What’s the Diagnosis – Case 220
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What’s the Diagnosis – Case 220
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Findings The radiographs show no abnormality and particularly no fracture. On the MRI, along the volar aspect of the PIP of the small finger there is a focus of proximally displaced soft tissue and fluid of the volar recess of the PIP of the small finger. The adjacent pulleys and flexor tendons are intact. There is a thickening of both collateral ligaments of the small finger PIP but they are intact. No recent osseous injury is present.
What’s the Diagnosis – Case 220
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Diagnosis: Volar Plate Rupture A well recognized but still poorly understood entity with necrosis and collapse representing the end stage of the pathology. The reasons for the necrosis are likely multifactorial and relate to the anatomy of the wrist inclusive of ulnar variance and the anatomy of the vasculature to the lunate. Other inflammatory, biological processes and overuse/trauma also likely play a role in the development of the necrosis. The disease manifests by sclerosis of the lunate followed by collapse and fragmentation. This is then followed by abnormal orientation of the scaphoid in a palmar flexed position and then adjacent arthritis. These latter processes were not the focus of this case presentation. The MRI will show areas of low signal on all pulse sequences indicating the areas of devitalized bone. The foci of slightly increased signal are in keeping with areas of maintained perfusion and highlight the variable architecture and findings of Kienbock’s. The fragmentation and collapse of the bone are seen well on both CT and MRI. This case highlights the need for knowing and understanding the detailed anatomy of the hand and fingers. Multiple, small structures are present and the intricate, complicated anatomy is difficult for most of us. In this case, having a “control finger” with the ring finger to show the normal anatomy of the volar plate was very helpful in making the injury of the volar plate at the small finger PIP much more conspicuous. This technique is often very helpful particularly with detailed anatomy in areas which may not be as familiar to us as many other areas of the body.
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