A Concise and Comprehensive Description of Shoulder Pathology and Procedures: The 4D Code System
Patient 2’s diagnostic arthroscopy documentation. (a) Initial inspection shows an absent medial biceps pulley and a tear of at least the upper one-third of the subscapularis tendon. (b) There is intratendinous extension of the tear as demonstrated by the arthroscopic probe. (c) Inferiorly, the upper two-thirds of the lesser tuberosity is exposed after debridement. There is significant fraying of the dislocated biceps tendon on the right-hand side. There is also the “comma sign” from the medially retracted anterior-superior rotator cuff tear. (d) This is the articular view of the grade 2 supraspinatus tear retracted to level of the humeral head. (e) This is a lateral view of the exposed humeral head with the grade 2 infraspinatus tear. (f) Infraspinatus tendon has delaminated into two layers.