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MUSCULOSKELETAL IMAGING
Glenohumeral instability
C L MCCARTHY, MB ChB, FRCR
Summary
Normal anatomical variants:
s Sublabral foramen
s Sublabral recess
s Buford complex
s Capsular insertions
Shoulder instability:
s Anterior glenohumeral instability
Anteroinferior labral tear
s Bankart lesion
s Anterior labroligamentous periosteal sleeve avulsion lesion
s Perthes lesion
s Glenolabral articular disruption lesion
Extensive anterior labral tear
Anterosuperior labral tear
Glenohumeral ligament injury
doi: 10.1259/img.20110084
s SLAP lesion
s Posterior glenohumeral instability 2014 The Author. Published by
s Posterior superior glenoid impingement the British Institute of Radiology
Cite this article as: McCarthy CL. Glenohumeral instability. Imaging 2014;23:20110084
Abstract. MR arthrography is useful in diagnosing and a complex classification but the presence and the extent of
characterizing the labralligamentous lesions resulting in biceps tendon involvement is the most important feature. A
glenohumeral instability. The sublabral foramen, sublabral SLAP II lesion must be distinguished from a normal
recess and Buford complex are normal variants of the glenoid sublabral recess. Patterns of injury seen in posterior
labrum, which must not be confused with true labral instability are the reverse of those found following anterior
abnormalities. The most common type of glenohumeral dislocation with posterior labral tears referred to as a reverse
instability is anteroinferior instability, characterized by Bankart lesion. Posterior superior glenoid impingement or
avulsion of the anteroinferior labralligamentous complex, internal impingement is when the posterosuperior aspect of
which is termed a Bankart lesion. Variants of the Bankart the glenoid and the humeral head come into contact, causing
lesion, where the scapular periosteum remains intact, are the injury to the interposed rotator cuff and posterosuperior
anterior labroligamentous periosteal sleeve avulsion lesion, labrum.
the Perthes lesion and the glenolabral articular disruption
lesion. Anterosuperior labral tears are uncommon and must Glenohumeral instability refers to symptomatic sub-
be differentiated from a normal sublabral foramen. Anterior luxation or dislocation of the humeral head in relation to
glenohumeral instability also occurs following injury to the the glenoid fossa. The combination of the glenoid la-
glenohumeral ligaments, most commonly described as brum, the superior, middle and inferior glenohumeral
humeral avulsion of the inferior glenohumeral ligament ligaments is referred to as the labralligamentous com-
lesion. The superior labral anteroposterior (SLAP) lesion is plex. This complex functions as a static stabilizer of the
a superior labral tear that extends both anterior and posterior shoulder joint by anchoring the humerus to the glenoid
to the biceps tendon attachment. SLAP lesions have rim. The labralligamentous complex is commonly in-
jured in young patients with instability leading to
Address correspondence to: Dr Catherine L. McCarthy. E-mail: a spectrum of abnormalities that may be shown using
catherinemccarthy@doctors.org.uk MRI.
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CL McCarthy
is obtained. Oblique axial images are then acquired tendon and the glenohumeral ligaments. A number of
parallel to the long axis of the humeral shaft. The ABER normal variants described in relation to the labrum must
position places the anterior band of the inferior gleno- not be confused with true labral abnormalities. If the
humeral ligament (IGHL) into tension, which stresses glenoid articular surface is viewed as the face of a clock,
the anteroinferior labrum and increases the sensitivity in most of the normal anatomical variants occur at the
detecting anterior labral tears. Several studies have 113 oclock positions, involving the anterosuperior por-
shown that imaging in the ABER position is more ac- tion of the labrum. Pathological findings associated with
curate in detecting and revealing the extent of an ante- anterior glenohumeral joint instability usually occur at
rior labral tear than conventional axial MR arthrograms the 36 oclock position.
obtained with the arm in the neutral position.710 The ABER A sublabral foramen represents normal localized
position also kinks the rotator cuff, so the humeral head no detachment of the anterosuperior labrum from the
longer effaces the articular surface of the tendons. This glenoid1,1217 at the 2 oclock position, anterior to the
reduced tension allows intra-articular contrast to flow biceps tendon attachment13 (Figure 2). A normal sublabral
more easily along the articular surface of the tendons, in- foramen is present in approximately 10% of subjects1,18
creasing the detection of articular-sided partial thickness and may be difficult to distinguish from an anterosuperior
tendon tears (Figure 1). labral tear at MR arthrography.
