Download Shoulder Imaging

Lawrence Gulotta
Gillian Lieberman, MD
October 2002
Shoulder Imaging
Lawrence V. Gulotta, HMS IV
Gillian Lieberman, MD
10/16/02
Lawrence Gulotta
Gillian Lieberman, MD
Goals
• Review Anatomy of the Shoulder
-Dynamic Stabilizers -> Rotator Cuff
-Static Stabilizers -> Labrum and Capsule
• Systematic Approach to Reading Shoulder MRI
• Shoulder Pathology and its Imaging
Lawrence Gulotta
Gillian Lieberman, MD
Epidemiology
• Large range of motion predisposes to injury
• 4 million Americans seek treatment for
shoulder pain each year.
• Accounts for 1.5 million visits to
orthopaedic surgeons annually.
• Affects all age groups
Lawrence Gulotta
Gillian Lieberman, MD
Dynamic Stabilizers
Acromion
AC Joint
Supraspinatus
CA Lig
Coracoid
Rotator Interval
Subscapularis
Biceps-Long Head
Coracobrachialis
BicepsShort Head
www.venturaorthopedic.com
Lawrence Gulotta
Gillian Lieberman, MD
Dynamic Stabilizers
Scapular Spine
Supraspinatus
Infraspinatus
Quadrangular
Space
Teres Minor
Teres Major
www.venturaorthopedic.com
Lawrence Gulotta
Gillian Lieberman, MD
Static Stabilizers
Acromion
CA Ligament
SGHL
BicepsLong Head
Coracoid
MGHL
Labrum
IGHLAnterior Band
IGHLPosterior Band
www.venturaorthopedic.com
Lawrence Gulotta
Gillian Lieberman, MD
Approach to Shoulder MRI
1.
STIRs
-look for edema (high intensity)
Infraspinatus
Teres Minor
BIDMC
Lawrence Gulotta
Gillian Lieberman, MD
Approach to Shoulder MRI
1.
STIRs
-look for edema (high intensity)
Supraspinatus
BIDMC
Lawrence Gulotta
Gillian Lieberman, MD
Approach to Shoulder MRI
1.
2.
STIRs
-look for edema (high intensity)
Proton Density-Coronal
-Infraspinatus
-Teres Minor
-Lateral Sloping Acromion
-Supraspinatus
-Superior/Inferior Labrum
-AC Joint
BIDMC
Lawrence Gulotta
Gillian Lieberman, MD
Approach to Shoulder MRI
1.
2.
STIRs
-look for edema (high intensity)
Proton Density-Coronal
-Infraspinatus
-Teres Minor
-Lateral Sloping Acromiom
-Supraspinatus
-Superior/Inferior Labrum
-AC Joint
BIDMC
Lawrence Gulotta
Gillian Lieberman, MD
Approach to Shoulder MRI
1.
2.
STIRs
-look for edema (high intensity)
Proton Density-Coronal
-Infraspinatus
-Teres Minor
-Lateral Sloping Acromiom
-Supraspinatus
-Superior/Inferior Labrum
-AC Joint
BIDMC
Lawrence Gulotta
Gillian Lieberman, MD
Approach to Shoulder MRI
1.
2.
3.
STIRs
-look for edema (high intensity)
Proton Density-Coronal
-Infraspinatus
-Teres Minor
-Lateral Sloping Acromiom
-Supraspinatus
-Superior/Inferior Labrum
-AC Joint
Proton Density-Axial
-Long Head of Biceps
-Subscapularis
-Anterior/Posterior Labrum
BIDMC
Lawrence Gulotta
Gillian Lieberman, MD
Approach to Shoulder MRI
1.
2.
3.
4.
STIRs
-look for edema (high intensity)
Proton Density-Coronal
-Infraspinatus
-Teres Minor
-Lateral Sloping Acromiom
-Supraspinatus
-Superior/Inferior Labrum
-AC Joint
Proton Density-Axial
-Long Head of Biceps
-Subscapularis
-Anterior/Posterior Labrum
Proton Density-Sagittal
-Inferior Sloping Acromion
-Atrophy of RTC muscles
BIDMC
Lawrence Gulotta
Gillian Lieberman, MD
Our Patient
83 year old male who complains of pain in his
left shoulder for 8 months following a fall on
his outstretched arm.
-Unable to lift arm over head
-Pain wakes him up from sleep at night
-PE of left shoulder significant for:
-Abduction with a shrug to 45 degrees.
