shoulder girdle Flashcards

Question

Referral Criteria – Common Symptoms

Answer 1

Shoulder Reduced mobility of shoulder Shoulder instability Suspected arthritis Suspected Bony Lesion or Metastases Trauma Signs of infection or septic arthritis of shoulder joint Clavicle Trauma Visible Deformity Bony Tenderness Previous Fracture Review Post-operative Review

Answer 2

Osteoarthritis (OA) of Glenohumeral Joint Acromial Spurring Calcific Tendonitis Proximal Humerus Fracture (Diagnosis and follow-up) Dislocation of Glenohumeral joint Clavicle Fracture Scapular Fracture

Answer 3

Rotator cuff tear – MRI or Ultrasound Labral Tear - MRI Adhesive Capsulitis (Frozen Shoulder) – MRI NB: Often x-ray is used to rule out similar presenting conditions, in these cases there must be valid symptoms or suspected pathology in order to be justified under IR(ME)R 2017.

Answer 4

- Get patient changed as necessary - Check previous imaging - Ensure request form is justified - Confirm the patient’s ID via 3 point check - Confirm history with the patient - Confirm location and side of imaging - Patient should be risk assessed with regard to mobility in order to determine which projections are safe and appropriate to perform

Answer 5

Non-Trauma Projections AP Shoulder - Standard external rotation of the patient, approx. 15 degrees Axial Trauma Projections AP Shoulder - (Grashey view) Modified approach can include 45 degrees patient rotation to visualise the gleno-humeral joint Axial or; Lateral scapula - Also referred to as, but not formally: Y-View PA Shoulder

Answer 6

Patient is positioned with their back against the image receptor The median sagittal plane is perpendicular to the image receptor The patient is then rotated approximately 10-15 degrees towards the affected side, bringing the scapula parallel to the image receptor The patient’s affected arm should be externally rotated and abducted (SLIGHTLY) with the posterior humerus in contact with the receptor

Answer 7

The tube is positioned horizontally and perpendicular to the image receptor If using AEC, centering over the chamber should be maintained and positioning achieved by moving the patient The centering point is 2.5cm inferior to the palpable coracoid process Collimation should include: - Superiorly: The skin border superior to the clavicle/AC joint - Inferiorly: The inferior angle of scapula and proximal 1/3 of Humerus - Medially: The sternoclavicular joint - Laterally: The skin border lateral to the humerus

Answer 8

The use of a grid is usually not required An AEC (usually central chamber) can be used with DR systems SID = 110cm Focal Spot Size = Fine Estimated collimation size = 24 X 30 cm - Image Receptor = Landscape orientation Given Exposure Factors: - 60 kV & 5 mAs

Answer 9

The centering point is 2.5cm inferior to the palpable coracoid process Patient is rotated 40-45 degrees towards the affected side Collimation: - Superiorly/Inferiorly/Laterally as per AP projection and; - Medially collimation to midshaft of clavicle as projection foreshortens clavicle if this is a supplementary view Given Exposure Factors: 60 kV & 5 mAs

Answer 10

True AP Shoulder MSP is perpendicular to the image receptor (IR) Standard AP Shoulder MSP is 10-15 degrees towards affected side with respect to the IR Truned AP Shoulder (Grashey view) MSP is 45 degrees towards affected side with respect to the IR

Answer 11

Patient’s elbow is flexed to 90 degrees The hand is then rested against the back or abdomen depending on patient comfort The patient is rotated from a neutral PA until the lateral aspect of the shoulder is touching the receptor - Warning – Avoid having the patient lean forwards as this will foreshorten the scapula - If required, a small gap between the AC joint and the IR is acceptable

Answer 12

The tube is positioned horizontally and perpendicular to the image receptor Hint - Rotate the ‘box’ of the x-ray tube to align with the humerus AECs are difficult to use due to narrow and difficult to visualise bony anatomy The centering point is on the medial border of the scapula, at the height of the humeral head Collimation should include: - Superiorly: 2cm above acromion - Inferiorly: 2cm below inferior angle of scapula - Medially: The palpable coracoid process - Laterally: The lateral skin border of humerus

Answer 13

The use of a grid is recommended but not mandatory An AEC (usually central chamber) can be used with DR systems SID = 110cm Focal Spot Size = Fine Estimated collimation size = 24 X 30 cm Image Receptor = Portrait orientation Given Exposure Factors: 70 kV & 6.3 mAs (Increase mAs if using a grid)

Answer 14

Patient is usually seated Image receptor is placed on table Table is lowered to waist height (ALWAYS ensure that the patients knees/legs are NOT under the table when adjusting table height, to prevent serious injury) The patient abducts their arm and leans as far over the table as possible The elbow should be flexed to 90 degrees - This is helpful for support/balance The head should be titled forwards to bring posterior-lateral cranium away from region of interest

