0:00

Before I start, I just wanted

0:02

to show you this high resolution one millimeter on,

0:05

on just a regular man magnet with an arthrogram.

0:08

And frequently we don't perform arthrography in the wrist,

0:11

but just so you know, I know you're passot by ligaments,

0:14

but I wanna inculcate you with, with the terms

0:19

and, and prove that Dr.

0:21

Resnick is not making these up. They really do exist.

0:25

And here on an mr you can see

0:27

that radio SCA O capitated sling ligament.

0:30

There's your long radio NATO triquetral ligament,

0:33

not showing you the triquetral parts.

0:35

So there are two pretty important ones right there.

0:39

And you, you make an inverted V for the,

0:42

for the deltoid ligaments, you know, the superficial layer.

0:45

And then as you get deeper, you make a very, a smaller V.

0:49

And you can see that V here's one limit of the V right there

0:52

as part of the arcuate.

0:53

The other one not as well seen, uh,

0:56

he wasn't making up the radial collateral ligament.

0:58

It really, really is there.

1:00

And then as you get onto the dorsal side, you see

1:03

that your V is no longer inverted.

1:06

It's kind of sideways just to help you young

1:09

and sort of memorize some, some of these ligaments.

1:12

Here's the dorsal transverse carpal ligament,

1:15

and here is the long LAR radio lunate

1:19

or radio lu NATO triquetral ligament.

1:21

And there's your, there's your sideways beam right there.

1:25

So now let's get out of that and into the case.

1:30

Uh, there are a couple of views I use in the wrist when I'm

1:32

looking at scapholunate ligaments.

1:35

And, you know, I especially don't necessarily want

1:38

to put contrast in the joint.

1:39

It's not hard to do.

1:40

We've been doing 'em for a long time,

1:42

but we will use sometimes to elucidate dynamic and,

1:46

and static forms of instability, a steep radial

1:49

and ulnar deviation view.

1:50

And we'll bring the patient back.

1:52

And that's more efficient than, than doing the arthrogram.

1:55

Another thing we'll do

1:56

for radial ulnar instability is we'll do steep pronation

2:01

and supination of both wrists and compare the two sides.

2:05

Uh, let's look at our first case style.

2:07

And this is which one? 34. 34.

2:11

So this is a 25-year-old a youngin, uh,

2:14

with pain in the wrist.

2:16

He fell, he fell through a trailer

2:18

and landed on both of his outstretched hands.

2:22

He's got a, a, a history, a previous history of,

2:25

of fractures from it.

2:28

This case is interesting on a number of levels.

2:31

Uh, this happened several months ago, so most

2:34

of the fractures have bridged.

2:37

You can see he's got a little bit of residual bone edema.

2:40

But we do have a wide, uh, scapholunate interval.

2:44

So we have an example of at least sit, CID

2:49

and it looks like he's avulsed.

2:51

He has avulsed the scapholunate ligament from

2:54

the scaphoid side.

2:56

Remember, you can get it from the scaphoid side,

2:58

from the lunate side, uh, or, or, or in the middle.

3:02

Um, and you, you can volts from,

3:05

from either side of the bone.

3:06

So there are a few variations, I think, described

3:09

by Anderson in that classification system.

3:12

And then there's another finding

3:13

that I'm gonna come back to in a minute.

3:15

Look at the marrow. It looks, it looks a little strange.

3:19

He's a youngster. And you're seeing this sort

3:22

of window framing a little bit reminiscent

3:24

of say, Paget's disease.

3:26

This edema around the periphery in virtually every

3:29

bone in a young individual.

3:30

Look at these little stippled areas of hyperintensity.

3:33

When you see this, especially in somebody with persistent,

3:38

uh, pain in the extremity.

3:39

You have to think about CRPS

3:42

or complex regional pain syndrome.

3:44

Type one, formerly known as the artist,

3:47

RSD reflex sympathetic dystrophy.

3:50

Now let's look at our sagittal projection.

3:54

And we've got a, we've got a, um, a lunate

3:58

that is facing dorsally and, and why is that?

4:02

Earlier we described that some of these instabilities a

4:06

and changes in bone position don't occur just from, uh,

4:11

intrinsic disruption.

4:13

You have to have frequently extrinsic disruption.

4:16

Now remember, extrinsic doesn't mean extracapsular.

