Imaging of shoulder - Dr. Vishal Sankpal


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Shoulder imaging

by Dr. Vishal Sankpal
NIMS, Hyderabad,

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Imaging of shoulder - Dr. Vishal Sankpal

  1. 1. Imaging of shoulder Dr. Vishal Sankpal
  2. 2. Abbreviations• SST – supraspinatus• IST – infraspinatus• SSC – subscapularis• TM – teres minor• RTC – rotator cuff• GHL – glenohumeral ligament• IGHL – inferior glenohumeral ligament• GHLC – glenohumeral labral complex• PC – post contrast
  3. 3. IntroductionThe shoulder is one of the most sophisticated andcomplicated joints of the body:• It has the greatest range of motion than any joint in the body• To allow so much movement the joints need to be free to move, therefore the shoulder should be unstable compared to other joints of the body; However a series of complex ligaments and muscle help in stability.
  4. 4. Anatomy
  5. 5. Joints (shoulder complex)
  6. 6. Parts of Synovial Joint• Articulating bones• Synovial membrane• Fibrous capsule• Intra-articular structures (like labrum)• Ligaments• Bursae• Muscles
  7. 7. Glenohumeral Joint– Ball and socket synovial joint– Very mobile– instability– 45% of all dislocations !!– Joint stability depends on multiple factors (static and dynamic stabilizers)
  8. 8. Bones
  9. 9. Fibrous CapsuleLoose for maximum movementsGaps:• Anteriorly: allows communication between synovial membrane and subscapularis bursa.• Posteriorly: allows communication with infraspinatus bursa.Synovial Membrane• Attached around the glenoid labrum.• Lines the capsule.• Attached to articular margins of head of humerus.• Covers intracapsular area of surgical neck.• Communicates with 2 bursae through gaps in capsule.• Invests long head of biceps in a tubular sleeve.• Glides to and fro during adduction and abduction.
  10. 10. Glenoid labrum• Fibrocartilage similar to knee menisci• Deepens the glenoid fossa
  11. 11. Ligaments
  12. 12. Muscles
  13. 13. Bursae• Sac between two moving surfaces that contains a small amount of lubricating fluid• To reduce friction
  14. 14. Acromioclavicular joint• Diarthrodial joint / Gliding synovial joint• Thin capsule• AC ligaments – Anterior, posterior, superior, inferior• Coracoacromial ligament• Coracoclavicular ligaments – Trapeziod ligament – Conoid ligament
  15. 15. Stability• Static stabilizers – glenohumeral ligaments, glenoid labrum and capsule• Dynamic stabilizers – Predominantly rotator cuff muscles and biceps (long head) – Also scapular stabilizers • Trapezius, levator scapulae, serratus anterior, rhomboids
  16. 16. Radiography
  17. 17. Radiography• Initial investigation of choice for all shoulder problems.• Can detect most fractures, dislocations, calcific tendinitis and other skeletal causes of pain such as arthritis and bone tumors• Different situations require different types of plain films (AP/Lateral/Axillary views): – Impingement views in clinically suspected impingement syndrome and/or rotator cuff tears to detect subacromial spur – Axial or anterior oblique views in trauma
  18. 18. AP : Routine view• AP relative to thorax• Suboptimal view of Glenohumeral joint• Good view of AC joint
  19. 19. AP View: External RotationGreater tuberosity & soft tissues profiled and bettervisualized
  20. 20. AP View: Internal RotationMay demonstrate Hill-Sachs lesions
  21. 21. Axillary lateral ViewGood view of anterior-posterior relationship of GH joint
  22. 22. Scapular “Y” Lateral View of the Shoulder• Shoulder impingement: to evaluate the subacromial space and the supraspinatus outlet
  23. 23. Ultrasonography
  24. 24. USG• Preferred initial modality in suspected RTC pathologies• > 90 % sensitive and specific for RTC tears• Comparable to MRI in evaluation of full thickness rotator cuff tears• Bony pathologies not well seen
  25. 25. • Advantages: – no ionizing radiation, – no contrast agent, – relatively inexpensive, – readily available – Dynamic evaluation – Guided aspiration / injection possible• Limitations: – Less sensitive for detecting partial thickness rotator cuff tears – Cannot accurately evaluate the labral-ligamentous complex.
