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Hello and welcome to Noon Conference, hosted

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by MRI Online Noon Conference connects the global radiology

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community through free live educational webinars

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that are accessible for all

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and is an opportunity to learn alongside top

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radiologists from around the world.

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by creating a free MRI online account.

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Today we're honored to welcome Dr.

0:22

Rajas Chabo for a lecture entitled Ultrasound Anatomy

0:24

and Common Pathologies of Wrist Joint.

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Dr. Chabo is at a consultant

0:28

and director at Thayne Ultrasound Center.

0:31

His primary clinical interests

0:32

and expertise include various ultrasound interventions,

0:35

including fetal interventions

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and pain management procedures, ultrasound contrast,

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and elastography, and musculoskeletal ultrasound.

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At the end of this lecture, please join us in a q

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and a session where Dr.

0:47

Tra will address questions you may have on today's topic.

0:49

Please remember to use the q

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

0:53

as many as we can before our time is up.

0:55

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

0:58

Charbel, please take it from here.

1:02

Hi, uh, everyone, and, uh, I'm Dr. Rajas Charbel.

1:05

And, uh, uh, today I'll be discussing, uh, wrist ultrasound.

1:10

Uh, so what I will be doing is, you know, just, uh,

1:13

simplify the approach for having a look at the common

1:16

structures that we should see in our daily practice

1:19

and, you know, some of the common pathologies that, uh,

1:23

uh, should be doing.

1:25

Uh, I think, uh, this is a little bit

1:27

of a departure from the routine MRI that I think majority

1:31

of the audience is used to.

1:32

Uh, so I'm just trying to, uh,

1:35

simplify things a little bit on wrist, a little bit

1:37

of a different, uh, approach

1:39

and, you know, a little bit of a different view of things.

1:42

So, uh, let's see.

1:43

And of course, uh, please if you have any questions, uh,

1:46

please put it in the chat box and we will try

1:49

and answer as many as I can at the end of the session.

1:52

Okay. So the best thing about ultrasound

1:57

is, you know, over a period of time, the, uh,

2:00

probes have really evolved so much.

2:02

You know, when we started scanning the risk,

2:04

we were using these probes with a 12 megahertz frequency,

2:07

18 megahertz frequency,

2:09

but we are increasingly using higher

2:11

frequency probes right now.

2:13

We have the, uh, majority of the places will be, uh,

2:16

we have the availability of a hockey stick probe, a shot

2:19

of foot head probe, you know, which makes, uh,

2:22

the visualization of these small structures

2:24

in a joint like wrist.

2:25

Very, very easy. And we are increasingly seeing, you know,

2:28

higher resolution probes, higher frequency probes going up

2:31

to 20 and even 30 megahertz, right?

2:34

Which is going to just enable us to see, uh, smaller

2:37

and smaller structures as we'll be seeing

2:39

through the course of this topic.

2:43

So we'll be dividing, uh,

2:45

looking at the risk into the extensor

2:47

or the dorsal compartment and the flexi compartment.

2:51

So what we do is first position the patient.

2:54

So similar to what you know, you would do in an MRI,

2:57

how you place the patient, you know, how you place the coil.

3:00

It is in fact even more important on our sound as to

3:04

how we are positioning the patient, uh, how we, uh,

3:07

you know, uh, uh, evaluate a particular structure

3:10

that's won't be very, very critical.

3:12

So for the extent a compartment, well,

3:14

the position is very easy.

3:16

You can have the patient

3:17

or even supine at times if you're comfortable,

3:20

you have the wrist, you know, on a table.

3:22

And what you can do is maybe, you know, keep a little bit

3:25

of a pillow below the wrist joints that will just help you

3:28

to, um, you know, see the structures a little bit better.

3:31

So you give a little bit of flexion on the wrist

3:33

and the, uh, structures on the extensor aspect can be

3:37

much better visualized.

3:39

So this is going to be a checklist when we look at

3:42

the extensor compartment.

3:44

Uh, so we'll be looking at the extensor compartment tendons.

3:47

We'll be having a look at the scaffold lunate ligament.

3:50

We'll be having a look at the distal radio ulnar joint,

3:54

the radio radiocarpal, and the mid carpal joints.

3:56

And we'll also be having a quick look at the radial, no,

4:02

so the extensive compartment, right?

4:04

Uh, the extensive tendons, if you look at,

4:06

they're divided into these multiple compartments.

4:09

So what happens is you basically have this

4:12

extensor sheet, right?

4:14

And it dips at various levels

4:16

and it, you know, attaches to the bones.

4:18

And this is what creates these different

4:20

compartments, right?

4:22

And each of these compartment contains a single

4:25

or multiple tendons.

4:27

So this is a very, very important thing, you know, to no,

4:31

from an anatomical perspective as

4:34

to which tendons are located in which compartment.

4:37

So if you look at compartment one on the radial side,

4:40

we have the abuc abductor lysis longus,

4:43

and the extensa lysis brevis tendon.

4:45

Then we have the, uh, extensia carp radialis longus,

4:50

and the extensor carp radialis brevis

4:52

tendons in the compartment.

4:54

Two compartment three has a single tendon,

4:57

which is the extensor lysis longest tendon.

5:00

In compartment four, we have the extensor indicis propre

5:04

and the extensor dig room, longest tendons.

5:08

In compartment five, we have the single tendon

5:11

of the extensive digit quint propre.

5:15

And in compartment six, we have the extensive carp

5:18

and tendon, right?

5:20

So once we know that this is the anatomy that we are going

5:24

to be looking at, we can now move on

5:26

to looking at these tendons on the ultrasound.

5:30

Now, what happens

5:31

with ultrasound is if you keep your probe suddenly at one

5:34

point you're gonna be lost with different, you know,

5:36

soft tissue structures, which are going to be popping up.

5:40

So it is very important that we have some form

5:43

of a bony landmark in mind when you want

5:46

to evaluate the tendons.

5:48

So for the extensor compartment,

5:50

the most important landmark is going

5:52

to be this protuberance, which is the lister cubicle, right?

5:56

So on the dos aspect of the hand, very,

5:58

very important structure over here,

6:00

which is the lior tubercle.

6:02

Now, what this lior tubercle does is

6:04

that it separates the compartment,

6:06

two tendons on the radial side with the compartment,

6:09

three tendon on the nar side.

6:11

So the moment you keep your probe over here, again,

6:15

mind you, we are gonna be scanning this

6:16

with a high frequency probe.

6:18

Majority of the images that I'm gonna be showing are with,

6:21

uh, 12 megahertz.

6:22

There are images with 18 megahertz

6:25

or even 20 megahertz when needed, right?

6:29

So generally what we do is, you know, we start with say,

6:33

a 12 megahertz probe, get a good assessment of

6:36

what exactly is happening, you know, you may want

6:38

to see the different compartments,

6:40

and then once you narrowed on on the pathology, you may move

6:44

to a higher frequency trans, uh, transducer,

6:47

something like an 18 or a 20 megahertz,

6:49

and have a look at

6:50

that particular area a little better, right?

6:53

So again, coming back to our listers cubicle,

6:56

on the radial side, we have the compartment two,

6:58

and on the other side we have the compartment three tendon.

7:03

Now, once you have identified these tendons, you know, you,

7:06

it's always a good idea that we move back

7:08

and forth along the length of the tendon so

7:11

that you're looking at the pathologies in the short axis.

7:14

And then you can also go in longitudinal plane

7:17

and have a look at these tendons in long axis,

7:20

and we'll see some examples a little later.

