MR MR arthrography of arthrography of the shoulder:the shoulder:Techniques and role in Techniques and role in diagnosis of rotator diagnosis of rotator cuff and labral cuff and labral pathologypathology

Werner Werner HarmseHarmse

July 2011July 2011

MR shoulder MR shoulder arthrogramarthrogram Technique whereby injection of contrast Technique whereby injection of contrast

media into the joint allows for evaluation media into the joint allows for evaluation of capsule and internal joint structures.of capsule and internal joint structures.

Originally performed using plain Originally performed using plain radiography.radiography.

Now injection of gadolinium allows MR Now injection of gadolinium allows MR arthrography.arthrography.

CT arthrograms can also be performed.CT arthrograms can also be performed.

TechniqueTechnique

Fluoroscopically guided anterior Fluoroscopically guided anterior approach is most widely performed.approach is most widely performed.

Perform routine preparationPerform routine preparation– Correct patientCorrect patient– Correct sideCorrect side– No iodine allergiesNo iodine allergies– Explain procedure to patient. ? Informed Explain procedure to patient. ? Informed

consentconsent– Confirm indication Confirm indication

IndicationsIndications

Assessment of integrity of rotator Assessment of integrity of rotator cuffcuff

Evaluation of shoulder instabilityEvaluation of shoulder instability Diagnosis of labral pathologyDiagnosis of labral pathology Diagnosis of adhesive capsulitisDiagnosis of adhesive capsulitis

TechniqueTechnique

Sterile procedureSterile procedure Fluoroscopically guidedFluoroscopically guided Obtain control images of shoulderObtain control images of shoulder

– Patient supine, AP viewPatient supine, AP view– Arm in external and internal rotationArm in external and internal rotation– Angle tube to view acromion in profile – Angle tube to view acromion in profile –

clear visualisation of sub-acromial spaceclear visualisation of sub-acromial space– Evaluate for calcium deposition in Evaluate for calcium deposition in

tendonstendons

PositioningPositioning

Supine position creates Supine position creates oblique orientation of oblique orientation of glenoid surface.glenoid surface.

Posterior glenoid overlaps Posterior glenoid overlaps humeral headhumeral head

Anterior glenoid is however Anterior glenoid is however medial of humeral head.medial of humeral head.

Thus needle directed AP at Thus needle directed AP at humeral head will not humeral head will not injure anterior labruminjure anterior labrum

External rotation exposes a External rotation exposes a larger articular surface larger articular surface anteriorlyanteriorly

Placing a sandbag in the Placing a sandbag in the patient’s hand may help patient’s hand may help maintain the positionmaintain the position

TechniqueTechnique

Determine skin entry Determine skin entry sitesite

Just lateral to the medial Just lateral to the medial cortex of the humeral cortex of the humeral head (never medial)head (never medial)

At junction of middle At junction of middle and lower thirdand lower third

Ideally central in Ideally central in fluoroscopic imagefluoroscopic image

Locally anaethetise skin Locally anaethetise skin and sub-cutaneous and sub-cutaneous tissue tissue

TechniqueTechnique

Prepare contrast whilst allowing local anaestethic to Prepare contrast whilst allowing local anaestethic to take effect (can also be done before procedure starts)take effect (can also be done before procedure starts)

Our protocol:Our protocol:– 20 ml syringe20 ml syringe– 10 ml sterile water10 ml sterile water– 5 ml iodine based non-ionic LOCM (eg.Ultravist)5 ml iodine based non-ionic LOCM (eg.Ultravist)– 5 ml lignocaine5 ml lignocaine– 0.1 ml gadolinium0.1 ml gadolinium

Other:Other:– Test injection with 1-2 ml of lignocaineTest injection with 1-2 ml of lignocaine– Contrast: 10 ml saline, 10 ml Iodine LOCM, 0.1 ml Contrast: 10 ml saline, 10 ml Iodine LOCM, 0.1 ml

gadolinium, 0.3 ml 1:1000 adrenalinegadolinium, 0.3 ml 1:1000 adrenaline Syringe connected to connecting catheter(line)Syringe connected to connecting catheter(line)

TechniqueTechnique

Advance needle (usually 20G Advance needle (usually 20G spinal needle with stylet) in spinal needle with stylet) in direct AP direction direct AP direction posteriorly.posteriorly.

