13) of the posterior capsule. Tears of the supraspinatus tendon are best seen on coronal oblique and ABER-series. Methods MR arthrograms of 97 patients with isolated posterior glenoid labral tears by arthroscopy and those of 96 age and gender-matched controls with intact posterior labra were reviewed by two blinded . An anteroposterior (AP) Grashey image (also known as a true AP view because the beam is oriented perpendicular to the scapula, which is oriented 30 degrees anterior to the coronal plane) (Figure 17-1) along with an axillary x-ray (Figure 17-2), are the minimum radiographs that should be obtained. AJR Am J Roentgenol. Injuries isolated to labrum and capsule can often be successfully repaired with arthroscopic techniques including capsulolabral repair, capsular shift, and capsular shrinkage. 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. -, BMJ. Typically, physical therapy will start the first week or two after surgery. Also. (A) Lightbulb sign demonstrating rounded appearance of the humeral head with a posterior glenohumeral dislocation. Superior labral anterior posterior (SLAP) tears are injuries of the glenoid labrum. Multidirectional shoulder instability (MDI) is a condition characterized by generalized instability of the shoulder in at least 2 planes of motion (anterior, posterior, or inferior) due to capsular redundancy. 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. The labrum is a band of tough cartilage and connective tissue that lines the rim of the hip socket, or acetabulum. Saupe N, White LM, Bleakney R, et al. 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. The glenoid cavity is the shallow socket of the scapula. -. HHS Vulnerability Disclosure, Help 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. Successful nonoperative treatment of posterior shoulder instability has had varying rates of success, between 16 and 70% of patients. . 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). Imaging in three planes is advisable and additional orthogonal planes may be included in the protocol for a detailed assessment of the lesion. Radiographs are normal, and an MRI arthrogram is shown in Figure A. The thickened middle GHL should not be confused with a displaced labrum. What are the findings? Orthop Traumatol Surg Res. It cushions the joint of the hip bone, preventing the bones from directly rubbing against each other. Fraying of the anterior section means some tearing of the surface with wispy threads emanating from that Introduction. J Am Med Assoc 117: 510-514, 1941. 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. 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. 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. Diagnosis of a locked posterior humeral dislocation can be avoided by recognizing on the AP Grashey radiograph the presence of the lightbulb sign (Figure 17-3A), which is the humeral head taking on a rounded appearance similar to the shape of a lightbulb because of fixed internal rotation secondary to a posterior glenohumeral dislocation.4 In addition to recognizing the lightbulb sign on an AP Grashey radiograph, an axillary x-ray will confirm the diagnosis of a locked posterior dislocation (Figure 17-3B). Arch Orthop Trauma Surg. 2009 Jan;192(1):86-92. doi: 10.2214/ajr.08.1097. 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. Arthroscopy. 2019 Nov 7;19:199-202. doi: 10.1016/j.jor.2019.10.015. 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. The rotator cuff is made of the tendons of subscapularis, supraspinatus, infraspinatus and teres minor muscle. Imaging of superior labral anterior to posterior (SLAP) tears of the shoulder. Dr. Ebraheim's educational animated video describes posterior labral tear - posterior shoulder instability. A recess more than 3-5 mm is always abnormal and should be regarded as a SLAP-tear. The posterior labrum is avulsed, and stripped scapular periosteum remains attached to the posterior labrum (arrowhead). 4A, green line), the torn 9:00 posterior labrum is opposite the 3:00 anterior labrum on an axial image (Fig. 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. (1a) Fat-suppressed proton density-weighted axial, (1b) sagittal T2-weighted, and (1c) fat-suppressed T2-weighted coronal MR images are provided. A sublabral foramen or sublabral hole is an unattached anterosuperior labrum at the 1-3 o'clock position. Failure of one of the acromial ossification centers to fuse will result in an os acromiale. 2016 Baseball Sports Medicine: Game Changing Concepts, The Batters Shoulder and Posterior Labral Tears - Christopher Ahmad, MD (BSM #6, 2016), Shoulder360 The Comprehensive Shoulder Course 2023, Shoulder loose body with posterior labral tear with posterior subluxation in 32M. 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 important to recognise these variants, because they can mimick a SLAP tear. Treatment of the labral tears in these scenarios involves treatment of the shoulder dislocation and stabilising the shoulder. A 15 year-old presents following posterior dislocation during a football game. the removal of the acromion distal to the synchondrosis may further destabilize the synchondrosis and allow for Clinical History: A 72 year-old male presents with severe left shoulder pain and limited motion following a fall 10 days earlier. 