WEBVTT 00:00:00.000 --> 00:00:02.919 Welcome to Deep Dive Ortho. Today, we're getting 00:00:02.919 --> 00:00:06.559 to grips with a really common yet, well, often 00:00:06.559 --> 00:00:09.679 quite frustrating wrist injury, the trichetral 00:00:09.679 --> 00:00:12.039 fracture. That's right. It might actually surprise 00:00:12.039 --> 00:00:14.160 you just how prevalent these are. We're talking 00:00:14.160 --> 00:00:16.980 the second most common carpal bone fracture. 00:00:18.039 --> 00:00:21.460 Indeed. About 15 % to 18 % of all carpal fractures, 00:00:21.579 --> 00:00:24.219 give or take. Which is significant. But despite 00:00:24.219 --> 00:00:27.160 that, they're Let's face it, notoriously tricky 00:00:27.160 --> 00:00:30.039 to diagnose, often just labeled a wrist sprain. 00:00:30.320 --> 00:00:32.939 Exactly. Or if they're simply radiographically 00:00:32.939 --> 00:00:35.560 occult, just don't show up on the initial x -rays. 00:00:35.759 --> 00:00:38.320 So our aim today is to really give you a deep 00:00:38.320 --> 00:00:41.759 understanding of these elusive injuries. We want 00:00:41.759 --> 00:00:44.399 to look at the subtle diagnostic clues, the, 00:00:44.399 --> 00:00:46.840 well, the surprisingly complex ways they happen. 00:00:47.240 --> 00:00:49.679 Mechanisms, yes. Yeah. Which have evolved quite 00:00:49.679 --> 00:00:51.539 a bit. And the latest thinking on management, 00:00:51.679 --> 00:00:54.439 both conservative and surgical. We've got our 00:00:54.439 --> 00:00:56.179 expert here to guide us through all this. Thank 00:00:56.179 --> 00:00:57.600 you. It's great to be here. We're talking about 00:00:57.600 --> 00:01:00.479 a small bone, the trichobrum, but one that plays 00:01:00.479 --> 00:01:02.560 a really pivotal role in how the wrist works. 00:01:02.700 --> 00:01:04.659 Can you just remind us where it sits anatomically? 00:01:05.019 --> 00:01:07.799 Of course. So if you picture the wrist, the trichotrum 00:01:07.799 --> 00:01:10.500 is this sort of wedge -shaped bone. It's in the 00:01:10.500 --> 00:01:13.459 proximal carpal row over on the ulnar side, the 00:01:13.459 --> 00:01:16.319 little finger side. OK. And its position is key. 00:01:16.439 --> 00:01:18.620 It connects with several neighbors. The lunid 00:01:18.620 --> 00:01:21.140 bone next to it, the pisiform sits right on top. 00:01:21.340 --> 00:01:25.319 and the hamate is distal to it. Right. And it's 00:01:25.319 --> 00:01:27.480 connection to the ulna. Ah, well that's interesting. 00:01:27.579 --> 00:01:29.920 It doesn't directly touch the ulna. Instead, 00:01:30.040 --> 00:01:32.959 it connects via the TFCC, the triangular fibrocartilage 00:01:32.959 --> 00:01:37.099 complex. Disc. Precisely. Which acts as a crucial 00:01:37.099 --> 00:01:39.920 shock absorber and stabilizer for that medial 00:01:39.920 --> 00:01:42.420 side of the wrist. And another really important 00:01:42.420 --> 00:01:45.340 point, its dorsum medial surface, the back, has 00:01:45.340 --> 00:01:48.019 these two significant areas where ligaments attach. 00:01:48.280 --> 00:01:51.180 strong ligaments. Ah okay so not just bone -on 00:01:51.180 --> 00:01:53.780 -bone articulation but critical ligament anchor 00:01:53.780 --> 00:01:56.519 points too. Exactly and that's why when the tricotrum 00:01:56.519 --> 00:01:59.019 gets injured it's well it's really just the bone 00:01:59.019 --> 00:02:01.180 itself the surrounding structures especially 00:02:01.180 --> 00:02:03.379 those ligaments are often involved. It sort of 00:02:03.379 --> 00:02:05.040 sets the scene for why these injuries can be 00:02:05.040 --> 00:02:08.030 complex. That's a perfect setup. It immediately 00:02:08.030 --> 00:02:10.229 tells us, we're not just dealing with a simple 00:02:10.229 --> 00:02:13.129 chip. So let's dive into that complexity. How 00:02:13.129 --> 00:02:15.750 do these fractures actually happen? There's been 00:02:15.750 --> 00:02:17.689 quite a debate over the years, hasn't there? 00:02:17.750 --> 00:02:21.229 Oh, absolutely. A real sort of historical back 00:02:21.229 --> 00:02:23.449 and forth. It mainly centered around two competing 00:02:23.449 --> 00:02:26.569 ideas, ligament avulsion versus impaction. Pull 00:02:26.569 --> 00:02:28.810 versus push, essentially. You could put it like 00:02:28.810 --> 00:02:31.169 that, yes. The traditional views were fairly 00:02:31.169 --> 00:02:33.409 distinct. First, you had the ligament avulsion 00:02:33.409 --> 00:02:36.330 theory. Right. This suggested that these fractures 00:02:36.430 --> 00:02:38.870 particularly the common dorsal ones, happened 00:02:38.870 --> 00:02:41.409 when a ligament attaching to the trichotrum was 00:02:41.409 --> 00:02:44.810 pulled so hard, perhaps during a fall with the 00:02:44.810 --> 00:02:47.789 wrist bent sharply forward and inwards, palmar 00:02:47.789 --> 00:02:50.349 flexion and radial deviation, that the ligament 00:02:50.349 --> 00:02:53.030 just pulled a fragment of bone off with it. Simple 00:02:53.030 --> 00:02:55.069 tensile failure at the insertion site. Okay, 00:02:55.069 --> 00:02:57.469 so a pulling mechanism. What was the alternative? 00:02:57.650 --> 00:03:00.050 The alternative was the endocarpal impaction 00:03:00.050 --> 00:03:03.069 theory. Garcia Elias, a well -known hand surgeon, 00:03:03.270 --> 00:03:05.590 really detailed this. He proposed a chisel action. 