Humerus and Shoulder Procedures

What is a humerus routine?

AP and lateral

What SID is used for all humerus and elbow images?

40”

What is respiration for most humerus and elbow images?

suspend breathing

Explain positioning for an AP humerus image

• can be supine or upright

• can be grid or non grid

• supinate the hand

• epicondyles parallel to IR

• turn collimator head to go down long axis of arm

• ensure both joints are on each image

Where do you center for an AP or lateral humerus image?

mid-humerus

What are some things you need to look for on an AP humerus image (film eval)?

• 1-2 in past each joint

• greater tubercle in profile laterally

• epicondyles in profile

• collimated

• oriented properly

• marker placed laterally

Explain the positioning for a lateral humerus (if done with the arm down the side of the body)

• can be supine or upright

• rotate arm medially to place epicondyles perpendicular to the IR

• lateromedial projection

• turn collimator head to go down long axis of arm

• ensure both joints are on the image

Explain the positioning for a lateral humerus (if done with the arm in a “stop sign” position)

a lateral humerus is achieved by putting the arm in a stop sign position and a mediolateral projection

Explain the positioning for a lateral humerus (if done with the arm pulled back behind the body)

• not done frequently

• patient faces IR

• flex elbow 90^o

• oblique body for close contact with IR

• mediolateral projection

What are some things you need to look for on a lateral humerus image (film eval)?

• demonstrates true lateral of proximal humerus

• humeral epicondyles are superimposed

• lesser tubercle and humeral head in profile

• 2 in past each joint

• marker placed lateral

What is a trauma humerus routine?

AP, lateral proximal, lateral distal

How do you get an AP trauma humerus image?

just like an AP humerus, but don’t move the arm (keep arm as patient presents)

rotate patient towards affected side

What is the method and projection used to take a proximal lateral trauma humerus image?

Lawerence method with transthoracic lateral projection

Explain the Lawerence method (transthoracic lateral)

• 10×12 LW

• supine or erect

• lateral position with affected side toward IR

• unaffected arm above head

  • if patient is unable, use 10-15^o cephalic angle

• drop affected shoulder

  • if patient is unable, use 10-15^o cephalic angle

Explain the centering for a transthoracic lateral projection of the proximal humerus

central ray should exit at the surgical neck level of the affected arm

Explain the respiration for the Lawerence method

shallow breathing (breathing technique)

What are some things you need to look for on a proximal lateral trauma humerus image (film eval)?

• demonstrates lateral view of proximal humerus (through the thorax)

• humerus should be anterior to spine

• visible glenohumeral joint

• marker placed anterior

Explain the distal lateral trauma humerus image

• place cassette between arm and thorax

• flex elbow if possible

• CR perpendicular to midpoint of distal 2/3 of humerus

What are some things you need to look for on a distal lateral trauma humerus image (film eval)?

• demonstrates projection of distal humerus including the elbow joint

• marker placed anterior

• annotate as a shoot-thru

What is a shoulder routine?

AP external, AP internal, axillary view

Explain the AP shoulder view with neutral rotation (not part of routine)

• palm against thigh to put epicondyles at 45^o

• “oblique” shoulder

• central ray 1 in below coracoid

• demonstrates

  • greater tubercle superimposed on humeral head

  • slight overlap of the humeral head and glenoid cavity

  • ~2/3 of the clavicle

Explain the AP shoulder view with external rotation

• AP shoulder

• hand externally rotated with palmar surface up

• epicondyles parallel to IR

• central ray 1 in below coracoid process

• demonstrates

  • greater tubercle in profile

  • arrow pointing laterally or annotation saying “external”

  • marked lateral

Explain the AP shoulder view with internal rotation

• lateral shoulder

• hand medially rotated to place epicondyles perpendicular to IR

• central ray 1 in below coracoid process

• demonstrates

  • true lateral

  • lesser tubercle in profile medially

  • greater tubercle superimposing the humeral head

  • arrow pointing medially or annotation saying “internal”

  • marked laterally

What are the 2 ways to do the axillary view of the shoulder?

superoinferior and inferosuperior projections

Explain the superoinferior axial projection of the shoulder

• patient seated 90^o to the table with affected arm raised and over IR

• lean laterally to place joint as close to midpoint of IR as the patient can

• abduct arm and elbow flexed 90^o

• hand pronated

• lean head away from affected arm

• central ray:

  • angled 5-15^o toward elbow

  • greater angle if patient cannot extend the shoulder over the IR

What is the Lawrence method?

inferosuperior and superoinferior axial projection of the shoulder

Explain the inferosuperior axial projection (Lawrence method) of the shoulder

• supine position with shoulder elevated and head turned away from affected side

• IR above shoulder, close to neck

• abduct arm 90^o

• external rotation with palm up

• central ray:

  • directed horizontally through axilla

  • medial angulation 15-30^o

    • the greater abduction, the greater the angle

What do you need to ensure is included on an axial shoulder image?

• glenohumeral joint

• coracoid process pointing anteriorly

• lesser tubercle in profile pointing anteriorly

• acromion (SC joint) superimposed over humeral head

• marker anterior

What is a trauma shoulder routine?

AP as is, Y-view

Explain the AP trauma shoulder

do it as the patient presents, DO NOT rotate the hand

Explain the trauma Y-view

• light field LW

• PA projection if upright (RAO or LAO)

  • rotate patient 45-60^o toward affected side

  • CR perpendicular exiting at surgical neck

• AP projection if supine (RPO or LPO)

  • rotate patient 45-60^o away from affected side

  • CR perpendicular to scapulohumeral joint (surgical neck)

• arm stays at side

• scapula is perpendicular to IR

What do you need to ensure is included on an AP/PA trauma Y-view shoulder image?

• lateral view of scapula projected free of superimposition of ribs

• oblique view of the shoulder

• humerus overlies scapula

• determines anterior or posterior dislocation

• marker lateral

In a Y-view, what is the “Y” formed by?

the acromion, coracoid, and scapula body

Explain the Grashey method

• true AP shoulder

• rotate body 35-45^o toward affected side

• scapula parallel to IR with superimposed coracoid and acromion

• slightly abduct arm

• epicondyles 45^o (neutral rotation)

• centered 2 inches medial and 2 inches inferior to superolateral border of shoulder

• demonstrates glenoid joint in profile with open joint space between the humeral head and glenoid cavity

Explain the Neer method

• a Y-view with an angle

• CR 10-15^o

  • caudal angle if PA

  • cephalic angle if AP

• CR through superior margin of humeral head

• demonstrates coracoacromial arch for supraspinatus outlet region for possible shoulder impingement

What technique is used for shoulder images (with grid; ext., int., neutral, grashey)?

80 kVp @ 5 mAs

What technique is used for the axillary view?

grid: 80 kVp @ 5 mAs

non: 60 kVp @ 5 mAs

What technique is used for a Y-view (with grid)?

80 kVp @ 10 mAs (DON’T AEC)

What technique is used for AP and lateral humerus?

grid: 80 kVp @ 4 mAs

non: 60 kVp @ 4 mAs

If you AEC for humerus or shoulder images, which chamber(s) do you use?

center

What should the exposure index be for shoulder and humerus images?

EI: 200-600

S: 200-600