Transcript
- Welcome to the Sono Site webinar on ultrasound evaluation
of the dorsal wrist.
With us today we have Daniel Shelton.
Daniel Shelton is the director
of musculoskeletal market development
for Fujifilm Sono site.
Daniel spent 16 years
as a dedicated multi musculoskeletal sonographer
and 10 of those years have been here at Sono site.
He now leads musculoskeletal market development
where he works to spread the word about the benefits
of point of care ultrasound.
Daniel, I'll turn it over to you.
- Thank you Laura, for that introduction.
Again, my name's Daniel Shelton.
I'm the director of MSK market Development here at Fujifilm
Socy, and today we'll be discussing the dorsal wrist
ultrasound indications from the A IUM are
as follows, soft tissue injury tendon pathology,
arthritis, soft tissue masses, nerve entrapments
effusion, foreign bodies
and bone injury transducer recommendations can range from
a larger footprint, high frequency linear
to the smaller high, ultra high frequency transducers
such as the one that you see here, the L 19 on the right.
So I actually like to have a larger footprint linear
as a general survey
and it really helps me kind
of see all the anatomy all at once while I'm scanning.
And then when I do suspect pathology
or I really either can't find what might be a pain generator
or if, if I just need a closer look at something.
It's really nice to have the L 19 there.
It does have a smaller footprint.
It's roughly half the size of the L 15,
but I think in the,
especially today in the live demonstration,
you'll see the difference between the two
and you'll see how nice it is to kind of have this L 19,
especially in the transverse of these tendons.
I think the details really appreciated in cross-section
what we're gonna be discussing today is the,
the carpal bones largely
and their surface landmarks as well
as the radius and the ulna.
We're gonna be looking at soft tissue landmarks like these
joint recesses that we see here in the first
and mid carpal rows.
We're gonna be cutting the extensor tendons in half so
that we can see down them.
And also gonna be examining things like these little dorsal
reticulum that that live on each
of the extensor tendon compartments.
We're gonna be looking at these tendons and
and just kind
of demystifying the direction all these tendons go once
they've left the easy to scan area.
So we have this diagram up here as a really nice reference
and you'll be able to use it in the recording to go back
and reference where all these tendons go.
But we'll begin on the dorsal wrist
by covering the recesses first
and then we'll break to a live demonstration
and then we'll do the dorsal compartments
followed by the scaffold lunate.
First things first, let's find our landmarks.
You can palpate lister's tubercle on the dorsal recess.
It'll be a bony prominence just
before the bend of the wrist in dorsiflexion.
It's slightly radial to midline,
but it's pretty close to midline when you're palpating.
So I always start at lister's tubercle when I'm scanning,
even if I know I'm going over to compartment number one.
It's really nice to palpate this, put the probe down
and get an image of it distally.
Our landmarks are the scaphoid
and the lunate respectively to form that scapholunate,
not only joint and ligament,
but it's a very good landmark when it comes
to just navigating the rest of these carpal bones.
And then the other more common landmark is the capitate
here, it's, it's a bell shape, you'll see it in the diagram.
Less viewed trapezoid is not typically a huge
part of the exam.
The hamate will be in the ulnar side just
as a distal landmark.
And the trapezium for CMC joint, which is not covered here,
but we can do it in the life scan.
Those are, those are our major landmarks here, followed
by the ulna and the ulnar styloid.
Let's take a, a soft tissue slice here
and let's open this joint capsule in the first carpal row
and, and take a look at the scaffold lunate ligament.
It's a superficial component here.
There is a superficial and deep, we largely just see
for the most part the superficial component,
but this is just an illustration to kind of give you an idea
of what these synovial recesses are doing.
They have a redundant fold
and basically the,
the capsule extends not only over the joint
but past the joint comes back and folds
and then inserts closer to the joint.
And that just allows us to bend our wrist without stretching
the capsule out too much.
So it is, it is nice to have that kind of range of motion
to be able to be seen on ultrasound.
We can flex and dorsa, flex the wrist
and watch this joint capsule in action both
for the mid carpal recess
and the first carpal row
here in the animation you can see there's a transducer
orientation marker here.
This large.is representative of the left side of the screen.
So we have this.here, which will typically be proximal.
And then when we go to short axis,
depending on if it's a right
or left wrist, just be consistent and how you scan.
But just know that this big dot on the line is representing
the left side of the screen.
So I start in a midsagittal plane looking
for any joint effusion just over
the lunate and the capitate.
If you see an effusion over the lunate,
it's probably extended from the radius
and lunate, that first carpal row.
And we're looking right here at this little balloon.
You can see there's a little asterisk there in the first
carpal rose synovial recess.
This lies under the extensor tendon.
So if you see a large effusion in the area, just know that
the fluid collection can come from the joint or the tendon.
The MRI correlation down here, you can see the radius,
the lunate, the capitate,
and you can kind of see where the lunate gets its name,
Luna, like a moon.
You can see how it's how it's accepting of the capitate
and the capitate is just overall very bell shaped
and you can see the surface of the bell
of the capitate on ultrasound quite nicely
moving radial now as we've gone from midline
and now we're shifting over radially
and we have the left side of the screen still over the bony
landmark of the radius.
And then we see this almost a stair step
where we go back one slide where everything was kind
of in a row mid sagely.
And you can see that the lunate is,
is it's got its own shape, it's more rounded
and the capitate is also very rounded as well as the radius.
When we move radially you can see that the radius kind
of have, this has this abrupt stop
and then the scaphoid has this flat surface which is very
characteristic of this slice.
So you'll know how radial you've gone once you
see the scaphoid.
And it's really, really flat kind
of stair step geometry that we see here.