00:03:05.710 --> 00:03:08.909 Yes, the idea was that the ulnar styloid process, 00:03:09.050 --> 00:03:11.169 that bony bump on the end of your ulna, acted 00:03:11.169 --> 00:03:14.490 like a chisel. During forceful dorsiflexion, 00:03:14.710 --> 00:03:17.289 bending the wrist back hard combined with ulnar 00:03:17.289 --> 00:03:19.909 deviation towards the little finger. That classic 00:03:19.909 --> 00:03:22.770 fall mechanism. Exactly. The styloid would supposedly 00:03:22.770 --> 00:03:25.169 strike the dorsal aspect of the trichatrum and 00:03:25.169 --> 00:03:28.030 chip a piece off. And this theory gained some 00:03:28.030 --> 00:03:30.889 traction because some studies noted a slightly 00:03:30.889 --> 00:03:33.699 longer ulnar styloid in these patients. They 00:03:33.699 --> 00:03:35.979 measured the ulnar styloid process index, the 00:03:35.979 --> 00:03:37.900 USPI. Right, I remember reading about that. I 00:03:37.900 --> 00:03:42.000 mean USPI of about .29 was reported. That's the 00:03:42.000 --> 00:03:44.659 figure often cited, suggesting a longer styloid 00:03:44.659 --> 00:03:48.419 might predispose to this impaction. Then later, 00:03:48.740 --> 00:03:51.400 Hucker and Menchik sort of expanded on this impaction 00:03:51.400 --> 00:03:53.939 idea. How so? They suggested it wasn't maybe 00:03:53.939 --> 00:03:56.240 just the ulnar styloid. They argued that the 00:03:56.240 --> 00:03:58.659 edge of the hamat bone, the dorsoproximal edge, 00:03:58.939 --> 00:04:01.539 could also act as a chisel against the trichatrum 00:04:01.539 --> 00:04:04.659 in that same extended ulnar deviated position. 00:04:04.800 --> 00:04:07.460 OK, so a similar impact mechanism, but potentially 00:04:07.460 --> 00:04:09.599 from a different bony structure. So historically 00:04:09.599 --> 00:04:11.939 it was pull versus impact, either from the ulna 00:04:11.939 --> 00:04:14.300 or the hermit. That was the basic picture, yes. 00:04:14.659 --> 00:04:16.680 But as often happens in medicine, things aren't 00:04:16.680 --> 00:04:19.540 usually that simple, are they? What have newer 00:04:19.540 --> 00:04:23.389 techniques, especially MRI, shown us? Has it 00:04:23.389 --> 00:04:26.069 clarified things or, dare I say, made it even 00:04:26.069 --> 00:04:28.589 muddier? Huh. Well, complex might be a better 00:04:28.589 --> 00:04:31.069 word than muddy. But yes, you're absolutely right. 00:04:31.610 --> 00:04:34.290 Modern MRI studies, like the one by Bess and 00:04:34.290 --> 00:04:37.230 colleagues, have really peeled back the layers 00:04:37.230 --> 00:04:40.170 here. OK. And their findings don't just tweak 00:04:40.170 --> 00:04:42.470 the old theories. They, well, they challenge 00:04:42.470 --> 00:04:44.149 some of the fundamental assumptions and show 00:04:44.149 --> 00:04:46.629 it's often a much more mixed, multifactorial 00:04:46.629 --> 00:04:49.620 picture. How so? Let's take the ulnar styloid 00:04:49.620 --> 00:04:51.959 impaction theory first. What did the MRI data 00:04:51.959 --> 00:04:54.540 show there? Well, firstly, the average USPI they 00:04:54.540 --> 00:04:57.180 found in their patients was 0 .21. Which is normal. 00:04:57.339 --> 00:05:00.019 Exactly. Within the normal range. Yeah. Not consistently 00:05:00.019 --> 00:05:02.439 high like the theory predicted. But here's the 00:05:02.439 --> 00:05:05.379 really interesting bit. The median USPI was actually 00:05:05.379 --> 00:05:08.040 higher in patients whose injury story sounded 00:05:08.040 --> 00:05:10.920 more like an avulsion 0 .27. Higher in the avulsion 00:05:10.920 --> 00:05:14.620 group. Yes. Compared to those whose story suggested 00:05:14.620 --> 00:05:18.649 impaction. where it was .20. So that directly 00:05:18.649 --> 00:05:21.250 contradicts the simple idea that a long styloid 00:05:21.250 --> 00:05:23.550 equals impaction fracture. It's clearly not that 00:05:23.550 --> 00:05:25.709 straightforward. Okay, that's definitely counterintuitive. 00:05:26.350 --> 00:05:28.949 What else did the MRI reveal about the ulnar 00:05:28.949 --> 00:05:32.069 styloid's role? This is perhaps the most damning 00:05:32.069 --> 00:05:34.730 evidence against the direct ulnar styloid chisel 00:05:34.730 --> 00:05:37.430 idea. at least in the cases they studied. They 00:05:37.430 --> 00:05:40.910 found no fracture or even bone marrow edema bone 00:05:40.910 --> 00:05:43.389 bruising in the ulnar styloid process itself 00:05:43.389 --> 00:05:46.149 in any of their patients with trichotral fractures. 00:05:46.189 --> 00:05:49.329 None at all. None. And you'd really expect to 00:05:49.329 --> 00:05:52.189 see some sign of trauma on the styloid if it 00:05:52.189 --> 00:05:54.449 was directly hitting the trichotrum hard enough 00:05:54.449 --> 00:05:56.370 to break it. That seems pretty conclusive for 00:05:56.370 --> 00:05:58.589 those cases, doesn't it? It makes direct impaction 00:05:58.589 --> 00:06:01.050 from the ulna seem unlikely as the sole cause. 00:06:01.129 --> 00:06:02.970 It certainly makes it much less likely in those 00:06:02.970 --> 00:06:06.319 instances, yes. However, The heme impaction theory 00:06:06.319 --> 00:06:09.759 did get some support. Oh, OK. How? They did find 00:06:09.759 --> 00:06:12.560 bone marodema in the hamat bone in nearly a quarter 00:06:12.560 --> 00:06:16.279 of the patients, 23 .8%, which does suggest that 00:06:16.279 --> 00:06:18.779 the hemo hitting the trichotrum, as Hucker and 00:06:18.779 --> 00:06:21.339 Menchik proposed, could well be a contributing 00:06:21.339 --> 00:06:24.060 factor in that extended ulnar deviated position. 00:06:24.980 --> 00:06:27.579 So maybe the heme is the more common impactor 00:06:27.579 --> 00:06:29.639 than the ulna. Okay, so the picture is shifting. 00:06:30.199 --> 00:06:33.339 Less ulna, maybe more heme involvement in impaction. 