Transcript
Shoulder Girdle
Prepared By:Valerie Gentizon-OrpillaLorma Colleges
Shoulder Girdle
Shoulder GirdleThe shoulder girdle is formed by twobones, the clavicle and scapula. Their
function is to connect the upper limb tothe trunk.
ClavicleThe clavicle, classified as a long bone, has
a body and two articular extremities
The lateral aspect is termed the acromiaLextremity, and it articulates with theacromion process of the scapula. The
mediaL aspect, termed the sternal extremity,articulates with the manubrium of the sternum
and the first costal cartilage
Lateral aspectMedial aspect
Sternal extremity
Acromial extremity
clavicle
acromion
neck
Glenoid cavity
Coracoid process Scapular
notch
ANTERIOR SURFACE
Superior angle
Crest of spine
Inferior angle
Neck
Glenoid cavity
Medial border
DORSAL SURFACE
Dorsal surface
spine
acromion
Lateral border
Inferior angle
Costal (anterior)surface
Glenoid cavity
Coracoid process
LATERAL ASPECT OF THE SCAPULA
HumerusThe proximal end of the humerus consists of
a head, an anatomic neck, two prominentprocesses called the greater and Lesser
tubercles. and the surgical neck .The head is large, smooth, and rounded, and
it lies in an oblique plane on the superomedialside of the humerus.
Surgical neck
Intertubercular groove
Greater tubercle head
Anterior Aspect of Right Proximal Humerus
headGreater tubercle
Intertubercular groove
Lesser tubercle
POSTERIOR PART
Structural classification
Joint TypeTissue Movement
Scapulohumeral
Acromioclavicular
Sternoclavicular
Synovial
Synovial
Synovial
Ball and Socket
Gliding
Double gliding
Freely movable
Freely movable
Freely movable
Scapulohumeral joint
SUMMARY OF PATHOLOGYbursitis Inflammation of the bursa
Dislocation Displacement of a bone from the joint space
Fracture Disruption in the continuity of bone
Hills-Sachs DefectImpacted fracture of the posterolateral aspect
of the humeralhead with dislocation
Metastases
osteoarthritis
Transfer of a cancerous lesion from one area to another
Form of arthritis marked by progressive cartilage deterioration insynovial joints and vertebrae
Osteopetrosis Increased density of atypically soft bone
Osteoporosis
Rheumatoid Arthritis
Tendonitis
Chondrosarcoma
Tumor
Loss of bone density
Chronic. systemic. inflammatory collagen disease
Inflammation of the tendon and tendon-muscle attachment
New tissue growth where cell proliferation is uncontrolled
Malignant tumor arising from cartilage cells
Shoulder“ AP PROJECTION”
External, Neutral, Internalrotation humerus
NOTE: Do not have the patient rotate the arm iffracture or dislocation is suspected.
Supinating the hand will position the humerus in external rotation
The palm of the hand placed againstthe hip will position the humerusin neutral rotation,
The posterior aspect of the handplaced against the hip will positionthe humerus in internal rotation.
AP shoulder. External rotation humerus,Greater tubercle (arrow),
AP shoulder, Neutral rotation humerus,Greater tubercle (arrow),
AP shoulder, Internal rotation humerus, Greatertubercle (arrow): lesser tubercle in profile,
Central ray• Perpendicular to a point I
inch (2.5 cm)inferior to the coracoid
process
clavicle
coracoid
acromion
Glenoid cavity/scapulohumeral joint
scapula
humerus
AP shoulder, external rotation humerus: greater tubercle (arrow).
AP shoulder, neutral rotation humerus: greater tubercle (arrow).
AP shoulder, internal rotation humerus: greater tubercle (arrow): lesser tubercle in profile (arrowhead
TRANSTHORACIC LATERALPROJECTION
‘’LAWRENCE METHOD‘’R or L position
The Lawrence method is used whentrauma exists and the arm cannot be
rotated or abducted because of an injury.
