0:00

I think we'll stop here and answer any questions.

0:02

Do you have any comments on this case? Yeah,

0:04

Well let, let me uh, start

0:05

with the acromial curricular, uh, case.

0:08

'cause we, we haven't discussed that.

0:11

One of the interesting things that I've learned about that,

0:13

that the, the classic teaching in these cases is

0:17

that the clavicle moves up.

0:19

But if you ever get large chest radiographs

0:23

where you compare the two sides, in many cases,

0:26

the clavicle doesn't move up.

0:28

And in fact, it is the scapula that moves down.

0:32

And so I, I think we've simplified this, uh, in, in,

0:37

I know I did for years thinking always

0:40

that the cla the clavicle would, uh, move up.

0:43

The other thing that's puzzling is the nomenclature.

0:46

You know, for most dislocations we talk about proximal

0:51

to distal sternal clavicular.

0:53

So why is this the acromial clavicular

0:56

and not the acromial dislocation?

0:59

I have no idea. Yeah. And I think,

1:01

I think the French probably described it.

1:03

It could be, uh, you know, I'm not, uh, I'm not sure,

1:05

but I always wondered about that

1:07

because the terminology's, uh, not the, uh, not the same.

1:11

I wanted to ask you about also, how often do you do

1:16

the, do you include the measurements in your dictation

1:19

or do you indicate on track, off track,

1:21

just as the general term?

1:23

And do, do you use that for every case

1:26

or is it certain orthopedic surgeons

1:28

Sure. Who request that?

1:29

So if I'm, you know, linguistic harmony,

1:34

um, breeds friendship.

1:35

So I, I like to speak the language of the doctor that I'm,

1:39

I'm, I'm giving my report to.

1:41

So if it's a shoulder surgeon,

1:43

I'm gonna give them more detail.

1:45

I am gonna give them the measurements.

1:46

I'm gonna give them on track, off track.

1:48

I'm gonna use the term bipolar and,

1:51

and I will give them the actual measurements in millimeters.

1:54

Whereas if it's a general orthopedic

1:57

surgeon, you'd be shocked.

1:58

Most of them don't even know what bipolar or unipolar is.

2:03

And, um, so I, I won't actually give them the measurements,

2:05

but I will say that there's a risk of engagement.

2:08

And I'll describe for them what engagement actually means.

2:11

I'll describe for them what actually bipolar means in a

2:14

non condescending way.

2:16

So would you say, just as an estimate,

2:18

how much longer does it take, uh, you, I mean, I'm impressed

2:22

how fast you move here as I look at, at the workstation,

2:25

but how much does it add to your exam time when you

2:28

Yeah, that particular

2:29

measurement takes me about two minutes.

2:31

Okay. Well, the people listening, I, they're probably,

2:34

they're not familiar with, they ought

2:36

to probably put aside 10

2:38

or 15 minutes initially to figure out,

2:41

but I think they should in fact, uh, you know, consult

2:44

with their orthopedic surgeons because it is a hot topic

2:49

and it may well be

2:50

that you'll get more referrals if you start including,

2:54

uh, that information. So I think it's important.

2:56

I think that's, that's a, uh, a valuable comment.

2:59

And, and, and I will say that, you know, I'm able to do this

3:02

with speed after 40 years.

3:04

When I started out, I certainly

3:06

didn't have that kind of screen. Right,

3:07

Right.

3:09

Okay. IgE, do we have any questions? We do.

3:12

How frequent is it to see resorption

3:14

of the bone fried menu in the latter J

3:17

and what clinical relevance does it have?

3:20

Um, I have not seen resorption.

3:23

If there is not failure of the fusion between,

3:27

and I think you mean the transferred bone, if

3:30

that stays solid, I have not seen resorption

3:32

of it over time, but if in fact it becomes loose

3:35

or displaced, I have seen at that point, resorption

3:39

and, uh, recurrent

3:41

and a second surgical procedure is generally required, uh,

3:45

because, you know, that is one of the important aspects

3:48

of increasing stability to the, uh,

3:51

to the glen joint.

3:54

The other question here is kind of, uh, interesting.

3:57

I understand the different types of anterior labral lesions.

4:01

Um, and, uh, why is it so important to differentiate them?

4:06

It probably isn't important in certain cases,

4:10

but some people believe

4:11

that if the orthopedic surgeon knows ahead of time,

4:15

for example, they are dealing with a SSA

4:19

or with a, uh, perthes lesion, they sometimes have

4:23

to convert them into soft tissue bank art

4:26

lesions to repair them.

4:28

I'm not exactly sure why that is important

4:31

or how that is done,

4:33

but I've heard several orthopedic surgeons tell me that.

4:36

So maybe that's one point of, uh,

4:38

differentiating between them.

