UPPER EXTREMITY.

THE SHOULDER GIRDLE.

ITM
MODULE 1.
 The Shoulder Girdle
Comprises;
1. Two scapulae.
2. Two clavicles.

The Shoulder Joint.

Indications for Radiography.
3. Pathology (Osteoarthritis, Osteomyelitis).OA/OM.
4. Trauma/injury fracture/dislocation.
5. Sublaxation.
6. Calcification.
7. Foreign bodies.
8. Age assessment.
 The Shoulder Girdle
Equipment.
• X-ray generator capable of producing about 300mA and
100kVp.
• Rotating anode and fine focus.
• X-ray couch/table.
• A vertical cassette holder.

Accessories.
a) Loaded screen films cassette sizes (24x30) cm, (18x24)
cm.
b) Anatomical side markers.
c) Lead rubber pieces and aprons.
d) Positioning soft-pads and sandbags.
 The Shoulder Girdle
Accessories cont;
a) Curved cassette sizes (18x24) cm.
b) Clean changing gowns.

Patient Preparation.
1. Positive identification.
2. Clear, precise explanation of the
procedure.
3. Instructions to undress from waist upwards
and provision of a clean changing gown.
 The Shoulder Joint.
Note;
• If circumstances would not allow the removal of
clothes all radiopaque items around the joint should
be removed e.g. zippers, buttons, chains and etc.

Basic Views.
1) Antero-Posterior AP.
2) Axial (supero-inferior) view.

Antero- Posterior (A.P)

• The patient is examined either in the erect or
horizontal position.
 The Shoulder Joint.
A) Patient Erect.
• A (30x24)cm screen film cassette with
appropriate side an anatomical maker in place is
vertically placed in the vertical cassette support

• It is adjusted so that the shoulder joint is at the

centre of the cassette erect.

• With the patient facing the x- ray tube is rotated

300 towards the joint under examination until the
scapula is parallel with the film .
 The Shoulder Joint.
A) Patient Erect;
• The elbow is flexed and the fore arm directed
forward the shoulder should be relaxed and not
elevated /lunched for this may simulate sublaxation
thus giving the wrong diagnosis .

• The head may face the injured part for comfort to

(immobilize the patient he should be instructed to
separate the legs slightly to preserve balance.

• Short exposure time should be employed to avoid

motion or blur and expose in arrested respiration.
 The Shoulder Joint.
Direction of centering of the x- ray beam.
• With the x-ray beam directed horizontally centre to
the coracoid process with the central ray
perpendicular to the film.

Note:
Modified Antero-Posterior:
• To demonstrate more clearly the gleno-humeral
space.
• Rotate the trunk 250 towards the side under
examination.
• Particularly abduct the humerus and centre to the
 The Shoulder Joint.
B) Patient Supine.
• The technique is the same with the patient in the erect
position except that cassette is placed on the x- ray couch.

• The patient is helped to lie in the supine position and

supported posteriorly to assume a 300 rotation towards the side
under examination.

• The patient is immobilized using pillows, soft pads and

sandbags.

• The central ray is vertical.

 The Shoulder Joint.
Note.
• A grid or and air gap is necessary in the case of the
patient with well developed deltoid muscles to
“improve contrast” by reducing the amount of
scattered radiation.

• None screen films and grid can be used where

extremely good details is required but this results
greatly increased radiation dose.

• The technique is probably best employed as a

supplementary rather than a routine method.
 The Shoulder Joint.
2; AXIAL (Supero-Inferior) View–Lateral.
• A (24x18)cm screen curved cassette with an
identification side marker is placed on the x-ray table.

• The patient sits besides the breath of the x-ray table

with arm abducted and the elbow flexed so that the
forearm is at right angle to the humerus .
• The curved cassette is placed under the axilla and
region is as flat as possible to avoid distortion of the
joint.
•The head of the patient may necessitate use of pillows
or raising the cassette.
 The Shoulder Joint.
Direction and centering of the x-ray beam.
• With the central ray to the cassette,
a) Centre to the head of the humerus.
b) Centre through the joint with the central x-ray angled 5-
10° to the humeral head.

Special Circumstances.
Inferior superior view is done when the patient is unable to
abduct the arm sufficiently.
• A superior inferior views to be taken with the patient in the
erect position.
 The Shoulder Joint.
Special Circumstances cont;
• The arm is abducted as much as possible, the
x-ray tube preferable with a long extension cone
is placed at the side of the patient and directed
upwards towards the axilla.

• A 24x18cm film cassette is supported

horizontally above the shoulder and pressed
firmly against the neck so that the shoulder will
not be projected off the film.
 The Shoulder Joint.
Direction of centering the x-ray beam.
• With the x-ray beam in a vertically upward
projection centre through the axilla with the central
ray to the cassette.

