Case Study – Abnormal Appearing Ganglion in the dorsal wrist

1. Case Study – Abnormal Appearing Ganglion in the dorsal wrist Paige Fabre

2. Patient Presentation • 34 year old female patient • Working as cleaner on the mines – FIFO worker • History • Several months dorsal wrist pain • Lump appearing on the dorsal aspect of the wrist, increasing in size while at work, decreasing while at home • No previous imaging, investigations or interventional treatment

3. Ultrasound Request • The examination was requested by the patient’s GP • A “wrist ultrasound +/- aspiration and injection” was requested • “Lump on dorsal wrist ? Ganglion” was the clinical indication given for the exam

4. Ultrasound Protocol • No exact protocol is require for a wrist ultrasounds • Images taken and areas examined are determined by the sonographer and reporting radiologist

5. Protocol for the Examination • As I am still in training, my supervisor suggested that I examine all compartments of the dorsal wrist in longitudinal and transverse to gain a better understanding of the anatomy. • If these areas were normal then I was to image them in transverse to demonstrate that these areas have viewed. An additional image was to be taken of Compartment 3 as it crosses over Compartment 2.

6. Room Prepartation • The room was prepared before the patient entered. • A chair was placed on the side of the bed (opposite the machine) facing the towards the bed. • A bluey was positioned on the table where the patient was to place their arms. • The ultrasound machine was moved to the foot end of the bed to allow for more ergonomic scanning. • Appropriate high frequency transducers were attached to the machine or within close proximity. • A pre-prepared injection trolley was brought into the room.

7. Room Preparation • Image of room to go here

8. Patient Preparation • At admission to the practice the patient read and completed a consent form for aspiration and injection of the wrist in preparation for this being carried out. • The patient was wearing an elbow length shirt and was therefore not required to change. • The patient’s identity was confirmed and they were invited into the room.

9. Patient Preparation • The examination was discussed with the patient before any scanning was attempted. • The patient was made aware that I was in training and that my supervisor would be assisting me with the scan. The patient was asked if this would be acceptable, and their consent was gained. • The patient was also made aware that we would first perform the diagnostic scan and from that the radiologist would decide the best course of action for the procedure.

10. Ultrasound Examination • The examination was performed on a Toshiba Aplio 500 using a variable frequency 18mHz linear transducer. • Thick ultrasound gel was applied to the area of examination to allow for light pressure and sufficient contact.

11. Ultrasound Images of the compartments

12. Compartment 1 Image 1: Left dorsal wrist in transverse showing abductor pollicuslongus and extensor pollicusbrevis tendons.

13. Compartment 2 Image 2: Left dorsal wrist in transverse showing extensor carpi radialislongus and extensor carpi radialisbrevis tendons.

14. Compartment 3 Image 3: Left dorsal wrist in transverse showing extensor pollicuslongus tendon. Also in view the ERCB, Lister’s tubercle and Compartment 4.

15. Compartment 3 Long Image 4: Left dorsal wrist showing the extensor pollicuslongus tendon crossing over Compartment 2.

16. Compartment 4 Image 5: Left dorsal wrist in transverse showing extensor digitorumcommunis and extensor indicisproprius tendons.

17. Compartment 4 Image 6: Left dorsal wrist in transverse showing extensor digitorumcommunis and extensor indicisproprius tendons. This image is taken distally to Image 5, demonstrating the distal separation of the tendons.

18. Compartment 5 Image 7: Left dorsal wrist in transverse showing extensor digitiminimi.

19. Compartment 6 Image 8: Left dorsal wrist in transverse showing extensor carpi ulnaris.

20. Extension of the Examination The compartments of the wrist were examined in both longitudinal and transverse planes. The compartments were all deemed normal and the examination was extended to allow for better visualisation of the lump as described by the patient.

21. Extension of the Examination • The following images were taken over the lump as identified by the patient as the region of interest.

22. ROI Images Image 9: Left dorsal wrist in the region of interest. This image displays the “lump” superior to the scapho-lunate ligament.

23. ROI Images Image 10: Left dorsal wrist in the region of interest. Calipers are used to measure the height and width of the predominately hypoechoic area present.

24. ROI Images Image 11: Left dorsal wrist in the region of interest. Calipers are used to measure the length of the predominately hypoechoic area present.

25. ROI Images Image 12: Left dorsal wrist in the region of interest. Colour Doppler has been used to identify the possibility of vascularity.

26. ROI Images Image 13: Left dorsal wrist in the region of interest. Colour Doppler used to demonstrate the possibility of vascularity. A second image was done to highlight the anechoic region.

27. ROI Images Image 14: Left dorsal wrist in the region of interest. Calipers are used to measure what appeared to be a neck of a possible ganglion extending from the radio-carpal joint.

28. Extension of Examination • In an attempt to better understand the origin of the possible ganglion/mass dynamic visualisation was attempted. • For these additional images a thick gel layer was applied to the wrist to maintain contact with light pressure.

29. Dynamic Images Image 15: Left dorsal wrist in the region of interest in flexion.

30. Dynamic Images Image 16: Left dorsal wrist in the region of interest in neural.

31. Dynamic Images Image 17: Left dorsal wrist in the region of interest in neutral. An arrow is used to indicate a possible point of origin.

32. Ultrasound Findings

33. Ultrasound Findings

34. Differential Diagnosis • Ganglion or Mass

35. Ganglions

36. Ganglion • Def • Aetiology • Population at increased risk

37. Ultrasound appearance of Ganglion

38. Alternative Imaging Modalities • MRI

39. Interventional Techniques • Non Invasive • Aspiration and injection • Rest • Bible • Invasive • Surgery

40. Radiologist Impression

41. Aspiration and Injection After a discussion with the radiologist and the patient it was decided that aspiration of the ganglia was to go ahead followed by an injection of xylocane, rupivicane and elestone.

42. Procedure Preparation • A sterile trolley was assembled. • The following was included • Sterile dressing back • 2 x 3ml luerlock syringes • Extension tube • Drawing-up needle • ___G needle • Sterile gloves were made available for the radiologist.

43. Procedure • A clean environment was established. • The patient’s wrist was positioned in slight flexion. This was achieved with a gel bottle being placed beneath the wrist covered with bluey. • Image of set up here

44. Procedure • The skin was prepped with an alcohol solution as per practice protocol. • Appropriate volumes of the drugs to be administered were decanted. • Local anaesthetic was first injected into the site and allowed to take effect. • An attempt to aspirate the suspected ganglion was made.

45. Aspiration Image 18: Area of suspected ganglion. An aspiration of several areas was attempted with nil fluid extracted.

46. Procedure • As no fluid was extracted, an injection of rupivicane and celestone was administered

47. Aspiration Image 19: Area of suspected ganglion. Injection of medication.

48. Post Procedure

49. Post Procedure • The patient appeared to tolerate the procedure well. • They were informed to rest the wrist for 24-48 hours and were given post procedure care instructions as per practice protocol. • A “pain chart” was also given to the patient to record the effectiveness of the procedure.

50. Reflection