Ajr Sonography of the Shoulder: Evaluation of the Subacromial-Subdeltoid Bursa

8/18/2019 Ajr Sonography of the Shoulder: Evaluation of the Subacromial-Subdeltoid Bursa

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56 1

S o n o g ra p h y o f th e S h o u ld e r: E v a lu a tio n o f th e

S u b a c ro m ia l-S u b d e lto id B u rs a

M arn ix van H o lsb eeck1 and P e te r J . S trou se

P ic to ria l E s s a y

T h e p u rp os e o f th is es sa y is to illu s tra te th e s o n o g ra p h ic

fin d ing s in p atie n ts w ith ab n o rm a lit ie s o f th e s u ba c ro m ia l-s u b -

d e lto id b urs a . T h e a n a to m y o f th e s u b ac ro m ia l-s u b d e lto id b u rsa

is

co m p lex . T h is p a p er illu s tra tes th e co m p lex ity o f th e n o rm a l

b u rs a an d the fin d in g s in sh o u ld e rs w ith b u rs a l d is ten s ion .

M e t h o d s

W e ob ta ine d s on o gra m s o f 6 1 a b no rm a l sh ou ld e rs in 5 9 p a tien ts

w h o h ad a rth ro sco p ic o r su rg ica l fo llo w -up . S tan da rd te chn iq u e w a s

u se d fo r bo th lo n g itu d in a l an d a x ia l sca n n ing o f th e ro ta to r cu ff ten -

do ns [1 -4 ]. S ca n s o f th e su b acrom ia l-su b de lto id (S A -S D ) b u rsa

a lso w e re inc lu de d in eve ry s tu dy . T he id ea l sca nn in g p la ne fo r th e

S A -S D b ursa is pa ra lle l to the lon g a x is o f th e h um eru s , e x ten d ing

from the o rig in o f th e de lto id m usc le o n the la te ra l e d ge o f th e ac ro -

m io n to the ins e rtion o f th e d e lto id m u sc le d is ta lly on th e s ide o f th e

h u m e ra l sh a ft. T h e la te ra l e dg e o f th e a c ro m io n is e as ily lo ca te d b y

p a lp a tio n . T h e tra n s d u ce r is th e n o rie n te d p e rp e n d icu la r to th is

e d ge fo r lo ng itu d ina l im ag es o f the b u rs a (F ig . 1 ) . S u bse q ue n tly ,

a x ia l im a ge s c an be ob ta in ed by ro ta ting th e tran sd uc e r 9 0 { 1 76 }.

N o rm a l S uba cro m ia l-S ubd e lto id B ursa

T he S A -S D b ursa is th e la rge st bu rsa in the b od y . S yn -

o v ia l f lu id w ith in the b u rsa d iss ipa tes fric tion b o th b e tw ee n

the ro ta to r cu ff an d the acro m io n an d be tw e en th e ro ta to r

cu ff a nd th e d e lto id m us c le (F ig . 2 ). T he b un sa a c ts as a jo in t

b e tw ee n the ro ta to r cu ff and the o ve rly in g s truc tu res , a llow -

in g fre e m o tio n o f th e ro ta to r cu ff re la tive to the ac rom ion

a n d th e d e lto id m u sc le . S u b d e lto id a n d su b a cro m ia l c o m po -

n e n ts o f th e bu rsa a re co n tig u ou s in a p pro x im a te ly 9 5% o f

p a tien ts . T he la rge

d e lto id m u s c le co v e rs th e e ntire sh o u l-

d e n , a s d o e s th e S A -S D b u n sa b e ne a th it (F ig . 3 ). T h e a n te -

n o r e x te nt o f th e b u rsa c o ve rs th e b ice p s te n d o n gro o ve ;

flu id in th e b u rsa o ve rly in g th e b ice p s te n d o n g ro o ve is a

co m m o n fin d in g a n d ca n e a s ily b e m is tak e n fo r d ila ta tio n o f

th e b ice ps te nd on sh ea th (F ig . 4 ) . T he S A -S D b u nsa is an a -

to m ic a lly s e p ara te d fro m th e g le n o h u m e ra l jo in t b y th e ro ta -

to n c uff.

