Procedure JUSTIFICATION, POSITIONING AND … · A significant number of radiological investigations...

ALBURY WODONGA HEALTH © PRO1483 – Page 1

Procedure

JUSTIFICATION, POSITIONING AND EXPOSURE PROTOCOLS FOR

X-RAY EXAMINATIONS

Definition / Description:

In accordance with the Victorian Radiation Act 2005 Wodonga Medical Imaging, Albury Wodonga

Health Wodonga Campus (AWHWC) requires all medical imaging referrals that will use medical

radiation, to be justified and optimised.

Personnel Able to Perform or Assist with Procedure:

Radiation Medical Practitioner.

Operators

Expected Outcomes:

To assist in implementation of the As Low As Reasonably Achievable (ALARA) principle.

To reduce inappropriate or over irradiation of patients.

To provide guidelines for appropriate investigations.

To comply with requirements of the Victorian Radiation Act 2005.

Equipment:

N/A.

Process Standards:

WHY ARE GUIDELINES AND REFERRAL CRITERIA REQUIRED?

A useful investigation is one in which the result – positive or negative – will alter management or add

confidence to the clinician’s diagnosis. A significant number of radiological investigations do not fulfil

these aims and may add unnecessarily to patient irradiation. The chief causes of this are:

Repeating investigations which have already been performed.

Investigating when the results are unlikely to affect patient management.

Investigating too often.

Requesting the wrong investigation.

Failing to provide appropriate clinical information and questions that the investigation should

answer.

Over-investigating.

SCOPE:

This document provides specific protocols that should be applied to medical imaging referrals prior to

any X-ray examination or procedure.

ROLES AND RESPONSIBILITIES:

It is the responsibility of the Radiation Medical Practitioner to define whether an X-ray examination is

justified. It is the role of the Operator to assess a referral and determine whether the X-ray falls within

the criteria of the generic justification protocol or whether it should be justified on an individual basis.

JUSTIFICATION, POSITIONING AND EXPOSURE PROTOCOLS FOR X-RAY EXAMINATIONS


DEFINITION OF JUSTIFICATION:

A radiation procedure is justified when it is determined that the radiation exposure will produce

sufficient benefit to the exposed individual to offset the risk associated with the radiation exposure. In

determining the net benefit from a radiation procedure, the Radiation Medical Practitioner must take

into account clause 3.2.2 of the Code.

JUSTIFICATION PROCESS:

Justification of X-ray examinations and procedures can be on the basis of generic justification

OR on an individual basis. In both cases the definitions are determined by the Radiation Medical

Practitioner.

As part of the justification process the Radiation Medical Practitioner should:

Communicate directly with the referrer to seek clarification if the referral is:

Inappropriate.

Ambiguous.

Would lead to a radiation exposure that does answer the clinical question being posed.

The Radiation Medical Practitioner should where it is clinically appropriate:

Substitute other imaging tests that do not use ionizing radiation.

Modify the examination.

Cancel the examination.

Limit the procedure scope, eg: limit number of phases.

Communicate decisions with the referrer.

ABBREVIATIONS:

AEC Automatic Exposure Control

AP Anteroposterior

COPD Chronic Obstructive Pulmonary Disease

DP Dorsiplantar

GI Gastrointestinal

kV Kilo Voltage

mAs Milliamps per second

NOF Neck of Femur

# Fracture

SCN Special Care Nursery

TMJ Temporomandibular Joint

OPG Orthopantomogram



LOWER LIMB

Foot (including toes) X-ray

Generic Justifications

Projections Adult Paediatrics kV mAs

Arthropathy

Bony Mass

Dislocation

Foreign Body

Fracture Follow Up

Osteomyelitis

Pain

Trauma

DP

Oblique

Lateral

55kV

2 mAs

No Grid

0 - 6 mths

6 – 18 mths

18 mths - 3 yrs

3 - 7 yrs

8 – 12 yrs

No Grid

40

40

50

52

52

4

5

2

2

2

Podiatrist’s referrals must have a

clinical indication for each foot.

