Wk 5, Case 5 - Review

Patient History
68-year-old female with right wrist pain with decreased mobility and strength.

Findings

ALIGNMENT:

Ulnar Variance: Slightly positive ulnar posture.

Distal Radioulnar Joint: Dorsal angulation of the distal ulna.

Carpal Instability: Unstable. See details below.

ARTICULATIONS:

Thumb Carpometacarpal Joint: Moderate osteoarthrosis with distal rupture of the anterior oblique/beak ligament with proximal retraction associated with radial subluxation of the 1st metacarpal base. The deltoid ligament is unaffected. Associated marginal osteophytes, chondromalacia and subchondral arthropathic cysts.

Scaphotrapeziotrapezoidal Joint: Diffuse chondromalacia and mild subchondral osteoedema.

Pisiform-Triquetral Joint: Mild chondromalacia and subchondral osteoedema.

Radiocarpal Joint: Diffuse chondromalacia with subchondral arthropathic cyst and diffuse osteoedema involving the ulnar side of the distal radial epiphysis and the entire lunate.

Distal Radioulnar Joint: Fluid distension of the distal radioulnar joint.

Carpal Effusion: Small joint effusion, mainly at the radial side.

INTRINSIC LIGAMENTS:

Scapholunate Ligament: Intact.

Lunotriquetral Ligament: Limited visualization. Suspect chronic tear.

Triangular Fibrocartilage: Complex fraying and tear/perforation of the central disc. The ulnar and foveal styloid attachments demonstrate diffuse swelling and are inconspicuous. Diffuse swelling throughout the meniscus homologous. Suspect longstanding ulnolunate abutment syndrome Palmer 2 C-D

Lunate Facet: Generalized chondromalacia, subchondral arthropathic cysts and diffuse osteoedema throughout.

Extensor Compartment: Stripping of the ulnar attachment of the extensor carpi ulnaris (ECU) subsheath with partial ulnar subluxation of the ECU. The extensor retinaculum is intact. Rest of the extensor tendons are noncontributory.

Flexor Compartment:

Carpal Tunnel: No space-occupying lesions.

Median Nerve: Normal diameter and signal intensity.

Flexor Retinaculum: No thickening or palmar bowing.

Flexor Tendons: No tears or tenosynovitis.

Guyon's Canal: No space-occupying lesions.

OTHER FINDINGS:

Skeleton: Diffuse capsulosynovial soft tissue swelling involving the dorsal intercarpal and palmar radioscaphocapitate extrinsic ligaments.

Soft Tissues: As described.

Vessels: Normal.

Impressions
1.Distal radioulnar joint instability with tearing of the volar radioulnar ligament and dorsal angulation of the distal ulna.
2.Findings result in generalized radiocarpal, ulnar and triquetral chondromalacia with subchondral arthropathic cysts and moderate to severe confluent osteoedema throughout the distal radial epiphysis, the entire lunate and to a lesser degree within the triquetrum.
3.Complex tear of the TFC disc central third, with swelling of its ulnar foveal and styloid attachments and the meniscus homologous.
4.Small joint effusion of the distal radioulnar joint.
5.Diffuse capsulosynovial swelling involving the dorsal and volar extrinsic wrist ligaments and a small intercarpal joint effusion.
6.Conglomerate of findings favor mechanical arthrosis over a primary inflammatory (rheumatoid) arthritis.
7.Ulnolunate abutment syndrome Palmer 2 C-D. Lunatotriquetral ligament status in question.
8.Ulnar side stripping of the ECU subsheath with mild subluxation. The extensor retinaculum is intact.