Ulnar Wrist Mass, Large But Not Giant

Abstract

HISTORY: An active 60 year old complained of a mass on the volar ulnar side of the right wrist. First appeared seven months prior and continued to grow in size. Initially symptoms were aching pain, decreased grip strength and reduced wrist flexion interfering with physical activity and work. One month later they developed ulnar side numbness. PHYSICAL EXAM: Soft non discrete, non pulsatile mass off the volar ulnar side of the wrist deep to the FCU tendon. No atrophy. Able to fully flex and extend fingers. Weakness with wrist extension and little finger extension. TFCC load test negative. Froment’s sign negative. Light touch sensation grossly intact. DIFFERENTIAL DIAGNOSIS: Triangular fibrocartilage complex cyst, Ganglion Cyst, Tenosynovial giant cell, tumorfibroblastic/myofibroblastic lesion. TEST AND RESULTS: Wrist frontal, lateral and oblique radiographs: No underlying osseous abnormalities. Focal soft tissue bulge along ulnar aspect of the wrist. No underlying erosion. No gas or radiopaque foreign body. Wrist MRI: Mass within the volar and medial soft tissues of the wrist from the level of the distal ulnar epiphysis to the proximal aspect of the pisotriquetral articulation causing a mass effect and displacement of the adjacent ulnar neurovascular bundle. The mass demonstrates low signal intensity on T2 FS and T1. Excisional Biopsy: benign paucicellular fibrocollagenous proliferation. FINAL DIAGNOSIS: Benign fibroma of tendon sheath. TREATMENT AND OUTCOMES: Surgical excision of the volar ulnar wrist mass. The ulnar neurovascular bundle was displaced radially due to the mass. The homogeneous mass measuring 3 x 2.8 x 1.5 cm was removed in one piece and sent to pathology. At the 2 week follow up, the patient was fitted with a customized thermoplastic volar hand, wrist and forearm based orthosis since OTC DME splint would not fit with the proximal end being over the surgical site. At 4 weeks post op, the patient was doing very well and beginning to wean out of the wrist brace.