0:00

And, um, my first case is a youngster.

0:06

Um, he's 16 years old

0:08

and his chief complaint was, he is a pitcher, um,

0:12

diminished range of motion.

0:15

And let's start out with the axial gradient echo.

0:18

And I'm a big fan of the gradient echo to evaluate the labra

0:23

with without contrast.

0:26

And anteriorly, he does have these small

0:29

minuscule little cracks in the anterior labrum,

0:31

and it's not uncommon to see anterior labral signal in, uh,

0:35

vigorous rigorous athletes.

0:38

And in, in adults sometimes you can even get CPPD in there.

0:42

You know, incidentally, that

0:44

that produces some irregularity and signal intensity.

0:47

Um, there isn't much swelling around this,

0:50

and it's, it's not in the typical location

0:52

where you would worry about a label tear.

0:54

It's sitting right about at the equator.

0:56

He's also got this pseudocyst in the back.

0:59

And on day one, I did emphasize that I use as a roadmap,

1:04

these patterns of pseudocysts to help determine

1:07

where the biomechanics have gone wrong,

1:10

especially in younger individuals

1:12

who don't have necessarily obvious static morphologic

1:15

abnormalities, but rather biomechanical ones.

1:18

And I can infer the biomechanical problem from the cyst.

1:21

This one's all the way in the back.

1:24

And if we look all the way in the back

1:25

and we scroll down on our calcium sensitive,

1:28

blood sensitive gradient echo image,

1:30

we see this very curious looking longitudinal dark snake

1:35

behind the, the scapula.

1:37

Now, uh, this is a Bennet like lesion,

1:40

and the reason I say Bennet like is in my experience,

1:45

80% of the Ben lesions, uh, are

1:48

connected intimately with the bone.

1:51

Uh, the bone appears heaped up

1:52

and proliferative, whereas about 20% of them,

1:56

maybe a little more, uh, you can see a cleavage plane

1:59

between the lesion and the bone.

2:01

And this is a person that has the right symptoms.

2:05

And other than this cleavage p plane has the right shape.

2:08

This, this was calcific on the ct, which I don't have

2:11

to show, but we did get one.

2:13

And you see how long it is from top to bottom.

2:15

It's very long as ben lesions are, are apt to do.

2:20

And I, I think about these as either capsular

2:24

or periosteal hemorrhages

2:25

that ossify when they have this plane.

2:27

So I think there's really a, a heterogeneous group

2:31

of Bennett like lesions.

2:32

And when we look at the posterior capsule in this young man,

2:36

it's a thick capsule as it should be in a thrower.

2:39

But I think this capsular thickening along

2:41

with the Bennett lesion, certainly with the Bennett lesion,

2:43

and the capsule blends with the periosteum, uh, and,

2:47

and perhaps contracts back here

2:48

and shortens, contributes to this, uh,

2:51

glenoid internal rotation deficit of this child.

2:55

Now, I, I left this image upright here

2:57

because, not just for the cyst,

3:00

but if you look down below at the site

3:02

where this Bennet like lesion exists, there's a fair amount

3:05

of swelling, uh, present there.

3:07

Um, he, he didn't complain of pain, by the way.

3:10

His, his chief complaint was diminished range of motion.

3:12

Any comments about this one, Don? Yeah,

3:14

I'm just wonder, uh, whether, uh, uh,

3:17

you say you've seen this particular kind of appearance.

3:20

Have you followed them?

3:21

Do they begin separate

3:23

or could they start connected to the bone?

3:26

Uh, or is there any possibility these are fractures

3:30

that have developed from the posterior glenoid?

3:32

It'd be nice to kind of trace the history of them over time.

3:37

I think that's a great thought.

3:38

If you look at the sagittal though, I,

3:39

I do see a pretty good cortex here on the T one.

3:43

And I have two cases where I've studied young individuals,

3:47

11, 12, 13 year olds who complained of pain.

3:51

They have edema on the proton density,

3:54

fat suppression image.

3:55

And then they come back three or four years later

3:57

and they have a benit lesion.

3:58

So I do think that these are acquired

4:01

and they, they develop, you know, a,

4:03

a little bit like a Nora lesion, you know,

4:05

a hemorrhage along the edge

4:07

of the bone, and then they ossify.

4:08

Okay.