AJR 2001; 176:393-397
© American Roentgen Ray Society
Focal Articular Cartilage Lesions of the Superior Humeral Head
MR Imaging Findings in Seven Patients
Kevin W. Carroll1,2,
Clyde A. Helms1 and
Kevin P. Speer3
1
Department of Radiology, Duke University Medical Center, Box 3808, Durham, NC
27710.
2
Present address: 680 Lalique Cir., Apt. 1206, Naples, FL 34119.
3
Department of Orthopaedic Surgery, Duke University Medical Center, Box 3371,
Durham, NC 27710.
Received April 12, 2000;
accepted after revision August 4, 2000.
Presented at the annual meeting of the American Roentgen Ray Society,
Washington, DC, May 2000.
Address correspondence to C. A. Helms.
Abstract
OBJECTIVE. We describe the MR imaging findings of focal articular
cartilage lesions of the superior humeral head and the clinical features in
seven patients.
CONCLUSION. Focal articular cartilage lesions of the superior
humeral head are rare lesions that may cause clinical symptoms and may be
easily overlooked on MR imaging. These lesions occur in a particular location
(along the superior surface of the posterior humeral head, medial to the
expected location of a Hill-Sachs lesion), are caused by trauma, and do not
seem to have a specific mechanism of injury. Because of improvements in MR
imaging of cartilage, this area of the shoulder should be inspected for this
lesion.
Introduction
The shoulder is the second most frequently examined joint on MR imaging at
our institution. In the clinical scenario of shoulder pain, imaging is often
restricted to the examination of the rotator cuff and glenoid labrum. However,
osseous, articular, and extraarticular soft-tissue disease may cause clinical
shoulder pain and disability. Although subchondral lesions are common as a
source of pain in the knee
[1,2,3],
they are seldom implicated in the shoulder. Imaging findings of osteochondral
defects of the glenoid fossa have been described
[4]. However, little has been
written in the radiology literature about articular cartilage lesions of the
humeral head [5]. In the
orthopedic literature, osteochondral lesions of the humeral head near the
rotator cuff insertion have been recently described in the setting of
posterior internal impingement in athletes who throw overhand
[6].
Our orthopedic surgeons reported three focal chondral lesions of the
superior humeral head found on arthroscopy, which were not correctly diagnosed
on the prospective interpretations of preoperative MR imaging and MR
arthrography. We retrospectively examined these images and detected focal
chondral lesions. These cases and four that were found prospectively form the
basis of this report. To our knowledge, focal cartilage defects of the
articular surface of the superior humeral head have not been described in the
radiology literature.
Materials and Methods
We retrospectively searched our computer database for MR imaging of the
shoulder performed from June 1997 through December 1999 to find cases
diagnosed with humeral head chondral defects. During this interval, 992 MR
imaging examinations of the shoulder were performed. This patient population
included 549 (55.3%) males and 443 (44.7%) females. Patients were 13-95 years
old (average, 44.1 years; median, 43 years). In addition, patients from the
same period with arthroscopically diagnosed humeral head chondral lesions from
our primary shoulder orthopedic surgeon were compared with those patients in
our database for preoperative shoulder MR imaging. Patients who had
osteonecrosis of the humeral head, Hill-Sachs lesions of the humeral head as
the chondral lesion, and osteoarthritis of the glenohumeral joint or other
generalized arthritides that affected the imaged shoulder were excluded.
An additional outside consultation case prompted our study after MR imaging
and arthroscopic correlation of a focal cartilage lesion of the superior
humeral head.
The shoulder MR imaging protocol varied slightly for the patients imaged.
All MR imaging was performed with Signa 1.5-T systems (General Electric
Medical Systems, Milwaukee, WI) with a dedicated phased array shoulder coil.
Fast spin-echo T2-weighted MR images with frequency-selective fat suppression
(TR range/TE range, 3000-5000/65-75) were obtained in the axial, oblique
coronal, and oblique sagittal planes. In addition, conventional spin-echo
T1-weighted images (TR/TE, 600/min full) in the oblique coronal and oblique
sagittal planes and axial conventional spin-echo proton density-weighted
images (2000/20) with fat saturation were obtained. Early in the study, axial
T2* gradient-echo images (550/15; flip angle, 15°) were
obtained rather than the proton density sequences. The field of view was 16
x 16 cm, and the slice thickness was 4.0 mm with a 0.4-mm interslice
gap. The matrix size was 256 x 192 with 1 excitation for the
conventional spin-echo sequences and 2 excitations for the fast spin-echo
sequences. For the MR arthrograms, additional conventional spin-echo
T1-weighted axial, oblique coronal, and oblique sagittal images were obtained
with fat suppression. Approximately 25% of the shoulder MR imaging during this
period was performed as direct MR arthrography. During our study, the
percentage of shoulder MR arthrography increased so that approximately 50% of
our current shoulder MR imaging is performed after direct arthrography with
diluted gadolinium (0.1 mL of gadopentetate dimeglumine [Magnevist; Berlex
Laboratories, Wayne, NJ] in 20 mL of sterile saline solution).
