Orthopedics

Radiologic Case Study 

Radiologic Case Study

Jeremie N. Karsenti, MS; Laura W. Bancroft, MD; Brad Homan, DO

Abstract

Mr Karsenti is from the Nova Southeastern University School of Medicine, Ft Lauderdale, and Dr Bancroft is from the Department of Radiology and Dr Homan is from the Department of Orthopedic Surgery, Florida Hospital, Orlando, Florida.

Mr Karsenti and Drs Bancroft and Homan have no relevant financial relationships to disclose.

Correspondence should be addressed to: Laura W. Bancroft, MD, Department of Radiology, Florida Hospital, 600 E Rollins, Orlando, FL 32803 (laura.bancroft.md@flhosp.org).

A 19-year-old football player presented with shoulder pain after a football tackling injury.

 

Figure 1: Radiograph (A) and magnetic resonance arthrographic image (B).

 

  

Reverse Humeral Avulsion of the Glehohumeral Ligament

A 19-year-old man sustained a reverse humeral avulsion of the glenohumeral ligament (HAGL) from a football tackling maneuver. Reverse HAGL lesions are the result of posterior capsular detachment and failure of the posterior band of the inferior glenohumeral ligament at the humeral attachment caused by sudden forces on the posterior capsule. Injuries of the inferior glenohumeral ligament are classified with the West Point nomenclature, categorized as either anterior or posterior, and then subclassified as purely ligamentous, associated with bony avulsion fragment, or floating.1

Convulsive disorders, direct traumas, and motor vehicle accidents account for the majority of traumatic causes of posterior shoulder injury with a mechanism of forceful adduction and internal rotation of the upper extremity.2 In addition to reverse HAGL injuries, other lesions caused by posterior shoulder instability include reverse Bankart lesions, reverse Hill-Sachs lesions, superior labral anterior and posterior lesions, and Bennett lesions.2,3

Diagnosis of a reverse HAGL injury is considered difficult because of the various clinical presentations.4 The clinical diagnosis is based on history and physical examination. Symptoms include reproduction of pain, instability, or apprehension when the arm is in the provocative position (ie, adduction, flexion, and internal rotation); positive provocative clinical maneuvers (ie, posterior stress, pivot-shift, jerk, or load and shifting tests); and load-shift and apprehension tests with a translation of humeral head on the glenoid fossa more than 1 cm.4 Pain reflects the innervation of the inferior glenohumeral ligament by redundant branches of the axillary nerve (95%) or, less commonly, the radial nerve (5%).5

Arthrography for the assessment of joint capsule integrity is optimally performed in conjunction with magnetic resonance or computed tomography arthrography if a contraindication exists to magnetic resonance imaging. Conventional arthrography will demonstrate extravasation of contrast from the glenohumeral joint into the posterolateral shoulder soft tissues on the internal rotation view (Figure 2).

Figure 2: Internal rotation view arthrogram showing reverse humeral avulsion of the glenohumeral ligament with extravasation of contrast (arrows) from the glenohumeral joint into the posterolateral shoulder soft tissues.

Magnetic resonance arthrography is widely believed to be the most sensitive non-invasive examination for the evaluation of the labrocapsular complex,6,7 specifically for HAGL.8–11 Hottya et al8 reported that magnetic resonance arthrography findings correlated well with surgical findings of tears involving the posterior stabilizers after posterior shoulder dislocation. Imaging studies were helpful in diagnosing posterior shoulder abnormalities, allowing for proper preoperative planning.8 Chung et al9 described magnetic resonance arthrographic findings in 17 patients with humeral avulsion of the posterior band of the glenohumeral ligament and reported that the lesions could be isolated or found in conjunction with posterior or anteroinferior capsulolabral abnormalities.

