Shoulder Girdle Procedures

Scapular Y: PA Oblique Projection (9+2)

IR 10 x 12 lengthwise (portrait) ▪This view is useful in diagnosing shoulder dislocations -The body composes the vertical portion of the "Y" with the acromion and coracoid processes forming the upper limbs ▪Performed upright or supine (upright preferred) -Done as an AP projection when performed supine. -Patient will be LPO or RPO and shoot the elevated side. ▪Place the anterior surface of the affected shoulder against the IR ▪Rotate the patient so the mid-coronal plane forms a 45-60 degree angle to the IR ▪Position of the arm is not important as it does not alter the relationship of the humeral head and glenoid cavity. ▪Palpate the scapula and place its flat surface perpendicular to the IR ▪Position the center of the IR at the level of the scapulohumeral joint. ▪Respiration: Suspend Central Ray: ▪Perpendicular to the scapulohumeral joint Structures Shown: ▪The scapular Y is shown on an oblique image of the shoulder.

AP Shoulder: Neutral Rotation Evaluation Criteria (3)

•Greater tubercle slightly superimposing the humeral head •Humeral head in partial profile •Slight overlap of the humeral head on the glenoid cavity

AP Shoulder: External Rotation Evaluation Criteria (4)

•Humeral head in profile •Greater tubercle in profile on lateral aspect of humerus •Scapulohumeral joint visualized with slight overlap of humeral head on glenoid cavity •Outline of lesser tubercle between humeral head and greater tubercle

AP Shoulder: Internal Rotation Evaluation Criteria (3)

•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 the external and neutral positions.

Acromioclavicular Joints: AP Projection (Bilateral Pearson Method) Evaluation Criteria (3)

▪Both AC joints with and without weights -Included on 1 or 2 images ▪No rotation of leaning by the patient ▪AC joint separation, if present, clearly seen on the images with weights

Anatomy: Shoulder Girdle - Scapula

▪Classified as a flat bone ▪2 surfaces: -Costal surface - anterior aspect -Dorsal surface - posterior aspect ▪3 borders: 1.Superior border 2.Lateral border 3.Medial border ▪Acromion - flattened projection at the posterior lateral superior border -Point of articulation with the clavicle (acromioclavicular joint) ▪Coracoid process - a bony process arising from the superior lateral border of the scapula -Slightly inferior and anterior to the acromion ▪Glenoid Cavity - concave depression on the lateral border of the scapula -Site of articulation with the humeral head (scapulohumeral or glenohumeral joint)

Scapular Y Anterior Shoulder Dislocation

Humeral Head is beneath the coracoid process

Scapular Y Posterior Shoulder Dislocation

Humeral head is projected beneath the acromion

Humerus Placement Tips

• Supinating the hand will position the humerus in external rotation • The palm of the hand placed against the hip will position the humerus in neutral rotation • The posterior aspect of the hand placed against the hip will position the humerus in internal rotation

Clavicle: AP Axial Projection Evaluation Criteria (3)

▪Entire clavicle along with AC and SC joints ▪Lateral 2/3 of the clavicle projected above the ribs and scapula with the medial end superimposing the thorax ▪Clavicle in a more horizontal orientation compared to the AP projection

Clavicle: AP Projection Evaluation Criteria (3)

▪Entire clavicle centered on the image ▪Lateral half of the clavicle above the scapula ▪Medial half superimposing the thorax

Scapular Y: PA Oblique Projection Evaluation Criteria (6)

▪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 medial borders superimposed.

AP Oblique Projection: Grashey Method Evaluation Criteria (2)

▪Open joint space between the humeral head and the glenoid cavity ▪Glenoid cavity in profile

Scapula: Lateral Projection (7+3)

▪Patient in upright or prone position (upright preferred) ▪Patient in LAO or RAO position rotated 45-60 degrees towards affected scapula -Proper angle is shown when the superior angle of the scapula and acromial tip are perpendicular to the IR ▪Position of the arm depends on the region of interest on the scapula ▪To show the acromion and coracoid process -Patient flexes elbow and place the back of the hand on the posterior thorax -This prevents the humerus from overlapping the scapula ▪To show the body of the scapula: -Patient extends the affected side arm upward and rest the forearm on the head -May also reach affected side arm across the upper chest grasping the opposite shoulder ▪In either position the tech can grasp the lateral and medial borders of the scapula between the thumb and forefinger to adjust the body of the scapula perpendicular to the IR ▪Respiration: Suspend Central Ray: ▪Perpendicular to the midmedial border of the affected scapula Structures Shown: ▪Lateral image of the scapula ▪Placement of the arm determines the portion of the superior scapula that is superimposed by the humerus.

