Ultrasound of wrist and hand masses

An adult with a finger mass is it benign or malignant?

We described the case of a 42-year-old man who presented with left index finger mass persisting for 6 months. The mass was small and, painless and had gradually increased in size with limited finger flexion. Physical examination showed a firm mass over the volar surface of the left index finger. There was no tenderness, redness, warmth or punctum. The overlying skin was normal, and the mass did not transilluminate. Further examination of the head and neck, chest, upper limbs and neurovascular system revealed normal findings. No similar masses were found elsewhere in the body. Bedside ultrasound with further investigation and management confirmed the suspected diagnosis.

Usefulness of the Ultrasound in Hand Surgery: Part I

In the last years, ultrasonography (US) of the wrist and hand have increased in popularity. Technical advances led us to improve image quality and have the ability to see superficial soft-tissue structures with high resolution with the patient in our office.

The advantages of US are the fact that it is noninvasive, its lack of ionising radiation, low cost, and portability. The dynamic real-time assessment in the office is an additional benefit.

Ultrasound can be used in hand surgery for both diagnostic and therapeutic purposes. We can use US for injections with needle guidance, for the evaluation of soft-tissue masses, foreign bodies, tendon injuries, compressive neuropathies, and rheumatologic joint disease. It also helps us perform ultrasound-guided procedures: carpal tunnel syndrome, trigger finger, and intersection syndrome or compartimental syndrome.

The aim of the present review is to describe different uses of US in hand surgery to show its important role of providing to the surgeon more information on the diseases of their patients.

Giant cell tumour of tendon sheath mimicking nodal osteoarthritis

Giant cell tumour of the tendon sheath (GCTTS) commonly presents as a slow-growing and painless soft-tissue lesion in the hand. It has a propensity to mimick other benign and malignant lesions of the hand including lipoma, haemangioma, myxoid cyst, synovial sarcoma, aneurysmal bone cyst, fibroma and osteosarcoma. GCTTS has a unique histopathological appearance that aids in definitive diagnosis. Although bony invasion and local aggressive characteristics have only been reported rarely, the treatment of choice is local excision. The following case illustrates a fairly typical presentation of GCTTS with certain atypical features.

A bump: what to do next? Ultrasound imaging of superficial soft-tissue palpable lesions

Soft-tissue palpable lesions are common in clinical practice, and ultrasound (US) represents the first imaging option in the evaluation of a patient with a soft-tissue swelling. A full and systematic US assessment is necessary, however. This includes grayscale, color- and power-Doppler, spectral-Doppler, and possibly elastography facilities, as well as a trained operator. Several lesions showing characteristic US features can be diagnosed confidently, without any further work-up, and the high spatial resolution of ultrasound in the superficial layers can be a powerful tool to discriminate their etiologies. Second-level options, to be reserved for indeterminate cases or those suspected malignant at initial ultrasound, include magnetic resonance imaging, percutaneous fine-needle aspiration or biopsy, and surgical-excision biopsy. In this article, we discuss the proper US approach for addressing superficial soft-tissue lesions.

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.

Imaging for Dupuytren disease: a systematic review of the literature

BACKGROUND

As treatment of Dupuytren disease (DD) is expected to shift towards prevention of progression, the use of imaging in patients with DD becomes more important. In this systematic review an overview is given of the different methods for and applications of imaging for DD that have been described.

METHODS

The MEDLINE and EMBASE databases were searched for articles reporting the use of imaging in patients with DD, published before May 17, 2018. Studies were systematically examined in two rounds by two observers according to the PRISMA systematic. All studies containing original data on imaging for DD were considered for inclusion.

RESULTS

Three hundred and seven unique studies were identified, of which 23 were included in the study. Only studies on the use of ultrasound (US) and magnetic resonance imaging (MRI) were identified. Broadly, articles could be divided into 5 categories. Seven studies were found on diagnosis, two on measurement of disease extent, four on measurement of disease activity, seven on guidance of minimally invasive procedures and five studies on evaluation of treatment. According to the Oxford CEBM, the levels of evidence were low, ranging from level 3 to 5.

CONCLUSIONS

A variety of applications for US and MRI for patients with DD has been described. Based on the results of this review, the largest value for imaging lies in the measurement of disease activity and the follow-up of treatment of patients with early stage disease. Unfortunately, the overall level of evidence of the available literature was low. Future research is necessary to define the exact value of US and MRI in the management of patients with DD.

Shear Wave Elastography in the Diagnosis of Hand Tumours

Diagnosis of hand tumours by conventional imaging remains difficult. Shear wave elastography (SWE) is a noninvasive method used to quantitatively assess the mechanical properties of tissues. We provide the first report of “histoelastographic” data concerning a finger tumour. Our data support the notion of ultrasound assessment using multiple parameters including morphology, elasticity, viscosity, and microflow vascularization likely contributing towards a more precise diagnosis in the future.

Ultrahigh Frequency Ultrasound Imaging of the Hand: A New Diagnostic Tool for Hand Surgery

BACKGROUND

Ultrasonography is a cost-effective, noninvasive, and expedient imaging modality with numerous clinical applications. Conventional ultrasound uses transducers with frequencies that range from 5 to 12 MHz. However, ultrahigh frequency ultrasound (UHFUS) is capable of producing frequencies up to 70 MHz, which can achieve tissue resolution up to 30 μm. The purpose of our study is to present the capabilities of a novel technology and to describe its possible clinical applications for hand surgery.

METHODS

The Vevo 2100 (VisualSonics, Toronto, Canada) system was used to perform all ultrasound exams. Four unique linear array transducers were employed. All studies were performed by the authors, who have no formal training in ultrasound techniques, on 5 healthy resident volunteers and 1 clinical patient under institutional review board approval.

RESULTS

A series of 10 static images per participant and dynamic, real-time videos were obtained at various locations within the hand and wrist. UHFUS is capable of quickly and reliably imaging larger structures such as foreign bodies, soft tissue masses, and the flexor tendons, and diagnosing an array of pathologies within these structures. In addition, UHFUS can identify much finer structures such as the intimal layer of the arteries in the hand and individual fascicles within the digital nerves to provide data about vessel quality and vascular and neural pathologies.

CONCLUSIONS

UHFUS is a novel technology that shows multiple advantages over conventional ultrasound for imaging the fine superficial structures of the hand and wrist, and can be deployed by the surgeon at the point of care.