Schreibman - Shoulder Imaging

Shoulder Imaging
Shoulder
Anterior View ACJ
page 1 of 21
Scapula
Anterior View Body Triangular
Body of Scapula
Scapula
GHJ
Ken L Schreibman, PhD/MD 2009
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Scapula
Medial View Body Paper Thin Non-articular Attachment site cuff muscles Shoulder Blade
Scapula
Medial View Spine
Gk. skaphein to dig scapula: shovel/spade-shaped may have been used as primitive digging tool
www.etymonline.com
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Scapula
Posterior-Medial View Spine
Scapula
Posterior View Spine
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Ken L Schreibman, PhD/MD 9/4/11
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Shoulder Imaging
Scapula
Lateral View Y-view Body Spine Coracoid Glenoid Acromion
Gk: akros, "highest", mos, "shoulder")
page 2 of 21
Scapula
Anterior-Lateral View Not Coronoid Coracoid Anterior structure Arises from Glenoid Gk korax, ravens beak
Ken L Schreibman, PhD/MD 2009 schreibman.info
arises from spine of scapula

http://en.wikipedia.org/wiki/Acromion
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Gleno-Humeral Joint
Anterior View Acromion arises from
Glenoid shallow socket the posterior Spine covers glenohumeral joint
Rotator Cuff Muscles

Medial View
Supraspinatus: Above Spine Below AC Joint Infraspinatus: Below Spine Subscapularis: Entire Ant Body Teres Minor: Below Infraspin
Coracoid arising anteriorly from Glenoid
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Rotator Cuff Tendons

Lateral View
Supraspinatus: Above Spine Below AC Joint Greater Infraspinatus: Tuberosity Below Spine Lesser Tuberosity Teres Minor: Subscapularis: Below Infraspin Entire Ant Body
Rotator Cuff Tendons

Anterior View
Greater Tuberosity
Supraspinatus: Above Spine Below AC Joint
Lesser Tuberosity
Subscapularis: Entire Ant Body
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Shoulder Imaging
Rotator Cuff: MR
Sagittal Plane
T1: Fat=Bright
page 3 of 21
Rotator Cuff: MR
Sagittal Plane
T2: Fluid=Bright (fat suppressed)
Infraspinatus
Post
Supraspinatus
Infraspinatus Teres Minor

Post
Supraspinatus
Brachial plexus neuropathy (inflammation of nerves to supra- & infra-spinatus muscles) Parsonage-Turner Syndrome
Ken L Schreibman, PhD/MD 2010 schreibman.info Ken L Schreibman, PhD/MD 2010 schreibman.info
Rotator Cuff: MR
Sagittal Plane
T1: Fat=Bright
Rotator Cuff: MR
Supraspinatus
Sagittal Plane
T1: Fat=Bright
Tendons=Black
Infraspinatus
Teres Minor
Post
Infraspinatus
Teres Minor
Post
Supraspinatus
Ant
Subscapularis
Subscapularis
Rotator Cuff Tendons (Black Arrows)

Rotator Cuff: MR
Sagittal Plane
Post
Rotator Cuff: MR
Sagittal Plane
T1: Fat=Bright Tendons=Black
T2: Fluid=Bright Tendons=Black (fat suppressed) Supra-
spinatus

Post
Supraspinatus
Ant
Ant
Subscapularis
Subscapularis

Ken L Schreibman, PhD/MD 2010 schreibman.info Ken L Schreibman, PhD/MD 2010

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Shoulder Imaging
Rotator Cuff: MR
Sagittal Plane
T2: Fluid=Bright Tendons=Black (fat suppressed)
page 4 of 21
Rotator Cuff: MR
Sagittal Plane
Acr
Post
Ant
Post
Ant


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Rotator Cuff: MR
Sagittal Plane
Rotator Cuff: MR
Axial Plane
Post
Ant
AC Jt

Rotator Cuff: MR
Axial Plane
Rotator Cuff: MR
Axial Plane
AC Jt
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Shoulder Imaging
Rotator Cuff: MR
Axial Plane
Ant
page 5 of 21
Rotator Cuff: MR
Axial Plane
Long Head Bicep
Ant
Gr Tub Hum Head

Spine
Lr Tub
Gr Tub
Infraspinatus
Post
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Post
Rotator Cuff: MR
Axial Plane
Long Head Bicep
Lr Tub
Rotator Cuff: MR
Ant
LHB
Coronal Plane T2: Fluid=Bright Tendons=Black

LT (fat suppressed)
GT
Long Head Bicep
Lr Tub
Gr Tub
Subscapularis
Infraspinatus
Post
Post
Ant
Slice through ANTERIOR Rotator Cuff

Rotator Cuff: MR
Coronal Plane
T2: Fluid=Bright Tendons=Black (fat suppressed) AC Jt
Rotator Cuff: MR
Coronal Plane T2: Fluid=Bright Tendons=Black
(fat suppressed)
Gr Tub
Supraspinatus
Post
Ant
Post
Ant
Slice through MIDDLE Rotator Cuff

Slice through POSTERIOR Rotator Cuff

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Shoulder Imaging
Shoulder: Radiographic Views AP View
Does NOTFrontal Profile G-H Joint Straight View
page 6 of 21
Shoulder: Radiographic Views Orientation X-ray Glenoid A beam relative to NOT body Parall G-H Jt Humerus relative to Rotate Patient Glenoid
35-45
A
Articular Head
Glenoid
Coracoid Points Straight Forward
Axillary AP View P View

Ken L Schreibman, PhD/MD 2010 schreibman.info schreibman.info Ken L Schreibman, PhD/MD 2010 schreibman.info
Shoulder: Radiographic Views Orientation Oblique View X-ray Glenoid Neer View A beam Grashey View relative to IS P A Parall body
Rotate Patient 35-45
Shoulder: Radiographic Views Oblique View

Does Profile G-H Joint
Parallelism
Articular Head Glenoid
G-H Jt
Axillary View P
The MOST Important View Neer View Grashey View

Glenoid
Shoulder: Radiographic Views Orientation Oblique View Glenoid Humerus Externally Rotated relative to body Humerus relative to Glenoid
Shoulder: Radiographic Views Oblique View

Humerus Externally Rotated Greater Tuberosity Profiled
GT
LT
Articular Head
Glenoid
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Shoulder Imaging
Shoulder: Radiographic Views AP View Orientation Humerus Internally Rotated Glenoid relative to A body Humerus relative to Glenoid
page 7 of 21
Shoulder: Radiographic Views AP View
Humerus Internally Rotated Greater Tuberosity en face
GT
View of Tertiary Importance
P
Shoulder: Radiographic Views Same AP Views

Humerus Externally Rotated Humerus Internally Rotated
Shoulder: Technical Points AP Oblique Patient

Upright Boomerang Filter X-ray protection
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Boomerang Filter
With Boomerang Filter Boomerang Filter
Need for Boomerang Filter

AP View Without Boomerang Filter ACJ Over-Exposed Repeat AP View With Boomerang Filter ACJ Well-Exposed
Both ACJ & GHJ Well Exposed
X-ray
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C,A 80yoF
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Shoulder Imaging
Shoulder: Radiographic Views
1) Obl View (Humerus Ext Rotated) 2) Axillary View 3) AP View (Humerus Int Rotated)
page 8 of 21
ACJ
Coracoid= Anterior
Axillary View Axillary View

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
25 Anterior
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Patient Prone Arm Less Abducted Techs should shoot WP view when unable to get Axially view
Targets Anterior Glenoid

Targets Anterior Glenoid
25 Anterior 25 Medial
25 Anterior 25 Medial
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Shoulder Imaging
Shoulder: Radiographic Views Axillary View West Point View
Anterior glenoid better seen on West Point than on axillary view.
page 9 of 21
1) Obl View (Humerus Ext Rotated) 2) Axillary View 2b) West Point View Instability Series 3) AP View (Humerus Int Rotated) 4) Lateral Y View Arch View Outlet View
P
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Shoulder: Radiographic Views Y View
P
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Shoulder Imaging
Dislocations: 2 Possible Sites
page 10 of 21
Dislocations: Gleno-Humeral Joint Anterior = Easy Posterior = Hard
ACJ
GHJ
GHJ
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Dislocations: Gleno-Humeral Joint Anterior = Easy

Anterior/Inferior
95% Sub-coracoid (most common)
Dislocations: Gleno-Humeral Joint Axillary view Coracoid= Anterior Dislocation Anterior

Humerus Glenoid
AP view
Obl view
(W,J 22yoM)
Y view
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Good Secondary View of GHJ

Dislocations: Gleno-Humeral Joint Axillary view Coracoid= Anterior Dislocation Anterior

