Shoulder Girdle

• Examine the patient in the upright or supine position, with coronal plane of thorax parallel to IR. Shoulder and arm lesions, whether traumatic or pathologic in origin, are extremely sensitive to movement and pressure. For this reason, the upright position should be used whenever possible.

• Center the shoulder joint to the midline of the grid.

• Adjust the position of the IR so that its center is 1 inch (2.5 cm) inferior to the coracoid process.

External rotation humerus

• Ask the patient to supinate the hand, unless contraindicated (Table 5-2).

TABLE 5-2

Hand position and its effect on the proximal humerus

Description	Hand position	Proximal humerus position
Supinating hand and adjusting epicondyles parallel to the plane of the IR positions the humerus in external rotation		AP shoulder. External rotation humerus. Greater tubercle (arrow)
Palm of the hand placed against hip and epicondyles adjusted at about a 45-degree angle with the plane of the IR positions the humerus in neutral rotation		AP shoulder. Neutral rotation humerus. Greater tubercle (arrows)
Posterior aspect of hand may be placed against hip and epicondyles adjusted perpendicular to the plane of the IR to position the humerus in internal rotation		AP shoulder. Internal rotation humerus. Greater tubercle (arrows); lesser tubercle in profile (arrowhead)

• Abduct the arm slightly, and rotate it so that the epicondyles are parallel with the plane of the IR. Externally rotating the entire arm from the neutral position places the shoulder and the entire humerus in the true anatomic position (Fig. 5-13).

Fig. 5-13 A, AP shoulder, external rotation humerus, standing position. B, Same projection in supine position.

Neutral rotation humerus

• Ask the patient to rest the palm of the hand against the thigh (see Table 5-2). This position of the arm rolls the humerus slightly internal into a neutral position, placing the epicondyles at an angle of about 45 degrees with the plane of the IR.

Internal rotation humerus

• Ask the patient to flex the elbow, rotate the arm internally, and rest the back of the hand on the hip (see Table 5-2).

• Adjust the arm to place the epicondyles perpendicular to the plane of the IR.

• Perpendicular to a point 1 inch (2.5 cm) inferior to the coracoid process, which can be palpated inferior to the clavicle and medial to the humeral head

• Adjust to 10 × 12 inch (24 × 30 cm) on the collimator.

Compensating Filter

Use of a specially designed compensating filter for the shoulder, called a boomerang, improves the quality of the image. See Chapter 2 for photo. These filters are particularly useful when digital imaging (CR or DR) systems are used for this projection because all bony and soft tissue structures can be seen without the need to “window.”

Structures shown

The image shows the bony and soft structures of the shoulder and proximal humerus in the anatomic position (Figs. 5-14 to 5-16). The scapulohumeral joint relationship is seen.

External rotation: The greater tubercle of the humerus and the site of insertion of the supraspinatus tendon are visualized (see Fig. 5-14, A).

Neutral rotation: The posterior part of the supraspinatus insertion, which sometimes profiles small calcific deposits not otherwise visualized (see Fig. 5-14, B), is seen.

Internal rotation: The proximal humerus is seen in a true lateral position. When the arm can be abducted enough to clear the lesser tubercle of the head of the scapula, a profile image of the site of insertion of the subscapular tendon is seen (see Fig. 5-15).

Evaluation Criteria

The following should be clearly shown:

▪ Superior scapula, clavicle (entire if IR crosswise, lateral half if IR lengthwise), and proximal humerus

▪ Soft tissue around the shoulder, along with bony trabecular detail

External Rotation

▪ Humeral head in profile

▪ Greater tubercle in profile on lateral aspect of the humerus

▪ Scapulohumeral joint visualized with slight overlap of humeral head on glenoid cavity

▪ Outline of lesser tubercle between the humeral head and greater tubercle

Neutral Rotation

▪ Greater tubercle partially superimposing the humeral head

▪ Humeral head in partial profile

▪ Slight overlap of the humeral head on the glenoid cavity

Internal Rotation

▪ Lesser tubercle in profile and pointing medially

▪ Outline of the greater tubercle superimposing the humeral head

▪ Greater amount of humeral overlap of the glenoid cavity than in external and neutral positions

Fig. 5-14 A, AP shoulder, external rotation humerus: greater tubercle in profile (arrow). B, AP shoulder, neutral rotation humerus: greater tubercle (arrows).

Fig. 5-15 AP shoulder, internal rotation humerus: greater tubercle (arrow); lesser tubercle in profile (arrowhead).

Fig. 5-16 A, AP oblique projection of right shoulder without use of compensating filter. B, AP projection of same patient with compensating filter. Note improved visualization of bony and soft tissue areas with filter.

Shoulder Joint

Glenoid Cavity

AP Oblique Projection

GRASHEY METHOD

RPO or LPO position

Image receptor: 8 × 10 inch (18 × 24 cm) or 10 × 12 inch (24 × 30 cm), depending on availability; crosswise to include entire clavicle, lengthwise to include more humerus

• Place the patient in the supine or upright position. The upright position is more comfortable for the patient and assists in accurate adjustment of the part.

