• No results found

Ulnar sided Wrist Pain

N/A
N/A
Protected

Academic year: 2021

Share "Ulnar sided Wrist Pain"

Copied!
40
0
0

Loading.... (view fulltext now)

Full text

(1)

Ulnar sided Wrist Pain

1

Susan Cross,

1

Anshul Rastogi,

2

Brian Cohen,

1

Rosy Jalan

1

Dept of Radiology, Barts Health NHS Trust, London, UK

2

London Orthopaedic Centre

Contact: susan.cross@bartshealth.nhs.uk

Abstract number: EE33

(2)

Purpose

• To review the complex anatomy of the ulnar

side of the wrist

• To provide a comprehensive pictorial review of

the varied diagnoses associated with Ulnar

sided wrist pain using 3.0 Tesla (T) MRI with

arthroscopic correlation where appropriate

• To illustrate and highlight pitfalls and

(3)

Anatomy

Image from - K. Sachar, Ulnar-sided wrist pain: evaluation and treatment of TFCC tears, ulnocarpal impacation syndrome, lunotriquetral ligament tears, Current concepts JHS. Vol 33A November 2008

(4)

Causes of ulnar sided wrist pain

Ulnar sided wrist pain Extensor carpi ulnaris pathology Triangular fibrocartilage complex injuries Ulnocarpal and inter carpal ligament injuries Ulnar impaction syndrome Fractures Inflammatory arthritis Ganglion Others including infection, AVM

(5)

One of the most common questions posed when a

patient presents with ulnar sided wrist pain, is whether

the TFCC is intact.

The following six cases demonstrate unenhanced, non

arthrographic 3 Tesla MRI appearances of the

symptomatic wrist with direct arthroscopic correlation.

Two MRIs were false positive for a TFCC tear which on

review post arthroscopy demonstrate quite marked

intrasubstance degeneration. When these findings are

observed it may be prudent to further evaluate with an

MR arthrogram

(6)

Case 1

• 54 yr old female complaining of left ulnar

sided wrist pain and swelling

(7)

Pre operative MRI

• Perforating tear of radial

attachment of the TFCC

(blue arrow)

• Non united ulnar styloid

fracture with 6mm loose

body (red arrow)

adjacent to the

triquetrum and pisiform,

likely secondary to a

degree of ulnar carpal

impaction

(8)

Arthroscopy findings:

•Radial side split of

TFCC (blue arrow)

•6 mm loose body,

demonstrated on

pre operative MRI,

retrieved from ulnar

side of wrist

(9)

Case 2

• 36 yr old female with ulnar sided wrist pain,

?TFCC tear

(10)

Pre operative MRI

• Negative ulnar

variance

• Full thickness

tear of the radial

attachment of the

TFCC (blue arrow)

with abnormal

fluid signal within

the gap of the tear

and immediately

deep to it (white

arrows)

(11)

Arthroscopy confirmed MRI findings

• Tear of the radial

attachment of the

TFCC was confirmed at

arthroscopy (red

arrow)

(12)

Case 3

(13)

Pre operative MRI

Findings:

• Intrasubstance tear of the TFCC

(red arrow) with detachment of

the distal ulnar attachment (blue

arrow).

• The scapholunate and

lunotriquetral ligaments appear

intact.

• Normal articular surfaces of the

distal radius, scaphoid, lunate and

triquetrum.

(14)

Arthroscopy found intact TFCC despite

the MRI appearances (false positive) :

• The TFCC was intact

throughout but surrounded by

synovitis.

• On review of the

preoperative MRI, there was

marked intermediate signal

within the TFCC but no overt

fluid signal component.

•In such cases it may be

prudent to further evaluate

with IV contrast or an MR

arthrogram .

(15)

Case 4

(16)

Pre operative MRI

Findings:

• Partial tear of the

scapholunate

ligament (white

arrow)

• TFCC intact

(uniform low signal

throughout)

• Lunotriquetral

intact

(17)

Arthroscopy correlated with the MRI:

Findings:

•Tear of the scapholunate

ligament confirmed at

arthroscopy

• TFCC intact

• Articulating surfaces of

the distal radius, scaphoid,

lunate and triquetrum

(18)

Preoperative MRI findings:

• Intrasubstance signal

change in the ulnar aspect

of TFCC ( blue arrow) with

direct extension of

hyperintense fluid signal

into the distal radioulnar

joint (red arrow), in

keeping with a TFCC tear

Case 5

(19)

Arthroscopy correlated with MRI

• Confirmed partial tear

of the TFCC (arrow). This

was debrided.

• SL and LT ligaments

normal

• Articular surfaces of

distal radius, scaphoid,

lunate and triquetrum

are normal

(20)

Case 6

• 44 yr old female with ulnar sided wrist pain

?TFCC tear

(21)

MRI findings

• Complex tear of the TFC with

extension to superior and inferior

surfaces with direct extension of fluid

into the distal radioulnar joint (red

arrow)

• The meniscal homologue is

oedematous (blue arrow)

• Subchondral oedema of the lunate

with chondral cartilage thinning

(white arrow)

•Tear of the Lunotriquetral ligament

• Palmar DRUJ ligamentous injury

(black arrow)

(22)

Arthroscopy found intact TFC despite

MRI appearances (false positive)

• There was some synovitis within the ulnar recess

• Chondral cartilage damage of the distal radius

• Intact TFC

False positive for TFCC tear on the pre operative MRI.

