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Tutorial Article Imaging of the Shoulder W EQUINE VETERINARY EDUCATION / AE / april 2010 199 Tutorial Article Imaging of the shoulder W. R. Redding* and A. P. Pease† Department of Clinical Sciences; and †Department of Molecular Biomedical Sciences, College of Veterinary Medicine, North Carolina State University, 4700 Hillsborough Street, Raleigh, North Carolina 27606, USA.eve_55 199..209 Keywords: horse; lameness; shoulder; ultrasonography; radiology Summary be performed before intra-articular anaesthesia to determine if effusion is present in the joint and to assist with Diagnosis of lameness associated with the shoulder region directing the placement of the needle into the shoulder requires a careful clinical examination, the use of joint. specifically placed intra-articular analgesia and a This paper discusses the normal anatomy as well as the combination of some common imaging techniques to radiographic and ultrasonographic examination of the accurately define the source of pain. Most equine shoulder area. In addition, reference to the use of nuclear practices performing lameness examinations in the horse scintigraphy and the benefits to help localise lesions to the have the radiographic and ultrasonographic equipment shoulder is discussed. necessary to accurately image the shoulder. This article presents a description of the unique anatomy of the Normal anatomy of the shoulder region shoulder and the specific application of radiographic and ultrasonographic techniques to provide a complete set of The most proximal joint in the appendicular skeleton of the diagnostic images of the shoulder region. A brief discussion forelimb is the scapulohumeral joint. It is composed of 2 of nuclear scintigraphy of this region is also included. bones, the distal end of the scapula and the proximal humerus (Sisson 1975). The large amount of musculature Introduction covering the scapula along with their corresponding tendons act as collateral ligaments supporting the Front limb lameness referable to the proximal aspect of the scapulohumeral joint (Tnibar et al. 1999). The lateral head limb can be difficult to accurately define. Localisation of of the supraspinatus muscle and the infraspinatus muscle the lameness to the shoulder region requires a act as lateral stabilisers and insert on the caudal eminence combination of careful clinical examination followed by of the greater tubercle of the humerus. The supraspinatus radiographic, ultrasonographic and occasionally nuclear muscle also has a medial head that inserts on the lesser scintigraphic examinations. Because most injuries to the tubercle of the humerus. The subscapularis muscle which shoulder are traumatic in nature it is necessary to assess originates on the medial side of the scapula and inserts on both bony and soft tissue structures involved to the caudal eminence of the lesser tubercle of the humerus appropriately determine prognosis and most effectively acts as a stabiliser for the medial aspect of the joint. The treat the injuries of this area. Radiographic and nuclear biceps brachii tendon crosses the cranial aspect of scintigraphic examinations can be helpful in defining the scapulohumeral joint coursing distally from its origin on osseous involvement but generally requires sophisticated the supraglenoid tubercle passing between the medial imaging equipment. Even when adequate radiographic and lateral lobes of the supraspinatus tendon, to support and nuclear scintigraphic images are obtained the joint cranially as it runs in the intertubercular groove. ultrasonographic imaging is necessary to provide The long head of the triceps brachii and teres major complementary information on soft tissue injuries muscle, originating on the caudal border of the scapula associated with this area. Ultrasonographic examination is acts to support the scapulohumeral joint caudally (Figs 1, easily performed with equipment normally used for other 2, 3 and 4). musculoskeletal examinations in the horse. In addition, The bicipital bursa lies deep to the biceps tendon as it ultrasonographic examination of the shoulder should courses through the intertubercular groove. The bursa is interposed between the biceps brachii tendon and the *Author to whom correspondence should be addressed. proximal humerus. The bursa extends around the medial and © 2010 EVJ Ltd 200 EQUINE VETERINARY EDUCATION / AE / april 2010 Fig 1: The normal anatomy of the shoulder region is demonstrated in this series of MRI images of a cadaver limb. The biceps tendon originates on the supraglenoid tubercle of the scapula. It appears as a crescent shape structure on cross section. Fig 2: Coursing distally, the biceps tendon begins to appear bi-lobed and of mixed signal due to adipose tissue within the tendon and interposed between the tendon