England Rugby CPD: Imaging of the Developing Rugby Shoulder

England Rugby held a fantastic CPD day as part of the annual Wellington Festival at Wellington College. This is the presentation I gave on developing rugby shoulder injuries.

Transcript

1. Imaging of the Developing Rugby Shoulder Dr Daniel Fascia Consultant Musculoskeletal Radiologist @danfascia Wellington Festival 2019
2. Case Based Discussion • Acromioclavicular joint injury • Anterior glenohumeral dislocation
3. Case 1: Acromioclavicular Joint
4. AC joint - 17yo - Tackled > lands on shoulder - Pain over ACJ - Increased swelling after D+1 - Scarf test +ve - Focal ACJ pain on examination Questions to address with imaging • Fracture • Dislocation / misalignment • Soft tissue injury • Need for treatment • Prognosis
5. Quick Anatomy Acromioclavicular Joint Coracoclavicular ligament(s) • Conoid • Trapezoid Coracoacromial ligament
6. Imaging Strategy 1. Plain radiography (Clavicle, ACJ, GHJ) a. Fractures b. Dislocations c. Soft tissue swelling (clues) d. Anatomical variation / morphology Views Shoulder / ACJ AP view Clavicle series (supplement above with angled view) Glenohumeral axial Glenohumeral joint (Grashey view) Acute Normal AP Shoulder 11yo Normal Axial
7. AP vs Grashey View - ACJ effect Grashey AP
8. AP vs Grashey View - GHJ effect Grashey AP
9. Imaging Strategy 1. MR Shoulder (wider FOV to include clavicle) a. Bone marrow oedema i. Bruising ii. Fracture (displaced vs trabecular) b. Muscle / Soft tissue oedema i. AC joint capsule oedema / disruption / effusion ii. Coraco-clavicular ligament iii. Coraco-acromial ligament iv. Pectoral attachments Sub Acute
10. Imaging Strategy 1. MR Shoulder (wider FOV to include clavicle) a. Bone marrow oedema i. Bruising ii. Fracture (displaced vs trabecular) b. Muscle / Soft tissue oedema i. AC joint capsule oedema / disruption / effusion ii. Coraco-clavicular ligament iii. Coraco-acromial ligament iv. Pectoral attachments Sub Acute
11. Imaging Strategy 1. MR Shoulder (wider FOV to include clavicle) a. Bone marrow oedema i. Bruising ii. Fracture (displaced vs trabecular) b. Muscle / Soft tissue oedema i. AC joint capsule oedema / disruption / effusion ii. Coraco-clavicular ligament iii. Coraco-acromial ligament iv. Pectoral attachments Sub Acute Clav Apoph Acrom Post Traumatic Apophysitis / Apophysiolysis
12. Imaging Strategy 1. Dynamic radiography “Suspected instability / obvious deformity or piano key sign” a. Relaxed and stressed AC joint views (supervised examination by MSK radiologist) i. Standard unweighted views (Always compare both sides) ii. Stress views (If symptomatic side looks normal unstressed) Experienced Radiographer Needed • Activation of pectoral muscles is a pitfall especially in well built players. • Must be coached to allow the weight to come through the shoulder / AC joint and dangle Clinic Allman & Rockwood Classification
13. Clearly abnormal without stress view NO STRESS
14. Demonstrated only by stress view CONTROL WB NO STRESS
15. Images of reduced and fixed ACJs Lars ligament Arthroscopically assisted dog bone Yorkshire Shoulder Clinic: Mr Charlie Talbot
16. Pitfalls Secondary Ossification Centres From: radsource.us
17. What about Ultrasound for ACJ? - Not diagnostically that useful You might pick up ACJ injury during a shoulder USS - Interventionally useful Injections for ACJ capsulitis Slow to settle… No fracture / displacement shown USS swollen capsule and Doppler vascularity
18. Case 2: Glenohumeral Dislocation
19. Anterior Dislocation - 17yo - Tackled > lands on outstretched arm - Clinically clear dislocation - ED attendance - X-Ray > no # - Reduction Questions to address with imaging • Fracture • Joint congruity (post reduction) • Need for ortho referral • Plan for further imaging
20. Dislocated Reduced
21. You always need a GHJ axial view Dislocated Reduced
22. 1. Plain radiography Pre-dislocation (diagnostic) Whatever view you can achieve… Post-reduction - AP Glenohumeral Joint - Axial or modified axial oblique (pain) Review by experienced skeletal radiologist Imaging Strategy Acute
23. Did you spot the bony Bankart fracture?
24. Did you spot the bony Bankart fracture?
25. Dr Jon Sharpe Consultant MSK Radiologist
26. Assume no fractures post reduction … like our case
27. NORMAL MRI - Image within 2 weeks post dislocation Free auto-arthrogram caused by blood - If it’s no good -> MR Arthrogram MR ARTHROGRAM - Delayed Imaging more likely to go direct to MR Arthrography MRI Scanning Sub Acute Questions to address with MRI/MRA • Sensitive for fracture (bone marrow oedema) • Bankart lesion (bony occult / cartilaginous) • Hill Sachs impaction fracture • Labral injuries (shopping list) • Articular damage • Rotator cuff (tear < contusion) Clinic Debate: 3T non arthrographic?
28. MRI Auto-arthrogram 48hrs post dislocation MRI Arthrogram later VS Anterior Labral Periosteal Sleeve Avulsion (ALPSA) Injury
29. Hill Sachs Bone bruising Flattening of posterosuperior humeral head
30. Bankart Lesions Only Cartilaginous ABER position CT to grade and plan Mixed
31. + Articular cartilage delamination (GLAD)
32. + SLAP tear (+ biceps anchor) Yorkshire Shoulder Clinic: Mr Charlie Talbot
33. Rotator Cuff tears (usually supraspinatus) Normal
34. Rotator Cuff tears (picked up on arthrograms) ABER view excellent for supraspinatus footprint
35. USS vs MRI for rotator cuff Same patient
36. Oddities...
37. USS vs MRI for rotator cuff Footprint intact
38. Posterior Dislocations Modified Axial AP(ish) View Posterior Labral Tear ABER view Lightbulb Sign
39. Inferior dislocation RARE!
40. Young athletes… young normal people
41. Thanks for listening Practical USS shoulder to follow