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Bontrager's Textbook of Radiographic Positioning and Related Anatomy 9th Edition John Lampignano
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This book and the individual contributions contained in it are protected under copyright by the Publisher (other than as may be noted herein).
Notices
Knowledge and best practice in this field are constantly changing.
As new research and experience broaden our understanding, changes in research methods, professional practices, or medical treatment may become necessary.
Practitioners and researchers must always rely on their own experience and knowledge in evaluating and using any information, methods, compounds, or experiments described herein. In using such information or methods they should be mindful of their own safety and the safety of others, including parties for whom they have a professional responsibility. With respect to any drug or pharmaceutical products identified, readers are advised to check the most current information provided (i) on procedures featured or (ii) by the manufacturer of each product to be administered, to verify the recommended dose or formula, the method and duration of administration, and contraindications. It is the responsibility of practitioners, relying on their own experience and knowledge of their patients, to make diagnoses, to determine dosages and the best treatment for each individual patient, and to take all appropriate safety precautions. To the fullest extent of the law, neither the Publisher nor the authors, contributors, or editors, assume any liability for any injury and/or damage to persons or property as a matter of products liability, negligence or otherwise, or from any use or operation of any methods, products, instructions, or ideas contained in the material herein.
Executive Content Strategist: Sonya Seigafuse
Senior Content Development Specialist: Tina Kaemmerer
Ms. Leslie Kendrick, of Boise State University, joined us as the coauthor for the ninth edition of Bontrager's text and ancillaries. Leslie is a dedicated educator and talented writer who has brought a high degree of quality and currency to this edition. Leslie has the insights, skills, and dedication of a veteran educator and writer. I am blessed to have her as a partner for this edition and other editions to follow.
Ms. Tina Kaemmerer, our editor, deserves praise for her dedication and vision in coordinating this project. She supported us tirelessly and professionally through every phase of this new edition. She has become a close friend to us and we hope to work with her for many future editions. Special thanks also to Ms. Sonya Seigafuse, Executive Content Strategist, for her leadership on the text and related ancillaries. Ms. Angela Bosovski, RT(R), and Ms. Karina Delgado, RT(R), GateWay Community College, and Ms. Sarah Johnston, RT(R), and Ms. Maricruz Parkinson, from Boise State University, reviewed every exercise and assessment for this edition of the workbook. These individuals did a stellar job in their attention to detail and ensuring the accuracy of every exercise and assessment. They will be outstanding radiologic technologists. Special thanks to Mr. Janish Ashwin Paul, the Production Project Manager, for his attention to detail and his professionalism during the editing phase of the workbook.
This edition is dedicated to the students who continue to provide us with valuable feedback on how we can improve the text and workbook materials. A special thanks goes to Michele L. Murphy
BSRS, RT(R)(M), of the faculty at Allen College in Waterloo, Iowa. Michele and her students have been valuable resources in providing feedback on how we can make the text and workbook more meaningful and accurate.
Finally, my gratitude goes to the faculty who dedicated their careers to preparing future generations of health care professions. My colleagues at GateWay Community College are always willing to assist me with all aspects of the text and materials. Thank you.
JPL
Thank you to Mr. John P. Lampignano for granting me the opportunity to be part of this project. John's passion for the field, true respect for others, and insatiable drive to provide a valuable, lasting resource for radiologic sciences are admirable. It is truly an honor to work with John and also to receive the chance to contribute to the profession in this manner. Thank you again for trusting in me.
I wish to reiterate John's expression of appreciation to all individuals at Elsevier who made this publication possible. Many thanks especially to Tina Kaemmerer, our editor. She truly is a master of her trade. It has been more than a pleasure to have Tina guiding us toward the completion of this project.
A word of appreciation is also extended to all of the faculty and students who are so willing to provide us with feedback on methods for keeping these materials accurate, current, and useful for student learning. It is my hope that this workbook continues to be a valued teaching tool for the enhancement of student success.
LEK
Preface
Because of the success of the first eight editions of this workbook and laboratory manual, as well as the accompanying textbook, along with the associated ancillary materials, many schools of radiologic technology throughout the United States, Canada, and other countries have adopted and used all or parts of these instructional media for more than 38 years.