Continue until contact with Continue until contact with humeral head.humeral head.

Consider test injection with Consider test injection with lignocaine.lignocaine.

Should only meet low Should only meet low resistance when in joint resistance when in joint spacespace

If high resistance – possibly If high resistance – possibly in hyaline cartilige – carefully in hyaline cartilige – carefully manipulate needle by manipulate needle by rotation and minimal rotation and minimal retraction (few mm)retraction (few mm)

Loss of resistance indicates Loss of resistance indicates intra-articular or bursal intra-articular or bursal locationlocation

TechniqueTechnique

Inject iodinated contrast Inject iodinated contrast to distinguish between to distinguish between intra-articular and bursal intra-articular and bursal locationlocation

Intra-articular contrast Intra-articular contrast will collect in gleno-will collect in gleno-humeral joint spacehumeral joint space

If intra-articular position If intra-articular position is confirmed – continue is confirmed – continue with proper contrast with proper contrast injectioninjection

Usually inject between Usually inject between 14 – 16 ml of contrast, 14 – 16 ml of contrast, depending on patient depending on patient and pathology.and pathology.

AdvantagesAdvantages

Joint distension, outlining intra-Joint distension, outlining intra-articular structuresarticular structures

Improved detection of tears, Improved detection of tears, including articular surface partial including articular surface partial tearstears

Demonstration of communication Demonstration of communication between joint and extra-articular between joint and extra-articular abnormalities eg. Paralabral cysts abnormalities eg. Paralabral cysts and bursae.and bursae.

Disadvantages and Disadvantages and pitfallspitfalls Risks assoc with needle placement into Risks assoc with needle placement into

joint: infection, haemorrhage, synovial joint: infection, haemorrhage, synovial reaction.reaction.

Avoid oblique position – glenoid in Avoid oblique position – glenoid in profile – aiming for joint space places profile – aiming for joint space places the labrum at riskthe labrum at risk

Correct needle positioning is essentialCorrect needle positioning is essential– Extra articular contrast can complicate Extra articular contrast can complicate

findings on MR and simulate tearsfindings on MR and simulate tears

Posterior approachPosterior approach

When suspecting anterior pathology. When suspecting anterior pathology. AAvoids the interpretative difficulties that may be voids the interpretative difficulties that may be

associated with anterior extracapsular contrast associated with anterior extracapsular contrast extravasation extravasation

Aim for the Aim for the inferomedial quadrant of humeral head inferomedial quadrant of humeral head within boundary of anatomic neck (within boundary of anatomic neck (interrupted lineinterrupted line). ).

Other techniquesOther techniques

Advance needle with Advance needle with stylet removed and stylet removed and lignocaine placed in lignocaine placed in needle hub – drop in needle hub – drop in fluid level indicates fluid level indicates intra-articular intra-articular positionposition

Internal rotation Internal rotation when needle against when needle against humeral head – humeral head – facilitates intra-facilitates intra-articular placementarticular placement

Ultrasound guided Ultrasound guided approachapproach

MR techniqueMR technique

Three plane T1 with fat satThree plane T1 with fat sat T2 with fat sat axial and coronal oblique (Consider T2 with fat sat axial and coronal oblique (Consider

Ax GRE to evaluate for calcification)Ax GRE to evaluate for calcification) Sagittal oblique T1/PD without fat suppressionSagittal oblique T1/PD without fat suppression Some protocols suggest pre contrast T2 Some protocols suggest pre contrast T2

sequences. sequences. – Detection of intra-substance and bursal surface tears.Detection of intra-substance and bursal surface tears.– Pre-existing fluid collections and cystsPre-existing fluid collections and cysts

Coronal oblique parallel to supraspinatus tendon Coronal oblique parallel to supraspinatus tendon (not muscle)(not muscle)

