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Shoulder Imaging

Shoulder
Anterior View ACJ

page 1 of 21
Scapula
Anterior View Body Triangular
Body of Scapula

Scapula

GHJ

Ken L Schreibman, PhD/MD 2009

schreibman.info

Ken L Schreibman, PhD/MD 2009

schreibman.info

Scapula
Medial View Body Paper Thin Non-articular Attachment site cuff muscles Shoulder Blade

Scapula
Medial View Spine

Gk. skaphein to dig scapula: shovel/spade-shaped may have been used as primitive digging tool
Ken L Schreibman, PhD/MD 2009

www.etymonline.com

schreibman.info

Ken L Schreibman, PhD/MD 2009

schreibman.info

Scapula
Posterior-Medial View Spine

Scapula
Posterior View Spine

Ken L Schreibman, PhD/MD 2009

schreibman.info

Ken L Schreibman, PhD/MD 2009

schreibman.info

Ken L Schreibman, PhD/MD 9/4/11

www.schreibman.info

Shoulder Imaging
Scapula
Lateral View Y-view Body Spine Coracoid Glenoid Acromion
Gk: akros, "highest", mos, "shoulder")

page 2 of 21
Scapula
Anterior-Lateral View Not Coronoid Coracoid Anterior structure Arises from Glenoid Gk korax, ravens beak
Ken L Schreibman, PhD/MD 2009 schreibman.info

arises from spine of scapula


http://en.wikipedia.org/wiki/Acromion

Ken L Schreibman, PhD/MD 2009

schreibman.info

Gleno-Humeral Joint
Anterior View Acromion arises from
Glenoid shallow socket the posterior Spine covers glenohumeral joint

Rotator Cuff Muscles


Medial View
Supraspinatus: Above Spine Below AC Joint Infraspinatus: Below Spine Subscapularis: Entire Ant Body Teres Minor: Below Infraspin

Coracoid arising anteriorly from Glenoid

Ken L Schreibman, PhD/MD 2009

schreibman.info

Ken L Schreibman, PhD/MD 2009

schreibman.info

Rotator Cuff Tendons


Lateral View
Supraspinatus: Above Spine Below AC Joint Greater Infraspinatus: Tuberosity Below Spine Lesser Tuberosity Teres Minor: Subscapularis: Below Infraspin Entire Ant Body

Rotator Cuff Tendons


Anterior View
Greater Tuberosity

Supraspinatus: Above Spine Below AC Joint

Lesser Tuberosity

Subscapularis: Entire Ant Body

Ken L Schreibman, PhD/MD 2009

schreibman.info

Ken L Schreibman, PhD/MD 2009

schreibman.info

Ken L Schreibman, PhD/MD 9/4/11

www.schreibman.info

Shoulder Imaging
Rotator Cuff: MR
Sagittal Plane
T1: Fat=Bright

page 3 of 21
Rotator Cuff: MR
Sagittal Plane
T2: Fluid=Bright (fat suppressed)

Infraspinatus
Post

Supraspinatus

Infraspinatus Teres Minor


Post

Supraspinatus

Brachial plexus neuropathy (inflammation of nerves to supra- & infra-spinatus muscles) Parsonage-Turner Syndrome
Ken L Schreibman, PhD/MD 2010 schreibman.info Ken L Schreibman, PhD/MD 2010 schreibman.info

Rotator Cuff: MR
Sagittal Plane
T1: Fat=Bright

Rotator Cuff: MR
Supraspinatus

Sagittal Plane

T1: Fat=Bright

Tendons=Black

Infraspinatus
Teres Minor
Post

Infraspinatus
Teres Minor
Post

Supraspinatus

Ant

Subscapularis

Subscapularis

Rotator Cuff Tendons (Black Arrows)


Ken L Schreibman, PhD/MD 2010 schreibman.info Ken L Schreibman, PhD/MD 2010 schreibman.info

Rotator Cuff: MR
Sagittal Plane
Infraspinatus Teres Minor
Post

Rotator Cuff: MR
Sagittal Plane
T1: Fat=Bright Tendons=Black

T2: Fluid=Bright Tendons=Black (fat suppressed) Supra-

spinatus

Infraspinatus Teres Minor


Post

Supraspinatus
Ant

Ant

Subscapularis

Subscapularis

Rotator Cuff Tendons (Black Arrows)


