Imaging of Anatomical Variants Around the Wrist and Hand.

Wrist and hand anatomy may present several clinically relevant variants that involve bones, muscles, tendons, and nerves. Thorough knowledge of these abnormalities and their appearance in imaging studies is useful for proper management. In particular, it is necessary to differentiate the incidental findings that do not represent a trigger for a specific syndrome from those anomalies causing symptoms and functional impairment. This review reports the most common anatomical variants encountered in clinical practice and briefly discusses their embryogenesis, related clinical syndrome if present, and their appearance using different imaging techniques. The information each diagnostic study (ultrasonography, radiographs, computed tomography, and magnetic resonance imaging) may provide is described for each condition.

Extensor digitorum brevis manus bilateral / Bilateral extensor digitorum brevis manus

Introducción: El extensor digitorum brevis manus (EDBM) es unmúsculo accesorio del dorso de la mano que puede presentarse comouna masa dolorosa. Su tratamiento es quirúrgico, generalmente consisteen la extirpación del mismo. Caso clínico: Varón de 14 años que presenta tumoraciones dolorosas bilaterales en la cara dorsal de las manos. La ecografía confirma eldiagnóstico de EDBM. Debido a la sintomatología asociada, se decidetratamiento quirúrgico, con resección de ambas masas musculares. Comentarios: El EDBM constituye una causa poco frecuente dedolor a nivel de la muñeca, especialmente en población infanto-juvenil.El tratamiento quirúrgico ha demostrado un impacto significativo en lamejoría de la sintomatología que presentan estos pacientes.(AU)

Introduction: The extensor digitorum brevis manus (EDBM) isan accessory muscle of the dorsum of the hand that may appear as apainful mass. It is treated surgically, usually by excision of the muscle. Clinical case: 14-year-old male with bilateral painful masses onthe dorsal aspect of his hands. Ultrasound confirmed the diagnosis ofEDBM. Due to the associated symptoms, decision was made to conductsurgical treatment with resection of both muscle masses. Discussion: EDBM is an infrequent cause of wrist pain, especiallyin children and adolescents. Surgical treatment has proven to have asignificant impact on the improvement of the symptoms suffered bythese patients.(AU)

Rapid diagnosis of trisomy 18 of maternal origin by quantitative fluorescent polymerase chain reaction analysis following tissue culture failure for conventional cytogenetic analysis in a fetus with holoprosencephaly, ventricular septal defect, arthrogryposis of bilateral wrists and aplasia of the thumbs.

OBJECTIVE: We present rapid diagnosis of trisomy 18 of maternal origin by quantitative fluorescent polymerase chain reaction (QF-PCR) analysis following tissue culture failure for conventional cytogenetic analysis in a fetus with holoprosencephaly (HPE), ventricular septal defect (VSD), arthrogryposis of bilateral wrists and aplasia of the thumbs. CASE REPORT: A 22-year-old, primigravid woman was referred for first-trimester ultrasound screening at 13 weeks of gestation, and the fetus was found to have HPE and VSD. The pregnancy was subsequently terminated at 14 weeks of gestation, and a malformed fetus was delivered with cebocephaly, arthrogryposis of bilateral wrists and aplasia of the thumbs. The umbilical cord and placental tissues were collected for genetic analysis. However, tissue culture failure for conventional cytogenetic analysis occurred because of contamination. QF-PCR analysis using the polymorphic DNA markers of D18S1369 (18q12.2) and D18S1361 (18q22.3) confirmed trisomy 18 of maternal origin. CONCLUSION: QF-PCR analysis is useful for rapid confirmation of trisomy 18 and the parental origin when tissue culture failure for conventional cytogenetic analysis occurs in pregnancy suspicious of fetal trisomy 18.

Morphological and functional assessment of the flexor carpi radialis brevis using conventional ultrasound and elastography.

PURPOSE: The flexor carpi radialis brevis (FCRB) is a supernumerary musculotendinous structure of the wrist that has been the focus of some interest in the last decade. While its anatomy is well known, its in vivo function remains unknown as it has never been studied. METHODS: Eleven cases of FCRB underwent a multimodal ultrasound consisting of B-mode, color Doppler and shear wave elastography. RESULTS: A pennate shape was observed in all cases and the mean value of the cross-sectional area was 0.8 cm2 (SD 0.3 cm2). Young's modulus was significantly (p < 0.01) different between the resting position and active flexion or passive extension. CONCLUSION: Our study demonstrates that the FCRB shows biomechanics of a typical skeletal muscle and is voluntarily controlled by flexing the wrist. Absent in other vertebrate taxa, the FCRB probably plays a role in active stability of the wrist in Human.

