5 TFCC MRI From Easy to Hard — Transcript

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1. 0:00Most radiologists struggle to report the
2. 0:02TFCC on MRI scans and they're often
3. 0:05completely wrong. In one study of over
4. 0:06800 MRI reports by over 100
5. 0:09radiologists, the TFCC was incorrectly
6. 0:11called normal in 45% of the time when in
7. 0:15fact there was a pathology. These missed
8. 0:16tears [music] mean delayed treatment or
9. 0:18surgery for the patient. The study also
10. 0:20found that one in three reported tears
11. 0:22[music]
12. 0:23was wrong, like there was no tear at
13. 0:25all. These false positives
14. 0:26[clears throat] can lead to unnecessary
15. 0:28surgery and an angry surgeon.
16. 0:31And we don't want it, right? I'm Dr.
17. 0:33Kristoff Acton. I'm a skeletal
18. 0:35radiologist and founder of the virtual
19. 0:37MSK fellowship where I have been
20. 0:39coaching and giving feedback to over 400
21. 0:41radiologists on thousands on their own
22. 0:44MSK MRI cases to increase their
23. 0:46confidence and speed in MSK MRI
24. 0:49reporting. So, today I'm going to walk
25. 0:51you through five messy real world TFCC
26. 0:53cases that my fellows shared with me in
27. 0:56our coaching sessions. By the end, you
28. 0:58will have a framework for reading the
29. 1:00TFCC that goes beyond the disk. We will
30. 1:02start with a complete peripheral tear
31. 1:05that any radiologist should be able to
32. 1:07report. Then the cases get harder. I
33. 1:10show you a more deceptive case and
34. 1:12explain the anatomy of the peripheral
35. 1:13TFCC you need to know to make the right
36. 1:15call. Third, a misleading arthrogram.
37. 1:18Fourth, a wrist MRI with many findings
38. 1:20where your job is to tell the surgeon
39. 1:22which one is driving the pain. And
40. 1:24finally, a fracture that most
41. 1:26radiologists just call a fracture and
42. 1:28move on but miss the findings that
43. 1:30decide whether the patient needs [music]
44. 1:31a cast or surgery. Let's get into it.
45. 1:35Now, let's have a look at the first
46. 1:36case.
47. 1:37Ulnar attachment tear. When we look at
48. 1:39this image here,
49. 1:41we have
50. 1:43resolution is not great. Maybe if you
51. 1:44can reduce the field of view to
52. 1:47something like this, you might get a
53. 1:48little bit more resolution out of an
54. 1:50image like or a scan like this.
55. 1:52Uh when we go in, so what I would see
56. 1:54here and what's the age? Just want to
57. 1:56confirm. 39, so
58. 1:59there is probably a central perforation
59. 2:01that's happening in the disc itself. We
60. 2:03see here on the 3D
61. 2:05also very at least very thin thinning
62. 2:07maybe questionable perforation.
63. 2:09And then I think you're right the foveal
64. 2:11attachment is torn. The fovea itself
65. 2:14would be somewhere here.
66. 2:16Uh you can see this here better the J
67. 2:19shape. But there is a lot of fluid like
68. 2:21signal here and there is nothing really
69. 2:23that's connecting the disc here with the
70. 2:26fovea itself. This might be a remnant of
71. 2:29the foveal attachment, but it's not
72. 2:31attached. So this is torn.
73. 2:33So contrast would most likely leak in
74. 2:35there. And now the question is do we
75. 2:37call or what do we call this here? So
76. 2:41this one this layer here is meniscus
77. 2:43homolog and then this one here would be
78. 2:45part of the styloid attachment. And I
79. 2:49also it's too irregular. I wouldn't
80. 2:51really I mean it's at least partially
81. 2:53torn and I think I would be okay by
82. 2:55calling this a complete tear of both now
83. 2:58with granulation tissue in the subacute
84. 3:00phase making it even harder. But there
85. 3:04is edema, there is abnormality
86. 3:06uh here and I don't think there was much
87. 3:09else going on. So I think yeah,
88. 3:11peripheral TFCC tear
89. 3:13uh with
90. 3:14the injury here. So this is styloid
91. 3:16process. And if you look at other wrist
92. 3:17MRIs, you will often see the black
93. 3:19styloid attachment. And here this is
94. 3:21just torn with granulation tissue
95. 3:23synovitis here. So yeah, I agree.
96. 3:28Okay, hi Shobha. Thanks for this case
97. 3:30wrist MRI.
98. 3:32And the suspicion is a TFCC injury. And
99. 3:34what we can see here on the axial is the
100. 3:37disc itself is fine.
