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Basic and Special projections for Humerus Basic: AP rotational lateral (mediolateral or lateromedial) Horizontal beam lateral
Special: transthoracic lateral projection
Trauma and Non trauma humerus routines Non trauma: AP, rotational lateral Trauma: AP neutral, horizontal beam lateral and transthoracic lateral
AP Humerus SID kV IR CR
75-85 kV larger pt- 14 x 17 smaller pt- 11 x 14 horizontal and perpendicular to midpoint of humerus- include elbow and shoulder joints
AP Humerus patient position part position
-can be doneerect or supine -adjust IR so both joint are equidistant from ends of IR -rotate body if needed so affected side is against bucky, hand and arm extended as much as pt can, epicondyles are parallel to IR, hand supinated and arm is abducted slightly -do not rotate the arm if a fracture or dislocation is suspected, take w/ neutral hand-
Humerus true AP evidenced by
-greater tubercle in profile laterally -humeral head partially seen in profile medially -minimal superimposition of humeral head on glenoid cavity -lateral and medial epicondyles seen in profile
Rotational Lateral Humerus SID kV IR CR
75-85 kV 14 x 17 or 11 x 14 CR is horizontal and perpendicular to the midpoint of humerus
Rotational Lateral of Humerus lateromedial projection
Patients back is to IR elbow partially flexed body rotated toward affected side as needed arm is internally rotated so epicondyles are perpendicular to IR
Rotational Lateral of Humerus mediolateral projection
Patient faces IR and is oblique 20-30° from PA to bring shoulder and humerus in contact with IR Elbow flexed 90° Epicondyles are perpendicular
Humerus True Lateral evidenced by
epicondyles superimposed lesser tubercle in medial profile and partially superimposed by lower portion of glenoid cavity
Horizontal Beam Lateral Humerus SID kV grid or non grid? IR CR Why performed
Non grid 10x12 small pt, 11 x 14 larger pt crosswise CR horizontal and perpendicular to midpoint of distal 2/3rd of humerus to visualized the mid and distal humerus on a trauma pt.
Horizontal Beam Lateral Humerus pt and part position
Patient is supine, placing support under arm to build up anatomy Flex elbow to 90° without rotation, humerus is on table, forearm is up Palm is facing pt IR is gently place between the arm and thorax, top of IR at axilla
What projections are done on a non-trauma pt for humerus?
AP, rotational lateral
external rotation shoulder anatomy demonstrated
AP projection of proximal humerus, lateral 2/3rds of clavicle and upper scapula greater tubercle in profile laterally lesser tubercle superimposed over humeral head
AP internal rotation shoulder SID kV grid or non grid? CR why done other names
75-85 kv grid 14x 17 CR perpendicular to IR and 1" inferior to coracoid process, which is 3/4" inferior to lateral clavicle Shows fractures dislocations of proximal humerus and shoulder girdle, calcium deposits in muscle tendons or soft tissue, osteoporosis and osteoarthritis Lateral shoulder
AP internal rotation shoulder pt and part position
pt supine or erect- erect is more comfortable rotate body slightly toward affected side to put shoulder on IR scapulohumeral joint centered on IR arm abducted and slightly extended pronate hand and internally rotate so back of hand is on pants until epicondyles are perpendicular to IR
internal rotation of shoulder evidenced by lesser tubercle visualized in full profile medially outline of greater tubercle superimposed over humeral head greater amount of superimposition of humeral head and glenoid cavity than the external rotation or neutral
external rotation of shoulder evidenced by greater tubercle in lateral profile lesser tubercle superimposed over humeral head slight superimposition of humeral head over glenoid cavity
neutral rotation of shoulder evidenced by neither tubercles are in profile epicondyles are at a 45° angle
Lawrence method (shoulder non trauma) SID kV grid or non grid IR size CR why done other names
grid 8x10 crosswise CR directed horizontally and medially 25-30° toward the axilla and humeral head
- if pt can't place arm 90° decrease angle to 15-20° to visualize a hill sachs defect Inferosuperior axial projection (non trauma)