T h e su rfa ce a rea

o f th e b u rs a is la rge ; h o w e ve r, th e tw o

o pp os in g s id es o f th e bu rsa a re se pa ra te d no m o re th an 2

m m in a n o rm a l sh o u lde r. N o rm a l flu id w ith in th e b u rsa

a p p e a rs a s a th in h y p oe c h o ic la y e r sa n d w ic h e d b e tw e e n

hyp e rec ho ic p en ib un sa l

fa t, in tu rn s a n d w ich e d b e tw e e n th e

h yp o e ch o ic d e lto id m u sc le a n d su p ra sp in a tu s te nd o n (F ig . 5 ).

D iste ns ion o f th e S uba crom ia l-S ubd e lto id B ursa

D is ten s ion o f th e S A -S D b u nsa

is b e s t s e e n o n lo n g itu d i-

n a l s o n o g ra m s d is ta l to th e la te ra l ed g e o f th e g re a te r tu b e r-

o s ity . A n a b n o rm a l b u rs a is re co g n ize d a s a te a rd ro p -sh a p e d

stru c tu re w ith th e m o s t d is te n d e d se g m e n t o f th e b u n sa m o st

d is ta l a nd m os t d ep e nd en t (F ig . 6 ). It is no t u nu su a l to se e

e x ten s io n o f a d ila te d bu n sa se ve ra l c en tim e te rs be yo nd th e

in se rtio n o f th e ro ta to r c u ff. P ro x im a lly , th e b u n s a is lo c a ted

be tw e en the d e lto id a n d su prasp in a tu s m u sc le s ; w h ere a s ,

d is ta lly , th e b u rs a is lo c a ted b e tw e e n th e d e lto id m u s c le a n d

th e h u m e ra l sh a ft. F a ilu re to e xa m in e th e d is ta l p o rtio n o f th e

bu rsa is a c om m o n re a son fo r flu id in th is b u rs a no t b e ing

de tec te d du ring a ro ta to r c u ff e xam in a tion .

R ec e iv ed Ju ly 2 9 , 19 92 ; a cc ep ted a fte r rev is io n O ctob e r 5 , 1 99 2 .

1 B o th au th o rs : D e pa rtm en t o f D ia gn os tic R a d io lo gy a nd M e d ic a l Im a g in g (K 3), H en ry F o rd H o sp ita l. 27 99 W . G rand B lvd . , D e tro it, M I 48 202 . A dd res s re p rin t

req ues ts to M . va n H ols be ec k.

A JR

1 99 3;1 60 :5 61 -5 64 0 36 1-8 03 X/9 3/ 16 03 -0 56 1 ( A m eric an R oe n tge n R a y S o c ie ty


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56 2

V A N H O LS B E E C K A N D S T R O U S E

A J R :1 60 , M arc h 1 99 3

F ig . 1 -T e ch n iq u e u s ed fo r s o n o g rap h ic

exa m in a tio n o f s u b acro m ia l-s u b d e lto id 5 A -

S D ) b u rs a . A cro m lo n Is ea s ily p a lpa te d . S A -

S D b u rsa is Id e n tified b y s ca n n in g in fe r io r to

a cro m io n In lo n g itu d In a l c o ro n a l) p lan e , p a r-

a lle l to f ibers o f d e lto id m us cle .

F ig . 2 .-N orm al su ba c ro m ia l-sub d e lto id

S A -S D ) b u rsa . D o u b le -co n tras t ra d iog ra ph

sh ow s p ortio n

b lack a rro w

o f b u rs a ex ten d -

in g m e d ia lly be n ea th a c ro m io n ; th is p o r tion is

th ere fo re o bs cu red o n s on o g ram s. B eca u se

p a tien t is u p rig h t d u r in g s o n o g rap h ic ex am in a -

tio n , as w ith th is rad io g rap h , f lu id co lle c ts in

m o st d ep en d en t p o r tio n o f b u rsa , d is ta l to

g rea te r tu b e ro s ity n e ar in se rtio n o f d e lto id

m u sc le

w hite a rrow .

