MRI of Shoulder Instabilities
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1 MRI of Shoulder Instabilities Anna Hirschmann, MD Musculoskeletal Division Clinic of Radiology and Nuclear Medicine University of Basel Hospital
2 Glenohumeral Articulation Centering of the humeral head
3 Glenohumeral Articulation Posterior decentering of the humeral head
4 Glenohumeral Articulation Anterior decentering of the humeral head
5 GHJ Stabilizers SSP SUB Anterior complex
6 GHJ Stabilizers ISP TM Posterior complex
7 Glenoid Anatomy Mean retroversion of 7 normal Increased retroversion atraumatic shoulder instability 8
8 Glenoid Anatomy CAVEAT: Glenoid may be shallow or hypoplastic can predispose to GH instability Labral hypertrophy in hypoplastic glenoids Pointed Weishaupt D et al. Skeletal Radiol 2000 Rounded J 60% asymptomatic Triangluar Delta
9 Glenoid Anatomy CAVEAT: Centrally thickening of subchondral bone with cartilage thinning bare area NO cartilage defect
10 Labral Anatomy Anterior superior Anterior inferior Superior Inferior Posterior superior Posterior inferior Superior: anterior labrum SMALLER than posterior Inferior: anterior labrum LARGER than posterior
11 Labral Anatomy Cartilage underneath the labrum undercuts the labrum Tears BELOW humeral head aquator Anatomical variations ABOVE aquator ANTERIOR NO developmental variants POSTERIOR V
12 Labral Anatomy Different shapes and heterogeneous SI AI labrum rounded triangula r cleaved hooked flat
13 Glenohumeral Ligaments IGHL Anterior band Posterior band Main stabilizer * * *Axillary recess
14 SGHL Glenohumeral Ligaments CHL MGHL Absent in 25%
15 Labral Ligamentous Complex Posterior insertion always at the labrum Anterior insertion medial to or at the labrum
16 Labral Ligamentous Lesions in Shoulder Instability
17 Labral Ligamentous Lesions in Shoulder Instability
18 Anterior Instability - Bankart detachment of anteroinferior labrum and GHL Chung C, Steinbach L. MRI of the upper extremity Williams&Wilkins 2010
19 Anterior Instability - ALPSA = anterior labral periosteal sleave avulsion Avulsion of AI GHL complex with intact periosteum Labrum displaces medially and rotates inferiorly Nevasier TJ Arthroscopy 1993 Chung C, Steinbach L. MRI of the upper extremity Williams&Wilkins 2010
20 Anterior Instability - GLAD = glenolabral articular disruption non-displaced AI labral tear PLUS glenoid cartilage lesion progress to rapid degenerative joint disease Nevasier TJ Arthroscopy 1993 Chung C, Steinbach L. MRI of the upper extremity Williams&Wilkins 2010
21 Anterior Instability - HAGL = Humeral Avulsion of the IGHL Anterior band J -sign +/- bony avulsion +/- SUB tear J-sign U-sign = normal Chung C, Steinbach L. MRI of the upper extremity Williams&Wilkins 2010
22 Anterior Instability Bony Bankart 21 y/o m snowboard accident
23 Glenoid Bone Loss r r cadaveric specimens; 2 readers; foto, CT+MR no significant differences Gyftopoulos S, Recht MP AJR 2014 Huijsmans PE J Shoulder Elbow Surg 2007
24 Glenoid Bone Loss Flattended glenoid vs. displaced fragment 90% recurrent dislocation; 22% first dislocation No definite method of measuring! Glenoid depth/length/area! Check with your referring shoulder surgeon Gyftopoulos S, Recht MP AJR 2014 Huijsmans PE J Shoulder Elbow Surg 2007
25 Glenoid Bone Loss Best-fit circle method: easy, 2D/3D, sagittal Cut off > 25% bone loss instability 6.8/28.3 x 100 = 6.8 mm 24% glenoid bone loss Gyftopoulos S, Recht MP AJR 2014
26 * Hill-Sachs Lesion - Pitfall Hill Sachs Hill Sachs Groove Groove
27 Hill-Sachs Lesion - Pitfall
28 Hill Sachs Lesion - Pitfall Cystic changes: Asymptomatic Symptomatic bare area ISP Chung C, Steinbach L. MRI of the upper extremity Williams&Wilkins 2010
29 Hill Sachs Lesion 45 = 13% of the circumference of the humeral head > 40% of the humeral head surface instability Gyftopoulos S, Recht MP AJR 2014 Skendzel JG American J Sports Medicine 2012
30 On-Track / Off-Track Method Glenoid track Contact area humeral head and glenoid ABD/ER Comprises appr. 84% of glenoid width Evaluation of risk of engagement On-track lesion of glenoid track Maintained contact Decreased risk of engagement Off-track lesion of glenoid track Decreased contact Increased risk of engagement Gyftopoulos S et al. AJR 2015
31 On-Track / Off-Track Method Glenoid track = 0.84 D d 0.84 x = 17.0 mm Hill Sachs Intervall = 24.3 mm Gyftopoulos S, Recht MP AJR 2014; Gyftopoulos S et al. AJR 2015
32 Glenoid Track Off track On track Omory Y ORS 2011; Yamamoto N. et al. J Should Elbow Surg 2007
33 Associated RC Tears Commonly > age 40 (preexisting tendinosis/partial tear) SUB in anterior and posterior dislocation ISP and TM in posterior dislocation SSP/ISP tear SUB tear + dislocation of LBT Chung C, Steinbach L. MRI of the upper extremity Williams&Wilkins 2010
34 Posterior Instability Atraumatic recurrent posterior multidirectional instability Overhead-throwing athletes Posterior labral lesion/labroligament lesion Reversed bony bankart Other Instabilities Multidirectional Instability Atraumatic Capsuloligamentous laxity Overheadthrowing/Swimming Posterior dislocation Chung C, Steinbach L. MRI of the upper extremity Williams&Wilkins 2010
35 Take Home Remember shape variety of the anteroinferior labrum Anterior instability most common Analyze: Labral/GHL tears Bony Bankart glenoid bone loss (mm + %) Hill-Sachs RC-tear size/location Glenoid track theory, bipolar lesions 25%
36
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