You can even see a little slither
of lene cartilage overlying the scaphoid.
This is not necessarily the window
that we would do a scaphoid evaluation for a fracture
for example, that's more coronal and Boer, but,
but this is cartilage on the scaphoid.
So this is an intraarticular portion of the scaphoid.
We're looking for the joint effusion here and here distally.
This is a pretty classic example
of a inflammatory synovitis case
where we could see these little vessels
of hyperemia invading the walls
of those capsules that we just talked about.
And, and really, you know,
one artery over the capitate iss pretty normal.
That's, you're always gonna see this, this normal landmark
of an artery that rests just over the capitate,
but to see multiple vessels feeding into the walls
of these distended capsules is abnormal
and should be considered inflammation of some sort.
And, and it's time to kind
of look into the patient's history a little
bit further at that point.
So let's move to a live demonstration of
that area over these recesses.
Alright, so we'll begin with a live demo.
I like to begin with a larger linear array transducer.
So 15 to four megahertz is the L 15 transducer.
The larger field of view provides me a kind
of a general survey of the gross anatomy
and what's going on here.
It's much easier with a larger footprint transducer to kind
of associate if there's ganglion cysts,
if there's tenovus, what do they communicate with.
And then to get a more detailed look at things,
I'll switch over to the L 19.
So the 19 megahertz probe will really give us the ability
to zoom in on what's going on
with each individual either tendon or joint capsule.
So I'll begin with the thumb orientation marker on the side
of the transducer facing the radius
and long axis, that's, that's pretty typical.
And the distal, the right side
of the screen will be facing the metacarpals.
So in the long axis what I like to do is just begin with
the dot side of the probe right over mid sagittal
and sometimes it's helpful to palpate lister's tubercle.
We will talk about that in the next,
when the slides start back up.
But mid sagittal is roughly lister's tubercle
and we're just gonna go long axis here.
I can feel that lister's tubercle under my finger
and then I just lay the probe down
and I don't want to collapse all
of the soft tissue structures.
So I started with a gel heap on purpose.
When I start with a gel heap, what
that does is it does not collapse the synovial
information basically.
So if, if I have a joint effusion, which we're evaluating
for right now, it would, it would occur here in
that first metacarpal row, or sorry, the first carpal row
or the mid carpal row here.
So in order, let's start with our bony landmarks.
We have the distal radius,
we have the lunate and that bell shaped capitate
that we talked about in the talk here.
So here's the neck of the capitate right there.
More superficially we have the extensor compartment
of compartment number four
and if we just kind of wiggle the fingers, we'll see
that move here.
We are just above the extensors right here.
We see the extensor reticulum.
So we don't wanna call that tenino synovitis,
we don't wanna call that any, any form of fusiform swelling
or, or anything like that.
So just know that the extensor reticulum looks like this,
just like it does kind of down in the flexor tendon
of the hand where it kind
of looks like an airplane wing cut in half
and it is the strap that's holding everything down.
If I'm looking at somebody else's pictures
and I don't notice at least a sliver of a vein, one
of these little dorsal veins,
if I don't see those, I'm gonna assume
that they're applying too much pressure to see any synovitis
or they will collapse any joint
effusions that we might have.
So I'm gonna pay attention to how much I see superficially.
If you've already collapsed that vein
and you want to get a really good look again
and say, man, maybe I was, I was compressing too much
to see the synovitis, what I would coach you
to do is find your, your cortical landmarks
of the distal radius lunate and capitate
and then what you do is you just a little bit
of firm pressure and then you let up quickly
and I can see this big long rectangular shape in the gel
and what I'm gonna do is float a gel heap right over that.
So I have this bead of gel
and what you can see, just like we we do in some
of the other superficial structures like the MCP joints,
is I'm gonna use my fingers as stilts.
So I'm gonna set those down here
and I'm just going to slowly rest the transducers pressure
in the gel first.
And the effort here is not to collapse the gel.
And if I'm not collapsing the gel
or any of these subcutaneous veins,
that means I'm not collapsing these synovial recesses
that we're trying to evaluate.
So here we have the radius ate and capitate.
So that's your midsagittal plane.
And now what I'm gonna do is I'm just gonna roll the probe
radially as I go.
Radially, you'll see the radius change shape.
Here's lister's tubercle and profile here.
And that lets me know that I'm over compartment two,
I'm gonna keep on going towards compartment one
but not quite too compartment one.
And I see this kind of stair shaped cortical change
that we talked about in the slides.
So we see the radius has a more abrupt termination here,
like a step off ledge.
We see that the scaphoid bone here not only has a,
a flat surface here,
but a little bit of a hint of articular hyalean cartilage.
And then above that articular lene cartilage,
we see a synovial recess here.
So we're looking for that first metacarpal row
to show a a joint effusion.
Basically we will see a little bit
of mid carpal effusion here,
but not as much as we would if we were mid sagittal.
So when I'm looking for a,
a joint effusion specifically in the dorsal wrist,
I start mid sagal here
and get those, the, the capitated end view
and then I work my way radially until I see
that stair step looking shape
of the scaphoid and the radius there.
Third window that I look for that was not on the slides,
I go from mid sagittal here and I pan ulnar.
And as I'm scanning something like a wrist,
a smaller extremity, whether it be the the foot and ankle
or the, the wrist
or hand, I have to stay 90 degrees to the bones.
I can't just keep the probe
and it's just sagittal axis.
I have to convert to the sagittal oblique
and then eventually corona coronal plane here.
What you're not seeing on the camera very well is my fingers
hanging down right here.