Ken L Schreibman, PhD/MD 2010 schreibman.info Ken L Schreibman, PhD/MD 2010

Rotator Cuff Tendons (Black Arrows)


schreibman.info

Ken L Schreibman, PhD/MD 9/4/11

www.schreibman.info

Shoulder Imaging
Rotator Cuff: MR
Sagittal Plane
T2: Fluid=Bright Tendons=Black (fat suppressed)

page 4 of 21
Rotator Cuff: MR
Sagittal Plane
T2: Fluid=Bright Tendons=Black (fat suppressed)
Acr

Post

Ant

Post

Ant

Rotator Cuff Tendons (Black Arrows)


Ken L Schreibman, PhD/MD 2010 schreibman.info Ken L Schreibman, PhD/MD 2010

Rotator Cuff Tendons (Black Arrows)


schreibman.info

Rotator Cuff: MR
Sagittal Plane
T2: Fluid=Bright Tendons=Black (fat suppressed)

Rotator Cuff: MR
Axial Plane

Post

Ant

AC Jt

Rotator Cuff Tendons (Black Arrows)


Ken L Schreibman, PhD/MD 2010 schreibman.info Ken L Schreibman, PhD/MD 2010 schreibman.info

Rotator Cuff: MR
Axial Plane

Rotator Cuff: MR
Axial Plane

AC Jt

Ken L Schreibman, PhD/MD 2010

schreibman.info

Ken L Schreibman, PhD/MD 2010

schreibman.info

Ken L Schreibman, PhD/MD 9/4/11

www.schreibman.info

Shoulder Imaging
Rotator Cuff: MR
Axial Plane
Ant

page 5 of 21
Rotator Cuff: MR
Axial Plane
Long Head Bicep
Ant

Gr Tub Hum Head


Spine

Lr Tub

Gr Tub

Infraspinatus
Post
schreibman.info Ken L Schreibman, PhD/MD 2010 schreibman.info

Post
Ken L Schreibman, PhD/MD 2010

Rotator Cuff: MR
Axial Plane
Long Head Bicep
Lr Tub

Rotator Cuff: MR
Ant

LHB

Coronal Plane T2: Fluid=Bright Tendons=Black


LT (fat suppressed)

GT
Long Head Bicep
Lr Tub

Gr Tub

Subscapularis

Infraspinatus
Post
Ken L Schreibman, PhD/MD 2010 schreibman.info

Post

Ant

Slice through ANTERIOR Rotator Cuff


Ken L Schreibman, PhD/MD 2010 schreibman.info

Rotator Cuff: MR
Coronal Plane
T2: Fluid=Bright Tendons=Black (fat suppressed) AC Jt

Rotator Cuff: MR
Coronal Plane T2: Fluid=Bright Tendons=Black
(fat suppressed)

Gr Tub

Supraspinatus

Post

Ant

Post

Ant

Slice through MIDDLE Rotator Cuff


Ken L Schreibman, PhD/MD 2010 schreibman.info

Slice through POSTERIOR Rotator Cuff


Ken L Schreibman, PhD/MD 2010 schreibman.info

Ken L Schreibman, PhD/MD 9/4/11

www.schreibman.info

Shoulder Imaging
Shoulder: Radiographic Views AP View
Does NOTFrontal Profile G-H Joint Straight View

page 6 of 21
Shoulder: Radiographic Views Orientation X-ray Glenoid A beam relative to NOT body Parall G-H Jt Humerus relative to Rotate Patient Glenoid
35-45

A
Articular Head

Glenoid

Coracoid Points Straight Forward

Axillary AP View P View


Ken L Schreibman, PhD/MD 2010 schreibman.info schreibman.info Ken L Schreibman, PhD/MD 2010 schreibman.info

Shoulder: Radiographic Views Orientation Oblique View X-ray Glenoid Neer View A beam Grashey View relative to IS P A Parall body
Rotate Patient 35-45

