Unformatted text preview: Chapter 5
Humerus & Shoulder Girdle
Pages 173 – 205 Anatomy Review
Humerus Anatomy: Humerus Long bone in the upper arm
Head articulates with scapula, specifically
the glenoid fossa, to form shoulder joint
Distal end forms part of elbow joint
Distal anatomy Medial epicondyle
Lateral epicondyle
Trochlea
Capitulum
Coronoid fossa
Olecranon fossa (posterior) Proximal anatomy Head
Neck
Surgical neck (common FX location)
Greater tubercle
Lesser tubercle FX @ Surgical Neck
(fracture) AP
Lateral AP
Ext. ORIF
Open Reduction Internal
Fixation AP
Int. Room, Patient, & Equipment
Considerations
Humerus Room & Patient Preparation
Room:
Clean Room
Gather supplies
Prep equipment
Pillow (for supine images)
Patient:
Remove artifacts from anatomy of interest Examples: clothing and/or bra (waist up)
Secure all patient possessions in designated
manner and location
6 Patient Instructions Explain and demonstrate positions
Respirations suspended on expiration
Transthoracic lateral projection may use breathing
technique (normal steady breathing) Low mA with long exposure time
Console will be set in the mA/time mode (not mAs mode) General Patient Position Ambulatory patients Exam may be completed using either wall bucky
or table bucky Nonambulatory patients Most often, exam is completed using the table
bucky IR, Collimated Field Size & Markers Collimated field size – 2 inches distal to the
elbow joint and superior to the shoulder, and 1
inch on the sides
Correct marker is required on all images
Marker should not be in area of interest
Place maker close to skin line and collimate to the
marker – close collimation
Marker placed on the lateral side of the patient Radiation Protection For our purposes, we shield
EVERY PATIENT
Other radiation protection
measures Close collimation
Optimum technique Full lead apron preferred ½ apron used Radiographic Procedures
Humerus Essential Projections: Humerus AP
Lateral
Transthoracic lateral – RADR 2401 Note: Humerus is usually imaged using the Bucky, if possible. AP Humerus Part position CR Place top border of IR approximately 1½ inches (3.8
cm) above humeral head
Slightly abduct humerus from body and supinate hand
Coronal plane passing through humeral epicondyles
should be placed parallel to IR plane
Elbow and should be in the same plane
Perpendicular to midportion of humerus and centered
to IR Collimation angled to match the long axis of the
part AP Humerus Projection Include both
shoulder and elbow
joints
CR to midhumerus 14 Evaluation Criteria Entire humerus
demonstrated
Greater tubercle in
profile
Medial and lateral
epicondyles in
profile
Exposure factors 15 Lateral Humerus Part position
Place top border of IR approximately 1½ inches (3.8 cm)
above humeral head Internally rotate humerus, flex elbow 90 degrees if
possible, and rest back of hand on hip Coronal plane passing through epicondyles should be
perpendicular to plane of IR Elbow and shoulder must be in the same plane CR Perpendicular to midportion of humerus and centered to
IR Collimation angled to match the long axis of the part Lateromedial and Mediolateral
Humerus Projections Epicondyles
perpendicular to IR
CR to midhumerus 17 Lateral Humerus
Recumbent Rotational Lateral Epicondyles perpendicular to IR 18 Evaluation Criteria Entire humerus
demonstrated
Lesser tubercle in
profile
Epicondyles
superimposed
Exposure factors 19 Trauma Humerus Transthoracic Lateral Humerus Part position
Patient may be erect or supine based on patient comfort Place top border of IR approximately 1½ inches (3.8
cm) above humeral head Place patient in a lateral position, side of interest closest
to the IR Affected humerus is in a neutral position
• ASSESS your patient. DO NOT move the patient’s humerus if severe TRAUMA is obvious
• FX or dislocation Raise opposite arm above patient’s head, elevate
shoulder as much as possible to prevent
superimposition of affected shoulder. Transthoracic Lateral Humerus CR For lateral recumbent position: perpendicular to
midportion of humerus, directed through the
thorax and centered to IR
For recumbent (supine) position: horizontal beam
and perpendicular to midportion directed through
the thorax and centered to IR – X-table (TRAUMA) Collimated field Include as much of proximal humerus as possible
to below the elbow joint Horizontal Beam Transthoracic
Lateral Humerus (Trauma) Demonstrates entire
humerus without
rotation
Unaffected limb
raised over head
CR to mid aspect to
involved humerus 23 Horizontal Beam Transthoracic
Lateral Humerus (Trauma) Demonstrates entire humerus without rotation
