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Schreibman - Shoulder Imaging
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©Ken L Schreibman, PhD/MD 9/4/11 www.schreibman.info
Shoulder Imaging page 1 of 21
©Ken L Schreibman, PhD/MD 2009 schreibman.info
Shoulder Anterior View
Scapula
GHJ
ACJ
©Ken L Schreibman, PhD/MD 2009 schreibman.info
Scapula Anterior View Body Triangular
Body of
Scapula
©Ken L Schreibman, PhD/MD 2009 schreibman.info
Scapula Medial View Body Paper Thin Non-articular Attachment site
cuff muscles
“Shoulder Blade” Gk. skaphein “to dig” scapula: shovel/spade-shaped may have been used as primitive digging tool
www.etymonline.com
©Ken L Schreibman, PhD/MD 2009 schreibman.info
Scapula Medial View Spine
©Ken L Schreibman, PhD/MD 2009 schreibman.info
Scapula Posterior-Medial View Spine
©Ken L Schreibman, PhD/MD 2009 schreibman.info
Scapula Posterior View Spine
©Ken L Schreibman, PhD/MD 9/4/11 www.schreibman.info
Shoulder Imaging page 2 of 21
©Ken L Schreibman, PhD/MD 2009 schreibman.info
Scapula Lateral View Y-view Body Spine Coracoid
Glenoid
Acromion arises from spine of scapula
Gk: akros, "highest", ōmos, "shoulder")
http://en.wikipedia.org/wiki/Acromion
©Ken L Schreibman, PhD/MD 2009 schreibman.info
Scapula Anterior-Lateral View Coracoid
Anterior structure
Arises from Glenoid
Gk korax, “raven’s beak”
Not Coronoid
©Ken L Schreibman, PhD/MD 2009 schreibman.info
Gleno-Humeral Joint Anterior View
Coracoid arising anteriorly from Glenoid
Glenoid shallow socket
Acromion arises from the posterior Spine covers glenohumeral joint
©Ken L Schreibman, PhD/MD 2009 schreibman.info
Rotator Cuff Muscles Medial View
Supraspinatus: Above Spine Below AC Joint
Infraspinatus: Below Spine
Teres Minor: Below Infraspin
Subscapularis: Entire Ant Body
©Ken L Schreibman, PhD/MD 2009 schreibman.info
Rotator Cuff Tendons Lateral View
Supraspinatus: Above Spine Below AC Joint
Infraspinatus: Below Spine Teres Minor:
Below Infraspin Subscapularis: Entire Ant Body
Greater Tuberosity
Lesser Tuberosity
©Ken L Schreibman, PhD/MD 2009 schreibman.info
Rotator Cuff Tendons Anterior View
Greater Tuberosity
Lesser Tuberosity
Supraspinatus: Above Spine Below AC Joint
Subscapularis: Entire Ant Body
©Ken L Schreibman, PhD/MD 9/4/11 www.schreibman.info
Shoulder Imaging page 3 of 21
©Ken L Schreibman, PhD/MD 2010 schreibman.info
Rotator Cuff: MR Sagittal Plane T1: Fat=Bright
Supra- spinatus Infra-
spinatus Post
©Ken L Schreibman, PhD/MD 2010 schreibman.info
Rotator Cuff: MR Sagittal Plane
Supra- spinatus Infra-
spinatus Post
T2: Fluid=Bright (fat suppressed)
Brachial plexus neuropathy (inflammation of nerves to
supra- & infra-spinatus muscles)
“Parsonage-Turner Syndrome”
Teres Minor
©Ken L Schreibman, PhD/MD 2010 schreibman.info
Rotator Cuff: MR Sagittal Plane
Supra- spinatus Infra-
spinatus Post
Teres Minor
T1: Fat=Bright
Sub- scapularis
©Ken L Schreibman, PhD/MD 2010 schreibman.info
Rotator Cuff: MR Sagittal Plane
Supra- spinatus Infra-
spinatus Ant
Teres Minor
Sub- scapularis
Post
