The https:// ensures that you are connecting to the Between 2006 and 2008, 444 patients who had both shoulder arthroscopy and an MRI (non-contrast or MR arthrography) for shoulder pain at our institution prior to surgery were identified and included in the study. The image shows the typical findings of a sublabral recess. (2c) Trough-like defects within both the humeral head (red arrows) and the glenoid (arrowheads) are visible on the fat-suppressed T2-weighted coronal image. Chang IY, Polster JM. Posterior Labral Tear, Shoulder Soterios Gyftopoulos, MD, MSc ; Michael J. Tuite, MD To access 4,300 diagnoses written by the world's leading experts in radiology. Additionally, a recent study by Meyer et al9 highlighted the importance of x-rays in evaluation of posterior shoulder instability. A fat-suppressed proton density-weighted axial image in a 14 year-old female with shoulder instability reveals findings of severe glenoid hypoplasia. Radiographic features MRI. Unable to process the form. True anteroposterior or Grashey x-ray. Patients often do not experience frank posterior dislocation events such as that with anterior shoulder instability and more commonly develop attritional lesions. A wide ligament that surrounds and stabilises the joint is known as the capsule. Posterior subluxation of the humeral head is also apparent. The Bennett lesion (Fig. The glenohumeral joint has the following supporting structures: The tendon of the subscapularis muscle attaches both to the lesser tuberosity aswell as to the greater tuberosity giving support to the long head The shoulder capsule, including the glenohumeral ligaments, is one of the most important structures for restricting posterior translation of the humeral head.6The subscapularis, and to a lesser extent the infraspinatus and teres minor muscles, provide dynamic restriction of posterior humeral head translation.7The rotator interval is also thought to play a role, though its significance is somewhat controversial.8. PMC 1998 Apr 30;17(8):857-72 A 22-year-old male wrestler presents to your clinic with complaints of deep left shoulder pain for the past 6 weeks. Imaging in three planes is advisable and additional orthogonal planes may be included in the protocol for a detailed assessment of the lesion. The following algorithm has been previously proposed 25. 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. [ 41] Findings are usually normal. Mild glenoid hypoplasia results in a rounded contour of the posterior glenoid with normal or only mildly thickened posterior labral tissue. A recess more than 3-5 mm is always abnormal and should be regarded as a SLAP-tear. Shah N and Tung GA. The glenoid labrum is a cartilage rim that attaches to the glenoid rim. In order to cover an array of clinical scenarios, we used a pretest probability range of 20-80% at 20% increments according to the likelihood of pathology. Diagnosis can be made clinically with positive posterior labral provocative tests and confirmed with MRI studies of the shoulder. A posterior labral tear (reverse Bankart) is also present (arrowhead), and a bone bruise is seen within the anterior humeral head (asterisk). 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. Glenoid labral tears are the injuries of the glenoid labrum and a possible cause of shoulder pain. These tears include numerous variations designated by acronyms similar to those used for the more commonly seen anterior labral tears. Eur J Radiol. The IGHL, labrum, and periosteum are stripped and medially displaced along the anterior neck of the scapula. Shah AA, Butler RB, Fowler R, Higgins LD. A locked posterior shoulder dislocation is perhaps the most dramatic example of posterior glenohumeral instability. On these axial images a Buford complex can be identified. Objective To determine the prevalence of shoulder (specifically labral) abnormalities on MRI in a young non-athletic asymptomatic cohort. Postoperatively, there are strict instructions to avoid adduction and internal rotation of the operative shoulder. A Meta-Analysis of the Diagnostic Test Accuracy of MRA and MRI for the Detection of Glenoid Labral Injury. Radiology. It cushions the joint of the hip bone, preventing the bones from directly rubbing against each other. Adv Orthop. The posterior labrum is enlarged to replace the deficient glenoid rim. Tears of the supraspinatus tendon are best seen on coronal oblique and ABER-series. Broadly, clinical unidirectional . It should always be possible to trace the middle GHL upwards to the glenoid rim and downwards to the humerus. FOIA In patients with posterior instability, the presence of glenoid hypoplasia is predictably higher, with one report finding deficiency of the posteroinferior glenoid in 93% of patients with atraumatic posterior instability.10 When diagnosing posterior glenoid hypoplasia on MRI, care should be taken not to overcall the entity, as volume averaging can result in a false appearance of dysplasia on the most inferior axial slice. Superior labral anterior posterior (SLAP) tears are injuries of the glenoid labrum. (14b) In a 39 year-old weightlifter with persistent posterior shoulder pain and instability, the axial image reveals the posterior capsule outlined by arthrographic fluid along both sides of the capsule, strongly suggestive of a capsular tear. posterior labral tear surgery. (14a) Normal