Shoulder: Radiographic Views Oblique View


Does Profile G-H Joint
Parallelism
Articular Head Glenoid

G-H Jt

Axillary View P
Ken L Schreibman, PhD/MD 2010 schreibman.info

The MOST Important View Neer View Grashey View


Ken L Schreibman, PhD/MD 2010 schreibman.info

Ken L Schreibman, PhD/MD 2010

Glenoid

Shoulder: Radiographic Views Orientation Oblique View Glenoid Humerus Externally Rotated relative to body Humerus relative to Glenoid

Shoulder: Radiographic Views Oblique View


Humerus Externally Rotated Greater Tuberosity Profiled

GT

LT

Articular Head

Glenoid

schreibman.info

Ken L Schreibman, PhD/MD 2010

schreibman.info

Ken L Schreibman, PhD/MD 9/4/11

www.schreibman.info

Shoulder Imaging
Shoulder: Radiographic Views AP View Orientation Humerus Internally Rotated Glenoid relative to A body Humerus relative to Glenoid

page 7 of 21
Shoulder: Radiographic Views AP View
Humerus Internally Rotated Greater Tuberosity en face

GT

View of Tertiary Importance

P
Ken L Schreibman, PhD/MD 2010 schreibman.info Ken L Schreibman, PhD/MD 2010 schreibman.info

Shoulder: Radiographic Views Same AP Views


Humerus Externally Rotated Humerus Internally Rotated

Shoulder: Technical Points AP Oblique Patient


Upright Boomerang Filter X-ray protection

Ken L Schreibman, PhD/MD 2010

schreibman.info

Ken L Schreibman, PhD/MD 2010

schreibman.info

Boomerang Filter
With Boomerang Filter Boomerang Filter

Need for Boomerang Filter


AP View Without Boomerang Filter ACJ Over-Exposed Repeat AP View With Boomerang Filter ACJ Well-Exposed

Both ACJ & GHJ Well Exposed

Ken L Schreibman, PhD/MD 2010

X-ray

schreibman.info

Ken L Schreibman, PhD/MD 2010

C,A 80yoF

schreibman.info

Ken L Schreibman, PhD/MD 9/4/11

www.schreibman.info

Shoulder Imaging
Shoulder: Radiographic Views
1) Obl View (Humerus Ext Rotated) 2) Axillary View 3) AP View (Humerus Int Rotated)

page 8 of 21
Shoulder: Radiographic Views
ACJ
Coracoid= Anterior

Axillary View Axillary View


Good Secondary View of GHJ
Ken L Schreibman, PhD/MD 2010 schreibman.info Ken L Schreibman, PhD/MD 2010 schreibman.info

Shoulder: Technical Points Axillary View

Patient Supine Arm Abducted

Shoulder: Technical Points West Point View


Patient Prone Arm Less Abducted Techs should shoot WP view when unable to get Axially view
25 Anterior

Ken L Schreibman, PhD/MD 2010

schreibman.info

Ken L Schreibman, PhD/MD 2010

schreibman.info

Shoulder: Technical Points West Point View


Patient Prone Arm Less Abducted Techs should shoot WP view when unable to get Axially view
Targets Anterior Glenoid

Shoulder: Technical Points West Point View


Targets Anterior Glenoid

25 Anterior 25 Medial

25 Anterior 25 Medial

Ken L Schreibman, PhD/MD 2010

schreibman.info

Ken L Schreibman, PhD/MD 2010

schreibman.info

Ken L Schreibman, PhD/MD 9/4/11

www.schreibman.info

Shoulder Imaging
Shoulder: Radiographic Views Axillary View West Point View
Anterior glenoid better seen on West Point than on axillary view.

page 9 of 21
Shoulder: Radiographic Views
1) Obl View (Humerus Ext Rotated) 2) Axillary View 2b) West Point View Instability Series 3) AP View (Humerus Int Rotated) 4) Lateral Y View Arch View Outlet View
Ken L Schreibman, PhD/MD 2010

