hello again i'm greg fritz a doctor of physical therapy and a specialist in musculoskeletal sonography and i am fortunate to have with me today my friend and patient randy and recently randy has been dealing with some building building wrist pain and so i'm fortunate in my practice to be able to have access to the scanner from clarius that will allow me to take a window into his wrist and look at some of the bony ligament soft tissue and certainly identify areas where inflammation exists simply taking the probe going long axis on the back of the wrist we're going to be able to see the white hyperechoic echo texture of the wrist joint you can see just with this easy scan on the back of the wrist what the carpal bones look like and unlike a young healthy wrist you're seeing debris around all of the different carpal joint regions and darkness showing effusion and the amount of irritation that that surrounds that i'm just showing you from on on the on the left of the screen is uh is the radius and as we come down you can see the the carpal bones that are showing all types of topography and the important part is the dark fluid filled areas that basically document a significant amount of osteoarthritis that that is already part of this and then all the way over to extensor carpi ulnaris but while you're looking at that you can also see that darkened area around that the the thickening of the synovial sheath continuing to demonstrate that that he's put some miles on these wrists however as i'm now going to go down distal i'm going to be taking a look at the scaffold lunate ligament trying to also have you realize that there is such a um the topography of these carpal bones are showing such hills and valleys and potholes this is the definition of wrist osteoarthritis but we are seeing at the center of the screen there that his scapholunate ligament is intact does not show any compromise from this position what i'm going to be doing next is i'm going to be doing long axis the top white line is the distal ulna and as we drop off the distal ulna we're going to be coming on to the trequestrium or or the the the ulnar the carpal ulnar joint and in between those two and i'm going to be radially deviating i'm going to have you leave your elbow right there and i'm going to turn your wrist just a little bit there so i want to open that up we're going to be looking down between the ulna that is that bone on the left and the carpal bone here the triquitrium and we're going to be looking for fluid we're going to be looking for that classic tfcc cartilage and i'm coming from the dorsal component because you're seeing the fibers of the extensor carpi ulnaris show up there you're also seeing the end of the ulna showing some periosteal defects in that region and we're getting a window down deep between the ulna and the carpal bone i'm not seeing a cyst i'm not seeing any type of of fluid containing reactive effusion but i am also not seeing a homogeneous fibrocartilage disc that we would expect so in order to clarify that more i'm simply going to take his wrist we'll turn it over this way how you doing buddy you're good let's have you put your uh arm over this so that there we go now i can come down underneath i'm going to look here that's actually a fabulous view of the tfcc we can see all the way through to the distal radius so we're actually seeing all of the ligaments that are associated with triangular fibrocartilage on that view right there it's just that there is enough darkness that are that's surrounding this fibrocartilage and uh and that's right where his discomfort is um i and the actual [Music] fibrocartilaginous complex is showing me enough heterogeneity or or inconsistency that i i am i am feeling concerned about us needing to go to a little bit more of a gold standard imaging which would most likely be an mri in this case and i'm actually thinking i'm i'm pretty well able to confirm a tear in that complex think about it to actually be able to identify the structures of the triangular fibrocartilage with with ultrasound in your own clinic is has got to be something that just is blowing your mind after reviewing randy's wrist from a physical therapy standpoint i've identified enough pathology involving the tfcc that i'm going to elevate this to specialty consultation without this uh ability to confirm uh that there are there were not components of uh the wrist scan that were flagged as pathological we do have a green light to proceed forward with range of motion and a very appropriate referral for specialty intervention
