0:00

The history we are given is a 68 year old male, uh,

0:04

complaining of pain over the hook of the hamate and in the region of Dion's

0:09

Canal. And, uh,

0:11

left hand ulnar neuropathy going to the, uh,

0:15

so for a wrist, uh,

0:16

I like my coronals on top and axials and a sagittal on the bottom.

0:22

And, uh, I apologize, we cannot, I'm not able to share all six screens,

0:26

but I believe these are the, uh,

0:28

pertinent sequences and going right to the salient findings,

0:32

paying attention to, uh, Ian's Canal, which, uh, is a triangular, uh,

0:39

tunnel. Right?

0:39

Obviously along the ulnar aspect of the wrist that kind of intertwines and

0:44

weaves its way, uh, in and about the, uh, pisiform.

0:49

Okay. A along its radio or, okay. So,

0:54

as I was saying, so Ion's Canal is, um, uh,

0:58

a tunnel along the ulnar aspect of the wrist.

1:00

And within that tunnel contains obviously the ulnar artery nerve, uh,

1:05

and, uh, vein. And it kind of weaves its, uh,

1:09

itself sort of in a sigmoid fashion or ASS shaped fashion.

1:14

Okay. Uh, passing along the, uh,

1:18

pisiform bone on its radial or lateral aspect, and then wrapping,

1:23

uh, along or coursing along the ulnar side or medial side of the hook of the

1:28

hammock. Um, more distally, excuse me one second.

1:32

So here, as, as we can see in, in, uh, in these images right here, uh,

1:37

just blowing up the axial sequence, we see that, uh,

1:41

we have some abnormal signal, okay. About the ulnar artery,

1:46

and it's, it's a little bit, uh, uh, aneurysmal or ectatic at the lease.

1:51

Okay? And we have some surrounding, uh, soft tissue, uh, changes. Um,

1:57

we can see that that, uh, pans out okay.

2:00

On our sagittal sequence Okay. As well as

2:06

our coronal sequence right here. Okay? So this,

2:10

uh, is a nice case of, uh,

2:13

an aneurysmal dilatation or ectasia of the ulnar artery, um,

2:18

with, uh, likely clot within it. Now, in some of the, uh,

2:23

grading, in grading in some of the cases, um, this, um,

2:28

was, uh, a challenging case. Um,

2:32

and obviously if you're worried about, uh, thrombosis, the,

2:36

probably the better thing to do, or, or at least to consider doing,

2:40

is perhaps an MRA or even an ultrasound to confirm that there is, uh,

2:44

clot in this region. Unfortunately, we do not have, uh, history to suggest,

2:49

uh, things like, um, a patient is, uh, in involved with, uh,

2:54

jackhammers or, uh, clubbing sports such as golf or,

2:59

or tennis or whatnot that would, uh, chronically, uh, load or,

3:03

or cause, uh, pressure, if you will, trauma to the, uh, uh,

3:08

vol ulnar aspect of the, uh, wrist and hand,

3:10

which would obviously predispose to these, uh, uh, to these findings of, uh,

3:15

ulnar artery, uh, uh, pathology, including this, uh, thrombosis here.

3:21

But if you're thinking of it, uh, you could, uh, raise that diagnosis and, uh,

3:25

could potentially confirm this with appropriate, um, with, uh,

3:30

further vascular imaging. Um, and, um, you know,

3:34

potentially even since the diagnosis, or even suggest the diagnosis of,

3:37

of things like a hypo or hammer syndrome, particularly if you have a,

3:41

a corroborative or a supportive, uh, history such as, uh, uh,

3:45

maybe a construction worker using, uh, jackhammer, uh, or, or whatnot.

3:50

Um, so with that, uh, I'll pause for a moment, uh,

3:53

for any questions or comments and concerns.

3:57

I noticed in the flex attendance,

3:59

there's some amount of fluid along the tendons. Um,

4:04

just should we really comment on that? Was it just reactive fluid?

4:09

Yeah, let me pull that up. Okay, so, sorry,

4:13

which reactive fluid are we talking about?

4:15

Uh, involving the flex attendants, the deep flex attendants,

4:20

Yeah. Yeah. So, so this, I mean,

4:22

this is probably just a small amount of reactive, but I just wanna highlight,

4:25

just, just, just so we, uh, you know, just,

4:29

just to be aware that, uh, you know, these, these are palmar ese.

4:33

I've seen some people, um, call these, um, um,

4:39

tendon sheaths. Uh, I, if, if you're speaking to a purist, uh,

4:44

just be aware that these are called palmar ese. Um, so,

4:48

and, and they may communicate more distally, especially, uh,

4:52

for the flexor polys as longus and the digi minimi, um,

4:57

those tendon sheaths. Okay? But, but, uh, just be aware that some,

5:02

some, some surgeons and nanas out there call these, uh,

5:06

ulnar and radial sided bur se, and typically it's gonna be like e shaped,

5:11

like a, it's gonna make like a little e. So, um, but yeah, this,

5:16

this is probably reactive or, you know,

5:18

sometimes I'll just dictate and say non-specific. Um, yeah, but I, I'll,

5:23

I'll tend to worry more if, you know, there's, you know,

5:26

nearby if there's synovitis within it or, you know, if they're worried about,

5:31

uh, an infection with erosions. And you know, if I've given,

5:35

if I'm given that history, then sure, I, I, I'll, I'll, uh,

5:38

I'll raise that possibility including atypical micro organisms,

5:42

but also remember other things in this region that can cause, uh,

5:47

you know, a palmer bursitis or pretty much any bursitis or,

5:51

or teno synovitis, right?

