1. Proximal Humerus and Shoulder

2. Evaluation Criteria Structures shown Position/projection
Collimation/central Ray
Exposure criteria
Acceptable and unacceptable proximal humerus and shoulder based on errors i.e.:
Motion
Collimation
Positioning
Exposure factors
Side markers and patient demographic information
Every time a radiographer completes an image, an evaluation must be made to determine whether the image is diagnostically optimal for the radiologist to provide an accurate diagnosis. A radiologist should NEVER have to return an image for repeat if proper evaluation of the image is done by the radiographer.
Here are five basic criteria for radiographic evaluations and critique. These should be used every time a radiographic image is performed.

3. Introduction
The shoulder joint, sometimes called the gleno-humeral joint, is a ball-and-socket joint that allows the greatest range of motion of any joint in the human body. An articular capsule surrounds the joint; however, it is very thin and does little to restrict movement. A number of tendons and ligaments also surround the joint to lend it considerable stability. Four of these tendons, collectively known at the rotator cuff, can tear when the arm is severely circumducted. This type of injury is common in baseball pitchers. The shoulder or pectoral girdle consists of the clavicle and the scapula. The shoulder girdle attaches the upper limb to the axial skeleton.

4. AP Shoulder Imaging Basics
<Images #1, 2, 3>
Reasons for obtaining shoulder images are numerous and include fracture, dislocation, bursitis, tendon or ligament damage, bony tumors and cysts. Structures demonstrated on the images include the proximal humerus and most of the clavicle and scapula. Routine images for the shoulder include the AP with internal and external rotation.

5. AP Shoulder Imaging Criteria
Technical Considerations
Grid
kVp range: 70-80
SID: 40 inches (100 cm)
IR size 10x12 inch (24x30cm)
Patient Position
Supine or upright, depending on the patient’s condition
Posterior surface of the patient’s body against the IR
All potential artifacts removed from the part
Part Position
AP internal rotation:
Place the affected arm by the patient’s side with the back of the hand resting on the lateral thigh to place the intercondylar line perpendicular to the IR
AP external rotation:
Place the affected arm by the patient’s side with the hand supinated to place the intercondylar line parallel to the IR
AP neutral rotation:
Place the affected arm by the patient’s side with the palm resting on the thigh
Central Ray (CR)
For all three positions/projections CR is perpendicular to a point 1” inferior to the coracoid process
Patient Instructions
“Take in a breath and hold it. Don’t breathe or move.”
Evaluation Criteria
Proximal humerus present on the image
The distal 2/3 of the clavicle present on image
Most of the scapula should be present on the image
Lesser tubercle should be demonstrated in profile on the medial aspect of the humerus
Humeral head should be slightly more superimposed on the glenoid fossa as compared to the neutral position
Distal 2/3 of the clavicle present on image
Greater tubercle should be demonstrated in profile on the lateral aspect of the humerus
Humeral head should be slightly superimposed on the glenoid fossa
Neither the greater nor lesser tubercle should appear in profile
Additional Information
Internal rotation of the shoulder should never be performed if the patient presents with acute trauma
External rotation of the shoulder should never be performed if the patient presents with acute trauma
Neutral position is generally used with trauma patient because the arm should not be rotated in cases of acute injury
Click each button for more information about AP shoulder imaging.
Technical Considerations
Evaluation Criteria
Additional Information

6. Knowledge Check <Images #4 & 5>
With the shoulder in the AP position with is the angle of obliquity of the scapula?
10-20 degrees
20 to 25 degrees
30-40 degrees
35-45 degrees

7. Scapular “Y” Imaging Basics
<Images 6, 10, 11>
The scapular Y is an alternate and sometimes a routine view (depending on departmental protocol) of the shoulder used primarily with trauma patients to evaluate possible dislocation of the head of the humerus. Structures demonstrated on the image include the glenoid cavity, humeral head, and most of the scapula.

