(4-M) 301 - A Shoulder to Clavicle.pptx

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1. (#3) 301- A positioning Shoulder to Clavicle

2. Shoulder Girdle

3. Anatomy of Proximal Humerus on Radiograph Fig. 5-3 is an anteroposterior (AP) radiograph of the shoulder taken with external rotation, which places the humerus in a true AP or frontal position. Fig. 5-2 represents a neutral rotation (natural position of the arm without internal or external rotation). This places the humerus in an oblique position midway between an AP (external rotation) and a lateral (internal rotation). Some anatomic parts are more difficult to visualize on radiographs than on drawings. However, a good understanding of the location and relationship between various parts helps in this identification. The following parts are shown in Fig . 5-3 : A. Head of humerus B. Greater tubercle C. Intertubercular groove D. Lesser tubercle E. Anatomic neck F. Surgical neck G. Body

4. SHOULDER GIRDLE The shoulder girdle consists of two bones: the clavicle and the scapula . The function of the clavicle and scapula is to connect each upper limb to the trunk or axial skeleton. Anteriorly, the shoulder girdle connects to the trunk at the upper sternum; however, posteriorly, the connection to the trunk is incomplete because the scapula is connected to the trunk by muscles only. Each shoulder girdle and each upper limb connect at the shoulder joint between the scapula and the humerus . Each clavicle is located over the upper anterior rib cage. Each scapula is situated over the upper posterior rib cage

5. AP PROJECTION - NEUTRAL ROTATION: SHOULDER ( NONTRAUMA ) CI • Fractures or dislocations of proximal humerus and shoulder girdle • Calcium deposits in muscles, tendons, or bursal structures • Degenerative conditions including osteoporosis and osteoarthritis SID - 40 inches (102 cm) • IR size - 24 × 30 cm (10 × 12 inches) Part/ Px pos.,• Rest palm of hand against thigh / hip • Medial and lateral epicondyles at a 45 degrees angle to plane of cassette. • IR 2 in. above top of shoulder. • CR - perpendicular to the coracoid process 1 inch (2.5 cm) inferior to the coracoid process AD - • Greater tubercle partially superimposed the humeral head • Humeral head in partial profile. • Best demonstrate the posterior part of the supraspinatus insertion. • Oblique view of the proximal humerus .

6. AP PROJECTION - INTERNAL ROTATION: SHOULDER ( NONTRAUMA ) CI • Fractures or dislocations of proximal humerus and shoulder girdle • Calcium deposits in muscles, tendons, or bursal structures. • Degenerative conditions including osteoporosis and osteoarthritis • Medially ( internally ) rotate palm of hand (thumb side down) • Back of the hand against thigh/hip. • Medial and lateral epicondyles are perpendicular to the plane of the cassette • CR perpendicular to the coracoid process 1 inch (2.5 cm) inferior to the coracoid process • Best demonstrate the lesser tubercle in profile medially. • Profile image of the site of the supraspinatus tendon. • Lateral view of the humerus .

7. SHOULDER AP PROJECTION EXTERNAL ROTATION CI • Fractures or dislocations of proximal humerus and shoulder girdle • Calcium deposits in muscles, tendons, or bursal structures. • Degenerative conditions including osteoporosis and osteoarthritis • Laterally ( Externally ) rotate palm of the hand (extreme supination) • Medial and lateral epicondyles are parallel to the plane of cassette. Anatomy Demonstrated : • AP projection of proximal humerus and lateral two-thirds of clavicle and upper scapula, including relationship of the humeral head to the glenoid cavity • Best demonstrate the greater tubercle in profile on the lateral aspect of the humerus • The true AP projection of the humerus in the anatomic position. • Profile image of site of insertion of the supraspinatus tendon .

8. SHOULDER JOINT INFEROSUPERIOR AXIAL PROJECTION LAWRENCE METHOD CI • Degenerative conditions including osteoporosis and osteoarthritis • Hill-Sachs defect with exaggerated rotation of affected limb PX Part / Px Pos ,• Patient in supine position • Abduct arm of the affected side 90° • Humerus in external rotation with the palm up. CENTRAL RAY: • 1. Horizontally through the axilla to the acromioclavicular joint. • 2. 15°-30° if abduction of arm is less than 90° • Best demonstrate the lesser tubercle in profile directed anteriorly • Demonstrate an inferosuperior axial image of the proximal humerus .

