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Practical Reporting of Musculoskeletal Imaging

Studies:

MRI Shoulder James F Griffith

Practical reporting

Everyday clinical scenarios

Trainees and those not experienced with MR MSK reporting

Informal

Lecture series

Shoulder

Approach differs whether rotator cuff or dislocation history

No need to get a history otherwise

Shoulder pain poorly localised

Don’t mention any feature without grading it

Qualitative measure :

Minimal, mild, moderate, severe

Quantitative measure:

Small, medium, large (mm long x mm deep x mm wide)

Grade ……….

If you can definitely exclude:

“No Hill-Sachs deformity present”

Correct terminology ……….

If you cannot definitely exclude:

“No superior labral tear evident”

Rotator cuff tendinosis

Rotator cuff tear

SA-SD bursitis

Labral injury

Glenoid bone loss

This talk : outline

Normal Tendinosis

Tendinosis (tendon degeneration)

Collagen disorganization Proteoglycan deposition

Most common pathology encountered on shoulder MRI

Tears occur on background of tendinosis

Very uncommon to see tear in normal tendon

Size & signal intensity are MR criteria of tendinosis

Tendinosis

Normal supraspinatus tendon

Mild tendinosis supraspinatus

Moderate tendinosis supraspinatus

Moderate tendinosis supraspinatus

Severe tendinosis supraspinatus

Supraspinatus tendinosis

Normal Mild

Moderate Severe

“There is mild/ moderate/ severe tendinosis affecting the anterior to mid-fibres of the supraspinatus tendon. The posterior fibres of the supraspinatus tendon are normal as are the remainder of the rotator cuff tendons without tendinosis or tear”

“There is moderate supraspinatus and subscapularis tendinosis with mild tendinosis of the infraspinatus and long head of biceps tendons”

Report

Complete: when tendon completely torn Partial : when part of tendon torn anterior, middle, posterior fibres supraspinatus upper, mid, lower fibres subscapularis Longitudinal split tears biceps tendon

Rotator cuff tears

Complete tear

“ There is a complete avulsive-type tear of the supraspinatus tendon. The tendon is retracted 12m from the insertional area”

Partial full-thickness avulsive-type or intra-substance partial thickness avulsive-type bursal surface articular surface intra-substance - Bursal surface fraying

Rotator cuff tears

Full-thickness partial tear

“ There is a full-thickness avulsive-type tear of the anterior fibres supraspinatus tendon. The tear measures 6mm wide and is retracted 10mm from the insertional area”

Full-thickness partial tear

“ There is a full-thickness tear of the mid-fibres subscapularis tendon measuring 11mm mediolateral x 4mm inferosuperior and involving 30% depth of the tendon at this location”

Partial thickness partial tear

“ There is a partial-thickness bursal surface (or articular surface or intrasubstance tear ) tear of the mid-fibres supraspinatus tendon measuring 5mm medio-lateral x 4mm anteroposterior and involving 30% depth of the tendon at this location”

Articular surface tear Bursal surface tear

Partial thickness tears

“ There is a partial-thickness deep surface tear of the upper fibres subscapularis tendon measuring 5mm medio-lateral x 4mm inferosuperior and involving 30% depth of the tendon at this location”

Muscle atrophy – supraspinatus

Mild: <30% muscle atrophy

Severe: >60% muscle loss

Moderate

SA-SD bursitis

“ There is mild SA-SD bursitis”

Structural compromise

Acromial osteophytes, hooks or hypostotic ridge

Thickening coracromial ligament

AC joint osteoarthritis

Laterally down-sloping acromion

Acromial shape

Structural compromise

spur hook

laterally downsloping

ACJ marginal osteophytosis

Coracoacromial and coracohumeral ligaments

Thickened coracoacromial ligament insertion and thickened ligament

“ There is a moderate-severity (2mm thick) hyperostotic ridge at the undersurface of the acromion with moderate (3.3mm, normal < 2.5mm) thickening of the coaracohumeral ligament”

Acromial undersurface shapes

Flat Curved Hooked Convex

Can use reverse clock face Descriptive terminology Anterior, anterosuperior, anterinferior Posterior, posterosuperior, posteronferior Superior

Labral pathology localisation

12

3 9

6

Length

Undisplaced or displaced (mild, moderate, severe)

Location on glenoid

Type of tear (chondral-bony attachment, intrasubstance)

Labral condition (attrition, mucoid degeneration)

