Topic 4 hand and wrist Flashcards
(82 cards)
1
Q
What is tenosynovitis?
A
Inflammation of the synovial lining of tendon sheath
• can occur in any single or group of tendons
• is a common problem of the hand
2
Q
What are the clinical signs of tenosynovitis?
A
tenderness, swelling, and pain on specific movements
3
Q
What are the causes of tenosynovitis?
A
o repetitive over use o rheumatoid arthritis o gout o amyloidosis o and infection.
4
Q
How does tenosynovitis appear on ultrasound?
A
o tendon sheath fluid and/or debris o nodularity o sheath thickening. o tendinopathy o Colour Doppler may show increased flow in the thickened synovium.
5
Q
What can happen if the tendon itself becomes involved in tenosynovitis?
A
o When the tendon becomes involved in this process and develops a tendinosis, tears of tendon fibres and even rupture may follow.
6
Q
What can persistent swelling of the knuckles indicate?
A
• the possibility of tenosynovitis of the extensor tendons.
7
Q
How does extensor tenosynovitis appear on ultrasound?
A
increase in the peritendinous fluid and minimal thickening of the tendons
• A comparison with the opposite side at the same level is crucial for the diagnosis.
• It is easier to demonstrate a sliver of fluid than a thickened tendon in the synovial sheath.
• Comparative transverse scans of the metacarpal heads will show a tendinous asymmetry
8
Q
What is De Quervain tenosynovitis ?
A
- A type of tenosynovitis
* involves the abductor pollicis longus and the extensor pollicis brevis tendons in compartment 1.
9
Q
How does De Quervain tenosynovitis present clinically?
A
• The patient complains of pain specifically over the radial styloid, worse with thumb movements, sometimes with swelling localised to the styloid.
10
Q
How does De Quervain tenosynovitis appear on ultrasound?
A
o fusiform tendon swelling and thickening of the tendon sheath at the level of the radial styloid
o increased synovium, usually around APL, +/- swelling of tendon.
o Anomalies of this first compartment may include the APL having multiple slips.
o The APL/EPB may also have separate sheaths which is very useful if steroid injections are considered in the treatment protocol.
o In the chronic stage, there is thickening of the tendon and synovial sheaths, with formation of cysts and nodules
11
Q
What causes De Quervains tenosynovitis?
A
Repetitive over use
12
Q
What is trigger finger?
A
- locking of a digit in a flexed position
- usually caused by a stenosing tenosynovitis at the level of the A1 pulley on the volar aspect of a metacarpo-phalangeal joint.
13
Q
How does trigger finger appear on ultrasound?
A
o tendon thickening
o synovial sheath fluid and thickening
o small peritendinous cysts.
o The tendon proximal to the restricting lesion may appear to buckle slightly, with flexion.
14
Q
What is a stener lesion?
A
- occurs with rupture and displacement of the ulnar collateral ligament at the metacarpophalangeal joint of the thumb during a hyperextension injury to the thumb.
- It is also known as ‘gamekeeper’s thumb’ or ‘skier’s thumb’.
15
Q
How does a stener lesion appear on ultrasound?
A
- With complete tears, the displaced UCL is seen as a linear echogenic structure that is redundant and retracted with a hypoechoic hematoma surrounding the redundant margin
- An avulsed fragment is seen as a small hyperechoic structure.
- With incomplete tears, the UCL may be markedly thickened but in a normal position
16
Q
What is a scapholunate ganglia?
A
- actually arise from the dorsum of the wrist.
* The ganglion cyst penetrates through the scapholunate ligament and communicates with the joint.
17
Q
How does a scapholunate ganglia present clinically?
A
- Ganglia can present as large and asymptomatic firm masses
* or small and painful non-palpable masses
18
Q
What is the typical ultrasound appearance of a ganglion?
A
o Noncompressible
o Anechoic
o well defined
o with acoustic enhancement.
o Debris or thin septae may be present in the cyst.
o Ganglions can arise from many locations remote to the scapholunate ligament
o and are thus a differential diagnosis for many types of wrist pain.
19
Q
What is intersection syndrome?
A
- A type of tenosynovitis
- occurs at the site where abductor pollicis longus and extensor pollicis brevis cross extensor carpi radialis longus and brevis at the distal radius.
- It is also known as ‘Rowers’ Syndrome’ due to the incidence of this condition amongst rowers.
20
Q
What can intersection syndrome be confused with?
A
De Quervains tenosynovitis
21
Q
What is carpal tunnel syndrome?
A
- neuropathy
* involves a compressive mass effect to the median nerve at the level of the carpal bones
22
Q
What is the clinical presentation of carpal tunnel syndrome?
