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X-Ray Rounds: (Plain) Radiographic Evaluation of the ShoulderGarry W. K. Ho, M.D.Sports Medicine Fellow - VCU / Fairfax Family PracticeDecember 2006
Anatomy3 BonesHumerusScapulaClavicle3 JointsGlenohumeralAcromioclavicularSternoclavicular1 ArticulationScapulothoracic
AnatomyHumerusHead *Anatomic neckSurgical neckGreater tubercle*Lesser tubercle*Intertubercular grooveDeltoid tuberosityShaft *
AnatomyScapulaBodyVentral (Costal) surfaceDorsal surfaceBordersSuperiorLateral (Axillary)Medial (Vertebral)AnglesSuperiorInferiorLateral (Head)
AnatomyScapulaGlenoidAcromionCoracoidSubscapular fossaScapular spineSupraspinatus fossaInfraspinatus fossaGreat scapular notchSuprascapular notch
AnatomyScapular Y (Lateral)
AnatomyClavicleFirst bone to start ossification; last to finishThe only bony strut b/w UE and axial skeletonFlat outer (lateral, acromial) thirdTraps, Delt, AC / CC ligamentsTubular medial (inner, sternal) thirdStrongest in axial loadMiddle thirdMost vulnerable to Fx
AnatomyGlenohumeral jointBall and socketPurpose: placement of primary prehensile limbVery mobile; majority (0-120) of shoulder movement (0-180)Price: instability45% of all dislocationsJoint stability depends on multiple factors
AnatomyGlenohumeral jointPassive stabilityJoint conformityVacuum effect of jt volSynovial fluid adhesion and cohesionScapular inclinationGlenoid labrum (50%)Coracoid ligamentsCCL, CALJoint capsuleGlenohumeral ligamentsSGHL, MGHL, IGHLCBony restraintsGlenoid fossa, Acromion, CoracoidCoracohumeral ligament
AnatomyGlenohumeral jointActive stability
Biceps (long head)
Rotator cuff
Pectoralis muscles, trapezius, serratus anterior, rhomboids, levator scapulae, etc. (NOT deltoid)
AnatomyAcromioclavicular jointDiarthrodial jointThin capsuleAC ligamentsAnterior, posterior, superior, inferiorCoracoacromial ligamentCoracoclavicular ligamentsTrapeziod ligamentConoid ligament
AnatomySternoclavicular jointDiarthrodial jointJoint capsuleArticular diskIntraarticular disk ligamentSternoclavicular ligamentsAnterior, posteriorInterclavicular ligament
AnatomyCoordinated shoulder motion
Glenohumeral motion
Acromioclavicular motion
Sternoclavicular motion
Scapulothoracic motionScapular-humeral rhythm
AP View of the ShoulderTransthoracic, or Routine AP ViewAP relative to thoraxSuboptimal view of Glenohumeral jointGood view of AC joint
Scapular, Grashey, or Glenohumeral AP ViewBetter visualize bony relationships incl GH jointSuboptimal view of AC joint
Both have been called True AP Views
AP View of the ShoulderRoutine AP ViewClavicleScapulaAcromion & scapular spineCoracoidBorders & anglesAC & SC jointsGlenoidBoth ant & post lipsMay obscure HHHumerusHead & necksGr & Lsr tuberosities
AP View of the ShoulderGlenohumeral, Grashey, or Scapular AP View
Same structures
AC joint not visualized as well
Better visualize the glenoid & humeral head (especially with ER view)
AP View of the Shoulder
AP View of the ShoulderAP View in External RotationGreater tuberosity & soft tissues profiled and better visualizedBest w/ Scapular AP
AP View in Internal RotationMay demonstrate Hill-Sachs lesionsGH instabilityBest w/ Routine AP
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)
Transthoracic Lateral View of the ShoulderNot usually done
Not as useful
Many obscuring over- and underlying structures
Axillary Lateral View of the ShoulderGood view of anterior-posterior relationship of GH joint
CoracoidAcromionHumerusGlenoidGH joint
Axillary Lateral View of the ShoulderAlternate Axillary views45Velpeau View magnified axillary view
Scapular Y Lateral View of the ShoulderRelationship b/w humeral head and glenoid
AcromionCoracoidScapular bodyScapular spine
Scapular Y Lateral View of the ShoulderScapular outlet viewA variation of scapular Y viewSame projection, but with beam tilted 5-10 caudadShoulder impingement: to evaluate the subacromial space and the supraspinatus outlet
Other Views of the Shoulder
IndicationsAmerican 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 dislocationSubacute (~3 months) shoulder pain suspicious for:Bursitis / tendonitisRTC tear or impingement (as initial study)
IndicationsStevenson and Trojian: JFP in July 2002No definitive studies on the needs of shoulder radiographs have been doneRecommended obtaining plain films for:Decreased ROM (especially: abduction < 90)Severe painHistory of traumaGlenohumeral AP, outlet & axillary lateral viewsAdd AP with IR & ER in cases of traumaAC joint views for suspected AC joint diseaseNeck, chest, abdominal imaging for suspected referred painStevenson JH, Trojian T. Applied evidence: evaluation of shoulder pain. J Fam Pract 2002; 51(7):605-611.