• Center the IR to the scapulohumeral joint. The joint is 2 inches (5 cm) medial and 2 inches (5 cm) inferior to the superolateral border of the shoulder.

• Rotate the body approximately 35 to 45 degrees toward the affected side (Fig. 5-17).

Fig. 5-17 A, Upright AP oblique glenoid cavity: Grashey method. B, Note position of shoulder and patient in relationship to IR.

• Adjust the degree of rotation to place the scapula parallel with the plane of the IR. This is accomplished by orienting the plane through the superior angle of the scapula and acromial tip, parallel to the IR.* The head of the humerus is in contact with the IR.

• If the patient is in the recumbent position, the body may need to be rotated more than 45 degrees (up to 60 degrees) to place the scapula parallel to the IR.

• Support the elevated shoulder and hip on sandbags (Fig. 5-18).

Fig. 5-18 Recumbent AP oblique glenoid cavity: Grashey method.

• Abduct the arm slightly in internal rotation, and place the palm of the hand on the abdomen. Other arm positions may be dictated by department protocol.

*NOTE: These landmarks are recommended by Johnston et al.¹ as useful to identify the plane through the scapular body.

• Perpendicular to the IR; the central ray should be at a point 2 inches (5 cm) medial and 2 inches (5 cm) inferior to the superolateral border of the shoulder

• Adjust to 8 × 10 inch (18 × 24 cm) on the collimator.

The joint space between the humeral head and the glenoid cavity (scapulohumeral or glenohumeral joint) is shown (Figs. 5-19 and 5-20).

Evaluation Criteria

The following should be clearly shown:

▪ Open joint space between the humeral head and glenoid cavity

▪ Glenoid cavity in profile

▪ Soft tissue at the scapulohumeral joint along with trabecular detail on the glenoid and humeral head

Glenoid Cavity

AP Oblique Projection

APPLE METHOD

RPO or LPO position

The Apple method ¹ is similar to the Grashey method but uses weighted abduction to show loss of articular cartilage in the scapulohumeral joint.

Image receptor: 10 × 12 inch (24 × 30 cm) crosswise

Position of patient

• Place the patient in a seated or upright position.

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

NOTE: To avoid motion, have the correct technical factors set on the generator and be ready to make the exposure before the patient abducts the arm.

The scapulohumeral joint (Fig. 5-22) is seen.

Evaluation Criteria

The following should be clearly shown:

▪ Glenoid cavity in profile

▪ The arm in a 90-degree abducted position

▪ Open joint space between the humeral head and the glenoid cavity

▪ Soft tissue at the scapulohumeral joint along with trabecular detail on the glenoid and the humeral head

RESEARCH: Catherine E. Hearty, MS, RT(R), performed the research and provided this new projection for this edition of the atlas.

Shoulder

Transthoracic Lateral Projection

LAWRENCE METHOD

R or L position

The Lawrence ¹ method is used when trauma exists and the arm cannot be rotated or abducted because of an injury. This method results in a projection 90-degrees from the AP projection and shows the relationship between the proximal humerus and the scapula.

Image receptor: 10 × 12 inch (24 × 30 cm) lengthwise

Position of patient

• Although this projection can be carried out with the patient in the upright or supine position, the upright position is much easier on a trauma patient. It also assists accurate adjustment of the shoulder.

• For upright positioning, seat or stand the patient in the lateral position before a vertical grid device (Fig. 5-23).

Fig. 5-23 Upright transthoracic lateral shoulder: Lawrence method.

• If an upright position is impossible, place the patient in a recumbent position on the table with radiolucent pads elevating the head and shoulders (Fig. 5-24).

Fig. 5-24 Recumbent transthoracic lateral shoulder: Lawrence method.

• No attempt should be made to rotate or otherwise to move the injured arm.

• Have the patient raise the noninjured arm, rest the forearm on the head, and elevate the shoulder as much as possible (see Fig. 5-23). Elevation of the noninjured shoulder drops the injured side, separating the shoulders to prevent superimposition. Ensure that the midcoronal plane is perpendicular to the IR.

• Center the IR to the surgical neck area of the affected humerus.

• Respiration: Full inspiration. Having the lungs full of air improves the contrast and decreases the exposure necessary to penetrate the body.

• If the patient can be sufficiently immobilized to prevent voluntary motion, a breathing technique can be used to blur the pulmonary vasculature. In this case, instruct the patient to practice slow, deep breathing. A minimum exposure time of 3 seconds (4 to 5 seconds is desirable) gives excellent results when low milliamperage is used.

• Perpendicular to the IR, entering the midcoronal plane at the level of the surgical neck

• If the patient cannot elevate the unaffected shoulder, angle the central ray 10 to 15 degrees cephalad to obtain a comparable radiograph.

• Adjust to 10 × 12 inch (24 × 30 cm) on the collimator. The field of light on the skin appears smaller because of the distance from the IR. Do not collimate larger than stated size.