Upright transthoracic lateral shoulder: Lawrence Method
Recumbent transthoracic lateral shoulder: Lawrence
Method
Central ray• Perpendicular to the IR, entering themidcoronal plane at the level of the surgical neck.• If the patient cannot elevate the unaffectedshoulder, angle the central ray 10 to 15 degrees cephalad to obtain a comparableradiograph.
Unaffected clavicle
Scapula (superior border)
SternumClavicle
Acromion processHumeral headScapula (lateral border)
Proximal humerus
Transthoracic lateral shoulder: Lawrence method.
Transthoracic lateral shoulder (patient breathing): Lawrence
method .
Structures shownA lateral image of the shoulder and proximal humerus is projected through thethoraxEVALUATION CRITERIAThe following should be clearly demonstrated:• Proximal humerus• Scapula, clavicle, and humerus seenthrough the lung field• Scapula superi mposed over the thoracicpine• Unaffected clavicle and humerus projectedabove the shoulder closest to the IR
1.INFEROSUPERIOR AXIALPROJECTION
(LAWRENCE METHOD)2.INFEROSUPERIOR AXIAL
PROJECTIONRAFERT ET AL MODIFICATION
Inferosuperior axial shoulder joint: Lawrence method.
Inferosuperior axial shoulder joint:Rafert modification. Note the exaggeratedexternal rotation of arm and thumb pointingdownward. If present. a Hill-Sachsdefect would show as a wedge-shapeddepression on the posterior aspect of thearticulating surface of the humeral head.arrow
Lesser tubercle
Humerus
Coracoid process
Acromioclavicular jt
clavicle
Scapulohumeral joint
acromionInferosuperior axial shoulder joint:
Lawrence method
INFEROSUPERIOR AXIALPROJECTION
WEST POINT METHOD
Inferosuperior axial shoulder joint: West Point method.
Central ray• Directed at a dual angle of 25 degrees anteriorly from the horizontal and 25 degrees medially. The central ray entersapproximately 5 inches ( 13 cm) inferior and I 1/2 inch (3.8 cm) medial to the acromialedge and exit the glenoid cavity.
West Point method with anterior and medial central ray angulation.
EVALUATION CRITERIAThe fol lowing should be clearly demonstrated:• Humeral head projected free of thecoracoid process• Articulation between the head of thehumerus and the glenoid cavity• Acromion superimposed over the posterior portion of the humeral head• Shoulder joint
Structures shownThe resulting image shows bony abnormalitiesof the anterior inferior rim of the glenoid in patients with instability of theshoulder
acromionScapulohumeral
jointGlenoid rim
clavicle
Coracoid
processLesser
tubercle
Inferosuperior axial shoulder joint: West Point method.
INFEROSUPERIOR AXIALPROJECTION
CLEMENTS MODIFICATION
Inferosuperior axial shoulder joint: Clements modification. A. Arm abducted90 degrees. B. Arm partially abducted
Position of patient• When the prone or supine position isnot possible, Clements suggested that the patient be radiographed in the lateral recumbent position lying, on the unaffected side.• Flex the patient's hips and knees.
Position of part• Abduct the affected arm 90 degrees,and point it toward the ceiling.• Place the fR against the Superior aspectof the patient's shoulder,holding it inplace with the unaffected arm or by securing i t appropriately • ShieLd gonads.• Respiration: Suspend.
Central ray• Horizontal to the midcoronal plane,passing through the midaxillary regionof the shoulder.• Angled 5 to 1 5 degrees medially whenthe patient cannot abduct the arm a full90 degrees (Fig. 5-28, B). The resultingradiograph
SUPEROINFERIOR AXIAL
PROJECTION
Superoinferior axial shoulder joint: standard IR.
Structures shownA superoinferior axial image shows thejoint relationship of the proximal end ofthe humerus and the glenoid cavity . The acromjoclavicular articulation,the outer portion of the coracoid process,and the points of insertion of the subcapularis muscle ( at body of scapula) and teres minor muscle ( at inferior axillaryborder) are demonstrated.
