Deciphering acute shoulder trauma with normal initial X-ray: Contributions of ultrasonography and MRI

Expert Panel on Musculoskeletal Imaging, Laur O, Ha AS, Bartolotta RJ, Avery R, Bateni CP, Chen KC, Dvorzhinskiy A, Flug J, Geannette CS, Hinkle T, Hogrefe C, Plotkin BE, Todd MJ, Chang EY. ACR Appropriateness Criteria® Acute Shoulder Pain: 2024 Update

Trauma is a predominant cause of acute shoulder pain, commonly secondary to fractures (clavicle, scapula, or proximal humerus) or soft tissue injuries (typically involving the rotator cuff, acromioclavicular ligaments, or labroligamentous complex). Radiography is the imaging modality of choice for initial assessment of acute shoulder pain and identification of potential fractures. In cases where radiographs yield normal or inconclusive results, additional imaging modalities such as ultrasound, MRI, or CT of the shoulder without contrast, or MR or CT arthrography, may be useful to diagnose the underlying pathology. These modalities aid in the detection of conditions including nondisplaced fractures, tears of the labrum and rotator cuff, as well as detailed assessment of soft tissue and bony injury following glenohumeral joint dislocation. This document presents a comprehensive review of the evidence supporting or refuting the use of various imaging modalities in diagnosing acute shoulder pain. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.

Pectoralis Major Tendon Rupture in an Occupational Medicine Setting: A Case Report

Pectoralis major (PM) rupture is a rare injury, commonly misdiagnosed, that affects mostly young male athletes aged 20-40 years. This type of injury is typically associated with weight lifting, especially bench pressing. In an occupational medicine setting, it is extremely rare and not much reported in the literature. We present the case of a 30-year-old trauma technician male who presented with right shoulder and chest pain following a popping sensation while pushing in full momentum a patient on a gurney accidentally set on break mode. PM rupture was suspected clinically. Magnetic resonance imaging confirmed the diagnosis and revealed a complete rupture of the sternal head of PM. Surgical reconstruction was performed to restore the anatomy and functionality of the shoulder girdle.

Quality assessment of shoulder MRI according to practice parameters of American College of Radiology: A multi-center study in Jordan

Magnetic resonance imaging (MRI) is essential for assessing shoulder conditions. This study aimed to evaluate current shoulder MRI practices in Jordan, including technical parameter patterns, and determine if they adhere to the American College of Radiology (ACR) guidelines. The retrospective analysis included data from 48 eligible participants from 13 MRI centers in March 2021. Descriptive and correlation data analysis were performed using IBM SPSS statistics version_20 and Excel 2013. Most MRI centers (50%) were private outpatient clinics with closed MRI machines above 1 Tesla. Most participants (62.5%) were male, and shoulder pain (47.9%) was the main clinical indication. Most shoulder orientations (68.7%, 33/48) were right shoulders, and the coronal MRI planes (43%, 121/280) were the most common. The alignment percentage for the axial plane was 100%, but MRI artifacts of the shoulder were present in 8.2% of cases (23/280). Dark fluid T1-W coronal sequence was not conducted in 25% of the cases. The percentage of the field view (FOV) within ACR recommendations was 45% (126/281), and slice thickness parameters were 96% (269/281). The recommended pixel area for all sequences was 47.9% (134/280), encompassing all axial, sagittal oblique, and coronal planes. However, crucial parameters, such as FOV and slice thickness, were inadequate and did not meet the ACR guidelines, resulting in suboptimal image quality of shoulder MRI. To improve MRI image quality, it is recommended that MRI technologists receive ongoing education and training on appropriate MRI image parameters.