And what I'm doing there is I'm gonna palpate as I scan
these, these boning landmarks
and specifically for the ulnar aspect, I'm, I'm feeling
for the ulna, this ulna and ulnar styloid right there.
And that's gonna tell me where I'm at while
I'm looking at the screen.
So as I set my finger behind the ulnar styloid
and I rest the probe down, we see this really pretty picture
of not only the ulnar, the the distal ulna
and that prominence of the ulnar styloid here,
which is right there where it terminates.
We see the TFCC,
we see the lunate and we see the
triquetrum
superficial to all of these, we see the
extensor carpi nearest tendon.
So I'm also looking for any ganglion cysts
or joint effusions.
I don't normally see a lot
of joint effusions this far ulnar,
but it, it definitely helps to go ahead
and scan to, to make a complete survey of that
of these metacarpal recesses.
Also, while we're in this area,
we talked about these synovitis
and what we look for in these dorsal recesses.
And there are normal, there are normal synovial
arterial flow structures that we don't wanna confuse
for cytovitis.
So let's just cover the one
that sits over the distal capitate really quick.
So let's put the arrow back on.
Let's follow the capitate, the bell-shaped capitate here
and the very distal capitate right in this area
just past the neck.
As I scan radial to ulnar,
we see this little dark oval here
and that is a normal artery.
And the reason that's important is when we're calibrating
our, our color powered doppler, we don't want
to call something like that synovitis,
but if we see anything beyond what we see in this area here,
especially a large collection of vessels like we saw on
that last slide, it, it's definitely accurate
to call it synovitis
'cause we should not normally see a collection
of vessels anywhere in these dorsal recesses.
So what I'm gonna do is just activate the
color powered doppler setting.
I'm gonna turn off the arrow
now I will activate the colored doppler
by pressing the C button on the key here
and I'm gonna switch to CPD
and just over the capitate we should see a nice little puls,
little artery if there it is.
So if we're not seeing that really clearly
as we are now in some machines, you just have
to amplify the gain just a little bit.
You can bring it up to what's called a noisy threshold
and you can see all the noise below the cortical level.
And I'm gonna reduce the gain just a little bit
until below the bone.
We don't see any color powered operate.
So that artery on the distal capitate is normal.
It is normal to see them just under the
extensor tendons as well.
And what we don't wanna see is a bunch of vessels collecting
around the synovial folds, but one
or two arteries here, especially just under the extensor
tendon is normal.
Don't, don't, don't call those synovitis.
I'm gonna exit outta my color powered setting by hitting 2D
and that won't conclude the longitudinal exam
of the dorsal synovial recesses.
Alright, we'll move on to the extensor tendon exam.
There's a lot going on in the dorsal wrist,
especially when it comes to the extensor tendons.
So what we're gonna do is just kind of methodically go
through the compartments first.
Primarily short axis exam is gonna help you get through this
with confidence first
and then we go long axis to just clarify any pathology.
But for the most part these are viewed in short axis.
Now there's a lot of acronyms over here.
We've got abductor, lysis, longus, extensor lysis, brevis,
and we have the extensor carp radius longus,
and then we have the extensor carp, radi, brevis,
extensor lysis, longus.
There's, there's a lot going on right here.
So at least until you get to compartment three there is kind
of a, a cool way to remember this.
First is a lot of people talk about compartment number one
as all peanut lovers eat peanut butter
and that kind of gets you going on the first compartment.
So all peanut lovers eat peanut butter.
So that, that really got me kind of a, a good start on how
to memorize these if you feel the need to memorize them.
And then from there, the second compartment is both ECRs,
so it's ECR, either L or ECRB.
And then you have the EPL.
So one way to remember the order that these go in is
that you have a longest and then you have a brevis
and then you have a longus and then you have a brevis
and then you have a longest, so longest brevis,
longest brevis longest.
So they alternate up until
that third compartment when you're trying to, you know,
decipher the differences between the longest
and the Brees, how it ends one way
was told to me this longest here, the
extensor lysis longest, that longest
has the longest way to go.
So it really does this third compartment.
This guy really travels very far up and over to your thumb
and we will in the live exam just wiggle the thumb
and we'll be able to activate just compartment number
three when we get over there.
But that's a good way to just start off
and how to memorize this acronym
and make it a little bit less intimidating.
So all peanut lovers eat peanut butter
and then the second compartment or ECRs
and then it's just a matter of whether
or not it's a longest or a brevis.
And we just went over how to tell if it's a longest
or a brevis next because they begin with longest
and then they alternate longest brevis longest,
brevis longest.
So now that I've totally kind of muddied up your head on on
that, I, one thing I do want you to remember is
that these compartments are also individually separated
by their own ulu.
So you can tell where one compartment begins
and ends based on its little tubercle between the ulu.
So each of these little prominences are insertion points
to each compartment's own little reticulum.
And you're gonna wanna scan through the compartments
transversely back
and forth kinda like we were scanning nerves or,
or we talked about the carpal tunnel.
The easy way to scan nerves is to pick one and go proximal
and distal when you're scanning relatively quickly.
So I would do that here.
And then just take a look at the bony landmarks.
When you see a prominence there,
you're gonna see a little dark shadow insert on
that prominence and that's the red A
for each individual compartment.
Let's start with compartment number one.
Our all peanut lovers eat peanut butter.
So we have the abductor lysis longest
and the extensor lysis brevis
starting in short axis, bottom right image.
And then if you feel the need to go long axis then turn and
and check out each individual tendon.
But like I said, for the most part
these exams are typically done in transverse
unless you suspect some pathology.
Now see these little bony prominences, that's
what I was talking about and we're in compartment number one
and you can see that it's got a little ridge on the radius
on each side of the compartment.
