AM
Uploaded byAkshay Mylar
PPTX, PDF1,040 views

Anatomy and xrays of shoulder joint

The document provides an in-depth overview of the anatomy and functioning of the shoulder joint complex, including details about its components (scapula, clavicle, and humerus) and associated ligaments and muscles that maintain stability and mobility. It describes four main joint types: glenohumeral, acromioclavicular, sternoclavicular, and scapulothoracic, alongside their specific movements, limitations, and supporting structures like the rotator cuff. Additionally, it touches on imaging techniques, especially radiographic methods, crucial for diagnosing various shoulder conditions.

Embed presentation

Downloaded 39 times
1 / 123
2 / 123
Most read
3 / 123
4 / 123
5 / 123
6 / 123
7 / 123
8 / 123
9 / 123
10 / 123
11 / 123
12 / 123
13 / 123
14 / 123
15 / 123
16 / 123
17 / 123
18 / 123
19 / 123
20 / 123
21 / 123
22 / 123
23 / 123
24 / 123
25 / 123
26 / 123
27 / 123
28 / 123
29 / 123
30 / 123
31 / 123
32 / 123
33 / 123
Most read
34 / 123
35 / 123
36 / 123
37 / 123
38 / 123
39 / 123
40 / 123
41 / 123
42 / 123
43 / 123
44 / 123
45 / 123
46 / 123
47 / 123
48 / 123
Most read
49 / 123
50 / 123
51 / 123
52 / 123
53 / 123
54 / 123
55 / 123
56 / 123
57 / 123
58 / 123
59 / 123
60 / 123
61 / 123
62 / 123
63 / 123
64 / 123
65 / 123
66 / 123
67 / 123
68 / 123
69 / 123
70 / 123
71 / 123
72 / 123
73 / 123
74 / 123
75 / 123
76 / 123
77 / 123
78 / 123
79 / 123
80 / 123
81 / 123
82 / 123
83 / 123
84 / 123
85 / 123
86 / 123
87 / 123
88 / 123
89 / 123
90 / 123
91 / 123
92 / 123
93 / 123
94 / 123
95 / 123
96 / 123
97 / 123
98 / 123
99 / 123
100 / 123
101 / 123
102 / 123
103 / 123
104 / 123
105 / 123
106 / 123
107 / 123
108 / 123
109 / 123
110 / 123
111 / 123
112 / 123
113 / 123
114 / 123
115 / 123
116 / 123
117 / 123
118 / 123
119 / 123
120 / 123
121 / 123
122 / 123
123 / 123
ANATOMY AND XRAY OF SHOULDER JOINT -AKSHAY M
ANATOMY
INTRODUCTION • The shoulder girdle consists of three bones scapula, clavicle and humerus. • The glenohumeral joint combined with the scapulothoracic, sternoclavicular and acromio clavicular joints comprise the shoulder joint complex. • It has the greatest range of motion of any joint in the body. • Due to wide range of movement it is also most unstable joint compared to other joints of the body. However a series of complex ligaments and muscle keep it in place.
• Ligaments around gleno-humeral joint limit the amount of joint movement o Capsular ligament o Coracohumeral ligament o Transverse Humeral ligament o Glenoid ligament • Shoulder is protected above by arched vault formed by: o Under surface of coracoid process o Under surface of acromion process o Coraco-acromial ligament
Joints of the Shoulder Complex 1. Glenohumeral joint 2. Acromioclavicular joint 3. Sternoclavicular joint 4. Scapulothoracic joint
1. Acromioclavicular joint • Synovial plane joint between oval facet of clavicle and concave area on anterior end of acromion process. • Joint line is oblique and slightly curved which helps the acromion to glide anteroposteriorly over the clavicle and thus keeps the glenoid continuously facing the humeral head. • Consists of a capsule and superior acromioclavicular ligament
2. Sternoclavicular joint • The only joint connecting the shoulder complex to the axial skeleton. • Plane synovial joint. But functions resembles a ball and socket joint. • Lacks congruity and ½ of lateral end of clavicle protrudes over a shallow sternal socket. • Mainly stabilized by articular disc and costoclavicular ligament. • Articular disc is circular fibrocartilage, attached superiorly to upper medial end of clavicle and inferiorly to sternum and first costal cartilage. Thereby acts as a hinge. • Costoclavicular ligament is bilaminar and attaches medial end of clavicle to first rib. • It allows elevation-depression, protraction-retraction and long axis rotation of clavicle.
3. Scapulothoracic Joint • Joint type: not a ‘true’ joint, but known as a ‘pseudo’ joint • Bones involved in the articulation: o Anterior surface of the Scapula o Ribcage of the Thorax • Movements: o Protraction and retraction o Elevation and depression o Anterior tilt and posterior tilt o Upward rotation and downward rotation • As there is minimal bony contact, it is up to the muscles attaching to the scapula and thorax to stabilise and control movement at this articulation • There is no joint capsule or synovial fluid.
4. Glenohumeral joint • The glenohumeral joint is the most mobile joint in the body. The ‘socket’ (glenoidfossa) is very shallow, and hence the inherent stability is minimal. • Joint type: Multi axial ball and socket synovial joint • Althought the articular surfaces are reciprocally curved, are oval and not sections of true spheres and are asymmetrical and are not congruent. • Only 25-30% on humeral head is in contact with glenoid fossa at any position.
Glenoid Cavity • Shallow, Pear Shaped “socket” • Directed Laterally and Upward • Glenoid Fossa is deepened by a fibrous and fibro- cartilaginous rim of Glenoid labrum. • Inner surface covered with synovium, outer surface attaches to the capsule and continuous with the periosteum of scapular neck. • The anterior labrum is thicker is larger and wider than the posterior labrum. • Function o Protect edges of glenoid o Assists in lubrication of joint o Stability o Attachment for glenohumeral ligaments
Capsular Ligament • Encirclesentire glenohumeraljoint. • Attached: o Medially:Above to the circumference ofglenoid cavity beyond the glenoid ligament o Laterally: Below to anatomicalneck of the humerus • Thickerabove andbelow. • Loose andlax • Allow bone to be separated from each othermore than an inch
Supplemental Bands of Capsular Ligament • Strengthen capsular ligament in the interior part of the joint. • Flood’s Ligaments o Situated on inner side of joint o Passes from inner edge of glenoid cavity o Attached to lower part of lesser tuberosity of humerus. • Schlemm’s Ligaments o Situated at lower part of the joint o Passes from under edge of glenoid cavity o Attached to under part of neck of humerus • Glenohumeral Ligaments o Situated at upper part of the joints, projects into its interior (can only be seen when capsule is open). Attached above apex of glenoid cavity close to root of coracoid process, attached below lesser tuberosity of humerus (Forms inner boundary of upper part of bicipital groove)
Muscles Supporting Capsular Ligament • Superiorly – Supraspinatus • Inferiorly - Long Head of Triceps • Posteriorly - Tendons of Infraspinatus and Teres Minor • Anteriorly - Tendon of Subscapularis
Rotator cuff The rotator cuff is another name for a cluster of 4 different muscles and their tendons that play an important role in providing strength and stability in the shoulder movement. • Supraspinatus: The main function of the supraspinatus muscle is to hold the humerus in its place and maintain the stability of the upper arm which ultimately helps to lift the arm. • Infraspinatus: Rotation and extension of the shoulder is the major function carried out by infraspinatus muscle. • Teres Minor: This is the smallest of all rotator cuff muscle. Its major function is to help in the rotation of the arm away from the body. • Subscapularis: This muscle keeps the upper arm intact to your shoulder blade and assists in rotation of the arm, hold it straight out and lower it.
Openings of Capsular Ligament Anteriorly • Foramen of Weitbrecht Below coracoid Process, connection between synovial membrane of the joint and a bursa beneath the tendon of subscapularis muscle. • Between the 2 tuberosities, passage of the biceps long head. o Posteriorly • Not constant, where a communication exists between joint and a bursal sac belonging to Infraspinatus muscle.
Synovial Membrane • Reflected from margin of glenoid cavity over fibro- cartilaginous rim surrounding it. • Over internal surface of capsular ligaments. • Covers lower part and sides of anatomical neck of humerus.
Ligaments 1. Glenohumeral ligament Provide anterior stability to the glenohumeral joint 1. Superior (SGHL) 2. Middle (MGHL) 3. Inferior (IGHL) They lie on anterior and inferior aspect of the joint.
A. Superior GH Ligament • Resists inferior translation of humeral head in rest or adducted arm • Well-developed in 50% • From superior glenoid tubercle, base of coracoid process, upper glenoid labrum then laterally to upper part of lesser tuberosity. B. Middle GH Ligament • Absent in 30% maximum variation. • Resists inferior translation in abduction and external rotation. • Restrains anterior translation (45° abduction) • From SGHL along the anterior margin of glenoid fossa, down till inferior 1/3 of glenoid rim then laterally to ant aspect of anatomical neck and lesser tubercle. • Intimately attached to subscapularis.
C. Inferior glenohumeral Ligament • Thickest and most important stabilizer of shoulder. • 3 components- anterior band, posterior band and axillary pouch. • Attaches to inferior, anterior and posterior margins of glenoid labrum • Anterior band wraps around the head like a hammock to prevent anterior mighation of head
2. Coracohumeral Ligament • Broad Thick band • It forms roof of bicipital tendon sheath and • strengthens capsule anteriorly. • Attachments o Arisesfrom outer borderof coracoid process o Blended with tendonof supraspinatusmuscles • United to capsulein greater part of its extend. • Importance-resists inferior and posterior translation. 3. Transverse Humeral Ligament • Bridges upper part of bicipital groove through which long head of biceps passes down.
4. Acromioclavicular ligament It acts to secure the acromion and clavicle and provides a complete capsule around the joint. 5. Coracoclavicular ligaments It anchor the lateral aspect of the clavicle to the coracoid process of scapula. It consists of two small ligaments holding the scapula laterally, these are: • Trapeziod - attaches to the trapezoid line on the inferior surface of the clavicle • Conoid - attaches to the conoid tubercle of the clavicle
Bursae In Relation To The Shoulder Joint 1) Subscapular Bursa 2) Infraspinatus bursa 3) Subacromial bursa (subdeltoid) 4) Subcoracoid Bursa
1. Subscapular Bursa Intervenes between the tendon of subscapularis and fibrous capsule. Communicates with the joint cavity through oval gap between superior and middle glenohumeral ligaments. 2. Infraspinatus Bursa Communicates with the joint from behind 3. Subacromial Bursa o Largest bursa of the body intervenes between supraspinatus and coraco- acromial arch. o It does not communicate with the joint. o It is of great value in the abduction of arm at the shoulder joint where is protects the supraspinatus tendon against friction with the acromion
Blood and Nerve Supply • Blood Supply 1. Anterior circumflex humeral vessels 2. Posterior circumflex humeral vessels 3. Suprascapular vessels • Nerve Supply 1) Axillary nerve 2) Musculocutaneous nerve 3) Suprascapular Nerve 4) Lateral pectoral nerve
Gateways to the Posterior Scapular Region 1. Suprascapular Foramen • It is formed by suprascapular notch of scapula and the superior transverse scapular ligament,which converts the notch into a foramen. • The suprascapular nerve passes trough the suorascapular foramen 2. Quadrangular Space • Its boundaries are formed by: o The inferior margin of the teres minor o Surgical neck of humerus o The superior margin of the teres major o Lateral margin of the long head of triceps brachii. • Axillary nerve and posterior circumflex humeral artery and vein pass trough this space
3. Triangular Space • Its boundaries are formed by o The medial margin of the long head of triceps brachii o The superior margin of the teres major o The inferior margins of the teres minor • The circumflex scapular artery and vein pass trough this space 4. Triangular Interval • Boundaries are formed by o The lateral margin of the long head of triceps brachii o The shaft of the humerus o The inferior margin of the teres major • Radial nerve,profunda brachii artery and associated veins pass trough it
Movements At The Shoulder Joints • Movement in every direction (Flexion,extension, abduction, adduction, rotation, circumduction) • Highly mobile dueto: o Largesizeof head of humerus incomparison with the depth of glenoid cavity(Even when supplemented by glenoid ligament) o Looseness of the capsule of the joint(Laxityof fibrouscapsule) o When movements of arm are arrested by contact of the bony surface Tensionof corresponding fibersand musclesacting on accessory ligaments farther movements of scapula and accessory structuresto the shoulder joint (acromio and sterno- clavicularjoints). • SpinalCord regulating Shouldermovements (C5,C6, C7 & C8) o Flexion,Abduction, & lateralrotation(C5, C6,). o Extension,Adduction, & Medial rotationis(C6,C7, C8) • Concave-convex rule o Convex humeral head moves within the concave glenoid fossa o The Convex joint surface (Humeral Head) moves in a direction opposite to the movement of the body segment (Humeral Shaft)
1. Flexion • Plane of Motion: o Sagittal Plane • Axis of Motion: o Transverse Axis through the center of the humeral head • Muscles Involved: o Pectoris major o Anterior Fibres od Deltoid o Coraco-brachialis o Biceps (When the foreare is flexed) • Humeral head glides posterior laterally in the glenoid cavity • Range of Motion o 0 – 90 degrees Factors Limiting Shoulder Flexion • Inferior Glenohumeral ligament • Tightness of posterior joint capsule
2. Extension • Plane ofMotion: o SagittalPlane • AxisofMotion: o TransverseAxisthrough the centerof the humeralhead • MusclesInvolve: o Latissimusdorsi o Teresmajor o Posterior fibers ofDeltoid o Triceps (When forearm isextended) • Humeral head glideanterior medially in glenoidcavity • Range ofMotion o 0–45degrees or 60degrees Factors Limiting Shoulder Extension- • Superior and medial gleno-humeral ligament
3. Abduction • Plane of Motion: o Frontal Plane • Axis of Motion: o Sagittal axis through the center of the humeral head • Muscles Involve: o Deltoid o Supraspinatus • Humeral head glide inferiorly in glenoid cavity • Range of Motion o Total : 0 – 165 degrees or 175 degrees o Full internal rotation of humerus: 0 – 60 degrees o Full external rotation of Humerus: 0 – 90 degrees Factors Limiting Shoulder Abduction • Inferior glenohumeral ligament • Tightness of the inferior joint capsule of the glenoumeral joint
