Objective To determine the prevalence of shoulder (specifically labral) abnormalities on MRI in a young non-athletic asymptomatic cohort. MRI is not uncommonly the key to the diagnosis as patients may present with vague clinical findings that are not prospectively diagnosed, in part because of the relatively less common incidence and awareness of this entity. Orthopedic surgeons will tell you that the labrum increases joint stability and serves as an anchor for ligaments and muscles. When the labrum gets damaged or torn, it puts the shoulder at increased risk for looseness and dislocation. Acute traumatic posterior shoulder dislocation: MR findings. In patients with glenoid deficiency or large impaction defects, osteotomies and osseous augmentation procedures may be required. Harper and colleagues, Arthroscopic Management of Posterior Instability, Radiographic and Advanced Imaging to Assess Anterior Glenohumeral Bone Loss, Management of In-Season Anterior Instability and Return-to-Play Outcomes, Decision Making in Surgical Treatment of Athletes With First-Time vs Recurrent Shoulder Instability, Management of the Aging Athlete With the Sequelae of Shoulder Instability, Instability in the Pediatric and Adolescent Athlete, History and Examination of Posterior Instability. 4B), which is what one would intuitively expect. 7-9). A wide ligament that surrounds and stabilises the joint is known as the capsule. A useful indirect sign to be aware of, whether using MR arthrography or routine MR, is to recognize that normally the shoulder capsule should only be outlined by fluid along its inner margin. MRI of the shoulder second edition by Michael Zlatkin. in Radiology in 2008 examined 36 patients following acute traumatic shoulder dislocation and revealed full-thickness tears in 19% of patients and partial or full-thickness tears in 42%.17As would be expected, subscapularis tears were most common, but tears were also identified in the supraspinatus and the infraspinatus. Dislocation of the long head of the biceps will inevitably result in rupture of part of the subscapularis tendon. Keith W. Harper1, Clyde A. Helms1, Clare M. Haystead1 and Lawrence D. Higgins Glenoid Dysplasia: Incidence and Association with Posterior Labral Tears as Evaluated on MRI. A normal glenoid labrum has a laterally pointing edge and normal posterior labral morphology. The undersurface of the supraspinatus tendon should be smooth. Imaging in three planes is advisable and additional orthogonal planes may be included in the protocol for a detailed assessment of the lesion. Look for variants like the Buford complex. Sports Health 2011 May, 3(3):253-263, Cooper A. This is not always the case. He has positive Kim and jerk tests and reproduction of symptoms with the shoulder in forward flexion, adduction, and internal rotation. J Bone Joint Surg Am 1993; 75:1175-1184. Simoni P, Scarciolla L, Kreutz J, Meunier B, Beomonte Zobel B. J Sports Med Phys Fitness. complex injuries to the shoulder. Although x-ray findings are typically normal, they must be scrutinized to avoid errors of diagnosis such as missed posterior dislocations. A 22-year-old male wrestler presents to your clinic with complaints of deep left shoulder pain for the past 6 weeks. "If physical therapy fails and the athlete still can't complete overhead motions, or the shoulder continues to dislocate, surgical treatment might be required to reattach the torn ligaments and labrum to the . (10b) A corresponding T2-weighted sagittal view in the same patient confirms the large ossification along the posteroinferior glenoid rim (arrows), compatible with a Bennett lesion. Introduction. On these axial images a Buford complex can be identified. The shoulder joint is the most unstable articulation in the entire human body. Due to the tension by the anterior band of the inferior GHL labral teras will be easier to detect. Advanced MRI techniques of the shoulder joint: current applications in clinical practice. 