9. PA TRANSAXILLARY PROJECTION: SHOULDER ( NONTRAUMA ) CI • Fractures or dislocations of the proximal humerus • Bursitis, shoulder impingement, osteoporosis, osteoarthritis, and tendonitis HOBBS MODIFICATION Part Position • The arm is raised superiorly as much as the patient can tolerate. CR is directed perpendicular to the axilla and the humeral head to pass through the glenohumeral joint. Anatomy Demonstrated : • Lateral view of proximal humerus in relationship to glenohumeral articulation is visualized. • Coracoid process of scapula is seen on end

10. INFEROSUPERIOR AXIAL PROJECTION: SHOULDER ( NONTRAUMA ) CLEMENTS MODIFICATION CI • Degenerative conditions including osteoporosis and osteoarthritis • Hill-Sachs defect with exaggerated rotation of affected limb Part / Px Pos ,• Patient in lateral recumbent position lying on the unaffected side. • Abduct the affected arm 90° and point it toward the ceiling. • 1. CR horizontal to the midcoronal plane passing through the midaxillary region of the shoulder. • 2 . 5°-15 ° medially when the patient cannot abduct the arm for a full 90°. Anatomy Demonstrated : • Lateral view of proximal humerus in relationship to scapulohumeral cavity is shown. • When the prone or supine is not possible for an inferosuperior projection of the shoulder joint. • Lesser tubercle in profile

11. GLENOID CAVITY AP OBLIQUE PROJECTION GRASHEY METHOD CI • Fractures or dislocations of proximal humerus • Fractures of glenoid labrum or brim • Bankart lesion, erosion of glenoid rim, the integrity of the scapulohumeral joint, and other degenerative conditions Part / Px Pos ,• Rotate the body 35°-45° toward the affected side. • CR perpendicular to the glenoid cavity at a point 2 inches (5cm) inferior to the superolateral border of the shoulder. • Abduct arm slightly with arm in neutral position Anatomy Demonstrated : • Glenoid cavity should be seen in profile without superimposition of humeral head. • Glenoid cavity in profile without superimposition of the humeral head.

12. INTERTUBURCULAR GROOVE TANGENTIAL PROJECTION FISK MODIFICATION • Pathologies of intertubercular groove including bony spurs of the humeral tubercles TANGENTIAL • Patient in supine, seated or upright position • Hand in supination • CR 10-15 ° posterior to the long axis of the humerus . • Demonstrate : Intertbercular groove ( Bicipital ).

13. SUPRASPINATUS “OUTLET’ TANGENTIAL PROJECTION NEER METHOD CI • Fractures or dislocations of proximal humerus and scapula • Specifically demonstrates coracoacromial arch for supraspinatus outlet region for possible shoulder impingement*† Part / Px pos • Rotate unaffected side away from the IR 45°-60° from the plane of the film. Palpate superior angle of scapula and AC joint articulation. Rotate patient until an imaginary line between those two points is perpendicular to IR. Because of differences among patients, the amount of body obliquity may range from 45° to 60°. Center scapulohumeral joint to CR and to center of IR. • Abduct arm slightly so as not to superimpose proximal humerus over ribs; do not attempt to rotate arm • CR 10 °- 15 ° caudad entering the superior aspect of the humeral head. • Demonstrate tangentially the coracoacromial arch or outlet for the supraspinatus outlet to diagnose shoulder impingement.

14. GLENOID CAVITY AP AXIAL OBLIQUE PROJECTION GARTH METHOD CI • Optimal trauma projection for possible scapulohumeral dislocations (especially posterior dislocations) • Glenoid fractures, Hill-Sachs lesions, and soft tissue calcifications*† Part / Px pos , Center scapulohumeral joint to CR and mid-IR. • Adjust IR so that 45° CR projects scapulohumeral joint to the center of IR. • Flex elbow and place arm across chest, or with trauma, place arm at side as is. CR 45 ° caudad , centered to scapulohumeral joint Anatomy Demonstrated : • Humeral head, glenoid cavity, and neck and head of the scapula are well demonstrated free of superimposition. Demonstrate any posterior scapulohumeral dislocations. Recommended projection for acute shoulder trauma.

15. SHOULDER JOINT SCAPULAR Y PA OBLIQUE PROJECTION CI • Fractures or dislocations of proximal humerus and scapula • Humeral head is demonstrated inferior to coracoid process with anterior dislocations; for less common posterior dislocations, humeral head is demonstrated inferior to acromion process • Excellent projection to demonstrate profile of coracoid process and scapular spine Part / Px Pos. Rotate patient’s body so that the midcoronal plane forms an angle of 45°-60° to the IR. CR perpendicular to IR, directed to scapulohumeral joint (2 or 21 2 inches [5 or 6 cm] below top of shoulder) Anatomy Demonstrated : • True lateral view of the scapula , proximal humerus , and scapulohumeral joint. Alternate view of the shoulder used primarily with trauma patients to demonstrate possible shoulder dislocations. • Demonstrate an oblique image of the shoulder . • True lateral view of the scapula, proximal humerus .

