Shoulder girdle radiography: Rad Tech

Shoulder girdle radiography helps evaluate shoulder pain, limited range of motion, instability, suspected fracture or dislocation, degenerative joint disease, and soft-tissue calcifications.

The shoulder girdle includes two bones: the clavicle and the scapula. Together, these bones help connect the upper limb to the trunk. The shoulder girdle is incomplete posteriorly because the scapulae are widely separated across the back, and it’s completed anteriorly by the sternum, where each clavicle articulates medially at the sternoclavicular joint.

Although the proximal humerus is part of the upper limb rather than the shoulder girdle, it’s included in shoulder imaging because the humeral head articulates with the glenoid cavity of the scapula at the shoulder joint.

As a radiologic technologist, understanding this anatomy is essential for accurate patient positioning, ensuring the resulting image clearly demonstrates the anatomy of interest.

Standard shoulder girdle imaging may include projections of the shoulder and proximal humerus, acromioclavicular or AC joints, the sternoclavicular or SC joints, clavicle, and scapula. The exact series depends on the clinical question and department protocol.

A routine shoulder series commonly includes anteroposterior, or AP views in external rotation and internal rotation.

If rotation of the affected part is not tolerated, an AP view in neutral rotation can be used. When the humerus is ordered, AP and lateral projections should include the shoulder and elbow joints when possible.

The AP oblique Grashey method is used to visualize the glenohumeral joint space and profile the glenoid cavity.

The Apple method modifies the Grashey position with weighted abduction to load the glenohumeral joint and help demonstrate cartilage loss or joint-space narrowing.

For a pain-limited or trauma-adjacent shoulder, don’t force arm rotation or abduction. Options may include AP neutral, scapular Y, or transthoracic lateral Lawrence method to assess the proximal humerus and glenohumeral relationship.

The Neer tangential outlet projection helps evaluate the supraspinatus outlet, subacromial space, and suspected impingement.

Clavicle radiography typically uses AP and AP axial projections. AC joint imaging is usually bilateral AP, with and without weights when ordered, to compare joint spaces.

Scapula imaging can include AP and lateral projections, for specific anatomy or clinical questions.

Radiologic technologists utilize the reason for the exam, such as pain, limited range of motion, suspected fracture, or dislocation, to adapt patient positioning and technique according to established protocols. Understanding the clinical question ensures that despite limitation in patient mobility or cooperation, the final images accurately demonstrate the joint space, alignment, and the anatomy of interest.

For patient positioning, upright positioning is preferred when the patient can safely stand or sit because it can show natural shoulder alignment.

Supine or recumbent positioning is appropriate when the patient can’t tolerate upright positioning.

For routine AP shoulder images using external rotation, the hand is supinated. This places the medial and lateral epicondyles at the elbow parallel to the image receptor, which externally rotates the humerus and brings the greater tubercle into lateral profile.

For internal rotation, the back of the hand rests on the hip, and the epicondyles are perpendicular to the receptor.

For pain-limited exams and potential dislocation, use neutral rotation. The patient keeps the arm relaxed with the palm against the thigh.

This avoids rotating a painful or potentially injured shoulder and places the humerus in a partially rotated position, with the greater tubercle partially superimposed on the humeral head.

When using the Grashey method, the patient’s body is rotated about 35 to 45 degrees toward the side of interest, so the scapula is parallel to the image receptor, opening the glenohumeral joint space.

For suspected fracture or dislocation, avoid rotating, abducting, or manipulating the arm beyond what the patient can tolerate.