All right, good morning, everyone. Welcome to another Friday Morning Sports Ultrasound Case Series. Today we have Dr. Malia Halei. She is a fellow currently at the University of Washington. She completed her PM&R residency at the University of Colorado. She ran track and cross country at University of North Carolina and did medical school at LSU. We'll be finishing her fellowship shortly and joining the Sedmon Clinic in Colorado next year. Go ahead, Dr. Halei. Thank you for the introduction. So let me share my slide here. All right, so we'll get started on our ultrasound case today on the dorsal wrist and proximal intersection syndrome. I have no disclosures for today's talk. I want to say thanks to the faculty at UW that has been an integral part of my ultrasound training this year, as well as my program director, Dr. Mark Harris, and Dr. Boettcher for organizing the lecture today and providing some pathologic pictures. So objectives for today's talk, we will review the dorsal wrist diagnostic ultrasound protocol for a complete exam. We'll discuss the normal and pathologic sonographic findings that are specific to this case. We'll compose a diagnostic ultrasound report, and then we'll briefly review injection technique. So our case history, we have a 38-year-old left-hand dominant male with type 1 diabetes who presents with a chief complaint of left dorsal wrist and forearm pain that has been present for the past six months. He reports insidious onset of symptoms, and it has been progressively worsening. He describes the pain as sharp and throbbing, and he also reports a popping sensation in his forearm. Symptoms are typically worse with wrist flexion and better with immobilization and a spica splint, and he denies any neck pain, any numbness, tingling, weakness, or radicular symptoms. On exam, he doesn't have any atrophy, asymmetry, swelling, or anathema in the region. He has full wrist and elbow range of motion, but there is increased pain with both passive and active range of motion of the wrist, specifically flexion. For palpation, there's tenderness proximal to the first dorsal compartment, more on the radial aspect of the dorsal wrist. And on his neurologic exam, there's full strength and normal sensation. Physical tests were negative, including Finkelstein's, CMC Grind, and Watson's test. So when this patient came to us, he had already undergone imaging, and so we have an AP, an oblique, and a lateral view of the wrist, and his x-rays were negative. So there was no evidence of any fractures or dislocations. There's no significant degenerative changes or any osteous abnormalities noted on his imaging. So our differential diagnosis for this patient who has dorsal radial wrist pain, the first thing on our differential was proximal intersection syndrome. This was because he did report that kind of popping sensation, and the location of his pain was pretty unique where those intersections, the intersection is. Other things we considered are extensor tendinopathy, specifically thinking about the extensor carpi radialis, day queer veins, tenosynovitis, scapholunate instability, scaphoid fracture, or CMC arthritis. This is a list just really focused on the dorsal radial aspect of the wrist, and is not including a differential for dorsal ulnar wrist pain. So our patient's goals are to achieve pain relief and to return to weightlifting. So the next step in our management was to perform a diagnostic ultrasound. So our diagnostic ultrasound of the dorsal wrist, this is the AMSSM complete protocol for a dorsal wrist exam. So on the left, we have our required components of the exam, and this includes the extensor tendons and muscles, the extensor retinaculum, the dorsal scapholunate ligament, which includes dynamic stress fuse, joints as clinically indicated, and the superficial radial nerve. And there are also optional criteria to include, and this can be done on a clinical basis depending on the case. So in our case, this was relevant. So intersection syndrome at the first and second and second and third compartment were completed and then other parts of this exam can be done on a case-by-case basis. So clinical considerations for our exam, our patient was positioned in a seated position with his hand pronated, and we do place a small towel underneath the wrist to provide slight flexion for our exam. We used a high-frequency linear probe, but you can also use a hockey stick. And then for the order of our scanning and the rest of the talk, this is the kind of what we'll go through. So we'll start with our bones and joints of the dorsal wrist. We'll then look at the dorsal compartments, including all six compartments in both long and short axis and dynamic evaluation. We'll then look at the ligaments, specifically the scapholunate ligament and the TFCC. And then we'll move on to neurovascular structures, which in this case, the pertinent structure will be the superficial radial nerve. So we'll start off with our joints of the dorsal wrist. So here in the top right, you can see kind of the anatomic location of the probe and then the location of the probe on the patient. And then if we look at our ultrasound picture here, if you can see my mouse, we have a hyper-echoic appearance of the ulna to the left of the screen, and then the hyper-echoic radius to the right. And we can see the joint space in the middle. This is a normal appearing joint here. We could be evaluating for any cortical irregularities or fluid in this case, but our patient doesn't have that. Next we can evaluate our radiocarpal joint. So again, we're