Transthoracic Lateral Shoulder

Introduction

The transthoracic lateral projection of the shoulder/proximal humerus is a technique that is not commonly practiced by most radiographers. The technique is a valid method for radiographic demonstration of the proximal humerus in particular and is worthy of inclusion in the radiographers' technique toolkit.

The reasons for the lack of favour of this technique are likely to be

• the inherent superimposition of the anatomy over the patient's chest
• the need for the patient to hold very still during a relatively long exposure
• and the fact that it is a very operator-dependent technique.. it takes some practice to master

Radiographic Technique

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These videos should provide the basic positioning technique. An exposure should be selected that provides sufficient penetration to adequately penetrate the patient's (> 70 kVp) chest and an exposure time that will provide sufficient blurring of the thoracic anatomy (at least 1 second). Shallow breathing will help to increase the blurring of the lung markings but will also increase the risk of undesirable movement unsharpness. Notes Raising the unaffected arm above the patient's head will tend to cause the affected arm to drop allowing a perpendicular central ray. Alternatively, angle the beam 15 degrees cephalad. A breathing technique over 3 to 4 seconds will provide best results but will also increase the risk of undesirable movement unsharpness. If a respirated respiration technique is used, exposure on full inspiration.

Cases

This 99 year old lady presented to the Emergency Department following a fall onto her left arm. She was found to have a painful left shoulder and was referred for left shoulder radiography with a provisional diagnosis of left NOH fracture/dislocation. The radiographer performed a bedside AP shoulder projection using CR and a non-grid technique. The shoulder AP image demonstrates some under-rotation of the patient but is acceptable given the circumstances s of the case. There is a comminuted fracture of the neck of humerus. There is also some evidence of subluxation of the GH joint which may be pseudosublaxation rather than a true dislocation of the glenohumeral joint. The radiographer decided that it was appropriate to perform a transthoracic lateral projection of the shoulder given the patient's age, injury and level of pain. Aortic calicifiction noted GH joint and AC joint degenerative changes noted ? mitral annulus calcification

The transthoracic lateral was performed with a Philips release I DR system using the wall detector. The fracture is well demonstrated. An SI/IS view is required to ensure that the glenohumeral joint is not dislocated. This may not have been possible in this case. A lateral scapula projection would also be of assistance in establishing the degree of subluxation/dislocation of the glenohumeral joint.

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