MR arthrography of glenohumeral lesions with arthroscopic correlation, using PD and T2 sequences in addition to standard fat saturated sequences

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1 MR arthrography of glenohumeral lesions with arthroscopic correlation, using PD and T2 sequences in addition to standard fat saturated sequences Poster No.: C-2217 Congress: ECR 2010 Type: Educational Exhibit Topic: Musculoskeletal - Joints Authors: C. G. Boulet, M. Shahabpour, N. Pouliart, J. de Mey, M. D. Maeseneer; Brussels/BE Keywords: superior middle inferior glenohumeral ligaments, shoulder instability, shoulder MRA Keywords: Musculoskeletal joint, Musculoskeletal system DOI: /ecr2010/C-2217 Any information contained in this pdf file is automatically generated from digital material submitted to EPOS by third parties in the form of scientific presentations. References to any names, marks, products, or services of third parties or hypertext links to thirdparty sites or information are provided solely as a convenience to you and do not in any way constitute or imply ECR's endorsement, sponsorship or recommendation of the third party, information, product or service. ECR is not responsible for the content of these pages and does not make any representations regarding the content or accuracy of material in this file. As per copyright regulations, any unauthorised use of the material or parts thereof as well as commercial reproduction or multiple distribution by any traditional or electronically based reproduction/publication method ist strictly prohibited. You agree to defend, indemnify, and hold ECR harmless from and against any and all claims, damages, costs, and expenses, including attorneys' fees, arising from or related to your use of these pages. Please note: Links to movies, ppt slideshows and any other multimedia files are not available in the pdf version of presentations. Page 1 of 26

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3 Learning objectives The aim of this poster is to describe the pathological MRA appearance of the superior (S-GHL) Fig.1, middle (M-GHL) Fig.2 and inferior (I-GHL) Fig.3 glenohumeral ligaments of the shoulder, using traditional T1 fat saturated sequences in the 3 orthogonal planes and additional dual protondensity - T2 (PD-T2) weighted sequences. To correlate the MRA with the detailed description and drawings of the arthroscopy Fig.4, provided by one skilled shoulder surgeon. Page 3 of 26

4 Images for this section: Fig. 0: The axial fat saturated T1-weighted sequence shows the normal aspect of the superior GHL (white arrow) in between the antero-superior gloid rim and the joint capsule. Page 4 of 26

5 Fig. 0: The axial fat saurated T1-weighted image depicts a normal thin middle GHL (white arrow) in the anterior joint capsule in between the humeral head and the subscapularis tendon. Page 5 of 26

6 Fig. 0: The coronal fat saturated T1-weighted image (left hand side) shows the normal 'U-pouch' configuration (white arrow) of the axillary pouch. The sagittal fat saturated T1-weighted image (right hand side) depicts a normal anterior band (AB-IGHL), demonstrated by the grey arrow, and posterior band (PB-IGHL), demonstrated by the black arrow, of the I-GHL. Page 6 of 26

7 Fig. 0: An example of a standardised file and a schematic drawing of the shoulder with the annotations of the shoulder surgeon, filled in after every arthroscopy. Page 7 of 26

8 Background The gleno-humeral ligaments are the most important passive stabilizers of the shoulderjoint. 1 The main function of the S-GHL (and coracohumeral ligament) is to prevent instability of the shoulder in the posterior and inferior direction, with the coracohumeral ligament. Together with the coracohumeral, transverse humeral ligament and subscapularis tendon it also forms the biceps 'reflective pulley' or 'sling', preventing the anterior luxation of the 2 long head of the biceps tendon. 1 The main function of the M-GHL is limiting external roatation. It may be absent in up to 3 30% of the normal population. The anterior portion of the I-GHL limits the anterior translation in abduction and external rotation. The posterior band limits the posterior translation in abduction and internal 1 rotation. The axillary pouch limits movement in abduction. Recognition of gleno-humeral ligament lesions is most important in the work-up of schoulder instability and trauma (for example Fig. 1 to 3). Page 8 of 26

9 Images for this section: Fig. 0: The axial fat saturated protondensity-weighted sequence shows a thickened SGHL: sprain (white arrow). Note also the Hill-Sachs lesion at the postero-superior side of the humeral head (grey arrow) as a result of an anterior shoulder luxation. Page 9 of 26

10 Fig. 0: Same patient as in Fig. 1. The axial protondensity-weighted image shows a typical soft-bankart lesion at the antero-inferior side of the glenoid (white arrow). Page 10 of 26

11 Fig. 0: Same patient as in Fig. 1 & 2. The consecutive PD-weighted image of Fig. 2, showing the thickened fibrotic anterior band of the I-GHL following a tear (white arrow), almost always associated with a Bankart lesion. Page 11 of 26

