Rev. bras. ortop. vol.52 número1

rev bras ortop.2017;52(1):115–118

SOCIEDADE BRASILEIRA DE ORTOPEDIA E TRAUMATOLOGIA

w w w . r b o . o r g . b r

Technical

Note

Modified

axillary

radiograph

of

the

shoulder:

a

new

position

夽

Luís

Filipe

Senna

,

Rodrigo

Pires

e

Albuquerque

a_{HospitalEstadualAdãoPereiraNunes,Servic¸odeOrtopediaeTraumatologia,DuquedeCaxias,RJ,Brazil}

b_{UniversidadeFederalFluminense,Servic¸odeOrtopediaeTraumatologia,Niterói,RJ,Brazil}

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Articlehistory:

Received18December2015 Accepted28January2016 Availableonline9December2016

Keywords: Shoulder

Shoulderdislocation Shoulderjoint Radiography

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Obtainingaxillaryradiographsoftheshoulderinacutetraumaisnotalwaysfeasible.The authorspresentanewmodificationofthisradiographicview,inordertoassesstheanatomic relationshipbetweenthehumeralheadandtheglenoidcavity.Theincidenceisperformed withthepatientsittingonX-raytable,withtheaffectedlimbsupportedthereon.Theauthors describethecaseofa28-year-oldmalewhosufferedananteriorglenohumeral disloca-tionthatwasclearlyevidencedbythismodifiedradiograph.Theconcentricrelationship betweenthehumeralheadandtheglenoidcavitywasalsoeasilyconfirmedbyobtaining suchradiographafterthereductionmaneuver.

©2016SociedadeBrasileiradeOrtopediaeTraumatologia.PublishedbyElsevierEditora Ltda.ThisisanopenaccessarticleundertheCCBY-NC-NDlicense(http:// creativecommons.org/licenses/by-nc-nd/4.0/).

Modificac¸ão

da

incidência

radiográfica

axilar

para

o

ombro:

uma

nova

posic¸ão

Palavras-chave: Ombro

Luxac¸ãodoombro Articulac¸ãodoombro Radiografia

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e

s

u

m

o

Aobtenc¸ãoderadiografiasemperfilaxilardoombroemsituac¸ãodetraumaagudonem sempreétarefafácil.Osautoresapresentamumamodificac¸ãoinéditadessaincidência radiográfica,comoobjetivodeavaliararelac¸ãoanatômicadacabec¸aumeralcoma cavi-dadeglenoide.Aincidênciaémedidacomopacientesentadosobreamesadeexamesde raiosX,comomembroacometidoapoiadosobreela.Osautoresdescrevemocasodeum pacientede28anosquesofreuumepisódiodeluxac¸ãoglenoumeralanteriorquefoi clara-menteevidenciadapelaradiografiamodificada.Arelac¸ãodeconcentricidadeentreacabec¸a umeraleacavidadeglenoidefoifacilmenteconfirmadapelaobtenc¸ãodareferidaincidência radiográficaobtidaapósamanobradereduc¸ão.

©2016SociedadeBrasileiradeOrtopediaeTraumatologia.PublicadoporElsevierEditora Ltda.Este ´eumartigoOpenAccesssobumalicenc¸aCCBY-NC-ND(http:// creativecommons.org/licenses/by-nc-nd/4.0/).

夽

StudyconductedatHospitalMunicipalDr.NelsondeSáEarp,Petrópolis,RiodeJaneiro,RJ,Brazil,andatHospitalEstadualAdãoPereira Nunes,DuquedeCaxias,RJ,Brazil.

∗ _{Correspondingauthor.}

E-mail:lfsenna@yahoo.com.br(L.F.Senna). http://dx.doi.org/10.1016/j.rboe.2016.12.001

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Introduction

Thereisageneralrecommendationforthecareoforthopedic traumapatients,whichistoobtainatleasttworadiographic viewsinorthogonalplanesforproperevaluationofthe trau-matized limb or joint.1 _{In the case of the shoulder joint,} suchrecommendationisparticularly valuable,asfailure to obtainX-raysinorthogonalplanes,especiallyfailuretoobtain axillaryradiographs,isconsidered tobethemaincause of misdiagnosisinglenohumeraldislocations.2_{Radiographsin} anteroposterior,lateralscapula,andaxillaryviewsareknown astheshouldertraumaseries3_{andmustbeperformedonall} patientswithtraumaofsuchjoint.Theaxillaryviewwasfirst describedin1915byLawrenceapudJensenandRockwood,4 and can bedone withthe patient standing or sitting. Ide-ally,itisnecessarytopositiontheshoulderinapproximately 70◦_–90◦_{ofabductiontoobtainthisradiograph.Inpatientswith} mildtrauma, this degreeofabductionisfeasible; however, forpatients withmoreseveretrauma, andespeciallythose withglenohumeraljointdislocation,itisextremelydifficult toobtaintheaxialimage,becausepainandjointincongruity greatlylimittheabductioncapacityofthejoint.Thus, modi-ficationsintheclassicalaxillaryviewhavebeenproposed.5,6 TheviewdescribedbyBloomandObata5_{isperhapsthebest} knownmethod,asitallowsforanaxillaryradiography with-outremovingthepatient’sarmfromthesling–whichwould inprinciplebemorecomfortable.Nonetheless, theauthors havefoundthis viewtobedifficulttoobtain, especiallyin the elderly, since it requires leaning the trunk posteriorly withthepatientstanding;maintainingbalanceisdifficultand limbpositioningishindered.TheviewdescribedbyCleaves6 requirestheuseofacurvedchassis,whichisnotwidely avail-able.Facedwiththesedifficulties,theauthorsidentifiedthe needtodevelopamodificationoftheLawrencetechniquein apositionthatwasmorecomfortableforthepatientand eas-iertoreproduce.Thepatient’spositioningfortheradiograph was namedthe Sennaposition, inreference tothe author andcreatorofthetechnique.Theincidencedescribedbelow aimstoshow,inaxialprojection,therelationshipbetweenthe humeralheadandglenoidcavity.