And then you can even see this little accessory ridge right
here, the middle of the compartment.
And in some of the patient population there is a little
dividing epi neurosis here
separating the abductor lysis longus from the extensor lysis
brevis even.
And there are multiple tendon slips
located within this actual compartment as well.
So that that could be something that you see in there.
Just don't confuse that for any pathology.
When you, when you do see one, you'll see this dark
vertical shadow coming down
to insert on this little prominence on the radius
in the middle of the compartment.
So don't let that throw you off.
But that is the first compartment.
And if, if you just call it first compartment,
even when you're labeling it, that's fine.
Don't go crazy identifying the individual tendons
unless you see pathology
and you feel the need to compartment number two,
we have the ecr.
So we have the ECRL and the ECRB for longest
and brevis again, short axis is where we like to start here.
And then we will follow up each one
with a long axis correlation.
So you can see the prominent tubercle
that show up on each side of the compartment
and that that's what's going to denote where our
Retin aum begin and end.
Just as a, as an aside from the tendons in transverse,
we can see the superficial radial nerve just sitting right
up right up here by this cephalic vein.
We're gonna move on to compartment number three,
extensor lysis longest.
This is actually one of my favorite ones to to view
because we, we go back to our landmark
of lister's tubercle here.
So we have this very large, very palp palpable bony landmark
of lister's tubercle here
and just dorsal to
that is your extensor lysis longest.
And the way to view that,
and we'll do this in the live demo,
is just to wiggle the thumb.
It's a very thin tendon
and you can see that here as it travels
diagonally across the wrist over the scaphoid, that is
where we will evaluate for the common intersection
syndromes and aqua veins.
10 acetyl in this area where you can have this intersection,
not not exclusively toque veins to this tendon
that would've been in the the compartment number two,
but this, this can be a very abrasive site when we're
scanning it and we'll scan that in the live demonstration
just to show how
how crazy its its trajectory is.
After it leaves the radius,
it immediately heads towards the thumb.
Here we have a video clip of the next group,
which is your extensor digitorum and indices.
Basically you're gonna take that short axis here,
it looks like kind of an egg over the radius
and just dorsal to lister's, tubercle.
And then we're gonna pivot
and spin the transducer into a long axis.
Back to our familiar dorsal recess view in the video clip.
There we go. And here it is here, transverse cut
of the extensor tendon.
Moving on over to compartment number five,
extensor digit MiniMe.
Basically very small tendon.
It rests right in the joint of the radius and the ulna.
And you can see it just is suspended kinda like a hammock in
its own tulu.
So we have a, a ulu that sits on top of it,
which is this dark triangular wedge.
And then where it's not dark, it becomes bright
because we have maximum reflectivity here.
And then it dives down into its own ulu that bridges the gap
between the radial ulnar joint
and it just kind of hangs there like a hammock suspended in
the, in this ulu here it is in long axis,
very thin tendon
and you can, you can see that we've crossed
that first carpal row
and we're seeing an an isotropic TFCC here.
And then lastly,
compartment number six is the extensor carpe ris,
which has its own nice groove here
in this groove we typically look for erosions to,
especially in rheumatoid patients, that's where a lot
of these erosive pathologies could be seen as in the groove
of the ecu, it does have its own prominent retin aum.
Here you can see the change in the bony cortex
of the ulnar styloid or just
before the ulnar styloid begins.
So we have a groove and on each side is a tubercle,
kinda like a a shoulder biceps groove.
And on each of those tubercle is a start
and endpoint for the ulu that we just talked about.
So short axis first, if you feel the need to go long axis,
this is a good view to also catch the TFCC deep,
which is not, not in these slides today,
but we can cover in the,
in the live view live demonstration.
Then after we leave the compartments, we'll go right back up
to the dorsal recess view and go short axis
and then we're gonna slide down to the scaffold joint.
So here you'll see the,
the animation sliding down in correlation
with this video loop until we see the scaphoid
and the lunate radially we got the
radial side is on screen, left ulnar is on screen right
and we can see here's that lister's tubercle.
And then as we pan the transducer just distal to the joint,
the first carpal row is where we see this V shape,
this valley right here.
And that's your SCA lunate joint.
And then here's that superficial ligament
that bridges over the sca lunate
and then there is a deep ligament that we don't see a lot of
at least relaxed.
You can do some stress maneuvers,
have the patient squeeze a tennis ball for example
and try to get that joint to open.
Incidentally over here on compartment three here you can see
that that EPL traversing over compartment number two.
So here's your extensor cardio carp, radialis brevis,
and then here's the EPL sitting right on top dynamically
and we'll cover that in the live demonstration.
Next, moving on to the live demo of those compartments
as well as the scaffold wound egg joint.
Alright, so we'll move to the demonstration
of the extensor tendon compartments.
So what I like to do when I'm doing these is I still begin
with the larger footprint L 15.
So start with lots of gel
right over that footprint, big gel heap,
no air bubbles is pretty important
and then I lister's tubercle.
So what I'm feeling for is this radial prominence.
If, if I was comparing what I'm seeing here on the,
on the surface it looks like it's kind of behind the,
the second or third metacarpal it, it's
that radial to mid midsagittal.
So mid sagittal, I'm feeling here
but I don't feel lister's, tubercle
and then slightly radial to mid sagittal.
I can feel lister's tubercle right here.
So what I'm gonna do is just, I'm gonna palpate that
and take note of that.
And then what I'm gonna do is I'm gonna place
that gel heap right there
again so I don't compress the gel first.
I've got my fingers back here like stilts
and I'm just gonna slowly rest the transducer into the gel
and I'm gonna activate the arrow on the machine and first
and foremost we're gonna find lister tubercle,
which is this bony prominence right here.
