Wk 5, Case 2 - Review

Patient History
76-year-old male with pain in the mid dorsal wrist with swelling.

Findings

ALIGNMENT:

Ulnar Variance: Neutral.

Distal Radioulnar Joint: Normal.

Carpal Instability: 1cm diastasis of the scapholunate interval with early proximal migration of the capitate. Mild dorsal tilt of the lunate.

ARTICULATIONS:

Multifocal biomechanical friction, intraosseous cysts throughout the carpal bones.

Thumb Carpometacarpal Joint: Moderate osteoarthrosis with marginal, beak-like osteophytes at the palmar aspect of the 1st metacarpal base and trapezium. Mild dorsal radial subluxation with thickening and irregularity of the anterior oblique ligament. Laxity of the deltoid ligament.

Scaphotrapeziotrapezoidal Joint: Mild osteoarthrosis.

Pisiform-Triquetral Joint: Normal.

Radiocarpal Joint: Chronic mildly displaced fracture at the dorsal aspect of the radial styloid associated with mild osteoedema, a small fluid cleft and large intraosseous cysts/geodes/“synovial pits”. Moderate osteoarthrosis of the radiocarpal joint with marginal osteophytes.

Distal Radioulnar Joint: Normal.

Fluid: Trace amount of free fluid at the radioscaphoid joint.

Carpal Effusion: Trace amount of fluid in the ulnar side carpometacarpal joints.

Distal Radioulnar Joint Effusion: None.

Chronic nonunited fracture of the hamate hook with associated osteoedema and an intraosseous cyst.

INTRINSIC LIGAMENTS:

Scapholunate Ligament: Complete derangement of the dorsal, intermedius and palmar segments of the scapholunate ligament.

Lunotriquetral Ligament: Intact.

Triangular Fibrocartilage: Low-grade strain of the foveal and styloid attachments of the triangular ligament/ligamentum subcruentum with diffuse edema at the meniscus homologous. The extensor carpi ulnaris appears intact.

Lunate Facet: Mild capitolunate osteoarthrosis.

Extensor Compartment: Prominent fluid distention of the extensor carpi radialis longus, extensor carpi radialis brevis (2nd extensor compartment) and the extensor pollicis longus (3rd extensor compartment) tendon sheaths proximal and distal to the Lister's tubercle.

Flexor Compartment:

Carpal Tunnel: No space-occupying lesions.

Median Nerve: Normal diameter and signal intensity.

Flexor Retinaculum: Normal thickness. No ventral bowing.

Flexor Tendons: No tendinosis or tears.

Guyon's Canal: No space-occupying lesions.

OTHER FINDINGS:

Soft Tissues: Diffuse soft tissue swelling throughout the dorsal radial aspect of the wrist with proximal extension to the distal forearm and distal extension to the dorsal hand.

Impressions
1.Chronic nonunited fracture of the dorsal radial styloid with a small fluid cleft and osteoedema.
2.Complete scapholunate ligament tear with 1cm diastasis, early proximal capitate migration and minimal dorsal lunate tilt. Mild osteoarthrosis of the radioscaphoid joint with intraosseous cysts/geodes/ “synovial pits”. Small amount of fluid in the radioscaphoid joint. Findings are compatible with scapholunate advanced collapse (SLAC) wrist, stage II.
3.Traumatic distal intersection syndrome with severe tenosynovitis involving the 2nd and 3rd extensor compartments.
4.Diffuse edema throughout the dorsal radial aspect of the distal forearm, wrist and proximal hand.
5.Mild sprain of the styloid and foveal attachments of the triangular ligament and diffuse edema throughout the meniscus homologous, Palmer class 1B injury.
6.Chronic nonunited fracture of the hamate hook. Instability suggested by the presence of osteoedema and a small intraosseous cyst.