Module 6 Lower Extremity Flashcards
FOOT BONES AND DIVISIONS
Foot has 26 bones divided into 3 groups
- Phalanges- 14
- Metatarsals - 5
- Tarsals- 7
TARSAL BONES 7
- Calcaneus
- Talus
- Navicular
- Cuneiforms x 3 - Medial - Intermediate- Lateral
- Cuboid
FOOT ARTICULATIONS
- Interphalangeal joints
- Metatrsophalangeal Joints
- Tarso metatarsal joints
- Intertarsal joint
ANKLE
Often referred to as the mortise joint or ankle mortise.
- Articulates with the talus on three surfaces :
- Lateral malleolus of the fibular
- Inferior surface of the distal tibia
- Medial malleolus of the tibia
TIBIA MEDIAL END ANATOMICAL FEATURES
- Medial condyle
- Lateral condyle
- Tibial plateaus
- Intercondylar eminence
- Tibial tuberosity
TIBIA DISTAL END ANATOMICAL FEATURES
- Medial malleolus
- Fibular notch
KNEE JOINT
Def: Is the articulation between the femoral condyles and the tibial plateaus with soft tissue support namely :
- Meniscus (( Lateral and medial )
- Cruciate ligament ( Posterior and anterior )
- Collateral ligament ( Tibial and fibula)
TIB FIB ARTICULATION
Proximal end - Synovial diarthrosis gliding type joint
Distal end- Fibrous syndemosis
KNEE JOINT ARTICULATION
Synovial diarthrosis hinge type of joint.
Articulation between the femoral condyles and the tibial plateaus
PATELLOFEMORAL JOINT ARTICULATION
Patellar and patellar surface of the anterior distal end of the femur.
- Synovial diarthrosis, gliding type of a joint
PATELLA
The largest and most constant sesamoid bone which develops in the quadriceps femoris tendon between the ages 3-5 years.
It serves as protection for the knee
FEMUR
Bone of the thigh region of the lower limb. Regarded as the longest and strongest bone in the human body
FEMUR PROXIMAL ANATOMICAL FEATURES
- Head
- Neck
- Greater trochanter
- Lesser trochanter
- Body
FEMUR DISTAL ANATOMICAL FEATURES
- Lateral epicondyles
- Medial epicondyles
- Inercondylar fossa
- Adductor tubercle
- Popliteal surface
AP OR AP AXIAL PROJECTION TOES
- Patient preferably seated on table
- Flex knee with plantar surface in contact with the IR
- CR to the 3rd metatarsal phalange all joint
- CR perpendicular to the IR when joint space is not critical
- CR 15 deg posteriorly to open up interphalangeal joints
AP OR AP AXIAL PROJECTION TOES STRUCTURES DEMONSTRATED
Open interphalangeal and metatarsi phalange all joint spaces
AP OR AP AXIAL PROJECTION TOES 1st to3rd MEDIAL ROT, 4th to 5th LATERAL ROT
- Foot plantar surface on IR with knee flexed
- Medially rotate the leg making the foot angle of 30-45 deg with IR
- CR perpendicular to the 3rd metatarsophalangeal joint
AP OR AP AXIAL PROJECTION TOES 1st to3rd MEDIAL ROT, 4th to 5th LATERAL ROT STRUCTURES DEMONSTRATED
Oblique phalanges, open joint spaces
LATERAL TOES PROJECTION
- Patient turns on to the unaffected side for the1stand2nd toes,
- Patient turns on to the affected side for the 3rd to 5 th toes
- CR perpendicular to the first toe and perpendicular to proximal interphalangeal joint for toes 2-5
LATERAL TOES PROJECTION STRUCTURES DEMONSTRATED
Phalanges and interphalangeal joints
AP OR AP AXIAL FOOT PROJECTION
- Patient seated
- Knee flexed with plantar surface in contact with the IR
- CR 10 towards the heel or perpendicular to the base of third metatarsal
AP OR AP AXIAL FOOT PROJECTION STRUCTURES DEMONSTRATED
- Tarsals anterior to the talus, metatarsals and phalanges
- General foot survey
- Foreign body localisation
- Fracture localisation
- Fracture fragments localisation
AP OBLIQUE FOOT PROJECTION MEDIAL ROTATION
- Patient seated with knee flexed with the plantar surface of foot in contact with the IR
- Rotate leg medially until the foot makes a 30-60 deg angle with the IR
- CR perpendicular to the base of the third metatarsal
AP OBLIQUE FOOT PROJECTION MEDIAL ROTATION STRUCTURES DEMONSTRATED
Open interspaces between:
- Cuboid and calcaneous
- Cuboid and fourth and fifth metatarsal
- Cuboid and the lateral cuneiform
- Talus and navicular
LATERAL FOOT PROJECTION
- Patient on the affected side
- Affected foot dorsiflexed
- Lateral surface of the foot parallel to the plane of the IR
- CR perpendicular to the base of the third metatarsal
LATERAL FOOT PROJECTION STRUCTURES DEMONSTRATED
- Metatarsals nearly superimposed
- Fibular overlapping the posterior portion of the tibia
- Tibiotalar joint and superimposed talar domes
AP AXIAL WEIGHT BEARING PROJECTION
- Patient standing erect with full weight evenly distributed on both feet
- Feet should be directed ahead parallel to each other
- CR 10 deg posteriorly to midpoint of feet
-
AP AXIAL WEIGHT BEARING PROJECTION STRUCTURES DEMONSTRATED
- Accurate evaluation and comparison of tarsals and metatarsals
LATERAL WEIGHT BEARING FOOT PROJECTION
- Patient standing on a low bench with IR on the adjacent side or between the feet
- Weight evenly distributed on both feet
- CR horizontal to the level of the base of the third metatarsal
LATERAL WEIGHT BEARING FOOT PROJECTION STRUCTURES DEMONSTRATED
- Entire foot should be demonstrated and a minimum of 2,5- 5cm of the distal tibia- fibula.
