0:00

So here we are again with my most favored nation status,

0:04

the coronal projection.

0:06

So it's a 57-year-old, let me give you the history.

0:11

They, they didn't give a lot of history.

0:14

They said they were concerned about ad ununited fracture.

0:18

I suspect that was from an X-ray in their office.

0:21

And as time has gone on, I started out,

0:24

I didn't have X-rays available to me in the eighties,

0:27

uh, most of the time.

0:28

And then I got X-rays all the time.

0:30

Then I said I didn't need them.

0:31

And I've matured to the point where I now like

0:34

to have a radiograph with, with my,

0:36

my Mrs for a number of reasons.

0:39

Uh, but through the years, you know, I, I attempted

0:42

to read them without it for expediency

0:44

and I often didn't get radiographs in the

0:46

teleradiology world.

0:47

But if you've got them, look at them.

0:49

If you don't have them and you need

0:51

them, absolutely ask for them.

0:53

It's important. And here we've got a, um,

0:57

a proximal carpal row arc disruption.

1:00

There. There's probably even a little bit of disruption

1:02

of the, of the mid carpal space the next row forward.

1:07

And there's some ate ha hammed erosive change, uh,

1:11

with this unstable trans located rotated lunate.

1:16

So we've got a, we've got a scap o lunate ligament problem.

1:20

We've got a ate triquetral ligament problem

1:23

because look at the position of that lunate relative to the,

1:28

uh, relative to the triquetrum.

1:31

And then let's go to the sagittal projection.

1:37

And in the sagittal projection, we've got a ventral

1:41

or lar facing lunate.

1:43

It's a bit fragmented as well.

1:45

So we have a component of

1:47

volar intercalary segmental instability.

1:49

And remember the case where I, I showed you the wrong side

1:52

of the scap o uh,

1:53

radio scap o capitate ligament by accident.

1:56

It's in the front and here it is. It really does exist.

2:00

It's beautiful. Uh,

2:01

you can almost always see the insertion on a decent quality,

2:05

uh, sagittal projection.

2:07

Um, so let's take a look at the axial

2:11

and look at the character of displacement.

2:13

This time we don't have as much lar displacement of the, uh,

2:18

mid carpal structures as we did before.

2:21

Um, any comments about this case

2:24

with a complex proximal carpal row pattern

2:27

of intrinsic failure and, and visi?

2:30

The, by the way, the, the

2:31

skateboard angle looks pretty good.

2:33

Yeah, I can't tell, uh, looking at that, uh,

2:36

lunate handmade disease, whether this patient began

2:40

with two distal facets of the, of the lunate I I'm looking

2:45

or whether that is acquired from the disease.

2:48

But I just again, would point out the association of

2:53

two distal facets of a lunate

2:55

and lunate amid arthrosis, which can be extremely painful.

3:00

I've known some one person who had it

3:03

and it was extremely painful.

3:04

So that too may have led to some of the changes

3:08

that we see there, particularly in proximal bowl

3:11

of the, of the handmaid. Uh,

3:13

Sure. And they can get

3:14

tris, Gaia arthrosis from that.

3:16

They can get pain right at this articulation from that.

3:19

I've seen 'em get even keen box.

3:21

Well, that is associated with

3:23

That. Associated with that.

3:24

And,

3:24

and interestingly, we do see, despite this pattern

3:27

of instability, we do see the short limb of

3:30

that arcuate ligament on the ulnar side.

3:32

The, the radial side is there as well.

3:35

But I was never able to resolve,

3:37

and I don't know the answer to this

3:38

'cause I wasn't at surgery, but I was never able

3:41

to resolve the ulnar triquetral capitate,

3:44

which is the long limb on the ulnar side of the deltoid.

3:47

And I suspect it is gone.

3:49

And, and that has contributed in part to the patient's,

3:53

uh, visi posture.

3:54

Yeah, I think identifying the deltoid ligament,

3:57

particularly looking for that vol,

4:00

no capitate ligament is probably the most difficult.

4:04

The arcuate, I think, is easier to see than

4:07

the entire deltoid ligament.

4:09

Yeah. And, and the, the radial, the radial limb

4:11

of the deltoid is beautifully seen.

4:13

So that makes you all the more suspicious

4:15

'cause it's good image quality, all the more suspicious

4:18

that the ulnar limb is gone.