Sonography of the hand and wrist

Hand Flexor Tendon Repair: From Biology to Surgery and Rehabilitation

Tendon biology and anatomy are crucial to manage hand flexor tendon injuries, not only for surgical treatment but also for rehabilitation; surgeon and physical therapist have to choose zone by zone the best way to manage and restore the normal function of hand flexor tendons.

MRI evaluation of solid soft tissue masses of the fingers with pathology correlation

OBJECTIVE

Space occupying lesions of the fingers are commonly encountered in clinical and radiology practice. The objective of this study was to determine the characteristics of these lesions on MRI and to correlate with surgical pathology results.

MATERIAL AND METHODS

This IRB-approved HIPAA-compliant study retrospectively evaluated the clinical, imaging and pathology findings of 100 consecutive patients referred for evaluation of solid soft tissue masses of the fingers. Only solid lesions with MR imaging prior to surgery were included in this study. MR images and when available corresponding radiographs were evaluated by two radiologist in regard to signal characteristics, relation to surrounding structures and enhancement. All masses were classified into different groups based on pathology results.

RESULTS

Tenosynovial giant cell tumor (TSGCT) and fibroma of the tendon sheath were the most common solid tumors (36 %) and malignant tumors represent only 5% of the cohort. 70 % of masses with low T2 signal were TSGCT and fibroma of tendon sheath; 100 % of masses with peripheral high T2 signal and central low T2 signal/thrombus were vascular lesions, representing 41 % of the total vascular lesions in the cohort. Additionally, 100 % of serpiginous/tubular shaped masses were vascular lesions and 67 % of masses with infiltrative borders were malignant masses. Enhancement was important in identifying solid lesions but there was no statistical difference between groups related to enhancement pattern. There was a good agreement for all analyses between both readers.

CONCLUSION

Typical MR findings can help to narrow the differential diagnosis in the evaluation of finger masses and provide crucial information to guide further management.

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.

Flexor tendon injuries in athletes

Flexor tendon injuries are not common in most sporting venues; however, recognition of the pertinent anatomy, clinical findings, and the utility of diagnostic imaging will assist the clinician in a thorough evaluation of the athlete's hand. Open injuries demand immediate wound care and evaluation as to the integrity of the flexor apparatus; however, closed injuries often present with the challenges of timing: delayed injury presentation and pressures of intervention and return to play. The purpose of this article is to provide a review of the pertinent anatomy of the flexor apparatus of the hand, to identify key aspects of the patient history, clinical evaluation, and diagnostic testing relevant to flexor function, and to discuss treatment options in the setting of injuries to the flexor tendons and flexor pulley system of the hand.

Ultrasound in hand and wrist: approach for a standardized examination

New very high-frequency ultrasound probes allow highly detailed imaging of superficial structures and thus are especially suitable for examination of the hand. For successful application, specific knowledge and experience as well as standardized examination techniques are required. Based on 11 determined sections of the flexor and extensor side of the hand, the authors present one approach to a standardized ultrasound examination allowing a quick view of all structures. An additional presentation of the most typical traumatic and degenerative disease patterns underlines the potency of this examination technique. With adequate equipment, training and expertise, ultrasound should be regarded as the first-line imaging modality for the assessment of a wide range of pathological conditions affecting the wrist and hand. An exact knowledge of the anatomical relation of the structures to each other gained from ultrasound experience is equally useful for following surgery of the cases.

Ultrasound of soft tissue masses of the hand

Most soft tissue mass lesions of the hand are benign. Ganglia are the commonest lesions encountered, followed by giant cell tumors of the tendon sheath. Malignant tumors are rare. Often a specific diagnosis can be achieved on imaging by considering the location and anatomical relations of the lesion within the hand or wrist, and assessing its morphology. Magnetic resonance imaging is an excellent modality for evaluating soft tissue tumors with its multiplanar capability and ability to characterize tissue. Ultrasound plays a complementary role to MRI. It is often the initial modality used for assessing masses as it is cheap and available, and allows reliable differentiation of cystic from solid lesions, along with a real time assessment of vascularity. This review describes the US appearances of the most frequently encountered soft tissue masses of the wrist and hand, correlating the findings with MRI where appropriate.

Modern imaging of the hand, wrist, and forearm

A review of the current state of the relevant diagnostic imaging technologies and methods and their clinical application in imaging common conditions of the hand, wrist, and forearm is presented. Evolving and future imaging technologies are also considered.

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

Recent improvements in ultrasound (US) software and hardware have markedly increased the role of this imaging modality in the evaluation of the musculoskeletal system. US is currently one of the main imaging tools used to diagnose and assess most tendon, muscle, and ligament disorders. Compared with magnetic resonance imaging, US is much less expensive; it has no contraindications and is also widely available. Diseases affecting the digital flexor system (DFS) require early diagnosis if treatment is expected to limit functional impairment of the hand. US scans performed with high-resolution, broad-band transducers allows superb visualization of the flexor tendons of the hand and the annular digital pulleys. In addition, dynamic US can be used to assess movement of the tendon within the pulleys during passive or active joint movements. This article examines the anatomy and US appearance of the normal DFS and reviews the US findings associated with the most common disorders affecting it.