4. Adduction • Plane of Motion: o Frontal Plane • Axis of Motion: o Sagittal axis through the center of the humeral head • Muscles Involve: o Subscapularis o Pectoralis Major o Latissimus dorsi o Teres major • Humeral head glide superiorly in glenoid cavity • Factors Limiting: o Trunk
5. Internal Rotation • Plane of Motion: o Transverse Plane • Axis of Motion: o Vertical axis through the center of humeral head • Muscles Involve: o Subscapularis o Pectoralis Major o Latissimus dorsi o Teres major • Humeral head glide posteriorlaterally in glenoid cavity • Range of Motion o 0-70º as the arm at 90º of shoulder abduction and 90º elbow flexion o If the elbow is extended, shoulder rotation occurs simultaneously with forearm rotation. Factors Limiting Internal Rotation • Posterior Capsule
6. External Rotation • Plane of Motion: o Transverse Plane • Axis of Motion: o Vertical axis through the center of humeral head • Muscles Involve: o Infraspinatus o Teres Minor • Humeral head glide anteriomedially in glenoid cavity • Range of Motion o 0-90º as the arm at 90º of shoulder abduction and 90º elbow flexion o If the elbow is extended, shoulder rotation occurs simultaneously with forearm rotation. Factors Limiting External Rotation • Coracohumeral ligament • 3 glenohumeral ligaments
7. Circumduction • A combinationof flexion,abduction, extension, and adduction orinthereversed sequence o glenohumeral flexion abduction extension adduction o glenohumeral extension abduction flexion adduction
Close and Loose Packed Position • Close Packed position o Position where the articular surfaces of joint are in maximal congruency status, resulting in greatest mechanical stability. o Most ligament and capsule surrounding joint are taut. o 90° of glenohumeral abduction and full external rotation • Loose Packed position o Position where the articular surface of joint are in minimal congruency status. o Supporting structures are most lax. o 55° of semi-abduction and 30° of horizontal adduction
X RAYS
RADIOGRAPHIC TECHNIQUE • Proper radiographic technique and positioning is important to understand the normal appearances which can direct us the various abnormalities & diseases. • A shoulder radiograph series may be needed for a particular condition, such as for evaluation of arthritis, trauma, instability, or impingement. • Additional views may be obtained in the search for specific abnormalities depending on the clinical situation and area of concern.
1. ANTEROPOSTERIOR (AP) VIEW • Two AP projections: • With the arm in external rotation: , the humeral head has the appearance of an Indian axe. • With the arm in internal rotation: the humeral head has the appearance of an ice-cream cone. • Since the glenohumeral joint is normally anatomically tilted 35–40 degree anteriorly, this projection results in overlap of the glenoid and humeral head. • Acute trauma- Coracoid Process Fracture, Glenoid Fracture, Proximal Humerus Fracture, compression fracture of humeral head. • Chronic shoulder pain, including Glenohumeral Arthritis, calcific tendonitis or bursitis, and AC joint arthritis. SHOULDER RADIOGRAPH PROJECTIONS
• The AP projection is usually obtained with the patient in the upright or supine position and with the coronal plane of the body parallel to the cassette. • The beam is directed in a true AP direction relative to the body. • This results in slight overlap of the glenoid rim and the humeral head as the glenohumeral joint is tilted anteriorly approximately 40°. • The lateral border of the scapula and the medial cortex of the proximal humerus form a gentle, smooth convex arch, known as scapulohumeral or Moloney’sarch.
The beam is oriented in true AP view to the patient with the arm positioned in either neutral, internal, or external rotation. The beam is centered on the coracoid process with the blade of the scapula almost parallel to the film.
AP external rotation. There is overlap of the humeral head and the glenoid (ellipse). The anterior (arrow) and posterior (thick dashes) margins of the glenoid are seen. The greater tuberosity (G) is seen in profile. The acromiohumeral distance (line) is normal (>7 mm).
AP internal rotation. The humeral head is round in appearance with a smooth posterior contour. The fat along the subacromial-subdeltoid bursa is seen as a lucent crescent (arrowheads).
Moloney’s arch
2. ROCKWOOD VIEW • The Rockwood view (AP with 30 º caudal angulation of the X-ray beam) is utilized in the impingement series to evaluate the acromion and subacromial space. • Angling the X-ray tube caudally or tilting the patient forward provides improved visualization of the subacromial space.
The Rockwood view is a modified AP view taken with 30 degree caudal angulation.
Normally, a line (dashed) along the inferior aspect of the clavicle intersects the undersurface of the acromion. Areas of bony prominence or osteophytes will extend below this line.
3. GRASHEY VIEW • The Grashey view is a true anterior–posterior view of the shoulder. • The overlap between the humerus and the glenoid seen on the AP view is removed in the Grashey projection by rotating the patient posteriorly or angling the beam laterally. • Helpful for: Glenohumeral Arthritis, Coracoid Process Fracture, Glenoid Fracture, Proximal Humerus Fracture. Posterior Glenohumeral Instability. • Evaluate: humeral head postion relative to glenoid; AC joint position/arthritis; RTC calcifications, acromial spurring • Acromiohumeral interval: normal = 7-14mm. <7mm indicates Massive RTC Tear. May appear falsely decreased with posterior subluxation of the humeral head.
Position: Patient erect, turned 30-35° toward the side being xrayed Tube: Perpendicular to plate
The glenohumeral joint is seen in profile (arrows) without overlap of the humerus and glenoid.
4. AXILLARY VIEW • Axillary view is a tangential view of the glenohumeral joint from below. • Demonstrates: glenohumeral joint narrowing (best view), Os Acromionale, glenoid version, glenoid erosion, humeral head subluxation. • Helpful for: determining the amount of acromion which remains in patients who have undergone previous surgery; relation of humeral head to glenoid; Hill-Sachs lesions, Os Acromionale, Acromioclavicular Arthritis, Shoulder Dislocation, osseous Bankart fracture involving the anterior glenoid rim. • The radiographic quality is often very limited because of the rapid change of overlying soft-tissue density.
Position: Patient seated at side of radiographic table or supine with the arm abducted 90º and axilla over the cassette. Beam: angle 5°-10° toward the elbow, central beam directed at the shoulder joint/humeral head.
The glenohumeral joint is seen in profile and is symmetrical. The humeral head is centred on the glenoid.
5. WEST POINT VIEW • The West Point View is a variation of the lateral axillary view that was developed to improve detection of a Bankart fracture of the anterior glenoid rim. • Demostrates: anteroinferior glenoid rim., best for osseous Bankart Lesion. • Helpful for: Shoulder Instability, Glenoid Fracture, osseous Bankart Lesion. • Although this projection improves detection of an osseous Bankart lesion, it can be difficult to obtain in the setting of acute trauma.
Postion: Patient prone with affected shoulder resting on a pad @8cm for the table top. Casette positioned against the superior apsect of the shoulder. Beam: aimed 25° from horizontal (to tables surface) and 25° medially (to patients midline).
The anteroinferior (arrow) portion of the glenoid is seen without overlap of the coracoid. Glenoi d Head of Humerus
6. GARTH APICAL OBLIQUE VIEW • The Garth view of the shoulder is a projection used in trauma when evaluating the glenohumeral joint for dislocations and trauma to the glenoid of the scapula. • It shows antero inferior glenoid rim. • This projection is often used as a replacement to the lateral scapula view in trauma. • It is an optimal projection to demonstrate Bankart and Hill-Sachs lesions
Position: Patient erect with rotating the patient 30-45° Beam: 45° caudal angle of the x-ray tube
7. SCAPULAR Y VIEW • The scapular body is seen in tangent and the glenoid fossa is seen en face as a Y- shaped intersection of the scapular body, acromion process, and coracoid process. • The humeral head should be centred over the glenoid fossa. • Demonstrates: lateral projection of scapular body and humeral head overlapping the glenoid. • Helpful for: Shoulder Dislocation; Proximal Humerus Fracture. ; Scapula Fracture, coracoid fracture • The scapular Y view is also used to evaluate the contour of the undersurface of theacromion process when “typing” the acromion.
Position: Erect with anterior aspect of affected shoulder against x-ray plate and rotating other shoulder out 40 deg°. Beam: aimed from posteriorly along scapular spine
Lines through the acromion, coracoid process, and body of the scapula intersect at the center of the glenoid. The humeral head is centred on this intersection point.
8. NEER’S SUPRASPINATUS OUTLET VIEW • The supraspinatus outlet view is useful for evaluating the acromion process and subacromial abnormalities such as osteophytes that may cause impingement. • It is similar to the Y-view but with caudal tube angulation. • This view is taken with the patient turned as for the Y projection and the cassette perpendicular to the body of the scapula and parallel to glenoid fossa. • Demonstrates: outlet/impingement of the supraspinatus and coracoacromial arch. • Helpful for: Subacromial Impingement, assessing Subacromial Morphology, unfused acromial epiphysis
Position: Erect with anterior aspect of affected shoulder against x-ray plate and rotating other shoulder out 40 deg°. Beam: aimed from posteriorly along scapular spine but with the beam aimed with 10° caudal tilt
The subacromial space (arrows) and contour of the acromion (A) are well seen. The water density of the supraspinatus muscle is shown (S).
9. STRYKER NOTCH VIEW • The Stryker notch view can be obtained with the patient in the supine or upright position. • Demonstrates: humeral head • Helpful for: Hill-Sachs lesions (best view), Bankart Lesion. • This view nicely demonstrates the posterolateral aspect of the humeral head and is excellent for depicting a Hill– Sachs deformity or flattening of the posterolateral humeral head. • Evaluation of glenoid rim fractures or subtle glenohumeral subluxation is limited on this view.
Position: Patient supine with cassette posterior to the shoulder. The hand placed on top of the head. The elbow should point straight upward. Beam: directed 10° superiorly/toward the head, centered over the coracoid process.
The humeral head is normally smoothly round in appearance. A small contour defect in this case is due to a Hill-Sachs impression fracture (arrow).
10. SERENDIPITY VIEW • Demonstrates: sternoclavicular joints and medial 1/3 of the clavicles. • Helpful for: Clavicle Fracture, Distal Clavicle Fracture, Sternoclavicular Joint Dislocation.
Postion: supine with cassette under upper chest Beam: aimed at clavicle or manubrium (SC pathology) with a 40° cephalic tilt.
11. BENNETT'S VIEW •External rotation of the humerus with tilting of the x-ray tube 5° cephalad •Bennett lesions of the shoulder, also called thrower's exostosis refers to the mineralisation of the posterior band of the inferior glenohumeral ligament.
12. ZANCA VIEW • Demonstrates: AC joint and distal clavicle • Helpful for: Acromioclavicular Arthritis, Acromioclavicular Joint Separations, Distal Clavicle Osteolysis, Distal Clavicle Fracture • AC joint spurring and cystic changes indicates Acromioclavicular Arthritis. • Distal clavicle elevation indicates Acromioclavicular Joint Separations.
Position: Erected with cassette behind shoulder. Beam: Xray beam aimed at the AC joint in 10° to 15° cephalic tilt. Xray penetration should be 1/2 normal to avoid overpenetration of AC joint.
13. BICIPETAL GROOVE VIEW Demonstrates: the bones and soft tissue of the shoulder, specifically the intertubercular groove free of superimposition of the shoulder. The central ray should be 10-15 degrees posterior at the intertubercular groove. For the Fisk modification, the central ray should be perpendicular to the image receptor at the intertubercular groove and the vertically positioned humerus is angulated at 10-15 degrees.
APPROACH TO ANALYZING SHOULDER RADIOGRAPH • The general principles promulgated by Forrester and Nesson provide a useful framework for evaluation of the shoulder. • ABCs must be assessed: Alignment Bone density Cartilage spaces Soft Tissues
DISTURBANCE IN ALIGNMENT
1. FRACTURES OF PROXIMAL HUMERUS • Neer classification system is widely used. • It is a 4 segment system representing the four anatomic components of the proximal humerus. • Fractures of the proximal humerus occur between one or all of these four major segments:  the articular segment (at the level of the anatomic neck)  the greater tuberosity  the lesser tuberosity  humeral shaft (at the level of the surgical neck).
• In minimally displaced fractures, there is no or minimal displacement between the segments. The fragments are held together by the rotator cuff, the joint capsule, and the periosteum. • In a two-part fracture, there is displacement of one segment in relation to the three non- displaced, nonangulated segments. • In a three-part fracture there is involvement of either the lesser or greater tuberosity. There may be anterior or posterior shoulder dislocation. The humeral head is rotated by the pull of one of the rotator cuff tendons, which can be a source of blood supply to the head. • In a four-part fracture, there is involvement of both the greater and lesser tuberosities and fracture of the surgical neck. There may be anterior or posterior shoulder dislocation. There is typically impaired blood supply to the humeral head due to lack of soft-tissue attachment, leading to the frequent development of humeral head osteonecrosis.
Minimally displaced Neer fracture. There are fractures of the greater tuberosity and surgical neck (arrows) but no significant displacement or angulation is present.
Two-part Neer fracture. Greater tuberosity (long arrow) is displaced greater than 1 cm from humeral head fragment (short arrow), which remains in near anatomic position
