Shoulder and Trauma Elbow

1. Label the Anatomy of shoulder and clavicle.

2. What are the 4 primary muscles of the rotator cuff?

o Responsible for stabilizing the shoulder during various
movements
o Consists of 4 primary muscles
Supraspinatus- assists the deltoid muscle in
abduction
Infraspinatus- lateral rotation
Teres minor- lateral rotation
Subscapularis- medial rotation
3. What do the various shoulder protocols depend on?
o Various shoulder protocols
Protocol dependent on pt history
Pain/pathology
Hx of trauma
Thoracic outlet syndrome
4. What is usually the pathology/pain protocol?
Pathology/ pain protocol
Usually 2 AP positions
AP with internal
AP with external
CR perp 1 inferior to coracoid
5. Why would you perform an AP internal shoulder? What does it
show?
AP Internal
o Used to r/o bursitis, tendonitis, Hill-Sachs defect

Hill-sachs- trauma to shoulder, caused by anterior

dislocation to humeral head
o Moves the lesser tubercle inferomedial and into profile
Neutral position of the arm will not move the lesser
tubercle
6. What is a Hill sachs? What position shows this?
Hill-sachs- trauma to shoulder, caused by anterior
dislocation to humeral head
Internal rotation
7. Why would you perform an AP external shoulder? What does it
show?
o AP External
Moves greater tubercle superiolateral and into profile
o Palm up
8. What is a Bankart lesions? What position shows this?
External rotation
Anterior dislocation of the rim of the glenoid
9. What does a 15-degree caudal angle show?
Sometimes do a 15 degree caudal angle to look for
osteophyte in subacromial space
10.
What is the usual trauma protocol?
Trauma Protocols
o Usually include AP (anatomical or neutral)
o Then any of the following:
Glenoid (AP Oblique)
Apical Oblqiue
PA Scapular Y
Inferosuperio axial
Transthoracic
11.
What is the AP Oblique? What is it also called? How is the
pt positioned?
Glenoid (AP Oblique)
o Patient is either AP with arm either anatomical or neutral
position
o MSP is rotated 45 degrees towards the affected side
o CR is perp glenoid
12.
What does the AP Oblique show?
o Shows glenoid in profile and glenohumeral space
Greater tubercle in profile
o When clavicle looks like a snake that means their obliqued
to that side
When ribs elongated and more vertical than
horizontal then turned
Not seeing face of glenoid

13.

What is the AP Apical oblique also called?

o Apical oblique
Referred to as 45-45
45 degrees towards affected side
Position is same as AP Oblique but CR is directed
@45 degrees caudal
14.
What does the AP Apical oblique show?
o Opens subacromial space, elongates the humeral head and
neck
o See glenoid in profile, glenohumeral space, and greater
tubercle
o Clavicle looks like dinosaur/ very vertical
Humeral head looks bitten off= Hill Sachs defect
15.
What is a PA scapular Y? What does it show? How is the
pt positioned?
o PA Scapular Y
Provides a lateral of the shoulder to r/o
anterior/posterior dislocations
Pt is PA with affected side towards the IR
Oblique shoulder 30-45
degrees towards IR
o CR is perp to mid scapula
Palpate superior angle of the
scapula
Palpate distal tip of acromin
Line them up so they are
perpendicular to IR
16.
Where is the coracoid always
pointing in PA? Where is the acromin?
o Coracoid should always be pointing
medially
o Acromin lateral
17.
What is seen FSI in the PA Y?
o Lesser tubercle should be seen free of superimposition and
pointing medially
18.
Where are most shoulder dislocations?
Scapular anterior dislocation
o 97% of all shoulder dislocations are anteriorly displaced
o 2% are posteriorly displaced
o 1% are interiorly displaced
humeral head down low/ underneath glenoid
19.
How do you position for an AP Y? What does the AP Y
increase?
AP Scapular Y

