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Here with Dr. Stern, Dr. P,

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3 00:00:02,009 --> 00:00:05,590 and we've got a 14-year-old woman that has

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ulnar-sided wrist pain after a twisting injury.

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And I actually, even though I'm a radiologist,

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I'm not a real doctor, I see this a lot.

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Uh, I've had a few of my techs that are opening

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jars and opening packages, this sort of rotatory

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movement, that have developed ulnar-sided

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wrist pain with an injury very similar to this.

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And actually, you've taken care of a few of them.

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Uh, so as we go dorsal, we've got

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this big, fat, long radial styloid.

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And just adjacent to it,

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tremendous amount of inflammation.

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Some stripping of the attachment of the styloid.

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You can see the pre-styloid recess is a bit swollen.

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And then as we, uh, as we parse towards the

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volar or palmar aspect of the wrist, we do

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see some peripheral signal in the TFCC itself.

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And then there's diffuse

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swelling in the ulnar capsule.

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Um, this is apparent on both these gradient echo

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images as well as the, uh, fat-suppressed PD sequence.

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Patient has open growth plates.

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Then we pull down, I'll pull

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down in the middle, the sagittal.

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And, uh, the patient, again,

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we see the large ulnar styloid.

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And the attachments do go into the fovea.

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The styloidal attachments, not,

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not as flush as you would like.

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There's a little space right here.

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So there has been a styloidal detachment problem.

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Whereas the foveal attachment, uh, still present.

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So, what do you do with this?

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The LT ligament looks absolutely fine.

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The space looks absolutely fine.

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The SL ligament looks absolutely fine.

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Yeah, so we were, we were

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talking off camera a little bit.

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We, uh, the, uh, TFCC has two

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attachments, uh, into the ulnar styloid.

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And, uh, many hand surgeons refer to

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the deep attachment, which is the more

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important one, as the ligamentum subcruatum.

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And the more superficial attachment is to the styloid.

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In this case, as you pointed out, the styloidal

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attachment, the more distal attachment, uh, is, uh, not

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intact, whereas there is perhaps some attenuation of

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the, uh, foveal attachment or the ligamentum subcruatum.

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I would be inclined, so we would examine

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the patient and try to assess for the,

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uh, dysradiated ulnar joint instability.

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My guess would be that the joint overall would

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be stable and we would treat this non-surgically

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in cast immobilization, uh, including the elbows.

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to preclude forearm

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rotation.

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Now I've noticed that in some cases that are

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chronic, that are kind of refractory, I've

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seen you inject them, and I've even seen

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you go in now and then and do a synovectomy.

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I actually had one patient with you that had

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CPPD that got better with that procedure.

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Um, what would prompt you to do that?

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The presence of CPPD or intractability or

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Well, uh, yeah, I think the failure of conservative

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treatment I think would be the primary reason

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for doing some type of arthroscopic procedure.

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It's a little, uh, overall, uh, and again, that's

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a completely different subject, but CPPD, uh, is

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fairly common, uh, in the senior age population.

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and sometimes you can get some transient.

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Uh, or even prolonged relief from doing an arthroscopic

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synovectomy, but it's certainly not a, not a slam dunk.

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And of course, as we know, there is a relationship

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between CPPD and carpal instability, particularly,

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uh, separation of the scapholunate interosseous ligament

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and the ultimate development of a, uh, so-called

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slack, uh, uh, slack wrist, a degenerative wrist.

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I mean, this is a really beautiful case

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because when I magnify the image on the

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left, you can see the ligamentum subcruatum.

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Uh, you know, the inferior or deeper

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attachment of the TFCC is intact.

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There it is right there.

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Maybe a little frayed near its origin, but

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the styloidal one is like a hanging chad.

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It goes out and then boom, it's just

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like a little stump right there.

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And then you don't see in the sagittal, the more

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distal of the two doesn't have a nice flush attachment.

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And it's just this irregular tissue here,

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you really have to magnify it up to get a feel for it.

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So this is a peripheral TFCC injury and

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it's going to be conservatively managed?

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It would be in my hands, yes.

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100 00:04:27,659 --> 00:04:27,939 Great.

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Okay, Dr. P and Dr. Stern, out.