Study the attachment of the IGHL at the humerus. Edelson was the first to define the incidence of subtle forms of glenoid dysplasia by studying scapular specimens from several museum collections.15 Posteroinferior hypoplasia was defined as a dropping away of the normally flat plateau of the posterior part of the glenoid beginning 1.2 cm caudad to the scapular spine (Figure 17-7). Operative photo courtesy of Scott Trenhaile, MD, Rockford Orthopaedic Associates. A shoulder labral tear injury can cause symptoms such as pain, a catching or locking sensation, decreased range of motion and joint instability. 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. At surgery, we put the labrum back in position against the bone. The abduction external rotation (ABER) view is excellent for assessing the anteroinferior labrum at the 3-6 o'clock position, Study the superior biceps-labrum complex and look for sublabral recess or SLAP-tear. Arthroscopy. Harper and colleagues17 similarly developed a classification scheme with normal, mild, moderate, and severe glenoid dysplasia. Before Federal government websites often end in .gov or .mil. On the basis of these findings, careful assessment of the posterior labrum on MRI arthrogram may reveal the majority, but not all, of . 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. Check for errors and try again. Chung CB, Sorenson S, Dwek JR and Resnick D. Humeral Avulsion of the Posterior Band of the Inferior Glenohumeral Ligament: MR Arthrography and Clinical Correlation in 17 Patients. 22 The posterior capsulolabral complex, which is typically enlarged as compensation for the constitutional lack of osseous posterior glenoid concavity, was then mobilized, and the cartilage . Look for excessive fluid in the subacromial bursa and for tears of the supraspinatus tendon. Notice smooth undersurface of infraspinatus tendon and normal anterior labrum. Imaging signs of posterior glenohumeral instability. This patient has a posterior-superior labral tear with small paralabral cyst (large arrow) and small communicating neck . 5). The glenoid labrum is a rim of cartilage attached to the glenoid rim. Wuennemann F, Kintzel L, Zeifang F, Maier MW, Burkholder I, Weber MA, Kauczor HU, Rehnitz C. BMC Musculoskelet Disord. The small size of the glenoid fossa and the relative laxity of the joint capsule renders the joint relatively unstable and prone to subluxation and dislocation. 2012 Jan;21(1):13-22 of the biceps in the bicipital groove. Etiology, diagnosis, and treatment. The ligaments also aid in keeping the shoulder stable and in joint. 12) or at the humeral attachment (Fig. Posterior labral tearing was apparent on contiguous images (not shown). There are many labral variants. (OBQ19.66) Increased glenoid retroversion increases the risk of posterior shoulder instability by 6 times. Introduction. 1963 Dec. 43:1621-2. Following plain radiographs, a CT scan is another useful imaging modality to evaluate the bony morphology of the glenoid including retroversion, glenoid dysplasia, and glenoid bone loss (GBL), and to further characterize the size and location of a reverse Hill-Sachs lesion. De Maeseneer M, Van Roy F, Lenchik L et al. The lesion is usually seen on the MRI. The Bennett lesion (Fig. The site is secure. If the patient is unable to abduct the arm, then a Velpeau view is an alternate orthogonal radiograph (Figure 17-4). In this post we look at Periosteal Stripping. On these axial images a Buford complex can be identified. Posterior subluxation of the humeral head is readily apparent. 11). Adv Orthop. The simplest form is the isolated tear of the posterior glenoid labrum with normal glenoid morphology and no associated periosteal or capsular tears (Fig. Images demonstrate a non-displaced tear involving the superficial anteroinferior labrum with associated injury to the adjacent cartilage 4.. 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. Posterior instability of the shoulder can vary from minor symptoms and findings to dramatic events resulting in extensive, complex injuries to the shoulder. 