1 14.1 Shoulder Radiography Routine Non-Trauma: A-P with internal and external rotation of humerus...

1

14.1 Shoulder Radiography

• Routine Non-Trauma: A-P with internal and external rotation of humerus

• Trauma or Dislocation Shoulder: A-P internal rotation, Lateral scapula or “Y” view, Apical Oblique,possible or Stryker Notch and P-A Axillary

• Shoulder Instability: Weighted internal and external rotation, Stryker Notch

2

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.

3


• 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.

4


• 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.

5

14.2 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

6

Shoulder A-P with Internal Rotation

• 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.

7


• 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.

8


• Breathing Instructions: suspended respiration

• Make exposure and let patient breathe and relax.

• Some facilities will use a 12” x 10 cassette

9

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.

10

14.3 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

11

Shoulder A-P with External Rotation


• 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.

12


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


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

13


• Breathing Instructions: suspended respiration


• Some facilities will use a 12” x 10 cassette

14

Shoulder A-P with External Rotation Film

• The glenohumeral joint should be open

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

15

14.4 Shoulder Apical Oblique


• Protection: Half apron


• Tube angle: 30 degrees caudal

• Film size: 10” x 12” Regular I.D. to spine

16

Shoulder Apical Oblique• Patient stands facing tube

with humerus internally rotated until the epicondyles are perpendicular to film

• The patient is rotated 15 to 45 degrees to get the scapula parallel to film and Bucky.

• SID adjusted for tube angle.

17

Shoulder Apical Oblique

• Horizontal CR: 2” above the coracoid process of glenohumeral joint.

• Vertical CR: Coracoid process to glenohumeral joint.


18

Shoulder Apical Oblique

• Collimation: to include all soft tissue around shoulder and proximal humerus

• Breathing Instructions: Suspended respiration

• Make exposure and let patient breathe and relax

19

Shoulder Apical Oblique Film

• Should visualize the head of the humerus within the glenoid fossa.

• The tube angle results in minimal superimposition

• Useful in detection of dislocations, Bankhart and Hill-Sachs defects.

• Can be taken with arm in sling.

20

14.5 Shoulder: Prone Axillary

• Measure: A-P at coracoid


• SID: 40” Non- Bucky

• Tube angle: 15 to 25 degrees down

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

• Special Equipment: rectangular and large angle sponge

21

Shoulder: Prone Axillary

• Table placed in front of tube. Two to three inch thick rectangular sponge placed on table top.

• Large angle sponge used to hold film vertical.

• Tube aligned to film and SID set at 40” using tape measure on collimator.

22


• The patient is asked to lean over table with arm abducted 90 degrees. The elbow is bent 90 degrees and hangs off the table.

• The arm and shoulder will be resting on rectangular sponge.

• The mid sagittal plane of the patient is turned 10 to 25 degrees medially.

23


• The head and neck is turned away from the affected shoulder.

• The film is placed next to the neck.

• Horizontal CR: 2” above the glenohumeral joint.

• Vertical CR: through the glenohumeral joint

24


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

• Breathing instructions: full inspiration or suspended respiration


25

Shoulder: Prone Axillary Film

• Also known as as West Point View.

• The best view for visualizing the glenohumeral joint space free of superimposition.

• This view is very difficult to set up with tube stands common to office practices.

26

14.6 Shoulder Outlet View• Measure: A-P at coracoid

process



• Tube Angle: 15 to 30 degrees caudal for Outlet View. 0 to 10 degrees for Lateral Scapula or “Y” view

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

27

Shoulder Outlet 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.

28

Shoulder Outlet 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

29


• 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.

30


• 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.

31


• There are four abnormal acromion shapes that predispose impingement.

• Flat Underside

• Underside concave following curve of the humeral head

• Anterioinferior acromial spur or hook

• Underside convex

32

14.16 Scapula Lateral View or “Y” View




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

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

33

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.

34

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.


35


• 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.

36


• 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.

37

14.7 Shoulder: Stryker Notch




• Tube angle: 45 degrees cephalad

• Film: 8” x 10” Regular with I.D. to spine

38

Shoulder: Stryker Notch

• Patient stands facing tube. The body is rotated 15 to 45 degrees to get scapula parallel to film

• The patient abducts arm and placed hand behind neck.

