Radiographic Positioning

1. 301 – A POSITIONING
Leg (TF) to Foot

2. Lower Limb
Distal Lower Limb. The bones of the distal lower
limb are divided into the foot, leg, and distal
femur. The ankle and knee joints. The proximal
femur and the hip are included along with the
pelvic girdle.
FOOT The bones of the foot are fundamentally
similar to the bones of the hand and wrist,
The 26 bones of one foot are divided into three
groups as follows:
1. Phalanges (toes or digits)
14
2. Metatarsals (instep)
5
3. Tarsals
7

3. Leg
(TF)
LEG - TIBIA AND FIBULA The second group of bones of the
lower limb to be studied in this chapter consists of the two
bones of the lower leg: the tibia and fibula.

4. LEG AP PROJECTION
CI - Pathologies involving fractures, foreign
bodies, or lesions of the bone
SID: 40”. IR size—35 × 43 cm (14 × 17 inches)
Place the patient in the supine position.
Medially rotate leg 5° for true AP projection.
Femoral epicondyles are parallel to IR.
CR - perpendicular to IR, directed to midpoint of
leg
Anatomy Demonstrated: • Entire tibia and fibula
must include ankle and knee joints on this
projection (or two if needed). • The exception is
alternative routine on follow-up examinations.

5. LATERAL - MEDIOLATERAL PROJECTION:
LEG TIBIA AND FIBULA
Place patient in the lateral recumbent position,
injured side down
Ensure that both ankle and knee joints are 1 – 2”
(3 to 5 cm) from ends of IR so that divergent rays
do not project either joint off IR.
CR - perpendicular to IR, directed to midpoint of
leg
Anatomy Demonstrated:
• Entire tibia and fibula must include ankle and
knee joints on this projection (or two if needed).
• Exception is alternative routine on follow-up
examinations.
Distal fibula lying posterior over half of the tibia.
Tibial tuberosity in profile
Overlap tibia on the proximal fibular head.

6. LEG OBLIQUE PROJECTIONS MEDIAL
AND LATERAL OBLIQUES
Rotate leg 45° medially.
Demonstrate proximal and tibiofibular joint.
AP oblique leg. medial rotation. showing a
fixation device.
Rotate leg 45° laterally.
Fibula superimposed by lateral portion of
the tibia.
AP oblique leg. lateral rotation. with a
fixation device in place.

7. Foot

8. T
O
E
S

9. AP / AP Axial PROJECTION: TOES
CI • Fractures or dislocations of the phalanges of the
digits in question • Pathologies such as
osteoarthritis and gouty arthritis (gout), especially in
the first digit
SID - 40 inches (102 cm) • IR size - 18 × 24 cm (8 × 10
inches)
Part pos., Center and align long axis of digit to CR
and long axis of portion of IR being exposed. •
Ensure that MTP joint of digit in question is centered
to CR.
AP PROJECTION • CR perpendicular to 3rd MTP (if
15° wedge is placed under foot).
AP AXIAL PROJECTION •
CR 10°-15° posteriorly to 3rd MTP (to open-up joint
space)
Anatomy Demonstrated: • Digits of interest and a
minimum of the distal half of metatarsals should be
included.

10. TOES PA PROJECTION
Patient prone on the x-ray table with the
dorsal aspect in contact with the IR.
CR - perpendicular to 3rd MTP joint.
Well demonstrated IP joint spaces because
the natural divergence of the x-ray beam
coincides closely with the position of the
toes.

11. AP OBLIQUE PROJECTION - MEDIAL OR
LATERAL ROTATION: TOES
CI • Fractures or dislocations of the phalanges of
the digits in question • Pathologies such as
osteoarthritis and gouty arthritis (gout), especially
in the first digit
Medially rotate leg 30°-45° from the plane of the IR.
For 1st, 2nd and 3rd digit
Laterally rotate leg 30°-45° from the plane of the IR
For 4th and 5th digit.
CR - perpendicular to 3rd MTP joint
Anatomy Demonstrated: • Digits in question and
distal half of metatarsals should be included without
overlap (superimposition).
Routine position of the foot that gives a different
perspective than that of the AP.

