bankurt radiology
TRANSCRIPT
7/30/2019 Bankurt Radiology
http://slidepdf.com/reader/full/bankurt-radiology 1/22
Home
Abdomen
Breast
Cardiovascular
Chest
Head Neck
Musculoskeletal
Neuroradiology
Pediatrics
Shoulder - BankartDislocation and Bankart lesions
Robin Smithuis and Henk Jan van der Woude Radiology department of the Rijnland hospital, Leiderdorp and the Onze Lieve Vrouwe Gasthuis, Amsterdam, the
Netherlands
Introduction o Clockwise approach to labral pathology
Dislocation o Anterior dislocation
o Bankart fracture
o
Hill-Sachs o Posterior dislocation
Bankart and variants o Bankart lesion
o Osseus Bankart
o Reverse Bankart
o Perthes lesion
o ALPSA
o GLAD
HAGL
Publicationdate May 21, 2012
A Bankart lesion is an injury of the anterior glenoid labrum due to anterior shoulder dislocation.
These labral tears make the shoulder unstable and susceptible to repeated dislocations.In this article we will focus on:
Shouder
dislocations
7/30/2019 Bankurt Radiology
http://slidepdf.com/reader/full/bankurt-radiology 2/22
Bankart tears and
variants
Introduction
Clockwise approach. Click on image to enlarge
Clockwise approach to labral pathology
A Clockwise approach to the labrum is the easiest way to diagnose labral tears and todifferentiate them from normal labral variants.
There are two types of labral tears: SLAP tears and Bankart lesions.
SLAP is an acronym that stands for 'Superior Labral tear from Anterior to Posterior'.SLAP tears start at the 12 o'clock position where the biceps anchor is located, which tears the
labrum off the glenoid.
SLAP tears typically extend from the 10 to the 2 o'clock position, but can extend more posteriorly or anteriorly and even extend into the biceps tendon.
Bankart lesions are typically located in the 3-6 o'clock position because that's where the humeral
head dislocates.
7/30/2019 Bankurt Radiology
http://slidepdf.com/reader/full/bankurt-radiology 3/22
There are many labral variants that may simulate a labral tear.They also have a typical location.
They are not in the 3-6 o'clock position, which makes it easy to differentiate them from a
Bankart tear.A Bankart tear can extend to the 1-3 o'clock position, but then there should also be a tear in the
3-6 o'clock position.
Labral variants however may mimick a SLAP tear.
Labral variants
Dislocation
Anterior dislocation
7/30/2019 Bankurt Radiology
http://slidepdf.com/reader/full/bankurt-radiology 4/22
The shoulder is a very mobile and therefore unstable joint.
It is the most dislocated joint in the body.
The humeral head is almost always displaced anteriorly, inferiorly and medially below thecoracoid process (95% of cases).
Motion to superior is limited by the acromion, coracoid process and rotator cuff (figure).
Motion in a posterior direction is limited by the posterior rim of the glenoid which is in ananteverted position.
The dislocation of the humeral head to antero-inferior causes damage to the antero-inferior rim
of the glenoid in the 3 - 6 o'clock position (marked in red).
Especially in younger patients this results in a Bankart fracture or a Bankart lesion which is atear of the anteroinferior labrum.
This results in instability and recurrent dislocations.Dye to these recurrent dislocations significant bone loss and erosion of the anterior glenoid rimmay occur, which will further increase the instability.
Anterior dislocation with Bankart fracture
The images show a subtle Bankart fracture (arrows).
7/30/2019 Bankurt Radiology
http://slidepdf.com/reader/full/bankurt-radiology 5/22
Bankart fracture
This is a post-reduction view.
Notice the very large fracure of the glenoid rim with displacement.
On the coronal-oblique and sagittal reconstruction the displaced fracment is seen in the 3-6
o'clock position.
There is also a large Hill-Sachs impression fracture.
