ABSTRACTS 18 ABSTRACTS SPECIAL FOCUS COURSE SHOULDER IMAGING Room Barbaros Paşa - Level 1 Friday, June 1st 2007 Shoulder Imaging Session 1 08:30-08:45 Shoulder Radiography J. Hodler (Switzerland) 08:45-09:05 Shoulder Trauma:Mechanism of Injuries A. Barile (Italy) 09:05-09:25 Imaging in Shoulder Trauma:Multislice CT vs MRI I. Boric (Croatia) 09:25-09:40 Sternoclavicular Joint Diseases A.G. Jurik (Denmark) 09:40-09:55 Congenital and Developmental Disorders K. Johnson (UK) 10:00-10:30 Coffee Break Shoulder Imaging Session 2 10:30-10:50 Normal MRI Anatomy of the Shoulder: Clinical H. Bloem (The Netherlands) Aspects for Imaging 10:50-11:10 Normal Variants and Pitfalls in MRI of Shoulder Joint W. Peh (Singapore) 11:10-11:30 MRI Protocols in the Shoulder G. Astrom (Sweden) 11:30-11:50 MR Arthrography: Technique and Indications C. Faletti (Italy) 12:00-12:30 Opening Ceremony 12:30-13:30 Lunch Shoulder Imaging Session 3 13:30-13:50 Impingement Syndrome: Pathology and Mechanism A. Stabler (Germany) 13:50-14:10 MRI Findings in Rotator Cuff Lesions C. Masciocchi (Italy) 14:10-14:30 MRI vs US Imaging in RC Pathologies: Clinical and E. Silvestri (Italy) Economical Aspects 14:30-14:50 Interventional Procedures in the Shoulder S. Ostlere (UK) 15:00-15:30 Coffee Break Shoulder Imaging Session 4 15:30-15:50 Glenohumeral Joint Instability: Definition J. Kramer (Austria) and Mechanism 15:50-16:10 MRI Findings in GHJ Instability K. Wörtler (Germany) 16:10-16:25 SLAP Lesions J. Beltran (USA) 16:25-16:40 Biceps Tendon Pathologies E. Llopis (Spain) 16:40-16:55 Postoperative Imaging of the Shoulder M. Zanetti (Switzerland) Saturday, June 2nd 2007 Shoulder Imaging Session 5 08:30-08:45 Soft Tissue Tumors around Shoulder Joint K. Vilanova (Spain) 08:45-09:05 Bone Tumors and TM like Lesions around D. Vanel (France) Shoulder Joint 09:05-09:20 Synovial Disorders of Shoulder Joint G. Allen (UK) 09:20-09:35 Bone Marrow Abnormalities A. Karantanas (Greece) 09:35-09:50 Imaging of Brachial Plexus A. Kassarjian (Spain) 10:00-10:30 Coffee Break Shoulder Imaging Session 6 10:30-12:00 Shoulder US Anatomy C. Martinoli (Italy) Shoulder US Pathology A. Klauser (Austria) Live Demonstration C. Martinoli (Italy) & A. Klauser (Austria) 19 Shoulder Imaging Session 1 Chairs: V. Pullicino (United Kingdom) and M. Reiser (Germany) Shoulder Radiography J. Hodler (Switzerland) Room “Barbaros Paşa” – Friday June 1st, 2007 – 08:30-08:45 Regardless of the increasing role of sonography and MR imaging, standard radiographs have maintained a key role in diagnosing shoulder abnormalities. Anteroposterior views in internal and/or neutral and/or external rotation and axial (cross-table), as well as supraspinatus outlet views are most commonly employed. Specialized projections such as Bernageau's or the Westpoint view may add information in glenohumeral instability. For assessing the damage in acromioclavicular joint trauma, bilateral radiographs are commonly obtained with weights in the patients' hands. Arthrography is only rarely used unless combined with either CT or MR imaging. Standard radiographs provide relevant information in rotator cuff disease. The acromiohumeral distance should be 7 mm or more on anteroposterior radiographs. Cranial migration of the humeral head occurs in the presence of a supraspinatus tear in combination with fatty degeneration of the rotator cuff muscles. Surgery may not be successful in severe fatty degeneration. Osteoarthritis of the glenohumeral and acromioclavicular joints are demonstrated by standard radiographs although they are not sensitive in degeneration of the glenohumeral joint. In calcific tendinitis, standard radiographs represent the easiest and most reliable means to demonstrate calcifications and to a certain degree the extend of activity. In instability, radiographs demonstrate Hill-Sachs lesions, bony Bankart lesions and the position of the humeral head in relation to the glenoid. In fractures, standard radiographs are the most important imaging method. The typical Neer's classification of proximal humeral fractures based on the number of dislocated parts may not be as reliable as desired but nevertheless are useful for predicting the prognosis including avascular necrosis. In frozen shoulder osteopenia may be seen on standard radiographs. Postoperatively, standard radiographs provide information about the position and stability of implants. 