Shoulder MR arthrography

Transcription

1 Shoulder MR arthrography Poster No.: C-2273 Congress: ECR 2010 Type: Topic: Educational Exhibit Musculoskeletal - Joints Authors: E. E. Martin, J. Cadena Berecoechea, A. Cadena Berecochea, D. Sarroca, C. Bruno; Buenos Aires/AR Keywords: Keywords: DOI: MR arthrography, Shoulder, SLAP tears Musculoskeletal joint, Musculoskeletal system /ecr2010/C-2273 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 12

2 Learning objectives To describe the utility of shoulder MR arthrography (shoulder MR arthro) illustrating the technique we apply in the intra-articular injection of contrast material. To show the normal anatomy of the shoulder and its variations emphasising the different pathological conditions which affect this joint. Page 2 of 12

3 Background Shoulder MR arthro is becoming the most frequently minimally invasive method applied and also an easily performed technique that yields an accurate picture of the joint, providing a correct evaluation of the glenoid labrum, articular surfaces and capsularligamentous structures. Arthrographic images are preferred to conventional MR images, providing essential information to avoid pitfalls and unnecessary surgeries. We retrospectively studied patients between January 2005 and August All underwent radioscopy with basculating table and a seriograph, and on a 1.5T Intera Achieva Resonator. Our study was based on a protocol with the patient in neutral position and finally on abduction and external rotation (ABER) position. Under radioscopic observation, an anterior puncture is performed in the scapular-humeral joint with a 21G spinal needle. Acurate intra-articular needle placement is confirmed with a small amount of iodinated contrast agent. 11 to 15ml of gadolinium are injected (0.4ml gadolinium in 50ml physiological serum) (Fig. 1 on page 4). Next, the patient is transferred to magnetic resonance imaging area. Protocolised sequences are performed, which include coronal T2- and T1- weighted SPIR, 3D WATSc, sagittal T1-weighted SPIR and axial T1-weighted SPIR and DP. Optionally, axial bffe sequences and volumetric THRIVE sequences are added. Finally the patient is placed in ABER position, and an axial bffe sequence is performed. Page 3 of 12

4 Images for this section: Fig. 0: Image 1: Puncture technique. Shoulder AP Rx. A. Pellet mark on the puncture site. B. Injection of iodinated contrast agent (1ml) inside the humeral osseous cortical, over the inferior third of the glen, to confirm the correct intra-articular location. C. Anterior intra-articular injection (12-15ml of diluted gadolinium solution) which produces capsule distension. Magnetic Resonance, Fundacion Cientifica del Sur - Buenos Aires/AR Page 4 of 12

5 Imaging findings OR Procedure details Intra-articular injection of contrast material allows us to recognise the anatomic characteristics of the shoulder and its anatomic variations (figure 2 on page 6). It also helps identify pathological conditions such as injuries of anterior glenoid labrum (figures 3 to 5), posterior glenoid labrum (figures 6 and 7), SLAP (figures 8 and 9), lining cartilage and glenohumeral ligaments. It also evaluates rotator cuff tendons as well, with a particular visualisation of the articular surfaces in ABER position (figures 10 and 12). Besides, it allows us to differentiate capsular defects and any variation of its content. In addition, it is very useful in the evaluation of the shoulder after surgeries (figure 13 on page ). Page 5 of 12

6 Images for this section: Fig. 0: Image 2: Arthro-MRI. Labroligamentous anatomical variants. Buford Complex. A. Sagittal T1-weighted SPIR. B. C. Axial FAT SAT. Note the thickened middle glenohumeral ligament (long arrow), which attaches directly to the biceps upper labrum with an absent anterior-superior glenoid labrum (short arrow). Image 3: Arthro-MRI. Labroligamentous anatomical variants. Sublabral foramen. A. Coronal T1-weighted SPIR. B. Sagittal T1-weighted. C. Axial 3D-bFFE. A linear hyperintense image is observed between the glenoid edge and the anterior-superior labrum (arrow), forming a separation between them. Image 4: Arthro-MRI. Labroligamentous anatomical variants. Deep sublabral recess. A. B. Coronal T1-weighted SPIR. C. Axial T1-weighted SPIR. It shows hyperintense linear indentation in the anterior-superior glenoid labrum (arrow), without producing a separation from the glenoid edge. Magnetic Resonance, Fundacion Cientifica del Sur - Buenos Aires/AR Page 6 of 12

