Introduction
Positioning is the part of radiography the technician owns. The veterinarian orders the study and reads it, but you place the patient, find the landmarks, set the collimator, place the marker and decide whether the image is good enough to keep. A radiograph of a poorly positioned patient can lead to a wrong diagnosis and the wrong treatment.1 Every retake also adds radiation for the patient and the team.2
This guide covers view names, measuring, landmarks for each body region, collimation, orthogonal views, markers and a quality checklist for every image.
Key facts
- A view is named for the path of the beam: the surface it enters first, then the surface it exits. A patient in dorsal recumbency gives a ventrodorsal (VD) view.1
- Lateral thorax and abdomen views are shortened to the exit side, which is the side against the table. A right lateral means the right side is down.13
- Take at least 2 orthogonal views (90 degrees apart) of every area of interest. A routine thorax is 3 views: right lateral, left lateral and a VD or DV.13
- Measure the patient at the thickest part of the area being imaged: the liver or thickest part of the thorax for the thorax, the liver or cranial abdomen for the abdomen, and the iliac crest for the pelvis.3414
- Thoracic radiographs are taken at peak inspiration. Abdominal radiographs are taken at expiration.113
- Thorax borders run from the manubrium to the last rib (T13). Abdomen borders run from just cranial to the xiphoid to the greater trochanter of the femur.134
- The OFA hip view is a VD with the pelvic limbs extended and parallel, the stifles rotated internally and the pelvis symmetric.15
- Left or right markers must be in the field during the exposure. Adding them digitally afterward is not best practice.2
How the VTNE tests this
- Name the view from the recumbency and the beam path, or choose the recumbency for a named view. Domain 6 Task B; K15 (patient preparation and positioning).12
- Choose the landmarks and borders for a study, or the point to measure for the technique chart. Domain 6 Task B; K39 (imaging equipment and procedures).12
- Spot a positioning error on a described image, such as rotation, limbs over the cranial thorax or a missing marker, and pick the fix. Domain 6 Task B; K40 (imaging quality assurance and safety).12
- Apply anatomy: which lung field a lateral view shows best, where gas moves in the stomach, why the spine must stay still after trauma. Domain 6 Task A.12
Core concepts
Naming views by the beam path
The American College of Veterinary Radiology standardized the names of radiographic projections. The name starts with the point where the primary beam enters the patient and ends with the point where it exits.1 With the tube above the table, the surface on the table is the exit point.
- Ventrodorsal (VD): patient on its back (dorsal recumbency). The beam enters the ventral surface and exits the dorsal surface.1
- Dorsoventral (DV): patient on its sternum (sternal or ventral recumbency). The beam enters dorsal and exits ventral.3
- Lateral: for the thorax and abdomen the name is shortened to the exit side. A left-to-right lateral is called a right lateral, and the patient lies on its right side.13
- Limbs use the same rule. In a mediolateral (ML) view the beam enters the medial side and exits the lateral side. In a caudocranial (CdCr) view it enters caudally and exits cranially; the patient lies in dorsal recumbency for the caudocranial shoulder and humerus views.18
Orthogonal views
A radiograph is a flat picture of 3-dimensional anatomy, so structures overlap. A second view at 90 degrees helps the veterinarian localize a lesion.1 Merck states that radiographs of any part of the musculoskeletal system, in any species, should always include at least 2 orthogonal views.13 A bone study should include the whole bone, from the joint above to the joint below.10
Why the side that is down matters
The lung on the down side (the dependent lung) partly collapses under the body's weight. A right lateral therefore shows the left lung lobes best, and a left lateral shows the right lobes best.1 Collapse in the dependent lobes can hide a lesion or look like disease, which is why both laterals are taken for a complete lung evaluation.5
In the abdomen, gas moves to the highest part of the stomach. The right lateral highlights the gastric fundus and body and is the view of choice for gastric dilatation and volvulus. The left lateral highlights the pyloric antrum, pyloric canal and duodenum, which helps find foreign material. The VD is preferred over the DV for the abdomen because it superimposes the organs less.1
Measuring the patient
Measure the part with calipers before choosing a setting from the technique chart. Dogs and cats are measured at the thickest part of the body being imaged, usually the liver or cranial abdomen for the abdomen.4 For the thorax the measurement is taken at the liver or thickest part of the thorax.3 The pelvis is measured at the iliac crest.14 For the spine, measure the thickest portion within the collimated field. A large dog's neck is measured in 2 places and imaged in 2 parts.67
The measurement also decides whether you use a grid, a thin plate of alternating lead and plastic strips placed between the patient and the detector to absorb scatter.13 Merck puts the point where scatter becomes a problem at 10 cm of thickness, or 15 cm for digital systems.13 The University of Florida technique articles call for an 8:1 grid when the thorax, abdomen or pelvis measures 15 cm or more. For the pelvis, dogs under 15 cm and cats get a tabletop technique (no grid).3414 The same series uses 10 cm for the skull.9 Follow your clinic's technique chart.