16. SHOULDER JOINT AP AXIAL PROJECTION 35 ° cephalad to the scapulohumeral joint • Demonstrate the relationship of the humeral head to the glenoid cavity . • Useful in diagnosing cases of posterior dislocation.

17. SHOULDER AP AXIAL PROJECTION STRYKER NOTCH METHOD Flex the arm slightly beyond 90° • 10 ° cephalad entering the coracoid process. • Demonstrate the posterosuperior and posterolateral areas of the humeral head.

18. GLENOID CAVITY AP OBLIQUE PROJECTION APPLE METHOD Rotate the body 35 °- 45 ° toward the affected side. CR perpendicular to level of the coracoid process. Abduct the arm 90 ° from the midline of the body holding a 1 pound weight on the affected side. Glenoid cavityin profile. Demonstrate loss of articular cartilage in the scapulohumeral joint but uses a weighted abduction. Similar to the Grashey method except for the use of the 1 pound weight.

19. SHOULDER JOINT INFEROSUPERIOR AXIAL PROJECTION WEST POINT METHOD • Abduct arm of the affected side 90 ° • Patient in prone position with approximately 3 inch pad under the shoulder being examined. • 25 ° anteriorly from the horizontal and 25° medially and enters 5 inches (13 cm.) and 1 ½ medial to the acromial edge and exits the glenoid cavity. • Humeral head projected free of coracoid process.

20. SHOULDER JOINT INFEROSUPERIOR AXIAL PROJECTION RAFERT MODIFICATION • Abduct arm of the affected side 90° • Humerus in exaggerated external rotation. • Hand form an angle of 45° oblique. • Thumb pointing downward. • Horizontal and angled 15° medially entering the axilla and passing through the acromioclavicular joint. • Demonstrate an inferosuperior axial image of the proximal humerus . • Best demonstrate the lesser tubercle in profile directed anteriorly • Demonstrate Hill-Sachs defect - Compression fracture of the articular surface of the humeral head with anterior dislocation of the humeral head.

21. CLAVICLE

22. CLAVICLE AP PROJECTION Patient in supine or upright position. • Perpendicular to the midshaft of the clavicle • Demonstrates a frontal image of the clavicle. • AP projection is performed when the patient cannot assume the prone position.

23. CLAVICLE AP AXIAL PROJECTION LORDOTIC POSITION • Erect position. • Patient lean backward in extreme lordotic position. • CR °- 15 ° cephalad to midshaft of the clavicle. This is an AP projection of the clavicle with 15 degrees of cephalic tube angulation. The tube angulation can typically range from 15 degrees . The greater the tube angulation applied, the greater the superior projection of the clavicle.

24. CLAVICLE AP AXIAL PROJECTION • Patient in supine position • CR 15 °- 30 ° cephalad to midshaft of the clavicle • For thinner patients (asthenic) - 10°-15° cephalad to midclavicle . This is an AP projection of the clavicle with 15 degrees of cephalic tube angulation. The tube angulation can typically range from 15 to 30 degrees. The greater the tube angulation applied, the greater the superior projection of the clavicle. Inclusion of the SC joint is reasonable in trauma situations. Note that the AC joint is more clearly demonstrated using this projection compared to the straight tube (non-angled) AP projection of the clavicle.

25. AP AND AP AXIAL PROJECTIONS: CLAVICLE CI - Fractures or dislocations of clavicle • Departmental routines commonly include both AP and AP axial projections SID - 40 inches (102 cm) • IR size—24 × 30 cm (10 × 12 inches) AP 0°• CR perpendicular to midclavicle Demonstrates a frontal image of the clavicle AP Axial • CR 15 ° to 30 ° cephalad to midclavicle AP ° Anatomy Demonstrated : • Entire clavicle visualized, including both AC and sternoclavicular joints and acromion AP Axial Anatomy Demonstrated : • Entire clavicle visualized, including both AC and sternoclavicular joints and acromion. AC AC SC SC

26. AP PROJECTION: AC JOINTS BILATERAL WITH AND WITHOUT WEIGHTS CI - Possible AC joint separation • Widening of one joint space compared with the other view with weights usually indicates AC joint separation Part pos., Position patient to direct CR to midway between AC joints. • Center midline of IR to CR (top of IR should be approximately 2 inches [5 cm] above shoulders). CR - perpendicular to midpoint between AC joints, 1 inch (2.5 cm) above jugular notch Suspend respiration during exposure Weights After the first exposure is made without weights and the cassette has been changed, for large adult patients, strap 8- to 10-lb minimum weights to each wrist, and, with shoulders relaxed, gently allow weights to hang from wrists while pulling down on each arm and shoulder Anatomy Demonstrated : • Both AC joints, entire clavicles, and SC joints are demonstrated. AC SC

