Sonography of Non-neoplastic Disorders of the Hand and Wrist Tendons

High-resolution ultrasound approach to quadrangular joint in carpal boss: Everything musculoskeletal sonographer should know

At the quadrangular joint (QAJ) of the carpus, a rare bony protuberance called carpal boss (CB) may occur. This bone abnormality may be due to osteophytes development or os styloideum. Symptomatic patients may complain pain, swelling, and restrictions in hand motion. These symptoms result from joint degenerative-inflammatory changes, development of ganglion cyst/bursitis, or tendons pathology. Correct diagnosis and appropriate management can be achieved through high-resolution ultrasonography (HR-US). The purpose of this review is to define the pathology spectrum around and within the QAJ in CB. The role of HR-US is highlighted and the standard technique for the QAJ assessment is described.

Platelet-rich plasma for de Quervain's tenosynovitis: A systematic review and meta-analysis

BACKGROUND

Platelet-rich plasma (PRP) injection is used as an alternative non-operative management for de Quervain's tenosynovitis (DQT) to regenerate tendon healing.

AIM

To assess and conclude the research-based study systematically to analyse the efficacy of PRP on DQT.

METHODS

This systematic review used the Cochrane Handbook for Systematic Reviews and the guideline of preferred reporting items for systematic review and meta-analysis. A systematic literature search was applied to 11 databases. The authors assessed the study quality and risk of bias of each included study. Results of the meta-analysis were presented using mean difference (MD)/standardized mean difference (SMD) and 95% confidence interval (CI).

RESULTS

The authors evaluated 275 studies found in the literature search; 12 studies met the criteria for this review, and then the study quality and risk of bias were assessed. Pooled analysis of data from two studies involving 194 subjects with DQT showed that, compared with conservative treatment, PRP injection was associated with a greater reduction in visual analog scale pain in one month and six months after treatment (MD: -0.67, P value < 0.00001; MD: -1.16, P value < 0.00001) and the increase of Mayo's wrist score in one month and six months after treatment (SMD: 3.72, P value < 0.00001; SMD: 4.44, P value < 0.00001).

CONCLUSION

PRP can be used as an alternative non-operative treatment for DQT due to the tissue regenerative effect of PRP.

Diagnostic performance of high-resolution ultrasound in the evaluation of intrinsic and extrinsic wrist ligaments after trauma

PURPOSE

To investigate the role of ultrasound (US) in the evaluation of intrinsic and extrinsic ligaments of the wrist with magnetic resonance arthrography (MRA) as the reference standard.

MATERIALS AND METHODS

This prospective study included patients referred for MRA after wrist trauma. US examination was performed just before MRA. On the dorsal and palmar sides of the wrist, the intrinsic interosseus and midcarpal, extrinsic, and collateral ligaments were evaluated. MRA was performed on a 1.5-T unit. In the first 20 patients included, ligament thickness was independently assessed using US and MRA and thickness reproducibility was calculated. Ligament integrity was evaluated in all patients.

RESULTS

38 patients (22 men, 16 women; mean age: 38 years) were included. Ligament thickness reproducibility ranged between 44% for the palmar ulnocapitate ligament and 71% for the palmar scaphotriquetral ligament. US had a sensitivity, specificity, positive and negative predictive values, and accuracy of 100% in the identification of tears of the palmar (n=8) and dorsal (n=3) bands of the scapholunate ligament and the ulnar collateral ligament (n=3). It had a sensitivity of 100%, specificity of 97%, positive predictive value of 50%, negative predictive value of 100%, and accuracy of 97% in the identification of tears of the palmar ulnolunate ligament (n=1).

CONCLUSION

Compared to MRA, US showed good reproducibility in the assessment of wrist ligament thickness and similar accuracy with respect to identifying tears of the scapholunate, palmar ulnolunate, and ulnar collateral ligaments.

