0:01

Okay, we're back.

0:02

This is the most fun I've ever had without laughing.

0:04

Drawing with all these colors is great.

0:07

I used to be an artist, but I don't know what happened.

0:10

But nothing good happened as time went on.

0:12

I can, I can assure you of that.

0:15

So now I'm, I'm on to shoulder week, shark week.

0:20

I'm on to depth.

0:22

The concept of depth is a little bit confusing.

0:26

Because when you're dealing with round tendons,

0:29

the concept of depth doesn't really apply.

0:32

You know, these round tendons can split,

0:35

they can have intrasubstance tears.

0:38

The concept of length and width and depth is different.

0:43

And we're going to discuss that for

0:44

round tendons as a separate subject.

0:47

So what we've been discussing about the

0:49

shoulder really applies to flat, broad tendons.

0:54

Which live inside the shoulder.

0:56

So let's do it.

0:58

Let's make another humeral head.

1:00

We need another one.

1:05

Another humeral head, and let's

1:06

make ourselves a rotator cuff.

1:09

And this time I am not going to draw all the sections of

1:12

the cuff, like the muscle section, and the myotendinous

1:16

unit, and the cable, and the crescent, and the footprint.

1:20

I'm just going to draw a simple yellow cuff.

1:25

Because I want to introduce the concept of

1:29

penetration depth.

1:31

Now you would think depth is a pretty simple thing.

1:35

This would be partial thickness.

1:37

This would be full thickness.

1:38

All the way through from the articular surface

1:41

all the way to the superficial surface.

1:46

And, and that, that's pretty true.

1:48

Because that's really what the clinician cares about.

1:51

But they also care about, you know, retraction and

1:54

length and some of the things we've been discussing.

1:56

But there are, there are a number of other

1:57

modifiers that you can get into as you

2:00

become more and more sophisticated In MRI.

2:05

Earlier on, we discussed the concept, and we're

2:07

going to have to make our arrow thinner now.

2:10

We discussed the concept of hidden tears, concealed tears.

2:15

And I'm going to use the color orange to illustrate this.

2:17

So, right here, we showed you earlier in another section,

2:23

in another session together, we showed you a concealed

2:27

interstitial delamination tear in That you couldn't

2:30

see from the outside from a deltoid splitting procedure

2:32

and you couldn't see from the arthroscopic view.

2:36

And so we called it concealed.

2:38

There are other places you can have concealed

2:40

tears too, but it's so important to tell the

2:43

clinician whether you think the tear is visible

2:45

from approach A or from approach B or both.

2:51

Well then it gets, it gets more complicated than that.

2:54

Tears that are partial or full thickness,

2:57

they can be vertical, but Like this.

3:00

But they could also be horizontal.

3:03

From the medial footprint to the lateral footprint.

3:07

All the way through the footprint.

3:09

But yet, it doesn't retract.

3:11

Remember when you used to do the

3:12

arthrogram and you'd see a little pinhole?

3:14

Go out from your arthrography and go out into

3:16

the bursal space, it was a tiny little line?

3:19

These are the tears that frequently did that.

3:22

So they are communicating full thickness tears.

3:25

But they're not articular surface tears.

3:27

You can only see them.

3:29

from the outside if they communicate.

3:32

Because there are still usually fibers of the foot

3:35

plate or footprint that are attached medial to them.

3:38

So you want to make very clear that these, this

3:41

type of horizontal rather than vertical full

3:45

thickness tear is a bursally communicating tear

3:49

that goes from the humeral side to the bursal side.

3:53

Not from the articular side to the bursal side.

3:55

This is critical.

3:57

For

4:00

And a lot of these don't retract.

4:02

These are frequently referred to as

4:05

footplate or footprint avulsion tears.

4:10

And when you hear avulsion you

4:11

think, okay, something came off.

4:13

Yeah, something did come off.

4:14

The tendon.

4:16

But almost never does the bone come off.

4:19

So they are avulsions without bone.

4:21

You have to make that clear and educate your audience.

4:26

Now are there tears where the bone comes off?

4:33

Let's talk about some other types of tears.

4:36

What if we had a little tear here?

4:39

Right next to the bare area.

4:41

Along the articular surface.

4:42

Let's pretend we're on the articular surface.

4:44

My, my lines are a little bit thick.

4:47

It looks like these two things are

4:49

attached to each other, but they're not.

4:50

There's a space there.

4:51

So let's make the joint space something, Hmm.

4:53

So you can see where the joint space ends.

4:57

The joint space ends right there.

5:02

So hopefully my green line shows through.

5:05

So I've got a little articular sided tear.

5:09

It's a partial thickness tear.

5:11

Again, it's articular sided, but it also has an eponym.

5:14

It has a name.

5:14

It's called a Stas lesion.

5:16

A supraspinatus tendon articular sided tear.

5:20

For Stas.

5:22

Could you have an infraspinatus, articular sided tear?

5:26

Sure.

5:27

Just has another eponym.

5:29

But the one that's popular is the stoss lesion.

5:32

And these are pretty darn common.

5:35

Now what if your stoss lesion does this?

