1. Radiography of the Shoulder Jennifer Nicol PGY-1 August 6, 2009

2. Objectives BRIEF Anatomy Review Standard shoulder views Radiographs of shoulder injuries NOT: ◦ Treatment ◦ Other imaging modalities ◦ Pediatric imaging

4. Anatomy

5. Shoulder Views Over 15 views of shoulder described Trauma series: ◦ 3 views:  AP  Trans-scapular “Y-view”  Axillary  Modified axillary

6. AP view True AP - 45˚tilt ◦ Glenohumeral joint with no bony overlap ◦ Preferred in trauma AP int/ext rotation ◦ Highlight tuberosities ◦ Soft tissue injuries Clavicle and AC joint

8. Transcapular view Projects along long axis scapula Simple, reproducible Good for visualising anterior, posterior dislocations

9. Acromion Coracoid Body

10. Axillary View Glenohumeral joint in cephalocaudal plane Lesions of glenoid rim, humeral head, caracoid Axial view of shoulder

12. Modified Axillary View Reverse axillary when pt can’t abduct

13. Retrospective 1690 shoulder exams ◦ Mod axillary view used 104 times ◦ Identified additional pathology in 30 cases No comparison b/t standard and modified axillary

14. Approach to Shoulder XR AP: ◦ If ext/int rotation look at tuberosity orientation ◦ Glenohumeral region  Alignment  Distance b/t humeral head and glenoid  Bones ◦ AC region ◦ Other regions (clavicle, ribs, scapular spine,lungs)

15. Approach to Shoulder XR Other views: ◦ Humeral head to glenoid ◦ Prox humerus ◦ Glenoid rim ◦ Scapula ◦ Carocoid ◦ Acromion

16. 1)Glenoid Alignment Distance bones 2)AC Alignment Carocoid-clavicle space 3)Other Lungs, scapula, ribs, clavicle Type I AC injury

17. Type III AC injury

18. Posterior Dislocation

19. Positive Rim Sign

20. Trough Sign

21. No Mercedes!!!!

22. Avulsion Lesser Tuberosity

25. Bilateral shoulder dislocation spontaneously reduced with bilateral reverse Hill-Sachs lesions

26. Posterior Dislocations Have high suspicion with correct mechanism Don’t miss – clinical exam important Look for associated fractures Types: ◦ Subacromial (98%) ◦ Subglenoid ◦ subspinosus

27. Anterior Dislocation

29. Scapular View: Anterior Dislocation

30. Hill-Sachs deformity

31. AP Bankhart Injury Axillary

32. Greater Tuberosity Fracture

33. Anterior Dislocations 4 Types ◦ Subcoracoid ◦ Subglenoid ◦ Subclavicular ◦ Intrathoracic

34. Anterior Dislocations Check Neurovascular exam pre-post reduction Don’t delay reduction – NV injury increases with time Recurrence high – 80% <30

35. Inferior Dislocation

36. Subglenoid anterior dislocation

37. Pseudodislocation