Shoulder and Trauma Elbow

1. Label the Anatomy of shoulder and clavicle.

2. What are the 4 primary muscles of the rotator cuff?o Responsible for stabilizing the shoulder during various movementso Consists of 4 primary muscles

Supraspinatus- assists the deltoid muscle in abduction Infraspinatus- lateral rotation Teres minor- lateral rotation Subscapularis- medial rotation

3. What do the various shoulder protocols depend on?o Various shoulder protocols

Protocol dependent on pt history Pain/pathology Hx of trauma Thoracic outlet syndrome

4. What is usually the pathology/pain protocol? Pathology/ pain protocol

Usually 2 AP positions AP with internal AP with external CR perp 1” inferior to coracoid

5. Why would you perform an AP internal shoulder? What does it show? AP Internal

o Used to r/o bursitis, tendonitis, Hill-Sach’s defect Hill-sachs- trauma to shoulder, caused by anterior dislocation

to humeral head o Moves the lesser tubercle inferomedial and into profile

Neutral position of the arm will not move the lesser tubercle6. What is a Hill sachs? What position shows this?

Hill-sachs- trauma to shoulder, caused by anterior dislocation to humeral head

Internal rotation 7. Why would you perform an AP external shoulder? What does it show?

o AP External Moves greater tubercle superiolateral and into profile

o Palm up8. What is a “Bankart lesions”? What position shows this?

External rotation Anterior dislocation of the rim of the glenoid

9. What does a 15-degree caudal angle show? Sometimes do a 15 degree caudal angle to look for osteophyte in

subacromial space 10. What is the usual trauma protocol?

Trauma Protocolso Usually include AP (anatomical or neutral)o Then any of the following:

Glenoid (AP Oblique) Apical Oblqiue PA Scapular “Y” Inferosuperio axial Transthoracic

11. What is the AP Oblique? What is it also called? How is the pt positioned? Glenoid (AP Oblique)o Patient is either AP with arm either anatomical or neutral positiono MSP is rotated 45 degrees towards the affected sideo CR is perp glenoid

12. What does the AP Oblique show?o Shows glenoid in profile and glenohumeral space

Greater tubercle in profile o When clavicle looks like a snake that means their obliqued to that side

When ribs elongated and more vertical than horizontal then turned

Not seeing face of glenoid13. What is the AP Apical oblique also called?

o Apical oblique Referred to as 45-45 45 degrees towards affected side Position is same as AP Oblique but CR is directed @45 degrees

caudal14. What does the AP Apical oblique show?

o Opens subacromial space, elongates the humeral head and neck o See glenoid in profile, glenohumeral space, and greater tubercle o Clavicle looks like dinosaur/ very vertical

Humeral head looks bitten off= Hill Sach’s defect

15. What is a PA scapular “Y”? What does it show? How is the pt positioned?o PA Scapular “Y”

Provides a lateral of the shoulder to r/o anterior/posterior dislocations

Pt is PA with affected side towards the IR Oblique shoulder 30-45 degrees

towards IRo CR is perp to mid scapula

Palpate superior angle of the scapula

Palpate distal tip of acromin Line them up so they are

perpendicular to IR16. Where is the coracoid always pointing in PA?

Where is the acromin?o Coracoid should always be pointing

mediallyo Acromin lateral

17. What is seen FSI in the PA Y?o Lesser tubercle should be seen free of superimposition and pointing

medially 18. Where are most shoulder dislocations?

Scapular anterior dislocationo 97% of all shoulder dislocations are anteriorly displacedo 2% are posteriorly displacedo 1% are interiorly displaced

humeral head down low/ underneath glenoid 19. How do you position for an AP Y? What does the AP Y increase?

