RADIOGRAPHIC POSITIONING & RADIOLOGIC PROCEDURES 1
Internal Rotation Humerus
o AP
o Transthoracic Lateral (R or L)
AP PROJECTION
External, Neutral, Internal Rotation
➤ IR: 10 × 12 inch (24 × 30 cm); crosswise to include entire
clavicle, lengthwise to include more humerus
➤ Patient Position: upright or supine position
➤ Part Position:
o Adjust the position of the IR so that its center is 1 inch
(2.5 cm) inferior to the coracoid process
External Rotation Humerus
➤ Supinate hand, unless contraindicated
➤ Abduct the arm slightly, and rotate it so that the
epicondyles are parallel with the plane of the IR
➤ Externally rotate the entire arm from the neutral
position to place the shoulder and the entire humerus in
the true anatomic position
➤ Supinating hand
➤ Epicondyles parallel to the plane of the IR positions
Neutral Rotation Humerus
➤ Palm of the hand against the thigh
➤ This position of the arm rolls the humerus slightly
internal into a neutral position, placing the epicondyles
at an angle of about 45 degrees with the plane of the IR
➤ Palm against hip
➤ Epicondyles 45- degree angle with the plane of the IR
➤ Posterior aspect of hand against hip
➤ Epicondyles perpendicular to the plane of the IR
➤ Ask the patient to flex the elbow, rotate the arm internally,
and rest the back of the hand on the hip
➤ Adjust the arm to place the epicondyles perpendicular to
the plane of the IR
➤ Shield gonads
➤ Respiration: Suspend
➤ CR: Perpendicular to a point 1 inch (2.5 cm) inferior to the
coracoid process, which can be palpated inferior to the clavicle
and medial to the humeral head
➤ SS:
o External rotation: Greater tubercle of the humerus
and the site of insertion of the supraspinatus tendon
o Neutral rotation: Posterior part of the supraspinatus
insertion, which sometimes profiles small calcific
deposits
o Internal rotation: Proximal humerus is seen in a true
lateral position
• When the arm can be abducted enough to
clear the lesser tubercle of the head of the
scapula, a profile image of the site of
insertion of the subscapular tendon is seen
➤ EC: Superior scapula, lateral half of the clavicle, and
proximal humerus
External Rotation
o Humeral head in profile
o Greater tubercle in profile on lateral aspect of the
humerus
o Scapulohumeral joint
o Outline of lesser tubercle between the humeral head
and greater tubercle
Neutral Rotation
o Greater tubercle partially superimposing the humeral
head
o Humeral head in partial profile
o Slight overlap of the humeral head on the glenoid
cavity
Internal Rotation
o Lesser tubercle in profile and pointing medially
o Outline of the greater tubercle superimposing the
humeral head
o Greater amount of humeral overlap of the glenoid
cavity than in external and neutral positions
TRANSTHORACIC LATERAL PROJECTION
Lawrence Method
R or L Position
➤ Used when trauma exists, and the arm cannot be rotated
or abducted because of injury.
➤ IR: 10 × 12 inch (24 × 30 cm)
➤ Patient Position: Upright or supine
1
RADIOGRAPHIC POSITIONING & RADIOLOGIC PROCEDURES 1

➤ Part Position: INFEROSUPERIOR AXIAL PROJECTION

o Have the patient raise the uninjured arm, rest the Lawrence Method
forearm on the head and elevate the shoulder as ➤ IR: 10 × 12-inch (24 × 30 cm) grid crosswise
much as possible ➤ Patient Position: Supine
o MCP perpendicular to the IR ➤ Part Position:
o Center the IR to the surgical neck area of the affected Lawrence Method
humerus o As much as possible, abduct the arm of the affected
o Shield gonads side at right angles to the long axis of the body. A
o Respiration: full inspiration minimum of 20 degrees is required to prevent
o 3 seconds of exposure time with low mA – gives superimposition of the arm on the shoulder.
excellent results o Keep the humerus in external rotation and adjust the
forearm and hand in a comfortable position.
o Have the patient turn the head away from the side
being examined.
o IR on the edge against the shoulder and as close as
possible to the neck.