P
schreibman.info

Ken L Schreibman, PhD/MD 2010

schreibman.info

Shoulder: Radiographic Views Y View

P
Ken L Schreibman, PhD/MD 2010 schreibman.info

Ken L Schreibman, PhD/MD 9/4/11

www.schreibman.info

Shoulder Imaging
Dislocations: 2 Possible Sites

page 10 of 21
Dislocations: Gleno-Humeral Joint Anterior = Easy Posterior = Hard

ACJ

GHJ

GHJ

Ken L Schreibman, PhD/MD 2010

schreibman.info

Ken L Schreibman, PhD/MD 2010

schreibman.info

Dislocations: Gleno-Humeral Joint Anterior = Easy


Anterior/Inferior
95% Sub-coracoid (most common)

Dislocations: Gleno-Humeral Joint Axillary view Coracoid= Anterior Dislocation Anterior


Humerus Glenoid

AP view

Obl view
(W,J 22yoM)

Y view
schreibman.info

Good Secondary View of GHJ


Ken L Schreibman, PhD/MD 2010 schreibman.info

Ken L Schreibman, PhD/MD 2010

Dislocations: Gleno-Humeral Joint Axillary view Coracoid= Anterior Dislocation Anterior


Humerus Glenoid

Impaction Fx

Dislocations: Gleno-Humeral Joint Axillary view Anterior Dislocation

Impaction Fx

AP view
Ken L Schreibman, PhD/MD 2010
(M,D 21yoM) schreibman.info

Ken L Schreibman, PhD/MD 2010

AP view

(L,K 19yoF) schreibman.info

Ken L Schreibman, PhD/MD 9/4/11

www.schreibman.info

Shoulder Imaging
Dislocations: Gleno-Humeral Joint Hill-Sachs Axillary view
Impaction Fx
D i l o c a t e d R e d u c e d
(L,K 19yoF) schreibman.info

page 11 of 21
Hill-Sachs Fracture
AP view Obl view Y view

Post-reduction

Ken L Schreibman, PhD/MD 2010

Axillary view

AP view

Ken L Schreibman, PhD/MD 2010

(H,B 49yoM) schreibman.info

Hill-Sachs Fracture
Harold Arthur Hill (1901-1973) Maurice David Sachs (1909-1987) Prominent San Francisco radiologists
Radiology 1940; 35:690-700
119 cases of shoulder dislocations. Showed that the defect resulted from direct impaction of the humeral head. Before their paper, the fracture was known to be a sign of dislocation, but the mechanism was uncertain.
Ken L Schreibman, PhD/MD 2010 schreibman.info

Dislocations: Gleno-Humeral Joint

Anterior Dislocations Fxs of:


Humeral Head =Hill-Sachs Glenoid (Ant-Inf corner) =Bankart
Arthur Sydney Blundell Bankart (1879-1951) British surgeon between Wars Orthopedic & Neurosurgeon www.whonamedit.com/doctor.cfm/835.html
Ken L Schreibman, PhD/MD 2010

schreibman.info

Bankart Fracture
AP view

Bankart Fracture
AP view

Anterior Dislocation
Ken L Schreibman, PhD/MD 2010

Relocated
(T,R 65yoM) schreibman.info

Ken L Schreibman, PhD/MD 2010

(P,T 16yoM) schreibman.info

Ken L Schreibman, PhD/MD 9/4/11

www.schreibman.info

Shoulder Imaging
Bankart Fracture
Axillary view (supine)
Cor (Ant) Cor (Ant)

page 12 of 21
Bankart Fracture
Oblique view Axillary view

West Point view (prone)

!
?

West Point view shows Anterior Glenoid better than Axillary view
Ken L Schreibman, PhD/MD 2010
(S,J 45yoF) schreibman.info

Cor (Ant)

West Point view


Ken L Schreibman, PhD/MD 2010
(P,T 28yoM) schreibman.info

Dislocations: Gleno-Humeral Joint Anterior = Easy


Anterior/Inferior
95% Sub-coracoid (most common)

Dislocations: Gleno-Humeral Joint Anterior = Easy


Anterior/Inferior
95% Sub-coracoid (most common) Sub-glenoid

AP view
Ken L Schreibman, PhD/MD 2010 schreibman.info

Obl view
(M,D 62yoF)