Answer 15

A grid is not usually required Manual exposures are usually used as it is unlikely to be able to center directly over a chamber SID = 110cm or more if needed - Note the OID (object image distance) Focal Spot Size = Fine Estimated collimation size = 18 X 24 cm - Image Receptor = Portrait orientation (in relation to humerus) Given Exposure Factors: 65 kV & 5 mAs

Answer 16

True AP position - Patient is positioned with their back against the image receptor - The median sagittal plane is perpendicular to the image receptor The patient’s arms should be in a neutral and relaxed position, external rotation is not necessary The tube is positioned horizontally and perpendicular to the image receptor The centering point is midway between the distal and proximal ends of the clavicle Collimation should include: - Superiorly: The skin border superior to the clavicle/AC joint - Inferiorly: The inferior most aspect of the clavicle - Medially: The sternoclavicular joint - Laterally: The acromio-clavicular joint/ soft tissues laterally

Answer 17

A grid is not required Manual exposures are recommended, AEC can be used however SID = 110cm Focal Spot Size = Fine Estimated collimation size = 24 X 30 cm Image Receptor = Landscape orientation Given Exposure Factors: 60 kV & 4 mAs

Answer 18

The patient's position is as for the AP Clavicle projection - True AP position - The patient’s arms should be in a neutral and relaxed position The tube is positioned horizontally, with 30* degrees cranial angulation and perpendicular to the image receptor The centering point is midway between the distal and proximal ends of the clavicle Collimation as AP Clavicle projection Exposure factors are the same as AP Clavicle: - No grid required, AEC can be used if wanted - SID = 110cm, Focal Spot Size = Fine - Estimated collimation size = 24 X 30 cm (landscape) - 60 kV & 4 mAs

Answer 19

The glenohumeral joint is the most commonly dislocated joint in the human body Over 95% of these are classified as anterior dislocations These injuries are particularly prevalent in younger people and males Common mechanisms of injury involve direct trauma or a fall onto outstretched hand Patients may present with further dislocations following the initial injury Usual management is closed reduction in the emergency department under sedation

Answer 20

Hill-Sachs - Posterolateral humeral head compression Bankart - Injury to antero-inferior aspect of the glenoid labrum. Can be soft-tissue or bony fragment 11 x more likely to occur together than separately (Raby et al., 2014)

Answer 21

1-4% of glenohumeral dislocations are posterior These injuries are usually the result of seizures or electrocution The classic radiographic appearance is the “lightbulb sign” - Not externally rotating the shoulder can simulate this appearance This pathology can be difficult to detect on plain film and its innocuous appearance on the AP projection, highlights the importance of taking multiple projections at orthogonal views Usual management is closed reduction in the emergency department under sedation

Answer 22

These are most common in the elderly population, especially those with osteoporosis Most common mechanisms of injuries: - Fall Onto Out-Stretched Hand (FOOSH) - Falls from height - High impact trauma (Sports/ Motorcycle accident) Fractures could be subtle avulsions from rotator cuff injuries Care must be taken when positioning for the second projection, a modified axial view may be required. Management will depend on the age and general health of the patient, treatments could be - ORIF/ K-wires - Arthroplasty - Conservative management

Answer 23

Open Reduction and Internal Fixation (ORIF) Inter-Medullary (IM) Nail Kirschner Wire (k-wire)

Answer 24

Open Reduction and Internal Fixation (ORIF) Inter-Medullary (IM) Nail Kirschner Wire (k-wire)

Answer 25

S – Slipped (Separated): The fracture involves only the growth plate, giving the appearance of a wider physis A – Above: The fracture is above the growth plate. It involves the metaphysis L – Lower: The fracture is below the growth plate. It involves the epiphysis T – Through: The fracture passes through the growth plate affecting both epiphysis and metaphysis R – Rammed: The growth plate is impacted

Answer 26

type 1 - is a fracture restricted to the growth plate. type 2-4 - represent various patterns of fractures involving the growth plate and the adjacent metaphysis and/or epiphysis

Answer 27

Clavicle fractures are most common among younger patients and children Common mechanisms of injury include: - RTCs - Falls - Sports-related injuries Most injuries involve the middle and distal sections of the bone, medial clavicle fractures are rare Clavicle fractures can be managed surgically or conservatively

Answer 28

ACJ injuries can be classified using the “Rockwood Classification”

Answer 29

Review the full radiograph Follow the cortex and alignment of the ribs to exclude easy to miss fractures These maybe pathological and therefore isolated

Answer 30

Review the full radiograph Follow the cortex and alignment of the ribs to exclude easy to miss fractures These maybe pathological and therefore isolated