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Radiographic Positioning
CHAPTER 3
Radiographic Positioning
Linda Carlson
RADIOGRAPHIC EQUIPMENT
RADIOGRAPHIC TECHNIQUE
PATIENT PREPARATION
USING THE CHARTS
This chapter is designed as a quick reference guide to radiographic positioning and technique.
Technical tips and supplemental views are provided to aid in obtaining optimal film quality using the
most appropriate views. The routine study is highlighted in blue; this is the minimal number of views
that must be performed to accomplish a complete evaluation of the area in question. For further
information on the views included in this chapter, a textbook dedicated to radiographic positioning
should be consulted. A list of recommended further reading is included at the end of this section.
Radiographic Equipment
The basic components of a radiography unit are a source of radiation (x-ray tube) and a receiving
medium (x-ray film in the case of conventional plain film radiography or an energized plate in the case
of computed radiography). Figures 3-1 and 3-2 identify a stool, table, shields, side markers, and other
accessories that are used for the radiographic setup.
FIG 3-1 Typical radiographic system and related equipment, including: A, grid cabinet (Bucky); B, x-
ray tube; C, collimator; D, movable table; E, positioning sponge; and F, stool.
FIG 3-2 Tools and accessories used for radiographic examinations, including A, measuring calipers;
B, lead apron; C, female gonad shield; D, male gonad shield; E, right and left side (Mitchell) markers;
F, filters; G, cassettes; and H, positioning sponges.
Radiographic Technique
The radiographic techniques listed in this chart were derived using the following parameters:
• 300/125 kVp single phase generator*
• 400-speed rare earth screens with matched film or
• Extremity detail screens with matched films†
• 10 : 1 stationary grids
• Automatic processor
The suggested technique is within a fixed kilovolt (kV) range per body part. In smaller patients, the
lower spectrum of the kV range is used; in larger patients, the upper range of kV is used. In this
system, the milliampere-seconds (mAs) is variable, and corrections in exposure factors require
changing the mAs only. To correct the exposure factors in a film that is underexposed, the mAs must be
changed by a minimum of 30% to note a detectable change or by 100% for a significant change. The
reverse is true for films that are overexposed. When a fixed kV system is used, only one exposure
factor, the mAs, needs to be changed to correct for errors. The techniques contained in the chart
provide a starting point of adequate exposures for a radiographic system similar to the one listed.
Corrections for individual variations in machines are made by adjusting the mAs only because the chart
was formulated using the fixed kV technique.
There may be instances when a change in penetration, or kVp, is necessary. When a film is
critiqued, if the bony detail is too light so as to appear nonexistent, a 15% increase in kVp provides the
necessary penetration. An increase in mAs is required if the bony detail is present but the overall
appearance of the film is too light.
Patient Preparation
Good patient education is essential and must include a thorough explanation of the study being
performed and the patient’s role during the examination. Protection methods and breathing instructions
should be reviewed. Patients should be properly gowned, and all artifacts should be removed before
the radiographic examination begins (Fig. 3-3). Female patients in their childbearing years should be
assessed for possible pregnancy. If there is a possibility of pregnancy, the examination should be
delayed, if possible, until it can be determined the patient is not pregnant, either by a negative human
chorionic gonadotropin test result or the start of menses. If possible, all radiographic examinations of
the lumbar spine, abdomen, and pelvis should be scheduled during the first 10 days after the onset of
menstruation because this is the least likely time for pregnancy to occur. Appropriate gonadal shielding
should be used in both male and female patients whenever possible.
FIG 3-3 The radiographic setup is done most proficiently by following a general sequence. The
sequence begins with patient preparation, including A, gowning; followed by, B, measurement
technique selection; C, cassette selection and placement; D, choice of focal-film distance; E, central
ray placement; F, alignment of the center of the film and the central ray. G, collimation to film size; H,
side marker placement; and sometimes, I, use of filter.
Using the Charts
The following tables present commonly performed radiographic projections. The routine study is
highlighted in blue. A routine study is the minimum number of views that must be performed to obtain a
complete study of the area. Additional views are included in most sections and can be added to the
basic study. Additional views are added to better demonstrate an area in question or to assess motion
or stability. As reference, radiographic views are named by the body part being examined and either
the direction the x-ray beam is passing through the body (anteroposterior [AP]) or the portion of the
body part touching the grid for oblique angles of the body (right posterior oblique [RPO]) (Fig. 3-4).
