Shoulder radiograph (an approach)

Capsule of

shoulder-joint (distended). Anterior aspect.

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The scapular

and circumflex arteries.

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Schultermuskulatur

von hinten

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Shoulder •

Shoulder anatomy (illustrations) - Ganzer Fall bei Radiopaedia

Skalski M, Shoulder anatomy (illustrations). Case study, Radiopaedia.org (Accessed on 24 Jan 2023) https://doi.org/10.53347/rID-31456 • CC by-nc-sa 3.0 (modified)

Shoulder •

Shoulder - annotated x-rays - Ganzer Fall bei Radiopaedia

Benoudina S, Shoulder - annotated x-rays. Case study, Radiopaedia.org (Accessed on 24 Jan 2023) https://doi.org/10.53347/rID-45952 • CC by-nc-sa 3.0 (modified)

Radiopaedia • CC-by-nc-sa 3.0 • de

Shoulder radiographs are common films to see in the Emergency Department, especially during the weekend after sporting events.

Systematic review

Choosing a search strategy and utilizing it consistently is a helpful method to overcome common errors seen in diagnostic radiology. The order in which you interpret the radiograph is personal preference. A recommended systematic checklist for reviewing musculoskeletal exams is: soft tissue areas, cortical margins, trabecular patterns,bony alignment, joint congruency, and review areas. Review the entire radiograph,regardless of perceived difficulty. Upon identifying an abnormality, do not cease the review, put it to the side and ensure to complete the checklist.

Soft tissue

Assess all soft tissue structure for any associated or incidental soft tissue signs

Bony cortex

cortex should be smooth
- humeral head
- glenoid fossa
- clavicle
- body of scapula
look for fracture fragments
remember the ribs

Joints and alignment

Glenohumeral joint

articular surfaces should be parallel
the humeral head should be on the glenoid in any other view
if the humeral head lies under the coracoid process, think anterior shoulder dislocation
if there is a joint effusion, think humeral head or glenoid fracture

Acromioclavicular joint

the inferior borders of distal clavicle and acromion should line up
if there is a step, think ACJ injury
- acromioclavicular (AC) distance >8 mm: AC ligament rupture
- coracoclavicular (CC) distance >13 mm: CC ligament rupture

Review areas

Although a majority of your focus may be on the shoulder girdle, be vigilant in inspecting the entire radiograph including the:

ribs
lung (e.g. pneumothorax, Pancoast tumor)
any bony/soft tissue regions included in the projection

Common pathology

Anterior shoulder dislocation

95% of all shoulder dislocations
young males and the elderly
forced abduction, external rotation and extension
humeral head lies anterior, medial and inferior to glenoid fossa
common associated fractures
- Hill-Sachs lesion
- Bankart lesion
more: anterior shoulder dislocation

Clavicle fracture

up to 10% of all fractures
predominantly midshaft
mostly children and the elderly
fall onto outstretched hand or shoulder
more: clavicle fracture

Acromioclavicular joint injury

very common injury
range from strain to complete joint disruption
direct blow or fall onto shoulder with adducted arm
step at AC joint, widening of AC joint and/or increased CC distance
more: acromioclavicular joint injury

Proximal humeral fracture

common injury resulting in significant disability
elderly females: mean age 65 years
fall on an outstretched arm
more: proximal humeral fracture

Don't miss

Posterior shoulder dislocation

less than 5% of glenohumeral dislocations but often overlooked
common in adults following a seizure or in the elderly
humeral head forced posteriorly in internal rotation whilst arm is abducted
classically, the humeral head is rounded on AP - light bulb sign
associated with anteromedial fracture of humeral head
more: posterior shoulder dislocation

Shoulder pseudosubluxation

usually secondary to trauma
an effusion or hemorrhage into the joint displaces the humeral head inferiorly
this effusion suggests intra-articular fracture
do not confuse with dislocation!
more: shoulder pseudosubluxation

Pancoast tumor

primary bronchogenic carcinoma arising in lung apex
account for up to 5% of all bronchogenic cancers
always review lung parenchyma, ribs and supraclavicular fossa in AP shoulder radiographs
more: Pancoast tumor

Approaches to radiographs

adult
- head, neck and spine
  - skull radiograph
  - facial radiographs
  - cervical spine radiograph
  - thoracolumbar spine radiograph
- upper limb
- chest
  - frontal
  - lateral
  - decubitus
- abdomen
- lower limb
child
- head, neck and spine
  - skull radiograph
  - facial radiographs
  - cervical spine radiograph
  - thoracolumbar spine radiograph
- upper limb
  - shoulder radiograph
  - elbow radiograph
  - wrist radiograph
  - hand radiograph
- chest
- abdomen
- lower limb
  - pelvic radiograph
  - knee radiograph
  - ankle radiograph
  - foot radiograph