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Practical Reporting of Musculoskeletal Imaging
Studies:
MRI Shoulder James F Griffith
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Practical reporting
Everyday clinical scenarios
Trainees and those not experienced with MR MSK reporting
Informal
Lecture series
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Shoulder
Approach differs whether rotator cuff or dislocation history
No need to get a history otherwise
Shoulder pain poorly localised
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Don’t mention any feature without grading it
Qualitative measure :
Minimal, mild, moderate, severe
Quantitative measure:
Small, medium, large (mm long x mm deep x mm wide)
Grade ……….
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If you can definitely exclude:
“No Hill-Sachs deformity present”
Correct terminology ……….
If you cannot definitely exclude:
“No superior labral tear evident”
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Rotator cuff tendinosis
Rotator cuff tear
SA-SD bursitis
Labral injury
Glenoid bone loss
This talk : outline
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Normal Tendinosis
Tendinosis (tendon degeneration)
Collagen disorganization Proteoglycan deposition
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Most common pathology encountered on shoulder MRI
Tears occur on background of tendinosis
Very uncommon to see tear in normal tendon
Size & signal intensity are MR criteria of tendinosis
Tendinosis
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Normal supraspinatus tendon
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Mild tendinosis supraspinatus
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Moderate tendinosis supraspinatus
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Moderate tendinosis supraspinatus
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Severe tendinosis supraspinatus
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Supraspinatus tendinosis
Normal Mild
Moderate Severe
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“There is mild/ moderate/ severe tendinosis affecting the anterior to mid-fibres of the supraspinatus tendon. The posterior fibres of the supraspinatus tendon are normal as are the remainder of the rotator cuff tendons without tendinosis or tear”
“There is moderate supraspinatus and subscapularis tendinosis with mild tendinosis of the infraspinatus and long head of biceps tendons”
Report
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Complete: when tendon completely torn Partial : when part of tendon torn anterior, middle, posterior fibres supraspinatus upper, mid, lower fibres subscapularis Longitudinal split tears biceps tendon
Rotator cuff tears
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Complete tear
“ There is a complete avulsive-type tear of the supraspinatus tendon. The tendon is retracted 12m from the insertional area”
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Partial full-thickness avulsive-type or intra-substance partial thickness avulsive-type bursal surface articular surface intra-substance - Bursal surface fraying
Rotator cuff tears
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Full-thickness partial tear
“ There is a full-thickness avulsive-type tear of the anterior fibres supraspinatus tendon. The tear measures 6mm wide and is retracted 10mm from the insertional area”
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Full-thickness partial tear
“ There is a full-thickness tear of the mid-fibres subscapularis tendon measuring 11mm mediolateral x 4mm inferosuperior and involving 30% depth of the tendon at this location”
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Partial thickness partial tear
“ There is a partial-thickness bursal surface (or articular surface or intrasubstance tear ) tear of the mid-fibres supraspinatus tendon measuring 5mm medio-lateral x 4mm anteroposterior and involving 30% depth of the tendon at this location”
Articular surface tear Bursal surface tear
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Partial thickness tears
“ There is a partial-thickness deep surface tear of the upper fibres subscapularis tendon measuring 5mm medio-lateral x 4mm inferosuperior and involving 30% depth of the tendon at this location”
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Muscle atrophy – supraspinatus
Mild: <30% muscle atrophy
Severe: >60% muscle loss
Moderate
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SA-SD bursitis
“ There is mild SA-SD bursitis”
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Structural compromise
Acromial osteophytes, hooks or hypostotic ridge
Thickening coracromial ligament
AC joint osteoarthritis
Laterally down-sloping acromion
Acromial shape
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Structural compromise
spur hook
laterally downsloping
ACJ marginal osteophytosis
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Coracoacromial and coracohumeral ligaments
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Thickened coracoacromial ligament insertion and thickened ligament
“ There is a moderate-severity (2mm thick) hyperostotic ridge at the undersurface of the acromion with moderate (3.3mm, normal < 2.5mm) thickening of the coaracohumeral ligament”
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Acromial undersurface shapes
Flat Curved Hooked Convex
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Can use reverse clock face Descriptive terminology Anterior, anterosuperior, anterinferior Posterior, posterosuperior, posteronferior Superior
Labral pathology localisation
12
3 9
6
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Length
Undisplaced or displaced (mild, moderate, severe)
Location on glenoid
Type of tear (chondral-bony attachment, intrasubstance)
Labral condition (attrition, mucoid degeneration)