5 A type 1 capsule inserts on the labrum, a type 2 capsule inserts on the junction of the labrum and glenoid, and a type 3 capsule inserts more medially on the glenoid ().The typical posterior capsule inserts on the labrum, either at the labral tip or the . Injuries isolated to labrum and capsule can often be successfully repaired with arthroscopic techniques including capsulolabral repair, capsular shift, and capsular shrinkage. {"url":"/signup-modal-props.json?lang=us\u0026email="}, Chmiel-Nowak M, Sheikh Y, Feger J, et al. Non-surgical treatment tends to be most successful in patients with a history of atraumatic subluxations, whereas patients who experience an acute, traumatic posterior dislocation are much less likely to report successful outcomes from conservative therapy.19 Non-operative therapy focuses on strengthening the dynamic shoulder stabilizers and activity modification. The radiologic diagnosis and surgical evaluation were compared to determine the accuracy of diagnosing a SLAP lesion by MRI. and transmitted securely. In Shoulder MR-Part I we will focus on the normal anatomy and the many anatomical variants that may simulate pathology. Occasionally, a SLAP (superior labrum, anterior and posterior) fracture, which represents a superior humeral head compression . Figure 17-5. Other radiographic lesions that may be associated with posterior labral pathology and instability include the Bennett lesion, which is an extra-articular posterior ossification of the posterior inferior glenoid. (2b) The T2-weighted sagittal image confirms posterior displacement of the humeral head (arrow) relative to the glenoid (asterisk). It is present in 5% of the population. When we assess the shoulder labrum there are 7 areas to look at which have some association with labral tears. American Journal of Sports Medicine 1994, 22:2:171-176. Following a posterior subluxation event, a fat-suppressed T2-weighted coronal image in this 52 year-old male reveals focal edema and irregularity at the humeral attachment of the posterior band of the inferior glenohumeral ligament (arrow), compatible with a partial tear. 2012 Jan;21(1):13-22 At this level also look for Bankart lesions. Orthop J Sports Med. A posterior labral tear is referred to as a reverse Bankart lesion, or attenuation of the posterior capsulolabral complex, and commonly occurs due to repetitive microtrauma in athletes. Radiology 2008; 248:185193. The labrum is a band of tough cartilage and connective tissue that lines the rim of the hip socket, or acetabulum. Posterior instability most often occurs either as a result of high force direct trauma to the shoulder such as from a motor vehicle accident or indirect trauma such as from seizures or electrocution. Locked posterior subluxation of the shoulder: diagnosis and treatment. Clipboard, Search History, and several other advanced features are temporarily unavailable. When you have a excessive posterior force on an adducted arm the resultant is a posterior labral tear. A recess more than 3-5 mm is always abnormal and should be regarded as a SLAP-tear. An axial image in a 53 year-old male following an acute traumatic posterior dislocation reveals tears of the posterior labrum (arrow) and posterior capsule (arrowhead). The ball of the shoulder can dislocate toward the front of the shoulder (an anterior dislocation), or it can go out the back of the shoulder (called a posterior dislocation). Dr. Ebraheim's educational animated video describes posterior labral tear - posterior shoulder instability. Bennett lesions are more commonly found in overhead athletes, typically baseball players, and can be visualized on axillary radiographs.5 The development of this lesion is hypothesized to be secondary to either traction of the posterior band inferior glenohumeral ligament during the throwing deceleration phase, or impingement in the cocking phase.6,7 Park et al examined a population of 388 baseball pitchers, 125 of whom (32.2%) had Bennett lesions. PMC American Journal of Roentgenology. Surg Clin North Am. 1998 Sep;171(3):763-8. These tears include numerous variations designated by acronyms similar to those used for the more commonly seen anterior labral tears. 