2. Shoulder Girdle
Shoulder Girdle
The shoulder girdle is formed by two
bones, the clavicle and scapula. Their
function is to connect the upper limb to
the trunk.
3. Clavicle
The clavicle, classified as a long bone,
has
a body and two articular extremities
The lateral aspect is termed the acromiaL
extremity, and it articulates with the
acromion process of the scapula. The
mediaL aspect, termed the sternal extremity,
articulates with the manubrium of the sternum
and the first costal cartilage
9. Humerus
The proximal end of the humerus consists of
a head, an anatomic neck, two prominent
processes called the greater and Lesser
tubercles. and the surgical neck .
The head is large, smooth, and rounded, and
it lies in an oblique plane on the superomedial
side of the humerus.
13. SUMMARY OF PATHOLOGY
bursitis Inflammation of the bursa
Dislocation Displacement of a bone from the
joint space
Fracture Disruption in the continuity of
bone
Hills-Sachs Defect
Impacted fracture of the posterolateral aspect
of the humeral
head with dislocation
Metastases
osteoarthritis
Transfer of a cancerous lesion from
one area to another
Form of arthritis marked by progressive cartilage
deterioration in
synovial joints and vertebrae
Osteopetrosis Increased density of atypically soft
bone
14. Osteoporosis
Rheumatoid Arthritis
Tendonitis
Chondrosarcoma
Tumor
Loss of bone density
Chronic. systemic. inflammatory collagen disease
Inflammation of the tendon and tendon-muscle
attachment
New tissue growth where cell proliferation is
uncontrolled
Malignant tumor arising from cartilage cells
15. Shoulder
“ AP PROJECTION”
External, Neutral, Internal
rotation humerus
NOTE: Do not have the patient rotate the arm if
fracture or dislocation is suspected.
16. Supinating the hand will position the
humerus in external rotation
The palm of the hand placed against
the hip will position the humerus
in neutral rotation,
The posterior aspect of the hand
placed against the hip will position
the humerus in internal rotation.
AP shoulder. External rotation
humerus,
Greater tubercle (arrow),
AP shoulder, Neutral
rotation humerus,
Greater tubercle (arrow),
AP shoulder, Internal
rotation humerus, Greater
tubercle (arrow): lesser
tubercle in profile,
22. Upright transthoracic lateral
shoulder: Lawrence Method
Recumbent transthoracic lateral
shoulder: Lawrence Method
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.
24. Transthoracic lateral shoulder
(patient breathing): Lawrence
method .
Structures shown
A lateral image of the
shoulder and proximal
humerus is projected
through the
thorax
EVALUATION CRITERIA
The following should be clearly
demonstrated:
• Proximal humerus
• Scapula, clavicle, and humerus
seen
through the lung field
• Scapula superi mposed over
the thoracic
pine
• Unaffected clavicle and
humerus projected
above the shoulder closest to
the IR
26. Inferosuperior axial shoulder joint:
Lawrence method.
Inferosuperior axial shoulder joint:
Rafert modification. Note the exaggerated
external rotation of arm and thumb pointing
downward. If present. a Hill-Sachs
defect would show as a wedge-shaped
depression on the posterior aspect of the
articulating surface of the humeral
head.arrow
29. Inferosuperior axial shoulder joint: West
Point method.
Central ray
• Directed at a dual angle of 25
degrees anteriorly from the
horizontal and 25 degrees
medially. The central ray enters
approximately 5 inches ( 13 cm)
inferior and I 1/2 inch (3.8 cm)
medial to the acromial
edge and exit the glenoid cavity.
31. EVALUATION CRITERIA
The fol lowing should be clearly
demonstrated:
• Humeral head projected free of the
coracoid process
• Articulation between the head of the
humerus and the glenoid cavity
• Acromion superimposed over the
posterior portion of the humeral head
• Shoulder joint
Structures shown
The resulting image
shows bony abnormalities
of the anterior inferior rim
of the glenoid in patients
with instability of the
shoulder
34. Inferosuperior axial shoulder joint:
Clements modification. A. Arm abducted
90 degrees. B. Arm partially abducted
Position of patient
• When the prone or
supine position is
not possible, Clements
suggested that the patient
be radiographed in the
lateral recumbent position
lying, on the unaffected
side.
