0:01

So let's, let's put the coronals up together

0:10

and the sagittal, and let's blow them up a little bit,

0:13

a little bit better image quality here.

0:15

This came off of a three TI believe,

0:21

and as they say in the Wizard of Oz, pay no attention

0:23

to the man behind the curtain.

0:26

Uh, pay no attention to the AC joint,

0:28

which in virtually every person,

0:30

I don't think this joint was meant to exist.

0:32

Beyond age 20, every person has some degree

0:35

of AC joint disease, and I,

0:37

and I will describe it as osteoarthritis,

0:39

if there are spurs, um,

0:41

they're usually symptomatic when they have capsular fluid on

0:44

the T two weighted image,

0:46

but that isn't this patient's problem.

0:47

Even though they describe pain here, they pointed

0:51

to the top of their shoulder.

0:52

So when you hear pain on top,

0:54

an orthopedic surgeon will think to themselves,

0:57

it's either the AC joint or it's the superior labrum.

1:00

Well, in this case, we have both.

1:02

So one has to be dismissed, and that's the AC joint.

1:05

Why are we dismissing it?

1:07

Because it doesn't have fluid in the joint capsule.

1:09

On the T two weighted image, on the, on the standard T two,

1:12

it doesn't even have fluid on the fat suppression sequence.

1:15

But what we do have is a complex signal right here,

1:20

and then that signal enters the base of the biceps

1:25

of the intraarticular portion of the biceps.

1:27

Now remember, the biceps is intraarticular,

1:31

but extra synovial when it leaves the joint,

1:33

it's extra articular yet intra synovial.

1:37

And that plays heavily into diagnoses

1:39

that you'll hear about tomorrow.

1:42

The, the standard T two weighted image,

1:45

a little more difficult to see the abnormality.

1:48

Uh, it's, it's a chronic abnormality

1:50

and that chronicity is inferred by the relative absence

1:53

of swelling or edema in

1:55

or around on the, on the standard T two

1:58

and here on the standard T two as well.

2:00

You, you really don't have much signal in the AC joint.

2:04

Then we turn our attention to the sagittal projection just

2:07

to reaffirm with fat suppression

2:09

that we do have involvement in the substance of the biceps.

2:13

There's your labral tear. There it is again.

2:15

Let me blow it up a little bigger.

2:17

Look how delicate it is, isn't hard to see.

2:20

Probably would've been a little bit easier with,

2:22

with arthrography.

2:23

And there is the tear entering the base

2:26

of the intraarticular biceps with a little tiny, uh,

2:31

OID defect in the center of it.

2:33

Then you can follow it on down.

2:35

Uh, but lemme show you the axial since we're a little

2:38

bit time constrained.

2:39

We'll blow this up. And here is that the tram track sign

2:43

that you'll see with a longitudinal tear

2:46

that involves the biceps, that is tendon, that's your tear,

2:49

that's a little bit of tendon anteriorly.

2:52

And there it is a attaching, uh, to the posterior aspect

2:56

of the superior tubercle of the glenoid.

2:58

And I'll show you really quick, quickly in conclusion,

3:02

a little video that demonstrates a slap for,

3:05

and it'll give you a feel for the diagnosis.

3:11

Here we are. And here is my, uh, esteemed colleague, Paul

3:17

Fado, uh, uh, shoulder surgeon, diving into the shoulder

3:20

and showing you the, the hemorrhage

3:23

and the defect that exists at the base of the labrum

3:26

and then extends longitudinally into the biceps right there.

3:30

And all this fraying and fibrillation is common.

3:33

This is a different, uh, a different slap lesion.

3:36

And we'll stop right there.

3:38

Uh, I think we're ready for questions.

3:41

Don, you have any comments on that? No.

3:42

No. I think that arthroscopy really helps

3:47

show what that.