Ultrasound of the digital flexor system: Normal and pathological findings()

Pediatric musculoskeletal ultrasound

Musculoskeletal (MSK) ultrasound is an exciting area of growth for pediatric radiology. It is very well suited for pediatrics as it has no radiation, needs no intravenous contrast or sedation, is painless, and parents are present during the exam for comfort. Many diagnoses that are traditionally made with CT and MRI can be confidently made with ultrasound. In fact, ultrasound is often more helpful than MRI in a growing number if indications. Gaining an understanding and appreciation for pediatric MSK ultrasound will give pediatric radiologists a very useful diagnostic tool to benefit their patients. After the explosion of MSK ultrasound in adult imaging, it is a natural progression of this modality for the pediatric population.

Flexor Tendon Pulley Injuries: A Systematic Review of the Literature and Current Treatment Options

Closed injuries of the finger flexor pulley system are rare among the general population, and most of them occur during rock climbing. During the last few decades, scientific interest on this topic has increased. We conducted a systematic review of the literature according to the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines. The research was limited from January 2000 to March 2022. PubMed and Scopus databases were investigated for full-text articles published in English, French, and Italian using the following MeSH terms: ([pulley rupture] OR [finger pulley lesion]) AND ([injur*] OR [ruptur*] OR [damage] OR [trauma*]). Initial screening results identified 461 studies, among which 172 were included after including additional records identified through other sources and excluding repeated studies. Finally, four clinical studies were included in the analysis. The methodological quality of the articles was evaluated through the methodological index for nonrandomized studies (MINORS) score. Our search identified four studies that enrolled a total of 189 patients, of whom 164 were male and 25 were female. We finally examined 154 patients with a total of 208 pulleys damaged. Except for the thumb, all fingers were involved. Depending on the type of flexor pulley injury, graded with Schöffl classification, 69 patients underwent a surgical procedure, whereas 85 patients were treated conservatively. Closed finger pulleys injury occurred in rock climbers and non - rock climbers. All patients had excellent results on the Buck-Gramcko score regardless of the return to sports activity. Considering the overall outcomes of the reviewed articles, functional results were satisfactory in both conservative and surgical treatment. Moreover, in grade 3 and 4, surgical results were positive regardless of the specific technique used for finger pulley reconstruction. Only minor complications were reported. Closed flexor tendon pulley injuries require a careful clinical and imaging examination to confirm the diagnosis. In most cases, positive clinical results can be achieved with either conservative or surgical therapy.

Diagnostic and Interventional US of the Wrist and Hand: Quadrant-based Approach

Diagnostic and interventional US of the wrist and hand can be challenging due to the small size and superficial location of structures and various disorders that need to be considered. A quadrant-based approach (volar, ulnar, dorsal, and radial) provides a rational method for performing a focused examination and joint positioning during both diagnostic imaging and intervention. Volar wrist disorders primarily involve the median nerve and the digital flexor system comprised of the flexor tendons and pulleys. The ulnar nerve and extensor carpi ulnaris tendon are chiefly responsible for ulnar-sided wrist pain. The differential diagnosis for dorsal-sided symptoms typically involves the extensor tendon compartments and includes distal intersection syndrome, extensor pollicis longus tear, and digital extensor apparatus injury. The soft-tissue ganglion is the most common abnormality in the dorsal wrist, typically associated with wrist ligaments or joint capsule. Radial-sided pain may be secondary to de Quervain tenosynovitis and must be differentiated from the more proximal intersection syndrome. US is an important tool for assessing the ulnar collateral ligament of the first metacarpophalangeal joint of the thumb and differentiating between displaced and nondisplaced tears, thereby influencing management. Despite the complexity of the anatomy and potential pathologic features within the wrist, a focused quadrant-based examination can permit the sonologist to focus on the structures of relevance. In conjunction with a systematic approach, this can aid in precise and efficient diagnostic scanning and intervention of the wrist and hand. ©RSNA, 2023 Supplemental material is available for this article. Quiz questions for this article are available through the Online Learning Center.

