Reason: evaluate for fluid collection History: 28-year-old female status post gunshot wound 6 wks ago, now with volar swelling Evaluation is slightly limited due to the patient's inability to fully extend her fingers. Bullet fragments from prior gunshot injury are better seen on prior radiographs, although the largest fragment is noted within the subcutaneous soft tissues of the mid palm. The bullet appears to lie within a subcutaneous fluid collection within the mid palm which measures approximately 3.5 cm in the longitudinal dimension and approximately 2 x 1 cm in the transverse dimension. This collection is hyperintense on T2-weighted images and is both iso and hyperintense to muscle on T1-weighted images. There is peripheral and septal enhancement following gadolinium administration. The signal characteristics of this collection are compatible with a hematoma although it is not possible to exclude superimposed infection. The palmaris longus tendon can be followed into the suspected hematoma at which point we can no longer identify its fibers.There is edema within the second metacarpal head, neck, and diaphysis indicating a fracture that is better seen on recent radiographs. There is disruption of the volar plate of the second MCP joint. The A1 pulley of the index finger is also indistinct and likely disrupted. There is edema within the soft tissues surrounding the second metacarpal as well as within the adductor pollicis muscle. The flexor digitorum superficialis tendons of the index finger appear intact, however, just distal to the adductor pollicis, the flexor digitorum profundus tendon of the index finger diverges laterally from the superficialis tendon and appears to terminate at the level of the MCP joint. More distally, however, at the level of the A2 pulley, and distally, the flexor tendon apparatus including both the superficialis and profundus components is grossly intact. The remaining tendons appear intact. There is edema just distal to the thenar musculature within the web space between the thumb and index finger as well as within the soft tissue volar to the index finger.
1. Fluid collection within the volar soft tissues of the mid palm which has the signal characteristics compatible with a hematoma. Please note we cannot exclude the possibility of an infected hematoma. A bullet fragment is identified within the hematoma.2. Nondisplaced fracture of the second metacarpal.3. Disruption of the volar plate and A1 pulley of the index finger.4. Findings suggestive of a tear of the flexor digitorum profundus tendons of the index finger at the level of the MCP joint.