Anatomy of the Scapula and Clavicle

General Considerations

• Regs Alunan, RRT is the presenter
• The notes cover various aspects of patient management, identification, matching information, time-outs, post-procedure, the role of the radiographer, scope of practice, specializations, work environment, and the chief complaint.

Patient Management

• Appear confident
• Explain procedures and reasons
• Answer questions; avoid unnecessary information
• Prioritize anterior films
• Work quickly and efficiently
• Empathize with patients
• Compliment patients

Patient Identification

• Verify patient information on arrival
• Ask for name, date of birth, address, and reason for visit

Matching Information

• Ensure the request/consent form is clear and legible
• Confirm patient details (name, date of birth, medical record number or full address)
• Verify procedure requested (including side, if applicable)
• Check clinical history

Time Out

• Confirm correct patient is present
• Verify correct examination is being performed
• Confirm clinical history matches requested examination
• Check correct side/site is being examined
• Confirm right/left side markers are correct

Post-procedure

• Ensure patient details and side markers on the post-processed image are correct

Role of the Radiographer

• Primarily responsible for operating X-ray equipment to produce high-quality images
• Aid patient diagnosis
• Can specialize in various imaging areas, including sonography, MRI, mammography, computed tomography, and vascular interventional radiography

What Does a Radiologic Technologist Do?

• Perform medical exams using X-rays
• Create images of specific body parts
• The doctor interprets the images to diagnose and monitor disease
• Prepare patients for exams, position them correctly, operate equipment
• Minimize radiation dose to the patient

Scope of Practice

• Assess, evaluate, and test patients
• Prepare and position patients for imaging procedures
• Attend to patient needs during imaging procedures
• Maintain up-to-date knowledge of radiation protection and safety practices
• Independently perform or assist licensed practitioners in procedures like mammograms, X-rays, MRIs, or radiation therapy to cancer patients
• Prepare, administer, and document medications as regulated by state and federal guidelines and institutional policies

Specializations

• Bone densitometry
• Cardiac-interventional radiography
• Computed tomography (CT)
• Magnetic resonance imaging (MRI)
• Mammography
• Vascular interventional radiography
• Nuclear medicine
• Sonography

Work Environment

• Work in hospitals, medical labs, doctors' offices, outpatient centers
• Full-time, part-time, or as-needed schedules
• May include evening, weekend, or on-call hours
• Specialize and provide imaging in operating rooms, emergency departments, procedural suites, and specialized imaging departments

Chief Complaint

• Concise statement of symptoms causing patients to seek medical care

DO / DON'T: Specific examples for the visit

• DO: Specify reason for the visit, and who requested a consult and why
• DON'T: Fail to specify reason for visit, and fail to specify consult reasons

History of Present Illness (HPI)

• Give specific details regarding the presenting illness
• Document own HPI

Allergy History

• Specify suspected allergen(s)
• Ask about personal and family history of atopic disease, or food allergies of family members
• Ask about cultural and religious factors impacting food choices
• Details of avoided foods and reasons.
• Source of concern regarding food allergy suspected

Pain Assessment

• Precise and systematic pain assessment required for correct diagnosis and treatment
• Include onset/mechanism of injury, location/distribution, duration, course/pattern, character/quality, aggravating/provoking factors, associated symptoms, severity (impact on function, sleep, mood), barriers to pain assessment
• Pain scales
  • Single-dimensional scales (assess intensity, self-report), useful for acute pain with clear etiology
  • Multidimensional scales (assess intensity, nature, location, impact on activity/mood), useful for complex or chronic pain
• Consider factors affecting pain assessment in elderly and infants

Pain Scales [Single and Multidimensional]

• Single-dimensional scales measure pain intensity through self-reporting & are useful in acute pain
• Multidimensional scales measure intensity, nature, location and impact on activity/mood; helpful in complex or persistent pain

