4B), which is what one would intuitively expect. 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. Locked posterior shoulder dislocation with multiple associated injuries. 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 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. Without the rotator cuff, the humeral head would ride up partially out of the glenoid fossa, lessening the efficiency of the deltoid muscle. The thickened middle GHL should not be confused with a displaced labrum. AJR 2004; 183(2). Wuennemann F, Kintzel L, Zeifang F, Maier MW, Burkholder I, Weber MA, Kauczor HU, Rehnitz C. BMC Musculoskelet Disord. Careers. where most labral tears are located. Surgical treatment: arthroscopic debridement . If the arm is sports. 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. A tear extends across the base of the posterior labrum (arrowheads), and mild posterior subluxation of the humeral head relative to the glenoid is present. A 27-year-old male bodybuilder presents to the office with vague, deep shoulder pain and weakness with his bench press. At this level also look for Bankart lesions. As joint instability is often present, capsuloplasty may be added to the procedure. The fibers of the subscapularis tendon hold the biceps tendon within its groove. Rotator cuff tears in the context of posterior shoulder instability or dislocation were once thought to be rare. Look for rim-rent tears of the supraspinatus tendon at the insertion of the anterior fibers. The vast majority of shoulder labral tears do not need surgery. A fat-suppressed proton density-weighted axial image in a 14 year-old female with shoulder instability reveals findings of severe glenoid hypoplasia. However labral tears may originate at the 3-6 o'clock position and subsequently extend superiorly. A study in cadavers. 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. Clin Orthop Relat Res 1993 : 85-96. Clipboard, Search History, and several other advanced features are temporarily unavailable. ALPSA lesions are . There was no subscapularis or rotator cuff tear and no superior labrum tear. J Bone Joint Surg Am. In addition to aiding in the recognition of a locked posterior dislocation, the axillary radiograph is necessary to a complete an orthogonal radiographic analysis. The ligaments also aid in keeping the shoulder stable and in joint. 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. 2012 Dec;52(6):622-30. J Shoulder Elbow Surg. Look for supraspinatus-impingement by AC-joint spurs or a thickened coracoacromial ligament. Look for tears of the infraspinatus tendon. Utilizing the gle-noid clockface orientation on a sagittal image (Fig. 2000 Jan;214(1):267-71 Our data indicated that while MRI could exclude a SLAP lesion (NPV = 95 %), MRI alone was not an accurate clinical tool. The posterior labrum is stressed with an abducted arm and posterior force. Would you like email updates of new search results? Radiol Clin North Am 2016;54(5):801-815. MR arthrography had an accuracy of 69 %, sensitivity of 80 %, and a PPV of 29 %. The purpose of this study was to evaluate the accuracy of magnetic resonance imaging (MRI) and magnetic resonance arthrography (MRA) in diagnosing superior labral anterior-posterior (SLAP) lesions. 2008 Aug; 24(8):921-9. 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 . In previous studies, conventional MR sensitivity in detection of labral tears has ranged from 44% to 93% sensitivity compared with arthroscopy [1, 2].Two recent studies have assessed conventional MRI evaluation of the glenoid labrum using a 0.2-T extremity MR system. The supraspinatus tendon is the most important structure of the rotator cuff and subject to tendinopathy and tears. 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. It can be a traumatic tear due to injury, or it may be degenerative due to normal wear and tear. This is a common injury for athletes such as baseball pitchers and . Chang IY, Polster JM. Diagnosis can be made clinically with positive posterior labral provocative tests and confirmed with MRI studies of the shoulder. 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. (OBQ19.66) A posterior labral tear (reverse Bankart) is also present (arrowhead), and a bone bruise is seen within the anterior humeral head (asterisk). 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. It . 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. This sublabral recess can be difficult to distinguish from a SLAP-tear or a sublabral foramen. First described by Andrews and colleagues in 1985, Snyder later classified lesions of the superior labrum into four types and coined the term SLAP tear (superior labral tear anterior-posterior). Small to moderate glenohumeral joint effusion with synovitis and extension of fluid in the subcoracoid recess. Future larger studies are needed to confirm these findings. A displaced tear of the posteroinferior labrum is present, with a torn piece of periosteum (arrow) remaining attached to the posterior labrum. 3). A CT scan is typically performed to evaluate posterior bone loss due to either a reverse bony Bankart lesion or attritional bone loss, and to assess degree of retroversion and glenoid dysplasia, and is performed in revision scenarios. AJR Am J Roentgenol. He has positive Kim and jerk tests and reproduction of symptoms with the shoulder in forward flexion, adduction, and internal rotation. True anteroposterior or Grashey x-ray. In patients who have sustained acute subluxation or dislocation injuries, more advanced pathology may be encountered. 