7:23

Now, moving more onto the radial side, what we are trying

7:27

to assess over here is the compartment one tes.

7:31

So for that, what we do is keep the hand in kind of a,

7:34

you know, mid supination, pronation, uh, position, right?

7:38

Maybe on a pillow you can give a little bit of, uh, flexion.

7:43

And, uh, what you should see the moment keep your probe on

7:46

the radial style.

7:47

Over here is this structure,

7:50

which is the compartment, one tendon.

7:53

And, uh, this again, as we saw it comprises of two tendons.

7:56

You have the abductor lysis longest tendon,

7:59

and the extensive lysis brevis tendon.

8:02

Majority of the times, this is covered

8:04

by single re inoculum,

8:05

which appears like this hypoechoic structure,

8:08

what we can see over here, right?

8:11

But at times, uh, you can have a septum

8:15

and these tendons may be divided.

8:17

So you may see a different extensive policies be ascend,

8:21

and you may see a separate abductor policies, longer tendon,

8:25

even as far as the abductor lysis,

8:27

longest tendon is concerned.

8:29

There may be, you know, multiple, uh, kind

8:31

of a penate ate kind of appearance, multiple, uh, you know,

8:35

sleeves to the tendon.

8:36

So we have to be little careful.

8:38

And, uh, this assumes more important when you're gonna be

8:42

injecting maybe a steroid or some other drug in this area,

8:46

and you want to know which is the tendon which is affected,

8:49

so that you can, uh, you know, put the steroid in

8:52

that particular area to relieve the patients

8:55

of its symptoms.

8:57

Now, coming back to our, uh, compartment, four tendons.

9:01

How do I come back over here? Well, I go back to my listers.

9:04

Typical, I know next

9:06

to the listers is the compartment three,

9:08

and I move a little more onto the ULA side,

9:10

and I'm able to see the compartment four tendons, right?

9:14

So the compartment four tendons, uh,

9:17

what you should keep in mind is that the synovium get the,

9:21

the retina killer, actually, sorry,

9:22

gets a little bit thickened over here.

9:24

If you can see this image over here.

9:26

So this should not be mistaken for a thickening.

9:29

This is the natural, you know, appearance of the, uh,

9:33

ulu in this area, right?

9:35

And the other thing you can do is, uh,

9:38

because it's a little difficult

9:39

to identify the separate tendons, you can ask the patient

9:43

to kind of, you know, just wr his, uh, fingers.

9:46

And you will be able to see the movements

9:48

of these tendons individually,

9:51

so you know which tendon is going to which finger.

9:54

Also, as you move a little more distally,

9:57

you can see the tendon separating a little bit better,

10:00

and you can identify to which, uh,

10:03

finger which extensor tendon is traversing.

10:07

So that is about the compartment four

10:10

and the compartment five tendons,

10:12

and next coming to the compartment six tendon.

10:15

So what we do is keep the hand in, uh, uh,

10:18

radial deviation position

10:20

and the image over the lar styloid process.

10:23

And the moment you image over this anah styloid process,

10:26

you should be able to see this tendon sitting right over

10:30

here, which is the extensor carp alais tendon.

10:35

Now also just

10:37

below the extensor carp alais tendon, if you, uh,

10:41

look at this structure, what you are able to see is,

10:45

you know, a triangular e echogenic,

10:47

inverted triangular genic structure, uh, like this,

10:50

which is actually your triangular fibrocartilage complex.

10:54

Now, the triangular, uh, uh,

10:56

triangular fibrocartilage complex is actually a complex

10:59

structure with, uh, you know, formed with, uh,

11:02

multiple structures, and we are not really able

11:04

to see the entire, uh, TFCC very well,

11:07

but we are able to visualize the superficial portion

11:11

of the TFCC quite well using our ultrasound.

11:15

Now, a very interesting thing happens with the tendons is

11:19

that when you trace these tendons back, right,

11:22

if you go towards your arm, what you

11:26

or, uh, your, or,

11:28

or forearm, what you will see is

11:30

that the tendons are actually not traversing in

11:32

a straight line, right?

11:34

So they are actually crossing over each other.

11:37

And this crossing is what is called

11:39

as the intersections, right?

11:41

So there are two intersections.

11:43

One is proximal intersection,

11:45

which is about four centimeters proximal

11:48

to the lister's cubicle.

11:49

And you are, what happens is

11:51

that the compartment one crosses the compartment

11:54

two tendon, right?

11:55

So you have the compartment,

11:57

one tendon crossing the compartment, two tendons.

11:59

And why is this important?

12:01

Because when you have a situation where, you know,

12:04

maybe this guy is a sportsman

12:06

or whatever, there's, uh, maybe playing a lot

12:08

of bracket sports or whatever, then in,

12:11

if there is a repetitive, uh, irritation over here,

12:15

this can cause 10 synovitis at this level,

12:19

and this more often affects the second compartment tendon.

12:23

Okay? So that is the clinical importance

12:25

of this crossing over.

12:27

Similarly, if you move just to the lister cubicle,

12:31

what you see over here is

12:33

that there is another com uh, tendon.

12:35

This is the, uh, compartment three tendon,

12:37

which is crossing over the compartment two tendon, right?

12:41

So again, approximately we saw it was the first compartment,

12:44

tendons distally.

12:45

It is the third compartment tendon, which is crossing the,

12:49

uh, compartment two.

12:50

Over here, you can see the crossover very well.

12:52

And again, uh, this assumes importance

12:55

because, uh, this can be prone to tenters

12:58

because of, uh, repeated friction.

13:00

And also what happens over here is that the sheets

13:03

of this compartment two

13:05

and the compartment three tendons actually communicate

13:08

with a foreman, right?

13:10

And as a result of this, if you have, uh, a tenitis

13:14

of compartment three, this can potentially spread

13:17

to the compartment two tendon as well.

13:20

Now, next, moving on to our distal video on our joint space.

13:25

So as we move up, uh, little more distally, we are able

13:30

to see that this will radio LA joint space.

13:32

This is how the radius will appear.

13:34

This will be your alna,

13:36

and, uh, we have to watch out for the presence

13:38

of any synovial thickening

13:40

or maybe even, um, you know, degenerative changes,

13:43

which can come up over here.

13:46

Now, once you look at the, uh, in this area,

13:50

in the longitudinal section, you are able

13:52

to see the radio couple

13:54

and the midco joint space as well, right?

13:56

So in the longitudinal position of your probe, you are able

14:00

to see the radius.

14:01

Over here you have the lunate, the capitate, and a deli.

14:06

You have the head of the metacarpal.

14:08

And again, uh, why is it important to have a look at this?

14:11

Because you may have this area filling up with fluid,

14:15

there may be area of synovitis.

14:18

And, uh, this is again, important to

14:21

identify when you're doing a scan.

14:24

Uh, next, another structure

14:26

that we look at is the scaffold ate ligament.

14:29

So how do we look at the scaffold ate ligament?

14:31

Well, we come back to our lister, tubical area

14:34

and go a little more distally

14:36

and with a hand in nar deviation

14:39

or nar deviation of the wrist, rather, we should be able

14:42

to see this dorsal bundle of the scaffold ate ligament.

14:46

Again, it may not be the best evaluation

14:48

of the scaffold ate ligament,

14:50

but at least the dorsal bundle can be decently visualized.

14:56

Now, this is, uh, one of the last structures

14:59

that we are going to be looking at on the da dorsal surface,

15:02

and that is going to be your radial artery and the, uh,

15:06

and the no, right?

15:07

So if you look at the distal, uh,

15:10

if you look at the proximal aspect of the wrist,

15:12

you are able to see the radial artery, right?

15:15

Somewhere over here on the flexor side actually.

15:18

And as you trace that down, you are able to see the nerve,

15:22

you know, traversing along the radial artery.

15:25

And then what happens is that the nerve actually

15:28

slips from the,

15:29

or the snaps from the ventral to the dorsal aspect

15:33

of the wrist or the compartment, one tendon, right?

15:37

So if you look at this video a little properly, you can see

15:41

that this is the radial nerve,

15:43

which is snapping from the ventral to the dorsal aspect.

15:48

This is just going very close to the cephalic vein.

15:51

And again, this is important

15:53

because sometimes you may identify some neuromas over here,

15:57

or at times, you know, if you're injecting the compartment,

16:00

one tendon with a steroid, which is frequently done

16:02

with a DEA vein stern synovitis, you may actually, you know,

16:07

uh, you have to be sure that you're not, uh,

16:09

enjoying the nerve in any which way

16:11

while doing this injection.

16:14

So next, coming to the flexor

16:17

or the lar compartment, uh, again,

16:20

the positioning over here is very simple.

16:22

You can, again, have this patient either sitting on a table

16:26

or, uh, at times I even do this, uh, with a supine position,

16:30

you can keep the hand on a pillow,

16:31

but this is not, uh, always really necessary.

16:34

It's quite easy to analyze the flexor compartment.

16:38

So as far as the flexor compartment is concerned,

16:41

what are we trying to identify?

16:43

We are trying to identify the most important structure,

16:46

which is the carpal tunnel.

16:48

I'm sure everyone has heard of that.

16:50

We'll be looking at the ple tendons,

16:53

we'll be looking at the median nerve very importantly.

16:56

And then the GaN scanner.

16:58

So the carpal tunnel, as we know, is a fibro tunnel, right,

17:03

which is bounded proximally by the scaphoid

17:07

and the pisiform and distally.

17:09

You have the trapezoid and the hammock.

17:12

And this is covered by this transverse carpal ligament,

17:16

which is, you know, kind of a trapezoidal, uh,

17:20

shaped ligament, which covers, uh,

17:22

or it forms the roof of this fibrous tongue.

17:27

So how do we identify this on ultrasound?

17:30

It's, uh, fairly simple.

17:32

Uh, again, what we do is go back

17:34

to identifying our bony landmarks.

17:36

So as far as the proximal aspect

17:39

of the car tunnel is concerned,

17:41

what we do is we identify the bony land monks

17:44

of this scaphoid and the pisiform.

17:47

And once we keep our probes, uh, you know, probe

17:50

with the edges joining these two uh, bones,

17:53

we should be able to identify the proximal aspect

17:56

of the carpal tunnel.

17:57

The other landmark, which we can use

18:00

to identify this is actually, uh,

18:02

look at the Palmer crease, right?

18:05

So the proximal aspect

18:06

of the carpal tunnel corresponds somewhere

18:08

to the palm of crease.

18:10

So this is again, a landmark which you can use

18:12

to identify the carpal tunnel.

18:15

As you move a little more distally,

18:17

you can identify the bony landmarks of the trapezium

18:20

and the hook of the hammit.

18:22

And this is the distal portion of your carpal tunnel, right?

18:26

And if you look at this,

18:27

there's this subtle hypo hypoechoic structure, which is, um,

18:32

you know, um, uh, traversing on top, forming the roof.

18:36

Uh, this is actually your flexor ulu.

18:39

And line underneath, below these flexor oculus are the, uh,

18:43

flexor macular is the, uh, content of the carpal tunnel,

18:47

which is formed predominantly by the flex tendon

18:49

and your median, no, right?

18:52

So, uh, once you are looking, uh,

18:55

once you have identified the boundaries of the carpal tunnel

18:58

and you start looking inside the carpal tunnel,

19:01

what you want to identify is these tendons.

19:05

So you have four flexor digital superficial tendons.

19:09

You have four flexor profundus tendon.

19:12

Next to that, you have the flexor s longest tendon, right?

19:17

So these are the important tendons that we want to identify,

19:21

and it's, uh, fairly easy.

19:23

It may be a little challenging to identify these tendons

19:27

and separate them out, you know, at the level

19:29

of the carpal tunnel, because the other problem which

19:31

happens over here is something called as a,

19:34

an isotropic, right?

19:35

So because of that, you know,

19:36

the tendons may appear a little hypo at times,

19:40

it may be a little confusing to identify the tendons,

19:42

but if you rock the probe, you know,

19:44

just angulate the probe a little approximately

19:47

and distally, you will be able to identify these tendons.

19:51

So you can see that the tendons are actually changing in

19:54

color from black to white, right?

19:56

So it is turning from hypoechoic to hyper echoic.

19:59

And, uh, this is, uh, definitely a tendon.

20:03

And if you see the structure sitting on top over here,

20:06

which is not really changing an appearance,

20:08

when you are toggling the probe,

20:09

this is actually your median node, right?

20:13

So this is the way you can really

20:15

identify the flex of tendon.

20:17

And once you have identified the flex tendon,

20:20

you can move this

20:21

and identify the flex tendons going

20:24

to the individual digits, right?

20:26

Which you may need to do in case of a trauma,

20:29

or you want to evaluate any other pathology

20:30

involving the flex tendon.

20:34

Then the other important structure over here,

20:36

like we mentioned, is the median nerve.

20:38

So the median nerve, uh, I told you

20:40

what happens is if you toggle the probe over here,

20:43

you should be able to identify this as this, you know,

20:46

hypo icic structure not changing in genicity.

20:50

And, um, uh, if you, uh,

20:53

look at it very properly in the actual section,

20:56

you get this kind of a honeycomb pattern, right?

20:59

So you see this hypoechoic hyper echoic areas.

21:02

This is, uh, very classical appearance of your median nerve.

21:06

So even the median nerve, we can trace it distally.

21:10

You can look at the branches of the median nerve,

21:12

the sensory branches, the motor branches, right?

21:15

It can be identified with a high resolution.

21:19

Now moving on from the caral tunnel, we move on

21:23

to the NAR aspect.

21:24

And here what we identify is the GYN canal, right?

21:28

So the gyn cannel is formed, uh, the roof

21:31

of the GYN canal is formed by the lar caral ligament.

21:34

The floor is formed

21:36

by the transverse carpal liga li transverse carpal ligament,

21:39

or the flexor retinal liga, which we saw on the radial side.

21:43

You have the hook of the habit

21:45

and the medial border is formed by the pisiform boat.

21:48

And what is lying within this GaN scan is actually

21:52

your NAR artery.

21:54

And next to that, what is sitting over here is your Allah.

21:57

No, right? So this is again, something that we, uh, uh, do,

22:01

uh, try to evaluate if there are suspected entrapments

22:05

of the al no.

22:07

Uh, the other important thing is, as you trace this, Al no,

22:12

you move a little more distally,

22:13

the alano splits into a motor and a sensory branch,

22:17

and the motor branch goes very close

22:20

to the hook of the hammit.

22:22

And this is prone to injury, uh, when there is a fracture

22:25

of the hook of the hammit, right?

22:27

So this is something that we can definitely try

22:31

and quite easily identify on our ultrasound.

22:35

Now, moving on from the wrist, I'll quickly cover up the,

22:39

uh, structure of the fingers as well.

