Humerus and Shoulder Girdle

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Chapter 3

Humerus and Shoulder Girdle

Humerus

AP (R)

Rotational lateral (R)

Trauma lateral (midhumerus and distal humerus) (S)

AP and lateral critique

Trauma transthoracic lateral (S)

Transthoracic lateral proximal critique

Shoulder

AP external and internal rotation (R)

AP external and internal rotation critique

Inferosuperior axial (Lawrence method) (S)

Inferosuperior axial critique

PA transaxillary projection (Hobbs modification) (S)

PA transaxillary projection critique

Inferosuperior axial (Clements modification) (S)

Inferosuperior axial (Clements modification) critique

Posterior oblique (Grashey method) (S)

Posterior oblique (Grashey method) critique

Tangential projection—intertubercular (bicipital) groove (Fisk modification) (S)

Tangential projection intertubercular groove critique

Scapular Y lateral—anterior oblique position and Neer method (S)

Scapular Y lateral and Neer method critique

AP trauma projection (neutral rotation) (S)

Transthoracic lateral (Lawrence method) (S)

Transthoracic lateral critique

AP apical oblique axial (Garth method) (S)

AP apical oblique axial critique

Clavicle

AP and AP axial (R)

AP and AP axial critique

Scapula

AP (R)

Lateral (R)

AP and lateral scapula critique

Acromioclavicular (AC) Joints

AP bilateral with and without weights (S)

AP AC joint critique

Important for humerus and shoulder projections: Do not attempt to rotate upper limb if fracture or dislocation is suspected without special orders by a physician.

(R) Routine, (S) Special

AP Humerus ^*

• 35 × 43 cm L.W. (14 × 17″) or for small patient 30 × 35 cm L.W. (11 × 14″)

• Grid >10 cm, IR only <10 cm

• Lead masking

Fig. 3-1 AP supine.

Rotational Lateral Humerus ^*

Warning:

Do not attempt to rotate arm if fracture or dislocation is suspected (see following page).

• 35 × 43 cm L.W. (14 × 17″) or 30 × 35 cm L.W.

• Grid >10 cm, IR only <10 cm

Fig. 3-3 Erect lateral (PA).

Fig. 3-4 Erect lateral (AP).

Position (May Be Taken Erect AP or PA, or Supine)

• Erect (PA): Elbow flexed 90°, patient rotated 15°–20° from PA or as needed to bring humerus and shoulder in contact with IR holder (epicondyles ⊥ to IR for true lateral)

• Erect or supine AP: Elbow slightly flexed, arm and wrist rotated for lateral position (palm back), epicondyles ⊥ to IR

• IR centered to include both elbow and shoulder joints

Fig. 3-5 Supine lateral.

Central Ray:

CR ⊥, to midhumerus

SID:

40-44″ (102-113 cm)

Collimation:

Collimate on sides to soft tissue borders of humerus and shoulder

Trauma Lateral Humerus ^*

(Midhumerus and Distal Humerus)

For proximal humerus, see transthoracic lateral or scapular Y.

• 30 × 35 cm L.W. (11 × 14″) or 24 × 30 cm L.W. (10 × 12″)

• Nongrid

Fig. 3-6 Lateral cross-table, midhumerus and distal humerus.

Position

• Gently lift arm and place support block under arm, rotate hand into lateral position if possible for true lateral elbow projection

• Place IR vertically between arm and thorax with top of IR at axilla (place shield between IR and patient)

Central Ray:

CR horizontal and ⊥ to IR, centered to distal ⅓ of humerus

SID:

40-44″ (102-113 cm)

Collimation:

Collimate on four sides, include distal and midhumerus, elbow joint, and proximal forearm

AP and Lateral Humerus

Fig. 3-7 AP humerus.

Fig. 3-8 Lateral erect humerus.

Evaluation Criteria

Anatomy Demonstrated:

• AP and lateral view of the entire humerus, including elbow and glenohumeral joints

Position: AP

• No rotation, medial and lateral epicondyles seen in profile, greater tubercle in profile laterally

• Humeral head and glenoid cavity demonstrated

Lateral (PA)

• True lateral, epicondyles are directly superimposed

Exposure:

• Optimal density (brightness) and contrast

• Sharp bony trabeculation clearly demonstrated, no motion

Trauma Transthoracic Lateral Humerus ^*

(Midhumerus and Proximal Humerus)

• 35 × 43 cm L.W. (14 × 17″)

• Grid

Fig. 3-9 Transthoracic lateral.