Y view
schreibman.info

Ken L Schreibman, PhD/MD 2010

Dislocations: Gleno-Humeral Joint Anterior = Easy


Anterior/Inferior
95% Sub-coracoid (most common) Sub-glenoid Sub-clavicular (uncommon)

Dislocations: Gleno-Humeral Joint Anterior = Easy


Anterior/Inferior
95% Sub-coracoid (most common) Sub-glenoid Sub-clavicular (uncommon) Luxatio Erecta Arm fixed in extreme abduction

AP view
schreibman.info

Ken L Schreibman, PhD/MD 2010

schreibman.info

Ken L Schreibman, PhD/MD 2010

Ken L Schreibman, PhD/MD 9/4/11

www.schreibman.info

Shoulder Imaging
Dislocations: Gleno-Humeral Joint Anterior=Easy
Anterior/Inferior
AP view
GT

page 13 of 21
Posterior Shoulder Dislocation
Obl view
GT
Cor Answer: Get (Ant) Axillary view!

Posterior=Hard

Straight Posterior 5% of Disloc. Unusual muscle contractions


Missed 50% of the time
Seizure Electrocution

en face

en face

Humerus

Always ask, Am I missing Post Disloc? Clues: 1) Humerus Stuck Int. Rotation 2) Lack of Parallelism of GHJ 3) Trough Line Sign
schreibman.info Ken L Schreibman, PhD/MD 2010
(C,D)

Cisternino,Rogers AJR1978;130:951

Ken L Schreibman, PhD/MD 2010

schreibman.info

AP view

Posterior Shoulder Dislocation


Obl view
Cor Answer: Get (Ant) Axillary view!

AP view

Posterior Shoulder Dislocation


Obl view Axial CT Axillary view

R e d u c e d
Ken L Schreibman, PhD/MD 2010

Reverse Hill-Sachs
(C,D)

R e d u c e d
Ken L Schreibman, PhD/MD 2010
(E,L 45yoM)

schreibman.info

schreibman.info

AP view

Posterior Shoulder Dislocation


Obl view Axial CT Axillary view

AP view

Posterior Shoulder Dislocation


Obl view

Chronic Dislocation

R e d u c e d
Ken L Schreibman, PhD/MD 2010

& F i x e d
(J,B 32yoM)

Axillary view
schreibman.info Ken L Schreibman, PhD/MD 2010
(R,M 51yoF)

schreibman.info

Ken L Schreibman, PhD/MD 9/4/11

www.schreibman.info

Shoulder Imaging
Acromio-Clavicular Joint Ligaments that ACJ stabilize ACJ: A-C Lig
Acromio-Clavicular
Coraco-Clavicular

page 14 of 21
Dislocations: Acromio-Clavicular Jt Grade 1
Sprain AC Lig

Grade 2

C-C Lig

Grade 3
Grade 4 Grade 5

Ken L Schreibman, PhD/MD 2010

schreibman.info

Ken L Schreibman, PhD/MD 2010

schreibman.info

Dislocations: Acromio-Clavicular Jt Grade 1


Sprain AC Lig

Dislocations: Acromio-Clavicular Jt Grade 1


Sprain AC Lig

Grade 2
Rupture AC Lig

Grade 2
Rupture AC Lig

Grade 3 Grade 4 Grade 5


Ken L Schreibman, PhD/MD 2010 schreibman.info

Grade 3
Rupture CC Lig

Grade 4 Grade 5
Ken L Schreibman, PhD/MD 2010 schreibman.info

Dislocations: Acromio-Clavicular Jt Grade 1


Sprain AC Lig

Dislocations: Acromio-Clavicular Jt Grade 1


Sprain AC Lig

Grade 2
Rupture AC Lig

Grade 2
Rupture AC Lig

Grade 3
Rupture CC Lig

Grade 3
Rupture CC Lig

Grade 4
Clav Post Disloc

Grade 4
Clav Post Disloc

Grade 5
Ken L Schreibman, PhD/MD 2010 schreibman.info

Grade 5
Clav thru Trap
Ken L Schreibman, PhD/MD 2010 schreibman.info

Ken L Schreibman, PhD/MD 9/4/11

www.schreibman.info

Shoulder Imaging
ACJ Radiographically Grade 1Normal
Sprain AC Lig (Dx by Physical Exam) Sprain AC Lig

page 15 of 21
ACJ Radiographically Grade 1Normal
(Dx by Physical Exam)

