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14b - Answer: 67-year-old female presents with rheumatoid arthritis

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 rheumatoid arthritis, and prior surgery for tendon repair in right wrist.

(QUIZ ANSWER) PRIMARY FINDING IN THIS CASE: 

Late-stage chronic distal radioulnar joint (DRUJ) 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:

There is late-stage course of the rheumatoid arthritis demonstrated in the radioulnar joint. The hallmark of rheumatoid arthritis is demonstrated in the radial DRUJ. The DRUJ demonstrates extensive synovitis and erosions and deformity in the ulnar styloid process as well as radial end. There are also fibrocystic changes seen in the distal ulna. Radial carpal joint also demonstrated. Advanced arthropathy, more likely represent arthritis rather than rheumatoid arthritis. 

There is fraying out of the TFCC demonstrated. The scapholunate ligament is also frayed and mild diastasis is also demonstrated in the scapholunate joint. Lunotriquetral joint is not widened. No marginal erosions or subarticular stress-induced change is demonstrated in the scapholunate and lunotriquetral joint. No development of intercarpal arthritis is demonstrated. 

The first carpometacarpal joint also demonstrates mild deformity and ligamentous laxity without arthropathy. The first metacarpophalangeal joint demonstrates altered joint conformity, mild stress-induced osteoedema, mild subluxation and ligamentous laxity, consistent with moderate osteoarthrosis. In fact, a bony segmentation is appreciated or developing in the radial end, just superior to the scapholunate joint space measuring approximately 5mm. 

The carpal tunnel is intact without tendinosis or tenosynovitis. The extensor tendons are unremarkable. No myoedema or muscle atrophy is demonstrated. The thenar and hypothenar muscles are intact. 

CONCLUSION: 

1. Late-stage chronic DRUJ rheumatoid arthritis with severe synovitis, severe bony deformity and erosions, fibrocystic change, and concomitant severe attritional change of the TFCC. No tenosynovitis. 

2. Advanced radiocarpal osteoarthritis with altered marginal deformity and a developing 5 mm bony fragment, chondral erosions, stress-induced osteoedema, and scapholunate ligamentous insufficiency is favored over rheumatoid arthritis. 

3. Mild-to-moderate first metacarpophalangeal osteoarthrosis.

LESSON 2, TOPIC 42

Case Challenge: Wrist MRI Cases

Case Challenge

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Content reviewed: September 28, 2021

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