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We're gonna finish up in the last, uh, three minutes

0:03

or so, talking about several syndromes

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that have been described involving the distal ulnar

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and the region of the triangular fibrocartilage complex.

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The first of these is designated radial ulnar

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and impingement syndrome.

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It's associated with an ulnar minus variance.

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The main abnormality occurs arthritic changes

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of the distal radio ulnar joint.

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As you can see in this particular example,

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this can be extremely painful,

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can be associated with marrow edema.

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The pain, particularly with pronation and supination.

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And one of the interesting aspects

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that you will see when you're dealing with a short ulnar is

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that the styloid process may enlarge.

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Okay? So you'll end up with something like this.

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This is an ulnar styloid IMP impaction syndrome

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with radio ulnar impingement.

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So the NARS minus, you have arthritic changes here,

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but the styloid process was very large.

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Now flattened because contact with the carpal bones

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in these cases, you know, lesions

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of the lunar triquetral ligament

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and cartilage abnormalities in the carpal

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bones would be expected.

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And then the nar carpal impaction syndrome,

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this is associated with positive ulnar variance

1:28

as shown here in a cadaver, narrowing the distance

1:32

between the distal ulma

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and the proximal carpal row, basically associated

1:38

with large degenerative defects within the triangular FI

1:42

fibrocartilage disc, cartilage loss

1:46

and bone abnormalities in the lunate and in the triquetral.

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So here's another cadaver, many cadavers with this

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four findings, the long ulna,

1:58

the abnormal triangular fibrocartilage disc, part

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of the complex, the abnormal lunar triquetral interosseous

2:06

ligament, and car bone abnormalities here

2:09

shown in the lunate.

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Here's the MR image in that case,

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showing you the same four findings.

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Uh, classic ulnocarpal impaction.

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This is what it will look like.

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It's one of the causes of cysts and edema in the lunate.

2:26

So here a slight ulnar positive variance changes in the

2:30

triangular fibrocartilage disc.

2:33

There was cartilage loss in the lunate.

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But I want to point out that typically when dealing

2:39

with all no carpal impaction

2:41

or abutment, the major abnormalities are on the medial

2:45

aspect of the lunate.

2:46

The marrow edema may involve the entire bone,

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but you're gonna look for changes in this location,

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and that's an important point with terms

2:55

of differential diagnosis.

2:58

Precondition shown here in one slide, this is

3:02

although carpal impaction

3:03

or abutment, where the abnormalities are mainly on the

3:07

medial aspect of the lunate, this is keen box disease,

3:11

which begins as a stress fracture associated

3:15

with ulnar neutral

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or ulnar minus variants, either not ulnar positive,

3:21

eventually leading to fragmentation of the lunate

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as shown in this case.

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And then the ganglia inst the most common location

3:29

of an interosseous ganglia inst in the carpal

3:32

bones is the lunate.

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The most common part of the lunate

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that is involved is the radial aspect,

3:39

and often associated with problems

3:41

with the scap lunate interosseous ligament,

3:44

in this case TFC problems as well.

3:47

So that's the main differential when dealing

3:50

with Olo carpal impaction syndrome.

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So what I've done in my allotted period of time is to go

3:57

through the triangular fibrocartilage complex.

4:00

Quadrangular complex, which I think is better.

4:04

I've shown you a lot of the normal anatomy, some

4:06

of the recent, uh, information that has been

4:10

provided over the last five

4:11

or 10 years, the usefulness

4:14

of the Palmer classification system,

4:17

although with exceptions, which I have, uh, shown you.

4:21

And, uh, hopefully that'll make it a bit easier for you

4:24

to interpret these studies.