unit 6 humerus and shoulder girdle x-rays

procedural considerations for humerus and shoulder girdle

40 inches (100 cm) minimum SID
Gonadal shielding
Four-sided collimation when possible
Long axis of part to long axis of IR
Side markers visible
CR directed perpendicular to IR unless otherwise indicated

how many inches minimum SID?

40 (100 cm)

_____ axis of part to _____ axis of IR

long, long

CR is directed ________ to IR unless otherwise indicated

perpendicular

what are the routine and special positions/projections for the humerus?

routine:

> AP 

> Rotational Lateral 

special: 

> horizontal beam lateral (distal humerus) 

> transthoracic lateral (proximal to full humerus) 

what are the routine positions/projections of the humerus?

AP, rotational lateral

what are the special positions for the humerus?

horizontal beam lateral (distal humerus)

transthoracic lateral (proximal to full humerus) 

the horizontal beam lateral projection of the humerus is a projection of the ….

distal humerus

the transthoracic lateral projection/position is proximal to….

full humerus

for all projections/positions of the humerus, the patient will be either _____ or ________

erect, recumbent

name the position/projection

AP humerus

name the projection/position

AP humerus

AP humerus guidelines

extend arm fully with hand supinated

rotate body toward affected side as needed to bring shoulder and arm close to IR 

abduct arm slightly 

epicondyles parallel to IR 

CR to mid humerus 

in an AP humerus projection, your arm should be fully _____ with your hand _____

extended, supinated

in an AP humerus projection, the epicondyles should be _____ to IR

parallel

in an AP humerus projection, the CR should be to the

mid humerus

evaluation criteria for AP humerus

entire humerus to include elbow/shoulder joints

greater tubercle in profile

medial/lateral epicondyles in profile 

name the position/projection

AP humerus 

name the projection/position

rotational lateral humerus (lateromedial)

name the projection/position

rotational lateral humerus (mediolateral)

guidelines for a rotational lateral humerus (lateromedial) 

patient facing tube with arm extended, elbow partially flexed 

rotate body toward affected side as needed to bring shoulder/arm close to IR

internally rotate arm until epicondyles are perpendicular to IR (back of hand against thigh)

when the back of the hand is against the thigh in a Rotational lateral humerus (lateromedial) projection/position, the epicondyles are ______ to the IR

perpendicular

name the position/projection

rotational lateral humerus (mediolateral projection)

evaluation criteria for rotational lateral humerus

entire humerus to include elbow/shoulder joints

lesser tubercle in profile

epicondyles superimposed 

name the position/projection

horizontal beam lateral distal humerus 

the horizontal beam lateral (distal humerus) position is done usually on what kind of patient?

trauma 

guidelines to horizontal beam lateral (distal humerus)

patient supine with arm supported by sponge

elbow flexed 90 degrees w/ hand and wrist in lateral position 

epicondyles perpendicular to IR 

IR placed between arm and thorax 

CR directed horizontally to midpoint of distal 2/3 of humerus 

in a horizontal beam lateral (distal humerus) position, the epicondyles are ______ to the IR

perpendicular

in a horizontal beam lateral (distal humerus) position, the CR is directed ______ to ______ of _____ ___ of _____

horizontally, midpoint, distal, 2/3, humerus 

name the position

horizontal beam lateral (distal humerus)

evaluation criteria for horizontal beam lateral (distal humerus) position

distal 2/3 of humerus and elbow demonstrated

epicondyles superimposed 

name the position

transthoracic lateral humerus

guidelines for transthoracic lateral humerus

affected arm in neutral rotation, drop shoulder if possible

unaffected limb raised over head 

CR to mid aspect of humerus (horizontal beam if patient supine) 

breathing technique: 

2-3 second exposure while patient takes shallow breaths 

blurs our superimposing ribs/lung structures 

in a transthoracic lateral humerus position, the CR is to the ___ ___ of the ______

mid aspect, humerus

if the patient is supine in a transthoracic lateral humerus position, the beam should be ______

horizontal

if the patient cannot drop affected shoulder in a transthoracic lateral humerus position, what should be done? what does it prevent?

the CR should be angled 10-15 cephalad, prevents superimposition of the shoulders 

name position/projection; in what position is the beam in? what position is the patient in? is there a breathing technique present?

