Chapter 5 humerus and shoulder PDF.pdf
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Chapter 5 Rad 101 References: Bontrager 10th edition Positioning and Related Anatomy 11th edition Humerus RAD 101 Reference: Bontrager 10th edition Positioning and Related Anatomy 11th edition Learning Outcomes Identify the following parts and prominences on an image or skeleton:...
Chapter 5 Rad 101 References: Bontrager 10th edition Positioning and Related Anatomy 11th edition Humerus RAD 101 Reference: Bontrager 10th edition Positioning and Related Anatomy 11th edition Learning Outcomes Identify the following parts and prominences on an image or skeleton: Humerus Head Anatomical neck Surgical neck Greater tubercle Lesser tubercle Intertubercular groove Medial epicondyle Lateral epicondyle Olecranon fossa Coronoid fossa Radial fossa Capitulum Trochlea Learning Outcomes Identify the structures best shown on routine images for the upper extremity and shoulder girdle Describe the routine and special projections for each of the following radiographic procedures: Humerus Discuss why each of the projections maybe requested Let’s Review Which side is the Ulna and Radius on? Ulna : 5th Digit (Medial Side) Radius: Thumb (1st Digit) (Lateral Side) Let's Review Distal Humerus What view is this? AP (Anterior View) What are the 3 Fossa’s? Olecranon Fossa Coronoid Fossa Radial Fossa What are the names of the projections that come off of the lateral and medial distal humerus? (Hint: We use them for positioning) Lateral Epicondyle Medial Epicondyle Let's Review Distal Humerus What is the name of the medial condyle that articulates with the ulna? (Hint: Shaped like a pulley) Trochlea What is the name of the lateral condyle that articulates with the radius? (Hint: “Cap” is on top of the “head”) Capitulum Let’s Review Distal Humerus What view is this? Lateral How do we know it’s a good lateral? Hint: 3 concentric arcs Trochlear Sulcus Capitulum & Trochlea Ridges Trochlear notch of ulna or semilunar notch Epicondyles are superimposed Names of the 2 fat pads & 1 Stripe? Posterior Fat Pad Anterior Fat Pad Supinator Fat Stripe Proximal Humerus Anatomy – Chapter 5 Proximal Humerus Anatomy Humerus Largest & longest bone in the upper extremity About 1/5 of an adult's height Articulates with the scapula at the shoulder joint Most proximal part of the humerus Rounded portion called the head Slightly constricted portion below the head is called the anatomic neck Proximal Humerus Anatomy The process directly below the anatomic neck on the anterior surface is the lesser tubercle The larger lateral process is greater tubercle Pectoralis major and supraspinatus muscles attach Deep groove between the two tubercles is the intertubercular groove (bicipital groove) Proximal Humerus Anatomy The tapered area below the head and tubercles Surgical neck Why? Distal to the surgical neck is the body (shaft) Deltoid tuberosity – rough raised elevation along the anterolateral surface of the body Deltoid muscle attaches here Joints Scapulohumeral joint (glenohumeral or shoulder joint) Elbow joint How Does the Anatomy Look Based on the Views? Neutral Rotation (natural arm position without internal or external rotation) Proximal humerus in an oblique position External Rotation Proximal humerus in in a TRUE AP position Internal Rotation Proximal humerus in a Lateral position Positioning Considerations 40 SID With or without a grid Use if greater than 10cm Collimation Accurate Centering Exposure factors Clinical Indications: Fracture & dislocation of humerus Pathologic processes, including osteoporosis Routine Projections - 2 AP Lateral AP Projection: Humerus 40 SID IR – Portrait Extend arm & forearm as much as patient can tolerate Abduct arm slightly & supinate hand Epicondyles should be parallel to IR CR perpendicular to IR, directed at midpoint of humerus Evaluation Criteria – AP Humerus Includes both joints True AP: Greater tubercle seen in profile laterally Humeral head partially seen in profile medially Minimal superimposition of the glenoid cavity Lateral Projection: Lateromedial or Mediolateral - Humerus Technical Factors 40 SID IR – Portrait CR – Midpoint of humerus (both views) Lateromedial Patients back to IR Elbow partially flexed Internally rotate arm – epicondyles are perpendicular to IR Abduct arm slightly Mediolateral Face patient toward IR Oblique as needed to allow close contact of humerus with IR Elbow flexed 90˚ Evaluation Criteria – lateral Humerus Includes both joints True Lateral Projection Epicondyles superimposed Lesser tubercle in profile medially Special Trauma Projections - 2 Horizontal beam lateral Transthoracic lateral AP Neutral Rotation Horizontal Beam Lateral – Humerus (Trauma) (Lateromedial