The document describes the anatomy and radiographic imaging of the shoulder. It discusses the bones, joints, ligaments, tendons, muscles, nerves, and blood vessels that make up the shoulder. It provides details on recommended radiographic projections to image the shoulder, including AP, axial, outlet, and glenohumeral joint views. Exposure factors, positioning, and evaluation criteria are outlined for each projection.

2. Anatomy of shoulder can be divided into several different categories, which are:
Bones
Joints
Ligaments
Tendons
Muscles
Nerves
Blood Vessels
Bursa
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4. Shoulder girdle contains two bones:
 Clavicle
Scapula
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8.  Shoulder girdle contains three synovial joints, which are:
 Gleno-humeral joint
 Acromio-clavicular joint
 Sterno-clavicular joint
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10. Ligaments of the shoulder forms a joint capsule that connects the humerus to the glenoid
cavity.These ligaments are the main source of stability for the shoulder.
Glenohumeral Ligaments (GHL)
Coraco-acromial Ligament (CAL)
Coraco-clavicular Ligaments (CCL)
Transverse Humeral Ligament (THL)
Acromioclavicular Ligament
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11. Glenoid Labrum
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12.  Although many muscles connect with, support, and enter into the function of the shoulder
joint, radiographers are chiefly concerned with the rotator cuff muscles
 ROTATOR CUFF MUSCLES:
 Subscapularis
 Supraspinatous
 Infraspinatous
 Ters minor
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14.  Trauma, Fracture Subluxation,
Dislocation
 Pathological condition associated with
joint space and bone(Osteoarthritis,
Rheumatoid arthritis,Osteopetrosis,
osteoporosis, Osteomyelitis & other
degenerative osteoarthropathy)
Check x-ray for post op and post
reduction.
Impingement of shoulder joint
Congenital anomalies.
Bone cyst, Tumor, Effusion
Calcified tendon.
General skeletal survey
Bursitis(inflammation of bursa)
INDICATIONS FOR SHOULDER RADIOGRAPHY:
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15. COMMON IMAGE CRITERIA FOR SHOULDER JOINT RADIOGRAPHY:
Well visualization of:
Proximal arm, ½ clavicle, scapula, lateral ribs cage, Glenohumeral joint, ACJ.
No rotation or image blur.
Open joint spaces.
Soft tissue & bony trabeculation details.
Part of interest (always be at the center of the IR.)
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16. General consideration for shoulder radiography:
Skeletal parts are projected usually with at least two different directions (usually
right angle to each other.)
No forceful positioning in case of trauma, contracture or suspected fracture.5/15/2017 16

17. Patient preparation:
 Checking of request form, identifications & verification.
 Explanation of procedure ,Removal of all radiopaque objects from the
region to be radiographed (Shoulder & Neck).
 Immobilization: pillows, sandbags, compression bands, sponges &
radiolucent pads for support & comfort.
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18. Patient head should be rotated away from side being examined
Proper patient positioning/ Beam collimation/ Exposure factors/ Immobilization of
parts i.e.; Proper technique and instruction to the patient to avoid repeat exposure
High speed screen-film combination if applicable
In case of young uncooperative children Bucky is omitted so that exposure time can
be minimized
If available, radiation protection shield should be used e.g. Thyroid shield, gonad
shield etc.
The central ray can be directed caudally after centering to the coracoid process so
that the primary beam can be collimated to the area under examination.
Radiation protection:
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19. RECOMMENDED PROJECTIONS:
Basic
 AP(neutral, internal, external rotation)
 Axial(supero-inferior, infero-superior)
Glenohumeral joint
 AP(erect/supine)
 Lateral oblique ‘Y’ projection
Acromioclavicular joints
 AP(erect)
Clavicle
 PA(erect),AP(supine)
 Axial(infero-superior)
Scapula
 AP(erect)
 Lateral(erect/prone)
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20. Radiographic anatomy of shoulder
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21. Equipment setting & exposure factor
Decrease 5 -10 kVp in case of destructive pathology (Active osteomyelitis,
Aseptic necrosis, Atrophy, Degenerative arthritis, Gout,Osteoporosis,old
age)
5-10kvp decrease for soft tissue radiography( bursitis, tendonitis ,foreign
body localization e.t.c.)
