Schreibman - Shoulder Imaging

©Ken L Schreibman, PhD/MD 9/4/11 www.schreibman.info

Shoulder Imaging page 1 of 21

©Ken L Schreibman, PhD/MD 2009 schreibman.info

Shoulder Anterior View

Scapula

GHJ

ACJ


Scapula Anterior View Body Triangular

Body of

Scapula


Scapula Medial View Body Paper Thin Non-articular Attachment site

cuff muscles

“Shoulder Blade” Gk. skaphein “to dig” scapula: shovel/spade-shaped may have been used as primitive digging tool

www.etymonline.com


Scapula Medial View Spine


Scapula Posterior-Medial View Spine


Scapula Posterior View Spine

http://www.etymonline.com/




Scapula Lateral View Y-view Body Spine Coracoid

Glenoid

Acromion arises from spine of scapula

Gk: akros, "highest", ōmos, "shoulder")

http://en.wikipedia.org/wiki/Acromion


Scapula Anterior-Lateral View Coracoid

Anterior structure

Arises from Glenoid

Gk korax, “raven’s beak”

Not Coronoid


Gleno-Humeral Joint Anterior View

Coracoid arising anteriorly from Glenoid

Glenoid shallow socket

Acromion arises from the posterior Spine covers glenohumeral joint


Rotator Cuff Muscles Medial View

Supraspinatus: Above Spine Below AC Joint

Infraspinatus: Below Spine

Teres Minor: Below Infraspin

Subscapularis: Entire Ant Body


Rotator Cuff Tendons Lateral View


Infraspinatus: Below Spine Teres Minor:

Below Infraspin Subscapularis: Entire Ant Body

Greater Tuberosity

Lesser Tuberosity


Rotator Cuff Tendons Anterior View

Greater Tuberosity

Lesser Tuberosity


Subscapularis: Entire Ant Body

http://en.wikipedia.org/wiki/Acromion




Rotator Cuff: MR Sagittal Plane T1: Fat=Bright

Supra- spinatus Infra-

spinatus Post


Rotator Cuff: MR Sagittal Plane


spinatus Post

T2: Fluid=Bright (fat suppressed)

Brachial plexus neuropathy (inflammation of nerves to

supra- & infra-spinatus muscles)

“Parsonage-Turner Syndrome”

Teres Minor




spinatus Post

Teres Minor

T1: Fat=Bright

Sub- scapularis




spinatus Ant

Teres Minor

Sub- scapularis

Post

Rotator Cuff Tendons (Black Arrows)

T1: Fat=Bright Tendons=Black




spinatus Ant

Teres Minor

Sub- scapularis

Post



Tendons=Black



Supra- spinatus

Infra- spinatus

Ant

Teres Minor

Sub- scapularis

Post


Tendons=Black T1: Fat=Bright





Ant Post


Tendons=Black T2: Fluid=Bright (fat suppressed)



Ant Post


Tendons=Black

Acr




Ant Post




Rotator Cuff: MR Axial Plane

AC Jt



AC Jt







Spine

Ant

Post

Hum Head

Gr Tub


Rotator Cuff: MR Axial Plane Ant

Post

Infraspinatus

Gr Tub

Lr Tub

Long Head Bicep


Rotator Cuff: MR Axial Plane Ant

Post

Infraspinatus

Gr Tub

Lr Tub

Long Head Bicep

LT

GT

LHB


Rotator Cuff: MR Coronal Plane

Ant Post

Sub- scapularis

Lr Tub

Long Head Bicep


Slice through ANTERIOR Rotator Cuff


Coronal Plane Rotator Cuff: MR

Ant Post

AC Jt

Supra- spinatus

Gr Tub


Slice through MIDDLE Rotator Cuff


Coronal Plane Rotator Cuff: MR

Ant Post


Slice through POSTERIOR Rotator Cuff




Straight Frontal View

Shoulder: Radiographic Views

A P

AP View

Coracoid Points

Straight Forward

Does NOT Profile G-H Joint

schreibman.info

Articular Head

Glenoid


Shoulder: Radiographic Views Orientation Glenoid

relative to body Humerus

relative to Glenoid

AP View Axillary

View

A

P

Rotate Patient 35-45°

X-ray beam NOT

Parall G-H Jt



relative to body

Axillary View

X-ray beam

IS Parall G-H Jt

Rotate Patient 35-45°

A

P

Oblique View “Neer View” “Grashey View”

