Imaging:
The patient’s right shoulder was scanned with magnetic resonance imaging (MRI) ten months prior to the injury because of chronic shoulder pain lasting for two years. At that point, the range of motion was normal. The MRI study showed intact rotator cuff, but degenerative cystic changes and bone marrow edema at the supraspinatus insertion were believed to result of chronic tractional forces. In addition, there were edematous changes at the posteroinferior part of the glenoid joint and the inferior glenohumeral ligament, probably due to a soft tissue injury to the capsule. The protocol covered the right proximal latissimus dorsi and the teres major in the coronal and sagittal planes, but there were no pathological changes in that area.
The patient was scanned again ten months later, one week post-injury. The MRI was performed as a standard shoulder protocol with a proton density fat-saturated sequence (PD fat sat) in all three planes, coronal T2 and sagittal T1. However, the technician added ten more axial slices because of soft tissue edema seen below the shoulder joint, covering 12 cm in the craniocaudal direction (standard coverage in the current shoulder MRI protocol is 9 cm) (Fig. 7a and b).
The scanner used for these two first MRI scans was an older model (1.5T GE Optima MR 360).
Despite some movement artifacts, the MRI showed extensive hematoma and edema in the soft tissues medial and anterior to the right proximal humerus, below the level of the subscapularis muscle and the axillary neurovascular bundle. The hematoma continued dorsally between the muscle belly of the proximal triceps laterally and the latissimus dorsi medially. The hematoma along the humerus measured 5 x 3 x 1.5 cm, and in this area a completely ruptured and avulsed tendon of the latissimus dorsi was identified, retracted 1.5-2.5 cm from its original attachment. The teres major, normally having a shorter tendinous attachment than the latissimus dorsi, was partially torn at its insertion at the proximal humerus. There was extensive edema in the bellies of both muscles near the musculotendinous junction, particularly in the latissimus dorsi, which had extensive muscle fiber defects and intramuscular hematoma (Fig. 8a-d).
The right shoulder was imaged again on three additional occasions with a 1.5T Siemens Aera MRI scanner: