14.1 Shoulder Radiography
• Routine Non-Trauma: A-P with internal
and external rotation of humerus
• Trauma or Dislocation Shoulder: A-P
internal rotation, Lateral scapula or “Y”
view, Apical Oblique,possible or Stryker
Notch and P-A Axillary
• Shoulder Instability: Weighted internal and
external rotation, Stryker Notch
1
Shoulder Radiography
• To evaluate the glenohumeral joint, the
scapula must be parallel to the film.
• Shoulder views can be taken with
suspended respiration
• The Clavicle and A C joints will have the
patient in a true A-P position with mid
sagittal plane perpendicular to film.
2
A-P and A-P with Scapula parallel to film. AP is used for
clavicle and AC joint. Scapula should be parallel to film for
shoulder joint.
3
Shoulder Radiography
• A-C Joint view are taken with full
inspiration to help open the joint space.
• A-C Joint views are taken weighted and
non-weighted when looking for a
separation. The weights must be 10 to 15
pounds and strapped around the wrists to
avoid the use of the arm muscles.
4
Shoulder Radiography
• A-C Joints views can also be taken to
detect metabolic or drug induced bone
loss. The view need not be taken with and
without weights.
• The Clavicle can be taken A-P or P-A. The
P-A view will have less magnification
distortion but is more difficult to position.
5
14.2 Shoulder A-P with Internal
Rotation
• Measure: A-P at
coracoid process
• Protection: Half Apron
• SID: 40” Bucky
• No Tube Angle
• Film: 10” x 8” I.D. toward
spine
• Marker: anatomical plus
“INT” or arrow pointing
inward
6
Shoulder A-P with Internal Rotation
• Patient stands facing
tube.
• The patient is rotated 15
to 45 degrees until the
scapula is parallel to the
film.
• The patient internally
rotates humerus until the
epicondyles are
perpendicular to the film.
7
Shoulder A-P with Internal Rotation
• Horizontal CR: 1” below
the coracoid process
Vertical CR: coracoid
process or through the
glenohumeral joint
• Film centered to
Horizontal CR
• Collimation: to include
soft tissue around
shoulder or slightly less
than film size.
8
Shoulder A-P with Internal Rotation
• Breathing
Instructions:
suspended respiration
• Make exposure and
let patient breathe and
relax.
• Some facilities will
use a 12” x 10
cassette
9
Shoulder A-P with Internal Rotation
Film
• The glenohumeral
joint should be open
• The lesser tubericle
will be in profile
medially.
• The humeral head and
greater tubericle will
be superimposed.
10
14.3 Shoulder A-P with External
Rotation
• Measure: A-P at
coracoid process
• Protection: Half Apron
• SID: 40” Bucky
• No Tube Angle
• Film: 10” x 8” I.D. toward
spine
• Marker: anatomical plus
“EXT” or arrow pointing
outward
11
Shoulder A-P with External
Rotation
• Patient stands facing
tube.
• The patient is rotated 15
to 45 degrees until the
scapula is parallel to the
film.
• The patient externally
rotates humerus until the
epicondyles are parallel
to the film.
12
Shoulder A-P with External
Rotation
• Horizontal CR: 1” below
the coracoid process
Vertical CR: coracoid
process or through the
glenohumeral joint
• Film centered to
Horizontal CR
• Collimation: to include
soft tissue around
shoulder or slightly less
than film size.
13
Shoulder A-P with External
Rotation
• Breathing
Instructions:
suspended respiration
• Make exposure and
let patient breathe and
relax.
• Some facilities will
use a 12” x 10
cassette
14
Shoulder A-P with External
Rotation Film
• The
glenohumeral
joint should be
open
• The greater
tubericle and
humeral head
will be in profile
.
15
14.4 Shoulder Apical Oblique
• Measure: A-P at
coracoid process
• Protection: Half apron
• SID: 40” Bucky
• Tube angle: 30 degrees
caudal
• Film size: 10” x 12”
Regular I.D. to spine
16
Shoulder Apical Oblique
• Patient stands facing
tube with humerus
internally rotated until
the epicondyles are
perpendicular to film
• The patient is rotated
15 to 45 degrees to get
the scapula parallel to
film and Bucky.
• SID adjusted for tube
angle.
17
Shoulder Apical Oblique
• Horizontal CR: 2” above
the coracoid process of
glenohumeral joint.
• Vertical CR: Coracoid
process to glenohumeral
joint.
