1.Imaging of shoulderDr. Vishal Sankpal

2. Abbreviations SST supraspinatus IST infraspinatus SSC subscapularis TM teres minor RTC rotator cuff GHL glenohumeral ligament IGHL inferior glenohumeral ligament GHLC glenohumeral labral complex PC post contrast 3. IntroductionThe shoulder is one of the most sophisticated andcomplicated joints of the body: It has the greatest range of motion than any jointin the body To allow so much movement the joints need tobe free to move, therefore the shoulder shouldbe unstable compared to other joints of thebody; However a series of complex ligaments andmuscle help in stability. 4. Anatomy 5. Joints (shoulder complex) 6. Parts of Synovial Joint Articulating bones Synovial membrane Fibrous capsule Intra-articular structures (like labrum) Ligaments Bursae Muscles 7. Glenohumeral Joint Ball and socket synovial joint Very mobile instability 45% of all dislocations !! Joint stability depends on multiple factors (staticand dynamic stabilizers) 8. Bones 9. Fibrous CapsuleLoose for maximum movementsGaps: Anteriorly: allows communication between synovial membrane and subscapularis bursa. Posteriorly: allows communication with infraspinatus bursa.Synovial Membrane Attached around the glenoid labrum. Lines the capsule. Attached to articular margins of head of humerus. Covers intracapsular area of surgical neck. Communicates with 2 bursae through gaps in capsule. Invests long head of biceps in a tubular sleeve. Glides to and fro during adduction and abduction. 10. Glenoid labrum Fibrocartilage similar to knee menisci Deepens the glenoid fossa 11. Ligaments 12. Muscles 13. Bursae Sac between two moving surfaces thatcontains a small amount of lubricating fluid To reduce friction 14. Acromioclavicular joint Diarthrodial joint / Gliding synovial joint Thin capsule AC ligaments Anterior, posterior, superior, inferior Coracoacromial ligament Coracoclavicular ligaments Trapeziod ligament Conoid ligament 15. Stability Static stabilizers glenohumeral ligaments, glenoid labrum and capsule Dynamic stabilizers Predominantly rotator cuff muscles and biceps (long head) Also scapular stabilizers Trapezius, levator scapulae, serratusanterior, rhomboids 16. Radiography 17. Radiography Initial investigation of choice for all shoulder problems. Can detect most fractures, dislocations, calcifictendinitis and other skeletal causes of pain such asarthritis and bone tumors Different situations require different types of plainfilms (AP/Lateral/Axillary views): Impingement views in clinically suspected impingement syndrome and/or rotator cuff tears to detect subacromial spur Axial or anterior oblique views in trauma 18. AP :Routine view AP relative to thorax Suboptimal view ofGlenohumeral joint Good view of ACjoint 19. AP View:External RotationGreater tuberosity & soft tissues profiled and bettervisualized 20. AP View: Internal RotationMay demonstrate Hill-Sachs lesions 21. Axillary lateral ViewGood view of anterior-posterior relationship of GH joint 22. Scapular Y Lateral View of the Shoulder Shoulder impingement: toevaluate the subacromial spaceand the supraspinatus outlet 23. Ultrasonography 24. USG Preferred initial modality in suspected RTCpathologies > 90 % sensitive and specific for RTC tears Comparable to MRI in evaluation of fullthickness rotator cuff tears Bony pathologies not well seen 25. Advantages: no ionizing radiation, no contrast agent, relatively inexpensive, readily available Dynamic evaluation Guided aspiration / injection possible Limitations: Less sensitive for detecting partial thickness rotatorcuff tears Cannot accurately evaluate the labral-ligamentouscomplex. 26. Shoulder USG Protocol(Radiology: Volume 260: Number 1July 2011 n radiology.rsna.org) Step 1 - Biceps brachii tendon, long head Step 2 - Subscapularis and biceps brachiitendon, subluxation/dislocation Step 3 - Supraspinatus and rotator interval Step 4 - Acromioclavicular joint, subacromial-subdeltoidbursa, and dynamic evaluation for subacromialimpingement Step 5 - Infraspinatus, teres minor, and posterior labrum 27. Step 1 - Biceps brachii tendon, long head 28. Step 2 - Subscapularis Step 2 - Subscapularis 29. Step 3 - SupraspinatusStep 3 - Supraspinatus 30. Step 4 - Acromioclavicular jointDynamic evaluation for subacromial impingement 31. Step 5 - Infraspinatus, teresminor, and