Technique 1 Upper limbs 3

Radiographic Technique 1
September, 2011
Prepared by:
Behzad Ommani
Bachelor of Radiology
Master of Medical Engineering

Shoulder
AP PROJECTION (External, Neutral, Internal rotation
humerus)
Image receptor: 24 x 30 cm crosswise
Position at patient: Examine the patient in the upright or
the supine position
• NOTE: Do not have the patient rotate the arm if
fracture or dislocation is suspected.
Position of part :
• Center the shoulder joint to the midline of the grid.
• Adjust the position of the IR so that its center is I inch
(2.5 cm) inferior to the coracoid process.

• If necessary to overcome the curve of the back and the
resultant obliquity of the shoulder structures, slightly
rotate the patient enough to place the body of the
scapula parallel with the plane of the IR.
Central ray : Perpendicular to a point I inch (2.5 cm)
inferior to the coracoid process.
Respiration: Suspend.
Shoulder

External Rotation Humerus
• Ask the patient to supinate the hand, unless
contraindicated .
• Abduct the arm slightly, and rotate it so that the
epicondyles are parallel with the plane of the IR.
• Externally rotating the entire arm from the neutral
position places the shoulder and entire humerus in the
true anatomic position.
 The greater tubercle of the humerus and the site of
insertion of the supraspinatus tendon are visualized.
Shoulder

Neutral Rotation Humerus
• Ask the patient to rest the palm of the hand against the
thigh . This position of the arm rolls the humerus slightly
internal into a neutral position. placing the epicondyles
at an angle of about 45 degrees with the plane of the IR.
 The posterior part of the supraspinatus insertion, which
sometimes profiles small calcific deposits not otherwise
visualized
Shoulder

Internal Rotation Humerus
• Ask the patient to flex the elbow somewhat, rotate the
arm internally. and rest the back of the hand on the hip.
Adjust the arm to place the epicondyles perpendicular to
the plane of the IR.
 The proximal humerus is seen in a true lateral position.
When the arm can be abducted enough to clear the
lesser tubercle of the head of the scapula, a profile
image of the site of the insertion of the subscapular
tendon is seen.
Shoulder

Shoulder
TRANSTHORACIC LATERAL PROJECTION
(R or L position) LAWRENCE METHOD
Image receptor: 24 x 30 cm lengthwise
Position at patient:
• For upright positioning. seat or stand the patient in the
lateral position before a vertical grid device. If an
upright position is not possible.
• place the patient in a recumbent position on the table
with radiolucent pads elevating the head and shoulders.

• Have the patient raise the uninjured arm, rest the
forearm on the head. And elevate the shoulder as much
as possible.
• Center the IR to the surgical neck area of the affected
humerus.
Respiration: Full inspiration.
Having the lungs full of air improves the contrast and
decreases the exposure necessary to penetrate the body.
 A minimum exposure time of 3 seconds (4 to 5 seconds is
desirable) will give excellent results when a low
milliamperage is used
Shoulder

Central ray : Perpendicular to the IR. entering the
midcoronal plane at the level of the surgical neck. If the
patient cannot elevate the unaffected shoulder. angle the
central ray 10 to 15 degrees cephalad to obtain a
comparable radiograph.
Shoulder

Shoulder Joint
SUPEROINFERIOR AXIAL PROJECTION
Image receptor: 18 x 24 cm placed lengthwise for accurate
centering to the shoulder joint.
Positionof patient : Seat the patient at the end of the table
on a stool or chair high enough to enable extension of
the shoulder under examination well over the IR.
Position at patient:
• Place the IR near the end of the table and parallel with
its long axis.
• Have the patient lean laterally over the IR until the
shoulder joint is over the midpoint of the IR.

• Bring the elbow to rest on the table. Flex the patient's
elbow 90 degrees, and place the hand in the prone
position.
• Have the patient tilt the head toward the unaffected
shoulder.
Central ray : Angled 5 to 15 degrees through the shoulder
joint and toward the elbow.
Shoulder Joint

AP AXIAL PROJECTION
• Image receptor: 8 x 10 inch (18 x 24 cm) crosswise
Position at patient: Position the patient in the upright or
supine body position.
Position of part :
Center the scapulohumeral joint of the shoulder being
examined to the midline of the grid .
Respiration: Suspend
Shoulder Joint

Central ray : Directed through the scapulohumeral joint at
a cephalic angle of 35 degrees.
 The axial image shows the relationship of the head of
the humerus to the glenoid cavity. This is useful in
diagnosing cases of posterior dislocation.
Shoulder Joint

PA OBLIQUE PROJECTION
(RAO or LAO position) Scapular Y
Image receptor: (24 x 30 cm)
• This projection, described by Rubin, Gray, and Green, I
obtained its name as a result of the appearance of the
scapula.
• The body of the scapula forms the vertical component of
the Y, and the acromion and coracoid processes form
the upper limbs.
• The projection is useful in the evaluation of suspected
shoulder dislocations.
Shoulder Joint

Position at patient : the upright position is preferred. RAO
or LAO position
Position of part :
• Position the anterior surface of the shoulder being
examined against the upright table.
• Rotate the patient so that the midcoronal plane forms
an angle of 45 to 60 degrees to the IR.
• Palpate the scapula, and place its flat surface
perpendicular to the IR. Position the center of the IR at
the level.
Central ray : Perpendicular to the scapulohumeral joint.
Shoulder Joint

• In anterior (subcoracoid) dislocations, the
humeral head is beneath the coracoid
process.
Shoulder Joint
In posterior (subacromial) dislocations,
it is projected beneath the acromion
process.

AP OBLIQUE PROJECTION (Glenoid Cavity)
(RPO or LPO position) GRASHEY METHOD
Image receptor : 8 x 10 inch (18 x 24 cm) crosswise
Position of patient : Achieve this position with the patient in
the supine or upright position.
Position of part :
• Center the IR to the scapulohumeral joint.
• Rotate the body approximately 35 to 45 degrees toward
the affected side.
Shoulder Joint

• Adjust the degree of rotation to place the scapula
parallel with the plane of the IR.
• This allows the head of the humerus to be in contact with
the IR.
• If the patient is in the supine position, the body may need
to be rotated more than 45 degrees to place the scapula
parallel to the IR.
• In addition, support the elevated shoulder and hip on
sandbags .
• Abduct the arm slightly in internal rotation, and place
palm of the hand on the abdomen.
Shoulder Joint

Shoulder Joint
Central ray : Perpendicular to the glenoid cavity at a point
2 inches (5 cm) medial and 2 inches (5 cm) inferior to the
superolateral border of the shoulder.

Shoulder Joint
AP AXIAL PROJECTION (Proximal Humerus)
STRYKER "NOTCH" METHOD
• Dislocations of the shoulder are frequently caused by
posterior defects involving the posterolateral head of the
humerus. Such defects, called Hill-Sachs defects, are
often not demonstrated using conventional radiographic
positions.
• Hall. Isaac. and Booth' described the notch projection.

Image receptor : 24 x 30 cm
Position of patient : Place the patient on the radiographic
table in the supine position.
Position of part :
• With the coracoid process of the affected shoulder
centered to the table.
• Ask the patient to flex the arm slightly beyond 90
degrees and place the palm of the hand on top of the
head with fingertips resting on the head.
Shoulder Joint

Central ray : Angled 10 degrees cephalad, entering the
coracoid process.
Shoulder Joint

Shoulder Joint
AP OBLIQUE PROJECTION (Glenoid Cavity)
(RPO or LPO position) APPLE METHOD
This projection is similar to the Grashey Method but uses
weighted abduction to demonstrate a loss of articular
cartilage in the scapulohumeral joint.
Image receptor : 24 x 30 cm crosswise
Position of patient : Achieve this position with the patient
seated or upright.
Position of part :
Similar Grashey.

• The patient should hold a 1 pound weight in his or her
hand on the same side as the affected shoulder in a
neutral position.
• While holding the weight have the patient abduct the
arm 90 degrees from the midline of the body .
Respiration : Suspend.
Central ray : Perpendicular to the IR at the level of the
coracoid process.
Shoulder Joint

Shoulder Joint
AP AXIAL OBLIQUE PROJECTION (Glenoid Cavity)
(RPO or LPO position) GARTH METHOD
This projection is recommended for acute shoulder trauma
and for identifying posterior scapulohumeral
dislocations, glenoid fractures, Hill-Sachs lesions, and
soft tissue calcifications.
Image receptor : 24 x 30 cm lengthwise
seated or upright.
Position of part :
Similar Grashey.

