Transcript lower extrem toe-ankle2012

Film Critique
1st year 5th class
Toes
Standard views
*AP
*Oblique (medioblique)
*Lateral (mediolateral/lateromedial)
Structures shown

AP projection of the phalanges of the foot
(*1st toe only has 2 phalanges the 2nd-5th
have 3 phalanges) ***We need from
distal phalanx to the distal end
metatarsal.
AP Right 1st Toe
Sesamoids
Check the film for:
No rotation of phalanges
 Interphalangeal and
metatarsophalangeal joint spaces
open (no bent toes)
 Toes should be separated from each
other so there is no soft tissue
overlap
 Soft tissue and bony trabeculation
(this is to check for a good
technique)

AP left 1st toe
Rotation of toe
Soft tissue overlap
AP
Oblique Toes
Oblique left 1st toe
Structures shown
****


We do a medioblique:
An oblique projection of the phalanges
The Interphalangeal joints and 2nd -5th
metatarsophalangeal joints open
***Distal phalanx to the distal end of the metatarsal


Toes should be separated from each other
Both soft tissue and bony trabeculation should be seen
(techn)
Oblique left 2nd toe
LT
Cadaver bone
Lateral left 1st toe
Might need tape, straw or tongue depressor to separate toes
Lateral toes
Lateral left 2nd toe
lateromedial
Lateral left 3rd toe
Mediolateral
Do lateromedial (1st-3rd) and
mediolateral (3rd-5th) to get the toe
closest to the film
Structures shown: Lateral toe


A lateral projection of the phalanges: Phalanges in profile
(toenail should appear lateral)
The interphalangeal joints spaces open. The MTP joints will
be overlapped but may be seen in some patients.
***The distal phalanx to the distal ends of the
metatarsals

Phalanx, without superimposition of adjacent toes. When
superimposition cannot be avoided, the proximal phalanx
must be demonstrated.

Toes should be separated from each other

Soft tissue and bony trabeculation (techn)
Lateral left 2nd toe
Lateral left 1st toe
Tongue depressor
Lateral Left 2nd toe
Foot

Standard views
*AP
* AP Oblique (medioblique)
*Lateral (mediolateral)
AP Right Foot
Intermediate
Base of the 5th
Common area for a foot fracture base of 5th Jones fracture
AP Right foot
**In this view you
Will not see the
Calcaneus!!
Structures shown:
Dorsoplanter (AP) projection of the
tarsals anterior to the talus, the
metatarsals,and the phalanges
 You will not see the whole calcaneus
on this view. Why?
 Some people angle 10 degrees
toward the heel on this view
***You want all of the phalanges,
metatarsals and tarsals distal to the
talus on your image

Check film for:



Motion
Rotation: there will be overlap of second- fifth
metatarsal bases
Open joint space between medial and
intermediate cuneiform

No overlap of toes

Density- are the toes burned out
Oblique Right foot
Oblique Right Foot
medioblique
Structures shown:
AP medioblique projection of the
phalanges and metatarsals
 Interspaces open between the cuboid
and calcaneus, the cuboid and the 4th
and 5th metatarsals, the cuboid and
the lateral cuneiform and the talus
and the navicular
 Cuboid is in profile
 Sinus tarsi, calcaneus, navicular,&
base of the fifth are seen

Oblique Left Foot
Calcaneus?
Check for:
Enough rotation when the 3rd – 5th
metatarsals bases are free from
superimposition
 The lateral tarsals with less
superimposition than in the AP
 Joint spaces open
 Base of the fifth metarsal is seen
 Density: are the toes seen and are
the tarsal seen
 Tip of toes to calcaneus on the image

Lateral Right Foot
Lateral Right Foot
R
mediolateral
Structures shown:

Mediolateral projection of the entire
foot. ***You need distal ends of the
tib/fib, ankle joint, calcaneus to the
distal phalanges.
Bad lateral foot
Check for:



Tip of toes to calcaneus and distal
tib/fib on the image
Metatarsals nearly superimposed
Density to see toes, metatarsals and
tarsals
Good Positioning
Poor : heel not flat
Poor : knee elevated
Poor : foot not flat
NO!
CALCANEUS

Standard views
*AP axial (plantodorsal)
*Lateral (mediolateral)
Sustentaculum
tali
Trochlear
process
tuberosity
Structures shown:

An axial projection of the calcaneus
***from the tuberosity to the
sustentaculum tali and trochlear
process
AP Axial Right Calcaneus
Check for:
Calcaneus should be visualized to
include the talocalcaneal joint
 No rotation of calcaneus (check the
first or fifth metatarsals)
 Density to see joint without burn out
of tuberosity (two films if not using
DR or CR)

Rotation / foot flexion
Rotation : can see
4th & 5th metatarsals
Good
Too much flexion
Can’t see joint space
Structures shown:

Lateral projection of the ankle joint
and the calcaneus and adjacent
tarsals.
Lateral Left
calcaneus
Check for:
No rotation of the calcaneus
 Density can you see soft tissue and
bone
 Sinus tarsi seen
 Ankle joint and adjacent tarsals
should be on the film

Ankle

Standard views
*AP
*OBL (mortise)
*Lateral (mediolateral)
AP
Right
Ankle
Structures shown

AP projection of the ankle joint,
***distal ends of tib/fib and the
proximal portion of the talus
Dorsal flex
AP Left ankle
Check for:

Talotibial joint space should be seen

Ankle joint should be centered

Moderate over lapping at the tibiofibular
articulation is normal
***Area from the distal tibia and fibula to
the talus should be included
Oblique Left Ankle
Structures shown:

Distal ends of the tib/fib with the
entire ankle mortise joint
demonstrated in profile.(all three
sides of the mortise joint should be
open.)
AP OBLIQUE ANKLE

The entire ankle mortise joint should be
demonstrated in profile. We oblique 15-20
degrees to open all three joints.
AP
Too
much
Oblique Right Ankle
is it open?
Don’t just dorsiflex the foot, roll
the leg
Check for:
Entire ankle mortise joint
 No overlap of the anterior tubercle of
the tibia and the superolateral
portion of the talus with the fibula
 Talofibular joint space in profile
 Talus demonstrated with proper
density

Lateral Right
Ankle
Lateral ankle (mediolateral)

A true lateral image of the lower
third of the tib/fib, the ankle joint
and the tarsals including the base of
the 5th metatarsal
Lateral Right Ankle
Poor positioning
Dorsiflex the foot
Check for:
Ankle joint should be centered
 Talotibial joint should be well
visualized
 Fibula should be over the posterior
half of the tibia
 Density of ankle should be sufficient
to see the outline of the distal
portion of the fibula
 Fifth metatarsal should be seen to
check for a Jones fracture