Increase 5 -10 kVp or 25 -50% mAs or both in case of additive pathology
(Acromegaly, Osteoma, Exostosis(benign growths of bone extending
outwards from the surface of a bone) etc.) & if the part on POP cast
KVP MAS FFD GRID FOCUS SCREEN
FILM SIZES
(INCH)
55-80 6-50 100 CM Y/N SMALL FAST 8X10 OR 10X12
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22. Shoulder joint: AP
Indications
Trauma, fracture,dislocation,calcifications
Infection, effusion arthritis & degenerative joint diseases &
other joint pathology
Patient positioning
Erect or supine with affected shoulder against the cassette
and rotated about 15 º (close contact)
Arm abducted,
Upper border of cassette 5cm above shoulder
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23. Fig, Shoulder AP in external, neutral and internal rotation
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.
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24. Central ray
Perpendicular to a point 1 inch (2.5 cm) inferior to the coracoid process
Evaluation criteria
Visualization of shoulder girldle, glenohumeral joint
Slightly overlapping glenoid cavity but separate from the acromion
process
Bony and soft tissue structures of shoulder and proximal humerus
CONT..
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25. Shoulder: axial
1. Supero inferior
2. Infero superior:
•Supine:
 Lawrence method
 Rafert Modification
• Prone:
 West Points view
•Lateral:
 Clements method5/15/2017 25

26. Shoulder: axial (superoinferior)
Indication
To evaluate glenohumeral joint, & calcified tendons
To demonstrate insertion region of infraspinatus muscle & the subacromial
part of the supraspinatus tendon
Patient positioning
Patient sits beside the x-ray table
IR is placed on the table top & the affected arm abducted over the
cassette
Patient leans towards the table to reduce OFD & to insure that the
axilla (glenoid cavity) included in the image.
(A curved cassette can be used to reduce OFD)
Elbow flexed, arm abducted to minimum 45º(injury permitting)
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27. Central ray
 through the proximal aspect of the
humeral head, beam can be angled 5°-
15° toward the elbow with CR directed at
the shoulder joint.
(FFD increased if large OFD to reduce
magnification)
SHOULDER: AXIAL (SUPEROINFERIOR)
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28. Evaluation criteria
Demonstration of head of humerus(Lesser
tuberosity in profile) , acromion process, coracoid
process and glenoid cavity
Open scapulohumeral joint (not open on patients
with limited flexibility)
SHOULDER: AXIAL (SUPEROINFERIOR)
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29. Axial (inferosuperior)
Patient position(Lawrence method)
Patient supine ,arm abducted and supinated
Affected shoulder and arm raised on non-opaque pads
Cassette supported vertically against the shoulder and
pressed against the neck(to include scapula)
Head turned to opposite direction
Central ray
center to axilla (to the region of ACJ )
 with the tube medially angled 15º- 30º. The greater the
abduction, the greater the angle.
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30. Cont…….
Patient position(RAFERT Modification )
To visualize Hill-Sachs defect
From the Lawrence method, the extended arm externally
rotated until the hand forms a 45º oblique & the thumb
pointing downwards.
Central ray
To the axilla with 15º medial angulation so that the CR
passes through ACJ
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31. Axial (inferosuperior)
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32. axial (inferosuperior)
Patient position(west point view)
Patient prone, Head turned away
3”pad placed under the affected shoulder
 affected arm abducted 90º & rotated to rest the forearm
over the edge of the table.
IR placed against superior aspect of shoulder with the edge
of IR in contact with the neck
Central ray
 directed at a dual angle of 25º anterior from the horizontal (to table surface) & 25º
medially
 Central ray enters approximately 5 inches inferior & 1.5 inches medial to the
acromial edge & exits through the glenoid cavity5/15/2017 32

33. Evaluation criteria
Humeral head projected free of the
coracoid process
Open glenohumeral joint.
