0:01

Okay, this is a 19-year-old,

0:04

and, uh, this is a patient

0:06

that had a fall on an outstretched hand, a so-called

0:10

boosh type, uh, abnormality.

0:12

And, and I don't think it's any secret

0:15

that there is a transverse fracture

0:18

and it, it is hard to miss a fracture on mr.

0:21

Of, of the scaphoid.

0:23

And I've seen many cases

0:24

where I've had microtrabecular intramedullary

0:27

fractures in young individuals, um, contact athletes

0:31

that went back out to play persistent pain in the

0:34

MR is done and it's obvious.

0:35

So this is a wonderful test, uh, to

0:39

absolutely exclude a scaphoid fracture when your playing

0:42

film is negative and you still have a strong suspicion.

0:45

We've got all our ligamentous friends back again.

0:48

Um, I won't, uh, I won't hit you with it again, uh,

0:52

but look at how beautiful the lar extrinsics

0:55

are on this one.

0:56

The radio scavo, capitate

0:58

and long radio triquetral ligament

1:01

or long radio lunate ligament.

1:03

But what's going on here?

1:04

This is a talk about the TFC and TFCC.

1:09

So let's start out along the vola aspect of the TFC.

1:12

We see a little bit of the, the hoal analog region here, uh,

1:16

blending with some of these distal, uh,

1:19

ulnocarpal ligaments.

1:20

There's one that's actually called the ulnocarpal ligament

1:24

that kind of centers itself right around the LT ligament.

1:27

The one that's kind of easiest to identify

1:30

is usually the ul no tri ligament.

1:33

And, uh, then you also have the ulna, uh, lunate ligaments,

1:37

part of which you see right here.

1:40

So there's a fair amount of swelling peripherally,

1:43

and one thing you have to be careful

1:44

of is if the wrist is rotated.

1:46

It may be really hard to tell

1:48

whether the peripheral attachments are detached

1:52

or whether they're just curving at you.

1:54

So that's why you have to get in the habit of resorting

1:57

to the, to the sagittal projection

1:59

and not rely on the, on the comfortable sweater,

2:03

namely the coronal projection.

2:05

And it's awfully swollen here.

2:08

The, the body, uh, and the substance of the TFC is spared.

2:13

And as mentioned, the most common tears are in the center.

2:16

They're usually treated conservatively

2:17

because you really can't get a stitch in them, nor

2:21

nor should you, they, they usually will

2:23

resolve on their own.

2:24

So now let's go to the, uh, let's go

2:27

to the sagittal projection

2:29

and let me see if I can find it underneath these letters.

2:31

Here we go. And let me blow it up for you.

2:39

And there is our radio scap capitate ligament.

2:41

Just to get you oriented, let's go over the radial side

2:44

where our fracture is.

2:46

Then back to the ulnar side.

2:48

Let's get, get it a little bit lighter.

2:50

And you look at the volar aspect of the TFC, the proximal

2:55

and distal attachments

2:57

to the vol oola radial ulnar ligament,

2:59

which is this tissue right here looks sweeping

3:03

and curve linear and contiguous.

3:05

They're intact.

3:06

But when you go to the back, there's this curious

3:10

vertical area of high signal intensity, uh,

3:13

which is reminiscent of your dorsal capsular injury

3:16

that you showed earlier.

3:18

And this is a dorsal capsular injury.

3:20

Now look how, look, how sweeping

3:22

and clear cut, uh, this, uh,

3:25

distal attachment is right here.

3:27

And when we go to the dorsal side,

3:29

it is truncated right there.

3:32

And you see the proximal portion,

3:33

but you never really see a very good, uh, distal portion.

3:37

So the distal portion of the TFC along

3:41

with the capsule is injured.

3:43

And then you go back and you look at the corone

3:45

and say, why does this, this looks so crimped looking

3:48

so wavy and irregular, and it's be perhaps

3:50

because you've lost the dorsal tether

3:54

of the triangular fibrocartilage posteriorly.

3:57

Um, any comments on this case,

3:59

Don? No, I thought this

4:00

was a, uh, a difficult, uh, case to try

4:03

to figure out in, in cross-referencing,

4:06

and I wasn't quite sure what was,

4:08

what was torn in this particular case.

4:11

And it may be multiple structures, but,

4:14

but I, I don't have a real good feeling about this case as

4:17

to, uh, we, we don't have the op notes

4:20

or anything on the case, do

4:22

We? Um, we

4:23

have the arthroscopy note

4:24

And what do, so, you know,

4:26

It was a peripheral, it was a di peripheral

4:28

and distal TFCC tear

4:30

And they thought that was a flap of tissue, or

4:32

It was, it was a flap of the all, no triquetral ligament.

4:35

Dorsal, okay. And then you've got this, which is dorsal.

4:40

There should be a, there should be something

4:41

that looks a bit like that right there,

4:44

and it is absent right there.

4:46

Yeah. All of those ligaments, by the way

4:48

that we were talking about, uh, ul no lunate, ul no triche,

4:53

there are dorsal ligaments as well,

4:56

although the, the literature on them is very, very limited.

5:00

Yeah. And I mean, generally they sh you know,

5:02

they're supposed to be paired.

5:03

There should be a vola set, there should be a dorsal set.

5:06

The volar set tends to be thicker

5:08

and more reliably identified.

5:10

But I think supporting the diagnosis is the inflammation

5:13

and swelling that you have back here in the

5:15

locus of the injury.

5:17

And he did have ulnar cied wrist pain.

5:19

Yeah. Another question,

5:20

and you know, that might be interesting to go back

5:23

to the escape fracture would be, I'm,

5:25

I'm curious on your workup of OID fractures.

5:30

Uh, in terms of osteonecrosis of the proximal pole.

5:34

Uh, you know, there's a lot of literature on this,

5:36

and in our practice, uh,

5:38

we rely not on intravenous gadolinium.

5:41

We're not doing that as a routine.

5:43

We rely on the signal intensity in the proximal fo,

5:47

which tends in the cases that, that we've seen

5:50

as osteo necrotic as generally low signal.

5:53

Low low is what we're looking for, uh, our results with,

5:57

with intravenous gadolinium.

5:59

We don't have a lot of experience,

6:00

but I've read the literature

6:02

and they're mixed results using IV GAD to determine whether

6:06

or not the proximal pole is necrotic.

6:08

Do you have a routine for that or?

6:10

I, I do. And unfortunately, youthful exuberance led me

6:13

to inject them all in the beginning, maybe

6:16

for the first eight or so, maybe 10 years.

6:19

And I realized that it was a lost leader. I gave up on it.

6:23

And, um, now I simply use sclerosis

6:27

and uniform hypo intensity to make the diagnosis.

6:30

I don't inject them anymore.

6:31

Yeah. And I, I think that's, uh, I do believe that's

6:35

what we're doing at at our universities, uh,

6:37

and the teleradiology cases that we don't have too many

6:40

of them, but I think they're relying without the gad.

6:44

But I think in general, that,

6:46

and, uh, I know some of the experts who lecture on

6:49

that particular topic have said that the GAD might not, uh,

6:53

provide additional information.

6:55

Well, I've got firsthand experience that it hasn't been

6:58

that reliable for me. Yeah.

7:00

Okay.