Shoulder girdle presentation

anatomy and different projections of the shoulder

1. Shoulder Girdle Prepared By: Valerie Gentizon-Orpilla Lorma Colleges

2. Shoulder Girdle Shoulder Girdle The shoulder girdle is formed by two bones, the clavicle and scapula. Their function is to connect the upper limb to the trunk.

3. Clavicle The clavicle, classified as a long bone, has a body and two articular extremities The lateral aspect is termed the acromiaL extremity, and it articulates with the acromion process of the scapula. The mediaL aspect, termed the sternal extremity, articulates with the manubrium of the sternum and the first costal cartilage

4. Lateral aspect Medial aspect Sternal extremity Acromial extremity clavicle

5. acromion neck Glenoid cavity Coracoid process Scapular notch ANTERIOR SURFACE

6. Superior angle Crest of spine Inferior angle Neck Glenoid cavity Medial border DORSAL SURFACE

7. Dorsal surface spine acromion Lateral border Inferior angle Costal (anterior)surface Glenoid cavity Coracoid process LATERAL ASPECT OF THE SCAPULA

8. Humerus The proximal end of the humerus consists of a head, an anatomic neck, two prominent processes called the greater and Lesser tubercles. and the surgical neck . The head is large, smooth, and rounded, and it lies in an oblique plane on the superomedial side of the humerus .

9. Surgical neck Intertubercular groove Greater tubercle head Anterior Aspect of Right Proximal Humerus head Greater tubercle Intertubercular groove Lesser tubercle POSTERIOR PART

10. Structural classification Joint Type Tissue Movement Scapulohumeral Acromioclavicular Sternoclavicular Synovial Synovial Synovial Ball and Socket Gliding Double gliding Freely movable Freely movable Freely movable

11. Scapulohumeral joint

12. SUMMARY OF PATHOLOGY bursitis Inflammation of the bursa Dislocation Displacement of a bone from the joint space Fracture Disruption in the continuity of bone Hills-Sachs Defect Impacted fracture of the posterolateral aspect of the humeral head with dislocation Metastases osteoarthritis Transfer of a cancerous lesion from one area to another Form of arthritis marked by progressive cartilage deterioration in synovial joints and vertebrae Osteopetrosis Increased density of atypically soft bone

13. Osteoporosis Rheumatoid Arthritis Tendonitis Chondrosarcoma Tumor Loss of bone density Chronic. systemic. inflammatory collagen disease Inflammation of the tendon and tendon-muscle attachment New tissue growth where cell proliferation is uncontrolled Malignant tumor arising from cartilage cells

14. Shoulder “ AP PROJECTION” External, Neutral, Internal rotation humerus NOTE: Do not have the patient rotate the arm if fracture or dislocation is suspected.

15. 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. AP shoulder. External rotation humerus , Greater tubercle (arrow), AP shoulder, Neutral rotation humerus , Greater tubercle (arrow), AP shoulder, Internal rotation humerus , Greater tubercle (arrow): lesser tubercle in profile,

16. Central ray • Perpendicular to a point I inch (2.5 cm) inferior to the coracoid process

17. clavicle coracoid acromion Glenoid cavity/ scapulohumeral joint scapula humerus AP shoulder, external rotation humerus : greater tubercle (arrow).

18. AP shoulder, neutral rotation humerus : greater tubercle (arrow).

19. AP shoulder, internal rotation humerus : greater tubercle (arrow): lesser tubercle in profile (arrowhead

20. TRANSTHORACIC LATERAL PROJECTION ‘’LAWRENCE METHOD‘’ R or L position The Lawrence method is used when trauma exists and the arm cannot be rotated or abducted because of an injury.

21. Upright transthoracic lateral shoulder: Lawrence Method Recumbent transthoracic lateral shoulder: Lawrence Method Central ray Perpendicular to the IR, entering the midcoronal plane at the level of the surgical neck. • If the patient cannot elevate the unaffected shoulder, angle the central ray 10 to 15 degrees cephalad to obtain a comparable radiograph.

22. Unaffected clavicle Scapula (superior border) Sternum Clavicle Acromion process Humeral head Scapula (lateral border) Proximal humerus Transthoracic lateral shoulder: Lawrence method.

