Shoulder, Clavicle & AC joints

Shoulder - AP Projection

Explain how the patient should be positioned for an AP projection of the shoulder.

1. Supine or erect AP

Explain how the patient's part should be positioned for an AP projection of the shoulder.

1. Rotate body slightly toward affected side to place scapula in contact (parallel) with IR
2. Abduct arm slightly

Shoulder - AP Projection in External Rotation

for non-trauma patients

Explain how the patient's part should be positioned for an AP projection in external rotation of the shoulder.

1. Supinate hand until humeral epicondyles are parallel to IR
2. Humerus is true AP (anatomical position)

Shoulder - Lateral Projection in Internal Rotation

for non trauma patients

Explain how the patient's part should be positioned for an AP projection in internal rotation of the shoulder.

1. Internally rotate hand until humeral epicondyles are perpendicular to the IR; back of hand on hip
2. Humerus is in lateral position

Shoulder - AP Projection in Neutral Rotation

for trauma patients

Explain how the patient's part should be positioned for an AP projection in neutral rotation of the shoulder.

1. Arm at side in neutral rotation (epicondyles are about 45-degrees to IR)

When taking AP projections (in external and neutral rotation) and lateral projection (in internal rotation) of the shoulder, the CR is _____ to the IR

perpendicular

When taking AP projections (in external and neutral rotation) and lateral projection (in internal rotation) of the shoulder, the CR enters where?

1" inferior to coracoid process of 1 3/4" inferior to lateral portion of clavicle

The structures shown in all 3 positions of the AP projections (in external and neutral rotation) and lateral projection (in internal rotation) of the shoulder is...

- slight overlap of humeral head over glenoid cavity

The structures shown and criteria for evaluation of the shoulder in external rotation are...

- greater tubercle in profile
- the lesser tubercle is superimposed on the head of the humerus
- head of the humerus seen in profile
- greater tuberosity seen in profile on lateral aspect
- lesser tuberosity seen between greater tuberosity and head of the humerus

The structures shown and criteria for evaluation of the shoulder in internal rotation are...

- demonstrates lesser tubercle in profile on the medial aspect of the humeral head
- greater tuberosity superimposed on the head of the humerus
- more overlap of humerus and glenoid fossa than external rotation

The structures shown and criteria for evaluation of the shoulder in neutral rotation are...

-proximal 1/3 of humerus
- upper scapula
- lateral 2/3 of scapula
- humeral head superimposing glenoid cavity
- greater and lesser tuberosities superimposed on head of humerus

What is the error in this internal rotation X-ray of the shoulder? How do you correct it?

Humerus is not in alignment. It is angled outward. To correct, the humerus should be placed parallel to the body if possible.

What device is used to absorb scattered radiation when taking a shoulder X-ray?

boomerang

Shoulder Joint - Inferosuperior Axial Projection - Lawrence Method (Axillary View)

for non-trauma patients

Explain how the patient should be positioned for an inferosuperior axial projection (Lawrence Method) of the shoulder joint.

1. Supine
2. Shoulder and entire arm elevated 2-3 inches

When should you not attempt an inferosuperior axial projection (Lawrence Method) of the shoulder joint?

if a fracture or dislocation is present

Explain how the patient's body part should be positioned for an inferosuperior axial projection (Lawrence Method) of the shoulder joint.

1. Abduct arm to right angle (90 degrees) to the body

2. Arm externally rotated with pad under entire arm

3. Turn head away from affected side

4. IR is vertical in holder against neck (parallel to joint)

When taking an inferosuperior axial projection (Lawrence Method) of the shoulder joint, the CR is horizontal through the axilla (armpit) and ________ to the shoulder joint

perpendicular

When taking an inferosuperior axial projection (Lawrence Method) of the shoulder joint, the CR is angled how?

medially 25-30 degrees

The structures shown in an inferosuperior axial projection (Lawrence Method) of the shoulder joint are the...

