0:01

Hello and welcome to Noon Conference, hosted by MRI Online

0:06

Noon Conference connects the global radiology community

0:08

through free live educational webinars that are accessible

0:12

for all and is an opportunity

0:13

to learn alongside top radiologists from around the world.

0:16

You can access the recording of today's conference

0:19

and previous noon conferences

0:20

by creating a free MRI online account.

0:23

Today we are honored to welcome Dr.

0:25

Ani Canelli for a lectured entitled Imaging

0:28

for sports related finger injuries.

0:31

Dr. Canelli is a MSK radiologist based in Sao Paulo, Brazil.

0:35

She completed her clinical MSK fellowship at H Core

0:38

where she continues to practice.

0:40

She also has a strong research background having completed a

0:43

re research fellowship at NYU.

0:46

Dr. Canelli is an active member

0:47

of several radiology societies

0:49

and has authored numerous publications on MSK radiology.

0:53

She's passionate about education,

0:55

frequently lecturing at Brazilian radiology meetings

0:57

and international radiology meetings,

0:59

and is deeply committed

1:00

to training the next generation MSK radiologist.

1:04

At the end of the lecture, please join her in a q

1:06

and a session where she will address questions you may have

1:08

on today's top topic.

1:10

Please remember to use the q

1:11

and a feature to submit your questions so we can get to

1:13

as many as we can before our time is up.

1:16

With that, we are ready to begin today's lecture. Dr.

1:18

Canelli, please take it from here.

1:21

Thank you so much for the introduction

1:23

and thank you everyone for attending.

1:26

So I'm glad to be here talking about sports related finger

1:29

injuries, especially during the Olympics.

1:31

So let's start. There's no conflicts of interest.

1:35

So about the background.

1:37

When it comes to sports injuries, uh,

1:39

hand injuries are usually traumatic

1:41

and lesions may occur from falls, axial loadings, off digits

1:45

or rotational falls due to grasping activities.

1:48

So the PIP, the proximal interphalangeal joint

1:50

of the fingers is the most injury joint in sports following

1:54

by the metacarpal langio

1:55

and carpal metacarpal langio joints off the thumb.

1:59

So, uh, radiologist needs to understand, uh, the anatomy

2:02

and the full spectrum of fingers

2:04

and thumb abnormalities in associating imaging findings.

2:09

So hand and wrist injuries are common occurrence in all

2:12

sports, and many of them are sports specific,

2:15

like the mal finger

2:17

for the baseball ball finger also can be found in

2:19

basketball, the bot air injury, the distal interphalangeal

2:24

injuries, the, the boxing injuries like the boxing duck box

2:28

fractures, uh, bowling.

2:29

Uh, we have the, the room of the owner digital nerve thumb,

2:32

uh, football or rugby.

2:34

We have metacarpal fractures

2:35

and the jersey finger, uh, rock climbing, flex poly lesions,

2:40

volley plates, and flexo tendon injuries.

2:42

And for skin and snowboard, we have the UCR thumbs injuries,

2:46

the scare thumb or gamekeepers thumb, and the volleyball.

2:49

We have fingers injuries

2:51

and the UCL thumb injuries

2:52

as most commonly related to these sports.

2:56

So, some learning objectives of this presentation is

2:59

to discuss the role of image in diagnosis

3:01

and management of different traumatic sports related, uh,

3:04

hand injuries, uh, is to review, uh,

3:08

the main anatomic regions and structures of the finger

3:10

and to describe and recognize the features of these lesions

3:14

that the radiologist must look for in order

3:17

to do an appropriate clinical approach for, uh,

3:19

to the diagnosis based on the image findings.

3:23

So, image, uh, plays a key role in the evaluation,

3:26

treatment planning of hand

3:27

and wrist injuries depending on the suspected injuries.

3:31

So a combination of conventional radiographics computers,

3:34

uh, tomography the ct, the MRI

3:36

and the ultrasound may be indicated.

3:39

Uh, also injuries off the hand often are diagnosed based on

3:43

a combination of clinical examination

3:45

and simple radiographs not necessarily needing.

3:48

Uh, uh, for the studies like MRI ultrasound, uh, uh,

3:53

initial radiographs, which consists of at least three views

3:56

of the affected area, the pa, the leak,

3:59

and the lateral, uh,

4:00

c should be obtained using things license, um,

4:04

that can be reformatted, any plane.

4:05

Usually they are used for, uh, surgical planning, planning,

4:10

um, indications,

4:13

and the superior contrast RESO resolution of MRI make,

4:17

its the modality of choice for evaluation

4:19

of suspected soft tissues injury, and the hand and wrist

4:22

and ultrasound also is a usable tool in the evaluation

4:25

of hand and wrist pathology,

4:26

particularly given its dynamic nature, the ability

4:29

to compare with the contralateral side, the

4:32

relative accessibility and relatively low cost,

4:35

and also the lack of ionizing radiation.

4:38

So first let's talk about the finger.

4:41

So when it comes to the fingers,

4:42

there are many important liga metals

4:44

and tendinous instructures that we need to be familiar with.

4:47

Uh, here we have, uh,

4:48

some diagrams from the proximal interphalangeal joints.

4:51

Uh, some of the ligaments, the structures include the proper

4:54

and the accessory collateral ligaments, the UCL,

4:58

not collateral ligament

4:59

and RCL, the radial collateral ligament.

5:02

And these ligaments helps to stabilize the finger joints.

5:05

In addition to this ligaments,

5:07

there are also important tendinous structures

5:09

to consider at the PIP, such as the exon tender, uh,

5:14

central sleep, and as well the vol plate here.

