The document describes various structures of the shoulder joint that provide stability, including the labrum, biceps tendon, and glenohumeral ligaments. It discusses common labral injuries like SLAP tears and Bankart lesions caused by anterior dislocation of the humeral head. It also describes variants like Buford complex and sublabral recesses that should not be confused with pathology.

1. SHOULDER –
LABRAL TEARS,
VARAINTS.

2. The glenohumeral joint has the
following supporting structures:
Superiorly
coracoacromial arch and
coracoacromial ligament
long head of the biceps tendon
tendon of the supraspinatus muscle
Anteriorly
anterior labrum
glenohumeral ligaments - SGHL, MGHL, IGHL (anterior band)
subscapularis tendon
Posteriorly
posterior labrum
posterior band of the IGHL
infraspinatus and teres minor tendon

3. Glenoid Labrum
The glenoid labrum is a fibrocartilaginous structure that
attaches to the glenoid rim and is about 4 mm wide.
The labrum may show considerable variation in shape and in
mechanism of attachment to the glenoid. It is usually rounded
or triangular on cross-sectional images.

4. Biceps Tendon
The tendon of the long head of the biceps muscle attaches to the
anterosuperior aspect of the glenoid rim.
The attachment of the biceps tendon may demonstrate four components,
including fibers that attach to the anterosuperior labrum, the
posterosuperior labrum, the supraglenoid tubercle, and the base of the
coracoid process.
From its site of attachment, the biceps tendon courses laterally and exits
the glenohumeral joint through the intertubercular groove, where it is
secured by the transverse ligament.

5. coronal section obtained at the level of the labral-bicipital complex illustrates the
biceps tendon (B), superior labrum (L), and glenoid cartilage (C), all of which are
intimately related in this region.
biceps tendon attachment at the level of the superior labrum and glenoid illustrates
attachments to the superior glenoid rim (1), the posterior (2) and anterior (3) labrum, and
the base of the coracoid process (4).

6. Glenohumeral Ligaments
Superior Glenohumeral Ligament.—
The glenohumeral ligaments play a role as shoulder stabilizers and consist of
thickened bands of the joint capsule.
The superior glenohumeral ligament is the most consistently identified capsular
ligament. It can arise from the anterosuperior labrum, the attachment of the
tendon of the long head of the biceps
muscle, or the middle glenohumeral
ligament.

7. Middle Glenohumeral Ligament.—
The middle glenohumeral ligament varies most in size and site of attachment to
the glenoid.
It may attach to the superior portion of the anterior glenoid labrum but more
frequently attaches medially on the glenoid neck.
The middle glenohumeral ligament may be absent or may appear thick and
cordlike (as, for example, in Buford complex).
CT arthrogram (2-mm section thickness) shows the middle glenohumeral ligament
(arrowhead) attached to the anterior labrum (arrow).

8. Transverse fat-saturated MR arthrogram (560/14) demonstrates the middle
glenohumeral ligament attaching medially on the glenoid neck (arrow).

9. Absent middle glenohumeral ligament in a 40-year-old woman. CT arthrogram (2-
mm section thickness) demonstrates absence of the middle glenohumeral
ligament (*) and a wide anterior joint recess (arrowheads).

10. Inferior Glenohumeral Ligament.—
The inferior glenohumeral ligament is an important stabilizer of the anterior
shoulder joint and consists of the axillary pouch and anterior and posterior
bands.
The anterior band inserts along the inferior two-thirds of the anterior glenoid
labrum. When redundant, it may overlap the anterior edge of the glenoid
cartilage.
The anterior band is usually quite prominent, although in approximately 25%
of cases it is very thin.
The posterior band is usually thinner than the anterior band.

