Shoulder Flashcards
Name minor criteria for rotator cuff tears
Intra or extra-articular fluid
Abnormal contour of the sub deltoid bursa
Elevation of the numeral head
Calcification tendinitis
Name the major indicators of a rotator cuff tear
1-Complete non visualisation of the cuff
2-Localised or focal no visualisation of the cuff
3-Discontinuity of the cuff
4-Abnormal cuff echogenicity
Name cause for shoulder pain other then tears
Cervical root compression ACJ inflammation Bursitis Fractures Adhesive capsulitis Glenoid Labral tears
Describe adhesive capsulitis
Insidious syndrome of shoulder pain and restricted movement in the abscence of shoulder impingement and rotator cuff injury.
Loss of movement particularly arm elevation and external rotation.
Hypervascularity leading to synovial proliferation followed by deposition of collagen and the formation of capsular adhesions leading to reduced articular volume and as a consequence to pain and severely restricted joint motion
U/S normal tendons, thickening of the soft tissue structures in the rotator cuff interval and increased vascularity.
Mild fluid distension of the biceps sheath and subscapular recess are seen.
What is a McLaughlin fracture
This occurs on the anteromedial aspect of the humeral head as a result of the impaction of the humerus against the anterior rim of the glenoid fossa.
What is a Hill-Sachs lesion?
This is a depressed inter articular compression fracture located on the posteriorlateral aspect of the humeral head typically occurs after anterior glenohumeral dislocation
Suprascapular nerve
Paralabral cysts found at the spinoglenoid or supra scapular notch can cause compression of the supra scapular nerve
What is the reflection pulley comprised of
It is formed by the SGHL, CHL.
It is a hypoechoic region seen adjacent to the BT at the rotator cuff interval, separating the supraspinatus and Subscapularis tendons
These ligaments can become thickened and hyperaemic in cases of adhesive capsulitis and can also rupture in the case of a dislocated or subluxing biceps.
Describe the subscapular is tendon
O-subscapular is fossa on the anterior surface of the scapula
I- lesser tuberosity of the humerus
A-medially rotates arm, stabilises GHJ
N-Subscapularis N
Describe the triceps brachii tendon
LH- infra glenoid tubercle of scapula
Lateral Head - upper half of the posterior shaft of humerus
Medial Head- posterior surface of the lower humeral shaft
I- posterior part of the olecranon process of the ulna
A-extends forearm
N-Radial N
Describe the Biceps Tendon
Origin LH- supraglenoid tubercle of the scapula SH-coracoid process of the scapula Insertion - tuberosity of radius, bidi petal aponeurosis into deep fascia on the medial part of forearm A-flexes forearm
Describe the Bracialis tendon
O-anterior lower half of humerus
I- tuberosity of ulna
A-flexes forearm
Describe the supraspinatus
O-supraspinatus fossa of scapula
I- the greater tuberosity of the humerus, some fibres into the shoulder capsule
A- assists deltoid in abduction, also stabilises the GHJ and draws the humerus towards the glenoid fossa
N- subscapular N
Describe the infraspinatus tendon
O-the infraspinatus fossa of the posterior surface of the scapula
I- middle facet of the GT of humerus
A- draws humerus towards the glenoid fossa to prevent posterior dislocation
N- subscapular
What is inpingement syndrome ?
-during forward flexion and abduction the supraspinatus depresses the humerus thereby stabilising the humeral head in the glenoid
-without this the humeral head will be uplifted by deltoid contraction causing inpingement of the supraspinatus and the bursa against one or more components of the acromian arch
A thickened bursa will bunch up under the coracoacromial ligament with abduction
What pathology should be looked for in the infraspinatus tendon view?
Tears
Tendinosis
Calcification
Hills-sach deformity
Describe the trapezius
O-occipital protuberance, spinous processes of all 7 C and T spine
I- upper lateral third of clavicle, lower portion of crest of scapula spine
A- extends arm
N- C3,C4
Describe the Deltoid
O-anterior -portion lateral third of clavicle
Mid-lateral border of acromian
Post- crest of spine of scapula
I- deltoid tuberosity mid shaft of humerus
A-abducts, medially rotates
N- Axillary N
Describe the coracohumeral ligament
It extends from the coracoid process of the scapula to the greater tuberosity of the humerus
Describe the coraco-acromial ligament
This extends between the lateral end of the acromion to the coracoid process of the scapula
Describe the stages of calcification Tendinopathy
Stage 1-silent formative stage
-calcium deposits within the tendon is sharpley defined and symptoms minimal.