2. DISLOCATION OF SHOULDER • Shoulder dislocation is the most common large joint dislocation presenting to the Emergency Department. • 3 types:  Anterior shoulder dislocations are the most common, accounting for 95% of all shoulder dislocations.  Posterior shoulder dislocations account for less than 5% of all shoulder dislocations.  Inferior or subglenoid dislocation (luxatio erecta) is very rare, occurring in approximately 0.5% of cases.
ANTERIOR DISLOCATION • Anterior shoulder dislocation is usually caused by trauma. • These dislocations tend to recur, especially in young adults. • The Bankart fracture( injury to anteroinferior part of glenoid labrum) and Hill- Sachs deformity (posterolateral humeral head compression fracture ) have been implicated as probable causes of recurrent shoulder dislocations. • The characteristic feature of anterior shoulder dislocation is malposition of the humeral head so that it lies anterior, medial and slightly inferior to the glenoid fossa. • This can be confirmed on the axillary view or the scapular Y-view.
AP view of glenohumeral joint demonstrates anterior dislocation of humeral head (arrow). Notice that humeral head has moved medially and inferiorly and sits below coracoid process.
(B) Axillary view and (C) scapular Y view demonstrate anterior dislocation of humeral head (arrow) relative to glenoid fossa (arrowhead).
HILL SACHS LESION • With anterior dislocation, the posterosuperior humeral head contacts the anteroinferior glenoid rim, which may result in a wedge-shaped posterosuperior humeral head impression fracture, termed a Hill-Sachs lesion. • The Hill–Sachs defect is usually best depicted on the AP radiograph of the shoulder with the arm in internal rotation and appears as an area of flattening or concavity of the posterolateral aspect of the humeral head. • The Stryker Notch view is also very useful in depicting a Hill–Sachs defect, whereas the defect may be completely obscured on the axillary view or AP radiograph with external rotation. • Hill-Sachs lesions smaller than 20% of the articular surface are unlikely to be clinically significant, lesions involving 20–40% have variable clinical significance, and lesions larger than 40% are likely to contribute to recurrent dislocation.
(A) An internal rotation view shows the indentation (impression fracture, arrow) of the posterolateral aspect of the humeral head. (B) The axillary view of another patient shows a Hill-Sachs lesion, (arrow) causing deformity of the posterior humeral head. In this case the defect involves less than 20% of the humeral articular surface. The Stryker notch view is also used to demonstrate Hill-Sachs lesions.
BANKART LESION • First-time dislocation in a young person (under 35 years of age) usually results in a tear or avulsion of the anterior labroligamentous complex from the inferior glenoid, referred to as a Bankart lesion. • A Bankart fracture refers to an injury that includes not only an anterior labral injury but also a fracture of the anteroinferior glenoid. • Osseous Bankart lesions involving the inferior glenoid rim are often subtle lesions that are best depicted on either the AP or the axillary view of the shoulder. • The West Point axillary view is a special adaptation of the axillary view that was developed to accentuate detection of a Bankart lesion.
(A)Axillary view of glenohumeral joint demonstrates small fracture fragment (arrow) adjacent to anterior glenoid. This fracture results from impaction injury of humeral head against anteroinferior glenoid rim and can lead to recurrent instability of glenohumeral joint. (B) Axial T1-weighted MR image with intraarticular gadolinium demonstrates minimally displaced Bankart fracture (arrow).
POSTERIOR DISLOCATION • Posterior dislocations are most often associated with a seizure or electrocution injury and almost all bilateral posterior shoulder dislocations are due to a seizure. • The mechanism of posterior shoulder dislocation is uneven muscle contraction with the internal rotators of the shoulder contracting with greater force than the external rotators, causing the humeral head(s) to move superiorly and posteriorly. • Humeral head fractures can occur due to continuing pressure against the glenoid. • The anteroposterior radiograph of the shoulder may appear nearly normal in patients with posterior dislocation, contributing to a high misdiagnosis rate and delays in treatment. • The addition of axillary views raises the diagnosis rate to 100%.
• If axillary views cannot be obtained due to patient pain, a scapular “Y” view can be obtained or CT, can demonstrate both the dislocation and any associated fractures. • On the AP radiograph the humeral head is usually in internal rotation and higher than normal. The posterior position of the humeral head can be shown on the scapular “Y” view or axillary view. • Often, the humeral head is subluxed, rather than completely dislocated. The anterior humeral head can impact against the posterior glenoid rim, which can result in an anterior humeral head impression fracture (reverse Hill-Sachs lesion, the trough sign) and/or posterior glenoid rim fracture (reverse Bankart lesion).
Posterior dislocation. (A) The AP view shows the humeral head fixed in internal rotation and slightly high in position with relation to the glenoid. An impression fracture (trough sign, arrow) is present. (B) A rotated Y-view shows the apposition of the trough fracture line (arrows) and the posterior lip of the glenoid. The displaced humeral head is posterior to the center of the glenoid (circle).
LUXATIO ERECTA • Luxatio erecta is also called inferior or subglenoid dislocation. • In this injury, the arm is raised, abducted and cannot be lowered. • Causes of luxatio erecta include hyperabduction and extension during a fall and attempting overhead shots in racket sports. • Typical radiographic features of luxatio erecta include humeral head dislocation inferior to the glenoid with the humerus locked in abduction. • Associated injuries: • 80% of the cases have associated greater tuberosity fracture or rotator cuff tear. • 60% of the cases have some degree of neurological impairment, most frequently to the axillary nerve. • 3.3% of the cases have significant vascular compromise.
Luxatio erecta. The humeral head is displaced inferiorly and the arm is abducted.
Luxatio erecta. AP radiograph of shoulder demonstrates humeral head (arrow) to be displaced directly inferiorly relative to glenoid fossa and arm is fixed in fully abducted position.
DISTURBANCE IN BONE DENSITY
1. AVASCULAR NECROSIS • Common etiology: • Post traumatic sequela • Corticosteroid use • Sickle cell disease. • The typical radiographic findings of avascular necrosis depend on its stage, and can progress through subtle lucency, sclerosis, fragmentation, sub-articular collapse, and arthritis and joint destruction in the final stages. • Classic descriptions of AVN include crescent-shaped sub-articular lucency (the crescent sign) as well as the “snowcap sign” due to focal sub-articular sclerosis.
Avascular necrosis. This Grashey projection shows a lucency with surrounding sclerosis (arrows) in the humeral head. In this case, there is no collapse of the humeral head and no crescent sign or cartilage space narrowing is seen.
AP radiograph of shoulder demonstrates linear subchondral fracture (arrow) involving medial aspect of subchondral bone of humeral head. Appearance and location are classic for advanced osteonecrosis of humeral head.
DISTURBANCE IN CARTILAGE SPACES
1. RHEUMATOID ARTHRITIS • The radiographic findings of RA of the shoulder consist of  periarticular osteopenia  marginal erosions develop at the bare area (the superolateral aspect of the humeral head adjacent to the greater tuberosity) where articular cartilage is thin.  uniform cartilage space narrowing in the absence of osteophytes  subchondral sclerosis and bursitis. • As the disease progresses, there is concentric erosion of the glenoid accompanied by medial migration of the humeral head. • Atrophy and tear of the rotator cuff with attendant superior migration of the humeral head may follow and erosion and thinning of the undersurface of the acromion can result. • The resulting juxtaposition of the medial humeral shaft and the inferior glenoid eventually produces a notch like defect of the humerus that predisposes to pathologic fracture.
Rheumatoid arthritis. AP radiograph of shoulder demonstrates numerous marginal erosions of proximal humerus, involving medial aspect of humeral head (arrowheads) and medial aspect of proximal humeral shaft (long arrow). In addition, there are erosions and tapering of distal clavicle (short arrow).
Rheumatoid arthritis. AP view shows deepening of the glenoid fossa owing to erosion. There is also erosion of the humeral head
1. OSTEOARTHRITIS • Since the shoulder is a nonweightbearing joint, primary osteoarthritis is unusual. • Most cases of osteoarthritis are, therefore, secondary. Underlying causes include prior trauma, systemic arthritis, chronic rotator cuff tear, congenital malformations, and acromegaly. • Typical of osteoarthritis are asymmetric cartilage space narrowing and osteophytes that arise from the glenoid rim and the anatomic neck of the humerus. • In acromegaly, the osteophytes are typically very large. • As the articular cartilage of the glenohumeral joint deteriorates, subchondral sclerosis and cysts develop. • Unlike inflammatory conditions, bone density is preserved in patients with OA. In late stages, posterior subluxation of the glenohumeral joint occurs.
Osteoarthritis in a patient with acromegaly. There is narrowing of the glenohumeral joint with large osteophytes. Opacities overlying the scapula are ossified bodies in the subscapularis recess.
DISTURBANCE IN SOFT TISSUES
1. CALCIFIC TENDONITIS • The shoulder is the most common site of calcific tendonitis or bursitis. • About half of the cases involve the supraspinatus tendon. • Radiography can localize calcification to a particular tendon and may indicate whether the process is chronic or acute. • Calcification within the supraspinatus tendon is seen in profile over the greater tuberosity on radiographs obtained in external rotation. • Because of their more posterior location, calcification in the infraspinatus or teres minor tendons is best seen on internal rotation radiographs. • Subscapularis calcification is located anteriorly adjacent to the lesser tuberosity and is best seen on axillary views. • Calcification of the long head of the biceps may occur at the musculotendinous junction or at the tendon insertion on the superior glenoid labrum.
• Chronic calcification is usually sharply marginated and dense whereas acutely inflamed deposits are less dense and may have surrounding edema causing obliteration of adjacent fat planes. • Correlation with clinical findings is necessary, however, to confirm the relevance of radiographically detected calcification. • Calcification in the rotator cuff may eventually rupture into the bursa and this can be documented on radiographs by the location of the calcification.
Calcific tendonitis. (A) Calcific tendinitis of the long head of the biceps brachii. The calcification in this case occurred at the musculotendinous junction (arrow). (B) Calcific tendinitis and bursitis of the infraspinatus tendon with bone erosion. Calcification in the infraspinatus tendon has extended into the subacromial-subdeltoid bursa (arrow) and has eroded into the bone (white arrow)
2. ROTATOR CUFF TEARS • In acute rotator cuff tears, radiographs are usually normal. • A decreased acromiohumeral distance can be seen on films obtained with active abduction. Accompanying atrophy of the supraspinatus muscle can be suspected on the outlet view if there is flattening or poor definition of its normally convex upper margin. • Fatty replacement of the muscle can be seen as areas of low density fat replacing the normally homogeneous muscle density. • Eventually, due to the unopposed action of the deltoid, lack of humeral stabilization by the supraspinatus, and lack of the mass of the supraspinatus tendon interposed between the humerus and acromion, the humeral head will be elevated in relation to the glenoid and the acromiohumeral interval will be narrowed to less than 7 mm.
• In chronic rotator cuff tears, remodeling of the humeral head and acromion may occur (cuff tear arthropathy). • Milwaukee shoulder syndrome (cuff tear arthropathy) is a rapidly destructive shoulder arthropathy that causes severe destruction of the articular cartilage and subchondral bone of the glenohumeral joint. • Massive rotator cuff tear, recurrent noninflammatory joint effusion, and synovial hyperplasia are present.
Chronic rotator cuff tear The high position of the humeral head is evident from the small acromiohumeral distance.
Milwaukee shoulder. There is a rotator cuff tear with marked elevation of the humeral head under the acromion. Bursal distension with splaying of the adjacent fat (arrows) is evident.
3. CPPD DEPOSITION DISEASE • Calcium pyrophosphate dihydrate deposition is a crystal deposition arthropathy that results from deposition of CPPD crystals into the hyaline cartilage, labrum, and other soft-tissue structures of the shoulder. • Radiographically, this results in the hallmark finding of chondrocalcinosis, which is not as common within the shoulder as it is in the knee or wrist. • Over time, CPPD results in secondary osteoarthritis of the glenohumeral joint. • With the exception of prior trauma, CPPD is the leading cause of secondary osteoarthritis in the shoulder, especially if the OA is bilateral.
Calcium pyrophosphate deposition disease. AP radiograph of left shoulder shows linear collection of chondrocalcinosis (arrows) within hyaline articular cartilage of humeral head.
4. SYNOVIAL OSTEOCHONDROMATOSIS • Primary synovial chondromatosis is a benign, predominately monoarticular disease. • It results from synovial membrane proliferation and metaplasia forming multiple cartilaginous nodules that may detach into the joint. • As the chondroid fragments are bathed and nourished in the synovial fluid, they can enlarge and ossify. • When the intra-articular chondroid fragments are not calcified or ossified, shoulder radiographs can appear normal. • As the fragments ossify, well defined circular opacities are seen within the joint or the bursae of the shoulder
Synovial osteochondromatosis. There are innumerable circular calcifications distributed in the joint and the capsular recesses.
SHOULDER IMAGING FOR VARIOUS CONDITIONS
THANK YOU

