0:01

I don't have the age on, on this patient,

0:06

but I think I'm going to to march through the severity

0:10

of some of these, uh, in instability cases.

0:13

And again, I think we have a, um,

0:17

in this case I think we have a Sid case.

0:20

Let's look at the physician of a, the oid.

0:23

It looks pretty good. And through the years,

0:26

I think I took a little bit of criticism

0:27

for this earlier on in my career.

0:30

I said, I never measure this angle.

0:32

I just estimated by looking at it.

0:34

I can usually tell what's about 45 degrees in the sagittal

0:37

projection when I look at this vertical axis.

0:40

And I allow 10 degrees in either way.

0:43

If I've got a very droopy scaphoid,

0:45

I know I have a more complex problem

0:47

that usually involves an extrinsic along with intrinsic,

0:51

and if I have it standing up similarly, I also, as,

0:54

as Don Resnick showed you earlier, I,

0:56

I could also have a form of complex instability.

0:59

So I don't wanna see it verticalized

1:01

and I don't wanna see it.

1:02

So-called lying down some, just some simple propositions

1:06

to help you get through the case.

1:08

So we look at the, the coronal projection

1:12

and the patient has a longstanding, uh, scapholunate, uh,

1:16

ligament area of widening.

1:18

You don't need an arthrogram for this.

1:20

The lu NATO triche ligament while,

1:22

while much smaller and harder to see.

1:24

Let me blow it up. Uh, you, you can infer that it's intact,

1:29

uh, because the joint looks absolutely perfect

1:32

and so do the adjacent structures connecting

1:34

to the styloid and phobia.

1:37

So we're focused here.

1:38

We go over to the sagittal projection.

1:40

We see that the, the scaphoid, uh, has a little bit

1:44

of a strange hump in the back.

1:45

So maybe it was fractured at some point.

1:48

There's a little bit of edema associated with it.

1:51

But the patient also has another interesting finding,

1:54

and that is, uh, the radius

1:59

and radial styloid is now very pointed,

2:02

and that can be one of the earliest signs.

2:03

It is one of the earliest signs of slack wrist

2:06

and look at the narrowing in the, in the skate fossa.

2:10

I've seen something similar to this

2:12

and I think Don showed you a picture reminiscent, uh,

2:16

of this appearance in, in somebody

2:18

with pyrophosphate disease, where you get this sort

2:21

of really weird scooped out appearance of the radius.

2:24

So this isn't the only cause of it,

2:26

but we do have a reason for it.

2:28

And then the next thing I'll do is I'll want

2:31

to see what's happening in the mid carpal space.

2:34

So I'll usually pull down the axial.

2:36

Let's do that where I wanna make sure not only are the mid

2:39

carpal structures, uh, starting to sag approximately,

2:43

but I wanna make sure they're not sagging

2:45

into a lar position.

2:47

Now they are a little bit,

2:49

but if they get to vola, you can end up

2:51

with secondary carpal tunnel, tunnel syndrome.

2:54

And here, here's your median nerve.

2:56

So this would be an example of a, a stage one, uh,

2:59

slack wrist where the scalid fossa is affected.

3:03

There are erosions in narrowing.

3:05

The lunate faucet is spared,

3:08

and the rest of the carpal bones while not perfect,

3:11

are are not heavily involved.

3:12

And while we're at it, there's another one of your

3:15

arcuate ligaments on the ulnar side

3:17

and another arcuate ligament on the radial side just

3:20

to get you a little more inculcated to these ligaments.

3:24

Any thoughts on this one, Don?

3:25

Yeah, the one thing I, I just would comment on is on

3:28

that sagittal, it looked like the images you had up

3:31

that the skateboard is dorsally sublux, which I, I,

3:36

i dunno if you go back to this.

3:37

Yeah. So it's significantly dorsally sublux

3:40

with respect to the radius.

3:42

And, and I, I bring that up

3:44

because that is associated

3:46

with scape illuminate dissociation in the later stages.

3:50

And I have found that to be a very useful, uh, thing to,

3:54

uh, to look for.

3:55

I would agree with you that, you know,

3:57

that hump on the dorsal surface

3:58

of the scap foot looks strange

4:01

and probably there was some, some, uh, injury there.

4:04

Uh, thanks for pointing that out. Which, which I did not.

4:07

And then also look at the coronal, look at the strange force

4:11

of the radio scap capitate ligament, which would go along

4:15

with atory abnormality, uh, of, of the scaphoid,

4:19

but would also go along with, with a slack wrist.

4:22

Shall we move on to the next one? Yes.