EVALUATION CRITERIAThe following should be clearly demonstrated:• Open scapulohumeral joint (not open on patients with limited flexibility)• Coracoid process projected above the clavicle• Lesser tubercle i n profile• Acromioclavicu lar joint through thehumeral head
Central ray• Angled 5 to 1 5 degrees through theshoulder joint and toward the elbow
CORACOID PROCESS
LESSER TUBERCLE
HUMERUS
ACROMION
CLAVICLE
Superoinferior axial shoulder joint.
AP AXIAL PROJECTION
AP axial shoulder joint.
Central ray• Directed through the capulohumeraljoint at a cephalic angle of 35 degrees
Structures shownThe axial image shows the relationship of the head of the humerus to the glenoid cavity. This is useful in diagnosing cases of posterior djslocation
EVALUATION CRITERIAThe following should be clearly demonstrated:• Scapulohumerai joint• Proximal humerus• Clavicle projected above superior angleof scapula
AP axial shoulder joint.
Scapular Y‘’ PA OBLIQUE PROJECTION’’
RAO or LAO positionThi projection, described by Rubin,
Gray, and Green, obtained its name as aresult of the appearance of the scapula.
The body of the scapula forms the verticalcomponent of the Y, and the acromion andcoracoid processes form the upper limbs.The projection is useful in the evaluation
of suspected shoulder dislocations.
PA oblique shoulder joint.
Central ray• Perpendicular to the scapulohumeral joint
Structures shownThe scapular Y is demonstrated on anoblique image of the shoulder. In the normalshoulder the humeral head is directlysuperimposed over the junction of the Y. In anterior (subcoracoid) dislocations, the humeral head is beneath the coracoid process (Fig. 5-36); in posterior( subacromial) dislocations, it is projected beneath the acromion process. An APshoulder projection is shown for comparison.
EVALUATION CRITERIAThe following should be clearly demonstrated:• No superimposition of the scapularbody over the bony thorax• Acromion projected laterally and freeof superimposition• Coracoid possibly superimposed orprojected below the clavicle• Scapula in lateral profile
10-15°
(AC Articulation)ALEXANDER
Shoulder( Scapular Y )
Scapula( Lateral )
Shoulder ( NEER)
Name Body Rotation Scapula Rel. to IR Central ray angle Central ray entrance pt Arm position
Acromioclaviculararticulation:1.AlexanderMethodShoulder jOint:2.Neer methodShoulder Joint:3.scapular Y4.Scapula lateral
45 to 60 degrees
PerpendicularT
15° caudad
10 to 15 degreesborder caudad
0 degrees
0 degrees
Acromioclavicular joint
Superior humeral
Scapulohumeral jointCenter of medial border of
scapula
Across chest
At the side
At the sidevariable
PA oblique shoulder Joint. Note the scapular Y components-body, acromion,and coracoid.
PA oblique shoulder Joint showing anterior dislocation(humeral head projected beneath coracoid process).
Glenoid CavityAP OBLIQUE PROJECTION
GRASHEY METHODRPO or LPO position
Upright AP oblique glenoid cavity: Grashey method.
Recumbent AP oblique glenoid cavity: Grashey method.
Central ray• Perpendicular to the glenoid cavity at a point 2 inches (5 cm) medial and 2 inches (5 cm) inferior to the superolateralborder of the shoulder.
Structures shownThe joint space between the humeral head and the glenoid cavity (scapulohumeraljoint) is shown.
EVALUATION CRITERIAThe fol lowing should be clearly demonstrated:• Open joint space between the humeralhead and glenoid cavity• Glenoid cavity in profi le• Soft tissue at the scapulohumeral jointalong with trabecular detail on the glenoidand humeral head
acromion
Humeral head
Glenoid cavity
clavicle
AP oblique glenoid cavity: Grashey method showing moderate deterioriation of the scapulohumeral joint.