More Related Content

PPTX
Presentation1.pptx, radiological anatomy of the shoulder joint.
byAbdellah Nazeer
 
PPTX
X ray of wrist and hand
byAthul Nampoothiri
 
PPTX
Radiographic evaluation of shoulder
bymrinal joshi
 
PPTX
Elbow joint anatomy
byHarshal Shinde
 
PPTX
Knee Joint Anatomy
byKommireddy Kumar
 
PPTX
Presentation1.pptx, normal spinal anatomy.
byAbdellah Nazeer
 
PPTX
Shoulder radiography
byACMC EM Residency
 
PPTX
Presentation1.pptx, radiological anatomy of the knee joint.
byAbdellah Nazeer
 
Presentation1.pptx, radiological anatomy of the shoulder joint.
byAbdellah Nazeer
 
X ray of wrist and hand
byAthul Nampoothiri
 
Radiographic evaluation of shoulder
bymrinal joshi
 
Elbow joint anatomy
byHarshal Shinde
 
Knee Joint Anatomy
byKommireddy Kumar
 
Presentation1.pptx, normal spinal anatomy.
byAbdellah Nazeer
 
Shoulder radiography
byACMC EM Residency
 
Presentation1.pptx, radiological anatomy of the knee joint.
byAbdellah Nazeer
 

What's hot

PPTX
Presentation1.pptx, radiological anatomy of the arm and forearm.
byAbdellah Nazeer
 
PPTX
Mr imaging of spine
byDr. Muhammad Bin Zulfiqar
 
PDF
Cross sectional anatomy of the neck
bySahil Chaudhry
 
PPT
Slideshow: Carpal Tunnel
byThe Funky Professor
 
PPTX
X ray knee joint
byAthul Nampoothiri
 
PPTX
Diagnostic Ultrasound of shoulder
byDr Ravi Shankar Sharma
 
PPTX
Anatomy of cervical spine
byPonnilavan Ponz
 
PPTX
Spine radiography
byDr. Muhammad Bin Zulfiqar
 
PPTX
RADIOLOGICAL ANATOMY OF UPPER LIMB(SHOULDER@ELBOW)
byBhaskar Sangamreddy
 
PPT
Anatomy of the knee joint
byRosshini Jegatheswaran
 
PPSX
Anatomy of ankle and foot
byDr VAIBHAV KALYANJI VIRA
 
PDF
1. vertebral column
bySaiBadugu
 
PPTX
Presentation1.pptx, radiological imaging of bursae.
byAbdellah Nazeer
 
PPTX
Role of ultrasound in clinical evaluation of shoulder Dr. Muhammad Bin Zulfiqar
byDr. Muhammad Bin Zulfiqar
 
DOC
Various Pelvic lines
bySelf
 
PPTX
Anatomy of shoulder joint
byvishal pushkarna
 
PPTX
Elbow joint with applied anatomy
byHETA PATEL
 
PPTX
HOW TO READ SHOULDER MRI
byArjun Kouloth
 
PPTX
Mri shoulder joint with common pathologies
byGobardhan Thapa
 
PDF
Muscular anatomy of upper limb, MRI Anatomy
byBishnu Khatiwada
 
Presentation1.pptx, radiological anatomy of the arm and forearm.
byAbdellah Nazeer
 
Mr imaging of spine
byDr. Muhammad Bin Zulfiqar
 
Cross sectional anatomy of the neck
bySahil Chaudhry
 
Slideshow: Carpal Tunnel
byThe Funky Professor
 
X ray knee joint
byAthul Nampoothiri
 
Diagnostic Ultrasound of shoulder
byDr Ravi Shankar Sharma
 
Anatomy of cervical spine
byPonnilavan Ponz
 
Spine radiography
byDr. Muhammad Bin Zulfiqar
 
RADIOLOGICAL ANATOMY OF UPPER LIMB(SHOULDER@ELBOW)
byBhaskar Sangamreddy
 
Anatomy of the knee joint
byRosshini Jegatheswaran
 
Anatomy of ankle and foot
byDr VAIBHAV KALYANJI VIRA
 
1. vertebral column
bySaiBadugu
 
Presentation1.pptx, radiological imaging of bursae.
byAbdellah Nazeer
 
Role of ultrasound in clinical evaluation of shoulder Dr. Muhammad Bin Zulfiqar
byDr. Muhammad Bin Zulfiqar
 
Various Pelvic lines
bySelf
 
Anatomy of shoulder joint
byvishal pushkarna
 
Elbow joint with applied anatomy
byHETA PATEL
 
HOW TO READ SHOULDER MRI
byArjun Kouloth
 
Mri shoulder joint with common pathologies
byGobardhan Thapa
 
Muscular anatomy of upper limb, MRI Anatomy
byBishnu Khatiwada
 

Similar to Anatomy and xrays of shoulder joint

PPT
Examination of shoulder joint
byVivek Mathew Philip
 
PPTX
The shoulder joint
byQuan Fu Gan
 
PPTX
Anatomy of shoulder
byDr_KF
 
PPT
shoulder joints anatomy and clinical significance
byMunnakumarsah5
 
PDF
Anatomy of shoulder joint
byRitika Gautam
 
PDF
Comparetive anatomy &amp; kinesiology of large important synovial joint of h...
byDr Lovely Jain
 
PPT
Anatomy of shoulder joint - vamshi kiran
bybadamvamshikiran
 
PPTX
Glenohumeral joint
byLucidante1
 
PPTX
Shoulder Joint Anatomical structures and clinical implications
byShanyaVishnoi2
 
PPTX
applied aspects of shoulder joint
bymrinal joshi
 
PPTX
Anatomy of the shoulder joint
byDr. Kaustav Basu Thakur
 
PPT
Shoulder joint, mbbs 3 9-2015, dr vvs
bySachin Patne
 
PPTX
shoulderjoint-180413132615.pptx
byMohi54
 
PPTX
The Shoulder Anatomy.pptx
byPeterBockarie
 
PPT
anatomy and biomechanics of Shoulder joint
byHarsha Nandini
 
PPTX
Shoulder joint (Biomechanics, Anatomy, Kinesiology)by Muhammad Arslan Yasin
byMuhammad Arslan Yasin Sukhera
 
