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Radiographic Technique 1
Prepared by:
Behzad Ommani
Bachelor of Radiology
Master of Medical Engineering
Instructor Radiology Group
September, 2011
Radiography
Toes
Toes
AP OR AP AXIAL PROJECTION
• Because of the natural curve of the toes, the
interphalangeal joint spaces are not best demonstrated
on the AP projection. When demonstration of these joint
spaces is not critical, an AP projection may be
performed .
• An Ap axial projection is recommended to open the joint
spaces and reduce foreshortening.
Image receptor: 8 x 10 inch (18 X 24 cm) crosswise for two
images on one IR.
Toes
Position at patient: Have the patient seated or placed
supine on the radiographic table.
Position of part :
• With the patient in the supine or seated position, flex the
knees, separate the feet about 6 inches (15 cm), and
touch the knees together for immobilization.
• Adjust the IR half with its midline parallel to the long
axis of the foot, and center it to the third
metatarsophalangeal joint.
Toes
Central ray :
• Perpendicular through the third metatarsophalangeal
joint .when demonstration of the joint spaces is not
critical.
• To open the joint spaces, either direct the central ray 15
degrees
posteriorly
through
the
third
metatarsophalangeal joint , or if the 15-degree foam
wedge is used, direct the central ray perpendicularly
Toes
Toes
PA PROJECTION
Image receptor: 8 x 10 inch (18 X 24 cm) crosswise for two
images on one IR.
Position at patient:
• Have patient lie prone on the radiographic table
because this position naturally turns the foot over so that
the dorsal aspect is in contact with the IR.
Toes
• Place the toes in the appropriate position by elevating
them on one or two small sandbags and adjusting the
support to place the toes horizontal.
• Place the IR half under the toes with the midline of the
side used parallel with the long axis of the foot, and
center it to the third metatarsophalangeal joint.
Toes
Central ray :
Perpendicular to the midpoint of the IR entering the third
metatarsophalangeal joint. The interphalangeal joint
spaces are shown well because the natural divergence of
the xray beam coincides closely with the position of the
toes
Toes
AP OBLIQUE PROJECTION
Medial Rotation
Image receptor: 8 x 10 inch (18 x 24 cm) crosswise for two
or more images on one IR.
Position of patient: Place the patient in the supine or seated
position on the radiographic table. Flex the knee of the
affected side enough to have the sole of the foot resting
firmly on the table.
Position of part :
• Position the IR half under the toes.
• Medially rotate the lower leg and foot, and adjust the
plantar surface of the foot to form a 30- to 45-degree
angle from the plane of the IR.
• Center the toes to the IR.
Toes
Central ray : Perpendicular and entering the third
metatarsophalangeal joint.
NOTE: Oblique projections of individual toes may be
obtained by centering the affected toe to the portion of
the IR being used and collimating closely. The foot may
be placed in a medial oblique position for the first and
second toes and in a lateral oblique position for the
fourth and fifth toes. Either oblique position is adequate
for the third (middle) toe.
Toes
Toes
LATERAL PROJECTION
Mediolateral or Lateromedial
• Image receptor: 8 x 10 inch (18 x 24 cm) crosswise for
multiple exposures on one IR.
Position of patient:
• Have the patient lie in the lateral recumbent position on
the unaffected side. Support the affected limb on
sandbags, and adjust it in a comfortable position.
• To prevent superimposition, tape the toes above the one
being examined into a flexed position; a 4 x 4 inch gauze
pad also may be used to separate the toes.
Toes
Position of part :
(Great toe, Second toe)
•
Place an 8 x 10 inch (18 X 24 cm) IR under the toe, and
center it to the proximal phalanx.
• Grasp the patient's limb by the heel and knee, and adjust
its position to place the toe in a true lateral position.
• Adjust the long axis of the IR so that is parallel with the
long axis of the toe.
Toes
Toes
(Third, fourth, fifth toes)
• Place the patient on the affected side for these three
toes. Select an 8 x 10 inch (18 x 24 cm) IR or an occlusal
film. If the occlusal film is used, place it with the
pebbled surface up between the toe being examined and
the subadjacent toe.
• Adjust the position of the limb to place the toe of
interest and the IR or film in a parallel position, placing
the toe as close to the IR or film as possible.