A
- patients present with hand pain
- often worse at night and reproducible with certain movements
- numbness in the thumb and second and third fingers.
23
Q
What can cause carpal tunnel syndrome?
A
• Any lesion that reduces the size of the carpal tunnel may lead to this syndrome • that is o flexor tendon tenosynovitis o ganglia o tumours o fractures o during pregnancy
24
Q
What is the clinical test for carpal tunnel syndrome?
A
Tinel’s sign for CTS - extend the hand and tap over the median nerve to produce tingling and altered sensation in the thenar muscle group and the digits one to three.
25
How does CTS appear on ultrasound?
* you need to exclude the above listed conditions as a cause of CTS
* and also to measure the median nerve at the level of the pisiform in a cross-sectional dimension to look for enlargement.
26
What are the normal measurements for the median nerve at the wrist crease?
The average measurement was shown to be 8.3 mm2 in men and 9.3 mm2 in women.
A cross sectional area of greater than 15 mm2 corresponds to an abnormal EMG and this is an appropriate criterion for diagnosis of an enlarged median nerve.
27
What is dupuytren contracture?
* palmar fibrosis
| * resulting in the deposition of nodules on the palmar aponeurosis.
28
What causes dupuytren contracture?
* Trauma is often an inciting factor
| * genetic predisposition, diabetes, alcohol abuse, and barbiturate treatments also contribute
29
How does dupuytren contracture appear on ultrasound?
* These nodules can be quite evident on ultrasound orientating along the pathway of the tendons.
* They are generally hypoechoic or isoechoic.
30
What is ulnar nerve compression of the wrist?
* Entrapment occurs at Guyon's canal
| * the nerve passes between the pisiform and the hook of the hamate, and the pisohamate ligament.
31
How does ulnar nerve compression of the wrist present clinically?
• Compression of the nerve will result in a hypothesia of the medial one and a half digits.
32
What does ulnar nerve compression of the wrist look like on ultrasound?
* Neuropathy will be evident as hypoechoic enlargement of the nerve.
* Anomalous muscles and muscle slips can cause classic neurological symptoms in this region when they hypertrophy
33
What is a clinical differential for a wrist ganglion?
• Differential diagnosis to occult ganglion is a Carpal boss, a developmental anomaly of the 2nd metacarpal base, which presents as a lump on the dorsum of the wrist, very close to the scapholunate joint.
34
What is important to try and demonstrate when you suspect a ganglion?
to try and demonstrate a neck leading back to the joint
35
What is jackhammer syndrome?
Ulnar artery thrombosis
• The ulnar artery in the proximal wrist can become traumatised by repetitive contact with the carpal bones
• specifically the hook of the Hamate
• It can thrombose or form an aneurysm- either way it increases in size, and compresses the ulnar nerve or one of its branches.
36
What are some causes of jackhammer syndrome?
using jackhammers, cycling, using the hypothenar eminence as a hammer, and fracturing the hook of Hamate
37
How do patient with jackhammer syndrome present clinically?
• Patients complain of diffuse pain with occasional paresthesia along the hypothenar region.
38
What does jackhammer syndrome look like on ultrasound?
• Sonography shows the ulnar artery in the Guyon’s canal to be distended with a hypoechoic thrombus, with no flow on Doppler study
39
What are two neoplasms you may encounter at the wrist?
Schwannoma and giant cell tumour
40
What are wrist schwannomas?
benign neural tumours, and arc characteristically eccentric in position.
• Like neurofibromas they contain low-level echoes
41
How might a patient with ulnar nerve schwannoma present clinically?
• This ulnar nerve schwannoma gave the obvious clinical symptoms of parathesia and/ or "pins and needles" in the last two digits because the canal's contents are increased, this compromises the nerve
42
How do giant cell tumours of the tendon sheath appear on sonography?
hypoechoic solid masses with well-defined margins, usually close to the flexor tendons.
• Unlike ganglia, these tumors have internal echoes and lack posterior acoustic enhancement.
• Doppler sonography can show internal vascularity
43
What is a differential for a giant cell tumour of the tendon sheath?
fibroma
44
What is a subungual glomus tumour?
It is a tumour that occurs on the dorsal aspect of the distal phalanx at the nail bed
45
How does a subungual glomus tumour appear on ultrasound?
Hypervascular
bony erosion of the underlying cortex
asymmetric thickening of the nail bed when compared to the other side
46
What is Disruption of the finger flexor (annular) pulley system ?