5:52

The things you want to keep in your differential are gonna be, you know, trauma,

5:57

uh, chronic, repetitive trauma, um, overuse that is, or,

6:01

or crystals inflammatory arthropathies, um,

6:04

lymphoma rarely can do it, right, or even, uh, sarcoid.

6:09

So those are some things to, uh, think about.

6:12

So essentially tno synovitis, ideally, often contrasts is given then you

6:17

Yeah, when, yeah, when I, when I see bursitis, teno synovitis, I just quickly,

6:22

I, I, I just have a, uh, I have a macro essentially, and I just say, you know,

6:26

non-specific teno synovitis may be secondary to trauma,

6:29

chronic repetitive trauma overuse, uh,

6:32

infection including atypical microorganisms and fungi, um,

6:37

and, um, uh, crystals and, uh, yeah, and inflammatory arthropathies.

6:43

And then I, you know, and if there's concern for infection, then image guided,

6:47

uh, sampling or tissue sampling is offered. That's, that's my standard, uh,

6:51

uh, sort of dictation or when I see tenino synovitis or bursitis, uh,

6:56

pretty much anywhere olecranon, uh, sub subacromial subdeltoid,

7:01

especially if there's like a lot of rice bodies, I make sure, you know,

7:05

as we know, it's originally described with tb, right?

7:08

So I'll pick up the phone and say, Hey, are you worried about tb?

7:11

Just to make sure, you know, that could be obviously a public health hazard.

7:15

So I, I'll get on the phone to my clinicians for that. So just, uh,

7:19

case by case basis, but that's usually what I say.

7:23

And certainly when you've not given contrast,

7:25

some of the rheumatological cases that come to us, we don't give contrast. Uh,

7:30

there's just a suspicion and there's not, not much clinical history.

7:34

So how can you confidently call it without contrast if it's steno synovitis,

7:39

Uh,

7:40

Isolated tendon involvement?

7:42

Well, I mean, you, yeah, I mean, if you see, uh, you know, I mean,

7:47

depending on who you read and, and you know, I don't have a,

7:51

I don't have a cutoff to call Tino synovitis, but I,

7:54

I think if you read some of the literature, let's,

7:56

let's talk about the posterior TBIs tendon real quick.

7:59

I think if you have like a rim of, of fluid,

8:02

like three or five millimeters or greater, then you can then that, you know,

8:07

that correlates with, uh, Tino synovitis or, or that's been found.

8:10

You can suggest it, I guess. But again, I would have to look up that literature.

8:14

I, I don't have a cutoff in mind. Um, working with, uh, some of my mentors,

8:19

including Dr. Resnick, he'll, he'll joke around and say, you know, is it,

8:23

is it drainable or is it, is the amount of fluid sipp? If, if,

8:28

if you feel you can put a straw on it and sip some out, then he'll raise,

8:31

he'll question tenosynovitis. But be, but also be aware too, right?

8:36

And this has been written up by, I believe it's, uh, Dr. Clyde Helms at all,

8:40

and AJR if, if you wait long enough, right? You,

8:44

and you give contrast IV intravenous, right? And let's say,

8:49

you know, the patient had claustrophobia or, or something happened and you know,

8:53

the patient had to be pulled out of the magnet and they had already given IV

8:57

contrast. If you wait long enough,

8:59

that synovium is gonna enhance like a Christmas,

9:01

like very bright and it's gonna look really thick.

9:04

And then you may be over calling teno synovitis in those cases.

9:08

So something to be aware of, just be aware that, hey, you know,

9:10

if you're imaging and giving IV contrast, make sure that you know,

9:15

your imaging post contrast, grabbing those post contrast, post contrast,

9:20

post contrast images in a timely manner. Because if you wait long enough,

9:25

you know,

9:26

all synovium is gonna light up and you're gonna get an indirect arthrogram,

9:29

right? So that's something to be aware of on the other side too.

9:34

Do you have a specific timing, post contrast administration?

9:37

No, we, I, yeah, I, I don't, no. Okay.

9:42

Typically, you know, usually right after slide them in. Um, but, um,

9:47

I think if you wait long enough, I think, um,

9:50

I would have to revisit like the indirect, uh,

9:52

arthrogram literature and figure out if anyone's done that.

9:55

But I think it's been written, I check out, check out Dr. Helms. I,

9:59

I think it was in AJR that they mentioned, and it was probably in the,

10:04

I don't know, probably when Mr. Was still relatively nascent,

10:06

maybe the nineties or something like that, maybe early two thousands that, uh,

10:11

I believe it was Dr. Helms and, and, um,

10:13

I'll try to look for that article too and,

10:15

and forward that to you along with the, uh,

10:17

the list of ligaments to look for if you guys like.