33b - Answer: 64-year-old female presents with left wrist pain for one month
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:
Flexor carpi radialis tear.
Using the diagnostic web viewer, we have provided images that assist in telling our clinical story. Areas of significance are indicated below.
FINDINGS:
Ulnar styloid intact. Subchondral pseudocyst formation in a pattern of ulnolunate abutment demonstrated. Perforation of the radial third of the triangular fibrocartilage disc demonstrated. Ulnomeniscal homologue, extensor carpi ulnaris intact. Thin distal radioulnar joint fusion. Dorsal and volar ligaments of the distal radioulnar joint intact.
Severe scaphotrapezoid chondromalacia with subchondral pseudocyst formation and extensive edema throughout the distal pole of the scaphoid. Malalignment of the carpal rows likely from microinstability. Chronic tear through the dorsal scapholunate ligament, with degeneration of the remaining segment and associated mild scapholunate gapping. Associated dorsal intercalated segmental instability posture (DISI).
Extensive osteophytic spurs project volar from the scaphotrapezoid articulation likely abutting the adjacent flexor carpi radialis which demonstrates an adjacent approximately 2cm split tear and hypertrophic tendinopathy. The remaining flexor and extensor tendons of the wrist intact. Secondary swelling from flexor carpi radialis and peritendinitis abut the carpal tunnel. No fat seen within the carpal tunnel which demonstrates bowstringing. Suggestion of enlargement of the median nerve as it exits the carpal tunnel. No evidence of ulnar entrapment neuropathy. Moderate thenar fatty atrophy noted. Hypothenar musculature intact.
Moderate 1st carpometacarpal arthropathy. No macrofracture.
CONCLUSION:
1. 2cm split tear involving the swollen, severely tendinopathic flexor carpi radialis at the level of the scaphotrapezoid articulation which demonstrates advanced arthropathy and volar osteophytes that likely contribute to friction-related degeneration of the adjacent flexor carpi radialis. Associated flexor carpi radialis peritendinitis without complete tear or retraction.
2. Swelling from the previously mentioned FCR tendon tear and peritendinitis contribute to stenosis of the carpal tunnel without visualized internal fat and demonstration of bowstringing of the superficial retinaculum. Swelling of the post carpal tunnel median nerve along with moderate fatty atrophy of the thenar musculature raise concern for a subacute carpal tunnel syndrome which should be correlated for sensation disturbance involving the 2nd and 3rd digits.
3. Ulnolunate abutment chondromalacic changes with perforation of the radial third of the triangular fibrocartilaginous disc. Constellation of findings compatible with a palmar class 2C lesion.
4. Degenerative tears of the scapholunate ligament with mild scapholunate disassociation contribute to DISI posture (dorsal intercalated segmental instability). No evidence of frank scapholunate advanced collapse (SLAC) wrist at this time.
Case Challenge: Wrist MRI Cases
Case Challenge
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Content reviewed: September 28, 2021