A P


Shoulder: Radiographic Views Oblique View Does Profile G-H Joint

The MOST Important View

“Neer View” “Grashey View”

Articular Head

Glenoid

Parallelism




relative to Glenoid

Gle

no

id

Oblique View Humerus Externally Rotated


Shoulder: Radiographic Views Oblique View Humerus Externally Rotated

LT GT

Articular Head

Glenoid

Greater Tuberosity Profiled






relative to Glenoid

A

P

AP View Humerus Internally Rotated


Shoulder: Radiographic Views AP View

Humerus Internally Rotated Greater Tuberosity en face

GT

View of Tertiary Importance


Shoulder: Radiographic Views Same AP Views

Humerus Internally Rotated Humerus Externally Rotated


Shoulder: Technical Points Patient Upright

Boomerang Filter

X-ray protection

AP Oblique


Boomerang Filter With Boomerang Filter

Boomerang Filter

X-r

ay

Both ACJ & GHJ Well Exposed


Need for Boomerang Filter

C,A 80yoF

AP View Without Boomerang Filter

ACJ Over-Exposed

Repeat AP View With Boomerang Filter

ACJ Well-Exposed




Shoulder: Radiographic Views 1)

2)

3)

Obl View (Humerus Ext Rotated)

Axillary View

AP View (Humerus Int Rotated)

Axillary View



Axillary View

Coracoid= Anterior ACJ

Good Secondary View of GHJ


Shoulder: Technical Points Axillary View Patient Supine Arm Abducted


Shoulder: Technical Points West Point View Patient Prone Arm Less

Abducted Techs should

shoot WP view when unable to get Axially view

25º Anterior


Shoulder: Technical Points West Point View Patient Prone Arm Less

Abducted Techs should

shoot WP view when unable to get Axially view

25º Anterior 25º Medial

Targets Anterior Glenoid


Targets Anterior Glenoid

25º Anterior 25º Medial

Shoulder: Technical Points West Point View




Shoulder: Radiographic Views West Point View Axillary View Anterior glenoid better seen on

West Point than on axillary view.


Obl View (Humerus Ext Rotated)

Axillary View

West Point View

“Instability Series”

AP View (Humerus Int Rotated)

Lateral Y View Arch View Outlet View

Shoulder: Radiographic Views 1)

2)

2b)

3)

4)

A

P



A P

A

P

“Y” View




Dislocations: 2 Possible Sites

GHJ

ACJ


Dislocations: Gleno-Humeral Joint Anterior = Easy

Posterior = Hard

GHJ


Dislocations: Gleno-Humeral Joint Anterior = Easy Anterior/Inferior 95% Sub-coracoid (most common)

(W,J 22yoM)

AP view Obl view Y view ©Ken L Schreibman, PhD/MD 2010 schreibman.info

Coracoid= Anterior

Humerus

Glenoid

Dislocations: Gleno-Humeral Joint Axillary view

Good Secondary View of GHJ

Anterior Dislocation


Coracoid= Anterior

Humerus

Glenoid

Dislocations: Gleno-Humeral Joint Axillary view Anterior Dislocation

AP view

Impaction Fx

(M,D 21yoM) ©Ken L Schreibman, PhD/MD 2010 schreibman.info


Impaction Fx Anterior Dislocation

AP view (L,K 19yoF)





(L,K 19yoF)

Hill-Sachs Impaction Fx

Axillary view AP view

Post-reduction

©Ken L Schreibman, PhD/MD 2010 schreibman.info (H,B 49yoM)

Hill-Sachs Fracture D i l o c a t e d

R e d u c e d

Y view AP view Obl view


Hill-Sachs Fracture Harold Arthur Hill (1901-1973)

Maurice David Sachs (1909-1987)

Prominent San Francisco radiologists Radiology 1940; 35:690-700 119 cases of shoulder dislocations.