Transthoracic Lateral Projection: Lawrence Method Evalutation Criteria (3)

▪Scapula, clavicle and proximal humerus seen through the lung field ▪Scapula superimposed over thoracic spine ▪Unaffected clavicle and humerus projected above shoulder closest to IR

Inferosuperior Axial Projection: Lawrence Method Evaluation Criteria (4)

▪Scapulohumeral joint with slight overlap ▪Coracoid process pointing anteriorly ▪Lesser tubercle in profile and directed anteriorly ▪AC joint, acromion and acromial end of the clavicle projected through the humeral head

Lateral Scapula Positions

1. Arm flexed with dorsal surface of hand resting on posterior thorax •For coracoid process and acromion delineation 2. Arm reaching across chest grasping on to opposite shoulder •For the body of the scapula 3.Arm reaching straight up with elbow flexed, forearm resting on head •For the body of the scapula

AP Shoulder: Internal Rotation (7+3)

IR: 10 x 12 crosswise ▪Performed either upright or supine -Upright performed to decrease the pain of laying on injured or lesion covered shoulder ▪Center the shoulder to the IR ▪Have the patient bend their elbow and rotate their hand internally and rest the back of their hand on the hip (unless contraindicated) ▪Adjust the arm so the epicondyles are perpendicular with the IR. ▪Suspend respiration ▪Shield gonads Central Ray: ▪Perpendicular to a point 1 inch inferior to the coracoid process -Palpable inferior to the clavicle and medial to the humeral head Structures Shown: ▪Lesser tubercle in profile on the medial border ▪Proximal humerus in true lateral position

AP Shoulder: Neutral Rotation (6+3)

IR: 10 x 12 crosswise ▪Performed either upright or supine -Upright performed to decrease the pain of laying on injured or lesion covered shoulder ▪Center the shoulder to the IR ▪Have the patient rest the palm of their hand against the thigh -This position rolls the humerus slightly internal placing the epicondyles at a 45 degree angle to the IR ▪Suspend respiration ▪Shield gonads Central Ray: ▪Perpendicular to a point 1 inch inferior to the coracoid process -Palpable inferior to the clavicle and medial to the humeral head Structures Shown: ▪Greater and lesser tubercles both superimposed by head and neck of the humerus ▪Small calcific deposits in the posterior supraspinatus insertion may be visible

AP Shoulder: External Rotation (7+2)

IR: 10 x 12 crosswise ▪Performed either upright or supine -Upright performed to decrease the pain of laying on injured or lesion covered shoulder ▪Center the shoulder to the IR ▪Supinate patient's hand (unless contraindicated) ▪Abduct arm slightly and rotate so the epicondyles are parallel with the IR -This is the true anatomic AP position ▪Suspend respiration ▪Shield gonads Central Ray: ▪Perpendicular to a point 1 inch inferior to the coracoid process -Palpable inferior to the clavicle and medial to the humeral head Structures Shown: ▪Greater tubercle in profile on the lateral border

Scapula: AP Projection (8+2)

IR: 10 x 12 lengthwise (portrait) ▪Performed upright or supine (upright preferred) ▪Center the affected scapula in the middle of the IR ▪Abduct the arm to a right angle with the body -This draws the scapula laterally for better visualization ▪Flex the elbow and support the hand in a comfortable position ▪Do NOT rotate the patient toward the affected side. -We want a true AP view of the scapula ▪Position the top of the IR 2 inches above the top of the shoulder. ▪Respiration: Breathing technique (slow natural breaths) to blur out lung detail Central Ray: ▪Perpendicular to the mid-scapular region -2 inches inferior to the coracoid process Structures Shown: ▪AP projection of the scapula

