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Dr. P here.

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3 00:00:01,540 --> 00:00:03,719 I'm here with my colleague, a world

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renowned wrist surgeon, Peter Stern,

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and we're talking about wrist MRI.

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Our case is a 21 year old woman who fell on

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an outstretched hand and now has wrist pain.

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Unfortunately, she doesn't have any radiographs,

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and we've got a series of three coronal images.

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On the left, a proton density fat suppression.

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On the right, a thin section 3D gradient echo.

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And in the middle, a basic

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anatomy T1 fat weighted image.

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And she obviously has a little Terry Thomas sign,

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some widening between the scaphoid and the lunate.

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And as we scroll back and forth, when we

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get to the, um, the palmar aspect of the

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wrist, she does have a ligament there.

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It looks a little bit triangular.

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Then as we scroll back towards the

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membranous portion, she widens out.

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There's just a little, little

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portion of the ligament present.

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And then, uh, as we go to the dorsal aspect

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of the wrist, uh, she doesn't have, uh, Yeah.

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Much of a ligament until we get to the very back, so

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it looks like the whole center of the ligament is gone.

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What do you do with a case like this?

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From a clinical perspective, we would normally start

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off, as you mentioned, with plain x-rays, and we

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would always get x-rays of the contralateral side.

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Oftentimes, there are radiographic abnormalities, i.e.,

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scapholunate,

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Uh, separation.

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But, uh, when it's a symmetric

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problem, uh, we become less concerned.

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Of course, clinical exam is critical, and if

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they're tender in this region on one side, and

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the contralateral side is non-tender, uh, we would

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be more suspicious that there was some type of

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injury to the scapholunate interosseous complex.

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So, uh, uh, two things.

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One is a good clinical exam that

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correlates with the radiographs.

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Uh, and, uh, secondly, x-rays

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of the contralateral side.

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And finally, if there's any question, one

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would get a so-called pencil grip view where

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the capitate, uh, through longitudinal forces

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will drive between the scaphoid and lunate.

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So is that a clenched fist view?

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Yes, a clenched fist view, correct.

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So another maneuver that we perform when we are

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unsure of the significance or the degree of separation

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or there's inflammation here and nowhere else.

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As we ask for either MR or radiographic

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ulnar and radial deviation views to

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see if there's dynamic instability.

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Is there clinical support for that

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or are we barking up the wrong tree?

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No,

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I think you're, I think you're absolutely dead on.

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We would probably call dynamic instability, just in,

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for terms from a clinical perspective, it's something

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provocative, either a, uh, fluoroscopy motion, uh,

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series or something like a clenched fist, uh, view

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where a static instability, what we're seeing here

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is when you look at the, uh, radiograph or MRI and

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there's a separation between the scaphoid and lunate.

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One other question for you, um, do you use the

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Geisler classification for SL ligament disease?

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We do.

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It's, uh, the Geisler classification is really

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an arthroscopic, uh, classification, uh, but,

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but we would, we would definitely use it.

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Yeah, we've begun in the last, say, couple of

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years to try and correlate, you know, we suggest

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MR findings compatible with Geisler 1, 2, 3, or 4.

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Um, do you find that helpful, or do

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you think we're, uh, overreaching?

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No, no, you're not overreaching.

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You're on good, solid grounds.

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Okay.

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Alright, let's move on to the next case.

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Dr. P and Dr. Stern out.