0:00

The fifth case is a 68 year old with wrist pain and numbness, uh,

0:04

middle finger region, no surgery and no injury.

0:08

So what we saw in case number two, the SLIL tear.

0:13

Now let's push it forward,

0:16

the disease that is of carpal instability. And look at this case.

0:21

And as you can see here, someone has already placed arrows,

0:25

but now this is probably stage four and you know beyond,

0:30

okay, depending on what classification you read. But this is slack wrist. Right?

0:35

Now what happens when,

0:36

when you have scap lunate interosseous ligament insufficiency?

0:41

And we can see here that the membranous, okay, the volar,

0:45

everything is torn. Okay?

0:47

We have the widen scap illuminate interval,

0:51

and we also see now, okay,

0:54

now that we understand right? That wedge shape of the lunate,

0:59

we understand why now the lunate is gonna spin out and cause this

1:04

DICI or dorsal interrelated segmental instability.

1:08

It's gonna tilt and, and face its distal surface is gonna face dorsally.

1:13

Okay? And along with that,

1:17

the capitate has a natural tendency to proximately,

1:21

migrate and wedge itself in between the scape void and the lunate

1:26

into this interval. Okay?

1:28

And when you start to get degenerative changes,

1:31

typically it's gonna start at the radio scape void, uh, compartment,

1:35

followed by the mid carpal compartment, specifically the capital lunate.

1:40

That's when you're dealing with slack wrist.

1:43

Now you have static carpal instability, and as you can see, okay?

1:47

And if you have a good, a nice radiograph, you can measure these lines.

1:53

Uh, the capital lunate normal is gonna be zero to 30 degrees.

1:57

And the scape lunate angles normal is gonna be, um, uh,

2:02

30 to 60 degrees. Okay? So other things you can see also,

2:07

as you develop carpal instability, the scape void again,

2:10

is gonna wanna tilt ly. When you have these, um,

2:15

scap lunate, uh, uh, ligamentous insufficiencies, the,

2:19

the scavo proximal pole is gonna tend to sublux sort of,

2:23

or move sort of dorsally, while the lunate is gonna,

2:29

uh, dorsi flex or, or get, uh, uh,

2:33

face dorsal or tilt dorsally, and also sort of boly slide.

2:38

The other things that you can notice here too, is that proximal migration,

2:42

and the capitate is gonna tend to sublux or rest on the dorsal lip

2:47

of the lunate. Okay? So now with this,

2:52

my surgeon personally, okay, at our institution,

2:55

they would be happy with me just suggesting, Hey, with this slack wrist, they,

2:59

and they already know about it, they're already planning for things like, uh,

3:04

wrist fusion,

3:05

or sometimes even a four four corner fusion or proximal row ectomy, okay?

3:10

To sort of, uh, make now create the,

3:14

make the distal row or salvage that interated, uh, segment,

3:18

okay?

3:19

Because that proximal caral row obviously has essentially failed as in this

3:23

case. So if I suggest that the secondary, uh,

3:27

extensor, uh, the, sorry, the secondary extrinsic ligaments supporting the scap,

3:33

lunate interosseous ligament, and that interval there,

3:37

and the rest of the carpus has failed, specifically the,

3:41

let's try to look at the radio scape capitate ligament.

3:44

And here prob probably whis about here, Palmer Lee.

3:49

And you can see that it runs from the radi, the,

3:52

the distal radius crosses over the scape weight and attaches upon the

3:57

capitate. Okay? The, uh,

4:00

s the scap trapezial triquetral or the STTL, okay?

4:05

Probably in here and arguably maybe some DGen in here, as you can see,

4:09

some gray area, okay. Or gray, uh, grayness to the, these ligaments.

4:15

And then finally, okay, the dorsal intercarpal,

4:19

uh, ligament, which is, uh, probably

4:26

we sort of cut off at the, uh, ax on the axials, but probably, uh,

4:31

some portion, is it? Some portions of it right here. Okay.

4:36

So those, that's my checklist for scape illuminate, um,

4:41

interosseous ligamentous failure. Okay? Uh,

4:47

dynamic or static instability, comma,

4:51

carpal instability, dissociative, and I'll put in parentheses,

4:55

CID, um, you know, Mayo classification, what have you.