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). Notice MGHL, which has an oblique course through the joint and study the relation to the subscapularis tendon. In part II we will discuss shoulder instability. Radiographics. 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. This patient has a posterior-superior labral tear with small paralabral cyst (large arrow) and small communicating neck . 2019 Oct 31;2019:9013935. doi: 10.1155/2019/9013935. Crossref, Medline, Google Scholar; 74. It is present in 5% of the population. Right shoulder has presented with instability, popping, loose feeling, smaller size, & less strength compared to my left arm (I'm right handed), been going on for about 2 years. (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. A Buford complex is a congenital labral variant. Notice the rotator cuff interval with coracohumeral ligament. A tear of the labrum can also occur in the back part of the socket. Imaging in three planes is advisable and additional orthogonal planes may be included in the protocol for a detailed assessment of the lesion. When there is an avulsion of the posterior inferior labrum, and the lesion is incomplete, concealed, or occult, it is called a Kim lesion. difficulty performing normal shoulder . The axial MR-images show an os acromiale with degenerative changes, i.e. 12) or at the humeral attachment (Fig. 1994 May; 3(3):173-90. Posterior Labral Tear. eCollection 2020 May-Jun. As joint instability is often present, capsuloplasty may be added to the procedure. . eCollection 2019. AJR 1998; 171:763-768. 2020 Aug 27;8(8):2325967120941850. doi: 10.1177/2325967120941850. In either case, the labrum can be torn off the bone. Imaging of Posterior Shoulder Instability, Josef K. Eichinger, MD, FAOA and Joseph W. Galvin, DO, FAAOS. Simoni P, Scarciolla L, Kreutz J, Meunier B, Beomonte Zobel B. J Sports Med Phys Fitness. 10 A paralabral cyst indicates the presence of a labral tear. In the healthy state, the humerus sits on the glenoid similar to the way a golf ball rests on a tee. Bethesda, MD 20894, Web Policies 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. Appendicitis - Pitfalls in US and CT diagnosis, Acute Abdomen in Gynaecology - Ultrasound, Transvaginal Ultrasound for Non-Gynaecological Conditions, Bi-RADS for Mammography and Ultrasound 2013, Coronary Artery Disease-Reporting and Data System, Contrast-enhanced MRA of peripheral vessels, Vascular Anomalies of Aorta, Pulmonary and Systemic vessels, Esophagus I: anatomy, rings, inflammation, Esophagus II: Strictures, Acute syndromes, Neoplasms and Vascular impressions, TI-RADS - Thyroid Imaging Reporting and Data System, The Abduction External Rotation (ABER) View for MRI of the Shoulder. 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. Eur J Radiol. Radiographics. Operative findings were used as the gold standard for posterior labral tear extension. Please enable it to take advantage of the complete set of features! PMC Fluid undermines a tear of the posterior glenoid labrum (arrow) in a 42 year-old male with persistent posterior shoulder pain. 2000;20 Spec No(suppl_1):S67-81. 2012;132(7):905-19. Diagnostic criteria for both anterior and posterior labral tears present similarly. It is not healed. Harper and colleagues17 similarly developed a classification scheme with normal, mild, moderate, and severe glenoid dysplasia. A 22-year-old male wrestler presents to your clinic with complaints of deep left shoulder pain for the past 6 weeks. Adv Orthop. (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). Glenoid retroversion has been shown to be a risk factor for posterior shoulder instability.3 In a prospective study of 714 West Point cadets who were followed for 4 years, 46 shoulders had a documented glenohumeral instability event, 7 of which (10%) were posterior instability. Evaluation and management of posterior shoulder instability. Clipboard, Search History, and several other advanced features are temporarily unavailable. Insertion of the shoulder capsule onto the labrum or glenoid has been categorized previously according to a system by Mosley et al. Shah N and Tung GA. Measurement of Friedmans angle and posterior humeral head subluxation (yellow lines depict Friedmans angle; red line depicts percentage of posterior humeral head subluxation). Wuennemann F, Kintzel L, Zeifang F, Maier MW, Burkholder I, Weber MA, Kauczor HU, Rehnitz C. BMC Musculoskelet Disord. 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. In Shoulder MR-Part I we will focus on the normal anatomy and the many anatomical variants that may simulate pathology. eCollection 2021. 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 . De Maeseneer M, Van Roy F, Lenchik L et al. Having a structure when assessing a Shoulder MRI is very useful. The shallow socket in the scapula is the glenoid cavity. 