Determination of congenital absence of palmaris longus tendon with clinical examination and ultrasonography.

OBJECTIVES: The tendon of the palmaris longus is commonly used as a tendon graft in many reconstructive surgeries. Palmaris longus absence (PLA) was found in 15% among individuals worldwide. In this prospective study, we aimed to conduct an incidence study in which physical examination methods were confirmed by ultrasonography in PLA, and to evaluate the relationship of absence with age, gender, laterality and dominant hand. METHODS: The study included 490 cases. They were initially tested to evaluated by physical examination using the Schaeffer's and Hiz-Ediz test for the assessment of the palmaris longus tendon. Additional ultrasonography was performed to confirm its absence in 129 wrists of 78 cases whose tendons could not be visualized or palpated. RESULTS: The incidence of tendon absence was 13% by physical examination methods. According to the final results when we added ultrasonography to physical examination methods, the incidence of unilateral, bilateral and overall absence of the palmaris longus were 5%, 9% and 11% respectively. There was no statistically significant difference between individuals with and without PLA in terms of gender, side, age and dominant hand (p = 0.796, p = 0.622, p = 0.397 and p = 0.187, respectively). However, bilateral PLA was statistically significantly higher than unilateral in both genders (p = 0.011). CONCLUSIONS: We think that agenesis should be proven accurately by ultrasonographic examination for the final result before any surgical procedure with palmaris longus tendon. Furthermore measuring the diameter of the palmaris longus tendon by preoperative ultrasonography can be useful for surgeons who plan a procedure that requires specific measurements.

Discondrosteosis de Léri-Weill. Presentación de una familia afectada / Léri-Weill dyschondrosteosis. Presentation of an affected family

RESUMEN Fundamentación: La discondrosteosis de Léri-Weill, displasia ósea de origen genético que afecta la región mesomélica con acortamiento de las extremidades, provoca talla baja con extremidades cortas con deformidad de Madelung; esta enfermedad muestra un patrón de herencia autosómico dominante con alta penetrancia. Objetivo: Describir las deformidades de esta discondrosteosis de baja frecuencia con expresividad variable, que se presentó de la misma forma en todos los afectados de esta familia. Presentación de caso: Se reportó una familia con enfermos en tres generaciones con deformidad de Madelung de ambas muñecas y baja estatura de origen mesomélico, que se mantiene seguimiento en consultas de Genética Clínica y Ortopedia. Conclusiones: El examen físico y radiológico imprescindibles para llegar al diagnóstico clínico. El método clínico y la valoración multidisciplinaria resultaron de gran valor para definir esta enfermedad y poder brindar un adecuado asesoramiento genético a esta familia.

ABSTRACT Background: Léri-Weill dyschondrosteosis, bone dysplasia of genetic origin that affects the mesomelic region with shortening of the extremities, causes short stature with short extremities with Madelung deformity.This disease shows an autosomal dominant inheritance pattern with high penetrance. Objective: To describe the deformities of this low frequency dyschondrosteosis with variable expressivity which was presented in the same way in all those affected in this family. Case presentation: A family with sick members was reported in three generations with Madelung deformity of both wrists and short stature of mesomelic origin which is followed up in consultations of Clinical Genetics and Orthopedics. Conclusion: The essential physical and radiological examination to reach the clinical diagnosis. The clinical method and the multidisciplinary assessment were of great value to define this disease and to be able to provide adequate genetic counseling to this family.

Discondrosteosis de Léri-Weill. Presentación de una familia afectada / Léri-Weill dyschondrosteosis. Presentation of an affected family

RESUMEN Fundamentación: La discondrosteosis de Léri-Weill, displasia ósea de origen genético que afecta la región mesomélica con acortamiento de las extremidades, provoca talla baja con extremidades cortas con deformidad de Madelung; esta enfermedad muestra un patrón de herencia autosómico dominante con alta penetrancia. Objetivo: Describir las deformidades de esta discondrosteosis de baja frecuencia con expresividad variable, que se presentó de la misma forma en todos los afectados de esta familia. Presentación de caso: Se reportó una familia con enfermos en tres generaciones con deformidad de Madelung de ambas muñecas y baja estatura de origen mesomélico, que se mantiene seguimiento en consultas de Genética Clínica y Ortopedia. Conclusiones: El examen físico y radiológico imprescindibles para llegar al diagnóstico clínico. El método clínico y la valoración multidisciplinaria resultaron de gran valor para definir esta enfermedad y poder brindar un adecuado asesoramiento genético a esta familia.