• Flex the patient's hips
and knees.
Position of part
• Abduct the affected
arm 90 degrees,and point
it toward the ceiling.
• Place the fR against the
Superior aspectof the
patient's
shoulder,holding it in
place with the unaffected
arm or by securing i t
appropriately
• ShieLd gonads.
• Respiration: Suspend.
Central ray
• Horizontal to the midcoronal plane,
passing through the midaxillary region
of the shoulder.
• Angled 5 to 1 5 degrees medially when
the patient cannot abduct the arm a full
90 degrees (Fig. 5-28, B). The resulting
radiograph
36. Superoinferior axial shoulder joint: standard IR.
Structures shown
A superoinferior axial image shows the
joint relationship of the proximal end
ofthe humerus and the glenoid cavity .
The acromjoclavicular articulation,
the outer portion of the coracoid
process,and the points of insertion of
the subcapularis muscle ( at body of
scapula) and teres minor muscle ( at
inferior axillary
border) are demonstrated.
EVALUATION CRITERIA
The following should be clearly
demonstrated:
• Open scapulohumeral joint (not
open on patients with limited
flexibility)
• Coracoid process projected above
the clavicle
• Lesser tubercle i n profile
• Acromioclavicu lar joint through the
humeral head
Central ray
• Angled 5 to 1 5 degrees through the
shoulder joint and toward the elbow
39. AP axial shoulder joint.
Central ray
• Directed through the capulohumeral
joint at a cephalic angle of 35 degrees
Structures shown
The axial image shows the relationship
of the head of the humerus to the
glenoid cavity. This is useful in
diagnosing cases of posterior
djslocation
EVALUATION CRITERIA
The following should be clearly demonstrated:
• Scapulohumerai joint
• Proximal humerus
• Clavicle projected above superior angle
of scapula
41. Scapular Y
‘’ PA OBLIQUE PROJECTION’’
RAO or LAO position
Thi projection, described by Rubin,
Gray, and Green, 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.
42. PA oblique shoulder joint.
Central ray
• Perpendicular to the
scapulohumeral joint
43. Structures shown
The scapular Y is demonstrated on an
oblique image of the shoulder. In the normal
shoulder the humeral head is directly
superimposed over the junction of the Y. In anterior (subcoracoid) dislocations, the
humeral head is beneath the coracoid process (Fig. 5-36); in posterior
( subacromial) dislocations, it is projected beneath the acromion process. An AP
shoulder projection is shown for comparison.
EVALUATION CRITERIA
The following should be clearly demonstrated:
• No superimposition of the scapular
body over the bony thorax
• Acromion projected laterally and free
of superimposition
• Coracoid possibly superimposed or
projected below the clavicle
• Scapula in lateral profile
44. 10-15°
(AC Articulation)
ALEXANDER
Shoulder
( Scapular Y )
Scapula
( Lateral )
Shoulder
( NEER)
Name Body Rotation Scapula Rel. to IR Central ray angle Central ray entrance pt Arm position
Acromioclavicular
articulation:
1.Alexander
Method
Shoulder jOint:
2.Neer method
Shoulder Joint:
3.scapular Y
4.Scapula lateral
45 to 60
degrees
Perpendicular
T
15° caudad
10 to 15 degrees
border caudad
0 degrees
0 degrees
Acromioclavicular
joint
Superior humeral
Scapulohumeral joint
Center of medial border of
scapula
Across chest
At the side
At the side
variable
45. PA oblique shoulder Joint. Note the scapular Y components-body, acromion,
and coracoid.
46. PA oblique shoulder Joint showing anterior dislocation
(humeral head projected beneath coracoid process).
48. Upright AP oblique glenoid cavity:
Grashey method.
Recumbent AP oblique glenoid cavity:
Grashey method.
49. 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.
Structures shown
The joint space between the
humeral head and the glenoid
cavity (scapulohumeral
joint) is shown.
EVALUATION CRITERIA
The fol lowing should be
clearly demonstrated:
• Open joint space
between the humeral
head and glenoid cavity
• Glenoid cavity in profi le
• Soft tissue at the
scapulohumeral joint
along with trabecular detail
on the glenoid
and humeral head
51. Supraspinatus "Outlet"
TANGENTIAL PROJECTION
NEER METHOD
RAO or LAO position
This radiographic projection is useful to
demonstrate tangentially the coracoacromial
arch or outlet to diagnose shoulder
i mpingement. The tangential image is
obtained by projecting the x-ray beam
under the acromion and acromioclavicular
joint, which defines the superior border of
the coracoacromial outlet.
