Musculoskeletal Radiology

Jin Gyoon Park, MD Joong

#{149} K. Lee, MD Carlton
#{149} T. Phelps, MD

Os Acromiale Associated with Rotator Cuff

Impingement: MR Imaging ofthe Shoulder’

PURPOSE: To evaluate the magnetic M AGNETIC resonance (MR) imag- sagittal images
the supraspinatus
obtained
tendon,
perpendicular
with a 20-25-cm
to
resonance (MR) imaging findings of ing is an important tool for the
Os acromiale in rotator cuff disease. evaluation of shoulder disorders. Ro- field of view (FOV), 320 x 512 matrix, and
taton cuff impingement commonly 4-mm section thickness with a I-mm gap;
MATERIALS AND METHODS: Ret- (c) 1,700-2,000/20-30, 80-90 for proton-
rospective analysis was performed of results from entrapment of the supra-
density- and 12-weighted oblique coronal
spinatus tendon between the humenal
10 shoulder MR studies of 10 patients images obtained parallel to the supraspi-
older than 25 years with os acromiale. head and the anterior portion of the natus tendon, with a 20-25-cm FOV, 300
The authors subdivided these pa- acromion, coracoacmomial ligament, on x 512 matrix, and 4-mm section thickness
tients into three types on the basis of acromioclaviculan joint (1-3). Pnedis- with a I-mm gap; and (d) 20-30/10 three-
posing factors include subacromial dimensional fast low-angle shot (FLASH),
seven possible configurations.
spun, hypentrophy or spur of the acro- with a 10#{176}-I5#{176}
flip angle, which included
RESULTS: Eight of the 10 patients mioclaviculan joint, thickening of the the acromion, with a 20-25-cm FOV, 170 x
with os acromiale showed failure of comacoacromial ligament, instability of 256 matrix, and 2-mm section thickness
fusion between the mesoacromion the glenohumeral joint, and anatomic
with axial data acquisition.
and meta-acromion (type A), one be- The studies were reviewed by two of
variations in the shape and slope of
tween the preacromion and mesoac- the authors (J.G.P., J.K.L.) with consensus
the acromion (4,5). It has been dem- to determine (a) the type and number of
romion (type B), and one between the onstrated that os acromiale may also high-signal acromial gaps on axial FLASH
meta-acromion and basiacromion contribute to rotator cuff impinge- images; (Ii) their visibility as low-signal
(type C). Osteophytic upping was ment (1,4,6-8). Four types of os acro- gaps on oblique sagittal or coronal images;
seen at the margins of the acromial miale have been described (9). (c) the presence or absence of osteophytic
gap in nine cases. The os acromiale Os acromiale has been evaluated lipping at the margin of the gaps; (d) acro-
could be detected on the oblique sag- with plain nadiographs (8,10,11), com- mioclavicular joint disease, erosion, or cyst
ittal image, oblique coronal image, or at the greater tuberosity; and (e) the status
puted tomography (CT) (i2), and at
both, and in each case, there was a of the supraspinatus tendon. Osteophytic
surgery (1,6,8), but we are unaware of
lesion in the supraspinatus tendon: lipping was considered present when
any description of the MR findings of bulging of the contour of the acromion at
tendinitis in four patients and tendon Os acromiale. The purpose of this an- either side of the acromial gap was dem-
tear in six. tide is to characterize the MR findings onstrated on the oblique sagittal or ob-
CONCLUSION: Os acromiale can be of os acromiale associated with rota- lique coronal images. The MR findings of
an important cause of rotator cuff im- ton cuff impingement and to propose rotator cuff tear were confirmed at sur-
pingement and can be detected with a method of classifying the seven gery, and the presence of os acromiale was
routine MR imaging of the shoulder. types of os acromiale. confirmed at surgery or plain axial radiog-
raphy of the shoulder.