ABSTRACT Background: Léri-Weill dyschondrosteosis, bone dysplasia of genetic origin that affects the mesomelic region with shortening of the extremities, causes short stature with short extremities with Madelung deformity.This disease shows an autosomal dominant inheritance pattern with high penetrance. Objective: To describe the deformities of this low frequency dyschondrosteosis with variable expressivity which was presented in the same way in all those affected in this family. Case presentation: A family with sick members was reported in three generations with Madelung deformity of both wrists and short stature of mesomelic origin which is followed up in consultations of Clinical Genetics and Orthopedics. Conclusion: The essential physical and radiological examination to reach the clinical diagnosis. The clinical method and the multidisciplinary assessment were of great value to define this disease and to be able to provide adequate genetic counseling to this family.

Ultrasound of the ulnar-palmar region of the wrist: normal anatomy and anatomic variations.

Ultrasound (US) assessment of the wrist is frequently used for the evaluation of carpal tunnel due to high frequency of local compression of the median nerve (MN), but the ulnar-palmar wrist region (UPWR) has received limited attention in the medical literature. The possibilities of US in the assessment of UPWR are therefore likely underestimated by sonologists. This review article is focused on the US assessment of the normal anatomy and anatomic variations of the UPWR. The anatomy of this region of the wrist is complex and less studied than the radial side. In an effort to simplify it and to present it didactically, we have divided this region in three parts on the basis of osseous landmarks. Our review indicates sonography is effective in identifying the UPWR and related disorders, and is thus a valuable tool for ensuring appropriate management of a variety of disorders.

Functional parameters, wrist posture deviations and comfort: A comparison between a computer mouse and a touch pen as input devices.

BACKGROUND: Performing common computer tasks such as pointing, clicking, and dragging requires repetitive movements that cause musculoskeletal disorders in the wrists and hands. Given the growing use of touch screens and touch pens, further studies on the ergonomics of these devices are needed. This study aimed to compare a touch pen and an ordinary computer mouse in terms of movement time, error rate, wrist posture, and comfort of use. METHODS: Performance parameters (movement time and error rate), wrist postures, and comfort when using a mouse and a touch pen were measured based on ISO 9241-9 standard with the help of 27 participants. For data analysis, paired t test was performed using SPSS version 22. RESULTS: Using the touch pen resulted in better performance parameters than using the mouse (p < 0.05). Wrist extension and flexion were lower when performing the task with the computer mouse than with the touch pen (p < 0.05). When using the touch pen to perform the task, ulnar deviation and radial deviation were lower (p < 0.05). The overall comfort was higher when using the mouse than the touch pen. CONCLUSION: Our results showed that the touch pen had better performance parameters than the ordinary mouse and also resulted in lower ulnar and radial deviations. Given the impact of habit and proficiency on users' comfort in using input devices, it is reasonable to expect users becoming more comfortable by using touch pens on the long term.

Hand and Wrist: A Kaleidoscopic View of Accessory Ossicles, Variants, Coalitions, and Others.

Accessory bones, variants, and coalitions are not uncommon at the hand-wrist region. They are often overlooked because they are usually asymptomatic and found incidentally on imaging. However, they may sometimes present as a (painful) swelling or mimic a (sequel of a) fracture. Other symptoms may be attributed to impingement and exercise-related pain. Thorough knowledge of the anatomy, systematic imaging analysis, and the awareness of their existence are the clues to a correct identification. Plain radiography and magnetic resonance imaging (MRI) play a pivotal role in the correct diagnosis. In general, signal intensity on MRI is similar to the normal bony structures. However, concomitant bone marrow edema may indicate the presence of impingement. Therefore, MRI sequences with fat suppression should be included in case of symptomatic findings. This article provides a kaleidoscopic overview of some of the prevalent bony anomalies of the hand-wrist region and their potential pathogenic nature.

Absence of flexor carpi radialis identified during volar approach for fixation of distal radius fracture: a case report.

