14.1 Shoulder Radiography Routine Non-Trauma: A-P with internal and external rotation of humerus Trauma or Dislocation Shoulder: A-P internal rotation, Lateral scapula or “Y” view, Apical Oblique,possible or Stryker Notch and P-A Axillary Shoulder Instability: Weighted internal and external rotation, Stryker Notch

Shoulder Radiography To evaluate the glenohumeral joint, the scapula must be parallel to the film. Shoulder views can be taken with suspended respiration The Clavicle and A C joints will have the patient in a true A-P position with mid sagittal plane perpendicular to film.

Shoulder Radiography A-C Joint view are taken with full inspiration to help open the joint space. A-C Joint views are taken weighted and non-weighted when looking for a separation. The weights must be 10 to 15 pounds and strapped around the wrists to avoid the use of the arm muscles.

Shoulder Radiography A-C Joints views can also be taken to detect metabolic or drug induced bone loss. The view need not be taken with and without weights. The Clavicle can be taken A-P or P-A. The P-A view will have less magnification distortion but is more difficult to position.

14.2 Shoulder A-P with Internal Rotation Measure: A-P at coracoid process Protection: Half Apron SID: 40” Bucky No Tube Angle Film: 10” x 8” I.D. toward spine Marker: anatomical plus “INT” or arrow pointing inward

Shoulder A-P with Internal Rotation Patient stands facing tube. The patient is rotated 15 to 45 degrees until the scapula is parallel to the film. The patient internally rotates humerus until the epicondyles are perpendicular to the film.

Shoulder A-P with Internal Rotation Horizontal CR: 1” below the coracoid process Vertical CR: coracoid process or through the glenohumeral joint Film centered to Horizontal CR Collimation: to include soft tissue around shoulder or slightly less than film size.

Shoulder A-P with Internal Rotation Breathing Instructions: suspended respiration Make exposure and let patient breathe and relax. Some facilities will use a 12” x 10 cassette

Shoulder A-P with Internal Rotation Film The glenohumeral joint should be open The lesser tubericle will be in profile medially. The humeral head and greater tubericle will be superimposed.

14.3 Shoulder A-P with External Rotation Measure: A-P at coracoid process Protection: Half Apron SID: 40” Bucky No Tube Angle Film: 10” x 8” I.D. toward spine Marker: anatomical plus “EXT” or arrow pointing outward

Shoulder A-P with External Rotation Patient stands facing tube. The patient is rotated 15 to 45 degrees until the scapula is parallel to the film. The patient externally rotates humerus until the epicondyles are parallel to the film.

Shoulder A-P with External Rotation Horizontal CR: 1” below the coracoid process Vertical CR: coracoid process or through the glenohumeral joint Film centered to Horizontal CR Collimation: to include soft tissue around shoulder or slightly less than film size.

Shoulder A-P with External Rotation Breathing Instructions: suspended respiration Make exposure and let patient breathe and relax. Some facilities will use a 12” x 10 cassette

Shoulder A-P with External Rotation Film The glenohumeral joint should be open The greater tubericle and humeral head will be in profile .

14.4 Shoulder Apical Oblique Measure: A-P at coracoid process Protection: Half apron SID: 40” Bucky Tube angle: 30 degrees caudal Film size: 10” x 12” Regular I.D. to spine

Shoulder Apical Oblique Patient stands facing tube with humerus internally rotated until the epicondyles are perpendicular to film The patient is rotated 15 to 45 degrees to get the scapula parallel to film and Bucky. SID adjusted for tube angle.

Shoulder Apical Oblique Horizontal CR: 2” above the coracoid process of glenohumeral joint. Vertical CR: Coracoid process to glenohumeral joint. Film centered to Horizontal CR

Shoulder Apical Oblique Collimation: to include all soft tissue around shoulder and proximal humerus Breathing Instructions: Suspended respiration Make exposure and let patient breathe and relax

Shoulder Apical Oblique Film Should visualize the head of the humerus within the glenoid fossa. The tube angle results in minimal superimposition Useful in detection of dislocations, Bankhart and Hill-Sachs defects. Can be taken with arm in sling.

14.5 Shoulder: Prone Axillary Measure: A-P at coracoid Protection: Half Apron SID: 40” Non- Bucky Tube angle: 15 to 25 degrees down Film: 12” x 10” Regular with I.D. to spine Special Equipment: rectangular and large angle sponge

Shoulder: Prone Axillary Table placed in front of tube. Two to three inch thick rectangular sponge placed on table top. Large angle sponge used to hold film vertical. Tube aligned to film and SID set at 40” using tape measure on collimator.

