Ovid: Musculoskeletal Imaging Companion

Editors: Berquist, Thomas H.
Title: Musculoskeletal Imaging Companion, 2nd Edition
> Table of Contents > Chapter 7 – Shoulder/Arm

Chapter 7
Thomas H. Berquist


Suggested Reading
Berquist TH. MRI of the musculoskeletal system, 5th ed. Philadelphia: Lippincott Williams & Wilkins; 2006:557–656.


Image Plane Pulse Sequence Thickness/Skip FOV Matrix Acquisitions
3-plane scout Fl 15/5 Three 1-cm sections 24 256 × 192 1
Axial SE 634/16 4 mm/0.5 mm 14 256 × 256 1
Axial GRE 613/19, 20 degrees 4 mm/0 14 256 × 256 1
Oblique coronal FSE PD 2000/19 4 mm/0.5 mm 14 256 × 256 1
Oblique coronal FSE T2 3500/91* 4 mm/0.5 mm 14 256 × 256 1
Oblique sagittal FSE PD 3050/26* 4 mm/0.5 mm 14 256 × 256 2
3-plane scout Fl 15/5 Three 1-cm sections 24 256 × 192 1
Axial SE 500/12* 4 mm/0.5 mm 14 256 × 256 1
Sagittal SE 544/12* 4 mm/0.5 mm 14 256 × 256 1
Oblique coronal SE 525/12* 4 mm/0.5 mm 14 256 × 256 1
Oblique coronal FSE PD 2000/19 4 mm/0.5 mm 14 256 × 256 1
Oblique corona FSE T2 4140.91* 4 mm/0.5 mm 14 256 × 256 1
ABER SE 500/12* 4 mm/0.5 mm 14 256 × 256 1
3-plane scout Fl 15/5 Three 1-cm sections 30–48 256 × 192 1
Axial FSE PD 3050/26 5 mm/0.5 mm 24 256 × 256 1
Axial FSE T2 3500/91 5 mm/0.5 mm 24 256 × 256 1
Coronal or Sagittal SE 634/13 4 mm/0.5 mm 24 256 × 256 1
Brachial Plexus
3-plane scout Fl 15/5 Three 1-cm sections 30–48 256 × 192 1
Coronal bilateral FSE T1 400/17 1.5 mm/0 36 256 × 256 1
Coronal bilateral FSE T2 3500/91 5 mm/1.5 mm 36 256 × 256 1
Axial (right and left) SE 419/17 5 mm/1.5 mm 18 256 × 256 2
Sagittal (right and left) SE 500/13 5 mm/1.5 mm 22 256 × 256 1
Axial bilateral FSE T2 3500/91 5 mm/1.5 mm 36 256 × 256 1
GRE, gradient-recalled echo;
FSE, fast spin-echo; SE, spin-echo; ABER, abducted and externally
rotated; PD, proton density; FOV, field of view.
*fat suppression


Fractures/Dislocations: Proximal Humeral Fractures
Fracture Type Description
One part (80% of cases) No fragment displacement
>1 cm or angulated
>45 degrees
Two part (13% of cases) One fragment displaced
>1 cm or angulated
>45 degrees
Three part (3% of cases) Two fragments displaced or angulated as in “two part”
Four part (4% of cases) Three fragments displaced or angulated as above


FIGURE 7-1 The four parts of proximal humeral fractures.


FIGURE 7-2 AP (A) and axillary (B) views of a comminuted impacted proximal humeral fracture. The fracture is angulated (lines) greater than 45 degrees.


FIGURE 7-3 Four-part fracture with marked displacement of the fragments. The patient was treated with a shoulder prosthesis. AP (A) and axillary (B) views.
Suggested Reading
Berquist TH, De Orio JK. The shoulder. In: Berquist TH, ed. Imaging atlas of orthopedic appliances and prostheses. New York, Raven Press; 1995:661–727.
Neer CS II. Displaced proximal humeral fractures. Part I: Classification and evaluation. J Bone Joint Surg 1970;52A:1077–1089.


