0:01

So, which, which case would you like to, uh, discuss?

0:04

Um, Or cases I'm at your disposal?

0:08

I've gotta just refresh my memory. Memory.

0:11

It's weeks nine and 10. Is it?

0:13

Yeah. So basically week nine was, um,

0:17

the ankle region, if you remember.

0:21

Yeah. Um,

0:24

There was the, uh, there was the synovial proliferation

0:28

case, which turned out to be, uh, PVNS or form.

0:33

Yeah, I took that artist, formerly known as PV NS. Yeah.

0:36

We had that, uh, neuroma

0:38

or that little mass in the tarsal tunnel.

0:40

Uh, a couple of ankle sprains and the lisfranc.

0:43

Yeah. Um, I mean, we can go

0:47

through several of them.

0:49

I think the, okay.

0:52

The tarsal tunnel is, you know, I, I watched some

0:55

of the videos or all of them of, um, Dr.

1:00

Rad and, you know, he, he summarized the,

1:03

the nerves pretty well.

1:05

Um, I've got some notes on that, but you know,

1:08

unless you're using it day in

1:09

and day out, you, you kind of get rusty on it.

1:13

But maybe if you want to go through some

1:15

of the nerves in there and

1:17

Yeah, yeah, sure, sure. Of

1:18

Course. I think some

1:19

more people have joined.

1:25

Okay. I think Raj has joined it.

1:32

Well, Dr. Yawar. Hello.

1:36

So we'll just go, we'll go over, I guess the, the first one.

1:40

Yeah. Um, uh, uh, which was,

1:44

or sorry, the second case of week nine, which, uh,

1:48

was the Tarsal tunnel case.

1:50

And Dr.

1:52

Schulman just asked just to go over some of the anatomy.

1:57

Um, so I guess this, here, hold on.

2:01

Let's see. What's the best sequence here?

2:07

What is the best sequence?

2:09

All right, so I, I, I guess let's just pull up a nice T one

2:11

just for, for anatomy's sake.

2:14

Um, so, so this, as you can see, obviously an axial sort of,

2:18

um, you know, just based off the localizers, we can see

2:23

that the, the patients sort of, uh,

2:26

plant or flex for us.

2:28

So, so that's kind of nice.

2:29

So the, the, uh, axials that were attained are essentially,

2:34

you know, whatever you guys, uh,

2:36

whatever you gentlemen call a coronal

2:38

or an axial oblique, I guess, through the, uh,

2:40

perineal tendons.

2:41

So, um, with that said, so this sort

2:46

of axial or axial bleak

2:48

or cornal bleak slash per perineal tendon sort

2:52

of, uh, sequence.

2:54

Um, in general, um, if you, you know, going back to,

2:59

um, some of my talks that are recorded by Dr.

3:02

P, um, I, I, I tend to, the way I, I approach,

3:08

uh, all joints, uh, I guess lemme say, yeah, so,

3:11

so the way I approach all joints, I tend, I'm,

3:13

I'm a structural person.

3:15

Um, so I tend to break it up into broad categories.

3:19

I do ligaments, tendons, joints, ancillary stuffs

3:23

to the joint or that respective joints, soft tissues,

3:26

muscles, bone, morphology, marrow signal.

3:29

So that's my checklist in general.

3:31

And, and that's how I sort of my, and also my search pattern

3:33

and my dictation, uh, sequence.

3:36

Uh, I will reorder it. I don't use templated reporting.

3:40

Um, I, I, I tend to just dictate, uh, to try

3:45

to answer the question for my clinical colleagues.

3:49

And, um, and then I sort of order it based on, uh,

3:53

importance or what,

3:55

what I think is the pain generator while it's answering the,

3:58

the clinical question.

4:00

So, extrapolating that checklist, ligaments wise, uh,

4:04

I'll do the syndesmotic ligaments, you know, as, as you can,

4:07

as we know, consists of the anterior interosseous

4:11

and then posterior, uh, tib fib ligaments.

4:15

Then, uh, I'll go down lower, um,

4:19

and I'll check out the low lateral ligaments complexes, uh,

4:22

both laterally

4:24

and then medially, uh, uh, deep and superficial.

4:29

And then, uh, going along

4:30

with the one along in one quick scroll,

4:34

I'll jump right into the spring.

4:36

Ligament is complex.

4:38

And then finally, the, uh, the, uh,

4:42

the Li Frank Ligaments interosseous,

4:45

I'll be paying the most attention to dorsal.

4:48

Sometimes I get lucky, we see.

4:50

And then the plantar, um, if you read some articles,

4:55

some people will say the hold is frank ligament complex is,

4:58

they'll consider it the whole tarsal metatarsal joints,

5:01

like one through five.

5:03

But those are the, probably the three

5:05

or four main parts that I, I try to look for,

5:07

particularly the intraosseous

5:09

and the plantar, uh, Liz Frank.

5:12

Um, but, uh, difficult,

5:16

slightly difficult to parse out here, but, uh, um,

5:19

because of the sort of obliquity and,

5:22

and the plantar flexion of this patient's foot.

5:25

But while I'm here at the Liz Frank,

5:27

I'll scroll back up on the tendons now,

5:30

next on my checklist, I'll go anterior extensors

5:33

and glance at the Achilles at the same time,

5:36

and then I'll do the medial flexors.

5:40

And finally, o on my tendons, I'll do the, uh,

5:43

the perineal twins, um,

5:45

making sure there's no tear morphology

5:48

or signal abnormalities.

5:49

And at the same time, make sure they're located

5:52

where they should be.

5:53

No subluxation

5:55

or dislocations, particularly of the, uh, PTT

5:59

and the, uh, peroneal twins.

6:02

Next on my checklist, I'll do the joints.

6:05

And here, um, I tend to use a sag.

6:08

And here I, I'm, I'm just looking for overall alignment,

6:11

looking for coalitions, fusions, erosions, uh, trying to do

6:16

that efficiently all at the same time.

