Radiographic positioning of humerus and shoulder

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1. Radiographic Positioning Of Humerus and Shoulder

2. Anatomy Of Humerus HUMERUS - Head - Anatomic neck - Surgical neck - Greater tubercle - Lesser tubercle - Intertubercular groove - Deltoid tuberosity - Shaft

3. BASIC VIEWS IN HUMERUS Axial- Bicipital Groove Humerus –Supracondylar Fracture. Lateral Antero posterior Lateral oblique Antero-posterior Lateral Special views

4. ANTERO POSTErIOR INDICATIONS Trauma Dislocation Fractures Soft tissue calcifications Arthitis survey Bone pain

5. Antero-posterior The patient sits or stands with their back in contact with the cassette. If the patient’s condition doesn’t allow,it can be performed in supine position. Adjust the height of the cassette to place its upper border 1.5 inches above the head of humerus.

6. Abduct the arm slightly,and supinate the hand so that epicondyles of the elbow are equidistant from IR. The coronal plane passing through the epicondyles should be parellel to the IR.

7. Center Ray -Perpendicular to the mid shaft of humerus and center to the cassette. Evaluvation -Long axis of humerus should be alinged to the long axis of IR. -The greater tubercle is seen in profile. -The humeral head is partially seen in profile medially,with minimal superimposition of glenoid cavity. -The distal radius should show both lateral and medial epicondyle visualised in profile .

8. LATERAL INDICATIONS Same as AP projection . POSITIONING OF PATIENT The Patient stands against the erect bucky or lies supine on the table. Place the top margin of the cassette 1.5 inches above the head of humerus. The arm is internally rotated ,and the elbow is flexed to 90 degrees and place the hand on the hip.

9. Center Ray To the Mid shaft of humerus. Evaluvation Epicondyles are superimposed. Lesser tubercle is profile in medially,partially superimposed by lower portion of glenoid cavity. Marker should be placed. Collimate the field of area .

10. Supracondylar fracture A type of injury commonly seen in children is a fracture of a lower end of humerus just proximal to the condyles. The injury is very painful and even small movements of the limb can exacerbate the injury. Further causing damage to the adjacent nerves and blood vessels.

11. Supracondylar fracture lateral The cassette is supported vertically in a cassette holder. The patient stands sideways,with the elbow flexed and the lateral aspect of the injured elbow in contact with the cassette. The arm is gently extended backwards from the shoulder. The patient is rotated forwards until the elbow is clear of the rib cage but still in contact with the cassette.

12. Direction and Centering of the beam The horizontal center ray is directed to the medial epicondyle and the beam collimated to the elbow. Image Characteristics The image should include the lower end of the humerus and the upper third of the radius and ulna.

13. Supracondylar fracture-lateral

14. Antero posterior The cassette is supported in a vertical cassette holder. From the lateral position,the patient’s upper body is rotated towards the affected side. The patient’s position is adjusted so that the posterior aspect of the upper arm is in contact with the cassette.

15. Supracondylar fracture-anterio posterior

16. AXIAL-BICIPITAL GROOVE The Bicipital groove is situated between the greater and the lesser tuberosities of the humerus. It transmits the tendon of the long head of the biceps. POSITION OF PATIENT The patient sits with their shoulder joint against a vertical cassette holder. Ideally this holder should be angled 15 degrees forward. But if this facility is not available the cassette can be supported above the shoulder.

17. Centering of the beam The central ray is directed cranially along the long axis of humerus . Centered to the anterior part of the head of humerus . The arm is abducted anteriorly and supported to bring the long axis of humerus perpendicular to the cassette. The hand is rotated 45 degrees laterally from prone to bring the bicipital groove in profile

18. Axial-bicipital groove

19. Humerus neck lateral oblique The patient stands or sits with the lateral aspect of the injured arm against the cassette . The patient is rotated forwards until the line joining the medial and lateral borders of scapula is at right angles to the cassette. The cassette is positioned to include the head of the humerus and the whole scapula.

20. Centering of the beam The horizontal x ray beam is directed to the medial border of scapula and directed to the head of humerus . Evaluvation The scapula and the upper end of the humerus should be demonstrated clear of the throxic cage .

21. Humerus lateral oblique

22. Anatomy of Shoulder joint 3 Bones Humerus Scapula Clavicle 3 Joints Glenohumeral Acromioclavicular Sternoclavicular

23. BASIC VIEWS IN SHOULDER Antero posterior Axial -superio inferior -inferio superior SPECIAL VIEWS Outlet projection Y projection Styker’s projection

24. Indications for shoulder x ray Scapulohumeral dislocations Fracture Osteoporosis Osteoarthitis Hill sach’s defect Burtitis Bony tumours

25. Anterio posterior The patient stands with the affected shoulder against the cassette. The patient is rotated 15-30 degrees to bring shoulder closer to the cassette. The arm is supinated and slightly abducted away from the body. The medial and lateral epicondyles of distal humerus should be parallel to the IR. The cassette is positioned 5 cm above the shoulder.

26. Center the horizontal ray to the palpable coracoid process of scapula. Evaluvation criteria The image should demonstrate the head and proximal end of humerus,the inferior angle of scapula and whole of the clavicle. The head of humerus should be seen slightly overlapping the glenoid cavity but separate from the acromion process. Arrested respirstion aids good rib detail in acute trauma.

