SHOULDER GIRDLE
PATHOLOGY  External Rotation: greater tubercle & site
1.) Hill-Sachs Defect
 Compression fracture of the articular surface
of the posterolateral aspect of the humeral
head
2.) Bankart Lesion
 Avulsion fx of anteroinferior aspect of
glenoid rim
3.) Impingement Syndrome
 Impingement of the greater tuberosity & soft
tissues on the coracoacromial ligamentous &
osseous arch
4.) AC separation
 Partial or complete tear of the AC &
coracoclavicular ligaments
5.) Idiopathic Chronic Adhesive Capsulitis
 Frozen shoulder
 Disability of the shoulder joints caused by
chronic inflammation of the joint
6.) Shoulder Dislocation
 Traumatic removal of humeral head from
the glenoid cavity
A.) SHOULDER
AP PROJECTION
External, Neutral, Internal Rotation
PP: Upright (more comfortable) or supine; patient
slightly rotated; scapula // to IR
 External Rotation: hand supinated;
humeral epicondyles // to IR; arm abducted
slightly
 Neutral Rotation: palmar/anterior aspect of
hand placed against the hip; humeral
epicondyles 45o to IR
 Internal Rotation: dorsal/posterior aspect
of hand against hip; humeral epicondyles ┴
to IR
RP: 1 in. inferior to coracoid process
CR: ┴
SS: Shoulder & proximal humerus
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of insertion of supraspinatus tendon
 Neutral Rotation: greater tubercle partially
superimposing humeral head; posterior part
of supraspinatus insertion
 Internal Rotation: lesser tubercle; site of
the insertion of the subscapular tendon;
proximal humerus in true lateral position
LAWRENCE METHOD
TRANSTHORACIC LATERAL PROJECTION
PP: Upright (more comfortable) or supine; patient
in lateral position; uninjured arm raised; forearm
rested on head; midcoronal plane ┴ to IR; full
inspiration (improves contrast & reduces exposure)
or breathing technique (slow, deep breathing)
RP: Level of surgical neck
CR: Horizontal or 10-15o cephalad (cannot elevate
unaffected shoulder)
SS: Proximal humerus
LAWRENCE METHOD
INFEROSUPERIOR AXIAL PROJECTION
PP: Supine; head, shoulder & elbow elevated (3
in.); arm abducted 90o; humerus rotated externally;
IR placed against the neck; head turn away from
side of interest
RP: Axilla
CR: Horizontal; 15-30o medially (greater
abduction, greater angle)
SS:
 Proximal humerus
 Scapulahumeral joint
 Lateral portion of coracoids process
 Acromioclavicular (AC) articulation
 Insertion site of subscapular tendon
 Point of insertion of teres minor tendon
 SHOULDER GIRDLE
ER: When prone (Westpoint) or supine (Lawrence
RAFERT-LONG MODIFICATION & Rafert-Long) position is not possible
INFEROSUPERIOR AXIAL PROJECTION
PP: Supine; head, shoulder & elbow elevated (3 SUPEROINFERIOR AXIAL PROJECTION
in.); arm abducted 90o; exaggerated external PP: Seated; patient lean laterally; elbow flexed 90o
rotation of the arm; hand 45o to IR; thumb pointing & rested on table; hand pronated; humeral
downward; IR placed against the neck; head turn epicondyles ┴ to table
away from side of interest RP: Shoulder joint
RP: Axilla CR: 5-15o toward the elbow
CR: Horizontal; 15o medially SS: Relationship of the proximal end of the
SS: Coracoid process pointing anteriorly; lesser humerus to the glenoid cavity
tubercle in profile  AC articulation
ER: Hill-Sachs compression fracture (defect)  Outer portion of the coracoid process
 Points of insertion of the subscapularis
WEST POINT METHOD muscle & teres minor muscle
INFEROSUPERIOR AXIAL PROJECTION  Coracoids process above clavicle
PP: Prone; shoulder elevated (3 in.); head turn  Lesser tubercle in profile
away from side of interest; arm abducted 90o;
forearm rested over the edge of table; IR placed
vertically AP AXIAL PROJECTION
RP: 5 in. inferior & 1.5 in. medial to acromial edge PP: Upright/supine; scapulohumeral joint centered
CR: 25o anteriorly & 25o medially to IR
SS: Humeral head projected free of the coracoid RP: Scapulohumeral joint
process CR: 35o cephalad
ER: SS: Relationship of the head of humerus to the
 Used when chronic instability of shoulder is glenoid cavity
suspected  Scapula humeral joint
 To demonstrate Bankart’s Lesion &  Proximal humerus
associated Hills-Sachs defect  Clavicle projected above the superior angle
of scapula
CLEMENTS MODIFICATION ER: Useful in diagnosing cases of posterior
INFEROSUPERIOR AXIAL PROJECTION dislocation
PP: Lateral recumbent; unaffected side against IR;
affected arm abducted 90o; IR against superior SCAPULAR Y
aspect of shoulder PA OBLIQUE PROJECTION
