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
1
 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.

2
 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.

3
 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.

4
 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
5
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.

6
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.
7
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

8
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.

9
 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
10
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.

11
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.
12
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

13
Shoulder A-P with External Rotation
Film
• The
glenohumeral
joint should be
open
• The greater
tubericle and
humeral head
will be in profile .

14
 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

15
 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.
16
 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

17
 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

18
 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.
19
 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
20
 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.

21
 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.
22
 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

23
 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.

24
 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.

25
 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
26
 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.
27
 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
28
 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.

29
 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.

30
 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

31
 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

32
 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.
33
 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
34
 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.

35
 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.

36
 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

37
 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.
38
 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.

39
 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.

40
 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

41
 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

42
 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
43
 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

44
 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.
45
 Scapula A-P Film
• Glenohumeral joint and
entire scapula should be
seen.
• Soft tissues of shoulder
should be seen.

46
 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

47
 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.

48
 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
49
 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.

50
 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

51
 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.

52
 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
53
 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.

54
 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

55
 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.

56
 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
57
 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.

58
 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

59
 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.

60
 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
61
 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.

62
 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

63
 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

64
 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

65
 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

66
 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

67
 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.

68
 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

69
 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

70
 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

71
 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.

72
 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.

73
 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.

74
 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

75
 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

76
 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
77
 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.

78
 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.

79
 Zanca View Films
• Weighted and Non-
Weighted Views are
taken as stress views of
the Acromioclavicular
Joint.
• Useful in detection
separations

80
 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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