1、肩关节失稳和肩袖损肩关节失稳和肩袖损失失INTRODUCTION Shoulder injuries comprise 8-13%of all athletes injuries Result from .repetitive overload activities:swimming,tennis.or direct trauma(collision):football,rugby2肩关节失稳和肩袖损失INCIDENCE SPORTS%TYPE OF LESIONS Baseball 11-17 AC,imping.,RC tenditis Wrestling 17 Glenohum subl
2、ux or dislocation,AC Tennis 56 RC tendinitis,imping.Volley-ball 44 Biceps tendinitis,imping.Javelin throwers 29 Biceps tendinitis,imping.etc 3肩关节失稳和肩袖损失SHOULDER ANATOMY Bones:humeral head and glenoid Cartilage and labrum Capsule and ligaments Muscles BELTRAN 4肩关节失稳和肩袖损失PLASTICITY OF LABRUMArticular
3、cartilage,and glenoid labrum.Labrum which have some plasticity seen on different positionsExternal rotation of humerus Internal rotation 5肩关节失稳和肩袖损失ANTERIOR CAPSULE INSERTIONType III,the more medial insertion,is prone to anterior glenohumeral instabilityFrom BELTRAN Imaging of orthopedic sports inju
4、ries SPRINGER 2007,p 1293 types of insertion6肩关节失稳和肩袖损失SHOULDER BIOMECHANICSShoulder is the most mobile joint in the human body Function requires coordinated motion of 4 joints .scapuloclavicular .acromioclavicular .glenohumeral .scapulothoracic 7肩关节失稳和肩袖损失SHOULDER BIOMECHANICS Motion 0-180%in eleva
5、tion internal and external rotation 150%anterior and posterior rotation 170%8肩关节失稳和肩袖损失STABILIZING MECHANISMS OF GLENOHUMERAL JOINT PASSIVE MECHANISMS .Size,shape,tilt ot the glenoid fossa .Negative intracapsular pressure .Adhesion,cohesion of articular surfaces .Ligaments and capsule .Glenoid labru
6、m .Oseous bone restraints:acromion,coracoid process9肩关节失稳和肩袖损失STABILIZING MECHANISMS OF GLENOHUMERAL JOINT ACTIVE STABILIZING MECHANISMS .long head of the biceps tendon .rotator cuff muscles .subscapularis muscleCoronal SagittalAxial ArthroMR10肩关节失稳和肩袖损失VICIOUS CIRCLE OF SHOULDER INJURIESPain occurs
7、 in women especially when there is a physiologic instability that may be multidirectional STONE 1994INSTABILITYCOMPRESSIONIMPINGEMENTPAINMUSCULAR IMBALANCEROTATOR CUFFWEAKNESS11肩关节失稳和肩袖损失LAXITY vs INSTABILITYDefinitions LAXITY:the ability to passively translate humeral head to the glenoid fossaINSTA
8、BILITY:a clinicalcondition in which symptoms are produced by the unwanted translation of the umeral head,giving rise to pain or diminished shoulder function12肩关节失稳和肩袖损失SHOULDER INSTABILITY This lecture is mainly devoted to gleno-humeral instability due to time limitations,but DO NOT FORGET please sc
9、apular,clavicular,acromio-clavicular,sternoclavicular injuries which are also seen in sports activities13肩关节失稳和肩袖损失THE OVERHEAD N THROWING MECHANISMCenter of rotationThe curved harrow represents the path and direction of the greater tuberosity a sthe arm externally rotates BELTRAN 200714肩关节失稳和肩袖损失IM
10、AGING TECHNIQUES RADIOGRAPHY AP,axial views CT,ARTHRO-CT MRI,ARTHRO-MR15肩关节失稳和肩袖损失RADIOGRAPHYAntero-inferior dislocation on AP and Neer views.Axial view is better than Neer to appreciate correctly the humeral head position Axial view16肩关节失稳和肩袖损失ARTHRO-CTArthro-CT for staging of lesions after bilater
11、al gleno-humeral dislocation:humeral head bone defects and glenoid lesions17肩关节失稳和肩袖损失ARTHRO-MRArthro-MR technique:iodine contrast and diluted Gd.Radiography after fluoscopic guidance and MR(3 planes,T1 w FS and T2w)18肩关节失稳和肩袖损失ANTERIOR INSTABILITY More frequent 90%Recurrences 50%In young patients,a
12、fter trauma19肩关节失稳和肩袖损失ABNORMALITIES IN ANTERIOR INSTABILITY Avulsion of gelnoid labrum 75%IGH ligament lesion,HILL-SACHS 50%SLAP lesions 25%Capsule laxity Rotator cuff teras(older patients)20%20肩关节失稳和肩袖损失ANTERO-INFERIOR DISLOCATIONFirst episode Third recurrence21肩关节失稳和肩袖损失BONE LESIONS AFTER ANTERO-
