Shoulder girdle presentation

Shoulder Girdle

Prepared By:Valerie Gentizon-OrpillaLorma Colleges

Shoulder Girdle

Shoulder GirdleThe shoulder girdle is formed by twobones, the clavicle and scapula. Their

function is to connect the upper limb tothe trunk.

ClavicleThe clavicle, classified as a long bone, has

a body and two articular extremities

The lateral aspect is termed the acromiaLextremity, and it articulates with theacromion process of the scapula. The

mediaL aspect, termed the sternal extremity,articulates with the manubrium of the sternum

and the first costal cartilage

Lateral aspectMedial aspect

Sternal extremity

Acromial extremity

clavicle

acromion

neck

Glenoid cavity

Coracoid process Scapular

notch

ANTERIOR SURFACE

Superior angle

Crest of spine

Inferior angle

Neck

Glenoid cavity

Medial border

DORSAL SURFACE

Dorsal surface

spine

acromion

Lateral border

Inferior angle

Costal (anterior)surface

Glenoid cavity

Coracoid process

LATERAL ASPECT OF THE SCAPULA

HumerusThe proximal end of the humerus consists of

a head, an anatomic neck, two prominentprocesses called the greater and Lesser

tubercles. and the surgical neck .The head is large, smooth, and rounded, and

it lies in an oblique plane on the superomedialside of the humerus.

Surgical neck

Intertubercular groove

Greater tubercle head

Anterior Aspect of Right Proximal Humerus

headGreater tubercle


Lesser tubercle

POSTERIOR PART

Structural classification

Joint TypeTissue Movement

Scapulohumeral

Acromioclavicular

Sternoclavicular

Synovial

Synovial

Synovial

Ball and Socket

Gliding

Double gliding

Freely movable

Freely movable

Freely movable

Scapulohumeral joint

SUMMARY OF PATHOLOGYbursitis Inflammation of the bursa

Dislocation Displacement of a bone from the joint space

Fracture Disruption in the continuity of bone

Hills-Sachs DefectImpacted fracture of the posterolateral aspect

of the humeralhead with dislocation

Metastases

osteoarthritis

Transfer of a cancerous lesion from one area to another

Form of arthritis marked by progressive cartilage deterioration insynovial joints and vertebrae

Osteopetrosis Increased density of atypically soft bone

Osteoporosis

Rheumatoid Arthritis

Tendonitis

Chondrosarcoma

Tumor

Loss of bone density

Chronic. systemic. inflammatory collagen disease

Inflammation of the tendon and tendon-muscle attachment

New tissue growth where cell proliferation is uncontrolled

Malignant tumor arising from cartilage cells

Shoulder“ AP PROJECTION”

External, Neutral, Internalrotation humerus

NOTE: Do not have the patient rotate the arm iffracture or dislocation is suspected.

Supinating the hand will position the humerus in external rotation

The palm of the hand placed againstthe hip will position the humerusin neutral rotation,

The posterior aspect of the handplaced against the hip will positionthe humerus in internal rotation.

AP shoulder. External rotation humerus,Greater tubercle (arrow),

AP shoulder, Neutral rotation humerus,Greater tubercle (arrow),

AP shoulder, Internal rotation humerus, Greatertubercle (arrow): lesser tubercle in profile,

Central ray• Perpendicular to a point I

inch (2.5 cm)inferior to the coracoid

process

clavicle

coracoid

acromion

Glenoid cavity/scapulohumeral joint

scapula

humerus

AP shoulder, external rotation humerus: greater tubercle (arrow).

AP shoulder, neutral rotation humerus: greater tubercle (arrow).

AP shoulder, internal rotation humerus: greater tubercle (arrow): lesser tubercle in profile (arrowhead

TRANSTHORACIC LATERALPROJECTION

‘’LAWRENCE METHOD‘’R or L position

The Lawrence method is used whentrauma exists and the arm cannot be

rotated or abducted because of an injury.