E a rly o r m ild e f fu s io n is

f requen t ly

m is s ed if s ca n s are n o t m ad e d is ta l

to g re at er tu be ro sity .

F ig . 3 .-C h ro n ic ro ta to r cu ff tea r. C T a rth ro -

g ra m o f g le n o h u m e ra l jo in t sh o w s ab n o rm a l

co m m u n ica t io n be tween jo in t a nd s ub acro m la l-

s u b d e lto id b u rsa

aster isks

a n d e xte n t o f th is

la rg e h o rse sh o e -sh ap ed b u rs a . A n terio rly , b u rsa

c o v ers b ic ep s te n d o n s h ea th

arrowhead

an d

e x ten d s as fa r as co rac o id p roc e ss

no t s ho wn .

L ate ra lly , b u rs a e x te n d s u n d er s u r fac e o f d e lto id

m usc le D ), w ith its p o ste rio r e x ten t s ep a ra tin g

d e lto id an d in fras p in a tu s I) m usc les .

F ig . 4 .-D is te nd ed s ub ac ro mia l-s ub de lto ld

S A -S D ) b u rs a . A x ia l s o n o g ra m sh o w s flu id

w ith in 5A -S D b u rs a . F lu id su rro u n d s h u m e ru s ,

b u t m o re flu id Is p res e n t an te rio r ly . T h is

p atien t w ith k n o w n ro ta to r c u ff tea r h a d a cu te ly

ex tended tea r 2 d ay s e arl ie r . B =

n orm a l b ic ep s

te nd on a nd s hea th .

F ig . 5 .-N orm al s ub ac rom la l-s ub de lto ld

b urs a. O n lo ng itu din al s o n o g ram , n o rm a l b u rsa

Is

le s s th a n 2 m m th ic k a n d is s e en a s a h y p e-

e ch o ic s trip

as ter isks

san d w ich ed b y hy pe r-

ec ho ic p erib ur sa l fa t, In tu rn sa n d w ic h e d b y

hy poec ho ic de lto id m usc le a nd su pra sp in atu s

te n d o n . S ub d e lto id p o rt io n o f bu rs a ex te n ds

o ver g rea te r tu be ro sity G D.

F ig . 6 .-D is ten de d s ub ac ro m ia l-s ub de lto id

S A-S D) b urs a w ith In tac t ro ta to r c u ff. L on gitu -

d in al s o no gra m o f a p atie n t w ith sy m pto ms s im -

lIa r to th o s e o f Im p in g e m e n t sh o w s a s lig h tly

d is ten d e d S A -S D b u rs a arrows .

D i s t e nde d

por t ion o f b u rsa Is d is ta l to g rea te r tu b e ro s ity

G D. R ota to r

cu f f

S U PR AS P) Is In ta ct.

F ig . 7 .-P o sttr au m atic s ub ac ro m ia l-s ub de l-

to ld 5 A -S D) b u rs itIs . L o n g itu d in a l s onogr am

s h o w s d is te n s io n o f S A -S D b u rs a

as ter isk ,

w hich co n ta in s h yp e re ch o ic b loo d c lo ts arrow .

T he se m ob ile h yp ere ch oic le sio ns

a re d if fe re n t

f ro m s es si le

prol i ferat ive

s yn o vl al l es io n s

s een

I n a r th r it is an d p ig me nte d v illo no du la r s yn ov itis .