5:18

And it's crucial to have a base understanding

5:20

of these liga metals

5:21

and tendinous structures to evaluate, uh,

5:24

properly these, the joint.

5:27

So in addition to bone in structures, uh, ligaments, uh,

5:31

flexor and, uh, station tenders,

5:33

there's a particular structure

5:34

that is a special tensions when is mag the hand

5:37

and fingers at the MCP joint, the sagittal bands.

5:41

So it is this structure here, the sagittal bands,

5:45

the structure here, uh, consists of fibrosis structures

5:49

that run along the top of the metacarpal langio joint.

5:52

So these bands are essential

5:53

and maintain the proper alignment of the extens

5:56

and tenders, which allows for smooth

5:58

and efficient movement of the fingers.

6:01

So another important anatomical structure that we need

6:04

to be from the is the fingers Poly system.

6:06

The poly are series of fibrous bands

6:08

that surround the flex standard keep then close to the bones

6:11

and prevent it, and from bone string

6:13

and from the joint as they contract.

6:17

How about the finger injuries?

6:19

The MCP

6:20

and the langio fractures are common injuries in the hand

6:23

and fingers often, uh, resulting from falls,

6:26

direct impact or twist and force.

6:28

So these fractures can be classified

6:30

as esra or intraarticular.

6:32

Usually they are esra articular in this location.

6:36

And the poly injuries are also frequently seen sports,

6:38

especially in competitive climbing.

6:40

Uh, the atypical poly is located at the base

6:43

of the proximal fall

6:44

and is the most commonly affected poly, uh, in the fingers.

6:48

So the proper ing treatment of those lesions are crucial

6:51

to prevent further damage

6:52

and restore the function of the joint.

6:56

So about the PIP joint, uh, the injuries, uh,

6:59

of the joints are common

7:00

and can result from various force apply to the joints.

7:03

Collateral ligament injuries are often caused

7:06

by axial loading.

7:07

Those flexions for the typically occur at the proximal

7:10

attachment of the ligaments, so usually at the level

7:13

of the mi phx, not the distal, so the proximal attachment

7:17

of these ligaments.

7:19

So these locations are common

7:20

and are frequently seen ball handling sports.

7:23

Um, also dislocations are the most common type in uncared

7:26

by hypertension with axial loading.

7:29

While, uh, volar plate injuries are typically caused

7:32

by injury at the distal attachment at the level of the basal

7:36

of the, the pha, uh, with

7:38

or without a tion, fractory of the basal of dis phalanx,

7:43

uh, lar dislocations, including straight volar,

7:46

lateral volar or rotatory types are typically caused it

7:49

by virus of vago force, coupled

7:51

with Ebola thrusts to the middle fall.

7:54

So fractures and dislocations often occur

7:57

through a similar mechanism as do dislocations

8:00

and isolated combining injuries to develop plate are common,

8:03

and these injuries are often called by dorsiflexion

8:07

and axial load stress.

8:08

So it's like a, when a a ball, uh, hits the, the, the tip

8:13

of the finger is can occur.

8:15

So the proximal

8:16

or me nose portion of the vola plate can also be affected

8:20

by intract fractures, including the condylar fracture, see

8:23

by ular or combind fracture.

8:28

So let's begin with the case at standard injuries.

8:30

So the first is the jersey finger or Herby finger.

8:33

So this first injury is, uh, is occurred due to now tion

8:38

of the flexor digitor profundus sternum for the ola aspect

8:42

of the distal phx base here, the flexo, the, the, the flexo

8:48

digital, it's, it's detached

8:50

or you have a bon version of this, this standal,

8:54

and it's typically caused by a certain hypertension

8:57

of an actively flexed fingers, such as grab

9:00

and open edge jersey knees during hug ball or football,

9:03

or as you can see here in soccer,

9:06

as we saw at the Brazilian Spain match

9:08

during the Olympics this week.

9:10

So the four fingers, the most common effect you can see here

9:14

is not flexed as the other.

9:16

So it it, it lost the, the flexion position of the finger.

9:21

And one of my symptoms is, as I say, is the inability

9:24

to flex the finger at the d uh,

9:27

IP joint here is not flexed along

9:30

with light extension at this joint.

9:32

So if there's a finger is not correct surgically the finger

9:35

will be, is still able to function,

9:37

but the active motion

9:39

of the injury finger will be very limited.

9:42

There is a classification system

9:44

for the injury based on tendon retraction and bone oc.

9:48

So the type one involves the tendon being posted without

9:52

fracture in retract to the palm.

9:53

The type two that tend retract to the level of the PIP,

9:57

the type three, a large tion fractures

10:00

that limits the retraction to the level

10:02

of the distal phalon joint.

10:04

And this fragment become caught in the A four poly

10:08

preventing for retractions.

10:10

And the type four is a combined ablution

10:13

and tendon tion for the bone fragment,

10:16

resulting a double tion with subsequent retraction

10:19

of the tendon usually in the palm.

10:21

And the type five, uh, involves a ruptured tend

10:23

with bone tion with bone combination

10:26

of the remain distal pha, which can be or intra.

10:32

So this is ultrasound image at the launch of the plane

10:35

at the PIP level, the big address finger, you can see the,

10:38

the here, the, the tion of the flexo with a bone flag

10:43

or by this yellow arrow.

10:46

So, and you can see here the tendon retracted

10:50

for this insection and, uh,

10:52

cortical irregularity at the base of the distal fallin.

10:57

This is another case of ager lesion,

10:59

demonstrated a complete rupture of the fall flexor,

11:02

a digital perform the tendon close to the in insert

11:05

of the distal phx.

11:06

We don't see the tendon here.

11:08

As you can see here in the axial.