capsular appearance on an axial fat-suppressed T1-weighted MR arthrographic image. Skeletal Radiol 2000; 29:204-210. In type I there is no recess between the glenoid cartilage and the labrum. Due to the tension by the anterior band of the inferior GHL labral teras will be easier to detect. The findings are compatible with a posterior GLAD lesion (glenolabral articular disruption). An os acromiale must be mentioned in the report, because in patients who are considered for subacromial decompression, Burkhart et al. Imaging of superior labral anterior to posterior (SLAP) tears of the shoulder. Arthroscopic Posterior Labral Repair - Randy S. Schwartzberg, M.D. Normal anatomy. Purpose: When you have a excessive posterior force on an adducted arm the resultant is a posterior labral tear. This sublabral recess can be difficult to distinguish from a SLAP-tear or a sublabral foramen. Materials and methods In this cross-sectional study, non-athletic young adults age 18-29 with no history of shoulder pain received bilateral shoulder MRIs . Diagnostic performance of 3D-multi-Echo-data-image-combination (MEDIC) for evaluating SLAP lesions of the shoulder. This top area is also where the biceps tendon attaches to the labrum. It helps provide stability to the shoulder by . We concluded that even with intra-articular contrast, MRI had limitations in the ability to diagnose surgically proven SLAP lesions. (A) Anteroposterior radiograph of severe glenoid dysplasia showing hypoplasia of the glenoid neck (blue arrow) and coracoid enlargement (orange star). The labrum is cartilage tissue that holds the "ball" (humeral head) in the "socket" (glenoid) of your shoulder. Study the cartiage. There was a posterior labrum tear. Typically, physical therapy will start the first week or two after surgery. the removal of the acromion distal to the synchondrosis may further destabilize the synchondrosis and allow for 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. 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. Tear of the posterior shoulder stabilizers after posterior dislocation: MR imaging and MR arthrographic findings with arthroscopic correlation. The shoulder joint is the most unstable articulation in the entire human body. Figure 17-6. 2019 Oct 31;2019:9013935. doi: 10.1155/2019/9013935. -. Clipboard, Search History, and several other advanced features are temporarily unavailable. The diagnostic value of magnetic resonance arthrography of the shoulder in detection and grading of SLAP lesions: comparison with arthroscopic findings. Shoulder dislocations account for 90% of shoulder instability cases and usually occur after a fall during sport or work activities ().This glenohumeral joint instability has been defined with the acronyms TUBS (traumatic, unidirectional, Bankart, surgery is the main treatment) ().Associated injuries to the labrum, to the glenoid bone, described in up to 40% of the cases (), and . Tendonitis of the long head of the biceps. A displaced tear of the posterior labrum (arrow) is present. Treatment may be nonoperative or operative depending on chronicity of symptoms, degree of instability, and patient activity demands. Does posterior labral tear require surgery? MR is the best imaging modality to examen patients with shoulder pain and instability. 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. Had axials been pre-scribed without regard to the glenoid clockface, then the 9:00 posterior posi- Injuries isolated to labrum and capsule can often be successfully repaired with arthroscopic techniques including capsulolabral repair, capsular shift, and capsular shrinkage. 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. Notice that the biceps tendon is attached at the 12 o'clock position. Utilizing the gle-noid clockface orientation on a sagittal image (Fig. Tearing of the inferior glenohumeral ligament at the humeral attachment (blue arrow) is also evident. This site needs JavaScript to work properly. Imaging in three planes is advisable and additional orthogonal planes may be included in the protocol for a detailed assessment of the lesion. Glenoid retroversion was significantly associated with the development of posterior shoulder instability (P < .001). Occasionally, a SLAP (superior labrum, anterior and posterior) fracture, which represents a superior humeral head compression . Notice smooth undersurface of infraspinatus tendon and normal anterior labrum. 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. His pain is aggravated when grappling with other wrestlers and when performing push-ups. 2008 Aug; 24(8):921-9. 2009; 38(10):967-975. by Herold T, Bachthaler M, Hamer OW, et al. The rotator cuff is made of the tendons of subscapularis, supraspinatus, infraspinatus and teres minor muscle. Notice the biceps anchor. (14c) An arthroscopic examination confirms the tear in the posterior capsule (arrow), which was subsequently repaired. ALPSA lesions are . MRI. In part III we will focus on impingement and rotator cuff tears. Figure 17-1. 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. Posterior labral periosteal sleeve avulsion injury (POLPSA) in a 19 year-old football player following acute injury. 