New to This Edition
The field of medical imaging is in constant evolution. It becomes a challenge to create a text and workbook that accurately reflects the technology and clinical practice of the profession. Through the diligence of the contributors and reviewers, we hope we have made these learning tools as current as possible.
New illustrations, photographs, and expanded questions have been added to the ninth edition of Bontrager's Textbook of Radiographic Positioning and Related Anatomy. The use of visuals in these review exercises is aimed not only at increasing comprehension but also at increasing retention. A team of faculty and students has assessed every review question to ensure that they are as accurate as possible.
The detailed laboratory activities have been updated and the positioning question and answer exercises have been expanded, with less emphasis on rote memory recall. More situational questions involving clinical applications have been added. These questions assist in the application of positioning principles and
critical evaluation of images. The clinically situational questions added to each chapter require students to analyze and apply this positioning information to specific clinical examples.
Pathology and clinical indication questions have been expanded to help students understand why they are performing specific exams and how exposure factors or positioning may be affected.
As in the textbook, updated information and concepts in digital imaging have been added in this edition. The bone densitometry section has also been expanded and included with other advanced modalities found in Chapter 20. Introductions to CT, MRI, nuclear medicine, PET, radiation oncology, ultrasound imaging, mammography, bone densitometry, and MRI have also been updated and expanded.
Bontrager's Handbook
The ninth edition of the expanded Bontrager's Handbook of Radiographic Positioning and Techniques is now available from Elsevier as part of this comprehensive learning package on radiographic positioning and imaging. The ninth edition of this handbook includes the unique added feature of a printed radiographic image of the position being described along with a basic critique checklist alongside each image. These primary image evaluation criteria are grouped in a consistent manner for all projections and are listed in more detail in the positioning pages of the textbook in the Evaluation Criteria section.
This unique handbook provides a guide for students to carry with them in the clinical setting as they learn what to look for when they evaluate each radiograph after it has been taken and processed. The image evaluation checklists also provide a system for clinical instructors to use in which they can check off each criterion for that radiograph and sign off on that exam as a completed competency for that student.
Information for Faculty
Instructor Resources
Electronic instructor resources are available on the Evolve website at http://evolve.elsevier.com/Bontrager, and they consist of the following four components:
▪ Self-Test Answer Keys: Each chapter in the workbook includes a self-test that appears after the review exercises, which the students can complete. Based on feedback in advance of the eighth edition from educators, the answer keys have been removed from the student workbook and have been placed on the Evolve website under Instructor Resources. Faculty can choose to share the answer keys with their students beforehand or can keep them for instructor access only, based on the level and immediacy of the feedback they wish to provide.
▪ Computerized Test Bank: This test bank features more than 2000 questions divided into 20 chapters. It has been updated, expanded, and revised into more registry-level questions that can be used as final evaluation exams for each chapter. Each question and the answers have been verified by a team of educators and student reviewers. They can be used to produce paper-based exams, or they can be integrated into a Learning Management System (LMS) such as Blackboard and Canvas. Answer keys are provided for each examination and can be found on the Evolve Educator's website. These questions can be downloaded to use for any assessment, and you will be able to delete or add questions to create your own personal test bank.
▪ Electronic Image Collection: Also available is an updated and expanded electronic collection of images from all 20 chapters of the ninth edition of the textbook. These nonannotated images can be used by instructors to create PowerPoint presentations or for other web-based applications.
▪ Electronic Instructional Presentation in PowerPoint: Now included is an updated and expanded electronic image PowerPoint program that is fully coordinated with all 20 chapters of the ninth edition textbook and workbook. These electronic images include text slides, some of which contain embedded anatomy and radiographic images, resulting in a visually led instructional narrative. This can then be used as a complete
chapter-by-chapter PowerPoint lecture guide. Sections from the more advanced chapters can also be used for in-service training or with postgraduate presentations. They can be downloaded to your desktop to personalize with your own content.
Student Instructions
The following information describes how to use this workbook and the accompanying textbook effectively to help you master radiographic anatomy and positioning.
Because this course becomes the core of all your studies and your work as a radiologic technologist, it is one that you must master. You cannot become a proficient technologist by marginally passing this course. Therefore, please read these instructions carefully before beginning Chapter 1.
