Bankart lesion with grade V SLAP tear (shoulder MR-arthrogram)

Case contributed by Dr Mohamed Hossam el Deen

Presentation

Recurrent attacks of shoulder dislocation.

Patient Data

Age: 30 years
Gender: Male

Pre-injection MRI shows a humeral head bone cyst and fluid signal inside the subacromial bursa with AC joint hypertrophy.

Under complete aseptic conditions, fluoroscopic guided needle insertion in the glenohumeral joint was performed, after the procedure patient did not show any discomfort except mild feeling of joint distension which encouraged us to stop joint injection at 14 cc of contrast volume.

The second image shows the ideal position of the spinal needle direction during the anterior shoulder injection where the needle hub and stylet should be on the same X-ray beam axis and more near the humeral cortical head at the junction between the upper third and lower two-third of the glenohumeral joint.

The last image shows the flow of contrast mixture into the subcoracoid bursa (normally connected to shoulder joint space).

After fluoroscopic guided needle insertion into the right glenohumeral joint, contrast flow passed into the subcoracoid bursa and glenohumeral joint space. No contrast leakage into the sub-acromial or sub-deltoid bursae could be seen, also no leakage along the needle tract was seen after needle withdrawal.

NB: Before needle insertion arm position was adjusted, the humerus was overriding the glenoid cavity. We applied some axial traction to place it again into its anatomical position.

A "non bony" Bankart lesion and a type V SLAP tear are clearly seen.

The axial views show

  • superior extension of the anterior labral tear (reaching 12 o'clock)  with contrast leakage into the subscapularis space and subcoracoid bursa. Note the middle glenohumeral ligament is normal
  • the humeral head cyst and a reversed Hill-Sachs lesion are present. No contrast leakage into bicipital tendon
  • the PD images also demonstrate normal cartilage covering the humeral head and glenoid bone
  • abnormal increased signal intensity of subscapularis tendon is noted at its myotendinous junction. No definitive tear could be seen in other rotator cuff muscles

Coronal views show

  • leakage of contrast from the joint space into the humeral bone cyst suggesting presence of an intraosseous synovial cyst
  • the axillary pouch looks OK and the inferior glenohumeral ligament is normal
  • the fluid signal of the subacromial bursa is present with no definitive contrast leakage through the supraspinatus tendon
  • no definitive tear in the supraspinatus or infraspinatus tendons
  • the signal of fluid inside the subacromial bursa is mostly related to bursal effusion rather than to contrast leakage. unfortunately, post-injection T1 image was not done to confirm

Sagittal views show

  • no apparent rotator cuff tear could be seen except some contrast signal in the subscapularis myotendinous junction
  • the labral tear appears to start at 5 o'clock of the anterior labrum and extends superiorly with no bone involvement of labral sleeve, suggesting presence of a Bankart lesion

Case Discussion

Bankart lesions are a common cause of recurrent joint dislocation. They may be associated with different grades of SLAP tear or reversed Hill-Sachs lesions in some cases. MRI arthrography is a useful and simple method to study and classify labral tears.

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