Toes
Toes
Central ray : Perpendicular to the plane of the IR or film,
entering the metatarsophalangeal joint of the great toe
or the proximal interphalangeal joint of the lesser toes.
Toes
TANGENTIAL PROJECTION
LEWISl AND HOLLY METHODS
Image receptor: 8 x 10 inch (18 x 24 cm) crosswise for
multiple exposures on one IR.
Position of patient:
• Place the patient in the prone position.
• Elevate the ankle of the affected side on sandbags for
stability, if needed. A folded towel may be placed under
the knee for comfort.
Position of part : Rest the great toe on the table in a
position of dorsiflexion, and adjust it to place the ball of
the foot perpendicular to the horizontal plane.
Toes
• Center the IR to the second metatarsal.
Central ray : Perpendicular and tangential to the first
metatarsophalangeal joint.
Toes
NOTE : Holly described a position that he believed was
more comfortable for the patient. With the patient seated
on the table, the foot is adjusted so that the medial
border is vertical and the plantar surface is at an angle
of 75 degrees with the plane of the IR. The patient holds
the toes in a flexed position with a strip of gauze
bandage. The central ray is directed perpendicular to
the head of the first metatarsal bone.
Toes
TANGENTIAL PROJECTION
CAUSTON METHODS
Image receptor: 8 x 10 inch (18 x 24 cm)
Position of patient:
• Place the patient in the lateral recumbent position on the
unaffected side, and flex the knees.
Position of part :
• Partially extend the limb being examined and put
sandbags under the knee and foot.
Toes
• Adjust the height of a sandbag under the knee to place
the foot in the lateral position, with the first
metatarsophalangeal joint perpendicular to the hori.
zontal plane of the IR.
• Place the IR under the distal metatarsal region, and
adjust it so that the midpoint will coincide with the
central ray.
Central ray : Directed to the prominence of the first
metatarsophalangeal joint at an angle of 40 degrees
towar.d the heel.
Toes
Radiography
Foot
Foot
AP or AP AXIAL PROJECTION
• Radiographs may be obtained by directing the central
ray perpendicular to the plane of the IR or by angling
the central ray 10 degrees posteriorly. When a 10
degree posterior angle is used, the central ray is
perpendicular to the metatarsals, therefore reducing
foreshortening. The tarsometatarsal joint spaces of the
midfoot are also demonstrated better.
Image receptor : 24 x 30 cm lengthwise
Position of patient:
• Place the patient in the supine position.
Foot
• Flex the knee of the affected side enough to rest the sole
of the foot firmly on the radiographic table.
Position of part :
• Position the IR under the patient's foot, center it to the
base of the third metatarsal, and adjust it so that its long
axis is parallel with the long axis of the foot.
• Hold the leg in the vertical position by having the
patient flex the opposite knee and lean it against the
knee of the affected side.
• In this foot position the entire plantar surface rests on
the IR; thus it is necessary to take precautions against
the IR slipping. .
• Ensure that no rotation of the foot occurs.
Foot
Central ray : Directed one of two ways:
(1) 10 degrees toward the heel to the Base of the third
metatarsal.
(2) Perpendicular to the IR and toward the Base of the third
metatarsal.
Foot
AP foot showing deformed
tarsal bones and displaced
medial cuneiform
AP foot of a 6-year-old patient.
Note the epiphyseal lines
Foot
AP OBLIQUE PROJECTION
Medial Rotation
Image receptor : 24 x 30 cm lengthwise
Position of patient :
• Place the patient in the supine position.
• Flex the knee of the affected side enough to rest the sole
of the foot firmly on the radiographic table.
Position of part :
Place the IR under the patient's foot, parallel with its long
axis, and center it to the midline of the foot at the level of
the base of the third metatarsal.
Foot
• Rotate the patient's leg medially until the plantar surface
of the foot forms an angle of 30 degrees to the plane of
the IR. If the angle of the foot is increased more than 30
degrees, the lateral cuneiform tends to be thrown over
the other cunei forms.
Central ray : Perpendicular to the Base of the third
metatarsal.
Foot
Foot
AP OBLIQUE PROJECTION
Lateral Rotation
Image receptor : 24 x 30 cm lengthwise
Position of patient :
• Place the patient in the supine position.