101. 3:40We see a little bit of the styloid
102. 3:41attachment here. This one here is part
103. 3:44of the foveal attachment. We'll see this
104. 3:46on the
105. 3:47coronals better. So going back here, we
106. 3:49see centrally the disc is fine. There's
107. 3:51nothing wrong here. This is the styloid
108. 3:53detachment. This is the I just This is
109. 3:56the volar attachment. This is the
110. 3:57styloid detachment like this. So, this
111. 3:59one
112. 4:00looks quite okay. But, then we have this
113. 4:02edema here. I think this is the main
114. 4:03problem in this case.
115. 4:05Now, this depends now on the clinical
116. 4:07information. I
117. 4:09you know, if there was a trauma, I would
118. 4:11call this like a a sprain
119. 4:13or even like a severe focal sprain of
120. 4:15the
121. 4:16dorsal
122. 4:18you know,
123. 4:19peripheral attachment of TFCC, meaning
124. 4:21part of the radioulnar joint or
125. 4:23radioulnar ligament. Although, the
126. 4:24actual attachment here is fine, and you
127. 4:26can see on the axial how this part here,
128. 4:29this is still okay. So, it's not
129. 4:31it's not torn. It's more like this
130. 4:33perifocal tissue, the peripheral
131. 4:35attachment of the TFCC ring that's
132. 4:38involved. So, we can also see here. We
133. 4:39follow this. You can see a nice sharp
134. 4:41triangular meniscus-like structure. But,
135. 4:43then there is this edema here at the
136. 4:45dorsum here, and this one here is the
137. 4:47styloid attachment, which is continuous.
138. 4:50And then, we have got these fibers
139. 4:51coming down into the
140. 4:53volar attachment. And I I think also
141. 4:55they for me would be intact. I don't see
142. 4:58a tear.
143. 4:59And I think the second thing on the
144. 5:00volar aspect that you mentioned, as
145. 5:02there is also some edema,
146. 5:04we can see
147. 5:05uh a little bit here and a little bit
148. 5:07here. I think one of them would be the
149. 5:08prestyloid recess. I think this one here
150. 5:11for me would be
151. 5:12the prestyloid recess here.
152. 5:15So, this is just a a pouch of the joint
153. 5:18space.
154. 5:19I here you can see homolog here, and
155. 5:21this is where the prestyloid recess goes
156. 5:23down. I think this bulges just down here
157. 5:25volarly to the styloid process.
158. 5:27And I'm not so sure whether or maybe
159. 5:30this is a ganglion cyst arising from
160. 5:32this area. And then, we've got another
161. 5:34pocket of fluid here,
162. 5:36which goes kind of like under the
163. 5:39or close to the styloid process. Maybe
164. 5:40this is still part of the prestyloid
165. 5:43recess. I think I wouldn't
166. 5:45make this a tear.
167. 5:48Now, when we look at the
168. 5:50location of this one, so this is a quite
169. 5:52a pronated position. The ulnar styloid
170. 5:55of the normally is here, or in
171. 5:57supination it's up here. So, this is
172. 5:58supination, down here is pronation, and
173. 6:01this would be neutral.
174. 6:02Um that also
175. 6:04twists a little bit the
176. 6:074-wheel attachments to here, styloid
177. 6:08attachments to here. So, there's some
178. 6:10variability here.
179. 6:12Um but yes, so I think there is a
180. 6:13definitely a sprain of the dorsal
181. 6:15radioulnar ligament or dorsal peripheral
182. 6:17TFCC attachment, no central perforation.
183. 6:20I don't see a distinct tear. So, if we
184. 6:21would give contrast into the distal
185. 6:23radioulnar joint, I think it would stay
186. 6:25contained.
187. 6:26Uh and I don't see how
188. 6:31Well, potentially the The question is,
189. 6:32what happens if we give contrast into
190. 6:34the radiocarpal compartment? Would it go
191. 6:35in between here, which would make then
192. 6:38maybe this styloid attachment partially
193. 6:41torn. But I think, you know, this one's
194. 6:43covered.
195. 6:44Ulnocarpal ligament come up here, like
196. 6:46this.
197. 6:48I think it's just the edema mainly
198. 6:50that's here the issue. Maybe small tears
199. 6:52at the peripheral thing might be okay.
200. 6:54Um
201. 6:55But yeah, this depends on the story.
202. 6:57Let's say if he is not a post-traumatic
203. 7:00case and it's a chronic situation, then
204. 7:02I would call this like some
205. 7:04peripheral irritation here.
