X-Ray Rounds: (Plain) Radiographic Evaluation of the Shoulder
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1 X-Ray Rounds: (Plain) Radiographic Evaluation of the Shoulder
2 Anatomy 3 Bones Humerus Scapula Clavicle 3 Joints Glenohumeral Acromioclavicular Sternoclavicular 1 Articulation Scapulothoracic
3 Anatomy Humerus Head * Anatomic neck Surgical neck Greater tubercle* Lesser tubercle* Intertubercular groove Deltoid tuberosity Shaft *
4 Anatomy Scapula Body Ventral (Costal) surface Dorsal surface Borders Superior Lateral (Axillary) Medial (Vertebral) Angles Superior Inferior Lateral (Head)
5 Scapula Glenoid Acromion Coracoid Subscapular fossa Scapular spine Supraspinatus fossa Infraspinatus fossa Great scapular notch Suprascapular notch Anatomy
6 Anatomy Scapular Y (Lateral)
7 Anatomy Clavicle First bone to start ossification; last to finish The only bony strut b/w UE and axial skeleton Flat outer (lateral, acromial) third Traps, Delt, AC / CC ligaments Tubular medial (inner, sternal) third Strongest in axial load Middle third Most vulnerable to Fx
8 Glenohumeral joint Anatomy Ball and socket Purpose: placement of primary prehensile limb Very mobile; majority ( ) ) of shoulder movement ( ) Price: instability 45% of all dislocations Joint stability depends on multiple factors
9 Anatomy Glenohumeral joint Passive stability Joint conformity Vacuum effect of jt vol Synovial fluid adhesion and cohesion Scapular inclination Glenoid labrum (50%) Coracoid ligaments CCL, CAL Joint capsule Glenohumeral ligaments SGHL, MGHL, IGHLC Bony restraints Glenoid fossa, Acromion, Coracoid Coracohumeral ligament
10 Glenohumeral joint Active stability Biceps (long head) Rotator cuff Pectoralis muscles, trapezius, serratus anterior, rhomboids, levator scapulae, etc. (NOT deltoid) Anatomy
11 Acromioclavicular joint Diarthrodial joint Thin capsule AC ligaments Anterior, posterior, superior, inferior Coracoacromial ligament Coracoclavicular ligaments Trapeziod ligament Conoid ligament Anatomy
12 Anatomy Sternoclavicular joint Diarthrodial joint Joint capsule Articular disk Intraarticular disk ligament Sternoclavicular ligaments Anterior, posterior Interclavicular ligament
13 Coordinated shoulder motion Glenohumeral motion Acromioclavicular motion Sternoclavicular motion Anatomy Scapulothoracic motion Scapular-humeral rhythm
14 AP View of the Shoulder Transthoracic, Transthoracic, or Routine AP View AP relative to thorax Suboptimal view of Glenohumeral joint Good view of AC joint Scapular, Scapular, Grashey, Grashey, or Glenohumeral AP View Better visualize bony relationships incl GH joint Suboptimal view of AC joint Both have been called True AP Views
15 AP View of the Shoulder Routine AP View Clavicle Scapula Acromion & scapular spine Coracoid Borders & angles AC & SC joints Glenoid Both ant & post lips May obscure HH Humerus Head & necks Gr & Lsr tuberosities
16 AP View of the Shoulder Glenohumeral, Glenohumeral, Grashey, Grashey, or Scapular AP View Same structures AC joint not visualized as well Better visualize the glenoid & humeral head (especially with ER view)
17 AP View of the Shoulder
18 AP View of the Shoulder AP View in External Rotation Greater tuberosity & soft tissues profiled and better visualized Best w/ Scapular AP AP View in Internal Rotation May demonstrate Hill-Sachs lesions GH instability Best w/ Routine AP
19 Which AP view should I get? Routine AP with humeral head in internal rotation (IR) Scapular / Glenohumeral AP with humeral head in external rotation (ER) Harding WG, Nowicki KD. Plane talk about shoulder radiographs. Phys Sportsmed 1998; 26(2)
20 Transthoracic Lateral View of the Shoulder Not usually done Not as useful Many obscuring over- and underlying structures
21 Axillary Lateral View of the Shoulder Good view of anterior- posterior relationship of GH joint Coracoid Acromion Humerus Glenoid GH joint
22 Axillary Lateral View of the Shoulder Alternate Axillary views 45 Velpeau View magnified axillary view
23 Scapular Y Lateral View of the Shoulder Relationship b/w humeral head and glenoid Acromion Coracoid Scapular body Scapular spine
24 Scapular Y Lateral View of the Shoulder Scapular outlet view A variation of scapular Y view Same projection, but with beam tilted caudad Shoulder impingement: to evaluate the subacromial space and the supraspinatus outlet
25 Other Views of the Shoulder
26 Indications American College of Radiology (ACR) Appropriateness Criteria for Musculoskeletal Imaging in Shoulder Trauma Developed in 1995, revised in 2005 AP with IR & ER, and lateral (axillary or scapular Y) views recommended for: R/O fracture or dislocation Subacute (~3 months) shoulder pain suspicious for: Bursitis / tendonitis RTC tear or impingement (as initial study)
