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And we're live now. Prayer. Thank you. So uh good evening everybody. And uh it is my pleasure to welcome you all to the sixth B SSR Grand Rounds. It's an honor to welcome Pro Resnick to the B SSR Grand Rounds. And uh as we know, prof needs no introduction, he's had 30 years of, you know, Musculosketal Radiology, education, more than 1000 scientific educational articles, book chapters and you know, many books in Musculosketal Radiology. And uh I listened to him so many times and every time it's an experience that I treasure. And so I was very thrilled when he accepted our invitation to come and speak at the P SSR Grand rounds. So for this session, we will first have the prof sharing the cause of wisdom of wrist imaging. And this will be followed by our resident Henry who will be presenting an interesting case related to wrist pain. And then we will have the questions from the audience. So without further ado I hand over the stage to prof Frenk. Thank you. Thank you very much. Uh It, it is a privilege for me to be able to present to the group and the topic is one of interest to me. I've always been interested in the risk. So we're gonna talk about wrist pain, articular, traumatic, infectious and other causes of this very, very common symptom. To give you an idea. There are two general objectives to this lecture. The first is to review the anatomy of the wrist, emphasizing its many articular compartments. We'll do that fairly shortly. But that is an important aspect of this lecture. Following that introduction, we're gonna look at a number of disorders, articular, traumatic infectious and a few other causes of wrist pain that affect one or more of these various compartments as well as the adjacent bones and tissues. So let's start and we'll start with that compartmental anatomy. In the middle of this slide is a drawing I had made probably about 25 years ago when I first became interested in the compartments of the wrist. I'm showing that drawing along with a coronal section at the bottom left and another drawing that I have made to indicate the very important various compartments of the wrist. So let's let's look at this. The major compartment of the wrist is the radial carpal compartment, abbreviated RC. You can see it here. You can see that it separates the distal radius and the proximal carpal rope. The second compartment is known as the distal or inferior radioulnar compartment labeled IR U here separated in most of us by a from the radiocarpal compartment by an intact triangular fibrocartilage as we move distally. The next compartment we see is the transcarpal or midcarpal compartment labeled MC. And you can see it in all of these images. And we're gonna do one thing. I'm gonna separate out the trica portion of the midcarpal compartment. Why I do that will become obvious a little bit later as we move more distally, we have a common carpal metacarpal compartment shown here that communicates with various intermetacarpal compartments and a first or separate first carpal metacarpal compartment. And then finally, a pisiform triquetral compartment that you can see in the section as well as in this area, which may normally communicate via a small opening with the radiocarpal compartment. So when I look at a conventional radiograph or a CT or even an Mr or Mr Arthrogram, I remember this compartmental arrangement and it helps me particularly when we discuss articular disorders. So let's look at the target area approach to some of the common articular disorders that involve the compartments of the wrist. The first of these, we'll call pattern number one, it's something we see in rheumatoid arthritis, in gout and even in psoriatic arthritis. And what it refers to is early and compartmental involvement early on in these diseases. We see involvement of all of the compartments of the wrist. So the example I show you on the right in a cadaver, a coronal sectional radiograph and a photograph shows you rheumatoid involving all of the compartments of the wrist manifest as cartilage loss and some osseous changes including cystic abnormalities, classic pan compartmental involvement. Now, if you're really good at this, let's introduce pattern one. A because if you're really good at this, you're gonna pick up rheumatoid arthritis when the only abnormalities are in the distal radioulnar and radiocarpal compartment and you know them. Well, it's those early erosions that we see involving the tip of the styloid process of the ulna show nicely here on a radiograph and look at this involvement with synovitis. This is in the prestyloid recess of the radiocarpal compartment. So yes, when you're good at it, you'll pick up rheumatoid. But soon in this disease, it will be pan compartmental in distribution. Now, there's another disorder that also often is pan compartmental and that is gout, rheumatoid tends to be symmetric. Gout tends to be bilateral but often asymmetric. But here's the pearl, here's the pearl. When you see pan compartmental involvement of the wrist with the largest erosions at the common carpal metacarpal compartment involving the metacarpal bases. Gout is the most likely diagnosis to consider. Now, septic arthritis also tends to be pan compartmental at an early stage. I show you one example here uh where all of the compartments of the wrist are involved in pyogenic septic arthritis. Let's introduce pattern. Number two, pattern. Number two is involvement of the radial compartments of the wrist. Be it the first carpal metacarpal joint alone or with involvement of the trica, the area of the midcarpal compartment. And when I see this particular distribution, the diseases I think about are osteoarthrosis and inflammatory osteoarthritis. Here's a beautiful example shown in the radiograph of osteoarthrosis involving these two regions. The first carpal metacarpal compartment and the trica the area of the midcarpal compartment. And here's another another example, same distribution. First carpal metacarpal and trica area of the midcarpal compartment. The third pattern I want to introduce is a pattern that we see in calcium pyrophosphate dihydrate crystal deposition disease. When there is structural joint damage. In that disease, we call it pyrophosphate arthropathy. The classic distribution is involvement of the radiocarpal and midcarpal compartments typically bilateral and rather symmetric. What I look for is narrowing between the scaphoid and radius with excavation or deepening of the scaphoid fossa of the distal radius disorganization in the midcarpal compartment with often abnormal tilting of the lunate. And if I'm lucky in this disease, I will see chondrocalcinosis involving the triangular fibrocartilage of the wrist. But you see this disease can occur without the calcification. And so you, the observer has to recognize the pyrophosphate arthropathy. Beautifully shown here in this example. Again, scaphoid radial narrowing, deepening of the scaphoid fossa disorganization involving the midcarpal compartment. Now, there are a couple other disorders that can simulate pyrophosphate arthropathy. But pyrophosphate arthropathy is a disease of the elderly men or women bilateral in these other disorders which are posttraumatic in nature. Patients of any age may be involved. There's a history of injury and indeed, there may be other findings on the radiograph. This is known as scapholunate advanced collapse. It's a posttraumatic condition. You can see again the findings similar to pyrophosphate arthropathy. And this is known as scaphoid non union advanced collapse with a chronic ununited fracture of the waist of the scaphoid and narrowing between the distal radius and the distal pole of the scaphoid simulating pyrophosphate arthropathy. But can occur at any age even in young persons with a history of injury and not with the calcification. Typical of calcium pyrophosphate disease. We move on to pattern four which is an unusual pattern seen in a bilateral distribution with involvement of the midcarpal and common carpal metacarpal joint seen in juvenile idiopathic arthritis, what we used to call JRA and adult onset stills disease. Here's an example of adult onset stills involvement of the mid carpal compartment. Common carpal metacarpal compartment, relative sparing of the radiocarpal compartment with all of the carpal bones being grouped together and moving toward the metacarpal basis. Classic example of pattern four. In this case, adult onset stills disease. When I see isolated involvement of the first carpal metacarpal compartment. Shown here. Pattern number five, I think of osteoarthrosis and scleroderma. This is an example of scleroderma with involvement of that compartment along with involvement of multiple pharyngeal joints. And here's another example of scleroderma with involvement of that compartment associated with extensive calcification, hydroxy appetite in nature in and around the affected joint pattern. Six is isolated involvement of the trica, the area of the midcarpal compartment. We can see this with osteoarthrosis but also in calcium pyrophosphate disease. That disease is shown here with involvement of the trica joint as well as abnormal calcification within the triangular fibrocartilage. And then finally, pattern number seven, extensive abnormality involving the pisiform triquetral compartment. I look for this pattern in cases of osteoarthrosis shown here as well as in cases of rheumatoid arthritis. These are images taken from an article of ours years ago showing rheumatoid erosions in the pisiform triquetral compartment which on an arthrogram are associated with synovial proliferation. Now let's move on to four interosseous spaces that may be involved in a number of processes that affect the risk. The lunate hamate shown by the white circle, the lunate triquetrum by the blue circle, the scapholunate shown by the orange circle and ulnar carpal space shown by the yellow circle. Let's look at some examples of problems in these areas. The first one is lunate hamate arthrosis. In most of us, we have a single distal facet of the lunate, but some of us have a second distal facet shown here. Those of us who have this particular facet may be prone to develop osteoarthrosis between the lunate and the base of the hamate shown in this example and shown here in a cadaver lunate hamate arthrosis in a cadaver with a type two lunate. The second space we'll look at is the lunotriquetral interosseous space. We recognize this as one of the common places. We see solid bone coalitions in the wrist shown here, which may be associated with developmental widening of the scapholunate interosseous space. But I wanna show you an example of a fibrocartilaginous coalition involving that space to point out that the diagnosis may be a little tricky. And on. Mr you may see marrow edema about the area of coalition and this can produce problems in differential diagnosis. I show you another example of that in the bottom images and an unusual coalition between the pisiform and hamate shown in the upper images. Another problem that occurs in the lunotriquetral interosseous space is dissociation. A form of carpal instability, dissociative with designated SID by our hand surgeons. We use Lula's arcs to indicate