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). Posterior periosteum (arrowheads) is extensively stripped but remains attached to the posterior labrum. Notice coracoclavicular ligament and short head of the biceps. Hottya GA, Tirman PF, Bost FW, Montgomery WH, Wolf EM, Genant HK. In patients with glenoid deficiency or large impaction defects, osteotomies and osseous augmentation procedures may be required. The shoulder, because of its wide range of motion, is anatomically predisposed to instability, but the vast majority of shoulder instability is anterior, with posterior instability estimated to affect 2-10% of unstable shoulders.1Although anterior shoulder dislocations have been recognized since the dawn of medicine, the first medical description of posterior shoulder dislocation did not occur until 1822.2In modern times, posterior shoulder instability is still a commonly missed diagnosis, in part due to a decreased index of suspicion for the entity among many physicians. The labrum is a thick fibrous ring that surrounds the glenoid. 2019 Nov 7;19:199-202. doi: 10.1016/j.jor.2019.10.015. . No Comments At this level study the middle GHL and the anterior labrum. Careers. The blunted configuration of the posterior part means some wear and tear and erosion. Measurement of Friedmans angle and posterior humeral head subluxation (yellow lines depict Friedmans angle; red line depicts percentage of posterior humeral head subluxation). 2021 May 5;12:61-71. doi: 10.2147/OAJSM.S266226. . Look for excessive fluid in the subacromial bursa and for tears of the supraspinatus tendon. AJR Am J Roentgenol. An example of this position is pushing open a door with a straight arm. CT and MR Arthrography of the Normal and Pathologic Anterosuperior Labrum and Labral-Bicipital Complex. 2020 Aug 27;8(8):2325967120941850. doi: 10.1177/2325967120941850. Posterior shoulder instability is a relatively rare phenomenon compared to anterior instability, comprising only 5-10% of all shoulder instability. This ring of cartilage encompasses the outer rim of the glenoid to provide cushiony support around the head of the humerus. Harper and colleagues17 similarly developed a classification scheme with normal, mild, moderate, and severe glenoid dysplasia. Imaging studies therefore are an important adjunct to the diagnosis and treatment of posterior shoulder instability. Often, muscle wasting is seen clearly on MRI, showing atrophy of the muscle and build-up of fat. A sublabral recess however is located at the site of the attachment of the biceps tendon at 12 o'clock and does not extend to the 1-3 o'clock position. In this post we look at Periosteal Stripping. Study the inferior labral-ligamentary complex. Posterior shoulder instability is becoming increasingly recognized in young, athletic populations, especially in the military.13 Compared to anterior shoulder instability, posterior instability can be more challenging to diagnose both clinically and radiographically. Introduction. Labral tears An anatomy drawing of a shoulder labrum. There is an ongoing debate on whether direct MR arthrography is superior to conventional MR in detecting labral tears. In Shoulder MR-Part I we will focus on the normal anatomy and the many anatomical variants that may simulate pathology. The term SLAP stands for Superior Labrum Anterior and Posterior. 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. Fluid undermines a tear of the posterior glenoid labrum (arrow) in a 42 year-old male with persistent posterior shoulder pain. In either case, the labrum can be torn off the bone. Look for impingement by the AC-joint. De Maeseneer M, Van Roy F, Lenchik L et al. (OBQ11.152) They did find that smaller glenoid width was a risk factor for failure.12. Dougherty MC, Kulenkamp JE, Boyajian H, Koh JL, Lee MJ, Shi LL. To provide the highest quality clinical and technology services to customers and patients, in the spirit of continuous improvement and innovation. The shoulder joint is a ball and socket joint that connects the bone of the upper arm (humerus) with the shoulder blade (scapula). These are depicted in Figure 17-7. 5). Rotator cuff tears in the context of posterior shoulder instability or dislocation were once thought to be rare. Once thought to be a relatively rare entity, a study by Harper et al. Clinical Relevance: . eCollection 2020 May-Jun. 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. Illustration by Biodigital. 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). Results: Accessibility While this certainly introduces vulnerability to injury, it also confers the advantage of broad range of motion. Study the cartilage. Not All SLAPs Are Created Equal: A Comparison of Patients with Planned and Incidental SLAP Repair Procedures. Locked posterior subluxation of the shoulder: diagnosis and treatment. 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. The glenohumeral joint has a greater range of motion than any other joint in the body. The labrum in the shoulder joint is a vital component that helps stabilize the humerus and shoulder blade during movement. The authors found that specific acromial morphology on scapular-Y x-rays is significantly associated with the direction of glenohumeral instability. Findings compatible with posterior shoulder subluxation with an intramuscular tear of the teres minor, a posterior labral tear, and posterior capsular disruption. 