Teaching Case

A 68-year-old left-handed housewife was admitted to our department for a MRI of the wrist and hand after about 3 years of atraumatic pain in the volar and dorsal side of the left hand and fingers that was exacerbated by grabbing objects such as a broom.

X-ray examination of the hand and wrist and ultrasonography of the wrist did not show pathological features. On clinical examination, the patient presented soft bluish subcutaneous nodules (stage 4 varices). Magnetic resonance imaging was performed using a Symphony Magnetom Maestro Class 1.5-T MRI system (Siemens Medical Solutions, Malvern, NJ, USA). Coronal T1-weighted, coronal and axial DP fat sat sequences (Fig. 1) and MIP reconstructions were performed.  MRI examination found no evidence of abnormalities in the musculotendinous structures or joint, but like the clinical examination, revealed venous dilatations. The post-processing MIP reconstructions helped to give an overview of the disease extent (Fig. 2). The patient refused surgery and is currently undergoing medical therapy and follow-up.

Palmar and finger varicosities are pathological dilated veins that are frequently found in clinical or imaging practice. The incidence is higher in the elderly population and onset may be favoured by repeated mechanical trauma such as vibrations. The typical locations are the palmar and dorsal surface of the fingers, proximal interphalangeal joints, and dorsal and volar surfaces of the hands, with frequent involvement of both sides [1, 2]. They have a variable clinical presentation from slight dilatations to prominent bluish nodules, and variable symptoms from asymptomatic to provoked or spontaneous pain [3]. The clinical diagnosis can be difficult, and imaging, particularly ultrasound, is necessary for the diagnosis and the identification of complications [4]. Therapy is related to symptomatology and surgery remains the main treatment in cases of painful varicosities [5]. Varicosities of the palm and fingers are relatively common particularly in elderly patients.  The palmar and dorsal arches are connected and the veins of the palm are valveless. Grasping movements cause increases in venous pressure that can lead to hypertrophy of the muscle layer of the veins [4]. The veins also become weakened with age. This can result in varicose vein formation. The varicosities present as bluish, subcutaneous venous dilatations. The symptoms are often deceptive and clinical diagnosis is sometimes difficult. Sonographic diagnosis is more straightforward and allows the evaluation of complications such as inflammation and thrombosis. Non–contrast-enhanced MR venography has been used as a standard method for visualisation of veins throughout the body including the upper limbs [6]. Varicose veins are easily recognised using non-contrast MR venography particularly on maximum intensity projection (MIP) and axial multiplanar reconstructions, and venous thrombosis may also be identified [7]. The results of MRI venography in the investigation of thrombosis and varicose veins are promising but due to the complex equipment and high costs, MRI-phlebography will be restricted to individual cases [8]. Despite this there are currently no MRI descriptions of hand and digit varicosities. We therefore decided to publish this case report to highlight the role of MRI in the diagnosis of diseases of the hand, even in unexpected cases. The case also confirms the role of MRI in the assessment of the extent of the lesions.

Written informed patient consent for publication has been obtained

The authors declare that they have no conflict of interest.