These are the same AP and lateral X-rays of the right shoulder seen in the previous post, now with orange arrows pointing to multiple loose bodies within the shoulder. The patient was absolutely right; she DOES have boulders rolling around in her shoulder. ⠀⠀⠀⠀⠀⠀⠀⠀⠀ ⠀⠀⠀⠀⠀⠀⠀⠀⠀ ⠀⠀⠀⠀⠀⠀⠀⠀⠀ ⠀⠀⠀⠀⠀⠀⠀⠀⠀⠀⠀⠀⠀⠀⠀⠀⠀⠀ ⠀⠀⠀⠀⠀⠀⠀⠀⠀ ⠀⠀⠀⠀⠀⠀⠀⠀⠀ ⠀⠀⠀⠀⠀⠀⠀⠀⠀ The loose bodies are most likely made of bone given that they have a similar density to the normal bone seen in the x-ray. Looking at the lateral (scapular-Y) X-ray on the right, we can tell that the loose bodies are focused within the anterior inferior aspect of the shoulder, likely within either the subscapularis recess or the subcoracoid recess which are common holding areas of loose bodies within the shoulder. ⠀⠀⠀⠀⠀⠀⠀⠀⠀ ⠀⠀⠀⠀⠀⠀⠀⠀⠀ ⠀⠀⠀⠀⠀⠀⠀⠀⠀ ⠀⠀⠀⠀⠀⠀⠀⠀⠀ These pieces of bone were most likely formed over time as an osteophyte growing off of the inferior medial part of the humerus (blue arrow), eventually breaking off and floating freely within the shoulder. This is a degenerative process and is different than synovial chondromatosis which is a proliferative disease that results in the presence of multiple intraarticular loose bodies that are commonly composed of firm modules of cartilage. ⠀⠀⠀⠀⠀⠀⠀⠀⠀ ⠀⠀⠀⠀⠀⠀⠀⠀⠀ ⠀⠀⠀⠀⠀⠀⠀⠀⠀ ⠀⠀⠀⠀⠀⠀⠀⠀⠀ Loose bodies within a joint can cause mechanical symptoms of locking and catching of the shoulder. If these symptoms are frequent and bothersome to the point of significantly negatively impacting someone’s quality of life, the treat is to remove them arthroscopically. ⠀⠀⠀⠀⠀⠀⠀⠀⠀ ⠀⠀⠀⠀⠀⠀⠀⠀⠀ ⠀⠀⠀⠀⠀⠀⠀⠀⠀ ⠀⠀⠀⠀⠀⠀⠀⠀⠀
These are AP and lateral X-rays of a right shoulder. Can you identify the pathology? ⠀⠀⠀⠀⠀⠀⠀⠀⠀ ⠀⠀⠀⠀⠀⠀⠀⠀⠀ ⠀⠀⠀⠀⠀⠀⠀⠀⠀ ⠀⠀⠀⠀⠀⠀⠀⠀⠀ Hint: This patient stated, “It feels like boulders are rolling around in my shoulder when I raise my arm.”
These three X-ray images show the postoperative images after a fusion of the painful os acromiale was performed (see previous two posts). I created a flat surface for each end of the bone (orange arrow) with a saw and then used those cut pieces of bone as local bone graft on top of the fusion (an on-lay technique). This avoids having to take bone graft from the patient’s hip bone which can result in significant, lasting pain. The two screws shown in the X-rays are cannulated, meaning that they are hollow. Utilization of cannulated screws for this surgery allows me to thread surgical cables through the screws, cinching them tightly around the bones, which provides additional fixation and compression across the fusion site. The fourth image shows a diagram of the acromion with its 3 ossification centers: ⠀⠀⠀⠀⠀⠀⠀⠀ ⠀⠀⠀⠀⠀⠀⠀⠀⠀ ⠀⠀⠀⠀⠀⠀⠀⠀⠀⠀⠀⠀⠀⠀⠀⠀⠀ * MTA: meta-acromion (base) - origin of posterior portion of deltoid * MSA: meso-acromion (mid) - origin of middle deltoid * PA: pre-acromion (tip) - origin of anterior deltoid fibers and coracoacromial ligament ⠀⠀⠀⠀⠀⠀⠀⠀⠀ ⠀⠀⠀⠀⠀⠀⠀⠀⠀ ⠀⠀⠀⠀⠀⠀⠀⠀⠀ ⠀⠀⠀⠀ An os acromiale is an unfused secondary ossification center.⠀⠀⠀⠀⠀⠀⠀⠀⠀ ⠀⠀⠀⠀⠀⠀⠀⠀⠀ ⠀⠀⠀⠀⠀⠀⠀⠀⠀ ⠀⠀⠀⠀⠀⠀⠀⠀⠀ * The most common location is the junction of meso- and meta-acromion (orange arrow in the xray)
This is the arthroscopic view of the os acromiale from the previous post. We’re looking upwards at the undersurface of the acromion. It should be a single bone but in this case, you can see the mobility in the unfused growth plate when pressure is applied to the top of the shoulder. ⠀⠀⠀⠀⠀⠀⠀⠀⠀ ⠀⠀⠀⠀⠀⠀⠀⠀⠀ ⠀⠀⠀⠀⠀⠀⠀⠀⠀ ⠀⠀⠀⠀⠀⠀⠀⠀⠀ There is an overall incidence of this condition of 8% with about 60% of patients having bilateral os acromiales. It is unknown how many people develop pain related to a symptomatic os acromiale, but the number is far less than the prevalence of shoulders with an os acromiale. Frequently, the finding of an os acromiale is simply an incidental one on X-ray. ⠀⠀⠀⠀⠀⠀⠀⠀⠀ ⠀⠀⠀⠀⠀⠀⠀⠀⠀ ⠀⠀⠀⠀⠀⠀⠀⠀⠀ ⠀⠀⠀⠀⠀⠀⠀⠀⠀ The pain generated by a symptomatic is acromiale is thought to be the result of an impingement-type process where the subacromial space is reduced due to flexion of the mobile anterior fragment with deltoid contraction and arm elevation.