11:09

There's, uh, just fluid at the level

11:12

of the tendon insertion.

11:15

Uh, there's soft tissue edema at the tendon is retracted

11:18

here you can see the tendon undulated here

11:22

at the proximal level completely retracted.

11:27

Moving on to the bhut air injuries, they are caused

11:29

by a disruption of the central sleep

11:31

of the Es digitor at ease insertions of the base

11:34

of the middle phx.

11:36

So this results in patients present with the Flex PIP.

11:41

Here you can see, uh, flex PAP

11:44

and a hyperextended distal inter joint.

11:47

So this is the, the aspect of the, the, the B nerve defor.

11:53

These injuries are most commonly seen.

11:55

Basketball and volleyball plays

11:57

and playing radiographs are used to assess the presence

12:00

and degree of bone improvement in addition

12:02

to joint reduction and alignment.

12:06

So this happens, this the perform happens, uh,

12:08

because we have, uh, progressive vula displacement

12:12

of the lateral bands making this, uh, DIP joint, uh,

12:17

be, uh, hyper re descendant in the first case.

12:22

Here we can see of my patient

12:23

with the formative affect in the 50 finger,

12:26

we see the B air, the flow deformity, the Flex D ip,

12:30

and the hyperextended, uh, PIP and

12:34

and hyperextended, uh, DIP.

12:37

So ultrasound image at the longitudinal plane showed the

12:41

disrupted, uh, central slip of the ST tender, uh,

12:46

which is indicated by this yellow arrow here.

12:48

And here there is no bone version evident

12:52

in this ultrasound.

12:54

It is important to note that deformity result here in a

12:59

flexed, uh,

13:00

proximal interphalangeal joint in a hyperextended in inter

13:05

distal interphalangeal joint.

13:08

Here we have, uh, radiographs in three positions

13:11

of these patients, uh, three, four year men present

13:14

with edema, the PIP uh, uh, joint, uh, following trauma.

13:19

So this result in a b near the format of the third finger.

13:24

So we see at the, the OBL view, a lateral view

13:28

of the fingers, the hyper and distal,

13:31

and the flex promo al joint with soft tissue swelling

13:35

around this joint.

13:37

So these same patients, uh, under the MRI

13:41

and you can see the disrupted central sleep here

13:45

at the level of the sens, uh,

13:47

insertion at the base of the middle fall.

13:50

Uh, we can see here also the dis central, uh,

13:55

slip and the vol displacement of the lateral bone bo uh,

14:00

bands here point, like this

14:03

red arrow you can see here also at the coronal plane.

14:08

The next lesion, the male fingers is a finger tendon injury

14:11

caused by a disruption

14:13

of the terminal extension tender at recessions

14:15

of the distal fall.

14:17

As you can see at the graphic here, a disruptive of the

14:21

distal tendon terminal, uh, extension tendon.

14:24

So it's considered the most prevalent finger

14:26

tendered injury in sports.

14:28

So malid fingers injuries may represent an isolate tendinous

14:31

injury or occur in a combination with a motion fracture

14:35

of the dorsal base of the distal phx.

14:37

And when assessing malate finger injuries, the percentage

14:40

of particular surface involvement on X-rays must be reported

14:44

because bone fragments

14:45

with greater than one third improvement

14:48

of the articular surface may require, uh, fixation.

14:51

So it's important to operate, diagnose,

14:53

and treat male finger also

14:54

to present long-term complications such as joint stiffness,

14:58

defor, and loss of ion.

15:01

So in this case, we can see x-ray image like in front

15:05

and oblique views, and is a close view, uh,

15:08

of the fourth of balance.

15:10

So we can see the bone fragment here at the insertion

15:14

of the terminal Este on excess

15:16

or tender in this

15:21

other case of a mallet finger

15:26

or the X-rays, um, looks normal with the exception

15:29

of the flexed fingertip.

15:32

We see a little bit flexed the fingertip.

15:35

Uh, however, upon examination with ultrasound,

15:38

we can see a disruption of the terminal tendon.

15:41

We can see fluid here at the level

15:43

of the terminal extens tender,

15:45

and at is insection of the distal phx.

15:49

We can see here again the disruptive extensor, uh, the

15:55

terminal extensor tendon.

15:57

In this other case, we can see the same injury,

16:01

the mallet finger on MRI on the,

16:03

the sagittal, uh, fluid sickness.

16:06

We can see the disruptive tendon here,

16:09

the same at the axial at the level of the injury.

16:14

Also, we can see, uh, the,

16:15

the fingertip a little bit flexed, uh,

16:19

during this examination.

16:22

This other case, uh, instead of a tendon tear,

16:24

the patient had, uh,

16:26

a bone flake from the dorsal side of the distal fall.

16:31

We can see here evidence, uh,

16:33

the correspond effect in the phal base.

16:35

We can see there are some, uh, is missing some bone here,

16:39

and there is a retraction of the terminal sleep.

16:42

Here we can see this, this echogenic

16:45

structure is the terminal tendon attached to the bone flake.

16:51

Another case also with, uh, a bone evolution on MRI,

16:54

we can see the bone and the terminal sleep, uh, attaches

16:59

to the bone fragment, uh, a little bit retracted.

17:04

So now let's discuss another type, uh, in of injuries.

17:07

The box knuckle. So the box knuckle is, uh,

17:10

conditioned character characterized by the disruptor

17:13

of the sagittal bandwidth, leads to instability

17:15

of the standard tender

17:17

and can also cause tear in the MCP capsular ligaments

17:20

and damage to the art cartilage.