Objectives
Gain a clear understanding of the competencies by reviewing the list of objectives found at the beginning of each chapter.
Textbook and Workbook
Chapter 1 includes a comprehensive introduction that prepares you for the remaining chapters of this positioning course. This chapter contains basic positioning and technical principles that will apply to the remainder of the text and workbook exercises. Your instructor may assign all or specific sections of these chapters at various times during your study of radiographic positioning or procedures. There is an expanded section on digital imaging. The radiation protection section reflects the best practices to protect both patient and technologist.
Chapters 2–14 are specific positioning chapters that include the
anatomy, positioning, and related procedures for most regions of the body.
Chapters 15–20 describe more specialized procedures and modalities that are commonly studied later in a medical radiography program.
Learning Exercises
These exercises are the focal point of this workbook. Using them correctly will help you learn and remember the important information presented in each chapter of the textbook. To maximize the benefits from each exercise, follow the correct six-step order of activities as outlined in the following.
Anatomy Activities
Step 1 (Textbook)
Carefully read and learn the radiographic anatomy section described in each of these chapters. Include the anatomic reviews on labeled radiographs provided in the textbook. Pay particular attention to those items in bold type and to the summary review boxes, where provided.
Step 2 (Workbook, Part I)
Complete Part I of the review exercises on radiographic anatomy. Do not look up the answers in the textbook or look at the answer sheet until you have answered as many of the questions as you can. Then refer to the textbook or the answer sheet and correct or complete those questions you missed. Reread those sections of the textbook in which you could not answer questions. Textbook page numbers are provided next to each review exercise in this workbook.
Positioning Activities
Step 3 (Textbook)
Carefully read and study Part II on all of the parts on radiographic positioning. Note the general positioning considerations, alternate modalities, and clinical indications for each chapter. Information from these sections will be seen on workbook review exercises and self-tests. Learn the specific positioning steps, the central ray location and angle, and the five-part radiographic criteria for each projection or position.
Step 4 (Workbook, Part II)
Complete Part II of the review exercises, which includes technical considerations and positioning. Also included is a section on problem solving for technical and positioning errors. As before, complete as many of the questions as you can before looking up the answers in the textbook or checking the answers on the answer sheet.
The last review exercise in each positioning chapter covers radiographic critique questions in the workbook. These questions may involve radiographic evaluation of images from the text. These important exercises will help you make the transition from factual knowledge to application and will help you prepare for clinical experience. Compare each critique radiograph that demonstrates errors with the correctly positioned radiographs in that chapter of the textbook, and see if you can determine which radiographic criteria points could be improved and which are repeatable errors.
With digital imaging, you will learn that in some cases postprocessing adjustments can be made to improve the exposures and the diagnostic value of the images rather than repeating the exam. Positioning errors, however, would still need to be repeated as they would with analog (film-screen) imaging and processing. Students who successfully complete these exercises will be ahead of those students who do not attempt them before coming to the classroom. The instructor will then explain and clarify the repeatable and nonrepeatable errors on each radiograph.
Laboratory Activity
Step 5 (Workbook, Part III—Laboratory Activity)
These exercises must be performed in a radiographic laboratory using a phantom or a student (without making exposure), an energized radiographic unit, illuminators for viewing radiographs, or monitors for viewing digital images. Arrange for a time when you can use your radiographic laboratory or a diagnostic radiographic room in a clinic setting.
This is one of the most important aspects of this learning series and should not be neglected or underemphasized. Students frequently have difficulty transferring the information they have learned about positioning to effective use in a clinical setting. Therefore you must perform the laboratory activities as described in each chapter. Your instructors or lab assistants will assist you as needed in these exercises.
Each radiograph taken of the phantom or other radiographs provided by your instructor should be evaluated as described in your lab manual. Critique and evaluate each radiograph for errors of less-than-optimal positioning or exposure factors based on radiographic criteria provided in the textbook. Also, with the help of your instructor, learn how to discriminate between less-thanoptimal but passable radiographs, and those that need to be repeated. This generally requires additional experience and practice before you can make these judgments without assistance from a supervising technologist or radiologist.