U/S-hypoechoic focus with a well defined shadow
Stage2-Mechanical or resistive phase
Deposits liquefy and is radio graphically less well defined
U/S-hyperechoic focus with a faint shadow
Stage 3- adhesive peri arthritis
Calcium deposits are associated with adhesive bursitis
Diminished range of movement and pain
Can be aspirated with u/s guidance
U/S- hyperechoic focus with no shadow
Describe Pectoralis Major
O-clavicular part- medial half of clavicle
Sternocostal part- sternum upper 6 costal cartilages, aponeurosis of external oblique
I-lateral lip of bicipital groove of humerus, crest below GT of the humerus
A- ad ducts, medially rotates arm
What makes up the rotator cuff?
Formed by the confluence of tendons ( supraspinatus, Subscapularis, infraspinatus and Teres minor). The joint capsule, the coracohumeral and glenohumeral ligament complexes all of which blend before inserting onto the humeral tuberosities
Describe cuff tear arthropathy
Due to medial retraction of the torn thinned tendons and contraction of the deltoid muscle cause upward displacement of the humeral head causing increased conflict between humeral head and acromion. Considered an end stage irreversible destructive arthropathy
Where is the transverse humeral ligament?
It is located inferior to the reflection pulley and holds the biceps tendon within the bicipital groove
Where is the subacromial deltoid bursa?
It lies superficial to the subscapular tendon
What is the rotator cuff interval?
The rotator cuff interval is the space between the BT and the supraspinatus tendon it appears as a hypoechoic gap and can be mistaken for a tear.
Where is the spinoglenoid notch?
It is formed by the lateral margin of the spine of the scapula and the dorsal surface of the neck of the scapula. Look for ganglia in this area.
What is the suprascapular notch?
It is a small indention on the superior border of the scapula. It is used to assess the supraspinatus muscle for atrophy.
Also large tears can be retracted back to the muscle and seen in this view.
Fluid is more pronounced with the hand on the opposite shoulder.
Also look for any trapezius hypertrophy to compensate for supraspinatus muscle atrophy
Bicep Tendon Pathology
Fluid in sheath- a little can be normal
In proximal 3 cm may be indicative of a joint effusion ( as the sheath is an extension of the joint capsule). Also can be a sign of adhesive capsulitis.
Fluid in sheath and bursa can be an indication of a full thickness tear.
Osteochondral bodies
Tendinopathy, intrasubstance tears, complete tears
Subluxation, dislocation
Subscapularis pathology
Tendinopathy, tendinosis
Partial or full thickness tear
Calcification
Supraspinatus pathology
Tendinopathy, tendinosis- underlying humeral cortex is normal
Calcific tendinitis- calcification May or may not have shadowing
-avulsion fractures can mimic calcification
Partial articular surface tears
Most common- must demonstrate plane in 2 planes
Associated with bony irregularity adjacent to tear
Hypoechoic within the substance of the tendon with/ without a decrease in cuff thickness
Associated with small bicep sheath effusions and small bursal fluid collections
Rim rent tears
Separation of retracted distal segment of the tendon which results in a new interface within the tendon which appears as a linear echogenic focus
Partial busal surface tears
Second most common
Hypoechoic concave defeat located at the bursal surface of the tendon.
Extremely tender with probe pressure
Intrasubstance/ delaminating tears
Small, thin linear hypoechoic defect within the tendon that does not reach either bursal or articular surfaces
Full thickness tear
- focal non- visualisation of tendon
- hernia tigon of the deltoid bursa and muscle into cuff
- direct communication through the tendon gap with a distended sub deltoid bursa
- assess supraspinatus muscle
- tendon may be retracted under the acromion process
- Subscapularis may be involved
- humeral contour may appear rounded in long due to wasting of the GT
- joint and bursal fluid may be present
- on X-ray the humeral head will be subluxed superiorly relative to coracoid and acromial processes
Name the muscles that stabilise the scapula
Trapezius Rhomboideus major Rhomboideus minor Levator scapulae Pectoralis minor Serratus anterior Subclavius
Where are the triceps origins?