Fractures/Dislocations: Glenohumeral Dislocations


FIGURE 7-4 Anterior dislocations. (A) AP radiograph shows an anterior dislocation with fracture fragments laterally. (B) AP postreduction radiograph shows the tuberosity fracture (arrow) and Bankart lesion (open arrow) adjacent to the inferior glenoid. (C) AP radiograph demonstrates an impaction fracture (arrows) or Hill-Sachs lesion in a patient with a prior dislocation.


FIGURE 7-5 Posterior dislocations. (A) AP radiograph showing overlap of the glenoid and humeral head with an anteromedial impaction fracture (arrowheads). The humerus is fixed in internal rotation. (B) Scapular “Y” view clearly showing the posterior dislocation of the humeral head. Axial (C) and sagittal (D) CT images demonstrate the position of the head and the humeral head fracture (arrow).
Suggested Reading
Robinson M, Aderinto J. Recurrent posterior shoulder instability. J Bone Joint Surg 2005;87A:883–892.
Turkel SJ, Pinto MW, Marshall JL, et al. Stabilizing mechanisms preventing anterior dislocation of the glenohumeral joint. J Bone Joint Surg 1981;63A:1208–1217.


Fractures/Dislocations: Acromioclavicular Dislocation
Classification Radiographic Features
Type I, few fibers torn Normal
Type II, rupture of the capsule and AC ligaments Joint widened, clavicle may be slightly subluxed
Type III, same as Type II, but coracoclavicular ligaments also disrupted Elevated clavicle, coracoclavicular space ↑
Type III and V, same as Type III Same as Type III, but posterior clavicular displacement with Type IV and superior with Type V
Type VI, disruption of all ligaments with anterior entrapment Clavicle trapped below coracoid


Acromioclavicular joint injuries. Type I: AC sprain, few fibers torn.
Type II: disruption of the acromioclavicular ligaments with
coracoclavicular ligaments intact. Type III: disruption of the AC and
coracoclavicular ligaments. Type IV: disruption of both ligament
complexes with posterior clavicular displacement. Type V: disruption of
both ligament complexes with marked superior clavicular displacement.
Type VI: disruption of the ligament complexes with anterior entrapment
beneath the coracoid.
Fractures/Dislocations: Acromioclavicular Dislocation


FIGURE 7-7 AC separation. (A) Normal coracoclavicular distance (lines) and slight AC joint widening (open arrow). (B) Weight-bearing stress view of both shoulders showing a coracoclavicular distance of 4 cm and a complete (Type III) separation (right). Note the normal relationship (left).
Suggested Reading
Allman FL. Fractures and ligamentous injuries of the clavicle and its articulations. J Bone Joint Surg 1967;49A:774–784.


Fractures/Dislocations: Sternoclavicular Dislocations
FIGURE 7-8 Axial CT image of an anterior sternoclavicular fracture dislocation (arrow).
Suggested Reading
Nettles JL, Linsheid R. Sternoclavicular dislocations. J Trauma 1968;8:158–164.


Fractures/Dislocations: Clavicle Fractures
FIGURE 7-9 (A) AP radiograph of a minimally displaced fracture of the mid-clavicle (arrow). (B) AP tomogram of a medial clavicular fracture. (C) AP radiograph of a distal clavicular fracture with coracoclavicular ligament disruption (double arrow).
Suggested Reading
Neviaser JS. The treatment of fractures of the clavicle. Surg Clin North Am 1963;43:1555–1563.


Fractures/Dislocations: Posttraumatic Osteolysis


FIGURE 7-10 (A) AP radiograph shows widening of the AC joint with irregularity of the distal clavicle. (B) Stress views of the AC joints show irregularity (arrow) with no displacement. (C) T2-weighted MR image shows increased signal intensity in the distal clavicle (arrow) as the result of edema.
Suggested Reading
Quinn SF, Glass TA. Posttraumatic osteolysis of the clavicle. South Med J 1983;76:307.


Fractures/Dislocations: Scapular Fractures


FIGURE 7-11 Scapular fracture. Axial (A,B), coronal (C), and sagittal (D–F) CT images demonstrate a fracture of the scapular wing involving the spine (open arrow) and glenoid neck (arrow), but sparing the articular surface.


