14.1 Shoulder Radiography

1. 14.1 Shoulder Radiography • Routine Non-Trauma: A-P with internal and external rotation of humerus • Trauma or Dislocation Shoulder: A-P internal rotation, Lateral scapula or “Y” view, Apical Oblique,possible or Stryker Notch and P-A Axillary • Shoulder Instability: Weighted internal and external rotation, Stryker Notch

2. Shoulder Radiography • To evaluate the glenohumeral joint, the scapula must be parallel to the film. • Shoulder views can be taken with suspended respiration • The Clavicle and A C joints will have the patient in a true A-P position with mid sagittal plane perpendicular to film.

3. Shoulder Radiography • A-C Joint view are taken with full inspiration to help open the joint space. • A-C Joint views are taken weighted and non-weighted when looking for a separation. The weights must be 10 to 15 pounds and strapped around the wrists to avoid the use of the arm muscles.

4. Shoulder Radiography • A-C Joints views can also be taken to detect metabolic or drug induced bone loss. The view need not be taken with and without weights. • The Clavicle can be taken A-P or P-A. The P-A view will have less magnification distortion but is more difficult to position.

5. 14.2 Shoulder A-P with Internal Rotation • Measure: A-P at coracoid process • Protection: Half Apron • SID: 40” Bucky • No Tube Angle • Film: 10” x 8” I.D. toward spine • Marker: anatomical plus “INT” or arrow pointing inward

6. Shoulder A-P with Internal Rotation • Patient stands facing tube. • The patient is rotated 15 to 45 degrees until the scapula is parallel to the film. • The patient internally rotates humerus until the epicondyles are perpendicular to the film.

7. Shoulder A-P with Internal Rotation • Horizontal CR: 1” below the coracoid process Vertical CR: coracoid process or through the glenohumeral joint • Film centered to Horizontal CR • Collimation: to include soft tissue around shoulder or slightly less than film size.

8. Shoulder A-P with Internal Rotation • Breathing Instructions: suspended respiration • Make exposure and let patient breathe and relax. • Some facilities will use a 12” x 10 cassette

9. Shoulder A-P with Internal Rotation Film • The glenohumeral joint should be open • The lesser tubericle will be in profile medially. • The humeral head and greater tubericle will be superimposed.

10. 14.3 Shoulder A-P with External Rotation • Measure: A-P at coracoid process • Protection: Half Apron • SID: 40” Bucky • No Tube Angle • Film: 10” x 8” I.D. toward spine • Marker: anatomical plus “EXT” or arrow pointing outward

11. Shoulder A-P with External Rotation • Patient stands facing tube. • The patient is rotated 15 to 45 degrees until the scapula is parallel to the film. • The patient externally rotates humerus until the epicondyles are parallel to the film.

12. Shoulder A-P with External Rotation • Horizontal CR: 1” below the coracoid process Vertical CR: coracoid process or through the glenohumeral joint • Film centered to Horizontal CR • Collimation: to include soft tissue around shoulder or slightly less than film size.

13. Shoulder A-P with External Rotation • Breathing Instructions: suspended respiration • Make exposure and let patient breathe and relax. • Some facilities will use a 12” x 10 cassette

14. Shoulder A-P with External Rotation Film • The glenohumeral joint should be open • The greater tubericle and humeral head will be in profile .

15. 14.4 Shoulder Apical Oblique • Measure: A-P at coracoid process • Protection: Half apron • SID: 40” Bucky • Tube angle: 30 degrees caudal • Film size: 10” x 12” Regular I.D. to spine

16. Shoulder Apical Oblique • Patient stands facing tube with humerus internally rotated until the epicondyles are perpendicular to film • The patient is rotated 15 to 45 degrees to get the scapula parallel to film and Bucky. • SID adjusted for tube angle.