Focal cartilage lesions of the superior humeral head were diagnosed if
there was a focal cartilage defect seen as a contour deformity with an area of
increased signal intensity on T2-weighted images that contrasted with the
normal adjacent gray articular cartilage or if there was a focal collection of
increased signal intensity from diluted gadolinium on T1-weighted
fat-suppressed images acquired on MR arthrography. No specific size criteria
were used. Each case was also examined for additional abnormal findings, such
as rotator cuff or labral abnormality.
Results
Six (0.6%) of the 992 patients from the database had cartilage defects of
the articular surface of the superior humeral head. Including the consultation
case, the study population comprised seven patients (five males; two females;
age range, 15-63 years; median age, 30 years; average age, 34 years). Four
patients underwent arthroscopy. One patient refused surgery, and two patients
were attempting conservative treatment, including physical therapy. Three
patients had MR arthrography, whereas the other four had conventional MR
imaging.
The clinical features of the seven patients are summarized in
Table 1. All seven patients
described a single traumatic event that produced the symptoms. Four lesions
were diagnosed prospectively on MR imaging (two standard MR imaging
examinations; two MR arthrograms), and one of these lesions (the consultation
case) had arthroscopic correlation. Three lesions were diagnosed
arthroscopically and identified only on retrospective interpretation of the
preoperative MR images (two standard MR imaging examinations; one MR
arthrogram).
The MR imaging and surgical findings are summarized in
Table 2. The focal cartilage
defects were seen as contour deformities with areas of abnormal signal
intensity on MR imaging and were located in the superior humeral head medial
to a typical Hill-Sachs lesion (Fig.
1A,1B,1C).
The patients who were imaged within 4 weeks of the injury had subjacent
abnormal marrow in the underlying bone
(Table 1), whereas those imaged
later did not. All patients had abnormal findings on MR imaging in addition to
the humeral head cartilage lesions. The patient who suffered anterior
dislocation had an osseous Bankart lesion and a distinct Hill-Sachs lesion and
a focal chondral lesion of the humeral head, which was in a characteristic
location medial to the Hill-Sachs lesion (Fig.
1A,1B,1C).
The former college swimmer had degeneration of the anterior labrum without
discrete tear in addition to the cartilage lesion, and both findings were
confirmed arthroscopically (Fig.
2A,2B,2C).
The focal cartilage lesion of the consultation case (Fig.
3A,3B)
was prospectively diagnosed and confirmed arthroscopically.
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Fig. 1A. —30-year-old man who sustained anterior shoulder dislocation
while playing rugby. Focal articular cartilage defect was diagnosed
prospectively on MR imaging. Patient has not undergone surgery because this
dislocation is his first, and he has responded to conservative therapy.
Oblique sagittal fast spin-echo T2-weighted MR image with fat suppression
(TR/TEeff, 3800/63) through left shoulder reveals focal defect
(arrow) of articular cartilage and subchondral bone along
posterosuperior humeral head (H). Anterior is to left.
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Fig. 1B. —30-year-old man who sustained anterior shoulder dislocation
while playing rugby. Focal articular cartilage defect was diagnosed
prospectively on MR imaging. Patient has not undergone surgery because this
dislocation is his first, and he has responded to conservative therapy. Axial
fast spin-echo T2-weighted MR image with fat suppression (3800/63) shows focal
articular cartilage defect (straight arrow) seen in A. Defect
and partial volume averaging with subjacent marrow edema are located medial to
distictly separate Hill-Sachs lesion (curved arrow). Anterior is
toward top. C = coracoid, G = glenoid, H = humerus.
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Fig. 1C. —30-year-old man who sustained anterior shoulder dislocation
while playing rugby. Focal articular cartilage defect was diagnosed
prospectively on MR imaging. Patient has not undergone surgery because this
dislocation is his first, and he has responded to conservative therapy.
Drawing based on B shows characteristic relative location of focal
articular cartilage lesion of humeral head. A = anterior, P = posterior, M =
medial, L = lateral.
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Fig. 2A. —30-year-old man, former college swimmer who experienced acute
shoulder pain while bench pressing. Cartilage defect was not diagnosed
prospectively on MR imaging but only seen in retrospect after arthroscopic
identification. Oblique coronal fast spin-echo T2-weighted MR image with fat
suppression (TR/TEeff, 3800/63) from MR arthrography of right
shoulder depicts irregular defect of articular cartilage of humeral head
(straight arrow). Focal area of cartilage thickening (curved
arrow) was found on arthroscopy (C) to be cartilage fraying.