posterior labrum 32. CT Superior to plain radiographs in evaluation ofcomplex fractures and fracture-dislocationsinvolving the head of the humerus Allows planning of treatment of complexproximal humeral fractures 33. CT1) Glenoid 9) Teres minor2) Humerus 10) Triceps3) Deltoid 11) Pec major4) Infraspinatus 12) Pec minor5) Scapula 13) Biceps (long)6) Supraspinatus 14) Biceps (short)7) Clavicle15) Teres major8) Subscapularis 16) Latissimus 34. MRI 35. MRI Highly accurate for evaluation of rotator cuffpathologies Indicated when further investigation of rotator cuffpathology is needed. Advantages: No ionizing radiation Non-invasive Multi-planar imaging Demonstrates other lesions such as ACJ osteoarthritis and avascular necrosis. Comprehensive display of soft tissue anatomy Demonstration of the causes for impingement Useful in characterization and staging of bone tumors 36. MRI Technique-T1 and T2 FS-Oblique Coronal -T1 and T2 FS -Oblique Sagittal -T2 FS and GRE -Axial 37. Normal T1 Normal FS T2 Normal FS PD 38. Rotator Cuff (Sagittal)Supraspinatus;Infraspinatus; Teres Minor; Subscapularis 39. Rotator Cuff (Coronal)-Primary Plane for Evaluating -Musculotendinous Junction atthe Supraspinatus Tendon12:00 Position 40. Rotator Cuff (Axial Plane)-Primary Plane for -InfraspinatusEvaluating Subscapularis Located Posteriorly 41. Rotator Cuff (Coronal)- Infraspinatus-Subscapularis- Located Posteriorly- Located Anteriorly- Slopes upward- Multi-slip tendon 42. Arthrography 43. Arthrography PREREQUISITES: Obtain signed consent. RISKS: Infection, Pain, Hematoma MATERIALS: 22G 3 needle 25G 1 needle 5 cc syringe with lidocaine for skin anesthesia 20 cc syringe with combination of 1% lidocaine Omnipaque 300 Gadolinium contrast (if performing MR) 44. Shoulder MR or CT Arthrography Place the patient supine Target the junction of the middle and inferior thirds of humeral head just lateral to the medialcortex of humeral head. Local lignocaine given Fill a 20 cc syringe with the proper contrast solution and fill connecting tubing being sure toeliminate all bubbles. Advance a 22 G spinal needle until contact bone at target site. Pull back 1 mm and turn bevel toward humeral head. Advance and feel the syringe drop into thejoint. MR Arthrogram: Inject 12 cc of a solution of 5 cc normal saline, 5 cc Omnipaque 300, 10 cc 1% lidocaine, and 0.1cc gadolinium. Instruct the patient on the importance of the ABER position and how it can help the surgeonfigure out how to fix them. CT Arthrogram: Inject 12 cc of a solution of 5 cc normal saline, 10 cc Omnipaque 300, and 5 cc 1% lidocaine Helical CT should be performed with thinnest slices available, preferably in a single breath hold inboth internal and external rotation. 45. MR arthrography Most accurate and first line imaging modality fordefining: Rotator cuff pathology Labral/capsule abnormalities in gleno-humeral instability Superior depiction of partial-thickness tearscompared to conventional MRI. Disadvantages : invasive, limited availability andhigh expense. 46. CT arthrography Alternative for assessment of gleno-humeralinstability (usually following dislocation) onlywhen MRI is contraindicated or unavailable Allows accurate evaluation of capsule / labraldisorders Disadvantage invasive, radiation 47. Shoulder Pathologies 48. Pathologies Rotator Cuff Biceps tendon Labrum and capsule Osseous structures Arthritis Neural impingement Tumors Miscellaneous 49. Rotator cuff Tendinopathy Partial tears Full thickness tears Calcific tendinitis Parsonage Turnersyndrome 50. Rotator cuff tendinopathyAlso known as - Rotator cuff tendinosis Definition collagenousdegeneration of rotatorcuff tendons, mostcommonlysupraspinatus (SST) 51. Radiographic findings Acromial remodeling / sclerosis AC joint hypertrophy Humeral head subchondral sclerosis / cysts 52. MRI T1W thickened heterogeneous tendons withintermediate signal intensity T2W low to intermediate signal FS PD and STIR heterogeneous tendons withincreased signal intensity Hyperintense effusion (glenohumeral joint) Hyperintense bursitis ( subacromial / subdeltoid ) Type III (hooked) acromion MR arthrography no cuff defect identified 53. HRUS Thickened hypoechoic Tears directly visible Less sensitive for partial thickness tears Advantage allows dynamic evaluation withpain correlation 54. Differentials