Suggested Reading
Rowe CR. Fractures of the scapula. Surg Clin North Am 1963;43:1565–1571.


Fracture/Dislocations: Humeral Shaft Fractures
FIGURE 7-12 Fractures of the humerus are described by location as upper, middle, or lower third.


Two views of the right humerus in a hanging cast demonstrate a
displaced spiral fracture of the middle third with overriding and
separation of the fragments. This can result in soft tissue
interposition and nonunion. There is also an undisplaced fracture of
the proximal third of the humerus and tuberosity (arrows).
Suggested Reading
Berquist TH, Broderson MP. Humeral shaft. In: Berquist TH, ed. Imaging atlas of orthopedic appliances and prostheses. New York: Raven Press; 1995:729–750.
Kleinerman L. Fractures of the shaft of the humerus. J Bone Joint Surg 1966;48B:105–111.


Rotator Cuff Disease: Basic Concepts
Primary impingement
Abnormal acromial configuration
Acromioclavicular osteophytes
Os acromiale
Thickened coracoacromial ligament
Secondary extrinsic impingement


FIGURE 7-14 (A) Normal AP shoulder radiograph with 11-mm humeroacromial distance, normal greater tuberosity, and acromion (black arrows), and no abnormalities in the AC joint (curved open arrow). (B)
AP radiograph in a patient with a chronic rotator cuff tear. The
humeroacromial space is 5 mm (normal >7 mm). There is a prominent
subacromial osteophyte (black arrow) causing impingement and bony irregularity (open curved arrow) in the greater tuberosity.
Suggested Reading
SM, Shelsy RC, Brown TR, et al. MR imaging of the rotator cuff tendon:
Inter-observer agreement and analysis of interpretive errors. Radiology 1997;204:191–194.
Zlatkin MB. MRI of the shoulder. Philadelphia: Lippincott Williams & Wilkins; 2003.


Rotator Cuff Disease: Impingement
Sagittal illustration demonstrating the capsule, labrum, and
coracoacromial arch (coracoid, coracoacromial ligament, and acromion).


FIGURE 7-16 Impingement syndrome. (A) Sagittal T1-weighted MR image showing hypertrophy of the AC joint (arrows) reducing the humeroacromial space. (B) Sagittal T1-weighted MR image showing an anteriorly angulated acromion with an inferior osteophyte (arrow) causing impingement.
Suggested Reading
ME, Breitenseher MJ, Roposch, et al. Comparison of MRI and conventional
radiography for assessment of acromial shape. AJR Am J Roentgenol 2004;184:671–675.
Neer CS II. Impingement lesions. Clin Orthop 1983;173:70–77.


Rotator Cuff Disease: Rotator Cuff Tears—Complete


FIGURE 7-17 Ultrasound of the rotator cuff. (A) Longitudinal sonogram in a healthy patient shows the echo texture of the supraspinatus (arrowheads). G = greater tuberosity, l = lateral, m = medial. Longitudinal (B) and transverse (C) images in a patient with a large tear from the articular surface to the bursal surface (double arrow). Note the retraction (arrow) of the proximal tendon and debris (arrowheads) within the defect. H = humeral head, D = deltoid, m = medial, l = lateral, a = anterior, p = posterior. (From

Lin J, Jacobson JA, Fessell DP, et al. An illustration tutorial of musculoskeletal sonography. Part II: upper extremity. AJR Am J Roentgenol 2000;175:1071–1079.




FIGURE 7-18 Arthrography. (A) Usual anterior entry site for shoulder arthrography and the rotator cuff interval entry site (+). (B) Normal double-contrast arthrogram with no air or contrast in the subacromial bursa. (C) Single-contrast arthrogram with contrast in the tear and subacromial bursa.


