0:01

69-year-old with a complex pattern of injuries,

0:05

which you have seen in another vignette.

0:07

The rotator cuff is just destroyed.

0:10

Every component of it is gone.

0:11

The supraspinatus is gone.

0:13

The anterior fibers of the infraspinatus are gone.

0:16

These are shards and shreds of the rotator cuff with blood.

0:21

The humeral head has lost its depressor mechanism.

0:25

It's elevated, and the patient also has an

0:29

injury, a high-grade tear of the subscapularis.

0:32

Here are some subscapularis fibers present, but as

0:35

you know, the subscapularis is a sheet, so we're

0:38

missing lots of fibers here, and the reason that's

0:41

relevant is subscapularis tears go with, like soup

0:46

and sandwich, like Vegemite and toast, they go

0:49

with infraaxillary labral ligamentous injuries.

0:53

So you've always got to go back and forth looking

0:57

for this complex that frequently is found together.

1:01

Now I'll give you the arthritis, I'll give you the

1:04

decentered upward position of the humeral head, I'll

1:07

give you the pseudocyst, I'll give you the pitting

1:10

of the humeral head, but I won't give you the infra

1:14

axillary portion of the glenohumeral ligament.

1:18

The anterior band of the IGHL and

1:20

the posterior band of the IGHL.

1:23

So the IGHL comes off like this.

1:27

Comes off, and then it inserts on the humeral neck.

1:31

And it blends with the labrum, which is

1:33

this black or dark gray object, which I will

1:37

make, well, I'll make it orange right here.

1:40

So here's our orange labrum, and that's why

1:43

we call this the labroligamentous complex.

1:47

Now, look over here on the T2-weighted image.

1:52

Where is our glenoid side of our labrum?

1:57

Inferoaxillary anterior band and posterior

2:00

band of the glenohumeral ligament.

2:02

No, it's not over here.

2:03

It's over here.

2:06

It should be over here.

2:07

It's medial to the labrum.

2:11

So, this is a glenohumeral avulsion of the

2:14

glenohumeral ligament or a Hagglund lesion.

2:18

But I'd like to show it for another reason.

2:21

And that reason is I want to show

2:23

you what's happening in the back.

2:25

You can see the posterior fibers of the

2:28

glenohumeral ligament on the PD and the T2 attached.

2:32

Although they are a little swollen and

2:34

gray on the T2, they're very gray on the

2:37

center fat-weighted, T1-weighted image.

2:41

That's back.

2:42

Now let's go forward.

2:43

And as we go forward, we see it's a little

2:45

stretched out, but present and swollen.

2:48

Let's go forward just a little more.

2:50

We're still posterior, by the way.

2:52

Look at the acromion.

2:53

And now things are getting a little bit messy.

2:56

We don't see a nice, clean line between,

2:58

say, that structure and that structure.

3:01

It's breaking up.

3:03

And that's because we've got a tear back here, posteriorly.

3:07

And that's why we would refer to this as a form frustum or

3:11

a minor manifestation of a reverse, sorry, of a reverse

3:17

humeral avulsion of the glenohumeral ligament, also

3:20

known as an R haggle, also known as a raggle or a raggle.

3:26

Then as we go forward to the anterior band, that

3:30

is where you'd have your conventional Hagglund.

3:33

And let's have a look at that.

3:35

So here is our glenoid side of the glenohumeral

3:40

ligament, which should be coming off over here.

3:43

Now, where is our humeral side?

3:46

Now, all the way in the front, we

3:47

see the humeral side very nicely.

3:50

Actually, I take that back.

3:51

In the middle, in the axillary

3:54

region, dead center, we see it nicely.

3:56

Let's go all the way forward.

3:59

All the way forward, whoa, it's gone.

4:01

So, the anterior attachment on the humeral neck is gone.

4:07

The posterior attachment on the humeral neck is injured.