* a recognized injury in elite rock climbers
* involves disruption of the A2 pulley of the fibrous retinacular sheath that arises from the distal end of the base of the proximal phalanx and extends 20 mm toward the proximal interphalangeal joint
* A tear of the A2 pulley results in volar subluxation of the flexor tendons
47
What does Disruption of the finger flexor (annular) pulley system look like on ultrasound?
increased distance between the volar cortex of the proximal phalanx and the flexor tendons
• becomes more pronounced on active finger flexion (bowstringing)
48
What is an important differential when investigating a ?traumatic ganglion?
aneurysm
49
What is a frequent result of penetrating injury to the palm?
Pseudoaneurysm
50
How does a pseudoaneurysm of the palm appear on sonography?
```
pulsatile and tender cystic lesion
painful when compressed
high-resistance flow
hypoechoic material within it.
These lesions are frequently located in the mid-palmar area, involving the superficial palmar arch.
```
51
What may you see surrounding a foreign body?
Hypoechoic granulomatous change
52
What can appear sonographically after a foreign body has ben in situ a couple days?
marked cellulitic change in the soft tissue seen as diffuse hyperechoic change
At times this can become attenuative and appear as a snow storm.
53
List the different nerve entrapments that can occur at the elbow
Posterior interosseus nerve entrapment aka radial tunnel syndrome (anterior) (radial nerve)
Pronator teres syndrome (medial) (median nerve)
Cubital tunnel syndrome (posterior) (ulnar nerve)
54
Explain some dynamic techniques used in the hand, wrist and forearm
* You may need to place the hand and wrist in a flexed position to better demonstrate a ganglion at the scapho-lunate joint.
* Often ulnar deviation will help in the examination of structures at the snuff box, that is, the APL and EPB tendons, or when looking for an occult scaphoid fracture.
* A history of clicking may be associated with carpal instability, triangular fibrocartilage tears, or extensor carpi ulnaris subluxation.
* To show this type of subluxation you will need to perform flexion and extension with radial deviation.
* To help you identify the median nerve, you can ask the patient to wriggle their fingers and watch the movement of the flexor digitorum superficialis and profundus. The median nerve will not move with them.
* 'Climber's finger' is a flexor tendon pulley (A2) rupture. On ultrasound 'bowstringing' of the flexor tendon during resisted contraction is seen, indicating a rupture of the pulley or annular ligament that would normally keep the tendon tethered close to bone.
55
What is characteristic of Du puytrens contracture?
characterised by shortening of the palmar fascia, resulting in progressive digital flexion deformity
56
What are some early clinical signs of Dupuytrens contracture?
thickening of the skin and formation of fibrous nodules in the palm, just distal to the palmar crease.
One or more longitudinal fibrous cords can form from the nodule to the finger, and these usually cross the MCP and PIP joints
57
What is boutonniere injury?
* French For “Button Hole”
* Describing the translation of the proximal phalanx through the lateral bands like a finger through a button
* name of a musculoskeletal manifestation of rheumatoid arthritis presenting in a digit, with the combination of:
* flexion contracture of a proximal interphalangeal (PIP) joint
* extension of a distal interphalangeal (DIP) joint
58
What causes boutonniere injury?
o inflammatory arthritis
| o central slip of extensor digitorum tendinopathy or rupture
59
What is guyons canal syndrome?
a collection of symptoms and signs due to compression of the ulnar nerve in the Guyon's canal, which is also known as the ulnar tunnel. When it is encountered in cyclists due to repetitive trauma, it is referred to as the handlebar palsy.
60
What is type 1 guyons canal syndrome?
* Proximal compression in Guyon's canal leads to motor weakness in all of the intrinsic muscles of the hand which are innervated by the ulnar nerve.
* There is also sensory loss in the territory of the hand served by the ulnar nerve.
61
What is type 2 guyons canal syndrome?
• common type of Guyon's canal syndrome
• caused by compression of the ulnar nerve at the lower wrist
Type II involves an impairment in motor function of the hand, with sensory innervation unaffected.
62
What is type 3 guyons canal syndrome?
* least common type of Guyon's canal syndrome
* caused by compression of the superficial branch of the ulnar nerve at the distal portion of Guyon's canal
* results in a loss of sensation from the cutaneous territory of the hand which is served by the ulnar nerve.
* There is no motor function impairment.
63
What is jersey finger?
* Traumatic avulsion of the flexor digitorum profunds (FDP) tendon
* The ring finger is most commonly affected as the FDP insertion into the ring finger is anatomically weaker than the middle finger
64
How does a patient with jersey finger present clinically?
* characterised by inability to flex the finger at the distal interphalangeal (DIP) joint.
