HIP AXIOLATERAL-CLEMENT NAKAYAMA METHOD

Axiolateral Hip(Clements Clements-Nakayama Modification)

If a patient has bilateral hip fractures, bilateral hip arthroplastyarthroplasty, or limited movement of the , unaffected hip, the DaneliusDanelius--Miller

method cannot be used.

POSITIONING

•Patient supine on the table, arms across upper chest

•Cushion for patients head

•The leg is not internally rotated as in other hip views but remains in a neutral or slightly externally rotated position (the CR is angled 15° posterior instead of the leg being internally rotated)

•Place IR in crease above iliac crest and adjust so that it is parrallel to femoral neck (use a dedicated cassette holder)

•Make sure IR is tilted 15° back to be perpendicular to CR to avoid grid cutoff

•CR angled 15° posterior, perpendicular to the femoral neck

AREA COVERED

• Hip and Proximal femur

IR Size & Orientation

• 24 x 30 cm • Landscape• Stationary grid• SID/FFD : 100 cm• 80 kVp and 40 mAs

COLLIMATION

• Four sides of collimation• Closely collimate to area of interest

CENTRAL RAY

• CR angled 15° posterior, perpendicular to the femoral neck.

• Tilt cassette 150 from vertical & adjust alignment of cassette to ensure it is perpendicular to CR to prevent grid cut off

• Cassette on extended Bucky tray , places bottom edge of cassette 5cm below level of tabletop

GENERAL EVALUATIONS

• Patient ID, Facility, Date (ID Window)• Markers• No Artifacts• No Unsharpness: Motion, Geometric & Photographic• Adequate Contrast & Density• Demonstrate surrounding soft tissue & bony structure• Sufficient penetration to visualise bony trabecular patterns & cortical outlines of Ischial spine, ilia, pubis, ischia, acetabulum, head & neck.

CONTINUE

• Optimal 75-85 KVp, 40-50 mAs• Use of grid to improve contrast• Collimation• Size of IR should commensurate part being

examined.

SACROILIAC JOINT

POSTERIOR OBLIQUE JOINT

PATHOLOGY DEMONSTRATED

• Position demonstrates sacroiliac joints farthest from IR to evaluate dislocation or subluxation of sacroiliac joints pathologic process.

• Both sides are examined for comparison.

TECHNICAL FACTORS

• IR size – 24 x 30 cm (10 x 12inches), lengthwise.

• Bucky / grid – Moving or stationary Grid.• Exposure – 75 kvp 20 mas

SHIELDING

• Carefully shield gonads without obscuring sacroiliac joint.

• Readily done on males but requires more care with females.

• Ensure close collimation.

PATIENT POSITION

• Patient supine position.• Provide pillow for head.

PART POSITION

• Rotate into 25 to 30 degree posterior oblique with side of interest elevated.

• Visualize right joint with LPO and left joint RPO.

• Place support under elevated hip and flex elevated knee.

• Align joint of interest to CR and to midline of table or IR.

CENTRAL RAY

• CR is perpendicular directed to point 1 inches medial to upside ASIS.

• FFD/SID – 100CM.• Collimate closely on four

sides to area of interest.• Suspend respiration during exposure.

RADIOGRAPHIC CRITERIA

• Structures Shown:i. Sacroiliac joints farthest

from IR are visible, with joint space appearing open.

• Position:i. The ala of the ilium and the

sacrum should have no overlap, indicating the correct obliquity.

RADIOGRAPHIC CRITERIA• Collimation And CR:i. Open SI joint should be in

the center of the collimation field.

• Exposure Criteria:i. Optimal exposure clearly

visualizes the margin of the joint space along it entirety.

ii. Bony margins and trabecular markings appear sharp, indicating no motion.

Sacroiliac Joints – AP EXIAL -

Part Positioning• Patient supine on the table• Cushion for patients head• Legs extended with support under the knees• Align midsagittal plane to CR and midline of table• Ensure no rotation of the pelvis (ASIS to table

distance equal both sides)• CR angled cephalad 30° to 35°• CR directed to midline 5cm below the level of ASIS

Position:

Area:

Area Covered• Sacroiliac joints, L5-S1

junction and entire sacrum

Pathology shown• Fracture, dislocation or

subluxation of sacroiliac joints

IR Size & Orientation• 24 x 30cm / 10 x 12in

Collimation:

Collimation• Laterally to include both sacroiliac joints

Superior and inferior to include entire sacrumRespiration• Suspend respiration during exposureCentral Ray• CR angled cephalad 30° to 35° • CR directed to midline 5cm below the level of

ASIS

Exposure:

Exposure• 75 kVp , 20 mAsFFD / SID• 100cmBucky / Grid• Moving or Stationary GridShielding• Gonadal shielding for male.Ovarian shielding on female is

not possible because such shielding directly obscures area of interest.

Markers:

Markers• Distal and Lateral

Marker orientation AP