Radiography Protocols (CUH)

Lower limb

  1. Toes
    1. DP
    2. DP Oblique
  2. Hallux
    1. DP
    2. Lateral
  3. Foot
    1. DP
    2. DP Oblique 
    3. Lateral - may be ordered by senior medical staff in cases of a suspected Lisfranc injury
  4. Ankle
    1. Mortice
    2. Lateral Requests for tib/fib & ankle must have separate ankle views centred over the joint space.
    3. Foot & Ankle Should not be ordered routinely.
    4. Ottowa ankle rules are used in the ED.
  5. Calcaneum
    1. Axial
    2. Lateral
  6. Tibia & Fibula
    1. AP
    2. Lateral full length.
      1. Include both joints.*
      2. Requests for tib/fib & ankle must have separate ankle views centred over the joint space. 
      3. * Fractures of the ankle involving the joint space must have tib/fib full length views, to show knee & ankle joints together.
  7. Knee
    1. AP
    2. Horizontal Beam Lateral
  8. Patella
    1. PA if possible, AP if not
    2. Horizontal Beam Lateral
    3. * Modified 20o skyline may be possible if patient is holding knee in a partially bent position.
    4. * Regular skyline views are rarely indicated. If requested do only after the referring doctor or a radiologist has seen the AP & Latl
  9. Femur
    1. AP - both joints on one film if possible
    2. Lateral from knee up
    3. Lateral NOF view only if clinically indicated
  10. Hips & Pelvis
    1. AP   For those with #NOF include 15cms of femur below the lesser trochanter for surgical planning.
    2. Lateral NOF must be horizontal beam for ?#
  11. Prostheses
    1. Patients with prosthesis do not need a lateral NOF view.
    2. They may need a full length femur as #s below the tip of the prosthesis are likely after trauma.
  12. DHS
    1. Patients with hip pinnings do need a lateral NOF.

Upper limb

  1. Fingers
    1. PA, include the finger next to the injured one. 
    2. Lateral
  2. Hand
    1. PA
    2. PA oblique
    3. Lateral - only if requested by senior medical staff.
  3. Thumb
    1. AP
    2. Lateral
  4. Wrist
    1. PA
    2. Lateral
  5. Scaphoid
    1. Presentation and follow up Full series
    2. PA with ulnar deviation 
    3. Anterior oblique with ulnar deviation 
    4. Lateral wrist
    5. Posterior oblique or Elongated scaphoid, 30o cranial angulation
  6. Forearm
    1. AP include both joints
    2. Lateral * All requests for forearm & elbow must have separate elbow views.
  7. Elbow
    1. AP
    2. Lateral
  8. Radial Head Full 3600 rotation of the radial head is achieved by the following 4 positions
    1. AP elbow
    2. True lateral thumb up
    3. Palm down
    4. Tthumb down
  9. Radial head views are almost never needed but if requested by senior medical staff after the AP and Lateral have been seen then do
    1. True lateral palm down
    2. True lateral thumb down or Lateral with 450 angulation cranially
  10. Humerus
    1. AP include both joints
    2. Lateral
  11. Shoulder ? dislocation
    1. Oblique axial - View of choice for ?dislocation
  12. Shoulder post relocation
    1. AP
    2. Oblique axial (15% of anterior dislocations have avulsions of the greater tuberosity not seen on AP only).
  13. Shoulder other injuries
    1. AP - hand supinated, no rotation of the patient (rotation can mimic posterior dislocation)
    2. Tailor the second projection to the injury. Choice of:
      1. Axial - if patient can assume the position, best overall second view 
      2. Y view - good overall second view 
      3. AP with internal rotation of humerus - to show greater tuberosity
  14. Clavicle
    1. PA or AP - include whole shoulder area
  15. AC joints
    1. AP of shoulder generally suffices.
    2. * Weight-bearing views requested requested by senior medical staff only
  16. Scapula
    1. AP shoulder 
    2. Y - view /lateral scapula

Thorax

  1. Chest
    1. Erect positioning if possible 
    2. PA if possible (AP if not)
    3. Lateral if indicated by the PA
  2. Minor trauma Low kV (65-77kV) CXR only in certain circumstances.
  3. Moderate /Major trauma Low kV CXR for demonstration of pneumo/haemothorax, rib, clavicular and scapular fractures, mediastinal widening / shift, aorta, fluid, lung contusion.
  4. Obliques specifically for demonstration of ribs are not indicated.
  5. Pneumothorax
    1. Low to medium kV CXR inspiration only
  6. Cardiology patients & others with no history of trauma
    1. High kV (80-110kV) CXR
  7. Pre-op CXR Not done routinely. All CXR requests must have clinical data with medical justification for the examination. (SI 478/ CUH Anaesthetic department)
  8. Sternum
    1. Lateral with grid
    2. CXR for demonstration of possible spinal, aortic and thoracic injuries following trauma
  9. Inhaled Foreign Body
    1. This is under review and may change.
    2. PA or AP CXR
    3. Lateral include neck on paediatric CXR

Abdomen

  1. Trauma
    1. PFA supine (may be KUB)
  2. GI Tract
    1. AP Supine
    2. Erect CXR may also be requested
  3. Renal system
    1. PFA supine
    2. Limited (3 film) IVU if indicated by radiologist/urologist
  4. Ingested Foreign body
    1. Small round foreign bodies e.g. coins do not need to be located by x-ray.
    2. Exception - anything toxic such as batteries, which could leak. (See Foreign bodies all areas )
  5. Erect PFA is never indicated

Multiple Trauma

Resus Series: This series is not meant to be detailed but a good series at this stage will not need repeats in the department and will therefore minimise the patient's radiation dose

