Hi there everyone,
many thanks for your numerous replies. I am posting some of them below for general edification (in some cases abridged):
- Capsular tears occur in the shoulder for a variety of reasons. I routinely inject 15ml into normal-sized people without evidence of capsular rupture (or symptoms), sometimes going to 20ml for the really big guys (using resistance as a guide). Sometimes I see extrav through the membranous portion of the IGHL (like this case) even with small volumes, without symptoms. It’s just a function of a thin portion of the capsule giving way against transient increases in intraarticular pressure during injection, and is usually entirely incidental and unimportant other than making your images look less pretty. Using a larger needle may allow for greater transient intraarticular pressure and therefore possibly greater likelihood of causing a capsular leak.
- I had a case like this once and I injected about the same amount with no resistance. I saw contrast fill inferior to the capsule immediately after injecting. I wasn’t sure whether there was a capacious pouch or mild chronic tear. Sometimes you just see contrast inferiorly. I doubt you created a perforation, and if you did, it would probably heal on its own.
- Not a common location for spontaneous leak down the shaft of the humerus.
- More likely either HAGL, or adhesive capsulitis with restricted joint capacity.
- Small thin normal subjects should be able to accommodate 10ml of contrast material with only mild leak.
I would think iatrogenic and probably will heal on its own over time.
- leave alone. prob give her some relief from restricted range of motion.
- Extra-articular suffusion of contrast media. It happens sometimes. Nothing to do. Not painful. Ddf HAGL but not here.
- Iatrogenic. Possible adhesive capsulitis.
- I’ve gotten the same thing often. Even with an anterior injection it will often extravasate out the posterior inferior capsule because it is the weakest spot. If she had pre-existing adhesive capsulitis then you may have helped her.
- Iatrogenic. Inferior glenohumeral ligament seems intact. This is the important stabilizer.
- I think that 8mL of contrast is highly unlikely to cause any sort of injury to the inferior capsule, even with a petite patient. The small tear may even be subclinical, and I have seen a number of these in patients with clear superior labral symptoms undergoing arthrography for labral repair planning.
Eric Chang sent the following comment along with a great article:
- We tried to look at this in the article attached. I find that all imaging planes are helpful, and would urge you to see if additional findings (or confirmation) can be made on the sagittal plane, but from what I can tell the anterior band is intact, and the axillary pouch and posterior bands are disrupted. The location is more helpful here than the morphology of the disrupted margin. I would highly doubt this needs to be treated, but if they were to scope I suspect they would see a tear. In the article this pattern came out to be ~84% specific.
Here´s the article:MR Arthrogram Features That Can Be Used to Distinguish Between True Inferior Glenohumeral Ligament Complex Tears and Iatrogenic Extravasation
Wilbur Wang, Brady K. Huang, Matthew Sharp, Lidi Wan, Niloofar Shojaeiadib, Jiang Du, and Eric Y. Chang. American Journal of Roentgenology 2019 212:2, 411-417
Peter Mercouris sent this comment along with a very interesting case, which I´m attaching to this post:
- I think this is extra capsular extravasation which in my experience happens often. [There can be some] difficulty in differentiating between iatrogenic extravasation and a capsular tear unless there’s a large defect. I attach a very recent case – unusual combination of a posterior labral tear and posterior midcaspular tear. I have arrowed where I think the capsular tear is (which I did not appreciate until we discussed the case) and the orthopaedic surgeon has arrowed it on his arthroscopy image. [See attached PDF.]
Thanks again everyone, your answers helped me learn a lot.
I wish you all happy holidays and a great start next year! 🌟 🎉
✨💫🚀
Andrei
On Tue, 13 Dec 2022 at 16:19, Andrei Dumitrescu <xisquare> wrote:
Hi there everyone,
I wonder if intra-articular contrast injection might have caused a capsular tear at the shoulder.
45 year old patient imaged for chronic pain in her right shoulder with decreased ROM. She described a ‘painful arc’ with severely restricted abduction.
I injected 8 cc of gadolinium against moderate resistance, judging this amount to be enough for this rather petite woman. She did not complain of any pain after needle placement, although having injected some anaesthetic first I wouldn’t have expected it anyway.
To me it seems there is a capsular defect with extraarticular contrast at the axillar recess. Would you concur? Is it iatrogenic? Does it need to be treated?
Thanks,
Andrei