00:06:33.420 --> 00:06:35.980 What else complicated the simple avulsion versus 00:06:35.980 --> 00:06:38.730 impaction story? Well, they looked at specific 00:06:38.730 --> 00:06:41.310 fracture patterns using the Gersi -Alias classification 00:06:41.310 --> 00:06:43.709 we'll discuss later. He'd suggested type III 00:06:43.709 --> 00:06:45.569 fractures partially displaced at the distal end 00:06:45.569 --> 00:06:48.170 were likely evulsions. And Besse's group did 00:06:48.170 --> 00:06:51.470 find a lower mean USPI for these, .17, which 00:06:51.470 --> 00:06:54.430 sort of fits. But crucially, they found this 00:06:54.430 --> 00:06:56.889 type III pattern was significantly more common 00:06:56.889 --> 00:06:58.910 in the group whose history suggested impaction. 00:06:59.029 --> 00:07:01.410 Oh, right. So the pattern associated with a lower 00:07:01.410 --> 00:07:04.110 USPI thought to be evulsion was actually more 00:07:04.110 --> 00:07:06.290 common in the impaction group. Precisely. Yeah. 00:07:06.639 --> 00:07:09.420 doesn't fit neatly into either box. It suggests 00:07:09.420 --> 00:07:11.779 a real overlap, maybe a combination of forces 00:07:11.779 --> 00:07:14.459 rather than one single mechanism defining the 00:07:14.459 --> 00:07:17.279 fracture type. Okay, it sounds truly multifactorial. 00:07:17.699 --> 00:07:19.839 And what about the ligaments in all this? Did 00:07:19.839 --> 00:07:22.319 they find differences between the evulsion and 00:07:22.319 --> 00:07:24.779 impaction groups there? This is probably the 00:07:24.779 --> 00:07:27.519 most critical finding. Clinically speaking, they 00:07:27.519 --> 00:07:29.980 found no significant difference in how often 00:07:29.980 --> 00:07:33.019 associated ligaments were torn between the supposed 00:07:33.019 --> 00:07:36.379 avulsion and impaction groups. Really? So regardless 00:07:36.379 --> 00:07:38.779 of whether it looked more like a pull or a push 00:07:38.779 --> 00:07:40.959 fracture? The surrounding ligaments were just 00:07:40.959 --> 00:07:43.639 as likely to be injured. It strongly points towards 00:07:43.639 --> 00:07:47.439 a complex combined injury mechanism where the 00:07:47.439 --> 00:07:49.819 soft tissues nearly always take a hit, whatever 00:07:49.819 --> 00:07:51.800 the primary force on the bone appears to be. 00:07:51.959 --> 00:07:54.879 Wow. So the key takeaway is forget simple either. 00:07:55.069 --> 00:07:57.750 It's a complex interplay and assume ligaments 00:07:57.750 --> 00:07:59.970 are involved. That sums it up perfectly. It's 00:07:59.970 --> 00:08:01.990 a dynamic event affecting the whole complex. 00:08:02.110 --> 00:08:05.029 So if the mechanism is this complex, does that 00:08:05.029 --> 00:08:07.089 translate into different types of tricatural 00:08:07.089 --> 00:08:09.850 fractures? And more importantly, given what we've 00:08:09.850 --> 00:08:12.970 just heard about ligaments, what associated injuries 00:08:12.970 --> 00:08:15.350 should we really be looking for? Absolutely. 00:08:15.810 --> 00:08:17.189 Yeah. Understanding the different fracture types 00:08:17.189 --> 00:08:19.589 is key for management. For the common dorsal 00:08:19.589 --> 00:08:21.889 cortical fractures, the Garcia -Elias system 00:08:21.889 --> 00:08:25.519 is useful. It goes from type 1 Undisplaced. Just 00:08:25.519 --> 00:08:28.459 a crack. Essentially, yes. Types 2 and 3 are 00:08:28.459 --> 00:08:30.920 partially displaced, either proximally or distally. 00:08:31.420 --> 00:08:33.899 Type 4 is completely displaced. Type 5 means 00:08:33.899 --> 00:08:36.700 multiple fragments, more committed. And type 00:08:36.700 --> 00:08:39.720 6 is a more significant vertical frontal fracture 00:08:39.720 --> 00:08:42.360 involving the whole dorsal surface. Right. But 00:08:42.360 --> 00:08:45.000 beyond those dorsal ones, what are the main anatomical 00:08:45.000 --> 00:08:47.360 types? Broadly, we think of three main types. 00:08:47.610 --> 00:08:49.690 First, the dorsal cortical fractures we've been 00:08:49.690 --> 00:08:52.309 discussing, they make up the vast majority, 93 00:08:52.309 --> 00:08:55.730 to 95%. And also called benign. Historically, 00:08:55.909 --> 00:08:58.730 yes, but maybe that's misleading given the ligament 00:08:58.730 --> 00:09:01.330 issue. They typically happen from falls onto 00:09:01.330 --> 00:09:04.950 an extended ulnar deviated wrist, the impaction 00:09:04.950 --> 00:09:07.690 scenario. But they can also result from avulsion 00:09:07.690 --> 00:09:10.549 of the dorsal radiotricotrol or scaphotricotrol 00:09:10.549 --> 00:09:12.789 ligaments, particularly in wrist flexion with 00:09:12.789 --> 00:09:15.870 radial deviation. So same fracture appearance. 00:09:16.159 --> 00:09:18.299 Potentially different initiating force. Understood. 00:09:18.600 --> 00:09:20.600 What's the second type? Second are trichotral 00:09:20.600 --> 00:09:23.639 body fractures. These are less common, but generally 00:09:23.639 --> 00:09:25.980 indicate higher energy trauma. More serious, 00:09:26.179 --> 00:09:28.200 then? Definitely. Because they involve the main 00:09:28.200 --> 00:09:30.559 structural part of the bone. You often see these 00:09:30.559 --> 00:09:33.039 alongside really significant wrist injuries, 00:09:33.200 --> 00:09:36.419 like peri -lunar fracture dislocations. Ah, right. 