2000;20 Spec No(suppl_1):S67-81. Glenoid labral tear. Common symptoms of a SLAP tear include: dull or aching pain in the shoulder, especially while lifting over the head. To investigate the utility of MRI, the researchers identified 41 patients who had undergone shoulder capsulorrhaphy by one of two senior surgeons over a two-year period. Non-contrast MRI had an accuracy of 85 %, sensitivity of 36 %, and a PPV of 13 %. This is not always the case. In Shoulder MR-Part I we will focus on the normal anatomy and the many anatomical variants that may simulate pathology. Numerous labral abnormalities may be encountered in patients with posterior glenohumeral instability. This can result in the damage to the anterior or front part of the labrum. Ferrari JD, Ferrari DA, Coumas J, Pappas AM. Labral repair or resection is performed. Study the labrum in the 3-6 o'clock position. In type II there is a small recess. It is important to recognise these variants, because they can mimick a SLAP tear. Without the rotator cuff, the humeral head would ride up partially out of the glenoid fossa, lessening the efficiency of the deltoid muscle. In a 20 year-old football player following acute injury, a reverse Bankart lesion is present. 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. The labrum is the cartilage dish that sits between the ball and the socket configuration of the shoulder joint. In part III we will focus on impingement and rotator cuff tears. In cases of severe dysplasia, advanced rounding and posterior sloping of the posterior glenoid is seen, and pronounced thickening of the labrum and other adjacent posterior soft tissues is apparent. -, J Shoulder Elbow Surg. 8 Therefore, although Bennett lesions are typically not associated with . sports. 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. 1. (B) Axillary radiograph demonstrating severe glenoid dysplasia with hypoplasia of the posterior glenoid and severe retroversion. 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). Glenoid labrum (marked lig.) Sometimes at this level labral tears at the 3-6 o'clock position can be visualized. Would you like email updates of new search results? Hottya GA, Tirman PF et al. It is present in 5% of the population. Major NM, Browne J, Domzalski T, Cothran RL, Helms CA. J Shoulder Elbow Surg. Sensitivity was 66 %, and specificity was 77 %. Look for supraspinatus-impingement by AC-joint spurs or a thickened coracoacromial ligament. Our data indicated that while MRI could exclude a SLAP lesion (NPV = 95 %), MRI alone was not an accurate clinical tool. 3. Failure of one of the acromial ossification centers to fuse will result in an os acromiale. They all attach to the greater tuberosity. American Journal of Roentgenology. There are a number of anatomical labral variants located between 11 and 3 o'clock, which can be mistaken for a SLAP tear: Please Note: You can also scroll through stacks with your mouse wheel or the keyboard arrow keys. In type III there is a large sublabral recess. complex injuries to the shoulder. Type 1 shoulder labrum tear. In that position the 3-6 o'clock region is imaged perpendicular. 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. Notice superior labrum and attachment of the superior glenohumeral ligament. Modern imaging techniques, in particular MRI, have greatly increased our ability to accurately diagnose posterior glenohumeral instability, and accurate recognition and characterization of the relevant abnormalities are critical for proper diagnosis and patient management.5, Multiple shoulder structures are important in resisting shoulder instability. If the pre-test probability was above 90% or below 10% . 15 Imaging of the patient in the ABER position can greatly increase the conspicuity of an ALPSA lesion, which can easily be overlooked on a routine MRI of the shoulder or on the standard axial sequence of an MRA. However,patients with acute lesions often have joint effusion, which also distends the joint space, making the contrast administration unnecessary. Surgical Management of Superior Labral Tears in Athletes: Focus on Biceps Tenodesis. Baseball pitchers are shown to have a high prevalence. In the ABER position the inferior glenohumeral ligament is stretched resulting in tension on the anteroinferior labrum, allowing intra-articular contrast to get between the labral tear and the glenoid. Diagnosis is made clinically with presence of increased anterior and posterior humeral translation, a sulcus sign, and overall increased . 10 A paralabral cyst indicates the presence of a labral tear. 14). Wuennemann F, Kintzel L, Zeifang F, Maier MW, Burkholder I, Weber MA, Kauczor HU, Rehnitz C. BMC Musculoskelet Disord. MeSH The insertion has a variable range. Notice the fibers of the inferior GHL. Probing of the posterior labrum is needed to rule out a subtle Kim lesion. of the biceps in the bicipital groove. If the patient is unable to abduct the arm, then a Velpeau view is an alternate orthogonal radiograph (Figure 17-4). Recurrent posterior shoulder instability: diagnosis and treatment. When there is an avulsion of the posterior inferior labrum, and the lesion is incomplete, concealed, or occult, it is called a Kim lesion. However, a study by Saupe et al. -, Stat Med. 4). These are also called ganglion cysts of the shoulder. Copyright 2023 Lineage Medical, Inc. All rights reserved. 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.
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