Pain Assessment in the elderly

• Underreporting of discomfort due to cognitive impairment or communication issues
• Other medical comorbidities potentially overshadowing pain complaints
• Hearing/vision decreases impacting effectiveness of some pain assessment tools

Pain Assessment in Infants

• CRIES scale uses 5 variables such as crying, oxygen requirement, increased vital signs, expression and sleeplessness
• Modified Behavioral Pain Scale uses 3 factors (facial expression, cry, movements) for children 2-6 months, validated for this age range

Pain Assessment in Young Children

• Limited cognitive/language skills affecting pain measurement, as do the consequences of children's behaviors relating to pain
• Children over 3-4 years may use self-report measures but may under-report pain to avoid procedures

Aggravating/Alleviating Factors

• Ask patients what makes their pain better or worse
• Include associated symptoms/side effects (Nausea, Vomiting, Constipation, Sleepiness, Confusion, Urinary Retention, Weakness) with pain and treatment

Special Considerations in Pediatric Imaging

• Special adjustments needed in imaging for children, especially in attitude & approach
• Radiologists must have good knowledge of equipment and its use

While coming for an examination most children are accompanied by parents. It is important to follow the protocol

• Introduce yourself as the technologist
• Follow instructions given by the pediatrician/physician
• Explain procedures and your needs/requirements during the examination

Preliminary Steps in Radiology

• Cassette with Film: A device with intensifying screens to imprint X-ray image on film.

Image plate (IP), Solid-state detectors (TFT), Portable digital radiography, and Fluoroscopic screen

• Image plate (IP): A device for computed radiography (CR).
• Solid-state detectors (TFT): A flat panel thin-film transistor (TFT) detector.
• Portable digital radiography: For image acquisition.
• Fluoroscopic screen: For real-time image viewing.

Radiograph

• Radiographers need to be fully familiar with radiographic attenuation patterns of normal anatomy for accurate imaging
• Superimposition: Overlapping anatomic structures.
• Relevant structures: Adjacent structures, Optical Density (OD), Contrast, Recorded Detail, Shape Distortion

ANATOMIC POSITION

• Standard anatomical position for patient positioning for radiography
• Patient standing erect, face and eyes forward, arms extended, palms facing forward, heels together, toes pointing anteriorly

DISPLAY OF RADIOGRAPHS

• Radiographs oriented according to the interpreting physician's preference and method
• Display methods largely based on common practice rather than established rules.

Posteroanterior(PA) and anteroposterior (AP) radiographs

• PA: Anterior aspect of chest closest to Image Receptor (IR).
• AP: Posterior aspect of chest closest to IR.

Exceptions to these guidelines

• Hands, fingers, wrists, feet, and toes are routinely displayed with digits pointed to the ceiling, and toes pointing towards ceiling.

Lateral radiographs

• Right/left side of patient placed against the Image Receptor (IR).

Oblique radiographs

• Patient's body rotated so the projection is not frontal, posterior, or lateral.

Clinical History

• Assess normal anatomy and variations to accurately position patients.
• Understand radiographic characteristics of abnormalities.
• Radiographers produce images clearly showing abnormalities.

Initial Examination

• Minimum radiographs obtained to detect demonstrable abnormalities.
• Supplemental studies done as needed.
• Saves time, unnecessary radiographs and reduces patient radiation exposure.

Diagnosis and the Radiographer

• Patients are anxious about results.
• Radiographers should tactfully advise patients that the referring physician will receive reports as soon as possible.

Care of the Radiographic Examining Room

• Maintain scrupulous cleanliness in the examining room as in other medical areas
• Wipe mechanical parts (tableside, supporting structure, collimator) with clean damp cloth daily
• Clean metal parts periodically with disinfectant.

Standard Precautions

• Handle patients on isolation status without contamination of hands, clothing, or apparatus.
• Radiographers must know to disinfect items when contaminated.

Standard precautions apply to

• Blood
• All body fluids
• Secretions and excretions (except sweat)
• Non-intact skin
• Mucous membranes

Handwashing

• Easiest and most convenient method to prevent spread of microorganisms
• Wash after examining patients, contact with blood or body fluids
• Before invasive procedures.
• Before touching patients at risk of infection.

Disinfectants and Antiseptics

• Chemical substances killing pathogenic bacteria classified as germicides and disinfectants.
• Disinfection kills pathogens only.
• Antiseptics inhibits growth of, but doesn't kill, pathogens.
• Alcohol commonly used in medical facilities having antiseptic but not disinfectant properties.
• Sterilization destroys all microorganisms (done with heat or chemicals)

Centers for Disease Control and Prevention (CDC)

• Issued handling recommendations for blood and body fluids.
• Treat all human blood and body fluids as if containing pathogens
• Wear gloves when contact with blood, mucous membranes, wounds or surfaces with body fluids/blood.

Body fluids that may contain pathogens

• Blood
• Any fluid containing blood
• Amniotic fluid
• Pericardial fluid
• Pleural fluid
• Synovial fluid
• Cerebrospinal fluid
• Seminal fluid
• Vaginal fluid
• Urine
• Sputum

Health care workers must be cautious to prevent needle stick injuries

• Recapping needles should never be done, instead place in a puncture-proof container and properly discard.

Operating Room

• Exercise extreme caution to prevent contaminating of sterile objects in the OR
• Wipe the X-ray equipment with a damp cloth before placing it in the OR.

Bowel Preparation

• Radiologic exams involving abdomen often necessitate complete colon cleansing.
• Employ different methods to cleanse the colon (limited diet, laxatives, enemas)

Motion and Its Control

• Patient motion is a major factor in radiography
• A: Image of a patient who moved during exposure shows fuzzy bone edges
• B: A still patient radiograph for comparison

Involuntary Muscles

• Involuntary motion can be due to heart pulsation, chill, peristalsis, tremor, or pain; and needs control through minimizing exposure time.

Anatomic and Radiographic Positioning Terminology

• Explanation of different planes/views with corresponding diagrams

Understanding patient positioning

• Basic terminology used in radiographic positioning (Anterior, Posterior, Superior, Inferior, Medial, Lateral).
• Describing body parts relative to each other or to the midline
• Describing body parts relative to the positions of other body parts

Body planes and positions

• Imaging body parts often have overlapping anatomical structures
• Radiographs used to show the presence (or absence) of a disease or condition.

Directional terms

• Terms are used to describe the positions of structures relative to other structures or locations within the body
• Explanation of Superior/Cranial, Inferior/Caudal, Anterior/Ventral, Posterior/Dorsal, Medial, Lateral, Proximal, Distal

Body Cavities

• Discusses the upper ventral (or thoracic) cavity which contains the heart, lungs, trachea, esophagus, large blood vessels, and nerves (bound by the ribs and diaphragm)
• Discusses abdominal cavity (contains gastrointestinal tract, kidneys, & adrenal glands); laterally bounded by the body wall, cranially by the diaphragm, and caudally by the pelvic cavity.
• Discusses pelvic cavity (contains the urogenital system, and rectum)
• Discusses cranial cavity (contains the brain)

Radiographic positioning terms (Body Positions)

• Erect: standing or sitting
• Recumbent: lying down
• Supine: lying on back
• Trendelenburg: supine position with head lower than feet
• Prone: lying face down
• Lateral: side touching the cassette (right or left lateral)
• Lateral decubitus: lying on one side (right or left lateral)

Movement

• Flexion: decreasing the angle of a joint
• Extension: increasing the angle of a joint
• Abduction: moving a limb away from the midline
• Adduction: moving a limb towards the midline
• Pronation: rotating the forearm so the palm faces posteriorly
• Supination: rotating the forearm so the palm faces anteriorly
• Circumduction: moving a limb in a circle
• Opposition: moving the thumb to touch other digits
• Reposition: returning the thumb to its anatomical position
• Elevation: moving a structure superiorly
• Depression: moving a structure inferiorly
• Eversion: moving the sole of the foot outward away from the midline
• Inversion: moving the sole of the foot inward towards the midline
• Protrusion: moving a structure (mandible, lips, or tongue) anteriorly
• Retraction: moving a structure (mandible, lips, or tongue) posteriorly

Projections

• Using radiographs to visualize regions of interest, depending on patient presentation, a single view or orthogonal projections may be performed
• Anteroposterior (AP): Central ray passes from anterior to posterior, perpendicular to coronal plane
• Posteroanterior (PA): Central ray passes from posterior to anterior, perpendicular to coronal plane
• Lateral: Central ray passes perpendicular to sagittal plane, parallel to coronal plane from one body side to the other
• Oblique: Central ray passes through the body/body part at an angle to the transverse/coronal plane.

Source-image-receptor distance (SID)

• Distance between X-ray tube and image receptor
• Inversely proportional to magnification/distortion
• Greater SID leads to less magnification/distortion. This is set at 100cm for most examinations, but upright chest x-rays are often set at 183cm

Tube film alignment :

• Alignment controls geometric distortion and grid cut-off for consistent radiographic image quality (similar methods used across most systems)

Longitudinal Alignment:

• Manually adjusted by radiographer
• Tubestand and bucky can be moved longitudinally

Lateral Alignment:

• Bucky's lateral position is fixed, even when table top is moved

Vertical Alignment:

• Tubestand switch engages to position focal spot at desired vertical distance from image receptor, often set at a 40 inch SID

Positioning aids

• Sandbags: Support/weigh limbs to maintain position
• Foam wedges/blocks: Placed under sternum to prevent spine rotation or raise/support limbs
• Rope ties: Pull limbs out of the collimated field

Calipers

• Helpful x-ray imaging ruler to measure thickness of the body part

Accessory equipment

• Widely used (hospitals, doctors offices, radiology clinics, dental offices, nursing homes, emergency rooms)
• Assist X-Ray technologists obtaining images for accurate diagnosis

X-Ray Viewer

• Used for viewing dry and wet X-ray images

X-Ray Protective Glasses

• Protect the practitioner's eyes during radiographic diagnosis and interventional treatment.

Lead Gloves

• Seamless surface preventing radiation leakage
• Convenient for wear and discard

Lead Apron - Wrap Around

• Protects medical workers & patients from unnecessary radiation exposure during diagnostic radiology

Lead Apron - Velcro Type

• Protects medical workers & patients from unnecessary radiation exposure during diagnostic radiology

Thyroid Collars

• Provides protection for the neck and thyroid area
• Helps reduce patient exposure during intraoral radiography

Gonad Shield

• Protects the male/female reproductive organs

Ovary Shield

• Protects the female reproductive organs

X-Ray Cassettes

• Made of aluminum alloy frame, engineering plastics and high stamina aluminum plate
• Various sizes (6.5" X 8.5", 8" X 10", 10" X 12", 14" X 17", 12" X 15", 14" X 14")

X-Ray Hangers

• Made of Stainless Steel
• Various sizes (6.5" X 8.5", 8" X 10", 10" X 12", 14" X 17", 12" X 15", 14" X 14")

Apron Stand for 5 Aprons

• Made of Stainless Steel
• Floor Type with wheels
• Also available for 3 or 7 aprons

Chest Stand Floor Model

• Made of Steel
• Wall mounted Chest Stand also available.

Safe Light for Dark Room

• Used in dark room environments

Protection Screen Single Panel with Lead Glass

• Provides protection during radiographic procedures

Lead Letters

• Used for visual marking/identification

Bony Thorax

• A description of the skeletal structure of the thorax, including the sternum, ribs, and thoracic vertebrae, from front and back views.

Bony Thorax (summary)

• Thorax comprised of Sternum, Ribs, and Thoracic Vertebrae
• Supports the walls of the pleural cavity and used for respiration
• Protects important internal organs (heart and lungs)

Sternum

• Situated anteriorly and inferiorly over the midline of the thorax
• Consists of three parts: Manubrium, Body, and Xiphoid Process
• Supports clavicles and provides attachment to the costal cartilages (first seven pairs of ribs)

Sternum (Anterior, Lateral, oblique aspects)

• Anterior view: Jugular notch, Clavicular notch, Manubrium, Sternal angle, Body, Xiphoid Process
• Lateral view: Sternum aspect & details
• Anterolateral oblique view: Sternum, oblique aspect & additional details.

Rib Structure and Numbering

• Twelve pairs of ribs numbered consecutively from superior to inferior
• Corresponds with the thoracic vertebra at which it's attached
• Typical ribs have a head, a neck, a tubercle, and a body
• Ribs head have articulation facets with the vertebrae.

Rib articulations (Costovertebral & Costotransverse)

• Superior aspect of Rib articulating with thoracic vertebrae and sternum illustrated
• Enlarged image showing costovertebral and costotransverse articulations
• MRI transverse image showing costovertebral articulations.

Bony Thorax Articulations

• Sternoclavicular Joints: Articulation between the upper limbs and trunk
• Costovertebral, Costotransverse, Costochondral and Sternocostal joints.
• Interchondral, Manubriosternal and Xiphisternal joints.

Summary of Pathology

• fracture
• metastases
• osteomyelitis
• osteopetrosis
• osteoporosis
• Paget Disease
• Tumor
• Chondrosarcoma
• Multiple myeloma

Exposure Technique Chart Essential Projections (Bony Thorax)

• Detailed table of exposure technique parameters for various bony thorax projections (Sternum, Sternoclavicular joints, anterior/posterior/oblique Ribs, etc) including cm, kVp, mA, mAs

Bony Thorax – Positioning Considerations

• The sternum routine, positioning techniques and considerations for a clear image (lateral and oblique)

Right Anterior Oblique (RAO) Sternum

• Positioning and technical factors for a clear RAO projection of the sternum

Lateral Sternum

• Positioning and technical factors for a clear lateral projection of the sternum.

Evaluation Criteria: Oblique (RAO) Sternum

• Demonstrating the sternum superimposed on the heart shadow
• Proper rotation and visualization along the vertebral column during the exposure
• Exposure time & technique considerations (ex: breathing technique) for optimal image quality/contrast/density

Ribs (AP)

• Specific projection employed for posterior rib assessment
• Image showing appropriate details (ribs numbered and labeled)

Patient position

• Erect patient facing X-ray tube with the posterior portion of the body resting on the upright detector
• Chin raised to avoid inclusion in the image area
• Hands placed at the patient's sides

Technical Factors

• Anteroposterior projection with suspended inspiration
• Centering point above the diaphragm at the level of T7
• Centering point below the diaphragm (midway between the xiphoid process and the 12th rib)
• Use of a 100cm SID
• Application of a grid

Image technical evaluation

• Correct structural alignment and arrangement for visualization of structures and regions
• Clear visualization of structures, bones and details within structures, regions, borders of structures.

Ribs (AP oblique view)

• AP oblique rib projection used to visualize axillary ribs
• Presented in anterior-oblique and posterior oblique views

Patient position

• Erect or supine patient with affected side closest to receptor side oriented 45 degrees
• Affected arm closest to receptor placed on patient head; opposite arm placed on hip

Transthoracic supine lateral scapula

• Performed to identify dislocations or fractures in patients who cannot move
• Patient positioned supine

Technical factors

• Respiration technique using suspended inspiration
• Centering point above the diaphragm at T7 level

Clavicle

• Description of Clavicle structure, position, and relevant bone landmarks (with diagrams)

Clavicle (functions)

• Attachments to the trunk
• Acts as a protector of structures
• Transmits force from upper limb to axial skeleton

Bony Landmarks and Articulations

• Clavicle's description (form/shape): a slender bone resembling an "S" shape
• Medial/Lateral aspects: convex/concave, respectively
• Sternal end, shaft and acromial end subdivisions.

