0:00

Okay, so this is a 38-year-old

0:04

with a work-related injury

0:07

with ulnar sighted pain radiating into the fourth

0:11

and fifth digits with according to the patient,

0:16

uh, clinical swelling.

0:19

So this is one where we do have a little bit of rotation

0:22

of the ulnar styloid.

0:23

And on the, on the initial T one,

0:25

let's blow it up just a little bit.

0:29

It's, it's very busy and intermediate

0:31

and signal intensity about the styloid.

0:33

We get over to the, the water weighted image,

0:37

and you can see there is an attachment there to the,

0:41

to the styloid and to the fovea.

0:44

It's a little easier to appreciate in the sagittal

0:47

projection and also on this proton density image.

0:50

The structures are still there.

0:51

Let me blow it up a little bit bigger,

0:57

but the abnormality this time is, is in the center.

1:01

Now, I don't, I don't like that term center, but I use it

1:04

because everybody recognizes it to me.

1:06

The center is like right in the middle of the TFC,

1:09

but I think what they mean is it's close to the radius,

1:12

it's close to the base of the lunate.

1:14

And as Don mentioned, you know, we're trying

1:17

to sort out the different signals in the lunate.

1:21

Um, the patients with ul, no lunate abutment, they're going

1:25

to have their abnormalities on the triquetral side.

1:27

And by the way, you can get abutment of the trium itself.

1:30

You can get TriCal abutment with negative ulnar variants.

1:34

You can get ul no radial A, a abutment a

1:37

and the variance does matter.

1:39

Now, hand surgeons are very particular people.

1:42

They're like the neurosurgeons of the body.

1:45

They're very precise.

1:46

And I, I can't tell you

1:47

how many times at Monday morning conference I've told 'em

1:50

there was negative on their variance.

1:51

And they said, no, you can't measure

1:52

that without a plain film, without these views

1:55

and these angles and a clench fist view, et cetera.

1:58

So I've gone to a little bit

2:00

of common sense calling it ulnar variance posture,

2:03

and they have readily accepted

2:05

that once I throw in the word posture.

2:07

So that's, you know, that's solved all the problems.

2:09

A little bit of linguistic, uh, uh, comradery.

2:13

And then the other thing I do, you know,

2:15

I don't do a clench fist view

2:17

and everybody, in fact, very few, uh,

2:20

but if I have, you know, more than eight millimeters

2:22

of disparity between the body of the ulna

2:25

and the radius, I'll, I'll,

2:26

I'll give the posture description,

2:28

whether it's distal or proximal.

2:30

Now, if it's distal, and a lot of times it's dynamic

2:33

with the hand clenched view

2:34

or with ulnar deviation, you know,

2:37

then they will get abutment.

2:38

Just, but just by inference, by the fact

2:41

that you have the osteo conval erosion, you know,

2:43

you must have abutment.

2:45

Now a negative ulnar variance.

2:46

You have other problems, one of which keen box,

2:48

but another one that is not well recognized,

2:51

but I see all the time in young individuals, significant

2:55

negative ulnar variance leads to

2:58

traction on the ulnar capsule on the TFC,

3:01

on the ECU and its sub sheet.

3:03

And I see an abundance of peripheral TFC tears

3:08

and ECU tears

3:09

and the negative ulnar variance group almost never see, uh,

3:13

keen box disease and that group.

3:15

So in classifying this, you know,

3:17

I go one a thinning Palmer, one A thinning,

3:20

and I do use a few classifications in radiology.

3:23

The Palmer is one I use

3:25

because the hand surgeons speak that language.

3:28

One A thinning, uh, one B uh, all no,

3:32

and ludo malacia one C-A-T-F-C tear and 1D

3:36

and LT ligament tear.

3:38

And then category two is more degenerative,

3:42

A, B, C, D, and E.

3:44

And, uh, a actually that, that is category two, my apology.

3:48

Category two is A thinning B, CIA

3:52

and lu nato, CIA C perforation, D LT ligament tear,

3:57

and then e generalized degeneration of, of the,

4:00

of the carpal bones.

4:03

One category one is purely traumatic,

4:05

and that would be central peripheral distal,

4:09

and then radial, which which I see very uncommonly

4:12

separation from the radial.

4:14

So I use those two Palmer one for trauma,

4:17

Palmer two for degenerative.

4:19

And the third thing I'll use that I'll discuss tomorrow

4:22

is the Leady packer classification

4:24

for flexor digitorum injuries,

4:26

which we'll be discussing, uh, separately.

4:29

So this is a Palmer degenerative to C.

4:34

The TFC is torn.

4:36

There's all no LAC

4:38

and the, uh, the patient has overall synovial reaction here.

4:43

Any comments on this one, Don?

4:44

Well, just a comment about NAR length, uh, one

4:49

of my best friends through the years was Lou Gall Lula

4:53

and Lou Gall Lula specialized in hand

4:56

and wrist that he spent his whole life on that,

5:00

and he lectured to all of the orthopedic surgeons

5:03

who were involved in hand and wrist surgery.

5:05

So I'm sure some of the people who

5:08

didn't accept initially the term you were using related

5:12

to the fact that Lal, Lulu would say you need perfect

5:16

positioning at the level of the shoulder, the elbow

5:20

and the wrist in order to measure the length of the ulnar.

5:23

But I can tell you in my practice, uh, in a lot

5:26

of the cases, we don't have conventional radiographs that I,

5:31

you know, eyeball it.

5:33

And even though I think we make mistakes sometimes, uh,

5:37

if it looks like it extends significantly

5:40

and that's an eyeball term,

5:41

then I will say it's all in their positive variance.

5:44

Although the positioning for MR varies so much for the risk

5:48

that I'm sure in some cases I'm over diagnosing it,

5:52

but we have Lou to blame for that.

5:54

Well, I'm glad we have somebody to blame.

5:57

Um, you know, I use the secondary signs too.

6:00

You know, when you're, you're into ulna malacia and Lomaia

6:03

and triquetral malacia, um,

6:05

and that you clearly the TFC is, is taking a hit, um,

6:10

you know, I feel comfortable either saying that there's

6:13

positive UL variance posture,

6:14

or I'll ask for a clench fist view

6:16

and say, likely this patient has

6:18

dynamic positive ulnar variance.

6:20

Okay, shall we do another one?