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40-year-old man, post MVA.

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It looks at first glance like he just has a posterior

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dislocation with the humeral head still out of the socket.

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And the longer the head is out of the socket,

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the more sequelae you can develop, including avascular

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necrosis and devitalization of the humerus.

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So you want to get that head back in,

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plus it's pretty darn uncomfortable.

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But let's analyze the back of the shoulder

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for a moment, because this is a little weird.

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The posterior labrum is still there.

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So, what is actually torn that's allowed this to come out?

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And this is what's torn.

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This little loop right here is the capsule.

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Now that end should have been over here.

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So the capsule has completely detached from the back

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of the humerus, allowing it to dislocate posteriorly.

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That's not all.

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There's no rotator cuff.

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There's a bit of the rotator cuff.

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Both the supraspinatus and the infraspinatus and the teres minor

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have come off in the back, further allowing this posterior

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dislocation, even though the labrum itself did not tear.

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There is a massive Hill-Sachs lesion.

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It involves probably 40 to 50 percent of

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the circumference of the humeral head if

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we start scrolling all the way around.

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And when these, when these defects get really large, you

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may have to augment them with bone or, or graft them.

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Defects involving up to 25 percent of the articular

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surface can be treated with closed reduction if

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they're stable and acute and it's been less than

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three weeks since dislocation and especially if

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the humeral head has come back into the joint.

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Now, one weird thing about this case, actually there

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are many weird things, but another weird thing is, look

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at the location of the Hill-Sachs or reverse Hill-Sachs.

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Which one is it?

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Well, the patient is in internal rotation.

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Which means that this abnormality

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is in the back and rotated this way.

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Where is the reverse Hill-Sachs found?

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Over here.

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Which means that this patient must have

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had an anterior dislocation as well.

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At some point, or maybe dislocated to the front, and then

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retracted to the back, or got collided with and hit in

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the front of the arm, pushing the humeral head backwards.

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He might have gotten pushed forward during the MVA,

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and then pushed backward during impact at the shoulder.

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At any rate, the anterior capsule is shredded.

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The anterior inferior labrum, gone.

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We see a hanging CHAD right here, the anterior

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labral ligamentous complex, which is not

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attached to the humerus, so that is detached.

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We do not have an anterior inferior labrum.

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Our biceps is here, and then gone.

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So our biceps is torn.

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Our subscapularis is shredded.

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So, we've had a combination of injuries.

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We've had both an anterior dislocation with a giant

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conventional Hill-Sachs, not a reverse Hill-Sachs.

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The patient has lost the anterior capsule, lost the

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subscapularis, lost the labrum, lost the biceps,

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dislocated out the back, lost the posterior capsule,

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and lost the posterior rotator cuff, stabilizing

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dynamic structures, and the humeral head is still

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way outside of the glenoid cup with massive swelling.

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Now that's a complex case.