8. Shoulder Scapular “Y” Imaging Criteria
Technical Considerations
Grid
kVp range: 70-80
SID: 40 inches (100 cm)
IR size 10x12 inch (24x30cm) lengthwise
Patient Position
Supine or upright, depending on the patient’s condition
The posterior surface of the patient’s body against the IR
All potential artifacts removed from the part
Part Position
Place the affected arm by the patient’s side in a neutral position
Turn the patient 30 degrees away form the affected side
LPO for injuries to the right side
RPO for injuries to the left side
Central Ray (CR)
CR directed perpendicular to the glenohumeral joint
2-3 inches below the acromion process
Patient Instructions
“Take in a breath and hold it. Don’t breathe or move.”
Evaluation Criteria
Scapula should be in a true lateral position, free from superimposition of the ribs
Shaft of the humerus should be superimposed on the body of the scapula
Additional Information
If the patient’s condition allows, anterior obliques may be performed upright to achieve less object-IR distance.
With the patient facing the IR rotate the patient into a 60 degree anterior oblique (30 degrees from lateral)
The RAO is used for injuries to the right side
The LAO is used for injuries to the left side
Click each button for more information about XYZ
Technical Considerations
Evaluation Criteria
Additional Information

9. Knowledge Check <(Images #7 & 8)
Label the following anatomy on the scapular Y image, acromion, coracoid, body of scapula, inferior angle of the scapula, humerus, (answers on image #8)
2. For an RPO position of the scapular Y, which scapula is being demonstrated?
Right side
Left side
both sides

10. Inferosuperior Axial Imaging Basics
<Image 10-2 & 10-3>
The inferosuperior axial projection is used primarily to obtain a lateral view of the proximal humerus and its relationship to the glenoid fossa. Structures demonstrated on the radiograph include the glenoid fossa and the proximal humerus.

11. Inferosuperior Axial Imaging Criteria
Technical Considerations
Grid or non-grid
kVp range: 70-80
SID: 40 inches (100 cm)
IR size 10x12 inch (24x30cm) lengthwise
Patient Position
Supine
All potential artifacts removed from the part
Part Position
Place the IR perpendicular to the table top
IR as close to the patient’s neck as possible
Abduct the affected arm 90 degrees from the body
Turn the patient’s head away from the affected shoulder
A non-opaque sponge may be placed under the affected shoulder to center the part to the IR
Central Ray (CR)
CR horizontal
Directed through the axilla to exit at the AC joint at the midpoint of the IR
Patient Instructions
“Take in a breath and hold it. Don’t breathe or move.”
Evaluation Criteria
Lesser tubercle should be visualized in profile superiorly
Glenohumeral joint should be clearly demonstrated on the image
Additional Information
A similar radiograph may be obtained with a superoinferior axial projection
It is desirable to keep the CR as close to perpendicular to the IR as possible
However, a 15 to 20 degree medial angulation may be necessary to align the tube, part, and IR accurately
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Technical Considerations
Evaluation Criteria
Additional Information

12. Knowledge Check <Images 10-3 & 10-4>
Label the following anatomy:
coracoid process, glenoid, acromion, lesser tuberosity, humeral head, greater tuberosity

13. AP Scapula Imaging Basics
<Images 12 & 13>
The most common reason for performing an AP scapula is trauma. Structures shown on the image include the scapular body, acromion process, glenoid fossa, and the scapular spine, mostly superimposed on the ribs and lungs. Routine positions/projections of the scapula include the AP projection and lateral scapula (this is the same as the scapular Y for the shoulder although depending on facility protocol, the arm on the affected side may be brought across the body so the scapula is not superimposed over the humerus).

14. AP Scapula Imaging Criteria
Technical Considerations
Grid
kVp range: 70-80
SID: 40 inches (100 cm)
IR size 10x12 inch (24x30cm) lengthwise
Patient Position
Supine or upright, depending on the patient’s condition
Posterior surface of the patient’s body against the IR
All potential artifacts removed from the part
Part Position
With the elbow flexed, abduct the arm 90 degrees from the body to place the scapula in better contact with the tabletop
The top of the IR is placed 1 to 2 inches (3-5 cm) above the acromion process
Central Ray (CR)
CR perpendicular to the mid-scapula
1-2 inches (3-5 cm) inferior to the coracoid process.
Patient Instructions
“Breathe normally, and don’t move.”
The patient is allowed to continue normal breathing during the exposure because this will blur the thorax shadows, which can obscure bony detail.
Evaluation Criteria
Entire scapula is included on the image
Most of the scapula should be superimposed over the lung and ribs
Lateral border of the scapula should be mostly free from superimposing rib and lung anatomy
Additional Information
In cases of acute trauma, the arm is kept in a neutral position
The patient may be turned slightly toward the affected side to place the scapula flat on the table or upright IR
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Technical Considerations
Evaluation Criteria
Additional Information

15. Knowledge Check <Image 15-1>
Why is the arm placed in a 90 degree angle abducted from the body?
To place the scapula flatter on the IR
To salute the technologist,
Increase the angle of the scapula with the IR

16. Clavicle Imaging Basics
<Images # 16 & 17>
The most common reason for imaging the clavicle is trauma. Children who have fallen off a bike or out of a tree or landed on their shoulder playing football, soccer, or skateboarding often need this type of imaging. Structures shown on the image include the entire clavicle, including the acromioclavicular (AC) and sternoclavicular joints (SC). Routine positions/projections of the clavicle are the AP and the AP axial projections.

