CASE 1(PATIENT # 13)

Clinical presentation 22 year female patient presented to the orthopaedics outpatient department with complaints of pain and paraesthesias and history of tingling sensation. The symptoms according to the patient worsened at night. Clinical examination Paraesthesias and tingling sensation in the area of sensory innervation. Positive Tinel sign and Phalen test median nerve

Sonographic imaging findings Sonography revealed increased median nerve cross sectional area of median nerve at the level of proximal carpal tunnel(12mm2) and increased difference of area at the level of proximal carpal tunnel(CSAc) and at the level of pronator quadratus muscle(CSAp) measured as 3.5mm2. It also revealed distal flattening of median nerve at the level of hook of hamate with major to minor axis ratio of 3.5(0.7/0.2). However palmar bowing of flexor retinaculum could not be seen on sonography. No increased fluid within flexor tendon sheath or any abnormal synovial thickening noted. No other abnormality was detected on sonography. MR imaging findings MRI examination revealed an increased cross-sectional area of median nerve when compared at the level of distal radius and pisiform bone. It also revealed

the palmar bowing of flexor retinaculum(bowing ratio=27.3%(5.5/20.1)) and increased signal intensity of median nerve on T2 weighted sequence. However no structural abnormality was identified in this patient. NCV findings: Reduction in median nerve sensory conduction velocity was seen which measured 76.5msec and increased distal motor latency of median nerve of approximately 4.8msec.

CASE 2 (PATIENT # 5)
Clinical presentation 30 year female patient presented to the orthopaedics outpatient department with complaints of pain and paraesthesias, swelling on volar aspect and history of tingling sensation which worsens at night. Clinical examination Paraesthesias and tingling sensation in the area of median nerve sensory innervation. Positive Tinel sign and Phalen test

Sonographic imaging findings Sonography revealed increased median nerve cross sectional area of median nerve at the level of proximal carpal tunnel (12.2mm2) and increased difference of area at the level of proximal carpal tunnel(CSAc) and at the level of pronator quadratus muscle (CSAp) measured as 2.2mm2. It also revealed distal flattening of median nerve at the level of hook of hamate with major to minor axis ratio of 3.12(0.5/0.16). However palmar bowing of flexor retinaculum could not be seen on sonography. Increased fluid within flexor tendon sheath is noted. No other abnormality was detected on sonography. MR imaging findings MRI examination revealed an increased cross-sectional area of median nerve when compared at the level of distal radius and pisiform bone. It also revealed the palmar bowing of flexor retinaculum (bowing ratio=24.3%(4.8/19.7)) and increased signal intensity of median nerve on T2 weighted sequence. On T1

weighted pre contrast image we can see abnormal hyperintense signal around the flexor digitorum superficialis tendon and flexor digitorum profundus tendons within carpal tunnel with enhancement of synovial sheath on post contrast images. This causes compression of median nerve within carpal tunnel. NCV findings Reduction in median nerve sensory conduction velocity was seen which measured 78.9msec and increased distal motor latency of median nerve of approximately 4.6msec.

CASE 3(PATIENT # 60)

Clinical presentation 21 year female patient presented to the orthopaedics outpatient department with complaints of swelling over volar aspect of left wrist since 1 year. Clinical examination A well defined swelling was observed on volar aspect of left wrist which was pulsatile in nature and soft in consistency. Sonographic imaging findings Sonography revealed a predominantly well defined hypoechoic lesion with multiple hypoechoic vascular channels within. However no extension in to joint cavity was noted. On Doppler evaluation there was pulsatile flow with arterial waveform with a peak velocity of 39.3cm/sec. The feeding vessel was seen to be from ulnar artery. MR imaging findings MRI examination revealed an isointense soft tissue swelling on the volar aspect related to the flexor carpi ulnaris tendon with multiple internal flow voids on T1 weighted sequence. On T2 weighted sequence multiple internal flow voids were seen clearly with multiple hyperintense foci within. On postcontrast fat sat(SPIR) image multiple enhancing channels are seen within. Surgical findings The feeding vessel was identified to be from ulnar artery which was ligated and soft tissue swelling was resected. Thus diagnosis of AV malformation was confirmed surgically.

CASE 4(PATIENT # 45)

Clinical presentation 20 year female patient presented to the orthopaedics outpatient department with complaints of swelling over dorsal aspect of left wrist on radial side since six months. Clinical examination A well defined swelling was observed on dorsal aspect of right wrist which was soft in consistency. Sonographic imaging findings Sonography revealed a predominantly well defined hypoechoic lesion with multiple internal septations and locules within. The swelling was seen between extensor carpi radialis brevis tendon and extensor pollicis longus tendon. The neck of ganglion was identified with extension into radio-carpal joint space. No internal calcification was seen. MR imaging findings MRI examination revealed a isointense soft tissue swelling on the dorsal aspect on radial side related to the extensor tendons on T1 weighted sequence. On T2 weighted coronal image the hyperintense lesion is seen extending into radio-carpal joint space. On T2 FFE sequence image the neck of ganglion can be traced up to the scapholunate ligament with evidence of disruption of ligament. On postcontrast T1 weighted image enhancement of septa are seen within the lesion. Surgical findings The lesion was resected completely and revealed a complex ganglion with multiple internal septation however the neck could not be traced upto the scapholunate ligament level.

CASE 5(PATIENT # 32)

Clinical presentation 40 year female patient presented to the orthopaedics outpatient department with complaints of pain and swelling over dorsal aspect of right wrist on radial side since three months. Clinical examination There was diffuse minimal swelling over the dorsal aspect of right wrist on the radial side Finkelstein test was positive

Sonographic imaging findings Sonography revealed hypoechoic fluid around the first extensor compartment tendons abductor pollicis longus and extensor pollicis brevis. Increased vascularity is seen along the tendon sheath suggestive of synovial sheath thickening and inflammation. MR imaging findings MRI examination revealed increased peritendinous fluid around the first extensor compartment tendons on Axial T2 weighted image and post contrast Axial T1 Fat Sat image showing increased peritendinous fluid and synovial enhancement. Clinical follow up The diagnosis of de Quevain tenosynovitis was made and patient was clinically followed up after local steroid injection therapy and subsequently patient became asymptomatic. Hence diagnosis was confirmed by therapeutic trial.

CASE 6(PATIENT # 37)

Clinical presentation 38 year female patient presented to the orthopaedics outpatient department with complaints of pain and swelling over dorsal aspect of right wrist on radial aspect since one month. Clinical examination A diffuse swelling ove the dorsal aspect of right wrist on the radial side

Sonographic imaging findings Sonography revealed hypoechoic synovial thickening around the wrist joint with increased vasularity of the synovium. The synovial thickening is also seen involving the extensor tendons. MR imaging findings MRI examination revealed increased isointense thickening of synovium around the radioulnar joint and extensor tendons on T1 weighted sequence with fluid seen in radioulnar joint space seen in T2 weighted sequence. On post contrast T1 weighted images homogenous enhancement of thickened synovium was noted. Clinical follow up The diagnosis of synovitis was made clinically and synovial biopsy was taken which revealed non specific inflammatory changes. On clinical follow up and biochemical investigations patient developed symmetrical arthritis involving multiple joints and showed RA positivity.