LH arises from the scapula the two other lateral and medial heads arise from the humerus. All insert via a common tendon on to thr olecranon process of the ulna.
Brachioradialis
O- lateral distal humerus
I- distal radius
A-flexes the forearm
N- radial N
Biceps pathology
- Fluid in sheath may indicate a joint effusion or adhesive capsulitis. A small amount may be considered normal
- Fluid in sheath and bursa may be indicative of a full thickness tear of the rotator cuff
- osteochondral bodies and synovial cysts of the sheath
- Tendinopathy
- Intrasubstance tears
- Complete rupture of biceps tendon
- Subluxation/ Dislocation
- Speeds test, resistance while flexing the forearm implies bicep injury
- Yergason’s test, hand pronates on thigh with resisted flexion of forearm implies biceps injury
Subscapularis pathology
-Tendinopathy/Tendinosis
-Partial Tear
-Full thickness tears- biceps tendon dislocation may be associated
-Calcification
Gerbers Test, dorsum of the hand is placed behind the small of the back, pain while pushing away from the body against resistance implies a subscapular tear
Supraspinatus pathology
-Tendinopathy/ Tendinosis , the underlying humeral cortex is normal
-Calcific tendinitis, calcification may or may not shadow
An avulsion fracture can mimic rotator cuff calcification
-Partial articular surface tears, most common ( demonstrate in 2 planes)
-rim rent tear
-partial bursal surface tears
- intrasubstance/ delaminating tear
-full thickness tear
-Sepinginous tear
-complete tear
-massive rotator cuff tear
-Tests -empty can test, Arm abducted 90 degrees with full internal rotation against resistance. Pain with this test implies supraspinatus abnormality
All tears must be described as to their position and size in 2 planes and distance from the biceps tendon
Supraspinatus Tendinopathy
Thickened tendon, underlying humeral cortex is normal
Supraspinatus Calcific tendinitis
- Calcification May or may not have a shadow
- Avulsion fracture can mimic rotator cuff calcification
Suprinspatus- partial articular surface tears
- Most common tear in supraspinatus tendon, demonstrate in 2 planes
- Associated with bony irregularity adjacent to tear
- Hypoechoic lesion within the substance of the tendon with or without a decrease in Cuff thickness
- Associated with small bicep sheath effusions and small bursal fluid collections
Supraspinatus - rim rents
-separation of retracted distal segment of the tendon which results in a new interface within the tendon which appears as a linear echogenic focus
Supraspinatus -Partial bursal surface tears
- Second most common tear
- Hypoechoic concave defect located on bursal surface of the tendon
- extremely tender with probe pressure
Supraspinatus- Intrasubstance/delaminating tears
-Small, thin linear hypoechoic defect within the tendon which does not reach either the bursal or articular surfaces
Supraspinatus-Full thickness tear
- Focal non visualisation of supraspinatus tendon
- Herniation of deltoid muscle and bursa in cuff
- Direct joint communication through a tendon gap with a distended sub deltoid bursa
- Always assess supraspinatus muscle. The surgeon needs to know if atrophied and/ or echogenic
Supraspinatus - Sepinginous tear
- An irregular full thickness tear
- May start at the bursal surface anteriorly and extend to the articular surface posteriorly
- on static scanning it may be shown as 3 partial tears, but in real time all 3 tears can be seen to communicate
Supraspinatus - complete tear
- naked tuberosity- no tendon seen covering humeral head, deltoid muscle sits directly on greater tuberosity
- involves the entire supraspinatus tendon from biceps to infraspinatus
- the torn tendon retracts proximally beneath the acromion process
- Subscapularis tendon may be involved
- biceps tendon if intact may be severley degenerated
- humeral contour will appear rounded in the longitudinal view due to wasting of the greater tuberosity
- joint and bursal fluid may be present
- on x-ray the humeral will be subluxed superiorly relative to coracoid and acromial processes.