22:42

Uh, so the, the flexor tendons, as we know,

22:45

as we trace these, uh, tendons more distally

22:48

and from the wrist as they go into the palm

22:51

and into the fingers, uh,

22:53

what happens is they are seeing these two

22:55

tendons very distinctly.

22:57

We have the flexor digitorum superficialis,

23:00

and we had the flexor digitorum profundus, right?

23:03

So what is situated deep over here,

23:06

this structure is your flexor digitorum profundus,

23:09

and what lies superficially is your flexor

23:12

digit superficialis.

23:14

So if you observe this very keenly,

23:17

as we move distally towards the fingers,

23:20

the flexor digitorum superficialis is actually

23:22

splitting into two.

23:24

This is what happens. And the two, uh, slips

23:27

of the flexor digitorum superficialis insert onto the

23:31

lateral aspects or the b uh, in the mid portion

23:34

of the mid failings, right?

23:36

So this is how we identify.

23:38

This is the flexor digitorum superficial tendons,

23:41

and whereas the flexor digitorum profundus tendon goes more

23:46

distill and inserts onto the base

23:49

of the distal balance, right?

23:51

So you can see that this is the pro, uh, uh,

23:54

profundus tendon, which is going more distill.

23:57

You can see that the superficial tendon has split up,

24:00

and the profundus tendon is going more dis it is deep

24:05

situated and going more dis,

24:07

these tendons can be very nicely evaluated on a

24:10

longitudinal plane as well.

24:12

You can very nicely see the insertion

24:14

of this flexor dig profundus at the base

24:17

of the distal balance, as you can see over here.

24:20

And this entire tendon, the superficial is as well

24:23

as the profound disc, can be very nicely traced on

24:26

or sound using our higher resolution probes, right?

24:29

And again, this is important when you are trying to look at,

24:33

uh, any trauma anywhere you're trying to identify the site

24:36

of trauma to be standards.

24:38

Another important structure, which is lying, just, uh,

24:41

below these, uh,

24:43

flexor tendons over here is the wall art plate.

24:46

And, uh, uh, this is again, something which can be injured

24:49

with a hyperextension injury.

24:51

So, very rarely, once in a while,

24:53

we do come across these pathologies as well.

24:56

Now, the best part about using ultra ultrasound is the

25:00

ability, uh, for us to do a dynamic scan, right?

25:04

So not only can we evaluate the length of the fingers,

25:07

we can actually, you know, see the function as to how these,

25:11

uh, tendons are performing.

25:13

So, uh, if you, you know, if you move the finger,

25:16

you can see that this, the flexer digitorum superficial is

25:20

as profundus are moving.

25:21

If you want to evaluate only the profundus, you can,

25:24

you know, uh, stabilize the proximal phalangeal joint move

25:27

only the distal interphalangeal joint.

25:29

And in that case, you can see only the flexer digitorum

25:32

profundus moving, right?

25:35

So again, very important aspect of ultrasound to evaluate,

25:38

uh, these tendons on, uh, with a dynamic scan.

25:42

Uh, the other important thing when it comes

25:44

to the flexor aspect at the level

25:46

of the fingers is the presence of the pullies, right?

25:49

So there are multiple pulleys,

25:51

I am sure all of us know about it.

25:53

And, uh, how they are seen on our sound is this hypoechoic

25:58

structure, which is surrounding the flex attendant

26:01

and, you know, kind of keeping the flex attendant

26:04

in place, right?

26:05

So this is how the, uh, uh, a one fully looks, uh,

26:09

this is even one at the level

26:10

of the metacarpal engine joint.

26:11

You can evaluate the A two, A three, A four, uh,

26:14

police as well.

26:16

And, uh, the other thing which is important

26:18

and which is very useful with the ultrasound,

26:20

especially we using our very high resolution transducers, is

26:24

that we can now actually even

26:26

evaluate the neurovascular bundles at the level

26:28

of the fingers, right?

26:29

So these are actually the digital vessels

26:33

and the digital norm next to it.

26:34

So we can identify the pathologies involving these

26:38

structures as well.

26:40

Uh, the dorsal aspect

26:41

of the fingers is relatively more difficult to, you know,

26:46

identify and visualize as compared to the, uh, uh,

26:50

flexor aspect, uh,

26:51

because the structures over here are very, very thin.

26:54

So you have to use a lot of jelly.

26:56

You have to, of course, use a high freq highest frequency

26:58

trans to be able to identify these structures.

27:01

And what you are able to see is the extensor tendon, similar

27:05

to how we saw the flex tendon.

27:07

You have the extensor tendon splitting into the lateral

27:10

bands and, uh, you know, inserting onto your distal phx,

27:13

whereas the central slip inserts somewhere in the, uh, uh,

27:17

in the, uh, proximal aspect of the mid.

27:20

And similar to what we saw on the flexor side

27:23

where we had the pulley,

27:24

you have these sagittal bands at the, uh,

27:27

or, you know, forming this extensor hood,

27:29

which stabilize the extensor tendon

27:31

and prevent any lateral displacement.

27:33

Uh, so again, using ultrasound, all

27:36

of this can be quite nicely seen.

27:39

So any, uh, injuries,

27:40

any pathologies over here can be fairly easily identified.

27:45

So now, once we have had a look at the basic anatomy

27:49

of the structures, we will move on to some

27:51

of the common pathologies that we encounter.

27:54

And for the ease of, uh, discussion, uh, just, uh,

27:57

split this into, um, the, uh, you know,

28:01

a vascular inflammatory infective, neurogenic traumatic, uh,

28:04

and miscellaneous pathologies.

28:06

So we'll just see a few of them.

28:08

Uh, now, vascular bowel formations are something which are

28:12

quite frequently seen on the hand

28:13

because, you know, especially they are, uh,

28:15

quite frequently prone to trauma, right?

28:18

And this typically present with, uh,

28:20

very heterogeneous appearance.

28:22

You may see, uh, you know, some amount of arterial,

28:25

some amount of venous flow.

28:26

You can see the strangle of vessels.

28:28

It's at times quite difficult to identify the feeding artery

28:32

or the drain vein if it's art,

28:35

two venous malformation, right?

28:37

And if there these are slow flow malformations,

28:40

then you may need to give a little bit of compression

28:42

to really see these, uh, uh,

28:45

to see the flow in these areas quite well.

28:48

And, uh, ultrasound plays a very important role, not only

28:51

to identify, but suppose if you've, you know, done, uh, uh,

28:55

embolization for these vascular malformations

28:57

or something to that effect,

28:58

you can just follow them up using an ultrasound rather than,

29:01

you know, needing to do an MR or anything else.

29:04

And it definitely gives you an answer as to

29:06

how well the surgery has gone off.

29:09

Well, Algio mask can typically present with these lipids

29:13

that can give shadowing,

29:14

and this is a cue that this can be, uh, hemangioma.

29:18

Uh, like I mentioned, we do come across, uh, trauma

29:21

to the finger, well, frequently.

29:23

Uh, and one of the complications can be an AV fistula.

29:26

So you can see dilated artery, uh, dilated veins rather,

29:31

and you can identify this kind

29:33

of an arterial flow within the radial vein, right?

29:36

So this is a very good clue as to, uh, that this is, uh,

29:40

probably an AV fistula now coming

29:42

to the inflammatory pathologies, which is

29:44

what we see most frequently in the hand, right?

29:47

And this, the vein sitis, I'm sure everyone has, uh,

29:51

heard about that is one of the commonest, um,

29:53

problems that we encounter.

29:55

Uh, so this is an atten cytovitis involving the

30:00

compartment one tendons.