  26. 26. Shoulder USG Protocol (Radiology: Volume 260: Number 1—July 2011 n• Step 1 - Biceps brachii tendon, long head• Step 2 - Subscapularis and biceps brachii tendon, subluxation/dislocation• Step 3 - Supraspinatus and rotator interval• Step 4 - Acromioclavicular joint, subacromial-subdeltoid bursa, and dynamic evaluation for subacromial impingement• Step 5 - Infraspinatus, teres minor, and posterior labrum
  27. 27. Step 1 - Biceps brachii tendon, long head
  28. 28. • Step 2 - Subscapularis Step 2 - Subscapularis
  29. 29. • Step 3 - Supraspinatus Step 3 - Supraspinatus
  30. 30. Step 4 - Acromioclavicular jointDynamic evaluation for subacromial impingement
  31. 31. • Step 5 - Infraspinatus, teres minor, and posterior labrum
  32. 32. CT• Superior to plain radiographs in evaluation of complex fractures and fracture-dislocations involving the head of the humerus• Allows planning of treatment of complex proximal humeral fractures
  33. 33. CT1) Glenoid 9) Teres minor2) Humerus 10) Triceps3) Deltoid 11) Pec major4) Infraspinatus 12) Pec minor5) Scapula 13) Biceps (long)6) Supraspinatus 14) Biceps (short)7) Clavicle 15) Teres major8) Subscapularis 16) Latissimus
  34. 34. MRI
  35. 35. MRI• Highly accurate for evaluation of rotator cuff pathologies• Indicated when further investigation of rotator cuff pathology is needed.• Advantages: – No ionizing radiation – Non-invasive – Multi-planar imaging – Demonstrates other lesions such as ACJ osteoarthritis and avascular necrosis. – Comprehensive display of soft tissue anatomy – Demonstration of the causes for impingement – Useful in characterization and staging of bone tumors
  36. 36. MRI Technique-T1 and T2 FS-Oblique Coronal -T1 and T2 FS -Oblique Sagittal -T2 FS and GRE -Axial
  37. 37. Normal T1 Normal FS T2 Normal FS PD
  38. 38. Rotator Cuff (Sagittal)Supraspinatus; Infraspinatus; Teres Minor; Subscapularis
  39. 39. Rotator Cuff (Coronal)-Primary Plane for Evaluating -Musculotendinous Junction atthe Supraspinatus Tendon 12:00 Position
  40. 40. Rotator Cuff (Axial Plane)-Primary Plane for -InfraspinatusEvaluating Subscapularis Located Posteriorly
  41. 41. Rotator Cuff (Coronal)- Infraspinatus -Subscapularis- Located Posteriorly - Located Anteriorly- Slopes upward - Multi-slip tendon
  42. 42. Arthrography
  43. 43. Arthrography• PREREQUISITES:• Obtain signed consent.• RISKS:• Infection, Pain, Hematoma• MATERIALS:• 22G 3 ½” needle• 25G 1 ½” needle• 5 cc syringe with lidocaine for skin anesthesia• 20 cc syringe with combination of 1% lidocaine• Omnipaque 300• Gadolinium contrast (if performing MR)
  44. 44. Shoulder MR or CT Arthrography• Place the patient supine• Target the junction of the middle and inferior thirds of humeral head just lateral to the medial cortex of humeral head.• Local lignocaine given• Fill a 20 cc syringe with the proper contrast solution and fill connecting tubing being sure to eliminate all bubbles.• Advance a 22 G spinal needle until contact bone at target site.• Pull back 1 mm and turn bevel toward humeral head. Advance and feel the syringe drop into the joint.• MR Arthrogram:• Inject 12 cc of a solution of 5 cc normal saline, 5 cc Omnipaque 300, 10 cc 1% lidocaine, and 0.1 cc gadolinium.• Instruct the patient on the importance of the ABER position and how it can help the surgeon figure out how to fix them.• CT Arthrogram:• Inject 12 cc of a solution of 5 cc normal saline, 10 cc Omnipaque 300, and 5 cc 1% lidocaine• Helical CT should be performed with thinnest slices available, preferably in a single breath hold in both internal and external rotation.
  45. 45. MR arthrography• Most accurate and first line imaging modality for defining: – Rotator cuff pathology – Labral/capsule abnormalities in gleno-humeral instability• Superior depiction of partial-thickness tears compared to conventional MRI.• Disadvantages : invasive, limited availability and high expense.
