Answer for BIR CoW 27 Aug 2023
Avulsion fracture involving greater tuberosity of right humerus at the insertion point of supraspinatus tendon and Anterior dislocation of shoulder joint
Findings
1)ABER view(abduction and external rotation ) of Right shoulder joint. 2)Avulsion fracture involving greater tuberosity of right humerus at the insertion point of supraspinatus tendon. Anterior dislocation of shoulder.
Discussion
The American College of Radiology suggests a recommended approach involving at least three distinct views for assessing shoulder injuries:
1. ADEQUACY AND ALIGNMENT ASSESSMENT:
- Evaluate Maloney's arch and the scapulohumeral arch.
- Measure the acromiohumeral space, typically around 10 mm.
- Check the glenohumeral joint space, which is normally 4-6 mm.
- Examine the acromioclavicular joint.
2. BONE EVALUATION:
- Trace the cortex of the following bones:
- Humerus
- Glenoid Fossa
- Clavicle
- Scapula
3. CARTILAGE AND JOINTS ASSESSMENT:
- Glenohumeral Joint:
- Articular surfaces should be parallel.
- In an AP view, if the humeral head is positioned below the coracoid process, consider an anterior shoulder dislocation.
- If there's uncertainty about glenohumeral alignment, consider obtaining an axillary view.
- A significant joint effusion alongside the humerus within the glenoid fossa on a scapula "Y" view may indicate humeral head or glenoid fractures.
- Acromioclavicular Joint:
- Ensure alignment of the inferior border of the clavicle and the acromion. Misalignment suggests an AC joint injury.
- An AC distance greater than 8 mm or more than 3 mm asymmetry compared to the opposite side may indicate an AC joint rupture.
- Coracoclavicular Joint:
- A CC distance exceeding 13 mm or showing a difference of more than 5 mm compared to the other side suggests a CC joint rupture.
4. ADDITIONAL VIEWS TO CONSIDER:
- Axillary View:
- Useful for suspected shoulder dislocations, proximal humerus issues, or glenohumeral surface abnormalities (requires arm abduction).
- Assesses post-surgery acromion and humeral head relation, Hill-Sachs lesions, AC joint, and shoulder dislocations.
- Grashey's View (Glenoid Cavity View)
- Apical Oblique View:
- Helpful for spotting fractures of the glenoid rim, dislocations, and humeral head impaction fractures (Hill-Sachs defect).
- Subacromial Impingement View:
- Inspects the undersurface of the acromion for spurs and unusual shape variations contributing to supraspinatus tendon impingement.
- Various Other Views:
- Westpoint View
- Bicipital Groove View
- Stryker Notch View
- Lawrence View
- AP Scapula
- Y View
- Outlet (Tunnel) View
- Coracoid View
- Scapula Notch View
ABDUCTION PROJECTION:
- An additional view examining the humerus, scapula, thoracic cage, and cervicothoracic spine.
- Dynamically assesses humeral position and potential rotator cuff impingement beneath the acromion process (acromiohumeral distance).
- Evaluates the acromioclavicular joint in motion.
References:
Hurov J. Anatomy and mechanics of the shoulder: review of current concepts. J Hand Ther. Vol 22, No 4, 2009. Oct-Dec 2009. PMID: 19665864 Emond, M.
Selective prereduction radiography in anterior shoulder dislocation: The Fresno-Quebec Rule. The Journal of Emergency Medicine. Vol. 55. Issue 2. Aug 2018. PMID: 29861274 Bonz, J et al.
Emergency Department Evaluation and Treatment of the Shoulder and Humerus. Emerg Med Clin N Am. Vol 33. No 2. May 2015. PMID: 25892723 Rudzinski, J. et al. Chapter 268.
Shoulder and Humerus Injuries. In: Tintinalli’s Emergency Medicine. A Comprehensive Guide, 7th edition. New York: McGraw-Hill Education, 2011. P1830-1841 Chan, Otto.
Introduction: ABCs and Rules of Two. ABC of Emergency Radiology, Third Edition. Edited by Otto Chan. 2013 John wiley & Sons, Ltd. Published 2013.
Findings
1)ABER view(abduction and external rotation ) of Right shoulder joint. 2)Avulsion fracture involving greater tuberosity of right humerus at the insertion point of supraspinatus tendon. Anterior dislocation of shoulder.