Rotator Cuff Tendons (Black Arrows)
T1: Fat=Bright Tendons=Black
©Ken L Schreibman, PhD/MD 2010 schreibman.info
Rotator Cuff: MR Sagittal Plane
Supra- spinatus Infra-
spinatus Ant
Teres Minor
Sub- scapularis
Post
Rotator Cuff Tendons (Black Arrows)
T2: Fluid=Bright (fat suppressed)
Tendons=Black
©Ken L Schreibman, PhD/MD 2010 schreibman.info
Rotator Cuff: MR Sagittal Plane
Supra- spinatus
Infra- spinatus
Ant
Teres Minor
Sub- scapularis
Post
Rotator Cuff Tendons (Black Arrows)
Tendons=Black T1: Fat=Bright
©Ken L Schreibman, PhD/MD 9/4/11 www.schreibman.info
Shoulder Imaging page 4 of 21
©Ken L Schreibman, PhD/MD 2010 schreibman.info
Rotator Cuff: MR Sagittal Plane
Ant Post
Rotator Cuff Tendons (Black Arrows)
Tendons=Black T2: Fluid=Bright (fat suppressed)
©Ken L Schreibman, PhD/MD 2010 schreibman.info
Rotator Cuff: MR Sagittal Plane
Ant Post
Rotator Cuff Tendons (Black Arrows)
Tendons=Black
Acr
T2: Fluid=Bright (fat suppressed)
©Ken L Schreibman, PhD/MD 2010 schreibman.info
Rotator Cuff: MR Sagittal Plane
Ant Post
Rotator Cuff Tendons (Black Arrows)
Tendons=Black T2: Fluid=Bright (fat suppressed)
©Ken L Schreibman, PhD/MD 2010 schreibman.info
Rotator Cuff: MR Axial Plane
AC Jt
©Ken L Schreibman, PhD/MD 2010 schreibman.info
Rotator Cuff: MR Axial Plane
AC Jt
©Ken L Schreibman, PhD/MD 2010 schreibman.info
Rotator Cuff: MR Axial Plane
©Ken L Schreibman, PhD/MD 9/4/11 www.schreibman.info
Shoulder Imaging page 5 of 21
©Ken L Schreibman, PhD/MD 2010 schreibman.info
Rotator Cuff: MR Axial Plane
Spine
Ant
Post
Hum Head
Gr Tub
©Ken L Schreibman, PhD/MD 2010 schreibman.info
Rotator Cuff: MR Axial Plane Ant
Post
Infraspinatus
Gr Tub
Lr Tub
Long Head Bicep
©Ken L Schreibman, PhD/MD 2010 schreibman.info
Rotator Cuff: MR Axial Plane Ant
Post
Infraspinatus
Gr Tub
Lr Tub
Long Head Bicep
LT
GT
LHB
©Ken L Schreibman, PhD/MD 2010 schreibman.info
Rotator Cuff: MR Coronal Plane
Ant Post
Sub- scapularis
Lr Tub
Long Head Bicep
Tendons=Black T2: Fluid=Bright (fat suppressed)
Slice through ANTERIOR Rotator Cuff
©Ken L Schreibman, PhD/MD 2010 schreibman.info
Coronal Plane Rotator Cuff: MR
Ant Post
AC Jt
Supra- spinatus
Gr Tub
Tendons=Black T2: Fluid=Bright (fat suppressed)
Slice through MIDDLE Rotator Cuff
©Ken L Schreibman, PhD/MD 2010 schreibman.info
Coronal Plane Rotator Cuff: MR
Ant Post
Tendons=Black T2: Fluid=Bright (fat suppressed)
Slice through POSTERIOR Rotator Cuff
©Ken L Schreibman, PhD/MD 9/4/11 www.schreibman.info
Shoulder Imaging page 6 of 21
©Ken L Schreibman, PhD/MD 2010 schreibman.info
Straight Frontal View
Shoulder: Radiographic Views
A P
AP View
Coracoid Points
Straight Forward
Does NOT Profile G-H Joint
schreibman.info
Articular Head
Glenoid
©Ken L Schreibman, PhD/MD 2010 schreibman.info
Shoulder: Radiographic Views Orientation Glenoid
relative to body Humerus
relative to Glenoid
AP View Axillary
View
A
P
Rotate Patient 35-45°
X-ray beam NOT
Parall G-H Jt
©Ken L Schreibman, PhD/MD 2010 schreibman.info
Shoulder: Radiographic Views Orientation Glenoid
relative to body
Axillary View