Self-Test
Step 6
You should take the self-test only after you have completed all of the preceding steps. Treat the self-test as if it is an actual exam. After completing the self-test, submit your test to your instructor. The faculty possesses the self-test answer keys. Instructors may
elect either to provide students with the answer key or to grade the self-test themselves. If your score is less than 90% to 95%, you should go back and review the textbook again; pay special attention to the areas you missed before you take the final chapter evaluation exam provided by your instructor.
Note: Statistics prove that students who diligently complete all the exercises described in this section will invariably achieve higher grades in their positioning courses and will perform better in the clinical setting than those who do not. Avoid the temptation of taking shortcuts. If you bypass some of these exercises or just fill in the answers from the answer sheets, your instructors will know by your grade and by your clinical performance that you have taken these shortcuts. Most important, you will know that you are not doing your best and when you graduate you will have difficulty in competing with better-prepared technologists in the workplace.
Go to it and enjoy the feeling of satisfaction and success that only comes when you know you're doing your best!
1
Terminology, Positioning, and Imaging Principles
Chapter Objectives
After you have successfully completed the activities in this chapter, you will be able to:
A General, Systemic, and Skeletal Anatomy and Arthrology
1. List the four basic types of tissues.
2. List the 10 systems of the body.
3. Match specific bodily functions to their correct anatomic system.
4. List the four general classifications of bone.
5. Identify specific characteristics and aspects of bone.
6. Classify specific joints by their structure and function.
7. Classify specific synovial joints by their movement types.
B Positioning Terminology
1. Define general radiographic and anatomic relational terminology.
2. Define the imaginary planes, sections, and surfaces of the body used to describe central ray angles or relationships among body parts.
3. Distinguish among a radiographic projection, position, and view.
4. Given various hypothetic situations, identify the correct radiographic projection.
5. Given various hypothetic situations, identify the correct radiographic position.
6. List the antonyms (terms with opposite meanings) of specific terms related to movement.
C Positioning Principles
1. Given a hypothetic clinical situation, identify the response as required in the professional code of ethics.
2. Identify the correct sequence of steps taken to perform a routine radiographic procedure.
3. Given a set of circumstances, apply the three general rules of radiography concerning the minimal number of projections required for specific regions of the body.
4. Identify the correct way to view a conventional radiograph, computed tomography (CT) image, and magnetic resonance (MR) image.
D Image Quality in Analog (Film-Screen) Imaging
1. Describe the major exposure factors that influence the diagnostic quality of the radiograph.
2. List the four image quality factors and their impact on a radiograph.
3. Define radiographic density and identify its controlling factors.
4. Given a hypothetic situation, select the correct factor to improve radiographic density.
5. Describe the correlation between radiographic density and the anode heel effect.
6. List three types of filters and the radiographic procedures that are enhanced by their use.
7. Define radiographic contrast and identify its controlling factors.
8. Distinguish between long- and short-scale radiographic contrast.
9. Given a hypothetic situation, select the correct factor to improve radiographic contrast.
10. In given situations, identify the type of grid cutoff errors present and their effect on image quality.
11. Define resolution and identify its controlling factors.
12. List the three geometric factors that influence image sharpness.
13. Identify the best ways of controlling voluntary and involuntary motion.
14. Given a hypothetic situation, select the correct factor to improve radiographic detail.
15. Define radiographic distortion and identify its controlling factors.
16. Given a hypothetic situation, select the correct factor to minimize radiographic distortion.
E Image Quality in Digital Radiography
1. List the six image-quality factors specific to digital imaging.
2. Define brightness and identify its controlling factors in the digital image.
3. Define contrast and identify its controlling factors in the digital image.
4. List the two types of pixel sizes.
5. Define spatial resolution and identify its controlling factors in the digital image.
6. Define distortion and identify its controlling factors in the digital image.
7. Define exposure indicator and describe its relationship to the amount of radiation striking the image receptor (IR).
8. Explain the concept of the signal-to-noise ratio (SNR).
9. Define specific terms related to the postprocessing of the digital image.
F Applications of Digital Technology
1. List the major components of a storage phosphor-based digital system (PSP).
2. Describe briefly how an image is recorded, processed, and viewed with a PSP system.
3. Explain the importance of correct centering, collimation, use of lead masking, and use of grids to the overall quality of the digital image.
