Posterior instability most often occurs either as a result of high force direct trauma to the shoulder such as from a motor vehicle accident or indirect trauma such as from seizures or electrocution. J Bone Joint Surg Am. 2020 Aug 27;8(8):2325967120941850. doi: 10.1177/2325967120941850. If the arm is An official website of the United States government. 2015;101(1 Suppl):S19-24. The posterior shoulder capsule plays a significant role in preventing posterior shoulder dislocation, particularly at the extremes of internal humeral rotation, the position in which most posterior dislocations occur. Utilizing the gle-noid clockface orientation on a sagittal image (Fig.
In part III we will focus on impingement and rotator cuff tears. Surgical Management of Superior Labral Tears in Athletes: Focus on Biceps Tenodesis. The shoulder capsule, including the glenohumeral ligaments, is one of the most important structures for restricting posterior translation of the humeral head.6The subscapularis, and to a lesser extent the infraspinatus and teres minor muscles, provide dynamic restriction of posterior humeral head translation.7The rotator interval is also thought to play a role, though its significance is somewhat controversial.8. PT (only saw once) suspected labral tear, suggested I see an orthopedic surgeon & get an MRI. His examination is somewhat difficult due to his large size, but no significant abnormal findings are noted. 5,6,7 The classic MRI findings of internal impingement, as seen in this month's case, include partial articular surface tears at the posterior supraspinatus/anterior infraspinatus insertion, greater tuberosity bony changes, and tearing of the . In previous studies, conventional MR sensitivity in detection of labral tears has ranged from 44% to 93% sensitivity compared with arthroscopy [1, 2].Two recent studies have assessed conventional MRI evaluation of the glenoid labrum using a 0.2-T extremity MR system. The insertion has a variable range. Posterior labral tear; < 15 decrease in affected shoulder internal rotation compared to contralateral shoulder . 2005;184: 984-988. difficulty performing normal shoulder . Multidirectional shoulder instability (MDI) is a condition characterized by generalized instability of the shoulder in at least 2 planes of motion (anterior, posterior, or inferior) due to capsular redundancy. Chang IY, Polster JM. eCollection 2021. AJR 2004; 183(2). Radiographs are normal, and an MRI arthrogram is shown in Figure A. Large tears of the rotator cuff may allow the humeral head to migrate upwards resulting in a high riding humeral head. In shoulders with posterior instability, the acromion is situated higher and is oriented more horizontally in the sagittal plane than in normal shoulders and those with anterior instability. The labrum is a thick fibrous ring that surrounds the glenoid. Radiology 2008; 248:185193. Check for errors and try again. Eur J Radiol. The general approach will include an X-ray, ultrasound, MRI, or CT scan of the shoulder joint to assess the cause of the symptom. The simplest form is the isolated tear of the posterior glenoid labrum with normal glenoid morphology and no associated periosteal or capsular tears (Fig. These terms are interchangeable because there is underdevelopment of the posterior inferior aspect of the glenoid. Edelson was the first to define the incidence of subtle forms of glenoid dysplasia by studying scapular specimens from several museum collections.15 Posteroinferior hypoplasia was defined as a dropping away of the normally flat plateau of the posterior part of the glenoid beginning 1.2 cm caudad to the scapular spine (Figure 17-7). These normal variants will usually not mimick a Bankart-lesion, since it is located at the 3-6 o'clock position, where these normal variants do not occur. J Am Med Assoc 117: 510-514, 1941. Posterior shoulder instability is a relatively rare phenomenon compared to anterior instability, comprising only 5-10% of all shoulder instability. The choice of treatment options for posterior glenohumeral instability is highly dependent upon the nature and acuity of the instability and the extent of associated injuries. A posterior labral tear (reverse Bankart) is also present (arrowhead), and a bone bruise is seen within the anterior humeral head (asterisk). Labral tears 2000 Jun; 82(6):849-57. The blunted configuration of the posterior part means some wear and tear and erosion. 2. 2019 Dec 12;20(1):598. doi: 10.1186/s12891-019-2986-1. Severe glenoid dysplasia or hypoplasia is a rare condition due to either brachial plexus birth palsy or a developmental abnormality with lack of stimulation of the inferior glenoid ossification center. There is an ongoing debate on whether direct MR arthrography is superior to conventional MR in detecting labral tears. Without the rotator cuff, the humeral head would ride up partially out of the glenoid fossa, lessening the efficiency of the deltoid muscle. The shoulder joint is a ball-and-socket joint that joins the upper arm's (humerus) bone with the shoulder blade (scapula). Glenoid dysplasia, also referred to as glenoid hypoplasia and posterior glenoid rim deficiency, is now increasingly recognized as an anatomic variant that predisposes patients to posterior glenohumeral instability. Small to moderate glenohumeral joint effusion with synovitis and extension of fluid in the subcoracoid recess. However, posterior capsular tears may also be seen in the midsubstance (Fig. (OBQ11.152)
Posterior capsular rupture causing posterior shoulder instability: a case report. Mild glenoid hypoplasia results in a rounded contour of the posterior glenoid with normal or only mildly thickened posterior labral tissue.
