Shoulder Anatomy Anatomy of shoulder and clavicle 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

Various shoulder protocolso Protocol dependent on pt history

Pain/pathology Hx of trauma Thoracic outlet syndrome

o Projections may vary facility to facility AP interal AP external AP neutral AP oblique PA Scapular Y AP Scapular Y Inferosuperio axial Superinferio axial Apical AP Neer method

o Pathology/ pain protocol Usually 2 AP positions AP with internal AP with external CR perp 1” inferior to coracoid

AP Internalo 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 tubercle

AP Externalo Moves greater tubercle superiolateral and into profileo Palm upo Also visualize “Bankart lesions”

Anterior dislocation of the rim of the glenoid Sometimes do a 15 degree caudal angle to look for osteophyte in subacromial

space If you cannot get external rotation you can use Grashey if you cannot get arm Trauma Protocols

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

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

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 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 glenoid Apical oblique

o Referred to as 45-45 o 45 degrees towards affected side o Position is same as AP Oblique but CR is directed @45 degrees caudalo 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 PA Scapular “Y”

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

o Pt is PA with affected side towards the IRo 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 IRo Coracoid should always be pointing

mediallyo Acromin lateral o Lesser tubercle should be seen free of

superimposition and pointing medially Scapular anterior dislocation

o 97% of all shoulder dislocations are anteriorly displaced

o 2% are posteriorly displacedo 1% are interiorly displaced

humeral head down low/ underneath glenoid 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 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 rotatedo 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

When you supinate the hand you see lesser tubercle o Internal, Y, and inferosuperio axial

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

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

Thoracic Outlet syndrome o Supraspinatus outlet syndrome or

impingement syndrome

o Requires positions/projections with caudal angles to better visualize subacromial space

o Attempting to visualize “osteophytes” extending from the inferior acromial surface

o Can also be performed to demonstrate subacromial bursitis Usual projections for TOS

o 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 oblique

o 45/45o Position same as AP/Garth

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

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

visibility Image critique

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

Lateral Scapulao RAO/LAO affected side closest to receptoro Position is similar to “Y”o Instruct pt to place forearm and hand over posterior wristo Palpate vertebral and axiallary borders to ensure superimposition

Image critiqueo See border of scapula o Can see stellate FX

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

Clavicle

o FX to the clavicle usually occur due to falls on the outstretched hand, or direct blow

o Recognized as the most common injury associated with childbirth, and children in general

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

PA Clavicleo Position affected side closest to receptoro Adjust shoulders to lie in the same transverse planeo CR perp to exit mid-shaft of clavicle o Must include S-C jointso Suspended exhalation

AP clavicle o Increase OID will result in increase magnification and decrease in

detail PA axial

o Projects clavicle superior to ribs/scapula Push clavicle up as much as you can

o Clavicle imaged horizontal placemento Position pt similar to PAo CR directed caudal, 25-30 degrees to exit the midshaft of the clavicle

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

clavicle above ribs/scapulao You want full inhalation o PA= caudally

AP Axialso Same image can be obtained in the AP erect or recumbent positiono 2 methods can be used

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

angle to try to straighten out the clavicle a little more Acromioclavicular articulations

o Performed frequently in orthopedic officeso Done to demonstrate separation, dislocation of the AC jointo Evidenced by widening of the joint of one side vs the othero Radiographs of the shoulder should be performed/ reviewed prior to

these projections to r/o FX in the shoulder girdle AC joints

o Always performed bilateral for comparisono Images performed in AP Erect position

No weight With weights

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

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