  46. 46. CT arthrography• Alternative for assessment of gleno-humeral instability (usually following dislocation) only when MRI is contraindicated or unavailable• Allows accurate evaluation of capsule / labral disorders• Disadvantage – invasive, radiation
  47. 47. Shoulder Pathologies
  48. 48. Pathologies• Rotator Cuff• Biceps tendon• Labrum and capsule• Osseous structures• Arthritis• Neural impingement• Tumors• Miscellaneous
  49. 49. Rotator cuff• Tendinopathy• Partial tears• Full thickness tears• Calcific tendinitis• Parsonage Turner syndrome
  50. 50. Rotator cuff tendinopathyAlso known as -• Rotator cuff tendinosis• Definition – collagenous degeneration of rotator cuff tendons, most commonly supraspinatus (SST)
  51. 51. Radiographic findings• Acromial remodeling / sclerosis• AC joint hypertrophy• Humeral head subchondral sclerosis / cysts
  52. 52. MRI• T1W – thickened heterogeneous tendons with intermediate signal intensity• T2W – low to intermediate signal• FS PD and STIR – heterogeneous tendons with increased signal intensity – Hyperintense effusion (glenohumeral joint) – Hyperintense bursitis ( subacromial / subdeltoid )• Type III (hooked) acromion• MR arthrography – no cuff defect identified
  53. 53. HRUS• Thickened hypoechoic• Tears directly visible• Less sensitive for partial thickness tears• Advantage – allows dynamic evaluation with pain correlation
  54. 54. Differentials• Partial tear – – T2 (without fat sat) shows diminished / intermediate signal intensity in tendinosis as compared to a hyperintensity of a true cuff tear• Calcific tendinitis – – thickened tendon with decreased signal on all sequences – Form of tendinopathy – Hyperintense surrounding edema on T2WI• Intratendinous cyst – – Well defined , usually oval – Hyperintense cyst on T2WI• Magic angle artifact – – Increased signal at curved portion of tendon – 55 degrees to external magnetic field – Affects biceps and SST tendon and labrum
  55. 55. Rotator cuff tears• Clinical – – Trauma (acute / chronic micro-trauma) – Adults > 4o with impingement – Collagen vascular diseases – Partial more painful than complete tears !!!!TYPES -• Partial – – supraspinatus most common – Types – bursal surface interstitial (not seen on arthroscopy) articular surface• Complete – – supraspinatus most common – Extends from bursal to articular surface
  56. 56. Partial tears
  57. 57. Radiographic findingsFindings associated with impingement anddegenerative changes• Acromial spurs• Type III (hooked) acromion• Humeral head arthritic changes at greater tuberosity• AC degenerative changes
  58. 58. MRIIncomplete defect in tendon filled with joint fluid +/- granulationtissue• T1WI – – thickening of RTC tendons – intermediate signal – Calcifications – hypointense bone impaction (Hill-Sachs) in case of anterior dislocation• T2WI – – Fluid signal intensity filling an incomplete gap in tendon – Fluid in subacromial bursa – Increased signal on FS PD (sensitive for partial tears) – Retraction and degeneration of tendon edges (bursal or articular)
  59. 59. • PC T1 – – enhancement of the granulation tissue• MR arthrography – – Contrast may fill the tear if articular surface of the tendon communicates with joint
  60. 60. USG• Decreased echogenicity and thinning in affected region• Loss of convexity of tendon / bursa interface in bursal surface tears• Calcific foci in tendons
  61. 61. Differentials• RTC tendinopathy• Full thickness tear without visible communication – closed by granulation tissue / fibrosis / adhesions• Intratendinous cyst – can be associated with partial tears• Calcific tendinitis – hypointense on all sequences
  62. 62. Full thickness tears
  63. 63. Full thickness tearsEtiology – similar to partial tearsAssociated with – – Hill Sach’s deformity (anterior dislocation) – Biceps tendinosis / tears / SLAP lesions with micro instability
  64. 64. Radiography• Acromial spurs• Type III (hooked) acromion• Humeral head arthritic changes at greater tuberosity• AC degenerative changes• Superior humeral head migration
  65. 65. MRI• T1WI – Thickened indistinct tendon – Tear edges not delineated on T1 – Calcifications (i/c/o calcific tendinitis)• T2WI – Hyperintense fluid signal filling a gap in the tendon (T2 and FS PD) – Bald spot sign – hyperintense fluid ‘bald spot’ within hypointense tendon • On sag and axial T2 – Fluid in subacromial bursa• Retraction and degeneration of tendon edges• Sometimes associated with fatty atrophy of muscles (fat signal on T1)
  66. 66. Bald spot sign
  67. 67. USG• Focal tendon interruption• Fluid filed gap (hypoechoic)• Loss of convexity of tendon / bursa interface• Tendon retraction• Uncovered cartilage sign
  68. 68. MRI Rotator cuff tear grading- Dr Yuranga Weerakkody and Dr Frank Gaillard et al.• grade 0 : normal• grade I : increased T2 signal with normal morphology• grade II : increased T2 signal with abnormal morphology (thickening, or irregularity of the tendon)• grade III : defined tear (e.g. partial or full thickness, complete or incomplete)