transthoracic lateral humerus, horizontal beam lateral, supine, yes

evaluation criteria for transthoracic lateral humerus

proximal 2/3 of humerus OR entire humerus w/ elbow joint

overlying ribs and lung marking blurred

non-trauma shoulder positions

routine:

AP external rotation 

AP internal rotation 

special: 

AP posterior oblique (grashley method) 

inferosuperior axial (lawrence method) 

PA transaxillary (Hobbs method) 

name the routine positions for a non-trauma shoulder

AP external rotation

AP internal rotation

name the special positions for a non-trauma shoulder and the methods

AP posterior oblique (grashley method)

inferosuprior axial (lawrence method) 

PA transaxillary (hobbs method) 

for a non-trauma shoulder, the patient can be ______ , _______ , or ______ for all projections/positions

erect, seated, recumbent

name the projection/position

AP shoulder external rotation 

guidelines for AP shoulder external rotation

extend arm fully with hand supinated

abduct arm slightly and externally rotate until epicondyles parallel to IR 

CR directed 1” inferior to coracoid process 

in an AP shoulder external rotation, the epicondyles are _____ to IR 

parallel 

in an AP shoulder external rotation, the CR is directed ___ ____ to _____ _______

1 inch, coracoid process

name the position/projection

AP shoulder external rotation

evaluation criteria for AP shoulder external rotation

greater tubercle seen in profile laterally

scapulohumeral joint centered 

proximal humerus, upper scapula, clavicle visualized 

name the position/projection 

AP shoulder internal rotation 

guidelines for AP shoulder internal rotation

extend arm fully with hand pronated

abduct arm slightly and internally rotate until epicondyles perpendicular to IR 

CR directed 1” inferior to coracoid process 

in an AP shoulder internal rotation position, the epicondyles are ______ to IR

perpendicular

when the epicondyles are perpendicular to the IR, the ____ of your hand is _____ the ____

back, against, thigh

in an AP shoulder internal rotation position, the CR is _____ ___ _____ _____ to _______ ______

directed 1 inch inferior, coracoid process

name the position/projection

AP shoulder internal rotation 

evaluation criteria for AP shoulder internal rotation 

lesser tubercle seen in profile medially 

scapulohumeral joint centered 

proximal humerus, upper scapula, clavicle visualized 

name the projection and rotational; label the part of the humerus the arrow is pointing to

AP external, greater tubercle

name the projection and rotational; label the part of the humerus the arrow is pointing to

AP internal, lesser tubercle 

name the projection/position and method

AP posterior oblique shoulder (grashley method)

guidelines for AP posterior oblique shoulder (grashley method) 

patient AP, extend arm fully 

body rotated 35-45 toward affected side 

abduct arm slightly and place hand in neutral position (palm facing thigh) 

CR directed to scapulohumeral joint — 2” inferior and medial from superolateral border of humerus 

name the position/projection and method if applicable 

AP posterior oblique shoulder (grashley method) 

evaluation criteria for AP posterior oblique shoulder (grashley method)

glenoid cavity seen in profile

scapulohumeral joint centered 

name the position/projection and method 

Inferosuperior Axial Shoulder (Lawrence Method)

guidelines for inferosuperior axial shoulder (lawrence method)

patient supine 

arm abducted 90 degrees if possible; keep in external rotation 

head rotated toward opposite direction 

IR placed against neck on superior aspect of arm 

CR directed medially 25-30 degrees to axilla 

name the position/projection and method if applicable

inferosuperior axial shoulder (lawrence method)

evaluation criteria for inferosuperior axial shoulder (lawrence method)

lateral view of scapulohumeral joint

lesser tubercle profiled anteriorly 

humeral head and glenoid fossa profiled 

name the position/projection and method

PA transaxillary shoulder (hobbs method) 

guidelines for PA transaxillary shoulder (hobbs method) 

Patient erect, seated, or leaning
over x-ray table
Arm extended over head

Head turned away from affected
side
IR place under axilla & arm
CR directed to the posterior
aspect of the shoulder at the
level of the axilla & humeral
head

name the position/projection and method if applicable 

PA transaxillary shoulder (hobbs method) 

evaluation criteria for PA transaxillary shoulder (hobbs method)

Lateral view of scapulohumeral joint
Coracoid process seen on end

name the positions for a shoulder (trauma)

routine:

