Summary

 

Along with thorough history and physical exam, appropriate imaging is integral to accurate diagnosis and treatment of shoulder pathology. Understanding the various shoulder imaging options can help confirm diagnosis while minimizing unnecessary testing. In this chapter, many imaging choices will be discussed, paired with corresponding pathology to add to your clinical armamentarium.

Keywords: Radiography, X-ray, MRI, CT, MR arthrogram

 

Radiography

 

The initial imaging modality for evaluation of the shoulder

Provides little information on soft tissue around the shoulder

Shoulder series should consist of at least two orthogonal views

Trauma evaluation includes:

True anteroposterior aka Grashey (▶Fig. 5.1):

Erect, sitting, or supine with patient rotated 30–45 degrees in relation to the image detector

Evaluate glenohumeral joint, fracture (proximal humerus, clavicle, scapula, and ribs), and proximal humeral migration.

 

Fig. 5.1 Grashey.

 

 

 

Fig. 5.2 Anteroposterior (AP).

 

 

 

Fig. 5.3 Axillary lateral.

 

 

 

Anteroposterior (AP) (▶Fig. 5.2):

Erect, sitting, or supine with beam perpendicular to body

Allows for viewing of shoulder in anatomical position

Utility similar to Grashey view with poorer view of glenohumeral joint.

Axillary lateral (▶Fig. 5.3):

Supine, arm abducted with beam parallel to body

Evaluate joint congruency, direction of dislocation, and glenoid pathology

Velpeau view can be used for patient who cannot abduct the arm:

Patient erect leaning backwards over cassette.

 

Fig. 5.4 Scapular Y lateral.

 

 

 

Scapular Y lateral (▶Fig. 5.4):

Sitting or erect, anterior oblique view with scapula in profile

Evaluate acromion type scapular fracture.

Additional views:

AP in external or internal rotation (▶Fig. 5.5a, b):

Same positioning as AP with humerus externally or internally rotated

External rotation:

Greater tuberosity on profile.

Internal rotation:

Lesser tuberosity on profile, best view of Hill-Sachs lesion.

Stryker notch (▶Fig. 5.6):

Arm extended over head with elbow flexed; beam directed at mid axilla

with 10 degrees caudal tilt

Excellent visibility of posterolateral humeral head for Hill-Sachs lesion.

 

Fig. 5.5 (a, b) Anteroposterior (AP) in external or internal rotation.

 

 

 

Supraspinatus outlet aka Neer (▶Fig. 5.7):

Affected shoulder on X-ray plate while rotating the other shoulder out 40 degrees; PA view with beam at 10 degrees caudal tilt

Ideal view for evaluating acromion type as well as supraspinatus impingement.

West point axillary:

Patient prone with arm abducted 90 degrees and forearm off table. Beam aimed at mid axilla, 25 degrees from midline and 25 degrees caudal tilt

Provides better view of anteroinferior glenoid for evaluation of bony Bankart lesion.

Apical oblique aka Garth:

Patient erect or sitting with back against receiver and affected side’s hand resting on unaffected side’s shoulder. Beam at 30–45 degrees in coronal plane and 45 degrees caudal tilt

 

Fig. 5.6 Stryker notch.

 

 

 

Provides improved view of glenohumeral joint to evaluate for Bankart

and Hill-Sachs lesions

Can be used in place of axillary or scapular Y to evaluate for glenohumeral dislocation.

Serendipity/Hobbs (▶Fig. 5.8):

Serendipity = Patient supine with beam 40 degrees tilt from horizontal

Hobbs = Patient bent over cassette with arms forward flexed and head

resting in hands

Evaluate for sternoclavicular dislocation.

Zanca (▶Fig. 5.9):

Patient erect or sitting with back against cassette; beam aimed at shoulder with 10–15 degrees cephalic tilt

Evaluate acromioclavicular joint en face for separation or arthritis.

 

Fig. 5.7 Neer.

 

 

 

Fig. 5.8 Serendipity.

 

 

 

Fig. 5.9 Zanca.

 

 

1. Computed tomography‌

   1. Better bony detail compared to radiography and magnetic resonance imaging (MRI) with higher radiation load

   2. Superior soft tissue detail compared to radiography especially with addition of contrast although still inferior to MRI

   3. Images reformatted in multiple planes to provide details useful in total shoulder arthroplasty, trauma, and oncological surgical planning:

      1. Axial (▶Fig. 5.10):

         1. Useful for visualization of fractures, degenerative disease, glenoid morpho-

            logy, dislocation, and bony defects (Hill-Sachs, reverse Hill-Sachs, Bankart).

      2. Sagittal (▶Fig. 5.11):

         1. Useful for visualization of fractures, glenoid morphology, and calcific

            tendonosis.

      3. Coronal (▶Fig. 5.12):

         1. Useful for visualization of fractures, arthritis, and proximal humeral migration.

   4. Three-dimensional reconstruction (▶Fig. 5.13):

      1. Useful for visualization of glenoid version for total shoulder arthroplasty surgical planning as well as better visualization of complex fracture patterns of the scapula.

   5. Computed tomography (CT) arthrography (▶Fig. 5.14):

      1. Injection of iodinated contrast dye into joint

      2. Allows for better visualization of joint space and evaluation of rotator cuff

         and labral integrity

      3. Commonly used when patient has had prior surgery or shoulder arthroplasty procedure, or there are concerns for labral pathology.

          

2. Magnetic resonance imaging

   1. Best imaging modality for evaluating soft tissues as well as bony contusion

   2. T1 weighted (▶Fig. 5.15):

      1. Hyperintense = Fat

      2. Hypointense = Fluid, bones, tendons, ligaments, muscles

      3. Generally considered to be best for viewing anatomy

      4. Useful for visualization of bony Bankart and Hill-Sachs lesions.

          

         Fig. 5.10 Computed tomography (CT), axial.

          

          

          

   3. T2 weighted (▶Fig. 5.16):

      1. Hyperintense = Fluid, bone marrow.

   4. Hypointense = Bones, ligaments, muscles

      1. Generally considered to be best for viewing pathology

      2. Useful for visualizing rotator cuff tears (especially subscapularis tendon),

         hairline fracture, and contusion.

   5. Short tau inversion recovery (STIR) (▶Fig. 5.17):

      1. Fat suppressed and fluid/edema accentuated

      2. Useful in evaluating edema versus fatty infiltration in rotator cuff tears.

   6. MR arthrogram (▶Fig. 5.18):

      1. Gadolinium contrast installed into joint

      2. Excellent visibility of superior labral anterior to posterior (SLAP), glenolabral articular disruption (GLAD), humeral avulsion of the glenohumeral ligament (HAGL), and anterior labroligamentous periosteal sleeve avulsion (ALPSA) lesions

      3. Superior soft tissue visualization compared to CT arthrogram.

 

Fig. 5.11 Computed tomography (CT), sagittal.

 

 

 

Fig. 5.12 Computed tomography (CT), coronal.

 

 

 

Fig. 5.13 Three-dimensional reconstruction.

 

 

 

Fig. 5.14 Computed tomography (CT) arthrogram.

 

 

 

Fig. 5.15 T1 magnetic resonance imaging (MRI).

 

 

 

Fig. 5.16 T2 magnetic resonance imaging (MRI).

 

 

 

Fig. 5.17 Short tau inversion recovery (STIR) magnetic resonance imaging (MRI).

 

 

 

 

Fig. 5.18 Magnetic resonance imaging (MRI) arthrogram.