Supraspinatus "Outlet"TANGENTIAL PROJECTION
NEER METHODRAO or LAO position
This radiographic projection is useful todemonstrate tangentially the coracoacromial
arch or outlet to diagnose shoulderi mpingement. The tangential image isobtained by projecting the x-ray beam
under the acromion and acromioclavicularjoint, which defines the superior border of
the coracoacromial outlet.Image receptor: 8 x 10
Structures shownThe tangential outlet image demonstrates the posterior surface of the acromion and theacromioclavicular joint identified as the superior border of the coracoacromial outlet.Central ray
• Angled 10 to 15 degree caudad, enteringthe superior aspect of the humeral head
EVALUATION CRITERIAThe following should be clearly demonstrated:• Humeral head projected below the acromioclavicular joint• Humeral head and acromioclavicular joint with bony detail• Humerus and scapular body, generallyParallel.
Shoulder joint: Neer method.Supraspinatus outlet (arrow).
Tangential supraspinatus outlet projection showing impingement of the shoulder outlet (arrow). B, Radiograph of same patient as in Fig. 5-48 after surgical removal of posterolateral surface of clavicle.
Proximal HumerusAP AXIAL PROJECTION
STRYKER " NOTCH " METHOD'dislocations of the shoulder are frequently
caused by posterior defectsinvolving the posterolateral head of thehumerus. Such defects, called Hill-Sachs
defects, are often not demonstrated usingconventional radiographic positions. Hall,
Isaac, and Booth' described the notch projection,from ideas expressed by Cm. W.S.
Stryker U . S . N . , as being useful in identifying the cause of shoulder dislocation.
AP axial humeral notch: Stryker notch method
EVALUATION CRITERIAThe following should be clearly demonstrated:• Overlapping of coracoid process andclavicle• Long axis of the humerus aligned withthe long axis of the patient's body• Bony trabeculation of the head of thehumerus
Structures shown:The resulting image will how the po -terosuperior and posterolateral areas of the humeral head.
Central ray• Angled 10 degrees cephalad, enteringthe coracoid process.
AP axial humeral notch: Stryker notch method. Same projection in a patient with a
small Hill-Sachs defect (arrow).
Humerus
AcromionClavicle
Coracoid prcess
Humeral head
Body of scapula
Scapular spine
Glenoid CavityAP OBLIQUE PROJECTION
APPLE METHOD!RPO or LPO position
This projection is similar to the GrasheyMethod but uses weighted abduction to
demonstrate a loss of articular cartilage inthe scapulohumeral joint.
Axial oblique projection: Apple method
Central ray• Perpendicular to the IR at the level of the coracoid process
Structures shownThe scapulohumeral joint
EVALUATION CRITERIAThe following should be clearly demonstrated:• Open joint space between the humeral head and the glenoid cavity• Glenoid cavity in profile• Soft tissue at the scapulohumeral joint along with trabecular detail on the glenoid and the humeral head• The arm in a 90 degree position
A, AP oblique projection: Grashey method, of the shoulder showing a normalscapulohumeral joint space. B, AP oblique projection: Grashey method, with weighted abduction showing loss of articular cartilage (arrow).
Glenoid CavityAP AXIAL OBLIQUE PROJECTION
GARTH METHOD )RPO or LPO position
This projection is recommended for acuteshoulder trauma and for identifying
posterior scapulohumeral dislocations, glenoid fractures, Hill-Sachs lesions, and soft
tissue calcifications.
AP axial oblique: Garth method. RPO position. Note 45 degree CR. B, Topview of same position as A. Note 45 degree patient position.
AB
Central ray• Angled 45 degree caudad through the scapulohumeral joint.
Structures shownThe scapulohumeral joint, humeral head, coracoid process, and scapular head and neck are shown.
EVALUATION CRITERIAThe following should be clearly demonstrated:• The scapulohumeral joint, humeral head, and scapular head and neck free of superimposition• The coracoid process should be well visualized• Posterior dislocations will project the humeral head superiorly from the glenoidcavity and anterior dislocations project inferiorly.