Shoulder Joint

Inferosuperior Axial Projection

Lawrence method ¹

Inferosuperior Axial Projection

Rafert et al.² modification

Image receptor: 10 × 12 inch (24 × 30 cm) grid crosswise, placed in the vertical position in contact with the superior surface of the shoulder

Position of patient

• With the patient in the supine position, elevate the head, shoulders, and elbow about 3 inches (7.6 cm) on a radiolucent sponge.

• As much as possible, abduct the arm of the affected side at right angles to the long axis of the body. A minimum of 20 degrees is required to prevent superimposition of the arm on the shoulder.

Lawrence method

• Keep the humerus in external rotation, and adjust the forearm and hand in a comfortable position, grasping a vertical support or extended on sandbags or a firm pillow. Support may be necessary under the forearm and hand. Provide the patient with an extension board for the arm.

• Have the patient turn the head away from the side being examined so that the IR can be placed against the neck.

• Place the IR on the edge against the shoulder and as close as possible to the neck.

• Support the IR in position with sandbags, or use a vertical IR holder (Fig. 5-27).

Fig. 5-27 Inferosuperior axial shoulder joint: Lawrence method.

Rafert modification

• Anterior dislocation of the humeral head can result in a wedge-shaped compression fracture of the articular surface of the humeral head, called the Hill-Sachs defect.¹ The fracture is located on the posterolateral humeral head. An exaggerated external rotation of the arm may be required to see the defect.

• With the patient in position exactly as for the Lawrence method, externally rotate the extended arm until the hand forms a 45-degree oblique angle. The thumb is pointing downward (Fig. 5-28).

Fig. 5-28 Inferosuperior axial shoulder joint: Rafert modification. Note exaggerated external rotation of arm and thumb pointing downward. If present, a Hill-Sachs defect would show as a wedge-shaped depression on posterior aspect of articulating surface of humeral head (arrow). (From Rafert JA et al: Axillary shoulder with exaggerated rotation: the Hill-Sachs defect, Radiol Technol 62:18, 1990.)

• Assist the patient in rotating the arm to avoid overstressing the shoulder joint.

• Horizontally through the axilla to the region of the AC articulation. The degree of medial angulation of the central ray depends on the degree of abduction of the arm. The degree of medial angulation is often between 15 degrees and 30 degrees. The greater the abduction, the greater the angle.

Lawrence method

Rafert modification

• Horizontal and angled approximately 15 degrees medially, entering the axilla and passing through the AC joint.

• Adjust to 12 inches (30 cm) in length and 1 inch (2.5 cm) above the anterior shadow of the shoulder.

An inferosuperior axial image shows the proximal humerus, the scapulohumeral joint, the lateral portion of the coracoid process, and the AC articulation. The insertion site of the subscapular tendon on the lesser tubercle of the humerus and the point of insertion of the teres minor tendon on the greater tubercle of the humerus are also shown. A Hill-Sachs compression fracture on the posterolateral humeral head may be seen using the Rafert modification (Figs. 5-29 and 5-30).

Evaluation Criteria

The following should be clearly shown:

▪ Scapulohumeral joint with slight overlap

▪ Coracoid process, pointing anteriorly

▪ Lesser tubercle in profile and directed anteriorly

▪ AC joint, acromion, and acromial end of clavicle projected through the humeral head

▪ Soft tissue in the axilla with bony trabecular detail

Fig. 5-29 A, Inferosuperior axial shoulder joint: Lawrence method. B, Inferosuperior axial shoulder joint: Rafert modification showing Hill-Sachs defect (arrow). C, Coronal MRI of shoulder joint showing Hill-Sachs defect (arrow) after recurrent shoulder dislocation. (A and B, From Rafert JA et al: Axillary shoulder with exaggerated rotation: the Hill-Sachs defect, Radiol Technol 62:18, 1990. C, From Jackson SA, Thomas RM: Cross-sectional imaging made easy, New York, 2004, Churchill Livingstone.)

Fig. 5-30 Inferosuperior axial shoulder joint: Lawrence method showing comminuted fracture of humerus. The patient came into emergency department with arm extended out.

Inferosuperior Axial Projection

West Point Method

The West Point ¹ method is used when chronic instability of the shoulder is suspected and to show bony abnormalities of the anterior inferior glenoid rim. Associated Hill-Sachs defect of the posterior lateral aspect of the humeral head is also shown.

Image receptor: 8 × 10 inch (18 × 24 cm) or 10 × 12 inch (24 × 30 cm) crosswise, depending on availability, placed in the vertical position in contact with the superior surface of the shoulder

Position of patient

• Adjust the patient in the prone position with approximately a 3-inch (7.6-cm) pad under the shoulder being examined.

• Turn the patient's head away from the side being examined.

• Directed at a dual angle of 25 degrees anteriorly from the horizontal and 25 degrees medially. The central ray enters approximately 5 inches (13 cm) inferior and inches (3.8 cm) medial to the acromial edge and exits the glenoid cavity.