➤ Hill-Sachs defect - anterior dislocation of the humeral head

can result in a wedge-shaped compression fracture of the
➤ CR: Perpendicular to the IR, entering the MCP at the level articular surface of the humeral head
of the surgical neck o Located on the posterolateral humeral head
o If the patient cannot elevate the unaffected shoulder,
angle the CR 10-15 degrees cephalad to obtain a
➤ An exaggerated external rotation of the arm may be
comparable radiograph
required to see the defect
➤ SS: shoulder and proximal humerus projected through the
thorax
➤ Rafert Modification: With the patient in position exactly as
➤ EC:
for the Lawrence method, externally rotate the extended arm
o Proximal humerus
until the hand forms a 45-degree oblique angle. The thumb is
o Scapula, clavicle, and humerus seen through lung field
pointing downward.
o Scapula superimposed over the thoracic spine
o Unaffected clavicle and humerus projected above the
shoulder closest to the IR

➤ Lawrence Method CR: Horizontally through the axilla to the

region of the AC articulation.
o The degree of medial angulation of the central ray
depends on the degree of abduction of the arm.
o The degree of medial angulation is often between 15
degrees and 30 degrees.
o The greater the abduction, the greater the angle.
➤ Rafert Modification CR: Horizontal and angled
o Inferosuperior Axial Projection – Lawrence Method approximately 15 degrees medially, entering the axilla and
o West Point Method passing through the AC joint.
o Clements Modification ➤ SS: Proximal humerus, the scapulohumeral joint, the
o Superoinferior Axial Projection lateral portion of the coracoid process, and the AC
o AP Axial Projection articulation

2
RADIOGRAPHIC POSITIONING & RADIOLOGIC PROCEDURES 1

o Insertion site of the subscapular tendon on the lesser

tubercle of the humerus and the point of insertion of
the teres minor tendon on the greater tubercle of the
humerus are also shown.
o A Hill-Sachs compression fracture on the
posterolateral humeral head may be seen using the
Rafert modification
➤ EC:
o Scapulohumeral joint with slight overlap
o Coracoid process, pointing anteriorly ➤ SS: Bony abnormalities of the anterior inferior rim of the
o Lesser tubercle in profile and directed glenoid and Hill-Sachs defects of the posterolateral humeral
o Anteriorly head in patients with chronic instability of the shoulder
o AC joint, acromion, and acromial end of clavicle ➤ EC:
projected through the humeral head o Shoulder joint
o Soft tissue in the axilla with bony o Humeral head projected free of the coracoid process
o trabecular detail o Articulation between the head of the humerus and
the glenoid cavity
o Acromion superimposed over the posterior portion of
the humeral head

SUPERIOINFERIOR AXIAL PROJECTION

INFEROSUPERIOR AXIAL PROJECTION
WEST POINT METHOD
➤ Used when chronic instability of the shoulder is suspected
and to show bony abnormalities of the anterior inferior glenoid
rim
➤ Shows the Hill-Sachs defect of the posterior lateral aspect
of the humeral head
➤ IR: 8 × 10 inch (18 × 24 cm) or 10 × 12 inch (24 × 30 cm)
crosswise,
➤ Patient Position: Prone
➤ Part Position:
o Abduct the arm of the affected side 90 degrees, and
rotate so that the forearm rests over the edge of the
table or a Bucky tray, which may be used for support
o Place a vertically supported IR against the superior
aspect of the shoulder with the edge of the IR in
contact with the neck.
o Respiration: Suspend
➤ CR: Directed at a dual angle of 25 degrees anteriorly from
the horizontal and 25 degrees medially
➤ RP: Approximately 5 inches (13 cm) inferior and 11 2 inches
(3.8 cm) medial to the acromial edge and exits the glenoid
cavity
➤ IR: 8 × 10 inch (18 × 24 cm) or 10 × 12 inch (24 × 30 cm)
➤ Patient Position: Seated
➤ Part Position:
o Patients lean laterally over the IR until the shoulder
joint is over the midpoint of the IR
o Elbow to rest on the table
o Flex the patient’s elbow 90 degrees, and place the
hand in the prone position
o Have the patient tilt the head toward the unaffected
shoulder
o Shield gonads
o Respiration: Suspend
➤ CR: Angled 5 to 15 degrees through the shoulder joint and
toward the elbow, a greater angle is required when the patient
cannot extend the shoulder over the IR