Clavicle: PA Axial Projection (3+2)

IR: 10x12 crosswise (landscape) ▪Patient is prone or standing ▪Respiration: Suspend on full inspiration -This elevates the clavicle as high as possible Central Ray: ▪Directed to the midshaft of the clavicle with an angle of 15-30 degrees caudad Structures Shown: ▪PA axial projection of the clavicle projected above the ribs

Clavicle: AP Projection (5+2)

IR: 10x12 crosswise (landscape) ▪Upright or supine ▪Center the clavicle to the midline of the IR ▪Rest both shoulders and arms so they are equal on both sides ▪Respiration: suspend on expiration -More uniform density on the image Central Ray: ▪Perpendicular to midshaft of clavicle Structures Shows: ▪AP image of entire clavicle

Acromioclavicular Joints: AP Projection (Bilateral Pearson Method) (10+4)

IR: 14x17 crosswise or (2) 10x12 crosswise SID: 72 in ▪Patient is in an upright (standing or seated) position ▪Midpoint of the IR lies at the same level as the AC joints ▪Center midline of the body to the midline of the IR ▪Evenly distribute weight on both feet to avoid rotation ▪Adjust the shoulders and arms to lie evenly on the same plane ▪Make 2 exposures: 1.One with the patient standing upright without weights attached 2.One with the patient standing upright with weights attached **Weights are 5-10 lbs attached to each wrist **Do not hold weights in hands, shoulder muscles contract reducing the chance of seeing AC separation ▪Respiration: Suspended Central Ray: ▪Perpendicular to the midline of the body at the AC joint level for a single image ▪Directed at each AC joint when shooting 2 separate images Structures Shown: ▪Bilateral images of the AC joints ▪Projection is used to show dislocation, separation and function of the joints

AP Oblique Projection: Grashey Method (7+3)

IR: crosswise to include more clavicle, lengthwise to include more humerus •Performed upright or supine •Center the IR to the scapulohumeral joint **Joint is 2 inches medial and 2 inches inferior to the superolateral border of the shoulder •Rotate the body approx. 35 - 45 degrees toward the affected side **Adjust the degree of angle to place the scapula (superior angle and acromial tip) parallel with the IR •*Note: In a recumbent position the body may need to rotated more than 45 degrees, up to 60 degrees to place the scapula parallel to IR* •Abduct the arm slightly and place the palm of the hand on the abdomen. •Suspend respiration Central Ray: •Perpendicular to the IR •CR should be 2 inches medial and 2 inches inferior to the superolateral border of the shoulder Structures Shown: •Joint space between the humeral head and the glenoid cavity **Scapulohumeral (glenohumeral) joint

Anatomy: Shoulder Girdle - Clavicle

▪Classified as a long bone ▪Has 2 articular ends: -Acromial Extremity - the lateral aspect of the clavicle **Articulates with the acromion of the scapula **Articulation is called the acromioclavicular joint (AC joint) -Sternal Extremity - the medial aspect of the clavicle **Articulates with the manubrium of the sternum and first costal cartilage **Articulation is called the sternoclavicular joint (SC joint) ▪The clavicle acts as a fulcrum for the movements of the arm ▪Doubly curved for strength ▪Curvature is more acute in males than females

Clavicle: PA Axial Projection Evaluation Criteria (3)

▪Entire clavicle along with AC and SC joints ▪Lateral 2/3 of the clavicle projected above the ribs and scapula with the medial end superimposing the thorax ▪Clavicle in a more horizontal orientation compared to the AP projection

Anatomy: Shoulder Girdle

▪Formed by 2 bones: -Clavicle (collar bone) -Scapula (shoulder blade) ▪The humerus is considered part of the upper limb and is NOT part of the shoulder girdle. -The proximal end of the humerus articulates with the scapula to form the shoulder joint. -The humerus is included when discussing the shoulder girdle, but is NOT part of the girdle anatomy.

