POSITIONING FOR SHOULDER RADIOGRAPHY AND INDICATION FOR SHOULDER X RAY

1. SHOULDERANAND GURMAITA

2. INDICATION OF SHOULDER
1. Shoulder Trauma.
2. Bony Tenderness At The Glenohumeral Joint/Region.
3. Restriction Of Rotation.
4. Instability.
5. Suspected Dislocation.
6. Ac Joint Injury.
7. Scapula Trauma.
8. Suspected Arthritis.
9. Non-traumatic Shoulder Pain

4. PROJECTIONS DONE FOR SHOULDER
1. Antero-posterior (15°) erect
2. Supero-inferior (axial)
3. Infero-superior (reverse axial)
4. Anterior oblique (‘Y’ projection)
5. Antero-posterior modified (Stryker projection)

5. BASIC PROJECTIONS
1. Antero-posterior (15°) erect
 The image is acquired using a 24 × 30 cm computed radiography (CR) cassette
Position of patient and image receptor
 The patient stands with the affected shoulder against the image receptor and is externally
rotated 15° to bring the shoulder under examination closer to the image receptor and the
plane of the acromioclavicular joint (ACJ) perpendicular to the image receptor.
 The arm is supinated and slightly abducted away from the body. A line joining the medial and
lateral epicondyles of the distal humerus should be parallel to the image receptor.

6.  The image receptor is positioned so that its upper border is at least 5 cm above the shoulder
to ensure that the oblique rays do not project the shoulder off the final image.
 The patent should be asked to rotate their head away from the side under examination to
avoid superimposition of the chin over the medial end of the clavicle. • Additionally the
humerus can be internally rotated (so a line joining the epicondyles is perpendicular to the
image receptor) or left in the neural position which will give a different perspective of the
humeral head.
Direction and location of the X-ray beam
 The collimated horizontal beam is directed to the palpable coracoid process of the scapula
and collimated to include the structures below.
Cassette size = 24 × 30 cm
Grid = may or may not be used
Exposure = 10-20 mAs
60-70 kvp
SID = 100 Cm

7. Antero-posterior
Humerus Dislocation

8. 2. Supero-inferior (axial)
Position of patient and image receptor
 The patient is seated with their affected side adjacent to the table, which is lowered to waist
level.
 The image receptor is placed on the tabletop, and the arm under examination is abducted
over the table.
 The patient leans towards the table to reduce the object-toreceptor distance (ORD) and to
ensure that the glenoid cavity is included in the image. A curved cassette, if available, can be
used to reduce the ORD.
 The elbow can remain flexed, but the arm should be abducted to a minimum of 45°, injury
permitting. If only limited abduction is possible, the receptor may be supported on pads to
reduce the OFD.

9. Direction and location of the X-ray beam
The collimated vertical beam is centred over the midglenohumeral joint. Some tube angulation,
towards the palm of the hand, may be necessary to coincide with the plane of the glenoid cavity.
Cassette size = 18 × 24 cm
Grid = may or may not be used
Exposure = 10-20 mAs
60-70 kvp
SID = 100 Cm

10. SUPERO-INFERIOR (AXIAL)

11. 3. Infero-superior
Position of patient and image receptor
 The patient lies supine, with the arm of the affected side abducted and supinated without
causing discomfort to the patient.
 The affected shoulder and arm are raised on non-opaque pads.
 The receptor is positioned vertically against the shoulder and is pressed against the neck to
include as much as possible of the scapula within the region of interest.
Direction and location of the X-ray beam
 The collimated horizontal beam is centred towards the axilla with minimum angulation
towards the trunk.
 The FRD will probably need to be increased, since the tube head will have to be positioned
below the end of the trolley. Consequently, the exposure is increased compared with the
supero-inferior.

12. Cassette size = 18 × 24 cm
Grid = may or may not be used
Exposure = 10-20 mAs
60-70 kvp
SID = 100 Cm

13. INFERO-SUPERIOR

14. ALTERNATIVE PROJECTIONS FOR TRAUMA
1. Anterior oblique (‘Y’ projection)
Position of patient and image receptor
 The patient stands or sits with the lateral aspect of the injured arm against the image receptor
and is adjusted so that the axilla is in the centre of the receptor.
 The unaffected shoulder is raised to make the angle between the trunk and the receptor
approximately 60°. A line joining the medial and lateral borders of the scapula is now at right-
angles to the receptor.
 The image receptor is positioned to include the superior border of the scapula.

15. Direction and location of the X-ray beam
 The collimated horizontal beam is centred towards the medial border of the scapula and
centred to the head of the humerus.
 Collimate to include the region 2 cm above the palpable acromion process superiorly; just
below the inferior aspect of the scapula inferiorly; the posterior skin margin; and 2 cm of the
rib cage anteriorly.
Cassette size = 24 × 30 cm
Grid = may or may not be used
Exposure = 10-20 mAs
60-70 kvp
SID = 100 Cm

16. ANTERIOR OBLIQUE (‘Y’ PROJECTION)

17. ANTERO-POSTERIOR MODIFIED (STRYKER PROJECTION)
Position of patient and receptor
 The patient lies supine on the X-ray table.
 The arm of the affected side is extended fully and the elbow then flexed to allow the hand to
rest on the patient’s head.
 The line joining the epicondyles of the humerus remains parallel to the tabletop.
 The centre of the receptor is positioned 2.5 cm superior to the head of the humerus.

