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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
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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.
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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.
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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.
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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
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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.
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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.
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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
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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.
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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.
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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
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Shoulder A-P with External Rotation Film
• The glenohumeral joint should be open
• The greater tubericle and humeral head will be in profile .
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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
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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.
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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
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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
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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.
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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
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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.
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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.
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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
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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.
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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.
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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
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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.
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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
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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.
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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.
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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
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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
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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.
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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
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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.
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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.
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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
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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.
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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.
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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.
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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
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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
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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
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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
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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.
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Scapula A-P Film
• Glenohumeral joint and entire scapula should be seen.
• Soft tissues of shoulder should be seen.
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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
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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.
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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
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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.
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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
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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.
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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
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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.
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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
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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.
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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
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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.
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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
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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.
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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
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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.
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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
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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
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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
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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
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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
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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.
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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
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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
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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
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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.
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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.
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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.
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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
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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
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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
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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.
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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.
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Zanca View Films
• Weighted and Non-Weighted Views are taken as stress views of the Acromioclavicular Joint.
• Useful in detection separations
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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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The End
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