Anatomy of shoulder can be divided into several different categories, which are:

BonesJointsLigamentsTendonsMusclesNervesBlood VesselsBursa

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Shoulder girdle contains two bones: Clavicle Scapula

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Shoulder girdle contains three synovial joints, which are:Gleno-humeral jointAcromio-clavicular joint Sterno-clavicular joint

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Ligaments of the shoulder forms a joint capsule that connects the humerus to the glenoidcavity.These ligaments are the main source of stability for the shoulder.

Glenohumeral Ligaments (GHL)

Coraco-acromial Ligament (CAL)

Coraco-clavicular Ligaments (CCL)

Transverse Humeral Ligament (THL)

Acromioclavicular Ligament

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Glenoid Labrum

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Although many muscles connect with, support, and enter into the function of the shoulderjoint, radiographers are chiefly concerned with the rotator cuff muscles

ROTATOR CUFF MUSCLES:

Subscapularis Supraspinatous Infraspinatous Ters minor

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Trauma, Fracture Subluxation, Dislocation

Pathological condition associated with joint space and bone(Osteoarthritis, Rheumatoid arthritis,Osteopetrosis,osteoporosis, Osteomyelitis & other degenerative osteoarthropathy)

Check x-ray for post op and post reduction.

Impingement of shoulder jointCongenital anomalies.Bone cyst, Tumor, EffusionCalcified tendon.General skeletal surveyBursitis(inflammation of bursa)

INDICATIONS FOR SHOULDER RADIOGRAPHY:

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COMMON IMAGE CRITERIA FOR SHOULDER JOINT RADIOGRAPHY:

Well visualization of:

Proximal arm, ½ clavicle, scapula, lateral ribs cage, Glenohumeral joint, ACJ.

No rotation or image blur.

Open joint spaces.

Soft tissue & bony trabeculation details.

Part of interest (always be at the center of the IR.)5/15/2017 15

General consideration for shoulder radiography:

Skeletal parts are projected usually with at least two different directions (usually right angle to each other.)No forceful positioning in case of trauma, contracture or suspected fracture.

Use alternative ways to take radiographs.5/15/2017 16

Patient preparation:

Checking of request form, identifications & verification.

Explanation of procedure ,Removal of all radiopaque objects from the

region to be radiographed (Shoulder & Neck).

Immobilization: pillows, sandbags, compression bands, sponges &

radiolucent pads for support & comfort. 5/15/2017 17

Patient head should be rotated away from side being examined

Proper patient positioning/ Beam collimation/ Exposure factors/ Immobilization ofparts i.e.; Proper technique and instruction to the patient to avoid repeat exposure

High speed screen-film combination if applicableIn case of young uncooperative children Bucky is omitted so that exposure time can

be minimizedIf available, radiation protection shield should be used e.g. Thyroid shield, gonad

shield etc.The central ray can be directed caudally after centering to the coracoid process so

that the primary beam can be collimated to the area under examination.

Radiation protection:

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RECOMMENDED PROJECTIONS:

Basic AP(neutral, internal, external rotation) Axial(supero-inferior, infero-superior)

Glenohumeral joint AP(erect/supine) Lateral oblique ‘Y’ projection

Acromioclavicular joints AP(erect)

Clavicle PA(erect),AP(supine) Axial(infero-superior)

Scapula AP(erect) Lateral(erect/prone)

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Radiographic anatomy of shoulder

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Equipment setting & exposure factor

Decrease 5 -10 kVp in case of destructive pathology (Active osteomyelitis, Aseptic necrosis, Atrophy, Degenerative arthritis, Gout,Osteoporosis,old age)5-10kvp decrease for soft tissue radiography( bursitis, tendonitis ,foreign

body localization e.t.c.)Increase 5 -10 kVp or 25 -50% mAs or both in case of additive pathology

(Acromegaly, Osteoma, Exostosis(benign growths of bone extending outwards from the surface of a bone) etc.) & if the part on POP castGrid; for thick parts & higher kVp use (thickness>4-5 inches; kvp>60)

KVP MAS FFD GRID FOCUS SCREEN FILM SIZES(INCH)

55-80 6-50 100 CM Y/N SMALL FAST 8X10 OR 10X12

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Shoulder joint: AP

IndicationsTrauma, fracture,dislocation,calcificationsInfection, effusion arthritis & degenerative joint diseases &

other joint pathologyPatient positioning

Erect or supine with affected shoulder against the cassetteand rotated about 15 º (close contact)

Arm abducted,Upper border of cassette 5cm above shoulder

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Fig, Shoulder AP in external, neutral and internal rotation

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.