6:19

And then my next would be the Taylor Dome.

6:23

And I'd like a nice sort of T two weighted sequence

6:26

or something to that equivalent, just looking

6:29

for any osteochondral injuries or o uh, dessicans

6:33

or whatever terms, injuries, lesions, whatever term you use.

6:38

I, uh, I debate here at my institution, we don't like

6:43

to use the term lesion

6:44

because lesion can also mean like a neoplasm,

6:47

and it's sort of broader category.

6:49

So I, I tend to use, uh, osteochondral injury

6:53

or defect or, or, uh, uh, with, with

6:57

or without subcon, uh, bone plate changes, cystic change,

7:01

what have you, then getting into the ancillary

7:05

stuff for this joint.

7:07

And, uh, next on the checklist, um,

7:11

I'll check first the tarsal tunnel.

7:13

So to answer your question, Dr.

7:15

Schumann in a long, uh, uh, roundabout

7:18

or long-winded answer.

7:20

So I'll pick up the tibial nerve,

7:23

which is this structure right here,

7:25

tibial neurovascular bundle, right here, tarsal tunnel.

7:28

The fibro osseous tunnel, which the roof is formed

7:31

by the flexor reticulum,

7:33

and then going all the way down along the tibia.

7:38

S and then down to about the cal, about the calcaneus, right

7:42

around here at the suum tail are the nurses made or,

7:45

or the nurse's elbow.

7:47

And what I'm just looking for is I, I'll just trace out,

7:51

uh, the tibial nerve.

7:52

This structure right here, uh,

7:55

hopefully you can see my cross hairs.

7:57

And we see

7:58

that lesion come pop up right here at about the level

8:03

of the calcan body.

8:05

Now it's about around here that the tibial nerve, and,

8:10

and we can sort of hallucinate it, branching off

8:15

into its medial

8:17

and lateral plantar components, plantar nerves,

8:20

that is okay.

8:22

And then the medial component will run sort

8:27

of right here in between the abductor hal

8:31

and the quadras plante,

8:33

and the flexor digitorum brevis, whilst the

8:38

lateral plantar nerve will sort of shoot in between the quad

8:43

plante and the FDB

8:46

to run closer towards the abductor digiti MiniMe.

8:51

And then run down the, the, uh, lateral aspect of the, uh,

8:56

plant lateral aspect of the foot.

8:58

So probably one

9:02

of these little dots right here is probably the lateral

9:06

plantar right there.

9:08

And then while I'm also here, I'll, I'll make sure,

9:11

you know, there's no, like plantar thrombosis, things like

9:15

that, which can, uh, rarely mimic, um, you know,

9:19

plantar foot pain.

9:20

Make sure that, uh, there's no, uh, you know, loss

9:23

of the flow void or, or,

9:25

or, uh, peri, more importantly for me, I use peral edema.

9:30

And then next on my checklist, uh,

9:34

I do the tarsal tunnel and canal, or AKA, the sinus tarsi.

9:39

I like to use the, uh, I like to run on the T twos fat sets

9:44

or whatever you're running, uh, to make, to look for edema.

9:47

But I also like to glance at the T ones

9:49

because if there's fibrosis,

9:51

obviously within the sinus tarsi, my eyes won't pick

9:55

that up on the T two fat set.

9:56

So I'll use the T ones just to look, make sure

9:59

that there's no fibrosis that's, uh, fooling me, not just,

10:03

uh, you know, edema or a hemorrhage.

10:06

And then wrapping up, I'll do the, uh, plantar fascia. Okay.

10:11

And then there was a couple, just a reminder,

10:13

the central cord comes off the, um, the calcan tuberosity.

10:18

That is the medial process.

10:20

Uh, and then the lateral process is

10:23

where the lateral cord comes off.

10:25

The medial cord comes off more distally off the central cord

10:29

at about the level of, uh, probably like midfoot area,

10:33

probably like around right here.

10:35

Okay. Just as a reminder, anatomy wise.

10:38

So here, okay, so here's the central cord.

10:42

Here's the lateral cords coming off the medial

10:45

and lateral, uh, processes of the, uh,

10:49

calcaneal tuberosity.

10:51

And then coming off more distally.

10:54

We don't get far out enough,

10:57

but this is where the medial, uh, portion

11:01

or the digital bands would come off of the central cord,

11:04

more distally to run towards the toes,

11:08

and then sort of splits

11:10

and then blends with the subcutaneous fat

11:12

and skin sort of imperceptibly.

11:15

And then finally, uh, I'll just run the, uh, muscles

11:20

here, muscles and soft tissues.

11:23

I, I tend to, uh, have my trainees and, and,

11:26

and tell, uh, mo run my eyes looking at all.

11:31

And this is where I start to count the muscles

11:33

and tendons, making sure, you know,

11:36

I don't have a pros corti, which, uh,

11:39

if you're a numbers person,

11:40

you should be calling in about in a, a,

11:43

a quarter of your cases.

11:45

So it'll be like a little, uh, little accessory muscle

11:49

and tendon usually right around here.

11:51

My next check is the accessory, uh, soleus.

11:55

Um, there's typically four

11:57

or five attachments described with the accessory soleus,

12:00

but that should lie superficial to the flexor

12:03

or the ret aum in the back here.

12:06

And then, then the last, uh, muscle i, I, I try to look

12:09

for is the flexor digit digitor accessor longest muscle,

12:13

which typically overlies the tarsal tunnel.

12:16

And that completes our discussion of the tarsal tunnel,

12:18

but it typically lies right there and then runs down

12:22

and sort of blends, uh, typically with the, uh,

12:26

quadratic plant tag or the sus

12:28

and, uh, sort of around this region right there,

12:31

that's its insertion.

12:34

And then finally wrapping up, uh,

12:36

glancing at the soft tissues for any edema

12:39

or pockets of fluid.

12:40

And then I just run the bones for the, uh, uh, uh,

12:44

marrow signal and bone morphology, uh, you know,

12:47

looking again for any fractures or,

12:50

or coalitions, what have you,

12:52

and really don't have that here.

