X-ray Positioning and Adequacy Check – A Practical Guide for Orthopaedicians

Plain radiography remains one of the most important investigations in orthopaedic practice. However, an X-ray should never be interpreted before confirming that the image is adequately positioned, centred, exposed and inclusive of the relevant anatomy. A technically inadequate radiograph can mimic deformity, conceal displacement, alter apparent joint congruity and lead to incorrect treatment decisions.

The orthopaedic surgeon should therefore develop the habit of asking two questions before reading every radiograph:

Only after these questions have been answered should fracture lines, alignment, joint spaces, implants or pathology be assessed.

Never make a major orthopaedic decision from a technically inadequate X-ray unless the clinical situation makes repeat imaging impossible or unsafe.

Poor positioning can create false impressions of:

• Fracture displacement.
• Joint subluxation.
• Varus or valgus deformity.
• Rotational malalignment.
• Loss of reduction.
• Abnormal joint-space narrowing.
• Abnormal implant position.
• Altered apparent fracture shortening.

The problem is particularly important when comparing serial radiographs. A fracture may appear to have displaced simply because the second image has been taken with different limb rotation.

Before diagnosing “loss of reduction”, first make sure you are comparing equivalent projections.

Before interpreting any orthopaedic X-ray, rapidly check:

1. Patient and side: Is this the correct patient, correct limb and correct side?
2. Correct view: Is the requested AP, lateral, oblique, mortise, skyline or other specialised projection actually present?
3. Coverage: Does the image include all relevant anatomy?
4. Positioning and rotation: Is the limb positioned correctly for that projection?
5. Image quality: Is exposure, penetration, sharpness and centering sufficient to answer the clinical question?

This simple approach can be used for almost every musculoskeletal radiograph.

Fractures are three-dimensional injuries assessed using two-dimensional images. Therefore, at least two appropriately oriented projections are generally required.

A traditional orthopaedic principle is:

• Two views – usually approximately 90° to each other.
• Two joints – image the joint above and below for many long-bone injuries when clinically relevant.
• Two sides – comparison views in selected paediatric or anatomically uncertain situations.
• Two occasions – repeat imaging when an initially occult injury is strongly suspected or when alignment must be monitored.

These are practical principles rather than rigid rules for every injury.

1. Exposure and Penetration

The image should demonstrate both cortical and trabecular detail sufficiently to assess bone. Excessive underpenetration may obscure internal structure, while excessive penetration may reduce useful contrast.

2. Sharpness

Cortical margins should be sharp. Patient movement can produce blur and may conceal subtle fractures.

3. Collimation

The field should include the relevant anatomy without unnecessarily exposing a very large region.

4. Centring

The area of clinical interest should be near the centre of the image where geometric distortion is minimised.

5. Marker

The correct side marker should be visible and should not obscure important anatomy.

Rotation is one of the commonest causes of misleading musculoskeletal radiographs. A true AP or lateral image should have predictable anatomical relationships.

Rotation can alter:

• Apparent width of bone.
• Overlap between adjacent bones.
• Joint-space appearance.
• Apparent angulation.
• Implant projection.
• Measurements such as tilt and alignment angles.

Many “abnormal measurements” are meaningless if the projection is not standardised.

For fractures of the humerus, radius-ulna, femur or tibia-fibula, radiographs should generally include sufficient length of the bone to understand fracture morphology and alignment.

When clinically relevant, the adjacent joints should be included because associated injuries may occur away from the obvious fracture.

Adequacy Check

• AP and lateral views obtained.
• Entire fracture visible.
• Adequate proximal and distal bone included.
• Joint above and below included when required.
• Rotation acceptable.
• Fracture alignment can be assessed in both planes.

Common Views

• AP shoulder.
• Grashey / true AP glenoid view.
• Scapular Y view.
• Axillary view.

Trauma assessment should ideally include orthogonal projections capable of demonstrating the relationship of the humeral head to the glenoid.

AP Shoulder Adequacy

• Humeral head, glenoid and proximal humerus visible.
• Acromioclavicular region included when relevant.
• No major motion blur.
• Exposure permits assessment through humeral head and glenoid region.

True AP / Grashey View

The patient is rotated so the scapular plane is approximately parallel to the detector. A satisfactory image profiles the glenohumeral joint space with less glenoid overlap.

Scapular Y View

The scapular body forms the stem of the Y, while the acromion and coracoid form the upper limbs. In a normally located shoulder, the humeral head should project around the centre of the Y.