Shoulder: Prone Axillary The patient is asked to lean over table with arm abducted 90 degrees. The elbow is bent 90 degrees and hangs off the table. The arm and shoulder will be resting on rectangular sponge. The mid sagittal plane of the patient is turned 10 to 25 degrees medially.

Shoulder: Prone Axillary The head and neck is turned away from the affected shoulder. The film is placed next to the neck. Horizontal CR: 2” above the glenohumeral joint. Vertical CR: through the glenohumeral joint

Shoulder: Prone Axillary Collimation: to include all soft tissue around the shoulder or slightly less than film size. Breathing instructions: full inspiration or suspended respiration Make exposure and let patient breathe and relax.

Shoulder: Prone Axillary Film Also known as as West Point View. The best view for visualizing the glenohumeral joint space free of superimposition. This view is very difficult to set up with tube stands common to office practices.

14.6 Shoulder Outlet View Measure: A-P at coracoid process Protection: Half apron SID: 40” Bucky Tube Angle: 15 to 30 degrees caudal for Outlet View. 0 to 10 degrees for Lateral Scapula or “Y” view Film: 10” x 12 regular with I.D. to spine

Shoulder Outlet View Patient is placed in a sixty degree anterior oblique. The arm of the affected shoulder is left in a neutral position or in the sling. The head of the affected shoulder aligned with the center line if the Bucky. By feeling the scapula, adjust position to get scapula perpendicular to film.

Shoulder Outlet View Horizontal CR: Head of humerus to slightly below head of humerus Vertical CR: 1” medial to the body of the scapula. Collimation: to include entire scapula and adjacent soft tissues of shoulder. Breathing Instructions: Full Inspiration

Shoulder Outlet View This is one of the best views to be taken when fracture or dislocation of shoulder is suspected. You should see the true relationship of the humerus head and the glenoid fossa. Very useful when detecting a dislocation or fracture.

Shoulder Outlet View The true Outlet View will allow evaluation of the subacromion space for the evaluation of impingement syndrome. Fractures of the scapula may also be seen on this view.

Shoulder Outlet View There are four abnormal acromion shapes that predispose impingement. Flat Underside Underside concave following curve of the humeral head Anterioinferior acromial spur or hook Underside convex

14.16 Scapula Lateral View or “Y” View Measure: A-P at coracoid process Protection: Half apron SID: 40” Bucky Tube Angle: 0 to 10 degrees for Lateral Scapula or “Y” view Film: 10” x 12 regular with I.D. to spine

Scapula Lateral View Patient is placed in a sixty degree anterior oblique. The arm of the affected shoulder is left in a neutral position or in the sling. The head of the affected shoulder aligned with the center line if the Bucky. By feeling the scapula, adjust position to get scapula perpendicular to film.

Scapula Lateral View Horizontal CR: Head of humerus to slightly below head of humerus Vertical CR: 1” medial to the body of the scapula. Collimation: to include entire scapula and adjacent soft tissues of shoulder. Breathing Instructions: Full Inspiration

Scapula Lateral View This is one of the best views to be taken when fracture or dislocation of shoulder is suspected. You should see the true relationship of the humerus head and the glenoid fossa. Very useful when detecting a dislocation or fracture.

Scapula Lateral View The true Outlet View will allow evaluation of the subacromion space for the evaluation of impingement syndrome. Fractures of the scapula may also be seen on this view.

14.7 Shoulder: Stryker Notch Measure: A-P at coracoid process Protection: Half Apron SID: 40” Bucky Tube angle: 45 degrees cephalad Film: 8” x 10” Regular with I.D. to spine

Shoulder: Stryker Notch Patient stands facing tube. The body is rotated 15 to 45 degrees to get scapula parallel to film The patient abducts arm and placed hand behind neck. The humerus should be internally turn to get humerus perpendicular to film.

Shoulder: Stryker Notch Horizontal CR: about 2” inferior to coracoid process or through the glenohumeral joint. Vertical CR: glenohumeral joint space Collimation: slightly less than film size or to include all soft tissue around shoulder.

Shoulder: Stryker Notch Breathing Instructions: Full Inspiration. Note : Make sure that the glenohumeral joint space stays within collimation and central ray placement by having patient take a full breathe in and hold it before taking film.