00:09:36.500 --> 00:09:38.799 Part of a bigger picture. Exactly. A trichotral 00:09:38.799 --> 00:09:40.740 body fracture is found in something like 12 to 00:09:40.740 --> 00:09:43.700 25 percent of peri -lunar injuries. It's a red 00:09:43.700 --> 00:09:46.649 flag for major carpal disruption. The mechanism 00:09:46.649 --> 00:09:48.970 is usually direct compression, axial loading, 00:09:49.210 --> 00:09:52.350 or crush injuries. OK. And because they're central 00:09:52.350 --> 00:09:54.370 in high energy, they're often associated with 00:09:54.370 --> 00:09:56.850 a whole host of other problems. Lunar trichotrial 00:09:56.850 --> 00:09:59.990 ligament tears, scaphoid fractures, distal radius 00:09:59.990 --> 00:10:02.590 fractures. You have to look carefully for these 00:10:02.590 --> 00:10:05.179 associated injuries. Missing them is bad news. 00:10:05.620 --> 00:10:07.799 Absolutely. And the third type. The least common, 00:10:08.080 --> 00:10:10.200 but potentially the most problematic for stability 00:10:10.200 --> 00:10:12.940 are volar cortical fractures. On the palm side? 00:10:13.120 --> 00:10:16.039 Yes. Usually caused by avulsion of the volar 00:10:16.039 --> 00:10:19.559 ligaments, like the ulnotrichotrol or lunotrichotrol 00:10:19.559 --> 00:10:22.000 ligament. Why are they more problematic? Because 00:10:22.000 --> 00:10:24.840 those volar ligaments are absolutely critical 00:10:24.840 --> 00:10:26.639 for maintaining the alignments of the carpal 00:10:26.639 --> 00:10:30.120 bones. Injuring them carries a much higher risk 00:10:30.120 --> 00:10:33.200 of leading to carpal instability, which can cause 00:10:33.200 --> 00:10:35.820 long -term pain and dysfunction if it's not picked 00:10:35.820 --> 00:10:37.779 up and managed correctly. They need a high index 00:10:37.779 --> 00:10:40.059 of suspicion. So it really hammers home that 00:10:40.059 --> 00:10:42.419 point about associated injuries. It's not just 00:10:42.419 --> 00:10:45.659 the bone. And that best study you mentioned really 00:10:45.659 --> 00:10:47.960 quantified this ligament issue, didn't it? It 00:10:47.960 --> 00:10:50.539 really did. And the figures are, well, quite 00:10:50.539 --> 00:10:53.899 sobering. They found that an incredible 95 .2 00:10:53.899 --> 00:10:56.980 % of patients with dorsal trichatrial fractures 00:10:56.980 --> 00:10:59.720 had at least one associated dorsal carpal ligament 00:10:59.720 --> 00:11:03.870 injury. 95%. 20 out of 21 patients. It essentially 00:11:03.870 --> 00:11:06.269 means if you diagnose a dorsal trichatral fracture, 00:11:06.789 --> 00:11:08.389 you should assume there's significant ligament 00:11:08.389 --> 00:11:10.590 damage until proven otherwise. That completely 00:11:10.590 --> 00:11:12.909 changes the perspective from a simple fracture 00:11:12.909 --> 00:11:15.870 or sprain? It absolutely should. The specific 00:11:15.870 --> 00:11:18.509 breakdown is also revealing. Dorsal ulnortrichatral 00:11:18.509 --> 00:11:21.889 ligament tears were seen in 81%. Dorsal intercarpal 00:11:21.889 --> 00:11:25.990 ligament tears in 76%. And dorsal radiocarpal 00:11:25.990 --> 00:11:29.350 ligament tears in about 67%. These ligaments 00:11:29.350 --> 00:11:31.610 are almost routinely injured alongside the bone. 00:11:31.769 --> 00:11:34.210 Is there any correlation between where the bone 00:11:34.210 --> 00:11:36.789 bruising is on MRI and which ligament is torn? 00:11:37.210 --> 00:11:40.370 Interestingly, no. They looked for that but found 00:11:40.370 --> 00:11:43.049 no statistically significant link. Where the 00:11:43.049 --> 00:11:45.169 bone marrow oedema was located didn't reliably 00:11:45.169 --> 00:11:47.149 predict which specific ligament was injured. 00:11:47.590 --> 00:11:49.470 So you can't rely on the bone oedema pattern 00:11:49.470 --> 00:11:51.549 to guide you on the ligaments? Not reliably, 00:11:51.769 --> 00:11:54.190 no. The implication is clear. High suspicion 00:11:54.190 --> 00:11:56.330 of ligament injury is warranted in nearly all 00:11:56.330 --> 00:11:59.149 cases, irrespective of the precise edema pattern 00:11:59.149 --> 00:12:01.909 on the MRI. Okay, that 95 % figure is the one 00:12:01.909 --> 00:12:04.549 I'll take away. Assume ligament injury. Now, 00:12:04.649 --> 00:12:06.710 if we need to assess these ligaments, especially 00:12:06.710 --> 00:12:09.370 with MRI, how well can we actually see them? 00:12:09.450 --> 00:12:11.610 Are there imaging pitfalls we need to be aware 00:12:11.610 --> 00:12:13.690 of? That's a very practical question. Generally, 00:12:13.850 --> 00:12:16.450 3D gadolinium enhanced MRI using sequences like 00:12:16.450 --> 00:12:18.929 VBE is pretty good. The best study identified 00:12:18.929 --> 00:12:21.549 over 92 % of these ligaments in healthy controls. 00:12:21.710 --> 00:12:24.279 So MRI is the tool. It's definitely our best 00:12:24.279 --> 00:12:27.799 tool for soft tissues, yes. But, and it's important, 00:12:28.220 --> 00:12:30.159 but visibility isn't perfect for all the ligaments. 00:12:31.139 --> 00:12:34.000 Which ones are tricky? Well, the dorsal intercarpal 00:12:34.000 --> 00:12:36.340 ligaments showed up very well. completely visible 00:12:36.340 --> 00:12:39.740 in almost 97 % of cases. The dorsal radiocarpal 00:12:39.740 --> 00:12:42.899 was also good, 80 % complete visibility. But 00:12:42.899 --> 00:12:45.259 the dorsal ulno -tree control ligament was much 00:12:45.259 --> 00:12:47.460 more challenging. It was only completely visible 00:12:47.460 --> 00:12:51.500 in about 53 % of cases. And worryingly, it wasn't 00:12:51.500 --> 00:12:55.440 seen at all in nearly a quarter. 