RADIOGRAPHIC PROCEDURES Essential Projections of the Shoulder 1/2

• AP projections

  1. External rotation

  2. Neutral position

  3. Internal rotation

• Transthoracic lateral (Lawrence method)

• Inferosuperior axial (Lawrence method)

• Inferosuperior axial (Rafert modification)

• Inferosuperior axial (Westpoint method)

• Inferosuperior axial (Clements modification)

• Superoinferior axial Projection

• AP Axial Projection

• Scapular Y Projection (Rubin, Gray and Green)

• Stryker Notch Method

ESSENTIAL PROJECTIONS: SHOULDER:

External rotation

Supinating hand and adjusting epicondyles parallel to the plane of the IR positions the humerus in

Neutral rotation

Palm of the hand placed against hip and epicondyles adjusted at about a 45 degree with the plane of the IR positions the humerus in

Internal rotation

Posterior aspect of hand may be placed against hip and epicondyles adjusted perpendicular to the plane of the IR to position the humerus in

Supine or upright

Shoulder AP PROJECTION Patient position

• External Rotation

• Neutral Rotation

• Internal Rotation

Shoulder AP PROJECTION Part position:

External Rotation

Hand supinated; humeral epicondyles parallel to IR; arm abducted slightly

Neutral Rotation

Palmar/anterior aspect of hand placed against the hip; humeral epicondyles 45° to IR

Internal Rotation

Dorsal/posterior aspect of hand against hip; humeral epicondyles perpendicular to IR

• Perpendicular

• Enters patient 1 inch inferior to coracoid process

Shoulder AP PROJECTION Central ray (CR):

• 10 × 12 inches (24 × 30 cm)

• Radiation field to 10 x 12 inch (24 x 30 cm).

• If crosswise include 1.5 inch (3.8 cm) above the shoulder, 1 inch (2.5 cm) beyond the lateral aspect of the shoulder, the sternal end of the clavicle and the proximal third of the humerus.

• If lengthwise, more humerus and less clavicle will be included.

Shoulder AP PROJECTION IR/Collimation:

The bony and soft structures of the shoulder and proximal humerus

Shoulder AP PROJECTION Structures Shown

• External Rotation

• Neutral Rotation

• Internal Rotation

Shoulder AP PROJECTION Evaluation Criteria:

External Rotation

Greater tubercle & site of insertion of supraspinatus tendon

greater tubercle and site of insertion of supraspinatus tendon

External rotation

Greater tubercle partially superimposing humeral head; posterior part of supraspinatus insertion, and oblique view of the proximal humerus

Neutral rotation

Lesser tubercle; site of the insertion of the subscapular tendon; proximal humerus in true lateral position

Internal Rotation

TRANSTHORACIC LATERAL (LAWRENCE METHOD)

Projection used for trauma patients who cannot rotate or abduct arm

• Supine, upright lateral or dorsal decubitus

• Affected limb closer to IR

• Unaffected limb elevated over head

Shoulder TRANSTHORACIC LATERAL (LAWRENCE METHOD) Patient position:

• Do not move injured limb

• Have the patient raise the non-injured arm

• Ensure elevated shoulder is higher than injured shoulder

• MCP perpendicular to the IR.

• Center surgical neck of humerus to IR

Shoulder TRANSTHORACIC LATERAL (LAWRENCE METHOD) Part position:

• perpendicular

• Enters MCP at surgical neck

• If shoulders are in same plane, CR angled 10 to 15 degrees cephalad

Shoulder TRANSTHORACIC LATERAL (LAWRENCE METHOD) Central Ray (CR):

• 10 × 12 inches (24 × 30 cm)

• The light field will appear smaller on the skin because of OID. Do not collimate larger than stated size

Shoulder TRANSTHORACIC LATERAL (LAWRENCE METHOD) IR/Collimation:

• exposure made on inspiration or set a breathing technique

• Slow, deep breathing and minimum exposure time of 3 seconds

Shoulder TRANSTHORACIC LATERAL (LAWRENCE METHOD) Respiration:

Shoulder and proximal humerus is projected through the thorax

Shoulder TRANSTHORACIC LATERAL (LAWRENCE METHOD) Structures Shown

• Scapula, clavicle, and humerus seen through the lung field

• Scapula superimposed over the thoracic spine

• Unaffected clavicle and humerus projected above the shoulder closest to the IR

Shoulder TRANSTHORACIC LATERAL (LAWRENCE METHOD) Evaluation Criteria:

Supine

Shoulder INFEROSUPERIOR AXIAL (LAWRENCE METHOD) Patient Position

• Affected side at right angles to the long axis of the body. A minimum of 20 degrees is required to prevent superimposition of the arm on the shoulder.

• Head, shoulder & elbow elevated (3 in.)

• Affected arm abducted 90°

• Humerus rotated externally

Shoulder INFEROSUPERIOR AXIAL (LAWRENCE METHOD) Part Position:

• Horizontally

• 15-30° medially

Shoulder INFEROSUPERIOR AXIAL (LAWRENCE METHOD) Central Ray (CR):

15-30° medially

if abduction is less than 90° (greater abduction, greater angle)

Horizontally

through the axilla to the AC joint.

• Proximal humerus, scapulohumeral joint, lateral portion of the coracoid process, and AC articulation

• The insertion site of the subscapular tendon on the lesser tubercle of the humerus and the point of insertion of the teres minor tendon on the greater tubercle of the humerus

Shoulder INFEROSUPERIOR AXIAL (LAWRENCE METHOD) Structures Shown:

Supine

Shoulder INFEROSUPERIOR AXIAL (RAFERT MODIFICATION) Patient Position

• Abduct arm of the affected side 90°

• Humerus is exaggerated external rotation

• Hand form an angle of 45° oblique

• Thumb pointing downward

Shoulder INFEROSUPERIOR AXIAL (RAFERT MODIFICATION) Part Position:

Horizontal and angled medially entering the axilla

Shoulder INFEROSUPERIOR AXIAL (RAFERT MODIFICATION) Central Ray (CR)

Hill-Sachs compression fracture on the posterolateral humeral head

Shoulder INFEROSUPERIOR AXIAL (RAFERT MODIFICATION) Structure Shown

• Prone with 3 inch pad under the shoulder being examined.

• Head turned away from the side being examined

Shoulder INFEROSUPERIOR AXIAL (WESTPOINT METHOD) Patient position:

Abduct arm of the affected side 90°) centered to shoulder joint

Shoulder INFEROSUPERIOR AXIAL (WESTPOINT METHOD) Part position

From horizontal 25° anteriorly and 25°medially and enters 5 inches (1.3cm) inferior and 1 ½ inch (3.8 cm) medial to the acromial edge and exit the glenoid cavity.

Shoulder INFEROSUPERIOR AXIAL (WESTPOINT METHOD) Central Ray

Bony abnormalities of the anterior inferior rim of the glenoid patients with instability of the shoulder

Shoulder INFEROSUPERIOR AXIAL (WESTPOINT METHOD) Structure Shown

• Lateral recumbent position lying, on the unaffected side.

• Flex the patient's hips and knees.

Shoulder INFEROSUPERIOR AXIAL (CLEMENTS MODIFICATION) Patient Position:

• Abduct the affected arm 90 degrees, and point it toward the ceiling.

• IR against the superior aspect of the patient's shoulder, holding it in place with the unaffected arm

Shoulder INFEROSUPERIOR AXIAL (CLEMENTS MODIFICATION) Part Position: