Shoulder Xray

True AP Shoulder in neutral rotation (taken in the plane of the scapula) (Grashey view)

• 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. (Weiner DS, JBJS 1970;52B:524). May appear falsely decreased with posterior subluxation of the humeral head.

Blue dot = Greater Tuberosity
Red dot = Lesser Tuberosity

Position:  Patient erect, turned 30-35° toward the side being xrayed
Tube: Perpendicular to plate

AP Shoulder in External rotation (taken in the plane of the scapula)

• Helpful for: Glenohumeral Arthritis, Coracoid Process Fracture, Glenoid Fracture, Proximal Humerus Fracture, compression fracture of humeral head.

Blue dot = Greater Tuberosity
Red dot = Lesser Tuberosity

Position:  Patient erect, turned 30-35° toward the side being xrayed; arm maximally externally rotated
Tube: Perpendicular to plate

AP Shoulder in Internal rotation (taken in the plane of the scapula)

• Helpful for: Hill-Sachs lesions, Glenohumeral Arthritis, Coracoid Process Fracture, Glenoid Fracture, Proximal Humerus Fracture.

Blue dot = Greater Tuberosity
Red dot = Lesser Tuberosity

Position:  Patient erect, turned 30-35° toward the side being xrayed; arm maximally internally rotated

Beam: aimed perpendicular to plate

Scapular Y Shoulder Xray

• Demonstrates: lateral projection of scapular body and humeral head overlapping the glenoid.
• Helpful for: Shoulder Dislocation; Proximal Humerus Fracture. ; Scapula Fracture

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

Axillary view Shoulder Xray

• 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,

Position: Patient seated at side of radiographic table with the arm abducted and axilla over the cassette.

Beam:angle 5°-10° toward the elbow, central beam directed at the shoulder joint.

Many alternative postions for similar xray, can be supine etc.

Supraspinatus Outlet view Shoulder Xray

• Demonstrates: outlet/impingement of the supraspinatus and coracoacromial arch.
• Helpful for: Subacromial Impingement, assessing Subacromial Morphology, unfused acromial epiphysis.

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

Zanca View Shoulder Xray

• 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.

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.

West Point Axillary View Shoulder Xray

• Demostrates: anteroinferior glenoid rim., best for osseous Bankart Lesion.
• Helpful for: Shoulder Instability, Glenoid Fracture, osseous Bankart Lesion.

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).

(Rokous JR, CORR 1972;82:84)

Stryker Notch View Shoulder Xray

• Demonstrates: humeral head
• Helpful for: Hill-Sachs lesions (best view), Bankart Lesion.

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.

(Hall RH, JBJS 1959;41-A:489-94)

Serendipity View Shoulder Xray

• Demonstrates: sternoclavicular joints and medial 1/3 of the clavicles.
• Helpful for: Clavicle Fracture, Distal Clavicle Fracture, Sternoclavicular Joint Dislocation,

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

Bennett's View (modified)Shoulder Xray

• Obtained by angling the tube 5° cephalad with the arm abducted 45°. Approximates an AP in ER view.
• Wright RW, AJSM 2004;32:121       

Bennett's view Shoulder Xray

• External rotation of the humerus with tilting of the x-ray tube 5° cephalad
• Bennett GE: Elbow and shoulder lesions of baseball players. Am J Surg 98: 484–492, 1959       

Acromiohumeral Interval

• average = 10.5mm. <7mm=full-thickness RTC tear. Measure on Grashey view. (Cotty P, J Radiol 1988;16:633).       

Garth View (apical oblique) Shoulder Xray

• Demostrates: the full extent of the glenoid rim bone loss and Hill-Sachs lesions
• Helpful for: Shoulder Instability, Glenoid Fracture, osseous Bankart Lesion. Hill-Sachs lesions.

Postion: Seated with shoulder adjacent to cassette and arm adducted and internally rotated (place hand over heart). Chest rotated 45º

Beam: beam perpendicular to the anterior-inferior glenoid rim and posterior-superior humeral head. (45º to the coronal plane and 45º caudally).

Rollover for example rendition.

Garth WP Jr, JBJS1984;66A:1450