± Paralabral cyst
Tears – describe
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Normal anterior and posterior labrum
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Inferiorly displaced labral avulsion – GLOM (glenoid labral ovoid mass)
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Bankart lesion (complete labral avulsion)
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Perthes lesion (incomplete labral avulsion
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ALPSA (anterior labral periosteal sleeve avuslion)
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Chronic ALPSA
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GLAD lesion (glenoid labral articular divot)
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Aber (abduction & external rotation) view
? Tear Tear
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• Labral avulsion with inferior retraction
• Complete labral avulsion (Bankart)
• Incomplete labral avulsion (Perthes)
• ‘Acute’ ALPSA
• ‘Chronic’ ALPSA
• Glenoid labral articular disruption (GLAD)
Labral tears – relative prevalence in dislocation
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• Undisplaced labral tear (intrasubstance or avulsive)
Labral tears – relative prevalance degeneration
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Length
Undisplaced or displaced (mild, moderate, severe)
Type of tear (chondral-bony attachment, intrasubstance)
Biceps anchor integrity
Extension
Labral condition (attrition, mucoid degeneration)
± Paralabral cyst
Superior Labral Tears (SLAP – superior labrum anterior to posterior)
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Superior bicipitalabral complex: normal
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Superior Labral Tears
Fraying Detached labrum
with intact biceps anchor Extending to
biceps anchor Extending into
biceps tendon
Extension into anterior or posterior labrum Extension into SGHL or MGHL
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Superior Labral Tear
Fraying Partial thickness
intra-substance tear Fraying
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Superior Labral Tear
“Undisplaced vertical tear base of superior
labrum not extending into biceps anchor”
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Superior Labral Tears
“Undisplaced vertical tear base of superior labrum not
extending into biceps anchor”
“Mildly displaced bucket handle tear not extending
into biceps anchor”
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Superior Labral Tear
“Moderately displaced bucket-handle tear extending to anterosuoperior aspect of glenoid labrum. The biceps anchor is not
torn”
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Superior Labral Tear
“Undisplaced avulsive-type vertical tear superior labrum extending
into the biceps anchor. The bicipitolabral complex is not displaced”
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Labral variants
Sublabral recess Sublabral foramen Buford complex
+ thickened MGHL
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• 50% single dislocation • 90% recurrent dislocation
Glenoid bone loss
Bone loss
Even easier dislocation
Even more bone loss Easier dislocation
More bone loss
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Maximum GBL = 33%
Severity of GBL
Mild < 10% Moderate 10-20% Severe > 20%
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• < 10% associated with fracture fragment
• Most due to compressive-type fracture
Glenoid bone loss
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• Assessed with arthroscopy, CT or MRI
Glenoid bone loss (GBL)
Bare area
Bare area
Bare area
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450 profile view (Bernageau)
450
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GBL: Difficult to appreciate on axial imaging
20% GBL Normal
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First sign of GBL = Anterior straight line
No anterior straight line = no GBL
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• Anterior straight line • glenoid width
CT: glenoid en-face view
Normal Affected
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superior
inferior
anterior posterior
- Left-side . Right-side
Excellent side-to-side glenoid symmetry
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To measure GBL on CT
28.4 – 24.7 = 3.7mm
3.7mm / 28.4mm x 100% = 13% GBL
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Progressive glenoid bone loss
Normal Mild Mild to moderate
Moderate Severe
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Obtain view en-face to glenoid surface
• T1-weighted FSE (1.5mm-thick sections with 0.75mm overlap), en-face to glenoid, 3 mins extra.
Look for ASL: if absent → No GBL
If ASL present → GBL
GBL : MR assessment No ASL
ASL
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Best-fit circle method
A B
A /A+B X 100 = %GBL
Almost as good as CT
“There is severe (4.6mm, 23%) anterior glenoid bone loss. No glenoid rim fracture is present”
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GBL on MR – examples
Normal Minimal Mild
Mild to moderate Moderate Severe
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Glenoid bone loss
Very common in shoulder dislocation
Assess with either MR (one side) or CT (both sides)
If ASL not present → no GBL
If ASL present → measure GBL by best-fit circle (MR) or compare with opposite side (CT).
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Hill-Sachs deformity
Describe as small, medium-sized or large
Non-angulated or angulated (engaging Hill-Sachs)
“Moderate severity non-angulated Hill-Sachs deformity”
“Large angulated Hill-Sachs deformity”
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Rotator cuff tendinosis
Rotator cuff tear
SA-SD bursitis
Labral injury
Glenoid bone loss
We talked about :
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Thank you