0:01

In the next few minutes, I want to emphasize

0:04

the least favored nation status of the

0:07

axial as it relates to the rotator cuff.

0:09

It's the oft ignored but extremely valuable projection.

0:14

Let's do a little drawing here for a moment.

0:17

We have our, our supraspinatus right here,

0:20

which I've just blocked off in, in yellow.

0:23

But what people fail to do most of the time

0:26

is to follow the supraspinatus tendons all

0:28

the way out over top of the humeral head.

0:31

Now the reason you don't see them

0:32

here is we're not quite high enough.

0:34

But I'm going to draw them in for you as

0:36

they would look on the next superior cut.

0:39

There'll be a series of linear tendon fibrils that will

0:43

arc or curve as they reach the top of the humeral head.

0:48

So I'm actually going to use maybe

0:50

a different color to show that arc.

0:52

Here they are arcing, and arcing, and arcing.

0:58

So they're going to come in from the back, from the

1:00

infraspinatus, and they're going to arc forward.

1:02

And they're going to come in from the supraspinatus,

1:04

and they're going to arc a little bit backward.

1:07

And the two are going to interdigitate.

1:11

What is extremely valuable about

1:13

the axial projection are two things.

1:17

One, and one of you asked this question the other day.

1:22

Anteriorly, when you have a tear that's all the

1:24

way in the front, for instance right here, you're

1:28

handicapped if you're going to do a coronal

1:30

projection because you are tangent to this tear.

1:34

You're lined up right with it.

1:36

So it's going to be very difficult for you to pick it up.

1:39

Whereas the axial and the sagittal are going to have

1:43

a much more favorable position to see that tear.

1:47

And very often, with these far anterior tears, you're

1:50

going to get quite a bit of bluster in the neighborhood.

1:52

There's going to be lots of swelling.

1:55

And sometimes the overall anatomy of this

1:57

tear, you know, its shape, is most conspicuous,

2:01

including the depth and the axial projection.

2:04

And this is why it's so important not to ignore.

2:08

The second major point that I want to make

2:11

for the axial projection, I'm going to use my

2:13

eraser here for a moment, is you get the bird's

2:18

eye orthopedic surgeon's view of the tear.

2:22

Let's have a try.

2:24

So here are, here are my tendon

2:26

fibrils, this time I made them in green.

2:31

And now when I have a tear, That

2:33

tear is going to whack these fibers.

2:36

I better use a better color.

2:38

Let's try blue.

2:41

And the fibers, which should be inserting right out here, at

2:44

the very edge of the humerus, are now lost or interrupted.

2:49

And that may produce a crescent

2:51

like appearance from the top down.

2:54

And you'll often hear the surgeon

2:55

say, it's a crescent like tear.

2:59

Or, you might even hear them say, it's a U shaped tear.

3:03

There's the U lying on its side.

3:06

And what's that filled in with?

3:07

Flammatory tissue.

3:09

So there's your U.

3:11

Should make it a little more rounded.

3:13

And when you say it's a U shaped tear,

3:15

that means there's more retraction.

3:17

Now these, these tears that are more

3:19

retracted tend to be more crescent dominant.

3:22

Types of rotator cuffs where the tendon fibrils

3:25

are a little thinner and a little more floppy.

3:28

Just by virtue of their development.

3:31

There's one other appearance that surgeons often refer to.

3:36

And I'll use my eraser again.

3:37

And that is the L shaped tear.

3:39

So let's draw in our tendon fibrils one more time.

3:43

This time we'll make our tendon fibrils blue.

3:45

Just out of complete convenience.

3:46

They go all the way to the tip.

3:49

And now if you take out Fibers here, and here.

3:57

It makes a reverse L.

3:59

And then if you fill that in, you'll fill

4:02

in your L, that's going to be your hole.

4:06

So instead of it having a round, crescent, shallow

4:09

configuration, or a deep U shaped configuration,

4:14

like this, it has a reverse L type configuration.

4:18

And in the opposite shoulder, it'll look like the letter L.

4:21

Just depends on which shoulder you're on.

4:23

So the axial projection, totally your friend.

4:27

It's invaluable when you're trying

4:29

to look at the subscapularis.

4:32

And that will be a separate subject, the subscapularis.