AP Scapular “Y”o PA scapular Y can be performed in the supine positiono The affected shoulder would be rotated 60 degrees away from the IRo 60 LPO would demonstrate the right shouldero 60 RPO would demonstrate the left shouldero AP “Y” would visualize all the same anatomy as the PA scapular “Y”

but with increased magnification= less detail 20. Why do you do an Inferosuperio axial? What does it show? How do you do

it? Inferosuperio axial (Lawrence Method) o Orthopedics’ choice of lateralo Relationship between humeral head and

glenoid o Can be done supine or seatedo If supine, arm is abducted 90 degrees and

externally rotated

o CR directed 15-20 degrees medially Tube is directed horizontally

o Build shoulder upo Supinate hand o Should be using a grid o Lesser tubercle is on top

21. What happens when you supinate the hand?o When you supinate the hand you see lesser tubercle

Internal, Y, and inferosuperio axial 22. How do you do a seated axillary?

o Seated Axillary Pt seated at the end of the table CR is directed distally at a 5-10 angle Goes superiorly to inferiorly Magnification with this projection Arm is pronanted

23. How do you do a transthoracic? What does it show? Transthoracic o Anterior/posterior displacement of the

shouldero Last resort because of heavy superimposition

of thoracic structureso Breathing technique (decrease mA and

increase exposure time) to blur lungs and vascular markings

o 3 seconds is a good amount of time in order to blur

24. What is the thoracic outlet syndrome? What is it also called? What angle does it require? What does it attempt to visualize?

Thoracic Outlet syndrome o Supraspinatus outlet syndrome or impingement syndromeo Requires positions/projections with caudal angles to better visualize

subacromial spaceo Attempting to visualize “osteophytes” extending from the inferior

acromial surfaceo Can also be performed to demonstrate subacromial bursitis

25. What are the usual projections for TOS? Usual projections for TOSo Apical APo Apical oblique (Garth)o Neer scap Yo Routine AP internal/external with 10 degree caudal angle

Apical AP

o PT is positioned similar to AP shoulder with arm in neutral

o 30 degree angle to open up subacromial space Apical obliqueo 45/45o Position same as AP/Garth

Neer Scapular “Y” o Pt is positioned similar to routine PA Scapo 10-15 degree caudal angleo Open subacromial space

26. What are most elbow traumas associated with? Most elbow trauma is associated with the patient’s inability to extend or

rotate the extremityo Never force into position

27. When do you do a partial flexion elbow? Partial flexion APo Use when pt cannot extend elbowo A series of 2 positions

28. What is the first position for a partial flexion AP? What does it show? 1st o Place humerus in same plane as receptor with epicondyles parallel o Bring humerus closer to IRo Demonstrate distal humerus o Extend eblow as much as possible then supporto CR perp distal humeruso +10 kVp from usual AP elbow make sure you penetrate through SI of

tissue and anatomy o Supracondila FX- make sure you don’t miss any o Lots of SI of tissue

29. What do you do for the 2nd image? 2nd o Place proximal radius and ulna in contact with receptor with hand

supinated Keep epicondyles // CR perp proximal radius/ulna

o With patient standing 30. How to you do a Coyles to show coronoid and radial head?

Axiolaterals (Coyle)o Trauma positions used as substitutes for visualization of coronoid and

radial head when pt cannot extend and rotate elbowo Can be easier than routine obliques- elbow remains in a “relaxed”

lateral position 31. How do you do a Coyles to show the radial head?

Axiolateral for Radial heado Elbow is placed in standard lateral positiono If possible rotate hand/wrist laterallyo CR @ 45 degrees toward shoulder/proximally o Parallel to long axis of humerus o CR enters approx 1 inch inferior to

elbow joint o +10 kVp from usual lateral

32. What is a Axiolateral for Radial head position good for showing?

o Excellent alternate for occult intra-articular FX

Bring elbow more towards upper part of cassette

o Supinator fat pads Communited vs simple fx

o Radius out from ulna shows proximal radius Radial head elongated

o Humeral anatomy superimposed 33. How do you do Axiolateral for coronoid?

o Elbow positioned same as standard lateralo Substitute for medial oblique o CR directed 45 from above shoulder, towards elbow o +10 kVp from usual lateralo Excellent for avulsion fx off coronoid process

34. What are the Full rotation laterals “round the clock”? When do you do this?o A series of 4 exposures with the hand and wrist in various stages of

rotationo Provides a profile of the entire radial heado Elbow is positioned in standard lateral, then wrist is rotated

Maximum supination Neutral lateral Pronation Maximum hyperpronation

o Turns radial head in a circle o By request only not routine

35. What does a Tangential (acute flexion) show? What is it also called? How do you do it?

o Used to assess olecranon process- 2nd most frequently fx region in adult elbow

o Aka “Jones Method” position o Humerus is placed in contact with receptor o Epicondyles //o Instruct pt to flex arm as much as possible

o CR perp and 2 inches distal to olecranon36. What is a little league elbow? What is it also called? How does it happen?