7 Fig. 0: Image 5: Arthro-MRI. Bankart lesion. Axial T1-weighted SPIR. It shows a tear in the insertion of anterior glenoid labrum (circle). Image 6: Arthro-MRI. Bony Bankart lesion. Axial T1-weighted SPIR. It shows an avulsion of the anterior labrum with small bone fragment associated (circle) and Hill-Sachs lesion (arrow). Image 7: Arthro-MRI. Perthes lesion. Axial bffe (right). Axial T1-weighted SPIR (left). It shows an anterior labral tear which remains attached to the glenoid edge through periosteum (circle) Image 8: Arthro- MRI. ALPSA. Axial T1-weighted SPIR. It shows anterior medial fixation of avulsionated anterior-inferior labrum and anterior band of the glenohumeral inferior ligament (circle). Image 9: Arthro-MRI. GLAD. Axial bffe (right). Axial T1-weighted SPIR (left). Anterior labral disruption associated to a lesion in the anterior inferior glenoid articular cartilage (circle). Image 10: Arthro-MRI. HAGL. Axial T1-weighted SPIR. Avulsion of the humeral insertion of the anterior band of the inferior glenohumeral ligament (circle). Magnetic Resonance, Fundacion Cientifica del Sur - Buenos Aires/AR Page 7 of 12

8 Fig. 0: Image 15: Arthro-MRI. SLAP tear. A. C. Coronal T1-weighted SPIR. B. Coronal T2-weighted SPIR (right) and coronal T1-weighted SPIR (left). D. Coronal T2-weighted SPIR (right) and coronal T1-weighted SPIR (left). A. Type I SLAP. B. Type II SLAP. C. Type III SLAP. D. Type IV SLAP. Magnetic Resonance, Fundacion Cientifica del Sur - Buenos Aires/AR Page 8 of 12

9 Fig. 0: Image 16: Arthro-MRI. Partial tear in the articular surface of the tendon of the supraspinal muscle. A. Coronal T2-weighted SPIR. B. Coronal T1-weighted SPIR. C. Axial bffe in ABER position (abduction and external rotation). (A, B) The tendon of the supraspinal muscle is observed without sign of lesion (arrow) and in (c) ABER position a partial tear of its articular surface is identified (circle). Image 17: Arthro- MRI. Fullthickness focal tear of the tendon of the supraspinal muscle. A. Coronal T2-weighted SPIR. B. Coronal T1-weighted SPIR. C. Axial T2-weighted SPIR. A small full-thickness focal tear at middle third level in the distal insertion of the tendon of the supraspinal muscle is identified (arrowhead). Image 18: Arthro-MRI. Complete tear of the rotating "buckethandle". A. B. Coronal T2-weighted SPIR. C. Sagittal T2-weighted SPIR. It shows full tear and retraction of the tendons of the supraspinal muscles (asterisk) and infraspinal muscle (arrowhead). Magnetic Resonance, Fundacion Cientifica del Sur - Buenos Aires/AR Page 9 of 12

10 Conclusion Correct knowledge of normal shoulder arthrogram anatomy and anatomic variations makes it possible to differentiate them from pathological conditions. Page 10 of 12

11 Personal Information Dr. MARTIN, Eduardo. MR Department, Fundación Científica del Sur. Buenos Aires, Argentina. Dr. CADENA BERECOECHEA, Juan Carlos. Resident, Fundación Cientifica del Sur. Buenos Aires, Argentina. Page 11 of 12

12 References 1-Linda J. Probyn,MD, Lawrence M. White,MD, David C. Salonen,MD, George Tomlinson, PhD, Erin L. Boynton,MD. Recurrent Symptoms after Shoulder Instability Repair: Direct MR Arthrographic Assessment-Correlation with Second-Look Surgical Evaluation. Radiology 2007; 245: Sang Yong Lee, MD; Joong K. Lee, MD. Horizontal Component of Partial-Thickness Tears of Rotator Cuff: Imaging Characteristics and Comparison of ABER View with Oblique Coronal View at MR Arthrography - Initial Results. Radiology 2002; 224: Emily N. Vinson, Nancy M. Major, Laurence D. Higgins. Magnetic resonance imaging findings associated with surgically proven rotator interval lesions. Skeletal Radiol. 2007; 36: Thomas Magee, David Williams, Nisha Mani. Shoulder MR Arthrography: Which Patient Group Benefits Most?. AJR 2004; 183: Mohana-Borges AV, Chung CB, Resnick D. MR imaging and MR arthrography of the postoperative shoulder: spectrum of normal and abnormal findings. RadioGraphics 2004; 24: Beall DP, Williamson EE, Ly JQ. Association of biceps tendon tears with rotator cuff abnormalities: degree of correlation with tears of the anterior and superior portions of the rotator cuff. AJR Am J Roentgenol 2003; 180: Guntern DV, Pfirrmann CW, Schmid MR, et al. Articular cartilage lesions of the glenohumeral joint: diagnostic effectiveness of MR arthrography and prevalence in patients with subacromial impingement syndrome. Radiology 2003; 226: Bencardino JT, Beltran J, Rosenberg ZS, et al. Superior labrum anterior-posterior lesions: diagnosis with MR arthrography of the shoulder. Radiology 2000; 214: Page 12 of 12