11. Sagittal fat-saturated T1-weighted MR
arthrogram (750/15) demonstrates the biceps
tendon (t), subscapularis tendon (S), and anterior
and posterior bands of the inferior glenohumeral
ligament (arrows).
CORONAL

12. Labral variants
There are many labral variants.
These normal variants are all located in the 11-3 o'clock position.

13. It is important to recognize these variants, because they can mimick a
SLAP tear.
These normal variants will usually not mimick a Bankart-lesion, since it is
located at the 3-6 o'clock position, where these normal variants do not
occur.
However labral tears may originate at the 3-6 o'clock position and
subsequently extend superiorly.

14. Sublabral recess
There are 3 types of attachment of the superior labrum at the 12 o'clock
position where the biceps tendon inserts.
In type I there is no recess between the glenoid cartilage and the labrum.
In type II there is a small recess.
In type III there is a large sublabral recess.
This sublabral recess can be difficult to distinguish from a SLAP-tear or a
sublabral foramen.

15. These images illustrate the differences between an sublabral recess and a SLAP-tear.

16. Type I labral ---On a coronal MR arthrogram , the
labrum (black arrow) is tightly attached to the
glenoid cartilage and biceps tendon (white arrow)
Type II labral attachment. Coronal fat-saturated T1-
weighted MR arthrogram shows a small recess
between the labrum and the glenoid cartilage (arrow).
Type III labral attachment ----coronal CT
arthrogram shows a large recess between
the labrum and the glenoid (arrow).

17. Sublabral Foramen
A sublabral foramen or sublabral hole is an unattached anterosuperior
labrum at the 1-3 o'clock position.
It is seen in 11% of individuals.
On a MR-arthtrogram a sublabral
foramen should not be confused
with a sublabral recess or SLAP-tear,
which are also located in this region.
A sublabral recess however is located
at the site of the attachment of the
biceps tendon at 12 o'clock and does
not extend to the 1-3 o?lock position.
A SLAP tear may extend to the 1-3 o'
clock position, but the attachment of
the biceps tendon to the superior
labrum should always be involved.

18. notice the unattached labrum at the 12-3 o'clock position at the site of the sublabral
foramen. Notice the smooth borders unlike the margins of a SLAP-tear.

19. Buford complex
A Buford complex is a congenital labral variant.
The anterosuperior labrum is absent in the 1-3 o'clock position and the
middle glenohumeral ligament is usually thickened.
It is present in approximately 1.5% of individuals.

20. On these axial images a Buford complex can be identified.
The anterior labrum is absent in the 1-3 o'clock position and there is a thickened
middle GHL.
The thickened middle GHL should not be confused with a displaced labrum.
It should always be possible to trace the middle GHL upwards to the glenoid rim and
downwards to the humerus.

21. Variation in the shapes of labrum

22. Labral pathology
• BANKART LESION
• BONY BANKART
• REVERSE BANKART
• PERTHES
• REVERSE PERTHES
• APLPSA
• POLPSA
• ALIPSA
• POLIPSA
• GLAD
• GARD
• GAGL
• HAGL
• BHAGL
• DOUBLE LESION
• TRIPLE LESION
Following are various labral pathologies :

23. Labral pathology
A Clockwise approach to the labrum is the easiest way to diagnose labral
tears and to differentiate them from normal labral variants.
There are two types of labral tears: SLAP tears and Bankart lesions.
SLAP is an acronym that stands for 'Superior Labral tear from Anterior to Posterior'.
SLAP tears start at the 12 o'clock position where the biceps anchor is located, which
tears the labrum off the glenoid.
SLAP tears typically extend from the 10 to the 2 o'clock position, but can extend
more posteriorly or anteriorly and even extend into the biceps tendon.
Bankart lesions are typically located in the 3-6 o'clock position because that's where
the humeral head dislocates.

24. Dislocation
Anterior dislocation
The shoulder is a very mobile and therefore unstable joint.
The humeral head is almost always displaced anteriorly, inferiorly and medially
below the coracoid process (95% of cases).
Motion to superior is limited by the acromion, coracoid process and rotator cuff
(figure).
Motion in a posterior direction is limited by the posterior rim of the glenoid which is
in an anteverted position.