7/30/2019 Bankurt Radiology
http://slidepdf.com/reader/full/bankurt-radiology 6/22
3D-reconstruction of a large bony Bankart in the 2 - 6 o'clock position.
LEFT: Hill-Sachs at level of coracoid. RIGHT: Normal groove seen at level below coracoid.
Hill-Sachs
On MR a Hill-Sachs defect is seen at or above the level of the coracoid process.
Hill-Sachs is a posterolateral depression of the humeral head.
It is above or at the level of the coracoid in the first 18 mm of the proximal humeral head.
It is seen in 75-100% of patients with anterior instability.It is chondral or osteochondral.
MRI is 94% accurate.The physiologic groove in the humerus or cysts and erosions at the attachment site of theinfraspinatus tendon can simulate a Hill-Sachs, but usually this is not a diagnostic problem
(figure).
7/30/2019 Bankurt Radiology
http://slidepdf.com/reader/full/bankurt-radiology 7/22
Posterior dislocation
Posterior dislocations are uncommon and easily missed, because there is less displacement
compared to the anterior dislocation.On the AP-view the head looks strange due to the internal rotation.
On the transscapular-Y view the humeral head is displaced posteriorly.
Sometimes the displacement is difficult to appreciate, especially when the transscapular-Y viewis slightly rotated.
Sometimes an axillary view can be of help, but when in doubt go to CT.
Posterior dislocation
Images of another patient with a posterior dislocation.On the transscapular-Y view the humeral head is displaced posteriorly. Notice the distance between the humeral head and the glenoid on the AP-view, which is
7/30/2019 Bankurt Radiology
http://slidepdf.com/reader/full/bankurt-radiology 8/22
abnormally wide.
Posterior dislocations are uncommon and not as obvious on the X-rays as an anterior
dislocation.Approximately half of the posterior shoulder dislocations go undiagnosed on initial presentation,
because of a low level of clinical suspicion and insufficient imaging.
Posterior dislocation-fracture
Posterior dislocations account for 2-4% of all shoulder dislocations.Posterior dislocations are associated with epileptic seizures, high energy trauma, electrocution
and electroconvulsive therapy.
This case is a posterior dislocation-fracture.
The MR-images are of a patient who had undergone both an anterior aswell as a posterior
dislocation.This resulted in both a Hill-Sachs impression fracture on the posterior aspect of the humeral head(blue arrow) and an impression fracture on the anterior aspect as a result of posterior dislocation
(red arrow).
7/30/2019 Bankurt Radiology
http://slidepdf.com/reader/full/bankurt-radiology 9/22
Superior dislocation
This was an incidental finding on a chest-film.There is a superior dislocation of the humeral head.This is probably the result of a very large long-standing rotator cuff tear with progressive
cranialisation of the humeral head and erosion of the acromion.
Bankart and
variants
Axial images of Bankart lesions and variants
7/30/2019 Bankurt Radiology
http://slidepdf.com/reader/full/bankurt-radiology 10/22
Bankart-lesions and variants like Perthes and ALPSA are injuries to the anteroinferior labrum.These injuries are always located in the 3-6 o'clock position because they are caused by an
anterior-inferior dislocation.The only exception to this rule is the reverse Bankart, which is the result of a posterior
dislocation and injury to the inferoposterior labrum.
Bankart tears may extend to superior, but this is uncommon.
Bankart
Detachment of the anteroinferior
labrum (3-6
o'clock) with
complete tearingof the anterior
scapular
periosteum with
or without anosseus fragment
of the glenoid.
Reverse
BankartDetachment of
the posteroinferior
labrum (6-9
o'clock) with
tearing of the posterior scapular
periosteum with
or without an
osseus fragmentof the glenoid.
Perthes Detachment of the anteroinferior
labrum (3-6
o'clock) with
medially stripped but intact perioste
um.