13、INFERIOR DISLOCATIONDislocation After reduction,Hill Sachs lesion 22肩关节失稳和肩袖损失ASSOCIATION OF LESIONSBankart lesion type 4 Hill Sachs lesion(same patient)23肩关节失稳和肩袖损失BANKART LESIONSArthro-MR:Bankart type III4 types of Bankart to 1:small,3 severe,4 fracture24肩关节失稳和肩袖损失ASSOCIATION OF LESIONS Avulsion,f
14、racture and loose body From BELTRAN,Radiographics 1994,66625肩关节失稳和肩袖损失POSTERIOR INSTABILITY Less common 5%Unidirectional is uncommon.Commonly bidirectional(post and inf)or multidirectional In epilepsy,ethanol,elcetricity shock(3 E rule)Also during repetitive applied athletic forces:swimming,throwing
15、,punching,and in sports collision such as football26肩关节失稳和肩袖损失POSTERIOR INSTABILITYClinical diagnosis much more difficult than in anterior instabilityImaging techniques are important Especially the first radiographic evaluation is ESSENTIAL 27肩关节失稳和肩袖损失POSTERIOR INSTABILITYPosterior dislocation with
16、fracture of anterior aspect of the humeral head(inverse of Hill.Sachs injury)28肩关节失稳和肩袖损失POSTERIOR INSTABILITYPosterior dislocation with poteriorBankart From TIRMAN,MRI clinics N Am 1997,88329肩关节失稳和肩袖损失MICROINSTABILITY OF SHOULDER Microinstability concerns the 1/3 sup joint in sportmen and sportwome
17、n,especially for risk of SLAP lesions Arthro-MR is superior to native MR for a good staging of lesions,including views in ABER position30肩关节失稳和肩袖损失MR in ABER POSITIONFor anterior shoulder instabilityFor capsule and labrum injuries For HILL SACHS injuriesWINTZELL 199831肩关节失稳和肩袖损失MULTIDIRECTIONAL INST
18、ABILITY Instability more than in one direction Antero-inferior,postero-inferior,or 3 directions Often atraumatic(without trauma),or violent injury,or repeated microtrauma32肩关节失稳和肩袖损失ISOLATED LABRUM TEARS Tears without instability But source of dysfunction In the athletic population Injury similar to
19、 gleno-humeral dislocation Sensation of instability33肩关节失稳和肩袖损失LABRUM TEARSSLAP lesion type 2 c,on arthro-MRSLAP=S superior L labrum A anterior P posteriorARTHRO-MR IS THE TECHNIQUE OF CHOICE34肩关节失稳和肩袖损失ROTATOR CUFF INJURIES Age is important in shoulder pathology According to Hoffmeyer 30 y.tendinop
20、athies,tears 40 y.tears,perforation 50 y.gleno-humeral osteoarthritis(OA)Med.Hyg 1998,56:221835肩关节失稳和肩袖损失IMPINGEMENT SYNDROME 95%of rotator cuff(RC)lesions,Neer 1972 Mechanical injury from compression of the subacromial structures:Suprasupinatus(SSP)tendon,greater tuberosity of humerus,subacromial b
21、ursa 36肩关节失稳和肩袖损失SECONDARY IMPINGEMENTIn young patients and athletesinvolved in throwing sports,shoulder impingement can occur with instability37肩关节失稳和肩袖损失IMAGING TECHNIQUES RADIOGRAPHY SONOGRAPHY MRI AND ARTHRO-MR38肩关节失稳和肩袖损失RADIOGRAPHYAP,neutral rotationInternalrotationExternal rotationNeer view A
22、t least AP neutral and Neer views,sometimes int.et ext.rotation!39肩关节失稳和肩袖损失SONOGRAPHY Technique.broadband-transducers 5-12 MHz .different types of probe,including typehockey-stick-shaped Multidirectional approach Dynamic and comparative study(both sides)Only perpendicular structures,because obliqui
23、ty creates artefacts Operator dependant40肩关节失稳和肩袖损失SONOGRAPHYESSENTIAL REQUIREMENTS:.personnal experience .rigourous examination .very good knowledge of anatomyPosition of probe for anterior approach of sholuder41肩关节失稳和肩袖损失SONOGRAPHY FINDINGSDegenerative suprasupinatus tendon and tearPosttraumatic S
24、SP tear42肩关节失稳和肩袖损失SIGNS OF RC TEARS DIRECT SIGNS OF COMPLETE TEAR 1.Flat area,scale of the border 2.Anechoic zone through the tendon 3.Massive thiness of the tendon 4.Tendon invisible INDIRECT SIGNS 1.Erosions of the greater tuberosity 2.Subacromial bursitis,joint fluid 3.Deltoid herniation 4.Muscl