30:02

So, uh, this can happen because of overuse,

30:04

and what we see on ultrasound is the thickening

30:08

of the sheath, right?

30:09

So normally this is a very thin sheet,

30:11

but here you can identify there is thickening of the sheath,

30:13

there may be muscularity.

30:16

Uh, you can always, uh, try to identify the vascularity,

30:20

but it doesn't really always add up to anything.

30:22

Uh, the thickening is what is more important,

30:25

and this is another huge advantage

30:27

of ultrasound sometimes when the thickening is very subtle,

30:30

and we have a doubt that the, as

30:31

to whether there's thickening or no, we can always go

30:34

and do a quick comparison on the other side as well

30:37

to get a quick answer, right?

30:40

Uh, this can be associated with tenitis.

30:42

Uh, not only, um, I mean, if you,

30:44

if you're looking at deca veins, yes,

30:46

they can be 10 synovitis of the, uh, tendon sheet.

30:49

I mean, along the, they can be fluid

30:51

along the tendons as well.

30:52

Uh, teno synovitis can occur along any of the tendons.

30:55

Uh, like I was talking to you sometime back about, you know,

30:58

the xeno virtus affecting the extensive tendons.

31:01

This is a very, very subtle tenino synovitis affecting the

31:05

compartment three tendons.

31:06

And the idea of showing this is, you know,

31:08

our sound is actually able to

31:10

identify these very subtle findings, right?

31:13

And the other important thing is that, you know,

31:16

invariably you have a patient with you on the bedside,

31:19

so you can actually ask the patient as to which is the side

31:22

of pain, which is the side of tenderness, you know,

31:24

trying do a good quick clinical correlation,

31:27

and you actually fair much better.

31:31

Uh, so yes, uh, tens synovitis is something

31:34

that we can frequently see.

31:36

This can go along the extens tendon,

31:38

the flex tendon, or wherever.

31:40

And, uh, when you do see, uh, tens synovitis, uh,

31:44

or, you know, sometimes this can be associated

31:46

with a trigger of finger, right?

31:48

Especially if you're looking at, uh, pain in this region.

31:52

And sometimes this patient can come with a trigger.

31:54

So, you know, they say that there's a, uh,

31:57

there's a flexion deformity,

31:58

and the moment they try

31:59

to extend the hand, it kind of clicks.

32:01

And what you are able

32:03

to identify is this fully

32:05

thickening something like this over.

32:06

So normally apui is, uh, say about, uh, three millimeters

32:10

or so in thickness normally.

32:12

So if you, uh, point, uh, if you, uh, 0.3 millimeters,

32:15

I'm sorry, 0.3 millimeters in thickness.

32:17

So if you see a thickening of the pulley more than that,

32:19

you are potentially looking at the pulley thickening.

32:22

And, uh, this can be associated with, uh, flexor, uh,

32:26

sitis as well.

32:28

But if you see this kind of a nodular appearance

32:31

of the fluid along the tendon, you have to think of, uh,

32:35

an inflammatory pathology.

32:37

And this can go not only along the tendons,

32:39

this is more frequent along the joint spaces.

32:43

So if you look at the distal radio, the joint space,

32:45

you can see that there is some, uh,

32:47

soft tissue proliferation over here,

32:49

some IL thickening over here,

32:51

and, uh, you can identify even, uh, increase vascularity,

32:56

or like in this case, they can be even bony erosions, right?

33:00

So this entire spectrum

33:01

of inflammatory arthritis you can potentially look at.

33:05

We are increasingly nowadays using the eular oac,

33:08

uh, PDUS scoring.

33:10

So which grades the, uh, cytovitis in terms of

33:14

what we see on B mode, uh, combined with

33:17

how we see this on the power doppler,

33:19

how the vascularity is coming up on power doppler.

33:22

We assign it a particular grade.

33:24

And when these patients come for a follow up, you know,

33:27

we can evaluate this again,

33:29

we can tell them whether the therapy is working

33:31

or not working as well.

33:33

And, uh, this is where ultrasound can, uh, you know,

33:37

or really help, uh,

33:38

identifying the subtle thickening

33:40

subtle increase in vascularity.

33:42

It's definitely very helpful.

33:45

Infective pathologies are not something

33:47

that we see very, very frequently.

33:49

Once in a while, yes,

33:51

you may see something like an infected penis titis,

33:54

you have a tendon which is thickened.

33:56

You can see these kind of moving equals over here.

33:59

Uh, and of course, uh,

34:00

this patient will have a typical clinical profile, uh,

34:04

maybe a diabetic, maybe a immunocompromised, you know,

34:07

he'll have a lot of pain, ery, mass swelling over the joint,

34:10

and this is how they typically present.

34:13

Uh, but more often we do end up seeing osteomyelitis

34:17

where you can have, uh, you know, inflammation of not only,

34:22

uh, uh, the tendon, uh, sheet,

34:24

but you, you may have this spreading into different

34:26

compartments of the tendons, uh,

34:29

different, uh, you know, layers.

34:31

Uh, this may be a skin substitute involvement,

34:34

thickening multiple things.

34:35

Uh, you know, you may have even like buny erosions.

34:38

So, uh, this is something that,

34:40

that we do come across once in a while, neurogenic, uh, uh,

34:45

lesions as far as, uh, they are concerned,

34:48

the commonest thing

34:49

that we do encounter is the nochi tumor, right?

34:52

So nochi tumor can of course, affect any part

34:55

of the nerve anywhere.

34:56

And what we do see is this very classical appearance

35:00

where we have a bulbous enlargement, a lesion,

35:03

which is a traversing along the no.

35:06

And the reason ultrasound plays a very important role over

35:09

here is that you can actually trace this

35:12

entire nerve, right?

35:13

So even the smaller branches of the nerve, you can trace,

35:16

you can see that this lesion is actually coming up along the

35:19

branch of, uh, this nerve, uh, uh,

35:21

which you can see identify over here.

35:24

And you know that yes,

35:25

you're definitely looking at a neuro sheet tumor.

35:28

And on ultrasound you can get these very nice images,

35:32

what we call as a sign.

35:34

So you can see that, uh,

35:36

this is the normal nerve on either side of this, uh, lesion.

35:41

So we are very sure that this is a nerve sheet tumor.

35:44

Uh, and the other thing is, you know, like I said, uh,

35:48

because the patient is going to be with you,

35:49

you can do some clinical correlation.

35:51

So the moment you press on this area where you,

35:54

you can see this lesion, uh, the patient will, you know,

35:58

probably have the sudden tingling numbness or shooting pain.

36:01

So you know that yes,

36:02

you're definitely looking at a neurogenic lesion, right?

36:07

Um, you can potentially identify, differentiate between s

36:12

and neurofibromas, so it can be a little difficult,

36:14

but, uh, shawa may have, uh, areas of calcification

36:18

or hemorrhage or, uh, something else.

36:20

Uh, this is again, uh, something very important.

36:24

Uh, because of the advent

36:26

of our very high resolution transducers,

36:28

we can now look at these digital nerves, like I said.

36:32

So in fact, this was a patient who had a trauma,

36:35

and you can see a very subtle pelvis lesion

36:38

along the digital nerve.

36:39

And this was actually a,

36:41

a post-traumatic neuroma involving the digital nerve,

36:44

which can be fairly easily identified

36:47

with a high resolution pro.

36:49

And if you do get this kind of a picture where, you know,

36:52

multiple nerves are getting affected, so this was, uh,

36:55

the median nerve, we have the NAR nerve, um, um,

36:58

the common peronial nerve in the foot,

37:00

you're thinking in terms of, uh, poly neuritis.