IndicationsOther indicationsSuspicion of instabilityWeakness of shoulder motionsThe patient cannot communicate (altered mental status, alcohol intoxication, or other)Persistent pain and decreased ROM Anytime your history and physical dont give you enough information
Normal routine AP in IRNormal routine AP in ERNormal axillary view
Routine AP and axillary views
Neer classification 3-part proximal humerus fracture involving:- Surgical neck- Lsr tuberosity
Tx: surgical eval
Proximal Humerus Fractures:Neer Classification2-part fracturesMay be Txd conservatively if:Displaced < 1 cmAngulation < 45 No dislocationsGood reductionNo intraarticular involvementAnatomic neck intactOtherwise: surgical evaluationAll else: surgical evaluation
Routine AP in ER, axillary, & scapular Y views
Anterior-inferior dislocationNo fracture
Tx: Conservative
Routine AP in ER, axillary, & scapular Y views
Bulb sign, rim sign, loss of parallelism
Posteriordislocation;No fracture
Tx: Conservative
Routine AP viewInferior GH dislocation(Luxatio erecta)- RareTx: may attempt CRPost-reduction AP film
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
Hill-Sachs Lesions
Bankart Lesions
Type III AC separationTx: conservative mostlyType I: conservative tx
Type II: conservative tx
Type III: conservative tx for most; may consider surgery for active heavy laborers, frequent overhead activity, athletes 20-25 y/o
Type IV-VI: surgery
Clavicle FracturesMostly conservative treatmentConsider surgery for:Group II Fxs (esp if medial to CCL)Open fracturesNeurovascular compromiseSevere associated injuriesE.g. flail chest, mult rib fxs, scapulothoracic dissociationNonunion / malunion
Scapular Fractures
Mostly conservative treatment
Surgical indications:ControversialDisplaced intraarticular fxs involving > 25% articular surfaceScapular neck Fxs with> 1 cm medial displacedAngulation > 40 Concomitant fxs of clavicles, coracoid, acromion, scapular spineFracture-dislocations
Routine AP and Axillary Lateral Views
Advanced L shoulder osteoarthritis
Tx:Symptomatic reliefPT / Rehab exercisesInjectionsConsider surgical eval
Scapular Y viewsA: normalB: Fracture / anterior dislocationC: Posterior dislocation
Routine AP, True AP, and Axillary lateral views
Split fracture of humeral head with dislocated GH joint
Tx: Surgerize!
34 y/o M with shoulder pn and it feel like it wants to go out of socketGlenohumeral AP & Scapular Y Lateral views of R shoulder
Multiple radiodense loose bodies (largest infra coracoid & infra glenoid)
Dx: Loose Bodies
Tx: Surgical consult
Glenohumeral AP view of shoulder and humerus
Radiolucent lesions spanning proximal third of L humerus
Enchondromas
Tx: Surgical consult (Biopsy)
Routine AP of R shoulder
Group 2, type 2 R clavicle fracture
Tx: Surgical repair
Glenohumeral AP, axillary lateral, and scapular Y views
Normal findings
Tx: as per clinical setting
Routine AP view
Scapular body fracture
Tx: mostly conservative
Routine AP view
Proximal humeral shaft fractureGlenohumeral dislocation
Tx: Orthopaedic consult
Axillary lateral view of L shoulder
Os acrominale; no acute fractureNormal variant; associated with increased risk of RTC pathology
Tx: conservative
Routine AP view of L shoulder
Neer class 3-part comminuted, displaced proximal humerus fracture
Tx: ORIF
Glenohumeral AP view of R shoulder
Humeral head collapse with loss of joint space
Tx: Ortho eval for hemi- vs. total arthroplasty
Routine AP view of R shoulder
Displaced group 1 clavicle fracture; risk of nonunion
Tx: ORIF (vs conservative)S/P ORIF
Routine AP view of L shoulder
Complete obliteration of L humeral head with heterotopic ossification
Dx: Charcots joint
Tx: Arthroplasty
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
SummaryKnow 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 lateralModified axillary lateral, Velpeau view, scapular Y
Know how to describe what you see
Thanks!Questions?
Ossification starts 5th wk GA laterally (acromial end); finishes at age 22-25 y/o medially (sternal end)Intramembranous ossification WITHOUT a cartilaginous stageAnterior acromial morphology1 (flat), 2 (curved), and 3 (hooked)
Acromial angleStryker notch view (looks like a modified axillary view) can be used to see Hill-Sachs Lesions
West Point View (also looks like a modified axillary view) can be used to see bony Bankart lesionsZanca Views (AP with 10 degrees of cephalic tilt) is ideal for eval of AC jt