Virtual MR arthroscopy has been described in a few The sublabral recess refers to a normal synovial re-
reports using three-dimensional gradient echo sequences. flection between the cartilage of the glenoid cavity
This can be used as an adjunct tool to MR arthrography and the superior labrum1216 located at the 12 oclock
in assessment of labral tears by providing visual in- position, at the site of the attachment of the biceps ten-
formation similar to arthroscopy.11 don13 (Figure 3). The sublabral recess may be continu-
ous with a sublabral foramen.13 This variant may be
misinterpreted as a SLAP tear (SLAP II lesion) at MR
Normal anatomy and variants arthrography.
The Buford complex is made up of a congenitally absent
Glenoid labrum anterosuperior labrum in association with a thickened
cord-like middle glenohumeral ligament (MGHL).1,1217,19
The glenoid labrum is a fibrocartilaginous structure
It is present in 1.26.5% of subjects.1 Axial MR images
that is situated along the periphery of the glenoid fossa
obtained at the level of the superior half of the glenoid
and demonstrates low signal intensity on all imaging
depict the cross-section of the thickened MGHL close
sequences. It increases the depth of the glenoid fossa and
to the anterior glenoid margin, which has an absent la-
serves as the site of attachment for the long head of biceps
brum (Figure 4). This combination of findings simulates
the appearance of an avulsed anterior labral fragment.15
Recognition that the apparent detachment is the
thickened MGHL is best identified in the oblique sag-
ittal plane and should aid in avoiding this pitfall.14,15 In
addition, the biceps anchor and sites of insertion of the
superior glenohumeral ligament (SGHL) and MGHLs
are normal.14,19
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CL McCarthy
whether this represents a true normal variant or old lon- Shoulder instability
gitudinal split tear is controversial.1,13,16,20
The IGHL consists of a thicker anterior band, a poste- Anterior glenohumeral instability
rior band and an interposed axillary recess. The bands
extend from the anteroinferior and posteroinferior
Anteroinferior labral tear
aspects of the labrum, respectively, to the surgical neck of
Anteroinferior instability is the most common type
the humerus where the insertion has a fan-shaped ap-
to involve the glenohumeral joint, occurring in 95% of
pearance (Figure 7). The anterior IGHL may arise be-
patients,12,16,17 and is seen secondary to anteroinferior
tween the 2 and 5 oclock positions but is most commonly
dislocation or subluxation, which produces a constel-
visualized from the 3 oclock position. With the arm in
lation of lesions. Avulsion of the labralligamentous
the ABER position, the anterior band of the glenohumeral
complex from the anteroinferior aspect of the glenoid,
ligament becomes taut and can be visualized in almost its
with complete disruption of the scapular periosteum, is
entire extension (Figure 1). Injuries to the anterior band
termed a fibrous or soft-tissue Bankart lesion1,12,1417,21
are more likely to be associated with clinically evident
(Figure 8). As the labrum is completely separated from
instability as this band is the single most important sta-
the glenoid, it may migrate from its normal site of at-
bilizer of the glenohumeral joint and should receive
tachment. With time, this displaced tissue may scar
careful attention during MR image analysis.1,13,16,20
into a rounded shape, which is known as a glenoid
labrum ovoid mass or GLOM.1 The presence of an as-
sociated adjacent anteroinferior glenoid rim fracture is
Capsule
referred to as an osseous or bony Bankart lesion. Quanti-
Variations in the anterior capsular insertions have been fication of bony Bankart lesions is clinically important as
described. Insertion at the glenoid margin is known as bone loss of .25% of the glenoid width, which typically
Type I, Type II refers to insertion at the glenoid neck gives the glenoid an inverted pear shape, requires
within 1 cm of the labral base and Type III describes an open bone grafting to prevent recurrent disloca-
insertion on the scapula .1 cm medial to the labral tion.23,24 A HillSachs impaction deformity or fracture
base.1417 It was generally believed that the further the involving the posterosuperior humeral head is a fre-
capsule attaches from the anterior glenoid margin, the quently associated finding.1,12,1417,21 HillSachs lesions
more unstable the joint; however, these insertion types are found at the uppermost part of the humeral head,
are currently not thought to correlate with clinically sig- above the level of the coracoid process, and should be
nificant instability and should be viewed with caution in differentiated from a normal humeral groove, which is
the absence of other signs. In addition, an overdistended located distal to the typical impaction site.