Projection: Mid-To-Distal Humerus) Warning: Do not attempt to rotate arm if a fracture or dislocation is suspected This projection is used in conjunction with the Transthoracic Lateral 40 SID With patient recumbent, place support under patients' arm Flex elbow if possible Place IR between arm and thorax CR – Perpendicular to midpoint of distal 2/3 of humerus Transthoracic Lateral Projection – humerus (Trauma) 40 SID Orthostatic Breathing technique What is that? Erect or Supine Affected side against IR Arm left in neutral position (drop shoulder if possible) Raise unaffected arm over head CR – Mid-diaphysis Note: If patient is unable to drop Clinical Indications: shoulder enough to prevent Fractures of the diaphysis superimposition angle CR 10-15 In addition to this view and AP degrees cephalad projection with neutral rotation is required Evaluation Criteria – Transthoracic Humerus Relationship between humeral head and glenoid cavity should be visualized Outline of humerus shaft should be visible No motion Recumbent Transthoracic Lateral AP Neutral Rotation – Humerus (Trauma) 40 SID Basically, just like AP view However, you leave arm in a neutral position (No rotating) “AS IS” AP with Neural rotation Practice Labeling Anatomy – AP Humerus A. – Greater Tubercule B. – Scapulohumeral A joint C. – Deltoid Tuberosity D. – Lateral Epicondyle C. B. E. - Capitulum F. - Trochlea G. – Medial Epicondyle D. E. G. F. Practice Labeling Anatomy – Lateral Humerus A. – Lesser Tubercule B. – Body (Shaft) A D. C. – Epicondyles superimposed D. – Surgical neck B. C. G. F. Shoulder/Scapula Rad 101 Reference: Bontrager 10 edition Positioning and Related Anatomy 11th edition https://ih1.redbubble.net/image.1087562118.8633/raf,750x1000,075,t,FFFFFF:97ab1c12de.jpg Learning Outcomes Identify the following joints on an image of the upper extremity: Acromio-clavicular joint Shoulder joint Sternoclavicular joint Learning Outcomes Identify the following parts and prominences on an image or skeleton: Scapula Head Neck Body Glenoid cavity Spine Acromion Coracoid process Angles: Medial, Superior, and Inferior Borders: Superior, Axillary, and Vertebral Scapular Notch https://allthingslearning.files.wordpress.com/2011/12/higher-order-thinking-cartoon.gif Learning Outcomes Identify the structures best shown on routine images for the shoulder girdle Describe the routine and special projections for each of the following radiographic procedures: Scapula Shoulder Discuss why each of the projections maybe requested https://p.kindpng.com/picc/s/113-1138696_thinking-clip-art-pictures-free-clipart-images-transparent.png Let's Review – Proximal Humerus What are the two neck names and where are they located? Anatomical neck (below the head) Surgical neck (constricted area below the lesser and greater tubercule) What is the smaller more medial tubercule called? Lesser tubercule What is the larger more lateral tubercule called? Greater tubercule What is the name of the groove that separates the tubercules? Intertubercular sulcus/groove (bicipital groove) Let's Review – Proximal Humerus What is the name of the rough elevation on the body of the humerus? Deltoid tuberosity What muscle attaches there? Deltoid muscle What muscles attach to the greater tubercle? Pectoralis major and supraspinatus muscles Let's Review – Proximal Humerus What are the other two names that also refer to the shoulder joint? Glenohumeral joint Scapulohumeral joint Shoulder Girdle Consist of 2 bones Clavicle Scapula Function of the 2 bones is to connect the upper limb to the trunk (axial skeleton) Shoulder girdle and upper The limb connect at the humerus is shoulder joint apart of which skeleton? What does Scapula Anatomy - Borders Axilla mean? Scapula (Shoulder blade) Forms the posterior part of the shoulder girdle Flat triangular bone The scapula has 3 borders: Superior border Uppermost margin Lateral (Axillary) border Border nearest axilla Medial (Vertebral) border Border near the vertebrae Scapula Anatomy - Angles The three corners of the scapula are called angles: Superior angle High - medial corner of the scapula Inferior angle Most inferior portion of the scapula Lateral angle (head) Sometimes called head of the scapula Thickest part Ends laterally in a shallow depression called the glenoid cavity (fossa) Shoulder Joint – Glenohumeral Joint Formed by the: Glenoid cavity (fossa) of the scapula Head of the humerus Scapula Anatomy – Anterior View Neck Constricted area between the head and body of the scapula Body (blade) Arched in shape for greater strength Thin flat lower portion of the body is referred to as the Wing or ala Scapula Anatomy – Anterior View Costal (Ventral) Surface Anterior surface of the scapula Costal (means