• Film centered to
Horizontal CR
18
Shoulder Apical Oblique
• Collimation: to include
all soft tissue around
shoulder and proximal
humerus
• Breathing Instructions:
Suspended respiration
• Make exposure and let
patient breathe and
relax
19
Shoulder Apical Oblique Film
• Should visualize the
head of the humerus
within the glenoid
fossa.
• The tube angle results
in minimal
superimposition
• Useful in detection of
dislocations, Bankhart
and Hill-Sachs defects.
• Can be taken with arm
in sling.
20
14.5 Shoulder: Prone Axillary
• Measure: A-P at
coracoid
• Protection: Half Apron
• SID: 40” Non- Bucky
• Tube angle: 15 to 25
degrees down
• Film: 12” x 10” Regular
with I.D. to spine
• Special Equipment:
rectangular and large
angle sponge
21
Shoulder: Prone Axillary
• Table placed in front of
tube. Two to three inch
thick rectangular sponge
placed on table top.
• Large angle sponge used
to hold film vertical.
• Tube aligned to film and
SID set at 40” using tape
measure on collimator.
22
Shoulder: Prone Axillary
• The patient is asked to
lean over table with arm
abducted 90 degrees.
The elbow is bent 90
degrees and hangs off
the table.
• The arm and shoulder will
be resting on rectangular
sponge.
• The mid sagittal plane of
the patient is turned 10 to
25 degrees medially.
23
Shoulder: Prone Axillary
• The head and neck is
turned away from the
affected shoulder.
• The film is placed next to
the neck.
• Horizontal CR: 2” above
the glenohumeral joint.
• Vertical CR: through the
glenohumeral joint
24
Shoulder: Prone Axillary
• Collimation: to include
all soft tissue around the
shoulder or slightly less
than film size.
• Breathing instructions:
full inspiration or
suspended respiration
• Make exposure and let
patient breathe and
relax.
25
Shoulder: Prone Axillary Film
• Also known as as West
Point View.
• The best view for
visualizing the
glenohumeral joint
space free of
superimposition.
• This view is very difficult
to set up with tube
stands common to office
practices.
26
Lateral Scapula
27
14.6 Shoulder Outlet View
• Measure: A-P at
coracoid process
• Protection: Half apron
• SID: 40” Bucky
• Tube Angle: 15 to 30
degrees caudal for
Outlet View. 0 to 10
degrees for Lateral
Scapula or “Y” view
• Film: 10” x 12 regular
with I.D. to spine
28
Shoulder Outlet View
• Patient is placed in a sixty
degree anterior oblique.
• The arm of the affected
shoulder is left in a neutral
position or in the sling.
• The head of the affected
shoulder aligned with the
center line if the Bucky.
• By feeling the scapula,
adjust position to get
scapula perpendicular to
film.
29
Shoulder Outlet View
• Horizontal CR: Head
of humerus to slightly
below head of humerus
• Vertical CR: 1” medial
to the body of the
scapula.
• Collimation: to include
entire scapula and
adjacent soft tissues of
shoulder.
• Breathing
Instructions: Full
Inspiration
30
Shoulder Outlet View
• This is one of the best
views to be taken when
fracture or dislocation of
shoulder is suspected.
• You should see the true
relationship of the
humerus head and the
glenoid fossa. Very useful
when detecting a
dislocation or fracture.
31
Shoulder Outlet View
• The true Outlet View
will allow evaluation
of the subacromion
space for the
evaluation of
impingement
syndrome.
• Fractures of the
scapula may also be
seen on this view.
32
Shoulder Outlet View
• There are four
abnormal acromion
shapes that
predispose
impingement.
• Flat Underside
• Underside concave
following curve of the
humeral head
• Anterioinferior
acromial spur or hook
• Underside convex
33
14.16 Scapula Lateral View
or “Y” View
• Measure: A-P at
coracoid process
• Protection: Half apron
• SID: 40” Bucky
• Tube Angle: 0 to 10
degrees for Lateral
Scapula or “Y” view
• Film: 10” x 12 regular
with I.D. to spine
34
Scapula Lateral View
• Patient is placed in a sixty
degree anterior oblique.
• The arm of the affected
shoulder is left in a neutral
position or in the sling.
• The head of the affected
shoulder aligned with the
center line if the Bucky.
• By feeling the scapula,
adjust position to get
scapula perpendicular to
film.
35
Scapula Lateral View
• Horizontal CR: Head
of humerus to slightly
below head of humerus
• Vertical CR: 1” medial
to the body of the
scapula.
• Collimation: to include
entire scapula and
adjacent soft tissues of
shoulder.
