Skeletal Radiol (1996) 25:513517 International Skeletal Society 1996

R E V I E W A RT I C L E

&roles:Nathalie J. Bureau Robert G. Dussault Theodore E. Keats

Imaging of bursae around the shoulder joint

Presented at the Annual Meeting of the Canadian Association of Radiologists, Montral, QC, Canada, June 1995

N.J. Bureau, M.D. (u) Department of Radiology, Htel-Dieu de Montral Hospital, 3840 St-Urbain, Montral, Qubec H2W 1T8, Canada R.G. Dussault, M.D. T.E. Keats, M.D. Department of Radiology, Health Sciences Center, University of Virginia, Charlottesville, Virginia, USA&/fn-block:

&p.1:Abstract The authors present a review of the anatomy of the major bursae around the shoulder joint and discuss the use of the different imaging modalities which demonstrate their radiologic features. The calcified subacromial-subdeltoid bursa has a characteristic appearance on plain radiographs. When inflamed it can be visualized by ultrasound and magnetic resonance imaging. Calcific bursitis may involve the subcoracoid bursa. This bursa may mimic adhesive capsulitis of the shoulder or

complete rotator cuff tear when injected inadvertently during shoulder arthrography. Less well known are three coracoclavicular ligament bursae. These are also subject to calcific bursitis and have a typical radiologic appearance. &kwd:Key words Shoulder bursitis Subcoracoid bursa Coracoclavicular bursa Subacromial-subdeltoid bursa Shoulder anatomy Shoulder arthrography Shoulder imaging&bdy:

Introduction
The shoulder girdle is a relatively complex anatomic structure. Its osseous and tendinous components are well known. The many bursae that accompany these components are less well recognized. Bursae are small pouches lined by synovium and normally contain a film of synovial fluid. Their purpose is to alleviate friction by creating a space between two tightly apposed structures that move relative to one another. These bursae may have clinical implications. With the advent of cross-sectional imaging, it has become mandatory for radiologists to expand their knowledge of soft tissue anatomy. The purpose of this paper is to review the anatomy of the major bursae around the shoulder joint and to demonstrate the radiologic features of calcific bursitis of these bursae.

Bursae around the shoulder joint

Subacromial-subdeltoid bursa The subacromial-subdeltoid (SA-SD) bursa is actually composed of two bursae, the subacromial and subdeltoid

bursae, which are contiguous in approximately 95% of patients [1]. The SA-SD bursa covers a large surface area and facilitates movement between the rotator cuff tendons and the coracoacromial arch and between the rotator cuff tendons and the deltoid muscle. Medially it extends to the coracoid process. Its lateral and inferior extent beneath the deltoid muscle is more variable, and it may extend 3 cm below the greater tuberosity of the humerus [2]. Anteriorly the SA-SD bursa extends to cover the bicipital groove (Fig. 1). The normal SA-SD bursa is a potential space and is not visible on plain radiographs. Its inner layers consist of synovial tissue whereas its outer layers consist of connective tissue with a certain amount of fat interposed between the rotator cuff tendons and the deltoid muscle. This extrasynovial fat may be seen on radiographs as a radiolucent stripe 12 mm wide [3] (Fig. 2A). According to Mitchell et al. [4] the peribursal fat plane is better delineated on internal rotation views of the shoulder. Partial or complete obliteration of this fat stripe is not a specific indicator of shoulder pathology. This fat plane can be well demonstrated by magnetic resonance imaging (MRI). On MRI, fluid is not detected in the normal bursa. In the coronal plane the peribursal fat appears as a

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sition disease are unknown. Calcification in the SA-SD bursa may present as a teardrop-shaped radiodense area adjacent to the undersurface of the acromion (Fig. 3). Large amorphous tumoral-like calcific deposits may be seen in association with chronic renal disease. Fluid accumulation in the SA-SD bursa may be seen with rotator cuff tear, inflammatory or crystal deposition disease, and with septic bursitis; the last is particularly a problem in intravenous drug users. Ultrasound is a fast and easy method of evaluating joint effusion and provides direct visualization for puncture and drainage. Subcoracoid bursa The subcoracoid bursa is located between the subscapularis tendon inferiorly, and the coracoid process and the combined tendon of the short head of the biceps and the coracobrachialis muscle superiorly [7] (Fig. 1). It extends posteriorly beneath the coracoid process. It facilitates movement by reducing friction between the subscapularis tendon and the tendons of the short head of the biceps and the coracobrachialis during the arc of rotation of the humeral head. The subcoracoid bursa may present as a calcific bursitis and should be recognized by its typical location (Fig. 4). During shoulder arthrography, direct injection of the subcoracoid bursa has been reported as a cause of technical failure and may be confused with adhesive capsulitis [8, 9]. In a small percentage of patients, a natural communication exists between the subcoracoid bursa and the SA-SD bursa. Hence, if not recognized, inadvertent injection of the subcoracoid bursa in such a patient would result in a false diagnosis of complete rotator cuff tear (Fig. 5A, B).