  69. 69. Rotator interval tears
  70. 70. Rotator interval tears• What is rotator interval ?? – Tunnel through which long head of biceps travels from its origin at the supraglenoid tubercle• Rotator interval tears – tears in the capsule between the supraspinatus and subscapularis tendons• Can be classified as subtype of RTC tears
  71. 71. MRI• T1 – – Thickened rotator interval – Biceps tendinosis and subluxation• T2 – – Visible tear in rotator interval – Associated tear of SST may be present – FS PD sag images are useful to detect abnormal fluid extension across rotator interval• MR arthrography – – Leakage of contrast through the tear in RI – Intact SST and SSC
  72. 72. Internal impingement
  73. 73. Internal impingement• Definition - Degeneration and tearing of posterior SST and anterior infraspinatus tendons (undersurface / articular surface) due to impingement by postero- superior labrum and humeral head• Postero-superior glenoid impingement (PSGI)• Overhead throwing activities – athletes (throwers)• Dynamic compression – occurs during abduction (> 120 degrees), retropulsion and extreme external rotation (ABER)
  74. 74. MRI• T1 – – Thickened posterior SST and anterior IST (tendinosis) – Postero-superior labral irregularity (fraying) – Tear in postero-superior labrum (can be avulsed) – Postero-superior humeral head irregularity• T2 – – Hyperintense signal on articular surface of posterior SST and anterior IST – Hyperintense signal (FS PD) in postero-superior humeral head, humeral head chondromalacia – Fraying +/- tear of PSGL
  75. 75. Axial FS PDSynovitis, labral fraying, sclerosis atposterosuperior glenoid, cystic changes inposterolateral humeral head
  76. 76. • MR arthrography – – Postero-superior labral fraying / tear demonstrated by contrast outline – ABER imaging shows undersurface tears – Chondromalacia outlined by contrast
  77. 77. • Best diagnostic clue - triad of damage at 1. Undersurface of RTC 2. Postero-superior labrum 3. Humeral head• Differentials – – Subacromial impingement (history differs) – SLAP without RTC pathology
  78. 78. Rotator cuff calcific tendinitis
  79. 79. Rotator cuff calcific tendinitis• Calcium Hydroxyapatite deposition disease (HADD)• Calcifying bursitis• Not typical Ca++ of degenerative disease of tendons, but crystalline Ca++• Pathology – deposition of Calcium Hydroxyapatite in RTC tendons• Etiology – Avascular change, trauma, abnormal Ca++ metabolism• Housewives and clerical workers more affected• Location – SST > IST > TM > SSC• Peri-articular soft tissues like capsule, bursae may be involved
  80. 80. Stages / classification (Moseley)• Silent• Mechanical – intra bursal or sub bursal rupture Physical restriction of movements• Adhesive peri-arthritis – tendinitis bursitis
  81. 81. • Radiography – Calcific deposits – Internal rotation demonstrates posterior tendons well (IST and TM) – Axillary view and scapula ‘Y’ view helpful• CT – Better localization of calcium deposits – Dense, granular, well demarcated calcifications
  82. 82. MRI• Globular decreased signal mass (on all pulse sequences) in RTC tendons• Often surrounded by edema / partial tear (hyperintense)• No involvement of articular cartilage• Hydroxyapatite deposits may have exactly same signal as normal cuff tendons• T2*GRE is helpful as calcifications bloom and increase sensitivity
  83. 83. Axial PD
  84. 84. Differentials• Degenerative calcification in torn tendon – Usually smaller calcifications – In older age group – Different chemical composition• Loose bodies – Chondral defects seen – Articular OA changes• Osteochondromatosis
  85. 85. Parsonage - Turner syndrome
  86. 86. Parsonage - Turner syndrome• Idiopathic denervation of the shoulder musculature• More than one nerve may be involved• Mainly affects the LMN of the brachial plexus and / or individual nerves or nerve fibers• Etiology – – Immune mediated reaction against nerve fibers – Trauma, infection, surgery, vaccination, systemic illness• Pathology – – Degenerative changes in affected muscles – Early and subacute – swollen muscle belly – Chronic - fatty atrophy
  87. 87. CT• Acute / subacute cases – mildly increased bulk of muscles• Chronic cases – fatty density in involved muscles
  88. 88. MRI• MRI abnormalities appear usually after 2 weeks• T1 – – Early – decreased signal (edema) – Chronic – muscle atrophy with streaky fat signals (fatty atrophy)• T2 – – Early – increased signal intensity, enlarged muscle bulk – Chronic – atrophic muscles – Nerve distribution pattern +/-• PC T1 – muscle belly enhance in early stages
  89. 89. Differentials• Traumatic neurapraxia• Non specific myositis ( usually nerve pattern not followed)• Direct trauma to the muscle belly (history)
  90. 90. Pathologies• Rotator Cuff• Labrum and capsule• Biceps tendon• Osseous structures• Arthritis• Neural impingement• Tumors
