0:01

Here on this case, 25 year old with acute pain of the left wrist,

0:05

fell through a trailer and landed on outstretched hands.

0:09

I wanted to talk about, uh, cases two, three, and five. 'cause it talks about,

0:14

uh, a concept, the concept of, uh, carpal instability. It is, uh,

0:19

it is a very difficult, uh, topic in, in my opinion. Um,

0:24

and I'm continuously or, or constantly learning, relearning, uh,

0:29

all the ligament names, um, that, uh,

0:33

that are involved in this, um, intricate wrist anatomy. Okay?

0:38

And, but you can, I guess let's, let's, uh,

0:43

take, take a moment and just talk about a few major things. So,

0:47

so to help us understand, uh, these three cases. So,

0:52

so you have to remember a few things, uh, or general principles, okay? That,

0:57

uh, the, uh, the, the glenoid,

1:01

okay, uh, the, sorry, the anti brachial glenoid, okay.

1:06

Of the wrist, right? The glenoid is a shallow cavity, right?

1:11

So that is formed by the distal radius,

1:14

which is broken down into the scaphoid and lunate fosse, right?

1:19

Then on the ulnar side, okay,

1:22

you have the triangle fiber cartilage complex, or the,

1:25

the triangle fiber cartilage, the central portion,

1:27

that's gonna be the main player. Those three components are gonna form,

1:31

form the, so-called anti brachial glenoid, okay?

1:36

Which articulates with the protuberance or the proximal articular

1:41

surface of the proximal carpal row, okay?

1:45

Which we know is comprised of the scaphoid, lunate and triquetrum. Okay?

1:50

So the, this proximal carpal row,

1:54

if you read the literature, this is what's called the inter collated segment,

1:58

okay? The wrist and forearm don't really move, okay?

2:03

And the distal carpal row, you can think of it,

2:06

and if you read some of the literature, some,

2:08

some articles and authors call this the monolith, okay? The distal copper row,

2:13

meaning it really doesn't move, okay? So the trapezium,

2:18

trapezoid, capitate, and to a lesser extent the hamate,

2:23

but pretty much the distal copper row, you can think of it as one big block,

2:27

okay? Or monolith. Now,

2:31

you can divide the wrist, okay? Into three columns, okay? When you're studying,

2:36

there's a radial, a middle, okay? And an ulnar column,

2:41

which with these three bones, the, uh, tra trapezium, trapezoid,

2:45

andoid in the radial column,

2:48

the middle column consisting of the capitate and lunate,

2:52

and then the hamate and trium and pisiform,

2:57

uh, lesser extent, the ulnar column, okay? Now,

3:00

the cool thing about the wrist is no matter if you think about it and move your

3:04

own wrist, you know, say bye-bye,

3:06

or pretending perhaps you're throwing a dart or something like that, or,

3:10

or cooking or something like that. The cool thing about the wrist in the hand,

3:14

even though you're able to circum conduct in all sorts of direction,

3:18

really allowing a lot of mobility for, for daily function, okay?

3:23

Um, the, you can, if you look at your hand and your wrist,

3:28

the height okay of the,

3:30

of the wrist and hand is pretty constant no matter how you move it. Okay?

3:34

You can imagine if you start to, um,

3:38

have developed fractures, be it from trauma or, you know,

3:43

uh, or longstanding rheumatoid or crystal deposition disease,

3:48

what have you, various other things, and you start to get carpal instability,

3:52

those biomechanics are really gonna be affected, okay?

3:56

So the height, maintaining the height is really important.

4:00

So things at the wrist and hand, uh, at the distal forearm,

4:05

and that monolith at the distal carpal row,

4:07

and the metacarpals really don't move, okay?

4:10

It's the proximal carpal row, that interrelated segment,

4:15

that's the one that sort of expands itself and shortens itself,

4:20

flex and extends to maintain the hi, the, the wrist height. Okay?

4:25

So when you have injuries of a row, okay? Uh,

4:29

one row within that row based on the Mayo

4:34

classification, that's called carpal instability,

4:37

dissociative or CID for short. Okay?

4:41

And for those of you that are interested in reading about all this stuff, uh,

4:45

uh, I highly recommend, uh, reading Garcia Elias,

4:49

and I can get you some other articles as well,

4:51

but some great articles out there on carpal instability, okay? So when you have,

4:56

when we talk about carpal instability, dissociative,

4:59

that's typically within a row,

5:01

and typically they're gonna be talking about the proximal carpal row,

5:04

and those carpal instability, dissociated, or CID for short,

5:09

can be further divided, obviously,

5:11

into scalid ligament problems and lunar choal interosseous

5:16

ligament problems. But not only ligamentous problems, you can have,

5:20

you can obviously have scalid waist fractures, right?

5:22

Because that not only do you have ligamentous problems,

5:26

but you can also have osseous problems that can cause carpal instability within

5:31

a row, or carpal instability, dissociative, A-K-A-C-I-D,

5:37

okay? If you have problems, okay? Between the,

5:42

between rows, okay?

5:43

That is between the distal forearm and the proximal carpal row,

5:48

or the proximal carpal row and the distal car row,

5:51

that is the mid carpal compartment. Then you're dealing with carpal instability,

5:56

non dissociative or CIND for short. Okay?

6:01

Now, if you have a combination, okay,

6:04

of instability within a row and between rows,

6:08

then that's upgraded to carpal instability complex,

6:12

or CIC if you have carpal instability,

6:16

pain clunking,

6:17

what have you because of something outside of

6:22

the carpus or that is the wrist,

6:25

and typically that's gonna be due to a distal radial fracture, okay?

6:29

Co these burdens, what, what have you, bartons, what have you, okay?

6:33

That's gonna be called carpal instability adaptive, okay?

6:37

So four main flavors of carpal instability, okay?

6:41

So there's carpal instability, dissociative that's in one row,

6:45

typically the proximal carpal row, carpal instability, non dissociative, okay?

6:49

That's between rows carpal instability complex.

6:53

That's bet that's a combination of the first two and carpal instability.

6:58

Adaptive is outside, uh, a cause,

7:02

a cause outside of the wrist bones, okay?

7:06

And typically that's gonna be because of a distal radial fracture. Okay?

7:10

So when you read and you study carpal instability, that's, that's what these,

7:15

uh, that's what our orthopedist and, uh,

7:17

risk enhanced specialists upper extremity specialists are talking about. Okay?

7:22

So with that in mind, okay?

7:26

So what we have here is we're dealing with a widen,

7:31

okay? And torn, okay? Completely torn, essentially, um,

7:36

membranous,

7:38

volar and dorsal components of the U-shape scape

7:42

lunate interosseous ligament. Okay? Now, the important,

7:46

the most important thickest, okay?

7:49

And horizontally oriented, uh, portions of, uh,

7:53

and the most important por portion of the scape illuminate interosseous ligament

7:57

is the dorsal component, okay? It is the thickest, the most taut,

8:02

okay? And, and it's usually horizontal and orientation.

8:08

Now, the ness portion, okay, is thin.

8:12

It really plays no role and is the most common, the first,

8:17

the first and the most common one to fail, okay? And that is right here,

8:22

okay?

8:23

And it's very thin and really serves no function.

8:28

Okay? Now, the voler component is less important, okay?

8:33

Than the dorsal component, okay? But the, and it's thinner,

8:38

and it's not as thick or horizontally oriented.

8:42

It's actually in a, if you read the literature, the anatomic literature, it's,

8:47

uh, obliquely oriented. And why is that? It's,

8:50

it's less for stability and it's more for, uh,

8:54

motion of the wrist with flexion and extension. Okay?

8:58

So the dorsal component of the scap lunate intraosseous ligament is the most

9:02

important. Now, flip that and talk, uh, the correlary to that,

9:06

or the flip side of all that is the luno tricoci intraosseous ligament. Okay?

9:12

Now, with the lu tri cubital intraosseous ligament,

9:16

although it is less u-shaped,

9:18

it's probably more v-shaped depending on who you read.

9:22

But the volar portion is gonna be the thicker,

9:25

more horizontal oriented and more important stabilizer for the, uh,

9:29

between the lunate and the triquetral creature. Okay?

9:34

The dorsal aspect is the more flimsy, and then again,

9:37

the MES portion is the least, uh, useful out of all of those three. Okay?

9:42

So the dorsal component for the SLIL is the more important one,

9:46

and the lu nal the volar portion is more important. Okay?

9:52

So laying, let's lay another layer to that groundwork. Okay?

9:56

So if you look okay at, uh,

9:59

a transverse section of a CT or, or an MRI, what you will notice,

10:05

okay? Is that the lunate, okay? Is wedge-shaped,

10:10

okay? And here you can see this wedge shape and it's wedge shape,

10:14

and it's thicker bolly. What does that mean?

10:18

It means that when, especially the scape lunate interosseous ligament fails,

10:23

okay? Because it's, we,

10:26

wed wedge-shaped and narrow on its dorsal aspect, it's gonna want to,

10:31

it's gonna tend to favor shooting out ly and tilting

10:36

dorsally,

10:36

which gives rise to the dorsal inter collated segmental instability phenomenon,

10:41

okay? Or that,

10:43

where that lunate is gonna flip up and face dorsally. Okay?

10:48

And that's partly because, okay,

10:51

the of the wedge-shaped appearance, as we can see here, okay?

10:55

Of the lunate in this transverse section, okay?

10:59

It's not gonna want to go and face boly when the ligaments fail,

11:03

especially that SLIL. Okay? The other thing,

11:07

the other thing we see too, okay, with these SLIS scap,

11:12

intraosseous ligament tears, okay?

11:16

Is the scaphoid naturally okay?

11:20

Is going to be oblique, okay? Not in two planes,

11:24

in the coronal and sagal plane, typically at about a 45 degree angle,

11:30

so that when it experiences, okay, typically, uh,

11:34

an injury's gonna occur from an axial load and dorsally loaded or dorsally

11:39

directed force, okay? As you can imagine, as falling on an outstretched hand,

11:45

that, that, uh,

11:47

that helps to explain the fractures that we see in the scape void,

11:51

but also how things fail. So the scaphoid job,

11:55

and as well as those ligaments, is to help resist those,

11:59

that axial load or that proximal load upon the,

12:05

the scaphoid and the dorsal load. Okay?

12:09

So now that being said, if we look at our case, okay,

12:13

we see that we have failure of all three components,

12:17

the dorsal, which is the most important, the membranous, okay?

12:23

And then to a lesser extent here, this, uh, LAR component,

12:28

okay? So depending on what stage this, uh, patient is,

12:33

if we catch them early, okay? The scap, lunate,

12:37

interosseous ligament failure,

12:39

you can think of it in two brow categories now, okay?

12:44

The first category is gonna be, uh, pre dynamic or, or,

12:49

um, uh, it looks pretty normal, okay? There's,

12:53

there's essentially four stages. But for, for intents and purposes,

12:56

I kind of group them into, I group the four into two. Okay?

13:01

That is when you have a pre dynamic and dynamic instability, okay?

13:06

That is, you only see the, you only the patient experiences,

13:10

and you only see it during sincy radiography. That is, okay.

13:14

During dynamic imaging and during clinical exam,

13:17

you hear the patient feels pain and clunking as they move their wrist,

13:22

or the latter two, which is the higher stage, uh, stages three and four,

13:26

which are, which is when you see static instability on our imaging study,

13:31

particularly on our radiographs. And that's where you're gonna see the,

13:34

so-called, you know,

13:36

ter thomasine with widening of the scape illuminate intraosseous ligament, okay?

13:40

Up to three millimeters.

13:42

And then you're gonna start to see the lar flexion of the scape void and

13:47

ultimately slack wrist,

13:48

which gets us into cases case number five in a bit. Okay?

13:53

So, but once you understand okay,

13:56

that early on you're gonna have free dynamic and dynamic instability,

14:01

and later on you're gonna have static instability,

14:05

then you can understand the progression, okay?

14:08

So in pre dynamic and dynamic instability, typically, okay?

14:13

The,

14:14

it's gonna be the membranous and the VOLR portions that are gonna be dinging,

14:19

okay?

14:20

Prog as the injury progresses and worsens, okay?

14:25

What happens is you're gonna get failure of the

14:29

important, the more important dorsal portion, okay?

14:34

And then to progress further to, uh,

14:38

static instability and ultimately slack wrist, okay?

14:43

You're gonna have failure of the secondary stabilizers of the wrist,

14:48

okay?

14:49

And in the case of the secondary stabilizers of the scap lunate

14:54

interosseous ligament, the ones you want to pay attention to,

14:57

and I'll try to pick them out for us right now. Okay?

15:01

Are the STTL or the scap trapezial trap,

15:06

uh, trapezium ligament, the, uh,

15:10

RSCL, the radio scape capitate ligament,

15:15

the FCR, the flexor carpi radialis, okay. Tendon.

15:20

And then finally on the dorsal side, you have the dorsal, uh,

15:24

dorsal intercarpal ligament or the, uh, DIC ligament for short. Okay?

15:30

So if we can try to pull up and look at some of these, uh, images,

15:35

and, and mind you, depending on your magnet, and if you're doing MR arthrograms,

15:40

I, and in my hands, I don't always see these ligaments,

15:43

but do I try to look for them? Sure. Okay.

15:47

In the hopes that one day I do get a,

15:50

a beautiful MR study. Um, and, uh,

15:54

but we can pick out some of these, uh, structures here. Okay?

16:00

So here, going to the volar side and the volar side,

16:03

or the palmer side is typically gonna be more important depending on who you

16:07

read, okay? But here you can see that you have the,

16:11

the extrinsic ligament here, or an extrinsic ligament here on the Palmer side,

16:16

and this is probably the radio scfo capitate ligament or RSC for

16:21

short. And this ligament is important, as you can see, okay?

16:26

That this acts as the fulcrum for the scaphoid to bend over,

16:30

but it also keeps the scaphoid in place, okay?

16:34

So when you have scap illuminate interosseous ligament as insufficiency,

16:39

if you have failure of this ligament,

16:42

that's when your patient's gonna pro start to progress to worse carpal

16:46

instability or that static carpal instability form. Okay?

16:51

The other ligaments that you want to pay attention to,

16:54

not only to this fulcrum ligament or, or the, um, I forget what it's called.

16:59

The, uh, the support ligament of the scaphoid. There's,

17:02

there's another term for it. I'll try to remember it, I apologize. Um,

17:06

but also the scap o trapezial or the scap o

17:11

trapezial trapezium ligament or STTL for short.

17:15

And this is typically gonna be two or three bands, uh,

17:19

typically about two bands right here between, uh,

17:22

the scaphoid and these two bones right here. Okay?

17:27

And then finally on the dorsal side,

17:30

you have the dorsal intercarpal ligament, okay?

17:33

Or DICL for short. And that ligament

17:39

is this ligament right here.

17:41

I can't unfortunately point it out as well, okay?

17:45

On the coronals, but maybe this is wiss wiss of it right here.

17:50

Okay?

17:51

But this ligament runs from the trapezium to send

17:56

fibers over to the trapezium and the distal pole of the scavo.

18:01

So e so when I look at a radiographs, I'm,

18:04

I'm pretty much reading these Mrs off of radiographs, and when I see,

18:09

uh, florid osteoporosis or slack wrist, okay,

18:12

which is the case in a subsequent, subsequent case, well, I'll,

18:16

which I'll pull up in a bit, then I will,

18:18

I will suggest that some of the secondary stabilizers are likely or probably

18:24

torn, and I try to pick that out for my hand surgeon. But a lot of being,

18:29

that being said, a lot of hand surgeons,

18:31

including some of mine are old school,

18:34

and they still rely on good old radiographs.

18:36

So they're not always getting MRIs to evaluate these secondary

18:42

extrinsic ligaments.

18:43

They already know about that based on their clinical examination and

18:47

radiographs and, um, uh, from what I am told. Okay.

18:52

So with that, I'll pause any questions. I know it's a lot.

18:57

Um, just wondering, with the extrinsic ligaments that you explained just now,

19:01

um, much of it, uh, if you describe it on the coronal plane,

19:05

it's going to be subject to partial voling as it moves in and out.

19:09

So would you recommend that you assess them on the axle images and which

19:14

sequence, I guess with the

19:16

Yeah, I, I, I tend to, yeah. So I will tend to use, um,

19:21

on, I, so we, and, and I have no full financial, I have no,

19:26

uh, we, we,

19:27

we use Vistage and Sectra as our pacs at our institution and, and merge.

