Date : 00.00.0000
Name of the Patient : Abc XyzSlmn / M / 24 yrs.
Referred by : Dr. Abc Xyzrankar.
Examination : M.R.I. of the Left Shoulder.
CLINICAL PROFILE :
Alleged H/O vehicular accident on 00.00.0000.
C/O pain in left shoulder with slight swelling and chest pain on the right side since then.
M.R.I of the left shoulder was performed using the following parameters :
4 mm thick T1 Weighted and T2 Weighted (with fat saturation) axial images.
4 mm thick T1 Weighted sagittal images.
4 mm thick T1 Weighted and T2 Weighted (with fat saturation) coronal images.
There is disruption of the acromio-clavicular joint with anterior and medial displacement of the clavicle. There is intermediate signal intensity lesion on the T1 Weighted images in the soft tissues around the clavicle and the widened acromio-clavicular joint which is seen to turn hyperintense on the T2 Weighted and Gradient images. This would represent inflammatory edema/fluid/soft tissue contusion, in the given clinical setting.
There are ill-defined, hypointense areas within the medial aspect of the left humeral head on the T1 Weighted images which are seen to turn hyperintense on the T2 Weighted images and would represent bone bruise/edema in the given clinical setting.
The head of the left humerus shows normal contour. 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 joint effusion.
The tendinous insertion of the supraspinatus muscle shows normal signal intensity. There is no evidence of fluid in the subdeltoid bursa. There is no evidence of a tear of the supraspinatus muscle. The subcutaneous soft tissues around the left shoulder joint show a hyperintense signal on the T2 Weighted images which may represent soft tissue contusion/edema.
There is no obvious bone erosion or destruction seen.
The visualized axilla is unremarkable.
In a known C/O trauma, the MRI features are suggestive of :
1. Disruption of the acromio-clavicular joint with inflammatory edema/contusion in the soft tissues, as described.
2. Altered signal within the medial aspect of the left humeral head would represent bone bruise/edema in the given clinical setting.