Sagittal oblique perpendicular to glenoid surfaceSagittal oblique perpendicular to glenoid surface (ABER – Abduction and External rotation (ABER – Abduction and External rotation

sometimes used for evaluation of anterior and sometimes used for evaluation of anterior and inferior GHLs)inferior GHLs)

Other techniquesOther techniques

Inject only water, no gadoliniumInject only water, no gadolinium– Achieves effect of distensionAchieves effect of distension– Need to use T2 sequencesNeed to use T2 sequences– Difficult to distinguish between small full thickness Difficult to distinguish between small full thickness

and partial tearsand partial tears Indirect arthrogramIndirect arthrogram

– 1 mmol/kg Gd IV1 mmol/kg Gd IV– Exercise joint for 5 to 5 minutesExercise joint for 5 to 5 minutes– Gd passes into joint spaceGd passes into joint space– Can perform T1 imagesCan perform T1 images– Joint however not distendedJoint however not distended– Beware – extra-articular structures will also enhanceBeware – extra-articular structures will also enhance

Rotator cuff tearsRotator cuff tears

Arthrography improves detection of Arthrography improves detection of tears as the joint is being distended tears as the joint is being distended and contrast forced into small defects.and contrast forced into small defects.

T1 (quicker) sequences with improved T1 (quicker) sequences with improved SNR can be usedSNR can be used

Diagnoses full thickness tears and Diagnoses full thickness tears and articular surface partial thickness teararticular surface partial thickness tear

Not of value in intra-substance or Not of value in intra-substance or bursal surface partial thickness tearsbursal surface partial thickness tears

Full-thickness tear will demonstrate the Full-thickness tear will demonstrate the gadolinium contrast solution extending gadolinium contrast solution extending first through a defect in the cuff and then first through a defect in the cuff and then into the subacromial-subdeltoid bursa.into the subacromial-subdeltoid bursa.

Articular-surface partial-thickness tears Articular-surface partial-thickness tears show a focal extension of the contrast show a focal extension of the contrast solution into the substance of the tendon.solution into the substance of the tendon.

Fat suppression is necessary as Fat suppression is necessary as peribursal fat may mimic contrast. peribursal fat may mimic contrast.

Full thickness rotator cuff tear with contrast extending through the supraspinatus tendon into the sub-acromial sub-deltoid bursa.

(A) T1-weighted image with fat saturation and (B) T2-weighted image with fat saturation depict contrast within the joint (yellow arrows). Note the presence of contrast within the subacromial-subdeltoid bursa (red arrows) due to the full-thickness tear within the distal supraspinatus tendon (green arrow)

Full thickness tearFull thickness tear

A) T1-weighted image with fat saturation and (B) T2-weighted image with fat saturation depict a partial-thickness articular surface tear (red arrows) of the supraspinatus tendon. Contrast enters the tear, and the tear is seen as a hyperintense area on both pulse sequences. Although there is a small amount of hyperintense fluid in the subacromial-subdeltoid bursa on the T2-weighted image, no contrast enters the bursa.

Partial thickness tear articular Partial thickness tear articular surfacesurface

Intra substance tearIntra substance tear

(A) T1-weighted image with fat saturation and (B) T2-weighted image with fat saturation depict contrast within the joint (yellow arrows). Note the intrasubstance tear (red arrow) of the distal supraspinatus tendon, seen as a hyperintense zone on the T2-weighted image. Note that contrast does not enter this area since the tear does not communicate with the articular surface of the tendon. There is hyperintense fluid in the subacromial-subdeltoid bursa on the T2-weighted image, but this area is hypointense on the T1-weighted image. This fluid should not be confused with contrast in the bursa.

Subscapularis tendonSubscapularis tendon Subscapularis tendon tears are common. Subscapularis tendon tears are common. They can result from acute trauma on an adducted arm in hyperextension They can result from acute trauma on an adducted arm in hyperextension

or in external rotation. They can result from an anterior shoulder or in external rotation. They can result from an anterior shoulder dislocation, they can be associated with massive tears of the rotator cuff dislocation, they can be associated with massive tears of the rotator cuff and with biceps tendon dislocations, or they can result from subcoracoid and with biceps tendon dislocations, or they can result from subcoracoid impingement. impingement.