Pediatric hand ultrasound: common indications, injury, inflammation and masses

Ultrasound is a uniquely valuable tool for evaluating musculoskeletal problems in the pediatric hand. Acute and chronic injuries involving tendons and ligaments of the hand can be quickly assessed and can guide surgical decision-making. Using ultrasound, palpable lesions and masses can be evaluated for cystic and solid components aiding in differential diagnosis. Additionally, ultrasound provides evaluation of acute versus chronic changes of inflammatory arthritis, assessing disease severity and subclinical synovitis and serving as an adjunct to medical management. This review will cover common indications and ultrasound findings of the pediatric hand, focusing on common injuries, inflammatory arthritis and masses. Important anatomical features of the hand will be discussed as well as imaging technique and evaluation in the pediatric patient.

Normal and abnormal tendons in children: evaluation with ultrasound

Ultrasound (US) has emerged as an essential diagnostic tool for evaluating the entire musculoskeletal system in children. The spatial resolution of modern US technology offers unparalleled depiction of superficial anatomy, and motion and blood flow are demonstrated in real time allowing for the quick diagnosis of a wide variety of pathologies. US evaluation of tendons and their structure and function represents one of the best applications of musculoskeletal US. This article reviews some of the more common indications for US of the tendons in children. While not an exhaustive list, the anatomy and pathology examples described should help any pediatric radiologist confronted with a case of tendon pain or loss of function.

Diagnostic Imaging of A2 Pulley Injuries: A Review of the Literature

Injury to the A2 pulley is caused by high eccentric forces on the flexor-tendon-pulley system. Accurate diagnosis is necessary to identify the most appropriate treatment options. This review summarizes the literature with respect to using ultrasound (US) to diagnose A2 pulley injuries, compares ultrasound to magnetic resonance imaging and computed tomography, and identifies current knowledge gaps. The results suggest that US should be used as the primary imaging modality given high accuracy, relatively low cost, ease of access, and dynamic imaging capabilities. Manual resistance is beneficial to accentuate bowstringing, but further research is needed to determine best positioning for evaluation.

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.

How Variable Is the Volar Subcutaneous Tissue of the Digits on B-Mode and Color Doppler Ultrasound in Non-Psoriatic Individuals and Could It Be Included in a Dactylitis Score?

BACKGROUND

 Digital subcutaneous tissue (SCT) changes are involved in dactylitis, a hallmark feature of psoriatic arthritis (PsA). There are no studies on the ultrasound (US) characteristics of the digital SCT in the general population.

OBJECTIVES

 To investigate the variability in US-measured thickness (TH) and color Doppler (CD)-detected blood flow of the SCT of the volar aspects of the fingers in a non-psoriatic population and to investigate the impact of the scanning method and demographics and clinical features on these measurements.

METHODS

 SCT TH and semiquantitative (SQD) and quantitative (QD) Doppler signals were measured in the bilateral second finger at the proximal and middle phalanges in 81 non-psoriatic volunteers [49 female, 32 men; 18-78 years]. Two scanning methods with and without (thick gel layer interposition) probe-skin contact were used. Demographics and clinical features were collected.

RESULTS

 There was high variability of SCT TH and Doppler measurements between individuals. All US measurements obtained without probe-skin contact were significantly greater than their corresponding measurements obtained with the probe contacting the skin (p < 0.001). SCT TH was positively related to dominant hand, age, masculine gender, weight, height, body mass index, and alcohol consumption while Doppler measurements were positively related to age and non-dominant hand.

CONCLUSIONS

 US-measured SCT thickness and Doppler-detected SCT blood flow of the volar aspect of the fingers seem to be highly variable in the non-psoriatic population as well as highly dependent on the US scanning method. This variability is of utmost importance for assessing dactylitis in PsA.

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.

Thumb Injuries and Instabilities. Part 1: Anatomy, Kinesiology, and Imaging Techniques of the Thumb

The unique anatomical characteristics of the thumb offer a broad range of motion and the ability to oppose thumb and finger, an essential function for grasping. The motor function of the thumb and its orientation make it particularly vulnerable to trauma. Pathologic lesions encountered in this joint are varied, and imaging techniques play a crucial role in injury detection and characterization. Despite advances in diagnostic accuracy, acute thumb injuries pose a challenge for the radiologist. The complex and delicate anatomy requires meticulous and technically flawless image acquisition. Standard radiography and ultrasonography are currently the most frequently used imaging techniques. Computed tomography is most often indicated for complex fractures and dislocations, and magnetic resonance imaging may be useful in equivocal cases. In this article, we present the relevant anatomy and imaging techniques of the thumb.