Position

• Patient recumbent or erect

• Affected limb closest to IR

• Raise opposite arm over head

Central Ray:

Center to mid-shaft of affected humerus

SID:

40-44″ (102-113 cm)

Collimation:

To soft tissue margins—entire humerus

Respiration:

Breathing technique is preferred.

If breathing lateral technique performed: Minimum of 2 seconds exposure time (between 2 and 4 seconds is desirable)

Transthoracic Lateral Proximal Humerus

Evaluation Criteria

Anatomy Demonstrated:

• Lateral view of the proximal half of humerus

Position:

• Proximal half of shaft of humerus should be clearly visualized

• Humeral head and glenoid cavity demonstrated

Fig. 3-10 Transthoracic lateral.

Exposure:

• Optimal density (brightness) and contrast

• Overlying ribs and lung markings blurred (with breathing technique)

AP Shoulder ^*

(External and Internal Rotation)

Warning: Do not attempt if fracture or dislocation is suspected.

• 24 × 30 cm (10 × 12″) C.W. (or lengthwise to show more of humerus)

• Grid

Fig. 3-11 External (AP humerus).

Fig. 3-12 Internal (lateral humerus).

Position

• Erect (seated or standing) or supine, arm slightly abducted

• Rotate thorax as needed to place posterior shoulder against IR

• Center of IR to scapulohumeral joint and CR

External Rotation:

Rotate arm externally until hand is supinated and epicondyles are parallel to IR.

Internal Rotation:

Rotate arm internally until hand is pronated and epicondyles are perpendicular to IR.

Central Ray:

CR ⊥, directed to 1″ (2.5 cm) inferior to coracoid process

SID:

40-44″ (102-113 cm)

Collimation:

Collimate closely on four sides.

Respiration:

Suspend during exposure.

AP Shoulder—External and Internal Rotation

Evaluation Criteria

Anatomy Demonstrated:

• Proximal humerus and lateral ⅔ of the clavicle (entire clavicle for crosswise IR) and upper scapula

Position: External Rotation

• Greater tubercle visualized in full profile laterally

• Lesser tubercle superimposed over humeral head

Fig. 3-13 AP shoulder external rotation.

Internal Rotation (Lateral)

• Lesser tubercle visualized in full profile medially

• Greater tubercle superimposed over humeral head

Exposure:

• Optimal density (brightness) and contrast

• Soft tissue and sharp bony trabeculation clearly demonstrated; no motion

Fig. 3-14 AP shoulder internal rotation.

Inferosuperior Axial ^*

(Lawrence Method)

Warning: Do not attempt if fracture or dislocation is suspected.

• 18 × 24 cm C.W. (8 × 10″)

• Grid; grid lines horizontal and CR to center line of grid

• Often performed nongrid for smaller shoulder

Fig. 3-15 Inferosuperior axial (Lawrence method).

Position

• Patient supine, to front edge of table or stretcher, with support under shoulder to center anatomy to IR, head turned away from IR

• Arm abducted 90° from body if possible

• Rotate arm externally, with hand supinated

Central Ray:

CR horizontal, directed 25°–30° medially to axilla, less angle if arm is not abducted 90° (place tube next to table or stretcher at same level as axilla)

SID:

40-44″ (102-113 cm)

Collimation:

Collimate closely on four sides

Respiration:

Suspend during exposure

Inferosuperior Axial

(Lawrence Method)

Evaluation Criteria

Anatomy Demonstrated:

• Lateral view of proximal humerus in relationship to the glenoid fossa

Position:

• Spine of scapula is seen in profile inferior to the scapulohumeral joint.

• Affected arm abducted about 90°

Fig. 3-16 Inferosuperior axial (Lawrence method).

Exposure:

• Optimal density (brightness) and contrast

• Soft tissue and sharp bony trabeculation clearly demonstrated; no motion

PA Transaxillary Projection ^*

(Hobbs Modification)

• 18 × 24 cm L.W. (8 × 10″)

• Grid

Position

• Patient recumbent or erect PA

• Affected arm raised superiorly

• Head is turned away

Central Ray:

Perpendicular to the IR, centered to the glenohumeral joint

SID:

40-44″ (102-113 cm)

Collimation:

Collimate closely on four sides.

Respiration:

Suspend during exposure.

Fig. 3-17 PA transaxillary (Hobbs modification).

PA Transaxillary Projection

(Hobbs Modification)

Evaluation Criteria

Anatomy Demonstrated:

• Lateral view of proximal humerus in relationship to glenohumeral joint

Position:

• Coracoid process of scapula is seen on end

• Affected arm elevated completely

Exposure:

• Optimal density (brightness) and contrast

• Soft tissue and sharp bony trabeculation clearly demonstrated; no motion

Fig. 3-18 PA transaxillary (Hobbs modification).