Shoulder: Stryker Notch Film This view will provide a clear view of the posterior and superior aspects of the head of the humerus. The inferior borders of the glenoid fossa and joint space will be seen. It is useful in detecting Hill-Sachs defects and anterior instability

14.15 Scapula A-P Measure: A-P at coracoid process Protection: Half Apron SID: 40” Bucky No Tube Angle Film: 12” x 10” Regular Speed with I.D. toward the spine

Scapula A-P Patient stands facing tube. Patient is rotated about 15° or until the scapula is parallel to film. The humerus may be left in a neutral position. Horizontal CR: 1” below the coracoid process. Vertical CR: 1” medial to coracoid process

Scapula A-P Film centered to horizontal CR. Collimation top to bottom: slightly less than film size or to include entire scapula and shoulder Collimation side to side: slightly less than film size or to include entire scapula and shoulder

Scapula A-P Breathing Instructions: Suspended Respiration Make exposure and let patient relax. Some texts recommend raising the arm to get scapula clear of the ribs cage. Usually you will be able to visualize scapula with arm in neutral position.

Scapula A-P Film Glenohumeral joint and entire scapula should be seen. Soft tissues of shoulder should be seen.

14.8 Clavicle P-A Measure: A-P at mid clavicle Protection: Half Apron SID: 40” Bucky No Tube Angle Film: 1/2 of 8” x 10” or 10” x 12” Regular Cassette

Clavicle P-A Patient stands facing Bucky with mid-sagittal plane perpendicular to film. Horizontal CR: centered to exit through clavicle Vertical CR: centered to clavicle Horizontal CR centered to top half of film.

Clavicle P-A Collimation Top to Bottom: less than 1/2 of film size or to include clavicle Collimation side to side: slightly less than film size or to include sternoclavicular and acromioclavicular joints Breathing Instructions: Suspended Respiration Take film and let patient relax

Clavicle P-A Film On this example, the A-P or P-A view is on the bottom of film. Must see the sternoclavicular and acromioclavicular joints and entire clavicle.

14.8 Clavicle P-A Axial Measure: A-P at mid clavicle Protection: Half Apron SID: 40” Bucky Tube Angle : 10 to 15 degrees caudal Film: 1/2 of 8” x 10” or 10” x 12” Regular Cassette

Clavicle P-A Axial Patient stands facing Bucky with mid-sagittal plane perpendicular to film. Horizontal CR: one inch above center of clavicle Vertical CR: centered to clavicle Horizontal CR centered to bottom half of film.

Clavicle P-A Axial Collimation Top to Bottom: less than 1/2 of film size or to include clavicle Collimation side to side: slightly less than film size or to include sternoclavicular and acromioclavicular joints Breathing Instructions: Suspended Respiration Take film and let patient relax

Clavicle P-A Axial Film On this example, the A-P or P-A axial view is on the top of film. Must see the sternoclavicular and acromioclavicular joints and entire clavicle. The P-A views will have less magnification but are more difficult to position.

14.9 Clavicle A-P Measure: A-P at mid clavicle Protection: Half Apron SID: 40” Bucky No Tube Angle Film: 1/2 of 8” x 10” or 10” x 12” Regular Cassette

Clavicle A-P Patient stands facing tube with mid-sagittal plane perpendicular to film. Horizontal CR: centered to clavicle Vertical CR: centered to clavicle Horizontal CR centered to top half of film.

Clavicle A-P Collimation Top to Bottom: less than 1/2 of film size or to include clavicle Collimation side to side: slightly less than film size or to include sternoclavicular and acromioclavicular joints Breathing Instructions: Suspended Respiration Take film and let patient relax

Clavicle A-P Film On this example, the A-P pr P-A view is on the bottom of film. Must see the sternoclavicular and acromioclavicular joints and entire clavicle.

14.11 Clavicle A-P Axial Measure: A-P at mid clavicle Protection: Half Apron SID: 40” Bucky Tube Angle : 15 to 25 degrees cephalad Film: 1/2 of 8” x 10” or 10” x 12” Regular Cassette

Clavicle A-P Axial Patient stands facing tube with mid-sagittal plane perpendicular to film. Horizontal CR: one inch below center of clavicle Vertical CR: centered to clavicle Horizontal CR centered to bottom half of film.

