X-ray Views for Lower Leg Hardware Evaluation
For evaluating lower leg hardware, obtain standard anteroposterior (AP) and lateral views of the tibia and fibula as the minimum requirement, with consideration for additional views based on hardware location and clinical concern.
Standard Imaging Protocol
Essential Two-View Series
- AP and lateral views are the fundamental requirement for initial assessment of lower leg hardware, as these provide adequate visualization of implant position, alignment, and bone healing in most cases 1
- The lateral view is critical for assessing sagittal plane alignment and anterior-posterior hardware positioning 1
- AP views should be obtained with the leg in neutral rotation to accurately assess coronal alignment and hardware positioning 2
When to Obtain Additional Views
- Four-view examinations (adding oblique views) increase fracture detection sensitivity to 85% compared to 79% with two views alone, making them valuable when assessing for complications around hardware 3
- Consider oblique views when evaluating for:
- Subtle peri-implant fractures
- Screw positioning relative to cortices
- Hardware loosening or backing out 3
Hardware-Specific Considerations
Intramedullary Nails
- Standard AP and lateral views adequately visualize nail position, interlocking screw placement, and alignment 4
- Include the entire length of the nail from proximal to distal locking screws 1
- Ensure visualization of both the knee and ankle joints if the nail extends proximally or distally 1
Plates and Screws
- AP and lateral views should capture all screws and the entire plate length 1
- Internal rotation of 10° on AP views can improve assessment of alignment and screw positioning 2
- When hardware extends to the ankle, include the base of the fifth metatarsal distally 1
Critical Technical Points
Rotation Assessment
- Proper rotational positioning is essential - the relative position of the proximal fibula to the tibia indicates knee rotation and affects measurement accuracy 5
- Excessive internal rotation (>20°) can distort measurements and should be avoided 5
- The fibular overlap with the tibia on AP views helps confirm appropriate rotation 5
Weight-Bearing Considerations
- Weight-bearing views provide superior functional assessment when evaluating hardware stability and alignment 1
- Non-weight-bearing films may miss subtle instability or malalignment that becomes apparent under load 6
- If weight-bearing is contraindicated due to healing status, clearly document this limitation 1
Common Pitfalls to Avoid
Inadequate Coverage
- Always include the joints above and below the hardware if there is any concern for extension of pathology 1
- In pediatric patients with ankle hardware, lower leg imaging may be necessary to assess the distal tibia and fibula 1
Rotation Errors
- Avoid obtaining radiographs in excessive internal rotation, as this significantly affects alignment measurements 2, 5
- The tibiofibular overlap should be assessed to confirm proper positioning 7, 5
Incomplete Series
- Do not rely solely on AP views - the lateral view is essential and non-redundant 3
- When clinical concern persists despite normal two-view series, obtain four views before advancing to CT 3
Advanced Imaging Indications
When Plain Films Are Insufficient
- CT is superior for detecting and classifying fractures around hardware and should be obtained when radiographs are equivocal 1
- MRI with metal artifact reduction sequences can assess soft tissue complications when radiographs are inconclusive 6
- These advanced modalities are not routine but should be used when plain films fail to answer the clinical question 1