49. Ultrasound
• Scanning procedure
• Minimal still image requirements:
• Annotations!!, lateralisation!!
– AC joint longitudinal: with cross arm test
– RC components longitudinal with thickness
• SS, SSC, IS
– Subdeltoid space thickness
– RC interval
– Biceps long head longitudinal
– Pathology
US
58. Minor Glenohumeral Instability
• Purpose: Detection and Grading of
– Causes of minor shoulder instability
• Anatomical variants
• Congenital disorders
• Lesions
– Lesions due to (minor) shoulder instability
• Techniques
– Radiography
– Ultrasound
– CT-arthrography
– MRI, direct and indirect arthro-MRI
US
MR
64. ♀WH °620609 ed 110701
RA: Biceps Tendon Sheat, Subdeltoid Bursa
US
65. Dynamic Constraints
• Rotator cuff
– Through Joint Compression
– Individual components of rotator cuff
– Through preloading glenohumeral ligaments
• Long head of biceps tendon
• (Supporting musculature)
• (Proprioception and reflexes)
• (Scapulothoracic motion)
US
MR
66. Rotator Cuff Components
• Supraspinatus
• Infraspinatus
• Teres minor
• Subscapularis
– tendinous insertions merge with glenohumeral
joint capsule and ligaments
US
MR
67. Rotator Cuff Lesions
• Histologic abnormalities: 50% age > 40y
– glycosaminoglycan infiltration
– fibrocartilaginous transformation
– loss of collagen fiber organisation
– degenerative changes
• Inflammatory infiltrates not predominant !
• Clinical and functional relevance?
US
MR
68. Cuff Ultrastructure
• Layer 1: corocohumeral ligament superficial fibres
• Layer 2: thick main cuff portion: parallel bundles
• Layer 3: thick cuff portion: smaller bundles with
less uniform oriëntation
• Layer 4: rotator cable or transverse band, force
distribution through perpendicular bundle
orientation, deep fibres of coracohumeral
ligament
• Layer 5: capsule, random fibre orientation
US
MR
69. Rotator Cable (C) and Crescent (B)
Cable: transverse force distribution
Articular side tears at cable: greater functional impact
US
MR
98. End Stage
Naked Tub. Maius
Effusion AC-joint
Effusion Subdelt.
Caput Longum Bic.
Supraspinatus tear
US
99. Grading RC Tears
• FT: Dimensions Anteroposterior and lateral
• CT: Goutallier
– Position of retracted SS tendon relative to the
acromion
• Grade 1: lateral to the acromion
• Grade 2: subacromial
• Grade 3: medial to the acromion
MR
US
100. Grading Supraspinatus Muscle Atrophy: MRI and CT
• Complete or Massive Supraspinatus Tear
• Goutallier classification:
– 0 = no intramuscular fat
– 1 = some fatty streaks
– 2 = fat less extensive than muscle
– 3 = fat equal to muscle
– 4 = fat more extensive than muscle
Clin Orthop Relat Res. 1994 Jul;(304):78-83.
Fatty muscle degeneration in cuff ruptures. Pre- and
postoperative evaluation by CT scan.
Goutallier D, Postel JM, Bernageau J, Lavau L, Voisin MC.
US
MR
101. Massive Supraspinatus Tear
Supraspinatus Muscle Evaluation: CT and
MRI
• Fatty infiltration:
– Goutallier classification:
– 2 = fat less extensive
than muscle
• Muscle volume:
– Zanetti Tangent Sign
– +: muscle below
tangent line
Clin Orthop Relat Res. 1994 Jul;(304):78-83.
Fatty muscle degeneration in cuff ruptures. Pre- and
postoperative evaluation by CT scan.
Goutallier D, Postel JM, Bernageau J, Lavau L, Voisin MC.
US
MR
102. Supraspinatus Muscle Atrophy: US grading
• Structure
– 0 = clearly visible muscle contours, fibers, and central tendon
– 1 = partially visible structures
– 2 = structures no longer visible
• Echogenicity in comparison to deltoid muscle
– 0 = iso- or hypoechoic
– 1 = slightly more echoic
– 2 = markedly more echoic
• Substantial fatty atrophy = grade 2 in at least one
of the evaluated US criteria
Strobel et al. Fatty atrophy of the supraspinatus, accuracy of US. Radiology 2005
US
103. Massive Supraspinatus Tear
Supraspinatus Muscle Evaluation: CT and
MRI
• Muscle volume:
• Zanetti Tangent Sign
– +: muscle below
tangent line
Invest Radiol. 1998 Mar;33(3):163-70.
Quantitative assessment of the muscles of the rotator cuff with
magnetic resonance imaging.
Zanetti M, Gerber C, Hodler J.
US
MR
105. • Fatty infiltration: Goutallier
classification:
– 0 = no intramuscular fat
– 1 = some fatty streaks
– 2 = fat less extensive than
muscle
– 3 = fat equal to muscle
– 4 = fat more extensive than
muscle
• Muscle volume: Zanetti Tangent
Sign
– +: muscle below tangent line
Invest Radiol. 1998 Mar;33(3):163-70.