• Flex the knee of the affected side enough to rest the sole
of the foot firmly on the radiographic table.
Position of part :
Place the IR under the patient's foot, parallel with its long
axis, and center it to the midline of the foot at the level of
the base of the third metatarsal.
Foot
• Rotate the leg laterally until the plantar surface of the
foot forms an angle of 30 degrees to the IR.
• Support the elevated side of the foot on a 30-degree
foam wedge to ensure consistent results.
Central ray : Perpendicular to the Base of the third
metatarsal.
Foot
Foot
LATERAL PROJECTION
Mediolateral
Image receptor : 24 x 30 cm lengthwise
Position of patient :
• Have the patient lie on the radiographic table and turn
toward the affected side until the leg and foot are
lateral.
• Place the opposite leg behind the patient.
Position of part :
• Elevate the patient's knee enough to place the patella
perpendicular to the horizontal plane, and adjust a
sandbag support under the knee.
Foot
• Center the IR to the mid area of the foot, and adjust it so
that its long axis is parallel with the long axis of the foot.
• Dorsi flex the foot to form a 90-degree angle with the
lower leg.
Central ray : Perpendicular to the Base of the third
metatarsal.
Foot
Foot
LATERAL PROJECTION
Lateromedial
• Whenever possible, lateral projections of the foot should
be made with the medial side in contact with the IR. In
the absence of an unusually prominent medial malleolus,
hallux valgus, or other deformity, the foot assumes an
exact or nearly exact lateral position when resting on its
medial side.
• Although the medial position may be more difficult for
some patients to achieve, true lateral projections are
more easily and consistently obtained with the foot in
this position.
Foot
Image receptor : 24 x 30 cm lengthwise
Position of patient :
• Place the patient in the supine position. Turn the patient
onto the unaffected side until the affected leg and foot
are laterally placed. The patient's body will be in an
LPO or RPO position.
Position of part :
• Elevate the patient's knee enough to place the patella
perpendicular to the horizontal plane, and support the
knee on a sandbag or sponge.
• Center the IR to the middle area of the foot, and adjust it
so that its long axis is parallel with the long axis of the
foot.
Foot
• Adjust the foot so that the plantar surface is
perpendicular to the IR.
Central ray : Perpendicular to the Base of the Third
metatarsal.
Foot
Foot
LATERAL PROJECTION (Longitudinal Arch)
Lateromedial standing
WEIGHT-BEARING METHOD
Image receptor : 24 x 30 cm lengthwise
Position of patient :
• Place the patient in the upright position, preferably on a
low riser that has an IR groove. If such a riser is not
available, use blocks to elevate the feet to the level of the
x-ray tube If needed.
• use a mobile unit to allow the x-ray tube to reach the
floor level.
Foot
Position of part :
• Place the IR in the IR groove of the stool or between
blocks. Have the patient stand in a natural position, one
foot on each side of the IR, with the weight of the body
equally distributed on the feet.
• Adjust the IR so that it is centered to the base of the third
metatarsal. After the exposure, replace the IR and
position the new one to image the opposite foot.
Central ray : Perpendicular to a point just above the base
of the third metatarsal.
Foot
Foot
AP AXIAL PROJECTION
WEIGHT-BEARING METHOD - Standing
Image receptor : 24 x 30 cm crosswise for both feet on one
IR.
SID: 48 inches (122 cm). This SID is used to reduce
magnification and improve recorded detail in the image.
Position of patient : Place the patient in the standingupright position.
Foot
Position of part :
• Place the IR on the floor, and have the patient stand on
the IR with the feet centered on each side.
• Pull the patient's pants up to the knee level, if necessary.
• Ensure that right and left markers and an upright
marker are placed on the IR.
• Ensure that the patient's weight is distributed equally on
each foot .
• The patient may hold the x-ray tube crane for stability
Foot
Central ray :
Angled 10 degrees toward the heel is optimal. A minimum
of 15 degrees is usually necessary to have enough room
to position the tube and allow the patient to stand.
The central ray is positioned between the feet and at the
level of the base of the third metatarsal.
Foot
Foot
AP AXIAL PROJECTION
COMPOSITE METHOD
WEIGHT-BEARING METHOD - Standing
Image receptor : 24 x 30 cm lengthwise
Position of patient : Place the patient in the standingupright position. The patient should stand at a
comfortable height on a low stool or on the floor.
