13b - Answer: 59-year-old female presents with severe pain and swelling in right wrist
HISTORY:
This 59-year-old female presents with severe pain and swelling in right wrist. Injured while cutting wood nine months prior. Limited range of motion.
(QUIZ ANSWER) FAVORED DIAGNOSIS:
Rheumatoid arthritis.
Using the diagnostic web viewer, we have provided images that assist in telling our clinical story. Areas of significance are indicated below.
FINDINGS:
History of bridging from triscaphe fusion involving scaphoid, capitate, greater and lesser multangular, but sparing the CMC.
A pattern of massive intra-articular swelling throughout the distal and proximal carpal row with reactive edema and erosions throughout the carpus is more compatible with a primary inflammatory arthropathy than diffuse septic arthropathy involving multiple compartments and spaces.
Possible considerations include rheumatoid arthritis, seronegative spondyloarthropathies, but crystalline-induced arthropathies are less likely.
The process is too diffuse for Lyme disease.
A mechanical etiology is implausible due to the diffuseness of the process even though a small perforation or fenestration exists in the TFC. Virtually every portion of the joint is involved including the DRUJ.
A dissecting capsulosynovial cyst may be an amenable source for joint aspiration and synovial analysis using the MRI as a guide and ultrasound of the hand to direct needle placement, as such collection resides around the flexor tendons three and four primarily. Rheumatologic workup should also carefully be entertained.
CONCLUSION:
Trauma history may be a "red herring" in this patient who has had prior surgical fusion and now presents with innumerable foci of osteoedema, erosive change, and capsulosynovial inflammation and thickening for which an inflammatory non-infectious etiology is favored over septic arthritis and other etiologies. Recommendations and detail are given in the body of the report. The favored diagnosis is RA or rheumatoid arthritis.
Case Challenge: Wrist MRI Cases
Case Challenge
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Content reviewed: September 28, 2021