肩关节失稳和肩袖损失专家讲座.pptx

SHOULDER INSTABILITY AND ROTATOR CUFF INJURIESJ.GARCIA肩关节失稳和肩袖损失第1页INTRODUCTION Shoulder injuries comprise 8-13%of all athletes injuries Result from .repetitive overload activities:swimming,tennis.or direct trauma(collision):football,rugby肩关节失稳和肩袖损失第2页INCIDENCE SPORTS%TYPE OF LESIONS Baseball 11-17 AC,imping.,RC tenditis Wrestling 17 Glenohum sublux or dislocation,AC Tennis 56 RC tendinitis,imping.Volley-ball 44 Biceps tendinitis,imping.Javelin throwers 29 Biceps tendinitis,imping.etc 肩关节失稳和肩袖损失第3页SHOULDER ANATOMY Bones:humeral head and glenoid Cartilage and labrum Capsule and ligaments Muscles BELTRAN 肩关节失稳和肩袖损失第4页PLASTICITY OF LABRUMArticular cartilage,and glenoid labrum.Labrum which have some plasticity seen on different positionsExternal rotation of humerus Internal rotation 肩关节失稳和肩袖损失第5页ANTERIOR CAPSULE INSERTIONType III,the more medial insertion,is prone to anterior glenohumeral instabilityFrom BELTRAN Imaging of orthopedic sports injuries SPRINGER,p 1293 types of insertion肩关节失稳和肩袖损失第6页SHOULDER BIOMECHANICSShoulder is the most mobile joint in the human body Function requires coordinated motion of 4 joints .scapuloclavicular .acromioclavicular .glenohumeral .scapulothoracic 肩关节失稳和肩袖损失第7页SHOULDER BIOMECHANICS Motion 0-180%in elevation internal and external rotation 150%anterior and posterior rotation 170%肩关节失稳和肩袖损失第8页STABILIZING MECHANISMS OF GLENOHUMERAL JOINT PASSIVE MECHANISMS .Size,shape,tilt ot the glenoid fossa .Negative intracapsular pressure .Adhesion,cohesion of articular surfaces .Ligaments and capsule .Glenoid labrum .Oseous bone restraints:acromion,coracoid process肩关节失稳和肩袖损失第9页STABILIZING MECHANISMS OF GLENOHUMERAL JOINT ACTIVE STABILIZING MECHANISMS .long head of the biceps tendon .rotator cuff muscles .subscapularis muscleCoronal SagittalAxial ArthroMR肩关节失稳和肩袖损失第10页VICIOUS CIRCLE OF SHOULDER INJURIESPain occurs in women especially when there is a physiologic instability that may be multidirectional STONE 1994INSTABILITYCOMPRESSIONIMPINGEMENTPAINMUSCULAR IMBALANCEROTATOR CUFFWEAKNESS肩关节失稳和肩袖损失第11页LAXITY vs INSTABILITYDefinitions LAXITY:the ability to passively translate humeral head to the glenoid fossaINSTABILITY:a clinicalcondition in which symptoms are produced by the unwanted translation of the umeral head,giving rise to pain or diminished shoulder function肩关节失稳和肩袖损失第12页SHOULDER INSTABILITY This lecture is mainly devoted to gleno-humeral instability due to time limitations,but DO NOT FORGET please scapular,clavicular,acromio-clavicular,sternoclavicular injuries which are also seen in sports activities肩关节失稳和肩袖损失第13页THE OVERHEAD N THROWING MECHANISMCenter of rotationThe curved harrow represents the path and direction of the greater tuberosity a sthe arm externally rotates BELTRAN 肩关节失稳和肩袖损失第14页IMAGING TECHNIQUES RADIOGRAPHY AP,axial views CT,ARTHRO-CT MRI,ARTHRO-MR肩关节失稳和肩袖损失第15页RADIOGRAPHYAntero-inferior dislocation on AP and Neer views.Axial view is better than Neer to appreciate correctly the humeral head position Axial view肩关节失稳和肩袖损失第16页ARTHRO-CTArthro-CT for staging of lesions after bilateral gleno-humeral dislocation:humeral head bone defects and glenoid lesions肩关节失稳和肩袖损失第17页ARTHRO-MRArthro-MR technique:iodine contrast and diluted Gd.Radiography after fluoscopic guidance and MR(3 planes,T1 w FS and T2w)肩关节失稳和肩袖损失第18页ANTERIOR INSTABILITY More frequent 90%Recurrences 50%In young patients,after trauma肩关节失稳和肩袖损失第19页ABNORMALITIES IN ANTERIOR INSTABILITY Avulsion of gelnoid labrum 75%IGH ligament lesion,HILL-SACHS 50%SLAP lesions 25%Capsule laxity Rotator cuff teras(older patients)20%肩关节失稳和肩袖损失第20页ANTERO-INFERIOR DISLOCATIONFirst episode Third recurrence肩关节失稳和肩袖损失第21页BONE LESIONS AFTER ANTERO-INFERIOR DISLOCATIONDislocation After reduction,Hill