So an interesting case again..
Heel spur- do you report- must- as it indicates full-thickness tear
So tear is not unusual
Notice
bursal rupture- do u report- should- as it indicates fall- I published 10 yrs ago on it. Often history is only pain as in this case.
Also note- blood clots- do you report- thye are not bodies
Do you do 3D- see how you can display biceps tendon intraarticular and genu portions- hard to see otherwise
To learn more about knee/shoulder/hip 3D etx- lets meet in ARRS- Hawaii!
Do you practice structured reporting?
Report as below
FINDINGS: Alignment: Posterosuperior decentering of the humeral head relative to the glenoid.
Fluid:
Subacromial / subdeltoid bursa: Moderate distention with partial rupture.
Glenohumeral: Large effusion. Synovial hypertrophy: Mild thickening with blood clots posteriorosuperiorly
Long head of biceps brachii tendon: Large effusion with blood clot.
Acromial arch:
Shape: Curved.
Subacromial spur: Heel type.
Os acromiale: Absent.
Lateral / Anterior downsloping: Absent.
Acromioclavicular joint: Moderate degenerative change.
Rotator cuff:
Supraspinatus: Mild to moderate tendinopathy. Full-thickness, full-width tear with retraction to the glenoid.
Infraspinatus: Moderate tendinopathy. Full-thickness, full-width tear with retraction to the glenoid.
Subscapularis: Moderate to severe tendinopathy. High-grade partial tear of the superior and mid fibers
Rotator Interval and Long head of biceps brachii tendon:
Rotator interval: Mild synovial thickening.
Horizontal portion: Moderate to severe tendinopathy.
Vertical portion: Intrasubstance split tears and moderate tendinopathy.
Genu: Split tear with medial subluxation.
Glenohumeral joint:
Labrum: Superior labral tear extending to the biceps labral anchor, SLAP type IV.
Biceps-labral anchor: Partial tear.
Glenohumeral ligaments: Normal.
Glenoid cartilage: Grade II cartilage thinning.
Humeral cartilage: Grade II cartilage thinning.
Subchondral bone marrow: Normal.
Bones: Greater tuberosity cysts and bony hypertrophy.
Muscles: Goutallier Stage 2 atrophy (less fat than muscle) of the of the infraspinatus more than supraspinatus with patchy edema of the infraspinatus.
Vessels: Normal.
Nerves: Normal.
Other: None.
IMPRESSION:
Massive rotator cuff tear with partial bursal rupture suggesting recent fall. Stage II muscle atrophy of the infraspinatus more than supraspinatus and patchy grade 1 muscle strain of the infraspinatus.
High-grade subscapularis tear of the superior and midportion fibers with biceps pulley injury and medial subluxation. Moderate to severe intra-articular biceps tendinopathy with SLAP type IV lesion and split tear of the genu and vertical portions.
Multiple blood clots in the posterior superior shoulder recess and biceps tendon sheath consistent with recent injury. Underlying chronic synovial proliferation.
Avneesh Chhabra, M.D. M.B.A.
Professor Radiology & Orthopedic Surgery
Chief, Division of Musculoskeletal Radiology
UT Southwestern Medical Center, Dallas, Tx
5373 Harry Hines Blvd.
Dallas, Tx-75390-9178
Office: 214-648-2122
avneesh.chhabra