Comparison views NOT

JUSTIFIED unless there is a

clinical reason OR as requested

by the Radiologist

DP Weight bearing

Lateral Weight bearing

Oblique

As above

Ankle X-ray Generic

Justifications


Arthropathy

Bony Mass

Dislocation

Foreign Body

Fracture Follow Up

Osteomyelitis

Pain

Trauma

AP

Oblique

Lateral

55kV

3.2mAs

No Grid

0 - 6 mths

6 – 18 mths

18 mths – 3 yrs

3 - 7 yrs

8 – 12 yrs

40

40

50

55

60

5

5

2

2

2

Podiatrist’s referrals must have a

clinical indication for each ankle.

Comparison views NOT

JUSTIFIED unless there is a

clinical reason OR as requested

by the Radiologist

AP Weight bearing

Oblique Weight bearing

Lateral Weight bearing

As above

Calcaneum X-ray Generic

Justifications


Foreign Body

Fracture Follow Up

Osteomyelitis

Pain

Trauma

Spur

AP

Lateral

60kV

2mAs

No Grid

0 - 6 mths

6 - 18 mths

18 mths – 3 yrs

3 - 7 yrs

8 – 12 yrs

Tibia & Fibula X-ray Generic

Justifications


Arthropathy

Bony Mass

Dislocation

Foreign Body

Fracture Follow Up

AP

Lateral

Paediatrics:

Oblique

60kV

2.8mAs

No Grid

0 - 6 mths

6 – 18 mths

18 mths – 3 yrs

3 - 7 yrs

55

55

55

57

60

1.6

1.6

1.6

1.6

2



Osteomyelitis

Pain

Trauma

8 – 12 yrs

Knee X-ray Generic

Justifications


Arthropathy

Bony Mass

Foreign Body

Fracture Follow Up

Osteomyelitis

Pain

AP (weight bearing)

Lateral

Intercondylar

Skyline if requested or

if patellar pathology

suspected

With

grid/AE

C

66kV

5mAs

0 - 6 mths

6 – 18 mths

18 mths - 3yrs

3 - 7 yrs

8 – 12 yrs

55

57

57

60

63

1.6

1.6

1.6

2

2

Trauma

Dislocation

Effusion / Swelling

AP

Lateral (Horizontal

Beam)

Skyline if patellar

pathology suspected

As above

Femur X-ray Generic

Justifications


Bony Mass

Bone Pain

Congenital Malformation-

Infection

Metastasis

Osteomyelitis

Painful Prosthesis

Post Operative

Primary Bone Tumour

Trauma

AP

Lateral

77kV

With

AEC

Grid

0 - 6 mths

6 – 18 mths

18 mths -3 yrs

3 - 7 yrs

8 – 12 yrs

63

63

63

66

70

No

Grid

2

2.5

2.5

AEC

AEC



PELVIS

Pelvis / Hip X-ray Generic

Justifications


Arthropathy

Avascular Necrosis

Bony Mass

Bone Pain

Congenital Malformation

Hip Pain

Infection

Metastasis

Osteomyelitis

Osteomalacia

Painful Prosthesis

Post Operative

Primary Bone Tumour

Sacroiliac Pain

Paget’s Disease

Trauma

AP

Oblique

Shoot through lateral (if

#NOF is suspected)

73kV

AEC

0 - 6 mths

6 – 18 mths

18 mths – 3 yrs

3 - 7 yrs

8 – 12 yrs

63

66

66

70

73

No

Grid

2.5

2.5

2.5

6.3

6.3

Slipped Epiphysis

Uneven creases

CDH

Follow Up CDH

AP

Frog’s Leg Lateral (only if

requested by Radiologist

or specialist)

As Above

-# Pubic Rami AP

AP 15 deg Cranial

AP 15 deg Caudal

As Above



GASTROINTESTINAL

Abdomen X-ray Generic

Justifications


Acute Abdominal Pain

Bowel Obstruction

Change in Bowel Habit

Foreign Body (surgical)

