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25 Year Old Male, Pain When Swinging Arm

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This 25-year-old has pain when swinging the arm.

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There's actually no history of discrete

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collision or catastrophic trauma, and that's

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usually the case, uh, for this type of lesion.

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So the patient's young, 25 years of age,

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and we've got a labeled image on your left.

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On the right side, we've got a gradient echo,

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a simple standard water-weighted gradient echo.

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And, um, let's scroll it a little bit.

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And let's you get a feel for, um, the labrum.

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And you can see we've labeled the

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labrum at the area of interest.

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And again, the, the labrum is abnormal at one slice down.

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So we'll go to the exact same slice and then one slice down.

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Back, down.

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And then things look a bit normal again.

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In fact, they are normal.

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Nice black labral ligamentous complex.

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This is a 1 Tesla.

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High field open.

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So we're looking at a partial rim

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tear that involves the labrum.

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Now I'm going to take my drawing tool out and I'm going to

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draw over this image here and use it as my reference point.

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I'll make my scapula nice and orange and then I'll

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take a nice color and make my labrum here and then

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I'll make my labrum over here and then I'll make

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my hyaline cartilage aquamarine blue just for fun.

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for consistency.

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And, um, let's talk about this particular

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lesion, which is known as a glenolabral articular

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disruption, a type of rim injury that is incomplete.

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So if I, if I blew up my labrum, I'd say,

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well, what's happening in the labrum?

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I'm having a partial tear in the labrum.

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It's coming from the inside out.

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And frequently, it'll clip the tissue.

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The base of the aquamarine blue hyaline

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cartilage, which is going to be over here.

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So you get a little bit of cartilaginous

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involvement, and then your tear, which

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is in green, goes right into the labrum.

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How is that any different than a, a true Bankart lesion?

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And a true Bankart lesion is, is

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actually an avulsion type of labral tear.

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That's how it was originally described.

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And if we took our green arrow, sorry, our green

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label, and we made a true Bankart, it would go all

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the way through, out the other side of the labrum.

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Now, what, what happens here, what

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happens over here to the labrum?

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It merges imperceptibly with

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capsular tissue, and with periosteum.

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And often you can't separate them apart.

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So let's make our periosteum, Uh,

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let's try deep blue in honor of IBM.

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There's deep blue right there.

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And, so your true Bankart lesion, which again we'll

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make in, in green, uh, I'll make it a lighter green

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this time, and it, it can go through the periosteum.

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So it doesn't have to go through the labrum.

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So avulsion through this area or this

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area is consistent with a true Bankart.

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Now the next question you're probably gonna ask

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me is what's the definition of a Perthes lesion.

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Let's, let's do that.

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I'm gonna have to take my eraser out.

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I think that's it right there.

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Nice erasing.

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Love this little system here.

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Of course, I'm an artist at heart.

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A failed artist, but, uh, so I love to draw.

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And, um, let's make our labrum again.

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And here's our, here's our labrum.

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This time I'm going to have to put some glenoid

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tissue in there, so let's put our glenoid tissue in.

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And then we've also got some aquamarine hyaline cartilage

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in there, and sometimes it'll be a fuzzy transition

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into the labrum, sometimes it'll be quite abrupt.

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And our labrum is going to transition

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into the capsule and the periosteum.

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So in a Perthes lesion, you do not

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have a through and through tear.

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You have a tear that goes into the labrum,

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But then dissects underneath the periosteum.

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But there's still a periosteal unit that stays intact.

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So if we said, okay, what does the tear actually look like?

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I'm going to take a tear color that's consistent.

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Let's go with, um, let's go with dark green again.

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So I'm going to take my dark green.

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My tear goes into the labrum and then it makes a,

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a turn medially and goes underneath the periosteum.

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It'll lift the periosteum up.

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And sometimes even the periosteum will puff up like this.

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It'll get lifted all the way up, but still attached.

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And filling it in will be this inflammatory

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material, and injurious material, that

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gives you a little pseudomass right there.

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So, the Perthes lesion differs significantly from

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the true Bankart, in that it is not an avulsion.