Partial tear T2 (without fat sat) shows diminished / intermediate signal intensity in tendinosis as compared to a hyperintensity of a true cuff tear Calcific tendinitis thickened tendon with decreased signal on all sequences Form of tendinopathy Hyperintense surrounding edema on T2WI Intratendinous cyst Well defined , usually oval Hyperintense cyst on T2WI Magic angle artifact Increased signal at curved portion of tendon 55 degrees to external magnetic field Affects biceps and SST tendon and labrum 55. Rotator cuff tears Clinical Trauma (acute / chronic micro-trauma) Adults > 4o with impingement Collagen vascular diseases Partial more painful than complete tears !!!!TYPES - Partial supraspinatus most common Types bursal surfaceinterstitial (not seen on arthroscopy)articular surface Complete supraspinatus most common Extends from bursal to articular surface 56. Partial tears 57. Radiographic findingsFindings associated with impingement anddegenerative changes Acromial spurs Type III (hooked) acromion Humeral head arthritic changes at greatertuberosity AC degenerative changes 58. MRIIncomplete defect in tendon filled with joint fluid +/- granulationtissue T1WI thickening of RTC tendons intermediate signal Calcifications hypointense bone impaction (Hill-Sachs) in case of anterior dislocation T2WI Fluid signal intensity filling an incomplete gap in tendon Fluid in subacromial bursa Increased signal on FS PD (sensitive for partial tears) Retraction and degeneration of tendon edges (bursal or articular) 59. PC T1 enhancement of the granulation tissue MR arthrography Contrast may fill the tear if articular surface of thetendon communicates with joint 60. USG Decreased echogenicity and thinning inaffected region Loss of convexity of tendon / bursa interfacein bursal surface tears Calcific foci in tendons 61. Differentials RTC tendinopathy Full thickness tear without visiblecommunication closed by granulation tissue/ fibrosis / adhesions Intratendinous cyst can be associated withpartial tears Calcific tendinitis hypointense on allsequences 62. Full thickness tears 63. Full thickness tearsEtiology similar to partial tearsAssociated with Hill Sachs deformity (anterior dislocation) Biceps tendinosis / tears / SLAP lesions with micro instability 64. Radiography Acromial spurs Type III (hooked) acromion Humeral head arthritic changes at greatertuberosity AC degenerative changes Superior humeral head migration 65. MRI T1WI Thickened indistinct tendon Tear edges not delineated on T1 Calcifications (i/c/o calcific tendinitis) T2WI Hyperintense fluid signal filling a gap in the tendon (T2 andFS PD) Bald spot sign hyperintense fluid bald spot withinhypointense tendon On sag and axial T2 Fluid in subacromial bursa Retraction and degeneration of tendon edges Sometimes associated with fatty atrophy of muscles (fatsignal on T1) 66. Bald spot sign 67. USG Focal tendon interruption Fluid filed gap (hypoechoic) Loss of convexity of tendon / bursa interface Tendon retraction Uncovered cartilage sign 68. MRI Rotator cuff tear grading- Dr Yuranga Weerakkody and Dr Frank Gaillard et al. grade 0 : normal grade I : increased T2 signal with normal morphology grade II : increased T2 signal with abnormal morphology(thickening, or irregularity of the tendon) grade III : defined tear (e.g. partial or fullthickness, complete or incomplete) 69. Rotator interval tears 70. Rotator interval tears What is rotator interval ?? Tunnel through which long head of biceps travelsfrom its origin at the supraglenoid tubercle Rotator interval tears tears in the capsulebetween the supraspinatus and subscapularistendons Can be classified as subtype of RTC tears 71. MRI T1 Thickened rotator interval Biceps tendinosis and subluxation T2 Visible tear in rotator intervalAssociated tear of SST may be presentFS PD sag images are useful to detect abnormal fluid extension across rotator interval MR arthrography Leakage of contrast through the tear in RIIntact SST and SSC 72. Internal impingement 73. Internal impingement Definition - Degeneration and tearing of posterior SSTand anterior infraspinatus tendons (undersurface /articular surface) due to impingement by postero-superior labrum and humeral head Postero-superior glenoid impingement (PSGI) Overhead throwing activities athletes (throwers) Dynamic