17:23

So these injuries is high prevalent among boxers

17:26

and is often sustained when landing OnApproach,

17:28

and most commonly occurs in the third MCP joint

17:31

because it's more superficial, it's more prone to injuries.

17:34

So this central tendon typically, typically dislocate mely

17:38

because, like you can see here,

17:40

because the radio bands more prone to rupture, uh, only

17:43

to an atomic weakness at attendance of MCP joint

17:46

to be deviated to the owner side.

17:50

So in this case of bug nole,

17:52

we can see the soft tissue swelling of the third MCP joint.

17:55

At the ultrasound, we can see, uh, injury, uh, lesion

18:00

of the radiosurgical bend.

18:03

Here we can see there is a gap.

18:05

We can see the, the, the nar uh, sagittal band intact,

18:09

and there's a fluid collection at the level

18:12

of the radio sagittal band.

18:14

And when it's flexed the finger, we can see

18:17

they extend the digital communist tendon.

18:20

Uh, sub blue shade to the inner side is located

18:24

to the inner side.

18:27

Now let's discuss the finger ligaments injuries.

18:29

So in this case, uh, present, uh,

18:32

18-year-old male goalkeeper, uh,

18:34

was reported experiencing right uh, finger pain

18:37

after hyperextension.

18:39

So upon MRI axial

18:40

and corona altitude weight, uh, pat, uh, image review IPR

18:45

of both radial radial

18:48

and inner collateral ligaments at the PIP

18:51

joint of the fourth finger.

18:52

Um, although there's no evidence of ligaments disruption.

18:56

So there is also a, uh, soft tissue edema,

19:00

but the ligaments are intact only

19:02

with edema surrounding this other case.

19:06

Uh, 55-year-old goalie, uh,

19:09

also experienced left finger pain following trauma

19:11

during sock sock training.

19:14

And during dissemination, the corona an axial

19:16

to fat su suppress image, uh, review of partial tear

19:20

of the collateral ligament at the original

19:22

of the radial collateral ligament.

19:25

At the level of the PIP joint, we see some, uh, irregular

19:29

of these ligament fibers as I can't, uh, I can't, uh,

19:34

I I said, uh, previously, uh,

19:36

usually they are the injuries allocate approximately not

19:39

distally, so at the level of the middle phalanx.

19:44

So, uh, now let's discuss the OLA plate injuries.

19:47

Uh, in case of OLA plate plate injuries, uh,

19:52

knowledge of the orthopedic ETO classification is crucial

19:56

as it helps in determine the management of, uh,

19:59

the management plan.

20:01

So the decision treatment depends on various factors

20:03

including the size of the fragment, if it's less than 40%

20:07

of the articular, uh, segment, the degree of impact

20:10

and the direction of the dislocation.

20:13

So the ETO classification include three types of VA plate

20:16

of motions, uh, injuries of the PIP joint.

20:20

So ETO type one involves a hypertension mechanism of injury

20:24

with aul of the VOLAF plate

20:26

and a longitudinal tear of the collateral ligaments.

20:30

And the it on type two, it's a dorsal dislocation with aul

20:34

of the volaf plate and a complete tear

20:36

of the collateral ligament.

20:38

And ETO type two three is divided into subtypes.

20:41

The three A involves a fractured dislocation

20:44

with a voltage small fragment, the less than 40%

20:47

of the articular surface,

20:49

and the type three involves a fracture dislocation

20:52

with a fracture infection of the articular surface

20:55

of more than 40%.

20:59

So in this case of OLA plate injuries, it's on type three,

21:02

there is an tion fracture.

21:03

We can see on time bone flag here, uh,

21:08

uh, at the level of the PIP joint.

21:11

Um, this fragment is related to the

21:15

tion at the vol plate at the base of the middle phx.

21:19

So, but there's no evidence of this location

21:22

of the proximal interferon joint joint at this exam.

21:28

So in this case, a 17-year-old male present

21:30

with left finger pain following a hypertensive

21:32

injury while playing soccer.

21:34

So we can see a partial tear of the vola plate.

21:38

So we can see here a gap at the SAL image

21:41

and the axial, we see this area of the partial test.

21:45

So there is no much retraction of the, the vola plate

21:49

because it's still, there are some fibers locate more, uh,

21:52

at the unit side than the radio side,

21:57

and also the tendons are preserved.

22:01

This another case. So we have, uh,

22:04

displaced volaf plate injury.

22:06

So, uh, the sagittal

22:08

and axial T two weight fat suppress image, uh,

22:10

the volaf plates locate at the central position.

22:13

Here we can see, uh, two fragments of the, the

22:18

volaf plate and also, uh, with, uh, gap here

22:21

that there is here.

22:23

And we can see here the, the,

22:25

the OLA plate retractably approximately.

22:28

And also there's some bony contusions associated

22:30

with no bone fragment of acid.

22:34

Another case now ultrasound showing, uh, showing, uh,

22:37

udal image, uh, of, uh, OLA plate tear.

22:42

But in this case, it's not distal 'cause.

22:44

Let me just go back. Here it is the distal portion.

22:47

Here we have the OSE portion.

22:49

So in this case it's proximal, proximal,

22:51

so it's the normal side.

22:53

And, uh, the side with the injury,

22:56

we can see this flute vivid at the me ose portion

22:59

of the vola plate.

23:01

Uh, uh, like the proximal segment

23:04

of the vola plate is injury

23:07

and the poly injuries, let's, uh, see some case.

23:11

So the climbers finger, it's a common injury

23:14

among rock climbers.

23:15

It's caused by strain tear in the tendons

23:18

and poly that control fingers movements.

23:20

So the most commonly injured pulley is the A two

23:24

followed by a four.

