SHOULDER GIRDLE

PATHOLOGY  External Rotation: greater tubercle & site

1.) Hill-Sachs Defect of insertion of supraspinatus tendon
 Compression fracture of the articular surface  Neutral Rotation: greater tubercle partially
of the posterolateral aspect of the humeral superimposing humeral head; posterior part
head of supraspinatus insertion
2.) Bankart Lesion  Internal Rotation: lesser tubercle; site of
 Avulsion fx of anteroinferior aspect of the insertion of the subscapular tendon;
glenoid rim proximal humerus in true lateral position
3.) Impingement Syndrome
 Impingement of the greater tuberosity & soft LAWRENCE METHOD
tissues on the coracoacromial ligamentous & TRANSTHORACIC LATERAL PROJECTION
osseous arch PP: Upright (more comfortable) or supine; patient
4.) AC separation in lateral position; uninjured arm raised; forearm
 Partial or complete tear of the AC & rested on head; midcoronal plane ┴ to IR; full
coracoclavicular ligaments inspiration (improves contrast & reduces exposure)
5.) Idiopathic Chronic Adhesive Capsulitis or breathing technique (slow, deep breathing)
 Frozen shoulder RP: Level of surgical neck
 Disability of the shoulder joints caused by CR: Horizontal or 10-15o cephalad (cannot elevate
chronic inflammation of the joint unaffected shoulder)
6.) Shoulder Dislocation SS: Proximal humerus
 Traumatic removal of humeral head from
the glenoid cavity LAWRENCE METHOD
INFEROSUPERIOR AXIAL PROJECTION
A.) SHOULDER PP: Supine; head, shoulder & elbow elevated (3
in.); arm abducted 90o; humerus rotated externally;
AP PROJECTION IR placed against the neck; head turn away from
External, Neutral, Internal Rotation side of interest
PP: Upright (more comfortable) or supine; patient RP: Axilla
slightly rotated; scapula // to IR CR: Horizontal; 15-30o medially (greater
 External Rotation: hand supinated; abduction, greater angle)
humeral epicondyles // to IR; arm abducted SS:
slightly  Proximal humerus
 Neutral Rotation: palmar/anterior aspect of  Scapulahumeral joint
hand placed against the hip; humeral  Lateral portion of coracoids process
epicondyles 45o to IR  Acromioclavicular (AC) articulation
 Internal Rotation: dorsal/posterior aspect  Insertion site of subscapular tendon
of hand against hip; humeral epicondyles ┴  Point of insertion of teres minor tendon
to IR
RP: 1 in. inferior to coracoid process
CR: ┴
SS: Shoulder & proximal humerus
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ER: When prone (Westpoint) or supine (Lawrence
RAFERT-LONG MODIFICATION & Rafert-Long) position is not possible
INFEROSUPERIOR AXIAL PROJECTION
PP: Supine; head, shoulder & elbow elevated (3 SUPEROINFERIOR AXIAL PROJECTION
in.); arm abducted 90o; exaggerated external PP: Seated; patient lean laterally; elbow flexed 90o
rotation of the arm; hand 45o to IR; thumb pointing & rested on table; hand pronated; humeral
downward; IR placed against the neck; head turn epicondyles ┴ to table
away from side of interest RP: Shoulder joint
RP: Axilla CR: 5-15o toward the elbow
CR: Horizontal; 15o medially\ SS: Relationship of the proximal end of the
SS: Coracoid process pointing anteriorly; lesser humerus to the glenoid cavity
tubercle in profile  AC articulation
ER: Hill-Sachs compression fracture (defect)  Outer portion of the coracoid process
 Points of insertion of the subscapularis
WEST POINT METHOD muscle & teres minor muscle
INFEROSUPERIOR AXIAL PROJECTION  Coracoids process above clavicle
PP: Prone; shoulder elevated (3 in.); head turn  Lesser tubercle in profile
away from side of interest; arm abducted 90o;
forearm rested over the edge of table; IR placed
vertically AP AXIAL PROJECTION
RP: 5 in. inferior & 1.5 in. medial to acromial edge PP: Upright/supine; scapulohumeral joint centered
CR: 25o anteriorly & 25o medially to IR
SS: Humeral head projected free of the coracoid RP: Scapulohumeral joint
process CR: 35o cephalad
ER: SS: Relationship of the head of humerus to the
