Download - Shoulder radiography avinesh shrestha
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Anatomy of shoulder can be divided into several different categories, which are:
BonesJointsLigamentsTendonsMusclesNervesBlood VesselsBursa
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Shoulder girdle contains two bones: Clavicle Scapula
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Shoulder girdle contains three synovial joints, which are:Gleno-humeral jointAcromio-clavicular joint Sterno-clavicular joint
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Ligaments of the shoulder forms a joint capsule that connects the humerus to the glenoidcavity.These ligaments are the main source of stability for the shoulder.
Glenohumeral Ligaments (GHL)
Coraco-acromial Ligament (CAL)
Coraco-clavicular Ligaments (CCL)
Transverse Humeral Ligament (THL)
Acromioclavicular Ligament
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Glenoid Labrum
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Although many muscles connect with, support, and enter into the function of the shoulderjoint, radiographers are chiefly concerned with the rotator cuff muscles
ROTATOR CUFF MUSCLES:
Subscapularis Supraspinatous Infraspinatous Ters minor
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Trauma, Fracture Subluxation, Dislocation
Pathological condition associated with joint space and bone(Osteoarthritis, Rheumatoid arthritis,Osteopetrosis,osteoporosis, Osteomyelitis & other degenerative osteoarthropathy)
Check x-ray for post op and post reduction.
Impingement of shoulder jointCongenital anomalies.Bone cyst, Tumor, EffusionCalcified tendon.General skeletal surveyBursitis(inflammation of bursa)
INDICATIONS FOR SHOULDER RADIOGRAPHY:
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COMMON IMAGE CRITERIA FOR SHOULDER JOINT RADIOGRAPHY:
Well visualization of:
Proximal arm, ½ clavicle, scapula, lateral ribs cage, Glenohumeral joint, ACJ.
No rotation or image blur.
Open joint spaces.
Soft tissue & bony trabeculation details.
Part of interest (always be at the center of the IR.)5/15/2017 15
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General consideration for shoulder radiography:
Skeletal parts are projected usually with at least two different directions (usually right angle to each other.)No forceful positioning in case of trauma, contracture or suspected fracture.
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Patient preparation:
Checking of request form, identifications & verification.
Explanation of procedure ,Removal of all radiopaque objects from the
region to be radiographed (Shoulder & Neck).
Immobilization: pillows, sandbags, compression bands, sponges &
radiolucent pads for support & comfort. 5/15/2017 17
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Patient head should be rotated away from side being examined
Proper patient positioning/ Beam collimation/ Exposure factors/ Immobilization ofparts i.e.; Proper technique and instruction to the patient to avoid repeat exposure
High speed screen-film combination if applicableIn case of young uncooperative children Bucky is omitted so that exposure time can
be minimizedIf available, radiation protection shield should be used e.g. Thyroid shield, gonad
shield etc.The central ray can be directed caudally after centering to the coracoid process so
that the primary beam can be collimated to the area under examination.
Radiation protection:
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RECOMMENDED PROJECTIONS:
Basic AP(neutral, internal, external rotation) Axial(supero-inferior, infero-superior)
Glenohumeral joint AP(erect/supine) Lateral oblique ‘Y’ projection
Acromioclavicular joints AP(erect)
Clavicle PA(erect),AP(supine) Axial(infero-superior)
Scapula AP(erect) Lateral(erect/prone)
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Radiographic anatomy of shoulder
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Equipment setting & exposure factor
Decrease 5 -10 kVp in case of destructive pathology (Active osteomyelitis, Aseptic necrosis, Atrophy, Degenerative arthritis, Gout,Osteoporosis,old age)5-10kvp decrease for soft tissue radiography( bursitis, tendonitis ,foreign
body localization e.t.c.)Increase 5 -10 kVp or 25 -50% mAs or both in case of additive pathology
(Acromegaly, Osteoma, Exostosis(benign growths of bone extending outwards from the surface of a bone) etc.) & if the part on POP castGrid; for thick parts & higher kVp use (thickness>4-5 inches; kvp>60)
KVP MAS FFD GRID FOCUS SCREEN FILM SIZES(INCH)
55-80 6-50 100 CM Y/N SMALL FAST 8X10 OR 10X12
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Shoulder joint: AP
IndicationsTrauma, fracture,dislocation,calcificationsInfection, effusion arthritis & degenerative joint diseases &
other joint pathologyPatient positioning
Erect or supine with affected shoulder against the cassetteand rotated about 15 º (close contact)
Arm abducted,Upper border of cassette 5cm above shoulder
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Fig, Shoulder AP in external, neutral and internal rotation
Supinating the hand will
position the humerus In
external rotation.