PDF
SHOULDER JOINT - Prof.Dr.N.Mugunthan.pdf
byKanyakumari Medical Mission Research Center, Muttom
 
PPTX
Shoulder bio-mechanics
byMaryam Alasfour
 
PPTX
Radiological anatomy of shoulder joint
byChandan Prasad
 
PPTX
shoulder anatomy for medicos muscles joint
byguptayash0344
 
Examination of shoulder joint
byVivek Mathew Philip
 
The shoulder joint
byQuan Fu Gan
 
Anatomy of shoulder
byDr_KF
 
shoulder joints anatomy and clinical significance
byMunnakumarsah5
 
Anatomy of shoulder joint
byRitika Gautam
 
Comparetive anatomy &amp; kinesiology of large important synovial joint of h...
byDr Lovely Jain
 
Anatomy of shoulder joint - vamshi kiran
bybadamvamshikiran
 
Glenohumeral joint
byLucidante1
 
Shoulder Joint Anatomical structures and clinical implications
byShanyaVishnoi2
 
applied aspects of shoulder joint
bymrinal joshi
 
Anatomy of the shoulder joint
byDr. Kaustav Basu Thakur
 
Shoulder joint, mbbs 3 9-2015, dr vvs
bySachin Patne
 
shoulderjoint-180413132615.pptx
byMohi54
 
The Shoulder Anatomy.pptx
byPeterBockarie
 
anatomy and biomechanics of Shoulder joint
byHarsha Nandini
 
Shoulder joint (Biomechanics, Anatomy, Kinesiology)by Muhammad Arslan Yasin
byMuhammad Arslan Yasin Sukhera
 
SHOULDER JOINT - Prof.Dr.N.Mugunthan.pdf
byKanyakumari Medical Mission Research Center, Muttom
 
Shoulder bio-mechanics
byMaryam Alasfour
 
Radiological anatomy of shoulder joint
byChandan Prasad
 
shoulder anatomy for medicos muscles joint
byguptayash0344
 

Recently uploaded

PPTX
CELL PHYSIOLOGY: STRUCTURE AND FUNCTIONS
byDR.P.S SUDHAKAR
 
PPTX
Full Endoscopic Interlaminar Lumbar Discectomy
byNtambi Rogers
 
PDF
MIndsets in Career of Emergency Medicine
byChing-Hsing Lee
 
PDF
classification & denaturation and structural -functional relationship of Prot...
byDr. Santhosh Kumar. N
 
PPTX
HD catheters, what do we need to know 2025 updated.pptx
byJAFAR ALSAID
 
PDF
Next-Generation Solutions to Optimize Glioma Care: Applying The Latest Eviden...
byPVI, PeerView Institute for Medical Education
 
PDF
Prosthetic Solutions Cranio-Maxillo-Facial
byDavide Decesari
 
PDF
COMPREHENSIVE SURVEY OF UPPER LIMB NERVES-Prof.Dr.N.Mugunthan.pdf
byKanyakumari Medical Mission Research Center, Muttom
 
PDF
Ppt bls basic life support for respiratory arrest developed by devansh and n...
bydevanshshankhwar05
 
PPTX
Research Methodology_UNIT_V_Declaration of Helsinki M. Pharm (IIIrd Sem.).pptx
byDHANASHREE KOLHEKAR
 
PDF
Schlosser Hemsley et al RPM Systematic Review ASHA 2025
byBronwyn Hemsley
 
PDF
Amino acids chemistry (classification & biological peptides)
byDr. Santhosh Kumar. N
 
PPTX
Human Reproductive System (RIT BRANCH): Physiology, Hormonal Control & Clinic...
byBALAJI SOMA
 
PPTX
MEDICAL RESEARCH UNIT_III_RESEARCH METHODOLOGY & BIOSTATISTICS.pptx
byDHANASHREE KOLHEKAR
 
PDF
Antibiotics: Cephalosporins & Monobactams.pdf
byPrerana Jadhav
 
PDF
2. Structural organization of Proteins & denaturation of proteins
byDr. Santhosh Kumar. N
 
PPTX
IgA Nephropathy: overview of Clinical trials (Journal Club)
byibrahimgalalah
 
PPTX
Differentiation between benign and malignant tumors.pptx
byalialiali20052016
 
PPTX
Human Digestive System (AOTT): Structure, Functions & Digestion.pptx
byBALAJI SOMA
 
PPTX
Central Venous Line: Insertion Technique & Complications
byDr Jebish Pradhan
 
CELL PHYSIOLOGY: STRUCTURE AND FUNCTIONS
byDR.P.S SUDHAKAR
 
Full Endoscopic Interlaminar Lumbar Discectomy
byNtambi Rogers
 
MIndsets in Career of Emergency Medicine
byChing-Hsing Lee
 
classification & denaturation and structural -functional relationship of Prot...
byDr. Santhosh Kumar. N
 
HD catheters, what do we need to know 2025 updated.pptx
byJAFAR ALSAID
 
Next-Generation Solutions to Optimize Glioma Care: Applying The Latest Eviden...
byPVI, PeerView Institute for Medical Education
 
Prosthetic Solutions Cranio-Maxillo-Facial
byDavide Decesari
 
COMPREHENSIVE SURVEY OF UPPER LIMB NERVES-Prof.Dr.N.Mugunthan.pdf
byKanyakumari Medical Mission Research Center, Muttom
 
Ppt bls basic life support for respiratory arrest developed by devansh and n...
bydevanshshankhwar05
 
Research Methodology_UNIT_V_Declaration of Helsinki M. Pharm (IIIrd Sem.).pptx
byDHANASHREE KOLHEKAR
 
Schlosser Hemsley et al RPM Systematic Review ASHA 2025
byBronwyn Hemsley
 
Amino acids chemistry (classification & biological peptides)
byDr. Santhosh Kumar. N
 
Human Reproductive System (RIT BRANCH): Physiology, Hormonal Control & Clinic...
byBALAJI SOMA
 
MEDICAL RESEARCH UNIT_III_RESEARCH METHODOLOGY & BIOSTATISTICS.pptx
byDHANASHREE KOLHEKAR
 
Antibiotics: Cephalosporins & Monobactams.pdf
byPrerana Jadhav
 
2. Structural organization of Proteins & denaturation of proteins
byDr. Santhosh Kumar. N
 
IgA Nephropathy: overview of Clinical trials (Journal Club)
byibrahimgalalah
 
Differentiation between benign and malignant tumors.pptx
byalialiali20052016
 
Human Digestive System (AOTT): Structure, Functions & Digestion.pptx
byBALAJI SOMA
 