Fig. 1 The bursae around the shoulder joint: 1 subacromial-subdeltoid bursa; 2 subscapularis bursa, located between the glenohumeral joint capsule and the subscapularis muscle, usually communicates with the glenohumeral joint and is considered by many to be a capsular recess; 3 subcoracoid bursa; 4 coracoclavicular bursa, located between the trapezoid and conoid parts of the coracoclavicular ligament; 5 supra-acromial bursa&ig.c:/f

stripe of high signal intensity on spin echo T1-weighted sequences (Fig. 2B). Kaplan et al. [5] have shown that focal obliteration of the peribursal fat line may be seen in normal subjects and usually occurs adjacent to the greater tuberosity of the humerus. The SA-SD bursa can be seen on plain films when involved by calcific bursitis, usually secondary to hydroxyapatite crystal deposits [6]. Patients may present with acute symptoms of pain, tenderness on palpation, surrounding edema and swelling, or may be entirely asymptomatic. The cause and pathogenesis of this crystal depo-

Fig. 2A, B Normal peribursal fat. A Radiograph of the shoulder in internal rotation demonstrates a crescentic radiolucent area extending from the undersurface of the acromion to the outer aspect of the proximal humerus (arrowheads). This represents fat layers adjacent to the normal subacromial-subdeltoid bursa. B Coronal T1weighted MR image shows the extension of the peribursal fat as a thin, crescentic hyperintense area (arrow) between the deltoid muscle (D), the supraspinatus tendon (S) and lateral margin of the proximal humerus (H). A acromion&ig.c:/f

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A
Fig. 3 Calcific subacromial-subdeltoid bursitis. Radiograph of the shoulder in neutral position shows amorphous calcifications extending along the outer margin of the upper humerus and below the greater tuberosity (arrowheads)&ig.c:/f

B
Fig. 5A, B Inadvertent injection of the subcoracoid bursa during shoulder arthrography. A At fluoroscopy the contrast medium flowed readily into what was thought to be the subscapularis bursa (black arrow). Then spontaneous communication with the subacromial-subdeltoid bursa occurred (white arrowhead). Note the absence of contrast in the glenohumeral joint. At this point a subcoracoid bursa injection was suspected and the needle was repositioned. B The glenohumeral joint (arrowheads), confirming intra-articular needle placement. Injection of the subcoracoid bursa during shoulder arthrography may mimic a complete rotator cuff tear in the rare instance when the subcoracoid bursa communicates with the subacromial-subdeltoid bursa&ig.c:/f

Fig. 4 Subcoracoid calcific bursitis. Radiograph of the shoulder in neutral position shows an oval, amorphous calcific deposit inferior to the coracoid process (arrowhead)&ig.c:/f

Coracoclavicular bursae The coracoid process and the clavicle are connected by the coracoclavicular ligament. This is composed of two fascicles: the conoid and trapezoid. In the angle between the conoid and trapezoid parts of the coracoclavicular ligament there is a quantity of fibro-fatty tissue frequently containing a large bursa, referred to in most textbooks as the coracoclavicular bursa [10] but as the supracoracoid bursa by some authors. The coracoclavicular bursa intervenes between the clavicle above and the posterior part of the superior surface of the coracoid below (Fig. 1). Other smaller bursae can be found in relation to either the trapezoid or conoid fascicles. Calcific coracoclavicular bursitis may be an incidental finding on roentgenography, and should be recognized by its typical location (Fig. 6AC). It has also been reported as a cause of chronic shoulder pain [11, 12]. Calcification in the coracoclavicular region may be the result of calcification of intact or torn ligaments, but in contrast to the amorphous

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appearance of calcific coracoclavicular bursitis, calcification of the ligaments will appear as streaks or lines in the shape of the ligaments [13]. Supra-acromial bursa The supra-acromial bursa is located on the superior aspect of the acromion and normally does not communicate with the glenohumeral joint (Fig. 1) [14]. Other bursae about the shoulder The glenohumeral joint capsule usually has two openings. One communicates with the subscapularis bursa (Fig. 1) [15] by the Weitbrecht foramen located between the superior and middle glenohumeral ligaments. The second is the opening at the bicipital groove between the humeral tuberosities for the tendon of the long head of the biceps and its synovial sheath. A third, inconstant opening may occur posteriorly and connects the joint to a bursa that separates the infraspinatus tendon and the joint capsule [16]. This unusual bursa is the infraspinatus bursa. The subscapularis bursa and infraspinatus bursa almost always communicate with the glenohumeral joint and although they are commonly referred to as bursae, they are considered by many to be joint recesses.

Conclusion
With the refinement of imaging modalities, it has become mandatory for radiologists to expand their knowledge of anatomy. Soft tissue structures that were formerly demonstrated by contrast studies are now readily seen, and in much detail, with MRI and ultrasound. With these modalities, certain pathologic processes may have similar appearances. For example, ganglion cysts may be difficult to differentiate from inflamed bursae, and at times may be diagnosed solely on the basis of their anatomic location. The subacromial-subdeltoid bursa is perhaps the most familiar bursa around the shoulder joint and is frequently involved in pathologic conditions. Less well known are the subcoracoid bursa and the coracoclavicular bursae, which may also present as bursitis and when calcified should be readily diagnosed on plain films by their typical location. C Knowledge of the soft tissue anatomy of these bursae is necessary to avoid misdiagnosis and pitfalls in interFig. 6AC Coracoclavicular bursitis. Radiographs of the shoulder pretation.
B

(A, B) and an antero-posterior coned-down view of the coracoclavicular area (C) in three different patients demonstrate examples of coracoclavicular bursitis seen as collections of amorphous calcification between the clavicle above and the coracoid process below (arrow)

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