FIG 3-4 Radiographic views. The term radiographic “projection” references the path of the central ray
as it exits the x-ray tube and passes through the patient’s body. For example, A denotes an
anteroposterior (AP) projection and B a posteroanterior (PA) projection. In the extremities, lateral
projections are similarly described by the direction of the central ray; hence, mediolateral and
lateromedial projections are possible. However, when one deals with the head, neck, or body trunk,
the lateral and oblique projections are further clarified by the specific “position” of the patient. Position
denotes the placement of the patient’s body, specifically the portion of the patient’s anatomy that is in
contact with the Bucky. For example, C indicates a lateral projection in a right lateral position, and D
indicates a lateral projection in a left lateral position. In E, the patient is in a left anterior oblique (LAO)
position, and in F, the patient is in a right anterior oblique (RAO) position, both corresponding to PA
oblique projections.
Each table explains the position setup, central ray placement, tube angulation, optimal film size, and
focal-film distance for each view. To conserve x-ray film and facilitate viewing, sometimes the film is
divided so that multiple views of a body part are seen on a single film (Fig. 3-5). For each setup in the
tables, there is a picture demonstrating the position and central ray placement and another to exhibit
the anatomy demonstrated by the setup. The kV and mAs section lists the type of film screen
combination used and whether the study is performed with the use of a grid or tabletop. If the use of a
grid is listed, a fast film screen combination such as rare earth is suggested. If detailed or nongrid is
listed, a slower speed film screen combination is suggested, such as those found in extremity
cassettes or 100-speed cassettes. A suggested kV and mAs range is also provided for systems
described in the previous section on technique. The “Additional Information” section describes other
views that may be done to better demonstrate the desired anatomy. Technical tips are also included to
aid in obtaining optimal studies.
FIG 3-5A to D, For some small body parts (e.g., foot and wrist), the x-ray film may be divided to
accommodate several projections. From Ballinger PW, Frank ED: Merril’s atlas of radiographic positions and radiologic procedures,
ed 10, St. Louis, 2003, Mosby.
TABLE 3-1
SKULL
Routine skull: PA Caldwell, AP Towne, Lateral Skull
Position PA Caldwell
Patient Remove any artifacts in the desired field (e.g., earrings, dentures, hair appliances)
preparation
Measurement Place caliper base at the back of the skull. Slide the caliper arm until it rests lightly at the nasion.
Shielding Secure lead apron around patient.
Film selection 10 × 12
Film Place vertical in Bucky.
placement
ID placement ID should be in lower corner of collimation field.
Patient Place patient with nose and forehead against Bucky so the orbitomeatal line is perpendicular to the
placement film.
Technique kVp 70 to 80; mAs 20 to 40
selection
SID 40″
Central ray Using a 15-degree caudal tube tilt, central ray enters the back of the skull so as to exit the nasion.
placement
Collimation To film size
Marker Within the collimation field on either the right side or left side of patient’s head
placement
Breathing Do not breathe. Do not move.
instructions
Anatomy Frontal bone, frontal and ethmoid sinuses, greater and lesser wing of the sphenoid, superior orbital
visualized fissure, foramen rotundum, orbital margins
Additional The caudal tube angle may be increased to 30 degrees to optimally define the inferior orbital rim
information area. Petrous pyramids appear in the lower third of the orbit as performed in the preceding
view. These are projected below the inferior orbital rim on the 30-degree angle.
Patient Remove any artifacts in the desired field (e.g., earrings, dentures, hair appliances).
preparation
Measurement Place base bar of caliper on occiput. Slide moveable bar in toward the patient’s head so as to
touch the glabella.
Shielding Secure lead apron around patient.
Film selection 10 × 12
Film Place vertically in Bucky.
placement
ID placement ID should be in lower corner of collimation field.
Patient Place patient in AP position so back of head touches Bucky. Tuck the chin so the orbitomeatal line
placement is perpendicular to the film.
Technique kVp 70 to 80; mAs 30 to 60
selection
SID 40″
Central ray Central ray is angled 30 degrees caudally and enters 2″ above the glabella (superciliary arch).
placement
Collimation To film size
Marker Within the collimation field on either the right side or left side of patient’s head
placement
Breathing Do not breathe. Do not move.
instructions
Anatomy Occipital bone, petrous pyramids, foramen magnum with dorsum sellae and posterior clinoids
visualized projected through it
Additional If the patient cannot tuck the chin sufficiently, adjust the head tilt so the infraorbitomeatal line is
information perpendicular to the film and increase the tube tilt to ≈37 degrees.