12:55

So, um, so sort of answer your question here, Dr. Schulman.

12:59

So here we have, obviously this, um,

13:03

likely peripheral nerve sheath tumor,

13:04

nerve fibrous schwannoma,

13:06

or whatever terms you use in the tarsal tunnel.

13:09

Uh, and then looking at this, I'll scroll real quickly

13:13

to see if there's any denervation changes at the, uh,

13:17

more distal or planter aspect of the foot.

13:20

Don't really see that here,

13:22

but we could, we could say,

13:23

maybe raise a question if there's a little touch of Baxter.

13:26

If you were, if you were reading this, maybe a touch of, uh,

13:30

fatty atrophy of the superior aspect

13:32

of the abductor digiti MiniMe right here.

13:35

So in theory, if you invoked Baxter, you know,

13:37

raise the possibility of Baxter neuropathy,

13:40

I probably didn't doc, uh, one for that.

13:42

And, you know, that would be a, a nice pick right there.

13:46

And then other nerves you can try to look for at the ankle,

13:50

you can look for the, the, uh, deep, uh, fibular

13:54

or peroneal right there, um,

13:57

before it branches off into its medial

13:59

and lateral components.

14:01

The medial will run towards the first web space

14:06

between the first and second metatarsal heads.

14:09

So that's the so-called anterior tarsal tunnel syndrome.

14:12

Uh, usually right around here, it'll get nicked

14:16

by an osteophyte of, of like the navicular

14:19

or an os inter metatars, right around here.

14:23

So that could, uh, lead to that every once in a while,

14:25

get asked to look for that.

14:27

And then finally, you can also look at the, uh, sal nerve,

14:30

which is on the posterior lateral aspect of the ankle.

14:34

And that divides typically into the more important one.

14:37

Probably the, uh, now you're not, I, at this point,

14:41

I'm usually looking up, uh, anatomy book or what have you,

14:44

but, uh, what is it?

14:46

The dorsal, the dorsal lateral cutaneous nerve

14:49

or something like that, uh, which runs over

14:52

and supplies the lateral sort

14:54

of dorsal lateral aspect of the foot.

14:57

And then the importance of

14:58

that is sometimes when people put, uh,

15:01

the fibular side plates in, they'll, they'll, uh,

15:05

sometimes the, uh, that nerve will get, uh, entangled within

15:08

that, or if there's some peroneal pathology

15:11

or prior, um, surgery, surgery, their L-shaped, uh,

15:16

incision will sort of scar that, uh,

15:18

nerve at the poster lateral aspect

15:20

of the ankle, hind foot region.

15:22

So those are probably the three major nerves.

15:25

And then you can start to get into, you know,

15:28

the superficial and,

15:29

and intermediate peroneal peroneal nerves,

15:33

which usually lie right about, uh, maybe this dot right here

15:37

and maybe that dot right here.

15:39

But that at that point, I'm definitely looking, um, uh,

15:43

I have an anatomy book open

15:45

and, uh, that's, that's typically coming from one of my, um,

15:49

specialist peripheral nerve surgeons or,

15:52

or, uh, orthopedic foot surgeons.

15:55

So with that, hopefully I answered your question and,

15:57

and happy to take it, or, um, questions are concerned case,

16:01

It's reassuring that, um,

16:03

we're not the only ones looking up those nerves in books,

16:07

those, the ones that, you know, the very small ones, um,

16:11

that you refer to at the end.

16:13

Yeah. Yeah. And I, I will say too, just as a side, uh,

16:18

just pertains to the diagnosis of this case, Dr.

16:20

Sch, sorry to cut you off, just real sec.

16:23

Um, just be careful.

16:24

There is, there is a case, uh, uh,

16:28

quite a large series actually out of, uh, new, uh,

16:32

the New York Group Malone, uh,

16:34

from Memorial Sloan Kettering.

16:36

They, they looked at a whole bunch of, uh, quote,

16:39

peripheral nerve sheath tumors.

16:41

And what they found was, I think in like a thousand

16:44

of their peripheral nerve sheath tumors,

16:47

I think it was like a n of like nine

16:49

or 19 turned out to be just synovial sarcomas.

16:53

So even though you have a mass along

16:56

or situated perfectly along a nerve in their case series

17:01

or, or, or, or, uh, group, they were able to find

17:06

that some of those peripheral nerve sheet tumors,

17:08

quote unquote actually turned out histological, is

17:11

to be synovial cell sarcomas.

17:13

So because I, uh,

17:16

because of that case, uh,

17:18

which is I think was published in skeletal radiology, um,

17:24

I tend to just say mass and then biopsy now.

17:28

Um, so

17:30

That's interesting because I had a,

17:32

a case which has proven biopsy, proven schwannoma, um,

17:37

a branch of the femoral nerve in the medial

17:40

thigh that I biopsied

17:42

Okay. Under

17:43

a femoral just last week under

17:45

a femoral nerve block.

17:46

And it went well, and the, the nice surgeon

17:49

who was gonna take it out more

17:52

or less insisted on doing a, a biopsy first,

17:56

because if they did a, just a on block excision of it,

18:00

an excision biopsy, and the, the rare chance it's a

18:04

sarcoma, they would've contaminated the field.

18:07

Yeah. So, I mean, it looked exactly like this one,

18:10

very benign looking,

18:11

but I guess even the benign looking ones can, um,

18:15

have sarcoma within them.

18:18

Yeah, yeah. No, the, it's a, i'll, I'll try to, I'll try

18:21

to think of that, uh, while we're,

18:25

while we're just discussing it, it's like, uh,

18:31

I forget their numbers, but here,

18:37

Okay, There we go.

18:39

Yeah, I think it was this one. Yeah. So it does happen.

18:43

And, and if you, if you search this article

18:47

and sort of, uh, dive down this rabbit hole,

18:51

um, very scary.