ALPSA =Anterior Labral
Periosteal Sleeve
Avulsion.Medially
displaced
7/30/2019 Bankurt Radiology
http://slidepdf.com/reader/full/bankurt-radiology 11/22
labroligamentous
complex with
absence of thelabrum on the
glenoid rim.
GLAD =GlenoLabralArticular
Disruption.
Represents a partial tear of
anteroinferior
labrum with
adjacent cartilagedamage.
Bankart lesion
Bankart lesion
Bankart lesions are labral tears without an osseus fragment.
MR arthrography or arthroscopy are optimal to diagnose Bankart or Bankart-like lesions.
There is a detachment of the anteroinferior labrum (3-6 o'clock) with complete tearing of the
anterior scapular periosteum.
The arrow points to the disrupted periosteum.
7/30/2019 Bankurt Radiology
http://slidepdf.com/reader/full/bankurt-radiology 12/22
On MR-athrography the labrum is missing on the anterior glenoid and the labral fragment isdisplaced anteriorly (arrow).
Osseus Bankart
Osseus Bankart
Bankart lesions with an osseus fragment are common findings in patients with an anterior
dislocation and are frequently seen on the x-rays or CT-scan.
7/30/2019 Bankurt Radiology
http://slidepdf.com/reader/full/bankurt-radiology 13/22
CT and MR-arthrography in a patient with an osseus Bankart (arrow)
On MR-arthrography it may be difficult to depict the osseus fragment.On CT it is easy to appreciate the osseus fragment of the anterior glenoid (arrow).
Bankart lesion with superior extension
Scroll through the images.There is an osseus Bankart lesion (curved red arrow).
The tear extends to superior (black arrows).
There is also a Hill-Sachs defect (red arrow).
7/30/2019 Bankurt Radiology
http://slidepdf.com/reader/full/bankurt-radiology 14/22
Bankart lesion with superior extention
Sagittal MR-arthrogram demonstrates the superior extension of the Bankart tear.
Osseus Bankart on a MR arthrogram ABER-view
Here another patient with an osseus Bankart seen on four consecutive images of a MR arthrogram in ABER-view.
Notice the abnormal contour of the anterior glenoid and the avulsed anterior rim (arrow)
7/30/2019 Bankurt Radiology
http://slidepdf.com/reader/full/bankurt-radiology 15/22
Reverse Bankart
CT-images in another patient show a reversed osseus Bankart in a patient with posterior
dislocation.
Axial MR-arthrogram of a reverse Bankart.
Reverse Bankart
Another example of a reverse Bankart.
Notice the detatched labrum at the 6-9 o'clock position on the sagittal MR-arthrogram.
7/30/2019 Bankurt Radiology
http://slidepdf.com/reader/full/bankurt-radiology 16/22
Perthes lesion: the labrum is thorn, but the periosteum is intact and only stripped (arrow)
Perthes lesion
A Perthes lesion is a labroligamentous avulsion like a Bankart, but with a medially
stripped intact periosteum.On images of the shoulder with the arm in a neutral position, the torn labrum may be held in its
normal anatomic position by the intact scapular periosteum, which thereby prevents contrast
media from entering the tear.This means that MR-arthrography with the arm in the neutral position may fail to detect the
labral tear.
In the ABER position however there is tension on the antero-inferior labrum by the stretched
anterior band of the inferior glenohumeral ligament and you have more chance to detect the tear.
The arrow points to the intact periosteum.
LEFT: normal ABER-view. RIGHT: Image rotated 90? anti-clockwise.
The images in ABER-position demonstrate a detached anterior labrum.The image on the right is rotated 90? anti-clockwise.
Sometimes this makes it easier to understand the anatomy.
7/30/2019 Bankurt Radiology
http://slidepdf.com/reader/full/bankurt-radiology 17/22
Images of a MR-arthrogram.The image on the left shows an absent anterosuperior labrum, which is called a Buford complex.
The image on the right shows a cartilage defect in the 4 o'clock position.
