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Next patient is a 24-year-old man with a

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history of a right shoulder dislocation and pain.

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Now, this was done at midfield.

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It's a midfield open.

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Let's start out really simply,

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won't get too complex just yet.

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And I'm going to just start out with an axial.

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Let's just scroll up and down on our axial.

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Now, look at the muscles on this guy.

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He is either genetically gifted

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or he is on the juice.

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He has taken some steroids because

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these are some big muscles.

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Pretty hard to get him this big without steroids.

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Or he's a professional athlete, which he is.

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Let's keep scrolling.

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Now, most of these professional athletes,

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they spend a ton of time in the weight room doing

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this bench pressing, doing this military pressing.

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What does that do?

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Forces the humeral head backwards.

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And so the humeral head is wiggling back and

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forth and back and forth with 300, 400,

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450 pounds on the barbell or some dumbbells.

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And eventually this thing starts to peel.

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Off, which it did.

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That's not a dislocation, however.

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That's a chronic repetitive phenomenon.

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There's a little signal in the labrum.

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Sometimes the labrum will peel off and you'll get

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a little pouch back here from

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this weightlifting activity.

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It'll kind of scooch around the back like that.

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The periosteum will stay attached,

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and that's known as a reverse

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perthes or Kim's lesion.

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So he does have an issue in

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the back of the shoulder,

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but that is not a dislocation type injury.

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That is a micro instability repetitive overuse

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type injury. The reverse perthes lesion,

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the small posterior labral micro tear.

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Another name given to the reverse Perthes lesion

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is Kim's lesion. So let's keep going.

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We go up high.

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We have our biceps takeoff, our superior.

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Labrum, some cartilage or a sulcus or a tear.

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We'll see. It's not a tear.

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Let's keep looking.

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We have the superior glenohumoral

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ligament complex right here.

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Let's keep going down.

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We have a little sulcus right here.

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We're in the upper quadrant of the shoulder.

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I don't mind having some variability in

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the upper quadrant of the shoulder.

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I do mind when I get below the equator.

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Remember earlier we said one of our rules

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is when you go from high to low,

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the labrum should get bigger.

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Let's see if that happens this time.

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We don't have a Buford complex.

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Here's our labrum.

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It's getting smaller.

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It's even smaller.

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I can't find it.

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I still can't find it now, all.

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The way down low,

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you probably won't be able to find it.

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But I can't find it on four consecutive cuts.

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And I have some fluid in the joint.

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Not a tremendous amount. Let's keep looking,

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shall we?

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Let's go to three up.

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I've got a T2 on the

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right, proton density in the middle,

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and another T2 on the left.

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The T2s were done with different TEs.

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I think they repeated it because

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the patient moved.

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So let's stay with the non-motion affected T2.

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One is not fat suppressed and

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one is fat suppressed.

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Let's look at the one that is not fat suppressed,

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the one that we were on initially,

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and maybe we'll add this first one here.

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So this was a gradient echo that

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we were looking at first.

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Here's your T2.

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I'm not liking that at all.

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I'm not liking the fact that the

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labrum gets kind of small,

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but what I'm liking even less is the architecture

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of the anterior bundle of the inferior Glenah

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humeral ligament. What's happening here?

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I'm having trouble attaching it to the humerus.

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So I'm concerned about this entire

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labro-ligamentous complex.

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I'm honestly not sure yet if I was reading

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this alone. What's going on?

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So now I'll turn my attention to the coronals.

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Let's pull down some coronals and see.

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What we're dealing with.

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Because when you get down all the way low here,

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it can be really hard with an axial that is

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parallel or tangent to the abnormality.

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So while the status of the anterior labrum that's

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coming at you is hard to ascertain, it was small.

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It did have a little tear in it.

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That wasn't the main finding.

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The main finding is here.

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Right there.

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The ighl, which has an anterior bundle,

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a middle bundle, and a posterior bundle.

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It never attaches.

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It never attaches to the humeral neck.

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So this is what's known as a hagel,

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a humeral avulsion of the glenohumural ligament.

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Now, if it takes a piece of bone with it,

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it's called a behagel or a bagel.

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If it comes off the glenoid side and the

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humeral side, it's called an igle,

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an anterior inferior glenahumural ligament

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attachment, also known as a floating ighl.

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Those are kind of the main findings that the main

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sort of eponyms that you're going to see in this

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area there are about three or four others

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we're not going to discuss today.

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But the main finding here is this young man has

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had a dislocation with detachment of the IgHL from

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the humeral neck without a fragment of bone

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with a small anterior labral tear.

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And look at his Hill-Sachs injury.

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It's not a trough, it's not an erosion,

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it's not a cyst. In fact, it's pretty minor.

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It's a microtrabecular subcortical fracture.

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It looks like a spider, doesn't it?

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That's not an impingement-related lesion.

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Impingement-related lesion is going

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to be very sharply defined.

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It's going to be a pseudocyst or it's going

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to be a well-etched trough like this.

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This is an ill-defined area of bone edema.

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It's a minor Hill-Sachs.

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So let's see.

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What other questions did you ask about this?

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You said Hill-Sachs defect.

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Not sure I'd use the word defect.

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I'd use the word Hill-Sachs equivalent.

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No Bankart lesion appreciated.

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I think that's fair.

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But the anterior inferior labrum is not normal,

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so I would call it a baby Bankart-type lesion.

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The main finding, though.

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Is the Hegel.

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And you should indicate that it has

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not taken a piece of bone with it.

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Some of you read an infraspinatus tear with

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fraying and I think that's absolutely fair.

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There is a small infraspinatus tear right there.

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It's probably not full depth.

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They didn't operate on it, I can tell you.

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And they didn't mess with it.

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They looked there,

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they saw some swelling and edema and just

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left it alone. That'll heal on its own.

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And then some of you probably read this,

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which is a cuff contusion.

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It's

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right over the hill sacks injury.

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So there is a little micro injury here.

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So absolutely fine to say in the conclusion,

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maybe number three or four micro tearing of the

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infraspinatus medially and posteriorally

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without macro tear of macro retraction.

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Number one should be dislocation of the shoulder

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with minor anterior labor injury and major

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detachment of the IGHL from the humeral neck,

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or so-called Hegel lesion.