the patient to indicate if the
compression becomes uncomfortable.
Vigorous compression is not necessary
for this view (Fig. 21-70).
• When full compression is achieved,
move the AEC detector to the appropri-
ate position, and instruct the patient to
stop breathing. It may be necessary to
increase exposure factors if compres-
sion is not as taut as in the routine
projections.
• Make the exposure.
• Release breast compression immedi-
ately
 Breast

Structures shown EVALUATION CRITERIA

This projection shows the axilla and the
AT of the breast, with emphasis on its
lateral aspect.
The following should be clearly shown:
■ AT with inclusion of axillary lymph
nodes under focal compression
(Fig. 21-71)
■ Uniform tissue exposure if compres-
sion is adequate
■ Slight skin reflection of affected arm on
superior border of image

Supplemental Projections
LAT

Fig. 21-71  Left AT projection demonstrating the axilla and its contents. Note
ductal carcinoma and metastasized lymph nodes (arrows).

453
 Breast
LATEROMEDIAL OBLIQUE (LMO)
PROJECTION
Image receptor: 8 × 10 inch (18 ×
24 cm) or 10 × 12 inch (24 × 30 cm)
Position of patient
• Have the patient stand facing the image
receptor, or seat the patient on an adjust-
able stool facing the unit.
Position of part
• Determine the degree of obliquity of
the C-arm apparatus by rotating the
assembly until the long edge of
the image receptor is parallel with
the upper third of the pectoral muscle
of the affected side. The central ray
enters the inferior aspect of the breast
from the lateral side. The degree of
obliquity should be between 30 degrees
Mammography
and 60 degrees, depending on the body
habitus of the patient.
454
• Adjust the height of the C-arm so that
the superior border of the image recep-
tor is level with the jugular notch.
• Ask the patient to place the opposite
hand on the C-arm. The patient’s elbow
should be flexed.
• Lean the patient toward the C-arm
apparatus, and press the sternum against
the edge of the image receptor, which
is slightly off-center toward the oppo-
site breast.
• Have the patient relax the affected
shoulder and lean it slightly anterior.
Gently pull the patient’s breast and pec-
toral muscle anteriorly and medially,
with the flat surface of the hand posi-
tioned along the lateral aspect of the
breast.
• Scoop breast tissue up with the hand,
gently grasping the breast between
fingers and thumb.
• Center the breast with the nipple in
profile, if possible, and hold the breast
in position.
Fig. 21-72  LMO projection.
• Inform the patient that compression of
the breast will be used. Continue to
hold the patient’s breast up and out
while sliding the hand toward the nipple
as the compression paddle is brought
into contact with the LOQ of the breast.
• Slowly apply compression until the
breast feels taut.
• Instruct the patient to indicate if the
compression becomes uncomfortable.
• Pull down on the patient’s abdominal
tissue to open the inframammary fold.
• Ask the patient to rest the affected
elbow on the top edge of the image
receptor.
• When full compression is achieved,
move the AEC detector to the appropri-
ate position, and instruct the patient to
stop breathing (Fig. 21-72).
• Make the exposure.
• Release breast compression immedi-
ately.
 Breast

Central ray EVALUATION CRITERIA ■ Pectoral muscle with anterior convexity

• Perpendicular to the image receptor
• The C-arm apparatus is positioned at an
angle determined by the slope of the
patient’s pectoral muscle (30 to 60
degrees). The actual angle is deter-
mined by the patient’s body habitus:
Tall, thin patients require steep angula-
tion, whereas short, stout patients
require shallow angulation.
Structures shown
This projection shows a true reverse pro-
jection of the routine MLO projection and
is typically performed to better show the
medial breast tissue. It is also performed
if the routine MLO cannot be completed
because of one or more of the following
conditions: pectus excavatum, extreme
kyphosis, post open-heart surgery, promi-
nent pacemaker, men or women with
The following should be clearly shown:
■ Medial breast tissue clearly visualized
(Fig. 21-73)
■ PNL measuring within 1 3 inch (1 cm)
of the depth of the PNL on the CC pro-
jection. (While drawing the PNL
obliquely, following the orientation of
the breast tissue toward the pectoral
muscle, measure its depth from nipple
to pectoral muscle or to the edge of the
image, whichever comes first.)
■ Inferior aspect of the pectoral muscle
extending to nipple line or below it if
possible
to ensure a relaxed shoulder and axilla
■ Nipple in profile if possible
■ Open inframammary fold
■ Deep and superficial breast tissueswell
separated when breast is adequately
maneuvered up and out from chest wall
■ Retroglandular fat well visualized to
ensure inclusion of deep fibroglandular
breast tissue
■ Uniform tissue exposure if compres-
sion is adequate

Supplemental Projections
prominent pectoralis muscles, or Port-A-
Cath/MediPort (Hickman catheters).

Fig. 21-73  LMO projection.

(From Svane G: Screening mammography, St

Louis, 1993, Mosby.)

455
 Breast

SUPEROLATERAL TO Position of part • Adjust the height of the C-arm to posi-

INFEROMEDIAL OBLIQUE
(SIO) PROJECTION
Image receptor: 8 × 10 inch (18 ×
24 cm) or 10 × 12 inch (24 × 30 cm)
Position of patient
• Have the patient stand facing the image
receptor, or seat the patient on an adjust-
able stool facing the unit.
Mammography
• Rotate the C-arm apparatus so that the
central ray is directed at an angle to
enter the superior and lateral aspect of
the affected breast. The LIQ is adjacent
to the image receptor.
• Adjust the degree of C-arm obliquity
according to the body habitus of the
patient, or, when the SIO projection is
being used as an additional projection
to image an area of the tissue more
clearly without superimposition of sur-
rounding tissue, adjust the C-arm to the
degree of angulation required by the
radiologist, generally a 20- to 30-degree
angle.
tion the patient’s breast over the center
of the image receptor.
• Instruct the patient to rest the hand of
the affected side on the handgrip
adjacent to the image receptor holder.
The patient’s elbow should be flexed.
For shallow-angled SIO projections,
the arm on the affected side should lie
straight against the patient’s side. The
handgrip is held by the hand on the
contralateral side.
• Place the upper corner of the image
receptor along the sternal edge adjacent
to the upper inner aspect of the patient’s
breast.
• With the patient leaning slightly
forward, gently pull as much medial
tissue as possible away from the sternal
edge while holding the breast up and
out. The breast should not droop. Ensure

that the patient’s back remains straight

during positioning, and that the patient
does not lean to the side or toward the
image receptor.
• Inform the patient that compression of
the breast will be used. Continue to
hold the breast up and out.
• Bring the compression paddle under the
affected arm and into contact with
the patient’s breast while sliding the
hand toward the patient’s nipple. For
shallow-angled SIO, the affected arm at
the patient’s side should be bent at the
elbow to avoid superimposition of the
humeral head over the breast tissue.
• Slowly apply compression until the
breast feels taut. The upper corner of
the compression paddle should be in the
axilla for the standard SIO projection.
A • Instruct the patient to indicate if the
compression becomes uncomfortable.
• When full compression is achieved on
the standard SIO, help the patient bring
the arm up and over with the flexed
elbow resting on top of the image
receptor.
• Gently pull down on the patient’s
abdominal tissue to smooth out any
skin folds.
• Move the AEC detector to the appropri-
ate position, and instruct the patient to
stop breathing (Fig. 21-74).
• Make the exposure.
• Release breast compression immedi-
ately.

B
Fig. 21-74  A, SIO projection. B, Shallow-angled SIO with arm down.

456
 Breast

Central ray EVALUATION CRITERIA ■ Deep and superficial breast tissues well
• Perpendicular to the image receptor The following should be clearly shown: separated when breast is adequately
• The C-arm apparatus is positioned at an ■ UIQ and LOQ free of superimposition maneuvered up and out from chest wall
angle determined by the patient’s body (these quadrants are superimposed on ■ Retroglandular fat well visualized to
habitus or tissue composition. MLO and LMO projections) ensure inclusion of deep fibroglandular
■ Lower inner aspect of breast visualized breast tissue
Structures shown with greater detail ■ Uniform tissue exposure if compres-
This projection shows the UIQ and LOQ ■ Nipple in profile if possible sion is adequate.
of the breast free of superimposition. In
addition, lesions located in the lower inner
aspect of the breast are shown with better
recorded detail. This projection may also
be used to replace the MLO ID projection
in patients with encapsulated implants
(Fig. 21-75).

Supplemental Projections

457
 Breast

RMLO RCC
Mammography

A B

C
Fig. 21-75  Patient presented with a palpable mass at 1:00 in the right breast. A BB was
placed on the skin over the lump, and standard MLO and CC projections were taken
(A and B). A tangential view taken in an SIO projection (C) places the palpable lump
within the dermis for best visualization. This proved to be invasive ductal carcinoma on
biopsy.

458
 Breast

Ductography
(Examination
of Milk Ducts) LMCC

Ductography is indicated in a patient who

presents with a unilateral spontaneous dis-
charge from the nipple that is either bloody
or clear and watery. This type of discharge
can be associated with a ductal carcinoma
that is mammographically occult. More
often, nipple discharge is the product of a
papilloma within the duct. The ductogram
can help the radiologist determine the
cause and location of the origin of the
discharge by injecting an opaque contrast
medium into the duct. These patients can
often be biopsied immediately using ste-
reotactic methods with contrast-enhanced
ducts (Fig. 21-76).
Equipment and supplies for the exami-
nation include a sterile hypodermic

Ductography
syringe (usually 1 to 3 mL); a 30-gauge
ductography cannula with a smooth, round
tip; a skin cleansing agent; sterile gauze
sponges or cotton balls; paper tape; a
waste basin; and an organic, water-soluble,
iodinated contrast medium.

LMML

B
Fig. 21-76  This 55-year-old patient presented with a spontaneous brown discharge from
the left nipple. Ductography was performed for visualization of the ducts. A probable
papilloma was noted as an area of lucency (arrow) on CC (A) and ML (B) views. This
patient was sent for stereotactic core biopsy (C, pre-fire images) where the area was
excised. It proved to be a papilloma. Continued
459
 After the nipple is cleaned, a small
amount of discharge is expressed to iden-
tify the correct ductal opening. The
cannula is inserted into the orifice of the
duct, and undiluted iothalamate meglu-
mine or iopamidol is gently injected. So
that the patient does not experience unnec-
essary discomfort and extravasation does
not occur, the injection is terminated as
soon as the patient experiences a sense of
fullness, pressure, or pain. The cannula is
taped in place before the patient is posi-
tioned for the radiographs. If cannulation
is unsuccessful, a sterile local anesthetic
Mammography
C
460
gel or warm compress may be applied to
the nipple and areola, and the procedure
is reattempted. If ductography is unsuc-
cessful after several attempts, the proce-
dure may be rescheduled in 7 to 14 days.
On successful injection, the following
guidelines are observed:
• Immediately obtain radiographs with
the patient positioned for the CC and
lateral projections of the subareolar
region using the magnification tech-
nique (see Fig. 21-76, A and B). If
needed, MLO or rolled CC and rolled
Fig. 21-76, cont’d
MLO magnification projections may be
obtained to resolve superimposed ducts.
• Employ the exposure techniques used
in general mammography.
• Leave the cannula in the duct to mini-
mize leakage of contrast material during
compression and to facilitate reinjec-
tion of the contrast medium without the
need for recannulation.
• If the cannula is removed for the images,
do not apply vigorous compression
because this would cause the contrast
medium to be expelled.
Localization and Biopsy
of Suspicious Lesions
Approximately 80% of nonpalpable lesions
identified by mammography are not malig-
nant. Nonetheless, a breast lesion cannot
be definitively judged benign until it has
been microscopically evaluated. When
mammography identifies a nonpalpable
lesion that warrants biopsy, the abnormal-
ity must be accurately located so that the
smallest amount of breast tissue is removed
for microscopic evaluation, minimizing
trauma to the breast. This technique con-
serves the maximal amount of normal
breast tissue unless extensive surgery is
indicated by pathologic findings.
Suspicious breast lesions can be biop-
sied using three techniques: (1) fine-
needle aspiration biopsy (FNAB),
(2) large-core needle biopsy (LCNB), and
support is available for use of this tech-
nique instead of surgical excisional biopsy
to diagnose pathology of a lesion. LCNB
may be used with clinical, ultrasound, ste-
reotactic, and MRI guidance. The method
used depends on the preference of the
radiologist and the surgeon and is typi-
cally determined by the modality with
which the lesion is most visible.
When a patient is a candidate for an
open surgical biopsy, needle-wire local-
ization is a predominant method for local-
izing nonpalpable lesions before surgery.
Needle-wire localization uses a long
needle containing a hooked guidewire,
which is inserted into the breast to lead the
surgeon directly to the lesion. The loca-
tion of the nonpalpable lesion can be
initially located using ultrasound or ste-
reotactic imaging, but it is primarily cal-
culated using a standard mammography
Hawkins (20-gauge) biopsy guides. A
small incision (1 to 2 mm) at the entry site
may be necessary to facilitate insertion of
a larger-gauge needle. With each system,
a long needle containing a hooked wire is
inserted into the breast until the needle’s
tip is adjacent to the lesion. When the
needle and wire are in place, the needle is
withdrawn over the wire. The hook on the
end of the wire anchors the wire within
the breast tissue. Some radiologists also
inject a small amount of methylene blue
dye to label the proper biopsy site visu-
ally. After needle-wire localization, the
patient is bandaged and taken to the surgi-
cal area for excisional biopsy (Fig. 21-77).
The surgeon then cuts along the guidewire
and removes the breast tissue around the
wire’s hooked end. Alternatively, the
surgeon may choose an incision site that
intercepts the anchored wire distant from

Localization and Biopsy of Suspicious Lesions

(3) open surgical biopsy. FNAB uses a unit with specialized compression plates. the point of wire entry. Ideally, the radi-
hollow small-gauge needle to extract The four most common needle-wire ologist and the surgeon should review the
tissue cells from a suspicious lesion. The localization systems are the Kopans, localization images together before the
location of the lesion is identified by the Homer (18-gauge), Frank (21-gauge), and excisional biopsy is performed.
doctor using palpation, ultrasonography,
or stereotactic guidance. FNAB can poten-
tially decrease the need for surgical exci-
sional biopsy by identifying benign lesions
and by diagnosing malignant lesions that
require extensive surgery rather than exci-
sional biopsy.
LCNB obtains small samples of breast
tissue by means of a larger-gauge (gener-
ally sized between 9-gauge and 14-gauge)
hollow needle with a trough adjacent to
the tip of the needle. A vacuum suction
system is frequently employed during this
procedure to pull the target tissue through
the trough into a collecting chamber. Once
the tissue sample has been obtained, a tita-
nium clip is often placed in the breast
through the needle to mark the exact loca-
tion of the biopsy. This clip can be used
by the surgeon to locate the areola during
an open surgical excision, or to indicate
the area of prior LCNB during subsequent Fig. 21-77  Material for breast localization using specialized compression plate:
mammography. Because larger tissue alphanumeric localization compression plate, sterile gloves, topical antiseptic, alcohol
samples are obtained with LCNB, and wipe, local anesthetic, 5-mL syringe, 25-gauge needle, scalpel blade, sterile gauze,
because results are very accurate, clinical tape, and needle-wire localization system.

461
 BREAST LESION LOCALIZATION
WITH A SPECIALIZED
COMPRESSION PLATE
Most breast cancers that are surgically
removed are nonpalpable lesions that have
been found during mammography. Preop-
erative localization of these lesions is often
performed to aid the surgeon in locating
the area of concern to ensure excision of
the lesion. Most mammography units are
adaptable with specialized compression
plates with openings that can be positioned
over a breast lesion. Through the opening,
a specialized localizing needle-wire set can
be introduced into the breast. The initial
mammogram and a 90-degree lateral pro-
jection are usually reviewed together to
determine the shortest distance from the
skin to the breast lesion. A lesion in the
inferior aspect of the breast may be best
approached from the medial, lateral, or
Mammography
no standardized procedure is known. The
following steps are typically taken:
• Perform preliminary routine full-breast
projections to confirm the existence of
the lesion (Figs. 21-79 and 21-80).
Orthogonal views will be more helpful
in visualizing the exact location of the
lesion; therefore the MLO projection
may be replaced by a 90-degree lateral
projection.
• Obtain informed consent after discuss-
ing the following topics with the patient:
1. Full explanation of the procedure
2. Full description of potential prob-
lems per facility policy: These may
include vasovagal reaction, excessive
bleeding, allergic reaction to lido-
caine, and possible failure of the pro-
cedure (failure rate of 0% to 20%).n,o,p
3. Answers to patient’s preliminary
questions
n
Jackman RJ, Marzoni FA Jr: Needle-localized
breast biopsy: why do we fail? Radiology 204(3):677,
1997.
o
Abrahamson PE et al: Factors predicting successful
needle-localized breast biopsy, Acad Radiol
10(6):601, 2003.
p
Kouskos E et al: Wire localisation biopsy of non-
palpable breast lesions: reasons for unsuccessful
excision, Eur J Gynaecol Oncol 27(3):262, 2006.

inferior surface of the breast but not from

the superior surface.
Two styles of fenestrated localization
compression paddles are currently in use:
a rectangular cutout with radiopaque
alphanumeric grid markings along at least
two adjacent sides, and a device in which
the plate may be fenestrated with several
rows of holes, each large enough to
accommodate insertion of a localization
needle (Fig. 21-78). There are proponents
for each of the paddles, and which one is
used is usually decided by the radiologist
performing the localization procedure.
The device with fenestrated holes allows
the breast tissue to be more firmly fixed
and compressed; this in turn allows the Fig. 21-79  CC projection shown with specialized open-hole compression plate.
area to be localized, making it more dis-
cernible from the surrounding tissue.
Needle-localization procedures vary
from radiologist to radiologist. As a result,

Fig. 21-78  Compression plates specifically

designed for breast localization
procedure. Fig. 21-80  ML projection shown with specialized open-hole compression plate.

462
• Position the patient so that the compres-
sion plate is against the skin surface
closest to the lesion as determined from
preliminary images.
• Tell the patient that compression will
not be released until the needle has been
successfully placed and that the patient
is to hold as still as possible.
• Disable the automatic release of the
compression paddle.
• Make a preliminary exposure using
compression. Ink marks may be placed
at the corners of the paddle window or
in several of the concentric holes away
from the area to be localized to deter-
mine whether the patient moves during
the procedure.
• Process the image without removing
compression. The resultant image
shows where the lesion lies in relation
to the compression plate openings (Fig.
21-81). If using the circularly fenes-
trated paddle, count the holes visible on
the image to determine the correct entry
point of the needle. If using the rectan-
gular hole, use the alphanumeric marker
system supplied with the paddle to
determine the location of the lesion and
the needle entry point.
• Clean the skin of the breast over the
entry site with a topical antiseptic.
Some radiologists may prefer to do this
before compression.
• Apply a topical anesthetic if necessary.
• Insert the localizing needle and guide-
wire into the breast perpendicular to the
compression plate and parallel to the
chest wall, moving the needle directly
toward the underlying lesion. Advance
the needle to the estimated depth of
the lesion. Because the breast is com-
pressed in the direction of the needle’s
insertion, it is better to pass beyond the
lesion than to be short of the lesion. Do
not advance the guidewire into the
tissue until the depth of the lesion has
been determined by the orthogonal
view.
• With the needle in position, make an
exposure. Be sure that the shadow of
the hub of the needle projects directly
over the insertion point of the needle
during the exposure to precisely indi-
cate the location of the tip. Slowly
release the compression plate, leaving

Localization and Biopsy of Suspicious Lesions

the needle-wire system in place. Obtain
an additional projection after the C-arm
apparatus has been shifted 90 degrees.
(These two orthogonal radiographs are
RCC RCC
used to determine the position of the
end of the needle-wire relative to the
depth of the lesion.)
• If the needle is not located adjacent
to or within the area of interest, reposi-
tion the needle-wire, and repeat the
exposures.
• When the needle is accurately placed
within the lesion, withdraw the needle,
but leave the hooked guidewire in
place.
A D • Place a gauze bandage over the breast.
• Transport the patient to surgery along
with the final localization images.
RLM RLM

B C
Fig. 21-81  CC and ML projections (A and B) taken to verify area to be excised. Clips
from prior core biopsy (arrows) indicate correct area for wire localization. These images
show that inserting the localization needle from the lateral aspect of the breast uses the
closest route, thereby minimizing trauma and scarring from surgery. The breast is
positioned in the LM projection using the alphanumeric fenestrated paddle. The needle
is inserted, and an image is taken to verify that it has been inserted over the lesion
(C). The arrow indicates the hub of the needle. A final image (D) is taken in the CC
projection to affirm that the needle passes through the area to be biopsied.

463
 Localization of dermal calcifications
For localization of nonpalpable dermal
calcifications, two projections are neces-
sary: (1) a localization projection (which
depends on the area of interest) and (2) a
TAN projection.
• From the routine CC and MLO projec-
tions, determine the quadrant in which
the area of interest is located.
• Determine which projection would best
localize the area of interest—the CC or
90-degree lateral projection.
• Turn off the automatic compression
release, and inform the patient that
compression will be continued while
the first image is processed.
• Using a localization compression
paddle, position the C-arm and breast
so that the paddle opening is positioned
over the quadrant of interest.
• Slowly apply compression until the
Mammography
breast feels taut.
• Instruct the patient to indicate if the
compression becomes uncomfortable.
• When full compression is achieved,
move the AEC detector to the appropri-
ate position, and instruct the patient to
stop breathing.
• Make the exposure.
• Do not release compression. Keep the
breast compressed while the initial
image is processed.
464
Tangential projection
• Check the initial image, and locate the
area of interest using the alphanumeric
identifiers.
• With the patient’s breast still under
compression, locate the corresponding
area on the breast and place a radi-
opaque marker or BB over the area.
• Release breast compression, and replace
the localization compression paddle
with a regular or spot compression
paddle.
• Rotate the C-arm apparatus until the
central ray is directed tangential to the
breast at the point identified by the BB
marker (the “shadow” of the BB is pro-
jected onto the image receptor surface).
• Compress the area while ensuring that
enough breast tissue covers the AEC
detector area.
• Slowly apply compression until the
breast feels taut.
• Instruct the patient to indicate whether
the compression becomes uncomfort-
able.
• When full compression is achieved,
move the AEC detector to the appropri-
ate position, and instruct the patient to
stop breathing.
• Make the exposure.
• Release breast compression immedi-
ately.
Central ray
• Perpendicular to the area of interest
Structures shown
This projection shows superficial lesions
close to the skin surface with minimal
parenchymal overlapping. It also shows
skin calcifications or palpable lesions
projected over subcutaneous fat (see
Fig. 21-63).
EVALUATION CRITERIA
The following should be clearly shown:
■ Palpable lesion visualized over subcu-
taneous fat
■ Tangential radiopaque marker or BB
marker accurately correlated with pal-
pable lesion
■ Minimal overlapping of adjacent
parenchyma
■ Calcification in parenchyma or skin
■ Uniform tissue exposure if compres-
sion is adequate
STEREOTACTIC IMAGING AND
BIOPSY PROCEDURES
Stereotactic imaging, or stereotaxis, is a
method of calculating the exact location
of a specific lesion in the breast using
mammographic imaging. Stereotaxis uses
three-dimensional triangulation to iden-
tify the exact location of a breast lesion by
taking two stereo images 30 degrees apart
(Fig. 21-82). Once the lesion has been
identified in a perpendicular scout image,
the x-ray tube is rotated +15 degrees for
the first stereo exposure, then −15 for the
second. At a computer workstation, the
lesion is marked in each stereo image, and
a digitizer calculates X, Y, and Z coordi-
nates (Fig. 21-83).
The X, Y, and Z coordinates allow the
physician to calculate the exact location of
the breast lesion in three dimensions. The
X coordinate identifies the transverse loca-
tion, right to left, or the inferior breast
versus the lateral breast. The Y coordinate
designates depth, front to back, or anterior
versus posterior breast. The Z coordinate
identifies the height of the lesion, top to
bottom, or superficial to the skin versus
the center of the breast (Fig. 21-84). Dif-
ferent stereotactic systems have different
methods for calculating a Z value depend-
ing on the location of the center reference
point. The operator should be familiar
with the system in use so that accurate
adjustments of the localization device can
be made.
Imaging with stereotactic units is avail-
able as conventional screen-film or small-
field (2 × 2 inch [5 × 5 cm]) digital imaging.
Although conventional screen-film systems
are considerably less expensive, digital
imaging is preferred because of its shorter
acquisition time. This is important, as the
breast is held in compression throughout
the procedure. Any slight movement
changes the X, Y, and Z values.

Localization and Biopsy of Suspicious Lesions

stereo images

breast support

compressed breast

biopsy/compression plate

abnormality

-X +X

-15º +15º
source
Fig. 21-82  Three-dimensional localization. Acquisition of two planar images from different Fig. 21-83  Digitizer calculates and
source positions provides the means for 3D localization. transmits X, Y, and Z coordinates to stage,
or “brain,” of biopsy system, where biopsy
(Reprinted with permission from Willison KM: Fundamentals of stereotactic breast biopsy. In: Fajardo
gun is attached. This information is used to
LL, Willison KM, Pizzutello RJ, eds: A comprehensive approach to stereotactic breast biopsy,
Cambridge, 1996, Blackwell Science, p14.) determine placement of biopsy needle.

(Courtesy Trex Medical Corp., LORAD Division,

Danbury, CT.)

465
 Once the lesion is localized using ste-
reotaxis, three general methods can be
used to biopsy a breast lesion. The physi-
cian’s preference generally determines the
procedure that is performed. The lesion
can be mapped with hooked guidewire in
needle-wire localization for subsequent
surgery, or it can be biopsied through
FNAB or LCNB. In FNAB, cells are
extracted from a suspicious lesion with a
thin needle. For large-core needle biop-
sies, core samples of tissue are obtained
by means of a larger needle with a trough
adjacent to its tip. Samples are then evalu-
ated to determine the benign or malignant
nature of the suspicious breast lesion.
Given that LCNB using stereotactic
imaging is a minor outpatient procedure
and the preferred biopsy method, it is dis-
cussed in depth in this chapter.
The benefits of stereotactic core needle
Mammography
only exceptions are patients who cannot
cooperate for the procedure, patients with
physical limitations prohibiting use of the
equipment, patients who have mammo-
graphic findings at the limits of percep-
tion, and patients with lesions of potentially
ambiguous histology.
Stereotactic biopsies are generally
quicker and easier to schedule than con-
ventional surgery. This can expedite
pathology results, so potential surgical
decisions regarding lumpectomy or mas-
tectomy can be made with minimal delay.
When operating on the basis of a core
biopsy diagnosis of cancer, surgeons are
more likely to obtain clean (negative)
lumpectomy margins with the first exci-
sion. Axillary lymph nodes, which are
evaluated to ascertain metastases, are
also sampled at the time of the initial
surgery. A woman with a known diagnosis
vantages of the upright add-on system
include a limited working space, increased
potential for patient motion, and greater
potential for vasovagal reactions, as the
patient can watch the biopsy procedure
(Fig. 21-85). The dedicated prone system
allows the patient to lie face down with
the breast hanging pendulous through a
hole in the table (Figs. 21-86 and 21-87).
This gives the technologists and doctors
more work space underneath the raised
table, and the procedure is out of sight of
the patient. The prone table is more expen-
sive than the add-on system, requires a
larger space, and should not be used for
conventional mammography. It can be
more difficult to locate suspicious lesions
close to the chest wall with the prone table
versus the upright add-on system. But the
success or failure of core needle breast
biopsy ultimately depends more on the

biopsy over open surgical biopsy include
less pain, less scarring, shorter recovery
time, less patient anxiety, and lower cost.
Most women with a mammographic or
clinical breast abnormality are candidates
for stereotactic core needle biopsy. The
of breast cancer may avoid a second
operation.
Two types of mammographic equip-
ment are commercially available for ste-
reotactic biopsy procedures: prone biopsy
tables and upright add-on devices. Disad-
experience and interest of the diagnostic
team, including a radiologist, a mammog-
rapher, a pathologist, and a specially
trained nurse or technologist, than on the
particulars of the system that is used.

+ abnormality

X
– +

–
0

+
breast

biopsy/compression plate
Frontal View

Fig. 21-84  Cartesian coordinates. A Cartesian system identifies the location of a unique
point by three axes intersecting at right angles.

(Reprinted with permission from Willison KM: Fundamentals of stereotactic breast biopsy. In: Fajardo
LL, Willison KM, Pizzutello RJ, eds: A comprehensive approach to stereotactic breast biopsy,
Cambridge, 1996, Blackwell Science, p16.)

466
 Localization and Biopsy of Suspicious Lesions
Fig. 21-85  Upright stereotactic system attached to dedicated mammography unit.

(Courtesy Hologic, Bedford, MA.)

Fig. 21-86  Prone stereotactic biopsy system with digital imaging.

(Courtesy Hologic, Bedford, MA.)

467
 Before beginning the procedure, the
physician reviews the initial mammo-
graphic images to determine the best
approach and projection of the breast to
allow for the shortest distance from the
surface of the skin to the breast lesion. The
biopsy needle should be inserted through
the least amount of tissue, limiting the
amount of trauma to the breast. A lesion
located in the lateral aspect of the UOQ
is approached from the lateral aspect,
whereas a lesion located in the medial and
superior portion of the breast is approached
from above. After the best approach to the
lesion has been determined, the affected
breast is positioned and compressed with
an open compression paddle for a scout
image to localize the breast lesion. Once
the breast lesion has been localized, stereo
images are taken to triangulate the lesion
and measure its X, Y, and Z coordinates Fig. 21-87  Open aperture in table for prone biopsy system allows breast to be positioned
Mammography

(Fig. 21-88). beneath table.

(Courtesy Trex Medical Corp., LORAD Division, Danbury, CT.)

Fig. 21-88  Stereo images showing three-dimensional view of breast lesion before
intervention.

468
 At the computer workstation, the physi-
cian reads the two side-by-side stereotac-
tic images and identifies the center of the
lesion on each image. The computer is
then used to calculate the exact X, Y, and
Z coordinates. At this point the physician
must determine whether the Z value, or
depth of the lesion, is within range for the
biopsy. If the lesion is very deep within
the breast with a high Z value, it may be
appropriate to change the approach and
positioning of the breast to minimize
trauma. If the Z value is too low, the lesion
is very shallow and close to the surface of
the skin; there may not be enough breast
tissue to cover the trough and tip of the
biopsy needle. In this case, another
approach would be justified. Once an
appropriate Z value is found, the physician
transmits the coordinates from the com-
puter workstation to the biopsy table stage
Swift firing of the needle into place and
capturing of specimens from the lesion are
dependent on the type of needle and
retrieval device selected by the physician.
The physician may use a spring-loaded
biopsy device to power the needle back
and forth through the target. After the pre-
fire images verify the needle’s tip adjacent
to the lesion, the needle is fired into the
lesion quickly to penetrate the tissue
without pushing it deeper within the
breast. Once the first pass is made, stereo-
tactic “post-fire” images confirm correct
needle placement. This image determines
the course of subsequent passes. Redigiti-
zation (use of a digitizer to repeat the steps
needed to calculate the new triangulation
coordinates) can be performed to obtain
additional samples. Alternatively, the phy-
sician can estimate where to move the
biopsy needle based on the initial needle
location within the breast. With the needle
located inside the lesion, a sheath, or
needle cover, slides over the trough of the
needle. The sheath cuts the tissue sample
within the trough and holds the sample in
place while the needle is withdrawn.
When the needle is outside the breast, the
sheath is pulled back, exposing the tissue
sample for collection.

Localization and Biopsy of Suspicious Lesions

(Fig. 21-89).
At the biopsy table, the breast is asepti-
cally cleansed to minimize infection, and
the skin is anesthetized at the area where
the biopsy needle enters. The physician
can effectively manage the pain associ-
ated with the procedure by anesthetizing
the tissue within the breast at the biopsy
site. The biopsy needle is then placed on
the stage, which holds it in place and
interprets the coordinates sent by the com-
puter. Next, the tip of the needle must be
zeroed by aligning it with the center refer-
ence point. The needle is then moved into
position within the opening of the com-
pression plate based on the appropriate X
and Y values sent from the workstation. A
small incision is made with a scalpel to Fig. 21-89  Stage of biopsy system supports biopsy gun. X, Y, and Z coordinates are
facilitate entry of the needle into the breast displayed.
and proper positioning of the Z axis.
Before the needle enters the lesion at the
exact Z axis, the needle is “dialed back,”
and “pre-fire” images are obtained with
stereotaxis to ensure proper positioning
(Fig. 21-90).

Fig. 21-90  Pre-fire stereo images showing placement of the biopsy needle adjacent to
calcium to be biopsied.

469
 An alternative technique is vacuum-
assisted core biopsy. The probe is fired
quickly into the lesion with the use of air
pressure. After post-fire images are
acquired, the tissue is gently vacuum-
aspirated through a trough in a rotating
cutter into the probe’s aperture and col-
lected in a basket. With the probe in the
center of the lesion, the cutter can be spun
in a circle to move the trough and collect
samples from every direction without
multiple insertions. When the biopsy is
complete, the cutter is removed, and a
radiopaque clip can be deployed through
the probe and into the biopsy site to mark
the area for future reference.
Radiopaque clips are placed following
most large-core needle biopsies, using
both spring-loaded and vacuum-assisted
devices. The titanium clip serves as a
marker, allowing radiologists to know the
Mammography
location of past biopsies for subsequent
Fig 21-91  Post-biopsy images in standard CC and lateral projections to document
accuracy of biopsy site and marker clip placement.
470
mammograms or for surgical guidance.
Immediately after the clip is seeded,
“post-clip” images are obtained to ensure
proper deployment and placement (Fig.
21-91). After this is done, the patient is
released from compression and is given
follow-up care. The time required to
perform a stereotactic procedure is
approximately 40 to 50 minutes.
With each technique, a minimum of 5
to a maximum of 20 tissue samples are
obtained to ensure proper sampling of the
abnormality. If the abnormality contains
radiopaque calcium, the radiologist may
choose to x-ray the sample to guarantee
the presence of calcium for accurate diag-
nosis. Following this image, the tissue
samples are transferred into a formalin
specimen container for transportation to
the pathology laboratory. For vacuum-
assisted biopsies, a larger amount of tissue
sample is obtained; this has been reported
LCC
to improve accuracy in diagnosing atypi-
cal ductal hyperplasia and ductal carci-
noma in situ lesions.1
After the LCNB procedure is com-
pleted, the breast is cleaned and bandaged
using sterile technique. Compression to
the biopsy site is necessary to prevent
excessive bleeding, and a cold compress
is applied to minimize discomfort and
swelling of related tissues. The patient
should limit strenuous activity and keep
the affected breast immobilized for at least
8 hours to prevent future bleeding or
excessive bruising. The patient may be
asked to return within 24 to 48 hours, so
the breast can be examined to ensure that
no bleeding or infection has occurred. The
physician who performed the biopsy dis-
cusses the biopsy results and subsequent
treatment options, if applicable, with the
patient.
1
Dershaw DD: Equipment, technique, quality assur-
ance, and accreditation for image-guided breast
biopsy procedures, Radiol Clin North Am 38:773,
2000.
LML
Breast Specimen
Radiography
When open surgical biopsy is performed,
the suspected lesion must be contained in
its entirety in the tissue removed during the
biopsy. Very small lesions that are charac-
terized by tissue irregularity or microcalci-
fications on a mammographic image and
that are nonpalpable in the excised speci-
men may be undetectable on visual inspec-
tion; a radiographic image of the biopsied
tissue may be necessary to determine that
the entire lesion has been removed. Com-
pression of the specimen is necessary to
identify lesions, especially lesions that do
not contain calcifications. Magnification
imaging is used to better visualize micro-
calcifications. Specimen radiography is
often performed as an immediate post-
excision procedure while the patient is still
under anesthesia. Speed is essential.
The procedure for handling the speci-
men must be established before the proce-
dure is started. Cooperation among
radiologist, mammographer, surgeon, and
pathologist is imperative. Together, a
system of identifying the orientation of
the tissue sample to the patient’s breast
(anterior, posterior, medial, or lateral
aspect of the sample) can be applied to
help the clinician confirm that the lesion
has been completely removed.q
q
Britton SE et al: Breast surgical specimen radio-
graphs: How reliable are they? Eur J Radiol 79:245,
2011.
Fig. 21-92  Radiograph of surgical specimen
containing suspicious microcalcifications.
The specimen may be imaged using the
magnification technique, with or without
compression, as ordained by the policy of
the facility. As patient radiation exposure
and patient motion are no longer factors,
imaging for high resolution regardless of
dose is appropriate. Exposure factors
depend on the thickness of the specimen
and the imaging modality that is used
(Fig. 21-92). Alternatively, radiographic
equipment is manufactured specifically
for imaging tissue specimens. These units
are self-contained, are often portable, and
allow specimens to be imaged directly in
the operating suite. Digital technology
allows the image to be seen by the surgeon
and the radiologist and the pathologist in
remote locations, almost immediately and
simultaneously.r,s
r
Kim SH et al: An evaluation of intraoperative digital
specimen mammography versus conventional speci-
men radiography for the excision of nonpalpable
breast lesions, Am J Surg S0002-9610(13)00081-0,
2013.
s
Layfield DM et al: The effect of introducing an
in-theatre intra-operative specimen radiography
(IOSR) system on the management of palpable breast
cancer within a single unit, The Breast 21:459, 2012.
Fig 21-93  Magnified radiograph of specimen obtained from core biopsy shown
in Figs. 21-88, 21-90, and 21-91. Note calcium indicating successful biopsy.
The pathologist often uses the specimen
radiograph to precisely locate the area of
concern, so a copy of the image should be
sent with the specimen. The next step is
to match the actual specimen to the speci-
men radiograph before the specimen is
dissected. Marking the area of concern
within the specimen by placing a radi-
opaque object, such as a 1- or 2-inch (2.5-
or 5-cm) needle, directly at the area of
concern helps the pathologist locate the
abnormality more accurately.
Specimens of tissue from large-core
needle biopsies (LCNBs) are frequently
radiographed, particularly when the
biopsy is performed for calcifications.
Radiographing tissue specimens can
confirm that the area of interest has been
sampled and is included within the tissue
sent for examination by the pathologist
(Fig. 21-93).
Breast Specimen Radiography
471

Breast Magnetic
Resonance Imaging
Breast MRI has proved most useful in
patients with proven breast cancer or at
high risk for breast cancer, to assess for
multifocal or multicentric disease, chest
wall involvement, chemotherapy response,
or tumor recurrence, or to identify the
primary site in patients with occult breast
disease.
INDICATIONS
Assessment of extent of disease
and residual disease
MRI can be helpful for patients who have
had a lumpectomy and have positive
margins and no evidence of residual
disease on conventional imaging (mam-
mography, ultrasound). Postoperative
mammography can help detect residual
Mammography
calcifications but is limited for residual
mass. MRI is very sensitive for detection
of residual mass and identifies other
potentially suspicious sites seen only on
MRI.
Assessment of tumor recurrence
Assessment of tumor recurrence on MRI
can be very complicated because scars can
become enhanced for 1 to 2 years after
surgery. Suggestion of recurrence can be
made by MRI, yet the cost of the proce-
dure should be weighed against a less
expensive needle biopsy of the area.
472
Occult primary breast cancer
Patients with axillary metastases suspi-
cious for primary breast cancer with a
negative physical examination, mammo-
gram, and ultrasound are good candidates
for MRI because of its high sensitivity for
invasive cancers. MRI has been shown to
detect 90% to 100% of cancers if tumor is
present in the breast. If the primary site is
detected, the patient may be spared a mas-
tectomy, and MRI can influence patient
surgical management.
Neoadjuvant chemotherapy
response
In patients with advanced breast cancer,
MRI may be used to predict earlier which
patients are responding to chemotherapy.
Mammography and physical examination
can sometimes be limited by fibrosis.
Studies suggest that MRI may be better for
assessing patients’ response to treatment.1
1
Yeh E et al: Prospective comparison of mammogra-
phy, sonography, and MRI in patients undergoing
neoadjuvant chemotherapy for palpable breast
cancer, AJR Am J Roentgenol 184:868, 2005.
High-risk screening
Breast MRI is recommended as an annual
screening examination for patients at high
risk for developing breast cancer.1 These
include women
1. Who have a first-degree relative
(parent, sibling, child) with a BRCA1
or BRCA2 mutation, even if they have
yet to be tested themselves.
2. Whose lifetime risk of breast cancer
has been scored at 20% to 25% or
greater, based on one of several
accepted risk assessment tools that
look at family history and other factors.
3. Who have received radiation to the
chest between 10 and 30 years of age.
4. Who have Li-Fraumeni syndrome,
Cowden syndrome, or Bannayan-
Riley-Ruvalcaba syndrome, or who
may have one of these syndromes
based on history in a first-degree
relative.
A study published in the New England
Journal of Medicine concluded that MRI
is “more sensitive than mammography in
detecting tumors in women with an inher-
ited susceptibility of breast cancer.”2 At
the present time, not all insurance compa-
nies cover breast MRI in these high-risk
women.
Breast MRI is recommended for women
at high risk to be used as an adjunct to
mammography. The most beneficial
method for screening is to schedule
6-month intervals alternating MRI with
mammography. Women who are found to
have MRI-detected foci suspicious of
cancer need to have these verified by
biopsy. Often these areas are reexamined
with mammography and directed ultra-
sound for potential biopsy. If these lesions
are not found by conventional imaging,
confirmation with MRI-guided biopsy
would be necessary before the patient is
committed to potential lumpectomy or
mastectomy or both.
1
American Cancer Society, March 2007.
2
Kriege M et al: Efficacy of MRI and mammography
for breast cancer screening in women with a familial
or genetic predisposition, N Engl J Med 351:427,
2004.
Thermography and
Diaphanography
Beginning in the 1950s, thermography
and diaphanography were actively inves-
tigated in the hope that breast cancer and
other abnormalities could be diagnosed
using nonionizing forms of radiation.
These two diagnostic tools are seldom
used today.
Thermography is the photographic
recording of the infrared radiation ema-
nating from a patient’s body surface. The
resulting thermogram shows areas of
increased temperature, with a temperature
increase often suggesting increased
metabolism. (More complete information
on this technique is provided in the fourth
through eighth editions of this atlas.)
Diaphanography is an examination in
which a body part is transilluminated
using selected light wavelengths and
special imaging equipment. With this
technique, the interior of the breast is
inspected using light directed through its
exterior wall. The light exiting the patient’s
body is recorded and interpreted. Rapid
advances in mammography have essen-
tially eliminated the use of this technique
for evaluating breast disease. (More com-
plete information on diaphanography is
given in this chapter in the fourth through
eighth editions of this atlas.)
Conclusion
Radiographic examination of the breast
is a technically demanding procedure.
Success depends in large part on the skills
of the mammographer—more so than in
most other areas of radiology. In addition
to skill, the mammographer must have a
strong desire to perform high-quality
mammography and must be willing to
work with the patient to allay qualms and
to obtain cooperation. In the course of
taking the patient’s history and physically
assessing and radiographing the breasts,
the mammographer may be asked ques-
tions about breast disease, BSE, screening
guidelines, and breast radiography that the
patient has been reluctant to ask other
health care professionals. The knowledge,
skill, and attitude of the mammographer
may be lifesaving for the patient. Although
Conclusion
most patients do not have significant
breast disease when first examined, statis-
tics show that approximately 12% of
patients develop breast cancer at some
time during their lifetime. An early posi-
tive mammography encounter may make
the patient more willing to undergo mam-
mography in the future. When properly
performed, breast radiography is safe, and
presently, it offers the best hope for sig-
nificantly reducing the mortality of breast
cancer.
473
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 ADDENDUM B
SUMMARY OF ABBREVIATIONS,
VOLUME TWO
AAA abdominal aortic aneurysm GML glabellomeatal line OID object–to–image receptor (IR)
ACR American College of Radiology GSW gunshot wound distance
AML acanthiomeatal line HSG hysterosalpingography OML orbitomeatal line
AP anteroposterior IAM internal acoustic meatus PA posteroanterior
ASRT American Society of Radiologic IOML infraorbitomeatal line PTC percutaneous transhepatic
Technologists IPL interpupillary line cholangiography
BE barium enema IR image receptor RUQ right upper quadrant
BPH benign prostatic hyperplasia IUD intrauterine device SID source–to–image receptor (IR)
BUN blood urea nitrogen IV intravenous distance
CDC Centers for Disease Control and IVP intravenous pyelogram SMV submentovertical
Prevention IVU intravenous urography TEA top of ear attachment
CPR cardiopulmonary resuscitation KUB kidneys, ureters, and bladder TMJ temporomandibular joint
CR central ray MML mentomeatal line UGI upper gastrointestinal
CT computed tomography MPR multiplanar reconstruction UPJ ureteropelvic junction
CTC CT colonography MRI magnetic resonance imaging UVJ ureterovesical junction
CVA cerebrovascular accident MVA motor vehicle accident VC virtual colonoscopy
EAM external acoustic meatus NPO nil per os (nothing by mouth) VCUG voiding cystourethrogram
ED emergency department
ERCP endoscopic retrograde
cholangiopancreatography

475
This page intentionally left blank

A Abdomen (Continued)
AAA (abdominal aortic aneurysm), 2:84t,
3:41
three-dimensional CT of, 3:313f
AAA (abdominal aortic aneurysm) endografts,
3:65-66, 65f-66f
Abbreviations
for contrast arthrography, 2:9b
for digestive system, 2:107b
for general anatomy and radiographic
positioning terminology, 1:98b
for long bone measurement, 2:2b
for lower limb, 1:239b
for pelvis and proximal femora, 1:334b
for preliminary steps in radiography, 1:52b
for shoulder girdle, 1:181b
for skull, 2:284b
for trauma radiography, 2:30b
for upper limb, 1:109b
for urinary system, 2:189b
for vertebral column, 1:379b
in Volume One, 1:521t
in Volume Two, 2:475t
ABC (aneurysmal bone cyst), 3:149, 149f
Abdomen, 2:81-94
abbreviations used for, 2:85b
anatomy of, 2:83, 83f, 84b
AP projection of
in left lateral decubitus position, 2:91,
91f-92f
mobile, 3:198-199, 198f-199f
for trauma, 2:40, 40f
mobile, 3:196, 196f-197f
in left lateral decubitus position, 3:198-199,
198f-199f
in neonate, 3:208-210
evaluation criteria for, 3:210b, 210f
position of part for, 3:208f-209f, 209
position of patient for, 3:208, 208f
structures shown on, 3:210, 210f
in supine position (KUB), 2:87, 89-90,
89f-90f
for trauma, 2:38-39, 38f-39f
in left lateral decubitus position, 2:40, 40f
in upright position, 2:89-90, 89f-90f
in children, 3:112-115
image assessment for, 3:123t
with intussusception, 3:114, 114f
with pneumoperitoneum, 3:115, 115f
positioning and immobilization for,
3:112f-113f, 113
CT of, 3:336f-338f
divisions of, 1:70, 70f
Page numbers followed by “f” indicate figures, “t”
indicate tables, and “b” indicate boxes.
INDEX
exposure technique for, 2:86, 86f
flat and upright images of, 2:87
immobilization for, 2:86, 87f
lateral projection of
in neonate, 3:211-212, 211f-212f
in R or L dorsal decubitus position, 2:94,
94f
in R or L position, 2:93, 93f
mobile radiography of, 3:196-199
AP or PA projection in left lateral decubitus
position for, 3:198-199, 198f-199f
AP projection for, 3:196, 196f-197f
MRI of, 3:360, 360f-361f
of neonate, 3:208-212
AP projection for, 3:208-210
evaluation criteria for, 3:210b, 210f
position of part for, 3:208f-209f, 209
position of patient for, 3:208, 208f
structures shown on, 3:210, 210f
lateral projection for, 3:211-212,
211f-212f
PA projection of, 2:91, 91f
in left lateral decubitus position (mobile),
3:198-199, 198f-199f
positioning protocols for, 2:87
sample exposure technique chart essential
projections for, 2:85t
scout or survey image of, 2:87
sequencing of projections for, 2:87-94,
87f-88f
summary of pathology of, 2:84t
summary of projections of, 2:82, 87
three-way imaging of (acute abdomen series),
2:87
trauma radiography of, AP projection in,
2:38-39, 38f-39f
in left lateral decubitus position, 2:40, 40f
ultrasonography of, 3:376-383, 376f-377f
Abdominal aorta
MR angiography of, 3:364f
sectional anatomy of, 3:282f, 284
in axial (transverse) plane
at Level A, 3:285, 285f
at Level B, 3:285, 286f
at Level C, 3:287f
at Level D, 3:288, 288f
at Level E, 3:289, 289f
at Level F, 3:290, 290f
at Level G, 3:291, 291f
in coronal plane, 3:298-299, 298f-299f
in sagittal plane, 3:297f
Abdominal aortic aneurysm (AAA), 2:84t, 3:41
three-dimensional CT of, 3:313f
Abdominal aortic aneurysm (AAA) endografts,
3:65-66, 65f-66f
Abdominal aortography, 3:41, 41f
Abdominal cavity, 1:68-69, 69f, 2:83
Abdominal circumference, fetal ultrasound for,
3:390, 390f
Abdominal duplex examinations, 3:392
Abdominal fistulae and sinuses, 2:180, 180f
Abdominal viscera, 2:83f
Abdominal wall, ultrasonography of, 3:383
Abdominopelvic cavity, 1:68, 69f, 2:83, 83f
Abdominopelvic region sectional anatomy,
3:282-299
on axial (transverse) plane, 3:284f, 285
at level A, 3:285, 285f
at level B, 3:285, 286f
at level C, 3:287, 287f
at level D, 3:288, 288f
at level E, 3:289, 289f
at level F, 3:290, 290f
at level G, 3:291, 291f
at level H, 3:292, 292f
at level I, 3:293, 293f
at level J, 3:294, 294f
at level K, 3:295, 295f-296f
on cadaveric image, 3:282, 282f
on coronal plane, 3:298f-299f, 299
on sagittal plane, 3:296, 297f
Abduct/abduction, 1:96, 96f
ABI (ankle/brachial index), 3:393, 397
Abscess
breast, 2:395
of epididymis, 2:253f
Absorbed dose
in nuclear medicine, 3:408, 437
in radiation oncology, 3:506-507
AC articulation. See Acromioclavicular (AC)
articulation.
Acanthion, 2:272, 272f-273f, 285f
Acanthioparietal projection
for cranial trauma, 2:46, 46f
of facial bones, 2:327, 327f-328f
for trauma, 2:328, 328f
Accelerated partial-breast irradiation (APBI),
3:504
Accelerators, particle, 3:404, 425, 438, 506
Accessory glands of digestive system, 2:97, 97f
Accessory process, 1:374, 374f
Accountability in code of ethics, 1:3
Acetabulum
anatomy of, 1:327, 327f, 329f-330f
AP oblique projection of (Judet and
modified Judet methods), 1:356-357,
356f-357f
comminuted fracture of, 3:201f
PA axial oblique projection of (Teufel method),
1:354-355, 354f-355f
sectional anatomy of, 3:295-296, 299
Achalasia, 2:109t
Acinus of breast, 2:380
Acoustic impedance, 3:371, 372f, 397-398
Acoustic neuroma, 2:282t, 3:357f
I-1
 Acoustic window in transabdominal
ultrasonography, 3:387, 397
Acromial extremity of clavicle, 1:175, 175f
Acromioclavicular (AC) articulation
Alexander method for AP axial projection of,
1:211-212, 211f-212f
anatomy of, 1:178t, 179f, 181, 181f
Pearson method for bilateral AP projection of,
1:209, 209f-210f
sectional anatomy of, 3:270, 272, 272f
Acromion, 3:272, 273f
Acromion process, 3:272f, 273
Acute abdomen series, 2:87
AD. See Alzheimer disease (AD).
AD (architectural distortion) of breast, 2:393, 393f,
394t-395t
Adam’s apple, 2:72
Adduct/adduction, 1:96, 96f
Adductor tubercle of femur, 1:232f, 233
Adenocarcinomas, 3:483
Adenoids, 2:71f, 72
Adenomatous polyposis coli (APC) gene, 3:483
ADH (atypical ductal hyperplasia), 2:395
Adhesion, 2:245t
Adipose capsule, 2:184
Adjacent structures, 1:5
Adolescent development, 3:104
Adrenal glands
anatomy of, 2:183, 183f
sectional anatomy of, 3:283, 288-289,
Index
288f-289f
ultrasonography of, 3:376f
Adrenaline, 2:226t
Advanced clinical practice, 1:14
Adventitia of arterial wall, 3:65
AEC. See Automatic exposure control (AEC).
Afferent arteriole of kidney, 2:185, 185f
Afferent lymph vessels, 3:26, 96-97
Age-based development, 3:102-104
of adolescents, 3:104
of infants, 3:102
of neonates, 3:102
of premature infants, 3:102
of preschoolers, 3:103, 103f
of school age children, 3:104
of toddlers, 3:103
Age-related competencies in elderly, 3:176
Age-specific competencies, 1:23, 24b, 24t
Aging. See also Elderly.
concept of, 3:164, 164f
demographics and social effects of, 3:162f-164f,
164b, 175
physical, cognitive, and psychosocial effects of,
3:166-168, 167b, 167f
physiology of, 3:168-173
endocrine system disorders in, 3:173
gastrointestinal system disorders in, 3:171,
171f
genitourinary system disorders in, 3:173
hematologic system disorders in, 3:173
immune system decline in, 3:172
integumentary system disorders in, 3:168
musculoskeletal system disorders in, 3:170,
170f-171f
nervous system disorders in, 3:168-169
respiratory system disorders in, 3:172,
172f
sensory system disorders in, 3:169
summary of, 3:173
Air calibration for CT, 3:329, 339-340
Air-contrast study of large intestine, 2:144
Airway foreign body, 2:62t
in children, 3:139, 139f
Ala of sacrum, 1:376, 376f
ALARA. See As low as reasonably achievable
(ALARA).
I-2
Alert value (AV) for CT, 3:330
Alexander method for AP axial projection of
acromioclavicular articulation, 1:211-212,
211f-212f
Algorithm in CT, 3:302, 339
Alimentary canal, 2:97, 97 See also Digestive
system.
Alpha particles, 3:403, 437-439
Alveolar ducts, 1:480f, 481
Alveolar process
anatomy of, 2:272, 273f
sectional anatomy of, 3:254
Alveolar sacs, 1:480f, 481
Alveolar sockets, 2:275t
Alveolus(i)
of breast, 2:381f
of lung, 1:480f, 481
Alzheimer disease (AD), 3:167-168, 174t
performing radiography with, 3:176
PET for, 3:434
stages and symptoms of, 3:177b
American Health Insurance Portability and
Accountability Act of 1996 (HIPAA), 3:460,
476
American Registry of Radiologic Technologists
(ARRT), positioning terminology used by,
1:85-95
American Society of Radiologic Technologists
(ASRT) Code of Ethics, 1:2
Amnion, 2:241
Amniotic cavity, ultrasonography of, 3:388,
389f
Amphiarthroses, 1:81
Ampulla
of breast, 2:381f
of ductus deferens, 2:242, 243f
of uterine tube, 2:239, 239f
Ampulla of Vater
anatomy of, 2:100f, 101, 105, 105f
sectional anatomy of, 3:283
Amyloid neurologic study, 3:434
Anabolic steroids for osteoporosis, 3:448t
Anal canal
anatomy of, 2:102f-103f, 103
defecography of, 2:172, 172f
sectional anatomy of, 3:283
Analogs, radioactive, 3:401-402, 437
Anaphylactic reaction, 2:235
Anastomose, 3:60, 96
Anatomic markers, 1:25, 25f-26f, 27, 27b
Anatomic neck of humerus, 1:104-105, 104f
Anatomic position, 1:8-12, 8f-9f, 66-67, 66f
Anatomic programmers, 1:40, 40f
Anatomic snuffbox, 1:102
Anatomically programmed radiography (APR)
systems with obese patients, 1:52
Anatomy
anatomic relationship terms in, 1:85, 85f
of bones, 1:75-79
appendicular skeleton in, 1:75, 75f, 75t
axial skeleton in, 1:75, 75f, 75t
classification of, 1:79, 79f
development in, 1:77-78, 77f-78f
fractures of, 1:84, 84f
general features in, 1:76, 76f
markings and features of, 1:84
vessels and nerves in, 1:77, 77f
defined, 1:66
general, 1:66-74
of body cavities, 1:68-69, 69f
body habitus in, 1:72-74, 72f, 73b,
74f
body planes in, 1:66-67, 66f-68f
divisions of abdomen in, 1:70, 70f
special planes in, 1:68, 69f
surface landmarks in, 1:71, 71f, 71t
Anatomy (Continued)
of joints, 1:80-82
cartilaginous, 1:80t, 81, 81f
fibrous, 1:80f, 80t, 81
functional classification of, 1:81
structural classification of, 1:80t, 81-82
synovial, 1:80t, 82, 82f-83f
sectional. See Sectional anatomy.
Andren–von Rosén method for congenital
dislocation of hip, 1:345
Anechoic structure or mass, 3:374, 375f, 397
Anemia in older adults, 3:173
Anencephaly, 3:391f
Anesthesia provider, 3:216
Aneurysm, 3:28, 96
of anterior communicating artery, 3:34f
aortic
abdominal, 2:84t, 3:41
endografts for, 3:65-66, 65f-66f
three-dimensional CT of, 3:313f
thoracic, 3:40
cerebral, 3:10f
Aneurysmal bone cyst (ABC), 3:149, 149f
Angina pectoralis, 3:75, 96
Angiocatheters, 2:228f, 229
Angiography, 3:28-39
aortic arch, for cranial vessels, 3:55, 55f
aortic root, 3:82, 83f
aortography as, 3:40-47
abdominal, 3:41, 41f
thoracic, 3:40, 40f, 55f
arteriography as. See Arteriography.
catheterization for, 3:36-38, 37f-38f
cerebral. See Cerebral angiography.
contrast media for, 3:29
coronary, 3:40f, 75
for cardiac catheterization, 3:84, 85f, 85t
for percutaneous transluminal coronary
angioplasty, 3:88, 88f-89f
procedures that may accompany, 3:76, 76t
CT. See Computed tomography angiography
(CTA).
defined, 3:18, 28, 96
definition of terms for, 3:96b-97b
digital subtraction. See Digital subtraction
angiography (DSA).
electron beam, 3:95
future of, 3:39
guidewires for, 3:35, 35f
historical development of, 3:20-21
indications for, 3:28
injection techniques for, 3:29
introducer sheaths for, 3:36, 36f
magnetic resonance, 3:363-364, 363f-364f
magnification in, 3:33
needles for, 3:35, 35f
patient care for, 3:38
peripheral, 3:46
lower limb arteriograms as, 3:47, 48f
lower limb venograms as, 3:47, 48f
upper limb arteriograms in, 3:46, 46f
upper limb venograms as, 3:46, 46f
preparation of examining room for, 3:39
radiation protection for, 3:39
radionuclide, 3:416
renal, 2:190, 191f
surgical, 3:74
team for, 3:39
three-dimensional intraarterial, 3:34, 34f
venography as. See Venography.
Angioplasty, percutaneous transluminal. See
Percutaneous transluminal angioplasty
(PTA).
Angle of incidence, 3:397
Angular notch of stomach, 2:98f
Anisotropic spatial resolution, 3:339
Ankle Anteroposterior (AP) projection, 1:10-11, 10f, 86, Archiving for CT, 3:309, 339
AP oblique projection of 87f Arcuate eminence, 2:269f
with knee included, 1:294-295, 294f-295f entry and exit points for, 1:86, 86f Arcuate line, 1:328
in lateral rotation, 1:286, 286f Anthracosis, 1:486t Areal technique, DXA as, 3:453, 477
in medial rotation, 1:283, 283f Anthropomorphic, 3:476-477 Areola, 2:380, 381f
AP projection of, 1:279, 279f Antiarrhythmia device implantation, 3:94, Arm. See Upper limb.
with knee included, 1:290-291, 290f-291f 94f Array-beam techniques, for DXA, 3:444, 454-457,
stress method for, 1:287, 287f Antisepsis, 3:250 454f, 476
weight-bearing method for, 1:288-289, Antiseptics, 1:16 Arrhythmia, 3:96
288f-289f Anus Arrhythmogenic, 3:96
lateral projection of anatomy of, 2:102f-103f, 103 ARRT (American Registry of Radiologic
lateromedial, 1:282, 282f sectional anatomy of, 3:283 Technologists), positioning terminology used
mediolateral, 1:280, 280f-281f ultrasonography of, 3:386f by, 1:85-95
with knee included, 1:292-293, Aorta Arterialized venous blood in PET, 3:430, 437
292f-293f abdominal. See Abdominal aorta. Arteries, 3:22f, 23
mortise joint of anatomy of, 3:22f, 25 coronary, 3:25, 25f
anatomy of, 1:230f-231f, 236t, 238 ascending, 3:22f, 25 defined, 3:96
AP oblique projection in medial rotation of, aortography of, 3:40f pulmonary, 3:22f, 23
1:284-289, 284f-285f sectional anatomy of, 3:270-271, 275-277 systemic, 3:23
MRI of, 3:363f on axial (transverse) section, 3:276f Arteriography, 3:28
surgical radiography of, 3:246f-247f on coronal section, 3:281f defined, 3:96
Ankle joint on sagittal section, 3:278-279, 280f peripheral
anatomy of, 1:230f-231f, 238 descending, 3:25, 25f lower limb, 3:47, 48f
AP oblique projection in medial rotation of, aortography of, 3:40f upper limb, 3:46, 46f
1:284-289, 284f-285f sectional anatomy of, 3:270-271, 271f pulmonary, 3:42, 42f
Ankle mortise on axial (transverse) section, 3:275-278, visceral, 3:42-45, 42f
anatomy of, 1:230f-231f, 236t, 238 276f, 278f celiac, 3:43, 43f
AP oblique projection in medial rotation of, on coronal section, 3:281, 281f hepatic, 3:43, 43f
1:284-289, 284f-285f on sagittal section, 3:279-280, 280f inferior mesenteric, 3:44, 45f
Ankle/brachial index (ABI), 3:393, 397 sectional image of, 2:107f other, 3:45

Ankylosing spondylitis, 1:331t, 380t
Annihilation radiation photons, 3:421-424, 421f,
437
Annotation, 1:25
Annulus fibrosus
anatomy of, 1:368
sectional anatomy of, 3:269-270
Anode heel effect, 3:186-187, 186t
Anomaly, 3:96
Antenna coil in MRI, 3:354, 354f
Antenna in MRI, 3:343, 367-368
Anterior, 1:85
Anterior arches of soft palate, 2:59, 59f
Anterior cerebral arteries
CT angiography of, 3:325f
MR angiography of, 3:363f
sectional anatomy of, 3:255, 257-258, 257f-259f,
260-261
Anterior cervical diskectomy, 3:227, 227f
Anterior clinoid processes
anatomy of, 2:258f, 264f-265f, 265
sectional anatomy of, 3:260f, 261-262
Anterior communicating artery
anatomy of, 3:51
aneurysm of, 3:34f
CT angiography of, 3:325f
Anterior cranial fossa, 2:260
Anterior crest of tibia, 1:230, 230f
Anterior cruciate ligament, 1:234f
Anterior facial artery and vein, 3:22f
Anterior fat pad of elbow, 1:107, 107f
Anterior fontanel, 2:259-260, 260f
Anterior horn, 3:4, 4f
Anterior inferior iliac spine, 1:327f, 328
Anterior nasal spine, 2:272, 272f-273f, 332f
Anterior superior iliac spine (ASIS)
anatomy of, 1:71f, 71t, 327f, 328, 330f
as bony landmark, 1:333, 333f
with obese patients, 1:47-49
sectional anatomy of, 3:293
Anterior tibial artery
anatomy of, 3:22f
arteriography of, 3:48f
Anterior tubercle of tibia, 1:231, 231f
Anteroposterior (AP) oblique projection,
1:88
thoracic, sectional anatomy of, 3:270-271,
278-280, 278f-279f
ultrasonography of, 3:376f, 380f
Aortic aneurysm
abdominal, 2:84t, 3:41
endografts for, 3:65-66, 65f-66f
three-dimensional CT of, 3:313f
thoracic, 3:40
Aortic arch
anatomy of, 3:22f, 25, 25f, 49f
angiography for cranial vessels of, 3:55, 55f
MR angiography of, 3:364f
sectional anatomy of, 3:270-271
on axial (transverse) plane, 3:275
on coronal plane, 3:280-281, 281f
on sagittal plane, 3:278-280, 280f
Aortic artery, 3:280f
Aortic dissection, 3:40, 96
Aortic root angiography, 3:82, 83f
Aortic valve
anatomy of, 3:25, 25f
sectional anatomy of, 3:270
Aortofemoral arteriography, 3:47, 48f
Aortography, 3:40-47
abdominal, 3:41, 41f
defined, 3:96
thoracic, 3:40, 40f, 55f
APBI (accelerated partial-breast irradiation),
3:504
APC (adenomatous polyposis coli) gene, 3:483
APDs (avalanche photodiodes), 3:409
Aperture diameter, maximum, 1:44-45, 45t
Aperture in CT, 3:310, 339
Appendicitis, 2:109t
Appendicular skeleton, 1:75, 75f, 75t
Apple method for AP oblique projection of glenoid
cavity, 1:190-191, 190f-191f
APR (anatomically programmed radiography)
systems with obese patients, 1:52
Aquaplast mask, 3:490f
Arachnoid
anatomy of, 3:3, 18
sectional anatomy of, 3:254
Arachnoid cisterns, 3:3
Architectural distortion (AD) of breast, 2:393,
393f, 394t-395t
Index
renal, 2:190, 191f, 3:45, 45f
splenic, 3:44, 44f
superior mesenteric, 3:44, 44f
Arterioles, 3:23, 96
Arteriosclerotic, 3:96
Arteriotomy, 3:96
Arteriovenous malformation, 3:96
Arthritis, rheumatoid, 1:109t, 182t
Arthrography, 1:82
contrast. See Contrast arthrography.
Arthrology, 1:80-82
of cartilaginous joints, 1:80t, 81, 81f
defined, 1:80
of fibrous joints, 1:80f, 80t, 81
functional classification of joints in, 1:81
structural classification of joints in, 1:80t,
81-82
of synovial joints, 1:80t, 82, 82f-83f
Arthroplasty, in older adults, 3:170, 171f
Articular capsule, 1:82, 82f
Articular cartilage, 1:76, 76f
of vertebrae, 1:368
Articular pillars. See Vertebral arch.
Articular processes, of vertebral arch, 1:368,
368f
Articular tubercle
anatomy of, 2:268, 268f
axiolateral oblique projection of, 2:352f
Artifacts
with children, 3:110-111, 110f-111f
in CT, 3:319, 319f-320f, 339
on MRI, 3:356, 367
in ultrasonography, 3:374, 375f
As low as reasonably achievable (ALARA), 1:2
in DXA, 3:458, 476
in nuclear medicine, 3:407
Asbestosis, 1:486t
Ascites, 2:84t
ASDs (autism spectrum disorders), 3:105-107,
105t
Asepsis, 1:15, 3:250
in mobile radiography, 3:191
Aseptic technique, 3:250
for minor surgical procedures in radiology
department, 1:17, 17f
in surgical radiography, 3:220, 220b