Central Venous Line: Insertion Technique & Complications
byDr Jebish Pradhan
 

Anatomy and xrays of shoulder joint

  • 1.
    ANATOMY AND XRAYOF SHOULDER JOINT -AKSHAY M
  • 2.
  • 3.
    INTRODUCTION • The shouldergirdle consists of three bones scapula, clavicle and humerus. • The glenohumeral joint combined with the scapulothoracic, sternoclavicular and acromio clavicular joints comprise the shoulder joint complex. • It has the greatest range of motion of any joint in the body. • Due to wide range of movement it is also most unstable joint compared to other joints of the body. However a series of complex ligaments and muscle keep it in place.
  • 4.
    • Ligaments aroundgleno-humeral joint limit the amount of joint movement o Capsular ligament o Coracohumeral ligament o Transverse Humeral ligament o Glenoid ligament • Shoulder is protected above by arched vault formed by: o Under surface of coracoid process o Under surface of acromion process o Coraco-acromial ligament
  • 5.
    Joints of theShoulder Complex 1. Glenohumeral joint 2. Acromioclavicular joint 3. Sternoclavicular joint 4. Scapulothoracic joint
  • 6.
    1. Acromioclavicular joint •Synovial plane joint between oval facet of clavicle and concave area on anterior end of acromion process. • Joint line is oblique and slightly curved which helps the acromion to glide anteroposteriorly over the clavicle and thus keeps the glenoid continuously facing the humeral head. • Consists of a capsule and superior acromioclavicular ligament
  • 7.
    2. Sternoclavicular joint •The only joint connecting the shoulder complex to the axial skeleton. • Plane synovial joint. But functions resembles a ball and socket joint. • Lacks congruity and ½ of lateral end of clavicle protrudes over a shallow sternal socket. • Mainly stabilized by articular disc and costoclavicular ligament. • Articular disc is circular fibrocartilage, attached superiorly to upper medial end of clavicle and inferiorly to sternum and first costal cartilage. Thereby acts as a hinge. • Costoclavicular ligament is bilaminar and attaches medial end of clavicle to first rib. • It allows elevation-depression, protraction-retraction and long axis rotation of clavicle.
  • 8.
    3. Scapulothoracic Joint •Joint type: not a ‘true’ joint, but known as a ‘pseudo’ joint • Bones involved in the articulation: o Anterior surface of the Scapula o Ribcage of the Thorax • Movements: o Protraction and retraction o Elevation and depression o Anterior tilt and posterior tilt o Upward rotation and downward rotation • As there is minimal bony contact, it is up to the muscles attaching to the scapula and thorax to stabilise and control movement at this articulation • There is no joint capsule or synovial fluid.
  • 9.
    4. Glenohumeral joint •The glenohumeral joint is the most mobile joint in the body. The ‘socket’ (glenoidfossa) is very shallow, and hence the inherent stability is minimal. • Joint type: Multi axial ball and socket synovial joint • Althought the articular surfaces are reciprocally curved, are oval and not sections of true spheres and are asymmetrical and are not congruent. • Only 25-30% on humeral head is in contact with glenoid fossa at any position.
  • 10.
    Glenoid Cavity • Shallow,Pear Shaped “socket” • Directed Laterally and Upward • Glenoid Fossa is deepened by a fibrous and fibro- cartilaginous rim of Glenoid labrum. • Inner surface covered with synovium, outer surface attaches to the capsule and continuous with the periosteum of scapular neck. • The anterior labrum is thicker is larger and wider than the posterior labrum. • Function o Protect edges of glenoid o Assists in lubrication of joint o Stability o Attachment for glenohumeral ligaments
  • 12.
    Capsular Ligament • Encirclesentireglenohumeraljoint. • Attached: o Medially:Above to the circumference ofglenoid cavity beyond the glenoid ligament o Laterally: Below to anatomicalneck of the humerus • Thickerabove andbelow. • Loose andlax • Allow bone to be separated from each othermore than an inch
  • 13.
    Supplemental Bands ofCapsular Ligament • Strengthen capsular ligament in the interior part of the joint. • Flood’s Ligaments o Situated on inner side of joint o Passes from inner edge of glenoid cavity o Attached to lower part of lesser tuberosity of humerus. • Schlemm’s Ligaments o Situated at lower part of the joint o Passes from under edge of glenoid cavity o Attached to under part of neck of humerus • Glenohumeral Ligaments o Situated at upper part of the joints, projects into its interior (can only be seen when capsule is open). Attached above apex of glenoid cavity close to root of coracoid process, attached below lesser tuberosity of humerus (Forms inner boundary of upper part of bicipital groove)
  • 14.
    Muscles Supporting CapsularLigament • Superiorly – Supraspinatus • Inferiorly - Long Head of Triceps • Posteriorly - Tendons of Infraspinatus and Teres Minor • Anteriorly - Tendon of Subscapularis
  • 15.
    Rotator cuff The rotatorcuff is another name for a cluster of 4 different muscles and their tendons that play an important role in providing strength and stability in the shoulder movement. • Supraspinatus: The main function of the supraspinatus muscle is to hold the humerus in its place and maintain the stability of the upper arm which ultimately helps to lift the arm. • Infraspinatus: Rotation and extension of the shoulder is the major function carried out by infraspinatus muscle. • Teres Minor: This is the smallest of all rotator cuff muscle. Its major function is to help in the rotation of the arm away from the body. • Subscapularis: This muscle keeps the upper arm intact to your shoulder blade and assists in rotation of the arm, hold it straight out and lower it.
  • 17.
    Openings of CapsularLigament Anteriorly • Foramen of Weitbrecht Below coracoid Process, connection between synovial membrane of the joint and a bursa beneath the tendon of subscapularis muscle. • Between the 2 tuberosities, passage of the biceps long head. o Posteriorly • Not constant, where a communication exists between joint and a bursal sac belonging to Infraspinatus muscle.
  • 18.
    Synovial Membrane • Reflectedfrom margin of glenoid cavity over fibro- cartilaginous rim surrounding it. • Over internal surface of capsular ligaments. • Covers lower part and sides of anatomical neck of humerus.
  • 19.
    Ligaments 1. Glenohumeral ligament Provideanterior stability to the glenohumeral joint 1. Superior (SGHL) 2. Middle (MGHL) 3. Inferior (IGHL) They lie on anterior and inferior aspect of the joint.
  • 20.
    A. Superior GHLigament • Resists inferior translation of humeral head in rest or adducted arm • Well-developed in 50% • From superior glenoid tubercle, base of coracoid process, upper glenoid labrum then laterally to upper part of lesser tuberosity. B. Middle GH Ligament • Absent in 30% maximum variation. • Resists inferior translation in abduction and external rotation. • Restrains anterior translation (45° abduction) • From SGHL along the anterior margin of glenoid fossa, down till inferior 1/3 of glenoid rim then laterally to ant aspect of anatomical neck and lesser tubercle. • Intimately attached to subscapularis.
  • 21.
    C. Inferior glenohumeralLigament • Thickest and most important stabilizer of shoulder. • 3 components- anterior band, posterior band and axillary pouch. • Attaches to inferior, anterior and posterior margins of glenoid labrum • Anterior band wraps around the head like a hammock to prevent anterior mighation of head
  • 22.
    2. Coracohumeral Ligament •Broad Thick band • It forms roof of bicipital tendon sheath and • strengthens capsule anteriorly. • Attachments o Arisesfrom outer borderof coracoid process o Blended with tendonof supraspinatusmuscles • United to capsulein greater part of its extend. • Importance-resists inferior and posterior translation. 3. Transverse Humeral Ligament • Bridges upper part of bicipital groove through which long head of biceps passes down.
  • 23.
    4. Acromioclavicular ligament Itacts to secure the acromion and clavicle and provides a complete capsule around the joint. 5. Coracoclavicular ligaments It anchor the lateral aspect of the clavicle to the coracoid process of scapula. It consists of two small ligaments holding the scapula laterally, these are: • Trapeziod - attaches to the trapezoid line on the inferior surface of the clavicle • Conoid - attaches to the conoid tubercle of the clavicle
  • 24.
    Bursae In RelationTo The Shoulder Joint 1) Subscapular Bursa 2) Infraspinatus bursa 3) Subacromial bursa (subdeltoid) 4) Subcoracoid Bursa
  • 25.
    1. Subscapular Bursa Intervenesbetween the tendon of subscapularis and fibrous capsule. Communicates with the joint cavity through oval gap between superior and middle glenohumeral ligaments. 2. Infraspinatus Bursa Communicates with the joint from behind 3. Subacromial Bursa o Largest bursa of the body intervenes between supraspinatus and coraco- acromial arch. o It does not communicate with the joint. o It is of great value in the abduction of arm at the shoulder joint where is protects the supraspinatus tendon against friction with the acromion
  • 26.
    Blood and NerveSupply • Blood Supply 1. Anterior circumflex humeral vessels 2. Posterior circumflex humeral vessels 3. Suprascapular vessels • Nerve Supply 1) Axillary nerve 2) Musculocutaneous nerve 3) Suprascapular Nerve 4) Lateral pectoral nerve
  • 27.
    Gateways to thePosterior Scapular Region 1. Suprascapular Foramen • It is formed by suprascapular notch of scapula and the superior transverse scapular ligament,which converts the notch into a foramen. • The suprascapular nerve passes trough the suorascapular foramen 2. Quadrangular Space • Its boundaries are formed by: o The inferior margin of the teres minor o Surgical neck of humerus o The superior margin of the teres major o Lateral margin of the long head of triceps brachii. • Axillary nerve and posterior circumflex humeral artery and vein pass trough this space
  • 28.
    3. Triangular Space •Its boundaries are formed by o The medial margin of the long head of triceps brachii o The superior margin of the teres major o The inferior margins of the teres minor • The circumflex scapular artery and vein pass trough this space 4. Triangular Interval • Boundaries are formed by o The lateral margin of the long head of triceps brachii o The shaft of the humerus o The inferior margin of the teres major • Radial nerve,profunda brachii artery and associated veins pass trough it
  • 29.
    Movements At TheShoulder Joints • Movement in every direction (Flexion,extension, abduction, adduction, rotation, circumduction) • Highly mobile dueto: o Largesizeof head of humerus incomparison with the depth of glenoid cavity(Even when supplemented by glenoid ligament) o Looseness of the capsule of the joint(Laxityof fibrouscapsule) o When movements of arm are arrested by contact of the bony surface Tensionof corresponding fibersand musclesacting on accessory ligaments farther movements of scapula and accessory structuresto the shoulder joint (acromio and sterno- clavicularjoints). • SpinalCord regulating Shouldermovements (C5,C6, C7 & C8) o Flexion,Abduction, & lateralrotation(C5, C6,). o Extension,Adduction, & Medial rotationis(C6,C7, C8) • Concave-convex rule o Convex humeral head moves within the concave glenoid fossa o The Convex joint surface (Humeral Head) moves in a direction opposite to the movement of the body segment (Humeral Shaft)
  • 30.
    1. Flexion • Planeof Motion: o Sagittal Plane • Axis of Motion: o Transverse Axis through the center of the humeral head • Muscles Involved: o Pectoris major o Anterior Fibres od Deltoid o Coraco-brachialis o Biceps (When the foreare is flexed) • Humeral head glides posterior laterally in the glenoid cavity • Range of Motion o 0 – 90 degrees Factors Limiting Shoulder Flexion • Inferior Glenohumeral ligament • Tightness of posterior joint capsule
  • 31.
    2. Extension • PlaneofMotion: o SagittalPlane • AxisofMotion: o TransverseAxisthrough the centerof the humeralhead • MusclesInvolve: o Latissimusdorsi o Teresmajor o Posterior fibers ofDeltoid o Triceps (When forearm isextended) • Humeral head glideanterior medially in glenoidcavity • Range ofMotion o 0–45degrees or 60degrees Factors Limiting Shoulder Extension- • Superior and medial gleno-humeral ligament
  • 32.
    3. Abduction • Planeof Motion: o Frontal Plane • Axis of Motion: o Sagittal axis through the center of the humeral head • Muscles Involve: o Deltoid o Supraspinatus • Humeral head glide inferiorly in glenoid cavity • Range of Motion o Total : 0 – 165 degrees or 175 degrees o Full internal rotation of humerus: 0 – 60 degrees o Full external rotation of Humerus: 0 – 90 degrees Factors Limiting Shoulder Abduction • Inferior glenohumeral ligament • Tightness of the inferior joint capsule of the glenoumeral joint
  • 33.
    4. Adduction • Planeof Motion: o Frontal Plane • Axis of Motion: o Sagittal axis through the center of the humeral head • Muscles Involve: o Subscapularis o Pectoralis Major o Latissimus dorsi o Teres major • Humeral head glide superiorly in glenoid cavity • Factors Limiting: o Trunk
  • 34.
    5. Internal Rotation •Plane of Motion: o Transverse Plane • Axis of Motion: o Vertical axis through the center of humeral head • Muscles Involve: o Subscapularis o Pectoralis Major o Latissimus dorsi o Teres major • Humeral head glide posteriorlaterally in glenoid cavity • Range of Motion o 0-70º as the arm at 90º of shoulder abduction and 90º elbow flexion o If the elbow is extended, shoulder rotation occurs simultaneously with forearm rotation. Factors Limiting Internal Rotation • Posterior Capsule
  • 35.
    6. External Rotation •Plane of Motion: o Transverse Plane • Axis of Motion: o Vertical axis through the center of humeral head • Muscles Involve: o Infraspinatus o Teres Minor • Humeral head glide anteriomedially in glenoid cavity • Range of Motion o 0-90º as the arm at 90º of shoulder abduction and 90º elbow flexion o If the elbow is extended, shoulder rotation occurs simultaneously with forearm rotation. Factors Limiting External Rotation • Coracohumeral ligament • 3 glenohumeral ligaments