27 Indications Stevenson and Trojian: JFP in July 2002 No definitive studies on the needs of shoulder radiographs have been done Recommended obtaining plain films for: Decreased ROM (especially: abduction < 90 ) Severe pain History of trauma Glenohumeral AP, outlet & axillary lateral views Add AP with IR & ER in cases of trauma AC joint views for suspected AC joint disease Neck, chest, abdominal imaging for suspected referred pain Stevenson JH, Trojian T. Applied evidence: evaluation of shoulder pain. J Fam Pract 2002; 51(7):
28 Indications Other indications Suspicion of instability Weakness of shoulder motions The patient cannot communicate (altered mental status, alcohol intoxication, or other) Persistent pain and decreased ROM Anytime your history and physical don t t give you enough information
29 Normal routine AP in ER Normal routine AP in IR Normal axillary view
30 Routine AP and axillary views Neer classification 3-part proximal humerus fracture involving: - Surgical neck - Lsr tuberosity Tx: surgical eval
31 Proximal Humerus Fractures: 2-part fractures May be Tx d conservatively if: Neer Classification Displaced < 1 cm Angulation < 45 No dislocations Good reduction No intraarticular involvement Anatomic neck intact Otherwise: surgical evaluation All else: surgical evaluation
32
33 Routine AP in ER, axillary, & scapular Y views Anterior- inferior dislocation No fracture Tx: Conservative
34 Routine AP in ER, axillary,, & scapular Y views Bulb sign, rim sign, loss of parallelism Posterior dislocation; No fracture Tx: : Conservative
35 Post-reduction AP film Routine AP view Inferior GH dislocation (Luxatio erecta) -Rare Tx: may attempt CR
36 Routine AP in IR and axillary lateral views No dislocation + concave osseous impression in postero-lateral aspect of humeral head What is this lesion called? Hill-Sachs lesion Tx: conservative vs. operative
37 Hill-Sachs Lesions
38 Bankart Lesions
39 Type I: conservative tx Type II: conservative tx Type III: conservative tx for most; may consider surgery for active heavy laborers, frequent overhead activity, athletes y/o Type III AC separation Type Tx: conservative IV-VI: surgery mostly
40 Clavicle Fractures Mostly conservative treatment Consider surgery for: Group II Fx s (esp if medial to CCL) Open fractures Neurovascular compromise Severe associated injuries E.g. flail chest, mult rib fx s, scapulothoracic dissociation Nonunion / malunion
41 Scapular Fractures Mostly conservative treatment Surgical indications: Controversial Displaced intraarticular fx s involving > 25% articular surface Scapular neck Fx s with > 1 cm medial displaced Angulation > 40 Concomitant fx s s of clavicles, coracoid, acromion, scapular spine Fracture-dislocations
42 Routine AP and Axillary Lateral Views Advanced L shoulder osteoarthritis Tx: Symptomatic relief PT / Rehab exercises Injections Consider surgical eval
43 Scapular Y views A: normal B: Fracture / anterior dislocation C: Posterior dislocation
44 Routine AP, True AP, and Axillary lateral views Split fracture of humeral head with dislocated GH joint Tx: Surgerize!
45 34 y/o M with shoulder pn and it feel like it wants to go out of socket Glenohumeral AP & Scapular Y Lateral views of R shoulder Multiple radiodense loose bodies (largest infra coracoid & infra glenoid) Dx: Loose Bodies Tx: Surgical consult
46 Glenohumeral AP view of shoulder and humerus Radiolucent lesions spanning proximal third of L humerus Enchondromas Tx: Surgical consult (Biopsy)
47 Routine AP of R shoulder Group 2, type 2 R clavicle fracture Tx: Surgical repair
48 Glenohumeral AP, axillary lateral, and scapular Y views Normal findings Tx: as per clinical setting
49 Routine AP view Scapular body fracture Tx: mostly conservative
50 Routine AP view Proximal humeral shaft fracture Glenohumeral dislocation Tx: Orthopaedic consult
51 Axillary lateral view of L shoulder Os acrominale; no acute fracture Normal variant; associated with increased risk of RTC pathology Tx: conservative
52 Routine AP view of L shoulder Neer class 3-part comminuted, displaced proximal humerus fracture Tx: ORIF
53 Glenohumeral AP view of R shoulder Humeral head collapse with loss of joint space Tx: Ortho eval for hemi- vs. total arthroplasty
54 Routine AP view of R shoulder Displaced group 1 clavicle fracture; risk of nonunion Tx: ORIF (vs conservative) S/P ORIF
55 Routine AP view of L shoulder Complete obliteration of L humeral head with heterotopic ossification Dx: Charcot s joint Tx: Arthroplasty
56 Routine AP and targeted AC views of R shoulder Degenerative changes with subchondral bone cystic changes in the AC joint AC joint posttraumatic OA with osteolysis Tx: conservative vs. operative
57 Summary Know what views to order when: In general: Routine AP with shoulder in internal rotation (IR) True glenohumeral AP in external rotation (ER) Axillary lateral view Use alternative lateral views if pt unable to tolerate axillary lateral Modified axillary lateral, Velpeau view, scapular Y Know how to describe what you see
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