- scapulohumeral joint
- coracoid process in profile
- lesser tubercle in profile
- dislocation of proximal humerus
- AC joint

When meeting criteria for an inferosuperior axial projection (Lawrence Method) of the shoulder joint, what should be met?

- slight overlap of scapulohumeral joint
- coracoid process seen in profile and pointing anteriorly
- lesser tubercle seen in profile

Shoulder Joint - Superior-Inferior Axial Lateral Projection

Explain how the patient should be positioned for a superior-inferior axial lateral projection of the shoulder joint.

1. Patient seated at end of x-ray table, leaning laterally over table

Explain how the patient's body part should be positioned for a superior-inferior axial lateral projection of the shoulder joint.

1. Elbow flexed 90 degrees, hand is pronated
2. Patient leans laterally over the IR
3. Abduct humerus as much as possible
4. Tilt the patient's head away from the shoulder

When taking a superior-inferior axial lateral projection of the shoulder joint, the CR is angled how much in order to make it perpendicular to a line between the AC joint and the superior angle of the scapula?

5-15 degrees

The structures shown in a superior-inferior axial lateral projection of the shoulder joint are the...

- lateral view of proximal humerus
- glenohumeral articulation is visualized
- coracoid process is seen on end
- bursitis, shoulder impingement, osteoporosis, osteoarthritis and tendonitis

What is the error in this axillary shoulder projection? How do you correct this?

Humerus is not in same plane as shoulder. Humerus is foreshortened. To correct, place entire arm in the same plane to correctly align CR, part, and IR. Arm is foreshortened.

What is the error in this axillary shoulder projection? How do you correct this?

Central ray not directed correctly to axilla. To correct, correctly align CR, part, and IR. Arm is elongated.

What is the error in this axillary shoulder projection? How do you correct this?

Incorrect centering of IR, also quantum mottle and incorrect collimation. To correct, center to IR correctly, collimate, and increase the amount of radiation.

What is the error in this axillary shoulder projection?

Collimation is open too much

Shoulder - PA Transaxillary Projection (Hobbs Modification)

Explain how the patient should be positioned for a PA axillary projection of the shoulder.

1. Prone or erect PA

Explain how the patient's body part should be positioned for a PA axillary projection of the shoulder.

1. The arm is raised superiorly as much as possible

2. The head is turned away from affect side

When taking a PA axillary projection of the shoulder, the CR is perpendicular to what?

the axilla and the humeral head passing through the glenohumeral joint

The structures shown and criteria for evaluation of the PA axillary projection of the shoulder are...

– Lateral view of proximal humerus in

relationship to glenohumeral articulation

– Coracoid process is seen on end

– Demonstrates bursitis, shoulder impingement, osteoarthritis, and tendonitis

What projections is considered non-trauma series' when looking at X-raying the shoulder?

1. AP projections: external and internal rotations

2. Inferosuperior axial projection (axillary view) (Lawrence Method)

Glenoid Cavity - AP Oblique Projections - RPO & LPO Positions (Grashey Method)

for non- trauma patients

Explain how the patient should be positioned for an AP oblique projections in RPO & LPO positions (Grashey Method) of the glenoid cavity.

1. Supine or erect

Explain how the patient's body part should be positioned for AP oblique projections in RPO & LPO positions (Grashey Method) of the glenoid cavity.

1. Affected shoulder rotated 35-45. degrees toward the IR

2. Scapula is parallel to the IR

3. Arm slightly abducted in neutral rotation (or placed across the body)

The structures shown in AP oblique projections in RPO & LPO positions (Grashey Method) of the glenoid cavity is the...

- glenoid cavity (scapulohumeral joint) in profile

When taking AP Oblique Projections in RPO & LPO positions (Grashey Method) of the glenoid cavity, the CR is centered directly at the scapulohumeral joint where?