This axial cut MRI image shows a developmental abnormality in the shoulder that can be a cause of significant pain. The orange arrows point to the os acromiale which is an unfused growth plate. The white is edema or swelling in the bone, indicating that there is irritation there. This patient had a diagnostic ultrasound-guided injection into the os acromiale which temporarily eliminated all of his shoulder pain. He tried physical therapy but this did not help with his symptoms. ⠀⠀⠀⠀⠀⠀⠀⠀⠀ ⠀⠀⠀⠀⠀⠀⠀⠀⠀ ⠀⠀⠀⠀⠀⠀⠀⠀⠀ ⠀⠀⠀⠀⠀⠀⠀⠀⠀ The white arrows point to the AC joint, which is a normal structure. This can also become irritated and be a source of pain in the shoulder but the location is in the front of the shoulder as opposed to the side.
These two X-rays show a humeral shaft fracture that has been surgically stabilized with a plate and screws. The left image is immediately postop and the image on the right is 4 weeks out from surgery. The white arrows in each image point to the fracture line. Immediately after surgery (left image) the fracture line is almost invisible, and 4 weeks out from surgery, the fracture line is slightly more visible which is normal at this point in the healing process (part of the healing process involves cells called osteoclasts removing bone to allow for the laying down of new bone by cells called osteoblasts) but there is new bone present spanning the fracture site (this is called “callus”). This is the bump directly under the white arrow tip in the image on the right.
These are the postop and preop X-rays from the previous post (Jay the ab roller extraordinaire). He had severe rotator cuff tear arthropathy with significant pain and limitations in his daily activities because of the pain. ⠀⠀⠀⠀⠀⠀⠀⠀⠀ ⠀⠀⠀⠀⠀⠀⠀⠀⠀ ⠀⠀⠀⠀⠀⠀⠀⠀⠀ ⠀⠀⠀⠀⠀⠀⠀⠀⠀ The first two images show the reverse total arthroplasty (AP and scapular Y X-rays). The third image shows his shoulder preoperatively with proximal migration of the humeral head and a very narrow humeral acromial interval (orange arrow and orange line). Another way to determine if these changes are present is to look at the inferior Gothic arch of the shoulder and see if it is broken (in this case it is, see the white curved lines). ⠀⠀⠀⠀⠀⠀⠀⠀⠀ ⠀⠀⠀⠀⠀⠀⠀⠀⠀ ⠀⠀⠀⠀⠀⠀⠀⠀⠀ ⠀⠀⠀⠀⠀⠀⠀⠀⠀ When these changes are present on an X-ray, we know that the rotator cuff is torn and has been for a long time. An excellent surgical solution for this problem in most cases is a reverse total shoulder arthroplasty. ⠀⠀⠀⠀⠀⠀⠀⠀⠀ ⠀⠀⠀⠀⠀⠀⠀⠀⠀ ⠀⠀⠀⠀⠀⠀⠀⠀⠀ ⠀⠀⠀⠀⠀⠀⠀⠀⠀
Guess what surgery Jay had?!? 💪🏽🤩
These images are the intraoperative X-rays of the patient with the left hip fracture from the previous post. This 95 year-old patient shattered her left hip in a fall. The treatment for this injury is surgical stabilization and I chose to perform a procedure called “cephalomedullary nailing” where I make an incision on the outside of the patient’s hip, manipulate the fracture back into an anatomic position (reduce the fracture) and insert a rod into the patient’s femur, a large screw into the femoral head (blue arrow), a metallic cable (red arrow) around the fracture fragments not adequately secured by the rod and large screw, and smaller screws through the rod at the distal end near the knee (images 4 and 5). ⠀⠀⠀⠀⠀⠀⠀⠀⠀ ⠀⠀⠀⠀⠀⠀⠀⠀⠀ ⠀⠀⠀⠀⠀⠀⠀⠀⠀ ⠀⠀⠀⠀⠀⠀⠀⠀⠀ The orange arrows point to the various fracture fragments also highlighted in the previous post. The purple arrow in image 3 points to the femoral head (indicating that the large screw is well inside the bone). ⠀⠀⠀⠀⠀⠀⠀⠀⠀ ⠀⠀⠀⠀⠀⠀⠀⠀⠀ ⠀⠀⠀⠀⠀⠀⠀⠀⠀ ⠀⠀⠀⠀⠀⠀⠀⠀⠀ This surgery allowed the patient to mobilize right away; the day after surgery, the physical therapists worked with the patient to sit up and she was working on walking with a walker right away.