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Central rayPerpendicular to a point 1 inch (2.5 cm) inferior to the coracoid process

Evaluation criteriaVisualization of shoulder girldle, glenohumeral jointSlightly overlapping glenoid cavity but separate from the acromion

processBony and soft tissue structures of shoulder and proximal humerus

CONT..

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Shoulder: axial

1. Supero inferior

2. Infero superior:•Supine:

Lawrence method Rafert Modification

• Prone: West Points view

•Lateral: Clements method5/15/2017 25

Shoulder: axial (superoinferior) Indication

To evaluate glenohumeral joint, & calcified tendonsTo demonstrate insertion region of infraspinatus muscle & the subacromial

part of the supraspinatus tendonPatient positioning

Patient sits beside the x-ray tableIR is placed on the table top & the affected arm abducted over thecassettePatient leans towards the table to reduce OFD & to insure that theaxilla (glenoid cavity) included in the image.(A curved cassette can be used to reduce OFD)Elbow flexed, arm abducted to minimum 45º(injury permitting)

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Central ray through the proximal aspect of the

humeral head, beam can be angled 5°-15° toward the elbow with CR directed at the shoulder joint.

(FFD increased if large OFD to reduce magnification)

SHOULDER: AXIAL (SUPEROINFERIOR)

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Evaluation criteriaDemonstration of head of humerus(Lesser

tuberosity in profile) , acromion process, coracoid process and glenoid cavity

Open scapulohumeral joint (not open on patients with limited flexibility)

SHOULDER: AXIAL (SUPEROINFERIOR)

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Axial (inferosuperior)

Patient position(Lawrence method)Patient supine ,arm abducted and supinatedAffected shoulder and arm raised on non-opaque padsCassette supported vertically against the shoulder and

pressed against the neck(to include scapula)Head turned to opposite direction

Central raycenter to axilla (to the region of ACJ ) with the tube medially angled 15º- 30º. The greater the

abduction, the greater the angle.5/15/2017 29

Cont…….Patient position(RAFERT Modification )

To visualize Hill-Sachs defect From the Lawrence method, the extended arm externally

rotated until the hand forms a 45º oblique & the thumb pointing downwards.

Central rayTo the axilla with 15º medial angulation so that the CR

passes through ACJ

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Axial (inferosuperior)

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axial (inferosuperior)

Patient position(west point view)Patient prone, Head turned away3”pad placed under the affected shoulder affected arm abducted 90º & rotated to rest the forearm

over the edge of the table. IR placed against superior aspect of shoulder with the edge

of IR in contact with the neckCentral ray

directed at a dual angle of 25º anterior from the horizontal (to table surface) & 25º medially

Central ray enters approximately 5 inches inferior & 1.5 inches medial to the acromial edge & exits through the glenoid cavity5/15/2017 32

Evaluation criteriaHumeral head projected free of the

coracoid processOpen glenohumeral joint.

CONT…..

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Patient preparation(Clements method)

Done if prone or supine position not possible

Patient in lateral recumbent position lying onunaffected side

Hips & knees flexed

90º abduction of affected arm & pointing towardsthe ceiling

IR against the superior aspect of the shoulder,holding in place with another arm or securing itproperly

AXIAL (INFEROSUPERIOR)

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Cont…..

Central rayTo the midcoronal plane, passing

through the mid axillary region of the shoulder.

Angled 5 to 1 5 degrees medially when the patient cannot abduct the arm a full 90 degrees

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IndicationWhen the arm can’t be rotated or abducted To demonstrate proximal humerus in a 90º

projection from the AP

SHOULDER: TRANSTHORACIC LATERAL

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Shoulder: transthoracic lateralPatient positioningPatient is in erect or supinePatient in lateral position with affected

side towards the IRUnaffected arm raised ,forearm flexed

and placed over the head, shoulderelevated as much as possible(Elevation ofthe non-injured shoulder drops theinjured side separating the shoulders toprevent superimposition.)

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Central raydirected to the midcoronal plane at the level of surgical neck

of the humerusFull inspiration exposure as the lungs full of air improves the

contrast and decreases the expoure necessary to penetrate the body.

