Radiography of the Shoulder

1. Radiography of the Shoulder Jennifer Nicol PGY-1 August 6, 2009

2. Objectives • BRIEF Anatomy Review • Standard shoulder views • Radiographs of shoulder injuries • NOT: • Treatment • Other imaging modalities • Pediatric imaging

4. Anatomy

5. Shoulder Views • Over 15 views of shoulder described • Trauma series: • 3 views: • AP • Trans-scapular “Y-view” • Axillary • Modified axillary

6. AP view • True AP - 45˚tilt • Glenohumeral joint with no bony overlap • Preferred in trauma • AP int/ext rotation • Highlight tuberosities • Soft tissue injuries • Clavicle and AC joint

8. Transcapular view • Projects along long axis scapula • Simple, reproducible • Good for visualising anterior, posterior dislocations

9. Acromion Coracoid Body

10. Axillary View • Glenohumeral joint in cephalocaudal plane • Lesions of glenoid rim, humeral head, caracoid • Axial view of shoulder

12. Modified Axillary View • Reverse axillary when pt can’t abduct

13. Retrospective • 1690 shoulder exams • Mod axillary view used 104 times • Identified additional pathology in 30 cases • No comparison b/t standard and modified axillary

14. Approach to Shoulder XR • AP: • 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)

15. Approach to Shoulder XR • Other views: • Humeral head to glenoid • Prox humerus • Glenoid rim • Scapula • Carocoid • Acromion

16. Type I AC injury • Glenoid • Alignment • Distance • bones • AC • Alignment • Carocoid-clavicle space • Other • Lungs, scapula, ribs, clavicle

17. Type III AC injury

18. Posterior Dislocation

19. Positive Rim Sign

20. Trough Sign

21. No Mercedes!!!!

22. Avulsion Lesser Tuberosity

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

26. Posterior Dislocations • Have high suspicion with correct mechanism • Don’t miss – clinical exam important • Look for associated fractures • Types: • Subacromial (98%) • Subglenoid • subspinosus

27. Anterior Dislocation

29. Scapular View: Anterior Dislocation

30. Hill-Sachs deformity

31. Bankhart Injury AP Axillary

32. Greater Tuberosity Fracture

33. Anterior Dislocations • 4 Types • Subcoracoid • Subglenoid • Subclavicular • Intrathoracic

34. Anterior Dislocations • Check Neurovascular exam pre-post reduction • Don’t delay reduction – NV injury increases with time • Recurrence high – 80% <30

35. Inferior Dislocation

36. Subglenoid anterior dislocation

37. Pseudodislocation