• Flex the elbow of the affected arm and place arm across
the chest.
Central ray : Angled 45 degrees caudad through the
scapulohumeral joint.
Shoulder Joint

Radiography
Acromioclavicular
Articulations

Acromioclavicular Articulations
AP PROJECTION (Bilateral)
PEARSON METHOD
Image receptor : 18 x 43 cm or two 8 X 10 inch (18 x 24
cm), as needed to fit the patient
SID: 72 inches (183 cm). A longer SID reduces
magnification, which enables both joints to be included
on one image.
• It also reduces the distortion of the joint space resulting
from central ray divergence.
seated or upright.

• Center the midline of the body to the midline of the grid.
• Ensure that the weight of the body is equally distributed
on the feet to avoid rotation.
• With the patient's arms hanging by the sides, adjust the
shoulders to lie in the same horizontal plane.
• It is important that the arms hang unsupported.
Make two exposures:
• one in which the patient is standing upright without
weights attached, and a second in which the patient has
equal weights (5 to 8 Ib) affixed to each wrist

AP AXIAL PROJECTION
ALEXANDER METHOD
Alexander' suggested that both AP and PA axial oblique
projections be used in cases of suspected
acromioclavicular subluxation or dislocation. Each side
is examined separately.
Image receptor : 8 x 10 inch (18 x 24 cm) lengthwise
seated or upright.

Positionof part :
• Center the affected shoulder under examination to the
grid.
• Adjust the height of the IR so that the midpoint of the
film is at the level of the acromioclavicular joint.
• Adjust the patient's position to center the coracoid
process to the IR.
Central ray : Directed to the coracoid process at a cephalic
angle of 15 degrees . This angulation projects the
acromioclavicular joint above the acromion.

PA AXIAL OBLIQUE PROJECTION
(RAO or LAO position) ALEXANDER METHOD
Image receptor : 8 x 10 inch (18 x 24 cm) lengthwise
seated or upright.
Positionof part :
• Stand or sit the patient facing the IR, and place the hand
of the affected side under the opposite axilla.
• Rotate the patient so the midcoronal plane forms an
angle of 45 to 60 degrees from the IR to place the
scapula perpendicular to the IR.

• Adjust the patient's position to center the
acromioclavicular joint to the midline of the grid.
Central ray : Directed through the acromioclavicular joint
at an angle of 15 degrees caudad.

Clavicle
AP PROJECTION
Image receptor : 24 x 30 cm Crosswise
Position of patient : Place the patient in the supine or
upright position.
 If the clavicle is being examined for a fracture or a
destructive disease or if the patient cannot be placed in
the upright position, use the supine position to reduce
the possibility of fragment displacement or additional
injury.

Position of part :
• Adjust the body to center the clavicle to the midline of
the table or vertical grid device.
• Place the arms along the sides of the body, and adjust
the shoulders to lie in the same horizontal plane. Center
the clavicle to the.
Respiration: Suspend at the end of exhalation to obtain a
more uniform density image.
Central ray : Perpendicular to the mid shaft of the
clavicle.
Clavicle

PA PROJECTION
The PA projection is generally well accepted by the patient
who is able to stand, and it is most useful when
improved recorded detail is desired. The advantage of
the PA projection is that the clavicle is closer to the
image receptor, thus reducing the OlD.
Positioning is similar to that of the AP projection. The
differences are as follows:
• The patient is standing upright (back toward the x-ray
tube) or prone .
• The perpendicular central ray exits midshaft of the
clavicle .
• Structures shown and evaluation criteria are the same
as for the AP projection.
Clavicle

Clavicle
AP AXIAL PROJECTION
Lordotic Position
Image receptor : 24 x 30 cm Crosswise
• Position of patient : Stand or seat the patient I foot in
front of the vertical IR device, with the patient facing the
x-ray tube.
• Alternatively, if the patient is unable to stand and
assume the lordotic position, place the patient supine on
the table

Position of part :
(Standing lordotic position )
• Have the patient lean backward in a position of extreme
lordosis, and rest the neck and shoulder against the
vertical grid device.
• The neck will be in extreme flexion. Center the clavicle
to the center of the IR.
(Supine position)
• Center the IR to the clavicle.
Respiration: Suspend at the end of full inspiration to further
elevate and angle the clavicle.
Clavicle

Central ray :
Directed to enter the midshaft of the clavicle.
• For the standing lordotic position, 0 to 15 degrees is
recommended.
• For the supine position, 15 to 30 degrees is
recommended
 Thinner patients require more angulation to project the
clavicle off the scapula and ribs.
Clavicle

PA AXIAL PROJECTION
• Positioning of the PA axial clavicle is similar to the AP
axial projection just described. The differences are as
follows:
• The patient is prone or standing, facing the vertical grid
device.
• The central ray is angled 15 to 30 degrees caudal .
Clavicle

Clavicle
TANGENTIAL PROJECTION (IS)
Image receptor : 8 x 10 inch (18 X 24 cm) crosswise
Position of patient : With the patient in the supine position,
place the arms along the sides of the body.
Positionof part :
• If possible, depress the shoulder to place the clavicle in
a horizontal plane .
• Have the patient turn the head away from the side being
examined.
• Place the IR on edge at the top of the shoulder and
support it in position.

