0:00

Okay, we're gonna move down our list in,

0:03

in the last portions of this particular, uh, talk

0:07

and we're gonna deal next with failure in the capsule.

0:11

So let me start by indicating by drawing,

0:13

which I've done here of the variety of lesions

0:16

that might fit into this particular area of failure.

0:23

You can see here in my drawing

0:25

in the foreground the Anor band

0:27

and in the distance posterior band axially pouch,

0:31

the blue are showing you a variety

0:33

of lesions that might be seen.

0:36

So capsule of failure might take the form of failure

0:40

of the Antra band, in this case a little bit

0:43

of a distance from the glenoid extending into

0:46

the aary pouch.

0:48

It might look like this failure of a large part

0:51

of the Antra band going all across the axi pouch

0:55

and involving a portion of the posterior band.

0:58

Or it might involve the axillary pouch itself.

1:02

Alright, so your job,

1:03

whether you're using standard Mr or Mr.

1:07

Arthrography, is to try to figure out where the lesion is.

1:11

Let me make one other point about it.

1:13

These patterns, particularly with involvement

1:15

of the axillary pouch, one

1:18

of the sports in which this has been emphasized is

1:22

volleyball, particularly the volleyball serve,

1:25

which can lead to a lot of injury to the lower part portions

1:29

of the ary pouch with or without involvement of the bands.

1:34

So what we're looking for,

1:35

and again, when we do arthrography,

1:38

but if there's a large joint effusion,

1:40

you might see the same findings is

1:42

where is the extravasation?

1:44

'cause the extravasation at least initially should occur at

1:48

or near the site of violation of this complex.

1:52

So that's what we are looking for right now.

1:56

This pattern of failure usually occurs

1:59

after the first dislocation.

2:01

If you don't get it, then you're probably not gonna get

2:04

it, uh, later.

2:05

Okay. And as I've indicated, it may be axillary pouch alone

2:09

or it may have bands

2:11

of the inferior li mal ligament, uh, involved.

2:16

Now there's one thing you have to realize

2:18

and my associates at UCSD wrote a beautiful article.

2:23

Uh, Wilbur Wang was the lead author.

2:25

You can see the reference at the bottom

2:27

because for those of you who have done arthrograms,

2:31

even without moving the shoulder,

2:33

after you inject the humeral joint,

2:37

you may get leakage of contrast.

2:40

And yet it doesn't indicate a lesion.

2:43

And so they tried to sort out using arthroscopy

2:46

as the gold standard.

2:48

What are the findings associated with iatrogenic leakage

2:52

of the contrast agent compared to a true lesion?

2:56

And typically, if there is involvement

2:58

Of the Anter band, it is going to be pathologic.

3:03

And I think the same rule holds up for the posterior band.

3:07

But if the area of leakage involves the axillary pouch,

3:11

particularly the posterior aspect of the axillary pouch,

3:15

it is often iatrogenic in that article.

3:19

They also pointed out, if you look at the morphology

3:23

of the ligament, you will see in fact

3:26

that it has abnormal morphology when it is a pathologic

3:31

uh, process as opposed to when it is iatrogenic

3:34

as shown in the lower uh, images.

3:37

I think it's a very good article

3:39

to look at if you're running into this problem and doing Mr.

3:43

Arthrography. So let me show you a couple cases in which

3:47

failure occurred in the capillary uh, kit, uh, tissues.

3:51

And this one, I'm showing you an MR arthrogram.

3:55

This is a pathologic leakage of contrast.

3:58

You'll note that I'm only showing you one image.

4:01

This is an anterior image.

4:02

There's a huge defect in the anterior band.

4:06

It's not at the glenoid attachment.

4:08

It's not at the humeral attachment. It's in between.

4:11

And although I'm not showing it here,

4:13

as we went back in the coronal plane and saw

4:16

and looked at other planes,

4:17

this particular lesion did go back

4:20

and involve a lot of the aary pouch,

4:23

but the posterior band appeared to be intact.

4:27

Here's a another one.

4:29

This is failure of the Anor band and Aary pouch.

4:33

You can see the leakage of contrast agent here.

4:36

So this is near its humeral attachment.

4:39

This sometimes produces what has been called the J sign.

4:42

It can be a reverse J sign.

4:45

You can see it kinda looks like a J

4:47

as the contrast material is leaking out.

4:50

Here's another one. And you look at this, there's failure,

4:54

although partial tearing

4:55

of the Anter band here at its humeral attachment,

4:59

and then complete tearing as we go

5:01

through the axi pouch from anterior to posterior.

5:05

And the posterior band

5:06

of the inferior li mal ligament complex is intact.

5:11

Okay? So it was failure of the Anter band and Theary pouch.