 Used when chronic instability of shoulder is glenoid cavity
suspected  AC articulation
 To demonstrate Bankart’s Lesion &  Outer portion of the coracoid process
associated Hills-Sachs defect  Points of insertion of the subscapularis
muscle & teres minor muscle
CLEMENTS MODIFICATION  Coracoids process above clavicle
INFEROSUPERIOR AXIAL PROJECTION
 Lesser tubercle in profile
PP: Lateral recumbent; unaffected side against IR;
affected arm abducted 90o; IR against superior
SCAPULAR Y
aspect of shoulder
PA OBLIQUE PROJECTION
RP: Midaxillary region
RUBIN-GRAY-GREEN
CR: Horizontal or 5-15o medially (cannot abduct
PP: Upright/recumbent; RAO/LAO; MCP 45-60o to
arm 90o)
IR; scapular flat surface ┴ to IR; RPO/LPO (for
SS: Acromioclavicular joint; scapulohumeral joint;
severely injured patient)
glenohumeral joint
RP: Scapulohumeral joint
CR: ┴
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SS: Scapular body (form the vertical component); APPLE METHOD
acromion & coracoid processes (form the upper AP OBLIQUE PROJECTION
limbs) PP: Upright; RPO/LPO; body rotated 35-45o
 Superimposed humeral head & glenoid toward the affected side; scapula // to IR; patient
cavity hold 1 lb. weight; arm abducted 90o
 Superimposed humeral shaft & scapular RP: Level of coracoid process
body CR: ┴
 Coracoid process superimposed or projected SS: Glenoid cavity (scapulahumeral joint)
below the clavicle ER: To demonstrate a loss of articular cartilage in
ER: Useful in evaluation of suspected shoulder the scapulohumeral joint
dislocations
 Anterior/subcoracoid dislocation: humeral GARTH METHOD
head beneath the coracoid process AP AXIAL OBLIQUE PROJECTION
 Posterior/subacromial dislocation: PP: Supine/seated/upright; RPO/LPO; body rotated
humeral head beneath the acromion process 45o toward the affected side; elbow flexed; arm
placed across the chest
STRYKER “NOTCH” METHOD RP: Scapulohumeral joint
AP AXIAL PROJECTION CR: 45o caudad
HALL-ISAAC-BOOTH SS: Glenoid cavity (scapulahumeral joint)
PP: Supine; arm flexed slightly beyond 90o; palm  Humeral head
of hand on top of head w/ fingertips resting on head  Coracoid process
(places humerus in a slight internal rotation); body  Scapular head & neck
of humerus // to MSP of body ER:
RP: Coracoid process  For acute shoulder trauma
CR: 10o cephalad  For identifying posterior scapulohumeral
SS: Posterosuperior & posterolateral areas of dislocations
humeral head o Posterior disocation: humeral head
ER: Useful for demonstration of Hill-Sachs defect projected superiorly from glenoid
cavity
B.) GLENOID CAVITY o Anterior disocation: humeral head
projected inferiorly from glenoid
GRASHEY METHOD cavity
AP OBLIQUE PROJECTION  Glenoid fxs
PP: Upright (more comfortable) or supine;  Hill-Sachs lesions/defect
RPO/LPO; body rotated 35-45o (upright)/>45o  Soft tissue calcification
(supine) toward the affected side; scapula // to IR;
arm slightly abducted; palm of hand on abdomen
RP: 2 in. medial & 2 in. inferior to superolateral
border of shoulder
CR: ┴
SS: Glenoid cavity (scapulahumeral joint)
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C.) SUPRASPINATUS CR: 15o cephalad
OUTLET/CORACOACROMIAL ARCH SS: AC joints above acromion
ER: For demonstration of suspected AC
NEER METHOD subluxation or dislocation
TANGENTIAL PROJECTION
PP: Seated/upright; RPO/LPO; unaffected side ALEXANDER METHOD
rotated 45-60o away from IR; arm at side AP AXIAL PROJECTION
RP: Superior aspect of humeral head PP: Upright/seated-upright; arms hanging at sides
CR: 10-15o caudad (unsupported); 2 exposures: with & without weights
SS: Posterior surface of acromion & AC joint (5-10 lbs.); affix the weights to patients wrist
(superior border of coracoacromial outlet) RP: b/n level of AC joints
ER: CR: ┴
 Useful to demonstrate tangentially the SS: Bilateral AC joints
coracoacromial arch/outlet ER: Used to demonstrate dislocation, separation &
 To diagnose shoulder impingement function of the joints

