shoulder dyslexia: the alphabet soup alison nguyen 4/13/06
DESCRIPTION
Shoulder Dyslexia: The Alphabet Soup Alison Nguyen 4/13/06. Mystery Cases. Case 1. Case 2. Case 3. Case 4. Shoulder Dyslexia: The Alphabet Soup. Shoulder dyslexia: addressing the endless alphabet soup. Ant-inf labrum: -Bankart, Perthes, ALPSA, GLAD Inferior capsule: - PowerPoint PPT PresentationTRANSCRIPT
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Shoulder Dyslexia: Shoulder Dyslexia: The Alphabet SoupThe Alphabet Soup
Alison NguyenAlison Nguyen4/13/064/13/06
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Mystery CasesMystery Cases
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Case 1Case 1
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Case 2Case 2
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Case 3Case 3
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Case 4Case 4
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Shoulder Dyslexia: Shoulder Dyslexia: The Alphabet SoupThe Alphabet Soup
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Shoulder dyslexia: addressing Shoulder dyslexia: addressing the endless alphabet soupthe endless alphabet soup
• Ant-inf labrum: -Bankart, Perthes, ALPSA, GLAD• Inferior capsule:
-HAGL, PHAGL, Axillary pouch injuries• Posterior labrum:
-GARD, GIRD, Kim’s lesion, Bennett lesion
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Shoulder dyslexia: Part 1Shoulder dyslexia: Part 1Ant-Inf LabrumAnt-Inf Labrum
Anterior inferior labral pathology:Consider in anterior shoulder dislocations
Bankart
Perthes
ALPSA
GLAD
Torn labrum, torn periosteum
Torn labrum, stripped but intact periosteum
“Medialized” labrum, intact periosteum
Glenoid labral articular disruption
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GLAD lesionGLAD lesion
• Glenoid Labral Articular Disruption
• Anterior-inferior labral tear involving the adjacent articular cartilage
AXIAL PLANE
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GLADGLAD
Clue: look for disrupted articular cartilage
Not associated w/ ant shoulder disloc/subluxation
Mechanism: Forced adduction of shoulder in ABER position with impaction of HH against glenoid fossa
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Shoulder dyslexia: Part 1Shoulder dyslexia: Part 1Ant-Inf LabrumAnt-Inf Labrum
Anterior inferior labral pathology:Consider in anterior shoulder dislocations
Bankart
Perthes
ALPSA
GLAD
Torn labrum, torn periosteum
Torn labrum, stripped but intact periosteum
“Medialized” labrum, intact periosteum
Glenoid labral articular disruption
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Bankart Lesion Perthes Lesion ALPSA Lesion
Normal Axial Plane
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Hill-Sachs and Bankart LesionsHill-Sachs and Bankart Lesions
18 yo w/ acute shoulder dislocation
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Classic Bankart lesion (case 2)Classic Bankart lesion (case 2)
-Detached ant-inf labrum
-Detached periosteum
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GLOM (glenoid labral ovoid GLOM (glenoid labral ovoid mass) in setting of Bankart lesionmass) in setting of Bankart lesion
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Shoulder dyslexia: Part 1Shoulder dyslexia: Part 1Ant-Inf LabrumAnt-Inf Labrum
Anterior inferior labral pathology:Consider in anterior shoulder dislocations
Bankart
Perthes
ALPSA
GLAD
Torn labrum, torn periosteum
Torn labrum, stripped but intact periosteum
“Medialized” labrum, intact periosteum
Glenoid labral articular disruption
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Perthes LesionPerthes Lesion
• Detached, labro-ligamentous complex
• Medial stripping of anterior scapular periosteum
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Perthes LesionPerthes Lesion
• Sometimes only seen on ABER position
• May look normal on arthroscopy
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Normal vs. Perthes lesionNormal vs. Perthes lesion
Axillary
ABER
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Shoulder dyslexia: Part 1Shoulder dyslexia: Part 1Ant-Inf LabrumAnt-Inf Labrum
Anterior inferior labral pathology:Consider in anterior shoulder dislocations
Bankart
Perthes
ALPSA
GLAD
Torn labrum, torn periosteum
Torn labrum, stripped but intact periosteum
“Medialized” labrum, intact periosteum
Glenoid labral articular disruption
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ALPSA: “medialized Bankart”ALPSA: “medialized Bankart”