206. 7:06I don't think I would call
207. 7:08synovitis per se because,
208. 7:13you know, the joint We can have
209. 7:14synovitis in the prestyloid recess,
210. 7:16which would be maybe somewhere like
211. 7:17here.
212. 7:18But there is This is extra-articular.
213. 7:21Uh so, this one is not inside the joint.
214. 7:22The joint
215. 7:24You can see this is This is the joint
216. 7:26line here, joint capsule here. And then,
217. 7:28of course, we have the recess here.
218. 7:31And then, we have the meniscal homolog.
219. 7:32We've got These are the compartments
220. 7:34that we fill up with contrast in
221. 7:35arthrograms. So, whatever this is, it's
222. 7:37outside of the joint. That's why I don't
223. 7:39like the term synovitis for this area. I
224. 7:40would just call it like soft tissue
225. 7:42irritation.
226. 7:43Uh or like chronic irritation. Or if you
227. 7:45want to go with the sprain route, like
228. 7:47chronic sprain of the dorsal digital
229. 7:48ulnar ligament or dorsal TFCC peripheral
230. 7:51attachment.
231. 7:52Um yeah, so I mean it doesn't look like
232. 7:54super cute, but it could be more like a
233. 7:56subacute injury. So, I think sprain is
234. 7:59would be my preferred
235. 8:00terminology here.
236. 8:04Uh we're looking at the TFCC injury
237. 8:06question, and this was an arthrogram.
238. 8:08The first comment that I would make is I
239. 8:11find it's slightly weird that the
240. 8:12radiocarpal compartment was injected
241. 8:14only. I would have preferred a first
242. 8:17distal radioulnar joint injection and
243. 8:19see what we can see. But, when we look
244. 8:21at this here, we can see the surface is
245. 8:23intact. There's nothing going down. So,
246. 8:25we don't have a communicating injury
247. 8:27somewhere. And even at the periphery
248. 8:29here, we can see the meniscus homolog
249. 8:31outline nicely and pre-styloid recess
250. 8:33here. And there's no contrast leaking
251. 8:35into the attachments or somewhere. So,
252. 8:38we have to rely really on the PD fat sat
253. 8:40here more for this case. And when we
254. 8:43look here,
255. 8:44again, we can confirm the disc is
256. 8:46intact. We see the dorsal radioulnar
257. 8:49ligament here intact. We see the volar
258. 8:50radioulnar ligament intact here. And
259. 8:53then, the disc itself is fine as well.
260. 8:55So, the area where we see a little bit
261. 8:57of fluid is here, and we know there is
262. 8:58no contrast in there. And this is the
263. 9:00processus styloideus ulna. And
264. 9:03because we have fluid here in a location
265. 9:05where we wouldn't expect it to be, I
266. 9:07would also give a high-grade partial
267. 9:08tear. I wouldn't call it a complete
268. 9:10tear, otherwise I would have suspected
269. 9:11the contrast to go in because it was
270. 9:12quite overblown. And there should have
271. 9:14been enough pressure to go in here on
272. 9:16the arthro
273. 9:18T1 fat sat, and it's not the case. So,
274. 9:19some of these fibers might still be
275. 9:20intact or at least scarred and and uh
276. 9:24kind of like prevents the contrast from
277. 9:25communi- communicating. So, I would say
278. 9:27high-grade partial tear foveal
279. 9:28attachment.
280. 9:29And then, I think you are correct that
281. 9:32there is some interstitial tear
282. 9:35component into the disc periphery here.
283. 9:38And I think the foveal attachment is a
284. 9:40bit hard to assess. I don't see fluid,
285. 9:43you know, transacting it somewhere here.
286. 9:45Um so, that's why I would probably also
287. 9:47go, as you said,
288. 9:49you know, that it's intact. Uh
289. 9:50unfortunately, we cannot really
290. 9:53use this T1 here because it was very,
291. 9:55very much movement in here. And the T1
292. 10:00is either like
293. 10:03And this one is also not much better.
294. 10:05Sorry for the phone. Because, you know,
295. 10:07we don't have an injection into the
296. 10:08distal ulnar joint, which might have
297. 10:09helped us in assessing this area here.
298. 10:14So, we have a wrist MRI
299. 10:17TFCC tear or UCL tear is the question.
300. 10:20You can see a perforation and something
301. 10:22on the volar aspect ligament and the
302. 10:23lunotriquetral ligament is intact. And
303. 10:25your question is UCL wave it torn and
304. 10:28partial thickness of the dorsal
305. 10:29radioulnar ligament. And whether to
306. 10:31discuss the meniscus homolog or the
307. 10:33triangular ligament. But, so the
308. 10:36meniscus homolog, I used to look at it,
309. 10:38but I never really see any pathology
310. 10:40there. So, I just stopped even
311. 10:43mentioning it.