This view is particularly useful when assessing dislocation.

Axillary View

The axillary projection demonstrates the relationship between the humeral head and glenoid in the axial plane and is especially useful for anterior or posterior translation.

If conventional abduction is painful or unsafe, modified trauma projections may be required.

A single AP shoulder radiograph is insufficient to confidently exclude glenohumeral dislocation, particularly posterior dislocation.

The entire clavicle should be demonstrated from the sternoclavicular region to the acromioclavicular joint.

Common Views

• AP clavicle.
• AP with cephalic tilt where required.

Adequacy

• Entire clavicle included.
• AC joint visible.
• Fracture ends fully demonstrated.
• Displacement and shortening can be assessed.

Apparent shortening is sensitive to projection and patient positioning; therefore serial measurements should ideally use comparable projections.

Standard Views

• AP elbow.
• True lateral elbow.

AP Elbow Adequacy

• Distal humerus and proximal radius-ulna included.
• Elbow extended where injury allows.
• Epicondyles approximately symmetric.
• Joint relationship assessable.

True Lateral Elbow

The elbow is typically flexed approximately 90° when clinically possible.

A good lateral should demonstrate:

• Near-superimposition of the humeral condyles.
• Olecranon in profile.
• Radial head aligned with the capitellum.
• Fat pads assessable.

The lateral view is particularly important for assessing the anterior and posterior fat pads, anterior humeral line and displacement in paediatric supracondylar fractures.

An anterior humeral line should only be interpreted on a reasonably true lateral elbow.

Forearm radiographs should include the entire radius and ulna as well as both the elbow and wrist when evaluating shaft injuries.

Why Both Joints Matter

A forearm fracture may be associated with:

• Distal radioulnar joint injury – Galeazzi pattern.
• Radial head dislocation – Monteggia pattern.

Missing the adjacent joint may therefore miss the defining feature of the injury.

Standard Views

• PA wrist.
• Lateral wrist.
• Oblique view when indicated.

PA Wrist – Positioning

The shoulder, elbow and wrist should ideally be positioned in the same horizontal plane with the elbow flexed approximately 90°. This is particularly important when measuring ulnar variance.

Adequate PA Wrist

• Distal radius and ulna included.
• Carpal bones clearly visualised.
• Metacarpal bases included.
• No major rotation.
• Carpal arcs can be assessed.

True Lateral Wrist

A satisfactory lateral projection should demonstrate near-superimposition of the distal radius and ulna with the carpus seen in profile.

The pisiform is commonly used as a clue to rotational adequacy: on a reasonably true lateral, it lies in a predictable relationship anterior to the distal pole of the scaphoid.

A true lateral is essential for assessing:

• Volar or dorsal tilt.
• Carpal alignment.
• Lunate/perilunate displacement.
• Distal radius reduction.

Do not measure distal radial tilt on an obviously rotated lateral wrist.

Common measurements include:

• Radial inclination.
• Radial height.
• Ulnar variance.
• Volar or dorsal tilt.
• Articular step and gap.

These measurements are affected by projection. Therefore:

• Use a properly positioned PA view for radial height/inclination and ulnar variance.
• Use a true lateral for sagittal tilt.
• Do not compare measurements across clearly different projections.

A suspected scaphoid fracture may require dedicated projections because standard wrist views can fail to demonstrate a subtle fracture.

Common Scaphoid Series

• PA wrist.
• Lateral wrist.
• Oblique projection.
• PA with ulnar deviation / dedicated scaphoid projection.

Ulnar deviation elongates the scaphoid and may improve visualisation of its waist.

A normal initial X-ray does not completely exclude an occult scaphoid fracture when clinical suspicion remains high.

Standard Views

• PA.
• Oblique.
• Lateral.

Adequacy

• Entire digits included when clinically relevant.
• Metacarpal bases and carpus included.
• No significant motion blur.
• Oblique view demonstrates metacarpals with partial rather than complete superimposition.

Rotation in finger fractures is primarily a clinical diagnosis; radiographs alone cannot reliably exclude rotational malalignment.

When a specific finger is injured, dedicated finger views are preferable to relying only on a whole-hand radiograph.

Adequacy

• Entire affected digit included.
• True or near-true lateral obtained.
• Joint above and below fracture visible.
• Adjacent fingers moved away where possible to avoid superimposition.

A poor lateral with overlapping adjacent fingers may conceal a small avulsion fracture or articular displacement.

AP pelvis is fundamental for trauma, hip disorders, arthritis and postoperative assessment.

