0:00

So my belief is in fact that when you describe lesions

0:05

that you think are slap lesions, you have

0:08

to describe three major things.

0:11

You have to describe the extent of labral abnormality,

0:15

the pattern of labral abnormality

0:19

and the involvement of adjacent structures.

0:22

Okay, by subst tending glen mal ligaments rotator interval.

0:27

So I show you an example here

0:28

with arthrography of a bucket handle.

0:31

This is how I would describe it.

0:33

A bucket handle tear

0:34

of labrum extending from the 10 o'clock position posteriorly

0:38

to a four ooc position anteriorly

0:42

with extension into the biceps anchor.

0:45

And in my reports, since I know the Roman numerals,

0:49

I placed them, but only at the end

0:51

of my description in Parentes here, a slap four lesion.

0:56

They do not matter.

0:58

And the orthopedic surgeons know very few

1:01

of those Roman numerals.

1:03

So let's look at these findings.

1:05

The first one is the extent of labral abnormalities.

1:09

And by the way, for these, if you like Roman,

1:11

Roman numerals, I'm gonna put 'em down here, right?

1:14

I may not mention them often,

1:16

but if you want Roman numerals,

1:18

they're always gonna be right here.

1:20

So the first is a classic lesion.

1:23

It's said to be a detachment, but it could be a tear.

1:27

It involves a superior labrum.

1:29

It may extend post row superiorly to anterior superiorly

1:33

or involve any of those three regions.

1:36

And it has numbers that are sometimes applied to it.

1:40

A, B, and C. Let me show you an example.

1:44

This would be an example of a detachment

1:48

involving the posterosuperior superior

1:51

and anterosuperior labrum extending from about 10

1:54

o'clock to one 30.

1:56

All right? Shown by the arrows, both in the coronal plane

2:00

and in the sagittal plane.

2:04

These superior labral lesions may be combined

2:09

with anterior labral lesions.

2:11

I'm showing you in most of my slides lesions in continuity

2:15

'cause that's mainly what I have seen here.

2:18

I show you an example

2:20

of involvement at the 12 o'clock position,

2:23

the three o'clock position,

2:24

and then an a sagittal plane extending all the way down

2:28

to about the four 30 or five o'clock position.

2:32

And this looks like a labral detachment

2:35

is the main morphology that's going on.

2:39

Here's another example. This one in cadavers.

2:42

Here you can see a 12 o'clock

2:44

that there is in fact abnormality.

2:46

It continues. Here is a tear at one o'clock

2:50

and a tear at three o'clock.

2:52

So a involving both the superior and anterior.

2:56

I tend not to use the word extended

2:59

'cause again, I don't know where it began

3:02

and I don't know where it was going

3:05

and whether it collided at some point.

3:07

Here's an example of involvement of the superior

3:10

and posterior uh, labrum detachment.

3:13

Okay? In continuity shown by the arrows

3:17

and the transverse plane at the top here,

3:20

probably at about the three

3:21

and nine o'clock position in here,

3:24

you can see the involvement of the entire posterior glenoid,

3:28

A labral detachment.

3:31

Here's another one. So this would be involved in both

3:34

of the superior

3:36

and uh, of the posterior labrum in continuity.

3:41

In this particular example, sometimes,

3:44

particularly in very young athletes, you'll see involvement

3:49

of the entire labrum global labral tearing or detachment.

3:54

The case I'm showing you here in the axial

3:57

and sagittal plane is continuous labral detachment

4:02

all around the glenoid.

4:04

And here's another one shown in two sagittal Mr.

4:07

Orthographic images in the middle showing you detachment

4:11

of the postero superior and superior labrum.

4:15

And here showing you detachment of the anter

4:18

and anthro inferior labrum.

4:21

Again, in continuity,

4:26

the pattern of labral abnormality is the second thing

4:29

that you need to look at.

4:30

And there are various patterns.

4:32

I'm showing you what is designated a bucket handle tear.

4:37

Now here we can see in fact part of the labrum.

4:41

Here's the tear. Here's the deeper part of the labrum.

4:44

So this is separated, that is a bucket handle tear

4:48

here in a patient.

4:50

I'm showing you what it looks like without traction

4:53

placed on the arm.

