Shoulder and Elbow

1. Radiological
Examination of
Shoulder and
elbow
Dr. Hein Htet Zaw
18.01.21

2. Introduction
Imaging of the Shoulder
vPlain films remain an initial investigation
• key role in identifying bone abnormalities
• secondary signs of soft tissue pathology
like impingement syndrome, calcific
tendinopathy
• limitations in identifying soft tissue abnormalities

3. vCT sensitive in trauma scenarios
• has limitation in studying soft tissue
• useful in quantifying degenerative disease
• Although MR arthrogram (MRA) is superior, CT arthrogram is
performed where is contraindicated.
vmainstay of shoulder imaging is US and MR

4. vUS is good to assess soft tissue abnormalities such as
tendinopathy, tendon tear and bursitis
- Diagnostic accuracy
• full thickness rotator cuff tears 100%
• partial thickness tears 91%
• comparable with MR
• Dynamic imaging is a further advantage of US.
• Inter-observer variability

5. vMR imaging is widely used to assess shoulder pain
• MR imaging in the assessment of
- rotator cuff
- labrum
- capsule
- biceps tendon
- articular cartilage
- ligaments and bone marrow abnormalities

6. Imaging of the elbow joint follows similar grounds
• Despite advances in elbow imaging with MR, US and CT, conventional
radiography remains the most appropriate initial imaging technique of the elbow
and its disorders.
• MR and CT - visualize the elbow in multiple planes
• US - evaluation of soft tissue and also US guided injections and interventions.

7. IMAGINGS OFTHE
SHOULDER

8. Radiography
• Initial investigation of choice
• Can detect
- Fractures
- Dislocations
- Calcific tendinitis
- Arthritis
- Bone tumours
AP/Lateral/Axillary/Scapula ‘Y’ views

9. • Routine AP view

10. • Radiograph showing subacromial
sclerosis, so-called sourcil sign
(arrow), from chronic loading of
undersurface of acromion in impingement
process

11. • Radiograph showing
- sourcil sign (white
arrow)
- loss of joint space (long
black arrow)
- humeral head osteophytes (short
black arrow) in rotator cuff tear
arthropathy

12. • calcium deposits

13. • 43 yrs, M
• Old anterior dislocation
• Duration – one month

14. AP: external rotation view
• GT & soft tissue profile

15. AP: internal rotation view
• Hill-Sachs lesions

16. Hill-Sachs lesion
• posterolateral humeral head indentation fracture is
created occuring from anterior shoulder dislocation, as
soft base of humeral head impacts against relatively
hard anterior glenoid;

17. Scapula ‘Y’ lateral
• Shoulder impingement
- subacromial space
- supraspinatous outlet

18. (A) Coracoacromial arch
(dashed line) does not overlap
with the arch formed by the
scapular body and spine (dotted
(B)These two arches overlap with
each other

19. Axillary lateral view
• AP relationship of GH joint

20. • Shoulder AP - Glenohumeral joint space, DJD
• True shoulder AP - Glenohumeral joint space, DJD, and proximal migration
of humerus
• AP in IR - Hill Sachs lesion

21. • AP in ER - Hill Sachs lesion
• Axillary - Anterior and posterior dislocation.
• Velpeau view - modification if unable to abduct the arm
• ScapularY Lateral - Allows classification of acromion

22. • Zanca - Help visualize the AC joint. Shows AC joint disease and distal
clavicle osteolysis.
• Stryker notch for Hill-Sachs lesion

23. • West Point Axillary - Anteroinferior glenoid, bony bankart, proximal
humerus fx
• Hobbs and Serendipity - Anterior and posterior sternoclavicular dislocation

24. USG
• Advantages
- Dynamic evaluation
-Guided aspiration/
injection
- No radiation
- No contrast
- Inexpensive
- Readily available
• Disadvantages
- Less sensitive in partial thickness
Rotator cuff tears
- Labral-ligamentous complex

25. • Biceps brachii tendon, long head

26. • Biceps tendon subluxation

27. • Subscapularis

29. • Supraspinatus

30. Longitudinal (a) and transverse (b) US image show loss of
supraspinatus mid fibres in keeping with full thickness
tear (arrows). LHB e Long head of biceps.

31. • AC joint

32. • AC joint effusion

33. • Dynamic evaluation for subacromial impingement

34. • Infraspinatus, teres minor and
posterior labrum

35. • USG guided diagnostic/ therapeutic injection of SA-SD bursa
Needle

36. CT
• Superior to plain radiographs in evaluation of complex fractures
and fracture-dislocations involving the head of the humerus
• Allows planning of treatment of complex proximal humeral
fractures

38. Bankart lesion
- is an avulsion of the anteroinferior
glenoid labrum at its attachment
to IGHL complex;
- lesion is felt to result from anterior
shoulder dislocation and is felt to be
primary lesion in recurrent anterior
instability;

39. MRI
• Highly accurate for rotator cuff pathologies
• Advantages
- No ionizing radiation
- Non-invasive
- Multi-planar imaging
- Demonstrates other lesions , ACJ OA & AVN
- Characterization and staging of tumours

45. Entrapment neuropathy of suprascapular nerve by
ganglion

46. (a). MR arthrogram coronal obliqueT2 fat suppressed image showing
downward sloping of the acromion (arrow) with impingement
and supraspinatus tendinopathy (thick arrow).
(b). Sagittal obliqueT1 image (different patient) shows acromion
with anteroinferior hook formation (small arrow).

