0:00

Thank you very much.

0:02

Uh, again, it's a privilege to be back with you, uh, today

0:05

or tonight, wherever you are.

0:08

Uh, I think we have an exciting topic

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or topics, uh, to discuss over the next few hours,

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including the first one shown here, which we'll deal

0:19

with Glen Humeral joint instability.

0:23

It's a massive subject

0:24

and so what I plan to present over an hour to an hour

0:27

and 15 minutes are the essentials related

0:31

to this particular problem.

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Let's return to our avocado that we introduced yesterday,

0:37

and I show you again, the hours on the avocado

0:41

that is the glenoid face

0:43

through period generally is regarded as 12 o'clock.

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Inferior is six o'clock anterior as three o'clock

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and posterior as nine o'clock.

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And most orthopedic surgeons use these hours in this

0:57

particular arrangement, whether they're dealing

1:00

with a right shoulder or a left shoulder

1:03

and independent of the way the images appear on your screen.

1:10

Now, the good news here for this particular time zone

1:13

that we'll be discussing, uh, in the first lecture,

1:18

the time zone between about two 30

1:21

and 6 37 o'clock, the good news is

1:25

that there are fewer structures with which to deal.

1:28

We'll be dealing with the labrum,

1:30

particularly the lower part of the labrum,

1:33

the subscapularis tendon,

1:34

the inferior then mal ligament complex.

1:38

And we'll be dealing with our old friend

1:40

that spiral ligament I mentioned yesterday, the Fas orcus.

1:45

And you can see from the time zone that I'll be discussing

1:48

with rare exception anterior instability,

1:52

not posterior instability of the glen joint,

1:55

but more about that a little bit later.

1:57

The good news is that this is a time zone

2:01

of many pathologic lesions

2:03

and few anatomic uh, variations.

2:06

So I think that is particularly important.

2:09

So in this particular region

2:11

where degenerative changes are less frequent in the labum

2:15

when compared to the upper

2:17

or the uh, superior equator,

2:19

initial consideration should be given

2:21

to a pathologic process and not a normal variation.

2:27

Now to start with some basic anatomy, I came up

2:29

with this particular drawing.

2:31

It's not beautiful, but I think it's effective.

2:34

You're the an we're looking for from the anterior aspect

2:37

of the shoulder, the humerus, obviously on your right,

2:41

the glenoid on your left, the labrum in yellow,

2:44

and I've opened this up a little bit.

2:46

I kind of externally rotated the humerus

2:49

and beyond that, I've even injected the lenal joint.

2:53

That hazy stuff is the contrast material present

2:57

within it, and I've added

2:59

The subscapularis muscle in front.

3:01

So let's get rid of some of these particular structures.

3:05

I'm gonna get rid of the subscapularis muscle.

3:08

We'll talk briefly about it later on in this presentation.

3:12

And I'm gonna go ahead and put a needle into the Glen Al

3:15

joint and aspirate the contrast material.

3:19

Now you can see that middle venum ligament in kind

3:22

of an orange color,

3:23

and then you see below it a large structure composed

3:27

of two red things and green in between.

3:30

And that's gonna be the inferior venum ligament complex.

3:34

Let's get rid of the middle linear mal ligament,

3:37

and that's the complex that we are left with.

3:40

Now, it may not look like much to you,

3:42

but I'm very, very proud of this particular drawing.

3:45

And the detail that I managed to show

3:48

in the foreground is in fact the Anter band.

3:51

Okay? And you can see

3:52

that big broad red structure running from a glenoid

3:56

attachment here over to a humeral attachment.

4:00

As we go more posteriorly, we cut into the axillary pouch,

4:04

which I'm showing in green.

4:06

And then in the distance you can see in fact

4:08

that posterior band of the inferior glen ligament complex,

4:12

again with glenoid and humeral attachments.

4:16

And the detail here is kind of interesting.

4:18

These are the strands of tissue that colle, uh,

4:21

that connect the axillary pouch to that region

4:25

of the proximal humerus, mainly in the area of the sur

4:29

of the surgical neck.

4:30

Those strands are visible, particularly with Mr.

4:33

Arthrography. I'll be talking a little bit more about them

4:36

later on in this lecture.

4:39

Now, if you look at this particular kind of configuration,

4:43

what does it look like?

4:44

It looks like a hammock.

4:46

You can see there a picture

4:48

of the hammock taken from the internet

4:50

and the resemblance

4:51

to the inferior numeral ligament complex.

4:54

And just like a hammock, if you were in it,

4:57

you could swing it forward and backward.

4:59

The same thing occurs with this particular complex,

5:03

depending upon the position of the humerus

5:05

with respect to it.

5:07

So here you can see this picture showing you neutral

5:11

rotation, internal rotation and external rotation,

5:15

and the way the hammock swings around the humeral head,

5:18

supporting its inferior aspect, moving,

5:22

but still supporting the inferior aspect

5:24

of the humeral head.

5:28

Now, just to give an idea using coronal sections,

5:31

the anterior section on your left,

5:34

the posterior section on your right, over on your left,

5:38

you can see the anterior band

5:39

and you can see the connections to the glenoid

5:42

and the humerus.

5:44

As we go a little bit more posteriorly,

5:46

we're seeing the axillary pouch in the center picture.

5:50

And you can see again, its attachments both to the glenoid

5:53

and to the humeral neck.

5:55

And then finally we can see

5:56

The posterior band in the image on your right.

6:01

Some people do not have a prominent posterior band,

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but we do have an anterior band and an axillary pouch.

6:08

And in most cases, we also have a posterior band

6:11

with which to deal.

6:13

Now, just to show you using a sagittal Mr.

6:16

Orthographic image, which is a good plane

6:20

for getting the overall anatomy of these ligaments,

6:23

I'm showing you the Anter band

6:26

of the inferior nueral ligament complex.

6:29

Typically, it arises from the two to four o'clock position,

6:33

uh, on the glenoid.

6:35

Occasionally it has a higher origin

6:38

or attachment, which can produce diagnostic, uh, confusion.

6:42

You can see it descends mainly vertical.

6:45

That's the typical appearance of that anterior band.

6:50

Let's put another label on this, this,

6:52

and that's the middle lineal mal ligament.

6:55

And as we talked about yesterday, there are various

6:58

orientations of that ligament, various structures

7:01

to which it attaches.

7:03

But what is particularly important

7:05

as it descends downward here, you can see it is intimate

7:09

with the posterior aspect of the subscapularis muscle.

7:13

That is a very good landmark

7:16

to identify the middle humeral ligament.