312. 10:44Um but, let's have a look at your case.
313. 10:46So, this is the image.
314. 10:48And yeah, there's a small perforation
315. 10:50here at the disc.
316. 10:51Here, that's okay. We can see there is
317. 10:54quite a large, you know, high signal
318. 10:56here in the foveal attachment with these
319. 10:59cysts here indicating there is a
320. 11:01high-grade partial tear and synovitis
321. 11:04going into this area here creating this
322. 11:06ganglion cyst and the perifocal edema
323. 11:08here. And also, when we look at the
324. 11:11styloid attachment, there is at least
325. 11:12some fraying. Often, we see the covering
326. 11:15of the ulnar styloid. I'm not sure
327. 11:17whether this is just anatomically
328. 11:18variant or whether I would even go with
329. 11:20a partial tear also for the styloid
330. 11:22attachment.
331. 11:24Uh meniscus homolog, we don't really see
332. 11:26much. It's probably this one here. So, I
333. 11:28would not mention this, but we can see
334. 11:30there is this dirty stuff here in the
335. 11:31prestyloid recess, which we will call
336. 11:34synovitis.
337. 11:35Um the dorsal and this is the dorsal
338. 11:38radioulnar ligament also shows some
339. 11:40degeneration. Uh the volar one, I think
340. 11:42it's better.
341. 11:44And for the ulnar collateral ligament,
342. 11:48you know, we don't really see it as a
343. 11:49distinct structure for the most part.
344. 11:51It's a and you know
345. 11:54enforcing the tendon sheath of the ECU
346. 11:57tendon, there's just a mild
347. 11:59tenosynovitis.
348. 12:00And I cannot really show you where that
349. 12:03ligament would be. It's going to It's
350. 12:05going to run somewhere along here, but I
351. 12:07would not mention this here as a sprain
352. 12:09or tear or anything. So, we got enough
353. 12:11stuff already happening here as is.
354. 12:14Uh LT ligaments,
355. 12:17we don't really know. I think the
356. 12:18resolution is not really giving us
357. 12:20enough information to be sure about the
358. 12:22membranous portion here. This bit here
359. 12:24is still disc.
360. 12:25And I wouldn't be surprised if there is
361. 12:27a perforation of the LT ligament
362. 12:29membranous portion.
363. 12:31Now, let's try to find the
364. 12:34LT ligament dorsal and volar one. So, we
365. 12:36got the dorsal one.
366. 12:38Uh we see somewhere here the volar one.
367. 12:41I think LT ligament the two main
368. 12:43components, maybe some degeneration of
369. 12:45the dorsal one. Volar one, I think we
370. 12:46just go with okay, membranous portion
371. 12:48not well seen.
372. 12:49And then for the SL ligament,
373. 12:52yeah, it looks too high.
374. 12:54Um I wouldn't make a tear out of it yet
375. 12:56here. I would just say some signal
376. 12:58increase and degeneration of the dorsal
377. 13:00SL ligament and also here the volar one.
378. 13:03I think we can probably be okay with a
379. 13:06advanced degeneration or even if you
380. 13:08want to go with a partial tear, I think
381. 13:09I would also be okay. We can see there's
382. 13:11some
383. 13:11fraying happening even here something
384. 13:13linear that goes into the ligament
385. 13:15itself. But I think that's quite a a
386. 13:17subtle case. Um clinically, I mean,
387. 13:20there are
388. 13:21these things are probably more
389. 13:22important, osteoarthritis,
390. 13:25and then the
391. 13:26changes on the owner carpal side here.
392. 13:28Where is the symptoms or but they even
393. 13:30ask about these things. So, most likely
394. 13:33patients really doesn't really have much
395. 13:35issues here in terms of the SL ligament
396. 13:37and the issue is the synovitis that we
397. 13:39can see here, which then also goes into
398. 13:41this partial tear of the foveal
399. 13:43attachment or even you know, even high
400. 13:45grade partial tear. There may be some
401. 13:46fibers still intact, so we just go with
402. 13:49high grade partial tear and joint space
403. 13:50gain information peripheral edema as the
404. 13:52main culprit, I think in this case in
405. 13:54addition to this one here.
406. 13:57We got the wrist MRI here in a
407. 13:5940-year-old man. He had an old trauma,
408. 14:01no recent injury. And I mean, the
409. 14:03obvious finding would be the styloid
410. 14:04arthrosis here after an old fracture.
411. 14:07There may be smaller you know, smaller
412. 14:08ossicles close by.