  91. 91. Labrum and capsule • Labral cyst • Antero-superior variations • Adhesive capsulitis • Bankart • Perthes • ALPSA • GLAD • HAGL • IGL • Bennett
  92. 92. Labral cyst
  93. 93. Labral cyst• Cyst arising from labral / capsular tear / capsular diverticulum• Etiology – cyst arising due to break in integrity of joint• 3-5 % of labral tears associated with labral cysts• Slow growing, original tear may heal• Associated abnormalities – – Instability (non healed) – SLAP (superior labrum anterior to posterior) – Denervation of SST and IST (compression)
  94. 94. MRICommon location – adjacent to postero-superior labrum funneled between SST and IST (path ofleast resistance)• T1 – – Decreased signal intensity cystic mass• T2 – – Hyperintense cystic lesion – Often multiloculated – Arising from / immediately adjacent to the labrum / capsule – Degenerative changes in SST / IST (suprascapular nerve) – Labral tear• MR arthrogrpahy – – Cyst filled with contrast
  95. 95. Differentials• Neoplasm – Internal enhancement – Not associated with labral / capsular tear• Normal vessel – – plexus in suprascapular notch – Can be enlarged in CHF
  96. 96. Antero-superior labrum variations
  97. 97. Antero-superior labrum variationsCongenital anatomical variationsMay be developmental Sub-labral foramen Buford complex (BC) Labral types Synovial recesses
  98. 98. Sublabral foramen• Relative lack of attachment of anterosuperior labrum to the glenoid rim in anterior superior quadrant• MRI – – Hyperintense fluid signal (mostly linear) on T2 undermining the antero-superior labrum – Should not be confused with SLAP lesion – Bankart’s lesion – below the equator (antero- inferior)
  99. 99. Axial FS PD - anterior labrum directlyattached to the hyaline cartilage
  100. 100. Buford complex• Complete absence of antero-superior labrum +• Thick cord-like middle glenohumeral ligament (MGHL) anterior to the anterosuperior glenoid rim
  101. 101. Buford complex
  102. 102. Labral typesVariations in labral attachment patterns• Superior wedge labrum• Posterior wedge labrum• Anterior wedge labrum• Meniscoid labrum
  103. 103. Synovial recesses• Visualized on sag images as capsular variations relative to MGHL
  104. 104. Adhesive capsulitis
  105. 105. Adhesive capsulitis• Frozen shoulder• Pathology - Inflammation of the inferior shoulder capsule (axillary pouch) causing limited range of motion• May accompany other disorders like impingement (secondary adhesive capsulitis)• Etiology – Idiopathic (primary), trauma, infection, surgery, metabolic (diabetes)
  106. 106. Radiography• Plain radiography not useful• Arthrography – – Contracted irregular capsule – Decreased volume +/- – Over-injection may leading to capsule rupture may be therapeutic !!! (improved ROM)
  107. 107. MRI• T1 – – Thickened indistinct capsule margins• T2 – – Thickened capsule (> 3mm on coronal images) – Increased signal – Thickening more conspicuous on FS PD, STIR and T2*GRE – FS more sensitive for capsular edema and synovitis – Sagittal images for rotator interval• MR arthrography – – Capsule enhances diffusely, acutely – Restricted capsular volume
  108. 108. Bankart lesion
  109. 109. Bankart lesion• Avulsion of inferior glenohumeral labral complex (IGHLC)• Etiology – – IGHLC is a ‘weak link’ among the static stabilizers of young shoulder – Occurs after initial anterior dislocation in young ( > 90% cases are < 40 years)
  110. 110. Asociated abnormalities Bony Bankart – osteochondral fracture in some cases Hill Sachs lesion – fracture at posterolateral superior humeral head Partial / complete RTC tears
  111. 111. Radiography• Subglenoid / subcoracoid dislocation• Glenoid rim fracture CT• Arthrography – contrast extending into the labral tear
  112. 112. MRI• T1 – – Hypointense edema / sclerosis at antero-inferior glenoid – Glenoid rim fracture (sag and axial more useful)• T2 – – Labrum – torn with hyperintense fluid, within or underlying labrum – fracture line at glenoid rim – Fracture at postero- lateral humeral head – Thickened and hyperintense IGHLC (acute dislocation) – ABER view better for visualization• T2*GRE – greater sensitivity for abnormal intra-labral signal as compared to FS PD or PD
  113. 113. Prognosis –• Recurrent instability (improper healing)Rx -• Conservative with a sling• Surgical or arthroscopic repair for repeated dislocations
  114. 114. Perthes lesion
  115. 115. Perthes lesion• Bankart variant (uncommon 5-10 % of Bankart lesions)• Detached IGHLC with intact scapular periosteum, which is stripped medially• Etio-pathology similar to Bankart lesion
  116. 116. MRI• T2 – – Subtle linear increased signal intensity at the base of usually non-displaced labrum – Bankart fracture – Redundant hypointense periosteum• STIR – – provides improved contrast for visualization of medially stripped scapular periosteum• MR arthrography – in ABER (arm placed behind the head)
