Shoulder 1. Intended Learning Outcomes The student should be able to recognize clinical radiographic...

Shoulder

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Intended Learning Outcomes

• The student should be able to recognize clinical radiographic technical principles of the shoulder

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Shoulder Radiography

• To evaluate the glenohumeral joint, the scapula must be parallel to the film.

• Shoulder views can be taken with suspended respiration

• The Clavicle and A C joints will have the patient in a true A-P position with mid sagittal plane perpendicular to film.

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• A-C Joint view are taken with full inspiration to help open the joint space.

• A-C Joint views are taken weighted and non-weighted when looking for a separation. The weights must be 10 to 15 pounds and strapped around the wrists to avoid the use of the arm muscles.

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• A-C Joints views can also be taken to detect metabolic or drug induced bone loss. The view need not be taken with and without weights.

• The Clavicle can be taken A-P or P-A. The P-A view will have less magnification distortion but is more difficult to position.

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Shoulder A-P with Internal Rotation

• Measure: A-P at coracoid process

• Protection: Half Apron

• SID: 40” Bucky

• No Tube Angle

• Film: 10” x 8” I.D. toward spine

• Marker: anatomical plus “INT” or arrow pointing inward

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• Patient stands facing tube.

• The patient is rotated 15 to 45 degrees until the scapula is parallel to the film.

• The patient internally rotates humerus until the epicondyles are perpendicular to the film.

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• Horizontal CR: 1” below the coracoid process Vertical CR: coracoid process or through the glenohumeral joint

• Film centered to Horizontal CR

• Collimation: to include soft tissue around shoulder or slightly less than film size.

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• Breathing Instructions: suspended respiration

• Make exposure and let patient breathe and relax.

• Some facilities will use a 12” x 10 cassette

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Shoulder A-P with Internal Rotation Film

• The glenohumeral joint should be open

• The lesser tubericle will be in profile medially.

• The humeral head and greater tubericle will be superimposed.

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Shoulder A-P with External Rotation




• No Tube Angle

• Film: 10” x 8” I.D. toward spine

• Marker: anatomical plus “EXT” or arrow pointing outward

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• The patient is rotated 15 to 45 degrees until the scapula is parallel to the film.

• The patient externally rotates humerus until the epicondyles are parallel to the film.

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• Horizontal CR: 1” below the coracoid process Vertical CR: coracoid process or through the glenohumeral joint

• Film centered to Horizontal CR

• Collimation: to include soft tissue around shoulder or slightly less than film size.

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• Breathing Instructions: suspended respiration

• Make exposure and let patient breathe and relax.

• Some facilities will use a 12” x 10 cassette

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Shoulder A-P with External Rotation Film

• The glenohumeral joint should be open

• The greater tubericle and humeral head will be in profile .

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Scapula Lateral View or “Y” View


• Protection: Half apron


• Tube Angle: 0 to 10 degrees for Lateral Scapula or “Y” view

• Film: 10” x 12 regular with I.D. to spine

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Scapula Lateral View• Patient is placed in a sixty

degree anterior oblique.

• The arm of the affected shoulder is left in a neutral position or in the sling.

• The head of the affected shoulder aligned with the center line if the Bucky.

• By feeling the scapula, adjust position to get scapula perpendicular to film.

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Scapula Lateral View

• Horizontal CR: Head of humerus to slightly below head of humerus

• Vertical CR: 1” medial to the body of the scapula.

• Collimation: to include entire scapula and adjacent soft tissues of shoulder.

• Breathing Instructions: Full Inspiration

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• This is one of the best views to be taken when fracture or dislocation of shoulder is suspected.

• You should see the true relationship of the humerus head and the glenoid fossa. Very useful when detecting a dislocation or fracture.

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• The true Outlet View will allow evaluation of the subacromion space for the evaluation of impingement syndrome.

• Fractures of the scapula may also be seen on this view.

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Scapula A-P




• No Tube Angle

• Film: 12” x 10” Regular Speed with I.D. toward the spine

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Scapula A-P


• Patient is rotated about 15° or until the scapula is parallel to film.

• The humerus may be left in a neutral position.

• Horizontal CR: 1” below the coracoid process.

• Vertical CR: 1” medial to coracoid process

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Scapula A-P

• Film centered to horizontal CR.

• Collimation top to bottom: slightly less than film size or to include entire scapula and shoulder

• Collimation side to side: slightly less than film size or to include entire scapula and shoulder

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Scapula A-P

• Breathing Instructions: Suspended Respiration

• Make exposure and let patient relax.

