Toes, Foot, Calcaneous, Ankle

PLEASE TURN ALL CELL PHONES TO
SILENT MODE
3
By the end of this Lecture the student will be able to:

List and identify the different bones and joints related to lower limbs
List the basic and Optional projections for radiographing toes ,foot
and ankle joint
Discus the correct body position, part position, central ray, and
center point for specific positions of toes ,foot and ankle joint
Critique and evaluate radiographs of shoulder based on (position,
collimation and central ray, exposure, and structure best shown)

Learning Objectives

4
Basic
Text book of radiographic positioning and related anatomy; Kenneth
L.Bontrager,5
th,
6
th
edition
Optional
Merrills Atlas of Radiographic Positions and Radiologic
Procedures,
P.W. Ballinger, E.D. Frank
Positioning in Radiography: By k.C.Clarke.

Websites
/ radiography.net - http://www.e

References

5
Lower Limbs ( Anatomy Review)
2
Right Foot
Right Tibia and fibula
Posterior view Anterior view
8
Right femur Right Patella
Bone cysts : Benign neoplastic bone lesions filled with a clear fluid near the
knee
joint in pediatric patients.
Chondromalacia patellae (Runners knee): Is the softening of cartilage
under the
patella at a later stage.
Ewing sarcoma : A primary bone malignancy in children, mainly in diaphysis
of
long bones.
Osgood Schlatter's disease : Is the inflammation of bone and cartilage in the
anterior proximal tibia (tibial tuberosity) of children.
Osteoclastoma: A benign lesion in the proximal tibia/distal femur, usually
affecting epiphyseal closure.

Osteogenic sarcoma Is a malignant primary bone tumor in long bones,
usually
causing gross destruction of the bone.
Pathological Indications (Lower limb)
th editions 6 Reference: Text book of radiographic positioning and related anatomy; L.Bontrager,
Positioning principles as for upper limb applies to lower limb. kV
should be lower to medium (50 70) KVp.
For all parts discussed, center and align the long axis of the part to
central ray (CR) and to long axis of the film.
No secondary radiation grid used, except for knee (> 10 cm) and
for the femur.
Radiation protection has to be well observed, using the special
gonad shields over pelvic region, or the lead apron as necessary.
Also, the LBD or cone has to be used.
FFD is generally 40 inches (100 - 102 cm).
Optimal contrast and density will allow visualization of bony
cortical margins soft tissue structures.

2
Technical Points
For fractures and dislocations, osteoarthritis (OA),
and gout (especially in the 1
st
digit).

Patient supine or seated, knee flexed, planter
surface of the foot (sole) on film.
Film: HD 18x24 cm.

CP: MTPJ(s).

CR: 10-15 toward the Calcaneus (the heel)
(90 to the phalanges).

NB/ If a 15 wedge is used, CR must be 90 to the
film.

AP Toes
B Lateral Toes

For fractures and dislocations,
osteoarthritis, and gout (especially in the
1
st
digit).
Patient supine or seated, knee flexed,
planter surface on the film, affected leg
and foot both rotated medially
(Lateromedial) for 1
st
, 2
nd
, and 3
rd
, and
laterally (for 4
th
and 5
th
), a cotton tape to
separate and flex sound toes to prevent
superimposition.
Film: HD 18x24 cm.

CP: IPJ (for 1
st
), proximal IPJ (2
nd
to
5
th
).

CR: 90 to film.

B AP (Dorsiplanter) foot

For #s and dislocations, tissue effusion, joint-
space abnormalities, opaque foreign bodies
(F.Bs.).

Patient in supine, the knee flexed, planter
surface on film, sandbags used to immobilize
the film, opposite knee flexed and rests against
affected knee.
Film: HD 24x30 cm.

CP: Base of 3
rd
metatarsal
CR: 10 posteriorly (toward the heel.

NB/ Perpendicular (0) for a F.B. and for a flat
foot (pes planes), 5 for a low arch foot, and
15 for a high arch foot.

7
A-E: Toes 1-5. (A:Great toe)
I-V. Metatarsals
1,3: Distal phalanx
4: Middle phalanx
2,5: Proximal phalanx
6. Interphalangeal joints
7. Metatarsophalangeal joints
8. Sesamoid
9. Head of metatarsal
10. Shaft (body) of metatarsal
11. Base of metatarsal
12. Cuneiforms
13. Navicular
14. Cuboid
15. Talus
16. Calcaneus
17. Tibia
18. Fibula
19. Tarsometatarsal joints
20. Transverse midtarsal joint
RADIOGRAPHIC ANATOMY
szeged.hu/Radiology/Anatomy/skeleton.htm - http://www.szote.u Reference :
B APO foot

For #s and dislocations, soft tissue effusion,
joint space abnormalities, opaque F.Bs.

