Download shoulder 2012

SHOULDER GIRDLE
Standard Shoulder Views:
*a. AP Internal Rotation
*b. Grashey (oblique)
*c. Scapular Y-view (oblique)
*d. Axillary Lateral
or Transthoracic Lateral/ Lawrence method
(when pts. can’t lift arm)
e. AP External Rotation or Neutral Rotation
AP Rt Shoulder Internal Rotation
* This image is clipping the end of the clavicle and scapula
Structures shown:
 AP Shoulder * The entire scapula, clavicle and the
proximal humerus
 Internal rotation shows lesser tubercle in profile
* this is different then Merrill’s
External vs. Internal Rotation
Greater
Tubercle
External
See arrow for greater tubercle
Internal
See arrow for lesser tubercle
 AP Internal Rotation:
 This view is taken with the arm internally rotated. The humeral head is
rotated so that structures not seen in the external rotation view may
now be seen. Note the following differences in the views:
 The greater tubercle is anterior on the humeral head and cannot be
clearly seen (it is in the most lateral portion of the humeral head on the
external rotation view).
 ****The lesser tubercle is seen medially (it is not seen on the external
rotation view).
 The glenohumeral joint is still partially obscured by the humeral head.
The entire clavicle and scapula should be on the film
 You should be able to identify the AC joint, coracoid process,
acromion, clavicle, the scapula and glenohumeral joint.
AP RT Shoulder Internal Rotation
Bursitis
AP Rt Shoulder Neutral Rotation
What is wrong with this shoulder?
AP Lt Shoulder ? Internal or external rotation
Grashey Rt Shoulder
Structures shown:
 Humeral head, open glenoid cavity and the neck of
the scapula
Grashey:
 Start with patient AP (standing is easier on the pt.) and roll
onto affected shoulder about 45 degrees.* With arm
internally rotated (some site use and external rotation)
 You want to get the glenoid
cavity in profile
 You can cone in on this one!
 Structures shown : Joint space open between the humeral
head and glenoid cavity (scapulohumeral joint)
Is it open?
Grashey Rt Shoulder
No: roll patient up onto shoulder more
Scapular Y Right Shoulder
**Preferred
R
PA
AP
Trauma pt
 Y-view : PA oblique projection
 When the shoulder is being imaged to rule out dislocation or
proximal humeral fracture, the patient’s humerus should not be
moved.
 The PA method is the preferred method(less magnification) but
when doing a trauma patient you should not stand them up or roll
them PA so do them AP.
 The Y-view is taken by aligning the plane of the scapula parallel with
the x-ray beams so that it can be seen "floating" over the thoracic rib
cage. In a healthy patient, have their arm hanging down to their side,
the humeral head should be in alignment with the glenoid fossa of
the scapula. However, following a traumatic dislocation, leave the
arm in the position it is in! The humeral head will not be resting in
the glenoid fossa when dislocated
 Structures shown: the scapula ,coracoid, acromion and the humeral
head
 You should be able to identify the scapula in profile, coracoid,
acromion, humeral head as it overlies the glenoid fossa, the
humeral shaft and the clavicle.
Can you see the “Y”?
What side of the scapula is the humeral head on?
Posterior
Coracoid
Acromion
Posterior
Anterior
Anterior
Normal
Anterior
dislocation
Posterior
dislocation
Did you know?
 Posterior shoulder dislocations, places the
humeral head posterior, and beneath the
acromion process
 Anterior shoulder dislocations, places the humeral
head anterior, and beneath the coracoid
Axillary Lateral Rt Shoulder
inferior to superior
superior to inferior
 Axillary Lateral View:
 The x-ray beam is directed either up into the
axilla (inferior to superior), or from the
superior aspect of the shoulder down
through the axilla (superior to inferior). The
axillary shows whether the humeral head is
within, the glenoid fossa.
Structures shown : Proximal humerus,
Scapulohumeral joint, coracoid process,
and the AC articulation.
Do you have:
 Open scapulohumeral joint
 Coracoid process projected above the clavicle
 Lesser tubercle in profile and directed anteriorly
 AC joint projected through the humeral head
**Is there extra soft tissue in the axilla (Breast tissue)
Transthoracic Lt Shoulder
pacemaker
Fractured Anatomic Neck
Transthoracic Lateral
(Lawrence Method)
 Usually done on trauma patients
 Done in place of the axillary view
 Usually done as is. If patient is supine do supine, if
patient is sitting up do sitting up. You need to raise
the uninjured arm above the head. Need to get the
unaffected shoulder up and out of the way. Ask
patient if they can move the other arm first.
Structures shown: Lateral projection of the
shoulder and head of the humerus through the
thorax.
