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42-year-old woman with ulnar-sided wrist pain.

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Pain began when she was putting on a glove.

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So not a very significant traumatic event.

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We've got three coronal images.

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A medic, which is a 3D, heavily water-weighted,

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steady-state type, uh, free procession image.

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In the middle, T1, fat-weighted.

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On the far right, proton density, fat-suppressed.

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Also water-weighted.

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These are thinner.

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These on the far right are not as thin.

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Let's scroll.

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I'm sure all of you are tapping into all this

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bright signal, which is not an improper thing to do.

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Look at the water-weighted images

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on the coronal AP projection.

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Line up all the coronals to start, so you can get a

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good idea of the anatomy, the arcs of the wrist, the

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intrinsics of the wrist, the relationships of carpal

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bones to one another, the distance between the proximal

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carpal row and the radius and ulna, the shape of the

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radius and ulna, which tell a very important story.

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And then look for those hot spots,

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which tells you where the pathology is.

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Here's a big hot spot right

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here in the pisotriquetral area.

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Here's another hot spot in the

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distal radial ulnar joint area.

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And so let's focus on that since

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she has ulnar-sided wrist pain.

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Now that's not to say this wouldn't be an important

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site of ulnar-sided wrist pain, but I know from

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experience that everybody and his mother on the

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face of the earth has pisotriquetral disease.

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So I often, at least initially, dismiss

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that area as the cause of ulnar-sided

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discomfort if I've got another good cause.

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We'll come back to it in a second, because this

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one may actually be contributing to symptoms.

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But I'm here to talk about grading of triangular

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fibrocartilage disease in the chronic setting,

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especially in patients who have abutment syndrome

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with either neutral or positive ulnar variance, where

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the ulna is a little more distal to the ventricle.

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And that classification system for

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chronic abnormalities, not traumatic

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ones, is Roman numeral II, A through E.

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So what would A be?

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A would be simply a thinned triangular fibrocartilage.

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This one's thinned, but it's

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also missing in the inner third.

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You cannot see where it comes

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off the cartilage of the radius.

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It's gone.

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The central third is torn.

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What's a B?

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A B would be when there's concomitant

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chondromalacia of the lunate. Yes, there is,

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there's a little nubbin or erosion right there

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and this is all swollen, and there's very thin

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little cartilage along the free edge of the ulna.

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So there is ulnar chondromalacia,

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lunato chondromalacia.

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So that takes us to a Palmar Roman numeral II, B.

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What's a C?

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A C is when you have a perforation or tear, usually

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of the central or inner one-third of the TFCC.

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We have that.

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We're missing the TFCC right here.

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Alright, the TFCC should go all the way in.

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What's a D?

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A D would be if we ruptured

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the lunato-triquetral ligament.

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Now, I admit that that's a very small nubbin

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like triangular structure, but it usually is.

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We've got some indirect signs that tell us

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the lunato-triquetral ligament is intact.

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Like, this space is not widened.

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There's no arthrosis.

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There's no synovitis.

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When you compare it with the SL

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interval, they look very different.

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The SL interval is insufficient.

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The SL ligament is deficient and torn.

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Not so for the small, but ever-present,

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all the way from the volar aspect of the

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wrist, to the dorsal aspect of the wrist,

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the lunato-triquetral ligament is present.

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So we do not have a TFCC palmar to what's an E.

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Generalized, advanced degeneration of the carpal bones.

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Now, what makes this case so much more complex is that

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there are three or four other additional findings.

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And I'd like to discuss those in a separate part of

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this vignette to keep it as a nice tight package.

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So I am giving you the Palmer classification

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for chronic TFCC disease, usually associated

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with positive ulnar variance, with ulno-lunate

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abutment. In fact, there's an erosion at the base

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of the lunate as part of the chondromalacia 1A. 62 00:02:50,025 --> 00:02:51,844 So there is ulnar chondromalacia,

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lunato chondromalacia.

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So that takes us to a Palmar Roman numeral II, B.

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What's a C?

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A C is when you have a perforation or tear, usually

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of the central or inner one-third of the TFCC.

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We have that.

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We're missing the TFCC right here.

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Alright, the TFCC should go all the way in.

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What's a D?

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A D would be if we ruptured

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the lunato-triquetral ligament.

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Now, I admit that that's a very small nubbin

3:25

like triangular structure, but it usually is.

3:27

We've got some indirect signs that tell us

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the lunato-triquetral ligament is intact.

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Like, this space is not widened.

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There's no arthrosis.

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There's no synovitis.

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When you compare it with the SL

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interval, they look very different.

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The SL interval is insufficient.

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The SL ligament is deficient and torn.

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Not so for the small, but ever-present,

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all the way from the volar aspect of the

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wrist, to the dorsal aspect of the wrist,

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the lunato-triquetral ligament is present.

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So we do not have a TFCC palmar to what's an E.

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Generalized, advanced degeneration of the carpal bones.

4:15

Now, what makes this case so much more complex is that

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there are three or four other additional findings.

4:23

And I'd like to discuss those in a separate part of

4:26

this vignette to keep it as a nice tight package.

4:29

So I am giving you the Palmer classification

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for chronic TFCC disease, usually associated

4:37

with positive ulnar variance, with ulno-lunate

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abutment. In fact, there's an erosion at the base

4:42

of the lunate as part of the chondromalacia 1A.

4:47

Thinning of the TFCC, 1B, lunatochondromalacia and

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ulnarchondromalacia, 1C, perforation or tear of the

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inner third or central one-third of the TFCC, 1D, tear

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of the lunato-triquetral ligament that we don't have,

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and 1E, advanced degeneration of the carpal bones.

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We do have some carpal degeneration, but it's

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for another reason to be discussed separately.

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Thanks.