ACCESSORY OSSICLES DEFINITION/LOCATION BEST PROJECTION OCCURRENCE ADDITIONAL NOTES

Os Trigonum lateral tubercle posterior process talus Lateral 2-8%

Steida's Process fused lateral tubercle of talus Lateral Shepherd's fracture

Os Tibiale Externum secondary ossification center of navicular tuberosity Medial Oblique 3-12% aka: pre-hallux' may also be in tibialis posterior

Os Intermetatarseum between 1st cuneiform & 1st & 2nd metatarsal bases Dorsal-Plantar/(also on lateral) 1-10% 1st IM space is most common followed by 4th IM

Os Supranaviculare dorsal aspect of T-N joint Lateral 1%

Os Calcaneus Secundarius anterior surface of calcaneus (anterior process) Lateral-Oblique/(Lateral) 1% can look like anterior process fx of calcaneus

Os Sustentaculi posterior to sustentaculum tali Axial/(lateral) <1% implicated in TCF bar bridge/usu fused to sus. tali

Os Supratalare dorsum of talar head Lateral easily confused with talar beaking and calcification of talonavicular lig

Os Vesalinum proximal tip styloid process 5th metabase Lateral Oblique 1/10 of 1% frequently confused with traction apophysis

Accessory Ossicle of Hallux IPJ ossicle med. or lat. aspect of joint near base of DP Anterior/Posterior or Medial-Oblique or lateral view of hallux frequently mistaken for old fracture

Os Subtibiale Distal medial malleolus Anterior-Posterior Ankle/mortise or lateral 4%

Os Subfibulare Distal lateral malleolus AP and mortise ankle/(Lateral Oblique of Ankle) anterior talofibular and calcaneofibular ligaments insert here and can be unstable if not fused to fibula

SESAMOIDS

Interphalangeal Sesamoid Hallux plantar head proximal phalanx hallux between condyles Lateral Raised Hallux Projection 50%

Sesamoids of Lesser MPJs 2nd (1), 4th (1), and 5th (2) metaheads

Os Peroneum tendon of peroneus longus near peroneal sulcus of cuboid Lateral Oblique present in nearly everyone ossified in 20%; calcified in majority

Sesamoids of 1st Metatarsal within joint capsule of and FHB Axial Sesamoid constant; nearly always present ossifies 10-12 yoa
 Tube Angle
Projection (degrees) Central Ray

Dorsal Plantar Foot WB 15 dorsal base 2nd MT

Dorsal Plantar 0 degrees

marked lesion 0 near metallic marker

dorsal lateral aspect

Lateral Foot WB 90 3rd-5th MT bases

Lateral Hallux WB 90 IPJ hallux

Lateral Hallux Alternate 90 IPJ hallux

Lateral Digit WB 90 Middle phalanx digit

Lateral Digit WB
Alternate 90 Middle phalanx digit

Dorsal lateral aspect

of foot near 3rd-5th
Lateral Oblique Foot WB 40 MT base

Dorsal medial
aspect of foot
between base of 1st
Medial Oblique Foot WB 25 MT to navicular

Plantar aspect 3rd

Axial Sesamoid WB 90 MT head

Alternate Axial Sesamoid Plantar aspect 3rd

WB 90 MT head

posterior superior
Axial Calcaneal WB 25 calcaneus

2 cm superior to the
axial calcaneal WB
Harris and Beath 35-45 position
 Midpoint anterior
Anterior Posterior Ankle surface of talus (@
WB 90 talar dome level)

Midpoint anterior
Mortise Ankle WB 90 surface of talus

Near lateral
Lateral Ankle WB 90 malleolus

Lateral Oblique Ankle Near anterior lateral

WB 90 ankle near malleolus

near anterior medial

Medial Oblique Ankle ankle near medial
WB 90 malleolus

Partial WB same as wb same as wb

Non WB 0

Medial aspect 1st

Lateral Foot NWB 0 MT base

Lateral Foot NWB

Variations 90

Obliques Foot NWB 0

Axial Calcaneal
Tangential Calcaneus, Midplantar
Plantar Axial 40-45 calcaneus
 Cassette Other

flat (horizontal) align long axis of foot parallel to long axis of lower leg & foot at 90 degrees; pt. in
cassette normal WB stance

x-ray tube close to pt.; metallic

flat/horizontal marker on foot; opposite leg is back

cassette in platform slot long axis follows long axis of foot--

adjust heel to maintain central axis of foot parallel to felt pad under foot to visualize plantar
cassette surface s.t.

Elevate hallux via gauze roll;felt pad

as in lateral foot; restrict field to FF
as in lateral foot area

use of gauze to elevate lesser digits

as in lateral foot 2nd-5th; felt pad as in lateral foot

elevate digit w/ gauze roll; restrict

field to FF area; felt pad as in lateral
as in lateral foot foot

use of gauze rolled & unrolled-patient

assists in elevating digit; felt pad as in
as in lateral foot lateral foot

placed flat; long axis of cassette is parallel to long axis of attention to distance lateral margin of
foot foot is from cassette's edge

placed flat (horizontal); long axis of foot is parallel to long attention to distance of medial border
axis of cassette of foot from edge of cassette

felt pad perpendicular to cassette

surface: 1. DF digits at MPJs 2.
elevate calcaneus > 2 inches from
surface 3. flex knee 4. place opposite
in platform slot as in lateral foot leg in front

use of axial sesamoid positioner;

in platform slot as lateral foot (same positions 1-4 as above)

flat/horizontal; long axis of cassette and long axis of foot

are parallel

dependent on posterior and middle

flat; long axis of cassette is parallel to the long axis of the STJ; flexion of knee; "ski jump"
foot position
cassette placed in cassette holder which is set into slot; this central axis of foot is perpendicular to
allows exposing lower leg the surface

rotate lower extremity until

intermalleolar plane is parallel to
vertical in slot using cassette holder cassette surface; view gutters

adjust heel to align central axis of foot

vertical in slot with cassette holder parallel to cassette surface

rotate lower leg 45 degrees internal:

vertrical in slot with cassette holder
vertical in slot using cassette holder
easy method to estimate: point hallux
to corner of platform to approximate
45 degree rotation
rotate lower leg externally 25
degrees; to approximate this:
externally rotate lower leg 1/2 way
from AP position and the same corner
of the platform

patient is standing w/ majority of

film placement is same as wb weight on contralateral leg

pt. seated in chair as close as

the foot/ankle will be rotated to desired degree instead of possible to positioning platform ot
tube angulation place film on floor as per equipment

place lateral aspect of foot on cassette surface; medial

surface facing tube; adjust plantar surface as close to 90
degrees as possible

lateral-medial: medial side against cassette; medial-lateral: use felt pad and place chair to either
lateral side against cassette side of platform if possible

DF at ankle as tolerated, unrolled gauze to aid in obtaining Pt. extend lower leg placing posterior
max. DF--pt. pulls on gauze roll ends aspect calcaneus on cassette