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sonography – supraspinatus LAX Technique • SAX and LAX in both positions • Middleton position demonstrates cuff interval best • capture stills and clips from coracoacromial ligament through insertion on the greater tuberosity • always adjust for anisotropy! sonography – supraspinatus LAX Technique • SAX and LAX in both positions • Middleton position demonstrates cuff interval best • capture stills and clips from coracoacromial ligament through insertion on the greater tuberosity • always adjust for anisotropy! modified Crass SAX - advantage Technique • SAX rotator cuff interval • occasionally helps visualize cuff more completely • routinely completed in adjunct with Crass • MUST FOR PATHOLOGY DETERMINATION! supraspinatus – tendon insertion Tendon fiber insert perpendicular to bone • enthesis – insertion of tendon into bone • do not mistake for articular cartilage or tear • surface is smooth and non-articular supraspinatus – deltoid shelf common area for fluid to collect in the subdeltoid (yellows arrows) • MUST be included in any LAX view of supraspinatus • • supraspinatus – deltoid shelf supraspinatus insertion ends at the greater tuberosity (yellows arrows) • any anatomy beyond this point is likely the subdeltoid-subacromial bursa (SDSA) • • sonography – supraspinatus LAX Humeral head Technique • SAX and LAX in both positions • Middleton position demonstrates cuff interval best • capture stills and clips from coracoacromial ligament through insertion on the greater tuberosity • always adjust for anisotropy! Anatomic neck Greater tuberosity SONOGRAPHY – SUBACROMIAL IMPINGEMENT SUPRASPINATUS Sonography • transducer LAX over acromion • arm abducted 30 degrees with thumb down • arm raised and lowered – assist if necessary anatomic structures - infraspinatus infraspinatus Tendon/Muscle • muscle arises from the infraspinatus fossa of the scapula • attaches to the greater tuberosity of the humerus laterally • slides beneath the subdeltoid subacromial bursa (SDSA) • primary external rotator of shoulder. Sonography • tendon is evaluate in LAX unless directed • LAX sweep • Note is made of atrophy in cases of suspected neurologic deficit sonography – infraspinatus LAX Technique • LAX only • patient is asked to put their arm in a “sling” • external rotation until tendon covers glenohumeral joint posteriorly • cine clips only if normal sonography – posterior glenoid labrum Technique • transducer slides slightly inferior and medial to the infraspinatus tendon. • palm up and the arm is moved from full adduction in 90degree external rotation • clip of humeral head slip over labrum • observe humeral head slip and relationship to glenoid labrum anatomic structures – posterior glenoid labrum Posterior glenoid labrum • fibrous attachment of the glenohumeral ligaments and capsule to the glenoid rim • majority of labrum not readily accessible by ultrasound (primary MRI) • posterior labrum imaged with shoulder • primary external rotator of shoulder. Sonography • tendon is evaluate in LAX unless directed • LAX sweep • Note is made of atrophy in cases of suspected neurologic deficit anatomic structures – spinoglenoid groove Posterior spinoglenoid groove/notch • contains suprascapular nerve, artery and vein • common site for fluid collection or paralabral cyst following posterior labrum tear Sonography • groove is evaluated in LAX unless directed • suprascapular vein may dilate with internal rotation sonography – spinoglenoid notch/groove Technique • transducer slides slightly medial and is turned clockwise 15 degrees from posterior labrum view • palm up and the arm is moved in slight external rotation • observe dilation of vein • observe humeral head slip and relationship to glenoid labrum MAJOR CRITERIA Absent cuff Cuff atrophy Hypoechoic defect Focal hyperechoic defect MINOR CRITERIA Abnormal fluid Naked tuberosity Cartilage interface Deltoid herniation ROTATOR CUFF PATHOLOGY MAJOR CRITERIA LAX SUPRASPINATUS – ATROPHY LAX LAX SAX SUPRASPINATUS – CUFF ABSENCE LAX SAX SUPRASPINATUS – HYPOECHOIC DEFECT LAX SAX SUPRASPINATUS – HYPERECHOIC DEFECT MINOR CRITERIA ABNORMAL FLUID COLLECTION SASD fluid collection ABNORMAL FLUID COLLECTION SASD fluid collection ABNORMAL FLUID COLLECTION SAX LAX Fluid around the long biceps tendon ABNORMAL FLUID COLLECTION – POSTERIOR LAX LAX Normal Abnormal Glenohumeral joint effusion DELTOID “HERNIATION” SIGN LAX Deltoid “herniates” fills void left by torn tendon SAX HYALINE CARTILAGE INTERFACE SIGN LAX SAX Highlighting of cartilage due sound transmission through fluid MAJOR CRITERIA 99% sensitive & accurate Easiest to observe NOT majority of studies MINOR CRITERIA 1 finding ~ 50% 2 > 90% Needs careful evaluation Majority of studies ROTATOR CUFF PATHOLOGY - CONCLUSION YOU MAKE THE CALL Seriously hope you were paying attention…………………………audience participation CASE#1
