0:01

All right, I'm gonna, I'm gonna three up this next group.

0:04

I'm gonna put up my two coronals and my sagittal,

0:08

which is how I would normally do it if I was sitting by myself.

0:13

So this is a patient with

0:17

worsening shoulder pain. He's 65 years old.

0:21

Extends into the biceps is limited range of motion and stiffness

0:26

for two years.

0:37

I'm gonna do a little scrolling here.

0:42

Let you have a full look at this case.

0:46

Gonna ask you to look at the medial arch,

0:50

the lateral subacromial arch,

0:53

the lateral subacromial arch in the sagittal projection,

0:59

the integrity of the cuff in the saal, in the coronal projection.

1:04

I might then pull down my axial and scroll through the axial.

1:09

I'll make that a little bigger for you.

1:14

And now let's call up our question for this case.

1:20

Which of the following is true?

1:23

The rotator cuff tear is visible from the articular surface.

1:29

B.

1:30

The rotator cuff tear is visible from the bursal surface C.

1:35

The rotator cuff cable is heavily involved. D.

1:39

There is two centimeters of macro retraction. E.

1:44

The subacromial arch is normal. The

1:49

correct answer is B.

1:52

And the majority of you got that right now.

1:55

Where is the articular surface?

1:58

Let's keep this question up for a minute so you can see how you all responded.

2:03

The articular surface is right here.

2:07

This is not an articular surface. This is a humeral surface.

2:11

There's no joint here. There is no cartilage here.

2:16

This is the footprint, attachment of the rotator cuff. So you,

2:21

if you go in arthroscopically and look here,

2:23

you're gonna get stuck right there on those fibers.

2:26

You are not gonna be able to see this tear.

2:28

This is critically important clinically because if they go in this way,

2:33

they can't wake the patient up and get permission to go the other way cuz the

2:36

patient's already anesthetized. The patient has to come back another day.

2:40

So this tear is visible from the bursal surface. The correct answer is beat.

2:45

Now the rotator cable is not heavily involved cuz the cable is the deeper

2:49

portion of the cuff. It condenses anteriorly and posteriorly. It's thick,

2:54

it's stiff, it's not a strong or major component of the footprint.

3:00

So that answer is false.

3:03

Two centimeters of macro retraction would mean to be retracted two centimeters

3:06

this way. So that's false. And finally,

3:09

the subacromial arch is not normal. Let's take a look at the arch.

3:14

The arch is composed of the acromion, which has this little pointy snout.

3:19

So it's a hypertrophied spur.

3:21

And it also has this thickened ligament right here,

3:24

which is the coracoacromial ligament. Together,

3:28

they impose upon the rotator cuff. And you might say, really,

3:34

that's not next to that? And you'd be right,

3:37

except when the patient puts their arm up over their head.

3:40

You bet this comes right in contact with that.

3:44

Now another thing I like to do is I like to look at the,

3:46

I like to look at the shape of the humorous.

3:48

So let's do that together In the Corona projection.

3:51

That is a nasty looking little humorous. Look at that thing.

3:56

When you pick your arm up over your head, that is gonna bang into that.

4:00

You're gonna get a pincher phenomenon, you're gonna get a crusher effect.

4:05

You're gonna impinge the cuff and eventually the footprint as it has is gonna

4:10

give way. So this is known as a footprint evulsion.

4:14

It is gonna be visible from the bursal side. So if they come in this way,

4:17

they're gonna see it. If they come in that way, they're not going to see it.

4:24

Now the medial arch commonly is abnormal.

4:27

The AC joint is the medial arch,

4:30

but it rarely induces or produces a rotator cuff tear because this,

4:35

this area is so strong as a myotendinous unit.

4:39

So this is an a very rare cause of rotator cuff rupture.

4:43

The coracoid arch anteriorly is an important cause,

4:47

but much less common than the subacromial arch as a contributor to

4:52

outlet related impingement. Now in young people,

4:56

I like to divide impingement into anatomic causes and movement instability

5:01

causes. In the middle-aged patient, it's usually a combination. In this case,

5:06

the subacromial arch is abnormal and the patient also has micro instability.

5:11

The humeral head is bobbing around in the glenoid cup.

5:16

How do I know that? I'm not an orthopedic surgeon. I didn't examine the patient,

5:21

but I know that by looking at the axial projection,

5:24

the patient is simply lying on their back and the center of the humus is

5:29

slightly posterior offset to the glenoid cup. Can see it right now.

5:34

See how the, the humus is leaning backwards.

5:38

It's pushing back a little bit. Why is that?

5:41

Because the patient had an old glenoid injury.

5:45

A fracture fracture healed but not perfectly.

5:51

The labrum is chronically torn.

5:53

There's posterior and posterosuperior chronic micro instability.

5:58

So a combination of micro movement and this abnormal

6:03

a Barrett hypertrophy, acromion and carac or acromial ligament,

6:07

which you can see in the saal projection right here. There it is,

6:12

how thick that thing is.

6:14

Those are contributing to our rotator cuff footprint

6:19

tear with bursal sided communication.

6:23

Are there any questions about this case in which we have outlet related

6:27

impingement? A less than one centimeter footprint,

6:33

full depth tear with bursal sided communication without macro retraction

6:38

and evidence of a chronic posterior labral tear with chronic posterior micro

6:42

instability syndrome.