Detection of differential gliding characteristics of the flexor digitorum superficialis tendon and subsynovial connective tissue using color Doppler sonographic imaging

OBJECTIVE

The subsynovial connective tissue (SSCT) is the most characteristic structure in the carpal tunnel and is substantially affected in cases of carpal tunnel syndrome. We investigated the usefulness of Doppler sonography for measuring velocity differences between the flexor tendon and its associated SSCT in the carpal tunnel of cadaver hands.

METHODS

Six human cadaver wrists were used in this study (mean age of death, 82.2 years). The velocity difference between the middle finger flexor digitorum superficialis tendon and its corresponding SSCT was measured on a sonography machine equipped with a fingertip 13-MHz linear probe.

RESULTS

At tendon velocities of greater than 2.5 cm/s, the tendon velocity was significantly greater than the SSCT velocity (P < .05). At less than 2.5 cm/s, there was no significant difference between tendon and SSCT velocities.

CONCLUSIONS

Color Doppler imaging can identify and track SSCT motion separately from that of its associated tendons. Analysis of SSCT motion characteristics by color Doppler imaging may be useful for studying its function clinically.

The role of ultrasound in the evaluation of sports medicine injuries of the upper extremity

The two major imaging modalities used for assessment of soft tissue injuries are ultrasound and MRI. Although ultrasound of the extremities is used only to a limited extent in the United States, it is widely used in many other countries for evaluation of extremity injuries. This article first considers the advantages and disadvantages of MRI and ultrasound. Understanding these differences will help the reader understand the role of ultrasound as compared with MRI in evaluating upper extremity injuries. The uses of ultrasound for evaluating sports medicine injuries in specific regions of the upper extremity are then reviewed. Where the data are available, the reported accuracy of ultrasound is compared with MRI for each type of injury.

[The importance of ultrasonography in orthopedics]

After patient history and clinical evaluation, sonography is a first-line modality in the orthopedic diagnostic algorithm together with laboratory results and standard radiographic findings. As an inexpensive investigation without known adverse effects it is used (and also repeated in the course of the disease) for the dynamic control of joint movements, and especially for imaging soft tissues. Sufficient training in the use of ultrasound in the musculoskeletal system is required; individual investigations are relatively time-consuming. The procedure is especially useful in evaluating the shoulder, hand, and knee regions and rheumatic illnesses.

[Sonography of the rheumatoid hand]

In the long-term course of rheumatoid arthritis, the hand is afflicted in more than 90% of the cases, but even at first manifestation of the disease the hand is affected at a frequency of almost 40%. It is necessary to reach the diagnosis as quickly as possible to initiate timely therapy. Since early manifestations appear predominantly in damaged soft tissue, plain film radiology usually provides no definitive results. In contrast, sonography not only facilitates detection of soft tissue damage, but also makes it possible to follow the spontaneous course and treatment outcome. The advantages of sonography include feasibility of dynamic examination, lack of side effects, reproducibility, low costs, and almost ubiquitous availability. The disadvantages are the considerable dependence on the examiner and as yet the limited differentiation between effusion and synovitis as well as visualization of the infiltration into the tendon to assess an impending or extant rupture. Based on experience with sonography gathered to date for diagnostic evaluation of inflammatory rheumatic diseases particularly of the hand, it can be stated that especially in the early phases it already provides evidence for inflammatory substrate. Using suitably high-resolution probes (> or =7.5 MHz), it is frequently possible to detect superficial usures and erosions before plain film X-rays which corresponds to the direct arthritic signs in the roentgenogram.

Sonography in wrist tendon pathology

Wrist tendons may be affected by a variety of pathologic conditions, including those caused by trauma and overuse, inflammatory and metabolic disorders, or infection. Sonography is a very sensitive means of detecting tendinous pathology because of its spatial resolution and its comparative and dynamic capabilities. Its wide availability makes it the preferred first-line imaging modality in the case of wrist pain. This article reviews the pathologic conditions that may involve the wrist and their sonographic appearances.

The accuracy of high-resolution ultrasound for evaluating focal lesions of the hand and wrist

PURPOSE

Although several articles have described the sonographic features of solid and cystic lesions of the hand and wrist, few have investigated its accuracy for diagnosing such lesions. The purposes of this retrospective study were to determine the accuracy of sonography for diagnosing focal lesions of the hand and wrist against the standard of histologic examination of the resected specimen and to compare the accuracy of sonography against the recorded initial clinical impression.