Fractured Head of Humerus
Transthoracic Rt Shoulder
Do you have:
 The proximal humerus on the image
 Can you see scapula, clavicle and humerus through
the lung field
 Scapula superimposed over the thoracic spine
 Unaffected clavicle and humerus projected above
the shoulder closest to the IR
AP Rt Shoulder External Rotation
 AP External Rotation:
***not a protocol film
 This view is taken with the patient
in the AP position either standing,
sitting or laying down depending on the patient. The arm is externally rotated
so that the thumbs points laterally.
 Structures shown: Entire clavicle ,scapula and proximal humerus
 ****The greater tubercle in the lateral aspect of the humeral head.
 Superior part of the humeral head obscures the glenoid fossa.
 Entire Scapula (the spine, borders and tip), and AC joint.
 The view of the coracoid process is head-on.
 Structures that you should be able to identify include the AC joint, coracoid
process, acromion, glenohumeral joint, greater tubercle of the humerus
and surgical neck of humerus.
DID YOU KNOW?
 AP shoulder films are taken in internal and
external rotation to improve visibility of
components of the head of the humerus (the
greater and lesser tubercles), the clavicle and
scapula. This is a good overview of the shoulder.
 But:
 The Y-view and transthoracic view are used to
evaluate for dislocations, where is the head of the
humerus sitting compared to the joint space?
AC joints
 Standard views:
 AP Bilateral AC Joints with out weights
 AP Bilateral AC Joints with weights
AP Rt AC joint with out weights
AP Lt Ac joint with out weighs
AP Bilateral AC Joints With Out Weights
with out wts
 The patient stands in the anatomical position and an AP film is taken
that includes both AC joints (right and left) at the same time (2;8x10’s
,7x17, or 14x17 ). This allows comparison of the two joints. A second film is
taken with the patient in the same position, but while holding weights in
both arms(give the patient the weight very carefully). This is the "stress
view", and helps in diagnosing AC joint separation by increasing the load
that the joint has to bear. If there is ligamentous injury, the joint space
will widen.
 The two spaces requiring careful evaluation are the
(1)acromioclavicular joint space and the (2)coracoclavicular space.
Both should be symmetric on right and left and should not be
abnormally widened. Increased distances across the spaces indicate a
degree of joint separation or sprain. The film from the previous slide was
taken of a college football player who suffered an AC separation on the
right. Note the widening compared to the left side.
 You should be able to see the following anatomical structures: bilateral:
clavicles (distal ends if two films are taken), acromion, coracoid
process, and humeral heads.
One 14x17 cut in half
AP Bilateral AC Joints With Out Weights
1
2
AP Bilateral AC Joints with weights
Scapula
Standard views: AP/Lateral
AP Rt Scapula
Lateral Rt Scapula
Scapula
 AP: **Abducted arm
(per patient’s condition)
 Structures shown: A true AP projection of the
scapula shows the lateral portion of the scapula
free of superimposition from the ribs and the rest
of the scapula seen thru the ribs.
AP RT Scapula
RT
* PA patient preferred
Lateral
Lateral Rt Scapula
AP patient position
RAO
LPO
Shows Rt Scapula
Shows Rt scapula
• Lateral:** (PA patient)RAO/LAO preferred (usually
done upright) roll patient 45 to 60 degree toward
affected side or (AP patient) RPO/LPO (usually done
supine) roll pt. 15-25 degrees away from affected side
• Structures shown: A lateral projection of the entire
scapula. Scapular lateral border should not be
superimposed on the ribs. ***Humerus should not
superimposed the area of interest. Acromion process
should be on film.
OUCH!
Scap “y”, Outlet and Lateral Scapula how do
you tell them a part?
 Central ray: is it angled? 10-15 caudal for a outlet
view. Where is it centered? The scapulohumeral
joint or mid scapula
 What do they show? The whole scapula,
the head of the humerus vs the joint or
acromion and AC joint area
 What position is the arm in? Is it neutral for
dislocation or is it moved to see the scapula?
 * I will not test you on the outlet view!
Lateral scapula
Arm out of the way
Scap Y
Arm relax
Outlet
Tube angle
Clavicle
 Standard views: AP and AP axial
 Structures shown: Entire clavicle on one film. Even
density from tip to middle to end. AP axial shows
the same structures but most of the clavicle should
be above the ribs and scapula. Clavicle should look
more horizontal.
AP Rt Clavicle
AP Axial Rt Clavicle
RT
L
AP Axial Lt clavicle
AP Lt
clavicle
AP axial
Why do we angle?
AP Lt clavicle
AP Axial Lt clavicle