The resulting image shows bony abnormalities of the anterior inferior rim of the glenoid and Hill-Sachs defects of the posterolateral humeral head in patients with chronic instability of the shoulder (Fig. 5-33).

Evaluation Criteria

The following should be clearly shown:

▪ Humeral head projected free of the coracoid process

▪ Shoulder joint

▪ Articulation between the head of the humerus and the glenoid cavity

▪ Acromion superimposed over the posterior portion of the humeral head

▪ Soft tissue and bony trabecular detail

Fig. 5-33 Inferosuperior axial shoulder joint: West Point method.

Superoinferior Axial Projection

Image receptor: 8 × 10 inch (18 × 24 cm) or 10 × 12 inch (24 × 30 cm), depending on availability, placed lengthwise for accurate centering to shoulder joint

• Seat the patient at the end of the table on a stool or chair high enough to enable extension of the shoulder under examination well over the IR.

• Angled 5 to 15 degrees through the shoulder joint and toward the elbow; a greater angle is required when the patient cannot extend the shoulder over the IR.

A superoinferior axial image shows the joint relationship of the proximal end of the humerus and the glenoid cavity (Fig. 5-35). The AC articulation, the outer portion of the coracoid process, and the points of insertion of the subscapularis muscle (at body of scapula) and teres minor muscle (at inferior axillary border) are shown.

Evaluation Criteria

The following should be clearly shown:

▪ Scapulohumeral joint (not open on patients with limited flexibility)

▪ Coracoid process projected above the clavicle

▪ Lesser tubercle in profile

▪ AC joint through the humeral head

▪ Soft tissue in the axilla with bony trabecular detail

Fig. 5-35 Superoinferior axial shoulder joint.

Scapular Y

PA Oblique Projection

RAO or LAO position

This projection, described by Rubin et al.,¹ obtained its name as a result of the appearance of the scapula. The body of the scapula forms the vertical component of the Y, and the acromion and the coracoid process form the upper limbs. This projection is useful in the evaluation of suspected shoulder dislocations.

Image receptor: 10 × 12 inch (24 × 30 cm) lengthwise

Position of patient

• Radiograph the patient in the upright or recumbent body position; the upright position is preferred.

• When the patient is severely injured and recumbent, modify the anterior oblique position by placing the patient in the posterior oblique position. This position does not require the patient to lie on the injured shoulder.

• Position the anterior surface of the shoulder being examined against the upright table.

• Rotate the patient so that the midcoronal plane forms an angle of 45 to 60 degrees to the IR. The position of the arm is not critical because it does not alter the relationship of the humeral head to the glenoid cavity (Fig. 5-36). Palpate the scapula, and place its flat surface perpendicular to the IR. According to Johnson et al.,¹ this is accomplished by orienting the plane through the superior angle of the scapula and acromial tip, perpendicular to the IR.

Fig. 5-36 A, PA oblique shoulder joint. B, Perspective from x-ray tube showing scapula centered in true lateral position. C, Top-down view showing positioning landmarks used for proper orientation of scapular body.

• Position the center of the IR at the level of the scapulohumeral joint.

Use of a specially designed compensating filter for the shoulder, called a boomerang, improves the quality of the image because of the large amount of primary beam radiation striking the IR. These filters are particularly useful when digital imaging (CR or DR) systems are used with this projection.

Compensating Filter

Central ray

• Perpendicular to the scapulohumeral joint (Table 5-3)

TABLE 5-3

Similar shoulder projections

Name	Body rotation	Scapula relationship to IR	Central ray angle*	Central ray entrance point*	Arm position*
Shoulder joint: Neer method	45-60 degrees	Perpendicular	10-15 degrees border caudad	Superior humeral	At side
Shoulder joint: scapular Y	45-60 degrees	Perpendicular	0 degrees	Scapulohumeral joint	At side
Scapula lateral	45-60 degrees	Perpendicular	0 degrees	Center of medial border of scapula	Variable

Collimation

• Adjust to 12 inches (30 cm) in length and 1 inch (2.5 cm) from the lateral shadow.

The scapular Y is shown on an oblique image of the shoulder. In the normal shoulder, the humeral head is directly superimposed over the junction of the Y (Fig. 5-37). In anterior (subcoracoid) dislocations, the humeral head is beneath the coracoid process (Fig. 5-38); in posterior (subacromial) dislocations, it is projected beneath the acromion. An AP shoulder projection is shown for comparison (Fig. 5-39).

Evaluation Criteria

The following should be clearly shown:

▪ Humeral head and glenoid cavity superimposed

▪ Humeral shaft and scapular body superimposed

▪ No superimposition of the scapular body over the bony thorax

▪ Acromion projected laterally and free of superimposition

▪ Coracoid possibly superimposed or projected below the clavicle

▪ Scapula in lateral profile with lateral and vertebral borders superimposed

• Place the patient in a seated or standing position facing the vertical grid device.

Fig. 5-37 PA oblique shoulder joint. Note scapular Y components—body, acromion, and coracoid process.

Fig. 5-38 PA oblique shoulder joint showing anterior dislocation (humeral head projected beneath coracoid process).