23:25

So the A two pull is located at the base

23:27

of the finger while the A four poly is located at the

23:30

middle of the finger.

23:32

So we can see here the A two pulley,

23:34

and here the A four pulley,

23:36

the most commonly injured police.

23:38

So the mechanism of the injuries often occur

23:40

during creeping when the fingers are bent at the first

23:43

and the first joint,

23:45

and the hand is held in a closed fist position.

23:48

When a climbs foot sleep unexpectedly, it puts inspect

23:51

and force on the hand cause the pull

23:53

to stress over or even tear.

23:55

So symptoms of climbing fingers often include an audible pop

23:59

and immediate pain followed by swelling

24:01

and possible bruising related.

24:04

So it's a case of a 30 5-year-old male present

24:07

with posttraumatic pain in his right

24:09

or finger, along with a feeling of a pop.

24:12

So upon examination, the ultrasound transverse image reveal,

24:15

uh, an abnormal thickening

24:18

and hypo callic part annular flexible A four, yeah,

24:24

uh, for dissemination through longitudinal ultrasound image,

24:26

they depict an increased distance between the tendons

24:30

and the DIA of the Beto phx of the right third finger.

24:35

So another case on ultrasound of finger pull injuries.

24:38

So the ultrasound transverses udal ultrasound image, uh,

24:42

shows a, uh, showing increased distance

24:44

between the flexor tendon.

24:46

We see the tendon here

24:47

and the distance to the cortical bone of the, the, the fall,

24:51

the middle phx at the proximal fall, uh, this is, was,

24:56

this was more proximal, so it's related

24:57

to the second poly injury, uh,

25:00

with a bow string of the tendon.

25:02

We can see here the, the, the distance between the tendon

25:06

and the, the phlange.

25:08

And at the normal side, it's very close.

25:10

The fall to the tendon here is very distant

25:16

Now on MRI.

25:17

So it's a case of acute atypical PLI injury, uh,

25:20

with a patient was practicing indoor climbing.

25:24

So an MRI image of the affecting your shows, uh,

25:27

increase the distance between the te the otten

25:32

of the forefinger, the proximal phx.

25:34

When you compare to the normal side disease very close in

25:38

here, there's a, uh, increased distance

25:41

between the tendon and the bone.

25:44

Additionally, there is tend synovitis, uh,

25:46

and also the disrupted poly.

25:49

We don't see all the fibers.

25:53

Another case in a chronic setting, uh, of, uh,

25:56

atypical injury involving, uh, the 50 finger, uh,

26:02

over three months ago.

26:03

So the MRI image showing increased distance between

26:06

the flexor tendon of the little finger

26:08

and the proximal ance resulting in, uh, both strings,

26:12

appearance of the tendon.

26:13

You see, again, the increased distance between the tendon

26:16

and the bone and the normal tendon

26:19

and the relationship with the bone is, is maintained.

26:25

Uh, let's move to the bone injuries.

26:27

So let's discuss about the box fractures.

26:30

Uh, they are minimally combind transverse factor fractures

26:34

of the fifth metacarpal neck.

26:36

They are considered the most common type

26:38

of metacarpal fracture.

26:40

Usually they happen as the result

26:41

of punching a heart object like a wall

26:44

with an unprotected fist.

26:46

Uh, typically they are diagnosed, uh, through x-ray.

26:49

They don't need, uh, advanced image like MRI

26:52

to the diagnosis.

26:54

So this is a case, uh, of x-ray, like different, uh, OBL

26:58

and lateral views showing the dis distal fifth, uh,

27:01

metacarpal fracturing involving the neck.

27:05

You can see here at the FormIt with, uh,

27:09

with palm mar angulation, which typical for this type

27:12

of fracture, the boxer fracturing.

27:16

Now let's focus on the thumb.

27:17

There are several specific injuries related to the thumb.

27:21

So again, let's review some anatomy.

27:23

So the term has important ligaments include in the onar

27:27

collateral ligaments at the MCP joint, uh,

27:32

close to then there, the S-S-R-U-C-L

27:34

and the most vulner aspects.

27:36

So these ligaments are common injuries

27:38

and require attention during evaluation and treatment.

27:42

The term also has some important ligaments at the volar

27:45

aspect related to the sesamoid bones

27:47

and the ola plate, including the lango glenoid

27:51

ligaments distally,

27:52

and the chara ligaments approximately here, the chara

27:56

and the lango glenoid oil ligaments.

28:00

And lastly, the tongue also has a flex of poly system

28:03

that includes the first and second poly here

28:06

and here, uh, as well, the variable

28:09

and oblique anular, uh, poly, the variable

28:12

and oblique the injuries of the tongue, uh,

28:16

CMC joint are commonly associated with

28:19

fractures such chest bennet's fractures.

28:21

So locations without frac is rare

28:24

and involve the rupture of the vola ligament

28:26

with dorsal displacement of the first, uh, MCP joint

28:31

first metacarpal bone.

28:33

Actually the term, uh, metacarpal, uh,

28:35

phang joints also prone

28:37

to several common injuries include dorsal dislocations

28:40

caused by hypertension with complete rupture

28:43

of the ola plate, usually approximately.

28:46

So collateral ligament injuries are also very common,

28:48

including scars

28:50

or gamekeeper's thumb, which is caused by radial direct

28:53

directed force or on abducted thumb.

28:56

And other specific injury is stem lesions,

28:58

which occur when the distal portion

29:00

of the UCL Voss from its attachment of the proximal balance

29:05

and herniate through theor apon theosis.

29:08

Let's see, some ligaments injuries.

29:10

So let's start with the most famous, the scar stems

29:13

or gamekeeper thumb.

