Shoulder

• Shoulder girdle


  • Formed by two bones: clavicle and scapula
  • Function: to attach the upper limb to the axial skeleton

  
• Anatomy of the shoulder

  • Upper margin of the scapula at level of 2nd posterior rib
  • Lower margin of the scapula at level of 7th posterior rib

  
• Bones of the shoulder girdle

  • Clavicle
  • Scapula

  
• Projections


  • AP External Rotation
  • AP Neutral Position
  • AP Internal Rotation
  • Inferosuperior Axial
  • Posterior Oblique Position- Glenoid Cavity
  • Transtoracic Lateral
  • Tangential
  • AP Apical Oblique Axial
• Technical considerations


  • Erect or supine patient position
  • Radiation protection
  • Use grid to improve contrast
  • Check position of humerus using epicondyles
  • Produce radiographs with good bone details
  • Ensure area of interest is free of radiopaque items
  • Do not force patient to rotate arm in cases of suspected fracture or dislocation

  
• Clinical indications


  • Trauma
  • Fracture
  • Dislocation or subluxation
  • Osteoarthritis
  • Hatched-shaped defect
  • Calcified tendons

  
• AP Shoulder projections


  • Internal rotation
  • External rotation

  
• Inferosuperior Axial (Lawrence Method) projection


  • Pathology demonstrated
  • Technical factors
  • Positioning
  • Central ray
  • Radiographic criteria
• Posterior Oblique Position - Glenoid Cavity (Grashey Method) projection


  • Pathology demonstrated

  
• Lateral view of proximal humerus in relationship to the scapulohumeral cavity


  • Coracoid process of scapula and lesser tubercle of humerus will be seen in profile
  • The spine of scapula will be seen on edge below scapulohumeral joint

  
• Position


  • Arm is seen to be abducted about 90° from the body
  • Superior and inferior borders of glenoid cavity should be directly superimposed, indicating correct CR angle

  
• Collimation and CR


  • Collimation must be visible on four sides to the area of affected shoulder
  • CR and center of the collimation field should be at the axilla and humeral head

  
• Exposure Criteria


  • Optimum density and contrast with no motion demonstrate clear, sharp bony trabecular markings
  • The bony margins of the acromion and distal clavicle will be visible through the humeral head

  
• Grashey Method


  • Fractures or dislocations of proximal humerus
  • Fractures of glenoid labrum or brim
  • Bankart fracture and the integrity of scapulohumeral joint
  • Osteoporosis
  • Osteoarthritis

  
• Technical Factors (Grashey Method)

  • IR sizes – 24 x 30 cm
  • Moving or stationary grid
  • 70 + 5 kV
  • 6 mAs
  • SID 100 cm
  • Gonad shielding
• Patient Position (Grashey Method)

  • Patient erect or supine
  • Erect : less painful
• Part Position (Grashey Method)

  • Rotate body 35° to 45° toward affected side
  • If patient supine – place supports under elevated shoulder and hip to maintain this position
  • Center mid scapulohumeral joint to CR and center of IR
  • Adjust cassette so that top of IR is 5 cm above shoulder and side of IR is 5 cm from lateral border of humerus
  • Abduct arm slightly with arm in neutral position
• Central Ray (Grashey Method)

  • CR perpendicular to IR
  • Center to scapulohumeral joint (5 cm inferior and medial to superolateral border of shoulder)
  • Suspend breathing
• Grashey Method


  • Glenoid cavity in profile without superimposition of humeral head
  • Scapulohumeral joint space should be open
  • Anterior and posterior rims of glenoid cavity are superimposed
• Collimation and CR (Grashey Method)

  • Collimation must be visible on four sides to the area of affected shoulder
  • CR and center of the collimation field should be at scapulohumeral joint
• Exposure Criteria (Grashey Method)

  • Optimum density and contrast with no motion demonstrate clear, sharp bony trabecular markings
  • Soft tissue detail of the joint space and axilla should be visualized

  
• Transthoracic Lateral


  • Fractures or dislocations of proximal humerus

  
• Technical Factors (Transthoracic Lateral)

