Patient History
21 yo M with right shoulder pain and instability ongoing after injury while trying to grab a tire from overhead.
Findings
ROTATOR CUFF: Mild undersurface contusional swelling of the infraspinatus. No tendinosis or tears.
SUBACROMIAL/SUBDELTOID BURSA: Normal.
MUSCLES (ROTATOR CUFF/DELTOID, TRAPEZIUS, PECTORALIS): Normal.
BICEPS TENDON: Normal.
AC JOINT: Normal.
CORACOCLAVICULAR LIGAMENTS: Normal.
SUBACROMIAL ARCH/OUTLET: Normal. Not narrowed.
SUBCORACOID ARCH: Normal. Not narrowed.
GLENOHUMERAL JOINT: Large joint effusion/hemarthrosis. No internal debris or free bodies. Reactive synovitis.
GLENOID LABRUM: Torn anteroinferior labrum with stripping and medial displacement of the periosteum and inferior glenohumeral ligament in keeping with anterior labroligamentous periosteal sleeve avulsion (ALPSA).
Chronic non inflamed posterior labral tear.
No paralabral cysts.
BONES: A 2 cm wide mildly depressed osteochondral fracture surrounded by moderate osteoedema involving the posterior humeral head facet.
Normal alignment.
SUBCUTANEOUS SOFT TISSUES: Mild periarticular soft tissue swelling.
AXILLA: No space-occupying lesions.
Impressions
1. Evidence of recent right shoulder anterior dislocation-relocation with off track demonstrated by a 2 cm mildly depressed Hill-Sachs at the posterior humeral head facet along with an ALPSA lesion.
2. Mild contusional undersurface swelling of the infraspinatus overlying the Hill-Sachs lesion.
3. Large joint hemarthrosis or effusion with reactive synovitis. No internal debris or free bodies.