19:32

So, so full disclosure, I I have no fi I have no financial issues with them,

19:37

but I will, I I I love to use whatever packs you're using,

19:42

the IntelliLink function that is, um, you know,

19:46

I'll use all planes and I'll scroll back and forth because again, uh, you're,

19:50

you're right, uh, I think that was Hari, um, that, um, you know,

19:55

there, you know, depending on how, how, how your magnets are.

19:59

And then sometimes they're scanned on a, a lower Tesla magnet.

20:02

You may not see all of these structures. And if that's the case, I,

20:06

I will try to suggest it, but will I give it a shot and try to look at it just,

20:10

um, just to build my experience so that when I do get a good study, I,

20:15

I kind of know what I'm looking at. Um, yeah, I, I will do that on, on,

20:20

I try to, at least on every risk case,

20:22

just to try to pick out at least one or two ligaments so that when I'm faced

20:26

with an actual case where I can see something, you know, I,

20:30

I would feel more confident. But yes, I, you know,

20:32

in this case where a coronal maybe you're getting, you know,

20:36

three millimeter thickness skip ones or however gaps you're running it, um,

20:42

you know, you may, you may not get lucky and you may skip out of those, uh,

20:47

extrinsic ligaments just going between slices. So, so in that case, yeah,

20:52

I will, I will go back and forth. So like in this case here, um,

20:56

going to the, uh, volar side or the palmer, uh, extrinsic ligaments,

21:01

let's say that this is the, uh, radio scape o capitate, you know,

21:05

something like that, right? I, I'll try to pick it out here. And I know,

21:10

you know, it's supposed to start at the distal radius,

21:12

cross over the scape void and attach upon the capitate,

21:16

and maybe that's it right there. But, but I will try to look at them,

21:19

especially, you know, in, in more normal MRIs, wrist MRIs,

21:24

so that I get a flavor for when something bad does happen. So,

21:28

so nor knowing normal, uh, uh, you know, in, in my, uh,

21:33

opinion is, is some of the, the first step to obviously, uh,

21:37

figuring out what's abnormal and, and helping our patients. So I,

21:41

I will try and, and cross reference between the, the, the, the different, uh,

21:44

planes. Yes.

21:46

And, and in describing these ligaments in your report,

21:49

I suppose the intrinsic ligaments are more essential,

21:51

but do you have to enumerate, uh,

21:53

all of the other extrinsic ligaments in

21:56

Describing? No, no, no, no. I, I don't, I I actually don't mention them. I, uh,

22:00

some of my fellows and trainees, and in some of their templates,

22:04

they have extrinsic ligament listed, and I saw that in some of,

22:08

in grading some of your reports. That's great. Um, but in, in, in some,

22:13

on some of the magnets, unfortunately, we,

22:15

there are still some open magnets that we help patients on because of

22:19

claustrophobia and things like that. I, in all honestly,

22:22

it's a challenge to see them. So I will take out that, um,

22:26

line if it's in the ma if it's in my trainees macros,

22:29

but I will try to look for them. Um, yeah. Um, but, uh,

22:34

I don't always mention them,

22:38

Uh, just bring a ditch.