I-3
 ASIS. See Anterior superior iliac spine (ASIS).
Aspiration, 1:486t
Aspiration pneumonia, 1:486t
ASRT (American Society of Radiologic
Technologists) Code of Ethics, 1:2
Asterion, 2:258f, 259
Asthenic body habitus, 1:72-74, 72f, 73b, 74f
and gallbladder, 2:106, 106f
skull radiography with, 2:289f
and stomach and duodenum, 2:99, 99f,
125f
and thoracic viscera, 1:479f
Asymmetric jaws of linear accelerators, 3:488f,
489, 506
AT. See Axillary tail (AT).
ATCM (automatic tube current modulation), 3:331,
331f
Atelectasis, 1:486t
Atherectomy, 3:96
Atherectomy devices, 3:90, 90f-91f
Atheromatous plaque, 3:75, 96
Atherosclerosis, 3:28, 96
echocardiography of, 3:393
in older adults, 3:170-171, 174t
Atherosclerotic stenosis, balloon angioplasty of,
3:63f, 64-65
Atlantoaxial joint, 1:378, 379t
Atlantooccipital joint, 1:369f, 378, 379t, 2:266f,
275t
Atlas
Index
Automatic tube current modulation (ATCM),
3:331, 331f
AV (alert value) for CT, 3:330
Avalanche photodiodes (APDs), 3:409
Axial image in CT, 3:302, 339
Axial plane, 1:66, 66f-67f
in sectional anatomy, 3:252
Axial projection, 1:86-87, 87f
Axial resolution in ultrasonography, 3:397
Axial skeletal measurements, 3:469-471,
469f-471f
Axial skeleton, 1:75, 75f, 75t
Axilla, labeling codes for, 2:403t-408t
Axillary arteries, 3:270-271, 273f, 281f
Axillary lymph nodes
anatomy of, 2:380, 381f, 3:27f
mammographic findings for, 2:387
Axillary prolongation. See Axillary tail (AT).
Axillary tail (AT)
anatomy of, 2:380f, 437f
axillary projection of, 2:452-453, 452f-453f
labeling codes for, 2:403t-408t
mediolateral oblique projection of, 2:412f, 432t,
450-451, 450f-451f
Axillary veins, 3:271, 273f, 280-281
Axiolateral projection, 1:88
Axis
anatomy of, 1:369, 369f
AP projection (open mouth) of, 1:384-385,
384f-385f
Barrett esophagus, 2:109t
Basal ganglia, 3:254-255
Basal nuclei, 3:254-255, 258-259, 267
Basal skull fracture, 2:282t
Basilar artery
CT angiography of, 3:325f
MR angiography of, 3:363f
sectional anatomy of, 3:255
on axial (transverse) plane, 3:259f-260f,
260-263, 262f
on sagittal plane, 3:264-265
Basilar portion of occipital bone, 2:266-267,
266f-267f
Basilic vein, 3:22f
anatomy of, 3:22f
venography of, 3:46f
BAT (B-mode acquisition technology), 3:497
BE. See Barium enema (BE).
Beam collimation in CT, 3:331-332, 332t-333t
Beam hardening artifact in CT, 3:319, 319f
Beam hardening with energy-switching systems for
DXA, 3:452
Beam-shaping filters for CT, 3:329-330, 329f
Béclère method for AP axial projection of
intercondylar fossa, 1:310, 310f
Becquerel (Bq), 3:405, 437
Benadryl (diphenhydramine hydrochloride),
2:226t
Benign prostatic hyperplasia (BPH), 2:188t
in older adults, 3:173, 174t

anatomy of, 1:369, 369f
AP projection (open mouth) of, 1:384-385,
384f-385f
AP tomogram of, 1:385, 385f
lateral projection of, 1:386, 386f
sectional anatomy of, 3:267-268
Atom
components of, 3:403
defined, 3:400, 437
Atomic number, 3:403, 403f
Atrial septal defect, balloon septoplasty for, 3:93,
93f
Atrioventricular valve, 3:25f
Atrium(ia)
anatomy of, 3:24-25, 25f, 96
sectional anatomy of, 3:270, 271f
on axial (transverse) plane, 3:278, 278f
on coronal plane, 3:280-281, 281f
on sagittal plane, 3:278-280, 280f
Atropine sulfate (Atropine), 2:226t
Attenuation
in CT, 3:339
in MRI vs. conventional radiography, 3:342,
367
in radiation oncology, 3:494, 506
in ultrasonography, 3:397
Attenuation coefficients, 3:402, 437
Attire of patient, 1:20, 20f
Atypical ductal hyperplasia (ADH), 2:395
Atypical lobular hyperplasia, 2:395
Auditory ossicles, 2:269f-270f, 271
Auditory tube, 2:270f, 271
Auricle
cardiac, 3:24
of ear
anatomy of, 2:270f, 271, 285f
sectional anatomy of, 3:260f, 261-262
Auricular surface
of ilium, 1:327f, 328
of sacrum, 1:376, 376f
Autism spectrum disorders (ASDs), 3:105-107,
105t
Automatic collimation, 1:32
Automatic exposure control (AEC), 1:38, 42
for mammography, 2:409
with obese patients, 1:52
AP tomogram of, 1:385, 385f Bennett fracture, 1:109t
lateral projection of, 1:386, 386f Beta emitters, 3:422f
sectional anatomy of, 3:267-268 Beta particles, 3:403, 437
Azygos vein, 3:271, 271f, 278, 279f, 285, Betatron, 3:506
285f Bezoar, 2:109t
BGO (bismuth germanium oxide) as scintillator for
B PET, 3:428t, 437
Baby box, 3:119-120, 119f-120f Biceps brachii muscle, 1:180f
Backboard in trauma radiography, 2:23, 23f Bicipital groove
Bacterial pneumonia, 1:486t anatomy of, 1:104f, 105
Ball and socket joint, 1:82, 83f Fisk modification for tangential projection of,
Ball-catcher’s position for AP oblique projection in 1:207-208, 207f-208f
medial rotation of hand, 1:130-131 Bicornuate uterus, 2:247f
evaluation criteria for, 1:131b Bicuspid valve, 3:25f
position of part for, 1:130-131, 131f Bifurcation, 3:96
position of patient for, 1:130 Bile, 2:104
structures shown on, 1:131, 131f Bile ducts, 2:97f, 104f-105f, 105
Balloon angioplasty, 3:20, 62-63, 63f Biliary drainage procedure, 2:175, 175f
Balloon kyphoplasty for osteoporotic fractures, Biliary stenosis, 2:109t
3:449, 449f Biliary tract
Balloon septoplasty, 3:93, 93f anatomy of, 2:97f, 104f-106f, 105
Barium enema (BE) biliary drainage procedure and stone extraction
double-contrast method for, 2:144, 144f, for, 2:175, 175f
150-153 cholangiography of
single-stage, 2:144, 150, 150f-151f percutaneous transhepatic, 2:174-175, 174f
two-stage, 2:144 postoperative (T-tube), 2:176-177, 176f-177f
Wellen method for, 2:152-153, 152f-153f endoscopic retrograde cholangiopancreatography
insertion of enema tip for, 2:148 of, 2:178, 178f-179f
preparation and care of patient for, 2:147 prefixes associated with, 2:173, 173t
preparation of barium suspensions for, 2:147 radiographic techniques for, 2:173
single-contrast, 2:144, 144f, 148-149, ultrasonography of, 3:373f, 378, 379f
148f-149f Biochemical markers of bone turnover, 3:448,
standard apparatus for, 2:146, 146f-147f 476
Barium studies Biometric measurements, fetal ultrasound for,
of esophagus, 1:483, 483f, 506f 3:390, 390f
of heart Biopsy, 3:480, 506
lateral projection for, 1:503 Biparietal diameter (BPD), 3:390, 390f, 397
PA oblique projection for, 1:505, 507 Biplane, 3:96
PA projection for, 1:499 Bismuth germanium oxide (BGO) as scintillator
Barium sulfate for PET, 3:428t, 437
for alimentary canal imaging, 2:111, 111f Bisphosphonates for osteoporosis, 3:448t
high-density, 2:144 Bit, 3:437
Barium sulfate suspension Bit depth in CT, 3:308
for alimentary canal imaging, 2:111, Black lung, 1:486t
111f-112f Bladder. See Urinary bladder.
for barium enema, 2:147 Bladder carcinoma, 2:188t

I-4
Bloch, Felix, 3:342 Body rotation method for PA oblique projection Bone mineral content (BMC), 3:442, 476
Blood, handling of, 1:16, 16b of sternoclavicular articulations, 1:465, Bone mineral density (BMD), 3:442, 476
Blood oxygen level dependent (BOLD) imaging, 465f calculation of, 3:453
3:366 Bohr atomic number, 3:403, 403f Bone remodeling, 3:445-446, 445f, 476
Blood pool agents for MRI, 3:355 BOLD (blood oxygen level dependent) imaging, Bone resorption, 3:445, 445f
Blood-brain barrier, 3:417, 437 3:366 Bone scan, 3:415-416
Blood-vascular system, 3:22-26, 22f Bolus chase method for digital subtraction Bone scintigraphy, 3:415-416
arteries in, 3:22f, 23 angiography, 3:30-31 Bone studies, 3:416
coronary, 3:25, 25f Bolus in CT angiography, 3:324, 339 Bone turnover, biochemical markers of, 3:448,
pulmonary, 3:22f, 23 Bone(s), 1:75-79 476
systemic, 3:23 appendicular skeleton of, 1:75, 75f, 75t Bone windows, 3:11, 11f
arterioles in, 3:23 axial skeleton of, 1:75, 75f, 75t Bony labyrinth, 2:271
capillaries in, 3:23-24 biology of, 3:445-446 Bony thorax, 1:445-476
complete circulation of blood through, 3:24 classification of, 1:79, 79f anatomy of, 1:447-453
defined, 3:96 compact (cortical), 1:76, 76f anterior aspect of, 1:447f
heart in, 3:23-24, 25f and bone densitometry, 3:445, 445t anterolateral oblique aspect of, 1:447f
main trunk vessels in, 3:23 defined, 3:476 articulations in, 1:449-453, 449t, 450f
portal system in, 3:23, 23f development of, 1:77-78, 77f-78f lateral aspect of, 1:448f
pulmonary circulation in, 3:23, 23f flat, 1:79, 79f ribs in, 1:447f-449f, 448
systemic circulation in, 3:23, 23f fractures of. See Fracture(s). sternum in, 1:447-448, 447f
veins in, 3:22f, 23 functions of, 1:75 summary of, 1:453b
coronary, 3:25, 25f general features of, 1:76, 76f body position for, 1:453
pulmonary, 3:22f, 23 irregular, 1:79, 79f function of, 1:447
systemic, 3:24 long, 1:79, 79f respiratory movement of, 1:451, 451f
velocity of blood circulation in, 3:26 markings and features of, 1:84 diaphragm in, 1:452, 452f
venules in, 3:23 sesamoid, 1:79, 79f ribs in. See Ribs.
Blowout fracture, 2:46f, 282t, 313, 313f short, 1:79, 79f sample exposure technique chart essential
Blunt trauma, 2:19 spongy, 1:76, 76f projections for, 1:455t
BMC (bone mineral content), 3:442, 476 trabecular (cancellous) sternoclavicular articulations of
BMD (bone mineral density), 3:442, 476 and bone densitometry, 3:445, 445t anatomy of, 1:449, 449t

Index
calculation of, 3:453 defined, 3:477 PA oblique projection of
BMI (body mass index), 1:44 in osteoporosis, 3:446f body rotation method for, 1:465,
B-mode acquisition technology (BAT), 3:497 vessels and nerves of, 1:77, 77f 465f
Body cavities, 1:68-69, 69f Bone cyst, 1:109t, 240t central ray angulation method for,
Body composition dual energy x-ray aneurysmal, 3:149, 149f 1:466, 466f-467f
absorptiometry, 3:442f, 471, 472f, 476 Bone densitometry, 3:441-478 PA projection of, 1:464, 464f
Body fluids, handling of, 1:16, 16b bone biology and remodeling and, 3:445-446, sternum in. See Sternum.
Body habitus, 1:72-74, 72f, 73b, 74f 445f-446f, 445t summary of pathology of, 1:454t
and body position for skull radiography central (or axial) skeletal measurements in, summary of projections for, 1:446
in horizontal sagittal plane, 2:289f 3:469-471, 469f-471f in trauma patients, 1:453
in perpendicular sagittal plane, 2:290f defined, 3:442, 476 Boomerang contact filter
and gallbladder, 2:106, 106f definition of terms for, 3:476b-477b applications of, 1:60t, 63-64, 63f
and stomach and duodenum, 2:99, 99f dual photon absorptiometry (DPA) for, 3:444, composition of, 1:57
PA projection of, 2:124, 125f 476 example of, 1:56f
and thoracic viscera, 1:479, 479f DXA for. See Dual energy x-ray absorptiometry placement of, 1:58, 58f
Body mass index (BMI), 1:44 (DXA). shape of, 1:57
Body movement, 1:96-97 fracture risk models in, 3:475 Bowel obstruction, 2:84t
abduct or abduction as, 1:96, 96f history of, 3:443-444, 444f Bowel preparation, 1:18
adduct or adduction as, 1:96, 96f and osteoporosis, 3:442, 447-450, 448t Bowing fractures, 3:130
circumduction as, 1:97, 97f bone health recommendations for, 3:450, Bowman capsule, 2:185, 185f
deviation as, 1:97, 97f 450t Bowtie filters for CT, 3:329-330, 329f
dorsiflexion as, 1:97, 97f defined, 3:477 Boxer fracture, 1:109t
evert/eversion as, 1:96, 96f fractures and falls due to, 3:449, 449f BPD (biparietal diameter), 3:390, 390f,
extension as, 1:96, 96f pediatric, 3:473-474, 473f 397
flexion as, 1:96, 96f peripheral skeletal measurements in, 3:474-475, BPH (benign prostatic hyperplasia), 2:188t
hyperextension as, 1:96, 96f 474f-475f in older adults, 3:173, 174t
hyperflexion as, 1:96, 96f principles of, 3:442-443, 442f Bq (becquerel), 3:405, 437
invert/inversion as, 1:96f quantitative computed tomography (QCT) for, Brachial artery
plantar flexion as, 1:97, 97f 3:444, 469, 469f, 477 anatomy of, 3:22f, 49f
pronate/pronation as, 1:97, 97f radiogrammetry for, 3:443, 477 arteriography of, 3:46f
rotate/rotation as, 1:97, 97f radiographic absorptiometry for, 3:443, 477 Brachiocephalic artery, 3:96
supinate/supination as, 1:97, 97f single photon absorptiometry (SPA) for, 3:444, anatomy of, 3:49f, 50
tilt as, 1:97, 97f 444f, 477 arteriography of, 3:40f
Body planes, 1:66-67 vertebral fracture assessment in, 3:469-470, sectional anatomy of, 3:270-271, 273-275, 274f,
coronal, 1:66, 66f-67f 470f-471f, 477 280-281, 281f
in CT and MRI, 1:67, 67f Bone formation, 3:445, 445f Brachiocephalic vein
horizontal (transverse, axial, cross-sectional), Bone health, recommendations for, 3:450, sectional anatomy of, 3:271
1:66, 66f-67f 450t on axial (transverse) plane, 3:273-275,
imaging in several, 1:67, 68f Bone marrow 273f-274f
interiliac, 1:68, 69f red, 1:76, 76f on coronal plane, 3:280-281, 281f
midcoronal (midaxillary), 1:66, 66f yellow, 1:76, 76f venography of, 3:60f
midsagittal, 1:66, 66f Bone marrow dose, 1:35, 35t Brachycephalic skull, 2:286, 286f
oblique, 1:66f-67f, 67 Bone mass Brachytherapy, 3:485, 506
occlusal, 1:68, 69f defined, 3:476 Bradyarrhythmia, 3:96
sagittal, 1:66, 66f-67f low, 3:447, 457, 476-477 Bradycardia, 3:96
special, 1:68, 69f peak, 3:446, 477 Bragg peak, 3:505

I-5
 Brain
anatomy of, 3:2, 2f
CT angiography of, 3:10f, 324-326, 325f
perfusion study for, 3:324-326, 326f
CT of, 3:10, 10f-11f, 315f
defined, 3:18
magnetic resonance spectroscopy for, 3:365,
365f
MRI of, 3:12, 13f, 357, 357f
PET of, 3:432f, 434
plain radiographic examination of, 3:5
sectional anatomy of, 3:254
SPECT study of, 3:411f, 417
vascular and interventional procedures of,
3:14-16, 14f-15f
ventricular system of, 3:2, 4, 4f
Brain perfusion imaging, 3:417
Brain stem
anatomy of, 3:2, 2f
sectional anatomy of, 3:255, 264
Brain tissue scanner, 3:305
BRCA1 gene, 2:378-379, 3:482
BRCA2 gene, 2:378-379, 3:482
Breast(s)
anatomy of, 2:380, 380f-381f, 394b
axillary tail of
anatomy of, 2:380f, 437f
axillary projection of, 2:452-453,
452f-453f
mediolateral oblique projection of, 2:412f,
Index
432t, 450-451, 450f-451f
connective tissue of, 2:381f, 382
density of, 2:383, 383f
digital breast tomosynthesis (3D imaging) of,
2:374-375
ductography of, 2:459-460, 459f-460f
fatty tissue of, 2:381f, 382
glandular tissue of, 2:382
involution of, 2:380
localization and biopsy of suspicious lesions of,
2:461-470
breast specimen radiography in, 2:471, 471f
for dermal calcifications, 2:464
material for, 2:461, 461f
stereotactic imaging and biopsy procedures
for, 2:465-470
calculation of X, Y, and Z coordinates in,
2:465, 465f-466f, 469, 469f
equipment for, 2:466, 467f-468f
images using, 2:468, 468f-470f
three-dimensional localization with, 2:465,
465f
tangential projection for, 2:464
MRI of, 2:418-419, 472, 3:358, 359f
oversized, 2:400, 401f
pathology of, 2:384-393
architectural distortions as, 2:393, 393f,
394t-395t
calcifications as, 2:389-393, 389f-392f
masses as, 2:384-388, 394t-395t
circumscribed, 2:384, 385f, 394
density of, 2:384, 386f
indistinct, 2:384, 394
interval change in, 2:387, 387f
location of, 2:387
margins of, 2:384, 394t-395t
palpable, 2:409, 429-430, 443
radiolucent, 2:384, 386f
seen on only one projection, 2:388,
388f
shape of, 2:384
spiculated, 2:384, 385f, 394
summary of, 2:394t-395t
during pregnancy and lactation, 2:382,
382f
radiography of. See Mammography.
I-6
Breast(s) (Continued)
in radiography of sternum, 1:456
thermography and diaphanography of, 2:473
tissue variations in, 2:382-393, 382f-383f
ultrasonography of, 2:418-419, 3:375f, 383, 384f
xerography of, 2:372, 372f
Breast abscess, 2:395
Breast augmentation
complications of, 2:418
mammography with, 2:417-419, 418f
craniocaudal (CC) projection of
with full implant, 2:420-421, 421f
with implant displaced, 2:422-423,
422f-423f
with implant displacement (ID), 2:403t-408t
mediolateral oblique (MLO) projection of
with full implant, 2:424
with implant displaced, 2:425
MRI with, 2:418-419
ultrasonography with, 2:418-419
Breast cancer
architectural distortion due to, 2:393f
calcifications in, 2:392f
genetic factors in, 3:482
in men, 2:426
prophylactic surgery for, 3:482, 507
radiation oncology for, 3:504, 504f
risk factors for, 2:378-379
ultrasonography of, 3:375f
Breast cancer screening, 2:377
vs. diagnostic mammography, 2:378
high-risk, 2:472
risk vs. benefit of, 2:377-378, 377f
Breast specimen radiography, 2:471, 471f
Breastbone. See Sternum.
Breathing, 1:451, 451f
for chest radiographs, 1:490, 490f
diaphragm in, 1:452, 452f
in radiography of ribs, 1:468
in radiography of sternum, 1:456, 457f
for trauma radiography, 2:30
Breathing technique, 1:41
Bregma, 2:258f-259f, 259
Bridge of nose, 2:272
Bridgeman method for superoinferior axial inlet
projection of anterior pelvic bones, 1:359,
359f
Broad ligaments, 3:284
Broadband ultrasound attenuation (BUA), 3:475
Bronchial tree, 1:480, 480b, 480f
Bronchiectasis, 1:486t
Bronchioles, 1:480, 480f
terminal, 1:480, 480f
Bronchitis, 1:486t
chronic, in older adults, 3:172
Bronchomediastinal trunk, 3:26
Bronchopneumonia, 1:486t
Bronchopulmonary segments, 1:482
Bronchoscopy, 3:226
Bronchus(i)
mainstem, 1:480f
primary, 1:480, 480f
secondary, 1:480, 480f
sectional anatomy of, 3:270, 275-277, 276f, 279,
280f-281f
tertiary, 1:480, 480f
BUA (broadband ultrasound attenuation), 3:475
Buckle fracture, 1:109t
Bucky grid with obese patients, 1:51
Built-in DR flat-panel IR detector position, 1:28f
Bulbourethral glands, 2:242
“Bunny” technique
for gastrointestinal and genitourinary studies,
3:116f
for limb radiography, 3:127, 127f
for skull radiography, 3:132, 133f
Burman method for first CMC joint of thumb,
1:120-121, 120f-121f
Bursae, 1:82, 82f, 178
of shoulder, 1:178, 178f
Bursitis, 1:109t, 182t
Butterfly sets, 2:228f, 229
Byte, 3:437
C
11
C (carbon-11) in PET, 3:425f, 426t
CAD (computer-aided detection) systems for
mammography, 2:376-379, 376f
Cadaveric sections, 3:252
Calcaneal sulcus, 1:229, 229f
Calcaneocuboid articulation, 1:236f-237f, 236t,
238
Calcaneus
anatomy of, 1:228f-229f, 229
axial projection of
dorsoplantar, 1:272, 272f-273f
plantodorsal, 1:271, 271f
weight-bearing coalition (Harris-Beath)
method for, 1:273, 273f
lateromedial oblique projection
(weight-bearing) of, 1:275, 275f
mediolateral projection of, 1:274, 274f
Calcifications of breast, 2:389-393, 389f-392f,
394t-395t
amorphous or indistinct, 2:391, 392f, 394
arterial (vascular), 2:389f-390f, 395
coarse heterogeneous, 2:389f-390f, 391,
394
fine heterogeneous, 2:391, 392f, 394
linear branching, 2:392f
male, 2:427
milk of calcium as, 2:391, 391f, 395
pleomorphic linear, 2:392f
popcorn-type, 2:389f-390f, 395
rim, 2:395
rodlike secretory, 2:389f-390f
round or punctate, 2:389f-390f, 394
skin (dermal), 2:395, 464
Calcitonin for osteoporosis, 3:448t
Calcium and osteoporosis, 3:447, 450, 450t
Calculus, 2:62t
renal, 2:188t, 190f
Caldwell method
for PA axial projection of facial bones,
2:329-330, 329f-330f
for PA axial projection of frontal and anterior
ethmoidal sinuses, 2:360-361, 360f-361f
in children, 3:136, 136f
for PA axial projection of skull, 2:296-300
evaluation criteria for, 2:299b
position of part for, 2:296, 297f
position of patient for, 2:296
structures shown on, 2:298f, 299
Calvaria, 2:257
Camp-Coventry method for PA axial projection of
intercondylar fossa, 1:308, 308f-309f
Canadian Association of Medical Radiation
Technologists (CAMRT)
Code of Ethics of, 1:2-3
positioning terminology used by, 1:85-95
Cancellous bone
and bone densitometry, 3:445, 445t
defined, 3:477
in osteoporosis, 3:446f
Cancer, 3:481-483
defined, 3:481, 506
epidemiology of, 3:481
metastasis of, 3:481, 507
most common types of, 3:482, 482t
PET imaging of, 3:433, 433f
radiation oncology for. See Radiation
oncology.
Cancer (Continued)
recurrence of, 3:480
risk factors for, 3:482-483, 482t
tissue origins of, 3:483, 483t
TNM classification of, 3:483, 483t
Cancericidal doses, 3:480, 506
Canthomeatal (CM) line, 3:437
Capillaries, 3:23-24, 26
Capitate, 1:101f-102f, 102
Capitulum, 1:104, 104f
Carbon dioxide (CO2) as contrast medium,
3:29
Carbon-11 (11C) in PET, 3:425f, 426t
Carcinogens, 3:482, 482t, 506
Carcinoma, 2:109t, 3:483, 506
Cardia of stomach, 2:98, 98f
Cardiac catheterization, 3:75-97
for advanced diagnostic studies
of conduction system, 3:86-88, 87f
of vascular system, 3:86, 86f-87f
for basic diagnostic studies of vascular system,
3:82-86
in adults, 3:82-86
in children, 3:86
of coronary arteries, 3:84, 85f, 85t
with exercise hemodynamics, 3:86
of left side of heart, 3:82, 83f-84f
of right side of heart, 3:84
catheter introduction in, 3:82
contraindications, complications, and associated
risks of, 3:77
defined, 3:75
definition of terms for, 3:96b-97b
vs. electron beam tomography, 3:95-97
equipment for, 3:78-80
angiographic, 3:78-79
catheters as, 3:78, 78f
contrast media as, 3:78
pressure injector as, 3:79, 79f
imaging, 3:79-80
other, 3:80, 80f, 80t
physiologic, 3:79-80, 79f, 82
historical development of, 3:20-21
indications for, 3:75-76, 75t
for interventional procedures of conduction
system, 3:94, 94f-95f
for interventional procedures of vascular system,
3:88-94
in adults, 3:88-92
in children, 3:92-94, 93f
intracoronary stent placement as, 3:88,
89f
vs. intravascular ultrasound, 3:80t, 91,
91f-92f
vs. optical coherence tomography, 3:80t, 92,
93f
percutaneous transluminal coronary
angioplasty as, 3:88, 88f-89f
percutaneous transluminal coronary rotational
atherectomy as, 3:80t, 90, 90f-91f
thrombolytic agents prior to, 3:92
vs. MRI, 3:95
patient care after, 3:95
patient care prior to, 3:81
patient positioning for, 3:81, 81f
procedures that may accompany, 3:76, 76t
trends in, 3:95-97
Cardiac cycle, 3:24
Cardiac ejection fraction, 3:410, 411f, 437
Cardiac gating
for CT angiography, 3:324-326, 326f
for MRI, 3:356, 356f
Cardiac MRI, 3:358, 359f
Cardiac muscular tissue, motion control of,
1:18
Cardiac notch, 1:481-482, 481f, 2:98, 98f
Cardiac orifice
anatomy of, 2:99
sectional anatomy of, 3:283
Cardiac output, 3:96
Cardiac perfusion study, 3:414, 414f
Cardiac sphincter, 2:98f, 99
Cardiac studies with barium
lateral projection for, 1:503
PA oblique projection for, 1:505, 507
PA projection for, 1:499
Cardiac viability, PET imaging for, 3:435
Cardiology imaging
nuclear medicine for, 3:416-417
PET for, 3:434-435
Cardiomyopathies, 3:96
congestive, 3:393
Cardiovascular and interventional technologist
(CIT), 3:96
Cardiovascular studies in nuclear medicine, 3:417
Cardiovascular system disorders in older adults,
3:170-171
Carina
anatomy of, 1:480, 480f
sectional anatomy of, 3:270
C-arm
dedicated, 2:20, 20f
mobile fluoroscopic, 2:20, 21f
in surgical radiography, 3:221, 221f
of cervical spine (anterior cervical diskectomy
and fusion), 3:227, 227f
of chest (line placement, bronchoscopy),
3:226, 226f
of femoral nailing, 3:234, 234f
for femoral/tibial arteriogram, 3:240
of hip (cannulated hip screws or hip pinning),
3:230-231, 230f
of humerus, 3:238-239, 238f
of lumbar spine, 3:228-229, 228f
operation of, 3:221, 222f
for operative (immediate) cholangiography,
3:224, 224f
radiation safety with, 3:223, 223f
of tibial nailing, 3:236, 236f
Carotid arteries. See also External carotid artery;
Internal carotid artery.
duplex sonography of extracranial, 3:392, 392f
MR angiography of, 3:364f
Carotid canal, 2:268, 269f
Carotid sinus, 3:270-271
Carotid sulcus, 2:264-265, 264f
Carpal(s)
anatomy of, 1:101-102, 101f
terminology conversion for, 1:101b
Carpal boss, 1:135, 135f
Carpal bridge, tangential projection of, 1:145
evaluation criteria for, 1:145b
position of part for, 1:145, 145f
position of patient for, 1:145
structures shown on, 1:145, 145f
Carpal sulcus, 1:102, 102f
Carpal tunnel, 1:102
Carpometacarpal (CMC) joint(s), 1:118-119
anatomy of, 1:106, 106f
Burman method for AP projection of, 1:120-121
evaluation criteria for, 1:121b
position of part for, 1:120, 120f
position of patient for, 1:120
SID for, 1:120
structures shown on, 1:121, 121f
Robert method for AP projection of, 1:118-119
evaluation criteria for, 1:119b
Lewis modification of, 1:119
Long and Rafert modification of, 1:119
position of part for, 1:118, 118f
position of patient for, 1:118, 118f
structures shown on, 1:119, 119f
Cartilaginous joints, 1:80t, 81, 81f
Cassette with film, 1:3, 4f
CAT (computed axial tomography), 3:302
Catheter(s) for cardiac catheterization, 3:78, 78f
Catheterization
for angiographic studies, 3:36-38, 37f-38f
cardiac. See Cardiac catheterization.
Cauda equina
anatomy of, 3:3, 3f, 18
sectional anatomy of, 3:296, 297f
Caudad, 1:85, 85f
Caudate nucleus, sectional anatomy of,
3:253f
on axial (transverse) plane, 3:257-259,
257f-258f
on coronal plane, 3:267, 267f
on sagittal plane, 3:265f
Cavernous sinus, 3:262, 262f, 267
CCD (charge-coupled device), 1:3
CDC (Centers for Disease Control and Prevention),
1:16, 16b, 16f
Cecum
anatomy of, 2:100f, 102, 102f
sectional anatomy of, 3:283, 292
Celiac arteriogram, 3:43, 43f
Celiac artery
anatomy of, 3:22f
sectional anatomy of, 3:284, 289, 298-299
Celiac axis, arteriography of, 3:41f
Celiac disease, 2:109t, 3:476
Index
Celiac sprue, 2:109t
Celiac trunk. See Celiac artery.
Centering
for digital imaging, 1:38
of obese patients, 1:47-48
Centers for Disease Control and Prevention (CDC),
1:16, 16b, 16f
Central nervous system (CNS), 3:1-18
anatomy of, 3:2-4
brain in, 3:2, 2f
meninges in, 3:3
spinal cord in, 3:3, 3f
ventricular system in, 3:2, 4, 4f
CT myelography of, 3:12, 12f
CT of, 3:10-12
brain in, 3:10, 10f-11f
spine in, 3:11, 11f-12f
definition of terms for, 3:18b
interventional pain management of,
3:16-18
MRI of, 3:12-13, 357-358
of brain, 3:12, 13f, 357, 357f
of spine, 3:13, 358
lumbar, 1:415, 416f, 3:13f, 358f
thoracic, 3:358f
myelography of. See Myelography.
nuclear medicine imaging of, 3:417
plain radiographic examination of, 3:5
provocative diskography of, 3:16, 17f
vascular and interventional procedures for,
3:14-16, 14f-15f
vertebroplasty and kyphoplasty of, 3:16,
16f-17f
Central nervous system (CNS) disorders in older
adults, 3:168-169
Central ray (CR), 1:31, 85
for trauma radiography, 2:30
Central ray (CR) angulation method for PA oblique
projection of sternoclavicular articulations,
1:466, 466f-467f
Central skeletal measurements, 3:469-471,
469f-471f
Cephalad, 1:85, 85f
Cephalic vein
anatomy of, 3:22f
venography of, 3:46f
I-7
 Cerebellar peduncles, 3:255, 265, 265f, 268
Cerebellar tonsils, rami of, 3:264
Cerebellum
anatomy of, 2:259f, 3:2, 2f
defined, 3:18
sectional anatomy of, 3:255
on axial (transverse) plane, 3:258f-260f,
259-263, 262f-263f
on coronal plane, 3:268, 268f
on sagittal plane, 3:264, 265f-266f, 266
Cerebral aneurysm, 3:10f
Cerebral angiography
of anterior circulation, 3:56-58
AP axial oblique (transorbital) projection for,
3:58, 58f
AP axial (supraorbital) projection for, 3:57,
57f
lateral projection for, 3:56, 56f
of aortic arch (for cranial vessels), 3:55,
55f
cerebral anatomy and, 3:49-51, 49f-52f
of cerebral arteries, 3:15f
circulation time and imaging program for, 3:53,
53f-54f
defined, 3:96
equipment for, 3:54
of internal carotid artery, 3:14f
position of head for, 3:54
of posterior circulation, 3:58-59
AP axial projection for, 3:59, 59f
Index
lateral projection for, 3:58-59, 58f
technique for, 3:52-54
of vertebrobasilar circulation, 3:49-61
Cerebral aqueduct (of Sylvius)
anatomy of, 3:4, 4f, 18
sectional anatomy of, 3:255
on axial (transverse) plane, 3:258-260,
258f-259f
on sagittal plane, 3:264
Cerebral arteries
CT angiography of, 3:325f
digital subtraction angiography of, 3:15f
MR angiography of, 3:363f
sectional anatomy of, 3:255, 257-258, 257f,
259f, 260-261
Cerebral blood flow, PET images of local, 3:427,
427f, 438
Cerebral cortex
anatomy of, 3:2, 18
sectional anatomy of, 3:256-257
Cerebral hemispheres, 3:256-257, 264
Cerebral lobes, 3:256-257
Cerebral peduncles, sectional anatomy of,
3:255
on axial (transverse) plane, 3:258-260,
258f-259f
on sagittal plane, 3:264-265, 265f
Cerebral veins, 3:255, 258-259
Cerebral vertebral arches, 3:265
Cerebral vertebral bodies, 3:265
Cerebrospinal fluid (CSF), 3:3, 18
sectional anatomy of, 3:254, 264-266
Cerebrum
anatomy of, 2:259f, 3:2, 2f
vascular, 3:49-51, 49f-52f
defined, 3:18
sectional anatomy of, 3:254-255
Cerrobend blocks, 3:489, 506
Certified surgical technologist (CST),
3:215
Cervical cancer, radiation oncology for, 3:503,
503f
Cervical curve, 1:366f, 367
Cervical diskectomy, anterior, 3:227, 227f
Cervical myelogram, 3:9f
Cervical nodes, 3:27f
I-8
Cervical vertebrae
anatomy of, 1:366f, 369-371
atlas in, 1:369, 369f
axis in, 1:369, 369f
intervertebral transverse foramina and
zygapophyseal joints in, 1:370-371, 371f,
371t
seventh, 1:370
typical, 1:370-371, 370f-371f
AP axial oblique projection for trauma of, 2:34,
35f-36f
AP axial projection of, 1:387-388, 387f-388f
for trauma, 2:33, 33f
AP projection of (Ottonello method), 1:397-398,
397f-398f
atlas of
anatomy of, 1:369, 369f
AP projection (open mouth) of, 1:384-385,
384f-385f
AP tomogram of, 1:385, 385f
lateral projection of, 1:386, 386f
axis of
AP projection (open mouth) of, 1:384-385,
384f-385f
AP tomogram of, 1:385, 385f
lateral projection of, 1:386, 386f
CT of, 2:53-55, 3:11, 11f-12f, 336f-338f
dens of
anatomy of, 1:369, 369f
AP projection of (Fuchs method), 1:383,
383f
PA projection of (Judd method), 1:383
dislocation of, 2:33f
fracture-dislocation of, 2:31f
fusion of, 3:227, 227f
intervertebral foramina of
anatomy of, 1:370f-371f, 371
AP axial oblique projection of, 1:393-394,
393f-394f
in hyperflexion and hyperextension,
1:394
PA axial oblique projection of, 1:395,
395f-396f
positioning rotations needed to show, 1:371,
371t
lateral projection of
Grandy method for, 1:389-390, 389f-390f
in hyperflexion and hyperextension,
1:391-392, 391f-392f
mobile, 3:206-207, 206f-207f
swimmer’s technique for, 1:402-403,
402f-403f
for trauma, 2:31, 31f
mobile radiography of, 3:206-207
lateral projection for, 3:206-207, 206f-207f
in operating room, 3:242, 242f-243f
sectional anatomy of, 3:265f, 267-268
surgical radiography of, 3:227, 227f
transverse foramina of, 1:370, 370f-371f
trauma radiography of
AP axial oblique projection in, 2:34, 35f-36f
AP axial projection in, 2:33, 33f
lateral projection in, 2:31, 31f
vertebral arch (articular pillars) of
anatomy of, 1:368, 368f, 370
AP axial oblique projection of, 1:401, 401f
AP axial projection of, 1:399-400,
399f-400f
zygapophyseal joints of
anatomy of, 1:371, 371f
positioning rotations needed to show, 1:371,
371t
Cervicothoracic region, lateral projection of
in dorsal decubitus position for trauma, 2:32,
32f
swimmer’s technique for, 1:402-403, 402f-403f
Cervix
anatomy of, 2:240, 240f
sectional anatomy of, 3:284, 295, 295f
ultrasonography of, 3:388f-389f
CF (cystic fibrosis), 1:486t, 3:141, 141f
Channel, 3:339
Charge-coupled device (CCD), 1:3
Chassard-Lapiné method for axial projection of
large intestine, 2:169, 169f
Chest CT, 3:336f-338f
Chest MRI, 3:358, 359f
Chest radiographs
AP projection in neonate for, 3:208-210
evaluation criteria for, 3:210b, 210f
position of part for, 3:208f-209f, 209
position of patient for, 3:208, 208f
structures shown on, 3:210, 210f
breathing instructions for, 1:490, 490f
in children, 3:118-124
with cystic fibrosis, 3:141, 141f
image evaluation for, 3:121, 123t
less than one year old, 3:119f-120f, 124
more than one year old, 3:121, 122f
Pigg-O-Stat for, 3:118, 118f
with pneumonia, 3:150-151, 151f
positioning for, 3:119
3 to 18 years old, 3:124, 124f
general positioning considerations for,
1:488
for lateral projections, 1:488, 489f
for oblique projections, 1:488
for PA projections, 1:488, 489f
upright vs. prone, 1:488, 488f
of geriatric patients, 3:177-178, 178f
grid technique for, 1:490, 491f
lateral projection in neonate for, 3:211-212,
211f-212f
of lungs and heart
AP oblique projection for, 1:508-509,
508f-509f
AP projection for, 1:510-511, 510f-511f
lateral projection for, 1:500-503
evaluation criteria for, 1:502b
foreshortening in, 1:501, 501f
forward bending in, 1:501, 501f
general positioning considerations for,
1:488, 489f
with pleura, 1:518-519, 518f-519f
position of part for, 1:500-501, 500f
position of patient for, 1:500
structures shown on, 1:502, 502f-503f
PA oblique projection for, 1:504-507
evaluation criteria for, 1:507b
LAO position for, 1:504f, 505, 506f
position of part for, 1:504f-505f, 505
position of patient for, 1:504
RAO position for, 1:505, 505f, 507f
SID for, 1:504
structures shown on, 1:506-507,
506f-507f
PA projection for, 1:496-499
breasts in, 1:497, 497f
evaluation criteria for, 1:499b
general positioning considerations for,
1:488, 489f
with pleura, 1:516-517, 517f
position of part for, 1:496-498, 496f
position of patient for, 1:496
respiration in, 1:498, 498f
SID for, 1:496
structures shown on, 1:499, 499f
of lungs and pleurae
AP or PA projection for, 1:483-484,
516f-517f
lateral projection for, 1:518-519,
518f-519f
Chest radiographs (Continued)
mobile, 3:192
AP or PA projection in lateral decubitus
position for, 3:194-195, 194f-195f
AP projection in upright or supine position
for, 3:192, 192f-193f
of neonate, 3:208-212
AP projection for, 3:208-210
evaluation criteria for, 3:210b, 210f
position of part for, 3:208f-209f, 209
position of patient for, 3:208, 208f
structures shown on, 3:210, 210f
lateral projection for, 3:211-212,
211f-212f
of pulmonary apices
AP axial projection for
in lordotic position (Lindblom method),
1:512-513, 512f-513f
in upright or supine position, 1:515,
515f
PA axial projection for, 1:514, 514f
SID for, 1:490, 491f
surgical, 3:226, 226f
technical procedure for, 1:490, 491f
Child abuse, 3:143f-145f
imaging protocol for, 3:124, 146t
Children, 3:99-159
abdominal radiography in, 3:112-115
image assessment for, 3:123t
with intussusception, 3:114, 114f
with pneumoperitoneum, 3:115, 115f
positioning and immobilization for, 3:112f-
113f, 113
age-based development of, 3:102-104
for adolescents, 3:104
for infants, 3:102
for neonates, 3:102
for premature infants, 3:102
for preschoolers, 3:103, 103f
for school age children, 3:104
for toddlers, 3:103
aneurysmal bone cyst in, 3:149, 149f
approach to imaging of, 3:100
artifacts with, 3:110-111, 110f-111f
with autism spectrum disorders, 3:105-107,
105t
cardiac catheterization in
for advanced diagnostic studies of conduction
system, 3:86-88
for advanced diagnostic studies of vascular
system, 3:86
for basic diagnostic studies, 3:86
for interventional procedures of conduction
system, 3:94, 94f-95f
for interventional procedures of vascular
system, 3:92-94, 93f
chest radiography in, 3:118-124
for children 3 to 18 years old, 3:124, 124f
for children less than one year old, 3:119f-
120f, 124
for children more than one year old, 3:121,
122f
image evaluation for, 3:121, 123t
Pigg-O-Stat for, 3:118, 118f
with pneumonia, 3:150-151, 151f
positioning for, 3:119
communication with, 3:101
CT of, 3:156, 156f, 336f-338f
cystic fibrosis in, 3:141, 141f
developmental dysplasia of hip in, 3:142,
142f
EOS system for, 3:153, 155, 155f
Ewing sarcoma in, 3:150, 150f
foreign bodies in, 3:139
airway, 3:139, 139f
ingested, 3:139, 140f
Children (Continued)
fractures in, 3:129-130
due to child abuse, 3:143-145, 144f-145f
greenstick, 3:130
growth plate, 3:131
due to osteogenesis imperfecta, 3:146t, 147
pathologic, 3:148-150
plastic or bowing, 3:130
Salter-Harris, 3:130, 130f
supracondylar, 3:131, 131f
toddler’s, 3:130-131
torus, 3:130
gastrointestinal and genitourinary studies in,
3:116-118
indications for, 3:118t
radiation protection for, 3:116, 116f
with vesicoureteral reflux, 3:117-118, 117f
image assessment for, 3:123t
immobilization techniques for
for abdominal radiography, 3:112-113,
112f-113f
for chest radiography, 3:118, 118f-120f,
124f
for gastrointestinal and genitourinary studies,
3:116f
holding as, 3:110
for limb radiography, 3:127-129, 127f-128f
for pelvis and hip radiography, 3:126, 126f
for skull radiography, 3:132, 133f, 135f
interventional radiography in, 3:157-158,
157f-158f
limb radiography in, 3:127-131
with fractures, 3:129-130, 130f-131f
image evaluation for, 3:123t, 131
immobilization for, 3:127-129, 127f-129f
radiation protection for, 3:129, 129f
MRI of, 3:155-156, 156f
nonaccidental trauma (child abuse) in,
3:143-146, 143f-145f
imaging protocol for, 3:146, 146t
osteochondroma in, 3:148, 148f
osteogenesis perfecta in, 3:147, 147f
osteoid osteoma in, 3:149, 149f
osteoporosis in, 3:473-474, 473f
osteosarcoma in, 3:150
paranasal sinus series in, 3:135-136,
136f-137f
pathologic fractures in, 3:148-150
pelvis and hip imaging in, 3:125-126
general principles of, 3:125-126, 125f
image evaluation for, 3:123t, 126
initial images in, 3:125
positioning and immobilization for, 3:126,
126f
preparation and communication for, 3:126
pneumonia in, 3:150-151, 151f
progeria in, 3:152, 152f
providing adequate care and service for,
3:101
radiation protection for, 3:108-111, 108f-109f,
109t
respect and dignity for, 3:101
safety with, 3:101
scoliosis in, 3:152-154
Cobb angle in, 3:154
congenital, 3:153
estimation of rotation in, 3:154
idiopathic, 3:152
image assessment for, 3:123t
imaging of, 3:153, 153f
lateral bends with, 3:154
neuromuscular, 3:153
patterns of, 3:154
skeletal maturity with, 3:154
symptoms of, 3:152, 152f
treatment options for, 3:154
Children (Continued)
skull radiography in, 3:132-135
AP axial Towne projection for, 3:132,
135t
AP projection for, 3:132, 134-135, 134f
with craniosynostosis, 3:132
with fracture, 3:132
immobilization for, 3:132, 133f, 135f
lateral projection for, 3:132, 134-135,
134f-135f
summary of projections for, 3:135t
soft tissue neck (STN) radiography in,
3:137-138, 137f-138f
with special needs, 3:105-107
ultrasound of, 3:156
waiting room for, 3:100, 100f-101f
Chloral hydrate (Noctec), 2:226t
Cholangiography, 2:173
operative (immediate), 3:223-225,
224f-225f
percutaneous transhepatic, 2:174-175,
174f
postoperative (delayed, T-tube), 2:176-177,
176f-177f
Cholangiopancreatography
endoscopic retrograde, 2:178, 178f-179f
magnetic resonance, 3:361f
Cholecystitis, 2:109t
ultrasonography of, 3:379f
Cholecystography, 2:173
Index
Cholecystokinin, 2:106
Choledochal sphincter, 2:105
Choledocholithiasis, 2:109t
Cholegraphy, 2:173
Cholelithiasis, 2:109t
Chondrosarcoma, 1:109t, 182t, 240t, 335t,
454t
Chorion, 2:241
Chorion laeve, ultrasonography of, 3:389f
Chorionic cavity, ultrasonography of, 3:389f
Choroid plexuses, 3:255, 257-259, 257f
Chromium-51 (51Cr), 3:406t
Chromosomes and cancer, 3:482, 506
Chronic bronchitis in older adults, 3:172
Chronic obstructive pulmonary disease,
1:486t
in older adults, 3:172, 172f, 174t
Chronologic age, age-specific competencies by,
1:23
Chyme, 2:99
Ci (curie), 3:405, 437
Cigarette smoking and cancer, 3:482, 482t
Cilia of uterine tube, 2:239
Cineangiography, 3:96
Cinefluorography, 3:96
Circle of Willis
anatomy of, 3:51, 51f
CT angiography of, 3:325f
MR angiography of, 3:363f-364f
sectional anatomy of, 3:255, 259-261
Circulator, 3:216
Circulatory system, 3:22
blood-vascular system in, 3:22-26, 22f
arteries in, 3:22f, 23
coronary, 3:25, 25f
pulmonary, 3:22f, 23
systemic, 3:23
arterioles in, 3:23
capillaries in, 3:23-24
complete circulation of blood through,
3:24
heart in, 3:23-24, 25f
main trunk vessels in, 3:23
portal system in, 3:23, 23f
pulmonary circulation in, 3:23, 23f
systemic circulation in, 3:23, 23f
I-9
 Circulatory system (Continued)
veins in, 3:22f, 23
coronary, 3:25, 25f
pulmonary, 3:22f, 23
systemic, 3:24
velocity of blood circulation in, 3:26
venules in, 3:23
lymphatic system in, 3:22, 26, 27f
Circumduction, 1:97, 97f
Cisterna chyli, 3:26
Cisterna magna, 3:254, 262-263
Cisternography, radionuclide, 3:417
CIT (cardiovascular and interventional
technologist), 3:96
Claudication, 3:28, 47, 96
Claustrum, 3:253f, 258-259, 258f
Clavicle
anatomy of, 1:175, 175f
AP axial projection of, 1:214, 214f
AP projection of, 1:213, 213f
function of, 1:175
PA axial projection of, 1:215, 215f
PA projection of, 1:215, 215f
sectional anatomy of, 3:269f, 270
on axial (transverse) plane, 3:272, 272f-273f
on coronal plane, 3:280-281, 281f
on sagittal plane, 3:279-280, 280f
Clavicular notch, 1:447-448, 447f
Clay shoveler’s fracture, 1:380t
Clear leaded plastic (Clear Pb) filter, 1:56f, 57
Index
Cleaves method
for AP oblique projection of femoral necks,
1:342-343
bilateral, 1:342, 342f
evaluation criteria for, 1:343b
position of part for, 1:342, 342f
position of patient for, 1:342
structures shown on, 1:343, 343f
unilateral, 1:342-343, 342f
for axiolateral projection of femoral necks,
1:344-345, 344f-345f
Clements-Nakamaya modification of Danelius-
Miller method for axiolateral projection of
hip, 1:352-353, 352f-353f
Clinical history, 1:13, 13f
Clivus, 2:258f-259f, 264-265, 265f, 267
Closed fracture, 1:84
Clubfoot
defined, 1:240t
deviations in, 1:267
Kandel method for dorsoplantar axial projection
of, 1:270, 270f
Kite method for AP projection of, 1:267, 267f,
269f
Kite method for mediolateral projection of,
1:268-269, 268f-269f
CM (canthomeatal) line, 3:437
CMC joints. See Carpometacarpal (CMC)
joint(s).
CNS. See Central nervous system (CNS).
CO2 (carbon dioxide) as contrast medium, 3:29
Coagulopathy, 3:96
Coal miner’s lung, 1:486t
Coalition position for axial projection of calcaneus,
1:273, 273f
Cobalt-57 (57Co), 3:406t
Cobalt-60 (60Co) units, 3:486-487, 487f, 506
Cobb angle, 3:154
Coccygeal cornua, 1:376-377, 376f
Coccygeal vertebra, 1:366
Coccyx
anatomy of, 1:330f, 366f
AP axial projection of, 1:431-432, 431f-432f
as bony landmark, 1:71f, 71t, 333f
lateral projections of, 1:433-434, 433f-434f
sectional anatomy of, 3:282, 296, 296f-297f
I-10
Cochlea, 2:269f-270f, 271
Cochlear nerve, 2:270f
“Code lift” process, 1:46
Cognitive impairment in older adults,
3:167
Coils in MRI, 3:346, 354, 354f, 367
Coincidence circuit, 3:422-424, 424f
Coincidence counts for PET, 3:429, 429f
Cold spot, 3:405, 437
Colitis, 2:109t
ulcerative, 2:109t
Collateral, 3:96
Collecting ducts, 2:185, 185f
Collecting system, duplicate, 2:188t
Colles fracture, 1:109t
Collimation
in digital imaging, 1:38
multileaf, 3:489, 489f, 507
with obese patients, 1:50, 50f
for trauma radiography, 2:30
of x-ray beam, 1:32-33, 32f-33f
Collimator(s)
of gamma camera, 3:408f, 409, 437
for linear accelerators, 3:488f, 489, 506
Collimator-mounted filter
example of, 1:56f
foot, 1:60t, 62f, 63
placement of, 1:58, 58f-59f
shape of, 1:57
shoulder, 1:59f, 60-63, 60t, 63f
swimmer’s, 1:60-63, 60t, 62f
Colloidal preparations for large intestine contrast
media studies, 2:144
Colon
anatomy of, 2:102f, 103
AP axial projection of, 2:161, 161f
AP oblique projection of
in LPO position, 2:162, 162f
in RPO position, 2:163, 163f
in upright position, 2:168, 168f
AP projection of, 2:160, 160f
in left lateral decubitus position, 2:166
in right lateral decubitus position, 2:165,
165f
in upright position, 2:168, 168f
ascending
anatomy of, 2:100f, 102f, 103
sectional anatomy of, 3:283, 291, 291f, 298,
298f
axial projection of (Chassard-Lapiné method),
2:169, 169f
colostomy studies of, 2:170
contrast media studies of, 2:144-148
contrast media for, 2:144-145
double-contrast method for, 2:144, 144f,
150-153
single-stage, 2:144, 150, 150f-151f
two-stage, 2:144
Wellen method for, 2:152-153,
152f-153f
insertion of enema tip for, 2:148
opacified colon in, 2:154
preparation and care of patient for,
2:147
preparation of barium suspension for,
2:147
preparation of intestinal tract for, 2:146,
146f
single-contrast method for, 2:144, 144f,
148-149, 148f-149f
standard barium enema apparatus for, 2:146,
146f-147f
CT colonography (virtual colonoscopy) for,
2:144, 145f
decubitus positions for, 2:164-172
defecography for, 2:172, 172f
Colon (Continued)
descending, 2:102f, 103
sectional anatomy of, 3:283
sectional anatomy on axial (transverse)
plane of
at Level D, 3:288, 288f
at Level E, 3:289, 289f
at Level F, 3:290, 290f
at Level G, 3:291, 291f
at Level H, 3:292, 292f
at Level I, 3:293f
sectional anatomy on coronal plane of,
3:298f
diagnostic enema for, 2:170, 170f-171f
lateral projection of
in R or L position, 2:159, 159f
in R or L ventral decubitus position, 2:167,
167f
in upright position, 2:168
opacified, 2:154
PA axial projection of, 2:156, 156f
PA oblique projection of
in LAO position, 2:158, 158f
in RAO position, 2:157, 157f
PA projection of, 2:154, 154f-155f
in left lateral decubitus position, 2:166,
166f
in right lateral decubitus position, 2:165
in upright position, 2:168, 168f
sectional anatomy of, 3:283
sigmoid, 2:102f, 103
axial projection of (Chassard-Lapiné method),
2:169, 169f
sectional anatomy of, 3:283, 294, 294f
transverse
anatomy of, 2:102f, 103
sectional anatomy of, 3:283
sectional anatomy on axial (transverse)
plane of
at Level D, 3:288, 288f
at Level E, 1:339, 3:289f
at Level F, 3:290, 290f
at Level G, 3:291, 291f
Colon cancer, familial adenomatous polyposis and,
3:483
Colonography, CT, 2:144, 145f
Colonoscopy, virtual, 2:144, 145f, 3:335, 335f
Colorectal cancer syndrome, hereditary
nonpolyposis, 3:483
Color-flow Doppler, 3:396-397
Colostomy stoma, diagnostic enema through,
2:170, 170f-171f
Colostomy studies, 2:170
Comminuted fracture, 1:84f
Common bile duct
anatomy of, 2:100f, 105, 105f
sectional anatomy of, 3:283
Common carotid artery
anatomy of, 3:22f, 49, 49f
arteriography of, 3:40f, 50f, 57f
digital subtraction angiography of, 3:31f, 55f
sectional anatomy of, 3:269f, 270-271
on axial (transverse) plane, 3:272-275,
272f-274f
on coronal plane, 3:280-281
on sagittal plane, 3:278-279, 280f
Common femoral artery, 3:22f, 25
Common femoral vein, 3:22f
Common hepatic artery, 3:284, 289, 289f, 298-299,
298f
Common hepatic duct
anatomy of, 2:100f, 105, 105f
sectional anatomy of, 3:283
Common iliac arteries
anatomy of, 3:22f, 25
arteriography of, 3:41f, 48f
Common iliac arteries (Continued) Compression paddle for abdominal imaging, 2:113, Computed tomography (CT) (Continued)
percutaneous transluminal angioplasty of, 113f vs. MRI, 3:333, 334f
3:64f Compression plate for breast lesion localization, multiplanar reconstruction in, 3:309, 313, 313f,
sectional anatomy of, 3:271, 284, 292, 292f, 2:462-464, 462f-463f 327f, 340
298-299 Computed axial tomography (CAT), 3:302 vs. nuclear medicine, 3:401t
Common iliac nodes, 3:27f Computed radiography (CR), 1:36, 36f of pelvis, 3:336f-338f
Common iliac vein Computed tomography (CT), 3:301-340 with PET, 3:327-329, 329f, 436
anatomy of, 3:22f of abdomen, 3:336f-338f pixels and voxels in, 3:308, 308f, 340
sectional anatomy of, 3:284, 292-293, of abdominal aortic aneurysm, 3:313f postprocessing techniques in, 3:326, 340
292f-293f algorithm in, 3:302, 339 primary data in, 3:302, 340
venography of, 3:48f, 60f aperture in, 3:310, 339 projections (scan profiles, raw data) in,
Communication archiving in, 3:309, 339 3:308
with children, 3:101 axial image in, 3:302, 339 protocols for, 3:303f, 319-320, 336-340
with autism spectrum disorders, 3:106 bit depth in, 3:308 quality control for, 3:329
with obese patients, 1:47 body planes in, 1:67, 67f quantitative
with older adults, 3:175 of cervical spine, 3:336f-338f for bone densitometry, 3:444, 469, 469f,
Compact bone, 1:76, 76f of chest, 3:336f-338f 477
and bone densitometry, 3:445, 445t of children, 3:156, 156f, 336f-338f peripheral, 3:475, 477
defined, 3:476 of CNS, 3:10-12 radiation dose in, 3:329-331
Compensating filters, 1:53-64 brain in, 3:10, 10f-11f equipment to reduce, 3:329-330, 329f
appropriate use of, 1:57 spine in, 3:11, 11f-12f estimating effective, 3:331
Boomerang contact contrast media for, 3:316-318, 316f factors that affect, 3:331-332
applications of, 1:60t, 63-64, 63f power injector for IV administration of, 3:317, automatic tube current modulation (ATCM)
composition of, 1:57 317f as, 3:331, 331f
example of, 1:56f and conventional radiography, 3:302-303, beam collimation as, 3:331-332,
placement of, 1:58, 58f 302f-304f 332t-333t
shape of, 1:57 of coronal sinuses, 3:336f-338f patient shielding as, 3:331
clear leaded plastic (Clear Pb), 1:56f, 57 cradle for, 3:310 patient size as, 3:332
composition of, 1:57 CT numbers (Hounsfield units) in, 3:308, 308t, “selectable” filters as, 3:331, 332f
convex and concave conical-shaped, 339 measurement of, 3:330, 330f

Index
1:64 curved planar reformations in, 3:313, 313f reporting of, 3:330, 331f
in Danelius-Miller method, 1:60-63, 62f data acquisition system for, 3:309, 339 for radiation treatment planning, 3:327, 328f
defined, 1:54-55 data storage and retrieval for, 3:309, 340 sectional anatomy for, 3:252
examples of, 1:55, 56f defined, 3:302, 302f, 339 after shoulder arthrography, 2:11, 11f
Ferlic collimator-mounted definition of terms for, 3:339-340 slice in, 3:302, 340
examples of, 1:56f detectors in, 3:305-306, 309, 339 slip ring in, 3:309, 340
placement of, 1:58, 58f-59f diagnostic applications of, 3:313-314, of soft tissue neck, 3:336f-338f
shape of, 1:57 313f-316f SPECT combined with, 3:401, 403f, 415, 415f,
Ferlic foot, 1:60t, 62f, 63 direct coronal image in, 3:310, 310f, 339 436
Ferlic shoulder, 1:59f, 60-63, 60t, 63f dual-energy source, 3:307, 308f spiral or helical
Ferlic swimmer’s, 1:60-63, 60t, 62f dynamic scanning with, 3:321, 339 defined, 3:339-340
highly specialized, 1:64 factors affecting image quality in, 3:318-320 multislice, 3:306, 323-324, 323f-324f
history of, 1:55 artifacts as, 3:319, 319f-320f, 339 single slice, 3:306, 321-323, 322f
mounting and removal of, 1:64, 64f contrast resolution as, 3:303, 318, 339 system components for, 3:309-313, 309f
need for, 1:54, 54f noise as, 3:318-319, 319f, 340 computer as, 3:309, 309f
physical principles of, 1:57-58 patient factors as, 3:319-320, 321f display monitor as, 3:311-312, 312f, 312t
placement of, 1:58, 58f-59f scan diameter as, 3:320, 340 gantry and table as, 3:309-310, 309f-310f,
in position, 1:55f scan times as, 3:320, 340 339
scoliosis, 1:57, 64, 64f spatial resolution as, 3:318, 340 operator’s console as, 3:311, 311f
shape of, 1:57 temporal resolution as, 3:318, 340 workstation for image manipulation and
specific applications of, 1:60-64, 60t field of view in, 3:308, 339 multiplanar reconstruction as, 3:309, 313,
in this atlas, 1:64 scan vs. display, 3:320 313f, 340
trough flat-panel, 3:307 technical aspects of, 3:308, 308f, 308t
applications of, 1:60, 60t, 61f fundamentals of, 3:301f, 302 of thoracic vertebrae, 1:405, 406f
example of, 1:56f future of, 3:333-335, 335f of thoracic viscera, 1:484, 485f
in position, 1:55f generation classification of scanners for, three-dimensional imaging with, 3:326-327,
shape of, 1:57 3:305-308, 339 327f
wedge first-generation, 3:305-306, 305f-306f of abdominal aortic aneurysm, 3:313f
applications of, 1:60, 60t, 61f second-generation, 3:306 future of, 3:335, 335f
example of, 1:56f third-generation, 3:306-307, 306f maximum intensity projection for,
in position, 1:55f fourth-generation, 3:307, 307f 3:326
shape of, 1:57 fifth-generation, 3:307, 307f shaded surface display for, 3:326
specialized, 1:62f, 63 sixth-generation, 3:307, 308f volume rendering for, 3:306-307, 321, 322f,
Compensatory curves, 1:367 grayscale image in, 3:311, 339 326-327
Complete reflux examination of small intestine, of head, 3:336f-338f for trauma, 2:20, 29
2:141, 141f high-resolution scans in, 3:319-320, 321f, 339 of cervical spine, 2:53-55
Complex projections, 1:88 historical development of, 3:305, 305f of cranium, 2:29, 29f, 53-55, 54f
Complex structure or mass in ultrasonography, image manipulation in, 3:303, 304f, 313, 313f of pelvis, 2:53f, 55
3:374, 374f, 397 image misregistration in, 3:321-323, 339 of thorax, 2:53-55
Compound fracture, 1:84f indexing in, 3:310, 339 of urinary system, 2:190, 190f
Compression cone for abdominal imaging, 2:113, for interventional procedures, 3:314, 314f-316f volume, 3:326-327
113f of knee, 3:336f-338f defined, 3:306-307
Compression devices for abdominal imaging, for long bone measurement, 2:6, 6f multislice spiral CT for, 3:323-324, 323f
2:113, 113f of lumbar vertebrae, 1:415, 416f single-slice spiral CT for, 3:321, 322f
Compression fracture, 1:84f, 380t matrix in, 3:302, 308, 308f, 339 windowing (gray-level mapping) in, 3:10, 312,
in older adults, 3:170, 170f, 174t of mediastinum, 1:484, 485f 312f, 312t, 340