Adequacy Check

• Entire pelvis and both hip joints included.
• Iliac wings visible.
• Proximal femora included sufficiently.
• Obturator foramina reasonably symmetric.
• Iliac wings reasonably symmetric.
• Sacrum and coccyx approximately centred over the pubic symphysis.
• No excessive pelvic rotation.

Femoral Rotation

In a routine non-trauma AP pelvis, the lower limbs are often internally rotated approximately 15–20° to compensate for femoral anteversion and better profile the femoral necks.

With appropriate internal rotation:

• Femoral necks appear elongated.
• Lesser trochanters become less prominent.

In suspected fracture or dislocation, forced internal rotation should not be performed simply to obtain a textbook image.

Pelvic rotation can distort measurements and apparent hip morphology.

Look for:

• Asymmetry of obturator foramina.
• Asymmetry of iliac wings.
• Off-centre sacrum/coccyx relative to the symphysis.

Pelvic tilt also affects acetabular morphology and apparent coverage.

Therefore, measurements for hip preservation surgery should only be made on appropriately standardised radiographs.

Common Views

• AP pelvis.
• AP hip.
• Cross-table lateral in trauma.
• Frog-leg lateral in suitable non-trauma situations.

In suspected femoral neck fracture, a cross-table lateral is preferred over forcibly positioning the painful limb into a frog-leg position.

Cross-Table Lateral Adequacy

• Femoral head and neck visualised.
• Proximal femur sufficiently included.
• Neck not excessively obscured by opposite thigh or soft tissue.
• Image penetrated enough to assess cortical margins.

For shaft fractures, the entire femur should be assessed and the hip and knee included when possible.

In high-energy femoral shaft fractures, special attention should be given to the ipsilateral femoral neck because an associated femoral neck fracture may be subtle or initially missed.

Adequacy

• Hip included.
• Knee included.
• Entire fracture pattern included.
• AP and lateral projections obtained.
• Rotation and shortening assessable.

Common Views

• AP.
• Lateral.
• Weight-bearing AP for arthritis when appropriate.
• Rosenberg / flexion weight-bearing view in selected evaluation.
• Skyline / Merchant / axial patellar view.
• Notch or tunnel view when indicated.

AP Knee Adequacy

• Distal femur and proximal tibia fully visible.
• Patella approximately centred.
• Fibular head partially superimposed by tibia in a standard projection.
• Tibiofemoral joint space assessable.

Degree of tibiofibular overlap helps indicate rotation. Excessive or absent overlap may suggest an oblique rather than true AP projection.

A proper lateral knee is essential for evaluating:

• Posterior condylar relationship.
• Patellar height.
• Joint effusion.
• Tibial slope.
• Fracture displacement.
• Implant position.

Adequacy

• Femoral condyles should be nearly superimposed.
• Patella should be seen in profile.
• Proximal tibia and fibula visible.
• No major rotational mismatch of posterior condyles.

Measurements such as posterior tibial slope or patellar height should not be made on an obviously rotated lateral image.

Weight-bearing radiographs are important when evaluating osteoarthritis because joint-space narrowing may be underestimated on non-weight-bearing films.

When comparing serial arthritis films, confirm:

• Both were weight-bearing or both non-weight-bearing.
• Degree of knee flexion is comparable.
• Rotation is similar.
• Beam projection is comparable.

Otherwise, apparent progression of joint-space narrowing may partly reflect technique rather than disease.

Axial patellofemoral views demonstrate the relationship between the patella and trochlea.

They are useful for:

• Patellofemoral arthritis.
• Patellar tilt.
• Patellar subluxation.
• Selected patellar fractures.

The amount of knee flexion varies with the specific technique. Therefore, comparison should preferably use the same projection and degree of flexion.

Tibial shaft imaging should include the entire tibia and fibula, with the knee and ankle included when evaluating shaft trauma.

Why This Matters

• Proximal fibular injuries may accompany ankle syndesmotic injuries.
• Distal extension of fracture may involve the ankle.
• Associated proximal or distal joint injury may change management.

Standard Trauma Series

• AP.
• Mortise view.
• Lateral.

The AP and mortise are not interchangeable. The mortise view is specifically designed to profile the ankle joint.

For a mortise projection, the leg is internally rotated approximately 15–20° so the intermalleolar line becomes more parallel to the detector.

Adequacy

• Ankle mortise opened adequately.
• Medial, superior and lateral aspects of the tibiotalar joint can be assessed.
• Distal tibiofibular overlap is reduced compared with a standard AP projection.
• Talar dome seen without major rotational distortion.