23. Transthoracic lateral shoulder (patient breathing): Lawrence method . Structures shown A lateral image of the shoulder and proximal humerus is projected through the thorax EVALUATION CRITERIA The following should be clearly demonstrated: • Proximal humerus • Scapula, clavicle, and humerus seen through the lung field • Scapula superi mposed over the thoracic pine • Unaffected clavicle and humerus projected above the shoulder closest to the IR

24. 1.INFEROSUPERIOR AXIAL PROJECTION (LAWRENCE METHOD) 2.INFEROSUPERIOR AXIAL PROJECTION RAFERT ET AL MODIFICATION

25. Inferosuperior axial shoulder joint: Lawrence method . Inferosuperior axial shoulder joint: Rafert modification. Note the exaggerated external rotation of arm and thumb pointing downward. If present. a Hill-Sachs defect would show as a wedge-shaped depression on the posterior aspect of the articulating surface of the humeral head. arrow

26. Lesser tubercle Humerus Coracoid process Acromioclavicular jt clavicle Scapulohumeral joint acromion Inferosuperior axial shoulder joint: Lawrence method

27. INFEROSUPERIOR AXIAL PROJECTION WEST POINT METHOD

28. Inferosuperior axial shoulder joint: West Point method . Central ray • Directed at a dual angle of 25 degrees anteriorly from the horizontal and 25 degrees medially. The central ray enters approximately 5 inches ( 13 cm) inferior and I 1/2 inch (3.8 cm) medial to the acromial edge and exit the glenoid cavity.

29. West Point method with anterior and medial central ray angulation .

30. EVALUATION CRITERIA The fol lowing should be clearly demonstrated: • Humeral head projected free of the coracoid process • Articulation between the head of the humerus and the glenoid cavity • Acromion superimposed over the posterior portion of the humeral head • Shoulder joint Structures shown The resulting image shows bony abnormalities of the anterior inferior rim of the glenoid in patients with instability of the shoulder

31. acromion Scapulohumeral joint Glenoid rim clavicle Coracoid process Lesser tubercle Inferosuperior axial shoulder joint: West Point method.

32. INFEROSUPERIOR AXIAL PROJECTION CLEMENTS MODIFICATION

33. Inferosuperior axial shoulder joint: Clements modification. A. Arm abducted 90 degrees. B. Arm partially abducted Position of patient • When the prone or supine position is not possible, Clements suggested that the patient be radiographed in the lateral recumbent position lying, on the unaffected side. • Flex the patient's hips and knees. Position of part • Abduct the affected arm 90 degrees,and point it toward the ceiling. • Place the fR against the Superior aspectof the patient's shoulder,holding it in place with the unaffected arm or by securing i t appropriately • ShieLd gonads. • Respiration: Suspend. Central ray • Horizontal to the midcoronal plane, passing through the midaxillary region of the shoulder. • Angled 5 to 1 5 degrees medially when the patient cannot abduct the arm a full 90 degrees (Fig. 5-28, B). The resulting radiograph

34. SUPEROINFERIOR AXIAL PROJECTION

35. Superoinferior axial shoulder joint: standard IR. Structures shown A superoinferior axial image shows the joint relationship of the proximal end ofthe humerus and the glenoid cavity . The acromjoclavicular articulation, the outer portion of the coracoid process,and the points of insertion of the subcapularis muscle ( at body of scapula) and teres minor muscle ( at inferior axillary border) are demonstrated. EVALUATION CRITERIA The following should be clearly demonstrated: • Open scapulohumeral joint (not open on patients with limited flexibility) • Coracoid process projected above the clavicle • Lesser tubercle i n profile • Acromioclavicu lar joint through the humeral head Central ray • Angled 5 to 1 5 degrees through the shoulder joint and toward the elbow

36. CORACOID PROCESS LESSER TUBERCLE HUMERUS ACROMION CLAVICLE Superoinferior axial shoulder joint.

37. AP AXIAL PROJECTION

38. AP axial shoulder joint . Central ray • Directed through the capulohumeral joint at a cephalic angle of 35 degrees Structures shown The axial image shows the relationship of the head of the humerus to the glenoid cavity. This is useful in diagnosing cases of posterior djslocation EVALUATION CRITERIA The following should be clearly demonstrated: • Scapulohumerai joint • Proximal humerus • Clavicle projected above superior angle of scapula

39. AP axial shoulder joint .

40. Scapular Y ‘’ PA OBLIQUE PROJECTION’’ RAO or LAO position Thi projection, described by Rubin, Gray, and Green, obtained its name as a result of the appearance of the scapula. The body of the scapula forms the vertical component of the Y, and the acromion and coracoid processes form the upper limbs. The projection is useful in the evaluation of suspected shoulder dislocations.