• The humerus should be internally turn to get humerus perpendicular to film.

39


• Horizontal CR: about 2” inferior to coracoid process or through the glenohumeral joint.

• Vertical CR: glenohumeral joint space

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

40


• Breathing Instructions: Full Inspiration.

• Note : Make sure that the glenohumeral joint space stays within collimation and central ray placement by having patient take a full breathe in and hold it before taking film.

41

Shoulder: Stryker Notch Film

• This view will provide a clear view of the posterior and superior aspects of the head of the humerus.

• The inferior borders of the glenoid fossa and joint space will be seen.

• It is useful in detecting Hill-Sachs defects and anterior instability

42

14.15 Scapula A-P




• No Tube Angle

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

43

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

44

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

45

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.

46

Scapula A-P Film

• Glenohumeral joint and entire scapula should be seen.

• Soft tissues of shoulder should be seen.

47

14.8 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

48

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.

49

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

50

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.

51

14.8 Clavicle P-A Axial




• Tube Angle : 10 to 15 degrees caudal


52

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.

53

Clavicle P-A Axial• Collimation Top to





54

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.

55

14.9 Clavicle A-P




• No Tube Angle


56

Clavicle A-P

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

• Horizontal CR: centered to clavicle



57

Clavicle A-P• Collimation Top to





58

Clavicle A-P Film

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


59

14.11 Clavicle A-P Axial




• Tube Angle : 15 to 25 degrees cephalad


60

Clavicle A-P Axial


• Horizontal CR: one inch below center of clavicle


• Horizontal CR centered to bottom half of film.

61

Clavicle A-P Axial• Collimation Top to





62

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.

63

14.12 Acromioclavicular Joint Unilateral




• 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

64

Acromioclavicular Joint Unilateral


• Horizontal CR: A-C joint

• Vertical CR: A-C joint


• Marker: anatomical

65


• 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

66


• 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

67


• Horizontal CR: A-C joint

• Vertical CR: A-C joint

• Center horizontal CR to bottom half of film.


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

68

Acromioclavicular Joint Unilateral Film

• The most common view here is the Zanca modification to the unilateral ribs.

• The Zanca Views will open the acromion space better than the straight A-P views.

69

14.13 Acromioclavicular Joints Bilateral A-P



• SID: 72” Non-Bucky

• Tube Angle: none Zanca View 15 degree cephalad angle

• Film: 17” x 7” or 17” x 14” I.D. to unaffected side

70

Acromioclavicular Joints Bilateral A-P

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


• Horizontal CR: at level of A-C Joints. Zanca: 1” below A-C Joints

71


• Vertical CR: mid-sagittal

• Collimation: to include both A-C joints and adjacent soft tissue and slightly less than film size on 17” x 7” film.


72


• 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.

73


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

• Breathing instructions: Deep Inspiration

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

74

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.

75

14.14 Zanca Views of the A C Joints


• Protection: half apron• SID: 40” Bucky• Tube Angle: 15°

cephalad• Film: 10” x 12”

Regular Speed

76

Zanca Views of the A C Joints

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

• Horizontal CR: 1” below A C Joint

• Vertical CR: through the A C Joint

77


• Bottom half of film centered to Horizontal CR.

• Collimation top to bottom: to include A- C Joint

• Collimation side to side: soft tissues adjacent to A-C Joint

78



• Rehearse breathing to make sure the A J joint will be seen on full inspiration.

• Make exposure and ask patient not to move.

• Strap weights around wrists.

79


• Adjust Horizontal CR for the weight, still 1” below A-C Joint

• Center remaining half of film to Horizontal CR

• Place arrow or weighted marker on film.

• Have patient take a deep breath and make exposure.

80

Zanca View Films

• Weighted and Non-Weighted Views are taken as stress views of the Acromioclavicular Joint.

• Useful in detection separations

81

Zanca View Films

• The Zanca View will open the sub-acromion space better than the standard A-P view.

• If separation is not suspected, it can be used to evaluate bone loss in the A-C Joint. A single view on an 8” x 10” is taken.

82

The End

Return to the Lecture Index

1 14.1 Shoulder Radiography Routine Non-Trauma: A-P with internal and external rotation of humerus...

Documents

Transcript of 1 14.1 Shoulder Radiography Routine Non-Trauma: A-P with internal and external rotation of humerus...