  • IR sizes – 24 x 30 cm
  • Moving or stationary grid
  • 70 + 5 kV
  • 60 mAs
  • SID 100 cm
  • Gonad shielding
• Patient Position (Transthoracic Lateral)


  • Patient erect or supine
  • Erect : more comfortable
  • Place patient in lateral position with side of interest against IR
• Part Position (Transthoracic Lateral)


  • Place affected arm at patient's side in neutral position, drop shoulder if possible
  • Raise opposite arm and place hand over top of head; elevate shoulder as much as possible to prevent superimposition
  • Center surgical neck and center of IR to CR as projected through thorax
  • Ensure thorax in true lateral position or with slight anterior rotation of unaffected side to minimize superimposition

  
• Central Ray (Transthoracic Lateral)


  • CR perpendicular to IR
  • Direct to surgical neck
  • Breathing technique is preferred – Short, shallow breath
• Transthoracic Lateral


  • Lateral view of proximal half of humerus and glenohumeral joint should be visualized through the thorax without superimposition of the opposite shoulder
  • The outline of shaft of proximal humerus should be clearly visualized anterior to the thoracic vertebrae
  • The relationship of the humeral head and glenoid cavity should be demonstrated

  
• Collimation and CR (Transthoracic Lateral)

  • Collimation must be visible on four sides to the area of affected shoulder
  • CR and center of the collimation field should be at the surgical neck of affected humerus

  
• Exposure Criteria (Transthoracic Lateral)


  • Optimum density and contrast will demonstrate entire outline of the humeral head and proximal half of humerus
  • Overlying ribs and lung markings should appear blurred because of breathing technique
  • Outlines of humerus should appear sharp, indicating no motion

  
• Tangential - Neer Method


  • Fractures or dislocations of proximal humerus and scapula
  • Specifically demonstrates the coracoacromial arch for the supraspinatus outlet region for possible shoulder impingement

  
• Technical Factors (Tangential - Neer Method)

  • IR sizes – 24 x 30 cm
  • Moving or stationary grid
  • 70 + 5 kV
  • 13 mAs
  • SID 100 cm
  • Gonad shielding
• Patient Position (Tangential - Neer Method)


  • Patient erect or recumbent
  • Erect : more comfortable
• Part Position (Tangential - Neer Method)


  • With patient facing IR, rotate into anterior oblique position as for a lateral scapula
  • Average patient will be in 45° to 60° anterior oblique position
  • Palpate scapula border to determine the correct rotation
  • Center scapulohumeral joint to CR and center of IR
  • Abduct arm slightly

  
• Central Ray (Tangential - Neer Method)

  • CR angle 10° to 15° caudally, centered posteriorly to pass through the superior margin of humeral head
  • Suspend breathing
• Tangential - Neer Method


  • Proximal humerus will be superimposed over thin body of scapula, which should be seen on end without rib superimposition
  • Position should be seen on end without rib superimposition
  • Acromion and coracoid processes should appear as nearly symmetric upper limbs of the Y
  • Humeral head should appear superimpose and centered to the glenoid fossa just below the supraspinatus region
  • Supraspinatus region will appear open, free superimposition by humeral head

  
• Collimation and CR (Tangential - Neer Method)


  • Collimation must be visible on four sides to the area of affected shoulder
  • CR and center of the collimation field should be at supraspinatus outlet region
• Exposure Criteria (Tangential - Neer Method)


  • Optimum density and contrast will demonstrate Y appearance of the upper lateral scapula superimposed over humeral head
  • Bony margins will appear sharp and clear indicating no motion

  
• Garth Method


  • Scapulohumeral dislocations
  • Glenoid fractures
  • Hill-Sachs lesions
  • Soft tissue calcifications
• Technical Factors (Garth Method)

  • IR sizes – 18 x 24 cm
  • Moving or stationary grid
  • 70 + 5 kV
  • 12 mAs
  • SID 100 cm
  • Gonad shielding
• Patient Position (Garth Method)

  • Patient erect or supine
  • Erect : less painful
  • Rotate body 45° toward affected side