37:03

And in fact, in India,

37:04

we do end up seeing Hansons once in a while,

37:07

maybe once a year or once in two years.

37:09

But we do come across this once in a while,

37:12

and now coming to, uh, one of the most, uh, important

37:16

and the commonest problem that we encounter,

37:18

which is the carpal tunnel syndrome.

37:21

So we have already had a look at the anatomy

37:23

of the carpal tunnel, and we know that, uh, you know,

37:25

we can very nicely identify the median nerve.

37:28

So the median nerve, uh, typically, um,

37:31

supplies these fingers.

37:33

So you have the, uh, first two, uh, first three,

37:35

and, uh, some, uh, the radial part of the fourth as well,

37:40

which can be supplied by the median nerve.

37:42

So we can identify the compression

37:45

of the median nerve in the carpal tunnel quite nicely

37:49

using ultrasound.

37:50

So, uh, if you remember,

37:52

I showed you a nice fascicular pattern

37:54

or honeycomb appearance of the nerve, um, uh,

37:57

when we saw it in the carpal tunnel

38:00

and the moin, you have, uh, carpal tunnel syndrome

38:03

because of the compression of the nerve,

38:06

you do end up getting this kind of a picture

38:08

where you see edema of the nerve,

38:11

and there's a loss of that honeycomb pattern.

38:13

There's a loss of that vascular structure.

38:15

And if you look at it in a longitudinal section, you can see

38:18

that yes, the nerve is, you know,

38:20

suddenly changing in diameter a little bit.

38:22

So this is where we use our criteria of size, right?

38:27

So we take the, uh, uh, circumference

38:31

of the no, and if the circumference is less than 10

38:35

millimeters square, we say that this is normal.

38:37

If it's between 10 to 14 millimeters square, it,

38:40

it tends to be borderline.

38:42

But if the patient is having symptoms and, you know,

38:46

or if there's, uh, some positive finding in the nerve

38:49

conduction study and you are seeing a diameter of about 10

38:52

to 14 millimeters, uh, square,

38:54

then you can consider this significant.

38:57

And if you see an a, uh, you know, uh, circumference,

39:00

which is area which is going more than 14 millimeters

39:02

square, you are definitely looking at a carpal

39:06

tunnel syndrome, right?

39:08

And one important thing that you need

39:10

to do is when you are doing these measurements,

39:13

it's important that we do this measurement

39:17

with a free hand, right?

39:19

So if you use a ellipse, which may be given

39:21

with the machine, which may be with the machine, uh, you,

39:26

you may have a little bit of a challenge getting it.

39:29

So using free hand

39:31

and drawing this caliper is very, very important.

39:34

And this is how you calculate the area

39:36

of the median, no, right?

39:38

And, uh, this 14 millimeter square is fairly sensitive

39:42

for saying whether, uh, uh,

39:44

this particular no is affected all.

39:47

No. The other important criteria that we use is

39:50

that we look at the area of the nerve at the level

39:54

of the carpal tunnel and at the proximal third

39:57

of the pronator quad muscle, right?

40:00

So a little proximally, we look at the level

40:03

of the pronator coordinators,

40:05

and if there difference in this area is more than two

40:10

millimeters square, then again, with a good degree

40:12

of certainty, we can say that yes, there is compression

40:15

of the nerve and, um, uh, there is a presence

40:18

of this carpal tunnel syndrome.

40:20

So again, what we are trying to identify is the presence

40:23

of edema, right?

40:25

So the moment there is compression of the nerve,

40:28

what we get is, uh, edema proximal

40:31

to the site of compression.

40:32

And this is what we are trying to identify using our area,

40:37

uh, parameters, right?

40:40

Uh, there are, uh, a lot

40:41

of other signs which are been described

40:43

for identifying carpal tunnel or art sounds.

40:45

You can have, you know, something like a knot sign

40:48

with nerve flattens at the side of compression,

40:51

and it thickens proximal to the side of compression.

40:54

Uh, you can always compare it to the other side.

40:56

You can see that this is definitely more

40:58

edemas as compared to this.

41:00

And at times you may end up seeing something like a bowing

41:03

of the flexor ulu as well, right?

41:07

Uh, so normally the flexor ulu has a flattened appearance,

41:11

but you're, you may end up seeing a little bit of a bowing.

41:14

Uh, but, uh, as far as routine clinical practice scores,

41:18

we rely on two things, uh, where, uh, the,

41:21

where we look at the area, number one

41:24

and second is the difference in the area

41:26

and the level of the carpal tunnel versus the level

41:29

of the prenatal quad is, right?

41:31

So this is what, uh, really a lot

41:33

of importance on in our routine practice.

41:35

But the other very, very important thing is that we have

41:39

to rule out secondary causes of the carpal tunnel, right?

41:42

It's a majority of the times when these patients present.

41:45

We already know that we are looking at the carpal tunnel

41:48

syndrome, right?

41:49

So we have to look, look out for any other causes,

41:52

if there's any, um, ganglion or any, uh, tenitis

41:56

or anything which is causing compression of the no,

41:59

because the management is going to be dependent on that.

42:02

Now, coming to the traumatic causes, uh, yes, we,

42:06

if there's a presence of trauma, uh, if there's a hemato due

42:10

to trauma, we can see a whole bunch of things.

42:12

You can see presence of, you know, uh,

42:14

hypoechoic areas if it's a acute fluid,

42:17

or you may see something like this

42:18

where there's a organized hema,

42:20

which is compressing the tendon or the nerve

42:22

or something, right?

42:23

Uh, and like I said, hand is something which is

42:26

very frequently injured.

42:28

Um, we do see a lot of foreign bodies as well,

42:31

and if there are foreign bodies,

42:32

there's like a wooden piece, uh, it appears

42:35

as this bright e echogenic lesion.

42:37

And, uh, sometimes you can see this kind of inflammatory

42:41

response around that, uh, uh, that foreign body once, uh,

42:45

granuloma is setting in.

42:48

But when you have a foreign body, uh, you know, one

42:51

of the things that we need to try

42:53

and identify is the presence of our tendon injury, right?

42:58

So, like I mentioned,

42:59

because our sound is, uh, dynamic in nature, we can actually

43:03

identify the tendons very nicely.

43:05

We can look at individual attendance,

43:07

we can look at the flex of digitorum superficial list.

43:10

We can look at the flex of digitorum to fund us.

43:12

We can identify the site of tear,

43:15

we can identify the distance between the tone edges.

43:18

Again, a lot of, uh, you know, uh, uh, important, uh, data

43:23

that we can provide to the surgeons.

43:26

And, uh, of course,

43:28

it's not only the tendons which can get injured,

43:30

you can have injury to the nerve as well.

43:32

For example, this was a penetrating injury

43:35

where you had injury to the median nerve as well,

43:38

apart from the tendons, right?

43:40

So, um, always we have to keep our, uh, eyes open.

43:45

Uh, again, a very important case where, uh,

43:48

there was a suspected, uh, tear of the extensor, uh,

43:53

s longest tendon, the compartment tree tendon,

43:55

which is very thin, you know,

43:57

and at times very difficult to identify.

44:00

So what helps over here is the comparison.

44:02

So you can see that this is the compartment,

44:04

two tendon on the right.

44:05

Uh, this is the compartment two on the left.

44:07

This is the listers,

44:08

and we should see this very small tendon sitting over here,

44:12

but we are seeing that there's no hyper coic

44:14

tendon sitting over here.

44:15

So the next step is going to be to try and trace the tendon

44:19

and see where it spins.