Let me adjust the gain just a touch right here on
the gain wheel.
There we go. So this bony prominence tells me
that I'm straddling compartment two
and compartment three,
so I'm not anywhere near compartment one.
So let's begin with compartment one,
which will be way down here towards the table.
What I'm gonna do is stay 90 degrees to the surface
of the radius and just roll the transducer over radially.
I'm gonna do a really quick survey of the compartments
and then we'll switch to the, to the smaller footprint
of more appropriate transducer for these compartments,
which is the L 19.
So here I am on the extreme coronal side
of the wrist, but I am still axial
and this is compartment one.
Take note of the two distinct tendon slips of the
A PL and the EPB,
they'll be a lot more noticeable within LL 19.
Now I'm gonna roll the probe over here to the ECRs.
As we talked about in the PowerPoint we have the,
we have the ECRB, sorry, the ECRL and the ECRB.
And remember those bony prominences that tell us where
that little ex, those little re aum,
the individual compartment re AUMs begin and end right here.
So we see a little bony prominence on the radius here
and it's pretty smooth in the compartment.
And then the more dorsal we go,
we see another bony prominence here, which is the insertion
of this in this dark shadow.
And that's compartment number two.
And then here we are in compartment number three.
We see this oval, it's kind of standalone, it's always
underneath one of these little superficial veins,
probably a branch of the cephalic.
And to just check our work, I'm gonna have our,
our model just twitch her thumb
and that's gonna activate this third compartment.
So let's do a flexion extension of the thumb. There we go.
And we can see this tendon rolling.
So that's the EPL in compartment three.
And then here we are on the the dorsal, the extensor tendons
and and props indices props here.
So wiggle the fingers
and this is what I mean by like a gross anatomy survey.
We're just looking for large joint effusions protruding
into the dorsal wrist.
We're looking for Tino synovitis
and where it might originate
but not necessarily the little details of its cause.
Here I can see the radius and the ulna.
And above this joint we see this little, an isotropic
kind of hammock of shape of another reticulum here.
And here's the fifth compartment
and I'm gonna have our model just wiggle the pinky in this
case and it's gonna elevate the digit MiniMe.
And then we're gonna roll over the ulna, not quite
to the ulnar styloid, but one scanning tip,
especially when we get to the smaller probe is I'm just
basically gonna lay the probe down on the side of the table
and fire into the ulna.
And you're gonna, you're gonna lay the probe right there
on the ECU.
So the extensor carpe narrows is right here.
So as a general anatomy survey,
the larger linear array is okay, it's not great.
The L 15 does an awesome job for the size of footprint it is
to evaluate these structures.
But what I'm gonna do now is switch over to the L 19
and that will be much like switching over
to a macro lens on a camera.
All right, so I'm gonna start again on lister's tubercle,
I can palpate here and I can see a much more large
bony prominence there.
I'm gonna bring our depth more shallow
and I like that about this.
This exam type on the musculoskeletal exam type is
that it doesn't start you off zoomed in.
So you don't really lose all the perspective.
It starts you off pretty zoomed out like this.
So you can kind of get a grasp
because we're really about to zoom in.
So relative to listers tubercle, I'm gonna go more shallow
and you can see that we're at one centimeter of depth.
I'll click down to 1.4
and I'm gonna work my way back over to compartment one.
So here is compartment two, just radial til lister,
tubercle compartment three sitting on its own ulnar
to lister tubercle lister's, tubercle being our lighthouse.
How we find where we are,
what I'm gonna do is just roll the probe,
staying 90 degrees to the radius.
I don't wanna lose my angle,
I can't just translate the probe over,
I won't get a good shot of these compartments.
You have to stay 90 degrees to the cortex
and I'm gonna keep rolling.
So this is compartment two,
here's compartment one, there we go.
So we can see a lot more in the image than we did before.
We can, we can still see the prominence of
where those little ret ulu begin.
So here's that ret ulu over compartment one.
So this is the A PL
and here's the EPB.
And you notice there there are two separate
and distinct tendons going two separate
and distinct directions.
So if I tilt the probe ever so slightly,
you'll notice the EPB changes,
its an isotropic property a little sooner than the A PL.
Just a little tilt there.
So the EPB really shows itself pretty quickly.
Now a PL is is normal in this case,
but in some, some cases can comprise
of multiple tendonous slips
and we don't wanna call those pathology in some people
this tendon can already show itself as a group
of tendon splitting slips.
As I go distally, you actually see those.
But at the level of the reticulum in some
of the patient population you can already
see the vertical slips.
But as I go distally,
we're seeing those slips already show themselves.
So here's one, here's one,
here's one there.
So we had this, this bundle already showing itself of
about 1, 2, 3, 4
individual tendon slips.
Maybe a fifth one right here.
So in in some
of the patient population right at the compartment level,
you can already see those group up
and you just don't wanna call it tendinosis,
you don't wanna call it longitudinal split
tearing or anything like that.
And then we'll go long axis.
So the the thumb orientation marker side
of the probe will go proximal this time.
And what I'm gonna do is just go elongate
these tendon fibers.
And it's pretty important to denote
where the extensor reticulum is for each compartment so
that you know where to look for swelling.
So within the compartments, I'm go back to short axis
where we see ret ulu, you won't see a lot
of effusion in these areas.
You usually see the effusion proximal to the reticulum
or distal to the reticulum,
but there's not a lot of room within the shadow
of the reticulum that you see here.
And the shadows are caused by an isotropy,
they're little ligaments holding the tendon down.