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.

Power Doppler Ultrasound Assessment of A1 Pulley. A New Target of Inflammation in Psoriatic Arthritis?

Objective: To determine the prevalence of grey scale and power Doppler (PD) ultrasound (US) features of A1 pulley inflammation in a cohort of psoriatic arthritis (PsA) patients compared with rheumatoid arthritis (RA) patients.

Methods: Sixty patients (30 with PsA and 30 with RA) were consecutively enrolled. The main clinimetric indexes were recorded, and US assessment of A1 pulleys from second to fifth fingers bilaterally was carried out. The presence of A1 pulley inflammation, defined as PD signal within a thickened pulley, was registered.

Results: A1 pulley inflammation was found in 15 of 240 fingers (6.3%) of eight PsA patients (26.7%) and in one of 240 fingers (0.4%) of one RA patient (3.3%) (p < 0.01 and p = 0.03, respectively). Seven of eight PsA patients (88%) with at least one inflamed A1 pulley had a moderate/high disease activity score. The regression linear analysis (R² = 0.36, adjusted R² = 0.31) showed that A1 pulley inflammation was correlated with Disease Activity Index for Psoriatic Arthritis (DAPSA) (β = 0.43, p = 0.03).

Conclusion: US A1 pulley inflammation appears to be relatively common at patient level in PsA, seems to be a characteristic feature of PsA compared to RA, and correlates with DAPSA.

Pyogenic Flexor Tenosynovitis as a Rare Complication of Dyshidrotic Eczema

Introduction: Pyogenic flexor tenosynovitis is an unusual complication of dyshidrotic eczema. The diagnosis has traditionally been made by Kanavel’s signs. Point-of-care ultrasound can be a useful adjunct in the diagnosis of this surgical emergency. Case Report: We report the case of a 23-year-old male who presented with right middle finger pain and swelling and an overlying eczematous rash. The use of point-of-care ultrasound was performed to aid in the diagnosis of pyogenic flexor tenosynovitis. An incision and drainage was performed with deep wound cultures positive for Staphylococcus aureus. Discussion: The presentation of pyogenic flexor tenosynovitis with underlying concomitant dermatological disease can complicate this challenging diagnosis. Point-of-care ultrasound can be an effective adjunct in revealing pyogenic flexor tenosynovitis rather than relying solely on the classical Kanavel’s signs, leading to earlier treatment. Conclusion: Our case demonstrates that point-of-care ultrasound can be a rapid and effective tool for the diagnosis of pyogenic flexor tenosynovitis in the setting of superimposed dermatological diseases.

VIDEO: Dynamic Ultrasound Evaluation for Soft-Tissue Injuries of the Extremities: Hand, Wrist, and Ankle

OBJECTIVE. The purpose of this article is to show the sonographic anatomy of the extremities relevant to various ligamentous, tendinous, and articular injuries occurring in the hand, wrist, and ankle. A brief discussion and depiction of the specific elements relevant to the pathophysiologic mechanism of these entities is followed by demonstrations of the dynamic ultrasound techniques that can be used to diagnose these injuries. The schematics and video clips illustrate the normal and pathologic features of these injuries. The first two videos discuss soft-tissue injuries to the hand and wrist, and the third addresses ankle injuries. CONCLUSION. After clinical assessment, dynamic ultrasound examination is a useful tool for diagnosing and assessing the degree of severity of several soft-tissue injuries to the extremities, some of which can be detected only during active movement. Familiarity with these specific dynamic techniques will enhance the value of the ultrasound examination.

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.