Image receptor: 8 x 10
52. Structures shown
The tangential outlet image
demonstrates the posterior
surface of the acromion and the
acromioclavicular joint
identified as the superior
border of the coracoacromial
outlet.Central ray
• Angled 10 to 15
degree caudad,
entering
the superior aspect
of the humeral head
EVALUATION CRITERIA
The following should be clearly
demonstrated:
• Humeral head projected
below the acromioclavicular
joint
• Humeral head and
acromioclavicular joint with
bony detail
• Humerus and scapular body,
generally
Parallel.
53. Shoulder joint: Neer method.
Supraspinatus outlet (arrow).
Tangential supraspinatus outlet projection
showing impingement of the shoulder outlet
(arrow). B, Radiograph of same patient as in
Fig. 5-48 after surgical removal of
posterolateral surface of clavicle.
54. Proximal Humerus
AP AXIAL PROJECTION
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,
from ideas expressed by Cm. W.S.
Stryker U . S . N . , as being useful in identifying
the cause of shoulder dislocation.
55. AP axial humeral notch: Stryker notch method
EVALUATION CRITERIA
The following should be clearly
demonstrated:
• Overlapping of coracoid process and
clavicle
• Long axis of the humerus aligned
with
the long axis of the patient's body
• Bony trabeculation of the head of
the
humerus
Structures shown:
The resulting image will how the po -
terosuperior and posterolateral areas
of the humeral head.
Central ray
• Angled 10 degrees cephalad, entering
the coracoid process.
56. AP axial humeral notch: Stryker
notch method.
Same projection in a patient with a
small Hill-Sachs defect (arrow).
Humerus
Coracoid
prcess
Humeral
head
Body of
scapula
57. Glenoid Cavity
AP OBLIQUE PROJECTION
APPLE METHOD!
RPO or LPO position
This projection is similar to the Grashey
Method but uses weighted abduction to
demonstrate a loss of articular cartilage in
the scapulohumeral joint.
59. Central ray
• Perpendicular to the IR at the
level of the coracoid process
Structures shown
The scapulohumeral joint
EVALUATION CRITERIA
The following should be
clearly demonstrated:
• Open joint space between
the humeral head and the
glenoid cavity
• Glenoid cavity in profile
• Soft tissue at the
scapulohumeral joint along
with trabecular detail on the
glenoid and the humeral head
• The arm in a 90 degree
position
60. A, AP oblique projection: Grashey method, of the shoulder showing a normal
scapulohumeral joint space. B, AP oblique projection: Grashey method, with
weighted abduction showing loss of articular cartilage (arrow).
61. Glenoid Cavity
AP AXIAL OBLIQUE PROJECTION
GARTH METHOD )
RPO or LPO position
This projection is recommended for acute
shoulder trauma and for identifying
posterior scapulohumeral dislocations,
glenoid fractures, Hill-Sachs lesions, and soft
tissue calcifications.
62. AP axial oblique: Garth method. RPO
position. Note 45 degree CR. B, Top
view of same position as A. Note 45
degree patient position.
A
B
63. Central ray
• Angled 45 degree caudad
through the scapulohumeral
joint.
Structures shown
The scapulohumeral joint,
humeral head, coracoid
process, and scapular head
and neck are shown.
EVALUATION CRITERIA
The following should be clearly
demonstrated:
• The scapulohumeral joint,
humeral head, and scapular
head and neck free of
superimposition
• The coracoid process should
be well visualized
• Posterior dislocations will
project the humeral head
superiorly from the glenoid
cavity and anterior dislocations
project inferiorly.
64. AP axial oblique: Garth method demonstrates an
anterior dislocation of the proximal humerus. The
humeral head is shown below the coracoid process, a
common appearance with anterior dislocation.
65. Intertubercular Groove
'" TANGENTIAL PROJECTION
FISK MODIFICATION )
In recent years, various modifications of the
intertubercular groove image have been devised. In all
cases the central ray is aligned to be tangential to the
intertubercular groove, which lies on the anterior
surface of the humerus.The x-ray tube head assembly
may limit the performance of this examination. Some
radiographic units have large collimators
and/or handles that limit flexibility in positioning. A
mobile radiographic unit may be used to reduce this
difficulty.