Humerus Glenoid
Impaction Fx
Dislocations: Gleno-Humeral Joint Axillary view Anterior Dislocation
Impaction Fx
AP view
(M,D 21yoM) schreibman.info
AP view
(L,K 19yoF) schreibman.info
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Shoulder Imaging
Dislocations: Gleno-Humeral Joint Hill-Sachs Axillary view
Impaction Fx
D i l o c a t e d R e d u c e d
(L,K 19yoF) schreibman.info
page 11 of 21
Hill-Sachs Fracture
AP view Obl view Y view
Post-reduction
Axillary view
AP view
(H,B 49yoM) schreibman.info
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
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Bankart Fracture
AP view
Bankart Fracture
AP view
Anterior Dislocation
Relocated
(T,R 65yoM) schreibman.info
(P,T 16yoM) schreibman.info
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Shoulder Imaging
Bankart Fracture
Axillary view (supine)
Cor (Ant) Cor (Ant)
page 12 of 21
Bankart Fracture
Oblique view Axillary view
West Point view (prone)
!
?
West Point view shows Anterior Glenoid better than Axillary view
(S,J 45yoF) schreibman.info
Cor (Ant)
West Point view

(P,T 28yoM) schreibman.info

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

Anterior/Inferior
95% Sub-coracoid (most common) Sub-glenoid
AP view
Obl view
(M,D 62yoF)
Y view
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Anterior/Inferior
95% Sub-coracoid (most common) Sub-glenoid Sub-clavicular (uncommon)

Anterior/Inferior
95% Sub-coracoid (most common) Sub-glenoid Sub-clavicular (uncommon) Luxatio Erecta Arm fixed in extreme abduction
AP view
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Shoulder Imaging
Dislocations: Gleno-Humeral Joint Anterior=Easy
Anterior/Inferior
AP view
GT
page 13 of 21
Posterior Shoulder Dislocation
Obl view
GT
Cor Answer: Get (Ant) Axillary view!
Posterior=Hard
Straight Posterior 5% of Disloc. Unusual muscle contractions

Missed 50% of the time
Seizure Electrocution
en face
en face
Humerus
Always ask, Am I missing Post Disloc? Clues: 1) Humerus Stuck Int. Rotation 2) Lack of Parallelism of GHJ 3) Trough Line Sign
schreibman.info Ken L Schreibman, PhD/MD 2010
(C,D)
Cisternino,Rogers AJR1978;130:951
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AP view

Obl view
Cor Answer: Get (Ant) Axillary view!
AP view

Obl view Axial CT Axillary view
R e d u c e d
Reverse Hill-Sachs
(C,D)
R e d u c e d
(E,L 45yoM)
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AP view

Obl view Axial CT Axillary view
AP view

Obl view
Chronic Dislocation
R e d u c e d
& F i x e d
(J,B 32yoM)
Axillary view
(R,M 51yoF)
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Shoulder Imaging
Acromio-Clavicular Joint Ligaments that ACJ stabilize ACJ: A-C Lig
Acromio-Clavicular
Coraco-Clavicular
page 14 of 21
Dislocations: Acromio-Clavicular Jt Grade 1
Sprain AC Lig
Grade 2
C-C Lig
Grade 3
Grade 4 Grade 5
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Sprain AC Lig

Sprain AC Lig
Grade 2
Rupture AC Lig
Grade 2
Rupture AC Lig
Grade 3 Grade 4 Grade 5

Grade 3
Rupture CC Lig
Grade 4 Grade 5

Sprain AC Lig

Sprain AC Lig
Grade 2
Rupture AC Lig
Grade 2
Rupture AC Lig
Grade 3
Rupture CC Lig
Grade 3
Rupture CC Lig
Grade 4
Clav Post Disloc
Grade 4
Clav Post Disloc
Grade 5
Grade 5
Clav thru Trap
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Shoulder Imaging
ACJ Radiographically Grade 1Normal
Sprain AC Lig (Dx by Physical Exam) Sprain AC Lig
page 15 of 21
(Dx by Physical Exam)
Grade 2Subluxation
Rupture AC Lig (Clavicle above Acromion)

Rupture CC Lig (Clavicle above Acromion) Clav Post Disloc (Best seen: Ax/WP view) Clav thru Trap (Clav WAY above Acrom)
(K,K 15yoF)
Grade 3Dislocation
Grade 4Lack of Parallelism Grade 5Big Time Disloc!

