X-Ray Rounds:

(Plain) Radiographic Evaluation

of the Shoulder
Garry W. K. Ho, M.D.
Sports Medicine Fellow - VCU / Fairfax Family Practice
December 2006
Anatomy
3 Bones
Humerus
Scapula
Clavicle
3 Joints
Glenohumeral
Acromioclavicular
Sternoclavicular
1 Articulation
Scapulothoracic
Anatomy
Humerus
Head *
Anatomic neck
Surgical neck
Greater tubercle*
Lesser tubercle*
Intertubercular
groove
Deltoid tuberosity
Shaft *
Anatomy
Scapula
Body
Ventral (Costal)
surface
Dorsal surface
Borders
Superior
Lateral (Axillary)
Medial (Vertebral)
Angles
Superior
Inferior
Lateral (Head)
Anatomy
Scapula
Glenoid
Acromion
Coracoid
Subscapular fossa
Scapular spine
Supraspinatus
fossa
Infraspinatus
fossa
Great scapular
notch
Suprascapular
notch
Anatomy
Scapular Y (Lateral)
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
Anatomy
Glenohumeral joint
Ball and socket
Purpose: placement of
primary prehensile
limb
Very mobile; majority
(0-120) of shoulder
movement (0-180)
Price: instability
45% of all dislocations
Joint stability depends
on multiple factors
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
Anatomy
Glenohumeral joint
Active stability

Biceps (long head)

Rotator cuff

Pectoralis muscles,
trapezius, serratus
anterior, rhomboids,
levator scapulae,
etc. (NOT deltoid)
Anatomy
Acromioclavicular
joint
Diarthrodial joint
Thin capsule
AC ligaments
Anterior, posterior,
superior, inferior
Coracoacromial
ligament
Coracoclavicular
ligaments
Trapeziod ligament
Conoid ligament
Anatomy
Sternoclavicular
joint
Diarthrodial joint
Joint capsule
Articular disk
Intraarticular disk
ligament
Sternoclavicular
ligaments
Anterior, posterior
Interclavicular
ligament
Anatomy
Coordinated
shoulder motion

Glenohumeral
motion

Acromioclavicular
motion

Sternoclavicular
motion

Scapulothoracic
motion
Scapular-humeral rhythm
AP View of the Shoulder
Transthoracic, or Routine
AP View
AP relative to thorax
Suboptimal view of
Glenohumeral joint
Good view of AC joint

Scapular, Grashey, or
Glenohumeral AP View
Better visualize bony
relationships incl GH joint
Suboptimal view of AC joint

Both have been called True
AP Views
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
AP View of the Shoulder
Glenohumeral,
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 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
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
Shoulder
Not usually done

Not as useful

Many obscuring
over- and
underlying
structures

Axillary Lateral View of the Shoulder
Good view of
anterior-
posterior
relationship of
GH joint

Coracoid
Acromion
Humerus
Glenoid
GH joint
Axillary Lateral View of the Shoulder
Alternate Axillary views
45
Velpeau View magnified axillary view
Scapular Y Lateral View of the
Shoulder
Relationship b/w
humeral head and
glenoid

Acromion
Coracoid
Scapular body
Scapular spine
Scapular Y Lateral View of the
Shoulder
Scapular outlet view
A variation of
scapular Y view
Same projection, but
with beam tilted 5-
10 caudad
Shoulder
impingement: to
evaluate the
subacromial space
and the
supraspinatus outlet
Other Views of the Shoulder
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)
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):605-611.
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 dont give
you enough information
Normal routine AP in IR Normal routine AP in ER
Normal 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 Classification
2-part fractures
May be Txd
conservatively if:
Displaced < 1 cm
Angulation < 45
No dislocations
Good reduction
No intraarticular
involvement
Anatomic neck intact
Otherwise: surgical
evaluation
All else: surgical
evaluation
Routine AP in
ER, axillary,
& scapular Y
views

Anterior-
inferior
dislocation
No fracture

Tx:
Conservative
Routine AP in ER,
axillary, &
scapular Y views

Bulb sign, rim
sign, loss of
parallelism

Posterior
dislocation;
No fracture

Tx: Conservative
Routine AP view
Inferior GH
dislocation
(Luxatio erecta)
- Rare
Tx: may attempt
CR
Post-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 separation
Tx: conservative
mostly
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 20-25
y/o

Type IV-VI: surgery
Clavicle Fractures
Mostly conservative
treatment
Consider surgery for:
Group II Fxs (esp if
medial to CCL)
Open fractures
Neurovascular
compromise
Severe associated
injuries
E.g. flail chest, mult rib
fxs, scapulothoracic
dissociation
Nonunion / malunion
Scapular Fractures

Mostly conservative treatment

Surgical indications:
Controversial
Displaced intraarticular fxs
involving > 25% articular surface
Scapular neck Fxs with
> 1 cm medial displaced
Angulation > 40
Concomitant fxs of clavicles,
coracoid, acromion, scapular spine
Fracture-dislocations
Routine AP and Axillary Lateral
Views

Advanced L shoulder osteoarthritis

Tx:
Symptomatic relief
PT / Rehab exercises
Injections
Consider surgical eval
Scapular Y views
A: normal
B: Fracture / anterior dislocation
C: 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 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
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 fracture
Glenohumeral
dislocation

Tx: Orthopaedic
consult
Axillary lateral view
of L shoulder

Os acrominale; no
acute fracture
Normal 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
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
Thanks!
Questions?