Index terms:
Magnetic resonance (MR), MATERIALS AND METHODS
414.1214 Os acromiale,
#{149} 412.92 Shoulder,
#{149} RESULTS
abnormalities, 41.481, 412.92, 414.25 #{149}Shoul-
Retrospective analysis was performed
der, MR, 414.1214 Tendons,
#{149} 41.481, 414.25 of 10 shoulder MR studies of 10 patients Seven types (types A through G) of
older than 25 years with os acromiale. The Os acromiale were considered on the
Radiology 1994; 193:255-257 patients had limited motion, shoulder basis of failure of fusion at the proxi-
pain, or both. After age 25 years, the acro- mal aspects of the three separate ossi-
mial ossification centers are normally
fication centers of the acromion (pre-
fused (9). The average age of patients with
acromion, mesoacromion, and meta-
Os acromiale was 51 years (range, 35-68
acromion). Of the 10 cases of os
years). Patients underwent MR imaging in
the supine position with the arm in slight acromiale, eight were type A, with
I From the Department of Diagnostic Radiol- external rotation or neutral position. failure of fusion between the mesoac-
ogy, Medical College of Chonnam University, MR imaging was performed with a I.0-T romion and meta-acromion; one was
Kwangju, Korea (J.G.P.); and the Department of superconducting system (Magnetom; Si- type B, with failure of fusion between
Diagnostic Radiology, Samaritan Hospital, 2215 emens, Erlangen, Germany); paired Helm- the preacromion and mesoacromion;
Burdett Aye, Troy, NY 12180 (J.K.L., C.T.P.). Re-
holtz receive-only surface coils were used. and one was type C, with failure of
ceived Febnuary 4, 1994; revision requested
In all studies, the following pulse se-
March 24; revision received May 16; accepted
quences were used: (a) 200/15 (repetition
June I. Address reprint requests to J.K.L., Em-
pire Medical Imaging PC, 451 Hoosick St. Troy, time [TR] msec/echo time [TEl msec) for
NY 12180. Ti-weighted coronal and axial localizer Abbreviations: FLASH = fast low-angle shot,
RSNA, 1994 images; (b) 450/15 for TI-weighted oblique FOV = field of view.

255
fusion between the meta-acromion
A B C
and basiacromion (Fig 1). All cases of
Os acromiale could be detected by a
high-signal-intensity gap that tra-
versed the acromion on axial FLASH
images (Fig 2).
In type
A os acromiale, a vertical
low-signal-intensity band that tra-
versed the acromion was seen on
both the oblique sagittal and oblique
coronal MR images. The band tra-
versed the acromion posterior to the D E F C