The palm of the hand placed
against the hip will position the
humerus in neutral rotation,
The posterior aspect of the
hand placed against the hip
will position the humerus in
internal rotation.
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Central rayPerpendicular to a point 1 inch (2.5 cm) inferior to the coracoid process
Evaluation criteriaVisualization of shoulder girldle, glenohumeral jointSlightly overlapping glenoid cavity but separate from the acromion
processBony and soft tissue structures of shoulder and proximal humerus
CONT..
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Shoulder: axial
1. Supero inferior
2. Infero superior:•Supine:
Lawrence method Rafert Modification
• Prone: West Points view
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Shoulder: axial (superoinferior) Indication
To evaluate glenohumeral joint, & calcified tendonsTo demonstrate insertion region of infraspinatus muscle & the subacromial
part of the supraspinatus tendonPatient positioning
Patient sits beside the x-ray tableIR is placed on the table top & the affected arm abducted over thecassettePatient leans towards the table to reduce OFD & to insure that theaxilla (glenoid cavity) included in the image.(A curved cassette can be used to reduce OFD)Elbow flexed, arm abducted to minimum 45º(injury permitting)
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Central ray through the proximal aspect of the
humeral head, beam can be angled 5°-15° toward the elbow with CR directed at the shoulder joint.
(FFD increased if large OFD to reduce magnification)
SHOULDER: AXIAL (SUPEROINFERIOR)
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Evaluation criteriaDemonstration of head of humerus(Lesser
tuberosity in profile) , acromion process, coracoid process and glenoid cavity
Open scapulohumeral joint (not open on patients with limited flexibility)
SHOULDER: AXIAL (SUPEROINFERIOR)
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Axial (inferosuperior)
Patient position(Lawrence method)Patient supine ,arm abducted and supinatedAffected shoulder and arm raised on non-opaque padsCassette supported vertically against the shoulder and
pressed against the neck(to include scapula)Head turned to opposite direction
Central raycenter to axilla (to the region of ACJ ) with the tube medially angled 15º- 30º. The greater the
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Cont…….Patient position(RAFERT Modification )
To visualize Hill-Sachs defect From the Lawrence method, the extended arm externally
rotated until the hand forms a 45º oblique & the thumb pointing downwards.
Central rayTo the axilla with 15º medial angulation so that the CR
passes through ACJ
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Axial (inferosuperior)
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axial (inferosuperior)
Patient position(west point view)Patient prone, Head turned away3”pad placed under the affected shoulder affected arm abducted 90º & rotated to rest the forearm
over the edge of the table. IR placed against superior aspect of shoulder with the edge
of IR in contact with the neckCentral ray
directed at a dual angle of 25º anterior from the horizontal (to table surface) & 25º medially
Central ray enters approximately 5 inches inferior & 1.5 inches medial to the acromial edge & exits through the glenoid cavity5/15/2017 32
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Evaluation criteriaHumeral head projected free of the
coracoid processOpen glenohumeral joint.
CONT…..
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Patient preparation(Clements method)
Done if prone or supine position not possible
Patient in lateral recumbent position lying onunaffected side
Hips & knees flexed
90º abduction of affected arm & pointing towardsthe ceiling
IR against the superior aspect of the shoulder,holding in place with another arm or securing itproperly
AXIAL (INFEROSUPERIOR)
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Cont…..
Central rayTo the midcoronal plane, passing
through the mid axillary region of the shoulder.
Angled 5 to 1 5 degrees medially when the patient cannot abduct the arm a full 90 degrees
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IndicationWhen the arm can’t be rotated or abducted To demonstrate proximal humerus in a 90º
projection from the AP
SHOULDER: TRANSTHORACIC LATERAL
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Shoulder: transthoracic lateralPatient positioningPatient is in erect or supinePatient in lateral position with affected
side towards the IRUnaffected arm raised ,forearm flexed
and placed over the head, shoulderelevated as much as possible(Elevation ofthe non-injured shoulder drops theinjured side separating the shoulders toprevent superimposition.)
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Central raydirected to the midcoronal plane at the level of surgical neck
of the humerusFull inspiration exposure as the lungs full of air improves the
contrast and decreases the expoure necessary to penetrate the body.