RP: Midaxillary region RUBIN-GRAY-GREEN
CR: Horizontal or 5-15o medially (cannot abduct PP: Upright/recumbent; RAO/LAO; MCP 45-60o to
arm 90o) IR; scapular flat surface ┴ to IR; RPO/LPO (for
SS: Acromioclavicular joint; scapulohumeral joint; severely injured patient)
glenohumeral joint RP: Scapulohumeral joint
CR: ┴
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 SHOULDER GIRDLE
SS: Scapular body (form the vertical component); APPLE METHOD
acromion & coracoid processes (form the upper AP OBLIQUE PROJECTION
limbs) PP: Upright; RPO/LPO; body rotated 35-45o
 Superimposed humeral head & glenoid toward the affected side; scapula // to IR; patient
cavity hold 1 lb. weight; arm abducted 90o
 Superimposed humeral shaft & scapular RP: Level of coracoid process
body CR: ┴
 Coracoid process superimposed or projected SS: Glenoid cavity (scapulahumeral joint)
below the clavicle ER: To demonstrate a loss of articular cartilage in
ER: Useful in evaluation of suspected shoulder the scapulohumeral joint
dislocations
 Anterior/subcoracoid dislocation: humeral GARTH METHOD
head beneath the coracoid process AP AXIAL OBLIQUE PROJECTION
 Posterior/subacromial dislocation: PP: Supine/seated/upright; RPO/LPO; body rotated
humeral head beneath the acromion process 45o toward the affected side; elbow flexed; arm
placed across the chest
STRYKER “NOTCH” METHOD RP: Scapulohumeral joint
AP AXIAL PROJECTION CR: 45o caudad
HALL-ISAAC-BOOTH SS: Glenoid cavity (scapulahumeral joint)
PP: Supine; arm flexed slightly beyond 90o; palm  Humeral head
of hand on top of head w/ fingertips resting on head  Coracoid process
(places humerus in a slight internal rotation); body  Scapular head & neck
of humerus // to MSP of body ER:
RP: Coracoid process  For acute shoulder trauma
CR: 10o cephalad  For identifying posterior scapulohumeral
SS: Posterosuperior & posterolateral areas of dislocations
humeral head o Posterior dislocation: humeral head
ER: Useful for demonstration of Hill-Sachs defect projected superiorly from glenoid
cavity
B.) GLENOID CAVITY o Anterior dislocation: humeral head
projected inferiorly from glenoid
GRASHEY METHOD cavity
AP OBLIQUE PROJECTION  Glenoid fxs
PP: Upright (more comfortable) or supine;  Hill-Sachs lesions/defect
RPO/LPO; body rotated 35-45o (upright)/>45o  Soft tissue calcification
(supine) toward the affected side; scapula // to IR;
arm slightly abducted; palm of hand on abdomen
RP: 2 in. medial & 2 in. inferior to superolateral
border of shoulder
CR: ┴
SS: Glenoid cavity (scapulahumeral joint)
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 SHOULDER GIRDLE
C.) SUPRASPINATUS exposures: with & without weights (5-10 lbs.); affix
OUTLET/CORACOACROMIAL ARCH the weights to patients wrist
RP: b/n level of AC joints; directed at each ACJ
NEER METHOD (broad-shouldered patients)
TANGENTIAL PROJECTION CR: ┴
PP: Seated/upright; RPO/LPO; unaffected side SS: Bilateral AC joints
rotated 45-60o away from IR; arm at side ER: Used to demonstrate dislocation, separation &
RP: Superior aspect of humeral head function of the ACJ
CR: 10-15o caudad
SS: Posterior surface of acromion & AC joint ALEXANDER METHOD
(superior border of coracoacromial outlet) AP AXIAL PROJECTION
ER: PP: Upright/seated-upright; coracoid process
 Useful to demonstrate tangentially the centered to IR
coracoacromial arch/outlet RP: Coracoid process
 To diagnose shoulder impingement CR: 15o cephalad (projects ACJ above acromion)
SS: AC joints above acromion
C.) INTERTUBERCULAR GROOVE ER: For demonstration of suspected AC
subluxation or dislocation
FISK MODIFICATION
TANGENTIAL PROJECTION ALEXANDER METHOD
PP: PA AXIAL OBLIQUE PROJECTION
 Supine: chin extended; head rotated away PP: Upright; RAO/LAO; MCP 45-60o from IR;
from affected side; hand supinated; IR scapula ┴ to IR; hand of affected side under
against superior surface of shoulder opposite axilla; lean affected shoulder against IR;
 Upright (fisk modification): elbow flexed; arm pulled firmly across the chest (draws scapula
posterior surface of forearm against table; laterally & forward & places joint close to IR)
patient grasps the IR; sandbag under hand; (scapula & ACJ in lateral position)
IR horizontal; patient lean forward; humerus RP: AC joints
10-15o from vertical CR: 15o caudad
RP: Intertubercular groove SS: AC joint
CR: ┴ (upright) or 10-15o posteriorly to long axis  Relationship of the bones of the shoulder
of humerus (supine)
SS: Intertubercular groove E.) CLAVICLE

