Buerger's Disease And Avascular Necrosis Of The Scaphoid

Abstract

HISTORY: 58 year old right-hand dominant, who comes in today for evaluation of her right wrist. She awoke 1.5-2 years ago one morning with pain. Denies any trauma or falls. She saw her PCM for what was presumed to be carpal tunnel syndrome, and was supposed to be sent to a specialist; however, this did not happen. Not seen again until late July 2020 with another provider. She reports intermittent pain but predominantly stiffness and limited flexion of her wrist. Cannot lift objects heavier than a gallon of milk. Reports carpal tunnel surgery in the same wrist in 1985. Reports a 24 pack-year history and is actively trying to quit. PHYSICAL EXAMINATION: Examination revealed swelling overlying the distal radius. Flexion of the right wrist was limited to 10 degrees, and extension was limited to 45 degrees. She demonstrated normal function of the FDS/FDP/FHL tendons, along with all of her extensor tendons. Sensation to light touch was in-tact in the median, radial, and ulnar nerve distributions. DIFFERENTIAL DIAGNOSIS: 1. Avascular necrosis of the scaphoid 2. Severe osteoarthritis of the radioulnar joint 3. Scapholunate dissociation TEST AND RESULTS: XRay of the right wrist-Chronic scaphoid avascular necrosis. MRI of the right wrist without contrast 1. Fragmentation, flattening, and partial collapse of the sclerotic edematous scaphoid, with mild volar flexion, with possible chronic osteonecrosis. 2. Severe osteoarthritis at the radiocarpal joint with high-grade cartilage injury, synovitis, capsular sprain, and small volar ganglion cysts. 3. Chronic appearing scarring and degeneration of the scapholunate ligament and TFCC. 4. Mild tenosynovitis and mild tendinosis of the tendons within the first and second extensor compartments. FINAL/WORKING DIAGNOSIS: Avascular necrosis of the scaphoid as a result of Buerger's Disease TREATMENT AND OUTCOMES: 1. Smoking cessation 2. Celestone injection of the scaphoid by Ortho-Hand Surgery 3. Thumb spica splint 4. Follow-up as needed