- The fibula should be seen superimposed over the posterior half of the tibia
ANKLE AP PROJECTION
- Patient supine of seated
- Adjust the ankle to make foot be in vertical position
- No rotation
- CR perpendicular to the ankle joint
ANKLE AP PROJECTION STRUCTURES DEMONSTRATED
- Tibiotalar joint
- Medial mortise
- Lateral and Medial malleoli visualisation
ANKLE AP OBLIQUE PROJECTION : Mortise
- Patient supine or seated
- Foot partially relaxed medially rotate leg15-20 deg until intermalleolar plane is parallel with IR
- CR midway between the malleoli
ANKLE AP OBLIQUE PROJECTION : Mortise STRUCTURES DEMONSTRATED
- Entire ankle mortise joint
- Open joint space between the talus and the malleoli
ANKLE AP OBLIQUE PROJECTION : Mortise 45 deg
STRUCTURES DEMONSTRATED
- Distal ends of the tibial and fibula parts of which are often superimposed over the talus
- Tibiofibular joint
- Open medial and lateral mortise
- Medial and lateral malleoli are in profile
ANKLE LATERAL PROJECTION
- Turn Patient on to the affected side until foot and ankle is lateral
- Straighten the leg
- Dorsiflex the foot to prevent rotation
- CR Entering the medial malleolus
ANKLE LATERAL PROJECTION STRUCTURES DEMONSTRATED
- Tibiotalar joint space
- Fibula over the posterior half of the tibia
- Supperimposed Talar domes
- 5th metatarsal to rule out Jones Fracture
CALCANEUS LATERAL PROJECTION
- Turn patient on to the affected side until leg and foot are lateral
- straighten the leg
- CR perpendicular to calcaneus, 2;5cm distal to the medial malleolus
CALCANEUS LATERAL PROJECTION STRUCTURES DEMONSTRATED
Ankle joint and the calcaneus in lateral profile
CALCANEUS AXIAL PROJECTION
- Patient seated with leg fully extended
- Foot 90 deg to leg
- Place ankle joint in the centre of IR
- CR directed 40 deg cephalade at the base of the third metatarsal
CALCANEUS AXIAL PROJECTION STRUCTURES DEMONSTRATED
Axial projection of the calcaneus from the tuberosity to the sustentaculum tali and trochlear process
TIB FIB AP PROJECTION
- Patient in supine or seated position
- Place leg in AP position with foot inverted slightly without rotation,
- Long axis of foot in vertical position
- Include both knee and ankle joints in one image if possible
- CR perpendicular to the mid shaft of TIB fib
TIB FIB AP PROJECTION STRUCTURES DEMONSTRATED
Proximal and distal articulations of the tibial fibula moderately
TIB FIB LATERAL PROJECTION
- Patient supine and lying on affected side with leg and foot lateral
- Patella perpendicular to IR
- Foot dorsiflexed with plantar surface perpendicular to the IR
- CR perpendicular to mid shaft of TIB/ FIB
TIB FIB LATERAL PROJECTION STRUCTURES DEMONSTRATED
- TIB fib and adjacent joints
- Distal fibula over posterior half of tibia
- Slight overlap of the tibia on the proximal Fibular head
AP KNEE PROJECTION
- Patient in supine position
- Place leg in true AP position
- patellar slightly off centred to the medial side
- CR perpendicular to the knee joint 1,3 cm inferior to the patella apex
Angling - 3-5 deg cauded for thin patients
- 3-5 deg cephalad for large patients
AP KNEE PROJECTION STRUCTURES DEMONSTRATED
- Open femora tibial joint space
- Patella completely superimposed on femur
- Head of Fibular slightly superimposed by the tibia
LATERAL KNEE PROJECTION
- Turn Patient on to affected side until knee is lateral
- Flex knee 20-30 deg to relax muscles
- Patella must be perpendicular to the IR
- CR directed at knee joint 2,5 cm distal to the medial epicondyles at an angle of 5-7 deg cephalad
LATERAL KNEE PROJECTION STRUCTURES DEMONSTRATED
- Patella in profile
- Open femoropatellar space
- Joint space free of medial femoral epicondyl superimposition
AP OBLIQUE EXTERNAL ROTATION PROJECTION KNEE
- Patient supine with leg extended
- Externally rotate the foot and raise the hip with the extremity forming a 45 deg angle with the IR laterally
