Student: Agnes Kaweme Student Number: 17324438Email Address: Agnes.kaweme@postgrad.curtin.edu.auSchool: Science and EngineeringWorkplace: My Radiology Centre (MRC) PerthLecturer: Le-Anne GrimshawDue Date: 30/05/2014 

 I declare that this assignment is my own work and has not been submitted in any form for another unit, degree or diploma at any university or other institute of tertiary education. Information derived from the published or unpublished work of others has been acknowledged in the text and a list of references is given. I warrant that any disks and or computer files submitted as part of this assignment have been checked for viruses and reported clean. Student Signature: akawemeDate: 30/05/2014

SHOULDER ULTRASOUND

BACKGROUND INFORMATION The shoulder girdle comprises of the scapular, humerus and clavicle. Below is a table of the muscles found in the shoulder, their points of origin and insertion.

MUSCLE ORIGIN INSERTION

Anterior deltoid Lateral 3rd aspect of clavicle

Lateral body of humerus

Middle (lateral) deltoid

Acromion Deltoid tuberosity of humerus

Supraspinatus Supraspinatus fossa Greater tuberosity of humerus

Subscapularis Subscapular fossa Lesser tubercle of humerus

Long head of biceps Supraglenoid tubercle

Radial tuberosity and bicipital aponeurosis

in elbow

Short head of biceps Coracoid process of Scapula

Radial tuberosity

Pectoralis majorAnterior surfaces of

sternal portion of clavicle and sternum

Crest of greater tubercle of humerus

Pectoralis minor 3rd 4th and 5th ribs Coracoid process

Table 1: Anterior shoulder muscles and tendons (Human Anatomy Atlas 2014)

PATHOLOGIES

The most common pathologies identified with shoulder ultrasound include but are not limited to:

1) Bursitis-, which refers to fluid within the bursa.2) Adhesive capsulitis-commonly known as frozen shoulder 3) Calcific tendinosis-calcium deposit within the tendons4) Tendon tears- these include; partial bursal tear, partial thickness tea, full thickness tear, intra-substance tear, serpiginous tear, rim rent tear, complete massive tear (2)

PROTOCOL

The following is the protocol set for ultrasound of the shoulder (3) Biceps trans prox and mid Biceps long proximal and MTJ Coracohumeral ligament (CHL) Subscapularis long Subscapularis trans Supraspinatus trans with arm in “karate” position

Biceps tendon should be in view in this image Supraspinatus trans with arm behind back Supraspinatus trans at insertion Supraspinatus long anterior Supraspinatus long mid Supraspinatus long posterior Acromio-clavicular joint Infraspinatus long at insertion Glenoid labrum Suprascapular notch

Dual image left and right if there is full thickness tear of supraspinatus

Supraspinatus and bursa under the coraco-acromio ligament with the arm abducted 90 degrees

SHOULDER EXAMINATION

TECHNIQUEThe following technique was used during the semester for shoulder examination (Grimshaw 2014):

1) LONG HEAD OF THE BICEPS

• Patient was positioned -erect on a swivel stool facing me (I find it hard to scan with patient’s back towards me). Maintaining a straight back posture.The forearm was supinated and elbow flexed, at 90 degrees the humerus is in close contact with the patient’s body. Sometimes the affected side is supported at the wrist joint by the opposite hand

• The transducer was placed on the anterior aspect of the humeral head, and the bicipital groove can be seen as a bony curvature in the head of the humerus separating the greater and lesser tuberosities, this space is also known as the rotator interval. The Biceps tendon lies within the bicipital groove, with the transducer in transverse plane the tendon was seen as a round to oval echogenic structure, heel toeing the probe helped to avoid anasotropy.

• Scanning the tendon in transverse from proximal humeral head down along the shaft to the level of insertion of the pectoralis major, on the lateral aspect of the bicipital groove, to the muscle belly where the short head joins the long head to form a fusiform muscle.