FIGURE 7-19 Coronal MR arthrogram image of a moderate-sized full-thickness rotator cuff tear with retraction (arrow).
Suggested Reading
Carrino JA, McCauley TR, Katz LD, et al. Rotator cuff: Evaluation with fast spin-echo versus conventional spin-echo imaging. Radiology 1997;202:533–539.
H, Bureau NJ, Cardinal E, et al. Arthrography of the shoulder: A simple
fluoroscopically guided approach to target the rotator cuff interval. AJR Am J Roentgenol 2004;182:329–332.
Lin J, Jacobson JA, Fessell DP, et al. An illustrated tutorial of musculoskeletal sonography: Part 2, upper extremity. AJR Am J Roentgenol 2000;175:1071–1079.


Rotator Cuff Disease: Partial Tears


FIGURE 7-20 Ultrasound in a 67-year-old man with a partial tear of the rotator cuff. Longitudinal (A) and transverse (B) images showing a bursal surface tear (black arrows) and intact fibers (white arrows). a = anterior; l = lateral; m = medial; p = posterior. (From

Lin J, Jacobson JA, Fessell DP, et al. An illustrated tutorial of musculoskeletal sonography: Part 2, upper extremity. AJR Am J Roentgenol 2000;175:1071–1079.



FIGURE 7-21 Arthrogram of a partial cuff tear. (A) Routine radiograph showing an erosion (curved arrow) near the greater tuberosity. (B) Arthrogram showing a linear collection of contrast (arrowhead) without communication with the subacromial bursa.
FIGURE 7-22 Sagittal MR arthrogram with T1-weighted sequence showing a large partial tear (arrow).
Suggested Reading
Evanto AM, Stiles RG, Fajman WA, et al. MR imaging diagnosis of rotator cuff tears. AJR Am J Roentgenol 1988;151:751–754.


Lin J, Jacobson JA, Fessell DP, et al. An illustrated tutorial of musculoskeletal sonography: Part 2, upper extremity. AJR Am J Roentgenol 2000;175:1071–1079.
K, Thesing J, Montgomery WJ, et al. MR arthrograph of partial tears of
the undersurface of the rotator cuff: An arthroscopic correlation. Skel Radiol 2004;33:136–141.


Rotator Cuff Disease: Tendinitis/Tendinosis


FIGURE 7-23 Tendinosis. Coronal proton density (A) image shows an area of increased signal intensity in the supraspinatus (arrow). Fast spin-echo T2-weighted MR image with fat suppression (B) shows a focal articular surface partial tear (white arrowhead) with adjacent tendinosis (black arrow). Note the marked hypertrophy of the AC joint (large white arrow).
Suggested Reading
I, Ho CP, Cervilla V, et al. Alterations in supraspinatus tendon at MR
imaging. Correlation with histologic findings in cadavers. Radiology 1991;181:837–841.


Rotator Cuff Disease: Postoperative Changes


FIGURE 7-24 AP radiograph of an arthrogram demonstrating a recurrent tear with contrast in the subdeltoid bursa (arrows). Note the resected clavicle (large arrow).


FIGURE 7-25 (A) Routine radiograph after rotator cuff repairs with resection of the distal clavicle and soft tissue anchors in the humerus. (B) Coronal fast spin-echo fat-suppressed T2-weighted MR arthrogram image shows a recurrent tear (arrows).
Suggested Reading
Rand T, Trattnig S, Breitenseher M, et al. The postoperative shoulder. Top Magn Reson Imaging 1999;10:203–213.
Steinbach LS, Palmer WE, Schweitzer ME. MR arthrography. Radiographics 2002;22:1223–1246.


Instability: Basic Concepts
Suggested Reading
Iannotti JP, Gabriel JP, Schneck SL, et al. The normal glenohumeral relationship. J Bone Joint Surg 1992;74A:491–500.


Instability: Recurrent Subluxation/Dislocations—Capsular Abnormalities
FIGURE 7-26 Axial MR image demonstrating the types of capsular attachment (broken lines): Type I at glenoid margin, Type II just medial to margin, and Type III more than 1 cm beyond the glenoid margin.


FIGURE 7-27 Axial MR arthrogram image in a patient with prior anterior dislocation. There is stripping of the anterior capsule (white arrow) and a labral tear (black arrow) with a complete subscapularis tear.
Multidirectional instability. Stress arthrogram image after prior
anterior repair shows inferior subluxation of the humeral head.