BACKGROUND: Volar locking plate fixation of distal radius fractures is commonly performed because of its good clinical outcomes. The flexor carpi radialis (FCR) approach is one of the most popular approaches to dissecting the volar side of the distal radius because of its simplicity and safety. We describe an extremely rare case of an absent FCR identified during a volar approach for fixation of a distal radius fracture. CASE PRESENTATION: A 59-year-old woman with distal radius fracture underwent surgery using the usual FCR approach and volar locking plate. We could not identify the absence of the FCR tendon preoperatively because of severe swelling of the distal forearm. At first, we wrongly identified the palmaris longus tendon as the FCR because it was the tendinous structure at the most radial location of the volar distal forearm. When we found the median nerve just radial to the palmaris longus tendon, we were then able to identify the anatomical abnormality in this case. To avoid iatrogenic neurovascular injuries, we changed the approach to the classic Henry's approach. CONCLUSIONS: Although the FCR approach is commonly used for fixation of distal radius fractures because of its simplicity and safety, this is the first report of complete absence of the FCR during the commonly performed volar approach for fixation of a distal radius fracture, to our knowledge. Because the FCR is designated as a favorable landmark because of its superficially palpable location, strong and thick structure, and rare anatomical variations, there is the possibility of iatrogenic complications in cases of the absence of the FCR. We suggest that surgeons should have a detailed knowledge of the range of possible anomalies to complete the fixation of a distal radius fracture safely.

Anatomic Anomalies Encountered in 467 Open Carpal Tunnel Surgeries.

Carpal tunnel syndrome is the most common compression neuropathy and carpal tunnel surgery is the most frequently performed hand surgery. Anatomic anomalies may predispose the median nerve to compression. The aim of the current study was to search for anatomic anomalies in open carpal tunnel surgeries through a cross-sectional study. During a cross-sectional study in a one-year period, 436 consecutive patients (307 females and 129 males) with the average age of 50.3 ± 2.4 years underwent 467 classic open carpal tunnel surgeries. Thirty-one patients had bilateral surgeries. A thorough inspection of the incisions was conducted to search for vascular, neural, tendon and muscular anomalies. Forty-two (8.9%) hands (14 males and 28 females) had anomalies. The average age of the patients with discovered anomalies was 48.6 ± 7.6 years. Ten anomalies were seen on the left hands and 32 anomalies were seen on the right hands. Among the 42 anomalies, there were 16 persistent median arteries, 14 anomalies of the median nerve, 7 intratunnel intrusion of the flexor and lumbrical muscle bellies and 5 anomalies of the origin of the thenar muscles. There was no correlation between the discovered anomalies and the age, gender or hand sides. Anatomical anomalies are not uncommon in carpal tunnel surgeries. However, the frequencies of the reported anomalies vary among different studies. Familiarity with these anomalies increases the safety of the operation.

Variant course of extensor pollicis longus tendon in the second wrist extensor compartment.

Among the muscles involved in thumb movement, the extensor pollicis longus (EPL) tendon of the hand is considered the most consistent structure with the least variation among individuals. There have been a few reports regarding different types of supernumerary tendons; however, an abnormal course of the EPL tendon is extremely rare. We describe a case of a variant course of a single EPL tendon appearing in the second extensor compartment of the wrist. This case was observed incidentally during wrist surgery, and demonstrates a unique variation of tendon course, which has not been reported previously. The knowledge of this anatomic variation is helpful in surgical planning and for making accurate diagnoses.

Preliminary experience with delayed non-operative therapy of multiple hand and wrist contractures in a woman with Freeman-Sheldon syndrome, at ages 24 and 28 years.

We describe two proof-of-concept trials of delayed non-operative therapy of multiple hand and wrist contractures in a woman with a severe expression of Freeman-Sheldon syndrome (FSS), at ages 24 and 28 years. Having presented as an infant to a university referral centre, passive correction was not accompanied by strengthening exercises, and correction was lost. FSS is described as a myopathic distal arthrogryposis; diagnosis requires the following: microstomia, whistling face appearance, H-shaped chin dimpling, nasolabial folds, and multiple hand and foot contractures. Spinal deformities, metabolic and gastroenterological problems, other craniofacial characteristics, and visual and auditory impairments, are frequent findings. To avoid possible FSS-associated complications of malignant hyperthermia and difficult intubation, and to reduce or eliminate need for surgery, we proceeded with passive manipulation without anaesthesia or sedation. We believe this is the first report of attempted non-operative correction of multiple hand and wrist contractures in an adult with FSS.