looking at the right side of the screen. We're lined up with our third metatarsal here. So when we look back at our ultrasound image on the left side, we have our hyper-echoic radius and then our radiocarpal joint here, where we then see our lunate. And then we see our mid-carpal joint between our lunate and our capitate. And then our carpometacarpal joint between the capitate and the third metacarpal. And then we can also evaluate our dorsal synovial recesses here. So following our mouse here, we have our recess at the radiocarpal joint, and then we have our recess at our mid-carpal joint. Here would be a view that we may be able to evaluate any hypo-echoic compressible structures that may be indicative of a ganglion cyst, but in our case, there are no abnormalities. So similarly, we can move our probe. So if we sweep ulnarly, we can line up our probe with our fifth metacarpal, and then we can evaluate our ulnar carpal joint. And so here we're looking at our ulna on the left, and this is the more proximal position. And then we have our ulnar carpal joint, then we have our triquetrum, and then we can see our mid-carpal joint. Next we have our hamate, and then our carpometacarpal joint, as then we see our fifth metacarpal here. And again, there are no abnormalities on our evaluation of the joints in the hand or wrist. And then we'll move on now to our extensor compartments. This will comprise the majority of our talk today, so we'll spend the most of the time on this. So I'll start off by doing a brief overview of these compartments. So as you can see in the top right corner, we have a short axis view of our different compartments in the wrist on this diagram. So starting from the right side of the screen, or the radial aspect of the wrist, we have our abductor pollicis longus and our extensor pollicis brevis in compartment one. We have our extensor carpi radialis longus and brevis in compartment two. We then move over Lister's tubercle to compartment three, which contains our extensor pollicis longus. Then we continue to move ulnarly to compartment four, and this is our extensor digitorum and our extensor indices. And then compartment five is comprised of our extensor digiti minimi, and lastly, compartment six is our ECU, or extensor carpi ulnaris. And then I do want to point out in the diagram below here, this is a long axis view of those compartments, and this is relevant to our case, because if you kind of look more proximally in the dorsal forearm here, we can see that that first compartment, which is comprised of our EPB and our APL, is crossing over our second compartment as it moves to its insertion point. So we can see that that happens proximally in the forearm, and then as we move more distally, we can see our third compartment, or our EPL, also crossing over that second dorsal compartment as it's moving to its distal insertion. So these are the intersection syndromes we'll talk about in more detail. To start out with our ultrasound images, so I have a home plate here, because Lister's tubercle is what serves as my home base when I'm evaluating the extensor compartments. So this is where I'll start just to get my orientation. So I always know if I find Lister's that to the radial aspect of Lister's, we'll have our second dorsal compartment, and then to the ulnar aspect, we'll have our third dorsal compartment. And then here we can see our ulna and our radius as well. And then as we, this is just a brief overview. So we see our first dorsal compartment as it goes away, as we're scanning from radial to ulnar. We have our second compartment, we have Lister's tubercle, our third compartment, and our fourth and fifth compartment here. And then lastly, our sixth compartment, or ECU, is present. So next we'll talk about our first dorsal compartment in more detail. So we'll spend a little more time on the first compartment, just because it is more commonly going to be a location of pathology that we're seeing in our clinics, and so we may be evaluating this more frequently. So on short axis view in the top left here, we can see that we have our EPB and our APL. Our APL is going to be located slightly more radial than our EPB. And overlying the top here, we can see our extensor retinaculum. So to the right on a more zoomed in view, we can see our extensor retinaculum here, and we typically will take a measurement of this. And there are some established values for thickening of the extensor retinaculum at this location. And a thickened mean is somewhere greater than 0.9 to about 1 centimeter, or 0.9 millimeters. So that can be evaluated. And then we'll always, when we're looking at our structures in both long axis, well, short axis here, and then we'll talk about long axis next, we'll follow them both proximally and distally. So this video is following our APL distally to its insertion. We're not seeing any abnormalities there, and then now where my pointer is, we're following our EPB distally to its insertion, and then back to where we started here. And then one other thing to note in this short axis view of our first dorsal compartment is that we will put on our Doppler imaging here to look for any signs of neovascularization or hyperemia. If that is seen and you are planning a procedure for a dacrovanes tenosynovitis, just one thing to note is that there are anatomic variables in which the tendons in the first compartment can either be contained within the same sheath or within different sheaths. And that becomes relevant if you're doing an injection to make sure that if they are in separate sheaths, that you