Grade 2Subluxation

Rupture AC Lig (Clavicle above Acromion)


Rupture CC Lig (Clavicle above Acromion) Clav Post Disloc (Best seen: Ax/WP view) Clav thru Trap (Clav WAY above Acrom)
schreibman.info Ken L Schreibman, PhD/MD 2010
(K,K 15yoF)

Grade 3Dislocation

Grade 4Lack of Parallelism Grade 5Big Time Disloc!


Ken L Schreibman, PhD/MD 2010

schreibman.info

ACJ Radiographically Grade 1Normal


Sprain AC Lig

(Dx by Physical Exam)

ACJ Radiographically Grade 1Normal


Sprain AC Lig

(Dx by Physical Exam)

Grade 2Subluxation

Rupture AC Lig (Clavicle above Acromion)

Grade 2Subluxation Grade 3Dislocation

Rupture AC Lig (Clavicle above Acromion) Rupture CC Lig (Clavicle above Acromion)

CC distance dislocated side 2X distance normal side


Ken L Schreibman, PhD/MD 2010
(D,V 21yoM)

schreibman.info

Ken L Schreibman, PhD/MD 2010

(H,C 30yoF)

schreibman.info

ACJ

Radiographically

ACJ Radiographically Grade 4Lack of Parallelism


AP

Clav Post Disloc (Best seen: Ax/WP view)


Axillary Obl

CC distance dislocated side > 2X distance normal side

Grade 5Big Time Disloc!


Clav thru Trap
Ken L Schreibman, PhD/MD 2010
(M,R 37yoM)

(Clav WAY above Acrom)


schreibman.info

(from Mike Tuite, MD)

Ken L Schreibman, PhD/MD 2010

(W,N 29yoF)

schreibman.info

Ken L Schreibman, PhD/MD 9/4/11

www.schreibman.info

Shoulder Imaging
Proximal Humeral Fractures Occur at 4 typical sites:
Greater Tuberosity Surgical Neck (most common) Anatomic Neck (least common) Lesser Tuberosity

page 16 of 21
Proximal Humeral Fractures Neer Classification System
Charles Sumner Neer, II Father of modern shoulder surgery
Born 1917 as of 2007 was still Emeritus Professor, Special Lecturer at Columbia University
www.ases-assn.org/web/about/usapioneer.html

Rotator Cuff

Tug of War

Shoulder Capsule
schreibman.info

Ken L Schreibman, PhD/MD 2010

www.cumc.columbia.edu/dept/ortho/residentsandfellows/documents/2007NYOHAAProgram.pdf Ken L Schreibman, PhD/MD 2010 schreibman.info

Proximal Humeral Fractures Neer Classification System


1-Part, 2-Part, 3-Part, 4-Part Wait a minute1-Part? Not according to Dr Neer To be considered a Part a fracture fragment must be:
Displaced > 1cm, or Angulated > 45
Ken L Schreibman, PhD/MD 2010

Proximal Humeral Fractures Neer Classification System

If there is a proximal humerus fracture isnt it broken into at least 2 parts?

If no fragment is displaced >1cm or angulated > 45 (1-Part Fx), then the fragments are already relatively anatomically aligned and do not need to be surgically reduced. Fractures with 2 or more Parts often require surgery.
schreibman.info

schreibman.info

Ken L Schreibman, PhD/MD 2010

Proximal Humeral Fractures


Neer 1-Part, Surgical Neck Fracture

Proximal Humeral Fractures


Neer 1-Part, Greater Tuberosity Fx

Displaced < 1cm Angulated < 45


Ken L Schreibman, PhD/MD 2010
(R,D 39yoF)

schreibman.info

Ken L Schreibman, PhD/MD 2010

(S,S 58yoF)

schreibman.info

Ken L Schreibman, PhD/MD 9/4/11

www.schreibman.info

Shoulder Imaging
Proximal Humeral Fractures
Neer 1-Part, Surgical Neck & GT Fx Neer 1-Part Surgical Neck

page 17 of 21
Proximal Humeral Fractures
Neer 2-Part Surgical Neck

Displaced < 1cm Angulated < 45


Ken L Schreibman, PhD/MD 2010

4 months later
(D,P 52yoF)