Tears of the subscapularis tendon are best evaluated on axial MRIs, where Tears of the subscapularis tendon are best evaluated on axial MRIs, where the entire length of the tendon is evident or on sagittal images. the entire length of the tendon is evident or on sagittal images.

The tears are seen best on T2W images or on T1W images after intra-The tears are seen best on T2W images or on T1W images after intra-articular gadolinium injection. articular gadolinium injection.

Tears may be seen as tendon discontinuity, contrast media entering into Tears may be seen as tendon discontinuity, contrast media entering into the tendon substance, intrasubstance abnormal tendon signal, abnormal the tendon substance, intrasubstance abnormal tendon signal, abnormal caliber of the tendon, and abnormal position of the tendon. caliber of the tendon, and abnormal position of the tendon.

Other helpful accessory signs are the leakage of intra-articular contrast Other helpful accessory signs are the leakage of intra-articular contrast material under the insertion of the subscapularis tendon onto the lesser material under the insertion of the subscapularis tendon onto the lesser tuberosity and fatty atrophy of the subscapularis muscle, usually localized tuberosity and fatty atrophy of the subscapularis muscle, usually localized at the cranial aspect of the muscle and seen as high signal intensity at the cranial aspect of the muscle and seen as high signal intensity streaks on T1W images. streaks on T1W images.

Abnormalities in the course of the long head of the biceps tendon Abnormalities in the course of the long head of the biceps tendon (subluxation or dislocation) usually are associated with subscapularis (subluxation or dislocation) usually are associated with subscapularis tendon tears. They often extend into the subscapularis muscle.tendon tears. They often extend into the subscapularis muscle.

A, T1 fat-suppressed axial shoulder MR arthrogram. The bicipital groove is empty. The biceps tendon (arrowhead) is located over the anterior glenohumeral joint and posterior to the subscapularis tendon (arrow), which has been avulsed from its attachment to the lesser tuberosity of the humerus. B, T1 fat-suppressed coronal oblique shoulder MR arthrogram. The biceps tendon (arrowheads) is dislocated medially overlying the shoulder joint.

Labral anatomy and Labral anatomy and pathologypathology The glenoid labrum is a The glenoid labrum is a

fibrocartilaginous structure fibrocartilaginous structure that attaches to the that attaches to the glenoid rim and is about 4 glenoid rim and is about 4 mm wide. mm wide.

Anteriorly, the glenoid Anteriorly, the glenoid labrum blends with the labrum blends with the anterior band of the anterior band of the inferior glenohumeral inferior glenohumeral ligament. Superiorly, it ligament. Superiorly, it blends with the biceps blends with the biceps tendon and the superior tendon and the superior glenohumeral ligament. glenohumeral ligament.

It is usually rounded or It is usually rounded or triangular on cross-triangular on cross-sectional images.sectional images.

VariantsVariants Sublabral recessSublabral recess 12’o clock12’o clock

Sub-labral foramenSub-labral foramen

2’o clock position. Anterior to biceps tendon2’o clock position. Anterior to biceps tendon

Buford complexBuford complex

Cord-like Cord-like thickening of thickening of middle middle glenohumeral glenohumeral ligament with ligament with absence of absence of anterior superior anterior superior labrum.labrum.

Anterior labrumAnterior labrum

Bankart lesionBankart lesion

The Bankart lesion is the most The Bankart lesion is the most common injury following anterior common injury following anterior dislocation of the glenohumeral joint. dislocation of the glenohumeral joint.

It is a detachment of the anteroinferior It is a detachment of the anteroinferior labrum (with or without labral tears) labrum (with or without labral tears) from the glenoid with a tear of the from the glenoid with a tear of the anterior scapular periosteum anterior scapular periosteum

The Bankart lesion may or may not be The Bankart lesion may or may not be associated with a fracture of the associated with a fracture of the anteroinferior glenoid.anteroinferior glenoid.

