Wrist Flashcards
Where do the dorsal tendons lie?
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
Tendons of dorsal wrist
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
What is a Stener lesion
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.
What is the flexor retinaculum
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
Name the structures within the carpal tunnel
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.
What is a ganglion
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
What is a giant cell tumour
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
What is a glomus tumour
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.
What is a schwannoma?
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
What is neurofibroma ?
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.
What is the palmar aponeurosis
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
What is snapping hip?
Occurs when the iliopsoas tendon jerks over the iliopectineal eminence .
A click can be felt while scanning
De Quervains tenosynovitis
- 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
What is tenosynovitis ?
- can occur in any of the extensor tendons over the wrist
- swelling over dorsum of wrist
- swollen tendons are in a fluid filled sheath
What is intersection syndrome?
- 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
Tendinopathy appearance
- tendon thickened and hypoechoic with no synovitis
- Be aware of where synovial sheaths start and end
Tendon rupture symptoms
-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
Tendon subluxation diagnosis
- 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!
Carpal Boss Syndrome
- 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
Pronator Quadratus haematoma
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
Mallet finger
-Extensor tendon rupture or lengthening avulsion fracture at the DP insertion of extensor tendon
Boutonnière deformity
-injury of the central slip of extensor tendon near its insertion at the base of the middle phalanx
Extensor hood injuries
-painful subluxation of common extensor tendon particularly in 3rd and 4 th fingers
Carpal tunnel syndrome
-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
Ulna nerve compression
-caused by ganglia, aneurysm or repetitive trauma eg cycling
Flexor tenosynovitis appearance
- Any of the flexor tendons may become inflamed with excessive activity
- thickened tendons with fluid in synovial sheath
Flexor Carpi Radialus Tendinopathy
- 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
Trigger Finger
- locking of digit in flexion
- Thickening of the flexor tendon which gets caught under the A1 pulley
- Pulley may appear thickened
Jersey Finger
- 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
Climbers finger
- flexor tendon pulley rupture
- bowstringing of the flexor tendons during resisted contraction
Skiers thumb
- 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
Dupruytrens contracture
Hypoechoic nodules in the palmar aponeurosis in the hand
Hypothenar hammer syndrome
Repetitive trauma to hypothenar eminence may cause spasm, aneurysm and thrombosis of the ulnar artery causing ischaemia of the hand and fingers
Aneurysm
-Following trauma particularly to the radial artery
Rheumatoid Disease
- 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
Other tests
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.
Pathology of Dorsal wrist/hand
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
Volar aspect injuries
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
Patient symptoms
-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
Describe an haemangioma
- 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