Fig. 5-39 AP shoulder (same patient as in Fig. 5-38).

Supraspinatus “Outlet”

Tangential Projection

NEER METHOD

RAO or LAO position

This radiographic projection is useful to show tangentially the coracoacromial arch or outlet to diagnose shoulder impingement.¹^,² The tangential image is obtained by projecting the x-ray beam under the acromion and AC joint, which defines the superior border of the coracoacromial outlet.

Image receptor: 8 × 10 inch (18 × 24 cm) or 10 × 12 inch (24 × 30 cm) lengthwise, depending on availability

Position of patient

• With the patient's affected shoulder centered and in contact with the IR, rotate the patient's unaffected side away from the IR. Palpate the flat aspect of the affected scapula and place it perpendicular to the IR. The degree of patient obliquity varies from patient to patient. The average degree of patient rotation varies from 45 to 60 degrees from the plane of the IR (Fig. 5-40).

Fig. 5-40 Tangential supraspinatus “outlet” projection.

• Place the patient's arm at the patient's side.

• Angled 10 to 15 degrees caudad, entering the superior aspect of the humeral head (see Table 5-3)

Structures shown

The tangential outlet image shows the posterior surface of the acromion and the AC joint identified as the superior border of the coracoacromial outlet (Figs. 5-41 and 5-42).

Evaluation Criteria

The following should be clearly shown:

▪ Humeral head projected below the AC joint

▪ Humeral head and AC joint with bony detail

▪ Humerus and scapular body, generally parallel

• Place the patient on the radiographic table in the supine position.

Fig. 5-41 Shoulder joint: Neer method. Supraspinatus outlet (arrow).

Fig. 5-42 A, Tangential supraspinatus outlet projection showing impingement of shoulder outlet by subacromial spur (arrow). B, Radiograph of same patient as in Fig. 5-41 after surgical removal of posterolateral surface of clavicle.

AP Axial Projection

Image receptor: 8 × 10 inch (18 × 24 cm) or 10 × 12 inch (24 × 30 cm) crosswise, depending on availability

Proximal Humerus

AP Axial Projection

Stryker Notch Method

Anterior dislocations of the shoulder frequently result in posterior defects involving the posterolateral head of the humerus. Such defects, called Hill-Sachs defects,¹ are often not shown using conventional radiographic positions. Hall et al.² described the notch projection, from ideas expressed by Stryker, as being useful to show this humeral defect.

Image receptor: 10 × 12 inch (24 × 30 cm)

Position of patient

• With the coracoid process of the affected shoulder centered to the table, ask the patient to flex the arm slightly beyond 90 degrees and place the palm of the hand on top of the head with fingertips resting on the head. (This hand position places the humerus in a slight internal rotation position.) The body of the humerus is adjusted to be vertical so that it is parallel to the midsagittal plane of the body (Fig. 5-45).

Fig. 5-45 AP axial humeral notch: Stryker notch method.

• Angled 10 degrees cephalad, entering the coracoid process

The resulting image shows the posterosuperior and posterolateral areas of the humeral head (Figs. 5-46 and 5-47).

Evaluation Criteria

The following should be clearly shown:

▪ Overlapping of coracoid process and clavicle

▪ Posterolateral lateral aspect of humeral head in profile

▪ Long axis of the humerus aligned with the long axis of the patient's body

▪ Soft tissues and bony trabecular detail of the humeral head

Fig. 5-46 AP axial humeral notch: Stryker notch method.

Fig. 5-47 Same projection as in Fig. 5-46 in a patient with small Hill-Sachs defect (arrow).

Glenoid Cavity

AP Axial Oblique Projection

GARTH METHOD

RPO or LPO position

This projection is recommended for assessing acute shoulder trauma and for identifying posterior scapulohumeral dislocations, glenoid fractures, Hill-Sachs lesions, and soft tissue calcifications.¹

Image receptor: 10 × 12 inch (24 × 30 cm) lengthwise

Position of patient

• Place the patient in the supine, seated, or upright position.

• Center the IR to the glenohumeral joint.

• Rotate the body approximately 45 degrees toward the affected side.

• The posterior surface of the affected side is closest to the IR.

• Flex the elbow of the affected arm and place arm across the chest (Fig. 5-48).

Fig. 5-48 A, AP axial oblique: Garth method, RPO position. Note 45-degree central ray (CR). B, Top view of same position as in A. Note 45-degree patient position.

• Angled 45 degrees caudad through the scapulohumeral joint

The scapulohumeral joint, humeral head, coracoid process, and scapular head and neck are shown (Fig. 5-49).

Evaluation Criteria

The following should be clearly shown:

▪ The scapulohumeral joint, humeral head, lateral angle, and scapular neck free of superimposition

▪ The coracoid process should be well visualized.

▪ Posterior dislocations project the humeral head superiorly from the glenoid cavity, and anterior dislocations project inferiorly.

▪ Soft tissues and bony trabecular detail of the humeral head

RESEARCH: Catherine E. Hearty, MS, RT(R), performed the research for this projection.