METHODS

A medical record search for all sonographic studies of the hand and wrist at our institution was performed. Eighty-four patients had correlative surgery and made up the study group. All sonogram reports were reviewed for the absence or presence of focal lesions and specific diagnoses and all medical records were reviewed for the initial clinical impression. Both were compared with histologic findings and tested for agreement with the kappa statistic and for significant differences with the McNemar test

RESULTS

Seventy-six of the 84 patients had focal lesions of the hand and wrist and 8 had normal sonograms. Overall, ultrasound correctly diagnosed 83% of the lesions and the initial clinical impression was correct in 54%. Of the 76 lesions ultrasound correctly diagnosed 87% of cystic lesions, 73% of solid lesions, 75% of tenosynovitis cases and the single-vessel thrombosis. The initial clinical impression was correct in 67% of cystic lesions and 75% of tenosynovitis cases. The solid or cystic nature of the 15 solid lesions and the single-vessel thrombosis could not be determined by history or physical examination alone. Of the 35 cases in which the recorded clinical impression was incorrect or not recorded ultrasound provided the correct diagnoses in 71% of these cases. Agreement with the kappa statistical analysis was only fair and the recorded initial clinical impression was less accurate than ultrasound.

CONCLUSIONS

Ultrasound was statistically more accurate than the initial clinical impression for distinguishing solid from cystic lesions of the hand and wrist. Ultrasound was very accurate for specifically diagnosing ganglions and slightly less for solid lesions and tenosynovitis.

High-Resolution Sonography of the Triangular Fibrocartilage:Initial Experience and Correlation with MRI and Arthroscopic Findings

OBJECTIVE

The aim of our study was to compare the findings of high-resolution sonography of the triangular fibrocartilage with those of MRI and arthroscopy. SUBJECTS AND METHODS. Thirteen patients with clinically suspected triangular fibrocartilage tears prospectively underwent sonography, followed by MRI, of their wrists. Triangular fibrocartilage tears were classified as predominantly ulnar or predominantly radial. Only the surgeon was aware of the results of both studies, and eight patients subsequently underwent arthroscopy. The findings of the different techniques were compared.

RESULTS

For the presence or absence of a tear, seven (87.5%) of eight sonographic examinations correlated with arthroscopy, and 11 (84.6%) of 13 sonographic examinations correlated with MRI. Sonography missed one small radial tear that was detected at arthroscopy and MRI, but sonography showed an ulnar tear in triangular fibrocartilage that appeared normal on MRI.

CONCLUSION

High-resolution sonography shows good correlation with MRI and arthroscopy for the evaluation of triangular fibrocartilage tears. Sonography has the potential to be a rapid and cost-effective means of diagnosing tears of the triangular fibrocartilage, particularly those involving the ulnar aspect of the cartilage.

Ultrasound in sports medicine

Musculoskeletal sonography has been shown to be effective for many applications related to sports medicine. Some advantages of sonography over MR imaging include portability, accessibility, high resolution, and relative lower cost. More importantly, dynamic imaging under sonography visualization allows diagnoses that cannot be made with routine MR imaging. Additionally, direct imaging correlation with patient symptoms provides important information to the referring clinicians. The disadvantages of sonography include operator dependence and long learning curve. This can be minimized, however, with proper training and standardized technique. Musculoskeletal sonography has proved itself as one of several imaging methods invaluable to the diagnosis of sport medicine-related abnormalities.

Sonographic Evaluation of Extensor Tenosynovitis

This is a case report of tenosynovitis of the second and third extensor tendon compartments of the wrist. The report is unique in that tenosynovitis was evaluated with a combination of gray-scale sonographic images with and without an acoustic standoff pad, real-time examination, and color and spectral Doppler interrogation. Tenosynovitis is a nonspecific, inflammatory process affecting the tendon sheath and may occur as a result of infection, trauma, or inflammatory arthropathy such as rheumatoid arthritis. This case most likely represents an inflammatory type of extensor tenosynovitis. Symptoms, sonographic findings, and treatment options are briefly discussed.

Hand and wrist sonography

Although the anatomy of the hand and wrist is complex and the pathologic conditions encountered are diverse, many of the disease processes are localized, and in many situations, the clinical question is specific and limited. Because of this, ultrasound has always been an attractive imaging modality for evaluation of hand and wrist problems. Unfortunately, intrinsic difficulties in ultrasound image acquisition and interpretation have slowed the acceptance of hand and wrist sonography. Recently, however, new developments in high-resolution transducers and signal processing have dramatically improved image quality and scanning flexibility. For this reason, hand and wrist sonography is now more widely accepted and is taking its place along side other traditional modalities such as radiography, computed tomography, magnetic resonance imaging, and arthrography. Specific situations in which ultrasound offers definite benefits include evaluation of tendon inflammation and rupture, evaluation of palpable masses or suspected occult masses, and evaluation of suspected foreign bodies. Analysis of the median nerve is also possible and in the future, may have a role in patients with carpal tunnel syndrome.