Safety and Efficacy of Ultrasound-Guided Perineural Hydrodissection as a Minimally Invasive Treatment in Carpal Tunnel Syndrome: A Systematic Review

Ultrasound-guided perineural hydrodissection (HD) is a novel technique that has been found to be effective in providing mechanical release of perineural adhesions and decompression of the nerve, reducing inflammation and edema and restoring its physiological function. It has a significant impact on chronic neuropathic pain (20 ± 4 weeks with VAS < 5 or VAS diminished by 2 points after the procedure). Carpal tunnel syndrome (CTS) is a common entrapment mononeuropathy, and its distribution is typically innervated by the median nerve. Patients with mild or moderate CTS may benefit from nonsurgical treatments or conservative therapies. This review was conducted following the preferred reporting items for systematic reviews and meta-analysis (PRISMA) statement guidelines. Four investigators assessed each title, abstract, and full-text article for eligibility, with disagreements being resolved by consensus with two experienced investigators. The qualitative assessment of the studies was carried out using the modified Oxford quality scoring system, also known as the modified Jadad score. Furthermore, risk of possible biases was assessed using the Cochrane collaboration tool. The results of this review suggest that US-guided HD is an innovative, effective, well-tolerated, and safe technique (11 out of 923 patients had collateral or side effects after the procedure). However, further studies comparing all drugs and with a larger sample population are required to determine the most effective substance.

"Daddy wrist": A high-resolution ultrasound diagnosis of de Quervain tenosynovitis

De Quervain's tenosynovitis involves the first of the six dorsal compartments of the wrist, which contains the abductor pollicis longus (APL) and extensor pollicis brevis (EPB) tendons. It seems to be associated with female sex (F:M = 10:1), middle age (30-50 years) and activities involving repetitive hand and wrist motions such as typing, piano playing or repetitively lifting children head, such as in postpartum females (hence the term "baby wrist" or "mommy wrist"). Aim of this paper was to illustrate high-resolution ultrasound (US) features of the DQD by describing a well-documented case that occurred in a "new dad" taking care of his babe. Hence, firstly in literature we could refer to this condition with the term of "daddy wrist".

Ultrasound of the Hook of Hamate Region: Pictorial Review

The hook of hamate is a complex anatomical region with many small but important structures. A sound knowledge of anatomy along with a systematic ultrasound technique can help delineate a variety of disorders. In this pictorial review, we discuss the ultrasound anatomy and the possible pathologies that can be encountered in this region.

Median nerve instability in the wrist: Ultrasound diagnosis

Instability of the nerves, which does not follow traumatic injury, is relatively rare. The ulnare nerve is most typically involved. Median nerve instability is far less common. The identification of instability of the median nerve in the wrist is definitely an indication for ultrasound examination before carpal tunnel release.

Sonography, My Personal Assistant at Hand Outpatient Clinic

Ultrasonography in hand surgery offers the option of imaging trauma consequences or degenerative problems in the wrist and fingers, involving bones, joints, ligaments, tendons, annular pulley, carpal and digital changes, soft masses, and foreign bodies including dynamic changes during motion. In the hands of the treating surgeon, ultrasonography allows immediately to plan conservative treatment versus surgery, to precisely infiltrate joints or tendon spaces as well as to perform miniinvasive assisted surgery.

Diagnostic performance of high-resolution ultrasound in pre- and postoperative evaluation of the hand tendons injuries

Background

Hand tendon injuries are recognized clinical entities that are frequently seen. Clinical examinations usually warrant radiological correlative studies for confirmation and as a postoperative screening test. Here is a prospective observational cohort study enrolling 30 patients who were diagnosed clinically to have hand tendon injuries either pre- or postoperative; their ages were ranging from 5 to 64 years with a mean ± SD of 31.43 ± 12.19 years; 23 male patients (76.7%) and 7 female patients (23.3%) were evaluated by high-resolution ultrasound examination and a correlative evaluation was done by either intra-operative assessment or MRI study as gold standards.

