A 60-year-old female presented with trauma on the dorsum of the left hand, with functional limitation, oedema, ecchymosis and pain on the dorsal aspect of the first and second metacarpophalangeal joints and in the area of the scaphoid and trapezium. She also referred a burning sensation and increased oedema with activity.
Radiograph of the left hand: no fractures.
Left hand CT: no fractures or dislocations.
Wrist ultrasound was performed including dorsal and palmar evaluation: subcutaneous oedema with a hypoechoic lesion measuring 6 x 4 mm is observed at the pain site (figure 2). The lesion is pulsatile with colour Doppler demonstrating central flow, “ying-yang” sign with peripheral thrombosis and a neck of 1 mm (figures 2, 3). The lesion originates from the distal radial artery in its course through the first intermetatarsal space. The distal radial artery and palmar arch are permeable (figure 4). Findings are consistent with pseudoaneurysm of the dorsal division of radial artery. Carpal relations were preserved, no injuries were observed in the ulna, radius, or carpal bones (figure 1). Extensor retinaculum and scapholunate ligament were intact.
Non-contrast enhanced magnetic resonance imaging of the left wrist after compression treatment: no image of pseudoaneurysm in the radial artery or its branches. There are no significant ligament injuries.
Pseudoaneurysms are blood collections between the arterial wall and the surrounding tissues, with persistent blood flow and communication with the parent artery. They are caused by any aetiology that leads to dissection of all layers of the arterial wall, such as blunt or penetrating trauma or infections. (1–3). Upper limb peripheral artery pseudoaneurysms are rare, with the rarest location being the radial artery. (1,4)
Pseudoaneurysms manifest as pulsatile and expansive masses along the course of a vessel, which can compress neighbouring structures, causing neuropathy, venous obstruction, and thrombosis resulting in persistent pain after trauma. Symptoms occur primarily as a mass effect and include pain, oedema, and paresthesia. (1,3,4)
The diagnostic method of choice is colour Doppler ultrasound, as it is an inexpensive, non-invasive and rapid method that provides information about the size, shape, location and flow of the pseudoaneurysm. (3) Ultrasound findings consist of a lesion adjacent to a blood vessel with turbulent flow inside, known as the "ying-yang" sign. At the junction neck between the mass and the vessel, retrograde blood flow during diastole and antegrade blood flow during systole is observed. The presence of a thrombus within the lumen may also be present. (1,4)
In some cases, computed tomography and magnetic resonance imaging may be necessary, especially to identify the parent vessel. (2)
Complications include rupture, haemorrhage, emboli formation, ischemia, loss of skin integrity, and infections. (1,4)
Various treatments have been described, ranging from ultrasound-guided observation and compression, to ultrasound-guided percutaneous injection of thrombin, endovascular exclusion and surgery. (1,2,4)
Our patient presented with persistent dorsal wrist pain after blunt trauma. She was referred for US examination to rule out ligament or tendinous lesions.
During the examination, soft-tissue oedema and sharp pain was identified. A hypoechoic lesion, continuous with the dorsal carpal branch of the radial artery was identified. With colour doppler, turbulent internal flow was noted, showing the previously mentioned “Ying - Yang” sign with partial peripheral thrombosis.
Vigorous compression during 3 hours was performed with a prior upper limb regional block for anaesthesia.
CDUS demonstrated total closure of the pseudoaneurysm sac with partial resolution of the symptoms. There were no complications, and the patient was discharged.
Written informed patient consent for publication has been obtained.
Post-traumatic pseudoaneurysm of the dorsal division of radial artery
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Based on the multiple color Doppler ultrasound images provided and the patient’s clinical symptoms, the following key points are observed:
Combining the clinical information (history of trauma, local pain, swelling, burning sensation) and the imaging findings, the main possible diagnoses include the following:
Considering the patient’s age, history of trauma, site and nature of pain (local swelling, burning sensation, exacerbation of swelling after activity), and the ultrasound findings of an arterial connection with turbulent flow on color Doppler, the most likely diagnosis is:
Pseudoaneurysm of the Dorsal Branch of the Radial Artery at the Wrist.
For further confirmation, if needed, CTA or MRA can be performed to clarify the arterial supply and the relationships between the pseudoaneurysm and adjacent structures, guiding optimal treatment planning.
Disclaimer: This report is for reference only and does not replace a physician’s consultation or professional opinion. Please combine it with clinical findings and consult a relevant specialist for specific diagnostic and treatment plans.
Post-traumatic pseudoaneurysm of the dorsal division of radial artery