Foot
Position of part
• With the patient standing upright, adjust the IR under
the foot and center its midline to the long axis of the
foot.
• To prevent superimposition of the leg shadow on that of
the ankle joint, have the patient place the opposite foot
one step backward for the exposure of the forefoot and
one step forward for the exposure of the hindfoot or
calcaneus.
Foot
Central ray :
• To use the masking effect of the leg, direct the central
ray along the plane of alignment of the foot in both
exposures.
• With the tube in front of the patient and adjusted for a
posterior angulation of 15 degrees, center the central
ray to the base of the third metatarsal for the first
exposure.
• Caution the patient to carefully maintain the position of
the affected foot and place the opposite foot one step
forward in preparation for the second exposure.
Foot
• Move the tube behind the patient, adjust it for an
anterior angulation of 25 degrees, and direct the central
ray to the posterior surface of the ankle.
• The central ray emerges on the plantar surface at the
level of the lateral malleolus.
• An increase in technical factors is recommended for this
exposure.
Foot
Foot
Clubfoot
AP PROJECTION
Congenital Clubfoot
KITE METHODs
Image receptor: 8 x 10 inch (18 x 24 cm)
Position of patient : Place the infant in the supine
position. with the hips and knees flexed to permit
the foot to rest flat on the IR. Elevate the body on
firm pillows to knee height to simplify both gonad
shielding and leg adjustment.
Clubfoot
Position of part :
Rest the feet flat on the IR with the ankles extended slightly
to prevent super-imposition of the leg shadow. Hold the
infant's knees together or in such a way that the legs are
exactly vertical (i.e., so that they do not lean medially or
laterally).
Using a lead glove. hold the infant's toes. When the
adduction deformity is too great to permit correct
placement of the legs and feet for bilateral images
without overlap of the feet, they must be examined
separately.
Clubfoot
Central ray :
Perpendicular to the tarsals. Midway between the tarsal
areas for a bilateral projection.
An approximately 15-degree posterior angle is generally
required for the central ray to be perpendicular to the
tarsals. Kite"! stressed the importance of directing the
central ray vertically for the purpose of projecting the
true relationship of the bones and ossification centers.
Clubfoot
Clubfoot
LATERAL PROJECTION
Congenital Clubfoot
KITE METHODs
 The Kite method lateral radiograph demonstrates the
anterior talar subluxation and the degree of plantar
flexion (equinus).
Image receptor: 8 x 10 inch (18 x 24 cm)
Position of patient :
• Place the infant on his or her side in as near the lateral
position as possible.
• Flex the uppermost limb, draw it forward, and hold it in
place
Clubfoot
Position of part :
• After adjusting the IR under the foot, place a support
that has the same thickness as the IR under the infant's
knee to prevent angulation of the foot and to ensure a
lateral foot position.
• Hold the infant's toes in position with tape or a protected
hand .
Central ray : Perpendicular to the midtarsal area.
Clubfoot
Clubfoot
AP AXIAL PROJECTION
Congenital Clubfoot
KITE METHODs
Kandel recommended the inclusion of a dorsoplantar axial
projection in the examination of the patient with a
clubfoot.
For this method the infant is held in a vertical or a bendingforward position. The plantar surface of the foot should
rest on the IR, although a moderate elevation of the heel
is acceptable when the equinus deformity is well marked.
The central ray is directed 40 degrees anteriorly
through the lower leg, as for the usual dorsoplantar
projection of the calcaneus .
Clubfoot
• Freiberger, Hersh, and Harrison Stated that
sustentaculum talar joint fusion cannot be assumed on
one projection, because the central ray may not have
been parallel with the articular surfaces.
• They recommended that three radiographs be obtained
with varying central ray angulations (35, 45, and 55
degrees).
Clubfoot
Radiography
Calcaneous
Calcaneous
AXIAL PROJECTION
Plantodorsal
Image receptor : 8 x 10 inch (18 x 24 cm)
Position of patient : Place the patient in the supine or
seated position with the legs fully extended.
Position of part :
• Place the IR under the patient's ankle, centered to the
midline of the ankle.
• Place a long strip of gauze around the ball of the foot.
Have the patient grasp the gauze to hold the ankle in
right angle dorsi flexion.