5,6,7 The classic MRI findings of internal impingement, as seen in this month's case, include partial articular surface tears at the posterior supraspinatus/anterior infraspinatus insertion, greater tuberosity bony changes, and tearing of the . A mid-substance tear of the posterior capsule is present with the medial component appearing lax and retracted (arrow). This usually happens from an interior shoulder dislocation (a dislocation when the humeral head comes out of the front of the socket). Numerous labral abnormalities may be encountered in patients with posterior glenohumeral instability. Skeletal Radiol 2000; 29:204-210. (B) Axillary radiograph of locked posterior glenohumeral dislocation. These normal variants are all located in the 11-3 o'clock position. Posterior labral tearing was apparent on contiguous images (not shown). It is not healed. Introduction. Notice MGHL, which has an oblique course through the joint and study the relation to the subscapularis tendon. True anteroposterior or Grashey x-ray. In the event of a shoulder dislocation, the . Look for rim-rent tears of the supraspinatus tendon at the insertion of the anterior fibers. Sometimes at this level labral tears at the 3-6 o'clock position can be visualized. The concavity at the posterolateral margin of the humeral head should not be mistaken for a Hill Sachs, because this is the normal contour at this level. Conclusions: Uncategorized. Surgical treatment: arthroscopic debridement . Diagnosis can be made clinically with positive posterior labral provocative tests and confirmed with MRI studies of the shoulder. 2008 Aug; 24(8):921-9. Shoulder Labral Tear Repair Surgery. the removal of the acromion distal to the synchondrosis may further destabilize the synchondrosis and allow for (OBQ11.152) Bethesda, MD 20894, Web Policies Such injuries may be referred to as reverse HAGL (humeral avulsion of the glenohumeral ligament) or RHAGL lesions (Fig. 14). There are many elements that work in combination to offset the inherent instability of the glenohumeral joint, but the glenoid labrum is perhaps related most often. Examples include the reverse Bankart lesion, the POLPSA lesion, and the posterior GLAD lesion (sometimes referred to as a PLAD lesion) (Figs. Hottya GA, Tirman PF, Bost FW, Montgomery WH, Wolf EM, Genant HK. They developed a classification system in which a pointed glenoid on axial imaging sequences is a normal-appearing glenoid without dysplasia, a lazy J has a rounded appearance of the posterior inferior glenoid, and a delta glenoid is a triangular osseous deficiency. Tearing of the inferior glenohumeral ligament at the humeral attachment (blue arrow) is also evident. Unable to load your collection due to an error, Unable to load your delegates due to an error. The posterior labrum is stressed with an abducted arm and posterior force. A Treatise on Dislocations and Fractures of the Joints. Posterior labral tear; < 15 decrease in affected shoulder internal rotation compared to contralateral shoulder . Study the cartiage. Posterior shoulder instability is a relatively rare phenomenon compared to anterior instability, comprising only 5-10% of all shoulder instability. Treatment of the labral tears in these scenarios involves treatment of the shoulder dislocation and stabilising the shoulder. When a dislocation or subluxation occurs, the glenoid labrum is torn from the bone and the capsule is stretched. The labrum in the shoulder joint is a vital component that helps stabilize the humerus and shoulder blade during movement. A posterior labral tear is referred to as a reverse Bankart lesion, or attenuation of the posterior capsulolabral complex, and commonly occurs due to repetitive microtrauma in athletes. Saupe N, White LM, Bleakney R, et al. Clinical Relevance: . Study the superior biceps-labrum complex and look for sublabral recess or SLAP-tear. doi: 10.1002/14651858.CD009020.pub2. The anterosuperior labrum is absent in the 1-3 o'clock position and the middle glenohumeral ligament is usually thickened. There is . The lesion is usually seen on the MRI. Open Access J Sports Med. Diagnostic criteria for both anterior and posterior labral tears present similarly. There is an ongoing debate on whether direct MR arthrography is superior to conventional MR in detecting labral tears. Diagnostic performance of 3D-multi-Echo-data-image-combination (MEDIC) for evaluating SLAP lesions of the shoulder. The Bennett lesion (Fig. After addressing the disease prevalence, HPI and PMH, the pre-test probability likelihood of long head bicep pathology was appointed. nor be effaced against the humeral head, and intra-articular contrast can enhance visualization of the tear (3). Imaging in three planes is advisable and additional orthogonal planes may be included in the protocol for a detailed assessment of the lesion. 2005;184: 984-988. MR arthrography had an accuracy of 69 %, sensitivity of 80 %, and a PPV of 29 %. Bennett GE: Shoulder and elbow lesions of the professional baseball pitcher. 