Orthopedics

Tips & Techniques 

The Wheelchair Axillary View of the Shoulder

Howard Routman, DO

Abstract

The wheelchair axillary view of the shoulder allows a good image to be obtained in the seated position, and it can be used in the nonambulatory or multiply injured patient.

The axillary view of the glenohumeral joint was first described in 1915 by Lawrence.1,2 The view has since become critical for the clinician who is evaluating the injured or unstable shoulder. Many authors have reported on the importance of the axillary view, particularly for identifying posterior dislocations and fracture configurations.3-5 Additionally, the axillary view is the most valuable plain radiograph for evaluating glenohumeral joint surfaces for consideration of shoulder arthroplasty.6

Frequently, the office environment can be a difficult place to obtain an axillary view of good technical quality. A patient with an acute injury seldom can abduct the glenohumeral joint for the standard axillary view. The Velpeau axillary view7 requires thoracic and lumbar spine flexibility and truncal stability that may not be possible in the elderly patient. The trauma axillary view8 can be uncomfortable to perform, and requires a radiograph room with compound angle capability (Figure 1).

Figure 1: Illustrations show the standard (A), Velpeau (B), and trauma (C) axillary views of the shoulder.

A new technique has been developed for obtaining an axillary view in the elderly, injured, and noninjured patient who does not require supine positioning or the ability to lean back over the edge of the radiograph table. This view also can be obtained if the patient is wheelchair-bound. This radiographic view has become a useful tool in the evaluation of shoulder disorders.

The patient is positioned in a wheelchair at the edge of the radiograph table with a bolster behind the back to maintain upright posture and tilt the patient slightly forward. The cassette is placed on the arm of the wheelchair, and the patient leans forward into the cassette with slight abduction of the affected arm. The patient uses the opposite hand to stabilize the cassette, and the head is typically anterior to the shoulder joint. The beam passes from above the patient’s head with a 20°-30° lateral angle of the beam (Figure 2). Excellent views can be obtained with a relatively short learning curve for the radiograph technician (Figure 3).

Figure 2: Patient positioning for the anterior (A), posterior (B), and lateral (C) wheelchair axillary view. The patient is supporting the cassette on the arm of the wheelchair.

Figure 3: Radiograph obtained using the wheelchair axillary view
Figure 3: Radiograph obtained using the wheelchair axillary view.

Axillary views of the shoulder can be taken with the patient in the supine, prone, or upright position. Flat or curved cassettes can be used to obtain the image.9 The Velpeau axillary view is an upright technique that requires the patient to lean back over the radiograph table and cassette. With this view, the patient must have both the ability to stand and the balance and flexibility to maintain the position. The “wheelchair axillary view” technique allows a good image to be obtained in the seated position, and it can be used in the nonambulatory or multiply injured patient. It also is possible to obtain this view in a standard chair with the cassette on the edge of the radiograph table, but the height of a wheelchair armrest is ideal for positioning.

We have been using this technique since 2002, when a posterior dislocation was suspected in an elderly patient in a wheelchair was sent to our office with oblique radiographic views taken elsewhere that suggested a posterior dislocation. With one wheelchair axillary view image, we were able to exclude this diagnosis.

Dr Routman is from Palm Beach Shoulder Service, Atlantis Orthopaedics, Atlantis, Fla.

The author thanks…

The wheelchair axillary view of the shoulder allows a good image to be obtained in the seated position, and it can be used in the nonambulatory or multiply injured patient.

The axillary view of the glenohumeral joint was first described in 1915 by Lawrence.1,2 The view has since become critical for the clinician who is evaluating the injured or unstable shoulder. Many authors have reported on the importance of the axillary view, particularly for identifying posterior dislocations and fracture configurations.3-5 Additionally, the axillary view is the most valuable plain radiograph for evaluating glenohumeral joint surfaces for consideration of shoulder arthroplasty.6

Frequently, the office environment can be a difficult place to obtain an axillary view of good technical quality. A patient with an acute injury seldom can abduct the glenohumeral joint for the standard axillary view. The Velpeau axillary view7 requires thoracic and lumbar spine flexibility and truncal stability that may not be possible in the elderly patient. The trauma axillary view8 can be uncomfortable to perform, and requires a radiograph room with compound angle capability (Figure 1).