Respiration
Thoracic radiographs are taken at peak inspiration, when the lungs are fully inflated and the diaphragm is pulled caudally.1 An expiratory thorax can make the heart look falsely enlarged and can kink the trachea in the cranial thorax.5 The abdomen is the opposite. Expose at expiration, when the diaphragm moves cranially and the abdominal organs separate.110
Collimation and centering
Collimation means narrowing the x-ray beam to the area of interest. It reduces scatter radiation, which gives a clearer image and less exposure for the patient and staff.2 The x-ray beam diverges as it leaves the tube, so structures at the edge of the field are distorted and magnified.11 In the spine, only the center of the field shows true disk space widths, which is why spinal views are centered on the area of concern and repeated if a suspect lesion sits at the edge.67
Magnification and distortion
Magnification increases as the object-film distance (from the part to the detector) increases, so keep the area of interest as close to the detector as possible.2 If the part is not parallel to the detector, it will be elongated or foreshortened, a common problem with limbs.2
Procedure or technique
- Confirm the order and ask about sedation. Sedation lowers stress, cuts repeats and controls pain in patients with fractures or arthritis.13
- Remove external objects: collars, leashes and harnesses come off before imaging.2
- Measure the thickest part of the area with calipers and set kVp and mAs from the technique chart.4
- Position with aids, not hands: tape, sandbags, foam wedges and V-troughs.13
- Make it straight: for a lateral thorax, the sternum and spine sit the same distance from the table; a foam wedge under the elbows or a little ventral padding helps.23 For a lateral abdomen, the iliac crests should be even; place the wedge under the stifles, not under the sternum or cranial abdomen.4
- Collimate to the landmarks for that study (Table 1).4
- Place the marker inside the field before the exposure. For the thorax, put it in the axillary region outside the body wall. For a lateral abdomen, put it caudal and ventral to the inguinal region.2
- Expose at peak inspiration for the thorax or at expiration for the abdomen.1
- Check the image with the CALIPER checklist (Figure 1) before you move the patient, so any retake is quick.25
| Study | Routine views | Center | Borders | Measure at |
|---|---|---|---|---|
| Thorax | Right lateral, left lateral, VD or DV | Vertical line at the caudal border of the scapula, so the heart is centered | Cranial edge of the manubrium to the 13th rib head (T13); include the sternum | Liver or thickest part of the thorax |
| Abdomen | Right lateral, left lateral, VD | No fixed vertical line; the borders set the field. VD: long axis on the midline | A short distance cranial to the xiphoid (2 finger widths, or about 3 ribs cranial to it) to the greater trochanter | Thickest part, usually the liver or cranial abdomen |
| Pelvis | Lateral and extended-leg VD | Lateral: vertical center through the greater trochanter | Cranial to the iliac crest to just distal to the stifles (include the proximal crus) | Iliac crest |
| Cervical spine | Lateral and VD, plus collimated cervicothoracic views | Horizontal line along the cervical vertebrae | Caudal skull to at least T1 | Thickest part of the neck in the field; 2 sites in large dogs |
| Thoracic spine | Lateral and VD, plus the thoracolumbar junction | VD: halfway between the manubrium and xiphoid landmarks, on the midline | C7 to at least L1; thoracolumbar lateral field T10 to L3 | Thickest part of the spine in the field |
