0:01

I like to do things in three,

0:02

since I have six children divided by two, that makes three.

0:07

And we're gonna start out with the axial.

0:11

And I do use the axial to look at my rotator cuff tears,

0:16

especially, you know, if I'm talking

0:18

to a high level surgeon, uh,

0:21

because they do look from the top down

0:24

and, you know, they like the description of a u-shaped tear,

0:27

an L-shaped tear, um, a a, uh,

0:31

a deep retracted tear or not.

0:33

Um, it is hard sometimes to find the, uh,

0:37

caracal humeral ligament or the rotator cuff cable.

0:40

But once again, we have a similar situation as before.

0:43

I'm gonna continue to step up, uh, the degree

0:46

of rotator cuff pathology.

0:48

And now this time we have a problem with the medial arch

0:51

as well as the lateral arch.

0:53

The lateral arch is, is hypertrophied again in phy, um,

0:57

I'll show you in the sagittal.

0:58

There is, there is some hypertrophy of the CAL.

1:01

There is a full thickness tear involving the footprint.

1:05

Uh, we can measure it medial laterally

1:07

to get our retraction dimension.

1:09

Uh, it's sometimes a little easier to get a feel for

1:12

that retraction on the,

1:13

the true T two rather than the proton density.

1:17

And then let's pull up the sagittal.

1:20

I'm just gonna flip it over here

1:23

and we can get a feel for the,

1:25

an posterior dimension of the tear.

1:27

We see Bart Simpson's hair back here for those curved fibers

1:31

that, that come in from the infra spinatus.

1:34

And we get a, we get a full thickness

1:36

tear from here to here.

1:37

Let me magnify it a little bit.

1:41

And let's look at the pattern of cyst formation.

1:45

Really not a lot of, of cyst formation,

1:48

which is pretty uncommon

1:49

to see rotator cuff pathology like this

1:52

with sparing of the humeral head.

1:54

But you do see this, um, uh, thick

1:57

and caracal acromial ligament.

1:58

And if we cross-reference it right here,

2:00

there's the CAL right there.

2:02

It's not quite as thick as in the last case.

2:05

It's a little bit grayer.

2:07

And, um, this patient also has

2:10

additional pathology anteriorly.

2:13

So we said that we look at the coracoid

2:18

and I will look at the position of the coracoid tip.

2:22

And if it's more than halfway down,

2:24

or at least halfway down the subscapularis,

2:26

which in this case it is, I become instantly concerned.

2:30

And I have little tricks that I use

2:31

to make me faster when I'm reading.

2:34

And in the axial projection,

2:36

indeed there is interstitial disease, there's delamination.

2:39

You've lost those parallel tendon micro fis

2:43

that you see in the subscapularis.

2:45

You've got some focal defects in the subscapularis

2:49

as it approaches the medial rim of the lesser tuberosity.

2:52

And then you also have a torn biceps.

2:55

The biceps is shredding as it comes out

2:57

of the bicipital groove.

2:59

Now sometimes a very strange thing can happen.

3:02

The subscapularis will de-laminate and then detach.

3:06

It may fold over on itself like dick fosbury.

3:09

It may do a fosbury flop.

3:12

And then the, the, the biceps comes inside

3:16

the subscapularis.

3:17

So you get an interstitial dislocation.

3:19

Sometimes the dislocation will sit on the top

3:23

and sometimes you'll be sitting there

3:25

and the biceps will be in the joint,

3:28

and the subscapularis will then flop back over

3:31

to its lesser tuberosity position and it will heal.

3:34

And you'll say to yourself, my God, how did

3:36

that biceps get inside the joint?

3:39

But it is a dynamic process that occurs over a period

3:42

of about four to six months.

3:43

And I have seen this, seen this happen dynamically, uh,

3:47

by following patients on numerous occasions.

3:50

So this patient has two arch disease.

3:53

They have disease in the subacromial arch.

3:56

They have disease in the subcoracoid arch.

3:58

They have a full thickness tear X by X centimeters

4:02

that you get from your coronal and from your sagittal.

4:05

There's in infraspinatus sparing,

4:08

there's some minor changes in the labrum, not, not really

4:11

that interested in those changes right now.

4:14

But you do have a, an interstitial complex tear

4:18

of the subscapularis with a little bit

4:21

of non interstitial tearing that's beginning, uh,

4:24

as the subscapularis begins

4:26

to delaminate from the lesser tuberosity.

4:28

And the biceps is eking its way out of the bicipital groove.

4:33

Now the transverse ligament usually holds that in place,

4:36

and we'll see that the transverse ligament later on

4:40

is produced by the caracal humeral ligament.

4:43

A little bit of contribution from the abdominal fibers

4:46

of the pectoralis major.

4:48

And, uh, uh, from the, um, uh, oh,

4:53

I'm blocking on the third.

4:54

Um, let's see, what is the Caro humeral ligament?

4:58

So thought subscap

4:59

Also. Oh, the subscap.

5:00

Yes. The upper fibers, uh, layer one, the,

5:03

the uppermost portion of the subscapularis.

5:06

So any comments on this case? Yeah,

5:08

One of the things, I'm glad you have the axio off.

5:10

One of the things that always comes up is

5:12

what is the top image that you can use

5:15

to assess the subscap?

5:18

And, and the reason I'm bringing it up is that the anatomy

5:20

of the subscap, it attaches obviously to

5:24

lesser tuberosity, surgical neck,

5:27

probably greater tuberosity,

5:28

but it also attaches to the top of the lesser tuberosity.

5:33

So can you look at it one image above where you see the bump

5:37

of the lesser tuberosity,

5:39

because that becomes important like in a case like this,

5:42

because is the biceps tend, I mean, it looks sublux,

5:45

but even that's the bump.

5:47

I can see lesser, if you go one image higher. Okay. Yeah.

5:51

So some people would say that's where you should start

5:55

to evaluate the subscap

5:56

because it attaches to the top of the tuberosity.

6:00

But there is it, you know, a debate about it.

6:02

And it's always a question, which is the first axial image

6:06

that it, that you would use.

6:08

So you use just when you see the lesser tuberosity?

6:10

No, um, I don't, actually, what I do is

6:13

what I have on the screen right here,

6:16

which is I go back and forth.

6:17

I usually have a two on one or a three on one,

6:20

and I scroll myself

6:22

and I find the top of the subscap and the sagittal.

6:25

And then when I, when I see myself getting into the rotator

6:28

interval, I know I'm at that very top layer okay.

6:31

Of the subscapularis.

6:33

So I will, I'll go back and forth between the axial

6:35

and sagittal to determine the character

6:38

of a subscapularis tear.

6:40

Now, for retraction, I'll frequently use the coronal,

6:43

especially if I have a very large tear,

6:44

which I think I have further down the road here.

6:47

Okay.