18:53

They, they, and they, like, I think there's a one

18:56

or two cases that they showed in their figures where,

18:59

you know, it looked exactly like a peripheral nerve tumor.

19:03

And, um, you know, which sort of highlights the fact that,

19:08

you know, even though it occurs along the nerve or,

19:10

or maybe it's a budding it,

19:12

but it, it can be, you know, a rare scary synovial sarcoma.

19:17

And I mean, you know, they looked at almost like,

19:20

like a thousand cases, you know, of quote,

19:23

peripheral nerve shaped tumors, it seems like.

19:25

So, um, you know, something

19:27

to be aware of and it can happen.

19:29

So because of this article that I, uh, reviewed, uh, I tend

19:34

to just say likely peripheral nerve sheath tumors,

19:37

and, you know, but I'll still offer, um, biopsy or,

19:41

or histo, uh, pathologic, you know, assistance, um,

19:46

with, uh, tissue sampling, you know, for my surgeon.

19:50

So because of this case.

19:52

So, um, but,

19:54

and that also speaks to too, um, you know,

19:59

soft tissue tumors, you know, even though quote benign

20:02

and appearance, well circumscribed

20:04

or perfectly ovoid, you know, we can't,

20:08

we really shouldn't be applying, uh, radiographic terms,

20:12

you know, geographic or, you know, non-aggressive appearance

20:16

because even though, you know, it's, it's sort of walled off

20:21

and sort of well circumscribed here in the soft tissues,

20:24

we can't apply those same sort of radiographic bone tumor

20:28

lesion descriptors to soft tissue tumors.

20:30

All bets are off, in my opinion.

20:33

Yeah, that's a good point. Yeah.

20:35

And with, with that case, this one, um,

20:38

the anterior impingement, I think, I thought,

20:42

I'm not sure if it was, if it's correct

20:44

or not, um, one of the anterior nerves, the, uh, medial

20:50

per, uh, medial peroneal nerve,

20:54

medial peroneal nerve been impinged by an osteophyte,

20:58

Uh, oh yeah.

21:00

This, this distally.

21:01

Yeah, I saw, yeah, some people had raised the possibility,

21:04

but I think, think it had to do with the projection

21:08

and it just made it look like an, uh, yeah, right here.

21:13

Yeah, it could have certainly been impinging upon one

21:16

of the branches of the, uh, uh, deep fibular

21:19

or deep peroneal nerve,

21:21

this little o osteophyte right here at the, uh, dorsal

21:23

as proximal dorsal aspect of the navicular, this right here.

21:29

So yeah, certainly could have said, you know, correlate for,

21:33

you know, uh, loss of sensation of the dorsum of the foot,

21:35

particularly if, uh, they're worried about anterior tarsal

21:38

tunnel syndrome with, uh,

21:39

that medial branch certainly right there.

21:44

Yeah. Yeah.

21:47

Here's probably just another look at it, just sort of

21:50

bunched up and yeah, sort

21:55

of little fibrotic sort of junk here,

21:58

overlying this osteophyte at the, uh,

22:00

proximal dorsal navicular.

22:01

So certainly right there.

22:04

And then here's that neurovascular bundle.

22:07

So certainly conceivably could have a, you know, sort

22:10

of an impingement upon those nerves.

22:12

Certainly.

22:16

Thanks. Of course.

22:18

Thank you, Dr. Yaar.

22:22

Any questions on this one, or any others

22:26

From Week nine?

22:33

No thanks. Yeah. Okay.

22:36

Um, let's see here.

22:40

Oh, uh, just wanted to point out on, just

22:44

before we move to week 10, um, there was a couple,

22:53

probably the main thing on, on this case, obviously was the,

22:56

uh, the, uh, the, uh, low lateral liga, this complex,

23:01

basically the anterior talo feal ligament is just, uh,

23:05

essentially completely torn here, as well

23:08

as the deep deltoid and its components.

23:12

But, uh, just wanna highlight, um, on this case

23:18

was, uh, the fracture right here at the, uh,

23:21

later malleolus.

23:23

And then we can sort of,

23:25

because obviously this, this person, uh,

23:28

is on the younger side, you know, we can sort of, uh,

23:31

you know, invoke Salter Harris sort of injuries if, uh,

23:35

one wants, but this was, uh, yeah,

23:38

this was a little extra fracture,

23:40

little non-displaced fracture coming off of the, uh,

23:43

distal fibular VICIS right here.

23:46

So I guess if this is, uh, going, I always have

23:49

to look it up now, but below,

23:51

so this would be a Salter Harris three equivalent.

23:54

Um, I, I typically am more descriptive, uh, uh,

24:00

a couple years, a few years back, I, I helped

24:02

to review an article that showed, I think, up to,

24:06

I think like Salter Harris nine or something like that.

24:09

Uh, some large number.

24:11

So, uh, because of that, reviewing that article, um, I,

24:16

I tend to look up the, the numbers for the Salter Harris.

24:18

Now, if it's not a two, which, uh,

24:21

as we know goes towards the, uh, above

24:24

or something like that, or the metaphysis, if,

24:27

if it's anything beyond that, I'm, I'm sort

24:29

of looking up on, uh, Dr.

24:31

Google or articles now.

24:33

So just wanted to point out that, um,

24:38

that fracture of that case there.

24:41

And then week 10

24:46

a any particular case you would like to go over on week 10?

24:51

I completely missed the goons canal. Um,

24:54

Oh, okay. Lesion.

24:55

Um,

25:00

Yeah, so here On, I just couldn't see it,

25:03

and I wasn't aware of the entity.

25:06

Yeah, so I, I kind of group it along the lines of,

25:09

you know, that whole, uh, you know, we could sort

25:13

of group it in a hypo or

25:14

Hamar syndrome and things like that.

25:17

Um, but probably, let me try

25:21

to window it in.

25:24

I think this was the, the saline finding of the case

25:28

and what I like to call a sort of, uh, corner shot.