* There is a slight extension at this joint.
* There is pain and tenderness over the volar distal finger
65
What are the different types of retraction associated with jersey finger?
o Type 1 retracts to palm
o Type 2 retracts to PIP joint.
o Type 3 bony fragment distal to A4.
66
Why is it important to treat jersey finger quickly?
* Very difficult to repair if it retracts into palm for longer than 7 days
* Attempts after two weeks will be unsuccessful due to swelling and adhesions
67
What is listers tubercle?
* Lister's tubercle or the dorsal tubercle
* bony protuberance on the dorsal surface of the distal radius
* separates the 2nd (ECRB and ECRL) and 3rd (EPL) extensor compartments.
* It acts as a pulley for the EPL tendon, changing its mechanical direction of action
68
What is Mallet finger?
* refers to injuries of the extensor mechanism of the finger at the level of the distal interphalangeal joint (DIP).
* They are the most prevalent finger tendon injury in sport.
* They may represent an isolated tendinous injury or occur in combination with an avulsion fracture of the dorsal base of the distal phalanx
69
What are the ultrasound findings of Mallet finger?
o loss of real-time movement of the tendon
o complete or partial extensor tendon tears
o fluid in the region of the extensor tendon insertion
o avulsion fracture
70
What is the difference between gamekeepers thumb and skiers thumb?
* Skier's thumb refers to acute injury due to trauma, from hyperabduction of the thumb as it is caught by the ski pole strap.
* Gamekeeper's thumb refers to chronic non-traumatic overuse injury (stress and repetitive trauma) that gradually injure the ulnar collateral ligament.
71
What is gamekeepers thumb/skiers thumb?
* Instability of the ulnar collateral ligament (UCL)
| * The most common soft tissue injury of the thumb Metacarpophalangeal (MP) joint is UCL sprain
72
What are the different classifications of gamekeepers/skiers thumb?
o Grade I – Stretching of the ligament without instability (usually don’t seek medical attention)
o Grade II – Partial tear with pain and swelling but no instability (25% seek medical attention)
o Grade III – Compete tear with instability
73
Why is ultrasound helpful when assessing skiers thumb/gamekeepers thumb?
• Ultrasound is helpful in identifying not only the tear and any retraction but also whether or not a Stener lesion is present.
74
What is a stener lesion?
* seen in the context of a torn ulnar collateral ligament of the thumb's metacarpophalangeal joint (gamekeeper's thumb).
* Normally, the ulnar collateral ligament lies deep to the adductor pollicis tendon.
* A Stener lesion is characterised by slippage of the torn end of the ulnar collateral ligament superficial to the adductor aponeurosis/adductor pollicis muscle
75
Why is identifying a stener lesion important?
• This prevents healing and is an indication for surgical repair
76
How does a stener lesion appear on ultrasound?
* a Stener lesion is proximal retraction of the ligament fibres which looks like a small mass displaced superficial to the adductor aponeurosis;
* this gives the yo-yo on a string appearance both on ultrasound and MRI images
77
What dynamic manouvre can aid in identifying a stener lesion?
• passive flexion of the interphalangeal joint of the thumb during dynamic ultrasound imaging of the ulnar collateral ligament (UCL) allows for identification of a non-displaced UCL tear from a Stener lesion
78
What is trigger finger?
* A trigger finger/thumb is a condition where the movement of the affected digit is arrested for a moment while flexed or extended and then continues with a jerk upon continued effort.
* locking of a digit in a flexed position
79
What causes trigger finger?
* usually caused by a stenosing tenosynovitis at the level of the A1 pulley on the volar aspect of a metacarpo-phalangeal joint.
* Usually a tendon thickening(nodule) that eventually passes through an annular pulley in flexion or extension.
* Can also be a normal tendon doing the same through a narrowed pulley
* Can be a combination of both of the above
80
What are the sonographic findings of trigger finger?
o tendon thickening
o synovial sheath fluid and thickening
o small peritendinous cysts.
o The tendon proximal to the restricting lesion may appear to buckle slightly, with flexion.
81
What is the role of ultrasound in ?trigger finger?
o To determine what is causing the movement dysfunction.
o That “Trigger Finger” should have specific ultrasound findings.
o Give the surgeon as much detail as possible.
o That other diagnoses be made if it is not Trigger Finger.
82
What is swan neck deformity?
• Hyper-extension of the PIPJ with hyper-flexion of the DIPJ
• Usually a result of an arthritic diseased PIPJ where the volar plate tear.
• Also the end result of an untreated Mallet Finger.
can be neurological eg stroke