So these are little pulley, almost like in the flexor tendon
of the hand holding these tendons down and
and we're, there's not a lot of room for fluid to collect.
So that's why it's important to trace proximally
or distally to look for fluid collections
but within the ulu area themselves.
So what I'm gonna do now is when I go long axis I'm gonna,
I'm gonna focus on proximal to the reticulum
or distal to the ulu looking for those fluid collections.
I'm, I'm on compartment one.
So when I go distal to the reticulum, I'm looking
for dequervains tenino synovitis, I'm looking for the A PL
and the EPB to, to really blow up that synovial
either thickening or a fusion.
You can see synovial wall thickening like a big
sponge around these.
And that is the classic dequervains tenino tenitis.
Now let's go back to the radius where we see those
little tubercle and those little reticulums there.
Now let's go proximal
and as we go proximal I'm gonna follow my A PL.
Okay, let's follow a PL first
and let's see what happens to it relative
to the underlying second compartment.
So here's a PL, again follow this oval
and here comes ECRB and ECRL underneath.
So right there, that grinding area
where you see those two areas
literally intersect over each other.
Okay, so here's compartment two underneath
and here's compartment one, mostly a PL
and they can grind on each other.
And that is the intersection syndrome of the wrist.
So proximal to those reticulum, I'm looking
for intersection syndrome
distal to those ulu.
I'm looking for a few things really I'm looking
for either veins, teno, synovitis, which is very painful
or any any pathology in the area
of this little superficial radial nerve.
So we have a radial nerve here,
it's gonna add some gel
'cause the little cephalic veins in these areas help us
identify where these nerves begin and end.
But what I can see here is this, this is one
of the superficial branches of the radial nerve.
As you go more proximally it will meet up
with a cephalic vein here.
So here's our cephalic vein.
Here's our superficial radial nerve.
You remember from the elbow when we evaluated this.
It keeps going and there's lots of branches to follow.
And this is the more radial branch of the radial nerve
and it's called the superficial radial nerve
and it will bifurcate
and then trifurcate to multiple sensory motor branches.
But right now we're, we're just gonna kind of focus on hey,
do we see any neuromas schwannomas com compression
neuropathies, tenino noes
that might be colla compressing on these little nerves.
And we're gonna watch them bifurcate still
following this guy here.
And there's another branch on the
other side of the cephalic.
But as we go distally, almost almost every centimeter
or so we see these radial,
superficial radial nerve branch is bifurcate again.
So here's another bifurcation
and you can roll it over that first compartment just
by tilting the transducer.
So what I'm gonna do is, is just do a roll of the probe over
that compartment and you'll see this radial nerve
almost almost make itself click
over the first compartment right there.
So all I'm doing is just rolling over
compartment one proximally to distally.
When you're more proximal, it borders cephalic
as you go distally it wants
to jump over compartment number one.
So go proximal to compartment one,
look at the cephalic vein.
Here's the ra, superficial radial nerve
and it's already bifurcated at this point.
Here's one bifurcation here.
So this is just a little off topic but relevant for pain
and burning in the area.
You can see all the little fales here as we go distally,
you'll see it bifurcates right there
and there it bifurcates again
but it rolled over compartment one.
So that's really important
because it can also get smashed superficially here.
Or if you've had a patient get blood gases lately,
this is usually the nerve for an A BG that gets stuck
and causes a a lot of residual pain later.
So we'll leave compartment one
and we're gonna work our way to compartment two.
Compartment two is more symmetrical where the ECRB,
or sorry, the ECRL
and the ECRB are right next to each other
and they're about the same size.
Whereas in compartment one ECR, or sorry A PL
and EPB are not symmetrical at all
where a PL is much larger
'cause it's got those multiple tendon slips.
And a PB is a much smaller, more of a dedicated tendon.
Brevis is tend to be shorter, longs tend to be longer
as we talked about in the PowerPoint.
So remember how to remember it from the PowerPoint.
We have longest brevis,
longest brevis over lister tubercle
longest again.
So here we are at EPL
and then this is ECRL
and ECRB.
More important approximately for intersection syndrome.
There you can see the two grinding on each other.
No pathology today, it's just how it goes.
Something to keep an eye out on right there.
I'm just panning proximal distal to show the relationship
and how close they come.
I'm gonna go distally.
A little less important now except we do have another
intersection style syndrome separate from de veins,
tenino synovitis where compartment number three,
let's go ulnar to lister's tubercle,
we have the extensor lysis longus here.
Let's follow it and watch it jump over.
Compartment number two.
So when I go distally,
I'm gonna rotate the probe towards the thumb.
So I'm gonna go after lister's tubercle
following where the arrow is.
Now it's at this point I leave lister's tubercle.
You already see EPL try to jump this way.
I can't keep my transducer orientation at this point.
What I have to do is turn the probe 90 degrees to the thumb.
I need to go in line this way
'cause that's the direction this tendon's gonna go
when I'm scanning an EPL.
Sometimes it's just neat
to have the patient wiggle their thumb first.
So what we're gonna do is just wiggle the thumb
and there with 19 megahertz,
we're probably seeing two heads of this tendon.
I've never studied whether or not there's two heads
or if that matters, but there's definitely a slip here
and two branches of this tendon.
And so what I'm gonna do now is
as I leave lister's tubercle, I'm gonna, I'm gonna trace,
I'm gonna go distally
and I can already see that tendon try
to jump over a compartment.
Number two, I'm gonna turn the probe
and aim it down the thumb.
And I get a nice oval superficially here.
And just like the median nerve on the volar wrist,
when we're scanning a small structure, that's an oval.
What we're gonna do is center it in the screen right here.
And we're gonna take small segments at a time here.