a disruption in arc number one between this line and this line indicating dissociation between the lunate and the triquetrum with abnormal tilting of the lunate. We see a similar problem in the scapholunate area where we may have ligamentous disruption between the scaphoid and lunate often combined with other ligamentous abnormalities. As this progresses, we may see something known as dorsal intercalated segment instability or DC deformity. We see it on lateral images owing to the malalignment between the lunate and the capitate. The type of ligament abnormalities that are associated with scapholunate dissociation vary. I show you here in the cadaveric pictures, ligament, thickening ligament, elongation and ligament disruption all involving the scapholunate interosseous ligament. And on the bottom images, I show you various stages of scapholunate dissociation beginning with widening of the interosseous space, volar subluxation of the distal pole of the scaphoid known as rotary subluxation of the scaphoid. And then the pattern I talked about earlier scapholunate advanced collapse. We now turn our attention to the ulnar carpal interosseous space. And to understand that we often try to figure out what is the length of the ulnar with respect to the adjacent radius? Is the length too long, so called ulnar positive variants. Is it too short, ulnar negative variants or is it the same ulnar neutral variants? When we have ulnar positive variants, we have abnormal contact between the ulna and the proximal carpal row. We end up with extensive damage to the triangular fibrocartilage disc to the cartilage of the lunate and sometimes the triquetrum and to bone remodeling in the region of the ulna and lunate. So this is ulnal carpal abutment when the ulna is too short. The disorder we see is Ken Box disease. Ken Box disease begins as a stress fracture of the lunate and then goes on to secondary osteonecrosis associated with a short ulnar or ulnar minus variant. And just to remind you that when we look at the MR images and see an abnormality in the lunate where that abnormality occurs provides clues to proper diagnosis when we are dealing with ulnar carpal abutment. The major abnormalities are on the ulnar aspect of the lunate. When we deal with Ken Box disease, there's more extensive abnormality involving much or the entire lunate bone. But we're gonna move on now and talk about the triangular fibrocartilage complex of the wrist. This is a drawing that I made years ago. OK, showing you the basic anatomy. This is a dorsal view of the wrist with the wrist flex. So let's look at this anatomy. The most dorsal structure we see is the meniscus homo, it extends over and then merges with the sheath and tendon of the extensor carpi ulnaris. Just deep to that. We can see here the dorsal and volar radioulnar ligaments and in the middle of it, the triangular fibrocartilage disc. Here I show you several of the volar ulnar carpal ligaments and more distally the lunotriquetral interosseous ligament. I throw in the short radiolunate ligament here. And frankly, at that point, I got tired and never finished the drawing in the area of the scapholunate interosseous space. So I want you to look at that particular drawing. Now, that's the shape why we call this a triangular fibrocartilage complex. I am not certain. OK? Because it doesn't look like that. A number of years ago at a conference, I asked someone uh the audience, what is this shape? Someone told me parallelogram, it is not, someone told me it was a rhomboid shape. It is not. And then at the end, someone said, well, they had once asked their young child what it was and that child knew exactly what it is. It is a, a quadrangular shape. So I hope in the years ahead, we changed the name of the T FCC to the QF CCI use it now. But I think I'm the only one in the world who uses that particular abbreviation. So let's look at that shape. There are four bony attachments to the Q FCC. You can see those attachments and so part of the pattern of failure are avulsion fractures. And I show you three examples. Here is a lunate avulsion of the extrinsic volar ulnar lunate ligament. Here is a radio avulsion of the volar radioulnar ligament and here is an ulnar avulsion of the foveal lamina of that disc. So these are patterns of failure. There are also soft tissue components to the Q FCC and I've listed their elements here in this particular drawing. Now, as you look at that quadrangular shape, there is a proximal triangle shown here consisting of the disc and the styloid and foveal lamina. And there is a distal triangle consisting of a number of the extrinsic volar, ulnar carpal ligaments and meniscus homolog. Now, as we look at abnormalities that can produce ulnar sided wrist pain. Here is a list, not of all of them causes but of many of them. And at top of the list are abnormalities of the triangular fibrocartilage complex. Those abnormalities are often divided according to a classification introduced by Palmer. Now, almost 25 years ago, he divided those lesions into those that were traumatic, less common and those more common that were degenerate. And he went further to introduce four patterns of traumatic lesions of the T FCC. Let me show you what those patterns look like. The first of these is a pattern one a known as a central perforation. It is a common pattern of failure. Typically, it does not cause instability of the distal radioulnar joint, central, it is not, it is located way to the radial aspect of the triangular fibrocartilage disc. This is the area of a one, a central perforation. The second is known as a proximal detachment. This too is common. It's associated with a number of other problems including radial fractures and indeed, lesions like this may be treated arthroscopically or via open repair. The third is known as a distal detachment. This one is rare. All right. Typically, when we see it, there are other abnormalities that are going on and usually conservative treatment is the method of therapy for these lesions. And then finally, the one D lesion which is a radial avulsion shown here. This is uncommon but not rare and its treatment varies according to how many tissues have been affected. So let me go on and show you the degenerative problem. These are far more frequent here we deal with thinning and eventually a perforation involving the disc that tends to occur further away from the radial attachment. When this is severe, it allows communication of the radiocarpal and distal radioulnar compartments. Now through the years, people have graded the type two lesion according to how many other structures are involved because you can have abnormalities involving cartilage, subchondral bone and even the lunotriquetral interosseous ligament as shown in these multiple diagrams taken from an RSN A exhibit. This is what a degenerative perforation looks like in a cadaver at the top, right? And in a patient at the bottom, right, you'll note here that the defect is further away from the radius than with the traumatic one a lesion. It's often associated with an ulnar positive variance and with cartilage loss involving the lunate and triquetrum as well as the distal ulna. Let's look at some examples. Now of the traumatic lesions starting with the one a lesion. The typical mechanism is a fall on an outstretched hand, typically with pronation of the forearm which leads to radial shortening and a and a prominent ulna. And owing to that, we get tearing of the disc in a type one, a pattern. Here's an example shown by Mr, you can see here the yellow arrows pointing to the defect full thickness within the triangular fibrocartilage disc in the coronal plane. And in the sagittal plane note that that defect is close to the radial attachment, but there is still a little bit of the disc still attached to the radius. So this is not a radial avulsion. The width of the defect is well shown in the sagittal plane. The type one B lesion is common and the most complicated because you see here, the failure can be in the soft tissues or in the bone or in both locations. And so I'm providing here a number of different lesions that would be all designated as a one B proximal avulsion. Here. The mechanism is again a fall on an outstretched hand leading to radial deviation and hyperextension of the wrist. And that is said to produce tension on the ulnar carpal ligaments, particularly the ulnar capitate ligament as they course around a very prominent triquetrum and lunate. Let me show you some examples of the one B lesion. This is a problem at the foveal insertion of the triangular fibrocartilage disc. You can see the abnormality here and here and note the associated reactive marrow changes in the ulna. Here is another example of a one B lesion where the pathology is at the attachment of the styloid lamina to the ulna. You can see that here pre arthrogram in this region and on the Ortho gram, we can see the abnormality here with a little bit of contrast passing along the medial aspect of the distal ulna. Here's another example of A one B lesion with involvement of both the styloid and foveal lamina, the arrows on the MR images are pointing to the area of abnormality with widening of the space between the disc and the ulna in a patient who also had a fracture of the distal radius. And then one further example to show you bone failure here, a fracture of the styloid process with an abnormality involving the styloid lamina. Here's the fracture and here is the tearing of the styloid lamina. The one C lesion is rare and I've only seen a few examples of it. Typically when that occurs, there is a wide communication between the radial carpal joint and the pisiform triquetral compartment. This is an arthrogram and you can see the contrast passing from the radiocarpal compartment through tears of the ulnar lunate and ulnotriquetral ligaments filling the pisiform triquetral compartment. And then finally, the one D palmar lesion, which is a radial avulsion. More recently, this has been classified into various types according to whether it is the disc that fails or the ligaments that fail or both. I'm gonna show you one example of a one D lesion here. This is an Mr arthrogram. Here is a coronal image showing you a radial avulsion of the disc. And then as we move in a more volar direction here is radial avulsion of the volar radioulnar ligament A type one D lesion. Now, just to complete our story of triangular fibrocartilage disc problems, I would mention to you that in recent years, there have been a number of other lesions that have been introduced into our literature. For example, bucket handle tears of the triangular fibrocartilage disc shown here by diagram taken from an exhibit at the RSN A. And here in a case showing you a bucket handle tear of the triangular fibrocartilage complex and then flap tears and these come in various forms. But this is one of the types that we may see where a portion of the disc is displaced into the distal radioulnar compartment. Now, another cause of problems producing pain on the ulnar side is abnormalities involving the extensor, carpi, ulnaris tendon or tendon sheath. So I thought I would show you just a couple. Here is an example of rheumatoid arthritis. The initial study on your left, one year