A poorly rotated AP image should not be mistaken for a true mortise view.

Assessment of medial clear space and syndesmotic relationships is meaningful only on an adequately positioned projection.

A true lateral ankle should demonstrate near-superimposition of the talar domes.

Adequacy Check

• Talar domes approximately superimposed.
• Distal tibia seen in profile.
• Talus and calcaneus clearly visible.
• Base of fifth metatarsal may be included depending on field and indication.

The lateral view is essential for assessing posterior malleolus fractures, talar displacement and sagittal alignment.

Stress or weight-bearing radiographs may be used in selected ankle injuries to assess functional instability.

Examples include:

• Gravity stress view.
• Manual external-rotation stress view.
• Weight-bearing mortise view.

Interpretation requires knowledge of which stress technique was used, because measurements should not be compared indiscriminately between different techniques.

Standard Views

• AP / dorsoplantar.
• Oblique.
• Lateral.

Weight-bearing views are particularly important when assessing alignment disorders such as:

• Hallux valgus.
• Flatfoot.
• Cavus deformity.
• Midfoot collapse.
• Selected Lisfranc injuries.

Non-weight-bearing radiographs may underestimate deformity or instability.

• Entire foot included from toes to hindfoot where clinically relevant.
• Metatarsal bases clearly visualised.
• Tarsometatarsal relationships assessable.
• Exposure adequate to visualise midfoot structures.
• No excessive rotation.

For suspected Lisfranc injury, special attention should be paid to alignment of the metatarsal bases with the corresponding cuneiforms and cuboid.

The oblique view helps separate structures that overlap on the AP projection.

It is particularly helpful for assessing:

• Fifth metatarsal.
• Cuboid.
• Calcaneocuboid region.
• Lateral midfoot.
• Selected tarsometatarsal injuries.

A lateral foot view is important for sagittal alignment, arch assessment and hindfoot-midfoot relationships.

Adequacy

• Calcaneus fully included.
• Talus visible.
• Metatarsal shafts approximately superimposed.
• Midfoot alignment assessable.

When evaluating flatfoot or cavus deformity, the image should generally be obtained weight-bearing.

Common Views

• Lateral calcaneus.
• Axial / Harris-type projection.

Lateral imaging allows assessment of calcaneal height, length and major angular relationships. The axial projection helps assess hindfoot width and varus-valgus displacement.

Measurements such as Böhler's angle should only be performed on a properly positioned lateral.

Spine radiographs may be obtained for trauma, deformity, degeneration, instability or postoperative assessment.

Adequacy Requires

• Correct spinal region included.
• Relevant junctional levels visible.
• Adequate penetration.
• No major rotation.
• Correct standing or supine technique for the clinical question.

Weight-bearing status is particularly important when assessing spinal alignment and deformity.

Common Views

• AP.
• Lateral.
• Open-mouth odontoid view when appropriate.
• Flexion-extension views in selected non-acute situations.

Lateral Cervical Spine Adequacy

The image should include the cervical spine from the skull base down to the C7–T1 junction.

Failure to visualise the cervicothoracic junction makes a trauma lateral incomplete.

Assess:

• Anterior vertebral line.
• Posterior vertebral line.
• Spinolaminar line.
• Interspinous distances.
• Prevertebral soft tissues.

A cervical trauma radiograph that does not adequately show C7–T1 is technically incomplete.

The purpose is to visualise the odontoid and C1–C2 relationship.

Adequacy

• Entire dens visible.
• Upper teeth and skull base do not obscure the dens.
• Lateral masses of C1 visible.
• Reasonable symmetry permitting assessment of C1–C2 relationship.

Apparent asymmetry may be caused by head rotation; therefore positioning must be considered before diagnosing C1 displacement.

AP Adequacy

• Relevant vertebrae included.
• Spinous processes approximately centred.
• Pedicles reasonably symmetric.
• Vertebral heights and coronal alignment assessable.

Lateral Adequacy

• Vertebral bodies seen clearly.
• Posterior vertebral borders visible.
• Relevant junctional levels included.
• No excessive rotation.

In suspected vertebral compression fracture, both anterior and posterior vertebral body heights should be visible to assess wedge deformity.

Deformity imaging requires standardised long-cassette or stitched full-length radiographs.

Essential Features

• Standing position unless clinically impossible.
• Entire relevant spine included.
• Pelvis included for balance assessment where required.
• Standardised arm position.
• Minimal rotation.