25:33

Um, you know,

25:35

and if you're not running it,

25:36

running the case all the way distal,

25:38

so this is just a nice corner shot sort of, uh, case.

25:44

Uh, and then here we can see, um,

25:48

that ulnar artery.

25:50

So, so normally though the, sorry, let me, let me, uh,

25:54

just side segue real quick.

25:56

So normally the ulnar artery, if you read the, an anatomic

26:00

literature at about the level of the wrist

26:03

and, uh, sort of Keon canal, the ulnar artery should be

26:09

less than about three millimeters in diameter.

26:12

So if we follow this structure right here, we see

26:16

as it goes out more distally, that sort of flares out.

26:20

And then definitely, probably more than

26:23

that three millimeter cutoff if you're a, a ruler person,

26:27

um, and like measurements.

26:29

But here, this sort of edema

26:33

and sort of peri, uh, vests, peri vessel

26:36

or peri arterial edema was supposed to be the tip off.

26:40

And, uh, to sort of, uh, scrutinize

26:43

that area a little bit more.

26:45

Um, and then it can get, uh, a little,

26:50

this was a tough case.

26:51

It was a very tough case.

26:52

'cause you know, we got all this other, um,

26:55

secondary findings of, uh,

26:57

particularly the DGen of the wrist.

27:00

Um, so people got sort of wrapped up with that.

27:06

And then, you know, along with, you know, maybe a touch

27:09

of DGen of the, uh, TFC and things like that,

27:12

but all the cystic changes, um, subchondral,

27:16

cystic changes in DGen sort of, uh, um,

27:20

distracted one's eyes to the, uh, to the finding.

27:24

But if, uh, the other potential was, uh,

27:28

the sagal, if, if you're looking again, sort

27:32

of arguably a corner shot, so tough case,

27:35

but, uh, conceivably, uh, uh, a getable case.

27:40

So, uh, and, and certainly when,

27:42

when I was shown this case initially I was, I was sort of,

27:46

uh, sort of shocked by it too, and, and scared by it too.

27:50

So, uh, good case. Good case. Yeah. Yeah. Thanks.

27:57

And then probably

28:04

let's close that.

28:06

Let's close these.

28:10

And I guess the other thing we can do real quick

28:15

is here, this was probably a cleaner case,

28:20

and then we can jump into the fifth, which was the far,

28:24

which is the Farone case of case two.

28:27

So if you, if you all remember case two was the, uh,

28:31

scape illuminate interosseous ligament tear,

28:34

the so-called quote, depending on, you know,

28:37

which celebrity you choose, the so-called, uh, gap two,

28:41

Terry Thomas or Madonna sign,

28:44

or Ronaldo, you know, pick a, pick a celebrity.

28:47

But you know, this scap illuminate interval is,

28:50

is, uh, too wide.

28:52

But that being said, I like, I like

28:54

to correlate with radiographs.

28:56

Sometimes I find that my texts, depending on how

29:01

the planes are prescribed, they can sort of elongate

29:05

or foreshorten, uh, interval

29:07

and measurements can be slightly off.

29:08

But here, obviously the ous portion for sure, uh,

29:12

including the ous portion, sort of torn

29:15

and chewed up here, particularly added

29:17

escape weight attachment.

29:18

And then sort of going back

29:20

and forth, we can see from the voler side,

29:24

likely degenerated and torn

29:27

and dorsally not looking too happy either.

29:30

And then sort of, uh, rotate this for us.

29:36

So going here,

29:37

and if you're doing, um, um, ultrasound of, uh,

29:42

for MSK, I like to just find lister tubercle,

29:46

and then if you find lister cubicles,

29:48

just slide a couple clicks distally or your probe distally,

29:52

and you'll just pick up the scape illuminate interval right

29:54

there, right underneath your probe just by finding lister,

29:58

tubercle slide ever so slightly, uh, distally.

30:01

And there you see the torn and sort of degenerated and,

30:05

and, uh, uh, dorsal all more, most important component

30:09

of the scape illuminate interval, as opposed

30:11

to the lunar tral inis ligament.

30:13

The lar is gonna be, uh, the,

30:15

the most important out of those three.

30:17

So just a nice case of, uh, staple lunate interosseous

30:22

ligament deficiency or tear.

30:26

And if, uh, you like the WHO classification,

30:29

this would be a, uh, now really getting fancy,

30:34

you can sort of invoke carpal instability, dissociative,

30:39

which is basically a problem within, um, a compartment

30:43

of a wrist followed by car carpal instability, uh,

30:48

non dissociative, which is problems across compartments.

30:54

Uh, carpal instability complex,

30:56

or CIC would be a combination of those two.

30:59

And then the final one, uh, classification, uh, in

31:03

that classification is the carpal instability adaptive,

31:06

which is basically, um, something outside of the carpus

31:10

that's causing the instability of the wrist.

31:12

And that's typically gonna be a mal united, uh,

31:15

distal radial fracture.

31:17

So there's C-I-D-C-I-N,

31:20

so CID within the com compar,

31:22

or within the row, CIND, CIND,

31:27

which is across rows CIC, which is combination of those two.

31:32

And then CIA, which is, uh, the distal radial, uh,

31:36

malunion typically.

31:38

So that said, um, the far gone

31:44

form or more advanced form of that scap illuminated injury

31:49

is gonna be this case, which is basically, you know,

31:53

slack wrist with that widen

31:56

and, um, torn, uh, so sorry,

32:00

that widen interval between the scape, uh, scape weight

32:03

and the lunate, the torn obviously ligament.

32:06

And then here we already start to see the, uh,

32:09

secondary degenerative changes of the radio SCA void,

32:13

and then capital lunate,

32:15

and obviously also the proximal migration of the capitate.

32:19

This just a nice case of, uh, of, uh, slack wrist.

32:23

So just a little bit more advanced from, um, case two.

32:28

Uh, we have this case with the, uh, slack wrist.