Bankart lesionsBankart lesions

A, T1 fat-suppressed axial shoulder MR arthrogram. The anteroinferior labrum is detached from the glenoid (arrowhead) and is irregular in shape and high signal from tears. There is no linear periosteum seen attached to the labrum because it has been torn. The flat posterolateral humerus in the lower portion of the joint is normal and not from a Hill-Sachs impaction fracture. B, T1 fat-suppressed axial shoulder MR arthrogram (different patient than in A). The anteroinferior labrum is absent from its normal position adjacent to the glenoid; it has been completely detached and torn free of the scapular periosteum, coming to rest in the medial aspect of the joint (open arrow).

ALPSA [anterior ALPSA [anterior labroligamentous periosteal labroligamentous periosteal sleeve avulsion] sleeve avulsion] Variant of Variant of

Bankart.Bankart. Periosteum Periosteum

stripped from stripped from scapula, not torn.scapula, not torn.

Potential of Potential of healing if healing if reducedreduced

GLAD (Gleno-labral GLAD (Gleno-labral articular disruption) articular disruption) lesionlesion GLAD refers to a nondisplaced anteroinferior GLAD refers to a nondisplaced anteroinferior

labral tear with an associated chondral injury labral tear with an associated chondral injury This lesion results more from an impaction This lesion results more from an impaction

type of injury, rather than a shearing injury, type of injury, rather than a shearing injury, as occurs with Bankart lesions. as occurs with Bankart lesions.

The labrum remains attached to the anterior The labrum remains attached to the anterior scapular periosteum, distinguishing this from scapular periosteum, distinguishing this from a Bankart lesion, which has a torn a Bankart lesion, which has a torn periosteum. periosteum.

On MR arthrography, contrast material On MR arthrography, contrast material extends into the cartilaginous defect. extends into the cartilaginous defect.

These patients complain of pain rather than These patients complain of pain rather than instability. instability.

Anterior labral lesionsAnterior labral lesions

SLAP SLAP (Superior Labrum Anterior to Posterior)(Superior Labrum Anterior to Posterior) lesionslesions

SLAPSLAP

SLAPSLAP

The inferior glenohumeral ligament is the ligament most The inferior glenohumeral ligament is the ligament most frequently affected with instability. frequently affected with instability.

It may be affected at its labral or its humeral attachment. It may be affected at its labral or its humeral attachment. Avulsion of the inferior glenohumeral ligament from the Avulsion of the inferior glenohumeral ligament from the

humerus, called a humerus, called a HAGL lesionHAGL lesion (humeral avulsion of the (humeral avulsion of the glenohumeral ligament), may result from shoulder dislocation. glenohumeral ligament), may result from shoulder dislocation.

It often is associated with a tear of the subscapularis tendon. It often is associated with a tear of the subscapularis tendon. HAGL lesions can be identified on axial, coronal, or sagittal HAGL lesions can be identified on axial, coronal, or sagittal

MRIs MRIs The inferior glenohumeral ligament may show high signal The inferior glenohumeral ligament may show high signal

intensity on T2 images, and may show morphologic disruption intensity on T2 images, and may show morphologic disruption at its insertion on the anatomic neck of the humerus and at its insertion on the anatomic neck of the humerus and wavy contours of the residual ligament, and the ligament may wavy contours of the residual ligament, and the ligament may be displaced inferiorly. be displaced inferiorly.

The diagnosis also can be inferred on MR arthrography when The diagnosis also can be inferred on MR arthrography when extravasation of contrast material from the joint occurs in the extravasation of contrast material from the joint occurs in the region of the ligament insertion on the humerus.region of the ligament insertion on the humerus.

