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40b - Answer: 55-year-old female presents with right wrist pain and swelling

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

HISTORY: 

This 55-year-old female presents with right wrist pain and swelling.

(QUIZ ANSWER) PRIMARY FINDING: 

Inflammatory arthritis with synovitis.

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

FINDINGS:

A large effusion and capsular inflammation are present at the wrist. The scapholunate ligament is partially torn with resulting widening of the scapholunate interval. Early proximal migration of the capitate noted with impaction of its proximal pole upon scaphoid and lunate. Extensive pseudocysts and / or erosions are present in the capitate, hamate, and lunate. The lunatotriquetral joint space is narrowed, limiting assessment of the lunatotriquetral ligament.

The triangular fibrocartilage complex is inflamed and there a central perforation is identified. A small pseudocyst present in the distal ulna.

There is generalized narrowing of carpometacarpal joint spaces with numerous periarticular erosions and / or subchondral cysts present within the periarticular carpal bones and metacarpal bases. 

Water-sensitive images demonstrate marked generalized osteoedema within all of the carpal bones and the bases of the 2nd through 5th metacarpals. However, osteoedema within the proximal 3rd metacarpal is noted to be disproportionately more intense, suggesting a superimposed stress injury or possibly a macrofracture. T1 coronal images further suggest this possibility by demonstrating a thin longitudinally-oriented, low signal line traversing the long axis of the metacarpal on the ulnar side from the carpometacarpal joint to the diaphyseal cortex. The appearance is suspicious for possible non-displaced macrofracture. 

The extensor and flexor tendons are intact and unremarkable. 

CONCLUSION: 

1. Myriad of findings as described above including marked synovitis, effusion, generalized carpal osteoedema, and multiple periarticular subchondral pseudocysts and / or erosions. These collective findings are most likely due to an inflammatory arthritis with synovitis, or less likely, to calcium pyrophosphate deposition disease. 

2. Partial or complete disruption of the scapholunate ligament with increased width of the scapholunate joint space and early proximal migration of the capitate, suggestive of developing SLAC wrist (scapholunate advanced collapse). 

3. Central perforation of the triangular fibrocartilage complex, corresponding to grade 2C or 2D. 

4. Disproportionate osteoedema within the proximal 3rd metacarpal and low signal line on T1, suggesting superimposed nondisplaced macrofracture.

LESSON 3, TOPIC 45

Case Challenge: Wrist MRI Cases

Case Challenge

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Content reviewed: September 28, 2021

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