I-11
 Computed tomography angiography (CTA),
3:324-326
advantages of, 3:324
bolus in, 3:324, 339
of brain, 3:10f, 324-326, 325f
perfusion study for, 3:324-326, 326f
cardiac, 3:324-326, 325f-326f
with cardiac gating, 3:324-326, 326f
defined, 3:324, 339
scan duration in, 3:324, 340
steps in, 3:324
table speed in, 3:324, 340
uses of, 3:324-326
Computed tomography (CT) colonography, 2:144,
145f
Computed tomography dose index (CTDI), 3:330,
339
Computed tomography dose index100 (CTDI100),
3:330, 339
Computed tomography dose indexvol (CTDIvol),
3:330, 339
Computed tomography dose indexw (CTDIw),
3:330, 339
Computed tomography (CT) enteroclysis, 2:141,
142f
Computed tomography myelography (CTM), 3:12,
12f
Computed tomography (CT) simulator for radiation
oncology, 3:489, 490f, 507
Computer(s)
Index
for CT, 3:309, 309f
for DXA, 3:460
in gamma ray cameras, 3:409-410, 410f-411f
Computer-aided detection (CAD) systems for
mammography, 2:376-379, 376f
Computerized planimetry for evaluation of
ventricle functions, 3:82-84, 84f
Concha, 2:270f
Condylar canals, 2:266f, 267
Condylar process, 2:264f, 274, 274f
Condyle, 1:84
Condyloid joint, 1:82, 83f
Condyloid process, 3:254
Cones, 2:315
Confluence of sinuses, 3:261-262, 261f
Conformal radiotherapy (CRT), 3:494, 506
Congenital aganglionic megacolon, 2:109t
Congenital heart defects, cardiac catheterization
for, 3:92-94, 93f
Congestive heart failure in older adults, 3:171,
174t
Conjunctiva, 2:314, 314f-315f
Connective tissue, cancer arising from, 3:483t
Console for MRI, 3:345, 345f
Construction in three-dimensional imaging,
3:326
Contact filter
applications of, 1:60t, 63-64, 63f
composition of, 1:57
example of, 1:56f
placement of, 1:58, 58f
shape of, 1:57
Contact shield, 1:33, 33f
Contamination, 3:250
Contamination control
CDC recommendations on, 1:16, 16b, 16f
chemical substances for, 1:16
for minor surgical procedures in radiology
department, 1:17, 17f
in operating room, 1:16-17, 16f-17f
standard precautions for, 1:15, 15f
Continuous wave transducers for ultrasonography,
3:372, 397
Contour in radiation oncology, 3:494, 506
Contractures in older adults, 3:174t
Contralateral, 1:85
I-12
Contrast, 1:5, 6f
in MRI vs. conventional radiography, 3:342,
367
Contrast arthrography, 2:7-16
abbreviations used for, 2:9b
defined, 2:8-9
double-, 2:8-9
of knee, 2:13, 13f
of hip, 2:14
AP oblique, 2:14f
axiolateral “frog”, 2:14f
with congenital dislocation, 2:8f, 14, 14f
prosthetic, 2:14, 15f
digital subtraction technique for, 2:14,
15f
photographic subtraction technique for,
2:14, 15f
of knee, 2:12
double-contrast (horizontal ray method), 2:13,
13f
vertical ray method for, 2:12, 12f
MRI vs., 2:8, 8f
of other joints, 2:16, 16f
overview of, 2:8-9
procedure for, 2:9, 9f
of shoulder, 2:10-11
CT after, 2:11, 11f
double-contrast, 2:10, 10f-11f
MRI vs., 2:8f
single-contrast, 2:10, 10f-11f
summary of pathology found on, 2:9t
Contrast media
for alimentary canal, 2:111-112, 111f-112f
for angiographic studies, 3:29
for cardiac catheterization, 3:78
for CT, 3:316-318, 316f
power injector for IV administration of, 3:317,
317f
for MRI, 3:355, 355f
for myelography, 3:6-7, 6f
in older adults, 3:176
for simulation in radiation oncology, 3:490,
491f-492f
Contrast media studies
of esophagus, 2:115-117, 115f
barium administration and respiration for,
2:119, 119f
barium sulfate mixture for, 2:115
double-contrast, 2:115, 117, 117f
examination procedures for, 2:116-117,
116f-117f
single-contrast, 2:115, 116f-117f
of large intestine, 2:144-148
contrast media for, 2:144-145
double-contrast method for, 2:144, 144f,
150-153
single-stage, 2:144, 150, 150f-151f
two-stage, 2:144
Wellen method for, 2:152-153, 152f-153f
insertion of enema tip for, 2:148
opacified colon in, 2:154
preparation and care of patient for, 2:147
preparation of barium suspensions for, 2:147
preparation of intestinal tract for, 2:146, 146f
single-contrast method for, 2:144, 144f,
148-149, 148f-149f
standard barium enema apparatus for, 2:146,
146f-147f
of stomach, 2:121-123
barium sulfate suspension for, 2:111, 111f
biphasic, 2:123
in children, 3:116
double-contrast, 2:122, 122f, 124f
single-contrast, 2:121, 121f, 124f
water-soluble, iodinated solution for, 2:111,
111f
Contrast media studies (Continued)
of urinary system, 2:190-197
adverse reactions to iodinated media for,
2:196
angiographic, 2:190, 191f
antegrade filling for, 2:191, 191f
contrast media for, 2:194, 195f
CT in, 2:190, 191f
equipment for, 2:198, 198f-199f
physiologic technique for, 2:192f, 193
preparation of intestinal tract for, 2:196-197,
196f-197f
preparation of patient for, 2:197
retrograde filling for, 2:192f, 193
tomography in, 2:190, 191f
Contrast resolution, 1:5
for CT, 3:303, 318, 339
Contre-coup fracture, 2:282t
Conus medullaris, 3:3, 3f, 18
Conus projection, 3:8
Convolutions, 3:256-257
Cooper’s ligaments, 2:380, 381f
Coracoid process
anatomy of, 1:176, 176f
AP axial projection of, 1:222, 222f-223f
defined, 1:84
sectional anatomy of, 3:270
Coregistration, 3:402, 402f, 438
Cornea, 2:314f-315f, 315
Corona radiata, 3:254-257
Coronal image, direct, in CT, 3:310, 310f, 339
Coronal image plane in ultrasonography, 3:397
Coronal plane, 1:66, 66f-67f
in sectional anatomy, 3:252
Coronal sinuses, CT of, 3:336f-338f
Coronal suture
anatomy of, 2:258f, 259, 275t
lateral projection of, 2:295f
Coronary angiography, 3:40f, 75
for cardiac catheterization, 3:84, 85f, 85t
CT, 3:324-326, 325f-326f
with cardiac gating, 3:324-326, 326f
for percutaneous transluminal coronary
angioplasty, 3:88, 88f-89f
procedures that may accompany, 3:76, 76t
Coronary angioplasty, percutaneous transluminal,
3:66, 88, 88f-89f
catheter system for, 3:88, 88f
with stent placement, 3:88, 89f
Coronary arteries
anatomy of, 3:25, 25f
sectional anatomy of, 3:270-271
stenosis and occlusion of, 3:75
Coronary arteriography, MRI, 3:95f
Coronary artery disease, 3:75
atherectomy devices for, 3:90, 90f-91f
intravascular ultrasound of, 3:80t, 91, 91f-92f
tools for diagnosis and treatment of, 3:80t
Coronary atherectomy devices, 3:90, 90f-91f
Coronary flow reserve, PET of, 3:435
Coronary sinus, 3:25f
Coronary veins, 3:25, 25f
Coronoid fossa, 1:104, 104f
Coronoid process
anatomy of, 1:103, 103f, 2:273f-274f, 274
axiolateral oblique projection of, 2:344f-345f
Coyle method for axiolateral projection of,
1:162-164
evaluation criteria for, 1:164
position of part for, 1:162, 162f-163f
position of patient for, 1:162
structures shown on, 1:164, 164f
defined, 1:84
PA axial projection of, 2:342f
sectional anatomy of, 3:254
submentovertical projection of, 2:346f
Corpora cavernosa, 3:297f
Corpora quadrigemina, 3:255, 259-260, 259f,
264
Corpus callosum
anatomy of, 3:2, 2f
genu of, 3:257-258, 257f-258f
sectional anatomy of, 3:254-255
on axial (transverse) plane, 3:256-258,
256f-257f
on coronal plane, 3:266-268, 267f-268f
on sagittal plane, 3:264, 265f
splenium of, 3:253f, 257-258, 257f-258f
Cortex of brain, 3:2, 18
Cortical bone, 1:76, 76f
and bone densitometry, 3:445, 445t
defined, 3:476
Costal cartilage, 1:447f, 448
Costal facets
of ribs, 1:447f-448f, 448
of thoracic vertebrae, 1:372, 372f, 373t
Costal groove, 1:448, 448f
Costochondral articulations, 1:449t, 450, 450f
Costophrenic angle
anatomy of, 1:481-482, 481f-482f
sectional anatomy of, 3:270
Costosternal articulations, 3:279-280
Costotransverse joints
in bony thorax, 1:449f-450f, 449t, 450
sectional anatomy of, 3:269-270, 272-275,
272f
Cranial region, sectional anatomy of (Continued)
at level C, 3:258, 258f
at level D, 3:259-260, 259f
at level E, 3:260f-261f, 261-262
at level F, 3:262, 262f
at level G, 3:263, 263f
on cadaveric image, 3:253, 253f
on coronal plane, 3:266-267, 266f
at level A, 3:266-267, 267f
at level B, 3:267-268, 267f
at level C, 3:268, 268f
on sagittal plane, 3:256f, 264, 264f
at level A, 3:264, 265f
at level B, 3:265, 265f
at level C, 3:266, 266f
Cranial suture synostosis, premature, 3:132
Craniosynostosis, 3:132
Cranium. See also Skull.
average or normal, 2:260
deviations from, 2:260
Crest, 1:84
Cribriform plate
anatomy of, 2:258f, 262, 262f
sectional anatomy of, 3:253, 261-263
Crista galli
anatomy of, 2:258f-259f, 262, 262f
PA axial projection of, 2:298f, 330f
sectional anatomy of, 3:253, 263, 263f
Crohn disease, 2:109t
Cross-calibration of DXA machines, 3:457, 476
Cystic duct
anatomy of, 2:100f, 105-106, 105f
sectional anatomy of, 3:283
Cystic fibrosis (CF), 1:486t, 3:141, 141f
Cystitis, 2:188t
Cystography, 2:192f, 214
AP axial or PA axial projection for, 2:216-217,
216f-217f
AP oblique projection for, 2:218, 218f-219f
contrast injection for, 2:214, 215f
contrast media for, 2:214
defined, 2:193
excretory
AP axial projection for, 2:217f
AP oblique projection for, 2:219f
indications and contraindications for, 2:214
injection equipment for, 2:214
lateral projection for, 2:220, 220f
preliminary preparations for, 2:214
retrograde
AP axial projection for, 2:216f-217f
AP oblique projection for, 2:218f-219f
AP projection for, 2:215f
contrast injection technique for, 2:214,
215f
Cystoureterography, 2:193, 193f, 214
Cystourethrography, 2:193, 193f, 214
female, 2:222-224, 222f
metallic bead chain, 2:222-224, 223f
male, 2:221, 221f

in thoracic spine, 1:372f, 378, 378f, 379t
Costovertebral joints
in bony thorax, 1:449f-450f, 449t, 450
sectional anatomy of, 3:269-270, 273-275
in thoracic spine, 1:372f, 378, 378f, 379t
Coyle method for axiolateral projection of radial
head and coronoid fossa, 1:162-164
evaluation criteria for, 1:164
position of part for, 1:162, 162f-163f
position of patient for, 1:162
structures shown on, 1:164, 164f
CR (central ray). See Central ray (CR).
CR (computed radiography), 1:36, 36f
51
Cr (chromium-51), 3:406t
Cradle for CT, 3:310
Cragg, Andrew, 3:20-21
Cranial bones
anatomy of, 2:257, 257b
anterior aspect of, 2:257f
ethmoid bone as
anatomy of, 2:262, 262f
location of, 2:259f
frontal bone as
anatomy of, 2:261, 261f
location of, 2:257f-259f
function of, 2:257
lateral aspect of, 2:258f-259f
in newborn, 2:259-260, 260f
occipital bone as
anatomy of, 2:266-267, 266f-267f
location of, 2:258f-259f, 264f
parietal bones as
anatomy of, 2:263, 263f
location of, 2:257f-259f
sectional anatomy of, 3:253
sphenoid bone as
anatomy of, 2:264-266, 264f-265f
location of, 2:257f-258f
temporal bones as
anatomy of, 2:268, 268f-269f
location of, 2:257f-259f
Cranial fossae, 2:258f, 260
Cranial region, sectional anatomy of, 3:253-268
on axial (transverse) plane, 3:256, 256f
at level A, 3:256-257, 256f-257f
at level B, 3:257-258, 257f
Index
The Crosser, 3:80t voiding, 2:214, 215f
Crossover with K-edge filtration systems for DXA, in children, 3:117, 117f
3:452
Cross-sectional plane, 1:66, 66f-67f D
Cross-table projections with obese patient, 1:49 Damadian, Raymond, 3:342
Crosswise position, 1:28, 28f Danelius-Miller method
CRT (conformal radiotherapy), 3:494, 506 for axiolateral projection of hip, 1:350-351,
Cruciate ligaments, double-contrast arthrography 350f-351f, 353f
of, 2:13 Clements-Nakamaya modification of,
Cryogenic magnets for MRI, 3:346, 367 1:352-353, 352f-353f
Cryptorchidism, 2:245t compensating filters in, 1:60-63, 62f
Crystalline lens, 2:314f-315f Data acquisition system (DAS) for CT, 3:309,
CSF (cerebrospinal fluid) 339
anatomy of, 3:3, 18 Data storage and retrieval for CT, 3:309, 340
sectional anatomy of, 3:254, 264-266 Daughter nuclide, 3:403-404, 437
C-spine filter for scoliosis imaging, 3:153 DBT (digital breast tomosynthesis),
CST (certified surgical technologist), 3:215 2:374-375
CT. See Computed tomography (CT). DCIS (ductal carcinoma in situ), 2:395
CT numbers, 3:308, 308t, 339 calcifications in, 2:392f
CTA. See Computed tomography angiography DDH (developmental dysplasia of hip), 2:9t,
(CTA). 3:142, 142f
CTDI. See Computed tomography dose index Deadtime losses in PET, 3:430, 432, 437
(CTDI). Decay
CTM (computed tomography myelography), 3:12, atomic, 3:403, 437
12f in radiation oncology, 3:486, 506
Cuboid bone, 1:228f, 229 of radionuclides, 3:403, 404f
Cuboidonavicular articulation, 1:236t, 237f, 238 Decidua capsularis, ultrasonography of, 3:389f
Cuneiforms, 1:228f, 229 Decidua parietalis, ultrasonography of, 3:389f
Cuneocuboid articulation, 1:236t, 237f, 238 Decidual basalis, ultrasonography of, 3:389f
Cure, 3:480, 506 DECT (dual-energy source CT), 3:307, 308f
Curie (Ci), 3:405, 437 Decubitus position, 1:94, 94f-95f
Curved planar reformations in CT, 3:313, 313f, Decubitus ulcers in older adults, 3:175
339 Dedicated radiographic equipment for trauma,
CyberKnife, 3:499-501, 501f 2:20, 20f
Cyclotron, 3:400, 425, 426f, 437 Deep, 1:85
Cyst Deep back muscles, 3:278, 297f
bone, 1:109t, 240t Deep femoral artery
aneurysmal, 3:149, 149f anatomy of, 3:22f
breast, 2:395 arteriography of, 3:48f
dermoid, 2:245t Deep inguinal nodes, 3:27f
oil, 2:386f Deep vein thrombosis, 3:70
ovarian ultrasonography of, 3:393, 394f
CT of, 3:315f Defecography, 2:172, 172f
ultrasonography of, 3:375f, 388 Degenerative joint disease, 1:109t, 182t, 240t,
renal, 2:210f-211f 335t, 380t
retroareolar, 2:385f in older adults, 3:170, 170f

I-13
 Deglutition in positive-contrast pharyngography,
2:74-75, 74f
Delayed cholangiography, 2:176-177, 176f-177f
Dementia, 3:167, 174t
in Alzheimer disease, 3:167-168, 174t, 176,
177b
multi-infarct, 3:169
Demerol (meperidine hydrochloride), 2:226t
Demifacets, 1:372, 372f, 373t
Dens
anatomy of, 1:369, 369f, 2:266f
AP projection of (Fuchs method), 1:383,
383f
PA projection of (Judd method), 1:383
sectional anatomy of, 3:267-268
submentovertical projection of, 2:311f
Dental ligament, myelogram of, 3:9f
Depressed skull fracture, 2:282t
Depressions in bone, 1:84
Dermoid cyst, 2:245t
Detail resolution in ultrasonography, 3:372,
397
Detector(s)
for CT, 3:305-306, 309, 339
for PET, 3:400, 437
Detector assembly for CT, 3:302, 339
Deuterons in radionuclide production, 3:425, 425f,
437
Development, 3:102-104
of adolescents, 3:104
Index
of infants, 3:102
of neonates, 3:102
of premature infants, 3:102
of preschoolers, 3:103, 103f
of school age children, 3:104
of toddlers, 3:103
Developmental dysplasia of hip (DDH), 2:9t,
3:142, 142f
Deviation, 1:97, 97f
DFOV (display field of view) in CT, 3:320
Diabetes mellitus in older adults, 3:173
Diagnosis and radiographer, 1:14
Diagnostic enema through colostomy stoma, 2:170,
170f-171f
Diagnostic medical sonographers, 3:370
characteristics of, 3:370, 371f
Diagnostic medical sonography. See
Ultrasonography.
Diagnostic reference levels (DRLs) for CT,
3:330
Diagonal position, 1:28, 28f
Diaper, infant, 1:20
Diaper rash ointment, 1:20
Diaphanography of breast, 2:473
Diaphragm
anatomy of, 1:479, 479f
hiatal hernia of
AP projection of, 2:134, 135f
defined, 2:109t
PA oblique projection of (Wolf method),
2:136-137, 136f-137f
upright lateral projection of, 2:135f
in respiratory movement, 1:452, 452f
sectional anatomy of
in abdominopelvic region, 3:282
on axial (transverse) plane, 3:285,
285f-287f
on coronal plane, 3:298f
on sagittal plane, 3:298
in thoracic region, 3:278-279, 280f
Diaphysis, 1:77, 77f
Diarthroses, 1:81
Diastole, 3:96
Diazepam (Valium), 2:226t
Differentiation, 3:484, 506
Diffusion study in MRI, 3:364-365, 365f, 367
I-14
Digestive system, 2:95-180
abbreviations used for, 2:107b
abdominal fistulae and sinuses in, 2:180, 180f
anatomy of, 2:97-106, 97f
biliary tract and gallbladder in, 2:97f,
104-106, 104f-106f
esophagus in, 2:97, 97f
large intestine in, 2:97f, 102-103,
102f-103f
liver in, 2:97f, 104-106, 104f-106f
pancreas and spleen in, 2:97f, 106, 107f
small intestine in, 2:97f, 100f, 101
stomach in, 2:97f-99f, 98-99
summary of, 2:108b
biliary tract and gallbladder in
anatomy of, 2:97f, 104-106, 104f-106f
biliary drainage procedure and stone
extraction for, 2:175, 175f
endoscopic retrograde
cholangiopancreatography of, 2:178,
178f-179f
percutaneous transhepatic cholangiography of,
2:174-175, 174f
postoperative (T-tube) cholangiography of,
2:176-177, 176f-177f
prefixes associated with, 2:173, 173t
radiographic techniques for, 2:173
contrast media for, 2:111-112, 111f-112f
endoscopic retrograde cholangiopancreatography
of pancreatic ducts in, 2:178, 178f-179f
esophagus in
anatomy of, 2:97, 97f
AP, PA, oblique, and lateral projections of,
2:118, 118f-119f
contrast media studies of, 2:115-117, 115f
barium sulfate mixture for, 2:115
double-contrast, 2:117, 117f
examination procedure for, 2:116-117,
116f-117f
opaque foreign bodies in, 2:117, 117f
PA oblique projection of distal (Wolf method),
position of part for, 2:134, 134f
examination procedure for, 2:110-114
exposure time for, 2:114
gastrointestinal transit in, 2:110
large intestine in. See Large intestine.
nuclear medicine imaging of, 3:418-419
preparation of examining room for, 2:114
radiation protection for, 2:114f, 115
radiologic apparatus for, 2:113, 113f
sample exposure technique chart essential
projections for, 2:108t
small intestine in. See Small intestine.
stomach in. See Stomach.
summary of pathology of, 2:109t
summary of projections for, 2:96
Digestive system disorders in older adults, 3:171,
171f
Digit(s)
anatomy of, 1:101, 101f
first. See Thumb.
second through fifth
anatomy of, 1:101, 101f
lateral projection of, 1:112-113
evaluation criteria for, 1:113b
position of part for, 1:112, 112f
position of patient for, 1:112
structures shown on, 1:113, 113f
PA oblique projection in lateral rotation of,
1:114
evaluation criteria for, 1:114b
medial rotation of second digit in, 1:114,
115f
position of part for, 1:114, 114f
position of patient for, 1:114
structures shown on, 1:114, 115f
Digit(s) (Continued)
PA projections of, 1:110-111
computed radiography for, 1:111-114
evaluation criteria for, 1:111b
position of part for, 1:110, 110f
position of patient for, 1:110
structures shown in, 1:111, 111f
Digital breast tomosynthesis (DBT), 2:374-375
Digital disk for digital subtraction angiography,
3:30
Digital imaging, 1:36-38, 36f
grids in, 1:38
kilovoltage in, 1:37, 37f
part centering for, 1:38
split cassettes in, 1:38
in this atlas, 1:38
Digital radiographic absorptiometry, 3:443, 474,
474f
Digital radiography (DR), 1:3, 4f, 36-37, 37f
mobile, 3:184, 185f
of cervical spine, 3:207
of chest, 3:193-195
of femur
AP projection for, 3:203-205
lateral projection for, 3:205
Digital subtraction angiography (DSA),
3:30-34
acquisition rate in, 3:30
biplane suite for, 3:31-32, 31f
bolus chase or DSA stepping method for,
3:30-31
cerebral, 3:14-16, 14f-15f
of common carotid artery, 3:31f
for hip arthrography, 2:14, 15f
historical development of, 3:21
magnification in, 3:33
misregistration in, 3:31
postprocessing in, 3:31
procedure for, 3:30-34
single-plane suite for, 3:32, 32f
three-dimensional intraarterial, 3:34, 34f
Digitally reconstructed radiograph (DRR) in
radiation oncology, 3:491, 493f
Dignity
in code of ethics, 1:2-3
of parents and children, 3:101
DIP (distal interphalangeal) joints
of lower limb, 1:236
of upper limb, 1:105, 105f-106f
Diphenhydramine hydrochloride (Benadryl),
2:226t
Diploë, 1:79, 2:258f-259f, 259
Direct coronal image in CT, 3:310, 310f, 339
Direct effects of radiation, 3:484, 506
Discordance in DXA, 3:457, 476
Disinfectants, 1:16
Disintegration. See Decay.
Diskography, provocative, 3:16, 17f
Dislocation, 1:109t, 182t, 240t, 335t, 2:9t
Displaced fracture, 1:84
Display field of view (DFOV) in CT, 3:320
Display monitor, 1:8
for CT, 3:311-312, 312f, 312t
Distal, 1:85, 85f
Distal convoluted tubule, 2:185, 185f
Distal humerus
AP projection of
in acute flexion, 1:158, 158f
in partial flexion, 1:156, 156f
PA axial projection of, 1:165, 165f
Distal interphalangeal (DIP) joints
of lower limb, 1:236
of upper limb, 1:105, 105f-106f
Distal phalanges, 1:228, 228f
Distal tibiofibular joint, 1:236t, 238
Distance measurements in CT, 3:304f
Distortion, 1:7, 7f
Diverticulitis, 2:109t
Diverticulosis, 2:109t
in older adults, 3:171
Diverticulum, 2:109t
Meckel, 2:109t
Zenker, 2:109t
DLP (dose length product), 3:330, 339
Documentation
of medication administration, 2:235
for trauma radiography, 2:30
Dolichocephalic skull, 2:286, 286f
Dopamine hydrochloride, 2:226t
Dopamine transporter study, 3:417
Doppler effect, 3:397
Doppler ultrasound, 3:397
Dorsal, 1:85
Dorsal decubitus position, 1:94, 94f
Dorsal recumbent position, 1:90, 90f
Dorsal surface of foot, 1:228-230
Dorsiflexion, 1:97, 97f
Dorsum, 1:85
Dorsum sellae
anatomy of, 2:258f, 264-265, 264f-265f
AP axial projection of
Haas method for, 2:309f
Towne method for, 2:305f
PA axial projection of, 2:298f
sectional anatomy of, 3:253-254, 261-262
Dose for nuclear medicine, 3:405, 437
Dose inhomogeneity in radiation oncology,
3:495
Dose length product (DLP), 3:330, 339
DoseRight, 3:331f
Dosimetry devices, 3:407
Dosimetry for radiation oncology, 3:480, 494-496,
494f-495f, 494t, 506
Dotter, Charles, 3:20-21
Dotter method for percutaneous transluminal
angioplasty, 3:62
Double-contrast arthrography, 2:8-9
of knee, 2:13, 13f
of shoulder, 2:10, 10f-11f
DPA (dual photon absorptiometry), 3:444, 476
DR. See Digital radiography (DR).
Dressings, surgical, 1:20
DRLs (diagnostic reference levels) for CT, 3:330
DRR (digitally reconstructed radiograph) in
radiation oncology, 3:491, 493f
DSA. See Digital subtraction angiography (DSA).
DSCT (dual-source CT), 3:307, 308f
Dual energy vertebral assessment (DVA),
3:469-470, 470f-471f, 477
Dual energy x-ray absorptiometry (DXA), 3:442
accuracy and precision of, 3:442, 455-457,
455f-456f
anatomy, positioning, and analysis for,
3:463-469
array-beam (fan-beam) techniques for, 3:444,
454-457, 454f, 476
compare feature (or copy) in, 3:463, 463f,
476
computer competency for, 3:460
vs. conventional radiography, 3:443
cross-calibration of machines for, 3:457, 476
defined, 3:476
discordance in, 3:457, 476
of forearm, 3:468-469, 468f
least significant change (LSC) in, 3:456, 476
longitudinal quality control for, 3:461-462,
461f-462f, 476
mean in, 3:455, 455f-456f, 476
patient care and education for, 3:459
patient history for, 3:459
pencil-beam techniques for, 3:444, 454-457,
454f, 477
Dual energy x-ray absorptiometry (DXA)
(Continued)
percent coefficient of variation (%CV) in, 3:455,
455f-456f, 477
peripheral, 3:475, 475f, 477
phantom scans for, 3:461, 462f
physical and mathematic principles of,
3:451-453
in energy-switching systems (Hologic),
3:451f-452f, 452
beam hardening in, 3:452
in K-edge filtration systems (rare-earth filters,
GE Lunar and Norland), 3:451,
451f-452f
crossover in, 3:452
scintillating detector pileup in, 3:452
physics problems with, 3:452
soft tissue compensation in, 3:452, 453f
volumetric density estimation in, 3:453, 453f,
477
as projectional (areal) technique, 3:453, 477
of proximal femur, 3:466-467, 466f-467f
radiation protection with, 3:458, 458t
reference population in, 3:457, 477
regions of interest in, 3:443, 477
reporting, confidentiality, record keeping, and
scan storage for, 3:460
scanners for, 3:442f, 443
serial scans in, 3:463-464, 463f, 477
spine scan in
equipment for, 3:442f
of lateral lumbar spine, 3:469
of posteroanterior lumbar spine, 3:464-466,
464f-465f
standard deviation (SD) in, 3:455, 455f-456f,
477
standardized hip reference database for, 3:457
as subtraction technique, 3:443, 477
T scores in, 3:457, 458t, 477
whole-body and body composition, 3:442f, 471,
472f
Z scores in, 3:457, 477
Dual photon absorptiometry (DPA), 3:444, 476
Dual-energy source CT (DECT), 3:307, 308f
Dual-source CT (DSCT), 3:307, 308f
Ductal carcinoma in situ (DCIS), 2:395
calcifications in, 2:392f
Ductal ectasia, 2:395
Ductography, 2:459-460, 459f-460f
Ductus deferens
anatomy of, 2:242, 242f-243f
sectional anatomy of, 3:284
Duodenal bulb
anatomy of, 2:98f, 100f, 101
sectional anatomy of, 3:289, 298f
Duodenography, hypotonic, 2:123, 123f
Duodenojejunal flexure, 2:100f, 101
Duodenum
anatomy of, 2:97f-98f, 100f, 101
AP oblique projection of, 2:130-131,
130f-131f
AP projection of, 2:134
evaluation criteria for, 2:134b
position of part for, 2:134, 134f
position of patient for, 2:134, 134f
structures shown on, 2:134, 135f
hypotonic duodenography of, 2:123, 123f
lateral projection of, 2:132-133, 132f-133f
PA axial projection of, 2:126-127, 126f-127f
PA oblique projection of, 2:128-129,
128f-129f
PA projection of, 2:124-125
body habitus and, 2:124-125, 125f
central ray for, 2:124
double-contrast, 2:124f
evaluation criteria for, 2:125b
Duodenum (Continued)
position of part for, 2:124, 124f
position of patient for, 2:124
single-contrast, 2:124f
structures shown on, 2:124-125, 125f
sectional anatomy of, 3:282f, 283
on axial (transverse) plane, 3:289-290,
289f-290f
on coronal plane, 3:298
sectional image of, 2:107f
Duplex sonography, 3:392, 392f, 397
Dura mater
anatomy of, 3:3, 18
sectional anatomy of, 3:254, 256-257
Dural sac, 3:3, 3f
Dural sinuses, 3:254
Dural venous sinuses, 3:255
DVA (dual energy vertebral assessment),
3:469-470, 470f-471f, 477
DXA. See Dual energy x-ray absorptiometry
(DXA).
Dynamic imaging in nuclear medicine,
3:412
Dynamic rectal examination, 2:172, 172f
Dynamic renal scan, 3:419
Dynamic scanning with CT, 3:321, 339
Dyspnea, 3:96
E
EAM. See External acoustic meatus (EAM).
Index
Ear, 2:270f, 271
external
anatomy of, 2:270f, 271
sectional anatomy of, 3:267-268
internal, 2:269f-270f, 271
middle, 2:270f, 271
EBA (electron beam angiography), 3:95
EBT (electron beam tomography), 3:95-97
Echo planar imaging, 3:352-353, 367
Echocardiography, 3:393-396
of congenital heart lesions, 3:396
history of, 3:371
indications for, 3:393
pathology in, 3:393-396, 396f
procedure for, 3:393, 395f
Echogenic structure or mass, 3:374, 374f,
397
ED (emergency department), 2:18
Effective dose for CT, 3:331
Efferent arteriole of kidney, 2:185, 185f
Efferent lymph vessels, 3:26, 96
Ejaculatory ducts, 2:242, 243f
Ejection fraction, 3:96, 410, 411f, 437
Eklund method or maneuver for mammography,
2:403t-408t
with craniocaudal (CC) projection, 2:422-423,
422f-423f
with mediolateral oblique (MLO) projection,
2:425
Elbow, 1:151
AP oblique projection of
with lateral rotation, 1:155, 155f
with medial rotation, 1:154, 154f
AP projection of, 1:151, 151f
with distal humerus
in acute flexion, 1:158, 158f
in partial flexion, 1:156, 156f
with proximal forearm in partial flexion,
1:157, 157f
articulations of, 1:107, 107f
Coyle method for axiolateral projection of radial
head and coronoid fossa of, 1:162-164
evaluation criteria for, 1:164
position of part for, 1:162, 162f-163f
position of patient for, 1:162
structures shown on, 1:164, 164f
I-15
 Elbow (Continued) Endografts for abdominal aortic aneurysm, Esophagus (Continued)
fat pads of, 1:107, 107f 3:65-66, 65f-66f distal
lateromedial projection of, 1:152-153 Endometrial cancer, phosphorus-32 for, 3:420 AP projection of, 2:119f
evaluation criteria for, 1:153b Endometrial polyp, 2:245t PA oblique projection of (Wolf method),
in partial flexion for soft tissue image, 1:153, Endometrium 2:117f, 136-137, 136f
153f anatomy of, 2:240 exposure time for, 2:114
position of part for, 1:152, 152f-153f defined, 3:397 lateral projection of, 2:116f, 118-119
position of patient for, 1:152 endovaginal ultrasonography of, 3:388, oblique projections of, 2:118-119, 118f
for radial head, 1:160-161 389f opaque foreign bodies in, 2:117, 117f
evaluation criteria for, 1:161b Endomyocardial biopsy, 3:86, 86f-87f PA projection of, 2:118, 118f-119f
four-position series for, 1:160 Endorectal transducer, 3:396-397 sectional anatomy in abdominopelvic region of,
position of part for, 1:160, 160f Endoscopic retrograde cholangiopancreatography 3:283, 285
position of patient for, 1:160 (ERCP), 2:178, 178f-179f sectional anatomy in thoracic region of, 3:269f,
structures shown on, 1:161, 161f Endosteum, 1:76, 76f 270, 271f
structures shown on, 1:152-153, 152f-153f Endovaginal transducers, 3:375f, 388, 388f, on axial (transverse) plane
PA axial projection of 396-397 at Level A, 3:272, 272f
with distal humerus, 1:165, 165f Enema at Level B, 3:273
with olecranon process, 1:166, 166f barium. See Barium enema (BE). at Level C, 3:274-275, 274f
PA projection with proximal forearm in acute diagnostic through colostomy stoma, 2:170, at Level E, 3:275-277, 276f
flexion of, 1:159, 159f 170f-171f at Level F, 3:278, 278f
Elder abuse, 3:165, 165b Energy-switching systems for dual energy x-ray at Level G, 3:279f
Elderly. See also Aging. absorptiometry, 3:451f-452f, 452 on coronal plane, 3:281, 281f
age-related competencies, 3:176 beam hardening in, 3:452 on sagittal plane, 3:279, 280f
attitudes toward, 3:165-166 English/metric conversion, 1:30 Estrogen for osteoporosis, 3:448t
chronic conditions of, 3:164, 164b Enteritis, regional, 2:109t Ethics, 1:2-3
contrast agent administration in, 3:176 Enteroclysis procedure, 2:141 Ethmoid bone
demographics of, 3:162-166, 162f air-contrast, 2:141, 141f anatomy of, 2:262, 262f
economic status of, 3:163, 163f barium in, 2:141, 141f location of, 2:259f, 272f
exercise for, 3:167 CT, 2:141, 142f in orbit, 2:275, 275f, 312f
health care budget for, 3:163 iodinated contrast medium for, 2:141, 142f sectional anatomy of, 3:253
Index

health complaints in, 3:166-167, 167b
patient care for, 3:162-166, 175b
communication in, 3:175
patient and family education in, 3:175
skin care in, 3:175
transportation and lifting in, 3:175
radiographer’s role with, 3:176-177, 177b
radiographic positioning of, 3:177-181
for chest, 3:177-178, 178f
for lower extremity, 3:181, 181f
for pelvis and hip, 3:179, 179f
for spine, 3:178-179, 178f-179f
technical factors in, 3:181
for upper extremity, 3:180, 180f
summary of pathology in, 3:174t
tips for working with, 3:175b
Electron(s), 3:403, 403f, 438
Electron beam angiography (EBA), 3:95
Electron beam tomography (EBT), 3:95-97
Electron capture, 3:403, 438
Electronic portal imaging devices (EPIDs),
3:497
Electrophysiology studies, cardiac catheterization
for, 3:86, 87f
Ellipsoid joint, 1:82, 83f
Embolic agents, 3:66-67, 67b, 67t
Embolization, transcatheter. See Transcatheter
embolization.
Embolus, 3:96
pulmonary, 3:70
Embryo, 2:241
defined, 3:397
ultrasonography of, 3:388, 389f-390f
Emergency department (ED), 2:18
Emphysema, 1:486t
in older adults, 3:172, 172f, 174t
Enchondral ossification, 1:77
Enchondroma, 1:109t, 240t
Endocarditis, echocardiography of sub-bacterial,
3:393
Endocardium, 3:24, 96
Endocavity coil in MRI, 3:354, 354f
Endocrine system, nuclear medicine imaging of,
3:417-418
Endocrine system disorders in older adults,
3:173
Enterovaginal fistula, 2:250, 250f-251f
EOS system, 3:153, 155, 155f
Epicardium, 3:24, 96
Epicondyle, 1:84
EPID(s) (electronic portal imaging devices),
3:497
Epididymis, 2:242, 242f-243f
abscess of, 2:253f
Epididymitis, 2:245t
Epididymography, 2:253, 253f
Epididymovesiculography, 2:253
Epidural space, 3:3, 18
Epigastrium, 1:70f
Epiglottis, 2:71f, 72, 73f
Epiglottitis, 1:486t, 3:137, 137f
Epilation due to radiation, 3:481
Epinephrine, 2:226t
Epiphyseal artery, 1:77, 77f
Epiphyseal line, 1:77f-78f, 78
Epiphyseal plate, 1:77f-78f, 78
Epiphysis, 1:77f-78f, 78
slipped, 1:335t
Epithelial tissues, cancer arising from, 3:483, 483t,
506
Equipment room for MRI, 3:345
ERCP (endoscopic retrograde
cholangiopancreatography), 2:178,
178f-179f
Ergometer, 3:96
Erythema due to radiation, 3:481
Esophageal stricture, 2:119, 119f
Esophageal varices, 2:109t, 119, 119f
Esophagogastric junction, 3:283
Esophagus
anatomy of, 1:483, 483f, 2:97, 97f
AP oblique projection of, 2:118, 118f
AP projection of, 2:116f, 118, 119f
Barrett, 2:109t
contrast media studies of, 2:115-117, 115f
barium administration and respiration for,
2:119, 119f
barium sulfate mixture for, 2:115
double-contrast, 2:115, 117, 117f
examination procedures for, 2:116-117,
116f-117f
single-contrast, 2:115, 116f-117f
Ethmoidal air cells. See Ethmoidal sinuses.
Ethmoidal notch, 2:261, 261f
Ethmoidal sinuses
anatomy of, 2:276f-278f, 279
CT of, 2:262f
lateral projection of, 2:359f
location of, 2:261f-262f, 262
PA axial projection of, 2:360-361, 360f-361f
in facial bone radiography, 2:330f
in skull radiography, 2:298f
parietoacanthial projection of, 2:363f
sectional anatomy of, 3:253, 261-262, 261f,
265f
submentovertical projection of, 2:311f, 366-367,
366f-367f
Etiology, 3:506
EU. See Excretory urography (EU).
Eustachian tube, 2:270f, 271
Evacuation proctography, 2:172, 172f
Evert/eversion, 1:96, 96f
Ewing sarcoma, 1:109t, 240t
in children, 3:150, 150f
ExacTrac/Novalis Body system, 3:498-499
Excretory cystography
AP axial projection for, 2:217f
AP oblique projection for, 2:219f
Excretory system, 2:183
Excretory urography (EU), 2:201-203
contraindications to, 2:201
contrast media for, 2:194, 195f
defined, 2:191, 191f
equipment for, 2:198
indications for, 2:201
patient positioning for, 2:202, 202f
postvoiding, 2:203, 203f
prevoiding, 2:203, 203f
radiation protection for, 2:201
radiographic procedure for, 2:202-203
time intervals for, 2:202f-203f, 203
ureteral compression for, 2:200, 200f
Exercise
for older adults, 3:167
weight-bearing, and osteoporosis, 3:450
Exostosis, 1:240t
Expiration, 1:41
Explosive trauma, 2:19

I-16
Exposure factors
for obese patients, 1:50-52
for trauma radiography, 2:23, 23f
Exposure techniques
adaptation to patients of, 1:40-41, 41f
with anatomic programmers, 1:40, 40f
chart of, 1:38, 39f
factors to take into account in, 1:40
foundation, 1:38-40, 39f
measuring caliper in, 1:38, 39f
Exposure time, 1:42
for gastrointestinal radiography, 2:114
Extension, 1:96, 96f
External, 1:85
External acoustic meatus (EAM)
anatomy of, 2:271, 273f
in lateral aspect of cranium, 2:258f
with sphenoid bone, 2:264-265
with temporal bones, 2:268, 268f-270f
axiolateral oblique projection of, 2:352f
as lateral landmark, 2:285f
lateral projection of, 2:293f, 322f
in decubitus position, 2:295f
sectional anatomy of, 3:267-268, 267f
External auditory canal, 3:262-263, 263f, 267-268
External carotid artery
anatomy of, 3:49f, 50
sectional anatomy of, 3:267
External ear
anatomy of, 2:270f, 271
sectional anatomy of, 3:267-268
External iliac artery
anatomy of, 3:25
arteriography of, 3:48f
sectional anatomy of, 3:284, 293-294, 293f-294f
External iliac vein
sectional anatomy of, 3:284, 293-294, 294f
venography of, 3:48f
External oblique muscle, sectional anatomy on
axial (transverse) plane of
at Level B, 3:285, 286f
at Level C, 3:287f
at Level D, 3:288f
at Level E, 3:290
at Level G, 3:291
at Level I, 3:293, 293f
External occipital protuberance
anatomy of, 2:258f, 266, 266f-267f
sectional anatomy of, 3:253
External radiation detectors, 3:400-401, 438
External-beam therapy, 3:485, 506
Extravasation, 2:235, 3:36, 96
Extremity MRI scanner, 3:347, 347f
Eye
anatomy of, 2:314-316, 314f-315f
lateral projection of, 2:317, 317f
localization of foreign bodies within, 2:316, 316f
PA axial projection of, 2:318, 318f
parietoacanthial projection of (modified Waters
method), 2:319, 319f
preliminary examination of, 2:316
Eyeball, 2:314, 315f
F absorptiometry, 3:444, 454-457, 454f, 476
18
F. See Fluorine-18 (18F).
Fabella of femur, 1:233
Facet(s), 1:84, 368, 368f
Facet joints. See Zygapophyseal joints.
Facial bones
acanthioparietal projection of (reverse Waters
method), 2:327, 327f-328f
for trauma, 2:328, 328f
anatomy of, 2:257, 257b, 259f
function of, 2:257
hyoid bone as, 2:257, 275, 275f
inferior nasal conchae as, 2:272f, 273
Facial bones (Continued)
lacrimal bones as, 2:272, 272f-273f
lateral projection of, 2:320-321, 320f, 322f
mandible as
anatomy of, 2:274, 274f
axiolateral oblique projection of, 2:343-345,
343f-345f
axiolateral projection of, 2:343-345, 343f
PA axial projection of body of, 2:342, 342f
PA axial projection of rami of, 2:340, 340f
PA projection of body of, 2:341, 341f
PA projection of rami of, 2:339, 339f
panoramic tomography of, 2:353-354,
353f-354f
submentovertical projection of, 2:346, 346f
maxillary bones as, 2:259f, 272, 272f-273f
modified parietoacanthial projection of (modified
Waters method), 2:304, 325f-326f
nasal bones as
anatomy of, 2:259f, 272
lateral projection of, 2:331-332, 331f-332f
orbits as
anatomy of, 2:275, 275f
lateral projection of, 2:317, 317f
localization of foreign bodies within, 2:316,
316f
PA axial projection of, 2:318, 318f
parietoacanthial projection of (modified
Waters method), 2:319, 319f
preliminary examination of, 2:316
radiography of, 2:312-313, 312f-313f
PA axial projection of (Caldwell method),
2:329-330, 329f-330f
palatine bones as, 2:259f, 273
parietoacanthial projection of (Waters method),
2:323, 323f-324f
sectional anatomy of, 3:254
vomer as, 2:259f, 272f, 273
zygomatic bones as, 2:272f-273f, 273
Facial trauma, acanthioparietal projection (reverse
Waters method) for, 2:46, 46f
Fairness in code of ethics, 1:3
Falciform ligament
anatomy of, 2:104, 105f
sectional anatomy of, 3:283, 288
Fall(s) due to osteoporosis, 3:449
Fallopian tubes
anatomy of, 2:239, 239f-240f
hydrosalpinx of, 2:246f
hysterosalpingography of, 2:246-247,
246f-247f
sectional anatomy of, 3:284
Falx cerebri
anatomy of, 3:3, 18
sectional anatomy of, 3:254
on axial (transverse) plane, 3:256-258,
256f-257f
on coronal plane, 3:267, 267f
Familial adenomatous polyposis and colon cancer,
3:483
Familial cancer research, 3:483
Family education for older adults, 3:175
Fan-beam techniques for dual energy x-ray
Faraday’s law of induction, 3:343
FAST (focused abdominal sonography in trauma),
2:55
Fat necrosis, 2:395
Fat pads of elbow, 1:107, 107f
Fat-suppressed images, 3:367
FB. See Foreign body (FB).
FDCT (flat-detector CT), 3:307
Feet. See Foot (feet).
Female contraceptive devices, 2:248, 248f-249f
Female cystourethrography, 2:222-224, 222f
metallic bead chain, 2:222-224, 223f
Female pelvis, 1:332, 332f, 332t
PA projection of, 1:338f
transabdominal ultrasonography of, 3:387-388,
387f
Female reproductive system
anatomy of, 2:239-241
fetal development in, 2:241, 241f
ovaries in, 2:239, 239f
summary of, 2:244b
uterine tubes in, 2:239, 239f
uterus in, 2:240, 240f
vagina in, 2:240
radiography of, 2:246
for imaging of female contraceptive devices,
2:248, 248f-249f
in nonpregnant patient, 2:246-251
appointment date and care of patient for,
2:246
contrast media for, 2:246
hysterosalpingography for, 2:246-247,
246f-247f
pelvic pneumography for, 2:246, 250,
250f
preparation of intestinal tract for, 2:246
radiation protection for, 2:246
vaginography for, 2:246, 250-251,
250f-251f
in pregnant patient, 2:252
fetography for, 2:252, 252f
pelvimetry for, 2:252
Index
placentography for, 2:252
radiation protection for, 2:252
sectional anatomy of, 3:284
Femoral arteries, 3:284, 295, 295f
Femoral arteriogram, 3:240-241, 240f-241f
Femoral head
accurate localization of, 1:333, 333f
anatomy of, 1:328f-329f, 329
sectional anatomy of, 3:295-296, 295f-296f,
299
Femoral nailing, surgical radiography of,
3:233-235, 233f
antegrade, 3:233
evaluation criteria for, 3:235b
method for, 3:234, 234f-235f
retrograde, 3:234, 234f
structures shown on, 3:235, 235f
Femoral neck(s)
accurate localization of, 1:333, 333f
anatomy of, 1:328f-329f, 329
angulation of, 1:330, 330f
AP oblique projection of (modified Cleaves
method), 1:342-343
bilateral, 1:342, 342f
evaluation criteria for, 1:343b
position of part for, 1:342, 342f
position of patient for, 1:342
structures shown on, 1:343, 343f
unilateral, 1:342-343, 342f
AP projection of, 1:337-339, 337f
axiolateral projection of (original Cleaves
method), 1:344-345, 344f-345f
Femoral veins
sectional anatomy of, 3:284, 295,
295f-296f
venography of, 3:48f
Femorotibial joint. See Knee joint.
Femur
anatomy of, 1:232-233, 232f-233f
AP projection of, 1:318-319, 318f-319f
mobile, 3:202-203, 202f-203f
lateromedial projection of (mobile), 3:204-205,
204f-205f
mediolateral projection of, 1:320-321,
320f-321f
mobile, 3:204-205, 204f-205f
I-17
 Femur (Continued)
mobile radiography of, 3:202-203
AP projection for, 3:202-203, 202f-203f
lateral projection for, 3:204-205, 204f-205f
proximal, 1:325-360
anatomy of, 1:328f-330f, 329-330, 334b
AP projection of, 1:337-339, 337f-338f
DXA of, 3:466-467, 466f-467f
lateral projection of, 1:340-341, 340f-341f
sample exposure technique chart essential
projections for, 1:335t
summary of pathology of, 1:335t
summary of projections for, 1:326
Femur length, fetal ultrasound for, 3:390, 390f
Ferguson method
for AP axial projection of lumbosacral junction
and sacroiliac joints, 1:425-426, 425f
for PA projection of scoliosis, 1:439-440
evaluation criteria for, 1:439b-440b
first radiograph in, 1:439, 439f
position of part for, 1:439, 439f-440f
position of patient for, 1:439, 439f
second radiograph in, 1:439, 440f
structures shown on, 1:439-440,
439f-440f
Ferlic collimator-mounted filter
examples of, 1:56f
placement of, 1:58, 58f-59f
shape of, 1:57
Ferlic foot filter, 1:60t, 62f, 63
Index
Ferlic shoulder filter, 1:59f, 60-63, 60t, 63f
Ferlic swimmer’s filter, 1:60-63, 60t, 62f
Ferlic wedge filter, 1:61f
Fetal development, 2:241, 241f
Fetography, 2:252, 252f
Fetus, 2:241, 241f
defined, 3:397
ultrasonography of, 3:388, 390f-391f
FFDM. See Full-field digital mammography
(FFDM).
Fibrillation, 3:96
Fibroadenoma, 2:385f, 395, 431f
ultrasonography of, 3:384f
Fibroid, 2:245t, 247f
MRI of, 3:361f
transcatheter embolization for, 3:68, 69f
Fibrous capsule, 1:82, 82f
Fibrous joints, 1:80f, 80t, 81
Fibula
anatomy of, 1:230f-231f, 231
AP oblique projections of, 1:294-295,
294f-295f
AP projection of, 1:290-291, 290f-291f
lateral projection of, 1:292-293, 292f-293f
Fibular collateral ligament, 1:234f
Fibular notch, 1:230f-231f, 231
Field light size with obese patients, 1:50, 51f
Field of view (FOV)
in CT, 3:308, 339
scan vs. display, 3:320
for PET, 3:428-429, 428f, 431
Fifth lobe. See Insula.
Film badges, 3:407
Film size, 1:30, 30t
Filters, compensating. See Compensating filters.
Filum terminale, 3:3, 18
Fimbriae
anatomy of, 2:239, 239f
sectional anatomy of, 3:284
Fine-needle aspiration biopsy (FNAB) of breast,
2:461
Finger radiographs, display orientation of, 1:11,
11f
Fisk modification for tangential projection of
intertubercular (bicipital) groove, 1:207-208,
207f-208f
I-18
Fission, 3:404, 438
Fissure, 1:84
Fistula
abdominal, 2:180, 180f
defined, 2:62t
of reproductive tract, 2:245t, 250, 250f-251f
in urinary system, 2:188t
FLAIR (fluid attenuated inversion recovery),
3:352-353, 353f
Flat bones, 1:79, 79f
Flat-detector CT (FDCT), 3:307
Flat-panel CT (FPCT), 3:307
Flexion, 1:96, 96f
plantar, 1:97, 97f
Flexor retinaculum, 1:102, 102f
Flexor tendons, 1:102
Flocculation-resistant preparations
for alimentary canal imaging, 2:111, 111f
for large intestine contrast media studies,
2:144
Flow in MRI, 3:344, 344f
“Flow” study, 3:412
Fluid attenuated inversion recovery (FLAIR),
3:352-353, 353f
Fluoride for osteoporosis, 3:448t
Fluorine-18 (18F), 3:406t
decay scheme for, 3:425f
in PET, 3:424, 426t
Fluorine-18 (18F)-2-fluoro-2-deoxy-D-glucose
(18F-FDG), 3:427, 427f, 430f, 438
Fluorine-18 (18F)-2-fluoro-2-deoxy-D-glucose
(18F-FDG) neurologic study, 3:434
Fluorine-18 (18F)-2-fluoro-2-deoxy-D-glucose
(18F-FDG) oncologic study, 3:433-434
Fluorine-18 (18F)-Florbetapir, 3:434
Fluoroscopic C-arm, mobile, 2:20, 21f
Fluoroscopic equipment
for alimentary canal, 2:110, 113, 113f
for positive-contrast pharyngography, 2:75
Fluoroscopic image receptor, 1:3, 4f
Fluoroscopic surgical procedures, 3:223-241
of cervical spine (anterior cervical diskectomy
and fusion), 3:227, 227f
of chest (line placement, bronchoscopy), 3:226,
226f
femoral nailing as, 3:233-235, 233f
antegrade, 3:233
evaluation criteria for, 3:235b
method for, 3:234, 234f-235f
retrograde, 3:234, 234f
structures shown on, 3:235, 235f
femoral/tibial arteriogram as, 3:240-241,
240f-241f
of hip (cannulated hip screws or hip pinning),
3:230-232, 230f-232f
of humerus, 3:238-239, 238f-239f
of lumbar spine, 3:228-229, 228f-229f
operative (immediate) cholangiography as,
3:223-225, 224f-225f
tibial nailing as, 3:236-237
evaluation criteria for, 3:237b
position of C-arm for, 3:236, 236f
position of patient for, 3:236
structures shown on, 3:237, 237f
fMRI (functional magnetic resonance imaging),
3:366
FNAB (fine-needle aspiration biopsy) of breast,
2:461
Focal spot with obese patients, 1:51
Focused abdominal sonography in trauma (FAST),
2:55
Folia
anatomy of, 3:2
sectional anatomy of, 3:255
Folio method for first MCP joint of thumb, 1:122,
122f-123f
Follicular cyst, ultrasonography of, 3:388, 397
Fontanels, 2:259-260, 260f
Foot (feet)
anatomy of, 1:228-230, 228f-229f
AP oblique projection of
in lateral rotation, 1:258-259, 258f-259f
in medial rotation, 1:256, 256f-257f
AP or AP axial projection of, 1:252-253
central ray for, 1:252f-253f, 253
compensating filter for, 1:254-255
evaluation criteria for, 1:255b
position of part for, 1:252f-253f, 253
position of patient for, 1:252
structures shown on, 1:254-255,
254f-255f
weight-bearing method for
for both feet, 1:264, 264f
composite, 1:265-266, 265f-266f
calcaneus of
anatomy of, 1:228f-229f, 229
axial projection of
dorsoplantar, 1:272, 272f-273f
plantodorsal, 1:271, 271f
weight-bearing coalition (Harris-Beath)
method for, 1:273, 273f
mediolateral projection of, 1:274, 274f
weight-bearing method for lateromedial
oblique projection of, 1:275, 275f
congenital club-
defined, 1:240t
Kandel method for dorsoplantar axial
projection of, 1:270, 270f
Kite method for AP projection of, 1:267, 267f,
269f
Kite method for mediolateral projection of,
1:268-269, 268f-269f
dorsum (dorsal surface) of, 1:228-230
fore-, 1:228-230
hind-, 1:228-230
lateromedial weight-bearing projection of, 1:262,
262f-263f
longitudinal arch of
anatomy of, 1:228-230, 228f
weight-bearing method for lateromedial
projection of, 1:262, 262f-263f
mediolateral projection of, 1:260, 260f-261f
metatarsals of, 1:228f, 229
mid-, 1:228-230
phalanges of, 1:228, 228f
plantar surface of, 1:228-230
sesamoids of
anatomy of, 1:228f, 230
tangential projection of
Holly method for, 1:251, 251f
Lewis method for, 1:250-251, 250f
subtalar joint of
anatomy of, 1:236t, 237f, 238
Isherwood method for AP axial oblique
projection of
with lateral rotation ankle, 1:278,
278f
with medial rotation ankle, 1:277,
277f
Isherwood method for lateromedial oblique
projection with medial rotation foot of,
1:276, 276f
summary of pathology of, 1:240t
summary of projections for, 1:226
tarsals of, 1:228f-229f, 229
toes of. See Toes.
transverse arch of, 1:228-230
trauma radiography of, 2:52f
Foot radiographs, display orientation of,
1:11
Foramen(mina), 1:77, 84
Foramen lacerum, 2:258f, 268
Foramen magnum Fracture(s) (Continued) Functional age, age-specific competencies by,
anatomy of, 2:258f, 266, 266f-267f Salter-Harris, 3:130, 130f 1:23
AP axial projection of supracondylar, 3:131, 131f Functional image, 3:421, 438
Haas method for, 2:309f toddler’s, 3:130-131 Functional magnetic resonance imaging (fMRI),
Towne method for, 2:305f-307f torus, 1:109t, 3:130 3:366
myelogram of, 3:9f classification of, 1:84, 84f Fundus
sectional anatomy of, 3:253 compression, 1:84f, 380t of stomach, 2:98, 98f
Foramen of Luschka, 3:4 in older adults, 3:170, 170f, 174t of uterus, 2:240, 240f
Foramen of Magendie, 3:4 defined, 1:84 Fungal disease of lung, 1:486t
Foramen of Monro, 3:4 fragility, 3:447, 449, 449f, 476
Foramen ovale, 2:258f, 264f, 265 overall risk of, 3:474, 477 G
Foramen rotundum, 2:264f, 265 general terms for, 1:84 G (gauss) in MRI, 3:346, 367
67
Foramen spinosum greenstick, 1:84f, 3:130 Ga (gallium-67), 3:406t
anatomy of, 2:258f, 264f, 265 growth plate, 3:131 Gadolinium, 3:18
submentovertical projection of, 2:311f of lower limb, 1:240t Gadolinium oxyorthosilicate (GSO) as scintillator
Forearm, 1:148-149 mobile radiography with, 3:191 for PET, 3:428t
anatomy of, 1:102-103, 103f pathologic, 3:148-150 Gadolinium-based contrast agents (GBCAs) for
AP projection of, 1:148-149 of pelvis and proximal femora, 1:335t MRI, 3:355, 355f
CT for, 1:149-150 plastic or bow, 3:130 Galactocele, 2:395
evaluation criteria for, 1:149b Salter-Harris, 3:130, 130f Gallbladder
position of part for, 1:148, 148f of shoulder girdle, 1:182t anatomy of, 2:97f, 100f, 104f-106f, 106
position of patient for, 1:148 of skull, 2:282t biliary drainage procedure and stone extraction
structures shown on, 1:149-150, 149f supracondylar, 3:131, 131f for, 2:175, 175f
for trauma, 2:47f-48f toddler’s, 3:130-131 and body habitus, 2:106, 106f
cross-table lateral projection for trauma of, torus, 1:109t, 3:130 cholangiography of
2:47f-48f of upper limb, 1:109t percutaneous transhepatic, 2:174-175, 174f
DXA of, 3:468-469, 468f of vertebral column, 1:380t postoperative (T-tube), 2:176-177,
lateromedial projection of, 1:150, 150f Fracture risk models, 3:475 176f-177f
proximal Fragility fractures, 3:447, 449, 449f, 476 endoscopic retrograde cholangiopancreatography
AP projection in partial flexion of, 1:157, overall risk of, 3:474, 477 of, 2:178, 178f-179f

Index
157f Frank et al. method for PA and lateral projections MRI of, 3:361f
PA projection in acute flexion of, 1:159, of scoliosis, 1:437-438, 437f-438f prefixes associated with, 2:173, 173t
159f FRAX tool, 3:475-476 radiographic techniques for, 2:173
trauma radiography of, 2:47, 47f-48f French size, 3:96 sectional anatomy of, 3:287, 288f
Forearm fracture, surgical radiography of, 3:247f Frenulum of tongue, 2:59, 59f on axial (transverse) plane, 3:287, 288f-289f,
Forebrain, 3:2 Frequency 289
Forefoot, 1:228-230 in MRI, 3:343, 367 on coronal plane, 3:298-299, 298f
Foreign body (FB) in ultrasonography, 3:397 ultrasonography of, 3:373f, 378, 379f
in airway, 2:62t Fringe field in MRI, 3:346, 367 Gallium-67 (67Ga), 3:406t
in children, 3:139, 139f Frog leg position. See Cleaves method, for AP Gallstone(s)
aspiration of, 1:486t oblique projection of femoral necks. extraction of, 2:175, 175f
in children Frontal angle of parietal bone, 2:263f ultrasonography of, 3:379f
airway, 3:139, 139f Frontal bone Gamma camera
ingested, 3:139, 140f anatomy of, 2:261, 261f defined, 3:400, 438
interventional radiology for removal of, 3:72 location of, 2:257f-259f historical development of, 3:400
in orbit or eye, 2:316, 316f in orbit, 2:275, 275f, 312f modern, 3:408-409, 408f
lateral projection for, 2:317, 317f PA axial projection of, 2:298f multi-crystal, 3:409
PA axial projection for, 2:318, 318f sectional anatomy of, 3:253, 256f-257f, multihead, 3:409
parietoacanthial projection for (modified 257-260 Gamma Knife, 3:486-487, 487f
Waters method), 2:319, 319f Frontal eminence, 2:261, 261f Gamma ray(s), 3:403, 438
preliminary examination for, 2:316 Frontal lobe, sectional anatomy of, 3:254-255, 256f Gamma ray source for radiation oncology, 3:485,
Forward planning in radiation oncology, 3:495 on axial (transverse) plane 506
Fossa, 1:84 at level B, 3:257-258 Gamma well counter, 3:430
Four-dimensional imaging, ultrasonography for, at level C, 3:258, 258f Gantry for CT, 3:309-310, 309f, 339
3:372-373 at level D, 3:259-260, 259f Garth method for AP axial oblique projection of
Fourth ventricle at level E, 3:262f, 263 glenoid cavity, 1:205-206, 205f-206f
anatomy of, 3:4, 4f at Level E, 3:260f, 261-262 Gas bubble, 2:98
sectional anatomy of, 3:255 on sagittal plane, 3:264, 265f-266f, 266 Gastric antrum, ultrasonography of, 3:377f
on axial (transverse) plane, 1:332f, 3:259-263, Frontal sinuses Gastric artery
260f anatomy of, 2:276f-278f, 279 arteriography of, 3:42f
on coronal plane, 3:268, 268f lateral projection of, 2:322f, 359f sectional anatomy of, 3:284
on sagittal plane, 3:264, 266, 266f location of, 2:259f, 261, 261f Gastritis, 2:109t
FOV. See Field of view (FOV). PA axial projection of (Caldwell method), Gastroduodenal artery, arteriography of,
Fovea capitis, 1:328f, 329 2:330f, 360-361, 360f-361f 3:42f
Fowler position, 1:90, 91f parietoacanthial projection of, 2:363f Gastroesophageal reflux, 2:109t
FPCT (flat-panel CT), 3:307 sectional anatomy of, 3:253 Gastrografin (meglumine diatrizoate) for simulation
Fractionation, 3:480, 506 on axial (transverse) plane, 3:259-260, in radiation oncology, 3:490
Fracture(s), 1:84 262-263, 262f-263f Gastrointestinal (GI) intubation, 2:143, 143f
of bony thorax, 1:454t on sagittal plane, 3:265f Gastrointestinal (GI) series, 2:120, 120f
in children, 3:129-130 Frontal squama, 2:261, 261f barium sulfate suspension for, 2:120
due to child abuse, 3:143-145, 144f-145f Fuchs method for AP projection of dens, 1:383, biphasic, 2:123
greenstick, 1:84f, 3:130 383f components of, 2:120
growth plate, 3:131 Full-field digital mammography (FFDM), double-contrast, 2:122, 122f
due to osteogenesis imperfecta, 3:146t, 147 2:374-375 for nonambulatory patients, 2:120
pathologic, 3:148-150 labeling for, 2:409 preparation of patient for, 2:120
plastic or bowing, 3:130 technique chart for, 2:394t single-contrast, 2:121, 121f