later on the right, we can see initially tendinosis and later on extensive tenosynovitis and full thickness split tearing of the extensor carpi narrows tendon in rheumatoid arthritis. And here is another example of what is designated a split tear of the extensor carpi narrows, tendon, split tears are full thickness, tears of a tendon, but as they traverse the tendon, they spare the collagen fibers they pass between and among them. So that is an example here of what a split tear would look like dividing the extensor carpal narrows tendon into two pieces. We see similar spli tears involving the peroneous brevis tendon at the level of the distal fibula. Now, just to complete our story of abnormalities of the extensor carpi ulnaris tendon. There are various patterns of subluxation and dislocation of this tendon that have been described in the literature owing to failure of its subsheath. That subsheath shown here can fail at the medial aspect of the ulna. It can fail at the lateral aspect of the ulna or that subsheath may be stripped away from its attachment to the ulna. And as shown on your right, taken from the literature here is failure within the mid portion of the subs sheet of the extensor carpi ulnaris tendon allowing medial subluxation of a partially torn tendon. There are other problems that involve the tendons and tendencies. For example, Degra vein syndrome. This represents a teno synovitis of the first dorsal extensor compartment. It has been described in young mothers known as baby wrist which relates to flexion and ulnar deviation of the wrist during bottle feeding or breastfeeding. A beautiful example of this shown in the bottom, right. And there are various intersection syndromes that involve the tendons of the wrist wherever tendons cross friction may develop. And in the wrist, this may occur proximal to the radiocarpal compartment or distal to it. The proximal intersection syndrome involves the extensor tendons in the 1st and 2nd dorsal extensor compartments. And this is what it looks like as you can see at their crossing. There's evidence of teno synovitis. The distal intersection syndrome occurs distal to the radiocarpal compartment where the tendons in the 2nd and 3rd extensor compartments cross and here is an example of teno synovitis in that region with tearing of the extensor p longus tendon ganglion cysts also can develop about the wrist. The most common location, dorsal a ganglion cyst shown here, communicating with the dorsal aspect of the scapholunate interosseous ligament and intraosseous ganglion cyst may also develop in the wrist. The most common location is the radial aspect of the lunate with communication often with the scapholunate interosseous ligament. We're gonna finish up in the last five minutes or so by talking about infectious disorders that may involve the wrist that can lead to wrist pain and other clinical manifestations. Here's a drawing I made years ago looking at the wrist and hand from the volar aspect. Let's add some things to this drawing. The first thing I'm gonna add is an I are the important soft tissue spaces. On the volar aspect you can see here the thenar space and the mid palmar space. Now I'm gonna add the flexor tendon sheaths, the volar aspect of the 2nd 3rd and 4th fingers. In most of us, those flexor tendon sheaths and just proximal to the metacarpal hip. Now, there are variations. So in some of us, that's not the anatomy but in most of us, that is the distribution of these digital flexor tendon sheaths in the 2nd, 3rd and 4th fingers, I'm gonna add now the flexor poly longest tendon sheath to indicate that in most of us, it communicates with a bursa within and around the carpal tunnel known as the radial bursa. And I'm gonna add now the digital extension here, the flexor tendon sheath of the fifth finger that you can see can communicate with a different bursa within and around the carpal tunnel known as the ulnar bursa. The radial and ulnar bursa may also communicate via intermediate bursa. So this is the important anatomy. Let's cover up that region with the transverse carpal ligament. And let's add another important soft tissue space volar to the distal radius known as the space of corona. Now, let's look at a couple of patterns of infection that may develop. The first of these is a horseshoe abscess where we have involvement of the tendon sheaths on the volar aspect of the hand in the thumb. And in the fifth finger, that infection may spread to the radial and ulnar bursa producing an abscess shaped like an horseshoe. Here's an example of a horseshoe abscess with extensive teno synovitis and bursal involvement in the shape of a horseshoe. Here's another example with the clinical picture showing you a horseshoe abscess involving the thumb, fifth finger and radial and ulnar bursae in the area of the carpal tunnel. The second condition I wanna show you is a little bit different. This is an infectious ulnar bursitis. That's the shape. And here's the example. So this looks like an hourglass shape. Here, we can see involvement of the ulnar bursa which is distended distal to the carpal tunnel and proximal to it but is narrowed within the carpal tunnel. This is a fluid sensitive sequence. This is a gadolinium uh sequence. So this is what ulnar bursitis looks like. It can relate to rheumatoid arthritis to the spondyloarthropathies, rarely to sarcoid, but it can relate also to infections. And here's an example of tuberculosis with extensive involvement of the ulnar bursa. You can see that in the coronal plane here is that kind of the hourglass shape. Here's what it looks like in the sagittal plane and these