In my never ending quest to confuse myself and others…
This wrist is clearly over pronated but very mildly ulnar deviated.
This 33 yr old man has had ulnar wrist pain since 2016 and TFCC surgery in
2018; I don’t have pre-op images, nor do I know if surgery provided any
relief.
TFCC looks intact,
I see post surgical thickening of the extensor retinaculum and, I believe,
the ECU subsheath. The dorsal ulnar groove is flat but I think the ECU is
located.
Can this degree of proximal migration of the Pisiform be Positional??
I’ve included serial Cor images that I believe show intact Piso Hamate and
Piso Metacarpal ligaments.
The ulnar styloid looks long…can that be causing pain if I don’t see
chondromalacia at the base of the triquetrum?
Can you see his Ulnar wrist pain???
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I have recommended comparison XRs…but those may or may not have been done
elsewhere by the referrer.
Hi
Taught to me by a peripheral nerve surgeon- long time ago:
What causes pain- is anyone’s guess!
Rads shouldn’t ascribe a radiological finding to pain
Pisiform is markedly subluxed- nearly dislocated.
Here is an image and video (attached) from one of our old papers- a great case of pisiform subluxation- it was resected and patient did well.
Demehri S, Wadhwa V, Thawait GK, Fattahi N, Means KR, Carrino JA, Chhabra A. Dynamic evaluation of pisotriquetral instability using 4-dimensional computed tomography. J Comput Assist Tomogr. 2014 Jul-Aug;38(4):507-12. doi: 10.1097/RCT.0000000000000074. PMID: 24834894.
Best!
AC
________________________________
Sent: Tuesday, February 9, 2021 1:35 PM
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In my never ending quest to confuse myself and others…
This wrist is clearly over pronated but very mildly ulnar deviated.
This 33 yr old man has had ulnar wrist pain since 2016 and TFCC surgery in 2018; I don’t have pre-op images, nor do I know if surgery provided any relief.
TFCC looks intact,
I see post surgical thickening of the extensor retinaculum and, I believe, the ECU subsheath. The dorsal ulnar groove is flat but I think the ECU is located.
Can this degree of proximal migration of the Pisiform be Positional??
I’ve included serial Cor images that I believe show intact Piso Hamate and Piso Metacarpal ligaments.
The ulnar styloid looks long…can that be causing pain if I don’t see chondromalacia at the base of the triquetrum?
Can you see his Ulnar wrist pain???
[2.jpg]
[1.jpg]
[3.jpg]
[4.jpg]
[5.jpg]
I have recommended comparison XRs…but those may or may not have been done elsewhere by the referrer.
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Thanks Avneesh, for the video—it is a beautiful piece of moving art….and congratulations on the attached reference. In that video, the pisoform seems orthotopic in neutral and extension, which does not mirror what I am seeing in this case.
I consulted with Dr. Luis Cerezal who is an authority on imaging Ulnar Wrist pathology
https://pubs.rsna.org/doi/full/10.1148/radiographics.22.1.g02ja01105
https://www.ajronline.org/doi/full/10.2214/AJR.13.11573?mobileUi=0
While MRI cannot necessarily tell us the pain generator….as we strive to help the patient and the referrer, I believe it makes sense to consider whether or not the imaging pathology is clinically relevant (otherwise we fall into the trap of reporting hip labral tears on absolutely everyone, giving surgeons license to operate on irrelevant “pathology” and us complicit in the crime….but I digress….).
Dr. Cerezal did not have a problem with considering the causes of ongoing ulnar pain in this case….which did not respond to the previous surgery—meaning, that surgery didn’t address the patient’s main problem. There are 2 imaging findings in this case that can contribute to ulnar wrist pain. He confirmed that the degree of proximal migration of the pisiform is definitely abnormal (cannot be positional) And the Ulnar styloid is long…and he pointed out very subtle chondromalacia at the base of the triquetrum.
He shared this, about Ulnar Impaction:
I think that the ulnar pain is related with ulnar styloid impaction (bone marrow edema in the styloid process and subtle chondromalacia at the dorsal aspect of the triquetrum). The clue is Ruby test. Pain in froream supination, wrist extension and ulnar deviation
and an excerpt from his reference (see attached untitled pdf).
He added: The piso-triquetral joint is unstable with a proximal subluxated pisiform and mild osteoarthritis. This can also be the source of pain. It is clear that the pisohamate and pisometacarpal ligaments are failing, either due to rupture, laxity or dysfunction.
The key is the clinical examination to discard abnormal mobility or pain with mobilization of the piso-triquetral joint. I think the ulnar styloid impaction is also part of the ulnar wrist pain in this patient.
And he shared 3 beautiful illustrations of the ulnar wrist anatomy focusing on the capsular and ligamentous structures related to the pisotriquetral joint.
I have heard from a few others that they are similarly challenged by variable MRI wrist positioning …. which is unsurprising, considering we utilize a variety of surface coils, positioning the wrist at the side or prone, superman, often constrained by patient size and condition—certainly at the mercy of the quality and care of the technologists. I do think we would benefit from a standard of proper positioning guidelines, be it for prone superman or wrist by the side in quadrature or flex coil….so that we don’t have to wonder what is real pathology or positional distortion.
Seems it is one attachment at a time
and