Proximal Humerus

Intertubercular (Bicipital) Groove

Tangential Projection

Fisk modification

Various modifications of the intertubercular (bicipital) groove image have been devised. In all cases, the central ray is aligned to be tangential to the intertubercular (bicipital) groove, which lies on the anterior surface of the humerus.¹

The x-ray tube head assembly may limit the performance of this examination. Some radiographic units have large collimators or handles, or both, that limit flexibility in positioning. A mobile radiographic unit may be used to reduce this difficulty.

Image receptor: 8 × 10 inch (18 × 24 cm) or 10 × 12 inch (24 × 30 cm), depending on availability

Position of patient

• Place the patient in the supine, seated, or standing position.

• To improve centering, extend the chin or rotate the head away from the affected side.

• With the patient supine, palpate the anterior surface of the shoulder to locate the intertubercular (bicipital) groove.

• With the patient's hand in the supinated position, place the IR against the superior surface of the shoulder and immobilize the IR as shown in Fig. 5-50.

Fig. 5-50 Supine tangential intertubercular groove.

Fisk first described this position with the patient standing at the end of the radiographic table. This employs a greater OID. The following steps are then taken with the Fisk technique:

Fisk modification.

• Instruct the patient to flex the elbow and lean forward far enough to place the posterior surface of the forearm on the table. The patient supports and grasps the IR as depicted in Fig. 5-51.

Fig. 5-51 Standing tangential intertubercular groove: Fisk modification.

• For radiation protection and for reduction of backscatter to the IR from the forearm, place a lead shielding between the IR back and the forearm.

• Place a sandbag under the hand to place the IR horizontal.

• Have the patient lean forward or backward as required to place the vertical humerus at an angle of 10 to 15 degrees.

• Angled 10 to 15 degrees posterior (downward from horizontal) to the long axis of the humerus for the supine position (see Fig. 5-50)

Fisk modification

• Perpendicular to the IR when the patient is leaning forward and the vertical humerus is positioned 10 to 15 degrees (see Fig. 5-51)

Collimation

• Adjust to 4 × 4 inch (10 × 10 cm) on the collimator.

The tangential image profiles the intertubercular (bicipital) groove free from superimposition of the surrounding shoulder structures (Figs. 5-52 and 5-53).

Evaluation Criteria

The following should be clearly shown:

▪ Intertubercular (bicipital) groove in profile

▪ Soft tissues and bony trabecular detail of the humeral head

Fig. 5-52 Supine tangential intertubercular groove.

Fig. 5-53 Standing tangential intertubercular groove: Fisk modification.

Acromioclavicular Articulations

AP Projection

Bilateral

PEARSON METHOD

Image receptor: 14 × 17 inch (35 × 43 cm) or two 8 × 10 inch (18 × 24 cm) or two 10 × 12 inch (24 × 30 cm), as needed to fit the patient

SID: 72 inches (183 cm). A longer SID reduces magnification, which enables both joints to be included on one image. It also reduces the distortion of the joint space resulting from central ray divergence.

• Place the patient in an upright body position, either seated or standing, because dislocation of the AC joint tends to reduce itself in the recumbent position. The positioning is easily modified to obtain a PA projection.

• Place the patient in the upright position before a vertical grid device, and adjust the height of the IR so that the midpoint of the IR lies at the same level as the AC joints (Fig. 5-54).

Fig. 5-54 Bilateral AP AC articulations.

• Center the midline of the body to the midline of the grid.

• Ensure that the weight of the body is equally distributed on the feet to avoid rotation.

• With the patient's arms hanging by the sides, adjust the shoulders to lie in the same horizontal plane. It is important that the arms hang unsupported.

• Make two exposures: one in which the patient is standing upright without weights attached, and a second in which the patient has equal weights (5 to 10 lb) affixed to each wrist.¹^,²

• After the first exposure, slowly affix the weights to the patient's wrist, using a band or strap.

• Instruct the patient not to favor (tense up) the injured shoulder.

• Avoid having the patient hold weights in each hand; this tends to make the shoulder muscles contract, reducing the possibility of showing a small AC separation (Fig. 5-55).

Fig. 5-55 Weights should be attached to wrists as shown and not held in hands. Note how separation of AC joint is shown by pulling of weights.

• Shield gonads. Also use a thyroid collar because the thyroid gland is exposed to the primary beam.

• Perpendicular to the midline of the body at the level of the AC joints for a single projection; directed at each respective AC joint when two separate exposures are necessary for each shoulder in broad-shouldered patients

• Single: to 6 × 8 inch (15 × 20 cm) (note 2 inch [5 cm] less than IR size)

• Double: to 6 × 17 inch (15 × 43 cm)

Bilateral images of the AC joints are shown (Figs. 5-56 and 5-57). This projection is used to show dislocation, separation, and function of the joints.