- CR directed 1,3 cm to the patellar apex
OBLIQUE PROJECTION KNEE EXTERNAL ROTATION STRUCTURES DEMONSTRATED
- Medial femoral and tibial condyles
- Tibial plateaus
- Fibula superimposed over the lateral half of the tibia
KNEE AP OBLIQUE INTERNAL ROTATION PROJECTION
- Patient supine with leg extended
- Invert foot and elevate the hip of the affected side until the extremity is 45deg to the IR
- CR directed 1,3 cm to the patellar apex
KNEE AP OBLIQUE INTERNAL ROTATION PROJECTION STRUCTURES DEMONSTRATED
- Posterior tibia
- Tibia and fibula separated at their proximal articulation
- Lateral condyles of the femur and tibia
- Both tibial plateaus
PA KNEE PROJECTION
- Place patient prone on table with toes resting on the table
- CR 1,3cm below the patellar apex
PA KNEE PROJECTION STRUCTURES DEMONSTRATED
- Open femorotibial joint space
- Slight superimposition of the Fibular head with the tibia
PA OBLIQUE INTERNAL ROTATION PROJECTION
- Patient is in prone position
- Internally rotate the affected leg raising the hip resulting in a 45-55 deg angle
- Flex the knee 5-10 deg
- CR perpendicular to the IR exiting the palpated patella
PA OBLIQUE INTERNAL ROTATION PROJECTION STRUCTURES DEMONSTRATED
Medial aspect of the patella free of superimposition of the femur
PA OBLIQUE KNEE EXTERNAL ROTATION
- Patient is prone
- Affected leg extended
- Rotate the affected leg 45-50 deg externally
- Flex the knee 5-10 deg
- CR perpendicular to the IR, exiting the palpated patella
PA OBLIQUE KNEE EXTERNAL ROTATION STRUCTURES DEMONSTRATED
Lateral aspect of the patella free of superimposition of the femur
AP WEIGHT. BEARING KNEES PROJECTION
- Patient standing with knees fully extended against erect Bucky
- Patient weight equally distributed with both knees in true AP position
- CR directed horizontally entering at the mid way point 1;3 cm below the patella apices
- Usually done bilateral
- CR angle parallel with tibial plateau
AP WEIGHT. BEARING KNEES STRUCTURES DEMONSTRATED
- Arthritic knees
- Narrowing of joint space that appears normal on the non weight bearing study
- More accurate examination of the degree of lower extremity varus or value deformity
-
VARUS DEFORMITY ON WEIGHT BEARING KNEES
Demonstrates a narrowed medial knee compartment
VALGUS DEFORMITY ON WEIGHT BEARING KNEES
Demonstrates a narrowed lateral knee compartment
PA PATELLA PROJECTION
- Patient prone with toes resting on the table
- Affected leg straight in true PA position
- CR entering the mid popliteal area exiting the patellar
PA PATELLA PROJECTION STRUCTURES DEMONSTRATED
- Open femorotibial joint space
- Slight superimposition of the Fibular head with the tibia
LATERAL PATELLA PROJECTION
- Turn patient towards affected side until the knee is lateral
- Flex the knee 5-10 deg to relax muscles NB: Not more than 10
- Patella perpendicular to the IR
- CR directed to the knee joint at the midpatellofemoral joint
LATERAL PATELLA PROJECTION STRUCTURES DEMONSTRATED
- Patella in profile
- Open femoropatellar space
PATELLA TANGENTIAL PROJECTION
- NB= Fragment displacement needs to be ruled out with a lateral projection before a tangential is performed
- Patient supine
- Flex knee 40-45deg or until patella is perpendicular to IR
- No leg rotation
- Place IR on edge, resting on mid thighs
- Adjust the leg so that it’s long axis is vertical
- CR Directed inferosuperior 10-15 deg depending on the fox ion of the leg
PATELLA TANGENTIAL PROJECTION STRUCTURES DEMONSTRATED
- Vertical fractures of the bone
- PATELLOFEMORAL articulation
INTERCONDYLOID FOSSA PA AXIAL PROJECTION ( Camp- Coventry Method )
- Patient in prone position with femoral portion of the knee on the IR
- Flex the knee 40 deg
- Ensure that there is no rotation
- Tilt tube to be perpendicular with TIB fib +-40 deg
- CR at the centre of the knee joint
INTERCONDYLOID FOSSA PA AXIAL PROJECTION ( Holmblad Method)
