0:00

You wanna take this one?

0:02

I understand theoretical facts,

0:04

but how categorical are they in clinic daily practice

0:07

with slap injuries?

0:09

How often do they struggle about this type of injury

0:13

considering the possibility of anatomical vari variance?

0:17

Uh, you know, this is interesting.

0:19

It brings up the question, who's the gold standard,

0:22

um, in this?

0:25

Is the radiologist the gold standard

0:28

in diagnosing slap lesions and variants,

0:30

or is the arthroscopist

0:32

and, uh, the arthroscopist relies on i

0:36

or should rely on not just the space, for example,

0:40

between the labrum and the glenoid margin,

0:42

but whether there's hemorrhage or edema that, that he

0:46

or she sees at the time of arthroscopy?

0:49

Because I think otherwise they too struggle trying

0:53

to separate variations from, uh, from, uh, slap lesions.

0:58

Uh, the practice, how they treat them. It's changing.

1:01

What, what I do know in reading the,

1:03

the recent literature is more of them are doing tenotomies

1:07

of the biceps or treating them conservatively,

1:11

particularly if they're degenerative.

1:13

But, uh, the number of diagnoses has gone up dramatic, uh,

1:18

drastically with regard to slap lesion.

1:20

So, so I think times are changing

1:24

and I think, uh, people are realizing this is being

1:26

overdiagnosed and I think overtreated as well.

1:29

I, I wholeheartedly agree.

1:31

I I think there are three things you can use

1:33

to help yourself in this scenario.

1:36

One I just showed you,

1:37

and Don alluded to it, blood in, in the area of interest.

1:42

And, and I earlier in that video, there's a slap too,

1:45

where you can pick up the labrum, which you can do in a lot

1:47

of individuals, but underneath, when you look inside,

1:50

there's blood underneath that area of pickup.

1:54

So there are some tools for the orthopedic surgeon to use,

1:57

but they do have difficulty telling recesses sometimes

2:01

and sulci from real tears.

2:03

The second thing that I use is the,

2:05

is the pattern of swelling.

2:06

If I see swelling in that area

2:08

and a wet joint, I'm more apt

2:11

to call an abnormality, uh, pathologic.

2:13

And the third one, which is obvious,

2:15

is a paralabral pseudocyst

2:18

Of interest. And there

2:19

was something kind

2:20

of paralabral cyst be intraosseous.

2:23

Uh, yes.

2:24

It, it can be, uh, I certainly have seen this

2:27

and a lot of times they extend, I don't know if they,

2:29

they begin in the bone, but they extend into the bone

2:33

and they often contain gas, uh,

2:36

derived nitrogen derived from the joint.

2:38

So in those cases, particularly when they get into bone,

2:41

they often communicate with the joint lumen.

2:45

The next one, I'm not, I'm not. Okay.

2:50

Do you ever question a slap lesion on an MRI

2:53

or shoulder without contrast?

2:55

Uh, well, obviously you do, uh,

2:59

or you diagnose 'em

3:00

and I guess you occasionally, uh, recommend arto grams.

3:03

I do. We certainly diagnose them on non-auto studies.

3:07

I don't want you, you know,

3:08

because it doesn't come always as rule out slap lesion

3:11

and we get an gram.

3:13

So a lot of times we diagnose 'em on standard. Mr.

3:17

Uh, my practice at UCSD is, uh, mainly teleradiology

3:22

for the university now.

3:23

So the quality of the imaging

3:25

that we get is highly variable.

3:27

Uh, we get good imaging from some sites,

3:30

but in others it's very, very difficult to diagnose any kind

3:33

of labral pathology.

3:34

We just don't, uh, we don't, uh, do very well.

3:37

So, uh, um,

3:40

but clearly you can diagnose flap lesions without, uh,

3:43

and the other point, which I wanted to make on one

3:45

of your cases, which I think is a good one,

3:48

I think the coronal images be they Mr.

3:50

Orthographic images or standard MR.

3:53

Fluid sensitive or terrific

3:55

for the posterosuperior labrum in your case, one

3:58

of 'em had a beautiful, uh, showing in the coronal plane

4:01

of the involvement of the posterosuperior labrum.