Inferosuperior Axial Projection: Lawrence Method (6+7)

▪IR: 10 x 12 crosswise (landscape) ▪Patient is supine, elevate the head, shoulders and elbow approx. 3 inches ▪Abduct the affected arm as much as possible to try and reach a 90 degree angle (minimum 20 degrees is required to prevent superimposition of arm over shoulder) ▪Humerus is externally rotated and hand is grasping a vertical support (IV pole is common) ▪Patient's head is turned towards the unaffected arm to allow IR to be placed against the neck -Place IR as close to the neck as possible and against the shoulder. -Support the IR with weights or sandbags to prevent it falling over ▪Respiration: suspended Central Ray: Horizontally through the axilla (armpit) to the AC joint -Medial angle depends on the amount of abduction of the arm -Medial angle is often 15 to 30 degrees -The greater the amount of abduction, the greater the angle Structures Shown: ▪An inferosuperior axial image of the scapulohumeral joint ▪Lateral portion of the coracoid process and AC joint ▪Insertion sites of the subscapular tendon on the lesser tubercle and the teres minor tendon on the greater tubercle of the humerus

Clavicle: AP Axial Projection (5+5)

▪IR: 10x12 crosswise (landscape) ▪Upright lordotic, upright vertical or supine -Upright Lordotic: Have patient stand 1 foot away from the IR and lean backwards into a position of extreme lordosis. Estimate bucky and angle positions and have the patient stand vertical again. Adjust the bucky and tube and have the patient reassume the position. -Upright Vertical: Center the clavicle to the upright bucky and IR. Make sure the shoulders and arms are equally rested on both sides. -Supine: Center the clavicle to the table bucky and IR ▪Respiration: Suspend on full inspiration -This elevates the clavicle as high as possible Central Ray: ▪Directed to the midshaft of the clavicle ▪Angle varies depending on thickness of patient's chest -Thinner patients require more angle to elevate the clavicle above the scapula and ribs ▪Standing vertical and Supine positions: 15 to 30 degrees cephalad ▪Standing lordotic: 0 to 15 degrees cephalad Structures Shown: ▪AP axial projection of the clavicle projected above the ribs

Scapula: Lateral Projection Evaluation Criteria (4)

▪Lateral and Medial scapular borders superimposed ▪No superimposition of the scapular body on the ribs ▪No superimposition of the humerus on the area of interest ▪Inclusion of the acromion and the inferior angle *Note the body of the humerus and body of the scapula are not directly superimposed like with the Scap Y view for the shoulder.*

Scapula: AP Projection Evaluation Criteria (4)

▪Lateral portion of the scapula free of superimposition from the ribs ▪Scapula horizontal and not slanted (True AP position) ▪Scapular detail through the superimposed lung and ribs -Shows a proper breathing technique ▪Acromion and inferior angle

Transthoracic Lateral Projection: Lawrence Method (7+3)

▪Lawrence method used when there is trauma and patient is unable abduct or rotate the arm. This method allows for an image 90 degrees from the AP ▪IR: 10 x 12 lengthwise ▪Upright position preferred ▪Have the patient raise the unaffected arm, rest the forearm on the head and elevate the shoulder as much as possible -Elevation of the non-injured shoulder drops the injured shoulder preventing superimposition ▪Do NOT attempt to rotate or move the injured arm ▪Center the IR to the surgical neck of the affected humerus ▪Respiration: full inspiration, the lungs full of air improves the contrast and decreases the exposure necessary to penetrate the body. -Breathing technique (Lawrence method) can also be used to blur out the lungs and ribs Central Ray: ▪Perpendicular to the IR, entering at the level of the surgical neck ▪If patient cannot elevate unaffected shoulder, angle the CR 10 - 15 degrees cephalad Structures Shown: ▪Lateral image of the shoulder and proximal humerus projected through the thorax

Shoulder Joint Types

▪Scapulohumeral (Glenohumeral) Joint -Joint formed by the head of the humerus and the glenoid cavity of the scapula -Synovial ball and socket type of joint. ▪Sternoclavicular Joint -Formed by the sternal extremity of the clavicle and the manubrium of the sternum and the 1st costal rib cartilage. -Synovial double-gliding joint ▪Acromioclavicular Joint -Formed by the acromial extremity of the clavicle and the acromion of the scapula -Synovial gliding joint