midplane of the humeral head on at

least one oblique sagittal image (Fig
2). The osseous gap of the acromion
appeared together with the acromio-
claviculan joint on the oblique sagittal
image in five of 10 cases of os acro-
miale, which gave a “double-joint”
appearance (Fig 3). Type B os acro- Figure 1. Ossification centers of the acromion and types of os acromiale. There are as many
as three ossification centers of the acromial process of the scapula: preacromion (PA), mesoac-
miale was detected on the oblique
romion (MSA), and meta-acromion (MTA). Dependent on where failure of fusion occurs (hatched
sagittal images by a low-signal-inten- lines), there are seven possible types of os acromiale (types A-G). Type A, which represents
sity gap at the anterior portion of the failure of fusion between the mesoacromion and meta-acromion, is most common. BA = basi-
acromion, which was not detectable acromion. (Modified from reference 9.)
on the oblique coronal images. Type
C os acromiale was detected on the
more posterior oblique coronal im-
ages by a low-signal-intensity band
adjacent to the base of the acromion,
which was not detectable on the ob-
lique sagittal images.
A variable degree of osteophytic
lipping on both sides of the acromial
gap was seen in all cases of types A
and C os acromiale (Fig 2). No osteo-
phytic lipping was associated with
type B acromial gap, but that case
showed downward angulation of the
preacromion on an oblique sagittal
MR image.
Complete tear of the supraspinatus
tendon was detected in six cases: four
type A and one each types B and C.
Of the remaining four cases of os ac-
a. b.
momiale, three demonstrated findings
Figure 2. Tear of the suprasinatus tendon in a 48-year-old man. (a) Type A os acromiale (0).
of supraspinatus tendon disease with TI-weighted (400/15) oblique sagittal image shows a vertical low-signal-intensity gap (open
increased signal intensity on proton- arrow) that traverses the acromion (A) posterior to the midplane of the humeral head with
density-weighted images that per- prominent marginal osteophytic lipping (solid arrows). P = posterior. (b) Type A os acromiale
sisted on the T2-weighted images but (0). Axial three-dimensional (25/10 image FLASH, 10#{176} flip angle) shows a high-signal-inten-
was less intense than fat, and one sity defect (arrow) between the mesoacromion and meta-acromion. C = clavicle, A = acro-
mion.
showed calcification in the supraspi-
natus tendon, which was confirmed
on plain radiographs. Erosion or a
cyst of the greater tuberosity of the ant unfused ossification center is tator cuff team. On the basis of his de-
humerus was seen in seven cases, and called an os acromiale (9). Os acro- scription, we would classify his cases
mild to moderate hypertrophy or os- miale occurs in 1%-15% of shoulders of os acnomiale as types A, C, and G.
teophyte formation of the acromiocla- (8,10,12), but it is not known how In our patients, we found eight cases
vicular joint was seen in nine cases. many of these are symptomatic. of type A and one each of types B and
We have designated seven possible C os acromiale.
types of os acromiale (types A through Os acromiale is well demonstrated
DISCUSSION
G), although Folliasson (9) described at plain radiography with axillary
One, two, or three ossification cen- only four, which correspond to our projections of the shoulder and pro-
tens in the acromial process of the types A, B, D, and G. Liberson (10) file views of the acromion (8,10,11)
scapula appear at about age 15-18 described 21 cases of os acromiale of but is better characterized at axial CT
years. These fuse to one another and the “typical” type (type A) and four (12). MR imaging of the shouldem can
to the base of the acromion at about of the “atypical” type (non-type A). depict os acmomiale in virtually any
age 22-25 years. When any one of Mudge et al (6) found seven cases of plane and can reveal associated ab-
these centers fails to fuse, the result- Os acromiale at surgery to repair a no- normalities such as osteophytic lip-

256 Radiology
#{149} October 1994
 have suggested that amthroscopic ac- Os acromiale is easy to detect on an
romial decompression is not a solu- axillary view of the shoulder on plain
tion to impingement syndrome radiographs but is difficult to see on a
caused by an unstable os acromiale, standard anteroposteriom view. The
and they emphasize that preoperative discovery of os acromiale on plain
recognition of the presence of an os madiogmaphs in a symptomatic patient
acromiale is essential so that the sun- should prompt a search for rotator
geon can choose the best approach to cuff tendon disease. The importance
decompression. of asymptomatic os acromiale should
Detection of os acromiale at MR be the subject of further study.
imaging of the shoulder may be ac- In conclusion, os acromiale, which
complished most reliably by using an can predispose to rotator cuff im-
axial sequence that includes the acro- pingement, can be detected on a rou-
Figure 3. Full-thickness tear of the supra- mion. Although we were able to iden- tine shoulder MR study. Its recogni-
spinatus tendon in a 55-year-old woman.
tify the acromial defect indicative of tion in patients with rotator cuff
Ti-weighted (400/15) oblique sagittal image
Os acromiale on the oblique
either disease may help the surgeon select
shows a double-joint appearance formed by
the acromioclavicular joint (open arrow) and coronal or oblique sagittal view in all an appropriate therapy. #{149}
the acromial defect (solid arrow). Acromial of our cases, we believe it may be easy
defect is located posterior to the midplane of to overlook the defect in these imag- References
the humeral head, whereas the acromiocla- ing planes or to mistake it for a nor- 1. Neer CS II. Anterior acromioplasty for the
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MR imaging.

Volume 193 Number

#{149} I Radiology 257
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