Radiological Anatomy of the Glenohumeral Region Scapula Region, Scapula, and basics of Brachial Plexus

Department of Radiology, p gy, Vancouver General Hospital

Dr. Savvas Nicolaou Director of ER/Trauma Radiology savvas.nicolaou@vch.ca i l @ h

Lecture Objectives
Be able to identify the following structures on a normal shoulder radiograph: Clavicle Acromial end- clavicle Sternal end - clavicle St l d l i l Scapula Superior, inferior, Superior inferior and lateral angles Superior, medial and lateral borders Suprascapular notch Spine Acromion Coracoid process p p Supraspinous fossa Infraspinous fossa Glenoid cavity Subscapular f S b l fossa Supraglenoid tubercle Infraglenoid tubercle g Humerus Greater tuberosity Lesser tuberosity Head Surgical neck Anatomical neck Deltoid tuberosity

Lecture Objectives
Be able to identify the following (rotator cuff muscles) structures on a shoulder MRI: Supraspinatus muscle Infraspinatus muscle p Teres minor muscle Subscapularis muscle

Outline
Gross Anatomy of the glenohumeral region Approach to Radiographs: AP, lateral and axillary view Radiology Anatomy Atlas: glenohumeral region Common clinical pathologies

This material is EXAMINABLE so pay attention!

Anatomy Review Anatom Re ie

Glenohumeral region Clavicle, Scapula and Humerus

Gross Anatomy of Glenohumeral region

3 2
3 Bones
1. 2. 3. Humerus Scapula Clavicle

Gross Anatomy of Glenohumeral region

2 1
3 Joints
1. 2. 3. 3 Glenohumeral Acromioclavicular Sternoclavicular

Clavicle + Scapula - Anterior

Anterior
1: Clavicle, acromial end 2: Clavicle, sternal end 3: Scapula, superior border 4: Scapula, medial border Scapula 5: Scapula, lateral border 6: Inferior angle of scapula 7: Acromion 8: Coracoid Process 9: Superior angle of scapula 9 S i l f l 10: Suprascapular notch p g 11: Supraglenoid tubercle 12: Subscapular fossa

Scapula - Posterior

Posterior
1: Spine of scapula 2: Lateral angle of scapula 3: Supraspinous fossa 4: Infraspinous fossa 5: Glenoid cavity 6: Infraglenoid tubercle 7: Lateral border of scapula 8: Medial border of scapula

9: Superior b d of scapula 9 S i border f l 10: Acromion

Glenohumeral region: Scapula + Clavicle

7 8

9 3 1
1: Clavicle sternal end 2: Clavicle acromial end 3: Superior border of scapula 4: Medial border of scapula

4 5

5: Lateral border of scapula 6: I f i 6 Inferior angle of scapula l f l 7: Acromion 8: Coracoid process p 9: Suprascapular notch

Scapula - Lateral
1: Supraspinous fossa 2: Spine 3: Subscapular fossa 4: Glenoid cavity 5: I f Infraspinous fossa i f 6: Coracoid process 7. Acromion 8: Supraglenoid tubercle 9: Infraglenoid tubercle

2 3 7

4 5

Humerus

1: Deltoid tuberosity

2: Greater Tuberosity 3: Lesser Tuberosity 4: Head of humerus 5: Anatomical neck 6: Surgical neck 7: 7 Bicipital Groo e Groove

Glenohumeral joint

Ball and socket joint

Very mobile flexion, extension, abduction, adduction, lateral and medial rotation

Price: instability

45% of all dislocations

Glenohumeral joint stability

Joint stability depends:

1. 2. 3. 3

Glenoid labrum Joint capsule Bony restraints Glenoid fossa, Acromion, Coracoid

Glenohumeral joint stability

Joint stability depends:

4.

Glenohumeral ligaments Superior, Middle, Inferior

5. 5

Rotator cuff muscles

Gross Anatomy of Glenohumeral region Rotator cuff muscles

4 3 1

Posterior 1. Subscapularis 2. Supraspinatus 3. 4. Infraspinatus Teres minor

Anterior

Rotator cuff muscles

Muscle Supraspinatus muscle

Origin on scapula supraspinous fossa

Attachment on Function Innervation humerus superior and middle facet of Suprascapular abducts the arm the greater nerve (C5) tuberosity posterior facet of the greater tuberosity inferior facet of the greater tuberosity externally rotates the arm externally rotates the arm Suprascapular nerve (C5-C6) Axillary nerve (C5) Upper and Lower subscapular nerve (C5 C6) (C5-C6)

Infraspinatus muscle Teres minor muscle

infraspinous fossa middle half of lateral border

Subscapularis muscle

subscapular fossa

lesser tuberosity (60%) or internally rotates humeral neck the humerus (40%)

AP View

Technique:

Cassette on patients back, x-ray beam at right angles to this plane and centered on shoulder

Lateral View
Technique:

anterior aspect of shoulder along plate, rotate, non-imaged shoulder 40 degrees out

x-ray tube is then placed posteriorly along scapular spine

Axillary View
Technique: q Cassette on patients shoulder, shoulder x-ray beam shot through the axilla
Allows assessment of humeral head anteriorly and p posteriorly y

RADIOLOGY ATLAS

Glenohumeral region clavicle, scapula and humerus

Deltoid Tuberosity Deltoid Muscle Suprascapular notch

What is the arrow pointing at? Deltoid tuberosity

What muscle attaches to it? Deltoid muscle

AP View

1. 2. 3. 4.

Clavicle acromial end Clavicle- sternal end Acromion Coracoid process

1 3 4 2

AP View

5. Glenoid cavity 6. Humerus greater tuberosity y 7. Humerus lesser tuberosity 8. Head of humerus

8 7 6

AP View

11

9. Surgical neck of humerus 10. 10 Anatomical neck of humerus 11. Supraglenoid tubercle 12. Infraglenoid tubercle 12 I f l id b l

10 9 12

AP View

1 1 4 2 3 4

1. Clavicle acromial end 2. Clavicle- sternal end

3. Acromion 4. Coracoid process

AP View

8 7 6

8 6

5. Glenoid Cavity 6. Humerus greater tuberosity

7. Humerus lesser tuberosity 8. Head of Humerus

AP View

11 10 9 12 10 9

9. Surgical neck of Humerus 10. Anatomical neck of Humerus

11. Supraglenoid tubercle 12. Infraglenoid tubercle

1 2 3 3

A) What are the borders of the scapula indicated by the yellow arrows? ? 1. Lateral border 2. Superior border 3. 3 Medial border B) What are the angles of the scapula indicated by the green arrows?

1. Superior angle 2. Inferior angle 3. Lateral angle

Lateral View

1 7 3 2 4 5

1. 1 Clavicle acromial end 2. Acromion 3. Coracoid process p 4. Spine of scapula 5. Head of humerus 6. Humerus 7. Superior angle of scapula 8. 8 Inferior angle of scapula

1 7 3 4 3 5

1 2 4

6 8

1. 2. 3. 4. 5. 6. 7. 8.

Clavicle acromial end Acromion Coracoid process Spine of scapula Head of humerus Humerus Superior angle of scapula Inferior angle of scapula

Axillary View
1. 2. 3. 4. 4 Humerus Coracoid Process Clavicle Glenoid cavity Gl id it 5. 6. 7. 8. Greater tuberosity Lesser tuberosity Intertubercular sulcus Head of humerus 9. Anatomical neck 10. Surgical neck 11. Acromion

2 5 7 6 1 10 8 9 11 4 3

CT Images- Axial
1. 1 Clavicle 2. Humerus 3. Coracoid Process 4. 5. 6. Glenoid Cavity Spine of Scapula Scapula

* Rotator Cuff Muscles

2 4 5

1 2 4 3

*
6

*
6

CT Images- Coronal
1. 2. 3. 4. 4 Clavicle Acromion Head of Humerus Glenoid Cavity

2 3 4

1 4

2 3

Anatomical Neck Surgical Neck

Lateral View

1
What fossa are here?

1. 1 2. 3.

Supraspinous f S i fossa Infraspinous fossa Subscapular fossa p

MRI of Muscles (Coronal)

2 3 4 1 1 4

1. 2. 3. 4.

Deltoid Muscle p p Supraspinatous Muscle Subscapularis Muscle Teres Minor

MRI of Muscles (Axial, Right Shoulder)

Anterior

1 5 2 6 4 3 5 2 6 4 1

1. 2. 3. 4. 5. 6.

Posterior Deltoid Muscle Supraspinatous Muscle p Subscapularis Muscle Infraspinatus Muscle Scapula Spine of scapula

MRI of Muscles (Axial, Right Shoulder)

Anterior

1 3

1 5 3 2 6 4

3 1

5 4 4

1. 2. 3. 4. 5. 6.

Deltoid Muscle Posterior Supraspinatous Muscle Subscapularis Muscle p Infraspinatus Muscle Scapula Spine of scapula

COMMON PATHOLOGIES

Glenohumeral- scapular region

Anterior shoulder dislocation

Humeral head displaces anteriorly (95%+) Most often post-trauma Repeat dislocation common, even with minor trauma Mechanism: abduction and external rotation most commonly Imaging: AP and Lateral views Tx: conservative, shoulder reduction

What view is this?

AP Vi View

Anterior shoulder dislocation AP view

humeral head is abnormally positioned displaced inferiorly and medially on AP radiographs

Anterior dislocation of the shoulder in a 59-year old female. The AP view shows the humeral head to be displaced inferiorly and medially in relation to the now empty glenoid fossa (red arrow).

What view is this?

Lateral view

Has the humerus moved anteriorly or posteriorly?

Anteriorly

Anterior Shoulder Dislocation lateral view

Lateral view of the glenohumeral joint demonstrating anterior dislocation of humerus (blue) and the empty glenoid cavity (orange)

humeral head is abnormally positioned

displaced anteriorly on lateral radiograph

Where is the fracture through? h h?

Surgical neck of humerus

Surgical neck of humerus fracture

Most common fracture of the proximal humerus; more frequent than fracture of anatomical neck

Extracapsular fracture area with good fracture, blood supply, thus, low risk of Avascular Necrosis

Fracture in this area is very likely to damage axillary nerve which supplies deltoid muscle Test by asking patient to ABDUCT arm

Surgical neck of humerus fracture

Surgical neck of humerus fracture