41. PA oblique shoulder joint . Central ray • Perpendicular to the scapulohumeral joint

42. Structures shown The scapular Y is demonstrated on an oblique image of the shoulder. In the normal shoulder the humeral head is directly superimposed over the junction of the Y . In anterior (subcoracoid) dislocations, the humeral head is beneath the coracoid process (Fig. 5-36); in posterior ( subacromial ) dislocations, it is projected beneath the acromion process. An AP shoulder projection is shown for comparison. EVALUATION CRITERIA The following should be clearly demonstrated: • No superimposition of the scapular body over the bony thorax • Acromion projected laterally and free of superimposition • Coracoid possibly superimposed or projected below the clavicle • Scapula in lateral profile

43. 10-15° (AC Articulation) ALEXANDER Shoulder ( Scapular Y ) Scapula ( Lateral ) Shoulder ( NEER) Name Body Rotation Scapula Rel. to IR Central ray angle Central ray entrance pt Arm position Acromioclavicular articulation: 1.Alexander Method Shoulder jOint : 2.Neer method Shoulder Joint: 3.scapular Y 4.Scapula lateral 45 to 60 degrees Perpendicular T 15° caudad 10 to 15 degrees border caudad 0 degrees 0 degrees Acromioclavicular joint Superior humeral Scapulohumeral joint Center of medial border of scapula Across chest At the side At the side variable

44. PA oblique shoulder Joint. Note the scapular Y components-body, acromion , and coracoid .

45. PA oblique shoulder Joint showing anterior dislocation (humeral head projected beneath coracoid process).

46. Glenoid Cavity AP OBLIQUE PROJECTION GRASHEY METHOD RPO or LPO position

47. Upright AP oblique glenoid cavity: Grashey method . Recumbent AP oblique glenoid cavity: Grashey method .

48. Central ray • Perpendicular to the glenoid cavity at a point 2 inches (5 cm) medial and 2 inches (5 cm) inferior to the superolateral border of the shoulder. Structures shown The joint space between the humeral head and the glenoid cavity ( scapulohumeral joint) is shown. EVALUATION CRITERIA The fol lowing should be clearly demonstrated: • Open joint space between the humeral head and glenoid cavity • Glenoid cavity in profi le • Soft tissue at the scapulohumeral joint along with trabecular detail on the glenoid and humeral head

49. acromion Humeral head Glenoid cavity clavicle AP oblique glenoid cavity: Grashey method showing moderate deterioriation of the scapulohumeral joint.

50. Supraspinatus "Outlet" TANGENTIAL PROJECTION NEER METHOD RAO or LAO position This radiographic projection is useful to demonstrate tangentially the coracoacromial arch or outlet to diagnose shoulder i mpingement . The tangential image is obtained by projecting the x-ray beam under the acromion and acromioclavicular joint, which defines the superior border of the coracoacromial outlet. Image receptor: 8 x 10

51. Structures shown The tangential outlet image demonstrates the posterior surface of the acromion and the acromioclavicular joint identified as the superior border of the coracoacromial outlet. Central ray • Angled 10 to 15 degree caudad , entering the superior aspect of the humeral head EVALUATION CRITERIA The following should be clearly demonstrated: • Humeral head projected below the acromioclavicular joint • Humeral head and acromioclavicular joint with bony detail • Humerus and scapular body, generally Parallel.

52. Shoulder joint: Neer method. Supraspinatus outlet (arrow). Tangential supraspinatus outlet projection showing impingement of the shoulder outlet (arrow). B, Radiograph of same patient as in Fig. 5-48 after surgical removal of posterolateral surface of clavicle.

53. Proximal Humerus AP AXIAL PROJECTION STRYKER " NOTCH " METHOD' dislocations of the shoulder are frequently caused by posterior defects involving the posterolateral head of the humerus . Such defects, called Hill-Sachs defects, are often not demonstrated using conventional radiographic positions. Hall, Isaac, and Booth' described the notch projection, from ideas expressed by Cm. W.S. Stryker U . S . N . , as being useful in identifying the cause of shoulder dislocation.

