Date : 00.00.00
Name of the Patient : Abc Xyz Khlmn / M / 32 yrs.
Referred by : Dr. Abc Xyzolakia.
Examination : M.R.I. of the Left Shoulder.
CLINICAL PROFILE :
H/O fall with injury to the left shoulder 2 1/2 months back with pain, swelling and inability to lift the LUE since then.
M.R.I of the left shoulder was performed using the following parameters :
4 mm thick T1 Weighted and GRASS axial images.
4 mm thick T1 Weighted sagittal images.
4 mm thick T1 Weighted, Proton and T2 Weighted coronal images.
There appears to be blunting of the anterior labrum with a break in the anterior labrum (se/im 107/10, 103/10).
Fluid is seen within the left shoulder joint and the subdeltoid bursa. Fluid is also noted to track along the tendon of biceps in the bicipital groove.
There is a break in the cortex along the postero-lateral margin of the left humeral head with an ill-defined, hyperintense area on the proton, T2 Weighted and GRASS images in that region. This is hypointense to normal marrow on the T2 Weighted images and would represent a Hill Sachs lesion.
The upper shaft of the left humerus show normal signal intensity. The visualized scapula appears normal.
The articular cartilage of the head of the left humerus appears normal.
The tendinous insertion of the supraspinatus muscle shows an intermediate signal intensity on all pulse sequences, suggesting tendineous degeneration.
There is no evidence of a tear of the supraspinatus muscle. The soft tissues around the left shoulder joint are unremarkable.
The acromio-clavicular joint is normal.
The visualized axilla is unremarkable.
1. Blunting of the anterior labrum suggests an anterior labral tear.
2. Altered signal along the postero-lateral margin of the head of the left humerus represents a Hill Sachs lesion in
the given clinical setting.
3. Fluid within the left shoulder joint and the subdeltoid bursa and along the tendon of biceps in the bicipital groove.
4. Tendineous degeneration in the supraspinatous tendon.