X-ray beam
IS Parall G-H Jt
Rotate Patient 35-45°
A
P
Oblique View “Neer View” “Grashey View”
A P
©Ken L Schreibman, PhD/MD 2010 schreibman.info
Shoulder: Radiographic Views Oblique View Does Profile G-H Joint
The MOST Important View
“Neer View” “Grashey View”
Articular Head
Glenoid
Parallelism
©Ken L Schreibman, PhD/MD 2010 schreibman.info
Shoulder: Radiographic Views Orientation Glenoid
relative to body Humerus
relative to Glenoid
Gle
no
id
Oblique View Humerus Externally Rotated
©Ken L Schreibman, PhD/MD 2010 schreibman.info
Shoulder: Radiographic Views Oblique View Humerus Externally Rotated
LT GT
Articular Head
Glenoid
Greater Tuberosity Profiled
©Ken L Schreibman, PhD/MD 9/4/11 www.schreibman.info
Shoulder Imaging page 7 of 21
©Ken L Schreibman, PhD/MD 2010 schreibman.info
Shoulder: Radiographic Views Orientation Glenoid
relative to body Humerus
relative to Glenoid
A
P
AP View Humerus Internally Rotated
©Ken L Schreibman, PhD/MD 2010 schreibman.info
Shoulder: Radiographic Views AP View
Humerus Internally Rotated Greater Tuberosity en face
GT
View of Tertiary Importance
©Ken L Schreibman, PhD/MD 2010 schreibman.info
Shoulder: Radiographic Views Same AP Views
Humerus Internally Rotated Humerus Externally Rotated
©Ken L Schreibman, PhD/MD 2010 schreibman.info
Shoulder: Technical Points Patient Upright
Boomerang Filter
X-ray protection
AP Oblique
©Ken L Schreibman, PhD/MD 2010 schreibman.info
Boomerang Filter With Boomerang Filter
Boomerang Filter
X-r
ay
Both ACJ & GHJ Well Exposed
©Ken L Schreibman, PhD/MD 2010 schreibman.info
Need for Boomerang Filter
C,A 80yoF
AP View Without Boomerang Filter
ACJ Over-Exposed
Repeat AP View With Boomerang Filter
ACJ Well-Exposed
©Ken L Schreibman, PhD/MD 9/4/11 www.schreibman.info
Shoulder Imaging page 8 of 21
©Ken L Schreibman, PhD/MD 2010 schreibman.info
Shoulder: Radiographic Views 1)
2)
3)
Obl View (Humerus Ext Rotated)
Axillary View
AP View (Humerus Int Rotated)
Axillary View
©Ken L Schreibman, PhD/MD 2010 schreibman.info
Shoulder: Radiographic Views
Axillary View
Coracoid= Anterior ACJ
Good Secondary View of GHJ
©Ken L Schreibman, PhD/MD 2010 schreibman.info
Shoulder: Technical Points Axillary View Patient Supine Arm Abducted
©Ken L Schreibman, PhD/MD 2010 schreibman.info
Shoulder: Technical Points West Point View Patient Prone Arm Less
Abducted Techs should
shoot WP view when unable to get Axially view
25º Anterior
©Ken L Schreibman, PhD/MD 2010 schreibman.info
Shoulder: Technical Points West Point View Patient Prone Arm Less
Abducted Techs should
shoot WP view when unable to get Axially view
25º Anterior 25º Medial
Targets Anterior Glenoid
©Ken L Schreibman, PhD/MD 2010 schreibman.info
Targets Anterior Glenoid
25º Anterior 25º Medial
Shoulder: Technical Points West Point View
©Ken L Schreibman, PhD/MD 9/4/11 www.schreibman.info
Shoulder Imaging page 9 of 21
©Ken L Schreibman, PhD/MD 2010 schreibman.info
Shoulder: Radiographic Views West Point View Axillary View Anterior glenoid better seen on
West Point than on axillary view.
