Wrist/Hand

Two cases of De Quervain’s Tenosynovitis. TSV or not TSV – that is the question? – Allister Taggart (@allistertaggart) Consultant Rheumatologist

For those sonographers, like myself, who deal with a lot of inflammatory disease, Doppler has become an important part of the sonographic assessment of any patient. Take the tenosynovium as an example. Tenosynovitis (TSV) is best assessed using a transverse probe position so that one gets a view of the whole tendon and its surrounding sheath. Tenosynovitis is often seen as a “ring of fire” around the tendon and this represents increased vascularity of the tenosynovium. Figure 1 shows the transverse scan of the first dorsal compartment of the wrist in a 33 year old nursing mother who developed classical …

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Sonographic appearance of Chondrocalcinosis – Dr Peter Browne, Consultant Rheumatologist (@peterbrowne42 )

A gentleman in his 80' scame to the clinic with a background of haemachromatosis which was diagnosed in his 70s, rotator cuff disease bilaterally and he had been diagnosed with rheumatoid arthritis several years earlier and treated with methotrexate with good benefit in terms of symptoms. He tolerated methotrexate well and was wondering if he could come off it at this stage. He reported no early morning stiffness and interestingly had never had early morning stiffness.. Ultrasound demonstrates chondrocalcinosis in the 2nd and 3rd MCPs bilaterally. There were no erosions. His wrists were unremarkable. Normal inflammatory markers are noted and …

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Scapholunate ligament tear – Rob Mast, Extended Scope Physiotherapist

This is a case of a patient in their 30's. They reported their wrist was forced into a position of extreme flexion and feeling something "go" in the wrist. Ever since then they had noticed an unstable feeling at the wrist. At times when extending from a flexed position the wrist locked.  They also reported difficulty picking up a kettle and generally felt less confident when using the wrist.   On clinical examination it was clear that there was dorsal subluxation of a carpal bone, most noticeable when returning from palmar flexion into extension. Palpation of the Lunate bone was …

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Avulsion injury of the distal phalanx – Sophie Cochran – MSK Sonographer / Stuart Wildman – Extended Scope Physiotherapist

This post will outline two cases of the sonographic presentation of an avulsion injury to the distal phalanx. For the first time we have had two cases presented,with thanks to Sophie Cochran for sending her case into The Ultrasound Site to contribute! Case 1 This patient in their early 30's, presented with a left 3rd metacarpal injury.  She recalled falling over and feeling pain and discomfort in the distal interphalangeal joint. She also noticed an inability to extend her finger fully. On examination, she presented with a mallet finger, and no activation of DIP extension. On ultrasound in clinic, there …

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Trigger Finger..or was it? -Stuart Wildman (@SWildmanPhysio) Extended Scope Physiotherapist

Giant Cell Tumour on MSK ultrasound

This patient was in their late teens and was referred for a 'trigger finger, please inject', I thought it made an interesting case so have written it up here for discussion. Initial thoughts were that this would be a fairly straight forward referral as trigger finger is often a pleasing condition to treat with good response rates to a local steroid injection. I then saw the patients age being in the late teens, and immediately you become fairly sure that it isn't a trigger finger, or at least an unusual presentation in someone of that age. The patient reported a …

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Angioleiomyoma – Bev Roos, Ultrasonographer, South Africa

This gentleman in his 40's, who is right hand dominant presented with a mass on the ulnar aspect of his right palm in the region of the pisiform. It does not feel like a ganglion. Machine used:  Philips IU22  Musculoskeletal Ultrasound report: There is a well circumscribed, oval hypoechoic 9.4 x 5.1 x 10.5 mm mass (Figure 1), overlying the pisiform and ulnar nerve, but not overlying the ulnar artery, within the deep dermis and subcutaneous layer. Low level echoes within the mass are consistent with solid tissue, although there does appear to be a small cystic component, demonstrated by the …

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Schwannoma of the median nerve – Bev Roos , Ultrasonographer–Special Interest MSK, South Africa

This patient was a gentleman in his 40's, right hand dominant, who presented with a right radial volar wrist “ganglion” for a few months. Clinically there was a large multilobulated soft mass between Flexor Carpi Radialis (FCR) and Palmaris Longus (PL). It did not feel like a ganglion and there was positive Tinnel's over the mass. The patient was referred for an ultrasound to examine the region further. The report for the ultrasound is outlined below and the images displayed in the gallery above. Please click on the individual images to view them. 'There is a well circumscribed, lobulated, hypoechoic 28 …

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Ulnar collateral ligament injury of the thumb – Stuart Wildman, Extended Scope Physiotherapist

Ulnar collateral ligament on MSK ultrasound

This patient presented six months after having a fall onto an outstretched hand. She felt a sharp pain in her left thumb at the time, and reported difficulties with gripping and using it since. On examination there was some visible enlargement and localised swelling of the ulnar aspect of the metacarpophalangeal joint (MCPJ) of the left thumb. There was also localised tenderness to palpation on the joint line. Joint range was reduced to approximately 1/2 the normal range of flexion and extension,limited by pain. Radial deviation was particularly painful with valgus stress testing (See Figure 1 and 2), but there …

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Lump compressing median nerve – Suresh Sudula, MSK Consultant Physiotherapist