4. Identify specific differences and similarities between PSP and digital radiography (DR).
5. Define the terms PACS, RIS, HIS, and DICOM.
6. Compare and contrast differently sized image receptors between metric and English units of measurement.
7. Define specific imaging terms and acronyms.
G Radiation Protection
1. List the three methods to reduce exposure to patients and staff.
2. List and define the traditional units and International System of Units (SI units) of radiation measurement and the conversion factors used to convert between systems.
3. List the specific annual dose-limiting recommendations of whole-body effective dose for the general population and occupationally exposed workers.
4. Define ALARA.
5. Apply the principles of ALARA to a given hypothetic
situation.
6. List the different types of personnel dosimeters.
7. Define and provide examples of effective dose (ED).
8. Identify specific methods to reduce exposure to the technologist during fluoroscopic and radiographic procedures.
9. Describe the seven methods to reduce exposure to the patient during radiographic procedures.
10. Identify the major types of specific area shields and how they should be applied during radiographic procedures.
11. Define patient dose terminology for specific regions of the body.
12. Identify methods to ensure a dose to the patient is minimized when using digital imaging systems.
13. Explain the Image Wisely and Image Gently initiative and its purpose.
Learning Exercises
The following review exercises should be completed only after careful study of the associated pages in the textbook as indicated by each exercise. Because certain topics may be too advanced for the entry-level student, the review exercises for Chapter 1 are divided into sections A through C. You can complete specific sections of review exercises, as directed by your instructor, to best meet your learning needs.
After completing each of these individual exercises, check your answers with the answers provided at the end of the review exercises.
REVIEW EXERCISE A: General, Systemic, and Skeletal Anatomy and Arthrology (see textbook pp. 3–15)
1. The lowest level of the structural organization of the human body is the .
2. List the four basic types of tissues in the body.
A.
B.
C.
D.
3. List the 10 systems of the human body.
A.
B. ______________
C. ______________
D. ______________
E. ______________
F. ______________
G. ______________
H. ______________
I. ______________
J. ______________
4. Match the following functions to the correct body system.
1 Eliminates solid waste from the body
2. Regulates fluid and electrolyte balance and volume
3. Maintains posture
4 Regulates body activities with electrical impulses
5 Regulates bodily activities through various hormones
6. Eliminates carbon dioxide from blood
7. Receives stimuli, such as temperature, pressure, and pain
8 Reproduces the organism
9 Helps regulate body temperature
10. Supports and protects many soft tissues of the body
A Skeletal system
B. Circulatory system
C. Digestive system
D Respiratory system
E Urinary system
F. Reproductive system
G. Nervous system
H Muscular system
I Endocrine system
J. Integumentary system
5. True/False: One of the six functions of the circulatory system is to protect against disease.
6. Which of the following body systems regulate body temperature?
A. Endocrine
B. Integumentary
C. Digestive
D. Circulatory
7. What is the largest organ system in the body?
A. Digestive
B. Nervous
C. Integumentary
D. Respiratory
8. List the two divisions of the human skeletal system. A.
9. True/False: The adult skeleton system contains 256 separate bones.
10. True/False: The scapula is part of the axial skeleton.
11. True/False: The skull is part of the axial skeleton.
12. True/False: The pelvic girdle is part of the appendicular skeleton.
13. List the four classifications of bones.
______________ B. ______________
______________ D. ______________
14. The outer covering of a long bone, which is composed of a dense, fibrous membrane, is called what?
A. Spongy or cancellous bone
B. Compact bone
C. Medullary aspect
D. Periosteum
15. Which aspect of long bones is responsible for the production of red blood cells?
A. Spongy or cancellous bone
B. Compact bone
C. Medullary aspect
D. Periosteum
16. Which aspect of the long bone is essential for bone growth, repair, and nutrition?
A. Medullary aspect
B. Compact bone
C. Periosteum
D. Articular cartilage
17. Identify the primary and secondary growth centers for long bones.
A. Primary growth center:
B. Secondary growth center:
18. True/False: Epiphyseal fusion of the long bones is complete by the age of 16 years.
19. The is the wider portion of a long bone in which bone growth in length occurs.