D.) ACROMIOCLAVICULAR JOINTS AP PROJECTION

PEARSON METHOD
BILATERAL AP PROJECTION
PP: Upright/seated-upright (ACJ reduces itself in
recumbent); arms hanging at sides (unsupported); 2
PP: Supine/upright; arms along the sides; clavicle
center to IR; supine reduces the possibility of
fragment displacement or additional injury
RP: Midshaft of clavicle
CR: ┴
SS: Frontal image of clavicle

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 SHOULDER GIRDLE
PA Projection: reduces OID & improved image
contrast
 Well accepted by patient who can stand
AP AXIAL PROJECTION
Lordotic Position
PP:
 Upright: 1 foot in front; lean backward
(lordotic); neck & shoulder against IR; neck
in extreme flexion
 Supine: cannot assumed lordotic position
 Suspend at end of full inspiration
RP: Midshaft of clavicle
CR: 0-15o cephalad (upright); 15-30o cephalad
(supine)
SS: axial projection of clavicle
 Clavicle projected above the ribs; true/exact
axial projection of clavicle
 Slightly distorted image due to angulation
PA AXIAL PROJECTION
PP: same with previous except prone/standing
RP: Midshaft of clavicle
CR: 15-30o caudad
SS: Clavicle projected above the ribs; axial image
of clavicle
TANGENTIAL PROJECTION
PP: Supine; arms along sides; shoulder depressed;
head turn away from side of interest
RP: b/n clavicle & chest wall
CR: 25-40o from horizontal/cephalad
 Places CR nearly // to rib cage
SS: Inferosuperior image of the clavicle
 Clavicle projected free of the chest wall
TARRANT METHOD
TANGENTIAL PROJECTION
PP: Seated; patient lean slightly forward; increased
SID recommended (due to increased OID)
RP: midshaft of clavicle
5
CR: 25-35o anteroinferiorly to midshaft of
clavicle
SS: clavicle above the thoracic cage
ER: Useful with patients who cannot
assume lordotic or recumbent position
F.) SCAPULA
AP PROJECTION
PP: Supine/upright; arm abducted 90o w/ the body
(draw scapula laterally); elbow flexed; IR 2 in.
above top of shoulder
RP: 2 in. inferior to coracoid process
CR: ┴
SS: Scapula
 Lateral portion of scapula free of
superimposition
LATERAL PROJECTION
PP: Upright/seated; RAO/LAO (more difficult to
perform); 45-60o from IR; RPO/LPO (magnified
scapula; for trauma px)
Arm Placement:
 Elbow flexed & arm on posterior chest
o For demonstration of acromion &
coracoid process
 Arm extended upward & forearm rested on
head or across upper chest
o For demonstration of scapular body
RP: Midmedial border of protruding scapula
CR: ┴
SS: Lateral image of scapula
Mazujian Suggestion: arm across the upper chest
(grasping opposite shoulder)
LORENZ-LILIENFELD METHODS
PA OBLIQUE
PP: Upright/lateral recumbent;
Lorenz Method: arm of affected side 90o to long
axis of body; elbow flexed; hand rested against head
 SHOULDER GIRDLE
Lilienfeld Method: arm of affected side obliquely PP: Supine; scapular body // (horizontal) to IR;
upward; hand rested against head head turned away from side of interest (prevent
RP: b/n chest wall & midarea of protruding scapula superimposition)