29:14

So mosquito thumbs, uh,

29:17

and gamekeeper thumbs are two similar injuries

29:19

that involve the tongue.

29:22

So mosquito thumbs is an acute injury that occurs due

29:25

to trauma for, uh, hyper duction of the thumb, as is caught

29:29

by the skip pole strap.

29:31

As you can see here in this image here on the other hand,

29:36

uh, gamekeeper thumbs up,

29:37

chronic non-traumatic overuse injuries

29:39

that gradually injure the un collateral ligament.

29:42

So Gamekeepers who killed the small animals, were severe

29:46

to have this injury due to repetitive trauma.

29:49

So the term, uh, gamekeepers was coin in

29:52

1955 in Scotland, it's actually refer

29:55

to a gamekeepers breaking the necks

29:58

of the animals primary head.

29:59

This is from the original paper which described this injury.

30:05

This x-ray shown avo fracture at the nar corner of the base

30:09

of the proximal phage of the thumb characteristics

30:11

of gamekeeper's thumb.

30:14

And there's also a classification of cure cure thumb

30:17

that was proposed by Hinterman in 1993.

30:22

And it's based on whether a fracture is present

30:25

and whether their injury is stable, resulting six types

30:28

where the types is, uh, two, four,

30:31

and six requiring surgery.

30:34

So the X-ray and the diagram saw multiple more fragments

30:37

of bone, uh, at the attachment

30:39

of the ary collateral ligament

30:41

of the first me metacarpal fall joint.

30:43

So this is type one scar stem lesion.

30:48

Here we have, uh, ultrasound image, uh,

30:50

long no image at the level of the MCP joint, uh,

30:53

revealing an AVO fracture can see the bone fracture,

30:58

the bone ul here at the side of the attachment

31:02

of the unor collateral ligament.

31:04

So the ligament appears hypo equate.

31:06

Uh, however, both the ligament

31:09

and bone flake are located deep to the upon theosis.

31:12

We have here the, upon the rose

31:14

and the, the bone fragment, the ligament are deep,

31:17

so there is no, uh, formation of cell mass.

31:21

Uh, at this level we can see here the ane roses.

31:25

They are deeply located at the asymptomatic,

31:27

showing their normal a neuros and the normal ligament.

31:33

So this is a case of, uh, four ear, uh, goalie, uh, had a,

31:38

uh, injury after hyper abduction of the thumb.

31:41

So longitudinal exhale, uh, tissue fat breast image review,

31:44

a complete distal tear of the, uh, UCL

31:48

with the ligament is stu

31:49

and retracted here, went by this, this red arrow.

31:54

So there's some bone edema

31:57

and the radial collateral ligaments is normal.

32:00

So this is an example

32:01

of a UCL tear without a standard lesion.

32:04

When the ligaments becomes a trap

32:07

or the ap, uh, the abdo aor aral so is located deeper

32:11

to the upper is not superficially.

32:13

So there is no standard lesion in this case.

32:17

And, uh, now let's talk about the standard lesion.

32:19

The UCL normally lies deep to the auditor poly standard

32:24

and i standard lesion is characterized by the slippage

32:26

of the torn and of the ary.

32:28

Collateral ligament superficial to theosis

32:32

or auditor muscle become superficial to neurosis.

32:36

So, uh, this caused thearon neuros was close

32:40

to be interposes, uh, and preventing prop proper healing.

32:45

And in those case, surgical repairs necessary

32:47

to correct these injuries.

32:50

As we can see here, we can see the external lesion, the,

32:54

the ligament rapid, uh, as superficially

32:57

to the auditor aosis.

33:01

So this is a case of high standard lesion in, uh,

33:03

30 5-year-old patients, uh, with some pain

33:05

after, uh, trauma.

33:08

So axial and coronary MRI show a torn

33:12

and retracted onor collateral ligament.

33:14

We can see here the a neuros and the ligament retracted

33:18

and superficially located to the hor neurology.

33:21

So this is a classic standard lesion of the tongue,

33:26

and we can see these lesions, uh, with ultrasound.

33:29

So ultrasound, uh, findings.

33:31

And, uh, in this case here we have, uh, a symptomatic,

33:36

uh, side of the MCP, uh, showing, uh,

33:40

the ulnar collateral ligament, uh, absent, there is no here

33:45

and there's a cell mass here, retract at the level

33:48

of the metacarpal head.

33:50

So performance stress view.

33:52

There is a significant open of this articular, uh,

33:56

the joint space with herniation

33:59

of paricular soft tissue into the joint.

34:01

So this is caused by the, the ligament tear,

34:05

which is retracted here, the EO mass.

34:09

Another case now, uh, talking about, uh,

34:13

vol ligament injuries of the thumb.

34:14

So this 18-year-old Mayo patient, uh, uh, soccer play

34:19

that sustained LAR ligament injuries.

34:21

So sagittal

34:23

and coronary two weight fat express image, uh,

34:26

review a complete disruption

34:29

of the radio check brain ligament.

34:31

We can see this gap with a bone edema of the radios andoid,

34:35

and there's li with some edema of the muscles

34:39

of the 10 region of the, the, the, the hand.

34:44

And, uh, another thing we can see here,

34:46

the ligament retracted.

34:48

And, uh, this starts location of the radio oid when compared

34:53

to the OID white, sorry,

34:59

this is another case.

35:00

A 70-year-old male soccer plays, so sagittal to weight, uh,

35:05

image review at temple or ligament injury.

35:08

So again, completed disruption of thenar shrine ligament.

35:12

Uh, we can see here the gap with put fill

35:17

and ITA of the muscles around the, the, the joint.