23 .3 % of the 00:12:55.440 --> 00:12:57.600 healthy controls. Not seen at all, even when 00:12:57.600 --> 00:13:00.159 presumably intact. Exactly. So if you don't see 00:13:00.159 --> 00:13:02.519 it clearly on the scan, you can't automatically 00:13:02.519 --> 00:13:05.220 assume it's torn or absent. There might be technical 00:13:05.220 --> 00:13:08.139 limitations. Why is that one harder to see? It's 00:13:08.139 --> 00:13:10.279 likely due, at least in part, to something called 00:13:10.279 --> 00:13:12.639 the magic angle artifact. Right, I've heard of 00:13:12.639 --> 00:13:15.139 that. Because ligaments are ordered collagen 00:13:15.139 --> 00:13:18.629 fibers, If they lie at roughly 55 degrees to 00:13:18.629 --> 00:13:21.730 the main magnetic field of the MRI scanner, they 00:13:21.730 --> 00:13:23.950 can produce an artificially high signal. Making 00:13:23.950 --> 00:13:26.309 it look like a tear. Precisely. Or just making 00:13:26.309 --> 00:13:29.149 it blurry. The dorsal ulnitricular ligament has 00:13:29.149 --> 00:13:31.970 a curved path, and combined with the short echo 00:13:31.970 --> 00:13:35.570 time, TE, used in some sequences, it's particularly 00:13:35.570 --> 00:13:38.769 susceptible. So you have to interpret findings 00:13:38.769 --> 00:13:41.269 relating to that specific ligament with a degree 00:13:41.269 --> 00:13:44.389 of caution. Reported tear rates might be slightly 00:13:44.389 --> 00:13:46.889 inflated due to this artifact. That's a really 00:13:46.889 --> 00:13:50.389 crucial point for interpreting MRI reports. Combine 00:13:50.389 --> 00:13:52.549 the imaging with the clinical picture and be 00:13:52.549 --> 00:13:54.970 aware of potential artifacts. Absolutely. Clinical 00:13:54.970 --> 00:13:57.009 correlation is paramount. Know the limitations 00:13:57.009 --> 00:14:00.049 of the test. Which leads us perfectly into evaluation 00:14:00.049 --> 00:14:03.230 and diagnosis. Given these challenges, occult 00:14:03.230 --> 00:14:05.940 fractures, tricky ligaments. What should alert 00:14:05.940 --> 00:14:08.120 us clinically? What's the typical presentation? 00:14:08.379 --> 00:14:10.039 Well, the starting point is always that high 00:14:10.039 --> 00:14:12.299 index of suspicion, especially with the right 00:14:12.299 --> 00:14:14.919 history. Clinically, patients usually complain 00:14:14.919 --> 00:14:17.720 of quite specific ulnar -sided wrist pain. Often, 00:14:17.879 --> 00:14:20.639 yes. They might say it's worth with bending the 00:14:20.639 --> 00:14:23.519 wrist, flexion, or extension. You often find 00:14:23.519 --> 00:14:25.919 some swelling on the dorsal side. And the key 00:14:25.919 --> 00:14:28.480 sign is usually localized tenderness right over 00:14:28.480 --> 00:14:31.139 the dorsal aspect of the trichotrum. If you press 00:14:31.139 --> 00:14:34.009 there, they'll likely jump. OK. And the history? 00:14:34.710 --> 00:14:36.750 Typically, it involves excessive load or the 00:14:36.750 --> 00:14:39.350 classic fall onto an outstretched hand injury, 00:14:39.769 --> 00:14:41.850 often with the wrist extended and pushed towards 00:14:41.850 --> 00:14:44.029 the little finger side, that ulnar deviation. 00:14:44.169 --> 00:14:46.629 Right. Think of someone falling backwards. But 00:14:46.629 --> 00:14:49.309 remember, the flexion radial deviation mechanism 00:14:49.309 --> 00:14:52.809 can also occur. So keep an open mind. Some also 00:14:52.809 --> 00:14:55.730 say wrist flexion can be more painful if it displaces 00:14:55.730 --> 00:14:58.809 a dorsal fragment. Good tip. Now, the radiographic 00:14:58.809 --> 00:15:01.090 challenges. You mentioned occult fractures. How 00:15:01.090 --> 00:15:03.529 often are we talking? It's surprisingly often. 00:15:03.750 --> 00:15:06.549 Some older studies suggested up to 80 % might 00:15:06.549 --> 00:15:09.409 be missed on initial plane x -rays. 80%. That's 00:15:09.409 --> 00:15:13.129 huge. It is. Even the best MRI study found 19 00:15:13.129 --> 00:15:15.769 % were occult on the initial radiographs they 00:15:15.769 --> 00:15:18.490 reviewed. It just highlights how insensitive 00:15:18.490 --> 00:15:22.210 standard x -rays can be for these small, complexly 00:15:22.210 --> 00:15:26.190 located bones. Compared to, say, a scaphoid fracture, 00:15:26.399 --> 00:15:29.100 The combined sensitivity of clinical exam and 00:15:29.100 --> 00:15:31.740 x -ray is often lower for the trichotrum. So 00:15:31.740 --> 00:15:34.440 what x -ray views should we be ordering to maximize 00:15:34.440 --> 00:15:37.139 our chances? You definitely need more than just 00:15:37.139 --> 00:15:39.519 the standard PA and lateral, although the lateral 00:15:39.519 --> 00:15:42.080 is often the most useful for seeing dorsal fragments 00:15:42.080 --> 00:15:44.960 displaced posteriorly. Okay. You should also 00:15:44.960 --> 00:15:48.259 get a 45 -degree pronated oblique view. This 00:15:48.259 --> 00:15:50.279 can sometimes rotate the trichoderm out from 00:15:50.279 --> 00:15:53.220 overlapping bones, and a radial deviation view 00:15:53.220 --> 00:15:56.019 might help highlight volar fractures by tensioning 00:15:56.019 --> 00:15:58.639 those ligaments. Any specific signs to look for? 00:15:58.740 --> 00:16:01.480 There's the slightly amusingly named pooping 00:16:01.480 --> 00:16:04.460 duck sign. The what now? The pooping duck. On 00:16:04.460 --> 00:16:06.539 the lateral view, sometimes the trigger profile 00:16:06.539 --> 00:16:08.960 looks a bit like a duck's head, and a dorsal 00:16:08.960 --> 00:16:11.399 cortical fragment can look like it's, well, exiting 00:16:11.399 --> 00:16:13.570 posteriorly. It's quite memorable. if you see 00:16:13.570 --> 00:16:15.649 it. I'll definitely remember that one. But even 00:16:15.649 --> 00:16:18.049 with these views, many are still missed. Yes, 00:16:18.129 --> 00:16:20.990 a significant number. So the rule has to be, 00:16:21.450 --> 00:16:24.389 if you strongly suspect a trichetral fracture 00:16:24.389 --> 00:16:27.389 based on the clinical picture, but the x -rays 