12. LATERAL - MEDIOLATERAL OR
LATEROMEDIAL PROJECTIONS: TOES
Patient in lateral recumbent position.Rotate affected
leg and foot medially (lateromedial) for first, second,
and third digits and laterally (mediolateral) for fourth
and fifth digits.
1ST - 2nd digit
• Lateral recumbent on unaffected side.
2nd - 5th digit
• Lateral recumbent on affected side.
CR - perpendicular to PIP joint
Anatomy Demonstrated: • Phalanges of digit in
question should be seen in lateral position free of
superimposition by other digits, if possible. • (When
total separation of toes is impossible, especially
third to fifth digits, the distal phalanx at least should
be separated, and the proximal phalanx should be
visualized through superimposed structures.)

13. TANGENTIAL PROJECTION: TOES –
SESAMOIDS LEWIS METHOD
CI - This projection provides a profile image of the
sesamoid bones at the first MTP joint for evaluation of
extent of injury
Patient in prone position
Dorsiflex the foot so that plantar surface of foot forms
about 15°-20° angle from vertical
CR - perpendicular and tangential to the 1st MTP joint.
Demonstrate possible fracture of the sesamoid bone.
Uncomfortable and often painful position for the
demonstration of the sesamoid bone.

14. TANGENTIAL PROJECTION: TOES—
SESAMOIDS HOLLY METHOD
Patient in supine/sitting position.
Plantar surface form an angle of 75° with plane of film.
CR- perpendicular to the head of the 1st metatarsal
bone
Sesamoid bone in profile
• A position that is more comfortable for the patient as
compared with Lewis method.
CR perpendicular to IR, directed tangentially to
posterior aspect of first MTP joint (depending on
amount of dorsiflexion of foot, may need to angle CR
slightly for a true tangential projection)
Demonstrate possible fracture of the sesamoid bone.

15. SESAMOID BONE CAUSTON METHOD
Patient in lateral recumbent position.
Directed to the prominence of the 1st MTP joint at
an angle of 40° toward the heel.
Sesamoid bone projected axiolaterally with a slight
overlap.

16. AP PROJECTION:
FOOT DORSOPLANTAR PROJECTION
CI - Location and extent of fractures and fragment
alignments, joint space abnormalities, soft tissue
effusions
• Location of opaque foreign bodies
SID—40 inches (102 cm) • IR size—
24 × 30 cm (10 × 12 inches),
CR - Angle CR 10° posteriorly (toward heel) with CR
perpendicular to metatarsals (see Note). • Direct CR to
base of third metatarsal.
CR perpendicular to the base of the 3rd metatarsal.
Dorsoplantar is the preferred name for the AP
projection of the foot.
Anatomy Demonstrated: • Entire foot should be
demonstrated, including all phalanges and metatarsals
and navicular, cuneiforms, and cuboids.

17. AP PROJECTION: FOOT AP AXIAL PROJECTION
Clinical Indications
• Location and extent of fractures and fragment
alignments, joint space abnormalities, soft tissue
effusions • Location of opaque foreign bodies
Part Position • Extend (plantar flex) foot but maintain
plantar surface resting flat and firmly on IR.
CR - 10° posteriorly towards the calcaneus entering the
base of the 3rd MT.
The purpose of the 10° posterior angulation is to place
the CR more perpendicular to the metatarsals therefore
reducing foreshortening.
TMT joint spaces of the midfoot best demonstrated.

18. AP OBLIQUE PROJECTION - MEDIAL ROTATION:
FOOT
Clinical Indications
• Location and extent of fractures and fragment alignments,
joint space abnormalities, soft tissue effusions
• Location of opaque foreign bodies
Part pos., Rotate foot medially to place plantar surface
30° to 40° to plane of IR
CR - perpendicular to IR, directed to base of 3rd metatarsal
NOTE: Some references suggest only a 30° oblique
routinely. This text recommends greater obliquity, 40° to
45°, to demonstrate tarsals and proximal metatarsals best
relatively free of superimposition for the foot with an
average transverse arch.
3rd - 5th MT bases free of superimposition
Tuberosity of 5th MT well seen
Best demonstrate the cuboid bone and Sinus tarsi

19. FOOT AP OBLIQUE PROJECTION LATERAL
OBLIQUE
Clinical Indications
• Location and extent of fractures and fragment
alignments, joint space abnormalities, soft tissue
effusions
• Location of opaque foreign bodies
Rotate foot laterally 30°- 45° to plane of IR.
CR perpendicular to IR, directed to medial
cuneiform (at level of base of 3rd metatarsal)
Best demonstrate the 1st and 2nd MT.
Best demonstrate the navicular bone.
Space between 1st and 2nd cuneiforms.

