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%

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