Inferosuperior Axial ^*

(Clements Modification)

• 18 × 24 cm L.W. (8 × 10″)

• Nongrid (can use grid if CR is perpendicular to it)

Position

• Lateral recumbent position

• Affected arm up

• Abduct arm 90° from body if possible.

Central Ray:

Direct horizontal CR perpendicular to the IR.

(Angle the tube 5°–15° toward the axilla if the patient cannot abduct the arm 90°)

SID:

40-44″ (102-113 cm)

Collimation:

Collimate closely on four sides.

Respiration:

Suspend during exposure.

Fig. 3-19 Inferosuperior axial (Clements modification).

Inferosuperior Axial

(Clements Modification)

Evaluation Criteria

Anatomy Demonstrated:

• Lateral view of proximal humerus in relationship to the scapulohumeral joint

Fig. 3-20 Inferosuperior axial (Clements modification).

Position:

• Arm is abducted 90° from the body.

Exposure:

• Optimal density (brightness) and contrast

• Soft tissue and sharp bony trabeculation clearly demonstrated; no motion

Posterior Oblique ^*

(Grashey Method)

A special projection for visualizing glenoid cavity in profile with open joint space

• 18 × 24 cm C.W. (8 × 10″)

• Grid

Fig. 3-21 Glenoid cavity (35°–45° post. oblique).

Position

• Erect or supine (erect preferred)

• Oblique 35°–45° toward side of interest (body of scapula should be parallel with IR), hand and arm in neutral rotation

• Center scapulohumeral joint and IR to CR (2″ [5 cm] inferior and medial from the superolateral border of shoulder)

Central Ray:

CR ⊥, to midscapulohumeral joint

SID:

40-44″ (102-113 cm)

Collimation:

Collimate so upper and lateral borders of the field are to the soft tissue margins.

Respiration:

Suspend during exposure.

Posterior Oblique

(Grashey Method)

Evaluation Criteria

Anatomy Demonstrated:

• View of head of humerus in relationship to glenoid cavity

Position:

• Open scapulohumeral joint space

• Anterior and posterior rims of glenoid cavity are superimposed

Fig. 3-22 Posterior oblique.

Exposure:

• Optimal density (brightness) and contrast

• Soft tissue and sharp bony trabeculation clearly demonstrated; no motion

Tangential Projection—Intertubercular (Bicipital) Groove ^*

(Fisk Modification)

• 18 × 24 cm C.W. (8 × 10″)

• Nongrid

Position

• Supine or erect. Palpate anterior humeral head to locate groove.

Supine:

Abduct arm slightly, supinate hand.

• Center IR and groove to CR.

• CR 10°–15° down from horizontal position of x-ray tube, centered to groove, IR vertical against top of shoulder, perpendicular to CR

Alternative Erect:

Patient leans forward 15°–20°, CR vertical, ⊥ to IR

SID:

40-44″ (102-113 cm)

Collimation:

Collimate closely on four sides to area of anterior humeral head.

Respiration:

Suspend during exposure.

Fig. 3-23 Supine inferosuperior projection (CR 15°–20° from horizontal).

Fig. 3-24 Erect superoinferior (humerus 15°–20° from vertical, CR, ⊥ to IR).

Tangential Projection Intertubercular (Bicipital) Groove

(Fisk Modification)

Fig. 3-25 Tangential projection (intertubercular groove).

Evaluation Criteria

Anatomy Demonstrated:

• Humeral tubercles and intertubercular groove seen in profile

Position:

• Intertubercular groove and tubercles in profile

• No superimposition of acromion process

Exposure:

• Optimal density (brightness) and contrast

• Soft tissue and sharp bony trabeculation clearly demonstrated; no motion

Scapular Y Lateral—Anterior Oblique Position and Neer Method ^*

• 24 × 30 cm L.W. (10 × 12″)

• Grid

Position

• Erect or recumbent (erect preferred)

• Rotate patient into a 45°–60° anterior oblique as for a lateral scapula (body of scapula perpendicular to IR).

• Unaffected arm up in front of patient, affected arm down (don’t move with possible fracture or dislocation)

• Center scapulohumeral joint and CR.

Fig. 3-26 Scapular Y lateral position—CR ⊥.

Fig. 3-27 Neer method—CR 10°–15° caudad.

