What can Imaging tell us?
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- Eileen Glenn
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1 What can Imaging tell us? David Connell FRANZCR, FFSEM (UK) Assoc Professor Dept of Medicine, Nursing & Healthcare Monash University, Melbourne, Australia Assoc Professor Sport & Exercise Medicine Research Centre La Trobe University, Melbourne, Australia
2 Case Study A 94yo presents with a stiff but not painful shoulder
3 Case Study A 94yo presents with a stiff but not painful shoulder
4 Imaging offers an anatomical snapshot, but in isolation is meaningless
5 Ask yourself: Why am I imaging this patient? 1. Diagnosis No idea what is going on 2. Facilitate Management Pretty good idea what is going on but want confirmation before implementing Rx plan 3. Patient expectation 4. End point of consultation/manage workload 5. Risk management cover my ass
6 Common Shoulder problems 1. Impingement 2. Rotator Cuff Tears 3. Arthritis 4. Capsulitis 5. Trauma
7 Impingement MUSCLE TENDON BONE Tensile Undersurface Fiber Failure (TUFF)
8 AC arthrosis Hypertrophic bony change, capsular thickening, cystic change and bony oedmea Indentation of the muclotendinous unction of SS Chronic inflammation of the bursa Bursal thickening and fluid collections Dynamic ultrasound shows bunching Role of imaging Exclude rotator cuff tear Accurate guidance of injection
9 Impingement Narrow subacromial space: Bony hypertrophy of AC joint/ca ligament Superior migration of humeral head Tendon thickening Inflammation of bursa Fraying/tearing of the tendon Impingement is a clinical diagnosis Lots of people impinge but are asymptomatic Pain generator might be AC joint
10 So what do I request for impingement? 1. XR and Ultrasound? XR might show AC Joint arthritis. So what? US might demonstrate impingement.?so what 2. Nothing (no change to my RX plan) 3. US-guided injection Pain goes away. (Hi Ho Hi Ho Off to physio we go!) Pain doesn t go away (Whoops! Wrong diagnosis. Rethink)
11 Common Shoulder problems 1. Impingement 2. Rotator Cuff Tears US right?! 3. Arthritis 4. Capsulitis 5. Trauma
12 Greater Tuberosity Facets SS Superior: Supraspinatus tendon IS Middle: Supraspinatus and infraspinatus tendons Inferior: Teres minor tendon P A
13 Greater Tuberosity Facets Superior: Supraspinatus tendon Middle: Infraspinatus tendons Inferior: Teres minor tendon IS IS SS P A
14 Mechanisms of Cuff Injury 1.Impingement 2.Ischaemia 3.Intrinsic Structure 4. Degeneration 5. Trauma
15 Ischaemia In some tendons, such as the supraspinatus tendon, normal avascular regions (critical zones) may bevulnerable to degeneration and subsequent failure
16 Ischaemia
17 Mechanisms of Cuff Injury 1.Impingement 2.Ischaemia 3.Intrinsic Structure 4. Degeneration 5. Trauma
18 Intrinsic Structure Anterior Supraspinatus muscle consists of 2 muscle bellies: Posterior 1. Anterior belly: Larger with central tendon 2. Posterior belly: Straplike with terminal tendon
19 Intrinsic Structure Clark s Layers II - superficial part of tendon III deep part of tendon
20 Rotator Partial Cuff Tears Rotator Cuff Shoulder Concepts
21 Delaminating Tears In the presence of a joint effusion, delaminated tears that violate the articular surface may be accompanied by sentinel cysts at the myotendinous junction
22 Rotator Delaminating Cuff Tears Tears Rotator Cuff Shoulder Concepts
23 Rotator Cuff Tears What does the surgeon want to know? Tendon torn or not? Dimensions of tear Tendon edge morphology Preexisting tendon path Other:?AC arthrosis? Glenouhumeral OA?Gr Tuberosity?Capsulitis
24 Rotator Cuff Failure Chronic Massive Tears: Progressive tendon failure with retraction Tendon not seen with ultrasound Superior humeral migration Muscle fatty infiltration?surgical repair Compensation by other muscles?teres minor
25 So what do I ask for?rotator cuff tear 1. Ultrasound US only shows a small part of the rotator cuff US performed badly in the community and most shoulder surgeons have no confidence in the report US does not provide adequate roadmap for surgery 2. Nothing (no change to my RX plan) Many elderly patients is community cope quite well with chronic RC tears 3. US-guided injection 4. Call your friendly neighbourhood surgeon 5. MRI Quality and interpretation improved; cost effective; best test
26 What is the role of shoulder ultrasound? 1. Overused in general community Cheap and accessible, but poorly performed Qualify for rebate need radiologist supervision 2.. Operator dependent Difficult for referring doctor to interpret 3. Confined to specialist centres 4. Occasionally ordered by specialists Integrity postoperative repair, document healing C/I MRI i.e. pacemaker, claustrophobia 5. Role for Guided injections
27 Common Shoulder problems 1. Impingement 2. Rotator Cuff Tears 3. Arthritis - radiographs 4. Capsulitis 5. Trauma
28 Rotator Interval Osteoarthritis Clinically obvious in many cases Radiographs confirm diagnosis +/-severity MRI can be useful for early OA +/- intraarticular bodies Surgeons sometimes order CT scans for surgical Shoulder planning/prosthesis Problem: OA often does not occur in isolation Concepts
29 Common Shoulder problems 1. Impingement 2. Rotator Cuff Tears 3. Arthritis 4. Capsulitis - MRI 5. Trauma
30 Rotator Interval Capsulitis Rotator Interval Space Shoulder Concepts 30
31 Common Shoulder problems 1. Impingement 2. Rotator Cuff Tears 3. Arthritis 4. Capsulitis 5. Trauma
32 Rotator Interval Trauma Bone Trauma radiographs +/- CT Soft tissue Trauma radiographs +/- MRI Shoulder Concepts 32
33 Shoulder Dislocation MRI best test for assessing labral-capsular-ligament complex Also chondral insult, bone bruise
34 Soft Tissue Trauma Case Study : 23yo professional AFL player tackled by pulling his arm across his body Infraspinatus rupture Case Study: 27yo rugby player with tackling injury Subscapularis rupture
35 Common Shoulder problems What about Ultrasound???
36 Calcific Tendonitis Ax unknown Crystals migrate into bursa Secondary bursitis Often self-limiting US most sensitive
37 Common Shoulder problems Ultrasound is fantastic for injections, aspirations and biopsies Ancillary information/dynamic scanning Shoulder specialists prefer MRI
38 Imaging Shoulder problems 1. Impingement?diagnostic imaging unnecessary, US-guided injection 2. Rotator Cuff Tears - MRI 3. Arthritis Radiographs +/- MRI 4. Capsulitis MRI (US in specialist centres) 5. Trauma Radiographs +/- CT +/- MRI
39 What can Imaging tell us? David Connell FRANZCR, FFSEM (UK) Assoc Professor Dept of Medicine, Nursing & Healthcare Monash University, Melbourne, Australia Assoc Professor Sport & Exercise Medicine Research Centre La Trobe University, Melbourne, Australia
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