5 Shoulder Imaging

Joseph Ferraro and Matthew Binkley

Summary

Along with thorough history and physical exam, appropriate imaging is integral to accurate diagnosis and treatment of shoulder pathology. Understanding the various shoulder imaging options can help confirm diagnosis while minimizing unnecessary testing. In this chapter, many imaging choices will be discussed, paired with corresponding pathology to add to your clinical armamentarium.

Radiography – X-ray – MRI – CT – MR arthrogram

5 Shoulder Imaging

I. Radiography

The initial imaging modality for evaluation of the shoulder
Provides little information on soft tissue around the shoulder
Shoulder series should consist of at least two orthogonal views
Trauma evaluation includes:
1. True anteroposterior aka Grashey (▶ Fig. 5.1 ):
  1. Erect, sitting, or supine with patient rotated 30–45 degrees in relation to the image detector
  2. Evaluate glenohumeral joint, fracture (proximal humerus, clavicle, scapula, and ribs), and proximal humeral migration.
    
    Fig. 5.1 Grashey.
    
    Fig. 5.2 Anteroposterior (AP).
    
    Fig. 5.3 Axillary lateral.
2. Anteroposterior (AP) (▶ Fig. 5.2 ):
  1. Erect, sitting, or supine with beam perpendicular to body
  2. Allows for viewing of shoulder in anatomical position
  3. Utility similar to Grashey view with poorer view of glenohumeral joint.
3. Axillary lateral (▶ Fig. 5.3 ):
  1. Supine, arm abducted with beam parallel to body
  2. Evaluate joint congruency, direction of dislocation, and glenoid pathology
  3. Velpeau view can be used for patient who cannot abduct the arm:
    - i. Patient erect leaning backwards over cassette.
      
      Fig. 5.4 Scapular Y lateral.
4. Scapular Y lateral (▶ Fig. 5.4 ):
  1. Sitting or erect, anterior oblique view with scapula in profile
  2. Evaluate acromion type scapular fracture.
Additional views:
1. AP in external or internal rotation (▶ Fig. 5.5a, b ):
  1. Same positioning as AP with humerus externally or internally rotated
  2. External rotation:
    - i. Greater tuberosity on profile.
  3. Internal rotation:
    - i. Lesser tuberosity on profile, best view of Hill-Sachs lesion.
2. Stryker notch (▶ Fig. 5.6 ):
  1. Arm extended over head with elbow flexed; beam directed at mid axilla with 10 degrees caudal tilt
  2. Excellent visibility of posterolateral humeral head for Hill-Sachs lesion.
    
    Fig. 5.5 (a, b) Anteroposterior (AP) in external or internal rotation.
3. Supraspinatus outlet aka Neer (▶ Fig. 5.7 ):
  1. Affected shoulder on X-ray plate while rotating the other shoulder out 40 degrees; PA view with beam at 10 degrees caudal tilt
  2. Ideal view for evaluating acromion type as well as supraspinatus impingement.
4. West point axillary:
  1. Patient prone with arm abducted 90 degrees and forearm off table. Beam aimed at mid axilla, 25 degrees from midline and 25 degrees caudal tilt
  2. Provides better view of anteroinferior glenoid for evaluation of bony Bankart lesion.
5. Apical oblique aka Garth:
  1. Patient erect or sitting with back against receiver and affected side’s hand resting on unaffected side’s shoulder. Beam at 30–45 degrees in coronal plane and 45 degrees caudal tilt
    
    Fig. 5.6 Stryker notch.
  2. Provides improved view of glenohumeral joint to evaluate for Bankart and Hill-Sachs lesions
  3. Can be used in place of axillary or scapular Y to evaluate for glenohumeral dislocation.
6. Serendipity/Hobbs (▶ Fig. 5.8 ):
  1. Serendipity = Patient supine with beam 40 degrees tilt from horizontal
  2. Hobbs = Patient bent over cassette with arms forward flexed and head resting in hands
  3. Evaluate for sternoclavicular dislocation.
7. Zanca (▶ Fig. 5.9 ):
  1. Patient erect or sitting with back against cassette; beam aimed at shoulder with 10–15 degrees cephalic tilt
  2. Evaluate acromioclavicular joint en face for separation or arthritis.