Glenohumeral joint visualized through thorax
No superimposition of unaffected humrus 24 Lateral Mid and Distal Humerus
Trauma Position 25 Evaluation Criteria Mid and distal
humerus
Distal ⅔ humerus
demonstrated
90° perspective from
AP projection
Epicondyles
superimposed
Exposure factors
26 Anatomy Review
Shoulder Girdle Shoulder Girdle Consists of Articulates with Clavicle
Scapula Head of humerus (shoulder joint)
Manubrium of sternum (sternoclavicular [SC] joint)
Acromioclavicular (AC) joint Functions to connect the upper limb to the trunk of
the body Shoulder Articulation of the upper limb with the girdle
Humerus is not considered to be part of the
shoulder girdle Because the upper portion articulates with the
shoulder girdle, proximal humeral anatomy is
considered in evaluation of radiographs of the
shoulder joint Proximal Humerus 30 Joints of Shoulder Girdle
(Synovial, Diarthrodial)
Acromioclavicular (AC) Scapulohumeral Sternoclavicular (SC)
31 Room, Patient, & Equipment
Considerations
Shoulder Clavicle Classified as a long bone
Lies just above the first rib
Acromial extremity (lateral end) articulates with acromion on scapula
(AC joint)
Sternal extremity (medial end) articulates with manubrium of sternum
(SC joint)
Double curve to body
Curve more pronounced in males than in females Scapula Classified as a flat bone
Forms the posterior portion of the
shoulder girdle
Triangular in shape
Two surfaces Costal (anterior) Dorsal (posterior)
Three borders Lateral Medial Superior
Three angles Superior Inferior Lateral Anterior Posterior Lateral Aspect of Shoulder Girdle General Procedural Guidelines
Shoulder General Procedural Guidelines Patient preparation General patient position 10 x 12
Collimation open to IR size SID Upright or recumbent IR/Collimated field size Remove artifacts 40” ID markers - ALWAYS
Radiation protection - ALWAYS Patient Instructions Respirations suspended on expiration
Transthoracic lateral projection may use
breathing technique (normal steady breathing) Low mA with long exposure time
Console will be set in the mA/time mode (not mAs
mode) Radiographic Procedures
Essential Projections of the
Shoulder Essential Projections: Shoulder AP projections External rotation
Internal rotation
Neutral position Transthoracic lateral (Lawrence method)
AP oblique (Grashey method)
Inferosuperior axial (Lawrence method)
PA oblique (scapular Y) AP Projection in External Rotation Patient position Part position Rotate patient slightly toward affected shoulder in
necessary to place shoulder in contact with bucky
Place body of scapula parallel with plane of IR
Important for patients with extreme kyphosis (humpback
curvature of the spine)
Center scapulohumeral joint to the IR
Abduct arm slightly
Rotate arm externally and supinate hand
Place humeral epicondyles parallel to IR CR 1 inch distal to coracoid, perpendicular to IR AP Shoulder External Rotation
(AP Proximal Humerus) Epicondyles parallel
CR 1 inch (2.5 cm)
inferior to coracoid
process 42 AP Proximal Humerus
(External Rotation) Epicondyles parallel
to IR Shoulder
joint
collimation A. Greater tubercle
lateral (in profile)
B. Lesser tubercle
anterior 43 Evaluation Criteria
AP Shoulder (External Rotation) Greater tubercle
profiled laterally
Scapulohumeral
joint centered
Proximal humerus,
upper scapula, and
clavicle visualized
Optimal exposure
factors
44 AP Projection in Internal Rotation Patient position Part position Rotate patient slightly toward affected shoulder
Place body of scapula parallel with plane of IR
Important for patients with extreme kyphosis (humpback
curvature of the spine)
Center scapulohumeral joint to the IR
Abduct arm slightly
Flex elbow slightly
Rotate arm internally and rest back of hand on hip
Place humeral epicondyles perpendicular to IR CR 1 inch distal to coracoid, perpendicular to IR Internal Rotation
(Lateral Proximal Humerus) Epicondyles
perpendicular
CR 1 inch (2.5 cm)
inferior to coracoid
process 46 Evaluation Criteria
(Internal Rotation) Lesser tubercle
profiled medially
Scapulohumeral
joint centered
Proximal humerus,
upper scapula, and
clavicle visualized
Optimal exposure
factors
47 AP Projection in Neutral Position For trauma cases If possible, have patient rest the palm of the
hand against the thigh
Part position Leave arm in neutral position Center scapulohumeral joint to the IR
Place patient’s arm “as is” neutral position
• epicondyles usually at 45-degree angle to IR CR Perpendicular to IR to midscapulohumeral joint
3/4 inch inferior to coracoid and slightly lateral AP Neutral Rotation CR to scapulohumeral joint 49 Evaluation Criteria Greater tubercle
