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10b - Answer: 45-year-old male presents with sprain of the metacarpophalangeal joint

Pomeranz, Stephen
Stephen J Pomeranz, MD
Chief Medical Officer, ProScan Imaging. Founder, MRI Online
Includes DICOM files

HISTORY: 

This 45-year-old male presents with sprain of the metacarpophalangeal joint of right thumb. Patient injured his right thumb playing softball two months prior with pain, swelling, limited range of motion and limited grip.

(QUIZ ANSWER) IS A FINDING IN THIS CASE: 

All of the above.

Using the diagnostic web viewer, we have provided images that assist in telling our clinical story. Areas of significance are indicated below.

FINDINGS:

High-grade tears of both the ulnar and radial collateral ligaments of the metacarpophalangeal joint of the thumb are present with probable partially fibrosed / scarred ligamentous ruptures in this patient with history of injury two months prior. It is of note that the ulnar collateral ligament remains deep to the adductor aponeurosis without Stener lesion. 

A partial-thickness deep surface teno-osseous separation / tear of the extensor pollicis brevis tendon at its insertion on the dorsal aspect of the base of the proximal phalanx of the thumb is present. Otherwise, the extensor and flexor tendons within the thumb and the remainder of the visualized hand are intact with no evidence of tendinosis, tenosynovitis, or tendon tear. 

Bone marrow edema is present within the proximal phalanx of the thumb and to a lesser extent within the first metacarpal head compatible with bone contusions. Linear hypointense signal alteration within the base of the proximal phalanx of the thumb which is most prominent ventrally is favored to represent a physeal scar over a small nondisplaced subcortical fracture. There is otherwise no evidence of fracture within the right thumb (bearing in mind the small cortical chip or avulsion fracture which would be much more sensitively detected on radiographs or CT than on MRI). 

Apparent bone marrow signal alteration within the distal phalanx of the thumb on sagittal T2 fat sat sequences is not confirmed on axial T2 fat sat sequences without corresponding T1 signal alteration is believed to artifactual related to inhomogeneous fat suppression, although a bone contusion (without macrofracture) at this site cannot be excluded. 

Mild subcutaneous edema/soft tissue swelling is present within the right thumb. 

CONCLUSION: 

1. High-grade tears of both the ulnar and radial collateral ligaments of the metacarpophalangeal joint of the thumb with probable partially fibrosed / scarred ligamentous ruptures in this patient with history of injury two months prior. The ulnar collateral ligament remains deep to the adductor aponeurosis without Stener lesion and is the dominant rotatory valgus injury. . 

2. Partial-thickness teno-osseous separation/tear of the extensor pollicis brevis tendon at its insertion on the dorsal aspect of the base of the proximal phalanx of the thumb. 

3. Bone marrow edema within the proximal phalanx of the thumb and to a much lesser extent within the first metacarpal head compatible with bone contusions. Linear hypointense signal within the base of the proximal phalanx of the thumb which is most prominent ventrally is favored to represent a physeal scar over a nondisplaced fracture. 

4. Mild subcutaneous edema/soft tissue swelling within the right thumb. 

5. Additional findings and pertinent negatives as detailed above.

LESSON 2, TOPIC 30

Case Challenge: Thumb & Finger MRI Cases

Case Challenge

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Content reviewed: October 27, 2021

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