X-ray Ordering for Left Upper Back Near the Neck/Shoulder Junction
For imaging the left upper back near the neck/shoulder junction, order a minimum of three radiographic views: anteroposterior (AP), lateral, and oblique views, with consideration of an additional "swimmer's lateral view" if the cervicothoracic junction is not adequately visualized. 1
Standard Radiographic Views Required
- Anteroposterior (AP) view - provides the most comprehensive initial assessment, detecting approximately 88% of injuries in the shoulder and upper back region 2
- Lateral view - essential for visualizing the cervicothoracic junction and scapular body/coracoid process 1
- Oblique view - complements the AP view by revealing injuries that might be missed, particularly for the sternoclavicular region 3, 2
- Consider adding a "swimmer's lateral view" if the cervicothoracic junction is not visible on the conventional lateral radiograph 1
Special Considerations for Neck/Shoulder Junction
- For the cervicothoracic junction specifically, ensure visualization includes the C7-T1 region, which may require the additional swimmer's view 1
- If sternoclavicular involvement is suspected, consider a Rockwood view (upright 30° angled caudad radiograph) to better visualize this region 3
- For comprehensive shoulder evaluation, include both internal and external rotation AP views to assess for potential glenohumeral pathology 3, 4
When Additional Imaging May Be Necessary
- If radiographs are negative but clinical suspicion remains high, CT is significantly more sensitive than radiographs for identifying fractures, with radiographs depicting only about one-third of fractures visible on CT 1
- MRI should be considered if there are neurologic signs or symptoms, as it is superior for identifying soft-tissue injuries 1
- For patients with trauma history, the apical oblique view (45° posterior oblique with 45° caudal angulation) may provide additional valuable information, detecting up to 81% of injuries and uniquely identifying certain pathologies like glenoid rim fractures 4
Common Pitfalls to Avoid
- Inadequate visualization of the cervicothoracic junction is a common error - always ensure this region is properly imaged 1
- Relying solely on AP views is insufficient - multiple projections at right angles to each other are necessary for comprehensive evaluation 2, 5
- Flexion-extension views are often inadequate for assessing cervical instability and rarely demonstrate instability not identified on conventional radiographs 1
- Over-utilization of radiographs occurs frequently - consider clinical findings such as deformity or history of fall when determining necessity 6