• The probe was rotated through a 90-degree angle for a longitudinal plane, displaying long linear echogenic fibers of the tendon structure. Angling and scanning superiorly at the rotator cuff interval demonstrates the coracohumeral ligament.

IMAGES PRODUCED AT THE BEGINNING OF SEMESTER

Image 1: BICEPS TENDON- transverse view of the biceps tendon in the bicipital groove. This shows normal anatomy.

Image 2: BICEPS longitudinal view- normal echogenic fibres of the biceps

Image 3: Coracohumeral ligament can be seen supporting the biceps in normal position

2) SUBSCAPULARIS TENDON

• Patient remained in the same position as for biceps, was asked to rotate the forearm externally to obtain a longitudinal view of the tendon with the transducer in a transverse plane. The scapularis has a convex margin shows echogenic linear fibers, which inserts into the lesser tuberosity.

• The transducer was turned through 90° to obtain a short axis (transverse plane), of the tendon which appeared heterogeneous with hypoechoic clefts interposed related to muscle fibers mixed with hyperechoic tendon fibers are visualised.

Image 4: SUBSCAPULARIS LONG TENDON- insertion on the lesser tuberosity

Image 5:Mid portion of the subscapularis tendon-normal fibres

Image 6:Posterior portion of the subscapularis- normal fibres

Image 6: shows transverse view of the subscapularis tendon – displaying heterogeneous tendon fibres interposed with muscle fascicles

3) SUPRASPINATUS TENDON-LONG

• The patient’s elbow was pushed backwards in a “karate position” or in a modified Crass position, scanning superiorly on the humeral head keeping in mind the transverse biceps tendon as a landmark.

• The articular surface of the tendon is on the greater tuberosity of the humeral head.

• The tendon is demonstrated as an echogenic structure with the bursal surface perpendicular to the humeral head.

SUPRASPINATUS LONG- ANTERIOR

Image 7:showing longitudinal plane of the supraspinatus tendon anterior fibres insertion on the greater tuberosity of the humerus

SUPRASINATUS LONG-MID

Image 8:showing normal mid fibres of the tendon insertion on the greater tuberosity

SUPRASPINATUS LONG POSTERIOR

Image 9:Normal posterior fibres of the supraspinatus tendon inserting on the greater tuberosity

4) ACROMIO-CLAVICULAR JOINT• With the affected arm relaxed and placed in the initial position,

that is- flexed at the elbow joint and the forearm in supination, the transducer was placed superiorly on the humeral head the whole area was scanned to examine the acromio-clavicular joint to rule out pathology of the joint like osteoarthritis

AC-JOINT

Image 10:Normal acromio-clavicular joint

5) INFRASPINATUS TENDON

• The patient was asked to bring the affected arm across the chest and the hand positioned on the opposite shoulder.

• The probe was placed in longitudinal plane on the postero-lateral aspect of the shoulder gliding the probe from the greater tuberosity to the infraspinatus fossa the tendon is well demonstrated and assessed for possible tears and tendinopathy

INFRASPINATUS LONG

Image 11:Normal infraspinatus tendon

6) POSTERIOR LABRUM

• With the patient in the same position as for Infraspinatus and scanning inferio-posterior to the humeral head in longitudinal plane the posterior labrum comes into view with the articular cartilage aligned to the humeral head and the deep fibres of the infraspinatus follow the contour of the humerus. The area was assessed for possible joint fluid collection, tears or labrum cysts

Image 12: Normal appearances of the posterior labrum

7) SPINOGLENOID NOTCH• The patient remains in the same position as for the

infraspinatus tendon and posterior labrum the depth was increased and scanning medially brought the spinoglenoid notch into view with the labrum still showing at the same level.