I-19
 Gastrointestinal (GI) studies in children, 3:116-118
indications for, 3:118t
radiation protection for, 3:116, 116f
Gastrointestinal (GI) system. See Digestive system.
Gastrointestinal (GI) transit, 2:110
Gastroschisis, fetal ultrasound of, 3:391f
Gastroview (meglumine diatrizoate) for simulation
in radiation oncology, 3:490
Gating
cardiac
for CT angiography, 3:324-326, 326f
for MRI, 3:356, 356f
for MRI, 3:356, 356f, 367
respiratory, for radiation oncology, 3:498,
499f
Gauss (G) in MRI, 3:346, 367
Gaynor-Hart method for tangential projections of
wrist, 1:146
evaluation criteria for, 1:147b
inferosuperior, 1:146, 146f-147f
superoinferior, 1:147, 147f
GBCAs (gadolinium-based contrast agents) for
MRI, 3:355, 355f
Genant grading system, 3:470, 470f
Genetic mutations and cancer, 3:482
Genitourinary nuclear medicine, 3:419
Genitourinary studies in children, 3:116-118
indications for, 3:118t
radiation protection for, 3:116, 116f
with vesicoureteral reflux, 3:117-118, 117f
Index
Genitourinary system disorders in older adults,
3:173
Geriatrics, 3:161-182
age-related competencies in, 3:176
and attitudes toward older adult, 3:165-166
contrast agent administration in, 3:176
defined, 3:161-162, 174t
demographics and social effects of aging in,
3:162f-164f, 164b, 175
and elder abuse, 3:165, 165b
Joint Commission criteria for, 3:176
patient care in, 3:162-166, 175b
communication in, 3:175
patient and family education in, 3:175
skin care in, 3:175
transportation and lifting in, 3:175
physical, cognitive, and psychosocial effects of
aging in, 3:166-168, 167b, 167f
physiology of aging in, 3:168-173
endocrine system disorders in, 3:173
gastrointestinal system disorders in, 3:171,
171f
genitourinary system disorders in, 3:173
hematologic system disorders in, 3:173
immune system decline in, 3:172
integumentary system disorders in, 3:168
musculoskeletal system disorders in, 3:170,
170f-171f
nervous system disorders in, 3:168-169
respiratory system disorders in, 3:172, 172f
sensory system disorders in, 3:169
summary of, 3:173
radiographer’s role in, 3:176-177, 177b
radiographic positioning in, 3:177-181
for chest, 3:177-178, 178f
for lower extremity, 3:181, 181f
for pelvis and hip, 3:179, 179f
for spine, 3:178-179, 178f-179f
technical factors in, 3:181
for upper extremity, 3:180, 180f
summary of pathology in, 3:174t
Germicides, 1:16
Gerontology, 3:161-162, 174t
Gestational age, 3:371, 390, 397
Gestational sac, ultrasonography of, 3:388, 390f,
397
I-20
Gestational weeks, 3:388
GI. See Gastrointestinal (GI).
Giant cell tumor, 1:240t
Gianturco, Cesare, 3:20-21
Ginglymus joint, 1:82, 83f
Glabella
in anterior aspect of cranium, 2:257f
with frontal bone, 2:261f
in lateral aspect of cranium, 2:258f
in skull topography, 2:285f
Glabelloalveolar line, 2:285f
Glenohumeral joint, 1:178-180, 178t, 179f-181f
Glenoid, 3:273f
Glenoid cavity
anatomy of, 1:176f, 177
AP axial oblique projection (Garth method) of,
1:205-206, 205f-206f
AP oblique projection of
Apple method for, 1:190-191, 190f-191f
Grashey method for, 1:188-189, 188f-189f
Glenoid process, 1:179f
Gliding joint, 1:82, 83f
Globes, 3:261-262, 266, 266f
Glomerular capsule, 2:185, 185f
Glomerulonephritis, 2:188t
Glomerulus, 2:185, 185f
Glottis, 2:73
Gloves, 1:15
Glucagon, 2:106, 226t
Glucose, local metabolic rate of, 3:427, 427f
Glucose metabolism, PET image of, 3:430
Gluteus maximus muscle, 3:293-294, 293f-296f
Gluteus medius muscle, 3:293-294, 293f-294f
Gluteus minimus muscle, 3:293-294, 294f
Gomphosis, 1:80f, 81
Gonad(s), 2:242
Gonad dose, 1:35, 35t
Gonad shielding, 1:33-35, 33f-34f
for children, 3:108, 108f-109f
for upper limb, 1:110, 110f
Gonion, 2:274, 274f
in lateral aspect of skull, 2:273f
as surface landmark, 1:71f, 71t, 2:285f
Gout, 1:109t, 240t
Gowns
for patients, 1:20, 20f
for personnel, 1:15
Graafian follicle, 2:239, 239f
Gradient echo pulse sequence, 3:352-353, 367
Grandy method for lateral projection of cervical
vertebrae, 1:389-390, 389f-390f
Granulomatous disease of lung, 1:486t
Grashey method for AP oblique projection of
glenoid cavity, 1:188-189, 188f-189f
Graves disease, radioiodine for, 3:420
Gray matter, 3:2
Gray (Gy) units in radiation oncology, 3:494,
506
Gray-level mapping in CT, 3:10, 312, 312f,
312t
Grayscale image
in CT, 3:311, 339
in ultrasonography, 3:372, 397
Great cardiac vein, 3:25f
Great saphenous vein, ultrasonography of,
3:394f
Great vessels, 3:23, 25f
origins of
anomalous, 3:50
digital subtraction angiography of, 3:55f
transposition of, 3:97
Greater curvature of stomach
anatomy of, 2:98, 98f
sectional anatomy of, 3:283
Greater duodenal papilla, 2:101
Greater omentum, 3:283, 285, 286f-287f
Greater sciatic notch
anatomy of, 1:327f, 328, 330f
sectional anatomy of, 3:282
Greater trochanter
anatomy of, 1:232f, 328f-330f, 329
with obese patients, 1:49
sectional anatomy of, 3:295-296, 295f-296f
as surface landmark, 1:71f, 71t, 333, 333f
Greater tubercle
anatomy of, 1:104f, 105
defined, 1:76f
Greater wings of sphenoid
anatomy of, 2:258f, 259, 264f-265f, 265
sectional anatomy on axial (transverse) plane of,
3:263
at Level C, 3:258
at Level E, 3:260f, 261-262
at Level F, 3:262-263, 262f
Greenstick fracture, 1:84f, 3:130
Grenz rays, 3:506
Grids
in digital imaging, 1:38
for mammography, 2:374
in mobile radiography, 3:185-186, 185f-186f
in trauma radiography, 2:20
Groove, 1:84
Ground state, 3:403, 438
Growth hormone for osteoporosis, 3:448t
Growth plate fractures, 3:131
Gruntzig, Andreas, 3:20
GSO (gadolinium oxyorthosilicate) as scintillator
for PET, 3:428t
Guidewires for angiographic studies, 3:35, 35f,
96
“Gull-wing” sign, 1:340
Gunson method for positive-contrast
pharyngography, 2:75, 75f
Gy (gray) units in radiation oncology, 3:494, 506
Gynecography, 2:246, 250, 250f
Gynecologic applications of ultrasonography,
3:386-388
anatomic features and, 3:386, 386f
endovaginal transducers for, 3:375f, 388, 388f,
397
indications for, 3:387
of ovaries, 3:373f, 375f, 388, 389f
transabdominal, 3:387-388, 387f
of uterus, 3:387f-389f, 388
Gynecomastia, 2:426
Gyrus(i), 3:254-257, 256f
H
Haas method for PA axial projection of skull,
2:308-309
central ray for, 2:308, 308f
evaluation criteria for, 2:309b
position of part for, 2:308, 308f
position of patient for, 2:308
structures shown on, 2:309, 309f
Half-life (T 1 2 ), 3:403-404, 404f, 438
in brachytherapy, 3:485, 506
Half-value layer, 3:506
Hamartoma, 2:386f, 395
Hamate, 1:101f, 102
Hamulus, 1:84
Hand, 1:124
anatomy of, 1:99f, 101-102
articulations of, 1:105-107, 105f-106f
bone densitometry of, 3:474f
digits of. See Digit(s).
display orientation of, 1:11, 11f
fan lateral projection of, 1:128-129
evaluation criteria for, 1:129b
position of part for, 1:128, 128f
position of patient for, 1:128
structures shown on, 1:129, 129f
Hand (Continued)
lateromedial projection in flexion of, 1:130, 130f
mediolateral or lateromedial projection in
extension of, 1:128-129
evaluation criteria for, 1:129b
position of part for, 1:128, 128f
position of patient for, 1:128
with posterior rotation, 1:129
structures shown on, 1:129, 129f
Norgaard method for AP oblique projection in
medial rotation (ball-catcher’s position) of,
1:130-131
evaluation criteria for, 1:131b
position of part for, 1:130-131, 131f
position of patient for, 1:130
structures shown on, 1:131, 131f
PA oblique projection in lateral rotation of,
1:126-127
evaluation criteria for, 1:127b
position of part for, 1:126
to show joint spaces, 1:126, 126f
to show metacarpals, 1:126, 126f
position of patient for, 1:126
structures shown on, 1:127, 127f
PA projection of, 1:124
computed radiography for, 1:124-131
evaluation criteria for, 1:124b
position of part for, 1:124, 124f
position of patient for, 1:124
special techniques for, 1:124
structures shown on, 1:124, 125f
reverse oblique projection of, 1:127
tangential oblique projection of, 1:127
Handwashing, 1:15, 15f
Hangman’s fracture, 1:380t
Hard palate, 2:59, 59f, 71f
Hardware, 3:460
Harris-Beath method for axial projection of
calcaneus, 1:273, 273f
Haustra, 2:102, 102f
Haustral folds, 3:294
HBV (hepatitis B virus) and cancer, 3:482
HDR (high-dose-rate) brachytherapy, 3:485,
506
Head. See also Skull.
of bone, 1:84
Head and neck cancers, radiation oncology for,
3:503
Head circumference, fetal ultrasound for, 3:390,
390f
Head trauma
acanthioparietal projection (reverse Waters
method) for, 2:46, 46f
AP axial projection (Towne method) for,
2:44-45, 44f-45f
CT of, 2:29, 29f, 53-55, 54f
lateral projection for, 2:42-43, 42f-43f
Health Insurance Portability and Accountability Act
of 1996 (HIPAA), 3:460, 476
Hearing impairment in older adults, 3:169
Heart
anatomy of, 3:23-24, 25f
AP oblique projection of, 1:508-509
catheterization of
left side, 3:82, 83f-84f
right side, 3:84
CT angiography of, 3:324-326, 325f-326f
with cardiac gating, 3:324-326, 326f
echocardiography of, 3:393-396
for congenital heart lesions, 3:396
history of, 3:371
indications for, 3:393
pathology in, 3:393-396, 396f
procedure for, 3:393, 395f
lateral projection with barium of, 1:503
nuclear cardiology studies of, 3:416-417
Heart (Continued)
PA chest radiographs with barium of, 1:499
PA oblique projection with barium of, 1:505,
507
PET of, 3:434-435
in radiography of ribs, 1:468
in radiography of sternum, 1:456, 457f
sectional anatomy of, 3:270, 278-279, 285f
Heart shadows, 1:502f-503f
Heat trauma, 2:19
Heel, bone densitometry of, 3:475f
Helical CT, 3:339
multislice, 3:306, 323-324, 323f-324f
single slice, 3:306, 321-323, 322f
Helix, 2:270f, 271
Hemangioma of liver, 3:360f
Hematologic studies, in vivo and in vitro, 3:419
Hematologic system disorders in older adults,
3:173
Hematoma, 2:395
during catheterization, 3:36, 96
scalp, 3:10f
Hematopoietic tissue, cancer arising from,
3:483t
Hemidiaphragm, 3:278, 285
Hemodynamics, 3:96
Hemopneumothorax, 2:37f
Hemostasis, 3:96
Hepatic arteriogram, 3:41f-43f, 43
Hepatic artery
anatomy of, 2:104
sectional anatomy of, 3:283, 288f
ultrasonography of, 3:377f
Hepatic bile ducts, 3:283
Hepatic ducts
anatomy of, 2:105
sectional anatomy of, 3:283
Hepatic flexure
anatomy of, 2:102f, 103
sectional anatomy of, 3:283
on axial plane, 3:290, 290f
on coronal plane, 3:298-299, 298f
Hepatic veins
anatomy of, 2:104, 105f
sectional anatomy of, 3:284-285, 285f
Hepatic venography, 3:61, 61f
Hepatitis B virus (HBV) and cancer, 3:482
Hepatitis C virus and cancer, 3:482
Hepatopancreatic ampulla
anatomy of, 2:100f, 101, 105, 106f
sectional anatomy of, 3:283
Hereditary nonpolyposis colorectal cancer
syndrome, 3:483
Hernia
hiatal
AP projection of, 2:134, 135f
defined, 2:109t
PA oblique projection of (Wolf method),
2:136-137, 136f-137f
upright lateral projection of, 2:135f
inguinal, 2:109t
Herniated nucleus pulposus (HNP), 1:368, 380t,
3:358f
Heterogeneous structure or mass in
ultrasonography, 3:374, 374f, 397
Hiatal hernia
AP projection of, 2:134, 135f
defined, 2:109t
PA oblique projection of (Wolf method),
2:136-137, 136f-137f
upright lateral projection of, 2:135f
Hickey method for mediolateral projection of hip,
1:348, 349f
Hickman catheter placement, 3:226f
High-dose-rate (HDR) brachytherapy, 3:485,
506
Highlighting in CT, 3:304f
High-osmolality contrast agents (HOCAs) in
children, 3:116
High-resolution scans, 3:319-320, 321f, 339
Hill-Sachs defect, 1:182t
AP axial oblique projection of, 1:205
AP axial projection of, 1:204, 204f
inferosuperior axial projection of
Rafert modification of Lawrence method for,
1:194, 194f-195f
West Point method for, 1:196-197
Hindbrain, 3:2, 18
Hindfoot, 1:228-230
Hinge joint, 1:82, 83f
Hip(s)
AP projection of, 1:346-347, 346f-347f
axiolateral projection of (Danelius-Miller
method), 1:350-351, 350f-351f, 353f
Clements-Nakamaya modification of,
1:352-353, 352f-353f
in children, 3:125-126
developmental dysplasia of, 2:9t, 3:142,
142f
general principles for, 3:125-126, 125f
image evaluation for, 3:123t, 126
initial images of, 3:125
positioning and immobilization for, 3:126,
126f
preparation and communication for, 3:126
congenital dislocation of
Index
Andren–von Rosén method for, 1:345
AP projection for, 1:339, 339f
contrast arthrography of, 2:8f, 14, 14f
developmental dysplasia of, 2:9t, 3:142, 142f
DXA of, 3:466-467, 466f-467f
in geriatric patients, 3:179, 179f
mediolateral projection of (Lauenstein and
Hickey methods), 1:348, 348f-349f
MRI of, 3:362f
surgical radiography of, 3:230-232, 230f-232f
Hip arthrography, 2:14
AP oblique, 2:14f
axiolateral “frog”, 2:14f
with congenital dislocation, 2:8f, 14, 14f
of hip prosthesis, 2:14, 15f
digital subtraction technique for, 2:14, 15f
photographic subtraction technique for, 2:14,
15f
Hip bone
anatomy of, 1:327-328, 327f-328f, 334b
sample exposure technique chart essential
projections for, 1:335t
sectional anatomy of, 3:282
summary of pathology of, 1:335t
Hip dysplasia, congenital, 1:331t
Hip fractures due to osteoporosis, 3:449
Hip joint
anatomy of, 1:331, 331f, 331t
sectional anatomy of, 3:299, 299f
Hip joint replacement, surgical radiography of,
3:246f
Hip pads, 3:449
Hip pinning, 3:230-232, 230f-232f
Hip prosthesis, contrast arthrography of, 2:14, 15f
digital subtraction technique for, 2:14, 15f
photographic subtraction technique for, 2:14,
15f
Hip screws, cannulated, 3:230-232, 230f-232f
HIPAA (Health Insurance Portability and
Accountability Act of 1996), 3:460, 476
Hirschsprung disease, 2:109t
Histogram in CT, 3:304f
Histoplasmosis, 1:486t
History for trauma patient, 2:26
HNP (herniated nucleus pulposus), 1:368, 380t,
3:358f
I-21
 HOCAs (high-osmolality contrast agents) in
children, 3:116
Hodgkin lymphoma, radiation oncology for, 3:503
Holly method for tangential projection of
sesamoids, 1:251, 251f
Holmblad method for PA axial projection of
intercondylar fossa, 1:306-307
evaluation criteria for, 1:307b
position of part for, 1:307, 307f
position of patient for, 1:306, 306f
structures shown on, 1:307, 307f
Homeostasis, 3:402, 438
Homogeneous structure or mass in
ultrasonography, 3:374, 374f, 397
Hook of hamate, 1:102, 102f
Horizontal fissure of lungs, 1:481f, 482
Horizontal plane, 1:66, 66f-67f
Horizontal plate of palatine bones, 2:273
Horizontal ray method for contrast arthrography of
knee, 2:13, 13f
Horn, 1:84
Horseshoe kidney, 2:188t
Host computer for CT, 3:309, 339
Hot spots in radiation oncology, 3:495
Hounsfield units, 3:308, 308t, 339
HPV (human papillomavirus) and cancer, 3:482
Hughston method for tangential projection of
patella and patellofemoral joint, 1:313,
313f
Human papillomavirus (HPV) and cancer, 3:482
Index
Humeral condyle, 1:104, 104f
Humeral head, 3:273f
Humeroradial joint, 1:107, 107f
Humeroulnar joint, 1:107
Humerus
anatomy of, 1:104-105, 104f
AP projection of
recumbent, 1:169, 169f
for trauma, 2:49, 49f
upright, 1:167, 167f
distal
AP projection of
in acute flexion, 1:158, 158f
in partial flexion, 1:156, 156f
PA axial projection of, 1:165, 165f
lateromedial projection of
recumbent, 1:170, 170f
recumbent or lateral recumbent, 1:171,
171f
upright, 1:168, 168f
mediolateral projection of, 1:168, 168f
proximal
anatomic neck of, 1:177
anatomy of, 1:177-178, 177f
greater tubercle of, 1:177, 177f
head of, 1:177, 177f
intertubercular (bicipital) groove of
anatomy of, 1:177, 177f
Fisk modification for tangential projection
of, 1:207-208, 207f-208f
lesser tubercle of, 1:177, 177f
Stryker notch method for AP axial projection
of, 1:204, 204f
surgical neck of, 1:177, 177f
sectional anatomy of, 3:269f, 272f, 273
surgical radiography of, 3:238-239,
238f-239f
Hutchison-Gilford syndrome, 3:152
Hyaline membrane disease, 1:486t
Hybrid imaging, nuclear medicine in, 3:436
Hydrogen, magnetic properties of, 3:343, 343f
Hydronephrosis, 2:188t
ultrasonography of, 3:382f
fetal, 3:391f
Hydrosalpinx, 2:246f
Hydroxyzine hydrochloride (Vistaril), 2:226t
I-22
Hyoid bone, 2:257, 275, 275f
axiolateral oblique projection of, 2:344f
larynx and, 2:72f
pharynx and, 2:72
in sagittal section of face and neck, 2:71f
as surface landmark, 1:71f, 71t
Hyperechoic structure or mass, 3:397
Hyperextension, 1:96, 96f
Hyperflexion, 1:96, 96f
Hyperparathyroidism, 3:448, 476
Hypersthenic body habitus, 1:72-74, 72f, 73b, 74f
and gallbladder, 2:106, 106f
skull radiography with, 2:289f-290f
and stomach and duodenum, 2:99, 99f, 125f
and thoracic viscera, 1:479f
Hypertension
portal, 3:72
renal, 2:188t
Hypochondrium, 1:70f
Hypodermic needles, 2:228f, 229
Hypoechoic structure or mass, 3:397
Hypogastric artery, 3:25
Hypogastrium, 1:70f
Hypoglossal canals, 2:258f, 267, 267f
Hypophysis, 3:2f
Hyposmia, 3:169
Hyposthenic body habitus, 1:72-74, 72f, 73b
and gallbladder, 2:106, 106f
skull radiography with, 2:289f-290f
and stomach and duodenum, 2:99, 99f, 125f
and thoracic viscera, 1:479f
Hypothalamus, 3:259-260
Hypotonic duodenography, 2:123, 123f
Hysterosalpingography (HSG), 2:246-247, 247f
of bicornuate uterus, 2:247f
of fibroid, 2:247f
of hydrosalpinx, 2:246f
of IUD, 2:248f
I 36f
123
I (iodine-123), 3:406t
for thyroid scan, 3:417
131
I (iodine-131), 3:406t
for residual thyroid cancer or thyroid metastases,
3:420
131
I (iodine-131) thyroid uptake measurement,
3:418, 418f
IAM (internal acoustic meatus), 2:259f, 268, 268f,
270f, 271
Iatrogenic, 3:96
ICD (implantable cardioverter defibrillator), cardiac
catheterization for, 3:94, 94f
ID technique. See Implant displacement (ID)
technique.
Identification of radiographs, 1:25, 25f
IGRT (image-guided radiation therapy), 3:498,
498f, 506
Ileocecal studies, 2:139, 140f
Ileocecal valve
anatomy of, 2:102, 102f
sectional anatomy of, 3:283, 291
Ileum
anatomy of, 2:100f, 101, 102f
sectional anatomy of, 3:283, 291, 292f
Ileus, 2:84t, 109t
Iliac arteries, MR angiography of, 3:364f
Iliac bifurcation, MR angiography of, 3:364f
Iliac crest
anatomy of, 1:327f, 328, 330f
as bony landmark, 1:71f, 71t, 333, 333f
with obese patients, 1:47-49
sectional anatomy of, 3:292
Iliac fossa, 1:327f, 328
Iliac spine
anatomy of, 1:327f, 328
sectional anatomy of, 3:282
Iliac vessels as sonographic landmark, 3:373, 373f
Iliac wings, 3:299
Iliacus muscle, 3:293, 293f
Ilioischial column, 1:327, 327f, 356
Iliopectineal line, 3:386, 397
Iliopsoas muscles, 3:295, 295f
Iliopubic column, 1:327, 327f, 356
Ilium
anatomy of, 1:327-328, 327f
AP and PA oblique projections of, 1:360,
360f-361f
sectional anatomy of, 3:282
on axial (transverse) plane, 3:292f-294f,
293-294
on coronal plane, 3:298f-299f
Illuminator, 1:8
Image coregistration, 3:402, 402f, 438
Image enhancement methods for mammography,
2:427
magnification technique (M) as, 2:403t-408t,
428-429, 428f-429f, 432t
spot compression technique as, 2:403t-408t,
429-431, 430f-431f, 432t
Image intensification system, 2:113, 113f
Image magnification in CT, 3:304f
Image manipulation in CT, 3:303, 304f, 313, 313f
Image misregistration in CT, 3:321-323, 339
Image receptor (IR), 1:3, 4f
placement and orientation of anatomy on,
1:28-29, 28f-29f
size of, 1:30, 30t
with obese patients, 1:50, 50f
for trauma radiography, 2:30
Image receptor (IR) holders for trauma
radiography, 2:20
Image receptor (IR) units, over-table, 1:44-45, 45f
Image-guided radiation therapy (IGRT), 3:498,
498f, 506
“Imaging plates” (IPs) in digital radiography, 1:36,
Immobilization devices, 1:19, 19f
for simulation in radiation oncology, 3:490,
490f-491f
trauma radiography with, 2:23, 23f, 28, 30
Immobilization techniques
for abdominal radiography, 2:86, 87f
of children, 3:112-113, 112f-113f
for children
for abdominal radiography, 3:112-113,
112f-113f
for chest radiography, 3:118, 118f-120f, 124f
for gastrointestinal and genitourinary studies,
3:116f
holding as, 3:110
for limb radiography, 3:127-129, 127f-128f
for pelvis and hip radiography, 3:126, 126f
for skull radiography, 3:132, 133f, 135f
Immune system decline in older adults, 3:172
Impacted fracture, 1:84f
Implant displacement (ID) technique for
mammography, 2:403t-408t
with craniocaudal (CC) projection, 2:422-423,
422f-423f
with mediolateral oblique (MLO) projection,
2:425
Implantable cardioverter defibrillator (ICD),
cardiac catheterization for, 3:94, 94f
Implantation, 2:241
IMRT (intensity modulated radiation therapy),
3:489, 496, 506
111
In (indium-111), 3:406t
111
In (indium-111) pentetreotide (OctreoScan) for
tumor imaging, 3:415f, 420
In vitro hematologic studies, 3:419, 438
In vivo examination in nuclear medicine, 3:415,
438
In vivo hematologic studies, 3:419, 438 Innominate artery, 3:96 Internal oblique muscle, 3:288f, 290-291, 293,
Incontinence in older adults, 3:173, 174t anatomy of, 3:50 293f
Incus, 2:271 digital subtraction angiography of, 3:55f Internal occipital protuberance
Independent jaws of linear accelerators, 3:488f, Innominate bone. See Hip bone. anatomy of, 2:266, 267f
489, 506 In-profile view, 1:89 sectional anatomy of, 3:253, 259-260, 259f
Indexing in CT, 3:310, 339 Inspiration, 1:41 Interpeduncular cistern, 3:254, 259-260, 259f
Indirect effects of radiation, 3:484, 506 Instant vertebral analysis (IVA), 3:469-470, Interphalangeal (IP) joints
Indium-111 (111In), 3:406t 470f-471f, 477 of lower limb, 1:236, 236t, 237f
Indium-111 (111In) pentetreotide (OctreoScan) for In-stent restenosis, 3:96 of upper limb, 1:105, 105f-106f
tumor imaging, 3:415f, 420 Insula, 3:253f, 254-255, 258, 258f, 266-267 Interpupillary line, 2:285f
Infant development, 3:102 Insulin, 2:106 Intersinus septum, 2:276f, 279
Infection, nuclear medicine imaging for, Integrity in code of ethics, 1:3 Interstitial implant technique for brachytherapy,
3:419 Integumentary system disorders in older adults, 3:485
Infection control 3:168 Interstitial pneumonitis, 1:486t
for MRI, 3:348 IntellBeam adjustable filter, 3:332f Intertarsal articulations, 1:236t, 238
for venipuncture, 2:228 Intensity modulated radiation therapy (IMRT), Intertrochanteric crest, 1:328f, 329
Inferior angle of scapula, 1:71f, 71t, 85 3:489, 496, 506 Intertrochanteric line, 1:328f, 329
Inferior articular process, 1:368, 368f Interarticular facet joints. See Zygapophyseal Intertubercular groove
Inferior costal margin, 1:71f, 71t joints. anatomy of, 1:104f, 105
Inferior horn, 3:4, 4f Intercarpal articulations, 1:106, 106f Fisk modification for tangential projection of,
Inferior mesenteric arteriogram, 3:42f, 44, 45f Interchondral joints, 1:449t, 450, 450f 1:207-208, 207f-208f
Inferior mesenteric artery, 3:284, 298-299 Intercondylar eminence, 1:230, 230f Intervention, 3:96
Inferior mesenteric vein Intercondylar fossa Interventional, 3:96
anatomy of, 2:105f, 3:22f anatomy of, 1:232f-233f, 233 Interventional pain management, 3:16-18
sectional anatomy of, 3:284-285 Béclère method for AP axial projection of, Interventional procedures, CT for, 3:314, 314f-316f
Inferior nasal conchae 1:310, 310f Interventional radiology (IR), 3:62-74
anatomy of, 2:272f, 273 PA axial (tunnel) projection of for abdominal aortic aneurysm endografts,
sectional anatomy of, 3:254, 263f, 264, 265f Camp-Coventry method for, 1:308, 3:65-66, 65f-66f
Inferior orbital fissure, 2:272f, 312f, 313 308f-309f for cardiac catheterization. See Cardiac
Inferior orbital margin Holmblad method for, 1:306-307 catheterization.

Index
modified Waters method for parietoacanthial evaluation criteria for, 1:307b for children, 3:157-158, 157f-158f
projection of, 2:326f position of part for, 1:307, 307f of CNS, 3:15
PA axial projection of, 2:298f position of patient for, 1:306, 306f defined, 3:18
Inferior ramus, 1:327f-328f, 328 structures shown on, 1:307, 307f definition of terms for, 3:96b-97b
Inferior rectus muscle, 3:266, 266f Intercostal arteries, arteriography of, 3:40f historical development of, 3:20-21
Inferior sagittal sinus, 3:257-258, 257f, 267 Intercostal spaces, 1:448, 448f for inferior vena cava filter placement, 3:68-71,
Inferior thoracic aperture, 1:479, 479f Intercuneiform articulations, 1:236t, 237f, 238 70f-71f
Inferior vena cava (IVC) Interhemispheric fissure, 3:2 other procedures in, 3:72
anatomy of, 2:105f, 3:22f, 24, 25f Interiliac plane, 1:68, 69f percutaneous transluminal angioplasty as,
sectional anatomy in abdominopelvic region of, Intermembranous ossification, 1:77 3:62-65
3:278, 279f Intermetatarsal articulations, 1:236t, 237f, 238 balloon in, 3:62-63, 63f
on axial (transverse) plane, 3:282f, 284 Internal, 1:85 of common iliac artery, 3:64f
at Level A, 3:285, 285f Internal acoustic meatus (IAM), 2:259f, 268, 268f, Dotter method for, 3:62
at Level B, 3:285, 286f 270f, 271 for placement of intravascular stents, 3:65,
at Level C, 3:287f Internal capsule, 3:253f, 258-259, 267, 267f 65f
at Level D, 3:288, 288f Internal carotid artery of renal artery, 3:64f
at Level E, 3:289, 289f anatomy of, 3:49f, 50 present and future of, 3:74, 74f
at Level F, 3:290f arteriography of, 3:50f, 53f-54f transcatheter embolization as, 3:66-68
at Level G, 3:291, 291f AP axial oblique projection for, 3:58f in cerebral vasculature, 3:68, 69f
at Level I, 3:293 AP projection for, 3:52f embolic agents for, 3:66-67, 67b, 67t
on coronal plane, 3:298-299, 298f lateral projection for, 3:52f-53f, 56f of hypervascular uterine fibroid, 3:68, 69f
sectional anatomy in thoracic region of, 3:271 digital subtraction angiography of, 3:31f lesions amenable to, 3:66-67, 67b
sectional image of, 2:107f MR angiography of, 3:363f stainless steel occluding coils for, 3:68, 68f
ultrasonography of, 3:376f-377f sectional anatomy of, 3:255 vascular plug for, 3:68, 68f
Inferior vena cava (IVC) filter placement, 3:68-71, on axial (transverse) plane for transjugular intrahepatic portosystemic shunt,
70f-71f at Level D, 3:259f, 260-261 3:72, 72f-73f
Inferior vena cavogram, 3:60, 60f at Level E, 3:261-262, 261f Interventricular foramen, 3:4, 4f
Inferior vertebral notch, 1:368f at Level F, 3:262-263, 262f Interventricular septal integrity, 3:96
Infiltration, 2:235 at Level G, 3:263f, 264 Interventricular septum, 3:270, 278, 278f-279f
Inframammary crease, 2:381f on coronal plane, 3:267 Intervertebral disks, 1:368
Infraorbital foramen, 2:272, 272f on sagittal plane, 3:265, 265f Intervertebral foramina
Infraorbital margin, 2:285f, 330f stenosis of, 3:14f anatomy of, 1:368
Infraorbitomeatal line (IOML), 2:44, 320, 346 three-dimensional reconstruction of, 3:34f sectional anatomy of, 3:269-270, 278-279, 280f
Infrapatellar bursa, 1:82f Internal carotid venogram, 3:52f Intervertebral joints, 1:378, 379t
Infraspinatus muscle Internal iliac artery Intervertebral transverse foramina, 1:371, 371f,
anatomy of, 1:180f anatomy of, 3:25 371t
sectional anatomy of, 3:271, 273-275, sectional anatomy of, 3:284, 293, 293f Intestinal intubation, 2:143, 143f
273f-274f Internal iliac vein, 3:284, 293 Intestinal tract preparation
Infundibulum, 2:239, 239f Internal jugular vein for contrast media studies
Ingested foreign body, 3:139, 140f anatomy of, 3:22f of colon, 2:146, 146f
Inguinal hernia, 2:109t sectional anatomy of, 3:255, 262-264, 262f, of urinary system, 2:196-197, 196f-197f
Inguinal ligament, 3:295 269f, 271 for female reproductive system radiography,
Inguinal region, 1:70f on axial (transverse) plane, 3:272-273, 2:246
Inion, 2:258f, 266, 266f 272f-273f Intima
Initial examination, 1:14 on coronal plane, 3:280-281 anatomy of, 3:65
Inner canthus, 2:285f Internal mammary lymph nodes, 2:380, 381f ultrasonography of, 3:383, 397

I-23
 Intracavitary implant technique for brachytherapy, Isherwood method Kidney(s), 2:184-185
3:485 for AP axial oblique projection of subtalar joint anatomy of, 2:184-185, 185f
Intracoronary stent, 3:88, 89f, 96 with lateral rotation ankle, 1:278, 278f angiography of, 2:190, 191f
Intraperitoneal organs, 3:283 with medial rotation ankle, 1:277, 277f CT of, 2:190, 191f
Intrathecal injections, 3:6, 12, 18 for lateromedial oblique projection of subtalar function of, 2:183
Intrauterine devices (IUDs) joint, 1:276, 276f horseshoe, 2:188t
imaging of, 2:248, 248f-249f Ishimore, Shoji, 3:21 location of, 2:183f-184f, 184
ultrasonography of, 3:389f Island of Reil. See Insula. nephrotomography of, 2:190, 191f
Intravascular stent placement Islet cells, 2:106 AP projection in, 2:209, 209f
percutaneous transluminal angioplasty for, 3:65, Islets of Langerhans, 2:106 percutaneous renal puncture for, 2:210-211,
65f Isocentric machine, cobalt-60 unit as, 3:486, 210f
percutaneous transluminal coronary angioplasty 506 pelvic, 2:188t
for, 3:88, 89f Isodose line/curve in radiation oncology, 3:494, polycystic, 2:188t
Intravascular ultrasound (IVUS), 3:80t, 91, 506 sectional anatomy of, 3:282f, 283
91f-92f Isoechoic structure or mass, 3:397 on axial (transverse) plane, 3:290, 290f-291f
Intravenous (IV) medication administration. See Isolation unit on coronal plane, 3:299, 299f
Venipuncture. mobile radiography in, 3:189 sectional image of, 2:107f
Intravenous urography (IVU). See Excretory standard precautions for patient in, 1:15, 15f ultrasonography of, 3:382-383, 382f
urography (EU). Isotopes, 3:403, 438 urography of. See Urography.
Intraventricular foramina (of Monro), 3:264 in radiation oncology, 3:486, 506 Kidney stone, ultrasonography of, 3:382f
Introducer sheaths for angiographic studies, 3:36, Isotropic emission, 3:429, 438 Kilovoltage (kV) in digital imaging, 1:37, 37f
36f, 97 Isotropic spatial resolution, 3:339 Kilovoltage peak (kVp)
Intubation examination procedures for small Isthmus control of, 1:42
intestine, 2:143, 143f of uterine tube, 2:239, 239f in digital imaging, 1:37, 37f
Intussusception, 2:109t of uterus, 2:240, 240f for obese patients, 1:50
in children, 3:114, 114f IUDs (intrauterine devices) in this atlas, 1:42
Invasive/infiltrating ductal carcinoma, 2:395, 449f, imaging of, 2:248, 248f-249f Kinetics, 3:421, 438
458f ultrasonography of, 3:389f Kite method
architectural distortion due to, 2:393f IV (intravenous) medication administration. for AP projection of clubfoot, 1:267, 267f, 269f
Inversion recovery, 3:352-353, 367 See Venipuncture. for mediolateral projection of clubfoot,
Index

Invert/inversion, 1:96f IVA (instant vertebral analysis), 3:469-470, 1:268-269, 268f-269f

Involuntary muscles, motion control of, 470f-471f, 477 Kleinschmidt, Otto, 2:372
1:18-19 IVC. See Inferior vena cava (IVC). Knee
Involution of breasts, 2:380 IVU (intravenous urography). See Excretory contrast arthrography of, 2:12
Iodinated contrast media urography (EU). double-contrast (horizontal ray method), 2:13,
for alimentary canal imaging, 2:111-112, IVUS (intravascular ultrasound), 3:80t, 91, 13f
111f-112f 91f-92f vertical ray method for, 2:12, 12f
for angiographic studies, 3:29 CT of, 3:336f-338f
for large intestine studies, 2:145 J MRI of, 3:347, 347f
for urinary system imaging, adverse reactions to, Jefferson fracture, 1:380t Knee joint
2:196 Jejunum anatomy of, 1:234-235, 234f-235f, 236t, 238,
Iodine-123 (123I), 3:406t anatomy of, 2:100f, 101 238f
for thyroid scan, 3:417 sectional anatomy of, 3:283, 289 AP oblique projection of
Iodine-131 (131I), 3:406t Jewelry, 1:20, 21f in lateral rotation, 1:304, 304f
for residual thyroid cancer or thyroid metastases, Joint(s), 1:80-82 in medial rotation, 1:305, 305f
3:420 cartilaginous, 1:80t, 81, 81f AP projection of, 1:296, 296f-297f
Iodine-131 (131I) thyroid uptake measurement, fibrous, 1:80f, 80t, 81 weight-bearing method for, 1:302, 302f
3:418, 418f functional classification of, 1:81 mediolateral projection of, 1:300-301,
IOML (infraorbitomeatal line), 2:44, 320, in long bone studies, 1:28, 29f 300f-301f
346 structural classification of, 1:80t, 81-82 PA projection of, 1:298-299, 298f-299f
Ionization, 3:484, 506 synovial, 1:80t, 82, 82f-83f Rosenberg weight-bearing method for, 1:303,
Ionizing radiation and cancer, 3:482, 506 Joint capsule tear, 2:9t 303f
IP(s) (imaging plates) in digital radiography, 1:36, Joint effusion, 1:109t Kneecap. See Patella.
36f Joint Review Committee on Education in Knuckles, 1:101
IP (interphalangeal) joints Radiologic Technology (JRCERT), 1:23 KUB projection of abdomen, 2:87, 89-90, 89f-90f
of lower limb, 1:236, 236t, 237f Jones fracture, 1:240t kV (kilovoltage) in digital imaging, 1:37, 37f
of upper limb, 1:105, 105f-106f Judd method for PA projection of dens, 1:383 kVp. See Kilovoltage peak (kVp).
Ipsilateral, 1:85 Judet method for AP oblique projection of Kyphoplasty, 3:16, 18
IR. See Image receptor (IR); Interventional acetabulum, 1:356-357, 356f-357f balloon, for osteoporotic fractures, 3:449, 449f
radiology (IR). Judkins, Melvin, 3:20 Kyphosis, 1:367, 367f, 380t
Iris, 2:314f, 315 Jugular foramen, 2:258f, 267 adolescent, 1:380t
Iron oxide mixtures for MRI, 3:355 Jugular notch and bone densitometry, 3:476
Irregular bones, 1:79, 79f anatomy of, 1:447-448, 447f in older adults, 3:170, 170f, 174t
Ischemia, ultrasonography of, 3:397 with obese patients, 1:49, 49f Kyphotic curves, 1:366f, 367
Ischemic, 3:97 sectional anatomy of, 3:256, 273
Ischial ramus, 1:327f, 328 as surface landmark, 1:71f, 71t L
Ischial spine Jugular process, 2:267f L5-S1 junction
anatomy of, 1:327f, 330f Jugular veins, 3:271 AP oblique projection of, 1:421, 422f
sectional anatomy of, 3:296 lateral projection of, 1:419-420, 419f-420f
Ischial tuberosity K Labyrinths
anatomy of, 1:327f-328f, 328, 330f Kandel method for dorsoplantar axial projection of anatomy of, 2:262
as bony landmark, 1:333f clubfoot, 1:270, 270f sectional anatomy of, 3:253, 253f
Ischium K-edge filtration systems for DXA, 3:451, Lacrimal bones
anatomy of, 1:327-328, 327f 451f-452f anatomy of, 2:272, 272f-273f
sectional anatomy of, 3:282, 294-295, crossover in, 3:452 in orbit, 2:275, 275f, 312f
295f-296f scintillating detector pileup in, 3:452 sectional anatomy of, 3:254