22:39

I'll, yeah, but I will say that, you know,

22:42

when I'm dealing with the scap lunate intraosseous ligament injury, I'll,

22:46

I'll rattle off,

22:47

or I'll at least try to look at for those three or four ligaments and tendons

22:51

that I rattled off. And then, uh,

22:54

if the lunar charcoal intraosseous ligament is damaged, then I'll rattle,

22:59

I'll, I'll try to check those other three ligaments. And again, uh, I,

23:03

I think this, uh, this session is being recorded, but I'm happy to, um,

23:08

uh, write down and forward to Olivia and Jennifer so that you guys can get, uh,

23:13

my checklist if you guys like,

23:14

for those respective ligament ligamentous injuries later on today. That's

23:18

Great. And, and I guess with acute trauma,

23:20

especially if there's been associated fracture bleeding in the sites. Yeah. Uh,

23:25

do you recommend a period of, uh, uh, uh, when you should do the mr

23:30

Oh, just complicate things? Um, yeah, I, I, I, I leave it to the discretion of,

23:34

uh, of our clinical colleagues. But again, um, we,

23:38

we typically do not, we, we very rarely image, uh,

23:43

wrist injuries early on because, especially if, you know, there's a,

23:47

a fracture distal radius scaphoid, maybe like a dorsal TriCal uls fracture,

23:52

things like that. As, as, uh, as for those that read, uh, you know,

23:56

bone mr you know, as you know,

23:58

the edema early on acutely can really obscure things. So, you know, some of us,

24:04

when we see that, you know, we'll, we'll, we'll recommend, you know,

24:07

considering repeat MRI, uh, you know, after the edema has gone down. But,

24:12

but our hand surgeons are, are really good about their,

24:16

with their clinical exam. And, and quite honestly, we, we, we very rarely,

24:22

uh, get, get these wrist images, uh, Mr images acutely. Um,

24:27

they, they tend to know, they tend to just go in, uh,

24:30

based on their clinical exam and, um, and radiographic, uh, findings.

24:36

So,

24:38

Uh, can I bring your attention to case number two? Sure.

24:41

And I was just looking at the triangular fibrocartilage,

24:45

and there's a lot of high signal within the area on the fluid sensitive

24:50

sequences.

24:50

Okay.

24:52

Um, if it is, I'm

24:53

Sorry. So this is, I think this was five, let me pull up. Alright,

24:57

so our concern was the fluid sensitive.

25:01

Yeah, that's right. Yes. So there,

25:03

there's a lot of high signals surrounding the triangular fiber cartilage.

25:08

So I was just wondering if there was an actual injury to the structure.

25:13

Uh, I, if we can raise,

25:18

I forget what the, what the master sheet had said,

25:23

but we, yeah, I, I don't recall.

25:28

I was, I, from what I remember, I just, I,

25:31

I don't wanna misspeak and go against, um,

25:34

what I was given as the standard report,

25:39

but uh, I'm pulling it up as we speak too.

25:42

But if you notice here,

25:44

so the TFC can be hard to evaluate particularly,

25:49

okay. At its radial attachment. Okay.

25:52

And at its peripheral laminar attachments, okay?

25:56

And be careful calling tears,

26:00

particularly in that one to two millimeters ish by that radial attachment

26:04

because this is, this histologically is cartilage, okay?

26:09

From my understanding the last I reviewed the literature more la more

26:14

ly or medially towards the ulnar styloid and, uh,

26:17

and the ulnar fovea and the styloid where you have the distal attachments,

26:22

okay? You have a proximal lamina, okay,

26:26

of the triangular fiber cartilage complex,

26:28

which as inserts at the ulnar fovea typically.

26:31

And you have a more distal attachment that inserts upon the, uh,

26:35

tip of the ulnar styloid. Now, in between this region,

26:39

which is this stuff right here, in my opinion, okay,

26:43

this is what's called the ligamentum submentum, okay?

26:48

And if you read, um, I believe it's a radiographics article of, uh,

26:53

several years back, and I can try to look for it,

26:55

it talks about normal wrist MRI. Okay?

26:58

And this ligamentum submentum area is just normal

27:04

fibro ular tissue with some small amounts of lymphatics and vessels, nerves,

27:09

what have you, apparently. Okay? But I have to review the exact contents,

27:13

but that's what gives rise to this elevated signal in this region

27:19

between the two lamina. So you don't wanna call that tear,

27:25

okay? If you are concerned about tear, okay?

27:29

And if they're younger and you know, uh, you know,

27:32

they're really worried about tear, then just get a simple Mr. Arthogram, right?

27:36

And see if there's communication obviously as patients as we all

27:41

age, okay? This central portion is gonna degenerate and you know, it's thin,

27:46

it's gonna tear. Um, and that may be asymptomatic in a lot of patients,

27:51

so you have to correlate clinically, okay?

27:54

But those are some ways that I try that, those are some things, uh,

27:57

that I think about that, that ligament and subquantum. So to try to,

28:01

not to overcall tears there, okay?

28:04

But also if I'm really concerned then, you know,

28:06

I'll just get a suggestion Arthogram. So,

28:10

Yeah,

28:10

so it's a bit caught out 'cause there's a lot of high signal within that area,

28:13

and structures don't look very clean anymore. And, uh, in the distal radio,

28:18

uh, joint, there's some high signal there.