Upright transthoracic lateral shoulder: Lawrence Method

Recumbent transthoracic lateral shoulder: Lawrence

Method

Central ray• Perpendicular to the IR, entering themidcoronal plane at the level of the surgical neck.• If the patient cannot elevate the unaffectedshoulder, angle the central ray 10 to 15 degrees cephalad to obtain a comparableradiograph.

Unaffected clavicle

Scapula (superior border)

SternumClavicle

Acromion processHumeral headScapula (lateral border)

Proximal humerus

Transthoracic lateral shoulder: Lawrence method.

Transthoracic lateral shoulder (patient breathing): Lawrence

method .

Structures shownA lateral image of the shoulder and proximal humerus is projected through thethoraxEVALUATION CRITERIAThe following should be clearly demonstrated:• Proximal humerus• Scapula, clavicle, and humerus seenthrough the lung field• Scapula superi mposed over the thoracicpine• Unaffected clavicle and humerus projectedabove the shoulder closest to the IR

1.INFEROSUPERIOR AXIALPROJECTION

(LAWRENCE METHOD)2.INFEROSUPERIOR AXIAL

PROJECTIONRAFERT ET AL MODIFICATION

Inferosuperior axial shoulder joint: Lawrence method.

Inferosuperior axial shoulder joint:Rafert modification. Note the exaggeratedexternal rotation of arm and thumb pointingdownward. If present. a Hill-Sachsdefect would show as a wedge-shapeddepression on the posterior aspect of thearticulating surface of the humeral head.arrow

Lesser tubercle

Humerus

Coracoid process

Acromioclavicular jt

clavicle

Scapulohumeral joint

acromionInferosuperior axial shoulder joint:

Lawrence method

INFEROSUPERIOR AXIALPROJECTION

WEST POINT METHOD

Inferosuperior axial shoulder joint: West Point method.

Central ray• Directed at a dual angle of 25 degrees anteriorly from the horizontal and 25 degrees medially. The central ray entersapproximately 5 inches ( 13 cm) inferior and I 1/2 inch (3.8 cm) medial to the acromialedge and exit the glenoid cavity.

West Point method with anterior and medial central ray angulation.

EVALUATION CRITERIAThe fol lowing should be clearly demonstrated:• Humeral head projected free of thecoracoid process• Articulation between the head of thehumerus and the glenoid cavity• Acromion superimposed over the posterior portion of the humeral head• Shoulder joint

Structures shownThe resulting image shows bony abnormalitiesof the anterior inferior rim of the glenoid in patients with instability of theshoulder

acromionScapulohumeral

jointGlenoid rim

clavicle

Coracoid

processLesser

tubercle

Inferosuperior axial shoulder joint: West Point method.

INFEROSUPERIOR AXIALPROJECTION

CLEMENTS MODIFICATION

Inferosuperior axial shoulder joint: Clements modification. A. Arm abducted90 degrees. B. Arm partially abducted

Position of patient• When the prone or supine position isnot possible, Clements suggested that the patient be radiographed in the lateral recumbent position lying, on the unaffected side.• Flex the patient's hips and knees.

Position of part• Abduct the affected arm 90 degrees,and point it toward the ceiling.• Place the fR against the Superior aspectof the patient's shoulder,holding it inplace with the unaffected arm or by securing i t appropriately • ShieLd gonads.• Respiration: Suspend.

Central ray• Horizontal to the midcoronal plane,passing through the midaxillary regionof the shoulder.• Angled 5 to 1 5 degrees medially whenthe patient cannot abduct the arm a full90 degrees (Fig. 5-28, B). The resultingradiograph

SUPEROINFERIOR AXIAL

PROJECTION

Superoinferior axial shoulder joint: standard IR.

Structures shownA superoinferior axial image shows thejoint relationship of the proximal end ofthe humerus and the glenoid cavity . The acromjoclavicular articulation,the outer portion of the coracoid process,and the points of insertion of the subcapularis muscle ( at body of scapula) and teres minor muscle ( at inferior axillaryborder) are demonstrated.