  117. 117. ALPSA lesion
  118. 118. ALPSA lesionAnterior Labro-ligamentous Periosteal SleeveAvulsion• Components - – Anterior IGHLC avulsion from antero-inferior glenoid – Intact periosteum – Medial displacement and inferior shift of the anterior IGHLC
  119. 119. MRI• T2 – – Medial displacement of IGHLC on axial and coronal images – Hyperintense in acute cases – Hypointense in chronic cases – Hyperintense edema and hemorrhage in joint capsule and adjacent soft tissues• MR arthrography – – Medial and inferior displacement of labrum – Chronic cases with re-synovialisation show minimal displacement
  120. 120. GLAD lesion
  121. 121. GLAD lesionGlenoid Labrum Articular Disruption• Definition - Partial tear of anterior glenoid labrum with adjacent articular cartilage defect• Young physically active patients• Pain on IR and adduction
  122. 122. MRI• Irregular increased signal intensity on T2 / FS PD within the anterior labrum and adjacent hyaline articular cartilage• Labral tear is typically not detached• Chondral defect well seen on FS PD (not well seen on T2)• MR arthrography – – Contrast filling the labral tear – Contrast may fill the chondral defect – ABER – demonstrates partial labral tears by placing stress on capsular ligamentous attachments
  123. 123. HAGL• Humeral Avulsion of Glenohumeral Ligament• Inferior GHL involved• CT arthrography – extravasation of contrast through humeral interface defect into anterior para-humeral soft tissue• MRI – – discontinuous capsule at humeral interface (anatomic neck attachment of IGL) – Capsule assumes ‘J’ shape on coronal images (normal axillary pouch has ‘U’ shaped contour )• MR arthrography – extravasation of contrast inferior to axillary pouch
  124. 124. Bennett lesion• Extra-articular posterior ossification associated with posterior labral injury and posterior cuff pathology• Dystrophic / heterotopic ossification• Throwing athletes (javelin, baseball)
  125. 125. • Radiography – – Mineralization adjacent to posterior glenoid – Better visualized on axillary view• CT arthrography – – Posterior labral tear• MR – – Crescent shaped areas of ossification – Adjacent to posterior labrum – Labral tear – T2*GRE show blooming – MR arthrography – posterior labral tear
  126. 126. Posterior labral tear• Reverse Bankart• Secondary to posterior dislocation• Posterior band of IGHLC ‘weak link’ among static stabilizers in most shoulders• Radiography and CT – – Posterior glenoid rim fracture – Trough sign – reverse Hill Sachs on anterior humerus creating a trough / defect – Lesser tuberosity avulsion fracture
  127. 127. Pathologies• Rotator Cuff• Labrum and capsule• Biceps tendon• Osseous structures• Arthritis• Neural impingement• Tumors
  128. 128. Biceps tendon pathologies
  129. 129. Tendinosis
  130. 130. Tendinosis• Degeneration of long head of biceps• Long head of biceps – – LHBT originates at supra glenoid tubercle – Passes through the antero-superior joint – Enters the humeral bicipital groove• Chronic micro-trauma• Acute trauma (rare cause)• Accompanies RTC disease (especially impingement)• Common with subacromial impingement (30-60% association)• Biceps tenosynovitis may accompany
  131. 131. • Radiography - Sclerosis at the superior aspect of bicipital groove (chronic cases with instability)• USG – – Thickened hypoechoic tendon – Tears often directly visible – Allows dynamic evaluation
  132. 132. MRI• T1 – – Thickened intermediate signal intensity tendon – SST tendinopathy• T2 – – Thickened (> 5 mm), irregular frayed tendon – Increased signal – FS PD and PD more sensitive for tendinosis – T2 more sensitive for fraying / tears – SST tendinopathy• MR arthrography – thickened filling defect (enlarged tendon)
  133. 133. Biceps tendon tear
  134. 134. Biceps tendon tear• Tendinosis predisposes• Associated with SST tear• Distal tendon edge may retract into upper arm
  135. 135. • CT arthrography – – Bicipital groove filled with contrast – Absence of normal ‘filling defect’• MRI – – Irregular stump at superior aspect of joint – Partial or complete hyperintense fluid gap in the tendon (T2) – Synovitis (PD)
  136. 136. Biceps tendinitis grading for tenodesis (repair) –• Reversible tendon change  < 25 % partial tear (width)  normal bicipital groove location  normal size• Irreversible tendon change  > 25 % partial tear  subluxation  disruption of bicipital groove osseous / ligamentous anatomy
  137. 137. SLAP lesions
  138. 138. SLAP lesions• Superior Labrum Anterior to Posterior lesions / tears• Location –  SLAP I – superior labrum  SLAP II – superior labrum + biceps anchor  SLAP III - superior labrum  SLAP IV– superior labrum + biceps tendon SLAP V to IX have also been classified• Pathology – – Focal fraying and degeneration of labrum at BLC in SLAP I – Complete anterior to posterior extension in SLAP II - IV