• Breathing
Instructions: Full
Inspiration
36
Scapula Lateral View
• This is one of the best
views to be taken when
fracture or dislocation of
shoulder is suspected.
• You should see the true
relationship of the
humerus head and the
glenoid fossa. Very useful
when detecting a
dislocation or fracture.
37
Scapula Lateral View
• The true Outlet View
will allow evaluation
of the subacromion
space for the
evaluation of
impingement
syndrome.
• Fractures of the
scapula may also be
seen on this view.
38
14.7 Shoulder: Stryker Notch
• Measure: A-P at
coracoid process
• Protection: Half Apron
• SID: 40” Bucky
• Tube angle: 10 degrees
cephalad
• Film: 8” x 10” Regular
with I.D. to spine
39
Shoulder: Stryker Notch
• Patient stands facing
tube. The body is rotated
15 to 45 degrees to get
scapula parallel to film
• The patient abducts arm
and placed hand behind
neck.
• The humerus should be
internally turn to get
humerus perpendicular to
film.
40
Shoulder: Stryker Notch
• Horizontal CR: about 2”
inferior to coracoid
process or through the
glenohumeral joint.
• Vertical CR:
glenohumeral joint space
• Collimation: slightly less
than film size or to
include all soft tissue
around shoulder.
41
Shoulder: Stryker Notch
• Breathing Instructions:
Full Inspiration.
• Note : Make sure that the
glenohumeral joint space
stays within collimation
and central ray
placement by having
patient take a full breathe
in and hold it before
taking film.
42
Shoulder: Stryker Notch Film
• This view will provide a
clear view of the posterior
and superior aspects of
the head of the humerus.
• The inferior borders of
the glenoid fossa and
joint space will be seen.
• It is useful in detecting
Hill-Sachs defects and
anterior instability
43
14.15 Scapula A-P
• Measure: A-P at
coracoid process
• Protection: Half Apron
• SID: 40” Bucky
• No Tube Angle
• Film: 12” x 10” Regular
Speed with I.D. toward
the spine
44
Scapula A-P
• Patient stands facing
tube.
• Patient is rotated about
15° or until the scapula is
parallel to film.
• The humerus may be left
in a neutral position.
• Horizontal CR: 1” below
the coracoid process.
• Vertical CR: 1” medial to
coracoid process
45
Scapula A-P
• Film centered to
horizontal CR.
• Collimation top to
bottom: slightly less than
film size or to include
entire scapula and
shoulder
• Collimation side to
side: slightly less than
film size or to include
entire scapula and
shoulder
46
Scapula A-P
• Breathing Instructions:
Suspended Respiration
• Make exposure and let
patient relax.
• Some texts recommend
raising the arm to get
scapula clear of the ribs
cage. Usually you will be
able to visualize scapula
with arm in neutral
position.
47
Scapula A-P Film
• Glenohumeral joint and
entire scapula should
be seen.
• Soft tissues of shoulder
should be seen.
48
14.8 Clavicle P-A
• Measure: A-P at mid
clavicle
• Protection: Half Apron
• SID: 40” Bucky
• No Tube Angle
• Film: 1/2 of 8” x 10” or
10” x 12” Regular
Cassette
49
Clavicle P-A
• Patient stands facing
Bucky with mid-sagittal
plane perpendicular to
film.
• Horizontal CR: centered
to exit through clavicle
• Vertical CR: centered to
clavicle
• Horizontal CR centered
to top half of film.
50
Clavicle P-A
• Collimation Top to
Bottom: less than 1/2 of
film size or to include
clavicle
• Collimation side to side:
slightly less than film size
or to include
sternoclavicular and
acromioclavicular joints
• Breathing Instructions:
Suspended Respiration
• Take film and let patient
relax
51
Clavicle P-A Film
• On this example, the
A-P or P-A view is
on the bottom of
film.
• Must see the
sternoclavicular and
acromioclavicular
joints and entire
clavicle.
52
14.8 Clavicle P-A Axial
• Measure: A-P at mid
clavicle
• Protection: Half Apron
• SID: 40” Bucky
• Tube Angle : 10 to 15
degrees caudal
• Film: 1/2 of 8” x 10” or
10” x 12” Regular
Cassette
53
Clavicle P-A Axial
• Patient stands facing
Bucky with mid-sagittal
plane perpendicular to
film.
• Horizontal CR: one inch
above center of clavicle
• Vertical CR: centered to
clavicle
• Horizontal CR centered
to bottom half of film.