27. AP PROJECTION: AC JOINTS BILATERAL WITH AND WITHOUT WEIGHTS Alternative AP axial projection ( Alexander method) Alternative AP axial projection ( Alexander method) CR 15 ° caudad angle centered at the level of the AC joints projects the AC joint superior to the acromion, providing optimal visualization. Alternative supine position If the patient’s condition requires, the radiograph may be taken supine by tying both ends of a long strip of gauze to the patient’s wrists and placing the strip around the patient’s feet with knees partially flexed and slowly and gently straightening legs and pulling down on shoulders. Also, an assistant, with proper protective shielding, can gently pull down on arms and shoulders. Warning : This method should be used only by experienced and qualified personnel to prevent additional injury.

28. CLAVICLE PA PROJECTION • Patient in prone or upright position. • Useful when improved detail is desired. • Clavicle is closer to the IR as compared with AP projection. • Prone position – for patient who can stand, for improved detail (reduced OID ). CR . Directly perpendicular to the mid-shaft. • Must see the sternoclavicular joints and entire clavicle.

29. CLAVICLE PA AXIAL PROJECTION • Patient in prone or standing position facing the vertical grid device. • Structures shown same as AP AXIAL PROJECTION. • SID : 40” Bucky. • Tube angle: 15 °- 30 ° caudad . This is an AP projection of the clavicle with 15 degrees of cephalic tube angulation. The tube angulation can typically range from 15 to 30 degrees. The greater the tube angulation applied, the greater the superior projection of the clavicle. Inclusion of the SC joint is reasonable in trauma situations. Note that the AC joint is more clearly demonstrated using this projection compared to the straight tube (non-angled) AP projection of the clavicle .

30. CLAVICLE TANGENTIAL PROJECTION • Patient in supine position • The tangential projection is similar to the AP axial projection. • CR 25-40 ° cephalad to pass between the clavicle and chest wall • CR for medial 3rd - 15 °- 25 ° cephalad . The greater the tube angulation applied, the greater the superior projection of the clavicle. Note that the AC joint is more clearly demonstrated using this projection compared to the straight tube (non-angled) AP projection of the clavicle.

31. TARRANT METHOD • Patient in seating position • Demonstrate the clavicle above the thoracic cage • 25 °- 35 ° Directed anterior and inferior to the midclavicle . • Requires increased SID because of increased OID

32. ZANCA VIEW CR – 10 ˚ cephalic - is a specialized projection of the acromioclavicular joint, it is used to both demonstrate the AC joint free from superimposition, and aid in the assessment of distal osteophytes . Osteophytes are bony lumps (bone spurs) that grow on the bones of the spine or around the joints. They often form next to joints affected by osteoarthritis, a condition that causes joints to become painful and stiff. Osteophytes can grow from any bone, but they're most often found in the: neck. shoulder.

33. SERENDIPITY VIEW - which is an AP view obtained by angling the x-ray tube 40 degrees cephalad with the patient in the supine position. Px Pos ,. Erect or in Supine position Serendipity View ( Rockwood view). - The name given to the 40 deg cephalic tilt view of the SC joints; - used to visualize the sternoclavicular joints and medial 1/3 of the clavicles for fractures or dislocation - SC joints are visualized on the same film and compared side to side.

34. TERES MINOR INSERTION PA PROJECTION BLACKETT-HEALY METHOD • Patient in prone position • Place IR under shoulder and center 1 inch below the coracoid process • Arm in extreme internal rotation. • Demonstrate tangential image of the insertion of the teres minor. • Lesser tubercle in profile. • CR : Directly pependicular .

35. AP AXIAL PROJECTION INFRASPINATUS INSERTION The  infraspinatus  originates from the infraspinous fossa of the scapula (shoulder blade). ... From this location, the  infraspinatus  muscle travels upward diagonally and inserts onto the greater tubercle of the humerus (long bone of the upper arm). • Patient in supine position • Arm in external rotation • Arm in neutral position • Arm in internal rotation • CR 25° caudad to the coracoid process • Demonstrate the greater tubercle in profile. • Demonstrate the insertion of the infraspinatus tendon. • Demonstrate an open subacromial space

36. SUBSCAPULARIS INSERTION AP PROJECTION BLACKETT-HEALY METHOD • Patient in supine position • Affected arm alongside of the body and rotate internally • Flex the elbow and pronate hand. • Demonstrate an image of the insertion of the subscapularis at the lesser tubercle.