0:00

Let's put up some images on the 17-year-old male with a football

0:04

injury two months ago, American football, the real football.

0:08

So let's take a look at our gradient echo axial image.

0:13

Let's put up something water weighted like this water

0:19

weighted proton density image, which is my favorite

0:22

sort of search and destroy sequence for detection.

0:26

I use this for detection and I use everything

0:28

else to sort of modify what's going on.

0:32

And this time they have done a proton density with the proper TE.

0:37

I like the TE to be around 38 to 50, 55 maybe.

0:42

So I don't like it to be too T2-weighted.

0:44

I don't like the TE to be too short either.

0:47

Even though they've used fat suppression, I

0:49

like the TE to be around 40–45 is my ideal one.

0:54

So they made a little mistake here, but there is

0:56

fat suppression and there is fat suppression here.

0:59

So two fat suppression sequences.

1:01

And this is a young man, and he has diminished

1:06

range of motion concern for Bankart tear.

1:09

So let's take a look at where we would see a Bankart

1:12

tear, that would be down here, and it is a little

1:18

ill-defined there's very little swelling present.

1:21

And if we look in the axial projection we see

1:24

the IGHL and subscapularis there's the IGHL.

1:29

There's, there's the subscapularis.

1:32

There's more of the IGHL right here.

1:36

And while the labrum is a little bit blunted, a little

1:38

bit flat, it has some signal in it that would be within

1:42

the realm of acceptability for a contact athlete at

1:45

age 17 who's constantly lifting weights, et cetera.

1:49

In addition, I can see periosteum there, the

1:55

capsule and the periosteum coming together.

1:58

And then medially, the rest of the

2:00

periosteum and cortex is normal.

2:03

I'm inspecting the hyaline cartilage.

2:05

I'm inspecting the labrum.

2:07

I'm inspecting the, the capsule and the periosteum.

2:12

I'm inspecting the glenohumeral ligament.

2:15

I'm inspecting the remainder of the periosteum.

2:17

I'm inspecting the glenoid bone.

2:20

All of them are within the realm of acceptability.

2:25

I like what I see for the IGHL which has an

2:30

anterior component, which is usually where you

2:33

injure the IGHL, it's like a little loop right here.

2:37

And then I get into the middle portion of the IGHL, the so-called

2:41

axillary portion, and I don't like what I see as well here.

2:45

I see a little bit of medialization of the IGHL.

2:50

I like it to come off right here at the

2:52

apex, so I'm a little curious about that.

2:54

And I've also got this funny little fissure right

2:57

here, which is a little bit confusing and disturbing.

3:01

And then I get into the posterior aspect of the IGHL.

3:05

It's inserting nicely on the humeral neck.

3:07

It's inserting beautifully.

3:09

on the glenoid.

3:10

But when I come up a little bit, there's some

3:12

signal that says simply does not belong right there.

3:16

Now, this is a more advanced case.

3:18

So let's scroll it.

3:20

Let's keep scrolling all the way

3:21

back and let's follow that signal.

3:23

Let's plow the road.

3:25

There's the initiation of that signal.

3:27

There it is again.

3:28

There it is again.

3:29

And there it continues.

3:31

And it starts to diffuse a little bit as we get all the way back.

3:35

So something is rotten in the state of the posterior quadrant of

3:40

the right humerus, for those of you who are Shakespeare fans.

3:45

Then let's keep looking at the superior labrum.

3:48

We inspect it anteriorly, we inspect it inferiorly,

3:51

we even inspect it posteriorly in the coronal plane.

3:55

We're not done yet.

3:56

We haven't inspected superiorly.

3:58

Let's start out in the front.

4:00

Remember, we have our SGHL, we have our superior labrum.

4:05

We have our biceps taking off from the

4:08

superior tubercle of the glenoid right here.

4:12

Can't see the coracohumeral ligament that well, but

4:14

it would be here and then here is your supraspinatus.