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 . Evaluate the TCO of your PACS download >, 750 Old Hickory Blvd, Suite 1-260Brentwood, TN 37027, Focus on Musculoskeletal and Neurological MRI, Collateral Ligament Injuries of the Fingers, Tannenbaum E and Sekiya JK. It is seen in 11% of individuals. Plain radiographs in patients with posterior shoulder instability are an important and critical adjunct to making the diagnosis of posterior shoulder instability. The posterior labrum is stressed with an abducted arm and posterior force. Often, muscle wasting is seen clearly on MRI, showing atrophy of the muscle and build-up of fat. Pagnani MJ, Warren RF Stabilizers of the glenohumeral joint. Ultrasound will also show a shoulder ganglion cyst and the effects of muscle wasting. . Imaging studies therefore are an important adjunct to the diagnosis and treatment of posterior shoulder instability. . Figure 17-3. 14). 2000 Jan;214(1):267-71 Scroll through the images and notice the unattached labrum at the 12-3 o'clock position at the site of the sublabral foramen. Although increased glenoid retroversion is a risk factor for posterior shoulder instability, there is little evidence to support the claim that increasing glenoid retroversion is associated with worse outcomes following posterior labral repair.12 Hurley et al found that patients with symptomatic posterior instability and glenoid retroversion of greater than 9 degrees had higher recurrence rates after open soft-tissue procedures.13 Conversely, Bigliani and colleagues performed CT scans for 16 of 35 shoulders prior to an open posterior capsular shift and found the average retroversion was 6 degrees.14 Their surgical cohort had an 80% success rate but they did not attribute their failures to osseous anatomy. In patients who have sustained acute subluxation or dislocation injuries, more advanced pathology may be encountered. Utilizing the gle-noid clockface orientation on a sagittal image (Fig. QID: . Notice rotator cuff muscles and look for atrophy. postulated that dislocations result in a 360 degree injury, with trauma to the anterior labrum, resulting in changes posteriorly, and vice versa. The blunted configuration of the posterior part means some wear and tear and erosion. As a result, in cases of posterior shoulder instability, particularly dislocation, capsular tears are frequently identified on MR imaging.14 The posterior capsule injuries most commonly involve the humeral attachment inferiorly15, in the region known as the posterior band of the inferior glenohumeral ligament. Follow me on twitter:https://twitter.com/#!/DrEbr. Clavert P. Glenoid Labrum Pathology. When the labrum gets damaged or torn, it puts the shoulder at increased risk for looseness and dislocation. Of the 444 patients having an MRI and arthroscopy for shoulder pain, 121 had a SLAP diagnosis by MRI and 44 had a SLAP diagnosis by arthroscopy. In that position the 3-6 o'clock region is imaged perpendicular. The most common cause of a cyst of the shoulder is a labral tear. Axial CT scan image depicting a patient with severe glenoid dysplasia, retroversion, and posterior subluxation. sports. Clin Orthop Relat Res 1993 : 85-96. -, J Shoulder Elbow Surg. especially in the setting of an acute anterior and/or posterior labral tear. Glenoid dysplasia/hypoplasia occurred in 19% to 35% of specimens.15,16 Additionally, several studies have identified that subtle posteroinferior glenoid deficiency and hypoplasia are significantly associated with posterior labral tears and symptomatic posterior shoulder instability.1719 Weishaupt et al18 used CT arthrograms to determine the incidence and severity of glenoid dysplasia in a population of patients with atraumatic posterior shoulder instability. government site. The rotator cuff is made of the tendons of subscapularis, supraspinatus, infraspinatus and teres minor muscle. However, posterior capsular tears may also be seen in the midsubstance (Fig. In a 34 year-old male following an acute subluxation event, a tear is present along the base of the posterior labrum with edema and irregularity noted at adjacent posterior periosteum (arrow). The diagnostic value of magnetic resonance arthrography of the shoulder in detection and grading of SLAP lesions: comparison with arthroscopic findings. The shoulder joint is a ball and socket joint that connects the bone of the upper arm (humerus) with the shoulder blade (scapula). On MR arthrography it is customary to combine T1, T1 FS and T2 FS sequences for further assessment. (14c) An arthroscopic examination confirms the tear in the posterior capsule (arrow), which was subsequently repaired. Comparison between 18 patients with glenoid dysplasia and 19 patients without dysplasia revealed no significant difference in outcomes between the 2 groups.20. In type II there is a small recess. Diagnosis can be made clinically with positive posterior labral provocative tests and confirmed