I thought I would start a thread specifically between us to try and refrain from breaking the continuity in both our own discussion and that of the persons within their own posting. I'm sure the proctors will be grateful.
I recommended an arthrography because you previously mentioned that she had already underwent an MRI with negative findings. I would, at some point, considered something like an early osteonecrosis of the lunate that can produce pain like sprained wrists and yet indicate negative imaging results, but whether this could present itself bilaterally would not be within my realm of experience.
The tricompartmental arthrography is naturally a three-injection technique, with infiltration into the radiocarpal, midcarpal, and distal radial-ulnar joints. Bilateral tricompartmental arthrography is often recommended because bilateral intercarpal communications are not uncommon. With this test, we're looking for damage to the ligaments that would typically not be revealed with other imaging studies.
I suppose the concern here would be that prior to arriving at a diagnosis of exclusion, it would be warranted to obtain the arthrography to determine the patency of the ligaments which could characteristically produce bilateral wrist pain subsequent to insult.
If the arthrography does not yield positive results, then combined with the negative MRI, you may well have greater support for the diagnosis of conversion, although again I will share with you that I've never encountered such a presentation. But then again, I am without question not the repository for all things encountered in the world of medicine to be certain.
I hope that helps to offer some direction. Please let me know how things proceed and I'm glad to hear that you joined Medscape. I very much enjoy it because it provides access to the broadest spectrum of literature, research and updates that I've encountered. You can also keep up your CME credits to some extent if you're still in practice. It's just a safe haven for old birds like me.
J Cottle, MD
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