Results

High-resolution ultrasound (HRUS) findings were binned into seventeen cases (56%) that had tendon tears, of which 10 cases (33.3%) had a complete tear and 7 cases (23.3%) had a partial tear. Postoperative tendon integrity was present in 13 cases (43.3%), a tendon callus was found in 2 cases (6.66%), and a postoperative abnormal motion on the dynamic study was present in 15 cases (50%). Intra-tendinous foreign bodies were detected in two cases (6.66%), a gap between the torn ends was found in 10 cases (33.3%), and re-tear (rupture) of the repaired tendons was present in four cases (13.3%). Coexistent nerve injuries were seen in two cases (6.66%); for the forementioned findings, HRUS had gained high accuracy measures as correlated to the gold standards (100% sensitivity and 100% specificity).

Conclusion

High-resolution ultrasound serves as a highly accurate potential diagnostic modality for preoperative evaluation of hand tendon injuries and the postoperative follow-up.

Sonography of tendon pathology in the hand and wrist

Traumatic and non-traumatic tendon lesions are common at the wrist and hand. For the diagnosis, therapy management, and long-term prognosis of tendon lesions, a detailed understanding of the complex anatomy and knowledge of typical injury patterns is crucial for both radiologists and clinicians. Improvements in high-resolution ultrasound are producing high-quality images of the superficial tendinous and peritendinous structures. Thus, ultrasound is a valuable first-choice tool for visualizing traumatic, inflammatory, and degenerative conditions of the extensor and flexor tendons, particularly with the advantage of possible dynamic examination. The additional use of duplex-Doppler and power Doppler ultrasound imaging is recommended for detection of tenosynovitis in overuse injury, inflammatory disease, infection, and after traumatic conditions. In traumatic tendon injuries, knowing the precise injury zone is important for treatment decision-making. In cases of tendon rupture, the radiologist should report the tear type (i.e., complete or partial-thickness) and assess the degree of tendon retraction and associated avulsion injury, including the degree of fragment displacement. The function of intact flexor tendons may be impaired by thickening, strain, or rupture of corresponding annular pulleys. This review describes in detail the typical ultrasound imaging features of common pathologies of hand and wrist tendons, including annular pulley lesions.

Stenosing tenosynovitis of the extensor digitorum tendons of the hand: clinical and sonographic features

OBJECTIVE

To describe the ultrasound (US) features of 18 patients with extensor digitorum communis stenosing tenosynovitis (EDCST).

MATERIALS AND METHODS

A retrospective search in the radiologic information systems of two separate Institutions was performed to identify all patients presenting EDCST between January 2010 and September 2019. A total of 18 patients (ten males and eight females; mean age, 57.4 years) were identified and included. Sonographic examinations were retrospectively reviewed by two senior radiologists to assess morphologic changes and power Doppler activity of the extensor retinaculum (ER) and of the extensor digitorum communis (EDC) tendons and sheath. The presence of dynamic impingement between the EDC and the ER was evaluated using video clip records.

RESULTS

At the ultrasound, all patients (18/18; 100%) presented thickening of both the ER and EDC tendons associated with EDC tendon sheath effusion. Power Doppler hyperemia of the ER was inconstant and observed in 11 cases (11/18; 61.1%) as tendon sheath effusion observed in 16 cases (16/18; 88.9%). A cyst located inside the EDC of the index finger was observed in three of these patients (3/18; 17%). Dynamic examination showed impingement of the EDC against the ER during active tendon extension in all patients (18/18; 100%). Four of these patients (4/18; 22%) underwent surgery allowing diagnosis confirmation and release of EDCST, while the remaining fourteen patients (14/18; 78%) were either treated conservatively or using US-guided steroid injection.

CONCLUSION

US findings of EDCST include thickening of the ER and EDC tendons, EDC tendon sheath effusion, and in some cases presence of an EDC intratendinous cyst. Impingement of the EDC tendons against the ER is well demonstrated using dynamic US.

