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 any medication.
On examination, there was full radial and ulnar deviation. Wrist flexion was preserved, but there was a restriction to 3/4 the normal range of wrist extension. Limited by stiffness and discomfort. Direct palpation revealed some local discomfort in the region of the 2,3,4th extensor compartments. Resisted tests were unremarkable, including biasing for ECRB, ECRL and EPL. Initial thoughts were that given the location, and restriction of movement that this was suggestive of intra-articular pathology of the radiocarpal joint. The patients age however did however reduced the likelihood of this being a degenerative joint condition.There was no trauma, making carpal instability unlikely, and no other signs of any systemic inflammatory conditions or risk factors. The other possibility was tenosynovitis of the extensor tendons in that region, but one would expect resisted tests to potentially be uncomfortable.
On musculoskeletal ultrasound. The tendons of the 1st, 2nd , 3rd and 4th extensor compartments appeared intact with no thickening or local effusion.There was no indication of intersection syndrome (for more details on a case study for this see here). There was however a visible anechoic lesion in the region between the 3rd and 4th extensor compartments (Figure 1). This was not compressible. had no vascularity (Figure 2) and appeared to communicate with the radiocarpal joint on longitudinal view (Figure 3). It was also tender on probe palpation. In summary, this appeared to be consistent with a symptomatic Ganglion on the dorsum of the wrist, and the patient was subsequently referred onto Orthopaedics.
Musculoskeletal ultrasound facilitated this patients management, and led to a prompt referral to secondary care. From a clinical examination, it was not possible to diagnose the nature of this patients complaint, beyond clarifying there was an unusual block to wrist extension. Ultrasound enabled me the opportunity to obtain more information, and in this case highlight the likely complaint.
Another useful resource can be found here
We hope you have found some useful learning points from this article, please continue to share with colleagues. Further case studies can be found here. You can sign up to receive these case studies as they are released FREE to your email inbox here. All feedback welcome at [email protected] More pathology demonstrated on ultrasound can be found in the video gallery and image gallery.