I-24
Lacrimal foramen, 2:272
Lacrimal fossae, 2:272
Lacrimal sac, 2:314f
Lactation, breasts during, 2:382, 382f
Lactiferous ductules, 2:380, 381f
Lambda, 2:258f, 259
Lambdoidal suture, 2:258f, 259, 275t
Laminae of vertebral arch, 1:368, 368f
Landmarks, 1:71, 71f, 71t
with obese patients, 1:47-49, 49f
LAO (left anterior oblique) position, 1:92, 92f
Laquerrière-Pierquin method for tangential
projection of scapular spine, 1:224, 224f
Large intestine. See Colon.
Large part area shield, 1:33, 34f
Large saphenous vein, 3:22f
Large-core needle biopsy (LCNB) of breast,
2:461
Larmor frequency in MRI, 3:343
Laryngeal cancer, radiation oncology for,
3:504
Laryngeal cavity, 2:73
Laryngeal vestibule, 2:73
Laryngopharynx, 2:71f, 72
Larynx
anatomy of, 2:71f-73f, 72-73
AP projection of, 2:76-77, 76f-77f
lateral projection of, 2:78-79, 78f-79f
methods of examination of, 2:74-75
Laser printer for digital subtraction angiography,
3:31
Lateral, 1:85
Lateral apertures, 3:4
Lateral collateral ligament, 1:236f
Lateral condyle
of femur, 1:232f-233f, 233
of tibia, 1:230, 230f
Lateral decubitus position, 1:94, 94f
Lateral epicondyle
of femur, 1:232f, 233
of humerus, 1:104, 104f
Lateral fissure, 3:258f, 266-267, 267f
Lateral intercondylar tubercle, 1:230, 230f
Lateral malleolus, 1:230f-231f, 231
Lateral mass. See Vertebral arch.
Lateral meniscus
anatomy of, 1:234f-236f, 235
double-contrast arthrography of, 2:13, 13f
Lateral position, 1:91, 91f
Lateral projection, 1:11, 12f, 88, 88f
of obese patients, 1:49
Lateral pterygoid lamina, 2:265f, 266
Lateral recess, 3:4f
Lateral recumbent position, 1:90, 90f
Lateral resolution in ultrasonography, 3:397
Lateral rotation, 1:93, 93f, 97, 97f
Lateral sinus, 3:255
Lateral sulcus, 3:2f
Lateral ventricles
anatomy of, 3:2, 4, 4f
anterior horn of, 3:253f, 258f, 264
posterior horn of, 3:253f, 258f
sectional anatomy of, 3:255
on axial (transverse) plane, 3:257-259, 257f
on coronal plane, 3:267, 267f-268f
on sagittal plane, 3:265-266, 265f-266f
temporal horn of, 3:258f-259f
Lateral vertebral assessment (LVA), 3:469-470,
470f-471f, 477
Lateromedial projection, 1:88, 88f
Latissimus dorsi muscle, sectional anatomy of
in abdominopelvic region, 3:285,
285f-287f
in thoracic region, 3:278, 278f-279f
Lauenstein method for mediolateral projection of
hip, 1:348, 348f-349f
Lauterbur, Paul, 3:342 Lipoma, 2:386f, 395, 447f
Law method (modified) for axiolateral oblique Lithotomy position, 1:90, 91f
projection of TMJ, 2:345f, 351-352, Liver
351f-352f anatomy of, 2:104-106, 104f-105f
Lawrence method combined SPECT/CT of, 3:415f
for inferosuperior axial projection of shoulder functions of, 2:104
joint, 1:194, 194f-195f hemangioma of, 3:360f
for transthoracic lateral projection of shoulder, MRI of, 3:360f
1:192-193, 192f-193f nuclear medicine imaging of, 3:418
LCBF (local cerebral blood flow), PET images of, sectional anatomy in abdominopelvic region of,
3:427, 427f, 438 3:282f, 283
LCIS (lobular carcinoma in situ), 2:395 on axial (transverse) plane, 3:285, 285f-290f,
LCNB (large-core needle biopsy) of breast, 287-290
2:461 at Level A, 3:285, 285f
LDR (low-dose-rate) brachytherapy, 3:485, 506 at Level B, 3:285, 286f
Le Fort fracture, 2:282t at Level C, 3:287, 287f
Least significant change (LSC) in DXA, 3:456, at Level D, 3:288, 288f
476 at Level E, 3:289, 289f
Left anterior oblique (LAO) position, 1:92, 92f at Level F, 3:290, 290f
Left colic flexure, 2:102f, 103, 114f on coronal plane, 3:298-299, 298f
Left lower quadrant (LLQ), 1:70, 70f sectional anatomy in thoracic region of, 3:278,
Left posterior oblique (LPO) position, 1:93, 93f 279f-280f
Left upper quadrant (LUQ), 1:70, 70f sectional image of, 2:107f
Left ventricular ejection fracture, computerized ultrasonography of, 3:373f-374f, 376f-378f,
planimetry for evaluation of, 3:82-84, 84f 378
Left ventriculography, 3:82-84, 83f-84f LLQ (left lower quadrant), 1:70, 70f
Leg. See Lower limb. Lobar pneumonia, 1:486t
Legg-Calvé-Perthes disease, 1:335t in children, 3:151
Leiomyoma, 3:397 Lobes of breast, 2:380
Lengthwise position, 1:28, 28f Lobular carcinoma in situ (LCIS), 2:395
Index
Lens Lobular pneumonia, 1:486t
anatomy of, 2:314f-315f Lobules of breast, 2:380, 381f
sectional anatomy of, 3:253f LOCA(s) (low-osmolality contrast agents) in
Lentiform nucleus, 3:253f, 258-259, 258f, 267f children, 3:116
Lesions, 3:97, 480, 506 Local cerebral blood flow (LCBF), PET images of,
Lesser curvature of stomach 3:427, 427f, 438
anatomy of, 2:98, 98f Local metabolic rate of glucose, 3:427, 427f
sectional anatomy of, 3:283 Long bone(s), 1:79, 79f
Lesser sciatic notch, 1:327f, 328 anatomy of, 1:76
Lesser trochanter, 1:232f, 328f, 329 vessels and nerves of, 1:77, 77f
Lesser tubercle, 1:104f, 105 Long bone measurement, 2:1-6
Lesser wings of sphenoid abbreviations for, 2:2b
anatomy of, 2:258f, 264f-265f, 265 bilateral, 2:4-5, 4f
sectional anatomy of, 3:253-254, 262 CT for, 2:6, 6f
LET (linear energy transfer), 3:484, 506 digital imaging for, 2:2
Levator scapulae, 3:272f digital postprocessing for, 2:2
Level I trauma center, 2:19 imaging methods for, 2:2
Level II trauma center, 2:19 with leg length discrepancy, 2:4f-5f, 5
Level III trauma center, 2:19 localization of joints in, 2:2-5
Level IV trauma center, 2:19 magnification in, 2:2-3, 3f
Lewis method for tangential projection of orthoroentgenogram for, 2:2-3, 3f
sesamoids, 1:250-251, 250f position of part for, 2:2
Life stage, age-specific competencies by, 1:23 position of patient for, 2:2
Lifting of older adults, 3:175 radiation protection for, 2:2
Ligament of Treitz scanogram for, 2:2
anatomy of, 2:100f, 101 teleoroentgenogram for, 2:2
sectional anatomy of, 3:283 unilateral, 2:4f-5f, 5
Ligament tear, 2:9t of upper limb, 2:2, 5, 5f
Ligamentum capitis femoris, 1:329f Long bone studies
Ligamentum teres, 3:283, 287 joint in, 1:28, 29f
Ligamentum venosum, 3:283 in tall patients, 1:28
Light pipe of gamma camera, 3:408f, 409, 438 Longitudinal angulation, 1:87
Limb(s). See Lower limb; Upper limb. Longitudinal arch
Lindblom method for AP axial projection of anatomy of, 1:228-230, 228f
pulmonary apices, 1:512-513, 512f-513f weight-bearing method for lateromedial
Line, 1:84 projection of, 1:262, 262f-263f
Line placement, chest radiography during, 3:226, Longitudinal cerebral fissure, 3:256-257
226f Longitudinal fissure, 3:254-255, 257-258, 257f
Linear accelerators (linacs) for radiation oncology, Longitudinal plane in MRI, 3:343, 367
3:485, 487-489, 488f, 506 Longitudinal quality control for DXA, 3:461-462,
Linear energy transfer (LET), 3:484, 506 461f-462f, 476
Linear skull fracture, 2:282t Longitudinal sulcus, 3:2
Linens, 1:15 Loop of Henle, 2:185, 185f
Lingula Lordosis, 1:367, 367f, 380t
anatomy of, 1:482 Lordotic curves, 1:366f, 367
sectional anatomy of, 3:270, 278 Lordotic position, 1:94, 95f
I-25
 Low-dose-rate (LDR) brachytherapy, 3:485, 506
Lower limb, 1:225-322
abbreviations used for, 1:239b
anatomy of, 1:242
articulations in, 1:236-238, 236f-238f, 236t
femur in, 1:232-233, 232f-233f
fibula in, 1:231, 231f
foot in, 1:228-230, 228f-229f
knee joint in, 1:234-235, 234f-235f
patella in, 1:233, 233f
summary of, 1:239b
tibia in, 1:230-231, 230f-231f
ankle of. See Ankle.
arteriography of, 3:47, 48f
calcaneus of
anatomy of, 1:228f-229f, 229
axial projection of
dorsoplantar, 1:272, 272f-273f
plantodorsal, 1:271, 271f
weight-bearing coalition (Harris-Beath)
method for, 1:273, 273f
mediolateral projection of, 1:274, 274f
weight-bearing method for lateromedial
oblique projection of, 1:275, 275f
in children, 3:127-131
with fractures, 3:129-130, 130f-131f
image evaluation for, 3:123t, 131
immobilization for, 3:127-129, 128f
radiation protection for, 3:129, 129f
dislocation-fracture of, 2:51f
Index
femur of
anatomy of, 1:232-233, 232f-233f
AP projection of, 1:318-319, 318f-319f
mediolateral projection of, 1:320-321,
320f-321f
fibula of
anatomy of, 1:230f-231f, 231
AP oblique projections of, 1:294-295,
294f-295f
AP projection of, 1:290-291, 290f-291f
lateral projection of, 1:292-293, 292f-293f
foot (feet) of. See Foot (feet).
of geriatric patients, 3:181, 181f
intercondylar fossa of
anatomy of, 1:232f-233f, 233
Béclère method for AP axial projection of,
1:310, 310f
PA axial (tunnel) projection of
Camp-Coventry method for, 1:308,
308f-309f
Holmblad method for, 1:306-307, 306f-307f
knee joint of
anatomy of, 1:234-235, 234f-235f
AP oblique projection of
in lateral rotation, 1:304, 304f
in medial rotation, 1:305, 305f
AP projection of, 1:296, 296f-297f
weight-bearing method for, 1:302, 302f
mediolateral projection of, 1:300-301,
300f-301f
PA projection of, 1:298-299, 298f-299f
Rosenberg weight-bearing method for,
1:303, 303f
long bone measurement of. See Long bone
measurement.
MRI of, 3:360-362, 362f-363f
patella of
anatomy of, 1:233, 233f
mediolateral projection of, 1:312, 312f
PA projection of, 1:311, 311f
tangential projection of
Hughston method for, 1:313, 313f
Merchant method for, 1:314-315,
314f-315f
Settegast method for, 1:316-317,
316f-317f
I-26
Lower limb (Continued)
patellofemoral joint of
anatomy of, 1:238, 238f
tangential projection of
Hughston method for, 1:313, 313f
Merchant method for, 1:314-315, 314f-315f
Settegast method for, 1:316-317, 316f-317f
radiation protection for, 1:242
sample exposure technique chart essential
projections for, 1:241t
subtalar joint of
anatomy of, 1:236t, 237f, 238
Isherwood method for AP axial oblique
projection of
with lateral rotation ankle, 1:278, 278f
with medial rotation ankle, 1:277, 277f
Sherwood method for lateromedial oblique
projection with medial rotation foot of,
1:276, 276f
surgical radiography of, 3:246-250, 246f-247f,
249f
tibia of
anatomy of, 1:230-231, 230f-231f
AP oblique projections of, 1:294-295,
294f-295f
AP projection of, 1:290-291, 290f-291f
lateral projection of, 1:292-293, 292f-293f
toes of. See Toes.
trauma radiography of, 2:50-53
patient position considerations for, 2:22f-23f,
50
structures shown on, 2:52-53, 52f
trauma positioning tips for, 2:50, 50f
venography of, 3:47, 48f
Lower limb alignment, weight-bearing method
for AP projection to assess, 1:322,
322f-323f
Lower limb arteries, duplex sonography of,
3:393
Lower limb length discrepancies, weight-bearing
method for AP projection to assess, 1:322,
322f-323f
Lower limb veins, duplex sonography of, 3:393,
394f
Low-osmolality contrast agents (LOCAs) in
children, 3:116
LPO (left posterior oblique) position, 1:93, 93f
LSC (least significant change) in DXA, 3:456,
476
LSO (lutetium oxyorthosilicate) as scintillator for
PET, 3:428-429, 428t
Lumbar curve, 1:366f, 367
Lumbar discogram, 3:17f
Lumbar fusion, 3:229f
Lumbar intervertebral disks, PA projection of,
1:435-436, 435f
Lumbar myelogram, 3:8f
Lumbar nodes, 3:27f
Lumbar vein, ultrasonography of, 3:377f
Lumbar vertebrae
anatomy of, 1:366f, 374-375, 375f
accessory process in, 1:374, 374f
intervertebral foramina in, 1:374
mamillary process in, 1:374, 374f
pars interarticularis in, 1:374, 374f
superior aspect in, 1:374, 374f
transverse processes in, 1:374, 374f
zygapophyseal joints in, 1:374, 374f-375f,
375t
AP projection of, 1:413-415, 413f-415f
for trauma, 2:36-37, 36f-37f
compression fracture of, 3:464, 464f
CT myelogram of, 3:12f
CT of, 1:415, 416f
for needle biopsy of infectious spondylitis of,
3:314f
Lumbar vertebrae (Continued)
DXA of
equipment for, 3:442f
lateral, 3:469
PA, 3:464-466, 464f-465f
fracture-dislocation of, 2:35f
intervertebral disks of, PA projection of,
1:435-436, 435f
intervertebral foramina of
anatomy of, 1:374
positioning rotations needed to show, 1:371t
lateral projection of, 1:417-418, 417f-418f
for trauma, 2:35, 35f
MRI of, 1:415, 416f, 3:13f, 358f
PA projection of, 1:413-415, 413f-414f
sectional anatomy of, 3:282
on axial (transverse) plane, 3:290-292
on coronal plane, 3:299
on sagittal plane, 3:296, 297f
spinal fusion of
AP projection of, 1:441-442, 441f-442f
lateral projection in hyperflexion and
hyperextension of, 1:443-444, 443f-444f
spondylolysis and spondylolisthesis of, 1:375,
375f
surgical radiography of, 3:228-229, 228f-229f
mobile, 3:244, 244f-245f
trauma radiography of
AP projection in, 2:36-37, 36f-37f
lateral projections in, 2:35, 35f
zygapophyseal joints of
anatomy of, 1:374, 374f-375f, 375t
AP oblique projection of, 1:421-422
position of part for, 1:421, 421f
position of patient for, 1:421
positioning rotations needed to show, 1:371t
Lumbosacral angle, 1:367
Lumbosacral junction, AP axial projection of
(Ferguson method), 1:425-426, 425f
Lumbosacral vertebrae
AP and PA projections of, 1:413-415, 415f
AP axial projection of (Ferguson method),
1:425-426, 425f
lateral projection of, 1:417-418, 418f
at L5-S1 junction, 1:419-420, 419f-420f
PA axial projection of, 1:426, 426f
Lunate, 1:101f, 102
Lung(s)
anatomy of, 1:481-482, 481f-482f
AP oblique projection of, 1:508-509,
508f-509f
AP projection of, 1:510-511, 510f-511f
with pleura, 1:516-517, 516f-517f
coal miner’s (black), 1:486t
general positioning considerations for, 1:488
for lateral projections, 1:488, 489f
for oblique projections, 1:488
for PA projections, 1:488, 489f
upright vs. prone, 1:488, 488f
lateral projection of, 1:500-503
evaluation criteria for, 1:502b
foreshortening in, 1:501, 501f
forward bending in, 1:501, 501f
general positioning considerations for, 1:488,
489f
with pleura, 1:518-519, 518f-519f
position of part for, 1:500-501, 500f
position of patient for, 1:500
structures shown on, 1:502, 502f-503f
lobes of, 1:481f, 482
nuclear medicine for imaging of, 3:419
PA oblique projection of, 1:504-507
evaluation criteria for, 1:507b
LAO position for, 1:504f, 505, 506f
position of part for, 1:504f-505f, 505
position of patient for, 1:504
Lung(s) (Continued)
RAO position for, 1:505, 505f, 507f
SID for, 1:504
structures shown on, 1:506-507,
506f-507f
PA projection of, 1:496-499
breasts in, 1:497, 497f
evaluation criteria for, 1:499b
general positioning considerations for, 1:488,
489f
with pleura, 1:516-517, 517f
position of part for, 1:496-498, 496f
position of patient for, 1:496
respiration in, 1:498, 498f
SID for, 1:496
structures shown on, 1:499, 499f
PET of, 3:433f
primary lobules of, 1:482
pulmonary apices of
AP axial projection of
in lordotic position (Lindblom method),
1:512-513, 512f-513f
in upright or supine position, 1:515,
515f
PA axial projection of, 1:514, 514f
sectional anatomy of
in abdominopelvic region, 3:285f-286f
in thoracic region, 3:269f, 270, 271f
on axial (transverse) plane, 3:273f,
274-275, 278, 278f
on coronal, 3:280-281
Lung cancer
in older adults, 3:172
PET of, 3:433f
radiation oncology for, 3:502, 502f
Lung markings in radiography of sternum, 1:456,
457f
Lung perfusion scan, Tc-99m MAA, 3:419
Lung ventilation scan, xenon-133, 3:419
LUQ (left upper quadrant), 1:70, 70f
Lutetium oxyorthosilicate (LSO) as scintillator for
PET, 3:428-429, 428t
Lutetium yttrium orthosilicate (LYSO) as
scintillator for PET, 3:428t
LVA (lateral vertebral assessment), 3:469-470,
470f-471f, 477
Lymph, 3:22, 24, 97
Lymph nodes, 3:26, 27f
Lymph vessels, 3:26, 97
Lymphadenography, 3:97
Lymphangiography, 3:97
Lymphatic system, 3:22, 26, 27f
Lymphocytes, 3:26
Lymphography, 3:26, 27f, 97
Lymphoma, Hodgkin, radiation oncology for,
3:503
Lymphoreticular tissue, cancer arising from,
3:483t
LYSO (lutetium yttrium orthosilicate) as scintillator
for PET, 3:428t
M Magnification technique (M) for mammography,
M (magnification technique) for mammography,
2:403t-408t, 428-429, 428f-429f, 432t
mA (milliamperage), 1:42
Macroaggregated albumin (MAA) in
radiopharmaceuticals, 3:405, 405f
Magnet(s) for MRI, 3:346
Magnet room for MRI, 3:346-347,
346f-347f
Magnetic field strength for MRI, 3:346
Magnetic resonance (MR), 3:367
Magnetic resonance angiography (MRA),
3:363-364, 363f-364f
Magnetic resonance cholangiopancreatography
(MRCP), 3:361f
Magnetic resonance imaging (MRI), 3:341-368
of abdomen, 3:360, 360f-361f
body planes in, 1:67, 67f
of breast, 2:418-419, 472, 3:358, 359f
cardiac, 3:358, 359f
of chest, 3:358, 359f
of children, 3:155-156, 156f
claustrophobia in, 3:349, 353
of CNS, 3:12-13, 357-358
of brain, 3:12, 13f, 357, 357f
of spine, 3:13, 358
lumbar, 1:415, 416f, 3:13f, 358f
thoracic, 3:358f
coils for, 3:346, 354, 354f, 367
contrast media for, 3:355, 355f
vs. conventional radiography, 3:342
CT vs., 3:333, 334f
defined, 3:342, 438
definition of terms for, 3:367b-368b
diffusion and perfusion techniques for,
3:364-365, 365f
equipment for, 3:345-347
console as, 3:345, 345f
equipment room as, 3:345
magnet room as, 3:346-347, 346f-347f
extremity scanner for, 3:347, 347f
fast-imaging pulse sequences for, 3:357
functional, 3:366
gating for, 3:356, 356f, 367
historical development of, 3:342
imaging parameters for, 3:350f-353f, 351-353
imaging time in, 3:352
infection control for, 3:348
of musculoskeletal system, 3:360-362,
362f-363f
vs. nuclear medicine, 3:401t, 402
patient monitoring for, 3:354
of pelvis, 3:360, 361f
PET combined with, 3:401, 436
planes in, 3:350f, 351
positioning for, 3:353
principles of, 3:342
pulse sequences in, 3:344, 352, 352f-353f, 367
in radiation oncology, 3:494
safety of, 3:348-349, 349f
sectional anatomy of, 3:252
signal production in, 3:343, 343f
significance of signal in, 3:344, 344f
slice in, 3:342, 368
slice thickness in, 3:351-352
three-dimensional, 3:351, 351f
of vessels, 3:363-364, 363f-364f
Magnetic resonance imaging (MRI) coronary
arteriography, 3:95f
Magnetic resonance (MR) mammography,
2:418-419, 472, 3:358, 359f
Magnetic resonance spectroscopy (MRS), 3:365,
365f-366f
Magnification, 1:7, 7f
in angiography, 3:33
Magnification radiography, 1:28-29
2:403t-408t, 428-429, 428f-429f, 432t
Main lobar fissure as sonographic landmark, 3:373,
373f
Main trunk vessels, 3:23, 25f
Major calyx(ces), 2:185, 185f
Major duodenal papilla, 2:100f, 105, 105f
Malabsorption syndrome, 2:109t
Male(s)
calcifications of breast in, 2:427
cystourethrography in, 2:221, 221f
mammography in, 2:426, 426f-427f
osteoporosis in, 3:447
Male pelvis, 1:332, 332f, 332t
PA projection of, 1:338f
Male reproductive system
anatomy of, 2:242
ductus deferens in, 2:242, 242f-243f
ejaculatory ducts in, 2:242, 243f
prostate in, 2:242f-243f, 243
seminal vesicles in, 2:242, 243f
summary of, 2:244b
testes in, 2:242, 242f
radiography of, 2:253-254
of prostate, 2:254
of seminal ducts, 2:253
epididymography for, 2:253, 253f
epididymovesiculography for, 2:253
grid technique for, 2:253
nongrid technique for, 2:253
vesiculography for, 2:253, 254f
sectional anatomy of, 3:284
Malignancy, 3:482, 506
Malleolus, 1:84
Malleus, 2:271
Mamillary process, 1:374, 374f
Mammary fat, 2:381f
Mammary gland. See Breast(s).
Mammillary bodies, 3:259-260
Mammography, 2:369-474
artifacts on, 2:396, 396f
of augmented breast, 2:417-419, 418f
craniocaudal (CC) projection of
with full implant, 2:420-421, 421f
with implant displaced, 2:422-423,
Index
422f-423f
with implant displacement (ID),
2:403t-408t
mediolateral oblique (MLO) projection of
with full implant, 2:424
with implant displaced, 2:425
automatic exposure control for, 2:409
for breast cancer screening, 2:377
vs. diagnostic mammography, 2:378
risk vs. benefit of, 2:377-378, 377f
comfort measures for, 2:374, 409, 410f
compression in, 2:402
computer-aided detection (CAD) systems for,
2:376-379, 376f
descriptive terminology for lesion location in,
2:411, 413f
equipment for, 2:373-374, 373f
evolution of systems for, 2:373, 373f
findings on, 2:384-393
architectural distortions as, 2:393, 393f
calcifications as, 2:389-393, 389f-392f
masses as, 2:384-388, 385f-388f
full-field digital, 2:374-375
labeling for, 2:409
technique chart for, 2:394t
grids for, 2:374
historical development of, 2:371-372,
371f-372f
image enhancement methods for, 2:427
magnification technique (M) as, 2:403t-408t,
428-429, 428f-429f, 432t
spot compression technique as, 2:403t-408t,
429-431, 430f-431f, 432t
labeling in, 2:402, 402f, 403t-408t
during lactation, 2:382, 382f
magnetic resonance (MR), 2:418-419, 472,
3:358, 359f
male, 2:426, 426f-427f
method of examination for, 2:396
mosaic imaging or tiling in, 2:400, 401f
of oversized breasts, 2:400, 401f
patient preparation for, 2:396, 396f-399f
posterior nipple line in, 2:409, 410f
principles of, 2:371-374
procedures for, 2:400-409, 401f
respiration during, 2:409
I-27
 Mammography (Continued)
routine projections in, 2:411
craniocaudal (CC), 2:403t-408t, 411f,
413-414, 413f-414f
mediolateral oblique (MLO), 2:403t-408t,
411f, 415-416, 415f-416f
screening, 2:377
diagnostic vs., 2:378
risk vs. benefit of, 2:377-378, 377f
standards for, 2:373, 377
summary of projections in, 2:370-379, 411,
411t-412t
supplemental projections in, 2:432-457
90-degree lateromedial (LM), 2:411f,
435-436
applications of, 2:403t-408t, 432t
evaluation criteria for, 2:436b
labeling codes for, 2:403t-408t
position of part for, 2:435, 435f
position of patient for, 2:435
structures shown on, 2:436, 436f
90-degree mediolateral (ML), 2:411f,
433-434
applications of, 2:403t-408t, 432t
evaluation criteria for, 2:434b, 434f
labeling codes for, 2:403t-408t
position of part for, 2:433, 433f
position of patient for, 2:433
structures shown on, 2:434
axillary for axillary tail as, 2:452-453,
Index
452f-453f
captured lesion or coat-hanger (CL), 2:445,
446f-447f
applications of, 2:403t-408t, 432t
labeling codes for, 2:403t-408t
caudocranial (FB), 2:412f, 448-449
applications of, 2:403t-408t, 432t
evaluation criteria for, 2:449b
labeling codes for, 2:403t-408t
position of part for, 2:448, 448f
position of patient for, 2:448
structures shown on, 2:449, 449f
craniocaudal for cleavage (cleavage view, CV)
as, 2:412f, 439-440
applications of, 2:403t-408t, 432t
evaluation criteria for, 2:440b, 440f
labeling codes for, 2:403t-408t
position of part for, 2:439, 439f
position of patient for, 2:439
structures shown on, 2:440
craniocaudal with roll lateral (rolled lateral,
RL), 2:412f, 441-442
applications of, 2:403t-408t, 432t
evaluation criteria for, 2:442b
labeling codes for, 2:403t-408t
position of part for, 2:441, 441f
position of patient for, 2:441
structures shown on, 2:442, 442f
craniocaudal with roll medial (rolled medial,
RM), 2:412f, 441-442
applications of, 2:403t-408t, 432t
evaluation criteria for, 2:442b
labeling codes for, 2:403t-408t
position of part for, 2:441, 441f
position of patient for, 2:441
structures shown on, 2:442
elevated or pushed-up craniocaudal (ECC),
2:403t-408t
exaggerated craniocaudal (XCCL), 2:412f,
437-438
applications of, 2:403t-408t, 432t
evaluation criteria for, 2:438b, 438f
labeling codes for, 2:403t-408t
position of part for, 2:437, 437f
position of patient for, 2:437
structures shown on, 2:438
I-28
Mammography (Continued)
inferolateral to superomedial oblique (LMO),
2:403t-408t
inferomedial to superolateral oblique (ISO),
2:403t-408t
lateromedial oblique (LMO), 2:412f, 454-455,
454f-455f
mediolateral oblique for axillary tail, 2:412f,
432t, 450-451, 450f-451f
superolateral to inferomedial oblique (SIO),
2:412f, 456-457
applications of, 2:403t-408t, 432t
evaluation criteria for, 2:457b
labeling codes for, 2:403t-408t
position of part for, 2:456, 456f
position of patient for, 2:456
structures shown on, 2:457, 458f
tangential (TAN), 2:412f, 443
applications of, 2:403t-408t, 432t
evaluation criteria for, 2:443b
labeling codes for, 2:403t-408t
position of part for, 2:443, 443f-444f
position of patient for, 2:443
structures shown on, 2:443, 444f
xero-, 2:372, 372f
Mammography Quality Standards Act (MQSA),
2:377
MammoSite applicator, 3:504
Mandible
alveolar portion of, 2:274, 274f
anatomy of, 2:272f-274f, 274
axiolateral oblique projection of, 2:343-345
evaluation criteria for, 2:345b
position of part for, 2:343, 343f-344f
position of patient for, 2:343
structures shown on, 2:343-345, 344f-345f
axiolateral projection of, 2:343-345, 343f
body of
anatomy of, 2:274, 274f
axiolateral oblique projection of,
2:344f-345f
axiolateral projection of, 2:343f-344f
PA axial projection of, 2:340f, 342, 342f
PA projection of, 2:339f, 341, 341f
submentovertical projection of, 2:346f
lateral projection of, 2:322f
modified Waters method for parietoacanthial
projection of, 2:326f
panoramic tomography of, 2:353-354,
353f-354f
rami of
anatomy of, 2:274, 274f
AP axial projection of, 2:348f
axiolateral oblique projection of, 2:344f-345f,
345
axiolateral projection of, 2:343f, 345, 345f
lateral projection in decubitus position of,
2:295f
PA axial projection of, 2:340, 340f, 342f
PA projection of, 2:339, 339f, 341f
sectional anatomy of, 3:263f, 264
submentovertical projection of, 2:346f
sectional anatomy of, 3:254
submentovertical projection of, 2:311f, 346,
346f, 367f
symphysis of
anatomy of, 2:274, 274f
axiolateral oblique projection of, 2:345, 345f
axiolateral projection of, 2:343f-344f, 345
PA axial projection of, 2:342f
PA projection of, 2:341f
submentovertical projection of, 2:346f
Mandibular angle
anatomy of, 2:274, 274f
axiolateral oblique projection of, 2:344f-345f
in lateral aspect of skull, 2:273f
Mandibular angle (Continued)
parietoacanthial projection of, 2:324f
modified, 2:326f
as surface landmark, 1:71f, 71t, 2:285f
Mandibular condyle
anatomy of, 2:273f-274f, 274
AP axial projection of, 2:306f, 348f
axiolateral oblique projection of, 2:345f,
352f
PA axial projection of, 2:342f
PA projection of, 2:339f
sectional anatomy of, 3:262, 262f
submentovertical projection of, 2:311f,
346f
Mandibular fossa
anatomy of, 2:268, 268f, 274f
axiolateral oblique projection of, 2:352f
sectional anatomy of, 3:253-254
Mandibular notch, 2:273f-274f, 274
Mandrel, 3:97
Manifold for cardiac catheterization, 3:78, 78f
Manubriosternal joint, 1:447f, 449t, 450
Manubrium
anatomy of, 1:447-448, 447f
sectional anatomy of, 3:256
on axial (transverse) plane, 3:274-275, 274f
on coronal plane, 3:280, 281f
on sagittal plane, 3:278-280, 280f
Mapping in maximum intensity projection, 3:326,
339
Marginal lymph sinus, 3:26
Markers
anatomic, 1:25, 25f-26f, 27, 27b
of bone turnover, 3:448, 476
for trauma radiography, 2:24, 24f
Mass, Dierk, 3:20-21
Masseter muscles, 3:255-256, 264
Mastication, 2:59
Mastoid air cells
anatomy of, 2:268, 269f-270f
AP axial projection of, 2:309f
PA projection of, 2:339f
parietoacanthial projection of, 2:363f
sectional anatomy of, 3:259-263
Mastoid angle of parietal bone, 2:263f
Mastoid antrum, 2:269f-270f, 271
Mastoid fontanel, 2:259-260, 260f
Mastoid process
anatomy of, 2:258f, 268, 268f-269f
PA axial projection of, 2:342f
submentovertical projection of, 2:311f
Mastoid tip, 1:71f, 71t
Mastoidian cells, 2:269f
Mastoiditis, 2:282t
Matrix in CT, 3:302, 308, 308f, 339
Maxilla. See Maxillary bones.
Maxillary bones
anatomy of, 2:259f, 272, 272f-273f
lateral projection of, 2:322f
in orbit, 2:275, 275f, 312f
parietoacanthial projection of, 2:324f
modified, 2:326f
sectional anatomy of, 3:254, 262
Maxillary sinuses
acanthioparietal projection of, 2:328f
anatomy of, 2:276, 276f-278f
lateral projection of, 2:322f, 359f
location of, 2:272
parietoacanthial projection of, 2:363f, 365f
Waters method for, 2:324f, 362-363,
362f-363f
open-mouth, 2:364-365, 364f-365f
sectional anatomy of, 3:262, 262f, 264, 266,
266f
submentovertical projection of, 2:311f, 367f
Maximum aperture diameter, 1:44-45, 45t
Maximum intensity projection (MIP), 3:326,
339-340
MCP (metacarpophalangeal) joint(s)
anatomy of, 1:105, 105f-106f
folio method for first, 1:118-119
MDCT (multidetector CT), 3:306, 323-324,
323f-324f
Mean glandular dose, 2:377, 377f
Mean in DXA, 3:455, 455f-456f, 476
Mean marrow dose (MMD), 1:35, 35t
Meatus, 1:84
Meckel diverticulum, 2:109t
Media of arterial wall, 3:65
Medial, 1:85
Medial collateral ligament, 1:236f
Medial condyle
of femur, 1:232f-233f, 233
of tibia, 1:230, 230f
Medial epicondyle
of femur, 1:232f, 233
of humerus, 1:104, 104f
Medial intercondylar tubercle, 1:230, 230f
Medial malleolus, 1:230f-231f, 231
Medial meniscus
anatomy of, 1:234f-236f, 235
double-contrast arthrography of, 2:13, 13f
Medial orbital wall, 2:262f
Medial pterygoid lamina, 2:265f, 266
Medial pterygoid muscle, 3:266, 266f
Medial rotation, 1:93, 93f, 97, 97f
Median aperture, 3:4
Median nerve, 1:102, 102f
Mediastinal structures in radiography of sternum,
1:456, 457f
Mediastinum
anatomy of, 1:483-484, 483f-484f
CT of, 1:484, 485f
defined, 1:479
lateral projection of superior, 1:494-495,
494f-495f
sectional anatomy of, 3:270, 280
Medical dosimetrist, 3:480, 506
Medical physicist, 3:480, 506
Medical terminology, 1:98, 98t
Medication administration via venipuncture.
See Venipuncture.
Mediolateral projection, 1:88
Medulla oblongata
anatomy of, 3:2, 2f-3f
sectional anatomy of, 3:255
on axial (transverse) plane, 3:262-264,
262f-263f
on sagittal plane, 3:265f
Medullary cavity, 1:76, 76f
Medulloblastoma, radiation oncology for, 3:504,
505f
Megacolon, congenital aganglionic, 2:109t
Meglumine diatrizoate (Gastrografin, Gastroview)
for simulation in radiation oncology, 3:490
Melanoma, PET of, 3:433f
Membranous labyrinth, 2:271
Membranous urethra, 2:186f, 187
Meninges
anatomy of, 3:3, 97
sectional anatomy of, 3:254
Meniscus, 1:82, 82f
Meniscus tear, 2:9t
Menstrual cycle, 2:240
Mental foramen, 2:273f-274f, 274
Mental point, 2:285f
Mental protuberance, 2:272f, 274, 274f
Mentomeatal line, 2:327f-328f
Meperidine hydrochloride (Demerol), 2:226t
Merchant method for tangential projection of
patella and patellofemoral joint, 1:314-315,
314f-315f
Mesentery
anatomy of, 2:83
sectional anatomy of, 3:283, 290, 293f
Mesocephalic skull, 2:286, 286f
Mesovarium, 2:239
Metabolic neurologic study, PET for, 3:434
Metacarpals, 1:101, 101f
Metacarpophalangeal (MCP) joint(s)
anatomy of, 1:105, 105f-106f
folio method for first, 1:118-119
Metal objects, 1:20, 21f
Metallic bead chain cystourethrography, 2:222-224,
223f
Metastable technetium-99 (99mTc). See Technetium-
99m (99mTc).
Metastasis(es)
to abdomen, 2:84t
to bony thorax, 1:454t
to lower limb, 1:240t
to pelvis and proximal femora, 1:335t
radiation oncology for, 3:481, 507
to shoulder girdle, 1:182t
to skull, 2:282t
to thoracic viscera, 1:486t
to upper limb, 1:109t
to vertebral column, 1:380t
Metatarsals
anatomy of, 1:228f, 229
surgical radiography of, 3:249f
Metatarsophalangeal (MTP) articulations,
1:236f-237f, 236t, 238
Method, 1:95
Metric/English conversion, 1:30
MI (myocardial infarction), 3:75, 97
echocardiography after, 3:393, 396f
Microbial fallout, 3:250
Micturition, 2:186
Midaxillary plane, 1:66, 66f
Midazolam hydrochloride (Versed), 2:226t
Midbrain
anatomy of, 3:2, 2f
sectional anatomy of, 3:255, 258-259, 265f
Midcoronal plane, 1:66, 66f
Middle cerebral arteries
CT angiography of, 3:325f
MR angiography of, 3:363f
sectional anatomy of, 3:255
on axial (transverse) plane, 3:257-261,
259f
on coronal plane, 3:267
Middle cranial fossa, 2:260
Middle hepatic vein as sonographic landmark,
3:373, 373f
Middle nasal concha
anatomy of, 2:262, 262f
sectional anatomy of, 3:253
Middle phalanges, 1:228, 228f
Midfoot, 1:228-230
Midsagittal plane, 1:66, 66f, 2:285f
Milk ducts, examination of, 2:459-460, 459f-460f
Milk of calcium, 2:391, 391f, 395
Miller-Abbott tube, 2:143, 143f
Milliamperage (mA), 1:42
Minor calyx(ces), 2:185, 185f
MIP (maximum intensity projection), 3:326,
339-340
Misregistration in digital subtraction angiography,
3:31, 97
Mitral valve
anatomy of, 3:25f
sectional anatomy of, 3:270
Mitral valve regurgitation, 3:82-84, 83f
MLC (multileaf collimation), 3:489, 489f, 507
MMD (mean marrow dose), 1:35, 35t
99
Mo (molybdenum-99), 3:404, 404f
Mobile PET units, 3:436, 436f
Mobile radiography, 3:183-212
of abdomen, 3:196-199
AP or PA projection in left lateral decubitus
position for, 3:198-199, 198f-199f
AP projection for, 3:196, 196f-197f
of cervical spine, 3:206-207
lateral projection for, 3:206-207, 206f-207f
of chest, 3:192
AP or PA projection in lateral decubitus
position for, 3:194-195, 194f-195f
AP projection in upright or supine position
for, 3:192, 192f-193f
of chest and abdomen of neonate, 3:208-212
AP projection for, 3:208-210
evaluation criteria for, 3:210b, 210f
position of part for, 3:208f-209f, 209
position of patient for, 3:208, 208f
structures shown on, 3:210, 210f
lateral projection for, 3:211-212,
211f-212f
digital, 3:184, 185f
of cervical spine, 3:207
of chest, 3:193-195
of femur
AP projection for, 3:203-205
lateral projection for, 3:205
examination in, 3:190
of femur, 3:202-203
AP projection for, 3:202-203, 202f-203f
lateral projection for, 3:204-205, 204f-205f
Index
history of, 3:184
initial procedures in, 3:190, 190b
isolation considerations with, 3:189
machines for, 3:184, 185f
for obese patients, 1:52
patient considerations with, 3:190-191
assessment of patient’s condition as, 3:190
with fractures, 3:191
interfering devices as, 3:191, 191f
patient mobility as, 3:191
positioning and asepsis as, 3:191
of pelvis, 3:200-201
AP projection for, 3:200-201, 200f-201f
principles of, 3:184, 184f
radiation safety with, 3:188, 188f-189f
surgical, 3:242-250
of cervical spine, 3:242, 242f-243f
of extremities
for ankle fracture, 3:246f
of ankle with antibiotic beads, 3:247f
for fifth metatarsal nonhealing fracture,
3:249f
for forearm fracture, 3:247f
for hip joint replacement, 3:246f
lower, 3:246-250
for tibial plateau fracture, 3:247f
for total shoulder arthroplasty, 3:248f
for wrist fracture, 3:249f
of thoracic or lumbar spine, 3:244,
244f-245f
technical considerations for, 3:184-187
anode heel effect as, 3:186-187, 186t
grid as, 3:185-186, 185f-186f
radiographic technique charts as, 3:187,
187f
source-to-image receptor distance as,
3:187
for trauma patients, 2:21f, 32
Mobility and mobile radiography, 3:191
Mold technique for brachytherapy, 3:485
Molybdenum-99 (99Mo), 3:404, 404f
Moore method for PA oblique projection of
sternum, 1:460-461, 460f-461f
Morphine sulfate, 2:226t
Morphometric x-ray absorptiometry (MXA),
3:469-470, 470f, 476
I-29
 Mortise joint
anatomy of, 1:230f-231f, 236t, 238
AP oblique projection in medial rotation of,
1:284-289, 284f-285f
Motion artifact on MRI, 3:356
Motion control, 1:18-19, 18f
of involuntary muscles, 1:18-19
with obese patients, 1:50-51
for trauma radiography, 2:23, 23f
of voluntary muscles, 1:19, 19f
Mouth, 2:57-67
anatomy of, 2:59, 59f, 61b
salivary glands of. See Salivary glands.
summary of pathology of, 2:62t
summary of projections of, 2:58-59
Movement terminology. See Body movement
terminology.
MPR (multiplanar reconstruction) in CT, 3:313,
313f, 327f, 340
MR (magnetic resonance), 3:367
MR (magnetic resonance) mammography,
2:418-419, 472, 3:358, 359f
MRA (magnetic resonance angiography),
3:363-364, 363f-364f
MRCP (magnetic resonance
cholangiopancreatography), 3:361f
MRI. See Magnetic resonance imaging (MRI).
MRI conditional implants, 3:348-349, 367
MRI safe implants, 3:348-349, 367
MRS (magnetic resonance spectroscopy), 3:365,
Index
365f-366f
MSAD (multiple scan average dose) for CT, 3:330,
340
MSHCT (multislice helical CT), 3:306, 323-324,
323f-324f
MTP (metatarsophalangeal) articulations,
1:236f-237f, 236t, 238
Multidetector CT (MDCT), 3:306, 323-324,
323f-324f
Multiformat camera for digital subtraction
angiography, 3:31
Multi-gated acquisition (MUGA) format, 3:416
Multi-infarct dementia, 3:169
Multileaf collimation (MLC), 3:489, 489f, 507
Multiplanar reconstruction (MPR) in CT, 3:313,
313f, 327f, 340
Multiple exposures, 1:29, 29f
Multiple imaging windows in CT, 3:304f
Multiple myeloma, 1:335t, 380t, 454t
of skull, 2:282t
Multiple scan average dose (MSAD) for CT, 3:330,
340
Multislice helical CT (MSHCT), 3:306, 323-324,
323f-324f
Musculoskeletal system
MRI of, 3:360-362, 362f-363f
ultrasonography of, 3:383, 383f
Musculoskeletal system disorders in older adults,
3:170, 170f-171f
Mutations and cancer, 3:482
MXA (morphometric x-ray absorptiometry),
3:469-470, 470f, 476
Mycoplasma pneumonia, 3:151
Myelography, 3:6-8
cervical, 3:9f
contrast media for, 3:6-7, 6f
conus projection in, 3:8
CT, 3:12, 12f
of dentate ligament, 3:9f
examination procedure for, 3:7-8, 7f
of foramen magnum, 3:9f
lumbar, 3:8f
preparation of examining room for, 3:7, 7f
of subarachnoid space, 3:9f
Myeloma, multiple, 1:335t, 380t, 454t
of skull, 2:282t
I-30
Myocardial infarction (MI), 3:75, 97
echocardiography after, 3:393, 396f
Myocardial perfusion study
technetium-99m sestamibi, 3:416
thallium-201, 3:414, 414f, 416
Myocardium, 3:24
Myometrium, ultrasonography of, 3:388, 397
N Nephrourography, infusion, equipment for, 2:198
13
N (nitrogen-13), 3:406t
in PET, 3:425f, 426t
NaI (sodium iodide) as scintillator for PET, 3:428t
NaI (sodium iodide) scintillation crystals of gamma
camera, 3:408f, 409
Nasal bones
anatomy of, 2:259f, 272, 273f
lateral projection of, 2:322f, 331-332, 331f-332f
sectional anatomy of, 3:254, 261-262, 261f
Nasal conchae
anatomy of, 2:262, 262f
sectional anatomy of, 3:253-254
on axial (transverse) plane, 3:263f, 264
on sagittal plane, 3:265, 265f
Nasal septum
anatomy of, 2:71f, 273
modified Waters method for parietoacanthial
projection of, 2:326f
sectional anatomy of, 3:262
Nasal spine, 2:261, 261f
Nasion, 2:261, 261f, 285f
Nasofrontal suture, 2:332f
Nasopharynx
anatomy of, 2:71f, 72
sectional anatomy of, 3:263f, 264, 267
National Trauma Database (NTDB), 2:18-19,
18f-19f
Navicular bone, 1:228f, 229
Naviculocuneiform articulation, 1:236t, 237f, 238
Neck
anterior part of, 2:69-79
anatomy of, 2:71, 71f
larynx in, 2:71f-73f, 72-73
parathyroid glands in, 2:71, 72f
pharynx in, 2:71f, 72
summary of, 2:73b
thyroid gland in, 2:71, 72f
radiography of, 2:74-79
AP projection of pharynx and larynx in,
2:76-77, 76f-77f
deglutition in, 2:74-75, 74f
fluoroscopic, 2:75
Gunson method for, 2:75, 75f
lateral projection of soft palate, pharynx,
and larynx in, 2:78-79, 78f-79f
methods of examination for, 2:74-75
positive-contrast pharyngography for,
2:74-75
summary of projections for, 2:70
soft tissue
in children, 3:137-138, 137f-138f
CT of, 3:336f-338f
Neck brace, trauma radiography with, 2:23, 23f
Needle(s)
for angiographic studies, 3:35, 35f
disposal of, 1:16, 16f
for venipuncture, 2:228-229, 228f
anchoring of, 2:233, 233f
discarding of, 2:234, 234f
Needle-wire localization of breast lesion,
2:461-463
Neer method for tangential projection of
supraspinatus “outlet”, 1:202-203, 202f
Neointimal hyperplasia, 3:97
Neonatal development, 3:102
Neonatal neurosonography, 3:385, 385f
Neonate, cranial bones in, 2:259-260, 260f
Neoplasm, 3:506
Nephron, 2:185, 185f
Nephron loop, 2:185, 185f
Nephrotomography, 2:190, 191f, 202
AP projection in, 2:209, 209f
percutaneous renal puncture for, 2:210-211,
210f
Nephrotoxic, 3:97
Nerve tissue, cancer arising from, 3:483t
Nervous system disorders in older adults,
3:168-169
Networking, 3:409-410
Neuroangiography, surgical, 3:74
Neurologic imaging, PET for, 3:434
Neuroma, acoustic, 2:282t
Neutron(s), 3:403, 403f, 438
Neutron-deficient nucleus, 3:422, 423f
Neutron-to-proton ratio, 3:403
Newborn. See Neonate.
Nipple
anatomy of, 2:380, 381f
ductography of, 2:459-460, 459f-460f
in mammography, 2:402
Paget disease of, 2:395
Nitrogen-13 (13N), 3:406t
in PET, 3:425f, 426t
NMR (nuclear magnetic resonance) imaging,
3:342, 367
Noctec (chloral hydrate), 2:226t
Noise
in CT, 3:318-319, 319f, 340
in MRI, 3:367
Nonaccidental trauma to children, 3:143f-145f
imaging protocol for, 3:124, 146t
Nondisplaced fracture, 1:84
Noninvasive technique, ultrasonography as, 3:370,
397
Nonocclusive, 3:97
Nonsterile surgical team members, 3:215f, 216
Norgaard method for AP oblique projection in
medial rotation of hand, 1:130-131
evaluation criteria for, 1:131b
position of part for, 1:130-131, 131f
position of patient for, 1:130
structures shown on, 1:131, 131f
Notch, 1:84
Notification values for CT, 3:330
NTDB (National Trauma Database), 2:18-19,
18f-19f
Nuclear cardiology, 3:416-417
Nuclear magnetic resonance (NMR) imaging,
3:342, 367
Nuclear medicine, 3:399-439
clinical, 3:415-420
bone scintigraphy as, 3:415-416
of CNS, 3:417
of endocrine system, 3:417-418, 418f
of gastrointestinal system, 3:418-419
genitourinary, 3:419
for infection, 3:419
in vitro and in vivo hematologic studies as,
3:419
nuclear cardiology as, 3:416-417
respiratory, 3:419
sentinel node, 3:420
special procedures in, 3:420
therapeutic, 3:420
of tumor, 3:420
defined, 3:400
definition of terms for, 3:437b-439b
future of, 3:435-436
hybrid imaging as, 3:436
for PET, 3:436, 436f
radioimmunotherapy as, 3:435
historical development of, 3:400-401
Nuclear medicine (Continued)
imaging methods for, 3:410-415
combined SPECT and CT as, 3:401, 415, 415f
dynamic, 3:412
SPECT as, 3:413-414, 413f-414f
static, 3:410-411
whole-body, 3:412, 412f
instrumentation in, 3:408-410
computers as, 3:409-410, 410f-411f
quantitative analysis using, 3:410, 411f, 438
modern-day gamma camera as, 3:408-409,
408f
vs. other modalities, 3:401-402, 401t, 402f-403f
patient preparation for, 3:415
physical principles of, 3:403-405
basic nuclear physics as, 3:403-404, 403f-404f
nuclear pharmacy as, 3:404-405, 405f, 406t
positron emission tomography (PET) as. See
Positron emission tomography (PET).
principles of, 3:400
radiation safety in, 3:407, 407f
therapeutic, 3:420
Nuclear particle accelerators, 3:404, 425, 438
Nuclear pharmacy, 3:404-405, 405f, 406t
Nuclear physics, 3:403-404, 403f-404f
Nuclear reactors, 3:400, 438
in radiation oncology, 3:486, 507
Nucleus
atomic, 3:343, 367, 403, 403f
neutron-deficient (proton-rich), 3:422, 423f
Nucleus pulposus
anatomy of, 1:368
herniated, 1:368, 380t, 3:358f
sectional anatomy of, 3:269-270
Nuclide, 3:403, 438
Nulliparous uterus, 2:240
Nutrient artery, 1:77, 77f
Nutrient foramen, 1:77, 77f
O OMAR (orthopedic metal artifact reduction),
15
O. See Oxygen-15 (15O).
Obese patients, 1:44-52
automatic exposure control and anatomically
programmed radiography systems with,
1:52
Bucky grid with, 1:51
centering of, 1:47-48
communication with, 1:47
defined, 1:44, 44f
equipment for, 1:44-45, 45f, 45t
exposure factors for, 1:50-52
field light size with, 1:50, 51f
focal spot with, 1:51
image receptor sizes and collimation with, 1:50,
50f
imaging challenges with, 1:47-50, 47f-48f
landmarks with, 1:47-49, 49f
mobile radiography of, 1:52
oblique and lateral projections with, 1:49
radiation dose for, 1:52
technical considerations for, 1:52, 52b
transportation of, 1:46, 46f
Object–to–image receptor distance (OID), 1:7,
3:33
Oblique fissures of lungs, 1:481f, 482
Oblique fracture, 1:84f
Oblique plane, 1:66f-67f, 67
pancreas in, 3:380, 397
Oblique position, 1:92-93, 92f-93f
Oblique projection, 1:12, 12f, 88, 89f
of obese patients, 1:49
Obstetric ultrasonography, 3:388-391
in first trimester, 3:388, 389f-390f
history of, 3:371
in second trimester, 3:390, 390f
in third trimester, 3:390-391, 391f
Obturator foramen
anatomy of, 1:327f, 328
sectional anatomy of, 3:282
Obturator internus muscle, 3:295, 295f
Occipital angle of parietal bone, 2:263f
Occipital bone
anatomy of, 2:266-267, 266f-267f
AP axial projection of, 2:305f-306f
fracture of, 2:44f
location of, 2:258f-259f
PA axial projection of, 2:309f
sectional anatomy of, 3:253, 258-260,
262-263
submentovertical projection of, 2:311f
Occipital condyles, 1:369f, 2:266-267, 266f
Occipital lobe, sectional anatomy of, 3:254-255
on axial (transverse) plane, 3:258-260
on sagittal plane, 3:264, 265f-266f, 266
Occipitoatlantal joints, 2:267
Occluding coils, stainless steel, 3:68, 68f
Occlusal plane, 1:68, 69f
Occlusion, 3:28, 97
OCT (optical coherence tomography), 3:80t, 92,
93f
Octagonal immobilizer, 3:116f
OctreoScan (indium-111 pentetreotide) for tumor
imaging, 3:415f, 420
OD (optical density), 1:5, 5f
Odontoid process. See Dens.
OI (osteogenesis imperfecta), 3:147, 147f
OID (object–to–image receptor distance), 1:7,
3:33
Oil cyst, 2:386f
Older adults. See Aging; Elderly.
Olecranon fossa
anatomy of, 1:104, 104f
PA axial projection of, 1:166, 166f
Olecranon process, 1:103, 103f, 107f
-oma, 3:506
3:319, 320f
Omentum(a), 2:83, 83f
OML (orbitomeatal line), 2:44
Oncologist, 3:480, 507
radiation, 3:480, 507
Oncology, 3:480, 507
radiation. See Radiation oncology.
Oncology imaging, PET for, 3:433, 433f
Opaque arthrography, 2:8-9, 8f
Open fracture, 1:84, 84f
Open mouth technique for atlas and axis,
1:384-385, 384f-385f
Open surgical biopsy of breast, 2:461
Operating room (OR), contamination control in,
1:16-17, 16f-17f
Operating room (OR) attire, 3:217, 217f
Operating room (OR) suite, 3:216f
Operator’s console
for CT, 3:311, 311f
for MRI, 3:345, 345f
Optic canal
anatomy of, 2:312f, 314f
correct and incorrect rotation for, 2:287, 287f
in lateral aspect of cranium, 2:258f
sectional anatomy of, 3:253-254
with sphenoid bone, 2:264f-265f, 265
Optic chiasm, 3:259-260, 262, 262f, 264, 267f
Optic foramen
anatomy of, 2:312f, 314f
in anterior aspect of cranium, 2:257f
and apex of orbit, 2:312
with facial bones, 2:272f
in lateral aspect of cranium, 2:258f
sectional anatomy of, 3:262, 262f
with sphenoid bone, 2:265, 265f
Optic groove, 2:258f, 264f, 265
Optic nerve
anatomy of, 2:314, 314f-315f
sectional anatomy of, 3:261-262, 261f, 266,
266f
Optic tracts, 3:259-260
Optical coherence tomography (OCT), 3:80t, 92,
93f
Optical density (OD), 1:5, 5f
OR. See Operating room (OR).
Oral cavity. See Mouth.
Oral vestibule, 2:59
Orbit(s)
acanthioparietal projection of, 2:328f
anatomy of, 2:275, 275f, 312, 312f
blowout fracture of, 2:46f, 282t, 313, 313f
functions of, 2:313
lateral projection of, 2:317, 317f
localization of foreign bodies within, 2:316, 316f
PA axial projection of, 2:318, 318f
parietoacanthial projection of, Waters method
for, 2:324f
modified, 2:319, 319f
preliminary examination of, 2:316
radiography of, 2:312-313, 312f-313f
sectional anatomy of, 3:262-263, 262f-263f, 266
Orbital base, 2:312
Orbital fat, 2:314f
Orbital floor, blowout fracture of, 2:46f
Orbital mass, CT for needle biopsy of, 3:314f
Orbital plates, 2:258f, 261, 261f
Index
Orbital roof
lateral projection of, 2:295f
sectional anatomy of, 3:262, 262f
Orbital wall, medial, 2:262f
Orbitomeatal line (OML), 2:44
Orientation of anatomy on image receptor, 1:28-29,
28f-29f
Ornaments, 1:20, 21f
Oropharynx, 2:59, 71f, 72
Orthopedic metal artifact reduction (OMAR),
3:319, 320f
Os coxae. See Hip bone.
Osgood-Schlatter disease, 1:240t
Ossification, 1:77-78
enchondral, 1:77
intermembranous, 1:77
primary, 1:77, 77f
secondary, 1:72-74, 77f-78f
Ossification centers, primary and secondary, 1:77,
77f-78f
Osteoarthritis
of lower limb, 1:240t
in older adults, 3:170, 170f, 174t
of pelvis and proximal femora, 1:335t
of shoulder girdle, 1:182t
of upper limb, 1:109t
of vertebral column, 1:380t
Osteoblasts, 3:445, 445f, 476
Osteochondroma, 1:240t
in children, 3:148, 148f
Osteoclast(s), 3:445, 445f, 476
Osteoclastoma, 1:240t
Osteogenesis imperfecta (OI), 3:147, 147f
Osteogenic sarcoma. See Osteosarcoma.
Osteoid osteoma, 1:240t
in children, 3:149, 149f
Osteology, 1:75-79
appendicular skeleton in, 1:75, 75f, 75t
axial skeleton in, 1:75, 75f, 75t
bone development in, 1:77-78, 77f-78f
bone vessels and nerves in, 1:77, 77f
classification of bones in, 1:79, 79f
defined, 1:66
fractures of, 1:84, 84f
general bone features in, 1:76, 76f
markings and features of, 1:84
I-31
 Osteoma
osteoid, 1:240t
in children, 3:149, 149f
of skull, 2:282t
Osteomalacia, 1:240t, 3:448, 476
Osteomyelitis, 1:109t, 240t, 454t, 2:282t
Osteopenia, 3:447, 457, 476-477
Osteopetrosis
of bony thorax, 1:454t
of lower limb, 1:240t
of pelvis and proximal femora, 1:335t
of shoulder girdle, 1:182t
of skull, 2:282t
of upper limb, 1:109t
of vertebral column, 1:380t
Osteophytosis, 3:464, 477
Osteoporosis, 3:447-450
biochemical markers for, 3:448
bone densitometry for, 3:442
bone health recommendations for, 3:450, 450t
of bony thorax, 1:454t
causes of, 3:447
cost of, 3:447
defined, 3:447, 477
epidemiology of, 3:447
fractures and falls due to, 3:447, 449, 449f
medications for, 3:448, 448t
in men, 3:447
in older adults, 3:170, 174t
pediatric, 3:473-474, 473f
Index
of pelvis and upper femora, 1:335t
primary, 3:448, 477
risk factors for, 3:447
secondary, 3:448, 477
of shoulder girdle, 1:182t
of skull, 2:282t
type I, 3:448, 477
type II, 3:448, 477
of upper limb, 1:109t
of vertebral column, 1:380t
Osteosarcoma, 1:109t, 240t
in children, 3:150
Ottonello method for AP projection of cervical
vertebrae, 1:397-398, 397f-398f
Outer canthus, 2:285f
Oval window, 2:270f, 271
Ovarian cancer, phosphorus-32 for, 3:420
Ovarian cyst
CT of, 3:315f
ultrasonography of, 3:375f, 388
Ovarian follicles, 2:239, 239f
Ovarian ligament, 2:240f
Ovaries
anatomy of, 2:239, 239f-240f
sectional anatomy of, 3:284
ultrasonography of, 3:373f, 375f, 388, 389f
Over-table IR units, 1:44-45, 45f
Over-the-needle cannula, 2:228f, 229
Ovulation, 2:239
Ovum(a), 2:239
Oximetry, 3:97
for cardiac catheterization, 3:80, 80f, 82
Oxygen saturation, 3:97
Oxygen-15 (15O)
decay scheme for, 3:425, 425f
in PET, 3:426t
production of, 3:425, 425f
Oxygen-15 (15O)-water, production of, 3:427
P anatomy of, 2:276f-278f, 279
32
P (phosphorus-32), therapeutic use of, 3:420
PA. See Posteroanterior (PA).
Pacemaker implantation, cardiac catheterization
for, 3:94, 94f-95f
PACS. See Picture archiving and communication
system (PACS).
I-32
Paget disease
of bony thorax, 1:454t
of lower limbs, 1:240t
of nipple, 2:395
of pelvis and proximal femora, 1:335t
of skull, 2:282t
of vertebral column, 1:380t
Pain management, interventional, 3:16-18
Palatine bones
anatomy of, 2:259f, 273
in orbit, 2:275, 275f
sectional anatomy of, 3:254
Palatine tonsil, 2:59, 59f
Palliation, 3:480, 507
Palmar, 1:85
Palmaz, Julio, 3:20-21
Pancreas
anatomy of, 2:97f, 100f, 105f, 106, 107f
endocrine, 2:106
exocrine, 2:106
functions of, 2:106
sectional anatomy of, 3:282f, 283
on axial (transverse) plane, 3:288-290,
288f-290f
on coronal plane, 3:299, 299f
sectional image of, 2:107f
ultrasonography of, 3:377f, 380, 380f
Pancreatic duct
anatomy of, 2:100f, 105f, 106
sectional anatomy of, 3:283
Pancreatic juice, 2:106
Pancreatic pseudocyst, 2:109t
Pancreatitis, 2:109t
Pangynecography, 2:246, 250, 250f
Panoramic tomography of mandible, 2:353-354,
353f-354f
Pantomography of mandible, 2:353-354,
353f-354f
Papilloma, 2:395
with atypia, 2:395
Paramagnetic contrast agents for MRI, 3:355,
367
Parametric image, 3:421, 438
Paranasal sinuses
anatomy of, 2:276-279, 276f-278f
in children, 3:135-136, 136f-137f
ethmoidal
anatomy of, 2:276f-278f, 279
CT of, 2:262f
location of, 2:261f-262f, 262
PA axial projection of anterior (Caldwell
method), 2:360-361, 360f-361f
submentovertical projection of, 2:366-367,
366f-367f
frontal
anatomy of, 2:276f-278f, 279
location of, 2:259f, 261, 261f
PA axial projection of (Caldwell method),
2:360-361, 360f-361f
lateral projection of, 2:358, 358f-359f
maxillary
anatomy of, 2:276, 276f-278f
location of, 2:272
parietoacanthial projection of
open-mouth Waters method for, 2:364-365,
364f-365f
Waters method for, 2:362-363,
362f-363f
sphenoidal
location of, 2:259f, 264-265, 264f-265f
parietoacanthial projection of
(open-mouth Waters method),
2:364-365, 364f-365f
submentovertical projection of, 2:366-367,
366f-367f
Paranasal sinuses (Continued)
technical considerations for radiography of,
2:355-357
body position and central ray angulation as,
2:356, 356f-357f
exposure level as, 2:355, 355f
exudate as, 2:356
Parathyroid glands, 2:71, 72f
Parathyroid hormone for osteoporosis, 3:448t
Parenchyma, ultrasonography of, 3:376, 397
Parent nuclide, 3:403-404, 438
Parietal, 1:85
Parietal bones
anatomy of, 2:263, 263f
AP axial projection of, 2:305f
location of, 2:257f-259f
PA axial projection of, 2:298f
sectional anatomy of, 3:253, 256f-257f,
257-258
Parietal eminence, 2:263, 263f
Parietal lobe, sectional anatomy of, 3:254-255,
256f
on axial (transverse) plane, 3:257-258, 257f
on sagittal plane, 3:264, 265f-266f, 266
Parietal peritoneum, 2:83, 83f
Parietal pleura, 1:482
Parietoacanthial projection
of facial bones, 2:323, 323f-324f
modified, 2:304, 325f-326f
of maxillary sinuses
Waters method for, open-mouth, 2:364-365,
364f-365f
Waters methods for, 2:362-363, 362f-363f
of orbit, 2:319, 319f
of sphenoidal sinuses, 2:364-365, 364f-365f
Parotid duct, 2:60, 60f
Parotid gland
anatomy of, 2:60, 60f, 97f
lateral projection of, 2:66-67, 67f
sectional anatomy of, 3:267-268, 267f
sialography of, 2:63f
tangential projection of, 2:64-65
evaluation criteria for, 2:65b
position of part for, 2:64-65, 64f
position of patient for, 2:64
in prone body position, 2:64f, 65
structures shown on, 2:64f-65f, 65
in supine body position, 2:64, 64f
Pars interarticularis, 1:374, 374f
Part centering for digital imaging, 1:38
Partial volume averaging for CT, 3:340
Particle accelerators, 3:404, 425, 438, 506
Patella
anatomy of, 1:233, 233f
mediolateral projection of, 1:312, 312f
PA projection of, 1:311, 311f
tangential projection of
Hughston method for, 1:313, 313f
Merchant method for, 1:314-315, 314f-315f
Settegast method for, 1:316-317, 316f-317f
Patellar surface of femur, 1:232f, 233
Patellofemoral joint
anatomy of, 1:236t, 238, 238f
tangential projection of
Hughston method for, 1:313, 313f
Merchant method for, 1:314-315,
314f-315f
Settegast method for, 1:316-317,
316f-317f
Patency, 3:97
Patent ductus arteriosus, cardiac catheterization for,
3:93
Patent foramen ovale, 3:97
Pathogen contamination control, 1:16
Pathologic fractures in children, 3:148-150
Pathologist, 3:480, 507
Patient(s)
attire, ornaments, and surgical dressings on,
1:20, 20f-21f
ill or injured, 1:22-23, 22f
interacting with, 1:21-23
preexposure instructions to, 1:41
Patient care for trauma patient, 2:26, 27t
Patient education for older adults, 3:175
Patient moving device, 1:46, 46f
Patient positioning for trauma radiography, 2:24,
24f, 28
Patient-centered care in code of ethics, 1:3
PBL (positive beam limitation), 1:32
PC (phase contrast) imaging, 3:363
pDXA (peripheral dual energy x-ray
absorptiometry), 3:475, 475f, 477
Peak bone mass, 3:446, 477
Pearson method for bilateral AP projection of
acromioclavicular articulation, 1:209,
209f-210f
Pectoralis major muscle
anatomy of, 2:380, 380f-381f
sectional anatomy of, 3:271, 273-275, 273f-274f,
276f
Pectoralis minor muscle
anatomy of, 2:380f
sectional anatomy of, 3:271, 273-275, 273f-274f,
276f
Pediatric patients. See Children.
Pedicles of vertebral arch, 1:368, 368f
Pelvic cavity, 1:68-69, 69f, 332, 332f, 2:83
Pelvic curve, 1:366f, 367
Pelvic girdle, 1:327
Pelvic kidney, 2:188t
Pelvic pneumography, 2:246, 250, 250f
Pelvic sacral foramina, 1:376, 376f
Pelvicaliceal system, 2:183
retrograde urography of, 2:212-213, 212f-213f
Pelvimetry, 2:252
Pelvis, 1:325-360
anatomy of, 1:332, 332f, 334b
anterior bones of
AP axial outlet projection of (Taylor method),
1:358, 358f
superoinferior axial inlet projection of
(Bridgeman method), 1:359, 359f
AP projection of, 1:337-339, 337f-338f
for congenital dislocation of hip, 1:339,
339f
mobile, 3:200-201, 200f-201f
for trauma, 2:41, 41f
articulations of, 1:331, 331f, 331t, 334b
bony landmarks of, 1:333-334, 333f
brim of, 1:332, 332f
in children, 3:125-126
general principles for, 3:125-126, 125f
image evaluation for, 3:123t, 126
initial images of, 3:125
positioning and immobilization for, 3:126,
126f
preparation and communication for, 3:126
components of, 1:327
CT of, 2:55, 3:336f-338f
false or greater, 1:332, 332f, 3:386, 397
in geriatric patients, 3:179, 179f
inferior aperture or outlet of, 1:332, 332f
lateral projection of, 1:340-341, 340f-341f
localization planes of, 1:346f
male vs. female, 1:332, 332f, 332t
PA projection of, 1:338f
mobile radiography of, 3:200-201
AP projection for, 3:200-201, 200f-201f
MRI of, 3:360, 361f
radiation protection for, 1:336, 336f
sample exposure technique chart essential
projections for, 1:335t
Pelvis (Continued)
summary of pathology of, 1:335t
summary of projections for, 1:326
superior aperture or inlet of, 1:332, 332f
trauma radiography of, 2:41, 41f
true or lesser, 1:332, 332f, 2:83, 3:386
Pencil-beam techniques for DXA, 3:444, 454-457,
454f, 477
Penetrating trauma, 2:19
Penis, 2:242, 243f
Percent coefficient of variation (%CV) in DXA,
3:455, 455f-456f, 477
Percutaneous, 3:97
Percutaneous antegrade pyelography, 2:211, 211f
Percutaneous antegrade urography, 2:191
Percutaneous renal puncture, 2:210-211, 210f-211f
Percutaneous transhepatic cholangiography (PTC),
2:174-175, 174f
Percutaneous transluminal angioplasty (PTA),
3:62-65
balloon in, 3:62-63, 63f
of common iliac artery, 3:64f
defined, 3:97
Dotter method for, 3:62
historical development of, 3:20
for placement of intravascular stents, 3:65, 65f
of renal artery, 3:64f
Percutaneous transluminal coronary angioplasty
(PTCA), 3:66, 88, 88f-89f
catheter system for, 3:88, 88f
defined, 3:97
with stent placement, 3:88, 89f
Percutaneous transluminal coronary rotational
atherectomy (PTCRA), 3:90, 90f-91f, 97
Percutaneous vertebroplasty, 3:16
Percutaneously, 3:97
Perfusion lung scan, 3:405, 405f
Perfusion study
for CT angiography of brain, 3:324-326, 326f
in MRI, 3:364-365, 367
Pericardial cavity, 1:69f, 479, 3:24
Pericardial sac, 3:24
Pericardium
anatomy of, 3:24, 97
sectional anatomy of, 3:270
Periosteal arteries, 1:77, 77f
Periosteum, 1:76, 76f
Peripheral, 1:85
Peripheral angiography, 3:46
lower limb arteriograms in, 3:47, 48f
lower limb venograms in, 3:47, 48f
upper limb arteriograms in, 3:46, 46f
upper limb venograms in, 3:46, 46f
Peripheral dual energy x-ray absorptiometry
(pDXA), 3:475, 475f, 477
Peripheral lymph sinus, 3:26
Peripheral quantitative computed tomography
(pQCT), 3:475, 477
Peripheral skeletal bone density measurements,
3:474-475, 474f-475f
Peripherally inserted central catheters (PICCs),
3:157, 157f
Perirenal fat, 3:283
Peristalsis, 1:18, 2:110
Peritoneal cavity, 2:83, 83f
Peritoneum
anatomy of, 2:83, 83f
sectional anatomy of, 3:283
Permanent magnets for MRI, 3:346, 367
Peroneal artery, arteriography of, 3:48f
Perpendicular plate
anatomy of, 2:262, 262f
CT of, 2:262f
sectional anatomy of, 3:253, 253f, 262
Personal hygiene in surgical radiography, 3:217
PET. See Positron emission tomography (PET).
Petrosa, submentovertical projection of, 2:311f,
367f
Petrous apex, 2:268, 269f
Petrous portion of temporal bone, 2:258f-259f
Petrous pyramids, 2:268, 286
Petrous ridge
acanthioparietal projection of, 2:328f
anatomy of, 2:268, 269f
AP axial projection of
Haas method for, 2:309f
Towne method for, 2:305f-306f
PA axial projection of, 2:298f, 330f
parietoacanthial projection of, 2:324f, 363f
sectional anatomy of, 3:261-263
submentovertical projection of, 2:346f
Phalanges
of foot, 1:228, 228f
of hand, 1:101, 101f
Phantom scans for DXA, 3:461, 462f
Pharmaceuticals, 3:438
in radiopharmaceuticals, 3:404-405, 405f
Pharyngeal tonsil, 2:71f, 72
Pharyngography, positive-contrast, 2:74-75
deglutition in, 2:74-75, 74f
fluoroscopic, 2:75
Gunson method for, 2:75, 75f
Pharynx
anatomy of, 2:71f, 72, 97f
AP projection of, 2:76-77, 76f-77f
lateral projection of, 2:78-79, 78f-79f
Index
methods of examination of, 2:74-75
positive-contrast pharyngography of, 2:74-75
deglutition in, 2:74-75, 74f
fluoroscopic, 2:75
Gunson method for, 2:75, 75f
sectional anatomy of, 3:265f, 267f
Phase contrast (PC) imaging, 3:363
Phasic flow, 3:393, 397
Phenergan (promethazine hydrochloride), 2:226t
Philips Medical Systems iDose, 3:319, 320f
Phleboliths, 2:188t
Phosphorus-32 (32P), therapeutic use of, 3:420
Photodiodes, 3:409
Photographic subtraction technique for hip
arthrography, 2:14, 15f
Photomultiplier tube (PMT), 3:400, 409, 438
Photopenia, 3:405, 438
Photostimulable storage phosphor image plate
(PSP IP), 1:3, 4f
Physician assistant, 3:215
Physiologic equipment for cardiac catheterization,
3:79-80, 79f, 82
Physiology, defined, 1:66
Pia mater
anatomy of, 3:3
sectional anatomy of, 3:254
Pica, 3:139, 140f
PICCs (peripherally inserted central catheters),
3:157, 157f
Picture archiving and communication system
(PACS)
for digital subtraction angiography, 3:31
for DXA, 3:460, 477
for nuclear medicine, 3:410
Picture element (pixel), 3:308, 308f, 340
in nuclear medicine, 3:438
Piezoelectric effect, 3:372, 397
Pigg-O-Stat
for abdominal imaging, 3:112, 112f
for chest imaging, 3:118, 118f
Pilot image in radiation oncology, 3:490-491
Pineal gland, 3:258-259, 265f
PIP (proximal interphalangeal) joints
of lower limb, 1:236
of upper limb, 1:105, 105f-106f
Piriform recess, 2:71f, 72
I-33
 Pisiform, 1:101f-102f, 102 Porta hepatis Positron emission tomography (PET) (Continued)
Pituitary adenoma, 2:282t anatomy of, 2:104 defined, 3:421, 438
Pituitary gland sectional anatomy of, 3:283, 287-288, 298-299 detectors for, 3:400, 437
anatomy of, 2:264-265, 3:2 ultrasonography of, 3:376f, 378, 397 future of, 3:436, 436f
sectional anatomy of, 3:261-262, 264, 265f, 267, Portal hypertension, 3:72 historical development of, 3:400
267f Portal system, 2:104, 105f, 3:23, 23f, 72, 97 image reconstruction and image processing for,
Pituitary stalk, 3:259-260, 259f Portal vein, 3:22f 3:400, 431-432, 431f, 438
Pivot joint, 1:82, 83f anatomy of, 2:104, 105f of local cerebral blood flow, 3:427, 427f
Pixel (picture element), 3:308, 308f, 340 sectional anatomy of, 3:282f, 283-285 of local metabolic rate of glucose, 3:427, 427f
in nuclear medicine, 3:438 on axial (transverse) plane, 3:287-289, mobile units for, 3:436, 436f
Placement of anatomy on image receptor, 1:28-29, 287f-289f vs. other modalities, 3:401t, 402, 421, 421f
28f-29f on coronal plane, 3:298-299, 298f patient preparation for, 3:432
Placenta Portal venography, 3:61, 61f positrons in, 3:421-424, 422f-424f, 423t-424t
anatomy of, 2:241, 241f Portal venous system, 3:284-285, 298-299 principles and facilities for, 3:421-432, 421f
previa, 2:241, 241f Portosystemic shunt, transjugular intrahepatic, in radiation oncology, 3:494
ultrasonography of, 3:389f 3:72, 72f-73f radionuclide production in, 3:425, 425f-426f,
Placentography, 2:252 Portsman, Werner, 3:20 426t
Plane(s), body. See Body planes. Position(s), 1:86b, 89-95 radiopharmaceuticals for
Plane joint, 1:82, 83f decubitus, 1:94, 94f-95f choice of, 3:421
Planimetry, 3:97 Fowler, 1:90, 91f new, 3:436
Plantar, 1:85 general body, 1:89-90 production of, 3:427-428, 427f
Plantar flexion, 1:97, 97f lateral, 1:91, 91f septa in, 3:400, 439
Plantar surface of foot, 1:228-230 lithotomy, 1:90, 91f transmission scan in, 3:402, 439
Plasma radioactivity measurement in PET, lordotic, 1:94, 95f Positron emission tomography/computed
3:430 note to educators, students, and clinicians on, tomography (PET/CT) scanners, 3:327-329,
Plastic fractures, 3:130 1:95 329f, 401, 436
“Plates” in digital radiography, 1:36, 36f oblique, 1:92-93, 92f-93f Positron emission tomography/magnetic
Pledget, 3:97 vs. projection, 1:95 resonance imaging (PET/MRI) system,
Pleura(e) prone, 1:90, 90f 3:401, 436
anatomy of, 1:480f, 482 radiographic, 1:89 Positron-emitting radionuclides, 3:421-422,
Index

AP or PA projection of, 1:483-484, 516f-517f recumbent, 1:90, 90f 422f

lateral projection of, 1:518-519, 518f-519f seated, 1:90 Posterior, 1:85
Pleural cavity(ies), 1:69f, 479, 482 Sims, 1:90, 91f Posterior acoustic enhancement, 3:397
Pleural effusion, 1:486t supine, 1:90, 90f Posterior acoustic shadowing, 3:375f, 397
mobile radiograph of, 3:195f Trendelenburg, 1:90, 90f Posterior arches of soft palate, 2:59, 59f
Pleural space, 1:480f upright, 1:87f, 90 Posterior cerebral arteries
Plural endings for medical terms, 1:98, 98t uses of term, 1:89 CT angiography of, 3:325f
Plural word forms, frequently misused, 1:98, Position sensitive photomultiplier tubes (PSPMTs), sectional anatomy of, 3:255, 260-261
98t 3:409 Posterior clinoid processes
PMT (photomultiplier tube), 3:400, 409, 438 Positioning aids for trauma radiography, 2:20 anatomy of, 2:258f, 264-265, 264f-265f
Pneumoarthrography, 2:8-9 Positive beam limitation (PBL), 1:32 AP axial projection of
Pneumococcal pneumonia, 3:151 Positive-contrast pharyngography, 2:74-75 Haas method for, 2:309f
Pneumoconiosis, 1:486t, 499f deglutition in, 2:74-75, 74f Towne method for, 2:305f
Pneumonia, 1:486t fluoroscopic, 2:75 sectional anatomy of, 3:253-254
in children, 3:150-151, 151f Gunson method for, 2:75, 75f Posterior communicating artery
in older adults, 3:172, 172f Positron(s), 3:421-424 anatomy of, 3:51
Pneumonitis, 1:486t characteristics of, 3:422, 423t arteriography of, 3:51f, 53f, 56f
Pneumoperitoneum, 2:84t decay of, 3:421-422, 423f, 425, 425f CT angiography of, 3:325f
in children, 3:115, 115f defined, 3:438 sectional anatomy of, 3:255
mobile radiograph of, 3:199f range of, 3:424, 424t Posterior cranial fossa, 2:260
Pneumothorax, 1:486t, 490, 498f, 503f Positron emission tomography (PET) Posterior cruciate ligament, 1:234f, 236f
PNL (posterior nipple line), 2:409, 410f clinical, 3:432-435, 432f-433f Posterior fat pad of elbow, 1:107, 107f
Polonium, 3:400 for cardiology imaging, 3:434-435 Posterior fontanel, 2:259-260, 260f
Polycystic kidney, 2:188t for neurologic imaging, 3:434 Posterior fossa, 3:261-262
Polycythemia, sodium phosphate for, 3:420 for oncology imaging, 3:433, 433f Posterior horn, 3:4, 4f
Polyp, 2:109t data acquisition in, 3:428-430 Posterior inferior iliac spine, 1:327f, 328
cranial, 2:282t coincidence counts in, 3:429, 429f Posterior interosseous artery, arteriography of,
endometrial, 2:245t cross-plane information in, 3:429, 429f 3:46f
Pons deadtime losses in, 3:430, 432, 437 Posterior nipple line (PNL), 2:409, 410f
anatomy of, 2:259f, 3:2, 2f-3f decay-corrected radioactivity curves in, 3:430, Posterior superior iliac spine, 1:327f, 328
defined, 3:18 430f Posterior tibial artery
sectional anatomy of, 3:255 detector arrangement for, 3:428-429, 428f anatomy of, 3:22f
on axial (transverse) plane, 3:259-262, direct-plane information in, 3:429, 429f arteriography of, 3:48f
259f-260f, 262f electronic collimation for, 3:430 Posteroanterior (PA) axial projection, 1:88
on sagittal plane, 3:265f field of view for, 3:428-429, 428f Posteroanterior (PA) oblique projection, 1:88
Pontine cistern, 3:254, 261-262 for glucose metabolism, 3:429-430 Posteroanterior (PA) projection, 1:10-11, 10f, 86,
Popliteal artery for plasma radioactivity measurement, 3:430 87f
anatomy of, 3:22f quantitative parametric images in, 3:430, Postoperative cholangiography, 2:176-177,
arteriography of, 3:48f 438 176f-177f
ultrasonography of, 3:394f for region of interest (ROI) analysis, 3:430, Postprocessing, 3:97
Popliteal surface of femur, 1:232f 438-439 in CT, 3:326, 340
Popliteal vein resolution in, 3:428-429 in digital subtraction angiography, 3:31
anatomy of, 3:22f scanner for, 3:428-429, 428f Pott fracture, 1:240t
ultrasonography of, 3:394f scintillators, 3:428-429, 428t Pouch of Douglas, 3:386, 386f, 398
venography of, 3:48f sensitivity of, 3:429-430 Power injector for IV administration of contrast
Port(s) in children, 3:158, 158f three-dimensional, 3:429-430 media for CT, 3:317, 317f

I-34
Power lifts, 1:46, 46f
Poznauskis, Linda, 3:119-120
pQCT (peripheral quantitative computed
tomography), 3:475, 477
Precession, 3:343, 343f, 367
Preexposure instructions, 1:41
Pregnancy
breasts during, 2:382
radiography of female reproductive system
during, 2:252
fetography for, 2:252, 252f
pelvimetry for, 2:252
placentography for, 2:252
radiation protection for, 2:252
Premature infants, development of, 3:102
Presbycusis, 3:169
Presbyopia, 3:169
Preschoolers, development of, 3:103, 103f
Pressure injector for cardiac catheterization, 3:79,
79f
Pressure sores in older adults, 3:175
Pressure transducers for cardiac catheterization,
3:79-80, 82
Pressure wire for cardiac catheterization, 3:80t
Primary curves, 1:367
Primary data in CT, 3:302, 340
Primary ossification, 1:77, 77f
Procedure book, 1:17
Processes, 1:84
Proctography, evacuation, 2:172, 172f
Progeria, 3:152, 152f
Projection(s), 1:86-89, 86b
anteroposterior (AP), 1:10-11, 10f, 86, 87f
entry and exit points for, 1:86, 86f
anteroposterior (AP) oblique, 1:88
axial, 1:86-87, 87f
axiolateral, 1:88
of bone, 1:84
complex, 1:88
defined, 1:86
entrance and exit points of, 1:86, 86f
in-profile, 1:89
lateral, 1:11, 12f, 88, 88f
of obese patients, 1:49
lateromedial and mediolateral, 1:88, 88f
note to educators, students, and clinicians on,
1:95
oblique, 1:12, 12f, 88, 89f
other, 1:12
vs. position, 1:95
posteroanterior (PA), 1:10-11, 10f, 86, 87f
posteroanterior (PA) axial, 1:88
posteroanterior (PA) oblique, 1:88
tangential, 1:86-87, 87f
transthoracic, 1:88
true, 1:89
vs. view, 1:95
Projectional technique, DXA as, 3:453, 477
Promethazine hydrochloride (Phenergan), 2:226t
Pronate/pronation, 1:97, 97f
Prone position, 1:90, 90f
Prophylactic surgery for breast cancer, 3:482,
507
Prophylaxis, 1:15
Prostate
anatomy of, 2:184f, 186f, 187, 242f-243f,
243
MRI of, 3:360
radiologic examination of, 2:214, 254
sectional anatomy of, 3:284, 296, 296f
Prostate cancer, 2:245t
in older adults, 3:173
radiation oncology for, 3:497, 502-503
Prostatic hyperplasia, benign, 2:188t
in older adults, 3:173, 174t
Prostatic urethra, 2:186f, 187
Prostatography, 2:214, 254 Pulmonary arteries
Protocol book, 1:17 anatomy of, 3:22f, 23, 25f
Protocol(s) for CT, 3:303f, 319-320, 336-340 sectional anatomy of, 3:270-271
Proton(s), 3:403, 403f, 438 on axial (transverse) plane, 3:275-277,
magnetic properties of, 3:343, 343f 276f
Proton density in MRI, 3:344, 367 on coronal plane, 3:280-281, 281f
Proton-rich nucleus, 3:422, 423f on sagittal plane, 3:278-280, 280f
Protuberance, 1:84 Pulmonary arteriography, 3:42, 42f
Provocative diskography, 3:16, 17f Pulmonary circulation, 3:23, 23f, 97
Proximal, 1:85, 85f Pulmonary edema, 1:486t
Proximal convoluted tubule, 2:185, 185f Pulmonary embolus, 3:70
Proximal femur, 1:325-360 Pulmonary trunk, 3:275-279, 276f
anatomy of, 1:328f-330f, 329-330, 334b Pulmonary valve
AP projection of, 1:337-339, 337f-338f anatomy of, 3:25, 25f
lateral projection of, 1:340-341, 340f-341f sectional anatomy of, 3:270, 280f
sample exposure technique chart essential Pulmonary veins
projections for, 1:335t anatomy of, 3:22f, 23, 25f
summary of pathology of, 1:335t sectional anatomy of, 3:270, 278-281, 278f,
summary of projections for, 1:326 281f
Proximal humerus Pulse, 3:26, 97
anatomic neck of, 1:177 Pulse height analyzer, 3:409, 438
anatomy of, 1:177-178, 177f Pulse oximetry, 3:97
greater tubercle of, 1:177, 177f for cardiac catheterization, 3:82
head of, 1:177, 177f Pulse sequences in MRI, 3:344, 352, 352f-353f,
intertubercular (bicipital) groove of 367
anatomy of, 1:177, 177f Pulse wave transducers for ultrasonography, 3:372,
Fisk modification for tangential projection of, 397
1:207-208, 207f-208f Pupil, 2:314f
lesser tubercle of, 1:177, 177f Purcell, Edward, 3:342
Stryker notch method for AP axial projection of, Pyelography, 2:191
Index
1:204, 204f percutaneous antegrade, 2:211, 211f
surgical neck of, 1:177, 177f Pyelonephritis, 2:188t
Proximal interphalangeal (PIP) joints Pyloric antrum
of lower limb, 1:236 anatomy of, 2:98, 98f
of upper limb, 1:105, 105f-106f sectional anatomy of, 3:283, 288
Proximal phalanges, 1:228, 228f Pyloric canal
Proximal tibiofibular joint, 1:236t, 238 anatomy of, 2:98, 98f
Pseudocyst, pancreatic, 2:109t sectional anatomy of, 3:282f, 289, 289f
Psoas muscle, sectional anatomy of, 3:282f Pyloric orifice, 2:98f, 99
on axial (transverse) plane, 3:291, 291f-293f Pyloric portion of stomach, 2:98, 100f
on coronal plane, 3:298f-299f Pyloric sphincter
PSP IP (photostimulable storage phosphor image anatomy of, 2:98f, 99
plate), 1:3, 4f sectional anatomy of, 3:283
PSPMTs (position sensitive photomultiplier tubes), Pyloric stenosis, 2:109t
3:409 Pylorus, 3:282f
PTA. See Percutaneous transluminal angioplasty Pyrogen-free radiopharmaceuticals, 3:404-405,
(PTA). 438
PTC (percutaneous transhepatic cholangiography),
2:174-175, 174f Q
PTCA. See Percutaneous transluminal coronary Quadrants of abdomen, 1:70, 70f
angioplasty (PTCA). Quadratus lumborum muscles, 3:291, 291f-292f
PTCRA (percutaneous transluminal coronary Quadrigeminal cistern, 3:254
rotational atherectomy), 3:90, 90f-91f, 97 Quantitative analysis in nuclear medicine, 3:410,
Pterion, 2:258f, 259 411f, 438
Pterygoid hamulus, 2:259f, 265f, 266 Quantitative computed tomography (QCT)
Pterygoid laminae, 2:265f, 266 for bone densitometry, 3:444, 469, 469f, 477
Pterygoid muscles, 3:255-256, 264 peripheral, 3:475, 477
Pterygoid processes Quantitative ultrasound (QUS), 3:475, 475f,
anatomy of, 2:265f, 266 477
sectional anatomy of, 3:253-254 Quantum noise in CT, 3:318-319, 340
Pubic symphysis Quench during MRI, 3:349
anatomy of, 1:331, 331f, 331t
with obese patients, 1:49, 49f R
sectional anatomy of, 3:282, 290, 296, 299 RA (radiographic absorptiometry), 3:443, 474,
as surface landmark, 1:71f, 71t, 333-334, 474f, 477
333f RA (radiologist assistant), 1:14
Pubis Ra (radium), 3:400, 507
anatomy of, 1:327-328, 327f, 330f Radial artery, 3:22f, 49f
sectional anatomy of, 3:282, 294, 295f, Radial fossa, 1:104, 104f
297f Radial head
Pulmonary apices Coyle method for axiolateral projection of,
AP axial projection of 1:162-164
in lordotic position (Lindblom method), evaluation criteria for, 1:164
1:512-513, 512f-513f position of part for, 1:162, 162f-163f
in upright or supine position, 1:515, 515f position of patient for, 1:162
PA axial projection of, 1:514, 514f structures shown on, 1:164, 164f
I-35
 Radial head (Continued) Radiation protection (Continued) Radiographic positioning terminology (Continued)
lateromedial projection of, 1:160-161 for female reproductive system radiography, Sims, 1:90, 91f
evaluation criteria for, 1:161b 2:246 supine, 1:90, 90f
four-position series for, 1:160 during pregnancy, 2:252 Trendelenburg, 1:90, 90f
position of part for, 1:160, 160f for gastrointestinal radiography, 2:114f, 115 upright, 1:87f, 90
position of patient for, 1:160 for long bone measurement, 2:2 for projections, 1:86-89, 86b, 86f
structures shown on, 1:161, 161f for lower limb, 1:242 AP, 1:86, 87f
Radial notch, 1:103, 103f for pelvis, 1:336, 336f axial, 1:87, 87f
Radial scar, 2:395 for shoulder girdle, 1:183 complex, 1:88
Radial styloid process, 1:103, 103f for skull, 2:288 lateral, 1:88, 88f
Radial tuberosity, 1:103, 103f for sternum, 1:456-462 note to educators, students, and clinicians on,
Radiation, 3:403, 438 for thoracic viscera, 1:492-493 1:95
tolerance doses to, 3:494, 494t for trauma radiography, 2:25 oblique, 1:88, 89f
Radiation dose for urinary system, 2:201 PA, 1:86, 87f
for nuclear medicine, 3:405, 437 Radiation safety in profile, 1:89
for obese patients, 1:52 for children, 3:101 tangential, 1:87, 87f
Radiation dose profile for CT, 3:330, 330f with mobile radiography, 3:188, 188f-189f true, 1:89
Radiation exposure considerations in surgical with MRI, 3:348-349, 349f for view, 1:95
radiography, 3:223, 223f in nuclear medicine, 3:407, 407f Radiographic room, care of, 1:14, 14f
Radiation fields, 3:486-487, 506 Radiation therapist, 3:480, 507 Radiographic technique charts for mobile
Radiation oncologist, 3:480, 507 Radiation therapy. See also Radiation oncology. radiography, 3:187, 187f
Radiation oncology, 3:479-508 defined, 3:480, 507 Radiography, defined, 1:85
and cancer, 3:481-483 image-guided, 3:498, 498f, 506 Radioimmunotherapy, 3:435
most common types of, 3:482, 482t intensity modulated, 3:489, 496, 506 Radioindicator, 3:400
risk factors for, 3:482-483, 482t stereotactic, 3:499, 507 Radioiodine for Graves disease, 3:420
tissue origins of, 3:483, 483t Radioactive, 3:400, 438 Radioisotope, 3:438
clinical applications of, 3:502-504 Radioactive analogs, 3:401-402, 437 Radiologic technology, defined, 1:2
for breast cancer, 3:504, 504f Radioactive decay, 3:403, 404f Radiologic vertebral assessment (RVA), 3:469-470,
for cervical cancer, 3:503, 503f Radioactive source in radiation oncology, 3:485, 470f-471f, 477
for head and neck cancers, 3:503 507 Radiologist assistant (RA), 1:14
Index

for Hodgkin lymphoma, 3:503 Radioactivity, 3:400, 403, 438 Radiology practitioner assistant (RPA), 1:14
for laryngeal cancer, 3:504 Radioactivity concentration in PET, 3:421 Radionuclide(s)
for lung cancer, 3:502, 502f Radiocarpal articulations, 1:106, 106f for conventional nuclear medicine, 3:401-402,
for medulloblastoma, 3:504, 505f Radiocurable, 3:507 404-405, 405f, 406t
for prostate cancer, 3:497, 502-503 Radiofrequency (RF) ablation, cardiac decay of, 3:403, 404f
for skin cancer, 3:504 catheterization for, 3:94 defined, 3:438
CT for treatment planning in, 3:327, 328f Radiofrequency (RF) antennas in MRI, 3:346 for PET, 3:425, 425f-426f, 426t
for cure, 3:480, 506 Radiofrequency (RF) pulse in MRI, 3:343, 367 positron-emitting, 3:421-422, 422f
defined, 3:480, 507 Radiogrammetry, 3:443, 477 in radiopharmaceuticals, 3:404-405, 405f
definition of terms for, 3:506b-507b Radiograph(s), 1:5-12 Radionuclide angiography (RNA), 3:416
dose depositions in, 3:485, 485f adjacent structures on, 1:5 Radionuclide cisternography, 3:417
equipment for, 3:485-489 anatomic position in, 1:8-12, 8f-9f Radiopaque markers for trauma radiography, 2:24,
cobalt-60 units as, 3:486-487, 487f, 506 AP, 1:10-11, 10f 24f
linear accelerators (linacs) as, 3:485, 487-489, contrast on, 1:5, 6f Radiopaque objects, 1:20, 21f
488f, 506 defined, 1:5 Radiopharmaceuticals, 3:404-405
multileaf collimation system as, 3:489, display of, 1:8 commonly used radionuclides in, 3:404-405,
489f of foot and toe, 1:11 406t
external-beam therapy and brachytherapy in, of hand, fingers, and wrist, 1:11, 11f components of, 3:404-405, 405f
3:485 identification of, 1:25, 25f defined, 3:400, 438
fractionation in, 3:480, 506 lateral, 1:11, 12f dose of, 3:405
future trends in, 3:505 magnification of, 1:7, 7f formation of, 3:404, 404f
historical development of, 3:481, 481t oblique, 1:12, 12f for perfusion lung scan, 3:405, 405f
for palliation, 3:480, 507 optical density (OD) on, 1:5, 5f for PET
principles of, 3:480 other, 1:12 choice of, 3:421
skin-sparing effect of, 3:486, 486f, 507 PA, 1:10-11, 10f new, 3:436
steps in, 3:489-501 shape distortion on, 1:7, 7f production of, 3:427-428, 427f
contrast administration as, 3:490, 491f-492f spatial resolution of, 1:5, 6f qualities of, 3:404-405
creation of treatment fields as, 3:491, superimposition on, 1:5 Radiosensitivity, 3:484, 507
492f-493f Radiographer, 1:2 Radiotracers, 3:400, 402, 438
CyberKnife as, 3:499-501, 501f Radiographic absorptiometry (RA), 3:443, 474, Radioulnar joints, 1:107, 107f
dosimetry as, 3:480, 494-496, 494f-495f, 474f, 477 Radium (Ra), 3:400, 507
494t, 506 Radiographic positioning terminology, 1:85-95 Radius(ii)
immobilization devices as, 3:490, for method, 1:95 of arm, 1:101f, 102-103, 103f
490f-491f for positions, 1:86b, 89-95 defined, 3:403
reference isocenter as, 3:490-491 decubitus, 1:94, 94f-95f Radon, 3:400
simulation as, 3:489-491, 490f Fowler, 1:90, 91f Rafert et al. modification of Lawrence method for
TomoTherapy as, 3:499, 500f general body, 1:90 inferosuperior axial projection of shoulder
treatment as, 3:496-501, 497f-499f lateral, 1:91, 91f joint, 1:194, 194f
theory of, 3:484, 484t lithotomy, 1:90, 91f Rafert-Long method for scaphoid series, 1:142,
Radiation protection lordotic, 1:94, 95f 142f-143f
for angiographic studies, 3:39 note to educators, students, and clinicians on, RANKL inhibitor for osteoporosis, 3:448t
for children, 3:108-111, 108f-109f, 109t 1:95 RAO (right anterior oblique) position, 1:92,
for gastrointestinal and genitourinary studies, oblique, 1:92-93, 92f-93f 92f
3:116 prone, 1:90, 90f Rapid acquisition recalled echo, 3:367
for limb radiography, 3:129, 129f recumbent, 1:90, 90f Rapid film changers, 3:21
with DXA, 3:458, 458t seated, 1:90 Rapid serial radiographic imaging, 3:32

