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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.