Single finger movements in the aging hand: changes in finger independence, muscle activation patterns and tendon displacement in older adults

With aging, hand mobility and manual dexterity decline, even under healthy circumstances. To assess how aging affects finger movement control, we compared elderly and young subjects with respect to (1) finger movement independence, (2) neural control of extrinsic finger muscles and (3) finger tendon displacements during single finger flexion. In twelve healthy older (age 68-84) and nine young (age 22-29) subjects, finger kinematics were measured to assess finger movement enslaving and the range of independent finger movement. Muscle activation was assessed using a multi-channel electrode grid placed over the flexor digitorum superficialis (FDS) and the extensor digitorum (ED). FDS tendon displacements of the index, middle and ring fingers were measured using ultrasound. In older subjects compared to the younger subjects, we found: (1) increased enslaving of the middle finger during index finger flexion (young: 25.6 ± 12.4%, elderly: 47.0 ± 25.1%; p = 0.018), (2) a lower range of independent movement of the index finger (young_middle = 74.0%, elderly_middle: 45.9%; p < 0.001), (3) a more evenly distributed muscle activation pattern over the finger-specific FDS and ED muscle regions and (4) a lower slope at the beginning of the finger movement to tendon displacement relationship, presenting a distinct period with little to no tendon displacement. Our study indicates that primarily the movement independence of the index finger is affected by aging. This can partly be attributed to a muscle activation pattern that is more evenly distributed over the finger-specific FDS and ED muscle regions in the elderly.

Flexor Tendon Lacerations Secondary to Closed Proximal Phalangeal Fracture

We report a case of complete laceration of both flexor tendons in the dominant ring finger of a young male caused by a closed volar fracture fragment of the proximal phalanx. Careful clinical examination, reasonable index of suspicion and ultrasound confirmation play a pivotal role in the diagnosis and surgical planning of this rare yet consequential injury. Good outcomes can be achieved from the surgical management and rehabilitation of both soft tissue and bony injuries when planning of surgical approaches and fixation techniques are facilitated by an accurate pre-operative diagnosis.

Pyogenic Flexor Tenosynovitis by Point-of-care Ultrasound in the Emergency Department

Introduction

Pyogenic flexor tenosynovitis (PFT) is difficult to diagnose on clinical grounds alone as many patients requiring an operation do not have all four of Kanavel’s signs. Previous studies have shown that hypoechoic fluid surrounding the flexor tendon on ultrasound is associated with this diagnosis. We sought to determine if emergency physicians (EPs) could recognize this finding in patients with suspected flexor tenosynovitis using point-of-care ultrasound (POCUS).

Methods

We present a retrospective case series of seven patients suspected of PFT who had hypoechoic fluid surrounding the tendon on POCUS performed by the treating EP. We report on the patient characteristics, history of trauma by puncture wound, number of Kanavel’s signs, treatment course, and operative findings.

Results

We identified seven patients suspected to have flexor tenosynovitis by the emergency department attending physician who had anechoic or hypoechoic fluid surrounding the flexor tendon on real-time POCUS examination. Patients ranged in age from 16 – 51 years. All were male. All patients had at least two of Kanavel’s signs on examination. Five of seven (71%) patients had history of recent trauma to the affected hand. Four of seven (57%) were managed in the operating room. One of seven (14%) had incision and drainage at the bedside, and the remaining two (28%) were managed non-operatively and successfully with antibiotics alone.

Conclusion

Our study demonstrates that EPs can recognize the finding of hypoechoic or anechoic fluid surrounding the flexor tendon on POCUS.

Usefulness of ultrasound for the diagnosis of pyogenic flexor tenosynovitis: A prospective single-center study of 57 cases

Pyogenic flexor tenosynovitis (PFT) is a functional emergency in hand surgery; however, its diagnosis can be difficult to make. It should always be considered when a patient presents with an inflamed finger. The goal of this study was to investigate the usefulness of ultrasound in the diagnosis of early PFT. Seventy-three patients with suspected pyogenic flexor tenosynovitis were candidates for the study. Since the diagnosis of PFT was obvious in 16 patients, they were excluded from the study and immediately underwent surgery. The remaining 57 patients underwent a clinical examination by a senior surgeon, a blood test for C-reactive protein levels and an ultrasound (US). The US results were compared to the intraoperative findings if the patients were operated or to the clinical outcome in non-operated patients. Seventeen patients had the US diagnosis of PFT confirmed intraoperatively. In 10 patients, the US diagnosis of PFT was not confirmed intraoperatively. In 29 other patients, the diagnosis of PFT was ruled out by US; they all had good outcomes after being treated with antibiotics. In one patient for whom the diagnosis of PFT had been ruled out by US, PFT was actually present. Ultrasound had 94% sensitivity, 65% specificity, 63% positive predictive value, and 95% negative predictive value. Ultrasound is useful as a diagnostic tool for managing early PFT thanks to its excellent negative predictive value and specificity. This objective examination complements the surgeon's subjective clinical examination.