Evaluation criteriashows a lateral radiograph of the shoulder & true lateral view
of proximal humerus through the thorax
Scapulae superimposed over the thoracic spines
Unaffected clavicle & humerus projected above the shoulder
SHOULDER: TRANSTHORACIC LATERAL
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Shoulder : outlet projection(AP)Indications
Suspected shoulder impingement syndrome
To visualize anterior portion of acromion process
Patient positioning
Patient stands with affected shoulder against the IR and rotated 15 º to bring scapula parallel to IR
Arm abducted slightly
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Central rayDirected 30º caudally and centered to palpable
coracoid processEvaluation criteria
Demonstration of anterior part of acromion projected inferiorly
Subacromial joint space seen above the humeral head
Shoulder : outlet projection(AP)
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outlet projection(lateral)neer methodPatient positionPt stands or sits facing the cassette with lateral aspect of
affected arm in contactArm extended backward and back of hand rests on the
waistPt is rotated forward and body of scapula is made at right
angle to the cassette
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outlet projection(lateral)neer method
Central rayHead of humerus with 10º caudal angulation
Evaluation criteria Sub-acromial joint space seen
clearly
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Shoulder :PA oblique( scapular Y)
Indication
Suspected dislocation
Proximal humerus #
Scapular body #
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Cont…
Patient positioningErectAnterior aspect of affected shoulder towards
IRUnaffected shoulder raised so midcoronal
plane form angle of 45º-60º to the IR. I.e.; untilScapular flat surface perpendicular to IR
Central rayto the medial border of the scapula
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Cont…
Evaluation criteriaSuperimposed humeral head & glenoid
cavity; humeral shaft & scapular body.Acromion projected laterally & free of
superimposition
Coracoid superimposed with or projected below the clavicle
Scapula in lateral profile
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Glenohumeral joint:AP
Indications
To demonstrate glenoid cavity and glenohumeraljoint space(Coracoid#,glenoid#,proximalhumerus#)
Patient positionStand with affected shoulder against the cassetteRotated 30º to bring plane of glenoid fossa
perpendicular to the cassetteArm supinated and slightly abducted away from
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Central rayDirected toward the palpable coracoid process
GLENOHUMERAL JOINT:AP
Evaluation criteriaClear visualization of joint space between head of
humerus and glenoid cavity
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Glenohumeral joint:RPO or LPO
Patient positioning(Grasheymethod)Supine or erect (erect is comfortable)Body rotated towards the affected side until
the scapula is parallel with the plane of the IRso that the head of humerus in contact withthe IRSlight abduction of arm in internal rotation
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Central ray
Perpendicular to the glenoid cavity
Evaluation criteria
Should demonstrate clearly the joint space between head of humerus and glenoid cavity
CONT…
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Similar to Grashey method but uses weighted abduction to demonstrate a loss of articular cartilage in the glenohumeral joint.
SHOULDER JOINT : Glenoid cavity RPO or LPO (Apple method)
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PATIENT POSITIONINGSimilar to Grashey method except;
Should hold ½ kg weight in hand on the affected side.While holding the weight, the patient should abduct the arm 90º from the midline of the
body.
CONT…
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EVALUATION CRITERIAOpen scapulohemeral joint.Soft tissue & bony trabecular
detail.
CONT…
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INDICATIONSShoulder instability,Glenoid #, Glenoid rim erosion.Hill-Sachs lesions, Bankart lesion.Soft tissue calcifications.
SHOULDER JOINT: GLENOID CAVITY RPO or LPO Axial oblique (Garth method)
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PATIENT POSITIONINGBody Rotated approximately 45º towards the
affected side.Affected arm adducted & elbow flexed to place
the forearm across the abdomen
CENTERING OF X-RAY BEAMAngled 45º caudad, through the
scapulohumeral joint
SHOULDER JOINT: GLENOID CAVITY RPO or LPO Axial oblique (Garth method)
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EVALUATION CRITERIAThe scapulohumeral joint, humeral head,
and scapular head and neck free ofsuperimposition
The coracoid process should be wellvisualized
Apical oblique: Garth view
SHOULDER JOINT: GLENOID CAVITY RPO or LPO Axial oblique (Garth method)
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Recurrent dislocation
Is associated with defects on head of humerus
In case of recurrent anterior dislocation, defect will occur on posterolateral aspect of head of humerus(hill sach’s lesion)
In case of recurrent posterior dislocation, defect will be on anterior part of head
Dislocated head of humerus also impacts on glenoid rim
In case of recurrent dislocations, 3 Ap projections (with humerus lateral, oblique & Stryker’s) & Inferosuperior views are done.
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lateral &oblique humerus
Patient position
Patient lies erect or supine
Unaffected shoulder raised 30degree to bring glenoidcavity right angle to centre of IR
lateral humerus
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oblique humerusThe elbow is extended, allowing the arm to rest in
partial abduction by the patient’s side.
The humerus is now in an oblique position
LATERAL &OBLIQUE HUMERUS)
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Central rayDirected to head of the humerus
Evaluation criteriaShould demonstrate head and neck of humerus and glenoid cavity with
glenohumeral joint clearly shown
LATERAL &OBLIQUE HUMERUS)
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AP(modified)-Stryker notch view
Patient positioningPatient lies supineArm of affected side is extended fully and the elbow is flexed to allow the
hand to rest on patient’s head
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Cont..Central rayAngled 10º cranially and directed through the
centre of the axilla
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INDICATIONSTo evaluate the tendon of the long head of biceps.