ribs) The large depression on the anterior side is known as the Subscapular fossa Scapula Anatomy – Anterior View Acromion Long, curved process that extends laterally over the head of the humerus Coracoid process Thick, beaklike process that projects anteriorly beneath the clavicle Suprascapular notch Is on the superior border that is partially formed by the base of the coracoid process Scapula Anatomy – Posterior View Posterior surface Aka dorsal surface Prominent structure on the dorsal surface is called the spine Starts at the vertebral border as a smooth area and continues laterally to end at the acromion Crest of spine Is the thickened ridge of the spine Scapula Anatomy – Posterior View The spine separates the posterior surface into the: Infraspinous fossa Supraspinous fossa (Both fossae serve as surfaces attachments for shoulder muscles) Scapula Anatomy The lateral view of the scapula looks like what letter? Y The upper portions of the Y are the acromion and coracoid Acromion extends superior and posteriorly in relation to the glenoid cavity Coracoid is located anteriorly in relation to the joint or glenoid cavity Lower portion of Y is the body Proximal Humerus Rotation External Rotation Internal Rotation Neutral Rotation What anatomy is A & B labeling? Which Projection places the humerus in an AP? Which projection places the humerus in a lateral? Positioning Considerations 40 SID Grid (greater than 10cm) Remove anything that could cause artifacts Suspend respiration https://external-preview.redd.it/tDBP-A4NkjcegKZS00j8AfK-YqZ93kvMNV-c28jgE_I.jpg?auto=webp&s=a1b084bebc7704e94772e209c6bb9be1538ba8fe Clinical Indications – Shoulder/Scapula Degenerative conditions: Osteoporosis Osteoarthritis Hill-Sachs defect Fractures & Dislocations Bursitis https://www.atlantaboneandjoint.com/uploads/5/5/2/5/55255055/published/xray-showing-a-comparison-of-normal-versus-dislocated-shoulder.png?1526173234 Routine ( Nontrauma) Projections AP External Rotation (AP) AP Internal Rotation (Lateral) AP Shoulder: External Rotation 40 SID GRID Patient erect or supine Abduct extended arm slightly Externally rotate arm (supinate hand) until epicondyles are parallel to IR CR – 1 inch inferior to coracoid process Evaluation Criteria (External Rotation) Greater tubercle profiled laterally Scapulohumeral joint centered Proximal humerus, upper scapula, and clavicle visualized Optimal exposure factors AP Shoulder – Internal Rotation 40 SID Grid Patient erect or supine Internally rotate arm (Pronate hand) until epicondyles are perpendicular to IR CR – 1 in inferior to coracoid process Evaluation Criteria (Internal Rotation) Lesser tubercle profiled medially Scapulohumeral joint centered Proximal humerus, upper scapula, and clavicle visualized Optimal exposure factors Special (nontrauma) Projections Inferosuperior Axial Projection (Lawrence Method) AP oblique projection (Grashey method) Inferosuperior Axial Projection: Shoulder (Lawrence Method) 40 SID Position patient supine & shoulder raised about 2 inches from tabletop Rotate head toward opposite side Abduct arm 90 degrees from body Externally rotate arm with palm up CR – Directed medially 25-30˚, Centered to axilla & humeral head Note: If arm is abducted less than 90˚ angle medially 15-20˚ Evaluation Criteria (Inferosuperior Axial Projection) Lesser tubercle profiled anteriorly Humeral head and glenoid fossa profiled Optimal exposure factors AP Oblique Projection: Grashey method **Glenoid Cavity should be visualized 40 SID Grid Erect or Supine Rotate body 35-45˚ toward affected side (posterior oblique) CR – Centered to scapulohumeral joint Evaluation Criteria: Grashey Method (Posterior Oblique) Glenoid cavity profiled Scapulohumeral joint centered Optimal exposure factors Routine (trauma) Projections AP Neutral rotation PA Oblique (Scapular Y Lateral) AP Neutral: Shoulder (Trauma) 40 SID Grid Erect or Supine Arm at side in “as is” position CR – Mid-scapulohumeral joint Evaluation Criteria Greater tubercle superimposed Scapulohumeral joint centered Optimal exposure factors PA Oblique-Scapular Y Lateral: Shoulder (Trauma) 40 SID Grid Erect or supine Rotate patient into anterior oblique position 45-60˚ Palpate the superior angle of the scapula & AC joint articulation Rotate patient until two points are perpendicular to IR Evaluation Criteria (Scapular Y Lateral) Dislocated Body of scapula superimposed on end Acromion and coracoid processes in profile Humeral head and glenoid cavity superimposed Optimal exposure factors Special (Trauma) Projections Supraspinatus outlet (Neer method) Supraspinatus Outlet: Shoulder (Trauma)’ Neer Method Specifically demonstrates coracoacromial arch for supraspinatus outlet region for possible shoulder impingement 40 