Two weeks later


Ken L Schreibman, PhD/MD 2010
(H,L 75yoF)

schreibman.info

schreibman.info

Proximal Humeral Fractures


Neer 2-Part, Surgical Neck Fracture

Proximal Humeral Fractures


Neer 2-Part, Surgical Neck Fracture

Displaced > 1cm Angulated > 45


Ken L Schreibman, PhD/MD 2010
(J,S 69yoF)

3 months post-surgery
Ken L Schreibman, PhD/MD 2010

Required pin fixation


(J,S 69yoF)

schreibman.info

schreibman.info

Proximal Humeral Fractures


Neer 2-Part, Surgical Neck Fracture

Proximal Humeral Fractures


Neer 2-Part, Surgical Neck Fracture

required surgical reduction and pin fixation


Ken L Schreibman, PhD/MD 2010
(C,B 23yoM)

schreibman.info

Ken L Schreibman, PhD/MD 2010

(C,B 23yoM)

schreibman.info

Ken L Schreibman, PhD/MD 9/4/11

www.schreibman.info

Shoulder Imaging
Proximal Humeral Fractures
Neer 2-Part, Surgical Neck Fracture

page 18 of 21
Proximal Humeral Fractures
Neer 3-Part, Surgical Neck & GT Fx

2 months post-pinning required plating 2m later


Ken L Schreibman, PhD/MD 2010
(C,B 23yoM)

repaired Displaced > 1cm Angulated > 45 Primarily ORIF with plate
Ken L Schreibman, PhD/MD 2010
(G,S 59yoF)

schreibman.info

schreibman.info

Proximal Humeral Fractures


Neer 3-Part, Surgical Neck & GT Fx

Primarily repaired with shoulder prothesis


Ken L Schreibman, PhD/MD 2010
(B,P 65yoM)

schreibman.info

Ken L Schreibman, PhD/MD 9/4/11

www.schreibman.info

Shoulder Imaging
Shoulder: What to Order When
Radiographs (Oblique, Axillary, AP)
Dislocations, Fractures, Healing Instability (Obl, Ax, West Point) Contralateral side is helpful
ACJ Peds

page 19 of 21
Shoulder: What to Order When
Radiographs (Oblique, Axillary, AP)
Dislocations, Fractures, Healing Instability (Obl, Ax, West Point) Contralateral side is helpful Weighted views NOT helpful
ACJ Peds

Little Leaguers Shoulder

Wide Physis Salter-Harris 1

Painful side Normal side


Ken L Schreibman, PhD/MD 2010 schreibman.info Ken L Schreibman, PhD/MD 2010
Greenspan Figure 5.38

schreibman.info

Shoulder Arthritis Osteoarthritis (OA)

ACJ: VERY Common

Shoulder Arthritis Osteoarthritis (OA)

ACJ narrows with age Superior osteophytes not significant Inferior osteophytes can impinge upon supraspinatus tendon
Best seen on Arch (Y) view
(A,A 67yoM)

GHJ: Not so common


Often secondary OA Osteophytes off inferior head Narrowing GHJ
Axillary view Oblique view

Early OA GHJ

Ken L Schreibman, PhD/MD 2010

schreibman.info

Ken L Schreibman, PhD/MD 2010

(T,A 64yoF)

schreibman.info

Shoulder Arthritis Osteoarthritis (OA)

GHJ: Not so common


Often secondary OA Osteophytes off inferior head Narrowing GHJ
Axillary view Oblique view

Advanced OA GHJ

Shoulder Arthritis Osteoarthritis (OA)

GHJ: Not so common Progressive

Advanced OA GHJ
Ken L Schreibman, PhD/MD 2010
(N,D 78yoM)