17. Shoulder Apical Oblique • Horizontal CR: 2” above the coracoid process of glenohumeral joint. • Vertical CR: Coracoid process to glenohumeral joint. • Film centered to Horizontal CR

18. Shoulder Apical Oblique • Collimation: to include all soft tissue around shoulder and proximal humerus • Breathing Instructions: Suspended respiration • Make exposure and let patient breathe and relax

19. Shoulder Apical Oblique Film • Should visualize the head of the humerus within the glenoid fossa. • The tube angle results in minimal superimposition • Useful in detection of dislocations, Bankhart and Hill-Sachs defects. • Can be taken with arm in sling.

20. 14.5 Shoulder: Prone Axillary • Measure: A-P at coracoid • Protection: Half Apron • SID: 40” Non- Bucky • Tube angle: 15 to 25 degrees down • Film: 12” x 10” Regular with I.D. to spine • Special Equipment: rectangular and large angle sponge

21. Shoulder: Prone Axillary • Table placed in front of tube. Two to three inch thick rectangular sponge placed on table top. • Large angle sponge used to hold film vertical. • Tube aligned to film and SID set at 40” using tape measure on collimator.

22. Shoulder: Prone Axillary • The patient is asked to lean over table with arm abducted 90 degrees. The elbow is bent 90 degrees and hangs off the table. • The arm and shoulder will be resting on rectangular sponge. • The mid sagittal plane of the patient is turned 10 to 25 degrees medially.

23. Shoulder: Prone Axillary • The head and neck is turned away from the affected shoulder. • The film is placed next to the neck. • Horizontal CR: 2” above the glenohumeral joint. • Vertical CR: through the glenohumeral joint

24. Shoulder: Prone Axillary • Collimation: to include all soft tissue around the shoulder or slightly less than film size. • Breathing instructions: full inspiration or suspended respiration • Make exposure and let patient breathe and relax.

25. Shoulder: Prone Axillary Film • Also known as as West Point View. • The best view for visualizing the glenohumeral joint space free of superimposition. • This view is very difficult to set up with tube stands common to office practices.

26. 14.6 Shoulder Outlet View • Measure: A-P at coracoid process • Protection: Half apron • SID: 40” Bucky • Tube Angle: 15 to 30 degrees caudal for Outlet View. 0 to 10 degrees for Lateral Scapula or “Y” view • Film: 10” x 12 regular with I.D. to spine

27. Shoulder Outlet View • Patient is placed in a sixty degree anterior oblique. • The arm of the affected shoulder is left in a neutral position or in the sling. • The head of the affected shoulder aligned with the center line if the Bucky. • By feeling the scapula, adjust position to get scapula perpendicular to film.

28. Shoulder Outlet View • Horizontal CR: Head of humerus to slightly below head of humerus • Vertical CR: 1” medial to the body of the scapula. • Collimation: to include entire scapula and adjacent soft tissues of shoulder. • Breathing Instructions: Full Inspiration

29. Shoulder Outlet View • This is one of the best views to be taken when fracture or dislocation of shoulder is suspected. • You should see the true relationship of the humerus head and the glenoid fossa. Very useful when detecting a dislocation or fracture.

30. Shoulder Outlet View • The true Outlet View will allow evaluation of the subacromion space for the evaluation of impingement syndrome. • Fractures of the scapula may also be seen on this view.

31. Shoulder Outlet View • There are four abnormal acromion shapes that predispose impingement. • Flat Underside • Underside concave following curve of the humeral head • Anterioinferior acromial spur or hook • Underside convex

32. 14.16 Scapula Lateral View or “Y” View • Measure: A-P at coracoid process • Protection: Half apron • SID: 40” Bucky • Tube Angle: 0 to 10 degrees for Lateral Scapula or “Y” view • Film: 10” x 12 regular with I.D. to spine

33. Scapula Lateral View • Patient is placed in a sixty degree anterior oblique. • The arm of the affected shoulder is left in a neutral position or in the sling. • The head of the affected shoulder aligned with the center line if the Bucky. • By feeling the scapula, adjust position to get scapula perpendicular to film.