C.) INTERTUBERCULAR GROOVE ALEXANDER METHOD

PA AXIAL PROJECTION
FISK MODIFICATION PP: Upright; RAO/LAO; MCP 45-60o from IR;
TANGENTIAL PROJECTION scapula ┴ to IR; lean affected shoulder against IR;
PP: arm pulled firmly across the chest (draws scapula
 Supine: chin extended; head rotated away laterally & forward & places joint close to IR)
from affected side; hand supinated; IR RP: AC joints
against superior surface of shoulder CR: 15o caudad
 Upright (fisk modification): elbow flexed; SS: AC joint
posterior surface of forearm against table;  Relationship of the bones of the shoulder
patient grasps the IR; sandbag under hand;
IR horizontal; patient lean forward; humerus E.) CLAVICLE
10-15o from vertical
RP: Intertubercular groove AP PROJECTION
CR: ┴ (upright) or 10-15o posteriorly to long axis PP: Supine/upright; arms along the sides; clavicle
of humerus (supine) center to IR
SS: Intertubercular groove RP: Midshaft of clavicle
CR: ┴
D.) ACROMIOCLAVICULAR JOINTS SS: Frontal image of clavicle
PA Projection: reduces OID & improved image
PEARSON METHOD contrast
BILATERAL AP PROJECTION
PP: Upright/seated-upright; coracoid process
centered to IR
RP: Coracoid process
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AP AXIAL PROJECTION LATERAL PROJECTION
Lordotic Position PP: Upright/seated; RAO/LAO (more difficult to
PP: perform); 45-60o from IR; RPO/LPO (magnified
 Upright: 1 foot in front; lean backward scapula)
(lordotic); neck & shoulder against IR; neck Arm Placement:
in extreme flexion  Elbow flexed & arm on posterior chest
 Supine: cannot assumed lordotic position o For demonstration of acromion &
 Suspend at end of full inspiration coracoid process
RP: Midshaft of clavicle  Arm extended upward & forearm rested on
CR: 0-15o cephalad (upright); 15-30o (supine) head or across upper chest
SS: Clavicle projected above the ribs; true/exact o For demonstration of scapular body
axial projection of clavicle RP: Midmedial border of protruding scapula
CR: ┴
PA AXIAL PROJECTION SS: Lateral image of scapula
PP: Prone/standing Mazujian Suggestion: arm across the upper chest
RP: Midshaft of clavicle (grasping opposite shoulder)
CR: 15-30o caudad
SS: Clavicle projected above the ribs; axial image LORENZ-LILIENFELD METHODS
of clavicle PA OBLIQUE
PP: Upright/lateral recumbent;
TANGENTIAL PROJECTION Lorenz Method: arm of affected side 90o to long
PP: Supine; arms along sides; shoulder depressed; axis of body; elbow flexed; hand rested against head
head turn away from side of interest Lilienfeld Method: arm of affected side obliquely
RP: b/n clavicle & chest wall upward; head rested against head
CR: 25-40o from horizontal/cephalad RP: b/n chest wall & midarea of protruding scapula
SS: Inferosuperior image of the clavicle CR: ┴
SS: Oblique image of scapula
F.) SCAPULA
AP OBLIQUE
AP PROJECTION PP: Supine/upright; RPO/LPO; shoulder rotate 15-
PP: Supine/upright; arm abducted 90o w/ the body 25o away from affected side or 25-35o (steeper
(draw scapula laterally); elbow flexed oblique)arm extended superiorly; elbow flexed;
RP: 2 in. inferior to coracoids process hand supinated under head; arm of affected side
CR: ┴ across anterior chest
SS: Scapula RP: Midscapular area
 Lateral portion of scapula free of CR: ┴ to lateral border of rib cage
superimposition SS: Oblique image of scapula free or nearly free of
rib superimposition

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G.) CORACOID PROCESS

AP AXIAL PROJECTION
PP: Supine; arm of affected side slightly abducted;
hand supinated
RP: Coracoid process
CR: 15-45o cephalad
SS: Coracoid process with minimal self-
superimposition
Kwak-Espiniella-Kattan Recommendation: CR
30o
H.) SCAPULAR SPINE

LAQUERRIERE-PEIRQUIN METHOD
PP: Supine; scapular body // to IR; head turned
away from side of interest
Funke: use of 15o radiolucent wedge for patient
with small breast
 Prevent clavicular superimpostion
RP: Scapular spine (posterosuperior region of
shoulder)
CR: 45o caudad
SS: Scapular spine free of superimpostion

LAQUERRIERE-PIERQUIN METHOD
PP:
 Prone: arms along sides; head rested on
chin/cheek of affected side; hand supinated;
scapular // to IR
 Upright: back rested against the end of
table; IR placed 45o from table (wedge
support)
RP: Scapular spine
CR: 45o cephalad (prone); 45o posteroinferiorly
(upright)
SS: Scapular spine free of superimpostion

 THE END 
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03/19/14