413. 14:11And
414. 14:12the head looks quite big.
415. 14:14And when we have these styloid arthrosis
416. 14:16or these old fractures, especially when
417. 14:18they go through the base of the styloid
418. 14:19process, what that means is that
419. 14:21basically
420. 14:23the foveal and styloid detachment are
421. 14:26affected. So, you know, this one will go
422. 14:28in here. So, both are affected. So, this
423. 14:31makes the TFCC or the distal radio-ulnar
424. 14:34joint unstable.
425. 14:36And that's why we see also to some
426. 14:38degree like like you mentioned already,
427. 14:40dorsal subluxation. If we use these
428. 14:43different methods, then the center of
429. 14:44rotation would be here.
430. 14:46You know, it's too high, so dorsal
431. 14:48subluxed. And I think the reason for
432. 14:51this
433. 14:52is mostly injury to the dorsal one, the
434. 14:55dorsal radio-ulnar ligament. Um it's not
435. 14:58really the volar one. Uh and when we go
436. 15:01to the volar one, we can see the volar
437. 15:02ulnolunate ligament here very nicely
438. 15:04black. We go here, we see part of the
439. 15:06ulnar
440. 15:07triquetral ligament also quite okayish.
441. 15:11The disc itself then here is also not
442. 15:14perforated or anything like that, but
443. 15:16when we go from here, which is still
444. 15:18disc,
445. 15:19to the next level, which will now show
446. 15:20the dorsal radio-ulnar ligament. You can
447. 15:23see there is ill ill-definition. You
448. 15:26know, it's
449. 15:27There's no really nice ligament
450. 15:29structure visible here as opposed to the
451. 15:31volar side where we have nice and black
452. 15:32ligaments here, right? So, this is just
453. 15:35uh like scarred
454. 15:37uh hardly visible dorsal radioulnar
455. 15:39ligament. We've got the bone marrow
456. 15:41edema here at the fragment. We've got a
457. 15:43bit of fusion in the pisiform
458. 15:44triquetrum.
459. 15:46The attachments are continuous with this
460. 15:48fragment.
461. 15:49Destabilizing this most likely.
462. 15:52We see a little bit of edema also here.
463. 15:54Maybe a little bit of a fusion and
464. 15:55synovitis in the distal radioulnar
465. 15:56joint. And as you said already,
466. 15:58dorsal subluxation.
467. 16:00And yeah, so I think that's the main
468. 16:03issue.
469. 16:04Uh
470. 16:05for the ECU tendon, some flattening,
471. 16:07maybe a split tear here.
472. 16:09I
473. 16:11see not too much in terms of
474. 16:13tenosynovitis, though.
475. 16:15I I think I would just keep it with a
476. 16:16little bit of tendinosis and a split
477. 16:17tear.
478. 16:18Um
479. 16:20pisiform triquetral joint is fine. The
480. 16:22ulnar nerve
481. 16:23here. You can follow my my mouse. This
482. 16:26is ulnar nerve. Comes up here.
483. 16:28Then this is deep branch, superficial
484. 16:30branch. Deep branch goes in here.
485. 16:33Then we lose it. It's fine. Not much to
486. 16:35be seen there. Then we've got some
487. 16:37smaller dorsal ganglion cysts here at
488. 16:39this level.
489. 16:40Uh and then SL ligament is okay. The
490. 16:43other extensor tendons, we don't see
491. 16:45much there either. So, we don't see too
492. 16:47much. Maybe some subtle degeneration of
493. 16:49the dorsal LT ligament. The volar one is
494. 16:51fine.
495. 16:52Volar SL ligament fine. Dorsal SL
496. 16:54ligament fine.
497. 16:55Uh let's go through the extrinsic
498. 16:57ligaments here.
499. 17:00Dorsal intercarpal ligament is fine.
500. 17:01Maybe some degeneration of the dorsal
501. 17:04radiocarpal ligament, which is a bit
502. 17:07ill-defined.
503. 17:08The volar extrinsic ligaments are fine.
504. 17:10So, I think that will be the assessment
505. 17:12here from my side. Now you have seen how
506. 17:15subtle TFCC pathology can be in real
507. 17:18clinical cases. But, you'll never be
508. 17:20able to see what's hidden in plain sight
509. 17:22unless you understand this subtle wrist
510. 17:24anatomy. Watch this video where I walk
511. 17:26you through the full MRI anatomy of the
512. 17:28TFCC. It is one of the most popular
513. 17:31videos of mine, and according to some
514. 17:33surgeons and radiologists in the
515. 17:34comments, one of the clearest
516. 17:35explanations of the TFCC online.