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. Lenza M, Buchbinder R, Takwoingi Y, Johnston RV, Hanchard NC, Faloppa F. Cochrane Database Syst Rev. Sports Health 2011 May, 3(3):253-263, Cooper A. Labral repair or resection is performed. We hypothesized that the accuracy of MRI and MRA was lower than previously reported. 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. Since that time, other authors have expanded this classification to the current . Notice that the biceps tendon is attached at the 12 o'clock position. At this level study the middle GHL and the anterior labrum. This is not always the case. The https:// ensures that you are connecting to the Surgery may be required if the tear gets worse or does not improve after physical therapy. 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. Treatment may be nonoperative or operative depending on chronicity of symptoms, degree of instability, and patient activity demands. 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 . Philadelphia, Pa: Lea & Blanchard; 1822, Pollock RG, Bigliani LU. Does posterior labral tear require surgery? The ligaments also aid in keeping the shoulder stable and in joint. 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. 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. doi: 10.1002/14651858.CD009020.pub2. Background:The literature demonstrates a high prevalence of asymptomatic knee and hip findings on magnetic resonance imaging (MRI) in athletes. This site needs JavaScript to work properly. 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 . Arthroscopy. Which of the images (Figures A-E) most likely corresponds to the patient's initial diagnosis? Tear of the posterior shoulder stabilizers after posterior dislocation: MR imaging and MR arthrographic findings with arthroscopic correlation. A shoulder labral tear is an injury to this piece of cartilage, due to direct trauma, overuse, or instability. (OBQ12.268) When you plan the coronal oblique series, it is best to focus on the axis of the supraspinatus tendon. Sensitivity was 66 %, and specificity was 77 %. The abduction external rotation (ABER) view is excellent for assessing the anteroinferior labrum at the 3-6 o'clock position, In moderate dysplasia, the posterior glenoid is more rounded and the glenoid articular surface slopes medially. 2006; 240(1):152-160. Study the inferior labral-ligamentary complex. Accessibility Diagnosis is made clinically with presence of increased anterior and posterior humeral translation, a sulcus sign, and overall increased . complex injuries to the shoulder. An arthroscopic examination confirmed the MRI findings and showed multiloculated cysts in the inferior labrum, mostly between 5 o'clock to 7 o'clock positions with labral tear. Clavert P. Glenoid Labrum Pathology. The shoulder joint is a ball-and-socket joint that joins the upper arm's (humerus) bone with the shoulder blade (scapula). Clinical Relevance: . Due to the tension by the anterior band of the inferior GHL labral teras will be easier to detect. Introduction. MRI is well recognized as an effective means to diagnose internal impingement of the shoulder. Hill Sachs lesions are only seen at the level of the coracoid. eCollection 2020 Aug. J Orthop. Smith T, Drew B, Toms A. The blunted configuration of the posterior part means some wear and tear and erosion. 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. An impaction fracture is also present at the posterior glenoid rim (blue arrow). Also, although better visualized on MRA imaging, a hypertrophied posterior glenoid labrum is evident in patients with glenoid dysplasia (Figure 17-8). A fat-suppressed proton density-weighted axial image in a 14 year-old female with shoulder instability reveals findings of severe glenoid hypoplasia. Usually it is an incidental finding and regarded as a normal variant. 4). Hottya GA, Tirman PF, Bost FW, Montgomery WH, Wolf EM, Genant HK. Notice the fibers of the inferior GHL. -, Stat Med. There are many labral variants. Notice superior labrum and attachment of the superior glenohumeral ligament. 2016;36(6):1628-47. The posterior labrum is enlarged to replace the deficient glenoid rim. The shoulder joint is a ball and socket joint that connects the bone of the upper arm (humerus) with the shoulder blade (scapula). Normal anatomy. What is your diagnosis? Fluid distends the joint and only lies along the inner margin of the joint capsule (arrowheads). Bookshelf On the basis of these findings, careful assessment of the posterior labrum on MRI arthrogram may reveal the majority, but not all, of . The most common cause of a cyst of the shoulder is a labral tear. On MR arthrography, the mean posterior humeral translation was greater (6.2 mm +/- 0.08; p = 0.019), posterior labral tears were longer (19.4 mm +/- 1.7; p = 0.0008), and labrocapsular avulsion was more common (83%; p = 0.0001) in patients with posterior instability than in patients who had a posterior labral tear but a clinically stable shoulder. On conventional MR labral tears are best seen on fat-saturated fluid-sensitive sequences. They may extend into the tendon, involve the glenohumeral ligaments or extend into other quadrants of the labrum. Notice smooth undersurface of infraspinatus tendon and normal anterior labrum. FOIA (A) Anteroposterior radiograph of severe glenoid dysplasia showing hypoplasia of the glenoid neck (blue arrow) and coracoid enlargement (orange star). 