- Patient in prone position kneeling on the table ( all fours) leaning forward about 20 deg
- Ensure patient knee is in true PA position
- CR perpendicular to the lower leg entering popliteal fossa exiting apex of the patella
INTERCONDYLOID FOSSA PA AXIAL PROJECTION
- Open intercondyloid fossa, tibial spines
- Apex of patella not superimposing the fossa
- Detection of joint mice ( loose bodies)
AP AXIAL INTERCONDYLOID FOSSA PROJECTION ( Beclere Method )
For patient who can’t assume the prone position
- Patient supine
- Partially flex the knee of interest 60 deg and provide padding support
- Place IR under neath knee
- Ensure true AP position; No rotation;
- CR perpendicular to lower leg (40-45 deg cephalad) directed 1;3 cm to the patella apex
-
AP AXIAL INTERCONDYLOID FOSSA PROJECTION ( Beclere Method )STRUCTURES DEMONSTRATED
- INTERCONDYLOID fossa in profile, open with out superimposition by patella apex
- Tibial spines
- Tibial plateau and femoral condyles are seen
AP FEMUR PROJECTION
- Patient in supine position
- Femur cantered to the midline of the table/ IR
- The body in true AP position
- Internally rotate the affected leg 10-15 to open up the femoral neck
- Collimate from the top of the ASIS to 5cm below the knee
- CR mid shaft
FFEMUR PROJECTION STRUCTURES DEMONSTRATED
- Femoral neck not foreshortened
- Greater trochanter
- Include both joints, included
FEMUR LATERAL PROJECTION
- Have patient turn on to affected side
- Centre affected thigh in the mid line of table
- Adjust pelvis to open up the hip joint ( proximal femur)
- Adjust pelvis to true lateral position ( distal femur)
- CR Mid shaft to include hip ( proximal femur)
- CR Mid shaft to include knee (Distal femur )
FEMUR LATERAL PROJECTION STRUCTURES DEMONSTRATED
BOth joints included
AP AXIAL FOOT IMAGE ANALYSIS
- Include for toes to proximal calcaneus
- Ensure No rotation medially or laterally
- Open joint space between the medial and intermediate cuneiforms
- Tarsometatarsal joint space open
- Navicular- cuneiform joint space is open
AP OBLIQUE PROJECTION IMAGE ANALYSIS
- 3rd-5th metatarsals are free from superimposition
- 5th metatarsal tuberosity in profile
- Sinus tarsi
- Open cuboid and calcaneous space
- Open cuboid and fourth and fifth metatarsal space
- Open cuboid and the lateral cuneiform space
- Open Talus and navicular space
GOUT
This is deposition of Uris acid crystals in the joints which is caused by increase of blood level Uric acid.
- Manifests as painful arthritis primarily in the first metatarsophalangeal joint.
OSTEOARTHRITIS
Degenerative joint disease which mainly affects weight- bearing joints (hips, knee, ankles and spine
-
OSTEOARTHRITIS RADIOGRAPHIC APPEARANCE
- Loss of joint cartilage
- Joint space narrowing
- Development of small bony spurs
OSTEOGENIC SARCOMA
Malignant bone tumour, typically found in end of long bones especially above the knees.
- Patient May complaining of localised pain and swelling, may also exhibit a fever, weight loss and anemia
RADIOGRAPHIC appearance of sunburst pattern and or mixed destructive and sclerotic lesion
EWINGS SARCOMA
Malignant tumour often seen in children,
- Found in bone marrow and soft tissue of long bones ( pelvis and or femur)
Clinical signs- Bone pain and fever
RADIOGRAPHIC appearance- Bone destruction in the medullary canal
MULTIPLE MYELOMA
Malignant condition which results in bone destruction.
- Malignant plasma cells rapidly divide and remove normal blood cells
Clinical signs = anemia and fatigue
RADIOGRAPHIC appearance = Multiple lessions throughout the bone
= Commonly found in bones containing red bone marrow ( pelvis, ribs, vertebrae)
OSGOOD- SCHLATTER DISEASE
Incomplete avulsion of the tibial tuberosity
OSTEOID OSTEOMA
Benign lession of cortical bone
SHOCK ABSORBER WITHIN THE KNEE JOINT
MENISCI CARTILAGE
TENDON THAT ECASES OR SURROUNDS THE PATELLA
Quadriceps Femoris