4:40

I think it also is that, you know,

4:42

the soft tissue bank art lesions that have no

4:46

intact scapular periosteum,

4:49

their repair may be more complex

4:51

because they can be displaced,

4:53

as I've indicated at the top of the joint.

4:56

You gotta bring them down reattachment.

4:58

So I think the time of surgery will also be influenced

5:02

by the, by the pathology.

5:04

But I think more important is differentiation of failure

5:08

at the glenoid from failure at the humeral site,

5:11

or failure at multiple sites,

5:12

because particularly the humeral failure,

5:16

that hagel lesion is often missed

5:17

by the orthopedic surgeon. I dunno if you have any comments.

5:20

No, as Don pointed out earlier, you know, it's easy

5:23

to blow by these, these capsular injuries when you're

5:25

so focused on these big banker lesions.

5:28

It's also easy, easy to forget

5:30

to look at the subscapularis when you have

5:32

a, a hagel or a bagel.

5:33

And I, I see that happen with,

5:35

with young radiologists, not infrequently.

5:37

And one other comment, when you have ansa

5:40

and there's extreme medialization of the labrum

5:42

where it's just crept underneath the periosteum

5:45

and really wedged in there, the clinicians like to know that

5:49

What volume do I use in an arthrogram, I guess is okay.

5:54

Um, generally, uh, 10 to 12 to 13.

5:59

If you go beyond that and go to 15

6:02

or beyond, there's a higher likelihood that, uh,

6:06

you will get extravasation

6:08

and run into the problem that I show, particularly

6:10

with lesions of the, uh, capsule.

6:13

Uh, the other thing that we do with our arthrograms, uh, is

6:17

that we don't move the shoulder after we've injected

6:22

because that will increase the likelihood of extravasation.

6:25

Uh, we do the, a bear rejection where you have

6:28

to move the shoulder.

6:30

We do it as the last, uh, sequence just

6:34

because they, you will get in some cases extravasation.

6:38

But, um, but those are the general rules that,

6:41

that we, uh, use.

6:43

You use a posterior approach or

6:45

That's interesting.

6:46

Uh, you know, what approach to, to use, I can tell you

6:48

that most of our fellows now who do the arthrograms like

6:53

to use the rotator interval approach.

6:55

But the general rule,

6:56

and it's something to remember, wherever you put the needle,

7:00

you're gonna run into diagnostic difficulties.

7:03

So that is why a number of years ago,

7:05

my associate Christine Chung,

7:07

who's talking at this particular meeting,

7:10

she did write an article that you can refer

7:12

to on the posterior approach, um, when you're dealing with,

7:17

uh, anterior instability of the glenohumeral joint.

7:21

I have done maybe about 20

7:23

of those I have don't have a great deal of experience.

7:26

Uh, initially they're a little more difficult

7:28

and the needle tends to run medially

7:31

as you go deeper and deeper.

7:33

But once you've learned that,

7:34

and the other advantage

7:36

to it is the patient doesn't see the needle ahead of time,

7:39

which can have a, a, an advantage.

7:42

So, so I would recommend that if you're dealing

7:44

with anterior uh, problems, putting the needle

7:48

through the rotator interval, I think is the easiest.

7:50

But there are rotator interval tears

7:53

that can be clinically significant.

7:55

And once you've done the interval approach,

7:58

contrast leaking out there is fairly common following the,

8:02

uh, arthrogram or at the time of the arthrogram.

8:05

So you can't tell very well.

8:07

I, I atrogenic from a, uh, rotator interval, uh, tear.

8:13

Any tips on how to differentiate

8:15

a acromioclavicular joint capsular injury

8:18

and degeneration of the AC joint?

8:21

I sometimes find traumatic versus degenerative changes.

8:24

Tricky in some case. Appreciate any clues from the experts.

8:29

Um, well fir first of all, most people

8:31

that have chronic disease will have spurs,

8:36

arthrosis, and the ligaments are still there.

8:39

If you look, you know carefully, they may be irregular,

8:41

they may be thickened,

8:43

and you should inspect all four quadrants, anterior,

8:46

posterior, superior, and inferior.

8:49

Also, much of the time, you don't have the kind of

8:52

soft tissue swelling that you have with an AC joint, uh,

8:55

capsular injury, nor do you have the,

8:58

the signal abnormalities at the trapezius reflection or,

9:01

or at the lateral deltoid reflection.

9:04

And probably the easiest thing of all is the history.

9:07

You know, somebody that has an AC joint capsular injury,

9:09

usually, you know, they've fallen down somewhere.

9:13

They've fallen directly on one shoulder with folks,

9:16

you know, falling on top of the opposite shoulder

9:18

with the arm in abduction.

9:20

So the history is very helpful.