compression occurs during abduction (> 120degrees), retropulsion and extreme external rotation(ABER) 74. MRI T1 Thickened posterior SST and anterior IST (tendinosis) Postero-superior labral irregularity (fraying) Tear in postero-superior labrum (can be avulsed)Postero-superior humeral head irregularity T2 Hyperintense signal on articular surface of posterior SSTand anterior IST Hyperintense signal (FS PD) in postero-superior humeralhead, humeral head chondromalacia Fraying +/- tear of PSGL 75. Axial FS PDSynovitis, labral fraying, sclerosis atposterosuperior glenoid, cystic changes inposterolateral humeral head 76. MR arthrography Postero-superior labral fraying / teardemonstrated by contrast outline ABER imaging shows undersurface tears Chondromalacia outlined by contrast 77. Best diagnostic clue - triad of damage at1. Undersurface of RTC2. Postero-superior labrum3. Humeral head Differentials Subacromial impingement (history differs) SLAP without RTC pathology 78. Rotator cuff calcific tendinitis 79. Rotator cuff calcific tendinitis Calcium Hydroxyapatite deposition disease (HADD) Calcifying bursitis Not typical Ca++ of degenerative disease of tendons, but crystallineCa++ Pathology deposition of Calcium Hydroxyapatite in RTC tendons Etiology Avascular change, trauma, abnormal Ca++ metabolism Housewives and clerical workers more affected Location SST > IST > TM > SSC Peri-articular soft tissues like capsule, bursae may be involved 80. Stages / classification (Moseley) Silent Mechanical intra bursal or sub bursal rupture Physical restriction of movements Adhesive peri-arthritis tendinitisbursitis 81. Radiography Calcific deposits Internal rotation demonstrates posterior tendonswell (IST and TM) Axillary view and scapula Y view helpful CT Better localization of calcium deposits Dense, granular, well demarcated calcifications 82. MRI Globular decreased signal mass (on all pulsesequences) in RTC tendons Often surrounded by edema / partial tear(hyperintense) No involvement of articular cartilage Hydroxyapatite deposits may have exactly samesignal as normal cuff tendons T2*GRE is helpful as calcifications bloom andincrease sensitivity 83. Axial PD 84. Differentials Degenerative calcification in torn tendon Usually smaller calcifications In older age group Different chemical composition Loose bodies Chondral defects seen Articular OA changes Osteochondromatosis 85. Parsonage - Turner syndrome 86. Parsonage - Turner syndrome Idiopathic denervation of the shoulder musculature More than one nerve may be involved Mainly affects the LMN of the brachial plexus and / or individualnerves or nerve fibers Etiology Immune mediated reaction against nerve fibers Trauma, infection, surgery, vaccination, systemic illness Pathology Degenerative changes in affected muscles Early and subacute swollen muscle belly Chronic - fatty atrophy 87. CT Acute / subacute cases mildly increased bulkof muscles Chronic cases fatty density in involvedmuscles 88. MRI MRI abnormalities appear usually after 2 weeks T1 Early decreased signal (edema) Chronic muscle atrophy with streaky fat signals (fatty atrophy) T2 Early increased signal intensity, enlarged muscle bulk Chronic atrophic muscles Nerve distribution pattern +/- PC T1 muscle belly enhance in early stages 89. Differentials Traumatic neurapraxia Non specific myositis ( usually nerve patternnot followed) Direct trauma to the muscle belly (history) 90. Pathologies Rotator Cuff Labrum and capsule Biceps tendon Osseous structures Arthritis Neural impingement Tumors 91. Labrum and capsule Labral cyst Antero-superior variations Adhesive capsulitis Bankart Perthes ALPSA GLAD HAGL IGL Bennett 92. Labral cyst 93. Labral cyst Cyst arising from labral / capsular tear / capsulardiverticulum Etiology cyst arising due to break in integrity ofjoint 3-5 % of labral tears associated with labral cysts Slow growing, original tear may heal Associated abnormalities Instability (non healed) SLAP (superior labrum anterior to posterior) Denervation of SST and IST (compression) 94. MRICommon location adjacent to postero-superior labrumfunneled between SST and IST (path ofleast resistance) T1 Decreased signal intensity cystic mass T2 Hyperintense cystic lesion Often multiloculated Arising from / immediately adjacent to the labrum / capsule Degenerative changes in