EVALUATION CRITERIAThe following should be clearly demonstrated:• Open scapulohumeral joint (not open on patients with limited flexibility)• Coracoid process projected above the clavicle• Lesser tubercle i n profile• Acromioclavicu lar joint through thehumeral head

Central ray• Angled 5 to 1 5 degrees through theshoulder joint and toward the elbow

CORACOID PROCESS

LESSER TUBERCLE

HUMERUS

ACROMION

CLAVICLE

Superoinferior axial shoulder joint.

AP AXIAL PROJECTION

AP axial shoulder joint.

Central ray• Directed through the capulohumeraljoint at a cephalic angle of 35 degrees

Structures shownThe axial image shows the relationship of the head of the humerus to the glenoid cavity. This is useful in diagnosing cases of posterior djslocation

EVALUATION CRITERIAThe following should be clearly demonstrated:• Scapulohumerai joint• Proximal humerus• Clavicle projected above superior angleof scapula

AP axial shoulder joint.

Scapular Y‘’ PA OBLIQUE PROJECTION’’

RAO or LAO positionThi projection, described by Rubin,

Gray, and Green, obtained its name as aresult of the appearance of the scapula.

The body of the scapula forms the verticalcomponent of the Y, and the acromion andcoracoid processes form the upper limbs.The projection is useful in the evaluation

of suspected shoulder dislocations.

PA oblique shoulder joint.

Central ray• Perpendicular to the scapulohumeral joint

Structures shownThe scapular Y is demonstrated on anoblique image of the shoulder. In the normalshoulder the humeral head is directlysuperimposed over the junction of the Y. In anterior (subcoracoid) dislocations, the humeral head is beneath the coracoid process (Fig. 5-36); in posterior( subacromial) dislocations, it is projected beneath the acromion process. An APshoulder projection is shown for comparison.

EVALUATION CRITERIAThe following should be clearly demonstrated:• No superimposition of the scapularbody over the bony thorax• Acromion projected laterally and freeof superimposition• Coracoid possibly superimposed orprojected below the clavicle• Scapula in lateral profile

10-15°

(AC Articulation)ALEXANDER

Shoulder( Scapular Y )

Scapula( Lateral )

Shoulder ( NEER)

Name Body Rotation Scapula Rel. to IR Central ray angle Central ray entrance pt Arm position

Acromioclaviculararticulation:1.AlexanderMethodShoulder jOint:2.Neer methodShoulder Joint:3.scapular Y4.Scapula lateral

45 to 60 degrees

PerpendicularT

15° caudad

10 to 15 degreesborder caudad

0 degrees

0 degrees

Acromioclavicular joint

Superior humeral

Scapulohumeral jointCenter of medial border of

scapula

Across chest

At the side

At the sidevariable

PA oblique shoulder Joint. Note the scapular Y components-body, acromion,and coracoid.

PA oblique shoulder Joint showing anterior dislocation(humeral head projected beneath coracoid process).

Glenoid CavityAP OBLIQUE PROJECTION

GRASHEY METHODRPO or LPO position

Upright AP oblique glenoid cavity: Grashey method.

Recumbent AP oblique glenoid cavity: Grashey method.

Central ray• Perpendicular to the glenoid cavity at a point 2 inches (5 cm) medial and 2 inches (5 cm) inferior to the superolateralborder of the shoulder.

Structures shownThe joint space between the humeral head and the glenoid cavity (scapulohumeraljoint) is shown.

EVALUATION CRITERIAThe fol lowing should be clearly demonstrated:• Open joint space between the humeralhead and glenoid cavity• Glenoid cavity in profi le• Soft tissue at the scapulohumeral jointalong with trabecular detail on the glenoidand humeral head

acromion

Humeral head

Glenoid cavity

clavicle

AP oblique glenoid cavity: Grashey method showing moderate deterioriation of the scapulohumeral joint.