Patient supine or seated, knee flexed, planter
surface on film, foot rotated medially so that
the sole is 30 to 40 to film. A 45 wedge can
be used to support the foot and prevent motion.
Film: HD 24x30 cm.

CP: Base of 3
rd
metatarsal.
CR: 90 perpendicular.

A-E: Toes 1-5. (A:Great toe)
1,3: Distal phalanx
4: Middle phalanx
2,5: Proximal phalanx
6. Interphalangeal joints
7. Metatarsophalangeal joints
8. Sesamoid
9. Head of metatarsal
10. Shaft (body) of metatarsal
11. Base of metatarsal
12. Cuneiforms
13. Navicular
14. Cuboid
15. Talus
16. Calcaneus
17. Tibia
18. Fibula
19. Tarsometatarsal joints
20. Transverse midtarsal joint
B lateral foot

For #s and dislocations, tissue effusion, joint
space abnormalities, opaque F.Bs.

Patient in lateral recumbent, pillow under
head, knee flexed 45, opposite leg behind
injured leg, foot carefully dorsiflexed for a
true lateral position, support under leg and
knee, sole of foot 90 to film.

Film: HD 18x24 cm.

CP: Medial cuneiform (level of the base
of the 3
rd
metatarsal).
CR: 90 perpendicular to film.

11
A. Tibia.
B. Calcaneus.
C. Calcaneus tuberosity.
D. Cuboid.
E. 5th MT tuberosity.
F. Superimposed cuneiforms.
G. Navicular.
H. Subtalar joint.
I. Talus.

Lateral foot
B AP/Lat both feet (Weight-bearing technique) Flat Foot

B AP/Lat both feet (Weight-bearing technique)
To show condition of the longitudinal arches under full
weight of body to exclude a flat foot abnormality .
AP: Patient standing erect, full weight evenly distributed
on both feet (on the fluoroscopic foot-rest).
Lat: Patient stand erect on wood blocks on the foot rest,
film vertically between feet, cassettes changed in turn
for lateral of the other foot for comparison.
Film: HD 24x30 cm, 18x24 (for laterals).
CP: (AP): CR 15 posteriorly to midpoint between the
feet, at the level of the base of metatarsals.
( Perpendicular is preferred for flat foot)
(Lat): Horizontally to the level of base of the
metatarsals.

B Mediolateral Calcaneus
For bony lesions of Calcaneum,
talocalcaneal joint, and talus. Also shows
fractures.
Patient lateral recumbent, with affected
knee flexed 45, opposite leg behind
injured limb, support under knee and leg,
sole 90 to the film, ankle and foot in the
true lateral.
Film: HD 18x24 cm.
CP: 1 inch inferior to medial malleolus.
CR: 90 to film.

Calcaneal (Heel) spur
B Mediolateral Calcaneus

To show fractures, pathology, and lateral or
medial displacement.
Patient supine or seated, legs fully
extended, foot dorsiflexed (sole 90 to
film), cotton ribbon looped around foot
pulled by patient for support.
Film: HD 18x24 cm.
CP: Base of 3
rd
metatarsal.

CR: 40 cephalic from long axis of foot.

B Axial Calcaneus
B Axial Calcaneus
B AP Ankle
For bony lesions of ankle joint, distal tibia
and fibula (NB/ Lateral aspect of ankle
joint must not appear open in this
projection).
Patient supine, legs fully extended, foot in
the natural position, foot and ankle in true
AP.
Film: HD 24x30 cm.
CP: Midway between malleoli.
CR: 90 to film.

1. Fibula
2. Tibia
3. Distal Tibiofibular joint
4. Malleolar fossa
5. Lateral malleolus
6. Ankle joint
7. Medial malleolus
8. Talus
AP Ankle
B Lateral Ankle (Mediolateral)

For pathology and fractures, dislocations, joint effusions.
Patient in lateral recumbent, the affected side down,
knee of affected limb flexed 45,
sound leg behind the affected leg,
foot and leg in a true lateral, sole 90 to film.
Film: HD 24x30 cm.
CP: Medial malleolus.
CR: 90 to film.

B APO Ankle 45 (medial rotation)
For pathology/fractures of distal Tibiofibular joint and distal fibula and base of
5
th
MT.

Patient supine, legs fully extended, foot dorsiflexed so that planter surface is (80
to 85) from the film, leg and foot rotated internally 45 (similar position to
ankle mortise).
Film: HD 24x30 cm.

CP: A point midway between malleoli.

CR: 90 to film.

ANY QUESTIONS?

Toes, Foot, Calcaneous, Ankle

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