Image Evaluation:

Lateral Ankle (Mediolateral)

By: Heather Mattingly

● This image was modified so it would be HIPAA compliant.o No patient information is visibleo Patient confidentiality was not

violated.

HIPAA Compliance

● Correct anatomical marker is shown.● The marker was placed correctly, on lateral

side if the body.Marker should have been placed

lengthwise with the body part.Marker did not superimpose any body anatomy

Any additional markers?An arrow marker showing an area of

interest could have been usedA weight bearing marker if patient was

standing on it. The image is displayed correctly.

Marker and Patient ID

● Appropriate beam restriction should show at least three sides of beam restriction on any image.o No beam restriction is visible on

any sides of the image

● Gonadal shielding must be provided if the gonads are within five centimeters of the primary beamBeam collimation is not shown on the

superior side. No other shields or protection is shown

Radiation Hygiene

● Projections Required for Routine Procedure○ AP ankle○ Lateral ankle (Lateromedial)○ Lateral ankle (Mediolateral)○ AP oblique ankle, external rotation

(45 degrees)○ AP oblique ankle, medial rotation

(45 degrees)○ AP oblique for mortise joint medial

rotation(15 - 20 degrees)● Other positions

○ AP ankle, stress (Dorsiflexed)

Completeness of Position / Projection

● This image does comply with the routine position.

● All anatomical parts are correctly visualized.

Completeness of Position / Projection

● There are no preventable artifacts appear to be on the image

● No body parts are superimposed that should not be.

● No hospital paraphernalia appears to be present.

● No visible patient clothing or belongings appears to be visible.

● No indwelling artifacts or foreign bodies appears to be visible.

Artifact Identification

● There appears to be no excess fogging on this image that may affect the contrast or recorded detail.

● There are no CR / DR artifacts visible

Artifact Identification

● No gross voluntary motion appears visible.

● No excessive quantum mottle appears visible.

● No ghosting / Double exposure appears to be seen on this image.

Image Sharpness

● Grid lines / cutoff / artifacts are not visible in this image.o A grid should not be used for a

body part less than 10cm.

Size distortion does not appear greater than expected.

Shaped distortion by poor CR / IR / Part alignment is minimal since centering is less than 1cm

Image Sharpness

● The part appears to be lined up longitudinally to the image media.

● The part is accurately centered to the image media

● The CR appears to be less than 1 cm

The CR is aligned to the image mediaThe CR alignment shows no sides of

collimation; which is a recognized field.Always try to have three sides of

collimation.

Accurate Part Positioning

According to Merrill’s Atlas and McQuillen’s Radiographic Image Analysis:

● Patient is supine and turned toward affected side to rest lateral surface of ankle on IR.○ Provides mediolateral projection○ Maximizes patient comfort and

cooperation● IR is centered to ankle joint.

○ Centers anatomy of interest to IR○ Reduces distortion

● Dorsiflex foot, placing it at a 90 degree angle with lower leg.

Accurate Part Positioning

● Plantar surface is perpendicular to IR.○ Demonstrates true lateral of distal

third of tibia and fibula (McQuillen states one fourth of the leg), the ankle joint, and adjacent tarsals, including the base of the fifth metatarsal.

○ Superimposition of talar domes● Perpendicular CR enters medial

malleolus.○ Places ankle joint in center of IR

and collimated field

Accurate Part Positioning

● Collimate to 1 inch on the sides of the ankle and 8 inches lengthwise to include the heel and fifth metatarsal base.○ Demonstrates all anatomy of

interest○ Provides radiation protection○ Improves image quality

● Provide gonadal shielding.○ Provides radiation protection/fulfills

ethical responsibility● Instruct patient to hold still in position

for exposure.○ Reduces possibility of motion.

Accurate Part Positioning

● 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● Fifth metatarsal should be seen to check

for Jones fracture.● Density of the ankle sufficient to make the

outline of distal portion of the fibula visible.● Foot dorsiflexed

Is the anatomical part correctly positioned: Yes

Accurate Part Positioning Evaluation Criteria: Merrill’s and McQuillen

● The most radiolucent structure is the soft tissue ; which is visible on the image.

● The most radiopaque structure is the bony cortex; which is visible on the image.

● The image contrast (window width) is the display of grays within an image.o Contrast should be short scale for

bony structuresI believe it has the appropriate contrast.

Judicious Exposure Technique

● The image brightness (window level / E.I. value) was not given in the image.o The level is how light or dark the

picture appears.o Even though no EI value is given, I

believe within range since no fogging is shown, no quantum mottle is visible.

o I believe the picture has adequate brightness.

Judicious Exposure Technique

According to the evaluation of Merrill’s and McQuillen, I would accept this image.

Corrections for this image● Rotate marker to go lengthwise with

body part.● Center just slightly lower to be

centered on the medial mallelous.

Accept or Reject

References:

McQuillen-Martensen (2015). Radiographic Image Analysis. Vol 4

St. Louis, MO: Elsevier

Frank,E.D.,Long B.W.,Smith,B.J.,Merrill,V.,& Ballinger, P.W. (2007). Merrill’s atlasof radiographic positioning & procedures. St Louis,MO: Mosby/Elsevier

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