Discussion
The American College of Radiology suggests a recommended approach involving at least three distinct views for assessing shoulder injuries:
1. ADEQUACY AND ALIGNMENT ASSESSMENT:
- Evaluate Maloney's arch and the scapulohumeral arch.
- Measure the acromiohumeral space, typically around 10 mm.
- Check the glenohumeral joint space, which is normally 4-6 mm.
- Examine the acromioclavicular joint.
2. BONE EVALUATION:
- Trace the cortex of the following bones:
- Humerus
- Glenoid Fossa
- Clavicle
- Scapula
3. CARTILAGE AND JOINTS ASSESSMENT:
- Glenohumeral Joint:
- Articular surfaces should be parallel.
- In an AP view, if the humeral head is positioned below the coracoid process, consider an anterior shoulder dislocation.
- If there's uncertainty about glenohumeral alignment, consider obtaining an axillary view.
- A significant joint effusion alongside the humerus within the glenoid fossa on a scapula "Y" view may indicate humeral head or glenoid fractures.
- Acromioclavicular Joint:
- Ensure alignment of the inferior border of the clavicle and the acromion. Misalignment suggests an AC joint injury.
- An AC distance greater than 8 mm or more than 3 mm asymmetry compared to the opposite side may indicate an AC joint rupture.
- Coracoclavicular Joint:
- A CC distance exceeding 13 mm or showing a difference of more than 5 mm compared to the other side suggests a CC joint rupture.
4. ADDITIONAL VIEWS TO CONSIDER:
- Axillary View:
- Useful for suspected shoulder dislocations, proximal humerus issues, or glenohumeral surface abnormalities (requires arm abduction).
- Assesses post-surgery acromion and humeral head relation, Hill-Sachs lesions, AC joint, and shoulder dislocations.
- Grashey's View (Glenoid Cavity View)
- Apical Oblique View:
- Helpful for spotting fractures of the glenoid rim, dislocations, and humeral head impaction fractures (Hill-Sachs defect).
- Subacromial Impingement View:
- Inspects the undersurface of the acromion for spurs and unusual shape variations contributing to supraspinatus tendon impingement.
- Various Other Views:
- Westpoint View
- Bicipital Groove View
- Stryker Notch View
- Lawrence View
- AP Scapula
- Y View
- Outlet (Tunnel) View
- Coracoid View
- Scapula Notch View
ABDUCTION PROJECTION:
- An additional view examining the humerus, scapula, thoracic cage, and cervicothoracic spine.
- Dynamically assesses humeral position and potential rotator cuff impingement beneath the acromion process (acromiohumeral distance).
- Evaluates the acromioclavicular joint in motion.
References:
Hurov J. Anatomy and mechanics of the shoulder: review of current concepts. J Hand Ther. Vol 22, No 4, 2009. Oct-Dec 2009. PMID: 19665864 Emond, M.
Selective prereduction radiography in anterior shoulder dislocation: The Fresno-Quebec Rule. The Journal of Emergency Medicine. Vol. 55. Issue 2. Aug 2018. PMID: 29861274 Bonz, J et al.
Emergency Department Evaluation and Treatment of the Shoulder and Humerus. Emerg Med Clin N Am. Vol 33. No 2. May 2015. PMID: 25892723 Rudzinski, J. et al. Chapter 268.
Shoulder and Humerus Injuries. In: Tintinalli’s Emergency Medicine. A Comprehensive Guide, 7th edition. New York: McGraw-Hill Education, 2011. P1830-1841 Chan, Otto.
Introduction: ABCs and Rules of Two. ABC of Emergency Radiology, Third Edition. Edited by Otto Chan. 2013 John wiley & Sons, Ltd. Published 2013.
Note:
We do not discourage differential diagnosis. But all the differentials must satisfy the findings noted in the case.
If you feel you have answered rightly but cannot find your name in the above list, please call 09551942599.
Did you Know?
The order in which the names appear in this winner's list is based on the time of submission. The first person to send the correct answer gets his/her name on top of the list!
We do not discourage differential diagnosis. But all the differentials must satisfy the findings noted in the case.
If you feel you have answered rightly but cannot find your name in the above list, please call 09551942599.
Did you Know?
The order in which the names appear in this winner's list is based on the time of submission. The first person to send the correct answer gets his/her name on top of the list!