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This is a 55-year-old man with wrist

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pain and quote unquote instability.

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Where do you start in a case like

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this where everything is wrong?

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I personally would start in the AP frontal

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projection like I would a regular X-ray.

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And there are several things I immediately notice.

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There are multiple erosions throughout the mid portion

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of the wrist, and especially around the triquetrum.

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So I go to the water-weighted image, and I use

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the water-weighted image to find the hot spots.

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It's pretty simple.

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Caveman radiology.

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Where are the white areas?

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And they seem to be concentrated

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here, and that is no coincidence.

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So we'll come back to that in a moment.

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Let's look at some other spots where

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there are areas of high signal.

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The capitate.

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The midcarpal space.

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So we've got a triquetral ulnar-sided bony problem.

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We've got a midcarpal space bony problem.

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Which often means the ligaments that live next

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door to these structures are going to be abnormal.

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Which is the case.

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And there's also an effusion present.

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There's more.

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There's bright signal intensity between the scaphoid

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and the lunate such that there's a huge gap.

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So, even though I'm not yet attacking the ligaments,

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it's already obvious that we are missing a key

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stabilizing structure of the proximal carpal row.

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There's also a little bit of

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swelling of the distal ulnar styloid.

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Since we're looking at the scapholunate

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interval, we might as well complete the ring

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and look at the lunate-triquetral interval.

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And I think I'll jump over to the T1 to do that.

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The relationship of the lunate

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to the triquetrum is incongruent.

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In other words, the base of this should be over here.

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So the fact that these two bones are touching

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each other, bone on bone, sclerotic, eroded,

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and they're improperly aligned, you now

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know that this ligament is also absent.

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So within about 60 seconds, looking at the hot spots,

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using the bones as a landmark, and as a director to

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the areas of soft tissue pathology, you've already

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very quickly figured out that your scapholunate

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ligament is gone, and there's widening of this space.

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This space is too narrow, and your

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lunate-triquetral ligament is gone.

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That there is an erosion present, and that

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all of this inflammation and arthritis

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is at least in part, related to such.

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We're gonna come back to this case.

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Stay tuned.