What’s the Diagnosis – Case 130
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Findings The ulnoluate (UL) ligament is intact as is the volar radioulnar ligament (VRUL). There is T2 hyperintensity along the longitudinal axis of the ulnotriquetral (UT) ligament and a small flap of low signal tissue is interposed between the TFCC articular disc (which is intact) and the triquetrum. Mild findings about the ECU were not clinically relevant.
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Diagnosis: Complex tear UT ligament with longitudinal and distal components As compared to many of the cases that have been presented this is somewhat more of an eye test and also a test of some rather detailed and intricate anatomy. The TFCC is a complex structure which when injured can produce pain, tenderness to palpation, and/or instability about the distal radioulnar joint (DRUJ). Particularly along the volar aspect of the TFCC there is the VRUL. The UL and UT ligaments extend from the VRUL to the lunate and the triquetrum, respectively. Additionally, there is a slightly more superficial ulnocapitate ligament which is not germane to this case. The UL ligament runs in a direct fashion between the VRUL to the lunate where as the UT ligament runs in a more oblique fashion. Injuries of the TFCC are typically classified as traumatic (Palmer I) injuries or degenerative (Palmer 2) injuries. The traumatic type injuries are varied and frequently associated with findings of instability of the DRUJ. One of the Palmer I injuries is a distal disruption that involves a distal disruption of the ulnolunate and/or ulnotriquetral ligaments.
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Diagnosis: Complex tear UT ligament with longitudinal and distal components More recently, there has been description of a longitudinal tear of the UT ligament (along the long axis of the ligament) which may produce pain but is not typically associated with DRUJ instability. On arthroscopy these injuries are typically associated with prominent synovitis which once removed, reveals the longitudinal split within the UT ligament. In this case there was the longitudinal component accounting for the T2 hyperintensity of the ligament but also a small, distal disruption accounting for the small flap that was interposed between the triquetrum and the TFCC articular disc. At the time of surgery there was prominent synovitis about the TFCC and the flap was found and resected.
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References MR imaging of the traumatic triangular fibrocartilaginous complex tear. Ng AWH, Griffith JF, Fung CSY, Lee RKL, Tong CSL, Wong CWY, Tse WL, Ho PC. Quant Imaging Med Surg. 2017 Aug;7(4):443-460. doi: 10.21037/qims.2017.07.01. Utility of magnetic resonance imaging for detection of longitudinal split tear of the ulnotriquetral ligament. Ringler MD, Howe BM, Amrami KK, Hagen CE, Berger RA. J Hand Surg Am. 2013 Sep;38(9):1723-7. doi: 10.1016/j.jhsa.2013.05.040. Epub 2013 Jul 30. Longitudinal split tears of the ulnotriquetral ligament. Tay SC, Berger RA, Parker WL. Hand Clin. 2010 Nov;26(4):495-501. doi: 10.1016/j.hcl.2010.07.004.
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