Diagnostic imaging of the shoulder - Chris Roberts
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1. When ordering imaging for shoulder pathology, it is important to understand the clinical question and how the results may impact patient management. 2. Different imaging modalities have advantages and disadvantages for evaluating various shoulder conditions. Plain radiographs are useful initial tests but MRI, ultrasound, CT and arthrography provide additional information in certain cases. 3. Common shoulder pathologies include rotator cuff tears, labral tears, bony lesions, and instability. The appropriate imaging tests depend on factors like the suspected diagnosis, cost, availability, and expertise required.
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Diagnostic imaging of the shoulder - Chris Roberts
- 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
- 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
- 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