Imaging and Patient Selection

Mr Chris RobertsIpswich HospitalWatanabe Club

York 2010

NB

• You must know– How to take x-ray views– What MRI sequences– What CT views

• The result of the investigation must affect patient management

• Don’t order an investigation for the sake of it

Why investigate?

• Diagnosis– Do we need to operate?

• Informed consent

• Patient planning

• List planning– Positioning– Timing

Which imaging modality?

• Likely diagnosis

• Cost

• Availability

• Access

• Expertise

Imaging modalities

• X-ray

• Ultrasound

• CT

• MRI

• Arthrography

Plain radiography

• AP shoulder– Beam perpendicular to

body– Commonest view– Good view of ACJ– Poor view of GHJ

Plain radiography

• AP GHJ– Beam perpendicular to

scapula– Good view GHJ– Poor view ACJ

Plain radiography

• Scapular lateral– Perpendicular to AP

GHJ view– Conirms enlocation

GHJ– Alignment for fractures

Plain radiography

• Outlet view– As for scapular lateral

but beam tipped caudally 10 degrees

– Acromial morphology– Guide to

decompression– Localise lesions

Plain radiography

• Axillary view– Good view of GHJ

space– Eccentric erosion– Bone lesions– Os acromiale

Plain radiography

• Modified axillary views– Post trauma

Plain radiography

• Bernageau view– Anterior glenoid bone loss

MRI

• Imaging is performed in three planes relative to glenohumeral joint

• Typical sequences• Coronal oblique T1 and T2 spir• Sagittal oblique T2• Axial Watts (T2 fat suppressed)• Axial T1 in instability

• Difficult for large patients – not central in bore

MRI

• Coronal oblique– Supra and

infraspinatus tendons– Subacromial space– A-C joint– Superior labrum– Biceps tendon– Subscapularis

MRI

• Sagittal oblique– Rotator cuff

• Tendons• Muscle atrophy

– Acromial morphology– Glenoid

MRI

• Axial plane– Biceps tendon– Glenoid labrum

• Bankart lesion

– Subscapularis attachment

Common Pathology

• Rotator cuff disease

• Biceps tendon

• Glenoid labrum

• Bony lesion

Rotator Cuff

• Partial thickness– Articular surface– Bursal surface

• Full thickness– Size– Tendon retraction– Muscle atrophy

Rotator Cuff

Rotator Cuff

Rotator Cuff

Bony Lesions

Instability

• Hill-Sach’s lesions• Anterior labral tears –

Bankart lesion

Other lesions

• Cysts

MR arthrography

• Anterior labral lesions

MR arthrography

• SLAP lesion

MR arthrography

• HAGL lesion

• Axial images• Coronal and sagittal

reconstructions relative to plane GHJ

• Quantifying bone lesions

CT scans

CT scans

• 3D reconstructions

Ultrasound

• Soft tissue imaging– Coronal and sagittal

views– SST, IST and SBSC– Intratendinous lesions – Muscle atrophy– Not labrum– Very user dependent– Static images not very

useful

Ultrasound

• Cuff tears

Ultrasound

• Calcium

Ultrasound

• Effusions

Arthrography

How I image for cuff pathology

• Impingement– Xrays: AP, outlet and axillary

• Impingement vs Sml cuff tear– Add USS

• Large/massive cuff tear– Add MRI

How I image for instability

• Atraumatic– Xray AP shoulder

• Traumatic anterior– Xrays: AP and Bernegeau– If bone lesion or contact sportsperson add CT

• NB beware the HAGL

Case 1

• 43 y.o. female• Painful arc• Full movement

passively• Cuff strong on testing

Case 2

• 55 y.o. man• Painful arc, night pain• No cuff wasting• Full active movement • Cuff painful and weak

on testing

Case 3

• 55 y.o. man• Painful arc, night pain• Cuff wasted• Restricted active but

full passive range• Cuff painful and weak

on testing• Positive drop arm and

Hornblowers

Case 4

• 75 y.o. man• Painful arc, night pain• Cuff wasted• Restricted active but

full passive range• Cuff painful and weak

on testing• Positive drop arm and

Hornblowers

Case 5

• 29 year old sedentary worker

• 3rd traumatic anterior shoulder dislocation

• No sports

Case 6

• 23 year• 3rd traumatic anterior

shoulder dislocation• Professional rugby

player