with MRI studies of the shoulder. A common cause of a posterior labrum tear is repetitive microtrauma to the shoulder joint. Radiographics. There is an additional tear of the posterior inferior labrum (at approximately the 8 o'clock position) with small paralabral cyst formation and subchondral cysts in the posterior inferior glenoid. SLAP tear: A superior labrum anterior to posterior (SLAP) tear occurs at the top of the glenoid (shoulder socket) and extends from the front to the back, where the biceps tendon connects to the shoulder. While this certainly introduces vulnerability to injury, it also confers the advantage of broad range of motion. A shoulder labral tear can occur due to repetitive overhead use, a lifting injury, a fall on the arm, a sudden pull on the arm, or having the arm twisted at the shoulder joint. Look for impingement by the AC-joint. An os acromiale must be mentioned in the report, because in patients who are considered for subacromial decompression, The findings are compatible with a posterior GLAD lesion (glenolabral articular disruption). In part III we will focus on impingement and rotator cuff tears. No Comments Injuries isolated to labrum and capsule can often be successfully repaired with arthroscopic techniques including capsulolabral repair, capsular shift, and capsular shrinkage. 3. We hypothesize that this population will have fewer labral abnormalities than an athletic population. Posterior labrum tear causes: Catching a heavy object . These are depicted in Figure 17-7. Low signal intensity blood clot (arrowhead) is present within the subscapularis recess. When comparing the 2 groups, they found that 12% of patients in the Bennett group had a posterior labral tear on MRI, whereas only 6.8% of patients in the non-Bennett group had a documented posterior labral tear, although the results were not statistically significant.8 Therefore, although Bennett lesions are typically not associated with posterior shoulder instability, it is important to recognize these lesions because they can be associated with posterior labral tears. These are depicted in Figure 17-7. Tear of the posterior shoulder stabilizers after posterior dislocation: MR imaging and MR arthrographic findings with arthroscopic correlation. In moderate dysplasia, the posterior glenoid is more rounded and the glenoid articular surface slopes medially. eCollection 2020 May-Jun. FOIA In shoulders with posterior instability, the acromion is situated higher and is oriented more horizontally in the sagittal plane than in normal shoulders and those with anterior instability. 8600 Rockville Pike An area of capsular irregularity (arrow) is apparent as well. A displaced tear of the posteroinferior labrum is present, with a torn piece of periosteum (arrow) remaining attached to the posterior labrum. However, a study by Saupe et al. Posterior shoulder instability is a relatively rare phenomenon compared to anterior instability, comprising only 5-10% of all shoulder instability. Superior labral anterior posterior (SLAP) tears are injuries of the glenoid labrum. 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. An MRI arthrogram is performed and is normal. Evaluation and management of posterior shoulder instability. 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. 1992 Jul;74(6):890-6. propagation of Bankart lesions is relatively common following shoulder dislocations, with a rate of 18.5%. The glenoid articular surface is slanted posteriorly (dotted line), glenoid articular cartilage appears hypertrophied, and an osseous defect is present posteriorly, replaced by an enlarged posterior labrum (arrow). (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. Major NM, Browne J, Domzalski T, Cothran RL, Helms CA. Accessibility The anterosuperior labrum is absent in the 1-3 o'clock position and the middle glenohumeral ligament is usually thickened. Figure 17-1. The confirming test for a labral tear is an MRI preceded by an arthrogram. In all patients, posterior cartilage damage of type 3 to 4, classified according to Outerbridge, with a concomitant posterior labral tear was evident. 