CONT…..
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34. Patient preparation(Clements method)
Done if prone or supine position not possible
Patient in lateral recumbent position lying on
unaffected side
Hips & knees flexed
90º abduction of affected arm & pointing towards
the ceiling
IR against the superior aspect of the shoulder,
holding in place with another arm or securing it
properly
AXIAL (INFEROSUPERIOR)
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35. Cont…..
Central ray
To the midcoronal plane, passing
through the mid axillary region of the
shoulder.
Angled 5 to 1 5 degrees medially when
the patient cannot abduct the arm a full
90 degrees
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36. Indication
When the arm can’t be rotated or abducted
To demonstrate proximal humerus in a 90º
projection from the AP
SHOULDER: TRANSTHORACIC LATERAL
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37. Shoulder: transthoracic lateralPatient positioning
Patient is in erect or supine
Patient in lateral position with affected
side towards the IR
Unaffected arm raised ,forearm flexed
and placed over the head, shoulder
elevated as much as possible(Elevation of
the non-injured shoulder drops the
injured side separating the shoulders to
prevent superimposition.)
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38. Central ray
directed to the midcoronal plane at the level of surgical neck
of the humerus
Full inspiration exposure as the lungs full of air improves the
contrast and decreases the expoure necessary to penetrate the
body.
Evaluation criteria
shows a lateral radiograph of the shoulder & true lateral view
of proximal humerus through the thorax
Scapulae superimposed over the thoracic spines
Unaffected clavicle & humerus projected above the shoulder
SHOULDER: TRANSTHORACIC LATERAL
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39. Shoulder : outlet projection(AP)
Indications
Suspected shoulder impingement syndrome
To visualize anterior portion of acromion process
Patient positioning
Patient stands with affected shoulder against the IR and
rotated 15 º to bring scapula parallel to IR
Arm abducted slightly
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40. Central ray
Directed 30º caudally and centered to palpable
coracoid process
Evaluation criteria
Demonstration of anterior part of acromion
projected inferiorly
Subacromial joint space seen above the humeral
head
Shoulder : outlet projection(AP)
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41. outlet projection(lateral)neer methodPatient position
Pt stands or sits facing the cassette with lateral aspect of
affected arm in contact
Arm extended backward and back of hand rests on the
waist
Pt is rotated forward and body of scapula is made at right
angle to the cassette
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42. outlet projection(lateral)neer method
Central ray
Head of humerus with 10º caudal angulation
Evaluation criteria
 Sub-acromial joint space seen
clearly
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43. Shoulder :PA oblique( scapular Y)
Indication
Suspected dislocation
Proximal humerus #
Scapular body #
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44. Cont…
Patient positioning
Erect
Anterior aspect of affected shoulder towards
IR
Unaffected shoulder raised so midcoronal
plane form angle of 45º-60º to the IR. I.e.; until
Scapular flat surface perpendicular to IR
Central ray
to the medial border of the scapula
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45. Cont…
Evaluation criteria
Superimposed humeral head & glenoid
cavity; humeral shaft & scapular body.
Acromion projected laterally & free of
superimposition
Coracoid superimposed with or projected
below the clavicle
Scapula in lateral profile
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46. Glenohumeral joint:AP
Indications
To demonstrate glenoid cavity and glenohumeral
joint space(Coracoid#,glenoid#,proximal
humerus#)
Patient position
Stand with affected shoulder against the cassette
Rotated 30º to bring plane of glenoid fossa
perpendicular to the cassette
Arm supinated and slightly abducted away from
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47. Central ray
Directed toward the palpable coracoid process
GLENOHUMERAL JOINT:AP
Evaluation criteria
 Clear visualization of joint space between head of
humerus and glenoid cavity
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48. Glenohumeral joint:RPO or LPO
Patient positioning(Grashey
method)
Supine or erect (erect is comfortable)
Body rotated towards the affected side until
the scapula is parallel with the plane of the IR
so that the head of humerus in contact with
the IR
Slight abduction of arm in internal rotation
with palm of the hand on the abdomen
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49. Central ray
 Perpendicular to the glenoid cavity
Evaluation criteria
 Should demonstrate clearly the joint space
between head of humerus and glenoid cavity
CONT…
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50. Similar to Grashey method but uses weighted abduction to demonstrate a loss of
articular cartilage in the glenohumeral joint.
