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Diagnostic imaging of the shoulder - Chris Roberts
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Diagnostic imaging of the shoulder - Chris Roberts

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  • 1. Imaging and Patient Selection Mr Chris Roberts Ipswich Hospital Watanabe Club York 2010
  • 2. NB• You must know – How to take x-ray views – What MRI sequences – What CT views• The result of the investigation must affect patient management• Don’t order an investigation for the sake of it
  • 3. Why investigate?• Diagnosis – Do we need to operate?• Informed consent• Patient planning• List planning – Positioning – Timing
  • 4. Which imaging modality?• Likely diagnosis• Cost• Availability• Access• Expertise
  • 5. Imaging modalities• X-ray• Ultrasound• CT• MRI• Arthrography
  • 6. Plain radiography• AP shoulder – Beam perpendicular to body – Commonest view – Good view of ACJ – Poor view of GHJ
  • 7. Plain radiography• AP GHJ – Beam perpendicular to scapula – Good view GHJ – Poor view ACJ
  • 8. Plain radiography• Scapular lateral – Perpendicular to AP GHJ view – Conirms enlocation GHJ – Alignment for fractures
  • 9. Plain radiography• Outlet view – As for scapular lateral but beam tipped caudally 10 degrees – Acromial morphology – Guide to decompression – Localise lesions
  • 10. Plain radiography• Axillary view – Good view of GHJ space – Eccentric erosion – Bone lesions – Os acromiale
  • 11. Plain radiography• Modified axillary views – Post trauma
  • 12. Plain radiography• Bernageau view – Anterior glenoid bone loss
  • 13. MRI• Imaging is performed in three planes relative to glenohumeral joint• Typical sequences • Coronal oblique T1 and T2 spir • Sagittal oblique T2 • Axial Watts (T2 fat suppressed) • Axial T1 in instability• Difficult for large patients – not central in bore
  • 14. MRI• Coronal oblique – Supra and infraspinatus tendons – Subacromial space – A-C joint – Superior labrum – Biceps tendon – Subscapularis
  • 15. MRI• Sagittal oblique – Rotator cuff • Tendons • Muscle atrophy – Acromial morphology – Glenoid
  • 16. MRI• Axial plane – Biceps tendon – Glenoid labrum • Bankart lesion – Subscapularis attachment
  • 17. Common Pathology• Rotator cuff disease• Biceps tendon• Glenoid labrum• Bony lesion
  • 18. Rotator Cuff• Partial thickness – Articular surface – Bursal surface• Full thickness – Size – Tendon retraction – Muscle atrophy
  • 19. Rotator Cuff
  • 20. Rotator Cuff
  • 21. Rotator Cuff
  • 22. Bony Lesions
  • 23. Instability• Hill-Sach’s lesions• Anterior labral tears – Bankart lesion
  • 24. Other lesions• Cysts
  • 25. MR arthrography• Anterior labral lesions
  • 26. MR arthrography• SLAP lesion
  • 27. MR arthrography• HAGL lesion
  • 28. CT scans• Axial images• Coronal and sagittal reconstructions relative to plane GHJ• Quantifying bone lesions
  • 29. CT scans• 3D reconstructions
  • 30. Ultrasound• Soft tissue imaging – Coronal and sagittal views – SST, IST and SBSC – Intratendinous lesions – Muscle atrophy – Not labrum – Very user dependent – Static images not very useful
  • 31. Ultrasound• Cuff tears
  • 32. Ultrasound• Calcium
  • 33. Ultrasound• Effusions
  • 34. Arthrography
  • 35. How I image for cuff pathology• Impingement – Xrays: AP, outlet and axillary• Impingement vs Sml cuff tear – Add USS• Large/massive cuff tear – Add MRI
  • 36. How I image for instability• Atraumatic – Xray AP shoulder• Traumatic anterior – Xrays: AP and Bernegeau – If bone lesion or contact sportsperson add CT• NB beware the HAGL
  • 37. Case 1• 43 y.o. female• Painful arc• Full movement passively• Cuff strong on testing
  • 38. Case 2• 55 y.o. man• Painful arc, night pain• No cuff wasting• Full active movement• Cuff painful and weak on testing
  • 39. Case 3• 55 y.o. man• Painful arc, night pain• Cuff wasted• Restricted active but full passive range• Cuff painful and weak on testing• Positive drop arm and Hornblowers
  • 40. Case 4• 75 y.o. man• Painful arc, night pain• Cuff wasted• Restricted active but full passive range• Cuff painful and weak on testing• Positive drop arm and Hornblowers
  • 41. Case 5• 29 year old sedentary worker• 3rd traumatic anterior shoulder dislocation• No sports
  • 42. Case 6• 23 year• 3rd traumatic anterior shoulder dislocation• Professional rugby player