Central Ray:

CR ⊥ to scapulohumeral joint

Neer Method:

Angle CR 10°–15° caudad to better demonstrate the acromiohumeral space (supraspinatus outlet), CR to superior margin of humeral head

SID:

40-44″ (102-113 cm)

Collimation:

Collimate on four sides to area of interest.

Respiration:

Suspend during exposure.

Scapular Y Lateral—Anterior Oblique Position and Neer Method

Fig. 3-28 Scapular Y projection.

Fig. 3-29 Supraspinatus outlet projection (Neer method).

Evaluation Criteria

Anatomy Demonstrated:

• Scapular Y: True lateral view of the scapula, proximal humerus

• Neer method: Supraspinatus outlet region is open

Position:

• Scapular Y: Thin body of the scapula seen on end without rib superimposition. Upper limb is not elevated or moved with possible fracture or dislocation.

• Neer method: Thin body of the scapula seen on end; humeral head below supraspinatus outlet (arrow)

Exposure:

• Optimal density (brightness) and contrast

• Soft tissue and sharp bony trabeculation clearly demonstrated; no motion

AP Shoulder Trauma Projection ^*

(Neutral Rotation)

• 24 × 30 cm C.W. (10 × 12″) (or lengthwise to show more of humerus if injury includes proximal half of humerus)

• Grid

Note:

Evaluation of AP shoulder-neutral position is similar to external/internal rotation, but neither the greater nor lesser tubercle is in profile (if limb can be moved).

Fig. 3-30 AP—neutral rotation.

Position

• Erect (seated or standing) or supine, arm slightly abducted

• Rotate thorax slightly as needed to place posterior shoulder against IR

• Arm in neutral position (generally this is with palm inward—no acute trauma present)

Central Ray:

CR ⊥, to ≈2-3 cm (1″) inferior to coracoid process

SID:

40-44″ (102-113 cm)

Collimation:

Collimate on four sides to area of interest.

Respiration:

Suspend during exposure.

Lateral Shoulder Trauma Projection ^*

Transthoracic Lateral (Lawrence Method)

• 24 × 30 cm L.W. (10 × 12″)

• Grid

• Breathing technique is preferred if patient can cooperate

Fig. 3-31 Erect transthoracic lateral.

Fig. 3-32 Supine transthoracic lateral.

Position

• Erect or supine, affected arm against IR, arm at side in neutral position

• Raise unaffected arm above head.

• Elevate unaffected shoulder, or angle CR 10°–15° cephalad to prevent superimposition of unaffected shoulder.

• True lateral, or slight anterior rotation of unaffected shoulder

• Center grid IR to CR.

Central Ray:

CR ⊥, through thorax to surgical neck

SID:

40-44″ (102-113 cm)

Collimation:

Collimate on four sides to area of interest.

Respiration:

3-4 sec with breathing technique or suspended respiration

Transthoracic Lateral Shoulder Projection

(Lawrence Method)

Evaluation Criteria

Anatomy Demonstrated:

• Lateral view of proximal humerus and glenohumeral joint

Position:

• Shaft of the proximal humerus should be clearly visualized

• Humeral head and the glenoid cavity visualized

Exposure:

• Optimal density (brightness) and contrast

• Soft tissue and sharp bony trabeculation clearly demonstrated; no motion

Fig. 3-33 Transthoracic lateral.

AP Apical Oblique Axial Shoulder ^*

(Garth Method)

A good projection for acute shoulder trauma, demonstrating shoulder dislocations, glenoid fractures, and Hill-Sachs lesions

• 24 × 30 cm L.W. (10 × 12″)

• Grid

Fig. 3-34 Erect apical oblique (45° posterior obli., CR 45° caudad).

Position

• Erect preferred (recumbent if necessary)

• Rotate thorax 45° with affected shoulder against IR

• Flex affected elbow and place hand on opposite shoulder

• Center IR to exiting CR

Central Ray:

CR 45° caudad, to medial aspect of scapulohumeral joint

SID:

40-44″ (102-113 cm)

Collimation:

Collimate on four sides to area of interest.

Respiration:

Suspend during exposure.

AP Apical Oblique Axial Projection

(Garth Method)

Evaluation Criteria

Anatomy Demonstrated:

• Humeral head, glenoid cavity, and neck and head of scapula free of superimposition

Position:

• Acromion and AC joint projected superior to humeral head

Exposure:

• Optimal density (brightness) and contrast

• Soft tissue and sharp bony trabeculation clearly demonstrated; no motion

Fig. 3-35 AP apical oblique.

AP and AP Axial Clavicle ^*

• 24 × 30 cm C.W. (10 × 12″)

• Grid

Fig. 3-36 AP, 0°.

Fig. 3-37 AP axial, 20° cephalad.

