Am J Roentgenol. Appropriate MR imaging protocols and sequences and applied MR anatomy of the shoulder (including normal variants) are proposed to help assist management and treatment of common shoulder pathologies encountered (such as rotator cuff tears, impingement syndromes, and instability as well as less frequent causes of shoulder pain). The most flexible joint in the entire human body is the shoulder joint; this is due to a synergistic action of four separate articulations: the glenohumeral, acromioclavicular, sternoclavicular, and scapulothoracic joints [2]. There are two main recesses of the capsule, the subscapular recess and the axillary recess (Figure 23). The shoulder joint space is still preserved (red arrow). The different anatomical pitfalls mimicking pathologies are represented in Table 4. The study of Guerini et al., indicates that the supraspinatus tendon may consist of two distinct strings representing the superficial and deep bundles of the tendon. The inferior portion of the joint is also reinforced by fibers of the coracoacromial ligament, which blends with the undersurface of the capsule [2]. Under normal circumstances this bursa does not communicate with the joint space and is not seen on MRI unless it is distended by fluid. All of these cystic lesions were located in lateral humeral heads just posterior to the greater tuberosity (Figs. 2014; 18(4): 374–397. The lesser tuberosity is situated on the anterior portion of the proximal humerus, medial to the greater tuberosity. The biceps pulley, also known as the ‘biceps sling’, is comprised of a combination of the coracohumeral, superior glenohumeral and transverse humeral ligaments. Geodes, also known as a subchondral cysts, are well-defined lytic Subchondral cysts of the humeral head and normal bare area. Different variations in shape are described anteriorly and posteriorly, as triangular (most common), round, cleaved, notched, flat as well as an absent labrum [2, 3, 4]. DOI: https://doi.org/10.2106/JBJS.H.01426, Guerini, H, Fermand, M, Godefroy, D, et al. The surgical neck forms the axial circumference of the humerus immediately inferior to the tuberosities and is often involved in fractures. On sagittal CTA, the ligament appears as a T-shaped structure (thin white arrow, (B) Interposed between the long head of the biceps tendon posteriorly and the subscapularis tendon anteriorly. Also, shoulder joint spaces were filled with contrast medium of high signal intensity on fat-suppressed T1-weighted images, which established the presence of connections between joint spaces and cystic lesions of the humeral heads. i have been in pain manegment four this shoulder is there anything else to do ? The incidence of this variant can reach up to 15% of the population [3]. It is hypothesized that the hooked acromion is in fact an acquired form and is highly associated with subacromial impingement syndrome and rotator cuff abnormalities [2, 3, 4, 6, 10]. ... i.e. After detecting cortical dimples in posterosuperior portions of the humeral heads that were suggestive of cystic lesions on MR images, we selected five humeral heads with clearly visible cystic lesions in the humeral heads. Individuals with a larger cable are termed ‘cable dominant’. Here, we report two cases, with different destruction patterns, which were most probably due to subchondral insufficiency fractures (SIFs). True cartilage defects of the humeral head are often located in the posterosuperior portion medial to the location of the bare area [3, 5, 6, 7]. 2017;101(S2):3. Instead, they are typically pseudocysts that communicate with the joint space and represent a normal variant (Figure 3) [4, 6]. It is a strong fibrous triangular band that forms part of the roof of the glenohumeral joint. The main function of these ligaments is to prevent upward dislocation of the clavicle (Figure 2, additional material) [2, 11]. OBJECTIVE. The supraspinatus muscle is required for normal lateral abduction of the upper extremity. A bare area has also been described in the mid third of the glenoid cavity; this is an oval area denuded of cartilage, probably developmental and should be differentiated from true cartilage injury (Figures 6 and 7) [6, 9]. After fixing the bone segments, we divided each segment into undecalcified bone sections (10-mm in thickness) with a soft-tissue cutting machine to avoid damage to soft tissue in or near cysts. This space contains the scapular circumflex artery (Figure 3, additional material) [1, 2]. it's visible in X-rays of the joints and is the result of a reactive bone response, resulting in increased bone density of the underlying articular cartilage bone (that's underneath the joint).. As for the tubercle of Assaki, the bare area of the glenoid may be mistaken for a cartilage ulceration. Prominent synovial folds of the axillary recess may stimulate loose bodies on MRI. Also known as ‘sublabral sulcus’, this physiological recess is most common and represents a variation of the configuration of the biceps labral complex at the 11 and 1 o’clock positions. In addition, about 91% of cysts were connected to the joint cavity. For example, osteoarthritis, rheumatoid arthritis, intraosseous ganglia, neoplastic processes, posttraumatic processes, and calcium pyrophosphate deposition disease all may cause subchondral cysts. This variant is very uncommon and can be encountered in 1.5–2% of individuals [3, 6, 13]. The long head of the biceps tendon inserting in the superior aspect of the