0:00

So now let's go on to our next case, uh, which is his

0:05

follow-up exam that we performed as a result of this debate

0:09

between the Midwest

0:11

and the East Coast, where the Midwest usually wins,

0:13

even though we're we're flyover country.

0:16

And I want to share with you what we did.

0:19

Now, you saw, uh, Dr.

0:22

Resnick's, you saw Don's fever position.

0:25

You've got some other positions too.

0:26

You've got the arm over the head for, for the biceps.

0:30

And you've also got the Mickey Mouse position

0:32

where you're lying prone.

0:34

And the arm is in the center of the magnet bore.

0:36

And I hope you, you can see me on, on the video.

0:40

The problem with that is you've gotta be pretty nimble

0:42

and pretty young to stay in that position

0:45

for any period of time.

0:46

Fortunately, he was 29 years old and he was able to do so.

0:51

And then we dropped our microscopy coil, uh,

0:55

which which was our, um, a coil that we use

0:59

for the TMJ.

1:00

And we do this routinely, uh, when we have

1:03

to get microscopic.

1:04

We got about 90 microns of in plain resolution.

1:08

Uh, noteworthy is the fact

1:11

that we didn't inject a joint first.

1:12

We didn't need to. Second, we don't like to.

1:16

And third, the team didn't like us to, nor did he want.

1:20

Uh, most of these athletes are pretty twitchy.

1:22

They're very protective as they should be, uh, of, of their,

1:26

uh, orthopedic anatomy.

1:27

So they don't like to get injections.

1:30

And here is a magnified view of the UCL.

1:33

Now, the UCL anterior bundle,

1:36

the major stabilizer is fan shaped,

1:39

as you saw in Don's elegant talk.

1:41

And it'll have some ill-defined signal.

1:44

'cause it's flatter, it's less compact.

1:47

And as you come down, it tapers

1:49

and that tapering should be very consistent.

1:51

In other words, it shouldn't get irregular as you come down

1:54

and right there you can see some subtle irregularity.

1:57

Let me take my, my, um, arrow away and you can see it.

2:01

Let, let, let's let you stare at it for a few moments.

2:04

And yes, the flexor digitorum superficialis upon miosis

2:08

layer number one is affected.

2:11

Layer number two, the anterior bundle of the, uh, UCL,

2:16

uh, or medial collateral ligament is affected.

2:20

Uh, the capsule is a little bit swollen,

2:23

and we do have a recess that's too long

2:28

or too deep for a 29-year-old performance athlete.

2:32

Uh, usually I'll see something that

2:34

that ends about here or nothing at all.

2:37

So you have to look at these, uh, three

2:39

and a half millimeters is the number that's used.

2:42

But in a, in a performance athlete who's under age 30,

2:45

I'll allow a millimeter and no more.

2:48

And I don't want to see associated findings with it.

2:51

So then the, the question arose, okay,

2:53

we've got three abnormalities.

2:55

The conclusion read partial thickness, distal tear

2:58

of the substance of the anterior bundle of the UCL layer.

3:03

Number one, sprain of the flexor digitorum, superficialis

3:08

pons, and a stripping injury of the distal UCL.

3:12

That was the conclusion. 1, 2, 3.

3:15

And I know some of you have asked for that.

3:17

So now, what's a mother to do?

3:20

Do you operate on this and do a docking procedure

3:23

and replace the UCL or do you wait in a football player?

3:28

Those of us that deal with this type, these types

3:31

of athletes, uh, without retraction, we wait.

3:35

Now in New York, they were very aggressive.

3:37

They wanted to make the replacement.

3:39

And so we sent him to a, an adjudicator in Indianapolis

3:44

for the Indianapolis cults, and they agreed with us.

3:47

We waited, this occurred in November.

3:49

The original injury was in October, September,

3:53

November was this scan.

3:55

By April, he was back to normal.

3:57

By May, he was on the field throwing the ball, 70,

4:00

70 yards down field.

4:02

So this microscopy coil dedicated Mickey Mouse position,

4:07

image was extremely helpful in adjudicating this case

4:11

and coming up with the right answer.

4:13

Don, any comments on this case?

4:15

Well, the, the one thing clearly that I think is very,

4:18

very helpful here.

4:19

First of all, the resolution is beautiful, is the edema

4:22

that's located, uh, particularly superficial.

4:25

Was he pitching in between, uh, his initial

4:29

and follow up or, or not?

4:31

He, he was not. Once he was injured, he,

4:35

he did not proceed with, with any throwing.

4:37

Now, he did throw during the game,

4:39

after the injury, he continued throwing,

4:41

but he wasn't throwing very far.

4:42

I just wonder how long, I mean,

4:44

because I, I think edema is such a friend to, to us,

4:48

you know, you see edema,

4:49

you've gotta start looking in that area.

4:51

And I just wonder how long that sort of

4:55

bind would persist if he were no longer.

4:58

Do you have any idea about that

5:00

Or, I don't know the answer to that, but you

5:02

and I both know, we've seen edema persist for months,

5:04

sometimes even years in the skeleton and per skeletal area.

5:09

So the absence of edema I found to be very helpful.

5:12

The presence of edema not so helpful in terms of timing, uh,

5:16

but it certainly directs you to an area of abnormality

5:20

and helps you quite a bit.

5:21

And then the other quick comment I would make on this,

5:24

and I I I emphasize it again, that in the young person that

5:30

the cleft

5:31

or recess should, you know, it can go to the level

5:34

of cartilage and to the subc chondral bone plate,

5:37

but once it goes below the level

5:39

of the subc chondral bone plate is shown here in a young

5:43

person, that's not going to be, uh, a normal finding.

5:46

And as, as Don indicated, you have

5:48

to take everything in context.

5:49

You know, when you're dealing with somebody that's older,

5:52

you're more likely to have stripping degeneration, CPPD.

5:57

But when you're dealing with a 20-year-old

5:59

or a 29-year-old, things should appear pretty clean to you.

6:03

Uh, shall we move on to the next case?

6:04

Yeah, yeah, let's do it.