AP axial oblique: Garth method demonstrates an anterior dislocation of the proximal humerus. The humeral head is shown below the coracoid process, a common appearance with anterior dislocation.
Intertubercular Groove'" TANGENTIAL PROJECTION
FISK MODIFICATION )
In recent years, various modifications of the intertubercular groove image have been devised. In all cases the central ray is aligned to be tangential to the intertubercular groove, which
lies on the anterior surface of the humerus.The x-ray tube head assembly may limit the performance of this
examination. Some radiographic units have large collimatorsand/or handles that limit flexibility in positioning. A mobile
radiographic unit may be used to reduce this difficulty.
Supine tangential intertubercular groove. Standing tangential intertubercular groove: Fisk modification.
Central rayAngled 10 to 15 degrees posterior (downward from horizontal) to the longaxis of the humerus for the supine position
Fisk Modification• Perpendicular to the I R when the patient is leaning forward and the verticalhumerus is positioned 10 to 15 degrees.
Structures shownThe tangential image profiles the intertubercular groove free from superimpositionof the surrounding shoulder structures.
EVALUATION CRITERIAThe following should be clearly demonstrated:• Intertubercular groove in profile• Soft tissue along with enhanced visibili ty of the intertubercular groove.
Supine tangential intertubercular groove.
Standing tangential intertubercular groove: Fisk modification.
Intertubercular groove
Lesser tubercle
Coracoid process
Greater tubercle
Proximal Humerus
Teres Minor InsertionPA PROJECTION
BLACKED-HEALY METHOD
Supraspinatus
infraspinatus
Teres major
Teres minnor
Lateral head
triceps
Muscles on dorsal surface (posterior) part of the scapula and humerus
PA proximal humerus for teres minor insertion.
PA proximal humerus for teres minor insertion.
PA proximal humerus for teres minor insertion.
clavicle
acromion
Greater tubercle
Lesser
tubercle
Teres minor
insertion
Structures shownThis position rotates the head of the humerus so that the greater tubercle is brought anteriorly, giving a tangential image of the insertion of the teres minor atthe outer edge of the bone just below the articular surface of the head.
EVALUATION CRITERIAThe following should be clearly demonstrated:• Outline of the greater tubercle superimposingthe humeral head• Lesser tubercle in profile and pointing medially• Soft tissue around the humerus alongwith trabecular detail on the humeral head.
Central ray• Perpendicular to the head of the humerus.
Proximal Humerus
Subscapular InsertionAP PROJECTION
BLACKED-HEALY METHOD
subscapularis
Long head head of biceps brachii
biceps
Muscles on costal (anterior) surface of the scapula and proximal humerus
AP proximal humerus for subscapularis insertion. AP proximal humerus for subscapularis insertion.
AP proximal humerus for subscapularis insertion .
Humeral head
Glenoid cavity
Subscapularis
insertion
Lesser tubercle
Greater tubercle
Central ray•Perpendicular to the shoulder joint, entering the coracoid process
Structures shownThis method provides an image of the insertion of the subscapularis at the lesserTubercle.
EVALUATION CRITERIAThe following should be clearly demonstrated:• Lesser tubercle in profile and pointing inferiorly• Outline of the greater tubercle superimposingthe humeral head• Soft tissue around the humerus along with trabecular detail on the humeral head.
Acromioclavicular Articulations
Infraspinatus InsertionAP AXIAL PROJECTION
Place the patient in the supine position with the affected arm by the patient's side.Turn the arm in external rotation to open the subacromial space (Fig. 5-62, A ) . Rotate the arm to the neutral position (Fig. 5-62, B) and then in complete internalrotation (Fig. 5-62, C) to allow full evaluation of the humeral head. Direct the centralray to enter the coracoid process at an angle of 25 degrees caudad. The imageprofiles the greater tubercle, the site of insertion of the infraspinatus tendon, andopens the subacromial space.