4:55

And here with traction

4:56

where the humeral head has been depressed

4:58

and we can see the bucket an there for about five years.

5:02

We used traction with about 20 pounds of traction.

5:06

Uh, sandbags compatible with magnets.

5:09

Not all sandbags are compatible with the magnet

5:12

and a rope extending along the length of the table

5:14

with the sandbags at the end of the rope near the floor.

5:18

We don't use that technique, uh, now,

5:21

but it is helpful as you can see in this particular case.

5:25

And as you look here, this is what would happen.

5:29

You would have a double Oreo cookie appearance.

5:32

Here's labrum dark. Here is the labral tear.

5:36

It's a bucket handle tear that's bright.

5:38

Here is the base of the labrum that's dark.

5:42

Here's a sub labral recess.

5:44

Okay, that is bright fluid or contrast.

5:48

And then cartilage and bone, which would be dark.

5:51

So this is one of the signs and I think Dr.

5:54

Uh Palance will talk about that. And

5:56

The Oreo sign, which has been described

5:59

with this sort of involvement.

6:02

Another example of the double Oreo with an Mr arthrogram.

6:07

I'm showing you here the two parts

6:08

of the labrum with the arrows.

6:10

And you can see the contrast located between.

6:13

So this is a bucket handle tear involving

6:16

the superior labrum.

6:18

Another pattern of morphology we see is a flap tear.

6:22

Um, I've seen flap tears elsewhere.

6:25

We'll be talking about that tomorrow.

6:28

But this is a flap tear involving the superior labrum

6:31

extending downward.

6:33

Okay? Typically not a detachment,

6:36

but a partial tear of the labrum.

6:41

The final factor that we'd like

6:43

to put in our description is the involvement

6:45

of adjacent structures.

6:46

And there are a number that can be involved here is

6:49

involvement both of the superior labrum

6:51

and the biceps anchor in continuity in this particular case.

6:56

And once again, I, for those

6:57

of you who've been following Roman numerals,

7:00

they're down here.

7:01

So this is a bucket handle there involving

7:05

the vice subs tendon.

7:07

Here is one involving both the superior labrum

7:10

and the middle li mal ligament.

7:13

And you can see that ligament is split into two parts.

7:18

Here is one involving the superior labum in continuity

7:22

with involvement of the superior glen ligament.

7:25

And I've seen a number of these

7:27

and they produced this target appearance in

7:29

the coronal plane.

7:32

And this one unusual involvement of the superior

7:36

and anterosuperior labrum.

7:38

Along with both the superior and middle menu mal ligaments.

7:42

I put arrows on all the lesions, complex lesion,

7:46

again shown by Mr.

7:47

Arthrography. Uh, a word about Mr. Arthrography.

7:51

Uh, in my practice we use it a lot.

7:54

We probably overdo it in other practice.

7:57

It's not used at all. I think they're not using it enough.

8:01

The truth probably lies somewhere in between.

8:05

We like direct Mr.

8:06

Arthrography because it distends

8:09

lenal joint indirect.

8:11

Mr. Arthrography will,

8:13

the gadolinium will leak into the joint,

8:15

but it doesn't distain the joint.

8:18

Now there is involvement of cartilage

8:20

and subc chondral bone in rare slap lesions.

8:23

When first described it was called a slap

8:26

fracture when the bone was involved on your right.

8:29

And you can see the flattening

8:31

of the subc chondral bone plate, the marrow edema,

8:34

and the abnormal appearance of the

8:37

binded just above that area.

8:40

This is a lesion that is debated a bit.

8:45

Some people think there is a high association of this sort

8:49

of cartilage and bone abnormality with slap lesions.

8:53

Others suggest, no, you don't

8:54

See it that often with slap lesions.

8:56

And further, you may see it following slap repair.

9:00

And I see this lesion in one other condition

9:03

that I won't be talking about,

9:05

and that is adhesive capsulitis owing to adhesions

9:08

between the biceps tendon and the humerus.

9:13

And then rarely you will get a chondral

9:16

or osteochondral avulsion.

9:19

Here's one example shown by diagram and by Mr. Arthrography.

9:23

This is an osteochondral tion involving the superior

9:28

labrum men bone.