PATIENT POSITIONINGSupine, seated or standing.Forearm extended & hand supinated 45º.Chin extended & head rotated away from the
affected side.IR supported vertically above the shoulder.
SHOULDER JOINT: BICIPITAL GROOVE TANGENTIAL
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CENTERING OF X-RAY BEAMAngled 10º-15º downward from the
horizontal & to the long axis of the humerusfor the supine position. ( 10º-15º cephaladfor erect).
Fisk modification: Perpendicular to the IR when the patient is
leaning 10º-15º forward from the vertical humerus position.
SHOULDER JOINT: BICIPITAL GROOVE TANGENTIAL
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EVALUATION CRITERIAIntertubercular groove free from superimposition with surrounding shoulder structures.
SHOULDER JOINT: BICIPITAL GROOVE TANGENTIAL
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Acromioclavicular joints:AP
IndicationTo visualize dislocation, Separation, SubluxationTo compare functional difference of ACJsAC arthritis & Osteopathy
Patient positioningPatient stands facing the x-ray tube, arms relaxed to the sideCenter the midline of the body to the midline of the grid.
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Cont…
weight bearing comparison projection of both ac joint can be done for subluxation(Pearson method) i;e Equal weight is strapped around lower arm (wrist) of the patient
Central rayIf bilateralprojection then :Perpendicular to the midline of the body at the level
of the acromioclavicular jointsIf only one side then:To the palpable lateral end of clavicle at acromioclavicular
joint(to avoid superimposition 25 º cranial angulation can be given)
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Evaluation criteriaDemonstration of acromioclavicular joint Soft tissue around the articulation must be visible
CONT…
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Clavicle :PAPreferable since clavicle lies close to cassette-
optimum bony detail, reduces the radiation dose tothyroid and eyes
Patient positioningPatient stands facing the IR with clavicle in centre
of IRPatient’s head is turned away from side being
examinedCentral ray
Perpendicular to the midshaft of clavicle
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AP(alternate)Patient positioning
Adjust the body to center the clavicle to the midline of the table or vertical grid device.
Place the arms along the sides of the body, and adjust the shoulders to lie in the same horizontal plane.
Center the clavicle to the IRCentral ray
Perpendicular to the midshaft of clavicle
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Cont….
Evaluation criteriaEntire length of clavicle should be
included along with the acromioclavicularand sternoclavicular jointsLateral end of clavicle demonstrated clear
of thoracic cage
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Clavicle :Ap axial(Lordotic position)
Patient positioningPatient is made to sit or stand in front of the vertical IR facing the x-ray
tube(supine-alternate)Patient leans backward in a position of extreme lordosis and rest the neck and
shoulder against the vertical grid deviceNeck in extreme flexion
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Cont…
Central rayOver the mid shaft of the clavicle
with angulations(0-15)degree for standing &(15-30) degrees for supine
Evaluation criteriaClavicle projected above the ribs and
scapula with medial end overlapping the 1st and 2nd ribEntire clavicle with AC and SC joint
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Scapula :AP
Patient positioningAbduct the arm to a right angle with the body to draw the scapula
laterally. flex the elbow, and support the hand in a comfortable position.For this projection, do not rotate the body toward the affected side
because the resultant obliquity would offset the effect of drawing the scapula laterally
Central rayPerpendicular to the mid scapular area at a point approximately 2
inches (5 cm) inferior to the coracoid process
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Cont..
Evaluation criteria
Lateral portion of the scapula free of superimposition from the ribsScapula horizontal and not obliqueScapular detail through the superimposed lung
and ribs (Shallow breathing should help obliterate lung detail)
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Scapula :lateral
Patient positioningPatient stands with affected side against the IRArm is either adducted across the body or abducted
with the elbow flexed and back of hand rest on the hipPatients trunk is rotated forward until the body of
scapula is at right angles to the cassetteCentral ray
To the midpoint of medial border of scapula
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Scapula :lateral
Evaluation criteriaLateral and medial border superimposedNo superimposition of the scapular body on
the ribs No superimposition of the humerus on the
area of interest
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Questions?
1. Bone involved in the shoulder joint formation?2. What kind of joint in shoulder and it’s type?3. Basic projection of shoulder joint?4. Basic projection of clavicle ?5. What is Hill-sach defects ,what is projection done for
it?6. Mention position of patients in superior interior axial
projections?7. What is bursa and what is projection for bursitis?
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