and humerus. lateral lobes of the biceps brachii tendon assuming a more bursa located between the infraspinatus tendon and the sheath-like function. Unlike the canine, the bicipital bursa caudal part of the greater tubercle. Occasionally, a bursa does not routinely communicate with the scapulohumeral can be found at the supraglenoid tubercle (Sisson 1975) that joint, but occasionally a communication does exist (Sisson protects the supraspinatus muscle as it divides into the lateral 1975; Grant et al. 1992; Dyson and Dik 1995). There is also a and medial lobes. © 2010 EVJ Ltd EQUINE VETERINARY EDUCATION / AE / april 2010 201 Fig 3: The biceps tendon is now uniquely bilobed. The bicipital bursa lies deep to the biceps tendon as it courses through the intertubercular groove. The bursa is interposed between the biceps brachii tendon and the proximal humerus. Fig 4: In the most distal aspect of the tendon at the musculotendinous junction the signal again becomes variable due to the increased fat content as the tendon blends into the low signal muscle of the biceps brachii. The fat pad can easily be seen separating the tendon from the humerus. Radiographic examination of the shoulder standing animal; however the quality of the radiograph can be significantly improved when the horse is positioned Good quality radiographs are best obtained with high under general anaesthesia with the affected side closest output x-ray generators with fixed or oscillating (‘Bucky’) to the radiographic plate. Portable x-ray generators have grids. Radiographs of the shoulder can be obtained in the a limited power output necessitating longer exposure times © 2010 EVJ Ltd 202 EQUINE VETERINARY EDUCATION / AE / april 2010 to achieve the appropriate exposure factors. These longer exposure times decrease the detail of the radiograph due to motion artifact which can be minimised by the use of cassette stands, though patient movement is still problematic. Radiographs of the shoulder are technically difficult to achieve because of the large muscle mass covering the joint as well as the superimposition of the opposite shoulder, cervical spine, and neck musculature. Radiographic exposures are made with the patient nonweightbearing with the limb pulled cranially from the body and superimposed on the trachea to minimise overlying soft tissues to help reduce the needed exposure settings. Fast film and fast rare earth screen combinations can help reduce exposure times but are often insufficient to improve the diagnostic quality of the shoulder radiographs due to the large crystal size therefore limiting anatomic detail when using portable machines. In addition, since portable developers are not readily available, any screen-film images acquired are not available for review or interpretation until the veterinarian is able to develop the radiographs. Digital radiographic Fig 6: Craniomedial-caudolateral oblique projection of a shoulder and proximal humerus. Soft tissue swelling and bone remodelling systems are becoming more available to the equine of the deltoid tuberosity is present. practitioner and these systems provide a larger latitude to help compensate for the decreased generator power. In addition, since most systems come with portable readers, caudolateral oblique projections (Figs 5 and 6). For the the images are available for review in a more timely mediolateral projection, the affected limb should be manner. However, the lack of high kVp settings as well as pulled forward and slightly distally and the shoulder should the sharp contrast of the thick shoulder region surrounded be positioned as close as possible to the cassette. The by air can still make diagnostic images of the shoulder medial rim of the glenoid is normally projected more region challenging using portable x-ray units. At best, good proximally than the lateral rim. Frequently, the lateral rim of quality radiographs may not detect osteochondrosis the glenoid is superimposed over the cranial part of the lesions and consistently underestimate the extent and humeral head creating a radiolucent defect (Dyson 1986). severity of many of the lesions affecting the shoulder. The caudal edge of the glenoid rim is sharply pointed. The The typical radiographic examination of the shoulder subchondral bone of the caudal two-thirds of the glenoid should include mediolateral and craniomedial- cavity is uniform in thickness and quite dense. The craniomedial-caudolateral oblique view is useful to highlight the lesser tubercle, the intermediate tubercle and the deltoid tuberosity. A cranioproximal-craniodistal oblique view can be obtained when the tubercles of the humerus are thought to be involved. This projection has been especially helpful in defining osseous cyst-like lesions of the greater or intermediate tubercles.
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