5. An arthrogram is a test using X-rays to
obtain a series of pictures of a joint
after a contrast material (such as a
dye, water, air, or a combination of
these) has been injected into the joint.
Impingement Syndrome
• common cause of shoulder pain
• impingement of tendons or bursa from bones or spurs
• Overhead activity, repeated activity, is a risk factor (painting,
lifting, swimming, tennis, and other overhead sports)
• can lead to bursitis, rotator cuff tendinitis and tear.
7. Complex Regional Pain Syndrome (CRPS)
(Reflex sympathetic dystrophy/ shoulder-hand syndrome)
• intense burning pain,
stiffness, swelling, and
discoloration (all may
or may not be present)
• exaggerated response
to a traumatic lesion
or nerve damage
• stroke, spinal lesion,
neck Sx or myocardial
infarction
• 1/3rd – cause unknown
9. Osteomyelitis
• Acute hematogenous
osteomyelitis common in
the shoulder in children
(also seen in adults – esp.
arthroplasty)
• Metaphysis prone to
bacterial implantation
(rich blood supply,
sluggish flow)
• Confounding labs: WBC,
ESR unreliable
• X-rays positive much later
10. Osteomyelitis vs. Cellulitis
Osteomyelitis
3-phase 99mTc – MDP bone imaging
shows increasing tracer accumulation
that becomes focal in the delayed phase.
Cellulites
Multiphase bone imaging presents as
a diffusely increased soft tissue and
bony activity in early phases, with
decreasing activity on later phases
11. Fig 2. Infantile and adult osteomyelitis:
(A) Anterior delayed static image and
(B) Posterior static image. Febrile infant with
negative plain radiographs protecting left
upper extremity. Diffuse uptake in humeral
shaft with photopenic defect in humeral head.
(Just above arrow) is a common manifestation
of osteomyelitis in neonates and infants,
(C) (D) Anterior and posterior static images
of humeral head osteomyelitis in an adult,
Diffuse increase uptake (Arrow).
Osteomyelitis: Adult vs. Child
13. WBC imaging: Fever of Unknown Origin
(A) Anterior and (B) Posterior image of
shoulder. Marked aeeumulation of labeled
WBCs around shoulder (Arrow), (C) CT Scan--
shows fluid in and around shoulder
(Arrowheads) with soft tissue inflammation.
Fig 3. Shoulder
Abscess--Indium 111
WBC scan: Elderly
bedridden patient
undergoing evaluation
for fever of unknown
origin.
14. Stress Fractures - Humerus
Ringmans lesion
• Cortical desmoid like lesion in the proximal
humerus (esp. in gymnasts)
• Seen in antero-lateral aspect at pectoralis
major tendon insertion site
15. Posttraumatic Myositis Ossificans
• Seen in contact sports (eg.
karate)
• Early x-rays –ve, w/ soft
tissue mass corresponding
to hard palpable mass in
area of pain.
• Pain relief by Sx removal of
heterotopic bone
• TPBS used to age lesion/
confirm maturation.
Radiograph of the humerus, taken 6
weeks after injury, denoting
maturing myositis ossificans with
increased peripheral mineralization
16. Avascular Necrosis (AVN)
• interruption of blood supply
to bone edema
intraosseous pressure
• Most common: Sickle cell
disease AVN of humeral
head
• Other reasons: traumatic
interruption of blood
supply, fat embolism, lupus
vasculitis, and radiation
osteonecrosis.
• Photopenic defects in bone
scintigraphs (recent infarcts)
• MRI preferred
17. Fractures &
Non-Union of Fracture
Better prognosis
Nonunion of humeral neck
fracture: (A) Oblique
delayed static view shows
increased uptake at site of
nonunion, reactive type.
(Atopic photopenic)
18. Osteoid Osteoma
• Relatively common
• Benign bone tumor in
adolescents and
young adults
• Presented with pain
• Majority seen in
diaphysis of long
bones
• Hot central nidus with
cooler periphery on
TPBS
Osteoid osteoma of
humeral shaft in a
young adult male: (A)
Blood pool image.
Moderate hyperemia,
with a central round
focus of more intense
uptake. (B) Delayed
static image-- focal
intense increased
uptake. (C)(D) Plain
radiograph and CT
scan show cortical
sclerosis and focal
lucency. Definite nidus
not visualized.
19. Overuse Elbow Injuries
Osteochondritis Dissecans (OCD)
• Results from
repetitive
compressive force
between radial
head and
capitellum.
• most frequent
site is capitellum
of elbow
• If untreated, may
lead to loose
intraarticular
bodies, loss of
motion, and
locking and
clicking
20. • Overuse at
the margin of
extensor carpi
radialis brevis
muscle
Overuse Elbow Injuries
Lateral Epicondylitis (Tennis elbow)
Medial Epicondylitis:
Delayed static image
shows focal increased
uptake in medial
epicondyle. Plain
radiographs negative.
21. Overuse Elbow Injuries
Medial Epicondylitis (Golfer’s elbow)
• Secondary to
overuse at the
insertion of flexor
and pronator
muscle groups
22. Stress fracture
• Occult fracture: fracture with or without
trauma
Occult radial head fracture: Normal
elbow x-ray films following injury
with persistent pain
(A) Blood pool images shows
focal hyperemia left radial head
(Arrowhead). Injection site in
right antecubital fossa, partially
shielded. (B) Delayed static
image anterior with intense uptake
(Arrow). (C) Delayed lateral
shows focal uptake in radial head
(Arrow).
Ulnar Stress Fractures: (A) Delayed static images show
bilateral mid-ulnar shafts stress fractures in a weight
lifter, less focally fusiform than usually seen in shafts of
long bones. (B) Ulnar styloid avuision fracture delayed
static image shows focal uptake at styloid process.
23. Stress Fracture
Radial & Ulnar styloid avulsion fracture
• Involves the
brachioradialis tendon
insertion at the styloid
process of radius
• Small bone fragments
not visible in x-ray
Delayed static dorsal
projection shows focal
increased uptake at site
of avulsion (Arrow).