20. FOOT PA PLANTODORSAL OBLIQUE GRASHEY
METHOD
Patient in prone position
CR perpendicular to base of 3rd metatarsal.
Alternative projection for medial or lateral oblique of the
foot.
1. Rotate foot and heel medially 30°
Navicular
Same as AP lateral oblique
demonstrate interspaces between 1st & 2nd metatarsal
2. Rotate foot and heel laterally 20°
Demonstrate interspaces between 2nd, 3rd, 4th & 5th
metatarsal
Tuberosity of 5th metatarsal
Cuboid same as AP medial oblique

21. LATERAL - MEDIOLATERAL OR
LATEROMEDIAL PROJECTIONS: FOOT
Flex knee of affected limb about 45°; place
opposite leg behind the injured limb to
prevent over-rotation of affected leg.
CR - perpendicular to IR, directed to medial
cuneiform (at level of base of 3rd metatarsal)
Alternative lateromedial projection A lateromedial
projection may be taken as an alternative lateral.
This position can be more uncomfortable or
painful for the patient, but it may be easier to
achieve a true lateral.
Anatomy Demonstrated: • Entire foot should
be demonstrated, with a minimum of 1” (2.5
cm) of distal tibia-fibula. • Metatarsals are
nearly superimposed with only the tuberosity
of the fifth metatarsal seen in profile.

22. AP WEIGHT-BEARING PROJECTIONS: FOOT
Clinical Indications • Demonstrate the bones of the feet to
show the condition of the longitudinal arches under the full
weight of the body • May demonstrate injury to structural
ligaments of the foot such as a Lisfranc joint injury
NOTE: Bilateral projections of both feet often are taken for
comparison. Some AP routines include separate
projections of each foot taken with CR centered to
individual foot.
Patient pos,. in standing erect with full weight evenly
distributed on both feet
CR 15° posteriorly to midpoint between feet at the level of
the base of metatarsal.
This projection can be used to show the alignment of the
metatarsals and phalanges in cases of hallux valgus.
Hallux valgus is the commonest forefoot deformity, with an
estimated prevalence of 23% to 35%. It causes symptoms
on the medial edge of the foot, the sole, and the small toes.
Non-operative treatment may alleviate symptoms but does
not correct the deformity of the big toe

23. LATERAL WEIGHT-BEARING PROJECTIONS: FOOT
Have patient stand erect, with weight evenly
distributed
Horizontally directed to a point just above the
base of the 3rd metatarsal.
Demonstrate the structural status of the
longitudinal arches under full weight bearing.
Best demonstrate pes planus or flat foot
Flatfoot (pes planus) is a condition in which the
longitudinal arch in the foot, which runs
lengthwise along the sole of the foot, has not
developed normally and is lowered or flattened
out. One foot or both feetmay be affected.

24. AP AXIAL PROJECTION WEIGHT-BEARING
COMPOSITE METHOD Standing
SID: 40” IR: 24 x 30 cm lengthwise
Patient standing upright, adjust the IR under the
foot and center its midline to the long axis of the
foot
CR - Frontal projection of all bones of the foot
using the masking effect of the leg. With the tube
in front of the patient and adjusted for a
posterior angulation of 15˚, center the central ray
to the base of the third metatarsal for the first
exposure
AD - The following should be clearly
demonstrated: • All tarsals
• Shadow of leg not overlapping the tarsals •
Foot not rotated • Tarsal , metatarsals, and toe
with similar densities

25. Congenital Clubfoot AP PROJECTION
KITE METHODS
The typical clubfoot, called talipes equinovarus, hows
three deviations from the normal alignment of the foot in
relation to the weight-bearing axis of the leg.
The classic Kite methods - exactly placed AP and lateral
projections for radiography of the clubfoot are used to
demonstrate the anatomy of the foot and the bone or
ossification centers of the tarsal and their relation to one
another. Ossificstion means the natural process of bone
formation
Place the infant in the supine position, with the hip and
knees flexed to permit the foot to rest flat on the fR.
Elevate the body on firm pil lows to knee height to
simplify both gonad shielding and leg adjustment.
CR perpendicular midway between the tarsals (Bilateral).
15° posteriorly (CR perpendicular to tarsal area).
(15°) True relationship and ossification centers of the
tarsals.
Demonstrate the degree of inversion of the calcaneus.
Demonstrate the degree of adduction of the forefoot.

