Compilation of detailed anatomy and xray views, their techniques and applicability in clinical practice.

1. ANATOMY AND XRAY OF
SHOULDER JOINT
-AKSHAY M

2. ANATOMY

3. 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.

4. • 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

5. Joints of the Shoulder 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
• 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

13. 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)

14. Muscles Supporting Capsular Ligament
• Superiorly – Supraspinatus
• Inferiorly - Long Head of Triceps
• Posteriorly - Tendons of Infraspinatus and Teres Minor
• Anteriorly - Tendon of Subscapularis

15. 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.

17. 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.

18. 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.

19. 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.

20. 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.

21. 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

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
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

24. Bursae In Relation To The Shoulder Joint
1) Subscapular Bursa
2) Infraspinatus bursa
3) Subacromial bursa (subdeltoid)
4) Subcoracoid Bursa

25. 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

26. 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

27. 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

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 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)

30. 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

31. 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

32. 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

33. 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

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
• A combinationof flexion,abduction, extension, and adduction orinthereversed
sequence
o glenohumeral flexion abduction extension adduction
o glenohumeral extension abduction flexion adduction

38. 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

39. X RAYS

40. 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.

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 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.

43. 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.

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. Moloney’s
arch

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 view is 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 joint is 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 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.

56. The glenohumeral joint is seen in profile and is symmetrical. The humeral head is centred on the glenoid.

57. 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.

58. 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).

59. The anteroinferior (arrow) portion of the glenoid is seen without overlap of the coracoid.
Glenoi
d
Head of
Humerus

60. 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

61. Position: Patient erect with rotating the patient 30-45°
Beam: 45° caudal angle of the x-ray tube

62. 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.

63. 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

64. 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.

66. 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

67. 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

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 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.

70. 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.

72. 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).

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 with cassette under upper chest
Beam: aimed at clavicle or manubrium (SC pathology) with a 40° cephalic tilt.

75. 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.

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 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.

78. 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.

79. 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

80. DISTURBANCE IN ALIGNMENT

81. 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).

82. • 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.

83. Minimally displaced Neer fracture. 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 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.

86. 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.

87. 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.

88. (B) Axillary view and (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 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.

91. 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.

92. (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).

93. 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%.

94. • 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).

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
• 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.

97. Luxatio erecta. The humeral head is displaced inferiorly and the arm is abducted.

98. 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.

99. DISTURBANCE IN BONE DENSITY

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. 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.

102. 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.

103. DISTURBANCE IN CARTILAGE SPACES

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. 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).

106. Rheumatoid arthritis. AP view shows deepening of the glenoid fossa owing to erosion.
There is also erosion of the humeral head

107. 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.

108. 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.

109. DISTURBANCE IN SOFT TISSUES

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 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.

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 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.

114. • 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.

115. Chronic rotator cuff tear
The high position of the humeral head is evident from the small acromiohumeral
distance.

116. 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.

117. 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.

118. Calcium pyrophosphate deposition disease. 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. There are innumerable circular calcifications distributed in the joint and the capsular recesses.

121. SHOULDER IMAGING FOR VARIOUS CONDITIONS

123. THANK YOU