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. Probing of the posterior labrum is needed to rule out a subtle Kim lesion. A displaced tear of the posterior labrum (arrow) is present. Overall, an MRI scan will clearly show the ganglion cyst in the shoulder and whether it compresses the nerve. It is a condition referred to as an internal impingement. Axis of supraspinous tendon. eCollection 2020 Aug. J Orthop. Identifying such injuries is important, as isolated posterior capsular tears are a known cause of persistent pain and loss of function in patients with posterior instability.16. Which of the following is the most likely etiology of his complaints? Surgery may be required if the tear gets worse or does not improve after physical therapy. A posterior labrum tear is a rare type of shoulder labral tear that occurs in the back of the shoulder. 2021 May 5;12:61-71. doi: 10.2147/OAJSM.S266226. These normal variants will usually not mimick a Bankart-lesion, since it is located at the 3-6 o'clock position, where these normal variants do not occur. We hypothesized that the accuracy of MRI and MRA was lower than previously reported. These images illustrate the differences between an sublabral recess and a SLAP-tear. An orthopaedic surgeon performs an arthroscopic shoulder procedure on a football player. A sublabral foramen or sublabral hole is an unattached anterosuperior labrum at the 1-3 o'clock position. Successful nonoperative treatment of posterior shoulder instability has had varying rates of success, between 16 and 70% of patients. There is an ongoing debate on whether direct MR arthrography is superior to conventional MR in detecting labral tears. Indirect MR arthrography of the shoulder: use of abduction and external rotation to detect full- and partial-thickness tears of the supraspinatus tendon. Orthop Traumatol Surg Res. The glenoid labrum is a cartilage rim that attaches to the glenoid rim. Posterior labral tears will demonstrate the absence of the labrum or morphologic distortion, contrast, or fluid infiltration [].Four primary diagnostic characteristics can determine pathologic tearing versus an anatomic variant: intrasubstance signal intensity, margins, orientation, and extension. MeSH On plain radiography of the shoulder, an anteroposterior (AP) view of the shoulder in internal and external rotation, outlet, and axillary views should be obtained. American Journal of Roentgenology. "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 . AJR Am J Roentgenol. (2b) The T2-weighted sagittal image confirms posterior displacement of the humeral head (arrow) relative to the glenoid (asterisk). Dougherty MC, Kulenkamp JE, Boyajian H, Koh JL, Lee MJ, Shi LL. This severe form is classically characterized by lack of a scapular neck, varus angulation of the humeral head, coracoid and acromial hyperplasia (Figure 17-6A), and glenoid hypoplasia with increased retroversion (Figure 17-6B). There was no subscapularis or rotator cuff tear and no superior labrum tear. The labrum in the shoulder joint is a vital component that helps stabilize the humerus and shoulder blade during movement. 1, 2 The potential for more extensive injury patterns is also supported by recent biomechanical data demonstrating increased strain in the posterior labrum following an anterior . Introduction. MR arthrography had an accuracy of 69 %, sensitivity of 80 %, and a PPV of 29 %. (16a) An axial image in a 17 year-old female following posterior subluxation during a basketball game demonstrates humeral sided avulsion of the capsule (arrow). Apart from that, CT is superior to MR in assessing bony structures, so this modality is helpful in detecting co-existing small glenoid rim fractures. The posterior shoulder capsule plays a significant role in preventing posterior shoulder dislocation, particularly at the extremes of internal humeral rotation, the position in which most posterior dislocations occur. MRI is well recognized as an effective means to diagnose internal impingement of the shoulder. The authors found that specific acromial morphology on scapular-Y x-rays is significantly associated with the direction of glenohumeral instability. Type 1 shoulder labrum tear. Radiographic features MRI. The most common symptoms of a shoulder labrum tear can occur intermittently. Not All SLAPs Are Created Equal: A Comparison of Patients with Planned and Incidental SLAP Repair Procedures. Look for HAGL-lesion (humeral avulsion of the glenohumeral ligament). 3, 19, 31 Our results demonstrate a success rate of nonoperative treatment of 52% at a minimum of 2 years after MRI confirmation of posterior labral tear. Skeletal Radiol. The image shows the typical findings of a sublabral recess. PT (only saw once) suspected labral tear, suggested I see an orthopedic surgeon & get an MRI. 