do need to infiltrate both sheaths with the medication in order to treat both tendons, because it won't spread from one to the other, unlike if they're in the same sheath. So then on a long axis view of our first dorsal compartment here outlined, we have again that extensor retinaculum, and you can take a measurement of the thickness of that retinaculum in long axis and short axis. And we typically do that and make sure that those numbers are comparable as they should be. And then we'll look at this again in a video format to make sure we're evaluating both tendons. So in this video, it's proximal to distal, and we are sweeping from the ulnar to radial aspect to evaluate both the APL and the EPB. So in our case, we don't have any tenosynovitis on Doppler imaging, there is no thickening of the extensor retinaculum, and we are visualizing normal APL and EPB tendons. So next, this is where when we follow our first dorsal compartment more proximally is where we'll encounter our proximal intersection syndrome. So this is typically where I'll do this in my diagnostic ultrasound exam. So in this video in the top left here, you can see as we have that scanning more proximally, the first dorsal compartment goes over our second, and then as we go back distally, we can see that intersection again, the first compartment more superficial and the second compartment deeper. And so the patient in our case did have sonographic tenderness to palpation in this area and reproduction of his symptoms. So when we put on Doppler imaging, we can see here that there is some significant neovascularization in the area. And you can kind of see the intersection here in the border between the first and second compartment. And the hyperemia or neovascularization is also seen on our long axis. So we can see from proximal to distal, our more superficial tendon is our first compartment. So here, and then as we sweep radially, we are seeing our deeper extensor carpi radialis and brevis. And we can see at the intersection here, the hyperemia that is occurring. So we have a suggested diagnosis at this point in our exam, but we will continue on with the remainder of our dorsal wrist exam. So next we will evaluate our second and third dorsal compartments. So on the left side of the screen, we have our short axis view of our second compartment. So we have ECRL and ECRB at the radial aspect of Lister's tubercle here. Again, we can look at the extensor retinaculum overlying the top. And then in long axis view here, we have our tendon, and we can evaluate those by sweeping both ulnar and radially to make sure we're visualizing both tendons in that compartment. Next we can move on to looking at our third dorsal compartment. So here, Lister's tubercle again, our home base, and to the ulnar aspect of Lister's tubercle, we'll have our EPL, which is our third dorsal compartment. And one other thing to note out just for a orientation here, your EDC will be, our extensor digitorum communis, will be ulnar to that, the EPL. And sometimes you may be able to visualize the distal aspect of your PIN here. And so that's what this arrow is pointing out. This is not part of the scanning protocol, but just to point out other structures that you may be seeing on your imaging. And the PIN is typically located at the deep portion and radial aspect of the fourth compartment. So then moving to our video here, again, we will evaluate the third compartment in long axis view. We can see it over the top here. And then just to point out, we have this kind of oblique view here, deep to the third compartment. And that's where we're actually seeing the crossover of our second compartment beneath the third compartment. So that's what we'll move on to. Next is our distal intersection syndrome. So if we follow our third compartment or our EPL distally to its insertion, we can see that it's going to cross over our second compartment superficially as it travels distally. And this is an area that you can also evaluate if there's suspicion or tenderness that you would want to put on your Doppler imaging or Doppler ultrasound to look for any signs of neovascularization and hyperemia. And then on the picture to our left, I just included this one to point out that the orientation. So if you look at the top right picture, you can see that there's a relatively sharp curve that is taken by the EPL as it travels distally over the second compartment. So you're at nearly a perpendicular angle here when we're looking at these two compartments crossing. And so we have our ECRL here in long axis view. And then you're also seeing the EPL here in short axis. And so just to orient you of what you might be seeing on your ultrasound examinations. All right, moving on to our fourth and fifth dorsal compartment. So here again, we have our Lister's tubercle. And then to the ulnar aspect, we have our EPL. And then here is our fourth and fifth compartment. Sometimes it can be difficult to differentiate the fourth and fifth compartments or fourth compartment containing our EDC and our extensor indices, and then the fifth containing EDM. And so what I'll normally do is just have the patient kind of move or passively move their fingers for them. So I'll have them move their second through fourth digits for, sorry, there we go. And then so moving their second through fourth digits, we can see EDC and then isolating the EDM here, we can see just that tendon moving. So we can evaluate those separately. And then you can also, there are some normative values for the thickness of the extensor retinaculum at this level. So