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43b - Answer: 50-year-old female presents with mass in right wrist

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

HISTORY: 

This 50-year-old female presents with mass in right wrist that started on right distal forearm two years prior. Very painful. Also, has many small bumps on right wrist. Has shooting pain in right hand and arm. Right forearm / wrist mass, mass 5cm proximal wrist crease. No known injury, cancer, or wrist surgery.

(QUIZ ANSWER) PRIMARY FINDING: 

Neurilemmoma.

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

FINDINGS:

A 1.9cm length mass approximately 1.6cm in diameter, is present along the radial aspect of the wrist, centered 5.2cm from the radiostyloid. A small vessel or nerve branch extends directly to the mass and then from the mass. It is likely the source. Differential includes a neoplasm such as a neural cell origin tumor (neurilemmoma favored over neurofibroma given the well-marginated character and speckled appearance). Less likely a myxoid neoplasm. Even less likely a vascular lesion given the lack of pulsation, although a sealed pseudoaneurysm (calcified with a lamellated margin on MRI) may be considered. Unlikely a true aneurysm. A dynamic contrast-enhanced study will be of value prior to surgery.

Moderate arthropathy of the wrist with capsulitis. 

Scapholunate ligament is intact. Lunotriquetral ligament is not well demonstrated. TFC shows chronic degeneration and thinning in particular involving the junction of the inner one-third with the middle one-third. Peripheral TFC is intact. 

Extensor carpi ulnaris shows moderate tendinopathy and subtle chronic interstitial tear within the tendon. The tear is centered at the level of the ulnar styloid. 

The remaining extensor and flexor tendons are intact. 

Neurovascular bundles are unremarkable. 

No AVN, OCD or fracture. No malalignment at this time. 

No additional masses. 

Furthermore, contrast enhanced study may be of value in fully evaluating the small bumps on the wrist described in the history but not seen as discrete masses on today's study. 

CONCLUSION: 

1. A 1.9cm length mass approximately 1.6cm in diameter, is present along the radial aspect of the wrist, centered 5.2cm from the radiostyloid. A small vessel or nerve branch extends directly to the mass and then from the mass. It is likely the source. Differential includes a neoplasm such as a neural cell origin tumor (neurilemmoma favored over neurofibroma given the well-marginated character and speckled appearance). Less likely a myxoid neoplasm. Even less likely a vascular lesion given the lack of pulsation, although a sealed pseudoaneurysm (calcified with a lamellated margin on MRI) may be considered. Unlikely a true aneurysm. A dynamic contrast-enhanced study will be of value prior surgery. 

2. Moderate arthropathy of the wrist with capsulitis. 

3. Extensor carpi ulnaris shows moderate tendinopathy and subtle chronic interstitial tear within the tendon. 

4. Furthermore, contrast enhanced study may be of value in fully evaluating the small bumps on the wrist described in the history but not seen as discrete masses on today's study. 

ADDENDUM: 

These results were confirmed by direct visualization at surgery to arise from the radial nerve and favored to represent a neurilemmoma by the surgeon. 

LESSON 3, TOPIC 54

Case Challenge: Wrist MRI Cases

Case Challenge

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Content reviewed: September 28, 2021

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