S y no vi al l es io n s

ar e

m o st o ft en h yp o ec ho ic

rela-

fi ve t o s urr ou nd in g

c ap su le an d m usc le . R ota to r

cu f f

w as in ta ct . A rth ro grap hic fin din gs w ere n or-

m al, an d b lo o d w as as p ira ted d u rin g bur s og r a -

p h y . D = d el to id m u sc le .


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F ig . 8 .-C hro nic im pin ge m en t sy n dro me .

A,

O n lo n g itu d in a l s o n o g ra m o f le ft s id e , n o rm al s u b ac ro m ia l-s u b d e lto id S A-S D)

bur s a arrows

Is im ag ed a s a th in h yp oe ch oic line sa n dw ic h ed

b e t w e e n hy per ec ho ic

p e rib u rs a l fa t, In tu rn s an d w ich e d

b e tw e en h ypo ec ho ic

d e lto id m u s c le an d

s up ra sp in at us te nd on .

B, O n lo n g itu d in a l s o n o g ra m o f rig h t s id e , h yp o e ch o ic flu id d is ten d s S A -S D b u rs a

arrows , separa t ing

h yp erec ho ic p er lb ursa l fa t.

F ig . 9 .-R he um ato id a rth rIt is . Lo ng itu d ina l

s o n o g ra m o f

p a t ie n t w ith rec e n t on s e t o f s h o u ld e r p a in sh o w s th a t

su p ras p in a tu s te n d o n S U P R A ) Is in tac t. H y p o ec h o ic z o n e

be tween d e lto id m u sc le a n d s u p ra sp in a tu s te n d o n re p re -

s en ts a d is te n d ed s u b ac ro m ia l-s u b d e lto ld b u rsa . B u rsa l

syn o vec to m y w as

s ub se qu en tly p er fo rm e d.

A J R :1 60 , M a rch 19 93

S O N O G R A P H Y O F T H E S H O U L D E R 5 63

B u rsa l d is te n s io n m ay b e d u e to c o m m u n ica tin g o r n o n -

co m m un ic a tin g ab n orm a lit ie s . C o m m un ic a tio n im p lie s p a th o -

lo g ic in te rco n n e c tio n w ith th e g le n o h u m e ra l jo in t, u s u a lly

a sso c ia ted w ith a te a r o f the ro ta to r cu ff. M o re th a n 90 % o f

p a tien ts w ith p a th o lo g ic d is ten s io n o fth e S A -S D bu rsa h a ve a

ro ta to r c u ff te a r, a n d it is a n im p o rta n t in d ire c t s ig n o f d is ea s e .

S e p tic in fla m m a tio n o f th e b u n sa w ith o u t co n co m ita n t in fe c-

tiou s a rth rit is o f the g len o hu m e na l jo in t is ra re , bu t ca n res u lt

from d ire c t ino cu la tio n w ith a con ta m in a te d n e e d le , p a rtic u -

la rly in IV d ru g ab us e rs (F ig s . 1 0 an d 11 ). Id en tif ic a tion o f s ep -

tic b urs it is

is n e c es sa ry to a vo id p o s s ib le se e d in g o f a n

u n in fe c te d g le no h um e n a l jo in t d u rin g a tte m p ts a t a sp ira tio n .

N o n c o m mu n ica tin g b u t A b n o rm al S u b ac ro m ia l-

S u b d e lto id B ursa

A d ire c t b low to the S A -S D bun sa can cause th e bun sa to

fi ll w ith b lo o d . O n s o no g n a m s , th e b u ns a is in itia lly h y pe r-

e ch o ic , b u t in su bs eq ue n t d ay s it b e com es m ixed h yp en -

e c ho ic a n d h yp o e ch o ic a fte r b re a kd o w n o f b lo o d (F ig . 7 ).

T h is in ju ry is u n co m m o n , b u t it ca n m im ic ro ta to r cu ff d ise a s e

a nd ca n ca us e co m p le te fun c tio na l los s fo r s eve ra l w ee ks .