44:21

So if you look at this image a little properly, you can see

44:23

that there's a bunch of tendons sitting somewhere

44:25

over here, right?

44:26

So this is where the retracted portion of the tendon was.

44:30

So this was the proximal edge, this was the distal edge,

44:34

and it is important, uh, like I said, you know,

44:36

you mentioned how far, uh, what is the gap

44:39

between the two edges?

44:40

And, and this is very important from a surgical perspective,

44:44

but the best part about this is, you know, we can

44:47

identify these edges on ultrasound without really having

44:51

to change our coil, without having to really,

44:54

you know, move the patient.

44:55

All you have to do is just, you know, mobilize your probe,

44:58

move it little approximately, move it little history,

45:00

and you can get a whole bunch of this information.

45:03

Uh, very rarely you do end up seeing collateral

45:06

ligament injuries as well.

45:08

You can identify them, uh, maybe a thickening,

45:11

maybe a partial tear, maybe even a complete tear.

45:13

But, uh, again, the idea

45:15

of showing this is using our high resolution probes.

45:18

We can identify these small structures like

45:21

the collateral ligaments.

45:22

A place where ultrasound plays a very,

45:25

very important role is in postoperative assessment, right?

45:29

So a good number of times these patients may not mean a

45:32

position to undergo mr, or if you do go Mr.

45:34

Undergo Mr, there may be some, uh, possibility of artifacts.

45:37

Yes, there are, you know, ways to suppress the artifacts

45:40

as well now, but, uh, artisan provides a very,

45:43

very easy answer.

45:44

So, for example, this was a patient who had, uh,

45:47

10 synovitis along the XI tendon.

45:49

So this, uh, the patient initially had fracture,

45:52

there was a screw plate put at the distal end of the radius.

45:56

Uh, patient came with, uh, you know,

45:58

difficulty in moving, uh, the fingers.

46:00

And what we saw is that there's, uh,

46:03

definitely some synovitis along the flexor

46:06

digital room tendons.

46:07

And the cause of it was actually this orthopedic hardware,

46:11

which was upgrading against the tendon sheet, causing,

46:15

you know, repeated irritation.

46:16

And, uh, as a result of this, there was a 10

46:19

of synovitis, right?

46:21

So very easily we can really give up these

46:24

answers on ultrasound.

46:26

Now, coming to neoplasms, uh, not something

46:28

that we see very frequently,

46:29

but what we do encounter frequently is lipomas, again,

46:33

very easy to diagnose clinically on ultrasound, they appear

46:36

as iso two hyper lesions.

46:39

There's no vascularity.

46:40

You see this very classical code, uh, you know,

46:43

eco lines parallel to the skin surface.

46:46

But what is important is

46:48

that we identify the plane they're in, whether they are,

46:51

you know, in the subcutaneous tissues,

46:52

whether they're in the, in the muscular plane,

46:54

if they're in the intermuscular plane, are they segregating?

46:57

You know, are they pushing, uh, different structures?

47:01

So this is, uh, something that we need to give an answer on.

47:05

And more important, rather than just saying

47:07

that there is a lipoma, uh, another common thing

47:10

that we do encounter is the GCT of the tendon sheet.

47:14

Now, this is actually a localized nodular, you synovitis.

47:19

So what we do see is this kind of a soft issue,

47:22

hypoechoic soft tissue,

47:24

and just in the tendon, uh,

47:26

it can show vascularity on doppler very,

47:28

very closely associated to the tendon sheep

47:31

eccentrically located to the tendon, something like this.

47:34

And if you move the tendon,

47:35

the tendon will actually show a normal movement, right?

47:38

So again, that's something

47:39

that you can do dynamically on your heart.

47:41

So, and at times, uh, you may see this kind of a picture,

47:46

you may see this little bit of a scalloping of the bone.

47:49

So all very, uh, classical features of a GCT

47:52

of the 10 sheet,

47:54

or once in a while, we do come across a lumous tumor,

47:57

which is a benign

47:58

or vascular tumor at the base of the fingernail.

48:01

Extremely sensitive to touch.

48:03

But once you put your probo here, you can see

48:06

that you can actually identify the nail bed over here.

48:09

Uh, so this is again, the magic

48:11

of high resolution ultrasound.

48:12

You can identify the nail bed, you can identify

48:15

that there's a lesion sitting over here,

48:16

which is a very vascular lesion in Subungual location.

48:20

So we know that yes, you are potentially looking

48:22

at a GLO tumor.

48:24

And again, if doubt persist, you can always go

48:28

and compare to your other side.

48:30

So this is, again, I'm stressing on this

48:32

because, you know, these are just some wonderful images,

48:34

and every time you see this on ultrasound, it kind

48:36

of carries you away.

48:38

But you can see these nail beds

48:39

and, you know, structures like this

48:40

so very nicely on our ultrasound.

48:44

And then we can once in a while come across things like

48:46

epidermal inclusion system.

48:48

I'm not gonna be stressing on that.

48:49

Pseudo rheumatoid nodules, uh, which, uh, you know, uh,

48:53

which can come up in a young age group.

48:55

They are painless, solitary masses.

48:58

Uh, doesn't nothing really be needs to be done for them.

49:01

Uh, you just follow them up, then they

49:05

shouldn't be a problem.

49:07

Uh, you can encounter soft tissue calcifications in cases

49:10

like scleroderma.

49:12

Again, um, this is not very frequent.

49:14

Once in a while you can, uh, come across,

49:17

but, uh, if you're talking about the wrist,

49:21

the most common thing

49:22

that we really encounter is the ganglion, right?

49:25

So I'm sure all of us have encountered this, uh,

49:28

which is a cystic structure

49:31

and, uh, filled with, uh, ness, material

49:34

and wrist is a very, very common, uh, location of, uh,

49:38

the ganglion cyst, right?

49:40

So commonly, uh, found somewhere

49:42

or possibly over the scap ligament on the ULA side

49:45

between the radial art and the ple carpit DL is tendon.

49:49

Again, it's a painless mass.

49:51

Uh, and again, you know, majority of the times, uh, uh,

49:54

the clinician is aware that this is going

49:56

to be a ganglion cyst.

49:58

We are idea is just to confirm the diagnosis,

50:01

tell them the location.

50:03

And also very important, uh,

50:05

aspect is identifying the relation

50:07

to the ent important structures, right?

50:10

So if, uh, the surgeon is gonna go in

50:12

and excise, you want to know whether really artery is,

50:15

whether no is, you know, um, so that is the, um,

50:19

information that we really need to give them.

50:24

Uh, the other thing, uh, that we need to tell them is

50:27

where the gang ancestors is coming from.

50:29

And majority of the times, uh, there is a communication

50:33

with the bone, so if,

50:34

or the intercarpal joint spaces, right?

50:37

So, uh, if you make a little bit of an attempt

50:40

and, uh, give it a little bit of a hard look,

50:42

you will be able to identify this kind of a very subtle,

50:46

you know, um, uh, stock kind of a thing,

50:49

which goes all the way somewhere towards the bone, so

50:52

that you know, you know that yes,

50:54

this is probably arising somewhere from the joint spaces.

50:58

Uh, very rarely, uh, you do have, uh,

51:00

ganglions coming up from the tendon.

51:03

She or, uh, very, very rare you can have them, uh,

51:06

located within the muscles as well.

51:10

Um, so thank you for patient hearing.