Patient Remove any artifacts in the desired field (e.g., earrings, dentures, hair appliances).
preparation
Measurement Place the base bar of the calipers on the temporal bone of one side of the head and move the
slider bar toward the patient’s head so as to touch the temporal bone on the other side of the
head.
Shielding Secure lead apron around patient.
Film selection 10 × 12
Film Place horizontally in Bucky.
placement
ID placement ID should be in lower corner of collimation field.
Patient Place patient with side of head against Bucky. Oblique the patient’s body for comfort. The
placement interpupillary line is perpendicular to the film. The external occipital protuberance and the
nasion should be equidistant from the film to prevent rotation.
Technique kVp 70 to 80; mAs 20 to 40
selection
SID 40″
Central ray The central ray enters 1″ superior and anterior to the external auditory meatus.
placement
Collimation To film size
Marker Within the collimation field denoting which side of the patient’s head is touching the Bucky
placement
Breathing Do not breathe. Do not move.
instructions
Anatomy Lateral cranium closest to film, sella turcica, anterior and posterior clinoids, and ethmoid sinuses
visualized
AP, Anteroposterior; ID, identification; PA, posteroanterior; SID, source-to-image distance.
Right image from Frank DF, Long BW, Smith BJ: Merrill’s atlas of radiographic positions and radiographic procedures, ed 12,
St. Louis, 2012, Mosby.
TABLE 3-2
FACIAL BONES
Routine Facial Bones: PA Caldwell, PA Waters, Lateral Facial Bones
Position PA Waters
Patient Remove any artifacts in the desired field (e.g., earrings, dentures, hair appliances).
preparation
Measurement Place base bar of calipers on back of skull and move slider bar toward patient’s face until it
touches between bottom lip and tip of chin.
Shielding Secure lead apron around patient.
Film selection 8 × 10
Film Place vertically in Bucky so center of cassette is centered to the acanthion.
placement
ID placement ID should be in lower corner of collimation field.
Patient Place patient in PA position with neck in slight extension so chin and nose rest against Bucky. The
placement orbitomeatal line should form a 55-degree angle to the film.
Technique kVp 70 to 80; mAs 20 to 40
selection
SID 40″
Central ray The central ray is directed perpendicular to the Bucky and is centered to the center of the cassette.
placement
Collimation To film size
Marker Within the collimation field on either the right side or left side of patient’s head
placement
Breathing Do not breathe. Do not move.
instructions
Anatomy Floor of the orbits, maxillary sinuses
visualized
Additional Should be done in upright position to evaluate air fluid levels in the maxillary sinuses. Petrous
information ridges should be projected in the lower half of the maxillary sinuses below the inferior orbital
rim. Good view for evaluation of possible “blowout” orbital fractures.
Position PA Caldwell
Patient Remove any artifacts in the desired field (e.g., earrings, dentures, hair appliances).
preparation
Measurement Place base bar of calipers against back of head. Move slider bar toward patient’s face to rest on
nasion.
Shielding Secure lead apron around patient.
Film selection 8 × 10
Film Place vertically in Bucky with center of cassette aligned to the nasion.
placement
ID placement ID should be in lower corner of collimation field.
Patient Place patient in the PA position against the Bucky so the nose and forehead are against the Bucky
placement and the orbitomeatal line is perpendicular to the cassette.
Technique kVp 70 to 80; mAs 20 to 40
selection
SID 40″
Central ray The central ray is angled 15 degrees caudally and is centered to cassette.
placement
Collimation To film size
Marker Within the collimation field on either the right side or left side of patient’s head
placement
Breathing Do not breathe. Do not move.
instructions
Anatomy Orbital rim, maxillae, nasal septum, and zygomatic bones
visualized
Additional For better definition of the inferior orbital rim area, increase the tube angle to 30 degrees. Petrous
information pyramids should be projected in the lower third of the orbit with a 15-degree tube tilt and below
the inferior orbital rim on the 30-degree tube tilt.
Position Lateral Facial Bones
Patient Remove any artifacts in the desired field (e.g., earrings, dentures, hair appliances).
preparation
Measurement Place the base bar of the calipers against the zygomatic arch. Move the slider bar of the calipers
toward the patient’s face so it rests on the opposite zygomatic arch.
Shielding Secure lead apron around patient.
Film selection 8 × 10
Film Place vertically in Bucky.
placement
ID placement ID should be in lower corner of collimation field.
Patient Place the patient in an anterior oblique position. Place the patient’s head in a lateral position with
placement the side of interest resting against the Bucky.