It is not clear whether the labrum is normal.
Continue with the images in ABER-position.
Buford complex
Buford complex
In the ABER-position it is obvious that there is a Perthes lesion (black arrow).Due to the ABER-position the anterior band of the inferior GHL creates tension on theanteroinferior labrum and contrast fills the tear.
The red arrow points to the absent labrum - Buford complex.
7/30/2019 Bankurt Radiology
http://slidepdf.com/reader/full/bankurt-radiology 18/22
ALPSA.
ALPSA
An ALPSA-lesion is an Anterior Labral Periosteal SleeveAvulsion.The anterior labrum is absent on the glenoid rim.
The arrow points to the medially displaced labroligamentous complex.
ALPSA
Images of a patient with an ALPSA-lesion. Notice the medially displaced labrum.
7/30/2019 Bankurt Radiology
http://slidepdf.com/reader/full/bankurt-radiology 19/22
ALPSA-lesion
Images of another patient with an ALPSA-lesion.The ABER-view shows an absent antero-inferior labrum.
The coronal images shows the medially displaced labrum (red arrow).
ALPSA-lesion
This is a difficult case.First scroll through the images and try to find out what is going on.
Then continue reading.
First notice the Hill-Sachs defect indicating a prior anterior dislocation (blue arrow). Now you know that you have to look for a Bankart or variant.
Next notice the high signal at 12 o' clock (red arrows).
On coronal images you want to make sure whether this is a variant like a labral recess or labral
foramen or whether this is a SLAP. Notice how this high signal continues posteriorly, which means that it is a SLAP-lesion.
The yellow arrow points to the anterior glenoid rim.
7/30/2019 Bankurt Radiology
http://slidepdf.com/reader/full/bankurt-radiology 20/22
The anterior labrum is absent at the 1-3 o 'clock position
This is a Buford complex, which is a normal variant.
The structure anterior to the glenoid is not a thorn labrum, but the middle glenohumeralligament.
Notice extention of the SLAP-tear further to posterior (red arrow).
Finally there is a medially displaced inferoanterior labrum at the 3-6 o 'clock position, i.e. anALPSA-lesion (black arrow).
GLAD-lesion
GLAD
A GLAD-lesion is a GlenoLabral Articular Disruption.
It represents a patial tear of the anteroinferior labrum with adjacent cartilage damage.The arrow points to the cartilage defect.
GLAD-lesion
The images show a partial tear of the anteroinferior labrum with adjacent cartilage damage at the4-6 o 'clock position (arrows).
7/30/2019 Bankurt Radiology
http://slidepdf.com/reader/full/bankurt-radiology 21/22
GLAD lesion
Scroll through the images.There is a Bankart lesion with extension into the cartilage, i.e a GLAD-lesion (red arrows).
HAGL
LEFT: Normal axillary recess (blue arrow). RIGHT: Abnormal axillary recess due to avulsion of the IGHL (red arrow)
HAGL is a Humeral Avulsion of the inferior GlenohumeralLigament.There is discontinuity of the IGHL attachment on the humerus with leakage of contrast.
7/30/2019 Bankurt Radiology
http://slidepdf.com/reader/full/bankurt-radiology 22/22
Another patient with an avulsion of the inferior glenohumeral ligament from the humeral
insertion.
1. Usefulness of the Abduction and External Rotation Views in Shoulder MR Arthrography
by Asgar M. Saleem, Joong K. Lee, Leon M. Novak
AJR 2008; 191:1024-1030
2. MR Imaging and MR Arthrography of Paraglenoid Labral Cysts
by Glenn A. Tung et al
AJR June 2000 vol. 174 no. 6 1707-1715
3. CT and MR Arthrography of the Normal and Pathologic Anterosuperior Labrum andLabral-Bicipital Complex
by Michel De Maeseneer et al
October 2000 RadioGraphics, 20, S67-S81.