Intussusception

Palpable Mass

Post Surgical

Supine

PA Erect

Add CXR for acute

abdo

Lt PA Decubitus if

Erect not possible

Lateral Decubitus if

PT can’t hold

position

81kv

AEC

With

Grid

0 - 6 mths

6 – 18 mths

18 mths – 3 yrs

3 - 7 yrs

8 – 12 yrs

63

66

63

63

63

73

2.5

2.5

AEC

AEC

AEC

AEC

Constipation Supine Only

(unless there are

obvious signs of

obstruction OR

perforation

Paediatric Requests from SCN

Necrotising Enterocolitis

Position of Umbilical Lines

Abdominal Distension

Supine

Decubitus on

request of

Paediatrician

Foreign Body (self-inflicted)

Foreign Body (trauma)

Supine

Lateral

Upper GI Fluoroscopic X-ray

Generic Justifications


Dysphagia

Foreign Body

Malignancy

Pre Surgical Planning

Post Surgical Assessment

Oesophageal dilatation

Aspiration

To optimally

demonstrate

pathology

Variable with AEC

Upper GI Fluoroscopic X-ray with

Speech Pathology Team Generic

Justifications


Dysphagia

Malignancy

Aspiration

Stroke

Swallowing assessment

As requested by

Speech Pathology

Team

Variable with AEC

Lower GI Fluoroscopic X-ray with

Speech Pathology Team Generic

Justifications


Malignancy

Pre surgical anastomosis

Anastomosis leak

Failed Colonoscopy

Fluoroscopy as

required

Extra views as

requested: AP

Variable with AEC



Supine, PA 40 deg

Caudal, Right

Decubitus, Left

Decubitus



RESPIRATORY AND CARDIOVASCULAR SYSTEM

Chest X-ray Generic Justifications Projections Adult Paediatrics kV mAs

Acute Chest Pain

Angina (unstable)

Air entry decrease

Anaphylaxis

Aortic Dissection

Aspiration

Asthma

Bronchiectasis

Bronchiolitis

(wheeze or stridor)

Cardiomegaly

Collapse

Confusion

Consolidation

COPD

Chronic Cough

Cystic Fibrosis

Haemoptysis

Haemothorax

Heart Failure

Heart Murmur

Hypertension

Infection Lung Disease

Low Oxygen

Saturation

Lower Respiratory

Tract

Myocardial Infarction

Oesophageal

Perforation

Osteosarcoma

Perforation -

Pericarditis

Pleural Effusion

Pleurisy

Pulmonary Embolism

Post CABG

Pyrexia

Respiratory Tract

Infection

Shortness of Breath

Sternal Fracture

Trauma

Thoracic Inlet

Obstruction

Tuberculosis

Valvular Heart Disease

PA + Lateral

If patient’s

condition does

not permit:

AP (Mobile)

AP Erect (in

bed)

AP Supine

PAEDIATRIC

CHEST:

AP OR PA

ONLY UNLESS

SPECIFIED BY

RADIOLOGIST

/ SPECIALIST

AP / PA

OBLIQUE RIBS

FOR #

125KV

AEC

109 kV

0.8 mAs

0 - 6 mths

6 – 18 mths

18 mths – 3 yrs

3 - 7 yrs

8 – 12 yrs

No Grid

63

77

77

85

90

1.6

2

2.5

AEC

AEC

Pneumothorax PA Inspiration

+ PA Expiration

Lateral

Inspiration

ONLY for

follow up

examinations

See Chest Exposures

Pre-employment

Passport/Immigration

Post Procedure: PICC Line, Biopsy, Drainage

PA Only

AP if patient’s

condition does

not permit

See Chest Exposures

Foreign Body -PA OR AP

with inspiration

and expiration

See Chest Exposures

-# Rib

-Metastases

-PA Chest

-Lateral

-AP or PA

Oblique Ribs

See Chest Exposures



SPINE

Cervical Spine X-ray Generic

Justifications


Atlanto-Axial Subluxation

Cervical Rib

Congenital Abnormalities

Degenerative Change

Neck Pain

Paraesthesia Upper Limb

Cervical Rib

AP 15 deg Cranial

PEG

Lateral

AP OR PA Obliques

Swimmer’s if C7-T1 not

visualised

70/AEC 0 -6 mths

6 – 18 mths

18 mths – 3 yrs

3 - 7 yrs

8 – 12 yrs

NO GRID

66

66

70

70

73

2

2

2

2.5

5

Foreign Body Soft Tissue Neck AP 15 deg Cranial

Lateral

Using Val Salva

See Cervical Spine Exposures

Trauma Lateral Horizontal Beam

AP 15 deg Cranial

PEG

Swimmer’s if C7-T1 not

visualised


Chiropractic OR Osteopathic

Request

AP 15 deg Cranial

Lateral

PEG


Pre Anaesthetic Lateral flexion

Lateral extension


Thoracic X-ray Generic

Justifications


Degenerative Change

Osteoporotic Collapse

Pain

Scoliosis

Congenital Anomalies

Malignancy

Trauma

AP

Lateral

77/AEC 0 - 6 mths

6 – 18 mths

18 mths – 3 yrs

3 - 7 yrs

8 – 12 yrs

66

70

70

70

70

NO

GRID

2

AEC

AEC

AEC

AEC


Request

AP

Lateral

Lumbosacral X-ray Generic

Justifications

Projections A

du

lt

Paediatrics kV mAs

Degenerative Change

Osteoporotic Collapse

Pain

Congenital Anomalies

Malignancy

AP

Lateral

Obliques

L5/S1 if not demonstrated

75

/A

E

C

0 - 6 mths

6 – 18 mths

18 mths – 3 yrs

3 - 7 yrs

8 – 12 yrs

NO GRID

66

70

70

70

70

2

AEC

AEC

AEC

AEC

Trauma AP

Lateral Horizontal Beam

L5/S1 if not demonstrated

See Lumbar Spine Exposures



Scoliosis

AP

Lateral



Request

AP to include ischial

tuberosities (cones open

laterally)

Lateral


Sacroiliac Joint Pathology AP 25 deg Cranial

Left and Right Obliques


Coccyx Pathology AP 15 deg Cranial

Both Laterals




HEAD AND FACIAL BONES

Skull X-ray Generic Justifications Projections Technical Factors

Craniosynostosis PA

Lateral

Townes

73/AEC (PAEDS NO GRID)

Foreign Body PA

Lateral

Tangential View


Paediatric Trauma AP

Townes

Lateral


Facial Bones X-ray Generic Justifications Projections Technical Factors

CT is preferred modality

Paediatric Trauma

OM

OM 30 deg

Lateral


# Nasal Bones OM

Lateral Nose (Bilateral)


Foreign Body pre MRI OM with eyes up and

eyes down

Lateral


Sinus X-ray Generic Justifications Projections Technical Factors

CT is preferred modality PA 15 deg Caudal

OM 30 deg

Lateral


OPG / TMJ Generic Justifications Projections Technical Factors

Dental caries

Pre Treatment

Pain

TMJ Dysfunction

Trauma

OPG

TMJ

As per OPG machine



Skeletal Surveys

Skeletal Survey Adult X-ray Generic

Justifications

Projections Technical Factors

Renal Osteodystrophy PA Chest

AP Pelvis

AP Femora

Lateral Lumbar Spine


PA Hands

As per appropriate area

Multiple Myeloma PA Chest

AP Pelvis

AP Humeri

AP Femora

Lateral Skull

Lateral Cervical Spine

Lateral Thoracic Spine


Metasteses Lateral Skull

PA Chest with Oblique

Ribs on affected side

AP and Lateral Whole

Spine

AP Pelvis

X-ray any abnormal

areas detected on other

imaging

Skeletal Survey Paediatric X-ray Generic

Justifications

Projections Technical Factors

Non Accidental Injury Lateral Skull

AP Chest

Lateral Thoracic Spine


AP Abdomen (including

Pelvis)