28:20

So I thought there was some structure that's given way.

28:24

Yeah, so, so this, this I would read, I,

28:27

I would personally read this as, uh, a pretty unremarkable TFCI think,

28:32

uh, the distal radio owner joint, there's a,

28:36

a sliver or a, a tiny amount of fluid there,

28:40

but nothing beyond physiologic in my opinion.

28:44

Here's that radio cartilage and that attachment of the, uh, TFC,

28:48

that central portion right there. And again,

28:50

don't be calling this a Terry because that's just where, you know,

28:54

the TFC central portion attaches. Okay?

28:58

And then here too, as you scroll back and forth, okay,

29:02

you're gonna have some obliquely oriented fibers.

29:05

Sometimes you see it better on your sort of gradients, let me pull that up.

29:11

I guess we call it merge or something here.

29:16

But sometimes you see like an obliquely oriented fibers,

29:19

and that's the dorsal radial ulnar and the volar radial ulnar ligament

29:23

flanking either side, okay? Uh,

29:26

the central portion of the triangular fiber cartilage, okay? But,

29:30

so sometimes that can look striated and not as transverse appearing.

29:33

And I've seen some people call that terror too,

29:36

but that's just normal ligament on either side, okay?

29:41

Of the central portion of the triangle fiber cartilage. Okay. And let me,

29:44

lemme see if I can, uh, yeah, this, let me see.

29:48

Sometimes you could see it on the sags, but yeah, so like here,

29:55

okay, so here, this central port,

29:58

that would be the central portion of the TFC for me.

30:00

And then on either side you have the, the vu,

30:04

the VRUL or the U-L-D-R-U-L,

30:08

the volar radial ulnar ligament,

30:10

and the dorsal radial ulnar ligament on either side. Okay?

30:14

And then come out laterally or on, sorry,

30:17

medially only you can see that attachment,

30:20

the more distal lamina and the more proximal attachment coming down right here.

30:24

So this stuff right here, that bright stuff, that's that ligamentum submentum,

30:29

so you shouldn't be calling that a tear. Okay? And then, and then,

30:34

uh,

30:34

to tie it furthermore to what we were talking about earlier,

30:40

okay? About some extrinsic ligaments. If you go, sorry,

30:44

if you go far bolly, okay,

30:48

you can start to see wisp of that ulnar TriCal and the ulnar, uh, uh,

30:53

ulnar lunate ligaments, the ul, the the UL L and the,

30:58

uh, UTL ligaments, okay?

31:01

And those attach again between the distal aspect of the triangle fiber cartilage

31:05

complex and those bones. So that's all part of the TFCC as well.

31:10

So you can see, just appreciate, I mean, this complex anatomy,

31:15

I mean,

31:15

and we haven't even begun to talk about the menal meniscal hoog out laterally.

31:20

And you know, the remainder of, of these, uh, the complex, uh,

31:24

wrist anatomy at the, the, uh, radiocarpal compartment.

31:29

So Dave, if you think about the knee, uh, you've got the collateral ligaments,

31:32

the all non radial components, uh,

31:35

are those structures that we should be worried about when we are looking at

31:39

structures like these?

31:42

You mean the radial collateral ligament of the wrist or

31:45

The, the, the small nar collateral and radial collateral ligaments?

31:50

I, yeah, I mean, I will, I will try, yeah, I will try to parse it out. Uh,

31:53

especially if I have, um, you know, good images, I, I'll, I'll go,

31:58

I I'll give it a shot, but you know, if I, I don't see it, I don't see it,

32:02

but if there's edema in that region, uh, you know, I may suggest, hey, you know,

32:06

some of the ex uh, some of the extrinsic ligament, uh,

32:10

extrinsic ligaments at the, you know, the ulnar,

32:13

the middle or the radio column of the wrist, you know, uh,

32:17

may be injured, but you know, not definitively identified, something like that.

32:21

I, I will give it a shot. But in all honesty, I think, I think most, uh, of our,

32:27

most of my referers, they care about, uh,

32:30

the SLIL and whether there's, uh, degenerative changes and then,

32:35

and then some of the other tendons that, that may help as, uh,

32:38

as secondary stabilizers.