  1. CXR - Low kV (65-77kV) To show free fluid, widened mediastinum, pneumo/haemothorax. Do not repeat a film which shows this, even if it is poor quality.
  2. Pelvis
    1. For assessing pelvic ring integrity. Must be good quality. Use a grid. Include the sacrum and transverse processes of L5 as well as pubic rami. Repeat if sacrum is not seen. Do not repeat (in resus) for hips.
  3. Lateral Cervical Spine
    1. Do last. C spine immobilisation must be maintained until the spine can be cleared.
  4. Departmental Series Will change according to the injuries but for all high-energy trauma expect requests for some or all of these:
    1. Cervical /Thoracic /Lumbar spine;
    2. Shoulders / Extremities;
    3. Calcaneum (in falls greater than 4m) Prioritise demonstration of serious/life-threatening injuries in case patient becomes unstable and imaging is cancelled.
    4. * If no resus series was done start with 1. CXR and Pelvis. then do 2. lateral c spine 3. all other lateral spine views 4. AP spine views 5. all other views If resus series was done this is the order of imaging: 1. lateral spine views 2. AP spine views 3. all other views For spine and pelvis protocols see Section: Spine & Pelvis

 

Spine & Pelvis

  1. Cervical Spine
    1. AP
    2. Open mouth
    3. Lateral must include occiput to T1, soft tissues anteriorly & whole spinous processes posteriorly. (An AP projection of the skull will often show the odontoid peg when an open mouth is not possible),
  2. C7/T1
    1. Coned True Lateral (CTL) - for those whose lateral had 6 or more vertebrae visible. Must include whole of spinous processes for identification of levels and repeat for these if necessary. Very low dose.
    2. Swimmers - where CTL is unsuitable or did not work.
    3. Flexion / extension views may be requested by orthopaedics and EM consultants when suspecting ligamentous injury.
  3. Thoracic Spine
    1. AP
    2. Horizontal beam lateral.
  4. Lumbar Spine
    1. AP
    2. Horizontal beam lateral.

Hips & Pelvis

  1. Hips & Pelvis
    1. AP. - * For those with #NOF include 15cms of femur below the lesser trochanter for surgical planning.
    2. Lateral NOF - ? # - must be horizontal beam
  2. Prostheses
    1. Patients with prosthesis do not need a lateral NOF view. They may need a full length femur as #s below the tip of the prosthesis are likely after trauma.
  3. DHS
    1. Patients with hip pinnings do need a lateral NOF
  4. Inlet/Outlet views
    1. Only when requested by the orthopaedic team. Rarely indicated in the ED.
  5. Coccyx
    1. Not indicated. Normal appearances are often misleading and findings do not alter management.

Foreign Bodies - all areas

  1. Under review by ED and Radiology consultants. For the moment the following is the protocol.
    1. AP/PA
    2. Lateral for localisation PLUS
    3. Tangential for FBs in face and head area
  2. Inhaled Foreign Body
    1. PA or AP CXR
    2. Lateral CXR *Include neck on paediatric CXR
  3. Ingested Foreign body
    1. Small round foreign bodies e.g. coins do not need to be located by x-ray unless inhalation is suspected.
    2. Exception: anything toxic such as batteries, which could leak, or sharp objects which could cause perforation.
    3. If indicated do;
      1. Adults - 1. Lateral CXR only; include neck
      2. Children - 1. PA (or AP) CXR; include neck
    4. Sharp objects may have to be followed up by x-ray over a period of time.
    5. PFA may be indicated also in this case

Fish Bone Visible on x-ray

  1. Cod, Haddock, Colefish, Lemon sole, Gurnard

More difficult to see

  1. Grey mullet, Plaice, Monkfish, Red snapper

Not visible on x-ray

  1. Herring, Kipper, Salmon, Mackerel, Trout, Pike

Skull & Facial bones

  1. Skull
    1. Unreliable history/drunk/difficult assessment are not indications for a skull x-ray.
  2. Indications for SXR in adult
    1. Penetrating trauma 
    2. ? depressed skull #
  3. Indications for SXR in child (please see Paediatric Head Injury) - all others requiring imaging need a CT scan.
    1. Penetrating trauma
    2. Head injury with suspected NAI
  4. Skull Views
    1. AP
    2. Lateral
    3. Townes if suspected occipital injury.
  5. Facial Bones
    1. ? # zygoma
      1. OM
      2. OM 30
    2. Facial Bones - all other queries
      1. OM only unless # seen then
      2. OM
      3. OM 30
  6. Sinuses
    1. Not indicated unless sinusitis has persisted for more than 10days on appropriate treatment. If this is the case:
      1. OM only
  7. Orbits ?# 
    1. Undertilted OM
    2. ?FB
      1. Eyes UP but if FB seen also do: Eyes DOWN
  8. Mandible
    1. OPG
  9. TMJs Clinical diagnosis X-ray not necessary in ED
  10. Nasal Bones Not indicated in the ED. (Maxillo-facial follow-up).

Paediatrics

  1. Extremities - AP and lateral (or oblique) as for adult.
  2. Foreign bodies - See above
  3. Skull Under review by the Radiology and EM consultant staff.
    1. If indicated do: - AP & Lateral  Where occipital injury exists include Townes
    2. < 2yrs - indicated in ?NAI 
    3. Over 2 yrs - As above.
  4. Pelvis
    1. Under 5 yrs - AP only
    2. Perthes - AP and frog lateral 
    3. Trauma - AP and lateral of affected side
    4. Over 5 yrs - AP & frog lateral.
    5. Slipped upper femoral epiphysis (SUFE) - AP and frog lateral

Emergency IVU

Indications: Renal colic

  1. KUB
  2. 5 minute renal area
  3. 20 minute full length
  4. Post micturition full length
  5. Delayed films as needed
  6. Always done in conjunction with a radiologist who may change this protocol as necessary.

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