54. AP axial humeral notch: Stryker notch method EVALUATION CRITERIA The following should be clearly demonstrated: • Overlapping of coracoid process and clavicle • Long axis of the humerus aligned with the long axis of the patient's body • Bony trabeculation of the head of the humerus Structures shown: The resulting image will how the po - terosuperior and posterolateral areas of the humeral head. Central ray • Angled 10 degrees cephalad , entering the coracoid process.

55. AP axial humeral notch: Stryker notch method. Same projection in a patient with a small Hill-Sachs defect (arrow). Humerus Acromion Clavicle Coracoid prcess Humeral head Body of scapula Scapular spine

56. Glenoid Cavity AP OBLIQUE PROJECTION APPLE METHOD! RPO or LPO position This projection is similar to the Grashey Method but uses weighted abduction to demonstrate a loss of articular cartilage in the scapulohumeral joint.

57. Axial oblique projection: Apple method

58. Central ray • Perpendicular to the IR at the level of the coracoid process Structures shown The scapulohumeral joint EVALUATION CRITERIA The following should be clearly demonstrated: • Open joint space between the humeral head and the glenoid cavity • Glenoid cavity in profile • Soft tissue at the scapulohumeral joint along with trabecular detail on the glenoid and the humeral head • The arm in a 90 degree position

59. A, AP oblique projection: Grashey method, of the shoulder showing a normal scapulohumeral joint space. B, AP oblique projection: Grashey method, with weighted abduction showing loss of articular cartilage (arrow).

60. Glenoid Cavity AP AXIAL OBLIQUE PROJECTION GARTH METHOD ) RPO or LPO position This projection is recommended for acute shoulder trauma and for identifying posterior scapulohumeral dislocations, glenoid fractures, Hill-Sachs lesions, and soft tissue calcifications.

61. AP axial oblique: Garth method. RPO position. Note 45 degree CR. B, Top view of same position as A. Note 45 degree patient position. A B

62. Central ray • Angled 45 degree caudad through the scapulohumeral joint. Structures shown The scapulohumeral joint, humeral head, coracoid process, and scapular head and neck are shown. EVALUATION CRITERIA The following should be clearly demonstrated: • The scapulohumeral joint, humeral head, and scapular head and neck free of superimposition • The coracoid process should be well visualized • Posterior dislocations will project the humeral head superiorly from the glenoid cavity and anterior dislocations project inferiorly.

63. AP axial oblique: Garth method demonstrates an anterior dislocation of the proximal humerus . The humeral head is shown below the coracoid process, a common appearance with anterior dislocation.

64. Intertubercular Groove '" TANGENTIAL PROJECTION FISK MODIFICATION ) In recent years, various modifications of the intertubercular groove image have been devised. In all cases the central ray is aligned to be tangential to the intertubercular groove, which lies on the anterior surface of the humerus.The x-ray tube head assembly may limit the performance of this examination. Some radiographic units have large collimators and/or handles that limit flexibility in positioning. A mobile radiographic unit may be used to reduce this difficulty.

65. Supine tangential intertubercular groove. Standing tangential intertubercular groove: Fisk modification.

66. Central ray Angled 10 to 15 degrees posterior (downward from horizontal) to the long axis of the humerus for the supine position Fisk Modification • Perpendicular to the I R when the patient is leaning forward and the vertical humerus is positioned 10 to 15 degrees. Structures shown The tangential image profiles the intertubercular groove free from superimposition of the surrounding shoulder structures. EVALUATION CRITERIA The following should be clearly demonstrated: • Intertubercular groove in profile • Soft tissue along with enhanced visibili ty of the intertubercular groove.

67. Supine tangential intertubercular groove. Standing tangential intertubercular groove: Fisk modification. Intertubercular groove Lesser tubercle Coracoid process Greater tubercle

68. Proximal Humerus Teres Minor Insertion PA PROJECTION BLACKED-HEALY METHOD

69. Supraspinatus infraspinatus Teres major Teres minnor Lateral head triceps Muscles on dorsal surface (posterior) part of the scapula and humerus

70. PA proximal humerus for teres minor insertion. PA proximal humerus for teres minor insertion. PA proximal humerus for teres minor insertion. clavicle acromion Greater tubercle Lesser tubercle Teres minor insertion

71. Structures shown This position rotates the head of the humerus so that the greater tubercle is brought anteriorly , giving a tangential image of the insertion of the teres minor at the outer edge of the bone just below the articular surface of the head. EVALUATION CRITERIA The following should be clearly demonstrated: • Outline of the greater tubercle superimposing the humeral head • Lesser tubercle in profile and pointing medially • Soft tissue around the humerus along with trabecular detail on the humeral head. Central ray • Perpendicular to the head of the humerus .

