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A-1293 Case discussion
Zaf Naqui, UK
Wednesday, June 13, 2018 · 3:13 p.m. · 24m 47s
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but we're not gonna put 'em
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put all this into practised hopefully
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um we've got our experts here we will hopefully uh help on some of the questions but actually
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really this should be an interactive session so maybe you want to volunteer
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your thoughts um uh all for uh your questions or comments um
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straight hopefully straightforward routing cases that you see in your packets
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um so the these are combination cases from the monks transcend and also
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uh from uh my friends uh n. caplan or and and barcelona so
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recognition to to them for a are providing some of these cases as well so
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first guy uh thirty two years all these right handed he's a
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bill that he fell on his outstretched hand three months ago
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he's got ongoing pain on that also radio aspect of his wrist
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full range of motion um and um but a loss
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of grip strength and we have the images there so um
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any thoughts initial thoughts about what how you take this
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oh
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i i i i. s. o.
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so you're gonna go for a um when you talk about reconstruction what would you what would you be doing for this or yeah yeah
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a lot i think you're that because of the wind of acute repairs possibly some limit there to fix
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and so uh with so so this is the thing in the in the national health service in the u. k.
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uh maybe maybe elsewhere as well you know um a lot of us as research as will be seen as patients
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after significant reliance i would love to see even in the first two weeks but it
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just doesn't happen uh in reality so so so he's come up three months
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yeah so but again i think is a priceless oh look at repair
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that we would go about whatever dorsal capitalise on top of that
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and uh our profit more bit over her type screw crossed the whole worker a crack
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so um it three months i think you getting i i agree with what we're actually out of
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the the cute face i think you look new looking at doing some sort of reconstruction
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we probably use the technique that i just represented probably half an hour ago yeah this
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okay any other comments on that
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no yes
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thank you ah up question full full double to bleep of you um three months three months old up i've done
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a few and and sometimes as a uh the to the counsellor said you can find something to read
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but the thing is that i'm not very comfortable with the reconstruction
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especially if you're not uh if you have a plan it it's a plan
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for it a previously so would be to i don't know um
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uh oh uh would be such of problem to do and
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and up there or try to read repair what's left
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and uh and and maybe see if it doesn't work um it plan
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for reconstruction nah i don't know three to six months later
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yeah i think i think that that's the that's the next option as well but i mean i yeah i
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can i think you gotta add something onto your your your repairs like just a little primer repair
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probably figured it also kept a decision that burning bridges so that fails like yours your three
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six was the lighting you do it more for reconstruction that would still be an option
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i think when you get at it you're a tricky spot um
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i think it might be good time but don't framed as a it is difficult so uh i think if if
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there are some cases my this is one of them way you you may pass them on where is
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he might be and manage a lot of many other things i'm in my pet psychic what if you these would be saint
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at this stage but unfortunately it's on the same after surgery at nine months
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and i don't do very will have to do the previous city i i'm gonna ask and i you
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you obviously you are within the scope this patient even though it's three months down the line
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the chances of a ligament being there are limited you probably gonna do reconstruction
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um would cost implications in time implications is it monday through to do
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was coconut situation would what would would you go straight for
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or would even do we need to do it in my skull do we need to screw this or should we just actually list this for reconstruction
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closer 'cause we all know who's gonna say um but i think the in my right doesn't really add a lot
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but so i wouldn't be critical of anyone it doesn't but with dedicated a lot i think was actually right
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but i would actually scope because then i can actually see the articulation so if you get in there and there's a great
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did a lot of on taking off a kappa to aid over this summer as a major the
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clone to injury on what actually lot to know that the atrocities the best way to say that
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one procedure scope then straightaway reconstruct idea so everybody could be the last minute the atrocities
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part of the diagnostic work because the the thing we're we're we can help you
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they have here six here they're too busy is does it really been three months that that is
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the year two years out things that's right if we changed a lot of people know about
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so i don't think that's good if you don't get while this was getting much more on
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economics uh that they got wanted to take a look take a peek in there okay
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so second case is a forty two year old lady she's a lawyer
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yeah she fell on her wrists six weeks ago was playing tennis she
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has been raised an extreme for share half was was was normal
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ah no evidence of any bony injury or by spaces
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let's go for the night um and be she did have a number i scanned before in fact she i was referred
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and uh be amorous kind has has the radiologist described that partial
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interest substance tear someone asked mike first how you've managed s.
