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A-1156 Assessment and Investigation
Michael Solomons, South Africa
Friday, June 15, 2018 · 8:23 a.m. · 13m 13s
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00:00:00
only in thank you so uh i really enjoyed that talk to alex and i agree with many things but lack a or less resurgence
00:00:06
we uh green something's and disagree in other things but uh there's a lot of uh a crossover not talks
00:00:12
so we can as river this morning it's a difficult area on the side respond
00:00:16
uh but i'm hoping to show you that it's maybe not as difficult uh in uh
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may in decision making an algorithmic thinking as you uh uh might expect so
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alex gave us a list i think of twenty nine courses and i'm sure the even more
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uh but in my opinion and these are the the the the group that we
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think about every day when we see a only started respect not left off
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we could have made fractures an uplift all for track we prefer to the many things of
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leftovers less but this isn't a database when you see that pace with only some respect
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this is the last in your mind that you thinking what does the uh are common problem so let's just go through it
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so marketing and uh we had a great talk a um a little bit on the d. o. j.
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i think if you look at the or you just you have to separate pain
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instability i think pain in my opinion is pretty easy and pretty obvious
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uh when you do you see that patient with obvious offices or even if your choices
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you can do the screen is test you can rotate them and the loading a and you can do the pinocchio
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share taste than usual to pick up the d. r. u. j. pains i don't think that's a difficult one
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instability can be problematic you get the obvious post traumatic this
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is a young rugby player does together these uh
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a a joint and end up with a gross instability but has
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a very obvious uh and as usual major traumatic event
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the difficult one is the cycle instability like uh we saw um and i lectured as well
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where you got this patient whose and stable and it's only slightly different other side
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and really fall than the realm of the t. f. c. c. and i'll i'll probably come back to that a little bit later don't wanna spend too much time on that
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so that's the dior huge i dealt with in terms of the a quick uh decision making
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what about you see you others we had to uh disagree with alex and also disagree with my colleague remarking
00:01:57
that shouldn't we having breakfast together i think is you did not this is reported as common but
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have a big respect this and i'll look for it all the time and have very seldom find true you see you tonight is
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when you do see it it's obvious there's a nice a sausage shaped uh uh easy to not as i
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probably stay senate and everything seems to be positive when you saw examine on the side of the rest
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so i think ten an artist and select section that's the group of the tennis players
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when you see it it's very obvious but once again i look for all the time and uh very seldom find it
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so i'm not convinced that easy to not this is that common there's a patient at the same to me is the uh
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it robert in more ah m. are also the only non union nurture the t. f. c. k. and easy to matters
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and it was seen by another doctor it was before scoping department came to me for a second opinion
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how does it um i think you know problem is easy to not the second with the non union went in this role one of cinnamon incision to
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got a nonunion the broader the easy which is obviously somebody because of it
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of course and at the end some uh marker to isn't it
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and this patients back then right be a three weeks so i think when you see when
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you say it is pretty obvious but i think it's actually very uncommon that's my opinion
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so uh that's easier dealt with if he cannot is i think it's very uncommon but when you
00:03:11
do see it it's fairly obvious it presents almost like an infection you get the red heart
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only technical subject tonight is and the to it almost looks like an infection when you see that too if see you tonight is
00:03:22
and a few diagnosing it more than a couple times a year and it's not that obvious i think you need to be questioning with the making the right call
00:03:29
part of what we do with it a extent uh it's a pretty easy diagnosis to mike
00:03:33
and it's very obvious when you do see that patient it's not a difficult one
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so uh that really is the new net united talk little joint only interactions in rome and then the t. f. c.
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so uh there's a patient with plaza truck whittle away once again fairly obvious you do
00:03:49
the grand uh the grand and the and this and the uh uh push test
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and it's a straight for darkness if you really wanna be sure you can maybe inject the positron
00:03:57
crucial joint with cortisone and see that patient gets a a medium uh and short term response
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uh only impassioned syndrome relatively straightforward you do the uh granted you force them into only
00:04:08
deviation with without presentations stipulation unusual had pain in in rage all the deviation
00:04:14
you can confirm the next train if you got any don't you can do in a more ah in almost always see the changes in
00:04:19
the uh only hit all in the uh uh on the corner of the loo night so it's a fairly easy diagnosis to my
00:04:27
i'll be honest the limited what we truly meant to me is the real black box of
00:04:31
uh of on the side wrist problems and even at this meeting up into a
00:04:34
lot of only thought it was talks and no one talks about only not to talk
00:04:38
with the joint in any form of a a definite of uh uh statements
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ah i'm a cell phone and show the clinical relevance you know it's like you see this patient sometimes only find out about when you discover
00:04:49
when you don't open procedure you see the united talked not the united truck which only comment is gone and the some condom malaysia
00:04:56
and you never quite sure how relevant or irrelevant that actually is we know that we get the test the block contest you
00:05:01
you basically whole the party foreman the a truck region and the lunatic new shit in a relative to each other
00:05:08
all block them you can squeeze them from side to side and it'll tell you that there's something going on the l.
00:05:13
t. ligament but you're never quite sure what it means because all that is a very sensitive but they probably specific
00:05:18
so everything will be painful but you never quite know what you what you examining so i'm gonna be the first to admit
00:05:23
i really don't know much about the network which really meant and when to bring it into the the treatment algorithm
00:05:29
so uh this is put that aside for the moment and as i say you can see it on a more ah you can see it on this got it's a
00:05:34
difficult injection test because i it's the little joint injecting be pet quarters and all that
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what injecting is going to hold joint and really nullify everything that is painful
00:05:45
so that hopefully excludes most of the problems uh on this list but it does
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leave us with the uh problematic t. v. c. c. which are um
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as we hit is the number one cause and the the most likely corporate uh all problems
00:05:58
on the on the side of the so this is the classification bop on that
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um and we all know it uh but you know i think it's uh some accomplice got a categorise
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about all categories so complex to degree i'd like to do because principle keep it simple stupid
00:06:13
for me this is the most common cause almost all the spine and
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uh the literature will tell you it's pain on production p. p.
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i think it's more painful on super nation but uh you need to test in both directions
00:06:25
but most importantly this exquisite ten ten in this in the on the snuff box
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does the uh is the diagnostic a test that you need to be doing so in the neutral position
00:06:33
you push hard in that uh on the snuff box all the all the focus on you can call it was remember what you call it
00:06:39
but it's between f. c. u. in the easy you directly of the only it and you push hard and then compared to other side it's a painful spot
00:06:45
we did you solve it slightly tended and it was placed a pain in that's part and
00:06:50
uh planes you can see this is one of my patients just to show the uh
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uh the examination so it'll push dorsal e. not that painful so that was the teaching to push dorsey but it's
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very seldom painfully you push them in the all the snuff box and push your quality c. doesn't like it
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and then if you got in principle nation compared to the other side it's it's really painful
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and uh
00:07:16
okay now and what is in this about the um the good looking women in south africa
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but uh you can see tennis in the uh snuff box again really doesn't enjoy that and then in range connection
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is slightly painful but if you see me to take them into in rejuvenation the really don't like it
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so what is the common older than that we all get total older she'll tell us
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you get a place on the side of her spine usually have an x-ray
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you spent the rest in eventually someone has had enough and that weren't and more ah with without an altar graham
00:07:48
and then eventually someone froze in the scope and has a look around so that's the the common algorithm
00:07:53
and just to show you study that we did not gonna go into much detail about the stable but
00:07:57
it was a daughter base of a call a a smorgasbord of patients but we want to just look at the t.
