<p begin="00:00:05.100" end="00:00:06.790" style="s2">- [Voiceover] The<br />following are case studies</p>
<p begin="00:00:06.790" end="00:00:09.121" style="s2">presenting pictures of the posterior</p>
<p begin="00:00:09.121" end="00:00:12.497" style="s2">glenoid labrum and its abnormalities.</p>
<p begin="00:00:12.497" end="00:00:13.998" style="s2">In our anatomical review we have the</p>
<p begin="00:00:13.998" end="00:00:16.087" style="s2">posterior surface of the humeral head</p>
<p begin="00:00:16.087" end="00:00:19.265" style="s2">with articular hyaline cartilage in blue,</p>
<p begin="00:00:19.265" end="00:00:22.863" style="s2">the proximal origin of the infraspinatus</p>
<p begin="00:00:22.863" end="00:00:25.248" style="s2">tendon here in yellow, with the more</p>
<p begin="00:00:25.248" end="00:00:28.199" style="s2">laterally light blue<br />landmark of the greater</p>
<p begin="00:00:28.199" end="00:00:30.251" style="s2">tuberosity which will act as its</p>
<p begin="00:00:30.251" end="00:00:33.418" style="s2">insertion of the infraspinatus tendon.</p>
<p begin="00:00:34.419" end="00:00:37.328" style="s2">Highlighted here in green is the</p>
<p begin="00:00:37.328" end="00:00:39.911" style="s2">spine of the scapula with a red</p>
<p begin="00:00:40.949" end="00:00:43.821" style="s2">posterior acromion process, which</p>
<p begin="00:00:43.821" end="00:00:46.850" style="s2">serves as a great palpation point to begin</p>
<p begin="00:00:46.850" end="00:00:50.136" style="s2">the examination of the<br />infraspinatus tendon.</p>
<p begin="00:00:50.136" end="00:00:54.041" style="s2">Highlighted here in<br />purple is the posterior</p>
<p begin="00:00:54.041" end="00:00:57.753" style="s2">bony glenoid of the scapula, and the</p>
<p begin="00:00:57.753" end="00:01:00.703" style="s2">structure here in white represents</p>
<p begin="00:01:00.703" end="00:01:03.870" style="s2">the posterior glenoid labrum, which is</p>
<p begin="00:01:05.250" end="00:01:07.513" style="s2">only clearly identified by ultrasound</p>
<p begin="00:01:07.513" end="00:01:10.002" style="s2">and its approximate 9 o'clock position.</p>
<p begin="00:01:10.002" end="00:01:12.872" style="s2">Overlying these structures is the large</p>
<p begin="00:01:12.872" end="00:01:15.465" style="s2">infraspinatus muscle and tendon</p>
<p begin="00:01:15.465" end="00:01:18.838" style="s2">followed by the teres minor resting</p>
<p begin="00:01:18.838" end="00:01:23.010" style="s2">just inferior to the infraspinatus tendon.</p>
<p begin="00:01:23.010" end="00:01:25.559" style="s2">Corresponding ultrasound image here</p>
<p begin="00:01:25.559" end="00:01:27.573" style="s2">of the posterior glenoid labrum.</p>
<p begin="00:01:27.573" end="00:01:30.166" style="s2">We have highlighted here the bony</p>
<p begin="00:01:30.166" end="00:01:33.793" style="s2">glenoid of the scapula, followed by</p>
<p begin="00:01:33.793" end="00:01:36.816" style="s2">a highlighted image of the bony</p>
<p begin="00:01:36.816" end="00:01:40.359" style="s2">posterior humerus with a dark rim</p>
<p begin="00:01:40.359" end="00:01:41.962" style="s2">over the bone representing the</p>
<p begin="00:01:41.962" end="00:01:44.712" style="s2">posterior articular hyaline cartilage.</p>
<p begin="00:01:44.712" end="00:01:46.439" style="s2">Highlighted here would<br />be the infraspinatus</p>