Cobb angle measurements should ideally be compared using similar patient positioning and the same end vertebrae.

Full-length standing radiographs are used for deformity analysis, osteotomy planning and assessment of mechanical alignment.

Adequacy

• Hip, knee and ankle included on the same image.
• Patient standing and weight-bearing as instructed.
• Patellae facing forward.
• Knees appropriately extended unless protocol specifies otherwise.
• No major limb rotation.
• Both limbs included when comparison is required.

Patellar orientation is often used as a practical indicator of rotational positioning. External or internal limb rotation can significantly alter apparent mechanical axis deviation and joint orientation angles.

Never plan a corrective osteotomy from a malrotated long-leg alignment film.

Paediatric radiographs require particular care because much of the skeleton may still be cartilaginous.

Important considerations include:

• Know age-dependent ossification centres.
• Do not mistake physes for fracture lines.
• Look for subtle metaphyseal or physeal injury.
• Assess alignment rather than relying only on visible fracture lines.
• Comparison view of the opposite side may occasionally help but should not be routine without indication.

Many commonly used paediatric elbow parameters are projection-dependent.

Anterior Humeral Line

Assessed on a true lateral elbow and used in the evaluation of supracondylar fractures.

Baumann Angle

Assessed on an AP projection and sensitive to positioning.

Radiocapitellar Line

A line through the long axis of the radius should intersect the capitellum on appropriate projections.

If the paediatric elbow is rotated, apparent abnormalities in the anterior humeral line or Baumann angle may be technical rather than pathological.

For every trauma radiograph ask:

1. Is the entire injury demonstrated?
2. Are two orthogonal views available?
3. Are the adjacent joints included if required?
4. Is there enough exposure to assess cortex and joint surfaces?
5. Is rotation acceptable?
6. Could pain-related positioning have hidden displacement?
7. Do I need an additional specialised view or CT?

Post-reduction imaging should answer whether the reduction is satisfactory and whether the immobilisation itself has affected assessment.

Check

• AP and lateral views.
• Alignment in both planes.
• Rotation where assessable.
• Joint congruity.
• Length and translation.
• Cast or splint does not obscure the relevant region excessively.
• Comparison with pre-reduction images uses similar projection when possible.

A good-looking AP does not compensate for an unacceptable lateral reduction.

Postoperative films should demonstrate enough anatomy to assess both fracture reduction and implant position.

Evaluate

• Overall reduction.
• Joint congruity.
• Implant location.
• Screw length and possible joint penetration.
• Plate or nail position.
• Alignment in AP and lateral planes.
• Fracture gap or distraction.
• Relevant adjacent joints.

An apparently satisfactory implant position in one projection may still be intra-articular or malpositioned in another plane.

Orthopaedic radiographs frequently involve measurements, but numerical precision is meaningless when positioning is poor.

Before measuring:

1. Confirm the correct view.
2. Confirm adequate positioning.
3. Check for rotation.
4. Check whether the image is weight-bearing where required.
5. Use the appropriate anatomical landmarks.
6. Compare with prior studies only if projections are reasonably comparable.

Common measurements strongly influenced by positioning include:

• Volar tilt.
• Ulnar variance.
• Baumann angle.
• Patellar height.
• Posterior tibial slope.
• Mechanical axis deviation.
• Hip coverage measurements.
• Cobb angle.

Radiographic magnification occurs because the patient lies between the X-ray source and detector. Structures farther from the detector appear more magnified.

This is important when:

• Templating arthroplasty.
• Measuring implant dimensions.
• Estimating limb length.
• Planning corrective surgery.

A calibration marker placed at an appropriate anatomical level may be required for accurate digital templating.

Repeat imaging should be considered when the technical limitation could alter management.

Examples

• Relevant anatomy has been cut off.
• No true lateral obtained when sagittal alignment is critical.
• Severe rotation invalidates measurement.
• Motion blur obscures fracture detail.
• Joint congruity cannot be assessed.
• Post-reduction position cannot be determined reliably.
• Suspected implant penetration cannot be excluded.

Repeat imaging should not be ordered simply to achieve cosmetic perfection when the existing image already answers the clinical question.

The question is not “Is this X-ray beautiful?” but “Is it technically sufficient to make a safe clinical decision?”

Even technically excellent radiographs may be insufficient in complex injuries.