27. Shoulder anterio posterior

28. Axial superio inferior The patient is seated at the side of the table,which is lowered at waist level. The cassette is placed on the tabletop,and the arm under examination is abducted over the cassette. The patient leans towards the table to reduce the object-to-film distance. The elbow can remain flexed,but the arm should be abducted to a minimum 45 degrees.

29. DIRECTION AND CENTERING OF THE BEAM The vertical center ray is directed through the proximal aspect of head of humerus. If there is a large OFD,it may be necessary to increase the overall FFD to reduce magnification. EVALUVATION CRITERIA Lateral view of proximal humerus in relationship to the glenohumeral articulation is visualised. Corocoid process of scapula is seen on end.

30. Shoulder superio inferior view

31. Inferio superior Lawrence view Pathology Demonstrated : Osteoporosis, osteoarthritis, and the Hill-Sachs defect with exaggerated rotation may be demonstrated. Positioning of patient: The patient lies supine on the table. The arm of the affected side slightly abducted and supinated. The affected shoulder and arm raised on non-opaque pads.

32. The cassette is supported vertically against the shoulder And pressed against the neck to include as much as possible of the scapula on the film. Center Ray The horizontal center ray is directed towards the axilla. With minimum angulation towards the trunk.

33. Evaluvation The image should demonstrate the Head of humerus Acromion process Corocoid process Glenoid cavity The lesser tuberosity in profile. The acromion process and the superior aspect of glenoid cavity will be superimposed on the head of humerus.

34. Shoulder inferio superior

35. Outlet view The patient stands or sits facing the cassette. With lateral aspect of the affected arm in contact. The arm is extended backwards,with the dorsum of the hand resting on the patient’s waist. The patient is now rotated forward until a line joining the medial and lateral borders of scapula is at right angles to the cassette.

36. The scapula and proximal end of the humerus is clear of the rib cage. Center Ray Requires a 10 to 15 degree CR caudal angle. Centered posteriorly to pass through the superior margin of humeral head

37. Evaluvation criteria The humeral head should appear superimposed and centered to the glenoid fossa. The extent of the anterior projection of the acromion and the subacromial space.

38. Shoulder outlet view

39. scapula lateral oblique Y view The patient stands or sits with the lateral aspect of the injured arm against the cassette. And adjusted so that the axilla is in center of the film. The patient rotates 45-60 degrees. The arm is abducted with the elbow flexed to allow the back of the hand to rest on the hip. The cassette is positioned to include the superior border of scapula.

40. Center Ray CR to the medial border of scapula. Evaluvation criteria Entire scapula Body of scapula should be seen in profile,free of superimposition of ribs. The scapula and head of humerus are clear of rib cage.

41. Shoulder Y view

42. Stryker’s view The patient is supine or erect,with the posterior aspect the affected shoulder against the cassette. The arm of the affected side is abducted to above shoulder level . Allow the hand to rest on the patients head. The patient is now rotated slightly to bring the affected side away from the cassette. The position of the cassette is adjusted so that it is centered to axilla.

43. Center ray Centered to the axilla of the affected side. Evaluvation The clear view of posterior and superior aspects of the head of humerus. The inferior borders of glenoid fossa and joint will be seen. It is useful in detecting hill-sach’s defects and anterior instability.

44. Stryker’s notch view

45. Anatomy of clavicle

46. BASIC VIEWS Antero posterior Posterio anterior SPECIAL VIEWS Inferio superior-axial view

47. Anterio posterior INDICATION Fracture Dislocation POSITION The patient is supine on the table with the arms at side. The posterior aspect of shoulder should be in contact with the IR. No rotation of body. Center clavicle and IR to CR.

48. CENTER RAY CR perpendicular to Mid clavicle. EVALUVATION CRITERIA Entire clavicle Acromio clavicular joint Sterno clavicular joint No rotation of clavicle.

49. Clavicle anterio posterior view

50. Posterio anterior The patient sits or stands facing an erect cassette holder. The position is adjusted that the middle of clavicle is in center of the cassette. The patient’s head is turned away from the side being examined. The affected shoulder is rotated slightly forward to allow the clavicle in close contact with the cassette.

51. CENTER RAY To the mid clavicle. EVALUVATION CRITERIA Entire length of clavicle. The lateral end of clavicle will be clear of the thoracic cage. No foreshortening of clavicle.

52. Clavicle posterio anterior view

53. Axial Inferio superior The patients sits facing the x ray tube with the cassette placed cassette holder. Some holders allow 15 degrees angulation towards the shoulder. This reduces the distortion caused by the cranial angulation. The unaffected shoulder is raised slightly to bring the scapula in contact. The patient’s head is turned away.

54. CENTER RAY The center ray is angled 30 degrees cranially. Centered to the mid clavicle. The 30 degrees is needed to separate the clavicle. The medial end of clavicle can be shown in good detail by adding 15 degrees lateral angulation. EVALUVATION CRITERIA Entire length of clavicle. No foreshortening.

55. Clavicle axial view-inferio superior

56. Hill sach’s defect