Wrist and Hand Pathology

Wrist and Right Hand Pathology – additional opinion
Short Summary

47-year-old male has injured his right wrist while playing football 30 years ago. He always had some manageable pain while playing tennis. The pain increased during the last 12 months. The wrist CT scan that the expert recommended revealed diastasis between scaphoid and semilunar bone, palmar dislocation, dorsal intercalated segmental instability (DISI), marked radio-scaphoid arthritis and reactive sclerosis of the subchondral bone. This findings conformed the previous diagnosis of post traumatic osteoarthritis of radio-carpal joint brought upon by ligamentous injuries due to trauma.

Patient's Questions

In the light of this further examination the patient asked the following questions:
1. Do you confirm the diagnosis?

2. What therapy could you advise?

3. Prognosis?

4. Centres of excellence in Italy or in Europe?
 

Medical Background

47 yrs, male , Italy
Diagnosis: Pathology of the Wrist and Right Hand.

“Except the NMR I do not have any other medical information , I had it done because my wrist got worse during the last few months .

What has happened has been a trauma many years ago, probably 30, playing football I felt with my face ahead and I felt on my hands to try to stop the fall.

I had pain to my wrist and I had to stop playing tennis for a period , I have been playing tennis all my life and since that fall I always had some pain but still manageable.

During the last few years the pain has been increasing until the point during the last 12 months where I am not able to play almost anymore and this is why I asked to check what was going on.

I love sports , not only tennis, but I am having now also issues with weights (even though I am not using heavy stuff) and I would like to know if there is a chance to get it fixed or if I just have to live with that.

I also noticed that now it is bothering me even when I swim, which has never happened before.

I don’t really have a strong pain if I don’t use the wrist by the way, I feel it just stiff.

By the way, I don’t know what type of clinical data are needed here, if I know I can get some tests done I guess.

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Wrist NMR findings:
Wrist-hand NRM exam performed on 06/2009, the finding of which states: “Right wrist Diastasis between scaphoid and semilunar bone in agreement with a lesion of the scapholunate ligament; it is associated with a palmar dislocation and a dorsal angulation of the semilunar bone (DISI). Pronounced radioscaphoid arthrotic manifestations with a marked decrease of breadth of the articular rim and reactive edema of the spongy bone on the opposite articular sides have been found. Presence of articular perfusion mostly on the dorsal ulnar side of the wrist. The triangular fibrocartilage keeps the morphology normal and shows moderate lack of homogeneity of signal without evident fractures. Presence of a small bone core on the dorsal side of the wrist, located between the capitate head and scaphoid. Lesions sustained by the regional tendon components are insignificant. Pathological expansions of the soft tissues are insignificant, and in particular images of cystic formations.

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Previous Answer
It seems that the patient who is 47 years old now, has injured his right wrist while playing football 30 years ago. Over the years, up until now, he was never examined by a specialist and no investigation such as x-rays was performed although the wrist was painful on sport activities. The pain increased during the last 12 months, and following this, MRI studies were performed on June 2009.

It seems that the patient is suffering from post traumatic osteoarthritis of radio-carpal joint brought upon by ligamentous injuries due to trauma. Since according to the description the arthritic changes are well advanced, there are two possible solutions, both of them involving surgery:

1. Total wrist joint replacement using an artificial joint. This operation preserves wrist motion and diminishes the pain, however the grip strength will decrease and strenuous physical activities such as tennis playing might not be possible.

2. Another viable option is wrist fusion - procedure which will give a stable wrist and preserve most of the strength as a trade off to motion.

I would like to see wrist x-rays and CT scan on top of the MRI studies to consolidate my opinion.

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The previous expert thought it was useful to carry out a wrist CT scan in order to integrate and complete the previous Magnetic Resonance.

Following this advice, the patient underwent a CT scan examination of the right wrist on 08/2009 with the following report: “Survey carried out according to axial planes, completed with reconstructions according to coronal and sagittal planes and 3D reconstructions. Diastasis between scaphoid and semilunar bone, linked to a lesion of the scapholunate ligament; a palmar dislocation and a dorsal intercalated segmental instability (DISI) is connected. There are proofs of marked radio-scaphoid arthritis with clear reduction in the width of the articular rima and reactive sclerosis of the subchondral bone. Small bone cores are placed on the dorsal wrist, between the scaphoid and the capitate head. Neither focal structural abnormalities in progress nor abnormalities due to actual trauma involving the skeleton elements are observed."

 

Expert's Opinion

The current report is an update on my previous letter, following additional information (CT scan of the injured wrist). The enclosed CT scan confirms my previous diagnosis and consolidates my opinion as expressed in my first report.

The treatment I recommended in my first report is viable.

I am not familiar with centers in Italy dealing with this kind of injury, but there are several centers in Europe – particularly several hand surgeons in Paris, France, dealing with this kind of injury.
 

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