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Intended Learning Outcomes
• The student should be able to recognize clinical radiographic technical principles of the shoulder
3
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.
4
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.
5
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.
6
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
7
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.
8
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.
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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
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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.
11
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
12
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.
13
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.
14
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
15
Shoulder A-P with External Rotation Film
• The glenohumeral joint should be open
• The greater tubericle and humeral head will be in profile .
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
17
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.
18
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
19
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.
20
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.
21
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
22
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
23
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
24
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.
25
Scapula A-P Film
• Glenohumeral joint and entire scapula should be seen.
• Soft tissues of shoulder should be seen.
26
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
27
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.
28
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
29
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.
30
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
31
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.
32
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
33
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.
34
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
35
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.
36
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
37
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.
38
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
39
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.
40
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
41
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.
42
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
43
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
44
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
45
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
46
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
47
Acromioclavicular Joints Bilateral A-P
• Measure: A-P at coracoid
• Protection: Half apron
• SID: 72” Non-Bucky
• Tube Angle: none 15 degree cephalad angle
• Film: 17” x 14” I.D. to unaffected side
48
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.
49
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 Breathing Instructions: Deep Inspiration
50
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.
51
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.
52
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.