0:00

Okay, this is a 51 year old woman whose history is

0:05

non contributory, rule out rotator cuff tear, and

0:10

her rotator cuff looks just fine relative to her age.

0:15

The finding of note is this bone fragment which

0:19

lies in the distribution of the lesser tuberosity.

0:22

Attaching to it are the upper, middle, and lower

0:26

fibers of the subscapularis whose shape has been

0:29

likened to the state of Nevada in the United States.

0:33

I'm not quite sure I can hallucinate that, but at any

0:36

rate, you can see the entire sheet from top to bottom of

0:40

the subscapularis is attached to this detached fragment.

0:45

Now lesser tuberosity fractures are exceedingly

0:49

uncommon in patients with shoulder dislocations.

0:53

And, uh, the myotendinous, uh, area is very,

0:58

very strong, so usually you don't get tears here.

1:01

You're either going to get tears at the

1:02

insertion of the subscap, or or you'll

1:05

have separation of the lesser tuberosity.

1:09

The implication, though, is substantive.

1:12

Because if you lose, if you, if you affect the anterior

1:16

labrum and the IGHL and you lose the stability of the

1:20

subscapularis and or the tissues behind it, now the

1:24

patient is, is not going to do well with a banquet repair.

1:27

So, it is absolutely critical that you recognize this.

1:32

Another critical thing to recognize is that subscapularis,

1:36

lesser tuberosity, middle glenohumeral ligament injuries

1:39

go hand in hand with axillary IGHL abnormalities like the

1:45

glenohumeral ligament, the gaggle, the anterior inferior

1:50

avulsion of the glenohumeral ligament, the floating IGHL

1:53

or the IGHL, or the humeral avulsion of the glenohumeral

1:56

ligament from the humeral neck called the haggle.

2:01

And the bony haggle, or the bony avulsion

2:04

of the, um, glenohumeral ligament from

2:08

the humerus, so called B haggle or bagel.

2:11

Now this patient has a B haggle, it's

2:14

an unusual one, because most B haggles,

2:17

you'll take off a little flake of bone.

2:19

And you might have a hard time seeing this.

2:22

But, let's concentrate together.

2:23

So, we're more in the back, where we can

2:26

see the posterior band and axillary band of

2:29

the IGHL, attaching nicely to the humerus.

2:32

Now, let's move forward.

2:33

Things are getting a little smoky looking right there.

2:37

And then, right there, a little smokier looking.

2:40

So, that's ligament.

2:41

That is not subscap.

2:43

Let's see subscap over here.

2:45

Ligament here.

2:47

Ligament here.

2:48

Subscap here.

2:49

Ligament here.

2:50

So, you'd say, okay, the ligament isn't torn.

2:52

You'd be right.

2:54

But it's attached to this detached piece of bone.

2:58

So the bone is off, but the ligament is on the bone.

3:02

So this is kind of a giant variant of a haggle.

3:06

Uh, those of you that are culturally, uh, in tune, we might

3:10

call this a bialy, you know, a giant bagel, so to speak.

3:14

And let's look at the axial projection in case you

3:16

don't believe that the IGHL is attached to this thing.

3:21

Here is an axial.

3:22

Let's scroll it.

3:23

Let's go high.

3:25

We're going high.

3:26

We see our subscap attached to our

3:29

large lesser tuberosity fragment.

3:31

Now let's go a little bit lower.

3:34

That is the IGHL.

3:36

It's more curved.

3:37

We're too low for the subscapularis.

3:40

It's attached to the fragment.

3:41

There's another band of the IGHL attached to the fragment.

3:45

And then there's the rest of the IGHL.

3:47

So these components of the IGHL are still

3:50

present, but attached to a detached fragment.

3:54

piece of bone from the lesser tuberosity, and as

3:57

previously stated, uh, this changes management, because

4:02

if you have an unstable scenario, you've detached

4:06

the labral ligamentous complex in a dislocation,

4:09

and you lose the subscapularis support, the odds

4:13

are a bankart repair is just not going to cut it.