This document provides information on positioning and anatomy for radiographic imaging of the shoulder, clavicle, ribs, and specialized projections. It discusses patient positioning, part positioning, measurements, demonstrations, and clinical correlations for AP, PA, internal and external rotation views of the shoulder, as well as views of the clavicle, acromioclavicular joint, and ribs. Common pitfalls and specialized projections are also outlined.

1. NORMAL RADIOGRAPHIC
POSITIONING AND ANATOMY OF
SHOULDER, CLAVICLE, RIBS

2. Demonstrates: Proximal humerus, scapula, clavicle,
rib cage, and lung.
Measure: Between the coracoid process and
scapula.
Patient Position: Upright or supine.
Part Position: The patient is rotated to be at 30° to
the bucky. The coracoid is centered to the bucky
and the arm internally rotated until the elbow
epicondyles are perpendicular to the film.
CR: To the coracoid process.
SHOULDER AP VIEW
INTERNAL ROTATION
.

4. COMMON PITFALLS
Insufficient internal humeral rotation: A comfortable positioning
alternative for the patient with an acute shoulder is to allow 90° of
elbow flexion and then rest the forearm against the abdomen.
Tennis racquet appearance: Superimposition of the humeral head on
the metaphysis in this position creates the impression of the
presence of a cyst in the humeral head (pseudocyst, tennis racquet
appearance). If this artifact persists on external rotation it may be a
sign of posterior humeral dislocation.

5. CLINICORADIOLOGIC CORRELATIONS
1. Alignment: Assess the position of the humeral head relative to the
glenoid fossa by tracing the smooth transition from the medial humerus
across the glenoid fossa to the axillary border of the scapula, creating a
smooth continuous arc (Maloney’s arch, scapulo- humeral arch).
2.Bone: the greater and lesser tuberosi- ties, The distal clavicle, scapula,
and upper ribs are visible.
3.cartilage:The glenohumeral articulation and acromio- clavicular joint also
may not be clearly displayed, but both the surfaces should be smooth and
congruous.

6. SPECIALIZED PROJECTIONS
1. Grashey’s view (glenoid cavity view): The body is rotated 45° toward
the affected side, with the CR at the coracoid process. The glenoid joint
cavity is seen clearly along with a tangential depiction of the articular
surfaces. It can be performed in internal and ex- ternal rotation.
2. Apical oblique: The body is rotated 45° degrees, as for the Grashey
view, and the tube is angled cau- dally 45°. This view is useful for
demonstrating fractures of the glenoid rim, dislocation, and impaction
fractures of the humeral head (Hill-Sachs defect).

7. 3. Subacromial impingement view:An APview with 30° caudad tube
angulation and no body rotation will allow depiction of the undersurface
of the acromion for spurs and abnormal shape variations, as a factor in
impingement of the supraspinatus tendon.

8. Internal Rotation, Shoulder,
Osteochondroma. The internal
rotation has profiled a
posteriorly placed humeral
shaft osteochondroma, which
was virtually indiscernible on
the external rotation view.

9. Internal Rotation, Shoulder,
Paget’s Disease. The bone
density is increased, and the
cortex is thickened. There is a
trans- verse pathologic
fracture in the midshaft.

10. Demonstrates: Proximal humerus (especially the
greater tuberosity), scapula, clavicle, rib cage, and
lung.
Measure: Between the coracoid process and the
scapula.
Patient Position: Upright or supine.
Part Position: The patient is rotated to 30° to the
bucky. The coracoid is centered to the bucky, and the
arm externally rotated until the elbow epicondyles are
parallel to the film.
CR: To the coracoid process.
SHOULDER AP VIEW
EXTERNAL ROTATION

12. CLINICORADIOLOGIC CORRELATION
1. Alignment: Elevation of the humerus within the glenoid fossa with
disruption of maloney’s arch/scapulohumeral arch is a sign of rotator
cuff tendon tear.
2. Bone:
• The greater tuberosity is shown as a sharply angular bony shelf.
• The lesser tuberosity lies immediately medially with the
intertubercular groove interposed between them.
• The surgical neck lies inferior to the tuberosities. The glenoid fossa,
coracoid, acromion process, and scapular spine can be identified.