I-36
Rare-earth filtration systems for DXA, 3:451,
451f-452f
crossover in, 3:452
scintillating detector pileup in, 3:452
Raw data in MRI, 3:345, 367-368
Ray, 3:438
82
Rb (rubidium-82), 3:406t
RBE (relative biologic effectiveness), 3:484, 484t,
507
RDCSs (registered diagnostic cardiac
sonographers), 3:370
RDMSs (registered diagnostic medical
sonographers), 3:370
characteristics of, 3:370, 371f
Real time, 3:327, 340
Real-time ultrasonography, 3:387, 397
Receiving coil in MRI, 3:343
Recombinant tissue plasminogen activators,
3:20-21
Reconstruction
for CT, 3:309, 340
multiplanar, 3:313, 313f, 340
for PET, 3:400, 438
Recorded detail, 1:5, 6f
Rectal ampulla, 2:103, 103f
Rectal examination, dynamic, 2:172, 172f
Rectilinear scanner, 3:408, 438
Rectosigmoid junction, axial projection of
(Chassard-Lapiné method), 2:169, 169f
Rectouterine pouch, ultrasonography of, 3:386,
386f, 398
Rectouterine recess, ultrasonography of, 3:388f
Rectovaginal fistula, 2:251f
Rectum
anatomy of, 2:97f, 102f-103f, 103
axial projection of (Chassard-Lapiné method),
2:169, 169f
defecography of, 2:172, 172f
sectional anatomy of, 3:283
on axial (transverse) plane, 3:294-296,
294f-296f
on sagittal plane, 3:296, 297f
ultrasonography of, 3:386f
Rectus abdominis muscle, sectional anatomy of,
3:285
on axial (transverse) plane
at Level B, 3:286f
at Level C, 3:287f
at Level D, 3:288f
at Level E, 3:290
at Level G, 3:291
at Level I, 3:293
at Level J, 3:294, 294f
on sagittal plane, 3:296, 297f
Rectus muscles, 3:261-262
Recumbent position, 1:90, 90f
Red marrow, 1:76, 76f
Reference isocenter in simulation in radiation
oncology, 3:490-491
Reference population in DXA, 3:457, 477
Reflection in ultrasonography, 3:372f, 397
Refraction in ultrasonography, 3:372f, 397
Region(s) of abdomen, 1:70, 70f
Region(s) of interest (ROI)
in CT, 3:340
in DXA, 3:443, 477
Region of interest (ROI) analysis in PET, 3:430,
438-439
Regional enteritis, 2:109t
Registered diagnostic cardiac sonographers
(RDCSs), 3:370
Registered diagnostic medical sonographers
(RDMSs), 3:370
characteristics of, 3:370, 371f
Registered vascular technologists (RVTs), 3:370
Regurgitation, cardiac valvular, 3:370, 393, 397
Relative biologic effectiveness (RBE), 3:484, 484t, Respiratory system
507 anatomy of, 1:479-482
Relaxation in MRI, 3:344, 368 alveoli in, 1:480f, 481
Relaxation times in MRI, 3:342, 344, 368 bronchial tree in, 1:480, 480b, 480f
Renal angiography, 2:190, 191f lungs in, 1:481-482, 481f-482f
CT, 3:324-326, 325f trachea in, 1:480, 480b, 480f
Renal arteriography, 2:190, 191f, 3:41f-42f, 45, lungs in. See Lung(s).
45f pleura in
Renal artery(ies) AP or PA projection of, 1:516-517,
anatomy of, 3:22f 516f-517f
MR angiography of, 3:364f lateral projection of, 1:518-519, 518f-519f
percutaneous transluminal angioplasty of, trachea in
3:64f anatomy of, 1:480, 480b, 480f
sectional anatomy of, 3:284, 298-299, 299f AP projection of, 1:492-493, 492f-493f
ultrasonography of, 3:377f lateral projection of, 1:494, 494f-495f
Renal calculus, 2:188t, 190f radiation protection for, 1:492-493
Renal calyx(ces) Respiratory system disorders in older adults, 3:172,
anatomy of, 2:183, 185, 185f 172f
sectional anatomy of, 3:283 Restenosis, 3:97
Renal capsule, 2:184, 185f Restricted area, 3:250
Renal cell carcinoma, 2:188t Retina, 2:314f, 315
Renal columns, 2:185, 185f Retroareolar cyst, 2:385f
Renal corpuscle, 2:185 Retrograde cystography
Renal cortex, 2:185, 185f AP axial projection for, 2:216f-217f
Renal cyst, 2:210f-211f AP oblique projection for, 2:218f-219f
Renal failure in older adults, 3:174t AP projection for, 2:215f
Renal fascia contrast injection technique for, 2:214, 215f
anatomy of, 2:184 Retrograde urography, 2:192f, 193
sectional anatomy of, 3:283 AP projection for, 2:212-213, 212f-213f
Renal hilum, 2:184, 185f contrast media for, 2:194, 195f
Index
Renal hypertension, 2:188t defined, 2:193
Renal medulla, 2:185, 185f preparation of patient for, 2:197
Renal obstruction, 2:188t Retromammary fat, 2:381f
Renal papilla, 2:185, 185f Retroperitoneal cavity, ultrasonography of, 3:380,
Renal parenchyma, nephrotomography of, 2:209, 382, 397
209f Retroperitoneal fat, ultrasonography of, 3:377f
Renal pelvis Retroperitoneum
anatomy of, 2:183, 185, 185f anatomy of, 2:83, 83f
sectional anatomy of, 3:283 sectional anatomy of, 3:283
Renal puncture, percutaneous, 2:210-211, sectional image of, 2:107f
210f-211f ultrasonography of, 3:376-383, 376f-377f
Renal pyramids, 2:185, 185f Reverse Waters method
Renal scan, dynamic, 3:419 for cranial trauma, 2:46, 46f
Renal sinus, 2:184, 185f for facial bones, 2:327, 327f-328f
Renal study, nuclear medicine for, 3:409, 410f with trauma, 2:328, 328f
Renal transplant, ultrasonography of, 3:383 RF. See Radiofrequency (RF).
Renal tubule, 2:185 Rheolytic thrombectomy, 3:80t
Renal vein Rheumatoid arthritis, 1:109t, 182t
anatomy of, 3:22f Rhomboid major muscle, 3:271, 274-275,
sectional anatomy of, 3:284, 290, 290f 274f
Renal venography, 3:61, 61f Rhomboid minor muscle, 3:271, 274-275, 274f
Rendering in three-dimensional imaging, 3:326, Ribs
340 anatomy of, 1:447f-449f, 448
Reperfusion, 3:97 anterior, 1:468
Reproductive system, 2:237-254 PA projection of upper, 1:469-470,
abbreviations used for, 2:245b 469f-470f
female. See Female reproductive system. axillary portion of, 1:468
male. See Male reproductive system. AP oblique projection for, 1:473-474,
summary of pathology of, 2:245t 473f-474f
summary of projections for, 2:238 PA oblique projection for, 1:475-476,
Resistive magnets for MRI, 3:346, 368 475f-476f
Resolution cervical, 1:448
of collimator, 3:409, 439 components of, 1:448, 448f-449f
in ultrasonography, 3:371, 397 false, 1:447f, 448
Resonance in MRI, 3:343, 368 floating, 1:447f, 448
Respect and heart, 1:468
in code of ethics, 1:2-3 localization of lesion of, 1:468
for parents and children, 3:101 lumbar, 1:448
Respiratory distress syndrome, 1:486t positioning for, 1:453, 468
Respiratory gating for radiation oncology, 3:498, posterior, 1:468
499f AP projection of, 1:471-472, 471f-472f
Respiratory movement, 1:451, 451f in radiography of sternum, 1:456, 457f
diaphragm in, 1:452, 452f radiography of, 1:468
in radiography of ribs, 1:468 respiratory movement of, 1:451, 451f,
in radiography of sternum, 1:456, 457f 468
Respiratory syncytial virus (RSV), 3:150 diaphragm in, 1:452, 452f
I-37
 Ribs (Continued)
sectional anatomy of
in abdominopelvic region, 3:298-299
in thoracic region, 3:269f
on axial (transverse) plane, 3:273f-274f,
278
on coronal plane, 3:280-281, 281f
on sagittal plane, 3:279-280, 280f
trauma to, 1:453, 468
true, 1:447f, 448
Rickets, 1:240t
Right anterior oblique (RAO) position, 1:92, 92f
Right colic flexure, 2:102f, 103
Right jugular trunk, 3:26
Right lower quadrant (RLQ), 1:70, 70f
Right lymphatic duct, 3:26
Right posterior oblique (RPO) position, 1:88, 93,
93f
Right upper quadrant (RUQ), 1:70, 70f
Rima glottidis, 2:71f, 73, 73f
RLQ (right lower quadrant), 1:70, 70f
RNA (radionuclide angiography), 3:416
Robert method for first CMC joint of thumb,
1:118-119
central ray for, 1:119, 119f
evaluation criteria for, 1:119b
Lewis modification of, 1:119
Long and Rafert modification of, 1:119
position of part for, 1:118, 118f
position of patient for, 1:118, 118f
Index
structures shown on, 1:119, 119f
Rods, 2:315
ROI. See Region(s) of interest (ROI).
Rosenberg method for weight-bearing PA
projection of knee, 1:303, 303f
Rotablator, 3:90, 90f-91f
Rotate/rotation, 1:97, 97f
medial and lateral, 1:93, 93f, 97, 97f
Rotational burr atherectomy, 3:97
Rotational tomography of mandible, 2:353-354,
353f-354f
Rotator cuff, sectional anatomy of, 3:271,
274-275
Rotator cuff tear, 2:9t
contrast arthrography of, 2:10, 10f
Round ligament
anatomy of, 2:239f-240f
ultrasonography of, 3:376f
Round window, 2:270f, 271
RPA (radiology practitioner assistant), 1:14
RPO (right posterior oblique) position, 1:88, 93,
93f
RSV (respiratory syncytial virus), 3:150
Rubidium-82 (82Rb), 3:406t
Rugae
of stomach, 2:98, 98f, 3:283
of urinary bladder, 2:186
RUQ (right upper quadrant), 1:70, 70f
RVA (radiologic vertebral assessment), 3:469-470,
470f-471f, 477
RVTs (registered vascular technologists), 3:370
S structures shown on, 1:140, 140f
Sacral canal, 1:376, 377f
Sacral cornua, 1:376, 376f-377f
Sacral hiatus, 1:377f
Sacral promontory, 1:332f, 376, 376f
Sacral teratoma, fetal ultrasound of, 3:391f
Sacral vertebrae, 1:366
Sacroiliac (SI) joints
anatomy of, 1:331, 331f, 331t, 376f-377f
AP axial oblique projection of, 1:428, 428f
AP axial projection of (Ferguson method),
1:425-426, 425f
AP oblique projection of, 1:427-428, 427f-428f
PA axial oblique projection of, 1:430, 430f
I-38
Sacroiliac (SI) joints (Continued)
PA axial projection of, 1:426, 426f
PA oblique projection of, 1:429-430, 429f-430f
sectional anatomy of, 3:282, 293, 293f
Sacrum
anatomy of, 1:330f, 366f
AP axial projection of, 1:431-432, 431f
lateral projections of, 1:433-434, 433f-434f
PA axial projection of, 1:431-432, 432f
sectional anatomy of, 3:282
on axial (transverse) plane, 3:293f-294f, 294
on sagittal plane, 3:296, 297f
Saddle joint, 1:82, 83f
Safety. See Radiation safety.
Sagittal plane, 1:66, 66f-67f
kidneys in, 3:382, 398
in sectional anatomy, 3:252
Sagittal suture, 2:259, 275t
Salivary duct, 2:62t
Salivary glands
anatomy of, 2:60-62, 60f-61f, 61b, 97f
lateral projection of parotid and submandibular
glands for, 2:66-67, 66f-67f
sialography of, 2:62-63, 62f-63f
summary of pathology of, 2:62t
summary of projections of, 2:58-59
tangential projection of parotid gland for,
2:64-65
evaluation criteria for, 2:65b
position of part for, 2:64-65, 64f
position of patient for, 2:64
in prone body position, 2:64f, 65
structures shown on, 2:64f-65f, 65
in supine body position, 2:64, 64f
Salter-Harris fractures, 3:130, 130f
Sarcoidosis, 1:486t
Sarcoma
of breast, 2:395
Ewing, 1:109t, 240t
in children, 3:150, 150f
osteogenic. See Osteosarcoma.
SAVI (strut adjusted volume implant applicator),
3:504
SBRT (stereotactic body radiation therapy),
3:499
SC articulations. See Sternoclavicular (SC)
articulations.
Scan diameter in CT, 3:320, 340
Scan duration in CT angiography, 3:324, 340
Scan field of view (SFOV) in CT, 3:320
Scan in CT, 3:340
Scan times in CT, 3:320, 340
Scaphoid, 1:140-141
anatomy of, 1:101f, 102
Rafert-Long method for scaphoid series (PA and
PA axial projections with ulnar deviation)
of, 1:142, 142f-143f
Stecher method for PA axial projection of,
1:140-141
evaluation criteria for, 1:140b
position of part for, 1:140, 140f
position of patient for, 1:140
variations of, 1:141, 141f
Scaphoid series, 1:142, 142f-143f
Scapula(e)
acromion of, 1:176, 176f
anatomy of, 1:176-177, 176f
AP oblique projection of, 1:220, 220f-221f
AP projection of, 1:216-217, 216f-217f
coracoid process of
anatomy of, 1:176, 176f
AP axial projection of, 1:222, 222f-223f
costal (anterior) surface of, 1:176, 176f
dorsal (posterior) surface of, 1:176, 176f
function of, 1:175
Scapula(e) (Continued)
glenoid surface of, 1:176f
inferior angle of, 1:71f, 71t, 176f, 177
infraspinous fossa of, 1:176, 176f
lateral angle of, 1:176f, 177
lateral border of, 1:176, 176f
lateral projection of, 1:218, 218f-219f
medial border of, 1:176, 176f
neck of, 1:176f, 177
sectional anatomy of, 3:269f, 270, 273-275,
274f, 278f
superior angle of, 1:176f, 177
superior border of, 1:176, 176f
supraspinous fossa of, 1:176, 176f
Scapular notch, 1:176, 176f
Scapular spine
anatomy of, 1:176, 176f
crest of, 1:176, 176f
Laquerrière-Pierquin method for tangential
projection of, 1:224, 224f
sectional anatomy of, 3:269f, 273f
Scapular Y, PA oblique projection of,
1:199-201
central ray for, 1:201, 201t
compensating filter for, 1:199-201
evaluation criteria for, 1:201b
position of part for, 1:199, 199f
position of patient for, 1:199
structures shown on, 1:200f, 201
Scapulohumeral articulation, 1:178-180, 178t,
179f-181f
Scatter radiation in CT, 3:318-319, 319f
Scattering in ultrasonography, 3:398
Schatzki ring, 2:119f
Scheuermann disease, 1:380t
School age children, development of, 3:104
Schüller method
for axiolateral projection of TMJ,
2:349-350
evaluation criteria for, 2:350b
position of part in, 2:349, 349f-350f
position of patient in, 2:349
structures shown on, 2:350, 350f
for submentovertical projection of cranial base,
2:310-311
central ray for, 2:310f, 311
evaluation criteria for, 2:311b
position of part for, 2:310-311, 310f
position of patient for, 2:310
structures shown on, 2:311, 311f
Sciatic nerve, 3:294, 294f-296f
Scintillate, 3:408
Scintillating detector pileup with K-edge filtration
systems for DXA, 3:452
Scintillation camera, 3:400, 439
Scintillation counter, 3:444, 477
Scintillation crystals of gamma camera, 3:408f,
409
Scintillation detector, 3:408, 439
Scintillators, 3:400, 438
for PET, 3:401t, 428-429
Sclera, 2:315
Scoliosis, 3:152-154
Cobb angle in, 3:154
congenital, 3:153
C-spine filter for, 3:153
defined, 1:380t, 437, 3:152
DXA with, 3:464, 465f
estimation of rotation in, 3:154
idiopathic, 3:152
image assessment for, 3:123t
imaging of, 3:153, 153f
lateral bends with, 3:154
neuromuscular, 3:153
PA and lateral projections of (Frank et al.
method), 1:437-438, 437f-438f
Scoliosis (Continued)
PA projection of (Ferguson method), 1:439-440
evaluation criteria for, 1:439b-440b
first radiograph in, 1:439, 439f
position of part for, 1:439, 439f-440f
position of patient for, 1:439, 439f
second radiograph in, 1:439, 440f
structures shown on, 1:439-440, 439f-440f
patterns of, 3:154
skeletal maturity with, 3:154
symptoms of, 3:152, 152f
treatment options for, 3:154
Scoliosis filters, 1:57, 64, 64f, 367, 367f
Scottie dog
in AP oblique projection, 1:421-422,
421f-422f
in PA oblique projection, 1:423, 423f-424f
Scout image
of abdomen, 2:87
in radiation oncology, 3:490-491
Scrotum, 2:242
Scrub nurse, 3:215
SD (standard deviation) in DXA, 3:455, 455f-456f,
477
Seated position, 1:90
Secondary curves, 1:367
Secondary ossification, 1:72-74, 77f-78f
Sectional anatomy, 3:251-300
of abdominopelvic region, 3:282-299
on axial (transverse) plane, 3:284f, 285
at level A, 3:285, 285f
at level B, 3:285, 286f
at level C, 3:287, 287f
at level D, 3:288, 288f
at level E, 3:289, 289f
at level F, 3:290, 290f
at level G, 3:291, 291f
at level H, 3:292, 292f
at level I, 3:293, 293f
at level J, 3:294, 294f
at level K, 3:295, 295f-296f
on cadaveric image, 3:282, 282f
on coronal plane, 3:298f-299f, 299
on sagittal plane, 3:296, 297f
axial (transverse) planes in, 3:252
of cadaveric sections, 3:252
coronal planes in, 3:252
of cranial region, 3:253-268
on axial (transverse) plane, 3:256, 256f
at level A, 3:256-257, 256f-257f
at level B, 3:257-258, 257f
at level C, 3:258, 258f
at level D, 3:259-260, 259f
at level E, 3:260f-261f, 261-262
at level F, 3:262, 262f
at level G, 3:263, 263f
on cadaveric image, 3:253, 253f
on coronal plane, 3:266-267, 266f
at level A, 3:266-267, 267f
at level B, 3:267-268, 267f
at level C, 3:268, 268f
on sagittal plane, 3:256f, 264, 264f
at level A, 3:264-265, 265f
at level B, 3:265, 265f
at level C, 3:266, 266f
of CT, 3:252
of MRI, 3:252
oblique planes in, 3:252
overview of, 3:252
sagittal planes in, 3:252
of thoracic region, 3:269-281
on axial (transverse) plane, 3:272, 272f
at level A, 3:272, 272f
at level B, 3:273, 273f
at level C, 3:274-275, 274f
at level D, 3:275, 275f
Sectional anatomy (Continued)
at level E, 3:275-277, 276f-277f
at level F, 3:278, 278f
at level G, 3:278, 279f
on cadaveric image, 3:269, 269f, 271f
on coronal plane, 3:280, 281f
at level A, 3:280, 281f
at level B, 3:280-281, 281f
at level C, 3:281, 281f
on sagittal plane, 3:278-279, 279f
at level A, 3:278-279, 280f
at level B, 3:279, 280f
at level C, 3:279-280, 280f
Segmentation in three-dimensional imaging, 3:326,
340
Segmented regions, 3:402
Seldinger technique, 3:20, 36, 37f
Selective estrogen receptor modulators (SERMs)
for osteoporosis, 3:448t
Self-efficacy, 3:166
Sella turcica
anatomy of, 2:258f, 264-265, 264f-265f
lateral projection of, 2:293f, 322f, 359f
in decubitus position, 2:295f
sectional anatomy of, 3:253-254, 260f, 261-262
Sellar joint, 1:82, 83f
Semicircular canals, 2:269f-270f, 271
Seminal duct radiography, 2:253
epididymography for, 2:253, 253f
epididymovesiculography for, 2:253
grid technique for, 2:253
nongrid technique for, 2:253
vesiculography for, 2:253, 254f
Seminal vesicles
anatomy of, 2:242, 243f
sectional anatomy of, 3:284, 296, 296f
tuberculous, 2:254f
Seminoma, 2:245t
Semirestricted area, 3:250
Sensitivity of collimator, 3:409
Sensory system disorders in older adults, 3:169
Sentinel node imaging, nuclear medicine for, 3:420
Septum(a)
pellucidum, 3:257-258, 257f, 266-267, 267f
in PET, 3:400, 439
Serial imaging, 3:21, 97
Serial scans in DXA, 3:463-464, 463f, 477
SERMs (selective estrogen receptor modulators)
for osteoporosis, 3:448t
Serratus anterior muscle
anatomy of, 2:380, 380f
sectional anatomy of
in abdominopelvic region, 3:285, 285f
in thoracic region, 3:271, 278, 278f-279f
Sesamoid bones, 1:79, 79f
of foot
anatomy of, 1:228f, 230
tangential projection of
Holly method for, 1:251, 251f
Lewis method for, 1:250-251, 250f
of hand, 1:101, 101f
Settegast method for tangential projection of
patella and patellofemoral joint, 1:316-317
evaluation criteria for, 1:317b
position of part for, 1:316-317
position of patient for, 1:316
lateral, 1:316f
seated, 1:316, 316f
supine or prone, 1:316, 316f
structures shown on, 1:317, 317f
SFOV (scan field of view) in CT, 3:320
Shaded surface display (SSD), 3:326, 340
Shading in three-dimensional imaging, 3:326, 340
Shadow shield, 1:33, 34f
Shape distortion, 1:7, 7f
Sheets, 1:15
Shewhart Control Chart rules, 3:461, 477
Shielding
for CT, 3:331
gonad, 1:33-35, 33f-34f
for children, 3:108, 108f-109f
Short bones, 1:79, 79f
Short tau inversion recovery (STIR),
3:352-353
Shoulder
AP oblique projection for trauma of, 2:48,
48f-49f
AP projection of, 1:183-188
compensating filter for, 1:185-188, 187f
evaluation criteria for, 1:186b-188b
with humerus in external rotation
evaluation criteria for, 1:186
position of part for, 1:184f-185f, 185
structures shown on, 1:186, 186f
with humerus in internal rotation
evaluation criteria for, 1:186-188
position of part for, 1:184f, 185
structures shown on, 1:186, 187f
with humerus in neutral rotation
evaluation criteria for, 1:186
position of part for, 1:184f, 185
structures shown on, 1:186, 186f
position of part for, 1:183-185
position of patient for, 1:183
structures shown on, 1:186-188, 186f
Lawrence method for transthoracic lateral
Index
projection of, 1:192-193, 192f-193f
surgical radiography of, 3:238-239,
238f-239f
trauma radiography of, 2:48, 48f-49f
Shoulder arthrography, 2:10-11
CT after, 2:11, 11f
double-contrast, 2:10, 10f-11f
MRI vs., 2:8f
single-contrast, 2:10, 10f-11f
Shoulder girdle, 1:173-224
acromioclavicular articulation of
Alexander method for AP axial projection of,
1:211-212, 211f-212f
anatomy of, 1:178t, 179f, 181, 181f
Pearson method for bilateral AP projection of,
1:209, 209f-210f
anatomy of, 1:175, 175f
acromioclavicular articulation in, 1:178t, 179f,
181, 181f
bursae in, 1:178, 178f
clavicle in, 1:175, 175f
proximal humerus in, 1:177-178, 177f
scapula in, 1:176-177, 176f
scapulohumeral articulation in, 1:178-180,
178t, 179f-181f
sternoclavicular articulation in, 1:178t, 179f,
181-182, 181f
summary of, 1:181b
AP projection of, 1:183-188
compensating filter for, 1:185-188, 187f
evaluation criteria for, 1:186b-188b
with humerus in external rotation
evaluation criteria for, 1:186
position of part for, 1:184f-185f, 185
structures shown on, 1:186, 186f
with humerus in internal rotation
evaluation criteria for, 1:186-188
position of part for, 1:184f, 185
structures shown on, 1:186, 187f
with humerus in neutral rotation
evaluation criteria for, 1:186
position of part for, 1:184f, 185
structures shown on, 1:186, 186f
position of part for, 1:183-185
position of patient for, 1:183
structures shown on, 1:186-188, 186f
I-39
 Shoulder girdle (Continued)
clavicle of
anatomy of, 1:175, 175f
AP axial projection of, 1:214, 214f
AP projection of, 1:213, 213f
PA axial projection of, 1:215, 215f
PA projection of, 1:215, 215f
defined, 1:175
glenoid cavity of
Apple method for AP oblique projection of,
1:190-191, 190f-191f
Garth method for AP axial oblique projection
of, 1:205-206, 205f-206f
Grashey method for AP oblique projection of,
1:188-189, 188f-189f
central ray for, 1:189
inferosuperior axial projection of
Lawrence method and Rafert et al.
modification of, 1:194, 194f-195f
West Point method for, 1:196-197,
196f-197f
Lawrence method for transthoracic lateral
projection of, 1:192-193, 192f-193f
proximal humerus of
anatomy of, 1:177-178, 177f
intertubercular (bicipital) groove of
anatomy of, 1:177, 177f
Fisk modification for tangential projection
of, 1:207-208, 207f-208f
Stryker notch method for AP axial projection
Index
of, 1:204, 204f
radiation protection for, 1:183
sample exposure technique chart essential
projections for, 1:182t
scapula of
anatomy of, 1:176-177, 176f
AP axial projection of coracoid process of,
1:222, 222f-223f
AP oblique projection of, 1:220, 220f-221f
AP projection of, 1:216-217, 216f-217f
Laquerrière-Pierquin method for tangential
projection of spine of, 1:224, 224f
lateral projection of, 1:218, 218f-219f
scapular Y of, PA oblique projection of,
1:199-201
central ray for, 1:201, 201t
compensating filter for, 1:199-201
evaluation criteria for, 1:201b
position of part for, 1:199, 199f
position of patient for, 1:199
structures shown on, 1:200f, 201
summary of pathology of, 1:182t
summary of projections for, 1:174
superoinferior axial projection of, 1:198,
198f
supraspinatus “outlet” of
AP axial projection of, 1:203, 203f
Neer method for tangential projection of,
1:202-203, 202f
Shoulder joint
glenoid cavity of
Apple method for AP oblique projection of,
1:190-191, 190f-191f
Garth method for AP axial oblique projection
of, 1:205-206, 205f-206f
Grashey method for AP oblique projection of,
1:188-189, 188f-189f
inferosuperior axial projection of
Lawrence method and Rafert et al.
modification of, 1:194, 194f-195f
West Point method for, 1:196-197, 196f-197f
PA oblique projection of scapular Y of,
1:199-201
central ray for, 1:201, 201t
compensating filter for, 1:199-201
evaluation criteria for, 1:201b
I-40
Shoulder joint (Continued)
position of part for, 1:199, 199f
position of patient for, 1:199
structures shown on, 1:200f, 201
Stryker notch method for AP axial projection of
proximal humerus of, 1:204, 204f
superoinferior axial projection of, 1:198, 198f
supraspinatus “outlet” of
AP axial projection of, 1:203, 203f
Neer method for tangential projection of,
1:202-203, 202f
SI joints. See Sacroiliac (SI) joints.
Sialography, 2:62-63, 62f-63f
SID (source–to–image receptor distance), 1:7,
31-32, 31f, 3:33
in mobile radiography, 3:187
Sieverts (Sv), 3:458, 477
Sigmoid sinuses, 3:255, 262-263, 262f
Signal in MRI
defined, 3:368
production of, 3:343, 343f
significance of, 3:344, 344f
Silicosis, 1:486t
Simple fracture, 1:84f
Sims position, 1:90, 91f
Simulation in radiation oncology, 3:489-491
contrast materials for, 3:490, 491f-492f
creation of treatment fields in, 3:491, 492f-493f,
507
CT simulator for, 3:489, 490f, 507
immobilization devices for, 3:490,
490f-491f
reference isocenter in, 3:490-491
Simulator, CT, for radiation oncology, 3:489, 490f,
507
Single energy x-ray absorptiometry (SXA), 3:470,
475, 477
Single photon absorptiometry (SPA), 3:444, 444f,
477
Single photon emission computed tomography
(SPECT), 3:413-414
of brain, 3:411f, 417
combined with CT, 3:401, 403f, 415, 415f,
436
common uses of, 3:414, 414f
computers for, 3:409, 411f
defined, 3:439
dual-detector, 3:413-414, 413f
historical development of, 3:400-401
vs. other modalities, 3:401t, 402
reconstruction technique for, 3:413
Single slice helical CT (SSHCT), 3:306, 321-323,
322f
Singular endings for medical terms, 1:98, 98t
Singular word forms, frequently misused, 1:98,
98t
Sinogram data in PET, 3:431, 439
Sinus(es)
abdominal, 2:180, 180f
defined, 1:84
paranasal. See Paranasal sinuses.
Sinusitis, 2:282t
Skeletal metastases, strontium-99 for, 3:420
Skeletal studies, 3:416
Skeleton
appendicular, 1:75, 75f, 75t
axial, 1:75, 75f, 75t
Skin cancer, radiation oncology for, 3:504
Skin care for older adults, 3:175
Skin disorders in older adults, 3:168
Skin-sparing effect in radiation oncology, 3:486,
486f, 507
Skull, 2:255-367
abbreviations used for, 2:284b
anatomy of, 2:257-260, 257b, 257f-260f
summary of, 2:280b-281b
Skull (Continued)
AP axial projection of, 2:299-300, 301f
Towne method for, 2:302-306
central ray for, 2:303f, 304
in children, 3:132, 135t
evaluation criteria for, 2:304b
for pathologic condition or trauma, 2:306,
306f-307f
position of part for, 2:302, 303f
position of patient for, 2:302
structures shown on, 2:304, 305f
variations of, 2:302
articulations of, 2:275, 275t
temporomandibular. See Temporomandibular
joint (TMJ).
asymmetry of, 2:286
brachycephalic, 2:286, 286f
in children, 3:132-135
AP axial Towne projection of, 3:132, 135t
AP projection of, 3:132, 134-135, 134f
with craniosynostosis, 3:132
with fracture, 3:132
immobilization of, 3:132, 133f, 135f
lateral projection of, 3:132, 134-135,
134f-135f
summary of projections of, 3:135t
cleanliness in imaging of, 2:288
correct and incorrect rotation of, 2:287, 287f
cranial bones of. See Cranial bones.
CT of, 3:336f-338f
dolichocephalic, 2:286, 286f
ear in, 2:270f, 271
eye in
anatomy of, 2:314-316, 314f-315f
lateral projection of, 2:317, 317f
localization of foreign bodies within, 2:316,
316f
PA axial projection of, 2:318, 318f
parietoacanthial projection of (modified
Waters method), 2:319, 319f
preliminary examination of, 2:316
facial bones of. See Facial bones.
general body position for, 2:288
adjusting OML to vertical position in, 2:290f
adjusting sagittal planes to horizontal position
in, 2:289f
lateral decubitus position of
for pathologic conditions, trauma, or
deformity, 2:306
for stretcher and bedside examinations,
2:299-300, 299f
lateral projection of
in children, 3:132, 134-135, 134f-135f
in dorsal decubitus or supine lateral position,
2:294-300, 295f
in R or L position, 2:291, 292f-293f
mesocephalic, 2:286, 286f
morphology of, 2:286-287, 286f-287f
PA axial projection of
Caldwell method for, 2:296-300
evaluation criteria for, 2:299b
position of part for, 2:296, 297f
position of patient for, 2:296
structures shown on, 2:298f, 299
Haas method for, 2:308-309
central ray for, 2:308, 308f
evaluation criteria for, 2:309b
position of part for, 2:308, 308f
position of patient for, 2:308
structures shown on, 2:309, 309f
radiation protection for, 2:288
sample exposure technique chart essential
projections for, 2:283t-284t
sinuses of. See Paranasal sinuses.
summary of pathology of, 2:282t
summary of projections of, 2:256
Skull (Continued)
technical considerations for radiography of,
2:288
topography of, 2:285, 285f
trauma to
acanthioparietal projection (reverse Waters
method) for, 2:46, 46f
AP axial projection (Towne method) for,
2:44-45, 44f-45f
CT of, 2:29, 29f, 53-55, 54f
lateral projection for, 2:42-43, 42f-43f
Skull base, submentovertical projection of
(Schüller method), 2:310-311
central ray for, 2:310f, 311
evaluation criteria for, 2:311b
position of part for, 2:310-311, 310f
position of patient for, 2:310
structures shown on, 2:311, 311f
Skull fracture, 2:43f
in children, 3:132
Slice, 3:18
in CT, 3:302, 340
in MRI, 3:342, 368
Slice thickness in CT, 3:331-332, 332t-333t
Slip ring in CT, 3:309, 340
Slipped disk, 1:368
Slipped epiphysis, 1:335t
SMA. See Superior mesenteric artery (SMA).
Small bowel series, 2:138
Small intestine
anatomy of, 2:97f, 100f, 101
complete reflux examination of, 2:141, 141f
duodenum of. See Duodenum.
enteroclysis procedure for, 2:141
air-contrast, 2:141, 141f
barium in, 2:141, 141f
CT, 2:141, 142f
iodinated contrast medium for, 2:141, 142f
exposure time for, 2:114
intubation examination procedures for, 2:143,
143f
PA or AP projection of, 2:139
evaluation criteria for, 2:139b
ileocecal studies in, 2:139, 140f
position of part for, 2:139, 139f
position of patient for, 2:139
structures shown on, 2:139, 139f-140f
radiologic examination of, 2:138
oral method for, 2:138
preparation for, 2:138
sectional anatomy of, 3:283
on axial (transverse) plane
at Level E, 3:289, 289f
at Level G, 3:291, 291f
at Level H, 3:292, 292f
at Level I, 3:293, 293f
at Level J, 3:294f
on coronal plane, 3:298-299, 298f
on sagittal plane, 3:296
SmartShape wedges for CT, 3:329-330, 329f
Smith fracture, 1:109t
Smooth muscles, motion control of, 1:18
SMV projection. See Submentovertical (SMV)
projection.
SOD (source-to-object distance), 3:33
Sodium iodide (NaI) as scintillator for PET,
3:428t
Sodium iodide (NaI) scintillation crystals of
gamma camera, 3:408f, 409
Sodium phosphate for polycythemia, 3:420
Soft palate
anatomy of, 2:59, 59f, 71f
lateral projection of, 2:78-79, 78f-79f
methods of examination of, 2:74-75
Soft tissue(s), ultrasonography of, 3:383
Soft tissue compensation in DXA, 3:452, 453f
Soft tissue neck (STN)
in children, 3:137-138, 137f-138f
CT of, 3:336f-338f
Software, 3:460
Solid-state digital detectors, 1:3, 4f
Soloman, Albert, 2:372
Sonar, 3:371, 398
Sonography. See Ultrasonography.
SOS (speed of sound), 3:475
Sound, velocity of, 3:372, 398
Sound waves
defined, 3:372, 398
properties of, 3:372, 372f
Source–to–image receptor distance (SID), 1:7,
31-32, 31f, 3:33
in mobile radiography, 3:187
Source-to-object distance (SOD), 3:33
Source–to–skin distance (SSD), 1:31f, 32
SPA (single photon absorptiometry), 3:444, 444f,
477
Spatial resolution, 1:5, 6f
for CT, 3:318, 340
Special needs, children with, 3:105-107
Special planes, 1:68, 69f
SPECT. See Single photon emission computed
tomography (SPECT).
Spectral analysis, 3:392
Spectroscopy, 3:368
magnetic resonance, 3:365, 365f-366f
Speed of sound (SOS), 3:475
Spermatic cord, 3:284, 296, 296f
Sphenoid angle of parietal bone, 2:263f
Sphenoid bone
anatomy of, 2:264-266, 264f-265f
greater wings of, 2:258f, 259, 264f-265f, 265
lesser wings of, 2:258f, 264f-265f, 265
location of, 2:257f-258f
in orbit, 2:275, 275f, 312f
sectional anatomy of, 3:253-254
Sphenoid sinus effusion, 2:295f
Sphenoid strut, 2:265
Sphenoidal fontanel, 2:259-260, 260f
Sphenoidal sinuses
anatomy of, 2:276f-278f, 279
AP axial projection of, 2:309f
lateral projection of, 2:359f
in decubitus position, 2:295f
location of, 2:259f, 264-265, 264f-265f
PA axial projection of, 2:361f
parietoacanthial projection of, 2:365f
open-mouth Waters method for, 2:364-365,
364f-365f
sectional anatomy of, 3:253-254
on axial (transverse) plane, 3:261-263, 261f,
263f
on coronal plane, 3:267, 267f
on sagittal plane, 3:264, 265f
submentovertical projection of, 2:311f, 366-367,
366f-367f
Spheroid joint, 1:82, 83f
Sphincter of Oddi, 2:105, 105f
Sphincter of the hepatopancreatic ampulla, 2:105,
105f
Spin echo pulse sequence, 3:352-353, 368
Spina bifida, 1:368, 380t
Spinal cord, 2:259f
anatomy of, 3:2f-3f, 3
CT myelography of, 3:12, 12f
CT of, 3:11, 11f-12f
defined, 3:18
interventional pain management of, 3:16-18
MRI of, 3:12-13, 13f
myelography of, 3:6-8
cervical, 3:9f
contrast media for, 3:6-7, 6f
conus projection in, 3:8
Spinal cord (Continued)
of dentate ligament, 3:9f
examination procedure for, 3:7-8, 7f
of foramen magnum, 3:9f
lumbar, 3:8f
preparation of examining room for, 3:7, 7f
of subarachnoid space, 3:9f
plain radiographic examination of, 3:5
provocative diskography of, 3:16, 17f
sectional anatomy of, 3:269f, 272f
vertebroplasty and kyphoplasty of, 3:16,
16f-17f
Spinal fusion
AP projection of, 1:441-442, 441f-442f
lateral projection in hyperflexion and
hyperextension of, 1:443-444,
443f-444f
Spine examinations for geriatric patients,
3:178-179, 178f-179f
Spine of bone, 1:84
Spine scan in DXA
equipment for, 3:442f
lateral lumbar, 3:469
PA lumbar, 3:464-466, 464f-465f
Spin-lattice relaxation, 3:344, 368
Spinous process, 1:368, 368f
Spin-spin relaxation, 3:344, 368
Spiral CT, 3:340
multislice, 3:306, 323-324, 323f-324f
single slice, 3:306, 321-323, 322f
Index
Spiral fracture, 1:84f
Spleen
anatomy of, 2:97f, 105f, 106
nuclear medicine imaging of, 3:418
sectional anatomy of, 3:282f, 283
on axial (transverse) plane
at Level B, 3:285, 286f
at Level C, 3:287, 287f
at Level D, 3:288, 288f
at Level E, 3:289, 289f
at Level F, 3:290, 290f
on coronal plane, 3:299, 299f
sectional image of, 2:107f
ultrasonography of, 3:376f, 381, 381f
Splenic arteriogram, 3:41f-42f, 44, 44f
Splenic artery
sectional anatomy of, 3:282f, 284
on axial (transverse) plane, 3:288-289,
288f-289f
on coronal plane, 3:298-299, 298f
ultrasonography of, 3:376f
Splenic flexure
anatomy of, 2:102f, 103
sectional anatomy of, 3:283, 287, 287f, 298,
298f
Splenic vein
anatomy of, 2:105f
sectional anatomy of, 3:282f, 284-285, 288f,
298-299
ultrasonography of, 3:380, 380f
Splenomegaly, ultrasonography of, 3:381f
Split cassettes in digital imaging, 1:38
Spondylitis, infectious, CT for needle biopsy of,
3:314f
Spondylolisthesis, 1:375, 375f, 380t
Spondylolysis, 1:375, 380t
Spongy bone, 1:76, 76f
Spongy urethra, 2:186f, 187
Spot compression technique for mammography,
2:403t-408t, 429-431, 430f-431f, 432t
Squama of occipital bone, 2:266, 266f-267f
Squamosal suture. See Squamous suture.
Squamous cell carcinoma, 3:483
Squamous suture
anatomy of, 2:258f, 259, 275t
sectional anatomy of, 3:253-254
I-41
 99
Sr (strontium-99) for skeletal metastases, 3:420
SRS (stereotactic radiosurgery), 3:486-487, 499,
507
SRT (stereotactic radiation therapy), 3:499, 507
SSD (shaded surface display), 3:326, 340
SSD (source–to–skin distance), 1:31f, 32
SSHCT (single slice helical CT), 3:306, 321-323,
322f
Stable elements, 3:422f
Stainless steel occluding coils, 3:68, 68f
Standard deviation (SD) in DXA, 3:455, 455f-
456f, 477
Standard precautions, 1:15, 15f
in trauma radiography, 2:28
Standardized hip reference database for DXA,
3:457
Stapes, 2:270f, 271
Starburst artifacts in CT, 3:319
Starching of gowns, 1:20
Static imaging in nuclear medicine, 3:410-411
Statins for osteoporosis, 3:448t
Statscan, 2:20, 21f-22f
Stecher method for PA axial projection of scaphoid,
1:140-141
evaluation criteria for, 1:140b
position of part for, 1:140, 140f
position of patient for, 1:140
structures shown on, 1:140, 140f
variations of, 1:141, 141f
Stenosis, 2:62t, 3:28, 97
Index
in urinary system, 2:188t
Stent, 3:97
Stent graft for abdominal aortic aneurysm, 3:65-66,
65f-66f
Stereotactic body radiation therapy (SBRT),
3:499
Stereotactic imaging and biopsy procedures for
breast lesions, 2:465-470
calculation of X, Y, and Z coordinates in, 2:465,
465f-466f, 469, 469f
equipment for, 2:466, 467f-468f
images using, 2:468, 468f-470f
three-dimensional localization with, 2:465,
465f
Stereotactic radiation therapy (SRT), 3:499, 507
Stereotactic radiosurgery (SRS), 3:486-487, 499,
507
Stereotactic surgery, 3:18
Stereotaxis. See Stereotactic imaging and biopsy
procedures.
Sterile, 3:250
Sterile environment in operating room, 1:16-17,
16f-17f
Sterile field in surgical radiography
contamination of, 3:220
image receptor handling in, 3:219-220,
219f-220f
maintenance of, 3:218-220, 218f
Sterile surgical team members, 3:215, 215f
Sternal angle
anatomy of, 1:447f, 448
sectional anatomy of, 3:256, 278-279, 280f
as surface marker, 1:71f, 71t
Sternal extremity, 1:175, 175f, 447f
Sternal notch, 3:256
Sternoclavicular (SC) articulations
anatomy of, 1:178t, 179f, 181-182, 181f, 449,
449t
PA oblique projection of
body rotation method for, 1:465, 465f
central ray angulation method for, 1:466,
466f-467f
PA projection of, 1:464, 464f
sectional anatomy of, 3:270, 274-275, 274f, 280,
280f
Sternocleidomastoid muscle, 3:272, 272f
I-42
Sternocostal joints
anatomy of, 1:449t, 450, 450f
sectional anatomy of, 3:280f
Sternum
anatomy of, 1:447-448, 447f
and breasts, 1:456
and heart and other mediastinal structures,
1:456, 457f
lateral projection of, 1:462, 462f-463f
PA oblique projection of
in LPO position, 1:458
in modified prone position (Moore method),
1:460-461, 460f-461f
in RAO position, 1:458-459, 458f-459f
and posterior ribs and lung markings, 1:456,
457f
and pulmonary structures, 1:456, 457f
radiation protection for, 1:456-462
radiography of, 1:456
sectional anatomy of, 3:269-270, 271f
on axial (transverse) plane, 3:276f, 278,
278f-279f
on sagittal plane, 3:280f
and thoracic vertebrae, 1:456, 456f, 456t
Sthenic body habitus, 1:72-74, 72f, 73b
and gallbladder, 2:106, 106f
and stomach and duodenum, 2:99, 99f, 125f
and thoracic viscera, 1:479f
STIR (short tau inversion recovery), 3:352-353
STN (soft tissue neck)
in children, 3:137-138, 137f-138f
CT of, 3:336f-338f
Stomach
anatomy of, 2:97f-99f, 98-99
AP oblique projection of, 2:130-131, 130f-131f
AP projection of, 2:134
evaluation criteria for, 2:134b
position of part for, 2:134, 134f
position of patient for, 2:134, 134f
structures shown on, 2:134, 135f
and body habitus, 2:99, 99f
contrast studies of, 2:121-123
barium sulfate suspension for, 2:111, 111f
biphasic, 2:123
double-contrast, 2:122, 122f, 124f
single-contrast, 2:121, 121f, 124f
water-soluble, iodinated solution for, 2:111,
111f
exposure time for, 2:114
functions of, 2:99
gastrointestinal series for, 2:120, 120f
lateral projection of, 2:132-133, 132f-133f
PA axial projection of, 2:126-127, 126f-127f
PA oblique projection of, 2:128-129,
128f-129f
Wolf method for, 2:136-137, 136f-137f
PA projection of, 2:124-125
body habitus and, 2:124-125, 125f
double-contrast, 2:124f
evaluation criteria for, 2:125b
position of part for, 2:124, 124f
position of patient for, 2:124
single-contrast, 2:124f
structures shown on, 2:124-125, 125f
sectional anatomy of, 3:283
on axial (transverse) plane
at Level A, 3:285f
at Level B, 3:285, 286f
at Level C, 3:287, 287f
at Level D, 3:288f
at Level E, 3:289, 289f
on coronal plane, 3:298-299, 298f-299f
sectional image of, 2:107f
ultrasonography of, 3:376f
Stopcocks for cardiac catheterization, 3:78, 78f
Straight sinus, 3:255, 259f, 260-261, 264-265
Streak artifacts in CT, 3:319, 319f, 340
Striated muscular tissue, motion control of, 1:19
Strike-through, 3:250
Strontium-99 (99Sr) for skeletal metastases, 3:420
Strut adjusted volume implant applicator (SAVI),
3:504
Stryker notch method for AP axial projection of
proximal humerus, 1:204, 204f
Styloid process
anatomy of, 1:84, 2:258f, 268, 268f-269f
sectional anatomy of, 3:253-254
Subacromial bursa, 1:178, 178f
Subarachnoid space
anatomy of, 3:3
myelogram of, 3:9f
sectional anatomy of, 3:254
Sub-bacterial endocarditis, echocardiography of,
3:393
Subclavian arteries
anatomy of, 3:22f, 49f
arteriography of, 3:40f, 46f, 55f
sectional anatomy of, 3:269f, 270-271
on axial (transverse) plane, 3:273-275,
273f-274f
on coronal plane, 3:281, 281f
on sagittal plane, 3:279-280, 280f
Subclavian trunk, 3:26
Subclavian veins
anatomy of, 3:22f
sectional anatomy of, 3:269f, 271, 273, 273f,
280-281
venography of, 3:46f
Subdural space, 3:3
Sublingual ducts, 2:60f, 61-62
Sublingual fold, 2:59, 59f
Sublingual glands, 2:60f-61f, 61-62, 97f
Sublingual space, 2:59, 59f
Subluxation, 1:380t
Submandibular duct, 2:60, 60f
Submandibular gland
anatomy of, 2:60, 60f-61f, 97f
lateral projection of, 2:66-67, 66f-67f
sialography of, 2:62f
Submentovertical (SMV) projection
of cranial base, 2:310-311
central ray for, 2:310f, 311
evaluation criteria for, 2:311b
position of part for, 2:310-311, 310f
position of patient for, 2:310
structures shown on, 2:311, 311f
of ethmoidal and sphenoidal sinuses, 2:366-367,
366f-367f
of mandible, 2:346, 346f
of zygomatic arch, 2:333-334, 333f-334f
Subscapular fossa, 1:176f
Subscapularis muscle
anatomy of, 1:180f
sectional anatomy of, 3:271, 273-275, 273f-274f
Subtalar joint
anatomy of, 1:236t, 237f, 238
Isherwood method for AP axial oblique
projection of
with lateral rotation ankle, 1:278, 278f
with medial rotation ankle, 1:277, 277f
Isherwood method for lateromedial oblique
projection with medial rotation foot of,
1:276, 276f
Subtraction technique
DXA as, 3:443, 477
for hip arthrography
digital, 2:14, 15f
photographic, 2:14, 15f
Sulci tali, 1:229
Sulcus(i)
defined, 1:84
sectional anatomy of, 3:254-257, 256f
Superciliary arch, 2:261f
Superconductive magnets for MRI, 3:346, 368
Superficial, 1:85
Superficial femoral artery
anatomy of, 3:22f
arteriography of, 3:48f
Superficial inguinal nodes, 3:27f
Superficial structures, ultrasonography of, 3:383,
384f
Superimposition, 1:5
of coordinates in CT, 3:304f
Superior, 1:85
Superior articular process, 1:368, 368f
Superior cistern, 3:254, 258-260, 268, 268f
Superior mesenteric arteriogram, 3:41f-42f, 44, 44f
Superior mesenteric artery (SMA)
anatomy of, 3:22f
sectional anatomy of, 3:284, 290, 290f, 298-299,
298f
ultrasonography of, 3:376f, 380, 380f
Superior mesenteric vein
anatomy of, 2:105f, 3:22f
sectional anatomy of, 3:284-285, 290, 290f,
298-299
ultrasonography of, 3:377f
Superior nasal concha
anatomy of, 2:262, 262f
sectional anatomy of, 3:253
Superior orbital fissures
anatomy of, 2:257f, 265, 265f, 272f, 312f, 313
PA axial projection of, 2:298f
Superior orbital margin
lateral projection of, 2:317f
PA axial projection of, 2:298f
Superior ramus, 1:327f, 328, 329f
Superior sagittal sinus
anatomy of, 3:22f
sectional anatomy of, 3:255
on axial (transverse) plane, 3:256-258,
256f-257f, 260-261
on coronal plane, 3:267, 267f
on sagittal plane, 3:264-265, 265f
Superior thoracic aperture, 1:479, 479f
Superior vena cava
anatomy of, 3:22f, 24, 25f
sectional anatomy of, 3:271
on axial (transverse) plane, 3:273, 275-278,
276f
on coronal plane, 3:280-281, 281f
Superior vena cavogram, 3:60, 60f
Superparamagnetic contrast agents for MRI, 3:355,
368
Supertech trough filter, 1:61f
Supertech wedge collimator-mounted Clear Pb
filter, 1:56f, 57
Supinate/supination, 1:97, 97f
Supinator fat pad of elbow, 1:107, 107f
Supine position, 1:90, 90f
Supracondylar fracture, 3:131, 131f
Supraorbital foramen, 2:257f, 261, 261f
Supraorbital margins
anatomy of, 2:261, 261f
lateral projection of, 2:293f
Suprapatellar bursa, 1:82f
Suprarenal glands
anatomy of, 2:183, 183f
sectional anatomy of, 3:283, 288-289, 288f-289f
ultrasonography of, 3:376f
Supraspinatus muscle
anatomy of, 1:179f
sectional anatomy of, 3:269f, 271, 273, 273f
Supraspinatus “outlet”
AP axial projection of, 1:203, 203f
Neer method for tangential projection of,
1:202-203, 202f
Surface coils in MRI, 3:354, 354f
Surface landmarks, 1:71, 71f, 71t
with obese patients, 1:47-49, 49f
Surgeon, 3:215
Surgical angiography, 3:74
Surgical assistant, 3:215
Surgical attire, 3:216
Surgical bed, 3:480, 507
Surgical dressings, 1:20
Surgical neck of humerus, 1:104-105, 104f
Surgical neuroangiography, 3:74
Surgical radiography, 3:213-250
aseptic techniques in, 3:220, 220b
attire for, 3:217, 217f
definition of terms for, 3:250b
equipment for, 3:221, 221f-222f
cleaning of, 3:222
fluoroscopic procedures in, 3:223-241
of cervical spine (anterior cervical diskectomy
and fusion), 3:227, 227f
of chest (line placement, bronchoscopy),
3:226, 226f
femoral nailing as, 3:233-235, 233f
antegrade, 3:233
evaluation criteria for, 3:235b
method for, 3:234, 234f-235f
retrograde, 3:234, 234f
structures shown on, 3:235, 235f
femoral/tibial arteriogram as, 3:240-241,
240f-241f
of hip (cannulated hip screws or hip pinning),
3:230-232, 230f-232f
of humerus, 3:238-239, 238f-239f
of lumbar spine, 3:228-229, 228f-229f
operative (immediate) cholangiography as,
3:223-225, 224f-225f
tibial nailing as, 3:236-237
evaluation criteria for, 3:237b
position of C-arm for, 3:236, 236f
position of patient for, 3:236
structures shown on, 3:237, 237f
mobile, 3:242-250
of cervical spine, 3:242, 242f-243f
of extremities
for ankle fracture, 3:246f
of ankle with antibiotic beads, 3:247f
for fifth metatarsal nonhealing fracture,
3:249f
for forearm fracture, 3:247f
for hip joint replacement, 3:246f
lower, 3:246-250
for tibial plateau fracture, 3:247f
for total shoulder arthroplasty, 3:248f
for wrist fracture, 3:249f
of thoracic or lumbar spine, 3:244, 244f-245f
personal hygiene in, 3:217
radiation exposure considerations in, 3:223, 223f
role of radiographer in, 3:216
scope of, 3:214, 214b
sterile field in
contamination of, 3:220
image receptor handling in, 3:219-220,
219f-220f
maintenance of, 3:218-220, 218f
Surgical suite, 3:216f
Surgical team, 3:214-216
nonsterile members of, 3:215f, 216
sterile members of, 3:215, 215f
Survey image of abdomen, 2:87
Suspensory muscle of duodenum, 2:100f, 101
Sustentaculum tali, 1:229, 229f
Sutures, 1:80f, 81, 2:258f, 259, 275t
Sv (sieverts), 3:458, 477
Swimmer’s technique for lateral projection
of cervicothoracic region, 1:402-403,
402f-403f
mobile, 3:207
SXA (single energy x-ray absorptiometry), 3:470,
475, 477
Symphysis, 1:81, 81f
Symphysis pubis. See Pubic symphysis.
Synarthroses, 1:81
Synchondrosis, 1:81, 81f
Syndesmosis, 1:80f, 81
Synostosis, 3:132
Synovial fluid, 1:82, 82f
Synovial joints, 1:80t, 82, 82f-83f
Synovial membrane, 1:82, 82f
Syringes for venipuncture, 2:228-229, 228f
recapping of, 2:229, 229f
System noise in CT, 3:340
Systemic arteries, 3:23
Systemic circulation, 3:23, 23f, 97
Systemic disease, 3:480, 506
Systemic veins, 3:24
Systole, 3:97
T
T 1 2 (half-life), 3:403-404, 404f, 438
in brachytherapy, 3:485, 506
T (tesla) in MRI, 3:343, 346, 368
T scores in DXA, 3:457, 458t, 477
T1, 3:344, 368
T1-weighted image, 3:352, 352f-353f
T2, 3:344, 368
T2-weighted image, 3:352, 352f-353f
Table for CT, 3:309-310, 309f
Index
Table increments in CT, 3:340
Table pad, 1:19
Table speed in CT angiography, 3:324, 340
Tachyarrhythmia, 3:97
Tachycardia, 3:97
Taeniae coli, 2:102, 102f
Talipes equinovarus. See Clubfoot.
Tall patients, long bone studies in, 1:28
Talocalcaneal articulation, 1:236t, 237f, 238
Talocalcaneonavicular articulation, 1:236t, 237f,
238
Talofibular joint, 1:238
Talus, 1:228f, 229
Tangential projection, 1:86-87, 87f
Target in nuclear medicine, 3:439
Targeted lesion, 3:97
Tarsals
anatomy of, 1:228f-229f, 229
trauma radiography of, 2:52f
Tarsometatarsal (TMT) articulations, 1:236f-237f,
236t, 238
Taylor method for AP axial outlet projection of
anterior pelvic bones, 1:358, 358f
TBI (total body iodine-123) scan, 3:418
TBLH (total body less head) bone densitometry,
3:477
TEA (top of ear attachment), 2:268, 270f, 271,
285f
Teamwork, 3:250
Technetium-99m (99mTc), 3:404, 404f-405f,
406t
Technetium-99m (99mTc) ethylcysteinate dimer
(ECD) for brain SPECT study, 3:417
Technetium-99m (99mTc) hydroxymethylene
diphosphonate (HDP) for bone scan,
3:415
Technetium-99m (99mTc)-labeled red blood cells for
radionuclide angiography, 3:416
Technetium-99m (99mTc) mertiatide (MAG3) for
dynamic renal scan, 3:419
Technetium-99m (99mTc) microaggregated albumin
(MAA) lung perfusion scan, 3:419
Technetium-99m (99mTc) pertechnetate for thyroid
scan, 3:417
Technetium-99m (99mTc) sestamibi myocardial
perfusion study, 3:416
I-43
 Technetium-99m (99mTc) sulfur colloid
for liver and spleen scan, 3:418
for sentinel node imaging, 3:420
Technical factors, 1:42, 42f-43f
Teeth, 2:59
Teletherapy, 3:507
Temporal bones
anatomy of, 2:268, 268f-269f
coronal CT through, 2:269f
location of, 2:257f-259f
mastoid portion of, 2:268, 268f-270f
sectional anatomy of, 3:253-254, 259f-260f,
262, 268
petrous portion of
anatomy of, 2:268, 268f-270f
lateral projection of, 2:293f
in decubitus position, 2:295f
location of, 2:258f-259f
sectional anatomy of, 3:253-254, 260f, 262,
267-268
sectional anatomy of, 3:253-254, 258-260, 267f
squamous portion of
anatomy of, 2:268, 268f-269f
sectional anatomy of, 3:253-254
tympanic portion of
anatomy of, 2:268, 268f
sectional anatomy of, 3:253-254
zygomatic arch of
anatomy of, 2:273
AP axial projection of (modified Towne
Index
method), 2:337, 337f-338f
submentovertical projection of, 2:333-334,
333f-334f
tangential projection of, 2:335-336, 335f-336f
zygomatic process of
anatomy of, 2:268, 268f
sectional anatomy of, 3:253-254
Temporal lobe, sectional anatomy of, 3:253f,
254-255
on axial (transverse) plane
at Level C, 3:258, 258f
at Level D, 3:259-260
at Level E, 3:260f, 261-262
at Level F, 3:262f
at Level G, 3:263f
on sagittal plane, 3:266, 266f
Temporal process of zygomatic bones, 2:273, 273f
Temporal resolution for CT, 3:318, 340
Temporalis muscle, sectional anatomy of, 3:253f,
255-256
on axial (transverse) plane, 3:257-262,
257f-259f
Temporomandibular joint (TMJ)
anatomy of, 2:268, 275, 275t
AP axial projection of, 2:347-348, 347f-348f
axiolateral oblique projection of, 2:345f,
351-352, 351f-352f
axiolateral projection of, 2:349-350
evaluation criteria for, 2:350b
position of part for, 2:349, 349f-350f
position of patient for, 2:349
structures shown on, 2:350f
lateral projection of, 2:293f
panoramic tomography of mandible for,
2:353-354, 353f-354f
sectional anatomy of, 3:254
Temporomandibular joint (TMJ) syndrome, 2:282t
Tendinitis, 1:182t
Tentorium, 3:3, 18
Tentorium cerebelli, sectional anatomy of, 3:254
on axial (transverse) plane, 3:259-262, 261f
on coronal plane, 3:268, 268f
on sagittal plane, 3:266
Teres major muscle
anatomy of, 1:180f
sectional anatomy of, 3:271, 274f
I-44
Teres minor muscle
anatomy of, 1:180f
sectional anatomy of, 3:271, 273-275, 274f
Terminology
body movement, 1:96-97
for positions, 1:86b, 89-95
for projections, 1:86-89, 86b, 86f
Tesla (T) in MRI, 3:343, 346, 368
Testicles. See Testis(es).
Testicular torsion, 2:245t
Testis(es)
anatomy of, 2:242, 242f-243f
ultrasonography of, 3:383, 384f
Teufel method for PA axial oblique projection of
acetabulum, 1:354-355, 354f-355f
TFT (thin-film transistor), 1:3
Thalamus, sectional anatomy of, 3:253f, 258-259,
264-265, 265f, 267f
Thallium-201 (201Tl), 3:406t
Thallium-201 (201Tl) myocardial perfusion study,
3:414, 414f, 416
Therapeutic nuclear medicine, 3:420
Thermography of breast, 2:473
Thermoluminescent dosimeters for CT, 3:330, 330f
Thermoluminescent dosimetry (TLD) rings, 3:407
Thin-film transistor (TFT), 1:3
Third ventricle
anatomy of, 3:2, 4, 4f, 258
sectional anatomy of, 3:255
on axial (transverse) plane, 3:258f
on coronal plane, 3:267-268, 267f
on sagittal plane, 1:331, 3:267, 267f
Thoracic aortography, 3:40, 40f, 55f
Thoracic cavity, 1:68-69, 69f, 479, 479f
Thoracic curve, 1:366f, 367
Thoracic duct, 3:26, 27f
Thoracic inlet, 3:269
Thoracic region, sectional anatomy of, 3:269-281
on axial (transverse) plane, 3:272, 272f
at level A, 3:272, 272f
at level B, 3:273, 273f
at level C, 3:274-275, 274f
at level D, 3:275, 275f
at level E, 3:275-277, 276f-277f
at level F, 3:278, 278f
at level G, 3:278, 279f
on cadaveric image, 3:269, 269f, 271f
on coronal plane, 3:280, 281f
at level A, 3:280, 281f
at level B, 3:280-281, 281f
at level C, 3:281, 281f
on sagittal plane, 3:278-279, 279f
at level A, 3:278-279, 280f
at level B, 3:279, 280f
at level C, 3:279-280, 280f
Thoracic vertebrae
anatomy of, 1:366f, 372-373, 373f
costal facets and demifacets in, 1:372, 372f,
373t
posterior oblique aspect in, 1:372, 372f, 373t
superior and lateral aspects in, 1:372, 372f
zygapophyseal joints in, 1:373, 373f
AP projection of, 1:404-405, 404f-406f
for trauma, 2:36-37, 36f-37f
CT of, 1:405, 406f
intervertebral foramina of
anatomy of, 1:372f-373f, 373
positioning rotations needed to show, 1:371t
lateral projection of, 1:407-409
central ray for, 1:408, 408f
evaluation criteria for, 1:409b
improving radiographic quality of, 1:409
position of part for, 1:407, 407f-408f
position of patient for, 1:407
structures shown on, 1:409, 409f
for trauma, 2:35, 35f
Thoracic vertebrae (Continued)
mobile radiography in operating room of,
3:244
MRI of, 3:358f
in radiography of sternum, 1:456, 456f, 456t
sectional anatomy of, 3:269-270, 274-275,
278-280
trauma radiography of
AP projection in, 2:36-37, 36f-37f
lateral projections in, 2:35, 35f
upper
lateral projection of, swimmer’s technique for,
1:402-403, 402f-403f
vertebral arch (pillars of)
AP axial oblique projection of, 1:401,
401f
AP axial projection of, 1:399-400,
399f-400f
zygapophyseal joints of
anatomy of, 1:372f-373f, 373
AP or PA oblique projection of, 1:410-412
in recumbent position, 1:411-412,
411f-412f
in upright position, 1:410, 410f, 412f
positioning rotations needed to show, 1:371t
Thoracic viscera, 1:477-519
anatomy of, 1:479-484
body habitus and, 1:479, 479f
mediastinum in, 1:483-484, 483f-484f
respiratory system in, 1:479-482
alveoli of, 1:480f, 481
bronchial tree of, 1:480, 480b, 480f
lungs of, 1:481-482, 481f-482f
trachea of, 1:480, 480b, 480f
summary of, 1:484b
thoracic cavity in, 1:479, 479f
breathing instructions for, 1:490, 490f
CT of, 1:484, 485f, 2:55
general positioning considerations for, 1:488
for lateral projections, 1:488, 489f
for oblique projections, 1:488
for PA projections, 1:488, 489f
for upright vs. prone position, 1:488, 488f
grid technique for, 1:490, 491f
heart as
AP oblique projection of, 1:508-509
lateral projection with barium of, 1:503
PA chest radiographs with barium of, 1:499
PA oblique projection with barium of, 1:507
lungs as. See Lung(s).
mediastinum as
anatomy of, 1:483-484, 483f-484f
CT of, 1:484, 485f
lateral projection of superior, 1:494-495,
494f-495f
pleura as
AP or PA projection of, 1:516-517,
516f-517f
lateral projection of, 1:518-519, 518f-519f
sample exposure technique chart essential
projections for, 1:487t
SID for, 1:490, 491f
summary of pathology of, 1:486t
summary of projections for, 1:478
technical procedure for, 1:490, 491f
trachea as
anatomy of, 1:480, 480b, 480f
AP projection of, 1:492-493, 492f-493f
lateral projection of, 1:494, 494f-495f
radiation protection for, 1:492-493
Thoracolumbar spine, scoliosis of
PA and lateral projections of (Frank et al.
method), 1:437-438, 437f-438f
PA projection of (Ferguson method), 1:439-440
evaluation criteria for, 1:439b-440b
first radiograph in, 1:439, 439f
Thoracolumbar spine, scoliosis of (Continued)
position of part for, 1:439, 439f-440f
position of patient for, 1:439, 439f
second radiograph in, 1:439, 440f
structures shown on, 1:439-440,
439f-440f
Thorax, bony. See Bony thorax.
Three-dimensional conformal radiotherapy (CRT),
3:494, 506
Three-dimensional imaging
of breast, 2:374-375
CT for, 3:326-327, 327f
ultrasonography for, 3:372-373
Three-dimensional intraarterial angiography, 3:34,
34f
Three-dimensional MRI, 3:351, 351f
Threshold values in shaded surface display, 3:326,
340
Thrombectomy, rheolytic, 3:80t
Thrombogenesis, 3:97
Thrombolytic, 3:97
Thrombolytic therapy
prior to cardiac catheterization, 3:92
interventional radiology for, 3:72
Thrombosis, 3:97
Thrombus, 3:97
Through-transmission techniques for
ultrasonography, 3:371
Thumb
anatomy of, 1:101, 101f
AP projection of, 1:116
evaluation criteria for, 1:117
position of part for, 1:116, 116f
position of patient for, 1:116
structures shown on, 1:117, 117f
first CMC joint of, 1:118-119
Burman method for AP projection of,
1:120-121, 120f-121f
Robert method for AP projection of,
1:118-119
evaluation criteria for, 1:119b
Lewis modification of, 1:119
Long and Rafert modification of,
1:119
position of part for, 1:118, 118f
position of patient for, 1:118, 118f
structures shown on, 1:119, 119f
folio method for PA projection of first
MCP joint of, 1:122, 122f-123f
lateral projection of, 1:116
evaluation criteria for, 1:117
position of part for, 1:116, 116f
position of patient for, 1:116
structures shown on, 1:117, 117f
PA oblique projection of, 1:117
evaluation criteria for, 1:117
position of part for, 1:117, 117f
position of patient for, 1:117
structures shown on, 1:117, 117f
PA projection of, 1:116
evaluation criteria for, 1:117
position of part for, 1:116f
position of patient for, 1:116
structures shown on, 1:117, 117f
Thymus gland, 1:484, 484f
Thyroid cancer, iodine-131 for, 3:420
Thyroid cartilage
anatomy of, 2:71-72, 71f-72f
as surface landmark, 1:71f, 71t
Thyroid gland
anatomy of, 2:71, 72f
nuclear medicine imaging of,
3:417-418
sectional anatomy of, 3:272, 272f
ultrasonography of, 3:375f, 383, 384f
Thyroid scan, 3:417
Tibia
anatomy of, 1:230-231, 230f-231f
AP oblique projections of, 1:294-295,
294f-295f
AP projection of, 1:290-291, 290f-291f
lateral projection of, 1:292-293, 292f-293f
Tibial arteriogram, 3:240-241, 241f
Tibial collateral ligament, 1:234f
Tibial nailing, surgical radiography of, 3:236-237
evaluation criteria for, 3:237b
position of C-arm for, 3:236, 236f
position of patient for, 3:236
structures shown on, 3:237, 237f
Tibial plafond, 1:231f
Tibial plateau(s), 1:230, 230f
Tibial plateau fracture, surgical radiography of,
3:247f
Tibial tuberosity, 1:230, 230f
Tibiofibular joints, 1:238
Tilt, 1:97, 97f
Time of flight (TOF) imaging, 3:363
TIPS (transjugular intrahepatic portosystemic
shunt), 3:72, 72f-73f
201
Tl (thallium-201), 3:406t
201
Tl (thallium-201) myocardial perfusion study,
3:414, 414f, 416
TLD (thermoluminescent dosimetry) rings,
3:407
TMJ. See Temporomandibular joint (TMJ).
TMT (tarsometatarsal) articulations, 1:236f-237f,
236t, 238
TNM classification, 3:483, 483t
Toddlers, development of, 3:103
Toddler’s fracture, 3:130-131
Toes
anatomy of, 1:228-230, 228f
AP axial projection of, 1:242-249, 243f
AP oblique projection of, 1:245, 245f
AP projection of, 1:242-249, 243f
display orientation of, 1:11
lateral projections of, 1:246-249
evaluation criteria for, 1:249b
for fifth toe, 1:247, 247f, 249f
for fourth toe, 1:247, 247f, 249f
for great toe, 1:246f, 247, 248f
position of part for, 1:247
position of patient for, 1:246
for second toe, 1:246f, 247, 248f
structures shown on, 1:248-249
for third toe, 1:246f, 247, 249f
PA projection of, 1:244, 244f
trauma radiography of, 2:52f
TOF (time of flight) imaging, 3:363
Tolerance doses to radiation, 3:494, 494t
TomoTherapy, 3:499, 500f
Tongue
anatomy of, 2:59, 59f, 97f
sectional anatomy of, 3:265, 265f
Tonsil
palatine, 2:59, 59f
pharyngeal, 2:71f, 72
Top of ear attachment (TEA), 2:268, 270f, 271,
285f
Torus fracture, 1:109t, 3:130
Total body iodine-123 (123I) (TBI) scan, 3:418
Total body less head (TBLH) bone densitometry,
3:477
Total joint replacement in older adults, 3:170,
171f
Total shoulder arthroplasty, surgical radiography of,
3:248f
Total-body dual energy x-ray absorptiometry,
3:442f, 471, 472f
Tourniquet for venipuncture
application of, 2:232f, 233
release of, 2:233f
Towne method
for AP axial projection of skull, 2:44-45,
44f-45f, 302-306
central ray for, 2:303f, 304
in children, 3:132, 135t
evaluation criteria for, 2:304b
for pathologic condition or trauma, 2:306,
306f-307f
position of part for, 2:302, 303f
position of patient for, 2:302
structures shown on, 2:304, 305f
variations of, 2:302
modified for AP axial projection of zygomatic
arches, 2:337, 337f-338f
Trabeculae, 1:76, 76f
Trabecular bone
and bone densitometry, 3:445, 445t
defined, 3:477
in osteoporosis, 3:446f
Tracer, 3:400, 405f, 439
Tracer principle, 3:400
Trachea
anatomy of, 1:480, 480b, 480f, 2:71f-72f
AP projection of, 1:492-493, 492f-493f
lateral projection of, 1:494, 494f-495f
sectional anatomy of, 3:269f, 270
on axial (transverse) plane, 3:272-275,
272f-274f
on coronal plane, 3:280-281, 281f
on sagittal plane, 3:278-279, 280f
Index
Tragus, 2:270f, 271
Transabdominal ultrasonography of female pelvis,
3:387-388, 387f
Transcatheter embolization, 3:66-68
in cerebral vasculature, 3:68, 69f
embolic agents for, 3:66-67, 67b, 67t
of hypervascular uterine fibroid, 3:68, 69f
lesions amenable to, 3:66-67, 67b
stainless steel occluding coils for, 3:68, 68f
vascular plug for, 3:68, 68f
Transducer, 3:97
for ultrasonography, 3:372, 372f, 398
Transesophageal transducer, 3:396
Transfer
of ill patients, 1:15f, 22
of obese patients, 1:46, 46f
Transjugular intrahepatic portosystemic shunt
(TIPS), 3:72, 72f-73f
Transmission scan, 3:402, 439
Transportation
of obese patients, 1:46, 46f
of older adults, 3:175
Transposition of the great arteries, 3:97
Transthoracic projection, 1:88
Transverse abdominal muscles, 3:290-291, 293,
293f
Transverse arch of foot, 1:228-230, 228f
Transverse fracture, 1:84f
Transverse plane, 1:66, 66f-67f
in MRI, 3:343, 368
pancreas in, 3:380, 398
in sectional anatomy, 3:252
Transverse processes, 1:368, 368f
Transverse sinus
anatomy of, 3:22f
sectional anatomy of, 3:255, 261-262, 268f
Transverse venous sinuses, 3:262-263, 268
Trapezium
anatomy of, 1:101f-102f, 102
Clements-Nakayama method for PA axial
oblique projection of, 1:144, 144f
Trapezius muscle, sectional anatomy of, 3:269f,
271
on axial (transverse) plane, 3:272-275, 272f,
274f, 278
Trapezoid, 1:101f-102f, 102
I-45
 Trauma
blunt, 2:19
defined, 2:18
explosive, 2:19
heat, 2:19
other imaging procedures for, 2:53-55
CT as, 2:20, 29
of cervical spine, 2:53-55
of cranium, 2:29, 29f, 53-55, 54f
of pelvis, 2:53f, 55
of thorax, 2:53-55
sonography as, 2:55
penetrating, 2:19
radiography of. See Trauma radiography.
statistics on, 2:18-19, 18f-19f
Trauma center, 2:19
Trauma patients, handling of, 1:22-23, 22f
Trauma radiography, 2:17-56
abbreviations used in, 2:30b
of abdomen, AP projection in, 2:38-39, 38f-39f
in left lateral decubitus position, 2:40, 40f
best practices in, 2:28
breathing instructions for, 2:30
with immobilization devices, 2:30
central ray, part, and image receptor alignment
in, 2:30
of cervical spine
AP axial oblique projection in, 2:34,
35f-36f
AP axial projection in, 2:33, 33f
Index
lateral projection in, 2:31, 31f
of cervicothoracic region, lateral projection in
dorsal decubitus position in, 2:32, 32f
common projections in, 2:29-30
of cranium
acanthioparietal projection (reverse Waters
method) in, 2:46, 46f
AP axial projection (Towne method) in,
2:44-45, 44f-45f
and CT scan, 2:29, 29f
lateral projection in, 2:42-43, 42f-43f
documentation of, 2:30
exposure factors for, 2:23, 23f
grids and IR holders for, 2:20
image evaluation in, 2:30
image receptor size and collimated field for,
2:30
with immobilization devices, 2:23, 23f, 28, 30
of lower limb, 2:50-53
patient position considerations for, 2:22f-23f,
50
structures shown on, 2:52-53, 52f
trauma positioning tips for, 2:50, 50f
overview of, 2:18
patient care in, 2:26, 27t
patient preparation for, 2:29
of pelvis, AP projection in, 2:41, 41f
positioning aids for, 2:20
positioning of patient for, 2:24, 24f, 28
radiation protection for, 2:25
specialized equipment for, 2:20
dedicated C-arm–type trauma radiographic
room as, 2:20f
mobile fluoroscopic C-arm as, 2:20, 21f
Statscan as, 2:20, 21f-22f
standard precautions in, 2:28
of thoracic and lumbar spine
AP projection in, 2:36-37, 36f-37f
lateral projections in, 2:35, 35f
of upper limb, 2:47-49
patient position considerations for, 2:47-48
for forearm, 2:47, 47f-48f
for humerus, 2:49, 49f
for shoulder, 2:48, 48f-49f
structures shown on, 2:49, 49f
trauma positioning tips for, 2:47
I-46
Trauma team, radiographer’s role as part of,
2:25-26
Treatment fields in radiation oncology, 3:491,
492f-493f, 507
Trendelenburg position, 1:90, 90f
Triceps muscle, 1:180f
Tricuspid valve
anatomy of, 3:25f
sectional anatomy of, 3:270
Trigone, 2:186, 186f
Tripod fracture, 2:282t
Triquetrum, 1:101f-102f, 102
Trochanter(s)
AP projection of, 1:337-339, 337f
defined, 1:84
Trochlea, 1:229, 229f
Trochlear groove of femur, 1:233, 233f
Trochlear notch, 1:103, 103f-104f
Trochlear surface, 1:228f, 229
Trochoid joint, 1:82, 83f
Trough filter
applications of, 1:60, 60t, 61f
example of, 1:56f
in position, 1:55f
shape of, 1:57
True projections, 1:89
T-tube cholangiography, 2:176-177, 176f-177f
Tubercles, 1:76, 84
Tuberculosis, 1:486t
Tuberculum sellae
anatomy of, 2:258f, 264-265, 264f
sectional anatomy of, 3:253-254
Tuberosities, 1:76, 84
Tumor(s), 3:480
Tumor imaging, nuclear medicine for, 3:420
Tumor/target volume, 3:494, 507
Tunneled catheters in children, 3:158, 158f
Twining method for mobile radiography of cervical
spine, 3:207
Tympanic cavity, 2:270f, 271
Tympanic membrane, 2:270f, 271
U articulations in, 1:105-107, 105f-107f, 105t
UGI (upper gastrointestinal) series. See
Gastrointestinal (GI) series.
Ulcer, 2:109t
decubitus, in older adults, 3:175
Ulcerative colitis, 2:109t
Ulna, 1:101f, 102-103, 103f
Ulnar artery
anatomy of, 3:22f, 49f
arteriography of, 3:46f
Ulnar styloid process, 1:103, 103f
Ultrasonography, 3:369-398
of abdomen and retroperitoneum, 3:376-383,
376f-377f
anatomic relationships and landmarks for, 3:373,
373f
artifacts in, 3:374, 375f
of breast, 2:418-419, 3:375f, 383, 384f
cardiologic applications of, 3:393-396
cardiac pathology in, 3:393-396, 396f
for congenital heart lesions, 3:396
procedure for echocardiography in, 3:393,
395f
characteristics of image in, 3:374, 374f-375f
of children, 3:156
defined, 3:370
definition of terms for, 3:397b-398b
of gallbladder and biliary tree, 3:373f, 378,
379f
gynecologic applications of, 3:386-388
anatomic features and, 3:386, 386f
endovaginal transducers for, 3:375f, 388,
388f, 397
indications for, 3:387
Ultrasonography (Continued)
of ovaries, 3:373f, 375f, 388, 389f
transabdominal, 3:387-388, 387f
of uterus, 3:387f-389f, 388
historical development of, 3:371
intravascular, 3:80t, 91, 91f-92f
of kidneys and bladder, 3:382-383, 382f
of liver, 3:373f-374f, 376f-378f, 378
of musculoskeletal structures, 3:383, 383f
for neonatal neurosonography, 3:385, 385f
obstetric applications of, 3:388-391
in first trimester, 3:388, 389f-390f
history of, 3:371
in second trimester, 3:390, 390f
in third trimester, 3:390-391, 391f
of pancreas, 3:377f, 380, 380f
personnel for, 3:370, 371f
principles of, 3:370-371
properties of sound waves in, 3:372, 372f
quantitative, 3:475, 475f, 477
resource organizations for, 3:371
of spleen, 3:376f, 381, 381f
of superficial structures, 3:383, 384f
through-transmission techniques for, 3:371
transducer selection for, 3:372, 372f
of trauma, 2:55
vascular applications of, 3:392-393, 392f,
394f
volume scanning and three-dimensional and
four-dimensional imaging in, 3:372-373
Ultrasound, defined, 3:372, 398
Umbilical region, 1:70f
Umbrella, 3:97
Undifferentiation, 3:484, 507
Unrestricted area, 3:250
UPJ (ureteropelvic junction), 2:185
Upper gastrointestinal (UGI) series.
See Gastrointestinal (GI) series.
Upper limb, 1:99-171
abbreviations used for, 1:109b
anatomy of, 1:101
arm in, 1:104-105, 104f
fat pads in, 1:107, 107f
forearm in, 1:102-103, 103f
hand in, 1:101-102, 101f
summary of, 1:108b
wrist in, 1:101b, 102, 102f
arteriography of, 3:46, 46f
in children, 3:127-131
with fractures, 3:129-130, 130f-131f
image evaluation for, 3:123t, 131
immobilization for, 3:127-129, 127f, 129f
radiation protection for, 3:129, 129f
elbow in
articulations of, 1:107, 107f
fat pads of, 1:107, 107f
radiography of, 1:151
first digit (thumb) in
anatomy of, 1:101, 101f
radiography of, 1:116-122
forearm in
anatomy of, 1:102-103, 103f
radiography of, 1:148-149
general procedures for, 1:110
of geriatric patients, 3:180, 180f
hand in
anatomy of, 1:101-102, 101f
articulations of, 1:105-107, 105f-106f
radiography of, 1:124
humerus in
anatomy of, 1:104-105, 104f
distal
anatomy of, 1:104-105, 104f
radiography of, 1:165
radiography of, 1:167-171
Upper limb (Continued)
long bone measurement of, 2:2, 5, 5f
MRI of, 3:360-362, 362f
olecranon process in
anatomy of, 1:103, 103f, 107f
radiography of, 1:166
sample exposure technique chart essential
projections for, 1:108t
second through fifth digits in
anatomy of, 1:101, 101f
radiography of, 1:110-111
shielding gonads for, 1:110, 110f
summary of pathology of, 1:109t
summary of projections for, 1:100
surgical radiography of, 3:246-250, 247f-249f
trauma radiography of, 2:47-49
for humerus, 2:49, 49f
patient position considerations for, 2:47-48
for forearm, 2:47, 47f-48f
for shoulder, 2:48, 48f-49f
structures shown on, 2:49, 49f
trauma positioning tips for, 2:47
venography of, 3:46, 46f
wrist in
anatomy of, 1:101b, 102, 102f
articulations of, 1:105-107, 106f
radiography of, 1:132
Upper limb arteries, duplex sonography of,
3:393
Upper limb veins, duplex sonography of, 3:393
Upright position, 1:87f, 90
Ureter(s)
anatomy of, 2:183f-184f, 186, 186f
defined, 2:183
radiologic examination of, 2:214
retrograde urography of, 2:212-213, 212f-213f
sectional anatomy of, 3:283, 292, 292f, 294,
294f
Ureteral compression for excretory urography,
2:200, 200f
Ureterocele, 2:188t
Ureteropelvic junction (UPJ), 2:185
Ureterovesical junction (UVJ), 2:186
Urethra
anatomy of, 2:186f, 187
defined, 2:183
radiologic examination of, 2:214
sectional anatomy of, 3:283, 296, 296f-297f
Urethral orifice, 2:240, 240f
Urethral stricture, 2:192f
Urinary bladder
anatomy of, 2:186, 186f
AP axial or PA axial projection of, 2:216-217,
216f-217f
AP oblique projection of, 2:218, 218f-219f
cystography of. See Cystography.
cystourethrography of
female, 2:222-224, 222f-223f
male, 2:221, 221f
serial voiding, 2:214, 215f
defined, 2:183, 186
location of, 2:183f-184f, 186
MRI of, 3:360
sectional anatomy of, 3:283
on axial (transverse) plane, 3:295, 295f
on coronal plane, 3:298, 298f-299f
on sagittal plane, 3:296, 297f
ultrasonography of, 3:382-383, 386f
Urinary incontinence in older adults, 3:173, 174t
Urinary system, 2:181-235
abbreviations used for, 2:189b
anatomy of, 2:183-187, 183f-184f
kidneys in, 2:183f-185f, 184-185
prostate in, 2:184f, 186f, 187
summary of, 2:187b
suprarenal glands in, 2:183, 183f
Urinary system (Continued)
ureters in, 2:183f-184f, 186, 186f
urethra in, 2:186f, 187
urinary bladder in, 2:183f-184f, 186, 186f
angiography of, 2:190, 191f
AP oblique projection of, 2:206, 206f
AP projection of, 2:204
evaluation criteria for, 2:205b
position of part for, 2:204
position of patient for, 2:204, 204f
in prone position, 2:204
in semi-upright position, 2:204, 205f
structures shown on, 2:204, 205f
in supine position, 2:204, 204f-205f
in Trendelenburg position, 2:204, 205f
contrast studies of, 2:190-197
adverse reactions to iodinated media for,
2:196
angiographic, 2:190, 191f
antegrade filling for, 2:191, 191f
contrast media for, 2:194, 195f
CT in, 2:190, 191f
equipment for, 2:198, 198f-199f
physiologic technique for, 2:192f, 193
preparation of intestinal tract for, 2:196-197,
196f-197f
preparation of patient for, 2:197
retrograde filling for, 2:192f, 193
tomography in, 2:190, 191f
CT of, 2:190, 190f
cystography of. See Cystography.
cystoureterography of, 2:193, 193f, 214
cystourethrography of, 2:193, 193f, 214
female, 2:222-224, 222f
metallic bead chain, 2:222-224, 223f
male, 2:221, 221f
serial voiding, 2:214, 215f
image quality and exposure techniques for,
2:199, 199f
lateral projection of
in dorsal decubitus position, 2:208, 208f
in R or L position, 2:207, 207f
motion control for, 2:199
nephrotomography of, 2:190, 191f
AP projection in, 2:209, 209f
percutaneous renal puncture for, 2:210-211,
210f
overview of radiography of, 2:190-201
pelvicaliceal system in, retrograde urography of,
2:212-213, 212f-213f
preliminary examination of, 2:201
prostate in
anatomy of, 2:184f, 186f, 187
radiologic examination of, 2:214
pyelography of, 2:191
percutaneous antegrade, 2:211, 211f
radiation protection for, 2:201
renal parenchyma in, nephrotomography of,
2:209-211
AP projection for, 2:209, 209f
percutaneous renal puncture for, 2:210-211,
210f
respiration for, 2:200
sample exposure technique chart essential
projections for, 2:189t
summary of pathology of, 2:188t
summary of projections for, 2:182-183
ureteral compression for, 2:200, 200f
ureters in
anatomy of, 2:183f-184f, 186, 186f
radiologic examination of, 2:214
retrograde urography of, 2:212-213,
212f-213f
urethra in
anatomy of, 2:186f, 187
radiologic examination of, 2:214
Urinary system (Continued)
urinary bladder in
anatomy of, 2:183f-184f, 186, 186f
AP axial or PA axial projection of, 2:216-217,
216f-217f
AP oblique projection of, 2:218, 218f-219f
cystourethrography of
female, 2:222-224, 222f-223f
male, 2:221, 221f
serial voiding, 2:214, 215f
lateral projection of, 2:220, 220f
radiologic examination of, 2:214
urography of. See Urography.
voiding study of, 2:192f
Urography
AP oblique projection for, 2:206, 206f
AP projection for, 2:204
evaluation criteria for, 2:205b
position of part for, 2:204
position of patient for, 2:204, 204f
in prone position, 2:204
in semi-upright position, 2:204, 205f
structures shown on, 2:204, 205f
in supine position, 2:204, 204f-205f
in Trendelenburg position, 2:204, 205f
in upright position, 2:204, 204f
defined, 2:190
equipment for, 2:198, 198f-199f
excretory (intravenous). See Excretory urography
(EU).
Index
image quality and exposure technique for, 2:199,
199f
intestinal tract preparation for, 2:196-197,
196f-197f
lateral projection for
in dorsal decubitus position, 2:208, 208f
in R or L position, 2:207, 207f
motion control for, 2:199
percutaneous antegrade, 2:191
preparation of patient for, 2:197
respiration during, 2:200
retrograde, 2:192f, 193
AP projection for, 2:212-213, 212f-213f
contrast media for, 2:194, 195f
defined, 2:193
preparation of patient for, 2:197
ureteral compression for, 2:200, 200f
Useful patient dose in CT, 3:340
Uterine fibroid, 2:245t, 247f
MRI of, 3:361f
transcatheter embolization for, 3:68, 69f
Uterine ostium, 2:240, 240f
Uterine tube(s)
anatomy of, 2:239, 239f-240f
hydrosalpinx of, 2:246f
hysterosalpingography of, 2:246-247, 246f-247f
obstruction of, 2:245t
sectional anatomy of, 3:284
Uterus
anatomy of, 2:240, 240f
bicornuate, 2:247f
hysterosalpingography of, 2:246-247, 246f-247f
sectional anatomy of, 3:284, 294, 294f, 296,
297f
ultrasonography of, 3:386f-389f, 388
UVJ (ureterovesical junction), 2:186
Uvula, 2:59, 59f, 71f, 72
V
Vacuum bag immobilization device for radiation
oncology, 3:491f
Vacuum-assisted core biopsy of breast, 2:470
Vagina
anatomy of, 2:240
sectional anatomy of, 3:284
ultrasonography of, 3:386f
I-47
 Vaginal orifice, 2:240, 240f
Vaginal vestibule, 2:240
Vaginography, 2:246, 250-251, 250f-251f
Valium (diazepam), 2:226t
Valsalva maneuver, 2:72
Valvular competence, 3:97
Varices
defined, 3:97
esophageal, 2:109t, 119, 119f
venous, 3:72
Vascular access devices in children, 3:157,
157f-158f
Vascular access needles for angiographic studies,
3:35, 35f
Vascular applications of ultrasonography,
3:392-393, 392f, 394f
Vascular plug, 3:68, 68f
Vascular procedures of CNS, 3:14-16, 14f-15f
Vascular stent placement, percutaneous
transluminal angioplasty for, 3:65, 65f
coronary, 3:88, 89f
Vascular system. See Blood-vascular system.
Vasoconstricting drugs in transcatheter
embolization, 3:67-68
Vasoconstriction, 3:97
VC (virtual colonoscopy), 2:144, 145f, 3:335,
335f
VCT. See Volume CT (VCT).
VCUG (voiding cystourethrogram), 2:214, 215f
in children, 3:117, 117f
Index
Veins, 3:22f, 23
coronary, 3:25, 25f
defined, 3:97
pulmonary, 3:22f, 23
systemic, 3:24
Velocity of sound, 3:372, 398
Venipuncture, 2:225-235
discarding needles after, 2:234, 234f
documentation of, 2:235
infection control during, 2:228
medication preparation for, 2:229-230, 229f
from bottle or vial, 2:229, 229f
identification and expiration date in, 2:230,
230f
nonvented tubing in, 2:230, 230f
recapping of syringe in, 2:229, 229f
tube clamp in, 2:230, 230f
vented tubing in, 2:230, 230f
medications administered via, 2:225, 226t
needles and syringes for, 2:228-229, 228f
patient assessment for, 2:228
patient education on, 2:225
professional and legal considerations for, 2:225
reactions to and complications of, 2:235
removing IV access after, 2:234, 234f
site preparation for, 2:232, 232f
site selection for, 2:230-231, 231f
technique for, 2:232-234
administering medication in, 2:233-234, 233f
anchoring needle in, 2:233, 233f
applying tourniquet in, 2:232f, 233
direct (one-step), 2:232
gloves and cleaning of area in, 2:232f, 233
indirect (two-step), 2:232
local anesthetic in, 2:233
releasing tourniquet in, 2:233f
stabilizing skin and entering vein in, 2:233,
233f
verifying venous access in, 2:233
Venography, 3:28, 60
defined, 3:97
inferior venacavogram in, 3:60, 60f
peripheral
lower limb, 3:47, 48f
upper limb, 3:46, 46f
superior venacavogram in, 3:60, 60f
I-48
Venography (Continued)
visceral, 3:61
hepatic, 3:61, 61f
portal, 3:61, 61f
renal, 3:61, 61f
Venotomy, 3:97
Venous insufficiency, ultrasonography of, 3:393
Venous varices, 3:72
Ventral, 1:85
Ventral decubitus position, 1:94, 95f
Ventral recumbent position, 1:90, 90f
Ventricles
cardiac
anatomy of, 3:24-25, 25f, 97
sectional anatomy of, 3:270, 271f
on axial (transverse) plane, 3:278,
278f-279f
on coronal plane, 3:280-281, 281f
on sagittal plane, 3:278-280, 280f
cerebral
anatomy of, 3:2, 4, 4f
sectional anatomy of, 3:255
Ventricular function, echocardiography of, 3:393
Ventricular system, 3:2, 4, 4f
Ventriculography, left, 3:82-84, 83f-84f
Ventriculomegaly, ultrasonography of, 3:385f
Venules, 3:23, 97
Vermiform appendix
anatomy of, 2:97f, 102, 102f
sectional anatomy of, 3:283
Vermis
anatomy of, 3:2, 18
sectional anatomy of, 3:255
Versed (midazolam hydrochloride), 2:226t
Vertebra(e)
defined, 1:366
false (fixed), 1:366
prominens, 1:71f, 71t, 370
true (movable), 1:366
typical, 1:368, 368f
Vertebral arch
anatomy of, 1:368, 368f, 370
AP axial oblique projection of, 1:401, 401f
AP axial projection of, 1:399-400, 399f-400f
sectional anatomy of, 3:253, 272
Vertebral arteries
anatomy of, 3:49, 49f, 51
arteriography of, 3:51f
AP axial projection for, 3:59f
AP projection for, 3:52f
lateral projection for, 3:52f, 58f
sectional anatomy of, 3:255, 262-264, 262f-263f
thoracic aortography of, 3:55f
transcatheter embolization of, 3:68, 69f
Vertebral articulations, 1:378-382, 378f, 379t
Vertebral canal, 1:368
Vertebral column, 1:363-444
abbreviations used for, 1:379b
anatomy of, 1:366-382, 366f
cervical vertebrae in, 1:369-371
coccyx in, 1:376f, 377
lumbar vertebrae in, 1:374-375, 375f
sacrum in, 1:376, 376f-377f
summary of, 1:379b
thoracic vertebrae in, 1:372-373, 373f
typical vertebra in, 1:368, 368f
vertebral articulations in, 1:378-382, 378f,
379t
vertebral curvature in, 1:367, 367f
articulations of, 1:378-382, 378f, 379t
cervical vertebrae of. See Cervical vertebrae.
coccyx of, 1:376f, 377
curvature of, 1:366f-367f, 367
defined, 1:366
functions of, 1:366
lumbar vertebrae in. See Lumbar vertebrae.
Vertebral column (Continued)
sacrum of, 1:376, 376f-377f
sample exposure technique chart essential
projections for, 1:381t
summary of pathology of, 1:380t
summary of projections for, 1:364-366
oblique, 1:382t
thoracic vertebrae of. See Thoracic vertebrae.
Vertebral curvature, 1:366f-367f, 367
Vertebral foramen, 1:368, 368f
Vertebral fracture assessment (VFA), 3:469-470,
470f-471f, 477
Vertebral fracture(s) due to osteoporosis, 3:449,
449f
Vertebral notches, 1:368, 368f
Vertebrobasilar circulation
AP axial projection for, 3:59, 59f
digital subtraction angiography of, 3:15f
lateral projection for, 3:58-59, 58f
Vertebroplasty, 3:16, 16f-17f, 18
for osteoporotic fractures, 3:449
Vertical plate of palatine bones, 2:273
Vertical ray method for contrast arthrography of
knee, 2:12, 12f
Vesicoureteral reflux, 2:188t
in children, 3:117-118, 117f
Vesicovaginal fistula, 2:250, 250f
Vesiculography, 2:253, 254f
Vessels, MRI of, 3:363-364, 363f-364f
Vestibular folds, 2:73, 73f
Vestibule of internal ear, 2:271
VFA (vertebral fracture assessment), 3:469-470,
470f-471f, 477
View, 1:95
Viewbox, 1:8
Villi, 2:100f, 101
Viral pneumonitis, 1:486t
Virtual colonoscopy (VC), 2:144, 145f, 3:335,
335f
Virtual simulations in radiation oncology, 3:489,
492f
Visceral, 1:85
Visceral arteriography, 3:42-45, 42f
celiac, 3:43, 43f
hepatic, 3:43, 43f
inferior mesenteric, 3:44, 45f
other, 3:45
renal, 2:190, 191f, 3:45, 45f
splenic, 3:44, 44f
superior mesenteric, 3:44, 44f
Visceral pericardium, 3:24
Visceral peritoneum, 2:83, 83f
Visceral pleura, 1:482
Visceral venography, 3:61
hepatic, 3:61, 61f
portal, 3:61, 61f
renal, 3:61, 61f
Vision in older adults, 3:169
Vistaril (hydroxyzine hydrochloride), 2:226t
Vitamin D and osteoporosis, 3:450
Vitreous body, 2:314f
VMAT (volumetric modulated arc therapy),
3:496
Vocal cords, 2:71f
false, 2:73, 73f
true, 2:71f, 73, 73f
Vocal folds, 2:71f, 73, 73f
Voiding cystourethrogram (VCUG), 2:214,
215f
in children, 3:117, 117f
Voiding study, 2:192f
Volume CT (VCT), 3:326-327
defined, 3:306-307
multislice spiral CT for, 3:323-324, 323f
single-slice spiral CT for, 3:321, 322f
Volume element (voxel), 3:308, 308f, 340
Volume rendering (VR), 3:326-327
defined, 3:306-307
multislice spiral CT for, 3:323-324, 323f
single-slice spiral CT for, 3:321, 322f
Volume scanning, 3:372-373
Volumetric density in DXA, 3:453, 453f, 477
Volumetric modulated arc therapy (VMAT), 3:496
Voluntary muscles, motion control of, 1:19, 19f
Volvulus, 2:109t
Vomer
anatomy of, 2:259f, 272f, 273
sectional anatomy of, 3:254
submentovertical projection of, 2:367f
Voxel (volume element), 3:308, 308f, 340
VR. See Volume rendering (VR).
W anatomy of, 1:102, 102f
Waiting room for children, 3:100, 100f-101f
Wallsten, Hans, 3:20-21
Ward triangle, 3:477
Warren, Stafford, 2:372
Washout in nuclear medicine, 3:419, 430f, 439
Waters method
for facial bones, 2:323, 323f-324f
modified, 2:304, 325f-326f
reverse, 2:327, 327f-328f
with trauma, 2:328, 328f
for maxillary sinuses, 2:362-363, 362f-363f
in children, 3:136, 136f
open-mouth, 2:364-365, 364f-365f
modified
for facial bones, 2:304, 325f-326f
for orbits, 2:319, 319f
open-mouth, for maxillary and sphenoidal
sinuses, 2:364-365, 364f-365f
reverse
for cranial trauma, 2:46, 46f
for facial bones, 2:327, 327f-328f
with trauma, 2:328, 328f
Water-soluble, iodinated contrast media
for alimentary canal imaging, 2:111-112,
111f-112f
for large intestine studies, 2:145
Wedge filter(s)
applications of, 1:60, 60t, 61f
example of, 1:56f
in position, 1:55f
for radiation oncology, 3:495, 495f, 507
shape of, 1:57
specialized, 1:62f, 63
Weight limits, 1:44-45, 45t
Weight-bearing exercise and osteoporosis, 3:450
Wellen method for double-contrast barium enema,
2:152-153, 152f-153f
West Point method for inferosuperior axial
projection of shoulder joint, 1:196-197,
196f-197f
Wheelchairs for obese patients, 1:46, 46f
White matter
anatomy of, 3:2
sectional anatomy of, 3:256-257
Whole-body dual energy x-ray absorptiometry,
3:442f, 471, 472f
Whole-body imaging in nuclear medicine, 3:412,
412f
Wilms tumor, 2:188t
Window level (WL) in CT, 3:312, 312t, 340
Window width (WW) in CT, 3:312, 312t, 340
Windowing in CT, 3:10, 312, 312f, 312t, 340
Wolf method for PA oblique projection of superior
stomach and distal esophagus, 2:136-137,
136f-137f
Wrist, 1:132
AP oblique projection in medial rotation of,
1:137, 137f
AP projection of, 1:133, 133f
articulations of, 1:105-107, 106f
bone densitometry of, 3:475f
display orientation of, 1:11, 11f
lateromedial projection of, 1:134-135
with carpal boss, 1:135, 135f
evaluation criteria for, 1:135b
position of part for, 1:134, 134f
position of patient for, 1:134
structures shown on, 1:134-135, 134f-135f
PA oblique projection in lateral rotation of,
1:136, 136f
PA projection of, 1:132, 132f
with radial deviation, 1:139, 139f
with ulnar deviation, 1:138, 138f
scaphoid of, 1:140-141
anatomy of, 1:101f, 102
Rafert-Long method for scaphoid series (PA
and PA axial projections with ulnar
deviation) of, 1:142, 142f-143f
Stecher method for PA axial projection of,
1:140-141
surgical radiography of, 3:249f
tangential projections of
of carpal bridge, 1:145
Gaynor-Hart method for, 1:146
evaluation criteria for, 1:147b
inferosuperior, 1:146, 146f-147f
superoinferior, 1:147, 147f
Wrist arthrogram, 2:16, 16f
WW (window width) in CT, 3:312, 312t, 340
X in orbit, 2:275, 275f, 312f, 314f
Xenon-133 (133Xe), 3:406t
Xenon-133 (133Xe) lung ventilation scan, 3:419
Xerography of breast, 2:372-373, 372f
Xeromammography, 2:372, 372f
Xiphisternal joint, 1:447f, 449t, 450
Xiphoid process
anatomy of, 1:447f, 448
sectional anatomy of, 3:256, 285, 285f
as surface landmark, 1:71f, 71t
X-ray beam, collimation of, 1:32-33, 32f-33f
Y
Yellow marrow, 1:76, 76f
Yolk sac, ultrasonography of, 3:388,
389f-390f
Z
Z scores in DXA, 3:457, 477
Zenker diverticulum, 2:109t
Zygapophyseal joints, 1:368, 378, 378f, 379t
cervical
anatomy of, 1:371, 371f, 371t
positioning rotations needed to show, 1:371,
371t
lumbar
anatomy of, 1:374, 374f-375f, 375t
AP oblique projection of, 1:421-422
position of part for, 1:421, 421f
position of patient for, 1:421
positioning rotations needed to show,
1:371t
sectional anatomy of, 3:269-270, 278-279,
280f
thoracic
anatomy of, 1:372f-373f, 373
Index
AP or PA oblique projection of, 1:410-412
in recumbent position, 1:411-412,
411f-412f
in upright position, 1:410, 410f, 412f
positioning rotations needed to show,
1:371t
Zygomatic arches
anatomy of, 2:273
AP axial projection of (modified Towne method),
2:337, 337f-338f
parietoacanthial projection of, 2:324f
sectional anatomy of, 3:263f, 264
submentovertical projection of, 2:333-334,
333f-334f
tangential projection of, 2:335-336,
335f-336f
Zygomatic bones
acanthioparietal projection of, 2:328f
anatomy of, 2:272f-273f, 273
modified Waters method for parietoacanthial
projection of, 2:326f
sectional anatomy of, 3:254, 262
Zygomatic process
anatomy of, 2:268, 268f
sectional anatomy of, 3:253-254
Zygote, 2:241
I-49
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 INDEX