00:16:27.389 --> 00:16:30.690 are normal or equivocal, you must pursue further 00:16:30.690 --> 00:16:35.149 imaging. Which brings us to CT and MRI. If x 00:16:35.149 --> 00:16:37.250 -rays aren't enough, what's the specific role 00:16:37.250 --> 00:16:39.710 for each of these? When do you choose one over 00:16:39.710 --> 00:16:42.769 the other? Excellent question. They both have 00:16:42.769 --> 00:16:46.269 critical but slightly different roles. CT is 00:16:46.269 --> 00:16:48.950 brilliant for bone detail. It's really the next 00:16:48.950 --> 00:16:51.409 step if you suspect an occult fracture that X 00:16:51.409 --> 00:16:53.600 -ray missed. better at seeing the fracture line. 00:16:53.720 --> 00:16:56.340 Much better. The cross -sectional views cut through 00:16:56.340 --> 00:16:59.299 the overlap issues. CT is also more accurate 00:16:59.299 --> 00:17:01.519 for measuring the exact size and volume of any 00:17:01.519 --> 00:17:03.600 fragments, which can be really important if you're 00:17:03.600 --> 00:17:05.859 considering surgery deciding if a piece is big 00:17:05.859 --> 00:17:08.039 enough to fix, for example. So high clinical 00:17:08.039 --> 00:17:10.660 suspicion, negative x -ray CT for bone. That's 00:17:10.660 --> 00:17:13.460 a very common and logical pathway, yes. But MRI 00:17:13.460 --> 00:17:15.460 comes into its own, crucially, when you're worried 00:17:15.460 --> 00:17:18.160 about instability or, as we've discussed extensively, 00:17:18.980 --> 00:17:20.700 associated ligament injury. Which is almost always. 00:17:20.910 --> 00:17:23.930 Which is in over 95 % of cases, according to 00:17:23.930 --> 00:17:27.710 that best study. So MRI is often essential. It's 00:17:27.710 --> 00:17:30.329 also useful if CT is negative, but you still 00:17:30.329 --> 00:17:33.410 suspect an occult fracture, as MRI can pick up 00:17:33.410 --> 00:17:36.500 bone marrow edema. the bruising, even before 00:17:36.500 --> 00:17:38.599 a clear fractal line forms. And it shows the 00:17:38.599 --> 00:17:42.039 soft tissues. Exactly. Ligaments, the TFCC, cartilage. 00:17:42.599 --> 00:17:44.980 Given the high rate of ligament tears, you could 00:17:44.980 --> 00:17:47.440 argue MRI is needed in most cases to get the 00:17:47.440 --> 00:17:50.000 full picture and planned treatment probably to 00:17:50.000 --> 00:17:52.279 avoid long -term problems like instability. So 00:17:52.279 --> 00:17:55.140 it's not really an either with CT and MRI sometimes? 00:17:55.299 --> 00:17:57.779 Often not. You might need both, depending on 00:17:57.779 --> 00:18:00.099 the clinical question. CT for the bone detail, 00:18:00.559 --> 00:18:02.740 MRI for the soft tissues, and subtle bone injury. 00:18:02.880 --> 00:18:04.900 And don't forget to look at the other carpal 00:18:04.900 --> 00:18:07.900 bones too. Best found edema in the hemat in nearly 00:18:07.900 --> 00:18:11.799 24 % of cases and in other wrist bones in 19%. 00:18:11.799 --> 00:18:14.579 It's often a wider injury pattern. Right, a comprehensive 00:18:14.579 --> 00:18:17.000 assessment is key. Okay, let's say we've navigated 00:18:17.000 --> 00:18:19.000 the diagnosis, we got the imaging, we know the 00:18:19.000 --> 00:18:21.180 fracture type and any associated injuries. How 00:18:21.180 --> 00:18:23.140 do we manage these? What's the first line approach 00:18:23.140 --> 00:18:26.920 usually? For the majority, especially those undisplaced 00:18:26.920 --> 00:18:29.720 or minimally displaced dorsal cortical fractures 00:18:29.720 --> 00:18:32.700 without instability. non -displaced body fractures, 00:18:33.279 --> 00:18:36.380 and stable volar fractures, non -operative management 00:18:36.380 --> 00:18:38.619 is definitely the way to go. Good news for the 00:18:38.619 --> 00:18:41.380 patient. Absolutely. The trichotrum generally 00:18:41.380 --> 00:18:44.339 heals well thanks to a decent blood supply. The 00:18:44.339 --> 00:18:47.319 mainstay is immobilization, usually for about 00:18:47.319 --> 00:18:49.779 four to six weeks. How is that typically done? 00:18:49.880 --> 00:18:52.740 Just a cast? It's usually phased. Yeah. Initially, 00:18:52.980 --> 00:18:54.680 say for the first few weeks while things are 00:18:54.680 --> 00:18:57.519 swollen and sore, a volar splint is often preferred. 00:18:57.759 --> 00:19:00.380 wrist in slight extension. Oh, movable. Yes, 00:19:00.400 --> 00:19:02.920 which allows for gentle range of motion exercises, 00:19:03.200 --> 00:19:05.759 just wiggling fingers and thumb, and for hygiene. 00:19:06.299 --> 00:19:08.240 Cold packs are also really helpful in this early 00:19:08.240 --> 00:19:10.579 phase, especially the first 72 hours, to manage 00:19:10.579 --> 00:19:13.259 that swelling and pain. Okay, split first, then 00:19:13.259 --> 00:19:15.650 what? Once the initial swelling settles, maybe 00:19:15.650 --> 00:19:17.630 around the 2 -4 week mark, depending on the case, 00:19:18.109 --> 00:19:20.170 you might transition to a proper short arm cast 00:19:20.170 --> 00:19:22.150 for more rigid support as healing progresses. 