54
Clavicle P-A Axial
• Collimation Top to
Bottom: less than 1/2 of
film size or to include
clavicle
• Collimation side to side:
slightly less than film size
or to include
sternoclavicular and
acromioclavicular joints
• Breathing Instructions:
Suspended Respiration
• Take film and let patient
relax
55
Clavicle P-A Axial Film
• On this example, the
A-P or P-A axial view
is on the top of film.
• Must see the
sternoclavicular and
acromioclavicular
joints and entire
clavicle.
• The P-A views will
have less
magnification but are
more difficult to
position.
56
14.9 Clavicle A-P
• Measure: A-P at mid
clavicle
• Protection: Half Apron
• SID: 40” Bucky
• No Tube Angle
• Film: 1/2 of 8” x 10” or
10” x 12” Regular
Cassette
57
Clavicle A-P
• Patient stands facing
tube with mid-sagittal
plane perpendicular to
film.
• Horizontal CR: centered
to clavicle
• Vertical CR: centered to
clavicle
• Horizontal CR centered
to top half of film.
58
Clavicle A-P
• Collimation Top to
Bottom: less than 1/2 of
film size or to include
clavicle
• Collimation side to side:
slightly less than film size
or to include
sternoclavicular and
acromioclavicular joints
• Breathing Instructions:
Suspended Respiration
• Take film and let patient
relax
59
Clavicle A-P Film
• On this example, the
A-P pr P-A view is on
the bottom of film.
• Must see the
sternoclavicular and
acromioclavicular
joints and entire
clavicle.
60
14.11 Clavicle A-P Axial
• Measure: A-P at mid
clavicle
• Protection: Half Apron
• SID: 40” Bucky
• Tube Angle : 15 to 25
degrees cephalad
• Film: 1/2 of 8” x 10” or
10” x 12” Regular
Cassette
61
Clavicle A-P Axial
• Patient stands facing
tube with mid-sagittal
plane perpendicular to
film.
• Horizontal CR: one inch
below center of clavicle
• Vertical CR: centered to
clavicle
• Horizontal CR centered
to bottom half of film.
62
Clavicle A-P Axial
• Collimation Top to
Bottom: less than 1/2 of
film size or to include
clavicle
• Collimation side to side:
slightly less than film size
or to include
sternoclavicular and
acromioclavicular joints
• Breathing Instructions:
Suspended Respiration
• Take film and let patient
relax
63
Clavicle A-P Axial Film
• On this example, the
A-P or P-A axial view
is on the top of film.
• Must see the
sternoclavicular and
acromioclavicular
joints and entire
clavicle.
• The P-A views will
have less
magnification but are
more difficult to
position.
64
14.12 Acromioclavicular Joint
Unilateral
• Measure: A-P at
coracoid
• Protection: Half Apron
• SID: 40” Bucky
• Tube Angle : None
• Film: 2 views on 10” x
12” Regular Cassette
• Special equipment: 10
to 15 pounds of weight
that can be strapped to
wrists
65
Acromioclavicular Joint
Unilateral
• Patient stands facing
tube with mid-sagittal
plane perpendicular to
film.
• Horizontal CR: A-C joint
• Vertical CR: A-C joint
• Horizontal CR centered
to top half of film.
• Marker: anatomical
66
Acromioclavicular Joint
Unilateral
• Collimation: soft tissue
around A-C joint but less
than 1/2 of film size.
• Breathing Instructions:
Deep Inspiration
• Make sure the A-C
Joint remains in
collimation with deep
inspiration
67
Acromioclavicular Joint
Unilateral
• Make exposure and let
patient breathe but
remain in position.
• Strap weights to both
wrists.
• Marker: arrow pointed
down or “weighted
marker on bottom half
of film
68
Acromioclavicular Joint
Unilateral
• Horizontal CR: A-C joint
• Vertical CR: A-C joint
• Center horizontal CR to
bottom half of film.
• Breathing Instructions:
Deep Inspiration
• Make exposure and let
patient breathe and
relax. Remove weights
69
Acromioclavicular Joint
Unilateral Film
• The most common view
here is the Zanca
modification to the
unilateral ribs.
• The Zanca Views will
open the acromion
space better than the
straight A-P views.
70
14.13 Acromioclavicular Joints
Bilateral A-P
• Measure: A-P at
coracoid
• Protection: Half apron
• SID: 72” Non-Bucky
• Tube Angle: none
Zanca View 15 degree
cephalad angle
• Film: 17” x 7” or 17” x 14”
I.D. to unaffected side
71
Acromioclavicular Joints
Bilateral A-P
• Non-Bucky film holder
hung on Bucky. Film
placed in Non-Bucky
Holder.
