Wk 2, Case 1 - Review

Patient History
51-year-old male with worsening right wrist pain and swelling after falling out of a tree 1 month ago.

Findings
ALIGNMENT:

Ulnar Variance: Negative ulnar variance.

Distal Radioulnar Joint: Normal.

Carpal Instability: Severe volar tilt of the lunate.

ARTICULATIONS:

Thumb Carpometacarpal Joint: Mild osteoarthrosis.

Scaphotrapeziotrapezoidal Joint: Moderate osteoarthrosis

Pisiform-Triquetral Joint: Mild joint effusion.


Radiocarpal Joint: Moderate osteoarthrosis with marginal osteophytes and subchondral arthropathic cysts in the distal radial epiphyses.

Distal Radioulnar Joint: No joint effusion.

Carpal Effusion: Moderate effusion with reactive synovitis.

INTRINSIC LIGAMENTS:

Scapholunate Ligament: Sprain but otherwise intact.

Lunotriquetral Ligament: Complete tear involving its dorsal, volar and proximal segments.

Triangular Fibrocartilage: Wearing of the TFC disc proper. No tears.

Lunate Facet: Fragmentation and sclerosis of the entire lunate.

Extensor Compartment: No tendinopathy or tendon tears.

Flexor Compartment: No tendinopathy or tendon tears.

Carpal Tunnel: Palmar bowing of the carpal tunnel components.

Median Nerve: Minimal increased diameter with normal signal intensity.

Flexor Retinaculum: No scarring.

Flexor Tendons: Palmar bowing. No evidence of tendinopathy or tears.

Guyon's Canal: No space-occupying lesions.

OTHER FINDINGS:

Skeleton: Fragmentation, sclerosis and eburnation of the entire lunate with severe volar tilt. Moderate radiocarpal osteoarthrosis and palmar bowing of the carpal tunnel components. 7mm osseous body anterior to the ulna. Innumerable dorsal bodies, series 8 images 12 and 13.

Deformity, sclerosis and arthropathic cyst formation of the scaphoid. Dorsal displacement and proximal migration of the capitate with large, intraosseous arthropathic cysts.

Up to 1cm corticated osseous structures localized to the dorsal proximal capitate and ventral to the distal radial epiphysis, likely fragments of the lunate.

Soft Tissues: The thenar and hypothenar eminences and intrinsic hand muscles are normal.

Vessels: Noncontributory.

Impressions
1.Background of negative ulnar variance posture with lunate dislocation, rotatory displacement and progressing arthrosis. Patient is progressing to advanced stages of SLAC wrist, Watson 3-4.
2.Complete disruption of the lunotriquetral ligament with lunate volar tilt in keeping with volar intercalated segmental instability (VISI).
3.Rotation of the scaphoid with chronic mal or nonunion.
4.Mass effect of the tilted lunate on the carpal tunnel components with mild thickening of the median nerve. Correlate for the presence of carpal tunnel syndrome.
5.Mild effusion with reactive synovitis of the carpal joint.