AP axial. 25-degree caudal angulation. demonstrating calcareous peritendinitis(arrows). A, External rotation. B, Neutral position. C, Internal rotation.
AcromioclavicularArticulations
AP PROJECTIONBilateral
PEARSON METHOD
SID: 72 inches ( 183 cm). A longer SIDreduces magnification, which enables
both joints to be included on one i mage.It also reduces the distortion of the joint
space resulting from central ray divergence.
Bilateral AP acromioclavicular articulations.
Bilateral AP acromioclavicular joints demonstrating normal left joint and separation of right joint (arrow).
Normal acromioclavicular joints requiring two separate radiographs.
Structures shownBilateral images of the acromioclav icularjoints are demonstrated (Figs. This projection is used to demontrate dislocation, separation, and functionof the joints.
Central ray• Perpendicular to the midl ine of the body at the level of the acromioclavicular joints for a single projection; directed at each respective acromioclavicular joint when two separate exposures are needed for each shoulderin broad-shouldered patients.
EVALUATION CRITERIAThe following should be clearly demonstrated:• Acromioclavicular joints visualized with some soft tissue and withoutexcessive density• Both acromioclavicular joints, with andwithout weight , entirely included on one or two single radiographs• No rotation or leaning by the patient• Right or left and weight or nonweight markers• Separation, if done,clearly seen on the images with weights.
Acromioclavicular ArticulationsAP AXIAL PROJECTIONALEXANDER METHOD
Alexander suggested that both AP and PAaxial oblique projections be used in cases
of suspected acromioclavicular subluxationor dislocation. Each side is examjned
separately.
AP axial acromioclavicular articulation: Alexander method.
Unilateral AP axial acromioclavicular articulation: Alexander method
Central ray• Directed to the coracoid process at a cephalic angle of 15 degrees .This angulation projects the acromioclavicularjoint above the acromion.
Structures shownThe resulting image will show the acromioclavicular joint projected slightly superiorly compared with an A P projection.
EVALUATION CRITERIAThe following should be clearly demonstrated:• Acromioclavicular joint and c lavicle projected above the acromion.• Acromioclavicular joint visualized with some soft tissue and without excessiveDensity.
ClavicleAcromioclavicular
Joint (AC jt)
Acromion
Coracoid process
Humeral
head
AP axial acromioclavicular articulation: Alexander method.
Acromioclavicular Articulations
PA AXIAL OBLIQUE PROJECTION(ALEXANDER METHOD)
RAO or LAO position
Central ray• Directed through the acromioclavicular joint at an angle of 15 degrees caudad.
Structures shownThe PA axjal oblique image demonstrates the acromioclavicular joint and the relationship of the bones of the shoulder.
EVALUATION CRITERIAThe following should be clearly demonstrated:• Acromioclavicular articulation in profile• Acromioclavicular joint visualized with some soft tissue without excessiveDensity.
Acromioclavicular joint
acromion
clavicle
coracoid
scapula
humerus
PA axial oblique acromioclavicular articulation.
Clavicle AP PROJECTION
Central ray• Perpendicular to the midshaft of theclavicle
Structures shownThis projection demonstrates a frontalimage of the clavicle.
EVALUATION CRITERIAThe following should be clearly demonstrated:• Entire clavicle centered on the image• Uniform density• Lateral half of the clavicle above the scapula, with the medial half superimposingthe thorax.
Acromion
AC joint
ClavicleSuperior angle
of scapula
Coracoidprocess
SC joint
Clavicle PA PROJECTION
The PA projection is generally well accepted by the patient who is able to stand, and it is most
useful when improved recorded detail is desired. The advantage of the PA projection is
that the clavicle is closer to the image receptor, thus reducing the OID. Positioning is similar to that of the A P projection. The differences are
as follows:
•The perpendicular central ray exits midshaft of the clavicle
•Structures shown and evaluation criteria are the same as for the AP projection.
Clavicle AP AXIAL PROJECTION
Lordotic positionNOTE: If the patient is injured or unable to
assume the lordotic position, a slightly distortedimage results when the tube is angled. An
optional approach for improved recorded detailis the PA axial projection.