34. Scapula Lateral View • Horizontal CR: Head of humerus to slightly below head of humerus • Vertical CR: 1” medial to the body of the scapula. • Collimation: to include entire scapula and adjacent soft tissues of shoulder. • Breathing Instructions: Full Inspiration

35. Scapula Lateral View • This is one of the best views to be taken when fracture or dislocation of shoulder is suspected. • You should see the true relationship of the humerus head and the glenoid fossa. Very useful when detecting a dislocation or fracture.

36. Scapula Lateral View • The true Outlet View will allow evaluation of the subacromion space for the evaluation of impingement syndrome. • Fractures of the scapula may also be seen on this view.

37. 14.7 Shoulder: Stryker Notch • Measure: A-P at coracoid process • Protection: Half Apron • SID: 40” Bucky • Tube angle: 45 degrees cephalad • Film: 8” x 10” Regular with I.D. to spine

38. Shoulder: Stryker Notch • Patient stands facing tube. The body is rotated 15 to 45 degrees to get scapula parallel to film • The patient abducts arm and placed hand behind neck. • The humerus should be internally turn to get humerus perpendicular to film.

39. Shoulder: Stryker Notch • Horizontal CR: about 2” inferior to coracoid process or through the glenohumeral joint. • Vertical CR: glenohumeral joint space • Collimation: slightly less than film size or to include all soft tissue around shoulder.

40. Shoulder: Stryker Notch • Breathing Instructions: Full Inspiration. • Note : Make sure that the glenohumeral joint space stays within collimation and central ray placement by having patient take a full breathe in and hold it before taking film.

41. Shoulder: Stryker Notch Film • This view will provide a clear view of the posterior and superior aspects of the head of the humerus. • The inferior borders of the glenoid fossa and joint space will be seen. • It is useful in detecting Hill-Sachs defects and anterior instability

42. 14.15 Scapula A-P • Measure: A-P at coracoid process • Protection: Half Apron • SID: 40” Bucky • No Tube Angle • Film: 12” x 10” Regular Speed with I.D. toward the spine

43. Scapula A-P • Patient stands facing tube. • Patient is rotated about 15° or until the scapula is parallel to film. • The humerus may be left in a neutral position. • Horizontal CR: 1” below the coracoid process. • Vertical CR: 1” medial to coracoid process

44. Scapula A-P • Film centered to horizontal CR. • Collimation top to bottom: slightly less than film size or to include entire scapula and shoulder • Collimation side to side: slightly less than film size or to include entire scapula and shoulder

45. Scapula A-P • Breathing Instructions: Suspended Respiration • Make exposure and let patient relax. • Some texts recommend raising the arm to get scapula clear of the ribs cage. Usually you will be able to visualize scapula with arm in neutral position.

46. Scapula A-P Film • Glenohumeral joint and entire scapula should be seen. • Soft tissues of shoulder should be seen.

47. 14.8 Clavicle P-A • Measure: A-P at mid clavicle • Protection: Half Apron • SID: 40” Bucky • No Tube Angle • Film: 1/2 of 8” x 10” or 10” x 12” Regular Cassette

48. Clavicle P-A • Patient stands facing Bucky with mid-sagittal plane perpendicular to film. • Horizontal CR: centered to exit through clavicle • Vertical CR: centered to clavicle • Horizontal CR centered to top half of film.

49. Clavicle P-A • Collimation Top to Bottom: less than 1/2 of film size or to include clavicle • Collimation side to side: slightly less than film size or to include sternoclavicular and acromioclavicular joints • Breathing Instructions: Suspended Respiration • Take film and let patient relax

50. Clavicle P-A Film • On this example, the A-P or P-A view is on the bottom of film. • Must see the sternoclavicular and acromioclavicular joints and entire clavicle.