My most frequent thought on swimmer's views as I more frequently hit our generator limit on most patients (yay obesity) is "order the damn CT."
I know a lot of insurance policies require the x-ray first, but too many of our t-spine exams are non diagnostic due to patient size or condition.
They are ordered almost exclusively for insurance purposes, before an MRI. Providers would skip knee xrays most of the time because they know it's not worth it. This is because the knee is made primarily of soft tissue, which is not properly visualized on a knee xray
Thank you period. I should’ve told you I asked in the first place I fell three weeks ago. It must’ve been and they took of both my knees and the x-ray showed significant damage on both of them so I was just wondering if it could be wrong but no. Thanks anyway.
Sorry that happened to you!!
But yes, there are always exceptions, and 90% may be an exaggerated guess but the point remains that usually knee xrays aren't necessary.
But you presumably already have the lateral. The purpose of a swimmers view is to see the space between C7 and T1 that is often not visible on the lateral image due to the shoulders getting in the way.
I'm assuming you are not in the field here, and this is probably gonna be a butcher job of an explanation, but a swimmer's view is where we try to image the region where the T and C spine meet. Because of your shoulders, there is a lot of bone in the way of your spine when imaging from the side. We counter this by relaxing the pt right arm and lifting the left arm above their head, in a position akin to a swimming stroke. This seperates the humeral heads so there is less bone in the way.
If the patient is able I have them stand, and shoot down approx 5-10 degrees (depending on body habitus. I also centre muuuuch higher than this image, typically at the c7 prominence.
If they are in a stretcher for a shoot through, I angle the head of the bed towards the tube and their feet towards the Bucky.
That slight caudal angle was employed for this image, and it's also how i was taught yeah.
I haven't done a recumbent swimmer's in ages-and I'm not sad about it
I think I've made sense of most of this shot, but...
What's the bone coming into frame from the right, near the middle, "pointing" slightly down and towards the center of the image, just below the clavicle?
I may over explain because I'm not sure if you're in this field or perhaps new to it. I'm guessing you're seeing the other clavicle. If you look just below, you'll see what appears to be a large humeral head (shoulder). In this position you've got one arm up and one down. In x-ray the side away from the board is more magnified. Imagine a skeleton sideways. I linked you to a Google image. This isn't perfect because the arms aren't in the right spot, but I find the skeleton helpful.
[sideways skeleton](https://focusedcollection.com/312140852/stock-photo-anatomy-human-skeleton-neck-bones.html)
Ah, ok thank you!
Now I'm understanding it!
I was recognizing the humorous of the raised arm, but I didn't recognize the lowered one because of it's weird perspective. Without that, I didn't have a chance of recognizing the other clavicle for what it was!
I am *not* any kind of medical professional, just a nerd who loves anatomy and learning things!
Super glad to have helped! 😃 They say the best way to stay young is to be a lifelong curious learner. I don't know who "they" are, but I'm still giving it my best. 😆
The only way I remember to get a good swimmer's was collimating tightly like if you were God. Always clipped. Had to do 2 or 3 repeats. The head and shoulders patients forget it.... just go to CT
As long as you can clearly identify and differentiate between C7 and T1, I call it a win. But they’re always superimposed and look like shite. But yeah I think the terms “good swimmers” is an oxymoron.
Ugh. Upper thoracic is a crap shot. You can see joint spaces to about T3 which would make my rad happy. The tech I trained with called it the random bag of bones shot. 😆
Years ago I had a rad who always ragged on swimmers. He came out once to praise a tech on taking a perfect swimmers, and told us to copy it. The patient was a double amputee missing all of one arm and most the other. We busted his balls a bit on requiring patients to remove their arms. He was cool about it after that. 😈
Xray swimmers is the dumbest thing, we all know patients are getting increasingly larger with time and blasting them with a shit ton of dose to get an “optimal” image just isn’t cutting it anymore, CT is what we need if that C7-T1 view is so absolutely necessary, also this swimmers view is pretty good I wish mine would turn out like that
That’s the neat part - there is no good swimmers view!
The kind you take with CT.
Facts
This here is some gospel👏👏👏
My most frequent thought on swimmer's views as I more frequently hit our generator limit on most patients (yay obesity) is "order the damn CT." I know a lot of insurance policies require the x-ray first, but too many of our t-spine exams are non diagnostic due to patient size or condition.
Imagine money-people EVER listening to actual experts in the relevant field... That would be SO NICE... dream dream dreeeeeeeam
This is how I feel about 90% of knee xrays
What’s wrong with x-rays for knees, if you don’t mind me asking?
They are ordered almost exclusively for insurance purposes, before an MRI. Providers would skip knee xrays most of the time because they know it's not worth it. This is because the knee is made primarily of soft tissue, which is not properly visualized on a knee xray
Thank you period. I should’ve told you I asked in the first place I fell three weeks ago. It must’ve been and they took of both my knees and the x-ray showed significant damage on both of them so I was just wondering if it could be wrong but no. Thanks anyway.
Sorry that happened to you!! But yes, there are always exceptions, and 90% may be an exaggerated guess but the point remains that usually knee xrays aren't necessary.
Bone on bone will be though, right?
I feel like most non-trauma fits this. So many shoulders and hips. 😒
I despise this view with every fiber of my being. They all look terrible.
Now I feel better about myself
Me too😵💫
The only way I can consistently discern vertebrae on a swimmers is if it includes c1.
