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ke/sb/nl/rg.
Date : 00.00.00

Name of the Patient : Abc Xyzen lmn / F / 81 yrs.
Referred by : Dr. Abc Xyznna / Dr. Abc Xyzah.
Examination : M.R.I. of the Right Shoulder.

CLINICAL PROFILE :

H/O fall 1 month back with pain in the right shoulder joint, swelling and inability to the lift the RUE since then.

EXAMINATION :

M.R.I of the right 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.

OBSERVATION :

There is a break in the cortex in the region of the greater tuberosity of the right humerus. Resultant avulsion fracture of the greater tuberosity is noted which is displaced slightly supero-laterally. Hypointense areas on the T1 Weighted images are seen in the greater tuberosity region which are seen to turn hyperintense on the proton, T2 Weighted and Gradient images and would represent bone edema/bruise in the given clinical setting. Fluid is seen in the subdeltoid and subacromion regions, within the right shoulder joint and along the bicipital tendon. Minimal fluid collection is also noted just anterior to the subscapularis muscle.

The supraspintous tendon is seen upto its insertion at the greater tuberosity. Intermediate signal on all the pulse sequences at its insertion may suggest tendinitis/tendon degeneration.

The visualized scapula appears normal. The glenoid labrum is unremarkable.
..2/.






Acromio-clavicular joint degeneration is noted.

The soft tissues around the right shoulder joint are unremarkable.

The visualized axilla is unremarkable.

IMPRESSION :

1. Avulsion fracture of the greater tuberosity.

2. Altered signal in the greater tuberosity region would represent bone edema/bruise in the given clinical setting.

3. Fluid in the subdeltoid and subacromion regions, within the right shoulder joint and along the bicipital tendon and minimal fluid collection just anterior to the subscapularis muscle.

4. Intermediate signal in the supraspinatous tendon would suggest tendinitis/tendon degeneration.






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