that can be measured if clinically indicated and give you an idea if there's any thickening present. And then in our bottom left corner here, we have our EIP in long axis view. You can also evaluate all the extensor digitorum tendons in long axis if it's relevant to the case, but in this case, we're just using an example here, and the tendon does have a normal fibular appearance in this case, and there are no abnormalities. And the same goes for our EDM tendon at the bottom right corner. It is traveling from proximally to distally here, and it has a normal fibular appearance and no abnormalities. So moving on to our last dorsal compartment, here in our top left corner, we'll first evaluate this in short axis view. So we have our ECU to the left side of the screen, and this is the ulnar aspect of the wrist. It's overlying the hyperechoic ulna in this case. And then on the radial aspect of the wrist to the right side of this picture, we have our hypochoic radius. This is just to give you an orientation of this area. So we have our third, fourth, and fifth compartment here, and then we have our sixth compartment. And then we can also evaluate the ECU in long axis view. So here we're looking at that tendon as it travels proximally to distally. Again, it has a normal fibular appearance and no abnormalities. It's important to always evaluate the sixth dorsal compartment for any dynamic subluxation. So in this case, we'll have our patient flex and extend their wrist and evaluate if there's any movement or subluxation of that tendon. And in this case, it is stable, so we're not seeing that. All right, we made it through all of the dorsal compartments. So now we'll move on to the triangular fibrocartilage complex, or our TFCC. So here we'll have our patient in a slightly hyperpronated position to best visualize this area. And you're gonna be looking at the TFCC through what we call the ECU window. So we can see the ECU overlying the top. And as we look deep to this, we can see this hyperechoic looking structure as we move distally from the ulna to the carpal bones. And what we're evaluating here is for any obvious signs of hypoechoic fluid coming from the joint or abnormalities. It's just really important to point out for this that while we are able to see any pathology in the TFCC that's present on our ultrasound, it's not a complete exam because we're not able to completely visualize the TFCC. So when we're writing our report, all we can really say is that no abnormality was seen in the visualized portion of the TFCC. And that is the case for our patients. So the TFCC appears normal. All right, and then we have our scapholunate ligament. On the left side of the screen here, this is a video on how I like to localize the scapholunate joint. So I'll again start at my home base at our Lister's tubercle, and then I'll move distally into the hand. And you can see that as you move distally, the first joint that you're gonna come upon as you scan is gonna be the scapholunate joint. So that's how I know that I'm coming to that joint. You can see in the top right corner kind of where you would be here. So Lister's, and then you'd be moving over this joint. So then once you've localized your scapholunate joint, you can visualize the ligament, and then you wanna evaluate it for any dynamic instability. So ulnarly deviating the patient's wrist, we're looking for any widening of that joint. So here we have the ulnar deviation, and that joint appears stable. So there is no instability. All right, and then lastly, we look at our neurovascular structures. And for this case, the pertinent structure will be our superficial radial nerve. And so in this video, we're following the nerve from its more proximal location in the forearm to its distally, and so we'll go here. So I'll kind of use my arrow to follow this. So we're following distally, and you can appreciate as we get into the forearm, its location to that, here's our proximal intersection syndrome. So it's proximity to that. And then as we move more distally, there's a branch here that's sitting right off of our second compartment. And the superficial radial nerve does kind of branch as you get more distally there. But I think it's important to always visualize our neurovasculature, specifically the superficial radial nerve in this case, especially when injection planning. So it's supposed to diagnostic and to localize prior to procedures. And in our case, there's no evidence of entrapment of that nerve on our exam. All right, so we completed our diagnostic ultrasound of the dorsal wrist. So this is an example ultrasound report and what we'll include in our studies. So we'll typically put the patient position, the probe we used, the indication for the procedure, and then a complete scanning protocol. And the scanning protocol will just include every structure that we looked at in the axes or dynamic evaluation that was completed. Then in the finding section of our report, that's where we'll include any pathology that was noted. And so in our case, I won't read the whole thing, but there was no stenosing to new synovitis of the first dorsal compartment. We typically will include the thickness of the extensor retinaculum. In this case, it was about 0.4 millimeters, which is in our normal range. And then there were no other abnormalities noted on our exam as we discussed throughout the talk, except for here bolded. There was evidence of proximal intersection syndrome with sonographic tenderness to palpation in neovascularization on evaluation with Doppler. So our impression or diagnosis