Evaluation Criteria

The following should be clearly shown:

▪ AC joints visualized with some soft tissue and without excessive density

▪ Both AC joints, with and without weights, entirely included on one or two single radiographs

▪ No rotation or leaning by the patient

▪ Right or left and weight or nonweight markers

▪ AC joint separation, if present, clearly seen on the images with weights

Fig. 5-56 Bilateral AP AC joints showing normal left joint and separation of right joint (arrow).

Fig. 5-57 Normal AC joints requiring two separate radiographs.

AP Axial Projection

Alexander Method

Alexander ¹ suggested that AP and PA axial oblique projections be used in cases of suspected AC subluxation or dislocation. Each side is examined separately.

Image receptor: 8 × 10 inch (18 × 24 cm) or 10 × 12 inch (24 × 30 cm) lengthwise, depending on availability

Position of patient

• Place the patient in the upright position, either standing or seated.

• Have the patient place the back against the vertical grid device and sit or stand upright.

• Center the affected shoulder under examination to the grid.

• Adjust the height of the IR so that the midpoint of the film is at the level of the AC joint.

• Adjust the patient's position to center the coracoid process to the IR (Fig. 5-58).

Fig. 5-58 Unilateral AP axial AC articulation: Alexander method.

• Directed to the coracoid process at a cephalic angle of 15 degrees (Fig. 5-59). This angulation projects the AC joint above the acromion.

Fig. 5-59 AP axial AC articulation: Alexander method.

The resulting image shows the AC joint projected slightly superiorly compared with an AP projection (Fig. 5-60).

Evaluation Criteria

The following should be clearly shown:

▪ AC joint and clavicle projected above the acromion

▪ AC joint visualized with some soft tissue

Fig. 5-60 AP axial AC articulation: Alexander method.

Clavicle

AP Projection

Image receptor: 10 × 12 inch (24 × 30 cm) crosswise

• Place the patient in the supine or upright position.

• If the clavicle is being examined for a fracture or a destructive disease, or if the patient cannot be placed in the upright position, use the supine position to reduce the possibility of fragment displacement or additional injury.

• Adjust the body to center the clavicle to the midline of the table or vertical grid device.

• Place the arms along the sides of the body, and adjust the shoulders to lie in the same horizontal plane.

• Center the clavicle to the IR (Fig. 5-61).

• Respiration: Suspend at the end of exhalation to obtain a more uniform-density image.

• Perpendicular to the midshaft of the clavicle

• Adjust to 8 × 12 inch (18 × 30 cm) on the collimator.

This projection shows a frontal image of the clavicle (Fig. 5-62).

Evaluation Criteria

The following should be clearly shown:

▪ Entire clavicle centered on the image

▪ Lateral half of the clavicle above the scapula, with the medial half superimposing the thorax

NOTE: If the patient is injured or is unable to assume the lordotic position, a slightly distorted image results when the tube is angled. An optional approach for improved spatial resolution is the PA axial projection.

AP Axial Projection

Lordotic position

Image receptor: 10 × 12 inch (24 × 30 cm) crosswise

• Stand or seat the patient 1 foot in front of the vertical IR device, with the patient facing the x-ray tube.

• Alternatively, if the patient cannot stand and assume the lordotic position, place the patient supine on the table.

• This is directed to enter the midshaft of the clavicle.

• Cephalic central ray angulation can vary from the long axis of the torso; thinner patients require increased angulation to project the clavicle off the scapula and ribs.

• For the standing lordotic position, 0 to 15 degrees is recommended (see Fig. 5-63).

• For the supine position, 15 to 30 degrees is recommended (see Fig. 5-64).

Collimation

• Adjust to 8 × 12 inch (18 × 30 cm) on the collimator.

An axial image of the clavicle is projected above the ribs (Fig. 5-65).

Evaluation Criteria

The following should be clearly shown:

▪ Most of the clavicle projected above the ribs and scapula with the medial end overlapping the first or second rib

▪ Clavicle in a horizontal placement

▪ Entire clavicle along with AC and SC joints

• The patient is standing upright (back toward the x-ray tube) or is prone (Fig. 5-66).

Fig. 5-65 AP axial clavicle. Same patient as Fig. 5-62. Note slightly different projection of the bone.

PA Projection

The PA projection is generally well accepted by the patient who can 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, reducing the OID. Positioning is similar to that of the AP projection. Differences are as follows:

• The perpendicular central ray exits the midshaft of the clavicle (Fig. 5-67).

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

PA Axial Projection

Positioning of the PA axial clavicle is similar to the AP axial projection described previously. The differences are as follows:

• The patient is prone or standing, facing the vertical grid device.

• The central ray is angled 15 to 30 degrees caudad (Fig. 5-68).

Structures shown and evaluation criteria are the same as described previously for the AP axial projection.

Scapula

AP Projection

Image receptor: 10 × 12 inch (24 × 30 cm) lengthwise

• Place the patient in the upright or supine position. The upright position is preferred if the shoulder is tender.

• Adjust the patient's body, and center the affected scapula to the midline of the grid.

• Abduct the arm to a right angle with the body to draw the scapula laterally. Flex the elbow, and support the hand in a comfortable position.