4:19

There aren't that many extracapsular ligaments,

4:22

the pizzo hamme, the pizzo metacarpal

4:24

and maybe one other one.

4:26

Uh, so how did he get this?

4:28

Well, you saw earlier, I know it was a blur

4:32

'cause it's a lot of ligaments,

4:33

but where is the radios scfo capitate ligament.

4:37

Uh, we can see a little bit

4:38

of the short radio lunate ligament here,

4:41

but the radio sca capitate ligament should come

4:44

plugging in right about here.

4:47

And you ne you never see it. Uh, come in.

4:50

Let's look at the coronal projection. Let, let's, sorry.

4:55

I, the radio scap capitate ligament is here.

4:57

My apology here on the lar side of the scaphoid

5:01

where it should be obvious right there.

5:03

And then as we get to the coronal projection,

5:07

we see the long radio lunate ligament, also known

5:10

as the radio triquetral ligament.

5:12

But look at the weird, almost sagging like position

5:17

of the radio scap capitate, uh, ligament

5:20

and even its base looks a little bit strange

5:23

as it comes off the, uh, periphery

5:25

or stylo styal portion of the radius.

5:29

So this patient has torn the radio

5:32

sca ffo capitate ligament, a very important volar extrinsic.

5:36

And they've also avol the scapholunate ligament off

5:41

of the sca filling.

5:43

Remember in the scapholunate ligament, it's the dorsal SLD

5:47

that's most, most important.

5:49

On the lunate side, it's LTV, like a TV

5:53

and that kind of has helped me through the years,

5:56

remember which one is more important?

5:58

Vola on the lunate side.

6:01

Dorsal on the scaphoid side are most important.

6:04

Don, do you have any comments on this one?

6:05

Yeah, I'm gonna comment on, on one

6:08

of the findings you mentioned,

6:09

which kind of had an interest.

6:10

And, and that's the marrow, uh, changes and,

6:14

and, uh, this is a very distinctive pattern

6:17

where you have a, like a bone within bone appearance where

6:22

the major abnormalities along the periphery.

6:25

And, uh, this is an interesting finding.

6:27

It was actually emphasized probably about five

6:29

or six years ago by Larry White in the knee,

6:33

not in the, in the wrist.

6:34

And he was talking about patients who had had

6:37

injuries, uh, to the knee.

6:38

And in the subacute stage he was pointing out the hyperemia

6:42

that occurs and the border like, uh, finding.

6:45

And in the knee it's usually the patella where you see

6:48

that in major, uh, it seemed best in the patella

6:52

and it is hyperemia.

6:54

And it certainly, when you see it, you have to think

6:56

of complex regional pain syndrome.

6:59

It also can occur particularly in the subacute stage of

7:03

injuries in young people without having

7:06

complex regional pain syndrome.

7:08

Um, so I usually give 'em a, a, a differential

7:12

for that, uh, finding.

7:14

Once you give someone complex regional pain syndrome,

7:17

I think it's kind of like a lifelong diagnosis.

7:20

It's in, in many pathway of, my associate always told me,

7:24

uh, don't give it as a single diagnosis.

7:27

That that often.

7:28

The other point, if you think back to radiographs

7:31

and you look at patterns of osteoporosis

7:34

that occur fairly rapidly

7:37

as in complex regional pain syndrome.

7:39

The other one are bands of lucency

7:42

that occur either in the epiphysis

7:44

or at the metaphysis where the physio plate was.

7:48

So that's another pattern sometimes you'll see with Mr,

7:52

where you see bands

7:53

and that do suggest hyperemia

7:55

as you indicated in this particular case.

7:58

And I, and I don't think this patient turned out to have,

8:00

well this patient did not turn out to have CRPS,

8:04

but I unfortunately, I've had

8:06

very deep personal experience within my own

8:08

family with this condition.

8:10

It affecting the essay node in this person, the intestines,

8:14

the bladder, the throat,

8:16

and of course the lower extremity, which

8:19

she nearly lost as a result of the condition.

8:21

So I'm very sensitive to it.

8:22

Anytime I see this peripheralization, uh,

8:26

of marrow hyperintensity,

8:27

it's at least something you've gotta think about.

8:29

'cause if you miss it, the longer it goes, the harder it is

8:32

to get rid of and treat.

8:33

But it is a real thing. Yeah,

8:35

Yeah. Okay,

8:36

let's move on to the next one. I.