-Positive impingement signs
-Supraspinatus strength 1/5
Lawrence Gulotta
Gillian Lieberman, MD
Our Patient: Plain Films
Impingement Series
Internal Rotation
IR and ER views are
used to evaluate for
fractures, bone lesions,
DJD, and the
relationship between
humerus and glenoid.
BIDMC
->Humerus rides high in
RTC deficient shoulder.
Axillary views evaluate
for dislocations.
Axillary
External Rotation
BIDMC
Scapular Outlet View
Scapular Outlet view is
used to assess the space
available for supraspinatus
BIDMC
Wheeless Online
Lawrence Gulotta
Gillian Lieberman, MD
Our Patient
• This patient’s plain films are normal.
• The next appropriate step in his work-up
would be an MRI.
• MRI is 100% sensitive and 95% specific in
the diagnosis of complete tears of the
rotator cuff. (Ionnotti et al. JBJS(Am);73(1):17-29)
Lawrence Gulotta
Gillian Lieberman, MD
Our Patient: MRI
Findings:
1. Hyperintense lesion through full
thickness of supraspinatus
BIDMC
Lawrence Gulotta
Gillian Lieberman, MD
Our Patient: MRI
Findings:
1.
2.
Hyperintense lesion through
full thickness of supraspinatus
Laterally sloping acromion
completely occluding
supraspinatus outlet
BIDMC
Lawrence Gulotta
Gillian Lieberman, MD
Our Patient: MRI
Findings:
1.
2.
3.
Hyperintense lesion through
full thickness of supraspinatus
Laterally sloping acromiom
completely occluding
supraspinatus outlet
Retraction of supraspinatus
with fatty degeneration
BIDMC
Lawrence Gulotta
Gillian Lieberman, MD
Our Patient: MRI
Findings:
1.
2.
3.
4.
Hyperintense lesion through
full thickness of supraspinatus
Laterally sloping acromiom
completely occluding
supraspinatus outlet
Retraction of supraspinatus
with fatty degeneration
Degeneration of supraspinatus
on sagittal images
BIDMC
Lawrence Gulotta
Gillian Lieberman, MD
Our Patient: MRI
Findings:
1.
2.
3.
4.
5.
Hyperintense lesion through
full thickness of supraspinatus
Laterally sloping acromiom
completely occluding
supraspinatus outlet
Retraction of supraspinatus
with fatty degeneration
Degeneration of supraspinatus
on sagital images
Absence of long head of
biceps in bicipital groove
BIDMC
Lawrence Gulotta
Gillian Lieberman, MD
Our Second Patient
34 year old RHD male former minor league
baseball pitcher who complains of right shoulder
pain for the past 6 months.
-Can feel clicking in shoulder when playing
catch with his son but no sensation of instability.
-PE of right shoulder significant for:
-Positive O’Brien’s test suggestive of a
Superior Labral tear from Anterior to
Posterior (SLAP).
-Negative apprehension tests.
-Plain radiographs were unremarkable.
Lawrence Gulotta
Gillian Lieberman, MD
Our Second Patient (con’t)
• MRI without intra-articular contrast has a
sensitivity anywhere from 60-98% in the diagnosis
of SLAP lesions.
-Depends on the series and the severity
of the tear.
• MR-Arthrography has an 89% sensitivity and 91%
2
specificity in the diagnosis of SLAP lesions .
• The appropriate imaging study for SLAP tears is
controversial
-At this institution, it is recommended that
labral tears be evaluated by MR-arthrography.
2. Bencardino et al; Radiology; 214(1):267-71
Lawrence Gulotta
Gillian Lieberman, MD
Our Second Patient: MR Arthrogram
SLAP Lesion
BIDMC
BIDMC
BIDMC
Normal Inferior Labrum
Lawrence Gulotta
Gillian Lieberman, MD
Summary
Rotator Cuff Tears
Labral Tears
-Older Patients
-Pain with Rest
-PE c/w Impingement and
RTC weakness
-Plain films can show high
riding humerus and
obstructed outlet
-MRI diagnostic
-Younger Patients
-Pain with Activity
-PE c/w Labral tear and
possibly instability
-Plain films usually normal
-MR-arthrography diagnostic
Lawrence Gulotta
Gillian Lieberman, MD
Acknowledgements
Dr. Gillian Lieberman
Pamela Lepkowski
Dr. Mary Hochman
Larry Barbaras