Hypertrophic synovial plica in the radiohumeral joint

Clinical History

A 53-year-old male patient presented with painful right elbow snapping for one year without any improvement by conservative treatment. Clinical examination of the diseased elbow revealed visible snapping during flexion-extension of the pronated forearm.

Imaging Findings

Plain radiography of symptomatic right elbow demonstrated absence of loose bodies, progressed osteoarthritis and joint dislocation.

The patient underwent magnetic resonance imaging (MRI), which confirmed the presence of thickened posterolateral fold with increased cross-sectional area and heterogeneous signal intensity (Fig. 1, 2, 3 and 4). Areas of signal abnormality in the subcortical bone of the adjacent capitellum and in the radial head were also seen (Fig. 5).

Discussion

BACKGROUND:
The symptomatic radiohumeral plica is an infrequent cause of lateral elbow pain. Synovial plicae are thought to be embryological remnants of the normal articular development, and are usually asymptomatic. Plicae can cause clinical symptoms when they become hypertrophied due to direct blow or repetitive microtrauma [1-5].

CLINICAL PERSPECTIVE:
Clinically, patients may present with pain and mechanical symptoms, including locking and snapping. These patients are usually diagnosed with lateral epicondylitis and the diagnosis of elbow synovial plica syndrome may be only established after failure of conservative treatment [1-5].

IMAGING PERSPECTIVE:
MRI is the preferred imaging technique for the investigation of elbow pathologic processes. MRI enables an accurate evaluation of hypertrophic synovial plicae, articular cartilage and associated injuries. T2-weighted and fat-sat MR images are especially helpful for the evaluation of plicae, which are characterized by thickening, greater than 3 mm, and irregular appearance. MRI is also used to evaluate synovitis and chondral lesions in the radial head and capitellum [1, 2].
MR arthrography assures the visualization of hypertrophic plicae and chondromalacia of the radial head and capitellum in patients without joint fluid [1].

OUTCOME:
Initially, nonsurgical treatment, including rest, physiotheraphy and nonsteroidal antiinflammatory agents. Failure of conservative therapy leaves arthroscopic debridement of the pathologic plica and physical therapy, leading to excellent outcomes [1, 2, 3].

TEACHING POINTS:
Hypertrophic synovial plica in the radiohumeral joint represents an embryological remnant of a synovial membrane. It is a rare cause of lateral elbow impingement, therefore it is usually misdiagnosed. Arthroscopic intervention should not be delayed by prolonged conservative treatment and leads to excellent outcomes.

Differential Diagnosis List

Final Diagnosis

Hypertrophic synovial plica in the radiohumeral joint.

URL:	https://www.eurorad.org/case/12247
DOI:	10.1594/EURORAD/CASE.12247
ISSN:	1563-4086