Clavicle A-P Axial Collimation Top to Bottom: less than 1/2 of film size or to include clavicle Collimation side to side: slightly less than film size or to include sternoclavicular and acromioclavicular joints Breathing Instructions: Suspended Respiration Take film and let patient relax

Clavicle A-P Axial Film On this example, the A-P or P-A axial view is on the top of film. Must see the sternoclavicular and acromioclavicular joints and entire clavicle. The P-A views will have less magnification but are more difficult to position.

14.12 Acromioclavicular Joint Unilateral Measure: A-P at coracoid Protection: Half Apron SID: 40” Bucky Tube Angle : None Film: 2 views on 10” x 12” Regular Cassette Special equipment: 10 to 15 pounds of weight that can be strapped to wrists

Acromioclavicular Joint Unilateral Patient stands facing tube with mid-sagittal plane perpendicular to film. Horizontal CR: A-C joint Vertical CR: A-C joint Horizontal CR centered to top half of film. Marker: anatomical

Acromioclavicular Joint Unilateral Collimation: soft tissue around A-C joint but less than 1/2 of film size. Breathing Instructions: Deep Inspiration Make sure the A-C Joint remains in collimation with deep inspiration

Acromioclavicular Joint Unilateral Make exposure and let patient breathe but remain in position. Strap weights to both wrists. Marker: arrow pointed down or “weighted marker on bottom half of film

Acromioclavicular Joint Unilateral Horizontal CR: A-C joint Vertical CR: A-C joint Center horizontal CR to bottom half of film. Breathing Instructions: Deep Inspiration Make exposure and let patient breathe and relax. Remove weights

Acromioclavicular Joint Unilateral Film The most common view here is the Zanca modification to the unilateral ribs. The Zanca Views will open the acromion space better than the straight A-P views.

14.13 Acromioclavicular Joints Bilateral A-P Measure: A-P at coracoid Protection: Half apron SID: 72” Non-Bucky Tube Angle: none Zanca View 15 degree cephalad angle Film: 17” x 7” or 17” x 14” I.D. to unaffected side

Acromioclavicular Joints Bilateral A-P Non-Bucky film holder hung on Bucky. Film placed in Non-Bucky Holder. Patient stands facing tube with mid-sagittal plane perpendicular to film. Horizontal CR: at level of A-C Joints. Zanca: 1” below A-C Joints

Acromioclavicular Joints Bilateral A-P Vertical CR: mid-sagittal Collimation: to include both A-C joints and adjacent soft tissue and slightly less than film size on 17” x 7” film. Breathing Instructions: Deep Inspiration

Acromioclavicular Joints Bilateral A-P Make exposure and let patient relax. Change films or move to unexposed half of 17” x 14” film. Strap weights to wrists. Horizontal and vertical CR same as non-weighted view.

Acromioclavicular Joints Bilateral A-P Place arrow pointing down or “ weighted” marker on film. Breathing instructions: Deep Inspiration Make exposure and let patient breathe and relax. Remove weights.

Acromioclavicular Joints Bilateral A-P Film The bilateral exam provides a comparison view of both A-C Joints. The increased SID and Non-Bucky exposure is 25% of the unilateral view. Magnification is reduced.

14.14 Zanca Views of the A C Joints Measure: A-P at coracoid process Protection: half apron SID: 40” Bucky Tube Angle: 15° cephalad Film: 10” x 12” Regular Speed

Zanca Views of the A C Joints Patient stands facing tube with mid sagittal plane perpendicular to film. Horizontal CR: 1” below A C Joint Vertical CR: through the A C Joint

Zanca Views of the A C Joints Bottom half of film centered to Horizontal CR. Collimation top to bottom: to include A- C Joint Collimation side to side: soft tissues adjacent to A-C Joint

Zanca Views of the A C Joints Breathing Instructions: Full Inspiration Rehearse breathing to make sure the A J joint will be seen on full inspiration. Make exposure and ask patient not to move. Strap weights around wrists.

Zanca Views of the A C Joints Adjust Horizontal CR for the weight, still 1” below A-C Joint Center remaining half of film to Horizontal CR Place arrow or weighted marker on film. Have patient take a deep breath and make exposure.

Zanca View Films Weighted and Non-Weighted Views are taken as stress views of the Acromioclavicular Joint. Useful in detection separations

Zanca View Films The Zanca View will open the sub-acromion space better than the standard A-P view. If separation is not suspected, it can be used to evaluate bone loss in the A-C Joint. A single view on an 8” x 10” is taken.

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