labrum and the triceps tendon inserting on the infraglenoid tubercle inferiorly constitute additional supportive structures of the glenohumeral joint [1]. In: Peh, WC (ed. Humeral head cysts: association with rotator cuff tears and age Eur J Orthop Surg Traumatol. This is usually observed bilaterally and without epiphyseal involvement. The width of the medial border and depth of the groove both affect the risk of subluxation of the long head of the biceps tendon [2, 3, 4]. A large lytic process (arrows) is seen in the humeral head, which is a subchondral cyst or geode often seen in association with DJD. Solitary bone cyst, also known as unicameral bone cyst, is a true cyst. Recognition of normal thinning of peripheral humeral cartilage is essential in order to not mistaken it with posttraumatic or degenerative sequels. The supernumerary head is thought to be present in 9.1–22.9% of the population, more commonly seen in Asians. However, cystic changes are also observed in normal shoulders [2-4]. A variable deep notch or a physiological flattening in the humeral neck is located posterior to the greater tubercle and best visualized on axial images; this pitfall should not be mistaken for a Hill-Sachs impaction which is seen at or above the level of the coracoid process (Figure 4) [4, 5]. Pictorial essay. In humeral heads, cystic changes occur because of articular diseases and tumorous conditions. It may originate from the anterior, posterior or both aspects of the labrum. All muscles originate from the scapula. The subcoracoid bursa is located between the subscapularis muscle and the coracoid process, whereas the superior subscapular recess also known as the subscapular bursa is located between the anterior surface of the scapula and the subscapularis muscle (Figure 13, additional material). (A) Axial and (B) Sagittal fat suppressed T1-weighted MR arthrogram of a sublabral foramen. Case 1 involved a 77-year-old woman with right shoulder pain. MRA using fat-saturated T1-weighted images and CTA in the axial plane show a cord-like middle glenohumeral ligament adjacent to an absent anterosuperior labrum. In daily practice, the anteroposterior view is performed in neutral position and with internal and external rotation of the arm and completed by a lateral view of the scapula (Y view). The coracohumeral ligament is not a true ligament connecting two bones. The coracoglenoid ligament arises from the middle of the coracoid process and inserts posterior to the supraglenoid tubercle, covering the top of the glenoid rim, superior labrum, and long tendon of the biceps. Subacromial pseudospur. Cysts in the posterosuperior portion of the humeral head (the bare area) were located in the lateral humeral head just posterior to the greater tuberosity. Shoulder Anatomy and Normal Variants. I have subchondral cyst humeral head 1.5 cm in my shoulder. Osteoarthritis typically develops in stages: 1. This can result in a thinner, wavier appearance on axial fat-saturated proton density MRA image (arrows, B) with a longer section of the ligament (arrows) on CTA (A). An inferior location of the anterior acromion relative to the undersurface of the distal clavicle has been described as ‘low lying acromion’. The clavicle is an S-shaped bone which articulates medially with the sternoclavicular joint and laterally with the acromioclavicular joint. The subchondral cyst underwent 2 direct needling treatments over a 3-month time span. SGHL: superior glenohumeral ligament, MGHL: middle glenohumeral ligament, IGHL: anterior band of the inferior glenohumeral ligament, spiral GHL: spiral glenohumeral ligament or fasciculus obliquus. The dorsal aspect of the scapula is divided by the scapular spine into the supraspinous and infraspinous fossa where the supraspinatus and infraspinatus muscles attach respectively [3, 6]. In rheumatoid arthritis, geodes result from inflammatory changes in the synovial lining of the articular cavity creating pannus that extends across the cartilaginous surface and eventually destroys cartilage and bone. 13 years experience Radiology ... A hill-sachs deformity refers to an impaction injury to the back side of the humeral head & is a sign of a prior dislocation of the shoulder. Coracohumeral ligament (thin arrow, A). Radiol Clin North Am. On axial images a marked retroversion is found. The inner trabeculae and the bone marrow also showed normal findings near pseudocysts. The sublabral foramen provides a communication between the glenohumeral joint and the subscapularis recess [7]. There are several bursae around the shoulder, the most important being the subacromial, subdeltoid, subscapular, and subcoracoid bursae (Figure 13, additional material). Subsequently, the nine shoulders were dissected under the supervision of one experienced orthopedic surgeon, who used an anterior approach that was designed to avoid damage to the posterior and lateral portions of the humeral head. Berlin Heidelberg Springer, DE. It is composed of two separate bundles, the trapezoid and conoid ligaments. 2017; 46(8): 1101–1111. It is best seen on axial images as a circular, signal void structure in the intertubercular groove. (a) Radiograph of the shoulder (Grashey view) shows the subcoracoid ossification center (straight arrow). The radiographic signs of rotator cuff tear may include secondary degenerative changes as sclerosis, subchondral cysts, osteolysis, and notching or pitting of the greater tuberosity. 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