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This is a 67 year old man with constant,

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moderate and dull pain in the left hand with difficulty lifting or using the

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hand. Quite a few of you said effusions, synovitis,

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marrow edema. Um, now mar edema is a finding,

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but it's not, not a diagnosis. A few of you said no degenerative disease.

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A few of you said the intrinsics were intact,

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no flexor extensor pathology. And um, the history was a dull,

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a dull pain, especially when lifting. Now, when I,

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when I look at a wrist case or any case for that matter,

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um, but especially in the wrist, I like to,

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I like to pony up the coronals 'cause I really feel like I am,

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I am looking at a radiograph. You know,

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I understand the anatomy in this projection so well. Now,

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if you remember earlier I was talking to you about the,

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the extrinsics and I said that they make an inverted v. Well,

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here is the inverted V right there.

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There's one limit of the V gorgeous on this gradient echo image.

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There's one limit of the V and there's the other limit of the V.

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And this potential weak space, uh,

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underneath it is known as Corona's space with with ap.

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Then you've got another set of shorter vs that, that sit underneath it.

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And those are a little bit beyond our discussion today.

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One of the most important vs is the radio sca o capitate ligament,

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also known as the sling ligament that prevents rotary subluxation of the

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scaphoid.

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Another one is the long radio ludo triquetral ligament.

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It goes to here, but then it keeps going over to the triquetrum.

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So that one also is intact. So a, a great,

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a wonderful view of the extrinsics.

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And remember I said that on the dorsal aspect of the wrist,

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the extrinsics make a sideways V. Well, here it is.

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There's the sideways V, the dorsal intercarpal ligament.

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And then there's the other component of the V. So there's your sideways V,

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beautifully illustrated. Now again, I,

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I love this coronal projection because of its anatomic character.

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I got my T one for marrow.

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I've got my my water weighted image for detection

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and I've got my gradient echo image for the capsule

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and the cartilage. Here's the cartilage right here.

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So it's an intraarticular sequence and true to form, there's your membranous,

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triangular scapholunate ligament.

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And then there's your lu NATO triquetral ligament,

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which is so much better seen than in the last case. You have cartilage,

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cartilage and then the capsule in between.

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Everything is just peachy in the ludo triquetral interval.

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Everything is perfect in the

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Scapholunate interval. Here you are dorsally,

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there's the trapezoid shape of the ligament.

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And here you are in the LAR portion.

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And here's the more band like shape of the SL ligament.

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So that's not the problem. Now,

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whenever you're looking at an M MSS K case and you're new to MSS K,

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one of the easiest things for you to do is to play nuclear

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medicine doctor.

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So what does a nuclear medicine doctor do on a bone scan?

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They look for hotspots. Do we have hotspots? We most certainly do.

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Let's go one up and let's go. Searching for hotspots. Oh,

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we got one right there. A little tiny one. Could be an injury,

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could be an erosion. We've got a big hotspot in the, in the hammid.

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We've got a big hotspot at the base of this metacarpal and the base of that

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metacarpal. And let's check out the triquetrum. Maybe not,

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maybe not.

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Now let's look at the T one weighted image because that's gonna help us

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determine whether it's a micro fracture or a macro fracture.

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Now a macro fracture is gonna have a discrete line.

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And here is my discrete line right here. Right there.

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And you can see a cortical step off. There's the cortical step off.

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Let's take my lines away. There's your cortex,

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no cortex. So you've got a non-displaced fracture.

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You're gonna see that on an x-ray. Unlikely, unlikely.

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And look at how big this handmaid fracture is.

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You can hardly see anything on the T one. So when I see it here,

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but I can't really see a line on the T one,

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I'm gonna call that a micro trabecular fracture

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or an intramedullary fracture or an Inc.

4:50

Chondral bone fracture or a spongy bone fracture.

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Let's go to the base of a fourth.

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Now here it's a little more challenging. There's a lot of edema there,

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but I can surmise a little line there.

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So this is another one you're probably not gonna see on the X-ray.

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I would also call a microtrabecular fracture.

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So this is a non-displaced fracture. This is a microtrabecular fracture.

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This despite the edema is a microtrabecular fracture. Why is that?

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'cause it has these little tiny spidery lines,

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but it's not transcortical like these right here. Now,

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if you wanted to call it a high grade contusion outta mind,

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high grade contusion microtrabecular fracture, fine.

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And I often say that there is likely to go going to

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be no correlate on radiography.

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Now one other thing you have to do is make sure you don't have any chippers.

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What's a chipper?

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A little piece of cortex or edge of bone that's come off that you can see on an

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x-ray. So let's

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Scroll very carefully and I think we, we may have a chipper right here,

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right there.

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And right there there's your chipper. So our,

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our handmaid fracture,

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which was originally intramedullary without a discrete fracture line,

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now has become a microtrabecular fracture with a

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chip fracture. And if you had a radiograph, you would see that.

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Now let's go to our short axis view and let's make sure that the hook of the

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handmaid is not detached. It is not,

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it is not detached.

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And you can see the edema fades as you go into the handmaid hook.

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So that's all good news.

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And then here are our metacarpal abnormalities, which we described earlier.

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And you can see the one that I said was a fracture.

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There it is again with the fracture line going anterior posterior.

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The one next to it very ill defined microtrabecular macro

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trabecular. And let's see if there's anything else going on here.

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Now, I don't mind that the median nerve is bright. Why don't I mind?

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Because it's not a T two. It's a proton density, fat suppression.

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The median nerve can be bright on that. It's just not supposed to be bright.

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On a true T two, this is a true T two.

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That is the normal signal of the median nerve to compare with our introductory

7:28

case.

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So you see the dramatic difference between a normal and the earlier one that

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was abnormal.

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So this is a series of bone injuries that show you the spectrum of

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contusion, microtrabecular fracture,

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macro fracture, ship fracture with a little bit of displacement.

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And here's how I grade the, the bone injuries. I go from low grade contusion,

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I only see it on the water weighted fat suppressed image, high grade contusion.

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I see it on the T one, I see it on the water weighted image,

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microtrabecular fracture. I see intramedullary.

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Very tiny delicate spidery lines that are not transcortical.

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Macro fracture lines, a little thicker transcortical extension.

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And then I go into displacement, depression, rotation, gapping,

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and so on. And by the way, gorgeous view of ion's canal right here.

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Look at that. Here are the structures in ion's canal.

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There's a vein. There are a couple little arteries.

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There are some nerves right here. There's the triangular shape of ion's canal.

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And here's the flexor Rett macular ulnar palming,

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which forms the roof of ion's canal.

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And this is the, this is the ulnar nerve right here.

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The common ulnar nerve right there.