ROTATOR CUFF TEAR PATTERNS and normal.pptx

shoulder

1. ROTATOR CUFF TEAR PATTERNS: MRI APPERANCE AND SURGICAL RELEVANCE

2. Objectives

3. Outline

4. What is rotator cuff ? Rotator cuff includes both rotator cuff tear and impingement syndrome. Rotator cuff is made up of muscles, tendons & bones. Fine adjustments of the humeral head within the glenoid is achieved by coordinated activity of 4 intra-related muscles, arising from the scapula and is called rotator cuff.

5. Rotator cuff injury

6. Normal Joint Motions and Bony Positions Around the Shoulder Joint SCAPULA Rotation through arc of 65 degrees with shoulder abduction Translation on thorax up to 15 cm GLENOHUMERAL JOINT Abduction 140 degrees Internal/external rotation 90 degrees/90 degrees Translation Anterior–posterior 5-10mm Inferior–superior 4–5 mm

7. Bones of rotator cuff- Scapula Humerus Clavicle Muscles of rotator cuff- Supraspiantus Infraspinatus Teres minor subscapularis

8. SUPRASPINATUS Origin: Spine of the shoulder blader (Supraspinatus fossa) Insertion: Greater tuberosity of the humerus (Superior facet) Bellies: Superficial - Most exterior, most directly involved in abduction and stabilization Middle - Complex movement and contributes to fine movement Deep - Stabilizing the head of the humerus within the glenoid cavity, pr

9. SUPRASPINATUS Nerve: Suprascapular nerve, C5 &6, superior trunk of brachial plexus Blood supply: Suprascapular artery and dorsal scapular arteries

10. SUPRASPINATUS Action: Abduction: 0 - 15 degrees Assists deltoid abduction up to 90 degrees Upper trapezius: >90 degrees Function: Shoulder stability Active movement

11. SUPRASPINATUS Characteristic Anterior belly > Voluminous > Tubular > Bipennate confguration > Generates greater contractile forces than the posterior belly, partly because of its long intramuscular tendon Posterior belly > Smaller > Unipennate > Tendon is fatter and wider. > Generates less contractile forces

12. ROTATOR CUFF TEARS

13. Posterosuperior cuff tears MR Arthography Abducted and External rotated position (ABER) - improves its visualization

14. Posterosuperior cuff tears MR Arthography Abducted and External rotated position (ABER) - improves its visualization

15. Partial thickness posterosuperior cuff tears ARTICULAR < 50% THICKNESS MOST FREQUEST OF RC TEAR 15 - 60% FIBERS that are in contact with the HUMERAL HEAD Exposed to HIGH tension LESS elastic MORE resistant to deformation

16. Partial thickness posterosuperior cuff tears ARTICULAR < 50% THICKNESS MOST FREQUEST OF RC TEAR 15 - 60% FIBERS that are in contact with the HUMERAL HEAD Exposed to HIGH tension LESS elastic MORE resistant to deformation MR Arthography Abducted and External rotated position (ABER) - improves its visualization

17. Partial thickness posterosuperior cuff tears BURSAL > 50% THICKNESS 18% FIBERS close to the SUBACROMIAL BURSA LESS stiff

18. Partial thickness posterosuperior cuff tears INTERSTIAL (INTRASUBSTANCE/ INTRATENDINOUS > 50% THICKNESS 22% However Within the TENDON

19. Posterosuperior cuff tears ARTICULAR < 50% THICKNESS MOST FREQUEST OF RC TEAR 15 - 60% FIBERS that are in contact with the HUMERAL HEAD Exposed to HIGH tension LESS elastic MORE resistant to deformation BURSAL > 50% THICKNESS 18% FIBERS close to the SUBACROMIAL BURSA LESS stiff INTERSTIAL (INTRASUBSTANCE/ INTRATENDINOUS > 50% THICKNESS 22% However Within the TENDON

20. Posterosuperior full thickness tears Tear extending from articular side to the bursal side of the tendon These types of tendinous lesions often involve the SS and IS. A teres minor full thickness tear is extremely rare

21. ISAKOS consensus recommends for full thickness tears MRI assessment: Pattern Extension Retraction of the tendons Pattern description Geometric shape/pattern(Four types) by Davidson and Burkhart: crescent-shaped U-shaped L shaped Inverted L shape Posterosuperior full thickness tears

22. PATTERN CRESCENT U- SHAPED L- SHAPED/INVERTED L Posterosuperior full thickness tears

23. Posterosuperior full thickness tears SYNDER CLASSIFICATION C1 Small full thickness tear with a pinhole Superficial layers are affected, but the overall structural integrity of the tendon is maintained. C2 Moderate full thickness tear <2 cm involving one tendon with/without retraction Larger partial-thickness tears where a more significant portion of the tendon thickness is torn, but still not a full rupture.

