(Translated from German)

The shoulder is one of the most mobile and complex joints in the human body. However, it is not only anatomically versatile - there are also numerous possibilities for optimal imaging in X-ray diagnostics.

Standard X-ray images are often taken in AP and Y-projections. But is this really enough?
Does it make sense to always image such a complex joint with the same two projections? Is imaging in just two projections sufficient to recognize all findings? Of course, a second projection is essential to reliably detect pathological changes. But which two views are ideal for the optimal visualization of a specific problem?

This article is intended to help integrate diagnostic X-ray techniques simply and efficiently into everyday clinical practice. After all, targeted imaging can often avoid the need for extended diagnostics.

For example: a Glenoid fracture and postoperative follow-up

Questions that arise:
- Is it an image of the shoulder or the scapula?
- Which projections are optimal for correctly imaging the glenoid?

Contents:

TRUE-AP-PROJECTION – THE FOUNDATION FOR SHOULDER AND GLENOID DIAGNOSTICS

STEP-BY-STEP GUIDE TO THE TRUE-AP (IN CASE OF TRAUMA)

TUBE ANGULATION: YES OR NO?

WHICH SECOND VIEW IS BEST?

EFFECTIVE SECOND VIEW: AXIAL SHOULDER PROJECTION

WHAT IF THE PATIENT CANNOT ABDUCT THE ARM?

CONCLUSION

True-AP-projection – THE FOUNDATION FOR SHOULDER AND GLENOID DIAGNOSTICS

The True-AP scan ensures that the glenoid is displayed in a line shape. This is achieved by raising the opposite side by 45° - with the help of a 45° wedge. Such a wedge is not only helpful, but also enables reproducible adjustment. By elevating the opposite side, the humeral head and glenoid can be imaged without any overlap and with a good view into the joint space.

STEP-BY-STEP GUIDE TO THE TRUE-AP (In Case of TRAUMA)

1. Position the tube parallel to the wall stand.
2. Limit collimation to 13 x 15 cm.
3. Stabilize the patient with a 45° wedge at the elbow (we use the ProFoam Wedge).
4. Turn the healthy side 45° away from the wall stand.
5. Align the centering device so that the longitudinal central beam runs through the shoulder joint gap.
6. Arm in neutral position (elbow ap position to the detector).

Repeat exposure necessary if:
- Humeral head is projected into the glenoid.

TUBE Angulation: YES OR NO?

A key aspect of imaging the glenoid is deciding whether it is necessary to angulate the tube. This raises the question:

• Does the glenoid require a 15-20° cranio-caudal angulation of the tube to obtain a better view of the subacromial space and to optimally visualize the acromion?
• Or should the tube remain parallel to the detector and thus also parallel to the glenoid?

It is advisable not to angulate the tube to ensure that the glenoid remains undistorted and in its natural shape. Angulation leads to the glenoid and postoperative screws being slightly projected.

Which second view is best?

In most cases, a Y projection is carried out. But is this really the best option? The glenoid is superimposed by the humeral head so that the diagnostically relevant area remains concealed - screws or implants are visible, but their exact position in the glenoid remains unclear in the second plane.

Image 1: True ap with 20° tube tilt - better for the case without tube tilt

Image 2: Glenoid superimposed on the humeral head and scapula.

EFFECTIVE SECOND VIEW: AXIAL SHOULDER PROJECTION

An axial view provides an axial projection of the glenoid. There are several possible positioning techniques:

• Bernageau view: A modified scapular projection with 30° cranio-caudal tube angulation performed at the wall stand.

• West Point view: A complex prone positioning technique that is rarely practical in routine imaging.

• Axial shoulder view in seated or supine position: A simple and effective option, provided the patient can abduct the arm to 90°, or at least 45°.

Let’s take a closer look at these positioning techniques:

All of these views resemble an axial shoulder projection. Therefore, it is often advisable to choose the simple and effective standard axial shoulder view, rather than resorting to unnecessarily complex techniques like the West Point or Bernageau views.

WHAT IF THE PATIENT CANNOT ABDUCT THE ARM?

Plan B
If the patient is unable to abduct the arm, there are alternative, indication-specific approaches that are more suitable than the Y view:

• Option 1: Modified axial shoulder projection in supine position
  • According to the Hermodsson technique: The patient places the hand on the opposite shoulder/clavicle. The X-ray tube is angled approximately 20° latero-medially, and the detector is positioned vertically at the neck, parallel to the tube.

• Option 2: Grath View

• The patient is seated in a position similar to the true AP shoulder view, but places the hand on the opposite side—between the clavicle and humeral head. The X-ray tube is angled 45° cranio-caudally. This projection can be performed either standing/seated at the wall stand or in a supine position.

• The resulting image is similar to the Merrill or Velpeau view but with a significantly shorter object-to-detector distance—resulting in a sharper image and reduced radiation exposure.

Conclusion

Targeted Radiographic Technique Instead of Standard Routine

• True AP without tube angulation for accurate glenoid visualization.
• Avoid the Y-view! Instead, use:
   – Axial shoulder view in seated or supine position, or
   – Modified scapular view with 30° cranio-caudal angulation.
• If abduction is not possible:
   – Modified axial shoulder projection in supine position (Plan B – Option 1), or
   – Grath view with 45° tube angulation (Plan B – Option 2)).

• Field collimation for all views: 13 x 15 cm.

Source regarding Velpau: Radiopedia

FURTHER TRAINING OPPORTUNITIES IN X-RAY - WITH LEVEL UP COURSES BY AGATA EPLER – "Alles Einstellungssache"

I offer in-house training to optimize indication-based positioning techniques and support the development of SOPs.

Flexible learning – when it suits you and exactly when you need it.

The practical radiography online courses by Alles Einstellungssache provide a structured, easy-to-understand approach with a strong focus on clarity, consistency, and reproducible, indication-based solutions in radiographic positioning.

X-Ray with Clarity – for effective diagnostics!

Alles Einstellungssache

Agata Epler