M o re co m m o n ly , th e S A -S D b u rsa is irr ita te d b y ch ro n ic

rep e tit ive tra um a in p a tien ts w ith a n a rrow ed su prasp in a tu s

o u tle t (“ im p in g em en t syn d rom e”).

O n so n o g n a m s, th e se

th icke n ed b urs ae are d is ten de d w ith h yp o ech o ic a n d

an e cho ic flu id (F ig . 8 ). T h e in te g rity o f th e un de rly in g ro ta to r

cu ff d e te rm in e s th e g ra d e o f im p in g e m e n t, ra n g in g fro m an

in ta c t ro ta to r cu ff w ith bu ns a l he m o rrh ag e , fib ro s is , a n d ten -

do n e de m a (g ra d es I a nd II) to a to rn ro ta to r c u ff (g rad e III) .

In fla m m a tio n o f th e S A -S D b u rsa w ith syn o v ia l w a ll th ic k -

en in g is co m m o n in b o th se rop o s itive a nd sen o ne ga tiv e

rh e u m a to id a rth ritis (F ig . 9 ). A m ylo id o s is , po lym ya lg ia n h e u -

m a tica , a nd hyd ro xya pa tite d e po s ition a ls o can ca u se

in fla m m a tio n o f th e S A -S D b u n sa .

C om mu n ica tin g and A bno rm al S uba cro m ia l-S ub de lto id

Bu r s a

T h e s w o lle n co m m u n ica tin g S A -S D b u n sa h a s a te a rd ro p

c o n fig u ra tio n id e n tica l to th a t o f th e n o n co m m u n ic a tin g

b urs a ; h ow ev er, co m m un ic a tio n w ith th e g le no hu m e ra l jo in t

th ro u g h a ro ta to r cu ff tea r is o fte n s o n og n a p h ica lly d e te c t-

a b le . C op io u s flu id w ith in the S A -S D b un sa c an o ften b e

fo rce d th ro u g h th e te a r in to th e jo in t, e n ha n c in g te a r id e n tifi-

c a tio n o n so n o g ra m s (F ig . 1 2 ). M o re co m m o n ly , a c o lle c tio n

o f bu rsa l flu id is s ee n ove rly in g th e g re a te n tu be ro s ity a d ja -

c en t to a re tra c ted se g m e n t o f ro ta to r cu ff te n do n (F ig . 1 3 ) .

T h is o fte n su b tle fin d in g re p re se n ts a th icke n e d o r s lig h tly

d is te n d e d S A -S D b u rsa a n d m a y b e th e o n ly ov e rt s ig n o f a

te a r in th e su p ra sp in a tu s te n do n . In o u r ex pe rie n ce , the

m o s t c om m o n a sso c ia te d fin d ing s o f ro ta to r cu ff tea r a re

lo ca l d is ten s ion o f th e S A -S D b urs a o ve r th e an te rio r th ird o f

th e g re a te r tu b e n o s ity a n d th e p re se n c e o f a flu id la y e r c o y-

e n ing th e b ic ep s ten d on g ro ove a x ia lly (F ig . 4 ). In u n usu a l

ca se s , a s tum p o f to rn s up ra sp ina tus te nd on s til l a ff ixe d to

th e h u m e ru s is id e n tifie d (F ig . 1 4 ).


4/7

-

-

-

.

.-.- --

-. y..-... {149 } {149 }

56 4

V A N H O L S B E E C K A N D S T R O U S E

A J R :1 60 , M arc h 1 993

F ig . 1 0 .-S ep tic sub a c ro m ia l-sub d e lto id

S A-S D) b urs itis . A xia l, co ntra s t-e n han ce d C T

sc an o f sh o u ld er s h o w s h ors es h o e-s h ap e d

S A -S D b u rs a is p a th o lo g ic a lly d is ten d e d w ith

d eb r is an d g as

s ma ll so lid arrow s .

5A - 5D

b u rsa ex te n d s p o s te rio r to h u m e ra l h e ad , b u t

w he n d is ten de d , an te r io r p ortio n is m os t p ro m-

i n en t

o p en arrows .

