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Wrist and Hand MRI Medical Transcription Sample Report

Coronal and axial images were taken using different types of imaging sequencing.

There is no definite bone fracture noted. No focal edema noted, which is persistent. There is a very small amount of degenerative spurring seen at the distal end of the scaphoid but no definite scaphoid or navicular neck fracture is noted, nor is there edema or fractures noted elsewhere. No definite tendon rupture is seen.

The triangular fibrocartilage is intact. No significant joint effusion is noted within the wrist or at the radiocarpal regions.

There is a questionable injury to the area of the radioscaphoid interosseous ligament, which is not definitely visualized on this exam. Also, there is some small edema involving the lateral wrist, which would be approximately in the area of the extensor pollicis brevis location. It does not appear to be a complete tendon tear on this exam, but there could be some injury to that area. The greater and lesser multangulars and the first metacarpal bones are all intact. No chip fracture or definite joint effusion is seen in that area as well.

IMPRESSION:
1. Very small spurring is suggested of the distal end of the scaphoid but no evidence of a definite scaphoid or other bony fracture is noted.
2. Triangular fibrocartilage is intact.
3. Complete visualization of the radioscaphoid interosseous ligament is not seen on this exam and could indicate that this has been partially torn or injured. Also, a small amount of edema is suggested on the radial aspect of the wrist in the area of the expected extensor pollicis brevis tendon. I do not see evidence to suggest a complete tendon tear however.

RIGHT WRIST MRI WITHOUT CONTRAST

DATE OF STUDY:  MM/DD/YYYY

REFERRING PHYSICIAN:  John Doe, MD

INDICATION FOR STUDY:  Evaluate right osteochondroma.

TECHNIQUE AND FINDINGS:  Routine imaging through the distal forearm and wrist was performed without contrast.

There is a focal bony protrusion extending from the distal radius in the volar and radial direction.  It would be consistent with a benign osteochondroma.  The margins are well defined and the substance is equal in signal intensity to the bone matrix of the distal radius.  It extends up to about 1.4 cm from the radius.  It extends out to the flexor carpi radialis and palmaris longus tendons.

On the coronal images, it projects and divides the flexor carpi radialis tendon to the radial aspect of this bony protuberance and the flexor digitorum superficialis tendon to the ulnar aspect.  It divides these tendons, which surround it in their longitudinal course.

We see no tears or indications of tendinitis.  There is a very small amount of edema suggested around the very tip of this osteochondroma.  Other etiologies of this lesion could be an exostosis, though felt less likely.

It does appear to present in a way that tug lesions appear in other parts of the body, but we do not see any attached tendons to suggest that etiology as well.  Most likely, it is a benign osteochondroma.

The remaining aspects of the radius are intact.  We see no lytic or blastic changes to the radius or the ulna.  This small bony protuberance does extend just under the skin and flexor carpi radialis tendon surface.

IMPRESSION:
1.  There is an approximately 1.4 cm bony extension from the distal radius oriented to the volar and radial aspect of the distal forearm.  This extends up to the flexor carpi radialis tendon and appears to divide it from the flexor digitorum superficialis tendon, projecting between these two structures.  A small amount of edema is suggested near the tip of this bony protuberance.  It is otherwise unremarkable in its signal intensity when compared to the remaining radius and bony structures.  The cortex is well maintained with some indistinctness directly at the tip beneath the tendon.
2.  No evidence of tendon rupture or tendinitis is noted.  There is no aggressive component noted to this bony irregularity.
3.  No other remarkable findings are seen.

MRI OF THE RIGHT WRIST

INDICATIONS FOR STUDY:  Fell on outstretched arm.  Evaluated for navicular fracture, radial side pain.

TECHNIQUE AND FINDINGS:  Multiplanar images were obtained without contrast.  In the distal radius, there is a large area of low attenuation on T1 that is high signal on STIR sequences suggestive of a bone bruise/contusion.  There is suggestion of a microfracture along the dorsal aspect of the distal radius on the sagittal images.  There may possibly be some minimal intra-articular involvement.  There is no displacement of fracture fragment.

There is a 5 mm area of low attenuation in the lunate that is round and is along the surface abutting the radius.  This may be a small cyst.  Alternatively, it could represent some focal contusion.

There is another area, 5 mm, in the base of the scaphoid that could be a cyst as it is low signal on T1 and high signal on STIR sequences.  Alternatively, this could be minimal contusion.

However, both of these lesions in the carpal bones are rather round and are more suggestive of cystic-type change.  There is no large fluid collection.

The scaphoid is intact and unremarkable.  Muscle bundles appear preserved.  Tendons are grossly unremarkable.

IMPRESSION:
1.  Large area of edema in the distal radius suggestive of contusion.  There is suggestion of some microfractures as there is a linear line along the dorsal aspect of the distal radius on the sagittal images.  This line may possibly involve the articular surface.  This is difficult to completely identify with certainty.  On the coronal images, the break in the cortex may be along the radial aspect of the distal radius.  Followup plain films may be of value to determine if there is callus formation.
2.  There are a couple of cystic areas in the scaphoid and lunate that probably represents cysts.  These less likely represent focal areas of contusion or edema.
3.  No large fluid collection.  Muscle bundles and tendons are grossly unremarkable.

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