• “Differs from the classic Bankart lesion because the avulsed anterior labroligamentous structure is pulled medially by an intact anterior scapular periosteum and eventually heals in this abnormal position, leading to an incompetent anteroinferior glenohumeral ligament. This lesion has been referred to as the medialized Bankart lesion. The significance of the ALPSA lesion to the arthroscopist is that the labrum and attached ligaments, rather than floating free, heal in an abnormal position and eventually resynovialize, and may be difficult to identify as abnormal at the time of arthroscopy”
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Acute ALPSA lesionAcute ALPSA lesion
• Medially/inferiorly displaced, detached anterior labrum
• Intact ant scapular periosteum
MGHL
Torn labrum
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Chronic ALPSA lesionChronic ALPSA lesion
• Thickening, irregularity of anterior medial aspect of capsule-periosteal junction synovialized ALPSA lesion
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ALPSAALPSA
Medially & inferiorly displaced labrum
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ALPSAALPSA
Clue: look for “labral mass” medial and inferior to glenoid.“MEDIALIZED BANKART LESION”
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ALPSA: “Medialized” Bankart ALPSA: “Medialized” Bankart lesion (case 1)lesion (case 1)
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Shoulder Dyslexia, Part IIShoulder Dyslexia, Part IIAxillary SlingAxillary Sling
Axillary Sling/Inferior Capsule
AIGHL:-HAGL
-BHAGL
Axillary Pouch:“hammock”
PIGHL:-PHAGL
CLUE: All have MR@ contrast leakage below the inferior capsule. Look for location to differentiate: anterior, axillary pouch, or posterior
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HAGL PHAGLHAGL PHAGL• Humeral avulsion of
AIGHL• BHAGL (bony
avulsion of AIGHL)• CLUE: arthrogram
contrast extravasation at humeral neck
• Associated w/ subscapularis tendon tears
• Posterior humeral avulsion of PIGHL
• CLUE: arthrogram contrast extravasation at humeral neck
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HAGL (case 3)HAGL (case 3)
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PHAGLPHAGL
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Probable Axillary Probable Axillary Pouch InjuryPouch Injury
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Shoulder Dyslexia, Part IIShoulder Dyslexia, Part IIAxillary SlingAxillary Sling
Axillary Sling/Inferior Capsule
AIGHL:-HAGL
-BHAGL
Axillary Pouch:“hammock”
PIGHL:-PHAGL
CLUE: All have MR@ contrast leakage below the inferior capsule. Look for location to differentiate: anterior, axillary pouch, or posterior
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Shoulder Dyslexia: Part IIIShoulder Dyslexia: Part IIIPosterior Capsule/LabrumPosterior Capsule/Labrum
Posterior capsule/labrum
Kim’s lesion
GIRD
Bennett
GARD
“Cyst” at jxn of cartilage + post labrum
Bone & cartilage disruption at post glenoid rim
Post labrum thickening in throwing shoulder
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Shoulder Dyslexia: Part IIIShoulder Dyslexia: Part IIIPosterior Capsule/LabrumPosterior Capsule/Labrum
Posterior capsule/labrum
GIRD
GARD
Kim’s lesion
Bennett LesionCrescentic bone at post-inf glenoid; EXTRA-articular
“Cyst” at jxn of cartilage + post labrum
Bone & cartilage disruption at post glenoid rim
Post labrum thickening in throwing shoulder
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Bennett lesionBennett lesionMechanism: traction of PIGHL during deceleration phase of pitching
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Bennett lesion: throwing athletes Bennett lesion: throwing athletes (case 4)(case 4)
-“crescentic” bony mineralization at posterior-inferior glenoid rim
-EXTRA-articular posterior capsule avulsive injury
-Assoc w/ posterior labral tears and RCTs
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Shoulder Dyslexia: Part IIIShoulder Dyslexia: Part IIIPosterior Capsule/LabrumPosterior Capsule/Labrum
Posterior capsule/labrum
GIRD
GARD
Kim’s lesion
Bennett LesionCrescentic bone at post-inf glenoid; EXTRA-articular
“Cyst” at jxn of cartilage + post labrum
Bone & cartilage disruption at post glenoid rim
Post labrum thickening in throwing shoulder
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Kim’s LesionKim’s Lesion
Loss of posterior labral height & contour
•Mechanism: force applied in posterior direction.•Force exerted on PIGHL post labral tear, propagating in medial to lateral direction•Preserved chondro-labral junction.
