0:00

<v ->Okay. So now I think we are ready for the third round.

0:05

(doctors laughing)

0:07

The third round, so let's go to it.

0:09

Third round of cases of today's conference.

0:14

And, for this first case of our third session,

0:20

we have a 79 years-old female

0:24

with history of chronic shoulder pain

0:27

that is getting worse, especially in the last two weeks.

0:32

And here in this case, we can see

0:36

a lot of degenerative changes.

0:39

We can see supraspinatus and infraspinatus tendinopathy.

0:44

We can see just (indistinct) tear

0:48

of the supraspinatus tendon here,

0:51

close to the greater tuberosity of the humerus.

0:56

And we can also see tendinopathy

1:00

of the subscapularis, with maybe here,

1:04

a small area of a delaminated tear

1:09

in this region right here.

1:11

And we also can see in this case

1:15

degenerative change of the glenohumeral joint.

1:18

You can see that there is exposure of the

1:26

of the subchondral bone here with bone, with osteophytes.

1:33

And we can see a great bone effusion here

1:40

with some degree of synovitis.

1:42

We should remember that degenerative changes

1:46

that are osteoarthritis can also do,

1:52

can also course with synovitis, okay?

1:55

So this probably it's synovitis,

1:58

secondary to degenerative change.

2:01

But I'm showing this case here to illustrate

2:05

one of the places where we can see

2:12

articular bodies,

2:15

intra-articular bodies, and, in this case,

2:17

we can see the articular bodies in the biceps tendon sheath.

2:21

As Dr. Resnick already said in his lecture,

2:26

in the shoulder we have some areas

2:30

where we can have always to double check

2:33

if there is some intra-articular body.

2:37

And one of these areas is the bicipital,

2:41

the tunnel sheath of the biceps.

2:43

Another area is here.

2:46

Let me put the sagittal plane here.

2:50

Yeah. The other area is here.

2:52

That's the area of the subscapularis recess.

2:57

Do not,

3:00

do no make the mistake to call this area here,

3:05

the subscapularis recess, okay?

3:08

This is the subcoracoid bursa, okay?

3:12

The subscapularis recess is this area here.

3:15

The subcoracoid bursa, it's more laterally,

3:19

and it covers the middle and the lower portion

3:25

of the subscapularis here.

3:28

So this area is the subcoracoid bursa here.

3:32

And this area is the area of the subscapularis

3:37

subscapular recess.

3:38

And the other area that we always have to look,

3:43

to double check,

3:45

in order to get some

3:47

intra-articular bodies in the shoulder is here.

3:50

It's the axillary pouch.

3:52

So when I'm,

3:55

every articulation, every joint

3:58

has it's recess and it's gutters, right Don?

4:02

<v ->Yeah.

4:05

because that these are the areas

4:08

where the intra-articular bodies,

4:11

they will hide, they will stay.

4:14

And if you don't know these areas,

4:16

we will let these lesions pass

4:19

and we will not put that in our report.

4:22

So, one thing that I use a lot,

4:24

I think that I'm a detective, right?

4:28

And these loose bodies are criminals, and I try to get them.

4:33

And that gives me a personal satisfaction

4:37

when I find one of these

4:38

because it can be kind of boring to find

4:41

these intra-articular bodies.

4:44

But doing that, I can feel that I feel more

4:52

that I'm I feel more like going through

4:55

this intra-articular bodies.

4:58

So that's, for this first case,

5:00

that's what I'd like to show you.

5:04

That is the mindset that I want you to have

5:08

when you think about intra-articular bodies.

5:11

They are criminals.

5:12

You have to look the recess, the gutters

5:15

when they are hiding from you

5:18

and you have to get them, okay?

5:20

So that's the first case.

5:21

Do you have any comments, Don?

5:23

<v ->No. I just think you,

5:25

the point you made about differentiating

5:29

the subscapularis recess of the glenohumeral joint

5:32

from the subcoracoid bursa is a good one.

5:35

It's not always easy,

5:36

but most of the times you can make that differentiation.

5:40

<v ->Yeah. And it's just in this case, we also have the

5:44

also have the x-ray.

5:45

In the x-ray, we also could see the intra-articular bodies

5:50

in the area of the biceps tendon sheath.

5:54

We have to be careful because sometimes when

5:57

we see calcifications in this area,

6:01

one differential diagnosis could be hydroxyapatite,

6:06

could be some kind of crystal deposition.

6:11

So this could be a experiential diagnosis for a case.

6:15

Of course, when you look the air

6:17

when you look the morphology of the lesion

6:21

it's easier to define.

6:24

And another tip that I can give is

6:28

here we can see the intra-articular bodies

6:32

in the biceps tendon sheath.

6:34

And when we have a intra-hydroxyapatite deposit,

6:40

a crystal deposition, generally it's located

6:43

in the soft tissue around

6:46

not inside the tendon sheath.

6:50

And we have some edema,

6:53

some inflammatory tissue, around the lesion.

6:57

Just to make the differential diagnosis.

7:01

Okay? So let's go to the next case.