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Imaging and Patient Selection
Mr Chris RobertsIpswich HospitalWatanabe Club
York 2010
NB
• You must know– How to take x-ray views– What MRI sequences– What CT views
• The result of the investigation must affect patient management
• Don’t order an investigation for the sake of it
Why investigate?
• Diagnosis– Do we need to operate?
• Informed consent
• Patient planning
• List planning– Positioning– Timing
Which imaging modality?
• Likely diagnosis
• Cost
• Availability
• Access
• Expertise
Imaging modalities
• X-ray
• Ultrasound
• CT
• MRI
• Arthrography
Plain radiography
• AP shoulder– Beam perpendicular to
body– Commonest view– Good view of ACJ– Poor view of GHJ
Plain radiography
• AP GHJ– Beam perpendicular to
scapula– Good view GHJ– Poor view ACJ
Plain radiography
• Scapular lateral– Perpendicular to AP
GHJ view– Conirms enlocation
GHJ– Alignment for fractures
Plain radiography
• Outlet view– As for scapular lateral
but beam tipped caudally 10 degrees
– Acromial morphology– Guide to
decompression– Localise lesions
Plain radiography
• Axillary view– Good view of GHJ
space– Eccentric erosion– Bone lesions– Os acromiale
Plain radiography
• Modified axillary views– Post trauma
Plain radiography
• Bernageau view– Anterior glenoid bone loss
MRI
• Imaging is performed in three planes relative to glenohumeral joint
• Typical sequences• Coronal oblique T1 and T2 spir• Sagittal oblique T2• Axial Watts (T2 fat suppressed)• Axial T1 in instability
• Difficult for large patients – not central in bore
MRI
• Coronal oblique– Supra and
infraspinatus tendons– Subacromial space– A-C joint– Superior labrum– Biceps tendon– Subscapularis
MRI
• Sagittal oblique– Rotator cuff
• Tendons• Muscle atrophy
– Acromial morphology– Glenoid
MRI
• Axial plane– Biceps tendon– Glenoid labrum
• Bankart lesion
– Subscapularis attachment
Common Pathology
• Rotator cuff disease
• Biceps tendon
• Glenoid labrum
• Bony lesion
Rotator Cuff
• Partial thickness– Articular surface– Bursal surface
• Full thickness– Size– Tendon retraction– Muscle atrophy
Rotator Cuff
Rotator Cuff
Rotator Cuff
Bony Lesions
Instability
• Hill-Sach’s lesions• Anterior labral tears –
Bankart lesion
Other lesions
• Cysts
MR arthrography
• Anterior labral lesions
MR arthrography
• SLAP lesion
MR arthrography
• HAGL lesion
• Axial images• Coronal and sagittal
reconstructions relative to plane GHJ
• Quantifying bone lesions
CT scans
CT scans
• 3D reconstructions
Ultrasound
• Soft tissue imaging– Coronal and sagittal
views– SST, IST and SBSC– Intratendinous lesions – Muscle atrophy– Not labrum– Very user dependent– Static images not very
useful
Ultrasound
• Cuff tears
Ultrasound
• Calcium
Ultrasound
• Effusions
Arthrography
How I image for cuff pathology
• Impingement– Xrays: AP, outlet and axillary
• Impingement vs Sml cuff tear– Add USS
• Large/massive cuff tear– Add MRI
How I image for instability
• Atraumatic– Xray AP shoulder
• Traumatic anterior– Xrays: AP and Bernegeau– If bone lesion or contact sportsperson add CT
• NB beware the HAGL
Case 1
• 43 y.o. female• Painful arc• Full movement
passively• Cuff strong on testing
Case 2
• 55 y.o. man• Painful arc, night pain• No cuff wasting• Full active movement • Cuff painful and weak
on testing
Case 3
• 55 y.o. man• Painful arc, night pain• Cuff wasted• Restricted active but
full passive range• Cuff painful and weak
on testing• Positive drop arm and
Hornblowers
Case 4
• 75 y.o. man• Painful arc, night pain• Cuff wasted• Restricted active but
full passive range• Cuff painful and weak
on testing• Positive drop arm and
Hornblowers
Case 5
• 29 year old sedentary worker
• 3rd traumatic anterior shoulder dislocation
• No sports
Case 6
• 23 year• 3rd traumatic anterior
shoulder dislocation• Professional rugby
player