Case of the Month
 
 
Clinical History
 

 Case of the Month

Patient presented with ulnar sided  wrist pain

 

 

MRI WRIST : Clinical reference from consultant

Ulnar pain

Radial side pain

Look for TFCC

Ulnar collateral ligament

Extensor carpi Ulnaris


 

 

 

– Courtesy,

 
 Dr. Rajendra Solanki MD ( Consulting Radiologist, Suyog Imaging Centre, Mahesana & GIC-PGIR, Ahmedabad )

Dr. Drushi Patel

Dr. Ankur Shah

Dr. Brijesh Gajjar

 

 

 

   
Dr. Rajendra Solanki MD
Consulting Radiologist
Suyog Imaging Centre, Mahesana
Radiscan diagnostics, Ahmedabad.
 
Governing body member, ICRI
Treasurer,  Gujarat State Chapter, IRIA
 
+91 9924204697
 
 
 
 

  

 

 
ANSWER

  Important MRI sequences:

 Position:

Ø Wrist in pronation with fingers held in extension.

Ø Long axis of distal radius & central metacarpal   axis should be in alignment.
 

 

Sequences:

1)  FS PD TSE - Axial

2)  FS PD TSE - Coronal

3)  FS PD TSE - Sagittal

4)  T1  TSE Coronal

5)T2  TSE Coronal

6)T2 TSE Axial

7) GRE/IR coronal (Particularly for TFCC and Intrinsic ligaments)

 

TFCC Anatomy

Coronal FS PD & T2W images are important.

à TFCC complex:     - Dorsal Radioulnar ligament.

                                   - Volar Radioulnar ligament

                                  - Central disc of TFC

                                 - Extensor carpi Ulnaris sheath

                                 - Ulnolunate ligament

                                 - Ulnotriquetral ligament

                                

Diagnosis:

    - TFCC 1B Type Tear 

       Ulnar avulsion  without distal ulnar fracture

       As per palmer Classification

 

 

I B – subdivision significance for reporting 

Tear of distal lamina at ulnar styloid process – conservative treatment –  Above elbow cast for 6 weeks  in supination position.

 

Tear of proximal lamina at foveal attachment – requires surgery

 
 

Arthroscopic repair     

OR

Surgical repair

 

Palmar Classification:

 

Class I (traumatic)

Class II (Degenerative)

Class IA -  Tear of TFC disc

                    Proper

IIA – TFC complex wear

IB – Ulnar avulsion with or

Without ulnar styloid fracture.

IIB – TFC complex wear with

lunate and / or ulnar

Chondromalacia

IC – Asso. Tear of ulnolunate ligament or ulnotriquetral ligament

 

IIC – TFC complex perforation

with lunate and / or ulnar

chondromalacia.

ID – Radial avulsion at the level of distal sigmoid notch with  or without associated fracture

IID – as above + ulnotriquetral

ligament perforation

 

IIE – IID + ulnocarpal arthritis


 

 

Important Differential Diagnosis

 

ECU ( extensor carpi Ulnaris tendon )     

Tendinosis

Tenosynovitis

Subluxation

Ulnar collateral ligament injury

 

Potential Pitfalls

Normal variation in TFCC signal intensities and morphology.

 

Striation within the triangular ligament and ligamentum subcruentum (space between proximal and distal lamina of the ligament) often demonstrate increased internal signal intensities. These should not be misinterpreted as tears.

 

TFCC degeneration manifest as increased signal intensities without

extension to the articular surface. It should not be confused with a partial tear.

 

Perforation of the TFCC central portion may be found in normal asymptomatic subjects. Prevalence of perforation increases linearly with age.

 

Proximal lamina of the triangular cartilage has relatively high signal intensity, and should no be misinterpreted as a partial tear.

 

 

 

• The prestyloid recess is a synovium lined pouch bordered by meniscalhomologue distally, the TFCC attachment to ulnar styloid proximally and central TFCC disk radially.

 

The recess may appear in different shapes: saccular, tubular and conical. Again, it should not be confused with a tear.

 

• Supination and pronation of the wrist may result in a thinner appearance of the TFCC.

 

 

 

 

 

 

 
 
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