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This middle-aged woman was working in a nursing facility

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and one of the residents there jerked her arm downwards.

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And now she's got pain in the

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shoulder extending to the elbow.

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Now typically pain in the shoulder extending

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to the elbow is a sign for me that the

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patient potentially has adhesive capsulitis.

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They frequently get contraction of the

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shoulder from fibroinflammatory disease.

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And fluid then tracks into the biceps sheath.

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and creates a bicipital peritendinitis or tenosynovitis.

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That actually hasn't happened here, but in

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my experience, it's not uncommon for people

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that have antero infero axillary abnormalities

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to get referred pain down into the elbow.

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And sometimes that occurs because you've injured the

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inferior capsule, say down in here, fluid extravasates

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down, let me just draw it, fluid extravasates down,

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and what's in the neighborhood as you come forward.

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The, the nerves, the quadrilateral space.

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I don't know if that's the answer here, but there is a

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fair amount of swelling inferiorly on the axial image.

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So let's scroll the axial image, and I've given

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you three images, a simple T1 anatomy image

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for bone, an axial water-weighted GRE, and a

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coronal proton density fat suppression image.

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So let's scroll the axial first, and as we

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move from top, there's the biceps anchor.

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To bottom, we're in the mid-portion.

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There's the MGHL, middle glenohumeral ligament.

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There's a fissure separating our labrum from the bone.

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Is it a fissure?

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Is it tear?

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It should close down as we go down, and it does.

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It should get bigger and better and

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blacker than the posterior labrum.

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It should be triangular in shape.

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Sometimes they can be a little rounded at their tip.

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Sometimes they can be a little frayed

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along their free lateral margin.

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This one is, I don't mind that.

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I don't mind that little fissure right

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there, it's too small to bother me.

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And so, I'm unimpressed with the

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anteroinferior axillary labrum.

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And I feel good about this case, I'm wiping my

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hands clean and I'm ready to go home, right?

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Let's look at the posterior labrum for a moment.

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The posterior capsule should come

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off the tip of the posterior labrum.

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Is it?

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It's not, there's a small area of

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separation and the periosteum is elevated.

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So this patient has an ellipse, sorry, a polypsa,

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a posterior labrum intact, posterior labrum

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is intact, capsuloperiosteal sleeve avulsion.

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Very common in individuals that are physically active,

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especially those involved in pushing activities.

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In other vignettes, you've seen reverse Perthes lesions.

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Or Kim's lesions.

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But that's not why we're here.

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That's a distractor.

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That's just telling us we've got

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multidirectional instability.

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But perhaps we have multidirectional instability with

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macro instability with one geography predominating.

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And which geography is it?

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Anteroinferior.

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Let's look at our coronal projection.

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Let's put up all three coronals.

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Our T2, in the middle, which gives us perhaps our

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best ligamentous to surrounding tissue evaluation,

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our sensitive proton density fat suppression,

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and our T1 on the left, our anatomy image.

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Now our anatomy image just shows a

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glom, a glop, a mass of gray signal.

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It doesn't really sort out the

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characteristics of the anatomy.

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But our T2 weighted image, It does so pretty well.

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It shows us a curly Q structure that has a J shape

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right there that does not attach to the humeral neck.

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Or at least it doesn't appear to.

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Let's scroll it on the sensitive PD spur.

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Let's go to the back.

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Not very well attached.

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So there is a posterior inferior

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glenohumeral ligament detachment.

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Let's go to the middle.

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It's certainly swollen.

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Let's go anterior.

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It is barely attached.

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So, this is an example of somebody with a Hagel.

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From anterior to posterior.

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That is probably just a little bit of granulation tissue.

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that is trying to hold this structure in place.

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It's corrugated, it's crimped, it's clearly not taut.

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The patient has a humeral avulsion of the

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glenohumeral ligament from the humeral neck.

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Now there are several variations of this.

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This can occur isolated only in the back.

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When that occurs, it's called a raggle, or an R haggle.

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When it occurs in the middle,

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it's called an axillary haggle.

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When it occurs in the front, it's called a haggle.

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When it occurs with a piece of bone,

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it's called a behagel or a bagel.

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When it occurs on the humeral side, and it also

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takes off the glenoid side, but leaves the labrum on.

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It's called a floating IGHL or an IGLE.

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Now let's, let's attack the labral ligamentous complex.

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Is it normal?

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No.

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Is it retracted?

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No.

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But where the labrum should be, it's awfully swollen.

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So that inferior force, that downward and anterior

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force that's been applied to this shoulder has

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resulted in a strain/sprain/swelling

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of the labrum And detachment of the inferior

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glenohumeral ligament, the posterior band for sure,

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the anterior band is for sure, the axillary band is

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injured, there's swelling in this area right here.

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Sometimes when you have a Hagel, this little pouch

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right here can get bigger and bigger and bigger.

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And then that pouch is confused

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for a mass, a recess, a ganglion.

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Especially if you do an arthrogram.

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This pouch is going to distend, and distend,

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and distend, and it may even completely pull

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away and allow your arthrographic material

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to extravasate down into the axillary space.

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Hagel lesions, in general, are more likely to

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be identified when you get them acutely because

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they have a strong tendency to reattach and to

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scar down, and then you end up missing them.

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When you distend the joint, you are highly

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likely to form this pseudo pouch and

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sometimes get extravasation through the pouch.

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If this pouch gets really big and really scarred,

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it may encroach on the quadrilateral space.

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The quadrilateral space being the

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space between the teres and the psoas.

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Minor, the teres, major, the humerus, and the triceps.

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So this is your quadrilateral space right here.

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It is not encroached upon, but

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it contains the axillary nerve.

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So big, chronic Hagels with pseudopouched distention

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can result in quadrilateral space syndrome.

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So this concludes our discussion of the Hagel lesion.

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The sagittal projection really doesn't add very much.

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And by the way, do we have a Hill-Sachs lesion?

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Let's look at the sagittal just to be sure.

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I'll blow it up a little bit just to be consistent.

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And the answer is no.

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We do not have a Hill-Sachs lesion.

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And it's not uncommon for Hagels and their

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related entities, B Hagels, R Hagels, Rag

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Ragels, not to have Hill-Sachs lesions.

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Diagnosis, Hagel lesion.

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or humeral avulsion of the

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glenohumeral ligament, without bone.