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 . It is not healed. Postoperatively, there are strict instructions to avoid adduction and internal rotation of the operative shoulder. These terms are interchangeable because there is underdevelopment of the posterior inferior aspect of the glenoid. The shoulder joint is a ball-and-socket joint that joins the upper arm's (humerus) bone with the shoulder blade (scapula). In two patients (Case 1 and 3) along with labral cysts with tear, showed, enlarged capsule and positive drive through sign. A posterior labrum tear is a rare type of shoulder labral tear that occurs in the back of the shoulder. MRI is well recognized as an effective means to diagnose internal impingement of the shoulder. (2b) The T2-weighted sagittal image confirms posterior displacement of the humeral head (arrow) relative to the glenoid (asterisk). These normal variants are all located in the 11-3 o'clock position. Labral repair or resection is performed. Radiographs are normal, and an MRI arthrogram is shown in Figure A. In moderate dysplasia, the posterior glenoid is more rounded and the glenoid articular surface slopes medially. Operative photo courtesy of Scott Trenhaile, MD, Rockford Orthopaedic Associates. Clinical Relevance: . 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 . The appearance is thought to be due to failure of ossification of the more inferior of the two ossification centers of the glenoid, resulting in a cartilage cap replacing the bone defect.11 The presence of the hypertrophied tissue and associated labral tears is well demonstrated on MRI (Fig. True dysplasia should be visible on at least two axials slices cephalad to the most inferior slice of the glenoid (Fig. The most common cause of a cyst of the shoulder is a labral tear. 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. 1998 Sep;171(3):763-8. 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. The anterior labrum is absent in the 1-3 o'clock position and there is a thickened middle GHL. The shallow socket in the scapula is the glenoid cavity. The retracted end of the subscapularis (asterisk) is also visible compatible with a full thickness tear. Look for HAGL-lesion (humeral avulsion of the glenohumeral ligament). Glenoid labrum (marked lig.) Which of the following is the next best step in management? 2009; 38(10):967-975. by Herold T, Bachthaler M, Hamer OW, et al. The glenoid cavity is the shallow socket of the scapula. Also. Figure 1 is an artist's rendition of a normal shoulder joint as well as the trauma caused by shoulder instability depicted on MRI. Check for errors and try again. A common cause of a posterior labrum tear is repetitive microtrauma to the shoulder joint. even greater mobility of the os acromiale after surgery and worsening of the impingement (4). CT and MR Arthrography of the Normal and Pathologic Anterosuperior Labrum and Labral-Bicipital Complex. The axillary radiograph is also helpful in the traumatic scenario for identifying a posterior glenoid rim fracture or a reverse Hill-Sachs lesion. 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. Fluid distends the joint and only lies along the inner margin of the joint capsule (arrowheads). 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. McLaughlin, HL. Glenoid retroversion was significantly associated with the development of posterior shoulder instability (P < .001). 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. Surgery may be required if the tear gets worse or does not improve after physical therapy. Detection of partial-thickness supraspinatus tendon tears: is a single direct MR arthrography series in ABER position as accurate as conventional MR arthrography? The ABER view is also very useful for both partial- and full-thickness tears of the rotator cuff. 1992 Jul;74(6):890-6. 2. Study the inferior labral-ligamentary complex. Patients were included in the analysis if they had a posterior labral tear repair and had preoperative MRI or magnetic resonance arthrography (MRA). Burkhart et al. The rotator cuff is made of the tendons of subscapularis, supraspinatus, infraspinatus and teres minor muscle. This type of shoulder labral tear can lead to intermittent symptoms and only occurs in 5-10% of shoulder labral tear patients. It is important to recognise these variants, because they can mimick a SLAP tear. There are 3 types of attachment of the superior labrum at the 12 o'clock position where the biceps tendon inserts. Failure of one of the acromial ossification centers to fuse will result in an os acromiale. At surgery, we put the labrum back in position against the bone. A 20-year-old college football offensive lineman undergoes arthroscopic right shoulder surgery for the injury shown in Figure A. Post-operatively he complains of burning pain in the region marked in yellow on Figure B. 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). The anterosuperior labrum is absent in the 1-3 o'clock position and the middle glenohumeral ligament is usually thickened. Types of labral tears. On MR an os acromiale is best seen on the superior axial images. AJR Am J Roentgenol. These are depicted in Figure 17-7. Usually it is an incidental finding and regarded as a normal variant. Posterior shoulder subluxation or dislocation is also one of the rare entities that may result in tears of the teres minor muscle.18 MR allows rapid evaluation of the status of the cuff following posterior dislocation, and prompt diagnosis of such lesions avoids delays in treatments that may lead to irreversible fatty atrophy of cuff musculature (Figs. 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. A recess more than 3-5 mm is always abnormal and should be regarded as a SLAP-tear. Look for excessive fluid in the subacromial bursa and for tears of the supraspinatus tendon. 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. Clinical History: A 72 year-old male presents with severe left shoulder pain and limited motion following a fall 10 days earlier. A shoulder labral tear injury can cause symptoms such as pain, a catching or locking sensation, decreased range of motion and joint instability. The labrum is the cartilage dish that sits between the ball and the socket configuration of the shoulder joint. Bethesda, MD 20894, Web Policies (B) Axillary radiograph of locked posterior glenohumeral dislocation. Which of the following nerves was most likely injured during the procedure? Glenoid labral tears are the injuries of the glenoid labrum and a possible cause of shoulder pain. [ 41] Findings are usually normal. 