Supraspinatus "Outlet"TANGENTIAL PROJECTION

NEER METHODRAO or LAO position

This radiographic projection is useful todemonstrate tangentially the coracoacromial

arch or outlet to diagnose shoulderi mpingement. The tangential image isobtained by projecting the x-ray beam

under the acromion and acromioclavicularjoint, which defines the superior border of

the coracoacromial outlet.Image receptor: 8 x 10

Structures shownThe tangential outlet image demonstrates the posterior surface of the acromion and theacromioclavicular joint identified as the superior border of the coracoacromial outlet.Central ray

• Angled 10 to 15 degree caudad, enteringthe superior aspect of the humeral head

EVALUATION CRITERIAThe following should be clearly demonstrated:• Humeral head projected below the acromioclavicular joint• Humeral head and acromioclavicular joint with bony detail• Humerus and scapular body, generallyParallel.

Shoulder joint: Neer method.Supraspinatus outlet (arrow).

Tangential supraspinatus outlet projection showing impingement of the shoulder outlet (arrow). B, Radiograph of same patient as in Fig. 5-48 after surgical removal of posterolateral surface of clavicle.

Proximal HumerusAP AXIAL PROJECTION

STRYKER " NOTCH " METHOD'dislocations of the shoulder are frequently

caused by posterior defectsinvolving the posterolateral head of thehumerus. Such defects, called Hill-Sachs

defects, are often not demonstrated usingconventional radiographic positions. Hall,

Isaac, and Booth' described the notch projection,from ideas expressed by Cm. W.S.

Stryker U . S . N . , as being useful in identifying the cause of shoulder dislocation.

AP axial humeral notch: Stryker notch method

EVALUATION CRITERIAThe following should be clearly demonstrated:• Overlapping of coracoid process andclavicle• Long axis of the humerus aligned withthe long axis of the patient's body• Bony trabeculation of the head of thehumerus

Structures shown:The resulting image will how the po -terosuperior and posterolateral areas of the humeral head.

Central ray• Angled 10 degrees cephalad, enteringthe coracoid process.

AP axial humeral notch: Stryker notch method. Same projection in a patient with a

small Hill-Sachs defect (arrow).

Humerus

AcromionClavicle

Coracoid prcess

Humeral head

Body of scapula

Scapular spine

Glenoid CavityAP OBLIQUE PROJECTION

APPLE METHOD!RPO or LPO position

This projection is similar to the GrasheyMethod but uses weighted abduction to

demonstrate a loss of articular cartilage inthe scapulohumeral joint.

Axial oblique projection: Apple method

Central ray• Perpendicular to the IR at the level of the coracoid process

Structures shownThe scapulohumeral joint

EVALUATION CRITERIAThe following should be clearly demonstrated:• Open joint space between the humeral head and the glenoid cavity• Glenoid cavity in profile• Soft tissue at the scapulohumeral joint along with trabecular detail on the glenoid and the humeral head• The arm in a 90 degree position

A, AP oblique projection: Grashey method, of the shoulder showing a normalscapulohumeral joint space. B, AP oblique projection: Grashey method, with weighted abduction showing loss of articular cartilage (arrow).

Glenoid CavityAP AXIAL OBLIQUE PROJECTION

GARTH METHOD )RPO or LPO position

This projection is recommended for acuteshoulder trauma and for identifying

posterior scapulohumeral dislocations, glenoid fractures, Hill-Sachs lesions, and soft

tissue calcifications.

AP axial oblique: Garth method. RPO position. Note 45 degree CR. B, Topview of same position as A. Note 45 degree patient position.

AB

Central ray• Angled 45 degree caudad through the scapulohumeral joint.

Structures shownThe scapulohumeral joint, humeral head, coracoid process, and scapular head and neck are shown.

EVALUATION CRITERIAThe following should be clearly demonstrated:• The scapulohumeral joint, humeral head, and scapular head and neck free of superimposition• The coracoid process should be well visualized• Posterior dislocations will project the humeral head superiorly from the glenoidcavity and anterior dislocations project inferiorly.