what is a hill sachs defect? a compression fracture of the articular surface of the posterolateral aspect of the humeral head from hitting the anterior glenoid -often associated with an anterior dislocation of the humeral head -from chronic dislocations
Lawrence Method (shoulder non trauma) pt and part position
Supine on front edge of table top affected shoulder raised about 2 inches rotate head toward unaffected side arm abducted 90° with palm up place IR vertically behind shoulder crosswise with medial aspect as close to neck as possible
Lawrence Method (shoulder non trauma) alternate position
Rafert Modification exaggerated external rotation thumb downward form supinated hand best views hill sachs defect
Lawrence Method (shoulder non trauma) anatomy demonstrated
lateral view of proximal humerus with relationship of scapulohumeral joint coracoid process in profile medially and lesser tubercle in profile laterally scapular spine seen below humeral head AC joint, acromion, acromial end of clavicle projected through humeral head
Lawrence Method (shoulder non trauma) correct CR placement evidenced by
superior and inferior borders of glenoid cavity are superimposed indicating correct CR angle
Hobbs Method (shoulder non trauma) SID kV grid or non grid IR size CR why done other names
PA
grid 8x10 lengthwise CR perpendicular through axilla and humeral head to pass through scapulohumeral joint to indicate bursitis, shoulder impingement, osteoporosis, osteoarthritis and tendonitis alternative method to demonstrate axillary view of proximal humerus Superoinferior PA trans-axillary
Hobbs Method (shoulder non trauma) part and pt position
pt erect or leaning flat over table, oblique 5-10° anteriorly affected arm exerted superior as much as pt can tolerate, head turned away
Hobbs Method (shoulder non trauma) anatomy demonstrated
lateral view of proximal humerus in relationship to glenohumeral joint coracoid process is seen on end bony margins of acromion and coracoid process visible through the humeral head
Fisk Method (shoulder non trauma) SID kV grid or non grid IR size CR why done other names
non grid 8x10 cross wise CR supine: AP 10-15° posterior from horizontal to groove at mid anterior margin of humeral head CR erect: PA perpendicular to IR directed toward groove at mid anterior margin of humeral head pathologies of intertubercular grove and bony projections of humeral tubercles Tangential Projection- intertubercular groove
Fisk (shoulder non trauma) part and pt position
supine: arms at side hand supinated cassette vertical against top of shoulder and neck, head turned away from affected side 10-15° posterior from horizontal CR
erect: perp CR patient standing and leaning over table with elbow flexed leaning in 10-15° lead on forearm, cassette on top of that head turned away from affected side
Fisk (shoulder non trauma) anatomy
anterior margin of humeral head in profile humeral tubercles and intertubicular groove in profile
What are the basic and special projections for shoulder trauma
basic: AP Neutral Rotation and Transthoracic lateral Lawerence or scapular Y special: Tangential projection- supraspinatous outlet Neer method and Apical oblique Garth Method
AP Shoulder trauma SID kV grid or non grid IR size CR why done other names
10 x 12 crosswise 75-85 kvp CR at midscapulohumeral joint visualize the proximal humerus to see features, dislocations, calcium deposits, burial structures, osteoporosis and osteoarthritis AP projection Neutral rotation
GPS nav for midscapulohumeral joint in relation to coracoid
3/4 inches (2 cm) inferior and slightly lateral from coracoid process, where the coracoid is 2 cm inferior to the lateral portion of the clavicle
GPS nav for the coracoid process 3 cm inferior to lateral portion of the clavicle
Other way to find the midscapulohumeral joint with palpation
the base or pit of the concave like depression just medial to the humeral head
GPS midscapulohumeral joint in relation to top of shoulder
2-2.5 inches (5 or 6 cm) below top of shoulder
AP shoulder trauma pt and part position
erect or supine, body angled slightly to place shoulder in contact with IR arm 'as is' in neutral rotation, epicondyles are 45 degree angle
AP shoulder trauma anatomy demonstrated
proximal third of humerus and upper scapula, lateral 2/3rds of clavicle -relationship between humeral head and glenoid cavity -soft tissue visible -medial aspect of humeral head visible through glenoid cavity