Showed that the defect resulted from direct impaction of the humeral head.

Before their paper, the fracture was known to be a sign of dislocation, but the mechanism was uncertain.


Dislocations: Gleno-Humeral Joint Anterior Dislocations Fxs of: Humeral Head =“Hill-Sachs”

Glenoid (Ant-Inf corner) =“Bankart”

Arthur Sydney Blundell Bankart (1879-1951) British surgeon between Wars Orthopedic & Neurosurgeon

www.whonamedit.com/doctor.cfm/835.html

©Ken L Schreibman, PhD/MD 2010 schreibman.info (T,R 65yoM)

Bankart Fracture AP view

Relocated Anterior Dislocation ©Ken L Schreibman, PhD/MD 2010 schreibman.info (P,T 16yoM)

Bankart Fracture AP view

http://www.whonamedit.com/doctor.cfm/835.html



©Ken L Schreibman, PhD/MD 2010 schreibman.info (S,J 45yoF)

Bankart Fracture Axillary view (supine)

Cor (Ant)

Cor (Ant)

Cor (Ant)

West Point view (prone)

West Point view shows Anterior Glenoid better than Axillary view

©Ken L Schreibman, PhD/MD 2010 schreibman.info (P,T 28yoM)

Bankart Fracture Oblique view

?

Axillary view

Ø

West Point view

!


Dislocations: Gleno-Humeral Joint Anterior = Easy Anterior/Inferior 95% Sub-coracoid (most common)


Dislocations: Gleno-Humeral Joint

(M,D 62yoF)

AP view Obl view Y view

Anterior = Easy Anterior/Inferior 95% Sub-coracoid (most common) Sub-glenoid


Dislocations: Gleno-Humeral Joint Anterior = Easy Anterior/Inferior 95% Sub-coracoid (most common) Sub-glenoid Sub-clavicular (uncommon)


Dislocations: Gleno-Humeral Joint Anterior = Easy Anterior/Inferior 95% Sub-coracoid (most common) Sub-glenoid Sub-clavicular (uncommon)

Luxatio Erecta Arm fixed in

extreme abduction AP view




Dislocations: Gleno-Humeral Joint Anterior=Easy Anterior/Inferior

Posterior=Hard Straight Posterior 5% of Disloc. Unusual muscle

contractions Seizure Electrocution

Missed 50% of the time

©Ken L Schreibman, PhD/MD 2010 schreibman.info (C,D)

Posterior Shoulder Dislocation

Always ask, “Am I missing Post Disloc?” Clues: 1) 2) 3)

Humerus Stuck Int. Rotation Lack of Parallelism of GHJ Trough Line Sign Cisternino,Rogers AJR1978;130:951

Answer: Get Axillary view!

AP view Obl view Cor (Ant)

GT en face

GT en face

Humerus

©Ken L Schreibman, PhD/MD 2010 schreibman.info (C,D)

Posterior Shoulder Dislocation Answer: Get Axillary view!

AP view Obl view Cor (Ant)

R e d u c e d

“Reverse Hill-Sachs”

©Ken L Schreibman, PhD/MD 2010 schreibman.info (E,L 45yoM)

Posterior Shoulder Dislocation AP view Axillary view Axial CT Obl view

R e d u c e d

©Ken L Schreibman, PhD/MD 2010 schreibman.info (J,B 32yoM)

Posterior Shoulder Dislocation Obl view AP view Axillary view Axial CT

R e d u c e d

&

F i x e d

©Ken L Schreibman, PhD/MD 2010 schreibman.info (R,M 51yoF)

Posterior Shoulder Dislocation Obl view AP view

Axillary view

Chronic Dislocation




Acromio-Clavicular Joint

ACJ Ligaments that stabilize ACJ:

A-C Lig Acromio-Clavicular

C-C Lig Coraco-Clavicular


Dislocations: Acromio-Clavicular Jt Grade 1

Sprain AC Lig

Grade 2

Grade 3

Grade 4

Grade 5



Sprain AC Lig

Grade 2 Rupture AC Lig

Grade 3

Grade 4

Grade 5



Sprain AC Lig


Grade 3 Rupture CC Lig

Grade 4

Grade 5



Sprain AC Lig



Grade 4 Clav Post Disloc

Grade 5



Sprain AC Lig




Grade 5 Clav thru Trap




ACJ Radiographically Grade 1

Sprain AC Lig





………Normal (Dx by Physical Exam)