72. Proximal Humerus Subscapular Insertion AP PROJECTION BLACKED-HEALY METHOD

73. subscapularis Long head head of biceps brachii biceps Muscles on costal (anterior) surface of the scapula and proximal humerus

74. AP proximal humerus for subscapularis insertion . AP proximal humerus for subscapularis insertion. AP proximal humerus for subscapularis insertion . Humeral head Glenoid cavity Subscapularis insertion Lesser tubercle Greater tubercle

75. Central ray Perpendicular to the shoulder joint, entering the coracoid process Structures shown This method provides an image of the insertion of the subscapularis at the lesser Tubercle. EVALUATION CRITERIA The following should be clearly demonstrated: • Lesser tubercle in profile and pointing inferiorly • Outline of the greater tubercle superimposing the humeral head • Soft tissue around the humerus along with trabecular detail on the humeral head.

76. Acromioclavicular Articulations Infraspinatus Insertion AP AXIAL PROJECTION

77. Place the patient in the supine position with the affected arm by the patient's side. Turn the arm in external rotation to open the subacromial space (Fig. 5-62, A ) . Rotate the arm to the neutral position (Fig. 5-62, B) and then in complete internal rotation (Fig. 5-62, C) to allow full evaluation of the humeral head. Direct the central ray to enter the coracoid process at an angle of 25 degrees caudad . The image profiles the greater tubercle, the site of insertion of the infraspinatus tendon, and opens the subacromial space. AP axial. 25-degree caudal angulation . demonstrating calcareous peritendinitis (arrows). A, External rotation. B, Neutral position. C, Internal rotation .

78. Acromioclavicular Articulations AP PROJECTION Bilateral PEARSON METHOD SID: 72 inches ( 183 cm). A longer SID reduces magnification, which enables both joints to be included on one i mage. It also reduces the distortion of the joint space resulting from central ray divergence.

79. Bilateral AP acromioclavicular articulations. Bilateral AP acromioclavicular joints demonstrating normal left joint and separation of right joint (arrow). Normal acromioclavicular joints requiring two separate radiographs.

80. Structures shown Bilateral images of the acromioclav icular joints are demonstrated (Figs. This projection is used to demontrate dislocation, separation, and function of the joints. Central ray • Perpendicular to the midl ine of the body at the level of the acromioclavicular joints for a single projection; directed at each respective acromioclavicular joint when two separate exposures are needed for each shoulder in broad-shouldered patients. EVALUATION CRITERIA The following should be clearly demonstrated: • Acromioclavicular joints visualized with some soft tissue and without excessive density • Both acromioclavicular joints, with and without weight , entirely included on one or two single radiographs • No rotation or leaning by the patient • Right or left and weight or nonweight markers • Separation, if done,clearly seen on the images with weights.

81. Acromioclavicular Articulations AP AXIAL PROJECTION ALEXANDER METHOD Alexander suggested that both AP and PA axial oblique projections be used in cases of suspected acromioclavicular subluxation or dislocation. Each side is examjned separately.

82. AP axial acromioclavicular articulation: Alexander method. Unilateral AP axial acromioclavicular articulation: Alexander method

83. Central ray • Directed to the coracoid process at a cephalic angle of 15 degrees .This angulation projects the acromioclavicular joint above the acromion . Structures shown The resulting image will show the acromioclavicular joint projected slightly superiorly compared with an A P projection. EVALUATION CRITERIA The following should be clearly demonstrated: • Acromioclavicular joint and c lavicle projected above the acromion . • Acromioclavicular joint visualized with some soft tissue and without excessive Density.

84. Clavicle Acromioclavicular Joint (AC jt ) Acromion Coracoid process Humeral head AP axial acromioclavicular articulation: Alexander method.

85. Acromioclavicular Articulations PA AXIAL OBLIQUE PROJECTION (ALEXANDER METHOD) RAO or LAO position

86. Central ray • Directed through the acromioclavicular joint at an angle of 15 degrees caudad . Structures shown The PA axjal oblique image demonstrates the acromioclavicular joint and the relationship of the bones of the shoulder. EVALUATION CRITERIA The following should be clearly demonstrated: • Acromioclavicular articulation in profile • Acromioclavicular joint visualized with some soft tissue without excessive Density.