  • 36.
    7. Circumduction • Acombinationof flexion,abduction, extension, and adduction orinthereversed sequence o glenohumeral flexion abduction extension adduction o glenohumeral extension abduction flexion adduction
  • 38.
    Close and LoosePacked Position • Close Packed position o Position where the articular surfaces of joint are in maximal congruency status, resulting in greatest mechanical stability. o Most ligament and capsule surrounding joint are taut. o 90° of glenohumeral abduction and full external rotation • Loose Packed position o Position where the articular surface of joint are in minimal congruency status. o Supporting structures are most lax. o 55° of semi-abduction and 30° of horizontal adduction
  • 39.
  • 40.
    RADIOGRAPHIC TECHNIQUE • Properradiographic technique and positioning is important to understand the normal appearances which can direct us the various abnormalities & diseases. • A shoulder radiograph series may be needed for a particular condition, such as for evaluation of arthritis, trauma, instability, or impingement. • Additional views may be obtained in the search for specific abnormalities depending on the clinical situation and area of concern.
  • 41.
    1. ANTEROPOSTERIOR (AP)VIEW • Two AP projections: • With the arm in external rotation: , the humeral head has the appearance of an Indian axe. • With the arm in internal rotation: the humeral head has the appearance of an ice-cream cone. • Since the glenohumeral joint is normally anatomically tilted 35–40 degree anteriorly, this projection results in overlap of the glenoid and humeral head. • Acute trauma- Coracoid Process Fracture, Glenoid Fracture, Proximal Humerus Fracture, compression fracture of humeral head. • Chronic shoulder pain, including Glenohumeral Arthritis, calcific tendonitis or bursitis, and AC joint arthritis. SHOULDER RADIOGRAPH PROJECTIONS
  • 42.
    • The APprojection is usually obtained with the patient in the upright or supine position and with the coronal plane of the body parallel to the cassette. • The beam is directed in a true AP direction relative to the body. • This results in slight overlap of the glenoid rim and the humeral head as the glenohumeral joint is tilted anteriorly approximately 40°. • The lateral border of the scapula and the medial cortex of the proximal humerus form a gentle, smooth convex arch, known as scapulohumeral or Moloney’sarch.
  • 43.
    The beam isoriented in true AP view to the patient with the arm positioned in either neutral, internal, or external rotation. The beam is centered on the coracoid process with the blade of the scapula almost parallel to the film.
  • 44.
    AP external rotation.There is overlap of the humeral head and the glenoid (ellipse). The anterior (arrow) and posterior (thick dashes) margins of the glenoid are seen. The greater tuberosity (G) is seen in profile. The acromiohumeral distance (line) is normal (>7 mm).
  • 45.
    AP internal rotation.The humeral head is round in appearance with a smooth posterior contour. The fat along the subacromial-subdeltoid bursa is seen as a lucent crescent (arrowheads).
  • 46.
  • 47.
    2. ROCKWOOD VIEW •The Rockwood view (AP with 30 º caudal angulation of the X-ray beam) is utilized in the impingement series to evaluate the acromion and subacromial space. • Angling the X-ray tube caudally or tilting the patient forward provides improved visualization of the subacromial space.
  • 48.
    The Rockwood viewis a modified AP view taken with 30 degree caudal angulation.
  • 49.
    Normally, a line(dashed) along the inferior aspect of the clavicle intersects the undersurface of the acromion. Areas of bony prominence or osteophytes will extend below this line.
  • 50.
    3. GRASHEY VIEW •The Grashey view is a true anterior–posterior view of the shoulder. • The overlap between the humerus and the glenoid seen on the AP view is removed in the Grashey projection by rotating the patient posteriorly or angling the beam laterally. • Helpful for: Glenohumeral Arthritis, Coracoid Process Fracture, Glenoid Fracture, Proximal Humerus Fracture. Posterior Glenohumeral Instability. • Evaluate: humeral head postion relative to glenoid; AC joint position/arthritis; RTC calcifications, acromial spurring • Acromiohumeral interval: normal = 7-14mm. <7mm indicates Massive RTC Tear. May appear falsely decreased with posterior subluxation of the humeral head.
  • 51.
    Position: Patient erect,turned 30-35° toward the side being xrayed Tube: Perpendicular to plate
  • 52.
    The glenohumeral jointis seen in profile (arrows) without overlap of the humerus and glenoid.
  • 54.
    4. AXILLARY VIEW •Axillary view is a tangential view of the glenohumeral joint from below. • Demonstrates: glenohumeral joint narrowing (best view), Os Acromionale, glenoid version, glenoid erosion, humeral head subluxation. • Helpful for: determining the amount of acromion which remains in patients who have undergone previous surgery; relation of humeral head to glenoid; Hill-Sachs lesions, Os Acromionale, Acromioclavicular Arthritis, Shoulder Dislocation, osseous Bankart fracture involving the anterior glenoid rim. • The radiographic quality is often very limited because of the rapid change of overlying soft-tissue density.
  • 55.
    Position: Patient seatedat side of radiographic table or supine with the arm abducted 90º and axilla over the cassette. Beam: angle 5°-10° toward the elbow, central beam directed at the shoulder joint/humeral head.
  • 56.
    The glenohumeral jointis seen in profile and is symmetrical. The humeral head is centred on the glenoid.
  • 57.
    5. WEST POINTVIEW • The West Point View is a variation of the lateral axillary view that was developed to improve detection of a Bankart fracture of the anterior glenoid rim. • Demostrates: anteroinferior glenoid rim., best for osseous Bankart Lesion. • Helpful for: Shoulder Instability, Glenoid Fracture, osseous Bankart Lesion. • Although this projection improves detection of an osseous Bankart lesion, it can be difficult to obtain in the setting of acute trauma.
  • 58.
    Postion: Patient pronewith affected shoulder resting on a pad @8cm for the table top. Casette positioned against the superior apsect of the shoulder. Beam: aimed 25° from horizontal (to tables surface) and 25° medially (to patients midline).
  • 59.
    The anteroinferior (arrow)portion of the glenoid is seen without overlap of the coracoid. Glenoi d Head of Humerus
  • 60.
    6. GARTH APICALOBLIQUE VIEW • The Garth view of the shoulder is a projection used in trauma when evaluating the glenohumeral joint for dislocations and trauma to the glenoid of the scapula. • It shows antero inferior glenoid rim. • This projection is often used as a replacement to the lateral scapula view in trauma. • It is an optimal projection to demonstrate Bankart and Hill-Sachs lesions
  • 61.
    Position: Patient erectwith rotating the patient 30-45° Beam: 45° caudal angle of the x-ray tube
  • 62.
    7. SCAPULAR YVIEW • The scapular body is seen in tangent and the glenoid fossa is seen en face as a Y- shaped intersection of the scapular body, acromion process, and coracoid process. • The humeral head should be centred over the glenoid fossa. • Demonstrates: lateral projection of scapular body and humeral head overlapping the glenoid. • Helpful for: Shoulder Dislocation; Proximal Humerus Fracture. ; Scapula Fracture, coracoid fracture • The scapular Y view is also used to evaluate the contour of the undersurface of theacromion process when “typing” the acromion.
  • 63.
    Position: Erect withanterior aspect of affected shoulder against x-ray plate and rotating other shoulder out 40 deg°. Beam: aimed from posteriorly along scapular spine
  • 64.
    Lines through theacromion, coracoid process, and body of the scapula intersect at the center of the glenoid. The humeral head is centred on this intersection point.
  • 66.
    8. NEER’S SUPRASPINATUSOUTLET VIEW • The supraspinatus outlet view is useful for evaluating the acromion process and subacromial abnormalities such as osteophytes that may cause impingement. • It is similar to the Y-view but with caudal tube angulation. • This view is taken with the patient turned as for the Y projection and the cassette perpendicular to the body of the scapula and parallel to glenoid fossa. • Demonstrates: outlet/impingement of the supraspinatus and coracoacromial arch. • Helpful for: Subacromial Impingement, assessing Subacromial Morphology, unfused acromial epiphysis
  • 67.
    Position: Erect withanterior aspect of affected shoulder against x-ray plate and rotating other shoulder out 40 deg°. Beam: aimed from posteriorly along scapular spine but with the beam aimed with 10° caudal tilt
  • 68.
    The subacromial space(arrows) and contour of the acromion (A) are well seen. The water density of the supraspinatus muscle is shown (S).
  • 69.
    9. STRYKER NOTCHVIEW • The Stryker notch view can be obtained with the patient in the supine or upright position. • Demonstrates: humeral head • Helpful for: Hill-Sachs lesions (best view), Bankart Lesion. • This view nicely demonstrates the posterolateral aspect of the humeral head and is excellent for depicting a Hill– Sachs deformity or flattening of the posterolateral humeral head. • Evaluation of glenoid rim fractures or subtle glenohumeral subluxation is limited on this view.
  • 70.
    Position: Patient supinewith cassette posterior to the shoulder. The hand placed on top of the head. The elbow should point straight upward. Beam: directed 10° superiorly/toward the head, centered over the coracoid process.
  • 72.
    The humeral headis normally smoothly round in appearance. A small contour defect in this case is due to a Hill-Sachs impression fracture (arrow).
  • 73.
    10. SERENDIPITY VIEW •Demonstrates: sternoclavicular joints and medial 1/3 of the clavicles. • Helpful for: Clavicle Fracture, Distal Clavicle Fracture, Sternoclavicular Joint Dislocation.
  • 74.
    Postion: supine withcassette under upper chest Beam: aimed at clavicle or manubrium (SC pathology) with a 40° cephalic tilt.
  • 75.
    11. BENNETT'S VIEW •Externalrotation of the humerus with tilting of the x-ray tube 5° cephalad •Bennett lesions of the shoulder, also called thrower's exostosis refers to the mineralisation of the posterior band of the inferior glenohumeral ligament.
  • 76.
    12. ZANCA VIEW •Demonstrates: AC joint and distal clavicle • Helpful for: Acromioclavicular Arthritis, Acromioclavicular Joint Separations, Distal Clavicle Osteolysis, Distal Clavicle Fracture • AC joint spurring and cystic changes indicates Acromioclavicular Arthritis. • Distal clavicle elevation indicates Acromioclavicular Joint Separations.
  • 77.
    Position: Erected withcassette behind shoulder. Beam: Xray beam aimed at the AC joint in 10° to 15° cephalic tilt. Xray penetration should be 1/2 normal to avoid overpenetration of AC joint.
  • 78.
    13. BICIPETAL GROOVEVIEW Demonstrates: the bones and soft tissue of the shoulder, specifically the intertubercular groove free of superimposition of the shoulder. The central ray should be 10-15 degrees posterior at the intertubercular groove. For the Fisk modification, the central ray should be perpendicular to the image receptor at the intertubercular groove and the vertically positioned humerus is angulated at 10-15 degrees.
  • 79.
    APPROACH TO ANALYZINGSHOULDER RADIOGRAPH • The general principles promulgated by Forrester and Nesson provide a useful framework for evaluation of the shoulder. • ABCs must be assessed: Alignment Bone density Cartilage spaces Soft Tissues
  • 80.
  • 81.
    1. FRACTURES OFPROXIMAL HUMERUS • Neer classification system is widely used. • It is a 4 segment system representing the four anatomic components of the proximal humerus. • Fractures of the proximal humerus occur between one or all of these four major segments:  the articular segment (at the level of the anatomic neck)  the greater tuberosity  the lesser tuberosity  humeral shaft (at the level of the surgical neck).
  • 82.
    • In minimallydisplaced fractures, there is no or minimal displacement between the segments. The fragments are held together by the rotator cuff, the joint capsule, and the periosteum. • In a two-part fracture, there is displacement of one segment in relation to the three non- displaced, nonangulated segments. • In a three-part fracture there is involvement of either the lesser or greater tuberosity. There may be anterior or posterior shoulder dislocation. The humeral head is rotated by the pull of one of the rotator cuff tendons, which can be a source of blood supply to the head. • In a four-part fracture, there is involvement of both the greater and lesser tuberosities and fracture of the surgical neck. There may be anterior or posterior shoulder dislocation. There is typically impaired blood supply to the humeral head due to lack of soft-tissue attachment, leading to the frequent development of humeral head osteonecrosis.
  • 83.
    Minimally displaced Neerfracture. There are fractures of the greater tuberosity and surgical neck (arrows) but no significant displacement or angulation is present.
  • 84.
    Two-part Neer fracture.Greater tuberosity (long arrow) is displaced greater than 1 cm from humeral head fragment (short arrow), which remains in near anatomic position
  • 85.
    2. DISLOCATION OFSHOULDER • Shoulder dislocation is the most common large joint dislocation presenting to the Emergency Department. • 3 types:  Anterior shoulder dislocations are the most common, accounting for 95% of all shoulder dislocations.  Posterior shoulder dislocations account for less than 5% of all shoulder dislocations.  Inferior or subglenoid dislocation (luxatio erecta) is very rare, occurring in approximately 0.5% of cases.
  • 86.
