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