67. Central ray
Angled 10 to 15 degrees
posterior (downward from
horizontal) to the long
axis of the humerus for the
supine position
Fisk Modification
• Perpendicular to the I R
when the patient is leaning
forward and the vertical
humerus is positioned 10 to
15 degrees.
Structures shown
The tangential image profiles
the intertubercular groove
free from superimposition
of the surrounding shoulder
structures.
EVALUATION CRITERIA
The following should be clearly
demonstrated:
• Intertubercular groove in
profile
• Soft tissue along with
enhanced visibili ty of the
intertubercular groove.
71. PA proximal humerus for teres minor
insertion.
PA proximal humerus for teres minor
insertion.
PA proximal humerus for teres minor insertion.
clavicle
72. Structures shown
This position rotates the head of
the humerus so that the greater
tubercle is brought anteriorly,
giving a tangential image of the
insertion of the teres minor at
the outer edge of the bone just
below the articular surface of
the head.
EVALUATION CRITERIA
The following should be
clearly demonstrated:
• Outline of the greater
tubercle superimposing
the humeral head
• Lesser tubercle in profile
and pointing medially
• Soft tissue around the
humerus along
with trabecular detail on
the humeral head.
Central ray
• Perpendicular to the head
of the humerus.
74. subscapularis
Long head head
of biceps brachii
biceps
Muscles on costal (anterior) surface of the scapula and proximal humerus
75. AP proximal humerus for subscapularis insertion. AP proximal humerus for subscapularis insertion.
AP proximal humerus for subscapularis insertion .
Humeral head
Greater tubercle
76. Central ray
•Perpendicular to the shoulder
joint, entering the coracoid
process
Structures shown
This method provides an
image of the insertion of the
subscapularis at the lesser
Tubercle.
EVALUATION CRITERIA
The following should be
clearly demonstrated:
• Lesser tubercle in profile and
pointing inferiorly
• Outline of the greater
tubercle superimposing
the humeral head
• Soft tissue around the
humerus along with trabecular
detail on the humeral head.
78. Place the patient in the supine
position with the affected arm
by the patient's side.
Turn the arm in external
rotation to open the
subacromial space (Fig. 5-62,
A ) . Rotate the arm to the
neutral position (Fig. 5-62, B)
and then in complete internal
rotation (Fig. 5-62, C) to allow
full evaluation of the humeral
head. Direct the central
ray to enter the coracoid
process at an angle of 25
degrees caudad. The image
profiles the greater tubercle,
the site of insertion of the
infraspinatus tendon, and
opens the subacromial space.
AP axial. 25-degree caudal angulation. demonstrating
calcareous peritendinitis(arrows). A, External rotation. B,
Neutral position. C, Internal rotation.
80. Bilateral AP acromioclavicular
articulations.
Bilateral AP acromioclavicular joints
demonstrating normal left joint and
separation of right joint (arrow).
Normal acromioclavicular joints requiring two
separate radiographs.
81. Structures shown
Bilateral images of the
acromioclav icular
joints are demonstrated (Figs.
This projection is used to
demontrate dislocation,
separation, and function
of the joints.
Central ray
• Perpendicular to the midl ine
of the body at the level of the
acromioclavicular joints for a
single projection; directed at
each respective
acromioclavicular joint when
two separate exposures are
needed for each shoulder
in broad-shouldered patients.
EVALUATION CRITERIA
The following should be
clearly demonstrated:
• Acromioclavicular joints
visualized with some soft
tissue and without
excessive density
• Both acromioclavicular
joints, with and
without weight , entirely
included on one or two
single radiographs
• No rotation or leaning by
the patient
• Right or left and weight or
nonweight markers
• Separation, if done,clearly
seen on the images with
weights.
82. Acromioclavicular Articulations
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 examjned
separately.
83. AP axial acromioclavicular articulation:
Alexander method.
Unilateral AP axial acromioclavicular
articulation: Alexander method
84. Central ray
• Directed to the coracoid
process at a cephalic angle of
15 degrees .This angulation
projects the acromioclavicular
joint above the acromion.