AP axial oblique: Garth method demonstrates an anterior dislocation of the proximal humerus. The humeral head is shown below the coracoid process, a common appearance with anterior dislocation.

Intertubercular Groove'" TANGENTIAL PROJECTION

FISK MODIFICATION )

In recent years, various modifications of the intertubercular groove image have been devised. In all cases the central ray is aligned to be tangential to the intertubercular groove, which

lies on the anterior surface of the humerus.The x-ray tube head assembly may limit the performance of this

examination. Some radiographic units have large collimatorsand/or handles that limit flexibility in positioning. A mobile

radiographic unit may be used to reduce this difficulty.

Supine tangential intertubercular groove. Standing tangential intertubercular groove: Fisk modification.

Central rayAngled 10 to 15 degrees posterior (downward from horizontal) to the longaxis of the humerus for the supine position

Fisk Modification• Perpendicular to the I R when the patient is leaning forward and the verticalhumerus is positioned 10 to 15 degrees.

Structures shownThe tangential image profiles the intertubercular groove free from superimpositionof the surrounding shoulder structures.

EVALUATION CRITERIAThe following should be clearly demonstrated:• Intertubercular groove in profile• Soft tissue along with enhanced visibili ty of the intertubercular groove.

Supine tangential intertubercular groove.

Standing tangential intertubercular groove: Fisk modification.


Lesser tubercle

Coracoid process

Greater tubercle

Proximal Humerus

Teres Minor InsertionPA PROJECTION

BLACKED-HEALY METHOD

Supraspinatus

infraspinatus

Teres major

Teres minnor

Lateral head

triceps

Muscles on dorsal surface (posterior) part of the scapula and humerus

PA proximal humerus for teres minor insertion.



clavicle

acromion

Greater tubercle

Lesser

tubercle

Teres minor

insertion

Structures shownThis position rotates the head of the humerus so that the greater tubercle is brought anteriorly, giving a tangential image of the insertion of the teres minor atthe outer edge of the bone just below the articular surface of the head.

EVALUATION CRITERIAThe following should be clearly demonstrated:• Outline of the greater tubercle superimposingthe humeral head• Lesser tubercle in profile and pointing medially• Soft tissue around the humerus alongwith trabecular detail on the humeral head.

Central ray• Perpendicular to the head of the humerus.

Proximal Humerus

Subscapular InsertionAP PROJECTION

BLACKED-HEALY METHOD

subscapularis

Long head head of biceps brachii

biceps

Muscles on costal (anterior) surface of the scapula and proximal humerus

AP proximal humerus for subscapularis insertion. AP proximal humerus for subscapularis insertion.

AP proximal humerus for subscapularis insertion .

Humeral head

Glenoid cavity

Subscapularis

insertion

Lesser tubercle

Greater tubercle

Central ray•Perpendicular to the shoulder joint, entering the coracoid process

Structures shownThis method provides an image of the insertion of the subscapularis at the lesserTubercle.

EVALUATION CRITERIAThe following should be clearly demonstrated:• Lesser tubercle in profile and pointing inferiorly• Outline of the greater tubercle superimposingthe humeral head• Soft tissue around the humerus along with trabecular detail on the humeral head.

Acromioclavicular Articulations

Infraspinatus InsertionAP AXIAL PROJECTION

Place the patient in the supine position with the affected arm by the patient's side.Turn the arm in external rotation to open the subacromial space (Fig. 5-62, A ) . Rotate the arm to the neutral position (Fig. 5-62, B) and then in complete internalrotation (Fig. 5-62, C) to allow full evaluation of the humeral head. Direct the centralray to enter the coracoid process at an angle of 25 degrees caudad. The imageprofiles the greater tubercle, the site of insertion of the infraspinatus tendon, andopens the subacromial space.