Again, there is intrasubstance intermediate signal

within the TFC but no discrete overt fluid signal within

the TFC. The fluid within the distal radioulnar joint

may be attributable to the distal volar radioulnar

ligamentous disruption.

(23)

Extensor Carpi Ulnaris Tendinopathy

Coronal (left) and axial (right)T2W fat saturated images of the wrist:

Demonstrates markedly thickened extensor carpi ulnaris tendon (red arrow) with intrinsic

abnormal high signal , more than the usual high signal,in keeping with florid tendinopathy. There

is also associated surrounding soft tissue odema and mild tenosynovitis. Note also ulnar

(24)

Extensor carpi ulnaris tear

Axial T2 Fat saturated image of the wrist :

Demonstrates ulnar styloid fracture (blue arrow). This is relatively acute as quite marked bone marrow oedema persists within the distal ulna. There is extensor carpi ulnaris tenosynovitis with partial tears (red arrow). Oedema present within the related soft tissues is in keeping with post traumatic change

(25)

Distal volar radio-ulnar ligament injury

Axial T2W fat saturated image of the wrist at the level of the distal radioulnar joint:

Demonstrates disruption of distal volar radio-ulnar ligament following trauma (red arrow). There is also ulnar styloid undisplaced fracture (blue arrow). The ECU is intact.

(26)

Intercarpal ligament injury

Axial T2W fat saturated images of the wrist at the mid carpal level:

Demonstrate high signal with loss of congruity (red arrow) in the dorsal intercarpal ligaments in keeping with ligamentous disruption

(27)

TFCC Anatomy

Left: TFCC disc (broad white arrow), proximal and distal laminae (thin arrows), meniscus homologue (open white arrow). Right: Ulnotriquetral ligament (open arrow head) ² ² Images from review article, P.S. Vezeridis et al, Ulnar-seded wrist pain. Part 1: anatomy and physical examination. Skeletal

(28)

Triangulofibrocartilage (TFC) Tears

Left: High signal on the ulnar styloid side of TFCC (red arrow).

(29)

Traumatic TFC Tears

Left: Coronal T2W Fat saturated image of the wrist

Demonstrates traumatic TFC radial perforation with fluid extending into the distal radio-ulnar joint (white arrow). Also note is made of ulnar styloid fracture (red arrow).

Right: Axial T2W fat saturated image of the wrist

There is a full thickness TFC tear with fluid in distal radio-ulnar joint (blue arrow), with triquetral fracture (green arrow)

(30)

Ulnar impaction syndrome

Coronal T2 Fatsaturated and T1W images:

Demonstrate bone marrow oedema (red arrow) due to ulnar impaction. In addition there is also partial disruption of the scapholunate ligament (white arrow)

(31)

Ulnar impaction syndrome

Coronal T2W fat saturated and T1W images of the wrist:

Demonstrates subchondral cysts in the proximal lunate (blue arrows) suggestive of ulnarcarpal impaction. There is also TFCC strain and fluid around the meniscal homologue (white arrow)

(32)

Fractures

Coronal T1W and T2W fat saturated images :

Demonstrates a displaced ulnar styloid fracture, marrow oedema (red arrow), and small TFCC radial perforation with fluid in distal radio-ulnar joint (green arrow). Note is also made of

(33)

Fractures

Full thickness TFCC tear with fluid in distal

radio-ulnar joint (red arrow); triquetral

fracture (green arrow)

(34)

Fractures

Patient with known distal radial fracture (left) also had an occult pisiform fracture

(green arrow)

(35)

Synovitis

Axial T1W fat saturated post contrast images in a patient with swollen wrist show florid synovitis and enhancement post contrast (red arrow), there is also extensor carpi ulnaris tendinopathy (black arrow)

(36)

Ganglion

Coronal and axial T2W fat saturated images demonstrate scapholunate ganglion with intra-osseous extension into the lunate ( blue arrow)

(37)

Masses

Left: Pre contrast T1W axial image shows a well defined low signal lesion (red arrow)

(38)

Vascular malformations

Images above show serpiginous (red arrow) lesion with avid enhancement in keeping with an arteriovenous

(39)

Conclusion

• We have shown a number of common

pathologies seen in patients presenting with

ulnar sided wrist pain using 3T MRI, with

arthroscopic correlation where appropriate.

• Contrast may be helpful in situations where

(40)

Conflict of Interest

• Susan Cross: None

• Anshul Rastogi: None

• Brian Cohen: None

• Rosy Jalan: None

Acknowledgements:

References

Related documents

Seismic Retrofit of a Historical Building in Tehran University Museum Using FRP Technology and Steel Jacketing.. Omid Rezaifar 1* , Adel Younesi 2 , Majid

• In RU40 HSUPA Processing Set license allows to reach up to 5.8Mbps and 24 users simultaneously • The HW reservation inside System Module is not reflecting the number of HSUPA

21 Mature stage of convective cloud in second step (The black circle shows the cell who produce heavy

This review article focuses on the existing proteomics-based medicinal plant research and discusses the following topics: (i) plant metabolic pathways that synthesize an array

From the sequence analysis of phage SHPA it is evident that this phage, isolated from the extreme environment sediments of Lake Shala, is a novel phage

This prompted the following model study on patient groups with different diseases, aimed at the develop- ment of a procedure for differential diagnosis, based on analysis of

The eLearning peer creation concept is applied onto two different processes of content creation, with students creating complex Web Based Trainings (WBTs) as well as more

The present study demonstrated that SWCNTs and DWCNTs enhanced the adhesion of THP-1 monocytes to HAECs through the up-regulation of expression of various adhesion molecules. We