<p begin="00:01:46.439" end="00:01:49.888" style="s2">muscle belly, which is seen obliquely</p>
<p begin="00:01:49.888" end="00:01:52.861" style="s2">in this slice, so that<br />we can have a clear image</p>
<p begin="00:01:52.861" end="00:01:56.370" style="s2">of the posterior glenoid labrum here,</p>
<p begin="00:01:56.370" end="00:01:59.826" style="s2">highlighted as a hyperechoic triangle.</p>
<p begin="00:01:59.826" end="00:02:02.553" style="s2">Internal and external rotations</p>
<p begin="00:02:02.553" end="00:02:04.805" style="s2">are great dynamic maneuvers for the</p>
<p begin="00:02:04.805" end="00:02:07.730" style="s2">posterior glenoid labrum,<br />as a greater tegrocity</p>
<p begin="00:02:07.730" end="00:02:12.285" style="s2">is brought posteriorly<br />towards the bony glenoid,</p>
<p begin="00:02:12.285" end="00:02:16.120" style="s2">the posterior glenoid<br />labrum is brought under</p>
<p begin="00:02:16.120" end="00:02:19.956" style="s2">tremendous stress, forcing a blunting</p>
<p begin="00:02:19.956" end="00:02:22.139" style="s2">of the posterior glenoid labrum.</p>
<p begin="00:02:22.139" end="00:02:24.222" style="s2">Seen here is a disruption</p>
<p begin="00:02:25.764" end="00:02:29.440" style="s2">of the normally homogeneous pattern</p>
<p begin="00:02:29.440" end="00:02:31.650" style="s2">of the posterior glenoid labrum.</p>
<p begin="00:02:31.650" end="00:02:33.461" style="s2">On external rotation this becomes</p>
<p begin="00:02:33.461" end="00:02:36.037" style="s2">even more noticeable as the tissue</p>
<p begin="00:02:36.037" end="00:02:40.037" style="s2">interfaces are brought<br />together and then relaxed</p>
<p begin="00:02:41.165" end="00:02:44.668" style="s2">under this dynamic stress maneuver.</p>
<p begin="00:02:44.668" end="00:02:47.634" style="s2">On internal rotation we may also see</p>
<p begin="00:02:47.634" end="00:02:50.603" style="s2">loose bodies deeper than the joint.</p>
<p begin="00:02:50.603" end="00:02:52.616" style="s2">This image of an external rotation</p>
<p begin="00:02:52.616" end="00:02:55.120" style="s2">reveals a false joint effusion.</p>
<p begin="00:02:55.120" end="00:02:57.989" style="s2">What looks like a large<br />hypoechoic structure</p>
<p begin="00:02:57.989" end="00:03:00.406" style="s2">protruding from the<br />posterior joint surface</p>
<p begin="00:03:00.406" end="00:03:04.158" style="s2">is actually just contracted muscle belly,</p>
<p begin="00:03:04.158" end="00:03:06.759" style="s2">which contains a large amount of water,</p>
<p begin="00:03:06.759" end="00:03:09.946" style="s2">as well as a high incidence of anisotropic</p>
<p begin="00:03:09.946" end="00:03:13.604" style="s2">artifact due to the angle<br />of tendon insertion.</p>
<p begin="00:03:13.604" end="00:03:15.596" style="s2">Special care should be used when</p>
<p begin="00:03:15.596" end="00:03:17.774" style="s2">identifying a posterior joint effusion</p>
<p begin="00:03:17.774" end="00:03:21.028" style="s2">to overlay the infraspinatus tendon</p>
<p begin="00:03:21.028" end="00:03:24.559" style="s2">over the joint, creating an interface</p>
<p begin="00:03:24.559" end="00:03:28.401" style="s2">for fluid to rest that is not hypoechoic.</p>
<p begin="00:03:28.401" end="00:03:31.001" style="s2">By bringing this hyperechoic<br />interface over the</p>