Central ray• Directed to enter the midshaft of the clavicle.• Cephalic central ray angulation can vary from the long axis of the torso.Thinner patients require more angulation to project the clavicle off thescapula and ribs.
clavicle
Coracoid process
Acromioclavicular joint
Sternoclavicular joint
AP axial clavicle of 3-year-old child. showing fracture (arrow). This is the same patient as Figure.
PA AXIAL PROJECTION
Positioning of the PA axial clavicle is similar to the A P axial projection just described. The differences are as
follow :• The patient is prone or standing, facing the vertical
grid device.• The central ray is angled 15 to 30 degrees caudad.
Structures shown and evaluation criteriaare the same as for the AP axial projection
described previously.
PA axial clavicle.
TANGENTIAL PROJECTION
The tangential projection is similar to theAP axial projection described previousIy.However, the increased angulation of the
central ray required for this approachplaces the central ray nearly parallel with
the rib cage. The clavicle i s thus projectedfree of the chest wall .
Structures shownAn inferosuperior image of the clavicle is demonstrated, projected free of superimposition.
EVALUATION CRITERIAThe following should be clearly demonstrated:• Midclavicle without superimposition• Acromial and sternal ends superimposed• Entire clavicle along with the acromioclavicularand sternoclavicular joints
Central ray• Angled so that the central ray will pass between the clavicle and the chest wall , perpendicular t o the plane of the lR . The angulation will be about 25 to 40 degrees from the horizontal.• If the medial third of the clavicle is in question, it is also necessary to angle the central ray laterally ; 15 to 25degrees is usually sufficient.
Tangential clavicle.
Tangential alignment for clavicle.
Tangential clavicle.
clavicle
acromion
1st rib
Clavicle TANGENTIAL PROJECTION
TARRANT METHOD
The Tarrant method is particularly usefulwith patients who have multiple injuries
or who cannot assume the lordotic orrecumbent position.
Tangential clavicle: Tarrant method.
Central ray• Directed anterior and inferior to the mjdshaft of the clavicle at a 25- to 35-degree angle. It should pass perpendicular to the longitudinal axjs of the clavicle.• Because of the considerable 010, anincreased SID is recommended toreduce magnification.
EVALUATION CRITERIAThe following should be clearly demonstrated:• Most of the clavicle above the ribs and scapula with the medial end overlapping the first or second ribs• Clavicle in a horizontal orientation• Entire clavicle along with the acromioclavicular and sternoclavicular joints.
Structures shownThe clavicle above the thoracic cage isDemonstrated.
Sternoclavicular joint
clavicle
acromion
Acromioclavicular joint
coracoid
Tangential clavicle: Tarrant method .
Scapula AP PROJECTION
AP scapula.
Central ray• Perpendicular to the midscapular area ata point approximately 2 ‘’ (5 cm)inferior to the coracoid process.
Structures shownAn AP projection of the scapula is demonstrated
EVALUATION CRITERIAThe following should be clearly demonstrated:• Lateral portion of the scapula free of superimposition from the ribs• Scapula horizontal and not obliqued• Scapular detail through the superimposed lung and ribs (Shallow breathing should help obliterate lung detail.)• Acromion process and inferior angle.
acromion
clavicle
Coracoid process
Glenoid cavity
Lateral border of scapula
Medial border of scapula
Inferior angle of scapula
Scapula
LATERAL PROJECTIONRAO or LAO body position
Lateral scapula, RAO body position.
Central ray• Perpendicular to the midmedial borderof the protruding Scapula.
acromion
coracoid
humerusBody of scapula
Inferior angle of scapula
Structures shownA lateral image of the scapula is demonstrated by this projection. The placement of the arm determine the portion of the superior scapula that is superimposed over the humerus.