HAGLHAGL

A, T1 fat-suppressed coronal oblique shoulder MR arthrogram. The anterior limb of the inferior glenohumeral ligament (arrowhead) is detached from the humerus (arrow) in this patient with a previous anterior dislocation. There also is a bucket-handle superior labral anterior and posterior (SLAP) tear of the superior labrum. B, T1 fat-suppressed sagittal oblique shoulder MR arthrogram (different patient than in A). The anterior limb of the inferior glenohumeral ligament (open arrow) is avulsed from its humeral attachment, is thickened, and is drooping inferiorly (compare with normal posteroinferior glenohumeral ligament [arrowhead]). The patient had several prior dislocations.

Indirect MR Indirect MR arhtrogramarhtrogram

Complete tear of supraspinatus Anterior glenoid labrum tear

Acronyms and Acronyms and Eponyms Related to Eponyms Related to the Shoulderthe Shoulder ALPSA: Anterior labroligamentous periosteal sleeve avulsion. A variation of ALPSA: Anterior labroligamentous periosteal sleeve avulsion. A variation of

the Bankart lesion with injury to the anteroinferior labrum, but the anterior the Bankart lesion with injury to the anteroinferior labrum, but the anterior scapular periosteum is intact.scapular periosteum is intact.

Bankart lesion: Tear of the anteroinferior glenoid labrum with torn anterior Bankart lesion: Tear of the anteroinferior glenoid labrum with torn anterior scapular periosteum. May have an associated fracture of the anteroinferior scapular periosteum. May have an associated fracture of the anteroinferior glenoid rim.glenoid rim.

Bennett lesion: Mineralization of the posterior band of the inferior Bennett lesion: Mineralization of the posterior band of the inferior glenohumeral ligament and posterior capsule from chronic traction forces.glenohumeral ligament and posterior capsule from chronic traction forces.

HAGL lesion: Humeral avulsion of the glenohumeral ligament occurs from HAGL lesion: Humeral avulsion of the glenohumeral ligament occurs from shoulder dislocation with avulsion of the inferior glenohumeral ligament from shoulder dislocation with avulsion of the inferior glenohumeral ligament from the anatomic neck of the humerus.the anatomic neck of the humerus.

BHAGL lesion: Bony HAGL lesion.BHAGL lesion: Bony HAGL lesion. Buford complex: Congenital absence of the anterosuperior glenoid labrum Buford complex: Congenital absence of the anterosuperior glenoid labrum

associated with a thickened middle glenohumeral ligament.associated with a thickened middle glenohumeral ligament. GLAD lesion: Glenolabral articular disruption is a tear of the anteroinferior GLAD lesion: Glenolabral articular disruption is a tear of the anteroinferior

labrum with a glenoid chondral defect.labrum with a glenoid chondral defect. Hill-Sachs lesion: Impaction fracture of the posterolateral aspect of the Hill-Sachs lesion: Impaction fracture of the posterolateral aspect of the

humeral head from anterior shoulder dislocation.humeral head from anterior shoulder dislocation. SLAP lesion: Superior labrum tear propagating anterior and posterior to the SLAP lesion: Superior labrum tear propagating anterior and posterior to the

biceps anchor.biceps anchor. DYN: Drives you nuts.DYN: Drives you nuts.

ReferencesReferences1.1. Jacobson et al. Jacobson et al. Aids to Successful Shoulder Arthrography Aids to Successful Shoulder Arthrography

Performed with a Fluoroscopically Guided Anterior Performed with a Fluoroscopically Guided Anterior Approach. Radiographics. 2003; 23:373–379Approach. Radiographics. 2003; 23:373–379

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4.4. De Maeseneer et al. De Maeseneer et al. CT and MR Arthrography of the Normal CT and MR Arthrography of the Normal and Pathologic Anterosuperior Labrum and Labral-Bicipital and Pathologic Anterosuperior Labrum and Labral-Bicipital Complex. Radiographics. 2000; 20:S67–S81Complex. Radiographics. 2000; 20:S67–S81

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7.7. Tuite et al. Rotator cuff injury MRI. Medscape Reference Tuite et al. Rotator cuff injury MRI. Medscape Reference URL: URL: http://emedicine.medscape.com/article/401714-overviewhttp://emedicine.medscape.com/article/401714-overview

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