SID Rotate patient into anterior oblique 45-60˚ CR – angle 10-15˚ caudal centered to pass through humeral head Evaluation Criteria (Neer Method vs. Scapular Y Lateral Projection) Outlet projection CR perpendicular Supraspinatus outlet (Neer method) open and in profile Demonstrates coracoacromial arch Optimal exposure factors Routine Scapula Projections AP Lateral AP Projection: Scapula 40 SID Erect or supine Abduct arm 90˚ and supinate hand CR – perpendicular to midscapula, (level of axilla and 2 inches medial from lateral border of patient) Orthostatic breathing technique preferred Evaluation Criteria Entire scapula demonstrated Lateral border of scapula free of ribs and lungs Optimal exposure factors Lateral: Scapula - Erect Have patient reach a crossed chest and grasp opposite shoulder to demonstrate body of scapula Let arm hang by patients' side to demonstrate acromion and coracoid processes Rotate patient 45-60˚ CR – Midvertebral border of scapula Lateral Scapula- Recumbent Patient supine Rotate patient till AC joint articulation and superior border of scapula are perpendicular to IR CR- midscapula lateral border Body of Scapula in Profile (Lateral Scapula) Borders of scapula superimposed Free of superimposition by ribs Arm elevated to demonstrate scapular body Quiz Me Which of the following projections will best demonstrate a possible Hill-Sachs defect? A. Inferosuperior axial projection with exaggerated external rotation B. PA transaxillary (Hobbs modification) C. Posterior oblique (Grashey method) D. Tangential projection (Fisk modification) Quiz Me How much is the body rotation for a posterior oblique position (Grashey method)? A. 5° to 8° B. 10° to 15° C. 20° to 25° D. 35° to 45° Quiz Me Which of the following humeral structures is most distal? A. Anatomic neck B. Greater tubercle C. Lesser tubercle D. Surgical neck Quiz Me 2 What is another term for the mid area of the costal surface of the scapula? A. Subscapular fossa B. Infraspinous fossa C. Supraspinous fossa D. Scapulohumeral surface Clavicle & AC Joints Chapter 5 Continued Learning Objectives Identify the following joints on an image of the upper extremity: AC - ? SC - ? Describe the anatomy and positioning of the shoulder girdle and upper extremity. Identify the following parts and prominences on an image or skeleton: Clavicle 1. Body 2. Sternal end 3. Acromial end Learning Objectives Describe the routine and special projections for each of the following radiographic procedures Clavicle AC joints Discuss why each of the projections maybe requested Clavicle Anatomy Clavicle Anatomy Continued… Size and shape differ between males and females Female: Shorter and less curved Male: Thicker & more curved Most curved in heavily muscled men https://library.kissclipart.com/20180907/tqq/kissclipart-men-and-women-clipart-woman-clip-art-68b06114f7f60dee.pn Clinical Indications AC Joint Separation: Trauma resulting in partial or complete tear of the AC or coracoclavicular (CC) ligament or both ligaments AC joint injuries represent almost half of all athletic shoulder injuries Acromioclavicular dislocation: Distal clavicle usually displaced https://www.drgordongroh.com/wp-content/uploads/2018/08/image-result-for-x-ray-of-shoulder-separation.jpeg superiorly, most commonly cause by fall Routine Clavicle Projections AP or PA AP Axial or PA Axial Note: Exam can be done PA AP: Clavicle 40 SID Erect or supine Center clavicle to IR CR – midclavicle Respiration: suspend at end of inhalation Why? https://www.docjoints.com/wp- content/uploads/2015/07/clavicle-pa.png Note: Can be done as a PA Axial Angle CR 15-30˚ caudal AP Axial: Clavicle 40 SID Position same as AP Angle CR 15-30˚ cephalad CR- Midclavicle Suspend on Inhalation *Thin (asthenic) patients require 25-30˚, Patients with thick shoulders and chest (Hypersthenic) require 15-20˚ Need to know! Routine AC Joint Projections AP Bilateral With and Without Weights AC Projection (Pearson Method): AC Joints Without weights 40 or 72in to include both joints on same study Erect Posterior shoulders against IR CR – Midpoint between AC joints, 1 in above jugular notch Unilateral study: CR 1 in below affected AC joint AC Projection (Pearson Method): AC Joints With weights Adding weights 8-10 pounds 5-8 pounds (Asthenic patient) Check department protocol Do not have patient hold onto weights with their hands Weights should be attached to wrists, so the hands and shoulders are relaxed Alternative Supine Position Evaluation Criteria Both AC joints demonstrated No motion Optimal exposure factors Correct markers visible Close collimation evident Quiz Me 6 How much should the CR be angled for an AP axial projection of the clavicle on an asthenic patient? A. 5° B. 10° C. 20° D. 30°