<p begin="00:03:31.001" end="00:03:35.168" style="s2">joint space, it is easy to<br />identify joint effusions.</p>

<p begin="00:00:09.732" end="00:00:12.901" style="s2">- Next we're going to examine<br />the acromioclavicular joint,</p>
<p begin="00:00:12.901" end="00:00:15.431" style="s2">also known as the AC joint.</p>
<p begin="00:00:15.431" end="00:00:18.348" style="s2">Now this structure is<br />very easy to identify</p>
<p begin="00:00:18.348" end="00:00:20.456" style="s2">and I begin by just looking at the patient</p>
<p begin="00:00:20.456" end="00:00:22.798" style="s2">and identifying their bony acromion,</p>
<p begin="00:00:22.798" end="00:00:25.331" style="s2">which you can feel by palpation.</p>
<p begin="00:00:25.331" end="00:00:27.907" style="s2">Next, I'm going to place<br />the probe on the patient,</p>
<p begin="00:00:27.907" end="00:00:31.077" style="s2">again with the notch facing<br />medially towards the patient.</p>
<p begin="00:00:31.077" end="00:00:33.163" style="s2">Now with this structure,<br />it's obviously close</p>
<p begin="00:00:33.163" end="00:00:35.891" style="s2">to the surface, so we can<br />use a very short depth,</p>
<p begin="00:00:35.891" end="00:00:40.051" style="s2">and here we are, which<br />should be adequate at 2.7.</p>
<p begin="00:00:40.051" end="00:00:43.241" style="s2">So here we can visualize<br />the acromioclavicular joint</p>
<p begin="00:00:43.241" end="00:00:46.715" style="s2">and if we suspect pathology<br />with this in a patient,</p>
<p begin="00:00:46.715" end="00:00:49.467" style="s2">we can do a dynamic study<br />and have the patient</p>
<p begin="00:00:49.467" end="00:00:52.118" style="s2">strain his acromioclavicular joint and see</p>
<p begin="00:00:52.118" end="00:00:55.765" style="s2">if there's any separation<br />or ligamentous laxity.</p>
<p begin="00:00:55.765" end="00:00:58.422" style="s2">So what I do is I recommend<br />that the patient slowly takes</p>
<p begin="00:00:58.422" end="00:01:02.102" style="s2">his right arm and reaches it<br />across to his left shoulder</p>
<p begin="00:01:02.102" end="00:01:05.102" style="s2">while maintaining contact<br />over the AC joint.</p>
<p begin="00:01:05.102" end="00:01:08.685" style="s2">You can go ahead and<br />slowly move your left.</p>
<p begin="00:01:10.102" end="00:01:11.917" style="s2">Great, and back.</p>
<p begin="00:01:11.917" end="00:01:14.718" style="s2">And what we look for is if<br />there's an abnormal separation</p>
<p begin="00:01:14.718" end="00:01:18.551" style="s2">between the two acromion<br />and clavicular bones.</p>
<p begin="00:01:19.655" end="00:01:23.333" style="s2">In some cases of degeneration<br />and osteoarthritis,</p>
<p begin="00:01:23.333" end="00:01:26.345" style="s2">we'll see irregular bone<br />formations or even something</p>
<p begin="00:01:26.345" end="00:01:30.013" style="s2">known as the Geyser phenomenon,<br />which is bursal fluid</p>
<p begin="00:01:30.013" end="00:01:34.180" style="s2">extending out of the<br />acromioclavicular joint upwards.</p>

<p begin="00:00:09.407" end="00:00:11.804" style="s2">- Next we're going to<br />demonstrate ultrasound-guided</p>
<p begin="00:00:11.804" end="00:00:13.971" style="s2">injection of the shoulder.</p>
<p begin="00:00:15.150" end="00:00:18.023" style="s2">Before we get started, keep<br />in mind that as with any</p>