O n s o n o g ra m s, flu id in

an te rio r p o rtio n o f b u rs a m ust b e d if fe ren tia ted

fro m flu id w ith in b ice p s ten d o n sh e ath . Large

arrow

= b ice p s ten d o n w ith s m all am o u n t o f

ad ja ce nt flu id ,

arrowheads

= flu id in p os te rio r

a sp e ct o f g le n o hu m era l jo in t. N o te en h a n ce -

m e n t o f b u rsa l w a lls .

F ig . 1 1 .-S ep tic su ba cro mia l-su bd elto id

S A -S D) b u rs itis . A x ia l s o n o g ra m o f s h o u ld e r

o f an IV d ru g ab u se r sh o w s h yp o e ch o ic zo n e

be tween

d e lto id m u sc le a n d b ice p s ten d o n

s h ea th re p re se n tin g a d is ten d e d S A -S D b u rs a

aster isks .

D iffu se lo w -le ve l in ho m og en eo us

e ch oe s a re p res en t w ith in b ursa . N o p ath olo gic

flu id is p re se n t w ith in e ith er b ic ep s ten d o n

sh ea th o r g len o h u m era l jo in t P u s-filled S A -5 D

b u rsa w as s u rg ic a lly d ra in e d . v isu a liz a t io n o f

se p t ic b u rs itis is a c le ar ad va n ta g e o f so n o g ra -

p h y o v er “ b lin d ” a rth ro g rap h y , in w h ic h an

un in fe cted s hou ld er co u ld b e see d e d .

F ig . 1 2 .-R o ta to r c u ff tea r.

A , L o n g itu d in a l so n o g ra m s h o w s typ ica l

teard ro p sh a p e o f d is ten d e d su b a cro m ia l-su b -

d e lto id 5 A -S D ) b u rs a arrowheads . Debr is

arrows

is p res en t w ith in b urs a.

B,

L o n g itu d in a l so n o g ra m o b ta in ed afte r

p re s su re w as ap p lied to d is te n d ed 5A -S D

b u rsa arrowheads ,

e x p re ss in g flu id fro m

b u rs a th ro u g h ro ta to r c u ff tea r a n d In to g len o -

h um era l jo in t.

D = d e lto id m u s c le , G T = g re at er t ub e ro s it y,

aster isk =

s ite o f ro ta to r c u ff te ar.

F ig . 1 3 .-R o ta to r cu ff

te ar. L on gitu din al

s onogr am sh ow s s ub ac ro mia l-s ub de lto id b urs a

d is ten d e d b e ca u se o f a tea r w ith in s u p ra sp in a -

tu s ten d o n S U P R A ). Aster isk = s ite o f te ar.

G re ate r tu be ro sit y

T U B ) is irreg ula r in co nto ur

a dja ce nt to te ar.

F ig . 1 4.-R o ta to r c u ff te ar . L o n g itu d in a l

s o n o g ram sh o w s a “s tu m p ” o f s u p ras p in a tu s

ten d o n a t its in s ert io n . F lu id fills g ap c re a te d

b y tea r w ith in su p ra sp in a tu s te n d o n aster isk .

A r ro w s =

flu id in s ub ac ro mia l-s ub de lto id

b urs a , G T

=

g rea te r tu bero sity . Th is fin din g is

u n u s u a l; in m os t fu ll- th ick n e ss te ars , n o s ig n if -

Ica n t tissu e is a tta che d to g rea te r tub e ro s ity

cf. F ig . 1 3 ) .

R E F E R E N C E S

1 . van H o lsbe ec k M , In troca so JH . M u sc ul os ke le ta l u ltra so un d, 1 st ed . C hi-

c ag o: M os by -Y ea r B oo k, 1 99 0:2 65 -2 84

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Ajr Sonography of the Shoulder: Evaluation of the Subacromial-Subdeltoid Bursa

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