  139. 139. MRI (T2)• SLAP I –Intermediate to hyperintense labral degeneration without labral tearRepresents intra substance degenerationCan be age related normal finding• SLAP II –Linear hyperintense fluid signal between superior labrum and superior pole ofglenoid (> 5 mm displacement of labrum and biceps anchor on coronal images)• SLAP III –Identify fragmented superior labrum into two separate components on sag andcor images through BLC )Bucket handle tear through the meniscoid superior labrum• SLAP IV –Split of the biceps tendon with hyperintense linear longitudinal tear withavulsion
  140. 140. SLAP I SLAP II
  141. 141. SLAP III
  142. 142. SLAP IV
  143. 143. Rx• Conservative – – NSAIDs – PT• Surgical –• Type I – debridement• Type II – stabilize, bioabsorbable tack (sutures)• Type III – debridement• Type IV – suturing of biceps , reattachment of labrum
  144. 144. Biceps tendon dislocation
  145. 145. Biceps tendon dislocation• Biceps instability• Definition – dislocation of long head of biceps tendon from bicipital groove• Etiology – – Due to disruption of stabilizing ligaments (RTC tears) – SSC and coracohumeral ligament are major stabilizers of biceps – Shallow bicipital groove predisposes
  146. 146. MRI• T1 – – Increased signal intensity fat fills the bicipital groove• T2 – – Tendon not in groove – Mostly displaced medially – Flattened / thickened (if previous tendinosis) – SSC partial / complete tear• T2*GRE – more sensitive for visualization of hypointense biceps fiber• MR arthrography – empty groove, tendon sheath filled with contrast
  147. 147. USG• Empty groove• Displaced biceps tendon hypoechoic and edematousBest diagnostic clue –• Empty bicipital groove with oval structure outside the groove with hypointense signal on all pulse sequences (MRI)
  148. 148. Pathologies• Rotator Cuff• Labrum and capsule• Biceps tendon• Osseous structures• Arthritis• Neural impingement• Tumors
  149. 149. Osseous structures
  150. 150. Osseous structures• Subacromial impingement• Os acromiale• AVN• Dislocation• Osteochondral injuries
  151. 151. Subacromial impingement
  152. 152. Subacromial impingement• Physical impingement with repeated micro traumaEtiology –• Primary extrinsic - Subacromial spur, AC OA• Type III (hooked) acromion• Lateral down sloping of anterior acromion• Os acromiale• Secondary extrinsic – no osseous abnormality of coracoacromial archRx – conservative, Acromioplasty
  153. 153. Acromial Types Type I
  154. 154. Acromial Types Type II
  155. 155. Acromial Types Type III
  156. 156. Acromial Types Type IV
  157. 157. MRI• Hooked acromion on sagittal images with decreased subacromial outlet• Lateral down sloping seen on coronal images• Subacromial space < 7 mm considered increased risk• Changes of RTC tendinopathy• Partial tears may be seen• Bursitis• Thickened coracoacromial ligament
  158. 158. Coracoid Impingement-Normal Coracohumeral -Narrowed C-H Distance canDistance is 11 mm Impinge on Subscapularis
  159. 159. Os acromiale
  160. 160. Os acromiale• Unfused acromial ossification center• Normally fuses by 25-30 years• Mature bone with synchondrosis between os and acromion• +/- mobile distal acromion• Can cause impingement• Rx – conservative, preacromian excison, stabilization
  161. 161. Types • Basi-meta (type C) • Meta-meso (type A) • Meso-pre (type B – most common)
  162. 162. MRI• Age > 25-30 years• Unfused bony fragment• Corticated structure with medullary fat in it (hyperintense)• Hypointense sclerosis at its margins• Pseudo double AC joint (axial and cor)• T2*GRE – unfused ossification demarcation (hyperintense)
  163. 163. Double AC joint sign
  164. 164. Avascular Necrosis
  165. 165. AVN• AVN / osteonecrosis• It is ischemic death of cellular elements of bone and marrow• Etiology – steroids, alcohol, smoking, trauma, collagen vascular diseases, arteritis, storage disorders (Gaucher’s), idiopathic• 2nd most common (after femoral head)
  166. 166. Radiography• Arc like subchondral fracture (crescent sign)• Articular collapse (step sign)• Fragmentation• Subchondral lytic sclerotic areas• Subchondral cysts• Deformed humeral head• Secondary degenerative changes
  167. 167. AVN
  168. 168. Class Description I Normal (can be seen on MRI) sclerosis in superior central II portion of the head crescent sign - caused by III subchondral bone collapse; may have mild flattening significant collapse of humeral IV articular surface. V degenerative joint disease.Cruess X-ray Classification of AVN Humeral Head
  169. 169. MRI• Supero-medial part of head most commonly involved• Serpiginous hypointense lines (T1)• Double line sign – increased signal in the center of the line (vascular granulation tissue) with decreased signal on both sides (T2 and T2*GRE)• Non specific edema• Subchondral collapse and cysts• FS PD – more sensitive for ischemic edema in acute cases
  170. 170. • PC T1 – the granulation component of ‘double line sign’ may enhance• MR arthrography – contrast extend into the necrotic boneBest diagnostic clue – Supero-medial involvement Double line sign on T2W