51:13

Um, and, uh, the, the, the idea of this talk was just to,

51:18

uh, you know, uh, let you know how, uh, uh,

51:21

wonderful ultrasound can be as a primary modality,

51:25

and there are a whole lot of answers

51:26

that we can really go in,

51:28

and not every case of, uh, uh,

51:30

wrist will probably need an MRI for a diagnosis. Thank you.

51:35

Awesome. Thank you so much Dr.

51:36

Trouble for that lecture today.

51:39

I think I see one question popping up in the q

51:42

and a, if you wanna open that up

51:43

and start answering some of those.

51:44

Um, yes.

51:50

Okay, so the question over here is where should we, uh,

51:53

measure the median nerve before or in the canal?

51:57

Okay, so the, uh, like I showed you, there are two places

52:00

where measurement is most important.

52:03

One is at the site where it's entering the canal,

52:05

so at the proximal edge of the carpal tunnel.

52:08

And, uh, then we measure it somewhere a little more

52:10

proximally at the level of the ator quad, right?

52:13

So you're actually able to see this ator quad

52:17

and, um, at the ator quads muscle,

52:19

and that is what we use for identification.

52:22

Having said that, the median nerve compression can also

52:25

happen within the tunnel.

52:26

It can happen distal to the tunnel.

52:28

So it's always a good idea that you trace the entire aspect

52:32

of the median nerve till it branches out.

52:34

And, uh, you may end up picking, uh,

52:37

up some compressions over there as well.

52:43

Okay, so somebody's requesting for A-T-F-C-C again, uh,

52:47

I'll show that, but, you know, TFCC is not something

52:50

that we really go all out and go, go on ultrasound.

52:54

Uh, but yes, if you do want to evaluate the TFCC, sorry,

52:58

I'm trying to share my screen again.

53:02

Yeah, so, uh, so what we do is with the hand in the

53:06

PDL deviation, right?

53:07

Uh, my, um, idea is first

53:10

identify the extensia carpi RIS tendon, right?

53:13

And just below the extensa carpi RIS tendon,

53:16

I do end up seeing, oh, sorry, I'm sorry about that.

53:20

Yeah. And just below the extensia carpi tendon,

53:24

I end up seeing this structure over here,

53:26

and this is my TFCC.

53:28

So, um, again, uh, um, it is not, um, uh,

53:32

you may not be able to see the deeper aspects of the TFCC,

53:35

so you can't always, uh, see whether there's an injury

53:39

or no, but at times, if you want to inject into the TFCC,

53:42

this is, uh, you know, something like a landmark

53:45

that you can use if you want to do that.

53:52

So there's a question.

53:54

Do you use comparison everywhere in a borderline media

53:58

now or always?

53:59

Okay, so if you go back to, in fact, I'll try

54:04

and show you this, uh, slide again.

54:10

Yes. So, uh, see if you, if you, if you, um,

54:13

look at this slide, you know, a, uh, when,

54:16

when are we looking at a couple tunnel syndrome?

54:19

Now, majority of the times when these patients come in,

54:21

you know, we already know there's a couple

54:23

tunnel syndrome, right?

54:25

So again, one of the ideas is to confirm,

54:27

and the second is to rule out any other, you know,

54:30

secondary cause of the carpal tunnel.

54:32

That is what we want to do on al ultrasound.

54:35

Now, uh, if you have a patient who is symptomatic, right,

54:39

uh, and you are getting these values of say, about 10 to 14,

54:42

then yes, we can say that, you know,

54:44

there's potentially a carpal tunnel.

54:46

And yes, in these cases I would want to compare

54:49

with the other side and see if, uh, you know,

54:51

how the other nerve is looking.

54:53

Um, but if, you know, if you have, um, um, no,

54:56

which is very significantly enlarged,

54:58

maybe 20 millimeters square

54:59

or so, you can say with more certainty.

55:01

And you know, in those cases you may not always need a

55:05

comparison, but, uh, it's always maybe a good idea to just,

55:09

uh, have a look at the other side.

55:10

And I think that's the advantage of ultrasound.

55:12

You don't really need to put the patient, uh, you know,

55:15

in the canter, again, you don't need to change the coil.

55:17

You can just, uh, quickly place your probe on the other side

55:20

and get a quick answer.

55:23

Uh, there's a question.

55:25

What is the norm of, in the GaN canal,

55:30

I didn't quite get it.

55:32

Um, what is the norm, as in, if you could, uh, just,

55:36

uh, dimension.

55:41

Okay. Okay. Okay. Sorry. Uh, okay.

55:43

Um, uh, actually we don't really bother about the

55:46

dimension of the alarm.

55:47

Now, again, what if, if I'm thinking in terms of, uh,

55:51

compression, uh, what I would probably want to look at is,

55:55

you know, if there's any edema proximally, um,

55:58

I don't always really get into the, uh, dimension

56:02

and, you know, really measuring the number over there.

56:07

So may maybe there is a normal, um, um,

56:11

number which, uh, you know, maybe we can look up

56:15

and have a look at that.

56:18

I do see one more question just popped in.

56:20

If you wanna answer that one, then we can wrap this up.

56:23

Um, I think about the dimension, I think I answered

56:26

That. How do I identify the

56:27

ulnar artery and nerve in ion's canal?

56:31

Oh, I couldn't see that. Sorry. Okay, so how it just

56:34

Came through.

56:35

Sorry. You're good.

56:37

It just came through one second ago.

56:39

Oh, okay. Okay, okay. Okay, fine, fine. Okay.

56:41

So how do you identify? So actually it's fairly easy. Okay.

56:45

So what you do is, I'm gonna go back to my presentation.

56:51

Yeah, there you go. Okay.

56:52

So what, what, what what we do is, you know, um, uh,

56:57

what what we are doing is using the SIF form

57:00

as a bony landmark, right?

57:02

So once you identify the pisiform, a bang next to that,

57:06

if you turn on your color doppler over here,

57:08

you'll see this pulsating vessel, which is your NAR artery.

57:12

And if you look at the structure line between the nar artery

57:16

and the pisiform, you will be able to identify the no again,

57:21

uh, uh, once uh, you start looking at ultrasound,

57:26

you realize that you know everywhere all nerves are going

57:30

to have that kind of a honeycomb appearance, right?

57:33

So whether you're looking at the alarm nerve,

57:36

whether you're looking at the median nerve,

57:38

whether you're looking at the radio now, uh,

57:40

once you are in a cross section,

57:42

you identify this kind of a honeycomb pattern.

57:44

So if you trace this back

57:46

and forth, you know, you'll be able to see

57:48

that honeycomb pattern.

57:49

And, uh, that is what will help you to identify

57:53

and say that, yes, this is the online no,

57:55

but like I said what helps you over here is using the

57:58

pisiform as a bony landmark,

58:00

and you can, uh, identify that now quite quickly over there.

58:05

All right, I think that is our final question

58:07

that just came in, so I just wanted to say thank you again

58:09

for that lecture today

58:10

and all of your questions,

58:11

answering all those questions for us.

58:12

And thank you to all of you for participating in our noon

58:15

conference and asking these awesome questions.

58:17

You can access the recording of today's conference

58:19

and all previous noon conferences

58:21

by creating a free MRI online account.

58:23

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

58:26

Be sure to join us next week on Thursday,

58:28

July 11th at 12:00 PM Eastern Time, where Dr.

58:31

Felice Diarco will deliver a lecture entitled Pediatric

58:34

Epilepsy, but the Radiologist Needs to Know.

58:36

You can register for that@mrionline.com

58:39

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58:40

for updates on future noon conferences.

58:43

Thanks again and have a great day. Bye.