26. Congenital Clubfoot AXIAL PROJECTION
Dorsoplantar KANDEL METHOD
For this method the infant is held in a vertical or a
bending-forward position.
CR - 40° anteriorly through the lower leg.
Démontrâtes sustentaculum talar joint fusion.
Recommended dorsoplantar axial projection of the
patient with clubfoot.

27. PLANTODORSAL (AXIAL) PROJECTION:
LOWER LIMB - CALCANEUS
Clinical Indications • Pathologies or fractures with
medial or lateral displacement
PX pos., Supine/sitting
Direct CR to base of 3rd metatarsal to emerge at a
level just distal to lateral malleolus.
Angle CR 40° cephalad from long axis of foot (which
also would be 40° from vertical if long axis of foot is
perpendicular to IR
Best demonstrate medial or lateral displacement of
the calcaneus.
Open Talocalcaneal joint
Sustentaculum tali

28. AXIAL PROJECTION Dorsoplantar
Place the patient in the prone position.
Elevate the patient's ankle on sandbags.
CR 40° caudad to dorsal surface of the ankle
joint.
Best demonstrate medial or lateral displacement
of the calcaneus.
Axial projection of the calcaneus
Open Talocalcaneal joint
Sustentaculum tali

29. CALCANEUS WEIGHT BEARING
COALITION METHOD
Patient in standing upright position
Unaffected foot placed 1 step forward.
CR 45° anteriorly to posterior surface of flexed
ankle at the level of the base of the 5th
metatarsal.
Demonstrate the calcaneotalar coalition.

30. LATERAL-MEDIOLATERAL PROJECTION:
LOWER LIMB - CALCANEUS
Clinical Indications • Bony lesions involving
calcaneus, talus, and talocalcaneal joint •
Demonstrate extent and alignment of fractures
Place patient in lateral recumbent position, affected
side down. Provide a pillow for patient’s head. Flex
knee of affected limb about 45°; place opposite leg
behind injured limb.
CR perpendicular to IR, directed to a point 1 inch
(2.5 cm) inferior to medial malleolus
Anatomy Demonstrated: • Calcaneus is
demonstrated in profile with talus and distal tibia-
fibula demonstrated superiorly and navicular and
open joint space of the calcaneus and cuboid
demonstrated distally.
Best demonstrate calcaneal spur.

31. Calcaneus LATEROMEDIAL OBLIQUE PROJECTION
WEIGHT-BEARING METHOD
Have the patient stand with the affected heel centered
toward the lateral border of the IR
Part pos., Center the calcaneus so that it will be
projected to the center of the IR. • Center the lateral
malleolus to the midline axis of the IR.
CR - Directed medially at a caudal angle of 45˚ to enter
the lateral malleolus.
Anatomy Demonstrate• Calcaneal tuberosity • Sinus
tarsi • Cuboid
Useful in diagnosing stress fractures of the calcaneus
and tuberosity.

32. Subtalar Joint PA AXIAL OBLIQUE
PROJECTION Lateral rotation
Have the patient lie on the affected side in the
lateral position.
Ask the patient to extend the affected limb. •
Roll the Limb lightly forward from the lateral
position.
CR - Directed to the ankle joint at a double angIe
of 5˚ anterior and 23˚ caudal.
The following should be clearly demonstrated: •
Open subtalar (talocalcaneal) joint articulations
• Sinus tarsi • Lateral malleolus seen in profile