3
RADIOGRAPHIC POSITIONING & RADIOLOGIC PROCEDURES 1

➤ SS: AP AXIAL PROJECTION

o Joint relationship of the proximal end of the humerus ➤ IR: 8 × 10 inch (18 × 24 cm) or 10 × 12 inch (24 × 30 cm)
and the glenoid cavity ➤ Patient Position: Supine/upright
o AC articulation, the outer portion of the coracoid ➤ Part Position:
process, and the points of insertion of the o Center the
subscapularis muscle (at body of scapula) and teres scapulohumeral joint
minor muscle (at inferior axillary border) of the shoulder being
➤ EC: examined to the
o Scapulohumeral joint (not open on patients with midline of the grid
limited flexibility) o Shield gonads
o Coracoid process projected above the clavicle o Respiration
➤ CR: Directed through the
scapulohumeral joint at a
cephalic angle of 35 degrees

➤ Shows the relationship of the

head of the humerus to the glenoid
cavity.
➤ Useful in diagnosing cases of
posterior dislocation
Supraspinatus “Outlet”
TANGENTIAL PROJECTION ➤ EC:
NEER METHOD o Scapulohumeral joint
RAO or LAO position o Proximal humerus
o Clavicle projected above
➤ Useful to show tangentially the coracoacromial arch or
superior angle of scapula
outlet to diagnose shoulder impingement
o Soft tissues and bony trabecular detail
➤ Tangential image is obtained by projecting the x-ray beam
under the acromion and AC joint, which defines the superior
➤ SS: Posterior surface of the acromion and
border of the coracoacromial outlet.
the AC joint identified as the superior
➤ IR: 8 × 10 inch (18 × 24 cm) or 10 × 12 inch (24 × 30 cm) border of the coracoacromial outlet
lengthwise
➤ EC:
➤ Patient Position: Seated or standing position facing the o Humeral head projected
vertical grid device. below the AC joint
➤ Part Position: o Humeral head and AC joint
o With the patient’s affected shoulder centered and in with bony detail
contact with the IR, rotate the patient’s unaffected o Humerus and scapular body,
side away from the IR. generally parallel
o Average degree of patient rotation varies from 45 to
60 degrees from the plane of the IR Proximal Humerus
o Patient’s arm at the patient’s side AP AXIAL PROJECTION
o Shield gonads STRYKER NOTCH METHOD
o Respiration: Suspend ➤ Demonstrates Hill-Sachs defects
➤ IR: 10 × 12 inch (24 × 30 cm)
➤ CR: Angled 10 to 15 degrees caudad, entering the superior
➤ Patient Position: Supine
aspect of the humeral head
➤ Part Position:
o Patient to flex the arm slightly beyond 90 degrees and
place the palm of the hand on top of the head with
fingertips resting on the head
o Shield gonads.
o Respiration: Suspend.
➤ CR: Angled 10 degrees cephalad, entering the coracoid
process

4
RADIOGRAPHIC POSITIONING & RADIOLOGIC PROCEDURES 1

➤ SS: Posterosuperior and ➤ SS: Joint space between the humeral head and the glenoid
posterolateral areas of the humeral cavity (scapulohumeral or
head glenohumeral joint)
➤ EC: ➤ EC:
o Overlapping of coracoid o Open joint space
process and clavicle between the humeral
o Posterolateral lateral aspect head and glenoid cavity
of humeral head in profile o Glenoid cavity in profile
o Long axis of the humerus o Soft tissue at the
aligned with the long axis of scapulohumeral joint
the patient’s body along with trabecular
detail on the glenoid
and humeral head