12 Imaging findings OR Procedure details The following section will describe and show the MR arthrographic appearance of a sprain of the superior and middle glenohumeral ligament, a mid-substance tear or avulsion of the middle and inferior glenohumeral ligament, fibrous thickening of middle glenohumeral ligament, as well as some of their associated lesions. Superior glenohumeral ligament (S-GHL): The superior GHL originates from the superior glenoid margin, just anteriorly to the origin of the long head of the biceps tendon, and inserts upon the lesser tubercle, together with 3 the coracohumeral ligament and passes through the rotator interval. Due to its small size and position, the S-GHL is only torn if associated with other lesions in the antero4 superior shoulder capsule, as there are the anterosuperior labrum (Fig.1 and 2), middle GHL (Fig.3) or long head of biceps tendon and capsular tears (Fig.4). The S-GHL is sometimes difficult to see as a result of its thin aspect or the absence of a sufficient amount of contrast surrounding it. Middle glenohumeral ligament (M-GHL): The middle GHL arises mostly together with, or just below, the superior GHL and long head of the biceps tendon at the antero-superior part of the glenoid labrum. It inserts most frequently at the base of the tubercle, or can blend with the joint capsule before 3 reaching the tubercle. It crosses thus the anterior capsular space. When associated with the absence of the antero-superior labrum it may appear thick and cord like, the 5 so-called 'Buford complex', simulating an antero-superior labral tear. A sprain of the M-GHL can be seen as undulated (elogated) fibrous band (Fig.5) or as a thickened hyperintense structure in the anterior shoulder capsule (Fig. 6). There are several types of MGHL tear: detachment of its labral insertion, capsular desinsertion (Fig. 7 and 8) or 6,10 longitudinal fissuration. The most common associated lesions are labral tears (SLAPlesion, anterior avulsion (Fig.7), ALSPA and Bankart lesion) and 'rotator interval' lesions 3 (Fig.4). Inferior glenohumeral ligament complex (I-GHL): The complex of the inferior GHL is made out of a thick anterior and posterior bundle and the axillary recess of the joint capsule in between. They originate from the antero-inferior 3 and postero-inferior labrum and insert onto the chirurgical neck of the humerus. The anterior band of the I-GHL is the most frequently injured capsulo-ligamentous structure 7 in the shoulder, mostly because of antero-inferior luxation of the humeral head. It goes 1 hand-in-hand with the antero-inferior labral tear, aslo known as the Bankart lesion (see Page 12 of 26

13 Fig.1-3 at the 'Background' section). Labral- or mid-substance tears of the axillary pouch are seldomly seen and only in combination with severe or repetitive trauma (Fig.8 and 9). 8 Posterior IGHL lesions on the other hand are not always associated with trauma. They are mostly found in cases of a posterior shoulder luxation (Fig. 11). Associated lesions 9 are the 'reversed Hill-Sachs' and 'reversed Bankart' lesions and posterior labral tears. 7 Although quite rare according to the literature, the HAGL-lesion (humeral avulsion of the gleno-humeral ligament) is the best known I-GHL lesion, transforming the normal 'U-shape' (see Fig.3 in the 'Learning objectives' section) of the inferior capsule as seen on the coronal sequences in the so-called 'J-shape' configuration (Fig.12). The best diagnostic imaging clue is the contrast leakage along the humeral shaft in the acute phase (Fig. 13). Page 13 of 26

14 Images for this section: Fig. 0: 38-year old female presenting with vague anterior shoulder pain at clinical examination and no remembrance of any recent trauma. The axial PD and T2-weighted images respectively show a SLAP lesion of the antero-superior labrum (black arrow) with an adjecent fissuration of the S-GHL (white arrow). Page 14 of 26

15 Fig. 0: Schematic drawing of the arhroscopical procedure on the patient in Fig.1, demonstrating the ligature of the antero-superior labrum and the adjecent superior GHL. Page 15 of 26

16 Fig. 0: 33-year old female with persisting pain after a motoring accident. The axial protondensity-weighted image shows a disrupted and irregular S-GHL (white arrow). Note also the slightly thickened middle GHL (grey arrow) corresponding to a sprain, visualized on the consecutive T2-weighted image. Fig. 0: 55 year old woman after a motoring accident. The axial fat saturated protondensity-weighted image (left hand side) shows a disruption (full-thickness tear) of the capsular insertion of the S-GHL (white arrow). The sagittal protondensity-weighted image (right hand side) depicts also the associated torn joint capsule and 'bicipital sling'(grey arrows). The long head of the biceps tendon remains in the intertubercular sulcus (black arrow). Page 16 of 26