A Acinus of breast, 380 Appendicitis, 109t

AAA (abdominal aortic aneurysm), 84t Acoustic neuroma, 282t Architectural distortion (AD) of breast, 393, 393f,
Abbreviations Acute abdomen series, 87 394t-395t
for contrast arthrography, 9b AD (architectural distortion) of breast, 393, 393f, Arcuate eminence, 269f
for digestive system, 107b 394t-395t Areola, 380, 381f
for long bone measurement, 2b Adam’s apple, 72 Arm. See Upper limb.
for skull, 284b Adenoids, 71f, 72 Arteriography
for trauma radiography, 30b ADH (atypical ductal hyperplasia), 395 visceral
for urinary system, 189b Adhesion, 245t renal, 190, 191f
in Volume Two, 475t Adipose capsule, 184 Articular tubercle
Abdomen, 81-94 Adrenal glands anatomy of, 268, 268f
abbreviations used for, 85b anatomy of, 183, 183f axiolateral oblique projection of, 352f
anatomy of, 83, 83f, 84b Adrenaline, 226t Ascites, 84t
AP projection of AEC. See Automatic exposure control (AEC). Asterion, 258f, 259
in left lateral decubitus position, 91, 91f-92f Afferent arteriole of kidney, 185, 185f Asthenic body habitus
for trauma, 40, 40f Aging. See also Elderly. and gallbladder, 106, 106f
in supine position (KUB), 87, 89-90, 89f-90f Air-contrast study of large intestine, 144 skull radiography with, 289f
for trauma, 38-39, 38f-39f Airway foreign body, 62t and stomach and duodenum, 99, 99f, 125f
in left lateral decubitus position, 40, 40f Alimentary canal, 97, 97 See also Digestive AT. See Axillary tail (AT).
in upright position, 89-90, 89f-90f system. Atlantooccipital joint, 266f, 275t
exposure technique for, 86, 86f Alveolar process Atropine sulfate (Atropine), 226t
flat and upright images of, 87 anatomy of, 272, 273f Atypical ductal hyperplasia (ADH), 395
immobilization for, 86, 87f Alveolar sockets, 275t Atypical lobular hyperplasia, 395
lateral projection of Alveolus(i) Auditory ossicles, 269f-270f, 271
in R or L dorsal decubitus position, 94, 94f of breast, 381f Auditory tube, 270f, 271
in R or L position, 93, 93f Amnion, 241 Auricle
PA projection of, 91, 91f Ampulla of ear
positioning protocols for, 87 of breast, 381f anatomy of, 270f, 271, 285f
sample exposure technique chart essential of ductus deferens, 242, 243f Automatic exposure control (AEC)
projections for, 85t of uterine tube, 239, 239f for mammography, 409
scout or survey image of, 87 Ampulla of Vater Axilla, labeling codes for, 403t-408t
sequencing of projections for, 87-94, 87f-88f anatomy of, 100f, 101, 105, 105f Axillary lymph nodes
summary of pathology of, 84t Anal canal anatomy of, 380, 381f
summary of projections of, 82, 87 anatomy of, 102f-103f, 103 mammographic findings for, 387
three-way imaging of (acute abdomen series), 87 defecography of, 172, 172f Axillary prolongation. See Axillary tail (AT).
trauma radiography of, AP projection in, 38-39, Anaphylactic reaction, 235 Axillary tail (AT)
38f-39f Aneurysm anatomy of, 380f, 437f
in left lateral decubitus position, 40, 40f aortic axillary projection of, 452-453, 452f-453f
Abdominal aortic aneurysm (AAA), 84t abdominal, 84t labeling codes for, 403t-408t
Abdominal cavity, 83 Angiocatheters, 228f, 229 mediolateral oblique projection of, 412f, 432t,
Abdominal fistulae and sinuses, 180, 180f Angiography 450-451, 450f-451f
Abdominal viscera, 83f arteriography as. See Arteriography.
Abdominopelvic cavity, 83, 83f digital subtraction. See Digital subtraction B
Abscess angiography (DSA). Backboard in trauma radiography, 23, 23f
breast, 395 renal, 190, 191f Barium enema (BE)
of epididymis, 253f Angular notch of stomach, 98f double-contrast method for, 144, 144f,
Acanthion, 272, 272f-273f, 285f Anterior arches of soft palate, 59, 59f 150-153
Acanthioparietal projection Anterior clinoid processes single-stage, 144, 150, 150f-151f
for cranial trauma, 46, 46f anatomy of, 258f, 264f-265f, 265 two-stage, 144
of facial bones, 327, 327f-328f Anterior cranial fossa, 260 Wellen method for, 152-153, 152f-153f
for trauma, 328, 328f Anterior fontanel, 259-260, 260f insertion of enema tip for, 148
Accessory glands of digestive system, 97, 97f Anterior nasal spine, 272, 272f-273f, 332f preparation and care of patient for, 147
Achalasia, 109t Anus preparation of barium suspensions for, 147
anatomy of, 102f-103f, 103 single-contrast, 144, 144f, 148-149, 148f-149f
Aorta standard apparatus for, 146, 146f-147f
sectional image of, 107f Barium sulfate
Page numbers followed by “f” indicate figures, “t” Aortic aneurysm for alimentary canal imaging, 111, 111f
indicate tables, and “b” indicate boxes. abdominal, 84t high-density, 144

e1
 Barium sulfate suspension Breast(s) (Continued) Caldwell method
for alimentary canal imaging, 111, 111f-112f MRI of, 418-419, 472 for PA axial projection of facial bones, 329-330,
for barium enema, 147 oversized, 400, 401f 329f-330f
Barrett esophagus, 109t pathology of, 384-393 for PA axial projection of frontal and anterior
Basal skull fracture, 282t architectural distortions as, 393, 393f, ethmoidal sinuses, 360-361, 360f-361f
Basilar portion of occipital bone, 266-267, 394t-395t for PA axial projection of skull, 296-300
266f-267f calcifications as, 389-393, 389f-392f evaluation criteria for, 299b
BE. See Barium enema (BE). masses as, 384-388, 394t-395t position of part for, 296, 297f
Benadryl (diphenhydramine hydrochloride), circumscribed, 384, 385f, 394 position of patient for, 296
226t density of, 384, 386f structures shown on, 298f, 299
Benign prostatic hyperplasia (BPH), 188t indistinct, 384, 394 Calvaria, 257
Bezoar, 109t interval change in, 387, 387f Carcinoma, 109t
Bicornuate uterus, 247f location of, 387 Cardia of stomach, 98, 98f
Bile, 104 margins of, 384, 394t-395t Cardiac notch, 98, 98f
Bile ducts, 97f, 104f-105f, 105 palpable, 409, 429-430, 443 Cardiac orifice
Biliary drainage procedure, 175, 175f radiolucent, 384, 386f anatomy of, 99
Biliary stenosis, 109t seen on only one projection, 388, 388f Cardiac sphincter, 98f, 99
Biliary tract shape of, 384 C-arm
anatomy of, 97f, 104f-106f, 105 spiculated, 384, 385f, 394 dedicated, 20, 20f
biliary drainage procedure and stone extraction summary of, 394t-395t mobile fluoroscopic, 20, 21f
for, 175, 175f during pregnancy and lactation, 382, 382f Carotid canal, 268, 269f
cholangiography of radiography of. See Mammography. Carotid sulcus, 264-265, 264f
percutaneous transhepatic, 174-175, thermography and diaphanography of, 473 Cecum
174f tissue variations in, 382-393, 382f-383f anatomy of, 100f, 102, 102f
postoperative (T-tube), 176-177, 176f-177f ultrasonography of, 418-419 Celiac disease, 109t
endoscopic retrograde cholangiopancreatography xerography of, 372, 372f Celiac sprue, 109t
of, 178, 178f-179f Breast abscess, 395 Central ray (CR)
prefixes associated with, 173, 173t Breast augmentation for trauma radiography, 30
radiographic techniques for, 173 complications of, 418 Cerebellum
Bladder. See Urinary bladder. mammography with, 417-419, 418f anatomy of, 259f
Index

Bladder carcinoma, 188t craniocaudal (CC) projection of Cerebrum

Blowout fracture, 46f, 282t, 313, 313f with full implant, 420-421, 421f anatomy of, 259f
Blunt trauma, 19 with implant displaced, 422-423, 422f-423f Cervical vertebrae
Body habitus with implant displacement (ID), 403t-408t AP axial oblique projection for trauma of, 34,
and body position for skull radiography mediolateral oblique (MLO) projection of 35f-36f
in horizontal sagittal plane, 289f with full implant, 424 AP axial projection of
in perpendicular sagittal plane, 290f with implant displaced, 425 for trauma, 33, 33f
and gallbladder, 106, 106f MRI with, 418-419 CT of, 53-55
and stomach and duodenum, 99, 99f ultrasonography with, 418-419 dislocation of, 33f
PA projection of, 124, 125f Breast cancer fracture-dislocation of, 31f
Bony labyrinth, 271 architectural distortion due to, 393f lateral projection of
Bowel obstruction, 84t calcifications in, 392f for trauma, 31, 31f
Bowman capsule, 185, 185f in men, 426 trauma radiography of
BPH (benign prostatic hyperplasia), 188t risk factors for, 378-379 AP axial oblique projection in, 34, 35f-36f
Brachycephalic skull, 286, 286f Breast cancer screening, 377 AP axial projection in, 33, 33f
BRCA1 gene, 378-379 vs. diagnostic mammography, 378 lateral projection in, 31, 31f
BRCA2 gene, 378-379 high-risk, 472 Cervicothoracic region, lateral projection of
Breast(s) risk vs. benefit of, 377-378, 377f in dorsal decubitus position for trauma, 32, 32f
anatomy of, 380, 380f-381f, 394b Breast specimen radiography, 471, 471f Cervix
axillary tail of Breathing anatomy of, 240, 240f
anatomy of, 380f, 437f for trauma radiography, 30 Chassard-Lapiné method for axial projection of
axillary projection of, 452-453, 452f-453f Bregma, 258f-259f, 259 large intestine, 169, 169f
mediolateral oblique projection of, 412f, 432t, Bridge of nose, 272 Chloral hydrate (Noctec), 226t
450-451, 450f-451f Bulbourethral glands, 242 Cholangiography, 173
connective tissue of, 381f, 382 Butterfly sets, 228f, 229 percutaneous transhepatic, 174-175, 174f
density of, 383, 383f postoperative (delayed, T-tube), 176-177,
digital breast tomosynthesis (3D imaging) of, C 176f-177f
374-375 CAD (computer-aided detection) systems for Cholangiopancreatography
ductography of, 459-460, 459f-460f mammography, 376-379, 376f endoscopic retrograde, 178, 178f-179f
fatty tissue of, 381f, 382 Calcifications of breast, 389-393, 389f-392f, Cholecystitis, 109t
glandular tissue of, 382 394t-395t Cholecystography, 173
involution of, 380 amorphous or indistinct, 391, 392f, 394 Cholecystokinin, 106
localization and biopsy of suspicious lesions of, arterial (vascular), 389f-390f, 395 Choledochal sphincter, 105
461-470 coarse heterogeneous, 389f-390f, 391, 394 Choledocholithiasis, 109t
breast specimen radiography in, 471, 471f fine heterogeneous, 391, 392f, 394 Cholegraphy, 173
for dermal calcifications, 464 linear branching, 392f Cholelithiasis, 109t
material for, 461, 461f male, 427 Chorion, 241
stereotactic imaging and biopsy procedures milk of calcium as, 391, 391f, 395 Chyme, 99
for, 465-470 pleomorphic linear, 392f Cilia of uterine tube, 239
calculation of X, Y, and Z coordinates in, popcorn-type, 389f-390f, 395 Clivus, 258f-259f, 264-265, 265f, 267
465, 465f-466f, 469, 469f rim, 395 Cochlea, 269f-270f, 271
equipment for, 466, 467f-468f rodlike secretory, 389f-390f Cochlear nerve, 270f
images using, 468, 468f-470f round or punctate, 389f-390f, 394 Colitis, 109t
three-dimensional localization with, 465, skin (dermal), 395, 464 ulcerative, 109t
465f Calculus, 62t Collecting ducts, 185, 185f
tangential projection for, 464 renal, 188t, 190f Collecting system, duplicate, 188t

e2
Collimation
for trauma radiography, 30
Colloidal preparations for large intestine contrast
media studies, 144
Colon
anatomy of, 102f, 103
AP axial projection of, 161, 161f
AP oblique projection of
in LPO position, 162, 162f
in RPO position, 163, 163f
in upright position, 168, 168f
AP projection of, 160, 160f
in left lateral decubitus position, 166
in right lateral decubitus position, 165,
165f
in upright position, 168, 168f
ascending
anatomy of, 100f, 102f, 103
axial projection of (Chassard-Lapiné method),
169, 169f
colostomy studies of, 170
contrast media studies of, 144-148
contrast media for, 144-145
double-contrast method for, 144, 144f,
150-153
single-stage, 144, 150, 150f-151f
two-stage, 144
Wellen method for, 152-153, 152f-153f
insertion of enema tip for, 148
opacified colon in, 154
preparation and care of patient for, 147
preparation of barium suspension for, 147
preparation of intestinal tract for, 146, 146f
single-contrast method for, 144, 144f,
148-149, 148f-149f
standard barium enema apparatus for, 146,
146f-147f
CT colonography (virtual colonoscopy) for, 144,
145f
decubitus positions for, 164-172
defecography for, 172, 172f
descending, 102f, 103
diagnostic enema for, 170, 170f-171f
lateral projection of
in R or L position, 159, 159f
in R or L ventral decubitus position, 167, 167f
in upright position, 168
opacified, 154
PA axial projection of, 156, 156f
PA oblique projection of
in LAO position, 158, 158f
in RAO position, 157, 157f
PA projection of, 154, 154f-155f
in left lateral decubitus position, 166, 166f
in right lateral decubitus position, 165
in upright position, 168, 168f
sigmoid, 102f, 103
axial projection of (Chassard-Lapiné method),
169, 169f
transverse
anatomy of, 102f, 103
Colonography, CT, 144, 145f
Colonoscopy, virtual, 144, 145f
Colostomy stoma, diagnostic enema through, 170,
170f-171f
Colostomy studies, 170
Common bile duct
anatomy of, 100f, 105, 105f
Common hepatic duct
anatomy of, 100f, 105, 105f
Complete reflux examination of small intestine,
141, 141f
Compression cone for abdominal imaging, 113,
113f
Compression devices for abdominal imaging, 113,
113f
Compression paddle for abdominal imaging, 113, Contrast media studies (Continued)
113f single-contrast method for, 144, 144f,
Compression plate for breast lesion localization, 148-149, 148f-149f
462-464, 462f-463f standard barium enema apparatus for, 146,
Computed tomography (CT) 146f-147f
for long bone measurement, 6, 6f of stomach, 121-123
after shoulder arthrography, 11, 11f barium sulfate suspension for, 111, 111f
for trauma, 20, 29 biphasic, 123
of cervical spine, 53-55 double-contrast, 122, 122f, 124f
of cranium, 29, 29f, 53-55, 54f single-contrast, 121, 121f, 124f
of pelvis, 53f, 55 water-soluble, iodinated solution for, 111,
of thorax, 53-55 111f
of urinary system, 190, 190f of urinary system, 190-197
Computed tomography (CT) colonography, 144, adverse reactions to iodinated media for, 196
145f angiographic, 190, 191f
Computed tomography (CT) enteroclysis, 141, antegrade filling for, 191, 191f
142f contrast media for, 194, 195f
Computer-aided detection (CAD) systems for CT in, 190, 191f
mammography, 376-379, 376f equipment for, 198, 198f-199f
Concha, 270f physiologic technique for, 192f, 193
Condylar canals, 266f, 267 preparation of intestinal tract for, 196-197,
Condylar process, 264f, 274, 274f 196f-197f
Cones, 315 preparation of patient for, 197
Congenital aganglionic megacolon, 109t retrograde filling for, 192f, 193
Conjunctiva, 314, 314f-315f tomography in, 190, 191f
Contrast arthrography, 7-16 Contre-coup fracture, 282t
abbreviations used for, 9b Cooper’s ligaments, 380, 381f
defined, 8-9 Cornea, 314f-315f, 315
double-, 8-9 Coronal suture
of knee, 13, 13f anatomy of, 258f, 259, 275t
Index
of hip, 14 lateral projection of, 295f
AP oblique, 14f Coronoid process
axiolateral “frog”, 14f anatomy of, 273f-274f, 274
with congenital dislocation, 8f, 14, 14f axiolateral oblique projection of, 344f-345f
prosthetic, 14, 15f PA axial projection of, 342f
digital subtraction technique for, 14, submentovertical projection of, 346f
15f CR (central ray). See Central ray (CR).
photographic subtraction technique for, 14, Cranial bones
15f anatomy of, 257, 257b
of knee, 12 anterior aspect of, 257f
double-contrast (horizontal ray method), 13, ethmoid bone as
13f anatomy of, 262, 262f
vertical ray method for, 12, 12f location of, 259f
MRI vs., 8, 8f frontal bone as
of other joints, 16, 16f anatomy of, 261, 261f
overview of, 8-9 location of, 257f-259f
procedure for, 9, 9f function of, 257
of shoulder, 10-11 lateral aspect of, 258f-259f
CT after, 11, 11f in newborn, 259-260, 260f
double-contrast, 10, 10f-11f occipital bone as
MRI vs., 8f anatomy of, 266-267, 266f-267f
single-contrast, 10, 10f-11f location of, 258f-259f, 264f
summary of pathology found on, 9t parietal bones as
Contrast media anatomy of, 263, 263f
for alimentary canal, 111-112, 111f-112f location of, 257f-259f
Contrast media studies sphenoid bone as
of esophagus, 115-117, 115f anatomy of, 264-266, 264f-265f
barium administration and respiration for, 119, location of, 257f-258f
119f temporal bones as
barium sulfate mixture for, 115 anatomy of, 268, 268f-269f
double-contrast, 115, 117, 117f location of, 257f-259f
examination procedures for, 116-117, Cranial fossae, 258f, 260
116f-117f Cranium. See also Skull.
single-contrast, 115, 116f-117f average or normal, 260
of large intestine, 144-148 deviations from, 260
contrast media for, 144-145 Cribriform plate
double-contrast method for, 144, 144f, anatomy of, 258f, 262, 262f
150-153 Crista galli
single-stage, 144, 150, 150f-151f anatomy of, 258f-259f, 262, 262f
two-stage, 144 PA axial projection of, 298f, 330f
Wellen method for, 152-153, 152f-153f Crohn disease, 109t
insertion of enema tip for, 148 Cruciate ligaments, double-contrast arthrography
opacified colon in, 154 of, 13
preparation and care of patient for, 147 Cryptorchidism, 245t
preparation of barium suspensions for, 147 Crystalline lens, 314f-315f
preparation of intestinal tract for, 146, 146f CT. See Computed tomography (CT).
e3
 Cyst Digestive system (Continued) Ductus deferens
breast, 395 small intestine in, 97f, 100f, 101 anatomy of, 242, 242f-243f
dermoid, 245t stomach in, 97f-99f, 98-99 Duodenal bulb
oil, 386f summary of, 108b anatomy of, 98f, 100f, 101
renal, 210f-211f biliary tract and gallbladder in Duodenography, hypotonic, 123, 123f
retroareolar, 385f anatomy of, 97f, 104-106, 104f-106f Duodenojejunal flexure, 100f, 101
Cystic duct biliary drainage procedure and stone Duodenum
anatomy of, 100f, 105-106, 105f extraction for, 175, 175f anatomy of, 97f-98f, 100f, 101
Cystitis, 188t endoscopic retrograde AP oblique projection of, 130-131, 130f-131f
Cystography, 192f, 214 cholangiopancreatography of, 178, AP projection of, 134
AP axial or PA axial projection for, 216-217, 178f-179f evaluation criteria for, 134b
216f-217f percutaneous transhepatic cholangiography of, position of part for, 134, 134f
AP oblique projection for, 218, 218f-219f 174-175, 174f position of patient for, 134, 134f
contrast injection for, 214, 215f postoperative (T-tube) cholangiography of, structures shown on, 134, 135f
contrast media for, 214 176-177, 176f-177f hypotonic duodenography of, 123, 123f
defined, 193 prefixes associated with, 173, 173t lateral projection of, 132-133, 132f-133f
excretory radiographic techniques for, 173 PA axial projection of, 126-127, 126f-127f
AP axial projection for, 217f contrast media for, 111-112, 111f-112f PA oblique projection of, 128-129, 128f-129f
AP oblique projection for, 219f endoscopic retrograde cholangiopancreatography PA projection of, 124-125
indications and contraindications for, 214 of pancreatic ducts in, 178, 178f-179f body habitus and, 124-125, 125f
injection equipment for, 214 esophagus in central ray for, 124
lateral projection for, 220, 220f anatomy of, 97, 97f double-contrast, 124f
preliminary preparations for, 214 AP, PA, oblique, and lateral projections of, evaluation criteria for, 125b
retrograde 118, 118f-119f position of part for, 124, 124f
AP axial projection for, 216f-217f contrast media studies of, 115-117, 115f position of patient for, 124
AP oblique projection for, 218f-219f barium sulfate mixture for, 115 single-contrast, 124f
AP projection for, 215f double-contrast, 117, 117f structures shown on, 124-125, 125f
contrast injection technique for, 214, 215f examination procedure for, 116-117, sectional image of, 107f
Cystoureterography, 193, 193f, 214 116f-117f Dynamic rectal examination, 172, 172f
Cystourethrography, 193, 193f, 214 opaque foreign bodies in, 117, 117f
Index

female, 222-224, 222f PA oblique projection of distal (Wolf method), E

metallic bead chain, 222-224, 223f position of part for, 134, 134f EAM. See External acoustic meatus (EAM).
male, 221, 221f examination procedure for, 110-114 Ear, 270f, 271
voiding, 214, 215f exposure time for, 114 external
gastrointestinal transit in, 110 anatomy of, 270f, 271
D large intestine in. See Large intestine. internal, 269f-270f, 271
DBT (digital breast tomosynthesis), 374-375 preparation of examining room for, 114 middle, 270f, 271
DCIS (ductal carcinoma in situ), 395 radiation protection for, 114f, 115 ED (emergency department), 18
calcifications in, 392f radiologic apparatus for, 113, 113f Efferent arteriole of kidney, 185, 185f
DDH (developmental dysplasia of hip), 9t sample exposure technique chart essential Ejaculatory ducts, 242, 243f
Dedicated radiographic equipment for trauma, 20, projections for, 108t Eklund method or maneuver for mammography,
20f small intestine in. See Small intestine. 403t-408t
Defecography, 172, 172f stomach in. See Stomach. with craniocaudal (CC) projection, 422-423,
Deglutition in positive-contrast pharyngography, summary of pathology of, 109t 422f-423f
74-75, 74f summary of projections for, 96 with mediolateral oblique (MLO) projection,
Delayed cholangiography, 176-177, 176f-177f Digital breast tomosynthesis (DBT), 374-375 425
Demerol (meperidine hydrochloride), 226t Digital subtraction angiography (DSA) Elderly. See also Aging.
Dens for hip arthrography, 14, 15f Embryo, 241
anatomy of, 266f Diphenhydramine hydrochloride (Benadryl), 226t Emergency department (ED), 18
submentovertical projection of, 311f Diploë, 258f-259f, 259 Endometrial polyp, 245t
Depressed skull fracture, 282t Dislocation, 9t Endometrium
Dermoid cyst, 245t Distal convoluted tubule, 185, 185f anatomy of, 240
Developmental dysplasia of hip (DDH), 9t Diverticulitis, 109t Endoscopic retrograde cholangiopancreatography
Diagnostic enema through colostomy stoma, 170, Diverticulosis, 109t (ERCP), 178, 178f-179f
170f-171f Diverticulum, 109t Enema
Diagnostic medical sonography. Meckel, 109t barium. See Barium enema (BE).
See Ultrasonography. Zenker, 109t diagnostic through colostomy stoma, 170,
Diaphanography of breast, 473 Documentation 170f-171f
Diaphragm of medication administration, 235 Enteritis, regional, 109t
hiatal hernia of for trauma radiography, 30 Enteroclysis procedure, 141
AP projection of, 134, 135f Dolichocephalic skull, 286, 286f air-contrast, 141, 141f
defined, 109t Dopamine hydrochloride, 226t barium in, 141, 141f
PA oblique projection of (Wolf method), Dorsum sellae CT, 141, 142f
136-137, 136f-137f anatomy of, 258f, 264-265, 264f-265f iodinated contrast medium for, 141, 142f
upright lateral projection of, 135f AP axial projection of Enterovaginal fistula, 250, 250f-251f
Diazepam (Valium), 226t Haas method for, 309f Epididymis, 242, 242f-243f
Digestive system, 95-180 Towne method for, 305f abscess of, 253f
abbreviations used for, 107b PA axial projection of, 298f Epididymitis, 245t
abdominal fistulae and sinuses in, 180, 180f Double-contrast arthrography, 8-9 Epididymography, 253, 253f
anatomy of, 97-106, 97f of knee, 13, 13f Epididymovesiculography, 253
biliary tract and gallbladder in, 97f, 104-106, of shoulder, 10, 10f-11f Epiglottis, 71f, 72, 73f
104f-106f DSA. See Digital subtraction angiography (DSA). Epinephrine, 226t
esophagus in, 97, 97f Ductal carcinoma in situ (DCIS), 395 ERCP (endoscopic retrograde
large intestine in, 97f, 102-103, 102f-103f calcifications in, 392f cholangiopancreatography), 178, 178f-179f
liver in, 97f, 104-106, 104f-106f Ductal ectasia, 395 Esophageal stricture, 119, 119f
pancreas and spleen in, 97f, 106, 107f Ductography, 459-460, 459f-460f Esophageal varices, 109t, 119, 119f

e4
Esophagus External occipital protuberance Female reproductive system
anatomy of, 97, 97f anatomy of, 258f, 266, 266f-267f anatomy of, 239-241
AP oblique projection of, 118, 118f Extravasation, 235 fetal development in, 241, 241f
AP projection of, 116f, 118, 119f Eye ovaries in, 239, 239f
Barrett, 109t anatomy of, 314-316, 314f-315f summary of, 244b
contrast media studies of, 115-117, 115f lateral projection of, 317, 317f uterine tubes in, 239, 239f
barium administration and respiration for, 119, localization of foreign bodies within, 316, 316f uterus in, 240, 240f
119f PA axial projection of, 318, 318f vagina in, 240
barium sulfate mixture for, 115 parietoacanthial projection of (modified Waters radiography of, 246
double-contrast, 115, 117, 117f method), 319, 319f for imaging of female contraceptive devices,
examination procedures for, 116-117, preliminary examination of, 316 248, 248f-249f
116f-117f Eyeball, 314, 315f in nonpregnant patient, 246-251
single-contrast, 115, 116f-117f appointment date and care of patient for,
distal F 246
AP projection of, 119f Facial bones contrast media for, 246
PA oblique projection of (Wolf method), 117f, acanthioparietal projection of (reverse Waters hysterosalpingography for, 246-247,
136-137, 136f method), 327, 327f-328f 246f-247f
exposure time for, 114 for trauma, 328, 328f pelvic pneumography for, 246, 250,
lateral projection of, 116f, 118-119 anatomy of, 257, 257b, 259f 250f
oblique projections of, 118-119, 118f function of, 257 preparation of intestinal tract for, 246
opaque foreign bodies in, 117, 117f hyoid bone as, 257, 275, 275f radiation protection for, 246
PA projection of, 118, 118f-119f inferior nasal conchae as, 272f, 273 vaginography for, 246, 250-251,
Ethmoid bone lacrimal bones as, 272, 272f-273f 250f-251f
anatomy of, 262, 262f lateral projection of, 320-321, 320f, 322f in pregnant patient, 252
location of, 259f, 272f mandible as fetography for, 252, 252f
in orbit, 275, 275f, 312f anatomy of, 274, 274f pelvimetry for, 252
Ethmoidal air cells. See Ethmoidal sinuses. axiolateral oblique projection of, 343-345, placentography for, 252
Ethmoidal notch, 261, 261f 343f-345f radiation protection for, 252
Ethmoidal sinuses axiolateral projection of, 343-345, 343f Fetal development, 241, 241f
anatomy of, 276f-278f, 279 PA axial projection of body of, 342, 342f Fetography, 252, 252f