24. C3 Extensive full thickness tear with retraction 3 - 4 cm Full-thickness tears involving a complete tear through the tendon, typically leading to significant functional impairment. C4 Massive tear involving two or more tendons with marked retraction and scarring Massive tears involving multiple tendons or severe tendon degeneration, often associated with significant muscle atrophy or fatty infiltration. Posterosuperior full thickness tears

25. Posterosuperior full thickness tears PATTE CLASSIFICATION GRADE I Tear with minimal retraction GRADE II Rectracted over the vertex of the humeral head GRADE III Fibers rectacted to the superior glenoid margin

26. Posterosuperior full thickness tears repair CRESCENT U- SHAPED L- SHAPED/INVERTED L

27. DELAMINATED TEARS Intratendinous horizontal tears Splitting the Articular and Bursal layer Supraspinatus Infraspinatus W/or w/out retraction 38 - 82% of RC tears Articular layer is more frequently retracted than the bursal layer. Exceptionally, the retracted articular layer can be fipped downwards (Fig.  16). Sometimes, it is difcult to demonstrate on MRI a partial thickness delaminated tear due to the absence of fuid between the layers

28. Complete tear with articular layer more medially retracted than the superior layer Articular layer more retracted than bursal layer (arrow in a). Complete tear with bursal layer more medially retracted than the articular layer Bursal layer more retracted than articular layer (arrow in b)

29. Complete tear with both layers equally retracted. bursal and articular layers equally retracted (arrow in c) Partial thickness articular side tear with horizontal splitting extension Articular side tear with intratendinous extension and retraction (arrow in d)

30. Partial thickness bursal side tear with intratendinous splitting tear Bursal side tear (arrow in e) with intratendinous extension (dashed arrow). Intrasubstance tear with intratendinous extension Intrasubstance tear with horizontal intratendinous extension (arrow in f)

31. Treatment of delaminated tears is complicated and difers from tears without delamination. Many techniques have been described but essentially the objective is to repair the layers separately in order to restore their original insertions and restore the func_x0002_tion of the RC [52]. Te deep layer (superior gleno_x0002_humeral capsule, corresponding to layer 5 described above) is pulled laterally and fxed on the medial edge of the greater tuberosity and the superfcial layer (SS or IS) is pulled anterolaterally and fxed on the lateral edge of the footprint on the greater tuberosity

32. Fosbury fop tear In a full thickness tear, the tendon stump can flip backwards upon itself, hence the name "Fosbury” , and Adhere superomedial in the bursal-sided . On MRI, tendon stump is found to be thicker on the bursal-sided with a superomedial orientation

33. Intramuscular rotator cuff cysts Associated with partial or full thickness rotator cuff tears Intra-articular fluid - enters the tear and dissects horizontal plane into the muscle Located within the sheath or intrasubstance

34. Intramuscular rotator cuff cysts 1. Ganglion Cysts: Most common Associated with labral tears or glenohumeral joint pathology Fluid leakage from a joint or tendon sheath leading to a cystic structure within the muscle or tendon

35. Intramuscular rotator cuff cysts 2. Paralabral Cysts: Related to tear in the Glenoid Labrum Fluid leaks into the surrounding soft tissue , including the r otator cuff muscles Frequently occurs along: Posterior Anterior Superior aspect Inferior - Least common Posterosuperior - Most common

36. Myotendinous injuries They can be observed in all rotator cuff muscle Infraspinatus slight predominance Due to functional demand Key muscle for External rotation Abduction and Extrenal rotation - subjected to higher degree of stress and tension into this muscle Poor vascular supply Eccentric loading

37. Myotendinous injuries

38. Fatty infltration GRADE 1 GRADE 2 GRADE 3 GRADE 4 GRADE 5

39. Anterior tears

40. Anterior tears - Lafosse classification Type Description Clinical Feature MRI findings 1 Partial tear of the upper third of the subscapularis tendon. Mild weakness in internal rotation Partial-Thickness tear, limited to superior portion T2-weighted images: Hyperinensity (Fluid/Edema) Tendon show increase signal but still attached No retraction 2 Complete tear of the upper third of the subscapularis tendon, but the rest of the tendon is intact. Moderate weakness in internal rotation Full thickness, upper third of tendon Partial discontinuity, insertion of lesse tuberosity Middle and lower tendon intract No significant retraction T2-weighted images: Hyperinensity (Fluid/Edema) 3 Complete tear of the entire subscapularis tendon without significant tendon retraction. Significant loss of internal rotation Full thickness of subscapularis tendon Tendon show discontinuity, with complete detachment No or minimal tendon retraction Fluid in subcoracoid bursa 4 Complete tear of the subscapularis tendon with mild retraction of the tendon medially, toward the glenoid rim. More pronounced weakness with shoulder instability Full thickness with moderate retraction Retracted to medial margin of lesser tuberosity Mild atrophy or fatty infiltration Fluid in subcoracoid space and instability of long head 5 Complete tear of the subscapularis tendon with major retraction , typically to the level of the glenoid. Severe weakness, functional loss and shoulder instability Full thickness with severe retraction, medially or near glenoid Signficant muscle atrophy Long head of biceps tendon may be dislocated or subluxed

41. TYPE 1 TYPE 2 TYPE 3 TYPE 4 TYPE 5

42. BICEP PULLEY

43. Fatty infltration