0:00

Okay, this is a mature adult with impingement

0:04

evaluate for rotator cuff tear.

0:07

Not a particularly enlightening or deep history,

0:10

but let's get right to the axial projection.

0:13

We start up really high.

0:15

We'd like to see some tendon fibrils coursing

0:18

over the top of the humeral head.

0:20

Perhaps we see a few right here,

0:23

but not much else.

0:24

But let's go through our axial checklist.

0:27

We work our way down to the level of the coracoid,

0:31

and we see this floppy little structure right here,

0:34

which should be a straight line going from the coracoid,

0:37

all the way over to the humeral head.

0:40

The coracohumeral ligament, it's gone.

0:43

Let's keep going, shall we?

0:46

Let's go a little further, caudally.

0:49

Sorry, that's the wrong direction.

0:51

Here we go, caudally.

0:52

And the subscapularis,

0:54

which should have a broad footprint or plug

0:57

right here, is gone.

1:00

Let's keep looking at it.

1:01

Let's go down a little further.

1:03

That is not normal tendon tissue.

1:05

That is fibrous tissue and old blood.

1:08

Still, the subscapularis is gone.

1:10

And then when we get down really low,

1:13

we see a little bit of the subscapularis hanging on

1:16

by a thin thread and a little bit of the middle

1:19

glenohumeral ligament underneath it.

1:20

Let's go back up.

1:22

The middle glenohumeral ligament

1:23

is this grayish, ill-defined structure,

1:26

and I'm not attempting to define

1:29

its character at this very moment.

1:31

But clearly,

1:32

we have lost the coracohumeral ligament.

1:35

We've lost most of the subscapularis.

1:37

And then finally,

1:38

the axial projection shows us

1:40

the status of the biceps,

1:42

which is reduced to a thin thread that is perched

1:46

and sitting on the edge of the lesser tuberosity.

1:49

And as we work our way up higher,

1:51

there's the takeoff of the biceps.

1:53

And then we lose it as a very thin, wispy structure.

1:57

It never really seats itself

1:59

into the bicipital groove.

2:01

So we've got three components of the rotator cuff

2:05

already that are torn.

2:06

Remember, there are six components.

2:08

So let's finish off the other three.

2:11

What are they?

2:13

They're the supraspinatus.

2:14

Let's go to the front of the shoulder. Wow.

2:16

There's the grand canyon right here.

2:19

We'll draw the edge of the tear from here to here.

2:24

So this is our retraction dimension.

2:27

It's quite large.

2:29

And then let's keep scrolling backwards to the

2:32

infraspinatus, which is more posteriorly.

2:34

There's another canyon

2:36

through which you can drive your truck.

2:38

Here it is, from here to here.

2:41

So we have an infraspinatus tear

2:44

that's fairly massive.

2:45

It has substantial retraction,

2:48

which we could measure.

2:50

And then we've got the teres minor, which never tears.

2:53

Let's scroll back to that,

2:55

although we like the sagittal projection for it better.

2:58

Let's go all the way back to the teres.

3:01

Here's the teres, and it's fine.

3:03

So let's look at the sagittal projection for a moment.

3:07

We've got virtually a bald humeral head.

3:09

There are a few wispy fibers of the infraspinatus,

3:14

the supraspinatus.

3:15

These are just fibers flopping in the breeze,

3:17

surrounded by inflammatory tissue.

3:20

We are missing almost the entirety

3:23

of the subscapularis.

3:25

And my goal here is just to get you in the habit,

3:29

nothing else.

3:29

Get you in the habit of going through your checklist.

3:32

Supraspinatus, infraspinatus,

3:36

teres minor, coracohumeral ligament, subscapularis,

3:41

biceps labral anchor and capsule.

3:43

And here, the capsule is most likely torn.

3:46

You can ascertain that through just indirect

3:49

observation because there's

3:50

so much fluid everywhere.