0:01

Now we move down our list to humeral failure,

0:04

failure at the humeral site of attachment of the anter band,

0:09

of the inferior lial ligament.

0:12

And here we deal with what has been called a hagel lesion

0:15

and if there's a bony counterpart, a

0:18

what's called a vagal lesion or be hagel lesion.

0:21

So we're not dealing with failure here,

0:24

but over here, let me show you a few examples.

0:27

First of all, this is often associated with involvement

0:31

of the axi pouch

0:33

and often also the posterior band

0:37

typically occurs in a slightly older group.

0:40

Generally the patients over the age of 30,

0:43

and particularly if you see dislocations in middle age

0:46

or elderly persons, you better be looking for failure

0:50

at the humeral site, the hagel lesion,

0:54

hyper abduction, external rotation.

0:56

And there are other lesions

0:57

that involve structures about the glenohumeral joint.

1:01

It may be overlooked at surgery.

1:03

So here's an important role for you to mention it

1:07

because the orthopedic surgeon will then look for it.

1:10

So let me show you in this example, I have a yellow arrow on

1:16

the inferior

1:17

or the anterior band of the inferior glen ligament complex.

1:20

And that where that yellow arrow is should be

1:23

where it attaches to the humerus.

1:25

But there's a large gap here.

1:27

Maybe there's a little bit

1:28

of tissue still attached to the humerus.

1:31

So here in fact is that anterior band running from the

1:36

glenoid over to that area, but no further.

1:39

So this is a humeral of b******t. And here's the pearl.

1:44

Whenever you see this particular problem,

1:46

there can be problems of other tendons of the rotator cuff

1:51

and especially look for the subscapularis tendon

1:55

and especially its deep portion.

1:57

And here's an example that is a detachment

2:01

of the deeper portion of the subscapularis tendon.

2:04

So please look for that. Here's another example.

2:08

This is in fact that anter band

2:11

of the inferior glen mal ligament complex kind of ends here.

2:15

It should go up to the humerus. It doesn't.

2:17

This is a hagel lesion and one vagal lesion.

2:22

This is a bone evulsion occurring at the humeral attachment

2:26

of the Anter band shown by Mr

2:30

and by ct

2:31

and also by conventional radiography outlined

2:35

by the arrows in this uh, case.

2:38

So a B haal lesion.

2:40

Now there are a lot of posterior counterparts.

2:43

Uh, I'll mention them with the very last slide in this talk.

2:46

I'm not gonna illustrate 'em other than this one.

2:50

So this is a posterior humeral evulsion

2:52

of the glen ligament.

2:53

I've seen a number of these that is the posterior band.

2:57

It should be attaching to the humerus.

3:00

I've seen them only in the acute situation.

3:02

There's always a lot of edema in these cases.

3:05

And there may be tearing of the,

3:08

particularly the infraspinatus tendon.

3:10

There was some in this particular case.

3:14

And then finally at the bottom of the list,

3:16

somewhat rare supposedly,

3:18

but it may not be as rare as indicated, okay, is a

3:23

floating ligament failure at more than one site.

3:27

Here we can see failure of that anterior band

3:32

involving a bone bank art lesion as well

3:35

as a hagel lesion shown better ear.

3:38

Here's the bone bank art.

3:40

So this is called a floating anor band

3:43

of the inferior glen mal ligament.

3:46

But let's kind of review what these look like.

3:48

Here's my drawing, glenoid labrum anor band

3:53

of the uh, inferior lium mal ligament is shown.

3:57

I'm showing you the scapular periosteum.

4:00

Let's look at the lesions we've talked about.

4:02

The first of these is the soft tissue bank art lesion.

4:06

We wi deal with a detached displaced labrum, okay,

4:12

a torn anterior scapular periosteum.

4:16

So the degree of displacement may be extensive

4:19

and you end up with complex tissue, irregular

4:23

and outline consisting of periosteum, consisting

4:27

of ligament, and consisting of labrum.

4:31

The second is the sal, where you get a detached labrum

4:37

and an intact,

4:39

although stripped anterior scapular periosteum.

4:42

So this labrum may move but not very far.

4:46

Typically you should look

4:47

for it near the inferior aspect of the glenoid.

4:50

Here's what it looks like with an acute SIL lesion,

4:54

and you can see the stripped anterior scapular curiosity.

4:59

The third of these is a a little bit more

5:02

difficult to identify.

5:03

The degree of displacement is less dramatic.

5:07

I call it a Perth phase lesion when I see it only

5:10

or certainly best in the a bear position.

5:14

And this is what it looks like when you deal

5:17

with an older person.

5:18

The abnormality may occur at the humeral site

5:22

of uh, attachment.

5:24

Here's an example showing you that with the white arrow

5:28

humeral detachment of the anterior band,

5:31

of the inferior glen ligament complex.

5:34

And then the floating ligament shown here with failure

5:38

at both ends, humeral attachment as well

5:41

as the bone banquet.

5:42

Now we're gonna finish up in the last three

5:44

or four slides talking about the idea of a circle

5:49

or ring concept, emphasizing the importance

5:54

that if you find one abnormality

5:56

In the excitement that follows, keep looking

6:00

because there may in be another abnormality.

6:03

And that's the concept that when you have ring-like

6:07

structures as we have here with glenoid and ERUs

6:10

and ligaments, both anteriorly

6:12

and posteriorly, more than one lesion may occur.

6:16

For example, with an anterior dislocation, you may get

6:21

a soft tissue bancar lesion, but over time,

6:25

or even at the same time,

6:27

you may get a posterior haal lesion.

6:30

If we deal with a posterior dislocation, you may start

6:35

with a posterior haal lesion

6:37

and over a period of time you may develop an anterior haal

6:42

lesion or some other break in the ring

6:45

and to show that with one particular case.

6:48

This is an example of a soft tissue bank art lesion

6:53

here, a posterior hagel lesion shown here.

6:57

It's some, it was a hill sax lesion.

6:59

You see all of the marrow edema associated with it.

7:02

So this is the circle

7:04

or ring concept if you find one abnormality, keep looking.

7:09

And my last slide shown here is with all of these names

7:14

that we have in our literature describing so many

7:19

lesions differing in their site of abnormality

7:22

or degree of abnormality, we have similar lesions

7:26

that occur posteriorly.

7:28

I'm not gonna discuss those today, but they too have names.

7:32

I've listed some on this particular slide.

7:35

We'll have to save that discussion for another day.

7:39

So what I've done in this, uh,

7:40

lecture over my allotted period of time is

7:44

to run ba down the left side of that table.

7:47

We looked at macro instability in an anterior direction,

7:52

and indeed we looked at failure at the glenoid site

7:57

of attachment for varieties, failure in the capsule,

8:00

failure at the humeral site or failure at multiple sites.

8:05

I thank you very much for your attention.