4:11

And if that weren't insult enough,

4:13

so this would be a classic Hagglund.

4:15

The one in the back would be a Regal, which I've

4:17

already showed you, or a form frustum of a Regal.

4:20

If that wasn't bad enough, we've torn the middle

4:23

of the axillary band of the IGHL right there.

4:27

Here's one band of it, here.

4:29

Here's the other band of it, here.

4:32

And here's the hole, right there,

4:34

where the fluid is seeping out.

4:36

This is creating a rather large pouch.

4:39

Let me draw over the pouch with a different color.

4:42

Let me pick, uh, yellow looks nice.

4:45

So here is our pouch that's broken.

4:50

You can see it's squiggling all the way immediately.

4:51

Now let me take it away.

4:53

There's the pouch right there with

4:55

an opening in it because it's torn.

4:57

And that pouch is sticking down and encroaching on

5:01

the brachial plexus, which is a potential problem.

5:04

Another potential site of encroachment that From this large

5:09

pseudo mass of fluid, this sort of false pouch, which is

5:14

often walled off by scar tissue, is the quadrilateral space.

5:20

So let's go to the front, and how

5:22

do we know we're in the front?

5:23

We find the coracoid, we get oriented, now we scroll

5:26

backwards, and we find the Terry's major, sorry, Terry's

5:32

major and minor, and between those two is going to be

5:37

The neurovascular bundle of the quadrilateral space,

5:40

which is also bounded by the triceps and the humerus.

5:44

So the quadrilateral space right here, humerus lateral,

5:48

triceps medial, the teres minor upper border, the teres

5:52

major lower border, and that space is spared in this

5:57

patient with a very complex infraroaxillary injury.

6:02

Remembering, That's subscapularis and middle

6:05

lenihumeral ligament injuries commonly accompany

6:09

these complex infraroaxillary injuries.

6:15

So now let's do a quick summary.

6:20

We're going to have an IGHL with an anterior

6:23

band, a posterior band, and an axillary band.

6:26

When we have an injury to the attachment of the

6:29

humeral neck, Mid to anterior, we call that a humeral

6:32

avulsion of the glenohumeral ligament, or a Hagglund.

6:35

If it takes a piece of bone with it, usually a small piece,

6:38

but we did show you a big piece in one of the vignettes,

6:41

then it is a B Hagglund, or a bony Hagglund, or a bagel.

6:45

If it takes both sides, the humeral neck and

6:48

the glenoid side, then the whole thing floats.

6:52

So you have a floating glenohumeral ligament just sitting

6:54

there with no attachment on either side, the so-called

6:58

floating IGHL, or anterior inferior glenohumeral ligament.

7:01

Glenohumeral ligament tear.

7:03

Then we've got the same thing happening

7:05

in the back at the humeral neck.

7:07

Some of the fibers may stay on, or the whole

7:10

thing may come off, but it's posterior.

7:12

We call that a reverse Hagglund, or reverse

7:16

humeral avulsion of the glenohumeral ligament.

7:19

If we've got a tear away from the labrum on the

7:24

glenoid side, and the labrum stays on, this is a

7:27

formal or classic type of Hagglund, or Hagglund Hagglund.

7:32

Glenohumeral avulsion of the glenohumeral ligament.

7:35

This portion of the ligament from the glenoid

7:37

side may sit lateral to the labrum, or, as in

7:40

the case you just saw, medial to the labrum.

7:44

Then you've got an axillary mid-portion tear.

7:47

We had one of those.

7:49

And then this pouch can start to migrate and

7:51

fill up all over the place and get into the

7:53

brachial plexus in the quadrilateral space.

7:56

You could simply have a sprain with scar tissue

7:59

which may simulate Adhesive capsulitis, but it

8:02

usually occurs in young, athletic individuals, and

8:06

that scar can contract and produce a pseudomass.

8:10

That's our summary for infraro

8:12

axillary labral ligamentous injuries.