AP axial. 25-degree caudal angulation. demonstrating calcareous peritendinitis(arrows). A, External rotation. B, Neutral position. C, Internal rotation.

AcromioclavicularArticulations

AP PROJECTIONBilateral

PEARSON METHOD

SID: 72 inches ( 183 cm). A longer SIDreduces magnification, which enables

both joints to be included on one i mage.It also reduces the distortion of the joint

space resulting from central ray divergence.

Bilateral AP acromioclavicular articulations.

Bilateral AP acromioclavicular joints demonstrating normal left joint and separation of right joint (arrow).

Normal acromioclavicular joints requiring two separate radiographs.

Structures shownBilateral images of the acromioclav icularjoints are demonstrated (Figs. This projection is used to demontrate dislocation, separation, and functionof the joints.

Central ray• Perpendicular to the midl ine of the body at the level of the acromioclavicular joints for a single projection; directed at each respective acromioclavicular joint when two separate exposures are needed for each shoulderin broad-shouldered patients.

EVALUATION CRITERIAThe following should be clearly demonstrated:• Acromioclavicular joints visualized with some soft tissue and withoutexcessive density• Both acromioclavicular joints, with andwithout weight , entirely included on one or two single radiographs• No rotation or leaning by the patient• Right or left and weight or nonweight markers• Separation, if done,clearly seen on the images with weights.

Acromioclavicular ArticulationsAP AXIAL PROJECTIONALEXANDER METHOD

Alexander suggested that both AP and PAaxial oblique projections be used in cases

of suspected acromioclavicular subluxationor dislocation. Each side is examjned

separately.

AP axial acromioclavicular articulation: Alexander method.

Unilateral AP axial acromioclavicular articulation: Alexander method

Central ray• Directed to the coracoid process at a cephalic angle of 15 degrees .This angulation projects the acromioclavicularjoint above the acromion.

Structures shownThe resulting image will show the acromioclavicular joint projected slightly superiorly compared with an A P projection.

EVALUATION CRITERIAThe following should be clearly demonstrated:• Acromioclavicular joint and c lavicle projected above the acromion.• Acromioclavicular joint visualized with some soft tissue and without excessiveDensity.

ClavicleAcromioclavicular

Joint (AC jt)

Acromion

Coracoid process

Humeral

head

AP axial acromioclavicular articulation: Alexander method.

Acromioclavicular Articulations

PA AXIAL OBLIQUE PROJECTION(ALEXANDER METHOD)

RAO or LAO position

Central ray• Directed through the acromioclavicular joint at an angle of 15 degrees caudad.

Structures shownThe PA axjal oblique image demonstrates the acromioclavicular joint and the relationship of the bones of the shoulder.

EVALUATION CRITERIAThe following should be clearly demonstrated:• Acromioclavicular articulation in profile• Acromioclavicular joint visualized with some soft tissue without excessiveDensity.


acromion

clavicle

coracoid

scapula

humerus

PA axial oblique acromioclavicular articulation.

Clavicle AP PROJECTION

Central ray• Perpendicular to the midshaft of theclavicle

Structures shownThis projection demonstrates a frontalimage of the clavicle.

EVALUATION CRITERIAThe following should be clearly demonstrated:• Entire clavicle centered on the image• Uniform density• Lateral half of the clavicle above the scapula, with the medial half superimposingthe thorax.

Acromion

AC joint

ClavicleSuperior angle

of scapula

Coracoidprocess

SC joint

Clavicle PA PROJECTION

The PA projection is generally well accepted by the patient who is able to stand, and it is most

useful when improved recorded detail is desired. The advantage of the PA projection is

that the clavicle is closer to the image receptor, thus reducing the OID. Positioning is similar to that of the A P projection. The differences are

as follows:

•The perpendicular central ray exits midshaft of the clavicle

•Structures shown and evaluation criteria are the same as for the AP projection.

Clavicle AP AXIAL PROJECTION

Lordotic positionNOTE: If the patient is injured or unable to

assume the lordotic position, a slightly distortedimage results when the tube is angled. An

optional approach for improved recorded detailis the PA axial projection.

