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Figure legends:
Fig. 1a-c. Schematic drawings of the shoulder region in a
posterior (1a) and anterior (1b) view shows the latissimus dorsi (LD)
muscle curving along the thoracic wall and inserting on to the humerus
together with the teres major (TM). Partially resected views of the
following structures: Pectoralis major (PM); Long head of the biceps
(LHB); Short head of the biceps (SHB); Coracobrachialis (CB). Images by
Michael Stadnick, courtesy of Radsource
(www.radsource.us). Fig. 1c:
Schematic drawing of the tendon attachments on the proximal humerus.
Courtesy of Dr Nabil Jomaah.
Fig. 2. Day of injury. The arrow indicates the area of
swelling, tenderness, and pain.
Fig. 3. Two weeks post-injury. Arrow indicates abnormal contour
of the posterior axillary fold on the right side caused by retraction of
the teres major and latissimus dorsi muscles from the humeral insertion.
Fig. 4a and b. Fig. 4a: Three weeks post-injury. The image
shows the patient hanging from the upper bar of the uneven bars device
where she inferred her injury three weeks previously. Note the
involuntary compensatory deviation of the legs towards the left,
uninjured side – like a “banana”. Fig. 4b: Three weeks post-injury
performing handstand on the balance beam.
Fig. 5. Six months post-injury the patient demonstrates
“climbing the ropes”. Arrow indicates injured right side.
Fig. 6a and b. Fig. 6a: Six months post-injury. The patient
reports to have regained her pre-injury strength and performs the same
number of pull-ups as before the injury. The arrow indicates the
abnormal contour of the posterior axillary fold. Fig. 6b shows
negligible cosmetic sequela six months post-injury.
Fig. 7a and b . Coronal PD fatsat in a study (7a) performed
before the injury, showing a common placement of transverse slices in a
regular shoulder MRI exam. The latissimus dorsi (star) and its proximal
insertion (arrow) are not covered sufficiently by the axial slices
(lines 1-22). Coronal T2 one week post-injury (7b) was performed by an
experienced radiographer who extended the imaging of axial slices to
cover the injured area along the humerus.
Fig. 8a-d. Axial PD fatsat (8a), coronal T2 (8b), sagittal PD
fatsat in a medial position (8c) and a more lateral position along the
humerus (8d) show a total rupture of the latissimus dorsi with
retraction, muscle edema, and a large hematoma between the tendon stump
and the humerus. It is difficult to identify the teres major tendon, and
we assume that this muscle is also ruptured.
Fig. 9a and b. Seven weeks post-injury. The hematoma is largely
absorbed, but a small amount of fluid along the retracted tendon is
seen. Fig. 9a: Coronal PD fatsat. Arrow points to the retracted tendon,
and lateral to the tendon a small amount of fluid/hematoma is seen.
Coracoid process (proc cor); subscapularis muscle belly (subscap). Fig.
9b: Sagittal PD fatsat. The circle captures the retracted tendon with
surrounding soft tissue edema.
Fig. 10a-c. Eleven weeks post-injury. Fig. 10a: Axial PD
fatsat, shows the still thickened proximal end of the latissimus dorsi
and slight surrounding edema (arrow). Fig. 10b: Coronal PD fatsat, also
shows the proximal tendon of the latissimus dorsi, retracted and with
some surrounding edema (arrow). Fig. 10c: Coronal STIR with extended
field of view, shows the proximal end of the latissimus dorsi.
Fig. 11a-d . Thirty-eight weeks post-injury. The hematoma and
edema are completely absorbed. The muscle seems to have reattached to
the humerus, and there is some residual scar tissue at the
musculotendinous junction. Fig. 11a: Coronal T2. The tendon can be seen
as a slender structure all the way to its former insertion (arrows).
Fig. 11b: Sagittal T1. Part of the muscle is close to its humeral
insertion indicated by the circle. Compare with previous Fig. 8d. Fig.
11c: Axial PD fatsat. Scar tissue at the musculotendinous junction
indicated by the circle. Fig. 11d: Axial PD fatsat. The latissimus dorsi
indicated by the star is reconnected to the humerus by reattachment of
muscle tissue as indicated by the arrows.
Fig. 12a-b. Normal left side. Fig. 12a: Coronal T2. Compare
latissimus dorsi indicated by the star, with fig. 11a. Fig. 12b:
Sagittal T1. Compare latissimus dorsi indicated by the circle, with 11b.