± Paralabral cyst

Tears – describe

Normal anterior and posterior labrum

Inferiorly displaced labral avulsion – GLOM (glenoid labral ovoid mass)

Bankart lesion (complete labral avulsion)

Perthes lesion (incomplete labral avulsion

ALPSA (anterior labral periosteal sleeve avuslion)

Chronic ALPSA

GLAD lesion (glenoid labral articular divot)

Aber (abduction & external rotation) view

? Tear Tear

• Labral avulsion with inferior retraction

• Complete labral avulsion (Bankart)

• Incomplete labral avulsion (Perthes)

• ‘Acute’ ALPSA

• ‘Chronic’ ALPSA

• Glenoid labral articular disruption (GLAD)

Labral tears – relative prevalence in dislocation

• Undisplaced labral tear (intrasubstance or avulsive)

Labral tears – relative prevalance degeneration

Length

Undisplaced or displaced (mild, moderate, severe)

Type of tear (chondral-bony attachment, intrasubstance)

Biceps anchor integrity

Extension

Labral condition (attrition, mucoid degeneration)

± Paralabral cyst

Superior Labral Tears (SLAP – superior labrum anterior to posterior)

Superior bicipitalabral complex: normal

Superior Labral Tears

Fraying Detached labrum

with intact biceps anchor Extending to

biceps anchor Extending into

biceps tendon

Extension into anterior or posterior labrum Extension into SGHL or MGHL

Superior Labral Tear

Fraying Partial thickness

intra-substance tear Fraying

Superior Labral Tear

“Undisplaced vertical tear base of superior

labrum not extending into biceps anchor”

Superior Labral Tears

“Undisplaced vertical tear base of superior labrum not

extending into biceps anchor”

“Mildly displaced bucket handle tear not extending

into biceps anchor”

Superior Labral Tear

“Moderately displaced bucket-handle tear extending to anterosuoperior aspect of glenoid labrum. The biceps anchor is not

torn”

Superior Labral Tear

“Undisplaced avulsive-type vertical tear superior labrum extending

into the biceps anchor. The bicipitolabral complex is not displaced”

Labral variants

Sublabral recess Sublabral foramen Buford complex

+ thickened MGHL

• 50% single dislocation • 90% recurrent dislocation

Glenoid bone loss

Bone loss

Even easier dislocation

Even more bone loss Easier dislocation

More bone loss

Maximum GBL = 33%

Severity of GBL

Mild < 10% Moderate 10-20% Severe > 20%

• < 10% associated with fracture fragment

• Most due to compressive-type fracture

Glenoid bone loss

• Assessed with arthroscopy, CT or MRI

Glenoid bone loss (GBL)

Bare area

Bare area

Bare area

450 profile view (Bernageau)

450

GBL: Difficult to appreciate on axial imaging

20% GBL Normal

First sign of GBL = Anterior straight line

No anterior straight line = no GBL

• Anterior straight line • glenoid width

CT: glenoid en-face view

Normal Affected

superior

inferior

anterior posterior

- Left-side . Right-side

Excellent side-to-side glenoid symmetry

To measure GBL on CT

28.4 – 24.7 = 3.7mm

3.7mm / 28.4mm x 100% = 13% GBL

Progressive glenoid bone loss

Normal Mild Mild to moderate

Moderate Severe

Obtain view en-face to glenoid surface

• T1-weighted FSE (1.5mm-thick sections with 0.75mm overlap), en-face to glenoid, 3 mins extra.

Look for ASL: if absent → No GBL

If ASL present → GBL

GBL : MR assessment No ASL

ASL

Best-fit circle method

A B

A /A+B X 100 = %GBL

Almost as good as CT

“There is severe (4.6mm, 23%) anterior glenoid bone loss. No glenoid rim fracture is present”

GBL on MR – examples

Normal Minimal Mild

Mild to moderate Moderate Severe

Glenoid bone loss

Very common in shoulder dislocation

Assess with either MR (one side) or CT (both sides)

If ASL not present → no GBL

If ASL present → measure GBL by best-fit circle (MR) or compare with opposite side (CT).

Hill-Sachs deformity

Describe as small, medium-sized or large

Non-angulated or angulated (engaging Hill-Sachs)

“Moderate severity non-angulated Hill-Sachs deformity”

“Large angulated Hill-Sachs deformity”

Rotator cuff tendinosis

Rotator cuff tear

SA-SD bursitis

Labral injury

Glenoid bone loss

We talked about :

Thank you