0:01

I'm gonna follow up with, uh, a series of,

0:04

uh, slap lesions.

0:05

But just to comment about arthrography, I know many

0:10

of Don's cases are orthographically

0:12

augmented, many of mine are not.

0:14

And as a reference, we see about 500

0:19

to 600 orthopedic MR cases a day,

0:23

and we probably do somewhere in the neighborhood of five

0:25

to 10 arthrograms a day.

0:27

So less than one to 2%,

0:28

perhaps we're not doing enough arthrography, um, in,

0:32

in a busy private practice.

0:33

It also helps that we have our PAs doing,

0:35

doing the arthrograms now,

0:37

rather than having the radiologist sit in there

0:39

for 15 or 20 minutes.

0:40

So let's get started with this first case.

0:43

Um, this is a 52-year-old

0:47

and like, like dawn, I, I don't make the diagnosis

0:51

of slap lesions very often,

0:52

hardly ever in an elderly person, um,

0:55

unless I have a history that's commensurate with it.

0:57

And some really concrete findings.

0:59

This is a non-contrast case of 1.5 T.

1:03

And this was a gentleman who was a mover.

1:06

He was moving a, a washing machine

1:09

and pressed it up over his head and,

1:11

and felt a, a sharp pain and hurt a pop,

1:15

and came in for, for this mr.

1:17

So in this case, in this, uh, post 50-year-old,

1:19

we did make the diagnosis of a SLAP lesion.

1:21

And let me show it to you.

1:24

It's right here, and some of you, it's,

1:27

and it's also right here in the coronal projection.

1:29

Now, many of you're wondering, how do you differentiate, uh,

1:32

this lesion, a SLAP two versus a SLAP three?

1:37

Uh, they both have vertical signals in the

1:40

coronal projection.

1:42

Uh, and I, I'll say there are two ways. One is the width.

1:45

This isn't as wide as I would like for a SLAP three,

1:48

which it is, uh,

1:49

but it also has a piece of labrum at the base.

1:52

So in a SLAP two lesion, you're, you're cleaving the labrum

1:58

away from the cartilage and bone.

2:00

So it's a, it's a deeper vertical cleft.

2:03

And in a SLAP three, you have just like in a bucket handle

2:06

tear, you have a piece of cartilage

2:08

or piece of labrum than the defect, than

2:12

a more triangulated piece of labrum.

2:15

Now, another, um, and,

2:17

and here is another piece of the labrum at its base, uh,

2:20

consistent with the bucket handle tear.

2:22

Now, I know Dr.

2:24

Resnick alluded to this, but a, a real helpful sign

2:26

for those of you that don't do as much shoulder MRI as

2:30

as we do, and I'm sure you will, um, is

2:33

that when you're tracking a,

2:35

an abnormal signal in the superior labrum,

2:38

this is very important as you go posteriorly,

2:42

if you are dealing with a recess,

2:44

it should close down as you go posteriorly.

2:46

It should never get more conspicuous as you go from A to P.

2:51

And that rule is virtually a hundred percent.

2:54

And the other thing you should do

2:56

is anytime you see a SLAP lesion, one of the most important

3:01

adjacent structures to evaluate is the biceps.

3:04

You've seen the SGHL

3:06

and the middle glen of humoral ligament.

3:07

But if that tear goes to the biceps base,

3:10

the patient is gonna feel a sensation

3:13

that the shoulder is giving way.

3:14

They won't have necessarily macro instability,

3:17

but the shoulder will feel unstable to the patient due

3:20

to the hypermobility of the biceps.

3:23

And then as we get back to that Oreo cookie sign, um,

3:27

here's an axial showing you the Oreo cookie.

3:30

Uh, there's a piece of chocolate.

3:31

There's some, the cream in the middle,

3:34

there is another piece

3:36

of the labrum, another piece of cookie.

3:38

Then you have the recess

3:39

and volume average with a little bit of cartilage.

3:42

And then you have the, the cortical bone.

3:44

So you've got dark white, dark white, and then dark again.

3:48

And, and the sagittal projection, um,

3:50

it's not a high resolution image, it's about a four

3:53

or five millimeter cut.

3:54

You can see kind of the roundish shape of the labral tear.

3:58

So you have to be a bit experienced to make this diagnosis.

4:01

And one interesting sign is this high signal intensity deep

4:05

to the biceps, a little bit reminiscent of, of, uh,

4:08

don's chondral print.

4:10

Here you see it right here.

4:11

Um, so in summary, this is a proven, uh,

4:14

slap three lesion in this patient, um, diagnosed

4:18

by an experienced arthroscopy and shoulder surgeon,

4:22

and we'll move on to the next case.

4:24

Do you have any comments about this one?

4:26

Yeah, I, as I say, I, I don't commonly, you know,

4:29

diagnose slap lesions in el elderly people.

4:32

But if I'm dealing with a labral detachment

4:36

or a bucket handle tear of the labrum, not

4:40

because those are not the characteristics that I see

4:42

with a degeneration for degener tearing,

4:45

then I will make the exception of, of diagnosing it.

4:49

And, and one, one thing I will do in an elderly person is

4:52

if I see a vertically oriented, uh,

4:55

longitudinal tear in the upper quadrant, I, I'll refer to it

4:58

as a degenerative slap lesion if I use the term slap.

5:02

Um, but I, I do everything in my power

5:04

to keep the surgeon out of that shoulder.

5:06

Yeah. Should we move on to the next case? Okay.