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

Tendon disorders commonly cause hand and wrist disability and curtail the performance of work-related duties or routine tasks. Imaging is often needed for diagnosis, but it requires knowledge of the complex anatomic structures of the tendons of the hand and wrist as well as familiarity with related disorders. This review article aims to provide medical professionals with guidelines for the sonographic assessment of the tendons of hand and wrist and related disorders. Sonographic features of tendon disorders affecting the hand and wrist are described here, specifically: infectious tenosynovitis; tendon rupture or tearing; stenosing forms of tenosynovitis such as De Quervain disease and trigger finger; intersection syndrome; insertional tendinopathy; several forms of tendinous instability such as extensor carpi ulnaris instability, climber finger, and boxer knuckle; and tendinopathy in inflammatory rheumatic diseases. Postsurgical evaluation of the hand and wrist tendons is also discussed, including the healthy and pathologic appearances of operated tendons as well as impingement from orthopedic hardware. In conclusion, sonography is effective in assessing the tendons of the hand and wrist and related disorders and represents a valuable tool for diagnosis.

Case 247: Jersey Finger of the Fifth Finger

History A 34-year-old man without underlying medical conditions came to the emergency department for evaluation of persistent pain over the volar portion of his right fifth finger after a fall during a football match 3 days before. At physical examination, the injured finger was swollen and purple. Passive and active flexion of the proximal and distal interphalangeal joints were compromised, without interphalangeal instability. Radiography was performed in the emergency department, and the patient was released with a diagnosis of a fifth digit sprain. After the senior radiologist (V.M.C.) reviewed the radiographs, the patient was called back for assessment with ultrasonography (US) on the same day. US was performed with an Aplio 500 unit (Toshiba Medical Systems, Tokyo, Japan) using a multifrequency linear array 7.2-18.0-MHz PLT-1204BX transducer focused at the level of the flexor tendon. The patient was sitting in front of the examiner, with the hand lying palm up on the examination bed. No abnormality was observed during color Doppler US.

MRI in flexor tendon rupture after collagenase injection

Flexor tendon rupture is an unusual complication following collagenase injection to relieve contractures. These patients require a close follow-up and in the event of tendon rupture, a decision has to be made whether to repair the tendon or manage the complication conservatively. The authors report the utility of MRI in the prognostication and management of a patient with Dupuytren's contracture, who underwent collagenase injection and subsequently developed flexor digitorum profundus tendon rupture.

Ultrasound of the hand and wrist

There have been immense technical innovations and broadened clinical applications of ultrasound in the musculoskeletal system over the past 20 years. Specifically with regard to the hand and wrist, the advent of higher resolution transducers and postprocessing software applications have resulted in overall enhanced visualization of soft tissue structures (tendons/ligaments) as well as surface osseous lesions such as subclinical erosions in rheumatoid arthritis. Quantitative ultrasound, using either power Doppler or contrast-enhanced imaging, has become a central outcomes measure used to evaluate and document patient response to treatment in inflammatory arthropathies such as rheumatoid arthritis. This review will summarize the current state of clinical applications of ultrasound in the evaluation of the hand and wrist, with a summary of technical advances and specific applications in rheumatologic conditions.This review was exempt from institutional review board approval.