4:19

Let's take that away and start to scroll back.

4:21

And we have this funny little signal right there.

4:23

Right there.

4:24

Let's keep following that.

4:25

Now, as I go backwards, I don't like new signals to

4:28

crop up as I move from anterior to posterior and that is

4:32

persisting and it's getting a little more conspicuous.

4:35

Now it's a lot more conspicuous and now it's contiguous

4:38

with the rest of the signal that we saw earlier.

4:41

So something is happening over the top and around the back.

4:46

Now it's time to look at the axial.

4:49

We've already inspected the front.

4:51

Telling you to look at structure by

4:53

structure, the GHL, the subscapularis.

4:57

The labrum or labral ligamentous complex, the glenoid bone, the

5:03

glenoid cortex, the periosteum, but in the back, not so great.

5:08

In the back, we have the capsule, which

5:10

normally goes to the labral apex, like this.

5:14

There's the labral apex, capsule should go right to it.

5:17

And it does, right there.

5:20

But the labrum should not have this funny-looking gap right

5:24

here between itself you and the glenoid and the gap is filled

5:29

with goop high signal intensity goop inflammatory tissue

5:36

and there's some swelling right here around the periosteum

5:40

that is elevated but still preserved periosteum.

5:45

So the periosteum is off, the labrum

5:49

is off, but the periosteum isn't ruptured.

5:51

Now the reason that's relevant is when you rupture

5:54

the periosteum, let's pretend, let's use another

5:57

color. Let's pretend this is periosteum right here.

6:01

And then if you rupture that periosteum, you

6:05

know, that's the definition of a Bankart.

6:07

Or if you rupture the labrum through and

6:09

through, that's the definition of a Bankart.

6:12

When the labrum is not ruptured, when it's detached

6:15

and the periosteum is preserved, we call that a

6:18

type one or level one Perthes type labral tear.

6:23

So it is a labral tear.

6:24

It's just a slightly unique type.

6:27

Some have referred to it when it's

6:28

the only finding as a single lesion.

6:31

You'll also hear the term used, reverse Perthes

6:34

or Kim's lesion, if that was the only finding.

6:37

Sitting there all by itself and it didn't go

6:39

all the way up and around and over the top.

6:42

But let's continue scrolling.

6:44

You see this funny-looking big gap?

6:46

And not only is it in the back, Remember we said

6:49

we didn't like the way the posterior inferior,

6:53

capsule periosteal reflection looked, especially

6:57

in the axillary region looked a little medialized.

7:00

Well, you can see that there's a tear right here in

7:03

the inferior aspect of the labral ligamentous complex.

7:07

So, this posterior abnormality that we expect out is

7:14

extended inferiorly now let's go up and look

7:18

where we are we're still in the inferior quadrant is a

7:20

little gap here are Perthes-looking lesion, still present.

7:25

With our intact periosteum, a little bit more periosteal

7:30

elevation right here, still intact, this little very thin band.

7:34

There's more periosteum.

7:36

There's our labrum.

7:36

There's our capsule.

7:37

Let's keep going.

7:38

Let's keep going.

7:39

Let's keep going.

7:40

Still off.

7:41

And now look how high we are.

7:43

Let's keep going and going.

7:46

And we still have that tear that we can see

7:48

perhaps better in the coronal projection.

7:51

And now we're all the way to the top.

7:54

We also have another gradient echo image.

7:57

That's a little bit thinner section 1.

7:58

7 millimeter cuts that show you the Perthes-like

8:03

component of the tear doesn't show you

8:05

the superior component of the tear as well.

8:09

Let's see what the sagittal shows.

8:11

It's a little more challenging.

8:14

We can see the biceps taking off right here.

8:19

tear until you get right on FOSS to the cup.

8:23

And there is the Perthes-like separation of the labrum

8:27

from the glenoid, and there is the superior component

8:30

or superior quadrant of the tear, more swelling showing

8:33

you, showing you just how far anterior the tear occurs.