25. The dislocation of the humeral head to antero-inferior causes damage to the antero-
inferior rim of the glenoid in the 3 - 6 o'clock position (marked in red).
Especially in younger patients this results in a Bankart fracture or a Bankart lesion
which is a tear of the anteroinferior labrum.
This results in instability and recurrent dislocations.

26. The images show a subtle Bankart fracture (arrows).

27. Hill-Sachs
On MR a Hill-Sachs defect is seen at or above the level of the coracoid
process.
Hill-Sachs is a posterolateral depression of the humeral head.
It is above or at the level of the coracoid in the first 18 mm of the proximal
humeral head.
It is seen in 75-100% of patients with anterior instability.
It is chondral or osteochondral.

28. Bankart and variants
Bankart-lesions and variants like Perthes and ALPSA are injuries to the anteroinferior
labrum.
These injuries are always located in the 3-6 o'clock position because they are caused by
an anterior-inferior dislocation.

29. Bankart lesion
Bankart lesions are labral tears without an osseus fragment.
MR arthrography or arthroscopy are optimal to diagnose Bankart or Bankart-like
lesions.
There is a detachment of the anteroinferior labrum (3-6 o'clock) with complete
tearing of the anterior scapular periosteum.
The arrow points to the disrupted periosteum.

30. On MR-athrography the labrum is missing on the anterior glenoid and the labral
fragment is displaced anteriorly (arrow).

31. Osseus Bankart
Bankart lesions with an osseus fragment are common findings in patients with an
anterior dislocation and are frequently seen on the x-rays or CT-scan.

32. On MR-arthrography it may be difficult to depict the osseus fragment.
On CT it is easy to appreciate the osseus fragment of the anterior glenoid (arrow).

33. Reverse Bankart
CT-images in another patient show a reversed osseus Bankart in a patient with
posterior dislocation.
Axial MR-arthrogram of a reverse Bankart.

34. Perthes lesion
A Perthes lesion is a labroligamentous avulsion like a Bankart, but with a medially
stripped intact periosteum.
On images of the shoulder with the arm in a neutral position, the torn labrum may
be held in its normal anatomic position by the intact scapular periosteum, which
thereby prevents contrast media from entering the tear.
This means that MR-arthrography
with the arm in the neutral position
may fail to detect the labral tear.

35. In the ABER-position it is obvious that there is a Perthes lesion (black arrow).
Due to the ABER-position the anterior band of the inferior GHL creates tension
on the anteroinferior labrum and contrast fills the tear.
In the ABER position however there is tension on the antero-inferior labrum by
the stretched anterior band of the inferior glenohumeral ligament and you have
more chance to detect the tear.
The arrow points to the intact periosteum.

37. ALPSA
An ALPSA-lesion is an Anterior Labral Periosteal Sleeve Avulsion.
The anterior labrum is absent on the glenoid rim.
The arrow points to the medially displaced labroligamentous
complex.

38. Images of a patient with an ALPSA-lesion.
Notice the medially displaced labrum.

39. POLPSA
Posterior labral periosteal sleeve avulsion.
It is reverse of ALPSA.

40. GLAD
A GLAD-lesion is a GlenoLabral Articular Disruption.
It represents a patial tear of the anteroinferior labrum with adjacent
cartilage damage.
The arrow points to the cartilage defect.

41. The images show a partial tear of the anteroinferior labrum
with adjacent cartilage damage at the 4-6 o 'clock position
(arrows).
GLAD-lesion

42. Defect is at the base of the labrum, predominantly in the glenoid articular
hyaline cartilage.

43. HAGL is a Humeral Avulsion of the inferior Glenohumeral Ligament.
There is discontinuity of the IGHL attachment on the humerus with
leakage of contrast.
HAGL

44. Glenoid Avulsion of the inferior Glenohumeral Ligament.

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