Technique

Toobtainthepresentmodificationoftheaxillaryradiograph, the patientis requiredtosit withthe feet hanging onthe radiographic table. Then, the patient is requested to posi-tiontheopenhandoftheaffectedsideonthetable.Onlya smalldegreeofabductionisrequired.Theabductionangle formedbetweenthemedialaspectofthearmandthelateral chestshould beapproximately 30◦_{. TheX-raysare pointed} totheglenohumeraljoint,perpendiculartothetable,60cm fromtheshoulder.Thechassiswithradiographicfilmis pos-itioned on thetable, directly underthe shadowformed by the shoulder contour, with its anterior border just behind thegreater trochanter ofthefemur(Fig. 1). Itisimportant tonotethatthepatient’sbodyshouldslightlylean approxi-mately10◦_{totheaffectedside.Thetrunkshouldalsobetilted} backandthepatientshouldbeaskedtotrytoaccentuatethe

Fig.1–Schematicillustrationrepresentingthefrontal(A) andsuperiorview(B)ofthepatientandthechassis positioning,aswellastheincidenceangleofX-raysforthe modifiedaxillaryradiograph.

thoracickyphosis.Interestingly,thislateralinclinationofthe trunk, withaccentuationofthe thoracickyphosis, is natu-rallyadoptedbymostpatientssufferingfromglenohumeral dislocationwhenseated,whichmakestheexameasierand lesspainfulforthepatientasitrespectsthenaturalantalgic position.

Case

report

rev bras ortop.2017;52(1):115–118

117

Fig.2–Frontal(A)andlateral(B)photographsofthepatient fortheradiographicSennaposition.

reportedseverepainatanymanipulationoftheaffectedlimb. Theneurovascularexaminationoftheupperlimbswas unal-tered.Giventhe suspecteddislocationoftheglenohumeral joint,twoX-raysoftheleft shoulder,inorthogonalplanes, werenecessary.Inadditiontotheanteroposterior radiogra-phy, a modified axillary view (in the Senna position) was alsoobtained(Fig.2).Thelatterclearlyevidencedananterior glenohumeraldislocation.Thepatientunderwentsuccessful closedreductionthroughtractionandcountertraction.After reduction,anewradiographinSennapositionwasobtained,

Fig.3–Radiographsbeforereduction(A)andafterreduction (B)oftheglenohumeraldislocationofthepatientinFig.2.

whichconfirmedtheconcentricjointreduction(Fig.3).The patientwasthenimmobilizedwithaVelpeaushouldersling andreferredtooutpatienttreatment.

Final

remarks

The present modified axillary incidence was shown to be easytoperform,withminimaldiscomforttothepatient.The obtainedimagesclearlyevidenced theanatomical relation-shipbetweenthehumeralheadandglenoidcavityinanaxial view,andallowedforthesafeassessmentofglenohumeral dislocationanditsreduction.

Conflicts

of

interest

Theauthorsdeclarenoconflictsofinterest.

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2.RoweC,ZarinsB.Chronicunreduceddislocationofthe shoulder.JBoneJtSurgAm.1982;64(4):494–505. 3.NeerCS2nd.Displacedproximalhumeralfractures.I.

Classificationandevaluation.JBoneJtSurgAm. 1970;52(6):1077–89.

4.JensenKL,RockwoodCAJr.Radiographicevaluationof shoulderproblems.In:RockwoodCAJr,MatsenFA3rd,Wirth

MA,LippittSB,editors.Theshoulder.Philadelphia:Saunders Elsevier;2004.p.188.

5.BloomMH,ObataWG.Diagnosisofposteriordislocationofthe shoulderwithuseofVelpeauaxillaryandangle-up

roentgenographicviews.JBoneJtSurgAm.1967;49(5):943–9. 6.CleavesEN.Anewfilmholderforroentgenexaminationsof