• The IR should be as close to the neck as possible .
Central ray :
• Angled so that the central ray will pass between the
clavicle and the chest wall, perpendicular to the plane of
the IR.
• The angulation will be about 25 to 40 degrees from the
horizontal. If the medial third of the clavicle is in
question, it is also necessary to angle the central ray
laterally; 15 to 25 degrees is usually sufficient.
Clavicle

Clavicle
TANGENTIAL PROJECTION (SI)
Tarrant method
Image receptor : (24 x 30 cm) crosswise
Position of patient : Place the patient in a seated position.
Positionof part :
• Adjust a sheet of leaded rubber over the gonad area. A
folded pillow or blankets may be placed on the patient's
lap to support the horizontally placed IR if needed.
• Using the collimator light as the indicator, center the IR
to the projected clavicle area, and have the patient hold
the IR in position.

• Ask the patient to lean slightly forward
Central ray :
• Directed anterior and inferior to the midshaft of the
clavicle at a 25- to 35-degree angle. It should pass
perpendicular to the longitudinal axis of the clavicle.
• Because of the considerable OlD, an increased SID is
recommended to reduce magnificat
 The clavicle above the thoracic cage IS demonstrated.
Clavicle

Scapula
AP PROJECTION
Image receptor : (24 x 30 cm) lengthwise
• Position of patient : Place the patient in the upright or
supine position. The upright position is preferred if the
shoulder is tender.
Positionof part :
• Adjust the patient's body, and center the affected scapula
to the midline of the grid.
• Abduct the arm to a right angle with the body to draw
the scapula laterally. Then flex the elbow, and support
the hand in a comfortable position

Scapula
• Position the top of the IR 2 inches (5 cm) above the top
of the shoulder.
Respiration: Make this exposure during slow breathing to
obliterate lung detail.
Central ray : Perpendicular to the midscapular area at a
point approximately 2 inches (5 cm) inferior to the
coracoid process.

Scapula
LATERAL PROJECTION
(RAO or LAO body position)
Position of patient : Place the patient in the upright
position, standing or seated, facing a vertical grid
device.
Positionof part :
• Adjust the patient in an RAO or LAO position, with the
affected scapula centered to the grid. The average
patient requires a 45- to 60-degree rotation from the
plane of the IR.

• Place the arm in one of two positions according to the
area of the scapula to be demonstrated :
1. For delineation of the acromion and coracoid
processes of the scapula, have the patient flex the
elbow and place the back of the hand on the posterior
thorax at a level sufficient to prevent the humerus from
overlapping the scapula .
Scapula

• Mazujian' suggested that the patient place the arm
across the upper chest by grasping the opposite
shoulder.
• For demonstration of the body of the scapula, ask the
patient to extend the arm upward and rest the forearm
on the head or across the upper chest by grasping the
opposite shoulder.
Central ray :
Perpendicular to the mid medial border of the protruding
scapula.
Scapula

Coracoids Process
AP AXIAL PROJECTION
Position of patient : Place the patient in the supine position
with the arms along the sides of the body.
Position of part :
• Adjust the position of the body, and center the affected
coracoid process to the midline of the grid.
• Adjust the shoulders to lie in the same horizontal plane.
Scapula

• Abduct the arm of the affected side slightly, and supinate
the hand, immobilizing it with a sandbag across the
palm.
Respiration: Suspend at the end of exhalation for a more
uniform density.
Central ray :
• Directed to enter the coracoid process at an angle of 15
to 45 degrees cephalad.
• Kwak, Espiniella, and Kattan recommend 30 degrees.
 The degree of angulation depends on the shape of the
patient's back. Round-shouldered patient" require a
greater angulation than those with a straight back.
Scapula

Technique 1 Upper limbs 3

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Technique 1 Upper limbs 3