  171. 171. Osteochondral injuries
  172. 172. Osteochondral injuries• Definition - Injury to articular hyaline cartilage +/- underlying bone fracture, bone trabecular injury or associated reactive stress response• Tidemark zone is the weakest part of articular cartilage – between overlying cartilage and subchondral bone• Rotational forces – direct trauma – cause cartilage injury – secondarily involve the underlying bone
  173. 173. MRI• T1 – – Subchondral sclerosis and edema• T2, FS PD and STIR – – Increased signal in articular cartilage – Underlying bone edema (hyperintense)• T2*GRE – only sensitive to large chondral defects• MR arthrography – contrast fills the chondral defectBest diagnostic clue –• Increased signal in articular cartilage
  174. 174. ‘Outerbridge’ classification of articular cartilage injuries• Grade 0 – normal• Grade 1 – chondral softening and swelling (increased signal on FS PD)• Grade 2 – partial thickness defect, not reaching subchondral bone / < 1.5 cm in max dimension• Grade 3 – just reaching upto the subchondral bone / > 1.5 cm• Grade 4 – exposed bone / full thickness cartilage loss
  175. 175. Pathologies• Rotator Cuff• Labrum and capsule• Biceps tendon• Osseous structures• Arthritis• Neural impingement• Tumors
  176. 176. Arthritis
  177. 177. OsteoarthritisGlenohumeral jointAcromio-clavicular joint (AVC)• Relatively uncommon compared to impingement• Older patients• Younger patients (post trauma / post surgery)
  178. 178. Radiography• Joint space narrowing• Osteophytes• Subchondral cysts and sclerosis
  179. 179. MRI• Subchondral cyts• Osteophytes (marrow signal extends into it)• Generalized thinning of hyaline cartilage, with occasional focal defects• Synovitis• Loose bodies• Posterior glenoid wear leads to increased retroversion of glenoid• PC T1 – synovial enhancement in synovitis
  180. 180. Rheumatoid arthritis• Synovium – articular cartilage – subchondral bone• Marginal erosions (more at greater tuberosity)• Bilateral symmetrical involvement• Diffuse synovial thickening• Joint effusion• Bone erosions• Loss of joint space not prominent• Mild superior migration of humeral head (RTC rupture) – decreased space between HH and acromion• Clavicular erosions predominate at AC joint• Tapered and resorbed distal clavicle (chronic cases)
  181. 181. Pathologies• Rotator Cuff• Labrum and capsule• Biceps tendon• Osseous structures• Arthritis• Neural impingement• Tumors
  182. 182. Neural impingement
  183. 183. Quadrilateral space syndrome• Entrapment neuropathy (compression) of axillary nerve in quadrilateral space• Boundaries –• Superiorly – teres major• Inferiorly – teres minor• Medially – long head of triceps• Laterally – humerus• Best diagnostic clue –• Increased signal in teres minor and deltoid on FS PD or STIR (denervation)• Streaky decreased signal intensity (fibrosis)
  184. 184. Suprascapular / Spinoglenoid notch• Impingement of suprascapular nerve• Location - – SSN at superior glenoid – SGN at posterior glenoid• Best diagnostic clue –• Increased signal in SST and IST on FS PD or STIR (denervation)• Streaky decreased signal intensity (fibrosis)
  185. 185. Miscellaneous Pathologies • Dislocations • Fractures • Tumors • AC separation
  186. 186. DislocationTypes• Shoulder dislocations are usually divided according to the direction in which the humeral exits the joint:• anterior : > 95 % (subcoracoid)• posterior : 2 - 4 %• inferior (luxatio erecta) : < 1 %
  187. 187. Anterior Dislocation
  188. 188. Anterior Dislocation
  189. 189. Posterior dislocation Axillary viewAP Scapular ‘Y’ view
  190. 190. Luxatio erecta
  191. 191. Tumors• Proximal humerus – – Simple bone cyst – Aneurysmal bone cyst – Giant Cell Tumor of Bone – Osteosarcoma (common) – Enchondroma (relatively common) – Periosteal chondroma (just proximal to insertion of deltoid) – Osteochondroma – Chondroblastoma – Chondromyxoid fibroma – Metastases• Scapula – – Osteochondroma – chondrosarcoma: affects the shoulder girdle
  192. 192. Role of interventional radiology• US and fluoroscopy guided intra-articular and bursal infiltration (steroids, other drugs)• Percutaneous needle removal of calcific deposits• Capsular distension/infiltration of adhesive capsulitis• Therapeutic aspiration of suprascapular or spinoglenoid cysts (to relieve suprascapular nerve compression)• Percutaneous radio-frequency treatment of symptomatic bone metastases under CT guidance
  193. 193. Conclusion• Plain radiographs are useful as an initial screening test with patients with shoulder pain.• Ultrasound may be used for diagnosing rotator cuff disease (> 90 % sensitive and specific for tears).• CT useful only in cases of trauma and to detect associated bony abnormalities• MRI is the ‘modality of choice’ for most of the shoulder pathologies.• MR arthrography or CT arthrography is required for investigating instability
  194. 194. Thank you…….