5:39

I said stoss.

5:41

I meant stoss.

5:43

What if it does this?

5:43

I better get back to orange so as not to confuse you.

5:46

And myself.

5:48

What if it does this?

5:50

Then we've got A partial thickness, articular

5:56

sided tear, with interstitial extension.

6:00

Also known as partial P, articular

6:03

sided A, interstitial INT, paint lesion.

6:08

That's a paint.

6:10

So you gotta, you know, you gotta

6:11

have a little bit of length to it.

6:16

Let's keep going, shall we?

6:17

So, what if we had a partial thickness tear.

6:23

That ran along the length.

6:27

Oh, we gotta make it a little thicker, sorry.

6:29

Along the length of the tendon.

6:31

Maybe something like this.

6:37

And it retracted back to here.

6:40

But the outer half of our pancake stayed intact.

6:46

In other words, you delaminated the entire

6:49

deep section of the tendon and it retracted.

6:52

That's a post lesion.

6:56

So that would be a partial thickness.

7:01

A partial thickness supraspinatus tendon avulsion.

7:04

With retraction.

7:05

A so called pasta lesion.

7:09

Could you have it on the outside?

7:11

Could you have the upper surface do the

7:13

same thing and spare the deep surface?

7:15

In other words, this portion of the cuff tears and retracts.

7:19

But the deeper portion stays intact.

7:24

You absolutely could.

7:26

And you do, and that's what's

7:28

known as a reverse pasta lesion.

7:35

Oh, but there's more.

7:36

You thought, oh, just, just when you

7:37

thought it was safe to go back in the water.

7:39

Nope.

7:40

Here comes the tiger shark.

7:45

something that is pretty intuitive.

7:48

Let's make our cuff yellow again.

7:55

And this time, we're going to

7:56

take our tears, which are orange.

8:00

And we've already discussed articular sided

8:02

ones, stoss, and paint, and interstitial ones,

8:07

like the concealed interstitial delamination,

8:10

and then we've got bursal sided tears.

8:13

Bursal sided tears are often very saucerized.

8:16

In fact, some people will even use that

8:18

word, saucerized bursal sided tear.

8:21

If they look like little hairs and are very

8:22

tiny and ill defined, my lines are a little fat

8:25

for it, then we call it bursal sided fraying.

8:30

But very often, when you have a partial bursal

8:33

sided tear, it is at the footplate or footprint.

8:36

That's the most common place.

8:39

And it has a very distinct shape to it.

8:43

It looks a little bit like a gull wing or a W.

8:49

And that is called the gull wing sign.

8:52

Some people use to say the bird sign.

8:54

Some people say the W sign.

8:56

But when you see that shape, and especially if you don't

8:59

have high resolution, you know that you have a unique

9:05

bursal sided tear that is probably contained and doesn't

9:08

go all the way through and allow fibers to retract.

9:12

So it is a sign of a partial thickness tear.

9:18

Now let's finish with a flurry, but a

9:20

really important thing when you are serving

9:24

clinicians and therefore their patients.

9:32

can't figure out whether it goes through or not.

9:35

Whether it comes out the bursal surface.

9:38

That happens a lot.

9:40

Especially if you have a lot of swelling or you have

9:44

lower field and you don't have the spatial detail.

9:46

Well there are some indirect signs you can use.

9:50

Like if the fibers, the yellow fibers, crimp.

9:54

They micro retract.

9:56

They'll do this.

9:58

They'll wave on you.

10:00

Or you have macro retraction where they

10:02

just simply do this, then you know.

10:05

But another useful sign is if you can

10:08

see what I call the spillage sign.

10:10

The spillage sign is when you can see the signal going

10:12

this way, and then you see it spill on either end,

10:16

going either medial or lateral into the bursal space.

10:20

The mere presence of fluid is

10:22

suggestive, but it's not diagnostic.

10:25

But if you can connect the spillage to this hole,

10:29

then you know you've got a full thickness tear.

10:32

If you can't connect the spillage, if all you

10:34

see is fluid on the outside, and you have a

10:39

deeper tear, then you've got a decision to make.

10:43

And a good term to use in that

10:44

scenario is near full thickness tear.

10:50

But when you say near full thickness tear, You

10:53

want to always rectify it and clarify it by

10:59

saying that it is a pinhole, or it's diminutive,

11:02

or it's only one millimeter in diameter.

11:04

Because a lot of those tears, which used to be

11:06

surgical and sutured, are not surgerized anymore.

11:10

So if you use too big a word, you know,

11:13

near full thickness, or high grade, a lot of

11:15

you will use the term high grade out there.

11:17

If you use high grade, thought process

11:20

for surgeon, high grade, knife.

11:23

No, not a knife.

11:26

It's deep, but it's tiny.

11:31

So you've got to convey that message.

11:33

You've got to separate in your head

11:35

depth from length and retraction.

11:38

They've all got to come together to sell

11:42

the proper story of what should be done.

11:46

So let's take a deep breath there.

11:48

And we'll have at it one more time

11:51

for today,

11:52

for shoulder week or shark week.