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 .

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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.

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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.

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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

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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.

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14.8 Clavicle P-A Axial

• Measure A-P at mid clavicle
• Protection Half Apron
• SID 40 Bucky
• Tube Angle 10 to 15 degrees caudal
• Film 1/2 of 8 x 10 or 10 x 12 Regular
  Cassette

52
Clavicle P-A Axial

• Patient stands facing Bucky with mid-sagittal
  plane perpendicular to film.
• Horizontal CR one inch above center of clavicle
• Vertical CR centered to clavicle
• Horizontal CR centered to bottom half of film.

53
Clavicle P-A Axial

• 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

54
Clavicle P-A Axial Film

• On this example, the A-P or P-A axial view is on
  the top of film.
• Must see the sternoclavicular and
  acromioclavicular joints and entire clavicle.
• The P-A views will have less magnification but
  are more difficult to position.

55
14.9 Clavicle A-P

• 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

56
Clavicle A-P

• Patient stands facing tube with mid-sagittal
  plane perpendicular to film.
• Horizontal CR centered to clavicle
• Vertical CR centered to clavicle
• Horizontal CR centered to top half of film.

57
Clavicle A-P

• 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

58
Clavicle A-P Film

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

59
14.11 Clavicle A-P Axial

• Measure A-P at mid clavicle
• Protection Half Apron
• SID 40 Bucky
• Tube Angle 15 to 25 degrees cephalad
• Film 1/2 of 8 x 10 or 10 x 12 Regular
  Cassette

60
Clavicle A-P Axial

• Patient stands facing tube with mid-sagittal
  plane perpendicular to film.
• Horizontal CR one inch below center of clavicle
• Vertical CR centered to clavicle
• Horizontal CR centered to bottom half of film.

61
Clavicle A-P Axial

• 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

62
Clavicle A-P Axial Film

• On this example, the A-P or P-A axial view is on
  the top of film.
• Must see the sternoclavicular and
  acromioclavicular joints and entire clavicle.
• The P-A views will have less magnification but
  are more difficult to position.

63
14.12 Acromioclavicular Joint Unilateral

• Measure A-P at coracoid
• Protection Half Apron
• SID 40 Bucky
• Tube Angle None
• Film 2 views on 10 x 12 Regular Cassette
• Special equipment 10 to 15 pounds of weight that
  can be strapped to wrists

64
Acromioclavicular Joint Unilateral

• Patient stands facing tube with mid-sagittal
  plane perpendicular to film.
• Horizontal CR A-C joint
• Vertical CR A-C joint
• Horizontal CR centered to top half of film.
• Marker anatomical

65
Acromioclavicular Joint Unilateral

• Collimation soft tissue around A-C joint but
  less than 1/2 of film size.
• Breathing Instructions Deep Inspiration
• Make sure the A-C Joint remains in collimation
  with deep inspiration

66
Acromioclavicular Joint Unilateral

• Make exposure and let patient breathe but remain
  in position.
• Strap weights to both wrists.
• Marker arrow pointed down or weighted marker on
  bottom half of film

67
Acromioclavicular Joint Unilateral

• Horizontal CR A-C joint
• Vertical CR A-C joint
• Center horizontal CR to bottom half of film.
• Breathing Instructions Deep Inspiration
• Make exposure and let patient breathe and relax.
  Remove weights

68
Acromioclavicular Joint Unilateral Film

• The most common view here is the Zanca
  modification to the unilateral ribs.
• The Zanca Views will open the acromion space
  better than the straight A-P views.

69
14.13 Acromioclavicular Joints Bilateral A-P

• Measure A-P at coracoid
• Protection Half apron
• SID 72 Non-Bucky
• Tube Angle none Zanca View 15 degree cephalad
  angle
• Film 17 x 7 or 17 x 14 I.D. to unaffected
  side

70
Acromioclavicular Joints Bilateral A-P

• Non-Bucky film holder hung on Bucky. Film placed
  in Non-Bucky Holder.
• Patient stands facing tube with mid-sagittal
  plane perpendicular to film.
• Horizontal CR at level of A-C Joints. Zanca 1
  below A-C Joints

71
Acromioclavicular Joints Bilateral A-P

• Vertical CR mid-sagittal
• Collimation to include both A-C joints and
  adjacent soft tissue and slightly less than film
  size on 17 x 7 film.
• Breathing Instructions Deep Inspiration

72
Acromioclavicular Joints Bilateral A-P

• Make exposure and let patient relax.
• Change films or move to unexposed half of 17 x
  14 film.
• Strap weights to wrists.
• Horizontal and vertical CR same as non-weighted
  view.

73
Acromioclavicular Joints Bilateral A-P

• Place arrow pointing down or weighted marker
  on film.
• Breathing instructions Deep Inspiration
• Make exposure and let patient breathe and relax.
  Remove weights.

74
Acromioclavicular Joints Bilateral A-P Film

• The bilateral exam provides a comparison view of
  both A-C Joints.
• The increased SID and Non-Bucky exposure is 25
  of the unilateral view.
• Magnification is reduced.

75
14.14 Zanca Views of the A C Joints

• Measure A-P at coracoid process
• Protection half apron
• SID 40 Bucky
• Tube Angle 15 cephalad
• Film 10 x 12 Regular Speed

76
Zanca Views of the A C Joints

• Patient stands facing tube with mid sagittal
  plane perpendicular to film.
• Horizontal CR 1 below A C Joint
• Vertical CR through the A C Joint

77
Zanca Views of the A C Joints

• Bottom half of film centered to Horizontal CR.
• Collimation top to bottom to include A- C Joint
• Collimation side to side soft tissues adjacent
  to A-C Joint

78
Zanca Views of the A C Joints

• Breathing Instructions Full Inspiration
• Rehearse breathing to make sure the A J joint
  will be seen on full inspiration.
• Make exposure and ask patient not to move.
• Strap weights around wrists.

79
Zanca Views of the A C Joints

• Adjust Horizontal CR for the weight, still 1
  below A-C Joint
• Center remaining half of film to Horizontal CR
• Place arrow or weighted marker on film.
• Have patient take a deep breath and make exposure.

80
Zanca View Films

• Weighted and Non-Weighted Views are taken as
  stress views of the Acromioclavicular Joint.
• Useful in detection separations

81
Zanca View Films

• The Zanca View will open the sub-acromion space
  better than the standard A-P view.
• If separation is not suspected, it can be used to
  evaluate bone loss in the A-C Joint. A single
  view on an 8 x 10 is taken.

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The End

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