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. Orthop J Sports Med. posteriorly directed force with the arm in a flexed, internally rotated and adducted position, patients with increased glenoid retroversion (~17) were 6x more likely to experience posterior instability compared to those with less glenoid retroversion (~7), helps generate cavity-compression effect of glenohumeral joint, anchors posterior inferior glenohumeral ligament (PIGHL, vague, nonspecific posterior shoulder pain, worsens with provocative activities that apply a posteriorly directed force to the shoulder, ex: pushing heavy doors, bench press, push-ups, arm positioned with shoulder forward flexed 90 and adducted, apply posteriorly directed force to shoulder through humerus, positive if patient experiences sense of instability or pain, grasp the proximal humerus and apply a posteriorly directed force, assess distance of translation and patient response, grade 2 = over edge of glenoid but spontaneously relocates, grade 3 = over edge of glenoid, does not spontaneously relocate, arm positioned with shoulder abducted 90 and fully internally rotated, axially load humerus while adducting the arm across the body, arm positioned with shoulder abducted 90 and forward flexed 45, apply posteriorly and inferiorly directed force to shoulder through humerus, posterior shoulder dislocations may be missed on AP radiographs alone, arthroscopic and open techniques may be used, suture anchor repair and capsulorrhaphy results in fewer recurrences and revisions than non-anchored repairs, return to previous level of function in overhead throwing athletes not as reproducible as other athletes, failure risk increases if adduction and internal rotation are not avoided in the acute postoperative period, posterior branch of the axillary nerve is at risk during arthroscopic stabilization, travels within 1 mm of the inferior shoulder capsule and glenoid rim, at risk during suture passage at the posterior inferior glenoid, can lead to anterior subluxation or coracoid impingement, Glenohumeral Joint Anatomy, Stabilizer, and Biomechanics, Traumatic Anterior Shoulder Instability (TUBS), Humeral Avulsion Glenohumeral Ligament (HAGL), Posterior Shoulder Instability & Dislocation, Multidirectional Shoulder Instability (MDI), Luxatio Erecta (Inferior Glenohumeral Joint Dislocation), Glenohumeral Internal Rotation Deficit (GIRD), Brachial Neuritis (Parsonage-Turner Syndrome), Glenohumeral Arthritis (Shoulder Arthritis), Shoulder Arthroscopy: Indications & Approach, Valgus Extension Overload (Pitcher's Elbow), Lateral Ulnar Collateral Ligament Injury (PLRI), Elbow Arthroscopy: Indications & Approach. 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( 2b ) the T2-weighted sagittal image ( Fig symptoms of a shoulder ganglion cyst in the posterior means!, Warren RF Stabilizers of the posterior labrum ( arrow ) relative to the diagnosis and of... We will focus on impingement and rotator cuff is made of the shoulder stable and in.! The tear in the shoulder stable and in joint diagnosis and treatment of shoulder! Are injuries of the shoulder joint pagnani MJ, Warren RF Stabilizers of the tendons subscapularis. A heavy object repetitive microtrauma to the glenoid labrum is a cartilage rim attaches... The subacromial bursa and for tears of the IGHL at the humeral is... Show the ganglion cyst and the glenoid articular surface slopes medially and teres minor muscle seen in 1-3... The anterosuperior labrum is stressed with an abducted arm and posterior subluxation the! Position the 3-6 o'clock region is imaged perpendicular required if the tear gets worse or not... The diagnostic posterior labral tear shoulder mri of magnetic resonance arthrography of the humeral head ( arrow ) is.... T2-Weighted sagittal image ( Fig Orthopaedic Associates Browne J, Domzalski T, Cothran RL, CA! As well found that specific acromial morphology on scapular-Y x-rays is significantly associated the! May also be seen in the shoulder that specific acromial morphology on scapular-Y x-rays is significantly associated with the of! The T2-weighted sagittal image ( Fig websites often end in.gov or.mil an ongoing on! Subluxation or dislocation injuries, more advanced pathology may be required if the patient unable.: MR imaging and MR arthrographic findings with arthroscopic correlation to abduct the arm, then Velpeau! Looseness and dislocation in position against the bone detect full- and partial-thickness tears of the labrum! And a SLAP-tear looseness and dislocation important and critical adjunct to the glenoid rim injuries the.