CR: ┴ Funke: use of 15o radiolucent wedge for patient
SS: Oblique image of scapula with small breast (angle the shoulder caudally)
 Prevent clavicular superimpostion
AP OBLIQUE RP: Scapular spine (posterosuperior region of
PP: Supine/upright; RPO/LPO; shoulder rotate 15- shoulder)
25o away from affected side or 25-35o (steeper CR: 45o caudad; 35o caudad (for obese and round-
oblique)arm extended superiorly; elbow flexed; shouldered patients)
hand supinated under head; arm of affected side SS: Scapular spine in profile and free of
across anterior chest superimposition
RP: Midscapular area
CR: ┴ to lateral border of rib cage TANGENTIAL PROJECTION
SS: Oblique image of scapula free or nearly free of PP:
rib superimposition  Prone: arms along sides; head rested on
chin/cheek of affected side; hand supinated;
scapular // to IR
 Upright: back rested against the end of
G.) CORACOID PROCESS table; IR placed 45o from table (wedge
support)
AP AXIAL PROJECTION RP: Scapular spine
PP: Supine; arm of affected side slightly abducted; CR: 45o cephalad (prone); 45o posteroinferiorly
hand supinated (upright; increased SID recommended because of
RP: Coracoid process increased OID)
CR: 15-45o cephalad SS: Scapular spine in profile and free of
SS: Coracoid process with minimal self- superimposition of scapular body
superimposition (slight elongated)
 Cast a shadow on direct AP projection of I. TERES MINOR, SUBSCAPULARIS,
shoulder INFRASPINATUS INSERTION
 Rationale: because the clavicle is curved on
itself BLACKETT-HEALY METHOD
Kwak-Espiniella-Kattan Recommendation: CR PA PROJECTION
30o Teres Minor Insertion
 Greater angle: round shouldered patient
 Lesser angle: straight back PP:
 Prone: arms along sides; head rested
H.) SCAPULAR SPINE on chin/cheek of affected side; arm
in extreme internal rotation; elbow
LAQUERRIERE-PEIRQUIN METHOD flexed; hand at the back; IR center 1
TANGENTIAL PROJECTION in. inferior to coracoid process
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 SHOULDER GIRDLE
RP: Head of humerus
CR: ┴
SS: tangential image of the insertion of teres
minor
 This position rotates the humeral
head so that the greater tubercle is
brought anteriorly

BLACKETT-HEALY METHOD
AP PROJECTION
Subscapularis Insertion

PP: Supine; arms along sides; unaffected shoulder

elevated 15o with sandbag; abduct the affected arm;
elbow flexed; hand pronated (arm rotated internally)
RP: Shoulder joints
CR: ┴
SS: image of the subscapularis insertion at the
lesser tubercle

AP AXIAL PROJECTION
Infraspinatus Insertion
PP: Supine; affected arm at the side; arm in
external rotation (to open the subacromial space);
arm rotated in neutral position & in complete
internal rotation (allow full evaluation of humeral
head)
RP: Coracoid process
CR: 25o caudad
SS: Profile the greater tubercle, site of infraspinatus
tendon and opens subacromial space

 THE END 
“BOARD EXAM is a matter of PREPARATION. If
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03/19/14