Supraspinatus - massive tear
Complete tear of supraspinatus plus full thickness tear of infraspinatus and Subscapularis .
Supraspinatus -impingement
-During forward flexion and abduction the supraspinatus depresses the humerus thereby stabilising the humeral head in the glenoid
- Without this counter action, the humeral head will be uplifted by deltoid contraction causing impingement of supraspinatus and the bursa against one or more components of the acromial arch.
-A thickened bursa will bunch up under the coracoacromial ligament with abduction. If the bursa is thickened and is not seen to bunch at first externally rotate the hand and abduct the arm
Hawkins Kennedy test- a test for impingement , arm 90 degrees forward flexion with internal rotation of shoulder
Supraspinatus - post op
- A trough is created in the greater tuberosity where the tendon is reimplanted
- The tendon may be hyperechoic or hypoechoic and thinned compared to the other side
- Sutures will be seen as bright linear reflectors within the tendon extending from the troughs in a taut line along the tendon fibres in the longitudinal view. In transverse the sutures will appear as echogenic foci within the tendon
- In a retorn supraspinatus the sutures will appear wavy rather than taut and fluid will be seen in the tendon gap
- In some cases the bursa is resected therefore the peribursal fat stripe will not be visualised
Adhesive capsulitis
- Also termed a frozen shoulder
- the tendons will appear normal on ultrasound but the patient will have limited external rotation and abduction
- The coracohumeral ligament will appear thickened and hyperaemia will be seen along the CHL overlying proximal Subscapularis
ACJ
-Capsular hypertrophy - joint capsule distended by haematoma or fluid
-Geyser Sign - gross distension of joint, visible movement of debris within the joint with passive movement of forward flexion
-ganglion- cystic structures arising from ACJ, may be visible and non tender, “lump” may lie anterior to joint
Subluxation - separation of acromion from clavicle during forward flexion
Infraspinatus pathology
- Tears
- Tendinosis
- Calcification
- Hill Sachs lesion, bony depression in normally rounded contour of humeral head at the level of the infraspinatus insertion
Glenoid Labrum pathology
-Joint effusions
-Loose bodies
The hypoechoic line of the articular cartilage is closely aligned to the humeral head. If a joint effusion is present, when the patient externally rotates the arm, fluid will be seen to leak out of the joint
Spinoglenoid notch pathology
- Ganglia
- the notch is formed by the lateral margin of the spine of the scapula and the dorsal surface of the neck of the scapula
Supra scapular notch pathology
- look at echogenicity of supraspinatus muscle, compare with the contralateral side
- large tears may be seen retracting into muscle belly
Suprascapular Nerve Compression
- Ganglia pressing on nerve
- Fracture of scapula
Teres minor
Rarely has pathology
Deltoid muscle pathology
- Strain - focal area of hyperechoic muscle
- Tears
Masses
Ganglia
Lipomas
Trapezius pathology
Tears
Shoulder fractures
Step down deformity seen in bony contour
Pectoral us pathology
Tears may be seen at the insertion
Symptoms of Tendinopathy/Bursitis
- Night pain
- Progressive pain
- Pain with over head activities
- Pain over anterlateral part of shoulder and down arm into elbow
- Post traumatic continued pain
- activities less than 90 degrees pain free
Tears symptoms
- movement and strength is most affected with abduction, forward flexion, internal and external rotation
- some full thickness tears are asymptomatic
Adhesive capsulitis symptoms
- Marked limitation of all movements, abduction , forward flexion , internal and external rotation, both passive and active
- Past history of minor trauma or surgery
Calcific Tendinopathy symptoms
Pain on rest and movement
One third of cases are a symptomatic
Glenoid Labral Tears Symptoms
- Poorly localised pain in shoulder exacerbated by overhead and behind the back motions eg putting on seatbelt, reaching into back of car
- Popping, clicking or grinding may be present
- Patient may be tender over anterior shoulder and experience pain on resisted biceps contraction