are rice bodies or fibrous nodules within the infected bursa. So what I've done in my allotted period of time is to run through a variety of causes of wrist pain. We started by talking about the anatomy of the wrist, emphasizing the many articular compartments whether you're looking at conventional radiographs. Mr S CT S arthrograms, you need to know that articular anatomy, the wrist is not a single joint, it's a series of joints or compartments know the anatomy. It's gonna help you. And then following that introduction to the anatomy, we looked at a variety of causes of wrist pain, be they articular, traumatic, infectious or a few other causes. So with that, I will stop sharing my screen and pass this back to you. So we can hear about the particular case that was chosen by Henry to illustrate a cause of wrist pain. Thank you. Thanks a lot. Uh pro uh I mean, that's a very comprehensive tour of, you know, the wrist pain and it, it's in, in keeping with the theme of the grand rounds. So, uh I would like to now invite um uh Henry. He is one of our residents and uh he's currently doing his uh fellowship in uh leeds and uh he had uh completed his radiology training in Sheffield. So welcome Henry. A thank you, Dr Shash and thank you, Professor Rosnick for a really fantastic lecture with some great illustrations and really amazing cases. Um So I'm gonna not be too long. So it's a case presentation about a case of wrist pain that I encountered while in Leeds recently. So it was a 44 year old female right handed, former secretary past medical history of fibromyalgia, chronic migraine, for which she received Botox therapy, took surgery and pregabalin. So she had a five year history of pain and soreness on the ulnar aspect of her right wrist and some intermittent altered sensation in the little and ring fingers. And more recently, she has developed a positive Wartenberg sign wasting of the right hand musculature and a positive Tinel's test over Guillain Canal. So for those that don't know, and I was one of these before I started writing this talk, what is Wartenberg sign? And it is uh essentially what you're seeing here in the hand where you get the patient to put their hands out in front of them and in the affected hands, the positive sign is where you get um abduction and drifting of the fifth little finger digit out to the side and this is caused by unopposed action of the extensor digiti minimi. So before I reveal what the nerve conduction studies demonstrated, um if anyone can type in the chat, which nerve they think is affected in this case, so you can start uh using the chat function to please type your answers in. So which nerve do you think is affected in this uh patient who's presenting with weakness? We have one response from uh Phil. So ulnar. Yeah, that is correct. And Julia, so ulna. Yeah. Yeah. Ulna. Uh So the nerve conduction study is confirmed an ulnar neuropathy and it suggested it was likely due to pathology at the distal part of Guillain canal or in the palm. Uh And if we just go back to this case, so the reason that this is ulnar um so your normal adoption or sort of of the uh little finger and the digits is by your interossei muscles. Um but the extension digiti minimi is innervated by the radial nerve. So when you've got weakness of the interossei muscles, um this extension digiti minimi causes abduction in the little finger. So, um uh so we should have some images that are scrolling. Uh Let me just see if I can find those. Uh can you see those still? Um So I'm just gonna let those play a few times. I appreciate this is gonna be tricky with the moving reasonably quickly and probably being a bit small. Um, but I'll let those play and then if you type into the chat box, anybody that sees any findings, particularly in the context of what we're looking for an or neuropathy, is there anything that anybody sees? So Henry is playing the uh loop a few times. So if you can please type in, what do you think maybe the pathology that these axil images are demonstrating? So we have one response is uh pis triquetral effusion. Then we have uh markets replied, ulna sided ganglion cyst. Yep. Um OK. So yeah, yeah, all good answers. Uh So let's continue the presentation from there. Uh So what are the findings? So we'll talk through each finding in turn. So finding number one is of a ulnar sided ganglion cyst which a few people mentioned um which uh when we look at the Crohn's images is probably arising from the capito hamate joint. So we can see here this uh high PD fat sat signal, slightly septated lesion coming towards the palmar aspect of the rest on the side. And the coronal images show that this is probably tracking from that cap highlight articulation out in an ulnar Bolar direction. So finding two which I appreciate is gonna be really tricky on those moving images. And I wasn't expecting anybody to pick this up necessarily But when we look at these still images zoomed up, uh we follow the ulnar nerve here from proximal zooming in and coming a bit more distal. And we can see it's being displaced at this distal aspect. And as it comes through Guillain S canal and looking on the fluid sensitive sequences, the ulnar nerve here is high signal or edematous. Um And if you contrast that to the median nerve in the carpal tunnel, you can see that the old nerve here definitely is of higher signal. So finding two is of ulnar nerve displacement and edema due to this ganglion cyst and the third binding is of in interossei muscle wasting and denervation edema. So the coronal images nicely demonstrate this high fluid signal of edema in the muscles of the intraosteal contrast