SST / IST (suprascapular nerve) Labral tear MR arthrogrpahy Cyst filled with contrast 95. Differentials Neoplasm Internal enhancement Not associated with labral / capsular tear Normal vessel plexus in suprascapular notch Can be enlarged in CHF 96. Antero-superior labrum variations 97. Antero-superior labrum variationsCongenital anatomical variationsMay be developmental Sub-labral foramen Buford complex (BC) Labral types Synovial recesses 98. Sublabral foramen Relative lack of attachment of anterosuperiorlabrum to the glenoid rim in anterior superiorquadrant MRI Hyperintense fluid signal (mostly linear) on T2undermining the antero-superior labrum Should not be confused with SLAP lesion Bankarts lesion below the equator (antero-inferior) 99. Axial FS PD - anterior labrum directlyattached to the hyaline cartilage 100. Buford complex Complete absence of antero-superior labrum+ Thick cord-like middle glenohumeral ligament(MGHL) anterior to the anterosuperior glenoidrim 101. Buford complex 102. Labral typesVariations in labral attachment patterns Superior wedge labrum Posterior wedge labrum Anterior wedge labrum Meniscoid labrum 103. Synovial recesses Visualized on sag images as capsular variationsrelative to MGHL 104. Adhesive capsulitis 105. Adhesive capsulitis Frozen shoulder Pathology - Inflammation of the inferior shouldercapsule (axillary pouch) causing limited range ofmotion May accompany other disorders like impingement(secondary adhesive capsulitis) EtiologyIdiopathic(primary), trauma, infection, surgery, metabolic(diabetes) 106. Radiography Plain radiography not useful Arthrography Contracted irregular capsule Decreased volume +/- Over-injection may leading to capsule rupture maybe therapeutic !!! (improved ROM) 107. MRI T1 Thickened indistinct capsule margins T2 Thickened capsule (> 3mm on coronal images) Increased signal Thickening more conspicuous on FS PD, STIR and T2*GRE FS more sensitive for capsular edema and synovitis Sagittal images for rotator interval MR arthrography Capsule enhances diffusely, acutely Restricted capsular volume 108. Bankart lesion 109. Bankart lesion Avulsion of inferior glenohumeral labralcomplex (IGHLC) Etiology IGHLC is a weak link among the static stabilizersof young shoulder Occurs after initial anterior dislocation in young ( >90% cases are < 40 years) 110. Asociated abnormalities Bony Bankart osteochondral fracture in some cases Hill Sachs lesion fracture at posterolateral superior humeral head Partial / complete RTC tears 111. Radiography Subglenoid / subcoracoid dislocation Glenoid rim fractureCT Arthrography contrast extending into thelabral tear 112. MRI T1 Hypointense edema / sclerosis at antero-inferior glenoid Glenoid rim fracture (sag and axial more useful) T2 Labrum torn with hyperintense fluid, within or underlying labrum fracture line at glenoid rim Fracture at postero- lateral humeral head Thickened and hyperintense IGHLC (acute dislocation) ABER view better for visualization T2*GRE greater sensitivity for abnormal intra-labralsignal as compared to FS PD or PD 113. Prognosis Recurrent instability (improper healing)Rx - Conservative with a sling Surgical or arthroscopic repair for repeateddislocations 114. Perthes lesion 115. Perthes lesion Bankart variant (uncommon 5-10 % of Bankartlesions) Detached IGHLC with intact scapularperiosteum, which is stripped medially Etio-pathology similar to Bankart lesion 116. MRI T2 Subtle linear increased signal intensity at the base ofusually non-displaced labrum Bankart fracture Redundant hypointense periosteum STIR provides improved contrast for visualization of mediallystripped scapular periosteum MR arthrography in ABER (arm placed behind thehead) 117. ALPSA lesion 118. ALPSA lesionAnterior Labro-ligamentous Periosteal SleeveAvulsion Components - Anterior IGHLC avulsion from antero-inferiorglenoid Intact periosteum Medial displacement and inferior shift of theanterior IGHLC 119. MRI T2 Medial displacement of IGHLC on axial and coronalimages Hyperintense in acute cases Hypointense in chronic cases Hyperintense edema and hemorrhage in joint capsuleand adjacent soft tissues MR arthrography Medial and inferior displacement of labrum Chronic cases with re-synovialisation show minimaldisplacement 120. GLAD lesion 121. GLAD lesionGlenoid Labrum Articular Disruption