Calcaneous
• If the patient's ankles cannot be f1exed enough to place
the plantar surface of the foot perpendicular to the IR,
elevate the leg on sandbags to obtain the correct
position.
Central ray :
Directed to the midpoint of the IR at a cephalic angle of 40
degrees to the long axis of the foot. The central ray
enters the base of the third metatarsal
Calcareous
Calcaneous
AXIAL PROJECTION
Dorsoplantar
Image receptor : 8 x 10 inch (18 x 24 cm)
Position of patient : Place the patient in the prone position.
Position of part :
• Elevate the patient's ankle on sandbags.
• Adjust the height and position of the sandbags under the
ankle in such a way that the patient can dorsiflex the
ankle enough to place the long axis of the foot
perpendicular to the tabletop.
Calcaneous
• Place the IR against the plantar surface of the foot, and
support it in position with sandbags or a portable IR
holder.
Central ray : Directed to the midpoint of the IR at a caudal
angle of 40 degrees to the long axis of the foot. The
central ray enters the dorsal surface of the ankle joint.
Calcaneous
This method, described by Lilienfeld' (Holzknecht), has
come into use for the demonstration of calcaneotalar
coalition. For this reason it has been called the
"coalition position.
Position of patient : Place the patient in the standingupright position.
Position of part :
• Center the lR to the long axis of the calcaneus, with the
posterior surface of the heel at the edge of the IR.
• To prevent superimposition of the leg shadow, have the
patient place the opposite foot one step forward
Calcaneous
Central ray : Angled exactly 45 degrees anteriorly and
directed through the posterior surface of the flexed ankle
to a point on the plantar surface at the level of the base
of the fifth metatarsal.
Calcaneous
LATERAL PROJECTION
Medlolateral
Image receptor : 8 x 10 inch (18 x 24 cm)
Position of patient : Have the supine patient turn toward
the affected side until the leg is approximately lateral. A
support may be placed under the knee.
Position of part :
• Adjust the calcaneus to the center of the IR.
• Adjust the IR so that the long axis is parallel with the
plantar surface of the heel .
Calcareous
Central ray :
Perpendicular to the calcaneus. Center about 1 inch (2.5
cm) distal to the medial malleolus. This will place the
CR at the subtalar joint.
Calcaneous
LATEROMEDIAL OBLIAUE PROJECTION
WEIGHT-BEARING METHOD
Image receptor : 8 x 10 inch (18 x 24 cm)
Position of patient : Have the patient stand with the
affected heel centered toward the lateral border of the
IR. A mobile radiographic unit may assist in this
examination.
Position of part :
• Adjust the patient's leg to ensure that it is exactly
perpendicular.
Calcaneous
• 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.
Central ray : Directed medially at a caudal angle of 45
degrees to enter the lateral malleolus.
Radiography
Ankle
Ankle
AP PROJECTION
Image receptor : 8 x 10 inch (18 x 24 cm) lengthwise or 24
x 30 cm crosswise for two images on one IR.
Position of patient : Place the patient in the supine position
with the affected limb fully extended.
Position of part :
• Adjust the ankle joint in the anatomic position to obtain
a true AP projection. Flex the ankle and foot enough to
place the long axis of the foot in the vertical position.
Ankle
• ball and Egbert' stated that the appearance of the ankle
mortise is not appreciably altered by moderate plantar
flexion or dorsiflexion as long as the leg is rotated
neither laterally nor medially.
Central ray : Perpendicular through the ankle joint at a
point midway between the malleoli.
Ankle
NOTE: The inferior tibiofibular articulation and the
talofibular articulation will not be "open“ nor shown in
profile in the true AP projection.
• This is a positive sign for the radiologist because it
indicates that the patient has no ruptured igaments or
other type of separations.
• For this reason it is important that the position of the
ankle be anatomically "true" for the AP projection
demonstrated.
Ankle
LATERAL PROJECTION
Image receptor : 8 x 10 inch (18 x 24 cm) lengthwise or 24
X 30 cm crosswise for two images on one IR.
Position of patient : Have the supine patient turn toward
the affected side until the ankle is lateral.
Position of part :
• Place the long axis of the IR parallel with the long axis
of the patient's leg and center it to the ankle joint.
