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55-year-old man with wrist pain, MRI,

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we're looking at the coronal T1 fat-weighted,

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a coronal or AP projection, water-weighted,

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and a sagittal T1 fat-weighted image.

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Everything is wrong here, and for now I'm

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going to ignore the radial side of the

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abnormality, including the scapholunate

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ligament rupture, and focus on everything

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that's wrong with the ulnar side of the wrist.

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The lunotriquetral ligament, usually

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a small ligament that looks like an upside

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down T or a mustache, is nowhere to be found.

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The only remnant of it is this tiny,

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wispy, linear, gray signal structure.

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It's ruptured.

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Further documenting the rupture is the

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complete absence of the joint space.

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Sometimes the joint space indirectly tells

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you a ligament is torn by being too wide.

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That's the case here.

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Sometimes the joint space tells you the

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ligament is gone because it's too narrow.

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That's the case here, along with

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sclerosis and bone upon bone.

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The bones are also malaligned.

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The lunate is floating distally

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relative to the base of the triquetrum.

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That can't happen without failure of the LT ligament.

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Oh, but we're not done yet.

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There's also a tear of one of the

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distal peripheral attachments.

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distal peripheral attachments.

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The ulnotriquetral ligament right there

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is torn from the triangulofibrocartilage.

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Some of the peripheral attachments, including those to

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the styloid, like this one right here, which should go

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directly onto the tip of the styloid, are also torn.

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The foveal attachments of the triangulofibrocartilage

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are present, but swollen in the sagittal projection.

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As a manifestation of the failure of the lunotriquetral

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ligament, the lunate is now ventral

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facing, so-called volar intercalary segmental

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instability, there it is right there, or VISI.

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There's also arthritis developing between the

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base of the lunate and the base of the radius.

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Two spurs virtually kissing each other.

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This patient has complex ulnar

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sided ligamentous failure.

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That includes the lunotriquetral ligament, the

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ulnocarpal ligaments, the attachments of the TFC to

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the ulnar styloid, and a multitude of other findings

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that will be discussed in a separate vignette section.

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The wrist is diffusely inflamed and is

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developing midcarpal space arthritis, which

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goes along with LT ligament failure and volar

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intercalary segmental instability, or VISI.