What are the next steps if an MRI of the shoulder shows the scapula and potential pathology?

Next Steps for MRI Shoulder Showing Scapula Pathology

When an MRI of the shoulder shows scapular pathology, CT imaging is the next best step for better characterization of the scapular findings, especially if fracture is suspected. 1

Assessment of Scapular Findings on MRI

The scapula has complex osteology that can be difficult to fully evaluate on MRI alone. When scapular pathology is identified on MRI, further imaging may be necessary for complete assessment:

• Fractures: Scapular fractures may be missed or underappreciated on conventional radiography and even MRI due to the complex anatomy and overlying structures
• Glenoid involvement: Intra-articular extension of pathology requires careful evaluation
• Associated soft tissue injuries: Concomitant rotator cuff or labral pathology should be noted

Recommended Next Steps

1. CT Imaging

• Primary recommendation: CT is the best imaging modality for identifying and characterizing scapula fracture patterns 1
• CT provides superior assessment of:
  • Intra-articular extension
  • Glenopolar angulation
  • AP angulation
  • Lateral border offset
• 3D-reformatted CT images can better visualize scapula fracture displacement and angulation 1
• Contrast is generally not necessary unless arterial injury is suspected

2. Clinical Correlation

• Correlate imaging findings with clinical presentation
• Assess for:
  • Point tenderness over the scapula
  • Limited range of motion
  • Pain with specific movements
  • Associated shoulder girdle dysfunction

3. Surgical Planning Considerations

• Isolated scapula body fractures generally heal well without surgical fixation
• Surgical fixation may be indicated for:
  • Glenoid neck fractures
  • Significant displacement
  • Intra-articular involvement
  • Associated injuries with higher severity scores 1

Special Considerations

For Suspected Labral Pathology

• If labral tears are suspected in addition to scapular pathology:
  • MR arthrography is preferred for evaluating labroligamentous injuries 1
  • MR arthrography is superior to non-contrast MRI for this indication 1

For Suspected Instability

• If instability is a concern:
  • MR arthrography has been shown to be reliable in diagnosing labroligamentous injuries 1
  • MR arthrography is equivalent to CT in assessing glenoid and humeral head bone loss 1

Common Pitfalls to Avoid

1. Missing associated injuries: Scapular pathology is often associated with other injuries that may be overlooked
2. Inadequate imaging: Standard shoulder MRI protocols may not fully evaluate the scapula
3. Delayed diagnosis: Scapular fractures can be easily missed on conventional radiography, leading to delayed treatment
4. Underestimating complexity: The complex anatomy of the scapula requires careful evaluation, often with multiple imaging modalities

Remember that while isolated scapula body fractures often heal well without surgical intervention, fractures involving the glenoid neck or with significant displacement may require surgical fixation 1. CT imaging provides the most comprehensive assessment of scapular pathology and should be the next step when MRI reveals scapular abnormalities.