Diagnostic imaging of the shoulder - Chris Roberts

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Diagnostic imaging of the shoulder - Chris Roberts

  1. 1. Imaging and Patient Selection Mr Chris Roberts Ipswich Hospital Watanabe Club York 2010
  2. 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. 3. Why investigate?• Diagnosis – Do we need to operate?• Informed consent• Patient planning• List planning – Positioning – Timing
  4. 4. Which imaging modality?• Likely diagnosis• Cost• Availability• Access• Expertise
  5. 5. Imaging modalities• X-ray• Ultrasound• CT• MRI• Arthrography
  6. 6. Plain radiography• AP shoulder – Beam perpendicular to body – Commonest view – Good view of ACJ – Poor view of GHJ
  7. 7. Plain radiography• AP GHJ – Beam perpendicular to scapula – Good view GHJ – Poor view ACJ
  8. 8. Plain radiography• Scapular lateral – Perpendicular to AP GHJ view – Conirms enlocation GHJ – Alignment for fractures
  9. 9. Plain radiography• Outlet view – As for scapular lateral but beam tipped caudally 10 degrees – Acromial morphology – Guide to decompression – Localise lesions
  10. 10. Plain radiography• Axillary view – Good view of GHJ space – Eccentric erosion – Bone lesions – Os acromiale
  11. 11. Plain radiography• Modified axillary views – Post trauma
  12. 12. Plain radiography• Bernageau view – Anterior glenoid bone loss
  13. 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. 14. MRI• Coronal oblique – Supra and infraspinatus tendons – Subacromial space – A-C joint – Superior labrum – Biceps tendon – Subscapularis
  15. 15. MRI• Sagittal oblique – Rotator cuff • Tendons • Muscle atrophy – Acromial morphology – Glenoid
  16. 16. MRI• Axial plane – Biceps tendon – Glenoid labrum • Bankart lesion – Subscapularis attachment
  17. 17. Common Pathology• Rotator cuff disease• Biceps tendon• Glenoid labrum• Bony lesion
  18. 18. Rotator Cuff• Partial thickness – Articular surface – Bursal surface• Full thickness – Size – Tendon retraction – Muscle atrophy
  19. 19. Rotator Cuff
  20. 20. Rotator Cuff
  21. 21. Rotator Cuff
  22. 22. Bony Lesions
  23. 23. Instability• Hill-Sach’s lesions• Anterior labral tears – Bankart lesion
  24. 24. Other lesions• Cysts
  25. 25. MR arthrography• Anterior labral lesions
  26. 26. MR arthrography• SLAP lesion
  27. 27. MR arthrography• HAGL lesion
  28. 28. CT scans• Axial images• Coronal and sagittal reconstructions relative to plane GHJ• Quantifying bone lesions
  29. 29. CT scans• 3D reconstructions
  30. 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. 31. Ultrasound• Cuff tears
  32. 32. Ultrasound• Calcium
  33. 33. Ultrasound• Effusions
  34. 34. Arthrography
  35. 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. 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. 37. Case 1• 43 y.o. female• Painful arc• Full movement passively• Cuff strong on testing
  38. 38. Case 2• 55 y.o. man• Painful arc, night pain• No cuff wasting• Full active movement• Cuff painful and weak on testing
  39. 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. 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. 41. Case 5• 29 year old sedentary worker• 3rd traumatic anterior shoulder dislocation• No sports
  42. 42. Case 6• 23 year• 3rd traumatic anterior shoulder dislocation• Professional rugby player

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