Evaluation criteriashows a lateral radiograph of the shoulder & true lateral view

of proximal humerus through the thorax

Scapulae superimposed over the thoracic spines

Unaffected clavicle & humerus projected above the shoulder

SHOULDER: TRANSTHORACIC LATERAL

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Shoulder : outlet projection(AP)Indications

Suspected shoulder impingement syndrome

To visualize anterior portion of acromion process

Patient positioning

Patient stands with affected shoulder against the IR and rotated 15 º to bring scapula parallel to IR

Arm abducted slightly

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Central rayDirected 30º caudally and centered to palpable

coracoid processEvaluation criteria

Demonstration of anterior part of acromion projected inferiorly

Subacromial joint space seen above the humeral head

Shoulder : outlet projection(AP)

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outlet projection(lateral)neer methodPatient positionPt stands or sits facing the cassette with lateral aspect of

affected arm in contactArm extended backward and back of hand rests on the

waistPt is rotated forward and body of scapula is made at right

angle to the cassette

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outlet projection(lateral)neer method

Central rayHead of humerus with 10º caudal angulation

Evaluation criteria Sub-acromial joint space seen

clearly

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Shoulder :PA oblique( scapular Y)

Indication

Suspected dislocation

Proximal humerus #

Scapular body #

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Cont…

Patient positioningErectAnterior aspect of affected shoulder towards

IRUnaffected shoulder raised so midcoronal

plane form angle of 45º-60º to the IR. I.e.; untilScapular flat surface perpendicular to IR

Central rayto the medial border of the scapula

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Cont…

Evaluation criteriaSuperimposed humeral head & glenoid

cavity; humeral shaft & scapular body.Acromion projected laterally & free of

superimposition

Coracoid superimposed with or projected below the clavicle

Scapula in lateral profile

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Glenohumeral joint:AP

Indications

To demonstrate glenoid cavity and glenohumeraljoint space(Coracoid#,glenoid#,proximalhumerus#)

Patient positionStand with affected shoulder against the cassetteRotated 30º to bring plane of glenoid fossa

perpendicular to the cassetteArm supinated and slightly abducted away from

the body5/15/2017 46

Central rayDirected toward the palpable coracoid process

GLENOHUMERAL JOINT:AP

Evaluation criteriaClear visualization of joint space between head of

humerus and glenoid cavity

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Glenohumeral joint:RPO or LPO

Patient positioning(Grasheymethod)Supine or erect (erect is comfortable)Body rotated towards the affected side until

the scapula is parallel with the plane of the IRso that the head of humerus in contact withthe IRSlight abduction of arm in internal rotation

with palm of the hand on the abdomen5/15/2017 48

Central ray

Perpendicular to the glenoid cavity

Evaluation criteria

Should demonstrate clearly the joint space between head of humerus and glenoid cavity

CONT…

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Similar to Grashey method but uses weighted abduction to demonstrate a loss of articular cartilage in the glenohumeral joint.

SHOULDER JOINT : Glenoid cavity RPO or LPO (Apple method)

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PATIENT POSITIONINGSimilar to Grashey method except;

Should hold ½ kg weight in hand on the affected side.While holding the weight, the patient should abduct the arm 90º from the midline of the

body.

CONT…

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EVALUATION CRITERIAOpen scapulohemeral joint.Soft tissue & bony trabecular

detail.

CONT…

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INDICATIONSShoulder instability,Glenoid #, Glenoid rim erosion.Hill-Sachs lesions, Bankart lesion.Soft tissue calcifications.

SHOULDER JOINT: GLENOID CAVITY RPO or LPO Axial oblique (Garth method)

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PATIENT POSITIONINGBody Rotated approximately 45º towards the

affected side.Affected arm adducted & elbow flexed to place

the forearm across the abdomen

CENTERING OF X-RAY BEAMAngled 45º caudad, through the

scapulohumeral joint

SHOULDER JOINT: GLENOID CAVITY RPO or LPO Axial oblique (Garth method)

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EVALUATION CRITERIAThe scapulohumeral joint, humeral head,

and scapular head and neck free ofsuperimposition

The coracoid process should be wellvisualized

Apical oblique: Garth view

SHOULDER JOINT: GLENOID CAVITY RPO or LPO Axial oblique (Garth method)

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Recurrent dislocation

Is associated with defects on head of humerus

In case of recurrent anterior dislocation, defect will occur on posterolateral aspect of head of humerus(hill sach’s lesion)

In case of recurrent posterior dislocation, defect will be on anterior part of head

Dislocated head of humerus also impacts on glenoid rim

In case of recurrent dislocations, 3 Ap projections (with humerus lateral, oblique & Stryker’s) & Inferosuperior views are done.

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lateral &oblique humerus

Patient position

Patient lies erect or supine

Unaffected shoulder raised 30degree to bring glenoidcavity right angle to centre of IR

lateral humerus

Arm partially abducted, elbow flexed, and palm of handrest on patients waist5/15/2017 57

oblique humerusThe elbow is extended, allowing the arm to rest in

partial abduction by the patient’s side.

