I'm working a sample case with the following Dx: Detached but nondisplaced posterior labral tear:
FINDINGS: ROTATOR CUFF: There is a laminated interstitial tear at the conjoined distal supraspinatus/ infraspinatus tendon. No full-thickness rotator cuff tear is present.
MUSCLES: Normal in signal and volume. No fatty infiltration, edema, or atrophy.
LIGAMENTS: The glenohumeral ligaments are intact. The coracoclavicular, coracoacromial, and coracohumeral ligaments are intact.
LABRUM: There is a detached but nondisplaced tear of the posterior labrum. The superior, anterior, and inferior labra are intact.
AC JOINT: Normal. No osteoarthritic changes are present. No AC joint effusion or separation noted.
ACROMION: Normal. No encroachment. No subacromial/subdeltoid bursitis.
OTHER: The humeral head is intact. The long biceps tendon and biceps anchor are intact. The glenohumeral joint is maintained. The axillary recess is unremarkable. No lesion in the spinoglenoid notch.
CONCLUSION:
1. Detached but nondisplaced posterior labral tear. The superior, anterior, and inferior labra are intact.
2. Intact rotator cuff, humeral head, and long biceps tendon.
My first inclination is to search under Tear, articular cartilage. This leads to two possibilities. Either Sprain, or Derangement, old. Nowhere in the notes does it mention this being the result of an old injury, or old in any other fashion, yet I'm being told Derangement, old was the correct path to take. Am I missing something in the notes?
FINDINGS: ROTATOR CUFF: There is a laminated interstitial tear at the conjoined distal supraspinatus/ infraspinatus tendon. No full-thickness rotator cuff tear is present.
MUSCLES: Normal in signal and volume. No fatty infiltration, edema, or atrophy.
LIGAMENTS: The glenohumeral ligaments are intact. The coracoclavicular, coracoacromial, and coracohumeral ligaments are intact.
LABRUM: There is a detached but nondisplaced tear of the posterior labrum. The superior, anterior, and inferior labra are intact.
AC JOINT: Normal. No osteoarthritic changes are present. No AC joint effusion or separation noted.
ACROMION: Normal. No encroachment. No subacromial/subdeltoid bursitis.
OTHER: The humeral head is intact. The long biceps tendon and biceps anchor are intact. The glenohumeral joint is maintained. The axillary recess is unremarkable. No lesion in the spinoglenoid notch.
CONCLUSION:
1. Detached but nondisplaced posterior labral tear. The superior, anterior, and inferior labra are intact.
2. Intact rotator cuff, humeral head, and long biceps tendon.
My first inclination is to search under Tear, articular cartilage. This leads to two possibilities. Either Sprain, or Derangement, old. Nowhere in the notes does it mention this being the result of an old injury, or old in any other fashion, yet I'm being told Derangement, old was the correct path to take. Am I missing something in the notes?