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Fig. 2B. —30-year-old man, former college swimmer who experieced acute
shoulder pain while bench pressing. Cartilage defect was not diagnosed
prospectively on MR imaging but only seen in retrospect after arthroscopic
identification. Oblique coronal spin-echo T1-weighted MR image with fat
suppression (TR/TE, 600/20) shows diluted intraarticular gadolinium extending
into cartilage defect (open arrow). Note focal thickened cartilage
(curved arrow).
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Fig. 2C. —30-year-old man, former college swimmer who experienced acute
shoulder pain while bench pressing. Cartilage defect was not diagnosed
prospectively on MR imaging but only seen in retrospect after arthroscopic
identification. Arthroscopic image reveals fraying and thickening (curved
arrow) of articular cartilage of humeral head (H) and large focal defect
(straight arrows) seen on MR imaging (A and B). Glenoid
(G) was normal on MR imaging (A and B) and on arthroscopy
(C).
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Fig. 3A. —45-year-old man who experienced sudden shoulder pain
performing biceps curls while weight lifting. Focal cartilage defect of this
consultation case was diagnosed prospectively on MR imaging. Oblique sagittal
fast spin-echo T2-weighted MR image (TR/TEeff, 3900/105) shows
focal cartilage defect along posterosuperior humeral head (arrow).
Anterior is to left.
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Fig. 3B. —45-year-old man who experienced sudden shoulder pain
performing biceps curls while weight lifting. Focal cartilage defect of this
consultation case was diagnosed prospectively on MR imaging. Oblique coronal
fast spin-echo T2-weighted MR image with fat suppression (2700/69) shows focal
defect (arrow), which was confirmed on arthroscopy.
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On arthroscopy, all four patients had focal chondral defects of the
superior humeral head. Our primary shoulder surgeon, who correlated the
arthroscopic location of these cartilage lesions with the MR imaging
appearance, operated on the three patients from our institution. The smallest
lesion measured 8 x 12 mm along the superior pole of the humeral head.
The second smallest was 10 x 10 mm in a similar location. The largest
lesion measured 2 x 3 cm with extension more medially and posteriorly
(Fig. 2C). Arthroscopic
débridement of the smaller cartilage lesions
and treatment of the other disease has provided good short-term results. The
patient with the largest chondral lesion, however, has experienced persistent
pain despite arthroscopic débridement of the
cartilage defect.
Discussion
Shoulder pain is a common and sometimes challenging clinical problem.
Patients with shoulder pain often seek MR imaging to diagnose the underlying
cause. Whereas many of the patients' symptoms are explained by rotator cuff or
labral disease, other symptoms are not. We describe a finding of cartilage
defects of the articular surface of the superior humeral head that, to our
knowledge, has not been found in the radiology literature. This finding was
often easily overlooked. MR imaging findings in the first three patients were
not correctly diagnosed prospectively but were diagnosed arthroscopically and
found on retrospective review of the MR images. The conditions of the
consultation case and of the three additional patients in our series were
diagnosed prospectively on MR imaging.
The humeral head cartilage defects were all located in the posterosuperior
portion of the humeral head, medial to the expected location of a typical
Hill-Sachs lesion. This location implies a traumatic origin such as
compression or shearing of the humeral head against the undersurface of the
acromion. The presence of subchondral marrow edema in all patients imaged
within 1 month of injury and the absence of it in those patients imaged later
also support a traumatic cause. Patients with humeral head cartilage defects
presented clinically with acute onset of shoulder pain typically after a
single traumatic event. We postulate that a shear force was applied to the
cartilage to cause this injury, but the exact mechanism is not definitely
understood. The osteochondral lesions of the humeral head described in
athletes throwing overhand were located near the rotator cuff insertion and
were seen in patients who did not report a single traumatic episode
[6].
Only 0.6% of our shoulder MR imaging examinations in the past 6 years
revealed cartilage defects of the articular surface of the superior humeral
head, an uncommon lesion. It is likely, however, that many more lesions were
overlooked because three of our cases were diagnosed only after arthroscopy.
Therefore, the true incidence of this lesion is almost certainly greater than
the 0.6% we report. The clinical significance is difficult to accurately
assess with the small number of patients in our series and the relatively
short period of follow-up. With the improvements in MR imaging of cartilage
and the increasing frequency of MR arthrography of the shoulder
[7], this area should be
inspected for cartilage defects of the articular surface of the superior
humeral head on MR imaging. Although this lesion was rare in our patient
population, it may be more commonly found with the ongoing improvements in MR
imaging of articular cartilage. Because the three patients were diagnosed
prospectively within the last few months of the study period, an increased
awareness of this entity may lead to fewer MR imaging errors in diagnosis.
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Abstract
Introduction
