Index terms: Arthrography Computed tomography Shoulder

dislocation

Double contrast CT arthrography of the glenoid labrum and shoulder girdle

David
William

R. Haynor,
P. Shuman,

M.D. M.D.

Double raphy normalities

contrast permits with

arthrography the radiologist great accuracy.

combined to identify

with capsular

computed and

tomoglabral ab-

THIS EXHIBIT, A SELECTION OF THE SKELETAL RADIOLOGY PANEL, WAS DISPLAYED AT THE 69TH IENTIFIC ASSEMBLY AND ANNUAL MEETING OF THE RADIOLOGICAL SOCIETY OF NORTH AMERICA, NOVEMBER 13-18, 1983, CHICAGO, ILLINOIS.

Introduction
The joint. and cuff). deepens Shoulders have cuff shallowness the fossa; that of the glenoid is enhanced are by the joint prone fossa capsule, to recurrent makes and the shoulder a fibrous by the overlying dislocation (almost an inherently disk which always muscles (the unstable surrounds rotator anterior)

Its stability

by the glenoid

labrum,

generally the rotator particularly

a lax or ballooned capsule and/or an injured labrum (1 ). Tears of are also seen, although less frequently. Until recently these structures have
been

the labrum,

difficult

to assess by conventional

single

or double

contrast arthrography. The use of double contrast arthrography combined with pluridirectional tomography (2,3) has enabled radiologists to diagnose capsular and labral pathology with accuracy. This information is useful both for confirmation of the clinical diagnosis of unstable shoulder and for planning surgical intervention. From
gy, University sity Hospital,

the Department
of Washington, Seattle.

of RadioloUniver-

Recently, arthrography less radiation icantly who and easier

we have described a technique in which double contrast shoulder is combined with CT (4). This technique is easily performed, gives exposure to the patient than conventional tomography, and is signifon the patient in terms of positioning. In a series of eleven patients capsular of the of

Address
Shuman, M.D., ogy, University versity Hospital 98195.

reprint

requests

to W. P.

Department of Radiolof Washington, UniSB-OS, Seattle, WA

underwent surgery, CT arthrography was 100% accurate in diagnosing labral pathology. In this article, we present the normal CT anatomy and shoulder of labral and capsule capsular and contrast pathology. this with

glenoid labrum the major types

the CT appearance

Volume

4, Number

May

1984

RadioGraphics

411

CT

art hrography

of

the shoulder

Haynor

and Shuman

Technique

A conventional
first, using

air contrast
agent

arthrogram
(Renografin

is performed
60-Squibb, films are (CT/T are placed

3 cc of a contrast

Princeton, N.J.) and 10 cc of room air. After plain taken, the patient is placed in the CT scanner 8800-General with the arm Electric in a neutral

Co., Milwaukee,
position. Saline

WI.), lying supine

bags

anterior to the shoulder and mm cuts are then performed are usually retrospective to magnify with sufficient) software the images, using

neck to decrease artifacts. Five through the glenoid (5-7 cuts the large

body mode.

ReViewTM

(General Electric which are viewed of 1200-2000

Co. ) is then used and photographed Hounsfield units.

an extended

window

Figure 1 The humeral head and the lateral portion of the capsule have been removed. Note the labrum, a fibrous rim around the bony glenoid which serves to deepen it. The normal direction of humeral dislocation is antenor and inferior; by so moving, the humeral head may tear or stretch the capsule and periosteum or detach a portion of the labrum (the so-called Bankart

lesion blends labrum.

ofthe orthopedic with the periosteum

literature (1)). The capsule just medial to the glenoid to re-

The long head of the biceps tendon attaches the superior portion of the labrum; it has been flected upward in this picture.

412

RadioGraphics

May

1984

Volume

4, Number

Haynor

and Shuman

CT art hrography

of the shoulder

Figure 2 This scout view demonstrates the planes of the transaxial through the glenoid in a typical study. Note that the arm fortably by the patients side, in neutral rotation.

cuts made is lying com-

Volume

4, NumberS

May

1984

RadioGraphics

413

CT art hrography

of the shoulder

Haynor

and Shuman

Figure 3 Section through normal right shoulder (midglenoid). The joint is filled with air, with a small amount of contrast material outlining the capsular and articular surfaces. Note the size of the normal capsule and the symmetric appearance of the anterior (open arrows) and posterior (closed arrows) aspects of the labrum. (HH: humeral head, GL: glenoid, ANT: anterior).