00:19:22.430 --> 00:19:24.490 And after the cast comes off, usually around 00:19:24.490 --> 00:19:27.089 four weeks, maybe slightly longer, you'd move 00:19:27.089 --> 00:19:30.069 to a removable wrist splinter brace. This allows 00:19:30.069 --> 00:19:32.369 for gradual increases in movement and starting 00:19:32.369 --> 00:19:36.059 gentle strengthening exercises. The goal is regaining 00:19:36.059 --> 00:19:38.579 mobility without stressing the healing site too 00:19:38.579 --> 00:19:41.480 much. When can patients expect to get back to 00:19:41.480 --> 00:19:43.839 normal activities? Weight -bearing activities 00:19:43.839 --> 00:19:46.240 can usually be gradually resumed around eight 00:19:46.240 --> 00:19:48.799 weeks post -injury, assuming things are progressing 00:19:48.799 --> 00:19:52.180 well and pain allows. Full unrestricted activity 00:19:52.180 --> 00:19:54.859 might take a bit longer. And the outcomes with 00:19:54.859 --> 00:19:57.180 this conservative approach? Generally very good. 00:19:57.319 --> 00:20:00.640 Most fractures manage this way heal well, often 00:20:00.640 --> 00:20:03.099 with what's called a fibrous union. Not solid 00:20:03.099 --> 00:20:05.440 bone. Not always solid bone, but strong fibrous 00:20:05.440 --> 00:20:07.839 tissue connecting the fragments. And crucially, 00:20:07.839 --> 00:20:10.720 this is usually completely asymptomatic. Patients 00:20:10.720 --> 00:20:13.000 typically get significant pain relief and recover 00:20:13.000 --> 00:20:15.299 good wrist motion, often within six to eight 00:20:15.299 --> 00:20:18.019 weeks of starting treatment. So for most, surgery 00:20:18.019 --> 00:20:20.980 isn't needed. That's very reassuring. But inevitably, 00:20:21.259 --> 00:20:23.900 some cases do require surgery. What are the main 00:20:23.900 --> 00:20:25.880 indications for going down the operative route? 00:20:26.059 --> 00:20:29.500 Yes, surgery definitely has its place. The main 00:20:29.500 --> 00:20:31.660 triggers are significant displacement of the 00:20:31.660 --> 00:20:34.079 fracture fragments, clear evidence of carpal 00:20:34.079 --> 00:20:36.940 instability, associated fracture dislocations 00:20:36.940 --> 00:20:40.119 involving the trichotrum, or those relatively 00:20:40.119 --> 00:20:43.640 rare cases of symptomatic non -union where conservative 00:20:43.640 --> 00:20:45.980 treatment has failed and the patient still has 00:20:45.980 --> 00:20:49.079 pain or mechanical issues. So instability and 00:20:49.079 --> 00:20:52.220 significant displacement are key flags. Absolutely. 00:20:52.589 --> 00:20:54.750 The goal of surgery is to put things back where 00:20:54.750 --> 00:20:57.970 they belong, make the wrists stable, and optimize 00:20:57.970 --> 00:21:00.750 long -term function. What surgical techniques 00:21:00.750 --> 00:21:03.109 are typically used? It depends on the specifics, 00:21:03.170 --> 00:21:05.609 of course. Open reduction internal fixation, 00:21:05.849 --> 00:21:08.670 or ORAC -A, is common for displaced body fractures 00:21:08.670 --> 00:21:10.950 or instability. So opening it up and fixing it. 00:21:11.170 --> 00:21:13.170 Exactly. You make an incision, carefully reduce 00:21:13.170 --> 00:21:15.430 the fragments back into place, and then fix them 00:21:15.430 --> 00:21:17.910 internally. You might use small interfragmentary 00:21:17.910 --> 00:21:20.170 screws to compress the fragments, or perhaps 00:21:20.170 --> 00:21:23.230 K -wires, which are temporary pins. If ligaments 00:21:23.230 --> 00:21:25.609 need repairing, you might use suture anchors 00:21:25.609 --> 00:21:27.970 drilled into the bone. Right, like Herbert screws 00:21:27.970 --> 00:21:30.910 for fracture dislocations. Herbert screws were 00:21:30.910 --> 00:21:33.950 often used, yes, sometimes combined with K -wire 00:21:33.950 --> 00:21:36.849 stabilization across the lunatric ritual joint 00:21:36.849 --> 00:21:40.299 if needed. Okay, so... RIF is one option. Are 00:21:40.299 --> 00:21:42.599 there others? Yes. Particularly for those problematic, 00:21:42.759 --> 00:21:45.259 symptomatic non -unions. Especially if it's a 00:21:45.259 --> 00:21:47.559 small fragment and not involving the joint surface. 00:21:47.720 --> 00:21:51.180 Not articular. Precisely. In those cases, fragment 00:21:51.180 --> 00:21:53.500 excision, just removing the troublesome little 00:21:53.500 --> 00:21:55.799 piece, can be a very effective option. Just take 00:21:55.799 --> 00:21:58.700 it out. Yes. Sometimes trying to fix a tiny chip 00:21:58.700 --> 00:22:00.799 is more trouble than it's worth. There was a 00:22:00.799 --> 00:22:03.119 case report of a young man with a tiny, painful 00:22:03.119 --> 00:22:06.279 non -union, only about five millimeter. They 00:22:06.279 --> 00:22:09.480 excised it. brief immobilization, and he became 00:22:09.480 --> 00:22:12.339 pain -free. Others have reported success excising 00:22:12.339 --> 00:22:15.019 slightly larger fragments, too. It's a good option 00:22:15.019 --> 00:22:17.480 for selected cases. That makes sense for small, 00:22:17.619 --> 00:22:19.700 non -articular, persistently painful fragments. 00:22:19.900 --> 00:22:22.019 What about post -op? Still needs immobilization, 00:22:22.039 --> 00:22:24.579 of course. Maybe six weeks in a cast, then a 00:22:24.579 --> 00:22:27.220 brace, followed by rehab. Outcomes are generally 00:22:27.220 --> 00:22:30.220 good. Maybe some slight loss of flexion or extension 00:22:30.220 --> 00:22:32.900 compared to the other side. But usually satisfactory 00:22:32.900 --> 00:22:35.740 function and pain relief. And crucially, You 00:22:35.740 --> 00:22:38.200 have to address the associated injuries found 00:22:38.200 --> 00:22:41.380 earlier. Absolutely vital. If the pisiform is 00:22:41.380 --> 00:22:44.220 subloxed, you might need to excise it or fix 00:22:44.220 --> 00:22:47.019 the trichotrum. If the lunotrichotral ligament 00:22:47.019 --> 00:22:50.559 is unstable, it needs pinning or repair. Surgery 00:22:50.559 --> 00:22:53.019 has to address the whole problem, not just the 00:22:53.019 --> 00:22:56.240 trichotral fragment in isolation. It really highlights 00:22:56.240 --> 00:22:59.400 that holistic diagnostic approach again. Okay, 00:22:59.400 --> 00:23:02.329 so... After treatment, whether conservative or 00:23:02.329 --> 00:23:04.549 surgical, what's the general outlook and what 00:23:04.549 --> 00:23:06.269 potential complications should we be keeping 00:23:06.269 --> 00:23:08.789 an eye out for long term? The overall outlook 00:23:08.789 --> 00:23:11.430 is generally positive. As we said, functional 00:23:11.430 --> 00:23:13.609 recovery is typically good to excellent for most 00:23:13.609 --> 00:23:16.210 patients, even those with some associated ligament 00:23:16.210 --> 00:23:18.630 issues provided they're managed correctly. People 00:23:18.630 --> 00:23:20.730 often get back to good function relatively quickly. 