33. Subtalar Joint AP AXIAL OBLIQUE PROJECTION
BRODEN METHOD! Medial Rotation
Broden! recommended the lateromedial and
mediolateral right-angle oblique projection for
demonstration of the posterior articular facet of the
calcaneus to determine the presence of joint
involvement in cases of comminuted fracture.
Place the patient in the supine position. o Adjust a
small sandbag under each knee.
Adjust the IR so that the lower edge is about 1 inch
(2.5 cm) distal to the plantar surface of the heel
CR - Angled cephalad at 40, 30, 20, and 10˚,
respectively. Four separate images are obtained
For each image, direct the central ray to a point 2 or
3 cm caudoanteriorly to the lateral malleolus, to the
midpoint of an imaginary line
Demonstrated: • Anterior and posterior portions of
the posterior subtalar joint

35. Subtalar Joint AP AXIAL OBLIQUE PROJECTION
BRODEN METHOD Lateral rotation
Place the patient in the supine position. • Adjust a
small sandbag under each knee.
With the patient's ankle joint held in right-angle
flexion, rotate the leg and foot 45˚ laterally
Directed to a point 2 cm distal and 2 cm anterior to
the medial malleolus, at a cephalic angle of 15
degrees for the first exposure • Two or three images
may be made with a 3- or 4-degree difference in
central ray angulation
Demonstrated: • Posterior portion of the subtalar
joint

36. Subtalar Joint LATEROMEDIAl OBLIQUE
PROJECTION ISHERWOOD METHOD
Medial rotation foot
Isherwood devised a method for each of the three
separate articulations of the subtalar joint: (I) a
medial rotation foot position for the demonstration
of the anterior talar articular surface, (2) a medial
rotation ankle position for the middle talar articular
urface, and (3) a lateral rotation ankle position for
the posterior talar articular surface. Feistl later
described a similar position.
Ask the patient to flex the knee enough to place
the ankle joint in nearly right angle flexion and
then to lean the leg and foot medially.
CR - Perpendicular to a point 1 inch (2.5 cm) distal
and 1 inch (2.5 cm) anterior to the lateral malleolus
Demonstrated: • Anterior talar articular surface

37. Subtalar Joint AP AXIAL OBLIQUE PROJECTION
ISHERWOOD METHOD Medial rotation ankle
a semi lateral recumbent position is more comfortable,
adjust the patient accordingly.
Ask the patient to rotate the leg and foot medially enough
to rest the side of the foot and affected ankle on an
optional 30-degree foam wedge
CR - Directed to a point I inch (2.5 cm) distal and I inch
(2.5 cm) anterior to the lateral malleolus at an angle of 10
degrees cephalad.
Demonstrated: • Middle (subtalar) articulation • Open
sinus tarsi

38. ANKLE JOINT AP PROJECTION
Bony lesions or diseases involving the ankle joint,
distal tibia and fibula, proximal talus, and proximal
fifth metatarsal The lateral portion of the ankle joint
space should not appear open on this projection—
see AP Mortise Projection
Place patient in the supine position; place pillow
under patient’s head; legs should be fully extended
Adjust ankle joint in a true AP position by flexing
the ankle & foot (5 degree medial rotation of leg and
foot).
CR- perpendicular to IR, directed to a point midway
between malleoli
Anatomy Demonstrated: • Distal one-third of tibia-
fibula, lateral and medial malleoli, and talus and
proximal half of metatarsals should be
demonstrated
Tibiotalar joint space should be seen.

39. Ankle LATERAL PROJECTION Mediolateral
Have the supine patient turn toward the affected
side until the ankle is lateral
Dorsiflex the foot, and adjust it in the lateral
position. Dorsiflexion is required to prevent lateral
rotation of the ankle.
CR - Perpendicular to the ankle joint, entering the
medial malleolus
Demonstrated: • Ankle joint centered to exposure
area • Tibiotalar joint well visualized, with the medial
and lateral talar domes superimposed • Fibula over
the posterior half of the tibia • Distal tibia and fibula,
talus, and adjacent tarsals • Density of the ankle
sufficient to see the outline of distal portion of the
fibula
Tibiotalar joint well visualized