In the current patient, axial T1-weighted images without (Figure 3A) and with (Figure 3B) intra-articular contrast demonstrated focal discontinuity of the posterior band of the inferior glenohumeral ligament. Furthermore, the contrast extended posterolateral to the joint capsule through the defect. The axial T1-weighted magnetic resonance arthrographic image showed a focal collection of contrast posterolateral to the disrupted glenohumeral ligament (Figure 3C). The sagittal image delineated the…

Mr Karsenti is from the Nova Southeastern University School of Medicine, Ft Lauderdale, and Dr Bancroft is from the Department of Radiology and Dr Homan is from the Department of Orthopedic Surgery, Florida Hospital, Orlando, Florida.

Mr Karsenti and Drs Bancroft and Homan have no relevant financial relationships to disclose.

Correspondence should be addressed to: Laura W. Bancroft, MD, Department of Radiology, Florida Hospital, 600 E Rollins, Orlando, FL 32803 (laura.bancroft.md@flhosp.org).

The Case:

A 19-year-old football player presented with shoulder pain after a football tackling injury.

Your Diagnosis?

 

Radiograph (A) and magnetic resonance arthrographic image (B).

Figure 1: Radiograph (A) and magnetic resonance arthrographic image (B).

 

  

Reverse Humeral Avulsion of the Glehohumeral Ligament

A 19-year-old man sustained a reverse humeral avulsion of the glenohumeral ligament (HAGL) from a football tackling maneuver. Reverse HAGL lesions are the result of posterior capsular detachment and failure of the posterior band of the inferior glenohumeral ligament at the humeral attachment caused by sudden forces on the posterior capsule. Injuries of the inferior glenohumeral ligament are classified with the West Point nomenclature, categorized as either anterior or posterior, and then subclassified as purely ligamentous, associated with bony avulsion fragment, or floating.1

Convulsive disorders, direct traumas, and motor vehicle accidents account for the majority of traumatic causes of posterior shoulder injury with a mechanism of forceful adduction and internal rotation of the upper extremity.2 In addition to reverse HAGL injuries, other lesions caused by posterior shoulder instability include reverse Bankart lesions, reverse Hill-Sachs lesions, superior labral anterior and posterior lesions, and Bennett lesions.2,3

Clinical Presentation

Diagnosis of a reverse HAGL injury is considered difficult because of the various clinical presentations.4 The clinical diagnosis is based on history and physical examination. Symptoms include reproduction of pain, instability, or apprehension when the arm is in the provocative position (ie, adduction, flexion, and internal rotation); positive provocative clinical maneuvers (ie, posterior stress, pivot-shift, jerk, or load and shifting tests); and load-shift and apprehension tests with a translation of humeral head on the glenoid fossa more than 1 cm.4 Pain reflects the innervation of the inferior glenohumeral ligament by redundant branches of the axillary nerve (95%) or, less commonly, the radial nerve (5%).5

Imaging Findings

Conventional Arthrography

Arthrography for the assessment of joint capsule integrity is optimally performed in conjunction with magnetic resonance or computed tomography arthrography if a contraindication exists to magnetic resonance imaging. Conventional arthrography will demonstrate extravasation of contrast from the glenohumeral joint into the posterolateral shoulder soft tissues on the internal rotation view (Figure 2).

Internal rotation view arthrogram showing reverse humeral avulsion of the glenohumeral ligament with extravasation of contrast (arrows) from the glenohumeral joint into the posterolateral shoulder soft tissues.

Figure 2: Internal rotation view arthrogram showing reverse humeral avulsion of the glenohumeral ligament with extravasation of contrast (arrows) from the glenohumeral joint into the posterolateral shoulder soft tissues.

Magnetic Resonance Arthrography

Magnetic resonance arthrography is widely believed to be the most sensitive non-invasive examination for the evaluation of the labrocapsular complex,6,7 specifically for HAGL.8–11 Hottya et al8 reported that magnetic resonance arthrography findings correlated well with surgical findings of tears involving the posterior stabilizers after posterior shoulder dislocation. Imaging studies were helpful in diagnosing posterior shoulder abnormalities, allowing for proper preoperative planning.8 Chung et al9 described magnetic resonance arthrographic findings in 17 patients with humeral avulsion of the posterior band of the glenohumeral ligament and reported that the lesions could be isolated or found in conjunction with posterior or anteroinferior capsulolabral abnormalities.