<p begin="00:00:18.023" end="00:00:20.023" style="s2">procedure, it should be performed</p>
<p begin="00:00:20.023" end="00:00:21.549" style="s2">under sterile conditions.</p>
<p begin="00:00:21.549" end="00:00:25.100" style="s2">This is only a demonstration<br />of the appropriate setup.</p>
<p begin="00:00:25.100" end="00:00:28.433" style="s2">To begin the injection, we're<br />going to place the transducer</p>
<p begin="00:00:28.433" end="00:00:31.739" style="s2">on the patient's shoulder, with<br />the notch of the transducer</p>
<p begin="00:00:31.739" end="00:00:34.277" style="s2">aimed toward the patient's ear.</p>
<p begin="00:00:34.277" end="00:00:38.696" style="s2">And we can see the Supraspinatus<br />Tendon, in clear image.</p>
<p begin="00:00:38.696" end="00:00:41.154" style="s2">Just above the Supraspinatus Tendon,</p>
<p begin="00:00:41.154" end="00:00:44.750" style="s2">lies the Subachromial Subdeltoid Bursa.</p>
<p begin="00:00:44.750" end="00:00:48.800" style="s2">It's represented as a thin<br />black line above the tendon,</p>
<p begin="00:00:48.800" end="00:00:52.720" style="s2">and will be the target site<br />of our shoulder injection.</p>
<p begin="00:00:52.720" end="00:00:55.720" style="s2">Now that we've localized<br />the Subachromial Subdeltoid</p>
<p begin="00:00:55.720" end="00:00:58.796" style="s2">Bursa, we're ready for injection.</p>
<p begin="00:00:58.796" end="00:01:01.747" style="s2">Again remembering our<br />landmarks, that the notch</p>
<p begin="00:01:01.747" end="00:01:04.855" style="s2">of the upper-left-hand corner<br />of the ultrasound screen</p>
<p begin="00:01:04.855" end="00:01:08.763" style="s2">correlates with the<br />notch on the transducer.</p>
<p begin="00:01:08.763" end="00:01:12.473" style="s2">The goal is to introduce<br />the needle directly beneath</p>
<p begin="00:01:12.473" end="00:01:16.949" style="s2">the transducer; ideally,<br />the needle should be</p>
<p begin="00:01:16.949" end="00:01:20.532" style="s2">at the center point<br />beneath the transducer.</p>
<p begin="00:01:24.527" end="00:01:27.712" style="s2">And we can see it penetrate<br />the Deltoid, which is the area</p>
<p begin="00:01:27.712" end="00:01:30.184" style="s2">above the Supraspinatus Tendon.</p>
<p begin="00:01:30.184" end="00:01:31.724" style="s2">And then, it will penetrate</p>
<p begin="00:01:31.724" end="00:01:34.521" style="s2">the Subachromial Subdeltoid Bursa.</p>
<p begin="00:01:34.521" end="00:01:37.571" style="s2">It's important not to<br />continue needle penetration</p>
<p begin="00:01:37.571" end="00:01:40.328" style="s2">as this may penetrate<br />the Supraspinatus Tendon,</p>
<p begin="00:01:40.328" end="00:01:44.686" style="s2">and may cause pain as well<br />as eventual further injury</p>
<p begin="00:01:44.686" end="00:01:46.183" style="s2">to the patient.</p>
<p begin="00:01:46.183" end="00:01:49.427" style="s2">With injection of Kenalog<br />and Lidocaine into</p>
<p begin="00:01:49.427" end="00:01:53.289" style="s2">the Subachromial Subdeltoid<br />Bursa, we confirm proper</p>
<p begin="00:01:53.289" end="00:01:57.582" style="s2">location by seeing expansion of the Bursa.</p>
<p begin="00:01:57.582" end="00:02:01.688" style="s2">Here is an example of<br />fluid filling the Bursa.</p>
<p begin="00:02:01.688" end="00:02:05.855" style="s2">The injection is now complete<br />and the needle is withdrawn.</p>