87. Acromioclavicular joint acromion clavicle coracoid scapula humerus PA axial oblique acromioclavicular articulation.

88. Clavicle AP PROJECTION Central ray • Perpendicular to the midshaft of the clavicle Structures shown This projection demonstrates a frontal image of the clavicle. EVALUATION CRITERIA The following should be clearly demonstrated: • Entire clavicle centered on the image • Uniform density • Lateral half of the clavicle above the scapula, with the medial half superimposing the thorax.

89. Acromion AC joint Clavicle Superior angle of scapula Coracoid process SC joint

90. Clavicle PA PROJECTION The PA projection is generally well accepted by the patient who is able to stand, and it is most useful when improved recorded detail is desired. The advantage of the PA projection is that the clavicle is closer to the image receptor, thus reducing the OID. Positioning is similar to that of the A P projection. The differences are as follows:

91. The perpendicular central ray exits midshaft of the clavicle Structures shown and evaluation criteria are the same as for the AP projection.

92. Clavicle AP AXIAL PROJECTION Lordotic position NOTE: If the patient is injured or unable to assume the lordotic position, a slightly distorted image results when the tube is angled. An optional approach for improved recorded detail is the PA axial projection.

93. Central ray • Directed to enter the midshaft of the clavicle. • Cephalic central ray angulation can vary from the long axis of the torso. Thinner patients require more angulation to project the clavicle off the scapula and ribs. clavicle Coracoid process Acromioclavicular joint Sternoclavicular joint AP axial clavicle of 3-year-old child. showing fracture (arrow). This is the same patient as Figure.

94. PA AXIAL PROJECTION Positioning of the PA axial clavicle is similar to the A P axial projection just described. The differences are as follow : • The patient is prone or standing, facing the vertical grid device. • The central ray is angled 15 to 30 degrees caudad . Structures shown and evaluation criteria are the same as for the AP axial projection described previously.

95. PA axial clavicle .

96. TANGENTIAL PROJECTION The tangential projection is similar to the AP axial projection described previousIy . However, the increased angulation of the central ray required for this approach places the central ray nearly parallel with the rib cage. The clavicle i s thus projected free of the chest wall .

97. Structures shown An inferosuperior image of the clavicle is demonstrated, projected free of superimposition. EVALUATION CRITERIA The following should be clearly demonstrated: • Midclavicle without superimposition • Acromial and sternal ends superimposed • Entire clavicle along with the acromioclavicular and sternoclavicular joints

98. Central ray • Angled so that the central ray will pass between the clavicle and the chest wall , perpendicular t o the plane of the lR . The angulation will be about 25 to 40 degrees from the horizontal. • If the medial third of the clavicle is in question, it is also necessary to angle the central ray laterally ; 15 to 25 degrees is usually sufficient. Tangential clavicle. Tangential alignment for clavicle .

99. Tangential clavicle. clavicle acromion 1 st rib

100. Clavicle TANGENTIAL PROJECTION TARRANT METHOD The Tarrant method is particularly useful with patients who have multiple injuries or who cannot assume the lordotic or recumbent position.

101. Tangential clavicle: Tarrant method. Central ray • Directed anterior and inferior to the mjdshaft of the clavicle at a 25- to 35-degree angle. It should pass perpendicular to the longitudinal axjs of the clavicle. • Because of the considerable 010, an increased SID is recommended to reduce magnification. EVALUATION CRITERIA The following should be clearly demonstrated: • Most of the clavicle above the ribs and scapula with the medial end overlapping the first or second ribs • Clavicle in a horizontal orientation • Entire clavicle along with the acromioclavicular and sternoclavicular joints.

102. Structures shown The clavicle above the thoracic cage is Demonstrated. Sternoclavicular joint clavicle acromion Acromioclavicular joint coracoid Tangential clavicle: Tarrant method .

103. Scapula AP PROJECTION

104. AP scapula. Central ray • Perpendicular to the midscapular area ata point approximately 2 ‘’ (5 cm) inferior to the coracoid process. Structures shown An AP projection of the scapula is demonstrated

105. EVALUATION CRITERIA The following should be clearly demonstrated: • Lateral portion of the scapula free of superimposition from the ribs • Scapula horizontal and not obliqued • Scapular detail through the superimposed lung and ribs (Shallow breathing should help obliterate lung detail.) • Acromion process and inferior angle. acromion clavicle Coracoid process Glenoid cavity Lateral border of scapula Medial border of scapula Inferior angle of scapula

106. Scapula LATERAL PROJECTION RAO or LAO body position

107. Lateral scapula, RAO body position . Central ray • Perpendicular to the midmedial border of the protruding Scapula. acromion coracoid humerus Body of scapula Inferior angle of scapula Structures shown A lateral image of the scapula is demonstrated by this projection. The placement of the arm determine the portion of the superior scapula that is superimposed over the humerus .