    ANTERIOR DISLOCATION • Anteriorshoulder dislocation is usually caused by trauma. • These dislocations tend to recur, especially in young adults. • The Bankart fracture( injury to anteroinferior part of glenoid labrum) and Hill- Sachs deformity (posterolateral humeral head compression fracture ) have been implicated as probable causes of recurrent shoulder dislocations. • The characteristic feature of anterior shoulder dislocation is malposition of the humeral head so that it lies anterior, medial and slightly inferior to the glenoid fossa. • This can be confirmed on the axillary view or the scapular Y-view.
  • 87.
    AP view ofglenohumeral joint demonstrates anterior dislocation of humeral head (arrow). Notice that humeral head has moved medially and inferiorly and sits below coracoid process.
  • 88.
    (B) Axillary viewand (C) scapular Y view demonstrate anterior dislocation of humeral head (arrow) relative to glenoid fossa (arrowhead).
  • 89.
    HILL SACHS LESION •With anterior dislocation, the posterosuperior humeral head contacts the anteroinferior glenoid rim, which may result in a wedge-shaped posterosuperior humeral head impression fracture, termed a Hill-Sachs lesion. • The Hill–Sachs defect is usually best depicted on the AP radiograph of the shoulder with the arm in internal rotation and appears as an area of flattening or concavity of the posterolateral aspect of the humeral head. • The Stryker Notch view is also very useful in depicting a Hill–Sachs defect, whereas the defect may be completely obscured on the axillary view or AP radiograph with external rotation. • Hill-Sachs lesions smaller than 20% of the articular surface are unlikely to be clinically significant, lesions involving 20–40% have variable clinical significance, and lesions larger than 40% are likely to contribute to recurrent dislocation.
  • 90.
    (A) An internalrotation view shows the indentation (impression fracture, arrow) of the posterolateral aspect of the humeral head. (B) The axillary view of another patient shows a Hill-Sachs lesion, (arrow) causing deformity of the posterior humeral head. In this case the defect involves less than 20% of the humeral articular surface. The Stryker notch view is also used to demonstrate Hill-Sachs lesions.
  • 91.
    BANKART LESION • First-timedislocation in a young person (under 35 years of age) usually results in a tear or avulsion of the anterior labroligamentous complex from the inferior glenoid, referred to as a Bankart lesion. • A Bankart fracture refers to an injury that includes not only an anterior labral injury but also a fracture of the anteroinferior glenoid. • Osseous Bankart lesions involving the inferior glenoid rim are often subtle lesions that are best depicted on either the AP or the axillary view of the shoulder. • The West Point axillary view is a special adaptation of the axillary view that was developed to accentuate detection of a Bankart lesion.
  • 92.
    (A)Axillary view ofglenohumeral joint demonstrates small fracture fragment (arrow) adjacent to anterior glenoid. This fracture results from impaction injury of humeral head against anteroinferior glenoid rim and can lead to recurrent instability of glenohumeral joint. (B) Axial T1-weighted MR image with intraarticular gadolinium demonstrates minimally displaced Bankart fracture (arrow).
  • 93.
    POSTERIOR DISLOCATION • Posteriordislocations are most often associated with a seizure or electrocution injury and almost all bilateral posterior shoulder dislocations are due to a seizure. • The mechanism of posterior shoulder dislocation is uneven muscle contraction with the internal rotators of the shoulder contracting with greater force than the external rotators, causing the humeral head(s) to move superiorly and posteriorly. • Humeral head fractures can occur due to continuing pressure against the glenoid. • The anteroposterior radiograph of the shoulder may appear nearly normal in patients with posterior dislocation, contributing to a high misdiagnosis rate and delays in treatment. • The addition of axillary views raises the diagnosis rate to 100%.
  • 94.
    • If axillaryviews cannot be obtained due to patient pain, a scapular “Y” view can be obtained or CT, can demonstrate both the dislocation and any associated fractures. • On the AP radiograph the humeral head is usually in internal rotation and higher than normal. The posterior position of the humeral head can be shown on the scapular “Y” view or axillary view. • Often, the humeral head is subluxed, rather than completely dislocated. The anterior humeral head can impact against the posterior glenoid rim, which can result in an anterior humeral head impression fracture (reverse Hill-Sachs lesion, the trough sign) and/or posterior glenoid rim fracture (reverse Bankart lesion).
  • 95.
    Posterior dislocation. (A)The AP view shows the humeral head fixed in internal rotation and slightly high in position with relation to the glenoid. An impression fracture (trough sign, arrow) is present. (B) A rotated Y-view shows the apposition of the trough fracture line (arrows) and the posterior lip of the glenoid. The displaced humeral head is posterior to the center of the glenoid (circle).
  • 96.
    LUXATIO ERECTA • Luxatioerecta is also called inferior or subglenoid dislocation. • In this injury, the arm is raised, abducted and cannot be lowered. • Causes of luxatio erecta include hyperabduction and extension during a fall and attempting overhead shots in racket sports. • Typical radiographic features of luxatio erecta include humeral head dislocation inferior to the glenoid with the humerus locked in abduction. • Associated injuries: • 80% of the cases have associated greater tuberosity fracture or rotator cuff tear. • 60% of the cases have some degree of neurological impairment, most frequently to the axillary nerve. • 3.3% of the cases have significant vascular compromise.
  • 97.
    Luxatio erecta. Thehumeral head is displaced inferiorly and the arm is abducted.
  • 98.
    Luxatio erecta. APradiograph of shoulder demonstrates humeral head (arrow) to be displaced directly inferiorly relative to glenoid fossa and arm is fixed in fully abducted position.
  • 99.
  • 100.
    1. AVASCULAR NECROSIS •Common etiology: • Post traumatic sequela • Corticosteroid use • Sickle cell disease. • The typical radiographic findings of avascular necrosis depend on its stage, and can progress through subtle lucency, sclerosis, fragmentation, sub-articular collapse, and arthritis and joint destruction in the final stages. • Classic descriptions of AVN include crescent-shaped sub-articular lucency (the crescent sign) as well as the “snowcap sign” due to focal sub-articular sclerosis.
  • 101.
    Avascular necrosis. ThisGrashey projection shows a lucency with surrounding sclerosis (arrows) in the humeral head. In this case, there is no collapse of the humeral head and no crescent sign or cartilage space narrowing is seen.
  • 102.
    AP radiograph ofshoulder demonstrates linear subchondral fracture (arrow) involving medial aspect of subchondral bone of humeral head. Appearance and location are classic for advanced osteonecrosis of humeral head.
  • 103.
  • 104.
    1. RHEUMATOID ARTHRITIS •The radiographic findings of RA of the shoulder consist of  periarticular osteopenia  marginal erosions develop at the bare area (the superolateral aspect of the humeral head adjacent to the greater tuberosity) where articular cartilage is thin.  uniform cartilage space narrowing in the absence of osteophytes  subchondral sclerosis and bursitis. • As the disease progresses, there is concentric erosion of the glenoid accompanied by medial migration of the humeral head. • Atrophy and tear of the rotator cuff with attendant superior migration of the humeral head may follow and erosion and thinning of the undersurface of the acromion can result. • The resulting juxtaposition of the medial humeral shaft and the inferior glenoid eventually produces a notch like defect of the humerus that predisposes to pathologic fracture.
  • 105.
    Rheumatoid arthritis. APradiograph of shoulder demonstrates numerous marginal erosions of proximal humerus, involving medial aspect of humeral head (arrowheads) and medial aspect of proximal humeral shaft (long arrow). In addition, there are erosions and tapering of distal clavicle (short arrow).
  • 106.
    Rheumatoid arthritis. APview shows deepening of the glenoid fossa owing to erosion. There is also erosion of the humeral head
  • 107.
    1. OSTEOARTHRITIS • Sincethe shoulder is a nonweightbearing joint, primary osteoarthritis is unusual. • Most cases of osteoarthritis are, therefore, secondary. Underlying causes include prior trauma, systemic arthritis, chronic rotator cuff tear, congenital malformations, and acromegaly. • Typical of osteoarthritis are asymmetric cartilage space narrowing and osteophytes that arise from the glenoid rim and the anatomic neck of the humerus. • In acromegaly, the osteophytes are typically very large. • As the articular cartilage of the glenohumeral joint deteriorates, subchondral sclerosis and cysts develop. • Unlike inflammatory conditions, bone density is preserved in patients with OA. In late stages, posterior subluxation of the glenohumeral joint occurs.
  • 108.
    Osteoarthritis in apatient with acromegaly. There is narrowing of the glenohumeral joint with large osteophytes. Opacities overlying the scapula are ossified bodies in the subscapularis recess.
  • 109.
  • 110.
    1. CALCIFIC TENDONITIS •The shoulder is the most common site of calcific tendonitis or bursitis. • About half of the cases involve the supraspinatus tendon. • Radiography can localize calcification to a particular tendon and may indicate whether the process is chronic or acute. • Calcification within the supraspinatus tendon is seen in profile over the greater tuberosity on radiographs obtained in external rotation. • Because of their more posterior location, calcification in the infraspinatus or teres minor tendons is best seen on internal rotation radiographs. • Subscapularis calcification is located anteriorly adjacent to the lesser tuberosity and is best seen on axillary views. • Calcification of the long head of the biceps may occur at the musculotendinous junction or at the tendon insertion on the superior glenoid labrum.
  • 111.
    • Chronic calcificationis usually sharply marginated and dense whereas acutely inflamed deposits are less dense and may have surrounding edema causing obliteration of adjacent fat planes. • Correlation with clinical findings is necessary, however, to confirm the relevance of radiographically detected calcification. • Calcification in the rotator cuff may eventually rupture into the bursa and this can be documented on radiographs by the location of the calcification.
  • 112.
    Calcific tendonitis. (A)Calcific tendinitis of the long head of the biceps brachii. The calcification in this case occurred at the musculotendinous junction (arrow). (B) Calcific tendinitis and bursitis of the infraspinatus tendon with bone erosion. Calcification in the infraspinatus tendon has extended into the subacromial-subdeltoid bursa (arrow) and has eroded into the bone (white arrow)
  • 113.
    2. ROTATOR CUFFTEARS • In acute rotator cuff tears, radiographs are usually normal. • A decreased acromiohumeral distance can be seen on films obtained with active abduction. Accompanying atrophy of the supraspinatus muscle can be suspected on the outlet view if there is flattening or poor definition of its normally convex upper margin. • Fatty replacement of the muscle can be seen as areas of low density fat replacing the normally homogeneous muscle density. • Eventually, due to the unopposed action of the deltoid, lack of humeral stabilization by the supraspinatus, and lack of the mass of the supraspinatus tendon interposed between the humerus and acromion, the humeral head will be elevated in relation to the glenoid and the acromiohumeral interval will be narrowed to less than 7 mm.
  • 114.
    • In chronicrotator cuff tears, remodeling of the humeral head and acromion may occur (cuff tear arthropathy). • Milwaukee shoulder syndrome (cuff tear arthropathy) is a rapidly destructive shoulder arthropathy that causes severe destruction of the articular cartilage and subchondral bone of the glenohumeral joint. • Massive rotator cuff tear, recurrent noninflammatory joint effusion, and synovial hyperplasia are present.
  • 115.
    Chronic rotator cufftear The high position of the humeral head is evident from the small acromiohumeral distance.
  • 116.
    Milwaukee shoulder. Thereis a rotator cuff tear with marked elevation of the humeral head under the acromion. Bursal distension with splaying of the adjacent fat (arrows) is evident.
  • 117.
    3. CPPD DEPOSITIONDISEASE • Calcium pyrophosphate dihydrate deposition is a crystal deposition arthropathy that results from deposition of CPPD crystals into the hyaline cartilage, labrum, and other soft-tissue structures of the shoulder. • Radiographically, this results in the hallmark finding of chondrocalcinosis, which is not as common within the shoulder as it is in the knee or wrist. • Over time, CPPD results in secondary osteoarthritis of the glenohumeral joint. • With the exception of prior trauma, CPPD is the leading cause of secondary osteoarthritis in the shoulder, especially if the OA is bilateral.
  • 118.
    Calcium pyrophosphate depositiondisease. AP radiograph of left shoulder shows linear collection of chondrocalcinosis (arrows) within hyaline articular cartilage of humeral head.
  • 119.
    4. SYNOVIAL OSTEOCHONDROMATOSIS •Primary synovial chondromatosis is a benign, predominately monoarticular disease. • It results from synovial membrane proliferation and metaplasia forming multiple cartilaginous nodules that may detach into the joint. • As the chondroid fragments are bathed and nourished in the synovial fluid, they can enlarge and ossify. • When the intra-articular chondroid fragments are not calcified or ossified, shoulder radiographs can appear normal. • As the fragments ossify, well defined circular opacities are seen within the joint or the bursae of the shoulder
  • 120.
    Synovial osteochondromatosis. Thereare innumerable circular calcifications distributed in the joint and the capsular recesses.
  • 121.
    SHOULDER IMAGING FORVARIOUS CONDITIONS
  • 123.