Little league elbow o Medial epicondylar apophysitis- more for adult o Panner’s disease o Chronic avulsions of medial epicondyles o Twisting motion and chronic stresses

37. When is the olecranon FSI? Olecranon free of superimposition= acute flexion and lateral

38. What does this image show? What position?

PA Scap Y39. What does this image show? What position?

Inferosuperior Axial

40. What is the difference between these 2 pictures? What is the position for each? How do you know?

Left- AP external lesser tubercle is superimposed over humeral head

Right- AP Oblique see humeral head in relationship to glenoid cavity

41. How do you position for an AP Scapula? What are the breathing instructions?

PT positioned similar to AP shoulder Affected arm is abducted 90 degrees with hand in supination CR directed perpendicular and 2 inches medial to axilla Use breathing technique (3 seconds) or full exhalation to improve

visibility 42. What does an AP Scapula look like on an image? What do the lungs look like?

Humerus is horizontal See much more of the scapula See blurring of the lungs

43. How do you do a Lateral Scapula? What is this position similar to? RAO/LAO affected side closest to receptor Position is similar to “Y” Instruct pt to place forearm and hand over posterior wrist Palpate vertebral and axiallary borders to ensure superimposition

44. What does a lateral scapula look like on an image? What fx can you see? See border of scapula Can see stellate FX

i. Occurs from blow to scapula ii. Radiating fx lines in a star pattern

45. How does a fx to the Clavicle usually happen? Who is this most common in? FX to the clavicle usually occur due to falls on the outstretched hand,

or direct blow Recognized as the most common injury associated with childbirth,

and children in general

Images more easily obtained in the upright, PA position whenever possible

46. How do you position for a PA Clavicle? What are the breathing instructions? Position affected side closest to receptor Adjust shoulders to lie in the same transverse plane CR perp to exit mid-shaft of clavicle Must include S-C joints Suspended exhalation

47. What is the downfall of doing an AP clavicle? Increase OID will result in increase magnification and decrease in

detail 48. Why do you do a PA axial? What does this position do? What does the clavicle

look like? What are the breathing instructions? Projects clavicle superior to ribs/scapula

i. Push clavicle up as much as you can Clavicle imaged horizontal placement Position pt similar to PA CR directed caudal, 25-30 degrees to exit the midshaft of the clavicle

i. Thinner pt require greater of an angle All axial methods should employ full inhalation to further push

clavicle above ribs/scapula You want full inhalation PA= caudally

49. How do you do an AP Axial? What are the 2 ways you can do it? Same image can be obtained in the AP erect or recumbent position 2 methods can be used

o CR directed 25-30 degrees cephalico Patient is positioned the same as a lordotic chesto Thinner pt usually require the use of a 15 degree cephalic

angle to try to straighten out the clavicle a little more 50. What should be done before Acromioclavicular articulations? What does this

position demonstrate? Performed frequently in orthopedic offices Done to demonstrate separation, dislocation of the AC joint Evidenced by widening of the joint of one side vs the other Radiographs of the shoulder should be performed/ reviewed prior to

these projections to r/o FX in the shoulder girdle 51. How are AC joints always performed? What is the minimum weight? What is

the SID? Always performed bilateral for comparison Images performed in AP Erect position

i. No weightii. With weights

Minimum 10 pound weights provided- attached to wrists (do not allow pt to hold in hands)

72” SID with CR perp to MSP and 1 inch superior to jugular notch Use routine AP shoulder technique @ 72” Hypersthenic pt may require individual exposures