©Ken L Schreibman, PhD/MD 2010 schreibman.info
Obl View (Humerus Ext Rotated)
Axillary View
West Point View
“Instability Series”
AP View (Humerus Int Rotated)
Lateral Y View Arch View Outlet View
Shoulder: Radiographic Views 1)
2)
2b)
3)
4)
A
P
©Ken L Schreibman, PhD/MD 2010 schreibman.info
Shoulder: Radiographic Views
A P
A
P
“Y” View
©Ken L Schreibman, PhD/MD 9/4/11 www.schreibman.info
Shoulder Imaging page 10 of 21
©Ken L Schreibman, PhD/MD 2010 schreibman.info
Dislocations: 2 Possible Sites
GHJ
ACJ
©Ken L Schreibman, PhD/MD 2010 schreibman.info
Dislocations: Gleno-Humeral Joint Anterior = Easy
Posterior = Hard
GHJ
©Ken L Schreibman, PhD/MD 2010 schreibman.info
Dislocations: Gleno-Humeral Joint Anterior = Easy Anterior/Inferior 95% Sub-coracoid (most common)
(W,J 22yoM)
AP view Obl view Y view ©Ken L Schreibman, PhD/MD 2010 schreibman.info
Coracoid= Anterior
Humerus
Glenoid
Dislocations: Gleno-Humeral Joint Axillary view
Good Secondary View of GHJ
Anterior Dislocation
©Ken L Schreibman, PhD/MD 2010 schreibman.info
Coracoid= Anterior
Humerus
Glenoid
Dislocations: Gleno-Humeral Joint Axillary view Anterior Dislocation
AP view
Impaction Fx
(M,D 21yoM) ©Ken L Schreibman, PhD/MD 2010 schreibman.info
Dislocations: Gleno-Humeral Joint Axillary view
Impaction Fx Anterior Dislocation
AP view (L,K 19yoF)
©Ken L Schreibman, PhD/MD 9/4/11 www.schreibman.info
Shoulder Imaging page 11 of 21
©Ken L Schreibman, PhD/MD 2010 schreibman.info
Dislocations: Gleno-Humeral Joint Axillary view
(L,K 19yoF)
Hill-Sachs Impaction Fx
Axillary view AP view
Post-reduction
©Ken L Schreibman, PhD/MD 2010 schreibman.info (H,B 49yoM)
Hill-Sachs Fracture D i l o c a t e d
R e d u c e d
Y view AP view Obl view
©Ken L Schreibman, PhD/MD 2010 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.
©Ken L Schreibman, PhD/MD 2010 schreibman.info
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
©Ken L Schreibman, PhD/MD 2010 schreibman.info (T,R 65yoM)
Bankart Fracture AP view
Relocated Anterior Dislocation ©Ken L Schreibman, PhD/MD 2010 schreibman.info (P,T 16yoM)
Bankart Fracture AP view
©Ken L Schreibman, PhD/MD 9/4/11 www.schreibman.info
Shoulder Imaging page 12 of 21
©Ken L Schreibman, PhD/MD 2010 schreibman.info (S,J 45yoF)
Bankart Fracture Axillary view (supine)
Cor (Ant)
Cor (Ant)
Cor (Ant)
West Point view (prone)
West Point view shows Anterior Glenoid better than Axillary view
©Ken L Schreibman, PhD/MD 2010 schreibman.info (P,T 28yoM)
Bankart Fracture Oblique view
?
Axillary view
Ø
West Point view
!