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Shoulder Dyslexia: Part IIIShoulder Dyslexia: Part IIIPosterior Capsule/LabrumPosterior Capsule/Labrum
Posterior capsule/labrum
GIRD
GARD
Kim’s lesion
Bennett LesionCrescentic bone at post-inf glenoid; EXTRA-articular
“Cyst” at jxn of cartilage + post labrum
Bone & cartilage disruption at post glenoid rim
Post labrum thickening in throwing shoulder
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GIRDGIRD
• Glenoid internal rotation deficit• Tight posterior capsule in the throwing
shoulder (ie pitchers)• MRI finding: thickening of the posterior
capsule and labrum
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GIRDGIRD
Images courtesy of Arash Tehranzadeh
Major League Baseball Pitcher ( San Diego Padres)
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Shoulder Dyslexia: Part IIIShoulder Dyslexia: Part IIIPosterior Capsule/LabrumPosterior Capsule/Labrum
Posterior capsule/labrum
GIRD
GARD
Kim’s lesion
Bennett LesionCrescentic bone at post-inf glenoid; EXTRA-articular
“Cyst” at jxn of cartilage + post labrum
Bone & cartilage disruption of post glenoid rim
Post labrum thickening in throwing shoulder
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GARD: glenoid articular rim divotGARD: glenoid articular rim divot22 yo M w/ shoulder impaction injury while weightlifting, w/ posterior labral tear
Displaced posterior labral tear
Osseous defect at posterior glenoid rim
Labral cyst
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GARD vs GLADGARD vs GLAD
Both are similar lesions in different locations!
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Shoulder dyslexia: The alphabet Shoulder dyslexia: The alphabet soupsoup
• Ant-inf labrum: -Bankart, Perthes, ALPSA, GLAD• Inferior capsule:
-HAGL, PHAGL, Axillary pouch injuries
• Posterior capsule/labrum:-GARD, GIRD, Kim’s lesion, Bennett lesion
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The Donald
The Rest of Us
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The MSK Ladies of UCSD
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It’s called the BONE PIT for a reason!!!
The MSK Men of UCSD
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Thank you!Thank you!
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ReferencesReferences• Chung et al. AJR 2004; 183:355-359• Resnick D. Bone and Joint Imaging.• John Hunter's MSK Teaching File • Beltran et al. Shoulder: Labrum and Bicipital Tendon. Topics in Magnetic Resonance Imaging.
14(1): 35–50• Waldt et al. Anterior Shoulder Instability. Radiology 2005; 237:578–583• Parmar H et al: MR Arthrography in Recurrent Anterior Shoulder Instability. J Postgrad
Med 2002;48:270-274• De Maeseneer: J Comput Assist Tomogr, Volume 22(1).January/February 1998.31-34• Sanders et al. The American Journal of Sports Medicine 28:414-434 (2000)
• Kim et al. Arthroscopic Capsulolabroplasty for Posteroinferior Multidirectional Instability of the Shoulder. The American Journal of Sports Medicine 32:594-607 (2004)
• Kim et al. Kim’s lesion: An incomplete and concealed avulsion of the posteroinferior labrum in posterior or multidirectional posteroinferior instability of the shoulder. Arthroscopy: The Journal of Arthroscopic & Related Surgery Volume 20, Issue 7 , September 2004, Pages 712-720
• Nagakawa et al. Posterior shoulder pain. Journal of Shoulder and Elbow Surgery Volume 15, Issue 1 , January-February 2006, Pages 72-77