| Shoulder | Mediolateral and caudocranial | Just cranial to the shoulder joint (mediolateral) | Distal third of the scapula to the proximal third of the humerus | Humeral head at the thoracic inlet (mediolateral) |
| Humerus | Mediolateral and caudocranial | Middle of the humerus | Shoulder joint and distal scapula to the whole elbow and proximal radius and ulna | Halfway between shoulder and elbow (mediolateral) |
| Skull | Lateral and VD or DV | Lateral: mid cranium. VD or DV: caudal zygomatic arch, just caudal to the eyes | Lateral: nasal planum to C1 | Use a grid only if the part is thicker than 10 cm |
Sources: Today's Veterinary Practice Imaging Essentials series (thorax, abdomen, pelvis, cervical and thoracic spine, shoulder and humerus, skull); Today's Veterinary Nurse, Radiographic Soft Tissue Positioning Part 1.134678914
Pelvis and the OFA hip-extended view
A routine pelvis is a lateral and an extended-leg VD, both including the stifles.14 For the VD, slide the pelvis past the end of the V-trough onto the table to avoid a trough-edge artifact and reduce magnification. Pull the thoracic limbs cranially, extend each pelvic limb, rotate the femurs internally until they are parallel to each other and the table, and tape them at the stifles. Each patella should then sit in its trochlear groove.14
The Orthopedic Foundation for Animals (OFA) follows the AVMA positioning recommendation: dorsal recumbency, pelvic limbs extended and parallel, stifles rotated internally and a symmetric pelvis. OFA recommends chemical restraint to the point of relaxation.15 A patient that cannot extend its hips because of severe joint disease or a fracture gets a frog-leg VD instead, with the femurs flexed at about 90 degrees to the spine.14
| View | What a straight image shows |
|---|---|
| Lateral thorax | Rib heads superimposed along the thoracic spine; costochondral junctions paired |
| VD or DV thorax | Sternum superimposed on the spine; each thoracic spinous process seen end-on as a diamond or teardrop |
| Lateral abdomen | Transverse processes of the lumbar vertebrae superimposed (one "Nike swoosh"); wings of the ilium superimposed |
| VD pelvis | Obturator foramina symmetric and equal in size; femurs parallel; patellae over the trochlear grooves; caudal lumbar spinous processes seen as teardrops |
| Lateral cervical spine | Wings of the atlas (C1) even and superimposed |
| Lateral skull | Zygomatic arches, mandibles and tympanic bullae superimposed; wings of C1 even |
Sources: Today's Veterinary Nurse Part 2; Today's Veterinary Practice Imaging Essentials (thorax, abdomen, pelvis, cervical spine, skull).2347914
Limbs and skull
For the scapula, shoulder and humerus, the minimum standard is a mediolateral and a caudocranial view. In most situations, placing the patient on a large cassette and taking one lateral of the whole limb is not acceptable.8 The limb of interest goes against the table for a mediolateral shoulder or humerus. Pull it cranially, pull the other limb caudally, and push the head and neck dorsally so the cervical spine is not superimposed over the shoulder.8 For extremities, place the marker on the cranial aspect of the limb for a mediolateral view and on the lateral aspect for a caudocranial view.8
Some basic skull views can be taken under heavy sedation, but diagnostic skull radiographs need general anesthesia, because one view in each series needs the mouth open and the oblique and skyline views need exact positioning.9
Flowchart: is this radiograph diagnostic?
The Purdue University CALIPER checklist stands for collimation, artifacts, landmarks, identification, patient positioning, exposure techniques and radiographic presentation.2 Check quality while the patient is still on the table to keep retakes to a minimum.5 Figure 1 turns it into yes or no steps.
