Is this abnormal?

[YH LIN]

Is this abnormal?

The patient had shoulder joint dislocation several days before doing shoulder sonography.

Does the area beneath coracoacromial ligament seem unusual?
Is this fluid beneath coracoacromial ligament?
Or is this normal supraspinatus (SS) muscle?

Does the area superior to longitudinal biceps (BIC) tendon seem unusual?
Is this fluid?

There is no fluid in the biceps tendon sheath and bursa anterior to biceps.
There is no fluid in the lateral recess.
The subscapularis (SUBS), supraspinatus (SS), infraspinatus (IS), biceps (BIC) tendons seem normal, no tear.

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[Stephen Bird]

Howdy,

Great images!

What you are seeing is a little “fluid” beneath the coraco-acromial ligament.

Fluid here can either be burial or joint related fluid.

Given there is no fluid in any of the other burial recesses this is almost certainly a little bit of joint fluid.

Just adjacent to the coracoid you often see a little fluid recess that communicates with the joint. Some call it the sub-coracoid recess or bursa, but in my eyes it is just a little recess of GH joint fluid.

So if you have a little joint fluid there the next question is “is there a significant GH joint effusion”. To answer this I look in the long head of biceps sheath for fluid surrounding the long head of biceps tendon. Then I look at the posterior shoulder, and not at the level of infra and the labrum, but a little lower where you see trees minor and look for fluid in the axillary recess of the GH joint. If you see fluid in these locations you have an effusion. If not it is probably just physiological fluid.

The next question I have is “why does the fluid contain echoes?”
If it is blood and part of a haemarthrosis, this would explain the echoes.

So do we have a blood filled joint effusion?

Given the recent dislocation, a Hill Sachs deformity of the posterior humeral head or a Bankart fracture of the glenoid are possibilities.

So a set of plain X-rays at the very least are warranted.

If you see blood in the LHBT sheath or axillary recess then you will need some cross sectional imaging to complete the picture.

If there is no fluid or blood anywhere else it is possible the appearance might be from some normal fat or joint capsule.

But I would be chasing these other options first.

Nice case,

Steve.

[YH LIN]

Thanks!

[Stephen Bird]

Let us know if you get any follow up,

Steve

[YH LIN]

20240401 MR Arthro-Shoulder (ortho)
MR arthrography of left shoulder with intra-articular Gd (1/400 normal saline dilution)contrast enhancement, with pulse sequence axial, coronal, and sagittal T1WI with fat saturation, coronal T2 WI with fat saturation, and ABER position with oblique axial T1 WI with fat saturation showed:

> Labrum: suspicious subtle anterior inferior labral tear, with regional cartilage disruption.
> Hill-Sachs lesion: +
> IGHL: intact
> Rotator cuff tendons: intact
> Biceps long head tendon: intact

Conclusion:
suspicious subtle anterior inferior labral tear, with regional cartilage disruption.

[Stephen Bird]

Well well!

Its all makes sense.

I think we were on the money with this one.

The ultrasound was never going to make the final diagnosis, but the presence of a small haemarthrosis triggered the investigation of an intra-articular derangement and bingo, the MRI has found exactly that.

I do like these sort of cases where ultrasound plays a pivotal role in pressing for further cross sectional imaging and the other modalities justify our concern.

Great work.

Steve.

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