0:01

Okay, so what we're gonna do now in the second half,

0:05

or a little less than half of the lecture,

0:06

we're gonna now go through some

0:08

of the more subtle abnormalities.

0:11

Yesterday we talked about the slap lesions.

0:14

I'm not gonna cover these.

0:15

I will talk a little bit about, uh,

0:18

GLAD lesions in the second lecture,

0:20

and I'll talk about flap lesions a little bit.

0:24

In this lecture, what we're gonna decide is

0:27

with anterior macro instability, where is the abnormality?

0:32

Glenoid failure, which are four varieties,

0:35

occurs in about 70% of cases.

0:38

Cases failure in the capsule itself,

0:40

and 20% failure at the humeral, uh, side 10%

0:45

and at multiple sides producing a floating ligament.

0:49

Very, very rare.

0:51

So we're gonna go down this list showing you each

0:53

of these patterns of failure, starting

0:56

with failure at the glenoid attachment

1:00

of the anterior band,

1:01

of the inferior numeral ligaments shown here in a transverse

1:06

image in a cadaver,

1:08

which we did a MR air gram.

1:11

So looking at this, this is the first target site

1:14

that we're gonna look at.

1:16

The first of these lesions is a soft tissue bankart lesion.

1:20

So here's what happens.

1:22

The humeral head dislocates anteriorly,

1:26

this will put tension on the anterior band

1:29

of the inferior glen mal ligament.

1:32

It will lead to a labral detachment.

1:35

That detachment will elevate the anterior scapular

1:39

periosteum and, and eventually produce a break in

1:43

that periosteum.

1:44

So this is an anter labral ligamentous avulsion

1:48

with periosteal disruption.

1:51

And now what you have is ligament labrum periosteal tissue

1:55

no longer attached acutely to the glenoid margin.

1:59

So what can happen,

2:01

this can float up higher up in the joint.

2:04

So although this is derived anter inferiorly,

2:07

you may encounter it at three o'clock

2:10

or two o'clock, the displaced tissue,

2:13

and that becomes important to recognize diagnostically.

2:18

So let me show you the drawings on the left

2:20

from Mike Stadnik.

2:22

Here is an MR image showing you this soft tissue

2:26

bankart lesion, detached labrum, displaced

2:31

elevation, and rupture

2:32

of the periosteum labeled P in the drawing.

2:36

This is a beautiful example of what it looks like

2:39

and who tear here is the tear

2:41

of the anterior scapular periosteum.

2:44

Here's another case. This one with Mr. Arthrography.

2:49

The arrow is pointing to the detached and displaced labrum.

2:54

And as you look at this particular image,

2:56

you can see this is a grossly abnormal anterior

3:00

scapular periosteum.

3:01

Some of that is labral tissue.

3:04

Now, as that tissue

3:07

labrum periosteum ligament float up,

3:10

they create a ball of tissue that has a name it was named

3:14

by at the, uh, Naval Hospital in San Diego

3:18

and called glenoid labrum, ovoid mass or glom.

3:23

Some people call it the glom sign

3:26

and it's a sign of a Bankart lesion,

3:28

but it doesn't look like a Buford.

3:30

It's more irregular

3:31

and it doesn't look like it dislocated biceps tendon

3:36

'cause it has those strands.

3:37

This is the glom side.

3:40

Now, what can happen

3:41

with a sub glenoid anter Glen al joint dislocation

3:45

the labrum along with the aary pouch

3:48

and portions of the Anter band,

3:50

and sometimes the posterior band are pulled off

3:54

of the glenoid.

3:56

So this really is a variant of a soft tissue bankart lesion.

4:00

But you'll hear this term glenoid labrum, avulsion

4:03

of the glen mal ligaments.

4:05

Gaggle, I don't use that term.

4:08

I think this is simply a soft tissue

4:10

Bankart lesion occurring more inferiorly

4:13

with a sub glenoid dislocation.

4:17

The next point of failure

4:18

or lesion that occurs at the glenoid point of failure

4:22

is the ole lesion,

4:24

anterior labral ligamentous periosteal, sleep avulsion.

4:28

Acutely what occurs?

4:29

The humeral head dislocates, there's tension on

4:33

that anter band.

4:35

The labrum is a pulse.

4:37

The scapular periosteum is elevated, but it is not torn.

4:42

So this is a detached, slightly displaced labrum,

4:45

but it can't wander too far.

4:47

And if it wanders, it frequently does so

4:50

inferiorly and medially.

4:52

All right? But it doesn't have to wander at least acutely in

4:56

that direction.

4:58

So here's a beautiful example.

5:00

First by diagram, here's the detachment.

5:03

And you can see the lax

5:04

but intact anterior scapular periosteum.

5:08

Here is the detached labrum.

5:10

Here is the stripped intact periosteum.

5:13

And in this case, acutely, it's really not, uh,

5:17

far medially, uh, displaced.

5:19

Often it is, but it doesn't have to be

5:21

as shown in this example.

5:23

Here's another one. This one looks like it's been

5:26

around a while here.

5:28

In fact, it is displaced immediately, the detached labrum.

5:32

Here's the elevated and thickened anterior sca, uh,

5:35

scapular periosteum.

5:37

So this is an acute or subacute outsole lesion.

5:41

And one more, and you'll note

5:43

that we see this particular detachment, not just in the

5:48

a bear position, more about why I mention that in a moment,

5:51

but we see it in the transverse plane, the coronal plane,

5:55

and in the sagittal

5:56

Plane.

5:57

Now, over a period of time, a chronic SSA develops

6:02

and what occurs is fibrosis around the detached labrum

6:06

and in the adjacent tissues.

6:09

So you end up with a mass that is inferior,

6:12

immediately displaced.

6:14

To show you what some cases look like. Here is one example.

6:18

This is not a, a acute ulcer.

6:21

This is a chronic ulcer with a lot of peri labral fibrosis.

6:26

Here you can see it is somewhat medial in this

6:29

particular autograph.

6:30

Here's another one. The coronal images look similar.

6:34

Here it was, you can see two pieces of that displaced labrum

6:38

medial lies below the inferior margin of the glenoid.

6:43

So these are chronic aset.