Transcript diagnostic and therapeutic role of imaging in

DIAGNOSTIC AND THERAPEUTIC
ROLE OF IMAGING IN ADHESIVE
CAPSULITIS
DR.PREM CHAND PALADUGU
AARUPADAI VEEDU MEDICAL COLLEGE & HOSPITAL
DEFINITION : A CLINICAL CONDITION CHARACTERISED BY SEVERE RESTRICTION OF ACTIVE & PASSIVE
MOTION OF GLENOHUMERAL JOINT AND IN WHICH NO OTHER CAUSE CAN BE DOCUMENTED
SYNONYMS : CAPSULITIS / PERIARTHRITIS / FROZEN SHOULDER
LUNDBERG CLASSIFICATION
• PRIMARY : NO PREDISPOSING CAUSE / EVENT
• SECONDARY : PREVIOUS H/O TRAUMA
AGE : 40- 70 yrs
SEX : MORE COMMON IN FEMALES N.
PREDISPOSING FACTORS : TRAUMA, HEMIPLEGIA, CEREBRAL HEMORRHAGE, CERVICAL DISEASE,
DIABETES MELLITUS (10-20%), HYPERTHYROIDISM
ASSOCIATION - DUPUYTRENS CONTRACTURE
CAN INVOLVE : ANKLE , WRIST , HIP
UNILATERAL FOLLOWED BY BILATERAL INVOLVEMENT(20-40%)
PHASES OF DISEASE
•
PAINFUL PHASE - PROGRESSIVE PAIN ,WORSE AT NIGHT
OVER A PERIOD OF WEEKS TO MONTHS
•
STIFFENING PHASE - SLOW PROGRESSIVE LOSS OF
SHOULDER MOTION (4-12 m )
•
THAWING PHASE - SHOULDER MOTION GRADUALLY
REGAINED ( WEEKS TO MONTHS )
SELF LIMITED CONDITION (12-18 MONTHS)
VARIABLE OUTCOME - FULL RECOVERY OF SHOULDER
MOTION NEVER OCCURS IN SOME CASES
RADIOGRAPHY
•
MAIN ROLE IS TO RULE OUT OTHER CONDITIONS LIKE CHRONIC ROTATOR CUFF TEAR, CALCIFIC TENDINITIS
MAY SHOW
•
NONSPECIFIC PERIARTICULAR OSTEOPOROSIS
•
LOSS OF PERIARTICULAR BONE MINERAL DENSITY IS UNRELATED TO PATIENTS AGE, RANGE OF SHOULDER
MOTION, DURATION OF DISEASE
•
SCLEROTIC & CYSTIC CHANGES IN GREATER TUBEROSITY OF HUMERUS
•
RARELY BUTTRESSING OF CORTEX OF PROXIMAL & MEDIAL PORTION OF HUMERAL NECK
USG
•
•
•
NO ESTABLISHED ROLE
LIMITATION OF MOVEMENT OF SUPRASPINATUS TENDON WITH RESPECT TO ACROMION
HYPOECHOIC TEXTURE AND INCREASED VASCULARITY WITHIN ROTATOR INTERVAL
ARTHROSCOPY
•
NO ESTABLISHED ROLE
ARTHROGRAPHY
•
SINGLE CONTRAST STUDY IS PREFERABLE
FEATURES
• LOW CAPACITY OF JOINT (5-8 cc), WITH INCREASED RESISTANCE TO JOINT
INJECTION AND A TIGHT FEEL; WHEN HAND IS RELEASED FROM PLUNGER
FLUID REENTERS SYRINGE
• SUBSCAPULAR/ AXILLARY RECESS ARE SMALL/ ABSENT
• VARIABLE FILLING OF BICIPITAL TENDON SHEATH
• CONTRAST LEAK FROM SUBSCAPULAR RECESS, BICIPITAL TENDON
SHEATH
• OPACIFICATION OF LYMPHATIC CHANNELS
• IRREGULARITY AT CAPSULAR INSERTION SITE
ARTHROGRAPHY
TIGHT LOOKING JOINT
SMALL AXILLARY RECESS
OPACIFICATION OF LYMPHATIC CHANNELS
•
CRITERIA TO BE EVALUATED ON MRI
AT ROTATOR CUFF INTERVAL ( IN SAGITTAL OBLIQUE PLANE )
•
THICKNESS OF CORACOHUMERAL LIGAMENT
•
THICKNESS OF CAPSULE
•
PRESENCE OF INCREASED SIGNAL INTENSITY
SUBCORACOID FAT TRIANGLE
•
PARTIAL / COMPLETE OBLITERATION OF FAT
PRESENCE / ABSENCE OF SYNOVITIS LIKE ABNORMALITY
•
AT SUPERIOR BORDER OF SUBSCAPULARIS TENDON
•
AROUND LONG HEAD OF BICEPS TENDON
•
AROUND SUPRASPINATUS MUSCLE TENDON
SAGITTAL OBLIQUE MRI OF ROTATOR
INTERVAL
ON SAGITTAL OBLIQUE T 1 WEIGHTED SPIN ECHO
IMAGE
THICKEST PORTION OF CORACOHUMERAL LIGAMENT
SHOULD BE MEASURED