©Ken L Schreibman, PhD/MD 2010 schreibman.info
Dislocations: Gleno-Humeral Joint Anterior = Easy Anterior/Inferior 95% Sub-coracoid (most common)
©Ken L Schreibman, PhD/MD 2010 schreibman.info
Dislocations: Gleno-Humeral Joint
(M,D 62yoF)
AP view Obl view Y view
Anterior = Easy Anterior/Inferior 95% Sub-coracoid (most common) Sub-glenoid
©Ken L Schreibman, PhD/MD 2010 schreibman.info
Dislocations: Gleno-Humeral Joint Anterior = Easy Anterior/Inferior 95% Sub-coracoid (most common) Sub-glenoid Sub-clavicular (uncommon)
©Ken L Schreibman, PhD/MD 2010 schreibman.info
Dislocations: Gleno-Humeral Joint Anterior = Easy Anterior/Inferior 95% Sub-coracoid (most common) Sub-glenoid Sub-clavicular (uncommon)
Luxatio Erecta Arm fixed in
extreme abduction AP view
©Ken L Schreibman, PhD/MD 9/4/11 www.schreibman.info
Shoulder Imaging page 13 of 21
©Ken L Schreibman, PhD/MD 2010 schreibman.info
Dislocations: Gleno-Humeral Joint Anterior=Easy Anterior/Inferior
Posterior=Hard Straight Posterior 5% of Disloc. Unusual muscle
contractions Seizure Electrocution
Missed 50% of the time
©Ken L Schreibman, PhD/MD 2010 schreibman.info (C,D)
Posterior Shoulder Dislocation
Always ask, “Am I missing Post Disloc?” Clues: 1) 2) 3)
Humerus Stuck Int. Rotation Lack of Parallelism of GHJ Trough Line Sign Cisternino,Rogers AJR1978;130:951
Answer: Get Axillary view!
AP view Obl view Cor (Ant)
GT en face
GT en face
Humerus
©Ken L Schreibman, PhD/MD 2010 schreibman.info (C,D)
Posterior Shoulder Dislocation Answer: Get Axillary view!
AP view Obl view Cor (Ant)
R e d u c e d
“Reverse Hill-Sachs”
©Ken L Schreibman, PhD/MD 2010 schreibman.info (E,L 45yoM)
Posterior Shoulder Dislocation AP view Axillary view Axial CT Obl view
R e d u c e d
©Ken L Schreibman, PhD/MD 2010 schreibman.info (J,B 32yoM)
Posterior Shoulder Dislocation Obl view AP view Axillary view Axial CT
R e d u c e d
&
F i x e d
©Ken L Schreibman, PhD/MD 2010 schreibman.info (R,M 51yoF)
Posterior Shoulder Dislocation Obl view AP view
Axillary view
Chronic Dislocation
©Ken L Schreibman, PhD/MD 9/4/11 www.schreibman.info
Shoulder Imaging page 14 of 21
©Ken L Schreibman, PhD/MD 2010 schreibman.info
Acromio-Clavicular Joint
ACJ Ligaments that stabilize ACJ:
A-C Lig Acromio-Clavicular
C-C Lig Coraco-Clavicular
©Ken L Schreibman, PhD/MD 2010 schreibman.info
Dislocations: Acromio-Clavicular Jt Grade 1
Sprain AC Lig
Grade 2
Grade 3
Grade 4
Grade 5
©Ken L Schreibman, PhD/MD 2010 schreibman.info
Dislocations: Acromio-Clavicular Jt Grade 1
Sprain AC Lig
Grade 2 Rupture AC Lig
Grade 3
Grade 4
Grade 5
©Ken L Schreibman, PhD/MD 2010 schreibman.info
Dislocations: Acromio-Clavicular Jt Grade 1
Sprain AC Lig
Grade 2 Rupture AC Lig
Grade 3 Rupture CC Lig
Grade 4
Grade 5
©Ken L Schreibman, PhD/MD 2010 schreibman.info
Dislocations: Acromio-Clavicular Jt Grade 1