Structures shown
The resulting image will show
the acromioclavicular joint
projected slightly superiorly
compared with an A P
projection.
EVALUATION CRITERIA
The following should be
clearly demonstrated:
• Acromioclavicular joint and c
lavicle projected above the
acromion.
• Acromioclavicular joint
visualized with some soft
tissue and without excessive
Density.
87. Central ray
• Directed through the
acromioclavicular joint at an
angle of 15 degrees caudad.
Structures shown
The PA axjal oblique image
demonstrates the
acromioclavicular joint and the
relationship of the bones of the
shoulder.
EVALUATION CRITERIA
The following should be
clearly demonstrated:
• Acromioclavicular
articulation in profile
• Acromioclavicular joint
visualized with some soft
tissue without excessive
Density.
89. Clavicle
AP PROJECTION
Central ray
• Perpendicular to the
midshaft of the
clavicle
Structures shown
This projection
demonstrates a frontal
image of the clavicle.
EVALUATION CRITERIA
The following should be
clearly demonstrated:
• Entire clavicle centered on
the image
• Uniform density
• Lateral half of the clavicle
above the scapula, with the
medial half superimposing
the thorax.
91. 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 OID. Positioning is similar to
that of the A P projection. The differences are
as follows:
92. •The perpendicular central ray
exits midshaft of the clavicle
•Structures shown and
evaluation criteria are the same
as for the AP projection.
93. Clavicle
AP AXIAL PROJECTION
Lordotic position
NOTE: If the patient is injured or unable to
assume the lordotic position, a slightly distorted
image results when the tube is angled. An
optional approach for improved recorded detail
is the PA axial projection.
94. Central ray
• Directed to enter the
midshaft of the clavicle.
• Cephalic central ray
angulation can vary from
the long axis of the torso.
Thinner patients require
more angulation to project
the clavicle off the
scapula and ribs.
Coracoid
process
Acromioclavicular
joint
Sternoclavicular
joint
AP axial clavicle of 3-year-old child. showing fracture
(arrow). This is the same patient as Figure.
95. PA AXIAL PROJECTION
Positioning of the PA axial clavicle is similar to the A P
axial projection just described. The differences are as
follow :
• The patient is prone or standing, facing the vertical
grid device.
• The central ray is angled 15 to 30 degrees caudad.
Structures shown and evaluation criteria
are the same as for the AP axial projection
described previously.
97. TANGENTIAL PROJECTION
The tangential projection is similar to the
AP axial projection described previousIy.
However, the increased angulation of the
central ray required for this approach
places the central ray nearly parallel with
the rib cage. The clavicle i s thus projected
free of the chest wall .
98. Structures shown
An inferosuperior image of
the clavicle is demonstrated,
projected free of
superimposition.
EVALUATION CRITERIA
The following should be
clearly demonstrated:
• Midclavicle without
superimposition
• Acromial and sternal ends
superimposed
• Entire clavicle along with
the acromioclavicular
and sternoclavicular joints
99. Central ray
• Angled so that the central ray will pass
between the clavicle and the chest wall ,
perpendicular t o the plane of the lR . 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.
Tangential clavicle.
Tangential alignment for clavicle.
102. Tangential clavicle: Tarrant method.
Central ray
• Directed anterior and inferior to the
mjdshaft of the clavicle at a 25- to 35-
degree angle. It should pass
perpendicular to the longitudinal axjs
of the clavicle.
• Because of the considerable 010, an
increased SID is recommended to
reduce magnification.
EVALUATION CRITERIA
The following should be clearly
demonstrated:
• Most of the clavicle above the ribs
and scapula with the medial end
overlapping the first or second ribs
• Clavicle in a horizontal orientation
• Entire clavicle along with the
acromioclavicular and sternoclavicular
joints.
103. Structures shown
The clavicle above the thoracic cage is
Demonstrated.
Sternoclavicular joint
clavicle
acromion
Acromioclavicul
ar joint
coracoid
Tangential clavicle: Tarrant method .
105. AP scapula.
Central ray
• Perpendicular to the
midscapular area ata point
approximately 2 ‘’ (5 cm)
inferior to the coracoid
process.