8:38

The tear goes pretty far forward,

8:40

and then pretty far back then down.

8:43

And then as you saw around it even goes a little more interior

8:46

than this, based on the axial and the coronal projections.

8:51

So this is known as a SLAP VIII.

8:54

If it occurs on a chronic basis.

8:57

Some might refer to this as just a traumatic tear

9:01

and then describe it as a superior labral tear with

9:04

posterior extension with Perthes-like characteristics,

9:08

extending into the posterior inferior quadrant.

9:11

Now for the SLAP lesions.

9:13

The typical SLAP lesions are one through four.

9:17

So let's, let's scroll to the superior labrum

9:22

right here, and I'm going to draw over it.

9:27

So here's your labrum I'm just going to superimpose.

9:31

If you have a little fraying along the undersurface.

9:36

Get some delicate fraying right here, non full depth,

9:39

usually a little bit more anterior than posterior.

9:43

We call that a SLAP I.

9:45

If we get some signal that goes deeply through the labrum,

9:48

with or without a paralabral cyst, that would be a II.

9:52

If it's anterior, in the anterior quadrant, that would be a II A.

9:56

And the posterior quadrant would be a II B.

9:59

If it goes all the way from anterior

10:00

to posterior, it would be a II C.

10:05

Then let's redraw our labrum even.

10:07

Even though we know this labrum.

10:08

Superiorly is abnormal.

10:10

Right there.

10:11

We're gonna draw over the labrum.

10:14

And we're going to make a glenoid cup underneath

10:16

the labrum right there there's our glenoid cup.

10:19

This time we'll use yellow as the background.

10:22

And this time, we're going to create a bucket

10:25

handle tear, I think I'll use aquamarine blue.

10:29

So we'll have a big gap right here.

10:31

And then in the axial projection.

10:33

We'll see a piece of the labrum here, a piece of the labrum

10:37

here, and then in the middle we'll see some signal in

10:40

between which represents a little bit of goop, and that

10:43

is known as the Cheerio sign or the Oreo cookie sign.

10:48

Looks like an Oreo cookie there, and if you connect

10:50

them together it looks a little bit like a Cheerio.

10:53

That's when you're looking down in the axial projection.

10:56

So this bucket handle configuration of the tear with a

11:00

little bit of labrum here, and a little bit of labrum

11:06

here would be your type three or SLAP III lesion.

11:12

Then if you have a tear that extends into the biceps

11:17

long head longitudinally will take say green to do that

11:22

the tear goes into the biceps and it can go pretty far

11:25

and go all the way into the extra-articular biceps.

11:28

That would be a type four SLAP lesion.

11:32

If you have a tear that is associated with an antero

11:36

inferior labral tear or dislocation that goes all the way

11:39

from the bottom to the top, that would be a type five.

11:44

You can have that as two separate lesions, you can have a SLAP

11:47

lesion and a dislocation, and they can meet in the middle.

11:50

That's known as a collision lesion, or it can be one

11:53

injury that is contiguous from one single traumatic event.

11:57

So, those are SLAPs one through

11:59

five, they go all the way up to 10.

12:02

And there's there's even an 11 and a 12.

12:05

I think that's beyond the scope of our discussion today.

12:09

But those are the important ones, with one

12:11

more exception, the one you've seen today.

12:14

Which is incredibly common.

12:16

And that is the SLAP VIII.

12:18

The reason the SLAP VIII is so common is we have

12:20

these young men, look how muscular he is, they're bench

12:23

pressing, they're military pressing, they're driving

12:26

the humeral head backwards, and they're peeling back the

12:30

posterior superior, posterior, and posterior inferior

12:33

labrum from these repetitive movements.

12:36

So the ones you really should, should learn about, you don't have

12:39

to know the numbers, but be able to describe a one through five.

12:44

And then eight.