sb/ke/rg/nl

Name of the Patient : Abc Xyzobalmn / M / 57 yrs.
Referred by : Dr. Abc Xyzdy.
Examination : M.R.I. of the Right Shoulder.

CLINICAL PROFILE :

C/O pain in the right shoulder with inability to lift the RUE since 3 1/2 months

EXAMINATION :

M.R.I of the right shoulder was performed using the following parameters :

5 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 near complete tear (suspicious, minimal muscles fibres are noted in continuity) at the musculo-tendinous junction of the right supraspinatus muscle with retraction of the muscle belly. The tendinous insertion of the supraspinatus muscle into the greater tuberocity is well-identified. Fluid is noted in the subacromial and subdeltoid bursae.

Degenerative changes are noted at the acromio-clavicular joint with periarticular osteophytes at the site of the tear of the supraspinatous muscle.

There is depression along the posterior margin of the right humeral head without change in signal intensity of the underlying bone. This changes may either suggest a Hill-Sachs defect or may represent flattening of the contour of the right humeral head (scan: 107.7 & 104.7).

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The head and upper shaft of the right 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 right humerus appears normal. There is no gleno-humeral joint effusion.

The acromion process is seen to be sloping slightly anteriorly.

The visualized axilla is unremarkable.

IMPRESSION :

1. Near complete tear at the musculo-tendinous junction of the right supraspinatus muscle with retraction of the muscle belly and fluid in the subacromial and subdeltoid bursae.

2. Degenerative changes at the acromio-clavicular joint with periarticular osteophytes at the site of the tear of the supraspinatus muscle.

3. Depression along the posterior margin of the right humeral head without change in signal intensity of the underlying bone may either suggest a Hill-Sachs defect or may represent flattening of the contour of the right humeral head.