0:00

Things get a little more dicey on this case.

0:05

And as you can see, I, I like to begin for expediency.

0:11

I like to begin with my coronal projections.

0:14

So let me get them nice and magnified for you.

0:17

And let's take a, let's take the sagittal for now

0:23

and let's go to our reon.

0:25

We were talking earlier about, um, reon injuries,

0:31

and we do have a, a low grade reon injury

0:35

off the apex, more towards the,

0:37

more towards the lateral facet adjacent to the radius.

0:42

The, the tip of the raddon is, is fine.

0:45

The sublime tubercle is fine,

0:47

although there is a little bit of stripping

0:48

of the UCL distally

0:50

and the remainder of the UCL looks, uh, for lack

0:54

of a better term, not a scientific term, horrendous.

0:57

You can follow it up.

0:58

And unlike our our fan shape structure, we can follow

1:02

that black signal more approximately.

1:05

Uh, this signal is just too light gray in, in character.

1:09

And then on the T one, um, you can see a defect distally.

1:14

It's a little bit wiggly proximally,

1:16

and we never see that, that funnel shape plugin

1:21

of the anterior bundle

1:22

of the medial collateral, uh, ligament.

1:25

So that, that's problem number one.

1:27

Then I work my way over to the other side and I,

1:30

and I take a careful look at the grooves or bumps.

1:34

There should be two grooves and three bumps,

1:37

and there are, so there's not a, not much deformity, uh,

1:41

of the humerus.

1:43

Uh, again, we do have these bone abnormalities,

1:45

but we have a larger bone abnormality on the lateral side.

1:49

Now, usually when there's a valgus force, my preference is

1:54

to see the radio Capella abnormalities sort

1:58

of kissing each other, um, more on the articular surface.

2:02

This one is more eccentrically positioned.

2:05

So if you combine that with this large contusion

2:09

of the soft tissues, you've got to believe that the

2:12

below came from the lateral side

2:15

and resulted in disruption of,

2:17

of the medial collateral ligament.

2:19

And now let's look at these lateral collateral ligaments,

2:22

uh, which are a little bit challenging.

2:25

And let's see if we can get our bearing.

2:27

So if you look to the right,

2:29

I'm gonna magnify the right hand image.

2:31

And maybe I'll even put up a, um, well, let's leave

2:35

that one up for a moment.

2:37

And let's see where we are.

2:38

We're pretty far anterior, so let's work our way back.

2:42

And we do see a, a semblance

2:45

of a proper radial collateral ligament.

2:48

And it's not completely normal.

2:50

It's got this little bump to it.

2:52

And admittedly, this patient is in such discomfort,

2:55

they were unable to extend their arm.

2:58

But now let's, let's work our way to the back,

3:01

to the lateral ulnar collateral ligament.

3:04

That's where it should be.

3:06

This mushy area of intermediate signal intensity is,

3:11

is where the origin of the luck should be.

3:14

You could follow it around the edge and back of the radius

3:17

and onto the Christus Super naus, uh, of the ulna.

3:21

So we, we've lost the luck in this case.

3:24

And remember, in grading certain types of dislocations,

3:29

you know, you're, you're going to be looking at the,

3:31

the UCL, the luck, the proper collateral ligament.

3:36

And when you look at the UUCL,

3:37

you're gonna look at the Anter band.

3:39

And no, I've given it to you in no specific order. Dr.

3:43

Resnick, Don gave it to you in the proper order.

3:45

But let's look at the posterior bundle of the UCL

3:50

since we do have a rather dramatic injury.

3:54

And let's see if we can scroll onto that.

3:59

I think it's a little easier on the T two.

4:03

And here's the, the posterior bundle of the UCL right here.

4:06

And it's not normal. It has this wavy irregular appearance.

4:10

Uh, this is a, a floppy piece of, uh,

4:13

ligamentous tissue right here.

4:15

And here's the remainder of it.

4:17

So the posterior bundle of the UCL.

4:19

And then as mentioned earlier in the lecture, you've got to,

4:24

you've got to consciously evaluate it.

4:26

Every one of these, uh, cases of subluxation

4:29

or dislocation, the ulnar nerve.

4:31

And what am I looking for? I'm looking for swelling.

4:35

I'm looking for changes in signal, especially on the T two,

4:38

on the T two weighted image.

4:40

I want to see my ulnar nerve be gray,

4:44

or at least dark or gray.

4:46

And this one's pretty dark now. I don't want it too dark.

4:49

If it's too dark, I may have paradoxical fibrosis.

4:52

So I want an intermediate

4:54

and signal intensity not too swollen.

4:57

And then another aspect of it,

4:58

which we'll be discussing on the last day,

5:01

is I don't want the nerve to get small and then big

5:05

and then small again.

5:07

And then finally, as we look at the, the sagittal image,

5:11

a couple of other findings that are worthy,

5:14

the capsule has ruptured anteriorly, uh, and,

5:18

and thus fluid has extravasated into this defect

5:22

or tear of the brachialis.

5:25

Now, these ulnar shaft fibers

5:27

of the brachialis are still there,

5:30

but the oid fibers of the brachial,

5:33

which should be a delicate thorn, a very thin thread

5:37

inserting on the tip of the OID process, uh, are replaced

5:42

by an agglomeration of blood.

5:45

Do we have time for another case?

5:49

All right, one more, uh,

5:53

one comment I would make, and it'll come up in the last,

5:57

Uh, talk today that I'm gonna give.

6:00

When you look at the brachialis, uh, muscle and tendon

6:04

and study it at the level of the elbow, keep in mind that 90

6:08

to 95% of the surface area is muscle.

6:11

And so we deal much more often with muscle abnormalities

6:16

of the brachial that we do with, with, uh,

6:19

tendon abnormalities and hemorrhage and lacerations.

6:23

Uh, that does occur with elbow dislocations.

6:26

Quite often, I'll show, not a dramatic as dramatic,

6:29

but a somewhat similar case.

6:31

A a a shocking statement about this case is this patient

6:34

played the rest of a professional football game

6:37

with this elbow wrapped in a, a band wrap

6:41

and actually did not have surgery.

6:43

Amazing, Amazing.