4:04

I like that better than the axial, uh,

4:06

images in many cases. And

4:08

That, that scroll sign has helped me tremendously when I

4:10

scroll from A to p if, if the complexity increases,

4:15

if the depth increases, if the swelling increases

4:18

as I go from A to p, it's, it's over.

4:20

It's, it's a slap lesion.

4:22

One of my former fellows is sitting here, is now attending

4:25

to keep me honest, but I I will ask for a bring back

4:27

for an arthrogram, maybe one out of, one out of 50,

4:30

maybe one out of a hundred.

4:32

And, uh, but most of the time we do interpret

4:36

with good image quality without contrast

4:38

with lesser image quality

4:39

or with a highly suspicious case

4:41

where we haven't found the answer.

4:43

We'll, we'll put contrast in the joint.

4:45

There's a question here, which, oh,

4:48

how often do you call the presence

4:51

of blood in your shoulder?

4:53

MRIA couple things about that question.

4:55

Well, obviously we see blood more often

4:58

around the knee in the form of a he arthrosis

5:01

or lipo he arthrosis where we look in either case for, uh,

5:05

for, uh, fluid, uh, uh, levels, et et cetera.

5:10

And then in chronic bleeding you have low signal,

5:12

typical hemo, citrin, and occasionally blood clot.

5:16

The the point I wanted to make, which I find funny

5:18

'cause I bring it up to the fellows,

5:20

it really is not a shoulder, uh, MR arthrogram.

5:24

So when we, we do humeral, joint arthrography,

5:28

and when we talk about shoulder, uh, we, yeah,

5:31

we do shoulder MRI

5:32

but not shoulder, MR arthrography,

5:35

the shoulder's got multiple joints.

5:37

In fact, I'm gonna be talking about them tomorrow,

5:40

including the scapular thoracic joint.

5:42

And, uh, so, uh, it's more than one articulation.

5:47

I I'll say the most common, uh, time

5:50

that I see blood in the joint was some, somebody has a,

5:53

a big time dislocation and there's a hemos,

6:00

Uh, let's see, the upper one,

6:03

I personally find it difficult to evaluate

6:06

and be detailed when assessing the structures linked

6:08

to biceps instability.

6:10

Do you use the Haber Meier?

6:13

Actually, I, I use the a kind of a extension of it.

6:15

How confidently do you describe this type of injury?

6:19

Uh, unfortunately I'm not talking about the biceps tendon in

6:22

this course, but I do have a great interest in the stability

6:25

of the biceps tendon at the level of the pulley

6:29

and, uh, the medial stabilizers that occur.

6:32

There are the sub, the upper fibers

6:34

of the subscapularis tendon,

6:36

but also the medial limbs of the superior

6:40

semial ligament and the cortical al ligament.

6:43

So I've ended up with six different patterns of displacement

6:46

of the biceps tendon, depending upon whether, which

6:50

of those medial stabilizers are involved.

6:53

And the one that you showed

6:55

and its interest, you showed a intraarticular displacement

6:59

of the biceps,

7:01

which typically occurs when the subscap is detached or torn

7:05

and as well as the medial limbs.

7:07

But what's interesting about that dislocation,

7:10

as you follow it down, often it ends up anterior

7:14

to the lower fibers of the subscap, which are still intact.

7:18

So it moves from within the joint over the subscap,

7:21

through the tear of the subscap

7:24

and ends up anterior to the, which is very confusing.

7:26

It is very, and describing it, it's a long report, you know,

7:32

uh, for Arthur grams, do you recommend any gad

7:35

or just saline?

7:37

Um, I don't know if they say you wanna answer that.

7:40

Um, we, we use gadolinium, uh, dilute gadolinium one

7:45

to 200 in the dilution.

7:47

And, um, you know, if somebody has a joint effusion

7:50

and it's, it's moderate size,

7:52

you already have contrast in the joints.

7:54

So in that scenario, we'll use, you know, uh,

7:58

god's, god's contrast.

8:00

But, um, we will use dilute ga gadolinium

8:03

for most of our arthrograms.

8:04

Yeah, the only point I made years ago, we did a number of,

8:07

uh, cases using both gadolinium

8:09

and saline for multicom compar injections at the wrist.

8:14

And, uh, we found it somewhat useful,

8:17

but we gave up that technique.

8:19

We don't do any, uh, saline. Mr. Arthrography currently,

8:23

Lord do.