Technique kVp 70 to 80; mAs 10 to 20
selection
SID 40″
Central ray The central ray enters 1.5” posterior to the outer canthus.
placement
Collimation To film size
Marker Within the collimation field denoting the side of the head that is closest to the Bucky
placement
Breathing Do not breathe. Do not move.
instructions
Anatomy Ethmoid, frontal, sphenoid, and maxillary sinuses in the lateral projection
visualized
Additional This view should be performed with the patient in the upright position to evaluate air fluid levels in
information the sinuses.
ID, Identification; PA, posteroanterior; RAO, right anterior oblique; SID, source-to-image distance.
TABLE 3-3
CERVICAL SPINE: ROUTINE, TRAUMATIC, AND PALMER UPPER CERVICAL
Routine: AP Open Mouth, AP Lower Cervical, Lateral Cervical
Position AP Open Mouth
Patient Remove any artifacts in the desired field (e.g., earrings, dentures, hair appliances).
preparation
Measurement Place base bar of calipers on back of head. Instruct patient to open mouth. Move slider bar in
toward patient’s face to corner of mouth (without touching patient’s mouth).
Shielding Secure lead apron around patient.
Film selection 8 × 10
Film Place vertically in Bucky.
placement
ID placement ID should be in lower corner of collimation field.
Patient Place patient in the AP position with back of shoulders resting against Bucky. The plane of the
placement upper occlusal plate and occiput with mouth open should be parallel to the floor.
Technique kVp 70 to 80; mAs 10 to 15
selection
SID 40″
Central ray The central ray enters the midpoint of the open mouth.
placement
Collimation Collimate just under the eyes vertically and to the mastoids horizontally.
Marker Within the collimation field on either the right side or left side of patient’s head
placement
Breathing Do not breathe. Do not move.
instructions
Anatomy Lateral masses, anterior and posterior arches of C1, odontoid process, pedicles, lamina, and
visualized spinous process of C2
Additional Correct head placement is essential. If teeth superimpose odontoid, tip head back. If occiput
information superimposes odontoid, tip head forward. In extreme cases, the oblique odontoid or Fuchs
view may be used.
Position AP Lower Cervical
Patient Remove any artifacts in the desired field (e.g., earrings, dentures, hair appliances).
preparation
Measurement Place the base bar of the calipers against the posterior aspect of the cervical spine at the level of
C4. Move the slider bar toward the patient until it touches the anterior aspect of the cervical
spine at C4.
Shielding Secure lead apron around patient.
Film selection 8 × 10
Film Place vertically in Bucky.
placement
ID placement ID should be in upper corner of collimation field.
Patient Place patient in the AP position with back of shoulders against the Bucky. The plane of the upper
placement occlusal plate and base of occiput should be parallel to the floor so the mandible does not
superimpose on C3.
Technique kVp 65 to 75; mAs 6 to 12
selection:
SID 40″
Central ray The central ray should be angled 15 degrees cephalically so as to enter the area of C4 (thyroid
placement cartilage).
Collimation To film size vertically. To mastoids horizontally.
Marker Within the collimation field on either the right side or left side of patient’s head
placement
Breathing Do not breathe. Do not move.
instructions
Anatomy Pedicles, lamina, transverse processes, vertebral bodies, and uncinate processes of C3 to C7.
visualized Lung apices are also visualized.
Additional If mandible obscures C3 and C4, elevate chin slightly or increase the angulation on the tube. If a
information lesion is suspected in visualized lung apices, a PA and lateral chest radiograph should be
performed.
Position Lateral Cervical (Neutral Position)
Patient Remove any artifacts in the desired field (e.g., earrings, dentures, hair appliances).
preparation
Measurement Place base bar of calipers on lateral side of patient’s neck at C4 level. Move slider bar of calipers
toward patient’s neck so as to rest at the C4 level.
Shielding Secure lead apron around patient.
Film selection 8 × 10
Film Place vertically in Bucky.
placement
ID placement ID should be in upper corner of collimation field.
Patient Place patient (standing or seated) next to the Bucky in the lateral position. The plane of the upper
placement occlusal plate and the base of the occiput should be parallel to the floor. This ensures the
mandible does not superimpose the anterior vertebral bodies.
Technique kVp 70 to 80; mAs 15 to 30
selection
SID 72″
Central ray The central ray is directed horizontally to the C4 vertebral level (approximately the level of the
placement: thyroid cartilage) and vertically through the mastoid process.
Collimation To film size
Marker Within the collimation field on the side of the patient that is closest to the film.
