Patient History
Left wrist pain. Evaluate for ulnar impaction for cause of ulnar-sided wrist pain.
Findings
ALIGNMENT:
Ulnar Variance: Neutral ulnar variance posture.
Distal Radioulnar Joint: Advanced radiolunate joint arthrosis with mild osteoarthrosis and generalized chondral plate delamination/chondromalacia and arthropathic cyst formation at the articulating ulnar surface of the radius.
Carpal Instability: Volar intercalated segmental instability (VISI) . Volar tilt of the lunate with capitolunate angle of 45º (normal <30º).
Scapholunate angle of 11º (normal >30º).
ARTICULATIONS:
Thumb Carpometacarpal Joint: Severe osteoarthrosis with radial subluxation of the metacarpal base. Chondromalacia and subchondral arthropathic cyst formation at the ulnar surface of the 1st metacarpal base. Chronic injuries to the dorsal deltoid and the anterior oblique ligaments.
Scaphotrapeziotrapezoidal Joint: Mild osteoarthrosis and chondromalacia.
Pisiform-Triquetral Joint: Mild osteoarthrosis and chondromalacia.
Radiocarpal Joint: Severe narrowing of the radiolunate joint with generalized chondromalacia and subchondral arthropathic cyst formation.
Carpal Effusion: Moderate effusion with capsular synovitis. No internal debris or free bodies.
Distal Radioulnar Joint Effusion: Mild with synovitis.
INTRINSIC LIGAMENTS:
Scapholunate Ligament: Chronic appearing full-thickness tear.
Lunotriquetral Ligament: Chronic appearing full-thickness tear
Triangular Fibrocartilage: Diffuse fraying with lunate and triquetral chondromalacia. The foveal and styloid ligament attachments are frayed. Fibroinflammatory changes at the meniscus homologous.
Lunate Facet: Comminuted tear of the dorsal pole and midbody of the lunate with generalized chondromalacia at the capitolunate.
Hamate-Lunate Facet: Generalized chondromalacia and subchondral arthropathic cyst formation.
Extensor Compartment:
I: Normal abductor pollicis longus and extensor pollicis brevis.
II: Normal extensor carpi radialis longus and brevis.
III: Normal extensor pollicis longus
IV: Normal extensor digitorum communis.
V: Normal extensor digiti minimi.
VI: Superficial interstitial delamination with mild tenosynovitis of the extensor carpi ulnaris (ECU).
Flexor Compartment:
Carpal Tunnel: No space-occupying lesions.
Median Nerve: Normal size and volume.
Flexor Retinaculum:
Flexor Tendons: No tenosynovitis.
Guyon's Canal: No space-occupying lesions.
OTHER FINDINGS:
Skeleton: Comminuted fracture of the mid and dorsal lunate pole.
Soft Tissues: Diffuse periarticular soft tissue swelling.
Vessels: Normal neurovascular bundles.
Impressions
1. Comminuted nonunited fracture of the mid and dorsal lunate pole resulting in complex carpal instability due to full-thickness tears of the lunotriquetral and scapholunate ligaments with volar tilt of the lunate and features of volar intercalated segmental instability (VISI).
2. Posttraumatic advanced radiolunate and distal radioulnar joint arthrosis.
3. Moderate joint effusion with capsular synovitis and periarticular soft tissue swelling.
4. Superficial interstitial delamination with mild tenosynovitis of the extensor carpi ulnaris (ECU).