13. AP External Rotation, Shoulder, Lung Carcinoma

14. Demonstrates: Proximal humerus, scapula (especially
the coracoid and acromion), acromioclavicular joint,
upper rib cage, clavicle, and lung apex.
Measure: Between the coracoid process and the
posterior shoulder.
Patient Position: Upright or supine.
Part Position: The patient’s back is flat to the bucky.
The arm is abducted to 90°, the elbow is flexed to 90°,
and the palm of the hand faces the tube.
CR: At the midclavicular line at the level of the
coracoid process.
SHOULDER
ABDUCTION PROJECTION

16. CLINICORADIOLOGIC CORRELATION
This view serves five functions:
(a) to provide an additional view of the humerus, scapula, thoracic cage, and
cervicothoracic spine;
(b) to allow dynamic assessment of the humeral position, which may elevate
and impinge the rotator cuff beneath the acromion process (acromiohumeral
distance);
(c) to allow dynamic assessment of the acromio- clavicular joint;
(d) to provide the best view of the scapula, which is obscured in other views;
and
(e) to demonstrate the upper lobe of the lung.

17. AXILLARY VIEW:The axillary projection is obtained with the patient in the supine
position and the arm placed in 90 degree of abduction. The angle of the Xray beam is
approximately 30 degree towards the spine, with the beam centred on the middle of the
glenohumeral joint.

18. Westpoint view: The patient is placed in the prone position with the
shoulder resting on a cushion. The arm is abducted 90° and the patient's
forearm and hand are in pronation, hanging downwards off the edge of the
table.

19. The Stryker notch view is obtained with the patient in the supine
position with the arm externally rotated and abducted and the X-ray
beam angled 10° cephalad and centred on the coracoid process.
The patient’s hand supports the back of the head with the elbow
pointed towards the ceiling.

20. Demonstrates: Clavicle, upper ribs, scapula, and lung.
Measure: At coracoid process.
Tube Tilt: (a) PA: 10° caudad. (b) AP: 10° cephalad.
Patient Position: Upright.
Part Position: (a) PA: facing the bucky, with no body ro-
tation, the head is turned away from the side being
evaluated. The midpoint of the clavicle is centered to the
midline of the bucky. (b) AP: Facing the tube, with no body
rotation. The midpoint of the clavicle is centered to the
midline of the bucky.
CR: (a) PA: Through the midclavicle and 1 inch above the
level of the clavicle at the patient’s back. (b) AP: Through
the midclavicle.
CLAVICLE
PA PROJECTION

22. CLINICORADIOLOGIC CORRELATION
The PA projection is preferred over the AP view
1.Bone:The clavicle is broader medially than laterally and is curved in shape.
• Scapula, acromion, coracoid, spine, glenoid, superior and inferior angles,
and vertebral and axillary borders are identified.
• The humeral head, surgical neck, and proximal shaft are visible.
• The upper ribs from the costovertebral joints to the costochondral junctions
are depicted.
2.Cartilage: The sternoclavicular, acromioclavicular, glenohumeral, and
costal joints can all be identified.

23. SPECIALIZED PROJECTIONS
1. AP axial view:
• The standing patient can be placed leaning back on the bucky in an AP
lordotic position, with the tube angled 15–25° cephalad.
• These views are especially useful for detecting undisplaced clavicular
fractures.
2.Apical oblique view:
• The patient is placed AP and rotated away 45° (posterior oblique), with the
affected side against the bucky; the tube is angled 20° cephalad.
• This view is well suited to the detection of undisplaced fractures of the
clavicle in neonates and children.

24. Demonstrates: Distal clavicle and acromioclavicular
joint.
Measure: At the coracoid process;
Tube Tilt: 5° cephalad.
Patient Position: Upright.
Part Position: AP position, with no body rotation and
the acromioclavicular joint centered to the bucky.
Slight external rotation of the humerus is suggested to
show the greater tuberosity, which is commonly
fractured with acromioclavicular joint trauma and may
mimic pain at this joint.
CR: Through the acromioclavicular joint.
ACROMIOCLAVICULAR
JOINT
AP PROJECTION

26. COMMON PITFALLS
1. Body rotation: The joint space will not be accurately
demonstrated.
2. Film identification: If weights are applied the film should be
marked “with weights” or similar. Care should be taken not to
place markers over the joint or bony structure.