In the current patient, axial T1-weighted images without (Figure 3A) and with (Figure 3B) intra-articular contrast demonstrated focal discontinuity of the posterior band of the inferior glenohumeral ligament. Furthermore, the contrast extended posterolateral to the joint capsule through the defect. The axial T1-weighted magnetic resonance arthrographic image showed a focal collection of contrast posterolateral to the disrupted glenohumeral ligament (Figure 3C). The sagittal image delineated the superior-to-inferior extent of the extravasation (Figure 3D).

Axial T1-weighted magnetic resonance arthrographic images of a reverse humeral avulsion of the glenohumeral ligament without (A) and with (B) intra-articular contrast demonstrate focal discontinuity (arrows) of the posterior band of the inferior glenohumeral ligament (arrowheads). The contrast extends posterolateral to the joint capsule through the defect. Axial T1-weighted magnetic resonance arthrographic image showing a focal collection of contrast (asterisk) posterolateral to the disrupted glenohumeral ligament (arrow) (C). Sagittal magnetic resonance arthrographic image delineating the superior-to-inferior extent of the extravasation (arrows) (D).

Figure 3: Axial T1-weighted magnetic resonance arthrographic images of a reverse humeral avulsion of the glenohumeral ligament without (A) and with (B) intra-articular contrast demonstrate focal discontinuity (arrows) of the posterior band of the inferior glenohumeral ligament (arrowheads). The contrast extends posterolateral to the joint capsule through the defect. Axial T1-weighted magnetic resonance arthrographic image showing a focal collection of contrast (asterisk) posterolateral to the disrupted glenohumeral ligament (arrow) (C). Sagittal magnetic resonance arthrographic image delineating the superior-to-inferior extent of the extravasation (arrows) (D).

Surgical Management

Arthroscopic repair of a reverse HAGL is the standard method of treatment, and techniques have been well documented in the literature.12,13 After failing conservative management for 2 years, the current patient was scheduled for diagnostic arthroscopy and repair. The initial posterior portal was used for diagnostic arthroscopy, but the surgery used anterior and posterior portals and 30º and 70º scopes for viewing, and accessory posterior portals were created for insertion of suture anchors. The patient had posterior capsular avulsion of the humerus (reverse HAGL) and an under-surface tear of the supraspinatus and infraspinatus tendons. Furthermore, the patient had a labral tear involving the superior (type 2 superior labral anterior and posterior lesions) and the inferior and posterior aspects (reverse Bankart lesion). The anterior and anteroinferior aspects of the labrum, as well as the subscapularis, were intact.

The posterior labral tearing had the appearance of chronic scuffing from the posterior humeral instability as opposed to frank detachment from the bone and was not well delineated retrospectively on magnetic resonance arthrography. This was solidly fixed to the glenoid using suture anchors after thorough preparation of the medial glenoid rim and decortication. Next, the type 2 superior labral anterior and posterior lesion was repaired. Solid fixation of the labrum was achieved with suture anchors placed anterior and posterior to the biceps. Reat-tachment of the inferior glenohumeral ligament to the humerus was performed using a double-threaded corkscrew anchor (Figure 4). The under-surface tear of the supraspinatus involved 30% to 40% of the thickness and was debrided. The patient had a successful surgery and an uneventful postoperative course.

Arthroscopic photograph from the posterior portal showing disruption (arrows) of the posterior inferior glenohumeral ligament (IGHL) near its attachment onto the humerus (H) (A). Intraoperative photograph obtained after suturing of the ligamentous defect (B).

Figure 4: Arthroscopic photograph from the posterior portal showing disruption (arrows) of the posterior inferior glenohumeral ligament (IGHL) near its attachment onto the humerus (H) (A). Intraoperative photograph obtained after suturing of the ligamentous defect (B).

