 Hello, I'm Dr. Steven Pomerance from ProSky and Imaging. We have an orthopedic MRI advanced case review beginning February 27th in Vienna, and we're here today to give you a sneak peek at this exciting educational program, a course where each radiologist will work on their own individual workstation just like you were in your own practice. Let's take a look at a case. We have some MR images of this patient, a coronal T1 fat-emphasized image, we'll scroll it, paired with it is a coronal T2 fat-suppressed image, and then on the far right is a sagittal T2 fat-suppressed image. All three images were acquired in the orthogonal projection, and that's important. Let's take our questions. Which of the following findings are not present? A, diffuse thickening and or synovitic swelling of the carpus. B, scaphoid fracture of the waist. C, scaphoid non-union. D, palmar displacement of the carpus with a lunate dizzy posture in the sagittal projection. E, a vascular acrosis of the proximal pole of the scaphoid. Number two, the scaphoid fracture exhibits A, partial bridging. B bridging. C non-union. D, fibrous malunion. Let's go back to the images. The coronal projection T1 fat-emphasized shows a scaphoid with a large cleavage plane through it. It's through and through. The cortex is interrupted. The water-weighted T2 fat-suppressed image demonstrates high signal intensity in the scaphoid. Let's do a little drawing here so we can demonstrate the proper way to image a scaphoid, which in earnest was not done here optimally. What should have been done is the scaphoid imaged in the coronal projection should have had a sagittal oblique obtained through it. That would have produced a scaphoid that looks something like this from anterior to posterior. Then what should have been done optimally is another oblique could have been and should have been obtained will change our color and angled off of the sagittal oblique to create a short axis compound para-axial oblique. Nevertheless, the images are still diagnostic. We have a fracture through the scaphoid waste, the most common site for fracture, but in the fracture line is an area of high signal intensity that on a T2, not a stir, not a spur, but a T2 fat suppression, is high signal intensity with well-defined cortical margins on either side. That combination, we're going to blow it up a little bit for you, that combination of high signal intensity with cortication on either side is consistent with a non-union. On the other hand, you might say, well, what about a fibrous malunion? In a fibrous malunion, you may see a little bit of bridging or dark tissue that goes from the proximal fragment to the distal fragment. That's not present here. It's all nice and white in the middle and even around the edges if we scroll it. There's no communication between proximal fragment and distal fragment as would occur in a fibrous malunion. Furthermore, in this space in a fibrous malunion, you're less apt to have high signal intensity on a T2 weighted image. Now, as that abnormality continues to demonstrate movement, as the patient moves their wrist and as these two fragments wiggle, you're going to develop something that looks like this, back to our drawing. So here's our scaphoid. Make a nice picture of an egg for you and keep it rather simple. We have our fracture through the waist. We have fluid signal intensity in a non-union through the fracture line right in the middle, depicted in purple corresponding to our white signal. But then we have another finding. That finding is not present on the MR images, but I'm demonstrating with my drawing multiple or innumerable cysts and pseudo cysts, some of which are synovial line, many of which are not on either edge of the non-union. This is a sign. It's a sign that there is instability at the fracture. In other words, the proximal fragment is moving relative to the distal fragment. This is what happens with moderate to long-standing non-unions. We have several other findings. Yes, there is swelling of the wrist. There is capsulo-synovial thickening. Let's mag out a little bit on our water-weighted coronal image. All of this tissue is fluid and capsulo-synovitis. If we look at the T1-weighted image, why shouldn't I say that it's just fluid? Because just simple fluid wouldn't be gray iso-intense to muscle. It would be much lower than muscle. It would have pure water-like signal-intensity content. So the fact that it has a rather complex gray signal on T1 tells you that you're dealing with a protonaceous mixture of fluid and synovial capsular hypertrophy. Oh, we're not done yet. We have another finding. Look at the base of the capitate. It is actually starting to piston down on the lunate. That piston-ing due to micro-movement of the scaphoid and this wiggling between the lunate and the capitate results in sclerosis of the proximal aspect of the capitate. Oh, but we're not done yet. I wish we were. We have to look at the intrinsic, especially when somebody has a fuchs mechanism of fall. Here is the triangular shape, sometimes trapezoid shape, sometimes linearly shaped, scapholunate ligament, which has a dorsal, a middle, and a ventral or volar component. The dorsal component is the strongest. And if we scroll to the ventral side, that's the ventral component of the scapholunate ligament. That's still ventral right there. Now we're in the mid-portion and now we're in the dorsal portion, which is the thickest, widest, and broadest. There it is on the water-weighted image. It is contiguous from the base of the scaphoid to the lunate. It may attach to the bony contour and sometimes to the cartilage itself. In the sagittal projection, let's have a look at the position of the lunate. The lunate is a little bit volar in its position. It looks like it's squishing out a little bit. And the capitate is migrating proximally as it pistons down on the lunate. The lunate is also dorsal facing. This is known as dorsal intercalary segmental instability, or dorsal segmental instability posture. This occurs because the radioscaphal capitate ligament is injured, stretched, or torn. Let's go back to our questions. Question number one, which of the following findings are not present? Well, the answer is E, a vascular necrosis of the proximal pole of the scaphoid. We don't need to inject it. We don't need to do a bone centagram. If we are in a chronic stage, such as we are, by looking at the history, in other words, we're not one or two days out from an injury, where weeks out, the absence of any signal alteration in the proximal pole of the scaphoid is 97% predictive that we do not have a vascular necrosis. And we do not have a vascular necrosis. The other statements are true. There is synovitic swelling of the carpus, as discussed. There is a scaphoid waste fracture. There is scaphoid non-union, and there is palmar or volar displacement of the carpus with a dorsal tilting of the lunate, so-called dissy. Question number two, the scaphoid fracture exhibits, and the answer is non-union. Although we don't yet have a pseudarthrosis with pseudosists, as discussed, we don't have any bridging from one bone to the other. We don't have any partial bridging of any portion of the bone, nor do we have a fibrous malunion, for reasons already mentioned. That concludes our discussion of this case. You're welcome to further scroll it, if you wish. The great thing is that because every participant is going to have their own workstation, you can follow Dr. Pomeranz on his screen while scrolling through the images yourself on the workstation. So I think that makes it a very worthwhile educational experience, and I hope that you can join us in Vienna to learn from Dr. Pomeranz.