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England Rugby CPD: Imaging of the Developing Rugby Shoulder

E4f8866a7935b5790f7d6ba2eb3d2ced?s=47 Dr Daniel Fascia
April 17, 2019
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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.

E4f8866a7935b5790f7d6ba2eb3d2ced?s=128

Dr Daniel Fascia

April 17, 2019
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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