32:31

So, and, uh, yeah, that's,

32:34

that's probably the two major things I wanted to highlight

32:37

with the, with this group of risk case.

32:40

Uh, any question on either of, uh, these cases or,

32:46

Uh, after we finished that, um, those week tens cases,

32:51

um, and your description going through them?

32:54

I thought it was very usefully dizzy and busy.

32:57

Um, and which one relates to which ligament?

33:01

Um, so the dizzy, I think you said it was the sky for ate,

33:05

and the Izzy is the

33:07

Lunar triquetral. Yeah,

33:08

lu triquetral,

33:10

Yeah. Yeah.

33:11

So, so I, I, I try to, I try to remember that, uh,

33:15

the sort of, uh, the, the carpas, I kind of think of it

33:19

as I, I I, I try to ski

33:23

or I've tried to ski and I'm not any good.

33:27

Um, but sort of like a, um, the,

33:31

the wrist bones are sort of locked in together, not just by

33:36

all the facets and,

33:38

and, uh, grooves for the articulations,

33:41

but obviously the intrinsic and extrinsic ligaments

33:46

and the tendency of the wrist once, uh, like a skier,

33:50

when I ski, I, I sort of, uh, when I,

33:53

and I fall quite a bit, I sort of just flail about and,

33:57

and things just sort of unwind

33:59

and spring out, um, including, you know, mids,

34:04

skis, poles, everything.

34:06

So the tendency when

34:07

that happens is the skate void is gonna wanna boldly flex.

34:13

Okay? The lunate wants it, its tendency is to,

34:18

uh, uh, dorsally tilt.

34:22

And then if the connection, be it

34:28

scaphoid fracture

34:31

or a ligament tear,

34:33

that distal pole is gonna wanna ly flex while

34:38

the lunate is gonna wanna spin the opposite way.

34:42

And then if it's still attached,

34:44

but you have a skateboard waist

34:47

or proximal pole fracture that's gonna spin out

34:51

or dorsally with the lunate,

34:54

assuming the ligament is, is still intact.

34:56

And then if you have the lunar triquetral interosseous

35:01

ligament, that's, uh, that, um, uh,

35:06

the triquetrum tends to, uh, probably sort

35:10

of only sublux, uh, a little bit,

35:12

but then you typically, what I see sort of,

35:15

and we could sort of hallucinate in this case,

35:17

you get a sort of a, a vertical sort of step off

35:21

between the lunate and the triquetrum.

35:23

Uh, that's, that's what I tend to notice, uh,

35:26

particularly in, in these sort of farone cases

35:30

where patients are getting, uh, teed up more so for, uh,

35:34

either a proximal row ectomy

35:37

or a four corner fusion, uh, to sort of restore the wheel

35:42

of the carpus using the capitate as the, uh, the main,

35:47

um, sort of the fulcrum if, if you will, now of the wrist.

35:52

So that's what I tend to see. So right there.

35:58

So hopefully that answers your question, sir. Yep. Yeah.

36:04

Dr. Yawar, any, any questions, comments,

36:07

concerns from, from you or

36:10

Edward in regards to TFCC injuries?

36:12

Like what is, uh, like classifications,

36:15

whether traumatic de degenerative, or any word on those?

36:19

Oh, okay. So, so the Palmer classification, um,

36:24

so I tend, I, I know that it exists,

36:27

but I, I tend to be more descriptive.

36:30

Um, I, I'm not always dealing with my hand surgeon.

36:35

Um, so in general, um, I don't know, I,

36:40

I, I don't have a good cutoff,

36:41

but in general, probably, uh, you know, and,

36:46

and that sort of drifts as I age too.

36:49

But in general, like, uh, these days I use around 50 ish, 45

36:54

to 55, so maybe around 50 ish, I'll start to say just sort

36:58

of likely degenerative

36:59

or age hyper related degenerative tearing of the TFC.

37:03

I do know that the Palmer Classic and,

37:06

and that would be the type two, right?

37:08

Uh, the type one, if I remember correctly,

37:11

that would be the, your sort of traumatic lesions.

37:13

And if I'm asked, I will invoke that in,

37:16

in younger patients.

37:18

And, uh, typically what is it?

37:20

Uh, one it would be, was it one A through 1D?

37:26

And then, um, every once in a while, I'll still have

37:28

to look it up, but, uh, if I remember correctly, A is

37:32

for the central disc.

37:34

Um, B is for

37:37

the laminar attachments, be it, uh, the proximal

37:41

and distal lamina.

37:42

Please don't, uh, remember that there's a ligamentum

37:46

submentum, which is, maybe we see it better here

37:50

on the merge or the three Ds,

37:54

but there's typically like a sort of fibro ular tissue.

37:58

Maybe it's this stuff right here in between the proximal

38:01

and distal lamina.

38:03

Uh, and that's sort of, sort of this vascular sort of, uh,

38:07

fiber ular tissue between those two lamina.

38:10

And that can be bright, so don't confuse that for a tear.

38:13

And then one CI think it's, uh, the,

38:18

oh goodness, the, uh,

38:20

LAR attachments or something like that.

38:21

And then the 1D is

38:25

by the attachment or something like that.

38:28

And then some people will,

38:29

you can also look at the meniscal hoog region too.

38:32

But in general, um, beyond the bs, uh, A

38:37

and B, with the central perforation, the laminal, um, tears

38:42

I typically am, am just more descriptive.

38:45

I, I, I tend not to, uh, uh,

38:49

I I tend not to dictate the Palmer classification

38:52

unless specifically asked, uh, for,

38:55

by either the plastic surgeon that does hand, uh,

38:59

or upper extremity, uh, surgeries,

39:02

or my orthopedic hand surgeon.

39:04

So I, I, but I know it exists.

39:08

Okay, thanks. Yeah. Uh, Edward, one more.

39:10

Uh, like what are the extensive ligaments,

39:12

which are very important to have a look at?

39:15

Oh, Good. Extensive ligaments of the wrist,

39:17

which are the very important.