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). Despite multiple studies documenting a clear significant association between subtle glenoid dysplasia and posterior labral tears with associated posterior shoulder instability, there is little evidence demonstrating an association with worse outcomes following surgical intervention. The axillary radiograph is also helpful in the traumatic scenario for identifying a posterior glenoid rim fracture or a reverse Hill-Sachs lesion. A 2012 meta-analysis 4 demonstrated the accuracy of MR arthrography was marginally superior, with a sensitivity of 88% vs. 76% for conventional MR, and a specificity of 93% vs.87%. Posterior labrum tear: This tear occurs at the back of the shoulder joint. (14a) Normal capsular appearance on an axial fat-suppressed T1-weighted MR arthrographic image. There is . However, imaging studies do not always demonstrate obvious pathologic findings and thus a nuanced approach to the interpretation of x-rays, computed tomography (CT), and magnetic resonance imaging (MRI) is necessary to elucidate and identify subtle findings that can enable the clinician to make the correct diagnosis. the-glenoid labrum. Pagnani MJ, Warren RF Stabilizers of the glenohumeral joint. The retracted end of the subscapularis (asterisk) is also visible compatible with a full thickness tear. Glenoid retroversion was significantly associated with the development of posterior shoulder instability (P < .001). In this chapter we will review imaging findings of posterior instability on standard radiographs, CT scan, MRI, and magnetic resonance arthrogram (MRA), and 3-dimensional (3D) reconstruction CT and 3D MRI, which assist in the diagnosis and treatment of symptomatic posterior shoulder instability. 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 glenoid labrum stabilizes the joint by increasing glenoid depth and surface area, and provides a stable fibrocartilaginous anchor for the glenohumeral ligaments. Illustration by Biodigital. When we assess the shoulder labrum there are 7 areas to look at which have some association with labral tears. Figure 17-6. A fold is more commonly occur in the posterosuperior and posteroinferior capsular portions. 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. A posterior labral tear (reverse Bankart) is also present (arrowhead), and a bone bruise is seen within the anterior humeral head (asterisk). If there is a related partial thickness rotator cuff tear, there may also be lateral (on the side) pain. As a result posterior shoulder instability may present with vague shoulder pain, and a clinical examination is less demonstrative than anterior shoulder instability and may therefore be more difficult to diagnose. A hip (acetabular) labral tear is damage to cartilage and tissue in the hip socket. 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. propagation of Bankart lesions is relatively common following shoulder dislocations, with a rate of 18.5%. Type 1 shoulder labrum tear. He has full passive and active range of motion of the left shoulder that is symmetrical to his contralateral side. While this certainly introduces vulnerability to injury, it also confers the advantage of broad range of motion. The authors found that specific acromial morphology on scapular-Y x-rays is significantly associated with the direction of glenohumeral instability. The labrum is the cartilage of the shoulder joint that encircles the socket to stabilize the shoulder. ADVERTISEMENT: Supporters see fewer/no ads. Which of the listed structures augments the posterior-inferior glenohumeral ligament and is a static restraint to posterior translation of the humeral head on the glenoid when the shoulder is forward flexed, adducted, and internally rotated? The most common symptoms of a shoulder labrum tear can occur intermittently. 2015;101(1 Suppl):S19-24. Scroll through the images and notice the unattached labrum at the 12-3 o'clock position at the site of the sublabral foramen. Posterior labral periosteal sleeve avulsion injury (POLPSA) in a 19 year-old football player following acute injury. Numerous labral abnormalities may be encountered in patients with posterior glenohumeral instability. American Journal of Roentgenology. The findings are compatible with a posterior GLAD lesion (glenolabral articular disruption). Advances in knowledge:: On a direct MR arthrographic image, a posterior capsular synovial fold may be a normal anatomic variant. In a SLAP injury, the top (superior) part of the labrum is injured.
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