Hand-Wrist Disorders in Chainsaw Operators: A Follow-Up Study in a Group of Italian Loggers

Despite the mechanization process implemented in arboriculture, logging tasks are still manually performed by chainsaw operators, which therefore are exposed to the risk of developing hand-wrist musculoskeletal disorders. Our research aimed to: (a) define whether the slight changes observed in 2017 showed an evolution to overt diseases; (b) study some risk determinants for these diseases such as age, working experience, and performing a secondary job. We recruited in a two-year follow-up study, 38 male forestry workers performing logging tasks employed in the Sicilian Forestry Department located in Enna. All the subjects underwent: (1) personal data collection; (2) administration of questionnaire addressed at upper limbs symptoms with a hand chart; (3) physical examination of the upper limbs, including Tinel’s and Phalen’s maneuvers; (4) ultrasound investigation of the hand-wrist area. In the two-year follow-up study we registered an overall increasing in wrist disorders, thus we can assume that forestry workers may be a target population for wrist diseases and deserve a particular attention in workers’ health surveillance programs. Interestingly, the prevalence of wrist-hand disorders resulted to be higher in younger workers.

Ultrasound-guided musculoskeletal interventional procedures around the elbow, hand and wrist excluding carpal tunnel procedures

Ultrasound is a fast, reliable and radiation-free method for the assessment of a wide range of pathological conditions, as well as for the guidance of percutaneous interventional procedures around the elbow, hand and wrist. Intraarticular and periarticular interventional procedures can be easily performed under continuous ultrasound monitoring to ensure correct needle positioning and medication delivery to a specific target. The most common ultrasound-guided procedures performed around the elbow, wrist, and hand are described in this review, excluding carpal tunnel procedures. Specifically, elbow steroid injections are performed in patients with inflammatory disorders, while hyaluronic acid can be administered in case of osteoarthritis. Septic olecranon bursitis requires percutaneous drainage for diagnosis and appropriate treatment. Dry needling and injection of regenerative medications, such as blood derivatives, are among the treatment options for lateral epicondylosis. Steroid injections are performed to give symptom relief in patients with ulnar neuropathy at the elbow. Hand and wrist steroid injections are performed in case of osteoarthritis, subsequently followed by hyaluronic acid injections, and in inflammatory disorders. Wrist ganglia can be safely aspirated and injected with steroids under ultrasound guidance. De Quervain’s tenosynovitis and trigger finger are chronic tenosynovitides of the wrist and digits, respectively, which can be treated with steroid injections, subsequently followed by hyaluronic acid injections. In conclusion, proper knowledge of the musculoskeletal disorders around the elbow, hand and wrist, as well as US-guided treatment options and operator training, are prerequisites to achieve good outcomes.

Pulley, Flexor, and Extensor Tendon Injuries of the Hand

Tendon injuries represent the second most common injury of the hand (after fractures) and are a common scanning indication in radiology. Pulley injuries are very frequent in rock climbers with the A2 pulley the most commonly affected. Tendon and pulley injuries can be reliably evaluated using ultrasound (US) and magnetic resonance imaging (MRI). US can be postulated as a first-line imaging modality, allowing dynamic examination. MRI is essential for cases with ongoing diagnostic doubt post-US and also for preoperative pulley reconstruction assessment.

Sonography before and after carpal tunnel release: video article

Carpal tunnel release for compression of the median nerve at the wrist is a common procedure, often resulting in good clinical outcomes. There are, however, many anatomical variations in and around the carpal tunnel and it is important to be aware of these during carpal tunnel release. After surgery, recurrent carpal tunnel syndrome is uncommon, but difficult to diagnose and treat. Ultrasonography is often necessary for the evaluation of the anatomical variations before carpal tunnel release and to evaluate the most common complications after carpal tunnel release.