in this case will be left proximal intersection syndrome. So what do we do? So the patient had already failed conservative management with activity modification and wrist bracing alone. So we did discuss performing a first and second dorsal compartment intersection corticosteroid injection. And the patient did opt to proceed with the injection after the risks and benefits were reviewed. So here is a video of our injection that was performed on this particular patient. So we can see in the image that the, we have the ulnar aspect here of the forearm and we have the needle coming in from an ulnar to radial in plane direction. And so as we kind of play this here, we're using a 27 gauge, 1.5 inch needle, and we can see our injectate flowing between these two compartments. We use a three CC volume containing two CCs of buffered 1% lidocaine and one CC of 40 milligrams per mil triamcin alone. One thing to note here is that your approach to this, I've also done this from a radial to ulnar approach. It just depends on where the pathology is seen and localization of your structures. We chose an ulnar to radial approach in this case because of the location of the superficial radial nerve and our ability to get in between the two compartments without disrupting any of that or coming in contact with the tendon itself. So our clinical outcome, our patient did report immediate improvement in his symptoms during the anesthetic phase of the injection. And then on follow-up, he reported ongoing symptomatic relief and was able to return to weightlifting. So it was a good outcome for us. And these are my references. And I thank everyone for your attention today. I'm happy to take any questions at this point. All right. Thank you. Sorry. Thank you, Dr. Kelly. That was fantastic. You know, it's funny because the hand and the wrist, you know, everything is superficial other than some of the intrinsic ligaments. And so you think, gosh, it should be a really easy thing to ultrasound. And generally it is, but, you know, as our ultrasound machines get better and as the resolution improves, the number of things that we can see, you know, dramatically increases. And so where we used to say like, oh, we can look at the joints and the tendons and, you know, the nerves and maybe a couple of other things. Now we're getting to the point where you can look at a lot of the ligaments more detail, you know, in particular in the TFCC. Eric Adams within AMS has done a lot of work on, you know, helping us understand what we can and can't see, you know, within the TFCC and in the ligaments in that area. And so there's, you know, I think a lot of room for us to really expand our protocols in this area. And you highlighted exactly, you know, starting with kind of the standard structures and then branching out based on your clinical suspicion. And so you, you know, really kind of hit all the major things that I would consider hitting for this. Every now and then with radial sided wrist pain, I will roll around to the bolar side and take a look at things like maybe the FCR and maybe the CFC STT as well. But generally speaking, that was great. You mentioned that Lister's tubercle is kind of your home base. And that's one thing that we always teach our fellows as well as, you know, start with Lister's tubercle. It's something you can always find. Some people do have some anatomic variation in Lister's tubercle. And so you can have, you know, the EPL sitting like on top of Lister's or I've had a couple where it sits actually further radial than the tubercle or people have kind of a, almost like a camelback type appearance to their Lister's tubercle. And so don't be fooled if you see something that doesn't look exactly like you expect it to, but that's a great home base to start with. Just a couple of comments on some of the things that you mentioned. You're talking about the first dorsal compartment. And I think one thing that's important to remember as you're looking at the first dorsal compartment is don't be fooled by the edge shadowing similar to like the A1 pulley in the finger. Don't be fooled by that edge shadowing and think like, oh gosh, there's a ton of hypochord tissue here. This is tenosynovitis and fluid. It's really that thickness of the superficial portion of that retinaculum that you want to look at. And so just, you didn't say that, but just to mention that. You also mentioned the septum. And so the presence of an osseous ridge or within the first dorsal compartment at that level can be a pretty specific finding for subcompartment within that first dorsal compartment. So looking for that osseous ridge deep is really important. And I think those are the main comments I had. I had a couple of these where they don't have any hyperemia at all, but they have that kind of typical crepitus on exam and they're tender there with ultrasound. And then just one that had quite a bit of hyperemia, you know, kind of really showing that area off. And then the ones that don't have hyperemia, they do tend to have just like a little bit of fluid in that area. And so you really have to float your transducer to avoid compressing that fluid out between the first and second dorsal compartments. And so if you're not seeing a lot of hyperemia and you're highly suspicious, just make sure you float the transducer as you're looking at that area. That's a great point, because I think the hyperemic pictures in my presentation were from you, because our particular case, he did have that. He had a little bit of fluid and he had some crepitus, but there was not an impressive