1. 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

2. 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.

3. 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.

4. 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.

5. 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

6. 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.

7. 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.

8. 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

9. 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.

10. 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

11. 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.

12. 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.

13. 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

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

15. 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

16. 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.

17. 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

18. 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

19. 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.

20. 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

21. 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.

22. 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.

23. 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

24. 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.

25. 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.

26. 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

27. 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.

28. 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

29. 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.

30. 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.

31. 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

32. 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

33. 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.

34. 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

35. 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.

36. 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.

37. 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

38. 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.

39. 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.

40. 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.

41. 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

42. 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

43. 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

44. 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

45. 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.

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

47. 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

48. 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.

49. 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

50. 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.

51. 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

52. 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.

53. 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

54. 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.

55. 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

56. 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.

57. 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

58. 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.

59. 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

60. 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.

61. 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

62. 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.

63. 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

64. 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

65. 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

66. 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

67. 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

68. 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.

69. 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

70. 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

71. 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

72. 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.

73. 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.

74. 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.

75. 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

76. 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

77. 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

78. 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.

79. 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.

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

81. 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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