Carpal tunnel sonography

Carpal tunnel syndrome (CTS) is the most frequent entrapment neuropathy of peripheral nerves, with an incidence of 1-3 patients in 1000. CTS typically occurs between 45 and 60 years of age, and it is more frequent in women than in men. The main cause of CTS is chronic compression of the median nerve and ischemic suffering secondary to increased pressure in the carpal tunnel. There are many possible causes of CTS, which can be differentiated into idiopathic causes, which include most cases, and secondary causes. Classical CTS diagnosis is based on the patient's clinical examination and electrophysiological tests, such as electromyography and nerve conduction studies. The latter are helpful for determining the site of nerve compression, assessing its severity, monitoring the course of the disease after therapy, and excluding other causes of median nerve pain, such as cervical radiculopathies, brachial plexopathies, polyneuropathy, or other forms of mononeuropathies. However, clinical examination and electrophysiological tests are not able to differentiate idiopathic forms from secondary forms of CTS, and discrepancies are possible between clinical examination and electrophysiological tests (false negatives). Ultrasound examination is able to recognize most of the secondary forms of CTS. It can evaluate the morphological alterations of the nerve and correlate them with the severity of nerve suffering in all cases, even idiopathic ones, with a sensitivity and specificity equal to those of electrophysiological tests. It can also highlight some anatomical predisposing variants or conditions that may represent contraindications to minimally invasive treatments. Ultrasound examination also plays a fundamental role in evaluating patients with an unfavorable outcome after surgical treatment.

Ultrasound of local complications in hand surgery: a pictorial essay

Early detection of local complications (venipuncture complications, nerve lesions, infections, arthritis, and tenosynovitis, tendon adhesions and re-tears, complications related to orthopaedic hardware) after hand surgery is required for prompt treatment. Ultrasound has proven to be a valuable imaging modality for detecting and assessing a variety of disorders of the wrist and hand. The purpose of this pictorial essay is to present a wide range of complications after wrist and hand surgery assessed by ultrasound.

Ultrasound Features of Trigger Finger: Review of the Literature

Trigger finger is a common pathologic condition of the digital pulleys and flexor tendons in the hand. The key clinical finding is a transient blockage of the digit when it is flexed with subsequent painful snapping when it is extended. Imaging is a helpful guide for establishing the severity of the disease, identifying the underlying cause, and deciding the appropriate management. This narrative review aims to recall the anatomic and pathologic bases and describe the ultrasound features of trigger finger, also including common ultrasound findings and complications after therapy. Ultrasound enables an accurate static and dynamic evaluation of trigger finger as well as a comparison with the adjacent normal digits and thus should be considered the radiologic modality of first choice for its diagnosis.

Ultrasound-guided percutaneous treatment of volar radiocarpal ganglion cysts: Safety and efficacy

PURPOSE

To determine the safety and efficacy of ultrasound (US)-guided percutaneous treatment of volar radiocarpal ganglion cysts.

METHODS

The institutional review board approved the retrospective study of patients referred for US-guided percutaneous treatment of a volar radiocarpal ganglion cyst over a 5-year period. Treatment consisted of a combination of aspiration, lavage using anesthetic, wall fenestration, and steroid injection. Intraprocedural imaging and procedure notes were reviewed. Followup information was retrieved from postprocedure electronic medical records.

RESULTS

Eighty-eight patients comprised our study group. Complete decompression of the ganglion cyst was achieved in 92% of cases immediately after treatment. There were no instances of hematoma or infection. Of 38 patients with available followup information, 66% had a ganglion cyst recurrence at a median time of 9 months, regardless of their initial size or the injection of steroids. Cysts with internal septa had a statistically significantly higher rate of recurrence (P = 0.033).

CONCLUSIONS

US-guided percutaneous treatment of volar radiocarpal ganglion cysts is safe and ensures immediate decompression in most cases. However, cysts may recur, even after steroid injection or lavage.

