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34b - Answer: 67-year-old female presents with moderate pain and lump on right wrist

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

HISTORY: 

This 67-year-old female presents with moderate pain and lump on right wrist. For the past two months, there has been a sharp pinching while using the right hand or lifting objects.

(QUIZ ANSWER) PRIMARY FINDING: 

Intersection syndrome.

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

FINDINGS:

Dominant abnormalities are noted involving the 2nd and 3rd extensor compartments manifest as distal intersection syndrome beginning just proximal to the wrist. High-grade peritendinitis and partial high-grade tear involving the 3rd extensor tendon compartment (extensor pollicis longus) as it passes over the Lister's tubercle and over the 2nd extensor compartment (extensor carpi radialis longus and brevis). The 4th, 5th, 6th and 1st extensor tendon compartments appear normal. The peritendinitis and peritendinous fluid, however, continues distally along the tendons making up the 2nd compartment (carpi radialis longus and brevis). 

Extensive resorptive cystic change, likely arthropathic, noted involving the lunate, triquetrum and proximal half of the capitate. Mild generalized wrist capsulosynovitis noted with thickening and heterogeneous signal. 

Normal radioulnar, radiocarpal, midcarpal and carpometacarpal alignment. 

Normal radioulnar joint. 

Central full-thickness perforation or tear involving the central band of the triangular fibrocartilage with free communication of fluid between ulnocarpal joint and distal radioulnar joint.

Normal scapholunate and lunotriquetral ligaments. 

No soft tissue mass. 

Subtle hyperintensity involving the thenar eminence is noted and there is a moderate caliber change in the size of the median nerve from proximal to distal carpal tunnel. Carpal tunnel syndrome requires clinical exclusion. 

No soft tissue mass, carpal boss, macrofracture, microtrabecular injury, AVN noted. 

IMPRESSION:

Right Wrist: Distal intersection syndrome with peritendinous inflammation and tenosynovitis involving the 2nd extensor compartment and peritendinous inflammation with high-grade partial tear involving the 3rd extensor tendon compartment - as the 3rd extensor tendon compartment passes over Lister's tubercle dorsal to the 2nd tendon compartment in its distal course. The peritendinous inflammation of the tendons of the 2nd extensor compartment extend distally into the hand. 

Extensive arthropathic cystic resorptive changes involving the lunate, triquetrum, scaphoid and proximal half of the capitate. 

Generalized capsulosynovitis with capsular thickening, scant fluid in the intercarpal joints and synovitis. 

Central full-thickness perforation or tear involving the central band of the triangular fibrocartilage with free communication of fluid between ulnocarpal joint and distal radioulnar joint.

Subtle hyperintense signal involving the muscles of the thenar eminence for which median nerve impingement is suspected. Moderate caliber change is noted involving the proximal carpal location of the median nerve compared to its distal carpal location. Consider carpal tunnel syndrome.

LESSON 3, TOPIC 27

Case Challenge: Wrist MRI Cases

Case Challenge

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Content reviewed: September 28, 2021

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