17 Fig. 0: 33-year old female with persisting pain after a motoring accident.the axial and sagittal fat saturated PD-weighted images show an undulated course of the middle GHL, corresponding to an elongated M-GHL (white arrow). Note also the torn Rotator Interval with contrast leakage underneath the coracoid (grey arrow)on the sagittal image. Fig. 0: 61-year old male with a history of a motoring accident. The sagittal protondensityweighted image (left hand side) and the axial T2-weighted image at the same level show the thickened and hyperintense middle GHL: sprain (white arrows). Page 17 of 26

18 Fig. 0: 35-year old male after anterior shoulder luxation. The axial fat saturated protondensity and the sagittal T2-weighted sequence depict a M-GHL remnant in the anterior capsular recess (white arrows): full-thickness tear. Note also the fibrous strands in the axillary pouch after partial-thickness tear, as well as the absense of the anterior labrum on the glenoid rim due to an avulsion. Page 18 of 26

19 Fig. 0: Arthroscopical image of patient seen in Fig. 6. The grey arrow shows the torn antero-superior shoulder capsule, superior and middle GHL. Note also the partial tear of the articular portion of the long head of the biceps tendon on the upper left image. Fig. 0: 25-year old male with history of repeated anterior shoulder luxations. The coronal protondensity (left hand side) and sagittal T2-weighted sequence (right hand side) show thickened fibrous strands in the axillary pouch: cicatrised fibres (white arrows). Note also the sprain of the anterior band of the I-GHL on the T2-weighted image (grey arrow). Page 19 of 26

20 Fig. 0: Same patient as in Fig. 8. The arthroscopical images depict the thickened fibrous strands (grey arrow) in the inferior joint capsule, corresponding well to the MRarthrography. Page 20 of 26

21 Fig. 0: 58-year old male with history of a cycling accident and posterior shoulder luxation. The axial protondensity-weighted image (left hand side) shows sequelae of a 'reversed Hill-Sachs' lesion (anterior humeral head) and a 'reversed Bankart' lesion (postero-inferior glenoid rim. The sagittal T2-weighted image (right hand side) depicts a postero-inferior capsular tear underneath the teres minor muscle (white arrow). Note the thickened posterior band of the I-GHL anteriorly (grey arrow). Page 21 of 26

22 Fig. 0: 23-year old female with history of diaphyseal fracture of the humerus (grey arrow). The coronal fat saturated protondensity-weighted sequence (left hand side) shows a 'J-pouch deformity' of the axillary pouch: healed HAGL-lesion (white arrow). The sagittal protondensity weighted image (right hand side) shows a deep axillary recess with thickened cicatricial fibres (white arrow). Page 22 of 26

23 Fig. 0: The coronal fat saturated protondensity-weighted sequence depicts nicely the contrast leakage along the humeral shaft. The sagittal protondensity-weighted sequence shows clearly the torn axillary recess. Page 23 of 26

24 Conclusion 1. The gleno-humeral ligamentous lesions are well depicted by MR-Arthrography. 2. The dual PD-T2 images in the 3 orthogonal planes are useful for direct visualization of the ligaments, as are the concommitant capsulolabral lesions. 3. The retrospective correlation with the arthroscopical findings were useful in difficult or unclear cases. Page 24 of 26

25 Personal Information Dr. C. Boulet Department of Radiology UZ Brussel Laarbeeklaan 101 B-1090 Jette Belgium Page 25 of 26

26 References Wheeless' textbook of orthopaedics (online). Lee et al. MRI of the rotator interval of the shoulder. Clin Radiol. 2007; 62: Beltran et al. The MGHL: normal anatomy, variants and pathology. Skeletal Radiology 2002; 31: Barile et al. Antero-posterior lesions of the glenoid labrum: magnetic resonance evaluation. Radiol Med sep; 100(3): Massengill et al. Labrocapsular ligamentous complex of the shoulder : normal anatomy, anatomic variations and pitfalls on MR imaging and MR arthrography. Radiographics 1995; 196: De Maeseneer et al. CT and MR arthrography of the normal and pathological anterosuperior labrum and labral-bicipital complex. Radiographics Oct; 20 Spec NO:S Melvin et al. MRI of HAGL Lesions: Four Arthroscopically confirmed Cases of False-Positive Diagnosis. AJR 2008 sept; 191: Chung et al. Humeral avulsion of the posterior band of the inferior glenohumeral ligament: MR arthrography and clinical correlation in 17 patients. AJR 2004 Aug;183(2): Saupe N et al. Acute traumatic posterior shoulder dislocations: MR findings. Radiology 2008 Jul;248(1): Page 26 of 26