Echogenicity of Palmar Dupuytren's Nodules Is Not a Predictor of Disease Progression in Terms of Increase in Nodule Size

BACKGROUND

Ultrasound might enable us to measure Dupuytren's disease activity and predict disease progression. The aim of this study was to analyze whether echogenicity of Dupuytren's nodules can be used to predict progression in terms of increase in nodule size.

METHODS

Ultrasonographic assessment of a Dupuytren's nodule was performed in 91 patients participating in an existing longitudinal cohort study. Images were scored for echogenicity by two observers. Echogenicity of 89 nodules was matched to growth 1 year later using linear regression analysis. Sensitivity analysis was performed using data obtained 1 year before ultrasound. The interobserver and intraobserver reliability was calculated using the intraclass correlation coefficient.

RESULTS

Hypoechogenicity was not a predictor of growth 1 year later (beta = -0.019, p = 0.748). Sensitivity analysis looking at the year before ultrasonographic measurement showed that hypoechogenic nodules were more likely to have grown in the past year (beta = 0.173, p = 0.011). However, these data were influenced by nodules that developed in the year before ultrasound. The intraobserver reliability of echogenicity of Dupuytren's nodules was excellent (intraclass correlation coefficient, 0.996; 95 percent CI, 0.993 to 0.998) and the interobserver reliability was fairly good but imprecise (intraclass correlation coefficient, 0.688; 95 percent CI, 0.329 to 0.977).

CONCLUSIONS

Hypoechogenicity is not a predictor of progression in terms of increase in nodule size measured by physical examination 1 year later. When using ultrasound to assess echogenicity of Dupuytren's nodules, the use of a single observer leads to more consistent results.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Risk III.

Differential sonographic features of the extensor pollicis longus tendon rupture and other finger tendons rupture in the setting of hand and wrist trauma

PURPOSE

To investigate the difference between sonographic findings in extensor pollicis longus tendons rupture and other finger tendons rupture in patients sustaining hand and wrist trauma.

METHODS

Twenty-four patients who presented with signs and symptoms clinically suspicious for tendon injury and surgically confirmed tendon rupture were included in this study. We analyzed 6 sonographic features: discontinuity of the tendon, pseudomass formation, decreased echogenicity of the tendon, retraction of the ruptured tendon, fluid collection within the tendon sheath, and the motion of the tendon. We compared the sonographic features of ruptured extensor pollicis longus tendons with the other ruptured finger tendons.

RESULTS

Discontinuity of the tendon was the most common sonographic findings and retraction of the ruptured tendon was the second most common findings. Fourteen of 16 cases with a dynamic study on sonography showed loss of normal motion of the tendon. Pseudomass formation was the second most common feature in ruptured extensor pollicis longus tendons, in contrast to the other ruptured finger tendons (p < 0.05).

CONCLUSION

Using ultrasonography, detection of discontinuity of the tendon, retraction of the ruptured tendon, and limitation of tendon motion could be very helpful for diagnosing a tendon rupture in hand and wrist trauma. Pseudomass formation could be more specific for diagnosing extensor pollicis longus tendon ruptures compared with other finger tendons.

Injuries to the Collateral Ligaments of the Metacarpophalangeal and Interphalangeal Joints: Sonographic Appearance

Injuries to the collateral ligaments of the metacarpophalangeal (MCP) and interphalangeal (IP) joints are commonly encountered in both athletes and nonathletes. They require prompt evaluation to ensure proper management and prevent loss of joint motion and permanent disability. Imaging is often required to confirm the diagnosis and assess injury severity. This review article aims to provide physicians with guidelines for sonographic assessment of the collateral ligaments of the MCP and IP and related injuries. Sonographic features of ligament injuries ranging from sprains and partial-thickness tears to full-thickness tears are described. Specific lesions of the ulnar collateral ligament of the thumb MCP joint, such as gamekeeper's thumb, skier's thumb, and Stener lesions, are also included. In conclusion, sonography is effective in evaluating the collateral ligaments of the MCP and IP joints and related injuries and represents a valuable tool for diagnosis.