• Some texts recommend raising the arm to get scapula clear of the ribs cage. Usually you will be able to visualize scapula with arm in neutral position.

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Scapula A-P Film

• Glenohumeral joint and entire scapula should be seen.

• Soft tissues of shoulder should be seen.

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Clavicle P-A

• Measure: A-P at mid clavicle



• No Tube Angle

• Film: 1/2 of 8” x 10” or 10” x 12” Regular Cassette

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Clavicle P-A

• Patient stands facing Bucky with mid-sagittal plane perpendicular to film.

• Horizontal CR: centered to exit through clavicle

• Vertical CR: centered to clavicle

• Horizontal CR centered to top half of film.

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Clavicle P-A• Collimation Top to

Bottom: less than 1/2 of film size or to include clavicle

• Collimation side to side: slightly less than film size or to include sternoclavicular and acromioclavicular joints


• Take film and let patient relax

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Clavicle P-A Film

• On this example, the A-P or P-A view is on the bottom of film.

• Must see the sternoclavicular and acromioclavicular joints and entire clavicle.

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Clavicle P-A Axial




• Tube Angle : 10 to 15 degrees caudal


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Clavicle P-A Axial

• Patient stands facing Bucky with mid-sagittal plane perpendicular to film.

• Horizontal CR: one inch above center of clavicle


• Horizontal CR centered to bottom half of film.

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Clavicle P-A Axial• Collimation Top to





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Clavicle P-A Axial Film

• On this example, the A-P or P-A axial view is on the top of film.


• The P-A views will have less magnification but are more difficult to position.

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Clavicle A-P




• No Tube Angle


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Clavicle A-P

• Patient stands facing tube with mid-sagittal plane perpendicular to film.

• Horizontal CR: centered to clavicle



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Clavicle A-P• Collimation Top to





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Clavicle A-P Film

• On this example, the A-P pr P-A view is on the bottom of film.


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Clavicle A-P Axial




• Tube Angle : 15 to 25 degrees cephalad


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Clavicle A-P Axial


• Horizontal CR: one inch below center of clavicle


• Horizontal CR centered to bottom half of film.

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Clavicle A-P Axial• Collimation Top to





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Clavicle A-P Axial Film

• On this example, the A-P or P-A axial view is on the top of film.


• The P-A views will have less magnification but are more difficult to position.

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Acromioclavicular Joint Unilateral

• Measure: A-P at coracoid



• Tube Angle : None

• Film: 2 views on 10” x 12” Regular Cassette

• Special equipment: 10 to 15 pounds of weight that can be strapped to wrists

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• Horizontal CR: A-C joint

• Vertical CR: A-C joint


• Marker: anatomical

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• Collimation: soft tissue around A-C joint but less than 1/2 of film size.

• Breathing Instructions: Deep Inspiration

• Make sure the A-C Joint remains in collimation with deep inspiration

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• Make exposure and let patient breathe but remain in position.

• Strap weights to both wrists.

• Marker: arrow pointed down or “weighted marker on bottom half of film

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• Horizontal CR: A-C joint

• Vertical CR: A-C joint

• Center horizontal CR to bottom half of film.

• Breathing Instructions: Deep Inspiration

• Make exposure and let patient breathe and relax. Remove weights

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Acromioclavicular Joints Bilateral A-P

• Measure: A-P at coracoid

• Protection: Half apron

• SID: 72” Non-Bucky

• Tube Angle: none 15 degree cephalad angle

• Film: 17” x 14” I.D. to unaffected side

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• Non-Bucky film holder hung on Bucky. Film placed in Non-Bucky Holder.


• Horizontal CR: at level of A-C Joints.

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• Vertical CR: mid-sagittal

• Collimation: to include both A-C joints and adjacent soft tissue and slightly less than film size Breathing Instructions: Deep Inspiration

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• Make exposure and let patient relax.

• Change films or move to unexposed half of 17” x 14” film.

• Strap weights to wrists.

• Horizontal and vertical CR same as non-weighted view.

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• Place arrow pointing down or “ weighted” marker on film.

• Breathing instructions: Deep Inspiration

• Make exposure and let patient breathe and relax. Remove weights.

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Acromioclavicular Joints Bilateral A-P Film

• The bilateral exam provides a comparison view of both A-C Joints.

• The increased SID and Non-Bucky exposure is 25% of the unilateral view.

• Magnification is reduced.

ASSIGNMENT

One student will be selected for assignment

Question

Mention routine radiographic positioning of the wrist joint

Suggested Readings

Clark’s radiographic positioning and techniques

Thank You

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