Study the cartilage. Tendonitis of the long head of the biceps. What are the findings? Posterior shoulder subluxation or dislocation is also one of the rare entities that may result in tears of the teres minor muscle.18 MR allows rapid evaluation of the status of the cuff following posterior dislocation, and prompt diagnosis of such lesions avoids delays in treatments that may lead to irreversible fatty atrophy of cuff musculature (Figs. He has full passive and active range of motion of the left shoulder that is symmetrical to his contralateral side. When comparing the 2 groups, they found that 12% of patients in the Bennett group had a posterior labral tear on MRI, whereas only 6.8% of patients in the non-Bennett group had a documented posterior labral tear, although the results were not statistically significant.8 Therefore, although Bennett lesions are typically not associated with posterior shoulder instability, it is important to recognize these lesions because they can be associated with posterior labral tears. MRI of the shoulder has been found to be accurate in the diagnosis of labral tears. American Journal of Sports Medicine 1994, 22:2:171-176. (OBQ19.66)
Tears of the supraspinatus tendon are best seen on coronal oblique and ABER-series. The glenohumeral joint has a greater range of motion than any other joint in the body. While this certainly introduces vulnerability to injury, it also confers the advantage of broad range of motion. The rotator cuff muscles and tendons act to stabilize the shoulderjoint during movements. Rotator cuff tears PMC less common then antierior but 50% of traumatic posterior in ED missed 2-5% of all unsstable shoulders; RF- bony abnormality (glenoid retroversion or hypoplasia); ligamentous laxity 50% of cases are trauma; microtrauma -> labral tear, incomplete labral avulsion or erosion of posterior labrum -> gradual stretching of capsule & patulous posterior capsule; lineman/weight lifters/ over head . AJR Am J Roentgenol. There are 3 types of attachment of the superior labrum at the 12 o'clock position where the biceps tendon inserts. The abduction external rotation (ABER) view is excellent for assessing the anteroinferior labrum at the 3-6 o'clock position, The labrum is a band of tough cartilage and connective tissue that lines the rim of the hip socket, or acetabulum. Federal government websites often end in .gov or .mil. 4. Recurrent posterior shoulder instability: diagnosis and treatment. They involve the superior glenoid labrum, where the long head of biceps tendon inserts. Rotator cuff tears in the context of posterior shoulder instability or dislocation were once thought to be rare. In type II there is a small recess. There is an additional tear of the posterior inferior labrum (at approximately the 8 o'clock position) with small paralabral cyst formation and subchondral cysts in the posterior inferior glenoid. A 22-year-old male wrestler presents to your clinic with complaints of deep left shoulder pain for the past 6 weeks. The confirming test for a labral tear is an MRI preceded by an arthrogram. Fluid undermines a tear of the posterior glenoid labrum (arrow) in a 42 year-old male with persistent posterior shoulder pain. In two patients (Case 1 and 3) along with labral cysts with tear, showed, enlarged capsule and positive drive through sign. Figure 1. [ 41] Findings are usually normal. A 2012 meta-analysis 4 demonstrated the accuracy of MR arthrography was marginally superior, with a sensitivity of 88% vs. 76% for conventional MR, and a specificity of 93% vs.87%. Numerous labral abnormalities may be encountered in patients with posterior glenohumeral instability. Reference article, Radiopaedia.org (Accessed on 18 Jan 2023) https://doi.org/10.53347/rID-74948, {"containerId":"expandableQuestionsContainer","displayRelatedArticles":true,"displayNextQuestion":true,"displaySkipQuestion":true,"articleId":74948,"questionManager":null,"mcqUrl":"https://radiopaedia.org/articles/glenoid-labral-tear/questions/1679?lang=us"}, doi:10.1148/radiographics.20.suppl_1.g00oc03s67, pain or discomfort (usually a precise point of pain cannot be located). Capsule. A posterior labral tear (reverse Bankart) is also present (arrowhead), and a bone bruise is seen within the anterior humeral head (asterisk). Successful nonoperative treatment of posterior shoulder instability has had varying rates of success, between 16 and 70% of patients. Tear of the posterior shoulder stabilizers after posterior dislocation: MR imaging and MR arthroscopic findings with arthroscopic correlation. J Shoulder Elbow Surg. Posterior periosteum (arrowheads) is extensively stripped but remains attached to the posterior labrum. (10b) A corresponding T2-weighted sagittal view in the same patient confirms the large ossification along the posteroinferior glenoid rim (arrows), compatible with a Bennett lesion. When there is an avulsion of the posterior inferior labrum, and the lesion is incomplete, concealed, or