Chapter 8 — Skull Radiography
Introduction & Positioning Notes
Pg. 230
Interpretation of Skull Images
• Skull films = among the most difficult to interpret
• Complex bony structure: many bones joined by sutures
• Arterial & venous markings in the diploe can mimic fracture
• Facial skeleton superimposed over lower skull vault anteriorly
• Petrous temporal bone obscures skull base detail
• CSF leak risk with skull base fractures — hard to see on plain film
• Superimposed objects (ponytails, clips, hair matted with blood) cause confusion
• Surgical clips do not cause confusion & help mark injury site
Anatomical Terminology
Landmarks
• Outer canthus of eye: where upper & lower eyelids meet laterally
• Infra-orbital margin/point: inferior rim of orbit (lowest point)
• Nasion: articulation between nasal & frontal bones
• Glabella: bony prominence on frontal bone, superior to nasion
• Vertex: highest point of skull in median sagittal plane
• External occipital protuberance (Inion): bony prominence on occipital bone, median sagittal plane
• External auditory meatus (EAM): opening of external auditory canal
Lines
• Inter-orbital (inter-pupillary) line: joins centres of two orbits/pupils (eyes looking straight)
• Infra-orbital line: joins the two infra-orbital points
• Anthropological baseline (ABL): infra-orbital point → upper border of EAM (= Frankfurter line)
• Orbito-meatal baseline (OMBL) / Radiographic baseline (RBL): outer canthus of eye → centre of EAM; ~10° to ABL
Planes
• Median sagittal plane: divides skull → right & left halves; landmarks = nasion (anterior) & inion (posterior)
• Coronal planes: right angles to median sagittal; divide head → anterior & posterior
• Anthropological plane: horizontal; contains both ABLs & infra-orbital line; example of axial plane
• Auricular plane: perpendicular to anthropological; through both EAMs; example of coronal plane
Note: Median sagittal, anthropological, and coronal planes are mutually at right-angles.
Pg. 231
Radiographic Anatomy for Positioning
• Median sagittal plane & auricular/coronal plane shown as intersecting planes on skull
• Axial/anthropological plane = horizontal plane through skull base
• Lateral skull diagram labels: Vertex, Glabella, Nasion, Infra-orbital point, EAM, OMBL/RBL, ABL, External occipital
protuberance (Inion)
• Frontal skull diagram labels: Median-sagittal plane, Interorbital/interpupillary line, Infra-orbital line
• Photo labels: A = Orbito-meatal / Radiographic baseline (RBL); B = Anthropological baseline (ABL)
Pg. 234
Positioning Terminology
To describe a skull projection: state skull plane positions relative to image receptor, central ray direction, and centering point.
Occipito-Frontal (OF) Projection
• Central ray parallel to sagittal plane
• Beam enters through occipital bone → exits through frontal bone
• Named by entry → exit: Occipito-Frontal (OF)
Fronto-Occipital (FO) Projection
• Central ray parallel to sagittal plane
• Beam enters through frontal bone → exits through occipital bone
• Named: Fronto-Occipital (FO)
Beam Angulation
• Required for many OF & FO projections — beam angled along sagittal plane to orbital-meatal plane
• Angulation degree stated after projection name
• Cranial angulation (↑): beam points toward head
• Caudal angulation (↓): beam points toward feet
• Example: FO 30° caudal = FO30°↓
Lateral Projection
• Central ray passes along a coronal plane at right-angles to median sagittal plane
• Named by side of head closer to image receptor
• Example: beam enters left side, exits right side (IR on right) = Right Lateral
Pg. 235
Oblique Projections
• Central ray at angle to both median sagittal plane & coronal plane
• Named by: (1) anterior/posterior head contact with cassette, (2) left/right side contact
Lateral with Angulation
• Central ray along coronal plane but at angle to median sagittal plane
• Degree of angulation stated after name
• Example: R Lat 30°↓ = Right lateral with 30° caudal angulation
40° Left Anterior Oblique (40°LAO)
• Head rotated right → median sagittal plane 40° to cassette
• Left side of head in contact with cassette
Complex Oblique Projections
• Additional caudal/cranial angle added to a specified baseline
• Achieved by: raising/lowering chin, tube angulation, or combination
• Example: 55°LAO35°↓ = 55° LAO + 35° caudal angulation
• Can split angulation: e.g. 20° plane raise + 15° tube angle = 35° total
■ Warning — Grid Artefact
• Beam angulation must be parallel to grid lattice (parallel to grid lines)
• If beam is perpendicular to grid lines → grid cut-off artefact → image must be repeated
Pg. 236
Patient Preparation
• Remove all metal objects: hair clips, hairpins
• Untie bunches of hair (produce artefacts)
• Remove false teeth & metal dental bridges if mouth area included
• Explain movements & film positions to patient
Useful Accessories
• Foam pads: essential for immobilization; range of sizes for all ages
• 45° triangular pads: for children; parent can hold without entering primary beam
• Individual side markers: essential (clip-type markers easily lost in collimation)
• Velcro straps: useful for immobilizing patient on skull unit
General Image Quality & Radiation Protection
• Images must show visually sharp reproduction: outer/inner cranial lamina, trabecular structure, sinuses, sutures,
vascular channels, petrous bone, pituitary fossa
• Important detail resolution: 0.3–0.5 mm
• Use 400-speed (regular) imaging system
• Tube voltage: 70–85 kV
• Prefer OF (PA) over FO (AP) — greatly reduces dose to eyes
• Cassette size: 24 × 30 cm for plain skull
Pg. 237
Guide to Skull Technique — Recommended Technique (Flowchart)
Flowchart guides selection of correct technique based on clinical situation.
Is the patient a child?
• YES → Reduce radiation: 2 projections only — lateral + one of injured region (frontal projection or Towne's)
• NO → 3-projection skull series: lateral + occipito-frontal + half axial (Towne's)
Is patient ambulant & cooperative?
• YES — Is skull unit available?
• → YES: Use skull unit, PA (OF) techniques
• → NO: Vertical Bucky with PA (OF) techniques where appropriate
• NO — Can patient be safely moved to X-ray table?
• → YES — Is skull unit available?
• → YES: Skull unit, Bucky, PA (OF) techniques
• → NO: X-ray table, Bucky, AP (FO) technique
• → NO: Examine on trolley, AP (FO) technique with stationary grid
Chapter 8 — Skull Radiography | Study Notes