90 ques to SLC X-ray [10] and found improved visualization with manual traction alone and accompanied by inspiration and expiration. Interestingly, the study also found that traction using weights of over 18 kg did not improve visualization using the arm traction view. Boger and Ralls described an auto-traction device for radiography of the lower cervical spine. They used a belt attached to the wrist of patients and patients pulled this belt with their feet [12]. Norris et al. compared a traction device to manual traction [13]. Arm traction with weights used in our study showed benefit in increasing visualization. This technique also holds additional benefit, as it may lower the burdens of time spent and radiation exposure inherent in providing manual traction for trauma patients. Another finding of this study is that the length of the neck and the size of the shoulders do not affect the results of lateral cervical X-rays taken with arm traction and in the swimming position. Limitations There are some limitations to this study. The sample size is small and should be increased for more accurate subgroup analyses. Another limitation is that participants in our study did not use a cervical collar. However, patients who present to the ED needing cervical spine imaging are often the victims of trauma, who typically have a cervical collar placed when they present. Further study should observe patients wearing a cervical collar. Conclusion Lateral cervical X-rays with arm traction and swimming position enhance the view of SLC X-rays. An initial SLC X-ray including the lower third of the cervical spine (with C7), arm traction, and swimming position may be beneficial in visualizing the CTJ. However, patients with an increased BMI are unlikely to benefit from all three methods. The swimming position offered some visuali- zation of the posterior structures and thoracic vertebral bodies in some participants. Arm traction demonstrated visualization of posterior structures of all participants imaged. Int J Emerg Med (2010) 3:85–90 Acknowledgement This study was supported by Akdeniz Univer- sity Foundation. And great thanks to Dr. Joshua Schiller for his contributions to the article. References 1. American College of Surgeons Committee on Trauma (2004) Advanced trauma life support, 7th edn. Spine and spinal cord trauma, pp 178–204 2. Miller MD, Gehweiler JA, Martinez S, Charlton OP, Daffner RH (1978) Significant new observations on cervical spine trauma. AJR Am J Roentgenol 130:659–663 3. Nichols CG, Young DH, Schiller WR (1987) Evaluation of cervicothoracic junction injury. Ann Emerg Med 16:640–642 4. Gisbert VL, Hollerman JJ, Ney AL et al (1989) Incidence and diagnosis of C7-T1 fractures and subluxations in multiple-trauma patients: evaluation of the advanced trauma life support guide- lines. Surgery 106:702–709 5. Amin A, Saifuddin A (2005) Fractures and dislocations of the cervicothoracic junction. J Spinal Disord Tech 18:499–505 6. Ireland AJ, Britton I, Forrester AW (1998) Do supine oblique views provide better imaging of the cervicothoracic junction than swimmer’s views? J Accid Emerg Med 15:151–154 7. Hoffman JR, Mower WR, Wolfson AB, Todd KH, Zucker MI (2000) Validity of a set of clinical criteria to rule out injury to the cervical spine in patients with blunt trauma. National Emergency X-radiography Utilization Study Group. N Engl J Med 343:94–99 8. Jenkins MG, Curran P, Rocke LG (1999) Where do we go after the three standard cervical spine views in the conscious trauma patient? A survey. Eur J Emerg Med 6(3):215–217 9. Wang VY, Chou D (2007) The cervicothoracic junction. Neuro- surg Clin N Am 18:365–371 10. Bowe CT, Burton JH, Chandler RC, Davidson RM (2003) The effect of arm traction on the adequacy of cross-table lateral cervical spine radiographs. J Trauma 55:800–801 11. Ohiorenoya D, Hilton M, Oakland CD, McLauchlan CA, Cobby M, Hughes AO (1996) Cervical spine imaging in trauma patients: a simple scheme of rationalising arm traction using zonal divisions of the vertebral bodies. J Accid Emerg Med 13:175–176 12. Boger D, Ralls P (1981) New traction device for radiography of the lower cervical spine. AJR Am J Roentgenol 137:1202–1204 13. Norris CS, Silva WE, Dodson TF, Darrow J (1986) Shoulder harness traction for roentgenographic assessment of the cervical spine. Arch Surg 121:452–455 14. Rethnam U, Yesupalan RS, Bastawrous SS (2008) The swimmer’s view: does it really show what it is supposed to show? A retrospective study. BMC Med Imaging 15:2 Cenker Eken is 34 years old and has been working in the Emergency Department of Akdeniz University Medical Faculty, in Turkey, as an assistant professor. He started his residency program in 2000 and finished it in 2004. He is particularly interested in research, biostatistics, and evidence-based medicine.