27. CLINICORADIOLOGIC CORRELATIONS
The purpose of comparing non-weight- bearing and weight-bearing views is to attempt
to assess the integrity of the acromioclavicular and costoclavicular ligaments.
Alignment: There should be a smooth transition across the acromioclavicular joint,
with the distal clavicle aligned with the acromion.
Bone: The distal 1–2 inches of the clavicle are more radiolucent with a thin cortex.
The distal clavicular surface is often noticeably concave. (5) The acromion is variable
in shape: flat (17%), curved (43%), and hooked (40%). (7)

28. CONTD
Cartilage:The acromioclavicularjoint space is variable in depth,
sometimes being capacious in young patients. On weight
bearing the joint frequently widens up to 2 mm as a variant of
normal.
Soft tissue:The lung apex should be checked bilaterally for
aeration and symmetry. In cases of trauma, signs of
pneumothorax over the apex can be noted.

29. SPECIALIZED PROJECTION
Bilateral simultaneous anteroposterior comparison views:
• Single exposure of both joints can be obtained with a 7 × 17
inch film, horizontally orientated.
• The view is discouraged, unless appropriate shielding of the
thyroid is used.

30. AP Acromioclavicular Joint, Post-Traumatic Osteolysis of
the Clavicle. The articular cortex is irregular with resorption
of the distal bone matrix (arrow).

31. AP Acromioclavicular Joint, Subluxation. There is elevation of the distal
clavicle relative to the acromion process (arrow) with slight widening of the joint
space.

32. Demonstrates: Ribs (anterior and posterior), thoracic spine.
Measure: AP chest at CR.
Patient Position: Upright or recumbent.
Part Position: (a) AP: if rib lesion is posterior, centered to the
bucky.
(b) PA: if rib lesion is anterior, centered to the
bucky.
Breathing Instructions: Above-diaphragm rib projection:
suspended full inspiration. Below-diaphragm rib projec- tion:
suspended full expiration.
CR: To the area of complaint.
RIBS
AP AND PA PROJECTIONS

33. CLINICORADIOLOGIC CORRELATIONS
Alignment:
• Widened intercostal spaces can be a sign of tension pneumo thorax,
previous thoracotomy, and intercostal mass; they are common on the
convex side of scoliosis.
• Narrowed intercostal spaces may be found in myopathy, lung collapse,
skeletal dysplasia with broad ribs, and on the concave side of scoliosis.
Bone: The posterior ribs are narrowed, gradually widening and becoming
broader anteriorly.
The cortices of the posterior ribs are usually uniform and readily seen
though the inferior margins.Anteriorly, the cortices are thin and become
indistinct, with the lengths prone to variation.

34. CONTD
Cartilage:
• Identify the costotransverse and costovertebral joints.
• The gradual transition of the anterior ribs into the costal cartilages
may make the ends appear frayed and indistinct and frequently
cupped.
• The costochondral transitional zones are frequently calcified; in males
this is often peripheral in the cartilage as two parallel linear
calcifications, whereas in females this is displayed as more central
tongue-like calcifications.

35. Soft tissue:
• The bone–lung interface adjacent to each rib, represents the pleura, which is
normally adherent to the periosteum.
• If it appears locally thick or is convex away from the rib this may be a sign of rib
fracture with hematoma, bone destruction with soft tissue mass, or primary
pleural disease.
• Visible retraction of the visceral pleura from the rib is a sign of pneumothorax.
• For lower rib fractures, the outline of the spleen and liver are noted for signs of
rupture or hematoma.

36. SPECIALIZED PROJECTIONS:
Bilateral and unilateral ribs:Bilateral views are often obtained as part of
skeletal surveys or in the initial assessment of trauma but may require
subsequent spot views for better depiction of the abnormality.
Tangential: Turn the patient until the required rib lies tangential to the
beam, preferably as close to the bucky as possible.
Ribs1–3:An AP projection with 10–15°cephalad tube tilt will improve the
demonstration of the upper ribs.
Costovertebral joints: In the AP position the tube is angled cephalad at
20°, with the CR passing through the sixth thoracic vertebra.

37. Thank you