00:08:02
f. c. patients only and really all that the response to intro tequila quotas and to see how well they did
00:08:08
so with sixty three patients as you can see minimum payment in red carnation and
00:08:14
super nation but more them on isolated stupid action only then per nation
00:08:19
um so the mixed group young age group you issue related to an activity
00:08:23
profile a with a fairly substantial delay uh the whole injected and um
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question might also what about it more ah so you can see in the series only ate
00:08:33
at a more ah and there's a long list of you or the more on what
00:08:36
they found you can see it's a complete mess and it's a very confusing picture of what
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the tape see what am or ah show them how helped us in the algorithm
00:08:46
and that's not surprising because if you look at the study by battery in the general pensive american to twelve
00:08:52
he took a hundred and three a symptomatic volunteers i think that we're medical students and put them in
00:08:56
the amorous can and then sent those amorous to a blinded radiologist any young patients with no symptoms
00:09:04
thirty nine had a comp uh additives instead of which twenty three it's twenty three
00:09:08
percent of all patients in the study at a complete tail that you see
00:09:12
so how can you read anything and we know that other studies by hems and shall shout very put
00:09:17
sensitivity in spaces specificity and accuracy of a more and that's exact what alex was saying as well
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done the done right to have your name or ah it can get you out of trouble because you get into a lot of trouble as well
00:09:28
and this is supported by this is a study but i would ring with a
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show that in i symptomatic patients fifteen percent of patients and it under the
00:09:35
age of thirty whatever t. f. c. k. and once you get up to
00:09:38
over seventy it's around fifty percent and the the study borrow it all
00:09:43
look it's symptomatic all this other kind was a symptomatic and there's i guess subtle difference
00:09:47
in the a a degree of a positive seat is in these two groups
00:09:52
so are you only do anymore out when the part when i get a strong sense that i only to be sure about
00:09:57
something or the patient is the most common is the patience is all want anymore ah and i that than the
00:10:02
the google research and they the they know they're more articles then i wanted and i can everybody now
00:10:07
unit it's about five hundred dot uh euros for the patient to pay to get any more on
00:10:13
so this is just to show you that reject them all most patients anyone ejection some people need to once you start
00:10:18
injecting three or four times you probably hitting on them the the the uh the the line of uh ultimately failing
00:10:25
and uh you can see generally but i did the undo all the brinkley
00:10:28
but most of them are in a hundred percent all pretty a
00:10:31
cinematic and they can just live with a little bit of discomfort uh the occasional twinge et cetera so it's in the eighty plus percent
00:10:39
so it not martin and i think a cure tentative sees a clinical diagnosis
00:10:43
can be confronted made and separated from other cause on some
00:10:46
respect and you don't need frontline heartache expensive investigations
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we use it in particular course an ejection it's a great diagnostic tool and it's an effective treatment option
00:10:56
and only in the river into failure should even consider open office topic uh uh management
00:11:02
so back to the uh the last uh we say that the dried is is pretty easy and obvious that
00:11:07
he sees uncommon in my opinion it's use and common and easy the particle joint is easy and obvious
00:11:13
we've gone through the later truck we told all interactions alum and really we just get left with this the the
00:11:19
the the real issue which the t. c. n. r. unit the management of a. t. c. paint uh is
00:11:24
a patient on the stuff pops a tennis and
00:11:27
painted in range production and stipulation voice information
00:11:31
pain we inject them all a ninety percent we think will settle and those that don't
00:11:36
we get an m. r. ah and then to see just even if you choose to do that open office topic that you'll that you'll call
00:11:42
um so everybody's normally given you what about risk of us could be it doesn't it talk about investigation
00:11:48
well i think they will say in the this token assessment investigation i think it's important appreciate
00:11:54
but the scope is not an investigation button intervention if both expensive
00:11:59
it's in place of and the complications of using it as in the investigation
00:12:03
uh i think obviously thinking wrong it's an intervention to modern investigation to
00:12:08
and this is supported by david rings group uh as well showing that
00:12:12
really had limited diagnostic benefit uh when you just doing diagnostic with also restore first before nonspecific plane
00:12:18
obviously this is not monsters we planed it's uh on the side of pain but i think it's really it it is a difficult to be sure
00:12:25
and we we sold the uh from the uh front back instability test
00:12:30
um this is the whole can test the bookcase in the trampling taste and its uses that
00:12:34
as a gold standard test for d. r. u. j. instability in t. c. taste
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sorry i mean forty us it is and it is disturbing call subjective and just decisions they all
00:12:43
say that that's gotta be the biggest understatement since no looked up until it looks like right
00:12:48
you know you see people do you notice and i say well that's possible that's negative i don't know how to make that decision
00:12:54
so this is once again ah out of them um and so we inject
00:12:57
them all we prefer the small needle uh that's full of course and
00:13:01
rather than the big needle which is connected to t. v. monitor and uh and times and all
Conference Program
A-1153 Introduction
David Shewring, UK
June 15, 2018 · 8:01 a.m.
A-1154 Anatomy of the Distal Radioulnar Joint and Ulnocarpal Complex
Elisabet Hagert, Stockholm, Sweden
June 15, 2018 · 8:01 a.m.
284 views
A-1155 The Common Culprits (start)
Alex Lluch, Barcelona, Spain
June 15, 2018 · 8:11 a.m.
155 views
A-1155 The Common Culprits (main)
June 15, 2018 · 8:13 a.m.
138 views
A-1156 Assessment and Investigation
Michael Solomons, South Africa
June 15, 2018 · 8:23 a.m.
126 views