This gentleman, in his late 50's, presented with a lump over the volar wrist which had been there for a couple of years. He reported that the lump was not getting any bigger in size or painful, however he noticed the development of paraesthesia in the hand over the last 6/12. He had been referred to hand surgeon who asked for an ultrasound scan of the lump. Specifically the nature and anatomical relation to the median nerve. The report for the ultrasound images in the gallery above was  'There is a subcutaneous soft tissue mass which measures 1.5 x 0.5cm in …

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Ganglion on the dorsum of the wrist – Stuart Wildman, Extended Scope Physiotherapist

This patient in their 30s presented with an insidious, 3 year history of wrist pain. She had particularly noticed difficulty with pushing off her wrist, and extending her wrist fully. Previous Physiotherapy had not been helpful, hence her referral to the Extended Scope Physiotherapy clinic. On observation, her pain was primarily located to the dorsum of the wrist, and quite specifically towards the radial aspect (see demonstration above). There was no swelling, redness or deformity. The wrist essentially had a normal appearance. She did not report any paraesthesia. There was no other significant past medical history.The patient was not taking …

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Wrist effusion and ‘out of plane’ guided radiocarpal joint injection – Rob Mast, Extended Scope Physiotherapist

This is a case study of a patient with a wrist effusion and 'out of plane' guided radiocarpal joint injection. The patient was a jeweller in their 30's with a six month history of left wrist pain. The pain was felt more towards the radial side of the wrist and there was pain predominantly during gripping activities. Her work entailed gripping objects for extended periods of time and was therefore problematic. If she ignored the pain and continued working she then could experience some pins and needles in the fingers in the median nerve distribution reminiscent of Carpal Tunnel Syndrome …

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Scaphotrapeziotrapezoid joint osteoarthritis…and musculoskeletal ultrasound – Stuart Wildman, ESP

Once you have recovered from the 'tongue-twister' of a title...I hope you will find this useful. The  Scaphotrapeziotrapezoid  (STT) complex can be overlooked as a source of symptoms within musculoskeletal assessment clinics. It is the second most common cause of wrist arthritis, which often causes surprise. Patients typically present with a diffuse aching pain in the radial aspect of the wrist, potentially in the distribution in Figure 1. It is often aggravated with gripping,and repetitive upper limb activities. On office based ultrasound a localised effusion and prominent osteophyte was noted over the articulation of the trapezium and scaphoid (Figure 3). …

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Carpal Tunnel Syndrome – Rob Mast, Extended Scope Physiotherapist

Figure 1: Bifid median nerve at the carpal tunnel

I recently saw this middle aged lady with unilateral carpal tunnel syndrome. She presented with a four month history of right sided carpal tunnel syndrome type symptoms. Four years earlier she was diagnosed with the same and received a steroid injection which completely settled her symptoms. Clinically there was certainly a mild carpal tunnel syndrome and this fitted with the history of waking at night with numbness in the hand. Carpal tunnel provocation tests were mildly positive. Musculoskeletal ultrasound showed a bifid median nerve (as seen above) . Lanz et al (1977) were the first to describe anatomical variations of …

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De Quervains Tenosynovitis – Stuart Wildman, MSK Sonographer and Extended Scope Physiotherapist

I wanted to post a case on this very common condition, De Quervains Tenosynovitis. Ultrasound allows easy visualisation of the tendons and assists guidance of steroid injections if required. This is particularly common in young mothers through lifting their baby and also with occupations where repetitive thumb use is involved. Pain is localised to the radial aspect of the wrist, and there can be a localised effusion and redness to the skin. There is inflammation of the cellular lining membrane of the fibrous tunnel through which the tendons of abductor pollicis longus (APL) and extensor pollicis (EPB) brevis move, at the radial …

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Ulnar nerve irritation at the Guyons canal -Rob Mast, Extended Scope Physiotherapist

Musculoskeletal Ultrasound is also able to clearly visualise nerves, characteristically appearing in the transverse view best as a 'Pepper Pot' appearance. There is a building library of research regarding MSK Ultrasound appearances of nerve pathology, with a significant amount regarding the median nerve at the carpal tunnel. Indications of potential nerve pathology include thickening, and increased cross-sectional area. Rob Mast, Extended Scope Physiotherapist, has provided the following case study. This will hopefully be the first of a selection of peripheral nerve pathologies that we can post on the site. This lady in her 30's , presented with sensory loss and …

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Cellulitis on musculoskeletal ultrasound- Rob Mast

The following case was slightly unusual  in the sense that cellulitis is more often seen in the acute setting rather than in primary care. However as an Extended Scope Physiotherapist using musculoskeletal  ultrasound, you are likely to come across it at some point so it is important to know what cellulitis can look like on ultrasound. So I hope you find this case helpful. This was a case of a man in his thirties who was very physically active and involved in martial arts. I saw him a few weeks after he first noticed a small lesion on the dorsum …

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Radial intersection syndrome – Rob Mast, MSK Sonographer and Physiotherapist

I saw a middle aged lady last week who came in for an ultrasound scan of the wrist. She complained of radial wrist pain reminiscent of a De Quervain’s syndrome. However the symptoms were somewhat different. The main area of pain was 4 cm proximal of the radial styloid process. Resisted testing was more painful on extension but was not worse when adding ulnar deviation which is usually the case with De Quervain’s tenosynovitis. Finkelstein’s test was only mildly positive. Ultrasound revealed some tenosynovitis of the extensor pollicis brevis at the radial styloid. When moving proximal with the US probe transverse …

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