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Case 350

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Male patient, 23 years old, complains of pain in the right hand during extension and flexion of the wrist, in the last 15 days. He associates it with the fact that he slept with his head lying on the palm of his hand. At the physical examination: light edema and pain during the palpation of the scapholunate region of the right hand, associated with limitation of the extension and flexion of the ipsilateral wrist. Plain radiograph of the right hand and wrist without alteration, complementary Magnetic Resonance Imaging (MRI) requested.

Considering the clinical history and the images presented, what are the most likely diagnosis and mechanism of this kind of lesion?

a) Complete lesion of the scapholunate ligament; hyperextension + axial load + ulnar deviation

25%

b) Incomplete lesion of the scapholunate ligament; axial load

25%

c) Complete lesion of the scapholunate ligament; hyperextension + axial load

25%

d) Incomplete lesion of the scapholunate ligament; hyperextension + axial load + ulnar deviation

25%
   

Image Analysis

 

Image 1: T1-weighted MRI, coronal view of the right wrist. Compromised insertion of the intrinsic volar scapholunate ligament at the proximal pole of the scaphoid, characterized by small edema (green arrow) and small cyst in the adjacent bone marrow (yellow arrow). The alignment of the carpal bones is preserved.

 

Image 2: T1-weighted MRI, axial view of the right wrist. Compromised insertion of the intrinsic volar scapholunate ligament at the proximal pole of the scaphoid, enhanced after intravenous injection of contrast (gadolinium) (yellow arrow).

 

Image 3: T1-weighted MRI, coronal view of the right wrist, showing dorsal component of the scapholunate ligament intact (yellow arrow).

Highlights

  • - The scapholunate ligament can be injured when subjected to prolonged hyperextension;

  • - Plain radiography does not discard incomplete lesion of the scapholunate ligament;

  • - Asymmetric increase of the scapholunate space and lost of the parallelism between the articular surfaces of these structures characterize complete lesion at plain radiograph;                 

  • - The Watson test is a good test at the evaluation of the scapholunate ligament integrity;

  • - In the acute phase of the complete rupture, the surgical treatment is indicated.

References

- Canale S. Cirurgia ortopédica de Campbell. 10ª edição. Barueri, São Paulo: Manole, 2007;

- Filho T, Camargo O, Camanho G. Clínica Ortopédica. 1ª edição. Barueri, São Paulo: Manole, 2012;

-  Harrmann LGC, Rodrigues MB, Müller IS, D'lppoliro G, Rocha AJ. Musculoesquelético – Série Colégio Brasileiro de Radiologia e Diagnóstico por Imagem. 1ª edição. Rio de Janeiro: Elsevier, 2014;

- Boggess BR. Evaluation of the adult with subacute or chronic wrist pain. In: UpToDate, Post, TW (Ed), UpToDate, Waltham, MA, 2014;

- Manuel J, Moran S. The Diagnosis and Treatment of Scapholunate Instability. Hand Clinics. 2010; 26(1):129-144.

Author

Fernando Henrique Amorim Melo Pinto, 5th year medical student at Universidade Federal de Minas Gerais. 

E-mail: 12fernandoamorim[at]gmail.com

Supervisors

Gustavo Pacheco, orthopedist specialized in hand surgery. Orthopedic preceptor at HC-UFMG.
E-mail: gustavopmf[at]yahoo.com.br

 

Diego Correa Andrade, radiologist at HC-UFMG.

E-mail: diegocorreaandrade[at]gmail.com

Reviewers

Bruno Campos, Guilherme Carvalho, Daniela Manso, Professor José Nelson M. Vieira, Professor Viviane Santuari Parisotto Marino.

Translated by

Gabriella Yuka Shiomatsu, 4th year medical student at Universidade Federal de Minas Gerais.

E-mail: gabriellashiomatsu[at]gmail.com

Test question

(PUC-PR - 2012) The scaphoid structures with worst prognosis are related to consolidation and development of complications that occur on:

a) The distal third and present horizontal oblique trace

25%

b) The proximal third and present transverse trace

25%

c) The distal third and present vertical oblique trace

25%

d) The distal third and present transverse trace

25%

e) The proximal third and present vertical oblique trace

25%
   

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