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the m. in use by taking sarah a tremendous lawyers so actually would
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like to back that up with the other case only typing forward
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so it might be that this uh this in the healing
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of the second restraints and the patient maybe symptomatic
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so i'll be trying to might become a cinematic so which one going on up the first and then
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just see how she gets on of the next few months so how long you know wait
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white at least another six eight ten weeks some with the end of season proving that pfizer p. just holding you know
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do anything and and what are you gonna do a splint or rehab or a doctor we know what kind of
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so uh tend to give them a removable splint likeable crisply and uh
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often send a therapist we've got good therapist in inner city
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and uh we would be manager down throws it is a good is actually with discussions so that that throws
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teens to enable most of the motion to go through the mid cap joints as
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protecting the sky blue so i think that would be a good recommendation
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well for so you're just you're just keep yeah not more money right some physical therapy for a
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while just what is your fancy operation go to forty covers 'cause back it is it
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with product so so so that that's the question if if she then three months down the
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line you then operating on or if you have to justify to this to this lawyer
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you've just lost all this time so you you happy with your comfortable with that part yeah
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so i mean it's it's part of a consent process yeah it's uh and and you're right we was was gonna keep
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lines kind so ah i would all be trying with this scenario to just go a little bit longer yeah so
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you know that you know most x. a. s. r. let's hear it i would i i think that's the
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perfect one for the scope was they got i think you're still in that window you're very close
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without posted this go to so we've got a a a a a
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i consulted radiologist to is an expert in m. r. i.
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says this is a possible tear yeah okay um ross go um
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yeah so an office go and uh it she's a lawyer
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there is a risk obviously of complications from your office go so
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i've never injury tendon injury hopefully not see up yes
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so you're happy to to say to this lawyer that this is the way forward you we we must have a look inside
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well this is like rated either it's cassettes part part of the
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business that would work but yours can direct patiently while yep
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i would say obvious look that on the other hand out or must i don't think it's a chronic
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injury okay keep insert them back out probably i'll to get to meet our guest aggressive saying
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that's got us exactly where your and if you scope and it's a partial to air
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are you gonna do anything in terms of instrumentation or yeah so it if it's say
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oh i can if it's if it's just stretched here about probably put
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it below thermos wreckage i think that works very well the rest
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well before you get more of a a great preacher started gap that i'll probably put it put
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a scroll cross or maybe a little brighter so possibly for this lady the partial to
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thermal shrinkage person metalworking knows what yep okay any comments
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i don't think you can make a call to fall assessment of an m.
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around for minimise kind of uh to handle probably knows the members portion
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the orange cats only one point five millimetres you can nice to see if you
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could say and i think that what is under reported all of it
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they never actually useful tool so so child shall we is there any pointed
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well we may pick up other injuries besides potential stay for the night
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yeah i'm sorry my fucking mind and it i i just got off so i've so actually what what reading is which of escaping
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all of these potential potentially i think they're under reported i don't think you can sense any other comments before the next case
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yeah so yeah that's a good idea i would manage this patient yeah initially
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conservatively with rehab splints age and then review um hot show of hands
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okay i'm a i'm a i'm who would um get this patient i'm signed up
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um let them know their their uh their uh operating charges and get him in fit into an office party
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okay so i have to just one other question who woods to have said
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it was around wrist yeah that's a good idea so you who's gonna
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but the number out right down via a fifty eight percent well but
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so i run so that's interesting isn't it sorry well
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really that was fifty fifty in terms of what we do say that's
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why this um this uh this subject is so fascinating and challenging
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okay case what to do for uh the the way we with her conservative management yeah initially and
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she settled but anyway but but that's not yeah we don't know that that point so
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so case number three fifty two years old right handed mountain bike a lot
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of mountain biking no pain at all mild pain on wind surfing
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swelling for ah yeah mild swelling can recall no history of troll
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or went to see local a doctor who um a third
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total patient that you are you gonna get indian buffet for animal rights kind of query gangly
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okay so these are the i'm alright scans um so no pain
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fifty two years old very active
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mild swelling rack and how would be out i'm a conservative go he
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might be a trying to hold off she she doesn't really have a problem should for the but if everybody
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can you you happy to just i'm sure was what you can see let's go
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to the the skins show quite cryptic the image on the top right
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the the the white don't i stay says there's an eyeball motion of this covenant looking on
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the top left and the sky put in a lot of flexion is the d. c.