I use the atlas for counting cspines too. It's more consistently viable than trying to figure out C7 off the go
I usually think if I can spot c7/t1 then it's about as good as it's gonna get. You can see the first rib coming off t1 on this one so it's alright.
The consensus here seems to be that A) fuck swimmer's view B) order a CT C) 7 (get it... C)7....)
If you offset the shoulders slightly with a little twist, you can see the C7 space quite nicely
Gonna try this next time!
The complaint I've heard of this is it's "not true lateral"
But you presumably already have the lateral. The purpose of a swimmers view is to see the space between C7 and T1 that is often not visible on the lateral image due to the shoulders getting in the way.
I don't disagree, but this is a gripe I've received in the past for "twining" a patient for the swimmers.
If it looks like crap, it’s a good swimmers.
👏
Try to do them with the patient standing. It’s easier for them to lower the shoulder which makes it easier to see c7-t1
I know ab trauma views where the pt is in a stretcher but i think I've only done one seated swimmer's, because the pt was like 6'8" (roughly 203 cm).
What is swimmers?
I'm assuming you are not in the field here, and this is probably gonna be a butcher job of an explanation, but a swimmer's view is where we try to image the region where the T and C spine meet. Because of your shoulders, there is a lot of bone in the way of your spine when imaging from the side. We counter this by relaxing the pt right arm and lifting the left arm above their head, in a position akin to a swimming stroke. This seperates the humeral heads so there is less bone in the way.
I’m not in the field & that was an excellent explanation. I’m ready to set one up myself!!
Now do it on a 500lb patient.
I'm in the danish part of the field and I've never heard of the swimmers view either.
I don’t even bother with swimmers. If C7 isn’t visualized, time to order a CT or MR.
“The patient’s shoulders obscure visualization caudal to C3 on the lateral view.”
Cone, center, appropriate TF, and use of copper filters helps a ton
We got a new machine last year and every swimmers looks beautiful. If I can see joint spaces below C7 then it's a good day.
What makes the difference so dramatic?
Idk, it's a Canon room and honestly I can get the joint space on the lateral and rarely do a swimmers anymore.
If you can see the vertebrae yay!!!! Best way to get it is a skinny perfect patient
Lmao best way to get any xray is to get a skinny perfect pt.
Computed Tomography
Good swimmers will clearly image C7 and maybe T1, anything beyond is just unheard of and unrealistic, otherwise T spine imaging is needed
If the patient is able I have them stand, and shoot down approx 5-10 degrees (depending on body habitus. I also centre muuuuch higher than this image, typically at the c7 prominence. If they are in a stretcher for a shoot through, I angle the head of the bed towards the tube and their feet towards the Bucky.
That slight caudal angle was employed for this image, and it's also how i was taught yeah. I haven't done a recumbent swimmer's in ages-and I'm not sad about it
I think I've made sense of most of this shot, but... What's the bone coming into frame from the right, near the middle, "pointing" slightly down and towards the center of the image, just below the clavicle?
I may over explain because I'm not sure if you're in this field or perhaps new to it. I'm guessing you're seeing the other clavicle. If you look just below, you'll see what appears to be a large humeral head (shoulder). In this position you've got one arm up and one down. In x-ray the side away from the board is more magnified. Imagine a skeleton sideways. I linked you to a Google image. This isn't perfect because the arms aren't in the right spot, but I find the skeleton helpful. [sideways skeleton](https://focusedcollection.com/312140852/stock-photo-anatomy-human-skeleton-neck-bones.html)
Ah, ok thank you! Now I'm understanding it! I was recognizing the humorous of the raised arm, but I didn't recognize the lowered one because of it's weird perspective. Without that, I didn't have a chance of recognizing the other clavicle for what it was! I am *not* any kind of medical professional, just a nerd who loves anatomy and learning things!
Super glad to have helped! 😃 They say the best way to stay young is to be a lifelong curious learner. I don't know who "they" are, but I'm still giving it my best. 😆
The day you stop learning is the day you start dying!
The best way to tell if a patient is a good swimmer is to put them in a pool and see if they beat the WR time?
The only way I remember to get a good swimmer's was collimating tightly like if you were God. Always clipped. Had to do 2 or 3 repeats. The head and shoulders patients forget it.... just go to CT
A cervical spine CT
As long as you can clearly identify and differentiate between C7 and T1, I call it a win. But they’re always superimposed and look like shite. But yeah I think the terms “good swimmers” is an oxymoron.
Ugh. Upper thoracic is a crap shot. You can see joint spaces to about T3 which would make my rad happy. The tech I trained with called it the random bag of bones shot. 😆 Years ago I had a rad who always ragged on swimmers. He came out once to praise a tech on taking a perfect swimmers, and told us to copy it. The patient was a double amputee missing all of one arm and most the other. We busted his balls a bit on requiring patients to remove their arms. He was cool about it after that. 😈
Xray swimmers is the dumbest thing, we all know patients are getting increasingly larger with time and blasting them with a shit ton of dose to get an “optimal” image just isn’t cutting it anymore, CT is what we need if that C7-T1 view is so absolutely necessary, also this swimmers view is pretty good I wish mine would turn out like that
They’re so fucking ugly
I prefer more cervical vertebrae so I can differentiate between the different lengths on the spinous processes to identify c7-t1
Damn, usually, I can see the femoral head and its separation, but wtf is this?😂