that to the muscles. Elsewhere in the rest, you see definitely high signal and the axial T one images show uh fatty infiltration and wasting of these muscles particularly compared to the um thenar eminence muscles here which are preserved. So the diagnosis is of ulnar neuropathy due to compression by a ganglion cyst er in Guillain canal. And the management of this patient was surgical excision of the ganglion with release of Guillain s canal. Er and they also released the cubital tunnel at the same time to give the patient the best chance of recovery of the ulnar nerve. So, uh we had a follow up scan at one year which is actually the scan that I first encountered this case. Um And we can see on the follow up scan that uh this arrow has moved, but the ulnar nerve has returned to normal signal. Uh The muscles have improved in their muscle bulk and there is much less fatty atrophy on the follow up scan than on the pre op scan. And the denervation edema has completely resolved as well. So this patient had a really good outcome following surgery where their power and range of movement returned to normal. The paresthesia was much better but not completely resolved uh but they were pain free. So the key points from this case is we've looked at some of the clinical features of er ulnar neuropathy and particularly I learned about wartenberg sign in this case, uh Gulas canal ganglion cysts sort of causing ulnar neuropathy is reasonably uncommon. A much more common cause of ulnar neuropathy is due to compression or irritation at the carpal tunnel, sorry, cubital tunnel up around the elbow. Uh We've seen the MRI features of the ganglion cyst, which I'm sure you're all familiar with being homogenous high T two signal, low T one signal with internal septi. Uh and they track the joints or tendon sheaths. And we've seen the MRI features of neuropathy uh being nerve edema and swelling acutely, er with denervation, muscle edema and fatty atrophy in more chronic cases. Uh But what I hadn't necessarily appreciated was that the fatty atrophy is so recoverable. Uh I thought this would be a more permanent sort of fixed feature, but this case really nicely demonstrated a patient with really marked fatty atrophy that recovered POSTOP. Uh So these patients can recover and make a good um clinical outcome. Uh So I will now hand you back to er doctor Shes and Doctor Resnick for AQ and a. Thank you. Thanks a lot uh uh Henry. So uh prof your comments on the case, please. Yeah, II, have a, first of all, it's a, it's a beautiful case and uh II sent Henry an email or mentioned that to him. I it's really a beautiful case. II just wonder, I wondered at the time of surgery in this case, where was the ganglion cyst arising from? So the, the operation note didn't actually mention where it was arising from. It was just described as excision of sort of volar ulnar Gulas canal cyst, right? II just wanna mention, uh you know, because this comes up a lot in our reports and our discussions here at UCSD, the difference between a synovial cyst and a ganglion cyst. And there is, there are major differences but the way I look at it, a synovial cyst communicates directly with a joint lumen. And I say directly because you have meniscal cysts that often don't communicate directly with a joint lumen. A ganglion cyst does not uh communicate directly with a joint lumen. It can, can communicate with a ligament, a tendon, a tendon sheath, a joint capsule, uh, or any of the, or a labrum, you know, something of that sort. So, and I agree in your case, it looked like a ganglion cyst. I couldn't tell from the images exactly where it arose from. But, uh I would imagine at the time of surgery they traced it to a structure that was not the joint lumen. Otherwise, it, the, the proper diagnosis would have been a synovial cyst and not a uh a ganglion cyst. But yeah, II was also surprised uh how much muscle recovery occurred. I mean, that was not my teaching. And so I'm gonna have to kind of change what I've been been saying because that was pretty dramatic recovery of the muscle atrophy. Uh, a terrific case. II really enjoyed it. It was very, very good. Thank you. Thanks a lot. I think that was the most striking feature, the, the recovery of the muscle. I thought that was the most striking feature, you know, of the case like so, uh, no, th thanks a lot. Uh Henry, I have one question um from Sarah Jackson, how was the cubital tunnel surgery? Justified? I don't think, did you say it was the wrist surgery? So they, so no, they did do as well as excising the ganglion and releasing Guillain canal. They also released the cupit tunnel at the elbow. So I was looking through the literature to see if this was sort of accepted practice, couldn't really find anything but the clinic letter from uh plastic surgeries, er, was saying that their rationale was to give the best chance of ulnar nerve recovery. Uh I don't know if it's because, you know, compression at the cubital tunnel is relatively common and perhaps, um, they wanted to negate that as a potential sort of super added factor. I don't know. But uh that is what they did. They released both II thought. So we have an orthopedic surgeon, Julia, I saw your name on the thing. So, um uh you know, we were just trying to justify why, you know, the cubital uh internal surgery was performed. Um but Julia who's the surgeon has said, I think you can get fatty infiltration with this use. So may improve after use after the nerve released rather than, you know, from the nerve problem itself. So, uh thank you for that, but I don't know, you know, um I don't have any surgeons here to say why