Wrist

Question 0

Where do the dorsal tendons lie?

Answer 0

Comp 1 - located at the radial styloid process
Comp 2 - located on the radial side of Lister’s tubercle
Comp 3 - located on the ulna side of Lister’s tubercle
Comp 4 - located in a smooth shallow depression along the ulna side of the dorsal aspect of the radius.
Comp 5 - located over distal radio-ulna joint
Comp 6 - located in the groove adjacent to the ulna styloid process

Question 1

Tendons of dorsal wrist

Answer 1

Comp 1 APL EPB
Comp 2 ECRL ECRB
Comp 3 EPL
Comp 4  4 tendons of EDP and 1 EI
Comp 5 EM
Comp6 ECU

Question 2

What is a Stener lesion

Answer 2

A Stener lesion occurs when the UCL of the thumb is avulsed,during an hyperabduction injury of the thumb. The UCL is avulsed from its proximal phalangel insertion. The ULC gets displaced outside the adductor aponeurosis.

Question 3

What is the flexor retinaculum

Answer 3

The flexor retinaculum contains the contents of the volar wrist.
It defines the carpal tunnel and stretches from the pisiform bone and hook of hamate on the medial side(ulnar side) and extends to tubercle of the scaphoid and the trapezium on the lateral ( radial) side

Question 4

Name the structures within the carpal tunnel

Answer 4

The structures that transverse the carpal tunnel include: the four tendons of the flexor Digitorum Superficialis , the four tendons of the flexor Digitorum pro fundus, the flexor pollicis Longus and the median nerve.

Question 5

What is a ganglion

Answer 5

A ganglion is a fibrous lined cyst containing mucin.

• Arise most commonly from scapholunate, radiocarpal or mid carpal joints
• be aware that volar ganglia can arise from the scapholunate joint
• Can also communicate with synovial sheaths
• can be simple or loculated
• measure in two planes and look for neck

Question 6

What is a giant cell tumour

Answer 6

A giant cell tumour. These lesions arise along the volar surface of the thumb, index finger and middle fingers at the level of the DIP joint . Because they arise from the tendon sheath they do not move with the tendon. Solid , hypoechoic with well defined margins. Usually show colour Doppler

Question 7

What is a glomus tumour

Answer 7

Glomus tumours arise from the neuromyoarterial apparatus in the dermis, occur in the finger ( or toe) nail and are very tender. Often only a few mm in size, solid and well defined with hypoechoic internal echogenicity. Usually hypervascular. Usually situated between the nail bed and bone.

Question 8

What is a schwannoma?

Answer 8

Schwannomas originate within the Schwann cell of the nerve and are eccentrically located within the peripheral nerve. Typically painless , commonly found on the flexor surface of the forearm or hand

Question 9

What is neurofibroma ?

Answer 9

Another type of benign nerve tumour. These tumours arise fom within the nerve fasciculi and are inseparable from normal nervous tissue appearing centrally within the nerve cell. Well defined, hypoechoic, some posterior acoustic enhancement.

Question 10

What is the palmar aponeurosis

Answer 10

This is a fibrotendinous complex that functions as the tendinous extension of the palmaris longus and as a strong stabilising structure for the palmar skin of the hand. It has 5 longitudinal slips that project into the base of each digit and a deeper transverse portion that crosses the palm at the proximal end of the MC bones

Question 11

What is snapping hip?

Answer 11

Occurs when the iliopsoas tendon jerks over the iliopectineal eminence .
A click can be felt while scanning

Question 12

De Quervains tenosynovitis

Answer 12

• most common cause of wrist pain
• involves APL and EPB
• fusiform swelling and thickening and or fluid in synovial sheath at the level of the radial styloid. Sheath may simply be thickened with no fluid seen
• Finkelstein’s test : thumb in palm of hands, fingers flexed over thumb and ulnar deviate wrist. Pain with this movement confirms De Quervains disease

Question 13

What is tenosynovitis ?

Answer 13

• can occur in any of the extensor tendons over the wrist
• swelling over dorsum of wrist
• swollen tendons are in a fluid filled sheath

Question 14

What is intersection syndrome?

Answer 14

• frictional inflammation occurring at the site where APL and EPB cross ERCL/ECRB in the distal forearm
• thickening of tendons seen. Must compare with contralateral side
• no synovial sheath in this region therefore no fluid will be seen on ultrasound

Question 15

Tendinopathy appearance

Answer 15

• tendon thickened and hypoechoic with no synovitis

- Be aware of where synovial sheaths start and end

Question 16

Tendon rupture symptoms

Answer 16

-blunt trauma
-measure the distance between retracted ends of tendon, this can be difficult when haematoma fills the defect
-post surgical repair the tendon ends should appose and the sutures can be identified. The tendon should glide smoothly with movement
EPL may rupture within its compartment in rheumatoid arthritis or following a distal radius fracture

Question 17

Tendon subluxation diagnosis

Answer 17

• ECU can sublux from its groove on the ulna head
• Extensir Digitorum or indicis can sublux within their compartment
• Dynamic scanning
• Ask patient to perform the movement which causes the click or pain while you are scanning the area . This can be tricky!