Sprain AC Lig
Grade 2 Rupture AC Lig
Grade 3 Rupture CC Lig
Grade 4 Clav Post Disloc
Grade 5
©Ken L Schreibman, PhD/MD 2010 schreibman.info
Dislocations: Acromio-Clavicular Jt Grade 1
Sprain AC Lig
Grade 2 Rupture AC Lig
Grade 3 Rupture CC Lig
Grade 4 Clav Post Disloc
Grade 5 Clav thru Trap
©Ken L Schreibman, PhD/MD 9/4/11 www.schreibman.info
Shoulder Imaging page 15 of 21
©Ken L Schreibman, PhD/MD 2010 schreibman.info
ACJ Radiographically Grade 1
Sprain AC Lig
Grade 2 Rupture AC Lig
Grade 3 Rupture CC Lig
Grade 4 Clav Post Disloc
Grade 5 Clav thru Trap
………Normal (Dx by Physical Exam)
………Subluxation (Clavicle above Acromion)
………Dislocation (Clavicle above Acromion)
………Lack of Parallelism (Best seen: Ax/WP view)
………Big Time Disloc! (Clav WAY above Acrom)
©Ken L Schreibman, PhD/MD 2010 schreibman.info
ACJ Radiographically Grade 1
Sprain AC Lig ………Normal
(Dx by Physical Exam)
(K,K 15yoF)
©Ken L Schreibman, PhD/MD 2010 schreibman.info
ACJ Radiographically Grade 1
Sprain AC Lig
Grade 2 Rupture AC Lig
………Normal (Dx by Physical Exam)
………Subluxation (Clavicle above Acromion)
(D,V 21yoM) ©Ken L Schreibman, PhD/MD 2010 schreibman.info
ACJ Radiographically Grade 1
Sprain AC Lig
Grade 2 Rupture AC Lig
Grade 3 Rupture CC Lig
………Normal (Dx by Physical Exam)
………Subluxation (Clavicle above Acromion)
………Dislocation (Clavicle above Acromion)
CC distance dislocated side ≤ 2X distance normal side
(H,C 30yoF)
©Ken L Schreibman, PhD/MD 2010 schreibman.info
ACJ Radiographically
Grade 5 Clav thru Trap
………Big Time Disloc! (Clav WAY above Acrom)
CC distance dislocated side > 2X distance normal side
(M,R 37yoM) ©Ken L Schreibman, PhD/MD 2010 schreibman.info
ACJ Radiographically Grade 4
Clav Post Disloc
………Lack of Parallelism (Best seen: Ax/WP view)
(from Mike Tuite, MD)
(W,N 29yoF)
Obl Axillary AP
©Ken L Schreibman, PhD/MD 9/4/11 www.schreibman.info
Shoulder Imaging page 16 of 21
©Ken L Schreibman, PhD/MD 2010 schreibman.info
Proximal Humeral Fractures
Surgical Neck (most common)
Anatomic Neck (least common)
Greater Tuberosity
Lesser Tuberosity
Occur at 4 typical sites:
Tug Rotator
Cuff Shoulder Capsule
War of
©Ken L Schreibman, PhD/MD 2010 schreibman.info
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
www.cumc.columbia.edu/dept/ortho/residentsandfellows/documents/2007NYOHAAProgram.pdf
©Ken L Schreibman, PhD/MD 2010 schreibman.info
Proximal Humeral Fractures Neer Classification System 1-Part, 2-Part, 3-Part, 4-Part Wait a minute…1-Part? If there is a proximal humerus fracture isn’t it broken into at least 2 parts? Not according to Dr Neer
To be considered a “Part” a fracture fragment must be: Displaced > 1cm, or Angulated > 45°
©Ken L Schreibman, PhD/MD 2010 schreibman.info
Proximal Humeral Fractures Neer Classification System 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.
