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Shoulder
Anterior View ACJ
page 1 of 21
Scapula
Anterior View Body Triangular
Body of Scapula
Scapula
GHJ
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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
Ken L Schreibman, PhD/MD 2009
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Scapula
Posterior-Medial View Spine
Scapula
Posterior View Spine
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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
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Gleno-Humeral Joint
Anterior View Acromion arises from
Glenoid shallow socket the posterior Spine covers glenohumeral joint
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Lesser Tuberosity
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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
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: MR
Sagittal Plane
Infraspinatus Teres Minor
Post
Rotator Cuff: MR
Sagittal Plane
T1: Fat=Bright Tendons=Black
spinatus
Supraspinatus
Ant
Ant
Subscapularis
Subscapularis
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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
T2: Fluid=Bright Tendons=Black (fat suppressed)
Acr
Post
Ant
Post
Ant
Rotator Cuff: MR
Sagittal Plane
T2: Fluid=Bright Tendons=Black (fat suppressed)
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
Lr Tub
Gr Tub
Infraspinatus
Post
schreibman.info Ken L Schreibman, PhD/MD 2010 schreibman.info
Post
Ken L Schreibman, PhD/MD 2010
Rotator Cuff: MR
Axial Plane
Long Head Bicep
Lr Tub
Rotator Cuff: MR
Ant
LHB
GT
Long Head Bicep
Lr Tub
Gr Tub
Subscapularis
Infraspinatus
Post
Ken L Schreibman, PhD/MD 2010 schreibman.info
Post
Ant
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
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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
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
G-H Jt
Axillary View P
Ken L Schreibman, PhD/MD 2010 schreibman.info
Glenoid
Shoulder: Radiographic Views Orientation Oblique View Glenoid Humerus Externally Rotated relative to body Humerus relative to Glenoid
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
P
Ken L Schreibman, PhD/MD 2010 schreibman.info Ken L Schreibman, PhD/MD 2010 schreibman.info
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Boomerang Filter
With Boomerang Filter Boomerang Filter
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
Shoulder: Radiographic Views
ACJ
Coracoid= Anterior
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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
Shoulder: Radiographic Views
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
Ken L Schreibman, PhD/MD 2010
P
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P
Ken L Schreibman, PhD/MD 2010 schreibman.info
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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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AP view
Obl view
(W,J 22yoM)
Y view
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Impaction Fx
Impaction Fx
AP view
Ken L Schreibman, PhD/MD 2010
(M,D 21yoM) schreibman.info
AP view
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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
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.
Ken L Schreibman, PhD/MD 2010 schreibman.info
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Bankart Fracture
AP view
Bankart Fracture
AP view
Anterior Dislocation
Ken L Schreibman, PhD/MD 2010
Relocated
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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 shows Anterior Glenoid better than Axillary view
Ken L Schreibman, PhD/MD 2010
(S,J 45yoF) schreibman.info
Cor (Ant)
AP view
Ken L Schreibman, PhD/MD 2010 schreibman.info
Obl view
(M,D 62yoF)
Y view
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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
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
AP view
R e d u c e d
Ken L Schreibman, PhD/MD 2010
Reverse Hill-Sachs
(C,D)
R e d u c e d
Ken L Schreibman, PhD/MD 2010
(E,L 45yoM)
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AP view
AP view
Chronic Dislocation
R e d u c e d
Ken L Schreibman, PhD/MD 2010
& F i x e d
(J,B 32yoM)
Axillary view
schreibman.info Ken L Schreibman, PhD/MD 2010
(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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Grade 2
Rupture AC Lig
Grade 2
Rupture AC Lig
Grade 3
Rupture CC Lig
Grade 4 Grade 5
Ken L Schreibman, PhD/MD 2010 schreibman.info
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
Ken L Schreibman, PhD/MD 2010 schreibman.info
Grade 5
Clav thru Trap
Ken L Schreibman, PhD/MD 2010 schreibman.info
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Shoulder Imaging
ACJ Radiographically Grade 1Normal
Sprain AC Lig (Dx by Physical Exam) Sprain AC Lig
page 15 of 21
ACJ Radiographically Grade 1Normal
(Dx by Physical Exam)
Grade 2Subluxation
Grade 3Dislocation
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Grade 2Subluxation
Rupture AC Lig (Clavicle above Acromion) Rupture CC Lig (Clavicle above Acromion)
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(H,C 30yoF)
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ACJ
Radiographically
(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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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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(S,S 58yoF)
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Shoulder Imaging
Proximal Humeral Fractures
Neer 1-Part, Surgical Neck & GT Fx Neer 1-Part Surgical Neck
page 17 of 21
Proximal Humeral Fractures
Neer 2-Part Surgical Neck
4 months later
(D,P 52yoF)
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3 months post-surgery
Ken L Schreibman, PhD/MD 2010
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(C,B 23yoM)
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Shoulder Imaging
Proximal Humeral Fractures
Neer 2-Part, Surgical Neck Fracture
page 18 of 21
Proximal Humeral Fractures
Neer 3-Part, Surgical Neck & GT Fx
repaired Displaced > 1cm Angulated > 45 Primarily ORIF with plate
Ken L Schreibman, PhD/MD 2010
(G,S 59yoF)
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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
Shoulder: What to Order When
Radiographs (Oblique, Axillary, AP)
Dislocations, Fractures, Healing Instability (Obl, Ax, West Point) Contralateral side is helpful Weighted views NOT helpful
ACJ Peds
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ACJ narrows with age Superior osteophytes not significant Inferior osteophytes can impinge upon supraspinatus tendon
Best seen on Arch (Y) view
(A,A 67yoM)
Early OA GHJ
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(T,A 64yoF)
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Advanced OA GHJ
Advanced OA GHJ
Ken L Schreibman, PhD/MD 2010
(N,D 78yoM)
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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
Ken L Schreibman, PhD/MD 2010
(K,J 29yoF)
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Ext Rotation
(V,P 53yoM) (O,T 44yoM) (B,J 45yoM)
Int Rotation
(T,D 37yoM)
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>7mm
ACJ Peds
RG 77%
UW shoulder studies
(2005)
Normal Radiograph
(E,L 69yoF)
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Shoulder Imaging
Shoulder: What to Order When
MRI MR-Arthrogram (Intra-Articular contrast)
Best way to evaluate Labrum
RG 77%
MR 21%
page 21 of 21
Shoulder: What to Order When
CT
Primarily for surgical planning
High grade Neer fractures Scapular fractures Large Bankart fractures RG Multiplanar Reformat 77% 3D Reformat
MR 21%
CT
MR with IV contrast
Ken L Schreibman, PhD/MD 2010
UW shoulder studies
(2005)
Prosthesis loosening
Osteolysis
UW shoulder 2% studies
(2005)
CT-Arthrogram Ultrasound
Ken L Schreibman, PhD/MD 2010
Coronal Sagittal
Ax view
Ken L Schreibman, PhD/MD 2010
(P,C 32yoM)
Ax view
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(P,C 32yoM)
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(P,C 32yoM)
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(P,C 32yoM)
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