25、e atrophy PEETRONS 200043肩关节失稳和肩袖损失SONOGRAPHY EFFICIENCY IN PARTIAL RC TEARS Sensitivity 93%Specificity 94%HOLSBEECK Mv Radiology 1995,197:443 BUT ONLY BY EXPERIENCED OPERATOR!44肩关节失稳和肩袖损失MAGNETIC RESONANCE MR offers a multiplanar approach and a good tissue differenciation(the best)Examination in 3
26、planes:coronal,sagittal,axial Multiple sequences:PD for anatomy T2 w FS for signal FE 3 D for cartilage Arthro-MR for incomplete tears,labrum tears 45肩关节失稳和肩袖损失MAGNETIC RESONANCECoronalAxialSagittal46肩关节失稳和肩袖损失ANATOMIC VARIATIONS THAT MAY PREDISPOSE TO IMPINGEMENTAcromial shapeAcromial lateral tiltD
27、iminished arch eightCoracoid lenghtMuscle hypertrophyOs acromialeDisplaced greater tuberosity Acromial shape flat,curved,hocked 47肩关节失稳和肩袖损失ROTATOR CUFF TEARSFunctional infirmityElevation of R upper limb impossibleArthro-MR:complete tear of SSP tendon wit retraction49肩关节失稳和肩袖损失ROTATOR CUFF TEARSDime
28、nsions of full thickness tears classified on basis of greatest dimensions Small 5 cm De Orio,Cofield JBJS am 1984,66(4):56350肩关节失稳和肩袖损失PARTIAL RC TEARS Inferior SSP tear more common than superior tear Not treated may lead to chronic pain and invalidity May propagate to full thickness tear Grading of
29、 partial tears 1.less 3 mm 2.3-6 mm 3.more 6 mm51肩关节失稳和肩袖损失PARTIAL RC TEARS Arthro-MR:inferior partial of the suprasupinatus tendon;no perforation,no passage of contrast medium in subacromial bursa52肩关节失稳和肩袖损失MULTIPLE RC TEARSSometimes infrasupinatus and subscapularis tears are associated with a sup
30、rasupinatus tearA complete good staging is compulsory for choosing the best tt,especially before eventual surgery(which type of surgical repair)For a such evaluation,MR and sometimes arthroMR,are the techniques of choice53肩关节失稳和肩袖损失MULTIPLE RC TEARSSuprasupinatus complete tear,retraction of tendon,m
31、uscle atrophywith infrasupinatus partial tear and muscle atrophy.Also OA in AC54肩关节失稳和肩袖损失EXTENT OF RC TEARSTHOMAZEAUClin Orthop Relat Res 1997,344:27555肩关节失稳和肩袖损失MUSCLE ATROPHY Muscle atrophy follows a rotator cuff tear not treatedMuscle atrophy very well appreciated by MRDepends on the lenght of e
32、volution Stage 1.few fatty trails 2.more muscle than fat 3.muscle=fat 4.more fat than muscle After 6 months of evolution stage 2,after 1 year stage 4 Goutalier D Clin Orthop 1994,304:7856肩关节失稳和肩袖损失MUSCLE ATROPHYA normal SSP muscle occupy the whole supraspinatus areaWhen atrophy the volume decreased5
33、7肩关节失稳和肩袖损失ACROMIOCLAVICULAR JOINT INJURIES Very often in looking for an eventual RC tear,an acromioclavicular joint injury is discovered,such as osteoarthritis with bony spurs,and even with an inflammatory component(bone marrow edema,joint fluid,and sometimes a subacromial bursitis)58肩关节失稳和肩袖损失ACRO
34、MIOCLAVICULAR JOINT INJURIESPD T2w FSOsteoarthritis of the acromioclavicular joint with inflammatory signsand RC impingement59肩关节失稳和肩袖损失BICEPS TENDON INJURIES The long tendon of the biceps had an extraarticular portion in the bicipital groove and an intraarticular portion60肩关节失稳和肩袖损失BICEPS TENDON IN
35、JURIES Injuries of the long tendon of the biceps may mimic a RC impingement Biceps tendon injuries:.tendinopathy .partial thickness tear .complete disruption .dislocation of the extra-articular portion61肩关节失稳和肩袖损失BICEPS TENDON INJURIESPossibility of tendon tear Tendinitis:enlargement,increased signa
36、l into the tendon62肩关节失稳和肩袖损失CONCLUSIONS Shoulder instability and rotator cuff injuries are common in certain sport activities Even a good clinician can not always make a correct and complete diagnosis Therefore imaging techniques have a great role in giving precise informations,concerning the different contributing factors,and allows to choose the best treatement and to precise the procedure when a surgical treatement is on discussion63肩关节失稳和肩袖损失