capsule at MR arthrography may produce prominent A number of variants of the Bankart lesion, where the
anterior and posterior recesses, falsely simulating a Type periosteum remains intact, have been described.1 The
III insertion and capsular laxity.21 anterior labroligamentous periosteal sleeve avulsion le-
By contrast, the posterior capsule should always insert sion is characterized by the torn anteroinferior labrum
on the glenoid rim and the presence of fluid or contrast being displaced inferomedially by the IGHL and rolling up
medial to the rim is indicative of capsular stripping and like a sleeve (Figure 9). The displaced labrum remains at-
posterior instability.22 tached to the scapula via an intact anterior scapular
periosteum. 1,12,1417,21 Using the sleeve analogy, the
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CL McCarthy
instability when throwing together with periosteal de- extravasation from other sources, such as capsular inju-
tachment and irregularity of the labrum are consistent ries not involving the IGHL, soft-tissue trauma or even
with an anterosuperior labral tear.15,21 iatrogenic.27 In 20% of cases, a medial humeral avulsion
fracture is present.16,26 Rarely, a floating avulsion of the
Glenohumeral ligament injury inferior glenohumeral ligament lesion occurs, where there
Anterior glenohumeral instability can involve tears of are simultaneous avulsions at both the glenoid and hu-
the glenohumeral ligaments. The humeral avulsion of the meral sites of insertion of the anterior band.26
glenohumeral ligament lesion is an avulsion of the ante-
rior band of the inferior glenhumeral ligament from its Superior labral anteroposterior lesion
humeral attachment. There is inferomedial retraction of
The SLAP lesion is a superior labral tear that extends
the ligament, which appears thick and irregular, and on
both anterior and posterior to the biceps tendon attach-
the coronal oblique images, the normal U-shaped anterior
ment and commonly results from repetitive traction to
ligament and axillary recess is converted into a J-shape
the biceps tendon as seen in throwing athletes. Clinical
(Figure 12). The anterior capsule is ruptured, and there is
findings include pain, clicking and instability. The origi-
extravasation of the contrast anterior to the humeral
nal classification described four types of SLAP lesions
neck.1,16,17,26 The accuracy of MR arthrography in the
depending on the extent of injury to the superior labrum
detection of these lesions is not yet determined, and false
and biceps anchor. Type I is characterized by superior
positives may occur when there is contrast or fluid
labral degeneration and fraying; Type II, the most com-
mon of all SLAP lesions, consists of avulsion of the su-
perior labrum and long head of biceps tendon from the
glenoid; Type III is seen as an inferiorly displaced bucket-
handle superior labral tear with an intact biceps anchor;
and Type IV involves extension of a bucket-handle
superior labral tear into the proximal long head of
the biceps tendon.12,13,15,16,21,28 The classification has sub-
sequently been extended to include the so-called
extended SLAP tears, where the labral tear extends in-
to other structures. Simply put, any classification above
Type IV means that there is a further injury in addition to
the SLAP tear. Despite the complex classification, surgical
treatment is based on a compromise of the biceps anchor,
thus, as far as the surgeon is concerned, precise classifi-
cation is less useful than knowledge about the presence
and extent of the biceps tendon involvement.14
The key feature of a SLAP lesion on MR athrography is
tracking of contrast into the superior labral tear
(Figure 13). Contrast may be seen to extend into the biceps
tendon on coronal oblique images depending on the
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CL McCarthy
configuration of the tear. A further feature may be a dis- anterosuperior humeral head gives rise to the reverse
placed labral fragment resulting in a bucket-handle type HillSachs defect.1,12,1416,21
tear as seen in SLAP Types III, IV and VI (Figure 14).
A normal sublabral recess may be misinterpreted as
a SLAP II lesion at MR arthrography. Intra-articular
Paralabral cysts
contrast, which extends into a normal sublabral recess, is
smooth and tapering, with a width of only 1 or 2 mm and Paralabral cysts are lobulated fluid collections that
usually extends in a medial direction towards the glenoid are associated with labral tears and shoulder in-
attachment of the superior labrum. The superior labrum stability. The cysts may arise from extrusion of shoul-
maintains a normal triangular configuration with a sharp der joint fluid through labralcapsular tears, the
free edge and contains no abnormal signal within its location of the cyst indicating the position of the labral
substance.12,13,16,29 In general, SLAP II lesions are orien- tear. Cyst extension into the spinoglenoid (between the
tated in a lateral direction away from the glenoid scapular spine and the glenoid cavity) or suprascapular
rim13,15,16,28,29 (Figure 13) and may extend posterior to notch may result in neural compression with secondary
the biceps tendon.16,28,29 These lesions may be associated muscle atrophy.12,14,31
with a concomitant anterosuperior labral tear.29 In addi-
tion, intra-articular contrast between the glenoid and
superior labrum has a more globular configuration and
delineates an irregular labral margin.13,16,29
Posterior superior glenoid impingement revealing tears of the antero-inferior glenoid labrum. Korean
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