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Wk 2, Case 1 - Review

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51 year old falls off a tree and is having terrible

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wrist pain for the past month. There is a lot going on here.

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What I'd like to point out is this pie shape appearance of the,

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uh, which is related to the presence of LAR interrelated

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segmental instability with sub ation of the lunate

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along the palmer surface,

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which is causing compression of the carpal tunnel structure.

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So this patient's pain is in part related to the OSS and

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ligamentous injuries that he sustained during trauma,

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but it's also due to compression of the carpal tunnel

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by the displaced lunate in the, uh, carpal tunnel space.

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So that's very nicely is illustrated on this sagittal image

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with compression of the flexor tendons as well as medial nerve within

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the carpal tunnel. If we scroll through the Corona images,

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we can see why this patient has such severe mid carpal instability

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as well as, uh, skin association.

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So we have tiers of the ski for ate ligament,

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that's the ate there.

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Then we have the trium here and there is fluid standing through the

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interface between the ATE and the trium that is consistent

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with the lal tear. So we have a ski for ate out,

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we have lure out, and this is allowing the,

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uh,

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lunate to translate on the radius and be polarly tilted.

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We also see a kpho fracture.

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So this patient has a trans kpho carpal instability

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and that is contributing to what we're seeing also in the sagittal images with

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dorsal dislocation of the capitate with respect to the lu.

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So this is aate dislocation.

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So to summarize,

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we have VC Ebola intercalated segmental instability,

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contributing to carpal tunnel syndrome,

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and we have trans mid carpal

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instability with perone uh, dislocation.

Report

Patient History
51-year-old male with worsening right wrist pain and swelling after falling out of a tree 1 month ago.

Findings
ALIGNMENT:

Ulnar Variance: Negative ulnar variance.

Distal Radioulnar Joint: Normal.

Carpal Instability: Severe volar tilt of the lunate.

ARTICULATIONS:

Thumb Carpometacarpal Joint: Mild osteoarthrosis.

Scaphotrapeziotrapezoidal Joint: Moderate osteoarthrosis

Pisiform-Triquetral Joint: Mild joint effusion.


Radiocarpal Joint: Moderate osteoarthrosis with marginal osteophytes and subchondral arthropathic cysts in the distal radial epiphyses.

Distal Radioulnar Joint: No joint effusion.

Carpal Effusion: Moderate effusion with reactive synovitis.

INTRINSIC LIGAMENTS:

Scapholunate Ligament: Sprain but otherwise intact.

Lunotriquetral Ligament: Complete tear involving its dorsal, volar and proximal segments.

Triangular Fibrocartilage: Wearing of the TFC disc proper. No tears.

Lunate Facet: Fragmentation and sclerosis of the entire lunate.

Extensor Compartment: No tendinopathy or tendon tears.

Flexor Compartment: No tendinopathy or tendon tears.

Carpal Tunnel: Palmar bowing of the carpal tunnel components.

Median Nerve: Minimal increased diameter with normal signal intensity.

Flexor Retinaculum: No scarring.

Flexor Tendons: Palmar bowing. No evidence of tendinopathy or tears.

Guyon's Canal: No space-occupying lesions.

OTHER FINDINGS:

Skeleton: Fragmentation, sclerosis and eburnation of the entire lunate with severe volar tilt. Moderate radiocarpal osteoarthrosis and palmar bowing of the carpal tunnel components. 7mm osseous body anterior to the ulna. Innumerable dorsal bodies, series 8 images 12 and 13.

Deformity, sclerosis and arthropathic cyst formation of the scaphoid. Dorsal displacement and proximal migration of the capitate with large, intraosseous arthropathic cysts.

Up to 1cm corticated osseous structures localized to the dorsal proximal capitate and ventral to the distal radial epiphysis, likely fragments of the lunate.

Soft Tissues: The thenar and hypothenar eminences and intrinsic hand muscles are normal.

Vessels: Noncontributory.

Impressions
1.Background of negative ulnar variance posture with lunate dislocation, rotatory displacement and progressing arthrosis. Patient is progressing to advanced stages of SLAC wrist, Watson 3-4.
2.Complete disruption of the lunotriquetral ligament with lunate volar tilt in keeping with volar intercalated segmental instability (VISI).
3.Rotation of the scaphoid with chronic mal or nonunion.
4.Mass effect of the tilted lunate on the carpal tunnel components with mild thickening of the median nerve. Correlate for the presence of carpal tunnel syndrome.
5.Mild effusion with reactive synovitis of the carpal joint.

Case Discussion

Faculty

Stephen J Pomeranz, MD

Chief Medical Officer, ProScan Imaging. Founder, MRI Online

ProScan Imaging

Jenny T Bencardino, MD

Vice-Chair, Academic Affairs Department of Radiology

Montefiore Radiology

Todd D. Greenberg, MD

Radiologist

ProScan

Tags

Musculoskeletal (MSK)

MRI

Hand & Wrist