Suggested Reading
Ly JQ, Beall DP, Sanders JG. MR imaging of glenohumeral instability. AJR Am J Roentgenol 2003;181:203–213.
HG, Overgaard B. The anterior capsular mechanism in recurrent anterior
dislocation of the shoulder: Morphological and clinical studies with
special reference to the glenoid labrum and glenohumeral ligaments. J Bone Joint Surg 1962;44:913–927.


Instability: Labral Tears


Sagittal MR arthrogram demonstrating the six labral quadrants: 1,
superior; 2, anterior superior; 3, anterior inferior; 4, inferior; 5,
posterior inferior; 6, posterior superior. Most unstable injuries occur
in segment 3. The lesions may also be described like the face of a


Categories of SLAP lesions: 1, fraying of the superior labrum; 2,
stripping of the superior labrum and biceps tendon from the glenoid; 3,
bucket-handle tear of the labrum and intact biceps tendon; 4,
bucket-handle tear extending into the biceps tendon; 5, Bankart with
superior extension to include the superior labrum and biceps tendon; 6,
anterior and posterior flap tear with superior biceps involvement; 7,
biceps labral complex tear with extension into the middle glenohumeral
ligament; 8, superior labral tear with posterior extension; 9, nearly
complete labral detachment; 10, SLAP with extension of the tear to the
rotator interval and involved structures.


FIGURE 7-31 Axial MR arthrogram image demonstrating an anterior labral tear (arrow).
FIGURE 7-32 Coronal fat-suppressed arthrogram image demonstrating a Type 3 SLAP tear (arrow).


FIGURE 7-33 Perthes lesion. Normal labrum and its insertion (A) and the Perthes lesion (B). Axial MR arthrogram image showing the stripped periosteum (open arrow) and contrast extending under the labrum though position is anatomic.


Suggested Reading
Hunter JC, Blatz, DJ, Escobedo EM. SLAP lesions of the glenoid labrum: CT arthrographic and arthroscopic correlation. Radiology 1992;184:513–518.
MD, Van Roy F, Lenchek L, et al. CT and MR arthrography of the normal
and pathologic interior superior labrum and labral-bicipital complex. Radiographics 2000;20:567–581.
MJ, Cirillo RL, DeSmet AA, et al. Superior labral anterior posterior
tears: Evaluation of three MR signs on T2-weighted sequences. Radiology 2003;215:841–845.


Instability: Humeral Osteochondral Or Ligament Avulsions


FIGURE 7-34 Humeral avulsion of glenohumeral ligament lesion. Axial (A) and coronal (B) MR arthrogram images demonstrate anterior inferior capsular avulsion with a subscapularis tendon tear (arrow).
Suggested Reading
LT, Taylor DC, Uhorchak JM, et al. Humeral avulsion of the glenohumeral
ligament: Imaging features and review of the literature. AJR Am J Roentgenol 2002;179:649–655.


Instability: Posterior Instability
FIGURE 7-35 Axial MR arthrogram image demonstrating a large posterior capsule with glenolabral separation (arrow) and a small paralabral cyst (open arrow).
Suggested Reading
DJ, Ferrari DA, Coumas J, et al. Posterior ossification of the
shoulder: Posterior ossification of the shoulder: The Bennett
lesion-etiology, diagnosis, and treatment. Am J Sports Med 1994;22:171–176.
Yu JS, Ashman OJ, Jones G. The POLPSA lesion: MR arthrography and clinical correlation in 17 patients. Skel Radiol 2002;31;396–399.


Instability: Multidirectional Instability
Multidirectional instability. Axial MR arthrogram image demonstrates
anterior and posterior capsular enlargement with posterior humeral
subluxation. There is a subscapularis tendon tear (arrow).
Suggested Reading
Fischbach TJ, Seeger LL. Magnetic resonance imaging of glenohumeral instability. Top Magn Reson Imaging 1994;6:121–132.