Central ray• Directed to enter the midshaft of the clavicle.• Cephalic central ray angulation can vary from the long axis of the torso.Thinner patients require more angulation to project the clavicle off thescapula and ribs.

clavicle

Coracoid process


Sternoclavicular joint

AP axial clavicle of 3-year-old child. showing fracture (arrow). This is the same patient as Figure.

PA AXIAL PROJECTION

Positioning of the PA axial clavicle is similar to the A P axial projection just described. The differences are as

follow :• The patient is prone or standing, facing the vertical

grid device.• The central ray is angled 15 to 30 degrees caudad.

Structures shown and evaluation criteriaare the same as for the AP axial projection

described previously.

PA axial clavicle.

TANGENTIAL PROJECTION

The tangential projection is similar to theAP axial projection described previousIy.However, the increased angulation of the

central ray required for this approachplaces the central ray nearly parallel with

the rib cage. The clavicle i s thus projectedfree of the chest wall .

Structures shownAn inferosuperior image of the clavicle is demonstrated, projected free of superimposition.

EVALUATION CRITERIAThe following should be clearly demonstrated:• Midclavicle without superimposition• Acromial and sternal ends superimposed• Entire clavicle along with the acromioclavicularand sternoclavicular joints

Central ray• Angled so that the central ray will pass between the clavicle and the chest wall , perpendicular t o the plane of the lR . The angulation will be about 25 to 40 degrees from the horizontal.• If the medial third of the clavicle is in question, it is also necessary to angle the central ray laterally ; 15 to 25degrees is usually sufficient.

Tangential clavicle.

Tangential alignment for clavicle.

Tangential clavicle.

clavicle

acromion

1st rib

Clavicle TANGENTIAL PROJECTION

TARRANT METHOD

The Tarrant method is particularly usefulwith patients who have multiple injuries

or who cannot assume the lordotic orrecumbent position.

Tangential clavicle: Tarrant method.

Central ray• Directed anterior and inferior to the mjdshaft of the clavicle at a 25- to 35-degree angle. It should pass perpendicular to the longitudinal axjs of the clavicle.• Because of the considerable 010, anincreased SID is recommended toreduce magnification.

EVALUATION CRITERIAThe following should be clearly demonstrated:• Most of the clavicle above the ribs and scapula with the medial end overlapping the first or second ribs• Clavicle in a horizontal orientation• Entire clavicle along with the acromioclavicular and sternoclavicular joints.

Structures shownThe clavicle above the thoracic cage isDemonstrated.

Sternoclavicular joint

clavicle

acromion


coracoid

Tangential clavicle: Tarrant method .

Scapula AP PROJECTION

AP scapula.

Central ray• Perpendicular to the midscapular area ata point approximately 2 ‘’ (5 cm)inferior to the coracoid process.

Structures shownAn AP projection of the scapula is demonstrated

EVALUATION CRITERIAThe following should be clearly demonstrated:• Lateral portion of the scapula free of superimposition from the ribs• Scapula horizontal and not obliqued• Scapular detail through the superimposed lung and ribs (Shallow breathing should help obliterate lung detail.)• Acromion process and inferior angle.

acromion

clavicle

Coracoid process

Glenoid cavity

Lateral border of scapula

Medial border of scapula

Inferior angle of scapula

Scapula

LATERAL PROJECTIONRAO or LAO body position

Lateral scapula, RAO body position.

Central ray• Perpendicular to the midmedial borderof the protruding Scapula.

acromion

coracoid

humerusBody of scapula


Structures shownA lateral image of the scapula is demonstrated by this projection. The placement of the arm determine the portion of the superior scapula that is superimposed over the humerus.

EVALUATION CRITERIAThe following should be clearly demonstrated:• Lateral and medial border superimposed• No superimposition of the scapular body on the ribs• No superimposition of the humerus onthe area of interest• Inclusion of the acromion process andinferior angle• Lateral thickness of capula w i thproper density.

