In type IV SLAP lesions there is a bucket handle tear from the labrum that extends through the biceps tendon. The bucket-handle fragment is composed of the superior labrum and a portion of the tendon that might be displaced from the superior glenoid. There is also a double "Oreo cookie" sign with fluid between labrum and glenoid cartilage and between two pieces of labrum.

Surgical treatment is indicated in all types of SLAP lesions except for type 1, which has no clinical relevance. Type 2 and 4 injuries impair the stabilizing function of biceps insertion with glenohumeral instability, secondary impingement, and rotator cuff injuries, are usually treated by refixation.

Case courtesy Dr.ssa Laura Braccaioli.

Radiographer: TSRM Fabio Imola.