Transthoracic lateral (shoulder trauma) SID kV grid or non grid IR size CR why done other names
40" sid 75-85 kvp 10x12 lengthwise 3 second exposure orthostatic 4-5 seconds recommended for breathing CR perpendicular projected through surgical neck, angle CR 10-15 degree cephalad if can't get unaffected arm 90degrees to show fractures or dislocations of proximal humerus in a trauma pt Lawrence Method shoulder trauma
Transthoracic lateral trauma shoulder pt and part position
pt is erect (more comfortable) in lateral position with affected arm against board affected arm in neutral rotation and shoulder dropped unaffected arm is up and over head anteriorly rotated
Transthoracic lateral trauma shoulder anatomy demonstrated
-lateral view of proximal humerus and glenohumeral joint visualized through thorax -no superimposition of opposite shoulder -outline of proximal humerus visualized anterior to thoracic vertebrae -outline of humeral head with relation to glenoid cavity
What is the difference between the three orthostatic breathing techniques in shoulder girdle
humerus trauma: lateral view, CR directed to midiaphysis, 80-90 kvp, 14x 17 lengthwise, 2 sec minimum for breathing
shoulder trauma: lateral view, CR directed at surgical neck, 75-85 kvp, 10x lengthwise, 3 sec minimum for breathing
scapula: AP view, CR directed at mid scapula (2" medial from lateral level of axilla) affected arm is raised, 75-85 kvp, 10x12 lengthwise, 3 sec minimum for breathing
Scapular Y lateral Shoulder trauma SID kV grid or non grid IR size CR why done other names
PA projection 40" SID 75-85 kvp grid 10x12 lengthwise CR at scapulohumeral joint shows dislocation of proximal humerus and scapula, demonstrates profile of coracoid process and scapular spine
Scapular Y lateral shoulder trauma pt and part position
pt rotated in an anterior oblique position to make a lateral scapula palpate superior angle of scapula and AC joint, rotate pt 45-60 degrees to make that line perpendicular with IR
Scapular Y position for a PA projection of the R shoulder RAO
Scapular Y position for a PA projection of the L shoulder LAO
Neer Method special shoulder trauma anatomy demonstrated
-proximal humerus will be superimposed over body of scapula without rib superimposition -acromion and coracoid processes appear nearly symmetric -humeral head superimposed and centered to glenoid fossa just below the supraspinatus outlet region, which appears open, free of superimposition from humeral head
Apical oblique Garth Method special shoulder trauma SID kV grid or non grid IR size CR why done other names
10x12 lengthwise grid 75-85 kvp CR 45 degrees caudad at scapulohumeral joint demonstrates posterior dislocations as well as hill sachs lesions and calcifications in soft tissue
Apical oblique Garth Method special shoulder trauma pt and part position
AP
pt is erect, 45 degrees rotated toward affected side IR adjusted so with 45 degree CR projects in the center of the scapulohumeral joint arm in neutral rotation, as is.
Apical oblique Garth Method special shoulder trauma anatomy demonstrated
humeral head, glenoid cavity and neck and head of scapula are free of superimposition -coracoid process is projected over humeral head, which is elongated -acromion and AC joint are we'll projected superior to humeral head
if pt can't raise unaffected arm over head or drop the affected shoulder in a transthoracic lateral of the humerus, what do you do?
angle the tube 10-15 degrees cephalad at mid humerus
What rotation of the humerus gives the most superimposition over the glenoid cavity?
internal rotation
Describe the CR for the Lawrence method shoulder non trauma what happens if pt can't abduct affected arm to 90
its horizontal and 25-30 degrees toward axilla and humeral head -if pt can't raise their affected arm 90 degrees decrease angle to 15-20 degrees
what projection lets you see the coracoid process on end?
Hobbs
if pt can't raise arm up to 90 degrees in a clements projection, what do you do? what does this projection show?
angle tube 5-15 degrees down into axilla hill sachs defect but not as well visualized as a rafert modification of the lawernce method
How much pt rotation is used for grashey? 35-40 degrees
