Shoulder radiography

1. Shoulder Radiography

2. Shoulder anatomy 3 bones: Humerus Scapula Clavicle 3 joints: Glenohumeral Sternoclavicular Acromioclavicular

3. Scapula Anatomy Scapula: Glenoid Acromion Coracoid Coracoid

4. Scapula Lateral (Y) view

5. Routine ( transthoracic ) AP view of the shoulder AP relative to thorax Suboptimal view of glenohumeral joint Good view of AC joint

6. Scapular/ Glenohumeral AP view (aka Oblique view) Better visualize Glenohumeral joint/space Suboptimal view of AC joint

7. Normal AP view

8. Normal oblique Glenohumeral space

9. Lateral Scapula “Y” view Evaluate relationship of humeral head with glenoid Humeral head should be at bifurcation of the Y

10. Axillary view Not routinely performed Good for evaluating anterior-posterior relationship of glenohumeral joint

11. Quiz time AP and Y view Diagnosis?

12. Anterior dislocation

13. Anterior dislocation M ake up 96% of all shoulder dislocations May be associated with: Fracture of greater tuberosity (15%) Bankart lesion Fracture of anterior glenoid rim Hill-Sachs defect (50%) Impaction fracture of posterolateral humeral head 2/2 impaction of humeral head against glenoid during dislocation

14. Bankart and Hill-Sachs Hill Sachs deformity

15. Diagnosis? AP view – not too revealing…

16. Same patient, axillary and Y views

17. Answer: posterior dislocation

18. Posterior dislocation Makes up about 2-4% of dislocations, may be associated w / convulsive seizure (boards question) Common Xray findings: Rim sign (66%) = distance between medial border of humeral head and anterior glenoid rim >6 mm L ightbulb sign = Humeral head held in internal rotation, appearing bulb-like on AP view Trough sign (75%) = "reverse Hill-Sachs" = compression fracture of anteromedial humeral head

19. Posterior dislocation Trough sign Rim sign Lightbulb sign

20. Diagnosis?

21. Inferior dislocation, “ Luxatio Erecta ” Accounts for 1-2% of shoulder dislocations, Arm often held above head Results from severe hyperabduction of arm

22. Diagnosis?

23. Acromioclavicular separation, grade III

24. AC separation Treatment: Grade I-II: always conservative Grade III: usually conservative, surgical in few cases (young athlete, laborer who does a lot of lifting, etc) Grade IV-VI: surgical

25. Diagnosis?

26. C lavicle fracture Fracture 80% of fractures in middle third, 15% in distal third, 5% medial third Treatment mostly conservative Surgical mgmt if open fracture, severe skin tenting, neurovascular injury or severely comminuted/displaced fractures

27. Great site for x-ray cases: http://www.feinberg.northwestern.edu/emergencymed/residency/ortho-teaching/shoulder/