occult, it is called a Kim lesion. of the biceps in the bicipital groove. Figure 17-6. Figure 17-1. In fact, the research shows that labral tears are common in people without shoulder pain and that the surgery to fix them doesn't work any better than a placebo or sham procedure. Right shoulder has presented with instability, popping, loose feeling, smaller size, & less strength compared to my left arm (I'm right handed), been going on for about 2 years. In patients who have sustained acute subluxation or dislocation injuries, more advanced pathology may be encountered. (14b) In a 39 year-old weightlifter with persistent posterior shoulder pain and instability, the axial image reveals the posterior capsule outlined by arthrographic fluid along both sides of the capsule, strongly suggestive of a capsular tear. The site is secure. Crossref, Medline, Google Scholar; 74. doi: 10.1002/14651858.CD009020.pub2. Look for tears of the infraspinatus tendon. Broadly, clinical unidirectional . These tears include numerous variations designated by acronyms similar to those used for the more commonly seen anterior labral tears. the-glenoid labrum. Skeletal Radiol 2000; 29:204-210. Reverse-bankart lesion: Also known as a posterior labral tear, this injury affects the rear and lower ends of the labrum. Tear of the posterior shoulder stabilizers after posterior dislocation: MR imaging and MR arthrographic findings with arthroscopic correlation. where most labral tears are located. Fraying of the anterior section means some tearing of the surface with wispy threads emanating from that Epub 2011 Sep 9. Unable to process the form. De Coninck T, Ngai S, Tafur M, Chung C. Imaging the Glenoid Labrum and Labral Tears. QID: . Glenoid labrum (marked lig.) Wirth MA, Lyons FR, Rockwood CA Jr. Hypoplasia of the glenoid: a review of sixteen patients. The approach to surgery is dependent upon the type of injuries sustained by the patient, and the developmental or acquired alterations in anatomy that may be present. Notice the smooth borders unlike the margins of a SLAP-tear. A recess more than 3-5 mm is always abnormal and should be regarded as a SLAP-tear. When a dislocation or subluxation occurs, the glenoid labrum is torn from the bone and the capsule is stretched. Shoulder Labral Tear Repair Surgery. What is Anterosuperior acetabular labrum? Follow me on twitter:https://twitter.com/#!/DrEbr. They may extend into the tendon, involve the glenohumeral ligaments or extend into other quadrants of the labrum. In patients with posterior instability, the presence of glenoid hypoplasia is predictably higher, with one report finding deficiency of the posteroinferior glenoid in 93% of patients with atraumatic posterior instability.10 When diagnosing posterior glenoid hypoplasia on MRI, care should be taken not to overcall the entity, as volume averaging can result in a false appearance of dysplasia on the most inferior axial slice. These are depicted in Figure 17-7. Such lesions are generally found in patients with atraumatic posterior instability. The labrum has the same effect on the shoulder as the rounded lip of a golf tee has to a golf ball. Diagnostic criteria for both anterior and posterior labral tears present similarly. 12) or at the humeral attachment (Fig. (14c) An arthroscopic examination confirms the tear in the posterior capsule (arrow), which was subsequently repaired. Future larger studies are needed to confirm these findings. Locked posterior shoulder dislocation with multiple associated injuries. government site. MRA for SLAP - Is the threshold for referral too low? . 2012 Jan;21(1):13-22 This ring of cartilage encompasses the outer rim of the glenoid to provide cushiony support around the head of the humerus. FOIA Surgical treatment: arthroscopic debridement . Also, although better visualized on MRA imaging, a hypertrophied posterior glenoid labrum is evident in patients with glenoid dysplasia (Figure 17-8). sports. Burkhart et al. Sensitivity was 66 %, and specificity was 77 %. Biplanar radiographs should always be obtained when evaluating patients with suspected shoulder instability. The shoulder joint is a ball and socket joint that connects the bone of the upper arm (humerus) with the shoulder blade (scapula). postulated that dislocations result in a 360 degree injury, with trauma to the anterior labrum, resulting in changes posteriorly, and vice versa. Arch Orthop Trauma Surg. 5). (2a) The fat-suppressed proton density-weighted axial image reveals alignment of the humeral head posteriorly relative to the glenoid, with an impaction fracture of the humeral head articular surface (red arrow). Orthop J Sports Med. We hypothesized that the accuracy of MRI and MRA was lower than previously reported. In either case, the labrum can be torn off the bone. coracoacromial arch and coracoacromial ligament, glenohumeral ligaments - SGHL, MGHL, IGHL (anterior band). 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