Lateral.
This view is performed when the patient arm cannot
be abducted because it is in a sling or in a painful to
be moved.
• The patient is examined in a sitting, erect is at right
angle with the film cassette.
 The Shoulder Joint.
Lateral.
• A 18x24cm cassette is used and the patient should be
adequately immobilized to avoid motion or blur.
• In this view the shoulder joint is seen through minimal lung
tissue and the exposure should be made at arrested respiration.

Direction of centering of x-ray tube.

• If the patient is sited/erect the tube should be turned for
horizontal projection with the central ray perpendicular to the
film.
• Centre to the head of the humerus or just below the coracoids
process.
 The Shoulder Joint.
Radiation protection measures.
1) The x-ray beam should be coned/reduced to the
area of interest.

2) Lead shielding from below the diaphragm to cover

the gonads.

3) Short exposure time to be employed.

4) Accurate positioning of the patient.

5) Proper patient preparation and reassurance.

6) Good immobilization.
 The Shoulder Joint.
Radiation protection measures cont;
1) Use of correct exposure factors,

2) Proper film processing.

3) 10 days rule must be observed? Obsolete? 28

days rule.

4) High kilovoltage technique.

 The Shoulder Joint.
Supplementary Views.
1) Antero-posterior view with internal and external
rotation to demonstrate muscles and tendons
calcification.

2) Stryker’s view for recurrent sublaxation.(The

patient lies and touches his head then the X )

3) 250 antero-posterior to demonstrate sub-acromial

calcification.

4) Axial view to demonstrate bicipital groove.

 The Shoulder Joint..
1. Antero-posterior view with internal and
external rotation.
• Muscles and tendons calcification.
• Essential in obtaining further information
concerning any lesions shown on the basic views.

• Two radiographs are taken.

1. The patient is positioned as for the basic AP
views.
• The elbow remains flexed and the forearm is placed
either across the chest or behind the back to produce
full rotation of the shoulder joint.
 The Shoulder Girdle.
Antero-posterior view with internal and external
rotation.
2. The patient is re-position in the AP position with the
elbow flexed.

• The arm is then externally rotated as far as possible.

Centering for both views;

• Centre to the coracoids process.

 The Shoulder Girdle.
Stryker’s View (Recurrent Sublaxation).
• The patient lie supine on the x-ray couch facing
the tube.

• A 30x24cm screen film cassette appropriately

marked is transversely placed under the shoulder
being examined.

• The cassette is then adjusted so that the shoulder

under the examination is in the middle of the
cassette.
 The Shoulder Girdle.
Stryker’s View (Recurrent Sublaxation).
• The patient head is placed under the pillow for
comfort.

• The palm of the hand under examination is

placed on top of the head and the elbow directed
forward.

• The patient is immobilized by use of soft pads.

CR. The x-ray beam in the vertical projection,

centre to the coracoids process with the tube
angled 100 cephalad.
 The Shoulder Girdle.
250 Antero-Posterior. (Sublaxation).
• The patient lies supine on the x-ray table.

• A small pillow placed under the head for

comfort.

• The elbow is then flexed and the hand pronated

with the palm facing downwards and placed under
the back.

• A 18x24cm screen film cassette with the

appropriate identification side marker.
 The Shoulder Girdle.
250 Antero-Posterior. (Sublaxation).
• Is placed under the shoulder with its upper
border level with the upper border of the
shoulder.

CR: Center to the acromion process with the

tube angled 250 caudad.

Note.
• A lead rubber piece should be placed over the
genital organs for protection this is particularly
important for any caudal angulations.
 THE SCAPULA.
Indications.
a) Trauma e.g. fractures #.
b) Pathology.
c) Calcification.
d) Foreign bodies.

• The equipment, accessories, the patient

preparation and radiation protection as for the
shoulder joint.

Basic Views.
1. Antero-posterior.
2. Lateral –erect/semi-prone.
 THE SCAPULA.
1. Antero-Posterior View.
• The patient may be examined while standing,
sitting or lying supine.

• Faces the x-ray tube, and rotated about 300 to

bring the plain of the scapula parallel to the
cassette.

• A 24x30cm film cassette appropriately marked

is placed under the scapula with its upper border
2.5cm above the shoulder joint.
 THE SCAPULA.

1. Antero-posterior View.
• Along exposure time (5sec) is used with the
patient breathing gently.

• This is to blurs out the lungs and the ribs

shadows to give a clearer view of the scapula.

• CR; with the central ray at right angles to the

cassette centered over the head of the humerus.
 THE SCAPULA.
2. Lateral View.
Patient Erect;
• The patient faces the cassette.
• With elbow of side under examination flexed and the arm
slightly abducted to separate the humeral shaft from the
blade of the scapula.

• The patient is rotated about 600-700 to the side under

examination until the plane of the scapula is at right angle
with the cassette.

CR; centre to the medial border of the scapula at the level

of 4th to 5th thoracic vertebrae.
 THE SCAPULA.
b. Patient Semi-Prone.
• The patient lies prone and is then rotated 60 0
towards the side under examination.