the cital release was also done at the same time. So tha thanks a lot and um uh prof there was one question um that, that came from, you know, on, on, on my messages. Um Do we, I mean in your, in your center, do they, do you still use arthrograms or are you, have you switched to three DMR with high resolution images for the wrist? Yeah. So I have to tell you a funny story about that because we got our university, Mrs, I think in 1983 or 1984 and being someone who sees the future so accurately, I told people, Mr would never be useful for the musculoskeletal system because that was what I thought looking at the initial images. And then we had two very smart Mr research fellows who came up to the VA I was at the VA at the time and showed me Mr arthrographic images. Uh I wasn't even my idea, they were the ones who in fact came up with the idea of injecting gadolinium. And so the first article that was ever written on Mr Arthrography came from UCSD. My name is on it, but all I did was proofread it. The fellows did all the, all the work for that. Um And so we did for many years do a lot of Mr arthrograms. We used it particularly for the glenohumeral joint uh through the years occasionally for postoperative knees trying to determine if there was a meniscal tear. And then more recently, we used it uh for hip labral problems. But since now, our magnets have gone from 1.5 to 3 tesla. Uh We have found that the frequency of our doing Mr arthrograms is much, much lower. Uh We occasionally are asked to do it uh by particularly shoulder surgeons, but in general, we're not doing as many Mr Arthrograms as we used to and, and I'm not even sure we do one or two a week now in our at, at our university. But it, you know, it was something that I was very impressed with early on. But keep in mind early on the Mr images were terrible and that's why we thought we needed Mr Arthrography. Yes. Uh completely. Right. Like, I mean, the 3d uh images that we are getting now are really high resolution. So I think we should be able to answer most of the questions asked from the clinicians. So uh I have one other question from uh uh Harun Gupta. So is uh in usual practice, do you need to uh do you tend to report just cyst like ganglion or synovial? And do you comment on, you know, on the imaging, whether it's a ganglion cyst or a sy synovial cyst? Yeah. Uh So that's a good question. Yes. We uh uh we try to accurately describe whether we're dealing with a synovial cyst or ganglion cyst. In either case, the pathology is not always the cyst, it's the problem that's producing the cyst. So for a synovial cyst, you got to figure out why joint pressure is increased. There's usually something going on in the joint like a internal derangement or rheumatoid or, or what have you for a ganglion cysts, we try to tell them where we think this it is originating from because at the time of surgery, most of the surgeons want to remove, not just the cyst but the area of communication, the stalk down to the site of origin. So we use those terms very carefully and we definitely distinguish between synovial cysts and ganglion cysts whenever we can. There are times where it becomes difficult, I think. Thank you. Thanks a lot. And I think we will have uh one more question. Oh The uh uh the question was asked but it was deleted. So I can't see the question now. So I think um II can just um ask um delegates if you have any more questions. Can you please post? We can take one more question. Definitely. Now, uh we have time fine. Well, by the time they uh this one's in, uh I would like to thank uh uh prof II, have not seen any more questions. So I think we'll leave it at that. So thank you. Thanks a lot for, you know, uh joining us. Uh I think it's about 1030 or uh something like that in the morning there. So, so thank you for making time uh to join the session and uh uh for the delegates. Um you know, you have the feedback form and also the certificates of attendance that we posted to you. So please make use of that. And for those uh who have missed, you know, the first half, because I could see many people trying to join a little bit later. Uh The recording will be available, you know, for you to see for the, uh for a few weeks. So please access the um uh recording that uh prof had done. You know, we, because we promptly started at 530. So thanks a lot for your time and uh Henry well done and I had to tell, uh, I had to share this with you. Uh prof uh we had actually invited, you know, many residents to submit cases and you know, one of the best ones was uh uh chosen to be presented after your presentation. So I thought it was uh uh it will be a privilege for, you know, the resident to be presenting on the same stage as you. So, uh well done, Henry. So no, thank you, doctor. Sure. Uh Thank you for the opportunity in the invitation. Thank you. Thank you all. I II appreciate it. And by the way, if anyone does have questions that come up, uh my email is Resnick at ucsd.edu and I can tell you I am very, very good at answering emails. So if you don't hear from me, please call the police. All right, cause there's something wrong. All right. II will answer your email if you if you send me one. Thank you. Thanks a lot. So, uh there's a lo loads of thank you, great presentations, loads of comments from everybody and excellent talks and uh uh fantastic talks. Uh Yeah, just, just loads of uh uh just some comments coming through. So thank you. And I would like to also thank Kate and Sue who have been, you know, the admin support giving us this uh uh bringing us together on this platform. So thanks a lot pro we'll see you. Bye bye.