Sachs lesion 肩关节失稳和肩袖损失第22页ASSOCIATION OF LESIONSBankart lesion type 4 Hill Sachs lesion(same patient)肩关节失稳和肩袖损失第23页BANKART LESIONSArthro-MR:Bankart type III4 types of Bankart to 1:small,3 severe,4 fracture肩关节失稳和肩袖损失第24页ASSOCIATION OF LESIONS Avulsion,fracture and loose body From BELTRAN,Radiographics 1994,666肩关节失稳和肩袖损失第25页POSTERIOR INSTABILITY Less common 5%Unidirectional is uncommon.Commonly bidirectional(post and inf)or multidirectional In epilepsy,ethanol,elcetricity shock(3 E rule)Also during repetitive applied athletic forces:swimming,throwing,punching,and in sports collision such as football肩关节失稳和肩袖损失第26页POSTERIOR INSTABILITYClinical diagnosis much more difficult than in anterior instabilityImaging techniques are important Especially the first radiographic evaluation is ESSENTIAL 肩关节失稳和肩袖损失第27页POSTERIOR INSTABILITYPosterior dislocation withfracture of anterior aspect of the humeral head(inverse of Hill.Sachs injury)肩关节失稳和肩袖损失第28页POSTERIOR INSTABILITYPosterior dislocation with poteriorBankart From TIRMAN,MRI clinics N Am 1997,883肩关节失稳和肩袖损失第29页MICROINSTABILITY OF SHOULDER Microinstability concerns the 1/3 sup joint in sportmen and sportwomen,especially for risk of SLAP lesions Arthro-MR is superior to native MR for a good staging of lesions,including views in ABER position肩关节失稳和肩袖损失第30页MR in ABER POSITIONFor anterior shoulder instabilityFor capsule and labrum injuries For HILL SACHS injuriesWINTZELL 1998肩关节失稳和肩袖损失第31页MULTIDIRECTIONAL INSTABILITY Instability more than in one direction Antero-inferior,postero-inferior,or 3 directions Often atraumatic(without trauma),or violent injury,or repeated microtrauma肩关节失稳和肩袖损失第32页ISOLATED LABRUM TEARS Tears without instability But source of dysfunction In the athletic population Injury similar to gleno-humeral dislocation Sensation of instability肩关节失稳和肩袖损失第33页LABRUM TEARSSLAP lesion type 2 c,on arthro-MRSLAP=S superior L labrum A anterior P posteriorARTHRO-MR IS THE TECHNIQUE OF CHOICE肩关节失稳和肩袖损失第34页ROTATOR CUFF INJURIES Age is important in shoulder pathology According to Hoffmeyer 30 y.tendinopathies,tears 40 y.tears,perforation 50 y.gleno-humeral osteoarthritis(OA)Med.Hyg 1998,56:2218肩关节失稳和肩袖损失第35页IMPINGEMENT SYNDROME 95%of rotator cuff(RC)lesions,Neer 1972 Mechanical injury from compression of the subacromial structures:Suprasupinatus(SSP)tendon,greater tuberosity of humerus,subacromial bursa 肩关节失稳和肩袖损失第36页SECONDARY IMPINGEMENTIn young patients and athletesinvolved in throwing sports,shoulder impingement can occur with instability肩关节失稳和肩袖损失第37页IMAGING TECHNIQUES RADIOGRAPHY SONOGRAPHY MRI AND ARTHRO-MR肩关节失稳和肩袖损失第38页RADIOGRAPHYAP,neutral rotationInternalrotationExternal rotationNeer view At least AP neutral and Neer views,sometimes int.et ext.rotation!肩关节失稳和肩袖损失第39页SONOGRAPHY Technique.broadband-transducers 5-12 MHz .different types of probe,including typehockey-stick-shaped Multidirectional approach Dynamic and comparative study(both sides)Only perpendicular structures,because obliquity creates artefacts Operator dependant肩关节失稳和肩袖损失第40页SONOGRAPHYESSENTIAL REQUIREMENTS:.personnal experience .rigourous examination .very good knowledge of anatomyPosition of probe for anterior approach of sholuder肩关节失稳和肩袖损失第41页SONOGRAPHY FINDINGSDegenerative suprasupinatus tendon and tearPosttraumatic SSP tear肩关节失稳和肩袖损失第42页SIGNS OF RC TEARS DIRECT SIGNS OF COMPLETE TEAR 1.Flat area,scale of the border 2.Anechoic zone through the tendon 3.Massive thiness of the tendon 4.Tendon invisible INDIRECT SIGNS 1.Erosions of the greater tuberosity 2.Subacromial bursitis,joint fluid 3.Deltoid herniation 4.Muscle atrophy PEETRONS 肩关节失稳和肩袖损失第43页SONOGRAPHY EFFICIENCY IN PARTIAL RC TEARS Sensitivity 93%Specificity 94%HOLSBEECK Mv Radiology 1995,197:443 BUT ONLY BY EXPERIENCED OPERATOR!