Conclusion

The authors report a reverse HAGL in a 19-year-old man who sustained his injury in a football tackling maneuver. Reverse HAGL lesions are the result of posterior capsular detachment and failure of the posterior band of the inferior glenohumeral ligament at the humeral attachment caused by sudden forces on the posterior capsule. These lesions may be isolated or found in conjunction with posterior or anteroinferior capsulolabral abnormalities, are best identified on magnetic resonance arthrography, and are treated with arthroscopic repair.

References

  1. Bui-Mansfield LT, Banks KP, Taylor DC. Humeral avulsion of the glenohumeral ligaments: the HAGL lesion. Am J Sports Med. 2007; 35(11):1960–1966. doi:10.1177/0363546507301081 [CrossRef]
  2. Beltran J, Rosenberg ZS, Chandnani VP, Cuomo F, Beltran S, Rokito A. Glenohumeral instability: evaluation with MR arthrography. RadioGraphics. 1997; 17:658–673.
  3. Brown T, Barton RS, Savoie FH. Reverse humeral avulsion glenohumeral ligament and infraspinatus rupture with arthroscopic repair: a case report. Am J Sports Med. 2007; 35:2135–2139. doi:10.1177/0363546507305012 [CrossRef]
  4. Tung GA, Hou DD. MR arthrography of the posterior labrocapsular complex: relationship with glenohumeral joint alignment and clinical posterior instability. Am J Roentgenol. 2003; 180: 369–375.
  5. Gelber PE, Reina F, Monllae JC, Yema P, Rodriguez A, Caceres E. Innervation patterns of the inferior glenohumeral ligament: anatomical and biomechanical relevance. Clin Anat. 2006; 19:304–311. doi:10.1002/ca.20172 [CrossRef]
  6. Wise JN, Daffner RH, Weissman BN, et al. ACR appropriateness criteria on acute shoulder pain. J Am Coll Radiol. 2011; 8(9):602–609. doi:10.1016/j.jacr.2011.05.008 [CrossRef]
  7. McCarthy C. Glenohumeral instability. Imaging. 2003; 15:174–149.
  8. Hottya GA, Tirman PF, Bost FW, Montgomery WH, Wolf EM, Genant HK. Tear of the posterior shoulder stabilizers after posterior dislocation: MR imaging and MR arthrographic findings with arthroscopic correlation. Am J Roentgenol. 1998; 171:763–768.
  9. Chung CB, Sorenson S, Dwek JR, Resnick D. Humeral avulsion of the posterior glenohumeral ligament: MR arthrography and clinical correlation in 17 patients. Am J Roentgenol. 2004; 183:355–359.
  10. Stoller DW, Wolf EM, Li AE, Nottage WM, Tirman PF. The shoulder. In: Stoller DW, ed. Magnetic Resonance Imaging in Orthopaedics and Sports Medicine. 3rd ed. Philadelphia, PA: Lippincott; 2007:1131–1461.
  11. Barr MS, Anderson MW, Dixon M, Diduch D. Humeral avulsion of the posterior band of the inferior glenohumeral ligament. JBJS Case Connector. 2004; 86:2723–2736.
  12. Abrams JS. Arthroscopic repair of posterior instability and reverse humeral glenohumeral ligament avulsion lesions. Orthop Clin N Am. 2003; 34:475–483. doi:10.1016/S0030-5898(03)00090-7 [CrossRef]
  13. Page RS, Bhatia DN. Arthroscopic repair of humeral avulsion of glenohumeral ligament lesion: Anterior and posterior techniques. Tech Hand Up Extrem Surg. 2009; 13:98–103. doi:10.1097/BTH.0b013e3181976ecf [CrossRef]
 
Authors

Mr Karsenti is from the Nova Southeastern University School of Medicine, Ft Lauderdale, and Dr Bancroft is from the Department of Radiology and Dr Homan is from the Department of Orthopedic Surgery, Florida Hospital, Orlando, Florida.

Mr Karsenti and Drs Bancroft and Homan have no relevant financial relationships to disclose.

Correspondence should be addressed to: Laura W. Bancroft, MD, Department of Radiology, Florida Hospital, 600 E Rollins, Orlando, FL 32803 (laura.bancroft.md@flhosp.org).

10.3928/01477447-20120621-01

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