Wk 3, Case 4 - Review

Patient History
29-year-old male with left shoulder pain, inability to raise his left arm over his head, and difficulty sleeping. Evaluate for dislocation, rotator cuff tear, or impingement.

Findings
ROTATOR CUFF:

Supraspinatus: Intact.

Infraspinatus: Intact.

Subscapularis: Intact.

Teres minor: Intact.

Biceps tendon and anchor: Intact.

ACROMIOCLAVICULAR JOINT: Unremarkable. Coracoclavicular ligaments intact.

SUBACROMIAL ARCH/OUTLET: Mild lateral and anterior downsloping type 2 acromion. Coracoacromial ligament unremarkable. No evidence of lateral outlet impingement.

SUBACROMIAL/SUBDELTOID BURSA: Unremarkable.

GLENOHUMERAL JOINT: No high-grade chondromalacia of the glenohumeral articular surfaces. No glenoid dysplasia, retroversion or humeral head decentering. Trace effusion within the axillary recess. No capsulosynovial thickening or intra-articular loose body.

GLENOID LABRUM: No traumatic or displaced labral tear.

BONES: Proximal humeral (superior humeral head) epiphyseal area of thin serpiginous hypointense sclerosis, associated with a subjacent T2 hyperintense line (double line sign), consistent with avascular necrosis of the humeral head.
Area of avascular necrosis measures approximately 3 cm in transverse diameter. Less than 10 percent of the glenohumeral articular surface is involved with the arm in the adducted position. However, the area of AVN occupies more than 120 degrees of the humeral head. A small superimposed mall, superimposed superior humeral head subchondral fracture is noted. No evidence for gross subcortical/subchondral collapse or cortical flattening.
Prominent subcortical pseudocyst formation (measuring 10 mm in diameter) adjacent to the deep aspect of the avascular necrosis. No T2 hyperintense/fluid signal subcortical crescent to suggest potentially unstable fragment. No displaced fragment.
Mild reactive osteoedema is seen extending down the proximal humeral metadiaphysis.

MUSCLES: Intact. No volumetric muscle atrophy.

SOFT TISSUE: Unremarkable.

AXILLA: Unremarkable.

Impressions
Extensive superomedial humeral head avascular necrosis (Hass Disease):
Greater than >120° humeral head involvement.
Small superimposed subchondral fracture as an early sign of subcortical/subchondral collapse. No gross subchondral collapse.
Stage III AVN.
Etiologies include excess exogenous/endogenous corticosteroids, trauma, collagen vascular disorders, less likely hematological disorders etc.