20 Shoulder Trauma: Mechanism of Injuries A. Barile (Italy) Room “Barbaros Paşa” – Friday June 1st, 2007 – 08:45-09:05 The shoulder is the most mobile joint in the human body. Shoulder trauma is common throughout life, but the site of injury varies with age. The mechanism of shoulder trauma are several; generally, it is possible to distinguish acute direct trauma and chronic repetitive one. Humeral fractures are most commonly caused by a direct blow or a fall onto an outstretched hand. Clavicular fractures usually occur during a fall onto an outstretched hand, although some result from a blow to the shoulder. Scapular fractures, which are uncommon, result from a direct blow to the scapular area or from extremely high-force impact elsewhere to the thorax. A common injury among athletes and active patients is acromioclavicular sprain. A direct blow to the superior aspect of the shoulder or a lateral blow to the deltoid area often produces this injury. Anterior sternoclavicular joint separation occurs when the medial end of the clavicle is displaced anteriorly or anterosuperiorly with respect to the anterior border of the sternum. This injury is most commonly the result of a motor vehicle crash. Tears of the rotator cuff during trauma are most common in persons older than 40 years. Because of its lack of bony stability, the glenohumeral joint is the most commonly dislocated major joint in the body. Glenohumeral stability is due to a combination of ligamentous and capsular constraints, surrounding musculature and the glenoid labrum. Static joint stability is provided by the joint surfaces and the capsulolabral complex, and dynamic stability by the rotator cuff muscles and the scapular rotators (trapezius, serratus anterior, rhomboids and levator scapulae). The humeral head can dislocate anteriorly, posteriorly or inferiorly in relation to the glenoid fossa. Most shoulder dislocations are anterior. Patients usually hold the affected arm in external rotation and abduction. 21 Imaging in Shoulder Trauma: Multislice CT vs MRI I. Boric (Croatia) Room “Barbaros Paşa” – Friday June 1st, 2007 – 09:05-09:25 Shoulder traumatic injuries are common, and the glanohumeral joint is the most common joint dislocation treated in the emergency departments. The injury types vary with age and mechanism of injuriy. Regardless of injury types: acute direct traumatic injuries, acute indirect traumatic injuries or repetitive microtraumatic injuries, each injured shoulder requires sufficient radiological assessment. Different radiological modalities are available and give answers on clinitians questions. But, two most powerful diagnostic tools are multidetector computed tomography (MDCT) and magnetic resonance imaging (MRI). Each of those diagnostic modalities has owen advantages and disadvantages, but often are also complementary methods. The main advantages of MDCT include extremely rapid scan times, excellent temporal, spatial, and contrast resolution, and the ability to produce high- quality two-dimensional reformats (multiplanar reconstruction, MPR) and three- dimensional surface renderings. Due to those facts, MDCT is method of choice in evaluation of bony trauma and MDCT with MPR increases the accuracy of fracture classification especially in complex or comminuted shoulder fractures, helping surgical planning and decision making. MRI and MR arthrography are the imaging modalities of choice for the assessment of the many soft-tissue structures of the glenohumeral joint: rotator cuff, the glenoid labrum and the biceps tendon, as well as in detecting glenohumeral cartilage lesions. But, value of MDCT arthrograpyh for studying the articular cartilage of the entire shoulder is promising with high sensitivity and specificity range. 22 Sternoclavicular Joint Diseases A. G. Jurik (Denmark) Room “Barbaros Paşa” – Friday June 1st, 2007 – 09:25-09:40 The sternoclavicular joints (SCJs) are mechanically connected to the shoulder joints being the only synovial joints between the upper extremity and the trunk. Disorders of the joints encompass diseases occurring in other joints such as congenital and developmental abnormalities, traumatic disorders, arthritides, degenerative disorders and infections. The SCJ is often a diagnostic challenge to both the clinician and the radiologist. Disease involvement may cause referred pain in areas distant from the joints potentially leading to delayed diagnosis. The SCJ is moreover difficult to visualise by conventional radiography implying the need for more demanding examinations. Due to this the SCJ does not generally receive the attention it merits by radiologists. Learning Objective: Normal anatomy: The SCJ is a true diarthrodial synovial- lined joint. When fully developed it contains fibrocartilaginous and not hyaline articular cartilage. It contains a fibrocartilaginous intraarticular disc and is in addition to surrounding ligaments stabilized by the costoclavicular ligament making the region rich of entheses. Imaging modalities/strategy: The SCJs are often difficult to assess by conventional radiography, unless using tomography due to several over- projecting structures. Elimination of