0:00

Now.

0:01

Now we're gonna introduce in more detail

0:03

that particular cell BCUs,

0:05

let's call it the spiral ligament.

0:07

And just to give you an idea broadly of what it looks like,

0:11

again, I'm showing you a drawing that I came up with

0:14

and that particular drawing shows you the anterior band

0:18

and the posterior band, so labeled AB and PB

0:22

and their descent from the glenoid point of attachment

0:26

to the humeral point of attachment, the fosus

0:31

ocus in green has the opposite course.

0:34

It goes from a higher position on the humeral side

0:37

to a lower position on the glenoid side.

0:41

Now some people believe this is the holy grail

0:45

of the glen joint when it comes to stability.

0:49

I can tell you it's a bit difficult to identify.

0:52

I am gonna show you some images of it.

0:54

You do better when there is fluid in the joint

0:56

or if you're doing an MR arthrogram.

0:59

So I tried to come up with a 3D diagram of

1:03

what it looks like, and this is the best I can do.

1:06

Anter is to your right, posterior is to your left.

1:09

And I'm showing you the subscapularis muscle

1:12

and tendon in this area here.

1:14

We can appreciate in fact the faus ocus here.

1:19

Now it would descend, as I said, from a high

1:23

humeral position and then go underneath this particular area

1:27

beneath the aary pouch to attach to the glenoid.

1:31

You can see the middle Nia mal ligament

1:33

and the two bands of the inferior theum ligament complex.

1:38

Now to bring this to life, let's go ahead

1:41

and do a coronal section.

1:43

And this is what the ant, this spiral ligament looks like.

1:47

We're cutting just posterior to the subscapularis.

1:51

So this is not the subscapularis tendon, this is

1:55

that humeral attachment of the spiral ligament.

1:58

Now let's do another coronal image a little bit

2:01

more posteriorly.

2:03

And here you can see one

2:05

of the important characteristics of this ligament.

2:08

It indents the axillary pouch.

2:11

So often when you have fluid

2:12

or you've done an arthrogram, you'll see a bi

2:16

lobe appearance indicating the indentation

2:20

from this fascicular cus to prove that point here is one

2:25

of the sections showing you the antra band

2:28

of the inferior glen mal ligament with its glenoid

2:31

and humeral attachment.

2:33

And that is the sulu O ocus coming down

2:37

and passing then inferior to that axillary pouch

2:41

to attach to the glenoid.

2:44

So let me try to add that to my drawing

2:47

and here's what it would kind of look at.

2:48

This is the best that I could do in PowerPoint. It's purple.

2:52

You can see it descending from a higher humeral position,

2:57

intimate with the anter band

2:58

Of the inferior glen mal ligament.

3:00

And then extending deep two,

3:03

or I should say superficial to the axial pouch beneath it,

3:07

more inferior to attach to the glenoid.

3:12

Now that's kind of an interesting arrangement

3:14

and might explain why in fact

3:17

some orthopedic surgeons regard it as the holy rail

3:20

because what does it look like?

3:23

It looks like a baby bundle.

3:26

Here, in fact is a baby bundler.

3:28

And you see the two components on your left,

3:30

the anterior band and the Sulu sous,

3:34

and more detail on your right.

3:35

A beautiful drawing from Mike Stadnik at Rad Source showing

3:39

you the relationship

3:40

of the Fasciculus OBL is supporting the Anter band

3:44

of the inferior theum ligament complex.

3:47

So it may be a very important ligament

3:50

and I realize for many of you who are listening to this,

3:53

you've probably never heard of it

3:55

or certainly never identified it,

3:57

but you might wanna start looking for it now.

4:01

Part of the difficulty that we have

4:03

with this particular quadrant of the emeral joint

4:09

relates to the variability and size, shape,

4:13

and signal intensity of the labrum.

4:16

It can be small, it can be large,

4:18

and as you can see here, it can be actually discoid.

4:22

And indeed the discoid labrum

4:24

or a combination

4:26

of labral ligamentous structures may in fact invaginate

4:31

the anor aspect of the humeral joint as shown here

4:34

with the discoid labrum producing posterior subluxation

4:39

of the humeral head.

4:40

That may be clinically significant.

4:43

When you have invaginated tissue here, the discoid labrum

4:46

and a sagittal and is shown on the right,

4:48

you can see the shadow that is projected over

4:52

the glenoid related to this uh, tissue.

4:56

The second difficulty arises in

4:59

that the labrum may contain ous

5:01

and oid, uh, material degenerative changes.

5:05

Now I would emphasize these changes are less common in the

5:08

lower half of the glen humeral joint.

5:12

So where there are problems superiorly in the

5:14

differentiation of these from slap lesions, they are of less

5:18

of a problem when you get down to the lower portion,

5:22

the anteroinferior aspect of the uh, labrum.

5:27

But we do occasionally see extensive degenerative tearing,

5:31

particularly in older people.

5:34

This is a labrum probably at about four o'clock,

5:37

three o'clock or four o'clock,

5:38

and this is degenerative change.

5:41

But if you are worried about instability,

5:43

you might have a problem.

5:45

Inaccurate diagnosis in a few cases

5:48

that have this much degenerative change.

5:51

Fortunately in my practice, most of the cases

5:54

of anterior macro instability occur at a younger age group

5:58

so that degenerative changes are not severe.