Sternal (medial) End

• Features of the sternal end (large facet, oval depression for costoclavicular ligament) for articulation with manubrium of sternum at sternoclavicular joint

Shaft

• Shaft of the clavicle and points of origin & attachment for several muscles

Acromial (lateral) End

• Acromial end houses facet for articulation with acromion of scapula
• Attachment points for ligaments (conoid & trapezoid)

Clavicle series

• Used in emergency departments to assess the clavicle, acromioclavicular and sternoclavicular joint.
• Indications (e.g., trauma, bony tenderness, suspected fracture)

Clavicle AP

• Demonstrates shoulder in natural anatomical position
• Patient position: erect with midcoronal plane parallel to image receptor
• Affected side's clavicle centered on the receptor

Technical factors

• Centering point: mid-clavicle
• Orientation: landscape
• Exposure: 60-70 kVp, 10-18 mAs

Clavicle Tangential AP

• Projection that straightens out the clavicle, useful for visualizing subtle fractures & joint dislocations

Centering point

• Just below mid-clavicle in an angled cephalic position (15-30°)

Sternoclavicular Joint (serendipity view)

• Specialized projection utilized for suspect dislocations of sternoclavicular joint
• Indications relating to trauma resulting in significant dislocations or medial end clavicular fractures.

Patient position

• Supine on the table, axial projection
• Centering point at level of sternoclavicular joint with 40-degree cephalic angle

Acromioclavicular joint (AP weight-bearing view)

• Often performed along side normal non-weight bearing AP view for assessment of possible acromioclavicular joint separation

Patient position

• Patient position is erect, holding weight in affected hand.
• Affected side is against receptor, and acromioclavicular joint is centered on receptor.

Centering point

• Acromioclavicular joint

Acromioclavicular joint (Zanca view)

• Specialized projection used in the assessment of acute & chronic acromioclavicular joint injuries
• Optimizes visualization, useful for assessing distal osteophytes

Patient position

• Patient is erect with midcoronal plane parallel to the image receptor. Affected side is centred on the image receptor and affected arm is held neutrally by patient side.

Centering point

• At acromioclavicular joint with a 10-15° cephalad angle

Modified Alexander view (AC joint)

• Superior projection using AP axial view to delineate AC joint abnormalities.
• Central ray directed at the coracoid process with a 15° cephalic angle.

Scapula

• Description of structure and form of scapula
• Articulations: Glenohumeral joint connects to humerus, and Acromioclavicular joint connects to the clavicle
• Surfaces (Costal, Lateral, Posterior) including their landmarks and relevant structures.

Scapula AP

• A specialized projection used for assessment of the actual scapula/shoulder girdle.
• Can be performed in erect or supine positions involving 90-degree abduction of the affected arm.

Centering point for Scapula AP

• 5 cm inferior to the coracoid process.

Breathing technique for Scapula AP studies

• Breathing is a crucial technique for best results for the scapula AP studies

Shoulder (lateral scapula view)

• Projection for assessment of scapula fractures or dislocations, as well as degenerative changes.
• Useful in visualizing the coracoid & acromion process in profile.

Positioning considerations for shoulder (lateral scapula view)

• Patient erect or sitting, facing the upright detector.
• Rotated into an anterior oblique position to ensure the anterior portion of the shoulder touches the detector.
• Arm positioned on the patient's abdomen, flexed.
• Degree of anterior rotation varies by patient.
• The scapula is positioned end-on to the upright detector, through palpation

Centering point

• The level of the glenohumeral joint on the posterior aspect of the patient (5 cm below the top of the shoulder) centralized to the medial scapular border.