AP neutral rotation 

scapular Y lateral 

transthoracic lateral (lawrence method) 

for a traumatic shoulder injury, the patient can be ______, _______, or _______ for all projections/positions

erect, seated, recumbent

name the position'/projection

AP shoulder neutral rotation 

guidelines for AP shoulder neutral rotation

Arm at patient’s side in neutral position (palm against thigh; epicondyles 45º to IR) or left “as is”
CR directed to mid scapulohumeral joint - approximately ¾” inferior & slightly lateral to the clavicle

name the position/projection 

AP shoulder neutral rotation 

evaluation criteria for AP shoulder neutral rotation

Greater & lesser tubercles superimposed
Scapulohumeral joint centered

name the position/projection 

Scapular Y Lateral Shoulder – Anterior Oblique Position (PA Projection)

guidelines for scapular Y lateral shoulder

Patient erect
Rotate patient into 45º-60º
oblique:
RAO for R shoulder
LAO for L shoulder
Abduct arm slightly or leave “as is”
CR directed to scapulohumeral joint; enters back 2” to 2½” below top of shoulder

name the position/projection

Scapular Y Lateral Shoulder – Posterior Oblique Position (AP Projection)

Guidelines for Scapular Y Lateral Shoulder – Posterior Oblique Position (AP Projection)

Patient erect or recumbent
Rotate patient into 45º-60º oblique:
RPO for L shoulder
LPO for R shoulder
Abduct arm slightly or leave “as is”
CR directed to scapulohumeral joint; enters front 2” to 2½” below top of shoulder

the Scapular Y Lateral Shoulder – Posterior Oblique Position (AP Projection) is often done _____ in place of anterior oblique positions, but results in greater magnification due to increased OID 

erect 

name the position'/projection

Scapular Y Lateral Shoulder – Posterior Oblique Position (AP Projection)

evaluation criteria for Scapular Y Lateral Shoulder – Posterior Oblique Position (AP Projection)

Lateral view of scapulohumeral joint
Body of scapula superimposed over shaft of humerus

Acromion and coracoid processes in profile
Humeral head and glenoid cavity superimposed

is this a normal or dislocated shoulder? how do you know?

normal, head of humerus superimposed over base of Y

is this a normal or dislocated shoulder? in which direction is it dislocated?

dislocated, anterior 

name the x-ray position/projection and method

Transthoracic Lateral Shoulder (Lawrence Method)

guidelines for a transthoracic lateral shoulder lawrence method

Patient erect or recumbent
Affected arm in neutral rotation;
drop shoulder if possible*
Unaffected limb raised over head
CR to surgical neck; enter inferior
to axilla (horizontal beam if patient
supine)

where should the CR be for a transthoracic lateral shoulder lawrence method?

surgical neck, inferior to axilla

what is the breathing technique for a transthoracic lateral shoulder lawrence method?

2-3 second exposure while patient takes shallow breaths

by using a breathing technique for a transthoracic lateral shoulder lawrence method, what does it do to the lungs and ribs?

blurs them out

if patient cannot drop affected shoulder for a transthoracic lateral shoulder lawrence method, what should you do?

anglr CR 10-15 degrees cephalad to prevent superimposition of shoulders

name the x-ray/position/method 

transthoracic lateral shoulder (lawrence method) 

evaluation criteria for transthoracic lateral shoulder (lawrence method)

Proximal ½ of humerus &
scapulohumeral joint
demonstrated without
superimposition of the
opposite shoulder
Overlying ribs & lung marking
blurred

what are the two routine views for a clavicle?

AP, AP axial

name the position/projection

AP Clavicle 

guidelines for AP clavicle

arm at patient’s side in neutral position

chin raised 

CR directed to mid clavicle 

name the position/projection

AP axial clavicle 

guidelines for AP axial clavicle

Arm at patient’s side in
neutral position
Chin raised

CR directed 15º-30º to mid
clavicle*

for asthenic patients, the CR will be angled more towards __ degrees in an AP axial clavicle

30

evaluation criteria for an AP clavicle/axial

Entire clavicle demonstrated along with acromioclavicular (AC) & sternoclavicular (SC) joints

what position/projection is this? how can you tell?

AP clavicle — medial half of clavicle superimposed over scapula and ribs