Definition - Partial tear of anterior glenoidlabrum with adjacent articular cartilage defect Young physically active patients Pain on IR and adduction 122. MRI Irregular increased signal intensity on T2 / FS PDwithin the anterior labrum and adjacent hyalinearticular cartilage Labral tear is typically not detached Chondral defect well seen on FS PD (not well seenon T2) MR arthrography Contrast filling the labral tear Contrast may fill the chondral defect ABER demonstrates partial labral tears by placingstress on capsular ligamentous attachments 123. HAGL Humeral Avulsion of Glenohumeral Ligament Inferior GHL involved CT arthrography extravasation of contrast through humeralinterface defect into anterior para-humeral soft tissue MRI discontinuous capsule at humeral interface (anatomic neck attachment of IGL) Capsule assumes J shape on coronal images (normal axillary pouch has U shaped contour ) MR arthrography extravasation of contrast inferior toaxillary pouch 124. Bennett lesion Extra-articularposteriorossification associated withposterior labral injury andposterior cuff pathology Dystrophic / heterotopicossification Throwingathletes(javelin, baseball) 125. Radiography Mineralization adjacent to posterior glenoid Better visualized on axillary view CT arthrography Posterior labral tear MR Crescent shaped areas of ossification Adjacent to posterior labrum Labral tear T2*GRE show blooming MR arthrography posterior labral tear 126. Posterior labral tear Reverse Bankart Secondary to posterior dislocation Posterior band of IGHLC weak link among staticstabilizers in most shoulders Radiography and CT Posterior glenoid rim fracture Trough sign reverse Hill Sachs on anterior humeruscreating a trough / defect Lesser tuberosity avulsion fracture 127. Pathologies Rotator Cuff Labrum and capsule Biceps tendon Osseous structures Arthritis Neural impingement Tumors 128. Biceps tendon pathologies 129. Tendinosis 130. Tendinosis Degeneration of long head of biceps Long head of biceps LHBT originates at supra glenoid tubercle Passes through the antero-superior joint Enters the humeral bicipital groove Chronic micro-trauma Acute trauma (rare cause) Accompanies RTC disease (especially impingement) Common with subacromial impingement (30-60%association) Biceps tenosynovitis may accompany 131. Radiography - Sclerosis at the superior aspect ofbicipital groove (chronic cases with instability) USG Thickened hypoechoic tendon Tears often directly visible Allows dynamic evaluation 132. MRI T1 Thickened intermediate signal intensity tendon SST tendinopathy T2 Thickened (> 5 mm), irregular frayed tendon Increased signal FS PD and PD more sensitive for tendinosis T2 more sensitive for fraying / tears SST tendinopathy MR arthrography thickened filling defect(enlarged tendon) 133. Biceps tendon tear 134. Biceps tendon tear Tendinosis predisposes Associated with SST tear Distal tendon edge may retract into upper arm 135. CT arthrography Bicipital groove filled with contrast Absence of normal filling defect MRI Irregular stump at superior aspect of joint Partial or complete hyperintense fluid gap in thetendon (T2) Synovitis (PD) 136. Biceps tendinitis grading for tenodesis (repair) Reversible tendon change < 25 % partial tear (width) normal bicipital groove location normal size Irreversible tendon change > 25 % partial tear subluxation disruption of bicipital groove osseous / ligamentous anatomy 137. SLAP lesions 138. SLAP lesions Superior Labrum Anterior to Posterior lesions / tears Location SLAP I superior labrum SLAP II superior labrum + biceps anchor SLAP III - superior labrum SLAP IV superior labrum + biceps tendon SLAP V to IX have also been classified Pathology Focal fraying and degeneration of labrum at BLC in SLAP I Complete anterior to posterior extension in SLAP II - IV 139. MRI (T2) SLAP I Intermediate to hyperintense labral degeneration without labral tearRepresents intra substance degenerationCan be age related normal finding SLAP II Linear hyperintense fluid signal between superior labrum and superior pole ofglenoid (> 5 mm displacement of labrum and biceps anchor on coronal images) SLAP III Identify fragmented superior labrum into two separate components on sag andcor images through BLC )Bucket handle tear through the meniscoid superior labrum SLAP IV Split of the biceps