Question 18

Carpal Boss Syndrome

Answer 18

• lump on the dorsum of the wrist can be mistaken for a ganglion
• pain and tenderness may be associated at the bony prominence found at the base of the second MC dorsally
• check for Tendinopathy of the insertion of ECRB or ganglia at the CMCJ

Question 19

Pronator Quadratus haematoma

Answer 19

Radiographically occult fractures of the distal radius can become apparent as haematoma in the pronator Quadratus muscle
-pronator quadratus appears thickened and increased in echogenicity

Question 20

Mallet finger

Answer 20

-Extensor tendon rupture or lengthening avulsion fracture at the DP insertion of extensor tendon

Question 21

Boutonnière deformity

Answer 21

-injury of the central slip of extensor tendon near its insertion at the base of the middle phalanx

Question 22

Extensor hood injuries

Answer 22

-painful subluxation of common extensor tendon particularly in 3rd and 4 th fingers

Question 23

Carpal tunnel syndrome

Answer 23

-compression of median nerve by : flexor tenosynovitis , functional hypertrophy of anomalous or low lying flexor muscle bellies, ganglia, joint effusions or tumours. Anything which increases the volume of carpal tunnel
-swelling of median nerve
Tinel’s test for CTS- hand extended, tap over median nerve produces tingling and altered sensation in the distribution of the median nerve
Phalen’s test for CTS - reverse prayer position, push against each other and hold for 30 seconds. Positive if painful
-neuromas

Question 24

Ulna nerve compression

Answer 24

-caused by ganglia, aneurysm or repetitive trauma eg cycling

Question 25

Flexor tenosynovitis appearance

Answer 25

- Any of the flexor tendons may become inflamed with excessive activity - thickened tendons with fluid in synovial sheath

Question 26

Flexor Carpi Radialus Tendinopathy

Answer 26

- localised pain over this tendon proximal to the scaphoid tubercle particularly after exercise - Inhomogenous, hypoechoic thickening of the tendon at the level of its distal attachment - May see intratendinous calcification in chronic cases

Question 27

Trigger Finger

Answer 27

- locking of digit in flexion - Thickening of the flexor tendon which gets caught under the A1 pulley - Pulley may appear thickened

Question 28

Jersey Finger

Answer 28

- avulsion of FDP of the ring finger - can rupture distally and retract to palm level - or an avulsed fragment of the distal phalanx will retract to the PIJ level - or the avulsed fragment of the distal phalanx remains at the distal IP level

Question 29

Climbers finger

Answer 29

- flexor tendon pulley rupture | - bowstringing of the flexor tendons during resisted contraction

Question 30

Skiers thumb

Answer 30

- injury to the UCL of the 1st MCPJ - forced abduction and hyperextension of the MCPJ - Stener lesion, the torn proximal end of the UCL lies superficial to and at the proximal margin of the adductor aponeurosis - surgical treatment is required

Question 31

Dupruytrens contracture

Answer 31

Hypoechoic nodules in the palmar aponeurosis in the hand

Question 32

Hypothenar hammer syndrome

Answer 32

Repetitive trauma to hypothenar eminence may cause spasm, aneurysm and thrombosis of the ulnar artery causing ischaemia of the hand and fingers

Question 33

Aneurysm

Answer 33

-Following trauma particularly to the radial artery

Question 34

Rheumatoid Disease

Answer 34

- tenosynovitis - tendon rupture - joint effusion - Marginal bony erosions which U/S can visualise much earlier than x-rays - Nodules in periarticular soft tissues of fingers

Question 35

Other tests

Answer 35

X-rays - demonstrate fractures, arthritis, subluxation, calcification, bony deformity, foreign bodies Nuc med- demonstrates focal soft tissue or bony abnormalities CT- demonstrates the internal architecture of the bones Athrography - demonstrates ligament, capsule and cartilage tears MRI- best for TFCC and bone and joint pathology.

Question 36

Pathology of Dorsal wrist/hand

Answer 36

``` De Quervaines tenosynovitis Tenosynovitis Intersection syndrome Tendinopathy Tendon rupture Tendon subluxation Carpal Boss syndrome Ganglia Pronator Quadratus haematoma Mallet finger Boutonnière deformity Extensor hood injuries ```

Question 37

Volar aspect injuries

Answer 37

``` Carpal tunnel syndrome Luna nerve compression Flexor tenosynovitis Flexor Carpi Radialis Tendinopathy Ganglia Trigger finger Jersey finger Climbers finger Skiers thumb Dupuytrens contracture Hypothenar hammer syndrome Aneurysm Rheumatoid disease Tumours ```

Question 38

Patient symptoms

Answer 38

-chronic pain caused by repetitive movement with stiffness after a period suggests tendinosis -Associated neck or elbow pain is more likely to be referred pain -Watsons test for scapholunate injury - place your thumb on scaphoid tuberosity-palmar side with the wrist in ulnar deviation, deviate the wrist radially with the examiner placing pressure on the scaphoid Parenthesis symptoms- check the site of numbness and tingling and look for atrophy of hand muscles

Question 39

Describe an haemangioma

Answer 39

- slow growing - often associated with a raspberry skin discolouration due to the tendency to infiltrate the soft tissues - soft rubber consistency when palpated - appear either hypo or hyperechoic on U/S - colour Doppler may reveal a varying degree of vascularity