• The humerus is slightly abducted to allow the

scapula to be projected in profile.

CR; centre over the 5th thoracic vertebra.

 THE SCAPULA.
Special Circumstances.
1. If the arm is in a sling and abducted across
anterior chest wall.
• Lateral views can still be taken but the degree of
rotation is usually slightly reduce to about 30 0.
Centre over the 5th vertebra.

2. Patient on wheelchairs or stretcher;

• To obtain the lateral view of the scapula.

• The patient, whether sitting/lying faces the tube.

 THE SCAPULA.
Special Circumstances.
2. Patient on wheelchairs or stretcher;
• The hand of the side under examination is
placed on the opposite shoulder.

• From the AP position.

• The patient is rotated 250 to 300 with side under
examination away from the cassette until the
scapula can be felt separated from the thorax.

CR; centre to the head of the humerus.

 THE SCAPULA.
Supplementary Views.
To demonstrate.
1.Coracoids Process.
Antero- Posterior View
• The patient faces the x-ray tube and rotate 30 0 to
bring the plane of the scapula parallel with the
cassette.

• The palm of the side under examination is placed

over the lateral border of the scapula at the level
of glenoid fossa.
 THE SCAPULA.
Supplementary Views.
To demonstrate.
2.Supraspinous Fossa.
Antero-Posterior. AP.
• Instruct the patient to stand facing the x-ray tube.

• He is then asked to bend forward so as the spine

of the scapula is horizontal and thus to the vertically
placed cassette because of the large object film
distance.

• The ffd is increased to 180 cm. Centre just medial

to the acromio- clavicular joint.
 THE SCAPULA.
Supplementary Views.
To demonstrate.
3. Acromio-Clavicular Joint
Antero- Posterior View
• A view of each joint is always taken either
separately or both on the same radiograph.

• The patient stands facing the x-ray tube and if the

conditions allows it equal weight are held in each
hand.

• So as to increase the effect of gravity to open up

the joint spaces.
 THE SCAPULA.
Supplementary Views.
To demonstrate.
3. Acromio-Clavicular Joint
1. For views of both sides on the same
radiograph.

• The patient remains facing the tube and a

40x15cm screen film cassette is supported
vertically.

• Centre in mid-line at the level of the joints and

limit the beam to the areas of interest.
 THE SCAPULA.

Supplementary Views.
To demonstrate.
3. Acromio-Clavicular Joint
2. For a view of one side only.
• The patient is rotated slightly within 10 0 so that
this side is nearer the film.

• Centre just above the head of the humerus to the

joint space .
 THE SCAPULA.
Acromion Process.
Antero-Posterior.
• In this view the patient stands or sits facing the
x-ray tube.
• The acromion process under examination is
brought near the cassette by rotating the patient
100-150 towards the injured side.
• For minimal overshadowing, the humerus is
slightly abducted.
• The arm placed in supination use a 18x24cm
film cassette.
• CR; centre over the coracoids process
 THE CLAVICLE
Basic views.
• Posterior-Anterior AP.
• Infero-Superior.

Postero- Anterior View.

• The patient faces the cassette and is rotated
slightly so that the long axes of the clavicle is
parallel with it.

• The cassette is placed transversely and

adjusted so that the clavicle is in the midline of
the cassette.
 THE CLAVICLE
Postero- Anterior View.
• A narrow transverse aperture is used or limit
the x-ray beam to the area of interest.

• CR; Centre to the superior angle.

Infero-superior VIEW.
• The patient is rotated slightly so that the
clavicle is parallel with the film cassette.

• The cassette is placed transversely with its

upper boarder 7-5cm (3”) above the level on top
of the shoulder in line with the central ray.
 THE CLAVICLE
Infero-superior VIEW.
• CR; centre to the lower border of the clavicle.
• At the level of the mid-clavicular line.
• With the tube angled 350 cephalad 150 toward
the shoulder jt.

Special Circumstances.
For an injured patient.
• Positioning for Antero-Posterior (AP) is often
easier.
• He sits /lies facing the x-ray tube.
• Is then rotated slightly until the clavicle under
examination is parallel to the film cassette.
 THE CLAVICLE.
Special Circumstances.
For an injured patient.
• Positioning for Antero-Posterior (AP) is often
easier.
• He sits /lies facing the x-ray tube.
• Is then rotated slightly until the clavicle under
examination is parallel to the film cassette.
• A small pad is placed under the shoulder for
support and the head is turned towards the
injured side.
• CR; Centre to the middle of the clavicle.
 THE CLAVICLE
Special Circumstances.
For a child .
• A view of the both clavicle is usually taken.

• The child lies supine with the shoulder on the

cassette which must be wide enough to include
both shoulders .

• The beam is collimated to an arms transverse

aperture.

• Centre to the midline at the level of clavicles.