Instability: Labral Variants


FIGURE 7-37 (A) Buford complex with absent anterosuperior labrum and thickening of the middle glenohumeral ligament. (B) Axial MR image demonstrates an absent labrum (white arrow) and thickened middle glenohumeral ligament (black arrow).
Suggested Reading
Neumann CH, Petersen SA, Jahnke AH. MR imaging of the labral-capsular complex: Normal variations. AJR Am J Roentgenol 1991;157:1015–1021.
MJ, Blankenbaker DG, Siefert M, et al. Sublabral foramen and Buford
complex: Inferior extent of the unattached or absent labrum in 50
patients. Radiology 2002;223:137–142.


Biceps Tendon
FIGURE 7-38 Axial (A) and coronal (B) MR arthrogram images showing the normal course and low signal intensity of the long head of the biceps tendon (arrows).



FIGURE 7-39 Coronal (A) axial (B) MR images in a patient with a subscapularis tear and dislocation of the biceps tendon (arrow).


FIGURE 7-40 Axial T1-weighted (A) and sagittal T2-weighted image (B) showing a thinned atrophic biceps tendon (arrow).
Suggested Reading
Tuckman GA. Abnormalities of the long head of the biceps tendon of the shoulder. MR image findings. AJR Am J Roentgenol 1994;163:1183–1188.


Adhesive Capsulitis
FIGURE 7-41 Female with adhesive capsulitis treated with distention arthrography. (A) Initial arthrogram showing a small tight capsule (4 mL injected). (B,C) Increased volumes of contrast mixed with anesthetic showing volume increase (B) and eventual capsular rupture (C), which is the end point of the procedure.


Suggested Reading
Shaffer B, Tibone JE, Kerlan RK. Frozen shoulder. J Bone Joint Surg 1992;74A:738–746.


Nerve Entrapment Syndromes


FIGURE 7-42 Axial T2- (A) and sagittal T1-weighted (B) images demonstrating a ganglion cyst (arrow) compressing the suprascapular nerve.


Suggested Reading
RL, Helms CA. Quadrilateral space syndrome: Incidence of imaging
findings in a population referred for MRI of the shoulder. AJR Am J Roentgenol 2005;184:989–992.
Fritz RC, Helms CA, Steinbach LS, et al. Suprascapular nerve entrapment: Evaluation with MR imaging. Radiology 1992;182:437–444.
Robinson P, White LM, Lax M, et al. Quadrilateral space syndrome caused by glenoid labral cyst. AJR Am J Roentgenol 2000;175:1103–1105.


Infection/Inflammatory Arthropathies
FIGURE 7-43 AP radiograph showing extensive soft tissue calcification caused by peritendinitis.


FIGURE 7-44 Arthrogram showing multiple filling defects (arrows) resulting from synovitis.


FIGURE 7-45 Coronal fat-suppressed T2-weighted MR image in a patient with degenerative arthritis and multiple loose bodies (arrow).
Suggested Reading
Brower AC. Arthritis in black and white. 2nd ed. Philadelphia: WB Saunders; 1997:141–154.


FIGURE 7-46 T1-weighted coronal image of the shoulder showing a low signal intensity line (arrow) defining the margin of the avascular necrosis.


FIGURE 7-47 Lipoma. T1-weighted sagittal (A) and axial (B) images of a large superficial lipoma (arrows).


FIGURE 7-48 Malignant fibrous histiocytoma with soft tissue extension. (A) AP radiograph showing a large irregular lytic area in the humerus (arrows). (B,C) Coronal MR images showing the extent of marrow involvement and soft tissue extension.
Suggested Reading
Unni KK. Dahlin’s bone tumors: General aspects and data on 11,087 cases. 5th ed. Philadelphia: Lippincott-Raven; 1996.


Brachial Plexus
FIGURE 7-49 Anatomic illustration of the brachial plexus.


FIGURE 7-50 Metastatic tumor involving the brachial plexus. Coronal T1-weighted image demonstrates a large mass (arrows) encasing the brachial plexus.
Suggested Reading
Rapaport S, Blair DN, McCarthy SM, et al. Brachial plexus: Correlation of MR imaging with CT and pathologic findings. Radiology 1988;167:161–165.

This website uses cookies to improve your experience. We'll assume you're ok with this, but you can opt-out if you wish. Accept Read More