………Subluxation (Clavicle above Acromion)

………Dislocation (Clavicle above Acromion)

………Lack of Parallelism (Best seen: Ax/WP view)

………Big Time Disloc! (Clav WAY above Acrom)



Sprain AC Lig ………Normal

(Dx by Physical Exam)

(K,K 15yoF)



Sprain AC Lig




(D,V 21yoM) ©Ken L Schreibman, PhD/MD 2010 schreibman.info


Sprain AC Lig





………Dislocation (Clavicle above Acromion)

CC distance dislocated side ≤ 2X distance normal side

(H,C 30yoF)


ACJ Radiographically


………Big Time Disloc! (Clav WAY above Acrom)

CC distance dislocated side > 2X distance normal side

(M,R 37yoM) ©Ken L Schreibman, PhD/MD 2010 schreibman.info


Clav Post Disloc

………Lack of Parallelism (Best seen: Ax/WP view)

(from Mike Tuite, MD)

(W,N 29yoF)

Obl Axillary AP




Proximal Humeral Fractures

Surgical Neck (most common)

Anatomic Neck (least common)

Greater Tuberosity

Lesser Tuberosity

Occur at 4 typical sites:

Tug Rotator

Cuff Shoulder Capsule

War of


Proximal Humeral Fractures Neer Classification System Charles Sumner Neer, II

Father of modern shoulder surgery Born 1917

as of 2007 was still Emeritus Professor, Special Lecturer at Columbia University

www.ases-assn.org/web/about/usapioneer.html

www.cumc.columbia.edu/dept/ortho/residentsandfellows/documents/2007NYOHAAProgram.pdf


Proximal Humeral Fractures Neer Classification System 1-Part, 2-Part, 3-Part, 4-Part Wait a minute…1-Part? If there is a proximal humerus fracture isn’t it broken into at least 2 parts? Not according to Dr Neer

To be considered a “Part” a fracture fragment must be: Displaced > 1cm, or Angulated > 45°


Proximal Humeral Fractures Neer Classification System If no fragment is displaced >1cm or angulated > 45° (1-Part Fx), then the fragments are already

relatively anatomically aligned and do not need to be surgically reduced.

Fractures with 2 or more Parts often require surgery.


Proximal Humeral Fractures Neer 1-Part, Surgical Neck Fracture

(R,D 39yoF)

Displaced < 1cm Angulated < 45°



(S,S 58yoF)

Neer 1-Part, Greater Tuberosity Fx

http://www.ases-assn.org/web/about/usapioneer.html



http://www.cumc.columbia.edu/dept/ortho/residentsandfellows/documents/2007NYOHAAProgram.pdf





(D,P 52yoF)

Displaced < 1cm Angulated < 45°

Neer 1-Part, Surgical Neck & GT Fx

4 months later ©Ken L Schreibman, PhD/MD 2010 schreibman.info


(H,L 75yoF)

Neer 2-Part Surgical Neck

Neer 1-Part Surgical Neck

Two weeks later



(J,S 69yoF)

Angulated > 45°

Displaced > 1cm



(J,S 69yoF)

Neer 2-Part, Surgical Neck Fracture

3 months post-surgery Required pin fixation



(C,B 23yoM) ©Ken L Schreibman, PhD/MD 2010 schreibman.info


(C,B 23yoM)

required surgical reduction


…and pin fixation





(C,B 23yoM)

2 months post-pinning


…required plating 2m later ©Ken L Schreibman, PhD/MD 2010 schreibman.info

Proximal Humeral Fractures Neer 3-Part, Surgical Neck & GT Fx

(G,S 59yoF)

Angulated > 45° Displaced > 1cm Primarily repaired ORIF with plate


Proximal Humeral Fractures Neer 3-Part, Surgical Neck & GT Fx

(B,P 65yoM)