Index
CT of, 262f PA axial projection of rami of, 340, 340f Fetus, 241, 241f
lateral projection of, 359f PA projection of body of, 341, 341f FFDM. See Full-field digital mammography
location of, 261f-262f, 262 PA projection of rami of, 339, 339f (FFDM).
PA axial projection of, 360-361, panoramic tomography of, 353-354, Fibroadenoma, 385f, 395, 431f
360f-361f 353f-354f Fibroid, 245t, 247f
in facial bone radiography, 330f submentovertical projection of, 346, 346f Fimbriae
in skull radiography, 298f maxillary bones as, 259f, 272, 272f-273f anatomy of, 239, 239f
parietoacanthial projection of, 363f modified parietoacanthial projection of (modified Fine-needle aspiration biopsy (FNAB) of breast,
submentovertical projection of, 311f, 366-367, Waters method), 304, 325f-326f 461
366f-367f nasal bones as Fistula
EU. See Excretory urography (EU). anatomy of, 259f, 272 abdominal, 180, 180f
Eustachian tube, 270f, 271 lateral projection of, 331-332, 331f-332f defined, 62t
Evacuation proctography, 172, 172f orbits as of reproductive tract, 245t, 250, 250f-251f
Excretory cystography anatomy of, 275, 275f in urinary system, 188t
AP axial projection for, 217f lateral projection of, 317, 317f Flocculation-resistant preparations
AP oblique projection for, 219f localization of foreign bodies within, 316, for alimentary canal imaging, 111, 111f
Excretory system, 183 316f for large intestine contrast media studies, 144
Excretory urography (EU), 201-203 PA axial projection of, 318, 318f Fluoroscopic C-arm, mobile, 20, 21f
contraindications to, 201 parietoacanthial projection of (modified Fluoroscopic equipment
contrast media for, 194, 195f Waters method), 319, 319f for alimentary canal, 110, 113, 113f
defined, 191, 191f preliminary examination of, 316 for positive-contrast pharyngography, 75
equipment for, 198 radiography of, 312-313, 312f-313f FNAB (fine-needle aspiration biopsy) of breast,
indications for, 201 PA axial projection of (Caldwell method), 461
patient positioning for, 202, 202f 329-330, 329f-330f Focused abdominal sonography in trauma (FAST),
postvoiding, 203, 203f palatine bones as, 259f, 273 55
prevoiding, 203, 203f parietoacanthial projection of (Waters method), Fontanels, 259-260, 260f
radiation protection for, 201 323, 323f-324f Foot (feet)
radiographic procedure for, 202-203 vomer as, 259f, 272f, 273 toes of. See Toes.
time intervals for, 202f-203f, 203 zygomatic bones as, 272f-273f, 273 trauma radiography of, 52f
ureteral compression for, 200, 200f Facial trauma, acanthioparietal projection (reverse Foramen lacerum, 258f, 268
Explosive trauma, 19 Waters method) for, 46, 46f Foramen magnum
Exposure factors Falciform ligament anatomy of, 258f, 266, 266f-267f
for trauma radiography, 23, 23f anatomy of, 104, 105f AP axial projection of
Exposure time Fallopian tubes Haas method for, 309f
for gastrointestinal radiography, 114 anatomy of, 239, 239f-240f Towne method for, 305f-307f
External acoustic meatus (EAM) hydrosalpinx of, 246f Foramen ovale, 258f, 264f, 265
anatomy of, 271, 273f hysterosalpingography of, 246-247, Foramen rotundum, 264f, 265
in lateral aspect of cranium, 258f 246f-247f Foramen spinosum
with sphenoid bone, 264-265 FAST (focused abdominal sonography in trauma), anatomy of, 258f, 264f, 265
with temporal bones, 268, 268f-270f 55 submentovertical projection of, 311f
axiolateral oblique projection of, 352f Fat necrosis, 395 Forearm
as lateral landmark, 285f FB. See Foreign body (FB). AP projection of
lateral projection of, 293f, 322f Feet. See Foot (feet). for trauma, 47f-48f
in decubitus position, 295f Female contraceptive devices, 248, 248f-249f cross-table lateral projection for trauma of,
External ear Female cystourethrography, 222-224, 222f 47f-48f
anatomy of, 270f, 271 metallic bead chain, 222-224, 223f trauma radiography of, 47, 47f-48f

e5
 Foreign body (FB) Gonion, 274, 274f Hip arthrography (Continued)
in airway, 62t in lateral aspect of skull, 273f of hip prosthesis, 14, 15f
in orbit or eye, 316, 316f as surface landmark, 285f digital subtraction technique for, 14, 15f
lateral projection for, 317, 317f Graafian follicle, 239, 239f photographic subtraction technique for, 14,
PA axial projection for, 318, 318f Greater curvature of stomach 15f
parietoacanthial projection for (modified anatomy of, 98, 98f Hip prosthesis, contrast arthrography of, 14, 15f
Waters method), 319, 319f Greater duodenal papilla, 101 digital subtraction technique for, 14, 15f
preliminary examination for, 316 Greater wings of sphenoid photographic subtraction technique for, 14, 15f
Fracture(s) anatomy of, 258f, 259, 264f-265f, 265 Hirschsprung disease, 109t
of skull, 282t Grids History for trauma patient, 26
Frenulum of tongue, 59, 59f for mammography, 374 Horizontal plate of palatine bones, 273
Frontal angle of parietal bone, 263f in trauma radiography, 20 Horizontal ray method for contrast arthrography of
Frontal bone Gunson method for positive-contrast knee, 13, 13f
anatomy of, 261, 261f pharyngography, 75, 75f Horseshoe kidney, 188t
location of, 257f-259f Gynecography, 246, 250, 250f Humerus
in orbit, 275, 275f, 312f Gynecomastia, 426 AP projection of
PA axial projection of, 298f for trauma, 49, 49f
Frontal eminence, 261, 261f H Hydronephrosis, 188t
Frontal sinuses Haas method for PA axial projection of skull, Hydrosalpinx, 246f
anatomy of, 276f-278f, 279 308-309 Hydroxyzine hydrochloride (Vistaril), 226t
lateral projection of, 322f, 359f central ray for, 308, 308f Hyoid bone, 257, 275, 275f
location of, 259f, 261, 261f evaluation criteria for, 309b axiolateral oblique projection of, 344f
PA axial projection of (Caldwell method), 330f, position of part for, 308, 308f larynx and, 72f
360-361, 360f-361f position of patient for, 308 pharynx and, 72
parietoacanthial projection of, 363f structures shown on, 309, 309f in sagittal section of face and neck, 71f
Frontal squama, 261, 261f Hamartoma, 386f, 395 Hypersthenic body habitus
Full-field digital mammography (FFDM), 374-375 Hard palate, 59, 59f, 71f and gallbladder, 106, 106f
labeling for, 409 Haustra, 102, 102f skull radiography with, 289f-290f
technique chart for, 394t Head. See also Skull. and stomach and duodenum, 99, 99f, 125f
Fundus Head trauma Hypertension
Index

of stomach, 98, 98f acanthioparietal projection (reverse Waters renal, 188t

of uterus, 240, 240f method) for, 46, 46f Hypodermic needles, 228f, 229
AP axial projection (Towne method) for, 44-45, Hypoglossal canals, 258f, 267, 267f
G 44f-45f Hyposthenic body habitus
Galactocele, 395 CT of, 29, 29f, 53-55, 54f and gallbladder, 106, 106f
Gallbladder lateral projection for, 42-43, skull radiography with, 289f-290f
anatomy of, 97f, 100f, 104f-106f, 106 42f-43f and stomach and duodenum, 99, 99f, 125f
biliary drainage procedure and stone extraction Heat trauma, 19 Hypotonic duodenography, 123, 123f
for, 175, 175f Helix, 270f, 271 Hysterosalpingography (HSG), 246-247, 247f
and body habitus, 106, 106f Hematoma, 395 of bicornuate uterus, 247f
cholangiography of Hemopneumothorax, 37f of fibroid, 247f
percutaneous transhepatic, 174-175, 174f Hepatic artery of hydrosalpinx, 246f
postoperative (T-tube), 176-177, 176f-177f anatomy of, 104 of IUD, 248f
endoscopic retrograde cholangiopancreatography Hepatic ducts
of, 178, 178f-179f anatomy of, 105 I
prefixes associated with, 173, 173t Hepatic flexure IAM (internal acoustic meatus), 259f, 268, 268f,
radiographic techniques for, 173 anatomy of, 102f, 103 270f, 271
Gallstone(s) Hepatic veins ID technique. See Implant displacement (ID)
extraction of, 175, 175f anatomy of, 104, 105f technique.
Gas bubble, 98 Hepatopancreatic ampulla Ileocecal studies, 139, 140f
Gastritis, 109t anatomy of, 100f, 101, 105, 106f Ileocecal valve
Gastroesophageal reflux, 109t Hernia anatomy of, 102, 102f
Gastrointestinal (GI) intubation, 143, 143f hiatal Ileum
Gastrointestinal (GI) series, 120, 120f AP projection of, 134, 135f anatomy of, 100f, 101, 102f
barium sulfate suspension for, 120 defined, 109t Ileus, 84t, 109t
biphasic, 123 PA oblique projection of (Wolf method), Image enhancement methods for mammography,
components of, 120 136-137, 136f-137f 427
double-contrast, 122, 122f upright lateral projection of, magnification technique (M) as, 403t-408t,
for nonambulatory patients, 120 135f 428-429, 428f-429f, 432t
preparation of patient for, 120 inguinal, 109t spot compression technique as, 403t-408t,
single-contrast, 121, 121f Hiatal hernia 429-431, 430f-431f, 432t
Gastrointestinal (GI) system. See Digestive system. AP projection of, 134, 135f Image intensification system, 113, 113f
Gastrointestinal (GI) transit, 110 defined, 109t Image receptor (IR)
GI. See Gastrointestinal (GI). PA oblique projection of (Wolf method), size of
Glabella 136-137, 136f-137f for trauma radiography, 30
in anterior aspect of cranium, 257f upright lateral projection of, 135f Image receptor (IR) holders for trauma
with frontal bone, 261f Hip(s) radiography, 20
in lateral aspect of cranium, 258f in children Immobilization devices
in skull topography, 285f developmental dysplasia of, 9t trauma radiography with, 23, 23f, 28, 30
Glabelloalveolar line, 285f congenital dislocation of Immobilization techniques
Glomerular capsule, 185, 185f contrast arthrography of, 8f, 14, 14f for abdominal radiography, 86, 87f
Glomerulonephritis, 188t developmental dysplasia of, 9t Implant displacement (ID) technique for
Glomerulus, 185, 185f Hip arthrography, 14 mammography, 403t-408t
Glottis, 73 AP oblique, 14f with craniocaudal (CC) projection, 422-423,
Glucagon, 106, 226t axiolateral “frog”, 14f 422f-423f
Gonad(s), 242 with congenital dislocation, 8f, 14, 14f with mediolateral oblique (MLO) projection, 425

e6
Implantation, 241 J Ligament tear, 9t
Incus, 271 Jejunum Limb(s). See Lower limb; Upper limb.
Infection control anatomy of, 100f, 101 Linear skull fracture, 282t
for venipuncture, 228 Joint capsule tear, 9t Lipoma, 386f, 395, 447f
Inferior mesenteric vein Jugular foramen, 258f, 267 Liver
anatomy of, 105f Jugular process, 267f anatomy of, 104-106, 104f-105f
Inferior nasal conchae functions of, 104
anatomy of, 272f, 273 K sectional image of, 107f
Inferior orbital fissure, 272f, 312f, 313 Kidney(s), 184-185 Lobes of breast, 380
Inferior orbital margin anatomy of, 184-185, 185f Lobular carcinoma in situ (LCIS), 395
modified Waters method for parietoacanthial angiography of, 190, 191f Lobules of breast, 380, 381f
projection of, 326f CT of, 190, 191f Long bone measurement, 1-6
PA axial projection of, 298f function of, 183 abbreviations for, 2b
Inferior vena cava (IVC) horseshoe, 188t bilateral, 4-5, 4f
anatomy of, 105f location of, 183f-184f, 184 CT for, 6, 6f
sectional image of, 107f nephrotomography of, 190, 191f digital imaging for, 2
Infiltration, 235 AP projection in, 209, 209f digital postprocessing for, 2
Inframammary crease, 381f percutaneous renal puncture for, 210-211, imaging methods for, 2
Infraorbital foramen, 272, 272f 210f with leg length discrepancy, 4f-5f, 5
Infraorbital margin, 285f, 330f pelvic, 188t localization of joints in, 2-5
Infraorbitomeatal line (IOML), 44, 320, polycystic, 188t magnification in, 2-3, 3f
346 sectional image of, 107f orthoroentgenogram for, 2-3, 3f
Infundibulum, 239, 239f urography of. See Urography. position of part for, 2
Inguinal hernia, 109t Kleinschmidt, Otto, 372 position of patient for, 2
Inion, 258f, 266, 266f Knee radiation protection for, 2
Inner canthus, 285f contrast arthrography of, 12 scanogram for, 2
Insulin, 106 double-contrast (horizontal ray method), 13, teleoroentgenogram for, 2
Internal acoustic meatus (IAM), 259f, 268, 268f, 13f unilateral, 4f-5f, 5
270f, 271 vertical ray method for, 12, 12f of upper limb, 2, 5, 5f
Internal mammary lymph nodes, 380, 381f KUB projection of abdomen, 87, 89-90, 89f-90f Loop of Henle, 185, 185f

Index
Internal occipital protuberance Lower limb
anatomy of, 266, 267f L dislocation-fracture of, 51f
Interpupillary line, 285f Labyrinths foot (feet) of. See Foot (feet).
Intersinus septum, 276f, 279 anatomy of, 262 long bone measurement of. See Long bone
Intestinal intubation, 143, 143f Lacrimal bones measurement.
Intestinal tract preparation anatomy of, 272, 272f-273f toes of. See Toes.
for contrast media studies in orbit, 275, 275f, 312f trauma radiography of, 50-53
of colon, 146, 146f Lacrimal foramen, 272 patient position considerations for, 22f-23f, 50
of urinary system, 196-197, 196f-197f Lacrimal fossae, 272 structures shown on, 52-53, 52f
for female reproductive system radiography, Lacrimal sac, 314f trauma positioning tips for, 50, 50f
246 Lactation, breasts during, 382, 382f Lumbar vertebrae
Intrauterine devices (IUDs) Lactiferous ductules, 380, 381f AP projection of
imaging of, 248, 248f-249f Lambda, 258f, 259 for trauma, 36-37, 36f-37f
Intravenous (IV) medication administration. Lambdoidal suture, 258f, 259, 275t fracture-dislocation of, 35f
See Venipuncture. Large intestine. See Colon. lateral projection of
Intravenous urography (IVU). See Excretory Large-core needle biopsy (LCNB) of breast, 461 for trauma, 35, 35f
urography (EU). Laryngeal cavity, 73 trauma radiography of
Intubation examination procedures for small Laryngeal vestibule, 73 AP projection in, 36-37, 36f-37f
intestine, 143, 143f Laryngopharynx, 71f, 72 lateral projections in, 35, 35f
Intussusception, 109t Larynx
Invasive/infiltrating ductal carcinoma, 395, 449f, anatomy of, 71f-73f, 72-73 M
458f AP projection of, 76-77, 76f-77f M (magnification technique) for mammography,
architectural distortion due to, 393f lateral projection of, 78-79, 78f-79f 403t-408t, 428-429, 428f-429f, 432t
Involution of breasts, 380 methods of examination of, 74-75 Magnetic resonance imaging (MRI)
Iodinated contrast media Lateral meniscus of breast, 418-419, 472
for alimentary canal imaging, 111-112, double-contrast arthrography of, 13, 13f Magnetic resonance (MR) mammography, 418-419,
111f-112f Lateral pterygoid lamina, 265f, 266 472
for large intestine studies, 145 Law method (modified) for axiolateral oblique Magnification technique (M) for mammography,
for urinary system imaging, adverse reactions to, projection of TMJ, 345f, 351-352, 351f-352f 403t-408t, 428-429, 428f-429f, 432t
196 LCIS (lobular carcinoma in situ), 395 Major calyx(ces), 185, 185f
IOML (infraorbitomeatal line), 44, 320, 346 LCNB (large-core needle biopsy) of breast, 461 Major duodenal papilla, 100f, 105, 105f
IR. See Image receptor (IR); Interventional Le Fort fracture, 282t Malabsorption syndrome, 109t
radiology (IR). Left colic flexure, 102f, 103, 114f Male(s)
Iris, 314f, 315 Leg. See Lower limb. calcifications of breast in, 427
Islet cells, 106 Lens cystourethrography in, 221, 221f
Islets of Langerhans, 106 anatomy of, 314f-315f mammography in, 426, 426f-427f
Isthmus Lesser curvature of stomach Male reproductive system
of uterine tube, 239, 239f anatomy of, 98, 98f anatomy of, 242
of uterus, 240, 240f Lesser wings of sphenoid ductus deferens in, 242, 242f-243f
IUDs (intrauterine devices) anatomy of, 258f, 264f-265f, 265 ejaculatory ducts in, 242, 243f
imaging of, 248, 248f-249f Level I trauma center, 19 prostate in, 242f-243f, 243
IV (intravenous) medication administration. Level II trauma center, 19 seminal vesicles in, 242, 243f
See Venipuncture. Level III trauma center, 19 summary of, 244b
IVC. See Inferior vena cava (IVC). Level IV trauma center, 19 testes in, 242, 242f
IVU (intravenous urography). See Excretory Ligament of Treitz radiography of, 253-254
urography (EU). anatomy of, 100f, 101 of prostate, 254

e7
 Male reproductive system (Continued)
of seminal ducts, 253
epididymography for, 253, 253f
epididymovesiculography for, 253
grid technique for, 253
nongrid technique for, 253
vesiculography for, 253, 254f
Malleus, 271
Mammary fat, 381f
Mammary gland. See Breast(s).
Mammography, 369-474
artifacts on, 396, 396f
of augmented breast, 417-419, 418f
craniocaudal (CC) projection of
with full implant, 420-421, 421f
with implant displaced, 422-423, 422f-423f
with implant displacement (ID), 403t-408t
mediolateral oblique (MLO) projection of
with full implant, 424
with implant displaced, 425
automatic exposure control for, 409
for breast cancer screening, 377
vs. diagnostic mammography, 378
risk vs. benefit of, 377-378, 377f
comfort measures for, 374, 409, 410f
compression in, 402
computer-aided detection (CAD) systems for,
376-379, 376f
descriptive terminology for lesion location in,
411, 413f
Index
equipment for, 373-374, 373f
evolution of systems for, 373, 373f
findings on, 384-393
architectural distortions as, 393, 393f
calcifications as, 389-393, 389f-392f
masses as, 384-388, 385f-388f
full-field digital, 374-375
labeling for, 409
technique chart for, 394t
grids for, 374
historical development of, 371-372, 371f-372f
image enhancement methods for, 427
magnification technique (M) as, 403t-408t,
428-429, 428f-429f, 432t
spot compression technique as, 403t-408t,
429-431, 430f-431f, 432t
labeling in, 402, 402f, 403t-408t
during lactation, 382, 382f
magnetic resonance (MR), 418-419, 472
male, 426, 426f-427f
method of examination for, 396
mosaic imaging or tiling in, 400, 401f
of oversized breasts, 400, 401f
patient preparation for, 396, 396f-399f
posterior nipple line in, 409, 410f
principles of, 371-374
procedures for, 400-409, 401f
respiration during, 409
routine projections in, 411
craniocaudal (CC), 403t-408t, 411f, 413-414,
413f-414f
mediolateral oblique (MLO), 403t-408t, 411f,
415-416, 415f-416f
screening, 377
diagnostic vs., 378
risk vs. benefit of, 377-378, 377f
standards for, 373, 377
summary of projections in, 370-379, 411, 411t-412t
supplemental projections in, 432-457
90-degree lateromedial (LM), 411f, 435-436
applications of, 403t-408t, 432t
evaluation criteria for, 436b
labeling codes for, 403t-408t
position of part for, 435, 435f
position of patient for, 435
structures shown on, 436, 436f
e8
Mammography (Continued)
90-degree mediolateral (ML), 411f,
433-434
applications of, 403t-408t, 432t
evaluation criteria for, 434b, 434f
labeling codes for, 403t-408t
position of part for, 433, 433f
position of patient for, 433
structures shown on, 434
axillary for axillary tail as, 452-453,
452f-453f
captured lesion or coat-hanger (CL), 445,
446f-447f
applications of, 403t-408t, 432t
labeling codes for, 403t-408t
caudocranial (FB), 412f, 448-449
applications of, 403t-408t, 432t
evaluation criteria for, 449b
labeling codes for, 403t-408t
position of part for, 448, 448f
position of patient for, 448
structures shown on, 449, 449f
craniocaudal for cleavage (cleavage view, CV)
as, 412f, 439-440
applications of, 403t-408t, 432t
evaluation criteria for, 440b, 440f
labeling codes for, 403t-408t
position of part for, 439, 439f
position of patient for, 439
structures shown on, 440
craniocaudal with roll lateral (rolled lateral,
RL), 412f, 441-442
applications of, 403t-408t, 432t
evaluation criteria for, 442b
labeling codes for, 403t-408t
position of part for, 441, 441f
position of patient for, 441
structures shown on, 442, 442f
craniocaudal with roll medial (rolled medial,
RM), 412f, 441-442
applications of, 403t-408t, 432t
evaluation criteria for, 442b
labeling codes for, 403t-408t
position of part for, 441, 441f
position of patient for, 441
structures shown on, 442
elevated or pushed-up craniocaudal (ECC),
403t-408t
exaggerated craniocaudal (XCCL), 412f,
437-438
applications of, 403t-408t, 432t
evaluation criteria for, 438b, 438f
labeling codes for, 403t-408t
position of part for, 437, 437f
position of patient for, 437
structures shown on, 438
inferolateral to superomedial oblique (LMO),
403t-408t
inferomedial to superolateral oblique (ISO),
403t-408t
lateromedial oblique (LMO), 412f, 454-455,
454f-455f
mediolateral oblique for axillary tail, 412f,
432t, 450-451, 450f-451f
superolateral to inferomedial oblique (SIO),
412f, 456-457
applications of, 403t-408t, 432t
evaluation criteria for, 457b
labeling codes for, 403t-408t
position of part for, 456, 456f
position of patient for, 456
structures shown on, 457, 458f
tangential (TAN), 412f, 443
applications of, 403t-408t, 432t
evaluation criteria for, 443b
labeling codes for, 403t-408t
Mammography (Continued)
position of part for, 443, 443f-444f
position of patient for, 443
structures shown on, 443, 444f
xero-, 372, 372f
Mammography Quality Standards Act (MQSA),
377
Mandible
alveolar portion of, 274, 274f
anatomy of, 272f-274f, 274
axiolateral oblique projection of, 343-345
evaluation criteria for, 345b
position of part for, 343, 343f-344f
position of patient for, 343
structures shown on, 343-345, 344f-345f
axiolateral projection of, 343-345, 343f
body of
anatomy of, 274, 274f
axiolateral oblique projection of, 344f-345f
axiolateral projection of, 343f-344f
PA axial projection of, 340f, 342, 342f
PA projection of, 339f, 341, 341f
submentovertical projection of, 346f
lateral projection of, 322f
modified Waters method for parietoacanthial
projection of, 326f
panoramic tomography of, 353-354, 353f-354f
rami of
anatomy of, 274, 274f
AP axial projection of, 348f
axiolateral oblique projection of, 344f-345f,
345
axiolateral projection of, 343f, 345, 345f
lateral projection in decubitus position of,
295f
PA axial projection of, 340, 340f, 342f
PA projection of, 339, 339f, 341f
submentovertical projection of, 346f
submentovertical projection of, 311f, 346, 346f,
367f
symphysis of
anatomy of, 274, 274f
axiolateral oblique projection of, 345, 345f
axiolateral projection of, 343f-344f, 345
PA axial projection of, 342f
PA projection of, 341f
submentovertical projection of, 346f
Mandibular angle
anatomy of, 274, 274f
axiolateral oblique projection of, 344f-345f
in lateral aspect of skull, 273f
parietoacanthial projection of, 324f
modified, 326f
as surface landmark, 285f
Mandibular condyle
anatomy of, 273f-274f, 274
AP axial projection of, 306f, 348f
axiolateral oblique projection of, 345f, 352f
PA axial projection of, 342f
PA projection of, 339f
submentovertical projection of, 311f, 346f
Mandibular fossa
anatomy of, 268, 268f, 274f
axiolateral oblique projection of, 352f
Mandibular notch, 273f-274f, 274
Markers
for trauma radiography, 24, 24f
Mastication, 59
Mastoid air cells
anatomy of, 268, 269f-270f
AP axial projection of, 309f
PA projection of, 339f
parietoacanthial projection of, 363f
Mastoid angle of parietal bone, 263f
Mastoid antrum, 269f-270f, 271
Mastoid fontanel, 259-260, 260f
Mastoid process N Open surgical biopsy of breast, 461
anatomy of, 258f, 268, 268f-269f Nasal bones Optic canal
PA axial projection of, 342f anatomy of, 259f, 272, 273f anatomy of, 312f, 314f
submentovertical projection of, 311f lateral projection of, 322f, 331-332, 331f-332f correct and incorrect rotation for, 287, 287f
Mastoidian cells, 269f Nasal conchae in lateral aspect of cranium, 258f
Mastoiditis, 282t anatomy of, 262, 262f with sphenoid bone, 264f-265f, 265
Maxilla. See Maxillary bones. Nasal septum Optic foramen
Maxillary bones anatomy of, 71f, 273 anatomy of, 312f, 314f
anatomy of, 259f, 272, 272f-273f modified Waters method for parietoacanthial in anterior aspect of cranium, 257f
lateral projection of, 322f projection of, 326f and apex of orbit, 312
in orbit, 275, 275f, 312f Nasal spine, 261, 261f with facial bones, 272f
parietoacanthial projection of, 324f Nasion, 261, 261f, 285f in lateral aspect of cranium, 258f
modified, 326f Nasofrontal suture, 332f with sphenoid bone, 265, 265f
Maxillary sinuses Nasopharynx Optic groove, 258f, 264f, 265
acanthioparietal projection of, 328f anatomy of, 71f, 72 Optic nerve
anatomy of, 276, 276f-278f National Trauma Database (NTDB), 18-19, 18f-19f anatomy of, 314, 314f-315f
lateral projection of, 322f, 359f Neck Oral cavity. See Mouth.
location of, 272 anterior part of, 69-79 Oral vestibule, 59
parietoacanthial projection of, 363f, 365f anatomy of, 71, 71f Orbit(s)
Waters method for, 324f, 362-363, 362f-363f larynx in, 71f-73f, 72-73 acanthioparietal projection of, 328f
open-mouth, 364-365, 364f-365f parathyroid glands in, 71, 72f anatomy of, 275, 275f, 312, 312f
submentovertical projection of, 311f, 367f pharynx in, 71f, 72 blowout fracture of, 46f, 282t, 313, 313f
Mean glandular dose, 377, 377f summary of, 73b functions of, 313
Meckel diverticulum, 109t thyroid gland in, 71, 72f lateral projection of, 317, 317f
Medial meniscus radiography of, 74-79 localization of foreign bodies within, 316, 316f
double-contrast arthrography of, 13, 13f AP projection of pharynx and larynx in, PA axial projection of, 318, 318f
Medial orbital wall, 262f 76-77, 76f-77f parietoacanthial projection of, Waters method
Medial pterygoid lamina, 265f, 266 deglutition in, 74-75, 74f for, 324f
Medication administration via venipuncture. fluoroscopic, 75 modified, 319, 319f
See Venipuncture. Gunson method for, 75, 75f preliminary examination of, 316

Index
Megacolon, congenital aganglionic, 109t lateral projection of soft palate, pharynx, radiography of, 312-313, 312f-313f
Membranous labyrinth, 271 and larynx in, 78-79, 78f-79f Orbital base, 312
Membranous urethra, 186f, 187 methods of examination for, 74-75 Orbital fat, 314f
Meniscus tear, 9t positive-contrast pharyngography for, 74-75 Orbital floor, blowout fracture of, 46f
Menstrual cycle, 240 summary of projections for, 70 Orbital plates, 258f, 261, 261f
Mental foramen, 273f-274f, 274 Neck brace, trauma radiography with, 23, 23f Orbital roof
Mental point, 285f Needle(s) lateral projection of, 295f
Mental protuberance, 272f, 274, 274f for venipuncture, 228-229, 228f Orbital wall, medial, 262f
Mentomeatal line, 327f-328f anchoring of, 233, 233f Orbitomeatal line (OML), 44
Meperidine hydrochloride (Demerol), 226t discarding of, 234, 234f Oropharynx, 59, 71f, 72
Mesentery Needle-wire localization of breast lesion, 461-463 Osteoma
anatomy of, 83 Neonate, cranial bones in, 259-260, 260f of skull, 282t
Mesocephalic skull, 286, 286f Nephron, 185, 185f Osteomyelitis, 282t
Mesovarium, 239 Nephron loop, 185, 185f Osteopetrosis
Metallic bead chain cystourethrography, 222-224, Nephrotomography, 190, 191f, 202 of skull, 282t
223f AP projection in, 209, 209f Osteoporosis
Metastasis(es) percutaneous renal puncture for, 210-211, 210f of skull, 282t
to abdomen, 84t Nephrourography, infusion, equipment for, 198 Outer canthus, 285f
to skull, 282t Neuroma, acoustic, 282t Oval window, 270f, 271
Micturition, 186 Newborn. See Neonate. Ovarian follicles, 239, 239f
Midazolam hydrochloride (Versed), 226t Nipple Ovarian ligament, 240f
Middle cranial fossa, 260 anatomy of, 380, 381f Ovaries
Middle nasal concha ductography of, 459-460, 459f-460f anatomy of, 239, 239f-240f
anatomy of, 262, 262f in mammography, 402 Over-the-needle cannula, 228f, 229
Midsagittal plane, 285f Paget disease of, 395 Ovulation, 239
Milk ducts, examination of, 459-460, 459f-460f Noctec (chloral hydrate), 226t Ovum(a), 239
Milk of calcium, 391, 391f, 395 NTDB (National Trauma Database), 18-19, 18f-19f
Miller-Abbott tube, 143, 143f Nulliparous uterus, 240 P
Minor calyx(ces), 185, 185f Paget disease
Mobile radiography O of nipple, 395
for trauma patients, 21f, 32 Occipital angle of parietal bone, 263f of skull, 282t
Morphine sulfate, 226t Occipital bone Palatine bones
Motion control anatomy of, 266-267, 266f-267f anatomy of, 259f, 273
for trauma radiography, 23, 23f AP axial projection of, 305f-306f in orbit, 275, 275f
Mouth, 57-67 fracture of, 44f Palatine tonsil, 59, 59f
anatomy of, 59, 59f, 61b location of, 258f-259f Pancreas
salivary glands of. See Salivary glands. PA axial projection of, 309f anatomy of, 97f, 100f, 105f, 106, 107f
summary of pathology of, 62t submentovertical projection of, 311f endocrine, 106
summary of projections of, 58-59 Occipital condyles, 266-267, 266f exocrine, 106
MR (magnetic resonance) mammography, 418-419, Occipitoatlantal joints, 267 functions of, 106
472 Odontoid process. See Dens. sectional image of, 107f
MRI. See Magnetic resonance imaging (MRI). Oil cyst, 386f Pancreatic duct
Multiple myeloma Older adults. See Aging; Elderly. anatomy of, 100f, 105f, 106
of skull, 282t Omentum(a), 83, 83f Pancreatic juice, 106
Myeloma, multiple OML (orbitomeatal line), 44 Pancreatic pseudocyst, 109t
of skull, 282t Opaque arthrography, 8-9, 8f Pancreatitis, 109t

e9
 Pangynecography, 246, 250, 250f Pectoralis minor muscle Porta hepatis
Panoramic tomography of mandible, 353-354, anatomy of, 380f anatomy of, 104
353f-354f Pelvic cavity, 83 Portal system, 104, 105f
Pantomography of mandible, 353-354, 353f-354f Pelvic kidney, 188t Portal vein
Papilloma, 395 Pelvic pneumography, 246, 250, 250f anatomy of, 104, 105f
with atypia, 395 Pelvicaliceal system, 183 Positioning aids for trauma radiography, 20
Paranasal sinuses retrograde urography of, 212-213, 212f-213f Positive-contrast pharyngography, 74-75
anatomy of, 276-279, 276f-278f Pelvimetry, 252 deglutition in, 74-75, 74f
ethmoidal Pelvis fluoroscopic, 75
anatomy of, 276f-278f, 279 AP projection of Gunson method for, 75, 75f
CT of, 262f for trauma, 41, 41f Posterior arches of soft palate, 59, 59f
location of, 261f-262f, 262 CT of, 55 Posterior clinoid processes
PA axial projection of anterior (Caldwell trauma radiography of, 41, 41f anatomy of, 258f, 264-265, 264f-265f
method), 360-361, 360f-361f true or lesser, 83 AP axial projection of
submentovertical projection of, 366-367, Penetrating trauma, 19 Haas method for, 309f
366f-367f Penis, 242, 243f Towne method for, 305f
frontal Percutaneous antegrade pyelography, 211, 211f Posterior cranial fossa, 260
anatomy of, 276f-278f, 279 Percutaneous antegrade urography, 191 Posterior fontanel, 259-260, 260f
location of, 259f, 261, 261f Percutaneous renal puncture, 210-211, 210f-211f Posterior nipple line (PNL), 409, 410f
PA axial projection of (Caldwell method), Percutaneous transhepatic cholangiography (PTC), Postoperative cholangiography, 176-177, 176f-177f
360-361, 360f-361f 174-175, 174f Pregnancy
lateral projection of, 358, 358f-359f Peristalsis, 110 breasts during, 382
maxillary Peritoneal cavity, 83, 83f radiography of female reproductive system
anatomy of, 276, 276f-278f Peritoneum during, 252
location of, 272 anatomy of, 83, 83f fetography for, 252, 252f
parietoacanthial projection of Perpendicular plate pelvimetry for, 252
open-mouth Waters method for, 364-365, anatomy of, 262, 262f placentography for, 252
364f-365f CT of, 262f radiation protection for, 252
Waters method for, 362-363, 362f-363f Petrosa, submentovertical projection of, 311f, 367f Proctography, evacuation, 172, 172f
sphenoidal Petrous apex, 268, 269f Promethazine hydrochloride (Phenergan), 226t
Index

anatomy of, 276f-278f, 279 Petrous portion of temporal bone, 258f-259f Prostate
location of, 259f, 264-265, 264f-265f Petrous pyramids, 268, 286 anatomy of, 184f, 186f, 187, 242f-243f, 243
parietoacanthial projection of (open-mouth Petrous ridge radiologic examination of, 214, 254
Waters method), 364-365, 364f-365f acanthioparietal projection of, 328f Prostate cancer, 245t
submentovertical projection of, 366-367, anatomy of, 268, 269f Prostatic hyperplasia, benign, 188t
366f-367f AP axial projection of Prostatic urethra, 186f, 187
technical considerations for radiography of, Haas method for, 309f Prostatography, 214, 254
355-357 Towne method for, 305f-306f Proximal convoluted tubule, 185, 185f
body position and central ray angulation as, PA axial projection of, 298f, 330f Pseudocyst, pancreatic, 109t
356, 356f-357f parietoacanthial projection of, 324f, 363f PTC (percutaneous transhepatic cholangiography),
exposure level as, 355, 355f submentovertical projection of, 346f 174-175, 174f
exudate as, 356 Pharyngeal tonsil, 71f, 72 Pterion, 258f, 259
Parathyroid glands, 71, 72f Pharyngography, positive-contrast, 74-75 Pterygoid hamulus, 259f, 265f, 266
Parietal bones deglutition in, 74-75, 74f Pterygoid laminae, 265f, 266
anatomy of, 263, 263f fluoroscopic, 75 Pterygoid processes
AP axial projection of, 305f Gunson method for, 75, 75f anatomy of, 265f, 266
location of, 257f-259f Pharynx Pupil, 314f
PA axial projection of, 298f anatomy of, 71f, 72, 97f Pyelography, 191
Parietal eminence, 263, 263f AP projection of, 76-77, 76f-77f percutaneous antegrade, 211, 211f
Parietal peritoneum, 83, 83f lateral projection of, 78-79, 78f-79f Pyelonephritis, 188t
Parietoacanthial projection methods of examination of, 74-75 Pyloric antrum
of facial bones, 323, 323f-324f positive-contrast pharyngography of, 74-75 anatomy of, 98, 98f
modified, 304, 325f-326f deglutition in, 74-75, 74f Pyloric canal
of maxillary sinuses fluoroscopic, 75 anatomy of, 98, 98f
Waters method for, open-mouth, 364-365, Gunson method for, 75, 75f Pyloric orifice, 98f, 99
364f-365f Phenergan (promethazine hydrochloride), 226t Pyloric portion of stomach, 98, 100f
Waters methods for, 362-363, 362f-363f Phleboliths, 188t Pyloric sphincter
of orbit, 319, 319f Photographic subtraction technique for hip anatomy of, 98f, 99
of sphenoidal sinuses, 364-365, 364f-365f arthrography, 14, 15f Pyloric stenosis, 109t
Parotid duct, 60, 60f Piriform recess, 71f, 72
Parotid gland Pituitary adenoma, 282t R
anatomy of, 60, 60f, 97f Pituitary gland Radial scar, 395
lateral projection of, 66-67, 67f anatomy of, 264-265 Radiation protection
sialography of, 63f Placenta for female reproductive system radiography, 246
tangential projection of, 64-65 anatomy of, 241, 241f during pregnancy, 252
evaluation criteria for, 65b previa, 241, 241f for gastrointestinal radiography, 114f, 115
position of part for, 64-65, 64f Placentography, 252 for long bone measurement, 2
position of patient for, 64 Pneumoarthrography, 8-9 for skull, 288
in prone body position, 64f, 65 Pneumoperitoneum, 84t for trauma radiography, 25
structures shown on, 64f-65f, 65 PNL (posterior nipple line), 409, 410f for urinary system, 201
in supine body position, 64, 64f Polycystic kidney, 188t Radiopaque markers for trauma radiography, 24,
Patient care for trauma patient, 26, 27t Polyp, 109t 24f
Patient positioning for trauma radiography, 24, 24f, cranial, 282t Rectal ampulla, 103, 103f
28 endometrial, 245t Rectal examination, dynamic, 172, 172f
Pectoralis major muscle Pons Rectosigmoid junction, axial projection of
anatomy of, 380, 380f-381f anatomy of, 259f (Chassard-Lapiné method), 169, 169f

e10
Rectovaginal fistula, 251f Salivary glands Skull (Continued)
Rectum anatomy of, 60-62, 60f-61f, 61b, 97f structures shown on, 304, 305f
anatomy of, 97f, 102f-103f, 103 lateral projection of parotid and submandibular variations of, 302
axial projection of (Chassard-Lapiné method), glands for, 66-67, 66f-67f articulations of, 275, 275t
169, 169f sialography of, 62-63, 62f-63f temporomandibular. See Temporomandibular
defecography of, 172, 172f summary of pathology of, 62t joint (TMJ).
Regional enteritis, 109t summary of projections of, 58-59 asymmetry of, 286
Renal angiography, 190, 191f tangential projection of parotid gland for, 64-65 brachycephalic, 286, 286f
Renal arteriography, 190, 191f evaluation criteria for, 65b cleanliness in imaging of, 288
Renal calculus, 188t, 190f position of part for, 64-65, 64f correct and incorrect rotation of, 287, 287f
Renal calyx(ces) position of patient for, 64 cranial bones of. See Cranial bones.
anatomy of, 183, 185, 185f in prone body position, 64f, 65 dolichocephalic, 286, 286f
Renal capsule, 184, 185f structures shown on, 64f-65f, 65 ear in, 270f, 271
Renal cell carcinoma, 188t in supine body position, 64, 64f eye in
Renal columns, 185, 185f Sarcoma anatomy of, 314-316, 314f-315f
Renal corpuscle, 185 of breast, 395 lateral projection of, 317, 317f
Renal cortex, 185, 185f Schatzki ring, 119f localization of foreign bodies within, 316,
Renal cyst, 210f-211f Schüller method 316f
Renal fascia for axiolateral projection of TMJ, 349-350 PA axial projection of, 318, 318f
anatomy of, 184 evaluation criteria for, 350b parietoacanthial projection of (modified
Renal hilum, 184, 185f position of part in, 349, 349f-350f Waters method), 319, 319f
Renal hypertension, 188t position of patient in, 349 preliminary examination of, 316
Renal medulla, 185, 185f structures shown on, 350, 350f facial bones of. See Facial bones.
Renal obstruction, 188t for submentovertical projection of cranial base, general body position for, 288
Renal papilla, 185, 185f 310-311 adjusting OML to vertical position in,
Renal parenchyma, nephrotomography of, 209, central ray for, 310f, 311 290f
209f evaluation criteria for, 311b adjusting sagittal planes to horizontal position
Renal pelvis position of part for, 310-311, 310f in, 289f
anatomy of, 183, 185, 185f position of patient for, 310 lateral decubitus position of
Renal puncture, percutaneous, 210-211, 210f-211f structures shown on, 311, 311f for pathologic conditions, trauma, or

Index
Renal pyramids, 185, 185f Sclera, 315 deformity, 306
Renal sinus, 184, 185f Scout image for stretcher and bedside examinations,
Renal tubule, 185 of abdomen, 87 299-300, 299f
Reproductive system, 237-254 Scrotum, 242 lateral projection of
abbreviations used for, 245b Sella turcica in dorsal decubitus or supine lateral position,
female. See Female reproductive system. anatomy of, 258f, 264-265, 264f-265f 294-300, 295f
male. See Male reproductive system. lateral projection of, 293f, 322f, 359f in R or L position, 291, 292f-293f
summary of pathology of, 245t in decubitus position, 295f mesocephalic, 286, 286f
summary of projections for, 238 Semicircular canals, 269f-270f, 271 morphology of, 286-287, 286f-287f
Retina, 314f, 315 Seminal duct radiography, 253 PA axial projection of
Retroareolar cyst, 385f epididymography for, 253, 253f Caldwell method for, 296-300
Retrograde cystography epididymovesiculography for, 253 evaluation criteria for, 299b
AP axial projection for, 216f-217f grid technique for, 253 position of part for, 296, 297f
AP oblique projection for, 218f-219f nongrid technique for, 253 position of patient for, 296
AP projection for, 215f vesiculography for, 253, 254f structures shown on, 298f, 299
contrast injection technique for, 214, 215f Seminal vesicles Haas method for, 308-309
Retrograde urography, 192f, 193 anatomy of, 242, 243f central ray for, 308, 308f
AP projection for, 212-213, 212f-213f tuberculous, 254f evaluation criteria for, 309b
contrast media for, 194, 195f Seminoma, 245t position of part for, 308, 308f
defined, 193 Serratus anterior muscle position of patient for, 308
preparation of patient for, 197 anatomy of, 380, 380f structures shown on, 309, 309f
Retromammary fat, 381f Shoulder radiation protection for, 288
Retroperitoneum AP oblique projection for trauma of, 48, 48f-49f sample exposure technique chart essential
anatomy of, 83, 83f trauma radiography of, 48, 48f-49f projections for, 283t-284t
sectional image of, 107f Shoulder arthrography, 10-11 sinuses of. See Paranasal sinuses.
Reverse Waters method CT after, 11, 11f summary of pathology of, 282t
for cranial trauma, 46, 46f double-contrast, 10, 10f-11f summary of projections of, 256
for facial bones, 327, 327f-328f MRI vs., 8f technical considerations for radiography of,
with trauma, 328, 328f single-contrast, 10, 10f-11f 288
Right colic flexure, 102f, 103 Sialography, 62-63, 62f-63f topography of, 285, 285f
Rima glottidis, 71f, 73, 73f Sinus(es) trauma to
Rods, 315 abdominal, 180, 180f acanthioparietal projection (reverse Waters
Rotational tomography of mandible, 353-354, paranasal. See Paranasal sinuses. method) for, 46, 46f
353f-354f Sinusitis, 282t AP axial projection (Towne method) for,
Rotator cuff tear, 9t Skull, 255-367 44-45, 44f-45f
contrast arthrography of, 10, 10f abbreviations used for, 284b CT of, 29, 29f, 53-55, 54f
Round ligament anatomy of, 257-260, 257b, 257f-260f lateral projection for, 42-43, 42f-43f
anatomy of, 239f-240f summary of, 280b-281b Skull base, submentovertical projection of
Round window, 270f, 271 AP axial projection of, 299-300, 301f (Schüller method), 310-311
Rugae Towne method for, 302-306 central ray for, 310f, 311
of stomach, 98, 98f central ray for, 303f, 304 evaluation criteria for, 311b
of urinary bladder, 186 evaluation criteria for, 304b position of part for, 310-311, 310f
for pathologic condition or trauma, 306, position of patient for, 310
S 306f-307f structures shown on, 311, 311f
Sagittal suture, 259, 275t position of part for, 302, 303f Skull fracture, 43f
Salivary duct, 62t position of patient for, 302 Small bowel series, 138

e11
 Small intestine
anatomy of, 97f, 100f, 101
complete reflux examination of, 141, 141f
duodenum of. See Duodenum.
enteroclysis procedure for, 141
air-contrast, 141, 141f
barium in, 141, 141f
CT, 141, 142f
iodinated contrast medium for, 141, 142f
exposure time for, 114
intubation examination procedures for, 143,
143f
PA or AP projection of, 139
evaluation criteria for, 139b
ileocecal studies in, 139, 140f
position of part for, 139, 139f
position of patient for, 139
structures shown on, 139, 139f-140f
radiologic examination of, 138
oral method for, 138
preparation for, 138
SMV projection. See Submentovertical (SMV)
projection.
Soft palate
anatomy of, 59, 59f, 71f
lateral projection of, 78-79, 78f-79f
methods of examination of, 74-75
Soloman, Albert, 372
Sonography. See Ultrasonography.
Sphenoid angle of parietal bone, 263f
Index
Sphenoid bone
anatomy of, 264-266, 264f-265f
greater wings of, 258f, 259, 264f-265f,
265
lesser wings of, 258f, 264f-265f, 265
location of, 257f-258f
in orbit, 275, 275f, 312f
Sphenoid sinus effusion, 295f
Sphenoid strut, 265
Sphenoidal fontanel, 259-260, 260f
Sphenoidal sinuses
anatomy of, 276f-278f, 279
AP axial projection of, 309f
lateral projection of, 359f
in decubitus position, 295f
location of, 259f, 264-265, 264f-265f
PA axial projection of, 361f
parietoacanthial projection of, 365f
open-mouth Waters method for, 364-365,
364f-365f
submentovertical projection of, 311f, 366-367,
366f-367f
Sphincter of Oddi, 105, 105f
Sphincter of the hepatopancreatic ampulla, 105,
105f
Spinal cord, 259f
Spleen
anatomy of, 97f, 105f, 106
sectional image of, 107f
Splenic flexure
anatomy of, 102f, 103
Splenic vein
anatomy of, 105f
Spongy urethra, 186f, 187
Spot compression technique for mammography,
403t-408t, 429-431, 430f-431f, 432t
Squama of occipital bone, 266, 266f-267f
Squamosal suture. See Squamous suture.
Squamous suture
anatomy of, 258f, 259, 275t
Standard precautions
in trauma radiography, 28
Stapes, 270f, 271
Statscan, 20, 21f-22f
Stenosis, 62t
in urinary system, 188t
e12
Stereotactic imaging and biopsy procedures for
breast lesions, 465-470
calculation of X, Y, and Z coordinates in, 465,
465f-466f, 469, 469f
equipment for, 466, 467f-468f
images using, 468, 468f-470f
three-dimensional localization with, 465,
465f
Stereotaxis. See Stereotactic imaging and biopsy
procedures.
Sthenic body habitus
and gallbladder, 106, 106f
and stomach and duodenum, 99, 99f, 125f
Stomach
anatomy of, 97f-99f, 98-99
AP oblique projection of, 130-131, 130f-131f
AP projection of, 134
evaluation criteria for, 134b
position of part for, 134, 134f
position of patient for, 134, 134f
structures shown on, 134, 135f
and body habitus, 99, 99f
contrast studies of, 121-123
barium sulfate suspension for, 111, 111f
biphasic, 123
double-contrast, 122, 122f, 124f
single-contrast, 121, 121f, 124f
water-soluble, iodinated solution for, 111,
111f
exposure time for, 114
functions of, 99
gastrointestinal series for, 120, 120f
lateral projection of, 132-133, 132f-133f
PA axial projection of, 126-127, 126f-127f
PA oblique projection of, 128-129, 128f-129f
Wolf method for, 136-137, 136f-137f
PA projection of, 124-125
body habitus and, 124-125, 125f
double-contrast, 124f
evaluation criteria for, 125b
position of part for, 124, 124f
position of patient for, 124
single-contrast, 124f
structures shown on, 124-125, 125f
sectional image of, 107f
Styloid process
anatomy of, 258f, 268, 268f-269f
Sublingual ducts, 60f, 61-62
Sublingual fold, 59, 59f
Sublingual glands, 60f-61f, 61-62, 97f
Sublingual space, 59, 59f
Submandibular duct, 60, 60f
Submandibular gland
anatomy of, 60, 60f-61f, 97f
lateral projection of, 66-67, 66f-67f
sialography of, 62f
Submentovertical (SMV) projection
of cranial base, 310-311
central ray for, 310f, 311
evaluation criteria for, 311b
position of part for, 310-311, 310f
position of patient for, 310
structures shown on, 311, 311f
of ethmoidal and sphenoidal sinuses, 366-367,
366f-367f
of mandible, 346, 346f
of zygomatic arch, 333-334, 333f-334f
Subtraction technique
for hip arthrography
digital, 14, 15f
photographic, 14, 15f
Superciliary arch, 261f
Superior mesenteric vein
anatomy of, 105f
Superior nasal concha
anatomy of, 262, 262f
Superior orbital fissures
anatomy of, 257f, 265, 265f, 272f, 312f, 313
PA axial projection of, 298f
Superior orbital margin
lateral projection of, 317f
PA axial projection of, 298f
Supraorbital foramen, 257f, 261, 261f
Supraorbital margins
anatomy of, 261, 261f
lateral projection of, 293f
Suprarenal glands
anatomy of, 183, 183f
Survey image of abdomen, 87
Suspensory muscle of duodenum, 100f, 101
Sutures, 258f, 259, 275t
Syringes for venipuncture, 228-229, 228f
recapping of, 229, 229f
T
Taeniae coli, 102, 102f
Tarsals
trauma radiography of, 52f
TEA (top of ear attachment), 268, 270f, 271, 285f
Teeth, 59
Temporal bones
anatomy of, 268, 268f-269f
coronal CT through, 269f
location of, 257f-259f
mastoid portion of, 268, 268f-270f
petrous portion of
anatomy of, 268, 268f-270f
lateral projection of, 293f
in decubitus position, 295f
location of, 258f-259f
squamous portion of
anatomy of, 268, 268f-269f
tympanic portion of
anatomy of, 268, 268f
zygomatic arch of
anatomy of, 273
AP axial projection of (modified Towne
method), 337, 337f-338f
submentovertical projection of, 333-334,
333f-334f
tangential projection of, 335-336,
335f-336f
zygomatic process of
anatomy of, 268, 268f
Temporal process of zygomatic bones, 273, 273f
Temporomandibular joint (TMJ)
anatomy of, 268, 275, 275t
AP axial projection of, 347-348, 347f-348f
axiolateral oblique projection of, 345f, 351-352,
351f-352f
axiolateral projection of, 349-350
evaluation criteria for, 350b
position of part for, 349, 349f-350f
position of patient for, 349
structures shown on, 350f
lateral projection of, 293f
panoramic tomography of mandible for,
353-354, 353f-354f
Temporomandibular joint (TMJ) syndrome, 282t
Testicles. See Testis(es).
Testicular torsion, 245t
Testis(es)
anatomy of, 242, 242f-243f
Thermography of breast, 473
Thoracic vertebrae
AP projection of
for trauma, 36-37, 36f-37f
lateral projection of
for trauma, 35, 35f
trauma radiography of
AP projection in, 36-37, 36f-37f
lateral projections in, 35, 35f
Thoracic viscera Trauma radiography (Continued) Urethral orifice, 240, 240f
CT of, 55 exposure factors for, 23, 23f Urethral stricture, 192f
Three-dimensional imaging grids and IR holders for, 20 Urinary bladder
of breast, 374-375 image evaluation in, 30 anatomy of, 186, 186f
Thyroid cartilage image receptor size and collimated field for, 30 AP axial or PA axial projection of, 216-217,
anatomy of, 71-72, 71f-72f with immobilization devices, 23, 23f, 28, 30 216f-217f
Thyroid gland of lower limb, 50-53 AP oblique projection of, 218, 218f-219f
anatomy of, 71, 72f patient position considerations for, 22f-23f, 50 cystography of. See Cystography.
TMJ. See Temporomandibular joint (TMJ). structures shown on, 52-53, 52f cystourethrography of
Toes trauma positioning tips for, 50, 50f female, 222-224, 222f-223f
trauma radiography of, 52f overview of, 18 male, 221, 221f
Tongue patient care in, 26, 27t serial voiding, 214, 215f
anatomy of, 59, 59f, 97f patient preparation for, 29 defined, 183, 186
Tonsil of pelvis, AP projection in, 41, 41f location of, 183f-184f, 186
palatine, 59, 59f positioning aids for, 20 Urinary system, 181-235
pharyngeal, 71f, 72 positioning of patient for, 24, 24f, 28 abbreviations used for, 189b
Top of ear attachment (TEA), 268, 270f, 271, 285f radiation protection for, 25 anatomy of, 183-187, 183f-184f
Tourniquet for venipuncture specialized equipment for, 20 kidneys in, 183f-185f, 184-185
application of, 232f, 233 dedicated C-arm–type trauma radiographic prostate in, 184f, 186f, 187
release of, 233f room as, 20f summary of, 187b
Towne method mobile fluoroscopic C-arm as, 20, 21f suprarenal glands in, 183, 183f
for AP axial projection of skull, 44-45, 44f-45f, Statscan as, 20, 21f-22f ureters in, 183f-184f, 186, 186f
302-306 standard precautions in, 28 urethra in, 186f, 187
central ray for, 303f, 304 of thoracic and lumbar spine urinary bladder in, 183f-184f, 186, 186f
evaluation criteria for, 304b AP projection in, 36-37, 36f-37f angiography of, 190, 191f
for pathologic condition or trauma, 306, lateral projections in, 35, 35f AP oblique projection of, 206, 206f
306f-307f of upper limb, 47-49 AP projection of, 204
position of part for, 302, 303f patient position considerations for, 47-48 evaluation criteria for, 205b
position of patient for, 302 for forearm, 47, 47f-48f position of part for, 204
structures shown on, 304, 305f for humerus, 49, 49f position of patient for, 204, 204f

Index
variations of, 302 for shoulder, 48, 48f-49f in prone position, 204
modified for AP axial projection of zygomatic structures shown on, 49, 49f in semi-upright position, 204, 205f
arches, 337, 337f-338f trauma positioning tips for, 47 structures shown on, 204, 205f
Trachea Trauma team, radiographer’s role as part of, 25-26 in supine position, 204, 204f-205f
anatomy of, 71f-72f Trigone, 186, 186f in Trendelenburg position, 204, 205f
Tragus, 270f, 271 Tripod fracture, 282t contrast studies of, 190-197
Trauma T-tube cholangiography, 176-177, 176f-177f adverse reactions to iodinated media for, 196
blunt, 19 Tuberculum sellae angiographic, 190, 191f
defined, 18 anatomy of, 258f, 264-265, 264f antegrade filling for, 191, 191f
explosive, 19 Tympanic cavity, 270f, 271 contrast media for, 194, 195f
heat, 19 Tympanic membrane, 270f, 271 CT in, 190, 191f
other imaging procedures for, 53-55 equipment for, 198, 198f-199f
CT as, 20, 29 U physiologic technique for, 192f, 193
of cervical spine, 53-55 UGI (upper gastrointestinal) series. preparation of intestinal tract for, 196-197,
of cranium, 29, 29f, 53-55, 54f See Gastrointestinal (GI) series. 196f-197f
of pelvis, 53f, 55 Ulcer, 109t preparation of patient for, 197
of thorax, 53-55 Ulcerative colitis, 109t retrograde filling for, 192f, 193
sonography as, 55 Ultrasonography tomography in, 190, 191f
penetrating, 19 of breast, 418-419 CT of, 190, 190f
radiography of. See Trauma radiography. of trauma, 55 cystography of. See Cystography.
statistics on, 18-19, 18f-19f UPJ (ureteropelvic junction), 185 cystoureterography of, 193, 193f, 214
Trauma center, 19 Upper gastrointestinal (UGI) series. cystourethrography of, 193, 193f, 214
Trauma radiography, 17-56 See Gastrointestinal (GI) series. female, 222-224, 222f
abbreviations used in, 30b Upper limb metallic bead chain, 222-224, 223f
of abdomen, AP projection in, 38-39, 38f-39f long bone measurement of, 2, 5, 5f male, 221, 221f
in left lateral decubitus position, 40, 40f trauma radiography of, 47-49 serial voiding, 214, 215f
best practices in, 28 for humerus, 49, 49f image quality and exposure techniques for, 199,
breathing instructions for, 30 patient position considerations for, 47-48 199f
with immobilization devices, 30 for forearm, 47, 47f-48f lateral projection of
central ray, part, and image receptor alignment for shoulder, 48, 48f-49f in dorsal decubitus position, 208, 208f
in, 30 structures shown on, 49, 49f in R or L position, 207, 207f
of cervical spine trauma positioning tips for, 47 motion control for, 199
AP axial oblique projection in, 34, 35f-36f Ureter(s) nephrotomography of, 190, 191f
AP axial projection in, 33, 33f anatomy of, 183f-184f, 186, 186f AP projection in, 209, 209f
lateral projection in, 31, 31f defined, 183 percutaneous renal puncture for, 210-211,
of cervicothoracic region, lateral projection in radiologic examination of, 214 210f
dorsal decubitus position in, 32, 32f retrograde urography of, 212-213, 212f-213f overview of radiography of, 190-201
common projections in, 29-30 Ureteral compression for excretory urography, 200, pelvicaliceal system in, retrograde urography of,
of cranium 200f 212-213, 212f-213f
acanthioparietal projection (reverse Waters Ureterocele, 188t preliminary examination of, 201
method) in, 46, 46f Ureteropelvic junction (UPJ), 185 prostate in
AP axial projection (Towne method) in, 44-45, Ureterovesical junction (UVJ), 186 anatomy of, 184f, 186f, 187
44f-45f Urethra radiologic examination of, 214
and CT scan, 29, 29f anatomy of, 186f, 187 pyelography of, 191
lateral projection in, 42-43, 42f-43f defined, 183 percutaneous antegrade, 211, 211f
documentation of, 30 radiologic examination of, 214 radiation protection for, 201

e13
 Urinary system (Continued)
renal parenchyma in, nephrotomography of,
209-211
AP projection for, 209, 209f
percutaneous renal puncture for, 210-211,
210f
respiration for, 200
sample exposure technique chart essential
projections for, 189t
summary of pathology of, 188t
summary of projections for, 182-183
ureteral compression for, 200, 200f
ureters in
anatomy of, 183f-184f, 186, 186f
radiologic examination of, 214
retrograde urography of, 212-213,
212f-213f
urethra in
anatomy of, 186f, 187
radiologic examination of, 214
urinary bladder in
anatomy of, 183f-184f, 186, 186f
AP axial or PA axial projection of, 216-217,
216f-217f
AP oblique projection of, 218,
218f-219f
cystourethrography of
female, 222-224, 222f-223f
male, 221, 221f
serial voiding, 214, 215f
Index
lateral projection of, 220, 220f
radiologic examination of, 214
urography of. See Urography.
voiding study of, 192f
Urography
AP oblique projection for, 206, 206f
AP projection for, 204
evaluation criteria for, 205b
position of part for, 204
position of patient for, 204, 204f
in prone position, 204
in semi-upright position, 204, 205f
structures shown on, 204, 205f
in supine position, 204, 204f-205f
in Trendelenburg position, 204, 205f
in upright position, 204, 204f
defined, 190
equipment for, 198, 198f-199f
excretory (intravenous). See Excretory urography
(EU).
image quality and exposure technique for, 199,
199f
intestinal tract preparation for, 196-197,
196f-197f
lateral projection for
in dorsal decubitus position, 208, 208f
in R or L position, 207, 207f
motion control for, 199
percutaneous antegrade, 191
preparation of patient for, 197
respiration during, 200
retrograde, 192f, 193
AP projection for, 212-213, 212f-213f
contrast media for, 194, 195f
defined, 193
preparation of patient for, 197
ureteral compression for, 200, 200f
Uterine fibroid, 245t, 247f
Uterine ostium, 240, 240f
e14
Uterine tube(s) Visceral arteriography
anatomy of, 239, 239f-240f renal, 190, 191f
hydrosalpinx of, 246f Visceral peritoneum, 83, 83f
hysterosalpingography of, 246-247, 246f-247f Vistaril (hydroxyzine hydrochloride), 226t
obstruction of, 245t Vitreous body, 314f
Uterus Vocal cords, 71f
anatomy of, 240, 240f false, 73, 73f
bicornuate, 247f true, 71f, 73, 73f
hysterosalpingography of, 246-247, 246f-247f Vocal folds, 71f, 73, 73f
UVJ (ureterovesical junction), 186 Voiding cystourethrogram (VCUG), 214, 215f
Uvula, 59, 59f, 71f, 72 Voiding study, 192f
Volvulus, 109t
V Vomer
Vacuum-assisted core biopsy of breast, 470 anatomy of, 259f, 272f, 273
Vagina submentovertical projection of, 367f
anatomy of, 240
Vaginal orifice, 240, 240f W
Vaginal vestibule, 240 Warren, Stafford, 372
Vaginography, 246, 250-251, 250f-251f Waters method
Valium (diazepam), 226t for facial bones, 323, 323f-324f
Valsalva maneuver, 72 modified, 304, 325f-326f
Varices reverse, 327, 327f-328f
esophageal, 109t, 119, 119f with trauma, 328, 328f
VC (virtual colonoscopy), 144, 145f for maxillary sinuses, 362-363, 362f-363f
VCUG (voiding cystourethrogram), 214, 215f open-mouth, 364-365, 364f-365f
Venipuncture, 225-235 modified
discarding needles after, 234, 234f for facial bones, 304, 325f-326f
documentation of, 235 for orbits, 319, 319f
infection control during, 228 open-mouth, for maxillary and sphenoidal
medication preparation for, 229-230, 229f sinuses, 364-365, 364f-365f
from bottle or vial, 229, 229f reverse
identification and expiration date in, 230, 230f for cranial trauma, 46, 46f
nonvented tubing in, 230, 230f for facial bones, 327, 327f-328f
recapping of syringe in, 229, 229f with trauma, 328, 328f
tube clamp in, 230, 230f Water-soluble, iodinated contrast media
vented tubing in, 230, 230f for alimentary canal imaging, 111-112,
medications administered via, 225, 226t 111f-112f
needles and syringes for, 228-229, 228f for large intestine studies, 145
patient assessment for, 228 Wellen method for double-contrast barium enema,
patient education on, 225 152-153, 152f-153f
professional and legal considerations for, 225 Wilms tumor, 188t
reactions to and complications of, 235 Wolf method for PA oblique projection of superior
removing IV access after, 234, 234f stomach and distal esophagus, 136-137,
site preparation for, 232, 232f 136f-137f
site selection for, 230-231, 231f Wrist arthrogram, 16, 16f
technique for, 232-234
administering medication in, 233-234, 233f X
anchoring needle in, 233, 233f Xerography of breast, 372-373, 372f
applying tourniquet in, 232f, 233 Xeromammography, 372, 372f
direct (one-step), 232
gloves and cleaning of area in, 232f, 233 Z
indirect (two-step), 232 Zenker diverticulum, 109t
local anesthetic in, 233 Zygomatic arches
releasing tourniquet in, 233f anatomy of, 273
stabilizing skin and entering vein in, 233, 233f AP axial projection of (modified Towne method),
verifying venous access in, 233 337, 337f-338f
Vermiform appendix parietoacanthial projection of, 324f
anatomy of, 97f, 102, 102f submentovertical projection of, 333-334,
Versed (midazolam hydrochloride), 226t 333f-334f
Vertical plate of palatine bones, 273 tangential projection of, 335-336, 335f-336f
Vertical ray method for contrast arthrography of Zygomatic bones
knee, 12, 12f acanthioparietal projection of, 328f
Vesicoureteral reflux, 188t anatomy of, 272f-273f, 273
Vesicovaginal fistula, 250, 250f modified Waters method for parietoacanthial
Vesiculography, 253, 254f projection of, 326f
Vestibular folds, 73, 73f in orbit, 275, 275f, 312f, 314f
Vestibule of internal ear, 271 Zygomatic process
Villi, 100f, 101 anatomy of, 268, 268f
Virtual colonoscopy (VC), 144, 145f Zygote, 241