35:23

And additionally in this case we have, uh, a sprain

35:26

of the fungo glenoid ligament, which is distal.

35:29

So you can see, uh, signal alterations

35:32

and then around this, this ligament,

35:34

but without, uh, uh, clearly tear.

35:40

Also, we have ola plate injuries of the thumb.

35:46

So the ultrasound image, uh, showing, uh, ular plate

35:50

of the MCP joint of the thumb.

35:54

This is the normal side. This is, uh, the, the injury side.

36:00

Uh, the image indicates that tear at the proximal portion

36:04

of the volla T plate.

36:05

We can see this hypo coic area, which corresponded tear.

36:09

And here the volaf plate retracted

36:12

and insinuated at the joint space.

36:14

Here we can see the normal volaf plate of the thumb, no,

36:19

uh, also, uh, during the flexion, they, they continuing the,

36:22

the movement without radiation into the joint space

36:26

and compare it with the, the, this, the injury side.

36:30

When we can see at dislocation of the metacarpal head

36:33

and I simulation of this volaf plate into the joint space,

36:40

we also, uh, can have poly injuries of the thumb.

36:44

It is not common as seen as we see it, uh, at the fingers.

36:48

So in this, uh, there is a, uh, this is a case

36:51

of a 70-year-old male goalkeeper present with pain

36:54

after trauma of the thumb axial

36:57

and ality two, weight fat suppress,

36:59

eliminate show thickening and irregularity of the first ola.

37:02

Poly indicate by this red arrow.

37:05

You can see here that the irregularity, additionally,

37:08

there are stenosis ovide,

37:10

which can be associated in this injury, can see, see the,

37:13

the tendon sheet, uh, fill with flu,

37:16

but without hand disruption.

37:19

And some, uh, diffuse them of the tumor muscle related

37:22

to the bone contusion,

37:23

direct bone contusion in this, this patient.

37:28

Uh, lastly, we have bone injuries of the tongue.

37:34

So, uh, ben fractures,

37:36

the most common fracture involve the base of the thumb.

37:39

So intraarticular, uh, frac is that intraocular fracture

37:44

that separates the palmer on a aspect

37:47

of the first metacarpal base from the

37:49

remain first metacarpal.

37:51

We can see here this longitudinal fracture,

37:53

the bone fragment, separate the Palmer aspects, uh,

37:57

a palmer on aspect of the first metacarpal base

38:00

and the remaining, uh, first metacarpal.

38:03

Uh, the usual mechanism can be seen boxing,

38:05

but is also commonly seen sports such as football or rugby,

38:09

and is usually caused by a heart impact

38:12

or trauma, such as punching something hard

38:14

or falling onto your head

38:16

with the thumb is seeking out of the side.

38:19

So, uh, there's a, another fracture.

38:21

It is called a rollout fracture that is very similar

38:24

to the ben fracture,

38:26

but it's is more most related to, uh, trauma

38:29

with high energy, which, uh, it's a fracture of the base

38:33

of the, the, the first meta caral,

38:35

but it's a common fracture different

38:37

for the me benefit fracture is a longitudinal single, uh,

38:41

fracture line at the base of the first metacarpal.

38:46

So this is, uh, the first case of radiographic case.

38:49

Uh, 30 old male patients, uh, presented with,

38:51

uh, ben fracture.

38:53

So they actually shows the two-piece, fracture of the base

38:56

of the, the metacarpal bone.

38:58

He's in the front view.

38:59

You can see the line, the bone fracture at the Palmer.

39:02

And uh, al aspect of the basis is an,

39:06

an intraarticular fracture.

39:09

So, uh, so the fracture has an intraocular extension,

39:12

dorsal lateral displacement, usually, uh,

39:15

and this is fragments

39:17

of the first metacarpal bone can be attached

39:19

to the anterior oblique ligament,

39:21

and which continues to articulate it with the trapezium.

39:24

And also in this case, we can hit,

39:27

we can have lateral retraction of the first metacarpal joint

39:30

to the avatar to poly long, so can, can have a displacement

39:35

of the metacarpal, uh, remain bone.

39:40

This other case, uh, also have been a fracture of, uh,

39:43

three old male experience, a fall result injury, uh, uh,

39:46

to the hand, uh, which present with swelling

39:49

and tenderness of the base of the first metacarpal bone

39:52

and painful T movement.

39:54

So CTN X-ray, uh, review line intraocular fracture

39:58

in this case, uh, uh, a smaller fragment than the,

40:01

the last case, uh, with mild displacement of the base

40:06

of the metacarpal bone.

40:07

And you can see here clearly at the, the,

40:12

the ct, these oblique fracture lines tend into

40:15

the article phase.

40:16

So usually the ct, uh, they, they are ordered not

40:20

for the diagnosis, which you can see clear by the x-ray,

40:23

but to preparatory planning not for the diagnosis.

40:28

So, um, in conclusion,

40:31

finger thumb injuries are extremely common,

40:34

not only in athletes as we can, uh, watching the Olympics,

40:38

but also in re recreational athletes.

40:41

So image is used with frequency in order

40:43

to help in the evaluation of patients present

40:45

with suspect ligament

40:47

and tendon injuries of the hand and wrist.

40:49

And you, you have to use, uh, uh, the method

40:54

that which available for you is,

40:56

whether it's ultrasound on MRI

40:58

or x-ray, you need to be, uh, comfortable with the method

41:02

that, that i, you are using to diagnose this types

41:05

of injuries and image, uh, can lead

41:08

to an appropriate diagnosis

41:09

and better patient management as untreated injuries can lead

41:13

to chronic pain, stability,

41:14

and reduced function of the affected limb.

41:19

Uh, ham's reference. And thank you for watching.