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so it's it's a it's a great it's it goes the grateful
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oh for what is it what what the six six anyway so it's definitely brought up the
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um the problem is the the the treatments a or a or a best of a
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it's it's even let you put a flame thrower using people will this is
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to to do the reconstructions or a or a more complex so if you do say
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do you can really bring bring a back you can reduce the range of motion
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so i it she's not that symptomatic arbitrarily just hold off and so um so uh professor
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bane of i got a chance of arthritis if you don't do anything yes so
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so you don't know what do you have a chance about protestants is very well described in the foreman for sky
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forward fractures it's probably not as well defined for a scuffle instability but yes she has good chance about process
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but i think she's a hard if you do the surgery i'd much we can
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make a massive change to the states this is not an acute injury
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and um if you if i was really keen to have the operation because i
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don't want any chance of arthritis can you guarantee to me after your operation
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um but i will not have arthritis no no you can't so you need to get you get a chance
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i in fact those questions a good in the consulting room because he announces uh was very clear
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and my prick 'cause i'm sure with the simon was given the very direct answer never shipped those questions as
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was based to give them a direct answer so so essentially your indication to doing the series but
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i know that she's got no pine and she's functional
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so if i did this surgery in the x. rays look like that and should not trying to be sort of accepting of that
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i mean this is this is a case you show so far alright yeah i mean
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this is i think we agree alright so you're not you're not gonna touch it
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no i mean all i you appreciate it should have decreased motion a potentially but i don't
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think i don't think it helps label how many many people would operate on these guys
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not many very few
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okay alright it was your mother low there
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yeah
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any any comments yes uh huh
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yeah
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i had a similar case it was really a forty two year old
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as well lawyer two years old lady injury tennis play and
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when only i saw that highways she didn't have a clue history
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drawn when i go when they were little powerful swing crystals
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all along
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and sue point was
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the for more people to be sure that this is probably a room to watch precondition
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that i'm seeing barrier the whole um i don't know with anyone else's home
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okay yeah
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i'd like to comment on it i think the the power of phosphate condition
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we we and the rest of my uh it's it's important clinical phenomenon
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most patients are like yours that i just have this set that apply
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in the swirling another okay but there's some patients to come in
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we're it's really florida that i thought the marvellous of the rheumatoid arthritis or even the septic arthritis
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and so for those patients of manage them with the uh the product probably i first got big
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and make them actually get a definitive diagnosis but didn't always know that before hand
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and the classic changes of the castle location in the triangle fabric college and these
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s. picks uh you don't always say that the taken the key prize
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and that one thing really wanna say is that when you do the departments just trying to get rid
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of most of it don't sit there and try to get rid of the every bit of blind
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and when you do that if you need to do limited wrist fusion turbines actually very soft a whole list is hard to remake
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and so that your internal fixation you played c. screws it's not the simpler but
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it's not the same procedures if they got the gender poster throats okay um
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while we're on that subject what are your preferred partial refusing to have both of you at the moment
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i'm i'm why well i mean what the what we're talking about about a slack rest
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uh i'm i'm i'm before quarter for one yeah i i've got everything
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from from the staples of the plates to the headers grows
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i think ooh i think i had all these complications with the had the screws up i
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think with particular views of soccer plague in noise loose about rotational than it seems every
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time like i keep my rotation better which would look like they love to why do
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you need to fuse the um try creature mannheim right can you not just fuse
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decapitation look and illuminating be happy with that yeah i think that's a that's
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a i mean you have a very controversial question yeah yeah yeah
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that's my job yeah yeah go back and forth on that i think there's one standard sheriff just the other than a capping clinic
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but for the more pressure on the regular like fossil uh but i i i go back and forth on
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um i've i've uh strongly on this uh i think you just take the truck which i met so if you take the try
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creature met you download a it on to the owner column so
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you get less hong sort of complications it's an experience
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then simple mechanical studies will detect the truck which amount
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increases your range of extension and i wanna deviation
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in a clinical series we had um a modest improvement
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but wasn't significantly different from statistical point of view
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but we take the truck which minutes the base paragraph we get rid
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of the problem of infringement in complexion onus on the campus
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it's it's not a harder operation i just to be clear your fusing the
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balloon it kept i take a truck which might using that graph
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in between the two of us and so we um a lot of people would do the um
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the uh learn i take appetite grafting but what we can to try and is microphone just to write become one
00:19:00
a condo if you like remove the articulation it'd been drafting and then
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just make sure it's balanced the realities of at the top one
00:19:08
learn it tends to the limit teens the lawn and many with a camper trying to talk to it sits in the middle
00:19:14
we tend to use titles but i know that the state was can
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be technically demanding some other surgeons might have difficulty with it
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but i agree with will with that the ring plates it's the normal plate they the results are
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actually people is a high complication right and he's right they just sort of almost closed down
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the phone what is it the patient when they walk in the
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i smell like yes they smell of cigarettes had done didn't
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yeah yeah yeah that's right so people just that don't lead directly to men don't like it this little girl feasible
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so so what what you what we're saying here with kind of agreeing
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yeah it actually aim for lou nate stick appetite to ham it
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yes i can do what you want with a truck which are okay but they even in
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trial had a piper and we have a great respect in trial and and the group
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yeah but if you have a look at these series you know there are slight complication rain
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even at the end of it right that maybe we should take the truck we command
00:20:09
and we we know that they uh are good clinically doing good work so i don't think we should take is a bonus
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okay great so case um case in the full twenty two euro right handed
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a rugby player um a head injury ten months ago
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still playing rugby some i. e. it might be
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normal activities of daily living uh uh not much pain
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uh on examination found that them both a wrist hundreds
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were quite lax in turn the range of motion
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so these are his x. rays um that's the actual
00:20:52
yeah views no not really particularly unhelpful in terms of no real busy or
00:20:58
um does it deformity saying and that's the clenched fist use on both sides
00:21:03
so i'm sorry statement comments on 'em payment playing rugby so
00:21:10
what would be what would you do for this
00:21:15
i dunno was gonna ditch um i'd actually the uh it it it depends but
00:21:20
is right the situation surveys in season probably definitely talking that late into the into the season
00:21:26
i think we need to have an understanding of way he wants to go this creosote is a professional go i
00:21:31
i'm in east understand if we do the surgery it is this complications it's really gonna back him off
00:21:36
but if he's if he's a professional level any wants to keep going and he's okay then maybe later
00:21:42
but 'cause if you describe the the broad men or the radio frequency
00:21:47
i don't think that's gonna do anything you've either got to reconstruction
00:21:51
for doing nothing i think in so that that they need to be long discussion on this point
00:21:55
but it if he's if he's concerned about that i have a mind of doing it
00:21:59
the other thing i'm not sure of events picked up you look at the limit truck which will that's why does will
00:22:05
so you've the whole plot some cop rose unstable the and on the other wrist this guy from than it is a bit what results
00:22:12
arizona grappling yeah so that might be just physiological for him so
00:22:15
the this this needs more attention to the data that's um
00:22:20
okay and so if you're going to do reconstruction it would be the one that
00:22:24
you've described what kind of um a range of motion and strengthen unit
00:22:29
offer him in terms of getting back to what be so i think like a
00:22:33
more exact numbers but probably seventy five percent strength or something maybe seventy percent
00:22:38
and they're probably seventy percent range of motion so
00:22:42
they're not spectacular numbers but this table wrists
00:22:46
but i think one one thing is when when when you look at a later date is so or translated
00:22:52
well but there's not much any real operations can do that really work successfully get that much translation
00:22:59
with yours but but uh the it and um but the thing is simple
00:23:02
and what not gas you lost a whole lot says and um
00:23:06
definitely not directly to that is not null it's uh that is definitely something going on with this first
00:23:12
what would you be offering him a well in terms of a procedure
00:23:16
uh so if well first bought out by still apart tribe in dialogue on this guy one
00:23:25
a few still play rugby but we generally do uh when you
00:23:28
talk about being waxy somebody better very possible buttons or or
00:23:32
yes i'm popping out i'm only affected side yeah a girl you know
00:23:38
why you have a very big range of motion on the non affected side yeah
00:23:43
so we're dealing with a little bit different which we'll we still like buildings are
00:23:47
all uh ten transferred adjustable skateboard would also capsule basis as that's very simple
00:23:53
uh i think it's worked pretty pretty good or do you wanna just takes to score that so you you realise it from the second
00:24:00
yeah a couple put into that build it into several yeah so you it's it's a dynamic transferred packets go for it up
00:24:07
oh i'm genetic office on a minute short apple but at least make make
00:24:11
attention correct on on the on the transfer initiate web server push like
00:24:14
a or whatever to transferred in that we've been it's simple software back
00:24:19
and it works pretty good okay any comments or questions on this
00:24:32
okay so um thank you everybody um that was a great session um are
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