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Sprain AC Lig

Sprain AC Lig
Grade 2Subluxation
Rupture AC Lig (Clavicle above Acromion)
Grade 2Subluxation Grade 3Dislocation
Rupture AC Lig (Clavicle above Acromion) Rupture CC Lig (Clavicle above Acromion)
CC distance dislocated side 2X distance normal side

(D,V 21yoM)
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(H,C 30yoF)
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ACJ
Radiographically
ACJ Radiographically Grade 4Lack of Parallelism

AP
Clav Post Disloc (Best seen: Ax/WP view)

Axillary Obl
CC distance dislocated side > 2X distance normal side
Grade 5Big Time Disloc!

Clav thru Trap
(M,R 37yoM)
(Clav WAY above Acrom)

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(from Mike Tuite, MD)
(W,N 29yoF)
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Shoulder Imaging
Proximal Humeral Fractures Occur at 4 typical sites:
Greater Tuberosity Surgical Neck (most common) Anatomic Neck (least common) Lesser Tuberosity
page 16 of 21
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
Rotator Cuff
Tug of War
Shoulder Capsule
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www.cumc.columbia.edu/dept/ortho/residentsandfellows/documents/2007NYOHAAProgram.pdf Ken L Schreibman, PhD/MD 2010 schreibman.info

1-Part, 2-Part, 3-Part, 4-Part Wait a minute1-Part? Not according to Dr Neer To be considered a Part a fracture fragment must be:
Displaced > 1cm, or Angulated > 45
If there is a proximal humerus fracture isnt it broken into at least 2 parts?
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.
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Proximal Humeral Fractures

Neer 1-Part, Surgical Neck Fracture

Neer 1-Part, Greater Tuberosity Fx
Displaced < 1cm Angulated < 45

(R,D 39yoF)
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(S,S 58yoF)
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Shoulder Imaging
Neer 1-Part, Surgical Neck & GT Fx Neer 1-Part Surgical Neck
page 17 of 21
Neer 2-Part Surgical Neck
Displaced < 1cm Angulated < 45

4 months later
(D,P 52yoF)
Two weeks later

(H,L 75yoF)
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Displaced > 1cm Angulated > 45

(J,S 69yoF)
3 months post-surgery
Required pin fixation

(J,S 69yoF)
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required surgical reduction and pin fixation

(C,B 23yoM)
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(C,B 23yoM)
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Shoulder Imaging
page 18 of 21
Neer 3-Part, Surgical Neck & GT Fx
2 months post-pinning required plating 2m later

(C,B 23yoM)
repaired Displaced > 1cm Angulated > 45 Primarily ORIF with plate
(G,S 59yoF)
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Neer 3-Part, Surgical Neck & GT Fx
Primarily repaired with shoulder prothesis

(B,P 65yoM)
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Shoulder Imaging
Shoulder: What to Order When
Radiographs (Oblique, Axillary, AP)
Dislocations, Fractures, Healing Instability (Obl, Ax, West Point) Contralateral side is helpful
ACJ Peds
page 19 of 21
Dislocations, Fractures, Healing Instability (Obl, Ax, West Point) Contralateral side is helpful Weighted views NOT helpful
ACJ Peds
Little Leaguers Shoulder
Wide Physis Salter-Harris 1
Painful side Normal side

Greenspan Figure 5.38
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Shoulder Arthritis 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
(A,A 67yoM)
GHJ: Not so common

Often secondary OA Osteophytes off inferior head Narrowing GHJ
Axillary view Oblique view
Early OA GHJ
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(T,A 64yoF)
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GHJ: Not so common

Often secondary OA Osteophytes off inferior head Narrowing GHJ
Axillary view Oblique view
Advanced OA GHJ
GHJ: Not so common Progressive
Advanced OA GHJ
(N,D 78yoM)
9 months later 1 month later

(L,W 59yoM)
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Shoulder Imaging
Shoulder Arthritis Rheumatoid Arthritis (RA)
GHJ common site of RA
page 20 of 21
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
Marginal Erosion
(K,J 29yoF)
Supraspinatus>Infra>Teres>SubS Comes & Goes www.emedicine.com

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Shoulder Calcific Tendonitis

Supraspinatus Supraspinatus
Supraspinatus

Dislocations, Fractures, Healing Instability (Obl, Ax, West Point) Contralateral side is helpful (S,G 54yoM) Arthritis: OA, RA Calcific Tendonitis High-riding shoulder
ACJ Peds
Ext Rotation
(V,P 53yoM) (O,T 44yoM) (B,J 45yoM)
Infraspinatus 4 months later

Gone
Int Rotation
(T,D 37yoM)
Acromion-Humeral space 7mm <7mm = Chronic Rotator Cuff Tear

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Radiographs insensitive for RCT