So what I'm gonna do is just trace this tendon approximately
distally, approximately distally.
When I feel comfortable with its trajectory,
I'm gonna go a little more distal,
I'm gonna readjust my angle
and I'm gonna follow this oval again approximately distally,
proximally distally.
And you're just gonna keep evaluating
that tendon until you've left.
The area of concern again, I,
I think at 19 megahertz I'm still seeing two individual
ovals, one here and one here.
I haven't studied whether or not there's two heads
to this tendon, but it definitely seems like there is.
So we'll have to, we'll have to take a look at that,
maybe ask some of you physician experts
that have joined the webinar, if that's some sort of variant
or if it does split into two normally.
But on normal frequencies, larger footprint transducers,
we don't notice those subtleties.
So I just thought it was neat to kind of point that out.
I definitely see one
and two heads here with a little septum between the two.
I'm gonna go right back up to the
listers tubercle there.
I'm gonna go long axis now.
So I'm gonna switch this to long axis.
I'm gonna bring the left side of the screen proximal.
And if you get lost in this find lister's tubercle again,
you always have the option of going long axis every time.
But as we leave lister's tubercle here,
I'm gonna point the probe to the thumb
and I'm just gonna have the patient slowly
wiggle the thumb back forth.
Back forth. Flexion extension, flexion extension.
And I'm gonna follow the flexion extension of the EPL
still following flexion extension of the EPL
all the way
there.
It's a very skinny tendon.
It can be hard to follow
but at 19 megahertz with a small footprint linear,
it is much easier to follow than with a larger linear
and you can really trace these tendons down
to whatever might be the culprit.
Alright, so let's leave flip the probe orientation.
Let's leave compartment number three
and it's individual reac.
And let's go to compartment number four
where we see the extensor digitorum
and the indices props.
And then not mention in the slides is a
neurovascular structure.
At this point we scan the radial nerve at the elbow
and distally far distally, another branch of the radial.
We have the posterior interosseous nerve,
more distal termination that innervates the dorsal recess
of the wrist and is responsible
for motor dropping of the wrist.
If there's compression neuropathy here,
we'll have a wrist drop
of the posterior os posterior interosseous nerve.
So here's compartment number four, beautifully shown here,
especially at 19 megahertz.
Let's wiggle the fingers,
the patients when you're scanning this,
patients really love this view
because they can see their fingers wiggling,
they can see the tendons activate.
But what's even really cool here is you can see these
tendons grinding on the neurovascular structures
of the posterior interosseous nerve distally.
So let's go ahead and relax.
I'm gonna throw on color powered doppler
and let's just see if we can get the little artery
that accompanies the nerve to show up.
And there it is. So we have the artery arrow,
artery first, nerve second right here.
And if you're scanning small nerves that are accompanied
by arteries like this one, what you have
to do is tilt the probe and make a really ugly tendon.
Okay? All the tendons look bad,
but you have to aim down a vessel
to make the vessel show up really nice so
you can't remain perpendicular
to these small vessels when you know they're a landmark.
You can't stay 90 degrees to the vessel, you have
to aim down the vessel.
So I'm gonna tilt the probe down the vessel
and make the flow in this case,
see the blue on the upper left,
I'm gonna make the flow go away from the probe
a little bit more superficially here.
There we go. And there we see the artery of
that radial nerves.
Posterior interosseous branch at the fourth compartment,
which is responsible for a lot
of wrist drop if there's entrapment neuropathy.
So that is the fourth compartment in a short axis.
Again, we do most of our scanning in short axis,
but it's okay to go ahead and flip over
to long axis if we expect any pathology here.
And we can see the fibers beautifully.
We can see the extensor reticulum like a big airplane wing.
Superficially we can straighten
and flex those tendons superficially
and watch those tendons move
and evaluate for any tendinopathy that way.
But short axis is really where it's at in detail
when it comes to ultrasound.
If you can't see these little dots
and individual fales of tendons, you're dealing
with something that's overprocessed
and you'll never pick up the subtle tendinopathies
that you're looking for.
So that's compartment four.
I'm gonna slide over to compartment five.
And we locate compartment five between the ulna
and the radius, between the ulna and the radius.
We have another ret acum here, this bridge,
this bony bridge between the two bones.
And then above compartment five we have another reticulum.
So this one just really hangs out like a hammock like we
talked about in the slides.
And this right here is the extensor digit team mini me,
which conveniently controls the pinky.
If you're an Austin Powers fan, you'll get the reference.
Let's wiggle the pinky
and we can isolate that tendon in both short axis.
And I'm gonna go long axis here
and make sure that we are in indeed isolating
the compartment.
Five 10 into the pinky, fifth digit. Go ahead and relax.
And I'm gonna, I'm gonna go back to short axis here.
I scan with two hands all the time.
Don't be afraid to scan with two hands.
It really helps you maintain control of the transducer.
And we're gonna go back up to the ulna.
We're gonna wrap the probe around like we did
with the larger linear L 15.
And I'm just gonna, I'm gonna take a little shortcut here
and I'm gonna aim into the ulna
where I'm laying the probe almost to the table.
And here we are in the ECU groove.
So this groove contains the extensor carpi S
and it's pinned down by its own tulu.
And we wanna look for those bony prominences.
There'll be one on each side.
This one is less prominent,
so it's more dependent on the reticulum than the groove.
But here's ECU if I wanna confirm that.
I'm gonna tilt the probe down and make the tendon turn dark.
Her her tendon is very normal and healthy
and sometimes it will just blend in
with the surrounding connective tissue,
depending on the frequency of your transducer.