肩关节失稳和肩袖损失第44页MAGNETIC RESONANCE MR offers a multiplanar approach and a good tissue differenciation(the best)Examination in 3 planes:coronal,sagittal,axial Multiple sequences:PD for anatomy T2 w FS for signal FE 3 D for cartilage Arthro-MR for incomplete tears,labrum tears 肩关节失稳和肩袖损失第45页MAGNETIC RESONANCECoronalAxialSagittal肩关节失稳和肩袖损失第46页ANATOMIC VARIATIONS THAT MAY PREDISPOSE TO IMPINGEMENTAcromial shapeAcromial lateral tiltDiminished arch eightCoracoid lenghtMuscle hypertrophyOs acromialeDisplaced greater tuberosity Acromial shape flat,curved,hocked 肩关节失稳和肩袖损失第47页ACROMIAL SHAPE AND RC TEARSHocked acromion on AP and NEER viewsAtrhro-MR T1 FS:completetear of SSP tendon肩关节失稳和肩袖损失第48页ROTATOR CUFF TEARSFunctional infirmityElevation of R upper limb impossibleArthro-MR:complete tear of SSP tendon wit retraction肩关节失稳和肩袖损失第49页ROTATOR CUFF TEARSDimensions of full thickness tears classified on basis of greatest dimensions Small 5 cm De Orio,Cofield JBJS am 1984,66(4):563肩关节失稳和肩袖损失第50页PARTIAL RC TEARS Inferior SSP tear more common than superior tear Not treated may lead to chronic pain and invalidity May propagate to full thickness tear Grading of partial tears 1.less 3 mm 2.3-6 mm 3.more 6 mm肩关节失稳和肩袖损失第51页PARTIAL RC TEARS Arthro-MR:inferior partial of the suprasupinatus tendon;no perforation,no passage of contrast medium in subacromial bursa肩关节失稳和肩袖损失第52页MULTIPLE RC TEARSSometimes infrasupinatus and subscapularis tears are associated with a suprasupinatus tearA complete good staging is compulsory for choosing the best tt,especially before eventual surgery(which type of surgical repair)For a such evaluation,MR and sometimes arthroMR,are the techniques of choice肩关节失稳和肩袖损失第53页MULTIPLE RC TEARSSuprasupinatus complete tear,retraction of tendon,muscle atrophywith infrasupinatus partial tear and muscle atrophy.Also OA in AC肩关节失稳和肩袖损失第54页EXTENT OF RC TEARSTHOMAZEAUClin Orthop Relat Res 1997,344:275肩关节失稳和肩袖损失第55页MUSCLE ATROPHY Muscle atrophy follows a rotator cuff tear not treatedMuscle atrophy very well appreciated by MRDepends on the lenght of evolution Stage 1.few fatty trails 2.more muscle than fat 3.muscle=fat 4.more fat than muscle After 6 months of evolution stage 2,after 1 year stage 4 Goutalier D Clin Orthop 1994,304:78肩关节失稳和肩袖损失第56页MUSCLE ATROPHYA normal SSP muscle occupy the whole supraspinatus areaWhen atrophy the volume decreased肩关节失稳和肩袖损失第57页ACROMIOCLAVICULAR JOINT INJURIES Very often in looking for an eventual RC tear,an acromioclavicular joint injury is discovered,such as osteoarthritis with bony spurs,and even with an inflammatory component(bone marrow edema,joint fluid,and sometimes a subacromial bursitis)肩关节失稳和肩袖损失第58页ACROMIOCLAVICULAR JOINT INJURIESPD T2w FSOsteoarthritis of the acromioclavicular joint with inflammatory signsand RC impingement肩关节失稳和肩袖损失第59页BICEPS TENDON INJURIES The long tendon of the biceps had an extraarticular portion in the bicipital groove and an intraarticular portion肩关节失稳和肩袖损失第60页BICEPS TENDON INJURIES Injuries of the long tendon of the biceps may mimic a RC impingement Biceps tendon injuries:.tendinopathy .partial thickness tear .complete disruption .dislocation of the extra-articular portion肩关节失稳和肩袖损失第61页BICEPS TENDON INJURIESPossibility of tendon tear Tendinitis:enlargement,increased signal into the tendon肩关节失稳和肩袖损失第62页CONCLUSIONS Shoulder instability and rotator cuff injuries are common in certain sport activities Even a good clinician can not always make a correct and complete diagnosis Therefore imaging techniques have a great role in giving precise informations,concerning the different contributing factors,and allows to choose the best treatement and to precise the procedure when a surgical treatement is on discussion肩关节失稳和肩袖损失第63页