MENGIARDI ET AL
A - CAPUT HUMERI
B - CORACOID NOTCH
C - SUPRASPINATUS MUSCLE
ON SAGITTAL OBLIQUE T 1 WEIGHTED SPIN ECHO
IMAGE
THICKEST PORTION OF CAPSULE PERPENDICULAR TO
SURFACE OF HUMERAL HEAD SHOULD BE MEASURED
ALONG A RADIAL LINE DRAWN TO CENTRE OF
HUMERAL HEAD
MENGIARDI ET AL
A - CAPUT HUMERI
B - CORACOID NOTCH
C - SUPRASPINATUS MUSCLE
D - CORACOBRACHIAL MUSCLE
SAGITTAL OBLIQUE T 1 WEIGHTED SPIN ECHO IMAGE
OF SUBCORACOID FAT TRIANGLE
BORDERS OF SUBCORACOID FAT TRIANGLE
ANTEROSUPERIORLY - CORACOID PROCESS
SUPERIORLY - CORACOHUMERAL LIGAMENT
POSTEROINFERIORLY - JOINT CAPSULE
MENGIARDI ET AL
A - CAPUT HUMERI
B - CORACOID NOTCH
D - CORACOBRACHIAL MUSCLE
SUBCORACOID FAT TRIANGLE
MRI
• CAPSULAR THICKNESS > 4 mm IS 70% SENSITIVE AND 90%
SPECIFIC
• MOST SENSITIVE INDICATOR : QUANTITATIVE ASSESSMENT OF
ENTIRE WIDTH OF AXILLARY POUCH IF EQUAL TO OR MORE THAN 8
mm AS MEASURED ON CORONAL T1 WEIGHTED SPIN ECHO IMAGES
DURING INFLAMMATORY STAGE ON POST CONTRAST & WATER
SENSITIVE SEQUENCES
A. HIGH SIGNAL WITHIN AND ABOUT THE JOINT CAPSULE
B. ENHANCING FIBROUS TISSUE AT CORACOHUMERAL LIGAMENT &
BICEPS TENDON WITH MARROW OEDEMA IN ADJACENT HUMERUS
CHRONIC STAGE - THICKENING OF SYNOVIUM & CAPSULAR TISSUE;
CONSTRICTED / DISTORTED JOINT CAVITY ON MR ARTHROGRAPHY
BRISEMENT PROCEDURE
•
ARTHROGRAM SOLUTION : CONTRAST ,
CORTICOSTEROIDS, LIDOCAINE AND SALINE INJECTED
INTERMITTENTLY SO AS TO REACH LARGE VOLUMES
•
SOME FLUID MAY REENTER THE SYRINGE WITH EACH
INJECTION
•
WHEN INJECTED EXCESSIVELY, EXTRAVASATION CAN
OCCUR INTO SUBSCAPULAR RECESS, BICIPITAL TENDON
SHEATH
•
POSTPROCEDURAL PHYSICAL THERAPY
•
WITH SEVERE CAPSULAR RESTRICTION , PROCEDURE IS
LESS BENEFICIAL
NORMAL ROTATOR INTERVAL : OBLIQUE SAGITTAL T 1
WEIGHTED FAST SPIN ECHO MR IMAGE
CORONAL OBLIQUE T 2 WEIGHTED SPIN ECHO MR IMAGE
JOINT CAPSULE THICKENING ADJACENT TO
MEDIAL ASPECT OF HUMERAL NECK
OBLIQUE SAGITTAL FAT SUPPRESSED INTERMEDIATE
WEIGHTED FAST SPIN ECHO MR IMAGES
OBSCURATION OF CORACOHUMERAL LIGAMENT
BY HIGH SIGNAL INTENSITY OF INFLAMMATORY TISSUE IN
ROTATOR INTERVAL
CAPSULAR AND PERICAPSULAR OEDEMA
OBLIQUE SAGITTAL FAT SUPPRESSED
T 2 WEIGHTED FAST SPIN ECHO MR
INCREASED SIGNAL IN
ROTATOR INTERVAL
BICEPS TENDON
OBLIQUE SAGITTAL POST CONTRAST T1 WEIGHTED FAST SPIN ECHO
MR
ENHANCEMENT OF
CAPSULAR & PERICAPSULAR TISSUES
IN ROTATOR INTERVAL
POST CONTRAST T1 WEIGHTED SPIN ECHO MR IMAGE
OBLIQUE CORONAL
ENHANCING CAPSULAR & PERICAPSULAR TISSUES
THROUHOUT THE JOINT
MORE MARKED IN
ROTATOR INTERVAL ( ARROWS )
AXILLARY POUCH ( ARROW HEADS )
TRANSVERSE
TRANSVERSE
SAGITTAL
CONCLUSION
•
X - RAY , USG HAS ADJUNCT ROLE AND MRI
ARTHROGRAPHY HAS DEFINITIVE ROLE IN
THE DIAGNOSIS
•
BRISEMENT PROCEDURE GIVES IMMEDIATE
PAIN RELIEF TO HTE PATIENT , MAY NOT BE
BENEFICIAL IN LATE STAGES
REFERENCES
1.INTERNAL DERANGEMENT OF JOINTS; DONALD RESNICK, HEUNG SIK
KANG;
2. AN MRI STUDY OF SYMPTOMATIC ADHESIVE CAPSULITIS. PLOSONE
7(10): e47277. doi:10.1371