Javascript not enabled
Shoulder and ElbowFurther Opinion

Use of the fulcrum axis improves the accuracy of true anteroposterior radiographs of the shoulder

V Braunstein, C Kirchhoff, B Ockert, CM Sprecher, M Korner, W Mutschler, E Wiedemann, P Biberthaler

J Bone Joint Surg [Br] 2009;91-B:1049-53.


This paper at first sight would seem to be a no more than a simple ‘yet another’ method of taking a plain film of the shoulder. There are already plenty of views described for plain films of the shoulder, to the extent that most departments will have a strict protocol requiring any additional views to be specially requested.  Clinicians are under increasing pressure to reduce exposure to radiation, and other scanning methods give far more information with regard to soft tissues. Why then, does this paper justify a further opinion?

The standard anterior-posterior view of the shoulder is used to determine the congruity of the joint and the joint space. Ideally, the glenoid articular rims should be superimposed. This standard view is often poorly performed, in which case any orthopaedic surgeon will struggle to interpret the film. Most surgeons will require at least a second view to gauge congruity and joint space. Despite this, the number of missed shoulder dislocations, particularly posterior, is unacceptable. There is a reluctance from radiographers to undertake further views, citing difficulties in obtaining axillary views and patient distress.1 The rate for missed posterior dislocation is as high as 79%.2-4 The missed diagnosis results in extra surgery, poorer outcome and unwelcome litigation and expense.

In addition, when assessing glenohumeral joint arthritis, the degree of joint spacing narrowing is fundamental. A poor AP view is unhelpful to say the least.

The technique described is simple, uses easily identifiable landmarks and shows no requirement for a learning curve. Despite using the best possible method for conventional views, the use of the fulcrum axis technique demonstrates a dramatic improvement in accuracy for the standard AP view of the glenohumeral joint.

This newly described technique, if adopted widely, could see a sudden drop in the number of missed dislocations, a far more accurate assessment of glenohumeral joint space narrowing and, one suspects far less irradiation of patients from repeated attempts by a radiographer to get a ‘better’ view. If these results are reproduced in other institutions, the impact in terms of clinical practice, patient care and health economics could be enormous.

Every orthopaedic surgeon with a trauma or upper limb practice should read this paper and try the method for themselves, I will certainly be discussing it with my radiology and accident and emergency colleagues.


1. Espag MP, Back DL, Baroni M, Bennett AR, Peckham TJ. Diagnosing shoulder dislocations: time for a change of view. Ann Royal Coll Surg Eng 2002;84:334-7.
2. Mestdagh H, Maynou C, Delobelle JM, Urvoy P, Butin E. Traumatic posterior dislocation of the shoulder in adults: apropos of 25 cases. Ann Chir 1994;48:355-63.
3. Hawkins RJ, Neer CS, Pianta RM, Mendoza FX.  Locked posterior dislocation of the shoulder. J Bone Joint Surg [Am] 1987;69-A:9-18.
4. Rowe CR, Zarins B. Chronic unreduced dislocations of the shoulder. J Bone Joint Surg [Am] 1982:64-A:494-505.


Hackney R, FRCS (Orth), FFSEM, Consultant in Trauma and Orthopaedics, Honorary Senior Lecturer

Leeds General Infirmary, Leeds, United Kingdom