tendon with hyperintense linear longitudinal tear withavulsion 140. SLAP I SLAP II 141. SLAP III 142. SLAP IV 143. Rx Conservative NSAIDs PT Surgical Type I debridement Type II stabilize, bioabsorbable tack (sutures) Type III debridement Type IV suturing of biceps , reattachment oflabrum 144. Biceps tendon dislocation 145. Biceps tendon dislocation Biceps instability Definition dislocation of long head of bicepstendon from bicipital groove Etiology Due to disruption of stabilizing ligaments (RTC tears) SSC and coracohumeral ligament are major stabilizersof biceps Shallow bicipital groove predisposes 146. MRI T1 Increased signal intensity fat fills the bicipital groove T2 Tendon not in groove Mostly displaced medially Flattened / thickened (if previous tendinosis) SSC partial / complete tear T2*GRE more sensitive for visualization ofhypointense biceps fiber MR arthrography empty groove, tendon sheath filledwith contrast 147. USG Empty groove Displaced biceps tendon hypoechoic andedematousBest diagnostic clue Empty bicipital groove with oval structureoutside the groove with hypointense signal onall pulse sequences (MRI) 148. Pathologies Rotator Cuff Labrum and capsule Biceps tendon Osseous structures Arthritis Neural impingement Tumors 149. Osseous structures 150. Osseous structures Subacromial impingement Os acromiale AVN Dislocation Osteochondral injuries 151. Subacromial impingement 152. Subacromial impingement Physical impingement with repeated micro traumaEtiology Primary extrinsic - Subacromial spur, AC OA Type III (hooked) acromion Lateral down sloping of anterior acromion Os acromiale Secondary extrinsic no osseous abnormality ofcoracoacromial archRx conservative, Acromioplasty 153. Acromial Types Type I 154. Acromial Types Type II 155. Acromial Types Type III 156. Acromial Types Type IV 157. MRI Hooked acromion on sagittal images withdecreased subacromial outlet Lateral down sloping seen on coronal images Subacromial space < 7 mm considered increasedrisk Changes of RTC tendinopathy Partial tears may be seen Bursitis Thickened coracoacromial ligament 158. Coracoid Impingement-Normal Coracohumeral -Narrowed C-H Distance canDistance is 11 mm Impinge on Subscapularis 159. Os acromiale 160. Os acromiale Unfused acromial ossification center Normally fuses by 25-30 years Mature bone with synchondrosis between osand acromion +/- mobile distal acromion Can cause impingement Rx conservative, preacromianexcison, stabilization 161. Types Basi-meta (type C) Meta-meso (type A) Meso-pre (type B most common) 162. MRI Age > 25-30 years Unfused bony fragment Corticated structure with medullary fat in it(hyperintense) Hypointense sclerosis at its margins Pseudo double AC joint (axial and cor) T2*GRE unfused ossification demarcation(hyperintense) 163. Double AC joint sign 164. Avascular Necrosis 165. AVN AVN / osteonecrosis It is ischemic death of cellular elements of boneand marrow Etiology steroids, alcohol, smoking, trauma, collagenvascular diseases, arteritis, storage disorders(Gauchers), idiopathic 2nd most common (after femoral head) 166. Radiography Arc like subchondral fracture (crescent sign) Articular collapse (step sign) Fragmentation Subchondral lytic sclerotic areas Subchondral cysts Deformed humeral head Secondary degenerative changes 167. AVN 168. ClassDescriptionI Normal (can be seen on MRI)sclerosis in superior centralIIportion of the headcrescent sign - caused by IIIsubchondral bone collapse; mayhave mild flatteningsignificant collapse of humeral IVarticular surface. Vdegenerative joint disease.Cruess X-ray Classification of AVN Humeral Head 169. MRI Supero-medial part of head most commonly involved Serpiginous hypointense lines (T1) Double line sign increased signal in the center of theline (vascular granulation tissue) with decreased signal onboth sides (T2 and T2*GRE) Non specific edema Subchondral collapse and cysts FS PD more sensitive for ischemic edema in acute cases 170. PC T1 the granulation component of doubleline sign may enhance MR arthrography contrast extend into thenecrotic boneBest diagnostic clue Supero-medial involvement Double line sign on T2W 171. Osteochondral injuries 172. Osteochondral injuries Definition - Injury to articular hyaline cartilage+/- underlying bone fracture, bone trabecularinjury or associated reactive stress