29b - Answer: 68-year-old female presents with pain in right wrist
HISTORY:
This 68-year-old female presents with pain in right wrist. Patient's pain has been worsening over the last six months with decreased mobility and decreased strength.
(QUIZ ANSWER) PRIMARY FINDING:
Lunotriquetral ligament tear.
Using the diagnostic web viewer, we have provided images that assist in telling our clinical story. Areas of significance are indicated below.
FINDINGS:
A combination of radial ulnar instability with inflammation, ulnolunate impaction with lunate infraction and early loss of volume, lunatotriquetral ligament chronic degeneration and tear, and autodigestion or loss of the triangular fibrocartilage has resulted in massive swelling on the ulnar side of the wrist with secondary osteoedema.
As opposed to idiopathic Kienbock's disease with positive radial or negative ulnar variance, the patient demonstrates a pattern of infraction, pseudocyst formation, and diffuse lunate edema which most likely represents the early changes of lunatonecrosis secondary to trauma.
A pattern of lunate remodeling has created a focal area of abutment against the radius with radial edema, radial lunate erosion, and this likely represents the equivalent of idiopathic Kienbock's disease beginning at this locus. The lunate has assumed a conical shape proximally at this location.
The scapholunate ligament is intact.
Generalized inflammation and degeneration of the carpal bones are noted.
Radioulnar instability with dorsal displacement of the ulna.
CONCLUSION:
1. Massive autodigestion of the TFC and TFCC with:
a. Infraction and early collapse of the lunate.
b. Lunato - and ulnochondromalacia.
c. Remodeling of the lunate with focal area of necrosis (bone necrosis) at the base of the radius.
d. Radioulnar instability.
e. Generalized degeneration of the carpal bones.
Case Challenge: Wrist MRI Cases
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Content reviewed: September 28, 2021