108. EVALUATION CRITERIA The following should be clearly demonstrated: • Lateral and medial border superimposed • No superimposition of the scapular body on the ribs • No superimposition of the humerus on the area of interest • Inclusion of the acromion process and inferior angle • Lateral thickness of capula w i th proper density.

109. PA OBLIQUE PROJECTION LORENZ AND LlLIENFELD M ETHODS RAO or LAO position

110. PA oblique scapula : Lorenz method . PA oblique scapula : Lilienfeld method . Lorenz method • Adjust the arm of the affected side at a right angle to the long axis of the body, flex the elbow, and rest the hand against the patient's head. • Rotate the body slightly forward, and have the patient grasp the side of the table or the stand for support LiIienfeld method • Extend the arm of the affected side obliquely upward, and have the patient rest the hand on hjs or her head. • Rotate the body lightly forward, and have the patient grasp the side of the table or the stand for support.

111. Central ray • Perpendicular to the J R, between the chest wall and the mjdarea of the protruding Scapula. Structures shown An oblique image of the scapula is shown. The degree of obliquity depends on the position of the arm. The delineation of the different parts of the bone in the two oblique projections are shown. EVALUATION CRITERIA The following should be clearly demonstrated: • Oblique scapula • Medial border adjacent to the ribs • Acromion process and inferior angle.

112. Scapula AP OBLIQUE PROJECTION RPO or LPO position

113. AP oblique scapula, 20-degree body rotation . AP oblique scapula, 35-degree body rotation . Central ray • Perpendicular to the lateral border of the rib cage at the midscapular area Structures shown This projection show oblique image of the scapula, projected free or nearly free of rib superimposition. EVALUATION CRITERIA The following should be clearly demonstrated: • Oblique scapula • Lateral border adjacent to the ribs • Acromion process and i nferior angle

114. Humerus Acromion clavicle Coracoid process Scapular spine Vertebral border of scapula Inferior angle of scapula

115. Coracoid Process AP AXIAL PROJECTION

116. AP axial coracoid process. Central ray • Directed to enter the coracoid process at an angle of 15 to 45 degrees cephalad . Kwak , EspinieUa , and Kattan recommend 30 degrees. The degree of angulation depends on the shape of the patient's back. Round-shouldered patients require a greater angulation than those with a straight back. Structures shown A slightly elongated inferosuperior image of the coracoid process is illustrated . Because the coracoid i curved on itself, it casts a small, oval shadow in the direct AP projection of the shoulder.

117. EVALUATION CRITERIA The following should be clearly demonstrated: • Coracoid process with minjmal superimposition. • Clavicle slightly uperi mposing thecoracoid process clavicle Acromioclavicular joint acromion Coracoid process Glenoid cavity

118. Scapular Spine TANGENTIAL PROJECTION LAQUERRIERE-PIERQUIN M ETHOD

119. Central ray Directed through the posterosuperior region of the shoulder at an angle of 45 degrees caudad . A 35-degree angulation suffices for obese and round-shouldered patient . • After adjusting the x-ray tube, position the lR so that it is centered to the central ray. Structures shown The spine of the scapula is shown in profile and is free of bony superimposition, except for the lateral end of the clavicle.

120. Acromioclovicular jOint Acromion Glenoid cavity Scapular spine Superior border of scapula Humeral head Clavicle

121. Scapular Spine TANGENTIAL PROJECTION Prone position

122. Prone tangential scapular spine. Upright tangential scapular spine. Central ray • Direct through the scapular spine at an angle of 45 degrees cephalad . The central ray exits at the anterosuperior aspect of the shoulder. Upright position An i ncreased SID is recommended because of the greater OlD . Structures shown The tangential image shows the scapular spine in profile and free of superimposition of the scapular body. EVALUATION CRITERIA The following should be clearly demonstrated: • Scapular spine above the scapular wing • Scapular spine with some soft tissue around it and without excessive density.

123. Scapular spine Superior scapular border Acromion Clavicle Humeral head