CT may be required for:

• Complex intra-articular fractures.
• Acetabular fractures.
• Tibial plateau fractures.
• Pilon fractures.
• Complex calcaneal fractures.
• Selected carpal injuries.
• Subtle fracture extension relevant to surgery.
• Preoperative planning.

MRI may be required where occult fracture, ligament, cartilage, meniscal or soft-tissue pathology is suspected.

• Interpreting the film before checking the projection.
• Calling a rotated wrist film a true lateral.
• Measuring volar tilt on a non-lateral wrist.
• Assessing ankle clear spaces on an inadequate mortise view.
• Diagnosing loss of reduction from serial X-rays with different rotation.
• Accepting a shoulder AP as sufficient to exclude posterior dislocation.
• Not imaging the elbow in a suspected Monteggia injury.
• Not imaging the wrist in a suspected Galeazzi injury.
• Failing to include the entire femur in a femoral shaft fracture.
• Planning deformity correction from a malrotated long-leg film.
• Comparing standing and non-standing knee films for joint-space narrowing.
• Taking measurements without confirming magnification or calibration where relevant.

If the answer to the final question is no, obtain an additional or repeat image rather than forcing an interpretation from an inadequate study.

The “best X-ray” is not the most detailed image—it is the projection that best answers the clinical question.

Serial radiographs are commonly used to assess fracture healing, loss of reduction, deformity and implant behaviour.

Before comparing films, ask whether they were obtained with:

• Similar rotation.
• Similar beam projection.
• Similar weight-bearing status.
• Similar joint position.
• Comparable magnification.

If technique differs significantly, describe the limitation rather than falsely quantifying change.

When technical limitations affect interpretation, they should be explicitly acknowledged.

Examples include:

• “Lateral projection is limited by rotation.”
• “Ankle mortise is not adequately profiled.”
• “C7–T1 junction is not visualised.”
• “Assessment of volar tilt is limited by non-true lateral projection.”
• “Weight-bearing status differs from previous examination.”

Recognising technical limitation is better than giving a falsely precise interpretation.

• Always assess X-ray adequacy before pathology.
• Most fractures require at least two appropriately oriented projections.
• Long-bone shaft injuries commonly require assessment of the adjacent joints.
• A measurement is only as reliable as the projection on which it is made.
• A true lateral elbow should show near-superimposition of the humeral condyles.
• The anterior humeral line should be assessed only on an adequately positioned lateral elbow.
• A true lateral knee should demonstrate near-superimposition of the femoral condyles.
• A lateral ankle should demonstrate near-superimposition of the talar domes.
• The ankle mortise view requires approximately 15–20° of internal rotation.
• The PA wrist should ideally be obtained with the shoulder, elbow and wrist in the same plane when evaluating ulnar variance.
• Distal radius volar or dorsal tilt requires a true lateral projection.
• A single AP shoulder image is insufficient to confidently exclude posterior dislocation.
• A trauma cervical lateral should demonstrate the C7–T1 junction.
• In a routine AP pelvis, appropriate internal femoral rotation profiles the femoral neck and reduces lesser trochanter prominence.
• Do not forcibly internally rotate a limb with a suspected femoral neck fracture simply to obtain a standard projection.
• Weight-bearing radiographs are important for functional assessment of knee osteoarthritis and foot deformity.
• Patellae should face forward on full-length lower-limb alignment radiographs to minimise rotational error.
• Rotation can falsely alter apparent joint space, angulation and implant position.
• Before calling loss of reduction, compare the positioning of the current and previous radiographs.
• Post-reduction and postoperative assessment requires orthogonal projections.
• If the X-ray cannot answer the clinical question because of technical inadequacy, repeat or supplement the imaging rather than forcing a diagnosis.

1. Check identity and side first.
2. Confirm that the required projection has actually been obtained.
3. Make sure all clinically relevant anatomy is included.
4. Look for rotation before interpreting alignment.
5. Confirm that a “lateral” is genuinely close to a true lateral before making sagittal measurements.
6. Use specialised views for specialised questions: mortise for ankle congruity, axillary/Y for shoulder dislocation, scaphoid views for suspected scaphoid injury and weight-bearing views for functional deformity.
7. Compare equivalent projections on serial imaging.
8. Do not rely on measurements from technically inadequate films.
9. After reduction or surgery, assess the result in at least two planes.
10. If the image does not safely answer the clinical question, obtain a better view or additional imaging.

The first step in reading an orthopaedic X-ray is not identifying the fracture—it is confirming that the X-ray is technically adequate enough for the fracture to be interpreted correctly.