o Grashey Method – AP Oblique Projection AP OBLIQUE PROJECTION

o Apple Method – AP Oblique Projection
o Garth Method – AP Axial Oblique Projection
AP OBLIQUE PROJECTION
GRASHEY METHOD
RPO or LPO position
➤ IR: 8 × 10 inch (18 × 24 cm) or 10 × 12 inch (24 × 30 cm)
➤ Patient Position: supine/upright position
➤ Part Position:
o IR to the scapulohumeral joint (joint is 2 inches (5 cm)
medial and 2 inches (5 cm) inferior to the
superolateral border of the shoulder)
o 35 to 45-degree body obliquity toward the affected
side
o Scapula parallel with the plane of the IR
o If the patient is in the recumbent position, the body
may need to be rotated more than 45 degrees (up to
60 degrees) to place the scapula parallel to the IR
o Abduct the arm slightly in internal rotation, and place
the palm of the hand on the abdomen
o Shield gonads
o Respiration: Suspend
APPLE METHOD
RPO or LPO position
➤ Similar to the Grashey method but uses weighted abduction
to show loss of articular cartilage in the scapulohumeral joint.
➤ IR:10 × 12 inch (24 × 30 cm) crosswise
➤ Patient Position: Upright/seated
➤ Part Position:
o 35 to 45-degree body rotation toward the affected
side
o Posterior surface of the affected side is closest to the
IR.
o Hold a 1-lb weight in the hand on the same side as the
affected shoulder in a neutral position
o While holding the weight, the patient should abduct
the arm 90 degrees from the midline of the body
o Shield gonads
o Respiration: Suspend

➤ CR: Perpendicular to the IR at the level of the coracoid

process
➤ Note: To avoid motion, have the correct technical factors
set on the generator
➤ CR: Perpendicular to the IR; the central ray should be at a and be ready to make the exposure before the patient abducts
point 2 inches (5 cm) medial and 2 inches (5 cm) inferior to the the arm.
superolateral border of the shoulder
➤ SS: Scapulohumeral joint

5
RADIOGRAPHIC POSITIONING & RADIOLOGIC PROCEDURES 1

➤ EC: ➤ IR: 8 × 10 inch (18 × 24 cm) or 10 × 12 inch (24 × 30 cm)

o Glenoid cavity in profile
o The arm in a 90-degree abducted position
o Open joint space between the humeral head and the
glenoid cavity
➤ Patient Position: Supine, seated, or standing position
➤ Part Position:
o With the patient supine, palpate the anterior surface
of the shoulder to locate the intertubercular
(bicipital) groove
o With the patient’s hand in the supinated position,
place the IR against the superior surface of the
shoulder and immobilize the IR
➤ CR: Angled 10 to 15 degrees posterior (downward from
horizontal) to the long axis of the humerus for the supine
position

AP AXIAL OBLIQUE PROJECTION

GARTH METHOD
RPO or LPO position
➤ Recommended for assessing acute shoulder trauma
and for identifying posterior scapulohumeral dislocations,
glenoid fractures, Hill-Sachs lesions, and soft tissue
calcifications
➤ IR: 10 × 12 inch (24 × 30 cm) lengthwise Fisk Modification
➤ Patient Position: Supine, seated, upright ➤ Fisk – described this position with the patient standing at
➤ Part Position: the end of the radiographic table. This employs a greater OID
o Center the IR to the glenohumeral joint ➤ Instruct the patient to flex the elbow and lean forward far
o 45-degree body rotation toward the affected side enough to place the posterior surface of the forearm on the
o Posterior surface of table
the affected side is ➤ Have the patient lean forward or backward as required to
closest to the IR place the vertical humerus at an angle of 10 to 15 degrees
o Flex the elbow of the ➤ CR: Perpendicular to the IR when the patient is leaning
affected arm and place forward and the vertical humerus is positioned 10 to 15
arm across the chest degrees
o Shield gonad
o Respiration: Suspend
➤ SS: Scapulohumeral joint, humeral head, coracoid process,
and scapular head and neck
➤ EC:
o Scapulohumeral joint, humeral
head, lateral angle, and scapular
neck free of superimposition ➤ SS: Profiles the intertubercular (bicipital) groove free
o Coracoid process should be well from superimposition of the surrounding shoulder structures
visualized ➤ EC:
o Posterior dislocations project o Intertubercular (bicipital) groove in profile
the humeral head superiorly o Soft tissues and bony trabecular detail of the
from the glenoid cavity, and humeral head
anterior dislocations
◦ project inferiorly

Intertubercular (Bicipital) Groove

TANGENTIAL PROJECTION
FISK MODIFICATION
➤ Central ray is aligned to be tangential to the intertubercular
(bicipital) groove, which lies on
the anterior surface of the humerus