Date : 00.00.0000
Name of the Patient : Abc Xyzh S. Plmn / M / 31 yrs.
Referred by : Dr. Abc Xyzesai.
Examination : M.R.I. of the Left Shoulder.
CLINICAL PROFILE :
Alleged H/O fall from a bike with injury to the left shoulder with pain and restriction of movement of the LUE since then.
M.R.I of the left shoulder was performed using the following parameters :
4 mm thick T1 Weighted, GRASS and STIR axial images.
4 mm thick T1 Weighted sagittal images.
4 mm thick T1 Weighted, Proton, T2 Weighted and STIR coronal images.
There is an ill-defined, hyperintense signal on the T2 Weighted and STIR images in the tendinous insertion of the supraspinatus muscle of the left shoulder joint. This signal appears slightly hyperintense when compared to normal signal on the T1 Weighted images. Minimal fluid is noted deep to the tendinous insertion of the supraspinatus muscle and in the gleno-humeral joint. No retraction of the supraspinatus muscle and tendon is noted.
Hyperintense signal is seen in the subcutaneous soft tissues on the T2 Weighted and STIR images and the left supraclavicular fossa and this may represent soft tissue edema/contusion.
The head of the left humerus shows normal contour and the head and upper shaft of the left humerus show normal signal intensity. The visualized scapula appears normal. The glenoid labrum is unremarkable. The biceps tendon in the biciptical groove shows normal signal intensity.
The articular cartilage of the head of the left humerus appears normal.
There is no evidence of fluid in the subdeltoid bursa.
There is no obvious bone erosion or destruction seen.
The acromio-clavicular joint is normal. The acromion process is seen to sloping slightly posteriorly.
The visualized axilla is unremarkable.
1. Altered signal in the tendinous insertion of the supraspinatus muscle on the left would represent a partial tear/strain, in the given clinical setting. Minimal fluid is noted deep to the tendinous insertion of the supraspinatus muscle and in the gleno-humeral joint.
2. Soft tissue edema/contusion in the left supraclavicular fossa.