SHOULDER JOINT : Glenoid cavity RPO or LPO (Apple method)
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51. PATIENT POSITIONING
Similar to Grashey method except;
Should hold ½ kg weight in hand on the affected side.
While holding the weight, the patient should abduct the arm 90º from the midline of the
body.
CONT…
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52. EVALUATION CRITERIA
Open scapulohemeral joint.
Soft tissue & bony trabecular
detail.
CONT…
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53. INDICATIONS
Shoulder instability,Glenoid #, Glenoid rim erosion.
Hill-Sachs lesions, Bankart lesion.
Soft tissue calcifications.
SHOULDER JOINT: GLENOID CAVITY RPO or LPO Axial oblique (Garth method)
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54. PATIENT POSITIONING
Body Rotated approximately 45º towards the
affected side.
Affected arm adducted & elbow flexed to place
the forearm across the abdomen
CENTERING OF X-RAY BEAM
Angled 45º caudad, through the
scapulohumeral joint
SHOULDER JOINT: GLENOID CAVITY RPO or LPO Axial oblique (Garth method)
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55. EVALUATION CRITERIA
The scapulohumeral joint, humeral head,
and scapular head and neck free of
superimposition
The coracoid process should be well
visualized
Apical oblique: Garth view
SHOULDER JOINT: GLENOID CAVITY RPO or LPO Axial oblique (Garth method)
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56. Recurrent dislocation
Is associated with defects on head of humerus
In case of recurrent anterior dislocation, defect will occur on posterolateral aspect
of head of humerus(hill sach’s lesion)
In case of recurrent posterior dislocation, defect will be on anterior part of head
Dislocated head of humerus also impacts on glenoid rim
 In case of recurrent dislocations, 3 Ap projections (with humerus lateral, oblique &
Stryker’s) & Inferosuperior views are done.
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57. lateral &oblique humerus
Patient position
Patient lies erect or supine
Unaffected shoulder raised 30degree to bring glenoid
cavity right angle to centre of IR
lateral humerus
Arm partially abducted, elbow flexed, and palm of hand
rest on patients waist5/15/2017 57

58. oblique humerus
The elbow is extended, allowing the arm to rest in
partial abduction by the patient’s side.
The humerus is now in an oblique position
LATERAL &OBLIQUE HUMERUS)
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59. Central ray
Directed to head of the humerus
Evaluation criteria
Should demonstrate head and neck of humerus and glenoid cavity with
glenohumeral joint clearly shown
LATERAL &OBLIQUE HUMERUS)
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60. AP(modified)-Stryker notch view
Patient positioning
Patient lies supine
Arm of affected side is extended fully and the elbow is flexed to allow the
hand to rest on patient’s head
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61. Cont..
Central ray
Angled 10º cranially and directed through the
centre of the axilla
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62. INDICATIONS
To evaluate the tendon of the long head of biceps.
PATIENT POSITIONING
Supine, seated or standing.
Forearm extended & hand supinated 45º.
Chin extended & head rotated away from the
affected side.
IR supported vertically above the shoulder.
SHOULDER JOINT: BICIPITAL GROOVE TANGENTIAL
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63. CENTERING OF X-RAY BEAM
Angled 10º-15º downward from the
horizontal & to the long axis of the humerus
for the supine position. ( 10º-15º cephalad
for erect).
Fisk modification:
Perpendicular to the IR when the patient is
leaning 10º-15º forward from the vertical
humerus position.