• Ensure that the lateral surface of the foot is in contact
with the IR.
Ankle
• Dorsiflex the foot, and adjust it in the lateral position.
Dorsiflexion is required to prevent lateral rotation of the
ankle.
Central ray : Perpendicular to the ankle joint, entering the
medial malleolus.
Ankle
AP OBLIQUE PROJECTION
Medial Rotation
Image receptor : 8 x 10 inch (18 x 24 cm) lengthwise or 24
x 30 cm crosswise for two images on one IR.
Position of patient : Place the patient in the supine position
with the affected limb fully extended
Position of part :
• Center the IR to the ankle joint midway between the
malleoli. and adjust the IR so that its long axis is
parallel with the long axis of the leg.
• Dorsiflex the foot enough to place the ankle at nearly
right-angle flexion.
Ankle
• Rotate the patient's leg primarily and the foot for all
oblique projections of the ankle. Because the knee is a
hinge joint, rotation of the leg can come only from the
hip joint. Positioning the ankle for the oblique projection
requires that the leg and foot be medially rotated 45
degrees.
• Grasp the lower femur area with one hand and the foot
with the other. Internally rotate the entire leg and foot
together until the 45-degree position is achieved.
• The foot can be placed against a foam wedge for
support.
Ankle
Central ray : Perpendicular to the ankle joint. entering
midway between the malleoli.
Ankle
AP OBLIQUE PROJECTION
Medial Rotation
Mortise Joint
Image receptor : 8 x 10 inch (18 x 24 cm) lengthwise or 24
x 30 cm crosswise for two images on one IR.
Position of patient : Place the patient in the supine position
with the affected limb fully extended
Position of part :
• Center the patient's ankle joint to the IR.
• Grasp the distal femur area with one hand and the foot
with the other. Assist the patient by internally rotating
the entire leg and foot together 15 to 20 degrees until the
intermalleolar plane is parallel with the IR.
Ankle
• The plantar surface of the foot should be placed at a
right angle to the leg.
Central ray :
Perpendicular, entering the ankle joint midway between the
malleoli.
Ankle
Ankle
Ankle
Ankle
AP PROJECTION
STRESS METHOD
Image receptor : 8 x 10 inch (18 x 24 cm) lengthwise or 24
x 30 cm crosswise for two images on one IR.
Position of patient : Place the patient in the supine position
with the affected limb fully extended
Position of part :
• Center the patient's ankle joint to the IR.
• Grasp the distal femur area with one hand and the foot
with the other. Assist the patient by internally rotating
the entire leg and foot together 15 to 20 degrees until the
intermalleolar plane is parallel with the IR.
Ankle
• Stress studies of the ankle joint usually are obtained
after an inversion or eversion injury to verify the
presence of a ligamentous tear.
• Rupture of a ligament is demonstrated by widening of
the joint space on the side of the injury when, without
moving or rotating the lower leg from the supine
position, the foot is forcibly turned toward the opposite
side
Ankle
• When the injury is recent and the ankle is acutely
sensitive to movement, the orthopedic surgeon may
inject a local anesthetic into the sinus tarsi preceding
the examination.
• The physician adjusts the foot when it must be turned
into extreme stress and holds or straps it in position for
the exposure.
• The patient usually can hold the foot in the stress
position when the injury is not too painful or after he or
she has received a local anesthestic by asymmetrically
pulling on a strip of bandage looped around the ball of
the foot.
Ankle
Ankle
A
B
A, Eversion stress. No damage to the medial ligament is
indicated. 5, Inversion stress. Change in joint and rupture of
lateral ligament (arrow) are seen
Ankle
AP PROJECTION
WEIGHT-BEARING METHOD
This projection is performed to identify ankle joint space
narrowing with weight bearing.
Image receptor : 24 x 30 cm crosswise
Position of patient :
• Place the patient in the upright position, preferably on a
low platform that has a cassette groove. If such a
platform is not available, use blocks to elevate the feet to
the level of the x-ray tube .
• Ensure that the patient has proper support.
• Never stand the patient on the radiographic table
Ankle
Position of part :
• Place the cassette in the cassette groove of the platform
or between blocks.
• 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
Technical NOTE:
If needed, use a mobile unit to allow the x-ray tube to reach
the floor level.
Ankle