17. AP and AP Axial Clavicle Criteria
Technical Considerations
Grid
kVp range: 70-80
SID: 40 inches (100 cm)
IR size 10x12 inch (24x30cm) crosswise
Patient Position
Supine or upright, depending on the patient’s condition
Posterior surface of the patient’s body against the IR
All potential artifacts removed from the part including radiopaque pillows
Part Position
Place the affected arm by the patient’s side in a neutral position
Central Ray (CR)
AP clavicle:
CR perpendicular to the mid-clavicle
AP axial:
CR directed to the mid-clavicle at a degree cephalad angle
Patient Instructions
“Take in a breath and hold it. Don’t breathe or move.”
Evaluation Criteria
Both AC and SC joints are on the image
Proximal 1/3 of the clavicle will be superimposed on the thoracic shadows
AC and SC joints are demonstrated on the image
Clavicle may be superimposed on the thorax shadows depending on the degree of CR angle
Additional Information
Sometimes a PA axial projection is performed to project more of the clavicle off the thorax shadows.
Tube angle for a PA axial varies from 10 degrees to 30 degrees caudal
This depends on the department protocol and the size of the patient
Thinner patients require a larger tube angle
Tube angle varies from 10 degrees to 30 degrees depending on departmental protocol and the size of the patient
Greater tube angles project the clavicle away form the ribs and thorax superimposition
Greater tube angles also create more image distortion
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Technical Considerations
Evaluation Criteria
Additional Information

18. Knowledge Check <Images 18 & 20> Label the following anatomy:
clavicle, coronoid process

19. Acromioclavicular Joints Imaging Basics
<Image #21>
The AP acromioclavicular joint projection is taken to demonstrate dislocations. Because dislocations are often subtle, a complete series includes both right and left AC joints for comparison. To demonstrate small dislocations, the joint must be stressed by the use of weights. Routine positions/projections of the AC joints are AP (including both joints) and AP weight bearing.
Note-Are there better images out there? These look grainy and will probably not project well.-DS

20. Acromioclavicular Joints Imaging Criteria
Technical Considerations
Grid
kVp range: 70-80
SID: 40 or 72 inches (100 cm)(180 cm)
IR size (1) 7 x17 inch (17x42 cm) crosswise, four 8x10 inch (20x25 cm) crosswise (1) 14x17 inch (35x42 cm) crosswise (both images can be taken on one 14x17 (35x42 cm) IR one at the top of the IR and the other at the bottom)
Patient Position
Upright
Patient’s arms placed at his sides
All potential artifacts removed from the part
Part Position
Bilateral image without stress or weights
Bilateral image with the patient holding a lb. weight in each hand
Weights must be equal and the arms relaxed for the weight to stress the AC joints
Central Ray (CR)
CR perpendicular toe the midpoint between the AC joints
Centered 1-2 inches (3-5 cm) above the jugular notch
Patient Instructions
“Take a breath and let it all out. Don’t breathe or move.”
Evaluation Criteria
AP clavicle:
Both AC joints should be demonstrated on the image
Rotation, as observed by symmetry of the SC joints, should not be evident
Additional Information
Technical factors require some reduction in the mAs from an AP shoulder to demonstrate the soft tissue of the AC joint
Breathing is suspended after expiration because this usually depresses the shoulders
Whenever possible these images should be performed upright
If the patient cannot stand, the images may be performed with the patient supine
To stress the AC joints, the arms must be gently pulled down
Click each button for more information about XYZ
Technical Considerations
Evaluation Criteria
Additional Information

21. Knowledge Check <Images 24 & 25> Label the following anatomy:
clavicle, AC joint, coracoid process, acromion process

22. Summary
There are many alternate positions/projections of the proximal humerus and shoulder. This video includes the routine and a few alternate positions/projections of the proximal humerus and shoulder. Many positions/projections of the proximal humerus and shoulder depend on the departmental protocols where you work.