Structures shown
An AP projection of the
scapula is demonstrated
106. EVALUATION CRITERIA
The following should be clearly demonstrated:
• Lateral portion of the scapula free of superimposition from the ribs
• Scapula horizontal and not obliqued
• Scapular detail through the superimposed lung and ribs (Shallow breathing should
help obliterate lung detail.)
• Acromion process and inferior angle.
acromion
clavicle
Coracoid process
Glenoid cavity
Lateral border of
scapula
Medial border of
scapula
Inferior angle of
scapula
108. Lateral scapula, RAO body position.
Central ray
• Perpendicular to the
midmedial border
of the protruding Scapula.
coracoid
humerus
Body of
scapula
Inferior angle of
scapula
Structures shown
A lateral image of the scapula is
demonstrated by this
projection. The placement of
the arm determine the portion
of the superior scapula that is
superimposed over the
humerus.
109. EVALUATION CRITERIA
The following should be clearly demonstrated:
• Lateral and medial border superimposed
• No superimposition of the scapular body on the
ribs
• No superimposition of the humerus on
the area of interest
• Inclusion of the acromion process and
inferior angle
• Lateral thickness of capula w i th
proper density.
111. PA oblique scapula: Lorenz method.
PA oblique scapula: Lilienfeld
method.
Lorenz method
• Adjust the arm of the affected side at a
right angle to the long axis of the body,
flex the elbow, and rest the hand against
the patient's head.
• Rotate the body slightly forward, and
have the patient grasp the side of the
table or the stand for support
LiIienfeld method
• Extend the arm of the affected side
obliquely upward, and have the patient
rest the hand on hjs or her head.
• Rotate the body lightly forward, and
have the patient grasp the side of the
table or the stand for support.
112. Central ray
• Perpendicular to the J R,
between the chest wall and the
mjdarea of the protruding
Scapula.
Structures shown
An oblique image of the
scapula is shown. The degree
of obliquity depends on the
position of the arm. The
delineation of the different
parts of the bone in the two
oblique projections are
shown.
EVALUATION CRITERIA
The following should be clearly
demonstrated:
• Oblique scapula
• Medial border adjacent to the ribs
• Acromion process and inferior
angle.
114. AP oblique scapula, 20-degree
body rotation.
AP oblique scapula, 35-degree
body rotation.
Central ray
• Perpendicular to the lateral border of
the rib cage at the midscapular area
Structures shown
This projection show oblique image of
the scapula, projected free or nearly free
of rib superimposition.
EVALUATION CRITERIA
The following should be clearly
demonstrated:
• Oblique scapula
• Lateral border adjacent to the ribs
• Acromion process and i nferior angle
117. AP axial coracoid process.
Central ray
• Directed to enter the coracoid process at
an angle of 15 to 45 degrees cephalad.
Kwak, EspinieUa, and Kattan recommend
30 degrees. The degree of angulation
depends on the shape of the patient's
back. Round-shouldered patients require
a greater angulation than those with a
straight back.
Structures shown
A slightly elongated inferosuperior
image of the coracoid process is
illustrated . Because the coracoid i
curved on itself, it casts a small, oval
shadow in the direct AP projection of
the shoulder.
118. EVALUATION CRITERIA
The following should be clearly
demonstrated:
• Coracoid process with minjmal
superimposition.
• Clavicle slightly uperi mposing
thecoracoid process
Acromioclavicular
joint
Coracoid process
Glenoid cavity
120. Central ray
Directed through the
posterosuperior region of the
shoulder at an angle of 45
degrees caudad. A 35-degree
angulation suffices for obese
and round-shouldered patient .
• After adjusting the x-ray
tube, position the lR so that it
is centered to the central ray.
Structures shown
The spine of the scapula is shown in
profile and is free of bony
superimposition, except for the lateral
end of the clavicle.
123. Prone tangential scapular spine.
Upright tangential scapular spine.
Central ray
• Direct through the scapular spine at an
angle of 45 degrees cephalad. The central
ray exits at the anterosuperior aspect of the
shoulder.
Upright position
An i ncreased SID is recommended
because of the greater OlD.
Structures shown
The tangential image shows the scapular
spine in profile and free of superimposition
of the scapular body.
EVALUATION CRITERIA
The following should be clearly
demonstrated:
• Scapular spine above the scapular wing
• Scapular spine with some soft tissue
around it and without excessive density.