18. Direction and location of the X-ray beam
 The collimated vertical beam is angled 10° cranially and centred through the centre of the
axilla to the head of the humerus and the centre of the receptor.
Cassette size = 24 × 30 cm
Grid = may or may not be used
Exposure = 10-20 mAs
60-70 kvp
SID = 100 Cm

19. STRYKER PROJECTION

20. GLENOHUMERAL JOINT
1. Antero-posterior modified (Grashey projection)
Position of patient and image receptor
 The patient stands with the affected shoulder against the image receptor and the torso is
rotated approximately 35-45° toward the affected side to bring the plane of the glenoid fossa
perpendicular to the receptor.
 The arm is supinated and slightly abducted away from the body.
 The receptor is positioned so that its upper border is at least 5 cm above the shoulder to
ensure that the oblique rays do not project the shoulder off the receptor.

21. Direction and location of the X-ray beam
 The collimated horizontal beam is centred just below the palpable coracoid process of the
scapula.
Cassette size = 24 × 30 cm
Grid = may or may not be used
Exposure = 10-20 mAs
60-70 kvp
SID = 100 Cm

22. GRASHEY PROJECTION

23. ACROMIOCLAVICULAR JOINTS
1.Antero-posterior
Position of patient and image receptor
 The patient stands facing the X-ray tube, with the arms relaxed to the side.
 The shoulder being examined is placed in contact with the receptor, and the patient is then
rotated approximately 15° towards the side being examined to bring the ACJ space at right-
angles to the image receptor with the acromion process central to the field.

24. Direction and location of the X-ray beam
 The collimated horizontal beam is centred to the palpable lateral end of the clavicle at the
ACJ.
 To avoid superimposition of the joint on the spine of the scapula, the central ray can be
angled 15–25° cranially before centring to the joint.
Cassette size = 24 × 30 cm
Grid = may or may not be used
Exposure = 10-20 mAs
60-70 kvp
SID = 100 Cm

25. ACROMIOCLAVICULAR JOINTS

26. CLAVICLE
1. Postero-anterior
Position of patient and image receptor
 The patient sits or stands facing an erect image receptor.
 The patient’s position is adjusted so that the middle of the clavicle is in the centre of
the image receptor.
 The patient’s head is turned away from the side being examined and the affected
shoulder rotated slightly forward to allow the affected clavicle to be brought into close
contact with the image receptor or vertical DDR Bucky system.

27. Direction and location of the X-ray beam
 The collimated horizontal beam is centred to the middle of the clavicle.
Cassette size = 24 × 30 cm
Grid = may or may not be used
Exposure = 10-20 mAs
60-70 kvp
SID = 100 Cm

28. CLAVICLE AP

29. STERNOCLAVICULAR JOINTS
Postero-anterior
Position of patient and image receptor
 The patient sits or stands facing an erect cassette holder with their chin resting on
the top of the cassette holder.
 The patient’s position is adjusted so that the median sagittal plane is at right-angles
to the vertical central line of the cassette.
 The image receptor is adjusted vertically to the level of the middle of the manubrium.
 The arms are extended by the sides of the body or alternatively the patient can hold
onto the vertical imaging stand.

30. Direction and location of the X-ray beam
 The collimated horizontal beam is centred in the midline of the thorax at the level of the head
of the humerus.
Cassette size = 24 × 30 cm
Grid = may or may not be used
Exposure = 10-20 mAs
60-70 kvp
SID = 100 Cm

31. STERNOCLAVICULAR JOINTS

32. SCAPULA
1. Antero-posterior – erect
Position of patient and image receptor
 The patient stands with the affected shoulder against the vertical stand and rotated slightly to
bring the plane of the scapula parallel with the receptor.
 The arm is slightly abducted away from the body and medially rotated.
 The receptor is positioned so that its upper border is at least 5 cm above the shoulder to
ensure that the oblique rays do not project the shoulder off the field.

33. Direction and location of the X-ray beam
 The collimated horizontal beam is centred 2.5 cm inferior and medial to the head of the
humerus.
Cassette size = 24 × 30 cm
Grid = may or may not be used
Exposure = 10-20 mAs
60-70 kvp
SID = 100 Cm

34. SCAPULA

35. 2. Anterior oblique (lateral)
Position of patient and image receptor
 The patient stands with the side being examined against a vertical Bucky.
 The patient’s position is adjusted so that the centre of the scapula is at the level of the centre
of the image receptor.
 The arm is either adducted across the body or abducted with the elbow flexed to allow the
back of the hand to rest on the hip.
 Keeping the affected shoulder in contact with the Bucky, the patient’s trunk is rotated forward
until the body of the scapula is at right-angles to the receptor. This can be checked by
palpating the medial and lateral borders of the scapula near the inferior angle.

36. Direction and location of the X-ray beam
 The collimated horizontal beam is centred to the midpoint of the medial border of the scapula
and to the middle of the receptor.
Cassette size = 24 × 30 cm
Grid = may or may not be used
Exposure = 10-20 mAs
60-70 kvp
SID = 100 Cm

38. CORACOID PROCESS
Antero-posterior shoulder (arm abducted)
Position of patient and image receptor
 The patient is supine or erect, with the posterior aspect of the affected shoulder against the
receptor.
 The shoulder of the affected side is flexed to above-shoulder level and the elbow flexed,
allowing the hand to rest on the patient’s head.
 The patient is now rotated slightly to bring the affected side away from the image receptor.
 The position of the receptor is adjusted so that it is centred to the axilla.

39. Direction and location of the X-ray beam
 The collimated horizontal beam is centred at right-angles to the image receptor and centred to
the axilla of the affected side.
Cassette size = 18 × 24 cm
Grid = may or may not be used
Exposure = 10-20 mAs
60-70 kvp
SID = 100 Cm

40. CORACOID PROCESS FRACTURE

41. THANK YOU