3. However,patients with acute lesions often have joint effusion, which also distends the joint space, making the contrast administration unnecessary. It is seen in 11% of individuals. In a SLAP injury, the top (superior) part of the labrum is injured. Small to moderate glenohumeral joint effusion with synovitis and extension of fluid in the subcoracoid recess. Postoperatively, there are strict instructions to avoid adduction and internal rotation of the operative shoulder. Mauro et al found increased retroversion in a cohort of 118 patients who were operatively treated for posterior instability in comparison with a group of normal controls, but the authors did not attribute retroversion as a risk factor for failure. A hip (acetabular) labral tear is damage to cartilage and tissue in the hip socket. Smith T, Drew B, Toms A. MRA for SLAP - Is the threshold for referral too low? Severe glenoid dysplasia or hypoplasia is a rare condition due to either brachial plexus birth palsy or a developmental abnormality with lack of stimulation of the inferior glenoid ossification center. eCollection 2019. This procedure greatly enhances the diagnostic accuracy by allowing tears . In all patients, posterior cartilage damage of type 3 to 4, classified according to Outerbridge, with a concomitant posterior labral tear was evident. It is, however, becoming more frequently recognized, particularly in athletes such as football players and weightlifters, in which posterior glenohumeral instability has achieved increased awareness.3 As McLaughlin stated in 19634, the clinical diagnosis is clear-cut and unmistakable, but only when the posterior subluxation is suspected. When you plan the coronal oblique series, it is best to focus on the axis of the supraspinatus tendon. Reference article, Radiopaedia.org (Accessed on 18 Jan 2023) https://doi.org/10.53347/rID-74948, {"containerId":"expandableQuestionsContainer","displayRelatedArticles":true,"displayNextQuestion":true,"displaySkipQuestion":true,"articleId":74948,"questionManager":null,"mcqUrl":"https://radiopaedia.org/articles/glenoid-labral-tear/questions/1679?lang=us"}, doi:10.1148/radiographics.20.suppl_1.g00oc03s67, pain or discomfort (usually a precise point of pain cannot be located). We concluded that even with intra-articular contrast, MRI had limitations in the ability to diagnose surgically proven SLAP lesions. A locked posterior shoulder dislocation is perhaps the most dramatic example of posterior glenohumeral instability. Notice the biceps anchor. Eur J Radiol. The abduction and external rotation of the arm releases tension on the cuff relative to the normal coronal view obtained with the arm in adduction. An anatomy drawing of a shoulder labrum. Mild glenoid hypoplasia results in a rounded contour of the posterior glenoid with normal or only mildly thickened posterior labral tissue. J Shoulder Elbow Surg. The approach to surgery is dependent upon the type of injuries sustained by the patient, and the developmental or acquired alterations in anatomy that may be present. In type I there is no recess between the glenoid cartilage and the labrum. Advances in knowledge:: On a direct MR arthrographic image, a posterior capsular synovial fold may be a normal anatomic variant. Pathology involving the superior labrum presents a diagnostic and therapeutic challenge for the arthroscopic surgeon. Before The appearance is thought to be due to failure of ossification of the more inferior of the two ossification centers of the glenoid, resulting in a cartilage cap replacing the bone defect.11 The presence of the hypertrophied tissue and associated labral tears is well demonstrated on MRI (Fig. CT arthrography has been reported to have 97.3% accuracy for detecting Bankart lesions and 86.3% for SLAP lesions 4, which makes it comparable with MR arthrography and gives the possibility to examine the patients with contraindications to an MR examination. Plain radiographs in patients with posterior shoulder instability are an important and critical adjunct to making the diagnosis of posterior shoulder instability. The management of these labrum injuries will depend on the classification, severity of the injury and the stability of the shoulder. In addition to aiding in the recognition of a locked posterior dislocation, the axillary radiograph is necessary to a complete an orthogonal radiographic analysis. -, BMJ. -, J Shoulder Elbow Surg.
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