• Patient stands facing
tube with mid-sagittal
plane perpendicular to
film.
• Horizontal CR: at level of
A-C Joints. Zanca: 1”
below A-C Joints
72
Acromioclavicular Joints
Bilateral A-P
• Vertical CR: mid-sagittal
• Collimation: to include
both A-C joints and
adjacent soft tissue and
slightly less than film size
on 17” x 7” film.
• Breathing Instructions:
Deep Inspiration
73
Acromioclavicular Joints
Bilateral A-P
• Make exposure and let
patient relax.
• Change films or move
to unexposed half of
17” x 14” film.
• Strap weights to wrists.
• Horizontal and vertical
CR same as non-
weighted view.
74
Acromioclavicular Joints
Bilateral A-P
• Place arrow pointing
down or “ weighted”
marker on film.
• Breathing instructions:
Deep Inspiration
• Make exposure and let
patient breathe and
relax. Remove weights.
75
Acromioclavicular Joints
Bilateral A-P Film
• The bilateral exam
provides a comparison
view of both A-C Joints.
• The increased SID and
Non-Bucky exposure is
25% of the unilateral
view.
• Magnification is
reduced.
76
14.14 Zanca Views of the A C
Joints
• Measure: A-P at
coracoid process
• Protection: half
apron
• SID: 40” Bucky
• Tube Angle: 15°
cephalad
• Film: 10” x 12”
Regular Speed
77
Zanca Views of the A C Joints
• Patient stands facing
tube with mid sagittal
plane perpendicular
to film.
• Horizontal CR: 1”
below A C Joint
• Vertical CR: through
the A C Joint
78
Zanca Views of the A C Joints
• Bottom half of film
centered to Horizontal
CR.
• Collimation top to
bottom: to include A-
C Joint
• Collimation side to
side: soft tissues
adjacent to A-C Joint
79
Zanca Views of the A C Joints
• Breathing Instructions:
Full Inspiration
• Rehearse breathing to
make sure the A J joint
will be seen on full
inspiration.
• Make exposure and ask
patient not to move.
• Strap weights around
wrists.
80
Zanca Views of the A C Joints
• Adjust Horizontal CR
for the weight, still 1”
below A-C Joint
• Center remaining half of
film to Horizontal CR
• Place arrow or weighted
marker on film.
• Have patient take a
deep breath and make
exposure.
81
Zanca View Films
• Weighted and Non-
Weighted Views are
taken as stress views of
the Acromioclavicular
Joint.
• Useful in detection
separations
82
Zanca View Films
• The Zanca View will
open the sub-acromion
space better than the
standard A-P view.
• If separation is not
suspected, it can be
used to evaluate bone
loss in the A-C Joint. A
single view on an 8” x
10” is taken.
83
Introduction to Film Processor QC
• In order to understand how to problem
solve film processing problems, we need
to have a basic knowledge of how the
processor work.
• Review the information about the
processing chemicals in the text on page
423.
84
21.1 Automatic Film Processors
• Operation divided into six basic
systems
– Roller Transport System
– Developer Recirculation
– Water Circulation
– Fixer Recirculation
– Replenishment: Developer and Fixer
– Air Circulation (Dryer)
85
Roller Transport System
• Purpose
• Transport Film
• Control Processing Time
• Control Replenishment
Time
• Agitation
• Squeegee Action
• Help Prevent Overlap
86
Developer Recirculation
• Purpose
• Develop Films
• Maintain Solution Activity
• Temperature Control
• Filtration
• Control of Recirculation
• Help Control Fixer
Temperature
87
Water Circulation
• Purpose
• Wash Films
• Help Control Developer
Temperature
• Water Flow Control
• Agitation
• Help Control Fixer
Temperature
• Keep Developer Drain
Clean
88
Fixer Recirculation
• Purpose
• Stops Development
• Clears the Film
• Hardens the Emulsion
• Agitation
• Maintain Solution
Activity
• Constant Control of
Recirculation
89
Developer & Fixer
Replenishment
• Purpose
• Replenish chemical
• Maintain Solution
Activity and Solution
Level
• Control / Adjust Rate of
Replenishment
• Check Replenishment
Rates
• Prevent Siphoning of
Replenisher 90
Air Circulation/Dryer
• Purpose
• Dries the Film
• Temperature Control
• Constant Control of
Circulation and
Recirculation
91
End of Lecture
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92