Introduction: A 24-year-old male sustained a crush injury to his left ring finger by a concrete pit lid and underwent a delayed repair of the flexor digitorum profundus (FDP) tendon laceration at Zone 1, requiring fractional tendon lengthening and A4 pulley reconstruction with palmaris longus that loops around the middle phalanx (P2). After 2 months, he noticed no discernible active distal interphalangeal joint (DIPJ) flexion with troubles in fist clenching or full finger extension. No residual pain was noted.
Method: Both the flexor and extensor tendons of the ring finger as well as the A4 pulley was examined with static and dynamic active/passive flexion/extension of the DIPJ. The bony cortex of the phalanges was carefully assessed.
Results: 1.The FDP tendon was without tear or tenosynovitis but was adherent to an area of periosteal reaction of the mid P2, which presumably occurred from the original blunt injury. Periosteal reaction was also seen dorsally at mid P2. 2.The FDP tendon was also constricted by a tight reconstructed A4 pulley, as evidenced by wasting of the cortex of P2 shown on X-ray. 3. While the dorsally looped, reconstructed A4 pulley traversed just deep to the ulnar lateral band of the extensor tendon, it pierced the radial lateral band, thus also contributing to the lack of active extension/flexion of the DIPJ.
Conclusion & Take home message: The case study highlights the importance of dynamic assessment of tendons, visualisation of subtle bony abnormalities and knowledge of the postoperative complications of FDP tendon repair.

Introduction: A 28-year-old female sustained a comminuted fracture of the ring finger’s middle phalanx at the distal shaft and head with intra-articular extension and underwent internal fixation. After 4 months, serial radiographs showed bony non-union and she presented to our practice with an inability to flex or extend the distal interphalangeal joint (DIPJ).
Method: The flexors, the extensors as well as the articulations of the ring finger were assessed in both static and dynamic active/passive flexion/extension of the finger. Careful examination of the bony cortex of the non-united fracture fragments as well as the cerclage wires in relation to the soft tissue structures were performed.
Results: Incomplete union of the comminuted fracture of the distal shaft and head of the middle phalanx, with 40 degrees volar angulation at the site of the shaft fracture, with suspected mildly displaced ossicles or internally bony spurs, impinging on the deep margin of the flexor digitorum profundus (FDP) tendon. The 2 cerclage wires situated 10mm proximal to the DIPJ space penetrated the FDP tendon. The FDP tendon was without tear or marked tenosynovitis. The bony impingement by the non-union as well as the iatrogenic injury by the cerclage were the reasons why the FDP cannot glide, thus limiting the range of movement of the DIPJ.
Conclusion & take home message: Non-union and iatrogenic injuries are major complications following fractures of the phalanges and intervention. The case study highlights the importance of cross-modality correlation and dynamic ultrasound assessment in the imaging of the fingers.

Post Op RCR standardised published protocol

Ultrasound is a valuable tool for assessing the integrity and function of the rotator cuff following surgical repair, offering a dynamic, real-time, and cost-effective alternative to MRI. This presentation explores the role of ultrasound in post-operative evaluation, including tendon integrity, thickness, echotexture, vascularity, and muscle atrophy. The integration of shear wave elastography (SWE) for quantifying tendon stiffness and sonoelastographic techniques for monitoring healing progression will be examined. Additionally, clinical outcome measures and ultrasound grading scales for tendon healing and re-tear classification will be discussed. Through case studies and published works, this session will highlight the correlation between ultrasound findings and functional recovery, emphasizing its role in optimizing post-surgical management and rehabilitation strategies.

Adhesive capsulitis (AC)/ frozen shoulder is a painful condition that restricts active and passive range of motion in most directions. Diagnosis has been primarily based on clinical findings, until recently when features representing the pathological changes caused by AC are being recognised on imaging modalities including ultrasound. However, due to a continuous change in the pathological process of this condition over time, variable ultrasound findings have been proposed making the diagnosis still challenging. This lecture will go through all the ultrasound features suggestive of AC, with a main focus on the newly proposed ultrasound marker, the inferior glenohumeral capsule thickness ratio. The aim will be to help sonographers lead a step forward in the diagnosis of this condition. A need of careful correlation of ultrasound features with clinical examination will also be discussed.