response Tidemark zone is the weakest part of articularcartilage between overlying cartilage andsubchondral bone Rotational forces direct trauma causecartilage injury secondarily involve theunderlying bone 173. MRI T1 Subchondral sclerosis and edema T2, FS PD and STIR Increased signal in articular cartilage Underlying bone edema (hyperintense) T2*GRE only sensitive to large chondral defects MR arthrography contrast fills the chondral defectBest diagnostic clue Increased signal in articular cartilage 174. Outerbridge classification of articular cartilage injuries Grade 0 normal Grade 1 chondral softening and swelling (increasedsignal on FS PD) Grade 2 partial thickness defect, not reachingsubchondral bone / < 1.5 cm in max dimension Grade 3 just reaching upto the subchondral bone / >1.5 cm Grade 4 exposed bone / full thickness cartilage loss 175. Pathologies Rotator Cuff Labrum and capsule Biceps tendon Osseous structures Arthritis Neural impingement Tumors 176. Arthritis 177. OsteoarthritisGlenohumeral jointAcromio-clavicular joint (AVC) Relatively uncommon compared toimpingement Older patients Younger patients (post trauma / post surgery) 178. Radiography Joint space narrowing Osteophytes Subchondral cysts and sclerosis 179. MRI Subchondral cyts Osteophytes (marrow signal extends into it) Generalized thinning of hyaline cartilage, withoccasional focal defects Synovitis Loose bodies Posterior glenoid wear leads to increasedretroversion of glenoid PC T1 synovial enhancement in synovitis 180. Rheumatoid arthritis Synovium articular cartilage subchondral bone Marginal erosions (more at greater tuberosity) Bilateral symmetrical involvement Diffuse synovial thickening Joint effusion Bone erosions Loss of joint space not prominent Mild superior migration of humeral head (RTC rupture) decreased space between HH and acromion Clavicular erosions predominate at AC joint Tapered and resorbed distal clavicle (chronic cases) 181. Pathologies Rotator Cuff Labrum and capsule Biceps tendon Osseous structures Arthritis Neural impingement Tumors 182. Neural impingement 183. Quadrilateral space syndrome Entrapment neuropathy (compression) of axillary nerve inquadrilateral space Boundaries Superiorly teres major Inferiorly teres minor Medially long head of triceps Laterally humerus Best diagnostic clue Increased signal in teres minor and deltoid on FS PD or STIR(denervation) Streaky decreased signal intensity (fibrosis) 184. Suprascapular / Spinoglenoid notch Impingement of suprascapular nerve Location - SSN at superior glenoid SGN at posterior glenoid Best diagnostic clue Increased signal in SST and IST on FS PD or STIR(denervation) Streaky decreased signal intensity (fibrosis) 185. Miscellaneous Pathologies Dislocations Fractures Tumors AC separation 186. DislocationTypes Shoulder dislocations are usually dividedaccording to the direction in which the humeralexits the joint: anterior : > 95 % (subcoracoid) posterior : 2 - 4 % inferior (luxatio erecta) : < 1 % 187. Anterior Dislocation 188. Anterior Dislocation 189. Posterior dislocation Axillary viewAP Scapular Y view 190. Luxatio erecta 191. Tumors Proximal humerus Simple bone cyst Aneurysmal bone cyst Giant Cell Tumor of Bone Osteosarcoma (common) Enchondroma (relatively common) Periosteal chondroma (just proximal to insertion of deltoid) Osteochondroma Chondroblastoma Chondromyxoid fibroma Metastases Scapula Osteochondroma chondrosarcoma: affects the shoulder girdle 192. Role of interventional radiology US and fluoroscopy guided intra-articular andbursal infiltration (steroids, other drugs) Percutaneous needle removal of calcific deposits Capsular distension/infiltration of adhesivecapsulitis Therapeutic aspiration of suprascapular orspinoglenoid cysts (to relieve suprascapular nervecompression) Percutaneous radio-frequency treatment ofsymptomatic bone metastases under CT guidance 193. Conclusion Plain radiographs are useful as an initial screening test with patientswith shoulder pain. Ultrasound may be used for diagnosing rotator cuff disease (> 90 %sensitive and specific for tears). CT useful only in cases of trauma and to detect associated bonyabnormalities MRI is the modality of choice for most of the shoulder pathologies. MR arthrography or CT arthrography is required for investigatinginstability 194. Thank you.