0:00

Dr. Stern, this is a 60 something year old, uh,

0:00

3 00:00:03,620 --> 00:00:06,890 female with wrist pain and a supposed mass.

0:07

I think the mass they're feeling is

0:08

probably the ulna, as we'll see in a minute.

0:10

Here's the coronal T1, the gradient echo.

0:14

She wasn't that cooperative.

0:15

And the coronal fat-suppressed proton

0:18

density water-sensitive sequence.

0:20

So in searching for the triangular

0:23

fibrocartilage, it's this tiny little slit.

0:27

It's severely degenerated.

0:29

The peripheral attachments you can see

0:31

barely as these little lines into the fovea.

0:34

The styloidal attachments are a little irregular.

0:37

There's some peripheral synovitis,

0:38

but overall it looks like a mess.

0:40

And, uh, the patient has swelling of the distal

0:43

radial ulnar joint, a degenerated abnormal

0:47

LT ligament with widening of the LT interval.

0:50

Should look more like this with a little slit.

0:52

This little T shape on the distal end.

0:55

And sometimes you'll see a little

0:56

T shape on the proximal end.

0:58

None of these findings are present in the LT.

1:01

So there's an LT problem.

1:03

And then when we go to the short axis view, uh, you

1:06

can see the alignment of the proximal carpal row.

1:08

The arc is interrupted.

1:10

Things are just disorganized.

1:12

And then the radial ulnar articulation.

1:14

The ulna is displaced dorsally.

1:16

And I think that's real.

1:17

Here's the triangular shape

1:19

of the triangular fibrocartilage.

1:21

And this dark structure right here

1:23

is the volar radial nerve ligament.

1:25

So what do you do with a case that's this messy?

1:28

Is there anything to do short of fusing it?

1:31

This is a very difficult case.

1:34

The critical thing, some of the critical

1:36

things would be getting a good history.

1:38

The question is whether or not this is

1:41

a degenerative process or whether it's a traumatic

1:44

process or trauma on a degenerative process.

1:49

The TFC is in bad enough shape

1:54

that it's permitted dorsal translation

1:58

of the ulna on the sigmoid notch of the radius.

2:01

As Dr.

2:03

Pomerantz mentioned, there's fluid

2:06

in the distal radial ulnar joint, and actually

2:08

there may be some splay, increased distance

2:12

between the head of the ulna and the

2:15

sigmoid notch of the radius.

2:19

A lot, you would really need to do

2:23

a good clinical examination and find out

2:26

exactly why this lady was having pain.

2:31

I think it would be a big deal

2:35

to reconstruct the ligaments in someone this age.

2:39

And one might go to more of a salvage procedure.

2:43

The one interesting thing, and I

2:46

appreciate your comments, Steve, would be

2:50

there's no evidence, there's no evidence

2:53

that I can see of ulnar impaction here

2:55

and with the TFC blown out and their...

2:59

I would have thought that maybe there would

3:01

have been some cystic changes in the proximal

3:05

ulnar aspect of the triquetrum, or in the

3:08

perhaps in the ulnar aspect of the lunate.

3:12

We don't see that.

3:13

Actually, there are

3:14

some erosions right here.

3:15

Oh, there we go.

3:16

Okay.

3:16

So there are some erosions present.

3:18

So there probably is a component of abutment.

3:20

Nothing in the triquetrum, however.

3:22

Yeah.

3:22

Just in summary, from a clinical

3:24

standpoint, the question is, A, is she

3:27

symptomatic enough to have anything done?

3:29

Or do you treat her with immobilization,

3:31

anti-inflammatory medicine,

3:33

maybe a corticosteroid injection?

3:35

Or does she have surgery?

3:37

And if she has surgery, the issue is whether or

3:39

not you reconstruct the triangular fibrocartilage

3:43

complex,

3:44

try to keep the ulnar head seated in

3:46

the sigmoid notch of the radius, or

3:49

you do some type of salvage procedure.

3:51

I think there's some in the country

3:53

that would even put an implant in.

3:55

Probably I would.

3:57

Probably not.

3:58

A Dara procedure.

3:59

A number of different things could be done.

4:02

Question for you if you did an arthrogram.

4:04

'Cause some people are gonna recommend arthrography

4:07

and if you did an arthrogram and you had

4:09

rapid extravasation through the LT ligament.

4:12

into the mid-carpal space, or if you did some dynamic

4:16

evaluation and you saw that this was grossly unstable,

4:18

would that affect how you managed this patient?

4:20

Uh, very minimally.

4:22

I think the LT relationship, as you pointed

4:27

out, I think it's abnormal but not grossly abnormal.

4:30

The only other thing that I think is critical

4:33

to realize from the radiologist's

4:36

standpoint is, as we get older, the TFC deteriorates.

4:40

So, there are frequently small fenestrations

4:44

in the TFC that are clinically irrelevant.

4:47

They're acquired over time and still there

4:49

do not need to be treated.

4:51

And then there are cases like this

4:53

where the TFC is completely blown out.

4:56

So as we get older, say 6th, 7th, 8th decade,

5:00

well over 50 percent of people on MRI or MR, if

5:05

you do arthrography, will have fenestrations

5:09

or tears which are clinically not very significant.

5:12

And you make a great point because inexperienced

5:15

people that haven't done a lot of wrist imaging,

5:16

they latch onto these fenestrations and then the

5:18

patient gets a procedure or arthroscopy for something

5:22

that's incidental and unrelated to their symptoms.

5:24

One thing that MRI, coupled with an experienced reader,

5:27

is very good at is telling acute from chronic and also

5:31

telling whether something is actively inflamed or not.

5:33

MRI is really great at picking up inflammation.

5:36

Uh, this patient has some marked synovial hypertrophy.

5:39

This is a big synovial blob, if you will, right here.

5:42

One last question on this case

5:44

and then we'll get off it.

5:45

In the short axis projection, there's quite

5:47

a bit of dorsal positioning of the ulna.

5:51

And as you know, we do for you

5:54

and for others a lot of supination,

5:55

pronation views, comparing the two sides.

5:59

If this was grossly asymmetric from the

6:01

other side, and she's symptomatic from it, is

6:05

there anything you would or can do for that?

6:07

Uh, it's tough.

6:08

I mean, the TFC is blown out.

6:10

There are many things that provide

6:13

congruency to the dysradiated ulnar joint.

6:16

It's a sloppy joint, but the C-shaped contour of

6:20

the sigmoid notch somewhat holds in the ulnar head.

6:25

The ECU, depending on position, is more of a

6:28

dorsal structure and pushes the ulnar head down.

6:31

Uh, you can't quite see it in this view, but the

6:34

pronator quadratus, which goes from the

6:39

radius to the ulna, if you go more approximately,

6:42

that also helps stabilize the ulnar head.

6:46

And then there are interosseous ligaments,

6:49

there's a distal radio-ulnar interosseous ligament.

6:52

I'm not talking about the TFC radio-dorsal and volar

6:56

ligaments, which also help stabilize.

7:00

And there are a number of reconstructive procedures

7:04

to stabilize the distal radio-ulnar joint.

7:07

And I think the reason there's so many

7:10

of them is none of them reliably work.

7:12

The ultimate salvage, and I can't say this

7:16

with 100 percent certainty, is probably an

7:19

implant, the most common of which is the so

7:22

called Scheker implant, which is a semi

7:26

constrained radio-ulnar implant, which

7:29

would solve the problem, but there are a lot

7:33

of problems with implant arthroplasty in the wrist.

7:35

Well, I vote we Scheker this case.

7:37

Dr. P and Dr. Stern out.