©Ken L Schreibman, PhD/MD 2010 schreibman.info
Proximal Humeral Fractures Neer 1-Part, Surgical Neck Fracture
(R,D 39yoF)
Displaced < 1cm Angulated < 45°
©Ken L Schreibman, PhD/MD 2010 schreibman.info
Proximal Humeral Fractures
(S,S 58yoF)
Neer 1-Part, Greater Tuberosity Fx
©Ken L Schreibman, PhD/MD 9/4/11 www.schreibman.info
Shoulder Imaging page 17 of 21
©Ken L Schreibman, PhD/MD 2010 schreibman.info
Proximal Humeral Fractures
(D,P 52yoF)
Displaced < 1cm Angulated < 45°
Neer 1-Part, Surgical Neck & GT Fx
4 months later ©Ken L Schreibman, PhD/MD 2010 schreibman.info
Proximal Humeral Fractures
(H,L 75yoF)
Neer 2-Part Surgical Neck
Neer 1-Part Surgical Neck
Two weeks later
©Ken L Schreibman, PhD/MD 2010 schreibman.info
Proximal Humeral Fractures Neer 2-Part, Surgical Neck Fracture
(J,S 69yoF)
Angulated > 45°
Displaced > 1cm
©Ken L Schreibman, PhD/MD 2010 schreibman.info
Proximal Humeral Fractures
(J,S 69yoF)
Neer 2-Part, Surgical Neck Fracture
3 months post-surgery Required pin fixation
©Ken L Schreibman, PhD/MD 2010 schreibman.info
Proximal Humeral Fractures Neer 2-Part, Surgical Neck Fracture
(C,B 23yoM) ©Ken L Schreibman, PhD/MD 2010 schreibman.info
Proximal Humeral Fractures
(C,B 23yoM)
required surgical reduction
Neer 2-Part, Surgical Neck Fracture
…and pin fixation
©Ken L Schreibman, PhD/MD 9/4/11 www.schreibman.info
Shoulder Imaging page 18 of 21
©Ken L Schreibman, PhD/MD 2010 schreibman.info
Proximal Humeral Fractures
(C,B 23yoM)
2 months post-pinning
Neer 2-Part, Surgical Neck Fracture
…required plating 2m later ©Ken L Schreibman, PhD/MD 2010 schreibman.info
Proximal Humeral Fractures Neer 3-Part, Surgical Neck & GT Fx
(G,S 59yoF)
Angulated > 45° Displaced > 1cm Primarily repaired ORIF with plate
©Ken L Schreibman, PhD/MD 2010 schreibman.info
Proximal Humeral Fractures Neer 3-Part, Surgical Neck & GT Fx
(B,P 65yoM)
Primarily repaired with shoulder prothesis
©Ken L Schreibman, PhD/MD 9/4/11 www.schreibman.info
Shoulder Imaging page 19 of 21
©Ken L Schreibman, PhD/MD 2010 schreibman.info
Shoulder: What to Order When Radiographs (Oblique, Axillary, AP) Dislocations, Fractures, Healing Instability (Obl, Ax, West Point) Contralateral side is helpful ACJ Peds
Normal side Painful side
Wide Physis Salter-Harris 1
“Little Leaguer’s Shoulder”
©Ken L Schreibman, PhD/MD 2010 schreibman.info
Shoulder: What to Order When Radiographs (Oblique, Axillary, AP) Dislocations, Fractures, Healing Instability (Obl, Ax, West Point) Contralateral side is helpful ACJ Peds
Weighted views NOT helpful
Greenspan Figure 5.38
©Ken L Schreibman, PhD/MD 2010 schreibman.info
Shoulder Arthritis
(A,A 67yoM)
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 ©Ken L Schreibman, PhD/MD 2010 schreibman.info
Shoulder Arthritis Osteoarthritis (OA) GHJ: Not so common Often secondary OA Osteophytes off
inferior head Oblique view
Narrowing GHJ Axillary view
(T,A 64yoF)
Early OA
GHJ
©Ken L Schreibman, PhD/MD 2010 schreibman.info
Shoulder Arthritis Osteoarthritis (OA) GHJ: Not so common Often secondary OA Osteophytes off
inferior head Oblique view