Image 13 Normal appearance of the spinoglenoid notch

8) DYNAMIC MANOUVERS

• With the patient in erect position the affected arm was raised laterally, slowly abducting the limb, dynamically watching the supraspinatus tendon and the subacromial bursa (SAB) pass under the acromion and coracoid ligament. The SAB was noted to be filled with fluid indicating bursitis

ABDUCTION- SAB

Image 14: Dynamic imaging Showing fluid collection in the subacromial bursa (SAB) on with arm abduction at 60degrees

Image 15:Dynamic imaging of the shoulder showing the extent of fluid collection in the bursa

IMAGES PRODUCED MID- SEMESTER

The images taken in mid semester appear to be of better quality compared to those taken at the beginning of the semester. This could be attributed to the practical experience gained during the course of the semester.70% of the muscle skeletal referrals that come to our imaging centre are shoulder problems, the aim is to examine the shoulder and produce quality images of diagnostic value. It is easy to miss pathology as a beginner and because we work as a team this has gone a long way in helping me to evaluate my work and develop a firm and steady hand when scanning. Dynamic manoeuvre Images above were achieved as a result of that, the fluid in the bursa was not identified until the motion scanning was applied. This has helped me to remember to carryout internal, external rotation and abduction as major part in my scanning the shoulder.Images below are self explanatory, that I have come a long way in achieving this standard and hoping to improve further.

The pathology shown in the images below

A young athlete presented with history of trauma, which happened to be a shoulder dislocation, x-ray radiographs, showed the dislocation-no bony injury. 2 weeks post reduction of the dislocation the patient still complained of pain in the posterior shoulder region arm still in an arm sling, hence his appointment for ultrasound.

Upon scanning this patient-all tendons appeared normal, but demonstrated a depression fracture of the Posterolateral humeral head, most likely from the impaction of the head of the humerus against the glenoid rim. The labrum appeared bulky with ill-defined borders. While doing a dynamic manoeuvre the patient was very tender in external rotation, looking at the posterior shoulder in motion showed the presence of fluid in the labrum (see video clip) the diagnosis would possibly be posterior labrum effusion. According to Chloros et al (2013), posterior shoulder pain in athletes could be due to injuries inflicted on the glenoid labrum. The anatomy is made up of the glenoid labrum rims and glenoid cavity; these are made of articular cartilage. It is possible to have a focal detachment of the labrum due to a possible tear the fluid appears echogenic suggestive of haemorrhage (Zlatkin and Sanders 2013).

MID SEMESTER SHOULDER IMAGES

I mage 16 Transverse view of the biceps showing the coracohumeral ligament

Image 17: Transverse view of the biceps tendon in the bicipital groove

Image 18 Longitudinal view of the biceps tendon

Image 18: extension of the longitudinal view of the biceps tendon showing the muscle tendon junction

I mage 19 shows normal longitudinal view of the subscapularis tendon

Image 20 shows Transverse view of normal subscapularies with anisotropy

Image 21 showing normal insertion of the supraspinatus tendon anterior fibres

Image 22 shows normal mid fibres of the supraspinatus tendon

Image 23 shows the normal posterior fibres of the supraspinatus tendon

I mage 24 shows normal Infraspinatus in longitudinal view showing Hill Sach’s fracture.

I mage 25 shows the posterior labrum –bulky patients symptoms localised in this region

I mage 26 shows fluid in the posterior labrum

Image 27 shows the effect of dynamic manoeuvre

Image 28 showing the fluid in the labrum recess on external rotation

Reference

Bianchi,S., and C. Martinoli. 2007. Ultrasound of the MusculoskeletalSystem: New York: Springer http://www.curtin.eblib.com.au.dbgw.lis.curtin.edu.au/patron/SearchResults.aspx?q=Bianchi%2CS.%2C+and+C.+Martinoli.+2007+ultrasound+of+the+musculoskeletal+system%3ASpringer&t=quick

Chloros ,George D., Peter, Haar J.,Thomas, Loughran P and Curtis, Hayes W.2013.”Imaging of Glenoid labrum lesions.” Clinics insports medicine 32(3): 361-390.

Grimshaw, Le-Anne.2014 “Module Two- Shoulder Ultrasound.” Lecture notes. http://

Zlatkin, Michael and Sanders,Timothy.2013. “Imaging of the athletic injuries of the upper extremity.” Radiologic Clinics of North America 51(2): 279-297.