2" inferior and 2" medial to superio-lateral border of the shoulder

When meeting criteria for evaluation, what should be met for the AP oblique projections in RPO & LPO positions (Grashey Method) of the glenoid cavity?

- anterior and posterior rim of glenoid fossa are superimposed

- glenoid cavity seen in profile

What is the error in this Grashey projection? How should it be corrected?

Patient under-rotated. Head of humerus overlaps glenoid fossa. To correct, rotate the patient more.

Shoulder - Transthoracic Lateral Projection (Lawrence Method)

for trauma patients

Explain how the patient should be positioned for a transthoracic lateral projection (Lawrence Method)of the shoulder.

1. Erect or supine

Explain how the patient's body part should be positioned for a transthoracic lateralprojection (Lawrence Method)of the shoulder.

1. lateral position

2. affected shoulder against IR

3. unaffected arm raised and hand placed on top of head

4. affected arm in neutral position

When taking a transthoracic lateral projection (Lawrence Method) of the shoulder, the CR is _________ to the IR

perpendicular

When taking a transthoracic lateral projection (Lawrence Method) of the shoulder, the CR is centered to what?

surgical neck of the humerus to IR

The structures shown in a transthoracic lateral projection (Lawrence Method) of the shoulder is the...

- proximal humerus

- glenohumeral joint projected through thorax

NOTE: When is the transthoracic lateral projection (Lawrence Method) of the shoulder used?

used for trauma when arm cannot be moved, rotated, or abducted

NOTE: What may be used for the transthoracic lateral projection (Lawrence Method) to blur out lung structures?

breathing technique

When meeting criteria for evaluation of the transthoracic lateral projection (Lawrence Method), what should be met?

unaffected clavicle projected above shoulder closest to IR
- scapula superimposed over T-spine
- proximal humerus seen through lung field

Shoulder - PA Oblique Projection - RAO & LAO Positions (Scapular "Y" Method)

for trauma patients

Explain how the patient should be positioned for a PA oblique projection - RAO & LAO positions (scapular "Y" method) of the shoulder.

1. erect or recumbent

Explain how the patient's body part should be positioned for a PA oblique projection - RAO & LAO positions (scapular "Y" method) of the shoulder.

1. midcoronal plane rotated 45-60 degrees from IR

2. anterior surface of affected shoulder centered to IR

3. abduct the arm slightly

4. palpate scapula borders to determine correct rotation

When taking a PA oblique projection - RAO & LAO positions (scapular "Y" method) of the shoulder, the CR is ________ to the IR

perpendicular

When taking a PA oblique projection - RAO & LAO positions (scapular "Y" method) of the shoulder, the CR centered to what joint?

the glenohumeral joint

When taking a PA oblique projection - RAO & LAO positions (scapular "Y" method) of the shoulder, the CR centered to the glenohumeral joint where?

2” below the top of the shoulder

The structures shown in a PA oblique projection - RAO & LAO positions (scapular "Y" method) of the shoulder are the...

- humeral head superimposed directly over the "Y" intersection
- scapula in lateral profile
- useful to evaluate fractures and dislocations

When meeting criteria for evaluation for a PA oblique projection - RAO & LAO positions (scapular "Y" method) of the shoulder, what should be met?

- humeral shaft and body of scapula superimposed
- humeral head and glenoid cavity superimposed, acromion projects laterally
- coracoid superimposed on clavicle
- lateral and vertebral borders of scapula superimposed
- coracoid, acromion and humerus create the arms and legs of the Y

Shoulder - Modified Scapular Y Outlet (Neer Method)

When positioning for a modified scapular Y outlet (Neer Method), how should the patient be positioned?

same as a Y-view

When taking a modified scapular Y outlet (Neer Method), the CR is angled how?

5-15 degrees caudad

What does the modified scapular Y outlet (Neer Method) demonstrate?