Patient Upright Patient Supine Humeral Head banging into Acromion

Dislocations, Fractures, Healing Instability (Obl, Ax, West Point) Contralateral side is helpful Arthritis: OA, RA Calcific Tendonitis High-riding shoulder
>7mm
Humeral Head aligned with Glenoid
Humeral Head high riding relative to Glenoid
ACJ Peds
RG 77%
UW shoulder studies
(2005)
Normal Radiograph
(E,L 69yoF)
MRI 1 month earlier (Cor T2-FatSuppressed)

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Acromion-Humeral space 7mm <7mm = Chronic Rotator Cuff Tear

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Shoulder Imaging
MRI MR-Arthrogram (Intra-Articular contrast)
Best way to evaluate Labrum
RG 77%
MR 21%
page 21 of 21
CT
Primarily for surgical planning
High grade Neer fractures Scapular fractures Large Bankart fractures RG Multiplanar Reformat 77% 3D Reformat
Best way to evaluate Rotator Cuff
MR 21%
CT
MR with IV contrast
UW shoulder studies
(2005)
Prosthesis loosening
Osteolysis
UW shoulder 2% studies
(2005)
Infection (Septic joint, osteomyelitis) Tumor (Work-up, Follow-up)

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CT-Arthrogram Ultrasound
RCT in patients not MR compatible

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Shoulder CT for Fractures

AP view Obl view

Repeat AP view Obl view Obl view CT: Axial
Coronal Sagittal
Ax view
(P,C 32yoM)
Ax view
(P,C 32yoM)
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(P,C 32yoM)
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(P,C 32yoM)
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Schreibman - Shoulder Imaging

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Shoulder Imaging

Ken L Schreibman, PhD/MD 2009

Ken L Schreibman, PhD/MD 2009

Ken L Schreibman, PhD/MD 2009

Ken L Schreibman, PhD/MD 2009

Ken L Schreibman, PhD/MD 2009

Ken L Schreibman, PhD/MD 9/4/11

arises from spine of scapula

Ken L Schreibman, PhD/MD 2009

Rotator Cuff Muscles

Coracoid arising anteriorly from Glenoid

Ken L Schreibman, PhD/MD 2009

Ken L Schreibman, PhD/MD 2009

Rotator Cuff Tendons

Rotator Cuff Tendons

Supraspinatus: Above Spine Below AC Joint

Subscapularis: Entire Ant Body

Ken L Schreibman, PhD/MD 2009

Ken L Schreibman, PhD/MD 2009

Ken L Schreibman, PhD/MD 9/4/11

Infraspinatus Teres Minor

Rotator Cuff Tendons (Black Arrows)

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

Infraspinatus Teres Minor

Rotator Cuff Tendons (Black Arrows)

Rotator Cuff Tendons (Black Arrows)

Ken L Schreibman, PhD/MD 9/4/11

Rotator Cuff Tendons (Black Arrows)

Rotator Cuff Tendons (Black Arrows)

Rotator Cuff Tendons (Black Arrows)

Ken L Schreibman, PhD/MD 2010

Ken L Schreibman, PhD/MD 2010

Ken L Schreibman, PhD/MD 9/4/11

Gr Tub Hum Head

Coronal Plane T2: Fluid=Bright Tendons=Black

Slice through ANTERIOR Rotator Cuff

Slice through MIDDLE Rotator Cuff

Slice through POSTERIOR Rotator Cuff

Ken L Schreibman, PhD/MD 9/4/11

Coracoid Points Straight Forward

Axillary AP View P View

Shoulder: Radiographic Views Oblique View

The MOST Important View Neer View Grashey View

Ken L Schreibman, PhD/MD 2010

Shoulder: Radiographic Views Oblique View

Ken L Schreibman, PhD/MD 2010

Ken L Schreibman, PhD/MD 9/4/11

View of Tertiary Importance

Shoulder: Radiographic Views Same AP Views

Shoulder: Technical Points AP Oblique Patient

Ken L Schreibman, PhD/MD 2010

Ken L Schreibman, PhD/MD 2010

Need for Boomerang Filter

Both ACJ & GHJ Well Exposed

Ken L Schreibman, PhD/MD 2010

Ken L Schreibman, PhD/MD 2010

Ken L Schreibman, PhD/MD 9/4/11

Axillary View Axillary View

Shoulder: Technical Points Axillary View

Patient Supine Arm Abducted

Shoulder: Technical Points West Point View

Ken L Schreibman, PhD/MD 2010

Ken L Schreibman, PhD/MD 2010

Shoulder: Technical Points West Point View