0:00

Now there are some variations that have names,

0:03

so let's talk about those.

0:05

The first one that I'm gonna talk about is the

0:07

sub-label recess.

0:09

This is also known as the sub-label sulcus.

0:14

This occurs when the attachment

0:17

of the biceps label complex is more menis in type,

0:22

and therefore, because of that sort of attachment,

0:25

there is a space shown here, which is the sub-label recess

0:30

between the labrum and the articular cartilage.

0:32

You'll note it is thin,

0:34

typically not thicker than one or two millimeters.

0:36

It is smooth,

0:38

it points medially toward the patient's head.

0:42

And on the transverse plane, it's

0:44

of equal width anterior superiorly and poster superiorly.

0:49

And although not shown here, should not extend far posterior

0:53

or posterior at all to the biceps anchor.

0:57

Those are the criteria

0:59

to indeed identify a sub labral recess or sulcus.

1:03

Here's an example in one of our cadavers,

1:06

the arrows pointing

1:07

to the sub-label recess in the coronal plane.

1:11

You can see it is finger-like filled

1:13

with contrast material pointing toward the patient's head

1:17

in the transverse plane.

1:18

The arrow show it to be thin, one

1:21

or two millimeters in thickness,

1:23

and kind of ending right here at the posterior extent

1:27

of the attachment of the biceps tendon.

1:30

This then the classic sub-label recess.

1:35

The second named anatomic variation is the sub labral

1:39

foramen or hole.

1:41

This is said to occur

1:43

because the labrum develops

1:47

away from the glenoid margin, antho, superly,

1:51

and then rejoins the rest of the glenoid somewhere

1:55

around the three, or no lower than three.

1:59

Occasionally it'll get to four o'clock,

2:01

but it extends to rejoin the glenoid margin

2:04

and the rest of the labrum by something

2:06

that's very important to look for.

2:09

It's known as a labral slip. I'm showing you it.

2:13

Here is the red arrow, here is the foramen,

2:16

and you can see the problem diagnostically in

2:19

the transverse plane.

2:21

This looks like a labral detachment, okay,

2:25

but it should end by three,

2:28

rarely lower than three o'clock.

2:31

So this the next named variation, the Buford Complex.

2:37

The Buford Complex is said to have two findings, absence

2:41

of the anterosuperior labrum,

2:44

and indeed a cord like middle glen mal ligament.

2:48

Here's what it would look like in a transverse Mr.

2:51

Orthographic image. Here are three axial images.

2:55

This one at about one o'clock,

2:57

there is the cord, like middle

2:59

Mal ligament, no labrum.

3:01

This one at two o'clock, there is

3:04

that middle goum mal ligament, no labrum.

3:07

And here you can see a normal labrum at three o'clock.

3:11

If you look in the sagittal plane

3:13

and compare to the sagittal drawing cord,

3:16

like middle goum mal ligament, the labrum starts anew

3:20

at two or three o'clock.

3:22

And note, there is no labral slip

3:26

or connection between the cord like middle glen ligament

3:29

and the glenoid margin.

3:31

So let's compare the two here.

3:34

Buford complex on your left,

3:37

absent anterior superior labrum cord,

3:39

like middle glen mal ligament labrum starts anew at about

3:43

three o'clock sub labral frame.

3:46

On your right, there's the foramen.

3:49

Here is the middle glen mal ligament.

3:51

In this case, not cord like, but remember it may be.

3:54

And here is the labral slip extending back

3:57

to the glenoid margin.

3:59

And the reason I bring all of that up is

4:01

because the most important finding,

4:04

separating a buer complex

4:06

and a sub labral foramen may not be the cord like middle

4:10

glen ligament owing to the com, the variability in the size

4:14

of that ligament, it is the labral slip.

4:17

So you can see it there and you see it there,

4:19

but you don't see it in the lower image, the Buford complex.

4:24

Now, why is that important?

4:25

Because indeed, some people believe the most common

4:29

named anatomic variation is a sub-label frame

4:33

with a cord like middle gnu mal ligament.

4:37

So here we have by drawing that cord,

4:40

like middle gnu mal ligament, absence

4:42

of the anterosuperior ligament, we have a labral slip.

4:45

It's shown here is a little thin line.

4:48

You can see it better here.

4:50

So once you have that,

4:52

this is not the classic Buford complex.

4:55

It's a variation somewhere between a sub-label foramen

4:59

and the Buford complex.

5:03

Now, when you're dealing with a Buford complex

5:05

and you see it right there in the front

5:07

of the joint on your left, typically it is smooth.

5:10

It's often circular, oval or triangular.

5:15

The dislocated biceps tendon can have a similar appearance.

5:19

So you always wanna check,

5:21

before you call it a buret,

5:22

that you got a biceps tendon in the groove.

5:25

You don't have that biceps tendon in the groove.

5:28

In this case, it's over a year.

5:30

And then as I'll talk about tomorrow, OID labrum,

5:34

ovoid mass, a sign of a soft tissue, Bankart lesion

5:40

floating up, producing a lesion

5:43

that generally is irregular with strands of tissue.

5:49

The one other point that I think it's important

5:51

to make is are these really anatomic

5:54

variations? If you talk to

5:57

Pediatric bone radiologists, they'll tell you

6:00

that finding recesses or foramen

6:03

or a Buford complex, very

6:06

uncommon in the pediatric population.

6:09

Because I had an interest in that.

6:10

I even went back to look at the embryology

6:13

because if in fact,

6:14

the leberman ligaments developed separate from the glenoid

6:18

and normally migrated toward the glenoid

6:21

during development, it would make sense.

6:23

You could get variations that look like them.

6:27

But most books will tell you they develop at the glenoid

6:30

margin and not separate from it.

6:33

And then you look at cases like the one

6:35

I'm showing you here.

6:37

This was read by the radiologist

6:39

and the arthroscopist at the time of surgery

6:43

as a Buford complex.

6:44

But when you look at the magnified view, you kind

6:48

of wonder if there is a detached labrum

6:50

and a thick middle mal ligament.

6:53

So maybe this was a pathologic lesion misdiagnosed

6:58

by radiologists and surgeon alike.