Narrowing GHJ Axillary view
(N,D 78yoM)
Advanced OA GHJ
©Ken L Schreibman, PhD/MD 2010 schreibman.info
Shoulder Arthritis Osteoarthritis (OA) GHJ: Not so common Progressive
(L,W 59yoM)
9 months later 1 month later Advanced OA GHJ
©Ken L Schreibman, PhD/MD 9/4/11 www.schreibman.info
Shoulder Imaging page 20 of 21
©Ken L Schreibman, PhD/MD 2010 schreibman.info
Shoulder Arthritis Rheumatoid Arthritis (RA) GHJ common site of RA
(K,J 29yoF)
Marginal Erosion
©Ken L Schreibman, PhD/MD 2010 schreibman.info
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
Supraspinatus>Infra>Teres>SubS Comes & Goes www.emedicine.com
©Ken L Schreibman, PhD/MD 2010 schreibman.info
Shoulder Calcific Tendonitis
(V,P 53yoM)
Supraspinatus Supraspinatus
(O,T 44yoM)
Supraspinatus
Ext Rotation
Int Rotation
(B,J 45yoM)
(T,D 37yoM)
Infraspinatus… 4 months later
Gone
©Ken L Schreibman, PhD/MD 2010 schreibman.info
Shoulder: What to Order When Radiographs (Oblique, Axillary, AP) Dislocations, Fractures, Healing Instability (Obl, Ax, West Point) Contralateral side is helpful ACJ Peds
Arthritis: OA, RA Calcific Tendonitis High-riding shoulder Acromion-Humeral space ≥ 7mm <7mm = Chronic Rotator Cuff Tear
(S,G 54yoM)
©Ken L Schreibman, PhD/MD 2010 schreibman.info
Radiographs insensitive for RCT
>7mm
(E,L 69yoF)
Normal Radiograph
Humeral Head aligned with
Glenoid
MRI 1 month earlier (Cor T2-FatSuppressed)
Humeral Head banging into
Acromion
Humeral Head high riding relative to Glenoid
Patient Supine Patient Upright
©Ken L Schreibman, PhD/MD 2010 schreibman.info
Shoulder: What to Order When Radiographs (Oblique, Axillary, AP) Dislocations, Fractures, Healing Instability (Obl, Ax, West Point) Contralateral side is helpful ACJ Peds
Arthritis: OA, RA Calcific Tendonitis High-riding shoulder Acromion-Humeral space ≥ 7mm <7mm = Chronic Rotator Cuff Tear
UW shoulder studies
(2005)
RG 77%
©Ken L Schreibman, PhD/MD 9/4/11 www.schreibman.info
Shoulder Imaging page 21 of 21
©Ken L Schreibman, PhD/MD 2010 schreibman.info
Shoulder: What to Order When MRI Best way to evaluate Rotator Cuff
MR-Arthrogram (Intra-Articular contrast) Best way to evaluate Labrum
MR with IV contrast Infection (Septic joint, osteomyelitis) Tumor (Work-up, Follow-up)
UW shoulder studies
(2005)
RG 77%
MR 21%
©Ken L Schreibman, PhD/MD 2010 schreibman.info
Shoulder: What to Order When CT Primarily for surgical planning High grade Neer fractures Scapular fractures Large Bankart fractures
Multiplanar Reformat 3D Reformat
Prosthesis loosening Osteolysis
CT-Arthrogram RCT in patients not MR compatible
UW shoulder studies
(2005)
RG 77%
MR 21%
CT 2%
Ultrasound
©Ken L Schreibman, PhD/MD 2010 schreibman.info
Shoulder CT for Fractures
(P,C 32yoM)
AP view
Ax view
Obl view
©Ken L Schreibman, PhD/MD 2010 schreibman.info
Shoulder CT for Fractures
(P,C 32yoM)
AP view
Ax view
Repeat Obl view Obl view CT: Axial
Coronal
Sagittal
©Ken L Schreibman, PhD/MD 2010 schreibman.info
Shoulder CT for Fractures
(P,C 32yoM) ©Ken L Schreibman, PhD/MD 2010 schreibman.info
Shoulder CT for Fractures
(P,C 32yoM)