[Primary flexor tendons repair in zone 2]

Primary flexor tendon repair is still challenging even in the most experienced hands. With atraumatic surgery, the goal is to suture the tendon in a way that it will be strong enough to allow for tendon gliding without the risk of rupture or adhesions during the 12 weeks needed for the tendon to heal. After reviewing the zone 2 anatomy, the authors describe the state of art for flexor tendon repair along with their personal preferences. Although suture methods and postoperative rehabilitation programs are not universal, most specialized teams now use multistrand suturing techniques with at least 4 stands along with protected and controlled early active mobilization. Although the published rates of failure of the repair or postoperative adhesions with stiffness have decreased, these complications are still a concern. They will continue to pose a challenge for scientists performing research into the mechanics and biology of flexor tendon repairs, especially in zone 2.

[Finger flexor tenolysis]

Flexor tendon adhesions in zone II are common. The origin of these adhesions is multifactorial. Flexor tenolysis consists of releasing the adhesions to restore the tendon's normal path and the patient's active range of motion. This surgery is complex and extremely delicate. It must be associated with early active mobilization. Any surgical procedure that would hamper this active mobilization must be completed before the flexor tenolysis. The patient should be informed of the risk of flexor digitorum profundus rupture, which is the main complication of this surgery.

Septic complications involving hand and wrist in patients with pre-existing rheumatoid arthritis: The role of magnetic resonance imaging and sonography

PURPOSE

Septic arthritis (SA), frequently involving hand and wrist, is common in rheumatoid arthritis (RA) patients due to immunomediated etiology of RA and immunosuppressive drug use. Clinical and laboratory features might not be useful to differentiate between RA relapse and superimposed SA. The role of magnetic resonance imaging (MRI) has been described in several studies. Our aim is to evaluate the role of ultrasonography (US).

MATERIAL AND METHODS

In the last 4 years 31 MRI of hand and wrist has been performed in the suspect of SA complicating RA. A 1.5 T unit (Siemens Symphony, Erlangen, Germany) with standardized protocol, involving the administration of contrast medium, was used. Also US with power Doppler evaluation was performed. A Philips IU22 US scanner was used.

RESULTS

Eleven points (according to Graif's study) were analyzed for every MRI and US. At MRI joint effusion (37.5% of RA relapse vs 100% superimposed SA) and soft tissue edema (25% vs 100%) were indicative of SA. At US joint effusion (31.3% of RA relapse vs 73.3% superimposed SA) and soft tissue edema (12.5% vs 60%) were indicative of SA.

CONCLUSION

Our results suggest that joint effusion and soft tissue edema are markers suggestive for superimposed SA and that MRI is more sensitive in their evaluation. Although US is less sensitive than MRI, the former is important in guiding invasive procedure and evaluating patients that cannot undergo MRI.

Acute partial rupture of the common extensor tendon

Rupture of the common extensor tendon is the most common acute tendon injury of the elbow. The authors describe a case of a patient with a clinical history of tendinopathy caused by functional overload of the common extensor tendon, treated also with infiltrations of steroids, and subsequent partial rupture of the tendon during sport activity. The diagnosis was made clinically and at ultrasound (US) examination; US follow-up after some time showed the healing of the lesion. This case confirms that injections of steroids may be a contributory cause of tendon rupture, and emphasizes the sensitivity and specificity of US in the study of pathologies of the elbow tendons.

Aromatase inhibitor-induced arthralgia in early breast cancer: what do we know and how can we find out more?

Aromatase inhibitors (AIs) are a standard of care for the adjuvant treatment of hormone responsive early carcinoma of the breast as demonstrated in a number of large international phase III randomised trials. Arthralgia was a somewhat unexpected side effect of this class of agents and has proven to be potentially problematic in clinical practice. Although rates of up 35% have been reported in the randomised trials, the figure has been much higher in subsequent case series. There is concern that these symptoms are significant and may affect compliance and thus the overall efficacy of treatment. It is therefore extremely important that we evaluate this syndrome with a view to gaining more information regarding its clinical features and possible aetiological mechanism. The potential aetiological mechanisms and evidence for aromatase inhibitor-induced arthralgia (AIA) are reviewed in this article. Looking forward, it is now important that prospective clinical trials are well designed to evaluate this syndrome and potential therapeutic strategies to circumvent it. Radiological imaging and biochemical analyses may help our understanding of AIA and these are discussed.