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It can occur from a dislocation or a minor trauma.

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Usually GLAD lesions, glenolabral articular

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disruption, like this lesion, where the periosteum

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is intact, and there's a partial rim tear starting

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at the base of the cartilage going into the labrum.

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These are most often seen in lower grade

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types of injuries, lower velocity injuries.

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And the patients usually have odd complaints, you know.

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Pain when swinging the arm, pain when internally rotating.

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When they rotate the arm, they feel like the shoulder

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is giving way, but when you examine it, they don't lock.

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They don't dislocate on physical examination,

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but they do have some degree of loosening.

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And sometimes, even on MRI, if you internally and

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externally rotate the shoulder by putting the arm behind

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the back, with the thumb up and the thumb down, As the

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humerus rotates this way, like this, in and out, the

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labrum will swing in and out, and it'll get caught, and

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the patient may experience a tiny little click, or a

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sensation of a click, or you may even hear an audible sound.81 00:04:12,095 --> 00:04:14,825 And our labrum is going to transition

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into the capsule and the periosteum.

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So in a Perthes lesion, you do not

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have a through and through tear.

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You have a tear that goes into the labrum,

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But then dissects underneath the periosteum.

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But there's still a periosteal unit that stays intact.

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So if we said, okay, what does the tear actually look like?

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I'm going to take a tear color that's consistent.

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Let's go with, um, let's go with dark green again.

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So I'm going to take my dark green.

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My tear goes into the labrum and then it makes a,

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a turn medially and goes underneath the periosteum.

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It'll lift the periosteum up.

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And sometimes even the periosteum will puff up like this.

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It'll get lifted all the way up, but still attached.

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And filling it in will be this inflammatory

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material, and injurious material, that

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gives you a little pseudomass right there.

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So, the Perthes lesion differs significantly from

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the true Bankart, in that it is not an avulsion.

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It can occur from a dislocation or a minor trauma.

5:25

Usually GLAD lesions, glenolabral articular

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disruption, like this lesion, where the periosteum

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is intact, and there's a partial rim tear starting

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at the base of the cartilage going into the labrum.

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These are most often seen in lower grade

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types of injuries, lower velocity injuries.

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And the patients usually have odd complaints, you know.

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Pain when swinging the arm, pain when internally rotating.

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When they rotate the arm, they feel like the shoulder

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is giving way, but when you examine it, they don't lock.

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They don't dislocate on physical examination,

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but they do have some degree of loosening.

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And sometimes, even on MRI, if you internally and

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externally rotate the shoulder by putting the arm behind

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the back, with the thumb up and the thumb down, As the

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humerus rotates this way, like this, in and out, the

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labrum will swing in and out, and it'll get caught, and

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the patient may experience a tiny little click, or a

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sensation of a click, or you may even hear an audible sound.

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So this is known as functional instability.

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It's a type of micro instability.

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It's anterior quadrant, and one of the causes

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of this type of instability is the GLAD lesion.

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So in summary, you've gotten a definition of a true Bankart

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lesion, the periosteal type, or the soft Bankart type.

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You can also have a bony Bankart, which

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we're not going to discuss right now.

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We talked about the Perthes lesion, originally

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described, by the way, in 1906, a long, long time ago.

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So this isn't something new.

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That we created in the Perthes lesion.

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The periosteum remains intact.

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And there's a partial tear of the labrum

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with the section underneath the periosteum.

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And then we talked about the GLAD lesion.

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In which the periosteum isn't elevated.

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There's just a partial rim tear into the labrum.

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It doesn't go through.

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It doesn't elevate the periosteum.

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And just as a caveat.

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Uh, any variations of these can occur posteriorly.

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But the one that's most famous.

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is the reverse Perthes lesion, also

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known as the Kim's variant lesion.

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And that'll be a story for our

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posterior instability discussion.

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Let's move on, shall we?

Report

Description

Faculty

Stephen J Pomeranz, MD

Chief Medical Officer, ProScan Imaging. Founder, MRI Online

ProScan Imaging

Tags

Trauma

Shoulder

Musculoskeletal (MSK)

MRI

Bone & Soft Tissues

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