SHOULDER JOINT: BICIPITAL GROOVE TANGENTIAL
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64. EVALUATION CRITERIA
Intertubercular groove free from superimposition with surrounding shoulder structures.
SHOULDER JOINT: BICIPITAL GROOVE TANGENTIAL
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65. Acromioclavicular joints:AP
Indication
To visualize dislocation, Separation, Subluxation
To compare functional difference of ACJs
AC arthritis & Osteopathy
Patient positioning
Patient stands facing the x-ray tube, arms relaxed to the side
Center the midline of the body to the midline of the grid.
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66. Cont…
weight bearing comparison projection of both ac joint can be done for
subluxation(Pearson method) i;e Equal weight is strapped around lower arm
(wrist) of the patient
Central ray
If bilateralprojection then :Perpendicular to the midline of the body at the level
of the acromioclavicular joints
If only one side then:To the palpable lateral end of clavicle at acromioclavicular
joint(to avoid superimposition 25 º cranial angulation can be given)
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67. Evaluation criteria
Demonstration of acromioclavicular joint
Soft tissue around the articulation must be visible
CONT…
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68. Clavicle :PA
Preferable since clavicle lies close to cassette-
optimum bony detail, reduces the radiation dose to
thyroid and eyes
Patient positioning
Patient stands facing the IR with clavicle in centre
of IR
Patient’s head is turned away from side being
examined
Central ray
Perpendicular to the midshaft of clavicle
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69. AP(alternate)
Patient positioning
Adjust the body to center the clavicle to the midline of
the table or vertical grid device.
Place the arms along the sides of the body, and adjust the
shoulders to lie in the same horizontal plane.
Center the clavicle to the IR
Central ray
Perpendicular to the midshaft of clavicle
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70. Cont….
Evaluation criteria
Entire length of clavicle should be
included along with the acromioclavicular
and sternoclavicular joints
Lateral end of clavicle demonstrated clear
of thoracic cage
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71. Clavicle :Ap axial(Lordotic position)
Patient positioning
Patient is made to sit or stand in front of the vertical IR facing the x-ray
tube(supine-alternate)
Patient leans backward in a position of extreme lordosis and rest the neck and
shoulder against the vertical grid device
Neck in extreme flexion
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72. Cont…
Central ray
Over the mid shaft of the clavicle
with angulations(0-15)degree for
standing &(15-30) degrees for supine
Evaluation criteria
Clavicle projected above the ribs and
scapula with medial end overlapping
the 1st and 2nd rib
Entire clavicle with AC and SC joint
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73. Scapula :AP
Patient positioning
Abduct the arm to a right angle with the body to draw the scapula
laterally.
flex the elbow, and support the hand in a comfortable position.
For this projection, do not rotate the body toward the affected side
because the resultant obliquity would offset the effect of drawing
the scapula laterally
Central ray
Perpendicular to the mid scapular area at a point approximately 2
inches (5 cm) inferior to the coracoid process
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74. Cont..
Evaluation criteria
Lateral portion of the scapula free of
superimposition from the ribs
Scapula horizontal and not oblique
Scapular detail through the superimposed lung
and ribs (Shallow breathing should help
obliterate lung detail)
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75. Scapula :lateral
Patient positioning
Patient stands with affected side against the IR
Arm is either adducted across the body or abducted
with the elbow flexed and back of hand rest on the
hip
Patients trunk is rotated forward until the body of
scapula is at right angles to the cassette
Central ray
To the midpoint of medial border of scapula
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76. Scapula :lateral
Evaluation criteria
Lateral and medial border superimposed
No superimposition of the scapular body on
the ribs
 No superimposition of the humerus on the
area of interest
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80. 5/15/2017
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81. Questions?
1. Bone involved in the shoulder joint formation?
2. What kind of joint in shoulder and it’s type?
3. Basic projection of shoulder joint?
4. Basic projection of clavicle ?
5. What is Hill-sach defects ,what is projection done for
it?
6. Mention position of patients in superior interior axial
projections?
7. What is bursa and what is projection for bursitis?
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