39:19

And, uh, kindly show us a few important ligaments here.

39:23

So, so I tend to, uh, so the volar ligaments first off,

39:27

uh, tend to, if you read the literature, tend

39:30

to be more important than the dorsal.

39:34

The one dorsal ligament that I do look for is

39:39

the, uh, dorsal intercarpal ligament,

39:42

which is the DIC for short.

39:45

So probably this structure right here.

39:47

Um, but the reason why I look for that is, um, there, that's

39:51

where I notice, I tend

39:52

to notice the dorsal soft tissue ganglia, uh,

39:56

where patients will come in.

39:58

So I'll sort of, I,

39:59

I usually see it like right here or right there.

40:02

Um, but typically the, the boar in, uh,

40:07

extrinsic ligaments, um, the ones that I look

40:11

for are the, uh, radio scap, capitate,

40:15

and probably this structure right here.

40:21

And basically, I'm just looking for ligament structures

40:24

that's, that's running in between the, uh, bones,

40:28

but probably this wisps right here of

40:31

that radio scape capitate.

40:33

And then that's, uh, some,

40:36

some authors depending on who you read.

40:38

And I think, um, goodness,

40:40

who's the orthopedic hand surgeon, it,

40:42

it'll come to me, hopefully.

40:44

But, uh, oh, Elias Garcia, Elias,

40:49

E-E-L-I-A-S Garcia, I think he's, he's one of the major,

40:54

um, uh, wrist, uh, slash hand surgeons

40:58

that write a lot about it, if you're interested.

41:00

But, uh, um, I think, uh, that ligament, I like to look at

41:05

that ligament, uh,

41:06

'cause I, uh, my understanding is that ligament helps to,

41:10

uh, hold the s uh, the scape void in place,

41:14

particularly when you have the scap lunate

41:17

interosseous ligament tears.

41:19

If that starts to fail, a, a sort of glance at that to,

41:22

to see if that sort of hold, be, uh, still intact

41:24

and holding in the scaphoid.

41:27

Um, and then the other one I sort of try to look for is the,

41:33

um, uh, tri, the,

41:37

hold on, I always have to think.

41:39

The THC,

41:40

the TriCal hamo capitate ligament on the ulnar side.

41:45

So, um, perhaps this structure right there

41:50

coming in and out right there.

41:54

And then together, those two ligaments, uh, you know,

41:58

you may hear, uh, uh, the, those sort of come together

42:02

and form like an arcuate, like an arc.

42:05

So you, you'll hear about the, you know,

42:07

the arcuate ligament sort of complex.

42:10

And then through that,

42:12

or around there, you have this space right here,

42:15

which is the space of Poirier.

42:17

Now you're getting really fancy.

42:19

And, and that's where, um, if you're studying wrist, uh,

42:23

anatomy and ligaments, that's where the peri lunate,

42:26

that's why the, uh, because there's really no, um, uh,

42:31

robust ligaments in, in this region.

42:33

That's why those peri lunate dislocations

42:36

and lunate dislocations occur when you have, uh, injuries,

42:41

uh, around the lunate.

42:43

And, uh, we'll see that radiographically every,

42:45

every once in a while on these, uh, mort,

42:48

particularly our motorcycle motorcyclists.

42:51

So those are probably the, the, the few major ones.

42:56

Anything beyond that, I, I'm sort of looking up, um,

43:00

uh, anatomy books.

43:01

But, uh, just keeping in mind, um, you know,

43:05

I'm just looking for ligamentous structures.

43:08

Um, yeah, I, I'm just looking for the ligaments

43:11

and I just try to figure out the ligament that that's,

43:15

that's running in between the two or three bones.

43:18

And then I call it that ligament.

43:20

Interestingly, I, I recently had a capito

43:26

hamate isolated injury, which probably, um,

43:31

this structure right here, um, isolated injury in,

43:36

in a patient that had, uh, was

43:38

recently fell performing handstands.

43:41

So, and I learned that there's actually a dorsal and a lar

43:46

and even an interosseous, capital handmade ligaments.

43:50

So a lot of ligaments in the wrist.

43:52

Um, and yeah, yeah, I,

43:56

I'm oftentimes opening up the adding books,

43:58

but those are probably the three

44:00

or four major ones that I look for.

44:02

Hopefully that answers your question, sir.

44:05

Yeah, thanks sir. Any other

44:09

questions, comments, concerns?

44:15

Um, I think there was a, was there a Liz Frank,

44:18

or was that in the previous week? Um, uh,

44:21

Oh, yeah, Liz Frank was on the previous week,

44:23

but we, we can go back to that if you,

44:25

So while we, on the week 10 With

44:28

The entner lesions and the, um, sprains mm-hmm.

44:34

Is it, is it just I as important just

44:38

to differentiate between a entner

44:41

and a sprain rather than grade one, grade two?

44:45

Because they, they grade one

44:46

and two are gonna be treated non-surgically, I guess,

44:48

and Entner needs surgery.

44:51

Surgery, yeah. So, so the important thing here

44:53

with the standard lesion is, you know,

44:55

typically you're gonna have that tear, uh,

44:58

at the distal aspect of the ulnar collateral ligament.

45:01

And then it sort of, um, the distal aspect

45:05

of the torn ligament typically flips proximally

45:09

and then sort of won't be able to tack back down

45:13

because of the adductor APA neurosis,

45:15

which is probably this structure right there.

45:17

So that's, that's the important thing.

45:19

Um, but I, you know, uh, it's a big deal

45:23

for the orthopedist, um, surgically

45:26

because, you know, it,

45:27

it basically the adductor API neurosis, um,

45:32

probably this structure right here acts as an impediment

45:35

for, uh, ligament is healing, that's all.

45:39

So it it in that sense, yes, it, it is surgical, um,

45:44

you know, this is probably the torn UCL right there sort of

45:50

trying to form that, uh, what is it called?