47. post-traumatic distal clavicular stress fracture
(arrows), bone marrow edema, and mild
intracapsular and pericapsular edema at the AC
joint

48. Coronal oblique (A), transverse (B), and sagittal
oblique (C) MR images show a focus of calcified
tendonitis/ bursitis (arrows)

49. Coronal oblique (a) and sagittal (b)T2 fat saturated
image shows full thickness tear of supraspinatus
tendon (thick arrows). Severe osteoarthritis
of the AC joint (arrow).

50. HAGL - Humeral Avulsion
of glenohumeral Ligament
(arrow) with extravasation
of contrast inferiorly due to
inferior capsular avulsion
GLAD - Glenolabral Articular
Disruption lesion (arrow).

51. Arthroscopy
• Indications
Diagnostic
- Rotator cuff injury
- Labral tear
- Ligaments injury
Therapeutic
- Rotator cuff repair
- Repair of labrum
- Repair of ligaments
- Removal of inflamed tissue or loose
cartilage
- Repair of recurrent shoulder dislocation

54. IMAGINGS OFTHE
ELBOW

56. Radiography
• occult fracture
• joint effusion after trauma
• soft-tissue calcifications
• Ossification
• osteophyte formation
• Osteochondral defects, which may suggest tendon or ligament
injury as a consequence of repetitive microtrauma

59. Elbow dislocation. (a). Lateral and (b). AP views.There is a
tiny undisplaced fracture of the coronoid process (black
arrow).

60. Lateral radiograph of elbow showing calcification in the
region of the olecranon bursa in a patient with gout.

61. US
• cost-effective technique
• superficial soft-tissue injuries including ligament or tendon tears or
neurovascular injuries
Longitudinal US image in a 60-year-old man who fell off his bicycle and sustained a
ruptured distal biceps tendon.The tendon end is retracted proximally (arrow) and
surrounded by fluid.

62. • dynamic imaging can be performed—for example, in flexion/
extension, supination/pronation, or under valgus/varus stress.
• image-guided intervention
• US is less well suited for evaluation of osteochondral injuries and
deep structures within the joint

63. thickening of the common extensor tendons, altered echo
texture (arrow heads) and increased vascularity on power
Doppler in keeping common extensor origin tendinosis.

64. CT
• To evaluate fractures, particularly in intraarticular extension, small fracture
fragments and bony malalignment.
• “terrible triad” fracture-dislocation
(radial head fracture,
coronoid fracture,
LUCL injury
following dislocation)

65. • Similarly, CT can precisely demonstrate the degree of displacement of an
articular fracture (>2 mm step-off or gap), which would indicate the need
for internal fixation.

66. • osteochondral bodies
• heterotopic ossification
• myositis ossificans
• CT arthrography is performed for evaluation of ligamentous
integrity in patients with contraindications to MR imaging

67. MRI
• Evaluation of the supporting structures of the elbow
• The major ligaments, tendons, muscles, bones, and neurovascular
bundles of the elbow

68. • CoronalT2-weighted fat-saturated (FS) MR
image
• the UCL (black arrows)
• overlying common flexor tendon (black
arrowhead)
• the radial collateral ligament with an
adjacent synovial fold (white arrow),
• the annular ligament (white arrowhead),
• overlying extensor carpi radialis brevis
origin (open arrow).

69. • CoronalT2-weighted FS MR image in
a 20-year-old male gymnast with an
acute hyperextension injury
demonstrates a proximal
tear of the medial
collateral
ligament (arrow).

70. • Thickening and increased signal intensity in
the anterior band of the UCL (arrows),
compatible with partial tearing
and moderate grade sprain.
• Bone marrow edema in the capitellum and
radial head (∗) from associated impaction
injury

71. • Partial undersurface tear of the
distal UCL, with fluid
interposed between the distal UCL
and sublime tubercle, forming the
so-called T sign(arrow)

72. • two joint bodies in the olecranon
fossa (arrowheads).

73. Bone marrow edema around the medial
apophysis (arrow), compatible with
“Little Leaguer” elbow
Widening of the apophysis superiorly
(arrow) with minimal adjacent
sclerosis.

74. subtle sclerosis, subchondral lucency, and
cortical irregularity of the capitellum (arrow),
compatible with osteochondritis of the
capitellum or Panner disease
irregular low signal intensity in the capitellum
(arrow).

75. • avulsion of the distal biceps tendon
with the tendon end retracted
proximally (arrow).

76. • increasedT2-weighted signal
intensity in the common extensor
tendon (arrow), compatible with
lateral epicondylosis

77. Arthroscopy
• Indications
Diagnostic
- for evaluation of intra-
articular pathology
- osteochondritis dissecans
of capitellum
- lateral epicondylitis
- diagnostic anatomy for
complex elbow pain
Therapeutic
- loose body removal
- osteophyte debridement
- synovectomy
- capsular releases for
stiffness

78. Contraindications
- prior trauma
- surgical scarring
- previous ulnar nerve transposition

79. Advantages
- improved articular
visualization
- decreased postoperative
pain
- faster postoperative
recovery
Disadvantages
- technically demanding
- high risk of damage to
neurovascular
structures due to
proximity to the joint

80. • Anatomy

81. • Portal

82. • Relationship to NV structures

84. THANKYOU.