PA OBLIQUE PROJECTION

LORENZ AND LlLIENFELD M ETHODSRAO or LAO position

PA oblique scapula: Lorenz method.

PA oblique scapula: Lilienfeld method.

Lorenz method• Adjust the arm of the affected side at aright angle to the long axis of the body,flex the elbow, and rest the hand againstthe patient's head.• Rotate the body slightly forward, andhave the patient grasp the side of thetable or the stand for support

LiIienfeld method• Extend the arm of the affected sideobliquely upward, and have the patientrest the hand on hjs or her head.• Rotate the body lightly forward, andhave the patient grasp the side of thetable or the stand for support.

Central ray• Perpendicular to the J R, between the chest wall and the mjdarea of the protrudingScapula.

Structures shownAn oblique image of the scapula is shown. The degree of obliquity depends on theposition of the arm. The delineation of the different parts of the bone in the twooblique projections are shown.

EVALUATION CRITERIAThe following should be clearly demonstrated:• Oblique scapula• Medial border adjacent to the ribs• Acromion process and inferior angle.

Scapula

AP OBLIQUE PROJECTIONRPO or LPO position

AP oblique scapula, 20-degree body rotation.

AP oblique scapula, 35-degree body rotation.

Central ray• Perpendicular to the lateral border ofthe rib cage at the midscapular area

Structures shownThis projection show oblique image ofthe scapula, projected free or nearly free of rib superimposition.

EVALUATION CRITERIAThe following should be clearly demonstrated:• Oblique scapula• Lateral border adjacent to the ribs• Acromion process and i nferior angle

Humerus

Acromion

clavicleCoracoid process

Scapular spine

Vertebral borderof scapula


Coracoid ProcessAP AXIAL PROJECTION

AP axial coracoid process.

Central ray• Directed to enter the coracoid process atan angle of 15 to 45 degrees cephalad.Kwak, EspinieUa, and Kattan recommend30 degrees. The degree of angulationdepends on the shape of the patient'sback. Round-shouldered patients requirea greater angulation than those with astraight back.

Structures shownA slightly elongated inferosuperior image of the coracoid process is illustrated . Because the coracoid i curved on itself, it casts a small, oval shadow in the direct AP projection of the shoulder.

EVALUATION CRITERIAThe following should be clearly demonstrated:• Coracoid process with minjmal superimposition.• Clavicle slightly uperi mposing thecoracoid process

clavicleAcromioclavicular

joint

acromion

Coracoid process

Glenoid cavity

Scapular Spine

TANGENTIAL PROJECTIONLAQUERRIERE-PIERQUIN M ETHOD

Central rayDirected through the posterosuperior region of the shoulder at an angle of 45degrees caudad. A 35-degree angulation suffices for obese and round-shouldered patient .• After adjusting the x-ray tube, position the lR so that it is centered to the central ray.

Structures shownThe spine of the scapula is shown in profile and is free of bony superimposition, except for the lateral end of the clavicle.

AcromioclovicularjOint

Acromion

Glenoid cavity

Scapular spine

Superior borderof scapula

Humeral head

Clavicle

Scapular Spine

TANGENTIAL PROJECTIONProne position

Prone tangential scapular spine.

Upright tangential scapular spine.

Central ray• Direct through the scapular spine at anangle of 45 degrees cephalad. The centralray exits at the anterosuperior aspect of the shoulder.Upright positionAn i ncreased SID is recommendedbecause of the greater OlD.

Structures shownThe tangential image shows the scapularspine in profile and free of superimpositionof the scapular body.

EVALUATION CRITERIAThe following should be clearly demonstrated:• Scapular spine above the scapular wing• Scapular spine with some soft tissuearound it and without excessive density.

Scapular spine

Superior scapularborder

Acromion

Clavicle

Humeral head

Shoulder girdle presentation

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Transcript of Shoulder girdle presentation