9 months later 1 month later


(L,W 59yoM)

schreibman.info

Ken L Schreibman, PhD/MD 2010

schreibman.info

Ken L Schreibman, PhD/MD 9/4/11

www.schreibman.info

Shoulder Imaging
Shoulder Arthritis Rheumatoid Arthritis (RA)
GHJ common site of RA

page 20 of 21
Shoulder Calcific Tendonitis Crystal-based arthropathies:
Gout: Uric acid Pseudo-gout: Calcium pyrophosphate Shoulder: Hydroxyapatite
(Normal component bones, teeth) Ca++ common in RC tendons
Incidental finding in up to 20% asymptomatic shoulders 30-50yo 7% painful shoulders

Marginal Erosion
Ken L Schreibman, PhD/MD 2010
(K,J 29yoF)

Supraspinatus>Infra>Teres>SubS Comes & Goes www.emedicine.com


Ken L Schreibman, PhD/MD 2010 schreibman.info

schreibman.info

Shoulder Calcific Tendonitis


Supraspinatus Supraspinatus
Supraspinatus

Shoulder: What to Order When


Radiographs (Oblique, Axillary, AP)
Dislocations, Fractures, Healing Instability (Obl, Ax, West Point) Contralateral side is helpful (S,G 54yoM) Arthritis: OA, RA Calcific Tendonitis High-riding shoulder
ACJ Peds

Ext Rotation
(V,P 53yoM) (O,T 44yoM) (B,J 45yoM)

Infraspinatus 4 months later


Gone

Int Rotation
(T,D 37yoM)

Acromion-Humeral space 7mm <7mm = Chronic Rotator Cuff Tear


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Ken L Schreibman, PhD/MD 2010

schreibman.info

Ken L Schreibman, PhD/MD 2010

Radiographs insensitive for RCT


Patient Upright Patient Supine Humeral Head banging into Acromion

Shoulder: What to Order When


Radiographs (Oblique, Axillary, AP)
Dislocations, Fractures, Healing Instability (Obl, Ax, West Point) Contralateral side is helpful Arthritis: OA, RA Calcific Tendonitis High-riding shoulder
Ken L Schreibman, PhD/MD 2010

>7mm

Humeral Head aligned with Glenoid

Humeral Head high riding relative to Glenoid

ACJ Peds

RG 77%
UW shoulder studies
(2005)

Normal Radiograph
(E,L 69yoF)

MRI 1 month earlier (Cor T2-FatSuppressed)


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Acromion-Humeral space 7mm <7mm = Chronic Rotator Cuff Tear


schreibman.info

Ken L Schreibman, PhD/MD 2010

Ken L Schreibman, PhD/MD 9/4/11

www.schreibman.info

Shoulder Imaging
Shoulder: What to Order When
MRI MR-Arthrogram (Intra-Articular contrast)
Best way to evaluate Labrum
RG 77%
MR 21%

page 21 of 21
Shoulder: What to Order When
CT
Primarily for surgical planning
High grade Neer fractures Scapular fractures Large Bankart fractures RG Multiplanar Reformat 77% 3D Reformat

Best way to evaluate Rotator Cuff

MR 21%
CT

MR with IV contrast
Ken L Schreibman, PhD/MD 2010

UW shoulder studies
(2005)

Prosthesis loosening
Osteolysis

UW shoulder 2% studies
(2005)

Infection (Septic joint, osteomyelitis) Tumor (Work-up, Follow-up)


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CT-Arthrogram Ultrasound
Ken L Schreibman, PhD/MD 2010

RCT in patients not MR compatible


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Shoulder CT for Fractures


AP view Obl view

Shoulder CT for Fractures


Repeat AP view Obl view Obl view CT: Axial

Coronal Sagittal

Ax view
Ken L Schreibman, PhD/MD 2010
(P,C 32yoM)

Ax view
schreibman.info Ken L Schreibman, PhD/MD 2010
(P,C 32yoM)

schreibman.info

Shoulder CT for Fractures

Shoulder CT for Fractures

Ken L Schreibman, PhD/MD 2010

(P,C 32yoM)

schreibman.info

Ken L Schreibman, PhD/MD 2010

(P,C 32yoM)

schreibman.info

Ken L Schreibman, PhD/MD 9/4/11

www.schreibman.info