o PA scapular Y can be performed in the supine position

o The affected shoulder would be rotated 60 degrees away
from the IR
o 60 LPO would demonstrate the right shoulder
o 60 RPO would demonstrate the left shoulder
o AP Y would visualize all the same anatomy as the PA
scapular Y but with increased magnification= less detail
20.
Why do you do an Inferosuperio axial? What does it show?
How do you do it?
Inferosuperio axial (Lawrence Method)
o Orthopedics choice of lateral
o Relationship between humeral head
and glenoid
o Can be done supine or seated
o If supine, arm is abducted 90
degrees and externally rotated
o CR directed 15-20 degrees medially
Tube is directed horizontally
o Build shoulder up
o Supinate hand
o Should be using a grid
o Lesser tubercle is on top
21.
What happens when you supinate the hand?
o When you supinate the hand you see lesser tubercle
Internal, Y, and inferosuperio axial
22.
How do you do a seated axillary?
o Seated Axillary
Pt seated at the end of the table
CR is directed distally at a 5-10 angle
Goes superiorly to inferiorly
Magnification with this projection
Arm is pronanted
23.
How do you do a transthoracic? What
does it show?
Transthoracic
o Anterior/posterior displacement of the
shoulder
o Last resort because of heavy
superimposition of thoracic structures
o Breathing technique (decrease mA and
increase exposure time) to blur lungs
and vascular markings
o 3 seconds is a good amount of time in
order to blur

24.
What is the thoracic outlet syndrome? What is it also
called? What angle does it require? What does it attempt to
visualize?
Thoracic Outlet syndrome
o Supraspinatus outlet syndrome or impingement syndrome
o Requires positions/projections with caudal angles to better
visualize subacromial space
o Attempting to visualize osteophytes extending from the
inferior acromial surface
o Can also be performed to demonstrate subacromial bursitis
25.
What are the usual projections for TOS?
Usual projections for TOS
o Apical AP
o Apical oblique (Garth)
o Neer scap Y
o Routine AP internal/external with 10 degree caudal angle
Apical AP
o PT is positioned similar to AP shoulder with
arm in neutral
o 30 degree angle to open up subacromial
space
Apical oblique
o 45/45
o Position same as AP/Garth
Neer Scapular Y
o Pt is positioned similar to routine PA Scap
o 10-15 degree caudal angle
o Open subacromial space
26.

What are most elbow traumas associated with?

Most elbow trauma is associated with the patients inability to
extend or rotate the extremity
o Never force into position
27.
When do you do a partial flexion elbow?
Partial flexion AP
o Use when pt cannot extend elbow
o A series of 2 positions
28.
What is the first position for a partial flexion AP? What does
it show?
1st
o Place humerus in same plane as receptor with epicondyles
parallel
o Bring humerus closer to IR
o Demonstrate distal humerus

o Extend eblow as much as possible then support

o CR perp distal humerus
o +10 kVp from usual AP elbow make sure you penetrate
through SI of tissue and anatomy
o Supracondila FX- make sure you dont miss any
o Lots of SI of tissue
29.
What do you do for the 2nd image?
2nd
o Place proximal radius and ulna in contact with receptor
with hand supinated
Keep epicondyles //
CR perp proximal radius/ulna
o With patient standing
30.
How to you do a Coyles to show coronoid and radial head?
Axiolaterals (Coyle)
o Trauma positions used as substitutes for visualization of
coronoid and radial head when pt cannot extend and rotate
elbow
o Can be easier than routine obliques- elbow remains in a
relaxed lateral position
31.
How do you do a Coyles to show the radial head?
Axiolateral for Radial head
o Elbow is placed in standard lateral position
o If possible rotate hand/wrist laterally
o CR @ 45 degrees toward shoulder/proximally
o Parallel to long axis of humerus
o CR enters approx 1 inch inferior to elbow
joint
o +10 kVp from usual lateral
32.
What is a Axiolateral for Radial head
position good for showing?
o Excellent alternate for occult intraarticular FX
Bring elbow more
towards upper part of
cassette
o Supinator fat pads
Communited vs simple fx
o Radius out from ulna shows proximal radius
Radial head elongated
o Humeral anatomy superimposed
33.
How do you do Axiolateral for coronoid?
o Elbow positioned same as standard lateral
o Substitute for medial oblique
o CR directed 45 from above shoulder, towards elbow