41:23

Thank you for your attendance.

41:26

Thank you so much for that lecture, Dr. Canelli.

41:28

At this time we will open the floor for any questions,

41:31

so if you have a question, go ahead and put it into that q

41:34

and a feature so we can get through as many as we can

41:39

before we need to leave.

41:41

Um, the first question is,

41:42

how will we differentiate boxer versus barroom

41:46

fracture radiologically?

41:48

So, uh, usually this fractures the,

41:52

we use a simple x-ray,

41:55

so the boxer is more decently, so more in the neck.

41:59

Uh, usually the, the, the, the bar is, it's,

42:02

is more approximately, but it's basically the same,

42:04

the same mechanism to hit a wall, uh, unprotected.

42:07

Like you can punch a wall, you can fight it,

42:10

but it's, it's basically the same.

42:14

Uh, what is the image protocol of unsure fractures?

42:18

I think it's asking probably the MRI, uh, protocol

42:23

to diagnose, uh, probably, uh, image

42:31

because, uh, uh, the protocol that we have in our service

42:34

to, to finger injury, we usually include,

42:37

um, an x-ray.

42:40

'cause sometimes in the, the acute setting of the x-ray, uh,

42:44

uh, the, the acute setting of the, the, the injury, the MRI,

42:49

there's so much edema that we cannot see like a small,

42:52

uh, bone fragments.

42:54

And the protocol to MRI to detect this image,

42:57

like there's a negative x-ray.

43:00

Uh, we use a small slice like two millimeters,

43:03

focus on the articulation to see the ligaments with, uh,

43:07

more high resolution.

43:08

So we include, uh, uh, the three planes,

43:13

uh, T one without, uh, fat saturation

43:16

and three, uh, sequence axial sagittal

43:20

and coronal planes of the with flu, uh,

43:23

in steer OT two weight, uh, fat setted sequence

43:26

to diagnose these injuries.

43:29

Har we use like ct, it's more, uh,

43:32

usually the four fingers X-rays are enough to see the,

43:36

the, the bone fragment.

43:39

Um, the other questions,

43:40

do you have an experience using MRI?

43:42

Finger coil? Yeah, we use, uh, MRI finger coil,

43:45

but we usually use, uh,

43:48

because most of the time, uh, the patient, some, some,

43:52

some case they came to, to evaluate, uh, uh,

43:56

a specific lesion like a mallet finger

43:58

or, uh, so we use this,

44:03

this, this kind of coil.

44:06

Uh, another injury like the, uh, the,

44:11

uh, with, uh, we have like tendon injury to use, uh,

44:15

the hand coil to have a more broad view of the, the, the,

44:19

the, the, the structures.

44:22

But we use mostly the, the finger coil

44:25

to evaluate the nail plate with distal, uh, injuries

44:28

of the na use.

44:30

Uh, a direct, uh, uh, a small, uh, field of view

44:33

to see fingers, usually the distal interphalangeal joint,

44:36

not the proximal interphalangeal joint.

44:39

So it's mostly used to distal injuries, traumatic

44:42

or to evaluate the na, someone ask, uh,

44:47

all the patients with finger injuries should undergo

44:49

ultrasound with x-ray.

44:52

If you have they available, I think you is, is better

44:54

to have both, but not sometimes the patient don't.

44:58

Uh, you can choose like between MRI ultrasound,

45:01

which more available for you.

45:03

Sometimes the ultrasound is easier,

45:05

is at the, the emergency room.

45:07

Uh, you have more confidence to evaluate it

45:10

and use the M-R-I-M-R-I need to, to,

45:12

to schedule the patient.

45:14

So, uh, depends what is available.

45:17

But X-ray I think is, it's always, uh, a good choice to,

45:21

to primarily evaluate these injuries, to exclude, uh, some,

45:25

uh, bone fragments.

45:29

I wanna ask, uh, if it's mandatory to report all injuries

45:32

or enough to say with surgical versus conservative,

45:36

I always report all the injuries.

45:39

Uh, obviously I report with more detail.

45:42

The one with each surgical say how much the area

45:45

of the article surface is, is it's, uh,

45:52

is affected is one third

45:54

of more than 50% depend off the injuries,

45:57

but I report all the injuries.

45:58

'cause sometimes, uh, they, they change the, the, the,

46:02

the treatment, uh, with a combination of the lesions

46:05

that you see not only for one.

46:06

So sometimes you have a partial tear,

46:08

but you have partial tear of a lot of instructors

46:11

and they will not going

46:13

so much conservative to the treatment.

46:18

I think most of the questions were,

46:22

I think you got all the questions. Yes. Yeah,

46:25

A lot of questions. A lot

46:27

Of, well thank you so much for answering them all

46:29

and thank you so much for your excellent lecture.

46:31

We really appreciate you here today.

46:33

Thank you so much for the invitations.

46:36

Absolutely. And thank you all

46:37

for participating in our NOOM conference

46:39

and asking such great questions.

46:41

You can access the recording of today's conference

46:43

and all our previous noom conferences

46:45

by creating a free MRI line account.

46:48

We will also email out a link to the replay later today.

46:51

Be sure to join us next week on Thursday,

46:53

August 15th at 12:00 PM Eastern, where Dr.

46:56

Basak Dogan will deliver a lecture entitled

46:59

Artificial Intelligence at the Heart

47:00

of Breast Imaging Innovations and Insights.

47:03

This is going to be co-sponsored with A A WR.

47:07

So don't miss this.

47:08

You can register for it@mrionline.com

47:10

and follow us on social media

47:12

for updates on future noom conference conferences.

47:15

Thanks again and have a great day.