40. Ankle LATERAL PROJECTION Lateromedial
It is often recommended that the lateral projection of
the ankle joint be made with the medial side of the
ankle in contact with the IR. Exact positioning of the
ankle more easily and more consistently obtained
when the limb is rested on its comparatively flat
medial surface.
Have the supine patient turn away from the affected side
until the extended leg is placed laterally.
Have the patient turn anteriorly or posteriorly as required to
place the patella perpendicular to the horizontal plane
CR - Perpendicular through the ankle joint, entering 2 inch
(1.3 cm) superior to the lateral malleolus
Demonstrated: • Ankle joint centered to exposure area •
Tibiotalar joint well visualized, with the medial and lateral
talar dome superimposed • Fibula over the posterior half of
the tibia • Distal tibia and fibula talus , and adjacent tarsals •
Density of the ankle sufficient to see the outline of distal
portion of the fibula

41. Ankle AP OBLIQUE PROJECTION Medial rotation
Place the patient in the supine position with the
affected limb fully extended.
Rotate the patient's leg primarily and the foot for all
oblique projections of the ankle. Because the knee is
a hinge joint,
CR - Perpendicular to the ankle joint, entering
midway between the malleoli
Demonstrated: • Distal tibia, fibula, and talus • Distal
tibia and fibula overlap some of the talus • Talus and
distal tibia and fibula adequately penetrated •
Tibiofibular articulation

42. ANKLE MORTISE PROJECTION

43. AP MORTISE PROJECTION - 15° TO 20°
MEDIAL ROTATION: ANKLE
CI - • Evaluation of pathology involving the entire
ankle mortise* and the proximal fifth metatarsal,
a common fracture site
Part post. Internally rotate entire leg and foot
about 15° to 20° until intermalleolar line is
parallel to IR
CR perpendicular to IR, directed midway
between malleoli
Alternate or supplemental view for the ankle.
Useful in evaluating pathology of the entire
ankle mortise.
Common projection taken during open reduction
surgery of the ankle joint.
Best demonstrate talofibular joint
3 sides of the mortise joint well visualized.

44. AP STRESS PROJECTIONS: ANKLE INVERSION AND
EVERSION POSITIONS
Stress studies of the ankle joint usually are obtained
after an inversion or eversion injury to verify the
presence of a ligamentous tear. involving ankle joint
separation secondary to ligament tear or rupture
PX Pos., Place patient in supine position; place pillow
under patient’s head; leg should be fully extended,
with support under knee.
Part pos., Stress is applied with leg and ankle in
position for a true AP with no rotation, wherein the
entire plantar surface is turned medially for inversion
and laterally for eversion.
CR - perpendicular to midway between malleoli.
Demonstrate possible ligament tear or rupture.
Inversion stress study demonstrate possible lateral
ligament tear.
Eversion stress study demonstrate possible medial
ligament tear.

45. B
A
AP STRESS PROJECTIONS: ANKLE INVERSION AND EVERSION POSITIONS

46. ANKLE AP WEIGHT-BEARING METHOD
This projection is performed to identify ankle joint
space narrowing with weight bearing.
Patient in upright position.
Have the patient stand with heels pushed back against
the cassette and toes pointing straight ahead toward
the x-ray tube
Central ray Perpendicular to the center of the cassette
Demonstrate an AP projection of both ankles.
Demonstrates relationship of tibia and fibula under
weightbearing condition.
Demonstrates side to side comparison of the ankle
joint.

47. LAW - ANKLE
1. Ankle Mediolateral
2. Ankle Lateromedial
3. ANKLE JOINT AP
4. Ankle AP weight-bearing
CR - ankle joint, entering the medial malleolus
BD - Tibiotalar joint well visualized
CR - ankle joint, entering 2” (1.3 cm) superior
to the lateral malleolus.
BD - Density of the ankle sufficient to see the
outline of distal portion of the fibula
CR - midway between malleoli.
BD - Tibiotalar joint space should be seen.
CR - Perpendicular to the center of the
cassette.
Demonstrate an AP projection of both ankles.
Demonstrates relationship of tibia and fibula under
weightbearing condition.

48. ANKLE
1. Ankle MORTISE
2. AP Stress Ankle
Inversion & eversion.
Internally rotate entire leg and foot about 15° to 20°
CR - directed midway between malleoli,
Best demonstrate talofibular joint
CR - perpendicular to midway between malleol.i
Demonstrate possible ligament tear or rupture.
Inversion stress study demonstrate possible lateral
ligament tear.
Eversion stress study demonstrate possible medial
ligament tear.