Present every image the same way. Lateral views go with the patient's cranial end to the viewer's left and dorsal side up. VD and DV views go with cranial up and the patient's left on the viewer's right, like a mirror image.2
Species differences
- Cats and small dogs: for the pelvis, cats and dogs measuring under 15 cm are imaged with a tabletop technique.14 For the skull, brachycephalic and small breed dogs and cats may be better imaged DV, while deep-chested dogs are better imaged VD.9
- Large and deep-chested dogs: if the thorax or abdomen does not fit one image, turn the detector or take overlapping cranial and caudal images for each view.234
- Brachycephalic and chondrodystrophic breeds: bulldogs, pugs, dachshunds and basset hounds often cannot have the muzzle placed between the forelimbs for a VD. Keep the head and neck straight in front of the body instead.3
- Comfort for the DV: the thoracic DV can be taken with the patient in ventral recumbency in a "sphinx" position without the legs taped. The source stresses that patient comfort comes first, and the DV best shows lesions in the caudodorsal lung lobes.3
- Horses: a horse thorax needs 4 lateral views, because no plate covers it in one exposure, and VD or DV views are impossible.10 Intentional oblique views are common in large animal limb work.13
Calculation
Worked example: correcting a dark abdominal film. A lateral abdomen taken at 10 mAs is too dark. Image density depends in large part on the thickness of the part and the mAs, and the guideline is to decrease mAs by about 30% for an overexposed image.2 mAs is the mA station multiplied by the exposure time in seconds.3 Keep the time faster than 1/30 of a second to limit motion.4
Step 1. New mAs = 10 mAs × 0.70 = 7 mAs.
Step 2. At the 200 mA station: time = 7 mAs ÷ 200 mA = 0.035 s. That is slower than 1/30 s (0.033 s), so motion is more likely.
Step 3. At the 300 mA station: time = 7 mAs ÷ 300 mA = 0.023 s. The mA units cancel and leave seconds. This is faster than 1/30 s, so choose 300 mA.
Answer: 300 mA at about 0.023 s gives 7 mAs. Use the highest mA station that allows the fastest time.34
Safety, legal and client education
- ALARA means as low as reasonably achievable. Time, distance and shielding are the 3 controls. Good positioning the first time is itself radiation safety because it avoids retakes.1
- Hands-free first: restraint devices reduce the number of people in the room. PPE requirements vary by state. Best practice for anyone who must stay is a lead gown (0.5 mm lead), thyroid shield and full-coverage gloves, while keeping as far from the primary beam as possible.1
- Images are legal documents. They belong to the hospital and must show the practice name, exposure date and the patient's first and last name, with the marker applied during exposure.2
- Spinal trauma: if a fracture is suspected, do not flex or extend the spine and do not turn the patient for the orthogonal view. Use a horizontal beam for the VD if possible.6 With suspected atlantoaxial instability, take care not to worsen the luxation; sedation is highly recommended.7
- Sedation versus anesthesia for the thorax: sedation is preferred, because general anesthesia increases atelectasis and can hide lesions.5
- Client education for OFA films: explain that sedation helps get a good radiograph the first time and avoids repeats at the owner's expense.14
Common mistakes and exam traps
- Naming by the side that faces the tube. A right lateral has the right side down, against the detector. The name is the exit side.1
- Mixing up VD and DV. VD is dorsal recumbency (on the back); DV is sternal recumbency. Read the first letter as the side the beam enters.1
- Forelimbs not pulled forward on a lateral thorax. The triceps and elbows then cover the cranial thorax. Pull the limbs cranially.23
- Thorax at expiration. It can mimic an enlarged heart. Abdomen is the study taken at expiration.15
- Measuring in the wrong place. Measure the thickest part of the area of interest, not the narrowest part or a random point.4
- Digital markers after the fact. Lead markers in the field during exposure are best practice. Adding them digitally afterward invites left and right errors.2
Quick review
- Views are named entry point first, exit point second.1
- Right lateral equals right side down.1
- Always take at least 2 orthogonal views.1
- Thorax: 3 views, peak inspiration, manubrium to T13, centered at the caudal scapula.3
- Abdomen: right lateral, left lateral and VD, at expiration, xiphoid area to the greater trochanter.14
- Right lateral thorax shows the left lung best; left lateral shows the right lung.1
- Measure at the thickest part of the area being imaged.4
- A grid is used for thicker parts; the Florida articles use 15 cm for the trunk and 10 cm for the skull.39 Merck gives 10 cm for film and 15 cm for digital.13
- OFA hips: VD, limbs extended and parallel, stifles rotated internally, pelvis symmetric.15
- Collimate to the area of interest to cut scatter and improve the image.2
- Lead markers inside the field, during the exposure.2
- Check every image with CALIPER before moving the patient.2