0:01

77.

0:02

We're making a big jump here.

0:05

So as, as many of you know, I mentioned,

0:08

I have my most favorite nation status

0:10

for certain body parts.

0:13

And I'll use the axial routinely anytime I want,

0:16

you know, comfort food.

0:18

You know, I want anatomy that I've used

0:20

to been seeing forever, and I use this a lot when I have

0:23

masses and tunnel syndromes.

0:25

But when I'm looking at the wrist, my first move, uh,

0:29

because again, I'm in a busy practice,

0:31

I've gotta be efficient in what I do,

0:33

is I put up all the coronals and I,

0:36

and I scroll them together, and I,

0:38

and I get a very good, an posterior radiographic feel, uh,

0:43

for what's going on.

0:44

Uh, and I can see which joints are affected.

0:46

For instance, the carpal metacarpal joints not so much,

0:50

but the, uh, mid carpal space, not so good.

0:53

And the proximal carpal row, uh, gulas arcs are, um,

0:59

are hampered quite a bit.

1:00

They're, they're extremely distorted.

1:02

And this time the capitate is drastically

1:06

migrating proximally.

1:07

There's ulnar translocation, uh, of the lunate, uh, uh,

1:11

in fact a, a fragment of the lunate.

1:13

But now this time, not only do we have the pointed radial

1:17

styloid, not only do we have the scaphoid fossa

1:21

that is hollowed out with no cartilage.

1:24

Not only do we have the, uh, radio lunate articulation,

1:29

which is destroyed.

1:30

We also have generalized arthrosis

1:32

throughout the carpal bones.

1:34

So this would be considered a more advanced, you know,

1:37

stage three or four,

1:39

depending upon which classification system you use, uh, uh,

1:42

of slack wrist.

1:43

And then you go about, you know, trying to isolate, uh,

1:47

the extrinsic ligaments in a case like this.

1:50

Now, the dorsal ones, you can see pretty well,

1:53

here's the dorsal intercarpal uh, ligament.

1:56

And there is the radio scavo triquetral ligament

1:59

that looks a little bit skinny.

2:01

Um, also this patient has a swollen

2:04

but present ludo triquetral ligament, one of the intrinsics.

2:08

And now let's took, let's take a look at the axial

2:12

and see just how, uh, just

2:15

how palmer the, the structures have sagged.

2:20

And let's take a look at the capitate.

2:22

And you can see they're really sagging into a lar position.

2:25

The median nerve is still maintaining its shape, it's still

2:28

maintaining, its its signal.

2:31

Here's the deep transverse carpal ligament.

2:33

Looks a little bit irregular right there.

2:36

And then there's quite a bit of fluid in the extensor, uh,

2:39

communis, uh, the third extensor compartment in Indicis.

2:43

And in speaking with my orthopedic colleagues,

2:45

in doing some research on this, I've heard a couple

2:48

of theories as

2:50

to why this occurs preferentially in this location.

2:53

One theory and one anatomic dissection that I've seen is

2:57

that there's attachment of this bursa to the periosteum,

3:01

and there are little tiny micro perforations in

3:04

that interface that may allow fluid

3:06

and edema to seep into this space.

3:09

Any other comments on this one, Don?

3:11

No, I think, uh, I, I wasn't aware of that anatomic, uh,

3:14

point with the, uh, tendon sheets, the, uh,

3:18

coronal, uh, images.

3:20

I think just commenting that this same pattern

3:24

or arthropathy, they always bring it up to our residents

3:27

and fellows is arthropathy of calcium pyrophosphate disease.

3:31

So I'm always asked, well, when,

3:33

when is it a post-traumatic slack?

3:36

And when is it a related to calcium pyrophosphate disease?

3:41

And I think, uh, the things

3:42

that help you obviously is the history of the age

3:45

of the, of the person.

3:46

Because post-traumatic slacks can occur in young people

3:50

where calcium pyrophosphate disease is, you know,

3:53

if something that you see later on.

3:55

And in fact, whether it's bilateral or unilateral.

3:58

So in cases like this, i I,

4:00

I think it would sometimes instructive

4:02

to look at the other side to see, uh,

4:05

if they're the same findings going on.

4:07

If there are, you know, it always makes me favor,

4:10

particularly if the patient is older that we may be doing

4:13

with calcium pyrophosphate.

4:15

And then I'm asked, well,

4:17

shouldn't I see chondro calcinosis somewhere?

4:20

And the answer is usually, but not invariably

4:24

because the arthropathy can occur, uh,

4:27

before the, you know,

4:30

or even without calcification anywhere

4:33

or in that, uh, particular joint.

4:35

And I think as you mentioned, the erosion of that

4:38

scaphoid fossa is so distinctive both for, you know,

4:43

traumatic slack and pyrophosphate crystal deposition.

4:46

And you and I both know, uh,

4:48

as I've learned from you over the years, that, that these,

4:51

these nasty pyrophosphate cases,

4:53

they can look like a charco risk.

4:54

They can look like an osteoarthritic risk.

4:57

And it is a 77-year-old, right man.

5:00

So he is older and he is got this very complex effusion

5:03

and some crazy looking erosions.

5:06

And with this kind of scooped out appearance, uh, that is,

5:09

that is a very, that's a logical thought

5:11

and something that, uh, has

5:13

to come into your stream of consciousness.

5:15

Shall we do another one? Yep.