The humerus is now in an oblique position

LATERAL &OBLIQUE HUMERUS)

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Central rayDirected to head of the humerus

Evaluation criteriaShould demonstrate head and neck of humerus and glenoid cavity with

glenohumeral joint clearly shown

LATERAL &OBLIQUE HUMERUS)

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AP(modified)-Stryker notch view

Patient positioningPatient lies supineArm of affected side is extended fully and the elbow is flexed to allow the

hand to rest on patient’s head

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Cont..Central rayAngled 10º cranially and directed through the

centre of the axilla

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INDICATIONSTo evaluate the tendon of the long head of biceps.

PATIENT POSITIONINGSupine, seated or standing.Forearm extended & hand supinated 45º.Chin extended & head rotated away from the

affected side.IR supported vertically above the shoulder.

SHOULDER JOINT: BICIPITAL GROOVE TANGENTIAL

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CENTERING OF X-RAY BEAMAngled 10º-15º downward from the

horizontal & to the long axis of the humerusfor the supine position. ( 10º-15º cephaladfor erect).

Fisk modification: Perpendicular to the IR when the patient is

leaning 10º-15º forward from the vertical humerus position.

SHOULDER JOINT: BICIPITAL GROOVE TANGENTIAL

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EVALUATION CRITERIAIntertubercular groove free from superimposition with surrounding shoulder structures.

SHOULDER JOINT: BICIPITAL GROOVE TANGENTIAL

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Acromioclavicular joints:AP

IndicationTo visualize dislocation, Separation, SubluxationTo compare functional difference of ACJsAC arthritis & Osteopathy

Patient positioningPatient stands facing the x-ray tube, arms relaxed to the sideCenter the midline of the body to the midline of the grid.

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Cont…

weight bearing comparison projection of both ac joint can be done for subluxation(Pearson method) i;e Equal weight is strapped around lower arm (wrist) of the patient

Central rayIf bilateralprojection then :Perpendicular to the midline of the body at the level

of the acromioclavicular jointsIf only one side then:To the palpable lateral end of clavicle at acromioclavicular

joint(to avoid superimposition 25 º cranial angulation can be given)

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Evaluation criteriaDemonstration of acromioclavicular joint Soft tissue around the articulation must be visible

CONT…

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Clavicle :PAPreferable since clavicle lies close to cassette-

optimum bony detail, reduces the radiation dose tothyroid and eyes

Patient positioningPatient stands facing the IR with clavicle in centre

of IRPatient’s head is turned away from side being

examinedCentral ray

Perpendicular to the midshaft of clavicle

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AP(alternate)Patient positioning

Adjust the body to center the clavicle to the midline of the table or vertical grid device.

Place the arms along the sides of the body, and adjust the shoulders to lie in the same horizontal plane.

Center the clavicle to the IRCentral ray

Perpendicular to the midshaft of clavicle

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Cont….

Evaluation criteriaEntire length of clavicle should be

included along with the acromioclavicularand sternoclavicular jointsLateral end of clavicle demonstrated clear

of thoracic cage

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Clavicle :Ap axial(Lordotic position)

Patient positioningPatient is made to sit or stand in front of the vertical IR facing the x-ray

tube(supine-alternate)Patient leans backward in a position of extreme lordosis and rest the neck and

shoulder against the vertical grid deviceNeck in extreme flexion

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Cont…

Central rayOver the mid shaft of the clavicle

with angulations(0-15)degree for standing &(15-30) degrees for supine

Evaluation criteriaClavicle projected above the ribs and

scapula with medial end overlapping the 1st and 2nd ribEntire clavicle with AC and SC joint

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Scapula :AP

Patient positioningAbduct the arm to a right angle with the body to draw the scapula

laterally. flex the elbow, and support the hand in a comfortable position.For this projection, do not rotate the body toward the affected side

because the resultant obliquity would offset the effect of drawing the scapula laterally

Central rayPerpendicular to the mid scapular area at a point approximately 2

inches (5 cm) inferior to the coracoid process

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Cont..

Evaluation criteria

Lateral portion of the scapula free of superimposition from the ribsScapula horizontal and not obliqueScapular detail through the superimposed lung

and ribs (Shallow breathing should help obliterate lung detail)

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Scapula :lateral

Patient positioningPatient stands with affected side against the IRArm is either adducted across the body or abducted

with the elbow flexed and back of hand rest on the hipPatients trunk is rotated forward until the body of

scapula is at right angles to the cassetteCentral ray

To the midpoint of medial border of scapula

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Scapula :lateral

Evaluation criteriaLateral and medial border superimposedNo superimposition of the scapular body on

the ribs No superimposition of the humerus on the

area of interest

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Questions?

1. Bone involved in the shoulder joint formation?2. What kind of joint in shoulder and it’s type?3. Basic projection of shoulder joint?4. Basic projection of clavicle ?5. What is Hill-sach defects ,what is projection done for

it?6. Mention position of patients in superior interior axial

projections?7. What is bursa and what is projection for bursitis?

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