- shoulder impingement to evaluate the subacromial space and the supraspinatus outlet
- acromion is seen in profile

Routine Scapular Y vs Neer Method

What projection is this X-ray? Is this dislocation anterior or posterior? How can you tell?

natural rotation, it shows a posterior dislocation as the humeral head is inferior to the acromion process

What projection is this X-ray? Is this dislocation anterior or posterior? How can you tell?

Y- view; it show an anterior dislocation as the humeral head is inferior to the coracoid process

What is the error in this scapula Y-view error?

Obliqued too little. Humerus is too far from the body

What is the error in this scapula Y-view error?

Obliqued too much. Humerus is too close to the body

NOTE: How can a scapula Y-view for severely injured patients be performed?

in RPO or LPO position

Shoulder - Superoinferior Axial Projection (Velpeau Method)

Explain how the patient and patient's body part should be positioned for a superoinferior axial projection (Velpeau Method) of the shoulder.

1. Patient is standing with their back against the x-ray table
2. The humerus should be adducted to the body
3. The patient should lean BACK over the x-ray table as much as possible to prevent superimposition of the shoulder and the trunk
4. The IR is placed below the affected shoulder

When taking a superoinferior axial projection (Velpeau Method) of the shoulder, the CR is directed ___________ to the IR

perpendicular

When taking a superoinferior axial projection (Velpeau Method) of the shoulder, the CR enters where?

the shoulder joint

The superoinferior axial projection (Velpeau Method) of the shoulder demonstrates...

the relationship of the humeral head to the glenoid cavity

Clavicle - AP Projection

Explain how the patient should be positioned for an AP projection of the clavicle.

1. Supine or erect

Explain how the patient's body part should be positioned for an AP projection of the clavicle.

1. True AP position

2. Center clavicle to IR

When taking an AP projection of the clavicle, the CR should be perpendicular to what?

mid clavicle which should be open to get sternoclavicular and AC joint

The structures shown in an AP projection of the clavicle are the....

- clavicle with medial half superimposing the thorax

NOTE: For an AP projection of the clavicle, what would reduce OID if a patient is able to stand?

erect PA

When meeting criteria for evaluation of an AP projection of the clavicle, what should be met?

- entire clavicle seen
- lateral half above scapula
- medial half superimposed on thorax

Clavicle - AP Axial Projection

Explain how the patient should be positioned for an AP axial projection of the clavicle.

1. Upright or supine

When taking an AP axial projection of the clavicle, the CR is angled how?

15-30 degrees cephalad

When taking an AP axial projection of the clavicle, the CR is requires ________ of an angle for thin patients

more of an angle

When meeting criteria for evaluation for an AP axial projection of the clavicle, what should be met?

- majority of clavicle seen above ribs

Clavicle - PA Axial Projection

Explain how the patient should be positioned for a PA axial projection of the clavicle.

1. Prone

When taking a PA axial projection of the clavicle, the CR is angled how?

15-30 degrees caudad

NOTE: When should the PA axial projection of the clavicle not be used?

if fracture or destructive lesion is suspected

Acromioclavicular (AC) Joints - Bilateral AP (or PA) Projection (Pearson Method)

Explain how the patient should be positioned for a bilateral AP (or PA) projection (Pearson Method) of the acromioclavicular (AC) joints.

1. Erect PA

2. Use 72 inch SID

If a bilateral AP (or PA) projection (Pearson Method) of the acromioclavicular (AC) joints is done supine, what may happen?

AC separation may reduce or mask itself

Explain how the patient's body part should be positioned for a bilateral AP (or PA) projection (Pearson Method) of the acromioclavicular (AC) joints

1. Posterior shoulders against IR
2. Arms at sides
3. Two bilateral exposures made for comparison
4. First, without weights, then with weights after getting the okay from the radiologist

When taking a bilateral AP (or PA) projection (Pearson Method) of the acromioclavicular (AC) joints, the CR is perpendicular to what?

medicine at level of AC joints