5:00

So that's, that's how I tend to try to read these cases. But again, I,

5:04

I do try to tailor it for, for my clinical colleagues. If it's coming from,

5:09

you know, uh, uh, uh, uh, a,

5:11

a a a service provider that's not an, uh,

5:15

a hand surgeon that they're not familiar with all this anatomic lingo,

5:19

then I'll, I'll, I'll keep it more basic. And then I'll say, you know,

5:22

slack wrist refer to orthopedic, uh, surgeon or, or a plastic surgeon,

5:26

what have you. So with that, I'll pause for a moment just to, uh,

5:31

answer any questions about this case.

5:34

It seems like the risk for me is my achilles tendon, like,

5:38

especially when you're talking about couple instability. Uh,

5:40

a couple of things you already touched on in terms of the referring doctor,

5:44

and I know you've already mentioned you pick up the phone and phone the doctor.

5:48

Uh, in our, I think it's not so easy because one, the,

5:52

they see a lot of patients and then for us to describe which patient we're

5:55

talking about, then they'll have to go back to the notes.

5:57

They're not available at the notes. So the history is just trauma. So my,

6:01

my first question is, one,

6:03

do you have an approach that's standard for reviewing of wrist or two?

6:08

Uh, do you have a, a dedicated protocol for different types of, um,

6:13

pathologies that are sought in terms of like, um, they querying this,

6:17

but they just say trauma? Uh, and then you,

6:19

you speak to the patients a completely different history altogether. So, uh,

6:24

I'm not sure if I'm compounding things, but I just, I'd like, uh, like a,

6:28

a simplified approach for a broad spectrum of, uh, pathologies. If, if, if,

6:32

if you have one that you know of.

6:35

Yeah. So, so that goes back to some of our, uh, original sessions.

6:38

And if you go back to that session, so,

6:40

so I divide up every joint into my checklist is in general ligament,

6:45

tendon, joint, ancillary stuff to that joint, soft tissues, muscles, bones,

6:49

that's it. And it's, it's similar to the format some of you were,

6:54

were given for, for this course, and some of you I've seen, uh, submit,

6:59

but it's, it's pretty much similar thing, but I,

7:02

I just sort of condensed it down. I don't break it out into subcategories. Um,

7:07

so in the risks, uh, if I were to dictate it really quickly,

7:11

a normal risk for me would be, um, the triangle fiber, cartilage, scap, lunate,

7:16

intraosseous ligament, and lunar choal. Intraosseous ligaments are normal.

7:20

The flexor and extensor tendons are normal. The joint align is normal.

7:23

There's no evidence of static carpal instability. Uh,

7:26

the image portion of the median ulnar nerves are normal. The muscle,

7:29

soft tissues, bone morphology, marrow signal are normal. That's it.

7:33

And I use that ligament tendon joint ancillary stuff to the joint, uh,

7:37

muscles and bones and soft tissues. And I apply that to every joint,

7:42

be it the, you know, but obviously tailored to each joint, you know, the knee,

7:46

the elbow, what have you. But that's the way I, that's the way I,

7:49

I'm a structure by structured person. Some people, some of my senior staff,

7:53

they're, they're old, they're old school, so they trained on film,

7:57

and if you're still using film, that's fine. They, they,

7:59

they do it by compartments and by, um, basically more a,

8:04

a larger field of view. They do it by a compartment sometimes. So, uh,

8:08

some people do like flexor side, extensor side,

8:11

things like that for if you wanna apply that to the wrist, um, to,

8:15

to speak to your workflow, I guess. Um, we we're, we,

8:19

I have the benefit of sitting right next to my colleagues and being next to the

8:23

orthopedic clinic, and if I make a mistake, they will literally, uh,

8:28

and I welcome it. They, they gimme feedback. So, so, and, and we have a pretty,

8:34

uh, established, uh, electronic medical record system that we take advantage of.

8:38

So, so in that case, I think we have, um, I'm blessed in that,

8:43

and I, and I appreciate in that sense, um,

8:46

for protocols in general, um, if they're younger,

8:51

we like to do Mr. Arthrograms,

8:53

particularly if you know their planning surgery just to get it done. Um, that's,

8:58

and we just basically go by what our hand surgeons want.

9:02

But typically for traumas, um, radiographs and cts,

9:05

suffice for them for more chronic injuries. If they're worried about slack risk,

9:09

they wanna see prognostically, what they need to plan for, and,

9:13

and have that discussion with the patient, how much cartilage lost,

9:16

then they'll get a, a standard MRI without contrast.

9:20

But typically what I've noticed is in our practice, uh,

9:23

if it's younger and they're planning to do ATFC repair or a,

9:27

a ligamentous repair, then they'll tend to get the arthrograms, particularly in,

9:31

uh, high level athletes. Um, and,

9:35

and where they wanna return to play in, you know, um,

9:39

el in our elderly FO folks where the functional demand is less, you know,

9:44

there's, there's, there's not, I guess,

9:46

as much of a push to do orthographically.

9:48

If there's a mass is particularly a ganglion or things like that,

9:52

exclude ganglion versus mucinous tumor, then obviously we're gonna,

9:55

we're gonna push for iv, uh, or, uh,

9:58

if they can't get IV for whatever allergy or their, their claustropho,

10:02

they can't tolerate, then we'll, we'll, we'll,

10:04

we'll ask if they would like an ultrasound to confirm if there's any, um,

10:08

solid or vascular components within the lesion.

10:12

Thank you so much that, uh, that, that helps me a lot. Uh, I just found it that,

10:17

uh, for me, for all Ts CC injuries without fail, I'm, I'm doing it in rogram,

10:22

irrespective, because I'm not confident enough to, to do it without it, it just,

10:26

it makes it so much easier for me.

10:28

Oh, yeah, yeah, that's, and that's totally fine. And, and I'm sure too, I, I,

10:31

I don't know, I would have to revisit the literature, but you know, there's,

10:35

there's always gonna be, there's always gonna be those select few cases, right?

10:38

Where you have, let's say a tear, but it, it doesn't fill with fluid,

10:42

native fluid, right? And then it may be brought out by the arthogram,

10:46

same thing with the rotator cuff, right? If, depending on who you read, right,

10:49

5% of rotator cuff tears may fill with granulation tissue or maybe some

10:54

debris or synovitis or something. And,

10:56

and we may not see it with native joint fluid, but if you do an arthogram,

11:01

it fills out, and every once in a while, you know, the,

11:04

our surgeons will call and say, Hey, Eddie, you know, I totally, I, my,

11:08

by my exam,

11:08

I'm really convinced there's a undersurface tear here or a partial tear.

11:12

Can we do this arthrogram? I'll say, sure. You know, and, and, and that helps.

11:16

And I think that's been shown in the literature, at least for rotator cuffs,

11:19

I would have to visit for TFCs, TFC tears, but I think it helps in less than,

11:24

uh, 5% or less of patients. So it does help in a, in a select few,

11:29

Uh, sorry to take so much of your time. Um, when I do the agram, uh,

11:34

because the history and the fact that our patients are not based particularly at

11:39

our hospital, it can be, we,

11:41

we have some venues that have MR and some that don't. Mm-Hmm.

11:44

So sometimes they come with no imaging whatsoever. Mm-Hmm.

11:47

So I end up doing an agram not only at the, uh, distal radio joint,

11:51

but at the mid carpal row and at the, uh, skateboard pole. Mm-Hmm. Just to,

11:56

and that helps me with couple instability.

11:58

I don't know if that's a good thing or, or, or,

12:00

or you would advocate against it.

12:03

Uh, if, if you're doing it, I would say, I would say, you know, get, get, uh,

12:07

realtime images. So you kind of follow and you can figure out what,

12:11

what communicates with what. That's No, no, no. Otherwise, we,

12:15

we just inject the radiocarpal compartment

12:18

Only,

12:19

Only.

12:20

But what I'm saying is that,

12:21

And then we get delayed,

12:21

That's because your, your history is specific for that pathology.

12:25

Sorry, what

12:26

I'm saying, it's, that's because your history is specific for that pathology.

12:29

We, we've got no history. So I end up, uh, doing the,

12:34

the three rows, uh, yeah.

12:36

Yeah. And, and, and usually, you know, usually they're in, at least my,

12:40

my referring base, they, they care about TFCs and, uh,

12:44

SL IL injuries. So if you, if you inject the,

12:48

the RADIOCARPAL compartment and you have A-S-L-I-L tear or ATFC tear,

12:53

then usually you're gonna pick up both, right? If they're both present.

12:57

But again, too, sometimes you run into the situation where, hey, you know, um,

13:01

you have ATFC tear, but the, you inject the radiocarpal compartment,

13:05

but the distal radial ulnar joint doesn't fill through the TFC tear. Right.

13:08

It prefer, prefer it preferentially runs into the mid carpal compartment.

13:11

You have that sometimes too. Right?

13:13

So that's why sometimes it may be important to get a nice T two, right?

13:17

So that you, you know, you're not just relying on T one fat suppress, uh,

13:21

post contrast images, right? And then also too, right? Um,

13:24

I would highly recommend getting your delayed images, right,

13:27

when you're doing your fluoroscopy, right?

13:29

If you had the ability to screen grab and not, uh,

13:32

radiate the patient for a spot image or something, I'll do,

13:35

I'll just do screen grabs and then I'll, you know, ally deviate, radial deviate,

13:40

and get delayed images. And as I inject,

13:42

I'll puff one or two cc or puff a small amount of contrast,

13:46

and then watch what fills.

13:47

'cause so if I inject the radiocarpal compartment and it gradually fills the

13:51

tfs, uh, the drudge, then I know there's ATFC tear, right?

13:54

I I you really don't even need an MRI. Right? That's how they used

13:58

What, what's the purpose?

14:00

What,

14:01

What's the purpose of the delay though?

14:04

The delayed?

14:06

Yeah.

14:07

Oh, no. So, so when you're doing the arthrogram, right?

14:09

If you inject the radiocarpal compartment, right, let's say, and you see the,

14:13

the distal radial ulnar joint fill with your contrast, you know,

14:16

there's ATFC tear, right? Right.

14:19

And you really don't need an MRI if you really think about it.

14:21

And that's how we used to diagnose things. T uh,

14:24

we used to diagnose these injuries, uh, in back before MRI,

14:29

right? And then the same thing if you, if you're worried about sl IL tear,

14:33

and as you inject under fluoro and you, you inject the radiocarpal compartment,

14:36

and if you see your contrast shoot through

14:40

Alate,

14:41

You have a tear, right? So at least you have, you, you, you're able,

14:44

we're able to provide information. So I I, I will actually try to get these,

14:49

you know, delays or i'll, I'll grab images as you know, as we're injecting,

14:54

ah, follow the contrast.

14:56

Because you can imagine if you're doing a triple compartment injection, right,

15:01

with, if you're injecting the drudge,

15:03

the radiocarpal compartment and the mid carpal compartment,

15:07

how do you know where the defect is if you're not following your contrast?

15:12

Oh, I understand what you're saying. By delay, I mean, we wait a while,

15:15

not like, uh, yeah, take the paper. Yeah, no, no, no.

15:17

I'll, I'll do it. I'll do it. Yeah, I'll do it real time. Yeah. And,

15:20

and then I'll just a few

15:22

Delays, right?

15:23

And then sometimes the contrast just fills the compartment through a tear on a

15:26

delayed image, you know, I'll, I'll have them orally deviate, radial deviate,

15:31

sometimes circum conduct or, you know, whatever causes the pain. Yeah.

15:35

And then I'll, I'll watch it under, um, under, uh, ene, you know,

15:40

sometimes, or, or even, you know, sometimes you can see like a clunk, right?

15:43

If they have that, uh, that pre dynamic or dynamic instability.

15:47

So we can sometimes document that too. Rarely. So will

15:50

The, will the orthopedic surgeon be happy to just stopping at the, that day,

15:53

or will they look for cartilage loss or bone contusion thereafter? Because we,

15:58

we routinely from the, even though we've, same with the rotate cuff,

16:01

once you see that there's, there's contrast going up where,

16:04

where the supinate disease for a scenario or what you thought would've been

16:07

granulation tissue, uh, we end up doing the MRI Anyway.

16:12

S so sorry. So you,

16:14

you're asking if the surgeon wants me to comment on cartilage?

16:18

No, no, no. I'm saying,

16:19

do y'all stop there at the fluoro after the floral where you've diagnosed the

16:22

tear or

16:24

Oh, yeah.

16:24

No. Are they happy with that or are you, are you,

16:27

or they prefer that you take the patient back onto the table and

16:29

Find Oh, they, they want, they want everything. Yeah, there we go. Yeah. We're,

16:33

I think, I think we're in the age where more data better or, you know,

16:37

people like to have information. So you, and we're

16:41

Happy you stop there. Once you've diagnosed the table, then you,

16:44

there's no need for m mri. So I just want, there's,

16:46

There's no need. Yeah. Yeah. There's no need.

16:48

And that's how we used to do it in the old days, but Right.

16:52

We still proceed with the MR MRI these days. Right. We still do it, but, right.

16:57

But the nice thing is, if you,

16:58

if you do a nice fluoroscopic examination and the patient gets claustrophobic,

17:03

right? And they say, oh, I don't wanna do this, this at the MR portion anymore,

17:08

then you can, and you

17:09

Got, can I

17:10

Still have information, right? You say, oh, there's, you have to, you can,

17:14

we can infer that there's a tearer because of the communication, right?

17:17

So at least you can, you have a backup, a plan B to answer their question.

17:21

If the patient, uh, you know,

17:23

for whatever reason doesn't complete the r portion.