Primarily repaired with shoulder prothesis




Shoulder: What to Order When Radiographs (Oblique, Axillary, AP) Dislocations, Fractures, Healing Instability (Obl, Ax, West Point) Contralateral side is helpful ACJ Peds

Normal side Painful side

Wide Physis Salter-Harris 1

“Little Leaguer’s Shoulder”



Weighted views NOT helpful

Greenspan Figure 5.38


Shoulder Arthritis

(A,A 67yoM)

Osteoarthritis (OA) ACJ: VERY Common ACJ narrows with age Superior osteophytes

not significant Inferior osteophytes

can impinge upon supraspinatus tendon Best seen on

Arch (Y) view ©Ken L Schreibman, PhD/MD 2010 schreibman.info

Shoulder Arthritis Osteoarthritis (OA) GHJ: Not so common Often secondary OA Osteophytes off

inferior head Oblique view

Narrowing GHJ Axillary view

(T,A 64yoF)

Early OA

GHJ


Shoulder Arthritis Osteoarthritis (OA) GHJ: Not so common Often secondary OA Osteophytes off

inferior head Oblique view

Narrowing GHJ Axillary view

(N,D 78yoM)

Advanced OA GHJ


Shoulder Arthritis Osteoarthritis (OA) GHJ: Not so common Progressive

(L,W 59yoM)

9 months later 1 month later Advanced OA GHJ




Shoulder Arthritis Rheumatoid Arthritis (RA) GHJ common site of RA

(K,J 29yoF)

Marginal Erosion


Shoulder Calcific Tendonitis Crystal-based arthropathies: Gout: Uric acid Pseudo-gout: Calcium pyrophosphate Shoulder: Hydroxyapatite

(Normal component bones, teeth) Ca++ common in RC tendons Incidental finding in up to 20%

asymptomatic shoulders 30-50yo 7% painful shoulders

Supraspinatus>Infra>Teres>SubS Comes & Goes www.emedicine.com


Shoulder Calcific Tendonitis

(V,P 53yoM)

Supraspinatus Supraspinatus

(O,T 44yoM)

Supraspinatus

Ext Rotation

Int Rotation

(B,J 45yoM)

(T,D 37yoM)

Infraspinatus… 4 months later

Gone



Arthritis: OA, RA Calcific Tendonitis High-riding shoulder Acromion-Humeral space ≥ 7mm <7mm = Chronic Rotator Cuff Tear

(S,G 54yoM)


Radiographs insensitive for RCT

>7mm

(E,L 69yoF)

Normal Radiograph

Humeral Head aligned with

Glenoid

MRI 1 month earlier (Cor T2-FatSuppressed)

Humeral Head banging into

Acromion

Humeral Head high riding relative to Glenoid

Patient Supine Patient Upright



Arthritis: OA, RA Calcific Tendonitis High-riding shoulder Acromion-Humeral space ≥ 7mm <7mm = Chronic Rotator Cuff Tear

UW shoulder studies

(2005)

RG 77%

http://www.emedicine.com/




Shoulder: What to Order When MRI Best way to evaluate Rotator Cuff

MR-Arthrogram (Intra-Articular contrast) Best way to evaluate Labrum

MR with IV contrast Infection (Septic joint, osteomyelitis) Tumor (Work-up, Follow-up)

UW shoulder studies

(2005)

RG 77%

MR 21%


Shoulder: What to Order When CT Primarily for surgical planning High grade Neer fractures Scapular fractures Large Bankart fractures

Multiplanar Reformat 3D Reformat

Prosthesis loosening Osteolysis

CT-Arthrogram RCT in patients not MR compatible

UW shoulder studies

(2005)

RG 77%

MR 21%

CT 2%

Ultrasound


Shoulder CT for Fractures

(P,C 32yoM)

AP view

Ax view

Obl view



(P,C 32yoM)

AP view

Ax view

Repeat Obl view Obl view CT: Axial

Coronal

Sagittal



(P,C 32yoM) ©Ken L Schreibman, PhD/MD 2010 schreibman.info


(P,C 32yoM)

Schreibman - Shoulder Imaging

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