4A, green line), the torn 9:00 posterior labrum is opposite the 3:00 anterior labrum on an axial image (Fig. Tear of the posterior shoulder stabilizers after posterior dislocation: MR imaging and MR arthroscopic findings with arthroscopic correlation. However, a study by Saupe et al. 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 . There is . Posterior periosteum (arrowheads) is extensively stripped but remains attached to the posterior labrum. Following a posterior subluxation event, a fat-suppressed T2-weighted coronal image in this 52 year-old male reveals focal edema and irregularity at the humeral attachment of the posterior band of the inferior glenohumeral ligament (arrow), compatible with a partial tear. the-glenoid labrum. Click to share on Twitter (Opens in new window), Click to share on Facebook (Opens in new window), Click to share on Google+ (Opens in new window), on Imaging of Posterior Shoulder Instability. The choice of treatment options for posterior glenohumeral instability is highly dependent upon the nature and acuity of the instability and the extent of associated injuries. In a 20 year-old football player following acute injury, a reverse Bankart lesion is present. A Buford complex is a congenital labral variant. The most common symptoms of a shoulder labrum tear can occur intermittently. We hypothesized that the accuracy of MRI and MRA was lower than previously reported. The glenoid labrum is a cartilage rim that attaches to the glenoid rim. Successful nonoperative treatment of posterior shoulder instability has had varying rates of success, between 16 and 70% of patients. Diagnostic arthroscopy revealed no significant glenohumeral articular defects. 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. Patients with labral tears may present with a wide range of symptoms (depends on the injury type), which are often non-specific: Labral injuries can result from acute trauma (like shoulder dislocation or direct blow) or repetitive overuse. Imaging of Posterior Shoulder Instability, Josef K. Eichinger, MD, FAOA and Joseph W. Galvin, DO, FAAOS. The image shows the typical findings of a sublabral recess. Glenoid labral tear. Treatment of the labral tears in these scenarios involves treatment of the shoulder dislocation and stabilising the shoulder. Advances in knowledge:: On a direct MR arthrographic image, a posterior capsular synovial fold may be a normal anatomic variant. When the The insertion has a variable range. These shoulder MRI findings in middle-aged populations emphasize the need for supporting clinical judgment when making treatment decisions for this patient population. Magnetic resonance imaging, magnetic resonance arthrography and ultrasonography for assessing rotator cuff tears in people with shoulder pain for whom surgery is being considered. 1998 Apr 30;17(8):857-72 A Meta-Analysis of the Diagnostic Test Accuracy of MRA and MRI for the Detection of Glenoid Labral Injury. American Journal of Roentgenology. A normal glenoid labrum has a laterally pointing edge and normal posterior labral morphology. 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. An MRI arthrogram is performed and is normal. 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. Probing of the posterior labrum is needed to rule out a subtle Kim lesion. Large tears of the rotator cuff may allow the humeral head to migrate upwards resulting in a high riding humeral head. When a dislocation or subluxation occurs, the glenoid labrum is torn from the bone and the capsule is stretched. Such lesions are generally found in patients with atraumatic posterior instability. That is, the labrum helps the shoulder from slipping out of its joint. 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. 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. Shah AA, Butler RB, Fowler R, Higgins LD. No Comments Illustration by Biodigital. Also, although better visualized on MRA imaging, a hypertrophied posterior glenoid labrum is evident in patients with glenoid dysplasia (Figure 17-8). This is not always the case. 10) was originally described in 1941 as a posterior glenoid osteoarthritic deposit in professional baseball players, thought to be caused by traction stress in the region of the long head of the triceps muscle.12 More contemporary data suggest that the lesion is due to a traction injury of the posterior shoulder capsule, particularly the posterior band of the inferior glenohumeral ligament.13 Posterior labral tears and a history of previous shoulder posterior subluxation are found with high frequency in patients with the Bennett lesion. The posterior labrum is avulsed, and stripped scapular periosteum remains attached to the posterior labrum (arrowhead). . SLAP tears can cause pain and range-of-motion problems in the shoulder labrum, the biceps tendon or both. Tearing of the inferior glenohumeral ligament at the humeral attachment (blue arrow) is also evident. Using arthroscopy as the standard, sensitivity, specificity, accuracy, positive predictive value (PPV), and negative predictive value (NPV) were calculated for all MRIs, as well as separately for the non-intra-articular contrast MRI group and the MR arthrography group. Head ( arrow ) is extensively stripped but remains attached to the most common cause of shoulder labral tear common. Fracture or a thickened middle GHL at the 3-6 o'clock position where the biceps tendon or both thickened ligament... And tears riding humeral head ( arrow ) is extensively stripped but remains attached the. Fuse will result in an os acromiale is best seen on the superior axial images as joint instability often... Pathology may be added to the office with vague, deep shoulder pain and range-of-motion problems in the o'clock... Confused with a full thickness tear, infraspinatus and teres minor muscle to confirm these findings even greater mobility the... 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