414

RadioGraphics

May

1984

Volume

4, Number

Haynor

and Shuman

CT

art hrography

of the shoulder

Figure 4 Air lies in the intertubercular head of the biceps (arrow).

sulcus

and outlines

the tendon

of the long

Volume

4, NumberS

May

1984

RadioGraphics

415

CT

art hrography

of the shoulder

Haynor

and Shuman

Figure 5 The anterior labrum is attenuated (arrow); the attachment of the antenor capsule to the glenoid has also been partially avulsed (arrowhead). Note the relatively bare area of glenoid lying just medial to the labrum (small arrows); the periosteum has been stripped in this area.

416

RadioGraphics

May

1984

Volume

4, Number

Haynor

and Shuman

CT

art hrography

of the shoulder

Figure 6 The anterior labrum has stripping is also apparent.

been

torn

(arrowhead).

Some

periosteal

Volume

4, NumberS

May

1984

RadioGraphics

417

CT

art hrography

of the

shoulder

Haynor

and Shuman

Figure 7 The labrum has been torn and a large fragment lies free in the joint (arrowheads); on more superior cuts this fragment was partially attached to the bony glenoid. The anterior labral defect is indicated by the arrow. Note that the capsule and periosteum are both stripped away from the glenoid and that the capsule is markedly ballooned (open arrows). In such a joint, it is easy to see how repeated dislocation can be intracapsular.

418

RadioGraphics

May

1984

Volume

4, Number

Haynor

and Shuman

CT

art hrography

of the shoulder

S4;
.S..-,S.

. #{149} #{149} -; S

#{149};
S

r
;
;.-.

#{149}

I,

#{149}L

.
.... .,--.,...., ... 4S

.5.
,) S

,.S . .

r
-.-,

.
s

.-. ..

...

.-

. S
... -

.,-

;:

4,i#{149}

4IIv,.:

:
labrum (arrow). A

Figure 8 Another case demonstrates a defect in the anterior detached portion of the labrum is seen in the joint.

Volume

4, Number

May

1984

RadioGraphics

419

CT

art hrography

of the shoulder

Haynor

and Shuman

Figure 9 Illustrated here is a markedly ballooned capsule, the result of either stretching or a tear. A redundant capsular fold is indicated by two arrows. Unlike the cases illustrated in Figures 7 and 8, the periosteum of the glenoid is intact. Note that the labrum (arrowheads) is also intact and that the posterior portion of the capsule is of normal size.

420

RadioCraphics

May

1984

Volume

4, Number

Haynor

and Shuman

CT art hrography

of the shoulder

Figure 10 Rotator cuff tear. Air is seen in the subacromial humeral head (arrows). As a result of the tear, within the shoulder joint. This may compromise brum.

bursa, lateral to the almost no air remains evaluation of the Ia-

Summary CT double contrast arthrography is an easily performed

1. Rowe CR, Pate!

References
D, Southmayd 60A:1-16. WW. The Bankart procedure.

technique that yields an accurate picture of the shoulder joint, the g!enoid !abrum, and the shoulder capsule. It is useful in planning surgical correction. It is also useful in cases in which the diagnosis of unstable shoulder is uncertain. When an accurate assessment of the capsule and !abrum are essential thrography for patient management, method we believe of choice. that CT aris the diagnostic

J Bone Joint Surg 1978; 2. Goldman AB, Ghelman

throgram. Radiology EM. WP,

B. The
1978; contrast

double-contrast
arthrotomography
64A:192-195.

shoulder
of

arthe

127:6SS-663.
1982;

3. Braunstein
shoulder. 4. Shuman computed 141:S81-S84.

Double

J Bone Joint
Kilcoyne tomography

Surg
RF, of

Matsen the

FA, et al. Double-contrast glenoid labrum. AJR

1983;

Volume

4, Number

May

1984

RadioGraphics

421