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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