Radiological intervention of the hand and wrist

Diagnostic Reference Levels for Common Orthopedic Hand and Wrist Procedures Using Intraoperative Mini C-arm Fluoroscopy

BACKGROUND

Diagnostic reference levels are radiation dose levels in medical radiodiagnostic practices for typical examinations for groups of standard-sized individuals for broadly defined types of equipment. This study aimed to contribute to national diagnostic reference levels for common hand and wrist procedures using mini C-arm fluoroscopy. Small joint and digital fracture procedure diagnostic reference levels have not been reported in significant numbers previously with procedure-level stratification.

METHODS

Data were collected from fluoroscopy logbooks and were cross-referenced against the audit log kept on fluoroscopy machines. A total of 603 procedures were included.

RESULTS

The median radiation dose for wrist fracture open fixation was 2.73 cGycm2, Kirschner wiring (K-wiring) procedures was 2.36 cGycm2, small joint arthrodesis was 1.20 cGycm2, small joint injections was 0.58 cGycm2, and phalangeal fracture fixation was 1.05 cGycm2.

CONCLUSIONS

Wrist fracture fixation used higher radiation doses than phalangeal fracture fixation, arthrodeses, and injections. Injections used significantly less radiation than the other procedures. There are significant differences in total radiation doses when comparing these procedures in hand and wrist surgery. National and international recommendations are that institutional audit data should be collected regularly and should be stratified by procedure type. This study helps to define standards for this activity by adding to the data available for wrist fracture diagnostic reference levels and defining standards for digital and injection procedures.

Radio-carpal wrist MR arthrography: comparison of ultrasound with fluoroscopy and palpation-guided injections

OBJECTIVE

To compare ultrasound- (US), fluoroscopy- (FL), and palpation-guided contrast injection techniques used for dorsal radio-carpal wrist MRA.

MATERIALS AND METHODS

Patients with chronic wrist pain were randomized as to which injection technique they underwent into three groups of 50 participants. Dorsal radio-carpal contrast injection was performed under US, FL guidance (one radiologist for each), or palpation guidance by an orthopedic surgeon. The three techniques were compared by procedure time, success rate, number of attempts needed, frequency and grade of extravasation, joint distension, and MRA image quality. Additionally, any change from baseline wrist pain was recorded using the visual analog scale (VAS) at five time points (immediately, 8 h, 24 h, 48 h, and 1 week) after injection.

RESULTS

One hundred and fifty patients (83 males and 67 females; mean age 29 ± 6.5 years) were included. Success rates for US- and FL-guided injections were 100%, while palpation-guided approach was significantly less successful (72%) (P = 0.02) with significantly more frequent extravasation (56%)(P < 0.001). US guidance was the least time-consuming (6.5 ± 1.6 min) compared to FL guidance (12.5 ± 1.9 min) and palpation guidance (8 ± 1.2 min) (all P < 0.001). The mean number of joint puncture attempts was significantly lower with imaging-guided techniques (1.1 ± 0.24 and 1.2 ± 0.4 for US and FL, P = 0.23) compared to palpation-guided one (1.6 ± 0.8) (P = 0.007). The largest increases in baseline-pain were 8-h post-injection, and US guidance was the least painful at all-time points (all P < 0.05). Joint distension and image quality were significantly better with imaging-guided techniques (P < 0.001 and P = 0.003).

CONCLUSIONS

US-guided radio-carpal injection is a less time-consuming, more tolerable, and successful radiation-free method when compared to FL guidance. Palpation-guided injections require multiple attempts to enter the joint with high failure rates and frequent extravasation.

Ultrasound Imaging and Guidance in Common Wrist/Hand Pathologies

ABSTRACT

Wrist/hand pain is a prevalent musculoskeletal condition with a great spectrum of etiologies (varying from overuse injuries to soft tissue tumors). Although most of the anatomical structures are quite superficial and easily evaluated during physical examination, for several reasons, the use of ultrasound imaging and guidance has gained an intriguing and paramount concern in the prompt management of relevant patients. In this aspect, the present review aims to illustrate detailed cadaveric wrist/hand anatomy to shed light into better understanding the corresponding ultrasonographic examinations/interventions in carpal tunnel syndrome, trigger finger, de Quervain tenosynovitis, rhizarthrosis, and the radiocarpal joint arthritis. In addition, evidence from the literature supporting the rationale why ultrasound guidance is henceforth unconditional in musculoskeletal practice is also exemplified.

