The Swimmers View

Introduction

The swimmers view of the cervico-thoracic junction is the bane of the trauma radiographer. The increasing use of CT scanning to asses the cervical spine in trauma patients has reduced (and in some cases eliminated) the reliance on the swimmers view to demonstrate the cervico-thoracic junction in the lateral projection.

The swimmers view is one of those views that has the worst of everything
  • High dose
  • High scatter
  • Difficult positioning
  • Doesn't work well on large patients or patients with shoulder injuries
  • Often performed under pressure
  • Important anatomy

The swimmers view is one of those signature views for trauma radiographers- we all have our own techniques that we swear by. My experience is that all of the techniques work, and all of them don't work. I think that the true difficulty with this view is that it is difficult to assess a patient and be sure which technique will work- at times apparently defying all logic. When searching for the ultimate 100% reliable technique, you will think that you have found it, and then it will let you down.

One glimmer of hope is that CT scanning has become an increasingly popular technique for imaging cervical spine trauma. I have an increasingly low threshold for approaching the referring doctor to request CT scanning of the cervico-thoracic junction if I consider that the swimmers view is likely to fail. One disadvantage of using CT to clear a trauma spine is that it entails a higher radiation dose to the patient.

This page considers a variety of swimmers and swimmer-like techniques in no particular order.



Technique 1- Arms Forward
swimers 1
The swimmers view is all about getting the humeral heads out of the way. It is usually the humeral heads that obscure the cervico-thoracic junction. This technique involves moves both humeral heads anteriorly. This can be achieved by having the patient cross their arms in front of them or by holding onto a bar attached to the upright bucky. This technique is typically successful on patients who have flexibility in their shoulders. Having said that, it is difficult to be sure if this technique will be successful just by looking at a patient. The example above is a case in point- this is a swimmers on a broad shouldered man.

Note that one of the humeral heads is overlying the spine. In some patients both humeral heads can be moved clear of the spine. This image was taken using film/screen technology. A breathing technique has been employed to blur lung markings. A round cone has been utilized to reduce scatter radiation.



Technique 2- Arm-up, Arm-down
swimmers
This version of the swimmers achieves an unobscured lateral view of the cervico-thoracic junction by positioning one arm up and one arm down. In terms of demonstrating the anatomy, it doesn't matter which arm is raised and which is pulled down. Some radiographers try to raise the right arm (when the patient is in the left lateral position) to reduce the radiation dose to the patient's thyroid. A sponge under one shoulder can help to separate the humeral heads.

One of the flaws of this technique is that you tend to laterally flex the patient. This causes a loss of visualisation of the joint spaces.


Technique 3- The Arm Pull
Swimmers 2
 swimmers 4



This technique is sometimes utilised when you have come tantalisingly close to demonstrating the anatomy of interest, but not quite met the criteria. The idea is that if you can just get the shoulders down a little more, you will achieve a clear view of the vertebra that is obscured by the humeral head(s). The case above successfully uses this technique. This may, in reality, be much the same as the first technique given that the shoulders tend to roll forwards when pulled down.

Caution:
It is not considered acceptable practice in many institutions to arm-pull in patients with cervical trauma. This is now the case in my institution. A "ski rope" technique can be used in which the patient pulls their own arms down.



Technique 4- The Supine Lateral
Lateral Thoracic Spine Special Technique - wikiRadiography

This technique can be used in patients who do not have an acute injury and can lie on their sides. The position is very similar to a lateral thoracic spine position, except that the arm that is up (away from the table) is rolled posteriorly. One benefit of this position is that you can also include the whole of the thoracic spine in a single exposure.

Breathing technique can be used to great advantage

The patient often ends up slightly off lateral. I doubt that you are likely to miss a finding because the patient is a few degrees off true lateral.

Issues

 1. Coning
Radiologists have complained to me that they need to see C1 or C2 on the swimmers image so that they can count down and positively establish which levels have been imaged. The difficulty I have with this suggestion is that the image will be degraded by scatter radiation if I cone out. Of course, patient dose will also increase. It is not difficult to establish whether the area of interest is covered by considering the position of the first rib (although, this is not easy sometimes). If the area of interest is covered, and it appears normal, it becomes an academic exercise to establish extacly which normal vertebra are covered. Furthermore, in the majority of cases, there are characteristics of individual vertebral bodies that enable level identification on the swimmers image. For example, if C6 has a large anterior osteophyte, you will be able to establish which vertebra is C6 on the swimmers image. If there is an abnormality, the patient will likely proceed to CT.

A round cone is useful in reducing scatter radiation and can be used to standardise coning in an imaging department.


Discussion

 It is now widely considered best practice to never pull on a patient's arm(s) who has sustained a cervical spine injury.

The swimmers view will test any trauma radiographer. If anyone has developed a technique that works every time, please post it on this wiki.






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M.J.Fuller
M.J.Fuller 		Latest page update: made by M.J.Fuller , Jul 20 2008, 3:40 PM EDT (about this update About This Update M.J.Fuller Edited by M.J.Fuller

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Jamoix Swimmer's View 1 Oct 14 2008, 4:09 AM EDT by Anonymous
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Always raise the arm which is closest to the x-ray tube, this reduces thyroid dose and acts as a filter 'hardening' the beam BEFORE entering the patient. Therefore any photons which pass the patients midline are photons you want to reach the cassette/image plate.The only thing that raising the arm closest to the image plate will do is degrade or reduce useful information reaching the plate.
Modern practice is that any patient presenting with significant C.spine trauma should proceed to CT following a single cross table lateral view, and in some cases even this is not done. If the patient is intubated an AP and Peg views are ruled out and even if C7/T1 is demonstrated most physicians would still ask for CT.
Low kV high(er) mAs technique is also essential in the production of good images. Radiographers who use kVs of above 85 have forgotten how the image production process and human anatomy work.
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Keyword tags: c.spine Low kV Swimmers view trauma (edit keyword tags)
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