• For this projection, do not rotate the body toward the affected side because the resultant obliquity would offset the effect of drawing the scapula laterally (Fig. 5-69).

• Position the top of the IR 2 inches (5 cm) above the top of the shoulder.

• Respiration: Make this exposure during slow breathing to obliterate lung detail.

• Perpendicular to the midscapular area at a point approximately 2 inches (5 cm) inferior to the coracoid process

• Adjust to 10 × 12 inch (24 × 30 cm) on the collimator.

An AP projection of the scapula is shown (Fig. 5-70).

Evaluation Criteria

The following should be clearly shown:

▪ Lateral portion of the scapula free of superimposition from the ribs

▪ Scapula horizontal and not slanted

▪ Scapular detail through the superimposed lung and ribs (shallow breathing should help obliterate lung detail)

▪ Acromion and inferior angle

Image receptor: 10 × 12 inch (24 × 30 cm) lengthwise

Fig. 5-70 A, AP scapula. B, AP scapula showing fracture of scapula through glenoid cavity and extending inferiorly (arrows).

Lateral Projection

RAO or LAO body position

• Place the patient in the upright position, standing or seated, facing a vertical grid device.

• The prone position can be used, but the projection is more difficult to perform. The supine position can also be used; however, the scapula is magnified.

• Place the arm in one of two positions according to the area of the scapula to be shown.

• Adjust the patient in RAO or LAO position, with the affected scapula centered to the grid. The average patient requires a 45- to 60-degree rotation from the plane of the IR. According to Johnston et al.,¹ proper patient rotation is accomplished by orienting the plane through the superior angle of the scapula and acromial tip, perpendicular to the IR.

• For delineation of the acromion and the coracoid process of the scapula, have the patient flex the elbow and place the back of the hand on the posterior thorax at a level sufficient to prevent the humerus from overlapping the scapula (Figs. 5-71 and 5-72). Mazujian² suggested that the patient place the arm across the upper chest by grasping the opposite shoulder, as shown in Fig. 5-73.

Fig. 5-71 A, Lateral scapula, RAO body position. B, Perspective from x-ray tube showing scapula centered in true lateral position.

Fig. 5-72 Lateral scapula with arm on posterior chest.

Fig. 5-73 Lateral scapula with arm across upper anterior thorax.

• To show the body of the scapula, ask the patient to extend the arm upward and rest the forearm on the head or across the upper chest by grasping the opposite shoulder (Fig. 5-74; see Fig. 5-73).

Fig. 5-74 Lateral scapula with arm extended above head.

• After placing the arm in any of these positions, grasp the lateral and medial borders of the scapula between the thumb and index finger of one hand. Make a final adjustment of the body rotation, placing the body of the scapula perpendicular to the plane of the IR.

• Perpendicular to the midmedial border of the protruding scapula (see Table 5-3)

Collimation

• Adjust to 12 inches (30 cm) in length and 1 inch (2.5 cm) from the lateral shadow.

Compensating Filter

Use of a specially designed compensating filter for the shoulder, called a boomerang, improves the quality of the image because of the large amount of primary beam radiation striking the IR. These filters are particularly useful when digital radiography (CR or DR) systems are used with this projection.

AP Oblique Projection

RPO or LPO position

Image receptor: 10 × 12 inch (24 × 30 cm) lengthwise

• Place the patient in the supine or upright position.

• Use the upright position when the shoulder is painful unless contraindicated.

• Align the body and center the affected scapula to the midline of the grid.

• For moderate AP oblique projection, ask the patient to extend the arm superiorly, flex the elbow, and place the supinated hand under the head, or have the patient extend the affected arm across the anterior chest.

• Have the patient turn away from the affected side enough to rotate the shoulder 15 to 25 degrees (Fig. 5-75).

Fig. 5-75 AP oblique scapula, 20-degree body rotation.

• For a steeper oblique projection, ask the patient to extend the arm, rest the flexed elbow on the forehead, and rotate the body away from the affected side 25 to 35 degrees (Fig. 5-76).

Fig. 5-76 AP oblique scapula, 35-degree body rotation.

• Grasp the lateral and medial borders of the scapula between the thumb and index finger of one hand, and adjust the rotation of the body to project the scapula free of the rib cage.

• For a direct lateral projection of the scapula using this position, draw the arm across the chest, and adjust the body rotation to place the scapula perpendicular to the plane of the IR as previously described and shown in Figs. 5-71 to 5-74.

• Perpendicular to the lateral border of the rib cage at the midscapular area

Coracoid Process

AP Axial Projection

Image receptor: 10 × 12 inch (24 × 30 cm) crosswise

• Place the patient in the supine position with the arms along the sides of the body.

• Adjust the position of the body, and center the affected coracoid process to the midline of the grid.

• Position the IR so that the midpoint of the IR coincides with the central ray.

• Adjust the shoulders to lie in the same horizontal plane.

• Abduct the arm of the affected side slightly, and supinate the hand, immobilizing it with a sandbag across the palm (Fig. 5-79).

• Respiration: Suspend at the end of exhalation for a more uniform density.