AP Humeri

AP Femora

As per appropriate area



UPPER LIMB

Hand / Finger X-ray Generic Justifications Projections Adult Paediatrics kV mAs

Arthropathy

Bony Mass

Dislocation

Foreign Body

Fracture

Fracture Follow up

Osteomyelitis

Pain

PA

Oblique

Lateral with

fingers spread

50 kV

1.8mAs

0 - 6 mths

6 – 18 mths

18 mths – 3 yrs

3 - 7 yrs

8 – 12 yrs

40

40

40

46

46

4

4

4

2.5

2.5

Bone Age PA Non Dominant As for paediatric hand. Include wrist

Wrist X-ray Generic Justifications Projections Adult Paediatrics kV mAs

Arthropathy

Bony Mass

Dislocation

Foreign Body

Fracture

Fracture Follow-up

Osteomyelitis

Pain

PA

Oblique

Lateral

52 kV

2 mAs

0 - 6 mths

6 – 18 mths

18 mths – 3 yrs

3 - 7 yrs

8 – 12 yrs

40

40

40

48

50

4

5

5

2.5

2

Forearm X-ray Generic Justifications Projections Adult Paediatrics kV mAs

Arthropathy

Bony Mass

Dislocation

Foreign Body

Fracture

Fracture Follow up

Osteomyelitis

Pain

PA

Lateral

50 kV

2.5

mAs

0 - 6 mths

6 – 18 mths

18 mths – 3 yrs

3 - 7 yrs

8 – 12 yrs

50

50

50

50

52

2

2

2

2.5

2.5

Elbow X-ray Generic Justifications Projections Adult Paediatrics kV mAs

Arthropathy

Bony Mass

Dislocation

Foreign Body

Fracture

Fracture Follow up

Osteomyelitis

Pain

AP

Oblique

Lateral

Radial head view

if indicated

55 kV

2.8

mAs

0 - 6 mths

6 – 18 mths

18 mths – 3 yrs

3 - 7 yrs

8 – 12 yrs

50

50

50

55

57

2

2

2

2.5

2.5

Humerus X-ray Generic Justifications Projections Adult Paediatrics kV mAs

Arthropathy

Bony Mass

Foreign Body

Fracture

Fracture Follow up

Osteomyelitis

Pain

AP

Lateral

60 kV

AEC

0 - 6 mths

6 – 18 mths

18 mths – 3 yrs

3 - 7 yrs

8 – 12 yrs

NO GRID

60

60

63

63

66

1.6

2

2

2.5

2.5



Shoulder X-ray Generic Justifications Projections Adult Paediatrics kV mAs

Arthropathy

Bony Mass

Pain

AP Glenohumeral

with external

rotation

AP 20 deg Caudal

with Internal

Rotation

Lateral Scapula 20

deg Caudal

66 kV

AEC

0 - 6 mths

6 – 18 mths

18 mths – 3 yrs

3 - 7 yrs

8 – 12 yrs

60

60

63

63

66

1.6

2

2

2.5

2.5

Dislocation

Foreign Body

Fracture

Fracture Follow up

Osteomyelitis

AP

Lateral

As per Shoulder Exposures

Acromio Clavicular Pathology AP

Lateral

Weight bearing

and non weight

bearing both sides

if possible


# Clavicle AP

AP 20 deg Cranial




Annexes:

Related AWH Documents:

Accreditation Standards:

Other Relevant Information:

References:

Contact Point: Medical Imaging Manager.

In consultation with:

TITLE / POSITION

THIS SECTION FOR QUALITY & CLINICAL GOVERNANCE OFFICE USE ONLY

Approved by Executive / Delegate: Date Approved: SharePoint Location:

Executive Director of Medical Services

and Clinical Governance

7 October 2015 Procedures…

Responsible Department: Date for Review: Linked Documents:

Medical Imaging 7 October 2018

Version No: Original Approval Date: Previously Named As:

1 7 October 2015

Date post:	30-Jul-2018
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