MRI of the Wrist Ligaments

Technological advances in magnetic resonance imaging (MRI) have improved radiologists' ability to evaluate wrist ligaments. MRI interpretation often guides clinical management. This article aims to review the normal and pathologic appearance of intrinsic and extrinsic wrist ligaments with a focus on MRI. Variant anatomy, imaging pearls, and clinical significance are also discussed. Special attention is paid to key wrist ligaments that play a role in carpal stability.

Triggering of Thumb by a Ganglion Cyst of the Flexor Tendon Sheath at A1 Pulley: A Case Report

Introduction:

Ganglions of the wrist and hand are commonly seen but the most common sites are in the dorsum of the wrist followed by the volar side in the distal forearm at the wrist crease. The Ganglion cysts arising from the flexor tendon sheath are rare and only a few are reported in the literature.

Case Report:

We report a rare case of a ganglion cyst of the flexor tendon sheath at A1 pulley of thumb in a 35-year-old male who came with the complaint of chronic triggering of the left thumb. The histopathological examination confirmed the ganglion which was removed from the A1 pulley area.

Conclusion:

A1 pulley ganglion causing trigger thumb is uncommon entity. Although, traditional treatment for this is conservative or aspiration. High recurrence is observed. When it comes to preservation of fine movements such as thumb, aggressive approach involving exploration and excision of cyst gives good functional outcome and reduces chance of recurrence.

Injection Techniques for Common Chronic Pain Conditions of the Hand: A Comprehensive Review

INTRODUCTION

This compilation presents a comprehensive review of the literature on common chronic pain conditions of the hand. It briefly presents these common conditions with their biological background, diagnosis, and common management options. It then presents and compares the latest literature available for injection techniques to treat these diagnoses and compares the available evidence.

METHODS

A comprehensive literature review was performed in MEDLINE, PubMed, and Cochrane databases from 1996 to 2019 using the terms "hand pain", "injection techniques", "steroid injection", "chronic pain", "osteoarthritis", "rheumatoid arthritis", "carpal tunnel syndrome", "De Quervain's tenosynovitis", "ganglion cyst", "gout", "Raynaud's", and "stenosing tenosynovitis".

RESULTS

Hand pain is a common condition with 9.7% prevalence in men and 21.6% in women and can cause significant morbidity and disability. It also carries a significant cost to the individuals and the healthcare system, totaling in $4 billion dollars in 2003. Injection therapy is an alternative when conservative treatment fails. Osteoarthritis is the most common chronic hand pain syndrome and affects about 16% of the population. Its mechanism is largely mechanic, and as such, there is controversy if steroid injections are of benefit. Hyaluronic acid (HA) appears to provide substantial relief of pain and may increase functionality. More studies of HA are required to make a definite judgment on its efficacy. Similarly, steroid ganglion cyst injection may confer little benefit. Carpal tunnel syndrome is a compressive neuropathy, and only temporarily relieved with injection therapy. US-guidance provides significant improvement and, while severe cases may still require surgery, can provide a valuable bridge therapy to surgery when conservative treatment fails. Similar bridging treatments and increased efficacy under US-guidance are effective for stenosing tenosynovitis ("trigger finger"), though, interestingly, inflammatory background is associated with decreased effect in this case. When the etiology of the pain is inflammatory, such as in RA, corticosteroid (CS) injections provide significant pain relief and increased functionality. They do not, however, change the course of disease (unlike DMARDs). Another such example is De-Quervain tenosynovitis that sees good benefit from CS injections, and an increased efficacy with US-guidance, and similarly are CS injections for gout. For Raynaud's phenomenon, Botox injections have encouraging results, but more studies are needed to determine safety and efficacy, as well as the possible difference in effect between primary and secondary Raynaud's.

CONCLUSIONS

Chronic hand pain is a prevalent and serious condition and can cause significant morbidity and disability and interferes with independence and activities of daily living. Conservative treatment remains the first line of treatment; however, when first-line treatments fail, steroid injections can usually provide benefit. In some cases, HA or Botox may also be beneficial. US-guidance is increasing in hand injection and almost ubiquitously provides safer, more effective injections. Hand surgery remains the alternative for refractory pain.