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Andrew J Grainger

MSK Radiology

Leeds, UK

Norwegian MSK Imaging Seminar 25-26.04.2019 Farris Bad in Larvik

� Positioning & Technique

� Normal anatomy

� Rotator Cuff

� Labrum and Ligaments

� Arm by side

� Neutral to mild external rotation

� Axial scan from ACJ through glenohumeral joint� Sections will also included

Supraspinatus tendon� Use to set up coronal oblique plane

� Difficult to spot on sagittal and coronal images� Can be confusing� One of the reasons for including ACJ

on axial imaging

� Normal acromial apophysis fuses at 25 so can’t diagnose in young

� Problem with internal rotation� Intracapsular biceps & supraspinatus better

shown in neutral or external rotation� Subscapularis poorly visualised� Fat between infraspinatus and supraspinatus

may mimic tendon damage

� Single sequence in internalrotation can be helpful� Puts tension on posterior

capsule� Posterior labroligamentous

injury

� Advantage to angling axials obliquely to be perpedicular to the long axis of the glenoid

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� MRI Diagnosis of Glenoid LabralTear Using the Biceps LabralOblique Sequence (BLO)� Shah et al. ARRS Meeting 2013

Courtesy Dr H Umans, Albert Einstein College of Medicine, Bronx, NY

� ABER can also be helpful

� Takes tension off the supraspinatus� Allows fluid/contrast to enter an articular surface tear

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� Feature of the normal glenoid

� Central location

� Normally flattened posteriorly� Close to infraspinatus insertion

� Hill-Sachs lesion more superior� Look at and above coracoid

� Magic angle effect� Rotator cuff tendons almost inevitably have to pass through 55O to Bo

� Subject to magic angle effect� Abnormal increased signal on short TE sequence

� May simulate tendinosis

� Aim to include long TE (T2) sequence in coronal oblique plane� Also applies to MR-arthrography

� However a small percentage of tendinosis cases will show no increased T2 signal

T1 (fs) T2 (fs) � Frequently see acromial origin of coracoacromial ligament on coronal oblique sequence as dark body� Not osteophyte

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� Can be subtle� Low T1 signal

� Low signal in tendon� May decompress into bursa or

bone!!� Intensely inflammatory

� Need to recognise normal anatomy and variants

� Normal labrum has a variety of shapes

� Always project beyond the glenoid cartilage

� Need to recognise normal anatomy and variants

� Normal labrum has a variety of shapes

� Always project beyond the glenoid cartilage

Whatever the shape – check the position!

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� Chronic Bankart tear

� Reattached (often synovialised) in non-functional position

� High attachment of ligament can simulate Bankart lesion

� Need to carefully follow structures on contiguous images

� Highly variable� Shape� Attachment

� Most variation seen anterosuperiorly� 12 to 3 O’Clock

Blend with cartilage

Extend over cartilage

Sublabralsulcus (recess)

Sublabralforamen

Continuous

YESRecess

V RareCartilage Overlap

YesForamen

Never

� Most labral variation

Common Common Occasional

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� Absent anterosuperior labrum

� Large cord like MGHL

� Attachment of biceps and superior glenoid is highly variable

� Clean edges, < 5mm

� Only one

� Curves smoothly medially

� Not seen in posterior third of superior labrum

Tuite MJ et al. Radiology 2000;215:841

� Careful positioning� Neutral, avoid internal rotation

� Aware of normal anatomy

� Rotator Cuff

� Labrum & LigamentsT2 (fs)

T1 (fs)