Quantitative assessment of the muscles of the rotator cuff with
magnetic resonance imaging.
Zanetti M, Gerber C, Hodler J.
US
MR
Massive Supraspinatus Tear
Supraspinatus Muscle Evaluation: CT and
MRI
119. ♀ DDI °651002 ed1 30314
SS Complete Tear, Biceps CL superficial to SSC
Cor T1 FS Gad Cor T1 FS Gad Sag T1 Gad Sag T1 Gad
US
MR
120. Dynamic Constraints
• Rotator cuff
– Through Joint Compression
– Individual components of rotator cuff
– Rotator cuff through preloading glenohumeral ligaments
• Long head of biceps tendon
• Supporting musculature
• (Proprioception and reflexes)
• (Scapulothoracic motion)
US
132. Static Constraints
• Bony structures
– Humeral and glenoid version
– Surface area and articular conformity
– Coracoacromial arch
– (Acromioclavicular joint)
• Soft tissues
– Glenohumeral ligaments and capsule
– Glenoid labrum
– Subacromial bursa
• (Intraarticular pressure)
US
MR
133. Coracoacromial Arch
• Acromion
• Coracoacromial ligament
• Coracoid process
Roof above supraspinatus tendon: outlet
through which tendon must pass
US
185. ♂ ed 111214 Lipomatous Involution IS
Volleyball Player
Transverse Infraspinatus View Longitudinal Infraspinatus View
Teres Minor MuscleSpina Scapulae
Trapezius Muscle Trapezius Muscle
Humeral head
US
MR
Courtesy FYZZIO
188. Conclusion
• Conventional radiography
– Scapular Y view: acromion, GH-joint
– AC-joint
• Ultrasound
– Rotator Cuff, AC-joint, Subdeltoidal bursa
• Direct arthro-MRI
– Labral lesions, including SLAP: 67% accuracy
– Capsule
• Indirect arthro-MRI
– Most complete evaluation
– Labral lesions: 100% accuracy
– Excluding capsule
189. Conclusion Cuff Lesions
• Ultrasound
– State of the art
– Available, economical and accurate
– Primary examination
• MRI, gadolinium enhanced
– Direct or Non-direct
– Inconsistency of clinical and ultrasound findings
– Preoperatively
• Massive tears: feasibility of primary repair
• Additional information: muscle and musculotendinous
junction
190. References
• Takayuki S, Teruhiko N, Masamitsu T, Masafumi I. Prediction of primary reparability of massive tears of the rotator cuff on preoperative
magnetic resonance imaging. Journal of Shoulder and Elbow Surgery 2003;12:222-225.
• Seeger LL, Gold RH, Bassett LW, Ellman H.Shoulder impingement syndrome: MR findings in 53 shoulders. American Journal Of
Roentgenology 1988;150:343-347.
• Schroder RJ, Bostanjoglo M, Kaab M, Herzog H, Hidajat N, Rottgen R, Maurer J, Felix R.
• Fortschr Geb Rontgenstr Neuen Bildgeb Verfahr. 2003;175:920-928.
• Nakatani T, Fujita K, Iwasaki Y, Sakai H, Kurosaka M. MRI-negative rotator cuff tears. Magn Reson Imaging. 2003;21:41-45.
• Schulte-Altedorneburg G, Gebhard M, Wohlgemuth WA, Fischer W, Zentner J, Wegener R, Balzer T, Bohndorf K. MR arthrography:
pharmacology, efficacy and safety in clinical trials. Skeletal Radiol. 2003;32:1-12.
• Motamedi AR, Urrea LH, Hancock RE, Hawkins RJ, Ho C. Accuracy of magnetic resonance imaging in determining the presence and size of
recurrent rotator cuff tears. J Shoulder Elbow Surg. 2002 Jan-Feb;11(1):6-10. Related Articles, Links
• Chang CY, Wang SF, Chiou HJ, Ma HL, Sun YC, Wu HD. Comparison of shoulder ultrasound and MR imaging in diagnosing full-thickness
rotator cuff tears. Clin Imaging. 2002;26:50-54.
• Yamakawa S, Hashizume H, Ichikawa N, Itadera E, Inoue H. Comparative studies of MRI and operative findings in rotator cuff tear. Acta Med
Okayama. 2001;55:261-268.
• Oh CH, Schweitzer ME, Spettell CM. Internal derangements of the shoulder: decision tree and cost-effectiveness analysis of conventional
arthrography, conventional MRI, and MR arthrography. Skeletal Radiol. 1999;28:670-678.
• Prickett WD, Teefey SA, Galatz LM, Calfee RP, Middleton WD, Yamaguchi K. Accuracy of ultrasound imaging of the rotator cuff in shoulders
that are painful postoperatively. J Bone Joint Surg Am. 2003;85-A:1084-1089.
US
MR
191. References
• Magnetic Resonance Imaging in Orthopaedics and
Sports medicine; David W. Stoller; 2nd ed.
• Internal Derangements of Joints, Emphasis on MR
Imaging; Donald Resnick and Heung Sik Kang
• MRI, Arthroscopy, and Surgical Anatomy of the
Joints; David W. Stoller
US
MR