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.

Position

• Erect or supine with humerus aligned to long axis of IR (unless diagonal placement is needed to include both elbow and shoulder joints). Place shield over gonads.

• Abduct arm slightly, supinate hand for true AP (epicondyles parallel to IR)

Central Ray:

CR ⊥, to midhumerus

SID:

40-44″ (102–113 cm)

Collimation:

Collimate on sides to soft tissue borders of humerus and shoulder.

Fig. 3-2 AP erect.

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

^*Bontrager Textbook, 8th ed, p. 183.

^*Bontrager Textbook, 8th ed, p. 184.

^*Bontrager Textbook, 8th ed, p. 185.

^*Bontrager Textbook, 8th ed, p. 186.

^*Bontrager Textbook, 8th ed, pp. 187 and 188.

^*Bontrager Textbook, 8th ed, p. 189.

^*Bontrager Textbook, 8th ed, p. 190.

^*Bontrager Textbook, 8th ed, p. 191.

^*Bontrager Textbook, 8th ed, p. 192.

^*Bontrager Textbook, 8th ed, p. 193.

^*Bontrager Textbook, 8th ed, pp. 196 and 197.

^*Bontrager Textbook, 8th ed, p. 194.

^*Bontrager Textbook, 8th ed, p. 195.

^*Bontrager Textbook, 8th ed, p. 198.

^*Bontrager Textbook, 8th ed, p. 199.

^*AP lordotic position can be performed rather than angling CR for AP axial.

^*Bontrager Textbook, 8th ed, p. 202.

^*Bontrager Textbook, 8th ed, pp. 203 and 204.

^*Bontrager Textbook, 8th ed, p. 200.

Humerus and Shoulder Girdle

AP Humerus*

Position

Central Ray:

SID:

Collimation:

Rotational Lateral Humerus*

Warning:

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

Central Ray:

SID:

Collimation:

Trauma Lateral Humerus*

Position

Central Ray:

SID:

Collimation:

AP and Lateral Humerus

Evaluation Criteria

Anatomy Demonstrated:

Position: AP

Lateral (PA)

Exposure:

Trauma Transthoracic Lateral Humerus*

Position

Central Ray:

SID:

Collimation:

Respiration:

Transthoracic Lateral Proximal Humerus

Evaluation Criteria

Anatomy Demonstrated:

Position:

Exposure:

AP Shoulder*

Position

External Rotation:

Internal Rotation:

Central Ray:

SID:

Collimation:

Respiration:

AP Shoulder—External and Internal Rotation

Evaluation Criteria

Anatomy Demonstrated:

Position: External Rotation

Internal Rotation (Lateral)

Exposure:

Inferosuperior Axial*

Position

Central Ray:

SID:

Collimation:

Respiration:

Inferosuperior Axial

Evaluation Criteria

Anatomy Demonstrated:

Position:

Exposure:

PA Transaxillary Projection*

Position

Central Ray:

SID:

Collimation:

Respiration:

PA Transaxillary Projection

Evaluation Criteria

Anatomy Demonstrated:

Position:

Exposure:

Inferosuperior Axial*

Position

Central Ray:

SID:

Collimation:

Respiration:

Inferosuperior Axial

Evaluation Criteria

Anatomy Demonstrated:

Position:

AP Humerus^*

Rotational Lateral Humerus^*

Trauma Lateral Humerus^*

Trauma Transthoracic Lateral Humerus^*

AP Shoulder^*

Inferosuperior Axial^*

PA Transaxillary Projection^*

Inferosuperior Axial^*

Posterior Oblique^*

Tangential Projection—Intertubercular (Bicipital) Groove^*

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

AP Shoulder Trauma Projection^*

Lateral Shoulder Trauma Projection^*

AP Apical Oblique Axial Shoulder^*

AP and AP Axial Clavicle^*