45:53

The, uh, so-called yo-yo sign,

45:54

or some people call it like a, looks like a lollipop,

45:57

but it, it's basically, um, you know, that, that the torn

46:01

and sort of flipped approximately, um,

46:05

ligamentous structure, probably like that,

46:08

all this stuff right here. Yeah,

46:11

It doesn't appear that much else goes on around that, um,

46:14

joint, I mean,

46:16

Yeah, the, yeah, nothing really, I, I think, I think, uh,

46:19

just DGen, uh, just osteoporosis

46:23

Is probably can't recall ever seeing a

46:26

radio collateral tear.

46:29

Yeah, we, I, I do see it every once in a while, uh,

46:32

you know, if it's like a sort of bare sort of mechanism,

46:35

but typically, you know, the, this is, this is the one,

46:38

the valgus mechanism is, is the one that, uh, you know,

46:42

we usually get asked for with the, uh,

46:45

ulnar collateral ligament.

46:46

And then I, I, I think, I think it's just, uh, yeah,

46:50

maybe it's, maybe it's orthopedic training,

46:52

but, uh, um, you know, they're, they, they, they sort

46:56

of get harped on, uh, not to miss this.

47:00

Um, so maybe that's why we,

47:05

I don't know if in my institution if there's any thumb uh,

47:09

injury, um, that's, that's automatically sometimes that's,

47:14

that's what the PAs

47:16

and the, the younger physicians will ask for.

47:19

But, you know, looking at it, we,

47:21

we do get a rare radio collateral liga disc injury mixed

47:24

in there every once in a while.

47:26

But, uh, and, and then also too, uh, I'll, I'll ask my texts

47:31

to put a marker to sort of help, um, you know, delineate,

47:36

um, where the pain is coming from.

47:40

Um, so that, that also helps, uh, me, uh,

47:46

as I image, uh, hands and feet, you know,

47:50

'cause there may be, as you all know,

47:52

multiple pain generators.

47:54

And, um, yeah.

47:56

And then that sort of directs my eyes to, to focus on the,

47:59

uh, the pain generator hopefully.

48:02

So sometimes that helps. Any other questions or concerns?

48:08

Uh, Edward, um, uh, how do we, uh, describe about flexor

48:12

and extensa tendon injuries?

48:14

Like do we use any zal levels

48:16

or just to describe it and leave it?

48:18

Or is it,

48:19

Oh, okay.

48:20

So now we're, uh,

48:23

here maybe this is probably the best one.

48:29

Uh, well, typically, uh, I, I just,

48:34

I know that zones exist

48:36

and for that I do need to look up all the zones,

48:41

not just boldly, but dorsally.

48:44

Um, but, uh, you know, the, I I tend to just describe,

48:49

and I, I will look it up,

48:52

but, uh, you know, I, I am aware

48:54

that there is a zonal anatomy,

48:56

and the important thing is just to, I, I just, I,

48:59

I'm more descriptive

49:01

and I map out the, the, um, the degree

49:05

of tear, you know, whether it's partial or complete.

49:09

And then where the tendon is res,

49:11

the tendon ends are residing.

49:14

Um, you know, there is that so-called dead man or,

49:17

or dead person zone, which is, I forget now,

49:21

probably like right around, you know,

49:23

the metacarpal fial joint level.

49:25

But by that point, I'm, if, if they want zonal anatomy,

49:30

you know, I know that, you know, the dead man, um,

49:34

zone exists and,

49:35

and I am, I'm looking it up in articles at that point.

49:38

I, I tend to be more descriptive.

49:41

Um, I've shied away over the years from all

49:45

these classification systems.

49:47

'cause what I've found is what one person classifies

49:50

as something, someone else will classify it as another.

49:54

And if, if I do get asked, um,

49:58

for classification systems, I, I try

50:00

to specify in parentheses, which classifications, uh,

50:04

system I'm using, whether, you know, at the start of this,

50:08

uh, session, you know, the slack risks, you know, which,

50:13

which classification you're using there.

50:15

If you know, for TFC injuries, I'll put Palmer one A,

50:20

one B, D, or two, whatever, A or B.

50:24

And then in this case, I, I'd have

50:26

to look up the classification system here,

50:28

but I mean, from zones, what is it, one

50:30

through like seven or something like that?

50:33

Um, from, um, distal, proximal on the fingers,

50:38

all the ways to the, the distal forearm.

50:41

But I, I would have to look it up,

50:42

but I, I am aware that there is a dead, dead man

50:46

or dead person area, you know, at about this level.

50:50

And that, that, that can be problematic for the surgeons

50:53

because you know that that's just planning out there, the,

50:57

the, the degree

50:59

or the length of their zigzag incision to sort

51:03

of find the tendons to reapproximate them.

51:06

But I, I, I tend to just say, you know, for instance, like,

51:09

you know, there's a tear of the flexor digitorum, profundus

51:14

and superficialis, let's say at the level

51:16

of the proximal phalanx with retraction of the torn tendons

51:19

to approximately, I don't know, let's say like

51:22

the distal car row, creating a gap

51:25

of whatever centimeters or millimeters.

51:27

I tend not to use zones, but I do know that they exist.

51:32

Any other questions, concerns

51:34

as we're running out of time here?

51:38

Well, I think that's excellent. Thanks.

51:40

I think the whole course you guys have been superb. Thanks.

51:44

Well, we're glad you enjoyed it.

51:46

And, uh, you know, hopefully I, you know, you have access

51:50

for your, and, and you have access to me.

51:52

Any questions or concerns, reach out to Kim.

51:55

She has my email. If you guys don't have it, uh,

51:57

you gentlemen don't have it already.

51:58

Happy to help. Happy to, um, provide my 2 cents, uh, and,

52:03

and share my mistakes with y'all.

52:04

And, and thank you for, uh,

52:06

joining us for the last 10 weeks. Really appreciate it.

52:09

It's been superb. Thank you very much. Yeah,

52:11

Of course. Thank you very much.

52:12

Our pleasure. Our pleasure. Thank you.