And using an isotropic artifact
to your favor really helps you isolate, hey,
where does the tendon begin and where does the tendon end?
So here I am on the ECU
and if it were blending in more, maybe
with a lower frequency probe,
I would tilt the probe this way
and it would isolate just the ECU.
And in a healthy tendon, just like all tendons,
healthy tendons will turn an isotropic
and disease tendons will have partial parts of the tendon
that remain echogenic.
So I'm gonna go long axis by just spinning on that tendon.
I am now mid coronal and I see the ECU
and long axis distal ulna.
Here we see the TFCC,
which is not talked about in this talk.
It will have to be saved
for another talk over fibro cartilages
'cause there's a lot going on with the T Fs CC.
But we leave the ulnar styloid following the
extensor carpe ulnar and lung axis
from the extensor compartment survey.
That concludes the extensor compartments.
Let's go back to lister's tubercle
and we'll quickly evaluate the SCA lunar joint SCA
lunate joint there.
So here's lister, tubercle, nice bony prominence here.
And now what I'm gonna do is just slide distally
and slightly midsagittal.
So distal, we'll see the radius disappear.
I'm gonna go a little more midsagittal
and then I see a little joint show itself
very deep in the picture.
I'm gonna drop my depth just a little bit.
And here what I'm looking at is a joint
radially is going to be scaphoid.
Nope. Other way. So this is all scaphoid.
Here's the joint space and then here's lunate.
Okay, so when we're just evaluating these,
normally we're looking for ganglion cysts,
ligament disruptions, joint effusion,
superficially inflammation synovitis.
But for mechanical disruptions it's helpful
to do dynamics like squeezing the fist
and then reevaluating the joint.
Very deep, go down, hit auto.
And then what we're gonna wanna do is just crank the gain,
just a touch turn
on our TGC
and we're gonna crank up a little bit
of the far field gain there.
And it can help to squeeze a tennis ball,
which I don't have with me right now.
But just even squeezing something like a tennis ball is
what's really gonna activate.
Hey do we see, do we see a gaping in this ligament?
Do we see a ganglion cyst really show itself?
Those are, those are all things
that are really gonna help out when doing a
dynamic evaluation.
We have a superficial ligament
and a deep ligament down here that we don't see a lot
of detail in, but the superficial ligament is very easy
to see, which is this band right here.
And that sums up the dorsal wrist exam,
at least on a basic level.
We didn't go into a comprehensive exam for nerves,
we didn't go into a comprehensive exam for the TFCC.
There's a lot more on the dorsal wrist on an advanced level
that we'll cover in a future webinar, entrapment,
neuropathies, things like that.
That can be a little bit more complicated.
But from a general survey standpoint, this is definitely
where to start as far
as memorizing all the names of the compartments.
Not important unless you suspect actual pathology.
But I would, I would encourage you
to label at least compartment 1, 2, 3, 4, 5, 6 instead
of getting into the weeds of all the names.
That'll at least show that you did a general survey
of those extensor compartments.
You wanna also document
that you looked at the joint and the cartilage.
Thank you. Alright Laura,
any questions in the chat portal?
- Well, we had a couple pop up, but you answered them.
We're going. So those are great.
I'm looking to see if anyone has any questions and up now,
and I know we're at the hour, but
- Yeah, - A little bit.
- Questions tend to be very long-winded, so
we're definitely here to clarify anything.
- Okay, I'm, I'm thinking there's no questions
showing the recording on our behind the webinar space.
If you can sign from on the website since I got from the
education tab,
there's a webinar section there, but feel to check out.
Oh, we just put any thought in. Oh, just sorry.
This was great. So there you go Daniel.
- Thank you. Wipe the sweat off my forehead now.
- Perfect. Well thank you everyone for joining us today.
Thank you Daniel. Thank you Jamie back there.
Appreciate all your help with us right now.
- Thanks everybody. Appreciate your time.
If you have any questions, feel free to email us
me directly at daniel.Shelton@fujifilm.com
or Laura at Laura dot
jacob@fujifilm.com
and we can follow up with your questions after the webinar too.
- Yep. That good. Thanks everyone.
- Thank you. Have a great day.
Cool. It worked out.
Still goes basic
because at the end I'm like, that concludes this, you know,
basic risk.
Point-of-care ultrasound is noninvasive and offers real-time imaging, allowing for examinations of structures at rest and in motion.
This live webinar will discuss the benefits of using point-of-care ultrasound to diagnose dorsal wrist pathologies, and share expert techniques to visualize dorsal wrist structures.
What You'll Learn
- Review the anatomy within the dorsal wrist including bones, tendons, nerves, and ligaments
- List indications for an evaluation of the dorsal wrist
- Discuss possible pathology such as extensor intersection tendinopathies, De Quervain's syndrome, and tendinosis
Daniel Shelton, RT(R) is the Director of Musculoskeletal Market Development for FUJIFILM Sonosite. Daniel spent 18 years as a dedicated musculoskeletal sonographer and 12 of those years have been here at Sonosite. He now leads musculoskeletal market development, where he works to spread the word about the benefits of point-of-care ultrasound.
This educational webinar is intended for healthcare professionals and not for patients or consumers. The material is provided for general educational purposes, as a reference and a supplement to professional experience, education and training, and should not be considered the exclusive source for this type of information. This educational webinar is not intended to recommend any device for a particular indication or to provide indications for use for any device. At all times, it is the professional responsibility of the practitioner to exercise independent clinical judgment in each particular situation. Fujifilm assumes no responsibility or liability for any misuse of the information imparted in this webinar. This educational webinar does not supplement, replace, or supersede device labeling, including instructions for use, which accompanies any FUJIFILM Sonosite product.