Position

• Erect or recumbent

• Center clavicle and IR to CR (midway between jugular notch medially and AC joint laterally)

Central Ray:

CR to midclavicle

AP:

CR ⊥, to midclavicle

AP Axial:

15°–30° cephalad ^* (thin shoulders require 5°–10° more angle than thick shoulders)

Note:

Departmental routines may include AP 0°, or axial AP, or both.

SID:

40-44″ (102-113 cm)

Collimation:

Collimate to area of clavicle. (Ensure that both AC and sternoclavicular joints are included.)

Respiration:

Expose upon full inspiration.

AP and AP Axial Clavicle Projection

Fig. 3-38 AP clavicle and AP axial clavicle (lower image).

Evaluation Criteria

Anatomy Demonstrated:

• AP 0°: Entire clavicle

• AP axial: The clavicle above the scapula and ribs

Position:

• AP 0°: Entire clavicle from AC to SC joint

• AP axial: Only medial portion of clavicle will be superimposed by 1st and 2nd ribs.

Exposure:

• Optimal density (brightness) and contrast

• Soft tissue and sharp bony trabeculation clearly demonstrated; no motion

AP Scapula ^*

• 24 × 30 cm L.W. (10 × 12″)

• Grid

Fig. 3-39 AP scapula.

Position

• Erect or supine (erect preferred with pain in scapula area)

• Gently abduct arm 90° if possible, supinate hand (abduction results in less superimposition of scapula by ribs).

• Center IR and entire scapula to CR.

Central Ray:

CR ⊥, to midscapula (≈5 cm or 2″ inferior to coracoid process and ≈2-3 cm [1″] medial to lateral border)

SID:

40-44″ (102-113 cm)

Collimation:

Collimate on four sides of scapula borders.

Respiration:

Breathing technique can be employed or suspend during exposure.

Lateral Scapula ^*

• 24 × 30 cm L.W. (10 × 12″)

Position

• Erect or recumbent (erect preferred)

• Palpate borders of scapula and rotate thorax until body of scapula is perpendicular to IR (will vary from 45°–60° rotation).

• If area of interest is body of scapula, with arm up have patient reach across and grasp opposite shoulder.

Central Ray:

CR ⊥, to mid-medial (vertebral) border

SID:

40-44″ (102-113 cm)

Collimation:

To scapular region

Respiration:

Suspend during exposure.

Fig. 3-40 Lateral (palpate scapular borders).

Fig. 3-41 For body of scapula.

Fig. 3-42 Superior scapula (acromion or coracoid process), place arm down, flex elbow, palm out.

AP and Lateral Scapula Projections

Fig. 3-43 AP scapula.

Fig. 3-44 Lateral scapula.

Evaluation Criteria

Anatomy Demonstrated:

• AP: Entire scapula

• Lateral: Entire scapula in a lateral position

Position:

• AP: Lateral border of scapula free of superimposition

• Lateral: Humerus not superimposing over region of interest; ribs free of superimposition by body of scapula

Exposure:

• Optimal density (brightness) and contrast

• Soft tissue and sharp bony trabeculation clearly demonstrated; no motion

Acromioclavicular (AC) Joints ^*

(AP—Bilateral with and without Weights)

Warning: Rule out fracture first before taking “with weight” projection.

• 35 × 43 cm C.W. (14 × 17″) or (2) 18 × 24 cm (8 × 10″) for broad shoulders

• Grid or nongrid (depending on size of shoulder)

• Use markers “with weights” and “without weights”

Position

• Erect, standing if possible, or may be seated on chair

• Arms at sides, one exposure for bilateral without weights, and a second exposure with 8-10 lb (5-8 lb for smaller patient) weights tied to wrists, shoulders and arms relaxed, center IR to CR

Central Ray:

CR ⊥, to jugular notch

SID:

72-120″ (183-307 cm)

Collimation:

Long, narrow horizontal exposure field

Respiration:

Suspend during exposure.

Fig. 3-45 Bilateral with weights.

AP AC Joint Projections—Bilateral with and without Weights

Fig. 3-46 AC joints without weights.

Fig. 3-47 AC joints with weights.

Evaluation Criteria

Anatomy Demonstrated:

• Both R and L AC joints and SC joints included

Position:

• No rotation, symmetric SC joints

Exposure:

• Optimal density (brightness) and contrast; no motion

• Soft tissue and sharp bony trabeculation clearly demonstrated

Bontragers Handbook of Radiographic Positioning and Techniques

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Humerus and Shoulder Girdle

Humerus and Shoulder Girdle