EVALUATION CRITERIAThe following should be clearly demonstrated:• Lateral and medial border superimposed• No superimposition of the scapular body on the ribs• No superimposition of the humerus onthe area of interest• Inclusion of the acromion process andinferior angle• Lateral thickness of capula w i thproper density.
PA OBLIQUE PROJECTION
LORENZ AND LlLIENFELD M ETHODSRAO or LAO position
PA oblique scapula: Lorenz method.
PA oblique scapula: Lilienfeld method.
Lorenz method• Adjust the arm of the affected side at aright angle to the long axis of the body,flex the elbow, and rest the hand againstthe patient's head.• Rotate the body slightly forward, andhave the patient grasp the side of thetable or the stand for support
LiIienfeld method• Extend the arm of the affected sideobliquely upward, and have the patientrest the hand on hjs or her head.• Rotate the body lightly forward, andhave the patient grasp the side of thetable or the stand for support.
Central ray• Perpendicular to the J R, between the chest wall and the mjdarea of the protrudingScapula.
Structures shownAn oblique image of the scapula is shown. The degree of obliquity depends on theposition of the arm. The delineation of the different parts of the bone in the twooblique projections are shown.
EVALUATION CRITERIAThe following should be clearly demonstrated:• Oblique scapula• Medial border adjacent to the ribs• Acromion process and inferior angle.
Scapula
AP OBLIQUE PROJECTIONRPO or LPO position
AP oblique scapula, 20-degree body rotation.
AP oblique scapula, 35-degree body rotation.
Central ray• Perpendicular to the lateral border ofthe rib cage at the midscapular area
Structures shownThis projection show oblique image ofthe scapula, projected free or nearly free of rib superimposition.
EVALUATION CRITERIAThe following should be clearly demonstrated:• Oblique scapula• Lateral border adjacent to the ribs• Acromion process and i nferior angle
Humerus
Acromion
clavicleCoracoid process
Scapular spine
Vertebral borderof scapula
Inferior angle of scapula
Coracoid ProcessAP AXIAL PROJECTION
AP axial coracoid process.
Central ray• Directed to enter the coracoid process atan angle of 15 to 45 degrees cephalad.Kwak, EspinieUa, and Kattan recommend30 degrees. The degree of angulationdepends on the shape of the patient'sback. Round-shouldered patients requirea greater angulation than those with astraight back.
Structures shownA slightly elongated inferosuperior image of the coracoid process is illustrated . Because the coracoid i curved on itself, it casts a small, oval shadow in the direct AP projection of the shoulder.
EVALUATION CRITERIAThe following should be clearly demonstrated:• Coracoid process with minjmal superimposition.• Clavicle slightly uperi mposing thecoracoid process
clavicleAcromioclavicular
joint
acromion
Coracoid process
Glenoid cavity
Scapular Spine
TANGENTIAL PROJECTIONLAQUERRIERE-PIERQUIN M ETHOD
Central rayDirected through the posterosuperior region of the shoulder at an angle of 45degrees caudad. A 35-degree angulation suffices for obese and round-shouldered patient .• After adjusting the x-ray tube, position the lR so that it is centered to the central ray.
Structures shownThe spine of the scapula is shown in profile and is free of bony superimposition, except for the lateral end of the clavicle.
AcromioclovicularjOint
Acromion
Glenoid cavity
Scapular spine
Superior borderof scapula
Humeral head
Clavicle
Scapular Spine
TANGENTIAL PROJECTIONProne position
Prone tangential scapular spine.
Upright tangential scapular spine.
Central ray• Direct through the scapular spine at anangle of 45 degrees cephalad. The centralray exits at the anterosuperior aspect of the shoulder.Upright positionAn i ncreased SID is recommendedbecause of the greater OlD.
Structures shownThe tangential image shows the scapularspine in profile and free of superimpositionof the scapular body.
EVALUATION CRITERIAThe following should be clearly demonstrated:• Scapular spine above the scapular wing• Scapular spine with some soft tissuearound it and without excessive density.
Scapular spine
Superior scapularborder
Acromion
Clavicle
Humeral head
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