superimposed
Scapulohumeral
joint centered
Optimal exposure
factors 50 AP Oblique (Grashey Method) Patient position 35 to 45 degrees posterior oblique position
Affected shoulder closer to IR
More rotation may be necessary if patient is
recumbent
Rotation should place scapula parallel to IR
Head of humerus will be in contact with IR AP Oblique (Grashey Method) Part position
Rotate body 35-45 degrees toward affected side Center midscapulohumeral joint to IR Abduct arm slightly with neutral rotation Place palm of hand on abdomen CR
Perpendicular to glenoid cavity Enters 2 inches (5 cm) medial and inferior to
superolateral border of shoulder Collimation
Adjust to 8 x 10 inches (18 x 24 cm) To visualize just the shoulder joint Posterior Oblique: Glenoid Cavity
(Grashey Method) 35°-45° oblique CR perpendicular CR 2
inches (5 cm) inferior and
medial from superolateral
border of humerus 53 Evaluation Criteria:
(Posterior Oblique) Glenoid cavity
profiled
Scapulohumeral
joint centered
Optimal exposure
factors 54 Shoulder Trauma Routine Routine AP–neutral rotation
Scapular Y
Transthoracic lateral 55 PA Oblique (Scapular Y) So named because when properly positioned,
the acromion and coracoid process form a Y
shape
Position is particularly useful to diagnose
shoulder dislocations
In the normal shoulder, the humeral head is
directly superimposed over the junction of the Y
(acromion and coracoid) PA Oblique (Scapular Y) Patient position Upright, 45 to 60 degrees anterior oblique position
Affected shoulder closer to IR Part position Arm position in a neutral position
Maintain patient comfort
Palpate superior angle of scapula and AC joint
Rotate patient until an imaginary line between the
two points is perpendicular to the IR PA Oblique (Scapular Y) CR Perpendicular to scapulohumeral joint
2 to 2 ½ inches distal to the top of the shoulder Collimation Adjust to 12 inches (30 cm) in length and 1 inch
(2.5 cm) from the lateral shadow PA Oblique (Scapular Y) For lateral shoulder
and proximal
humerus
CR to proximal
humerus-2 inches (5
cm) below top of
shoulder 59 Evaluation Criteria
(Scapular Y Lateral) Body of scapula
superimposed on end
Acromion and
coracoid processes
in profile
Humeral head and
glenoid cavity
superimposed
Optimal exposure
factors Dislocated 60 Inferosuperior Axial Projection
(Lawrence Method) Patient position Supine
Head and shoulder elevated on 3-inch radiolucent
support
Head turned away from CR Inferosuperior Axial Projection
(Lawrence Method) Part position Elevate arm about 2 inches above the table to help
place anatomy closer to the center of the IR
Abduct arm 90 degrees from body
If possible, place arm in external rotation Place IR crosswise on table (in a holder)
centered to shoulder joint
Collimation Adjust to 12 inches (30 cm) in length and 1 inch
(2.5 cm) above the anterior shadow of the shoulder Inferosuperior Axial Projection
(Lawrence Method) CR Horizontal
Medial angulation of 25 to 30 degrees
Centered to axilla and humeral head
Enters axilla; passes through AC joint
Angle depends on abduction of humerus
More abduction = greater angle Inferosuperior Axial
(Lawrence Method) CR 25°-30° medial
to axilla
Arm supinated,
abducted 90° (or as
near 90° as
possible) Special
• Inferosuperior axial 64 Evaluation Criteria
(Inferosuperior Axial Projection) Lesser tubercle
profiled anteriorly
Humeral head and
glenoid fossa
profiled
Optimal exposure
factors 65 Trauma Shoulder Transthoracic Lateral
(Lawrence Method) Note: Projection used for trauma patients who
cannot abduct arm
Patient position Supine or upright lateral
Affected limb closer to IR
Unaffected limb elevated over head Transthoracic Lateral
(Lawrence Method) Part position Do not move injured limb
Ensure elevated shoulder is higher than injured
shoulder
Center surgical neck of humerus to IR Transthoracic Lateral (Lawrence) CR Perpendicular to surgical neck
If shoulders are in same plane, CR angled 10 to
15 degrees cephalad Collimation Adjust to 10 x 12 inches (24 x 30 cm) LW
The light field will appear smaller on the skin
because of OID. Do not collimate larger than
stated size. Transthoracic Lateral
Proximal Humerus CR perpendicular to
surgical neck
Breathing technique Similar positioning
to transthoracic
humerus but…
CHANGE IN CR
& IR size 70 Evaluation Criteria Proximal humerus
clearly seen
Humeral head and
glenoid cavity seen
Humeral head in
neutral rotation
Optimal exposure
factors 71 Questions?
Next Lecture:
Chapter 5
clavicle, scapula, & ACJ
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