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<v ->Dr P here, 21 year old that had an injury 20 days ago.

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This is a pretty fresh case.

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And let's give myself and you an anatomy lesson

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and here is an axial view up high.

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This is a sagittal view.

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This is a coronal view.

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And up high, we see this sort of

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Y shaped or bunny ear configuration.

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You've got some labrum here.

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You've got the biceps and the takeoff

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of the biceps a little bit posterior

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which is the rule rather than the exception.

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And then the superior glenohumeral ligament making the Y

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and then topping off the Y

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are the intraarticular and extra articular components

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of the coracohumeral ligament producing the

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triangular shape of the rotator interval.

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Now let's scroll down.

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You can see the cross-reference over here.

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As we go down, there's quite a bit of swelling, anteriorly

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and there's quite a bit

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of swelling between this structure and the glenoid.

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That structure is a high take off of the M G H L.

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It's very large and chord like

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but a little bit deformed and certainly swollen.

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And all of you have probably already picked up

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on this large Hill-Sachs depression fracture

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and signal throughout the labral tissues.

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Let's keep going.

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This cord like MGHL still deformed, still swollen,

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still irregular, now separating

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into the MGHL and capsule.

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Let's keep following it down.

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We see subscapularis and MGHL.

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They like to travel together.

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There's some torn labrum behind it

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let's keep going still linear, M G H L.

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And there's the subscap in front of it.

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Let's keep going.

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Now we have a curve, a linear shape of the GHL

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which is the I G H L and still a very abnormal labrum.

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Although we're not focusing on the labrum just yet.

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Now let's go back up for a minute and highlight the MGHL.

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And when we do, we go right over here

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we see immediately behind the subscapularis

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the vertically oriented M G H L going all the way up high

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taking off conjointly with the S G H L

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and the biceps right nearby.

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So this is the Buford variation

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and is often a sulcus between it and the underlying glenoid.

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But in this case

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the sulcus is too fluffy, too irregular,

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too ill-defined; let's look at it in the coronal projection.

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There's that sulcus right there.

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And it is very irregularly looking.

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Here's the MGHL, very cord like

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and look at the injurious signal, character and shape

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of this little medial portion of the MGHL.

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So we know we have a serious injury that involves ligaments

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even though they are conjoined

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even though they are misshapen

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we've got a big Hill-Sachs lesion.

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So this person is dislocated.

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Our next job is to figure out where the labrum is abnormal.

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So let's look at the sagittal for a minute

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and see if we've got any glenoid bone loss.

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Not really.

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The glenoid is nice and pear shaped

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and pretty round down at the bottom.

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Maybe some irregularity right there, but there's lots

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of separation between the labrum, and the glenoid

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there, there, there, all the way around.

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It just keeps on going.

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So the entire axillary region doesn't look so good.

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Let's confirm that in the coronal projection

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cause that's the easiest place to do it.

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It looks like a mess.

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The IGHL is true redundant.

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There are too many fishers separating

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the labral-ligamentous complex from the glenoid.

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And even the humeral attachment is markedly swollen.

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You can see areas of partial thickness tear right there.

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Then we look at the superior labrum

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on the coronal and it is a mess.

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We start out anteriorly

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the MGHL, cord like MGHL is abnormal.

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Now we go a little bit more posterior that's abnormal

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that's abnormal.

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That is abnormal.

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That is still very abnormal and getting bigger

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getting bigger, still getting bigger and still present.

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So our entire superior labrum is involved.

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Our entire inferior labrum is involved.

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There's your Tomahawk chop Hill-Sachs lesion

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in the postdrome superolateral humeral head.

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Now let's go to the anterior and posterior.

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It's already said there's an injury

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between the conjoint Buford complex

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and MGHL and the underlying glenoid.

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Cause it's just too swollen and fluffy

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but that keeps going and going.

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The labrum is detached.

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The labrum is still detached, still detached.

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There's the detachment persisting.

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There's the detachment still,

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now the labrum becomes dusty looking.

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In other words, it's lost its dark triangular shape.

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It should be darker, bigger

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and blacker than the postrum labrum, it's not.

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We keep going and it's diffusely swollen

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and pulverized, it's curling in and still swollen.

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Let's go to the posterosuperior labrum.

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Posterosuperior labrum abnormal, still very abnormal

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and complex, still complex signal, still complex signal

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with a tear in the posterior capsule presence.

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Still, still, still, all the way down on the three

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Tesla imaging and going down and around and underneath, just

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as we said in the sagittal image.

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So this patient has 360 degrees of involvement

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most likely related to trauma and perhaps some areas

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of chronicity in the back due to weightlifting.

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So I suspect there's a component

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of a collision lesion present,

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but we said there are two types of slap nine.

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The one where you have 270 degrees, that's more chronic.

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The one where you have 360 degrees,

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that's more acute on chronic.

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This is an acute on chronic one and never do we

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see a quadrant where the labrum is normal.

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Let's check out one more thing and see how

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the biceps is doing.

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Now, we already know that the tear undercuts the biceps.

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Cause there it is, but here's the biceps

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intrinsically right there.

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And you can see that it's a little bit swollen

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but it's still a nice dark tube.

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Yes, there's a little edema in it.

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Yes. There's a little edema as the right course.

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There's no vocality.

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Therefore the biceps in this particular example is spare.

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An example of a very complex case,

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acute superimposed on chronic.

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Dr. P.L.