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Case Review: Additional Findings Discussion From Previous Case

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It's a companion to TFC Roman numeral II

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palmar grading classification system.

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We have a palmar II C because the TFC is not only

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thinned, it's torn or ruptured in its inner third.

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It's got a full-thickness tear.

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There's lunatomalacia, there's ulnar malacia,

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but the lunotriquetral ligament is intact.

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Palmar II C.

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But there is quite a bit of

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irregularity throughout the carpal area.

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There are some pseudocysts, there are some erosions.

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And that is from the scapholunate instability

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and tear of the scapholunate ligament.

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So let's scroll that for a moment.

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We start out dorsally.

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The strongest part of the ligament

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right here, there's a big gap or hole.

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The membranous portion or central

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portion, there's also a gap or hole.

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The ventral portion, perhaps there's a

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little bit still intact, not as bright.

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Not as wide.

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There's some low-signal intensity material there.

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But clearly, we have scapholunate insufficiency, which

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has contributed to some generalized degeneration

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of the carpus, some swelling of the carpus, and

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even a little bit of hypertrophy of the radial

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styloid, which is one of the earliest signs seen

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in slack wrist or scapholunate advanced collapse.

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Now, another major reason for showing this

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case is the patient had ulnar-sided wrist pain.

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She's 42 years old, and we've got this large, bright

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object that's surrounding a ball, the pisiform.

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Let's have a look at the piso-triquetral recess.

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It's got a bursa in it.

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That bursa is synovial-lined.

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Now, everybody has some element

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of piso-triquetral disease.

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It's kind of like the acromioclavicular

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joint of the shoulder.

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Nobody has a normal one after age 20.

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So when is it symptomatic?

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When you have irregularity and arthrosis.

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When you have a mass that's under

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pressure or dissecting, like this one.

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When you have large pseudocysts

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in the triquetrum, like this one.

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So most likely, piso-triquetral disease, in this

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case, with a large piso-triquetral cyst coming right

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out of the bursal space, has contributed to this

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patient's TFC abutment syndrome, Roman numeral II C.

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So we have a third problem.

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We've got the TFC problem, we've got the

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scapholunate ligament problem, and now we've

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got the piso-triquetral articulation problem.

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We better finish checking out the ulnar side

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of the wrist, because we're not done yet.

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We've got one more major area that produces ulnar

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side of wrist pain, although more commonly in kids.

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This is not a kid, but still pretty young; 42's young.

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Let's have a look.

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So you are looking at the dorsal aspect of the wrist.

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This would be dorsal, this would be palmar, T1, T2.

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I think I'll flip them for you.

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I think it'll make it a little easier.

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Actually, now I had them the right way to begin with.

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Now they're flipped.

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So this is dorsal, this is palmar.

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So what is that other area that I'm interested in?

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It is the extensor carpi ulnaris.

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I'm gonna make this a little smaller

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so you can see a little better.

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That is a very common cause of ulnar-sided wrist pain.

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I'd like to draw for you a little bit,

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because here's a source of constant confusion.

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Here's our ulna, you can see, um, sometimes

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a pretty good drawer, sometimes not so much.

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And there inside our ulna is a tendon.

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We'll make our tendon orange today.

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Now that tendon is secured by something

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called the extensor carpi ulnaris.

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Subsheath.

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I'm gonna make the subsheath blue.

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It hugs very close to the ECU.

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That's really important.

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The subsheath is often incorrectly ascribed

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the name extensor retinaculum and vice versa.

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The extensor retinaculum is much thinner.

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I think I'll make it brown, and I think I'll

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also make it a lot thinner just to be accurate.

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So let me make it thinner for you.

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So here is the extensor retinaculum, which is

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often kind of dirty and irregular and often inflamed.

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So now let's have a look.

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There is our groove, our ulnar groove.

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We want to assess the depth of the

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groove, the smoothness of the groove.

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There is our extensor carpi ulnaris.

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It often has some signal inside

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it, because it gets used a lot.

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And sometimes, because of magic angle effect or the

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55-degree artifact, you'll see some signal in it.

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But not linear.

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Slit-like, coast-to-coast, surface-to-surface signal.

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And there it is.

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From the dorsal surface to the palmar surface.

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That's a split.

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So there's a split tear of the ECU with everything

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else going on in this soup of pathology.

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Where is our subsheath?

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Right there.

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That's our subsheath.

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Hugging close to the ECU.

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That's what helps secure it.

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The retinaculum, not so much.

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Where's the retinaculum?

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This irregular, fibrillated, somewhat

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dirty structure, more superficial to it.

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Well, that concludes this companion vignette,

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in which we've got a myriad of pathology.

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We like to be brief on these, but we've

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got TFCC, Roman numeral II C, scapholunate

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dissociation, extensor carpi ulnaris split tear,

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and piso-triquetral arthritis and bursitis.

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Let's move on, shall we?

Report

Faculty

Stephen J Pomeranz, MD

Chief Medical Officer, ProScan Imaging. Founder, MRI Online

ProScan Imaging

Tags

Trauma

Non-infectious Inflammatory

Musculoskeletal (MSK)

MRI

Hand & Wrist

Acquired/Developmental

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