00:23:20.869 --> 00:23:22.849 That's good to hear. What about non -union? You 00:23:22.849 --> 00:23:25.309 mentioned it's rare but can be symptomatic. Yes. 00:23:25.549 --> 00:23:28.029 True non -union is uncommon, especially in body 00:23:28.029 --> 00:23:31.339 fractures. Fibrous union is more frequent and 00:23:31.339 --> 00:23:34.140 usually fine. But if a true non -union does occur 00:23:34.140 --> 00:23:36.539 and becomes symptomatic, causing persistent pain 00:23:36.539 --> 00:23:39.079 or clicking, that's when it can cause significant 00:23:39.079 --> 00:23:42.000 disability and might need that surgical excision 00:23:42.000 --> 00:23:45.220 or fixation we discussed. Okay. What other long 00:23:45.220 --> 00:23:47.599 -term issues can crop up? Well, related to the 00:23:47.599 --> 00:23:50.740 associated injuries mostly. TFCC injury is common, 00:23:50.839 --> 00:23:53.420 especially with dorsal fractures. If it remains 00:23:53.420 --> 00:23:55.519 symptomatic despite initial treatment, it might 00:23:55.519 --> 00:23:57.980 need arthroscopic debridement or repair later 00:23:57.980 --> 00:24:01.119 on. Right. Pizzotrich or periosaurosis arthritis 00:24:01.119 --> 00:24:03.200 in the joint between the pisiform and trichotrum 00:24:03.200 --> 00:24:05.680 can develop if the fracture went into that joint 00:24:05.680 --> 00:24:08.660 or sometimes related to a nonunion there. If 00:24:08.660 --> 00:24:10.960 that becomes painful, excising the pisiform can 00:24:10.960 --> 00:24:13.220 be a good solution. Makes sense. And the big 00:24:13.220 --> 00:24:15.900 one, though thankfully less common if things 00:24:15.900 --> 00:24:19.140 are managed well initially, is persistent carpal 00:24:19.140 --> 00:24:22.299 instability. This usually results from missed 00:24:22.299 --> 00:24:24.859 or undertreated ligament injuries, especially 00:24:24.859 --> 00:24:27.660 involving the lunotrichotrial ligament. It really 00:24:27.660 --> 00:24:30.339 underlines why that initial thorough assessment 00:24:30.339 --> 00:24:33.180 with advanced imaging is so incredibly important 00:24:33.180 --> 00:24:36.119 to catch these instability patterns early. Absolutely. 00:24:36.680 --> 00:24:38.920 Preventing that long -term instability seems 00:24:38.920 --> 00:24:42.059 key. Well, this has been an incredibly thorough 00:24:42.059 --> 00:24:44.339 exploration. We've really covered the ground 00:24:44.339 --> 00:24:46.740 from presentation to long -term follow -up. We 00:24:46.740 --> 00:24:49.099 have. It's clear that these fractures, despite 00:24:49.099 --> 00:24:52.380 being common, are anything but simple. From understanding 00:24:52.380 --> 00:24:54.799 the shift in thinking about mechanisms away from 00:24:54.799 --> 00:24:58.420 simple, either to this complex, multifactorial 00:24:58.420 --> 00:25:02.079 picture revealed by MRI, to appreciating that 00:25:02.079 --> 00:25:05.160 staggering 95 % rate of associated ligament injuries, 00:25:05.480 --> 00:25:07.759 it really changes the game. It really does. It 00:25:07.759 --> 00:25:10.299 mandates that high index of suspicion and the 00:25:10.299 --> 00:25:12.519 readiness to use advanced imaging like CT and 00:25:12.519 --> 00:25:14.940 MRI, not just for the bone, but critically for 00:25:14.940 --> 00:25:17.299 those soft tissues. It's about seeing the whole 00:25:17.299 --> 00:25:20.259 wrist complex. Precisely. and then tailoring 00:25:20.259 --> 00:25:22.720 the management, knowing that most do well with 00:25:22.720 --> 00:25:25.799 straightforward immobilization, but also recognizing 00:25:25.799 --> 00:25:29.059 the clear indications for surgery, like ORIF, 00:25:29.359 --> 00:25:32.319 or even fragment excision when needed. This deep 00:25:32.319 --> 00:25:34.519 dive has certainly illuminated a corner of wrist 00:25:34.519 --> 00:25:37.329 trauma that deserves careful attention. It might 00:25:37.329 --> 00:25:39.289 look like a small chip, but the implications 00:25:39.289 --> 00:25:42.190 can be significant. Indeed. If you, listening, 00:25:42.450 --> 00:25:44.789 found this deep dive valuable, please do consider 00:25:44.789 --> 00:25:46.690 leaving us a rating or perhaps sharing it with 00:25:46.690 --> 00:25:49.170 a colleague. And finally, a thought to take away 00:25:49.170 --> 00:25:51.950 and perhaps ponder. Given everything we've discussed 00:25:51.950 --> 00:25:54.309 about the extensive soft tissue attachments and 00:25:54.309 --> 00:25:57.130 that near -universal ligament involvement, how 00:25:57.130 --> 00:25:59.529 might future advances perhaps in dynamic imaging 00:25:59.529 --> 00:26:02.289 techniques or maybe even intraoperative assessment 00:26:02.289 --> 00:26:04.849 tools further refine our understanding of wrist 00:26:04.849 --> 00:26:08.240 kinematics after these trick - How could that 00:26:08.240 --> 00:26:10.400 ultimately help us improve long -term stability 00:26:10.400 --> 00:26:12.299 and function for our patients even more?