Radiography of the Radiography of the ShoulderShoulder

Jennifer Nicol PGY-1August 6, 2009

ObjectivesObjectivesBRIEF Anatomy ReviewStandard shoulder viewsRadiographs of shoulder injuriesNOT:

◦Treatment◦Other imaging modalities◦Pediatric imaging

AnatomyAnatomy

Shoulder ViewsShoulder ViewsOver 15 views of shoulder

describedTrauma series:

◦3 views: AP Trans-scapular “Y-view” Axillary

Modified axillary

AP viewAP viewTrue AP - 45˚tilt

◦ Glenohumeral joint with no bony overlap

◦ Preferred in traumaAP int/ext rotation

◦ Highlight tuberosities

◦ Soft tissue injuriesClavicle and AC

joint

Transcapular viewTranscapular viewProjects along

long axis scapulaSimple,

reproducibleGood for

visualising anterior, posterior dislocations

Acromion Coracoid Body

Axillary ViewAxillary ViewGlenohumeral

joint in cephalocaudal plane

Lesions of glenoid rim, humeral head, caracoid

Axial view of shoulder

Modified Axillary ViewModified Axillary View

Reverse axillary when pt can’t abduct

Retrospective1690 shoulder exams

◦Mod axillary view used 104 times

◦ Identified additional pathology in 30 cases

No comparison b/t standard and modified axillary

Approach to Shoulder XRApproach to Shoulder XRAP:

◦If ext/int rotation look at tuberosity orientation

◦Glenohumeral region Alignment Distance b/t humeral head and glenoid Bones

◦AC region◦Other regions (clavicle, ribs, scapular

spine,lungs)

Approach to Shoulder XRApproach to Shoulder XROther views:

◦Humeral head to glenoid◦Prox humerus◦Glenoid rim◦Scapula◦Carocoid◦Acromion

1)GlenoidAlignmentDistancebones

2)ACAlignmentCarocoid-

clavicle space

3)OtherLungs,

scapula, ribs, clavicle

Type I AC injury

Type III AC injury

Posterior Dislocation

Positive Rim Sign

Trough Sign

No Mercedes!!!!

Avulsion Lesser Tuberosity

Bilateral shoulder dislocation spontaneously reduced with bilateral reverse Hill-Sachs lesions

Posterior DislocationsPosterior DislocationsHave high suspicion with correct

mechanismDon’t miss – clinical exam

importantLook for associated fracturesTypes:

◦Subacromial (98%)◦Subglenoid◦subspinosus

Anterior Dislocation

Scapular View: Anterior Dislocation

Hill-Sachs deformity

AP

Bankhart Injury

Axillary

Greater Tuberosity Fracture

Anterior DislocationsAnterior Dislocations4 Types

◦Subcoracoid◦Subglenoid◦Subclavicular◦Intrathoracic

Anterior DislocationsAnterior DislocationsCheck Neurovascular exam pre-

post reductionDon’t delay reduction – NV injury

increases with timeRecurrence high – 80% <30

Inferior Dislocation

Subglenoid anterior dislocation

Pseudodislocation