amount of hyperemia, but it didn't exclude the diagnosis. Yeah. Anyone else have comments or questions? I see John Sianka's hand is up. John, do you have a... Yeah, Brennan and Malia, very nice images. In evaluating distal compartment or distal intersection syndrome, be aware that sometimes the extensor pollicis longest does not, it starts out on the radial side of Lister's tubercle. It isn't always where we think it should be. So be aware of that as you scan. There are variants, even within an individual, they might be on one side of Lister's tubercle on one hand and on the other side, with the other hand, sometimes there's a bifid Lister's tubercle and the EPL will sit on top of it. That's the case with my own wrist, but I've seen it over the years that it's not always where we think it shouldn't be. Yeah, absolutely. Thank you for adding that. You saw a lot of pictures of my wrist, I think in today's talk. Mine's in the normal spot. Brennan, can I make a couple of comments? Yep, go ahead, Brandon. Yeah, so that was excellent, really well done. Great pictures, great protocol. I don't really have too many things to add. I agree with John's point and Brennan and that morphology of Lister's can certainly predispose people to various types of EPL pathology. So I think that was a good point to make. Within the first dorsal compartment, we talked about the potential presence of a septum. Excuse me. But the other thing to consider is that there is a ton of variability within the APL tendon, right? So we historically think of there's APL and EPB within the first dorsal compartment, but APL, depending on the paper that you look at, there's been reports of it splitting into 14 sub-tendons. There's been reports of it splitting into 14 sub-tendons, right? And so there's a lot of variability and not all of these tendon slips will insert on the base of the first. Some will, first metacarpal, some will insert on the trapezium, some will insert, have a muscular insertion on the APB. So there's a lot of variability. So just making sure you really scrutinize those tendons and be mindful of identifying an aberrant tendon slip versus a pathologic tear is important. You may have made this, and if you did, I apologize, but one thing that can be sometimes confusing when you're first starting to scan for intersection syndrome, sometimes these folks will have a distal muscle belly and the muscle appearance in the distal forearm tends to be more somewhat uniformly hypoechoic rather than that quote-unquote starry night appearance. And so really making sure that if you think you see fluid, you confirm that it's fluid through various techniques and not just a far distal muscle belly. I think that can be somewhat confusing as you're starting to scan this region. And obviously, fluid's gonna be compressible and displaceable, whereas muscles, certainly is not gonna be displaceable at all. The two other points. So this is one of the few regions where I don't start with a joint for my evaluation. I start, just like you said, I start at Lister's Tubercle as my home base and then go from there, being mindful of not forgetting to evaluate the joints. And for me, the dorsal synovial recesses of the wrist are critical and really give me a good view and a good idea of what's going on inside the joint. We've certainly picked up some folks with rheumatologic disease based on the appearance of the synovium and the dorsal synovial recess. So be mindful of that. And then last thing, obviously not the main point of your talk, but you did mention evaluation of ECU instability. And I think you mentioned wrist flexion and extension. I would advocate for wrist pronation and supination or that kind of ice cream scoop, whatever technique as a better way to really dynamically stress that. Yeah, I think that's all I had. You did a great job. You did a really good job. Yeah. Ryan, with the ECU, that was one thing I, sorry, I forgot to mention. Remembering that in the wrist, you have extensor retinaculum, but you also have like subretinaculi. And so the different compartments kind of had their individual retinaculi, but they also, there is also kind of an overlying retinaculum that crosses over. And so when you're looking at like a retinacular injury or something like that, especially with the ECU, being able to differentiate between that sub sheath and the overall wrist retinaculum is helpful. And so just remember when you're assessing that, you wanna take a look at both ECU if you're looking for instability. I know this is a radial side of wrist talk, but if you're looking at the ulnar side of wrist, make sure you compare both sides because there's a lot of athletes and individuals who have bilateral laxity and they'll dislocate bilaterally. And so making sure that we're not, you know, calling a subluxation, you know, an acute sub sheath injury when it's kind of their normal physiologic finding. Absolutely, great point. Just in general, I think with ultrasound doing, the contralateral side is always really helpful for most pathology. Certainly. All right, well, unless anyone else has questions or comments, I think we'll maybe end it there and let everyone get on with their holiday weekend. Just as a reminder, we'll be back in two weeks. Dr. Debra Pacek is gonna be presenting on June 9th on the lateral femur cutaneous nerve. Have a good day, everyone. Thank you.

3rd Edition, CASE 59

3rd Edition

Wrist

dorsal wrist issues

proximal intersection syndrome

ultrasound diagnosis

extensor tendinopathy

scaphoid fracture

corticosteroid injection

sports medicine