Figure 1A: Illustration shows the standard axillary view of the shoulder

Figure 1B: Illustration shows the Velpeau axillary view of the shoulder

Figure 1C: Illustration shows the trauma axillary view of the shoulder

Figure 1: Illustrations show the standard (A), Velpeau (B), and trauma (C) axillary views of the shoulder.

A new technique has been developed for obtaining an axillary view in the elderly, injured, and noninjured patient who does not require supine positioning or the ability to lean back over the edge of the radiograph table. This view also can be obtained if the patient is wheelchair-bound. This radiographic view has become a useful tool in the evaluation of shoulder disorders.

Technique

The patient is positioned in a wheelchair at the edge of the radiograph table with a bolster behind the back to maintain upright posture and tilt the patient slightly forward. The cassette is placed on the arm of the wheelchair, and the patient leans forward into the cassette with slight abduction of the affected arm. The patient uses the opposite hand to stabilize the cassette, and the head is typically anterior to the shoulder joint. The beam passes from above the patient’s head with a 20°-30° lateral angle of the beam (Figure 2). Excellent views can be obtained with a relatively short learning curve for the radiograph technician (Figure 3).

Figure 2A: Patient positioning for the anterior wheelchair axillary view

Figure 2B: Patient positioning for the posterior wheelchair axillary view

Figure 2C: Patient positioning for the lateral wheelchair axillary view

Figure 2: Patient positioning for the anterior (A), posterior (B), and lateral (C) wheelchair axillary view. The patient is supporting the cassette on the arm of the wheelchair.

Discussion

 

Figure 3: Radiograph obtained using the wheelchair axillary view
Figure 3: Radiograph obtained using the wheelchair axillary view.

Axillary views of the shoulder can be taken with the patient in the supine, prone, or upright position. Flat or curved cassettes can be used to obtain the image.9 The Velpeau axillary view is an upright technique that requires the patient to lean back over the radiograph table and cassette. With this view, the patient must have both the ability to stand and the balance and flexibility to maintain the position. The “wheelchair axillary view” technique allows a good image to be obtained in the seated position, and it can be used in the nonambulatory or multiply injured patient. It also is possible to obtain this view in a standard chair with the cassette on the edge of the radiograph table, but the height of a wheelchair armrest is ideal for positioning.

We have been using this technique since 2002, when a posterior dislocation was suspected in an elderly patient in a wheelchair was sent to our office with oblique radiographic views taken elsewhere that suggested a posterior dislocation. With one wheelchair axillary view image, we were able to exclude this diagnosis.

References

  1. Lawrence WS. New position in radiographing the shoulder joint. AJR Am J Roentgenol. 1915; 2:728-730.
  2. Lawrence WS. A method of obtaining an accurate lateral roentgenogram of the shoulder joint. AJR Am J Roentgenol. 1918; 5:193-194.
  3. Hawkins RJ, Neer CS II, Pianta RM, Mendoza FX. Locked posterior dislocation of the shoulder. J Bone Joint Surg Am. 1987; 69:9-18.
  4. Horsfield D, Jones SN. A useful projection in radiography of the shoulder. J Bone Joint Surg Br. 1987; 69:338.
  5. Sidor ML, Zuckerman JD, Lyon T, Koval K, Schoenberg N. Classification of proximal humerus fractures: The contribution of the scapular lateral and axillary radiographs. J Should Elbow Surg. 1994; 3:24-27.
  6. Neer CS II. Glenohumeral arthroplasty. In: Neer CS II, ed. Shoulder Reconstruction. Philadelphia, Pa: WB Saunders; 1990:143-271.
  7. Bloom MH, Obata WG. Diagnosis of posterior dislocation of the shoulder with the use of the Velpeau axillary and angle up roentgenographic views. J Bone Joint Surg Am. 1967; 49:943-949.
  8. Teitge RA, Ciullo JV. The CAM axillary xray. Orthop Tran. 1982; 6:451.
  9. Cleaves EN. A new film holder for roentgen examination of the shoulder. AJR Am J Roentgenol. 1941; 45:88-90.

Author

Dr Routman is from Palm Beach Shoulder Service, Atlantis Orthopaedics, Atlantis, Fla.

The author thanks Sandy Segal, RT for assistance with this technique and Carol Capers for the illustrations.

Correspondence should be addressed to: Howard Routman, DO, Palm Beach Shoulder Service, Atlantis Orthopaedics, 130 JFK Dr, Ste 201, Atlantis, FL 33462.

10.3928/01477447-20070401-18

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