o +10 kVp from usual lateral

o Excellent for avulsion fx off coronoid process
34.
What are the Full rotation laterals round the clock? When
do you do this?
o A series of 4 exposures with the hand and wrist in various
stages of rotation
o Provides a profile of the entire radial head
o Elbow is positioned in standard lateral, then wrist is rotated
Maximum supination
Neutral lateral
Pronation
Maximum hyperpronation
o Turns radial head in a circle
o By request only not routine
35.
What does a Tangential (acute flexion) show? What is it
also called? How do you do it?
o Used to assess olecranon process- 2nd most frequently fx
region in adult elbow
o Aka Jones Method position
o Humerus is placed in contact with receptor
o Epicondyles //
o Instruct pt to flex arm as much as possible
o CR perp and 2 inches distal to olecranon
36.
What is a little league elbow? What is it also called? How
does it happen?
Little league elbow
o Medial epicondylar apophysitis- more for adult
o Panners disease
o Chronic avulsions of medial epicondyles
o Twisting motion and chronic stresses
37.
When is the olecranon FSI?
Olecranon free of superimposition= acute flexion and lateral
38.
What does this image show? What position?

39.

PA Scap Y
What does this image show? What position?

Inferosuperior Axial
40.
What is the difference between these 2 pictures? What is
the position for each? How do you know?

Left- AP external lesser tubercle is superimposed over humeral head

Right- AP Oblique see humeral head in relationship to glenoid cavity

41.
How do you position for an AP Scapula? What are the
breathing instructions?
PT positioned similar to AP shoulder
Affected arm is abducted 90 degrees with hand in
supination
CR directed perpendicular and 2 inches medial to axilla
Use breathing technique (3 seconds) or full exhalation to
improve visibility
42.
What does an AP Scapula look like on an image? What do
the lungs look like?
Humerus is horizontal
See much more of the scapula
See blurring of the lungs
43.
How do you do a Lateral Scapula? What is this position
similar to?
RAO/LAO affected side closest to receptor
Position is similar to Y
Instruct pt to place forearm and hand over posterior wrist
Palpate vertebral and axiallary borders to ensure
superimposition
44.
What does a lateral scapula look like on an image? What fx
can you see?
See border of scapula
Can see stellate FX
i. Occurs from blow to scapula
ii. Radiating fx lines in a star pattern
45.
How does a fx to the Clavicle usually happen? Who is this
most common in?
FX to the clavicle usually occur due to falls on the
outstretched hand, or direct blow
Recognized as the most common injury associated with
childbirth, and children in general
Images more easily obtained in the upright, PA position
whenever possible
46.
How do you position for a PA Clavicle? What are the
breathing instructions?
Position affected side closest to receptor
Adjust shoulders to lie in the same transverse plane
CR perp to exit mid-shaft of clavicle
Must include S-C joints
Suspended exhalation
47.
What is the downfall of doing an AP clavicle?

Increase OID will result in increase magnification and

decrease in detail
48.
Why do you do a PA axial? What does this position do?
What does the clavicle look like? What are the breathing
instructions?
Projects clavicle superior to ribs/scapula
i. Push clavicle up as much as you can
Clavicle imaged horizontal placement
Position pt similar to PA
CR directed caudal, 25-30 degrees to exit the midshaft of
the clavicle
i. Thinner pt require greater of an angle
All axial methods should employ full inhalation to further
push clavicle above ribs/scapula
You want full inhalation
PA= caudally
49.
How do you do an AP Axial? What are the 2 ways you can
do it?
Same image can be obtained in the AP erect or recumbent
position
2 methods can be used
o CR directed 25-30 degrees cephalic
o Patient is positioned the same as a lordotic chest
o Thinner pt usually require the use of a 15 degree
cephalic angle to try to straighten out the clavicle a
little more
50.
What should be done before Acromioclavicular
articulations? What does this position demonstrate?
Performed frequently in orthopedic offices
Done to demonstrate separation, dislocation of the AC joint
Evidenced by widening of the joint of one side vs the other
Radiographs of the shoulder should be performed/
reviewed prior to these projections to r/o FX in the shoulder
girdle
51.
How are AC joints always performed? What is the minimum
weight? What is the SID?
Always performed bilateral for comparison
Images performed in AP Erect position
i. No weight
ii. With weights
Minimum 10 pound weights provided- attached to wrists
(do not allow pt to hold in hands)
72 SID with CR perp to MSP and 1 inch superior to jugular
notch

Use routine AP shoulder technique @ 72

Hypersthenic pt may require individual exposures