Failure to identify torn triangular fibular cartilage in left wrist post-fall in patient with prior TFC tear in right wrist.

The patient is a 60 year old female with a prior history of TFCC injury of the left wrist. TFCC injuries are typically treated initially with conservative management such as bracing, medication, injection, and if all else fails, ultimately surgery is an option. They are very commonly seen on MRI in patients who are advancing in age - as we age, TFCC injuries become increasingly commonplace to see incidentally on asymptomatic individuals. Thus, there is no specific impetus to order an MRI in an acute timeframe even if a TFCC injury is suspected, as it often clouds the diagnostic picture especially in a 60 year old (not clear whether the TFC tear is acute or degenerative [i.e. natural/incidental]) and would likely not change management as there are typically 3-6 months minimum conservative management prior to surgery being considered. The patient asking for an imaging study is not an indication to order it. MRI should be ordered when the treating physician has a question that needs to be answered by the imaging. If the physician already suspected a TFCC tear and/or ulnar positive variance causing chronic wrist pain and TFCC pathology, then the MRI was indeed unnecessary at that time, as the diagnosis was not in question and the properly-indicated treatment was a course of nonsurgical treatment. There would have been no clinical indication for advanced imaging unless nonsurgical treatment for the presumed diagnosis was not working and the surgeon then was planning a possible procedure. MRI would then be indicated for preoperative planning and/or to rule out other unsuspected or concomitant pathology. The patient probably never reached that crossroads with this doctor, as according to these notes, she was discharged due to noncompliance with prescribed therapy. Further, the surgeon who performed her wrist arthroscopy seemingly performed a debridement, and not a repair. This signifies that the tear was more likely a degenerative type of tear than an acute type of tear. This is supported by the concomitant ulnar shortening osteotomy that was performed. The ulnar shortening osteotomy is not something that is needed due to any delay in diagnosis, rather the patient typically would have that done because they anatomically have a longer ulna which can predispose them to ulnar sided wrist pathology. Indeed in this case the notes suggest the patient had ulnar positive variance meaning the ulna is longer than the radius (something they are born with and not an acquired condition). Finally, the subchondroplasty of the olecranon is something that occurs at the elbow and it is unclear whether or how that is even relevant to the wrist injury. It is also not a commonly-performed procedure, especially when done concomitantly with an ulnar shortening and wrist arthroscopy. It demands suspicion that perhaps the surgeon who performed it is rather aggressive. Either that or there is clerical error here.

The patient fell in October 2022 and had a surgery in April 2022 for a chronic condition (ulnar positive variance and TFCC pathology). There is nothing in these notes that suggests that a more rapid timeframe was indicated nor that the patient suffered any harm from this delay, nor is there any reason to believe that is true.

I think there are typos in the patient presentation paragraph. Did the pt have a rotator cuff tear that was repaired or a proximal humerus fracture? And did the pt actually have an olecranon chondroplasty? the olecranon is in the elbow, and there is no mention of elbow it the intial presentation. See below for explanation. This is an acute on chronic situation, the shoulder injury was the most severe and the priority. The wrist was most likely arthritic and aggravated by the fall. The fall did not cause the TFC tear

Eithor way, the majority of the impact was absorbed by the shoulder. Acute TFC tear presents with significant symptoms: swelling/effusion, decreased ROM and pain with supination/pronation that impairs ADLs. It would have been at least as problematic as the shoulder immediatley. At 60 years old , an MRI of non symptomatic pts would show a high incidence of TFC tears by radiology read, these would be chronic and not functionally significant. You did not state how many years prior the other wrist was injured, or what proceedure was performed to remedy the situation. Ulnar variance is set at birth, unless there is a fracture or similiar that changes the lengths of radius and ulna. There fore if this pt required ulnar shortening, it is highly unlikley that the fall created the problem. If the other wrist, years ago, also required ulnar shortening, it REALLY supports a pre exisitng anatomic variant, that chronically can lead to a degenerative tear, not an acute tear. There was also likley a large component of arthritis present, causing the wrist pain and stiffness. The fall can aggravate arhtitis pain,

Failure to diagnose. Incomplete workup of wrist complaints noted. If patient concerns continued, appropriate advanced imaging would have helped to diagnose the proper reason, rather than writing pain off as malingering.

Patient was not properly diagnosed, and therefore, inappropriately managed. Timely and appropriate management would have helped to minimize the injury and sequelae.