Musculoskeletal Sonography for Evaluation of Anatomic Variations of Extensor Tendon Synovial Sheaths in the Wrist.

OBJECTIVES: The purpose of this article is to show the anatomic variations of extensor tendon synovial sheaths in the wrist. METHODS: Videos from 157 patients that were available in the electronic database were reviewed. Sonography showed involvement of 186 tendon sheaths. RESULTS: We describe our center's experience with most tendon variants described in the literature and show the sonographic appearance of the most frequent ones. CONCLUSIONS: Sonography is an accepted, safe, and efficient method for evaluating conditions characterized by effusion into the synovial sheaths of the wrist extensor tendons. Knowledge of anatomy and anatomic abnormalities of these sheaths is essential for diagnosis and for correct ultrasound-guided injection therapy or, less frequently, planning a surgical approach.

Surgical correction of ulnar deviation deformity of the wrist in patients with birth brachial plexus palsy sequelae.

Ulnar deviation deformity of the wrist in patients with birth brachial plexus palsy is an important cosmetic concern among the patients and their relatives; especially in the patients who have recovered the basic limb functions. Though there is ample literature available regarding the management of the shoulder deformity there is paucity of literature regarding management of wrist ulnar deviation deformity. We report our experience with correction of this deformity in five cases with isolated ulnar deviation deformity without forearm rotational deformity or weakness of the wrist muscles. All the patients underwent extensor carpi ulnaris (ECU) to extensor carpi radialis longus (ECRL) tendon transfer. At a minimum of 18 months follow-up all the patients and their families were satisfied with the cosmetic appearance of the limb. Correction of the deformity improves the appearance of the limb, improves self-confidence of the child, and allows them to integrate well into the society. Interestingly, the patients expressed improvement in their grip strength and overall hand function after this surgery. The notable functions which improved were easy reach of the hand-to-mouth for feeding and easy handling of the things requiring bimanual activities. Although the main aim of this operation was to correct the appearance of the hand it was found to be also functionally useful by the patients and hence we are encouraged to report it for wider use. The results were maintained during the follow-up period of as long as 47 months.

Músculos accesorios de la muñeca: revisión pictográfica en us y rm / Accesory muscle of the wrist: a pictographic review

Although the accessories muscles are part of our nature, to recognize them allows us to avoid confusion with other pathologies. Even some accessories wrist muscles may be symptomatic and require surgical intervention. In this paper we present the anatomy and imaging aspects of ultrasound and magnetic resonance imaging of these muscles, so that the radiologist can become familiar with them, avoiding unnecessary interventions or diagnostic errors.

Si bien los músculos accesorios son parte de nuestra naturaleza, el saber reconocerlos nos permite evitar confusiones con otras entidades patológicas. Incluso algunos músculos accesorios en la muñeca pueden ser sintomáticos y requerir intervención quirúrgica. En este trabajo exponemos la anatomía y aspectos imaginológicos en ultrasonido y resonancia magnética de dichos músculos, para que el radiólogo esté familiarizado con ellos, evitando errores diagnóstico o intervenciones innecesarias.

Deformidad de madelung: criterios actuales en radiografía simple / Madelung deformity: current criteria in radiography

Madelung deformity is a common finding in various conditions affecting the wrist, with characteristic changes in the radius, carpus and ulna, the most characteristic being the triangular configuration of the carpal and the ulnar inclination of the distal radial epiphysis. It can be seen on simple radiography, computed tomography or magnetic resonance. As radiologists, we must know the currently recommended criteria, having it present for early diagnosis in young patients, or when the deformity is already established in older patients.

La deformidad de Madelung constituye un hallazgo común de varias patologías que afectan a la muñeca, con alteraciones características en el radio, carpo y cúbito, siendo la configuración triangular del carpo y la inclinación cubital de la epífisis distal del radio los más característicos. Puede ser visto en radiografía simple, tomografía computada o resonancia magnética. Como radiólogos, debemos conocer los criterios recomendados en la actualidad, teniéndolos presentes para su diagnóstico precoz en pacientes jóvenes o cuando la deformidad ya está establecida en pacientes de edad más avanzada.